Using an Adaptive Listening Tour and Survey to Promote Faculty Reflection on Diversity, Equity, and Inclusion (DEI) in the Pre-clinical Undergraduate Medical Curriculum

Descriptive studies regarding how to integrate diversity, equity, and inclusion (DEI) into medical education are lacking. We utilized the AAMC's Key Steps for Assessing Institutional Culture and Climate framework to evaluate our current curriculum via listening tours (n = 34 participants) and a survey of the 10 pre-clinical block directors, to better understand the opportunities and challenges of improving DEI in the pre-clinical curriculum. Opportunities included diversifying cases and standardized patients, enhancing information on systemic racism and social determinants of health, and increasing racial humility and population genetics/epigenetics training. Faculty had issues with "correct ways" to incorporate DEI and time constraints.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01924-7.

Perceptions of the COVID-19 Vaccination Within a Convenience Sample of Sudanese Americans

INTRODUCTION

Sudanese American and other immigrant and refugee communities are at greater risk for exposure to COVID-19. This survey sought to better characterize COVID-19 vaccination practices, motivators, and drivers for hesitancy among Sudanese Americans.

METHODS

We developed an online, cross-sectional survey in English and Arabic distributed by Sudanese American community leaders in April 2022 with data stored anonymously in REDCap. Inclusion criteria were self-reporting being born within Sudan and living in the US within the last 2 years. Descriptive analysis tested survey responses for possible associations between the primary outcome, self-reported vaccination status, and questions regarding vaccination history, perspectives on vaccination, and demographic characteristics using Fishers Exact and Chi Squared Tests.

RESULTS

Of 111 survey responses received, 107 met inclusion criteria. 93% of respondents reported COVID-19 vaccine uptake with the primary motivation to protect oneself from disease. The most cited reason for vaccine hesitancy was belief it had not been studied enough. The group that reported vaccination had higher levels of education (.032) and were more likely to perceive that COVID-19 vaccinations were able to reduce spread (.001), decrease severe outcomes (.004), and benefits outweighing their risks (.004).

DISCUSSION AND CONCLUSIONS

This survey population of Sudanese Americans demonstrated high levels of vaccine uptake (93%), far greater than either the corresponding US (78%) or Sudanese population (15%). It is likely that high levels of educational attainment moderated vaccine uptake, though our survey may not have had the power to fully evaluate vaccine hesitancy.

Fluorescence-guided photoimmunotherapy using targeted nanotechnology and ML7710 to manage peritoneal carcinomatosis

Fluorescence-guided intervention can bolster standard therapies by detecting and treating microscopic tumors before lethal recurrence. Tremendous progress in photoimmunotherapy and nanotechnology has been made to treat metastasis. However, many are lost in translation due to heterogeneous treatment effects. Here, we integrate three technological advances in targeted photo-activable multi-agent liposome (TPMAL), fluorescence-guided intervention, and laser endoscopy (ML7710) to improve photoimmunotherapy. TPMAL consists of a nanoliposome chemotherapy labeled with fluorophores for tracking and photosensitizer immunoconjugates for photoimmunotherapy. ML7710 is connected to Modulight Cloud to capture and analyze multispectral emission from TPMAL for fluorescence-guided drug delivery (FGDD) and fluorescence-guided light dosimetry (FGLD) in peritoneal carcinomatosis mouse models. FGDD revealed that TPMAL enhances drug delivery to metastases by 14-fold. ML7710 captured interpatient variability in TPMAL uptake and prompted FGLD in >50% of animals. By combining TPMAL, ML7710, and fluorescence-guided intervention, variation in treatment response was substantially reduced and tumor control improved without side effects.

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

Background

The approval of long-acting injectable cabotegravir/rilpivirine (LAI CAB/RPV) heightened the urgency of ensuring effective implementation. Our study assesses readiness and barriers to implement LAI CAB/RPV across Ryan White-funded clinics in the United States.

Methods

We conducted a cross-sectional survey between December 2020 and January 2021 using validated 4-item measures: acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM). Associations between measures and clinic characteristics were evaluated via Spearman rank correlations. A 5-point Likert scale ranked potential barriers of implementation responses. Open-ended questions were analyzed through a thematic approach.

Results

Of 270 clinics, 44 (16%) completed the survey: 38% federally qualified health centers, 36% academic, 20% community-based organizations, 14% hospital outpatient, and 9% nonprofit. Means (SD; range) were as follows: AIM, 17.6 (2.4; 12-20); IAM, 17.6 (2.4; 13-20); and FIM, 16.8 (2.9; 7-20). Twenty percent were not at all ready to implement LAI CAB/RPV, and 52% were slightly or somewhat ready. There was a significant association between AIM and the proportion of Medicaid patients (AIM, rho = 0.312, P = .050). Community-based organizations scored the highest readiness measures (mean [SD]: AIM, 19.50 [1.41]; IAM, 19.25 [1.49]; FIM, 19.13 [1.36]) as compared with other clinics. Implementation barriers were cost and patients' nonadherence to visits.

Conclusions

There is variability of readiness yet high levels of perceived acceptability and appropriateness of implementing LAI CAB/RPV among Ryan White clinics, necessitating tailored interventions for successful implementation. A special focus on addressing the barriers of adherence and the cost of implementation is needed.

Effectiveness and Safety of Bictegravir/Emtricitabine/Tenofovir Alafenamide in Patients With HIV-1 Infection and Ongoing Substance Use Disorder: The BASE Study

Background

People with human immunodeficiency virus (HIV) and substance use disorder (PWH/SUD) are at higher risk of nonadherence to antiretroviral therapy. Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) exhibits high rates of efficacy with a favorable adverse event profile. The BASE study (NCT03998176) is a phase 4, single-arm study evaluating the effectiveness and safety of B/F/TAF among PWH/SUD.

Methods

Viremic (HIV RNA >1000 copies/mL) PWH/SUD initiated B/F/TAF once daily for 48 weeks (W). The primary endpoint was proportion of participants with HIV RNA <50 copies/mL at W24. Secondary endpoints were proportion of participants with HIV-1 RNA <50 copies/mL at W48, safety, B/F/TAF adherence (dried blood spot [DBS] concentrations of emtricitabine triphosphate and tenofovir diphosphate [TFV-DP]), substance use (NIDA-ASSIST), and quality of life (SF-12).

Results

Forty-three participants were enrolled; 95% reported methamphetamine use. Median age was 38 (range, 21-62) years; 21% were female, 81% White, 14% Black, and 16% Hispanic. Thirty-two (74%) and 21 (49%) participants had HIV RNA <50 copies/mL (intention-to-treat) at W24 and W48, respectively. Seven participants (16%) experienced confirmed virologic failure through W48; 1 developed emergent drug resistance (M184V). Fifteen participants (35%) experienced grade ≥3 adverse events. Five participants (12%) reported suicidal ideation; none resulted in discontinuation. Median DBS concentrations were representative of 5-6 doses/week (TFV-DP, 1603 fmol/punches). NIDA-ASSIST scores declined from baseline to W48 with methamphetamine use decreasing most (-7.9 points; -29%), and SF-12 physical/mental scores increased 1.2 and 7.6 points, respectively.

Conclusions

B/F/TAF among a high-risk population of PWH/SUD resulted in an initial 72% viral suppression rate at W24 before dropping to 49% at W48 as retention declined. One participant developed emergent drug resistance (M184V).

1286. Telehealth Utilization and 2-year Outcomes among People with HIV at a Midwestern Clinic

Background

Telehealth platforms such as video and telephone visits serve as mechanisms for HIV care delivery during the COVID-19 pandemic. While telehealth may be instrumental in HIV care, its utilization, sustainability, and impact on patients’ outcomes remain an area for further research. Hence, we compared people with HIV (PWH) utilizing telehealth services to those receiving in-person clinic services at Nebraska's largest HIV clinic in Omaha.

