Ryan White Clinic Research Articles

Associations between interpersonal and community-level violence experiences and HIV outcomes: implications for violence screening in Ryan White Clinics

ABSTRACT Violence experience, interpersonal and community-level, is commonly reported by people living with HIV (PLWH). Understanding the impact of the various forms of violence on HIV outcomes is critical for prioritizing violence screening and support resources in care settings. From February 2021 to December 2022, among 285 PLWH purposively sampled to attain diversity by gender, race/ethnicity, and HIV care retention status in Atlanta, Georgia, we examined interpersonal and community violence experiences and proxy measures of violence (post-traumatic stress disorder (PTSD), anxiety, depression) and their associations with HIV outcomes (engagement and retention in care and HIV viral suppression) using multivariable analysis. Participants commonly reported lifetime intimate partner violence (89%), non-partner violence (97%), hate crimes (93%), and moderate-to-severe adverse childhood events (59%). Lifetime violence experiences were not significantly linked to HIV care engagement, retention, nor durable viral suppression, but were each individually associated with PTSD, which in turn, was significantly associated lower odds of durable viral suppression (AOR 0.35, CI 0.14-0.86). Thus, the high prevalence and multiplicity of interpersonal and community-level violence experienced among PLWH in Atlanta underscores the need for universal trauma-informed approaches and supports implementation of PTSD screening to identify patients at greatest need for trauma support services.

P-1412. HIV Retention in Care and Viral Suppression among Transgender Women in a Large Ryan White Clinic

Abstract Background Transgender women (TW) are disproportionately affected by HIV with 1 in 5 TW in the United States living with HIV. TW with HIV (TWH) have lower rates of retention and viral suppression than cisgender women and cisgender men, resulting in worse health outcomes and increased HIV transmission. The aim of this quality improvement initiative was to identify TWH at a large urban Ryan White clinic in New Orleans to guide future quality improvement efforts to improve retention and viral suppression of TWH.Table 1.Characteristics of Transgender Clinic Patients Reviewed Methods A list of established clinic patients with a gender identity of transgender was generated to create a database with basic demographic information, viral suppression, retention in care, and potential barriers to viral suppression or retention from April 1, 2023-March 31, 2024. Insurance status, mental health or substance use disorder, and prescription of gender affirming hormone therapy (GAHT) were documented for each patient. Patients were further subdivided into three categories “In Care and Virally Suppressed,” “Out of Care,” and “Not Virally Suppressed” for further analysis. Results Out of 1393 established clinic patients, 28 patients were identified as transgender (2%). 27/28 of these patients are black/African American, 1 is Hispanic/Latino. 64% were retained in care, compared to 81% of all clinic patients. 75% were virally suppressed, compared to 84% of all clinic patients. Detailed characteristics are displayed in Table 1. Patients who were out of care or not virally suppressed were younger and had higher rates of mental health diagnoses. 70% of patients who were out of care carried a mental health diagnosis. There was no correlation between GAHT, substance use, or insurance status and retention in care or viral suppression. Conclusion As suggested by previous studies, a significantly lower percentage of TWH were retained in care and virally suppressed when compared to the total clinic population, thus highlighting the need to focus on this disproportionately affected group. This TWH database will be used to track retention in care and viral suppression, and data regarding potential barriers will be used to guide quality improvement efforts among TWH, with a plan to focus on mental health services. Disclosures All Authors: No reported disclosures

P-578. Just “Short of a Cure”: Unique Considerations in Uptake and Use of Long-Acting Injectable Cabotegravir/Rilpivirine Among Long-Term Survivors with HIV

Abstract Background Understanding perspectives of subgroups of people with HIV (PWH) who have accessed long-acting cabotegravir/rilpivirine (CAB/RPV-LA) is crucial for optimizing implementation; especially among long-term survivors (LTS) who have lived through the trauma of the early epidemic to the innovation of today. Methods We analyzed semi-structured interviews collected from 08/2022-05/2023 via a parent study at four Ryan White clinics in Atlanta, Chicago, and San Francisco among early adopters of CAB/RPV-LA (received ≥3 injections or discontinued). Our analysis explored factors impacting CAB/RPV-LA uptake and use in LTS (living with HIV since 2000 or earlier) using a socioecological model of HIV care engagement. Results Among 20 LTS, median age was 56 (Q1-Q3 54-60) years and median time living with HIV was 27 (Q1-Q3 25-34) years. Thirteen (65%) identified as racial/ethnic minorities and seven (35%) as cis or trans women. We identified three primary themes: 1) The majority of LTS eagerly awaited CAB/RPV-LA and seemed unconflicted in their choice to switch from oral antiretroviral therapy (ART). Their confidence stemmed from experience using new iterations of oral ART over decades, with some citing CAB/RPV-LA as being a step closer to a cure. 2) Choosing to start CAB/RPV-LA was sometimes facilitated by input from longstanding, trusted relationships with healthcare providers or other PWH. 3) Reflections on the emotional gravity of witnessing loved ones die from AIDS-related illnesses early in the epidemic, and the mental imprisonment of around-the-clock pill taking required for their own survival, influenced use of CAB/RPV-LA. In fact, many reported transforming HIV-related psychological trauma and tragedy into education, support, and advocacy efforts: using CAB/RPV-LA was a unique mechanism to further benefit their community—indeed, it was an obligation to both PWH who have passed as well as PWH to come, who could learn from their experience. Conclusion The perspectives of LTS who initiated CAB/RPV-LA during early implementation revealed uptake and use was shaped by the emotional, psychosocial, and physical impact of living with HIV for decades. These data serve as a framework to tailor service delivery of current and future long-acting ART options in this population. Disclosures Moira McNulty, MD, Gilead Sciences, Inc.: Advisor/Consultant Katerina Christopoulos, MD, MPH, Janssen: Honoraria

