bluuebunny/crossref_metadata_2025_split huggingface dataset:
930. Clinical Presentation, Treatment, and Outcomes for People with HIV with Histoplasmosis in Memphis, Tennessee
Authors: Cook Julia C , Lin Corey , Menzies Barbara E , Fuchs Christian J , Animalu Chinelo N , Mazumder Shirin A , Thomas-Gosain Neena , Summers Nathan A 
Published: January 2021

Abstract

Background
There is limited data on the presentation, treatment, and outcomes in persons with HIV (PWH) with histoplasmosis in the era of modern antiretroviral therapy (ART). We conducted a retrospective review of PWH presenting with histoplasmosis in Memphis, TN.

Methods
All cases of PWH with Histoplasmosis diagnosed or treated between January 1, 2013 and December 31, 2019 at Regional One Health were identified. Cases captured in obsolete and inaccessible EMRs were excluded. Baseline demographics, presentation data, treatment, duration of treatment, and outcomes were abstracted by chart review. A pooled T-test was performed to compare outcomes between those receiving short (≤ 7 days) and longer courses (&gt; 7 days) of amphotericin.

Results
Thirty-four participants were included, of which 30 (88%) were diagnosed in the hosptial. The mean age of participants was 41 years, 25 (73.5%) were male, and 31 (91%) were black. Median CD4 cell count and HIV viral load were 15 cells/µL, and 415,220 copies/mL, respectively. Median length of time between HIV diagnosis and presentation with histoplasmosis was 3.25 years. Common presenting symptoms included weight loss (21, 61.76%), gastrointestinal symptoms (22, 64.76%), and respiratory symptoms (19, 55.88%). Twenty-seven (79.41%) of participants met SIRS criteria on presentation, two required intensive care, and two participants met HLH criteria. The time between presentation and initiation of appropriate anti-fungal treatment was a median of 1.5 days. The majority of participants received amphotericin B as initial treatment (67.65%, N = 23). Twenty-five (60%) participants ultimately received amphotericin, 14 of whom received it for 7 days or less. The median duration of hospitalization was observed to be shorter among the group receiving 7 days or less of amphotericin (7 vs. 10.5 days), although not statistically significant. Overall 30 day mortality was 0%.

Conclusion
This study describes a population of PWH presenting with histoplasmosis in Memphis, TN. Appropriate antifungal therapy was started quickly and patients did well whether they were treated with a short course (7 days or less) or long course of amphotericin. Further research on the duration of amphotericin B in this population is warranted.

Disclosures
All Authors: No reported disclosures
955. Addressing Gaps and Disparities in HIV testing in the Emergency Department
Authors: Huggett Ashley , Derrick Caroline , Shealy Stephanie , Ahuja Divya , Al-hasan Majdi , Weissman Sharon 
Published: January 2021

Abstract

Background
Early diagnosis of HIV is key to improving outcomes for persons living with HIV (PWH). The Emergency Department (ED) is a critical site for PWH to access care. Previous studies in South Carolina (SC) have shown that two-thirds of individuals newly diagnosed with HIV have visited a health care facility a mean 7 times prior to their HIV diagnosis. Over 80% of these visits were to the ED, thus representing missed opportunities. Failure to test results from a multitude of barriers, including avoidance of testing due to a perceived lack of follow up. To address this gap in care we established a rapid HIV engagement team (RHET) that assumes responsibility for post-HIV testing linkage and reporting. The goal of this study is to evaluate the effectiveness of this intervention.

Methods
This retrospective cohort study compared HIV testing rates and patterns in Prisma Health EDs from May 2018 through October 2018 (pre-RHET) to 5/2019 through 10/2019 (post-RHET). Included persons were ≥18 years of age and had ICD-10 codes for a sexually transmitted infection (STI), trichomonas, herpes simplex, and gonorrhea (GC) or Chlamydia (CT) NAAT, and/or presented with an initial complaint of a STI. Multivariable logistic regression analysis was utilized to examine impact of RHET implementation on HIV testing in ED.

