Design and methods of a randomized trial testing "Advancing care for COPD in people living with HIV by implementing evidence-based management through proactive E-consults (ACHIEVE)"

Chronic obstructive pulmonary disease (COPD) is one of the most common comorbid diseases among aging people with HIV (PWH) and is often mismanaged. To address this gap, we are conducting the study, "Advancing care for COPD in people living with HIV by Implementing Evidence-based management through proactive E-consults (ACHIEVE)." This intervention optimizes COPD management by promoting effective, evidence-based care and de-implementing inappropriate therapies for COPD in PWH receiving care at Veteran Affairs (VA) medical centers. Study pulmonologists are proactively supporting ID providers managing a population of PWH who have COPD, offering real-time evidence-based recommendations tailored to each patient. We are leveraging VA clinical and informatics infrastructures to communicate recommendations between the study team and clinical providers through the electronic health record (EHR) as an E-consult. If effective, ACHIEVE could serve as a model of effective, efficient COPD management among PWH receiving care in VA. This paper outlines the rationale and methodology of the ACHIEVE trial, one of a series of studies funded by the National Heart, Lung, and Blood Institute (NHLBI) within the ImPlementation REsearCh to DEvelop Interventions for People Living with HIV (PRECluDE) consortium to study chronic disease comorbidities in HIV populations.

Using Active Surveillance to Identify Monoclonal Antibody Candidates Among COVID-19-Positive Veterans in the Atlanta VA Health Care System

Background

Strategies for optimizing identification and outreach to potential candidates for monoclonal antibody (Mab) therapy for COVID-19 are not clear. Using a centralized, active surveillance system, the Atlanta Veterans Affairs Health Care System (AVAHCS) infectious disease (ID) team identified candidates for Mab infusion and provided treatment.

Observations

As part of a quality improvement project from December 28, 2020, to August 31, 2021, a clinical team consisting of ID pharmacists and physicians reviewed each outpatient with a positive COVID-19 polymerase chain reaction test daily at the AVAHCS. The clinical team used Emergency Use Authorization (EUA) criteria to determine eligibility. Eligible patients were contacted on the same day of review via telephone to confirm eligibility and obtain verbal consent. Telehealth follow-up occurred on day 1 and day 7 postinfusion to assess for adverse events. In total, 2028 patients with COVID-19 were identified; 289 patients (14%) were eligible, and 132 (46%) received Mab therapy. Similar to AVAHCS demographics, a majority of those who received Mab therapy were non-Hispanic Black patients (65%). The most common comorbidities were hypertension (59%) and diabetes (37%). The median time from symptom onset to positive COVID-19 polymerase chain reaction (PCR) test result was 6 days (range, 0-9), and the median time from positive COVID-19 PCR test result to Mab infusion was 2 days (range, 0-8). Twelve patients (9%) required hospitalization for worsening COVID-19 symptoms postinfusion. No deaths occurred.

Conclusions

Combining laboratory surveillance and active screening led to high uptake of Mab therapy and minimized delay from symptom onset to Mab infusion, thereby optimizing outpatient treatment of COVID-19. This approach also successfully screened and treated Black patients in the AVAHCS population.

The association between comorbidities and coronavirus disease 2019 hospitalization among people with HIV differs by age

OBJECTIVES

To determine whether factors associated with coronavirus disease 2019 (COVID-19) hospitalization among people with HIV (PWH) differ by age stratum.

DESIGN

Retrospective cohort study.

METHODS

All adult PWH with a positive SARS-CoV-2 PCR in a public safety-net health system between 1 March 2020 and 28 February 2021 and a Veterans Affairs Medical Center between 1 1 March 2020 and 15 November 2020 in Atlanta, Georgia were included. We performed multivariable logistic regression to determine demographic and clinical factors associated with COVID-19 hospitalization overall and stratified by age less than 50 and at least 50 years.

