bluuebunny/crossref_metadata_2025 huggingface dataset:
980. Drexel Medicine Resident Knowledge, Practices and Attitudes Regarding Pre-exposure prophylaxis (PrEP)
Authors: Mainville Jen E , Gracely Ed , Szep Zsofia
Published: January 2021

Background

Pre-exposure prophylaxis (PrEP) is a highly effective daily oral antiretroviral medication that was approved by the FDA in 2012 and has been shown to reduce the risk of HIV by 95% in real-world studies. Despite this, many healthcare providers are not offering PrEP to their patients who are at risk for HIV.

Methods

We performed a cross-sectional study among Drexel Internal Medicine, Family Medicine, and Obstetrics and Gynecology residents. The survey included questions about experience, knowledge, attitudes toward and barriers to using PrEP. The survey was adapted from previous studies regarding medical providers’ attitudes and knowledge about PrEP (Petroll, 2016; Seifman, 2016; Blumenthal, 2105). A Likert 5-point scale was used for attitude and barriers questions.

Results

Among 143 participants, 80% specialized in Internal Medicine. 43% of participants were in their first year of training and the mean age (+ SD) was 28.8 + 2. 76% reported never initiating a conversation about PrEP with a patient and only 18% reported ever prescribing PrEP to their patients. 92% reported being very or extremely willing to prescribe PrEP to a male with a current male partner known to be HIV positive. Only 43% of residents reported being moderately likely to prescribe PrEP to a patient coming in for a STI exposure. 68% of residents reported their knowledge about PrEP was a major barrier to prescribing PrEP.

Conclusion

We found that most residents have minimal experience with prescribing PrEP, and knowledge was identified as the largest barrier. Additional education and a better understanding of PrEP indications is necessary to ensure eligible PrEP patients have access to this highly effective HIV prevention method.

Disclosures

All Authors: No reported disclosures
982. Formal Education Improves Southeastern United States Primary Care Residents’ Understanding and Attitudes Towards HIV Pre-Exposure Prophylaxis: Results of a Regional Survey
Authors: Weaver Christian D , Mena Leandro A , Ward Lori M
Published: January 2021

Background

HIV pre-exposure prophylaxis (PrEP) has been identified as one of the pillars of the national plan to end the HIV epidemic. Notably, southern states have also been shown to have the lowest PrEP-to-need ratio in the country, and previous work on assessing clinician understanding of and attitudes towards PrEP has mainly focused on in-practice physicians, nurse practitioners, and other clinicians. We aimed to assess the attitudes towards and understanding of PrEP among residents training in programs categorized as primary care in the Southeastern United States.

Methods

Program directors in ACGME approved residency programs in Family Medicine, Internal Medicine, Internal Medicine-Pediatrics, and Obstetrics and Gynecology were asked to distribute an invitation with a link to the survey to their residents during a six week period in May and June 2019. The survey contained questions that assessed demographics, type of program, PrEP awareness, knowledge, attitudes, and formal education Logistic regression was utilized to assess association between formal PrEP education and comfort levels with PrEP and other STI related topics.

Results

We identified approximately 7,574 residents across 247 residencies in 11 states. We received 217 responses to our survey, of which 203 had complete data for analysis. The majority of the sample was 25-29 years old (75%), male (53%), White (46%), and PGY-2 (48%). Twenty-one percent of the sample received formal education on PrEP. After controlling for demographic variables, residents with prior formal PrEP education were more likely to be comfortable taking sexual history from LGBTQI patients, discussing/providing PrEP, discussing PrEP efficacy, discussing PrEP monitoring, side effects, drug resistance, and adherence compared to residents who did not have formal PrEP education (Table 1).

Association Between Formal PrEP Education and Comfort Levels with Discussing PrEP and other STI Related Topics

Conclusion

We found a strong association between formal PrEP education and resident’s confidence in discussing PrEP. Investing in formal resident education programs in the Southern region will be important in achieving the Ending the HIV Epidemic’s goal of reducing new infections by 75% in 5 years and 90% in 10 years.

Disclosures

Leandro A. Mena, MD, MPH, Binx Health (Grant/Research Support)Evofem (Grant/Research Support)Gilead Science (Consultant, Grant/Research Support, Speaker’s Bureau)GSK (Grant/Research Support)Janssen (Grant/Research Support)Merck (Consultant, Grant/Research Support)Roche Molecular (Consultant, Grant/Research Support)SpeedDx (Grant/Research Support)ViiV Healthcare (Consultant, Grant/Research Support, Speaker’s Bureau)
983. Hand Hygiene not only the Motion but the Moments
Authors: Darvish Shahrzad E , Rachoin Jean-Sebastien , Meredith Dennis , Polat Denise , McKnight Jessica , Smith Jes , Hamilton Tracey , Nahra Raquel
Published: January 2021

Background

Hand hygiene (HH) is a paradigm of infection prevention.Often emphasis has been placed on appropriate motion of hand hygiene.The implementation of the 5 moments of HH in clinical practice hindered by the perceived enormous lift of educating healthcare providers.

