bluuebunny/crossref_metadata_2025 huggingface dataset:
968. The Impact of Opt-Out HIV Screening and Patient Navigator-Assisted Linkage to Care of Newly Diagnosed Persons with HIV in a High-Prevalence Emergency Department
Authors: Kodali Swetha , Paer Jeffrey M , Sudyn Alexander W , Maldonado Samuel , Nyaku Amesika , Swaminathan Shobha
Published: January 2021

Background

Newark is the epicenter of the HIV epidemic in New Jersey. University Hospital, the state’s only public safety net hospital, plays a critical role in identifying and linking newly diagnosed persons with HIV (PWH) to care. We previously showed that the emergency department (ED) is the most common setting for missed testing opportunities. Therefore, in 2015 we implemented a routine opt-out HIV screening and patient navigator (PN)-assisted linkage to care (LTC) protocol in the ED, and this project examined the LTC rates for newly diagnosed PWH.

Methods

We conducted an IRB-approved retrospective chart review of patients who tested positive for HIV in the ED between 2015 and 2018. Descriptive statistics were used to summarize demographic and clinical data. Univariate and multivariate regression were used to identify demographic and clinical factors associated with LTC for newly diagnosed PWH. Age, sex, and factors with p ≤ 0.10 in the univariate analysis were included in the final model.

Results

Of the 464 patients who screened positive, 123 (26.5%) were new diagnoses. The mean age was 41.0 years (SD = 13.8); 82 (67%) male; 74 (60%) black, 26 (21%) Hispanic, 7 (6%) white. The median CD4 count was 242 (IQR = 120 - 478) cells/µL, and 10 patients (8.1%) had acute HIV infection. Six patients (4.9%) died before LTC. Among the remaining 117 patients, PN outreach resulted in scheduled appointments at the Infectious Disease Practice for 102 (87.2%). In total, 79 (67.5%) were linked to care and 38 (32.5%) were referred to the state for linkage. Of the patients linked to care, 49 (62.0%) attended their first appointment and 30 (38.0%) required additional PN outreach. Men who have sex with men (MSM) (OR = 17.2, p = 0.002) and heterosexual contact (OR = 6.3, p < 0.001) were predictive of LTC.

Conclusion

Our protocol resulted in LTC for the majority of newly diagnosed PWH. Among those linked to care, over a third required additional PN outreach after missing their first appointment, highlighting the importance of PN follow-up. MSM and heterosexual contact, the two highest risk factors for HIV in New Jersey, were predictive of LTC. Their successful LTC may be explained, in part, by the fact that PNs were demographically similar and lessened perceived stigma associated with entry into care.

Disclosures

All Authors: No reported disclosures
969. TNF-alpha inhibition in the setting of undiagnosed HIV infection: a call for enhanced screening guidelines
Authors: Claytor Jennifer , Viramontes Omar , Conner Stephanie , Wen Kwun Wah , Beck Kendall , Henrich Timothy J , Chin-Hong Peter , Chin-Hong Peter , Peluso Michael J
Published: January 2021

Background

Despite the risks of immunosuppression, recommendations regarding screening for HIV infection prior to initiation of biologic therapies targeting common autoimmune disorders, including inflammatory bowel disease (IBD) and inflammatory arthritides, are limited. Few cases of patients started on biologics while living with undiagnosed HIV have been reported.

Methods

We report 3 cases of patients initiated on biologics in the absence of recent or concurrent HIV screening who developed refractory disease or unanticipated complications and were later found to have undiagnosed chronic HIV infection.

Results

In Case 1, a 53-year-old man who has sex with men (MSM) with negative HIV testing 10 years prior presented with presumed rheumatoid arthritis. He did not respond to methotrexate (MTX), so adalimumab (ADA) was started. HIV testing to evaluate persistent symptoms was positive 9 months later; CD4 was 800 cells/uL. Antiretroviral therapy (ART) resulted in resolution of symptoms, which were attributed to HIV-associated arthropathy.

In Case 2, a 55-year-old woman with injection drug use in remission and no prior HIV testing presented with Hidradenitis Suppurativa (HS). She was initiated on infliximab (IFX) and MTX with good response. After she developed weight loss and lymphopenia, an HIV test was positive; CD4 was 334 cells/uL. Biologic HS therapy was discontinued, with subsequent poor HS control.

In Case 3, a 32-year-old MSM with no prior HIV testing presented with presumed IBD; IFX and steroids were started. Symptoms progressed despite IBD-directed therapy, and he was diagnosed with extensive Kaposi Sarcoma (KS) with visceral and cutaneous involvement likely exacerbated by immunosuppression. HIV testing was positive; CD4 was 250 cells/uL. KS initially worsened due to ART-associated immune reconstitution inflammatory syndrome. He is now improving with systemic chemotherapy and ART. HIV-associated KS is presumed to be hte underlying diagnosis.

Conclusion

All 3 patients had elevated risk for HIV infection, and 2 had final diagnoses attributed to chronic HIV infection, not warranting therapeutic immunosuppression. Screening for HIV infection prior to initiation of biologic therapy should be incorporated into clinical practice guidelines.

Disclosures

All Authors: No reported disclosures
972. Infection and Overdose Prevention for Persons with Injection Drug Use-Related Infections: Evaluation of an Inpatient Quality Improvement Program
Authors: Speight Carly C , Stoner Bobbi J , Guthrie George A , Brown Turkeisha S , Farel Claire E , Rivera M Patricia , Schranz Asher J
Published: January 2021

Background

Hospitalizations for injection drug use-related infections (IDU-I) are increasing in North Carolina and nationally. Many IDU-I, such as endocarditis, bone, joint, and spine infections, require long antimicrobial courses and extended inpatient stays. These hospitalizations are opportunities to engage patients in overdose and infection prevention.

