bluuebunny/crossref_metadata_2025 huggingface dataset:
1254. Association of Structural Stigma Due to Sexual Orientation and HIV Diagnosis/PrEP Use in the United States: An Ecological Analysis
Authors: Tran Nguyen K , Goldstein Neal
Published: October 2019

Background

Structural stigma has the potential to reduce engagement in HIV prevention and care, particularly for sexual and gender minorities (SGM) who account for the highest proportion of new HIV diagnosis in the United States. We considered if structural stigma related to sexual orientation, that is the social/cultural norms and institutional policies/practices that constrain the lives of the stigmatized, is associated with state-level HIV diagnosis and use of pre-exposure prophylaxis (PrEP).

Methods

We used a composite measure of structural stigma that was previously developed; components included proportion of same-sex couples, gay-straight alliances in public schools, policies related to discrimination of sexual orientation, and public perception toward homosexuality. Proportion of HIV diagnosis from 2008 to 2017 and PrEP use from 2012 to 2017 per 100,000 population were extracted from AIDSVu. To account for overdispersion and the hierarchical structure of our data, we used a Poisson model with robust standard errors using generalized estimating equations.

Results

States with higher (vs. lower) levels of structural stigma related to sexual orientation had lower rates of HIV diagnosis (β = −0.550; 95% CI: −0.628, −0.472) and PrEP use (β = −0.165; 95% CI: −0.203, −0.119), after adjusting for state-level covariates such as median age, percentage black race, and legislative majority party in 2013.

Conclusion

State-level stigma has been shown to reduce SGM visibility, therefore, restricting access to prevention services. These findings suggest that states with higher levels of structural stigma toward same-sex sexuality may also have lower rates of engagement in HIV prevention services.

Disclosures

All authors: No reported disclosures.
1256. Contemporary Evaluation of Racial/Ethnic Disparities in Survival and Disease Progression among People with HIV in the US Midwest
Authors: Khazanchi Rohan , Sayles Harlan R , Bares Sara H , Swindells Susan , Marcelin Jasmine R , Marcelin Jasmine R
Published: October 2019

Background

Combating HIV-related disparities is a major goal of the 2020 National HIV/AIDS Strategy. However, research on HIV disparities has primarily been conducted in urban settings. A 1997–2007 study of people with HIV (PWH) at our clinic noted significantly increased mortality among high-risk non-Hispanic (NH) Black PWH (73%) compared with NH Whites (88%). This study evaluated demographic disparities in survival and disease progression in a large Midwest clinical cohort.

Methods

We retrospectively reviewed records of 1,396 PWH receiving treatment at an HIV Clinic in Omaha, Nebraska from 2012 through 2017. We included patients over 19 years old with diagnosed HIV, a minimum of two visits, and no lapse in care >2 years. Patients were stratified into low-risk (CD4 >100 cells/mm3 and HIV viral load <250,000 copies/mL) and high-risk (all others) groups. Cox proportional hazard models and Kaplan–Meier curves with log-rank tests compared patient demographics and mortality. Generalized estimating equations modeled change in CD4 count over time.

Results

No significant difference in mortality was noted across race/ethnicity categories (P = 0.286). Several clinical and demographic characteristics, including CD4 counts <500 cells/mm3, were significantly associated with increased mortality (Figure 1). Compared with NH Whites, mean CD4 counts (Figure 2) were significantly lower for NH Blacks (P = 0.001), Hispanics (P = 0.006), and Others (P = 0.013). High-risk status was associated with mortality (P < 0.001), but no significant differences in mortality were noted across race/ethnicity categories after stratifying for patient risk status (Figures 3 and 4).

Conclusion

Significant racial/ethnic disparities in HIV disease progression among PWH at a Midwest HIV Clinic persist. However, in contrast to the 1997–2007 study, disparities in survival were not observed among high-risk PWH. As our patient demographics are essentially the same, the reduction of this disparity suggests needed investigation of whether these changes are the result of better antiretroviral efficacy or if social determinants of health in the region have improved. Systems-level interventions are needed to ensure all PWH benefit from continuing advances in HIV research and care.

Disclosures

All authors: No reported disclosures.
1268. Clinic Screening for Adverse Childhood Experiences among Persons with HIV: A Pilot Project
Authors: Anand Priyanka , Carter Bryce , Bronstein Abby , Schwartz Alexis , Harrington Brittney , Wilson Jennifer , Metzger David , Short William R , Torgersen Jessie
Published: October 2019

Background

Childhood trauma has long-lasting implications for adult health as prior work in the general population linked ≥4 adverse childhood experiences (ACEs) to multiple negative health outcomes in adulthood. History of childhood trauma is prevalent in people living with HIV (PLWH); however, screening for history of childhood trauma is not routinely performed in HIV clinical care.

Methods

We conducted a single-center, cross-sectional quality improvement pilot project to (1) define the prevalence of ACEs in PLWH engaged in care and (2) improve linkage with mental health resources. We hypothesized the prevalence of ≥4 ACEs in PLWH would be >21%, the prevalence previously reported in the local, general population. Patients were approached in the course of routine clinical care at an urban, academic HIV outpatient clinic between October 2018 and April 2019 and offered screening for ACEs, depression, and post-traumatic stress disorder (PTSD) using previously validated tools.