P-564. Long Term Follow Up of Rapid or Same-day Start of Antiretroviral Therapy (ART) in Patients Living With HIV (PWH) in the Midwestern US

Abstract Background Current DHHS guidelines recommend starting ART in PWH immediately or as soon as possible after HIV diagnosis to improve ART uptake, linkages to care and virologic suppression (VS). But there is little data measuring the longitudinal impact of rapidly starting ART. We previously showed that rapidly starting ART significantly decreased time to VS. This study compares the longitudinal effects of rapid ART start versus delayed ART initiation on retention in care and VS in a previously defined cohort of PWH. Methods IRB-approved follow up study of a single-center, retrospective cohort. The original cohort included all newly diagnosed, antiretroviral-naïve adult patients seen in the Ryan White Clinic (RWC) at a single site for their initial visit between 1/1/15-12/31/15 (delayed ART) and 1/1/17-12/31/17 (rapid ART): Table 1 and Table 2. In the original cohort, primary outcome of time from HIV diagnosis to VS [VL < 200 copies/ml (cp/ml)] was compared between groups. For the current study, the primary outcomes of VS (VL < 50 cp/ml) and retention in care (documented visit at study site or documented transition of care) were measured in the original cohort participants from 1/1/23-12/31/23. Reasons for lack of retention in care were death and loss to follow up. Results In the original cohort, 72 patients were screened and 60 met inclusion criteria; (24 delayed ART, 36 rapid ART). The long-term outcomes for VS and retention in care are shown in Table 3. 11/24 (delayed) and 23/36 (rapid) remained engaged in care at the study institution (p=.193). 9/11 (82%) and 22/23 (96%) maintained VS (p=.239), in the delayed ART and rapid ART, respectively. Participants were more likely to be retained in care (at study site or with documented transition in care) in the rapid ART group (11/22 delayed ART vs. 31/35 rapid ART, p=.002) If not retained in care at the study site, delayed ART participants were more likely to be lost to follow up versus having a documented transition in care or death [11/13 delayed ART vs 4/13 rapid ART, (p=.015)]. Conclusion A previous study showed a shortened time to VS with rapid start of ART. Long-term retention in care may be significantly improved with rapid start of ART and requires further study. Rapid start may also demonstrate a trend towards increased VS. Disclosures All Authors: No reported disclosures

P-462. Disparities in HPV Vaccination among HIV Patients at a Rural Federally Funded HIV Clinic- A Retrospective Study

Abstract Background Our study aimed to evaluate the demographic factors of HPV vaccination among racial minorities of HIV patients at a non-academic Ryan White clinic in rural Pennsylvania. Methods A retrospective cross sectional study (n=143) was conducted on a population composed of White (51.05%), White Hispanics WH (11.19%), Black (27.97%), Black Hispanics BH (1.4%), and Unknown (8.39%). Proportions and chi-square tests were used and multivariate regression analysis was done with p≤0.05 as significant. Results Our study found that 35% of the population was vaccinated, with 60.7% receiving three doses and 23.2% receiving two doses. Age was a key factor (p=0.000) for vaccination acceptance (VA), with those aged 25-45 years having a higher VA than the nonvaccinated (NonVA) (62% vs. 24.7%). VA was lower among those aged 46-65 years (30% vs. 61.3%) and those over 65 years (8% vs. 14%). Lack of awareness of the benefits and misconceptions about the side effects of vaccination are common among different age groups. Males were predominant in our study, with VA higher than NonVA (86% vs. 81.7%, p=0.5), though the difference was not significant. VA by race showed marginal significance (p=0.1), with Whites having the highest VA (40%), followed by Blacks (32%) and Hispanics (20%). Multivariate regression revealed that the 46-65 age group had 80% lower odds of VA compared to the 25-45 group (aOR 0.2, p=0.000), while >65 years had 78% lower odds (aOR 0.22, p=0.021). This regression analysis was adjusted for race (White=Ref, Black p=0.7, Hispanic p=0.1). Upon further stratification of the Hispanic population, VA in the 25-45 years was 6.4% for Black Hispanics and 22.6% for White Hispanics (p=0.000). Conclusion Our study highlights that age and ethnicity are significant predictors of vaccination acceptance, with younger individuals and Whites demonstrating a higher likelihood of vaccination acceptance. Among the racial minorities, vaccination acceptance was lowest in Hispanics. These findings underscore the importance of demographic and cultural factors affecting vaccination rates. Targeted interventions to increase awareness and future studies are needed to determine the factors associated with vaccine hesitancy and work toward implementing new strategies to improve it. Disclosures All Authors: No reported disclosures

