bluuebunny/crossref_metadata_2025_split huggingface dataset:
313. Bringing Hepatitis C into FOCUS: Evaluating the Efficiency of a Linkage to Care Program in Improving the Hepatitis C Care Cascade
Authors: Battle Brittany M , Gierlach Michael , Allen Brian , Jenkins Melissa O , Avery Ann 
Published: October 2019

Abstract

Background
In 2016, The MetroHealth System began enhanced hepatitis C (HCV) screening through decision support, coupled with linkage of newly diagnosed patients to specialty care by a Linkage to Care coordinator (LTCC). Prior to this, patients were notified of their HCV diagnosis by a provider and given a referral to a specialist. We hypothesized that an LTCC would shorten time from HCV diagnosis to HCV treatment.

Methods
Patients newly diagnosed with HCV between June 1, 2015 and December 31, 2015 (Pre-LTCC), were compared with patients newly diagnosed between January 1, 2016 and March 31, 2017 (Post-LTCC). Patients who were HCV RNA negative were excluded. The time between diagnosis and linkage, linkage and treatment start date, and diagnosis and treatment start date for each population were compared using unpaired t-tests.

Results
125 newly diagnosed patients were identified in the Pre-LTCC population. 83 (66%) were linked to specialty care and 27 (22%) received HCV treatment. 446 newly diagnosed patients were identified in the Post-LTCC population. 211 (47%) were linked to specialty care and 70 (16%) HCV positive persons were treated. No significant difference was noted between the groups in days between diagnosis and specialty care linkage (Pre-LTCC mean = 120 days; Post-LTCC mean = 102 days). The time from linkage to treatment was significantly longer in Pre-LTCC (260 days) than Post-LTCC persons (152 days), P < 0.05. The average time from diagnosis to treatment in pre-LTCC persons was also significantly longer than in Post-LTCC (332 days vs. 237 days, P < 0.05) (See Table).

Conclusion
We demonstrate that post-implementation of an LTCC program for HCV, the time between diagnosis and treatment of HCV was significantly reduced. This reduction, however, did not seem to be due to faster linkage to specialty care. A limitation of the study is that differences in HCV care (insurance restrictions, availability of new regimens) between the pre-LTCC and post-LTCC period were not considered. Although the linkage rate in the post-LTCC period was lower, some patients in post-LTCC may still be awaiting linkage. While there was an observed reduction in time between linkage and treatment, further research is needed to determine the causes of this reduction.

Disclosures
All authors: No reported disclosures.
315. Prenatal Hepatitis C Viral (HCV) Screening Practices and HCV-Associated Fetal, Neonatal and Pregnancy Outcomes in a Large Regional Healthcare System
Authors: Adhikari Tripti , Scott Rachel , Timalsina Utsav , Amgalan Ariunzaya , Sawney Shari L , Tefera Eshetu , Fernandez Stephen , Fishbein Dawn 
Published: October 2019

Abstract

Background
Prevalence of HCV in pregnancy is 0.1–3.6%. AASLD and IDSA now recommend HCV screening in pregnancy although CDC, USPSTF, or ACOG still do not—though HCV can be perinatally transmitted and carries associated complications for the mother and fetus. Our study objectives were to analyze prenatal HCV screening practices at a large regional healthcare system and the prevalence of HCV-associated maternal and fetal/neonatal outcomes.

Methods
We performed a nested propensity score (PS) case–control study of pregnant women who tested HCV Ab+ in a cross-sectional study of women presenting for prenatal care at a large regional healthcare system from January 17 to December 18. We collected retrospective EHR data, including state of residency, HCV Ab, RNA, care engagement, HCV risk factors, comorbidities, maternal and fetal/neonatal morbidity, and neonatal HCV testing (when available). Mixed and generalized linear models were used to examine differences in continuous and categorical variables, respectively, between cases and controls

Results
14,363 women were seen for prenatal care; 4,891 (34%) were HCV tested, 75 (1.5%) tested HCV Ab+. Demographic and comorbidity data are shown in Table 1. HCV Ab+ cases had more co-morbidities, including obesity, heart disease, opioid use, and behavioral health issues compared with the controls. HCV risk factors included IVDU (64%) and tattoos (24%) (Figure 1). Neither past/current pregnancy-related complications nor fetal or neonatal adverse events (Figure 2) were statistically significantly different except for cholestasis in HCV Ab+ cases (5.3 vs. 0%, P = 0.04).

