Viral Suppression Rates Research Articles

Viral Suppression in a Nationwide Sample of HIV-Infected Children on Antiretroviral Therapy in Rwanda.

Rwanda has made significant progress in expanding pediatric antiretroviral treatment coverage. This was a nationwide, cross-sectional study of pediatric HIV suppression rates. Of 292 children on antiretroviral treatment ≥12 months, 68.8% achieved viral suppression < 40 copies/ml, respectively. Rwanda achieved good pediatric viral suppression rates, comparable to those from other resource-limited settings, yet more efforts are needed to achieve the UNAIDS 90-90-90 target.

Immunomodulatory Effects of Combination Therapy with Bushen Formula plus Entecavir for Chronic Hepatitis B Patients.

Aim To compare the clinical efficacy of the combination therapy with Bushen formula (BSF) plus entecavir (ETV) in naïve chronic hepatitis B (CHB) patients and that in CHB patients with partial virological response to ETV and explore the relevant immunoregulatory mechanism. Materials and Methods Two hundred and twenty CHB patients were enrolled in the historical prospective cohort study. Patients were categorized into a treatment group (T-Group: combination therapy with BSF plus ETV) and a control group (C-Group: ETV). Patients in T-Group and C-Group were grouped into T1/C1 (treatment-naïve patients) and T2/C2 (patients with partial virological response to ETV). Biochemical assessment, viral load quantitation, and HBV markers were tested. Chinese medicine symptom complex score was evaluated and recorded as well. In addition, peripheral blood mononuclear cells were separated from blood samples in 56 patients and 11 healthy donors. The frequencies of Th1, Treg, and dendritic cells (DCs) and expression levels of PD-1/PD-L1 were examined by flow cytometry. Results In treatment-naïve CHB patients, complete viral suppression rates in HBeAg(−) patients were higher than those in HBeAg(+) patients in both T and C groups. In patients with partial virological response to ETV, the rate of HBsAg decline ≥ 20% in HBeAg(+) patients of T2-Group was higher than that in HBeAg(+) patients of C2-Group. A significant reduction of Chinese medicine symptom complex score was only observed in T-Group. The study of mechanism showed that, compared with healthy controls, Th1 and DC frequencies were decreased in all CHB patients, while Treg frequency was increased only in treatment-naïve patients. In addition, compared with healthy controls, PD-1 expression levels on Th1 and Treg were increased in all patients and PD-L1 expression levels on DCs were increased only in treatment-naïve patients. In treatment-naïve patients, the combination therapy with BSF plus ETV increased Th1 and DC frequencies and decreased Treg frequency, which was correlated with HBsAg decline. In addition, in patients with partial virological response to ETV, the combination therapy downregulated PD-L1 levels on DCs and the frequency of Treg, which was related with HBsAg decline. Conclusions In patients with partial virological response to ETV, HBeAg(+) patients tend to achieve ideal effects after the combination therapy with BSF plus ETV, which may correlate with the decrease of Treg frequency and the downregulation of PD-L1 levels on DCs.

Impact of NIMART training on HIV management in Ngaka Modiri Molema District, North WEST province

BackgroundThe purpose of NIMART training is to upscale the capacity of PNs with knowledge, skills, confidence and competencies to provide comprehensive and quality health care services to PLWH and thereby improve the performance of the HIV programme. Therefore, this study evaluates the impact of NIMART training on the implementation of the HIV programme to identify gaps and extend best practices. ObjectivesThe objective of the study is to determine and evaluate the impact of NIMART training on HIV programme in order to make recommendations leading to effective training and implementation. MethodsA quantitative descriptive design for programme evaluation was used to examine the impact of NIMART training on the implementation of the HIV programme. The study was conducted in rural districts of the North West province. A stratified simple random sampling method was used to select n = 10 PHC fixed clinics and community health centres that met the inclusion criteria. Five sub-districts were selected to participate in the study to allow a greater degree of representativeness. The statistics of ART indicators were collected from the DHIS from January 2012 to December 2016. These ART indicators have been measured against the number of PNs trained on NIMART. Descriptive statistics were used to analyse data. ResultsThe study results revealed ineffectiveness in the implementation of NIMART training programme and inefficiency in the management of HIV as there is no steady increase of new ART initiation in adults, children, and ANC pregnant women and below 90%, despite 99% of PHC selected facilities having 75% on PNs trained on NIMART, 42.8% were not certificated for competence and only 23% not trained, including the changes in eligibility criteria for treatment, introduction of PMTCT policy and universal test and treat (UTT) in September 2016. Sustainability of patient on ART is poor as the study results revealed fluctuation in both adults and children TROA and high LTFU at an average of 14%. Again, of Viral load collection (54%) & Viral load suppression (56%) rate at 12 months after ART initiation is far below the 90% target and had negative impact on patient treatment outcomes including decanting of stable patients out of the overcrowded facilities. However, adult patient death after 12 months of starting treatment declined. Conclusion and RecommendationsThere is a significant impact of NIMART training on HIV management with regard to increased access to PHC facilities. However, challenges still exist that reveal poor quality of HIV management, non-compliance to guidelines and monitoring of treatment effectiveness despite PNs trained on NIMART. Challenges or barriers that lead to the identified gaps need to be investigated in order to make recommendations that strengthen NIMART training and implementation.