Hand Hygiene Moments Opportunities

Methods

Retrospective evaluation of education on WHO 5 moments of HH implementation. Other data collected CLABSI, CAUTI, MDR Acinetobacter, MRSA, Clostridium difficile LabID. Education occurred between October and December 2018. Data was collected from January 2018 to December 2019. Baseline 5 Moments of HH was obtained for 3 weeks prior to education as this was newly introduced. Statistical analyses using control charts with testing for special cause variations included all data point before and after education of 5 moments of HH. We used Pearson correlation to assess relation between HAI and HH. 5 moments of HH education was done through direct observation with feedback, traditional lecturing, and computer-based education mandatory to all employees and posters placed in strategic locations through the institution. Determination of patient and hospital zone allowed to streamline the education process. Education on different moments was individualized for each discipline in accordance to its involvement with patients.

Zones by Lay Out

Patient Zone and Hospital Zone

Results

Education increased HH compliance over the 12 months period post intervention. The number of observations per moment per month ranged between 96 and 351 observations most observation opportunities during moment 1 (M1) and 5 (M5).

M1 correlated positively significantly with moment 2 (M2) (P=0.001) moment 3 (M3) (p < 0.001) moment 4 (M4) (p =0,001) but not moment 5 (M5)

M2 correlated positively with M3 (p < 0.001), M4 (p< 0.001) Not M5. M3 correlated positively with M4(p< 0.001) Not M5

No Correlations between CLABSI, CAUTI, CDI, MRSA and M1-M5 or Hand Hygiene.

There is a correlation between the decrease in MDR Acinetobacter incidence and point prevalence and compliance with M1 (p 0.04), M2 (p < 0.001), M3 (p 0.002) and M4 (p 0.028).

Conclusion

Education of 5 moments of HH in a combined effort between infection prevention and front-line staff to identify patient and hospital zone showed an increased adherence to Hand hygiene overtime. Compliance with M 1 was associated with increased compliance with M2, M3 and M4.

Disclosures

Raquel Nahra, MD, Medline sponsored the study (Other Financial or Material Support, Supported financially and provided material)
986. Improvement in Administration of HIV Post-Exposure Prophylaxis in the Emergency Department Following Sexual Assault
Authors: Silva-Nash Jennifer R , Bordelon Stacie , Dare Ryan K , Searcy Sherrie
Published: January 2021

Background

Nonoccupational post exposure prophylaxis (nPEP) following sexual assault can prevent HIV transmission. A standardized Emergency Department (ED) protocol for evaluation, treatment, and follow up for post assault victims was implemented to improve compliance with CDC nPEP guidelines.

Methods

A single-center observational study of post sexual assault patients before/after implementation of an ED nPEP protocol was conducted by comparing the appropriateness of prescriptions, labs, and necessary follow up. A standardized order-set based on CDC nPEP guidelines, with involvement of an HIV pharmacist and ID clinic, was implemented during the 2018-2019 academic year. Clinical data from pre-intervention period (07/2016-06/2017) was compared to post-intervention period (07/2018-08/2019) following a 1-year washout period.

Results

During the study, 147 post-sexual assault patients (59 Pre, 88 Post) were included. One hundred thirty-three (90.4%) were female, 68 (46.6%) were African American and 133 (90.4%) were candidates for nPEP. Median time to presentation following assault was 12.6 hours. nPEP was offered to 40 (67.8%) and 84 (95.5%) patients (P< 0.001) and ultimately prescribed to 29 (49.2%) and 71 (80.7%) patients (P< 0.001) in pre and post periods respectively.

Renal function (37.3% vs 88.6%; P< 0.001), pregnancy (39.0% vs 79.6%; P< 0.001), syphilis (3.4% vs 89.8%; P< 0.001), hepatitis B (15.3% vs 95.5%; P< 0.001) and hepatitis C (27.1% vs 94.3%) screening occurred more frequently during the post period.

Labratory, nPEP Prescription and Follow up Details for Patients Prescribed nPEP

Conclusion

The standardization of an nPEP ED protocol for sexual assault victims resulted in increased nPEP administration, appropriateness of prescription, screening for other sexually transmitted infectious and scheduling follow up care. While guideline compliance dramatically improved, further interventions are likely warranted in this vulnerable population.

Disclosures

Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support)
987. Improving Patient Access to HIV Post-Exposure Prophylaxis with Pharmacist Involvement
Authors: Grossman Katlyn H
Published: January 2021

Background

Appropriate use of post-exposure prophylaxis (PEP) after isolated sexual, injection drug use, or other exposures to HIV is an effective tool to reduce the risk of HIV acquisition. PEP completion rates are low, with literature reporting only 40% of sexual assaulted persons adhering to a full 28-day course. One important barrier to adherence can be access to medications in a timely manner. In the United States, a four week course of PEP costs nearly $4,000 without insurance and can remain unaffordable with high copays and deductibles for patients who are underinsured.

Methods

A pharmacist in the Infectious Disease (ID) clinic was notified of all non-occupational post-exposure prophylaxis (nPEP) cases referred from the Emergency Department for follow up and coordinated benefits investigation, ensured low or no cost medication access, completed medication reconciliation, counseled on PEP adherence, and coordinated filling of same day prescriptions at the hospital based pharmacy. To assess the impact of pharmacist involvement, a retrospective review of nPEP cases over a 6 month period were compared to a 6 month period prior to pharmacist presence in clinic.

Results

16 nPEP cases were seen by a pharmacist compared to 8 nPEP cases seen in the ID clinic without pharmacist involvement. 100% of patients received medications prior to leaving the medical center, compared to 63% of cases filling at the hospital pharmacy prior to pharmacist presence. 25% of patients required an insurance related override in order to access PEP urgently. The average out of pocket cost was $2.25 with maximum total cost being $7.30. Prior to pharmacist involvement, the average out of pocket cost was $475 for complete PEP regimen with a maximum total cost of $3,733.40. 42% of patients completed their entire PEP course and came to follow up appointment after pharmacist involvement, compared to 31% of patients prior to pharmacist presence.

