HIV Clinicians Research Articles

Guidelines for the transfer of people living with HIV attending primary healthcare facilities in South Africa: a scoping review

Abstract People living with HIV may move between health facilities: this is called ‘transfer’, and includes up- and down-referral based on clinical condition and lateral transfer (e.g. between primary healthcare [PHC] facilities for reasons such as geographic mobility or stigma). Transfers involving PHC facilities occur frequently and are associated with viraemia and disengagement. We reviewed the South African National Department of Health (NDOH) and Southern African HIV Clinicians Society websites and contacted NDOH officials to identify national guidelines applicable to HIV care in South Africa for recommendations on transfers involving PHC facilities. In total, 21/24 (88%) documents mentioned transfer, using the terms ‘referral’, ‘linkage’, ‘transfer’, ‘transition’ and ‘handover’. Guidelines defined ‘linkage to care’ as connecting individuals to care after HIV testing, but other terms were not well defined. Documents emphasised transfers between different levels of the health system, and transfers between PHC facilities received limited attention. The transfer process was delineated for linkage to care, up- and down-referrals, but not for transfers between PHC facilities. Clinical management of patients transferring between PHC facilities and tracing of patients who requested transfers and missed their visits were not specified. Overall, transfers between PHC facilities were not well addressed and require attention to improve HIV treatment outcomes.

Feasibility of Emergency Department-Initiated HIV Pre-Exposure Prophylaxis

Introduction: Pre-exposure prophylaxis (PrEP) for HIV—using antiretroviral medication in non-infected individuals to prevent HIV—has immense potential to slow the spread of the virus. However, uptake has been insufficient, and stark racial disparities exist in both HIV acquisition and PrEP usage, making PrEP access a health equity issue. A promising venue to engage high-risk populations in PrEP care is the emergency department (ED); however, existing ED PrEP initiatives have been costly or have had limited success. We hypothesize that two strategies could overcome these barriers: prescribing PrEP during an ED visit and providing patients with an initial supply of PrEP medication in the ED. Here, we describe the results of a qualitative study exploring multidisciplinary emergency clinicians and HIV clinicians’ needs and views about the feasibility of such an initiative. Methods: We conducted 22 semi-structured interviews with multidisciplinary clinicians from an urban, safety-net medical center in the ED and the on-site HIV clinic that provides PrEP services.We performed thematic analysis to summarize challenges and potential solutions described by participants. Results: Participants’ responses fell into three thematic categories: operational challenges; patient-level considerations; and potential impacts. Operational challenges highlighted the difficulty of PrEP initiation in a busy ED and clinician support needs. Patient-level considerations included the complex psychosocial needs of ED patients who could benefit from PrEP. Finally, participants anticipated that an ED-based PrEP initiation program could positively impact both individual patients and public health. Conclusion: Interviews with emergency department and HIV clinic staff revealed important considerations and potential solutions for ED-initiated PrEP workflows. Clinicians in both specialties were enthusiastic about such an initiative, which could facilitate its success. This study lays the groundwork for the future design of an efficient and innovative workflow to leverage the ED as an essential entry point into HIV prevention services.

The potential promise and pitfalls of point-of-care viral load monitoring to expedite HIV treatment decision-making in rural Uganda: a qualitative study