Methods

A quality improvement (QI) program was piloted for inpatients with IDU-I. Eligible patients admitted to the inpatient pulmonary or infectious disease teams from 11/2019 to 01/2020 were referred to the QI team if they reported or were suspected to have injected drugs over the past year, or felt to benefit from drug-related infection prevention and overdose services. A checklist of recommendations to the care teams included: (1) screening for HIV, Hepatitis B (HBV) and C (HCV), (2) immunization for Hepatitis A (HAV), HBV, and tetanus, (3) prescription of naloxone at discharge, and (4) information on a syringe services program in or near their county. After review of the medical record, the QI team made recommendations on the appropriate taks from the checklist. The number of QI checklist tasks performed on the two inpatient teams during a 9-week pilot period (the above period excepting a two-week break) was reviewed. Baseline comparison data was not incorporated, owing to the challenges in retrospective identification of IDU-I.

Results

20 patients were included in the intervention. The median age was 32 years (IQR 27-38) and 70% were female. The most common diagnosis was endocarditis (40%) and the median length of stay was 11 days (IQR 5-42). HIV and HCV tests were each conducted in 95% of patients (Table). Screenings for HAV and HBV immunity were done in 90% of patients. HAV, HBV, and Tdap immunizations were given to 20%, 35%, and 50%, respectively. Naloxone was provided to 60% of patients at discharge and half of patients were referred to syringe programs. HCV was detected in 8 patients and HBV in 2 patients. No patients were diagnosed with HIV.

Percentage of infection and overdose prevention services provided to eligible IDU-I patients during hospitalization.

Conclusion

In a setting without comprehensive addiction consultation, a simple intervention provided guideline-concordant infection and overdose prevention services for persons hospitalized for IDU-I.

Disclosures

All Authors: No reported disclosures
975. Why Sex Make a Difference in HIV Clinical Course? Bioinformatics Analysis of Differential Expressed Gene in Females and Males with HIV Disease
Authors: Suwanwongse Kulachanya , Shabarek Nehad
Published: January 2021

Background

Human immunodeficiency virus (HIV) disease progression are different among genders, in which women usually progress to acquired immunodeficiency syndrome (AIDS) faster than men. The mechanisms resulting in the gender biases of HIV progression are unclear. We conducted a bioinformatics analysis of differentially expressed genes (DEGs) in women and men with HIV disease to understand the sex-based differences in HIV pathogenesis.

Methods

We obtained microarray data from the Gene Expression Omnibus (GEO) database using our pre-defined search strategy and analyzed data using the GEO2R platform. The t-test was done to compare DEGs between females and males with HIV diseases. The Database for Annotation, Visualization, and Integrated Discovery (DAVID) was implemented to systematically extract biological features and processes of retrieving DEGs via gene ontology (GO) analysis. A Systemic search was performed to evaluate each DEG function and its possible association with HIV.

Results

One gene expression profiling data were retrieved: GSE 140713, composed of 40 males and 10 females with HIV1 infected samples. A GEO2R analysis yielded 19 DEGs (Table 1). The GO analysis result was demonstrated in Tables 2 and 3. Following a systemic search, we found two DEGs, which have previous studies reported an association with HIV: DDX3X (20 studies) and PDS5 (1 study). We proposed DDX3X (t 5.3, p 0.0037) is responsible for gender inequalities of HIV progression because of: 1. DDX3X is needed in the HIV1 life cycle. 2. Several studies confirmed a positive correlation between DDX3X expression and HIV1 replication. 3. Our study found an up-regulated DDX3X expression in women corresponded to the fact that women progress to AIDS faster than men. 4. Our GO analysis showed female up-regulated genes were enriched in positive regulation of the gene expression pathway, which can be explained by DDX3X and its underlying mechanism.

Table 1: DEGs in women and men with HIV1 disease

Table 2: GO functional enrichment pathway analyses of overall retrieving DEGs

Table 3: GO functional enrichment pathway analyses of down- and up-regulated clusters of DEGs

Conclusion

Aberrant DDX3X expression may contribute to sex-based differences in HIV disease. Drugs modifying DDX3X gene expression will be beneficial in the treatment of HIV especially resolving the HIV drug resistance problem because current anti-HIV drugs target viral components posed the risk of viral mutation.

Disclosures

All Authors: No reported disclosures
977. Bacterial STI Diagnoses as Missed Opportunities for HIV Pre-Exposure Prophylaxis
Authors: Reddy Archana K , Salazar Jorge , Waldman Sarah
Published: January 2021

Background

New HIV diagnoses in the United States have remained stagnant while the incidence has increased among certain groups; additional efforts towards HIV prevention are needed. Most adults who could benefit from HIV Pre-Exposure Prophylaxis (PrEP) in the United States are not receiving it. Many of these individuals present for healthcare visits for bacterial sexually transmitted infection (STI), an indication for PrEP in both men who have sex with men (MSM) and heterosexual individuals; we sought to characterize these visits and identify missed opportunities for PrEP prescription to inform future PrEP expansion efforts.

Methods

A retrospective chart review was conducted for all healthcare encounters of adult patients newly diagnosed with a bacterial STI within the UC Davis Health electronic medical record between January 1, 2017 and December 31, 2017. A bacterial STI was defined as a positive test result for gonorrhea, chlamydia, or syphilis. Patients were excluded if they had HIV, were pregnant or a prisoner, or if they were a woman or heterosexual man with a positive test result for chlamydia (not an indication for PrEP per CDC guidelines). Patient demographic, clinical, and visit-specific data were recorded; characteristics were described using frequencies for categorical variables, and median and quartiles for quantitative variables.

