912. Expansion of Hepatitis C Treatment with New Medicaid Subscription Model in Louisiana

Background

It is estimated that nearly 80,000 people with hepatitis C are living in Louisiana, many with Medicaid coverage. Previously, only Medicaid patients free from drugs and alcohol with a fibrosis score of F3 or F4 were eligible for treatment, resulting in few patients receiving treatment. Beginning in July 2019, generic sofosbuvir/velpatasvir was made available through the Medicaid program in a subscription model, allowing unlimited hepatitis C treatment in Louisiana’s Medicaid program for 5 years at a set price to the program. This has dramatically expanded access to Hepatitis C treatment for people with Medicaid in Louisiana.

Methods

Patients with Hepatitis C seen in the Infectious Diseases Center at University Medical Center in New Orleans, in 2020 by the 5 main hepatitis C providers were included. Demographics and laboratory data were collected to determine outcomes.

Results

Most patients with a hepatitis C (HCV) viral load and insurance data had Medicaid (80%, N=275). Twenty-two (8%) were HIV co-infected. Most were men (75%) and African-American (77%). Among the mono-infected patients with Medicaid and an HCV viral load, 216 (85%) had an undetectable viral load by the beginning of June 2021. Of the remaining 37 patients, 30 patients were prescribed treatment; but did not take it (n=4), didn’t follow-up (n=23), or followed-up but never got labs (n=3). One was treated but had a treatment failure (n=1). Six of the 37 were not prescribed medications due to a short life expectancy or significant drug interactions. The percentage of patients with an undetectable viral load was similar by gender and race, however younger age groups had lower viral suppression. In those aged less than 35, only 47% had an undetectable viral load and among those aged 36 to 44, it was 66%. Using the previous criteria of requiring a fibrosis score of F3 or F4, only 20% (n=44) would have been eligible for medicine to treat hepatitis C.

Conclusion

The new hepatitis C treatment subscription model with resultant removal of previous barriers has dramatically expanded treatment for people with Medicaid in Louisiana. More than five times the number of Medicaid patients received treatment in 2020 in our academic medical clinic.

Disclosures

Yussef Bennani, MD, MPH, Gilead Sciences (Scientific Research Study Investigator)ViiV Healthcare (Scientific Research Study Investigator)

Evaluating Factors Contributing to Dropout in a Large Peritoneal Dialysis Program

BACKGROUND

The low prevalence of peritoneal dialysis (PD) (9%) vs. hemodialysis (HD) (88.2%) is partly due to patient dropout from therapy.

METHODS

This retrospective study identified patients who withdrew from PD between 2016 and 2018 in our program. We evaluated all other factors as controllable losses. Analysis included time on therapy at dropout (very early, early or late) and method of initiation (HD to PD conversion, unplanned PD, or planned start).

RESULTS

Eighty-three patients enrolled into our PD program. 27 dropped out; 24 were due to controllable factors, 3 due to death, with a median age at dropout of 52 years old. We determined psychosocial factors (PF) to be the largest controllable factor influencing dropout; contributing a 63% rate among all controllable factors. When considering time until dropout, 100% of very early dropout patients and 50% of late dropout patients did so due to PF. Among early dropout patients 67% dropped out due to other medical reasons. The mean time to dropout for PF, other, and infection (INF) were 13, 26, and 33 months, respectively. When considering type of initiation, we found PF to be the largest attributable factor with 50% of unplanned, 100% of planned, and 50% of conversions stopping therapy.

CONCLUSIONS

Our study indicates that the primary reason for controllable loss from therapy was secondary to PF regardless of the time on therapy or the method of initiation to therapy.

Characteristics and genotype profiles of antiretroviral-naïve patients entering a Southern US HIV outpatient clinic 2009-2012

The US city of New Orleans was ranked second in the nation for estimated HIV case rates in 2011. Opt-out testing was established at the Interim Louisiana Hospital in New Orleans in 2013. The majority of new diagnoses were referred to the HIV outpatient program. We conducted a retrospective chart review of newly referred antiretroviral-naïve patients establishing HIV care between January 2009 and June 2013 to characterise demographic and genotype profiles to assist in clinical management and needed services. Of the eligible 226 patients, 68% were men, and 88% were African American. Nearly half of the study patients were younger than 35 years of age. Forty-six percent had an initial CD4 count <200 cells/mm(3), and 39% had a HIV viral load >100,000 copies/mL. The antiretroviral class with the most common major mutation was the non-nucleoside reverse transcriptase inhibitors (NNRTIs) where K103N was the most common major NNRTI mutation at presentation. We observed that male patients showed more advanced disease with later presentation to care, confirming the need for earlier HIV diagnosis. When considering initial antiretroviral therapy, baseline genotype information is encouraged, particularly if considering a NNRTI-based regimen.