Early Implementation and Outcomes Among People with HIV Who Accessed Long-Acting Injectable Cabotegravir/Rilpivirine at Two Ryan White Clinics in the U.S. South.

The use of long-acting injectable cabotegravir/rilpivirine (LAI-CAB/RPV) as maintenance therapy for persons with HIV (PWH), which may improve treatment access and outcomes, though real-world data on uptake are limited, was studied at two Ryan White clinics in Atlanta, Georgia. Among PWH referred from 4/1/2021 to 9/15/2022 to switch to LAI-CAB/RPV, characteristics were ascertained at time of referral; and disposition (initiated; ineligible; uninterested; pending) was recorded as of 9/15/2022. Among patients initiated on CAB/RPV, we assessed the drug procurement process and clinical outcomes through 6/1/2023. Among 149 PWH referred, 74/149 (50%) initiated CAB/RPV as of 9/15/2022, of whom, characteristics were median age 47 (Q1-Q3 36-55) years, 16% cisgender female, 72% Black race, median HIV duration 15 (Q1-Q3 9-19) years, and 64% had commercial health insurance. Of the 75 PWH not initiated, 35 were ineligible owing to a clinical concern (n = 16) or insurance issue (n = 19); 15 patients changed their mind about switching; and 25 were pending eligibility review or therapy initiation. Median time from CAB/RPV prescription to initiation was 46 (Q1-Q3 29-78) days. Of 731 total injections administered (median 11 injections/patient), 95% were given within 7 days of the target treatment date. Nearly all patients were virally suppressed upon referral and remained suppressed through follow-up. At two clinics in the U.S. South, half of the patients referred for LAI-CAB/RPV successfully accessed therapy nearly 2 years after U.S. drug approval. We identified barriers to uptake at the patient and structural levels, highlighting key areas to invest resource and personnel support to sustain and scale long-acting antiretroviral therapy programming.

Data to Care Pilot Program in Chicago: Experience, Outcomes, and Direction for the Future.

Data to Care (D2C) involves sharing HIV surveillance data between health care facilities and health departments to improve continuity of care for people living with HIV (PLWH). The Chicago Department of Public Health (CDPH) initiated a D2C pilot program at the University of Chicago Medicine (UCM) from June 2016 to September 2019. To describe the proportion of patients reported by UCM as not in care who were able to be matched to CDPH enhanced HIV/AIDS Reporting System (eHARS) and to report the individual-level factors associated with matching and viral suppression. Retrospective program evaluation. UCM, an academic health care center that provides HIV care to adults via a Ryan White clinic on the south side of Chicago. Adult PLWH who had received care at UCM but did not have current documented HIV care visit(s). Proportion of matched patients; factors associated with matching and viral suppression. Overall, 72.4% (n = 813/1123) of patients reported by UCM were matched by CDPH to eHARS. Individuals aged 40 to 49 years (odds ratio [OR] = 1.99; 95% confidence interval [CI], 1.10-3.62), 50 to 59 years (OR = 2.47; 95% CI, 1.37-4.47), and 60 years or older (OR = 6.18; 95% CI, 3.18-12.32) were more likely to match in eHARS. People who lived outside of Chicago (OR = 0.09; 95% CI, 0.05-0.15) or with unknown zip codes (OR = 0.08; 95% CI, 0.05-0.12) were less likely to match. Men who have sex with men and persons older than 50 years were more likely to be virally suppressed. D2C is an evidence-based strategy for reengagement of PLWH; however, program implementation relies on successful data matching. We found that a large proportion of patients from UCM were not matched, particularly those who were younger or lived outside of Chicago. Additional research is needed to understand ways to improve data matching to facilitate reengagement in HIV care.

Experiences of childhood, intimate partner, non-partner, and hate crime-related violence among a sample of people living with HIV in the epicenter of the U.S. HIV epidemic.

