Expanded or Risk Factor-Based Annual Screening for Hepatitis C Virus (HCV) Among Persons With HIV: Which Is the Best Approach?

Introduction. Universal one-time screening for hepatitis C virus (HCV) is recommended for all adults. For persons with HIV (PWH), guidelines recommend HCV screening at entry into care and annually in men who have unprotected sex with other men (MSM) and persons who inject drugs (PWID). Public health experts recommend expanded annual screening in all PWH given concerns for undiagnosed new HCV diagnoses when risk factors are not assessed. Electronic medical record (EMR) with clinical decision support using a Best Practice Advisory (BPA) tool can aid HCV risk factor assessment. We conducted a prospective study among three HIV clinics to compare the two screening approaches. Methods. Two clinics implemented the EMR-triggered risk factor-based screening; one clinic used the expanded screening approach. We evaluated BPA uptake and compared HCV testing and positivity rates from August 12, 2019 to March 12, 2020. Results. In the risk factor-based screening clinics, of 1,343 PWH, 239 tests were performed with 139 attributed to the BPA (testing rate 10%). At the expanded screening site, among 434 patients, 237 HCV tests were performed (testing rate 55%). The risk factor-based screening sites were less likely to test for HCV (odds ratio [OR] = 0.0884, p < .01) and identify positive cases (OR = 0.55, p = .025). Conclusions. An EMR-based clinical-decision support tool was successfully implemented for HCV risk factor-based screening resulting in a lower HCV annual screening rate compared with an expanded approach. Although in this group of HIV clinics with limited longitudinal follow-up, no previously undiagnosed HCV cases were detected, additional work is needed to guide the design of the best approach.

Dectin-1 stimulation promotes a distinct inflammatory signature in the setting of HIV-infection and aging

Dectin-1 is an innate immune receptor that recognizes and binds β-1, 3/1, 6 glucans on fungi. We evaluated Dectin-1 function in myeloid cells in a cohort of HIV-positive and HIV-negative young and older adults. Stimulation of monocytes with β-D-glucans induced a pro-inflammatory phenotype in monocytes of HIV-infected individuals that was characterized by increased levels of IL-12, TNF-α, and IL-6, with some age-associated cytokine increases also noted. Dendritic cells showed a striking HIV-associated increase in IFN-α production. These increases in cytokine production paralleled increases in Dectin-1 surface expression in both monocytes and dendritic cells that were noted with both HIV and aging. Differential gene expression analysis showed that HIV-positive older adults had a distinct gene signature compared to other cohorts characterized by a robust TNF-α and coagulation response (increased at baseline), a persistent IFN-α and IFN-γ response, and an activated dendritic cell signature/M1 macrophage signature upon Dectin-1 stimulation. Dectin-1 stimulation induced a strong upregulation of MTORC1 signaling in all cohorts, although increased in the HIV-Older cohort (stimulation and baseline). Overall, our study demonstrates that the HIV Aging population has a distinct immune signature in response to Dectin-1 stimulation. This signature may contribute to the pro-inflammatory environment that is associated with HIV and aging.

Long-term quantitative assessment of anti-SARS-CoV-2 spike protein immunogenicity (QUASI) after COVID-19 vaccination in older people living with HIV (PWH)

BACKGROUND

The durability of immune responses to COVID-19 vaccines among older people living with HIV (PWH) is clinically important.

METHODS

We aimed to assess vaccine-induced humoral immunity and durability in older PWH (≥ 55 years, n = 26) over 6 months (post-initial BNT162b2 series). A secondary and exploratory objective was to assess T-cell response and BNT162b2 booster reactogenicity, respectively. Our Visit 1 (3 weeks post-initial BNT162b2 dose) SARS-CoV-2 humoral immunity results are previously reported; these subjects were recruited for Visit 2 [2 weeks (+ 1 week window) post-second vaccination] and Visit 3 [6 months (± 2 week window) post-initial vaccination] in a single-center longitudinal observational study. Twelve participants had paired Visit 2/3 SARS-CoV-2 Anti-Spike IgG data. At Visit 3, SARS-CoV-2 Anti-Spike IgG testing occurred, and 5 subjects underwent T-cell immune response evaluation. Thereafter, subjects were offered BNT162b2 booster (concurrent day outside our study) per US FDA/CDC guidance; reactogenicity was assessed. The primary study outcome was presence of detectable Visit 3 SARS-CoV-2 Anti-Spike-1-RBD IgG levels. Secondary and exploratory outcomes were T-cell immune response and BNT162b2 booster reactogenicity, respectively. Wilcoxon signed-rank tests analyzed median SARS-CoV-2 Anti-Spike IgG 6-month trends.

RESULTS

At Visit 3, 26 subjects underwent primary analysis with demographics noted: Median age 61 years; male n = 16 (62%), female n = 10 (38%); Black n = 13 (50%), White n = 13 (50%). Most subjects (n = 20, 77%) had suppressed HIV viremia on antiretroviral therapy, majority (n = 24, 92%) with CD4 > 200 cells/µL. At Visit 3, 26/26 (100%) had detectable Anti-Spike-1-RBD (≥ 0.8 U/mL). Among 12 subjects presenting to Visit 2/3, median SARS-CoV-2 Anti-Spike 1-RBD was 2087 U/mL at Visit 2, falling to 581.5 U/mL at Visit 3 (p = 0.0923), with a median 3.305-fold decrease over 6 months. Among subjects (n = 5) with 6-month T-cell responses measured, all had detectable cytokine-secreting anti-spike CD4 responses; 3 had detectable CD4 + Activation induced marker (AIM) + cells. Two had detectable cytokine-secreting CD8 responses, but all had positive CD8 + AIM + cells.

