An Integrated mHealth App for Smoking Cessation in Black Smokers With HIV: Protocol for a Randomized Controlled Trial

BACKGROUND

Black adults who smoke and have HIV experience immense stressors (eg, racial discrimination and HIV stigma) that impede smoking cessation success and perpetuate smoking-related health disparities. These stressors also place Black adults who smoke and have HIV at an increased risk of elevated interoceptive stress (eg, anxiety and uncomfortable bodily sensations) and smoking to manage symptoms. In turn, this population is more likely to smoke to manage interoceptive stress, which contributes to worse HIV-related outcomes in this group. However, no specialized treatment exists to address smoking cessation, interoceptive stress, and HIV management for Black smokers with HIV.

OBJECTIVE

This study aims to test a culturally adapted and novel mobile intervention that targets combustible cigarette smoking, HIV treatment engagement and adherence, and anxiety sensitivity (a proxy for difficulty and responsivity to interoceptive stress) among Black smokers with HIV (ie, Mobile Anxiety Sensitivity Program for Smoking and HIV [MASP+]). Various culturally tailored components of the app are being evaluated for their ability to help users quit smoking, manage physiological stress, and improve health care management.

METHODS

This study is a pilot randomized controlled trial in which Black combustible cigarette smokers with HIV (N=72) are being recruited and randomly assigned to use either (1) the National Cancer Institute's QuitGuide app or (2) MASP+. Study procedures include a web-based prescreener; active intervention period for 6 weeks; smartphone-based assessments, including daily app-based ecological momentary assessments for 6 weeks (4 ecological momentary assessments each day); a video-based qualitative interview using Zoom Video Communications software at week 6 for participants in all study conditions; and smartphone-based follow-up assessments at 0, 1, 2 (quit date), 3, 4, 5, 6, and 28 weeks postbaseline (26 weeks postquitting date).

RESULTS

Primary outcomes include biochemically verified 7-day point prevalence of abstinence, HIV-related quality of life, use of antiretroviral therapy, and HIV care appointment adherence at 26 weeks postquitting date. Qualitative data are also being collected and assessed to obtain feedback that will guide further tailoring of app content and evaluation of efficacy.

CONCLUSIONS

The results of this study will determine whether the MASP+ app serves as a successful aid for combustible cigarette smoking cessation, HIV treatment engagement, and physiological stress outcomes among Black people with HIV infection. If successful, this study will provide evidence for the efficacy of a new means of addressing major mental and physical health difficulties for this high-risk population. If the results are promising, the data from this study will be used to update and tailor the MASP+ app for testing in a fully powered randomized controlled trial that will evaluate its efficacy in real-world behavioral health and social service settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05709002; https://clinicaltrials.gov/study/NCT05709002.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52090.

Adaptation of Chagas Disease Screening Recommendations for a Community of At-risk HIV in the United States

Chagas disease (CD), caused by Trypanosoma cruzi, is underdiagnosed in the United States. Improved screening strategies are needed, particularly for people at risk for life-threatening sequelae of CD, including people with human immunodeficiency virus (HIV, PWH). Here we report results of a CD screening strategy applied at a large HIV clinic serving an at-risk population.

Generalizable pipeline for constructing HIV risk prediction models across electronic health record systems

OBJECTIVE

The HIV epidemic remains a significant public health issue in the United States. HIV risk prediction models could be beneficial for reducing HIV transmission by helping clinicians identify patients at high risk for infection and refer them for testing. This would facilitate initiation on treatment for those unaware of their status and pre-exposure prophylaxis for those uninfected but at high risk. Existing HIV risk prediction algorithms rely on manual construction of features and are limited in their application across diverse electronic health record systems. Furthermore, the accuracy of these models in predicting HIV in females has thus far been limited.

MATERIALS AND METHODS

We devised a pipeline for automatic construction of prediction models based on automatic feature engineering to predict HIV risk and tested our pipeline on a local electronic health records system and a national claims data. We also compared the performance of general models to female-specific models.

RESULTS

Our models obtain similarly good performance on both health record datasets despite difference in represented populations and data availability (AUC = 0.87). Furthermore, our general models obtain good performance on females but are also improved by constructing female-specific models (AUC between 0.81 and 0.86 across datasets).

DISCUSSION AND CONCLUSIONS

We demonstrated that flexible construction of prediction models performs well on HIV risk prediction across diverse health records systems and perform as well in predicting HIV risk in females, making deployment of such models into existing health care systems tangible.

The New Era of Long-Acting Antiretroviral Therapy: When and Why to Make the Switch

PURPOSE OF REVIEW

Despite the availability of safe and effective oral combination antiretroviral therapy, barriers to maintaining viral suppression remain a challenge to ending the HIV epidemic. Long-acting injectable antiretroviral therapy was developed as an alternative to daily oral therapy. This review summarizes the current literature on the efficacy of long-acting cabotegravir plus rilpivirine for the treatment of HIV-1, reasons to switch to injectable therapy, and barriers to switching.

RECENT FINDINGS

Long-acting cabotegravir plus rilpivirine is safe and effective in maintaining HIV-1 virologic suppression. Ideal candidates for switching to long-acting cabotegravir plus rilpivirine are virologically suppressed on oral regimens with good adherence and no history of virologic failure or baseline resistance. Indications to switch to injectable therapy include patient preference, the potential for improved adherence, and avoidance of adverse effects. Implementation research is needed to assess and overcome system barriers. Long-acting cabotegravir plus rilpivirine is a novel alternative to oral antiretrovirals, with the potential to improve adherence and quality of life in people with HIV.

Rural Veterans with HIV and Alcohol Use Disorder receive less video telehealth than urban Veterans

PURPOSE

Alcohol use disorder (AUD) is highly prevalent among Veterans with HIV. Rural Veterans with HIV are at especially high risk for not receiving appropriate treatment. This retrospective cohort cross-sectional study aimed to investigate patterns of mental health treatment utilization across delivery modality among Veterans diagnosed with HIV and AUD. It was hypothesized that rural Veterans with HIV and AUD would receive a lower rate of mental health treatment delivered via video telehealth than urban Veterans with HIV and AUD.

METHODS

A national Veterans Health Association administrative database was used to identify a cohort of Veterans diagnosed with HIV and AUD (N = 2,075). Geocoding was used to categorize rural Veterans (n = 246) and urban Veterans (n = 1,829). Negative binomial regression models tested associations between rurality and mental health treatment delivered via face-to-face, audio-only, and video telehealth modalities.

FINDINGS

Results demonstrated that rural Veterans with HIV and AUD received fewer mental health treatment sessions delivered via telehealth than urban Veterans with HIV and AUD (incidence rate ratio = 0.62; 95% confidence intervals [0.44, 0.87]; P < .01). No differences were found in terms of treatment delivered face-to-face or by audio-only.

CONCLUSIONS

Rural Veterans with HIV and AUD represent a vulnerable subpopulation of Veterans who may most benefit from video telehealth. Efforts to increase access and improve the uptake of evidence-based mental health treatment delivered via video telehealth are needed.

Impact of the COVID-19 Pandemic on Medical Education during Inpatient Internal Medicine Rounds

OBJECTIVES

Inpatient rounding is a foundational component of medical education in academic hospitals. The coronavirus 2019 (COVID-19) pandemic disrupted traditional inpatient rounding practices. The objectives of this study were to describe how Internal Medicine inpatient team rounding changed because of COVID-19-related precautions and the effect of these changes on education during rounds.

METHODS

During February to March 2021, we conducted four virtual focus groups with medical and physician assistant students, interns, upper-level residents, and attending physicians at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, and designed a codebook to categorize focus group commentary.

RESULTS

Focus groups revealed that students believed that certain physical-distancing measures in place early on during the pandemic were ineffective and significantly limited their ability to evaluate patients in person. Residents described increased stress levels related to potential severe acute respiratory-coronavirus 2 exposure and limited time at the bedside, which affected their confidence with clinical assessments. Rounding-team fragmentation precluded the entire team learning from all of the patients on the team's census. Loss of intrateam camaraderie impaired the development of comfortable learning environments.

CONCLUSIONS

This study evaluated Internal Medicine team member focus groups to describe how the COVID-19 pandemic affected medical education during rounds. Academic teaching programs can adapt the findings from this study to address and prevent pandemic-related gaps in medical education during rounds now and during future potential disruptions to medical education.

Dementias Among Older Males and Females in the U.S. Medicare System With and Without HIV

BACKGROUND

Despite the growing concern that people with HIV (PWH) will experience a disproportionate burden of dementia as they age, very few studies have examined the sex-specific prevalence of dementia, including Alzheimer disease and related dementias (AD/ADRD) among older PWH versus people without HIV (PWOH) using large national samples.

METHODS

We constructed successive cross-sectional cohorts including all PWH aged 65+ years from U.S. Medicare enrollees and PWOH in a 5% national sample of Medicare data from 2007 to 2019. All AD/ADRD cases were identified by ICD-9-CM/ICD-10-CM diagnosis codes. Prevalence of AD/ADRD was calculated for each calendar year by sex-age strata. Generalized estimating equations were used to assess factors associated with dementia and calculate the adjusted prevalence.

