Proportion Of People Living With HIV Research Articles

The Influence of CD4+ T-Lymphocytes on the Strength of Anti-Diphtheria Immunity in Adult People Living with HIV

The Influence of CD4+ T-Lymphocytes on the Strength of Anti-Diphtheria Immunity in Adult People Living with HIV

Changes Over Time in the Proportion of Advanced HIV Disease in Two High HIV Prevalence Settings in Ndhiwa (Kenya) and Eshowe (South Africa).

The burden of advanced HIV disease remains a significant concern in sub-Saharan Africa. In 2015, the World Health Organization released recommendations to treat all people living with HIV (PLHIV) regardless of CD4 ("treat all") and in 2017 guidelines for managing advanced HIV disease. We assessed changes over time in the proportion of PLHIV with advanced HIV and their care cascade in two community settings in sub-Saharan Africa. Cross-sectional population-based surveys were conducted in Ndhiwa (Kenya) in 2012 and 2018 and in Eshowe (South Africa) in 2013 and 2018. We recruited individuals aged 15-59 years. Consenting participants were interviewed and tested for HIV at home. All participants with HIV had CD4 count measured. Advanced HIV was defined as CD4 < 200 cells/µL. Overall, 6076 and 6001 individuals were included in 2012 and 2018 (Ndhiwa) and 5646 and 3270 individuals in 2013 and 2018 (Eshowe), respectively. In Ndhiwa, the proportion of PLHIV with advanced HIV decreased from 2012 (159/1376 (11.8%; 95% CI: 9.8-14.2)) to 2018 (53/1000 (5.0%; 3.8-6.6)). The proportion of individuals with advanced HIV on antiretroviral therapy (ART) was 9.1% (6.9-11.8) in 2012 and 4.2% (3.0-5.8) in 2018. In Eshowe, the proportion with advanced HIV was 130/1400 (9.8%; 8.0-11.9) in 2013 and 38/834 (4.5%; 3.3-6.1) in 2018. The proportion with advanced HIV among those on ART was 6.9% (5.5-8.8) in 2013 and 2.8% (1.8-4.3) in 2018. There was a significant increase in coverage for all steps of the care cascade among people with advanced HIV between the two Ndhiwa surveys, with all the changes occurring among men and not women. No significant changes were observed in Eshowe between the surveys overall and by sex. The proportion with advanced HIV disease decreased between the first and second surveys where all guidelines have been implemented between the two HIV surveys.

Polypharmacy and potential drug–drug interactions among people living with HIV in the era of integrase strand transfer inhibitor-based antiretroviral therapy

We aimed to investigate the prevalence of polypharmacy and potential drug-drug interactions (DDIs) and the associated factors with DDIs among people living with HIV (PLWH) in the modern era of antiretroviral therapy (ART). This cross-sectional study included PLWH who had been on ART for at least 3 months at two designated hospitals for HIV care in Taiwan. All ART and non-ART prescriptions were collected from the NHI-MediCloud System and screened for DDIs using the University of Liverpool HIV drug interactions database. A case-control analysis was conducted to investigate the factors associated with DDIs. From June 2021 to August 2022, 1007 PLWH were included. Their median age was 40 years (interquartile range, 33-49) and 96.2% were taking INSTI-based ART. The proportions of PLWH with at least 1 non-communicable diseases and polypharmacy were 50.0% and 18.7%, respectively. Seven (0.7%) PLWH had red-flagged DDIs, and 159 (15.8%) had amber-flagged DDIs. In multivariable models, the prevalence of DDIs was higher in PLWH with an older age (aOR, per 1-year increase, 1.022), number of co-medications (aOR, 1.097), use of boosted INSTI-based ART (versus unboosted INSTI, aOR, 8.653), and concomitant medications in the category of alimentary tract and metabolism (aOR, 11.058) and anti-neoplastic and immunomodulating agents (aOR, 14.733). In the INSTI era, the prevalence of potential DDIs was lower than previously noted, but remained substantial. Clinicians should routinely monitor DDIs, especially in older PLWH, those with increased number of co-medications, and those who are taking booster-containing ART or medications from specific categories.