CONCLUSIONS

Among older PWH, SARS-CoV-2 Anti-Spike IgG and virus-specific T-cell responses are present 6 months post-primary BNT162b2 vaccination, and although waning, suggest retention of some degree of long-term protective immunity.

Longitudinal Improvements in Viral Suppression for Persons With New HIV Diagnosis Receiving Care in the Ryan White Program: A 10-Year Experience in New Haven, CT (2009-2018)

Background

The Ryan White (RW) program funds medical and other support services for low-income persons with HIV, significantly improving progress along the HIV care continuum. Although the program has shown overall improvements in achievement of viral suppression, the relative contributions of changes in clinical practice and RW service components to the optimization of the HIV care continuum, particularly for those with new HIV diagnoses, remain unknown.

Methods

The target population was patients with recent HIV diagnoses who received care at RW-funded clinics in the greater New Haven area between 2009 and 2018. Client data were extracted from the RW-funded database, CAREWare, and the electronic medical record. Primary outcomes included time between HIV diagnosis and first HIV primary care (PC) visit, antiretroviral therapy (ART) initiation, and viral suppression (VS).

Results

There were 386 eligible patients. Between 2009 and 2018, the median number of days from HIV diagnosis to first PC visit decreased from 58.5 to 8.5 days, and ART initiation decreased from 155 to 9 days. In 2018, 86% of participants achieved viral suppression within 1 year, compared with 2.5% in 2009. Patients who initiated single-tablet ART and integrase inhibitor-containing regimens were more likely to reach viral suppression within 1 year (P < .001). Receipt of medical case management services was also associated with achieving viral suppression (P < .001).

Conclusions

Longitudinal improvements over 10 years in ART initiation and viral suppression were observed due to clinical advances and their effective implementation through the RW comprehensive care model. Further study of the essential components promoting these outcomes is needed.

Lower Gastrointestinal Syphilis: Case Series and Literature Review

Background

Syphilis infections are increasing globally. Lower gastrointestinal syphilis (LGIS) is a rare manifestation of early syphilis transmitted through anal sexual contact. Misdiagnosis of LGIS as inflammatory bowel disease may result from clinician underawareness.

Methods

We searched the literature for articles describing cases of LGIS, and identified additional cases diagnosed within our institution. Data were extracted from the articles and medical records and analyzed to provide a summative account.

Results

Fifty-four cases of LGIS were identified in 39 articles published between 1958 and 2020. Eight additional cases were diagnosed at our institution between 2011 and 2020, totaling 62 cases. All cases were described in men and transwomen aged 15–73 years. Fifty (93%) individuals reported having sex with men. In 26 cases (52%), the individuals were human immunodeficiency virus (HIV) coinfected. LGIS presented most commonly with hematochezia (67%) and anal pain (46%). The most common physical examination findings were rectal mass (38%), lymphadenopathy (31%), and rash (26%). Nontreponemal titers ranged from 1:2 to 1:1024. Of the 52 cases in which endoscopy was reported, 22 (42%) showed anorectal mass and 18 (35%) showed anorectal ulcer. In 44 cases (75%), histopathology revealed a chronic inflammatory infiltrate with a prominent lymphocyte component (45%) and/or plasma cells (36%). Seventy-eight percent of specimens to which a tissue stain was applied were positive for spirochetes.

Conclusions

LGIS should be suspected in men and transwomen presenting with a lower gastrointestinal symptom or mucosal abnormality. A sexual history must be elicited and guide testing. Misdiagnosis can delay treatment and threatens patient and public health.

Qualitative assessment of anti-SARS-CoV-2 spike protein immunogenicity (QUASI) after COVID-19 vaccination in older people living with HIV

Objectives

Effective and safe COVID‐19 vaccines have been developed and have resulted in decreased incidence and severity of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and can decrease secondary transmission. However, there are concerns about dampened immune responses to COVID‐19 vaccination among immunocompromised patients, including people living with HIV (PLWH), which may blunt the vaccine's efficacy and durability of protection. This study aimed to assess the qualitative SARS‐CoV‐2 vaccine immunogenicity among PLWH after vaccination.

Methods

We conducted targeted COVID‐19 vaccination (all received BNT162b2 vaccine) of PLWH (aged ≥ 55 years per state guidelines) at Yale New Haven Health System and established a longitudinal survey to assess their qualitative antibody responses at 3 weeks after the first vaccination (and prior to receipt of the second dose of the COVID‐19 vaccine) (visit 1) and at 2–3 weeks after the second vaccination (visit 2) but excluded patients with prior COVID‐19 infection. Our goal was to assess vaccine‐induced immunity in the population we studied. Qualitative immunogenicity testing was performed using Healgen COVID‐19 anti‐Spike IgG/IgM rapid testing. Poisson regression with robust standard errors was used to determine factors associated with a positive IgG response.

