bluuebunny/crossref_metadata_2025_split huggingface dataset:
836. Significant Elevations in CD4+ Count, Post-treatment of Chronic Hepatitis C (HCV) with Direct Acting Antivirals (DAAs), in Human Immune Deficiency, HIV/HCV Co-infected Patients with Prolonged CD4+ lymphocytopenia, despite undetectable HIV RNA
Authors: Kuhn Ryan , Green Carolyn , Natesan Suganthini Krishnan 
Published: December 2021

Abstract

Background
Introduction of DAAs has revolutionized HCV therapy. Treatment of HIV/HCV co-infected patients is challenging and HCV treatment data on this group of patients are limited. Aim: To review pre-and post-DAA treatment parameters, identify measures to improve recruitment and improve quality of care in co-infected veterans. A QC/QI project.

Methods
A retrospective chart review of HIV/HCV co-infected patients treated for HCV with DAA at Detroit VAMC was performed. All patients were on anti-retroviral treatment for HIV with undetectable viral loads. Pre-and post-DAA treatment parameters were compared in patients who completed 12 weeks of treatment. Drug interactions, SVR, CD4+ counts AST, ALT, albumin, INR, platelets, creatinine, alpha-fetoprotein (AFP), HCV RNA, and FIB-4 score were recorded. Pearson correlation coefficient was used for data analysis.

Results
Out of 46 patients, 4 died and 20 were ineligible due to non-compliance, mental illness, or drug use; 22 eligible patients, who had well controlled HIV, received DAAs for 12 weeks. (Genotype was 1a in 14, 1b in 7 and 2b in 1 patient). Compliance rate was 100%, 21 patients were HCV treatment naïve, 1 treated with interferon in the past) and all 22 patients achieved SVR by 12 weeks (in 2 weeks), including patients (n=12) on long term opioids and/or mental health treatment. Among 10/24 patients who showed a significant increase in CD4+ (range &gt; 100 to 400 within 6 months), 8 were cirrhotic and had received DAA + RIB therapy. HIV therapy regimen change to alafenamide combination was required in 7/22 patients, for renal dysfunction. There were decreases in AST/ALT, but no changes in FIB-4 score, platelets, albumin, creatinine, or AFP were noted.

Conclusion
HIV/HCV Co-infected patients who received DAA + RIB had a significant increase in CD4+ lymphocyte counts (p&lt; 0.05) (unlike interferon-based regimen). Chronic opioid use and mental health treatment were not a hindrance to successful therapy. The clinical impact of our findings on long-term complications including cirrhosis, hepatocellular carcinoma, and extra-hepatic manifestations of HCV remain to be seen. Recognition of positive predictive markers will delineate the cohort of co-infected veterans who would benefit from DAA therapy beyond HCV eradication.

Disclosures
All Authors: No reported disclosures
837. Performance of Blood (1- &gt;3)-β-D-Glucan in People with AIDS Presenting with Respiratory Symptoms
Authors: Hasan Lana , Krishnan Gayathri , Saccente Michael 
Published: December 2021

Abstract

Background
The gold standard for diagnosis of Pneumocystis jirovecii pneumonia (PCP) is direct visualization of the microorganism in respiratory samples, usually obtained via bronchoalveolar lavage (BAL). Blood β-D-glucan (BDG) is used as a non-invasive adjunctive diagnostic test for PCP, but specificity is only modest, in part because other opportunistic fungal infections cause high BDG. We previously showed BDG-positivity in 94% of people with AIDS (PWA), progressive disseminated histoplasmosis (PDH), and respiratory symptoms in our hospital. In this study, we aim to assess the performance of BDG as a diagnostic test for PCP in PWA who have respiratory symptoms.

Methods
We retrospectively identified PWA who had a BDG result between 2014 and 2019. AIDS was defined as past or current absolute CD4 count &lt; 200 cells/µL, or a past or current AIDS-defining condition. Positive cytological or histological evidence of P. jirovecii in bronchoalveolar lavage (BAL) fluid or lung biopsy, or positive Pneumocystis PCR on sputum or BAL confirmed PCP. The Fungitell Assay (Associates of Cape Cod, East Falmouth, MA) determined BDG levels as follows: negative, &lt; 60 pg/mL; indeterminate, 60-79 pg/mL, and positive, ≥ 80 pg/mL. Values &lt; 31 pg/mL and those &gt;500 pg/mL were censored at 30 pg/mL and 500 pg/mL, respectively. Respiratory symptoms were defined as cough, dyspnea, chest pain, or hypoxia. We compared BDG results for participants with proven PCP and participants without proven PCP.