Experiences of violence among people living with HIV (PLWH) are thought to be highly prevalent but remain inadequately captured. As a first step toward acceptable, trauma informed practices that improve engagement and retention in care for PLWH, we must acquire more comprehensive understanding of violence experiences. We examined experiences of various forms of lifetime violence: adverse childhood experiences (ACES), intimate partner violence (IPV), non-partner violence (NPV), and hate crimes among diverse sample of PLWH in Atlanta, Georgia. Cross sectional data collected from in- and out-of-care PLWH (N = 285) receiving care/support from Ryan White Clinics (RWCs), AIDS Service Organizations (ASOs), or large safety-net hospital, February 2021-December 2022. As part of larger study, participants completed interviewer-administered survey and reported on experiences of violence, both lifetime and past year. Participant characteristics and select HIV-related variables were collected to further describe the sample. Univariate and bivariate analyses assessed participant characteristics across types of violence. High prevalence of past violence experiences across all types (ACES: 100%, IPV: 88.7%, NPV: 97.5%, lifetime hate crimes 93.2%). People assigned male at birth who identified as men experienced more violence than women, with exception of non-partner forced sex. Participants identifying as gay men were more likely to have experienced violence. Among our sample of PLWH at the epicenter of the United States HIV epidemic, histories of interpersonal and community violence are common. Findings emphasize need for RWCs, ASOs, and hospital systems to be universally trained in trauma-informed approaches and have integrated onsite mental health and social support services.

1578. Evaluation of comparative HIV care continuum outcomes following three years of program implementation of the PositiveLinks smartphone intervention among people with HIV with and without substance use

Abstract Background People with HIV (PWH) and substance use (PWSU) have demonstrated inferior HIV care continuum outcomes, including lower retention in care (RIC), poorer ART adherence, and lower rates of viral suppression (VS) relative to peers without substance use within the literature. We compared 3-year outcomes among people with and without substance use who are enrolled in a smartphone intervention, PositiveLinks (PL), to determine the relative impact of PL for this subgroup of PWH. Methods We performed retrospective chart review of clinical encounter and laboratory data and ICD-diagnoses for 600 PWH enrolled in PL from 2017-2020. Substance use was categorized by diagnoses of illicit substance use and/or substance use-related visits conducted at the UVA Ryan White Clinic. Patients with no documented substance use, or documented tobacco or reported alcohol use with no criteria for a substance use disorder were considered non-substance using. We analyzed HIV clinical outcomes (VS, RIC by HRSA-1 measure) for PL members in each group at baseline (April 2017) and three years later (April 2020, t-test). Results Chart review for the 3-year period of interest for 600 PWH enrolled in PL revealed 117 PWH meeting criteria for substance use and 483 not meeting criteria. A mean of 13 Ryan White Clinic visits were conducted per person among 117 PWSU, compared to 8 visits each among 483 PWH without documented substance use (p< .01) over 3 years. Among PWSU, RIC increased from 56% to 79% (p< .01) while among PWH without substance use, RIC increased from 47% to 69% (p< .01). VS increased significantly among PWSU from 71% to 90% (p< .01), while among PWH without documented substance use, VS increased from 70% to 87%, (p< .01). Differences between groups for RIC and VS were not statistically significant at either time point. Conclusion A sample of 600 PWH using PL demonstrated comparable HIV clinical outcomes across 3 years regardless of substance use status. This sample selects for PWSU who stayed enrolled in PL at 3 years, and may not reflect outcomes expected for a broader population of variably engaged PWSU offered non-tailored mobile health interventions for HIV care. Further analysis is planned to determine whether covariates including demographic characteristics and PL usage patterns influence outcomes observed. Disclosures Sylvia Caldwell, MPH, DHSc, Warm Health Technology: Advisor/Consultant Ben Elliott, MSW, Warm Health Technology: Advisor/Consultant Ava Lena Waldman, M.H.S., CHES, CCRP, Warm Health Technology: Advisor/Consultant Rebecca Dillingham, MD MPH, Warm Health Technology: Advisor/Consultant

Acceptability, Feasibility, and Appropriateness of Implementation of Long-acting Injectable Antiretrovirals: A National Survey of Ryan White Clinics in the United States.