Results

At visit 1, 45 of 78 subjects (57.7%) tested positive for SARS‐CoV‐2 anti‐Spike IgG after the first dose of COVID‐19 vaccine. Thirty‐nine subjects returned for visit 2. Of these, 38 had positive IgG (97.5%), including 20 of 21 subjects (95.2%) with an initial negative anti‐Spike IgG. Our bivariate analysis suggested that participants on an antiretroviral regimen containing integrase strand transfer inhibitors [relative risk (RR) = 1.81, 95% confidence interval (CI): 0.92–3.56, p = 0.085] were more likely to seroconvert after the first dose of the COVID‐19 vaccine, while those with a CD4 count < 500 cells/μL (RR = 0.59, 95% CI: 0.33–1.05, p = 0.071), and those diagnosed with cancer or another immunosuppressive condition (RR = 0.49, 95% CI: 0.18–1.28, p = 0.15) may have been less likely to seroconvert after the first dose of the COVID‐19 vaccine. The direction of these associations was similar in the multivariate model, although none of these findings reached statistical significance (RR_{integrase inhibitor} = 1.71, 95% CI: 0.90–3.25, p = 0.10; RR_{CD4 count} = 0.68, 95% CI: 0.39–1.19, p = 0.18; RR_{cancer or another immunosuppressive condition} = 0.50, 95% CI: 0.19–1.33, p = 0.16). With regard to immunogenicity, we were able to record very high rates of new seroconversion following the second dose of the COVID‐19 vaccine.

Conclusions

Our study suggests that completing a two‐dose series of BNT162b2 vaccine is critical for PLWH given suboptimal seroconversion rates after the first dose and subsequent improved seroconversion rates after the second dose.

VZV myelitis with secondary HIV CSF escape

A 52-year-old woman with HIV and recent antiretroviral therapy non-adherence presented with a 5-day history of widespread painful vesicular skin lesions. Direct fluorescent antibody testing of the skin lesions was positive for varicella zoster virus (VZV). On day 3, she developed profound right upper extremity weakness. MRI of the brain and cervical spine was suggestive of VZV myelitis. Lumbar puncture was positive for VZV PCR in the cerebrospinal fluid (CSF) and CSF HIV viral load was detected at 1030 copies/mL, indicating 'secondary' HIV CSF escape. She was treated with intravenous acyclovir for 4 weeks and subsequent oral therapy with famciclovir then valacyclovir for 6 weeks. She also received dexamethasone. The patient had an almost full recovery at 6 months. Myelitis is a rare complication of reactivated VZV infection that can have atypical presentation in immunocompromised patients. Such 'secondary' HIV CSF escape should be considered in immunosuppressed patients with concomitant central nervous system infection.

Race and ethnicity do not impact eligibility for remdesivir: A single-center experience

As the Coronavirus-2019 (COVID-19) pandemic continues, multiple therapies are rapidly being evaluated for efficacy in clinical trials. Clinical trials should be racially and ethnically representative of the population that will eventually benefit from these medications. There are multiple potential barriers to racial and ethnic minority enrollment in clinical trials, one of which could be that inclusion and exclusion criteria select for certain racial or ethnic groups disproportionately. In this observational cohort study at a single health care system, we examined if there were differences in eligibility for treatment with remdesivir based on clinical trial criteria for racial and ethnic minorities compared to non-Hispanic Whites. 201 electronic medical record charts were reviewed manually. Self-identified Whites were older than other racial or ethnic groups. At the time of presentation, Black, Latinx, and White participants met inclusion criteria for remdesivir at similar rates (72%, 80%, and 73% respectively), and exclusion criteria at similar rates (43%, 38% and 49% for Black, Latinx and White participants respectively). In this study, there was no difference in eligibility for remdesivir based on race or ethnicity alone.

Decreased Overall Survival in HIV-associated Non-small-cell Lung Cancer

INTRODUCTION

This study aimed to compare demographics, disease characteristics, and outcomes of patients with HIV-infection with non-small-cell lung cancer (NSCLC) with the general NSCLC population.

PATIENTS AND METHODS

A retrospective cohort study was used to compare the HIV-infected and -uninfected groups. Medical records of all patients who were HIV-positive diagnosed with NSCLC between 2000 and 2016 at Yale New Haven Hospital (New Haven, CT) were reviewed and compared with the general Yale NSCLC population regarding demographics, NSCLC characteristics, treatment, and survival. Log-rank tests and Kaplan-Meier curves were used to analyze survival differences. Unadjusted and adjusted Cox proportional hazard models were used to assess predictors of survival.

