bluuebunny/crossref_metadata_2025 huggingface dataset:
836. Significant Elevations in CD4+ Count, Post-treatment of Chronic Hepatitis C (HCV) with Direct Acting Antivirals (DAAs), in Human Immune Deficiency, HIV/HCV Co-infected Patients with Prolonged CD4+ lymphocytopenia, despite undetectable HIV RNA
Authors: Kuhn Ryan , Green Carolyn , Natesan Suganthini Krishnan
Published: December 2021

Background

Introduction of DAAs has revolutionized HCV therapy. Treatment of HIV/HCV co-infected patients is challenging and HCV treatment data on this group of patients are limited. Aim: To review pre-and post-DAA treatment parameters, identify measures to improve recruitment and improve quality of care in co-infected veterans. A QC/QI project.

Methods

A retrospective chart review of HIV/HCV co-infected patients treated for HCV with DAA at Detroit VAMC was performed. All patients were on anti-retroviral treatment for HIV with undetectable viral loads. Pre-and post-DAA treatment parameters were compared in patients who completed 12 weeks of treatment. Drug interactions, SVR, CD4+ counts AST, ALT, albumin, INR, platelets, creatinine, alpha-fetoprotein (AFP), HCV RNA, and FIB-4 score were recorded. Pearson correlation coefficient was used for data analysis.

Results

Out of 46 patients, 4 died and 20 were ineligible due to non-compliance, mental illness, or drug use; 22 eligible patients, who had well controlled HIV, received DAAs for 12 weeks. (Genotype was 1a in 14, 1b in 7 and 2b in 1 patient). Compliance rate was 100%, 21 patients were HCV treatment naïve, 1 treated with interferon in the past) and all 22 patients achieved SVR by 12 weeks (in 2 weeks), including patients (n=12) on long term opioids and/or mental health treatment. Among 10/24 patients who showed a significant increase in CD4+ (range > 100 to 400 within 6 months), 8 were cirrhotic and had received DAA + RIB therapy. HIV therapy regimen change to alafenamide combination was required in 7/22 patients, for renal dysfunction. There were decreases in AST/ALT, but no changes in FIB-4 score, platelets, albumin, creatinine, or AFP were noted.

Conclusion

HIV/HCV Co-infected patients who received DAA + RIB had a significant increase in CD4+ lymphocyte counts (p< 0.05) (unlike interferon-based regimen). Chronic opioid use and mental health treatment were not a hindrance to successful therapy. The clinical impact of our findings on long-term complications including cirrhosis, hepatocellular carcinoma, and extra-hepatic manifestations of HCV remain to be seen. Recognition of positive predictive markers will delineate the cohort of co-infected veterans who would benefit from DAA therapy beyond HCV eradication.

Disclosures

All Authors: No reported disclosures
837. Performance of Blood (1- >3)-β-D-Glucan in People with AIDS Presenting with Respiratory Symptoms
Authors: Hasan Lana , Krishnan Gayathri , Saccente Michael
Published: December 2021

Background

The gold standard for diagnosis of Pneumocystis jirovecii pneumonia (PCP) is direct visualization of the microorganism in respiratory samples, usually obtained via bronchoalveolar lavage (BAL). Blood β-D-glucan (BDG) is used as a non-invasive adjunctive diagnostic test for PCP, but specificity is only modest, in part because other opportunistic fungal infections cause high BDG. We previously showed BDG-positivity in 94% of people with AIDS (PWA), progressive disseminated histoplasmosis (PDH), and respiratory symptoms in our hospital. In this study, we aim to assess the performance of BDG as a diagnostic test for PCP in PWA who have respiratory symptoms.

Methods

We retrospectively identified PWA who had a BDG result between 2014 and 2019. AIDS was defined as past or current absolute CD4 count < 200 cells/µL, or a past or current AIDS-defining condition. Positive cytological or histological evidence of P. jirovecii in bronchoalveolar lavage (BAL) fluid or lung biopsy, or positive Pneumocystis PCR on sputum or BAL confirmed PCP. The Fungitell Assay (Associates of Cape Cod, East Falmouth, MA) determined BDG levels as follows: negative, < 60 pg/mL; indeterminate, 60-79 pg/mL, and positive, ≥ 80 pg/mL. Values < 31 pg/mL and those >500 pg/mL were censored at 30 pg/mL and 500 pg/mL, respectively. Respiratory symptoms were defined as cough, dyspnea, chest pain, or hypoxia. We compared BDG results for participants with proven PCP and participants without proven PCP.

Results

We identified 260 PWA with a BDG result, of whom 183 had at least one respiratory symptom. 84 (45.9%) of these participants had a positive BDG. BDG results among participants with and without PCP are shown in Table 1. Of the 44 participants with a positive BDG who did not have PCP, 29 (65.9%) had PDH. Other diagnoses included cryptococcosis and candidemia. The test performance of BDG for the diagnosis of PCP is shown in Table 2. Exclusion of participants with PDH increased the specificity of BDG for PCP to 86.4%.

Table 1. Results of (1->3)-β-D-glucan Testing by Pneumocystis jirovecii Pneumonia Diagnosis Among Participants with AIDS and Respiratory Symptoms

Table 2. Test Performance of (1->3)-β-D-glucan for the Diagnosis of Pneumocystis jirovecii Pneumonia*

Conclusion

At our center where histoplasmosis is endemic, a positive BDG should not be attributed to PCP among PWA with respiratory symptoms because of low specificity and low positive predictive value. However, a negative BDG can exclude PCP in this population.