BackgroundHIV treatment programs in Africa have implemented centralized testing for routine viral load monitoring (VLM), which may result in specimen processing delays inhibiting timely return of viral load results. Decentralized, point-of-care (PoC) VLM is a promising tool for expediting HIV clinical decision-making but remains unavailable in most African settings. We qualitatively explored the perceived feasibility and appropriateness of PoC VLM to address gaps along the viral load monitoring continuum in rural Uganda.MethodsBetween May and September 2022, we conducted 15 in-depth interviews with HIV clinicians (facility in-charges, clinical officers, nurses, counselors) and six focus group discussions with 47 peer health workers from three south-central Ugandan districts. Topics explored centralized VLM implementation and opportunities/challenges to optimizing routine VLM implementation with PoC testing platforms. We explored perspectives on PoC VLM suitability and feasibility using iterative thematic analysis. Applying the Framework Method, we then mapped salient constraints and enablers of PoC VLM to constructs from the Consolidated Framework for Implementation Research.ResultsClinicians and peers alike emphasized centralized viral load monitoring’s resource-intensiveness and susceptibility to procedural/infrastructural bottlenecks (e.g., supply stockouts, testing backlogs, community tracing of clients with delayed VLM results), inhibiting timely clinical decision-making. Participants reacted enthusiastically to the prospect of PoC VLM, anticipating accelerated turnarounds in specimen processing, shorter and/or fewer client encounters with treatment services, and streamlined efficiencies in HIV care provision (including expedited VLM-driven clinical decision-making). Anticipated constraints to PoC VLM implementation included human resource requirements for processing large quantities of specimens (especially when machinery require repair), procurement and maintenance costs, training needs in the existing health workforce for operating point-of-care technology, and insufficient space in lower-tier health facilities to accommodate installation of new laboratory equipment.ConclusionsAnticipated implementation challenges, primarily clustering around resource requirements, did not diminish enthusiasm for PoC VLM monitoring among rural Ugandan clinicians and peer health workers, who perceived PoC platforms as potential solutions to existing inefficiencies within the centralized VLM ecosystem. Prioritizing PoC VLM rollout in facilities with available resources for optimal implementation (e.g., adequate physical and fiscal infrastructure, capacity to manage high specimen volumes) could help overcome anticipated barriers to decentralizing viral load monitoring.

Patients’ and specialists’ perspectives on health care quality and on people living with HIV health-related quality of life in Spain: a cross-sectional survey

ABSTRACT Spain was close to meeting the 90–90–90-treatment target set by UNAIDS. However, data on health care quality regarding people with HIV and their health-related quality of life (HRQoL) after the COVID-19 pandemic onset is scarce. By considering the perspective of people with HIV and HIV specialists, we aimed to determine some aspects of the quality of care in Spain, such as access to health resources or satisfaction with primary and speciality care, and assess people with HIV health-related quality of life. Ex post facto cross-sectional surveys were administered to 502 people with HIV and 101 HIV clinicians. Unmet needs related to healthcare system and healthcare resources access and to antiretroviral treatment administered by hospital pharmacies were detected. There was also room for improvement in the primary care service delivery and in various aspects concerning people’s with HIV HRQoL. About one-fourth of them experienced stigmatisation in the healthcare setting, which was significantly related to HRQoL. Women, heterosexual participants and those with problems accessing the healthcare system scored poorer in the HRQoL scales. Moreover, according to our data, HIV specialists did not seem to be fully aware of patients’ with HIV needs and overestimated their HRQoL.

Southern African HIV Clinicians Society Guideline for the clinical management of syphilis.

Syphilis, 'the great imitator', caused by Treponema pallidum infection, remains a complex and multifaceted disease with a rich history of clinical diversity. This guideline aims to be a comprehensive guide for healthcare workers in Southern Africa, offering practical insights into the epidemiology, pathogenesis, clinical manifestations, diagnostic testing, therapeutic principles, and public health responses to syphilis. Although the syphilis burden has declined over the years, recent data indicate a troubling resurgence, particularly among pregnant women and neonates. This guideline highlights the diagnostic challenges posed by syphilis, stemming from the absence of a single high-sensitivity and -specificity test. While treatment with penicillin remains the cornerstone of treatment, alternative regimens may be used for specific scenarios. We highlight the importance of thorough patient follow-up and management of sex partners to ensure optimal care of syphilis cases. In the context of public health, we emphasise the need for concerted efforts to combat the increasing burden of syphilis, especially within high-risk populations, including people living with HIV.

Use of Electronic Quality Monitoring Tool and Central Dashboard to Improve Clinical and Programmatic Decisions.

The HIV service quality improvement tool is deployed in 123 health facilities in Ethiopia. The tool uses a central dashboard for visualization and decision making at the health facility and higher levels of the health systems. The dashboard is developed on excel with analytics about HIV testing, case finding, treatment linkage and quality indicators. The dashboard was developed based on the requirements requested during discussions with HIV clinicians and the program team.

Use of genotypic HIV DNA testing: a DELPHI-type consensus.