RESULTS

Three hundred and sixty-five PWH (mean age 49 years, 74% cisgender male, 82% black) were included. Ninety-six percent were on antiretroviral therapy (ART), 87% had CD4 + T-cell count at least 200 cells/μl, and 89% had HIV-1 RNA less than 200 copies/ml. Overall, age [adjusted odds ratio (aOR) 95% confidence interval (CI) 1.07 (1.04-1.10)], later date of SARS-CoV-2 infection [aOR 0.997 (0.995-1.00)], heart disease [aOR 2.27 (1.06-4.85)], and history of hepatitis C virus (HCV) [aOR 2.59 (1.13-5.89)] were associated with COVID-19 hospitalization. Age-adjusted comorbidity burden was associated with 30% increased risk of hospitalization [aOR 1.30 (1.11-1.54)]. Among 168 PWH less than 50 years old, older age [aOR 1.09 (1.01-1.18)] and no ART use [aOR 40.26 (4.12-393.62)] were associated with hospitalization; age-adjusted comorbidity burden was not ( P  = 0.25). Among 197 PWH at least 50, older age [aOR 1.10 (1.04-1.16)], heart disease [aOR 2.45 (1.04-5.77)], history of HCV [aOR 3.52 (1.29-9.60)], and age-adjusted comorbidity burden [aOR 1.36 (1.12-1.66)] were associated with hospitalization.

CONCLUSION

Comorbidity burden is more strongly associated with COVID-19 hospitalization among older, rather than younger, PWH. These findings may have important implications for risk-stratifying COVID-19 therapies and booster recommendations in PWH.

Trends in Cause-Specific Mortality Among Veterans With HIV: A 35-Year (1982-2016) Analysis of the HIV Atlanta VA Cohort Study

BACKGROUND

Causes of death and their trends among veterans with HIV (VWH) are different than those in the general population with HIV, but this has not been fully described. The objective was to understand the trends in, and risk factors for, all-cause and cause-specific mortality across eras of combination antiretroviral therapy (cART) among VWH.

SETTING

The HIV Atlanta VA Cohort Study includes all VWH who ever sought care at the Atlanta VA Medical Center.

METHODS

Age-adjusted all-cause and cause-specific mortality rates were calculated annually and compared between pre-cART (1982-1996), early-cART (1997-2006), and late-cART (2007-2016) eras. Trends were assessed using Kaplan-Meier curves, cumulative incidence functions, and joinpoint regression models. Risk factors were identified by Cox proportional hazards models.

RESULTS

Of the 4674 VWH in the HIV Atlanta VA Cohort Study, 1752 died; of whom, 1399 (79.9%), 301 (17.2%), and 52 (3.0%) were diagnosed with HIV in the pre-cART, early-cART, and late-cART eras, respectively. Significant increases were observed in rates of all-cause, AIDS-related, and non-AIDS-related mortality in the pre-cART era, followed by declines in the early-cART and late-cART eras. All-cause, AIDS-related, and non-AIDS-related mortality rates plummeted by 65%, 81%, and 45%, respectively, from the pre-cART to late-cART eras. However, VWH continue to die at higher rates due to AIDS-related infections, non-AIDS-related malignancies, respiratory disease, cardiovascular disease, and renal failure than those in the general population with HIV.

CONCLUSIONS

In older populations with HIV, it is important that providers not only monitor for and treat diseases associated with aging but also intervene and address lifestyle risk factors.

1885. Experience using combined antigen and RT-PCR tests for COVID-19 diagnosis at a Veterans Affairs (VA) Health Care System during the Omicron surge

Background

Combining rapid antigen and RT-PCR tests optimizes detection of COVID-19 compared with either test alone. Therefore, coincident with the Omicron surge, in November 2021, the Atlanta VA Health Care System (AVAHCS) initiated combination testing for all patients admitted from the emergency department (ED) to the inpatient wards. We retrospectively compared test performance for all patients with combination testing performed at AVAHCS, assessed impact of combination testing on ED disposition, and reviewed clinical characteristics of those admitted from the ED with discordant results.

Methods

We assessed concordance of antigen (Abbott BinaxNOW®) and RT-PCR (either Cepheid GeneXpert® or Roche cobas® 6800) tests performed within 24 hours of each other (i.e., combination test-pairs) for any patient during November 25, 2021–January 27, 2022, and calculated test characteristics of the antigen test using RT-PCR as the gold standard. For those patients evaluated in the ED who had discordant results, we determined ED disposition then performed standardized medical record reviews for those admitted to ascertain clinical history and hospital course and disposition.

