Background Whether persistent low-level viremia (pLLV) predicts virologic failure (VF) is unclear. We used data from the US Military HIV Natural History Study (NHS), to examine the association of pLLV and VF. Methods NHS subjects who initiated combination antiretroviral therapy (ART) after 1996 were included if they had 2 or more VLs measured with a lower limit of detection of ≤50 copies/mL. VF was defined as a confirmed VL ≥200 copies/mL or any VL >1000 copies/mL. Participants were categorized into mutually exclusive virologic categories: intermittent LLV (iLLV) (VL of 50–199 copies/mL on <25% of measurements), pLLV (VL of 50–199 copies/mL on ≥25% of measurements), high-level viremia (hLV) (VL of 200–1000 copies/mL), and continuous suppression (all VL <50 copies/mL). Cox proportional hazards models were used to evaluate the association between VF and LLV; hazard ratios and 95% confidence interval (CI) are presented. Results Two thousand six subjects (median age 29.2 years, 93% male, 41% black) were included; 383 subjects (19%) experienced VF. After adjusting for demographics, VL, CD4 counts, ART regimen, prior use of mono or dual antiretrovirals, and time to ART start, pLLV (3.46 [2.42–4.93]), and hLV (2.29 [1.78–2.96]) were associated with VF. Other factors associated with VF include black ethnicity (1.33 [1.06–1.68]) and antiretroviral use prior to ART (1.79 [1.34–2.38]). Older age at ART initiation (0.71 [0.61–0.82]) and non-nucleoside reverse transcriptase inhibitor (0.68 [0.51–0.90]) or integrase strand transfer inhibitor use (0.26 [0.13–0.53]) were protective. Conclusion Our data add to the body of evidence that suggests persistent LLV is associated with deleterious virologic consequences.

International travel to the developing world is becoming more common in elderly patients (defined here as individuals greater than 65 years old). When providing pre-travel counseling, providers must appreciate the changing physiology, comorbidities, immunity and pharmacokinetics associated with the aging process to prepare elderly patients for the stressors of international travel. These guidelines present an evidence-based approach to pre-travel counseling, immunization, and pharmacology concerns unique to elderly patients seeking care in a travel clinic setting.

BackgroundHIV-infected African-Americans [AA] are more likely to experience virologic failure (VF) compared with other ethnic groups. Decreased access to healthcare has been postulated as a potential cause. Using data from the US Military Natural History Study (NHS), we examined the effects of race on VF. The NHS is a longitudinal cohort comprised of Department of Defense (DoD) beneficiaries with unrestricted access to healthcare.MethodsWe included NHS participants who contributed follow-up after 2001. Demographic characteristics, antiretroviral therapy (ART) history, and serial viral loads (VL) were obtained from the database. Pharmacy records were used to calculate adherence. VF was defined as a VL of 3200 copies/mL on two consecutive measurements or one VL of >1,000 c/mL. A Cox model with time-updated covariates was used to examine the association between race and VF.ResultsA total of 1,521 subjects contributed follow-up after 2001 (41% AA; 95% male). Median age, CD4 count and VL at ART initiation (AI) were 31.6 years [IQR 26–39], 367 cells/μl [IQR 271–489] and 4.6 log10 copies/mL [IQR 4.0–5.0], respectively. Subjects were followed for a median of 4.8 years [IQR 2.7–7.9], and 13.2% (n = 201) met criteria for VF. Most subjects initiated ART with a non-nucleoside reverse transcriptase inhibitor (NNRTI) (64%), integrase strand transferase inhibitor (InSTI) (15%) or a boosted protease inhibitor (PI) (14%)-based regimen. Results of the adjusted Cox model are in the table below.ConclusionIn the NHS, in recent years, AA and Caucasians have similar responses to ART. NNRTI and InsTI use was protective, reinforcing that simpler medications with fewer adverse effects improve outcomes. Unrestricted access to care and modernization of ART should help narrow the disparities observed in virologic outcomes. Characteristics HR (95% CI) Race Ref.African-American0.78 (0.54–1.13)Caucasian0.70 (0.44–1.11)Hispanic/otherAge* (per 10-year)0.63 (0.50–0.79)VL at ART (per log10)1.27 (1.05–1.54)HIV Dx to AI* (per 5-year)1.25 (0.99–1.57)Use of antiretrovirals before ART1.95 (1.19–3.21)CD4 count* (per 100-cell)0.93 (0.87–1.00) ART regimen* Ref.Boosted PI0.36 (0.16–0.77)InSTI0.55 (0.35–0.86)NNRTI1.35 (0.79–2.29)Other combinations Adherence >90% vs. ≤90% 0.28 (0.20–0.41)*Time-updated covariate.Disclosures All authors: No reported disclosures.

Background In the era of effective antiretroviral therapy (ART) non-AIDS diagnoses (NAD) have emerged as significant concerns. HIV viremia is an important driver of systemic inflammation that has been linked to the development of NAD. In this study, we examined the distribution of NAD in a group of early diagnosed and treated HIV-infected individuals with equal access to care to evaluate the effect of continuous virologic suppression (CS) on NAD.Methods The U.S. Military HIV Natural History Study (NHS) is a prospective cohort of HIV-infected DoD beneficiaries the majority of whom are dated seroconverters. Medical record review and structured interviews are utilized to capture NAD. We included subjects initiating ART after 1996 if they had ≥2 viral loads (VLs) measured while on ART. CS was defined as having all VLs <50 copies/mL. A Cox proportional hazard model was used to evaluate the association between CS and NAD.ResultsOf the 2,642 eligible participants (93% male, 43% African-American AA), median follow-up 6.5 (IQR 3.31–12) years, 985 (37.3%) subjects (94% male, 42% AA, median follow-up 3.74 years) met criteria for CS. The median time from HIV diagnosis to ART initiation was 1.34 (IQR 0.19–5.46) years, while the median seroconversion window was 1.31 (IQR 0.8–2.1) years. A total of 402 (15.2%) NAD were recorded and were recorded (table). Factors associated with NAD included older age at ART initiation (HR 1.6 per 10-year increase [95% CI 1.4–1.8]) and female gender (HR 1.6 [95% CI 1.0–2.7]), while a higher CD4 count was protective (HR 0.93 per 50 cell increase [95% CI 0.90–0.95]). CS status was not associated with NAD (HR 0.75 [95% CI 0.50–1.11]). Total (n = 2,642) CS (n = 985) NAD402 (15.2%)49 (5%)CancerAnal Cancer27 (1.0%)1 (0.1%)Prostate Cancer17 (0.6%)2 (0.2%)Cardiovascular DiseaseCAD w and w/o MI115 (4.4%)8 (0.8%)NephropathyAcute Renal Failure74 (2.8%)4 (0.4%)CKD - eGFR <30ml/minute52 (2.0%)4 (0.4%)LiverCirrhosis22 (0.8%)0 (0.0%)ConclusionIn the ART era, about 1 in 7 NHS subjects had a NAD. The numbers of NAD in the CS subjects were lower than the rest of the cohort. While not statistically significant, the hazard ratios trended towards demonstrating a benefit for continuous virologic suppression. This trend is consistent with previous reports that have demonstrated a benefit of immunologic reconstitution and virologic control on the incidence of NAD.Disclosures All authors: No reported disclosures.