Disclosures

All Authors: No reported disclosures
839. Examining the Effects of HIV Infection on Severity of Outcomes in Those with COVID-19
Authors: Parkinson Melissa , Gerrity Rebecca , Strength Rachel , Fuchs Christian J , Jackson Christopher , Kadaria Dipen , Seth Ankur , Animalu Chinelo N , Summers Nathan A
Published: December 2021

Background

Throughout the SARS-CoV-2 pandemic, there have been many questions about how COVID-19 affects patients living with HIV (PLWH). We examined the clinical courses of 45 PLWH who required hospitalization with SARS-CoV-2 infection.

Methods

This is a retrospective cohort study in which ICD-10 codes were used to identify PLWH who were admitted to three large hospital systems in Memphis, TN with COVID-19. We included all patients ≥ 18 years of age with HIV and a documented positive SARS-CoV-2 PCR test. After manual abstraction from the electronic health records, chi-squared and T-tests were performed to evaluate associations between patient-level factors and outcomes.

Results

A total of 45 patients with HIV who tested positive for SARS-CoV-2 were admitted to Memphis, TN area hospitals between March 2020 and October 2020. 18 (40%) were female, 43 (95.6%) were Black, and the average age was 50.3 years (SD 12.6). The average BMI was 30.2 (SD 8.6). 40 (88.9%) patients admitted had at least one comorbidity with the most common being hypertension (28 patients, 62.2%) and diabetes (14 patients, 31.1%). 24 (46.7%) patients had a Charlson Comorbidity Index > 3. 15/43 (48.4%) patients had a CD4 count < 200, and 35 (77.8%) were on ART. 30 (66.7%) patients met SIRS criteria within 24 hours of admission, and 27 (60%) required some form of oxygen supplementation during hospitalization, including 4 (8.9%) who required intubation. The average length of stay was 10.4 days (SD 12.5). 9 (20%) patients required an ICU stay, and 3 (6.7%) died. BMI > 30, CD4 count < 200, and viral load > 1000 were not associated with worse outcomes. Both a Charlson Comorbidity Index > 3 and the absence of ART were associated with need for ICU-level care.

Conclusion

Viral load, CD4 count, and BMI were not correlated with differences in mortality or oxygen use in our study. Patients with higher Charlson Comorbidity Indices and patients who were not on ART at presentation were significantly more likely to require the ICU. Further study is needed to definitively determine factors affecting the outcomes of PLWH with SARS-CoV-2 infection.

Disclosures

All Authors: No reported disclosures
844. High Risk Behaviors, Suboptimal HIV Viral Suppression, and Limited PrEP Use among People Who Engage in Transactional Sex
Authors: Cover Amelia , Bijole Phyllis , Eyasu Rahwa , Ebah Emade , Ogbumbadiugha-Weekes Onyinyechi , Mount Julia , Stevens Jasmine , Gannon Catherine , Davis Ashley , Gayle Britt , Jones Miriam , Kier Randy , Sternberg David , Silk Rachel , Kattakuzhy Sarah , Masur Henry , Kottilil Shyam , Rosenthal Elana S
Published: December 2021

Background

In the United States, high rates of HIV transmission persist, particularly due to sexual transmission in marginalized populations. Transactional sex (TS) is a known risk factor for HIV transmission, yet risk behaviors and engagement in HIV treatment and prevention among those who have TS are poorly understood.

Methods

GRAVITY is cross-sectional investigation of people living with HIV (PLWH) or HCV in Washington, DC and Baltimore, MD. Epidemiologic survey data were collected at a single timepoint. Patients who endorsed previous year sex in exchange for drugs, money, or shelter were considered positive for TS. Fisher’s exact test was used for statistical analysis.

Results

Of 500 participants, 81(16%) endorsed TS, the majority of whom were HIV+ (51, 63%) and used drugs daily or more (57,70%; see Table 1). PLWH with TS were more likely to be Black (44, 86%, p= 0.05) and Trans female (17, 33%, p<0.01) than HIV- participants with TS. In the TS cohort, PLWH were more likely to engage in anal sex (38, 75%, p< 0.01), have sex weekly or more (46, 90%; p< 0.01), have sex with more than 2 partners (27, 77%, p=0.03), and have a history of syphilis (14, 27% p= 0.04) compared to HIV- participants. Only 21% and 35% of PLWH and 17% and 22% of HIV- always used condoms in vaginal sex and anal sex, respectively (p >0.05). Though 41 (80%) PLWH took ART, only 19 (41%) reported viral suppression. Of HIV- participants, 59% had interest in starting Pre-Exposure Prophylaxis (PrEP), but few had been offered (3,10%), or ever taken PrEP (2,7%).

Table 1: Participant Characteristics and Associations with Transactional Sex and HIV Status

Conclusion

In this cohort of people with TS, there were high rates of HIV and racial, sexual, and gender minorities. Notably, PLWH had higher rates of frequent sex, multiple partners, and anal sex, as well as suboptimal viral suppression and condom use during anal sex. As such, PLWH +TS may be a consequential part of HIV transmission networks. While those without HIV also had frequent sex and suboptimal condom use, PrEP experience was limited. As the majority had interest in PrEP, targeted strategies to initiate and maintain PrEP in people with TS may be critical in preventing HIV acquisition. Interventions to identify TS, address high-risk behaviors, achieve and maintain viral suppression amongst +TS PLWH, and connect +TS HIV- individuals to PrEP are key to a comprehensive strategy to end the HIV epidemic.

Disclosures

Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)
104. Plague Meningitis - A Systematic Review of Published Cases, Antimicrobial Treatment, and Outcomes
Authors: Cooley Katharine , Fleck-Derderian Shannon , Nelson Christina
Published: December 2021

Background

Plague meningitis is a rare but serious manifestation of infection with the bacterium Yersinia pestis. The risk factors, clinical evolution, and optimal treatment strategies of plague meningitis are not well understood, and data is limited to sporadic case reports. To advance knowledge of this condition and support clinical practice recommendations, we conducted a systematic review of published cases of plague meningitis.

