Background:  Current Department of Health and Human Services guidelines note that viral suppression should be achieved within 24 weeks of HAART initiation. Several cohorts have shown that African Americans have different virologic outcomes post HAART than European Americans. This disparity has been attributed, in part, to social and economic barriers to care. We evaluated the influence of a health care system with equal access to free healthcare on these differences.

Methods:  We analyzed 1031 HIV-infected subjects from a large longitudinal U.S. military cohort who initiated HAART between 1996 and 2006 to identify factors related to achieving an undetectable viral load (<400 copies/mL) after 6 months of HAART. Factors investigated were:  age, gender, race, baseline viral load, nadir CD4 count, prior AIDS event, prior antiretroviral use, HAART regimen, era, and co-morbidities. Logistic regression modeling was used for univariate and multivariate analyses.

Results:  Of the 1031 subjects (mean age 34.7 years, 93% male, 43% European American, 45% African American, median viral load at HAART start 33,100 copies/mL, mean CD4 nadir 305), 684 (66% overall, 73% of European American, 59% of African American) achieved viral suppression 6 months after starting HAART. In the multivariate model, the following were associated with increased odds of viral suppression after 6 months: increasing age (OR 1.3 per 10 years, 95%CI 1.1 to 1.5), European American vs African American race (OR 2.0, 1.4 to 2.7), lower baseline viral load (OR 1.6 per 1 log₁₀, 1.3 to 2.0), higher nadir CD4 count (OR 1.7 of CD4 >350 compared to <200, 1.1 to 2.6), no prior AIDS event (OR 1.5, 1.0 to 2.4), no prior antiretroviral use (OR 3.8, 2.6 to 5.4), NNRTI vs protease inhibitor (PI) regimen (OR 1.9, 1.3 to 2.7), and not having hepatitis B (OR 2.0, 1.1 to 3.8). Gender, hemoglobin, HAART era (before year 2000 or on or after year 2000), and hepatitis C were not associated with the odds of viral suppression at 6 months. There were no differences between the ethnicities in initial HAART regimens and at 6 months post HAART, equal percentages of European Americans and African Americans had changed or stopped their initial HAART regimens. The difference between ethnicities persisted at 12 months post-HAART, where European Americans had an OR of 1.7 (95%CI 1.3 to 2.0) of achieving viral suppression compared with African Americans.

Conclusions:  Despite access to free healthcare and starting similar HAART regimens, African Americans had only half the odds as European Americans of achieving viral suppression 6 months after starting HAART. This difference persisted at 12 months and was not explained by discontinuations or changes in initial therapy.