Conclusion
Our study showed only one-third of pregnant women are currently HCV screened in our health system. Universal screening would likely increase the number of HCV-infected women identified. Early HCV detection, repeated testing, and behavioral health intervention of those at high-risk may decrease further horizontal and vertical transmission of HCV in pregnancy.

Disclosures
All authors: No reported disclosures.
316. Hepatitis C and Engagement in Health Care Among Persons Who Inject Drugs and Persons Who Use Non-Injection Drugs, Philadelphia
Authors: Addish Eman , Zellman Hannah , Kostman Jay , Viner Kendra , Kuncio Danica , Trooskin Stacey 
Published: October 2019

Abstract

Background
The growing opioid epidemic is driving increasing rates of hepatitis C virus (HCV) infections in the United States. HCV transmission is most frequently attributed to unsafe injection behaviors, but can occur via other unsafe drug use and sexual behaviors. Differences in demographics, HCV rates and associated risk factors in non-injecting PWUD (NIPWUD), compared with people who inject drugs (PWID) must be understood in order to target elimination strategies.

Methods
Change is Philadelphia’s program to eliminate HCV among PWUD and enrollment includes HCV testing, linkage services, and an interviewer-administered survey including risk behaviors and healthcare engagement. This interim analysis includes the first 835 enrollees that identified as PWUD. For this analysis, PWID are enrollees who indicated ever injecting drugs and those who had not are NIPWUD.

Results
Among enrollees, 76% (N = 637) reported ever injecting drugs. PWIDs were younger and non-Hispanic (NH) white while NIPWUD were older and NH Black (age: P = 0.003; race/ethnicity: P < 0.0001). NIPWUDs had a high seropositivity rate though significantly lower than PWIDs (24% vs. 85%, respectively; P < 0.0001). Among PWID enrollees, 94% (N = 596) ever snorted. Of enrollees, 63% (N = 124) of NIPWUD and 56% (N = 356) of PWID identified having a PCP (P =0.07). PWIDs are more likely than NIPWUD to have overdosed (OD) (40% vs. 9%; P < 0.0001) though high rates of both groups ever witnessed an OD (84% vs. 67%, respectively). While 80% (N = 105) of NIPWUDs know how to use Narcan, 60% (N = 79) carry it, {94% (N = 503) and 71%(N = 381) in PWID, respectively}. NIPWUDs are more likely to be interested in drug treatment (P < 0.0001) and to have received it in the last 12 months (P = 0.0008).

Conclusion
Notable HCV infection exists among non-injecting PWUD reinforcing the need for harm reduction counseling and access to drug use equipment used for smoking and snorting. NIPWUD may be able to access drug and HCV treatment through PCPs and fatal ODs may be prevented by ensuring NIPWUDs have access to Narcan. In addition, PWID are likely to snort as well and should be counseled on non-injecting harm reduction methods. To succeed in micro elimination among PWUD, a focus on NIPWUDs as well as PWIDs is necessary to mitigate transmission of HCV.

Disclosures
All authors: No reported disclosures.
319. SWORD 1 and 2: Switch from TDF Containing Regimen to DTG+RPV Maintains Bone Mineral Density and Decreases Bone Turnover Markers Over 148 Weeks
Authors: Kahl Lesley , McComsey Grace A , Coronado Poggio Monica , Lupo Sergio , de Wet Joss , Parks David A , Wynne Brian , Gartland Martin , Angelis Kostas , Aylott Alicia , Cupo Michael , Vandermeulen Kati , van Wyk Jean A , Smith Kimberly 
Published: October 2019

Abstract

Background
HIV infection and antiretroviral therapy (ART), particularly tenofovir (TDF), is associated with loss of bone mineral density (BMD). The SWORD studies demonstrated noninferiority of the 2-drug regimen (2DR) dolutegravir (DTG) + rilpivirine (RPV) to continuing current triple-therapy ART (CAR) at 48 weeks and continued viral suppression on DTG+RPV through Week 148. A substudy of SWORD 1 and 2 evaluated a change in BMD by DEXA for those participants who switched from triple ART containing TDF to DTG+RPV. The primary analysis reported at 48 weeks showed a significant increase in total hip and lumbar spine BMD and a significant decrease in bone turnover markers in patients receiving DTG+RPV compared with CAR. Here we present data through Week 148.