Results
A total of 4104 individuals were identified, 2154 pre-RHET and 1950 post-RHET. Table 1 displays baseline characteristics for the two groups. Overall, 87% had GC testing; 9% had positive results; 95% had CT testing, 12.6% had positive results. Only 6% were tested for HIV pre-RHET implementation. HIV testing improved to 12% post-PHET implementation (p&lt; 0.001). In the multivariate regression analysis predictors for HIV testing were presenting post-RHET (OR 2.27; 95% CI 1.81 to 2.85), male gender (OR 2.98; 95% CI 2.39 to 3.73), white race (OR 2.27; 95% CI 1.81 to 2.85), and presenting to ED for STI (OR 3.58; 95% CI 2.03 6.33).

Conclusion
HIV testing rates increased post-RHET yet, despite indications for HIV testing, only a small proportion received HIV testing. Further interventions are needed to improve HIV testing in EDs, particularly in women and blacks. The overall HIV testing rate remained low, representing ongoing missed opportunities for early HIV diagnosis.

Disclosures
All Authors: No reported disclosures
956. Delayed HIV diagnosis in Philadelphia
Authors: Spacek Lisa A , Higgins Dana , Brady Kathleen 
Published: January 2021

Abstract

Background
Ending the HIV Epidemic (EHE) requires prompt diagnosis and treatment of HIV to reduce transmission. Delayed HIV diagnosis and late entry into care remain challenging. Strategic deployment of testing resources may leverage both targeted and universal testing to accomplish the timely diagnosis of HIV infection.

Methods
We extracted data from the City of Philadelphia’s Enhanced HIV/AIDS Reporting System for 3,856 individuals diagnosed with HIV infection in Philadelphia, PA from 2012-2018, to determine characteristics associated with delayed diagnosis, defined as: AIDS diagnosed within 90 days of HIV or date of AIDS diagnosis prior to HIV diagnosis. Independent variables included: time since HIV diagnosis, age category, birth sex, current gender, race/ethnicity, transmission risk, insurance status, and receipt of care from Ryan White medical provider. We used Chi-square and multivariate logistic regression to assess factors associated with delayed diagnosis.

Results
From 2012 to 2018, the number of HIV diagnoses declined from 731 to 422; those with delayed diagnosis declined from 28% to 18%. Age category of 25-34 years comprised the majority of HIV diagnoses N=1402 (36%). The majority were: born male (78%), current gender male (76%), black (69%), MSM (51%), insured (54%), and participating in Ryan White care (71%). In multivariate regression, current gender male, heterosexual transmission, race/ethnicity Asian, American Indian, Alaska Native, or Multi-race, unknown insurance status, and receipt of care from a Ryan White medical provider were 3.7 (95%CI, 1.2-11.4), 1.3 (1.0-1.7), 1.8 (1.2-2.8), 5.9 (4.9-7.1), and 1.4 (1.2-1.7) times as likely to have delayed diagnosis, respectively, after adjustment for time since diagnosis, age category, and birth sex.
Participants’ Characteristics and Logistic Regression Results

Conclusion
EHE will only be successful by reaching all people living with HIV and creating opportunities for early diagnosis. Routine opt-out universal screening combined with repeated, targeted testing will allow for identification and early treatment of HIV infection. As a medical care safety net, Ryan White program provides care to a disproportionate number of people with delayed diagnosis of HIV. By diagnosing HIV as early as possible, we may eliminate delayed diagnosis and reduce the risk of AIDS-related events or death.

Disclosures
All Authors: No reported disclosures
961. Implementing an HIV Ambulatory Curriculum in Internal Medicine Residency Programs
Authors: Aoun-Barakat Lydia , McKay Sharen E , Danvers karina , Sideleau Robert J , Brooks Ralph P , Villanueva Merceditas 
Published: January 2021

Abstract

Background
The advancement of anti-retroviral therapy (ART) has transformed HIV into a chronic disease and resulted in prolonging the lives of people living with HIV. Therefore, there is a projected shortage of HIV providers nationally and there is a need for increased training of primary care physicians in management of HIV over the lifespan as well as alongside common comorbidities found in aging HIV population.

Methods
The Yale AIDS program developed an interactive HIV ambulatory curriculum that included a set of didactics and workshops for trainees in internal medicine residency programs. This 3-hour interactive curriculum was implemented in 5 hospitals in Connecticut and was led by experienced HIV providers at the MD and RN levels. Trainees included PGY1, 2 and 3 residents. Knowledge areas encompassed HIV Epidemiology, Testing, ART Treatment, and prevention including Pre Exposure Prophylaxis (PrEP). In addition, 2 role-play sessions were integrated. Pre and Post Test knowledge assessment was evaluated including questions on practice regarding HIV screening and PrEP prescribing.

