bluuebunny/crossref_metadata_2025_split huggingface dataset:
295. South Carolina Hepatitis C Telehealth Initiative (SCHTI): Increasing Access to HCV Care
Authors: Derrick Caroline , Chastain Cody A , Meissner Eric G , Love Bryan , Wagner Tyler , Harrison Adrena , Crawford Kimberly , Ahuja Divya 
Published: October 2019

Abstract

Background
Lack of access to specialists is often a deterrent to comprehensive health care, especially in rural areas. Chronic Hepatitis C (CHC) affects 1% of the US population, and with the availability of highly efficacious treatment, it is imperative innovative steps are taken to screen and treat these patients. The South Carolina Hepatitis C Telehealth Initiative (SCHTI) is designed to provide Infectious Diseases (ID) consultation to rural providers caring for HCV-infected individuals across the Southeast. SCHTI is an interdisciplinary collaboration incorporating physicians, pharmacists, nurses and case managers from USC, MUSC, and Vanderbilt University.

Methods
SCHTI tele-consultation sessions were initiated in 2016, are held weekly, and provide a short didactic followed by discussion of patient cases with real-time feedback to the presenting providers. In addition, the program provides 1-hour continuing education certification for physicians, pharmacists and nurses. The South Carolina Department of Health and Human Services has approved SCHTI as an alternative to in-office expert consultation.

Results
From July 2016 through December 2018, 63 sessions were conducted, with 43 unique providers presenting cases and over 160 clinical attendees. Participating providers include Infectious Diseases, Family Medicine and Internal Medicine, amongst others. 259 cases have been reviewed, with a mean of 4.11 cases/session. Genotype 1a predominated and 44% of cases had advanced liver fibrosis. An increasing number of cases are young patients outside the high-prevalence birth cohort, and these individuals have a history of intravenous drug use. Overall, 13% of HCV cases were co-infected with HIV.

Conclusion
SCHTI provides multidisciplinary HCV teleconsultation to providers across the Southeast and is improving access to specialists and high-quality health care for patients across rural areas within the Southeast. Future outcomes to be assessed include sustained virologic response rates, relapse rates and impact on hepatic and extra hepatic morbidity and mortality from CHC.

Disclosures
All authors: No reported disclosures.
296. The Hepatitis C Cascade of Care across Four Safety Net Settings in the Southeast
Authors: Schranz Asher J , Kovasala Michael , Givens Candice , Hilton Alison , Maierhofer Courtney , Sena Arlene 
Published: October 2019

Abstract

Background
Despite advances in antivirals, disparities in hepatitis C (HCV) treatment remain. We evaluated persons diagnosed with HCV in 4 safety net sites in a large Southeastern county, using care cascades to conceptualize milestones in treatment.

Methods
Persons diagnosed with HCV in 4 screening sites across Durham County, North Carolina, from December 2015 to May 2018 were included, allowing for 9 months of follow-up. Sites included the county health department (CHD), a federally qualified health center (FQHC) where providers trained in HCV care, jail and community outreach. Persons with HCV were eligible for a bridge counselor intervention to enhance linkage to care with an HCV-treating provider (either primary care or specialist). Outcomes were monitored by chart review. Persons linked to care in the prison (n = 36) were censored from subsequent cascade steps due to inability to obtain records. Cascades were compared by the site of diagnosis. Multivariable logistic regression was used to evaluate predictors of being prescribed antivirals.

Results
505 persons were diagnosed with HCV: 216 in the FQHC, 158 in the jail, 72 in the CHD, and 59 in community outreach. Overall, 89% were counseled on their diagnosis, 65% were linked to care, 41% prescribed antivirals, 38% started medications, 34% completed medications and 24% achieved sustained viral response at 12 weeks (SVR-12). Progression through the cascade was highest for those diagnosed at the FQHC (figure). In analyses adjusted for demographics and risk factors, diagnosis in a community outreach setting had lower odds of antiviral prescription, compared with diagnosis in the FQHC (OR 0.33, 95% CI 0.12–0.89). Linkage to care at a specialist clinic (vs. primary care) was associated with antiviral prescription (OR 3.82, CI 1.95–7.46). Sex, race/ethnicity, insurance status and HCV risk factors were not associated with antiviral prescription.