Residual phenotypic susceptibility to doravirine in multidrug-resistant HIV-1 from subjects enrolled in the PRESTIGIO Registry

ObjectivesDoravirine shows a rather distinct resistance profile within the nonnucleoside reverse transcriptase inhibitor (NNRTI) class. This study aimed to evaluate the phenotypic susceptibility to doravirine, rilpivirine and etravirine in a panel of multidrug-resistant (MDR) HIV-1 isolates collected from people living with HIV (PLWH) enrolled in the PRESTIGIO Registry. MethodsRecombinant viruses expressing PLWH-derived protease, reverse transcriptase coding regions were generated from plasma samples at virological failure with documented resistance to protease inhibitors, nucleoside reverse transcriptase inhibitors, NNRTIs and integrase strand transfer inhibitors. In vitro susceptibility was assessed through a phenotypic assay measuring fold-change values with respect to the reference NL4-3 virus. Genotypic susceptibility was computed by the Stanford HIVdb algorithm 8.9-1. ResultsPlasma samples were collected from 22 PLWH: 20 (91%) were male, median age 55 years (IQR 50–58), time since HIV-1 diagnosis 27 years (23–31) and time on antiretroviral treatment 23 years (22–26). Median doravirine, etravirine and rilpivirine fold-change values were 9.8 (2.9–40.4), 42.9 (3.1–100.0) and 100.0 (17.9–100.0), respectively. According to the fold-change cut-offs, full susceptibility was observed in five (23%), four (18%) and one (5%) cases with doravirine, etravirine and rilpivirine, respectively. Irrespective of the presence of specific doravirine mutations, higher numbers of NNRTI mutations correlated with higher fold-change values for doravirine. By comparing the distribution of fold-change values with the Stanford HIVdb predicted susceptibility, a significant correlation was detected for doravirine and rilpivirine but not etravirine. ConclusionDespite extensive cross-resistance among NNRTIs, doravirine can be a valid option in a proportion of PLWH with MDR HIV-1. Doravirine activity appeared to be inferred with fair accuracy by the HIVdb algorithm.

Moderation effect of community health on the relationship between racial/ethnic residential segregation and HIV viral suppression in South Carolina: A county-level longitudinal study from 2013 to 2018.

Viral suppression is the ultimate goal of the HIV treatment cascade and a primary endpoint of antiretroviral therapy. Empirical evidence found racial/ethnic disparities in viral suppression among people living with HIV (PWH), but the evidence of the relationship between racial/ethnic residential segregation and place-based viral suppression is scarce. Further exploring potential structural moderators in this relationship has substantial implications for healthcare policymaking and resource allocation. The current study aimed to investigate the spatial-temporal disparities in the HIV viral suppression rate across 46 counties in South Carolina from 2013 to 2018. We also examined the impact of racial/ethnic residential segregation and the moderation effect of community health, one measurement of community engagement and volunteerism. The proportion of PWH who achieved viral suppression for each county and calendar year was calculated using de-identified electronic medical records. The isolation index was calculated and used to measure racial/ethnic residential segregation. The community health index and other county-level factors were directly extracted from multiple publicly available datasets. We used geospatial mapping to explore the spatial-temporal variations of HIV viral suppression rates. Hierarchical quasi-binominal regression models were used to examine the impacts of racial/ethnic residential segregation on county-level viral suppression rate by the extent of community health. From 2013 to 2018, the average viral suppression rate across 46 counties in SC increased from 64.3% to 65.4%. Regression results revealed that counties with high racial/ethnic residential segregation were more likely to have a low viral suppression rate (β = -0.56, 95% CI: -0.75 to -0.37). In counties with high levels of community health, the impact of racial/ethnic residential segregation on viral suppression rate decreased as compared with those with low levels of community health (β = 5.50, 95% CI: 0.95-10.05). Racial/ethnic residential segregation acts as a structural barrier to placed-based viral suppression rates and compromises the goal of the HIV treatment cascade. Concentrated and sustained county-level interventions aiming to improve community health can be practical approaches to promote health equity in HIV treatment and care.

