bluuebunny/crossref_metadata_2025 huggingface dataset:
Linkage to HIV Outpatient Care Following an Inpatient Stay
Authors: Nurutdinova Diana , Ramachandran Shruti , Kadam Sukanya , Mojica Vince , Mullen Michael , Baney Matt
Published: October 2017

Background

Immediate linkage to outpatient HIV follow-up care after hospitalization is a crucial opportunity to review treatment plan and coordinate necessary and additional services. The purpose of this review is to evaluate potential gaps in transition from inpatient to outpatient care services in persons with HIV. Data from multiple electronic medical records and billing systems were used to assess the rate of follow-up care at HIV outpatient facilities within the Mount Sinai Health System (MSHS), among patients hospitalized in four of the largest hospitals within MSHS.

Methods

ICD-10 codes were utilized to capture all hospitalized patients in 2016 with a primary or secondary diagnosis of HIV and their discharge date, across various electronic systems used by MSHS hospitals. Additional visit data was pulled from the EMR used by the five HIV outpatient facilities in order to determine the linkage to care rate. Linkage to HIV care was defined as the proportion of patients who attended an appointment at one of five HIV outpatient clinics within MSHS, within 90 days of discharge.

Results

A total of 3,992 inpatient discharges were associated with the diagnosis of HIV at the Mount Sinai Health System in 2016. Among these, 2,760 (69%) were male and 1,970 (49%) were African Americans while 56% were in the range of 50–69 years. The average length of stay was 6.6 days (SE±0.6). Out of these discharges, 1020 (25%) were scheduled to be seen at the system’s HIV outpatient care facilities within the 90 day interval. Subsequently, 275 patients (27%) have kept their appointments.

Conclusion

The data suggests that a smaller proportion of the inpatient discharges is linked to care within the system in addition to low appointment compliance rate. Further efforts to optimize early linkage to care and retention may help to affect patient outcomes. Interventions focusing on chronic disease management may assist to further improve these rates. At the systems level, enhanced and increased discharge planning and coordination is required between inpatient units and outpatient clinics in addition to greater outreach by outpatient clinics immediately upon discharge.

Disclosures

All authors: No reported disclosures.
Social Determinants of Health and Disparities in Linkage to Care Among Newly Diagnosed HIV Cases – South Carolina, 2009–2011
Authors: Gill Harmeet , Babatunde Oluwole , Weissman Sharon
Published: October 2017

Background

Key to improved HIV outcomes is early diagnosis, linkage to care (LTC), retention in care (RIC) and viral load (VL) suppression. As treatment for HIV has become more effective, the gap in racial disparities has widened for LTC, RIC and VL. Social determinants of health (SDH) are conditions such as poverty level, income, education, employment that are responsible for most health inequities. SDH are drivers of disparities in HIV prevalence. The objective of this study is to evaluate the impact of SDH on racial disparities on time to LTC for newly diagnosed HIV infected individuals in South Carolina (SC).

Methods

Data was obtained from the SC enhanced HIV/AIDS Reporting System. Analysis includes individuals diagnosed with HIV in SC from 2009–2011. LTC was calculated as the time from HIV diagnosis to first CD4 or VL test. Early LTC was defined as within 30 days. Late LTC was >30 to 365 days. Individuals not LTC by 365 days were considered to have never been linked to care (NLTC). Census tract data was used to determine SHD (poverty, education, income, and unemployment) based on residence at the time of HIV diagnosis. Descriptive analysis was performed on data from newly infected individuals. Factors potentially associated with late LTC and NLTC including patient demographics, behavioral risk, residence at diagnosis and SDH were investigated.

Results

From 2009–2011, 2151 individuals were newly diagnosed with HIV. Of these 1636 (76.1%) were LTC early, 285 (13.2%) were LTC late and 230 (10.7%) were NLTC. NLTC was associated with male gender, lower initial CD4 count, and earlier stage of HIV at time of diagnoses (P <0.01). In multivariable analysis early HIV stage at HIV diagnosis (aOR: 1.82; 95% CI 1.3, 2.5) and living in census tracts with lower income (aOR 0.65; 95% CI 0.44, 0.97) are associated with late LTC. Male gender (aOR 2.66; 95% CI 1.49, 4.76) unknown HIV risk group (aOR 2.03; 95% CI 1.11, 2.74) and early HIV stage at diagnosis (aOR 4.59; 95% CI 2.33, 9.04) are associated with NLTC.

Conclusion

In SC, almost ¼ of newly diagnosed HIV infected individuals from 2009–2011 were LTC late or NLTC. SDH were not associated with late LTC or NLTC. Living in a low income census tract was associated with a lower risk for late LTC, possible because of access to Ryan White Services. Male gender and earlier HIV stage were factors with greatest association with late LTC and NLTC.

Disclosures

All authors: No reported disclosures.
Impact of Patient Navigators in Linkage to Care for HIV-Positive Patients in an Urban Emergency Department in Newark, NJ
Authors: Maldonado Samuel , Sugalski Gregory , Closeil Garry , Swaminathan Shobha
Published: October 2017

Background

Despite CDC recommendations, areas with high HIV prevalence have not implemented routine HIV testing, stating among other concerns, inability to effectively link them to care. We implemented a routine HIV testing program in the Emergency Department (ED) at University Hospital in Newark, NJ that had 46,164 visits from July 2015 to November 2016 and looked at the impact of patient navigators (PN) on linkage to care (LTC) rates.

Methods

This was a retrospective study of all patients newly diagnosed (ND) with HIV or previously positive (PP) but lost to follow-up (LTFU) in select areas of the ED from July 2015 to November 2016. We collected information on demographics, HIV risk factor, and looked at the impact of PN on LTC by comparing months the PN was able to make personal contact compared with months when the PN was unavailable for substantial periods of time.

