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Abstract Background The principal goal of HAART is sustained viral load (VL) suppression resulting in immune reconstitution and improved HIV outcomes. We studied the factors associated with 10 years of continuous VL suppression on HAART in the US Military HIV Natural History Study. Methods Participants with continuous VL suppression (CS, n = 149) were compared to those who did not have continuous viral load suppression (NCS, n = 127) for ≥10 years on HAART. Factors associated with >10 years of VL suppression were evaluated by multivariate logistic regression. Additionally, association between CS and CD4 reconstitution was analyzed with a mixed effects model. Results Compared to NCS participants, a lower proportion of CS participants started HAART in the early HAART era (66 vs 90 %, for years 1996–1999; p < 0.001) and had less antiretroviral use prior to HAART (37 vs 83 %; p < 0.001). At initial HAART, the median CD4 cell count was higher and VL was lower for CS compared to NCS participants (375 cells/uL [256, 499] vs 261 cells/uL [146, 400]; p < 0.001 and 4.4 log 10 copies/mL [3.5, 4.9] vs 4.5 log 10 copies/mL [3.8, 5.0]; p = 0.048, respectively). New AIDS events were lower during HAART (5 vs 13 %; p = 0.032) and post-HAART CD4 trajectories were greater for the CS compared to NCS group. Factors negatively associated with ≥10 years of VL suppression included log 10 VL at first HAART (OR 0.61, 95 % CI 0.4, 0.92; p = 0.020) and antiretroviral use prior to HAART (OR 0.16, 95 % CI 0.06, 0.38; p < .001). Conclusions Sustained VL suppression is a key to long-term health in HIV-infected patients, as demonstrated by the lower proportion of AIDS events observed 10 years after HAART initiation. The current use of more potent and well-tolerated regimens may mitigate the negative factors of pre-HAART VL and prior ARV use encountered by treatment initiated in the early HAART era.

BACKGROUND: Older travelers (≥ 60 years) are a unique risk population for travel related infections and adverse events from antibiotics. We evaluated the differences in travel characteristics, exposures, illnesses and antibiotic use among older travelers and those between 18 – 59 y using a prospective, observational cohort of US Department of Defense (DoD) beneficiaries traveling outside the US for ≤ 6.5 months (TravMil). METHODS: Adult DoD beneficiaries were enrolled pre-travel. Itineraries limited to Western/Northern Europe, Canada, or New Zealand and active duty personnel on military travel were excluded. Demographics, itineraries and prescriptions were abstracted. A post-travel survey collected information on exposures and illnesses (travelers' diarrhea (TD), influenza-like illness (ILI) or febrile illness). Categorical variables were analyzed using chi-square or Fishers exact test and the Mann-U Whitney test was used for continuous variables. RESULTS: Of the 1468 travelers, 755 were ≥ 60y and 719 were < 60y. Asia (35%) and South/Central America (28%) were the most common travel regions. Older travelers were more likely to be Caucasian (80% vs. 67%), male (52% vs. 39%) and travel for tourism (84% vs. 51%) (p< 0.05). Younger travelers were more likely engage in risk behaviors (e.g. consume poorly cooked meat or seafood (16% vs 9%) or street vendor food (26% vs 8.6%), wade in fresh water (24% vs. 18%), and non-compliance with malaria prophylaxis (22% vs 12%) (p< 0.05). Older travelers had a lower incidence of TD (18% vs 24%), and a higher proportion of cases with loose stool or mild TD that did not interfere with daily activities (63% vs. 51%) (p< 0.05). Inappropriate antibiotic use for loose stool or mild TD were similar among the two age groups (67% vs 59%). Non-significant trends of lower incidence and mild infections were observed for ILI and febrile illness in older travelers. CONCLUSION: Older travelers were less likely to engage in risk behaviors, had a lower TD incidence and reported mild ...