Results
We identified 260 PWA with a BDG result, of whom 183 had at least one respiratory symptom. 84 (45.9%) of these participants had a positive BDG. BDG results among participants with and without PCP are shown in Table 1. Of the 44 participants with a positive BDG who did not have PCP, 29 (65.9%) had PDH. Other diagnoses included cryptococcosis and candidemia. The test performance of BDG for the diagnosis of PCP is shown in Table 2. Exclusion of participants with PDH increased the specificity of BDG for PCP to 86.4%.
Table 1. Results of (1-&gt;3)-β-D-glucan Testing by Pneumocystis jirovecii Pneumonia Diagnosis Among Participants with AIDS and Respiratory Symptoms

Table 2. Test Performance of (1-&gt;3)-β-D-glucan for the Diagnosis of Pneumocystis jirovecii Pneumonia*

Conclusion
At our center where histoplasmosis is endemic, a positive BDG should not be attributed to PCP among PWA with respiratory symptoms because of low specificity and low positive predictive value. However, a negative BDG can exclude PCP in this population.

Disclosures
All Authors: No reported disclosures
839. Examining the Effects of HIV Infection on Severity of Outcomes in Those with COVID-19
Authors: Parkinson Melissa , Gerrity Rebecca , Strength Rachel , Fuchs Christian J , Jackson Christopher , Kadaria Dipen , Seth Ankur , Animalu Chinelo N , Summers Nathan A 
Published: December 2021

Abstract

Background
Throughout the SARS-CoV-2 pandemic, there have been many questions about how COVID-19 affects patients living with HIV (PLWH). We examined the clinical courses of 45 PLWH who required hospitalization with SARS-CoV-2 infection.

Methods
This is a retrospective cohort study in which ICD-10 codes were used to identify PLWH who were admitted to three large hospital systems in Memphis, TN with COVID-19. We included all patients ≥ 18 years of age with HIV and a documented positive SARS-CoV-2 PCR test. After manual abstraction from the electronic health records, chi-squared and T-tests were performed to evaluate associations between patient-level factors and outcomes.

Results
A total of 45 patients with HIV who tested positive for SARS-CoV-2 were admitted to Memphis, TN area hospitals between March 2020 and October 2020. 18 (40%) were female, 43 (95.6%) were Black, and the average age was 50.3 years (SD 12.6). The average BMI was 30.2 (SD 8.6). 40 (88.9%) patients admitted had at least one comorbidity with the most common being hypertension (28 patients, 62.2%) and diabetes (14 patients, 31.1%). 24 (46.7%) patients had a Charlson Comorbidity Index &gt; 3. 15/43 (48.4%) patients had a CD4 count &lt; 200, and 35 (77.8%) were on ART. 30 (66.7%) patients met SIRS criteria within 24 hours of admission, and 27 (60%) required some form of oxygen supplementation during hospitalization, including 4 (8.9%) who required intubation. The average length of stay was 10.4 days (SD 12.5). 9 (20%) patients required an ICU stay, and 3 (6.7%) died. BMI &gt; 30, CD4 count &lt; 200, and viral load &gt; 1000 were not associated with worse outcomes. Both a Charlson Comorbidity Index &gt; 3 and the absence of ART were associated with need for ICU-level care.

Conclusion
Viral load, CD4 count, and BMI were not correlated with differences in mortality or oxygen use in our study. Patients with higher Charlson Comorbidity Indices and patients who were not on ART at presentation were significantly more likely to require the ICU. Further study is needed to definitively determine factors affecting the outcomes of PLWH with SARS-CoV-2 infection.

Disclosures
All Authors: No reported disclosures
844. High Risk Behaviors, Suboptimal HIV Viral Suppression, and Limited PrEP Use among People Who Engage in Transactional Sex
Authors: Cover Amelia , Bijole Phyllis , Eyasu Rahwa , Ebah Emade , Ogbumbadiugha-Weekes Onyinyechi , Mount Julia , Stevens Jasmine , Gannon Catherine , Davis Ashley , Gayle Britt , Jones Miriam , Kier Randy , Sternberg David , Silk Rachel , Kattakuzhy Sarah , Masur Henry , Kottilil Shyam , Rosenthal Elana S 
Published: December 2021

Abstract

Background
In the United States, high rates of HIV transmission persist, particularly due to sexual transmission in marginalized populations. Transactional sex (TS) is a known risk factor for HIV transmission, yet risk behaviors and engagement in HIV treatment and prevention among those who have TS are poorly understood.