Conclusion
Among persons diagnosed with HCV across four safety net sites, a quarter achieved SVR-12. Those diagnosed in community outreach had lower odds of antiviral prescription, and those who were linked to a specialist were more likely to receive antiviral prescription. Improving progression through cascade milestones across safety-net settings is integral to improving population-based HCV outcomes.

Disclosures
All authors: No reported disclosures.
306. CD8+ T-Cell Responses to Chronic Hepatitis C in Pregnancy
Authors: Brooks Stephanie , Coss Samantha , Walker Christopher , Honegger Jonathan 
Published: October 2019

Abstract

Background
Chronic hepatitis C virus (HCV) infection is marked by stable, high -level viremia and a failed T-cell response. HCV-specific CD4+ helper T cells are rare, and CD8+ cytotoxic T cells are functionally exhausted or ineffective due to viral escape mutations. Postpartum, a subset of infected women experience a substantial drop in viremia. Preliminary data indicate that this unusual viral decline may be linked to a resurgence of HCV-specific CD4+ T cells producing Th1 cytokines. How improved CD4+ helper T-cell function might affect viral replication in this scenario is not established. Here we tested the hypothesis that improved CD4+ T cell help mediates control of chronic HCV replication through enhanced CD8+ T-cell function.

Methods
We examined plasma HCV RNA viral load (VL) and HCV-specific T-cell responses in 33 women with chronic HCV during the third trimester (T3) and at 3 months postpartum (3P). HCV-specific CD4+ and CD8+ T-cell IL2 and IFNγ responses were measured by intracellular cytokine staining following stimulation of peripheral blood mononuclear cells with peptide pools corresponding to the HCV proteins NS3, NS4a, and NS4B.

Results
Median VL dropped from 5.87 log10 at T3 to 5.25 log10 at 3P (P < 0.0001, Wilcoxson signed rank), with a wide range from +0.4 log10 to -4.2 log10. The degree of decline correlated significantly with improved frequencies of HCV-specific CD4+ T cells producing IFNγ (P = 0.015 Spearman) but did not correlate with CD8+ T-cell changes. Nevertheless, improved T helper function correlated with increased HCV-specific CD8+ T-cell function (ΔCD4+IL2+ vs. ΔCD8+IFNγ+, P = 0.015 Spearman, graph 1; ΔCD4+IFNγ+ vs. CD8+IFNγ+ at 3P, P = 0.004 Spearman, graph 2).

Conclusion
Despite no significant association between virus-specific CD8+ T-cell Tc1 cytokine production and postpartum viral control, our data suggest that recovery of CD4+ T-cell help may augment CD8+ T-cell function. Further study incorporating viral genomic sequences to focus on intact class I epitopes is needed to clarify the relationship of improved CD8+ function and viral control in this unique model of immune restoration.

Disclosures
All authors: No reported disclosures.
325. Cancer Screening Disparities among Persons Living with HIV (PLWH)
Authors: Hysell Kristen , He Wei , Chang Yuchiao , Dryden-Peterson Scott , Triant Virginia A 
Published: October 2019

Abstract

Background
Cancer is now the leading cause of mortality for persons living with HIV (PLWH) in the United States, but it is uncertain whether PLWH access cancer screening that could lower this burden. We sought to assess cancer screening for breast, cervical, and colon cancer among PLWH compared with the HIV-uninfected population at a multicenter healthcare system over the past two decades.

Methods
Data were obtained from a prospective, observational HIV clinical care cohort comprised of PLWH engaged in care in the Partners Healthcare System. Patients eligible for cancer screening between the years 2002 and 2016 were included. Patients were matched in a maximum of 1:4 ratio with HIV-uninfected patients from the Massachusetts General Primary Care Practice-Based Research Network based on age, sex, race, year of study entry, and length of follow-up. The mean proportion of time in which eligible patients were guideline concordant for cervical, breast, and colon cancer screening was assessed. Non-parametric tests were used to compared screening rates between PLWH and HIV-infected and on the basis of multiple clinical and sociodemographic factors.