Conclusion

Pharmacist involvement led to a substantial cost savings to patients receiving nPEP. It was also associated with higher capture rates of prescriptions filled at the hospital pharmacy along with a higher rate of PEP completion and follow up.

Disclosures

All Authors: No reported disclosures
988. Overcoming Prescriber Concerns through Successful Access and Affordability of PrEP
Authors: Whelchel Kristen , Zuckerman Autumn , DeClercq Josh , Choi Leena , Rashid Shahristan , Kelly Sean
Published: January 2021

Background

Increasing the number of human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) providers expands PrEP access to more eligible patients and aids in ending the HIV epidemic. Non-prescribers of PrEP have noted perceived financial barriers as a limitation to prescribing. The purpose of this study is to describe the PrEP medication access process and outcomes in patients seen at a multidisciplinary PrEP clinic.

Methods

We conducted a single-center, retrospective, cohort study of patients prescribed PrEP with emtricitabine-tenofovir disoproxil fumarate from a multidisciplinary clinic with prescriptions filled by Vanderbilt Specialty Pharmacy between 9/1/2016 and 3/31/2019. Patient data were gathered from the electronic health records and pharmacy claims data. We evaluated three different time periods: patient initial evaluation to PrEP initiation, prescription of PrEP to insurance approval, and PrEP insurance approval to initiation. Treatment initiation was considered a delay of > 7 days from initial evaluation, and reasons for delay were recorded. Continuous variables are presented as median (interquartile range, IQR) and categorical variables are presented as percentages.

Results

Characteristics of the 63 included patients are in Table 1; most were male (97%), white (84.%), commercially insured (94%) with a median age of 38 years (IQR 29—47). The primary indication for PrEP was men who have sex with men at high risk for acquiring HIV (97%). The median time from initial appointment to treatment initiation was 7 days (IQR 4—8); Figure 1. Treatment delays were observed in 25% of patients and were mostly driven by patient preference (50% of delays). Insurance prior authorization was required in 27% of patients, all of which were approved. Median total out of pocket medication costs for the entire study period were $0 (IQR $0 – $0); Figure 2. Most patients (86%) used a manufacturer copay card.

Table 1 Patient Characteristics

Figure 1 Time to Treatment Initiation

Figure 2 Patient Out of Pocket Cost and Savings

Conclusion

In our cohort of mostly commercially insured men, the majority were able to access PrEP with low out of pocket costs facilitated by manufacturer assistance. Though generalizability beyond this population is limited, these results contradict perceived financial barriers to PrEP access.

Disclosures

All Authors: No reported disclosures
994. Risk for Viral Rebound in the Era of U=U; A CNICS Analysis
Authors: Hansen Blake , Liu Tao , Bazerman Lauri , Drainoni Mari-Lynn , Gillani Fizza S , Cachay Edward , Christopoulos Katerina , Crane Heidi , Kitahata Mari , Mayer Kenneth H , Moore Richard , Napravnik Sonia , Rana Aadia , Rodriguez Benigno , Beckwith Curt
Published: January 2021

Background

The “Undetectable equals Untransmittable (U=U)” HIV prevention campaign is a cornerstone of HIV prevention. However, there are few recommendations to guide patients and providers in U=U implementation and limited data on risk factors for viral rebound among persons eligible for U=U.

Methods

We conducted a retrospective multi-center study using data from the CNICS HIV research network to identify risk factors for viral rebound among persons with established viral suppression [two viral loads (VL) and all VLs of < 200 copies/ul within a one-year period (U=U eligible)]. Demographics, patient-reported outcomes, and longitudinal clinical data from 21,359 persons with HIV were analyzed. To include missing data in the analysis, they were treated as a separate category. The primary outcome of viral rebound was defined as any VL > 200 copies/ul within two years after U=U eligibility. A univariable logistic regression model was conducted to identify predictors of viral rebound. Significant variables (p< 0.05) were included in a multivariable logistic regression model. Predictive values of individual variables were captured by adjusted odds ratios (aORs).

Results

From 2011-2019, 12,150 patients met criteria for U=U eligibility and had two years of follow up data. The median age was 46 (IQR: 38-53); 68% male; 51% were white, 39% black. 1544 (13%) experienced viral rebound during follow-up. Forest plot summaries of univariable and multivariable logistic regression models are in Figures 1&2. In multivariable analysis, Black race (aOR=1.56, p< 0.001); MSM-IDU risk (aOR=1.38, p=0.006); lower QoL score (aOR=1.49, p=0.005); poorer ART adherence (aOR=1.84, p< 0.001); duration of lifetime ART [aOR=1.47 (10+yrs), = 1.37 (5-10 yrs); and = 1.28 (2-5 yrs), p< 0.001]; use of InSTIs after eligibility (aOR=1.60, p< 0.001); current smoker (aOR=1.49, p< 0.001), current amphetamine (aOR=1.83, p< 0.001) or cocaine use (aOR=1.46, p=0.012), were associated with viral rebound. In both analyses, older age was protective against viral rebound.