Results

Forty-nine patients completed the screening. Median age was 48 years [IQR: 37–55]; 69% were male and 53% were gay or bisexual. Most patients identified as black/African American (75%) and white (12%). Median ACEs score was 4 [IQR 1–6], with 51% (95% CI: 36–66%) reporting ≥4 ACEs (Figure 1), and most common ACE being guardian substance abuse (57%) (Figure 2). When compared with men, women had a higher median ACEs score (5 vs. 3, P = 0.04), history of childhood sexual abuse (67% vs. 26%, P <0.001), parent incarceration (53% vs. 24%, P = 0.04), and parental divorce or separation (73% vs. 41%, P = 0.04). Patients with ≥4 ACEs were more likely to have positive PTSD screens (56% vs. 21%, P = 0.02), moderate depression or greater (37% vs. 11%, P = 0.002), and were more likely to accept on-site mental health referral after screening (36% vs. 8%, P = 0.04). Acceptability of screening was deemed “very good” by patients, with median acceptability score 5 [IQR: 4–5] on a 5-point scale.

Conclusion

Over half of HIV+ patients screened in our clinic reported ≥4 ACEs, more than twice the prevalence of the general population. ACEs screening facilitated linkage of patients with high ACEs scores to mental healthcare. These results highlight the potential value of routine ACEs screening to enhance delivery of trauma-informed HIV primary care.

Disclosures

All authors: No reported disclosures.
1271. Pre-Exposure Prophylaxis (PrEP) Awareness and Uptake Between Men Who Have Sex with Men and Men Who Have Sex with Men and Women
Authors: Tao Jun , Montgomery Madeline , Sosnowy Collette , Nunez Hector R , Sowemimo-Coker Genoviva , Chu Christina , Nunn Amy , Chan Philip , Chan Philip
Published: October 2019

Background

Men who have sex with men are disproportionately impacted by HIV in the United States and may benefit most from pre-exposure prophylaxis (PrEP). However, differences may exist between men who only have sex with men (MSM) and men who have sex with both men and women (MSMW). MSMW may experience more barriers to accessing PrEP and may act as a potential bridge population for transmitting HIV to female sex partners. Differences in PrEP awareness and use between MSM and MSMW are unknown.

Methods

We evaluated all MSM and MSMW presenting to the Rhode Island Sexually Transmitted Diseases (STD) clinic and PrEP clinic from 2013–2017. Demographics and behavioral information were reviewed. Bivariate analyses were performed to present distributions of demographic and behavioral characteristics by sexual behavior. Logistic regression was conducted to explore associations between PrEP awareness/use and sexual behavior. Confounding variables were identified using the directed acyclic graphs (DAGs) and a priori.

Results

Of 1,795 male individuals, 84% (1,504) were MSM, and 16% (291) were MSMW. The median age of our study population was 29 (interquartile range [IQR]: 23–42). When compared with MSM, MSMW were more likely to be non-White (33% vs. 28%), uninsured (54% vs.46%), self-report more sexual partners in the past 12 months (median 6 [IQR: 3–9]: vs. 4 [IQR:2–10]), use intranasal cocaine (21% vs. 12%), and engage in selling (6% vs. 2%) or buying sex (12% vs. 4%, all P < 0.05). MSMW were also less likely to have a previous HIV test (77% vs. 89%) compared with MSM. MSMW were 59% (adjusted odds ratio [aOR]: 041, 95% confidence interval [CI]: 0.31–0.55) less likely to be aware of PrEP and 17% (aOR: 0.83, 95% CI: 0.41–1.66) less likely to report ever using PrEP after adjusting for age, race/ethnicity, and self-reported HIV risk.

Conclusion

Despite engaging in higher risk behaviors, MSMW were significantly less likely to be aware of or use PrEP compared with MSM. Future PrEP interventions are needed to target this potentially high-risk bridge population.

Disclosures

All authors: No reported disclosures.
1273. Reasons for Disengagement in Care among Individuals Receiving Pre-Exposure Prophylaxis (PrEP) from a Sexual Health Clinic
Authors: Zucker Jason , Theodore Deborah , Carnevale Caroline , LaSota Elijah , Richards Paul , Gordon Peter , Cohall Alwyn , Sobieszczyk Magdalena
Published: October 2019

Background

Pre-exposure prophylaxis (PrEP) effectively reduces HIV acquisition, but its efficacy depends on continued engagement through periods of high and low risk. Persistence in HIV prevention care has been low in real-world settings. In our program, 32% of patients are lost to care after their first visit and only 35% of patients are retained at their planned third visit. Reasons for low persistence in care are poorly described.

Methods

We identified all MSM who started PrEP between July 2015 and June 2018 at a sexual health clinic in an urban academic medical center in New York and had not had a visit in ≥6 months. We called patients between July 2018 and January 2019; those who were English speaking were given the option to complete an online questionnaire about current PrEP status, reasons for disengagement, and social and behavioral determinants of health (SBDH).

Results

Up to 710 patients were eligible for the study; over 700 calls were made. 125 participants agreed to participate and 57 (46%) completed the questionnaire. 24 patients (42%) were still actively taking PrEP. The most common reasons for starting PrEP were fear of getting HIV (58%), high self-perceived HIV risk (28%), and recommendations from friends (26%). Among those no longer taking PrEP, the most common reasons for discontinuation were cost/insurance issues (32%), lower perceived HIV risk (18%), concern about long-term side effects (12%), and trouble attending every-3-month appointments (12%). For those stopping due to lower perceived risk, 40% were in a monogamous relationship, 60% were less sexually active, and 20% always used a condom or did not engage in receptive anal intercourse. 56% of patients had at least 1 major life event in the preceding 3 months, including loss of a job (25%), breakup with a partner (12%), illness or death of a family member (11%), or unstable housing (8%). 47% used drugs or alcohol before sex in the past month including 39% not on PrEP.