RESULTS

PWH had a higher prevalence of AD/ADRD, which increased over time compared with PWOH, especially among female beneficiaries and with increasing age. For example, among those aged 80+ years, the prevalence increased from 2007 to 2019 (females with HIV: 31.4%-44.1%; females without HIV: 27.4%-29.9%; males with HIV: 26.2%-33.3%; males without HIV: 21.0%-23.5%). After adjustment for demographics and comorbidities, the differences in dementia burden by HIV status remained, especially among older age groups.

CONCLUSIONS

Older Medicare enrollees with HIV had an increased dementia burden over time compared with those without HIV, especially women and older subjects. This underscores the need to develop tailored clinical practice guidelines that facilitate the integration of dementia and comorbidity screening, evaluation, and management into the routine primary care of aging PWH.

Assessing incident depression among older people with and without HIV in U.S

PURPOSE

Despite substantially higher prevalence of depression among people living with HIV/AIDS (PLWHA), few data exist on the incidence and correlates of depression in this population. This study assessed the effect of HIV infection, age, and cohort period on the risk of developing depression by sex among older U.S. Medicare beneficiaries.

METHODS

We constructed a retrospective matched cohort using a 5% nationally representative sample of Medicare beneficiaries (1996-2015). People with newly diagnosed (n = 1309) and previously diagnosed (n = 1057) HIV were individually matched with up to three beneficiaries without HIV (n = 6805). Fine-Gray models adjusted for baseline covariates were used to assess the effect of HIV status on developing depression by sex strata.

RESULTS

PLWHA, especially females, had higher risk of developing depression within five years. The relative subdistribution hazards (sHR) for depression among three HIV exposure groups differed between males and females and indicated a marginally significant interaction (p = 0.08). The sHR (95% CI) for newly and previously diagnosed HIV (vs. people without HIV) were 1.6 (1.3, 1.9) and 1.9 (1.5, 2.4) for males, and 1.5 (1.2, 1.8) and 1.2 (0.9, 1.7) for females. The risk of depression increased with age [sHR 1.3 (1.1, 1.5), 80 + vs. 65-69] and cohort period [sHR 1.3 (1.1, 1.5), 2011-2015 vs. 1995-2000].

CONCLUSIONS

HIV infection increased the risk of developing depression within 5 years, especially among people with newly diagnosed HIV and females. This risk increased with older age and in recent HIV epidemic periods, suggesting a need for robust mental health treatment in HIV primary care.

Preliminary Validity of a Telephone-Based Neuropsychological Battery in a Consecutive Series of Persons with HIV Disease Referred for Clinical Evaluation

OBJECTIVE

The COVID-19 pandemic necessitated use of remote assessments by clinical neuropsychologists. Telehealth was particularly important for vulnerable groups, including persons living with HIV (PLWH); however, limited internet access can be a serious barrier to care. This study examined the preliminary validity of a telephone-based neuropsychological assessment in a clinical sample of PLWH.

METHOD

A consecutive series of 59 PLWH were assessed via telephone at an HIV clinic in the southern U.S. between April 2020 and July 2022. The battery included auditory-verbal neuropsychological tests of memory, attention, and executive functions, and questionnaires assessing self-reported mood and activities of daily living (ADL).

RESULTS

Study measures demonstrated acceptable internal consistency. PLWH demonstrated worse neuropsychological performance compared with expectations derived from the normal curve and an HIV-seronegative adult sample (N = 44). PLWH assessed via telephone demonstrated similar impairment rates to that of a consecutive series of PLWH (N = 41) assessed in-person immediately prior to the pandemic. Higher telephone-based global neuropsychological scores were related to younger age, more education, better fund of knowledge, White race/ethnicity, fewer medical conditions, and fewer depression symptoms. Global neuropsychological impairment was strongly and independently associated with greater dependence in ADL domains, particularly for instrumental activities.

CONCLUSIONS

Although telephone-based approaches to neuropsychological assessment are not ideal, these data provide support for the feasibility, internal consistency, and preliminary validity of this method in a consecutive clinical series of PLWH. The direct comparability of telephone-based and in-person neuropsychological assessments remains to be determined by prospective, counterbalanced study designs examining both PLWH and seronegative individuals.

Incident depression among Medicare beneficiaries with disabilities and HIV

OBJECTIVE

Despite disproportionally high prevalence of HIV and depression in persons with disabilities, no data have been published on the incidence and correlates of depression in Medicare beneficiaries with disabilities. We assessed the effect of HIV infection on developing depression in this population.

DESIGN

We conducted a retrospective matched cohort study using a 5% sample of Medicare beneficiaries who qualified for disability coverage (1996-2015).

METHODS

Beneficiaries with incident ( n  = 2438) and prevalent ( n  = 5758) HIV were individually matched with beneficiaries without HIV (HIV-, n  = 20 778). Fine-Gray models with death as a competing risk were used to assess the effect of HIV status, age, and cohort period on developing depression by sex strata.

RESULTS

Beneficiaries with HIV had a higher risk of developing depression within 5 years ( P  < 0.0001). Sex differences were observed ( P  < 0.0001), with higher subdistribution hazard ratios (sHR) in males with HIV compared with controls. The risk decreased with age ( P  < 0.0001) and increased in recent years ( P  < 0.0001). There were significant age-HIV ( P  = 0.004) and period-HIV ( P  = 0.006) interactions among male individuals, but not female individuals. The sHR was also higher within the first year of follow-up among male individuals, especially those with incident HIV.

CONCLUSION

Medicare enrollees with disabilities and HIV had an increased risk of developing depression compared to those without HIV, especially among males and within the first year of HIV diagnosis. The HIV-depression association varied by sex, age, and cohort period. Our findings may help guide screening and comprehensive management of depression among subgroups in this vulnerable population.

The Effect of Initial Patient Experiences and Life Stressors on Predicting Lost to Follow-Up in Patients New to an HIV Clinic

We conducted a prospective cohort study of 450 patients new to an HIV clinic in Houston, TX, to examine the roles of life stressors and initial care experiences in predicting being lost to follow-up in the first year of care. Patients completed a self-administered survey following their initial provider visit. In logistic regression models, patients who reported better experiences with the HIV provider at the first visit were less likely to be lost to follow-up at 6 months (aOR = 0.866, p = 0.038) and 12 months (aOR = 0.825, p = 0.008). Patients with a higher burden of stressful life events were more likely to be lost to follow-up at 6 months (aOR = 1.232, p = 0.037) and 12 months (aOR = 1.263, p = 0.029). Assessments of patient experience and life stressors at the initial visit have potential to predict patients at risk of dropping out of care.

Clinical Utility of the Signal-to-Cutoff Ratio of Reactive HIV Antigen/Antibody Screening Tests in Guiding Emergency Physician Management

BACKGROUND

The signal-to-cutoff (S/CO) ratio of the HIV antigen/antibody test may help immediately to differentiate true-positive results from false-positive results, which may be particularly useful in time-sensitive circumstances, such as when providing emergency department (ED) care.

SETTING

Seven US EDs with HIV screening programs using HIV antigen/antibody assays.

METHODS

This cross-sectional study of existing data correlated S/CO ratios with confirmed HIV status. Test characteristics at predetermined S/CO ratios and the S/CO ratio with the best performance by receiver operator characteristic (ROC) curve were calculated.

RESULTS

Of 1035 patients with a reactive HIV antigen/antibody test, 232 (22.4%) were confirmed HIV-negative and 803 (77.6%) were confirmed HIV-positive. Of the 803 patients, 713 (88.8%) experienced chronic infections and 90 (11.2%) experienced acute infections. S/CO ratios were greater for HIV-positive (median 539.2) than for HIV-negative patients (median 1.93) (P < 0.001) and lower for acute infection (median 22.8) than for chronic infection (median 605.7) (P < 0.001). All patients with an S/CO ratio < 1.58 (n = 93) were HIV-negative (NPV 100%), and nearly all with an S/CO ≥ 20.7 (n = 760) (optimal level by ROC analysis) were HIV-positive (PPV 98.6%). Of patients with S/CO values between 1.58 and 20.7 (n = 182), 29.7% were HIV-positive.

CONCLUSIONS

The S/CO ratio may be used in real time to classify most ED patients as almost certain to be either HIV-positive or HIV-negative long before nucleic acid confirmatory testing is available. When combined with clinical judgment, this could guide preliminary result disclosure and management.

Acceptability and feasibility of video-based coaching to enhance clinicians' communication skills with patients

BACKGROUND

Despite a growing call to train clinicians in interpersonal communication skills, communication training is either not offered or is minimally effective, if at all. A critical need exists to develop new ways of teaching communication skills that are effective and mindful of clinician time pressures. We propose a program that includes real-time observation and video-based coaching to teach clinician communication skills. In this study, we assess acceptability and feasibility of the program using clinician interviews and surveys.

METHODS

The video-based coaching intervention targets five patient-centered communication behaviors. It uses trained communication coaches and live feed technology to provide coaching that is brief (less than 15 min), timely (same day) and theory-informed. Two coaches were trained to set up webcams and observe live video feeds of clinician visits in rooms nearby. As coaches watched and recorded the visit, they time stamped illustrative clips in real time. Video clips were a critical element of the program. During feedback sessions, coaches used video clips to promote discussion and self-reflection. They also used role play and guided practice techniques to enforce new tips. Clinicians included residents (n = 15), fellows (n = 4), attending physicians (n = 3), and a nurse practitioner (n = 1) at two primary care clinics in Houston, Texas. We administered surveys to clinicians participating in the program. The survey included questions on quality and delivery of feedback, and credibility of the coaches. We also interviewed clinicians following the intervention. We used rapid analysis to identify themes within the interviews.