As many disparities in the clinical use of HIV DNA sequencing are observed, a DELPHI-type consensus was initiated in France to homogenize use, techniques and interpretation of results. Based on a literature review and clinical experience, a steering committee (SC) of eight virologists and one infectious disease specialist formulated statements. Statements were submitted to an independent and anonymous electronic vote of virologists and HIV clinicians in France, between October 2022 and December 2022. The SC developed 20 statements grouped into six categories: clinical situations for the use of HIV DNA genotyping; techniques for performing HIV DNA genotyping; consideration of apolipoprotein B mRNA editing enzyme (APOBEC) mutations; genotyping results reporting; recycling of antiretrovirals; and availability of HIV DNA genotyping tests and delays. Twenty-one virologists and 47 clinicians participated in two voting rounds and 18/20 (90%) assertions reached a 'strong' consensus. For example, that prior genotyping on HIV DNA is useful for clinical decision-making when considering switching to some long-acting regimens or to reduce the number of antiretroviral agents in virologically suppressed patients for whom RNA data are unavailable/not exploitable/not sufficiently informative. Two statements achieved no consensus: reporting any detected viral minority population for discussion in multidisciplinary meetings (virologists), and possible risk of virological failure when using a second-generation InSTI plus lamivudine or emtricitabine regimen in patients with undetectable viral load within ≥1 year and in the presence of a documented M184V mutation within the last 5 years (clinicians). This DELPHI-type consensus will facilitate the strengthening and harmonization of good practice when performing HIV DNA sequencing.

The forecasted prevalence of comorbidities and multimorbidity in people with HIV in the United States through the year 2030: A modeling study.

Estimating the medical complexity of people aging with HIV can inform clinical programs and policy to meet future healthcare needs. The objective of our study was to forecast the prevalence of comorbidities and multimorbidity among people with HIV (PWH) using antiretroviral therapy (ART) in the United States (US) through 2030. Using the PEARL model-an agent-based simulation of PWH who have initiated ART in the US-the prevalence of anxiety, depression, stage ≥3 chronic kidney disease (CKD), dyslipidemia, diabetes, hypertension, cancer, end-stage liver disease (ESLD), myocardial infarction (MI), and multimorbidity (≥2 mental or physical comorbidities, other than HIV) were forecasted through 2030. Simulations were informed by the US CDC HIV surveillance data of new HIV diagnosis and the longitudinal North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) data on risk of comorbidities from 2009 to 2017. The simulated population represented 15 subgroups of PWH including Hispanic, non-Hispanic White (White), and non-Hispanic Black/African American (Black/AA) men who have sex with men (MSM), men and women with history of injection drug use and heterosexual men and women. Simulations were replicated for 200 runs and forecasted outcomes are presented as median values (95% uncertainty ranges are presented in the Supporting information). In 2020, PEARL forecasted a median population of 670,000 individuals receiving ART in the US, of whom 9% men and 4% women with history of injection drug use, 60% MSM, 8% heterosexual men, and 19% heterosexual women. Additionally, 44% were Black/AA, 32% White, and 23% Hispanic. Along with a gradual rise in population size of PWH receiving ART-reaching 908,000 individuals by 2030-PEARL forecasted a surge in prevalence of most comorbidities to 2030. Depression and/or anxiety was high and increased from 60% in 2020 to 64% in 2030. Hypertension decreased while dyslipidemia, diabetes, CKD, and MI increased. There was little change in prevalence of cancer and ESLD. The forecasted multimorbidity among PWH receiving ART increased from 63% in 2020 to 70% in 2030. There was heterogeneity in trends across subgroups. Among Black women with history of injection drug use in 2030 (oldest demographic subgroup with median age of 66 year), dyslipidemia, CKD, hypertension, diabetes, anxiety, and depression were most prevalent, with 92% experiencing multimorbidity. Among Black MSM in 2030 (youngest demographic subgroup with median age of 42 year), depression and CKD were highly prevalent, with 57% experiencing multimorbidity. These results are limited by the assumption that trends in new HIV diagnoses, mortality, and comorbidity risk observed in 2009 to 2017 will persist through 2030; influences occurring outside this period are not accounted for in the forecasts. The PEARL forecasts suggest a continued rise in comorbidity and multimorbidity prevalence to 2030, marked by heterogeneities across race/ethnicity, gender, and HIV acquisition risk subgroups. HIV clinicians must stay current on the ever-changing comorbidities-specific guidelines to provide guideline-recommended care. HIV clinical directors should ensure linkages to subspecialty care within the clinic or by referral. HIV policy decision-makers must allocate resources and support extended clinical capacity to meet the healthcare needs of people aging with HIV.

Perspectives of people with HIV and HIV clinicians on characteristics of antiretroviral treatment and HIV-related symptoms.