Conclusion

Reasons for engagement, disengagement, and re-engagement are highly variable at the individual level. Cost and insurance issues were common in spite if clinic resources available to cover the cost of visits and medications. Life trauma was common. Individualized interventions to address SBDH may be required to engage and retain individuals in HIV prevention care.

Disclosures

All authors: No reported disclosures.
1278. Assessing Statewide HIV Pre-exposure Prophylaxis Implementation Using an All Payer Claims Database
Authors: Nocka Kristen , Raifman Julia , Crowley Christina , Galárraga Omar , Wilson Ira , Tao Jun , Chan Philip , Chan Philip
Published: October 2019

Background

Pre-exposure prophylaxis (PrEP) in the form of daily tenofovir disoproxil fumarate (TDF/FTC) is a potentially transformative tool to prevent HIV infection. However, PrEP scale-up in the United States has been slow and difficult to evaluate comprehensively. All payer claims databases (APCDs) are large datasets that contain information on medical and pharmaceutical claims from most public and private payers in each state, and provide an unusual opportunity to evaluate statewide PrEP implementation efforts.

Methods

We used 2012–2017 data from Rhode Island’s APCD and developed an algorithm to identify individuals prescribed TDF/FTC for PrEP. We compared APCD PrEP data to electronic medical record (EMR) data at the largest dedicated PrEP program in the state, and to other comprehensive pharmaceutical claims data (AIDSVu.org). We calculated the PrEP-to-Need ratio (PnR) based on annual HIV incidence, and used multivariable logistic regression to predict ZIP code-level PrEP use, and specialty of prescribing provider (primary care vs. infectious disease).

Results

The Rhode Island APCD included insurance claims for 917,633 individuals (87% of the Rhode Island population). PrEP use increased substantially in Rhode Island over the 5-year period, from 13 to 331 prescriptions between 2012 and 2017, with 546 total users during this time period. Users were predominantly male (89%) and privately insured (69.1%), and concentrated in Providence County (71.5%). The PnR ratio increased from 0.2 to 4.0 from 2012–2017. Compared with AIDSVu and EMR Data, the APCD underestimated the number of PrEP users in Rhode Island, but improved over time in documenting users. Infectious diseases specialists had 8.4 times the odds (95% CI: 5.4 to 12.9) of being a PrEP prescriber compared with primary care providers. A total of 2.6% of infectious disease specialists were PrEP prescribers compared with 0.33% of PCPs. The proportion of Black or Hispanic individuals in a ZIP-code was not a significant predictor of PrEP use.

Conclusion

APCDs offer an innovative approach to evaluate statewide PrEP implementation comprehensively. Engaging PCPs in PrEP implementation is critical to improve overall uptake among populations most at-risk.

Disclosures

All authors: No reported disclosures.
1279. Barriers to Acquiring Pre-Exposure Prophylaxis (PrEP), Risk Factors for HIV and Health Determinants in Adult Transgender Individuals
Authors: Sanchez Daniel , Conklin Jessica , Borrego Matthew , Newsome Cheyenne , Mercier Renee C
Published: October 2019

Background

Transgender women face many health disparities including higher rates of acquiring Human Immunodeficiency Virus (HIV). The prevalence of HIV in the transgender population is 14.1% with 31% of this population engaging in sex work. PrEP is an effective method to prevent HIV acquisition. With transgender women among the highest risk in acquiring HIV, this study aimed to describe the transgender population while identifying risk factors for acquiring HIV and barriers transgender females face in acquiring PrEP.

Methods

An IRB approved, cross-sectional study utilized an electronic questionnaire administered to 54 people at a community resource center who specializes in the care for transgender individuals between January and April 2019. Using a pre-questionnaire survey, participants were eligible for inclusion if they were deemed at high risk for acquiring HIV. A second survey was given to those who were deemed high risk and met the inclusion criteria ( ≥18 years old). Survey questions inquired about the individuals’ high-risk behaviors, social determinants of health and knowledge about PrEP. Descriptive statistics were used for data analysis.

Results

Of the 54 participants, 51 individuals met inclusion for enrollment. Two of the enrolled people were excluded due to incomplete surveys. Of the 49 individuals who completed the study, 43 of the participants had a gender identity other than their assigned sex. Nearly half of the people in this study were American Indian. Over 60% of the cohort had sex for money or other goods. Depression was reported by 71% of participants while homelessness by 59%. Approximately 69% were aware of PrEP however 70.8% had never taken PrEP. When asked about HIV risk, 41.7% felt that they were not at risk for HIV and chose not to take PrEP. Lack of self-awareness of HIV risk factors was the predominant barrier to PrEP.

Conclusion

This is, to the best of our knowledge, the first study to describe a significant proportion of transgender individuals of American Indian heritage who are at high-risk for HIV. Participants were aware of PrEP however despite high-risk behaviors they underestimated their risks and few took PrEP. Negative health determinants were reported in the majority of participants.

Disclosures

All authors: No reported disclosures.
1285. PrEP Acceptability, Uptake, and Adherence Among Young Men Who Have Sex with Men and Transgender Women in PrEP Demonstration Project, Chiang Mai, Thailand
Authors: Kaewpoowat Quanhathai , Saokhieo Pongpun , Songsupa Radchanok , Supindham Taweewat , Chariyalertsak Suwat
Published: October 2019

Background

Young men who have sex with men (YMSM) and transgender women (YTGW) are at high risk for HIV acquisition. In attempt to end the HIV epidemic, the comprehensive HIV prevention packages should be offered. However, the PrEP persistent among this population in western studies was low. The acceptability, uptake and persistent among Thai YMSM/YTGW PrEP clients were explored.