Results
In this study, we report the results of knowledge assessments and professional practices administered prior to (pre-) and following (post-) interactive learning sessions.
From July 2017 to June 2020, 15 HIV ambulatory curriculum sessions were held, with an average 5 sessions annually. A total of 170 residents attended this curriculum with an average of 10-15 trainees per session and 25% from underrepresented minority group. The pre-test and the post- test knowledge assessment score rates were 51% and 83% respectively with an estimated 63% improvement. A large proportion of trainees reported implementing routine HIV testing (97.2%). However, self-reported willingness to prescribe PrEP was low among residents prior to the educational intervention (12.5%) and increased considerably following education (93.3%).

Conclusion
Focused interactive HIV curriculum could represent a viable method to improve knowledge and practices in HIV medicine amongst primary care residents. This novel educational intervention has the potential to be disseminated an implemented in other residency programs curricula.

Disclosures
All Authors: No reported disclosures
967. The Association between PrEP Awareness and Behavioral, Demographic, and Socioeconomic Factors in NYC
Authors: Adekunle Adewumi , Fletcher Gerald , Fagir Marwa , Brimah Idayat , Tijani Sulaiman , Aminata Kamara , Sheppard Richard , Beale Stefani , Mannheimer Sharon 
Published: January 2021

Abstract

Background
Despite significant gains in the treatment of Human Immunodeficiency Virus (HIV), there are still over 38,000 newly diagnosed with the illness annually in the United States. One strategy to reduce HIV infections is Pre-Exposure Prophylaxis (PrEP) for HIV infection. PrEP involves daily oral emtricitabine/tenofovir disoproxil fumarate (FTC/TDF or Truvada®) to reduce infections in those with exposure(s) to HIV or high-risk groups. Studies have shown reduction in HIV transmission with PrEP treatment.
The objective of the study is to investigate how behavioral, demographic, and socioeconomic status (SES) influences the awareness of PrEP treatment in NYC.

Methods
Data on economic, behavioral, PrEP awareness at the UHF neighborhood level was collected by the Community Health Survey (CHS) from the New York City Department of Health and Mental Hygiene and the American Community Survey from the U.S. Census. The population is a cross-sectional telephone survey of NYC residents with landlines and mobile phones for 2016 and 2017. Household income and neighborhood poverty level were used as proxies for SES.
Sex-stratified, multivariate logistic regression model was constructed to estimate adjusted associations and determine differences in awareness of PrEP. The model controlled for age group, race, education level, men sex with men status (MSM), and having had an HIV test in the preceding 12 months.

Results
The final study sample was 5,515 and 5,761 in 2016 and 2017, respectively. In 2016 crude PrEP awareness rate was 24.3% and in 2017 it was 35.4%. In the multivariate analysis for both 2016 and 2017, PrEP awareness was independently associated with age group, education level, male MSM, and having had an HIV test in the preceding 12 months (p &lt; 0.01). The strongest predictors of PrEP awareness were participants with a preceding HIV test in the past 12 months and males who are MSM. PrEP awareness was associated with race for males in 2016 and 2017. PrEP awareness was associated with race for women in 2016, but not 2017.
Figure 1: (left) Median household income in NYC (right) HIV diagnoses and PrEP awareness for 2016 and 2017

Conclusion
Understanding the relationship of neighborhood socioeconomic status and PrEP awareness is essential for HIV epidemiology. By monitoring PrEP awareness, HIV diagnoses, and risk factors associated with the two, public health officials better target interventions and health policy.

Disclosures
All Authors: No reported disclosures
71. Impact of Prospective Audit and Feedback on Fluoroquinolone Use: A Large Academic Medical Center Experience
Authors: Simon Julio C , Vega Ana 
Published: January 2021

Abstract

Background
Fluoroquinolones are an effective class of antimicrobials; however, their use is not without consequence. Recent warnings have resulted in the FDA recommending to reserve this class for infections lacking alternative options. Antimicrobial stewardship significantly reduces targeted antimicrobial use, improves susceptibility patterns, decreases rates of Clostridium difficile infection (CDI), and reduces healthcare-associated costs. Literature on fluoroquinolone stewardship by antimicrobial stewardship programs report similar outcomes in addition to reductions in rates of extended-spectrum beta-lactamase (ESBL)-producing and methicillin-resistant S. aureus (MRSA) infection.