RESULTS

Survey measures showed high feasibility and acceptability ratings from clinicians, with mean item scores ranging from 6.4 to 6.8 out of 7 points. Qualitative analysis revealed that clinicians found that 1) coaches were credible and supportive, 2) feedback was useful, 3) video-clips allowed for self-reflection, 4) getting feedback on the same day was useful, and 5) use of real patients preferred over standardized patients.

CONCLUSIONS

Video-based coaching can help clinicians learn new communication skills in a way that is clinician-centered, brief and timely. Our study demonstrates that real-time coaching using live feed and video technology is an acceptable and feasible way of teaching communication skills.

A pilot study of cognition and creativity among persons with HIV disease referred for neuropsychological evaluation

Creativity can help people to innovate, overcome obstacles, and successfully navigate challenges in daily life. Some aspects of creativity rely on the prefrontostriatal loops and executive functions, which can be compromised in persons with HIV (PWH). This pilot study examined whether neuropsychological functioning plays a role in creativity in PWH. A consecutive series of 41 PWH who were referred to an urban neuropsychology clinic in southeastern Texas were enrolled. Participants completed the Abbreviated Torrance Test for Adults (ATTA) to measure creativity, from which standardized creativity scores of fluency, originality, elaboration, and flexibility were derived. Participants also completed several measures of everyday functioning and a brief clinical neuropsychological battery measuring executive functions, motor skills, memory, and visuoconstruction. Global neuropsychological functioning showed a large, positive association with ATTA creativity performance that did not vary meaningfully by creativity domain and was independent of premorbid IQ. ATTA creativity scores were not associated with any measure of everyday functioning. Findings from this pilot study suggest that higher levels of neuropsychological functioning may support multiple dimensions of creativity in adults with HIV disease. Future studies might examine whether creativity moderates the association between HIV-associated neurocognitive impairment and various health behaviors (e.g., adherence, appointment attendance).

607. Improving Health Maintenance Among Patients with HIV by Implementing a SmartPhrase and a Care Gap in the EPIC Electronic Medical Record

Background

Most deaths in HIV-infected patients receiving antiretroviral therapy are now related to conditions other than AIDS. HIV infection appears to increase the risk of many non-AIDS-related conditions, highlighting the importance of preventive care, however, recommended health maintenance items unique patients with HIV (PWH) are not always accomplished. We aimed to improve health maintenance by implementing a SmartPhrase and a Care Gap package in the EPIC Electronic Medical Record (EMR).

Methods

We developed a HIV health maintenance SmartPhrase in EPIC that included the last screening dates for syphilis, gonorrhea, chlamydia, hepatitis A, hepatitis B, hepatitis C, latent tuberculosis, hyperlipidemia, diabetes and human papilloma virus and the dates of receipt of hepatitis A vaccines, hepatitis B vaccines, pneumococcal conjugate vaccines, pneumococcal polysaccharide vaccines and influenza vaccines (Figure 1). Providers can select their plan for each health maintenance item based on these data and their plans are documented in the encounter notes. Providers were educated to use the SmartPhrase in each office visit. An HIV registry was built after choosing 509 HIV related medical conditions. The health maintenance topics were displayed in a “Care Gaps” summary using the data in the HIV registry (Figure 2). Completion rates for the health maintenance items were compared before and after implementation. The health maintenance package was implemented on 3/1/2020.

Figure 1. SmartPhrase .IDNOTE description and note documentation

Information relevant to health maintenance and providers' plan for each health maintenance are documented in the encounter notes.

Figure 2. CareGaps© 2021 Epic Systems Corporation

CD4 every 6 months is displayed as a part of the health maintenance in a “Care Gaps” summary using the data in the HIV registry, whether their HIV is well controlled or not.

Results

Of the 380 patients in the registry, 162 had office visits with the ID clinic from 1/1/20 to 6/5/20. Chart review of 100 patients who had office visits after implementation was performed and compared to the 62 patients prior to implementation (Table 1). The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly. Pneumonia vaccine administrations and anal pap smear performance compliance remained suboptimal. Providers reported that the time they spent searching for lab results and immunization records and documenting were shortened.

The rates of hepatitis A vaccination (P= 0.001), hepatitis B vaccination (P= 0.05) and influenza vaccination (P=0.035) were increased significantly.

Conclusion

A health maintenance package consisting of a SmartPhrase and summary display in the EMR with provider education likely helps improve health maintenance in PWH.

Disclosures

All Authors: No reported disclosures

964. Impact of the COVID-19 Pandemic on Bedside Medical Education: A Mixed-Methods Study

Background

The COVID-19 pandemic obligated academic medical programs to substantially alter the traditional Internal Medicine (IM) rounding model to decrease risk of inpatient nosocomial viral transmission. Our study aimed to describe how IM rounding practices changed during the COVID-19 pandemic and to understand the impacts of these changes on medical education.

Methods

We conducted a two-phase, mixed-methods study of inpatient IM rounding team practices at a large academic hospital in Houston, TX. In the first phase (January-February 2021), we organized and audio-recorded 4 virtual (Zoom) focus groups. Each included 5-6 rounding team members, divided by: attendings; senior residents; interns; and medical and physician assistant students. In the second phase (March-May 2021), we performed 6 direct observations of IM teams during rounds. Two observers systematically recorded variables such as time spent on non-bedside versus bedside rounds, number of each team member type entering patient rooms for bedside teaching, and types of personal protective equipment (PPE) worn.

Results

Topics discussed during focus groups included comparisons of rounding team size, rounding duration, physical distancing and PPE use, bedside education, communication methods, and patient safety before and after March 2020. Perceptions of changes in each topic were generally consistent across groups (Table 1). Direct observation data showed that team rounding styles remained diverse in the proportion of rounding time spent in an office versus on the wards, and in the number and types of team members entering patient rooms. IM team members uniformly wore respiratory PPE when entering all patient rooms; use of eye protection varied. Teams spent more total time discussing patients with or suspected to have COVID-19 compared to patients without COVID-19 (median 24 min versus 13 min, p< 0.0001).

Conclusion

Our results suggest that the COVID-19 pandemic adversely impacted bedside medical education, even into Spring of 2021. Conclusions from this study can be used to 1) address educational gaps related to COVID-19 pandemic-associated rounding changes and 2) create innovative methods of providing high-quality clinical education that will be minimally impacted by future respiratory virus pandemics.

Disclosures

Prathit A. Kulkarni, M.D., Vessel Health, Inc. (Grant/Research Support)

A Phenotyping Algorithm to Identify People With HIV in Electronic Health Record Data (HIV-Phen): Development and Evaluation Study

Background

Identification of people with HIV from electronic health record (EHR) data is an essential first step in the study of important HIV outcomes, such as risk assessment. This task has been historically performed via manual chart review, but the increased availability of large clinical data sets has led to the emergence of phenotyping algorithms to automate this process. Existing algorithms for identifying people with HIV rely on a combination of International Classification of Disease codes and laboratory tests or closely mimic clinical testing guidelines for HIV diagnosis. However, we found that existing algorithms in the literature missed a significant proportion of people with HIV in our data.

Objective

The aim of this study is to develop and evaluate HIV-Phen, an updated criteria-based HIV phenotyping algorithm.

Methods

We developed an algorithm using HIV-specific laboratory tests and medications and compared it with previously published algorithms in national and local data sets to identify cohorts of people with HIV. Cohort demographics were compared with those reported in the national and local surveillance data. Chart reviews were performed on a subsample of patients from the local database to calculate the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the algorithm.

Results

Our new algorithm identified substantially more people with HIV in both national (up to an 85.75% increase) and local (up to an 83.20% increase) EHR databases than the previously published algorithms. The demographic characteristics of people with HIV identified using our algorithm were similar to those reported in national and local HIV surveillance data. Our algorithm demonstrated improved sensitivity over existing algorithms (98% vs 56%-92%) while maintaining a similar overall accuracy (96% vs 80%-96%).

Conclusions

We developed and evaluated an updated criteria-based phenotyping algorithm for identifying people with HIV in EHR data that demonstrates improved sensitivity over existing algorithms.

The relationship between sex-related alcohol expectancies and hazardous drinking among persons with HIV disease

Hazardous drinking is a clinically significant problem among persons with HIV (PWH) disease, and is associated with a number of poor outcomes. Hazardous drinking among PWH is associated with risky substance use and sexual behavior, but little work has examined factors that may be associated with greater hazardous drinking and subsequent risky sexual behaviors among PWH. Research among the general population suggests that sex-related alcohol expectancies, defined as drinking to enhance sexual experience, increase sexual risk-taking, and disinhibition of sexual behavior, are associated with greater hazardous alcohol use and risky sexual behavior, but these relations have not been explored among PWH. Therefore, the current study examined the associations of sex-related alcohol expectancies with hazardous alcohol consumption, dependence, and problems among 146 PWH (M_age = 50.99, SD = 9.41) \ enrolled in a clinical trial examining a personalized feedback intervention to reduce hazardous drinking in primary HIV care. Results showed that only sexual disinhibition-related alcohol expectancies were significantly associated with the criterion variables, such that greater drinking alcohol for sexual disinhibition was associated with greater hazardous drinking behaviors. These results sit on the backdrop of a larger literature documenting the links between disinhibition and hazardous alcohol use and provide explanatory specificity to PWH who are hazardous drinkers.