White matter structural connectivity abnormalities in subjects with deficit schizophrenia: A diffusion tensor imaging study

Women living with HIV who use illicit drugs may be particularly vulnerable to HIV-1 RNA viral load (VL) rebound.We used longitudinal data from 2006 to 2017 to evaluate the impact of sociodemographic, behavioral, social-structural, and clinical factors on the hazard of viral rebound for women enrolled in the ACCESS study, a prospective cohort with systematic VL monitoring. Women were included if they achieved VL suppression (<50 copies/mL) following antiretroviral therapy (ART) initiation and had more than one study interview. Sociodemographic as well as substance use, social-structural, addiction treatment, and HIV clinical factors were evaluated as predictors of viral rebound (VL > 1000 copies/mL). Cox regressions using a recurrent events framework, time-varying covariates, robust standard errors, and a frailty component were used.Of the 185 women included, 62 (34%) experienced at least one viral rebound event over an 11-year period, accumulating a total of 87 viral rebound events. In adjusted analysis, stimulant use more than doubled the hazard of viral rebound (adjusted hazard ratio [AHR]: 2.35, 95% confidence interval [CI]: 1.07–5.14) while the only factor protective against viral rebound was receipt of opioid agonist treatment (OAT) in the past six months (AHR: 0.46, 95% CI: 0.26–0.81). After adjusting for ART adherence in the past six months, the effect of OAT was attenuated (AHR: 0.57, 95% CI: 0.32–1.02).Efforts to improve access to and retention within OAT programs and decrease stimulant use may improve rates of viral suppression for HIV-positive women who use illicit drugs.

Providing HIV Comprehensive Care to Latino/as Who Inject Drugs: Philadelphia, 2013-2018.

Latino/as who inject drugs have the lowest level of retention in HIV care and the lowest HIV viral suppression rates in the United States. We set up an intervention to provide comprehensive, integrated HIV primary care services to Spanish-speaking and bilingual HIV-positive people who inject drugs of Puerto Rican ancestry in Philadelphia, Pennsylvania. In 2016, the rate of HIV viral suppression in our intervention (83%) far exceeded the rate for all individuals diagnosed with HIV in Philadelphia (51%).

Prevalence of HIV-1 transmitted drug resistance and viral suppression among recently diagnosed adults in São Paulo, Brazil.

HIV-1 transmitted drug resistance (TDR) mutations may reduce the efficacy of antiretroviral therapy (ART), but pre-treatment testing to determine the virus genotype can improve the efficacy of ART. Unfortunately, issues related to cost and logistics of pre-treatment testing limit its use in resource-limited settings. We studied 596 ART-naive individuals who were newly diagnosed from 2014 to 2016 in São Paulo, Brazil, to evaluate TDR and virological outcome after 48weeks of genotype-guided therapy. One or more TDR (based on the WHO surveillance list) was observed in 10.9% (CI 95%, 8.6-13.6) of the sequences, the most common of which was the K103N mutation, which confers resistance to first-generation drugs of the non-nucleoside reverse transcriptase inhibitor (NNRTI) antiretroviral drug class. Dual-class (1%, 6/596) and triple-class (0.34%, 2/596) resistance were uncommon. After 48weeks of treatment with ART, infection was suppressed to below 200 copies/mL in most patients (95%), with full suppression (RNA target not detected) in 65%. The following characteristics at patient enrollment were independently associated with a lack of full suppression: CD4 T cell counts below 500 cells/µL, viremia above 100,000 copies/mL, older age, and TDR to NNRTI. The rates of resistance were intermediate, but genotype-guided therapy resulted in high rates of viral suppression. The observed resistance profile should not be an obstacle to the use of the dolutegravir-based regimen now recommended in Brazil, but genotype testing may be warranted before initiating first-generation NNRTI-based regimens.

