HIV Treatment in the U.S. Military: High Rates of Viral Suppression, 2012–2018

This page summarizes a report in CDC's MMWR by the Armed Forces Health Surveillance Branch and other military health researchers, covering January 2012 to June 2018.

HIV infection limits deployment in the U.S. armed forces, but service members with HIV can stay in the military if they can do their jobs. The Department of Defense (DoD) screens all service members for HIV routinely, to protect the force and the battlefield blood supply. Everyone with HIV gets care through the Military Health System, free, with evaluations by military infectious disease physicians after diagnosis and at least every 6 to 12 months afterward.

How well does that care work? Analysts used the Defense Medical Surveillance System and pharmacy records to follow active duty members diagnosed with HIV during 2012–2017. Reservists and National Guard members were left out because the system does not track their follow-up accurately.

Starting treatment

Among 1,050 service members with new HIV infections who stayed in service at least 6 months:

Starting within 6 months was more common among older members, men and Air Force members. First regimens were built mostly around integrase strand transfer inhibitors (63.0%), followed by nonnucleoside reverse transcriptase inhibitors (28.2%) and protease inhibitors (6.2%).

Staying on treatment and suppressing the virus

After excluding those with too little follow-up or incomplete viral load testing, and 14 with no record of ART, 793 members who stayed in service at least a year after starting ART were analyzed. Of the 14 without an ART record, chart review found four treated in civilian care, three "elite controllers" whose virus stayed suppressed without drugs, three who refused ART, three who started after the study period and one whose provider noted no indication because of a CD4 count above 500.

• Viral suppression within a year topped 96% in every demographic group.
• Continuous ART was more common among older members, non-Hispanic white and Black members, men, officers, and pilots and aircrew.
• Yearly suppression ranged from 91.6% of 787 people in the first year of follow-up to 100% of 15 people in the seventh.
• The median time from diagnosis to suppression fell from 6.9 months for those diagnosed in 2012 to 2.9 months in 2017.
• Median CD4 counts rose from 486 cells/μL at baseline to 717 at the last test.

Why the military does well

For comparison, CDC reported in 2014 that 96% of U.S. adults with HIV in outpatient care said they were taking ART, and national data show 81.5% to 85.9% of people in HIV care in 2016–2017 were virally suppressed at their last test.

Military results have improved over time. An Air Force study found 93% suppressed a year after starting ART in 2006–2011, up from 78.6% in 2000–2005, and the U.S. Military HIV Natural History Study found 84% suppressed a year after diagnosis in 2000–2007, up from 64% in 1996–1999. Service members now serve longer after diagnosis, and AIDS-defining illnesses have become rarer.

Likely reasons include:

• free, universal access to every step of care, from testing to specialist visits, lab monitoring and ART, despite a mobile and widely scattered population;
• more potent ART with fewer side effects, and single-tablet regimens;
• required periodic evaluations, with duty restrictions and possible medical review if illness or immune deficiency progresses, which likely encourages people to stay on treatment.

Viral suppression also protects others: CDC has reported that Treatment as Prevention can effectively eliminate sexual transmission from people virally suppressed on ART.

Limitations

• Dispensed prescriptions stood in for actual pill-taking, though viral load results suggest high adherence.
• Service members come and go, so outcomes could be measured only for those who stayed in service.

Sources

• Stahlman S, Hakre S, Scott PT, et al. "Antiretroviral Therapy and Viral Suppression Among Active Duty Service Members with Incident HIV Infection — United States, January 2012–June 2018." MMWR 69(13). https://www.cdc.gov/mmwr/volumes/69/wr/mm6913a2.htm