Pivoting to Video Telehealth for Delivery of HIV Care During COVID-19: A Brief Report

Background: The rapid spread of the SARS-CoV-2 pandemic obstructed human subjects research, including our own randomized hybrid type 2 effectiveness-implementation trial comparing multidisciplinary HIV care delivered by video telehealth to home (VTH) versus in-person delivery. Methods: Given the Veteran Health Administration's extensive telehealth infrastructure and our team's expertise in personalized implementation of virtual treatments (PIVOT), we shifted our focus to meet the immediate needs of our primary study site (implementation). Our implementation team began training the interdisciplinary infectious diseases clinical team in VTH after declaration of the pandemic in March 2020. We pivoted from a randomized clinical trial recruitment and supported modifications in clinic processes by introducing patients to VTH through personalized telephone calls and mailed brochures to inform them of telehealth options during the pandemic. Adaptations were made to provider locations, with some providers delivering care remotely from home and others delivering virtual care from the clinic. We also modified the external and internal facilitator roles to allow external facilitators to provide one-on-one training, troubleshooting assistance, and delivery of necessary equipment. Results: Within 6 weeks of the emergency declaration of the pandemic, 100% of providers (n = 27) had conducted at least one appointment, with 24.1% (n = 124) of unique patients using VTH. Despite challenges, we capitalized on temporary mandates to assist providers in delivering care virtually. Given our successes, we encourage researchers to be flexible and seek alternative approaches to preserve research efforts in extenuating circumstances. RCT registration: NCT04055207 at clinicaltrials.gov.

Assessing comorbidities and survival in HIV-infected and uninfected matched Medicare enrollees

OBJECTIVE

People with HIV infection experience excessive mortality compared with their noninfected counterparts. It is unclear whether the impact of HIV infection on mortality varies by comorbidities or whether sex difference exists in this relationship. This study assessed the effect of newly diagnosed HIV infection on overall mortality among Medicare beneficiaries for both disabled and older adults (≥65 years old) based on their original entitlement.

METHODS

We constructed a retrospective matched cohort using a 5% nationally representative sample of Medicare beneficiaries between 1996 and 2015. People with incident HIV diagnoses were individually matched to up to three controls based on demographics. Cox proportional hazards models adjusted for baseline demographics and comorbidities were used to assess the effect of HIV status on survival among four disabled groups by sex strata. Within each stratum, interactions between comorbidity variables and HIV status were examined.

RESULTS

People with HIV, especially older women, had a higher prevalence of baseline comorbidities than controls. HIV--mortality association varied according to sex in older adults (P = 0.004). Comorbidity--HIV interactions were more pronounced in disabled groups (P < 0.0001). People with HIV with more chronic conditions had a less pronounced increase in the risk of death than those with fewer conditions, compared with uninfected controls.

CONCLUSION

Medicare enrollees with newly diagnosed HIV had more prevalent baseline comorbidities and were at higher risk of death than people without HIV. HIV infection has a more pronounced effect among those with fewer comorbidities. Sex differences in HIV--mortality association exist among older Medicare enrollees.

Evaluation of an integrated treatment to address smoking cessation and anxiety/depressive symptoms among people living with HIV: Study protocol for a randomized controlled trial

BACKGROUND

Interventions that target anxiety/depressive symptoms in the context of smoking treatment have shown promise irrespective of psychiatric diagnosis. Yet, these tailored treatments are largely absent for persons who smoke and are living with HIV (SLWH).

OBJECTIVE

To evaluate a novel, smoking cessation intervention that addresses anxiety/depression and HIV-related health (QUIT) against a time-matched control (TMC) and a standard of care (SOC) condition.

METHODS

SLWH (N = 180) will be recruited and enrolled from 3 medical clinics in Boston, MA, and Houston, TX. The trial will consist of a baseline assessment, a 10-week intervention/assessment period, and follow-up assessments, accounting for a total study duration of approximately 8 months. All participants will complete a baseline visit and a pre-randomization standardized psychoeducation visit, and will then be randomized to one of three conditions: QUIT, TMC, or SOC. QUIT and TMC will consist of nine 60-min, cognitive behavioral therapy-based, individual weekly counseling sessions using standard smoking cessation counseling; additionally, QUIT will target anxiety and depressive symptoms by addressing underlying mechanisms related to mood and quit difficulty. SOC participants will complete weekly self-report surveys for nine weeks. All participants will be encouraged to quit at Session 7 and will be offered nicotine replacement therapy to help.

CONCLUSIONS

QUIT is designed to improve smoking cessation in SLWH by addressing anxiety and depression and HIV-related health issues. If successful, the QUIT intervention would be ready for implementation and dissemination into "real-world" behavioral health and social service settings consistent with the four objectives outlined in NIDA's Strategic Plan.

Reliability and Validity of a Brief Self-Report Adherence Measure among People with HIV Experiencing Homelessness and Mental Health or Substance Use Disorders

The study examines the reliability and validity of a 3-item self-report adherence measure among people with HIV (PWH) experiencing homelessness, substance use, and mental health disorders. 336 participants were included from nine sites across the US between September 2013 and February 2017. We assessed the validity of a self-report scale for adherence to antiretroviral therapy by comparing it with viral load (VL) abstracted from medical records at baseline, 6, 12, and 18 months. The items had high internal consistency (Cronbach's alpha coefficients at each time point were > 0.8). The adherence scale scores were higher in the group that achieved VL suppression compared to the group that did not. The c-statistic for the receiver-operating characteristic curves pooled across time points was 0.77 for each adherence sub-item and 0.78 for the overall score. The self-report adherence measure shows good internal consistency and validity that correlated with VL suppression in homeless populations.

A Clinical Pilot Study of Spaced Retrieval Practice with a Self-Generation Booster to Improve Health-Related Memory in Persons With HIV Disease

Objective

Spaced retrieval practice (SRP) and self-generation are among the most replicated and effective mnemonic strategies in the cognitive psychology literature, but their benefits have not yet been realized in healthcare settings. This study used a randomized, between-subjects design to examine the hypothesis that SRP with a self-generation booster can improve memory for health-related information among clinically referred persons with HIV (PWH), who often have difficulty acquiring new health knowledge.

Method

A consecutive series of 41 PWH referred to a county-funded urban neuropsychology clinic were enrolled. Participants were randomly assigned to learn four statements about the treatment of a mock infectious disease in either a massed study control condition (n = 20) or an SRP condition (n = 21) in which they received two distributed free recall training tests supplemented with self-generation for missed items. The primary outcome was participants’ free recall of the four treatment statements after a 20-minute delay filled with nonverbal tests.

Results

PWH participants in the SRP condition were four times more likely than controls to recall at least one treatment statement at the 20-minute delay. SRP was not related to post-test recognition or health-related decision-making performance but was associated with moderately better self-efficacy for decision-making.

Conclusions

Findings from this pilot study show the potential of SRP with a self-generation booster to improve learning and memory for health-related information among PWH in clinic.

Skin and Soft Tissue Infection in People Living With Human Immunodeficiency Virus in a Large, Urban, Public Healthcare System in Houston, Texas, 2009-2014

BACKGROUND

Skin and soft tissue infections (SSTIs) disproportionately impact patients with human immunodeficiency virus (HIV). Recent declines in the incidence of SSTIs have been noted in the non-HIV population. We sought to study the epidemiology and microbiology of SSTIs in a population of 8597 patients followed for HIV primary care in a large, urban county system from January 2009 to December 2014.

METHODS

SSTIs were identified from the electronic medical record by use of International Classification of Diseases-9 billing codes. Charts were reviewed to confirm each patient's diagnosis of acute SSTI and abstract culture and susceptibility data. We calculated the yearly SSTI incidences using Poisson regression with clustering by patient.

RESULTS

There were 2202 SSTIs identified. Of 503 (22.8%) cultured SSTIs, 332 (66.0%) recovered Staphylococcus aureus as a pathogen, of which 287/332 (86.4%) featured S. aureus as the sole isolated organism. Among the S. aureus isolates that exhibited antibiotic susceptibilities, 231/331 (69.8%) were methicillin resistant, and the proportion did not change by year. The observed incidence of SSTI was 78.0 per 1000 person-years (95% confidence interval 72.9-83.4) and declined from 96.0 infections per 1000 person-years in 2009 to 56.5 infections per 1000 person-years in 2014 (P < .001). Other significant predictors of SSTI incidences in both univariate as well as multivariate analyses included a low CD4 count, high viral load, and not being a Spanish-speaking Hispanic.

CONCLUSIONS

SSTIs remain a significant problem in the outpatients living with HIV, although rates of SSTIs appear to have declined by approximately 40% between 2009 and 2014.

Patients' Experiences with Refilling their HIV Medicines: Facilitators and Barriers to On-Time Refills

BACKGROUND

Adherence to antiretroviral therapy (ART) is particularly important for patients with HIV. Prior research on ART adherence has focused primarily on behavioral interventions targeting patients and providers. No study has focused on the pharmacy refill experience as a potential target for improving adherence to HIV medicines. Informed by patients' experiences, this study aimed to assess patients' experiences with refilling their HIV medicines and to explore facilitators and barriers to refilling medicines on time.

METHODS

We interviewed patients at three time points during their first year of care at an HIV clinic in Houston, TX. We analyzed interviews using directed and conventional content analysis.