Methods

HIV Care visits were classified into telehealth and in-person visits. We defined telehealth users as PWH who have utilized telephone or video visits at least once between April 2020 to March 2022. Clinical and demographic comparisons between both groups were made. We conducted bivariate analyses and descriptive statistics for associations and proportions of visit type, viral loads (VL), and completed visits.

Results

A total of 4,473 visits were completed among 1,308 unique patients (172 telehealth users versus 1136 in-person). Telehealth utilization was significantly higher among patients from cities other than Omaha (&lt; 0.001) and those with income levels above the Federal Poverty Line (FPL) (0.001). Telehealth users made up 73.3% of missed appointments and 50% of canceled visits. Telehealth users were significantly more likely to have undetectable VL than in-person visit users (0.018). In addition, patients who were ≥ 45 years were significantly more likely to have undetectable VL than younger patients (&lt; 0.001).

There was no association between gender, race, or year of HIV diagnosis and visit type. Notably, transgender patients (n = 18) did not use telehealth.

Overall telehealth utilization dropped from 64% of our total visits in April 2020 to 5% in March 2022.

Conclusion

In our patient population, telehealth users were more likely to have undetectable VL, live far from the clinic, and have income levels above the FPL than in-person visit users. However, telehealth users were more likely to cancel or miss their medical appointments. Our data also suggest a low preference for telehealth among transgender people. Future studies should develop strategies to improve rates of completed visits among telehealth users, promote telehealth use among transgender men, and sustain the utilization of telehealth beyond the pandemic.

Disclosures

All Authors: No reported disclosures.

1910. A Highly Effective ID Physician and Infection Preventionist-led Interactive Webinar Series for Infection Prevention and Control Training Among Frontline Healthcare Workers

Background

Nebraska Infection Control Assessment and Promotion Program (ICAP) is funded by Nebraska Department of Health and Human Services through Centers for Disease Control and Prevention (CDC) grants to support Infection Prevention and Control (IPC) activities in the state. In early 2022, ICAP launched COVID-19-specific basic infection prevention and control (IPC) training to frontline healthcare providers (HCPs) through a discussion-based webinar series using curricular materials created by the CDC Project Firstline. Here, we report pre- and post-training survey responses demonstrating improvement in participants' perceived knowledge across a number of IPC domains.

Methods

Training was completed over a 14-week period via a weekly, interactive 30-minute webinars with a new topic covered each week. A survey was administered to participants prior to the webinar series and at the conclusion of training to assess effectiveness. The pre-survey evaluated HCP confidence in their knowledge of each of the 14 topics to be covered in the course. The post-survey evaluated both confidence and perceived value in each of the training topics.

Results

Prior to the training series, a mean 40.3% of participants judge themselves “very confident” in IPC topics, versus 52.7% “somewhat confident” and 7.1% “not confident” (figure 1); by the end of the training, these levels had improved to 85.4%, 14.3%, and 0.4%, respectively (figure 2). The largest gains in the category “very confident” concerned “source control” (+65%) and “COVID-19 variants” (+63%). A majority of participants perceived each topic covered in the series to be “very valuable” (figure 3); 98% of participants indicated interest in a future IPC training series and 95% indicated that they would recommend the training series to a colleague. Figure 1Results of a pre-course survey on knowledge of training topics completed by participants.Figure 2Results of a post-course survey on knowledge of training topics completed by participants.Figure 3Results of a post-course survey on value of the training course completed by participants.

Conclusion

This survey data suggests that a discussion-based webinar using CDC Project Firstline materials is highly effective at conveying fundamental concepts in infection control to frontline HCPs. Moreover, HCPs rated themselves as likely to return, suggesting this format is a promising modality for simple and widespread dissemination of IPC training.

Disclosures

M. Salman Ashraf, MBBS, Merck & Co. Inc: Grant/Research Support.

1962. Perceptions of the COVID-19 Vaccine within the Sudanese-American Community

Background

One of the primary issues affecting COVID-19 vaccine uptake in high-income countries is vaccine hesitancy, which is prevalent in people from different countries of origin. Characterizing vaccine uptake in immigrant and refugee populations in the US could provide a unique window into both local and global health behaviors. The goal of this project is to characterize Sudanese American perspectives on the COVID-19 vaccine.

Methods

We conducted an anonymous, online, anonymous, cross-sectional survey directed toward Sudanese Americans, with survey development guided by principles from the Vaccine Examination Scale. The survey was distributed in both English and Arabic and included questions about vaccination history, motives for getting the vaccination, reasons for vaccine hesitancy, and barriers to vaccination. Fisher’s exact tests were used to analyze evaluate possible associations between vaccine uptake and sources of information on the vaccine and social media use, respectively. Data analysis was conducted using STATA SE v17.0 (StataCorp, College Station, TX).

Results

A total of 108 survey responses were received; 4 were excluded for failing to meet inclusion criteria. A total of 92% received at least one dose of COVID-19 vaccine, with the primary motivation being to protect oneself (62%). Only 8 had not been vaccinated and, of those, 2 were willing to take the vaccine. Of the 6 unwilling to take the vaccine, the most cited reason was a belief that it had not been studied enough. Of the 14 possible hesitancy responses, 9 were selected at least once.

When asked about their primary source of information on COVID-19, 44% used government websites, followed by mass media (22%), social media (12%) and health personnel (11%). Using Fisher’s exact tests, no statistically significant conclusions were drawn between vaccine uptake and primary source of information (P = .097) or specific types of social media.

Conclusion

Vaccine uptake among our survey population (92%) was much higher than that of the US (77%) or Sudanese population (11%). Overall motivators for vaccine hesitancy and vaccine uptake varied and no specific correlations were found to be associated to vaccine uptake. Future research should evaluate high levels of vaccine uptake in this community.

Disclosures

All Authors: No reported disclosures.

1258. B/F/TAF in HIV-Infected Adults with Substance Use Disorders: BASE Week 48 Results

Background

People with HIV (PWH) and substance use disorders (SUD) are at higher risk of non-adherence. Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) exhibits high rates of efficacy with a favorable adverse event profile. The BASE study (NCT03998176) is a Phase 4, single-arm study evaluating the effectiveness and safety of B/F/TAF among PWH and SUD.

Methods

Viremic (HIV RNA &gt;1000 copies [c]/mL) treatment-naïve or -experienced PWH and ongoing SUD initiated B/F/TAF once daily for 48 weeks (W). The primary endpoint was HIV RNA &lt; 50 c/mL (FDA Snapshot Algorithm) at W48. Secondary endpoints were safety, adherence (dried blood spot [DBS] levels of emtricitabine-triphosphate [FTC-TP] and tenofovir-diphosphate [TVF-DP]), substance use (NIDA ASSIST) and quality of life (SF-12).

Results

Forty-three participants enrolled; 95% reported methamphetamine use. Median age was 38 years (range: 21-62); 19% female, 81% White, 14% Black, 16% Latinx. At W48, 21 participants (49%) had HIV RNA &lt; 50 c/mL (ITT, Figure 1). Four participants (9%) experienced confirmed virologic failure; none developed treatment-emergent resistance. Seventeen participants (40%) experienced grade ≥3 adverse events; none attributed to B/F/TAF. Five participants reported suicidal ideation; none resulted in discontinuation. Observed mean FTC-TP and TVF-DP concentrations in DBS corresponded to 5-6 doses/week (FTC-TP: &gt;3.6 pmol/7mm punches; TVF-DP: &gt;1733 fmol/7 mm punches; Figure 2). NIDA ASSIST scores declined from baseline, with methamphetamine use decreasing most (-7.9 points; -29%). SF-12 physical/mental scores increased 1.2 and 7.6 points, respectively, but remained below mean US scores.

