B - 85 Medication Adherence in People Living with HIV: Analyzing Performance-Based Medication Management in Relation to Cognition and Real-World Adherence

OBJECTIVE

This study investigates relationships among neuropsychological functioning, medication management performance, and viral load in people living with HIV. We hypothesize that cognitive impairment, particularly in attention/working memory, executive function, and episodic memory, will negatively influence medication management and virologic control.

METHODS

Participants in this cross-sectional study were 29 HIV+ adults (ages 44-71, 90% Black) receiving cART and enrolled in the Temple/Drexel Comprehensive NeuroHIV Center (CNHC) cohort. Participants completed neuropsychological assessments, Medication Management Test-Revised (MMT-R), and blood sample collection. Linear regression examined cognitive domains as predictors of MMT-R performance. Logistic and linear regression examined cognition and MMT-R as predictors of viral load.

RESULTS

64% of participants had undetectable HIV RNA. The remainder had low-level viral replication. 89% were prescribed one-pill-a-day regimens. Verbal memory was positively associated with MMT-R (b = 0.60, p = 0.023). Neither cognition nor MMT-R were significant predictors of detectable vs. undetectable RNA. Among participants with detectable viral load, higher RNA was associated significantly with poorer visuospatial memory (b = 0.69, p = 0.028) and marginally with poorer performance on the MMT-R daily regimen subscale (b = 0.56, p = 0.094).

CONCLUSION

Verbal memory was related to better MMT-R performance, but neither cognition nor MMT-R were good predictors of detectable vs. undetectable viral load. However, among those with low-level viral replication, poorer visuospatial memory and difficulty with simple MMT-R items were preliminarily related to higher viral load. Given the small sample, results are limited by low statistical power. Future research will further explore relationships among cognition, MMT-R, RNA, and regimen complexity in larger samples to inform development of tools to monitor adherence difficulties.

Frailty impairs the endothelial function of elderly with chronic heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Frailty has a high prevalence of heart failure (HF). It is believed that existing circulatory disturbance increase oxidative stress and chronic inflammation, predisposing to anabolic-catabolic imbalance. Thus, there is impairment of the efficient use of oxygen by skeletal muscles, limiting the physical-functional performance in these individuals. However, little is known about the influence of frailty on endothelial function in the elderly.

Purpose

To analyze the influence of frailty on endothelial function in the elderly with and without HF.

Methods

This was a descriptive cross-sectional study, which included individuals aged ≥60 years, with or without HF, who did not have diabetes, anemia, peripheral obstructive arterial disease and/or congenital heart disease. The Cardiovascular Health Study (CHS) frailty scale criteria were used to assess frailty (phenotype). Endothelial function at rest was evaluated by near-infrared spectroscopy ([NIRS]; slope 1, lowest tissue oxygen saturation [StO2], area under the curve [AUC] of StO2, slope 2, StO2 peak, overshoot, ΔStO2nadir_peak and Δtime nadir_peak) during arterial occlusion maneuver on the forearm. Results were grouped according to the frailty phenotype: robust, pre-frail and frail. Shapiro-Wilk test was used to assess the normality of data. Quantitative data were compared using a two-way analysis of variance plus Bonferroni post hoc test to determine the influence of the frailty or HF on endothelial function variables. A p-value <0.05 was considered statistically significant.

Results

Fifty-two elderly people (61% women) participated in the study, with a mean age of 70.3 ± 7.1 years. Of these, 52% (n = 27) had a diagnosis of HF. Among the sample, 35% (n = 18) were robust, 45% (n = 23) pre-frail, and 20% (n = 11) frail. Endothelial function analysis identified that there was an influence of frailty on reperfusion rate (slope 2 and ΔStO2 nadir-peak; p < 0.05) and desaturation during arterial occlusion (AUC StO2; p < 0.05) only in the HF group.

Conclusion

The coexistence of frailty and HF seems to impair endothelial function since frail elderly with HF had lower reperfusion rate and higher desaturation during the arterial occlusion test.

Abstract Figure. Endothelial function assessment by NIRS

Muscle oxygenation assessment during talk test to determine the anaerobic threshold in individuals with cardiovascular disease

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.