Figure 1. Summary of Univariate Logistic Regression Model

Figure 2. Summary of Multivariable Logistic Regression Model

Conclusion

We identified multiple risk factors for viral rebound among PWH with viral suppression. Further research is needed to identify synergistic risk factors that increase probability of viral rebound to inform optimal implementation of U=U.

Disclosures

Edward Cachay, MD, MAS, Gilead (Consultant, Grant/Research Support)Merck Sciences (Grant/Research Support) Heidi Crane, MD, MPH, ViiV (Grant/Research Support) Benigno Rodriguez, MD, Gilead (Speaker’s Bureau)ViiV (Speaker’s Bureau)
996. The Potential for Reducing Opioid and Analgesic Prescriptions Via Herpes Zoster Vaccination
Authors: Poirrier Jean-Etienne , Carrico Justin , DeMartino Jessica K , Hicks Katherine A , Stoddard Jeffrey J , Nagar Saurabh P , Meyers Juliana
Published: January 2021

Background

Herpes zoster (HZ), or shingles, is a common neurocutaneous disease caused by the reactivation of latent varicella zoster virus that often includes rash and neuropathic pain that may last for months. Opioids and other analgesics may be prescribed. Recombinant zoster vaccine (RZV) is preferentially recommended for the prevention of HZ in adults aged 50 years and older. This study aimed to assess the impact of RZV vaccination on opioid and other analgesic prescription-related outcomes.

Methods

Estimates of analgesic prescription rates (opioids, benzodiazepines, and other analgesics) among HZ cases were established using Truven claims data from 2012-2018 for adults aged 50 years and older. HZ case avoidance with RZV vaccination was calculated using a previously published cost-effectiveness model. This data was included in a calculator assessing the impact of RZV vaccination on analgesic prescription-related outcomes (compared to no vaccination).

Results

Between 24.4% and 28.0% of HZ cases in the observed claims had at least one opioid prescription, dependent on age group (4.5%-6.5% and 8.6%-19.6% for benzodiazepines and other analgesics, respectively). The mean number of opioid prescriptions per person in each age group with at least one opioid prescription was between 1.7 and 1.9 (1.7-2.3 and 1.7-2.0 prescriptions for benzodiazepines and other analgesics, respectively). Assuming a 1-million-person population and 65% RZV coverage, the calculator predicts RZV vaccination will prevent 75,002 cases of HZ and will prevent 19,311 people from being prescribed at least 1 HZ-related opioid, 4,502 people from being prescribed benzodiazepines, and 12,201 people from being prescribed other analgesics. Additionally, 34,520 HZ-related opioid prescriptions will be avoided (9,413 benzodiazepine prescriptions; 22,406 other analgesic prescriptions).

Conclusion

HZ is associated with high levels of opioid, benzodiazepine, and other analgesic use. Primary prevention of HZ by vaccination could potentially reduce opioid and other medication exposure.

Disclosures

Jean-Etienne Poirrier, PhD, MBA, The GSK group of companies (Employee, Shareholder) Justin Carrico, BS, GlaxoSmithKline (Consultant) Jessica K. DeMartino, PhD, The GlaxoSmithKline group of companies (Employee, Shareholder) Katherine A. Hicks, MS, BSPH, GlaxoSmithKline (Scientific Research Study Investigator, GSK pays my company for my contractual services.) Saurabh P. Nagar, MS, RTI Health Solutions (Employee) Juliana Meyers, MA, GlaxoSmithKline (Other Financial or Material Support, This study was funded by GlaxoSmithKline.)
1001. HIV RNA monitoring after hospitalization for non-HIV-related illness in patients on combination antiretroviral therapy prior to admission
Authors: O’Donnell Paul , Murray Milena M , Kauer Sakhi , Motan Reem
Published: January 2021

Background

Hospitalization presents risk for loss of virologic suppression (VS) in people living with HIV (PLWH) due to issues with combination antiretroviral therapy (cART). cART medication errors or drug-drug interactions with new maintenance medications may lead to loss of VS. Appropriate monitoring of HIV RNA post-discharge to ensure ongoing VS may not occur following non-HIV-related illnesses. The objective of this multi-center study was to describe HIV RNA monitoring and VS in PLWH following hospitalization for non-HIV-related illnesses.

Methods

PLWH at least 18 years old with a CD4 count >200 cells/mm3 on cART prior to admission, hospitalized for 24 hours or more at either of two large, academic medical centers (where they also attended follow-up clinic visits) for a non-HIV-related illness, and that survived to hospital discharge between January 1st 2010 and December 31st 2015 were eligible for analysis. The primary outcome was the presence of an HIV RNA measurement as recommended by national guidelines within 6 months of hospital discharge. Secondary outcomes included the incidence of transient viremia and loss of VS after discharge.

Results

A total of 329 patients were included. The median age was 51 years (interquartile range [IQR] 44-58), 76.6% were male, and 48.3% were African American. The median CD4 count was 484 cells/mm3 (IQR 357-629) and 85.4% (n=281) had an undetectable HIV RNA prior to admission. Among the 97.6% (n=321) of patients with an HIV RNA measurement after hospital discharge, the median time to HIV RNA measurement was 2.4 months (IQR=1.2-4.1) and 86.3% (n=284) had an HIV RNA measurement within 6 months. Among patients who were undetectable prior to admission, transient viremia after discharge occurred in 7.1% (n=20) within a median of 2.5 months (IQR 1.3-4.1) and 4 of these patients lost VS. Three of the four patients with loss of VS were admitted for a non-HIV-related infection and all were on protease inhibitor-based regimens.