Results

205 encounters for bacterial STI were identified as potential opportunities for PrEP. The majority of PrEP candidates presented to the emergency department for their STI (44%), while 40% and 16% of encounters occurred in outpatient and inpatient settings, respectively. The majority of PrEP candidates were not offered PrEP within 6 months of their encounter for STI (86%). Of the 14% of PrEP candidates who were offered PrEP within 6 months of their STI diagnosis, the majority had presented to the outpatient setting for their STI (93%).

Conclusion

Visits to the emergency department for bacterial STI represent a disproportionate missed opportunity for PrEP discussion & prescription. Future PrEP expansion efforts should address emergency department visits as opportunities for linkage to PrEP and/or PrEP prescription.

Disclosures

All Authors: No reported disclosures
981. Extended Adherence and Persistence to HIV PrEP in a Multidisciplinary PrEP Clinic
Authors: Whelchel Kristen , Zuckerman Autumn , DeClercq Josh , Choi Leena , Rashid Shahristan , Kelly Sean
Published: January 2021

Background

Methods to identify and address barriers to human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) persistence are needed to improve low PrEP persistence rates beyond 6 months. We evaluated PrEP adherence and persistence in a multidisciplinary clinic model with an integrated specialty pharmacist.

Methods

We conducted a single-center, retrospective, cohort study of patients initiating PrEP in the multidisciplinary Vanderbilt PrEP Clinic with prescriptions filled by Vanderbilt Specialty Pharmacy between 9/1/2016 and 3/31/2019. In this model, integrated clinical pharmacists manage PrEP access, affordability, and therapy monitoring. Clinical data were collected from the electronic health records and pharmacy claims data. Adherence was calculated from fill data using proportion of days covered (PDC). Persistence at 6, 12 and 18 months was measured using patient-reported discontinuation date or the date of the last fill plus the fill’s days’ supply for patients lost to follow-up. The Kaplan-Meier estimation method was used to estimate persistence probabilities.

Results

Most of the 63 patients included were male (97%), white (84%), commercially insured (94%) with a median age of 38 years, and men who have sex with men at high risk for acquiring HIV (97%); Table 1. The majority of patients with at least one follow-up visit (n=58) reported no adverse effects (78%), no missed doses (71%), and had a median PDC of 99% (IQR 97% – 100%). Persistence at 6, 12 and 18 months was 0.87 (95% confidence interval, CI, 0.80 – 0.96), 0.81 (95% CI 0.72 – 0.91), and 0.74 (95% CI 0.64 – 0.86), respectively; Figure 1. Of the 18 patients who discontinued PrEP, 9 discontinued due to perceived lack of risk for acquiring HIV, 6 were lost to follow up, 1 moved, transferring PrEP care to a new provider, 1 had worsening depression, and 1 had renal function decline.

Table 1 Patient Characteristics

Figure 1 Persistence on HIV PrEP

Conclusion

Patients receiving PrEP treatment in a multidisciplinary clinic with an integrated clinical pharmacist had high rates of adherence and persistence up to 18 months. Patients reported few side effects and reasons for therapy discontinuation were appropriate. Efforts to incorporate pharmacy support in managing PrEP patients could be beneficial in increasing patient adherence and persistence.

Disclosures

All Authors: No reported disclosures
989. Pre-exposure Prophylaxis (PrEP) Short-Term Retention Among Heavy Alcohol Users in Rural South Africa
Authors: Grammatico Megan A , Choi Koeun , Moll Anthony , Shenoi Sheela
Published: January 2021

Background

Despite widespread access to HIV testing and antiretroviral therapy (ART), men, and especially young men, remain difficult to engage in HIV services. Alcohol use disorder (AUD) further complicates engagement. Congregate alcohol venues, known as shebeens, are an ideal place to engage with young men for HIV testing, treatment, and prevention services, including pre-exposure prophylaxis (PrEP). Here we report on one-month retention in care in eligible patrons recruited from shebeens into a community-based model of PrEP delivery.

Methods

An all-male field team offered HIV testing at mobile clinics outside shebeens in rural Msinga sub-district of Kwazulu-Natal (KZN) province. Eligible participants were offered enrollment into a community-based model of PrEP delivery. PrEP initiators completed the AUDIT scale, with hazardous alcohol use defined as score > 6 for women and > 8 for men, and had dried blood spot (DBS) analysis for phosphatidylethanol (PEth). Loss to follow up was defined as not attending the 1 month follow up appointment, non-response to 3 separate phone calls on three separate days, and unsuccessful tracing at least once at participant’s home address.

Results

Between February and May 2020, 16 eligible shebeen patrons initiated PrEP, a median of 14.5 days (IQR 12.5 – 19) after initial screening. Among initiators, 93.8% were male, median age was 29.5 years (IQR 22.25 - 37), 31.2% were employed, 56.3% had running water, and 68.8% were hazardous alcohol users. One-month follow-up visits were completed with 68.8% (11/16) participants. Of those retained in care, 90.9% reported at least one sexual partner in the last month, and 54.5% reported more than one sexual partner. All sexually active participants reported inconsistent condom use. In the prior 7 days, 63.7 % of participants reported taking “all of my medication” and 36.4% reported taking “most of my medication,” verified by pill count. Hazardous alcohol use and PEth results did not predict one-month retention in this small sample

Conclusion

Young men engaging in risky behavior were interested and willing to engage in PrEP through a community-based PrEP model. The majority were retained in care, and all reported good adherence to PrEP, suggesting the value of differentiated service delivery to engage men in HIV prevention.