RESULTS

Thirty-five patients with HIV-NSCLC and 5187 general patients with NSCLC were identified. The median age at cancer diagnosis was 54 years (interquartile range [IQR], 49-59 years) for patients with HIV-NSCLC versus 68 years (IQR, 61-76 years) for patients with NSCLC (P < .001). Both groups had high rates of tobacco use. At the time of NSCLC diagnosis, 80% of patients with HIV-NSCLC were on antiretroviral therapy, 60% had an HIV-1 RNA < 400 copies/mL, and their median CD4 was 407 cells/μL (IQR, 218-592 cells/μL). Histology, cancer stage, and first-line cancer treatment regimens were not significantly different between groups. The overall median survival was 12.4 months (95% confidence interval [CI], 7.2-20.4 months) for patients with HIV-NSCLC versus 22.8 months (95% CI, 21.2-24.1 months) for general patients with NSCLC. Patients with HIV-NSCLC had decreased survival at 2 years (P = .028) and 3 years (P = .014) compared with general patients with NSCLC. HIV status was an independent risk factor for poorer outcomes when controlling for other factors (hazard ratio, 1.8; 95% CI, 1.24-2.62).

CONCLUSION

Despite similar histology, stage, and treatment between groups, patients with HIV had worse outcomes for NSCLC.

0990 Evaluating Components Of Sleep Quality And The Sleep-Quality Of Life Relationship For Children With Acute Lymphoblastic Leukemia

Introduction

Poor sleep quality is associated with reduced health-related quality of life (HRQL) for children with Acute Lymphoblastic Leukemia (ALL). Research has yet to evaluate how components of child sleep quality uniquely contribute to HRQL beyond demographic characteristics. This study evaluates features of sleep and the relationship between sleep and HRQL for children in the maintenance phase of ALL treatment.

Methods

89 caregivers (ages 20-52, M=35.95, SD=7.10) of children with ALL (ages 3-12, M=5.73, SD=2.21; 13.76 months from diagnosis) completed demographic questionnaires and reports of child sleep quality (Child Sleep Habits Questionnaire; CSHQ), and 64 caregivers reported on child HRQL (Pediatric Quality of Life Inventory). Descriptive statistics were calculated. T-tests compared CSHQ subscales to ratings of healthy normative values. Pearson correlations evaluated associations between sleep and overall HRQL. Hierarchical regression assessed whether CSHQ subscales uniquely predicted HRQL beyond demographic characteristics.

Results

This sample reported greater bedtime resistance [t(88)=6.413, p&lt;.001], sleep onset delay [t(88)=3.180, p=.002], sleep anxiety [t(88)=4.271, p&lt;.001], night awakenings [t(88)=6.031, p&lt;.001], parasomnias [t(88)=3.900, p&lt;.001], and daytime sleepiness [t(87)=1.781, p=.078] than normative values, although sleep duration [t(88)=1.781, p=.078] and sleep disordered breathing (SDB) [t(88)=-.061, p=.951] did not differ. HRQL was related to SDB (r=-.289, p=.021), bedtime resistance (r=-.263, p=.036), and total sleep score (r=-.34, p=.006). The regression model with SDB and bedtime resistance explained 24.2% of variance but was not significant [F(6,31)=1.651, p=.167].

Conclusion

Caregiver ratings showed greater sleep impairments for children in this sample than of norms. Sleep subscales were associated with HRQL, but did not predict HRQL beyond demographic factors. Caregiver reports of child sleep and HRQL may vary depending on when during the monthly chemotherapy cycle questionnaires were completed. SDB did not differ from normative values but was related to HRQL, suggesting the need to screen for SDB symptoms to potentially improve child outcomes.

Support

This study was supported by funding from the American Cancer Society PF-13-238-01-PCSM (PI: Daniel).

0981 Sleep Practices In Pediatric Cancer—Does Sleep Hygiene Matter For Reducing Cancer Symptom Burden?

Introduction

Sleep disturbances are common during pediatric cancer treatment and recent evidence suggests a correlation between sleep and symptom burden. Improving nighttime sleep may impact patients’ ability to cope with symptoms. The current study tests the interaction between sleep hygiene and sleep disturbances in predicting cancer-related symptoms to determine if the relationship between sleep and symptoms is different for patients with better sleep hygiene.

Methods

102 caregivers of children with cancer (ages 5-17, M=10.12, SD=4.02; 58% female) completed parent-proxy Pediatric Sleep Practices Questionnaire (yielding routine consistency and sleep opportunity scores) and measures of cancer-related symptoms (PROMIS Sleep Disturbance, Fatigue, and Pain Interference; PedsQL—Cancer Module-Nausea subscale). The interaction between sleep disturbances and sleep hygiene (consistency, opportunity) on each symptom (pain, nausea, fatigue) were tested using PROCESS moderation.

Results

81% of caregivers report that their child receives sufficient sleep but only 12% reported regular consistent sleep patterns/routines. Sleep opportunity was not related to sleep disturbances or cancer-related symptoms, but more routine consistency was related to fewer sleep disturbances (r=.30, p=.003). The interaction between sleep disturbances and routine consistency significantly predicted pain interference [R2=.16, F(3, 98)=6.37, p&lt;.001; Bint =-0.17, p=.028] and nausea [R2=.16, F(3, 98)=6.47, p&lt;.001; Bint=0.46, p=.004]. The interaction between sleep disturbances and sleep opportunity significantly predicted nausea [R2=.15, F(3, 98)=5.76, p=.001; Bint =0.68, p=.016] but not pain interference. Both interaction models predicting fatigue were not significant.