Methods

We reviewed PubMed Central, Medline, Embase, and other databases for publications on plague meningitis in any language. Articles that contained reports of patients with plague meningitis plus information on patient outcome were included.

Results

Among 1,090 articles identified in our search, we found 54 articles describing 83 cases eligible for inclusion. Cases occurred between 1898 and 2015; mean age of patients was 20.5 years (range 6 wks - 64 yrs) and 65% were male. Most patients lived in the United States (23%), Argentina (18%), Vietnam (12%), or China (12%). Four patients (5%) had primary plague meningitis. More than half (59%) of patients developed meningitis secondary to primary bubonic plague; the remainder developed meningitis secondary to other or unknown forms of plague. Of patients with a bubo, 51% had an axillary bubo. The most common symptoms were fever (66%), nuchal rigidity (43%), and headache (35%); 23 patients had focal neurologic deficits such as cranial nerve abnormality. Case fatality rate was 96% (n=23/24) for patients who did not receive antimicrobial treatment and 42% (n=25/59) for patients treated with antimicrobials. Case fatality rate by antimicrobial received, including patients who received multiple antimicrobial classes, was 50% for sulfonamides (n= 38), 50% for fluoroquinolones (n=2), 19% for aminoglycosides (n=21), 11% for chloramphenicol (n=19), and 0% for tetracyclines (n=14).

Conclusion

Plague meningitis has a high fatality rate, but antimicrobial treatment can improve patient outcomes. Having an axillary bubo may be a risk factor for developing plague meningitis – in contrast to our findings, a recent analysis found that only 24% of patients with bubonic plague had buboes in the axillary region. Additional research would be helpful to investigate this association further.

Disclosures

All Authors: No reported disclosures
849. Impact of a Combined Education and Data Driven Intervention on PrEP Uptake at the Veterans Health Administration
Authors: Musoke Lewis , Allen Kristen A , Bray Kaylee , Lea Erin J , Briggs Janet , Shumaker Amy H , Wilson Brigid , Newman Nicholas J , Van Epps Puja
Published: December 2021

Background

Despite proven efficacy, uptake of pre-exposure prophylaxis (PrEP) for HIV prevention in the US remains suboptimal. Whether electronic medical record (EMR) driven data tools increase PrEP uptake is unknown. Our study sought to understand the impact of education and an EMR data tool to increase PrEP uptake at the Veterans Northeast Ohio Healthcare System (VANEOHS).

Methods

Using EMR data we identified persons at the VANEOHS with a diagnosis of bacterial Sexually Transmitted Illness (STI) as defined by a positive syphilis, gonorrhea or chlamydia test in the past 6 months. Beginning October 2020 Infectious Diseases (ID) staff launched an intensive PrEP education campaign for Primary care providers (PCP) and the emergency room (ER). During a 6-week intervention period, a ‘PrEP candidacy’ note was placed for the PCP in selected patients’ charts with recommendations for PrEP initiation and STI co-testing if appropriate. We measured the impact of the intervention on PrEP initiations from 3/1/21-5/31/21 and compared it to a pre-intervention period of 7/1/20-9/30/20 when candidates were identified in primary care only. We extracted pertinent data through the EMR and presented descriptive statistics as means and percentages. We compared outcomes using Chi-square test with simulated p-values due to small expected values.

Results

Forty-two potential PrEP candidates were identified during post-intervention period compared to 6 in the pre-intervention period. The post-intervention candidates included cis-gender women (5/42, 12%) and ER referrals (6/42, 14%), both absent from the pre-intervention cohort. Compared to the pre-intervention period there was an increase in PrEP consults to ID (6 vs. 16; p=0.003) and PrEP starts (4 vs. 9; p=0.04). We observed increased rates of STI (69% vs. 50%) and HIV co-testing (79% vs. 67%) from pre to post intervention but these were not statistically different. Of the 42 candidates, 24 had been identified using the STI data tool. Of these, only 4 were referred for PrEP and none were initiated on PrEP by the end of our observation period.

Conclusion

The use of the data tool had no direct impact on PrEP uptake. Instead, the doubling of PrEP starts was attributable to education. Further studies are needed to maximize the utility of data tools to increase PrEP uptake.

Disclosures

All Authors: No reported disclosures
851. Rate of Sexually Transmitted Infections and Engagement in HIV Pre-Exposure Prophylaxis at the Veterans Affair Maryland Health System
Authors: Harfouch Omar , Comstock Emily , Kaplan Roman , Talwani Rohit , Wilson Eleanor
Published: December 2021

Background

Rates of sexually transmitted infections (STIs) and uptake of HIV pre-exposure prophylaxis (PrEP) during the 2020 coronavirus pandemic are unknown. We evaluated data from the Veterans Affair Maryland Health Care System (VAMHCS) data to determine rates of STI and PrEP linkage in our Veterans.

Methods

We extracted patient-level data on demographics, STI testing (chlamydia, gonorrhea, and syphilis), International Classification of Diseases (ICD) diagnosis codes and refills of TDF-FTC and TAF-FTC. We compared the ratio of positive STI tests in 2018, 2019 and 2020 using chi-square tests. Individuals eligible for PrEP were defined as patients with a newly positive STI result or an ICD diagnosis of: high risk sexual behavior; an STI mentioned above; or gender identity disorder. We excluded anyone with a positive HIV test or a creatinine >1.8. We identified patients initiated on PrEP through pharmacy refill data to define initiation of care. Finally, we used chi-square tests to compare differences of initiation of PrEP between years and demographics.

