bluuebunny/crossref_metadata_2025_split huggingface dataset:
312. Treatment of Hepatitis C After Identification of Infection During Universal Screening Approach in Pregnant Women
Authors: Rose Michelle , Allen Myers John , Ryan Nicholas , Prince Alissa , Talbot Morgan , Espinosa Claudia M 
Published: October 2019

Abstract

Background
Identifying asymptomatic individuals with hepatitis C virus (HCV) infection is challenging. Pregnancy presents a unique opportunity to screen women for HCV and then link those positive to care. Universal screening in pregnant women, however, is not recommended by CDC or ACOG. Further, treatment with direct antiviral agents (DAAs) are not currently approved for pregnant women but are warranted following delivery and breastfeeding. We sought to compare treatment uptake before and after universal screening in pregnant women was implemented as the standard of care in our institution and then determine if universal screening leads to increased treatment after pregnancy.

Methods
A retrospective analysis of risk-based HCV screening in pregnant women was used for the first period (2014–2015) and a prospective design was used following 18 months of universal screening (2016–2017). Prenatal data were collected from all pregnant women that sought care at our institution in the prospective part of the study. We tested for differences in relevant outcomes (e.g., screening rates, rate of those eligible for treatment, and those who actually received treatment) between the two periods. Finally, we performed a cost-effective analysis of universal screening considering treatment rates.

Results
During the universal screening period, more women were screened for HCV and diagnosed with chronic infection. Universal screening was not associated with a significant increase in the odds of women receiving treatment after pregnancy. The increased cost for universal screening was $1060 per patient, resulting in an ICER of $219,391 per additional treatment received or $57,734 per quality-adjusted life-year (QALY) gained, which is below the willingness-to-pay threshold to be cost-effective. Universal screening, however, is cost-effective with an ICER well below the established willingness-to-pay threshold of $100,000 per QALY gained, if all women eligible for treatment receive therapy.

Conclusion
Universal screening may not lead to a significant increase in the odds that pregnant women receive DAAs therapy after pregnancy. Barriers to linkage to care should be addressed in an effort to increase antiviral therapy for these women and universal screening should be implemented within this patient population.

Disclosures
All authors: No reported disclosures.
326. Is Antiretroviral Treatment Averting AIDS and non-AIDS Defining Malignancies in Colombia?
Authors: Martínez Buitrago Ernesto , Arévalo Mora Leonardo , Mantilla Suárez Mónica , Valderrama Sandra , Gonzáles Claudia , Fabio Mueses Marín Héctor , Lenis William , Carlos Alzate Angel Juan , Franco Julieta , Sussmann Otto A , Milena Garcia Garzon Martha , Lucía Ramos Tique Olga , Favio Montero Leonardo , Antonio Pardo Rada Jose , Wilmar Tobón Vásquez Jose , Montero Leonardo F 
Published: October 2019

Abstract

Background
The use of effective antiretroviral therapy (ART) has shown to modify the trend of AIDS-defining malignancies (ADM) toward non-AIDS defining malignancies (NADM); however, Latin America is a region with a known late presentation of HIV/AIDS and late initiation of ART, which could not result in averting the incidence of ADM. The epidemiology of cancers that define or not AIDS in people living with HIV in Colombia is not known.

Methods
The purpose of our study was to identify the trend of ADM and NADM and the effect of ART in a collective cohort of 15 centers of 8 cities in Colombia. After the institutional review board approval, the study was conducted as a retrospective chart review of patients with any diagnosis of cancer presented after the diagnosis of HIV and a year before. Demographic and clinical data related to the HIV infection, ART treatment, and cancer diagnosis were analyzed with Stata 12 software, and associations between different variables were made using univariate and bivariate analyses.

Results
A total of 415 patients with malignancies were included since 1986 (table). Most common cancers were Kaposi sarcoma (n = 227; 54.7%), and non-Hodgkin lymphoma (n = 80, 19,3%). Median CD4+ cell count was very low in this population (median 115.5, P25-75 39.5–243) at the time of HIV diagnosis. Most common NADM were skin cancer (n = 22; 5.3%) and Hodgkin lymphoma (15; 3.6%). The ratio of ADM:NADM was 0.5 before 1995 and increased progressively up to 3.0 after 2010 (P = 0.001) (figure). By bivariate analysis, we found a correlation of ADM with older age (P < 0.001), male gender (P = 0.03), recent years (P < 0.001), lower CD4 and higher VL at the time of cancer (P < 0.0001 for both), and mortality (P = 0.027). Cancer-associated mortality was 3.9%.