RESULTS

Analyses revealed individual, interpersonal, and system-level barriers that affect patients' ability to pick up their HIV medicines on time. Many patients perceived the refill process as being difficult. For some patients, picking up their HIV medicines each month triggered anxiety. Positive interactions with pharmacists and pharmacy staff, as well as clear and consistent messaging, played a key role in augmenting patients' refill experience. Self-efficacy, social support, and workarounds to resolve issues were also key facilitators. Many patients said changing ART-dispensing protocols from 30- to 90-day refills could mitigate the anxiety experienced with picking up HIV medicines and decrease opportunities for missing a refill.

CONCLUSION

Offering 90-day refills for HIV medicines may decrease anxiety concerning missed doses and improve medication adherence. Providing pharmacy staff with communication skills training is another strategy that may improve the patients' refill experience.

Pathways to housing stability and viral suppression for people living with HIV/AIDS: Findings from the Building a Medical Home for Multiply Diagnosed HIV-positive Homeless Populations initiative

Background

People with HIV with co-occurring substance use and mental health diagnoses who are unstably housed have poorer outcomes for retention in care and viral suppression. Navigation models are a potential strategy to help this vulnerable population obtain the necessary medical and non-medical services across multiple service systems. The Health Resources and Services Administration’s Special Projects of National Significance: “Building a Medical Home for Multiply-Diagnosed HIV-positive Homeless Populations initiative 2012–2017 found that navigation models may be an effective intervention to support people with HIV with unstable housing improve HIV health outcomes. However, there is limited information about the mechanisms by which this intervention works. In this article, we explore the participant and program factors for achieving stable housing at 6 months and how these factors influence HIV health outcomes.

Methods and findings

This was a prospective study of 471 unstably housed people with HIV enrolled in a navigation intervention across nine sites in the United Stated from 2013–2017. All sites provided HIV primary medical care. Eight sites were located in urban areas and one site served a predominantly rural population. Two sites were federally qualified health centers, three were city or county health departments, one site was a comprehensive HIV/AIDS service organization, and three sites were outpatient or mobile clinics affiliated with a university -based or hospital system. Data were collected via interview and medical chart review at baseline, post 6 and 12 months. Type and dose of navigation activities were collected via a standardized encounter form. We used a path analysis model with housing stability at 6 months as the mediator to examine the direct and indirect effects of participant’s socio-demographics and risk factors and navigation on viral suppression and retention in care at 12 months. Housing stability at 6 months was associated with male gender, younger age, viral suppression at baseline, having a lower risk for opiate use, recent homelessness, lower risk of food insecurity, and a longer length of time living with HIV. Participants who increased self-efficacy with obtaining help by 6 months had significantly higher odds of achieving housing stability. Stable housing, fewer unmet needs, moderate to high risk for opiate use, and viral suppression at baseline had a direct effect on viral suppression at 12 months. The intensity of navigation contact had no direct effect on housing stability and a mixed direct effect on viral suppression. Recent diagnosis with HIV, women, greater social support, increased self-efficacy and higher intensity of navigation contact had a direct effect on improved retention in HIV primary care at 12 months.

Conclusions

In this sample of people with HIV who are experiencing homelessness, housing stability had a significant direct path to viral suppression. Navigation activities did not have a direct effect on the path to housing stability but were directly related to retention in care. These results identify key populations and factors to target resources and policies for addressing the health and social unmet needs of people with HIV to achieve housing stability and HIV health outcomes.

HIV in Lebanon: Reasons for Testing, Engagement in Care, and Outcomes in Patients with Newly Diagnosed HIV Infections

Little is known about clinical presentation and cascade of care among patients living with HIV (PLWH) in Beirut, Lebanon. The study aims to examine the reasons for HIV testing and to evaluate the clinical characteristics of, predictors of advanced HIV stage at presentation in, and rates of ART initiation, retention in care, and viral load suppression among PLWH in Lebanon. We conducted a retrospective study of PLWH presenting to a tertiary-care centre-affiliated outpatient clinic from 2008 to 2016 with new HIV infection diagnoses. We identified a total of 423 patients: 89% were men, 55% were 30-50 years old, and 58% self-identified as men who have sex with men. About 35% of the patients had concurrent sexually transmitted diseases at the time of HIV diagnosis. Thirty percent of infection cases were identified by provider-initiated HIV testing, 36% of cases were identified by patient-initiated testing, and 34% of patients underwent testing for screening purposes. The proportion of individuals presenting with advanced HIV disease decreased from 40% in 2008-2009 to 24% in 2014-2015. Age older than 50 years and identification of HIV by a medical provider were independent predictors of advanced HIV infection at presentation. Among patients having indications for treatment (n = 253), 239 (94%) were prescribed antiretroviral therapy, and 147 (58%) had evidence of viral suppression at 1 year. Furthermore, 266 patients (63%) were retained in care. The care continuum for PLWH in Lebanon is comparable with those in high-income countries yet still far behind the Joint United Nations Programme on HIV/AIDS 90-90-90 set target.

Retention in Care and Viral Load Improvement After Discharge Among Hospitalized Out-of-Care People With HIV Infection: A Post Hoc Analysis of a Randomized Controlled Trial

BACKGROUND

Understanding factors influencing retention in care (RIC) and viral load improvement (VLI) in people with HIV (PWH) who are out of care and hospitalized will assist in intervention development for this vulnerable population.

METHODS

The study was a post hoc analysis of prospectively collected data. Hospitalized participants were enrolled if they were newly diagnosed with HIV during the hospitalization or out of HIV care. Participants completed surveys at baseline and 6 months postenrollment and laboratory studies of viral load (VL). Outcomes were RIC (2 completed visits, 1 within 30 days of discharge) and VLI (VL <400 or at least a 1-log10 decrease) 6 months after discharge. Univariate and multivariate regression analyses were conducted examining the contributions of predisposing, enabling, and need factors to outcomes.

RESULTS

The study cohort included 417 participants enrolled between 2010 and 2013. The population was 73% male, 67% non-Hispanic black, 19% Hispanic, and 70% uninsured. Sixty-five percent had a baseline CD4 <200 cells/mm3, 79% had a VL >400 copies/mL or missing, and the population was generally poor with low educational attainment. After discharge from the hospital, 60% did not meet the definition for RIC, and 49% did not have VLI. Modifiable factors associated with the outcomes include drug use (including marijuana alone and other drugs), life instability (eg, housing, employment, and life chaos), and using avoidance coping strategies in coping with HIV.

CONCLUSIONS

Hospitalized out-of-care PWH in the United States are at high risk of poor re-engagement in care after discharge. Interventions for this population should focus on improving socioeconomic stability and coping with HIV and reducing drug use.

Acceptability and preferences for long-acting antiretroviral formulations among people with HIV infection

The study evaluates the acceptability and preferences for long-acting antiretroviral therapy (LA-ART) among a diverse cohort of people with HIV infection (PWH). It consists of a self-administered survey and chart review of PWH presenting to an HIV clinic in Houston, Texas, between February and June 2018; 374 participants were included; 61% indicated that they were likely or very likely to use LA-ART formulations. When asked about preference, 41% preferred pills, 40% preferred injections, and 18% preferred an implant. The most common benefit reported was eliminating the need to remember taking daily HIV pills (74%); 43% were worried that LA-ART will not be as effective as pills. Participants with a college degree, men who have sex with men, and ART-experienced were more willing to use LA-ART. Participants who reported poor or fair health, or who screened positive for depression or anxiety were significantly less willing to use LA-ART. The likelihood of using LA-ART did not correlate with self-reported adherence and HIV suppression. Patients with difficulty scheduling and attending clinic visits preferred injections and implant over pills. Most participants indicated a willingness to use new LA ART formulations. However, 41% still prefers pills, and those more interested in LA-ART were not less adherent.

Exploring the Attitude of Patients with HIV About Using Telehealth for HIV Care

Telehealth could address many of the factors identified as barriers for retention in HIV care. In this study, we explore people with HIV (PWH)'s attitudes about using telemedicine for HIV care instead of face-to-face clinic visits. We administered a one-time survey to PWH presenting to an outpatient HIV center in Houston, Texas, from February to June 2018. The survey items were used to assess PWH's attitudes toward and concerns for telehealth and explanatory variables; 371 participants completed the survey; median age was 51, 36% and were female, and 63% was African American. Overall 57% of respondents were more likely to use telehealth for their HIV care if available, as compared with one-on-one in-person care, and 37% would use telehealth frequently or always as an alternative to clinic visits. Participants reported many benefits, including ability to fit better their schedule, decreasing travel time, and privacy but expressed concerns about the ability to effective communication and examination and the safety of personal information. Factors associated with likelihood of using telehealth include personal factors (US-born, men who have sex with men, higher educational attainment, higher HIV-related stigma perception), HIV-related factors (long-standing HIV), and structural factors (having difficulty attending clinic visits, not knowing about or not having the necessary technology). There was no association between participants with uncontrolled HIV, medication adherence, and likelihood of using telehealth. Telehealth programs for PWH can improve retention in care. Availability and confidence using various telehealth technologies need to be addressed to increase acceptability and usage of telehealth among PWH.

What patient involvement means to new patients at two HIV clinics: A longitudinal, qualitative study

OBJECTIVES

This study 1) defines patient involvement from the perspective of patients new to a provider, 2) describes provider communication that patients perceive as promoting involvement, and 3) examines changes in patient definitions of involvement over time.