Ophthalmic Manifestations among HIV Patients at the Main Tertiary Hospital in Freetown, Sierra Leone: A Cross-Sectional Study

Ophthalmic diseases are common among people living with HIV (PLHIV) in developing countries. However, there are currently no published studies on ophthalmic complications among PLHIV in Sierra Leone. We conducted a cross-sectional study of PLHIV presenting at Connaught Hospital in Freetown, Sierra Leone from January through March 2020. Logistic regression was used to identify associations between ophthalmic manifestations and potential risk factors. A total of 103 PLHIV were studied (78.6% female, median age 41 years, 100% treatment-experienced). The median CD4 cell count was 374 cells/mm3 and 76.7% were virologically suppressed. Overall, 44.7% of study participants had at least one ophthalmic complication and 51.5% had poor visual acuity in at least one eye. The most common conditions were dry eye (21.4%), cataract (20.4%), blepharitis (10.7%), nucleosclerosis (6.8%), conjunctivitis (5.8%), penguecula (5.8%), toxoplasmic retinochoroiditis (3.9%), and posterior vitreous detachment (2.9%). In multivariate logistic regression analysis, poor visual acuity (adjusted odds (aOR) 2.75, 95% confidence interval (CI) [1.12–6.78]; p = 0.040) and CD4 cell count &lt; 100 cells/mm3 (aOR 3.91, 95% CI [1.07–14.31]; p = 0.028) were independently associated with ophthalmic disease. A high proportion of PLHIV in this study had ophthalmic complications. This calls for greater integration of HIV and ophthalmologic care.

Viral load monitoring for people living with HIV in the era of test and treat: progress made and challenges ahead – a systematic review

BackgroundIn 2016, we conducted a systematic review to assess the feasibility of treatment monitoring for people living with HIV (PLHIV) receiving antiretroviral therapy (ART) in low and middle-income countries (LMICs), in line with the 90-90-90 treatment target. By 2020, global estimates suggest the 90-90-90 target, particularly the last 90, remains unattainable in many LMICs. This study aims to review the progress and identify needs for public health interventions to improve viral load monitoring and viral suppression for PLHIV in LMICs.MethodsA literature search was conducted using an update of the initial search strategy developed for the 2016 review. Electronic databases (Medline and PubMed) were searched to identify relevant literature published in English between Dec 2015 and August 2021. The primary outcome was initial viral load (VL) monitoring (the proportion of PLHIV on ART and eligible for VL monitoring who received a VL test). Secondary outcomes included follow-up VL monitoring (the proportion of PLHIV who received a follow-up VL after an initial elevated VL test), confirmation of treatment failure (the proportion of PLHIV who had two consecutive elevated VL results) and switching treatment regimen rates (the proportion of PLHIV who switched treatment regimen after confirmation of treatment failure).ResultsThe search strategy identified 1984 non-duplicate records, of which 34 studies were included in the review. Marked variations in initial VL monitoring coverage were reported across study settings/countries (range: 12–93% median: 74% IQR: 46–82%) and study populations (adults (range: 25–96%, median: 67% IQR: 50–84%), children, adolescents/young people (range: 2–94%, median: 72% IQR: 47–85%), and pregnant women (range: 32–82%, median: 57% IQR: 43–71%)). Community-based models reported higher VL monitoring (median: 85%, IQR: 82-88%) compared to decentralised care at primary health facility (median: 64%, IRQ: 48-82%). Suboptimal uptake of follow-up VL monitoring and low regimen switching rates were observed.ConclusionsSubstantial gaps in VL coverage across study settings and study populations were evident, with limited data availability outside of sub-Saharan Africa. Further research is needed to fill the data gaps. Development and implementation of innovative, community-based interventions are required to improve VL monitoring and address the “failure cascade” in PLHIV on ART who fail to achieve viral suppression.

Effect of universal test and treat on retention and mortality among people living with HIV-infection in Uganda: An interrupted time series analysis.