The Influence of Housing Status on the HIV Continuum of Care: Results From a Multisite Study of Patient Navigation Models to Build a Medical Home for People Living With HIV Experiencing Homelessness.

Objectives. To examine the effect of patient navigation models on changes in housing status and its subsequent effects on HIV outcomes for 700 people living with HIV (PLWH) who were unstably housed with co-occurring substance use and psychiatric disorders across 9 demonstration sites in the United States between the years of 2013 and 2017.Methods. Self-reported housing status was collected at baseline, and at 6 and 12 months during the intervention. HIV outcomes included linkage and retention in care, antiretroviral therapy prescription, and viral suppression collected via chart review.Results. In the 12 months after the intervention, 59.6% transitioned to more stable housing. Compared with those who became or remained unstably housed, participants with greater stability achieved significantly higher rates of retention (adjusted odds ratio [AOR] = 2.12; 95% confidence interval [CI] = 1.11, 4.05), were more likely to be prescribed antiretroviral therapy (AOR = 2.06; 95% CI = 1.62, 2.63), and had higher rates of viral suppression (AOR = 1.62; 95% CI = 1.03, 2.55).Conclusions. The use of patient navigators to create a network of services for PLWH who are unstably housed can improve housing stability and lead to improvements in HIV-related outcomes.

Factors Associated with HIV Viral Suppression Among Transgender Women in Lima, Peru.

Globally, transgender women (TGW) experience a high burden of adverse health outcomes, including a high prevalence of HIV and sexually transmitted infections (STIs) as well as psychiatric disorders and substance use disorders. To address gaps in HIV research in Peru focused specifically on TGW, this study presents characteristics of a sample of HIV-positive TGW and identifies factors associated with viral suppression. Between June 2015 and August 2016, 50 HIV-positive TGW were recruited in Lima, Peru. Multivariable logistic regression was used to identify factors associated with viral suppression (<200 copies/mL) among the TGW. Among TGW, 85% achieved viral suppression. Approximately half (54%) reported anal sex with more than five partners in the past 6 months, 38% reported sex work, 68% had not disclosed their HIV status to one or more of their partners, and 38% reported condomless sex with their last partner. The prevalence of alcohol use disorders was high (54%), and 38% reported use of drugs in the past year. Moderate-to-severe drug use significantly reduced odds of achieving viral suppression (adjusted odds ratio 0.69; 95% confidence interval: 0.48-0.98). Our findings highlight the need for integrated treatment for substance disorders in HIV care to increase the viral suppression rate among TGW in Lima, Peru.

587. HIV Care Outcomes Among PWID in San Francisco, 2009–2015

BackgroundAround 16% of HIV infections in the United States are among persons who inject drugs (PWID). PWID have a higher mortality than other persons living with HIV due to delayed diagnosis, lower use of antiretroviral therapy (ART), and other factors. Understanding the specific barriers to virologic suppression, however, is challenging as PWID are less likely to engage in care. Here we present trends in HIV care indicators for PWID in San Francisco from 2009 to 2015, using a novel system of behavioral health surveys. These data will inform international and local initiatives for population-level HIV control, such as San Francisco’s “Getting to Zero” initiative and UNAIDS’s “90-90-90” targets.MethodsWe used data from serial cross-sectional surveys of PWID conducted in 2009, 2012, and 2015 as part of the CDC-led National HIV Behavioral Surveillance system. PWID were recruited using respondent-driven sampling, in which PWID refer their peers to the surveys. We tracked the number of PWID who were: (i) living with HIV, (ii) knew their HIV status, (iii) were on ART, and (iv) for 2015 only, were virally suppressed (self-reported).ResultsHIV prevalence among PWID was 11.4% in 2009, 12.0% in 2012, and 16.8% in 2015. The percentage of PWID living with HIV who knew their HIV+ diagnosis remained stable (57.8% in 2009; 57.3% in 2012) before increasing to 83.3% in 2015. Among PWID who knew their HIV status, the proportion reporting they were currently taking ART declined from 73.8% in 2009 to 66.3% in 2012 to 64.1% in 2015. In 2015, the only year the question was asked, 87.2% of HIV+ PWID reported that their most recent viral load was suppressed.ConclusionWe successfully tracked trends in engagement in HIV care among PWID from 2009 to 2015. Our data are notable for an apparent improvement in HIV diagnosis over time, a persistent gap in treatment with ART, and—in 2015—a relatively high rate of self-reported viral suppression when on ART. All three measures fall short of the UNAIDS 90-90-90 goals. The decline in getting PWID on ART from 2009 to 2015 is particularly concerning and warrants additional linkage to care and retention efforts. This is especially important given the high rates of viral suppression PWID can achieve once on ART, as seen in our study and other reports from published literature. Disclosures All authors: No reported disclosures.

