Antiretroviral Therapy Within 2 Years of Human Immunodeficiency Virus Acquisition Is Associated With Fewer Viral Blips: A Retrospective Analysis of More Than 20 Years of Data From the US Military HIV Natural History Study: A Retrospective Analysis of More Than 20 Years of Data From the US Military HIV Natural History Study

Background. Viral blips have been associated with larger reservoir size and slower decay. Earlier antiretroviral therapy (ART) initiation may decrease the risk of blips. Methods. We analyzed participants from the US Military HIV Natural History Study with an estimated human immunodeficiency virus (HIV) seroconversion date, viral suppression ≤400 copies/mL within 1 year after starting ART, and at least 3 HIV RNA measurements after suppression. A blip was defined as HIV RNA 401–1000 copies/mL preceded and followed by HIV RNA ≤400 copies/mL without changing ART. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for factors potentially associated with the time from viral suppression to first blip. Results. From 1996 through 2022, among 1413 participants on stable suppressive ART, 88 (6.2%) had at least one blip, including 68 (77.3%) with only a single blip. The overall incidence was 1.2 blips per 100 person-years (95% CI: .9–1.4). In multivariable modeling, ART initiation within 24 months of estimated HIV acquisition was independently associated with decreased hazard of viral blips compared with ART initiation after more than 24 months (0–6 months HR: 0.29 and 95% CI: .18–.48; 6–12 months HR: 0.43 and 95% CI: .31–.59; 12–24 months HR: 0.46 and 95% CI: .35–.60). Conclusions. Participants who initiated ART within 2 years of HIV acquisition had lower hazard of blips, potentially reflecting smaller reservoir size and suggesting reservoir plasticity that extends beyond the acute phase of HIV.