Progress towards ending HIV transmission in England by 2030

Background: England is committed to ending HIV transmission by 2030. The HIV Action Plan (2021) set an interim ambition to reduce HIV transmission by 80% to 600 new diagnoses first made in England by 2025. Here we present the progress between 2019 (baseline) and 2021, interpreted in the context of the COVID-19 pandemic. Method(s): People newly diagnosed with HIV were reported to the HIV and AIDS Reporting Section (HARS). The annual number of people having an HIV test in all sexual health services (SHS) including online testing were reported using GUMCAD. HIV diagnoses among people previously diagnosed abroad were excluded (25%). Result(s): New HIV diagnoses first made in England fell by 32% from 2,986 in 2019 to 1,987 in 2020, but plateaued in 2021 (2,023). Among gay/bisexual men, HIV diagnoses plateaued in 2021 (721) after a fall of 45% between 2019 and 2020, from 1,262 to 699. After a fall in HIV testing in 2020 (from 156,631 in 2019 to 144,800 in 2020), the number of people tested in 2021 (178,466) exceeded pre-COVID-19 levels. This suggests a decline in HIV incidence supported by a CD4 back calculation model (80% probability of a decline for the period 2019-2021), but at a slowing rate. Among heterosexual adults, new HIV diagnoses first made in England in 2021 also plateaued (798) following a 31% decrease (from 1,109 in 2019 to 761 in 2020). However, HIV testing coverage has not recovered to pre- COVID-19 levels (628,607 in 2019, 441,017 in 2020 and 489,727 in 2021). This provides no evidence of a fall in incidence in this population. Conclusion(s): A reduction by 360 new diagnoses first made in England year on year from 2022 onwards is required to meet the HIV Action Plan ambition. Despite an estimated 4,500 people with undiagnosed HIV and extremely high levels of antiretroviral therapy and viral suppression, PrEP access remains unequal. HIV testing numbers, which were affected by COVID-19 pandemic, have recovered in gay/bisexual men, but not among heterosexual adults. While the interim ambition is within reach for gay/bisexual men, PrEP and testing levels must be scaled up in heterosexual adults.

A Thorn in his Side

History: A 20 year old D1 men's basketball player with a history of COVID the month prior presented with worsening low back pain. He denied any injury, but reported the pain started as low back discomfort after a basketball game the week prior. He noted a progression and radiation of pain down his right lower extremity to his toes. He had tried physical therapy and dry needling, as well as cyclobenzaprine and naproxen from team physicians with mild improvement. The pain worsened and he went to the ED for evaluation. He was afebrile and had a lumbar radiograph with no acute fracture, grade 1 anterolisthesis of L5 on S1. He was discharged home with norco. Over the next 2 days, he developed chills and in the context of his worsening back pain, his team physicians ordered an MRI. Physical Exam: BMI 26.9 Temp 97.9degree Heart rate: 73 Respiratory rate 14 BP: 124/64 MSK: Spine- Intact skin with generalized pain over lumbar area, worse over the right paraspinal musculature. 5/5 strength of bilateral lower extremity flexion and extension of his hips, knees, and plantar and dorsiflexion of ankles and toes. Bilateral intact sensibility in the sciatic, femoral, superficial, and deep peroneal, sural, and saphenous nerve distributions. Slightly diminished sensibility over the right deep peroneal nerve distribution compared to left. 2/4 patellar and achilles DTRs. No clonus, downgoing Babinski sign. Positive straight leg raise at 45 degrees with the right lower extremity. Differential Diagnosis: 141. Sciatica 142. Lumbar Muscle Strain 143. Disk Herniation 144. Spondylolisthesis 145. Vertebral Osteomyelitis Test Results: CBC:WBC10, HGB13.2, neutrophils 75.7% (red 45%-74%). Unremarkable CMP. CRP =7.31, ESR 23 Blood culture negative, throat culture negative. TB test negative. COVID test negative. Flu test negative. Urine culture and UDS negative. HIV test negative. Procalcitonin of 0.07. IR guided aspiration and bacterial Culture yielded MSSA. MRI w/contrast: showing L1-L4 facet edema concerning for infectious spondylitis, intramuscular, and epidural abscess. Final Diagnosis: Acute intramuscular abscess, vertebral osteomyelitis, with epidural abscess. Discussion(s): Vertebral osteomyelitis is a serious but quite rare disease in the immunocompetent, elite athlete population. Staphylococcus Aureus is the culprit a majority of the time, with only 50% of cases showing neurologic symptoms. This case was unique given the proximity to a dry needling treatment which is the only explainable vector of infection, normal blood cultures in this disease which hematogenously spreads, negativeHIV and other infectious disease testing, and otherwise benign history. Early recognition of this disease yields better outcomes and reduces incidence of severe debility. 5% to 10%of patients experience recurrence of back pain or osteomyelitis later on in life. Outcome(s): Patient was hospitalized and started on Cefepime and Vancomycin. Had an echocardiogram revealing changes consistent with athlete's heart without signs of vegetation on his cardiac valves. Neurosurgery declined to treat surgically. He continued to improve until he was ultimately discharged on hospital day 4 with a picc line and Nafcillin and was later changed to oral augmentin per ID. Follow-Up: By his 6 week follow-up visit with infectious disease and the team physicians, his back pain had completely resolved and was cleared to start a return to play protocol. There was no progression of disease since starting antibiotics, and no recurrence of back pain since treatment.