The approval of long-acting injectable cabotegravir/rilpivirine (LAI CAB/RPV) heightened the urgency of ensuring effective implementation. Our study assesses readiness and barriers to implement LAI CAB/RPV across Ryan White-funded clinics in the United States. We conducted a cross-sectional survey between December 2020 and January 2021 using validated 4-item measures: acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM). Associations between measures and clinic characteristics were evaluated via Spearman rank correlations. A 5-point Likert scale ranked potential barriers of implementation responses. Open-ended questions were analyzed through a thematic approach. Of 270 clinics, 44 (16%) completed the survey: 38% federally qualified health centers, 36% academic, 20% community-based organizations, 14% hospital outpatient, and 9% nonprofit. Means (SD; range) were as follows: AIM, 17.6 (2.4; 12-20); IAM, 17.6 (2.4; 13-20); and FIM, 16.8 (2.9; 7-20). Twenty percent were not at all ready to implement LAI CAB/RPV, and 52% were slightly or somewhat ready. There was a significant association between AIM and the proportion of Medicaid patients (AIM, rho = 0.312, P = .050). Community-based organizations scored the highest readiness measures (mean [SD]: AIM, 19.50 [1.41]; IAM, 19.25 [1.49]; FIM, 19.13 [1.36]) as compared with other clinics. Implementation barriers were cost and patients' nonadherence to visits. There is variability of readiness yet high levels of perceived acceptability and appropriateness of implementing LAI CAB/RPV among Ryan White clinics, necessitating tailored interventions for successful implementation. A special focus on addressing the barriers of adherence and the cost of implementation is needed.

Development and feasibility testing of an integrated PTSD and adherence intervention cognitive processing therapy-life steps (CPT-L) to improve HIV outcomes: Trial protocol

Despite high rates of Post-Traumatic Stress Disorder (PTSD) in persons living with HIV (PLWH) and poor HIV-related health outcomes associated with PTSD, an effective evidence-based treatment for PTSD symptoms in PLWH does not exist. Negative reinforcement conceptual models posit that avoidant behavior (hallmark symptom of PTSD) demonstrated by PLWH with co-occurring PTSD can contribute to poor antiretroviral therapy (ART) adherence. However, research evaluating the impact of evidence-based treatment for PTSD among HIV infected populations on HIV outcomes is scarce. The Cognitive Processing Therapy (CPT) protocol is an evidence-based PTSD treatment that may address internalized stigma with targeted modifications and improve ART adherence and subsequent viral suppression through reduction of avoidant coping. This study will be the first pilot open-label randomized control trial (RCT) to test feasibility of an integrated evidence-based PTSD treatment (CPT) with an adherence intervention (Lifesteps) delivered in a Ryan White clinic to improve PTSD symptoms, adherence to ART, and retention in HIV care. Primary aims are to (1) conduct theater testing of the CPT and Lifesteps research protocol and evaluate acceptability (n = 12) and (2) deliver a modified CPT protocol (CPT-Lifesteps, or CPT-L) in 60 PLWH/PTSD exploring impact of CPT-L on PTSD symptoms and HIV outcomes compared to a Lifesteps + Standard of Care condition. This innovative research extends PTSD treatment approaches as a paradigm to reduce barriers to ART adherence. Findings of this innovative study are significant because they support the Undetectable = Untransmittable (UU) campaign and can help prevent the transmission of HIV infection through increased viral suppression.

Evaluation of treatment simplification strategies in patients living with HIV with multi-drug resistance.

Patients living with HIV (PLWH) with multi-drug resistance (MDR) and prior episodes of virologic failure have few therapeutic options remaining. These patients are often prescribed 'salvage' antiretroviral therapy (ART) regimens with high pill burdens, leading to potential decreased medication adherence and increased side effects and drug-drug interactions. In this retrospective, observational cohort study, we included adult patients with a diagnosis of HIV-1 who received care at our institution's Ryan White Clinic and who received 'salvage' ART, defined as three of more antiretroviral agents from at least three different HIV drug classes. Patients were grouped into two cohorts, simplified ART cohort and non-simplified ART cohort, based on whether their ART regimen was reduced by at least one tablet daily. The primary outcome was the percentage of patients who had their viral load suppressed (HIV-1 RNA <50 copies/ml) at their most recent clinic visit. Secondary outcomes were virologic failure (HIV-1 RNA ⩾200 copies/ml), percentage of time patients were virologically suppressed over the past 2 years, and the emergence of new treatment-resistant mutations. There were 50 patients included in the final analysis, 28 in the simplified ART cohort and 22 in the non-simplified ART cohort. The percentage of patients who had their HIV-1 viral load suppressed at their most recent clinic visit was n = 24 (86%) in the simplified ART cohort and n = 16 (73%) in the non-simplified ART cohort (p = 0.302). There were no statistically significant differences between the two cohorts in terms of the secondary outcomes. Our study found that simplification of ART regimens based on HIV genotype in PLWH with a history of MDR and prior virologic failures, regardless of the presence of HIV-1 viremia at the time of simplification, resulted in similar rates of virologic suppression and virologic failure as non-simplified ART regimens.

Support for Trauma-informed Care Implementation Among Ryan White HIV Clinics in the Southeastern United States.

