Hiv Viral Load Suppression and Racial Disparities during the Covid-19 Pandemic in Nyc

Background: Antiretroviral therapy is highly effective in achieving HIV viral load suppression (VLS) but requires sustained engagement in care. The COVID-19 pandemic disrupted medical care, and its impact on engagement in HIV care and VLS remains unclear. Health information exchanges (HIEs) enable examination of patient care across multiple health systems. We sought to leverage HIE data to examine the effect of pandemic-related disruptions in HIV care on VLS and to explore racial/ethnic disparities in VLS. Method(s): We performed a retrospective observational study of people living with HIV (PLWH) using de-identified data from Healthix, an HIE encompassing >20 million patients and 8,000 healthcare facilities in the greater New York City (NYC) region, between 1/1/2018 and 7/14/2022. We identified PLWH based on HIV viral load (VL) tests and HIV diagnosis codes (ICD and SNOMED). We established two cohorts: PLWH engaged in care in 2020 with >=1 VL test in 2019, 2020, and 2021(Group A) and PLWH not engaged in care in 2020 with >=1 VL test in 2019 and 2021 but 0 VL tests in 2020 (Group B). HIV VLS outcomes were categorized as suppressed (< 200 copies/mL) or not suppressed ( >200 copies/mL) using the last VL in 2019, first VL in 2021, and last recorded VL. We compared proportions using X2-tests and fit a group-stratified logistic regression to examine the effect of race/ethnicity on VLS. Result(s): We identified 711,358 VL tests representing 81,122 patients at 249 facilities. Of these patients, 36,199 met our definition of PLWH. Of those, 12,448 met the inclusion criteria for Group A, and 3,377 met the inclusion criteria for Group B. In 2019, Group B had a lower VLS proportion than Group A (85.9% vs 88.1%, X2 = 12.3, p< 0.0001). In 2021, this gap increased;the proportion of VLS was 80.7% in Group B and 88.0% in Group A (X2 = 121.8, p< 0.00001). Most recently, VLS in Group B had increased to 85.6%, but the inter-group gap in VLS had grown from 2.2% to 4.4%. Within both groups, Black and Hispanic patients had lower odds of VLS than white patients. This disparity was greatest in Group B when they reengaged in care in 2021, with 72.0% of Black patients (OR 0.30, 95% CI 0.22-0.42), and 79.1% of Hispanic patients (OR 0.45, 95% CI 0.31-0.63), compared to 89.5% of white patients achieving VLS. Conclusion(s): VLS remained high among PLWH who stayed engaged in care in 2020, dropped among PLWH who disengaged in care, and was lower in minoritized groups even after controlling for engagement in care.

Detection of SARS-CoV-2 IgG antibodies and inflammatory cytokines in saliva-a pilot study.

Objective: The pandemic caused by SARS-CoV-2 virus continues to have a profound effect worldwide. However, COVID-19 induced oral facial manifestations have not been fully described. We conducted a prospective study to demonstrate feasibility of anti-SARS-CoV-2 IgG and inflammatory cytokine detection in saliva. Our primary objective was to determine whether COVID-19 PCR positive patients with xerostomia or loss of taste had altered serum or saliva cytokine levels compared to COVID-19 PCR positive patients without those oral symptoms. Our secondary objective was to determine the correlation between serum and saliva COVID-19 antibody levels. Materials and methods: For cytokine analysis, saliva and serum were obtained from 17 participants with PCR-confirmed COVID-19 infection at three sequential time points, yielding 48 saliva samples and 19 paired saliva-serum samples from 14 of the 17 patients. For COVID-19 antibody analyses, an additional 27 paired saliva-serum samples from 22 patients were purchased. Results: The saliva antibody assay had 88.64% sensitivity [95% Confidence Interval (CI) 75.44%, 96.21%] to detect SARS-CoV-2 IgG antibodies compared to serum antibody. Among the inflammatory cytokines assessed - IL-6, TNF-α, IFN-γ, IL-10, IL-12p70, IL-1ß, IL-8, IL-13, IL-2, IL-5, IL-7 and IL-17A, xerostomia correlated with lower levels of saliva IL-2 and TNF-α, and elevated levels of serum IL-12p70 and IL-10 (p < 0.05). Loss of taste was observed in patients with elevated serum IL-8 (p < 0.05). Conclusions: Further studies are needed to construct a robust saliva-based COVID-19 assay to assess antibody and inflammatory cytokine response, which has potential utility as a non-invasive monitoring modality during COVID-19 convalescence.

The Role of Oral Health in the Acquisition and Severity of SARS-CoV-2: A Retrospective Chart Review.