Methods
HIV-infected adult patients with HIV-1 RNA < 50 c/mL received ART containing TDF for ≥6 months prior to randomization to DTG+RPV (Early Switch group, ES) or CAR on Day 1 (Baseline, BL) through Week 48 in SWORD-1/2. CAR patients suppressed at Week 48 switched to DTG+RPV at Week 52 (Late Switch group, LS). Hip and lumbar spine BMD were measured by DEXA scans read centrally. Secondary endpoints include a change in BMD and bone turnover markers through Week 148.

Results
Following switch to DTG+RPV significant increases were observed for total hip in the ES and LS groups through 100 weeks with a non-significant increase at Week 148 in ES (Figure 1a). Lumbar spine BMD significantly increased from BL at 48 weeks post switch, remained increased, though not significantly from BL through Week 148 (Figure 1b). The BMD of the LS group was similar to that of the ES group through 100 weeks exposure. The majority of patients remained in their pre-switch T-score category or improved a category for both hip and spine through Wk148 (Table 1). Through Wk148, BMI increased minimally and bone turnover markers significantly decreased (P < 0.001 to 0.042 across markers) from BL/LS BL except Type I Collagen C-Telopeptide at Wk148 in the LS group (P = 0.279).

Conclusion
Switch to the DTG+RPV 2DR was associated with sustained improvements in BMD through Week 148, along with a reduction in bone markers. The favorable effects on skeletal health were observed despite the ageing of study patients and other factors decreasing BMD. A switch to DTG+RPV in suppressed patients provides a robust option for preserving bone health while continuing suppressive HIV treatment.

Disclosures
All authors: No reported disclosures.
320. UK-HOPS (HIV Osteoporosis Prevention and Screening)-Gaps in the Care of HIV Patients with Bone Disease
Authors: Maibam Amita , Rao Madhumathi , Lia Castellanos Ana , Lima Florence , Stivers Tiffany , Holleman Donald , Thornton Alice 
Published: October 2019

Abstract

Background
With increasing life expectancy among people living with Human Immunodeficiency Virus (HIV), long-term complications such as osteoporosis/osteopenia and fractures are frequently seen. Although screening guidelines exist for bone disease in the HIV population, quantitative and qualitative gaps exist in screening and prevention. Bone disease in HIV is multifactorial, and FRAX may not accurately predict fracture risk. The aim of our study is to describe diagnostic features of bone disease and estimate the population at risk, and evaluate the frequency of screening, referral and treatment in patients attending an HIV Clinic.

Methods
We performed a retrospective analysis of 1220 patients with HIV infection ≥40 years of age who attended the HIV clinic under the Ryan White program, during January 2016 to December 2018, at University of Kentucky. We obtained demographic details (Table 1), comorbidities, laboratory testing, bone mineral density (BMD) testing and specialty bone clinic referral data from electronic health records, applying ICD -10 and CPT codes. We estimated the frequency of BMD measurement and prevalence of risk factors for bone disease specific to this population.

Results
BMD testing was performed in only 158 (13%) patients (CMS targets 60% for testing at-risk populations). Of these patients, 76 (48%) had osteopenia and 59 (37%) had osteoporosis; 22 (14%) received treatment (Figure 1). Seven patients with osteoporosis/osteopenia and fracture had bone biopsy, with low bone turnover in four (57%). Potential risk factors for secondary osteoporosis are presented in Table 2; at least one factor was present in 98% of patients. Fracture prevalence was likely underestimated because the ICD-10 /CPT coding was available only in 23 (2%) patients.

Conclusion
Bone disease is under-recognized and undertreated, and targeted screening programs are needed for earlier diagnosis and management in this population. Bisphosphonates may not be optimal first-line therapy for all HIV patients with bone loss. In addition to stress or fragility fractures and worsening osteoporosis, metabolic bone work-up should be performed in patients with secondary osteoporosis related to CKD, renal phosphate loss, prior bisphosphonate/Tenofovir/glucocorticoid treatment.

Disclosures
All authors: No reported disclosures.
323. Fragility Fracture Risk in HIV: Awareness Among Primary Care Providers
Authors: Abbate Anne , Chirch Lisa , Christopher. Thompson Michael , Wakefield Dorothy , Mirza Faryal , Zawadzka Sabina 
Published: October 2019

Abstract

Background
Recommendations on screening HIV-infected (+) patients for bone disease exist. We sought to characterize awareness of and adherence to HIV-specific recommendations and assess risk factors for fracture in this population.