Combination Antigen and RT-PCR Testing Algorithm for Patients in the Emergency Department, Atlanta VA Healthcare System

Results

Of 836 combination test-pairs, 112 (13%) were discordant, of which 111 were antigen-negative/RT-PCR positive. Sensitivity of the antigen test was 50%, specificity was 100%, positive predictive value 99%, and negative predictive value was 85%. Of 68 patients evaluated in the ED who had antigen-negative/RT-PCR positive results, 21 (31%) were admitted, of whom 17 (81%) had COVID-19-related symptoms at time of ED evaluation. Of the 21 admitted patients, all were admitted to a COVID isolation unit, 20 (95%) had ≥1 chronic comorbidity, 12 (57%) had not completed vaccination, 14 (67%) received COVID-19-specific treatment while inpatient, 6 (29%) received care in an intensive care unit, 17 (81%) discharged home, and 1 (5%) died during hospitalization.

Flow Diagram of Initial Analysis

Flow Diagram of ED Discordant Results

Characteristics of Discordant Hospitalized Patients

Conclusion

The sensitivity of antigen testing was 50% compared to RT-PCR among patients tested across AVAHCS, consistent with published literature. Combination testing facilitated earlier diagnosis, isolation, and treatment of some patients hospitalized from the ED, likely preventing nosocomial transmission.

Disclosures

All Authors: No reported disclosures.

Clinical characteristics and social determinants of health associated with 30-day hospital readmissions of patients with COVID-19

COVID-19 readmissions are associated with increased patient mortality and healthcare system strain. This retrospective cohort study of PCR-confirmed COVID-19 positive adults (>18 years) hospitalized and readmitted within 30 days of discharge from index admission was performed at eight Atlanta hospitals from March to December 2020. The objective was to describe COVID-19 patient-level demographics and clinical characteristics, and community-level social determinants of health (SDoH) that contribute to 30-day readmissions. Demographics, comorbidities, COVID-19 treatment, and discharge disposition data were extracted from the index admission. ZIP codes were linked to a demographic/lifestyle database interpolating to community-level SDoH. Of 7155 patients with COVID-19, 463 (6.5%) had 30-day, unplanned, all-cause hospital readmissions. Statistically significant differences were not found in readmissions stratified by age, sex, race, or ethnicity. Patients with a high-risk Charlson Comorbidity Index had higher odds of readmission (OR 4.8 (95% CI: 2.1 to 11.0)). Remdesivir treatment and intensive care unit (ICU) care were associated with lower odds of readmission (OR 0.5 (95% CI: 0.4 to 0.8) and OR 0.5 (95% CI: 0.4 to 0.7), respectively). Patients residing in communities with larger average household size were less likely to be readmitted (OR 0.7 (95% CI: 0.5 to 0.9). In this cohort, patients who received remdesivir, were cared for in an ICU, and resided in ZIP codes with higher proportions of residents with increased social support had lower odds of readmission. These patient-level factors and community-level SDoH may be used to identify patients with COVID-19 who are at increased risk of readmission.

Rapid Antiretroviral Therapy Program: Development and Evaluation at a Veterans Affairs Medical Center in the Southern United States

Early HIV viral suppression (VS) improves individual health outcomes and decreases onward transmission. We designed an outpatient clinic protocol to rapidly initiate antiretroviral therapy (ART) in a large Veterans Health Administration (VA) HIV clinic. A pre-post evaluation was performed using a retrospective cohort study design for new diagnoses of HIV infection from January 2012 to February 2020. Time-to-event analyses were performed using the Cox proportional hazards model with the intervention group as the main exposure adjusted for integrase inhibitor usage, baseline viral load, age, gender, and race. Most of the patients were men (historical control: 94.8%, n = 55; Rapid Start: 94.8%, n = 55) and Black or African American persons (historical control: 87.9%, n = 51; Rapid Start: 82.8%, n = 48). More patients initiated treatment with an integrase inhibitor-based regimen in the Rapid Start group (98.3%, n = 57) compared with the historical control group (39.7%, n = 23). Compared with controls, the Rapid Start patients were significantly more likely to achieve VS at any given time during the study period (hazard ratio 2.65; p < 0.001). Median days (interquartile range) from diagnosis to VS decreased from 180.5 (102.5-338.5) to 62 (40-105) (p < 0.001), first appointment to VS decreased from 123 (68.5-237.5) to 45 (28-82) (p < 0.001), referral to first visit decreased from 20 (10-43) to 1 (0-3) (p < 0.001), and from first visit to ART dispense date decreased from 27.5 (3-50) to 0 (0-0) (p = 0.01). Prioritizing immediate ART initiation can compress the HIV care continuum from diagnosis to linkage to VS. Implementation of the Rapid Start Protocol should be considered at all VA facilities providing HIV care.