Background

Cardiopulmonary exercise test (CPET) is the reference method for assessing gas exchange threshold (GET), a surrogate of the anaerobic threshold (AnT). However, muscle oxygenation has been shown as an additional tool for AnT determination, using the lower limb threshold (LLT). Besides, Talk Test (TT), a tool used to assess, prescribe, and monitor exercise intensity through speech comfort level, has shown a correlation with GET as well.

Purpose

To identify the AnT obtained from the traditional method from CPET (GET) and the LLT; to compare heart rate (HR) and tissue saturation index (TSI) data at AnT (GET and LLT); to compare the parameters of LLT on CPET and TT, and to correlate LLT and TT stages in cardiovascular disease (CVD) patients.

Methods

CVD patients underwent CPET and TT, both on a treadmill, in two distinctive days. During those tests, peripheral muscle oxygenation was assessed by the near-infrared spectroscopy method. GET (CPET) was determined by the V-slope method; LLT (CPET and TT) was determined by the visual inspection of oxyhemoglobin and deoxyhemoglobin curves. A TT protocol based on the prediction equation for the covered distance of the six-minute walk test (6MWD) was applied. TT protocol was incremental, with two-minutes stages starting at 70% of the average velocity predicted and 2% of inclination, increasing velocity in 10 percentage points (p.p.) at each stage, until the fifth stage, at which the inclination was increased in 2 p.p. until test completion. At the end of each stage, patients read a standardized paragraph and were asked about speech comfort. Shapiro-Wilk test was performed to assess data distribution. Wilcoxon test was applied to compare physiological variables (HR and TSI) at GET and LLT. Repeated measures analysis of variance (ANOVA), followed by Bonferroni post-hoc test was assessed to compare the variables at LLT and TT stages (last TT+ and first TT±). Spearman correlation coefficient was used to assess the relationship between variables. Statistical significance was set at 5%.

Results

24 cardiovascular patients were included. Similar values of HR (GET vs. LLT: 102 ± 15 bpm vs. 99 ± 14 bpm, p = 0,08), and TSI (GET vs. LLT: 64,6 ± 8,2% vs. 66,4 ± 7,8%, p = 0,09) were observed during CPET. Regarding LLT at CPET and TT, there was no difference between HR (CPET vs. TT: 99 ± 14 bpm vs. 100 ± 12 bpm, p = 1,00) and TSI (CPET vs. TT: 66,4 ± 7,8% vs. 65,3 ± 4,9%, p = 1,00). Furthermore, good relationship between HR in LLT and TT stages (LLT vs. TT+: r = 0,79; LLT vs. TT±: r = 0,76; p < 0,05 for both) was found.

Conclusions

Our results showed similarity between LLT and GET. Besides, TT showed a similar response of muscle oxygenation and heart rate comparing to CPET, with a good correlation between LLT and TT stages. These results endorse the validity of TT as an auxiliary and low-cost tool to identify the AnT.

Brief Report: Financial Incentives and Real-Time Adherence Monitoring to Promote Daily Adherence to HIV Treatment and Viral Suppression Among People Living With HIV: A Pilot Study

BACKGROUND

Interventions to promote medication adherence and viral suppression are needed among HIV-positive individuals. We aimed to determine the feasibility, acceptability, and preliminary impact of daily financial incentives linked to real-time adherence monitoring among treatment-experienced individuals.

METHODS

At an HIV clinic in Philadelphia, we conducted a pilot randomized trial among treatment-experienced HIV-positive adults with unsuppressed viral loads (>400 copies/mL). Participants randomized to the intervention group were eligible for daily lottery-based financial rewards dependent on antiretroviral therapy (ART) adherence, measured by a wireless-enabled electronic pill bottle. Participants also received a financial incentive for achieving viral suppression at 3 months. The control group received the standard of care. We measured acceptance and feasibility through follow-up survey at 3 months, viral suppression at 3 months, and adherence.

RESULTS

Among 29 participants, 28 (93%) completed 3-month follow-up, and 24 (83%) completed a 3-month laboratory visit. Electronic pill bottles were highly acceptable to participants, with most strongly agreeing that they worked well, were reliable, and easy to use. Among those who received the intervention, 77% were very satisfied with their experience. Among those who completed the 3-month laboratory visit, viral suppression was achieved by 40% in the intervention group and 29% in the control group. ART adherence ≥80% was achieved by 36% and 25% in the intervention and control groups, respectively.

