Outcomes From a Randomized Trial of a Bilingual mHealth Social Media Intervention to Increase Care Engagement Among Young Gay, Bisexual, and Other Men Who Have Sex With Men and Transgender Women With HIV

BACKGROUND

The North Carolina Community Research Partnership developed, implemented, and tested weCare, a 12-month bilingual mHealth social media intervention designed to reduce missed HIV care appointments and increase viral suppression among racially/ethnically diverse gay, bisexual, and other men who have sex with men (GBMSM) and transgender women living with HIV by harnessing established social media platforms (i.e., Facebook, texting, and dating apps).

METHODS

We randomized 198 GBMSM and transgender women (mean age = 26) living with HIV to the weCare intervention (n = 100) or usual-care (n = 98) group. Inclusion criteria included being newly diagnosed or not in care. Participants completed structured assessments at baseline and 6-month postintervention follow-up (18 months after baseline data collection). HIV care appointment and viral load data were abstracted from each participant's electronic health record at baseline and follow-up. Follow-up retention was 85.5%.

RESULTS

Among participants, 94% self-identified as cisgender men, 6% as transgender, 64% as African American/Black, and 13% as Latine. Participants in both groups significantly reduced missed HIV care appointments and increased viral suppression at follow-up compared with baseline. However, there were no significant differences between weCare and usual-care participants for either outcome at follow-up.

CONCLUSIONS

An intervention effect was not identified for our two primary outcomes. Several factors may have influenced the lack of significant differences between weCare and usual-care participants at follow-up, including intervention implementation (e.g., staffing changes and lack of fidelity to the intervention as originally designed by the partnership), data collection (e.g., data collection time points and retention strategies), and clinical (e.g., contamination) factors.

Writing Is Thinking: Implementation and Evaluation of an Internal Medicine Residency Clinical Reasoning and Documentation Curriculum

With increasingly complicated patients and faster throughput, time for thorough critical thinking and thoughtful clinical documentation is limited, especially in the training environment. Advocating for the value of clinical documentation as a robust opportunity for critical thinking, we describe the implementation and evaluation of a clinical reasoning and documentation curriculum for internal medicine residents. Our curriculum employed facilitated discussion, practical application, and a resident-as-teacher model. Resident surveys showed improved perceptions of the clinical and educational value of clinical documentation. Residents reported increased feedback to interns about their documentation and more appreciation of documentation as a venue for critical thinking.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s40670-022-01570-5.

A Cross-Sectional Geographic Information Systems Study of a Pediatric Emergency Department Child Restraint System Distribution Program

INTRODUCTION

A pediatric ED program sought to promote injury prevention through distribution of child restraint systems. Program funds are paid for child passenger safety technician certification of all personnel. Pediatric emergency nurses distributed child restraint systems at hospital discharge and dedicated technicians at fitting stations. Researchers described program characteristics, developed a baseline understanding of program outreach using geographic information systems, and evaluated adherence to manufacturer guidelines with a sensitivity analysis.

METHODS

This retrospective cross-sectional study used distribution forms linked to hospital records from 2013 to 2016. Testing for differences used nonparametric methods. Median values and interquartile ranges for weight and height of children were compared with manufacturer guidelines. Geographic information systems visualized recipients' street addresses and motor vehicle crashes on an underlying base map.

RESULTS

There were 312 child restraint systems distributed: of which 179 (57.4%) at the hospital, 126 (40.4%) at fitting stations, and 7 (2.2%) missing a location. Among those on Medicaid, 64.4% received a child restraint system at the hospital compared with 35.6% at fitting stations (χ² = 5.40, P < .02). Fitting stations had limited outreach to rural residents. Finally, results from the sensitivity analysis showed that devices were issued according to manufacturer guidelines.

DISCUSSION

Despite the workplace pressures of clinical care, pediatric emergency nurses delivered educational information and demonstrated hands-on installation at similar rates to dedicated technicians. Distribution of child restraint systems through the hospital reached a uniquely underserved population. Further research should investigate methods to improve fitting station outreach among Medicaid recipients.

Stigma, Social Support, and Substance Use in Diverse Men Who Have Sex With Men and Transgender Women Living with HIV in the US Southeast

OBJECTIVES

Human immunodeficiency virus (HIV) rates in the southeast United States are high and substance use is common among people living with HIV (PLWH). This study used baseline data from the weCare intervention study to examine factors associated with the use of alcohol, tobacco, and marijuana among racially and ethnically diverse young gay, bisexual, and other men who have sex with men (GBMSM) and transgender women in the southeast who were newly diagnosed as having HIV, not linked to care, out of care, and/or not virally suppressed.

