Retrospective Review of Virologic and Immunologic Response in Treatment-Experienced Patients on Third-Line HIV Therapy in Lusaka, Zambia

Established antiretroviral therapy (ART) programs in sub-Saharan Africa have well-defined first-and second-line therapies but no standard third-line ART regimen. The impact of third-line ART on patients with multiclass-resistant HIV in resource-limited settings has not been well characterized. We conducted a retrospective review of patients on third-line ART at the University Teaching Hospital in Lusaka, Zambia. We assessed virologic and immunologic outcomes following 6 months of third-line therapy and found among those with a documented viral load, viral suppression (≤1000 copies/ml) at 24 weeks was 95% (63/66) with a mean increase in CD4 count of 116 cells/mm³ and viral suppression of 63% (63/100) by imputation of missing data. This study suggests that third-line therapy is clinically and virologically effective among patients with multiclass-resistance in a resource-limited setting in sub-Saharan Africa.

Index and targeted community-based testing to optimize HIV case finding and ART linkage among men in Zambia

INTRODUCTION

Current healthcare systems fail to provide adequate HIV services to men. In Zambia, 25% of adult men living with HIV were unaware of their HIV status in 2018, and 12% of those who were unaware of their HIV statu were not receiving antiretroviral therapy (ART) due to pervasive barriers to HIV testing services (HTS) and linkage to ART. To identify men and key and priority populations living with HIV in Zambia, and link them to care and treatment, we implemented the Community Impact to Reach Key and Underserved Individuals for Treatment and Support (CIRKUITS) project. We present HTS and ART linkage results from the first year of CIRKUITS.

METHODS

CIRKUITS aimed to reach beneficiaries by training, mentoring, and deploying community health workers to provide index testing services and targeted community HTS. Community leaders and workplace supervisors were engaged to enable workplace HTS for men. To evaluate the effects of these interventions, we collected age- and sex-disaggregated routinely collected programme data for the first 12 months of the project (October 2018 to September 2019) across 37 CIRKUITS-supported facilities in three provinces. We performed descriptive statistics and estimated index cascades for indicators of interest, and used Chi square tests to compare indicators by age, sex, and district strata.

RESULTS

Over 12 months, CIRKUITS tested 38,255 persons for HIV, identifying 10,974 (29%) new people living with HIV, of whom 10,239 (93%) were linked to ART. Among men, CIRKUITS tested 18,336 clients and identified 4458 (24%) as HIV positive, linked 4132 (93%) to ART. Men who tested HIV negative were referred to preventative services. Of the men found HIV positive, and 13.0% were aged 15 to 24 years, 60.3% were aged 25 to 39, 20.9% were aged 40 to 49 and 5.8% were ≥50 years old. Index testing services identified 2186 (49%) of HIV-positive men, with a positivity yield of 40% and linkage of 88%. Targeted community testing modalities accounted for 2272 (51%) of HIV-positive men identified, with positivity yield of 17% and linkage of 97%.

CONCLUSIONS

Index testing and targeted community-based HTS are effective strategies to identify men living with HIV in Zambia. Index testing results in higher yield, but lower linkage and fewer absolute men identified compared to targeted community-based HTS.

Key Population Hotspots in Nigeria for Targeted HIV Program Planning: Mapping, Validation, and Reconciliation

Background

With the fourth highest HIV burden globally, Nigeria is characterized as having a mixed HIV epidemic with high HIV prevalence among key populations, including female sex workers, men who have sex with men, and people who inject drugs. Reliable and accurate mapping of key population hotspots is necessary for strategic placement of services and allocation of limited resources for targeted interventions.

Objective

We aimed to map and develop a profile for the hotspots of female sex workers, men who have sex with men, and people who inject drugs in 7 states of Nigeria to inform HIV prevention and service programs and in preparation for a multiple-source capture-recapture population size estimation effort.

Methods

In August 2018, 261 trained data collectors from 36 key population–led community-based organizations mapped, validated, and profiled hotspots identified during the formative assessment in 7 priority states in Nigeria designated by the United States President’s Emergency Plan for AIDS Relief. Hotspots were defined as physical venues wherein key population members frequent to socialize, seek clients, or engage in key population–defining behaviors. Hotspots were visited by data collectors, and each hotspot’s name, local government area, address, type, geographic coordinates, peak times of activity, and estimated number of key population members was recorded. The number of key population hotspots per local government area was tabulated from the final list of hotspots.

Results

A total of 13,899 key population hotspots were identified and mapped in the 7 states, that is, 1297 in Akwa Ibom, 1714 in Benue, 2666 in Cross River, 2974 in Lagos, 1550 in Nasarawa, 2494 in Rivers, and 1204 in Federal Capital Territory. The most common hotspots were those frequented by female sex workers (9593/13,899, 69.0%), followed by people who inject drugs (2729/13,899, 19.6%) and men who have sex with men (1577/13,899, 11.3%). Although hotspots were identified in all local government areas visited, more hotspots were found in metropolitan local government areas and state capitals.