Disclosures

All Authors: No reported disclosures
990. Prophylaxis against spontaneous bacterial peritonitis: too much or too little?
Authors: Dhanani Muhammad , Gupta Kalpana , Strymish Judith
Published: January 2021

Background

Prophylaxis against spontaneous bacterial peritonitis (SBP) is a guideline-recommended strategy; there are limited data on rates of concordance with guideline recommendations. We sought to evaluate rates of concordance, hypothesizing that antibiotics would overprescribed for prophylaxis against SBP.

Methods

This retrospective cohort study included all patients at the Boston Veterans Affairs Medical Center who underwent paracentesis between 1/1/2014 and 12/31/2018. Exclusion criteria included absence of cirrhosis and hepatic transplantation, either prior to enrollment or during the study period. Manual review was used to capture demographic data, guideline concordance, microbiology results and healthcare utilization within one year of enrollment. Descriptive and analytical statistics were performed.

Results

Of 259 patients eligible for analysis, 181 (70%) met inclusion criteria; 65 patients (25%) were excluded as cirrhosis was not confirmed. Small numbers of other patients were excluded for other reasons [Figure 1].

Incorrect antibiotic utilization was noted in 80 patients (44%) [Figure 2]. Among 93 patients meriting antibiotics, 65 (70%) did not receive them. Conversely, among 90 who did not have an indication for antibiotic prophylaxis, 15 (17%) received it (p = 0.03, chi-squared test).

Receipt of SBP prophylaxis was not correlated with gastroenterologist involvement, infection by antibiotic-resistant bacteria or development of illness due to Clostridioides difficile. No difference in hospital readmission rates was observed between groups receiving guideline-concordant and guideline-discordant prophylaxis.

Figure 1

Figure 2

Conclusion

We expected to find overprescription of SBP prophylaxis. In fact, we found that the largest error in prescribing was underprescribing, which may be equally as harmful as inappropriate use of antibiotics. SBP prophylaxis may be an important target for antibiotic stewardship and education.

Disclosures

All Authors: No reported disclosures
991. Psychosocial Factors and HIV Risk among Transgender Women Living in Miami
Authors: Rodriguez Jornan , Salguero Douglas , Abbamonte John M , Botero Patricia Raccamarich; Valeria , Montgomerie Emily K , Savita Pahwa , Martinez Claudia , Rodriguez Allan , Alcaide Maria L , Raccamarich Patricia , Solorzano Dalhila
Published: January 2021

Background

Transgender (TG) women are disproportionately affected by HIV infection and have poor health outcomes when compared to cisgender women. This study evaluates psychosocial factors, and HIV risk among transgender women with and without HIV infection living in Miami, the city with the highest incidence of HIV in the US.

Methods

Adults who identified themselves as TG living in Miami were recruited from the community and local clinics. Self-reported HIV status, sociodemographic, behavioral data (HIV risk behaviors, sexual partners, illicit substance and alcohol use), and psychosocial factors (depression, violence or abuse events, and HIV stigma) were collected with questionnaires into RedCap.

Results

A total of 22 participants completed assessments. Ten (45.5%) indicated being HIV uninfected (HIV-) and 12 (54.5%) had been diagnosed with HIV (HIV+). A total of 15 (68%) participants reported use of feminizing hormones and 11 (50%) had undergone feminizing surgeries. Median age was 55 (20, 69); 15 (69%) were white and 5 (23%) Black; 15 (69%) were of Hispanic ethnicity; Level of education 11 (12; 1.8) 12(55%) had completed at least high school; 2 (9%) were employed. 16 (73%) reported being sexually active in the previous month; median number of partners in the last month was 1.5 (1; 2.13); only 13 (60%) reported consistent condom use in the last sexual encounter; 14 (64%) engaged in receptive anal sex; 9 (41%) reported ever engaging in sex for money. Violence or abuse events were common, and participants had experienced an average of 3.9 lifetime events (Median = 3; SD = 3.45). Depression measured by the BSI-18 scale revealed low depression scores (Mean = 1.77; SD = 0.82). HIV infected participants were more likely to be black (p=0.05) and unemployed. We did not find significant differences by HIV status in other variables, including depression and violence or abuse. Among HIV+ participants, HIV stigma measured by the ‘Stigma Scale’ was low (Mean = 1.71; SD = 0.41).

Conclusion

We identified high rates of events of violence or abuse, that did not differ by HIV status. HIV infection was more common among black TG women.Further research is necessary to identify potential targets for HIV prevention and care in the vulnerable population of TG women. Study funded by the Miami CFAR (P30AI073961)

Disclosures

All Authors: No reported disclosures
993. Risk Factors for Periconception Non-Suppression Among Women Living with HIV in Kisumu, Kenya
Authors: Fisseha Ephrat , Hampanda Karen , Oyaro Patrick , Brown Evelyn , Mukui Irene , Odeny Beryne , Patel Rena , Abuogi Lisa
Published: January 2021

Background

Pregnant and postpartum women living with HIV (WLHIV) are a priority population for virologic monitoring and efforts to ensure viral suppression to reduce the risk for vertical-transmission and poor maternal health outcomes. Few studies have examined the role of parity on viral suppression during periconception in WLHIV.