Results

A total of 9,511 individuals were screened, and 151 (1.6%) had a positive HIV test; 8 died and 2 were incarcerated. Of the remaining 141, 102 (72%) were LTC. The mean age was 49, 57% Male, 77% Black, 14% Hispanic, and 6% White. The reported HIV risk factors were 67% Heterosexual, 9% MSM, 6% IV drug use (IDU) and 18% Other. Of the patients with a positive HIV test, 60 (43%) were ND and 81 (57%) were PP. Only 52% ND patients were LTC, while 88% PP patients were LTC. Black and Hispanic patients tended to be PP (60% of both groups), while White patients tended to be ND (75% of white patients were ND). The risk factors for ND were 44% Heterosexual, 39% MSM, and 25% IDU. Average LTC while the PN was unavailable decreased from 78% to 56%. There were no demographic differences in the LTC group compared with the LTFU group. IDU had the highest rate of being LTFU at 37% followed by MSM and Heterosexual at approximately 23% each. The primary reason for LTFU was incorrect contact information in the medical record such as wrong address or phone number. PN would make 3 phone calls, send 2 letters and 1 outreach attempt. If all of those failed, the PN notified the state health department.

Conclusion

PN have a positive impact on LTC even in busy ED settings. Given limitations of staffing a busy ED 24/7, we need to develop strategies to link patients even if the PN is not present. To address this limitation, we plan on looking at the impact of involving medical residents to help with linkage to care after business hours.

Disclosures

S. Swaminathan, Gilead Sciences: Grant Investigator and Scientific Advisor, Consulting fee and Research grant
Predictors of Viral Load Suppression in HIV-infected Patient in Rural Eastern North Carolina.
Authors: Fadul Nada , Taylor Peyton , Kearney Gregory
Published: October 2017

Background

Virologic suppression (VLS) has been shown to improve clinical outcomes and prevent disease transmission in Human Immunodeficiency Virus (HIV) infected patients. However, only 30% of those living with HIV in the United States (US) are currently VLS. HIV incidence and prevalence are increasing rapidly in the rural Southeastern region of the US and models to predict VLS in this population are needed.

Methods

We conducted a retrospective chart review of patients 18 years or older, who were newly diagnosed with HIV and receiving care at our Ryan White funded clinic between September 2014 and September 2016. We collected demographic information, comorbid conditions, clinic appointment data, and laboratory values. VLS suppression was defined as an HIV viral load <200 copies/mL at 3 months. Pearson Chi square analysis was done using SPSS to evaluate the association between these variables and VLS.

Results

A total of 183 patients were included in the study, 42 (23%) females, 39 (21%) white, 41 (22%) less than 25 years of age, 65 (36%) uninsured and 102 (56%) men who have sex with men. The majority 139 (76%) of patients lived below the 150% federal poverty limit. During 3 months follow up 113/183 (61%) were VLS. There were no statistically significant associations between age, gender, ethnicity, presence of mental health and substance abuse disorders, housing stability, education or poverty level level and VLS. 60/104 (56%) of those who were insured achieved VLS compared with 48/65 (73%) of those who were uninsured (P = 0.033)

Conclusion

VLS was achieved in 61% of the HIV infected patients in eastern North Carolina. Patients without insurance had a statistically significantly higher rate of VLS as compared with those with insurance. It is noteworthy that patients who were uninsured received ambulatory medical and support services as well as medication assistance through Ryan White funding. Future prospective studies are needed to further evaluate the association between insurance status and VLS in federally funded clinics.

Disclosures

All authors: No reported disclosures.
Travel time to Clinic but not Neighborhood Crime Rate is associated with Retention in Care among HIV-positive Patients
Authors: Ridgway Jessica P , Almirol Ellen , Schmitt Jessica , Schuble Todd , Schneider John
Published: October 2017

Background

Retention in HIV care can be impacted by structural factors such as crime, poverty, and clinic accessibility. We aimed to determine whether crime rate, travel time, or travel distance to clinic were associated with retention in care or viral suppression (VS) among people living with HIV (PLWH) at the largest provider of HIV care on the South Side of Chicago.

Methods

Using publicly available data in the Chicago Open Data Portal, we geocoded patient home addresses and clinic location. We measured distance from patient home to clinic, and travel time from patient home to clinic using car and Chicago Transit Authority (CTA) public transportation. We further measured crime rate within a two block radius of the public transportation route to clinic. Retention was defined as >2 visits, 90 days apart within 12 months, and patients were classified into 3 groups: continuously retained (CR), intermittently retained (IR), or lost to follow-up (LTFU), i.e., no visit in the last 12-months. Kruskal–Wallis rank-sum with Dunns pairwise test was used to determine whether travel time, travel distance, and crime rate were associated with retention or viral suppression.

Results

780 patients were included in the study. Of these 273 (35%) were CR, 392 (50%) were IR, and 115 (15%) were LTFU. Figure 1 shows maps with geocoded data. Median distance from clinic was 3.6 [2.1–5.6] miles among those CR, 3.9 [2.5–6.0] miles among the IR, and 3.9 [2.6–6.2] miles among those LTFU. Median travel time by CTA was 37.2 [31.8–53.0] mins for CR, 42.9 [33–53] mins for IR, and 42.9 [33–59.1] mins for LTFU; by car was 15.9 [9.6–33] mins for CR, 17.1 [11.8–24.6] mins for IR, and 17.5 [12.2–24.1] mins for LTFU. Crime rate was similar across all retention groups. Though no associations were statistically significant at P < 0.05, there was a trend toward shorter distance (P = 0.07) and shorter car travel time (P = 0.06) among CR vs. IR. There was also a trend toward lower neighborhood crime rates among those VS vs. those not VS (P = 0.07).

