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Police abuse affects people who inject drugs (PWID), including those with HIV, and negatively impacts care engagement. This cross-sectional study evaluated police abuse among PWID receiving MOUD (medication for opioid use disorder) living with HIV and associations with HIV treatment adherence and receipt of NGO services. We assessed lifetime and past six-month rates of police abuse among a cohort of Ukrainian PWID with HIV receiving MOUD (

Background Antiretroviral therapy (ART) is recommended for people with HIV (PWH), irrespective of CD4 cell count, to improve their health and reduce the risk of transmission to sexual partners through long-term viral suppression. We identified risk factors for viral rebound among patients with a period of stable viral suppression to inform counseling and monitoring. Methods We conducted a multi-site, retrospective study of PWH with a two-year period of sustained viral suppression in the United States using the Centers for AIDS Research Network of Integrated Clinical Systems cohort. We used multivariable logistic regression to identify characteristics independently associated with any viral rebound [viral load (VL) ≥200 copies/mL] and sustained viral rebound (VL ≥200 copies/mL followed by a VL that was also ≥200 copies/mL within six months), within two years of follow-up. Results Among 3,496 eligible patients with a two-year period of sustained viral suppression, most (90%) continued to have viral suppression over two additional years; 10% experienced viral rebound, and 4% experienced sustained viral rebound. In multivariable analyses, Black race, current smoking, integrase strand transfer inhibitor use, and five-to-nine-year duration of ART were positively associated, and being age ≥50 years was negatively associated, with any viral rebound. Only current smoking and five-to-nine-year (vs. two-to-four-year) duration of ART were positively associated, and being age ≥60 years was negatively associated, with sustained viral rebound. Conclusions Most people retained in clinical care and with HIV viral suppression on ART will have persistent viral suppression. However, some patients may benefit from additional treatment adherence supports.

Background Integrase Strand Transfer Inhibitors (INSTIs) are the most common antiretroviral therapy (ART) anchor drugs. Despite reassuring clinical trial data, real-life extent and characteristics of resistance at failure of INSTI-based regimens are unclear and can inform care. Methods We investigated drug resistance upon failure of INSTI-based regimens at the largest HIV program in Rhode Island (RI), caring for > 80% of the state’s people with HIV. Eligible patients had full ART history, were on INSTI-based regimens, and had available protease-reverse transcriptase-integrase sequences from clinical care. Resistance interpretation was done with Stanford Database tools. Results Of 1,169 eligible patients (55% of clinic population), 102 (9%) were failing INSTI-based regimens; mean age at genotyping 39 years, CD4 377 cells/µL, and 11 years on ART; 67% male; 53% white, 44% Black, 63% non-Hispanic; 58% US born; with prior exposure to 8 drugs and 4 regimens. Of these 102, 55% were on 1st-generation INSTI (41% elvitegravir (EVG); 14% raltegravir (RAL)), and 45% on 2nd-generation INSTI (23% bictegravir (BIC); 22% dolutegravir (DTG)); most (73%) with only 2 NRTIs. Overall, 57% had any intermediate-high level predicted resistance (55% on 1st-, 45% on 2nd-generation INSTI); NRTI 37%; NNRTI 40%; PI 3%; INSTI 22% (EVG 22%, RAL 21%, DTG/BIC/cabotegravir 8% each). Common INSTI mutations were N155H (n=7); E92Q, Q148H/R, S147G (5 each); T66I/K, E138A/K/T (4 each); G140A/S (3), R263K (2), Y143R (1). Multi (≥ 3) class resistance occurred in 12%, a third of whom had intermediate-high resistance to all five INSTIs (50% on 1st-, 50% on 2nd-generation). Resistance trends were stable over 2014-2021, and 2nd-generation INSTI resistance was only seen in those with prior exposure to 1st-generation INSTI. Conclusion At the largest RI HIV clinic, 9% of eligible patients were failing INSTI-based regimens, most with clinically relevant resistance that was stable over time, and 1% had multi-class resistance including some to all available INSTIs. Though low resistance levels to 2nd-generation INSTIs are encouraging, they exist; and continued ADR monitoring is important, particularly with increasing incorporation of INSTIs in HIV treatment and prevention and use of 2-drug regimens. Disclosures All Authors: No reported disclosures.

Background Two years into the pandemic, clinicians do not have access to a standardized measurement of SARS-CoV-2 viral load (VL) that allows for VL comparison across clinical specimens and different assays. Reliable VL measurement in diverse respiratory specimens, over time, and in response to treatments such as remdesivir (RDV), could better inform treatment and prevention. Methods To investigate the use of a standardized VL assay in respiratory specimens, we enrolled patients hospitalized with COVID-19 in Providence, RI, with/without RDV exposure; collected serial samples from 4 compartments (nasopharyngeal-NP, nasal-NA, oropharyngeal-OP, saliva-SA) in 3 visits during the 1st week of hospitalization; and characterized SARS-CoV-2 VL using a ChromaCode HDPCR™ quantitative research use only assay, calibrated to the first World Health Organization (WHO) International Standard (IS). Linear mixed effects models and associated regression coefficients were used to analyze inter-compartmental VL differences at enrollment, over time, and with/without RDV. Results Of 35 participants (60% male; 70% White, 14% Hispanic/Latino, 49% RDV exposure), all had visit 1 samples (median hospital day 1, IQR 0-2; pre-RDV for those exposed); 80% visit 2 samples (median hospital day 2, IQR 1-8); and 37% visit 3 samples (median hospital day 4, IQR 3-7). Overall, 38 NP, 67 NA, 57 OP, and 67 SA samples were collected. Mean log VLs (Log10IU/mL) differed by compartment at visit 1 (NP 6.3, NA 4.9, OP 4.1, SA 5.6, p=0.0001) and significantly decreased over time in all compartments (p< 0.04 for all comparisons). Log VL change over time was not significantly different between compartments or between people treated/not treated with RDV. Conclusion We successfully measured respiratory intercompartmental SARS-CoV-2 VL differences among hospitalized patients using a standardized assay calibrated to the WHO IS. Dissemination of standardized VL measurement methods will allow accurate VL comparisons across assay types quantified in IU/mL and improve assessment of the impact of COVID-19 treatments. Inter-compartmental VL differences at baseline may indicate sampling variability or different viral burden. RDV did not appear to accelerate viral decay. Disclosures Curt Beckwith, MD, Gilead Sciences, Inc: Grant/Research Support Jon Steingrimsson, PhD, Gilead: Grant/Research Support Angela Caliendo, MD, PhD, ChromaCode: Advisor/Consultant|Danaher/Cepheid: Advisor/Consultant|First Light: Advisor/Consultant|Hologic: Grant/Research Support|ID Connect: Advisor/Consultant|Quidel: Advisor/Consultant|Visby: Advisor/Consultant Rami Kantor, MD, Gilead Sciences: Grant/Research Support.