BackgroundFew studies have analysed the effect of HIV universal test and treat (UTT) on retention and mortality among people living with HIV (PLHIV) in routine care. We examined six-month retention and mortality at 11 health facilities (HFs) run by a large NGO, The AIDS Support Organisation (TASO), before and after UTT.MethodsWe used a quasi-experimental study using patient data extracted from 11 TASO HFs. Two periods, one before UTT (2015–2016) and the other during UTT (2017–2018) were compared. The primary outcome was six-month retention defined as the proportion of PLHIV who were alive and in care at six months from enrolment. The secondary outcome was six-month mortality defined as the proportion of PLHIV who died within six months from enrolment. We performed an interrupted time series analysis using graphical aids to study trends in six-month retention and mortality and a segmented regression to evaluate the effect of UTT. We used a generalized linear mixed model (GLMM) and generalized estimating equations (GEE) to account for facility-level clustering.ResultsOf the 20,171 PLHIV registered between 2015 and 2018 and included in the analysis, 12,757 (63.2%) were enrolled during the UTT period. 5256/7414 (70.9%) of the pre-UTT period compared to 12239/12757 (95.9%) of the UTT were initiated on ART treatment with 6 months from enrolment. The median time from enrolment to initiating ART was 14 (interquartile range (IQR): 0–31) days for the pre-UTT compared to 0 (IQR: 0–0) days for the UTT period. The median age at enrolment was 32.5 years for the pre-UTT and 35.0 years for the UTT period. Overall, the six-month retention just after scale-up of UTT, increased by 9.2 percentage points (p = 0.002) from the baseline value of 82.6% (95% CI: 77.6%-87.5%) but it eventually decreased at a rate 1.0 percentage point (p = 0.014) for cohorts recruited each month after UTT. The baseline six-month mortality was 3.3% (95% CI: 2.4%-4.2%) and this decreased by 1.6 percentage points (p = 0.003) immediately after UTT. The six-month mortality continued decreasing at a rate of 0.1 percentage points (p = 0.002) for cohorts enrolled each month after UTT. Retention differed between some health facilities with Rukungiri HF having the highest and Soroti the lowest retention. Retention was slightly higher among males and younger people. Mortality was highest among people aged 50 years and more. The effect of UTT on retention and mortality was similar across sex and age groups.ConclusionOverall, UTT significantly led to an immediate increase in retention and decrease in mortality among PLHIV enrolled in HIV care from 11 HFs run by TASO in Uganda. However, retention (and mortality) significantly decreased for cohorts enrolled each month after UTT. Retention was highest in Rukungiri and lowest in Soroti HFs and slightly higher in males and younger people. Mortality was highest in older patients and lowest in adolescents. We recommend for innovative interventions to improve the overall retention particularly in facilities reporting low retention in order to achieve the UNAIDS 2030 target of 95-95-95.

Virologic failure in people living with HIV in 1st line ART: A 10-year Mexican population-based study.

BackgroundIn Mexico, the number of people living with HIV (PLWH) receiving antiretroviral therapy (ART) has increased in the last 20 years. The elimination of a CD4 threshold to initiate publicly funded ART was a major policy implemented in 2014. The study objective was to assess the determinants of Virologic Failure (VF) in Mexican PLWH on first-line ART between 2008 and 2017 and to evaluate the effects of changes following the 2014 policy.MethodsA 10-year patient-level data analysis was conducted using the Mexican SALVAR database. The main outcome was the proportion of PLWH with VF. A multivariable logistic regression was conducted to identify the association between covariates and VF before and after the 2014 policy implementation.ResultsWe found a lower proportion of people with VF in 2014–2017 compared with 2008–2013 (50% vs 33%, p<0.001). The multivariable analysis showed a reduction in the odds of virologic failure after 2014 (Odds ratio: 0.50 [95% CI: 0.48–0.51]). Place of treatment and level of deprivation were significant predictors of VF in during 2014–2017, but not before.ConclusionThis study indicates that, by lowering threshold levels of CD4 required for treatment initiation in Mexico, a higher number of PLWH initiated treatment during 2014–2017, compared to 2008–2013 and the odds of VF were reduced.

76. Effects of the “Undetectable = Untransmittable” (“U=U”) Educational Campaign on Treatment Outcomes and Perceptions among People Living with HIV in North American Countries