METHODS

Self-reported data were collected from 196 GBMSM and transgender women living with HIV via Audio Computer-Assisted Self-Interview at enrollment. Measures assessed demographics; stigma; social support; basic and clinical service needs; HIV disclosure; social media use; and recent use of alcohol, tobacco, and marijuana. Logistic regression identified correlates of past 30-day substance use.

RESULTS

In multivariable analysis, increased age and needing basic support services were associated with past 30-day tobacco, cigarette, electronic cigarette, and/or hookah use. Increased HIV-related stigma and needing basic support services were associated with past 30-day marijuana use. Being White and needing clinical support services were associated with infrequent or no past 30-day marijuana use.

CONCLUSIONS

HIV-related stigma and needing basic support services were associated with substance use among GBMSM and transgender women living with HIV in the southeastern United States. Routine screening for basic needs could identify GBMSM and transgender women living with HIV at risk for substance use and offer insight into intervention leverage points.

951. Virtually the Same: Our Experience Teaching Abx Before and During the Pandemic

Background

Understanding core principles of empiric antibiotic (abx) therapy is essential for abx stewardship. Pre-pandemic, the “Abx 101” workshop taught students an initial approach to empiric abx. Due to the pandemic, the session became virtual. We hypothesized that the face-to-face version (FTF) would be more effective and more positively reviewed by students compared to the virtual.

Methods

For the FTF, 3 faculty facilitated workshops of 50 3rd year medical students. The intro reviewed the typical microbiota of body areas (or common pathogens for community-acquired disease in sterile spaces). Student small groups were assigned a category of abx coverage (e.g. “MRSA drugs”), and completed a worksheet to identify abx in the assigned category from a reference list of abx. Groups taught back to the class (jigsaw technique) about abx for their respective categories. Next, faculty facilitated a large group discussion in which they matched initial abx therapy for each body area’s typical microbiome or pathogens. Finally, groups presented cases to the class and identified likely diagnosis, most likely organisms, and appropriate empiric abx to target those organisms. For the virtual version, the format was adapted for a 1 hour online interactive session with 1 MD facilitator, 20-25 students, and no breakout groups/jigsaw technique. The content was unchanged other than fewer cases.

Results

26 of 140 (19%) students completed the survey (n=13 FTF, n=13 virtual). An independent-samples t-test compared FTF and virtual overall satisfaction scores. There were no significant differences in satisfaction from the FTF (M=8.54, SD=1.04) and virtual sessions (M=8.62, SD=1.94); t(24)=-.126. p=0.901. 100% of both groups rated the session as quite/extremely relevant to their training and 100% of respondents in both groups deemed the format of the sessions appropriate for the content. In the FTF group, 76% of respondents felt the session was quite/extremely effective for learning about abx spectra of activity, compared to 69% in the virtual group (X2 (1, N = 26) = .195, p = .658).

Conclusion

“Abx 101” was relevant, effective, and formatted well for learning about empiric abx, in FTF and virtual versions. These findings suggest that this curriculum is effective overall and adapts well for in-person and remote learning.

Disclosures

All Authors: No reported disclosures

Impact and correlates of sub-optimal social support among patients in HIV care

Social support (SS) predicts health outcomes among patients living with HIV. We administered a brief, validated measure of SS, the Multifactoral Assessment of Perceived Social Support, within a patient-reported outcomes assessment of health domains in HIV care at 4 U.S. clinics in English and Spanish (n = 708). In univariate analysis, low SS was associated with poorer engagement in care, antiretroviral adherence, and health-related quality of life; current methamphetamine/crystal use, depression, anxiety, and HIV stigma (all p < 0.001); any use of either methamphetamines/crystal, illicit opioids, or cocaine/crack (p = 0.001), current marijuana use (p = 0.012), nicotine use (p = 0.005), and concern for sexually transmitted infection exposure (p = 0.001). High SS was associated with undetectable viral load (p = 0.031). Multivariate analyses found low SS independently associated with depression (risk ratio (RR) 3.72, 95% CI 2.93-4.72), lower adherence (RR 0.76, 95% CI 0.64-0.89), poor engagement in care (RR 2.05, 95% CI 1.44-2.96), and having more symptoms (RR 2.29, 95% CI 1.92-2.75). Medium SS was independently associated with depression (RR 2.59, 95% CI 2.00-3.36), poor engagement in care (RR 1.62, 95% CI 1.15-2.29) and having more symptoms (RR 1.75, 95% CI 1.44-2.13). SS assessment may help identify patients at risk for these outcomes.