Viral infections are major causes of morbidity and mortality in solid-organ and hematopoietic stem cell transplant recipients. This study evaluated the performance of the Galileo Pathogen Solution metagenomics Next-Generation sequencing assay to detect and quantify 11 DNA viruses (cytomegalovirus, Epstein–Barr virus, BK virus, human adenovirus, JC virus, herpes simplex virus 1 and 2, varicella zoster virus, human herpesvirus 6A and 6B, and parvovirus B19) and to qualitatively detect torque teno virus. DNA extracted from 47 plasma samples of viremic transplant recipients were subjected to DNA library preparation with pathogen enrichment/human background depletion, sequencing, and automated data analysis. The viral loads were determined with the Galileo assay using a standard curve generated from a calibration panel. All of the samples tested had a 100% agreement with the real-time quantitative PCR (qPCR) assays in detecting the primary virus targets and the majority of the quantified samples had a viral load difference within 0.46 log10 IU/mL or copies/mL. The mean difference for cytomegalovirus between the Galileo and qPCR assays was 0.21 log10 IU/mL (SD, ±0.43 log10 IU/mL). The mean difference for BK virus between the Galileo and qPCR assays was 0.17 log10 cp/mL (SD, ±0.67 log10 cp/mL). Additionally, 75 co-infections were detected in 31 samples by the Galileo assay. The study findings show that the Galileo assay can simultaneously detect and quantify multiple viruses in transplant recipients with results that are comparable with standard-of-care qPCR assays.

Background HIV-1 transmitted drug resistance (TDR) remains a global challenge that can impact care, yet its comprehensive assessment is limited and heterogenous. We longitudinally characterized statewide TDR in Rhode Island. Methods Demographic and clinical data from treatment-naïve individuals were linked to protease, reverse transcriptase, and integrase sequences routinely obtained over 2004–2020. TDR extent, trends, impact on first-line regimens, and association with transmission networks were assessed using the Stanford Database, Mann-Kendall statistic, and phylogenetic tools. Results In 1123 individuals, TDR to any antiretroviral increased from 8% (2004) to 26% (2020), driven by non-nucleotide reverse transcriptase inhibitor (NNRTI; 5%–18%) and, to a lesser extent, nucleotide reverse transcriptase inhibitor (NRTI; 2%–8%) TDR. Dual- and triple-class TDR rates were low, and major integrase strand transfer inhibitor resistance was absent. Predicted intermediate to high resistance was in 77% of those with TDR, with differential suppression patterns. Among all individuals, 34% were in molecular clusters, some only with members with TDR who shared mutations. Among clustered individuals, people with TDR were more likely in small clusters. Conclusions In a unique (statewide) assessment over 2004–2020, TDR increased; this was primarily, but not solely, driven by NNRTIs, impacting antiretroviral regimens. Limited TDR to multiclass regimens and pre-exposure prophylaxis are encouraging; however, surveillance and its integration with molecular epidemiology should continue in order to potentially improve care and prevention interventions.

BACKGROUND: HIV molecular epidemiology is increasingly integrated into public health prevention. We conducted cluster typing to enhance characterization of a densely-sampled statewide epidemic towards informing public health. METHODS. We identified HIV clusters, categorized them into types, and evaluated their dynamics between 2004–2019 in Rhode Island (RI). We grouped sequences by diagnosis year, assessed cluster changes between paired phylogenies, t(0) and t(1), representing adjacent years and categorized clusters as stable (cluster in t(0) phylogeny = cluster in t(1) phylogeny) or unstable (cluster in t(0) ≠ cluster in t(1)). Unstable clusters were further categorized as emerging (t(1) phylogeny only) or growing (larger in t(1) phylogeny). We determined proportions of each cluster type, of individuals in each cluster type, and of newly-diagnosed individuals in each cluster type, and assessed trends over time. RESULTS. A total of 1,727 individuals with available HIV-1 subtype B pol sequences were diagnosed in RI by 2019. Over time, stable clusters and individuals in them dominated the epidemic, increasing over time, with reciprocally decreasing unstable clusters and individuals in them. Conversely, proportions of newly-diagnosed individuals in unstable clusters significantly increased. Within unstable clusters, proportions of emerging clusters and of individuals in them declined; while proportions of newly-diagnosed individuals in growing clusters significantly increased over time. CONCLUSIONS. Distinct molecular cluster types were identified in the RI epidemic. Cluster dynamics demonstrated increasing stable and decreasing unstable clusters driven by growing, rather than emerging clusters, suggesting consistent in-state transmission networks. Cluster typing could inform public health beyond conventional approaches and direct interventions.

With the ongoing human immunodeficiency virus (HIV) epidemic in the developing world, Pakistan has been registering 20,000 new HIV cases every year for the past few years, the highest rate of increase among all countries in the region.1 In Pakistan, HIV disease has affected high risk, key populations for more than 30 years2, with key populations defined as sex workers, men who have sex with men, transgender individuals, injections drug users, and recipients of contaminated blood.3,4 In April 2019, a completely new HIV landscape rose to the global spotlight when around 800 children tested positive (in 12 weeks period) for HIV in Sindh, Pakistan, followed by similar reports from other parts of the country.5 These new infections are attributed to new risk factors outside of the historical key populations, including use of contaminated needles for routine vaccination and intramuscular and intravenous medical treatment. These statistics were alarming: the country’s healthcare system was not ready, nor is it currently ready, for a widespread HIV epidemic. In addition to international aid, Pakistan requires active involvement from the local healthcare sector to curb the HIV epidemic. At the local level, an understanding of HIV disease is the first step towards this goal.

Background In order for healthcare systems to prepare for future waves of COVID-19, an in-depth understanding of clinical predictors is essential for efficient triage of hospitalized patients. Methods We performed a retrospective cohort study of 259 patients admitted to our hospitals in Rhode Island to examine differences in baseline characteristics (demographics and comorbidities) as well as presenting symptoms, signs, labs, and imaging findings that predicted disease progression and in-hospital mortality. Results Patients with severe COVID-19 were more likely to be older (p = 0.02), Black (47.2% vs. 32.0%, p = 0.04), admitted from a nursing facility (33.0% vs. 17.9%, p = 0.006), have diabetes (53.9% vs. 30.4%, p Conclusions Certain patient characteristics and clinical features can help clinicians with early identification and triage of high-risk patients during subsequent waves of COVID-19.

IntroductionHIV continues to have great impact on millions of lives. Novel methods are needed to disrupt HIV transmission networks. In the USA, public health departments routinely conduct contact tracing and partner services and interview newly HIV-diagnosed index cases to obtain information on social networks and guide prevention interventions. Sequence clustering methods able to infer HIV networks have been used to investigate and halt outbreaks. Incorporation of such methods into routine, not only outbreak-driven, contact tracing and partner services holds promise for further disruption of HIV transmissions.Methods and analysisBuilding on a strong academic–public health collaboration in Rhode Island, we designed and have implemented a state-wide prospective study to evaluate an intervention that incorporates real-time HIV molecular clustering information with routine contact tracing and partner services. We present the rationale and study design of our approach to integrate sequence clustering methods into routine public health interventions as well as related important ethical considerations. This prospective study addresses key questions about the benefit of incorporating a clustering analysis triggered intervention into the routine workflow of public health departments, going beyond outbreak-only circumstances. By developing an intervention triggered by, and incorporating information from, viral sequence clustering analysis, and evaluating it with a novel design that avoids randomisation while allowing for methods comparison, we are confident that this study will inform how viral sequence clustering analysis can be routinely integrated into public health to support the ending of the HIV pandemic in the USA and beyond.Ethics and disseminationThe study was approved by both the Lifespan and Rhode Island Department of Health Human Subjects Research Institutional Review Boards and study results will be published in peer-reviewed journals.