METHODS

We enrolled 56 patients at two HIV clinics in Houston, Texas, from August 2013 until March 2015. We interviewed patients three times during the first year of care and analyzed interviews using content analysis.

RESULTS

The mean age was 45 years; 54% were men. Patient definitions of involvement ranged from adherence- to decision-oriented. Analysis revealed three provider communication behaviors that patients perceive as promoting involvement: 1) soliciting patient feedback, 2) discussing treatment options and trade-offs, 3) narrating the decision-making process. Definitions of involvement can change over time as providers reframe the patient's illness as manageable and through perceived partnerships with the provider.

CONCLUSION

Provider communication plays a critical role in shaping new patients' perception of involvement and can make patients feel involved even when patients do not actively make medical decisions.

PRACTICAL IMPLICATIONS

Finding strategies to make patients feel involved in their care is important, particularly for new patients, even if those strategies do not necessarily promote more talk from the patient.

The psychology of the wait time experience - what clinics can do to manage the waiting experience for patients: a longitudinal, qualitative study

BACKGROUND

Wait time, defined as time spent in the waiting and exam rooms waiting to see a provider, is a key quality metric in a number of national patient experience surveys. However, the literature on wait time does not show a consistent correlation between long waits and worse overall patient care experiences. Herein, we examine contextual factors that can shape the manner in which patients may respond to different wait times. We also identify actions providers and clinics can take to promote positive wait experiences and mitigate negative ones.

METHODS

We conducted over 130 h of semi-structured interviews with patients new to two HIV primary care clinics in Houston, Texas. We interviewed patients before the first provider visit, again within two weeks of the first visit, and again at 6-12 months. We analyzed the interviews using directed and conventional content analysis.

RESULTS

Our study showed that patients' "willingness to wait" is the product of the actual wait time, individual factors, such as the perceived value of the visit and cost of a long wait, and clinic and provider factors. Analyses revealed key steps providers and clinics can take to improve the wait time experience. These include: 1) proactively informing patients of delays, 2) explicitly apologizing for delays, and 3) providing opportunities for diversion. Patients noted the importance of these steps in curtailing frustrations that may result from a long wait.

CONCLUSIONS

Our study highlights key steps cited by patients as having the potential to improve the wait time experience. These steps are practical and of particular interest to clinics, where waits are oftentimes inevitable.

Integration of telehealth services in the healthcare system: with emphasis on the experience of patients living with HIV

The US Health Resources and Services Administration defines telehealth as the use of electronic information and telecommunications technologies to support long-distance clinical healthcare, patient and professional health-related education, public health and health administration. Many studies have supported the use of telehealth to increase convenience to patients, improve patient satisfaction, diminish healthcare disparities, and reduce cost that will ultimately lead to improvement in clinical outcomes and quality of care. However, guaranteeing confidentiality, educating patients and providers, and obtaining insurance reimbursement are some of the challenges that face the implementation of telehealth program. The use of telehealth has been investigated in acute infections, such as endocarditis and chronic infections as in hepatitis C, and HIV. The purpose of this review is to focus on the use of telehealth services for people living with HIV (PLWH). For PLWH, telehealth could be particularly useful by connecting specialty providers to an underserved population and addressing many of the factors identified as barriers to HIV care. To date, the literature supports the use of telehealth for the management of chronic diseases including HIV. Most of the studies showed a high acceptability and positive experience with telehealth services among PLWH. However, fewer studies have evaluated telemedicine for chronic direct care of PLWH. Well-designed studies are needed to show that the implementation of telehealth could improve the HIV care continuum. In addition, future research should focus on identifying the group of patients that could benefit the most from such intervention.

Mobile Phones May Not Bridge the Digital Divide: A Look at Mobile Phone Literacy in an Underserved Patient Population

Purpose: Mobile health (mHealth) has promise to improve patient access to disease prevention and health promotion services; however, historically underserved populations may have poor access to mobile phones or may not be aware of or comfortable using phone features. Our objectives were to assess mobile phone ownership and mobile phone literacy among low-income, predominately racial and ethnic minority patients.

Materials and methods: We conducted a cross-sectional survey of a convenience sample of primary care patients in a publicly-funded clinic in Houston, TX.

Results: Of 285 participants, 240 owned a mobile phone and 129 owned a smartphone. The most common uses of phones were talk (89%) and text messaging (65%). Only 28% of smartphone owners had health apps. Younger age was significantly associated with smartphone ownership and use of smartphones for Internet browsing, social media, and apps.

Conclusion: Our findings from a safety-net patient population represent trends in mobile phone ownership and literacy. Despite the single-site location of our study, the findings could be helpful to health promotion practitioners working with similar underserved populations. mHealth interventions should employ phone features that are accessible and familiar to the target audience to avoid denying intervention benefits to those with low mobile phone literacy and therefore widen health disparities.

The Impact of Housing and HIV Treatment on Health-Related Quality of Life Among People With HIV Experiencing Homelessness or Unstable Housing

Objectives. To determine the impact of improvements in housing and HIV clinical parameters on health-related quality of life (HRQOL) in persons with HIV infection experiencing homelessness.Methods. This prospective cohort study took place in 9 US sites. Local efforts sought to improve HIV and housing status. Longitudinal data analyses determined the impact of changes in housing status, HIV suppression, and CD4 cell counts on HRQOL at 12 months, measured as mental and physical component summary scores.Results. Among 909 participants enrolled from 2013 to 2016, 75.1% were homeless, 51.6% did not have HIV suppression, and 23.6% had a CD4 count less than 200 cells per cubic millimeter. Median mental and physical component summary scores were 35.4 and 38.9, respectively. These 5 parameters all improved by 6 months. In multivariate modeling, maintaining or achieving stable housing predicted higher PCS at 12 months, but CD4 count and HIV suppression improvements did not. Improvements in housing, CD4 count, and HIV suppression did not predict mental component score at 12 months.Conclusions. Housing and HIV treatment are necessary but not sufficient to improve HRQOL in this challenging population. The high prevalence of socioeconomic and mental health needs we found support the call for patient-centered comprehensive care.

1770. The Association of Unmet Needs With Subsequent Retention in Care and HIV Suppression Among Hospitalized Patients With HIV Who Are Out of Care

Background

Unmet needs among hospitalized patients with HIV may prevent engagement in HIV care leading to worse clinical outcomes. Our aim was to examine the role of unmet subsistence needs (e.g., housing, transportation, food) and medical needs (e.g., mental health, substance abuse treatment) as barriers for retention in HIV care and viral load (VL) suppression.

Methods

We utilized data from the Mentor Approach for Promoting Patients’ Self-Care intervention study, the enrolled hospitalized HIV-patients at a large publicly funded hospital between 2010 and 2013, who were out-of-care. We examined the effect of unmet needs on retention in HIV care (attended HIV appointments within 0–30 days and 30–180 days) and viral load suppression, 6 months after discharge.

Results

A total of 417 participants were enrolled, 78% reported having ≥1 unmet need at baseline, most commonly dental care (55%), financial (43%), or housing needs (34%). Participants with unmet needs at baseline, compared with those with no needs, were more likely to be African American, have an existing HIV diagnosis, and be uninsured. Among participants who completed a baseline and 3-month survey (n = 320), 45% reported a need for dental care, 42% reported financial needs, and 32% reported housing needs that were unmet at either time point (Figure 1). Having a dental care need at baseline that was met was significantly associated with higher odds of VL improvements at 6-month follow-up (OR: 2.2; 95% CI: 1.04–4.50, P = 0.03) and higher odds for retention in care (OR: 2.06; 95% CI: 1.05–4.07, P = 0.04). An unmet need for transportation was associated with lower odds of retention in care (OR: 0.5; 95% CI: 0.34–0.94, P = 0.03), even after adjusting for other factors. Compared with participants with no need, those who reported ≥3 unmet subsistence needs were less likely to demonstrate viral load improvement (OR: 0.51; 95% CI: 0.28–0.92; P = 0.03) and to be retained in care (OR: 0.52; 95% CI: 0.28–0.95; P = 0.03).

Conclusion

An important and novel finding in our study is that the number of unmet subsistence needs had a significant effect on retention in care and VL suppression. Broader access to programs that can assist in meeting subsistence needs among hospitalized patients could have significant individual and public health benefits.

Disclosures

All authors: No reported disclosures.

934. Incidence of Skin and Soft-tissue Infection in People Living With HIV in a Large Urban Public Health Care System in Houston, Texas, 2009–2014

Background

Skin and soft-tissue infections (SSTIs) disproportionately impact patients with HIV. Recent declines have been noted in the incidence of SSTIs in the non-HIV population. We set out to study the epidemiology and microbiology of SSTIs in a population of 8,597 patients followed for HIV primary care in a large urban county system from January 1, 2009 to December 31, 2014.

Methods

SSTIs were identified from the electronic medical record (EMR) by the use of ICD-9 billing codes. Charts were reviewed to confirm the diagnosis of acute SSTI and abstract culture and susceptibility data. We calculated yearly SSTI incidence using Poisson regression with clustering by patient.

Results

2202 SSTIs were identified. Of 503 (22.8%) cultured SSTIs, 332 (66.0%) included S. aureus as a pathogen, of which 287/332 (86.4%) featured S. aureus as the sole pathogen. Of S. aureus isolates with susceptibilities, 231/331 (69.8%) were methicillin-resistant, and the proportion did not vary by year (P = NS).