Prevalence of Integrase Strand Inhibitor Resistance (INSTI)in New Orleans, Louisiana, 2012-2013

Integrase strand inhibitors (INSTI) are the newest class of antiretroviral (ARV) therapies available to patients. There is little surveillance data on INSTI resistance, particularly in the South. A retrospective review on all patients who underwent PhenoSense Integrase testing between January 1, 2012 and June 30, 2013 was performed to better identify who should be screened for integrase strand transfer inhibitor (INSTI) resistance at the Interim Louisiana State University Hospital (ILH). Fifty-three patients underwent PhenoSense testing for elvitegravir/raltegravir resistance during this time period. Resistance was significantly associated with INSTI experience but not with other characteristics including sex, age, race, CD4 cell count, or concurrent reverse transcriptase inhibitor or protease inhibitor mutations. The frequency of reduced elvitegravir/ raltegravir susceptibility among INSTI experienced patients with virologic failure at ILH was 14/41 (34%). Future surveillance monitoring will be useful for determining if baseline INSTI resistance testing needs to be performed for INSTI naïve patients in the future at ILH.

An analysis of chronic kidney disease risk factors in a Louisiana nursing home population: a cross-sectional study

BACKGROUND

Chronic Kidney Disease (CKD) and its progression are associated with multiple risk factors. CKD is prevalent in nursing homes residents, but factors related to CKD in this setting have not been defined.

METHODS

A cross-sectional study was conducted (n=103). Data was abstracted using standardized forms and analyzed (SAS 9.2). Chi square and t-test statistics were used to compare proportions and means; correlation coefficients were used to describe associations. Logistic models were fit to the data to determine multivariate associations. Modification of Diet in Renal Disease (MDRD) formula was used to estimate GFR. CKD was defined according to established standards. A cutoff point of 60 was chosen for further analysis.

RESULTS

Twenty-three percent of subjects had CKD. Mean age for eGFR <60 was 70.8 +/- 13 and for eGFR >60 was 61.7 +/-14. Frequent co-morbidities were hypertension (75%), GERD (40%), obesity (39%), dyslipidemia (35%), depression (34%), anemia (32%), and diabetes (32%).

CONCLUSIONS

Our population is unique in terms of its age and reasons for nursing home admission. Factors associated with CKD in our study include age >65 years old, being male, having a positive history of cardiovascular disease (including congestive heart failure and coronary artery disease,) anemia, polypharmacy, and being obese (BMI >30). Further analysis showed that age and anemia are the strongest factors associated with CKD in our population. Management targeted at CKD risk factor reduction may play a vital role in controlling the magnitude of this disease. Prospective studies to investigate the relationship between gender, a BMI greater than 30, cardiovascular disease, and CKD and its complications are warranted.

Risk factors for suboptimal vitamin D levels among adults with HIV attending an inner-city clinic of New Orleans, Louisiana

BACKGROUND

Vitamin D insufficiency and deficiency are highly prevalent in populations with HIV, but there is limited data on predictors for suboptimal levels.

METHODS

To determine risk factors for Vitamin D insufficiency/deficiency, 185 charts were retrospectively reviewed.

RESULTS

Proportions with Vitamin D levels < 10 ng/ml, 10 - 20 ng/ml, 20 - 30 ng/ml and > 30 ng/ml were 14.6%, 44.8%, 24.9%, and 15.7%, respectively. Bivariate analysis showed that Vitamin D levels < 20 ng/ml were associated with a lower albumin level (p =.02), female gender (p = .0003), and African-American (AA) race (p = .0001). Tenofovir exposure showed borderline significance (p = .09). AA race was the only significant factor in multivariate modeling.

CONCLUSIONS

Vitamin D insufficiency/deficiency was high. AA race was an independent risk factor. Although not significant, obese persons with a poorer nutritional status and possibly those on tenofovir may also be at higher risk.

Sex and race effects on risk for selected outcomes among elderly HIV-infected patients

The HIV-infected population in the United States is aging. A retrospective study of 132 patients (26 women, 106 men) ≥59 years of age was undertaken to evaluate the effect of race and sex on selected outcomes. With the exception of women being more likely to have diagnosis of depression compared with men, sex had little influence on risk for other conditions among elderly patients with HIV. In contrast, African American race was significantly associated with the risk for several selected disorders and outcomes. These results can assist in future prevention efforts among senior individuals with HIV infection.

Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study

INTRODUCTION

Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery.

METHODS

We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo.

RESULTS

The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score).

CONCLUSIONS

This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.

NF-Y histone fold alpha1 helices help impart CCAAT specificity

NF-Y is a conserved trimeric transcriptional activator with an extremely high specificity for CCAAT boxes. The NF-YB and NF-YC subunits have histone fold motifs with a high degree of homology to NC2alpha/beta, a TBP-binding repressor. The histone fold is composed of three alpha helices, alpha1, alpha2, alpha3, separated by short loops. Structural data on core histones showed that alpha1 are involved in DNA-binding. To understand the molecular basis of NF-Y sequence-specificity, we constructed deletion and swapping mutants, in which the alpha1 of NC2 and archeal HMfB, a bona fide histonic protein, was placed in NF-YB and NF-YC. Our analysis indicates that (i) subunit interactions are normal; (ii) NF-YB-NF-YC and NC2alpha/beta do not form heterodimers and NC2 cannot associate NF-YA. (iii) None of the NF-Y swaps can complex with TBP on a TATA box. (iv) Specific residues, R47 and K49 in NF-YC and N61 in NF-YB, are crucial for CCAAT-binding. We conclude that specificity of the NF-Y trimer is not due to NF-YA only, but stems in part from the contribution of the histone fold alpha1, particularly that of NF-YB.