Background Studies have demonstrated that persons with HIV (PWH) maintaining viral suppression do not transmit HIV to HIV-negative partners through condomless sex, leading to the “Undetectable = Untransmittable (U = U)” prevention campaign. However, few studies have examined the durability of suppression in the era of U = U. Methods This retrospective cohort study was conducted in Providence, Rhode Island. PWH aged ≥18 years with documented viral suppression (defined as at least 1 viral load [VL] Results A total of 1242 patients with viral suppression were included in the baseline cohort. In each follow-up year, 85%–90% maintained viral suppression, 2%–5% experienced viral rebound, and 8%–10% had a gap in VL monitoring. Among those with viral rebound, approximately one-half were suppressed again within 6 months. In the logistic regression models, retention in care was significantly associated with viral suppression, while younger age, black race, high school or equivalent education, non–men who have sex with men, and history of incarceration were significantly associated with viral rebound. Conclusions In the U = U era, most patients with viral suppression who are retained in care are likely to maintain viral suppression over time. Some patients require additional support for regular VL monitoring.

Public health interventions guided by clustering of HIV-1 molecular sequences may be impacted by choices of analytical approaches. We identified commonly-used clustering analytical approaches, applied them to 1886 HIV-1 Rhode Island sequences from 2004–2018, and compared concordance in identifying molecular HIV-1 clusters within and between approaches. We used strict (topological support ≥ 0.95; distance 0.015 substitutions/site) and relaxed (topological support 0.80–0.95; distance 0.030–0.045 substitutions/site) thresholds to reflect different epidemiological scenarios. We found that clustering differed by method and threshold and depended more on distance than topological support thresholds. Clustering concordance analyses demonstrated some differences across analytical approaches, with RAxML having the highest (91%) mean summary percent concordance when strict thresholds were applied, and three (RAxML-, FastTree regular bootstrap- and IQ-Tree regular bootstrap-based) analytical approaches having the highest (86%) mean summary percent concordance when relaxed thresholds were applied. We conclude that different analytical approaches can yield diverse HIV-1 clustering outcomes and may need to be differentially used in diverse public health scenarios. Recognizing the variability and limitations of commonly-used methods in cluster identification is important for guiding clustering-triggered interventions to disrupt new transmissions and end the HIV epidemic.

Great efforts are devoted to end the HIV epidemic as it continues to have profound public health consequences in the United States and throughout the world, and new interventions and strategies are continuously needed. The use of HIV sequence data to infer transmission networks holds much promise to direct public heath interventions where they are most needed. As these new methods are being implemented, evaluating their benefits is essential. In this paper, we recognize challenges associated with such evaluation, and make the case that overcoming these challenges is key to the use of HIV sequence data in routine public health actions to disrupt HIV transmission networks.

Introduction Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) has infected >6 million people worldwide since December 2019. Global reports of HIV/SARS‐CoV‐2 coinfection are limited. To better understand the impact of the coronavirus disease 2019 (COVID‐19) pandemic on persons with HIV and improve their care, we present an outpatient and inpatient clinical experience of HIV/SARS‐CoV‐2 coinfection from Rhode Island, US. Methods We describe outpatient and inpatient preparedness for the COVID‐19 pandemic, and present a case series of all known patients with HIV/SARS‐CoV‐2 coinfection at The Miriam Hospital and Rhode Island Hospital, and The Miriam Hospital Infectious Diseases and Immunology Center, in Providence, Rhode Island, US. Results and discussion The Infectious Diseases and Immunology Center rapidly prepared for outpatient and inpatient care of persons with HIV and SARS‐CoV‐2. Between 30 March and 20 May 2020, 27 patients with HIV were diagnosed with SARS‐CoV‐2. Twenty were male, six female and one transgender female; average age was 49 years; 13/27 were Hispanic and 6/27 were African American. All had HIV viral load

Introduction Co‐located treatment for HIV and opioid use disorder has been shown to improve care outcomes for HIV‐positive people who inject drugs (PWID) in Ukraine. However, patients continue to be stigmatized for both HIV and substance use. This study aimed to assess whether co‐located care for HIV‐positive PWID receiving opioid agonist treatment (OAT) services in Ukraine is associated with less stigma and better perceived quality of HIV services. Methods This cross‐sectional study enrolled 191 HIV‐positive PWID who received OAT services at three healthcare facilities providing substance use treatment (OAT only) and at four facilities that provided co‐located care (both OAT and HIV treatment) in six regions in Ukraine during July‐September, 2017. Primary outcomes were HIV stigma (Berger scale), substance use stigma (Substance Abuse Stigma Scale) and intersectional stigma (both stigma forms above 75th percentile). Secondary outcome was quality of HIV care, a composite score based on a package of received services. Linear and ordinal regressions were used to assess the predictors of selected outcomes. Results Study participants were 75% male, mean age 40 ± 7 years; 47% received co‐located care, and 10.5% had both high HIV and substance use stigma. Co‐located care was neither associated with HIV nor substance use stigma but it was linked to better quality of HIV care (adjusted odds ratio: 4.13; 95% CI: 2.31, 7.54). HIV stigma was associated with suicide attempts (adjusted beta (aβ): 5.90; 95% CI: 2.05, 9.75), and substance use stigma was linked to poor mental health (aβ: −0.26; 95% CI: −0.44, −0.08) and lower likelihood of receipt of services from non‐governmental organization (NGO; aβ: −6.40; 95% CI: −10.23, −2.57). Conclusion One in ten people with HIV in this cohort who received OAT services experienced high levels of both HIV and substance use stigma, which was associated with poorer mental health and less NGO support. Co‐located HIV and OAT services were linked to better perceived quality of HIV care, but did not seem to reduce stigma for this key population. Stigma interventions for PWID, possibly delivered involving NGOs, may be an approach to mitigate this challenge.