Conclusion

The sleep/pain and sleep/nausea relationships are stronger in patients with more consistent sleep routines and the sleep/nausea relationship is also stronger in patients with sufficient/well-timed sleep opportunities. Sleep and fatigue were moderately related across all levels of both sleep hygiene components. Clinical interventions that target sleep hygiene together with sleep disturbances such as nighttime awakenings and poor sleep quality may be more effective in addressing cancer-related symptoms such as pain and nausea.

Support

This work was supported in part by funding from the Patient-Centered Outcomes Research Institute (PCORI-D-17-00187; PI Christopher Forrest).

Impact of Aging and HIV Infection on the Function of the C-Type Lectin Receptor MINCLE in Monocytes

Both aging and HIV infection are associated with an enhanced pro-inflammatory environment that contributes to impaired immune responses and is mediated in part by innate immune pattern-recognition receptors. MINCLE is a C-type lectin receptor that recognizes trehalose-6,6'-dimycolate or "cord factor," the most abundant glycolipid in Mycobacterium tuberculosis. Here, we evaluated MINCLE function in monocytes in a cohort of HIV-infected and uninfected young (21-35 years) and older adults (≥60 years) via stimulation of peripheral blood mononuclear cells with trehalose-6,6-dibehenate, a synthetic analog of trehalose-6,6'-dimycolate and measurement of cytokine production (interleukin [IL]-10, IL-12, IL-6, tumor necrosis factor-α) by multicolor flow cytometry. Our studies show an age- and HIV-associated increase in cytokine multifunctionality of monocytes both at the population and single cell level that was dominated by IL-12, IL-10, and IL-6. These findings provide insight into the host response to M. tuberculosis and possible sources for the pro-inflammatory environment seen in aging and HIV infection.

Dysregulation of sterol regulatory element-binding protein 2 gene in HIV treatment-experienced individuals

Although antiretroviral therapy (ART) has resulted in a marked decrease in AIDS-related morbidity and mortality, the therapeutic benefit is often limited by side effects such as metabolic derangement such as lipodystrophy and hyperlipidemia and cardiovascular diseases. These side effects are pervasive in people living with HIV (PLWH). However, the underlying mechanisms are not completely understood. We investigated the effects of ART on cholesterol biosynthesis genes. This is a retrospective analysis of data and specimens collected during a cross-sectional, case-control study of ART-induced toxicity. Cases were HIV treatment-experienced individuals with HIV viral suppression and no diagnosis of ART-associated toxicity (n = 18), and controls were HIV-uninfected individuals (n = 18). The mRNA expressions of 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) and ATP binding cassette transporter A1 (ABCA1) were significantly upregulated in cases (HIV+) compared to controls (HIV-), as well as the corresponding protein expression level of HMGCR. We observed dysregulation between sterol regulatory element-binding protein 2 (SREBP-2, sensory control) and HMGCR and low-density lipoprotein receptor (LDLR) pathways. Dysregulation of cholesterol biosynthesis genes may predate clinical manifestation of ART-induced lipid abnormalities.

Implementing a Comprehensive HCV Clinic within an HIV Clinic: A Model of Care for HCV Micro-elimination

BACKGROUND

Among the 1.2 M persons living with HIV in the United States, 25% are co- infected with HCV. The availability of effective direct antiviral agents (DAAs) makes the goal of HCV elimination feasible, but implementation requires improvements to the HCV treatment cascade, especially linkage to and initiation of treatment in underserved populations.

METHODS

In this retrospective review, a cohort of patients receiving care at a hospital-based HIV clinic in New Haven, CT (1/1/2014-3/31/2017) with chronic HCV infection not previously treated with DAAs were followed longitudinally. Patients were referred to a co-located multi-disciplinary team. Standardized referral and treatment algorithms, electronic medical record templates were developed; monthly meetings were held; a registry was created to review progress.

RESULTS

Of 173 patients, 140 (80.9%) were 50-70 years old; 115 (66.5%) male; 99 (57.2%) African-American, 43 (24.9%) White, 23 (13.3%) Hispanic. Comorbidities included: cirrhosis (25.4%); kidney disease (17.3%) mental health issues (60.7%); alcohol abuse (30.6%); active drug use (54.3%). Overall, 161 (93.1%) were referred, 147 (85%) linked, 122 (70.5%) prescribed DAAs, 97 (56.1%) had SVR12. Comparison between those with SVR12 and those unsuccessfully referred, linked or treated, showed that among those not-engaged in HCV care, there was a higher proportion of younger (mean age 54.2 vs 57 years old, p=0.022), female patients (p= 0.001) and a higher frequency of missed appointments.

CONCLUSIONS

Establishing a co-located HCV clinic within an HIV clinic resulted in treatment initiation in 70.5% and SVR12 in 56.1%. This success in a hard-to-treat population is a model for achieving WHO micro-elimination goals.

575. Older HIV-Infected Adults Are Twice More Likely to Present Late to Care

Background

There are 36.7 million persons living with HIV globally and 1.1 million in the United States with additional ~45,000 new diagnosis annually. One in six newly diagnosed HIV-infected persons is older than 50 years of age. It is estimated that 45% of the US HIV population is over 50 years old and more than 10% are older than 60 years. HIV is more likely to be diagnosed at an advanced stage in older adults. Therefore there is a need to better understand the characteristics, staging of the disease, and response to treatment in older HIV-infected adults, in order to provide an effective treatment and prevention approach.