We aimed to assess HIV symptoms from the perspective of both patients and HIV specialists and the impact of discontinuing antiretroviral treatment (ART) on symptomology. We gathered opinions from HIV specialists and people living with HIV about ideal ART parameters and treatment satisfaction. Ex post-facto cross-sectional surveys were administered to 502 people living with HIV and 101 HIV clinicians in Spain (18 sites). The median age of participants with HIV was 43.2 years, 74.5% were male, and 91.6% had an undetectable viral load. The mean time since initiation of ART was 10.2 years. Between 54% and 67% of people living with HIV reported experiencing nervousness or anxiety, sadness, fatigue, sleep problems, or muscle/joint pain during the preceding 4 weeks. However, only 22%-27% of specialists acknowledged the presence of these symptoms. The most bothersome symptoms were related to mental health or the central nervous system. There were significant differences between the burden of symptoms reported by people living with HIV and those acknowledged by specialists. The symptoms that more frequently caused ART discontinuation were depression, dizziness, and sleep problems. Both people living with HIV and specialists prioritized ART efficacy and low toxicity, but their importance ratings differed for 5 of the 11 ART characteristics assessed. People living with HIV rated their satisfaction with ART at a mean (± standard deviation) of 8.9 ± 1.5 out of 10, whereas HIV specialists rated it lower, at 8.3 ± 0.7 (p < 0.001). Despite advances in HIV care and treatment, a large proportion of patients still experience symptoms. HIV specialists may not be fully aware of these. People living with HIV and HIV specialists are, overall, satisfied with ART. However, the importance they place on different ART characteristics may vary.

Cross-sectional survey of sexual health professionals’ experiences and perceptions of the 2022 mpox outbreak in the UK

ObjectiveTo understand the experiences and perceptions of sexual health professionals responding to the May 2022 mpox outbreak in the UK.DesignCross-sectional, anonymous, online survey collecting quantitative and qualitative data. Convenience sample...

782. Employing the 4MAT model of instruction to develop a novel interactive virtual geriatrics course for interprofessional HIV clinicians

Abstract Background With the advent of antiretroviral therapy, people with HIV (PWH) are living longer and experiencing geriatric syndromes. Many older PWH are cared for by teams of interprofessional HIV clinicians, most of whom lack geriatrics training. We aimed to increase geriatrics knowledge and preparedness to care for older PWH among interprofessional HIV clinicians through a unique application of the 4MAT model. Methods From July 2020-August 2021, we enrolled physicians, nurse practitioners, physician assistants, and pharmacists in a virtual 7-hour course. Learners were assessed by pre- and post-course quizzes and self-reported preparedness to care for older PWH. There were 75 learners (44% physicians, 31% nurse practitioners/physician assistants, 24% pharmacists). Results Before the course, 49.3% of learners felt prepared to care for older PWH vs. 93.7% post-course (p&amp;lt; 0.00). Average quiz scores improved on all topics (p&amp;lt; 0.00). Conclusion Our course is a unique application of the 4MAT model that improved geriatrics knowledge and clinical preparedness across a wide array of interprofessional HIV clinicians. Disclosures All Authors: No reported disclosures