'Don't forget the children' - even in a pandemic

Background: BHIVA's 'Don't Forget the Children' and Standards of Care (SoC) documents highlight the importance of routine HIV testing for children of people living with HIV (PLWH). Our HIV service audited child testing in 2008, 2009 and 2010 with 46%, 78% and 82% respectively of children requiring testing having a documented result. Having evolved a child testing pathway and MDT, with dedicated Health Advisor and Paediatric nurse support, we wanted to re-evaluate our child testing performance during the COVID-19 pandemic. Method(s): Newly diagnosed PLWH, 01/08/2020 - 31/12/2021, were identified via our HARS dataset. All 32 identified individuals case notes were reviewed and the relevant auditable outcomes from BHIVA's SoC document used. Result(s): 32/32 (100%) had documented evidence that child testing had been considered within 4 weeks of diagnosis (BHIVA target 95%). 13/32 had a total of 35 children, 29 of whom did not require testing. 20/29 had documented evidence their mother was not living with HIV post childbirth, 9/29 were >18 years and all but 1, not living in the UK, had either tested in sexual health or antenatal settings. 6/35 (17%) children required testing. 6/6 (100%) had a documented test result within 6 months of their parent's diagnosis, 1 of whom tested negative prior to parental diagnosis (BHIVA target 90%). 5/6 tested aged >18 months. 1 child <18 months, whose parent was diagnosed antenatally, awaits final 4th generation testing at 18 months. Conclusion(s): Our service has a robust mechanism in place for asking all newly diagnosed individuals, and those new to our service, about children during their first consultation. Where children without documented evidence of HIV testing are identified our child testing pathway ensures timely investigation and documentation - all child testing was completed within one month of parental diagnosis in this audit sample. Our service surpassed the BHIVA standards for child testing for all new diagnoses during the COVID-19 pandemic. Future planned work includes a re-audit of child testing for those already known to our HIV service. As neither parental status nor child location is static regular enquiry in relation to children needs embedding into routine HIV care. (Table Presented).

Using implementation science to support the adoption of routine HIV testing in a suburban emergency department

Background: Implementation science (IS) involves using techniques to promote implementation of evidence-based guidance to improve healthcare quality and outcomes. Sutton has an HIV prevalence rate of 2.5/1000 and a high late diagnosis rate. Testing in emergency departments (ED) has been shown to be effective and has been adopted in many UK metropolitan centres. Routine testing in EDs of high prevalence areas is recommended by NICE. Method(s): Our project started in November 2019 and was designed to promote uptake of opt-out HIV testing into routine practice through education, training, and incentives. Strategies employed outlined in table 1. We assessed acceptability and adoption of the guidance. Result(s): HIV testing increased from average 7.5 tests/ month to 592 tests/month (17,165 tests in 28 months). Three previously undiagnosed people and 1 individual with a known diagnosis who had disengaged were identified. Testing numbers ranged from 191-1229/month. Numbers dropped during the following challenging periods: 1. Tendering of the sexual health service 2. IT and sample processing issues on implementation 3. Emergence of SARS CoV-2 4. Blood bottle shortage in 2021 Conclusion(s): This project demonstrated that while implementation of routine opt out HIV testing in ED is feasible and acceptable, it took a long time for the practice to be embedded and it was easily de-railed by external circumstances. Acknowledgements- This project was conducted with support from an Implementation Science grant by ViiV. (Table Presented).

BHIVA Spring Conference 2023

The proceedings contain 159 papers. The topics discussed include: microelimination of hepatitis C among people living with diagnosed HIV in England;laboratory implementation of emergency department blood-borne virus (EDBBV) opt-out screening in a London tertiary center;a review of sexual health and blood-borne virus care provided to inmates at admission into UK prisons and secure facilities;implementation of routine opt-out blood-borne virus (BBV) screening in 34 emergency departments (EDs) in areas of extremely high HIV prevalence in England;impact and experiences of offering HIV testing across the whole city population through primary care clusters and GP surgeries in the texting 4 Testing (T4T) project;'Not PrEPared': barriers to accessing PrEP in England;HIV care during the SARS-COV-2 pandemic for Black people with HIV in the UK;clinical presentation of mpox in people with and without HIV;and 'if you don't know, how can you know?': a qualitative investigation of HIV pre-exposure prophylaxis knowledge and perceptions among women in England.