Trauma histories are common among people with HIV and associated with poor HIV outcomes, underscoring the importance of integrating trauma-informed care (TIC) into HIV services. As part of the quantitative phase of an explanatory sequential mixed-methods study, we assessed individual and clinic-wide support (using the Attitudes Related to Trauma-informed Care-45 (ARTIC-45)) and factors influencing TIC support through surveys with 152 administrators, providers, and staff from 38 Ryan White Clinics (RWCs) in the Southeastern US. Mean responses to the ARTIC-45 Personal and System Support Subscales were 5.18 (SE = 0.09; range 1-7) and 4.45 (SE = 0.16; range 1-7), respectively. In bivariate analysis, higher personal and system support were associated with strong clinic leadership culture (personal support: β = 0.08, t-value = 2.66, p = 0.009; system support: β = 0.16, t-value = 4.71, p < 0.001) and lower staff burnout (personal support: β=-0.05, t-value=-3.10, p = 0.002; system support: β=-0.07, t-value=-3.63, p < 0.001). System support was also associated with rural clinic setting (β = 0.61, t-value = 2.34, p = 0.021), strong staff culture (β = 0.14, t-value = 4.70, p = < 0.001), and resource availability (β = 0.16, t-value = 5.76, p < 0.001), and negatively associated with academic clinic setting (β=-0.52, t-value=-2.25, p = 0.026). Thus, while there is encouraging individual support for TIC, RWCs need tools (training and/or resources) to foster leadership and staff culture and trauma support to enable their transition to trauma-informed HIV care.

Impact of a Ryan White Clinic on Statewide New HIV Infections

Introduction The Ryan White (RW) program is a cohort of services for underinsured, uninsured, and low-income patients with human immunodeficiency virus (HIV) infection. Although the RW program is known to enhance patient engagement and continuity of care, there are no studies that have investigated the direct impact of a RW clinic on statewide HIV transmission. Methods A retrospective review of 372 patients was undertaken at an HIV clinical site receiving RW funds in West Virginia (WV) in 2009-2019. Demographics, comorbid conditions, and details regarding disease acquisition were noted. In-state transmission was measured as the proportion of patients with newly diagnosed HIV who self-reported HIV acquisition within WV. With high rates of viral suppression and patient retention in our clinic, our hypothesis was that this proportion should decrease over time. Results Despite maintaining a greater than 90% retention of care and viral suppression rate over the study period, our data did not show a significant decline in the ratio of patients newly infected with HIV within WV over time (54.2% at the beginning of the study period vs 58.6% at the end, p-value 0.199). Conclusion Our results show that maintenance of high retention of care and viral suppression rates in one RW clinical site did not significantly reduce in-state transmission of HIV. Additional studies are needed to determine if maintaining high engagement in clinical services and sustained viral suppression across all HIV providers can reduce spread of in-state HIV infection.

The seroprevalence of COVID-19 in patients living with HIV in metropolitan Detroit.

BackgroundCOVID-19, a novel respiratory illness caused by SARS-CoV-2, has become a global pandemic. As of December 2020, 4.8% of the 941 people living with HIV in our Ryan White clinic have tested polymerase chain reaction positive for SARS-CoV-2. The aim of our study was to estimate the seroprevalence of COVID-19 in our Ryan White people living with HIV, irrespective of known past infection.MethodsWe conducted a cross-sectional study that recruited people living with HIV in the Ryan White program at Henry Ford Hospital in Detroit, Michigan, from September 2020 through May 2021. All Ryan White patients were offered participation during clinic visits. After informed consent, patients completed a survey, and had blood sampled for SARS-CoV-2 antibody testing.ResultsOf the 529 individuals who completed the written survey, 504 participants were tested for SARS-CoV-2 antibody and 52 people living with HIV were COVID-19 immunoglobulin (Ig) G positive resulting in a seroprevalence of 10.3%. Among 36 persons with PCR-confirmed COVID-19, 52.8% were IgG negative. Inclusion of PCR positive but IgG-negative people living with HIV yields a COVID-19 infection prevalence of 14.1%.ConclusionsThese findings suggest that passive public health-based antibody surveillance in people living with HIV significantly underestimates past infection.

894. Trend of Transmitted Resistance Associated Mutations in People Living with HIV (PLWH) in a Large Southeastern U.S. Ryan White Clinic