Methods

We present data from the ongoing Opt4Mamas study which enrolled pregnant women with HIV on antiretroviral therapy between March and November 2019 attending antenatal care in five public health facilities in Kisumu County, Kenya. We evaluated associations between various sociodemographic and psychosocial factors and periconception viral suppression (< 40 copies/mL) within 12 months of study enrollment. We conducted univariate and multivariate logistic regressions, calculating odds ratios (OR) and 95% confidence intervals (CI).

Results

Among 497 women enrolled, mean age 29.9 years, 301 (61%) had viral load results available within 12 months of study enrollment. Viral loads were available a median of 18 days from conception (interquartile range 71 days before to 90 days after conception), and 237 women (79%) were virally suppressed. The majority (90%) of women were on a non-nucleoside reverse transcriptase inhibitor and 23 (9%) were on a protease inhibitor-containing regimen. In univariate analysis, women younger than 25 and primigravida women were less likely to be virally suppressed (OR 0.31, 95% CI [0.16 - 0.60] and OR 0.25, 95% CI [0.11 - 0.61] respectively; Table 1). The relationship between primigravida and periconception viral suppression is modified by age and duration on ART. Primigravida women who were younger than 25 years or who had less than 1 year of ART had significantly reduced odds of achieving viral suppression in the past year compared to primigravida women who were older or who had more experience taking ART (OR 0.09, 95%CI [0.03-0.31] and OR 0.09, 95%CI [0.02-0.48] respectively; Table 2).

Table 1: Comparison of Pregnant Women with HIV by Periconception Viral Suppression

Table 2: Interaction Effects with Primigravida Status

Conclusion

Risk factors for non-suppression around the time of conception in WLHIV include primigravida status, which is modified by age and duration on ART. Interventions targeting viral suppression among WLHIV leading up to their first pregnancy are needed, particularly among those who are newly initiated onto ART or younger age.

Disclosures

All Authors: No reported disclosures
73. Improving Cephalosporin Utilization in the Emergency Department for Penicillin Allergic Patients
Authors: Mattappallil Arun , Chew Debra , Magan Alyssa M , Zaeem Maryam , Scalgione Jaclyn , Sackey Joachim D
Published: January 2021

Background

Penicillin (PCN) allergies impact acute-care antibiotic prescribing practices, limit the use of first-line antibiotic agents and are associated with poor patient outcomes. Cephalosporins (CPN) are inconsistently prescribed to patients reporting PCN allergies despite reported low allergy cross-reactivity. The purpose of this study is to assess the impact of an education intervention on prescribing practices for CPN use in PCN allergic patients in the emergency department (ED).

Methods

This is a retrospective study evaluating all PCN allergic patients receiving a CPN in the ED from 07/01/2018 to 07/31/2019. The education intervention (consisting of circulating a locally developed guideline directing ED physicians to optimal CPN use given a designated PCN allergy along with lectures on suitable use of the guideline in recurring in-person sessions) occurred during 01/2019. We compared patient characteristics, CPN use, PCN allergy notation and adverse reactions between the “pre” (07/01/2018 – 12/31/2018) and “post” (02/01/2019 – 07/31/2019) groups.

Antibiotic Allergy Cross Reactivity/Sensitivity Chart

Results

A total of 123 patients are included (53 “pre” vs. 70 “post”). Patient characteristics are similar (Table 1). 31 (12.1% vs. 13%, P = 0.5) received previous treatment with CPN with the most common choices being cefazolin (14, 11.3%), ceftriaxone (18, 14.6%) and cefepime (9, 7.3%). 14 (11.3%) received pretreatment prior to CPN use. CPN given to patients in the ED include cefazolin (6 vs. 7), cephalexin (4 vs. 3), ceftriaxone (32 vs. 45) and cefepime (11 vs. 11). Common indications for CPN use include “empiric therapy” (38, 30.8%), “UTI” (17, 13.8%) and “pelvic region infection” (15, 12.1%). CPN administration routes include oral (10, 8.1%), intravenous (91, 73.9%) and intramuscular (22, 17.8%). 80 patients (65%) received a single dose of a CPN (37 vs. 43). No significant difference is noted in CPN use between groups (P = 0.1). Increased PCN allergy notation on tolerance to CPN after CPN use is noted, but later use of CPN use did not increase after notation (Table 2). No adverse events occurred from any CPN use.

Conclusion

Education interventions on CPN use in PCN allergic patients require support with other strategies and tools. This intervention provides groundwork to initiate efforts to further improve CPN use in PCN allergic patients.

Disclosures

All Authors: No reported disclosures
997. The Purview Paradox: PrEP Utilization at a Major Southern California County Teaching Hospital and Affiliated Clinics
Authors: Clavijo Stephanie , Herrmann Matthew , Corado Katya
Published: January 2021

Background

According to the Centers for Disease Control (CDC), PrEP coverage in the United States was approximately 18% in 2018 and 21.9% in California. We predict that PrEP prescription is lower at Harbor-UCLA Medical Center (HUMC) and affiliated clinics within Los Angeles County Department of Health Services.

Methods

A retrospective chart review of HIV-negative patients with ICD-10 coded diagnoses of sexually transmitted infections (STIs) or high-risk sexual behavior was performed across various medical specialties at HUMC and affiliated clinics in 2018. Documentation of sexual behavior risk reduction counseling, PrEP discussion and prescription was reviewed from electronic medical records for each encounter. Descriptive statistics and analysis were completed in STATA Version 16.1, StataCorp LLC.