Methods

A retrospective medical record review of all newly diagnosed HIV-infected patients was conducted at a single academic center HIV ambulatory clinic from January 1, 2010 to December 31, 2015. Patients demographics, age group, HIV staging, and response to antiretroviral treatment (ART) measured by HIV viral suppression at 12 weeks (HIV RNA <50 copies), and change in CD4 count were collected. Bivariate analysis was conducted comparing two groups of HIV-infected patients: younger group (age <50 years) and older group (age 50 years and older).

Results

From 2010 to 2015, 130 newly diagnosed HIV patients were enrolled in the clinic. Thirty-one (23.8%) were 50 years or older and of those 12 (38.7%) were 60 years and older. Older patients group were more likely to have AIDS defining illness at the time of diagnosis, compared with the younger group [19 (61.3%) vs. 29 (29.3%), respectively]. Of those eight (42%) were older than 60 years. Compared with the younger group, the majority of the HIV-infected patients in the older group who were on ART (61.5%) did not achieve HIV viral suppression at 12 weeks. However, both groups accomplished immune reconstitution with an increase in CD4 cell count in older and younger groups (mean CD4 count = 132 and 200 cell/dl, respectively). More than 80% of patients in both groups were on an integrase inhibitor ART-based regimen.

Conclusion

HIV-infected patients 50 years and older are more likely to present late to care, and to have a delay in HIV viral suppression compared with younger patient group. These findings are alarming and require emphasize on early HIV diagnosis. More data are required to understand the immune response to cART.

Disclosures

All authors: No reported disclosures.

599. Expanding HIV Training in Internal Medicine Residency Program: A Prospect to Meet the HIV Workforce Demand

Background

Methods

Results

Conclusion

Disclosures

Unusual presentation of disseminated Nocardia abscessus infection in a patient with AIDS

A 40-year-old man with AIDS presented with symptoms of a chronic cough, subacute headache, generalised weakness with falls, urinary and faecal incontinence, and acute onset subcutaneous nodules. A chest CT scan showed multiple cavitary and nodular pulmonary infiltrates. MRI of his brain and spinal cord revealed innumerable ring-enhancing lesions. Pathological examination of the purulent material obtained from his subcutaneous lesions, as well as transbronchial tissue specimens obtained by biopsy, revealed beaded and branching Gram-positive rods, subsequently identified by 16S RNA sequencing to be Nocardia abscessus species. We observed an excellent therapeutic response to a combination antimicrobial therapy with resolution of the subcutaneous, pulmonary and central nervous system (CNS) lesions. Infections caused by N. abscessus are rare and typically occur in immunocompromised patients. In this article, we will review the presentation, diagnosis and treatment of N. abscessus infection.

Steroid-exacerbated HIV-associated cutaneous Kaposi's sarcoma immune reconstitution inflammatory syndrome: 'Where a good intention turns bad'

A 51-year-old man with head and neck skin lesions was diagnosed with Kaposi's sarcoma (KS) as his initial presentation of acquired immunodeficiency syndrome. Following initiation of antiretroviral therapy and subsequent full virologic suppression, his facial lesions worsened, consistent with immune reconstitution inflammatory syndrome (IRIS). He was started on glucocorticoids in an attempt to ameliorate the KS-IRIS but experienced paradoxical worsening of the KS lesions. Steroids were subsequently discontinued and he required chemotherapy for severe and cosmetically disfiguring skin lesions. This article describes the potential for worsening of KS lesions in individuals started on glucocorticoids for KS-IRIS as this has been reported rarely in published literature. The mechanisms underlying this phenomenon remain poorly understood but potential explanations are offered in the case discussion. This article aims to raise clinician awareness on the harms of steroid use in patients with KS-IRIS.

Vasopressin-containing neurons of the hypothalamic parvocellular paraventricular nucleus of the jerboa: plasticity related to immobilization stress

The corticotropin-releasing hormone (CRH) neurons of the hypothalamic parvocellular paraventricular nucleus (PVN) have a high potential for phenotypical plasticity, allowing them to rapidly modify their neuroendocrine output, depending upon the type of stressors. Indeed, these neurons coexpress other neuropeptides, such as cholecystokinin (CCK), vasopressin (VP), and neurotensin, subserving an eventual complementary function to CRH in the regulation of the pituitary. Unlike in rats, our previous data showed that in jerboas, CCK is not coexpressed within CRH neurons in control as well as stressed animals. The present study explored an eventual VP participation in the phenotypic plasticity of CRH neurons in the jerboa. We analyzed the VP expression within the PVN by immunocytochemistry in male jerboas submitted to acute stress. Our results showed that, contrary to CRH and CCK, no significant change concerned the number of VP-immunoreactive neurons following a 30-min immobilization. The VP/CRH coexpression within PVN and median eminence was investigated by double immunocytochemistry. In control as well as stressed animals, the CRH-immunopositive neurons coexpressed VP within cell bodies and terminals. No significant difference in the number of VP/CRH double-labeled cells was found between both groups. However, such coexpression was quantitatively more important into the posterior PVN as compared with the anterior PVN. This suggests an eventual autocrine/paracrine or endocrine role for jerboa parvocellular VP which is not correlated with acute immobilization stress. VP-immunoreactive neurons also coexpressed CCK within PVN and median eminence of control and stressed jerboas. Such coexpression was more important into the anterior PVN as compared with the posterior PVN. These results showed the occurrence of at least two VP neuronal populations within the jerboa PVN. In addition, the VP expression did not depend upon acute immobilization stress. These data highlight differences in the neuroendocrine regulatory mechanisms of the stress response involving CRH/CCK or VP. They also underline that adaptative physiological mechanisms to stress might vary from one mammal species to another.