BACKGROUND The World Health Organization recommended increased dosages of the first-line antituberculosis (anti-TB) drugs for children in 2010. We examined the frequency of and factors associated with low plasma maximum concentration (Cmax) of each drug in children treated with the revised dosages. METHODS Children on anti-TB therapy for at least 4 weeks underwent pharmacokinetic testing. Plasma Cmax below the lower limit of proposed reference range was considered low. Bivariate and multivariate analyses were used to examine the factors associated with low Cmax of each drug. RESULTS Of the 100 children, 58% were male, 50% HIV-infected and 49% younger than 5 years old. The median (interquartile range) Cmax was 5.9 (4.5-7.7) µg/mL for isoniazid, 6.5 (4.9-8.8) µg/mL for rifampin, 26.0 (21.2-33.4) µg/mL for pyrazinamide and 1.7 (0.9-2.7) µg/mL for ethambutol. There was a strong correlation between Cmax and AUC0-8h for all drugs. Low Cmax occurred in 9/100 (9.0%), 61/100 (61.0%), 17/97 (17.5%) and 60/97 (61.9%) for isoniazid, rifampin, pyrazinamide and ethambutol, respectively. In addition, 75/97 (77.3%) children had pyrazinamide Cmax < 35 µg/mL. Factors associated with low Cmax were NAT2 metabolizer phenotype status for isoniazid; height, dosage and HIV coinfection status for rifampin; height for pyrazinamide; and age, dosage and HIV coinfection status for ethambutol. CONCLUSIONS The high frequency of low rifampin and ethambutol Cmax in our study is consistent with emerging pharmacokinetic data in children treated according to the new WHO recommendations. Higher dosages than currently recommended especially for rifampin may be necessary in children.

Background The “Undetectable equals Untransmittable (U=U)” HIV prevention campaign is a cornerstone of HIV prevention. However, there are few recommendations to guide patients and providers in U=U implementation and limited data on risk factors for viral rebound among persons eligible for U=U. Methods We conducted a retrospective multi-center study using data from the CNICS HIV research network to identify risk factors for viral rebound among persons with established viral suppression [two viral loads (VL) and all VLs of < 200 copies/ul within a one-year period (U=U eligible)]. Demographics, patient-reported outcomes, and longitudinal clinical data from 21,359 persons with HIV were analyzed. To include missing data in the analysis, they were treated as a separate category. The primary outcome of viral rebound was defined as any VL > 200 copies/ul within two years after U=U eligibility. A univariable logistic regression model was conducted to identify predictors of viral rebound. Significant variables (p< 0.05) were included in a multivariable logistic regression model. Predictive values of individual variables were captured by adjusted odds ratios (aORs). Results From 2011-2019, 12,150 patients met criteria for U=U eligibility and had two years of follow up data. The median age was 46 (IQR: 38-53); 68% male; 51% were white, 39% black. 1544 (13%) experienced viral rebound during follow-up. Forest plot summaries of univariable and multivariable logistic regression models are in Figures 1&2. In multivariable analysis, Black race (aOR=1.56, p< 0.001); MSM-IDU risk (aOR=1.38, p=0.006); lower QoL score (aOR=1.49, p=0.005); poorer ART adherence (aOR=1.84, p< 0.001); duration of lifetime ART [aOR=1.47 (10+yrs), = 1.37 (5-10 yrs); and = 1.28 (2-5 yrs), p< 0.001]; use of InSTIs after eligibility (aOR=1.60, p< 0.001); current smoker (aOR=1.49, p< 0.001), current amphetamine (aOR=1.83, p< 0.001) or cocaine use (aOR=1.46, p=0.012), were associated with viral rebound. In both analyses, older age was protective against viral rebound. Figure 1. Summary of Univariate Logistic Regression Model Figure 2. Summary of Multivariable Logistic Regression Model Conclusion We identified multiple risk factors for viral rebound among PWH with viral suppression. Further research is needed to identify synergistic risk factors that increase probability of viral rebound to inform optimal implementation of U=U. Disclosures Edward Cachay, MD, MAS, Gilead (Consultant, Grant/Research Support)Merck Sciences (Grant/Research Support) Heidi Crane, MD, MPH, ViiV (Grant/Research Support) Benigno Rodriguez, MD, Gilead (Speaker’s Bureau)ViiV (Speaker’s Bureau)

Background To better understand patient factors that impact clinical outcomes in COVID-19, we performed a retrospective cohort study of patients hospitalized with COVID-19 in Rhode Island to identify patient and clinical characteristics associated with severe disease. Methods We analyzed 259 patients admitted to our academic medical center during a three month period with confirmed COVID-19. Clinical data was extracted via chart review and lab results within the first 24 hours of admission were extracted directly from electronic medical records. Patients were divided in two groups based upon the highest level of supplemental oxygen (O2) required during hospitalization: severe COVID-19 (high flow O2, non-invasive, or invasive mechanical ventilation) and non-severe COVID-19 (low flow O2 or no supplemental O2). SAS 9.4 (Cary, NC) was used for statistical analyses. Chi-square or Fisher’s exact tests for categorical variables and the Student’s t-test for continuous variables were used to compare demographics, baseline comorbidities, and clinical data between the severe and non-severe groups. Table 1: Demographics Results Of 259 patients, 166 (64%) had non-severe disease, and 93 (36%) severe disease; median age [IQR] was 62 [51,73]. There were 138(53%) males and 75 (29%) Hispanics. Among non-Hispanics,124(48%) were White, 48(19%) African Americans, and 12(5%) other races. Sixty (23%) were admitted from a nursing facility and the in-hospital mortality rate was 15% (38/259). Severe COVID-19 was associated with older age (p=0.02), admission from nursing facility (p=0.009), increased BMI (p=0.03), diabetes mellitus (p=0.0002), and COPD (p=0.03). At the time of presentation, severe COVID-19 was associated with tachypnea, hypoxia, hypotension (all p< 0.0001), elevated BUN (p=0.002) and AST (p=0.001), and acute or chronic kidney injury (p=0.01). Median hospital stay [IQR] was 11 days [7,18] in the severe vs. 6 days [3,11] in the non-severe group. In the severe group, 72% required ICU admission and 39% died. Table 2: Medical comorbidities Table 3: Presenting symptoms and signs in the first 48 hours of admission Table 4: Basic labs in the first 24 hours Conclusion In this cohort of patients with COVID-19, specific comorbidities, and vital signs at presentation were associated with severe COVID-19. These findings help clinicians with early identification and triage of high risk patients. Disclosures All Authors: No reported disclosures

In the United States, high concern for iatrogenic reactivation to tuberculosis (TB) disease secondary to prescribed immunosuppression has resulted in increased use of the QuantiFERON-TB Gold In-Tube test (QFT-GIT) to screen for Mycobacterium tuberculosis (Mtb) infection. The aim of our study was to determine indications for QFT-GIT testing and risk factors for indeterminate QFT-GIT results. We retrospectively identified patients with QFT-GIT testing over a six-month period in a tertiary care academic health care system and performed a record review. Inpatients were 11 times more likely to have an indeterminate QFT-GIT result than outpatients (95% CI 7.6-16.2). 61.5% inpatient QFT-GITs were ordered during workup of active TB. Providers treating exogenously or endogenously immunosuppressed patients ordered the most QFT-GITs. We highlight the significant limitations of TB screening tests in the inpatient setting and the need to test earlier in those requiring immunosuppressive therapy to avoid indeterminate results.