Methods
Primary care provider (PCP) and ID specialist awareness of screening recommendations was assessed using an anonymous electronic survey. We conducted interviews of 45 HIV+ patients and chart review. We calculated risk using the fracture risk assessment tool (FRAX). Email notifications were sent if an indication dual-energy x-ray absorptiometry (DXA) scans was identified. Chart review was repeated 12 months later to assess response. Statistical methods included chi-square and Fisher’s exact test for categorical data, and t-tests or Wilcoxon rank-sum tests for continuous data. A multivariate logistic regression examined the relationship between adult fragility fractures and covariates.

Results
No immunologic or virologic factors or exposure to specific antiretroviral therapies (ART) were associated with FFX (Table 1). FRAX score (hip, major osteoporotic fracture) successfully predicted FFX history (P = 0.002, P = 0.001, respectively). Overall, 35 (78%) patients qualified for DXA; 23 (66%) were men, only 8 (23%) had a previous DXA. Following provider notification, an additional 5 patients had DXA ordered. DXA was recommended for all patients with FFX, compared with 68% without a fracture (P = 0.02). In logistic regression modeling, increasing age, male sex, and months of ART therapy were associated with FFX (Table 2). Twenty-seven providers responded to the pre-intervention survey, of whom only 35% were aware of screening recommendations for HIV+ patients. Of the 18 providers who responded post-intervention, 63% were aware of these recommendations (Table 3).

Conclusion
A brief educational intervention resulted in increased awareness of HIV-specific screening recommendations, but this translated into adherence to a lesser extent. HIV+ men were more likely to have a history of fragility fracture compared with females. No specific ART or immunologic marker predicted fracture risk or history. Fostering a greater understanding of unique characteristics and risks in this population is crucial to ensure appropriate preventive care.

Disclosures
All authors: No reported disclosures.
343. T-cell Subsets Associated with Diabetes in Veterans with and without HIV
Authors: Bailin Samuel , McGinnis Kathleen , McDonnell Wyatt J , So-Armah Kaku , Wellons Melissa , Doyle Margaret , Mallal Simon , Justice Amy , Freiberg Matthew , Koethe John 
Published: October 2019

Abstract

Background
Depletion of naïve CD4+ T cells and elevated adaptive immune activation are hallmarks of HIV infection. Higher proportions of memory CD4+ T cells are associated with prevalent diabetes in the general population, but few studies of persons with HIV (PWH) exist.

Methods
We analyzed data from 1532 PWH and 836 uninfected veterans in the longitudinal Veterans Aging Cohort Study (VACS), which archived peripheral mononuclear cells from these veterans between 2005 and 2007. We used flow cytometry to phenotype CD4+ and CD8+ T cells, including naïve, activated CD38+, senescent CD57+, total memory, and memory subsets. Prevalent diabetes (at blood collection) was identified in the VA electronic medical record using random glucose, hemoglobin A1c, ICD-9 codes, and medication. Cases were validated by two-physician chart review. We used multivariate logistic regression models adjusted for age, gender, body mass index, race/ethnicity, unhealthy alcohol use, hepatitis C, CMV status, and viral suppression stratified by HIV status to identify T-cell subsets associated with diabetes in PWH and uninfected.

Results
The cohort was 95% male, 68% African-American, and 22% diabetic. Higher CD4+CD45RO+ memory T cells were associated with prevalent diabetes in the uninfected and in PWH (P = 0.03 and P = 0.07, respectively; Figure A). Among subsets, diabetes was associated with higher transitional memory CD4+ T cells in the uninfected (P = 0.01), but higher central memory cells (P = 0.02) and lower effector memory cells (P = 0.04) in PWH. T effector memory RA+ cells were not associated with diabetes. Lower senescent CD4+CD57+ T cells were associated with diabetes in both PWH and uninfected (P = 0.03 and P = 0.04, respectively; Figure B), but results for naïve CD8+ T cells diverged: diabetes was associated with higher naïve CD8+cells in PWH but lower in uninfected (P = 0.01 and P &lt; 0.01, respectively; Figure C). We assessed interaction by HIV status in a pooled model, which was only significant for the naïve CD8+ T cells (P = 0.01).

Conclusion
The adaptive immune profile associated with prevalent diabetes was similar by HIV status and characterized by a shift in CD4+ T cells from senescent to memory phenotypes, suggesting that chronic immune activation contributes to the higher risk of diabetes in PWH.