Conclusion
The trend for diagnosis of ADM in Colombia is increasing despite antiretroviral treatment and exceeds NADM diagnosis. Potential explaining factors are the late presentation and initiation of ART, and poor treatment success in this population. Special efforts are required to diagnose and treat HIV patients in Colombia to avert this worrying trend.

Disclosures
All authors: No reported disclosures.
329. Health Disparities Among HIV-Positive Patients with Kaposi’s Sarcoma
Authors: Knights Sheena , Lazarte Susana , Kainthla Radhika , Krieger Demi , Bhattatiry Mitu , Chiao Elizabeth , Nijhawan Ank E , Nijhawan Ank E 
Published: October 2019

Abstract

Background
Kaposi’s sarcoma (KS) is an AIDS-related condition that is mediated by HHV-8. Although incidence and mortality of KS in the United States have decreased over time since the advent of HAART, there may be disparities in mortality based on geographic location and race/ethnicity, particularly African-American men in the South.

Methods
A retrospective electronic medical record review was conducted using integrated inpatient and outpatient data in EPIC from PHHS. We included all individuals with a diagnosis of HIV and Kaposi’s sarcoma between January 1, 2009 and December 31, 2018 based on ICD-9/10 codes. We collected demographic information, HIV history, variables related to HIV and KS diagnosis, treatment and outcomes data for each patient. We calculated hazard ratios using Cox proportional hazards modeling.

Results
We identified 252 patients with KS. 95% of patients were male, and the majority were MSM (men who have sex with men; 77% of all patients). 35% of patients were Hispanic, 34% were African-American and 31% were Caucasian. Over half (56%) of patients were funded through Ryan White or were uninsured. The median CD4 count and viral load at the time of cancer diagnosis were 44 and 73,450, respectively. 24% of patients were confirmed to have died by the end of the study time frame. However, due to loss to follow-up, 35% of the cohort had an unknown vital status at the time of the final chart review. Variables most strongly associated with mortality were >2 hospitalizations in the first 6 months of cancer diagnosis (aHR=4.93, P = 0.0003), IV drug use (aHR=3.61, P = 0.0009), and T1 stage of KS (aHR= 2.13, P = 0.0264). African American patients had lower survival than Caucasian or Hispanic patients, with a 5-year survival of 69%, 81% and 80% respectively, although this did not reach statistical significance (aHR 1.77, P = 0.1396).

Conclusion
We describe a large cohort of patients with HIV and HHV-8-related disease, who are predominantly of minority race/ethnicity, uninsured, and have advanced HIV disease. Factors associated with mortality include Black/African-American ethnicity, number of hospitalizations, IV drug use and T1 stage of KS. Our mortality analysis is limited due to high lost to follow-up rates, so we suspect overall mortality in our cohort is higher than currently reported.

Disclosures
Ank E. Nijhawan, MD, MPH, Gilead Sciences, Inc.: Research Grant.
341. Risk of Type 2 Diabetes Mellitus after Antiretroviral Therapy Initiation in Individuals Living with HIV in the United States
Authors: Hsu Ricky , Brunet Laurence , Fusco Jennifer S , Mounzer Karam , Vannappagari Vani , Henegar Cassidy , van Wyk Jean A , Curtis Lloyd D , Lo Janet , Fusco Gregory 
Published: October 2019

Abstract

Background
Limited data exist on the risk of type 2 diabetes mellitus (T2DM) with the use of integrase inhibitors. We assessed the risk of incident T2DM with antiretroviral therapy (ART).

Methods
ART-naïve (ART-N) and -experienced, suppressed (ART-ES; baseline viral load 13 years of age initiating dolutegravir (DTG), elvitegravir/cobicistat (EVG/c), raltegravir (RAL) or boosted darunavir (bDRV) in the OPERA® cohort. After excluding prevalent prediabetes/T2DM and missing baseline covariates, incidence rates of T2DM (i.e., diagnosis, antidiabetic drug, and/orHbA1C >6.5%) were estimated with Poisson regression. The association between core agents and incident T2DM was estimated with multivariate Cox proportional hazards regression adjusted for age, sex, race, HCV co-infection and BMI at baseline. Median (IQR) absolute BMI change from baseline was evaluated at 6, 12, 18, and 24 months in those who developed incident T2DM and those who did not. All analyses were stratified by ART experience.