Conclusion

Retention in care was not impacted by residing in high crime neighborhoods in Chicago. PLWHA who lived farther from HIV clinic and had longer travel time showed a trend toward being more likely to be IR in care vs. CR, but there was no such association for VS. Travel time may impact patient likelihood to attend HIV care appointments, but not necessarily adherence to ART.

Disclosures

J. P. Ridgway, Gilead FOCUS: Grant Investigator, Grant recipient
Improving Appointment Adherence among Young Adults with HIV in Peru with an mHealth Intervention: a Feasibility Study
Authors: Prochazka Mateo , Batey D Scott , Zinski Anne , Dionne-Odom Jodie , Otero Larissa , Rodriguez J Martin , González Elsa
Published: October 2017

Background

Mobile Health (mHealth) interventions, including short message services (SMS) reminders and motivational messages, are associated with improved HIV appointment adherence, though feasibility is context-dependent. We assessed the feasibility of an mHealth intervention to improve appointment adherence among young adults with HIV in Lima, Peru.

Methods

Between November 2016 and April 2017, we implemented a one-way mHealth pilot intervention in an outpatient hospital without electronic medical records. We enrolled young adults (age 18–29) entering HIV care in a 3-component intervention: (i) reminder SMS prior to scheduled appointments (provider, laboratory, pharmacy); (ii) motivational SMS after each visit; and (iii) phone call following a missed visit. Feasibility evaluation included enrollment acceptance, visit tracking (information captured in the study database within 3 days of attendance), and proportion of intervention delivery (threshold >90%). We performed a qualitative assessment to identify implementation challenges reviewing staff field notes and meeting minutes.

Results

We enrolled 80/94 (85.1%) eligible participants. The median age was 25 years and 83% were male. The median time of follow-up after enrollment was 115 [interquartile range (IQR): 84–141] days, and participants had a median of 10 (IQR: 8–14) visits during the study period. Among 850 total participant visits, study personnel tracked 751 (88.4%); most (80.8%) untracked visits were pharmacy pickups. Of all tracked visits, most (78.7%) were scheduled appointments and 160 (21.3%) were unscheduled walk-ins. Intervention delivery reached 556/591 (94.1%) for reminder SMS; 733/751 (97.6%) for motivational messages, and 169/170 (99.4%) phone calls for missed visits, 127 (75.1%) of which were answered. Qualitative assessment revealed 2 major themes: real-time appointment tracking in a paper-based system consumed most staff time and resources, and meticulous in-person coordination between the implementation and hospital staff was essential for tracking.

Conclusion

An mHealth intervention to improve appointment adherence among young adults with HIV in Peru appears feasible with dedicated staff and a reliable appointment tracking system. Digitalized appointment systems may be needed to address challenges for scale-up.

Disclosures

All authors: No reported disclosures.
Patient-level Factors Associated with HIV Suppression at Admission Across a Large Integrated Healthcare System
Authors: FigueroaSierra Marileys , Schmidt Monica , Spencer Melanie D , Leonard Michael
Published: October 2017

Background

Linkage to care is a critical step for achieving HIV viral suppression and improving outcomes in newly diagnosed individuals. An unexpectedly high number of patients who have undiagnosed HIV or ineffective viral suppression are identified upon admission to acute care. This study aims to understand factors that may be associated with lack of viral suppression for patients who are newly diagnosed at admission.

Methods

Patients with HIV, admitted to one of our eight acute care facilities were identified (n = 1,632) from medical records. Of these, 94 were newly diagnosed and 1,538 had a prior diagnosis of HIV. Factors that may impact the viral suppression status (<200 copies/mL) prior to admission were examined. Median income and percentage of individuals living below poverty were inferred from the American Community Survey (U.S. Census) data based on a patient’s zipcode. All other factors were extracted from the medical record at the time of admission. Chi square tests and t-tests were used to compare patients who were virally suppressed to those who were not.

Results

The average age was 48 years old and 60% were male and 82% black race. Patients who presented and were not virally suppressed were more likely to be between the ages of 40–60 and of black race. Distributions of age groups and race were significantly different between those virally suppressed and those who were not suppressed at admission (P < 0.05 for both). Blacks and whites between 40 and 60 years were more likely than other race and age groups to present at admission without viral suppression. Patients from geographic areas associated with high poverty and lower median income were less likely to be virally suppressed at admission (23.2% vs. 25.2%; P < 0.05 for poverty and $41,183 vs. $43,757; P < 0.05) for income.

Conclusion

These results indicate that age, race and geographically inferred income and poverty are significantly different between patients who are virally suppressed at admission and those who have a detectable viral load. Further investigation is needed to better understand how these patient-level factors, including socioeconomics, impact linkage to care as well as how best to allocate resources to better engage and retain patients in HIV care to improve their long-term outcomes.

Disclosures

All authors: No reported disclosures.
Antiretroviral Therapy Prescribing Practices and Virologic Response in HIV-Infected Individuals with the M184V Mutation: Results from the 550 Clinic Cohort Study
Authors: Kirkpatrick Lauren , Peyrani Paula , Raghuram Anupama , Spencer Cathy , Bishop Mary , Wojak Maura , Ross Ashley , Wiedmar Jennifer , Truelove Daniel
Published: October 2017

Background

Human immunodeficiency virus (HIV) treatment guidelines recommend using a regimen that contains three fully active antiretroviral agents in patients with drug resistance mutations. However, some evidence suggests that protease inhibitor (PI) based regimens containing less than three fully active drugs may be as efficacious in achieving viral suppression (VS) as a three-drug regimen in the presence of a M184V mutation. The purpose of this study was to identify current prescribing practices and determine if VS can be achieved with regimens containing less than three fully active agents in patients with a M184V mutation.