Longitudinal virologic outcomes, intent-to-treat analysis

Mean observed intracellular emtricitabine triphosphate (FTC-TP) and tenofovir diphosphate (TFV-DP) in dried blood spots at weeks 6, 24, and 48

Thresholds for 2-3 doses/week (Solid Line) and 4-5 doses/week (Dashed Line) are noted for both FTC-TP and TFV-DP based on TAF-DBS data [Yager J, et al. JAIDS, 2020].

Notes: Y-axis represents femtomoles/punches

Conclusion

B/F/TAF among a high-risk population of PWH and ongoing SUD resulted in a 49% viral suppression rate at W48. No emergent resistance was noted supporting the high barrier to resistance provided by B/F/TAF.

Disclosures

Sara H. Bares, MD, Gilead Sciences: Expert Testimony|GSK ViiV Healthcare: Grant/Research Support|Janssen: Grant/Research Support Kimberly Scarsi, PharmD, Organon: Grant/Research Support.

Structural vulnerability among patients with HIV and SARS-CoV-2 Co-infection: descriptive case series from the U.S. Midwest

HIV and COVID-19 disproportionately impact marginalized populations, especially racial and ethnic minorities. This descriptive case series from an HIV clinic in the U.S. Midwest explores the sociodemographic and clinical characteristics of 37 individuals with HIV and SARS-CoV-2 co-infection. All 37 had suppressed viral loads prior to diagnosis with COVID-19, and all 37 survived. Relative to our overall HIV clinic population, over twice as many Hispanic patients, three times as many undocumented patients, and four times as many refugee patients contracted COVID-19, highlighting the structural vulnerability of these sub-populations.

The Value of a Longitudinal HIV Track for Medical Students: Ten-Year Program Evaluation

We surveyed graduates of a longitudinal medical school human immunodeficiency virus curriculum to evaluate its impact. Respondents felt comfortable caring for people with human immunodeficiency virus (PWH) and found value from the curriculum regardless of ultimate career path. Programs like this contribute to the development of culturally sensitive clinicians comfortable caring for PWH.

Antiretroviral refill histories as a predictor of future HIV viremia

Background

The use of adherence measures as markers for virologic failure (VF) has been studied. Yet, there is currently no single adherence metric recommended for VF. Antiretroviral prescription refill histories, for people living with human immunodeficiency virus (HIV), are readily accessible and can be easily quantified to an estimated adherence level.

Methods

Participants from a Midwestern US HIV clinic were retrospectively evaluated from 2018 to 2020. Refill histories (RH) and last HIV RNA for each participant were abstracted for each study year. RH were quantified as a percentage of days covered (PDC) and VF was defined as HIV RNA >200 copies/mL. PDC values were matched with subsequent year HIV RNA (matched pair). Sample t test were used to compare mean PDC level by viral suppression status and generalized estimating equations models were used to determine the predictability of PDC level for VF. An optimal PDC threshold for VF was determined using receiver operating characteristic curve analysis and Youden index.

Results

A total of 1056 participants contributed to 1923 matched pairs (PDC/HIV RNA); mean age was 48.3 years, 24% women, and 30.6% Black. PDC levels differed significantly based on dichotomized HIV RNA (2018–2019: >200: 40% [95% confidence interval {CI}, 33%–46%] vs ≤200: 85% [95% CI, 84%–87%], P < .0001; 2019–2020: >200: 45% [95% CI, 38%–51%] vs ≤200: 87% [95% CI, 86%–89%], P < .0001). Based on the Youden index value of 0.66 (sensitivity 0.77, specificity 0.89), the optimal PDC threshold predictive of VF was 52%.

Conclusions

Lower antiretroviral therapy (ART) adherence levels were predictive of future VF when PDC ≤52%.

Low Rates of Lung Cancer Screening Referrals in Patients With Human Immunodeficiency Virus: A Correlational Study

People living with HIV (PLWH) have an increased risk of lung cancer compared to the general population. In 2013, the United States Preventive Services Task Force (USPSTF) released their lung cancer screening (LCS) guidelines. However, the impact of these guidelines has not been well established in PLWH. The objective of this retrospective descriptive study is to evaluate the frequency of lung cancer screening referrals and factors associated with LCS referrals using the 2013 USPSTF screening guidelines in at-risk PLWH. We collected demographic and clinical information on PLWH from electronic medical records from July 2016 to July 2018. Descriptive statistics, chi-square tests, t-tests, Wilcoxon rank sum tests, and Fisher’s exact tests were used for analysis. Only 14% of patients who met 2013 USPSTF screening guidelines were referred for screening. Patients who received a referral were more likely to have received tobacco cessation counseling. Patients who received and completed a referral were more likely to have hepatitis C infection. Quality improvement strategies are needed to improve rates of LCS in PLWH.

878. Telemedicine Implementation in a Midwestern HIV Clinic: One Year Outcomes

Background

During the COVID-19 pandemic, we realized the importance of limiting in-clinic interactions with patients who were stable on antiretroviral therapy to promote social distancing. Our HIV clinic adopted telemedicine practices, in line with the HHS Interim Guidance for COVID-19 and Persons With HIV. Several HIV clinics reported lower viral suppression rates during the pandemic. We aim to describe the implementation process as well as year one outcomes of telemedicine at our clinic.

Methods

In March 2020, we created telemedicine protocols; we also designed and continuously updated algorithms for determining patient eligibility for telemedicine based on recent viral loads and last clinic visit. We monitored outcomes through electronic medical record chart reviews between May 1, 2020, and April 30, 2021. We collected patient demographics, and federal poverty level (FPL) information. We collected baseline and post-intervention rates of viral load suppression (VLS, defined as HIV RNA < 200 copies per mL), medical visit frequency (MVF, defined as percentage of patients who had one visit in each 6 months of the preceding 24 months with at least 60 days between visits) and lost to care (LOC, no follow up within 12 months period).

Results

We conducted a total of 2298 ambulatory medical visits; 1642 were in person and 656 (29%) were telemedicine visits. Out of those, 2177 were follow up visits (649, 30% telemedicine). There was no difference of telemedicine utilization based on race (28% in African Americans vs. 32% in Whites); ethnicity (30% in Hispanic vs. 30% in Hon-Hispanic); gender (24% in females vs. 30% in males); or FPL (28% in FPL < 200% vs. 31% in FPL >200%). By the end of April 2021, overall clinic VLS rate was 94%, MVF was 48%, and there were 40 patients LOC compared to 92%, 49%, and 43 patients in April 2020, respectively.

Conclusion

Telemedicine was a safe alternative to routine in-person HIV care during the COVID-19 pandemic. We observed similar rates of utilization across demographic and FPL status. Applying selection criteria, viral suppression and retention in care rates were not adversely impacted by shift to telemedicine modality.

Disclosures

All Authors: No reported disclosures

884. Title: Factors Associated with Lack of Viral Suppression Among Women Living with HIV in the United States: An Integrative Review

Background

Women account for 19% of new HIV cases in the United States (US). Transgender women are 49 times more likely than other groups to be diagnosed with HIV. HIV is one of the top ten causes of death among women between 25 to 44 years. Adherence to antiretroviral therapy (ART) and consequent viral suppression (VS) are keys to preventing sexual transmission, risk of drug resistance, and improving health outcomes. Hence, it is essential to identify factors behind VS in women living with HIV (WLWH).

Methods

This review identified and synthesized peer-reviewed studies describing reasons for lack of VS among WLWH in the US. : Using the PRISMA model, we searched CINAHL, PubMed, Embase, Scopus, and PsycINFO, then selected US studies published from 2010 to April 2021. Studies that included men, non-adults, ongoing studies, and foreign studies were excluded. 1,359 studies were assessed and screened for duplicate and eligibility.