544. Using Active Surveillance to Identify Monoclonal Antibody Candidates Among COVID-19 Positive Veterans, Atlanta VA Healthcare System

Background

Monoclonal antibody (Mab) infusions have reduced hospitalization and mortality among higher risk patients with mild to moderate COVID-19 symptoms. Using an interdisciplinary team approach, we created a clinical team to proactively screen and outreach patients with COVID-19 to equitably offer Mab.

Methods

From December 28, 2020 - May 3, 2021, a clinical team consisting of an Infectious disease pharmacist and physician, reviewed each outpatient with a positive SARS-CoV-2 PCR test at the Atlanta VA Healthcare System (AVAHCS) daily. The clinical team used the published Emergency Use Authorization criteria to determine eligibility. Eligible patients were prioritized using the Veterans Health Administration (VACO) Index for COVID-19 Mortality, which estimates the risk of 30-day mortality after COVID-19 infection using pre-COVID-19 health status (Figure 1). Eligible patients were contacted via telephone to confirm eligibility and obtain verbal consent. We performed SARS-CoV-2 IgG antibody tests when possible prior to Mab infusion, but results did not preclude Mab receipt. Telehealth follow-up occurred at 1- and 7-days post infusion.

Figure 1. Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality

Results

In total, 1,346 COVID-19 patients were identified; 86 (6%) patients were eligible, and 48/86 (55%) received Mab infusions (Figure 2). The median time from symptom-onset to positive COVID-19 PCR test result was 6 days (0-9) and the median time from positive COVID-19 PCR test result to Mab infusion was 2 days (0-8). SARS-CoV-2 IgG antibodies were detected in 4 of 24 (17%) patients tested. The most common comorbidities were hypertension (73%) and diabetes, (42%) (Table). Five (10%) patients required hospitalization for worsening COVID-19 symptoms post infusion. No deaths occurred.

Figure 2. Overview of COVID-19 Monoclonal Antibody (Mab) infusion Process

Conclusion

This approach of combining laboratory surveillance and active screening minimized delay in symptoms onset to Mab infusion, thereby optimizing outpatient treatment of COVID-19 disease. Our approach successfully treated a more diverse patient population compared to clinical trials. Mab infusions overall was well tolerated with few hospitalizations and no deaths in this cohort.

Disclosures

All Authors: No reported disclosures

Use of Baricitinib in Patients With Moderate to Severe Coronavirus Disease 2019

Hyperinflammation is associated with increased mortality in coronavirus disease 2019 (COVID-19). In this retrospective, uncontrolled patient cohort with moderate -severe COVID-19, treatment with baricitinib plus hydroxychloroquine was associated with recovery in 11 of 15 patients. Baricitinib for the treatment of COVID-19 should be further investigated in randomized, controlled clinical trials.