Results

The sample included 250 individual patients, all with indications for PrEP. Of those, 47.2% identified as Latinx and 27.2% Black. Table 1 shows 74% of patients identified as heterosexual whereas 9.2% identified as gay, and 4.4% bisexual. Of the 250 individual patients, 87 (34.8%) returned for a 2nd visit, 35 (14.0%) for a third, and 9 (3.6%) for a 4th visit, for a total of 381 encounters. Of the total encounters, 49.3% had sexual behavior risk reduction counseling, 7.3% had discussions about PrEP with their provider, and only 2.1% were newly prescribed PrEP (Table 2). Of the 2.1% new PrEP prescriptions, 1.8% were prescribed by family medicine providers with no new prescriptions by OB/GYN or acute care providers. Only 25% of new PrEP prescriptions were female patients. A positive test for an STI occurred in 45.1% of total encounters while high risk sexual behavior was identified in 54.9% of encounters (Table 3).

Table 1: First Encounter Demographics (N=250 Individual Patients)

Table 2: Primary Outcomes by Specialty (N=381 Total Encounters)

Table 3: Sexually Transmitted Infections Frequency (N=381 Total Encounters)

Conclusion

Our findings demonstrate that the percent of individuals newly prescribed PrEP (2.1%) at HUMC and affiliated clinics is less than that reported nationally and in California. This suggests that municipal health systems fall short in PrEP usage, notably for structurally vulnerable populations such as racial minorities as well as heterosexual females. Ending racial/ethnic disparities in HIV and in PrEP coverage not only requires educating specialty providers on PrEP, but also addressing structural racism and identifying structural barriers to care in vulnerable communities.

Disclosures

All Authors: No reported disclosures
998. Understanding Retention in PrEP Care in the South: Insights from an Academic HIV Prevention Clinic
Authors: Burns Charles , Borges Monica , Frye Justin , Keicher Kathryn V , Elliott Scotty , Schwartz Sheila K , Shipp Kenneth W , Okeke Nwora L , McKellar Mehri , McKellar Mehri
Published: January 2021

Background

Daily emtricitabine-tenofovir disoproxil fumarate has emerged as one of the most effective tools to prevent HIV transmission. However, it remains poorly utilized in the South. We report on PrEP retention in care and sexually transmitted infections (STIs) in a large academic PrEP clinic in Durham, North Carolina.

Methods

We conducted a retrospective chart review of patients in the Duke University PrEP Clinic from Jan. 1, 2015 through Oct. 15, 2019. Short-term retention in care was completion of a 3 month (mo) follow up as per CDC guidelines. Long-term retention was defined as completion of a 3 mo visit and an additional visit between 8 and 12 mo. Baseline STI was defined as a diagnosis at or within 1 year prior to initial PrEP visit. STI diagnosis while on PrEP was any subsequent diagnosis while retained in care. Odds ratios (OR) were generated using multivariable logistic regression. Kaplan-Meier curves were generated for retention in care and compared using the log rank test.

Results

A total of 255 patients attended at least one PrEP clinic encounter; 89% were men, 37% were Black, and 73% identified as men who have sex with men (MSM); 153 (60%) returned for at least one follow-up visit. Short and long term retention in care were met by 130/237 (55%) and 80/217 (37%) patients respectively. OR for retention are reported in Table 1. MSM are more likely to be retained in the short-term (OR 5.22 [95% confidence interval (CI) 1.57-17.32]). Self-referred patients were more likely to be retained in the long-term (OR 2.18 [95% CI 1.12-4.23]). Patients without insurance were less likely to attain long-term retention in care outcomes (OR 0.32 [95% CI 0.11-0.91]). STI diagnoses include 30 (12%) patients for a total of 42 unique infections at baseline and 44 (17%) for a total of 69 unique infections at follow up. Two new HIV diagnoses were made at first PrEP clinic encounter with no new diagnoses made at follow-up. Baseline STI was not associated with retention in care over time with disengagement defined as 6 mo post last visit (Figure 1).

Table 1) Odds Ratios of Retention in Care at 3 and 12 Months

Figure 1) Retention in Care for Patients with Baseline STI Diagnosis.

Conclusion

Our PrEP clinic shows a decline in patient retention over time. STIs were also prevalent, reinforcing that frequent STI testing and counseling should be part of each PrEP encounter. Further investigations into how to increase and improve PrEP utilization for HIV prevention are needed.

Disclosures

All Authors: No reported disclosures
1000. HIV and the Treatment-Experienced Patient: The Positive Impact of Case-Based Education on Physicians’ Competence and Confidence
Authors: Hurst Simi Thomas , Blatherwick Don
Published: January 2021

Background

Despite therapeutic advances, treatment-experienced HIV patients can present a clinical challenge, even to experienced care providers.

Table. Assessment of Educational Effectiveness

Methods

This study assessed the ability of digital education to improve HIV/ID specialists’ ability to develop tailored strategies for treatment-experienced patients. A CME/ABIM MOC/CE-certified, case-based, educational program was developed. Modeled after the interactive grand rounds approach, a “test then teach” strategy with multiple choice questions was used to elicit cognitive dissonance. Evidence-based feedback was provided following each response. Educational effectiveness was assessed with a repeated-pairs pre-/post-assessment study design; each individual served as his/her own control. A chi-square test assessed changes pre- to post-assessment. P values < 0.05 are statistically significant. Effect sizes were evaluated using Cramer’s V (< 0.05 modest; 0.06-0.15 noticeable effect; 0.16-0.26 considerable effect; > 0.26 extensive effect). The activity launched on a website dedicated to continuous professional development on 09/12/19. Data for this matched-learner analysis were collected through 11/06/19.