Methods

This is a sub-study of PrEP implementation project in Chiang Mai Thailand which was conducted during December 2015–February 2017. In the main study, PrEP@PIMAN, 105 participants who were 18 years and older, able to read and write in Thai, creatinine clearance ≥60 mL/minute, negative urine protein, and HBs-Ag-negative YMSM/YTGW were enrolled. Twelve months of PrEP along with quarterly visit and comprehensive HIV prevention package were offered. The data were collected through interview and computer-assisted self-interview. Each participant voluntary made their own decision about PrEP uptake.

Results

Sixty participants (57% of the main study) were youth, aged 16–24 years old. Of those, 82% were gay men and 12% were TGW (self-identified). Mean age was 21 years old and 80% were university/college students. At baseline, median partner in past 3 month was 3 (range 0–52). Approximately one-fourth of the participants reported history of sexually transmitted diseases (STDs) and 8% has positive TPHA at baseline. Majority (72%) initiated PrEP with 70% at the enrollment 2% during the study. PrEP was discontinued in 25% (10/42) due to nonserious side effects, participant preference or lost to follow-up (see Figure 1). The retention rate at 12 month were 70%. PrEP use was not consistent (see Figure 2). Only 30% reported adherence ≥60% (or equivalent to ≥4 pills/ week) throughout the study period. There was no seroconversion during 49 person-year of follow-up with 5 confirmed new STDs (incidence of 10/100 person-year).

Conclusion

This project demonstrated a good uptake with varying PrEP adherence rate among Thai YMSM and YTGW. The PrEP persistent was persistence could be improved. Further interventions and strategies should be explored to enhance PrEP adherence among this population.

Disclosures

All authors: No reported disclosures.
1295. Mortality of Patients with HIV Infection Admitted to the Intensive Care Unit: A 16-Year Experience
Authors: Rosso Fernando , Marcela Martínez-Ruiz Diana , Castro Andres , Parra-Lara Luis Gabriel , Andrés Hoyos Jorge , Tovar Daniela , Granados Marcela
Published: October 2019

Background

The life expectancy of HIV patients has increased with antiretroviral therapy which has reduced the incidence of AIDS-associated illnesses. Longer life expectancy increases noncommunicable diseases cases and the demand for intensive care unit (ICU) care. ICU mortality is higher among HIV patients. Information about mortality and other relevant outcomes among HIV patients from developing countries is paramount for benchmarking purposes. This study aimed to evaluate the mortality of patients with HIV/AIDS admitted to the ICU during the years 1999 to 2015.

Methods

An observational retrospective study was conducted based on episodes of patients admitted to the ICU of the Fundación Valle del Lili from December 1998 to October 2015. The Cochran-Armitage test was used to evaluate the trend of HIV mortality by 4-year periods, considering sex and age groups ( <50 vs. >50 years). The Z test compared the mortality between HIV patients with non-HIV patients in the ICU; also it compared the mortality in HIV patients by sex and age group.

Results

A total of 53,798 episodes of ICU admissions were analyzed, 0.76% (414) were HIV patients, and of this 78.5% were men. Twenty-three percent were over 50 years old. Overall mortality in the ICU was 9.13%, and the mortality in HIV patients was 22.03%, which was higher when compared with a non-HIV group (9%, P < 0.001). Mortality due to HIV had a statistically significant decreasing trend (P < 0.001), going from 40% between 1999 and 2003 to 18.04% between 2012–2015, this trend was observed among men with HIV (P < 0.001) starting with 43. 5% and ending at 20%, but among women the decreasing trend was not statistically significant (P = 0.62). Mortality for HIV decreased, in the <50 years group: it went from 38. 3% to 18. 6% (P = 0.0003). Furthermore, in patients 50 years and older group mortality went from 50% to 17.9% (P = 0.025). During period 2008–2011, patients 50 years and older had more mortality compared with <50 years group (P = 0.019), but there were no differences by sex in any period.

Conclusion

This study found a statistically significant trend for mortality decrease over a 16-year period among HIV patients admitted to an ICU from a developing country.

Disclosures

All authors: No reported disclosures.
1307. Virologic Failure in HIV-Infected Men Who Have Sex with Men and Transgender Women Treated in a Community-Based Model vs. a Hospital-based Model
Authors: Brito Maximo O , Khosla Shaveta , Mehta Supriya D , Novak Richard M
Published: October 2019

Background

Men who have sex with men (MSM) and transgender women are disproportionately affected by HIV, especially those that belong to minority groups and lower socioeconomic status. The purpose of this study was to compare virologic failure in MSM and transgender women receiving HIV care at a community-based model (CBM) to a hospital-based model (HBM) of care.

Methods

This was a retrospective cohort study. We extracted data from electronic medical records of HIV-infected MSM and transgender women treated at one of the six community clinics or at a hospital-based clinic in Chicago between 2010 to 2014. The outcome was cumulative probability of virologic failure (i.e., viral load ≥200 copies/mL), measured in each semester of observation. We used multivariable Cox Proportional Hazards model to determine the association between CBM and HBM with virologic failure, adjusted for confounding variables.

Results

The sample consisted of 290 patients; of whom, 20 (7%) were transgender. Approximately half (49%) of the sample received care via CBM. Compared with patients receiving care at the HBM, CBM patients were more likely to be African American (72% vs. 61%), uninsured (50% vs. 39%) and with a history of substance abuse (38% vs. 24%). There was no difference in virologic failure between the two care models (57% in CBM vs. 52% in HBM; HRadj = 1.1; 95% CI: 0.8–1.6). Younger individuals (HRadj = 4.0; 95% CI: 2.3–7.1), alcohol users (HRadj = 1.6; 95% CI: 1.1–2.2) and patients without insurance (HRadj = 1.7; 95% CI: 1.1–2.6) were more likely to have virologic failure.