Methods
GRAVITY is cross-sectional investigation of people living with HIV (PLWH) or HCV in Washington, DC and Baltimore, MD. Epidemiologic survey data were collected at a single timepoint. Patients who endorsed previous year sex in exchange for drugs, money, or shelter were considered positive for TS. Fisher’s exact test was used for statistical analysis.

Results
Of 500 participants, 81(16%) endorsed TS, the majority of whom were HIV+ (51, 63%) and used drugs daily or more (57,70%; see Table 1). PLWH with TS were more likely to be Black (44, 86%, p= 0.05) and Trans female (17, 33%, p&lt;0.01) than HIV- participants with TS. In the TS cohort, PLWH were more likely to engage in anal sex (38, 75%, p&lt; 0.01), have sex weekly or more (46, 90%; p&lt; 0.01), have sex with more than 2 partners (27, 77%, p=0.03), and have a history of syphilis (14, 27% p= 0.04) compared to HIV- participants. Only 21% and 35% of PLWH and 17% and 22% of HIV- always used condoms in vaginal sex and anal sex, respectively (p &gt;0.05). Though 41 (80%) PLWH took ART, only 19 (41%) reported viral suppression. Of HIV- participants, 59% had interest in starting Pre-Exposure Prophylaxis (PrEP), but few had been offered (3,10%), or ever taken PrEP (2,7%).
Table 1: Participant Characteristics and Associations with Transactional Sex and HIV Status

Conclusion
In this cohort of people with TS, there were high rates of HIV and racial, sexual, and gender minorities. Notably, PLWH had higher rates of frequent sex, multiple partners, and anal sex, as well as suboptimal viral suppression and condom use during anal sex. As such, PLWH +TS may be a consequential part of HIV transmission networks. While those without HIV also had frequent sex and suboptimal condom use, PrEP experience was limited. As the majority had interest in PrEP, targeted strategies to initiate and maintain PrEP in people with TS may be critical in preventing HIV acquisition. Interventions to identify TS, address high-risk behaviors, achieve and maintain viral suppression amongst +TS PLWH, and connect +TS HIV- individuals to PrEP are key to a comprehensive strategy to end the HIV epidemic.

Disclosures
Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)
104. Plague Meningitis - A Systematic Review of Published Cases, Antimicrobial Treatment, and Outcomes
Authors: Cooley Katharine , Fleck-Derderian Shannon , Nelson Christina 
Published: December 2021

Abstract

Background
Plague meningitis is a rare but serious manifestation of infection with the bacterium Yersinia pestis. The risk factors, clinical evolution, and optimal treatment strategies of plague meningitis are not well understood, and data is limited to sporadic case reports. To advance knowledge of this condition and support clinical practice recommendations, we conducted a systematic review of published cases of plague meningitis.

Methods
We reviewed PubMed Central, Medline, Embase, and other databases for publications on plague meningitis in any language. Articles that contained reports of patients with plague meningitis plus information on patient outcome were included.

Results
Among 1,090 articles identified in our search, we found 54 articles describing 83 cases eligible for inclusion. Cases occurred between 1898 and 2015; mean age of patients was 20.5 years (range 6 wks - 64 yrs) and 65% were male. Most patients lived in the United States (23%), Argentina (18%), Vietnam (12%), or China (12%). Four patients (5%) had primary plague meningitis. More than half (59%) of patients developed meningitis secondary to primary bubonic plague; the remainder developed meningitis secondary to other or unknown forms of plague. Of patients with a bubo, 51% had an axillary bubo. The most common symptoms were fever (66%), nuchal rigidity (43%), and headache (35%); 23 patients had focal neurologic deficits such as cranial nerve abnormality. Case fatality rate was 96% (n=23/24) for patients who did not receive antimicrobial treatment and 42% (n=25/59) for patients treated with antimicrobials. Case fatality rate by antimicrobial received, including patients who received multiple antimicrobial classes, was 50% for sulfonamides (n= 38), 50% for fluoroquinolones (n=2), 19% for aminoglycosides (n=21), 11% for chloramphenicol (n=19), and 0% for tetracyclines (n=14).