Methods

A single-center retrospective chart review was conducted on patients receiving treatment at the 550 Clinic from January 2003 to July 2016. Patients were screened for a M184V mutation. Patients were excluded for lack of a genotype and inadequate documentation of viral load (VL) prior to initiating or changing therapy. Regimens were characterized as containing three fully active agents or less and evaluated for VS success (VL less than 200 copies/mL). Data was analyzed using descriptive statistics, Chi-square tests, and Fischer’s exact tests.

Results

A M184V mutation was identified in 100 of the 754 patients screened for inclusion. 90% of the 167 regimens evaluated contained less than three fully active drugs. PI-based regimens (n = 86) and integrase strand transfer inhibitor (INSTI)-based regimens (n = 25) were the most commonly prescribed regimens containing less than three fully active drugs. VS was achieved with 72% of regimens containing less than three fully active agents compared with 69% of those containing three fully active agents (P = 0.108). In patients with a baseline VL greater than 100,000 copies/mL, VS was achieved with 80% of INSTI-based regimens compared with 21% of PI-based regimens (P = 0.040). VS was achieved with 85% of INSTI-based regimens and 78% of PI-based regimens in those with a baseline VL less than 100,000 copies/mL (P = 0.513).

Conclusion

Regimens containing less than three fully active drugs may be as efficacious as regimens containing three fully active drugs in those with a M184V mutation. In those with a high baseline VL, INSTI-based regimens may have better efficacy compared with PI-based regimens.

Disclosures

All authors: No reported disclosures.
Moderate Levels of Pretreatment HIV Drug Resistance — Zimbabwe, April–July 2015
Authors: Da Silva Juliana , Dzangare Janet , Gonese Elizabeth , Mhangara Mutsa , Mugurungi Owen , Barr Beth , Lloyd Spencer , Raizes Elliot
Published: October 2017

Background

The World Health Organization (WHO) HIV Drug Resistance (HIVDR) report 2012 demonstrated that the levels of HIVDR to first-line antiretroviral therapy (ART) are increasing. This finding threatens to reverse a decade of gains in HIV/AIDS epidemic control. The WHO Global Action Plan for HIVDR emphasizes strengthening surveillance of drug resistance through the implementation of national cross-sectional surveys. We conducted such survey to determine the prevalence of HIVDR among ART-naive patients in Zimbabwe and to describe the profile of the surveillance drug resistance mutations (SDRM) encountered in the country.

Methods

A prospective, nationally representative, cross-sectional survey was conducted in 35 clinical sites selected using two stage probability proportional to size sampling. Patients were enrolled during April–July 2015. Specimens were sent for genotyping to CDC Atlanta. SDRM were interpreted using Stanford HIV Drug Resistance Database classification.

Results

A total of 361 subjects were surveyed. Most participants were female (60.3%) and the median age was 35.8 years. Thirty-four out of 361subjects presented with ≥1 SDRM (9.4%, 95% confidence interval: 6.8–12.8%) prior to initiation antiretroviral therapy (ART). Non-nucleoside reverse transcriptase inhibitor (NNRTI) mutations were the most commonly detected mutation (n = 30). Only two patients presented with a nucleoside reverse transcriptase inhibitor mutation and one patient presented with a protease inhibitor mutation. In two patients, ≥3 SDRMs were detected, which may suggest they were not truly ART-naïve.

Conclusion

This study provides national estimates of HIVDR in a high burden country with broad access to ART and provides valuable inisight on the state of HIVDR in such setting. Zimbabwe has reached moderate levels of HIVDR in ART-naive patients, as specified by the WHO classification. These levels may impact the ability to achieve viral suppression in a significant number of patients initiating standard ART regimens in Zimbabwe, where NNRTI-based regimens are used as the first line. The use of drugs with high resistance barrier, such as dolutegravir, may improve the care of patients in the developing world, where individualized pretreatment genotype is not feasible.

Disclosures

All authors: No reported disclosures.
Use of Oral Fluid in a Rapid Syphilis Test Assay
Authors: Shannon Chelsea , Bristow Claire , De Cortina Sasha Herbst , Chang Jennifer , Klausner Jeffrey
Published: October 2017

Background

From 2014 to 2015, the syphilis rate in the United States increased by 19%, reaching its highest rate since 1994. Currently, point-of-care syphilis assays use fingerstick or venipuncture whole blood to identify Treponema pallidum (TP) antibodies by qualitative immunoassay. However, patients and providers prefer oral fluid testing to whole blood testing. In this study, we aimed to determine whether a rapid syphilis test intended for use on whole blood could be used to detect TP antibodies in oral fluid.

Methods

Oral fluid was collected from 72 participants using the Super•SAL™ Oral Fluid Collection Device (Oasis Diagnostics®, Vancouver, WA). The device uses an absorbent cylindrical pad to collect and filter ~1 mlml of oral fluid. Oral fluid filtrate was tested using the SD Bioline Syphilis 3.0 rapid test (Alere Diagnostics, MA) following manufacturer directions for whole blood. TP particle agglutination (TPPA) and rapid plasma reagin (RPR) results derived from participants’ medical records were used as reference values. We used three different definitions as comparators: 1: TPPA reactive; 2: TPPA and RPR reactive and 3: TPPA reactive and RPR titer >1:4. Those with non-reactive TPPA and RPR results were considered seronegative. We calculated the sensitivity and specificity for definition 1 and sensitivity for definitions 2 and 3. We used the exact binomial method to determine 95% confidence intervals (CI).