Results

The STI positivity rate significantly increased (p< 0.01) from 44.2% (2018) and 42.9% (2019) to 61.6% (2020) [Table 1]. The median ages of those who had a positive STI test were 50 (2018), 44 (2019) and 44 (2020). In 2020, 17% of patients eligible for PrEP filled PrEP. Engagement was similar (p=0.33) in 2019 and 2018, where 14% and 11.6% of patients eligible for PrEP received a prescription (p-value=0.33) [Figure 1]. The median age of those refilling PrEP were: 44 (2018); 43 (2019) and 41 (2020)). In 2020, we observed a statistically significant difference (p< 0.01) in initiation of PrEP in care among Black patients with 11.7% of eligible patients filling PrEP as compared to white patients (26.2%) and other races (23.3%) [Figure 2].

Table 1. Rate of positive tests at VAMHCS from 2018-2020.

Figure 1. PrEP Cascade at VAMHCS by year. Non-statistically significant (P=0.33) when comparing engagement in care between different years.

Figure 2. Racial distribution of PrEP eligibility and initiation by year at the VAMHCS.

Conclusion

While during the coronavirus pandemic in 2020, fewer Veterans sought STI testing at the VAMHCS, the number of positive STI results remained steady, leading to a higher positivity rate. The rate of initiation of PrEP did not differ between 2020, 2019 and 2018. Racial inequities in initiation of PrEP increased in 2020.

Disclosures

All Authors: No reported disclosures
855. Persistence on F/TAF versus F/TDF for HIV Pre-Exposure Prophylaxis: A Real-World Evidence Analysis in the United States
Authors: Tao Li , Shvachko Valentina , Das Moupali , Carter Christoph C , Baeten Jared , Magnuson David
Published: December 2021

Background

Persistence to preexposure prophylaxis (PrEP) is an important determinant of its efficacy, but evidence on real-world persistence is lacking. This study assesses adherence to F/TDF and F/TAF for PrEP both in terms of discontinuation and re-initiation patterns.

Methods

We identified HIV-negative individuals in the United States who initiated F/TDF or F/TAF for PrEP between October 2019 and December 2020 from a de-identified prescription claims database; users taking generic F/TDF were excluded. Non-persistence was defined as a prescription fill gap of >30 days; discontinuation included switch from F/TDF to F/TAF or F/TAF to F/TDF. We used survival analyses to estimate persistence, Cox regressions to compare the hazard ratios (HR) of discontinuation, and logistic regression to compare the odds ratios of re-initiation after discontinuation.

Results

Among F/TAF users (N=82,402) median age at PrEP initiation was 35 years (interquartile range [IQR] 28−47) and median PrEP persistence was 4 months (IQR 1.8-8.9), compared to 31 years (IQR 25−40) and 2 months (IQR 1.0-3.8) for F/TDF users (N=48,501). PrEP persistence at 60 and 90 days was higher among F/TAF users than F/TDF users (Figure). F/TDF users were 2.5 times more likely to discontinue than F/TAF users, with more marked differences in older users than that in younger users (p for interaction between discontinuation and age group < 0.01, Table). We also observed a higher rate of discontinuation of F/TDF versus F/TAF if PrEP was prescribed by internal medicine or infectious disease physicians than by family medicine physicians (data not shown). After discontinuation, F/TAF users were 1.7 times more likely than F/TDF users to re-initiate PrEP; the association was not different by age.

Persistence rates of F/TAF and F/TDF for PrEP by time of PrEP initiation

Hazard ratios (HR) and corresponding 95% confidence intervals (CI) of non-persistence and odds ratios (OR) of re-initiation after discontinuation for users of F/TAF and F/TDF for PrEP in the US, Oct 2019 – Dec 2020

Conclusion

In this real-world analysis, the F/TAF for PrEP regimen was associated with higher persistence and re-initiation than F/TDF for PrEP. These findings underscore the dynamic nature of PrEP utilization in the real-world and the importance of interventions aimed at improving PrEP persistence and re-initiation in people who would benefit from PrEP.

Disclosures

Li Tao, MD, PhD, Gilead Sciences Inc (Employee, Shareholder) Valentina Shvachko, MS, Gilead Sciences Inc (Employee, Shareholder) Moupali Das, MD, Gilead Sciences Inc. (Employee, Shareholder) Christoph C. Carter, MD, Gilead Sciences Inc. (Employee, Shareholder) Jared Baeten, MD, PHD, Gilead Sciences Inc. (Employee, Shareholder) David Magnuson, PharmD, Gilead Sciences Inc (Employee, Shareholder)
856. Barriers to PrEP Implementation among Patient-Facing Staff in Three Urban Clinics
Authors: Shenoi Sheela , Sideleau Robert J , McKay Sharen E , Aoun-Barakat Lydia A
Published: December 2021

Background

PrEP implementation has lagged in the US. The role of multidisciplinary staff in PrEP rollout has been neglected. We sought to identify barriers to PrEP implementation among 3 urban federally qualified health centers (FQHCs) in Connecticut that provide HIV and PrEP services in order to inform development of staff training.

Methods

A link to an anonymous survey was emailed to patient-facing staff members or posted at the end of staff trainings October 2020-April 2021. The survey requested demographics, duration of employment, and using 4 and 5 point Likert scales, ascertained knowledge and beliefs toward PrEP based on established scales, and perceived individual and systemic barriers to PrEP uptake.

