title: Outcomes of highly active antiretroviral therapy in the context of universal access to healthcare: the U.S. Military HIV Natural History Study.
abstract: BACKGROUND
  To examine the outcomes of highly-active antiretroviral therapy (HAART) for individuals with free access to healthcare, we evaluated 2327 patients in a cohort study composed of military personnel and beneficiaries with HIV infection who initiated HAART from 1996 to the end of 2007.
  
  
  METHODS
  Outcomes analyzed were virologic suppression (VS) and failure (VF), CD4 count changes, AIDS and death. VF was defined as never suppressing or having at least one rebound event. Multivariate (MV) analyses stratified by the HAART initiation year (before or after 2000) were performed to identify risk factors associated with these outcomes.
  
  
  RESULTS
  Among patients who started HAART after 2000, 81% had VS at 1 year (N = 1,759), 85% at 5 years (N = 1,061), and 82% at 8 years (N = 735). Five years post-HAART, the median CD4 increase was 247 cells/ml and 34% experienced VF. AIDS and mortality rates at 5 years were 2% and 0.3%, respectively. In a MV model adjusted for known risk factors associated with treatment response, being on active duty (versus retired) at HAART initiation was associated with a decreased risk of AIDS (HR = 0.6, 95% CI 0.4-1.0) and mortality (0.6, 0.3-0.9), an increased probability of CD4 increase ≥ 50% (1.2, 1.0-1.4), but was not significant for VF.
  
  
  CONCLUSIONS
  In this observational cohort, VS rates approach those described in clinical trials. Initiating HAART on active duty was associated with even better outcomes. These findings support the notion that free access to healthcare likely improves the response to HAART thereby reducing HIV-related morbidity and mortality.
authors.affiliation: Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences, Bethesda, MD, USA. vcmarco@emory.edu
authors.forename: Vincent C
authors.initials: VC
authors.lastname: Marconi
authors.forename: Greg A
authors.initials: GA
authors.lastname: Grandits
authors.forename: Amy C
authors.initials: AC
authors.lastname: Weintrob
authors.forename: Helen
authors.initials: H
authors.lastname: Chun
authors.forename: Michael L
authors.initials: ML
authors.lastname: Landrum
authors.forename: Anuradha
authors.initials: A
authors.lastname: Ganesan
authors.forename: Jason F
authors.initials: JF
authors.lastname: Okulicz
authors.forename: Nancy
authors.initials: N
authors.lastname: Crum-Cianflone
authors.forename: Robert J
authors.initials: RJ
authors.lastname: O'Connell
authors.forename: Alan
authors.initials: A
authors.lastname: Lifson
authors.forename: Glenn W
authors.initials: GW
authors.lastname: Wortmann
authors.forename: Brian K
authors.initials: BK
authors.lastname: Agan