Results

With definitions 1, 2, and 3, respectively, sensitivity was 83.3% (CI: 67.2, 93.6), 86.4% (CI: 65.1, 97.1), and 100% (CI: 71.5, 100). Specificity was 47.2% (CI: 36.5, 75.5).

Conclusion

The high sensitivity of the SD Bioline Syphilis 3.0 test using oral fluid suggests a strong potential for the development of accurate rapid oral syphilis tests. Sensitivity increased with higher RPR titer. False positive results may be due to the presence of non-venereal treponemal antibodies in oral fluid. Further research and development are needed to optimize specificity.

Disclosures

All authors: No reported disclosures.
Identifying African American Women with HIV Infection in an Expanded HIV testing and Linkage to Care (X-TLC) Program in Healthcare Settings on the South and West Sides of Chicago.
Authors: McNulty Moira C , Almirol Ellen , Ridgway Jessica P , Schmitt Jessica , Eavou Rebecca , Taylor Michelle , Kern David , Schuette Stephanie , Stonehouse Patrick , Tobin Audra , Glick Nancy , Pitrak David
Published: October 2017

Background

Women account for 25 % of HIV infections nationally, and African American (AA) women are disproportionately affected. We report important gender differences observed in an expanded HIV testing and linkage to care (X-TLC) program conducted on the South and West Sides of Chicago.

Methods

X-TLC is funded by CDPH with CDC prevention B funds. X-TLC has expanded from 3 sites to 14 sites, including acute care hospitals (academic, community), community health centers (CHCs), and family planning clinics. We report descriptive stats, group comparisons by Chi-square, and multivariate analyses adjusted for demographics.

Results

Since 2011, X-TLC has conducted 308,038 HIV screens, and 63.7 % of those tested were women. Overall seroprevalence for HIV was 0.56 %, and 30.5 % of HIV patients identified were cis-gender women (seroprevalence 0.15 %). The seroprevalence for women testing in EDs was higher (0.44 %). Similar to men, only 52.9 % of HIV positive women were new diagnoses. Women accounted for 28.5 % of all new diagnoses, compared with 15.4 % for Chicago overall. In 2016 X-TLC screened 91,865 persons for HIV, and 65.2 % of those tested were women. There were 193 new diagnosis and 32.1 % (62) were women, 85.7 % AA. In comparison, in 2015 there were 139 women with a new HIV diagnosis for all of Chicago. Women newly diagnosed were less likely to be linked to care (adjusted odds ratio, aOR, 0.54, 0.35–0.85). Linkage was lower for women diagnosed at CHCs (84.6 % vs. 76.3 %, P = 0.02). Most CHCs did not have on site HIV providers. At our site, however, women linked to care were more likely to be retained in care (aOR 0.58, 0.43–0.78). We also conduct targeted outreach testing, partner services (PS) testing, and social network strategy (SNS) testing, but women are not identified by these programs (16/171 tested women, 8 new diagnoses were men for PS; 507 tested, 471 men and 36 trans-gender women, 38 new positives, 0 cis-gender women for SNS).

Conclusion

More women than men were offered and/or accept HIV screening in healthcare settings. The proportion of seropositive women identified was higher than the national average. X-TLC is reaching a large proportional of AA women with HIV unaware of their status. Other testing strategies will rarely identify cis-gender women with HIV infection. Gender differences in linkage to and retention in care will require strategies targeted at women.

Disclosures

J. P. Ridgway, Gilead FOCUS: Grant Investigator, Grant recipient; N. Glick, Gilead FOCUS: Grant Investigator, Grant recipient; D. Pitrak, Gilead Sciences FOCUS: Grant Investigator, Grant recipient
Making a Big Impact on Expanding HIV Inpatient Testing with a Small EHR Modification
Authors: Nguyen Tri
Published: October 2017

Background

The CDC estimates over 1.2 million Americans are living with HIV and, of those, approximately 14% are unaware of their HIV-positive status. Since 2014, most hospitals adopted some form of Electronic Health Records (EHR) and the Centers for Medicare & Medicaid Services extended Medicare coverage for annual HIV screenings. Despite these developments, there has been limited progress in expanding HIV testing in inpatient settings. The present study was conducted at Jersey City Medical Center (JCMC) in an effort to expand HIV testing by implementing EHR modification in the form of testing prompts.

Methods

This study began on January 1, 2016 at JCMC, a teaching hospital that passed all lab work orders through an EHR system. The number of daily orders for HIV screenings was recorded for 145 consecutive days before EHR modification (n = 145) to establish baseline data. EHR modification occurred on the 146th day of the study (May 25, 2016). This modification featured testing prompts displaying CDC guidelines for screening patients over the age of 18 for HIV whenever a physician ordered lab work for admitted patients. Orders for HIV screenings on this transitional date were excluded from analysis. After EHR modification was completed, the number of daily orders for HIV screenings was recorded for an additional 145 consecutive days (n = 145) for comparison. Testing data was available for all 145 consecutive days before and 145 consecutive days after EHR modification.

Results

Since the beginning of this study—before testing prompts were implemented—JCMC inpatient units ordered an average of 8.53 (SD=3.25) HIV screenings per day. The average number of daily orders for HIV screenings increased twofold after EHR modification (M=17.39, SD=4.26), t(288) = 19.90, P < .001. JCMC identified 86 HIV-positive and linked over 90% of these patients to care.