Results
During the observation period, a total of 495 PLWH were eligible for breast cancer screening, 1011 for cervical cancer screening, and 1965 for colon cancer screening. For each screening group, the majority of PLWH were on antiretroviral therapy (ART) and had relatively high CD4 cell counts (Table 1). Screening rates for PLWH compared with controls were 67.3% vs. 82.8% (P < 0.0001) for breast cancer, 49.0% vs. 73.3% (P < 0.0001) for cervical cancer, and 92.7% vs. 91.2% (P = 0.96) for colon cancer (Figure 1). Among PLWH, factors significantly associated with lower rates of screening guideline concordance were older age, lower CD4 count, HIV-1 RNA >1000 copies/mL, and HIV duration < 5 years for breast cancer, and older age, white race, English language, and lack of ART use for cervical cancer.

Conclusion
Among patients engaged in longitudinal care, PLWH had significantly lower rates of screening for breast and cervical cancer than HIV-uninfected. Disparity is not explained by racial or primary language differences. Further work to improve access to cancer screening for PLWH is needed.

Disclosures
All authors: No reported disclosures.
333. Weight Gain Among HIV-Infected Patients in Southern India on Treatment with Integrase Strand Transfer Inhibitor-based Antiretroviral Therapy
Authors: Khan Rifa , Pradeep Amrose , Devaraja Chithra , Krishnan Bala 
Published: October 2019

Abstract

Background
Addition of integrase strand transfer-inhibitors (mainly dolutegravir) has strengthened anti-retroviral therapy (ART), to sustain viral suppression in HIV-1 and 2-infected patients. For judicious use in the future, we examine weight gain in ART-naïve, and those exposed to INSTI-based regimens as first, second, and third-line ART.

Methods
We undertook a retrospective cross-sectional study of patients initiated on INSTI-based regimens from 15 January 2017 to 22 December 2018 (n = 333). Descriptive statistical analyses were performed using STATA 15.1. Cross-tabulation and stratification were conducted to measure the strength of association. A linear regression model was used to study the increase in weight per unit of time.

Results
331 patients are infected with HIV-1 and 2 with HIV-2. 66% are male, median age= 38 years (IQR 31–44). Median CD4 count at INSTI initiation was 226 cell/cubic mL (IQR 87–395). Median viral load at initiation of INSTI-based therapy was log104.768 copies/mL (IQR 2.9—5.63). Most common opportunistic infections were pulmonary tuberculosis (n = 97), oral candidiasis (n = 84), and herpes zoster (n = 44). Median hemeoglobin was 12gm% (IQR 10.5–13.8). 39% were initiated on TDF+3TC+DTG and 32% were initiated on TDF+FTC+DTG. 74% experienced weight gain; average increase was 3.69 Kg (SD 3.56) at 3 months. 19.5% gained >4 kg; median BMI at initiation of therapy was 22.56 kg/m2 (IQR 19.8–25.1) and 25.4 kg/m2 (IQR 22.5–28.7) at an average of 9.5 months post initiation of dolutegravir-based ART. 70% of ART naïve (n = 73) experienced weight gain; 17.8% gained 8.36 kg at 9 months. Higher weight gain was observed in patients with opportunistic infections. Association with gender (OR = 0.9 95%, CI 0.54 -1.5; P = 0.70) and age (OR=0.9, 95% CI 0.97–1.01;P = 0.71) was not significant. Weight gain was positively correlated with time (r=+1); predicted increase in weight per 0.1 months after initiation of INSTI-based regimen (F=4.62, P = 0.032).

Conclusion
Access and adherence to INSTI have positively influenced viral suppression of HIV-infection.To ensure the prevention of obesity and apt use of ART for malnourished patients, it is imperative to monitor weight gain in patients who are initiated on INSTI-based regimens. Further research to study the mechanism of weight gain is warranted.

Disclosures
All authors: No reported disclosures.
336. Disparities in Cardiovascular Disease Prevention Among Persons Living with HIV in the United States Military Natural History Study
Authors: Thomas Larson Derek , Won Seunghyun , Deiss Robert G , Ganesan Anuradha , Maves Ryan , Okulicz Jason , Kronmann Karl , Chu Xiuping , Schofield Christina , Agan Brian 
Published: October 2019

Abstract

Background
The use of antiretroviral therapy has reduced morbidity and mortality associated with HIV infection primarily due to the reduction of AIDS-related events. Although guidelines have aimed to standardize preventive care, disparities in prevention of cardiovascular disease remain prevalent across multiple cohorts.

