ABSTRACT
Background: The COVID-19 pandemic has had significant impacts on the healthcare system, including HIV outpatient care. Lockdowns, infection concerns, and staffing and resource shortages had the potential to affect patient care and viral suppression. Methods: We conducted a retrospective analysis of patients at six HIV primary care clinics in New York City in the Mount Sinai Health system. We compared outcomes in a pre-COVID period [PC], Mar 2019-Feb 2020, to a COVID period [CP] of Mar 2020-Feb 2021. Demographics of interest included age, sex, race/ethnicity, and HIV risk factor. In the two time periods we compared viral load suppression (VLS;HIV RNA <200 copies/mL), primary care encounters, antiretroviral (ART) prescribing, and hospitalizations. We then evaluated predictors of loss of VLS or loss to follow-up in a logistic regression model. Results: Our cohort was comprised of 9,740 HIV primary care patients with ≥1 viral load measurement PC. Median age was 53 years and 79% were male;20% were white, 37% Black, and 30% Hispanic. 42% had an HIV risk factor of MSM, 22% heterosexual sex, and 4% injection drug use (IDU). 87.9% (8559/9740) of the PWH during PC had VLS. While 90.7% (7268/8013) of the population assessed during CP had VLS, 18% of the initial cohort had no VL testing during this period and 15% had neither testing nor a clinical visit during CP. In CP, 13% had at least one measured detectable HIV VL (≥200 copies/mL). Primary care encounters decreased from 93% to 79%. ART prescription rates were unchanged: 88% had active prescriptions for >80% of the year both PC and in CP. All-cause hospitalizations decreased from 766 (7.9%) to 633 (6.5%;p<.001). Male sex (OR 1.32,CI 1.17-1.49), identification as a transgender woman (OR 1.81,CI 1.22-2.69), age <35 years (OR 1.74,CI 1.53-1.97), Black race (OR 1.4,CI 1.23-1.59), and HIV risk factor of heterosexual sex (OR 1.54,CI 1.34-1.77) and IDU (OR 1.73,CI 1.35-2.22) were associated with loss of VLS or loss to follow-up. Conclusion: In this large cohort of PWH in a NYC medical system, viral suppression of those who remained in care remained stable-yet a substantial portion of patients were not engaged in care and monitored for VLS during the CP. Strategies to retain patients in care and ensure suppression (eg, with televisits and care coordination) may have helped mitigate effects of the pandemic. Clinics must continue targeted efforts to re-engage patients, facilitate access to testing, and prevent longstanding loss to follow-up in at-risk groups.
ABSTRACT
Background. Candidemia is a rare but serious complication of SARS-CoV-2 hospitalization. Combining non-culture and culture-based diagnostics allows earlier identification of candidemia. Given higher reported incidence during COVID-19 surges, we investigated the use of (1-3)-β-D-glucan (BDG) assay at our institution in those who did and did not develop candidemia. Methods. Retrospective study of adults admitted to The Mount Sinai Hospital between March 15-June 30 2020 for SARS-CoV-2 infection, with either ≥1 BDG assay or positive fungal blood culture. Data was collected with the electronic medical record and Vigilanz. A BDG value ≥ 80 was used as a positivity cutoff. Differences in mortality were assessed by univariate logistic regression using R (version 4.0.0). Statistical significance was measured by P value < .05. Results. There were 75 patients with ≥1 BDG assay resulted and 28 patients with candidemia, with an overlap of 9 between the cohorts. Among the 75 who had BDG assay, 23 resulted positive and 52 negative. Nine of 75 patients developed candidemia. Of the 23 with a positive assay, 5 developed candidemia and 18 did not. Seventeen of the 18 had blood cultures drawn within 7 days +/- of BDG assay. Four patients with candidemia had persistently negative BDG;2 had cultures collected within 7 days +/- of BDG assay. With a cut-off of >80, the negative predictive value (NPV) was 0.92. When the cut-off increased to >200, NPV was 0.97 and positive predictive value (PPV) was 0.42. Average antifungal days in patients with negative BDG was 2.6 vs. 4.2 in those with a positive. Mortality was 74% in those with ≥1 positive BDG vs. 50% in those with persistently negative BDGs. There was a trend towards higher odds of death in those with positive BDG (OR = 2.83, 95% CI: 1.00-8.90, p < 0.06). Conclusion. There was substantial use of BDG to diagnose candidemia at the peak of the COVID-19 pandemic. Blood cultures were often drawn at time of suspected candidemia but not routinely. When cultures and BDG were drawn together, BDG had a high NPV but low PPV. High NPV of BDG likely contributed to discontinuation of empiric antifungals. The candidemic COVID-19 patients had high mortality, so further investigation of algorithms for the timely diagnosis of candidemia are needed to optimize use of antifungals while improving mortality rates.