Conclusions

The number of key population hotspots identified in this study is more than that previously reported in similar studies in Nigeria. Close collaboration with key population–led community-based organizations facilitated identification of many new and previously undocumented key population hotspots in the 7 states. The smaller number of hotspots of men who have sex with men than that of female sex workers and that of people who inject drugs may reflect the social pressure and stigma faced by this population since the enforcement of the 2014 Same Sex Marriage (Prohibition) Act, which prohibits engaging in intimate same-sex relationships, organizing meetings of gays, or patronizing gay businesses.

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

Background

As 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.

Methods

Using 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.

Results

There 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

Conclusion

The 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

1060. Evaluation of ALT at Sustained Virologic Response (SVR) in Patients with Treated Hepatitis C Virus (HCV) Infection

Background

With the advent of directly acting antiviral agents, HCV cure rates exceed 90% in real world studies with an excellent safety profile, but viral load tests of cure are expensive and may limit access to treatment, especially in resource-limited settings. Elevated alanine aminotransferase (ALT) has been shown to correlate with hepatocellular damage. Few studies have evaluated the use of ALT in direct acting antiviral (DAA) treated HCV patients post-treatment as a marker of treatment success. In this large retrospective cohort study, we evaluated the ability of serum ALT level at SVR to predict treatment outcome.

Methods

We collected baseline demographics, treatment characteristics, and outcomes of DAA-treated patients treated between January 2015 through January 2019 in the VA Maryland Healthcare System as standard of care, and patients in federally qualified health centers in Washington, DC treated between May and November 2015 in the ASCEND study (NCT02339038). Using the ASCEND study as a training set and VA data as the confirmatory set, receiver operating curves (ROC) were generated to determine the predictive value of ALT at SVR for treatment outcome.

Results

In total, 1415 patients were included, with 1010 patients from the VA and 405 from the ASCEND cohort. We found 96% (n=1360) of patients achieved SVR; < 4% (n =55) relapsed. Baseline demographics are in Table 1. The ALT at SVR were 21.19 IU/L (SD 13.98) and 17.89 IU/L (SD 11.62) in the VA and ASCEND data, respectively compared to 57.84 (SD 41.06) and 42.53 (SD 19.61) who relapsed. With the VA and ASCEND data combined, the mean ALT at SVR was 20.25 (SD 13.43) in comparison to an ALT of 53.11 (SD 36.33) for those patients who relapsed. ROC analysis revealed that ALT > 22 predicted an increased risk of relapse (Figure 1).

Table 1:Characteristics of Subjects Completing Hepatitis C Treatment

Figure 1: ROC Curve

Conclusion

In this real-world cohort, we found that ALT greater than 22 at SVR corresponded with an increased risk of relapse and was independent of variables previously associated with relapse, including HIV coinfection status, sex, treatment history, and fibrosis staging. Limiting HCV viral load testing to patients with ALT > 22 at SVR may reduce the overall burden of HCV treatment costs for the majority of HCV treated patients.

Disclosures

Shyam Kottilil, MD PhD, Arbutus Pharmaceuticals (Grant/Research Support)Gilead Sciences (Grant/Research Support)Merck Inc (Grant/Research Support, Advisor or Review Panel member)

Metabolic Changes in Chronic Hepatitis C Patients Who Carry IFNL4-ΔG and Achieve Sustained Virologic Response With Direct-Acting Antiviral Therapy

BACKGROUND

Clearance of hepatitis C virus (HCV) results in rapid changes in metabolic parameters early in direct-acting antiviral (DAA) therapy. Long-term changes after sustained virologic response (SVR) remain unknown.

METHODS

We investigated longitudinal changes in metabolic and inflammatory outcomes in chronic hepatitis C (CHC) patients: low-density lipoprotein (LDL), high-density lipoprotein, triglycerides, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) using a general linear model for repeated measurements at 5 clinical time points and by human immunodeficiency virus (HIV) coinfection and IFNL4 genotype.

RESULTS

The mean LDL increased markedly during DAA therapy (pre-DAA, 86.6 to DAA, 107.4 mg/dL; P < .0001), but then it decreased to 97.7 mg/dL by post-SVR year 1 (P < .001 compared with DAA; P = .0013 compared with SVR). In patients who carry the IFNL4-ΔG allele, mean LDL increased during treatment, then decreased at post-SVR year 1; however, in patients with TT/TT, genotype did not change during and after DAA treatment. The mean ALT and AST normalized rapidly between pre-DAA and DAA, whereas only mean ALT continued to decrease until post-SVR. Metabolic and inflammatory outcomes were similar by HIV-coinfection status.

CONCLUSIONS

Changes in LDL among CHC patients who achieved SVR differed by IFNL4 genotype, which implicates the interferon-λ4 protein in metabolic changes observed in HCV-infected patients.

