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: SARS-Cov-2 (severe acute respiratory disease coronavirus 2) causes Coronavirus Disease 2019 (COVID19) and is associated with respiratory failure and death in severe disease. This is associated with high levels of cytokines such as IL-6, IL-8 and TNF-alpha which are predictors of severe outcomes. SARSCoV- 2 leads to activation of the NLRP3 inflammasome which results in secretion of the cytokine IL-1ß. While high levels of IL-1ß are not observed in most patients with severe COVID-19, there is a subset of patients with high IL-1ß levels. Here we sought to characterize these patients and determine whether high IL-1ß levels are associated with adverse outcomes and death in COVID-19. Methods: We identified 90 patients with high IL-1ß levels (greater or equal to 2 pg/ml) and laboratory confirmed COVID-19 hospitalized in our hospital system in New York March 12 and May 8, 2020. We collected baseline clinical characteristics, laboratory values, COVID-19 treatment, and outcomes from this group and the group with IL-1ß levels below 2 pg/ml. Baseline clinical characteristics and outcomes were compared. Results: Comparing patients by IL-1ß level had similar demographics (age, sex, race/ethnicity, smoking status and comorbid disease prevalence). The group had comparable levels of adverse markers of disease severity but the patients with high IL-1ß had increased inflammatory biomarkers including IL-8 (629 vs. 68 pg/ml, p< 0.0001), TNF-alpha (30 vs. 51 pg/ml, p< 0.0001), IL-6 (173 vs. 5075 pg/ml, p< 0.0001), CRP (141 vs. 178, p=0.0007), d-dimer (2.6 vs. 4 p=0.0002), and increased rates of death (30% vs. 20%, p=0.008). Conclusion: Demographic and comorbid conditions are not effective at predicting high IL-1ß serum levels in COVID-19 patients, however those individuals with high levels are at risk for adverse outcomes of severe disease and death. Further investigation is required to probe the mechanism of NLRP3 inflammasome activation and IL-1ß signaling and the role of this cytokine in mediated inflammation and death in COVID-19.
ABSTRACT
Background: Some have advocated for hepatitis C virus (HCV) treatment simplification through reduced treatment monitoring, utilization of telehealth, and task-shifting The Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program at Mount Sinai Hospital in New York City provides HCV treatment services for people who use drugs through a harm reduction primary care model COVID-19 created unique barriers such as the sudden closure of REACH's outpatient practice mid-March 2020 and the reassignment of medical providers to inpatient COVID-19- related tasks In response to these barriers, REACH began utilizing telehealth for HCV treatment encounters and shifted toward a nurse-driven treatment-monitoring model We aimed to assess how this natural experiment in sudden treatment simplification affected REACH's ability to engage with and treat people who use drugs and are living with HCV during the COVID-19 pandemic Methods: Data was collected between March 20 and July 6, 2020 In place of in-person visits, telehealth visits were conducted over the phone or through video visits We were able to provide free cell phones with unlimited data plans to all patients who were not able to access telehealth visits due to lack of a phone or data plan A program RN monitored all active HCV-infected patients, reaching out to them by phone to discuss medication adherence and monitor side effects Notes from these encounters were then routed to the medical provider for review and to determine if follow-up from a physician was needed Results: During this 15-week period, REACH engaged twelve new HCV-infected patients and maintained engagement via telemedicine with thirteen additional patients already in the treatment work-up process Sixteen patients started treatment during this period, three of whom had entirely telehealth psychosocial (administration of PREP-C by social worker;prepc org) and medical work-up processes Of the ten patients on treatment at the beginning of this period, there was a treatment completion rate of 80% compared to REACH's pre-COVID treatment rate of 92% Of the eight patients who completed treatment, seven have completed end of treatment HCV RNA labs, all of which were undetectable In total, the program RN followed up with thirtyfour separate HCV-infected patients in fifty-five encounters. Conclusion: COVID-19 dramatically affected REACH's model of HCV care, forcing us toward sudden treatment simplification. Our rapid transition allowed us to provide uninterrupted care during the public health crisis We are now revising our existing HCV care model to systematically incorporate telemedicine, nurse-driven treatment-monitoring, and streamlined patient visit and lab schedules, thereby establishing a hybrid model of telehealth/in-person HCV care to best serve the needs of our patients in the context of ongoing limited in-person visits due to COVID-19.