Objective: Studies have shown that gingival crevices may be a significant route for SARS-CoV-2 entry. However, the role of oral health in the acquisition and severity of COVID-19 is not known. Design: A retrospective analysis was performed using electronic health record data from a large urban academic medical center between 12/1/2019 and 8/24/2020. A total of 387 COVID-19 positive cases were identified and matched 1:1 by age, sex, and race to 387 controls without COVID-19 diagnoses. Demographics, number of missing teeth and alveolar crestal height were determined from radiographs and medical/dental charts. In a subgroup of 107 cases and controls, we also examined the rate of change in alveolar crestal height. A conditional logistic regression model was utilized to assess association between alveolar crestal height and missing teeth with COVID-19 status and with hospitalization status among COVID-19 cases. Results: Increased alveolar bone loss, OR = 4.302 (2.510 - 7.376), fewer missing teeth, OR = 0.897 (0.835-0.965) and lack of smoking history distinguished COVID-19 cases from controls. After adjusting for time between examinations, cases with COVID-19 had greater alveolar bone loss compared to controls (0.641 ± 0.613 mm vs 0.260 ± 0.631 mm, p < 0.01.) Among cases with COVID-19, increased number of missing teeth OR = 2.1871 (1.146- 4.174) was significantly associated with hospitalization. Conclusions: Alveolar bone loss and missing teeth are positively associated with the acquisition and severity of COVID-19 disease, respectively.

Diabetic ketoacidosis and mortality in COVID-19 infection.

AIM: - Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients. METHODS: - Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19. RESULTS: - Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40-1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06-1.08) and need for pressors (HR 2.33, 95% CI 1.82-2.98). Glucocorticoid use was protective in patients with and without DKA. CONCLUSION: - The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

Intestinal permeability and microbial translocation are increased in severe COVID-19

Background: SARS-CoV2 can infect enterocytes, and plasma cells and lymphocytes infiltrate the GI tract. In HIV, increased intestinal permeability and the ensuing microbial translocation are thought to contribute to systemic inflammation. We hypothesize that severe COVID-19 is associated with increased intestinal permeability, leading to microbial translocation and systemic inflammation. Methods: Serum/plasma samples were obtained from participants enrolled in a longitudinal COVID-19 study. Participants had Mild (outpatient), Moderate (inpatient but not requiring Intensive Care Unit (ICU) level care or mechanical ventilation), or Severe (inpatient requiring ICU level care and mechanical ventilation or ECMO) COVID-19. Intestinal fatty acid binding protein (iFABP), lipopolysaccharide binding protein (LBP), and soluble CD14 (sCD14) were measured by ELISA. Student's t-tests were used for between group comparisons, and paired t-tests were used for within group comparisons. Results: Participants with Moderate and Severe COVID-19 presentations were older compared to the Mild group (p<0.001) (Mild: 42.2 years (range: 20-63 years), Moderate: 64.2 years (range: 33-97 years);Severe: 61.9 years (range: 32-86 years)). The Severe group had a greater proportion of men (69% vs 36%) than women and a greater proportion of black/African Americans (27% vs 6%) than whites versus the Mild group. iFABP, LBP, and sCD14 levels were significantly higher in participants with Moderate or Severe disease compared to Mild disease (Table 1), with no significant differences between Moderate and Severe groups. Among the 65 participants with samples from two timepoints (mean separation of 24.3+/-22.4 days), sCD14, iFABP, and LBP did not change significantly. Conclusion: Levels of biomarkers of enterocyte turnover (iFABP), microbial translocation (LBP), and lipopolysaccharide-induced monocyte activation (sCD14) were increased in patients with Moderate and Severe COVID-19 compared to Mild COVID-19. Whether interventions that improve gut health will attenuate the cytokine storm that precipitates Severe COVID-19 needs further study.

Long-term sequela of SARS-CoV-2 infection in a retrospective New York City Cohort

Background: The long-term sequelae of coronavirus disease 2019 (COVID-19) have been increasingly recognized. Cardiac, pulmonary, and neuropsychiatric symptoms have been reported to persist up to two months after hospitalization. However, much remains to be learned about the durable long-term effects of COVID-19 for patients and the health care system. Here, we describe the persistence of COVID-19 sequelae up to six months after presentation. Methods: We examined the electronic medical records of the first 1190 patients diagnosed with SARS-CoV-2 infection by reverse transcriptase polymerase chain reaction assay and hospitalized at a quaternary-care center in New York City. All initial hospital presentations occurred between March 1 and April 8, 2020. We manually abstracted data for two follow-up periods representing three-and six-months post-hospitalization. Abstracted information included type and dates of encounters;use of tele-health;presence and persistence of symptoms;morbidity;and mortality. Descriptive statistics for categorical and continuous variables were tabulated and distributions were examined by visit;at presentation, three months and six months. Results: Patients had a median age of 60 and 61 years at three and six months, respectively. About 45% were female and 50% identified as Hispanic/Latinx. Of 1190 patients, 78% (N=928) survived their initial hospitalization. Among the 61% (n=570) of survivors who had follow-up encounters at three and six months, patients frequently reported cardiopulmonary symptoms (35.7% and 28%), dyspnea (22.1% and 15.9%), generalized symptoms (25.4 % and 26.4%) and neuropsychiatric symptoms (20.1% and 24.2%). Tele-health encounters represented 59% and 28.2% of encounters at three and six-months, respectively. Twenty-percent of patients had reduced mobility or reduced independence in the six months after hospitalization. Of survivors, 17% weredischarged to a nursing or rehabilitation facility and 10.3% remained there at three months post-hospitalization. Conclusion: The prevalence was high of at least one COVID-associated symptom six months after hospitalization. Cardiopulmonary symptoms were most common and persisted longer than previously reported. Providers, patients, and their families must be sensitized to and anticipate these potential sequelae. Further follow-up and studies of COVID-19 survivors are necessary to confirm these findings and investigate outcomes beyond six months. (Figure Presented).