Results

To date, 14,181 HCPs (3128 physicians; 9518 nurses/NPs; 333 PAs; 172 pharmacists) have participated in the activity. Data from the subset of HIV/ID specialists (n=110) who answered all pre-/post-assessment questions during the initial study period were analyzed. Following activity participation, significant improvements were observed in the proportion of HIV/ID specialists who answered all assessment questions correctly (15% pre vs 81% post; P < .0001; V=.356). Improvements were also observed in several specific areas of assessment (Table). Additionally, 44% of HIV/ID specialists indicated they planned to modify their treatment approach for treatment experience patients because of participating in the education.Of note, this assessment also identified topics in which HIV/ID had a high degree of baseline knowledge.

Conclusion

Participation in this online, interactive, case-based, program significantly improved HIV/ID specialists’ ability to develop individualized care strategies for patients who are treatment experienced.

Disclosures

All Authors: No reported disclosures
74. Interrupted Time Series Analysis of the Impact of Fluoroquinolone Cascade Reporting
Authors: Nestler Matthew , Markley John D , Noda Andrew , Godbout Emily , Kim Jihye , Lee Kimberly B , Doern Christopher , Doern Christopher , Bryson Alexandra L , Doll Michelle , Bearman Gonzalo , Stevens Michael
Published: January 2021

Background

Cascade reporting is a form of selective reporting where antibiotic susceptibility results are revealed in a sequential order to optimize antibiotic use. On May 1, 2019, Virginia Commonwealth University Health implemented cascade reporting for ciprofloxacin and levofloxacin for E. coli from urine cultures. We hypothesize that suppressing fluoroquinolone (FQ) results for urine isolate E. coli susceptibility panels using cascade reporting led to a decrease in the overall rate of inpatient FQ use.

Methods

We compared inpatient FQ use (in days of therapy (DOT)/1000 patient days (PD)) for the one-year pre-cascade period (May 2018-April 2019) to the one-year post cascade period (May 2019-April 2020). Inpatient FQ use for May 2018-April 2020 was modeled as an interrupted time series (ITS) using ordinary least squares regression. The regression model followed the form of Y = B0 +B1T + B2 X + B3 XT with Y = (DOT/1,000 PD), T = time in months, X = cascade reporting represented with a binary digit, and XT= time since cascade reporting was implemented. Results were examined for autocorrelation and lag effects. Analysis conducted using Microsoft Excel and Python Statsmodel library v0.11.1.

Results

A segmented regression model was successfully fitted with R^2 = 0.73 (Figure 1). The pre-intervention slope (T), intervention change (X), and post-intervention slope (XT) were -3.9, -2.3, and 3.8 DOT respectively. A significant positive change in pre versus post intervention slope was detected (p = 0.01).

Conclusion

Results showed no significant change in FQ DOT/1000 PD when cascade reporting was implemented in May 2019. This may be due to empiric prescribing of FQs in the inpatient setting, due to the fact the rate of FQ use was already decreasing prior to cascade reporting adoption, or due to other factors.

We detected a significant positive change in the slope of FQ from -4 to 4 DOT/1000 PD each month post-cascade reporting. Our hospital has had a decrease in FQ use over the past 8 years so this may be due to a ‘floor’ effect where the true minimum of necessary FQ use was reached; further investigation is warranted. We believe our data will be of interest to other Antimicrobial Stewardship Programs considering cascade reporting.

Disclosures

All Authors: No reported disclosures
1008. Disease Severity Impact on Long-Term Virologic Response to Ibalizumab in Expanded Access Protocol (TMB-311)
Authors: Kumar Princy , Leider Jason , Slim Jihad , Moyle Graeme , Leonard Maurice , Cash R Brandon , Weinheimer Steven , Mesquita Pedro
Published: January 2021

Background

The principal goal of antiretroviral therapy (ART) is durable suppression of HIV RNA. In treatment-experienced (TE) patients, ongoing viremia can lead to further accumulation of drug resistance, increased morbidity and mortality. ART efficacy often depends on HIV disease severity; therefore, we sought to assess its impact on long-term virologic suppression in patients treated with Ibalizumab (IBA), the first long-acting, post-attachment inhibitor approved for multi-drug resistant (MDR) HIV-1 treatment.

Methods

In TMB-301, a Phase 3 study, 40 TE patients with viral load (VL) >1000 copies/mL (c/mL) received an intravenous (IV) loading dose of IBA (2000mg) followed by maintenance doses (800mg IV) every 2 weeks combined with an optimized background regimen. Patients who completed TMB-301 in the US (n=27) continued to an expanded access protocol TMB-311. To determine the impact of baseline (BL) disease on long-term virologic response, we conducted an on-treatment analysis stratified by BL VL and CD4 count up to week 96. Differences in the proportion of suppressed (< 50 c/mL) individuals among the strata were assessed by Fisher’s exact test.

Results

Median BL VL and CD4 count were 35,350 c/mL and 73 cells/mL, respectively. The number of patients in the VL strata were 11, 17 and 12 for VL < 10,000, 10,000-70,000, and >70,000 c/mL, respectively. There were 12, 10, 5 and 13 patients in the subgroups with CD4 count < 10, 10-100, >100-200 and >200 cells/µL. Population disease severity was reflected by four deaths (unrelated to study drug). Overall, the proportion of suppressed patients increased from 55% at week 24 (n=31) to 75% for patients remaining on treatment for 96 weeks (n=20). Median VL decrease was 2.9 log10 c/mL. Notably, no statistically significant differences were found across groups. Among patients with advanced HIV disease, 66.7% with CD4 count < 10 cells/mL and 71.4% with VL >70,000 c/mL at BL remained fully suppressed at week 96.

Conclusion

In TE patients with advanced HIV disease, maximal viral suppression with IBA was observed regardless of BL CD4 or VL strata if patients remained on treatment. This demonstrates that TE patients across the spectrum of HIV disease, can achieve viral suppression by using drugs with a new mechanism of action.