Results
Individuals prescribed these ART regimens varied significantly (Figure 1). Overall, incidence rate per 1,000 person-years was low for T2DM (ART-N IR: 9.1; 95% CI: 7.5, 10.9; ART-ES IR: 13.3; 95% CI: 11.6, 15.2; Figure 2). Among ART-N initiators, no statistical difference was observed in the risk of progression to T2DM between DTG and EVG/c (aHR: 0.70; 95% CI: 0.47, 1.05) or bDRV (aHR: 0.53; 95% CI: 0.26, 1.04); RAL could not be evaluated due to the small number of T2DM events. Among ART-ES initiators; no difference was observed between DTG and EVG/c (aHR: 0.96; 95% CI: 0.70, 1.33), RAL (aHR: 1.17; 95% CI: 0.70, 1.96) or bDRV (aHR: 0.90; 95% CI: 0.57, 1.42) (Figure 3). A greater absolute change in BMI was observed for ART-N initiators developing T2DM at all timepoints; reaching statistical significance at 12 and 18 months (Figure 4). No differences were observed for ART-ES initiators.

Conclusion
Incident T2DM was uncommon among ART-N and ART-ES persons initiating DTG, EVG/c, RAL or bDRV in this large clinical population. None of the comparisons between DTG and other core agents showed a statistically significant increased risk of T2DM. However, due to the small number of events in the ART-N population differential risk cannot be excluded and monitoring HbA1c remains prudent.

Disclosures
All authors: No reported disclosures.
354. Efficacy of Second-Generation Direct Acting Antivirals in the Setting of HCV/HIV Co-infection and Cirrhosis: A Review of Real-World Treatment Experiences
Authors: Saba Nicholas , Chirch Lisa , Banks Sarah H , Wu Geroge , Einstein Michael 
Published: October 2019

Abstract

Background
Patients co-infected with HIV and HCV represent a unique subpopulation with specific high-risk characteristics including increased transmission efficiency of HCV, higher HCV viral load and more rapid progression of liver disease when compared with mono-infected patients. Although virologic failure is rare in the direct acting antiviral (DAA) era, we have anecdotally observed a high rate of failure in our patients who are co-infected and have cirrhosis. Our objective was to evaluate the impact of cirrhosis on co-infected patients compared with co-infection without cirrhosis and mono-infected patients with cirrhosis as it relates to cure of HCV treated with DAAs.

Methods
A retrospective chart review was performed. Patients from UConn Health Infectious Diseases and Gastroenterology clinics and Hartford Hospital Comprehensive Liver Center treated January 1, 2014 through December 31, 2017 were included. Patients were grouped as follows: (1) HCV/HIV coinfected without cirrhosis, (2) HCV/HIV coinfected with cirrhosis, (3) HCV infected with cirrhosis. Data were analyzed in SAS, variables were compared by chi square analysis and Fishers Exact test to determine statistical significance.

Results
No differences in baseline characteristics were noted (Table 1). Cirrhotic patients were 63% of the total cohort. There was no statistical difference in the rates of sustained virologic response (SVR) among the 3 groups. The overall rate of SVR was 95%. SVR for patients with cirrhosis (co- and mono-infected) was 92%. All treatment failures (n = 3) in this cohort had cirrhosis. Among the 38 cirrhotic patients, 3 (8%) had treatment experience with DAAs. In contrast, none of the non-cirrhotic patients had prior DAAs. The use of protease inhibitors or ribavirin had no impact on cure; ribavirin was evenly distributed between the two groups with cirrhosis. SVR rates were lower with genotypes 2–4 as compared with genotype 1. No immunologic or virologic factors were correlated with SVR.

Conclusion
We found no differences in rates of SVR in coinfected patients with or without cirrhosis. However, all treatment failures were noted in patients with cirrhosis, and cirrhotic patients tended to have treatment experience with DAAs. Whether coinfected patients with cirrhosis should be managed differently will require additional study.