Results

Among 101 respondents, 40% were 36-54yo, 22% were male, 68% were non-prescribing clinicians, and median duration of employment was 6 years (IQR 2-14). Among 32 (31%) prescribers (physicians, PAs, APRNs), 97% felt comfortable discussing sexual risk with patients, though 15% were not familiar with PrEP efficacy and safety data, 28% responded that PrEP use would encourage risky behaviors, 34% were concerned about side effects, 53% responded that educational and behavioral interventions should be attempted prior to prescribing PrEP, and 59% identified lack of provider training as a barrier. Among 69 (68%) non-prescribers, barriers to PrEP uptake included: patients don’t ask for PrEP (43%), lack of insurance (47%), lack of clinic guidelines/protocol (42%), and staff time for counseling (31%).

Conclusion

Prescribers and non-prescribers identified distinct individual and systemic barriers to PrEP uptake at FQHCs. Among prescribers, uncertainty regarding indications for and safety of PrEP exist, which will be addressed with targeted training. Non-prescribers identified the need for patient outreach, financial assistance, and counseling as the top priorities. The input of clinic multidisciplinary team members is essential to addressing barriers to PrEP implementation.

Disclosures

Sheela Shenoi, MD, MPH, Merck (Other Financial or Material Support, SS’s spouse worked for Merck pharmaceuticals 1997-2007 and retains company stock in his retirement account. There is no conflict of interest, but it is included in the interest of full disclosure.)
858. Impact of Using an Order Set on PrEP Prescribing and Laboratory Monitoring in Primary Care
Authors: Dao Linda T , Medders Kathryn , Hill Lucas
Published: December 2021

Background

CDC 2017 pre-exposure prophylaxis (PrEP) guideline recommends laboratory monitoring at baseline and follow-up and specifies that a PrEP prescription should be written for once daily dosing with a supply of 90 days or less to ensure patients repeat HIV testing every 3 months. This presents an opportunity to utilize order sets in the electronic health record to improve PrEP prescribing habits and prescriber adherence to laboratory monitoring recommendations. This study assessed the impact of using an order set on the accuracy of PrEP prescriptions and the appropriateness of laboratory monitoring in the primary care setting.

Methods

This was a retrospective, single-center, observational cohort study conducted at primary care clinics at a large academic health system. A total of 228 PrEP prescriptions from adults at least 18 years of age and that were written between April 1, 2018 through May 31, 2020 were assigned to the two comparator groups: 176 prescriptions ordered without an order set and 52 prescriptions ordered with an order set. The primary outcome was a composite of correct prescription details, defined as once daily dosing of PrEP for a 90-day supply or less. Secondary outcomes included the frequency of having an HIV antigen/antibody (Ag/Ab) test ordered within 3 months of the PrEP prescription, and the composite of appropriate baseline labs ordered for those newly starting PrEP.

Results

Baseline characteristics are shown in Table 1. The primary outcome of correct prescription details occurred in 100% of PrEP prescriptions ordered with an order set compared to 65.9% of those ordered without an order set (P< 0.001). At least 1 HIV Ag/Ab test was appropriately repeated within 3 months for 65.4% of PrEP prescriptions ordered with an order set and 42.6% ordered without an order set (P=0.004). In those initiating PrEP, a composite of correct baseline labs ordered occurred with 14 (73.7%) new start prescriptions ordered with an order set versus 47 (42.7%) ordered without an order set (P=0.023).

Conclusion

When ordering PrEP, order set use significantly improved the accuracy of PrEP prescriptions and appropriateness of laboratory monitoring at baseline and at follow-up compared to no order set use at primary care clinics of a large academic health system.

Disclosures

All Authors: No reported disclosures
860. HIV Post-exposure Prophylaxis Availability at Small and Critical Access Hospitals in the Western Region
Authors: Castillo Alyssa Y , Bulger Peter , Lynch John B , Lynch John B , Pottinger Paul , Chu Carolyn , Chan Jeannie D , Jain Rupali , Naderi Mandana , Kassamali Zahra , Budak Jehan , Budak Jehan , Bryson-Cahn Chloe
Published: December 2021

Background

Post-exposure prophylaxis (PEP) is essential to minimize the risk of human immunodeficiency virus (HIV) acquisition following an occupational or nonoccupational exposure to potentially infectious body fluids. PEP is most effective when initiated as soon as possible after HIV exposure. Patients in rural areas may rely on small (< 50 beds) and critical access (< 25 beds) hospitals for access to PEP – especially after-hours and on holidays, when outpatient pharmacies are typically closed. However, PEP medications are costly to maintain on a hospital formulary due to unpredictable use and expiration. We hypothesized that PEP availability may be variable and limited at such hospitals.

Methods

The University of Washington Tele-Antimicrobial Stewardship Program (UW-TASP) is comprised of 68 hospitals in Washington, Oregon, Arizona, Idaho, and Utah, most of which are rural and critical access. In August 2020, we surveyed UW-TASP participating hospitals and a convenience sample of other networked rural hospitals in Western states using REDCap, a HIPAA-compliant, electronic data management program. Respondents reported all antimicrobials on their hospital formulary and their hospital size. Data were reviewed by physicians and pharmacists trained in infectious diseases. Preferred PEP regimens, defined by the CDC, for adults and adolescents ≥ 13 years, included combination tenofovir disoproxil fumarate-emtricitabine (TDF/FTC) and either raltegravir (RAL) or dolutegravir (DTG).

Results

Responses from 49 hospitals were received. Six were excluded – one was incomplete and five were excluded due to hospital size ( > 50 beds) (Table 1). The majority of hospitals (40/43, 93.0%) were critical access. Half of the hospitals’ formularies (22/43, 51.2%) contained a preferred PEP regimen. One hospital reported a non-preferred regimen. Most hospitals with a preferred PEP regimen on formulary (18/22, 86.3%) offered TDF/FTC + RAL, and the remainder (4/22, 18.2%) offered TDF/FTC + DTG.