BACKGROUND: In the U.S., military members experience a higher incidence of sexually transmitted infections (STIs) than the age and gender-adjusted general population, placing a costly and preventable burden on the military health system (MHS). These increased rates are likely due to differences in both individual and network level risk factors. To assess the feasibility of a survey examining the impact of sexual network risk factors on risk, a survey assessing STI individual and network level risk factors to include a 90-day sexual partnership inventory was piloted at a single military medical center. METHODS: A sample of 50 military beneficiaries completed a computer-assisted self-interview (CASI) cross-sectional egocentric survey administered on a tablet. Demographical and clinical data were captured from the electronic medical record. Non-parametric statistics were used to analyze the data. RESULTS: 45 of 50 subjects (90%) completed the survey. 40 (88%) subjects completed at least one partnership survey and reported 1 to 20 partners per subject. Respondents were mostly active duty (91.8%) and had been active duty for less than five years (68.2%). Common risk behaviors were explored and included meeting partners online (68.75%) and having partners who use drugs (48.94%) or are heavy drinkers (44.68%). Partnership inventories suggest sexual concurrency and disassortative mixing on age, racial and ethnic groups, and military service. CONCLUSION: While previous studies demonstrate that service members will complete sexual risk behavior surveys, this pilot egocentric partnership study demonstrates their willingness to provide detailed information on risk behaviors as well as detailed information on sexual partnerships. While we report on statistically significant associations, these may be subject to bias due to the underlying characteristics of the source population. As a result, these data will not likely be reflected in the full study population. 80% of pilot subjects completed the questionnaire and submitted ...

BACKGROUND: Since 1985, all active duty (AD) U.S. military service members have undergone periodic mandatory HIV screening. Subsequent care in the Military Health System (MHS) allows evaluation of clinical outcomes in a setting of open access to healthcare and medications. We describe ART outcomes in HIV-positive AD military utilizing data collected over 15 years in our prospective, multi-center HIV Natural History Study (NHS). METHODS: We included AD NHS participants diagnosed with HIV from 2002–2016 with ≥1 year of follow-up. Demographics, clinical diagnoses and laboratory data collected at study visits were compared for those on vs. never on ART by HIV diagnosis era at 5-year intervals. Among participants who initiated ART with ≥1 year of follow-up after ART initiation (AI), we assessed rates of virologic suppression (VS) and virologic failure (VF). RESULTS: From 2002 to 2016, 1,599 NHS participants were diagnosed with HIV infection; 1,482 had ≥1 year of follow-up. 1,337 (90.2%) received ART; ART recipients were more likely male (OR 2.5 [95% CI 1.2–5.3]), Caucasian (1.6 [1.1–2.3]), older (1.5 per 10 years [1.1–2.0]), diagnosed from 2012–2016 (14.6 [6.6–31.9]), and have lower CD4 counts (0.8 per 100 cells [0.7–0.8]) and higher VL at diagnosis (2.1 [1.8–2.5]). The median time from diagnosis to AI was 0.3 years [0.1–1.3], decreasing by era (P <0.0001). Of those ever on ART, 1,212 (90.7%) had ≥1 year of follow-up on ART; of whom, 1,196 (98.7%) achieved ≥1 measure with VS, 91% on their first regimen and 69% within 6 months. Participants not achieving VS were younger at diagnosis (0.87 per year [0.78–0.98]) and at AI (0.89 per year [0.81–0.98]), were diagnosed in 2002–2011 (9.11 [1.20–69.22]), and had lower CD4 counts at AI (0.50 per 100 cells [0.33–0.75]). 92 (7.7%) had subsequent VF after initial VS. VF was more likely in participants diagnosed in 2002–2006 (3.0 [2.0–4.7]). 281 (23.2%) had an AIDS-defining diagnosis (CD4<200 cells/uL in 88%), which decreased by era (P <0.05). There were 6 deaths in the ...

BACKGROUND: Depression is common among HIV-infected individuals and may contribute to suboptimal adherence to antiretroviral therapy (ART) and reduced rates of viral load (VL) suppression. We evaluated longitudinal HIV treatment outcomes in US Military HIV Natural History Study (NHS) participants with or without a diagnosis depression. METHODS: Male NHS participants with available ICD-9 data for mental health diagnoses and self-reported adherence (SRA) were included (n = 549). Groups were defined as having a history of depression (n = 188, 34.2%), classified as major depressive disorder and/or anxiety disorder, or no history of depression (n = 361, 65.8%). Delay in ART initiation was defined as the time from HIV diagnosis to ART start greater than the group mean (4.91 ± 4.69 years). SRA was defined as taking ≥95% of ART doses and continuous ART was defined as longitudinal ART use with gaps < 30 days. Continuous VL suppression was defined as maintaining VLs < 200 c/mL on ART. Logistic regression analysis was performed comparing variables for those with and without a coded diagnosis of depression. RESULTS: Participants had a mean age of 33 (±8.36) years at HIV diagnosis, and similar proportions were Caucasian (44.3%) or African American (40.8%). At ART initiation, the mean CD4 count was 370 (±154 cells/μL) and 362 (±163 cells/μL) for those with and without a history of depression, respectively. Overall, older participants at HIV diagnosis had greater odds of having high SRA (OR 1.07, 95% CI 1.03–1.11), and compared with Caucasians, African Americans had lower odds of having high SRA (OR 0.43, 95% CI 0.25–0.75; table). Participants with a history of depression had greater odds of experiencing delayed ART initiation (OR 2.12, 95% CI 1.11–4.05). However, they also had greater odds of remaining on continuous ART (OR 1.38, 95% CI 0.95–2.02) during follow-up compared with those without a history of depression. CONCLUSION: Although HIV-infected individuals with depression were more likely to experience delays in ...