Conclusion

HIV RNA monitoring appears to occur according to guideline recommendations in the majority of PLWH after hospitalization for a non-HIV-related illness. Despite the occurrence of transient viremia, loss of VS was rare. Future studies should focus on risk factors for loss of VS.

Disclosures

Milena M. Murray, PharmD, MSc, BCIDP, AAHIVP, Merck (Speaker’s Bureau)
1003. BIC/FTC/TAF Maintains Viral Suppression in Patients with Documented M184V/I Mutations: A Real World Experience
Authors: Chamberlain Nicholas , Brock James B , Mena Leandro A
Published: January 2021

Background

The M184V/I mutation is a common mutation in treatment-experienced patients with HIV and confers high-level resistance to lamivudine and emtricitabine. Our objective is to assess the effectiveness of bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) in a real-world setting in achieving and maintaining viral suppression in patients with documented M184V/I mutations.

Methods

This case series is comprised of treatment-experienced HIV-positive patients with documented historical or newly-identified M184V/I mutations who were placed on BIC/FTC/TAF as a switch strategy or as therapy for patients who had failed a prior regimen. Patients with any resistance to tenofovir or bictegravir were excluded. Our primary outcome was sustained viral suppression at 12 months after initiation of BIC/FTC/TAF.

Results

We included 33 patients (94% black, 52% male, median age 49, range 36-63) with an M184V/I mutation. The majority (91%) showed sustained viral suppression at 12 months of treatment. Non-adherence to medication was the common factor in all three cases of treatment failure. One patient developed an R263K mutation while on therapy, which conferred low-level resistance to bictegravir. There were no other instances of newly-acquired resistance to any of the components of BIC/FTC/TAF.

Conclusion

Our results demonstrate high success rates of BIC/FTC/ATF in achieving and maintaining viral suppression in patients with documented M184V/I mutations who adhere to medications in a real-world setting with a single instance of new treatment-emergent resistance to bictegravir. These findings are congruent with reported sub-group analysis in clinical trial data and support the use of BIC/FTC/TAF in patients with M184V/I mutations.

Disclosures

Leandro A. Mena, MD, MPH, Binx Health (Grant/Research Support)Evofem (Grant/Research Support)Gilead Science (Consultant, Grant/Research Support, Speaker’s Bureau)GSK (Grant/Research Support)Janssen (Grant/Research Support)Merck (Consultant, Grant/Research Support)Roche Molecular (Consultant, Grant/Research Support)SpeedDx (Grant/Research Support)ViiV Healthcare (Consultant, Grant/Research Support, Speaker’s Bureau)
1004. Clinical Decision Support System Alerts for HIV Retention in Care – A Pilot Implementation Research Study
Authors: Leonard Michael , Weber Rachel P , Brunet Laurence , Davis Bernard , Polk Christopher , Thompson Joel Wesley , Fusco Jennifer S , Evans Tammeka , Ferrer Pedro Eitz , Mood Rodney , Fusco Gregory
Published: January 2021

Background

Clinical decision support system (CDSS) alerts may help retain people living with HIV (PLWH) in care. A system of CDSS alerts utilizing the CHORUS™ portal was developed to identify PLWH at risk of being lost to care. To evaluate feasibility for a larger scale study, a before and after implementation research pilot study was implemented in the OPERA Cohort at three clinic sites in a southeastern US city.

Methods

Periods without intervention (before) or with CDSS alerts (after) were followed by 3 months of follow up. The study population consisted of PLWH with ≥ 1 electronic health record entry in the 2 years prior to, or during, the before or after period (Fig 1). To support clinicians through a discrete implementation strategy, alerts warning of suboptimal patient attendance were generated daily for the eligible PLWH at each site; providers or other clinic staff could respond to the alerts (Fig 2). Alerts, responses, and visits (i.e., meeting with provider or HIV lab measurement) were characterized. The proportion of PLWH with ≥ 1 visit in the before and after periods were compared at each site by Pearson’s Chi-square.

Figure 1. Pilot study timeline

Figure 2. CDSS alert criteria and response options

Results

A total of 12,230 PLWH were eligible (sites A: 11,271; B: 733; C: 1,344 PLWH), with > 75% in both the before and after periods. The ratio of alerts to responses was 11.9 at site A (2,245 alerts to 189 responses in 309 days; Fig 3A), and comparatively lower at sites B (756 alerts to 334 responses in 352 days, ratio=2.2; Fig 3B) and C (1,305 alerts to 896 responses in 246 days, ratio=1.5; Fig 3C). Responses to alerts were sporadic at sites A and B and consistent at site C. After the intervention, the proportion of PLWH with ≥ 1 visit stayed the same at site A (46% in both periods; p=0.47), decreased at site B (91% to 80%; p< 0.01), and increased at site C (72% to 81%; p< 0.01).

Figure 3. Alerts and responses over time in (A) Site A, (B) Site B, and (C) Site C

Conclusion

This pilot study was ecological by design: measures of retention in care were compared over two calendar periods, without accounting for changes in study populations, clinic characteristics, and policies in place over time (which could have impacted clinic attendance). Though engagement with the CDSS was suboptimal at some sites, this implementation pilot study has demonstrated the ability to implement a CDSS aimed at identifying at-risk PLWH, while highlighting areas for improvement in future larger scale studies.