548. Antiretroviral Therapy Regimen Characteristics Within an Urban, Safety-Net Clinic in the United States

BackgroundContemporary antiretroviral-therapy (ART) regimens have simple dosing, low toxicity, minimal side-effects, and few drug interactions. We evaluated ART regimens in an urban, safety-net, adult HIV clinic in the United States to determine proportions of patients on contemporary ART and identify opportunities to optimize ART for patients on older regimens.MethodsData including current ART regimen, HIV-1 RNA level, and age were extracted from the electronic medical record (EMR) for all patients seen in the prior 13 months. Viral suppression was defined as HIV-1 RNA < 200 copies/mL. A patient was “off-ART” if there were no fills within 270 days or ART had a stop date >90 days prior to end of the study. Unclear regimens from the EMR (n = 179) were chart reviewed. ART regimens were assigned the following designations: contemporary first-line, contemporary non-first-line, older three-drug, two-drug, salvage, or off-ART. ART was also categorized as boosted (containing cobicistat/ritonavir) vs. unboosted, by single-tablet regimen (STR) vs. multi-tablet regimen (MTR), and frequency of dosing. Correlations between ART regimen, viral suppression, and age were analyzed.ResultsThe ART review included 1,215 individuals. Most patients (64%) were on contemporary first-line regimens; 20% were on contemporary non-first-line regimens (figure). Patients on salvage regimens had lower rates of viral suppression than those in other ART categories (80% vs. 90%, P <0.05). Most patients (90%) were prescribed once daily regimens, and of those, 39% were prescribed STRs. There were no significant associations between viral suppression and regimen complexity (P = 0.8). There were 447 (37%) patients on boosting agents with no difference in viral suppression rate (88% suppressed on boosted regimens vs. 90% on unboosted, P = 0.3). Patients on older regimens and greater than equal to twice daily MTRs were older than those on contemporary regimens and STRs. Individuals off ART were younger than those on ART (average age 41 vs. 46 years).ConclusionIn a US urban, safety-net clinic, most patients were on contemporary ART regimens and 90% were on once-daily therapy. Despite these encouraging findings, systematic review identified many patients that could be considered for modernization and simplification with intent to minimize toxicity, side-effects, drug interactions, and cost. Disclosures All authors: No reported disclosures.

1904. Impact of Mail Order Pharmacy Use on Viral Suppression Among HIV-Infected Patients

BackgroundThere are many barriers to adherence to antiretroviral medications, including pharmacy accessibility. Few studies have evaluated the impact of pharmacy distance or use of mail order pharmacy services on HIV viral load suppression relative to use of an “in-person” pharmacy. The purpose of our study was to determine whether there is a difference in viral suppression rates among patients who utilize mail order pharmacy services vs. an in-person pharmacy for filling antiretroviral prescriptions. Our study also looked at the effect of distance and travel time to viral suppression for patients who use in-person pharmacy services.MethodsThis was a single-center, retrospective cohort study of adult HIV-positive patients who received care between 2006 and 2015 at an urban HIV care clinic. We collected patient demographic information, ART regimen, home address, pharmacy address, and laboratory values. For patients who utilized retail pharmacies, patients’ home addresses and the location of the pharmacy were geocoded using ESRI’s StreetMap Premium geocoding service. We calculated patients’ travel distance to pharmacy and travel time to pharmacy along a street network in a private vehicle. Chi-squared tests and logistic regression were used to determine the association between in-person or mail order pharmacy services and distance to pharmacy and viral suppression (viral load ≤200 copies/mL).ResultsThere were 214 patients in the mail order group and 214 patients included the in-person pharmacy group. Baseline characteristics were similar between the groups, with the exception of more people who inject drugs in the mail order group (6.1% vs. 1.8%, P = 0.05). No difference in viral load suppression was observed between groups (21.7% vs. 20.2%, P = 0.679). There was no difference in viral suppression depending on the distance (1.46 miles away in viral suppressed patients vs. 1.36 miles, P = 0.75) or travel time to pharmacy (7 minutes vs. 6.6 minutes, P = 0.75) for the in-person pharmacy group. Factors found to be significantly associated with suppressed viral loads were older age, white race, and higher CD4 counts.ConclusionViral suppression was not associated with pharmacy type, distance to pharmacy, or travel time to pharmacy.Disclosures All authors: No reported disclosures.