PRISMA Model

Results

15 studies were eligible for review; 8 included all WLWH, 5 focused on pregnant WLWH, 1 included only African American WLWH and 1 included only transgender WLWH. Based on study participants and findings, results were divided into pregnancy and non-pregnancy-related factors. Pregnancy-related factors: Early ART initiation and group prenatal care improved care retention and VS. WLWH in cities were more likely to be virally suppressed at delivery than those in rural regions. Intimate partner violence (IPV) was associated with poor ART adherence and time to achieve stable VS. Also, being postpartum was associated with high viral load regardless of ART. Non-pregnancy-related factors: The most reported common factors were substance use and IPV. Other factors included social determinants of health, age, race, health insurance, income, number of pills, and regimen. Transgender-specific factors were stress, race, age, relationship, transphobic experiences, gender satisfaction, and adherence to hormone therapy.

Conclusion

Substance use, income, mental health, health insurance, race, and ART regimen were the most common factors associated with VS in WLWH. There was paucity of data on transgender-specific VS factors. More research is needed to explore VS and treatment adherence amongWLWH, especially transgender women.

Disclosures

All Authors: No reported disclosures

464. Structural Vulnerability among Patients with HIV and SARS-CoV-2 Coinfection: Descriptive Case Series from the U.S. Midwest

Background

It is well known that the HIV epidemic and COVID-19 pandemic have both disproportionately harmed marginalized minority and immigrant communities in the United States. The risk factors associated with disease incidence and outcomes reaffirm that structural vulnerabilities—sociopolitically imposed risk factors like discrimination, legal status, poverty, and beyond which impact a patient’s opportunity to achieve optimal health—play a key role in facilitating the inequitable harms of COVID-19 and HIV alike. This study explores the role of structural forces in increasing the risk of SARS-CoV-2 coinfection among people with HIV (PWH).

Methods

We performed a retrospective chart review of PWH receiving care at the University of Nebraska Medical Center HIV clinic in Omaha, Nebraska, to collect patient demographics, comorbidities, HIV outcomes, and COVID-19 outcomes for 37 patients with HIV and SARS-CoV-2 coinfection as of August 27, 2020. As a comparison group, we obtained demographic data from a registry of all patients seen at the HIV clinic. We used R Statistical Software to perform descriptive statistical analysis.

Results

Relative to our overall HIV clinic population, over twice as many Hispanic patients (35.1% vs. 16.0%), three times as many undocumented patients (13.5% vs. 4.2%), and four times as many refugee patients (16.2% vs. 4.0%) had COVID-19. The majority (67.6%) of coinfected patients reported working in “essential” jobs during the pandemic. Thirty-four of the 37 people with HIV and COVID-19 (PWHC) had at least one comorbidity, including increased BMI (83.7%), hypertension (64.9%), or hyperlipidemia (48.6%). All 37 PWHC remained alive as of October 4, 2020.

Demographics and HIV Disease Progression of People with HIV and SARS-CoV-2 Coinfection vs. Overall HIV Clinic Registry

Demographics and HIV Disease Progression of People with HIV and SARS-CoV-2 Coinfection vs. Overall HIV Clinic Registry (continued)

Conclusion

The disproportionate burden of SARS-CoV-2 coinfection on Hispanic, undocumented, and refugee PWH may be a product of structural vulnerabilities contributing to greater risk of exposure. Although all 37 PWHC had well-controlled HIV and relatively mild COVID-19 courses, the broader theme of disproportionate COVID-19 incidence among vulnerable sub-populations of people with HIV reaffirms the importance of structural interventions to mitigate current and downstream harms.

Disclosures

All Authors: No reported disclosures

1196. A Multi-faceted, Iterative Program to Increase COVID-19 Vaccine Uptake in a Midwestern HIV Clinic

Background

The National Institutes of Health Office of AIDS Research recommend that patients with HIV be prioritized for COVID-19 vaccination due to high rates of co-morbidities and sociodemographic risk factors that place them at increased risk for severe disease. However, COVID-19 vaccines were not distributed specifically to those in high-risk medical categories in Nebraska, and HIV clinics were not included in the state’s COVID-19 vaccine delivery system. As a result, barriers to vaccine uptake emerged and interventions to mitigate them were needed.

Methods

A multi-faceted and iterative program aimed at improving COVID-19 vaccine uptake was implemented at the University of Nebraska Medical Center’s (UNMC) HIV clinic in Omaha, Nebraska in January 2021. A multidisciplinary task force was established in late January 2021 and met on a weekly basis to provide staff and patient education, linkage to vaccines, and review and analysis of vaccine completion rates as shown in the figure. Outreach interventions were continuously revised based on patient and staff feedback as well as updated data and vaccine availability.

Multidisciplinary COVID-19 Task Force Overview

Results

All 1188 patients of the UNMC HIV clinic were ultimately eligible for the COVID-19 vaccine, but availability was on a rolling basis by age group, profession, county, and, ultimately, co-morbidities. 76% were male, 45.8% non-white, median age 48, and 73% had income less than 400% of federal poverty level. Of the 1188 eligible patients, 63.1% (n=751) had received at least one dose the COVID-19 vaccine and 59.3% (n=705) had completed the COVID-19 vaccine series by June 4, 2021. In comparison, 49.32% of the population of the state of Nebraska had initiated the COVID-19 vaccine series and 43.12% had completed the vaccine series by that date. Among our clinic patients, 27.9% (n=261) of those who had received at least one vaccine were assisted by our task force. 4.5% were noted to have a potential barrier at the time of outreach and these included hesitancy (3.5%), language (1.2%) and transportation (0.9%).

Conclusion

A multi-faceted and iterative program to improve COVID-19 vaccine uptake in a high-risk patient population resulted in high rates of vaccine completion.

Disclosures

Sara H. Bares, MD, Gilead Sciences (Grant/Research Support)Janssen (Grant/Research Support)ViiV Healthcare (Grant/Research Support)

A Midwestern Academic HIV Clinic Operation during the COVID-19 Pandemic: Implementation Strategy and Preliminary Outcomes

During the COVID-19 pandemic, HIV clinics had to transform care delivery for people with HIV (PWH). We developed a multifaceted telehealth implementation strategy and monitored number of out of care patients (OOC), medical visit frequency (MVF), gap in care (GiC) and viral suppression (VS), and compared measures to baseline data. Between April and October 2020, 1559 visits were scheduled; 328 (21%) were missed, and 63 (4%) were new to care. Of the remaining 1168 follow-up visits, 412 (35%) were telehealth visits. As of October 2020, there were 53 patients OOC, MVF was 55% and GiC was 24% compared to 34, 69% and 14% at baseline, respectively. Overall VS rate remained high at 93% (97% for telehealth and 91% for in-person visits, p = 0.0001). Our implementation strategy facilitated quick provision of telehealth to a third of PWH receiving care in our clinic. While MVF decreased and GiC increased, VS rates remained high.

Addressing and Inspiring Vaccine Confidence in Black, Indigenous, and People of Color During the Coronavirus Disease 2019 Pandemic

During the coronavirus disease 2019 (COVID-19) pandemic, we have witnessed profound health inequities suffered by Black, Indigenous, and People of Color (BIPOC). These manifested as differential access to testing early in the pandemic, rates of severe disease and death 2-3 times higher than white Americans, and, now, significantly lower vaccine uptake compared with their share of the population affected by COVID-19. This article explores the impact of these COVID-19 inequities (and the underlying cause, structural racism) on vaccine acceptance in BIPOC populations, ways to establish trustworthiness of healthcare institutions, increase vaccine access for BIPOC communities, and inspire confidence in COVID-19 vaccines.