Conclusion
Plague meningitis has a high fatality rate, but antimicrobial treatment can improve patient outcomes. Having an axillary bubo may be a risk factor for developing plague meningitis – in contrast to our findings, a recent analysis found that only 24% of patients with bubonic plague had buboes in the axillary region. Additional research would be helpful to investigate this association further.

Disclosures
All Authors: No reported disclosures
849. Impact of a Combined Education and Data Driven Intervention on PrEP Uptake at the Veterans Health Administration
Authors: Musoke Lewis , Allen Kristen A , Bray Kaylee , Lea Erin J , Briggs Janet , Shumaker Amy H , Wilson Brigid , Newman Nicholas J , Van Epps Puja 
Published: December 2021

Abstract

Background
Despite proven efficacy, uptake of pre-exposure prophylaxis (PrEP) for HIV prevention in the US remains suboptimal. Whether electronic medical record (EMR) driven data tools increase PrEP uptake is unknown. Our study sought to understand the impact of education and an EMR data tool to increase PrEP uptake at the Veterans Northeast Ohio Healthcare System (VANEOHS).

Methods
Using EMR data we identified persons at the VANEOHS with a diagnosis of bacterial Sexually Transmitted Illness (STI) as defined by a positive syphilis, gonorrhea or chlamydia test in the past 6 months. Beginning October 2020 Infectious Diseases (ID) staff launched an intensive PrEP education campaign for Primary care providers (PCP) and the emergency room (ER). During a 6-week intervention period, a ‘PrEP candidacy’ note was placed for the PCP in selected patients’ charts with recommendations for PrEP initiation and STI co-testing if appropriate. We measured the impact of the intervention on PrEP initiations from 3/1/21-5/31/21 and compared it to a pre-intervention period of 7/1/20-9/30/20 when candidates were identified in primary care only. We extracted pertinent data through the EMR and presented descriptive statistics as means and percentages. We compared outcomes using Chi-square test with simulated p-values due to small expected values.

Results
Forty-two potential PrEP candidates were identified during post-intervention period compared to 6 in the pre-intervention period. The post-intervention candidates included cis-gender women (5/42, 12%) and ER referrals (6/42, 14%), both absent from the pre-intervention cohort. Compared to the pre-intervention period there was an increase in PrEP consults to ID (6 vs. 16; p=0.003) and PrEP starts (4 vs. 9; p=0.04). We observed increased rates of STI (69% vs. 50%) and HIV co-testing (79% vs. 67%) from pre to post intervention but these were not statistically different. Of the 42 candidates, 24 had been identified using the STI data tool. Of these, only 4 were referred for PrEP and none were initiated on PrEP by the end of our observation period.

Conclusion
The use of the data tool had no direct impact on PrEP uptake. Instead, the doubling of PrEP starts was attributable to education. Further studies are needed to maximize the utility of data tools to increase PrEP uptake.

Disclosures
All Authors: No reported disclosures
851. Rate of Sexually Transmitted Infections and Engagement in HIV Pre-Exposure Prophylaxis at the Veterans Affair Maryland Health System
Authors: Harfouch Omar , Comstock Emily , Kaplan Roman , Talwani Rohit , Wilson Eleanor 
Published: December 2021

Abstract

Background
Rates of sexually transmitted infections (STIs) and uptake of HIV pre-exposure prophylaxis (PrEP) during the 2020 coronavirus pandemic are unknown. We evaluated data from the Veterans Affair Maryland Health Care System (VAMHCS) data to determine rates of STI and PrEP linkage in our Veterans.

Methods
We extracted patient-level data on demographics, STI testing (chlamydia, gonorrhea, and syphilis), International Classification of Diseases (ICD) diagnosis codes and refills of TDF-FTC and TAF-FTC. We compared the ratio of positive STI tests in 2018, 2019 and 2020 using chi-square tests. Individuals eligible for PrEP were defined as patients with a newly positive STI result or an ICD diagnosis of: high risk sexual behavior; an STI mentioned above; or gender identity disorder. We excluded anyone with a positive HIV test or a creatinine &gt;1.8. We identified patients initiated on PrEP through pharmacy refill data to define initiation of care. Finally, we used chi-square tests to compare differences of initiation of PrEP between years and demographics.

