HCV Screening and Treatment Uptake Among Patients in HIV Care During 2014-2015

BACKGROUND

Despite the high prevalence of hepatitis C virus (HCV) among persons living with HIV (PWH), the prevalence of HCV screening, treatment, and sustained virologic response (SVR) is unknown. This study aims to characterize the continuum of HCV screening and treatment among PWH in HIV care.

SETTING

Adult patients enrolled at 12 sites of the HIV Research Network located in 3 regions of the United States were included.

METHODS

We examined the prevalence of HCV screening, HCV coinfection, direct-acting antiretroviral (DAA) treatment, and SVR-12 between 2014 and 2015. Multivariate logistic regression was performed to identify characteristics associated with outcomes, adjusted for site.

RESULTS

Among 29,071 PWH (age 18-87, 74.8% male, 44.4% black), 77.9% were screened for HCV antibodies; 94.6% of those screened had a confirmatory HCV RNA viral load test. Among those tested, 61.1% were determined to have chronic HCV. We estimate that only 23.4% of those eligible for DAA were prescribed DAA, and only 17.8% of those eligible evidenced initiating DAA treatment. Those who initiated treatment achieved SVR-12 at a rate of 95.2%. Blacks and people who inject drugs (PWID) were more likely to be screened for HCV than whites or those with heterosexual risk. Persons older than 40 years, whites, Hispanics, and PWID [adjusted odds ratio (AOR) 8.70 (7.74 to 9.78)] were more likely to be coinfected than their counterparts. When examining treatment with DAA, persons older than 50 years, on antiretroviral therapy [AOR 2.27 (1.11 to 4.64)], with HIV-1 RNA <400 [AOR 2.67 (1.71 to 4.18)], and those with higher Fib-4 scores were more likely to be treated with DAA.

CONCLUSIONS

Although rates of screening for HCV among PWH are high, screening remains far from comprehensive. Rates of SVR were high, consistent with previously published literature. Additional programs to improve screening and make treatment more widely available will help reduce the impact of HCV morbidity among PWH.

585. Hospitalization Rates and Diagnoses Vary by Age Group Among Persons with HIV (PWH) in 2014–2015

Background

Effective antiretroviral therapy has increased survival in persons with HIV (PWH). Over 45% of PWH are now over 50 years old, and comorbidities of aging are becoming more prevalent. The objective of this study was to evaluate hospitalization rates and causes for hospitalization among PWH in longitudinal HIV care by age.

Methods

Hospitalization rates and diagnoses were determined in PWH receiving longitudinal care at 13 sites in the HIV Research Network between 2014 and 2015. Using AHRQ Clinical Classification Software, we divided inpatient ICD9 discharge diagnoses into diagnostic categories. Multivariate negative binomial regression was performed to assess for factors associated with overall hospitalization and for each diagnostic category.

Results

The sample included 20,608 patients, 73% male, 46% black, 21% Hispanic, 47% MSM, and 12% IDU. Median age was 48 yo [range 18–89] of which 32% were 50–59 yo, 12% were ≥ 60 yo. 75% had CD4 ≥ 350, 81% had HIV-1 RNA < 50 copies. 20% had private insurance, 36% Medicaid, 10% Medicare, and 5% were uninsured. All cause hospitalization rate for 2014–2015 was 201/1000 person-years (PY). Non-AIDS defining infection (non-ADI) was the leading cause for admission (47/1,000 PY), followed by cardiovascular disease (CVD) (22/1,000 PY), psychiatric (14/1,000 PY), endocrine (14/1,000 PY) and ADI (13/1,000 PY). In multivariate analysis, the incidence rate ratio (IRR) for all-cause hospitalization increased by age group (18–29 yo reference): 30–39 yo IRR 1.05 (95% CI 0.88, 1.26), 40–49 yo IRR 1.28 (1.08, 1.51), 50–59 yo IRR 1.43 (1.22, 1.69), and 60 yo or greater IRR 1.97 (1.64, 2.37). Hospitalization rates increased significantly by age group for CV, GU, pulmonary, endocrine, and oncology diagnostic categories. Rates did not differ by age for non-ADI infection, GI and mental health diagnostic categories.