BackgroundDepartment of Health and Human Services (DHHS) guidelines recommend integrase strand transfer inhibitors (INSTIs) as the backbone of preferred initial antiretroviral (ART) regimens (1). Baseline mutation rates for the INSTI class is 0.8% compared with an overall rate of 19% for all ART classes, based on Centers for Disease Control and Prevention (CDC) U.S. data from 2013-16 (2). First-generation INSTIs (raltegravir and elvitegravir) have a lower genetic barrier to resistance compared with newer, second generation INSTIs (bictegravir and dolutegravir) (3, 4). DHHS guidelines do not currently recommend routine HIV genotypic resistance testing to INSTIs prior to ART initiation (1). Our study seeks to determine the current prevalence of transmitted INSTI and overall resistance in a large southeastern U.S. Ryan White clinic.MethodsThis was a single-center, retrospective analysis of treatment naïve PLWH presenting for care from January 1, 2017 to December 31, 2020. Of these, 164 had a baseline genotype performed by one of two commercially available assays – Vela Genomics or ViroSeq. Subsequent interpretations were based on Stanford HIV Drug Resistance Database. Results65 patients (39.6%) had at least one transmitted resistance associated mutation (RAMs). Of these, 24 (36.9%) had an INSTI RAM. Baseline PI, NRTI, and NNRTI RAMs declined during the four-year interval (2017-2020), while the rate of INSTI RAMs increased from 11.1% to 19%; all conferred resistance to the first generation INSTIs with one also conferring resistance to second generation INSTIs.INSTI Resistance Associated Mutation Prevalence 2017-2020 Frequency of Antiretroviral Therapy Class Mutations Per Year Trend of INSTI Mutations and Resistance Associated Mutations 2017-2020 ConclusionUnlike the CDC data which showed the overall prevalence of INSTI RAM transmission rates during 2013-2016 to be 0.8%, our data suggests a higher rate of INSTI RAMs (14.6%) with overall ART RAM transmission of 39.6%. This increase in baseline resistance to the INSTI class, which occurred over time, mimics the historical development of RAMs seen in the earlier ART classes. Though suboptimal adherence in the population promotes development of RAMs, increased frequency of INSTI RAMs may be due to a lower barrier to resistance of first generation INSTIs. Should our observed trend continue, routine baseline INSTI resistance testing may need to be considered prior to ART initiation.Disclosures Cheryl Newman, MD, Gilead (Scientific Research Study Investigator)GSK/ViiV (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker’s Bureau)Janssen (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)

869. A Qualitative Review of Social Barriers Impeding Retention in HIV Care at a Ryan White Clinic

BackgroundEnding the HIV Epidemic: A Plan for America aims to decrease new HIV diagnoses 75% by 2025 and 90% by 2030. To achieve this, we identified patients unable to achieve viral suppression with social-behavioral needs deemed ‘high-hanging fruit.’ Via extensive outreach efforts and creation of shared problem solving, we pursued the goals of rapid and effective treatment leading to viral suppression and prevention of HIV transmission. We (1) exhausted all avenues of outreach to re-engage patients in HIV care and (2) identified personal or social characteristics related to difficulties in visit retention and achieving viral suppression.MethodsOf 446 Ryan White-eligible patients seen in an urban, academic medical center, 46 did not achieve and/or maintain viral suppression, and qualified for the study. We conducted a mixed methods survey comprised of both multiple choice and open-ended questions to ascertain what barriers patients face to continuous engagement in care and to achieving viral suppression. We developed a re-engagement outreach cycle which included: text messages and phone calls, electronic messages via patient portal or email, phone call to pharmacy to cross-check contact information, outreach to patients’ emergency contact, and sending a letter by mail.ResultsOf 46 participants, 32 were reached and 14 were not found. Sixteen re-engaged in care and of these, 14 completed the survey (see Figure). Those who completed the survey noted the following barriers to care: poor mental health, financial issues, problems committing to an appointment due to work/family/transportation, and COVID-19. Out of all 46 participants, the 14 who were not found had an overall a higher index of chaos. This index of chaos included, but was not limited to: homelessness, IV drug use, domestic violence, and stigma.Outreach to re-engage in HIV care A. Participants in study, B. Outreach outcomes, C. Common survey themesConclusionIntensive efforts are required to re-engage patients, counsel on adherence, and achieve viral suppression. The reasons for lack of engagement in care are real and challenging. Multiple cycles of continuous outreach serve to establish trust, address barriers, and connect to HIV care.Disclosures All Authors: No reported disclosures

896. Examining the Impact of the COVID-19 Pandemic on Delivery of HIV Care and Prevention Services Among Patients in a Ryan White Clinic