Conclusion

The CBM was as effective as a traditional HBM in providing care to MSM and transgender women despite their more marginalized status. Intensive outreach and targeted case management likely contributed to the effectiveness of this model and need further study.

Disclosures

All authors: No reported disclosures.
1310. The Impact of Recent Incarceration on Post-Release HIV Linkage to Care and Risk-Taking Behaviors in the Setting of Enhanced Linkage to Care Policies in Florida
Authors: Teo Greg Matthew E , Nagaraj Suraj , Sunku Nisha , Aslam Sadaf , Mhaskar Rahul , Chen Liwei , Zhou Zhi , Cook Robert L , Morano Jamie P , Somboonwit Charurut
Published: October 2019

Background

The United States has the largest incarcerated population in the world with 6.61 million adults in 2016.1 While incarceration is a known risk factor for difficulties in linkage to care2–3 and adverse health outcomes4–6, little is published on post-release incarcerated persons living with HIV (PLWH) in Florida.

Methods

Data were acquired from the Florida Cohort, an ongoing, longitudinal, cross-sectional study of PLWH recruited across HIV clinics in the state of Florida, from 2014 to 2018. Chi-square and multiple regression analyses correlated recent incarceration (within last 12 months) with demographics, HIV care adherence, perceived barriers to care, and self-reported high-risk behaviors.

Results

Of 936 participants, 6.4% (n = 60) reported recent incarceration within the last 12 months. Those recently incarcerated were more likely to report missing at least one appointment in the last 6 months (46.7% vs. 22.2%; P < 0.0001), to have an excessively long travel time ( >60 minutes) to a HIV provider (34.5% vs. 16.6%, P = 0.002; OR 2.66 [95% CI: 1.20–5.92]), and to lack reliable transportation (70% vs. 47.5%, P = 0.0007; OR 1.70 [95% CI: 0.82–3.52]) Those not recently incarcerated reported having completed a high school education (OR: 0.69 [95% CI: 0.5–0.97]) and stated they “never missed an appointment” (OR: 0.42 [95% CI: 0.22–0.81]). Recently incarcerated PLWH also had higher occurrence of high-risk behaviors such as receiving (40.4% vs. 8.7%; P = 0.001) or providing (30.4% vs. 10.4%; P = 0.000) money or drugs for sex, having used IV drugs (15% vs. 4%; P = 0.001), and not using condoms during exchange of drugs for sex (OR: 9.43 [95% CI: 3.78–23.52]).

Conclusion

Recently incarcerated PLWH continue to have significant geographical and logistical barriers to care and self-report more high-risk behaviors than nonincarcerated peers. Enhanced case management and telehealth services may be useful in linkage to care when PLWH transition from correctional to community healthcare systems in the Florida setting.

Disclosures

All authors: No reported disclosures.
1317. Comparison of Access and Linkage to Care Among People Living with Human Immunodeficiency Virus When Enrolled in Florida AIDS Drug Assistance Program (ADAP)
Authors: Teo Greg Matthew E , Sunku Nisha , Nagaraj Suraj , Aslam Sadaf , Mhaskar Rahul , Chen Liwei , Zhou Zhi , Cook Robert L , Morano Jamie P , Somboonwit Charurut
Published: October 2019

Background

The Southeast region of the United States contains nine out of the 10 states with the most severe syndemic of poverty and HIV infection.1 The Florida AIDS Drug Assistance Program (FL-ADAP) and Ryan White network are crucial for linkage to care services. Data from FL-ADAP are available but seldom published; thus this study quantifies this program’s impact on Florida PLWH access and linkage to care.

Methods

Data were obtained from the Florida Cohort, an ongoing cross-sectional survey among health clinics across the State of Florida from 2015 to 2018. Chi-square and binomial multivariate logistic regression analyses correlated anti-retroviral therapy (ART) access and linkage to care stratified by insurance status (ADAP vs. non-ADAP), demographics, and sexual orientation

Results

Of the total 934 PLWH, n = 418 (44.8%) self-reported ADAP participation. Of these, 68.4% were male, 79.7% were non-Hispanic, and 55.5% were African American. FL ADAP participants did not significantly differ by race, ethnicity, marital or education status, transportation barriers, nor the actual number of missed appointments. However, ADAP participants were slightly more likely to have same-sex relationships [OR 1.41 (CI 1.02 to 1.96)] or to be bisexual [OR 2.05 (1.21 to 3.47)]. ADAP enrollees reported greater adherence to antiretroviral therapy (ART) (94.2% vs. 87.1%; P < 0.001) and to have a case manager (83.8% vs. 75.4%; P = 0.008). Likewise, PLWH with a case manager were more likely to have ADAP [OR 2.04; (CI 1.32 to 3.17)]. However, ADAP enrollees were more likely to report barriers to care for a missed appointment (28.9% vs. 22.2%; P = 0.02).

Conclusion

The Florida ADAP program is successful in providing ART access, facilitating linkage to care, and improving adherence through embedded case management services. However, more resources are needed to improve ART and medical appointment adherence as well as to decrease socioeconomic barriers to care.