Cardiovascular Disease Risk Management in Persons With HIV: Does Clinician Specialty Matter?

Background

The impact of clinician specialty on cardiovascular disease risk factor outcomes among persons with HIV (PWH) is unclear.

Methods

PWH receiving care at 3 Southeastern US academic HIV clinics between January 2014 and December 2016 were retrospectively stratified into 5 groups based on the specialty of the clinician managing their hypertension or hyperlipidemia. Patients were followed until first atherosclerotic cardiovascular disease event, death, or end of study. Outcomes of interest were meeting 8th Joint National Commission (JNC-8) blood pressure (BP) goals and National Lipid Association (NLA) non–high-density lipoprotein (HDL) goals for hypertension and hyperlipidemia, respectively. Point estimates for associated risk factors were generated using modified Poisson regression with robust error variance.

Results

Of 1667 PWH in the analysis, 965 had hypertension, 205 had hyperlipidemia, and 497 had both diagnoses. At study start, the median patient age was 52 years, 66% were Black, and 65% identified as male. Among persons with hypertension, 24% were managed by an infectious diseases (ID) clinician alone, and 5% were co-managed by an ID clinician and a primary care clinician (PCC). Persons managed by an ID clinician were less likely to meet JNC-8 hypertension targets at the end of observation than the rest of the cohort (relative risk [RR], 0.84; 95% CI, 0.75–0.95), but when mean study blood pressure was considered, there was no difference between persons managed by ID and the rest of the cohort (RR, 0.96; 95% CI, 0.88–1.05). There was no significant association between the ID clinician managing hyperlipidemia and meeting NLA non-HDL goals (RR, 0.89; 95% CI, 0.68–1.15).

Conclusions

Clinician specialty may play a role in suboptimal hypertension outcomes in persons with HIV.

Supporting Health Among Young Men Who Have Sex With Men and Transgender Women With HIV: Lessons Learned From Implementing the weCare Intervention

Young gay, bisexual, and other men who have sex with men and transgender women with HIV, particularly those who are racial or ethnic minorities, often have poor health outcomes. They also utilize a wide array of social media. Accordingly, we developed and implemented weCare, an mHealth (mobile health) intervention where cyberhealth educators utilize established social media platforms (e.g., Facebook, texting, and GPS-based mobile applications ["apps"]) designed for social and sexual networking) to improve HIV-related care engagement and health outcomes. As part of the process evaluation of weCare, we conducted 32 interviews with intervention participants (n = 18) and HIV clinic providers and staff (n = 14). This article highlights three key intervention characteristics that promoted care engagement, including that weCare is (1) targeted (e.g., using existing social media platforms, similarity between intervention participants and cyberhealth educator, and implementation within a supportive clinical environment), (2) tailored (e.g., bidirectional messaging and trusting relationship between participants and cyberhealth educators to direct interactions), and (3) personalized (e.g., addressing unique care needs through messaging content and flexibility in engagement with intervention). In addition, interviewees' recommendations for improving weCare focused on logistics, content, and the ways in which the intervention could be adapted to reach a larger audience. Quality improvement efforts to ensure that mHealth interventions are relevant for young gay, bisexual, and other men who have sex with men and transgender women are critical to ensure care engagement and support health outcomes.

Gathering Trauma Narratives: A Qualitative Study on the Impact of Self-Identified Traumas on People Living with HIV (PLWH)

BACKGROUND Trauma-emotional, physical, and psychological-is common and associated with increased risk behaviors, low rates of care engagement and viral suppression, and overall poor health outcomes for people living with HIV (PLWH). This article presents the results of 15 in-depth, semi-structured interviews with PLWH in the Southeastern United States in which participants identified a trauma and described its long-lasting impact on their lives. Participants' trauma narratives described a wide range of traumas, including childhood sexual abuse, the loss of a loved one, and their HIV diagnosis.METHODS Systematic qualitative analysis was used to delineate beliefs about causes, symptoms, treatments, quality of life, and health implications of trauma.RESULTS: Fifteen participants completed semi-structured interviews that lasted on average 32 minutes. Participants described a wide spectrum of personal trauma that occurred both prior and subsequent to their HIV diagnosis. The types of trauma identified included physical, sexual, and psychological abuse inflicted by intimate partners, family members, and/or strangers.LIMITATIONS A chief limitation of this study is selection bias. Additionally, the participant selection and content of the trauma narratives might have been affected by the surrounding context of the parent study centered on HIV, aging, and psychosocial stress. It is also difficult to interpret the distinction between discrete trauma experiences and the diagnosis of HIV, leading to potential information bias.CONCLUSION This study highlights the importance of social support in coping with trauma and the effect of trauma on health-related behaviors. It also illustrates the need for additional research on the topic of trauma and trauma-informed care for PLWH. Understanding how different types of trauma affect individuals' lives is necessary to inform recommendations to provide better care for PLWH.