590. Tackling HIV/AIDS in Brooklyn New York Within a Network of Federally Qualified Health Centers

BackgroundAs of June 30, 2016, 122,945 New Yorkers had been diagnosed and were known to be living with HIV/AIDS. The Family Health Centers at NYU Langone (FHC) has for the past 27 years continued to build an evolving network of services which aim to tackle the epidemic through the principles of hot-spotting, elevating cultural competency, and applying the continuum of care model for the communities we serve.MethodsFHC’s network covers a service area of six NYC Community Districts in Brooklyn. Utilizing best practices, FHC has built a network which addresses the cascade of care through EMR embedded screening, education on cultural competencies in the LGBTQ community, dedicated health navigators, and a comprehensive panel of providers to deal with biopsychosocial factors that prohibit access to healthcare delivery. Utilizing automated referral pathways within the EMR along with a daily review of all testing results performed within the network, care coordination teams and patient navigators are able to identify patients. Dedicated case management teams are then assigned to locate patients and link patients to treatment and assist in overcoming care access barriers.ResultsWithin the FHC catchment area the incidence of new HIV infections was heavily concentrated among poor minorities. Among the FHC population, minority races compromised 79.3% of those PLWHA, with 58% of the population having the risk factor of MSM activity. For those patients who fall under >20% below Federal poverty level, New York’s HIV/AIDS death rate is at 74.7%. Despite national and regional trends, the FHC over the last 3 years has managed to not only to provide greater opportunities for access to care, but has increased the rate of viral load suppression among patients served (393 patients in 2014 to 416 patients in 2016 and VLSR of 92.4–95.6%.)ConclusionHIV/AIDS prevalence is still characterized by wide gaps in healthcare disparities and inequality, particularly among those communities who are poor, LGTBQ and/or minority background. By building an infrastructure that follows best practices in a culturally sensitive context, the FHC is able to provide greater access to care in a dwindling population while creating a medical home for quality care regardless of payer base, race, or gender.Disclosures All authors: No reported disclosures.

1766. Sustained Viral Suppression with Dolutegravir and Boosted Darunavir Dual Therapy Among Highly Treatment-Experienced Individuals

BackgroundThe use of antiretroviral (ARV) dual therapy for treatment of HIV is increasing; raltegravir with boosted darunavir (bDRV) is recommended in certain clinical situations in DHHS guidelines. Dolutegravir (DTG) with bDRV has not been widely studied. We sought to determine the effectiveness of DTG/bDRV in treatment experienced patients.MethodsThis retrospective cohort study evaluated viral suppression in patients prescribed DTG/bDRV dual therapy within a large urban health system. Data collected included demographics, cumulative ARV exposure, reasons for use, regimen start/stop dates, and viral suppression (HIV-RNA ≤200). Follow-up was defined as the number of days from start of regimen until last HIV-RNA determination on the study regimen.ResultsFrom January 1, 2013 to December 31, 2017, 60 patients received DTG/bDRV dual therapy: 15% were female, median age was 56, 83% were ≥3 class ARV-experienced, and median time since starting ARVs was 20 years. Median follow-up on DTG/bDRV was 444 days (IQR 273–808). Viral suppression was achieved by 59 of 60 (98%) patients at some point on DTG/bDRV. When stratified by baseline viral suppression, 46 of 46 (100%) who had baseline viral suppression maintained viral suppression in comparison to 11 of 14 (79%) without baseline viral suppression (table). The most common reasons for DTG/bDRV were simplification in setting of prior resistance (47%), toxicity reduction (39%), and virologic failure (15%). At study end, 53 of 60 (88%) were still on DTG/bDRV and the most common reason for stopping was drug interactions.ConclusionIn a highly treatment-experienced cohort of patients, DTG/bDRV dual therapy demonstrated sustained rates of viral suppression, even in those who were failing therapy prior to initiating the regimen. Further study of this potent, simple, high-barrier dual class regimen is warranted.Table:Virologic OutcomesNFollow-up Days, Median (IQR)HIV-RNA Evera ≤200 cp/mLLastb HIV-RNA ≤200 cp/mLOverall60444 (273,808)59 (98%)57 (95%)Baseline HIV-RNA suppressed46423 (268,817)46 (100%)46 (100%)Baseline HIV-RNA not suppressed14613 (392,743)13 (93%)11 (79%)IQR, interquartile range. aEver refers to achieving suppression at any point while on DTG/bDRV. bLast refers to the last recorded HIV-RNA value while on DTG/bDRV.Disclosures S. Rowan, Gilead Sciences: Investigator, Research grant. S. C. Johnson, Viiv Healthcare: Scientific Advisor, Consulting fee.