Disclosures

Princy Kumar, MD, Gilead Sciences Inc. (Scientific Research Study Investigator) Jason Leider, MD, PhD, THERA (Speaker’s Bureau) Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau) Graeme Moyle, MD, Theratechnologies (Consultant) Maurice Leonard, PhD, Theratechnologies Europe Ltd (Employee, Shareholder) R Brandon Cash, PharmD, Theratechnologies (Employee) Steven Weinheimer, PhD, TaiMed Biologics USA (Employee) Pedro Mesquita, PhD, Theratechnologies, Inc. (Employee)
1013. Enhanced Oral Health Care Services for PLWHA - Midlands Region, South Carolina
Authors: Baello Christina M , Ahuja Divya , Finkley Norlica , Rao Rajee
Published: January 2021

Background

An estimated 58- 64 % of people living with HIV/AIDS (PLWHA) do not receive regular dental care and this gap may be attributed to barriers related to cost, access to dental care, logistical issues, indifference to or fear of dental care.1,2 The Immunology Center at Prisma- University of South Carolina, School of Medicine is a Ryan White funded Part B Program that provides care to > 2400 PLWHA. Based on the perceived barriers, an enhanced oral health care program was implemented in 2018, wherein patients in need of dental care and meeting inclusion criteria are referred to contracted local general dentistry and specialty practices.

Enhancements

Dedicated Dental Services Coordinator (DSC)

Facilitated transport to and from the dental clinic

Annual budget of $2700 per patient

Access to dental specialties (oral and maxillofacial surgery)

Restorative services (crowns, dentures and root canals)

Program Goals

The ultimate goal of the oral health care program is to provide biannual dental prophylaxis and expanded restorative services to PLWHA.

Inclusion criteria for referrals

1 Virological suppression over 6 months. (HIV Viral Load < 200 c/mL)

2 Adherence with HIV clinic appointments.

Midlands Region, South Carolina

Methods

The DSC completes the following: monitoring of referrals, patient compliance to program inclusion criteria, linkage to dental care, payments for dental services, and coordination with case management.

Results

Between 2018 and 2019, 535 patients were referred to the oral health care program. Almost 75% 399 completed at least one dental clinic visit. The average number of visits for patients from their enrollment date (2018-2019 to December 2019 was 1.56, with an average of 8.08 services, and 1.13 prophylaxis visits with their oral health care provider. Patients were predominantly African American and male but were spread across a wide age spectrum and 8 counties. Nearly 94% of patients remained virologically suppressed during their oral health care treatment.

Table 1: 2018-2019 Program Summary of Oral Health Care

Table 2 & Figure 1: Oral Health Care Patients by Age Group, Figure 2: Oral Health Care Patient by Gender

Table 3 & Figure 3: Oral Health Care Patients by Race and Ethnicity, Table 4 & Figure 4: Oral Health Care Patient by County

Conclusion

PLWHA have high rates of unmet oral health care needs and low utilization of oral health services. Adequate resources and coordination of care with local dentists can overcome traditional barriers and improve access to dental care.

Abstract References

Disclosures: All Authors: No reported disclosures
1016. Global trends in Integrase Strand Transfer Inhibitor resistance among HIV-1B Infected Patients
Authors: Gurley Stephen A , Nguyen Minh Ly , Anderson Albert
Published: January 2021

Background

Integrase strand transfer inhibitors (INSTIs), a new class of antiretroviral (ART) therapy for HIV, have quickly become a cornerstone of ART regimens globally. Here, we present the prevalence of INSTI resistance globally and over time among people living with HIV/AIDS (PLWHA), clade B.

Methods

To characterize trends in INSTI resistance, we conducted a literature search of articles published after 2010 via Pubmed and posters/abstracts from the Conference on Retroviruses and Opportunistic Infections (CROI) from 2016-2020. Included in our analysis are studies that include more than 100 individuals with INSTI resistance testing, who are infected with HIV clade B. We stratified the studies by country and by time period. We defined two time periods, 2008-2015 during which primarily first generation of INSTI were used (raltegravir and elvitegravir), and 2015-2020 during which second generation INSTIs (dolutegravir and bictegravir) use became widespread. We considered drug-resistance associated mutations (DRAM) in both ART-naive and in ART-experienced PLWHA.

Results

Overall, we reviewed 31 papers and 11 CROI abstracts that met the inclusion criteria. We observed that prevalence of DRAM in naïve patients is low globally and has remained low over time, ranging from 0%-8%. Meanwhile, we observed a downward trend in DRAM among INSTI-experienced patients from the 2008-2015 period to the 2015-2020 period from 11%-47.6% to 8%- 32.1%, reflecting higher barrier to resistance described in vivo among the 2nd generation INSTIs. See table below.

INSTI Resistance Summary Results Table

Conclusion

Here, we have analyzed the trends in INSTI prevalence over time and in different countries for HIV1 clade B. We demonstrate that globally, INSTI DRAM among INSTI-naïve patients are rare and incidence does not increase significantly over time despite increased usage. In addition, published studies showed a downward trend in INSTI DRAM among INSTI-experienced patients after 2015, reflecting the higher barrier to resistance in the second generation INSTIs. The most commonly occurring INSTI DRAMs observed were N155H (more common in the era of f1st generation INSTI), Q148H/K/R, and G140S. As INSTI usage continues to increase globally, continued vigilance and surveillance is needed to monitor continued INSTI resistance over time.

Disclosures

All Authors: No reported disclosures