Methods
The US Military HIV Natural History Study is an open cohort of Department of Defense beneficiaries. We included subjects aged 21–75 whose most recent study visit was between October 2015 and September 2016 and conducted a retrospective cross-sectional analysis of established cardiovascular disease risk factors and statin use. To determine statin eligibility we used the American College of Cardiology/American Heart Association 2013 atherosclerotic cardiovascular disease management guidelines and included subjects who had all necessary data elements for analysis.

Results
The participants (n = 1223) were predominantly middle-aged (median 47 years, Interquartile Range [IQR] 33–55), male (95%), and were racially diverse (46% African-American, 16% Hispanic/other). The rate of tobacco use was 16%, diabetes was 11%, and 36% had hypertension. In total, 486 (40%) patients met criteria for statin therapy, with 17% of those being for secondary prevention. As of their last visit, 52 (4%) had a detectable HIV viral load. Statins were prescribed to only 302 (62%) of those with an indication, with lower prescription rates in African Americans (52%) and Hispanics (58%) than Caucasians (73%). Average blood pressure, rates of tobacco use, and prevalence of diabetes were equal between the African American and Caucasian groups.

Conclusion
We found significant racial disparities in both primary and secondary cardiovascular disease mitigation within the military healthcare system. Previous studies have found similar racial differences attributed to socioeconomic factors and higher rates of intravenous drug use. As active duty service members have a stable income, open access to healthcare, and low rates of injection drug use, our findings challenge that premise. Understanding whether this is due to prescribing practices, physician-patient relationships, or healthcare uptake is critical to narrowing this major gap in care.

Disclosures
All authors: No reported disclosures.
340. Prevalence of Type II Diabetes Mellitus Among Patients Living with HIV in the United States
Authors: Birabaharan Morgan , Strunk Andrew , Garg Amit , Hagmann Stefan 
Published: October 2019

Abstract

Background
An aging HIV-infected population has growing recognition for its increasing prevalence of type 2 diabetes mellitus (T2DM). Most studies of T2DM prevalence among patients living with HIV involve selected samples and/or small cohorts which limit generalizability. We sought to evaluate the overall prevalence of T2DM among patients living with HIV in the United States as well as within specific demographic subgroups.

Methods
A cross-sectional analysis was performed using a large, multi-institutional database (Explorys), where clinical information across 27 healthcare networks are matched and standardized to create longitudinal records for each unique patient. At present, the database contains 63 million unique lives, representing 18% of the population across all 4 census regions of the United States. Patients with all types of insurance as well as those who are self-pay are represented. The analysis included adult patients with an active status in the database during April 2014- April 2019 who, not missing data on age, gender, race, and body mass index. The Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT) of “Human Immunodeficiency Virus,” “diabetes mellitus type 2,” “disorder due to type 2 diabetes mellitus,” and “Type II diabetes mellitus uncontrolled” were used to identify patients with HIV and T2DM.

Results
We identified 90,900 patients with HIV. The overall prevalence of T2DM among patients with HIV was 22.1% (20,080/90,900) compared with 14.9% (2,679,490/17,946,580) in the general population. In subgroup analysis, the prevalence of T2DM was highest among patients with HIV who were female, older, other race, obese, hypertensive, hyperlipidemic, smokers, alcoholics, and those with a history of hepatitis C infection. Patients with no exposure to antiretroviral therapy (ART) had higher prevalence of T2DM than those with exposure (24.9% vs. 17.6%).

Conclusion
In this US population-based study, we found 1 in 5 people living with HIV had prevalent T2DM. In addition, we observed that HIV-associated T2DM may not depend on chronic ART exposure. Physicians caring for patients with HIV should be aware of the association and should monitor for signs and symptoms of T2DM.

Disclosures
All authors: No reported disclosures.
342. The Impact of Glycemic Control on CD4 Cell Count in Persons Living with HIV and Diabetes Mellitus—Washington, DC
Authors: Powers Happ Lindsey J , Monroe Anne K , Young Heather A , Ma Yan , Greenberg Alan E , Benator Debra A , Horberg Michael A , Castel Amanda 
Published: October 2019

Abstract

Background
Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) <7%. This analysis examined the impact of HbA1c on trends in CD4 count among PLWH receiving care in Washington, DC.