BackgroundThe educational campaign “Undetectable = Untransmittable” (U=U) began in 2016 to improve the well-being of people living with HIV (PLHIV) and recalibrate HIV-related social norms. As medical practice can vary by region, we examined reports from PLHIV in North American countries to identify if the campaign affected healthcare provider (HCP) communication of U=U and if positive health outcomes differed by U=U-informed status or country.MethodsData were collected from the 2019 Positive Perspectives survey of PLHIV in Canada (n=120), Mexico (n=63), and the United States (US; n=400) and stratified by country. Outcomes were self-rated mental and sexual health (“Good”/”Very good”), viral suppression, and sharing of HIV status. Treatment perceptions were also assessed.ResultsWhether diagnosis occurred before or after the U=U campaign launch did not significantly affect the proportion of PLHIV who reported receipt of U=U from an HCP in any North American country. Whether an individual was informed of U=U varied significantly by sexual orientation (heterosexual, 62.8%; homosexual, 74.9%; other, 87.8%), sex (men, 64.7%; women, 89.8%; other, 100%), and metropolitan vs non-metropolitan residence (metropolitan, 78.2%; non-metropolitan, 65.2%) in the US (P< 0.01 for all) but not in Canada or Mexico. Prevalence of sharing of HIV status with ≥ 1 person besides an HCP varied among PLHIV (Canada, 87%; Mexico, 95%; US, 84%). Prevalence of other positive outcomes varied by country and whether PLHIV had been informed of U=U (Figure). Whether PLHIV were informed of U=U was also correlated with treatment satisfaction and the perception that treatment needs were being met among PLHIV in the US and Canada (P< 0.01 for all), and with the belief that treatment prevents transmission among PLHIV in the US (P=0.01).Figure. Prevalence of positive outcomes among PLHIV in Canada (n=120), Mexico (n=63), and the US (n=400). PLHIV, people living with HIV; US, United States; U=U, Undetectable = Untransmittable. *P<0.01 for U=U informed vs uninformed. ConclusionBeing informed of U=U was associated with higher treatment satisfaction, and higher mental and sexual health outcomes among PLHIV in North America. Receipt of U=U was associated with significantly higher treatment satisfaction among PLHIV in the US and Canada, and significantly more PLHIV with optimal mental and sexual health in the US.Disclosures Frank Spinelli, MD, ViiV Healthcare (Employee) Bruce Richman, JD, ViiV Healthcare (Consultant) Patricia De Los Rios, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Benjamin Young, MD, PhD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Nicolas Van de Velde, PhD, ViiV Healthcare (Employee) Chinyere Okoli, PharmD, MSc, DIP, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)

The challenge of minimizing tuberculosis burden in people living with HIV in the Asia Pacific.

The challenge of minimizing tuberculosis burden in people living with HIV in the Asia Pacific.

A comparison of different community models of antiretroviral therapy delivery with the standard of care among stable HIV+ patients: rationale and design of a non-inferiority cluster randomized trial, nested in the HPTN 071 (PopART) study

BackgroundFollowing the World Health Organization’s (WHO) 2015 guidelines recommending initiation of antiretroviral therapy (ART) irrespective of CD4 count for all people living with HIV (PLHIV), many countries in sub-Saharan Africa have adopted this strategy to reach epidemic control. As the number of PLHIV on ART rises, maintenance of viral suppression on ART for over 90% of PLHIV remains a challenge to government health systems in resource-limited high HIV burden settings. Non facility-based antiretroviral therapy (ART) delivery for stable HIV+ patients may increase sustainable ART coverage in resource-limited settings. Within the HPTN 071 (PopART) trial, two models, home-based delivery (HBD) or adherence clubs (AC), were offered to assess whether they achieved similar viral load suppression (VLS) to standard of care (SoC). In this paper, we describe the trial design and discuss the methodological issues and challenges.MethodsA three-arm cluster randomized non-inferiority trial, nested in two urban HPTN 071 trial communities in Zambia, randomly allocated 104 zones to SoC (35), HBD (35), or AC (34). ART and adherence support were delivered 3-monthly at home (HBD), adherence clubs (AC), or clinic (SoC). Adult HIV+ patients defined as “stable” on ART were eligible for inclusion. The primary endpoint was the proportion of PLHIV with virological suppression (≤ 1000 copies HIV RNA/ml) at 12 months (± 3months) after study entry across all three arms. Viral load measurement was done at the routine government laboratories in accordance with national guidelines, annually. The study was powered to determine if either of the community-based interventions would yield a viral suppression rate drop compared to SoC of no more than 5% in its absolute value. Both community-based interventions were delivered by community HIV providers (CHiPs). An additional qualitative study using observations, interviews with PLHIV, and FGDs with community HIV providers was nested in this study to complement the quantitative data.DiscussionThis trial was designed to provide rigorous randomized evidence of safety and efficacy of non-facility-based delivery of ART for stable PLHIV in high-burden resource-limited settings. This trial will inform policy regarding best practices and what is needed to strengthen scale-up of differentiated models of ART delivery in resource-limited settings.Trial registrationClinicalTrials.gov NCT03025165. Registered on 19 January 2017

Retrospective analysis of adherence to HIV treatment and healthcare utilization in a commercially insured population