Intravesicular Cidofovir in the Treatment of BK Virus-Associated Hemorrhagic Cystitis Following Hematopoietic Stem Cell Transplantation

Background: BK virus hemorrhagic cystitis (BKV-HC) is a common complication following hematopoietic stem cell transplant (HSCT); optimal management remains uncertain. Supportive care (bladder irrigation and blood transfusions) and intravenous and intravesicular cidofovir have all been used with varying success. Objective: The purpose of this study was to determine the safety and effectiveness of intravesicular cidofovir for BKV-HC following HSCT. Methods: A retrospective analysis of all HSCT patients with BKV-HC prescribed intravesicular cidofovir from 2012 to 2017. Results: 33 patients were treated for BKV-HC. The median age was 50 years (range 23-73), and 18 (55%) were male. The median HC symptom severity was 2, with a median BK urine viral load pretreatment of 100,000,000 IU/mL. Patients received a median of 2 intravesicular treatments (range 1-7) at a dosage of 5 mg/kg per instillation. In all, 19 (59%) patients demonstrated complete clinical resolution of symptoms; 9 (28%) had a partial response; and 4 (13%) had no change in symptoms. Patients with a high pretreatment BK viral load (>100 million) and high HC grade (2-4) had a lower frequency of complete remission. The main side effect of intravesicular instillation was severe bladder spasms in 4 patients (12%). Conclusion and Relevance: This is the largest study of intravesicular cidofovir treatment of BKV HC reported to date; 88% of patients with BVK-HC achieved clinical improvement of symptoms with minimal side effects. Clinical trials of intravesicular cidofovir could provide further evidence for this treatment for BKV-HC.

346. Factors Associated with Hypertension in Young Adults with Perinatally-Acquired HIV Infection: a Case–Control Study

Background

The incidence of systemic hypertension (HTN) among perinatally-HIV-infected (PHIV) patients appears to increase as they enter adulthood. Among non-perinatally HIV-infected adults both traditional and HIV-associated risk factors have been found to contribute to HTN. Whether these same factors contribute to HTN in PHIV is unknown. The purpose of this study was to determine the socio-demographic, clinical, virologic, and immunologic factors associated with HTN among a cohort of PHIV adolescents and young adults, aged ≥18 years.

Methods

We conducted a case–control study among a population of 160 PHIV adults with and without HTN who were receiving care at the University of Maryland and aged 18–35 years as of December 31, 2017. Covariates assessed included traditional risk factors such as age, family history of HTN, and smoking, as well as HIV- and antiretroviral-associated covariates.

Results

We identified 49 HTN cases (30.6%) and 111 (69.4%) controls. There were no significant differences in the odds of most traditional (age, gender, race, family history of HTN, tobacco, alcohol, and/or other drug use) or HIV-associated (CD4 nadir <100 cells/mm3, individual ART exposure, ART interruption) risk factors among PHIV adults with HTN compared with those with no diagnosis of HTN. Cases had lower odds of a history of treatment with lopinavir/ritonavir (LPV/r). Cases had 3.7 (95% CI 1.11, 12.56) times the odds of a prior diagnosis of chronic kidney disease (CKD) compared with controls after controlling for CD4 nadir and ARV treatment history.

Conclusion

The results of this study suggest that most traditional and HIV-related risk factors do not appear to increase the odds of having HTN in this PHIV cohort. However, HTN among PHIV may be driven in part by CKD, and a focus on the prevention and early management of CKD in this group may be necessary to prevent the development of HTN. Additionally, there may be as yet unidentified risk factors for HTN among PHIV which require further exploration. Given the large and growing population of PHIV entering adulthood worldwide, it is imperative to explore risk factors for and effects of HTN in large, diverse PHIV populations.

Disclosures

All authors: No reported disclosures.

2838. Safety and Immunogenicity of a gp120-CD4 Chimeric Subunit Vaccine: A Phase 1a Randomized Controlled Trial

Background

A primary challenge for HIV vaccine development is to raise antiviral antibodies capable of recognizing highly variable viral antigens. The full-length single chain (FLSC) gp120-CD4 chimeric protein was designed to present a highly conserved CD4-induced HIV-1 envelope structure that evokes cross-reactive humoral responses (Figure 1). IHV01 is an FLSC subunit vaccine formulated in alum adjuvant. The safety and immunogenicity of IHV01 was evaluated in this first-in-human phase 1a trial.

Methods

This randomized, double-blind placebo-controlled study involved three dose-escalating cohorts (75 µg, 150 µg, and 300 µg doses). Eligible participants were HIV-1 uninfected healthy volunteers aged 18 to 45 years. Participants in each cohort were block randomized in groups of four in a 3:1 ratio to receive either vaccine or placebo. Intramuscular injections were given on weeks 0, 4, 8, and 24. Participants were followed for an additional 24 weeks after the last immunization. Crossreactive antibody binding titers against diverse HIV envelopes and antigens and specific CD4i epitopes on gp120 were assessed.

Results

Sixty-five volunteers were enrolled—49 vaccine and 16 placebo. Majority (81%) of vaccinations with IHV01 produced no localized or systemic reactions; no different from the control group. The overall incidence of adverse events (AEs) was not significantly different between groups. Majority (89%) of vaccine-related AEs were mild in severity. The most common vaccine-related AEs were injection site pain (31%), pruritus (10%), and headache (10%). There were no vaccine-related serious AE, discontinuation due to AE, or intercurrent HIV infection. By the final vaccination, all subjects in all cohorts had developed antibodies against IHV01; all placebo recipients were negative. The antibodies induced by IHV01 reacted with envelope antigens from diverse HIV-1 strains (Figure 2).