Low Rates of Vaccination for Herpes Zoster in Older People Living With HIV

Herpes zoster (HZ) occurs at a higher age-specific rate in people living with HIV (PLWH) than in the general population. We implemented a quality improvement study to assess herpes zoster vaccine (HZV) usage among PLWH, assess HZV usage after additional reminders/prompts, and identify barriers to HZV among older PLWH. HZV rates in PLWH were determined in six institutions with varying payment structures. For the intervention, Part 1, PLWH eligible for HZV at the University of Colorado were identified, and providers were notified of patient eligibility. In Part 2, in addition to provider notification, an order for HZV was placed in the patient's chart before a clinic appointment. HZ vaccination rates ranged from 1.5% to 42.4% at six sites. Before the intervention, 21.3% of eligible University of Colorado patients had received HZV. An additional 8.3% received HZV with Part 1 and 17.8% with Part 2 interventions. At completion, a total of 53.2% of eligible patients had received HZV through routine clinical care or the interventions. Insurance coverage concern was cited as a common reason for not receiving HZV. Minor adverse reactions occurred in 26.7% patients and did not require medical care. HZV coverage was low at a majority of sites. Clinical reminders with links to vaccination orders or preplaced vaccination orders led to improved HZV coverage in our clinic, but published guidelines for use of HZV in PLWH and improvement in logistic or insurance barriers to HZV receipt are paramount to improved HZV coverage.

Retention in HIV care depends on patients' perceptions of the clinic experience

Institutional barriers in HIV primary care settings can contribute substantially to disparities in retention in HIV treatment and HIV-related outcomes. This qualitative study compared the perceptions of clinic experiences of persons living with HIV (PLWH) in a Veterans Affairs HIV primary care clinic setting who were retained in care with the experiences of those who were not retained in care. Qualitative data from 25 in-depth interviews were analyzed to identify facilitators and barriers to retention in HIV care. Results showed that participants not retained in care experienced barriers to retention involving dissatisfaction with clinic wait times, low confidence in clinicians, and customer service concerns. For participants retained in care, patience with procedural issues, confidence in clinicians, and interpersonal connections were factors that enhanced retention despite the fact that these participants recognized the same barriers as those who were not retained in care. These findings can inform interventions aimed at improving retention in HIV care.

Decreasing incidence of herpes zoster in the highly active antiretroviral therapy era

We evaluated the effect of highly active antiretroviral therapy (HAART) on the incidence of herpes zoster (HZ) in human immunodeficiency virus (HIV)-infected subjects. The annual incidence of HZ per 100 person-years decreased significantly from 6.3 episodes in 1987 to 1.0 episode in 2011, probably reflecting improved immune function.

Methicillin-resistant Staphylococcus aureus in HIV-infected patients

Concordant with the emergence of methicillin-resistant Staphylococcus aureus (MRSA) in the community setting, colonization and infections with this pathogen have become a prevalent problem among the human immunodeficiency virus (HIV)-positive population. A variety of different host- and, possibly, pathogen-related factors may play a role in explaining the increased prevalence and incidence observed. In this article, we review pathophysiology, epidemiology, clinical manifestations, and treatment of MRSA in the HIV-infected population.

Increasing incidence of herpes zoster among Veterans

BACKGROUND

The incidence of herpes zoster in the United States has been estimated to be > or =1 million cases annually, with a higher rate in adults older than 60 years. The morbidity of the disease, including postherpetic neuralgia, imposes significant effects on quality of life. We analyzed reports of herpes zoster in the Veterans Affairs (VA) population because these patients are older and could provide a reflection of disease trends in the aging US population. These data will provide a baseline for future analyses of the incidence of herpes zoster after the introduction of the herpes zoster vaccine in late 2007.

METHODS

To evaluate the trend in the annual incidence of herpes zoster for fiscal year 2000 (beginning October 1999) through fiscal year 2007 (through September 2007), we derived incidence rates using the Veterans Health Administration Decision Support System reports of herpes zoster by International Classification of Diseases, Ninth Revision codes from 2000 through 2007 and the corresponding denominator data for all veterans in care. These rates were validated by review of medical records of patients with diagnoses of herpes zoster at the Atlanta VA Medical Center.

RESULTS

The annual incidence of herpes zoster increased from 3.10 episodes per 1000 veterans in 2000 to 5.22 in 2007 (R(2)=0.9743; P<.001). This increasing rate was seen in both men and women but only in groups older than 40 years.

CONCLUSION

The increasing incidence of herpes zoster in our veteran population and its effect on the quality of life of the veterans validate the need for improved rates of vaccination in this population.