Methods
This study was a retrospective cohort study of adult patients receiving at least 3 days of a fluoroquinolone for an indication of pneumonia or urinary tract infection. Retrospective orders were assessed for prescribing patterns, duration of therapy, and antibiotic choice by indication. The primary outcome was reduction of fluoroquinolone consumption as a result of a prospective audit and feedback intervention, determined with days of therapy (DOT) and DOT per 1000 patient days. Secondary outcomes included hospital length-of-stay (LOS), 3-month post-exposure incidence of CDI, ESBL and MRSA infections, percentage of interventions accepted, and QT prolongation events. Mann-Whitney U was used to determine statistical significance for DOT and LOS, unpaired student t-test was used for DOT per 1000 patient days.

Results
333 patients were reviewed. Fluoroquinolone median days-of-therapy (DOT) was significantly reduced in the intervention phase (7 vs. 4 days, P &lt; 0.001). Median LOS was 8 days for the cohort and did not differ between groups. After adjusting for identifiable alternative causes, no difference in QT prolongation, CDI or ESBL infection was observed. However, these results were limited by lack of diagnostic testing for QT prolongation and inability to assess for other contributing factors related to infection control.

Conclusion
Antimicrobial stewardship is an effective intervention to reduce fluoroquinolone use. An increased LOS was not observed despite patients switching to parenteral therapies. More data is needed to assess differences related to adverse events.

Disclosures
All Authors: No reported disclosures
979. Disparities in PrEP uptake and adherence among cisgender women using a pharmacologic measure
Authors: Hebel Shane , Kahn-Woods Elijah , Enghuus Casper , Koenig Helen , Lalley-Chareczko Linden , Radix Asa , Daughtridge Giffin 
Published: January 2021

Abstract

Background
HIV pre-exposure prophylaxis (PrEP) is 99% effective at preventing new HIV infections if taken daily. To be successful, PrEP requires concurrent efforts to optimize uptake, persistence, and adherence.
In 2018, cisgender (cis) women accounted for 19% of new HIV infections in the US but comprised only 7% of all PrEP users. Studies show poor PrEP adherence amongst cis women, but there is a paucity of real-world clinical data describing PrEP adherence among cis women and gender minority people.

Methods
An adherence test that measures the concentration of tenofovir in urine samples using a liquid chromatography mass spectrometry (LC-MS/MS) was used to assess recent PrEP adherence at 8 clinics. Urine samples were collected during routine visits and analyzed using the LC-MS/MS assay. Test results were retrospectively paired with gender data, when available, and sex assigned at birth (SAAB) data. Adherence data were aggregated and analyzed to assess non-adherence proportions by sub-population.

Results
Gender data were available from 1,461 patients at 5 clinics, 1,344 (92%) of whom were cis males (Figure 1).
From the 5 clinics where gender and SAAB data were available, 3,835 tests were conducted and 517 (13.5%) indicated non-adherence (Figure 2).
3 additional clinics conduct routine adherence testing and collect SAAB data (gender data not available). At these 8 clinics, SAAB data were available for 2,773 PrEP patients, totaling 5,602 urine tests (Figure 3).
Among these 5,602 adherence tests, 813 (14.5%) indicated non-adherence (Figure 4). SAAB females demonstrated significantly higher non-adherence than SAAB males (22% vs 14%, p&lt; 0.001).
Across clinics, 89%-98% of PrEP patients are SAAB male (Figure 5).
Within these 8 clinics, SAAB female demonstrated consistently higher non-adherence (17%-44%, vs 12%-17% for SAAB males) (Figure 6).
Figures 1 and 2

Figures 3 and 4

Figures 5 and 6

Conclusion
Real-world data align with nationwide trends in PrEP utilization and show that the majority of PrEP patients are cis men. When initiated on PrEP, cis women exhibit higher rates of non-adherence than cis men. These data underscore the need to collect gender-identity data to monitor PrEP disparities and suggest that greater efforts are needed to target PrEP access, utilization, and accompanying support services to cis women and gender minority groups.