GAT-1 and reversible GABA transport in Bergmann glia in slices

Although glial GABA uptake and release have been studied in vitro, GABA transporters (GATs) have not been characterized in glia in slices. Whole cell patch-clamp recordings were obtained from Bergmann glia in rat cerebellar slices to characterize carrier-mediated GABA influx and efflux. GABA induced inward currents at -70 mV that could be pharmacologically separated into GABA(A) receptor and GAT currents. In the presence of GABA(A/B/C) receptor blockers, mean GABA-induced currents measured -48 pA at -70 mV, were inwardly rectifying between -70 and +50 mV, were inhibited by external Na(+) removal, and were diminished by reduction of external Cl(-). Nontransportable blockers of GAT-1 (SKF89976-A and NNC-711) and a transportable blocker of all the GAT subtypes (nipecotic acid) reversibly reduced GABA-induced transport currents by 68 and 100%, respectively. A blocker of BGT-1 (betaine) had no effect. SKF89976-A and NNC-711 also suppressed baseline inward currents that likely result from tonic GAT activation by background GABA. The substrate agonists, nipecotic acid and beta-alanine but not betaine, induced voltage- and Na(+)-dependent currents. With Na(+) and GABA inside the patch pipette or intracellular GABA perfusion during the recording, SKF89976-A blocked baseline outward currents that activated at -60 mV and increased with more depolarized potentials. This carrier-mediated GABA efflux induced a local accumulation of extracellular GABA detected by GABA(A) receptor activation on the recorded cell. Overall, these results indicate that Bergmann glia express GAT-1 that are activated by ambient GABA. In addition, GAT-1 in glia can work in reverse and release sufficient GABA to activate nearby GABA receptors.

Carrier-mediated uptake and release of taurine from Bergmann glia in rat cerebellar slices

Taurine uptake is essential for the maintenance of millimolar intracellular concentrations of taurine, which is released during ischaemia and is thought to be neuroprotective. To determine whether Bergmann glia express functional transporters that can mediate both taurine uptake and efflux, whole-cell patch-clamp recordings were obtained from these cells in rat cerebellar slices. Taurine-induced inward currents can be pharmacologically separated into GABA(A) receptor and taurine transporter currents. In the presence of GABA receptor blockers, residual taurine currents averaged -28 pA at -70 mV and were strictly inwardly rectifying between -70 and +50 mV. These residual currents were also abolished by external Na+ removal and diminished by reduction of external Cl-, consistent with transport currents. Taurine transport currents were reduced by a taurine transporter inhibitor, guanidinoethyl sulphonate (GES). Other classical inhibitors reduced taurine transport currents with an order of potency (hypotaurine > beta-alanine > GES > GABA) similar to that reported for cloned rat taurine transporters. Following intracellular taurine perfusion during the recording, a progressively developing outward current could be observed at -50 mV but not at -70 mV. Intracellular perfusion of taurine also decreased taurine-induced inward currents at both holding potentials. Outward currents induced by intracellular taurine increased in amplitude with depolarization, activated near -50 mV, and were affected by GES. For the first time, these results demonstrate that taurine activates both GABA(A) receptors and Na+/Cl--dependent taurine transporters in Bergmann glia in slices. In addition, our data show that taurine transporters can work in reverse and can probably mediate taurine efflux under ischaemic conditions.

Surviving cancer competently intervention program (SCCIP): a cognitive-behavioral and family therapy intervention for adolescent survivors of childhood cancer and their families

Psychological reactions to having had childhood cancer often continue after treatment ends, for survivors and their parents. Based on our previous research, we developed an intervention program for adolescent survivors of childhood cancer, their parents, and siblings. Surviving Cancer Competently: An Intervention Program--SCCIP--is a one-day family group intervention that combines cognitive-behavioral and family therapy approaches. The goals of SCCIP are to reduce symptoms of distress and to improve family functioning and development. SCCIP is described and data from a pilot study of 19 families are presented. Program evaluation data indicated that all family members found SCCIP helpful. Standardized measures administered before the intervention and again at 6 months after SCCIP showed that symptoms of posttraumatic stress and anxiety decreased. Changes in family functioning were more difficult to discern. Overall, the results were promising with regard to the feasibility of the program and its potential for reducing symptoms of distress for all family members.