Viral infections associated with haemophagocytic syndrome

Haemophagocytic syndrome (HPS) or haemophagocytic lymphohistiocytosis (HLH) is a rare disease caused by a dysfunction of cytotoxic T cells and NK cells. This T cell/NK cell dysregulation causes an aberrant cytokine release, resulting in proliferation/activation of histiocytes with subsequent haemophagocytosis. Histiocytic infiltration of the reticuloendothelial system results in hepatomegaly, splenomegaly, lymphadenopathy and pancytopenia ultimately leading to multiple organ dysfunctions. Common clinical features include high fevers despite broad spectrum antimicrobials, maculopapular rash, neurological symptoms, coagulopathy and abnormal liver function tests. Haemophagocytic syndrome can be either primary, i.e. due to an underlying genetic defect or secondary, associated with malignancies, autoimmune diseases (also called macrophage activation syndrome) or infections. Infectious triggers are most commonly due to viral infections mainly of the herpes group, with EBV being the most common cause. HPS can be fatal if untreated. Early recognition of the clinical presentation and laboratory abnormalities associated with HPS and prompt initiation of treatment can be life saving. HPS triggered by viral infections generally does not respond to specific antiviral therapy but may be treated with immunosuppressive/immunomodulatory agents and, in refractory cases, with bone marrow transplantation. Copyright © 2010 John Wiley & Sons, Ltd.

The AIDS resistance of naturally SIV-infected sooty mangabeys is independent of cellular immunity to the virus

In contrast to human immunodeficiency virus (HIV)-infected humans, natural hosts for simian immunodeficiency virus (SIV) very rarely progress to acquired immunodeficiency syndrome (AIDS). While the mechanisms underlying this disease resistance are still poorly understood, a consistent feature of natural SIV infection is the absence of the generalized immune activation associated with HIV infection. To investigate the immunologic mechanisms underlying the absence of AIDS in SIV-infected sooty mangabeys (SMs), a natural host species, we performed a detailed analysis of the SIV-specific cellular immune responses in 110 SIV-infected SMs. We found that while SIV-specific T-cell responses are detectable in the majority of animals, their magnitude and breadth are, in fact, lower than what has been described in HIV-infected humans, both in terms of cytokine production (ie, IFN-gamma, TNF-alpha, and IL-2) and degranulation (ie, CD107a expression). Of importance, SIV-specific T-cell responses were similarly low when either SIVmac239-derived peptides or autologous SIVsmm peptides were used as stimuli. No correlation was found between SIV-specific T-cell responses and either viral load or CD4+ T-cell count, or between these responses and markers of T-cell activation and proliferation. These findings indicate that the absence of AIDS in naturally SIV-infected sooty mangabeys is independent of a strong cellular immune response to the virus.

Emphysematous cholecystitis due to Salmonella derby

We present the case of a woman with diabetes mellitus who developed symptoms and signs consistent with gastroenteritis. After admission for hydration, the patient rapidly became critically ill and an abdominal catastrophe was suspected as the cause of her deterioration. Computed tomography of her abdomen was done and revealed gas in the lumen of the gallbladder consistent with emphysematous cholecystitis. She underwent emergent cholecystectomy, which revealed that the gallbladder had already ruptured. Blood cultures grew Salmonella derby. After a prolonged hospitalisation she eventually recovered and was discharged home. Emphysematous cholecystitis, thought to be a variant of acute cholecystitis, is a medical and surgical emergency. Diagnosis relies heavily on imaging findings by ultrasound or computed tomography since the clinical presentation is often non-specific. Cholecystectomy remains the treatment of choice in addition to broad spectrum antibiotics and other supportive measures.

CD4+ t-cell depletion in hiv infection: Killed by friendly fire?

Recent studies have emphasized the role of a chronic, generalized activation of the immune system as a prominent cause of CD4+ T-cell depletion in HIV-infected patients. The HIV-induced immune activation is a strong predictor of disease progression in humans, and lack of immune activation is a key feature of nonpathogenic simian immunodeficiency virus (SIV) infection of natural hosts. The mechanisms by which immune activation induces CD4+ T-cell depletion are still incompletely understood, but likely involve changes in the complex dynamics of the naive, memory, and effector subsets of T cells. A better understanding of how HIV-induced immune activation leads to CD4+ T-cell depletion may provide new targets for immune-based interventions that could be used, in addition to standard antiretroviral therapy, to slow disease progression in HIV-infected individuals.