Conclusion

Many small and critical access hospital formularies do not include antiretroviral agents needed for HIV PEP. Improving urgent access to these critical medications in rural communities is an opportunity for HIV prevention.

Disclosures

Jehan Budak, MD, Nothing to disclose Chloe Bryson-Cahn, MD, Alaska Airlines (Other Financial or Material Support, Co-Medical Director, position is through the University of Washington)
861. Impact of COVID-19 Mitigation Measures on PrEP Care at a Safety Net Health System in Atlanta
Authors: Cantos Valeria D , Ferencsik Kate , Prevot Jennifer , Reyna Kelly , Georgial Gabriela , Galaviz Karla I , Niles-Carnes Laris , Zheng Ziduo , Kundu Suprateek , Lora Meredith , Sheth Anandi N
Published: December 2021

Background

The Grady Health System pre-exposure prophylaxis (PrEP) program modified its care practices to accommodate COVID-19 mitigation measures. Changes enacted included: transition to telemedicine visits, medication mail delivery, and flexible timing of quarterly laboratory testing. These were implemented in March 2020 and remain in place presently. This study aimed to evaluate patients’ long-term acceptability of these modifications and to assess their impact on PrEP care.

Methods

This was a cross-sectional study in a convenience sample of PrEP patients, ages 18 and older, at an urban clinic in Atlanta. They were invited to complete a survey between December 2020 and April 2021. The survey assessed the impact of mitigation measures on overall PrEP care, follow up visits, medication access, and ability to complete laboratory testing. It also evaluated the usability, quality, satisfaction, and concerns with telemedicine. Data were examined using median and interquartile ranges, and proportions.

Results

Of 145 patients contacted, 61 completed the survey (median age 33 years, 72% Black, 75% cisgender men, 15% transgender women). Most participants did not report interruptions in their PrEP care (72%) or follow up visits (74%). Most found it easy to access medications (82%), as participants’ report of medication mail delivery usage increased from 57% (pre-pandemic) to 73% (in-pandemic period). Interruptions in completing quarterly labs were more frequently reported, as only 62% found this to be easy. Overall, 89% reported using telemedicine; telephone call was the most used method (78%). Telemedicine users’ ratings for quality, usability, and satisfaction of telemedicine was high (median score: 6/7) and nearly all users (97%) reported no concerns about its continued use for PrEP care. A few participants (5%) raised concerns about loss of telephone services due to financial issues, impacting their ability to complete telemedicine visits.

Conclusion

PrEP care at an urban clinic was well- maintained despite COVID-19 mitigation measures. Telemedicine was found to be acceptable and usable by surveyed participants. Future research on widescale implementation of telemedicine for PrEP care is needed

Disclosures

All Authors: No reported disclosures
862. A Survey of HIV PrEP Prescribing Practices at an Academic Medical Center in the Northwest United States
Authors: Nix Chad D , Bowden Sean , Babiarz Jane
Published: December 2021

Background

The prescribing of pre-exposure prophylaxis (PrEP) remains a major means of reducing the incidence of HIV infection in the United States. Many individuals are unaware of their HIV status until further symptom progression has ensued or continue to engage in high-risk behavior despite awareness of the risk of HIV transmission. Primary care providers are instrumental in identifying patients who are at high risk of HIV acquisition and prescribing PrEP with appropriate counseling and monitoring.

Methods

In order to identify existing barriers to prescribing HIV PrEP at a single academic medical center, a voluntary 14-question de-identified survey was administered electronically to ambulatory care providers in the following departments: family medicine, internal medicine and geriatrics, adolescent and young adult health, student health, and women’s health clinics.

Results

Following survey dissemination, the response rate was 28% (82/286). The results are displayed in Tables 1-3. Notably, though 74% of survey respondents reported being familiar with CDC 2017 and USTPF 2019 clinical practice guidelines for PrEP prescribing, only 36% (22/61) were able to correctly identify the clinical scenarios in the survey whereby an individual is eligible for HIV PrEP. 57% (47/82) reported that they discuss HIV PrEP with less than 25% of eligible patients.

Conclusion

A significant proportion of healthcare providers at a major regional academic medical center are either not familiar with HIV PrEP prescribing clinical practice guidelines or are unable to appropriately identify situations whereby an individual meets eligibility for PrEP. In addition, a significant proportion do not discuss HIV PrEP with eligible patients. As such, data from the conducted survey will be used to inform the creation of clinical decision support tool to identify risk factors for HIV acquisition in patients, educate providers on guideline-based indications, and provide the option of a telePrEP referral service. Downstream effects anticipated from this intervention include increased HIV/STI testing, case identification, and increased rates of PrEP counseling and prescribing.

Disclosures

All Authors: No reported disclosures
863. Pre-Exposure Prophylaxis (PrEP) Prescriptions among Individuals at High Risk for HIV in the United States, 2012-2018
Authors: Zhou Mo , Song Yan , Gao Emily , Whiteside Yohance , Billmyer Emma , Signorovitch James
Published: December 2021

Background

To describe trends in emtricitabine and tenofovir disoproxil fumarate (FTC/TDF) PrEP uptake in 2012-2018 and characterize high risk individuals who use PrEP.

Methods

The study identified individuals aged ≥ 15 years old with claims suggesting high risk for HIV infection in the IBM MarketScan® Commercial Claims and Multi-state Medicaid Databases. High risk was defined using ICD codes indicating high risk sexual behavior or rectal/repeated bacterial sexually transmitted infection (STI). The index date was defined as the earliest of the first high risk sexual behavior diagnosis, the first rectal bacterial STI diagnosis, or the second non-rectal bacterial STI diagnosis within 12 months. Individuals were considered PrEP users if they had at least one FTC/TDF PrEP prescription within 12 months of index date. Individuals with evidence of HIV prior to or within 30 days after PrEP initiation/index date were excluded. Comorbidities were assessed using a modified Charlson Comorbidity Index that excluded HIV/AIDS.