Aims: Single-tablet regimens (STRs) can improve antiretroviral therapy (ART) adherence; however, the relationship between long-term adherence and patient healthcare resource utilization (HRU) is unclear. The objective of this study was to assess long-term ART adherence among people living with HIV (PLHIV) using STRs and multi-tablet regimens (MTRs) and compare HRU over time by adherence. Materials and methods: This retrospective study analyzed medical and pharmacy claims (Optum Clinformatics® Data Mart Database). Included PLHIV were aged ≥18 years, had ≥1 medical claim with an HIV diagnosis, and had pharmacy claims for a complete STR or MTR. Adherence was analyzed as proportion of days covered (PDC), stratified as ≥95%, very high; 90–95%, high; 80–90%, moderate; <80%, low. Cumulative all-cause and HIV-related HRU were calculated across 4 years. Among PLHIV with ≥4-year follow-up, HRU was assessed by adherence. Results: Among 15,153 PLHIV included, 63% achieved PDC ≥90% during Year 1. Among the subgroup of PLHIV with ≥4-year follow-up (N = 3,818), the proportion maintaining PDC ≥90% fell from 67% in Year 1 to 54% by Year 4. Difference from Years 1 to 4 in the proportion of PLHIV with PDC ≥90% was 13% and 17% in the STR and MTR groups, respectively. Cumulative HRU across the 4-year follow-up was higher in PLHIV with low vs high adherence (27% with low adherence had ≥1 emergency room visit vs 17% for very high, p < 0.0001; 15% with low adherence had ≥1 inpatient stay vs 7% for very high, p < 0.0001). Conclusions: ART adherence showed room for improvement, particularly over the long-term. PLHIV receiving STRs exhibited higher adherence vs those receiving MTRs; this difference increased over time. The proportion of PLHIV with higher HRU was significantly higher among those with lower adherence, and became greater over time. Interventions and alternative therapies to improve adherence among PLHIV should be explored.

1004. Clinical Decision Support System Alerts for HIV Retention in Care – A Pilot Implementation Research Study

BackgroundClinical decision support system (CDSS) alerts may help retain people living with HIV (PLWH) in care. A system of CDSS alerts utilizing the CHORUS™ portal was developed to identify PLWH at risk of being lost to care. To evaluate feasibility for a larger scale study, a before and after implementation research pilot study was implemented in the OPERA Cohort at three clinic sites in a southeastern US city.MethodsPeriods without intervention (before) or with CDSS alerts (after) were followed by 3 months of follow up. The study population consisted of PLWH with ≥ 1 electronic health record entry in the 2 years prior to, or during, the before or after period (Fig 1). To support clinicians through a discrete implementation strategy, alerts warning of suboptimal patient attendance were generated daily for the eligible PLWH at each site; providers or other clinic staff could respond to the alerts (Fig 2). Alerts, responses, and visits (i.e., meeting with provider or HIV lab measurement) were characterized. The proportion of PLWH with ≥ 1 visit in the before and after periods were compared at each site by Pearson’s Chi-square.Figure 1. Pilot study timeline Figure 2. CDSS alert criteria and response options ResultsA total of 12,230 PLWH were eligible (sites A: 11,271; B: 733; C: 1,344 PLWH), with > 75% in both the before and after periods. The ratio of alerts to responses was 11.9 at site A (2,245 alerts to 189 responses in 309 days; Fig 3A), and comparatively lower at sites B (756 alerts to 334 responses in 352 days, ratio=2.2; Fig 3B) and C (1,305 alerts to 896 responses in 246 days, ratio=1.5; Fig 3C). Responses to alerts were sporadic at sites A and B and consistent at site C. After the intervention, the proportion of PLWH with ≥ 1 visit stayed the same at site A (46% in both periods; p=0.47), decreased at site B (91% to 80%; p< 0.01), and increased at site C (72% to 81%; p< 0.01).Figure 3. Alerts and responses over time in (A) Site A, (B) Site B, and (C) Site C ConclusionThis pilot study was ecological by design: measures of retention in care were compared over two calendar periods, without accounting for changes in study populations, clinic characteristics, and policies in place over time (which could have impacted clinic attendance). Though engagement with the CDSS was suboptimal at some sites, this implementation pilot study has demonstrated the ability to implement a CDSS aimed at identifying at-risk PLWH, while highlighting areas for improvement in future larger scale studies.DisclosuresJoel Wesley Thompson, MHS, PA-C, AAHIVS, DFAAPA, MHS, PA-C, AAHIVS, DFAAPA, Gilead (Shareholder, Speaker’s Bureau)Janssen (Speaker’s Bureau)Theratechnologies (Speaker’s Bureau)ViiV (Speaker’s Bureau) Tammeka Evans, MoP, ViiV Healthcare (Employee)