Disclosures

Joel Wesley Thompson, MHS, PA-C, AAHIVS, DFAAPA, MHS, PA-C, AAHIVS, DFAAPA, Gilead (Shareholder, Speaker’s Bureau)Janssen (Speaker’s Bureau)Theratechnologies (Speaker’s Bureau)ViiV (Speaker’s Bureau) Tammeka Evans, MoP, ViiV Healthcare (Employee)
1005. Comparison of Weight Changes in Treatment-Naïve, HIV-Infected Patients Receiving Integrase Inhibitor-Based Therapy Versus Protease Inhibitor-Based Therapy
Authors: Howe Zachary , Farmer Eric , Stevens Brooke , Huesgen Emily
Published: January 2021

Background

Recent data regarding integrase inhibitor (INSTI) therapy indicate possible association with weight gain. The incidence and degree of weight gain seems to vary by both patient-specific and regimen-related factors, such as nucleoside reverse transcriptase (NRTI) backbone.

Methods

This was a retrospective chart review of previously ART-naïve Indiana University Health LifeCare Clinic patients who started an INSTI- or PI-based regimens from 1/1/13 to 7/31/19. Adult patients without prior ART exposure receiving an INSTI- or PI-based regimen for at least 10 months were included. The primary objective was weight gain at 12 months after starting ART. Subgroup analyses were conducted by INSTI, PI, or NRTI backbone utilized. Statistical testing included Wilcoxon Rank-Sum Test and Chi Square analyses.

Results

The patient population (N=162) was predominately male and African American with relative immunocompetence, generally achieving viral suppression after 12 months of ART. Patients receiving PI-based therapy were more likely to be Asian American or Hispanic (p=0.04), and to receive a tenofovir disoproxil fumarate (TDF)-based regimen (p=0.0034). No statistically significant difference in weight change was observed between INSTI- and PI-based regimens (median weight gain 5.1 kg vs 3.9 kg, p=0.52). The proportion of obese or overweight patients in the INSTI arm increased significantly as compared to baseline (p=0.00001). Subgroup analyses demonstrated significant increases in weight gain and clinically significant weight gain with tenofovir-based (tenofovir alafenamide and TDF) regimens compared to those with abacavir/lamivudine (p< 0.05).

Primary Objective

BMI Category Changes by INSTI or PI Agent

NRTI Subgroup Analyses

Conclusion

Lack of power makes meaningful interpretation of the results for the primary objective difficult. However, several of the prespecified secondary objectives and subgroup analyses demonstrated clinically significant results related to increased weight gain or BMI category changes with INSTI-, PI-, and tenofovir-based regimens. Checking the patient’s weight at every appointment is considered standard practice at IU Health clinics, but missing values despite qualifying encounters were observed. Further commitment to standardized weighing practices should be a priority at clinics caring for patients living with HIV.

Disclosures

All Authors: No reported disclosures
1007. Criminal Justice Involvement Negatively Impacts Engagement in Treatments for HIV and Opioid Use Disorder in Vietnam
Authors: King Caroline , Cook Ryan , Minh Giang Le , Bart Gavin , Korthuis P Todd
Published: January 2021

Background

People living with HIV (PLWH) and opioid use disorder (OUD) commonly experience criminal justice involvement (CJI). We sought to estimate the impact of CJI on 1) HIV care engagement, 2) antiretroviral therapy (ART) prescription rates, and 3) receipt of medications for opioid use disorder (MOUD), among PLWH and OUD in Vietnam.

Methods

Participants were PLWH enrolled in a 12-month MOUD treatment trial of HIV clinic-based buprenorphine vs. methadone referral in Vietnam. We compared those with CJI (arrest, incarceration, or compulsory “06” drug rehabilitation) during the first 9 months of the study to those with no CJI. To ensure participants with CJI had the opportunity to re-engage in treatment, only those who were released before their 9-month study visit were included; participants still incarcerated at 9 months were excluded. Logistic regression models estimated the association between CJI and HIV care engagement (≥ 1 visit), ART prescription, and receipt of MOUD between 9 and 12 months, controlling for demographics, substance use, past CJI, and HIV history.

Results

At baseline, 234 of 281 participants (83.6%) had a history of arrest/incarceration, and 172 (61.2%) reported prior 06 detention. During their first 9 months of study participation, 14 participants (5.0%) were arrested and 14 participants (5.0%) were sent to compulsory 06 rehabilitation. Being arrested (OR=0.04, 95% CI= (0.007, 0.25)), sent to compulsory 06 rehabilitation (OR=0.08, 95% CI= (0.02, 0.38)), or either (OR=0.07, 95% CI= (0.02, 0.24)), were negatively associated with receipt of MOUD. CJI involvement was also negatively associated with HIV clinic engagement after release (OR=0.20, 95% CI= (0.05, 0.84)). A similar negative association was noted for ART prescription, though it did not reach statistical significance (OR=0.17, 95% CI= (0.03, 1.22)).

Conclusion

Arrest, incarceration, and compulsory 06 rehabilitation negatively impact HIV and OUD care among people with HIV and OUD in Vietnam. Policies that decrease incarceration, and the impacts of incarceration, for people with OUD and HIV may improve care outcomes in Vietnam and elsewhere.