Conclusion

IHV01 vaccine was safe, well tolerated, and immunogenic in all doses tested. The vaccine raised broadly reactive humoral responses against multiple gp120 domains, transition state structures, and CD4i epitopes.

Disclosures

All Authors: No reported Disclosures.

Factors Associated with Outcomes of Pre-ART HIV Care

The World Health Organization recommended removing all CD4 requirements for initiation of antiretroviral therapy (ART) in resource-limited settings. We examined the pre-ART period to identify and assess factors associated with outcomes of pre-ART care. Four modes of transition out of pre-ART care were considered. Beta estimates from the competing risks Cox models were used to investigate whether the effects of covariates differed by mode of transition. Median CD4 counts at entry showed no meaningful change over time. Advanced disease progression and presence of opportunistic infections were significant predictors of pre-ART mortality. Men were more likely to die before initiating ART, transfer to another facility, or be lost to follow-up than were women. Removing CD4 thresholds is not likely to substantially reduce program mortality prior to ART initiation unless and until patients enroll earlier in disease progression. Care programs should focus on diagnosis and treatment of opportunistic infections to reduce pre-ART mortality.

Evaluation of the clinical outcomes of the Test and Treat strategy to implement Treat All in Nigeria: Results from the Nigeria Multi-Center ART Study

In December 2016, the Nigerian Federal Ministry of Health updated its HIV guidelines to a Treat All approach, expanding antiretroviral therapy (ART) eligibility to all individuals with HIV infection, regardless of CD4+ cell count, and recommending ART be initiated within two weeks of HIV diagnosis (i.e., the Test and Treat strategy). The Test and Treat policy was first piloted in 32 local government areas (LGAs). The primary objective of this study was to evaluate the clinical outcomes of adult patients initiated on ART within two weeks of HIV diagnosis during this pilot. We conducted a retrospective cohort analysis of patients who initiated ART within two weeks of new HIV diagnosis between October 2015 and September 2016 in eight randomly selected LGAs participating in the Test and Treat pilot study. 2,652 adults were newly diagnosed and initiated on ART within two weeks of HIV diagnosis. Of these patients, 8% had documentation of a 12-month viral load measurement, and 13% had documentation of a six-month viral load measurement. Among Test and Treat patients with a documented viral load, 79% were suppressed (≤400 copies/ml) at six months and 78% were suppressed at 12 months. By 12 months post-ART initiation, 34% of the patients who initiated ART under the Test and Treat strategy were lost to follow-up. The median CD4 cell count among patients initiating ART within two weeks of HIV diagnosis was 323 cells/mm³ (interquartile range, 161–518). While randomized controlled trials have demonstrated that Test and Treat strategies can improve patient retention and increase viral suppression compared to standard of care, these findings indicate that the effectiveness of Test and Treat in some settings may be far lower than the efficacy demonstrated in randomized controlled trials. Significant attention to the way Test and Treat strategies are implemented, monitored, and improved particularly related to early retention, can help expand access to ART for all patients.

Immunological recovery in T-cell activation after sustained virologic response among HIV positive and HIV negative chronic Hepatitis C patients

BACKGROUND

Rapid decreases in activated CD4+ and CD8+ (HLA-DR + and CD38+ co-expressed) T-lymphocytes have been described within 1-2 weeks of initiating direct-acting antiviral (DAA) therapy among chronic Hepatitis C (CHC) patients. However, it is not known whether these changes are maintained past sustained virologic response (SVR), particularly in those who are HIV/HCV-coinfected.

METHODS

We investigated the changes in immune parameters of T-lymphocytes from pre-DAA therapy to post-SVR among HIV negative and HIV positive patients with CHC. Repeated measurements of activated CD4+ and CD8+ T cells were analyzed by flow cytometry at pre-DAA therapy, DAA therapy, end of treatment, SVR, and post-SVR. A general linear model for repeated measurements was used to estimate the mean outcome at each timepoint and change between timepoints.

RESULTS

HCV-monoinfected (n = 161) and HIV/HCV-coinfected (n = 59) patients who achieved SVR with DAA therapy were predominately middle aged, male, black, and non-cirrhotic. At pre-DAA therapy, HCV-monoinfected patients had significantly higher CD4+ T cells and CD4+:CD8+ T-cell ratio, while significantly lower CD8+ and activated CD4+ and CD8+ T cells compared to HIV/HCV-coinfected patients (p < 0.0001). HCV-monoinfected and HIV/HCV-coinfected patients had a significant mean decrease from pre-DAA therapy to post-SVR year 1 for activated CD4+ (HCV-monoinfected: 4.8-3.9%, p < 0.0001; HIV/HCV-coinfected: 6.6-4.5%, p < 0.0001) and activated CD8+ T cells (HCV-monoinfected V: 13.8-11.8%, p = 0.0002; HIV/HCV-coinfected: 18.0-12.4%, p < 0.0001).

CONCLUSION

This longitudinal study showed CHC patients treated with DAA therapy had continued decrease of T-lymphocytes from start of DAA therapy to after achievement of SVR suggesting improvement as HCV clearance normalizes activated T-cell phenotype.