BACKGROUND: Depression is common among HIV-infected individuals and may contribute to suboptimal adherence to antiretroviral therapy (ART) and subsequent inability to attain viral load (VL) suppression. We evaluated associations between depression, self-reported adherence, and longitudinal HIV treatment outcomes in US Military HIV Natural History Study (NHS) participants with and without depression. METHODS: Male NHS participants with available ICD-9 data for mental health diagnoses, Center for Epidemiological Studies Depression (CES-D) measures, and self-reported adherence (SRA) were included. ART use was defined as ART initiation between 2006 and 2010, with follow-up through 2015. SRA was defined as taking 95% of ART doses and continuous ART was defined as longitudinal ART use with gaps < 30 days. Continuous VL suppression was defined as maintaining VLs < 200 c/mL on ART. To analyse the association between depression and HIV treatment outcomes, latent class analysis was used to create classes of depression trajectories: low depression (LD), recent onset depression (ROD) and high Depression (HD). RESULTS: Participants had a mean age of 32 (± 8.3) years at HIV diagnosis, and similar proportions were Caucasian (44.3%) or African American (40.8%). Overall, older participants at HIV diagnosis had greater odds of having 95% self-reported adherence (OR 1.06, 95% CI 1.02–1.12), and African Americans had lower odds (OR 0.41, 95% CI 0.22–0.76) compared to Caucasians (OR 1.49, 95% CI 0.52–4.28). However, there was no difference in SRA by depression trajectory. Participants with HD had an increased odds of taking ART continuously (OR 1.75, 95% CI 0.99–3.09), and those with ROD had significantly higher odds of virologic failure (OR 0.58, 95% CI 0.38–0.91). CONCLUSIONS: Although there was no observed association between depression and SRA, participants with ROD had lower odds of attaining the HIV treatment goal of VL suppression. Continued efforts to identify and aggressively manage mental health disorders is ...

BACKGROUND: Increasing international travel places larger populations at risk for infections outside of their usual exposure. Deployed military personnel have unique risks for such infections. Our cohort's rates of travelers' diarrhea and influenza-like illness have been defined, but the rate of travelers with symptoms apart from a clinical syndrome has not. We present a survey of intra-travel symptoms of all travelers and confirmed diagnoses of ill-returned travelers in a cohort of military and civilian travelers. METHODS: TravMil is a prospective, multicenter observational study enrolling US military beneficiaries traveling outside the continental United States from 2010–2018; beneficiaries could also enroll after travel if they presented for a possible travel-related illness. Demographic information, intra-travel symptoms, and confirmed diagnoses were recorded. RESULTS: 2671 travelers embarked on 3050 trips: 63.1% male; median age 38 years (IQR 27, 57); median trip duration 20 days (IQR 13, 46). Common purposes of travel: military deployment (45.9%), vacation (23.7%), and visiting friends/relatives (10.9%). Ninety-seven travelers (3.2%) enrolled post-travel. Top regions of travel: Africa (31.5%), South and Central America/Caribbean (25.5%), and Southeast and North Asia/Oceania (19.4%). During travel, 56.6% experienced gastrointestinal (GI) symptoms, 11.9% respiratory symptoms, and 3.0% fever; of those, 10.3% sought medical care. Eighty returned travelers sought medical care (21 prospective enrollees vs. 59 post-travel enrollees): 5 vs. 17 malaria cases, 3 vs. 16 arbovirus infections, and 6 vs. 14 GI syndromes. All malaria cases in prospective enrollees were in military subjects. Post-travel enrollees accounted for 1 acute human immunodeficiency virus and 3 rickettsial infections. CONCLUSION: A majority of our travelers experienced symptoms during travel. Post-travel diagnoses, although uncommon, emphasize needed improvements in the application of known risk mitigation strategies. Our findings can help ...