Factors associated with viral non-suppression among adolescents living with HIV in Cambodia: a cross-sectional study

BackgroundAdolescents living with HIV on antiretroviral therapy (ART) have worse treatment adherence, viral suppression, and mortality rates compared to adults. This study investigated factors associated with viral non-suppression among adolescents living with HIV in Cambodia.MethodsA cross-sectional study was conducted in August 2016 among 328 adolescents living with HIV aged 15–17 years who were randomly selected from 11 ART clinics in the capital city of Phnom Penh and 10 other provinces. Clinical and immunological data, including CD4 count and viral load, were obtained from medical records at ART clinics. Adolescents were categorized as having achieved viral suppression if their latest viral load count was < 1000 ribonucleic acid (RNA) copies/mL. Multivariate logistic regression analysis was performed to identify factors independently associated with viral non-suppression.ResultsThe mean age of the participants was 15.9 years (SD = 0.8), and 48.5% were female. Median duration on ART was 8.6 (interquartile range = 6.0–10.6) years. Of total, 76.8% of the participants had achieved viral suppression. After adjustment for other covariates, the likelihood of having viral non-suppression remained significantly lower among adolescents who were: older/aged 17 (AOR = 0.46, 95% CI 0.21–0.98), had been on ART for more than 9 years (AOR = 0.35, 95% CI 0.19–0.64), had most recent CD4 count of > 672 (AOR = 0.47, 95% CI 0.26–0.86), had a relative as the main daily caregiver (AOR = 0.37, 95% CI 0.17–0.80), and did not believe that there is a cure for AIDS (AOR = 0.40, 95% CI 0.21–0.75) compared to their reference group. The likelihood of having viral non-suppression also remained significantly higher among adolescents who had first viral load > 628 RNA copies/mL (AOR = 1.81, 95% CI 1.05–4.08) and among those who were receiving HIV care and treatment from an adult clinic (AOR = 2.95, 95% CI 1.56–5.59).ConclusionsThe proportion of adolescents living with HIV with viral suppression in this study was relatively high at 76.8%, but falls short of the global target of 90%. Programs targeting younger adolescents and adolescents in transition from pediatric to adult care with a range of interventions including psychosocial support and treatment literacy could further improve viral suppression outcomes.

HIV Outcomes for Foreign-Born Patients Receiving Care at a Safety Net County Health System in the Southern US

Background: Foreign-born Human Immunodeficiency Virus (HIV) infected patients receiving care in the US have complex factors affecting their care outcomes. Methods: We analyzed viral suppression, CD4 count, and healthcare retention among foreign-born patients from non-Spanish speaking countries in a publicly funded health system in Dallas, Texas through a retrospective chart review from 2010 to 2016. Results: Foreign-born patients had a viral suppression rate of 79*3%. Unsuppressed viral load, CD4 counts less than 200, and loss to care were significantly associated with higher emergency room (ER) visits and hospital admissions. Lack of healthcare coverage (excluding Ryan White coverage) and missed primary care appointments were significantly associated with unsuppressed viral load and loss to care. In multivariate logistic regression, having Ryan White coverage made one less likely to be lost to care than other health care coverage options (OR 0*309). Interpretation: This study revealed that, factors related to healthcare utilization like ER visits, hospital admissions, and lack of healthcare coverage had a negative impact on HIV outcomes rather than socio-cultural factors like region of origion or language. Ryan White coverage, a payer of last resort in Texas, was predictive of retention in care of foreign-born patients in this area. Funding Statement: The authors declare None. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: This study was approved by the University of Texas, Southwestern Medical Center Institutional Review Board.