The association between gender and HIV viral suppression on third-line therapy in Zambia: a retrospective cohort study

Patient's gender may impact pharmacokinetics and play a role in viral suppression. Existing literature has focused on treatment-naïve patients and produced inconclusive results, often implicating differences in adherence as the driver of gender-based outcome differences. The present analysis assessed whether viral suppression on third-line HIV treatment among a closely followed population differs by gender. A retrospective cohort study of patients on third-line HIV treatment was initiated at the HIV Advanced Treatment Centre in Lusaka, Zambia between January 2012 and December 2015. The association between gender and viral suppression was assessed using log binomial regression adjusted for core drug, number of drug mutations, and baseline viral load. Of the 80 included patients (56% female; median age: 40 years), 50 (62%) were virally suppressed at six months. After adjustment, females were less likely to be virologically suppressed at six months on third-line treatment compared to male HIV patients (relative risk 0.82, 95% confidence interval: 0.56, 1.20). Our data suggest that women were less likely to be suppressed following six months of third-line therapy compared to men; however, the difference was not statistically significant. Larger studies are needed to determine whether women are at increased risk of viral failure on third-line therapy compared to men.

Bacterial burden is associated with increased transmission to health care workers from patients colonized with vancomycin-resistant Enterococcus

BACKGROUND

Health care workers (HCWs) are significant vectors for transmission of multidrug-resistant organisms among patients in intensive care units (ICUs). We studied ICU patients on contact precautions, colonized with vancomycin-resistant Enterococcus (VRE), to assess whether bacterial burden is associated with transmission to HCWs' gloves or gowns, a surrogate outcome for transmission to subsequent patients.

METHODS

From this prospective cohort study, we analyzed 96 VRE-colonized ICU patients and 5 HCWs per patient. We obtained samples from patients' perianal area, skin, and stool to assess bacterial burden and cultured HCWs' gloves and gowns for VRE after patient care.

RESULTS

Seventy-one of 479 (15%) HCW-patient interactions led to contamination of HCWs' gloves or gowns with VRE. HCW contamination was associated with VRE burden on the perianal swab (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.19, 1.57), skin swabs (OR, 2.14; 95% CI, 1.51, 3.02), and in stool (OR, 1.95; 95% CI, 1.39, 2.72). Compared with colonization with Enterococcus faecalis, colonization with Enterococcus faecium was associated with higher bacterial burden and higher odds of transmission to HCWs.

CONCLUSIONS

We show that ICU patients with higher bacterial burden are more likely to transmit VRE to HCWs. These findings have implications for VRE decolonization and other infection control interventions.

Health Workers' Perspectives on the Outcomes, Enablers, and Barriers to the Implementation of HIV "Test and Treat" Guidelines in Abuja, Nigeria

We evaluated health workers' perspectives on the implementation of the 2016 HIV "Test and Treat" guidelines in Nigeria. Using semi-structured interviews, qualitative data was collected from twenty health workers meeting inclusion criteria in six study sites. Data exploration was conducted using thematic content analysis. Participants perceived that the "Test and Treat" guidelines improved care for PLHIV, though they also perceived possible congested clinics. Perceived key factors enabling guidelines use were perceived patient benefits, availability of policy document and trainings. Perceived key barriers to guidelines use were poverty among patients, inadequate human resources and stock-outs of HIV testing kits. Further improvements in uptake of guidelines could be achieved by effecting an efficient supply chain system for HIV testing kits, and improved guidelines distribution and capacity building prior to implementation. Additionally, implementing differentiated approaches that decongest clinics, and programs that economically empower patients, could improve guidelines use, as Nigeria scales "Test and Treat" nationwide.

2243. Improving HIV Outcomes Among HIV-Infected Patients Diagnosed with Cancer and Followed in an Integrated, Multidisciplinary, Infectious Disease/Cancer Clinic

Background

Patients dually diagnosed with HIV and cancer have poorer outcomes compared with general cancer patients. HIV management in the setting of cancer is complicated by multiple specialist involvement, drug–drug interactions, and overlapping drug toxicities. Past studies of HIV-infected patients noted improved virologic suppression, CD4 counts, and adherence with access to multidisciplinary services. A multidisciplinary clinic (HIV specialists (doctors and nurses), pharmacists, social workers, etc.) embedded in the University’s Outpatient Cancer Center starting in late 2011 sought to improve virologic suppression and care coordination for dually diagnosed patients.

Methods

HIV outcomes for patients seen in the multidisciplinary clinic (≥2 visits) from 2012 to 2016 (N = 51) were compared with a historical cohort seen from 2007 to 2011 (N = 565).

Results

In the pre- vs. post-integration cohorts, the median age at cancer diagnosis was 51 vs. 46 years (range 24–76, P = 0.01), 78% vs. 72% were male (P = 0.37), and 86% vs. 73% were African American (P = 0.04). 53% in the post- cohort had stage IV disease vs. 32% in the pre- cohort. In both cohorts, less than half were on HIV therapy at the time of cancer diagnosis (42% pre- and 43% post-, P = 0.91). Baseline median CD4 count at cancer diagnosis in the post-cohort was lower (171, IQR 70–310) than the pre- cohort (274, IQR 120–462; P = 0.20), and baseline median HIV viral load was higher (post-16,802 vs. pre-1,985). Viral suppression at cancer diagnosis was similar (42% pre- vs. 40% post-), but at study end, 75% of patients in the post-cohort had viral suppression vs. 63% in the pre-cohort (P = 0.09). Patients followed in the integrated clinic were 1.41 (95% CI, 0.91, 3.53) times more likely to be virally suppressed at end of follow-up compared with patients from the pre-integration cohort.