Disclosures
All Authors: No reported disclosures
72. Improving Antibiotic Prescribing in Interventional Radiology Using Clinical Decision Support Tools to Assess Penicillin Allergies
Authors: Atluri Vidya , Marsland Paula , Johnson Luke M , Jain Rupali , Pottinger Paul , Rampur Lahari 
Published: January 2021

Abstract

Background
Patients labeled with penicillin allergies often receive alternative antibiotics, leading to increased cost, higher risk of adverse events, and decreased efficacy of procedural prophylaxis. However, most of those patients can tolerate a cephalosporin. University of Washington Medical Center – Montlake (UWMC-ML) Interventional Radiology (IR) frequently administer a pre-procedure prophylactic cephalosporin. We worked with the clinicians in IR to develop tools to allow them to better assess penicillin allergies, make the most appropriate antibiotic choice, and update the patient’s allergy documentation.

Methods
We identified all patients who underwent procedures in IR between 2017–2019. Chart review was done to determine the procedures performed, patient demographic information, allergies, allergy documentation, and prophylactic antibiotics received.
In May 2020 we implemented new Clinical Decision Support tools, including an online assessment app (https://tinyurl.com/IRPCNAllAssess) and handouts to guide antibiotic decision making to clinicians in IR.

Results
From 2017 to 2019, 381 patients underwent 958 procedures in IR. Of those, 379 patients underwent 496 procedures for which the recommended first line choice for antibiotic prophylaxis is a cephalosporin. Of patients who received pre-procedure prophylactic antibiotics for those procedures, 15.9% [n=11] of patients with penicillin allergies received the first line antibiotic, compared to 89.9% [n=319] of patients without a reported penicillin allergy. Since implementation, the online app has been used to evaluate 9 patients, of whom 8 had penicillin allergies. All 8 patients safely received the first line antibiotic (3 were delabeled, 4 reported a history of mild reactions, and 1 reported a history of an immediate IgE mediated response to penicillin but safely received cefazolin).

Conclusion
IR evaluates hundreds of patients who may receive prophylactic antibiotics each year. By providing tools to assess penicillin allergies, we were able to improve both their prescribing and de-label patients which will provide a much broader impact on their care than on just their current procedure. Our free tool can be accessed at the website above, and we will demonstrate in person.

Disclosures
All Authors: No reported disclosures
992. Rethinking the 28-day HIV nPEP Dispensing Practice: A Pediatric ID Clinic Analysis
Authors: Zhang David , Rosebush Julia , Bhagat Palak , Nelson Allison , Ramaiah Veena , Seaton Elaine 
Published: January 2021

Abstract

Background
In July 2017, The University of Chicago Comer Children’s Hospital Emergency Department (ED) transitioned from a 5-day to a 28-day HIV nPEP (non-occupational post-exposure prophylaxis) dispensation model in an effort to increase adherence. Anecdotal reports of patients lost to follow-up after ED discharge called into question the utility and cost-effectiveness of this practice. We analyzed HIV nPEP follow-up rates in our clinic, explored reasons for nonadherence, and performed basic cost-savings analyses to inform potential changes to our dispensation model.

Methods
A retrospective review of both electronic health and pharmacy records was conducted for patients prescribed 28-days of HIV nPEP in the ED and scheduled for outpatient follow-up in Pediatric ID clinic from July 2017-June 2019. Clinic provider documentation of nPEP adherence and reasons for nonadherence were examined. Patients were given an initial dose of nPEP regimen in the ED and provided all subsequent doses to complete at home. Using average wholesale price (AWP), we calculated the total cost of each regimen and potential savings if a shorter duration of HIV nPEP supply was dispensed.

Results
50 patients received a 28-day supply of HIV nPEP. Please refer to Table 1 regarding baseline patient characteristics. Of these, only 19 (38%) patients had documented outpatient follow-up after nPEP initiation. Median time to follow-up was 6 days (IQR: 3.0-9.0 days). Of the 19 patients with follow-up, 3 admitted to medication non-adherence. Although side effects were elicited in a total of 9 patients (18%), only 1 cited medication intolerance as the reason for discontinuing their nPEP. Given the relatively short time to follow-up, a potential savings of $1720-2211/patient could be achieved if a 10-14 day supply was dispensed.

Conclusion
Outpatient follow-up after 28-day HIV nPEP dispensation in our ED was &lt; 40%, calling into question the cost-effectiveness of this dispensation model. While our current practice alleviates nPEP interruption due to potential insurance issues and pick-up delays, follow-up and adherence are not assured. The significant cost-savings with a shorter supply at the outset may encourage more robust follow-up and adherence.

Disclosures
All Authors: No reported disclosures