Vitamin D3 deficiency and alterations of glucose metabolism in rat endocrine pancreas

After 5 weeks of vitamin D3 deficiency, rats exhibited signs of rachitism, hypocalcaemia and hypoinsulinaemia. As the glucose-induced insulin release process requires calcium and energy production from glucose metabolism within beta cells of Langerhans islets, several steps in the glycolytic pathway and the tricarboxylic acid cycle within beta cells were investigated in vitro. The sensitivity of islets to glucose was studied during incubations in the presence of crescent concentrations of glucose (4.2 to 16.7 mM). Comparison of 50% maximal insulin response showed no modifications induced by vitamin D3 deficiency despite a large fall in the secretory capacity of beta cells. The use of two secretagogues (D-glucose and D-glyceraldehyde) to stimulate insulin release at two different glycolysis steps gave similar responses during perifusions performed in the presence of crescent concentrations of these nutrients, indicating that vitamin D3 deficiency was not a major influence on the first steps in glycolysis. Glucose utilisation by islets, as determined by 3HOH production from D-[5-3H]glucose, was slightly decreased during glucose stimulation of islets from vitamin D3-deficient rats, whereas glucose oxidation inside the tricarboxylic acid cycle, as measured by 14CO2 production from D-[6-14C]glucose, was severely affected. These data, which suggest that vitamin D3 deficiency affects the glycolytic pathway after the D-glyceraldehyde step and mainly alters oxidative events within the tricarboxylic acid cycle, support the hypothesis of an alteration of mitochondrial metabolism.

Is posttraumatic stress a viable model for understanding responses to childhood cancer?

The application of a trauma model to understanding the impact of life-threatening illness has been informative. In the case of childhood cancer patients, it appears clear that a full PTSD syndrome is not the normative response either during or after treatment. Some aspects of cancer diagnosis and treatment, however, are experienced as traumatic by a subset of children, some of whom report symptoms of posttraumatic stress. There is some evidence that children may respond to cancer treatment as a repeated trauma, with the result of more subtle changes in affect modulation, world view, and interpersonal relationships. This area requires further investigation. The trauma model is also useful in understanding parental responses to childhood cancer. The epidemiologic data to date regarding posttraumatic stress symptoms in parents of childhood cancer survivors is consistent with the trauma literature regarding responses to moderate-magnitude traumatic exposure. These findings have important implications for clinical interventions for families of childhood cancer patients. More research is needed in the prediction and prevention of the long-term distress reported by so many parents of children who have undergone successful treatment for life-threatening illness.

Predictors of posttraumatic stress symptoms in childhood cancer survivors

OBJECTIVE

The diagnosis and treatment of childhood cancer are extremely stressful experiences, with psychological sequelae which can persist many years after the end of treatment. This study investigated the relative contributions of general anxiety, treatment intensity, medical sequelae of treatment, and the subjective appraisal of life threat and treatment intensity to later posttraumatic stress symptoms, such as intrusive memories, avoidance, and hypervigilance.

METHOD

One hundred eighty-six childhood cancer survivors ages 8 through 20 years, off of treatment for more than 1 year, and their parents completed questionnaires. Medical sequelae of treatment and intensity of treatment were rated by a pediatric oncologist.

RESULTS

Significant, independent predictors of persistent posttraumatic stress symptoms included: 1) the survivor's retrospective subjective appraisal of life threat at the time of treatment, and the degree to which the survivor experienced the treatment as "hard" or "scary"; 2) the child's general level of anxiety; 3) history of other stressful experiences; 4) time since the termination of treatment (negative association); 5) female gender; and 6) family and social support. Mother's perception of treatment and life threat contributed to anxiety and subjective appraisal for the survivor, but did not independently contribute to posttraumatic stress symptoms.

CONCLUSIONS

Symptoms of posttraumatic stress seem to decrease with time, but are persistent in a subset of childhood cancer survivors. Other than time and gender, the predictors of posttraumatic stress symptoms are primarily subjective factors (ie, anxiety and subjective appraisal) rather than objective stressors of treatment and medical sequelae.

Involvement of both calcium influx and calcium mobilization in growth hormone-induced [Ca2+]i increases in Chinese hamster ovary cells

This study reports rapid effects of growth hormone (GH) on the intracellular free calcium concentration ([Ca2+]i) in Chinese hamster ovary (CHO) cells stably expressing rabbit GH receptor. [Ca2+]i was measured by spectrofluorimetric methods in single cells and membrane Ca2+ currents by patch clamp techniques in the whole-cell configuration. In individual CHO cells, bathed in a standard saline solution containing 2 mM Ca2+, basal [Ca2+]i was 191 +/- 27 nM (mean +/- S.D.; n=83). Short term administration of GH (100 ng/ml, 30 s) induced a [Ca2+]i increase in 54% of cells tested (n = 398 of 743). Responses were clearly heterogeneous. Maximum calcium increase varied from 16 to 853 nM and time to peak varied from 4 to 320 s. On examination of the [Ca2+]i increases, it was possible to define two different types of calcium responses to GH. Experimental manipulations of extracellular and intracellular calcium concentrations demonstrated that GH-induced calcium increases involved both calcium influx and calcium mobilization. Calcium influx, a long lasting, small amplitude (63 +/- 34 nM) response, was observed in 121 out of 398 cells (30%) whereas calcium mobilization, a transient, large amplitude (263 +/- 175 nM) response, was observed in 277 out of 398 cells (70%). Moreover, patch clamp data show that influx did not involve the dihydropyridine-sensitive calcium channels.