Nevirapine-based antiretroviral therapy (ART) is one of the limited options in HIV-infected children younger than 3 years old (young children) with tuberculosis (TB) coinfection. To date, there are insufficient data to recommend nevirapine-based therapy during first-line antituberculosis (anti-TB) therapy in young children. We compared nevirapine pharmacokinetics (PK) in HIV-infected young children with and without TB coinfection. In the coinfected group, nevirapine PK was evaluated while on anti-TB therapy and after completing an anti-TB therapy regimen. Of 53 participants, 23 (43%) had TB-HIV coinfection. While the mean difference in nevirapine PK parameters between the two groups was not significant (P > 0.05), 14/23 (61%) of the children with TB-HIV coinfection and 9/30 (30%) with HIV infection had a nevirapine minimum concentration (C(min)) below the proposed target of 3.0 mg/liter (P = 0.03). In multivariate analysis, anti-TB therapy and the CYP2B6 516G>T genotype were joint predictors of nevirapine PK parameters. Differences in nevirapine PK parameters between the two groups were significant in children with CYP2B6 516GG but not the GT or TT genotype. Among 14 TB-HIV-coinfected participants with paired data, the geometric mean C(min) and area under the drug concentration-time curve from time zero to 12 h (AUC(0–12)) were about 34% lower when patients were taking anti-TB therapy, while the nevirapine apparent oral clearance (CL/F) was about 45% higher. While the induction effect of anti-TB therapy on nevirapine PK in our study was modest, the CYP2B6 genotype-dependent variability in the TB drug regimen effect would complicate any dose adjustment strategy in young children with TB-HIV coinfection. Alternate ART regimens that are more compatible with TB treatment in this age group are needed. (This study has been registered at ClinicalTrials.gov under identifier NCT01699633.)

We compared efavirenz pharmacokinetic (PK) parameters in children with tuberculosis (TB)/human immunodeficiency virus (HIV) coinfection on and off first-line antituberculosis therapy to that in HIV-infected children. Children 3 to 14 years old with HIV infection, with and without TB, were treated with standard efavirenz-based antiretroviral therapy without any efavirenz dose adjustments., We compared efavirenz pharmacokinetic (PK) parameters in children with tuberculosis (TB)/human immunodeficiency virus (HIV) coinfection on and off first-line antituberculosis therapy to that in HIV-infected children. Children 3 to 14 years old with HIV infection, with and without TB, were treated with standard efavirenz-based antiretroviral therapy without any efavirenz dose adjustments. The new World Health Organization-recommended antituberculosis drug dosages were used in the coinfected participants. Steady-state efavirenz concentrations after 4 weeks of antiretroviral therapy were measured using validated liquid chromatography with tandem mass spectrometry (LC-MS/MS) assays. Pharmacokinetic parameters were calculated using noncompartmental analysis. Between groups, PK parameters were compared by Wilcoxon rank-sum test and within group by signed-rank test. Of the 105 participants, 43 (41.0%) had TB coinfection. Children with TB/HIV coinfection compared to those with HIV infection were younger, had lower median weight-for-age Z score, and received a higher median efavirenz weight-adjusted dose. Geometric mean (GM) efavirenz peak concentration (Cmax), concentration at 12 h (C12h), Cmin, and total area under the curve from time 0 to 24 h (AUC0–24h) values were similar in children with HIV infection and those with TB/HIV coinfection during anti-TB therapy. Geometric mean efavirenz C12h, Cmin, and AUC0–24h values were lower in TB/HIV-coinfected patients off anti-TB therapy than in the children with HIV infection or TB/HIV coinfection on anti-TB therapy. Efavirenz clearance was lower and AUC0–24h was higher on than in patients off anti-TB therapy. Reduced efavirenz clearance by first-line anti-TB therapy at the population level led to similar PK parameters in HIV-infected children with and without TB coinfection. Our findings do not support modification of efavirenz weight-band dosing guidelines based on TB coinfection status in children. (The study was registered with ClinicalTrials.gov under registration number NCT01704144.)

SummaryBackground Human immunodeficiency virus infection and obesity are pro-inflammatory conditions that, when occurring together, may pose a synergistic risk for diabetes and cardiovascular disease. Purpose The aim of the current study was (i) to document the prevalence of obesity in HIV+ patients treated at the Miriam Hospital Immunology Center (Providence, RI) and (ii) to investigate the relationship between obesity and comorbidities. Methods The study population consisted of 1,489 HIV+ adults (70% men; average age 48 ± 11 years) treated between 01/01/2012 and 06/30/2014. Separate logistic regressions tested the associations between overweight and obesity and comorbid diagnoses (diabetes, hypertension and cardiovascular disease), as compared with normal weight. Covariates included age, gender and smoking status. Results Approximately 37% of patients were overweight (body mass index 25.0–29.9), and an additional 28% were obese (body mass index ≥30.0). Obesity was associated with higher odds of comorbid diabetes (OR = 3.26, CI = 1.98–5.39) and hypertension (OR = 2.11, CI = 1.49–2.98). There was no significant association between obesity and the presence of cardiovascular disease (OR = 1.12, CI = 0.66–1.90). Overweight was associated only with higher odds of comorbid diabetes (OR = 1.72; CI = 1.02–2.88). Conclusion Our findings demonstrate a heightened risk of comorbidities in overweight and obese HIV+ patients. Future studies should investigate whether weight loss interventions for this population can reduce cardiovascular and metabolic risk factors as they do in other populations.

Background Prevention of mother to child transmission (PMTCT) of Human Immunodeficiency Virus (HIV) requires a comprehensive approach and understanding the cultural backgrounds of pregnant women living with HIV (PWLH). In Rhode Island (RI), 70% of women newly diagnosed with HIV are foreign-born (FB) despite only representing 14% of RI’s population. Understanding the similarities and differences of pregnancy characteristics and engagement in postpartum HIV care between United States born (USB) and FB women is needed to ensure PWLH remain engaged in care and that appropriate resources are provided to all women with HIV in our state to maintain successful PMTCT of HIV. Methods A retrospective review of pregnant women living with HIV and their HIV-exposed infants evaluated in our hospital system were analyzed from 2012-2019. Clinical data were derived from medical records. Association between country of origin and sociodemographic, clinical, or lab variables were evaluated using chi-square test. Results A total of 72 pregnancies in 64 PWLH were included. Median # of pregnancies were 9 per year, median age at delivery 33 years, 54% of PWLH Black or African American, 33% Hispanic; 67.1% FB, most (56%) from Sub-Saharan Africa. Sixty-one % (n=42) with detectable (> 20 copies/mL) viral load (VL) during pregnancy, 23% (n=15) at delivery, only 1 VL > 200 at delivery. Pregnancy complications seen in 51%; 60% delivered vaginally; most (74%) at term. Engagement in postpartum HIV care declined from 71% at 6 months to 37% at 24 months. There was also decline in engagement in HIV care for the HIV exposed infants- 89% presented to the initial visit their children, from 89% attending the initial visit to 69% attending their last. DCYF involvement was more likely to occur in USB women compared to FB (P < 0.05). Other comparisons between FB & USB women including adherence to care were insignificant. Conclusion USB PWLH are at higher risk of DCYF involvement compared to FB women. Investigation into this disparity is warranted, given the cultural and language differences between groups. Additional research to determine barriers to long-term postpartum follow up for women and their infants is urgently needed. Disclosures All Authors: No reported disclosures