14 A Potential Behavioral Sign for Detection of Mild HIV-Related Neuropsychological Impairment

Objective:Even though the severity of HIV-associated neurocognitive disorders (HAND) has decreased with the introduction of combination antiretroviral therapy, mild forms of HAND remain prevalent. Many HIV-infected individuals live alone, so mild cognitive impairments are easily missed. It is important to check their neurocognitive and everyday functions during hospital visits; however, it is challenging for Japanese clinicians because many hospitals do not have enough clinical psychologists or neuropsychologists. Additionally, neuropsychological (NP) test results may not detect those mild cognitive impairments. A micro error has been given more attention as a new behavioral sign of the early stages of cognitive decline, especially among people with Mild Cognitive Impairment (MCI). The current study aimed to 1) develop a touch-panel HAND screening battery and 2) evaluate if the micro errors could differentiate individuals with HAND from their counterpart healthy individuals.Participants and Methods:Forty HIV-infected men (age: 49.0±8.51 years old, education: 18.5±2.17 years) and 44 healthy men (age: 45.4±8.49 years old, education: 14.4±2.27 years) completed the touch-panel HAND screening battery which assessed six NP domains by seven subtests, everyday functions, and depression. A micro error is defined as a subtle action disruption or hesitation occurring immediately before making final actions. We evaluated the micro errors in short-term memory (STM) and long-term memory (LTM) of verbal learning tests (VLT).Results:Mann Whitney U tests revealed that the HIV+ group made significantly more micro errors on both STM (HIV+: 1.45±0.90 times, Healthy: 0.52±0.84 times) and LTM (HIV+: 1.85±0.73 times, Healthy: 1.29±0.71 times) than the healthy group (STM: W=1362, p&lt; .001, Effect Size (EF)= .548; LTM: W=1199.5, p= .002, EF= .363). An independent samples T-test showed that the HAND group made significantly more micro errors than the non-HAND group (t=1.822, p= .038, ES= .595) on STM; moreover, the Asymptomatic Neurocognitive Impairment (ANI) group made significantly more micro errors than the healthy group (W=446, p&lt; .001, ES= .689). On LTM, no significant micro error differences between HAND and non-HAND (W=184.5, p= .539, ES= -.189) nor between ANI and healthy group (W=327.5, p= .103, ES= .241) were found.Conclusions:The present study suggests that a novel behavioral measure, micro errors, may be able to help detect even the mildest form of HAND, ANI. Given that the touch-panel HAND screening battery consists of NP and IADL tests, it is important to evaluate micro errors on these various measures. Additionally, the touch-panel screening battery requires minimal administrative staff involvement, which could be beneficial for busy HIV clinicians.

Does the Quality of Behavior Change Counseling in Routine HIV Care Vary According to Topic and Demand?

HIV clinicians face increasing time constraints. Our objective was to describe the prevalence and quality of behavior change counseling within routine HIV visits and to explore whether clinicians may provide lower quality counseling when facing increased counseling demands. We audio-recorded and transcribed encounters between 205 patients and 12 clinicians at an urban HIV primary care clinic. We identified and coded episodes of behavior change counseling to determine clinicians' consistency with motivational interviewing (MI) and used multi-level regression to evaluate counseling quality changes with each additional topic. Clinician counseling for at least one behavior was indicated in 92% of visits (mean 2.5/visit). Behavioral topics included antiretroviral medication adherence (80%, n = 163), appointment adherence (54%, n = 110), drug use (46%, n = 95), tobacco use (45%, n = 93), unsafe sex (43%, n = 89), weight management (39%, n = 80), and alcohol use (35%, n = 71). Clinician counseling was most MI-consistent when discussing drug and tobacco use and least consistent for medication and appointment adherence, unsafe sex, and alcohol use. In multilevel analyses, clinician counseling was significantly less MI-consistent (β = -0.14, 95% CI -0.29 to -0.001) with each additional behavior change counseling need. This suggests that HIV ambulatory care be restructured to allocate increased time for patients with greater need for behavior change.

Evidence2Practice (E2P): Leveraging Implementation Science to Promote Careers in HIV Research Among Students From Historically Black Colleges and Universities.

The HIV research workforce is not representative of populations most affected by the epidemic. Innovative educational programs are needed to motivate diverse student populations to pursue careers in HIV research. The Duke University Center for AIDS Research Evidence2Practice (E2P) program is a 3-day interactive workshop that introduces students from Historically Black Colleges and Universities (HBCU) to HIV pre-exposure prophylaxis, implementation science, and human-centered design. Participants develop 1-page action plans to increase awareness and uptake of pre-exposure prophylaxis on their campus. The program was evaluated using a partially mixed-method concurrent equal status study design with pre-program and post-program surveys and in-depth interviews. Among the 52 participating students, 44 completed the preworkshop survey, 45 completed the postworkshop survey, and 10 participated in an in-depth interview. Most participants identified as Black or African American and cisgender female. Participating in the E2P program was associated with: (1) an increase in median interest in pursuing a career in HIV research (P < 0.01) and (2) a decrease in median perceived difficulty in starting a career in HIV research (P < 0.01). Several students described that a lack of knowledge about initiating an HIV research career, a perceived lack of qualifications and knowledge about HIV science, and limited experience were major barriers to considering careers in HIV research. The E2P program enhanced HBCU students' interest in careers related to HIV research and improved their self-efficacy to pursue such careers. On-campus educational enrichment initiatives, led by active HIV researchers and clinicians, should be a critical part of diversifying the HIV workforce.