Features of the diagnosis and course of COVID-19 in HIV-infected patients hospitalized in a hospital

The global pandemic of coronavirus infection (COVID-19) has set complex diagnostic tasks for doctors of polyclinics and hospitals. Considering the simultaneous pandemic spread of two infectious diseases - COVID-19 and HIV infection, the problem of studying the clinical features of combined COVID-19/HIV infection becomes urgent. The aim of the study was to determine the features of the diagnosis and course of COVID-19 against the background of HIV infection in patients undergoing inpatient treatment. Material and methods. The study was conducted on the basis of the temporary Clinical Medical Center COVID-19 of the A.I. Yevdokimov Moscow State University of Medicine and Dentistry of the Ministry of Healthcare of the Russian Federation in Moscow from October 2020 to January 2022. The study included 31 233 patients with COVID-19 complicated by pneumonia. To analyze the features of the course of combined COVID-19/HIV infection, a group of 51 HIV-infected patients was identified. The diagnosis of COVID-19 was determined based on the detection of SARS-CoV-2 RNA by PCR in nasal/oropharyngeal smears and/or according to computed tomography of the lungs (CT). During the study, age, gender, anamnesis, objective examination data were analyzed, taking into account the results of CT scans of the chest organs, data from routine laboratory blood tests, oxygen support regimens, treatment outcomes and duration of detection of SARS-CoV-2 RNA. All patients were treated according to the Temporary Clinical Guidelines for the Diagnosis and Treatment of COVID-19, 14 version dated 12/27/2021. Results. The number of patients with combined HIV infection and SARS-CoV-2 out of the total number of hospitalized COVID-19 patients (n=31 233) was 0.16%. Upon admission, 30 (59%) patients reported having HIV infection and receiving antiretroviral therapy (ART). HIV infection was first diagnosed in 21 patients at 2-3 weeks of inpatient treatment. The average age of patients with SARS-Cov-2/HIV co-infection was 1.5 times less than in patients without HIV (41.1+/-5.3 and 64.4+/-10.1, respectively) (p<=0.05). Concomitant pathology (hypertension, type 2 diabetes mellitus, chronic kidney disease and chronic lung diseases) was less common (51%) in the group of combined infection than in the group without HIV (83%). However, in 41% of patients with coinfection, chronic viral hepatitis B, C was detected, in contrast to 0.3% of cases of COVID-19 patients without HIV. 26 (51%) patients were discharged with improvement, while the average bed-day did not differ from patients without HIV infection (13.4+/-4.5 days and 11.7+/-5.2, respectively) (p>=0.05). 7 (24%) patients at the time of discharge (16.8+/-4.2 days) with clinical and laboratory improvement maintained a positive result of PCR RNA on SARS-Cov-2. In 22 (43%) patients with coinfection, hospitalization was fatal for 3 to 21 days of treatment, with ARDS with respiratory and multiple organ failure, which is 3.6 times higher than in patients without HIV infection. The analysis showed that, regardless of the result of PCR on SARS-CoV-2 RNA, in non-specialized hospitals, HIV testing is indicated for young patients with fever for more than 14 days, with lung damage in the form of bilateral interstitial changes according to CT, a history of chronic hepatitis C, B, with progressive severity of the condition on against the background of COVID-19 therapy. Early consultation of an infectious disease specialist, examination of sputum/lavage by PCR for pathogens of opportunistic infections and the appointment of ART and drugs for the treatment of opportunistic diseases will improve the quality of medical care for patients in a non-core HIV hospital will improve the prognosis of COVID-19.Copyright © Eco-Vector, 2022.

Fanmi: A Randomized Trial of Community Cohort Hiv Care for Adolescent Girls, Haiti