Conclusion

HIV-infected patients who received care at the multidisciplinary, integrated HIV clinic were more likely to be virally suppressed at the end of study follow-up compared with patients who received HIV care at the medical center prior to HIV clinic incorporation. Integrating HIV care into Cancer Centers may improve HIV treatment outcomes for these dually diagnosed, medically fragile, and complicated patients.

Disclosures

All authors: No reported disclosures.

The new 2017 ACC/AHA guideline for classification of hypertension: changes in prevalence of hypertension among adults in Bangladesh

We analyzed the Bangladesh Demographic and Health Survey 2011 data to examine absolute differences in hypertension prevalence according to the hypertension definition of the "2017 American College of Cardiology/American Heart Association (2017 ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults" and "Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7)" 2003 guidelines. Among 7839 participants ≥35 years, the JNC7 and 2017 ACC/AHA classified 25.7% (95% confidence interval (CI): 24.5-27.0%) and 48.0% (95% CI: 46.4-49.7%) people hypertensive, respectively. The JNC7 prevalence was 19.4% (95% CI: 18.0-21.0%) among males and 31.9% (95% CI: 30.1-33.6%) among females. The prevalence was 41.4% (95% CI: 39.4-43.5%) among males and 54.5% (95% CI: 52.4-56.4%) among females as per the 2017 ACC/AHA guideline. From JNC7 to 2017 ACC/AHA, the overall difference in prevalence was 22.3% (95% CI: 19.8-24.8%). Males and females had similar differences, 22.0% (95% CI: 18.3-25.7%) and 22.6% (95% CI: 19.4-26.0%), respectively. As per the 2017 ACC/AHA guideline, >50% prevalence was observed among people with body mass index ≥25 kg/m2, college-level education, co-morbid diabetes, richest wealth quintile, females, age ≥55 years, urban residence, or living in Khulna, Rangpur or Dhaka divisions; the absolute difference was >20% in most categories. We found a substantial increase in the prevalence of hypertension due to change in blood pressure thresholds as per the 2017 ACC/AHA guideline. We recommend conducting more comprehensive population-based studies to estimate the recent burden of hypertension in Bangladesh. Future studies should estimate similar prevalence in other countries.

Estimated Change in Prevalence of Hypertension in Nepal Following Application of the 2017 ACC/AHA Guideline

Importance

The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults lowered the systolic and diastolic blood pressure thresholds for hypertension to 130 and 80 mm Hg, respectively. This represents a reduction of 10 mm Hg in both systolic and diastolic blood pressure levels used to define hypertension compared with previous guidelines, such as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7).

Objectives

To estimate the prevalence of hypertension among adults aged 18 years or older in Nepal per the 2017 ACC/AHA guideline and to determine the absolute difference in hypertension prevalence comparing the 2017 ACC/AHA and JNC 7 guidelines.

Design, Setting, and Participants

The cross-sectional analysis used data from the population-based 2016 Nepal Demographic and Health Survey. Data were collected from June 2016 to January 2017 using a multistage stratified sampling procedure that was applied in urban and rural areas, using wards as the primary sampling units. Individuals aged 15 years or older from selected households were interviewed. The survey had an overall response rate of approximately 97%.

Main Outcomes and Measures

The primary outcome was the prevalence of hypertension. Blood pressure was measured 3 times for each participant with 5-minute intervals between. Hypertension was present if blood pressure was greater than or equal to 130/80 mm Hg for the 2017 ACC/AHA guideline, and greater than or equal to 140/90 mm Hg for the JNC 7 guideline.

Results

Among 13 519 participants (median [interquartile range] age, 38 [26-53] years; 7821 [57.9%] female), 44.2% (95% CI, 43.4%-45.0%; n = 5977) had hypertension according to the 2017 ACC/AHA guideline compared with 21.2% (95% CI, 20.5%-21.9%; n = 2869) by the JNC 7 guideline. The new prevalence was associated with an absolute increase of 23.0% (95% CI, 22.3%-23.7%) from the JNC 7 guideline. When estimating the proportion of hypertension by background characteristics, the new 2017 ACC/AHA guideline definition increased the prevalence to 50% or greater for some categories, with the highest prevalence among those with a body mass index (calculated as weight in kilograms divided by height in meters squared) greater than or equal to 30 (71.6%; 95% CI, 67.7%-75.3%) and between 25 and 29.9 (62.1%; 95% CI, 60.1%-64.1%).

Conclusions and Relevance

For adults in Nepal, the new 2017 ACC/AHA guideline reveals a greater estimated prevalence of hypertension compared with the JNC 7 guideline. Because of the public health significance of hypertension, higher prevalence rates confirm the importance of developing effective prevention and control methods in this country.