Acute psychosis associated with recent SARS-CoV-2 infection: A case report

The COVID-19 pandemic has created overwhelming circumstances not only in the medical field, but in other walks of life. SARS-CoV-2, the causative virus of COVID-19 [1], primarily affects the respiratory system leading to respiratory illnesses of varying severity ranging from mild flu-like symptoms to acute respiratory distress syndrome [2]. However, the clinical manifestations of COVID-19 are not limited to the respiratory system [3]. There is a growing body of literature showing the incidence of a varying clinical spectrum of neuropsychiatric manifestations in a significant proportion of COVID-19 patients [4]. With the variability in neuropsychiatric presentation of COVID- 19, multiple mechanisms have been proposed to explain the pathophysiology of these presentations [5]. In this case report, we present a 20-year-old female with no significant respiratory symptoms or previous history of psychotic episodes who manifested with acute psychosis as a significant complication of COVID-19.

Re-opening Sudan: the Balance Between Maintaining Daily Living and Avoiding the Next Peak of COVID-19

Purpose of the Review

To describe the intersectionality of healthcare and economy, and potential solutions to prevent the next peak of COVID-19 in Sudan.

Recent Findings

Sudan has recently emerged from a 30-year dictatorship to face the COVID-19 pandemic in the midst of the worst economic crisis. Disease control measures that have been used in developed countries have been difficult to implement in Sudan due to economic, social, and structural challenges. There is a need for integration of data into the disease response plan and for community engagement to help with mitigation efforts. Youth-led community organizations were critical in the success of the Sudanese revolution. Their formal involvement in contact tracing and community awareness campaigns can be beneficial.

Summary

The COVID-19 pandemic has brought to the surface many of the challenges facing the healthcare system in Sudan. Culturally tailored interventions are needed to prevent the next peak of COVID-19 in the country.

Cultural Competence and Humility in Infectious Diseases Clinical Practice and Research

Infectious diseases as a specialty is tilted toward social justice, and practitioners are frequently on the front lines of the battle against health inequity in practices that are diverse and sometimes cross international borders. Whether caring for patients living with the human immunodeficiency virus, tuberculosis, or Ebola, infectious diseases practitioners often interact with those at the margins of societies (eg, racial/ethnic/sexual/gender minorities), who disproportionately bear the brunt of these conditions. Therefore, cultural barriers between providers and patients are often salient in the infectious diseases context. In this article, we discuss cultural competence broadly, to include not only the knowledge and the skills needed at both the organizational and the individual levels to provide culturally appropriate care, but also to include "cultural humility"-a lifelong process of learning, self-reflection, and self-critique. To enhance the quality and the impact of our practices, we must prioritize cultural competence and humility and be mindful of the role of culture in the patient-provider-system interactions, in our larger healthcare systems, and in our research agendas and workforce development.

112. A Quality Management Project of a Midwestern Academic HIV Clinic Operation During COVID-19: Implementation Strategy and Preliminary Outcomes

Background

During the COVID-19 pandemic, HIV clinics had to transform care delivery in order to ensure retention in care (RIC) for people with HIV (PWH). The objective of this quality management project is to maintain high rates of RIC and viral load suppression (VLS) during the pandemic for PWH receiving services at an academic HIV clinic in the Midwest.

Methods

We developed a multifaceted implementation strategy for clinic operation using a combination of telehealth and in-person visits. The strategy included: 1) assess for readiness and identify barriers and facilitators, 2) identify and prepare champions, 3) organize clinician implementation meetings, and 4) staff training. As a result, we developed an implementation blue print with criteria for telehealth vs. office visits, criteria for rescheduling patients, conducted staff training on telehealth and personal protective equipment, and changed the clinic structure to accommodate in-person visits for patients who did not meet telehealth criteria and walk-ins. We monitored VLS (defined as HIV RNA < 200 copies per mL) and RIC as measured by medical visit frequency (MVF, defined as percentage of patients who had one visit in each 6 months of the preceding 24 months with at least 60 days between visits); and gap in care (GiC, defined as no visit in the preceding 6 months).

Results

As of June 14, 2020, there were 1140 active PWH receiving care at the clinic. By February 29, 2020 there were 34 patients lost to care as (defined as no visit within the preceding 12 months). Between March 1 and June 14, 2020 we conducted a total 943 visits, out of which 642 (68%) were in person and 301 (32%) were telephone visits. By end of May 2020, there were 47 patients lost to care. MVF decreased to 40% compared to 69% for FY2020, and GiC increased to 25% compared to 14% for FY2020. VLS rate remained unchanged at 91%.

Conclusion

The COVID-19 pandemic resulted in a decrease in MVF and an increase in GiC for PWH. However, VLS remained high at 91%. Our implementation strategy facilitated quick adoption of telemedicine, which helped us provide clinical care to a third of PWH during the pandemic. Telemedicine provided a great tool for ensuring patients remain VLS. Evaluation of implementation outcomes including fidelity and reach remains ongoing.

Disclosures

All Authors: No reported disclosures

942. Lung Cancer Screening in at-risk patients with HIV in a Midwestern Clinic

Background

Patients with HIV (PWH) have an increased risk of lung cancer compared to the general population. In 2013, the U.S. Preventive Services Task Force (USPSTF) released their lung cancer screening (LCS) guidelines for the general population. The objective of this study is to evaluate the frequency of and factors associated with LCS using computed tomography in at-risk PWH.

Methods

A retrospective chart review of patients 55-80 years old seen at a Midwestern HIV Clinic between July 1, 2016 to June 30, 2018 was conducted. Demographic, clinical, laboratory, and referral for LCS information were collected. Descriptive statistics and logistic regression models were used for analysis.

Results

We reviewed 347 patients, out of whom 91 were excluded for the following reasons: never smoked (8), deceased (38), pack history unknown (39), and prior lung cancer diagnosis (6). Mean (sd, range) for age was 61 (5.0, 55-78). A total of 256 patients were included in the analysis, out of whom 104 (41%) met the USPSTF criteria. No effect was identified for demographic information including race, ethnicity, gender, or insurance status on LCS referral. LCS referral was made for 22 out of 256 patients (9%) (13% of patients who met the USPSTF criteria and 5% of those who did not). Patients who received tobacco cessation counseling (OR 7.83, P=0.047) and with hepatitis C infection (OR 4.32, P=0.002) were more likely to receive LCS referral. Out of those who received LCS referral, 12/22 (55%) completed the referral. Patients with hepatitis C infection were more likely to complete LCS referral (OR 8, P=0.038).

Conclusion

Only 13% of patients who met USPSTF criteria were referred for LCS. Patients who received tobacco cessation counseling were more likely to receive a referral. Patients with hepatitis C infection were more likely to receive and complete LCS referral. Quality improvement efforts to improve rates of LCS in PWH are needed. Future prospective studies should examine the factors associated with LCS in PWH.

Disclosures

Sara H. Bares, MD, Gilead Sciences (Grant/Research Support)

Impact of Pharmacy Type on HIV Viral Suppression: A Retrospective Cross-Sectional Cohort Study

Background

People with HIV (PWH) use various pharmacy types beyond traditional local pharmacies. Some specialized pharmacies offer additive adherence services such as refill reminders, expedited delivery, and adherence packaging.

Methods

This single-center, retrospective cohort study evaluated the impact of pharmacy type on the gain or loss of HIV viral suppression (VS; HIV RNA ≤50 copies/mL). Patients (≥19 years) were categorized by VS and pharmacy type: HIV-specialized (additive adherence/delivery services) vs traditional (without adherence/delivery services). Fisher exact tests examined the effect of pharmacy type on differences in VS between years, and logistic regression models identified possible predictors of gaining or losing VS.