Disclosures

P Todd Korthuis, MD, MPH, Alkermes & Indivior (Other Financial or Material Support, Dr. Korthuis serves at principal investigator for NIH-funded studies that accept donated study medicine from Indivior (buprenorphine) and Alkermes (extended-release naltrexone).)
1010. Effective Management of HIV in Rural Georgia Using Telemedicine
Authors: Lawal Folake J , Rao Arni S R Srinivasa , Vazquez Jose A
Published: January 2021

Background

The increasing incidence of HIV and lack of care in rural areas contributes to the ongoing epidemic. The dearth of specialized health services within remote communities and access of this population to available services poses a challenge to HIV care. Telemedicine (TM) is a potential tool to improve HIV care in these remote communities, but little is known about its effectiveness when compared to traditional (face-to-face) (F2F) care. The objective of this study is to examine the effectiveness of HIV care delivered through TM, and compare to F2F care.

Methods

This is a retrospective chart review of all HIV positive patients who attended either the F2F clinic (Augusta, GA) or the TM clinic (Dublin, GA) between May 2017 to April 2018. Data extracted included demographics, CD4 count, HIV PCR, co-morbidities, dates of clinic attendance, HIV resistance mutations and ART changes. Viral suppression and gain in CD4 counts were compared. T-test was conducted to test differences in characteristics and outcomes between the two groups.

Results

385 cases were included in the study (52.5% black, 82% females, F2F=200, TM=185). Mean CD4 count in the TM group was statistically higher (643.9 cells/mm3) than the F2F group (596.3 cells/mm3) (p< 0.001). There was no statistically significant difference in mean HIV viral load (F2F= 416.8 cp/ml, TM=713.4 cp/ml, p=0.3) and rates of year-round viral control (F2F= 73% vs TM = 77% p= 0.54). 38 patients achieved viral suppression during the study period (F2F= 24, TM =14) with a mean change of -3.34 x 104 vs -1.24 x 104, respectively. The difference in mean change was not statistically significant by Snedacor’s W Statistics. This indicates there was no significant difference between the two populations in terms of mean viral suppression among patients who were otherwise not suppressed before the study period.

Conclusion

To achieve an HIV cure, HIV care is required to extend to rural areas of the country and the world. Through delivery of care using TM, trained specialists can target communities with little or no health care. Moreover, use of TM achieves target outcome measures comparable to F2F clinics. Increase in the use of TM will improve the access to specialty HIV care and help achieve control of HIV in rural communities.

Disclosures

All Authors: No reported disclosures
75. Less is More: A Physician-Driven Quality Improvement Stewardship Initiative to Reduce Excessive Duration of Antibiotic Therapy in Veterans Hospitalized with Community-Acquired Pneumonia
Authors: Monday Lea M , Yazdanpanah Omid , Sokolowski Caleb , Sebastian Joseph , Kuhn Ryan , Kareem Bazzy , Dhar Sorabh
Published: January 2021

Background

The IDSA and American Thoracic Society (IDSA/ATS) Community Acquired Pneumonia (CAP) guidelines recommend 5 days of therapy for clinically stable patients that defervesce, however, duration of therapy (DOT) is often longer. Pharmacists curb this via antimicrobial stewardship (AMS), but budgetary constraints are barriers to robust AMS programs in some hospitals. Physicians are increasingly encouraged to participate in quality improvement (QI) and are a potential resource to improve AMS. We sought to determine the impact of a prospective, physician-driven stewardship intervention on DOT and clinical outcomes in hospitalized veterans with CAP, with the goal to reduce the median DOT by at least 1 day within 5 months.

Methods

This single center, quasi-experimental QI study evaluated two concurrent physician-driven interventions over a 5-month period in an inner-city Veterans Affairs Hospital. Using DMAIC (Define, measure, analyze, improve, and control) methodology, the Chief Resident in Quality and Safety (CRQS) provided monthly education and daily audit and feedback with patient-specific DOT recommendations. Clinical outcomes were followed until 30 days post discharge.

Results

A total of 123 patients with CAP were included (57 in the historic control group and 66 in the AMS intervention group). The AMS intervention significantly increased the proportion of CAP patients treated with a 5-day treatment course (56% versus 5.3%, p< 0.0001), and reduced the proportion of patients treated beyond 7 days (12.1% versus 70.2%, p< 0.0001). Median DOT per patient was reduced significantly (5 versus 8 days, p< 0.0001). Median excess antibiotic days were significantly reduced (0 versus 3, p< 0.0001) and 118 days of unnecessary antibiotics were avoided (62 versus 180). 30-day all-cause mortality, all-cause readmission, and Clostridium difficile infection were similar between groups. Median LOS was similar between groups (p=0.246).

DOT in the Historic Control Group Versus Stewardship Intervention Group

Conclusion

A physician driven QI stewardship intervention in hospitalized CAP patients significantly reduced the total antibiotic DOT and excess antibiotic days without adversely affecting patient outcomes. Providers can be educated through physician driven interventions resulting in substantial improvements in appropriate antibiotic use.

Disclosures

All Authors: No reported disclosures
1014. Factors Associated with Switching from Tenofovir Diproxil Phosphate to a Tenofovir Alafenamide Based Regimen in a Cohort with Unrestricted Access to Care and Medications
Authors: Ganesan Anuradha , Won SeungHyun , Ewers Evan C , Bradley William , Schofield Christina , Utz Gregory , Colombo Rhonda , Blaylock Jason M , Lalani Tahaniyat , Kronmann Karl , Okulicz Jason , Maves Ryan C , Agan Brian
Published: January 2021

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 on efavirenz-containing regimens were less likely to switch to a TAF-based regimen, possibly due to the lack of a co-formulated single tablet. These trends need to be followed and barriers to switching to TAF (both patient and provider) need examination.