Using Financial Incentives to Improve Rates of Viral Suppression and Engagement in Care of Patients Receiving HIV Care at 3 Health Clinics in Louisiana: The Health Models Program, 2013-2016.

The Care and Prevention in the United States Demonstration Project aimed to reduce HIV/AIDS-related morbidity and mortality among racial/ethnic minority groups in 8 states. We evaluated Health Models, a pay-for-performance program piloted by the Louisiana Department of Health that used financial incentives to improve rates of engagement in HIV medical care and viral suppression among people with HIV. We enrolled 2076 patients of 3 urban HIV specialty clinics in Louisiana in the Health Models pay-for-performance program on a rolling basis from September 2013 through September 2016 and gave patients cash incentives to attend HIV medical appointments, achieve or maintain viral suppression, and link to supportive services. We used laboratory data collected from Louisiana's HIV surveillance database to calculate rates of engagement in care and viral suppression during the first 24 months of enrollment. Of the 2076 patients who enrolled, 1400 (67.4%) were non-Hispanic black, 1480 (71.3%) were male, 1175 (56.6%) were men who have sex with men, and 1371 (66.0%) reported an annual income of <$15 000. At enrollment, 1456 (70.1%) patients were engaged in HIV care, and 1197 (57.7%) patients were virally suppressed. After 12 months of enrollment, 1474 of 1783 (82.7%) patients were virally suppressed. Of enrolled patients with at least 12 or 24 months of follow-up data, 1299 of 1317 (98.6%) patients were engaged in care during their first 12 months of enrollment, and 995 of 1033 (96.3%) patients were engaged in care between 12 and 24 months of enrollment. During the implementation of Health Models, enrolled patients had increases in rates of viral suppression and achieved rates of engagement in care and viral suppression that were higher than national levels; however, additional supportive services may be needed to further reduce socioeconomic disparities in the rates of viral suppression.

Impact of Alternative Encounter Types on HIV Viral Suppression Rates in an Integrated Health System.

Kaiser Permanente Mid-Atlantic States (KPMAS) members are increasingly utilizing electronic encounter types, such as telephone appointments and secure messaging for healthcare purposes, although their impact on health outcomes is unknown. We evaluated whether use of alternative encounters by adult human immunodeficiency virus (HIV)-infected patients affected the likelihood of achieving viral suppression (VS). Our study population of 3114 patients contributed 6520 patient-years between 2014 and 2016. We compared VS (HIV RNA <200 copies/mL) by number of in-person visits (1 or ≥2), with further stratification for additional phone and/or e-mail encounters (none, phone only, e-mail only, and both phone and e-mail). Rate ratios (RRs) for VS by number of in-person visits and encounter types were obtained from Poisson modeling, adjusting for age, sex, race/ethnicity, and HIV risk. Compared to those with ≥2 visits, patients with one in-person visit alone were significantly less likely to achieve VS (RR = 0.93; 95% confidence interval, CI: [0.87-1.00]), as were those with one in-person visit plus a telephone encounter (0.93; [0.90-0.97]). We did not find significant differences in VS comparing patients with one in-person visit plus e-mail only (RR = 1.00; 95% CI: [0.97-1.02]) or plus e-mail and telephone (0.99; [0.97-1.01]) to those with ≥2 in-person visits. If supplemented by e-mail communications (with or without telephone contact), patients with one in-person visit per year had similar estimated rates of VS compared with ≥2 in-person visits. More research is needed to know if these findings apply to other care systems.

Year 2 of Affordable Care Act Qualified Health Plans (QHPs) in a Medicaid Nonexpansion State: QHPs Associated With Viral Suppression for Virginia AIDS Drug Assistance Program Clients.