Results

During 2017–2018, no differences were observed for the gain or loss of VS across pharmacy types (VS gain vs continued viremia, P = .393; VS loss vs continued VS, P = .064). Predictors for the gain of VS included antiretroviral therapy adherence as percentage of days covered (PDC; adjusted odds ratio [aOR], 1.05; P < .001) and Federal Poverty Level 100%–138% (FPL; aOR, 0.17; P = .032). Predictors for the loss of VS included use of protease inhibitor (aOR, 2.85; P = .013), ≥1 other illicit substance including tobacco (aOR, 2.96; P = .024), PDC (aOR, 0.95; P < .001), FPL 139%–200% (aOR, 0.09; P = .031), and CD4 >200 cells/ccm (aOR, 0.19; P = .013).

Conclusions

The gain or loss of VS among PWH in this retrospective cohort was not impacted by pharmacy transitions within the 2-year study period. However, PDC, FPL, illicit substance use, protease inhibitor use, and CD4 >200 cells/ccm were identified as factors associated with changes in VS.

Integration of palliative care into COVID-19 pandemic planning

The COVID-19 pandemic is expected to surpass the healthcare system’s capacity to provide intensive care to all patients who deteriorate as a result of the disease. This poses a unique challenge to healthcare teams of rationing care during pandemic when resources are scarce. Healthcare providers will need to acquire new skills in care decision making and effective symptom control for patients who do not receive life-saving measures. In this review, we describe some of the important palliative care considerations that need to be incorporated into COVID-19 pandemic planning. The main aspects to be considered include decision algorithms for rationing care, training on effective symptoms management, alternative delivery methods of palliative care services such as telemedicine and finally death and bereavement support for surviving family members who are likely to be isolated from their loved one at the moment of death.

2274. Assessment of Anal Papanicolaou Smear Screening and Follow-up Rates in Eastern North Carolina for HIV-Positive Patients Who Are Men Who Have Sex With Men

The purpose of this research is to show the prevalence of anal Pap smear abnormalities and follow-up activities among MSM patients receiving HIV care at the ECU Infectious Diseases and International Travel Health Clinic (ECU ID).

1289. Knowledge, Attitudes and Barriers of Pre-exposure Prophylaxis for HIV Infection Among Resident Physicians in Rural, Eastern North Carolina

Background

North Carolina bears a high burden of HIV and was ranked number 8 for the number of new infections in 2015. In 2014, the Centers for Disease Control and Prevention (CDC) published updated practice guidelines recommending the use of pre-exposure prophylaxis (PrEP) with daily oral dosing of tenofovir/emtricitabine to help prevent HIV infection in high-risk individuals. However, the use of PrEP in the primary care setting remains low and 1 in three primary care physicians is not aware of PrEP. The objective of our study was to evaluate PrEP knowledge among primary care resident physicians.

Methods

149 resident physicians were surveyed at East Carolina University from the following specialties; Internal Medicine, Medicine-Pediatrics, Obstetrics Gynecology and Family Medicine. We collected participants’ age, biological sex, current residency program, and current year within the residency program.

Results

Sixty out 149 residents completed the online survey. 20% of residents had never heard of PrEP. 17% of residents did not feel comfortable discussing sexual preferences with their patients. 15% of residents thought prescribing would increase risky sexual behaviors and 12% would not prescribe PrEP to patients with multiple sexual partners. Only 3% of residents identified potential side effects of PrEP (e.g., an increase in creatinine levels or decrease in mineral bone density) as a reason to not prescribe PrEP. One resident had ever prescribed PrEP. 83% of residents wanted more information on PrEP and 95% of residents would be willing to prescribe PrEP if educational workshops were offered.

Conclusion

PrEP is an underutilized tool among resident physicians in Eastern, NC. We identified lack of knowledge of PrEP and concern for increased risky sexual behaviors as barriers to prescribing. Resident physicians require more education on PrEP in order to prescribe it to their patients.

Disclosures

All authors: No reported disclosures.

1273. Routine Opt-out HIV Screening and Detection of HIV Infection Among Emergency Department Patients

Background

The Southeastern United States bears a disproportionate burden of HIV infection, accounting for nearly half of all new cases. The Centers for Disease Control and Prevention released routine opt-out testing recommendations in 2006. Our emergency department collaborated with our infectious diseases clinic (ECU-ID) to implement suggested guidelines among adults since March 2017.

Methods

Our primary aim was to implement routine, opt-out HIV testing in the Vidant Medical Center Emergency Department (ED) for patients between 18 and 65 years of age who have blood work completed, and have not had a test documented in the electronic medical record (EMR) in the last year. A secondary aim was to successfully link HIV-positive patients to care at ECU-ID or preferred clinic. Methods defining programmatic success included developing nurse directed opt-out ordering protocol, integrating testing into normal ED workflow, utilizing the existing EMR to prompt testing, and hiring a linkage coordinator to initiate post-test counseling and linkage-to-care.

Results

Since March 2, 2017, a total of 7,109 HIV tests were performed; an average of 592 monthly tests conducted compared with a previous average of 10 stat tests. Testing increased 5,820% compared with 2015. Of the 21 HIV-positive patients found, 16 were newly diagnosed. Among those newly diagnosed, 14 (87.5%) were linked to care; and among the five known positives, two (40%) were linked to care. Reasons why patients could not be linked included incarceration, refusal to link to care, and re-location.

Conclusion

Joined with the implementation of a routinized ED HIV testing program, a seamless process was developed to link persons found to be positive in the ED to HIV care services; therefore, establishing a systems-level prevention model. Future plans include expanding testing to adolescents and utilizing similar methods to integrate Hepatitis C testing.

Disclosures

All Authors. Gilead Sciences, Inc.: Grant Investigator, Grant recipient and Salary.

Past Care Predicts Future Care in Out-of-Care People Living with HIV: Results of a Clinic-Based Retention-in-Care Intervention in North Carolina

Poor retention in care is associated with higher viral load (VL) results and decreased rates of viral load suppression (VS) in people living with HIV (PLWH). Therefore, improving retention in HIV care is a priority of national significance. The NC-LINK Retention Project utilized a systematic approach to identify, locate, and attempt to return to care patients who did not attend a clinic appointment for 6-9 months. Clinical and surveillance data were used to evaluate associations between patient characteristics and VL outcomes. Between January 1, 2013 and December 31, 2014, 1118 patients at participating clinics were identified as out-of-care and referred to retention staff. Of these, 712 (64%) were located in North Carolina. Patients with recent prior medical care (aPR 1.43, 95% CI 1.25, 1.66) and recent VS (aPR 1.28, 95% CI 1.16, 1.41) were more likely to be located. Of located patients, 58% re-engaged in care within 90 days of retention referral. Patients who achieved VS within 180 days were more likely to be 40-49 years (aPR 1.19 95% CI 1.01-1.40; compared with 18-29 age group), had insurance at their last visit (aPR 1.19 95% CI 1.01-1.77), had a care visit in the prior year (aPR 1.37 95% CI 1.05-1.77), and had VS at the prior care visit (aPR 2.54 95% CI 1.98-3.25). Clinic-based retention efforts may be effective at helping PLWH decrease out-of-care periods, but prior patterns of care usage persist.

Treatment-Naïve HIV-Infected Patients Have Fewer Gut-Homing β7 Memory CD4 T Cells than Healthy Controls

OBJECTIVES

The integrin α4β7 is the gut-homing receptor for lymphocytes. It also is an important co-receptor for human immunodeficiency virus (HIV) via glycoprotein (gp)120 binding. Depletion of gut cluster of differentiation (CD)4 T cells is linked to chronic inflammation in patients with HIV; however, measuring CD4 cells in the gut is invasive and not routine. As such, establishing a peripheral marker for CD4 depletion of the gut is needed. We hypothesized that α4β7 CD4 T cells are depleted in the peripheral blood of treatment-naïve patients with HIV compared with healthy controls.