Patient-level outcomes and virologic suppression rates in HIV-infected patients receiving antiretroviral therapy in Rwanda

The Rwanda national HIV program has been successful at scaling up antiretroviral therapy (ART) to achieve universal access. The AIDSRelief Model of Care focuses on four key principles: (1) earlier initiation of ART; (2) use of durable, highly-potent, and sequence-friendly first-line ART regimens; (3) early detection of treatment failure; and (4) provision of community-based care and support to ensure optimal adherence and follow up/engagement in care. We conducted a retrospective cohort study of randomly-selected HIV-infected patients at AIDSRelief-supported sites using a stratified, random sample of 583 adults (>15 years) who initiated ART from 30 June 2008 to 1 February 2010. At ART initiation, the median patient age was 38 years, and 67% were female. The baseline median CD4+ cell count was 309 cells/mm³. Overall virologic suppression was 91%. Married/ever married status (adjusted prevalence odds ratio [aPOR] 3.75, 95% confidence interval [CI] 1.30-10.78) and self-reported adherence ≥95% in the past month (aPOR 2.76, 95% CI 1.00-7.62) were significantly associated with viral suppression in the multivariable model. Excellent virologic outcomes were achieved in Rwandan AIDSRelief sites utilizing the AIDSRelief Model of Care during the scale-up of ART in the country.

Immunologic response to antiretroviral therapy by age among treatment-naive patients in Sub-Saharan Africa

OBJECTIVE

To estimate the association between age at antiretroviral therapy (ART) initiation and immunologic response over time by stratum of baseline CD4 cell counts.

DESIGN

Retrospective cohort analysis of data pooled from four President's Emergency Plan for AIDS Relief funded countries in Sub-Saharan Africa.

METHODS

General linear models were used to estimate the mean CD4 cell count by age group within groups defined by baseline CD4 cell count. Kaplan-Meier methods were used to estimate time to achieving a CD4 cell count of at least 500 cells/μl by age group and stratified by baseline CD4 cell count.

RESULTS

A total of 126 672 previously treatment-naive patients provided 466 482 repeated CD4 cell count measurements over 4 years of ART. The median baseline CD4 cell count for all age groups was less than 200 cells/μl. Patients aged 30-39, 40-49, 50-59, and 60 and older at ART initiation had significantly lower mean CD4 cell counts in most strata and at most time points than those 20-29 years old. Compared with those 20-29, all older age groups had a significantly longer time to, and lower rate of, achieving a CD4 cell count of 500 cells.

CONCLUSION

Age is associated with the magnitude of CD4 cell gain and the amount of time it takes to gain cells at different levels of baseline CD4 cell count. The delay in achieving a robust immune response could have significant implications for the risk of tuberculosis reactivation as well as comorbidities associated with age in the management of older HIV-infected patients.

Long-term follow-up of elite controllers: Higher risk of complications with HCV coinfection, no association with HIV disease progression

To estimate the effect of hepatitis C virus (HCV) coinfection on the development of complications and progression of human immunodeficiency virus (HIV) disease among HIV-infected elite controllers.Single-center retrospective cohort. Kaplan-Meier methods, prevalence ratios, and Cox proportional-hazards models were used.In all, 55 HIV-infected elite controllers were included in this study. Among them, 45% were HIV/HCV coinfected and 55% were HIV mono-infected. Median follow-up time for the cohort was 11 years. Twenty-five patients experienced a complication and 16 lost elite controller status during the study period. HCV coinfected patients were 4.78 times (95% confidence interval 1.50-15.28) more likely to develop complications compared with HIV mono-infected patients. There was no association between HCV coinfection status and loss of elite control (hazard ratio 0.75, 95% confidence interval 0.27-2.06).Hepatitis C virus coinfection was significantly associated with the risk of complications even after controlling for sex, injecting drug use, and older age. HCV coinfected patients had higher levels of cellular activation while also having similar levels of lipopolysaccharide and soluble CD14. HCV coinfection was not associated with loss of elite controller status. Taken together, this suggests that HCV coinfection does not directly affect HIV replication dynamics or natural history, but that it may act synergistically with HIV to produce a greater number of associated complications. Continued follow-up will be needed to determine whether HCV cure through the use of direct-acting antivirals among HIV/HCV coinfected elite controllers will make the risk for complications among these patients similar to their HIV mono-infected counterparts.