Conclusion

Conventional HIV screening methods in the inpatient setting might not be sufficient at detecting most HIV-positive cases. By implementing testing prompts in its EHR system to encourage increased testing for HIV, Jersey City Medical Center was able to increase the number of individuals aware of their HIV status and link them to care as needed.

Disclosures

T. Nguyen, Gilead FOCUS: Employee, Grant recipient
Viral Blips Were Infrequent in HIV-1-Infected Virologically-Suppressed Adults Treated with Tenofovir Alafenamide or Tenofovir DF Rilpivirine-Containing Regimens
Authors: Wohl David A , Kulkarni Rima , Garner Will , White Kirsten , Porter Danielle
Published: October 2017

Background

Differences between regimens in the frequency of transient episodes of viremia (viral blips) as well as the impact of these viral blips on the risk of virologic failure and resistance development is not fully understood. Here we investigate the frequency of viral blips in virologically-suppressed subjects switching to rilpivirine/emtricitabine/tenofovir alafenamide (R/F/TAF) vs. maintaining R/F/tenofovir disoproxil fumarate (TDF) and the association of viral blips with clinical outcome through Week 48 of study GS-US-366-1216.

Methods

GS-US-366-1216 is a randomized, double-blind, phase 3b study evaluating the safety and efficacy of switching to R/F/TAF from R/F/TDF in HIV-1-infected virologically-suppressed subjects. For the viral blip analysis, treated subjects with ≥1 post-baseline HIV-1 RNA value were included. All on-drug HIV-1 RNA data points and FDA snapshot outcome data through Week 48 were utilized. Plasma HIV-1 RNA was measured using the Roche Taqman 2.0 assay. A viral blip was defined as any post-baseline HIV-1 RNA value ≥50 c/mL preceded and followed by HIV-1 RNA <50 c/mL.

Results

Of the 627 subjects included in the analysis, 23 (3.7%) experienced ≥1 blip through Week 48 and were distributed similarly between treatment groups (10/315, 3.2% R/F/TAF; 13/312, 4.2% R/F/TDF; P = 0.53; median 6 viral load measurements per subject). Twenty subjects had single blips (8 R/F/TAF, 12 R/F/TDF) and 3 subjects experienced 2 blips each (2 R/F/TAF, 1 R/F/TDF). Of 26 total blip events, 19 (73%) were low-level at 50–199 c/mL. Among subjects with blips, 22/23 (96%) were virologic successes at Week 48 (9/10, 90% R/F/TAF; 13/13, 100% R/F/TDF), similar to those subjects without blips (568/604, 94% overall; 287/305, 94% R/F/TAF; 281/299, 94% R/F/TDF). One subject in the R/F/TAF group had 2 blips prior to experiencing virologic rebound with mutations also detected at baseline (determined by retrospective proviral DNA sequencing).

Conclusion

Viral blips were infrequent among subjects switching to R/F/TAF or maintaining R/F/TDF through Week 48 of study GS-US-366-1216. No differences in blip frequency or virologic failure post-blip were observed between treatment groups. Most blips were low-level (<200 c/mL) and most subjects with blips remained suppressed through Week 48.

Disclosures

D. A. Wohl, Gilead Sciences Inc.: Consultant and Investigator, Consulting fee and Research grant; ViiV: Consultant and Investigator, Consulting fee and Research grant; Janssen: Consultant, Consulting fee; Bristol Myers Squibb: Consultant, Consulting fee; R. Kulkarni, Gilead Sciences, Inc.: Employee and Shareholder, Salary; W. Garner, Gilead Sciences, Inc.: Employee and Shareholder, Salary; K. White, Gilead Sciences, Inc.: Employee and Shareholder, Salary; D. Porter, Gilead Sciences, Inc.: Employee and Shareholder, Salary
Principal Components and Costs of HIV-Associated Hospitalizations in the United States: A National Study in the Current Era
Authors: Santos Carlos , Tenorio Allan
Published: October 2017

Background

HIV-associated illness in the US has evolved with the advent of antiretroviral therapy and aging of the HIV-infected population. While changes in the causes of mortality in these patients are well documented, reasons for hospitalization and costs associated with hospital stays are not well studied at the national level.

Methods

We collected billing and demographic data of 84,666 HIV-associated hospitalizations across 3,564 hospitals nationwide using the 2012 and 2013 National Inpatient Sample, and used principal component analysis to arrive at predominant themes of HIV-associated hospitalization. Components with eigenvalues greater than one were retained, and orthogonal rotation was performed to identify variables that significantly loaded each component. Estimated hospital costs were determined by multiplying inflation-adjusted charges with hospital-specific cost-to-charge ratios and inverse wage indexes, and average costs associated with principal components were computed.

Results

Kidney disease predominated as a theme for HIV-associated hospitalization and accounted for 9% of the total variance. This was followed by liver disease, opportunistic infections with Pneumocystis and Candida, septicemia, and substance abuse, which accounted for 7%, 6%, 5% and 4% of the total variance respectively. Other significant contributors to hospitalization were heart disease, low socioeconomic status, complicated diabetes mellitus, and other opportunistic infections. The highest costs were associated with septicemia which averaged $25,557 per hospitalization, whereas the lowest costs were associated with substance abuse which averaged $7,534 per hospitalization.

Conclusion

Kidney and liver disease are important components of HIV-associated hospitalization in the current era reflecting an aging population overlain with complications from HIV and viral hepatitis. Opportunistic infections continue to be major contributors to hospitalization indicating ongoing challenges in access and adherence to antiretroviral therapy. Research efforts should focus on ameliorating HIV-related kidney and liver disease, as well as implementing strategies to promote early diagnosis and treatment of HIV.