Southern African HIV Clinicians Society 2023 Guideline for post-exposure prophylaxis: Updated recommendations.

No abstract available.

An introduction to gender affirming healthcare: What the family physician needs to know.

Gender affirming healthcare (GAHC) is a relatively new field in primary health care that describes a range of gender affirming practices, including hormone therapy, for transgender and gender diverse (TGD) people. In 2019, gender affirming hormones were approved by South African National Essential Medicine List Committee (NEMLC) for tertiary-level care, and in October 2021 the Southern Africa HIV Clinicians Society published a GAHC guideline for South Africa. Unfortunately, TGD people still experience discrimination and stigmatisation in healthcare facilities in South Africa, leading to poor access to care and higher health risks with poorer outcomes. Gender affirming care in the primary health care clinic can improve access to health care, with improved provision of preventative services. This article defines key transgender concepts, describes the informed consent process and outlines the initiation and monitoring of both feminising and masculinising hormone treatment for TGD people. Staff at healthcare facilities need to receive training on gender affirming practices and how to ensure a safe environment for TGD clients.

Erectile dysfunction prevalence and associated factors in men living with HIV from Western Turkey: A cross-sectional study.

The majority of people living with HIV in our country are younger men. However, limited data exist for the sexual health of these patients. Knowledge of the epidemiology in this population may improve health outcomes across the continuum of HIV care. The aim of this study was to determine the prevalence of erectile dysfunction (ED) and its association with some clinical and laboratory factors. A cross-sectional study was conducted using random sampling in men living with HIV (MLWH) at a tertiary hospital in Turkey. Patients were asked to fill out the five-item International Index of Erectile Function (IIEF-5), and blood was collected for HIV viral load, CD4+ T lymphocyte count, lipids and hormone levels to assess biological aspects at the same clinical visit. A total of 107 MLWH were recruited. Mean age was 40.4 ± 12.4 years. ED was found in 73.8% (n = 79) of the participants. Severe ED was found in 6.3%, moderate in 5.1%, mild-moderate 35.4%, mild 53.2% of the participants, respectively. The mean age of men with erectile dysfunction was 42.5 ± 12.5 years, while those without erectile dysfunction were 34.5 ± 10years (p:0.00). ED was detected more frequently in cases with high Low Density Lipoprotein (LDL) levels (p:0.003). There was no statistically significant difference between ED presence and having hormone abnormality. There was a moderate, negative correlation between age and ED score (r: -0.440, p < 0.001). A negative and low correlation was found between triglyceride level and ED score (r: -0.233, p:0.02). The only predictive variable was age in the multivariate analysis [B: -0.155 (95% CI -0.232 to -0.078), p: <0.001]. Our study revealed a high prevalence of ED in the MLWH cohort. Age was found to be the only factor associated with ED. HIV clinicians should consider routine ED screening with validated measures as a part of the follow-up scheme to improve integrated wellbeing in MLWH.

Prescribe to Save Lives: An Intervention to Increase Naloxone Prescribing Among HIV Clinicians.

Overdose is a major cause of preventable death among persons living with HIV. This study aimed to increase HIV clinicians' naloxone prescribing, which can reduce overdose mortality. We enrolled 22 Ryan White-funded HIV practices and implemented onsite, peer-to-peer training, posttraining academic detailing, and pharmacy peer-to-peer contact around naloxone prescribing in a nonrandomized stepped wedge design. Human immunodeficiency virus clinicians completed surveys to assess attitudes toward prescribing naloxone at preintervention and 6 and 12 months postintervention. Aggregated electronic health record data measured the number of patients with HIV prescribed and the number of HIV clinicians prescribing naloxone by site over the study period. Models controlled for calendar time and clustering of repeated measures among individuals and sites. Of 122 clinicians, 119 (98%) completed a baseline survey, 111 (91%) a 6-month survey, and 93 (76%) a 12-month survey. The intervention was associated with increases in self-reported "high likelihood" to prescribe naloxone (odds ratio [OR], 4.1 [1.7-9.4]; P = 0.001). Of 22 sites, 18 (82%) provided usable electronic health record data that demonstrated a postintervention increase in the total number of clinicians who prescribed naloxone (incidence rate ratio, 2.9 [1.1-7.6]; P = 0.03) and no significant effects on sites having at least one clinician who prescribed naloxone (OR, 4.1 [0.7-23.8]; P = 0.11). The overall proportion of all HIV patients prescribed naloxone modestly increased from 0.97% to 1.6% (OR, 2.2 [0.7-6.8]; P = 0.16). On-site, practice-based, peer-to-peer training with posttraining academic detailing was a modestly effective strategy to increase HIV clinicians' prescribing of naloxone.