Results
The STI positivity rate significantly increased (p&lt; 0.01) from 44.2% (2018) and 42.9% (2019) to 61.6% (2020) [Table 1]. The median ages of those who had a positive STI test were 50 (2018), 44 (2019) and 44 (2020). In 2020, 17% of patients eligible for PrEP filled PrEP. Engagement was similar (p=0.33) in 2019 and 2018, where 14% and 11.6% of patients eligible for PrEP received a prescription (p-value=0.33) [Figure 1]. The median age of those refilling PrEP were: 44 (2018); 43 (2019) and 41 (2020)). In 2020, we observed a statistically significant difference (p&lt; 0.01) in initiation of PrEP in care among Black patients with 11.7% of eligible patients filling PrEP as compared to white patients (26.2%) and other races (23.3%) [Figure 2].
Table 1. Rate of positive tests at VAMHCS from 2018-2020.

Figure 1. PrEP Cascade at VAMHCS by year. Non-statistically significant (P=0.33) when comparing engagement in care between different years.

Figure 2. Racial distribution of PrEP eligibility and initiation by year at the VAMHCS.

Conclusion
While during the coronavirus pandemic in 2020, fewer Veterans sought STI testing at the VAMHCS, the number of positive STI results remained steady, leading to a higher positivity rate. The rate of initiation of PrEP did not differ between 2020, 2019 and 2018. Racial inequities in initiation of PrEP increased in 2020.

Disclosures
All Authors: No reported disclosures
855. Persistence on F/TAF versus F/TDF for HIV Pre-Exposure Prophylaxis: A Real-World Evidence Analysis in the United States
Authors: Tao Li , Shvachko Valentina , Das Moupali , Carter Christoph C , Baeten Jared , Magnuson David 
Published: December 2021

Abstract

Background
Persistence to preexposure prophylaxis (PrEP) is an important determinant of its efficacy, but evidence on real-world persistence is lacking. This study assesses adherence to F/TDF and F/TAF for PrEP both in terms of discontinuation and re-initiation patterns.

Methods
We identified HIV-negative individuals in the United States who initiated F/TDF or F/TAF for PrEP between October 2019 and December 2020 from a de-identified prescription claims database; users taking generic F/TDF were excluded. Non-persistence was defined as a prescription fill gap of &gt;30 days; discontinuation included switch from F/TDF to F/TAF or F/TAF to F/TDF. We used survival analyses to estimate persistence, Cox regressions to compare the hazard ratios (HR) of discontinuation, and logistic regression to compare the odds ratios of re-initiation after discontinuation.

Results
Among F/TAF users (N=82,402) median age at PrEP initiation was 35 years (interquartile range [IQR] 28−47) and median PrEP persistence was 4 months (IQR 1.8-8.9), compared to 31 years (IQR 25−40) and 2 months (IQR 1.0-3.8) for F/TDF users (N=48,501). PrEP persistence at 60 and 90 days was higher among F/TAF users than F/TDF users (Figure). F/TDF users were 2.5 times more likely to discontinue than F/TAF users, with more marked differences in older users than that in younger users (p for interaction between discontinuation and age group &lt; 0.01, Table). We also observed a higher rate of discontinuation of F/TDF versus F/TAF if PrEP was prescribed by internal medicine or infectious disease physicians than by family medicine physicians (data not shown). After discontinuation, F/TAF users were 1.7 times more likely than F/TDF users to re-initiate PrEP; the association was not different by age.
Persistence rates of F/TAF and F/TDF for PrEP by time of PrEP initiation

Hazard ratios (HR) and corresponding 95% confidence intervals (CI) of non-persistence and odds ratios (OR) of re-initiation after discontinuation for users of F/TAF and F/TDF for PrEP in the US, Oct 2019 – Dec 2020

Conclusion
In this real-world analysis, the F/TAF for PrEP regimen was associated with higher persistence and re-initiation than F/TDF for PrEP. These findings underscore the dynamic nature of PrEP utilization in the real-world and the importance of interventions aimed at improving PrEP persistence and re-initiation in people who would benefit from PrEP.

Disclosures
Li Tao, MD, PhD, Gilead Sciences Inc (Employee, Shareholder) Valentina Shvachko, MS, Gilead Sciences Inc (Employee, Shareholder) Moupali Das, MD, Gilead Sciences Inc. (Employee, Shareholder) Christoph C. Carter, MD, Gilead Sciences Inc. (Employee, Shareholder) Jared Baeten, MD, PHD, Gilead Sciences Inc. (Employee, Shareholder) David Magnuson, PharmD, Gilead Sciences Inc (Employee, Shareholder)