The observed incidence of SSTI was 78.0 per 1,000 person-years (95% CI 72.9–83.4) and declined from 96.0 infections per 1,000 person-years in 2009 to 56.5 infections per 1,000 person years in 2014 (P < 0.001). Other significant predictors of SSTI incidence in both univariate as well as multivariate analysis included CD4 count, viral load, and being a Spanish-speaking Hispanic.

Conclusion

Although SSTI rates in a large urban HIV-infected outpatient cohort declined approximately 40% between 2009 and 2014, SSTIs remain a significant problem.

Disclosures

C. Arias, Merck & Co., Inc.: Grant Investigator, Research support. MeMed: Grant Investigator, Research support. Allergan: Grant Investigator, Research support

1276. Human Immunodeficiency Virus (HIV) Diagnostic Limbo: A Retrospective Review of Discordant HIV Test Results in a Large, Academic Health Center Over a 10-Year Period to Guide Clinicians in Distinguishing False-Positive vs. Acute HIV Infection

Background

The Centers for Disease Control and Prevention (CDC) recommends universal HIV screening with a fourth-generation HIV-1/2 antigen–antibody immunoassay followed by an HIV-1/-2 antibody differentiation immunoassay. Discordant results require nucleic acid testing (NAT) to distinguish acute HIV from false positives. In practice, NAT can be delayed, leaving clinicians and patients in limbo. Better understanding of factors associated with acute HIV vs. false positivity among discordant HIV tests is needed.

Methods

From 2014 to 2018, positive fourth-generation HIV-1/-2 enzyme-linked immunosorbent assay (ELISA) tests were retrospectively analyzed across centers in the Harris Health system in Houston, Texas. Discordant results were defined as a positive fourthgeneration HIV-1/2 ELISA with a negative HIV-1/-2 antibody confirmation test and were resolved via NAT (if possible). Duplicate results and patients with a previously positive HIV-1 viral load were excluded. Results were analyzed (Fisher’s exact test or Chi square) by year, setting (clinic/hospital), sex, age, race, and comorbid conditions (pregnancy, rheumatoid arthritis, lupus, hepatitis B and syphilis [rapid plasma reagin, or RPR&gt;1:4] for associations with acute HIV vs. false positivity).

Results

Of 7,077 positive fourth-generation HIV-1/2 ELISA tests, 488 (13%) discordant cases were identified. Eighty-six (18%) represented acute HIV while 322 (66%) were false positives; 80 remained unresolved (no NAT performed). Median time to resolution via NAT was 21 days. Clinic setting, female sex, older age, non-Black race, and negative RPR status were associated with significantly higher rates of false positivity vs. acute HIV (P &lt; 0.02 for all associations).

Conclusion

In this large HIV testing program in a multicenter metropolitan health system, 66% of discordant fourth-generation HIV tests represented false positives. Several clinical factors correlated with a higher rate of false positivity, likely reflecting the impact of disease prevalence on the positive predictive value of any diagnostic test. Clinicians may consider these factors when counseling their patients during the limbo period. Efforts to expedite NAT to resolve discordant cases is paramount to reducing diagnostic uncertainty.

Disclosures

All authors: No reported disclosures.

The Role of Text Messages in Patient-Physician Communication about the Influenza Vaccine

BACKGROUND

Racial and ethnic minorities face disparities in receiving the influenza vaccination. A text message intervention could deliver personalized and timely messages to counsel patients on asking their physician for the vaccination.

AIMS

We assessed whether patients would be receptive to influenza vaccination text messages.

METHODS

Participants were recruited from a sample of low-income, racial and ethnic minority primary care patients. Participants completed a self-administered survey. Descriptive statistics were used to analyze the data.

RESULTS

There were 274 patients who participated and answered the questions of interest, of whom 70% were racial and ethnic minorities and 85% owned a cell phone. Thirty-six percent reported they had never received an influenza vaccination recommendation from their physician. However, 84% would be comfortable asking their physician for the influenza vaccination. Of cell phone-owning participants who would be comfortable asking their physician about the influenza vaccination, 80% would also be comfortable receiving a text message reminder.

CONCLUSION

Text messages may be an acceptable channel to prompt patients to discuss the annual influenza vaccination with their physicians. Text messaging is a feasible tool to engage patients in their health and improve annual influenza vaccination rates among low-income, racial and ethnic minority patients.

Participants' perspectives on improving retention in HIV care after hospitalization: A post-study qualitative investigation of the MAPPS study

Few interventions have been shown to improve retention in HIV care. We recently completed a randomized, controlled trial of a peer mentoring intervention, which failed to increase retention in care or HIV suppression. We sought to gain insight into this negative result and elicit suggestions for future interventions. We conducted semi-structured one-on-one interviews with a sub-sample of participants and all available interventionists after completion of the primary study. Interviews were coded by two researchers and thematically analyzed. Participants in the intervention arm (N = 16) reported good rapport with and benefit from peer mentoring and found the mentors helpful in facilitating the transition from hospital to out-patient clinic. Control arm participants (N = 9) reported similar emotional and social support benefits from the health educators. In both arms, ongoing challenges including completing paperwork, securing transportation, and rescheduling missed appointments were cited, along with internalized stigma and lack of will to seek care, despite the mentors’ best efforts. Suggested improvements to the intervention included: more frequent contact with interventionists; additional support for mental health problems; and targeting overall health rather than a more selective focus on HIV. Mentors and health educators agreed with the participant-reported barriers and added that some participants were too sick to meaningfully participate in the intervention, while others appeared unwilling to engage with the interventionists in a meaningful way. Mentoring was highly acceptable and felt to be impactful, however it was not sufficient to overcome structural barriers or stigma and low motivation in some participants. The attention control intervention may have had an unintended positive impact. Future interventions should focus on broad aspects of health and well-being.

Understanding why HIV-infected persons disengaged from pre-ART care in Freetown, Sierra Leone: a qualitative study

In countries that have not implemented universal antiretroviral treatment (ART), loss to follow-up (LTFU) during pre-ART care remains a problem. We conducted semi-structured interviews with 41 HIV-infected persons who were LTFU during pre-ART care from a prospective cohort of persons newly diagnosed with HIV infection in Freetown, Sierra Leone, in 2012-2013. Interviews determined whether the participant disengaged or transferred care and explored the reasons for being LTFU. Of the 41 participants, 34 (83%) disengaged from care. For persons who disengaged from care, socioeconomic barriers emerged as a dominant theme in both ART-eligible and -ineligible groups while psychosocial barriers emerged as a dominant theme in the ART-ineligible group. Structural barriers emerged as a dominant theme for participants who transferred care. Interventions designed to address socioeconomic and psychosocial barriers may help reduce disengagement from pre-ART care.

Evaluation of a computer-based and counseling support intervention to improve HIV patients' viral loads

We sought to integrate a brief computer and counseling support intervention into the routine practices of HIV clinics and evaluate effects on patients' viral loads. The project targeted HIV patients in care whose viral loads exceeded 1000 copies/ml at the time of recruitment. Three HIV clinics initiated the intervention immediately, and three other HIV clinics delayed onset for 16 months and served as concurrent controls for evaluating outcomes. The intervention components included a brief computer-based intervention (CBI) focused on antiretroviral therapy adherence; health coaching from project counselors for participants whose viral loads did not improve after doing the CBI; and behavioral screening and palm cards with empowering messages available to all patients at intervention clinics regardless of viral load level. The analytic cohort included 982 patients at intervention clinics and 946 patients at control clinics. Viral loads were assessed at 270 days before recruitment, at time of recruitment, and +270 days later. Results indicated that both the control and intervention groups had significant reductions in viral load, ending with approximately the same viral level at +270 days. There was no evidence that the CBI or the targeted health coaching was responsible for the viral reduction in the intervention group. Results may stem partially from statistical regression to the mean in both groups. Also, clinical providers at control and intervention clinics may have taken action (e.g., conversations with patients, referrals to case managers, adherence counselors, mental health, substance use specialists) to help their patients reduce their viral loads. In conclusion, neither a brief computer-based nor targeted health coaching intervention reduced patients' viral loads beyond levels achieved with standard of care services available to patients at well-resourced HIV clinics.

Development and Evaluation of a Physician-Targeted Video to Promote HIV Screening

Introduction. Despite national recommendations, routine opt-out HIV testing has not been widely adopted by physicians. Guided by previous research on physician barriers to HIV testing, we developed a physician-targeted video to promote routine opt-out HIV screening. The objective of this study was to evaluate this video intervention. Methods. From June to July 2016, physicians in two primary care clinics completed an online survey prior to and after watching the video. Survey items assessed acceptability of the video and HIV testing knowledge, attitudes, and intention to screen. Descriptive statistics were generated to analyze data. Results. Of the 53 participants, 90% liked or strongly liked the video. Pre- to postvideo, significant improvements were seen in the knowledge of national HIV screening recommendations (45.3% to 67.9%; p = .010) and of the proportion of unaware Houstonians living with HIV (22.6% to 75.5%; p < .001). Participant beliefs about the likelihood of patients accepting HIV testing increased from 47.2% to 84.9% pre- to postvideo (p < .001). Intention to screen did not change; participants had high intentions pre- and postvideo. Conclusions. Our study found that a video is an acceptable HIV testing promotion medium for physicians. Our video improved physician HIV testing knowledge and attitudes, overcoming key barriers to HIV testing.