BACKGROUND: Background- Current guidelines recommend annual extragenital [EG] testing for all sexually active men who have sex with men (MSM), and every 3−6 months for MSM at risk for sexually transmitted infections (STIs). Compliance with this guideline is low and testing rates among MSM with HIV have ranged between 30–46%. Financial disincentives (such as the lack of reimbursement for EG testing) may contribute to the lower EG testing rates. To examine if access to free testing improves EG testing rates, we used data from the US Military HIV Natural History Study (NHS), a cohort comprised of HIV-infected Department of Defense beneficiaries with access to care and free testing. METHODS: Methods- Among NHS participants with a follow-up visit between 1/1/2013 and 1/1/2018, genital (primarily urine samples) and EG testing rates (pharyngeal and rectal) were calculated and temporal trends examined. Multivariate logistic regression analysis was used to examine factors associated with EG testing. In a sub-set of participants who answered a risk behavior survey we examined risk-related information. RESULTS: Results- Of the 1971 male participants who had a NHS visit during the study period, 1962 (99.5%) had genital and 1419 (72%) had EG testing performed at least once. Annual genital and EG testing rates ranged between 96 - 98% and 33% - 46% respectively. No temporal trends were observed in EG testing rates. EG testing rates were higher in those with a history of gonorrhea, chlamydia or syphilis in the year prior, ranging between 50 and 67%. EG testing was more likely to occur in those who were younger and those with a prior history of STI (Table 1). In a subset of participants with risk behavior information, those who reported being MSM were more likely to be tested [Referent heterosexual; Odds Ratio 2.35 [95% CI 1.60–3.46]. CONCLUSION: Conclusion-Despite the availability of free EG testing, EG testing rates were low in the NHS and similar to those observed nationwide This contrasts with the genital testing rates which ...

BACKGROUND: Background- Tenofovir alafenamide (TAF) is associated with fewer renal and bone toxicities than tenofovir disoproxil phosphate (TDF). Hence, most experts suggest switching to TAF. We examined factors associated with switching to TAF in the US Military HIV Natural History Study (NHS), a cohort of people living with HIV who have unrestricted access to care and medications. METHODS: Methods- The first formulation of TAF received FDA approval on 1 November 2015; hence, we included all NHS participants with visits between November 2015 and March 2019. Patient factors including race, gender, CD4 count, antiretroviral therapies (ART), viral load, HIV diagnosis era, presence of comorbidities (cancer, heart disease, dyslipidemia, kidney disease and obesity), were assessed for association with a switch to TAF with a logistic regression model. RESULTS: Results- Of the 1678 eligible participants, 1324 (63%) had received a TDF-based regimen. Participants who received a TDF-regimen were 94% male 44% African-American [AA], 39% Caucasians and 17% Hispanic. About half the participants who received TDF-based ART switched to a TAF-based regimen (n=682, 52%). Of the 425 (32%) participants receiving TDF/FTC co-formulated with efavirenz, 48% (n=206) switched to TAF. The proportions switching to TAF were higher in those receiving TDF/FTC co-formulated with rilpivirine [59%, n=90] or elvitegravir/cobicistat [68%, n=146]. The common ART regimens after the switch were: TAF co-formulated with elvitegravir/cobicistat (46%), rilpivirine (16%) or bictegravir (12%) and TAF/FTC combined with dolutegravir (15%). In an adjusted analysis, older participants, and participants receiving TDF/FTC in combination with efavirenz, dolutegravir, raltegravir, boosted protease inhibitors or a combination of boosted protease inhibitors and integrase inhibitors (other) were less likely to switch, table 1. CONCLUSION: Conclusions- Despite the unrestricted access to care and ART in the NHS, only half of the participants switched to TAF. Participants ...