Disclosures
All authors: No reported disclosures.
368. Incidental Findings on Brain MRI in People Living with HIV
Authors: Hanna Kevin F , Sayles Harlan R , O’Neil Jennifer , White Matthew , Wilson Tony , Swindells Susan 
Published: October 2019

Abstract

Background
HIV infection is associated with an array of neurocognitive changes, collectively referred to as HIV-Associated Neurocognitive Disorder (HAND). These changes have been the subject of a great deal of study, often including structural MRI of the brain. Incidental findings (IF) are a well-known complication of imaging studies done for both diagnostic and research indications, and can pose important ethical and clinical dilemmas. Little is known about the rates and types of IF found on brain MRI in patients with HIV infection. We identified and characterized such findings in participants who participated in a study of neurophysiological markers of HAND.

Methods
The parent study included 108 HIV-infected adults and 125 demographically matched uninfected controls without cognitive impairment who had undergone T1-weighted structural brain MRI for research purposes. Demographic and diagnostic data were abstracted from the research records. Each MRI study was read by the same neuroradiologist, blind to the participant’s HIV status. IF were classified as vascular, neoplastic, congenital, other neurologic, or non-neurologic. Categorical measures were compared using Pearson chi-square tests while continuous measures were compared using t-tests.

Results
Among HIV-infected participants, 36/108 (33.3%) had IF compared with 33/125 (26.4%) of controls (P = 0.248). Rates of IF were significantly correlated with increased age in both HIV-infected and control participants. We found no correlation among presence or absence of IF and sex, race/ethnicity, or CD4 count and HAND status for the HIV-infected cohort. The most common categories were neurologic (27), followed by non-neurologic (8), vascular (6), and neoplastic (2) (Table 1).

Conclusion
If were common in both HIV-infected participants and controls, at higher rates than previously reported, possibly because of increased sensitivity of MRI machines over time. Surprisingly, we found no significant difference between the groups and no correlation with HAND status or CD4 count. Age was the only factor correlated with rates of IF in either HIV-infected participants or controls. To our knowledge, this study is the first of its kind to characterize incidental findings in HIV-infected patients.

Disclosures
All authors: No reported disclosures.
370. Comparing Trends and Outcomes among HIV-Infected vs. HIV Uninfected Patients with Tuberculosis: A 5-Year Experience Within the Florida Department of Health in Hillsborough County
Authors: Moore-Pardo Shylah M , Addisu Anteneh , Reljic Tea , Aslam Sadaf , Casanas Beata 
Published: October 2019

Abstract

Background
Although the rate of tuberculosis (TB) has significantly declined in the United States, elimination has plateaued. Florida is one of the states with the greatest number of cases. The majority of cases occur in foreign-born individuals. Human immunodeficiency virus (HIV) is also a major contributor. HIV-TB coinfection leads to reciprocal interactions with significant clinical impact. We aim to compare the risk factors, clinical findings, and outcomes among HIV-infected vs. HIV uninfected patients.

Methods
A retrospective cohort study of TB cases over a 5 year period (2012–2017) was conducted. All patients with HIV co-infection with age- and gender-matched HIV negative controls were included. The diagnosis of TB was made via clinical, microbiological, radiological, and/or PCR based methods. SPSS was used for statistical data analysis.

Results
A total of 411 TB cases were identified and 66 patients (33 HIV-infected plus 33 HIV un-infected) were eligible for inclusion. The median age was 49 years (range 22–70). The male to female ratio was 21:12 and 50% of patients had TB symptoms; the rest had abnormal imaging or lab finding. Cases were confirmed via positive sputum smear, culture, or PCR (Figures 1–3). Only 11 patients were lost to follow-up, thus 83.3% completed therapy. A total of 5 persons died (Table 1).

Conclusion
The rate of HIV-TB coinfection in the United States was 5.3% in 2018; higher among injection drugs users, homeless persons, inmates, and alcoholics. In our study, the rate of HIV-TB coinfection was slightly higher (8%). The difference was not statistically significant in regards to foreign born, homelessness, and incarceration. Only 3 patients admitted to injection drug use and 9 used alcohol (all HIV negative). Traditionally, HIV-TB coinfected patients have extra-pulmonary TB with higher rates of negative sputum and are at increased risk of death. In our cohort, the difference was statistically significant (P = 0.009) only for cavitary TB (predominated in HIV un-infected) but no difference in outcomes was observed between the two groups. These findings suggest changing trends in HIV-TB coinfection which may be partly related to our setting and demographics but may be attributed to better access to care and antiretroviral therapy at large.