948. The Changing Dynamics of Hospitalizations Among People Living with HIV Over Time

BackgroundAs antiretroviral therapy for HIV has become more successful, people living with HIV (PLWH) are aging. Nearly half (48%) of all PLWH in the U.S. are now ≥ 50 years old, and this proportion is expected to continue to grow. The aging population of PLWH offers new challenges to the healthcare system beyond HIV management, with increased risks for chronic comorbidities and other complications of aging. Few studies have examined the causes and outcomes of hospitalizations among PLWH or how these diagnoses have changed over time.MethodsUsing U.S. hospitalization data from 1993 to 2014 from the National Inpatient Sample, we compared the primary diagnosis at admission among PLWH to HIV-negative hospitalizations and how this changed over time. We also compared the mean age at admission, hospital length of stay, total charges, and hospital disposition.ResultsThere were 654,783,064 hospitalizations recorded from 1993 - 2014, with 5,370,749 among PLWH (0.8%) and 649,412,315 among HIV-negative patients (99.2%). The mean age of PLWH on admission increased from 37.4 years in 1993 to 48.1 years in 2014 and was lower than HIV-negative patients every year (Figure 1). There was a significant decrease in the proportion of admissions with HIV as the primary diagnosis for PLWH between 1993 - 2014 (53.1% to 24.2%) with a corresponding increase in non-HIV diagnoses over that time (Figure 2). The proportions of primary admission diagnoses for HIV-Negative patients were largely unchanged over the period. Although mean hospital lengths of stay for PLWH decreased over time, they were consistently longer than HIV-negative patients (Figure 3). Similarly, mean total charges for PLWH increased over time but were consistently higher than those for HIV-negative patients (Figure 3). The proportion of PLWH who died during hospitalization declined from a peak of 8.8% in 1993 to 2.4% in 2014 while inpatient mortality among HIV-negative patients declined from 3.2% to 2.2% over the same time.Figure 1. Trends of Mean Age for PLWH and HIV-Negative Admissions from 1993 – 2014 Figure 2. Trends of HIV vs. non-HIV as the Primary Admission Diagnoses for PLWH from 1993 – 2014 Figure 3. Trends of Length of Hospital Admission and Total Charges for PLWH and HIV-Negative Patients from 1993 – 2014 ConclusionThe primary admission diagnoses for PLWH has shifted from HIV to non-communicable causes as PLWH are living longer. PLWH are typically younger on admission and have longer and more expensive hospitalizations than HIV-negative patients.Disclosures All Authors: No reported disclosures

What is needed to achieve HCV microelimination among HIV-infected populations in Andalusia, Spain: a modeling analysis

BackgroundScale-up of hepatitis C virus (HCV) treatment for HIV/HCV coinfected individuals is occurring in Spain, the vast majority (> 85%) with a reported history of injecting drug use and a smaller population of co-infected men who have sex with men (MSM). We assess impact of recent treatment scale-up to people living with HIV (PLWH) and implications for achieving the WHO HCV incidence elimination target (80% reduction 2015–2030) among PLWH and overall in Andalusia, Spain, using dynamic modeling.MethodsA dynamic transmission model of HCV/HIV coinfection was developed. The model was stratified by people who inject drugs (PWID) and MSM. The PWID component included dynamic HCV transmission from the HCV-monoinfected population. The model was calibrated to Andalusia based on published data and the HERACLES cohort (prospective cohort of HIV/HCV coinfected individuals representing > 99% coinfected individuals in care in Andalusia). From HERACLES, we incorporated HCV treatment among diagnosed PLWH of 10.5%/year from 2004 to 2014, and DAAs at 33%/year from 2015 with 94.8% SVR. We project the impact of current and scaled-up HCV treatment for PLWH on HCV prevalence and incidence among PLWH and overall.ResultsCurrent treatment rates among PLWH (scaled-up since 2015) could substantially reduce the number of diagnosed coinfected individuals (mean 76% relative reduction from 2015 to 2030), but have little impact on new diagnosed coinfections (12% relative reduction). However, DAA scale-up to PWLH in 2015 would have minimal future impact on new diagnosed coinfections (mean 9% relative decrease from 2015 to 2030). Similarly, new cases of HCV would only reduce by a mean relative 29% among all PWID and MSM due to ongoing infection/reinfection. Diagnosing/treating all PLWH annually from 2020 would increase the number of new HCV infections among PWLH by 28% and reduce the number of new HCV infections by 39% among the broader population by 2030.ConclusionTargeted scale-up of HCV treatment to PLWH can dramatically reduce prevalence among this group but will likely have little impact on the annual number of newly diagnosed HIV/HCV coinfections. HCV microelimination efforts among PWLH in Andalusia and settings where a large proportion of PLWH have a history of injecting drug use will require scaled-up HCV diagnosis and treatment among PLWH and the broader population at risk.