METHODS

The study groups were treatment-naïve patients with HIV and uninfected controls. Subjects were included if they were 18 years or older with no history of opportunistic infections, active tuberculosis, or cancer. We collected peripheral blood and examined on whole blood using flow cytometry for the following cell surface markers: CD4, CD45RO, chemokine receptor type 5, C-X-C chemokine receptor type 4 (CXCR4), and the integrin β7. We collected demographic information, including age, sex, and ethnicity, as well as viral load (VL) and CD4 count. Two-sample t tests and Fisher exact tests were used to compare the differences between the two groups. Spearman correlation coefficients were calculated between CD4 count and log10^- VL and percentage of CD4⁺/CD45RO⁺/β7⁺ and log10^- VL in patients.

RESULTS

Twenty-two subjects were enrolled in the study (12 patients with HIV and 10 controls). There were no differences in age or sex between the two groups. There were more Hispanics and fewer Asians in the group comprising patients with HIV compared with the control group (7 vs 2 and 0 vs 4, P = 0.05, respectively). Patients infected with HIV had significantly lower frequencies of CD4⁺/CD45RO⁺/β7⁺ cells (median 12%, range 5-18 compared with uninfected controls: median 20%, range 11-26, P = 0.0007). There was a statistically significant difference in the percentage of CD4⁺/CD45RO⁺/C-X-C chemokine receptor type 4⁺ cells between patients (72%, range 60%-91%) compared with controls (79%, range 72%-94%, P = 0.04). The percentage of CD4⁺/CD45RO⁺/chemokine receptor type 5⁺ did not differ between the group of patients with HIV and the control groups (22%, range 11%-57% vs 27%, range 14%-31%; P = 0.8, respectively). There was no correlation between percentage of CD4⁺/CD45RO⁺/β⁺ cells and log10^- VL as measured by the Spearman correlation coefficient (r = 0.05, P = 0.88) in patients infected with HIV.

CONCLUSIONS

Memory CD4 β7⁺ cells are reduced significantly in the peripheral blood of untreated patients infected with HIV, which could be used as a noninvasive indicator of intestinal CD4 T cell loss and recovery. Further studies are needed to examine whether depletion of these CD4⁺/CD45RO⁺/β7⁺ cells in the peripheral blood parallels depletion in the gut of treatment-naïve patients with HIV and whether levels return to control levels after treatment.

Darunavir and Dolutegravir Combination Therapy in ART experienced HIV-infected Patients: A Preliminary Report

Background

Patients with HIV may require change in therapy for simplification, salvage, or to avoid side effects. There is limited data on the use of dolutegravir (DTG) and ritonavir- or cobicistat-boosted darunvair (DRV) combination therapy alone or with additional active agents in patients with HIV. The objectives of this study were to describe the current use and indications of DTG/DRV combination and to evaluate its effectiveness on viral load suppression (VLS).

Methods

A retrospective chart review of HIV-infected patients, 18 years or older, seen at our clinic between August 2013 and December 2015 who were on DRV/DTG combination alone or with additional active agents was conducted. Demographic, clinical, and laboratory information was collected. Descriptive statistics were used for data analysis.

Results

Eighty-seven patients were included in the study: 64 (74%) on DRV/DTG alone and 23 (26%) on DRV/DTG plus additional agents. Mean age was 49.3 (18–79); 29 (33.3%) were female; and 77 (89%) were black. Coronary artery disease (CAD) or CAD equivalent was present in 27 (31%), chronic kidney disease in 24 (28%), and chronic hepatitis B infection in 3 (3%) patients. The majority 86 (99%) of patients were treatment experienced; 60 (69%) had been treated with 3 or more antiretroviral drug classes; 57 (66%) were integrase experienced, including 6 (6.9%) with baseline integrase resistance. Baseline HIV viral load was &gt;200 copies/mL in 41 (47%); and CD4 count was &lt;200 in 29 (33%) patients. Reason for switch was reported as salvage in 42 patients (48%) simplification in 33 patients (38%), renal impairment in 11 patients (13%), and other in 6 patients (7%). VLS was achieved or maintained in 40 of 46 patients (87%) who presented for follow up at 6–8 weeks, 25 of 28 (89%) at 3–4 months, 35 of 41 (85%) at 5–6 months, and 55 of 61 (90%) at 7–12 months after starting therapy. Six patients were later switched off of DRV/DTG to another combination, of whom only two required switch due to intolerance (rash in 1 and large pill size in 1).

Conclusion

Our preliminary results suggest that darunavir/dolutegravir combination is a viable switch option in HIV patients with the majority of patients achieving or maintaining VLS at 1 year of follow up and only 2 patients required a regimen change due to intolerance.

Disclosures

All authors: No reported disclosures.

Predictors of Viral Load Suppression in HIV-infected Patient in Rural Eastern North Carolina

Background

Virologic suppression (VLS) has been shown to improve clinical outcomes and prevent disease transmission in Human Immunodeficiency Virus (HIV) infected patients. However, only 30% of those living with HIV in the United States (US) are currently VLS. HIV incidence and prevalence are increasing rapidly in the rural Southeastern region of the US and models to predict VLS in this population are needed.

Methods

We conducted a retrospective chart review of patients 18 years or older, who were newly diagnosed with HIV and receiving care at our Ryan White funded clinic between September 2014 and September 2016. We collected demographic information, comorbid conditions, clinic appointment data, and laboratory values. VLS suppression was defined as an HIV viral load <200 copies/mL at 3 months. Pearson Chi square analysis was done using SPSS to evaluate the association between these variables and VLS.

Results

A total of 183 patients were included in the study, 42 (23%) females, 39 (21%) white, 41 (22%) less than 25 years of age, 65 (36%) uninsured and 102 (56%) men who have sex with men. The majority 139 (76%) of patients lived below the 150% federal poverty limit. During 3 months follow up 113/183 (61%) were VLS. There were no statistically significant associations between age, gender, ethnicity, presence of mental health and substance abuse disorders, housing stability, education or poverty level level and VLS. 60/104 (56%) of those who were insured achieved VLS compared with 48/65 (73%) of those who were uninsured (P = 0.033)

Conclusion

VLS was achieved in 61% of the HIV infected patients in eastern North Carolina. Patients without insurance had a statistically significantly higher rate of VLS as compared with those with insurance. It is noteworthy that patients who were uninsured received ambulatory medical and support services as well as medication assistance through Ryan White funding. Future prospective studies are needed to further evaluate the association between insurance status and VLS in federally funded clinics.

Disclosures

All authors: No reported disclosures.

Gemella Species Bacteremia and Stroke in an Elderly Patient with Respiratory Tract Infection

Gemella species are part of normal human flora. They are rarely associated with infections. As opportunistic pathogens, they can cause life-threatening infection in individuals with risk factors. We present an unusual case of an elderly patient, with no predisposing risk factors, who presented with respiratory tract infection and Gemella species bacteremia and suffered a stroke in the absence of features of endocarditis.

Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center

PURPOSE

Palliative care consultation services are now available in the majority of cancer centers, yet most referrals to palliative care occur late. We previously found that the term "palliative care" was perceived by oncology professionals as a barrier to early patient referral. We aimed to determine whether a service name change to supportive care was associated with earlier referrals.

PATIENTS AND METHODS

Records of 4,701 consecutive patients with a first palliative care consultation before (January 2006 to August 2007) and after (January 2008 to August 2009) the name change were analyzed, including demographics and dates of first registration to hospital, advanced cancer diagnosis, palliative care consultation, and death. One-sample proportions tests, median tests, χ(2) tests, and log-rank tests were used to identify group differences.