Although human immunodeficiency virus (HIV) coinfection is the most important risk factor for a poor antituberculosis (anti-TB) treatment response, its effect on the pharmacokinetics of the first-line drugs in children is understudied. This study examined the pharmacokinetics of the four first-line anti-TB drugs in children with TB with and without HIV coinfection. Ghanaian children with TB on isoniazid, rifampin, pyrazinamide, and ethambutol for at least 4 weeks had blood samples collected predose and at 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography-mass spectrometry methods and pharmacokinetic parameters calculated using noncompartmental analysis. The area under the concentration-time curve from 0 to 8 h (AUC 0–8 ), maximum concentration ( C max ), and apparent oral clearance divided by bioavailability (CL/F) for each drug were compared between children with and without HIV coinfection. Of 113 participants, 59 (52.2%) had HIV coinfection. The baseline characteristics were similar except that the coinfected patients were more likely to have lower weight-for-age and height-for-age Z scores ( P < 0.05). Rifampin, pyrazinamide, and ethambutol median body weight-normalized CL/F values were significantly higher, whereas the plasma AUC 0–8 values were lower, in the coinfected children than in those with TB alone. In the multivariate analysis, drug dose and HIV coinfection jointly influenced the apparent oral clearance and AUC 0–8 for rifampin, pyrazinamide, and ethambutol. Isoniazid pharmacokinetics were not different by HIV coinfection status. HIV coinfection was associated with lower plasma exposure of three of the four first-line anti-TB drugs in children. Whether TB/HIV-coinfected children need higher dosages of rifampin, pyrazinamide, and ethambutol requires further investigation. (This study has been registered at ClinicalTrials.gov under identifier NCT01687504.)

Human immunodeficiency virus (HIV) infection is a risk factor for pulmonary hypertension (PH). Chronic hepatitis C virus (HCV) infection may have unique or synergistic effects on the pulmonary vasculature, but the prevalence and risk factors for PH in HIV-HCV coinfected persons are not known.To define the prevalence of echocardiographic PH in a cohort of patients with HIV-HCV coinfection, to compare this estimate with the reported prevalence of PH among those with HIV infection alone, and to identify potential risk factors for PH in coinfected individuals.We performed a retrospective study of HIV-HCV coinfected patients followed at our institution from 2003 to 2012 with evidence of HCV infection (positive HCV antibody, measurable HCV ribonucleic acid viral load, and/or genotype) within 6 months of transthoracic echocardiogram. PH was defined by an estimated pulmonary artery systolic pressure (PASP) of greater than or equal to 40 mm Hg or more than moderate right ventricular dysfunction. We excluded those diagnosed with cirrhosis, left ventricular ejection fraction less than 50%, or more than moderate aortic or mitral valve disease.Sixty-eight patients were included, and 43 had adequate estimates of PASP. The median (interquartile range) age was 52 (48-57) years, and 45 (67%) were men. Eight (19%) had PH, and three (7%) had more than moderate right ventricular dysfunction. After age and sex adjustment, interferon (IFN)-based HCV treatment was associated with higher PASP (β, 6.00 mm Hg; 95% confidence interval, 0.09-11.90; P = 0.047) and with the risk of PH (odds ratio, 5.65; 95% confidence interval, 1.07-29.93; P = 0.042). These associations persisted after adjustment for comorbidities but were attenuated by adjustment for duration of HCV diagnosis.The prevalence of echocardiographic PH may be higher in HIV-HCV coinfected individuals than in those with HIV monoinfection. IFN-based HCV treatment and time since HCV diagnosis were associated with the development of PH as assessed by echocardiography. Further studies are needed to examine HIV-HCV coinfection, HCV treatment, and duration of infection as possible causes of pulmonary vascular disease.

Background The use of outpatient parenteral antimicrobial therapy (OPAT) is expanding, and although a significant proportion of OPAT patients are treated for prosthetic joint infections (PJIs), research on this population is limited. This study examined characteristics associated with 90-day hospital readmission rates for patients receiving OPAT for PJIs. Methods This retrospective study identified patients who received OPAT for hip and knee PJIs. Inclusion criteria included patients over 18 years who were discharged from 2015 to 2017 and had follow-up scheduled for OPAT. Patients with a planned readmission or a readmission unrelated to OPAT within 90 days were excluded. The primary outcome of interest was 90-day readmission. Results A total of 53 patients were identified. Patient characteristics were as follows: 57% male, 92% Caucasian, median age of 69, median BMI of 32; 34% had diabetes mellitus, and the median Charlson comorbidity score was 4 (IQR 0–5). Fifty-one percent were treated for hip infections and 49% for knee infections. Methicillin-susceptible Staphylococcus aureus PJIs were the most common, accounting for 28% of infections, whereas 6% were treated for methicillin-resistant S. aureus; 36% were discharged to home, 64% to skilled nursing facilities (SNFs); 66% attended their initial OPAT appointment, and the clinic received laboratory results for safety monitoring in 56% during their first week of OPAT. A total of 14 (26%) patients were readmitted within 90 days for OPAT-related complications. Of those readmitted, 57% were for worsening infections, 22% for adverse drug events, 14% for vascular access complications, and 7% for Clostridium difficile infection. None of the patient characteristics were significantly associated with greater readmission risk, and readmission was not associated with a missed initial outpatient appointment or initial safety laboratories. Conclusion Patients discharged on OPAT for PJI are at high risk of readmission. Overall, we found low rates of adherence with initial appointments and safety laboratories. Most readmissions were due to worsening infection, but it is not clear whether this was related to early hospital discharge, lapses in monitoring, or communication breakdown during transitions of care. More research is warranted in this population at risk for readmission. Disclosures All authors: No reported disclosures.

New HIV infections among younger men who have sex with men (MSM) in the United States are escalating. Data on HIV infections in college students are limited. In 2010, three MSM college students presented to our clinic with primary HIV infection (PHI) in a single month. To determine the number of college students among new HIV diagnoses, we reviewed clinical characteristics and molecular epidemiology of HIV-diagnosed individuals from January to December 2010 at the largest HIV clinic in Southern New England. PHI was defined as acute HIV infection or seroconversion within the last 6 months. Of 66 individuals diagnosed with HIV in 2010, 62% were MSM and 17% were academic students (12% college or university, 5% other). Seventy-three percent of students were MSM. Compared to nonstudents, students were more likely to be younger (24 versus 39 years), born in the United States (91% versus 56%), have another sexually transmitted disease (45% versus 11%), and present with PHI (73% versus 16%, all p-values

Background: HIV-infected refugees resettled in the United States face many challenges. Longitudinal data regarding HIV-specific outcomes in this population are limited. Methods: We reviewed charts of 51 HIV-infected sub-Saharan African refugees matched to 102 nonrefugees. Outcomes analyzed included CD4 counts, viral loads (VLs), antiretroviral treatment (ART) use, appointment adherence, opportunistic infections, and resistance mutations. Results: The ART initiation was similar. Appointment adherence was similar in year 1, but refugees were significantly less adherent beyond year 3. Refugees and nonrefugees spent similar amounts of time in care suppressed (83% vs 80%, P = .93). Refugees had higher odds of viremia following undetectable VL (OR 2.3, P < .05). Discussion: Initially, sub-Saharan African HIV-infected refugees have comparable appointment adherence, ART use, and VL suppression to nonrefugees. Overtime refugees were less adherent to appointments and more likely to have postsuppression viremia. The support services provided to refugees early in care may be important for retention in care and treatment success.