Disclosures

All authors: No reported disclosures.
1320. HIV Care Continuum Outcomes Among Newly Diagnosed PLWH in Washington, DC
Authors: Jaurretche Maria J , Byrne Morgan , Powers Happ Lindsey J , Levy Matthew E , Horberg Michael A , Greenberg Alan E , Castel Amanda , Monroe Anne K
Published: October 2019

Background

In 2019, the US Administration announced the Ending the HIV Epidemic plan to decrease new infections. A key component is the Test and Treat plan to diagnose early, treat rapidly and achieve viral suppression (VS) among persons living with HIV (PLWH). We assessed retention in care (RIC), antiretroviral therapy (ART) initiation and VS among newly diagnosed PLWH in Washington, DC.

Methods

We conducted a cross-sectional analysis using data from the DC Cohort, an observational longitudinal cohort of PLWH in care in 14 clinics in DC. We included participants enrolled from 2011 to 2016 whose HIV diagnosis was within 1 year of enrollment and with at least 12 months follow-up. RIC was defined as ≥2 visits or HIV lab results 90 days apart in the first year of follow-up. ART initiation was defined as being prescribed ART, VS was defined as HIV RNA <200 copies/mL, and both these outcomes were assessed at 2 time points: by 3 and 12 months. Adjusted multivariable logistic regression was used to identify clinical and sociodemographic factors associated with RIC, ART initiation and VS.

Results

Among the 455 newly diagnosed participants (6% of all enrollees), median age was 33 years (IQR 25, 45), 69% were Black, 79% male, 60% MSM. Median duration of HIV at enrollment was 4.9 months (IQR 2.3, 7.7). Median nadir CD4 count was 346 cells/μL (IQR 224, 494). Of the 455, 38% had a history of AIDS, 92% were RIC, 65% initiated ART by 3 months and 17% had VS by 3 months. There were no differences by sex or race for RIC, ART initiation and VS. An AIDS diagnosis at enrollment was associated with RIC (aOR 2.28; 1.01–5.15), ART initiation by 3 months (aOR 2.41; 1.54–3.76), and VS by 12 months (aOR 1.92; 1.06–3.46). Lower nadir CD4 (aOR 0.89 per 50 cell increase; 0.84–0.94) and younger age (aOR 0.747 per 10-year increase; 0.584–0.995) were associated with ART initiation by 12 months.

Conclusion

Although the majority of newly diagnosed PLWH were RIC, fewer started ART or achieved VS. With a large proportion of our sample having an AIDS diagnosis at enrollment, we illustrate the ongoing challenge of late HIV diagnosis in DC. Those with AIDS at diagnosis were more likely to initiate ART within the first 3 months. As same-day ART initiation is scaled up in DC, future research can evaluate if all PLWH, regardless of AIDS status, will achieve this milestone earlier.

Disclosures

All authors: No reported disclosures.
1340. The Effect of Continuous Renal Replacement Therapy on Body Temperature in Patients with and without Infection
Authors: Challener Douglas W , Kashani Kianoush , O’Horo John C
Published: October 2019

Background

Sepsis frequently leads to acute kidney injury. In severe cases, patients may require continuous renal replacement therapy (CRRT) which involves placement of a dialysis catheter and an extracorporeal blood filtration circuit. CRRT is commonly considered to “mask” fever, though this phenomenon has not been investigated.

Methods

We queried an institutional database of all patients on CRRT from 2007 to 2015 for inpatient temperature data and antibiotic administration records. Receipts of piperacillin–tazobactam, a carbapenem, or a third or fourth-generation cephalosporin, indicating a serious infection, were considered intervention arm. We analyzed temperatures recorded in the intensive care unit before, during, and after CRRT. Patients were divided into groups that did not receive antibiotics as well as those who did. Temperature data were Winsorized to correct for outliers. We also performed descriptive statistics for each group.

Results

There were 237,988 temperature readings for 1,568 ICU patients on CRRT. 1,153 patients received broad-spectrum antibiotics in ICU. In patients who received antibiotics in ICU and were presumed to have an infection, the mean temperature was 37.2°C prior to initiation of CRRT, 36.8°C while on CRRT, and 37.2°C following discontinuation of CRRT. In the 415 patients who did not receive IV antibiotics, the mean temperature was 36.9°C prior to initiation of CRRT, 36.6°C while on CRRT, and 37.0°C following discontinuation of CRRT. During each of the periods before, during, and after CRRT, patients who received antibiotics had significantly higher temperatures than those who did not (P < 0.001). Patients receiving antibiotics were generally younger (mean 60 years vs. 64 years, P < 0.001), had longer ICU stays (mean 29 days vs. 12 days, P < 0.001) and spent more time being ventilated (mean 23 days vs. 7 days, P < 0.001). The mean SOFA score on day one was similar (mean 11.1 in the antibiotic group and 10.5 in the other group).

Conclusion

This investigation suggests that patients have slightly lower temperatures while on CRRT, by on average less than half a degree. A similar effect is seen in both patients with infections as well as those without. Further work will be needed to determine what constitutes a true febrile response in this population.

Disclosures

All authors: No reported disclosures.
1351. How Do Infectious Diseases Clinicians Manage Patients with Suspected Ocular Tuberculosis? Results of an Emerging Infections Network Survey
Authors: Fraimow Henry S , Beekmann Susan E , Polgreen Philip M , Sunstrum James
Published: October 2019

Background

Ocular tuberculosis (OTb) is uncommon and many ID physicians (IDPs) have limited experience with OT. Ophthalmologists now include IGRAs in evaluating idiopathic uveitis, and some IDPs report increased referrals for possible OTb. Our goal was to understand how IDPs approach diagnosis, treatment, and reporting of OTb.

Methods

The Emerging Infections Network surveyed members treating adult ID patients in 2019 about referrals for suspected OTb. The survey used hypothetical case scenarios to evaluate factors influencing the management of possible OTb, and queried involvement of public health agencies.