BackgroundFor year 1 of the Affordable Care Act (ACA), Virginia AIDS Drug Assistance Program (ADAP) clients with Qualified Health Plans (QHPs) achieved a higher rate of viral suppression. This study characterizes the demographic and health care delivery factors associated with QHP enrollment in year 2 and assesses the relationship between 2015 QHP coverage and HIV viral suppression.MethodsThe cohort included Virginia ADAP clients who were eligible for ADAP-funded QHPs. Data were collected from 2014 to 2015. Multivariable binary logistic regression was conducted to assess the association of demographic and health care delivery factors with QHP enrollment and viral suppression.ResultsIn year 2, 63% of the cohort (n = 4631) enrolled in QHPs; 2015 ADAP-funded QHP enrollment was associated with 2014 ADAP-funded QHP (adjusted odds ratio [aOR], 111.11; 95% confidence interval [CI], 90.91–166.67), 2014 engagement in care (aOR, 2.16; 95% CI, 1.65–2.82), age (P < .001), race/ethnicity (P = .03), financial status (P < .001), and region (P < .001). For clients engaged in care (n = 2501), viral suppression was higher (83.3%) for those with ADAP-funded QHP coverage than for those who received medications from ADAP (79.9%). In multivariable binary logistic regression, achieving viral suppression was associated with 2015 QHP coverage (aOR, 1.27; 95% CI, 1.01–1.60), an initially undetectable viral load (aOR, 2.69; 95% CI, 2.13–3.39), gender (P = .03), age (P = .01), no AIDS diagnosis (aOR, 1.41; 95% CI, 1.12–1.78), financial status (P = .004), and region (P < .001).ConclusionsVirginia ADAP client 2015 QHP enrollment increased compared with year 1 and varied based on demographic and health care delivery factors. QHP coverage was again associated with viral suppression, an essential outcome for individuals and for public health.

Transmission dynamics among participants initiating antiretroviral therapy upon diagnosis of early acute HIV-1 infection in Thailand.

To assess transmission characteristics in a predominantly MSM cohort initiating antiretroviral therapy (ART) immediately following diagnosis of acute HIV-1infection (AHI). A longitudinal study (2009-2017) was performed in participants with AHI (n = 439) attending a single clinic in Bangkok. Plasma samples obtained prior to ART were used to obtain HIV-1 pol sequences and combined with clinical and epidemiologic data to assess transmission dynamics (cluster formation and size) using phylogenetic analysis. Clusters were estimated using maximum likelihood, genetic distance of 1.5% and visual inspection. The potential transmitter(s) in a cluster was determined using time to viral suppression and interview data. The cohort was predominantly MSM (93%) and infected with HIV-1 CRF01_AE (87%). Medians (ranges) for age and viral load prior to ART were 26 (18-70) years and 5.9 (2.5-8.2) log10 HIV-1 RNA copies/ml. Median time from history of HIV-1 exposure to diagnosis was 19 (3-61) days. Viral suppression was observed in 388 of 412 (94%) participants at a median time of 12 weeks following ART. Twenty-six clusters with median cluster size of 2 (2-5) representing 62 of 439 (14%) participants were observed. Younger age was associated with cluster formation: median 28 versus 30 years for unique infections (P = 0.01). A potential transmitter was identified in 11 of 26 (42%) clusters. Despite high rates of viral suppression following diagnosis and treatment of AHI within a cohort of young Thai MSM, HIV-1 transmission continued, reflecting the need to expand awareness and treatment access to the entire MSM population.

The Facility-Level HIV Treatment Cascade: Using a Population Health Tool in Health Care Facilities to End the Epidemic in New York State

BackgroundThe HIV treatment cascade is a tool for characterizing population-level gaps in HIV care, yet most adaptations of the cascade rely on surveillance data that are ill-suited to drive quality improvement (QI) activities at the facility level. We describe the adaptation of the cascade in health care organizations and report its use by HIV medical providers in New York State (NYS).MethodsAs part of data submissions to the NYS Department of Health, sites that provide HIV medical care in NYS developed cascades using facility-generated data. Required elements included data addressing identification of people living with HIV (PLWH) receiving any service at the facility, linkage to HIV medical care, prescription of antiretroviral therapy (ART), and viral suppression (VS). Sites also submitted a methodology report summarizing how cascade data were collected and an improvement plan identifying care gaps.ResultsTwo hundred twenty-two sites submitted cascades documenting the quality of care delivered to HIV patients presenting for HIV- or non-HIV-related services during 2016. Of 101 341 PLWH presenting for any medical care, 75 106 were reported as active in HIV programs, whereas 21 509 had no known care status. Sites reported mean ART prescription and VS rates of 94% and 80%, respectively, and 60 distinct QI interventions.ConclusionsSubmission of facility-level cascades provides data on care utilization among PLWH that cannot be assessed through traditional HIV surveillance efforts. Moreover, the facility-level cascade represents an effective tool for identifying care gaps, focusing data-driven improvement efforts, and engaging frontline health care providers to achieve epidemic control.