Transmission of HIV-1 drug resistance has important clinical and epidemiological consequences including earlier treatment failure and forward transmission of resistance strains in high-risk groups. To evaluate the prevalence and molecular epidemiology of transmitted drug resistance in Rhode Island, we collected genotypic, demographic, clinical, and laboratory data from treatment-naive individuals presenting to the largest outpatient HIV clinic in the state from January 2007 to November 2007. Sequences from 35 treatment-naive individuals were available, 83% of whom were men who had sex with men (MSM). All sequences were HIV-1 subtype B. Drug resistance mutations were identified in 7/35 [20%; 95% confidence interval (CI), 0.08-0.37] patients, six of whom had K103N. Two phylogenetic transmission clusters were found, involving 17% (6/35) of individuals, three in each cluster. We did not find an association between belonging to a cluster and age, gender, AIDS-defining illness, CD4 cell count, or viral load. Drug resistance mutations were more commonly observed in transmission clusters (p = 0.08). Individuals in one cluster all had K103N and were MSM who had attended local bathhouses. Individuals forming clusters were significantly more likely to have visited a bathhouse compared to nonclusters (p = 0.02). The prevalence of transmitted drug resistance in Rhode Island is high, further justifying genotypic testing on presentation to care and prior to treatment initiation. Molecular epidemiological analysis and association of resistance with phylogenetic networks using data obtained for clinical purposes may serve as useful tools for the prevention of drug resistance transmission and for contact tracing.

Examining how multiple concomitant factors interact to augment HIV transmission risk is needed to inform more effective primary and secondary HIV prevention programs for men who have sex with men (MSM) in the United States. The development of a “taxonomy” of long-term sexual and drug-related risk behavior profiles may have important implications for resource allocation and targeted HIV prevention programming. A secondary data analysis was conducted to explore longitudinal HIV transmission risk profiles among 423 MSM living with HIV enrolled in the Study to Understand the Natural History of HIV and AIDS in the Era of Effective Therapy (SUN Study). Between March 2004 and February 2012, participants completed semiannual, audio computer-assisted self-interviews that included demographics, employment status, medical information, alcohol use, stimulant use, sexual risk, and depression. Latent class analysis was used to identify patterns of risky behavior over time with respect to sexual risk, heavy drinking, and stimulant (i.e., methamphetamine and cocaine) use taken collectively. Three classes were identified: (a) High Sustained Heavy Drinker Class (33%), (b) High Mostly Stable Sexual Risk Class (17%), and (c) Overall Low Risk Class. (50%). Post hoc comparisons between classes revealed that men in Classes 1 ( p = .03) and 2 ( p = .02) were significantly younger than those in Class 3. In comparison to those in Classes 1 and 3, those in Class 2 were less likely to report being a racial/ethnic minority ( p = .04) and had the highest self-reported sexually transmitted infections ( p < .001). Findings indicate the need to better integrate sexual and substance use risk reduction strategies, including brief interventions and engagement in addiction treatment, for MSM living with HIV in the United States.

Summary Objectives The number of HIV-infected refugees entering the USA is increasing. There is little data describing the HIV-infected refugee population and the challenges encountered when caring for them. We performed a retrospective case–control analysis of HIV-infected refugees in order to characterize their co-morbidities, baseline HIV characteristics, and longitudinal care compared to HIV-infected non-refugees. Methods A retrospective chart review was performed of HIV-infected refugees and non-refugees who were matched for gender, age, and time of establishment of initial HIV care. Results The refugee population studied was largely from West Africa. Refugees were more likely than non-refugees to have heterosexual risk for HIV infection, latent tuberculosis infection, and active hepatitis B. Refugees were less likely than non-refugees to have a history of substance use, start antiretrovirals, and be enrolled in a clinical study. The baseline CD4 counts and HIV plasma viral loads were similar between the two groups. Conclusions Clinicians caring for West African HIV-infected refugees should be knowledgeable about likely co-morbidities and the impact of cultural differences on HIV care. Further studies are needed to develop culturally competent HIV treatment, education, and prevention programs for refugees who are beginning a new life in the USA.

There is a high burden of underlying substance use and mental illness in HIV-infected populations. HIV-care settings provide an important opportunity to assess substance and mental health needs among HIV-positive patients and to provide or make referrals for appropriate treatment services. In 2003, with funding from the Center for Substance Abuse Treatment (CSAT), we developed a model of integrated substance-use counselling and referral for treatment within a primary care HIV-care setting at The Miriam Hospital in Providence, Rhode Island. The project uses a multidisciplinary approach to provide linkage to treatment services for substance use and mental illness as well as to help participants with social service needs, such as housing and medical coverage, to ensure continuity of care and optimal HIV treatment adherence. Twelve percent of the 965 HIV-infected patients in care at our center have been enrolled in the project. Of these, all have a current substance-use disorder and 79.3% have been diagnosed with a mental illness. In addition, most participants are hepatitis C-positive (HCV) (65.5%). The majority of participants are on antiretroviral therapy (76.7%). Participants have been referred for the following treatment modalities: intensive outpatient services, methadone, buprenorphine, outpatient services and residential as well as individual and group counselling. Our model has been successful in assessing the substance-use and mental health needs of HIV-infected individuals with numerous co-morbidities and referring them for ancillary medical and social services.

Background. Pharmacokinetic data on the first-line antituberculosis drugs using the World Health Organization (WHO) revised dosages for children are limited. We investigated the pharmacokinetics of these drugs in children who were mostly treated with revised dosages. Methods. Children with tuberculosis on first-line therapy for at least 4 weeks had blood samples collected at predose, 1, 2, 4, and 8 hours postdose. Drug concentrations were determined by validated liquid chromatography mass spectrometry methods, and pharmacokinetic parameters were calculated using noncompartmental analysis. Factors associated with plasma peak concentration (Cmax) and the area under the time–concentration curve 0–8 hours (AUC0–8h) of each drug was examined using univariate and multivariate analysis. Results. Of the 62 children, 32 (51.6%) were male, 29 (46.8%) wereyounger than 5 years old, and 28 (45.2%) had human immunodeficiency virus (HIV) coinfection. Three patients had undetectable pyrazinamide and ethambutol concentrations. The median (interquartile range) AUC0–8h for isoniazid was 17.7 (10.2–23.4) µg·h mL –1 , rifampin was 26.0 (15.3–36.1) µg·h mL –1 , pyrazinamide was 144.6 (111.5–201.2) µg·h mL –1 , and ethambutol was 6.7 (3.8–10.4) µg·h mL –1 . Of the children who received recommended weight-band dosages, 44/51 (86.3%), 46/56 (82.1%), 27/56 (48.2%), and 21/51 (41.2%) achieved target Cmax for isoniazid, pyrazinamide, ethambutol, and rifampin, respectively. In multivariate analysis, age, sex, HIV coinfection status, and drug dosage in milligrams per kilogram were associated with the drugs’ plasma drug Cmax or AUC0–8h. Conclusions. The revised dosages appeared to be adequate for isoniazid and pyrazinamide, but not for rifampin or ethambutol in this population. Higher dosages of rifampin and ethambutol than currently recommended may be required in most children.