BACKGROUND: Influenza vaccination can reduce influenza burden, but questions have arisen about the duration of vaccine protection. While the timing of vaccination varies, annual receipt of influenza vaccine is mandated for active duty military personnel. The goal of this analysis is to determine if influenza vaccine effectiveness decreases over time. A secondary goal of this analysis is to determine if repeated influenza vaccination is associated with risk for influenza. METHODS: Otherwise healthy individuals presenting for treatment of acute respiratory infections at 5 military treatment facilities from 2009 to 2018 were enrolled in the Acute Respiratory Infection Consortium (ARIC) study. Individuals with complete demographics, influenza vaccination in the two years prior to illness, and influenza laboratory results were included in this analysis (n=1,273). Multivariate logistic regression was used to calculate the odds of an influenza diagnosis according to time since influenza vaccination, categorized in 90-day periods. The model also included age, race, month of diagnosis, influenza season, and whether the participant received 4+ influenza vaccinations in the past 5 years. RESULTS: One hundred and ninety-two individuals (15%) had laboratory confirmed influenza (Table 1). Participants were mostly active duty, male, and white. Over half of the participants received 4+ influenza vaccinations in the past 5 years. Participants who were vaccinated 90-179 and 180+ days ago had greater odds of being diagnosed with influenza than did individuals who were vaccinated < 90 days prior to illness onset (Table 2). Participants who were 18-24 years old had lower odds of influenza than individuals in other age groups. Vaccine experience (vaccinated against influenza for at least four of the past five years), race, and ethnicity were not statistically significantly associated with influenza diagnosis. Table 1. Characteristics of individuals included in the analysis of waning influenza vaccine effectiveness in the ARIC ...

We evaluated differences in pretravel care, exposures, and illnesses among pediatric and adult travelers, using a prospective, observational cohort. Eighty-one pediatric travelers were matched 1:1 with adult military dependents by travel region, destination's malaria risk, and travel duration. Pediatric travelers were more likely to have coverage for hepatitis A and B (90% versus 67% of adults; 85% versus 44%), visit friends and relatives (36% versus 16%), report mosquito bites (69% versus 44%), and have close contact with wild or domesticated animals (40% versus 20%) than adults (P < 0.05). Subjects < 10 years of age were less likely to be prescribed antibiotics (28% versus 95%; RR = 0.63; 95% CI: 0.46–0.85) and antidiarrheals (9% versus 100%; RR = 0.10; 95% CI: 0.03–0.29) for travelers' diarrhea (TD) self-treatment than adults. Travel medicine providers should emphasize strategies for vector avoidance, prevention of animal bites and scratches, and TD self-treatment in pediatric pretravel consultations.

Travelers to developing regions are at risk for development of influenza-like illness (ILI). Little is known of traveler and trip characteristics associated with the development of ILI. TravMil is a prospective observational study, enrolling subjects presenting to six military travel clinics or predeployment-screening sites. We analyzed pre- and post-travel surveys from travelers visiting regions outside of the continental United States, Western or Northern Europe, Canada, Australia, or New Zealand between January 2010 and March 2016. Influenza-like illness was defined as a self-reported fever associated with either sore throat or cough. Trip and traveler characteristics were analyzed to determine risk factors for the development of ILI. Two thousand nine hundred and thirty-two trips were recorded (55% male, median age 45 years, 69% white, 51% on vacation, median travel duration 17 days). The 2,337 trips included the number of self-reported influenza vaccinations in the preceding 5 years (median 5). Eleven percent of the trips were complicated by an ILI lasting a median of 5 days; 70% and 17% of these reported upper and lower respiratory tract infection, respectively, and 12% reported both. On multivariate analysis, increased risk of ILI was associated with female gender (odds ratio [OR]: 1.60 [confidence interval (CI): 1.25–2.05], P < 0.01), age (years) (OR: 1.01 [CI: 1.01–1.02], P < 0.01); and duration of travel (days) (OR: 1.01 [CI: 1.00–1.01], P < 0.01). Influenza-like illness is common in travelers, regardless of traveler characteristics, purpose of travel, destination, or season of year. Female gender, older age, and longer duration of travel were associated with an increased risk of ILI. Additional tools and strategies are needed to prevent ILI in international travelers.