Methods
We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control were compared using an LME model with random slopes and random intercepts, adjusted for sex, BMI, nadir CD4, a history of AIDS, or cancer diagnosis.

Results
Among 554 participants (median age 53.5; 70.8% male; 82.7% Black), there were 5,138 total CD4 count measurements. In unadjusted analysis, participants with moderate or uncontrolled HbA1c had higher mean CD4 counts over the follow-up period than those with strict HbA1c control (strict: 690 cells/μL, moderate: 712 cells/μL uncontrolled: 711 cells/μL; P = 0.0156 strict vs. moderate, 0.049 strict vs. uncontrolled). All DM control groups had a similar temporal increase over time in CD4 count (P = 0.46). In multivariate analysis, only moderate vs. strict control showed a significant difference in CD4 count (mean difference=18.1; P = 0.02). Results showed CD4 count change was not affected by the duration of HIV diagnosis or diabetes diagnosis. See Table 1 for additional results.

Conclusion
PLWH and DM with moderate HbA1c control had higher CD4 counts than those with strict HbA1c control and similar CD4 counts compared with those with uncontrolled HbA1c levels, while the rate of increase in CD4 count was similar in the three groups. These results show that moderate DM control may benefit CD4 count, which should be considered when revising DM control guidelines for PLWH.

Disclosures
All authors: No reported disclosures.
351. HIV and Aging: Multimorbidity in Older People Living with HIV in One Southeastern HIV Clinic
Authors: Crowder Arant Elizabeth , Harding Ceshae , Targonski Paul V , McManus Kathleen A 
Published: October 2019

Abstract

Background
While morbidity and mortality related to HIV are decreasing, age-related chronic conditions are becoming more common in people living with HIV (PLWH). We hypothesized that multimorbidity prevalence among PLWH would increase from 2006 to 2016 and that multimorbidity would be associated with demographic and healthcare system-level factors.

Methods
Cohorts included PLWH aged 45–89 who received care at the University of Virginia (UVA) Ryan White HIV clinic in 2006 (Cohort 1) and 2016 (Cohort 2). Multimorbidity was defined as the co-occurrence of ≥2 age-related chronic diseases. Demographics, HIV-specific clinical characteristics and multimorbidity were compared between the cohorts using a generalized linear model fit using a generalized estimating equation that accounted for repeated measures. Within each cohort, multivariable binary logistic regression was used to assess the association between participants’ characteristics and multimorbidity.

Results
Cohort 1 had 198 participants, and Cohort 2 had 378 participants. Cohort 1 represented 33% of the 2006 clinic population, and Cohort 2 represented 54% of the 2016 clinic population. Less Cohort 2 participants were uninsured (5% vs. 22%, P < 0.001) and more had private insurance (44% vs. 26%, P < 0.001). The prevalence of multimorbidity was higher in Cohort 2 (28% vs 21%, P < 0.001). For Cohort 1, multimorbidity was less likely for those with private insurance (8%, adjusted Odds Ratio [aOR] 0.81, 95% Confidence Interval [CI] 0.69–0.90) compared with those with Medicare (32%). For Cohort 2, multimorbidity was more likely for those with incomes < 100% Federal Poverty Level (FPL; 34%) compared with those with incomes 101–250% FPL (27%, aOR 0.86, 95% CI 0.74–1.00) and 251–500% FPL (21%, aOR 0.78, 95% CI 0.64–0.95). For Cohort 2, multimorbidity was associated with female sex (40%, aOR 1.21, 95% CI 1.01–1.45) compared with male sex (24%).

Conclusion
Older PLWH represented an increasing proportion of the studied Southeastern clinic population. Multimorbidity prevalence was higher in 2016 compared with 2006. Insurance status was associated with multimorbidity for Cohort 1. For Cohort 2, incomes < 100% FPL and female sex were associated with increased likelihood of multimorbidity. Future research will need to assess the reasons for these disparities.

Disclosures
All authors: No reported disclosures.