The objective of this study was to identify frequency and predictors of gaps in care in a longitudinal cohort of HIV-infected patients in urban New England. We conducted a retrospective cohort study in Providence, RI, of 581 newly diagnosed HIV patients >18 entering into care from 2004 to 2010, and followed their care through the end of 2011. The outcome of interest was gaps in care, defined as an interruption of medical care for >6 months. Time to the first gap was characterized using Kaplan-Meier (KM) curves. Anderson-Gill proportional hazards (AGPH) model was used to identify the risk factors of recurrent gaps in care. During the study period, 368 patients (63%) experienced at least 1 gap in care, 178 (30%) had ≥2 gaps, 84 (14.5%) had ≥3 gaps, and 21 (3.6%) died; 77% of the gaps were followed by a re-linkage with care The KM curves estimate that one-quarter of patients (95% CI = 22-29%) would experience ≥1 gap in care by Year 1; nearly one-half (CI = 45-54%) by Year 2; and 90% (CI = 93-96%) by Year 8. A prior gap was a strong predictor (HR = 2.36; CI = 2.16-2.58) of subsequent gaps; other predictors included age

To successfully implement the Seek, Test, and Treat (STT) strategy to curb the HIV epidemic, the criminal justice system must be a key partner. Increasing HIV testing and treatment among incarcerated persons has the potential to decrease HIV transmission in the broader community, but whether it is feasible to consider the implementation of the STT within jail facilities is not known. We conducted a retrospective review of Rhode Island Department of Corrections (RIDOC) medical records to assess whether persons newly diagnosed in the jail were able to start ART and be linked to community HIV care after release. From 2001 to 2007, 64 RIDOC detainees were newly diagnosed with HIV. During their index incarcerations, 64% were informed of positive confirmatory HIV test results, 50% completed baseline evaluations, and 9% began ART. Linkage to community care was confirmed for 58% of subjects. Subjects incarcerated for >14 days were significantly more likely to receive HIV test results and complete baseline evaluation (p

Meeting the needs of HIV-infected pregnant women requires understanding their backgrounds and potential barriers to care and safe pregnancy. Foreign-born women are more likely to have language, educational, and economic barriers to care, but may be even more likely to choose to keep a pregnancy. Data from HIV-infected pregnant women and their children in Rhode Island were analyzed to identify trends in demographics, viral control, terminations, miscarriages, timing of diagnosis, and adherence to followup. Between January 2004 and December 2009, 76 HIV-infected women became pregnant, with a total of 95 pregnancies. Seventy-nine percent of the women knew their HIV status prior to becoming pregnant. Fifty-four percent of the women were foreign-born and 38 percent of the 16 women who chose to terminate their pregnancies were foreign-born. While the number of HIV-infected women becoming pregnant has increased only slightly, the proportion that are foreign-born has been rising, from 41 percent between 2004 and 2005 to 57.5 percent between 2006 and 2009. A growing number of women are having multiple pregnancies after their HIV diagnosis, due to the strength of their desire for childbearing and the perception that HIV is a controllable illness that does not preclude the creation of a family.

This study examined the association between recent trends in CD4 and viral loads and cognitive test performance with the expectation that recent history could predict cognitive performance. Eighty-three human immunodeficiency virus (HIV)-infected patients with a mean CD4 count of 428 copies/ml were examined in this study (62% with undetectable plasma viral load [PVL]). We investigated the relationships between nadir CD4 cell count, 1-year trends in immunologic function/PVLs, and cognitive performance across several domains using linear regression models. Nadir CD4 cell count was predictive of current executive function (p = .004). One year clinical history for CD4 cell counts and/or PVLs were predictive of executive function, attention/working memory, and learning/memory measures (p < .05). Models that combined recent clinical history trends and nadir CD4 cell counts suggested that recent clinical trends were more important in predicting current cognitive performance for all domains except executive function. This research suggests that recent CD4 and viral load history is an important predictor of current cognitive function across several cognitive domains. If validated, clinical variables and cognitive dysfunction models may improve our understanding of the dynamic relationships between disease evolution and progression and CNS involvement.

While foreign-born persons constitute only 11% of the population in the state of Rhode Island, they account for more than 65% of incident tuberculosis (TB) annually. We investigated the molecular-epidemiological differences between foreign-born and U.S.-born TB patients to estimate the degree of recent transmission and identify predictors of clustering. A total of 288 isolates collected from culture-confirmed TB cases in Rhode Island between 1995 and 2004 were fingerprinted by spoligotyping and 12-locus mycobacterial interspersed repetitive units. Of the 288 fingerprinted isolates, 109 (37.8%) belonged to 36 genetic clusters. Our findings demonstrate that U.S.-born patients, Hispanics, Asian/Pacific islanders, and uninsured patients were significantly more likely to be clustered. Recent transmission among the foreign-born population was restricted and occurred mostly locally, within populations originating from the same region. Nevertheless, TB transmission between the foreign-born and U.S.-born population should not be neglected, since 80% of the mixed clusters of foreign- and U.S.-born persons arose from a foreign-born source case. We conclude that timely access to routine screening and treatment for latent TB infection for immigrants is vital for disease elimination in Rhode Island.

Data from the Centers for Disease Control and Prevention (CDC) indicate that reproductive-age black women in the Southeast are disproportionately affected by the HIV epidemic. There are few data describing HIV infection, pregnancies, and follow-up care in this population.A retrospective chart review was performed at the Perinatal HIV Service at the University of Mississippi Medical Center in Jackson, Mississippi, to identify HIV-infected women ≥ 18 years of age with deliveries from 1999 to 2006. Optimal follow-up was defined as at least two follow-up visits with an HIV provider within 1 year of delivery. Univariate and multivariate logistic regression analyses were used to identify factors associated with optimal adherence.We identified 274 women with 297 total deliveries. Median age was 25, and 89% were black. Only 37% of women had two or more visits with an HIV provider in the postpartum year. On univariate analysis, presentation before the third trimester was associated with optimal follow-up (p = 0.04). On multivariate analyses, presentation before the third trimester was the only variable associated with optimal follow-up (odds ratio [OR] 2.1, p = 0.02).The poor follow-up rates in this growing population highlight the critical need for research and development of targeted interventions to improve rates of retention in care, particularly in women with late trimester presentation.