2519. Urban vs Rural HIV-infected Persons Have Differential Gene Expression for Estrogen Signaling, Inflammation, and Cytokine Production Pathways

Background

People aging with HIV (PAWH) are living longer with effective antiretroviral therapy and new HIV diagnoses are rising in older populations. Concurrent with trends in age, the epidemiology of HIV infection in the United States has shifted geographically and racially; the Southeast and African Americans now have the highest HIV incidence and prevalence. Although there are marked health disparities for rural and African American PAWH, limited data exist comparing aging phenotypes between rural and urban PAWH, and no data exist comparing mechanistic pathways between these populations. Among African American PAWH, we hypothesize that rural PAWH will be more likely than urban PAWH to have a molecular profile of advanced aging associated with chronic disease burden and shorter health span.

Methods

Demographics, clinical data, and RNA were collected from 14 matched pairs from rural (Wake Forest University, Winston-Salem, NC) and urban cohorts (ALiVE cohort, Johns Hopkins University, Baltimore, MD) matched on age, sex, Short Physical Performance Battery score, smoking status, and sample collection date. Raw sequences were examined for quality, aligned using STAR, and normalized using DESeq2. DESeq2 tested matched pair differential gene expression. Genes with an average read count threshold > 5, a genomic control adjusted P-value < 0.01 and a fold change > 1.3 were retained for further analysis using STRING, MCODE, and IPA to find functional and biological patterns.

Results

Of the 399 genes meeting significance criteria, 212 showed higher expression in the rural group; the remaining 187 genes showed lower expression in the rural group. Top enriched canonical pathways in the IPA analysis identified differential estrogen signaling (P < 0.0001), inflammation (P < 0.001), and cytokine production (p = 0.005). Protein–protein interactions involved in cell–cell signaling and intracellular trafficking were also differentially identified between the 2 populations.

Conclusion

Urban and rural PAWH have differential gene expression, particularly centered around estrogen signaling and inflammatory cytokine production. These findings merit further investigation to determine clinical significance, including correlation with phenotypes and healthspan between rural and urban PAWH.

Disclosures

All authors: No reported disclosures.

1316. Gathering Trauma Narratives: A Qualitative Study on the Impact of Traumas on People Living with HIV (PLWH)

Background

Methods

Results

Conclusion

Disclosures

Effects of Religious Involvement on HIV Management Outcomes Among HIV-Positive Adults in Central North Carolina

OBJECTIVES

The goals of this pilot cross-sectional study were to determine the feasibility of and begin measuring the effect of religious institution affiliation on human immunodeficiency virus (HIV) clinical outcomes in the southern United States, a region marked by later initiation of antiretroviral therapy, higher HIV-related morbidity, and higher mortality rates than people living with HIV (PLWH) elsewhere in the country. It also is a region with a high density of religious institutions, which may facilitate improved health outcomes through leveraged social capital. Because spirituality is a personal construct and PLWH constitute a vulnerable population, we wanted to determine whether it would be feasible to survey patients about the topic. We hypothesized that PLWH would be willing to participate and that PLWH who report involvement in religious institutions would be more likely to have suppressed HIV viral loads (VLs) and better engagement in care than PLWH not involved in a religious institution.

METHODS

Eligible participants were enrolled from the Wake Forest Infectious Diseases Specialty Clinic to complete structured interviews using validated measures of religious institution affiliation, spiritual well-being, social support, and HIV-related stigma. HIV VL and engagement in care (clinic no-show rate) data were abstracted from the electronic medical record. Descriptive statistics calculated the prevalence of religious institution involvement, outcomes of interest, and potential confounders. t Tests compared continuous outcomes assuming normality, χ² tests compared binary outcomes, and the Wilcoxon Mann-Whitney test compared outcomes for non-normal data.

RESULTS

Fifty participants completed the study (55% participation rate); 72% identified as male and 28% identified as female. A total of 48% of participants identified as black/African American and 44% identified as white. Participants who identified as men who have sex with men made up 34%. More black/African American participants than white participants reported religious institution affiliation (23%; P = 0.15). There was no statistically significant relation between religious institution affiliation and CD4 or VL; however, higher levels of social support and spiritual well-being predicted a lower clinic no-show rate (P = 0.0077 and 0.0195, respectively). There was a trend toward greater perceived HIV-related stigma and CD4 (P = 0.0845) as well as more emergency department visits (P = 0.0976).