Global estimate of the prevalence of post-traumatic stress disorder among adults living with HIV: a systematic review and meta-analysis

ObjectivesAlthough people living with HIV (PLWH) have been disproportionately affected by post-traumatic stress disorder (PTSD), the global prevalence of PTSD among PLWH is unknown. This study aimed to systematically review...

Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa.

IntroductionIntegrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies.MethodsFrom 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster‐randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4‐point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach's alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma.ResultsThirty‐five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co‐worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma.ConclusionsWe developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large‐scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.

Longitudinal outcomes of HIV- infected persons re-engaged in care using a community-based re-engagement approach

ABSTRACT Re-engaging people living with HIV (PLWH) who are out of care (OOC) is of utmost importance to ending the HIV epidemic in the U.S. We used DC Department of Health (DCDOH) HIV surveillance data to determine whether re-engaging PLWH results in improved long-term clinical outcomes. PLWH identified as OOC for 6–12 months at both the clinic-level and using DCDOH data were targeted for re-engagement efforts through Recapture Blitz (RB). Uni- and bivariate analyses were conducted comparing engagement in care (EIC), CD4 counts, and viral suppression (VS) at 6, 12, and 18-months post-re-engagement between persons re-engaged through RB and those not re-engaged via RB. Of the 569 PLWH contacted; 57 were re-engaged through RB, 46 were not but may have reengaged on their own. Compared to those not re-engaged via RB, at 18-months of follow-up, more PLWH re-engaged through RB were EIC (71.9% vs. 56.5%) and VS (52.6% vs. 30.4%). Higher proportions of PLWH re-engaged through RB were virally suppressed at 6, 12, and 18-months (p = 0.0238, p = 0.0347, p = 0.0238, respectively). Combining surveillance and clinical data to identify persons OOC allowed for successful re-engagement and improved longer-term outcomes post-re-engagement, underscoring the importance of re-engagement efforts to improve rates of retention and viral suppression.

Non-HIV Comorbid Conditions and Polypharmacy Among People Living with HIV Age 65 or Older Compared with HIV-Negative Individuals Age 65 or Older in the United States: A Retrospective Claims-Based Analysis.

The number of people living with HIV (PLWH) ≥65 years is increasing in the United States. By 2035, the proportion of PLWH in this age group is projected to be 27%. As PLWH live longer, they face age-related comorbidities. We compared non-HIV disease and medication burden among PLWH (n = 2359) and HIV-negative individuals (n = 2,010,513) ≥65 years using MarketScan® Medicare Supplemental health insurance claims from 2009 to 2015. Outcomes were common diagnoses and medication classes, prevalence of non-HIV conditions, number of non-HIV conditions, and daily non-antiretroviral therapy (ART) medications over a 1-year period. We examined age-standardized prevalence rates and prevalence ratios (PRs) and fit multivariable generalized linear models, stratified by sex. PLWH were younger (mean 71 vs. 76 years) and a larger proportion were men (81% vs. 45%). The most common diagnoses among both cohorts were hypertension and dyslipidemia. Most non-HIV conditions were more prevalent among PLWH. The largest absolute difference was in anemia (29.6 cases per 100 people vs.11.7) and the largest relative difference was in hepatitis C (PR = 22.0). Unadjusted mean number of non-HIV conditions and daily non-ART medications were higher for PLWH (4.61 conditions and 3.79 medications) than HIV-negative individuals (3.94 and 3.41). In models, PLWH had significantly more non-HIV conditions than HIV-negative individuals [ratios: men = 1.272, (95% confidence interval, 1.233-1.312); women = 1.326 (1.245-1.413)]. Among those with >0 daily non-ART medications, men with HIV had significantly more non-ART medications than HIV-negative men [ratio = 1.178 (1.133-1.226)]. The disease burden associated with aging is substantially higher among PLWH, who may require additional services to effectively manage HIV and comorbid conditions.