Table 1- Factors associated with switching to a Tenofovir Alafenamide Based Regimen

Disclosures

All Authors: No reported disclosures
1017. Haves vs. Have-Nots in Healthcare Communication: Examining the Paradox Where PLHIV Who Need Quality Discussions with their Providers the Most, Access it the Least
Authors: Rios Patricia De Los , Young Benjamin , Muchenje Marvelous , Van de Velde Nicolas , Okoli Chinyere
Published: January 2021

Background

Quality communication between patients & HCPs is important to help to identify/address treatment gaps. Who initiates this communication may vary, but impact of good quality communication as a marker of successful care has not been fully explored in PLHIV. We investigated whether perceived comfort discussing salient issues with HCPs differed between PLHIV with vs without specific treatment challenges.

Methods

We analyzed self-reported data for 520 PLHIV from the 2019 Positive Perspectives study from Canada and USA. Engagement in care (low, moderate, high), was modified from the Observing Patient Involvement scale. Using Chi-squared tests, we compared communication barriers among those uncomfortable discussing with their HCP (p< .05).

Results

Mean age was 39.6 years. Perceived comfort discussing salient issues with HCPs was significantly lower among PLHIV with than without the specified challenges: discussing side effects (those experiencing side effects=50.4%[135/268] vs without=60.7%[153/252], p=.018); discussing privacy concerns (those hiding medications=41.3%[138/334] vs not hiding =66.7%[124/186], p< .001); discussing adherence challenges (those with suboptimal =42.4%[78/184] vs optimal adherence=57.7%[194/336], p=.001); discussing concerns about HIV illnesses (those without viral suppression=43.1%[90/209] vs virally suppressed=64.6%[201/311], p< .001); and discussing impact of HIV on their life (45.4%[100/220] vs 62.7%[188/300] among those reporting vs not reporting that HIV negatively impacts their life, respectively, p< .001). Among those uncomfortable discussing HCP/clinic-related barriers (eg, no time during visits, worried HCP might perceive them as “difficult”) and limited self-efficacy were particularly more prevalent among those with vs without specific challenges (Figure 2). Pooled analysis showed that optimal self-rated health was 33.9%[42/124]; 52.1%[112/215]; and 68.5%[124/181] among those with low, moderate, & high engagement (p< .001, Figure 3).

Figure 1

Figure 2

Figure 3

Conclusion

Individuals uncomfortable discussing issues with their HCP reported greater treatment challenges. Proactive HCP-driven high-quality communications with all patients is necessary to help address these concerns.

Disclosures

Patricia De Los Rios, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Benjamin Young, MD, PhD, ViiV Healthcare (Employee) Marvelous Muchenje, BSW, MSc. in Global Health, ViiV Healthcare Canada (Employee) Nicolas Van de Velde, PhD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Chinyere Okoli, PharmD, MSc, DIP, ViiV Healthcare (Employee)
76. Optimizing Clinical Outcomes in Geriatric Patients through a Multidisciplinary Hospital Antimicrobial Stewardship Program
Authors: Mauro James , Kannangara Saman , Tuma Roman A
Published: January 2021

Background

Antimicrobial Stewardship Programs (ASP) aim to ensure the appropriate use of antibiotics. There is limited literature evaluating ASP outcomes in hospitalized geriatric patients who are at higher risk for developing Clostridium difficile infection (CDI) or other adverse outcomes. The primary objective of this study was to determine if ASP efforts in this age group decreases the rate of 30-day hospital readmissions due to reinfection or development of CDI, hospital length of stay (LOS) and mortality.

Methods

A retrospective chart review was performed to compare the rates of 30-day hospital readmissions because of reinfection or development of CDI in patients 65 years and older who received ASP interventions between January and June 2017. A control group of patients 65 years and older who received antibiotics between January and June 2015 (pre-ASP) was analyzed for comparison. We also assessed their mortality rate and LOS. Patients were included if they received antibiotics for pneumonia (PNA), urinary tract infection (UTI), acute bacterial skin and skin structure infection (ABSSSI) and complicated intra-abdominal infection (cIAI). The ASP team consisted of an infectious diseases physician and a clinical pharmacist who met daily to review patients on broad spectrum antibiotics. ASP interventions consisted of de-escalation of empiric or definitive therapy, change in duration of therapy or discontinuation of therapy.

Results

Overall, 834 patients (540 control; 294 intervention) were included. The 30-day hospital readmission rate for all infection types decreased during the intervention period (19.6% vs 4.8%, P=0.0001). Both the development of CDI during hospital stay and 30-day readmission due to CDI during the intervention period decreased (2.6% vs 0.34%, P=0.019). There was no statistically significant decrease in 30-day hospital readmissions in the PNA (58.5% vs. 35.7%, P=0.11), UTI (18.9% vs. 35.7%, P=0.15), ABSSSI (12.3% vs. 21.4%, P=0.34) or cIAI (10.4% vs 7.1%, P=0.14) arms. There was no statically significant change in LOS (7.50 days vs 7.26 days, P=0.48) or mortality (9.6% vs 6.5%, P=0.12).

Conclusion

Multidisciplinary ASP efforts significantly reduced 30-day hospital readmission rates and development of CDI in hospitalized patients 65 years and older.

Disclosures

All Authors: No reported disclosures