Disclosures
All authors: No reported disclosures.
375. Cryptococcal Antigenemia in Advanced HIV Infection
Authors: Ahuja Jatin , Soneja Manish , Wig Naveet , Xess Immaculata , Biswas Ashutosh , Singh Gagandeep , Vibha Deepti , Nischal Neeraj 
Published: October 2019

Abstract

Background
Diagnostic importance of asymptomatic cryptococcal antigenemia is being increasingly recognized in the last few years. Recently, WHO (World Health Organization) has recommended routine screening of CrAg (cryptococcal antigen) among PLHA with CD4 ≤100/mm3, albeit this procedure is not yet adopted by many developing countries including India.

Methods
We conducted a prospective observational study in a large tertiary care center of North India, upon ethical clearance. Latex agglutination test was performed to assess serum CrAg levels, followed by the lumbar puncture for detection of CrAg levels in the CSF. We analyzed the prevalence and treatment outcomes of cryptococcal antigenemia among PLHA with CD4 ≤ 100 cells/mm3. Detailed clinical examination was conducted, with follow-up of upto 3 months. Multivariate analysis was performed for the estimation of risk factors.

Results
The mean age (years) and BMI (kg/m2) of all the participants were 41.4 ± 11.2 and 22.1 ± 2.6, respectively. Notably, the mean CD4 count (cu.mm) at the time of recruitment was 62.3 ± 20.5. Noteworthy, 62 (60.8%) of the patients were ART naïve. We found 9.8% (n = 10) of the patients were positive for serum CrAg, and only 2.9% (n = 3) had clinical features of meningitis and 6.8% (n = 7) were asymptomatic (subclinical) CrAg positive. Strikingly, 3.9% (n = 4) of the asymptomatic cryptococcal antigenemia patients were also positive for CrAg in CSF, with 1.9% (n = 2) were only serum CrAg positive, and 1 patient was lost to follow-up (Graph 1). Multivariate analysis revealed that patients with long duration of HIV (P = 0.04), headache symptoms (P = 0.004) and possessing features of meningismus (P value=0.08) are more likely to be CrAg positive. Conversely, patients on fluconazole were protective against cryptococcal antigenemia (P = 0.1) as shown in Table 1. Overall mortality observed was 11.3% among advanced HIV patients. Moreover, mortality in CrAg-positive patients was 33.3% in comparison to CrAg-negative patients who had 9% (P = 0.06) in 3-months follow-up.

Conclusion
Cryptococcal antigenemia is common (9.8%) among patients with CD4 count ≤100/mm3 in India. Screening for CrAg should be made routine for PLHA with CD4 count ≤100/mm3 and if required preemptive treatment to be given in this regard.

Disclosures
All authors: No reported disclosures.
382. Difference in Pathogens Between Hip and Knee Prosthetic Joint Infection
Authors: Henry Michael , Kapadia Milan , Nguyen; Barry Brause Joseph , Miller Andy O 
Published: October 2019

Abstract

Background
There is contradicting evidence characterizing the difference in pathogens that cause hip and knee prosthetic joint infection (PJI). A possible difference in microbiology may inform choice in antibiotic etiology, prophylaxis, and empiric treatment. We sought to analyze a large cohort of PJIs to see whether there was a significant difference in pathogen between joints.

Methods
A retrospective cohort of hip and knee PJIs, from 2008 to 2016, were identified by ICD code and surgical codes. The PJI pathogen was identified from synovial or intra-articular tissue cultures. The Student’s t-test was used to compare continuous variables. Chi-square tests were used to compare the categorical variables to joint.

Results
807 PJI cases were identified including 444 knees and 363 hips. There were no significant differences between hip and knee PJIs in age, sex, history of PJI, rheumatoid arthritis, Charlson comorbidity index and laterality. There was a higher frequency of diabetes in knee PJIs (25.3%) compared with hip PJIs (15.7%), P < 0.001. No significant difference was found in the prevalence of fungal, staphylococcal (including Staphylococcus aureus), streptococcal, or enterococcal pathogens between hip and knee PJIs.

Conclusion
In this single-center cohort, hip and knees PJIs are infected with similar pathogens. Multiple site studies are needed to characterize the microbiology of PJIs at a larger scale.

Disclosures
All authors: No reported disclosures.