CONCLUSION

PLWH in a southern US clinic were willing to answer questions about their spirituality. Religious institution affiliation was not significantly related to virologic suppression or CD4 in this sample. Higher levels of self-reported social support (P = 0.0077) and spiritual well-being (P = 0.0195) predict better clinic attendance. These results suggest that religious affiliation alone does not imply positive benefits for all. Social support and spiritual well-being, however obtained, predict engagement in care. The next steps should include a fully powered study to define the relations among social support, spiritual well-being, and relevant clinical outcomes. Our results also support further investigation of perceived HIV-related stigma and healthcare utilization, based on the trend toward significance between emergency department visits and stigma.

The Continuum of HIV Care in Rural Communities in the United States and Canada: What Is Known and Future Research Directions

The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural-urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.

HIV-infected men who have sex with men and histories of childhood sexual abuse: implications for health and prevention

A personal history of childhood sexual abuse (CSA) is prevalent and deleterious to health for people living with HIV (PLWH), and current statistics likely underrepresent the frequency of these experiences. In the general population, the prevalence of CSA appears to be higher in men who have sex with men (MSM) than heterosexual men, but there are limited data available for HIV-infected MSM. CSA is associated with poor mental and physical health and may contribute to high rates of HIV risk behaviors, including unprotected sex and substance abuse. CSA exposure is also associated with low engagement in care for PLWH. More information is needed regarding CSA experiences of HIV-infected MSM to optimize health and wellbeing for this population and to prevent HIV transmission. This article reviews the epidemiology, implications, and interventions for MSM who have a history of CSA.

Intimate partner violence: a predictor of worse HIV outcomes and engagement in care

For HIV-infected patients, experiencing multiple traumas is associated with AIDS-related and all-cause mortality, increased opportunistic infections, progression to AIDS, and decreased adherence to therapy. The impact of intimate partner violence (IPV) on adherence and HIV outcomes is unknown. HIV-infected patients recruited from a public HIV clinic participated in this observational cohort study (n=251). Participants completed interviews evaluating IPV and covariates. CD4 count <200 (CD4<200), detectable HIV viral load (VL), and engagement in care ("no show rate" [NSR]) were the outcomes of interest. Medication adherence was not measured. Univariate and multivariate regression analyses were performed with covariates included if p<0.3 in the univariate phase. Seventy-four percent of the participants were male, 55% Caucasian, and 52.2% self-identified as "men who have sex with men." IPV prevalence was 33.1% with no difference by gender or sexual orientation. In univariate analysis, IPV exposure predicted having a CD4<200 (p=0.005) and a detectable VL (p=0.04) but trended toward significance with a high NSR (p=0.077). Being threatened by a partner was associated with a CD4<200 (p=0.005), a detectable VL (p=0.011), and high NSR (p=0.019) in univariate analysis. In multivariate analysis, IPV predicted having a CD4<200 (p=0.005) and detectable VL (p=0.035). Being threatened by a partner predicted having a CD4<200 (p=0.020), a detectable VL (p=0.007), and a high NSR (p=0.020). Our results suggest IPV impacts biologic outcomes and engagement in care for HIV-infected patients. IPV alone predicts worse biologic outcomes, whereas the specific experience of being threatened by a partner was associated with all three outcomes in univariate and multivariate analyses.

Fluoroquinolones in the management of community-acquired pneumonia in primary care

A literature search was conducted to evaluate the pharmacokinetic and pharmacodynamic profile of the respiratory fluoroquinolones (gemifloxacin, levofloxacin and moxifloxacin) and their efficacy and safety in the management of community-acquired pneumonia (CAP). Data show that CAP is a common presentation in primary care practice, and is associated with high rates of morbidity and mortality, particularly in the elderly. Although the causative pathogens differ depending on treatment setting and patient factors, Streptococcus pneumoniae is the primary pathogen in all treatment settings. As a class, the respiratory fluoroquinolones have a very favorable pharmacokinetic and pharmacodynamic profile. Pharmacodynamic criteria suggest that moxifloxacin and gemifloxacin are more potent against S. pneumoniae, which may have the added benefit of reducing resistance selection and enhancing bacterial eradication. The respiratory fluoroquinolones are also generally well tolerated, and are first-line options for outpatient treatment of CAP in patients with comorbidities or previous antibiotic use.