CONCLUSIONS

Daily financial incentives coupled with real-time adherence monitoring are a promising strategy to support ART adherence among HIV-positive individuals who are not virally suppressed. This novel approach warrants testing in a larger trial.

564. Higher “No Show” Rates Are Associated with Lower Rates of Retention in HIV Care and Viral Suppression

Background

Retention in HIV care has become the keystone of effective HIV treatment, but with less than 50% of people living with HIV/AIDS (PLWHA) engaged in care, a demand exists to better address patients’ needs and to decrease viral transmission. While we know that missed visits can lead to poor outcomes, the science behind “no show” events, and the relationship of “no shows” to patients falling out of care has not been defined.

Methods

We performed a chart review of 1,179 patients from DUCOM’s HIV clinic, the Partnership Comprehensive Care Practice, and examined medical appointment outcomes between July, 2013 and December, 2014. “No show” was defined as a visit not attended, cancelled or rescheduled. An attended visit between January and July 2015 defined a patient as retained. Our aims were to evaluate “no show” events, characterize those who “no show,” and determine predictors of (i) No Show rate (NSR), (ii) Retention (including NSR as a predictor), and (iii) Viral suppression (VS) (including NSR and Retention as predictors). We queried three databases Allscripts, Careware, and RedCap, used SPSS for data analysis, and performed multiple linear and logistic regression to assess relationships between potential covariates and the three outcomes.

Results

80% of patients “no showed” at least once, and 23% of all appointments resulted in “no shows.” Nine hundred and forty-one patients (80%) were retained. 85% of all patients were virally suppressed. Gender, zip code, and housing status were not associated with any of the three outcomes. Being older (P < 0.001), white race (P = 0.001), and private insurance (P = 0.014) were associated with lower NSR, while substance use (P < 0.001) and mental illness (P = 0.038) were associated with a higher NSR. Among other findings, more years positive was associated with greater retention (P = 0.003), and notably, a higher NSR was a strong and significant predictor of not being retained in care (P < 0.001). In multivariate analysis, only NSR (P < 0.001) and retention in care (P = 0.037) predicted VS.

Conclusion

PLWHA who “no show” are at a higher risk of viral nonsuppression and of falling out of care than those who attend their appointments even after adjusting for confounding variables. Interventions to address “no shows” in a timely manner and identify barriers must be developed in order to prevent patients from falling out of care.

Disclosures

All authors: No reported disclosures.

Predictors of Linkage to Care for Newly Diagnosed HIV-Positive Adults

Introduction

Linkage to care following a human immunodeficiency virus (HIV) diagnosis is critical. In the U.S. only 69% of patients are successfully linked to care, which results in delayed receipt of antiretroviral therapy leading to immune system dysfunction and risk of transmission to others.

Methods

We evaluated predictors of failure to link to care at a large urban healthcare center in Philadelphia in order to identify potential intervention targets. We conducted a cohort study between May 2007 and November 2011 at hospital-affiliated outpatient clinics, emergency departments (EDs), and inpatient units.

Results

Of 87 patients with a new HIV diagnosis, 63 (72%) were linked to care: 23 (96%) from the outpatient setting and 40 (63%) from the hospital setting (ED or inpatient) (p<0.01). Those who were tested in the hospital-based settings were more likely to be black (p=0.01), homeless (p=0.03), and use alcohol or drugs (p=0.03) than those tested in the outpatient clinics. Patients tested in the ED or inpatient units had a 10.9 fold (p=0.03) higher odds of failure to link compared to those diagnosed in an outpatient clinic. When testing site was controlled, unemployment (OR 12.2;p<0.01) and substance use (OR 6.4;p<0.01) were associated with failure to link.

Conclusion

Our findings demonstrate the comparative success of linkage to care in outpatient medical clinics versus hospital-based settings. This study both reinforces the importance of routine opt-out HIV testing in outpatient practices, and demonstrates the need to better understand barriers to linkage.