Disclosures

All authors: No reported disclosures.
What Determines Do-Not-Resuscitate Status in Critically Ill HIV Patients?
Authors: Turvey Shannon L , Gregory Anne , Bagshaw Sean , Sligl Wendy I
Published: October 2017

Background

Mortality and morbidity of people living with HIV have declined in the era of combination antiretroviral therapy (cART). However, Intensive Care Unit (ICU) admission rates remain high. In this study, we identified predictors of Do-Not-Resuscitate (DNR) status in critically ill HIV patients.

Methods

Retrospective cohort study of all first-time admissions of HIV-infected patients to five ICUs in Edmonton, Alberta from 2002 to 2014. Data collected included demographics, comorbidities, markers of HIV disease severity and control, admission diagnoses, severity of illness, organ failure, and DNR status. Multivariable logistic regression analysis was performed to identify factors associated with DNR status.

Results

During the study period, 282 patients were admitted to the ICU for the first time. Mean (SD) age was 44 (±10) years, 169 (60%) were male, 134 (48%) aboriginal, 153 (55%) co-infected with hepatitis C virus, and 184 (65%) had a history of polysubstance use. Median (IQR) CD4 count and viral load were 125 (30–300) cells/mm3and 28,000 (110–270,000) copies/mL, respectively. Only 98 (35%) patients were receiving cART at the time of admission while 45 (16%) were newly diagnosed in the ICU. Most common admission diagnosis was sepsis 189 (64%), 213 (76%) received mechanical ventilation, 133 (47%) vasopressor support and 35 (12%) renal replacement therapy. Sixty-seven (24%) patients were DNR and support was withdrawn in 42 (15%). In multivariable analysis, APACHE II score (adjusted odds ratio [aOR] 1.13; 95% CI, 1.08–1.19, P < 0.001), coronary artery disease (CAD) (aOR 5.7; 95% CI, 1.2–27.8, P = 0.03), prior opportunistic infection (OI) (aOR 2.6; 95% CI, 1.2–5.6, P = 0.015) and duration of HIV infection (aOR 1.07 per year; 95% CI, 1.01–1.14, P = 0.025) were independently associated with DNR status. Other factors such as ethnicity, HIV risk factor(s), CD4 count and viral load were not associated with DNR status.

Conclusion

In this relatively young cohort, one in four patients had DNR status during ICU admission. DNR designation was associated with severity of illness, along with CAD, prior OI, and duration of HIV infection. Future work should characterize the timing of patient DNR orders relative to ICU admission and describe patient and provider-specific factors that may influence decision-making towards DNR status.

Disclosures

All authors: No reported disclosures.
Less Is More: Surgical Procedure Time and Risk of Infections, Length-of-Stay, and Readmission across Three Distinct Surgeries
Authors: Parikh Ronak , Shah Nirav , Saeed Huma , Bhaimia Eric , Lahrman Frances , McNulty Moira C , Robicsek Ari , Padman Rema , Grant Jennifer
Published: October 2017

Background

Longer surgical total procedure times (TPT) have been associated with increased postoperative complications. It is unclear what the effect of TPT is on length-of-stay (LOS) or 30-day readmission rate (RAR).

Methods

We performed a retrospective study of patients undergoing knee arthroplasty (KA), colectomy, and craniectomy at NorthShore University HealthSystem from 1/2007 to 12/2013. Clinical data were extracted from the Data Warehouse and charts were reviewed. We standardized surgery times for each procedure and categorized into two groups: times <75‰ (short procedures) vs. times >75‰ (long procedures). We used χ 2 and t-test to compare categorical and continuous variables. We performed multivariate logistic regression for predictors of surgical site infection (SSI).

Results

In univariate analyses, long procedures were associated with higher incidence of fevers, SSI, longer LOS, and 30-day RAR (Table 1). TPT was not associated with other postoperative complications. TPT remained an independent predictor of SSI in multivariate (MV) analysis (Table 2).

Conclusion

High TPT was associated with increased SSI, LOS, and 30-day RAR. Understanding variation in TPT may help decrease SSI and healthcare utilization.

Disclosures

All authors: No reported disclosures.
Hospitalization and Emergency Room Visits: The Opportunity for Re-Engagement for People Living with HIV/AIDS (PLWHA)
Authors: Almirol Ellen , Schmitt Jessica , Wesley-Madgett Lindsey , Eavou Rebecca , Pitrak David , Ridgway Jessica P
Published: October 2017

Background

Persons living with HIV/AIDS (PLWHA) who are not engaged in HIV medical care are at greater risk for adverse individual health outcomes, as well as potential transmission to others. Thus, detecting and re-engaging PLWHA who are not in care is a public health priority. Unplanned hospitalizations or Emergency Department (ED) visits provide a potential opportunity to re-engage PLWHA who are out of care. Our Data-to-Care (D2C) pilot project was launched in July 2016 to identify PLWHA in the ED and inpatient settings and subsequently, establish re-engagement in HIV care (RIC) among those out of care.

Methods

Our D2C program leverages electronic health records (EHR) as a mechanism to identify PLWHA and support RIC. An Infectious Diseases social worker (SW) generates an EHR-based report daily to identify PLWHA in the hospital in near real-time, then determines whether a patient currently receives HIV care. If not, the SW meets with the patient to determine needs, insurance status, schedules an HIV care appointment, and provides referrals for wraparound services. SW subsequently confirmed attendance at HIV care appointment. RIC was defined as attending an HIV clinical appointment, and X2 analyses were used to compare differences between RIC and not RIC.