BackgroundWe sought to characterize the impact of the COVID-19 pandemic on HIV-related outcomes in a cohort of patients by examining rates of viral load (VL) suppression, retention-in-care, PrEP access, and STIs.MethodsThis was a single center, retrospective study of adults receiving HIV treatment or HIV/STI prevention services from 01/2019 - 12/2020. HIV outpatient visits were identified through HRSA’s CareWARE. Visits (in-person, telehealth) only included HIV primary care. HRSA core performance measures were utilized (Table 1). STI positivity rates and descriptive characteristics were calculated. New and refill PrEP prescriptions were tabulated. Chi-square tests compared unmatched non-parametric variables; McNemar’s test matched non-parametric variables. Multivariable logistic regression identified variables associated with retention in care and viral suppression. Results1721 patients received care; 1234 were seen in both years, 334 only in 2019, 153 only in 2020. The number of telehealth visits increased significantly: video (0% to 31%, < 0.001), phone (0% to 0.4%, p < 0.001). Though the proportion of kept appointments increased (57.2% vs 61.2%), the annual retention in care rate decreased from 74.5% to 70.9% (p = 0.002). Overall, 9.7% of patients had detectable VLs at any point. Compared to 2019, a lower proportion of patients maintained VL suppression in 2020, (91.6% vs 83.5% p = 0.075). More patients did not have a VL drawn in 2020 than in 2019 (10.3% vs 2.0 %, p < 0.001). Patients with detectable VLs in 2019 were more likely than those who were undetectable to have detectable VLs in 2020 (OR 18.2, 95% CI 9.91-33.42). Black race was associated with higher likelihood of lack of VL suppression (OR = 2.0; 95% CI 1.10-3.66). There were no significant differences between gender or age groups in rates of viral suppression, number screened for bacterial STIs or positive results. Visits for new and refill PrEP prescriptions decreased by 59% and 7%, respectively.ConclusionRates of viral load suppression and retention in care decreased in 2020 compared to 2019. The proportion of clinic visits attended increased after the integration of telemedicine in 2020. These data may be used to inform evidence-based interventions to improve the HIV continuum of care through telehealth.Disclosures Ghady Haidar, MD, Karuys (Grant/Research Support)

Time between diagnosis and achievement of virologic suppression in people living with HIV.

Data support the individual and public health advantages of shortened time intervals between HIV diagnosis, initiation of antiretroviral therapy (ART), and virologic suppression. The time from HIV diagnosis to linkage to care, initiation of ART, and virologic suppression was evaluated in newly diagnosed, ART-naive individuals after structured programmatic changes were implemented to reduce time to virologic suppression (TVS). The retrospective cohort included newly diagnosed, ART-naive adult patients receiving care in a Midwestern Ryan White Clinic. Study periods were between January 1, 2015, and December 31, 2015 (delayed treatment group) and January 1, 2017, and December 31, 2017 (rapid treatment group). Changes during the intervention time period were related to access to care and ART. The primary outcome of time from HIV diagnosis to virologic suppression was compared between the groups. Secondary outcomes included the time from diagnosis to linkage to care and the time to initiation of ART. Twenty-four and 35 individuals were included in the control and intervention groups, respectively. Median (interquartile range) time from diagnosis to viral suppression was 137 (77-318) days in the delayed treatment group vs 76.5 (51-151) days in the rapid treatment group (P = 0.021). Time from diagnosis to first clinic visit remained similar (median of 13.5 vs 15 days, P = 0.859), while time from first clinic visit to initiation of ART decreased significantly (median of 15 vs 0 days, P < 0.001). Time from first clinic visit to ART initiation was significantly shortened in this intervention and was the driving force to decreasing TVS. Additional research into barriers impacting time from diagnosis to linkage to care are needed to further shorten TVS.

An Implementation Strategy to Expand Mobile Health Use in HIV Care Settings: Rapid Evaluation Study Using the Consolidated Framework for Implementation Research.

BackgroundMobile health (mHealth) apps can provide support to people living with a chronic disease by offering resources for communication, self-management, and social support. PositiveLinks (PL) is a clinic-deployed mHealth app designed to improve the health of people with HIV. In a pilot study, PL users experienced considerable improvements in care engagement and viral load suppression. To promote its expansion to other HIV clinics, we developed an implementation strategy consisting of training resources and on-demand program support.ObjectiveThe objective of our study was to conduct an interim analysis of the barriers and facilitators to PL implementation at early adopting sites to guide optimization of our implementation strategy.MethodsSemistructured interviews with stakeholders at PL expansion sites were conducted. Analysis of interviews identified facilitators and barriers that were mapped to 22 constructs of the Consolidated Framework for Implementation Research (CFIR). The purpose of the analysis was to identify the facilitators and barriers to PL implementation in order to adapt the PL implementation strategy. Four Ryan White HIV clinics were included. Interviews were conducted with one health care provider, two clinic managers, and five individuals who coordinated site PL activities.ResultsTen common facilitators and eight common barriers were identified. Facilitators to PL implementation included PL’s fit with patient and clinic needs, PL training resources, and sites’ early engagement with their information technology personnel. Most barriers were specific to mHealth, including access to Wi-Fi networks, maintaining patient smartphone access, patient privacy concerns, and lack of clarity on how to obtain approvals for mHealth use.ConclusionsThe CFIR is a useful framework for evaluating mHealth interventions. Although PL training resources were viewed favorably, we identified important barriers to PL implementation in a sample of Ryan White clinics. This enabled our team to expand guidance on identifying information technology stakeholders and procuring and managing mobile resources. Ongoing evaluation results continue to inform improvements to the PL implementation strategy, facilitating PL access for future expansion sites.