Virologic and Immunologic Outcomes in HIV-Infected Patients with Cancer

Achievement and maintenance of virologic suppression after cancer diagnosis have been associated with improved outcomes in HIV-infected patients, but few studies have analyzed the virologic and immunologic outcomes after a cancer diagnosis. All HIV-infected patients with a diagnosis of cancer between 2000 and 2011 in an urban clinic population in Baltimore, MD, were included for review. HIV-related outcomes (HIV-1 RNA viral load and CD4 cell count) were abstracted and compared for patients with non-AIDS-defining cancers (NADCs) and AIDS-defining cancers (ADCs). Four hundred twelve patients with baseline CD4 or HIV-1 RNA viral load data were analyzed. There were 122 (30%) diagnoses of ADCs and 290 (70%) NADCs. Patients with NADCs had a higher median age (54 years vs. 43 years, p < .0001) and a higher frequency of hepatitis C coinfection (52% vs. 36%, p = .002). The median baseline CD4 was lower for patients with ADCs (137 cells/mm³ vs. 314 cells/mm³) and patients with NADCs were more likely to be suppressed at cancer diagnosis (59% vs. 25%) (both p < .0001). The median CD4 for patients with NADCs was significantly higher than patients with ADCs at 6 and 12 months after diagnosis and higher at 18 and 24 months, but not significantly. Patients with an NADC had 2.19 times (95% CI 1.04-4.62) the adjusted odds of being suppressed at 12 months and 2.17 times the odds (95% CI 0.92-5.16) at 24 months compared to patients with an ADC diagnosis. For patients diagnosed with ADCs and NADCs in this urban clinic setting, both virologic suppression and immunologic recovery improved over time. Patients with NADCs had the highest odds of virologic suppression in the 2 years following cancer diagnosis.

One amino acid in mouse activated factor VII defines its endothelial protein C receptor (EPCR) binding and modulates its EPCR-dependent hemostatic activity in vivo

Essentials The lack of factor (F) VIIa-endothelial protein C receptor (EPCR) binding in mice is unresolved. A single substitution of Leu4 to Phe in mouse FVIIa (mFVIIa) enables its interaction with EPCR. mFVIIa with a Phe4 shows EPCR binding-dependent enhanced hemostatic function in vivo vs. mFVIIa. Defining the FVIIa-EPCR interaction in mice allows for further investigating its biology in vivo.

SUMMARY

Background Human activated factor VII (hFVIIa), which is used in hemophilia treatment, binds to the endothelial protein C (PC) receptor (EPCR) with unclear hemostatic consequences. Interestingly, mice lack the activated FVII (FVIIa)-EPCR interaction. Therefore, to investigate the hemostatic consequences of this interaction in hemophilia, we previously engineered a mouse FVIIa (mFVIIa) molecule that bound mouse EPCR (mEPCR) by using three substitutions from mouse PC (mPC), i.e. Leu4→Phe, Leu8→Met, and Trp9→Arg. The resulting molecule, mFVIIa-FMR, modeled the EPCR-binding properties of hFVIIa and showed enhanced hemostatic capacity in hemophilic mice versus mFVIIa. These data implied a role of EPCR in the action of hFVIIa in hemophilia treatment. However, the substitutions in mFVIIa-FMR only broadly defined the sequence determinants for its mEPCR interaction and enhanced function in vivo. Objectives To determine the individual contributions of mPC Phe4, Met8 and Arg9 to the in vitro/in vivo properties of mFVIIa-FMR. Methods The mEPCR-binding properties of single amino acid variants of mFVIIa or mPC at position 4, 8 or 9 were investigated. Results and conclusions Phe4 in mFVIIa or mPC was solely critical for interaction with mEPCR. In hemophilic mice, administration of mFVIIa harboring a Phe4 resulted in a 1.9-2.5-fold increased hemostatic capacity versus mFVIIa that was EPCR binding-dependent. This recapitulated previous observations made with triple-mutant mFVIIa-FMR. As Leu8 is crucial for hFVIIa-EPCR binding, we describe the sequence divergence of this interaction in mice, now allowing its further characterization in vivo. We also illustrate that modulation of the EPCR-FVIIa interaction may lead to improved FVIIa therapeutics.

Colonoscopy Findings in HIV-Infected Men and Women from an Urban U.S. Cohort Compared with Non-HIV-Infected Men and Women

INTRODUCTION

As HIV-infected patients live longer, non-AIDS-defining cancers are now a major cause of morbidity and mortality. The purpose of this study was to compare the prevalence, type, and location of colorectal neoplastic lesions found on colonoscopy in HIV-infected patients from an urban U.S. cohort with non-HIV-infected patients.

METHODS

We collected clinical data and colonoscopy findings on 263 HIV-infected patients matched with 657 non-HIV-infected patients on age, race, and sex. Frequency distributions and descriptive statistics were used to characterize the study population. The primary exposure was HIV infection, and the primary outcome was any adenoma or adenocarcinoma. Logistic regression models were used to estimate odds ratios with 95% confidence intervals (CIs).

RESULTS

Participants were primarily African American and 40% were women. HIV-infected patients were less likely to have any neoplastic lesions (21.3% vs. 27.7%, p < .05), adenoma (20.5% vs. 27.1%, p = .04), tubular adenomas >10 mm (0.4% vs. 2.9%, p = .02), and serrated adenomas (0.0% vs.2.6%, p = <.01). There was a nonsignificant increased prevalence of adenocarcinoma in HIV-infected individuals compared with non-HIV-infected individuals (1.5% vs. 0.8%, p = .29). The lower prevalence of any adenoma remained after controlling for age, sex, smoking status, body-mass index, and diabetes mellitus [adjusted odds ratio (aOR), 0.61; 95% CI, 0.43-0.88]. HIV-infected patients had a lower prevalence of colorectal neoplastic lesions, including high-risk adenomas, than non-HIV-infected patients.

CONCLUSIONS

Our findings suggest that HIV infection in a primarily African American population is associated with a lower prevalence of colorectal adenomas, but not adenocarcinoma, found by colonoscopy.