Understanding the revolving door: individual and structural-level predictors of recidivism among individuals with HIV leaving jail

Incarceration, particularly when recurrent, can significantly compromise the health of individuals living with HIV. Despite this, the occurrence of recidivism among individuals with HIV has been little examined, particularly among those leaving jail, who may be at especially high risk for return to the criminal justice system. We evaluated individual- and structural-level predictors of recidivism and time to re-incarceration in a cohort of 798 individuals with HIV leaving jail. Nearly a third of the sample experienced at least one re-incarceration event in the 6 months following jail release. Having ever been diagnosed with a major psychiatric disorder, prior homelessness, having longer lifetime incarceration history, having been charged with a violent offense for the index incarceration and not having health insurance in the 30 days following jail release were predictive of recidivism and associated with shorter time to re-incarceration. Health interventions for individuals with HIV who are involved in the criminal justice system should also target recidivism as a predisposing factor for poor health outcomes. The factors found to be associated with recidivism in this study may be potential targets for intervention and need to be further explored. Reducing criminal justice involvement should be a key component of efforts to promote more sustainable improvements in health and well-being among individuals living with HIV.

Blockade of leucocyte function-associated antigen-1 (LFA-1) decreases lymphocyte trapping in the normal pulmonary vasculature: studies in the isolated buffer-perfused rat lung

Adhesion molecules regulate the migration of lymphocytes in lymphoid and non-lymphoid organs. In the lung, little is known about lymphocyte sticking and migration through the pulmonary vascular endothelium in physiological or pathological situations. Therefore the isolated buffer-perfused rat lung was used to investigate the mobilization of lymphocytes out of the normal lung into the venous effluent and to the bronchoalveolar space. The lymphocyte subset composition was characterized in the venous effluent, the lung tissue and the bronchoalveolar lavage (BAL) using immunocytology. Lymphocytes continuously left the normal lung at a total of 5.0 +/- 0.7 x 106 cells within the first hour of perfusion. The injection of 200 x 106 lymphocytes via the pulmonary trunk increased the venous release of lymphocytes by 170%. To investigate the effect of LFA-1 and CD44 on the adhesion of lymphocytes to the pulmonary endothelium, lymphocytes preincubated with an anti-LFA-1 MoAb, which blocks the interaction of LFA-1 and intercellular adhesion molecule-1 (ICAM-1), or lymphocytes preincubated with an anti-CD44 MoAb, were injected. The injection of LFA-1-blocked lymphocytes led to an increase by 70% of injected cells recovered in the perfusate within the first hour, whereas anti-CD44 treatment of injected lymphocytes had no effect. The LFA-1-blocked lymphocytes showed higher numbers of T and B cells in the effluent. Thus, the present experiments demonstrate that LFA-1 influences the trapping of lymphocytes in the vasculature of the healthy rat lung.

Vasoregulatory prostanoid generation proceeds via cyclooxygenase-2 in noninflamed rat lungs

Prostanoids have been implicated in the regulation of lung vascular tone both under physiological and inflammatory conditions. The conversion of arachidonic acid (AA) to prostaglandin H2 is catalyzed at least by two isoforms of cyclooxygenase, named Cox-1 and Cox-2. Cox-1 is thought to be ubiquitously expressed, enrolled in physiological processes, whereas Cox-2 is mostly assumed to be dynamically regulated, responding to inflammatory conditions. We have recently shown by immunohistochemistry that Cox-2 is constitutively expressed in control rat lungs, with a predominant localization in smooth muscle cells of partially muscular vessels. We now asked whether Cox-2 is basically involved in the physiological regulation of pulmonary vascular tone. Isolated perfused rat lungs were challenged with intravascular bolus application of free AA to elicit thromboxane-related vasoconstrictor responses and to investigate the effects of three different selective Cox-2 inhibitors (NS-398, DUP697, SC-236). AA induced the liberation of prostaglandin I2 and thromboxane A2 into the intravascular space, and it provoked marked pulmonary artery pressure responses and concomitant lung edema formation. All events were dose-dependently inhibited by 1 to 50 micromol/liter NS-398, whereas control vasoconstrictor responses to angiotensin II and the stable thromboxane analogue U46619 were not affected by this agent. Similarly, marked inhibition of the AA elicited pressor response was achieved by 25 micromol/l DUP697 and by 10 micromol/l SC-236. These data suggest a physiological role of Cox-2 rather than Cox-1 in the regulation of vascular tone in rat lungs.