Results

754 of 1,379 (55%) physicians responded. 141 (19%) reported ≥1 referral for possible OTb in the past 3 years; 35% of these reported increasing referrals over time. Most frequent indications for referral were uveitis and positive IGRA (60%) and idiopathic uveitis without positive IGRA or TST (33%). For a hypothetical case with uveitis, positive IGRA but no other symptoms, respondents were much more likely (79% vs. 29%) to treat as TB disease if TB risk factors were present. Respondents were more likely to require a positive eye culture or NAAT prior to treating a risk factor-negative patient (39% vs. 12%). 54% of respondents believed <10% of eye specimens were culture or NAAT-positive for suspected OTb. 94% would treat suspected OTb with INH, RIF, PZA ± EMB but duration of treatment varied with 27% stopping therapy for lack of clinical response and 59% continuing for at least 6 months regardless of response. 44% were unsure if improvement should be expected on therapy. One-third of respondents either did not report or reported only culture-confirmed OTb cases on treatment to public health agencies.

Conclusion

IDPs report increased referrals for possible OTb, mainly for idiopathic uveitis and positive IGRAs. There is considerable practice variation in management of possible OTb. The decision to treat as TB disease is heavily influenced by TB epidemiologic risk factors, and there is heterogeneity in treatment duration and in expectation of response to therapy. Prospective studies to assess treatment responses in OTb and improved collaboration with ophthalmologists are necessary to better manage this emerging syndrome. Treated OTb cases should be reported to public health agencies.

Disclosures

All authors: No reported disclosures.
1353. Effect of Implementing Xpert MTB/RIF Ultra Assay on Diagnosis of Tuberculosis in a Medical Center in Central Israel
Authors: Schwartz Orna , Yossepowitch Orit , Maor Yasmin
Published: October 2019

Background

Tuberculosis (TB) is a worldwide public health concern both in developing and developed countries. The new Xpert MTB/RIF Ultra assay (Ultra, Cepheid, Sunnyvale, USA) recently endorsed by the WHO has high sensitivity to TB detection. The aim of this study was to assess the impact of this assay on TB diagnosis in a medical center in Israel where the baseline prevalence of TB is low.

Methods

The Xpert MTB/RIF Ultra assay is a cartridge-based automated diagnostic test that can simultaneously identify Mycobacterium tuberculosis complex and resistance to Rifampicin. We began using this test in 1.1.2018. To assess the impact of this assay on the rate of TB diagnosis we compared TB tests and positive cases during two time periods: period I (1.1.2017-31.10.2017) when TB diagnosis was based on the Xpert MTB/RIF assay to period II (1.1.2018 to 31.10.2018) when TB diagnosis was based on Xpert MTB/RIF Ultra assay. Included were all TB tests performed on sputum, deep suction or bronchoalveolar lavage. Files of positive patients were reviewed.

Results

The study included 1034 samples from 717 patients. Results are presented in Table 1. During the second period, TB rates increased by 231%. During the entire study there was no change in the hospital’s guidelines regarding TB diagnosis policy and there was no epidemiological change in the population served by the hospital. Only three cases had rifampicin resistance. In 5 cases (20%) during period II the result was trace amounts, an entity that did not exist in the former assay and in 3 cases culture results were negative. In 2017, 6 patients (60%) were African born, 3 patients (30%) originated from Eastern Europe, and one patient (10%) was born in the Middle East region. In 2018, 9 patients (36%) were born in Africa, 9 patients (36%) were born in Eastern Europe, and 7 patients (28%) were born in the Middle East region. Mean age at diagnosis was 38 years for patients diagnosed during period I and 53 years for patients diagnosed during period II.

Conclusion

The new assay enabled a significantly higher diagnosis rate for TB at our institution. We believe that this mainly reflects a higher diagnosis rate in patients with paucibacillary TB. Further study is needed to assess the relation between cultured confirmed diseases and the assay results, particularly in patients with trace results.

Disclosures

All authors: No reported disclosures.
1363. Does Genotypic Testing Improve Treatment Outcomes in Drug-Resistant Tuberculosis?
Authors: Thampy Anupa , Ninan Marilyn , Sarojini Michael Joy , Rupali Priscilla
Published: October 2019

Background

Treatment of drug-resistant tuberculosis (DR-TB) requires toxic and complex drug regimens. Dismal outcomes occur due to a delay in the report of susceptibility results. WHO endorses genotypic tests like line probe assay (Mtbdrsl) for an early diagnosis enabling start of robust treatment regimens. Data correlating Mtbdrsl and specific mutations with outcome are rare.

Methods

A concurrent cohort study was conducted on all patients diagnosed to have DR-TB between January 2016 and June 2017 in the departments of Pulmonary Medicine and Infectious Diseases at a tertiary care center in India. Patients aged >18 years with a positive Mtbdrsl (done on culture) or Mycobacterial culture were prospectively followed up till completion of therapy for assessment of outcomes. Patients were divided into 2 groups based on diagnostic method used: culture group and Mtbdrsl group. Risk factors for adverse outcomes were assessed.