Strategies to improve outcomes of youth experiencing healthcare transition from pediatric to adult HIV care in a large U.S. city

BackgroundThe healthcare transition (HCT) from pediatric to adult HIV care can be disruptive to HIV care engagement and viral suppression for youth living with HIV (YLH).MethodsWe performed qualitative interviews with 20 YLH who experienced HCT and with 20 multidisciplinary pediatric and adult HIV clinicians to assess and rank barriers and facilitators to HCT and obtain their perspectives on strategies to improve the HCT process. We used the Exploration Preparation Implementation Sustainment Framework to guide this qualitative inquiry.ResultsThe most impactful barriers identified by YLH and clinicians focused on issues affecting the patient-clinician relationship, including building trust, and accessibility of clinicians. Both groups reported that having to leave the pediatric team was a significant barrier (ranked #1 for clinicians and #2 for YLH). The most impactful facilitator included having a social worker or case manager to navigate the HCT (listed #1 by clinicians and #2 by YLH); case managers were also identified as the individual most suited to support HCT. While YLH reported difficulty building trust with their new clinician as their #1 barrier, they also ranked the trust they ultimately built with a new clinician as their #1 facilitator. Factors reported to bridge pediatric and adult care included providing a warm handoff, medical record transfer, developing relationships between pediatric clinics and a network of youth-friendly adult clinics, and having the pediatric case manager attend the first adult appointment. Longer new patient visits, increased health communication between YLH and clinicians and sharing vetted clinician profiles with YLH were identified as innovative strategies.ConclusionIn this multi-disciplinary contextual inquiry, we have identified several determinants that may be targeted to improve HCT for YLH.

1280. Real-World Comparison of HIV-ASSIST with Expert Opinion in Selecting Antiretroviral Therapy for Complex Patients

Abstract Background HIV-ASSIST is an online, clinical decision support tool that helps HIV clinicians select antiretroviral (ARV) regimens for patients with HIV by accounting for individual patient characteristics. Concordance between HIV-ASSIST recommendations and expert opinion has been reported to be as high as 89% in treatment-experienced patients. We evaluated the utility of the HIV-ASSIST tool for a heavily treatment-experienced, complex patient population at the University of California, San Diego (UCSD) by comparing regimens recommended by HIV-ASSIST with regimens recommended by HIV experts. Methods We identified 14 patients through a routine HIV drug resistance teaching conference at our clinic. Each case was reviewed by 5 HIV clinical experts who independently recommended an ARV regimen. A consensus “best” regimen was agreed upon among the 5 experts for each patient. Consensus regimens were compared for concordance to the top 5 regimens recommended by the HIV-ASSIST tool. HIV-ASSIST regimens were also reviewed to determine if any were high or moderate risk for virologic failure due to patient or resistance characteristics, or drug-drug interactions (DDIs). Results The patients analyzed were medically and psychosocially complex, with a high rate of multi-class resistance (Table 1). Expert-recommended regimens were concordant with one of the top five regimens recommended by the HIV-ASSIST tool for 4/14 (28%) patients (Table 2). We further classified 20/70 (29%) regimens as high risk for virologic failure and 12/70 (17%) regimens as moderate risk for virologic failure (Figure 1). Table 2.Expert-recommended consensus regimens compared to the top 5 HIV-ASSIST regimens for 14 patients with HIV and a history of drug resistance, multimorbidity, and polypharmacy.Figure 1Classification of HIV-ASSIST regimens by HIV clinical experts as either acceptable, moderate risk or high risk for virologic failure. Conclusion Compared to prior reports, we found lower concordance between ART regimens recommended by HIV experts vs those recommended by the HIV-ASSIST tool in patients with HIV drug-resistance and/or complex comorbidities and potential DDIs. Moreover, several HIV-ASSIST regimens were considered at risk for virologic failure. We recommend caution in using the HIV-ASSIST tool for complex patients with significant drug resistance. Disclosures Lucas Hill, PharmD, AAHIVP, Gilead Sciences: Speakers Bureau.