Results

FTC/TDF PrEP uptake increased from 0.1% to 7.3% among commercially insured individuals between 2012-2018, and from 0.01% to 0.5% among Medicaid insured individuals between 2012-2017. Individuals ≥ 35 years old had the largest increase in PrEP uptake (0.1% to 13.0%), while those 16-25 years old had the smallest increase (0.03% to 2.3%). The largest proportion of PrEP users across all years were aged 25-34 while the largest proportion of non-PrEP users were aged 18-24. Compared to PrEP users, a larger proportion of PrEP non-users were female (62.9% vs. 1.4%, p < 0.05) and blacks/African American (49.1% vs. 40.3%, p < 0.05). A larger proportion of PrEP users had a risk status of homosexual (46.6% vs. 1.5%, p < 0.05) or bisexual (3.9% vs. 0.8%, p < 0.05) behavior than non-PrEP users. PrEP users also had more comorbidities than non-users among individuals with Medicaid and were less likely to have fee-for-service insurance plans overall (p < 0.05).

Table 1. Characteristics of people at high-risk for HIV who do vs. do not use FTC/TDF PrEP measured during the follow-up period

Conclusion

Despite an increase in FTC/TDF PrEP initiations, uptake was low, especially among young adults, women, heterosexuals and blacks/African Americans. Low initiation rates in these groups may illustrate that FTC/TDF PrEP is not meeting the needs of all high-risk individuals.

Disclosures

Mo Zhou, PhD, Merck & Co., Inc. (Consultant) Yan Song, PhD, Merck & Co., Inc. (Consultant) Emily Gao, MS, MPH, Merck & Co., Inc. (Consultant) Yohance Whiteside, PhD, MSPH, Merck & Co., Inc. (Employee) Emma Billmyer, BA, Merck & Co., Inc. (Consultant) James Signorovitch, PhD, Merck & Co., Inc. (Consultant)
864. Adolescent Primary Care Provider Knowledge of HIV Pre-Exposure Prophylaxis (PrEP) and Universal Screening at a Midwest Academic Medical Center
Authors: Allen Genevieve , Riddell Jamie
Published: December 2021

Background

HIV remains a problem for adolescents with 21% of new infections in the United States in 2018 occurring in youth. In this study we attempted to assess the knowledge of and comfort with pre-exposure prophylaxis and universal HIV testing among adolescent primary care providers affiliated with one academic medical center.

Methods

We conducted a survey of internal medicine/pediatrics, pediatrics, and family medicine residents and attending physicians affiliated with an academic medical center. Data collected included provider prescribing and referring habits for PrEP and information on their universal HIV testing habits. A “test your knowledge” section followed the survey which asked participants to name PrEP medications and to correctly select laboratory monitoring required for PrEP. Correct answers and prescribing resources were provided on completion of the survey.

Results

138 (76%) respondents were aware that PrEP is approved for adolescents. There was no significant difference across specialties or between residents and attendings. 44.8% of respondents felt uncomfortable prescribing PrEP and two thirds had never prescribed PrEP. Reasons for not prescribing PrEP included: not seeing adolescents who qualify (n=80), not having enough training (66), confidentiality concerns (22), forgetting to address PrEP (19), and concern incidence of HIV is too low to recommend PrEP (15). Pediatricians were the least likely to test for HIV with 11% of pediatrician, 32% of internal medicine/pediatric, and 38% of family medicine respondents reported universal HIV testing for patients 15 years and older (p < 0.05). Residents were more likely to test for HIV than attendings (33.3% versus 16%, p < 0.05). 111 participants completed the “test your knowledge” section. 31.5% correctly named two approved PrEP medications. There were 183 responses to the survey (49% response rate).

Conclusion

Adolescent primary care providers are aware that PrEP is FDA approved for adolescents but a gap in PrEP prescribing and HIV testing persists. There remain perceptions that HIV incidence is too low to discuss PrEP and that providers are not seeing patients who qualify. Next steps include developing an institutional PrEP guideline and creating an electronic medical record order set to facilitate PrEP prescribing.

Disclosures

All Authors: No reported disclosures
106. Risk Classification to Differentiate Autoimmune from Viral Encephalitis
Authors: Granillo Alejandro , Hansen Michael , Samannodi Mohammed S , Hasbun Rodrigo , Hasbun Rodrigo
Published: December 2021

Background

Autoimmune encephalitis is an urgent treatable etiology that needs to be differentiated from viral encephalitis. Prompt recognition and therapy is of utmost importance.

Methods

We performed a retrospective cohort of encephalitis cases in 16 hospitals in Houston, Texas, between January 2005 and December 2019.

Results

A total of 1,310 adult (age ≥18 years) inpatient hospital admissions were identified by the presence of an encephalitis-related discharge diagnosis per the International Classification of Disease 9th edition codes. Of these, only 279 cases met the 2013 International Encephalitis Consortium criteria for probable encephalitis. A laboratory confirmed diagnosis of autoimmune encephalitis or viral encephalitis was identified in 36 (12.9%) and 88 (31.5%) cases, respectively. There were 155 cases (55.5%) that had no identifiable cause and were considered idiopathic.