Results

Total of 82 patients, of which 62.2% were males with a mean age of 32 years were included; 50 in the Mtbdrsl group and 32 in the culture group. Among these, 40.2% were multi-drug-resistant Tuberculosis (MDR-TB), 53.7% were Pre–XDR (pre-extensively drug resistant i.e, quinolone-resistant tuberculosis) and 6.1% were XDR (extensively drug-resistant TB). Isolated pulmonary involvement (46.3%) was common followed by disseminated TB (29.3%). Overall good outcome was seen in 39/82 (14.6% cured and 32.9% completed treatment) and bad outcome in 43/82 (41.5% lost to follow up, 7.3% treatment failure and 3.7% died). Good outcome was noted in Mtbdrsl group was 22/50 (44%) vs. 17/32 (53.1%) in the culture group. Mtbdrsl group had 140 days mean decrease in time to initiation of appropriate therapy but the odds of having a better outcome was 0.693 (CI: 0.284–1.690, P = 0.499). Among the 15 different types of mutations, FQ mutations gyrA 94Gly and gyrA 90Val comprised 15% each with gyrA 94Gly noted to have a poorer outcome [OR 2.5 (CI 0.471–13.265)]. All 5 patients with XDR TB (50 % had rrs 1401Gly mutation) had a poor outcome.

Conclusion

Contrary to what is expected, Mtbdrsl did not significantly contribute to better treatment outcomes. High-risk mutation gyrA 94Gly was prevalent and associated with poorer outcomes. Small sample size and a wide variety of mutations preclude generalizability of our results.

Disclosures

All authors: No reported disclosures.
1368. Tuberculosis in Older Patients in Cali, Colombia (2011–2016): A Hospital-Based Cohort Study
Authors: Fernando García-Goez Jose , Diego Velez Juan , Pino-Escobar Jessica , Lucía Mora Barbara , Parra-Lara Luis Gabriel , Caylà Joan A , Miró José M
Published: October 2019

Background

Tuberculosis (TB) in older adults is a public health concern worldwide. We aim to describe the outcomes of patients over 65 years old with a confirmed TB diagnosis. We furthermore assessed factors related to poor outcomes among this patient population.

Methods

This retrospective study included patients older than 65 years with a biological specimen positive by smear microscopy, culture, or GeneXpert. Clinical and microbiological data, information about drug-related side effects, adverse reactions, and TB treatment outcomes were reviewed. Patients were subsequently assigned to either the octogenarian group or non-octogenarian group, also the treatment success group or treatment nonsuccess group.

Results

A total of 108 patients were included. 59% were male, and 26% of patients were 80 years old or older. 81% of the patients presented pulmonary TB. Diagnostic delay greater than 90 days was present in 36% of the cases. There was a statistically significant difference in the rates of diabetes (P = 0.004) and COPD (P = 0.017) between the octogenarian group and non-octogenarian group. One hundred six patients started anti-TB therapy, 34% of cases were lost to follow-up, and 18% died. Patients of 65–79 years of age and those older than 80 years had similar mortality, 19% vs. 18%, respectively. When comparing treatment success (n = 45) and nonsuccess (n = 22) groups, most of the variables were found not to be statistically significant as TB risk factors, except malignancy (P = 0.013). Overall, survival of the patients was 78. 23% at 5 years follow-up; there were no differences between age groups.

Conclusion

The presence of baseline comorbidities as diabetes, malignancies and COPD, diagnosis delay, adverse events during anti-TB treatment and drug–drug interactions (DDI) makes this age group a different population, hence care models need to be evaluated to improve the indicators of the success of TB programs. Furthermore, the significant losses to follow-up require strict management of these patients and optimal coordination among health centers.

Disclosures

All authors: No reported disclosures.
1372. Patient’s Perceptions of Barriers to Tuberculosis Care in Private Sector in India
Authors: Yerramilli Aparna , Narreddy Suneetha , Anisetti Ravinder N , Grace K Angileena , Rakuditti Sandhya
Published: October 2019

Background

In spite of ambitious plans of all the stakeholders involved there is still a long way to go before Tuberculosis (TB) is eliminated In India due to barriers to care and cure. About half of the population affected with TB gets treated in the private sectors. This study was aimed to assess the patient knowledge on Tuberculosis and identify the barriers perceived by them.

Methods

A prospective study was conducted in a tertiary care center for a period of 3 months after obtaining approval from the Institutional ethics committee. All adults >18years diagnosed with tuberculosis (pulmonary, extrapulmonary) and receiving treatment in the Infectious Diseases Department were included. Subjects enrolled in the study were fully informed and gave their consent. A questionnaire was used to gather data regarding patient demographics, location, household size, co-morbid conditions, treatment, adverse drug reactions and barriers faced for their treatment.

Results

A total of 50 patients enrolled in the study. The majority of subjects belonged to age groups of 31–50 years (38%) with postgraduates accounting for 30%. About half (48%) of them were not working and 36 (72%) were married. About 31 (62%) were residing locally. The household size was 3–5 members (72%). Diabetes (13, 26%) and hypertension (11, 22%) were the common comorbid conditions seen. Newly diagnosed cases comprised of 35 (70%). Extrapulmonary TB was seen in 30 cases (60%) with lymph node and spine TB being more common. Adherence to the treatment was seen in 34(68%). Awareness regarding treatment duration and importance of treatment completion was seen in 64% and 82% of the study population, respectively. About 62% had visited more than one doctor for diagnosis with 42% responded that there was a delay in diagnosis. Common Barriers faced were stigma, adverse drug reactions, and transportation in 40 %, 12%, and 6% cases. The other factors faced by the respondents were the cost of diagnosis and treatment, adherence issues and loss of income.

Conclusion

India has the world’s highest incidence of Tuberculosis. Multifaceted barriers worsen the burden of Tuberculosis. Private sectors treat the majority of the extrapulmonary disease. Intensified efforts by means of public awareness and education are required to prevent the delay in diagnosis and reducing stigma.

Disclosures

All authors: No reported disclosures.