Conclusion

The hospitalization rates for noncommunicable diseases (NCDs) increase as PWH age. There is an increase CV hospitalizations among older PWH. ADI accounted for fewer hospitalizations than many chronic diseases. Our results suggest that HIV experts, primary care providers and other specialists may need to work together to optimize the care of older PWH.

Disclosures

A. E. Nijhawan, Gilead: Consultant, Research support.

1906. Hospitalization Rates Among Persons With HIV Who Gained Medicaid or Private Insurance in 2014

Background

The Ryan White Program (RWP), which provides safety net outpatient healthcare coverage to thousands of low-income persons with HIV (PWH), does not pay for inpatient care. Many PWH who relied on RWP transitioned to either Medicaid or private insurance (private) with the Affordable Care Act in 2014. It is unknown whether such transitions affected hospitalization rates.

Methods

We included patients from three HIV Research Network sites (two in Medicaid expansion states, one in a nonexpansion state) who relied solely on RWP in 2013. Patients either stayed in RWP through 2015, or changed to Medicaid or private in 2014. 2015 hospitalization rate ratios were modeled using negative binomial regression, adjusting for demographics, CD4 count, HIV viral load (VL), clinic site, and number of 2013 hospitalizations.

Results

Our sample of 1,634 patients was 73% male, 46% Black, 36% Hispanic; median age was 45 years (IQR 37,52) and median CD4 count 526 cells/μL (356, 716); 85% had a VL ≤400 copies/mL. Ninety-five patients were hospitalized in 2015. Unadjusted hospitalization rates (per 100 person years) were 8.4, 21.3, and 7.4 in 2013 and 6.3, 20.2, and 3.7 in 2015 for those who remained in RWP, switched to Medicaid, or switched to private, respectively. Switching to Medicaid or private was not associated with 2015 hospitalization rates (IRR 1.26 (95% CI 0.71–2.23) and 0.48 (0.18–1.28), table). Older age, CD4 <200, VL >400, and number of 2013 hospitalizations were associated with higher rates.

Conclusion

Among PWH relying on RWP in 2013, changing to either Medicaid or private insurance was not associated with a change in hospitalization rate. Among PWH, gaining inpatient coverage does not appear to increase inpatient utilization.

Disclosures

A. Nijhawan, Gilead: Consultant, Research support.

The HIV Care Continuum: Changes over Time in Retention in Care and Viral Suppression

BACKGROUND

The HIV care continuum (diagnosis, linkage to care, retention in care, receipt of antiretroviral therapy (ART), viral suppression) has been used to identify opportunities for improving the delivery of HIV care. Continuum steps are typically calculated in a conditional manner, with the number of persons completing the prior step serving as the base population for the next step. This approach may underestimate the prevalence of viral suppression by excluding patients who are suppressed but do not meet standard definitions of retention in care. Understanding how retention in care and viral suppression interact and change over time may improve our ability to intervene on these steps in the continuum.

METHODS

We followed 17,140 patients at 11 U.S. HIV clinics between 2010-2012. For each calendar year, patients were classified into one of five categories: (1) retained/suppressed, (2) retained/not-suppressed, (3) not-retained/suppressed, (4) not-retained/not-suppressed, and (5) lost to follow-up (for calendar years 2011 and 2012 only). Retained individuals were those completing ≥ 2 HIV medical visits separated by ≥ 90 days in the year. Persons not retained completed ≥ 1 HIV medical visit during the year, but did not meet the retention definition. Persons lost to follow-up had no HIV medical visits in the year. HIV viral suppression was defined as HIV-1 RNA ≤ 200 copies/mL at the last measure in the year. Multinomial logistic regression was used to determine the probability of patients' transitioning between retention/suppression categories from 2010 to 2011 and 2010 to 2012, adjusting for age, sex, race/ethnicity, HIV risk factor, insurance status, CD4 count, and use of ART.

RESULTS

Overall, 65.8% of patients were retained/suppressed, 17.4% retained/not-suppressed, 10.0% not-retained/suppressed, and 6.8% not-retained/not-suppressed in 2010. 59.5% of patients maintained the same status in 2011 (kappa=0.458) and 53.3% maintained the same status in 2012 (kappa=0.437).

CONCLUSIONS

Not counting patients not-retained/suppressed as virally suppressed, as is commonly done in the HIV care continuum, underestimated the proportion suppressed by 13%. Applying the care continuum in a longitudinal manner will enhance its utility.