Strategies for Linkage to and Engagement With Care: Focus on Intervention

Retention of HIV-infected patients in care is crucial to optimizing individual patient outcomes and reducing transmission of HIV. A number of strategies are available to improve linkage to care; among them, the AntiRetroviral Treatment and Access Services intervention should be considered standard of care at the clinic level. With regard to retention in care, the Retention Through Enhanced Personal Contact intervention has been shown to improve retention rates and the Centers for Disease Control and Prevention Data to Care program has been successful in assisting public health authorities to locate and return to treatment patients presumed to be lost to follow-up. Patient satisfaction with initial physician and clinic encounters also improves retention. There are some data to support same-day or rapid start of antiretroviral therapy in the clinic setting as a method to immediately establish care and more data on this approach are needed. This article summarizes a presentation by Thomas P. Giordano, MD, MPH, at the Ryan White HIV/AIDS Program Clinical Conference held in San Antonio, Texas, in August 2017.

Gaps Up To 9 Months Between HIV Primary Care Visits Do Not Worsen Viral Load

Current guidelines specify that visit intervals with viral monitoring should not exceed 6 months for HIV patients. Yet, gaps in care exceeding 6 months are common. In an observational cohort using US patients, we examined the association between gap length and changes in viral load status and sought to determine the length of the gap at which significant increases in viral load occur. We identified patients with gaps in care greater than 6 months from 6399 patients from six US HIV clinics. Gap strata were >6 to <7, 7 to <8, 8 to <9, 9 to <12, and ≥12 months, with viral load measurements matched to the opening and closing dates for the gaps. We examined visit gap lengths in association with two viral load measurements: continuous (log10 viral load at gap opening and closing) and dichotomous (whether patients initially suppressed but lost viral suppression by close of the care gap). Viral load increases were nonsignificant or modest when gap length was <9 months, corresponding to 10% or fewer patients who lost viral suppression. For gaps ≥12 months, there was a significant increase in viral load as well as a much larger loss of viral suppression (in 23% of patients). Detrimental effects on viral load after a care gap were greater in young patients, black patients, and those without private health insurance. On average, shorter gaps in care were not detrimental to patient viral load status. HIV primary care visit intervals of 6 to 9 months for select patients may be appropriate.

HIV Pre-exposure Prophylaxis Program Implementation Using Intervention Mapping

INTRODUCTION

HIV pre-exposure prophylaxis has been proven to be an effective tool in HIV prevention. However, numerous barriers still exist in pre-exposure prophylaxis implementation.

METHODS

The framework of Intervention Mapping was used from August 2016 to October 2017 to describe the process of adoption, implementation, and maintenance of an HIV prevention program from 2012 through 2017 in Houston, Texas, that is nested within a county health system HIV clinic. Using the tasks outlined in the Intervention Mapping framework, potential program implementers were identified, outcomes and performance objectives established, matrices of change objectives created, and methods and practical applications formed.

RESULTS

Results include the formation of three matrices that document program outcomes, change agents involved in the process, and the determinants needed to facilitate program adoption, implementation, and maintenance. Key features that facilitated successful program adoption and implementation were obtaining leadership buy-in, leveraging existing resources, systematic evaluation of operations, ongoing education for both clinical and nonclinical staff, and attention to emergent issues during launch.

CONCLUSIONS

The utilization of Intervention Mapping to delineate the program planning steps can provide a model for pre-exposure prophylaxis implementation in other settings.

Single tablet HIV regimens facilitate virologic suppression and retention in care among treatment naïve patients

Newer HIV regimens are typically taken once daily but vary in the number of pills required. Whether the number of pills in a once-daily HIV regimen affects clinical outcomes is unknown. We retrospectively compared adherence, retention in care, and virologic outcomes between patients starting a once daily single-tablet regimen (STR) to patients starting a once-daily multi-tablet regimen (MTR) in a publicly funded clinic in the United States. Outcomes were measured in the year after starting ART and included retention in care, virologic suppression, and medication possession ratio of at least 80%. Data from patients initiating therapy from 1 January 2008 to 31 December 2011 were analyzed with both unadjusted and propensity-score adjusted regression. Overall, 622 patients started with an STR (100% efavirenz-based) and 406 with an MTR (65% atazanavir-based and 35% darunavir-based) regimen. Retention in care was achieved in 80.7% of STR patients vs. 72.7% of MTR patients (unadjusted OR 1.57, 95% CI 1.17-2.11; adjusted OR 1.49, 95% CI 1.10-2.02). Virologic suppression occurred among 84.4% of STR patients vs. 77.6% of MTR patients (unadjusted OR 1.56; 95% CI 1.14-2.15; adjusted OR 1.41; 95% CI 1.02-1.96). There was no difference in the proportion of patients achieving at least 80% adherence, as measured by medication possession ratio (33.0% of STR patients and 30.1% of MTR patients; unadjusted OR 1.14; 95% CI 0.87-1.50; adjusted OR 1.04, CI 0.79-1.38). While it is difficult to eliminate confounding in this observational study, retention in care and virologic outcomes were better in patients prescribed STRs.

Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments

STUDY OBJECTIVE

Newer combination HIV antigen-antibody tests allow detection of HIV sooner after infection than previous antibody-only immunoassays because, in addition to HIV-1 and -2 antibodies, they detect the HIV-1 p24 antigen, which appears before antibodies develop. We determine the yield of screening with HIV antigen-antibody tests and clinical presentations for new diagnoses of acute and established HIV infection across US emergency departments (EDs).

METHODS

This was a retrospective study of 9 EDs in 6 cities with HIV screening programs that integrated laboratory-based antigen-antibody tests between November 1, 2012, and December 31, 2015. Unique patients with newly diagnosed HIV infection were identified and classified as having either acute HIV infection or established HIV infection. Acute HIV infection was defined as a repeatedly reactive antigen-antibody test result, a negative HIV-1/HIV-2 antibody differentiation assay, or Western blot result, but detectable HIV ribonucleic acid (RNA); established HIV infection was defined as a repeatedly reactive antigen-antibody test result and a positive HIV-1/HIV-2 antibody differentiation assay or Western blot result. The primary outcomes were the number of new HIV diagnoses and proportion of patients with laboratory-defined acute HIV infection. Secondary outcomes compared reason for visit and the clinical presentation of acute HIV infection.

RESULTS

In total, 214,524 patients were screened for HIV and 839 (0.4%) received a new diagnosis, of which 122 (14.5%) were acute HIV infection and 717 (85.5%) were established HIV infection. Compared with patients with established HIV infection, those with acute HIV infection were younger, had higher RNA and CD4 counts, and were more likely to have viral syndrome (41.8% versus 6.5%) or fever (14.3% versus 3.4%) as their reason for visit. Most patients with acute HIV infection displayed symptoms attributable to acute infection (median symptom count 5 [interquartile range 3 to 6]), with fever often accompanied by greater than or equal to 3 other symptoms (60.7%).

CONCLUSION

ED screening using antigen-antibody tests identifies previously undiagnosed HIV infection at proportions that exceed the Centers for Disease Control and Prevention's screening threshold, with the added yield of identifying acute HIV infection in approximately 15% of patients with a new diagnosis. Patients with acute HIV infection often seek ED care for symptoms related to seroconversion.

Enhancing VTA Cav1.3 L-type Ca2+ channel activity promotes cocaine and mood-related behaviors via overlapping AMPA receptor mechanisms in the nucleus accumbens

Genetic factors significantly influence susceptibility for substance abuse and mood disorders. Rodent studies have begun to elucidate a role of Ca_v1.3 L-type Ca²⁺ channels in neuropsychiatric-related behaviors, such as addictive and depressive-like behaviors. Human studies have also linked the CACNA1D gene, which codes for the Ca_v1.3 protein, with bipolar disorder. However, the neurocircuitry and the molecular mechanisms underlying the role of Ca_v1.3 in neuropsychiatric phenotypes are not well established. In the present study, we directly manipulated Ca_v1.3 channels in Ca_v1.2 dihydropyridine insensitive mutant mice and found that ventral tegmental area (VTA) Ca_v1.3 channels mediate cocaine-related and depressive-like behavior through a common nucleus accumbens (NAc) shell calcium-permeable α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (CP-AMPAR) mechanism that requires GluA1 phosphorylation at S831. Selective activation of VTA Ca_v1.3 with (±)-BayK-8644 (BayK) enhanced cocaine conditioned place preference and cocaine psychomotor activity while inducing depressive-like behavior, an effect not observed in S831A phospho-mutant mice. Infusion of the CP-AMPAR-specific blocker Naspm into the NAc shell reversed the cocaine and depressive-like phenotypes. In addition, activation of VTA Ca_v1.3 channels resulted in social behavioral deficits. In contrast to the cocaine- and depression-related phenotypes, GluA1/A2 AMPARs in the NAc core mediated social deficits, independent of S831-GluA1 phosphorylation. Using a candidate gene analysis approach, we also identified single-nucleotide polymorphisms in the CACNA1D gene associated with cocaine dependence in human subjects. Together, our findings reveal novel, overlapping mechanisms through which VTA Ca_v1.3 mediates cocaine-related, depressive-like and social phenotypes, suggesting that Ca_v1.3 may serve as a target for the treatment of neuropsychiatric symptoms.