Results

Over a 10-month period, we identified 237 PLWHA seen in the ED or hospitalized. The majority of patients were African-American (AA) (92.7%), male (66.1%) and mean age 44.6 ± 14.6 years old. Of the 237 patients identified, 172 (72.6%) confirmed already in care, 7 (3.0%) deceased, and 2 (0.8%) incarcerated. Among patients eligible for RIC, 44 (73.3%) were contacted by staff, 39 (65.0%) were referred to care, and 32 (53.3%) were RIC. Patients not RIC were all AA, 69.2% male, and mean age 38.5 ± 14.2 years old. Patients identified in the inpatient setting were more likely to be RIC vs. those identified in the ED (81.3% vs. 18.8%, P < 0.01). Interestingly, insurance type was not associated with RIC vs. not RIC (P = 0.17).

Conclusion

Our pilot program demonstrates the potential for using the EHR to identify PLWHA who are in need of RIC during unplanned hospitalizations and ED visits. Inpatients were more likely to be RIC than ED patients, likely due to the ability to make in-person contact during hospitalization compared with ED visit by SW staff.

Disclosures

D. Pitrak, Gilead Sciences FOCUS: Grant Investigator, Grant recipient
Healthcare Resource Utilization and Costs Associated with Switching First-line Antiretroviral Therapy among HIV-infected Patients in the United States
Authors: Mao Jianbin , Johnson Micheal , Mcpheeters Jeffrey , Prajapati Girish , Beyer Andrew
Published: October 2017

Background

Initial antiretroviral therapy (ART) is modified for non-virologic failure reasons in many patients, and the healthcare resource utilization (HRU) and costs associated with these switches in the real world is not well understood.

Methods

Administrative claims data from the Optum Research and Impact National Benchmark Databases were utilized. Adult patients (≥18 years) with HIV-1 diagnosis code, and claim for an anchor agent of the protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI) class in first-line ART between July 1, 2006 and December 31, 2015 were identified (see Figure 1 for addl. criteria). Patients with a claim for an anchor agent (PI or NNRTI) different from that in first-line ART were defined as switchers, with index date as date of first claim for new anchor agent. Switchers were matched to patients who did not switch (non-switchers) at 1:3 ratio using propensity score matching on patient and first-line ART characteristics. For non-switchers, date following corresponding duration of first-line ART in matched switcher was assigned as index date. Per-patient-per-month (PPPM) all-cause HRU and costs (US$) during switch period (±15 days of index date) were compared descriptively.

Results

11,302 patients met study criteria. After matching, switcher (1,204) and non-switcher (3,612) groups were comparable on mean age (41.9 vs. 41.7 years), percent male (85.8% vs. 82.6%), percent commercial enrollee (96.0% vs. 95.8%), mean Quan-Charlson comorbidity index score (both 0.4), and mean ART pill burden (both 2.2) with standard difference less than absolute value of 10%. During switch period, switchers had higher mean PPPM ambulatory visits (2.30 vs. 1.26), emergency room visits (0.12 vs. 0.06), inpatient stays (0.04 vs. 0.01), and pharmacy fills (4.52 vs. 3.01) than non-switchers (all P < 0.001). Switchers also incurred greater mean PPPM costs during switch than non-switchers, with an additional $2,261/month total cost, and $1,031/month pharmacy cost (Figure 2).

Conclusion

The study gives a more complete view of the burden of switching initial ART with pharmacy costs driving this burden. Assuming some patients will switch regardless of the regimen selected, less expensive initial ART could reduce this burden further.

Disclosures

M. Johnson, Merk & Co: Research Contractor, research funded by Merk; J. Mcpheeters, Merck & Co.: Research Contractor, Sarary from Optum; G. Prajapati, Merck & Co., Inc.: Employee, Salary; A. Beyer, Merck & Co., Inc: Employee and Shareholder, Salary
Management of End Stage Renal Disease in Persons Living with HIV: A Cost-Effectiveness Analysis
Authors: Joe Winston B , Eaton Ellen F
Published: October 2017

Background

HIV+ kidney transplant (KT) for persons living with HIV (PLWH) is both safe and effective, with comparable patient and graft survival rates relative to HIV- KT. The objective of this study was to evaluate the cost-effectiveness of HIV+ KT relative to HIV- KT and dialysis.

Methods

A decision-tree framework was used to assess the cost-effectiveness of the above treatment options for PLWH. Clinical outcomes at 3 years for KT and effectiveness data (expressed in QALYs) were abstracted from previous publications, when available. Costs were assigned from a payer’s perspective using the US Renal Data System and published literature (expressed in 2014 USD). This analysis assumed a three-year time horizon. Sensitivity analyses were explored to understand how changes in 1) acute KT rejection and 2) KT failure impact cost effectiveness. Limitations include small sample size and short follow up time in referenced studies and a lack of health utility data in HIV positive persons with renal failure. We used TreeAge Software (Williamstown, MA).

Results

HIV+ KT was most cost effective ($299,904/QALY) while both HIV- KT ($329,676) and dialysis ($444,645) were dominated, meaning more costly and less effective. Results were sensitive to the higher KT failure (26% vs. 16%) and acute rejection (39% vs. 17%) observed with HIV- KT relative to HIV+ KT. In sensitivity analysis, as HIV+ KT rejection rates approach 20%, HIV- KT becomes a cost-effective option. As HIV+ KT failure rates approach 26%, HIV- KT becomes cost effective.

Conclusion

Despite its limitations, this analysis demonstrates that HIV+ kidney transplantation is a cost-effective alternative for PLWH under certain conditions. As KT outcomes, like graft failure and acute rejection rates, continue to improve, it is likely that both HIV positive and negative KT will be cost-effective alternatives to dialysis.

Disclosures

All authors: No reported disclosures.