RESULTS

The median age was 59 years, 50% were male, and 90% had solid tumors. After the name change, we found: (a) a 41% greater number of palliative care consultations (1,950 versus 2,751 patients; p < .001), mainly as a result of a rise in inpatient referrals (733 versus 1,451 patients; p < .001), and (b) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio [HR], 0.85; p < .001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; p < .001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; p < .001).

CONCLUSION

The name change to supportive care was associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitates earlier access to supportive/palliative care and should be established in more centers.

Subcutaneous olanzapine for hyperactive or mixed delirium in patients with advanced cancer: a preliminary study

CONTEXT

Oral olanzapine is effective in controlling agitation in patients with delirium, but often, parenteral administration is necessary. Intramuscular (IM) olanzapine is approved for managing agitation in schizophrenia, but this route is inappropriate for terminally ill patients.

OBJECTIVES

The purpose of this pilot study was to determine the safety and tolerability of subcutaneous (SC) olanzapine in the management of hyperactive or mixed delirium in patients with advanced cancer.

METHODS

We conducted a prospective open-label study in patients with advanced cancer who had agitated delirium (Richmond Agitation Sedation Scale [RASS] score ≥+1) that had not responded to a 10mg or higher dose of parenteral haloperidol over 24 hours. Patients received olanzapine 5mg SC every eight hours for three days and continued haloperidol for breakthrough agitation. For patients requiring more than 8mg of rescue haloperidol daily, the olanzapine dose was increased to 10mg SC every eight hours. Injection site, systemic toxicity, and efficacy (RASS score <+1 and total haloperidol dose <8mg per 24 hours on the last study day) were evaluated.

RESULTS

Twenty-four patients received at least one olanzapine injection, and 15 (63%) completed the study. Median age of evaluable patients was 58 years (range 49-79), and 67% were males. No injection site toxicity was observed after 167 injections. Probable systemic toxic effects were observed in four patients (severe hypotension [blood pressure <90/50mmHg], paradoxical agitation, diabetes insipidus, and seizure). Efficacy was achieved in nine (37.5%) patients.

CONCLUSIONS

IM olanzapine is well tolerated subcutaneously. Further research is needed to evaluate its efficacy in controlling agitated delirium.

Availability and integration of palliative care at US cancer centers

CONTEXT

The current state of palliative care in cancer centers is not known.

OBJECTIVES

To determine the availability and degree of integration of palliative care services and to compare between National Cancer Institute (NCI) and non-NCI cancer centers in the United States.

DESIGN, SETTING, AND PARTICIPANTS

A survey of 71 NCI-designated cancer centers and a random sample of 71 non-NCI cancer centers of both executives and palliative care clinical program leaders, where applicable, regarding their palliative care services between June and October 2009. Survey questions were generated after a comprehensive literature search, review of guidelines from the National Quality Forum, and discussions among 7 physicians with research interest in palliative oncology. Executives were also asked about their attitudes toward palliative care.

MAIN OUTCOME MEASURE

Availability of palliative care services in the cancer center, defined as the presence of at least 1 palliative care physician.

RESULTS

A total of 142 and 120 surveys were sent to executives and program leaders, with response rates of 71% and 82%, respectively. National Cancer Institute cancer centers were significantly more likely to have a palliative care program (50/51 [98%] vs 39/50 [78%]; P = .002), at least 1 palliative care physician (46/50 [92%] vs 28/38 [74%]; P = .04), an inpatient palliative care consultation team (47/51 [92%] vs 28/50 [56%]; P < .001), and an outpatient palliative care clinic (30/51 [59%] vs 11/50 [22%]; P < .001). Few centers had dedicated palliative care beds (23/101 [23%]) or an institution-operated hospice (37/101 [37%]). The median (interquartile range) reported durations from referral to death were 7 (4-16), 7 (5-10), and 90 (30-120) days for inpatient consultation teams, inpatient units, and outpatient clinics, respectively. Research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon. Executives were supportive of stronger integration and increasing palliative care resources.

CONCLUSION

Most cancer centers reported a palliative care program, although the scope of services and the degree of integration varied widely.

The association between autonomic dysfunction and survival in male patients with advanced cancer: a preliminary report

CONTEXT

Autonomic nervous system dysfunction (AD) is a common syndrome in patients with advanced cancer. It is associated with decreased survival in several patient populations, including diabetes mellitus, heart failure, and neurological diseases. Based on this evidence, we hypothesized that autonomic dysfunction is associated with decreased survival in patients with advanced cancer.

OBJECTIVES

The objective of this preliminary study was to test the association between AD, as measured by the standardized Ewing test and heart rate variability (HRV) measures, and survival in this patient population.

METHODS

We examined the relationship between survival and parameters of AD in subjects who participated in a prospective study of autonomic dysfunction and hypogonadism in male patients with advanced cancer. Eligibility criteria were defined based on the prospective study protocol. We collected demographic information, date of death (obtained from the online Social Security Death Index database), date of study entry, and Ewing and HRV scores. We defined survival as the interval between study entry and date of death. A survival analysis was used to test the association between survival (in days) and Ewing test (0-5) and measures of HRV, including time domain (standard deviation of normal to normal beat interval [SDNN]) and frequency domain (ultra low, very low, low, and high). Four patients were still alive at the time of this study and included in the survival analysis as being censored.

RESULTS

Forty-seven male patients were included in this study. Median age was 59 years (range: 20-79), and 30 out of 47 (63%) were Caucasians. AD, defined as Ewing score greater than 2, was present in 38 out of 47 (80%) of the patients. Median Ewing score was 3 (1-5), indicating moderate to severe AD. Spearman correlation for Ewing score and SDNN was 0.44 (P = 0.002). There was a significant association between abnormal Ewing score and survival (P < 0.0001) and abnormal SDNN HRV and survival (P = 0.056).

CONCLUSION

AD is associated with shorter survival in male patients with advanced cancer. Further longitudinal research in a large cohort is justified based on.

Evaluation of the memorial delirium assessment scale (MDAS) for the screening of delirium by means of simulated cases by palliative care health professionals

BACKGROUND

Delirium is among the most common neuropsychiatric complications of advanced cancer. The Memorial Delirium Assessment Scale (MDAS) is a widely used and validated screening tool for delirium in cancer patients.

OBJECTIVE

The purpose of this study was to assess the use of the MDAS by different palliative care health professionals after receiving formal training and a guiding manual for administration and scoring.

MATERIALS AND METHODS

Thirty-one palliative care health professionals received a training session on the MDAS, including description of the tool, validation, and scoring. Participants also received copies of a proposed standardized manual for completion of the MDAS. Two of the investigators presented three simulated cases to the participants, who independently completed a scoring sheet for each case. The data were then analyzed according to the cases and the profession of the operators.

RESULTS

Thirty-one scoring sheets were analyzed (11 physicians, 12 nurses, and 8 others). A correct diagnosis was achieved by 30 (96.8%) of the 31 participants in case 1 (nondelirious, true score = 5, median = 5, range = 2-15), 28 of 31 (90.3%) in case 2 (severe mixed delirium, true score = 20, median = 18, range = 10-26), and 31 of 31 in case 3 (mild hypoactive delirium, true score = 14, median = 19, range = 13-25). Overall percentage of error was 31% for items 2, 3, and 4 (cognitive) and 45% for all other items (observational) (p < 0.001). The percentage of error did not differ between physicians and nurses and other palliative care professionals (p > 0.99).

CONCLUSIONS

Our preliminary results suggest that adequate training and a guiding manual can enhance the application of MDAS by palliative care health professionals in the teaching settings. Clinical studies to assess the utility of the MDAS as a screening tool are justified to further confirm these findings.