As compared to viral encephalitis, patients with autoimmune encephalitis were more likely to be younger (< 60 years old), have a subacute (6-30 days) or chronic ( >30 days) presentation, have seizures, and have psychiatric and/or memory complaints (P< 0.001). Furthermore, patients with autoimmune encephalitis were less likely to be febrile and to lack inflammatory cerebrospinal fluid (CSF) (defined as white blood cells < 50 per microliter or protein < 50 milligrams per deciliter) [See Table 1]. In the multivariable logistic regression model, subacute/chronic presentation, psychiatric and/or memory complaints, and lack of inflammatory CSF were significantly associated with autoimmune encephalitis. Using these 3 variables, patients were classified into 3 risk categories for autoimmune encephalitis: low risk (0-1 variables); 0%; intermediate risk (2 variables); 16%; and high risk (3 variables); 83% (P value < 0.001).

Conclusion

Adults with encephalitis can be accurately stratified for the risk of having autoimmune encephalitis using clinical variables available upon presentation.

Disclosures

Rodrigo Hasbun, MD, MPH, Biofire (Speaker's Bureau) Rodrigo Hasbun, MD, MPH, Biofire (Individual(s) Involved: Self): Consultant, Research Grant or Support
867. Telehealth and HIV Care During the COVID-19 Pandemic
Authors: Gudipati Smitha , Lee Monica , Brar Indira , Markowitz Norman
Published: December 2021

Background

The COVID-19 Pandemic led to many restrictions in health care services, and as a consequence, an expansion of telehealth capabilities. In order to meet the needs of PLWH along the Care Continuum, we developed a process to promote the use of our MyChart app. This HIPAA-compliant app allows patients to view their medical records, communicate with their providers, make appointments, and have video visits on their smart devices. This report describes our preliminary findings.

Methods

PLWH enrolled in the Ryan White Program, in the Infectious Diseases Clinic at Henry Ford Hospital who had not used telehealth services were asked to sign up for our MyChart (electronic medical record software) initiative. A telehealth Navigator interviewed and taught PLWH how to download and use MyChart, and supplied pre-loaded phones, as needed, to make virtual visits accessible. We collected demographic and clinical information and reasons for not using telehealth services.

Results

From October 2020 to May 2021, 209 PLWH were enrolled into our pilot program (Table 1). Of these: 48% were 45-64 years old (yo), while 21% were >/+ 60 yo and 3% < 25 yo; 75% were male, 85% Black; 48% MSM, and 84% virally suppressed (HIV RNA < 200 copies/mm3). When asked why they were not using telehealth services, 29% reported a lack of technology or capability to install MyChart on their phones, 27% needed further education, and 18% and had not prioritized installation of the application.

Conclusion

The crises created by the COVID-19 pandemic revealed a new role for telehealth services. Although available to all PLWH in our RW program, many had never used telehealth services. Over half lacked compatible devices or needed help to download or use the app. Compared to younger PLWH, older individuals were more likely to need assistance. Further work is needed to understand and promote digital parity.

Disclosures

All Authors: No reported disclosures
868. HIV, Opioid Use Disorder, and Injection related Infections: Clinical Outcomes in 4 Academic Hospitals
Authors: Bassler John R , Akselrod Hana , Burkholder Greer A , Rosenthal Elana S , Brokus Christopher J , Catalanotti Jillian S , Kuo Irene , McGonigle Keanan , Mai William , Notis Melissa , Burgan Kaylee W , Carpenter Joseph , Steck Alaina , Eaton Ellen , Eaton Ellen
Published: December 2021

Background

Because hospitals are a safety net for persons with injection drug use (IDU), they play a valuable role towards ending the HIV epidemic. The objective of this study is to evaluate the hospital outcomes of persons with HIV (PWH) and opioid use disorder (OUD).

Methods

CHOICE is a retrospective review of hospitalized persons with an infectious complication of OUD and IDU at University of Maryland, George Washington University, University of Alabama at Birmingham, and Grady Memorial Hospital. Participants were hospitalized between 1/2/2018-12/21/2018, had ICD9/10 diagnosis codes consistent with OUD and acute bacterial/fungal infection, and verification of OUD-associated infection. HIV was defined by chart review. We explored HIV viral load (VL), antiretroviral therapy (ART) and medications for opioid use disorder (MOUD) on admission, discharge, consultation, and community care.

Overall CHOICE Study Enrollment

Results

Overall, 287 were admitted with OUD and infections over the study period; 22 had HIV of whom 3 (14%) were diagnosed during the admission. Of the HIV negative, 1 was discharged on PrEP. Of PWH, most were Black (55%), male (68%), and Medicaid recipients (77%); median age was 48. Median length of stay was 10 days. Common bacterial infections were skin/soft tissue (55%), Bacteremia (41%), and Osteomyelitis (18%). On admission, few were on antiretroviral therapy (ART; 32%) or MOUD (23%). Of the 13 with a VL during admission, 100% had viremia (median VL 6,226 copies/mL). During the admission, 81% were evaluated by Infectious Diseases consultant and 50% by Addiction Medicine. At discharge, 11 and 6 had documentation of an ART plan and MOUD receipt, respectively. In the year following the admission, of 21 with follow up data, a majority were evaluated in the emergency department (68%) and readmitted (57%).

HIV Outcomes for Hospitalized Persons with Injection Related Bacterial Infections

Conclusion

For patients with IDU, hospitalization is a missed opportunity to address HIV treatment and prevention through PrEP, VL surveillance, and ART linkage. Because addiction treatment improves HIV outcomes, Addiction consultation should be standard of care but was under-utilized. Subsequent ED visits and readmissions suggest that hospitals provide continuity of care for patients with IDU who would benefit from HIV, HCV, and other services in acute settings.

Disclosures

Greer A. Burkholder, MD, MSPH, Eli Lilly (Grant/Research Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support) Ellen Eaton, MD , Gilead (Grant/Research Support) Ellen Eaton, MD , Gilead (Individual(s) Involved: Self): Research Grant or Support