BACKGROUND: D-dimer blood levels in persons with HIV infection are associated with risk of serious non-AIDS conditions and death. Black race has been correlated with higher D-dimer levels in several studies. We examined the effects of race and HIV on D-dimer over time and the impact of viral load suppression by longitudinally comparing changes in levels among healthy young adult male African Americans and Caucasians before HIV seroconversion, and before and after initiation of antiretroviral therapy (ART). METHODS: We analyzed D-dimer levels, clinical and laboratory data in 192 participants enrolled in the U.S. Military HIV Natural History Study, a 30 year cohort of military personnel infected with HIV. D-dimer levels were measured on stored sera from each participant at three time points: 1) pre-HIV seroconversion (Pre-SC), 2) =6 months post-HIV seroconversion but prior to ART initiation (Post-SC), and 3) =6 months post-ART with documented viral suppression (Post-ART). Levels were compared at each time point using nonparametric and logistic regression analysis. RESULTS: Compared to Caucasians (n=106), African Americans (n=86) had higher D-dimer levels post-SC (p=0.007), but in the same individuals, pre-SC baseline and post-ART levels were similar (p=0.40 and p=0.99 respectively). There were no racial differences in CD4 cell counts, HIV RNA viral load, time from estimated seroconversion to ART initiation, and duration of time on ART. CONCLUSIONS: Observed longitudinally, racial differences in D-dimer levels were seen only during HIV viremia. Higher levels of D-dimer commonly observed in African Americans are likely due to factors in addition to race.

BACKGROUND: Viral respiratory infections are a common cause of hospitalization for younger, otherwise-healthy populations. In this study, we describe the epidemiology of influenza-like illness in non-elderly adults within the U.S. Military Health System (MHS) by pathogen and hospitalization status. METHODS: The Acute Respiratory Infection Consortium (ARIC) is a prospective cohort of patients with influenza-like illness within the MHS. Participants between 18 and 65 years of age were identified in outpatient settings between 2012 and 2017, and were excluded if pregnant, if reporting chronic cardiac, respiratory, renal, or neurologic disease, or if on long-term aspirin therapy. Demographics, nasopharyngeal swabs and symptom data were collected; swabs were tested for viral pathogens using a target-enriched multiplex PCR panel (TEM-PCR(TM), Diatherix LLC). Data were analyzed to compare clinical features and risks for hospitalization. RESULTS: 397 participants met inclusion criteria. 34 participants required hospitalization; 363 were outpatients. Median length of hospitalization was 2 days. A virus was identified in 58.4% of outpatients (OP) and 55.9% of inpatients (IP); coronaviruses (63/363), enteroviruses (50/363), and influenza A (73/363) predominated in OP, whereas influenza A predominated among IP (35.3%, 12/34). There were no significant differences between OP and IP in terms of age, gender, ethnicity, or tobacco use. IP were more likely to be obese (BMI ≥30, 43.3% vs. 20.5%, P = 0.004) and less likely to have received influenza vaccination (45.5% vs. 16.9%, P > 0.001). IP with influenza did not report more severe symptoms (chills, cough, sore throat, diarrhea, myalgia, or headache) on enrollment but were more likely to have fever (temperature ≥38.0⁰ C) than OP (92.9 vs. 57.1%, P = 0.014). CONCLUSION: Influenza A is the most frequently identified cause of hospitalization among healthy, non-elderly adults with viral respiratory infection. Although age and tobacco use may be risks for viral acquisition, they ...

Travelers are at risk for arbovirus infection. We prospectively enrolled 267 Department of Defense beneficiaries traveling to chikungunya-outbreak regions in the Americas between December 2013 and May 2015 and assessed travel characteristics and serologic exposure to chikungunya virus (CHIKV) and dengue virus (DENV). Ten ill-returning travelers were also assessed retrospectively. Self-reported mosquito exposure was common (64% of 198 evaluable travelers saw mosquitoes; 53% of 201 reported ≥ 1 bite). Increased exposure was associated with active-duty travelers (odds ratio [OR] = 2.6 [1.3–5.4] for seeing mosquitoes) or travelers visiting friends and relatives (VFR) (OR = 3.5 [1.0–10.0] for high-intensity bite exposure). Arbovirus infection was defined as seroconversion on plaque reduction neutralization testing (PRNT) of pre- and posttravel sera. For ill subjects enrolled posttravel, infection was defined by a positive convalescent PRNT and/or a positive reverse transcription polymerase chain reaction for CHIKV or DENV. We identified seven cases of arbovirus infection: four with CHIKV, five with DENV, and two with both. The composite attack rate for CHIKV and DENV infection was 3.7% of 108 evaluable, immunologically naïve, prospectively assessed travelers; there was serologic and/or polymerase chain reaction evidence of arbovirus infection in three of four evaluable (three of 10 total) ill-returning travelers. We identified both symptomatic and asymptomatic cases. Military purpose of travel and VFR travel accounted for five of seven cases. Pretravel counseling is important and should target higher risk groups. Given a shared vector between CHIKV, DENV, and Zika virus (ZIKV), this study can also help guide counseling for travelers to ZIKV-outbreak regions.