Disclosures
All authors: No reported disclosures.
345. Acute Onset Diabetic Ketoacidosis/Hyperosmolar Hyperglycemic State in Patients Taking Integrase Strand Transfer Inhibitors
Authors: Ntem-Mensah Afua Duker , Millman Nina , Jakharia Niyati , Theppote Amanda , Toeque Mona-Gekanju , Riedel David J 
Published: October 2019

Abstract

Background
A few case reports have noted uncontrolled hyperglycemia in patients switched to dolutegravir. Several cohort studies have found increased weight gain among patients treated with integrase inhibitors (INSTI). We present clinical observations among 3 patients admitted to hospital for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) while receiving INSTIs for the management of HIV.

Methods
Case 1: A 44-year-old man with HIV and dyslipidemia presented with altered mental status and lethargy. A fingerstick glucose was >600 mg/dL. Chemistries revealed glucose of 1,600 mg/dL and an elevated β-hydroxybutyrate. HbA1c was 12.4%. His antiretroviral regimen consisted of cEVG/TAF/FTC for the last 3 years. Previous HbA1c levels were 5.7% and 6.2% (Figure 1). Case 2: A 55-year-old woman with HIV, hypertension, dyslipidemia, and obesity presented with polyuria and polydipsia. The blood glucose level was >1,200 mg/dL with an anion gap >30 and HbA1c of 15%. Previous HbA1c levels ranged between 5.6 and 5.8% (Figure 2). She had been taking ABC/FTC/DTG for 2 years.
Case 3: A 64 yo man with a history of HIV, hypertension, and obesity presented with polyuria and polydipsia. The blood glucose level was 1,152 mg/dL with no anion gap and HbA1c of 13.4%. Six months before, he had been switched from a c/DRV- based ART regimen to ABC/FTC/DTG. Previous HbA1c levels ranged between 5.8% and 6.2% (Figure 3).

Results
Discussion: In the first 2 patients, the presentation with acute onset DKA occurred more than a year after being on an INSTI-based regimen; however, the latter patient presented with HHS within 6 months of being switched to an INSTI-containing regimen. The mechanism of action of INSTIs causing weight gain or an association with hyperglycemia is still under investigation.

Conclusion
Although the temporal onset of DKA and HHS while receiving INSTIs was not precise, the possible association of INSTIs and their direct effects on insulin resistance and diabetes warrant additional attention from post-market data. Meanwhile, providers should monitor INSTI-treated patients closely, especially those with features of metabolic syndrome.

Disclosures
All authors: No reported disclosures.
346. Factors Associated with Hypertension in Young Adults with Perinatally-Acquired HIV Infection: a Case–Control Study
Authors: O’Neil Patrick , Ryscavage Patrick , Stafford Kristen A 
Published: October 2019

Abstract

Background
The incidence of systemic hypertension (HTN) among perinatally-HIV-infected (PHIV) patients appears to increase as they enter adulthood. Among non-perinatally HIV-infected adults both traditional and HIV-associated risk factors have been found to contribute to HTN. Whether these same factors contribute to HTN in PHIV is unknown. The purpose of this study was to determine the socio-demographic, clinical, virologic, and immunologic factors associated with HTN among a cohort of PHIV adolescents and young adults, aged ≥18 years.

Methods
We conducted a case–control study among a population of 160 PHIV adults with and without HTN who were receiving care at the University of Maryland and aged 18–35 years as of December 31, 2017. Covariates assessed included traditional risk factors such as age, family history of HTN, and smoking, as well as HIV- and antiretroviral-associated covariates.

Results
We identified 49 HTN cases (30.6%) and 111 (69.4%) controls. There were no significant differences in the odds of most traditional (age, gender, race, family history of HTN, tobacco, alcohol, and/or other drug use) or HIV-associated (CD4 nadir <100 cells/mm3, individual ART exposure, ART interruption) risk factors among PHIV adults with HTN compared with those with no diagnosis of HTN. Cases had lower odds of a history of treatment with lopinavir/ritonavir (LPV/r). Cases had 3.7 (95% CI 1.11, 12.56) times the odds of a prior diagnosis of chronic kidney disease (CKD) compared with controls after controlling for CD4 nadir and ARV treatment history.

Conclusion
The results of this study suggest that most traditional and HIV-related risk factors do not appear to increase the odds of having HTN in this PHIV cohort. However, HTN among PHIV may be driven in part by CKD, and a focus on the prevention and early management of CKD in this group may be necessary to prevent the development of HTN. Additionally, there may be as yet unidentified risk factors for HTN among PHIV which require further exploration. Given the large and growing population of PHIV entering adulthood worldwide, it is imperative to explore risk factors for and effects of HTN in large, diverse PHIV populations.

Disclosures
All authors: No reported disclosures.