Background: Adolescent girls and young women are the epicenter of the global HIV epidemic and in need of multilevel interventions to improve their health outcomes. Method(s): FANMI, a randomized-controlled trial, evaluated the effectiveness of community-based cohort HIV care versus standard of care (SOC) among adolescent and young adults living with HIV (AYALH) in Haiti. Females, 16-24 years who were newly diagnosed with HIV at clinic or community HIV testing sites, or defaulted >6 months from care, were randomized 1:1 to FANMI vs SOC. FANMI was designed to improve convenience, social support and stigma by grouping AYALH in cohorts of 6-10 peers to attend monthly HIV care sessions in a community center with integrated clinical care, group counseling, and social activities led by the same provider. National guideline changes during the study included switching participants to dolutegravir regimens and expanding SOC visits to 6 months. The primary outcome was 12-month retention defined as any visit 9-15 months from enrollment. Secondary outcomes included viral suppression (< 1000 copies/ml), risk behaviors, and acceptability using interviews. Result(s): 120 AYALH enrolled (60 per arm) between May 2018-January 2021. Median age was 21, 91% were newly diagnosed, and median CD4 count was 591 cells/mm3 (IQR 399-788). A total of 78.3% (47/60) FANMI participants vs 85.0% (51/60) in SOC achieved the primary outcome (unadjusted RR=0.92 95%CI 0.78-1.09, p=0.35). Excluding 9 participants who never attended a FANMI/SOC visit after enrollment, 12-month retention was 88.7% (47/53) in FANMI vs 87.9% (51/58) in SOC (RR =1.01 95%CI 0.88-1.15, p=0.90). Participants who presented for HIV testing vs community testing and achieved the primary outcome: 95% vs 70% (FANMI) and 83% vs 88% (SOC). Viral suppression among those retained at 12 months: 44.6% (21/47) in FANMI and 37.3% (19/51) in SOC (RR 1.20 95% CI 0.74-1.9, p=0.45). There were no differences in pregnancy and risk behaviors. Providers preferred FANMI reporting increased time for counseling and peer support. FANMI participants reported high acceptability, decreased stigma, and increased social support with no confidentiality breaches. Limitations included interrupted study operations during the COVID-19 pandemic. Conclusion(s): FANMI was not more effective for AYALH in Haiti but was preferred by providers and highly acceptable to participants. It offers promise as a complementary program for high-risk AYALH in low-income settings facing barriers to clinic-based care.

Changes in Service Access among People Who Inject Drugs in Philadelphia, 2018-2022

Background: The COVID-19 pandemic disrupted HIV prevention and treatment services, especially for structurally vulnerable individuals like many people who inject drugs (PWID). We sought to compare present levels of access to these services to their levels before the pandemic. Method(s): We used data from 2018 and 2022 collected through the National HIV Behavioral Surveillance (NHBS) survey among PWID in Philadelphia. Using generalized linear regression models, we estimated the associations between our exposure (year) and self-reported HIV testing, medical care, SSP access, PrEP use, and drug treatment in the year prior to interview. We calculated adjusted prevalence ratios (aPR) using multivariable models adjusted for age, race/ ethnicity, housing stability, and primary injecting drug. Result(s): There were 620 participants in 2018 and 604 in 2022 included in analyses. Compared to the 2018 sample, the 2022 sample was significantly older, non-Hispanic Black, and primarily injected drugs other than heroin. A significantly smaller proportion of participants in 2022 had a recent HIV test (57% vs. 71%), visited a health care provider (77% vs 82%), received sterile needles from an SSP (69% vs 75%), or participated in a drug treatment program (47% vs 54%). Between 2018 and 2022, PrEP awareness increased significantly (39% vs 54%) but PrEP use did not (3% vs 3%). In adjusted models, an 18% decrease in recent HIV testing was observed between 2018 and 2022 (aPR: 0.82;95% CI: 0.70-0.96). Among those who reported a recent HIV test, there was an 18% increase in testing in clinical settings observed between 2018 and 2022 (aPR: 1.18;95% CI: 1.10-1.26). Recent medical care, SSP access, PrEP use, and drug treatment were not associated with year in adjusted models. Conclusion(s): Access to a full range of social services is necessary for Ending the HIV Epidemic. These findings indicate that HIV prevention services, particularly HIV testing, among PWID have not rebound fully from the pandemic. Considering this and ongoing outbreaks of HIV among PWID, public health practitioners should closely monitor HIV testing frequency among PWID and prioritize expanding access to low-barrier HIV prevention and care services, especially in non-clinical settings.

SARS-CoV-2 SEROPREVALENCE TREND AMONG PREGNANT WOMEN IN ZAMBIA, 2021-2022

Background: Confirmed COVID-19 case counts underestimate SARS-CoV-2 infections, particularly in countries with limited testing capacity. Pregnant women attending antenatal care (ANC) clinics have served as healthy population surrogates to monitor diseases like HIV and malaria. We measured SARS-CoV-2 seroprevalence among women attending ANC clinics to assess infection trends over time in Zambia. Method(s): We conducted repeated cross-sectional surveys among pregnant women aged 15-49 years attending their first ANC visits in 3 districts of Zambia during September 2021-September 2022. Up to 200 women per district were enrolled each month, completing a standardized questionnaire. Dried blood spot samples were collected for serologic testing for prior infection using the Tetracore FlexImmArrayTM SARS-CoV-2 Human IgG Antibody Test and HIV testing according to national guidelines. We calculated odds ratios (ORs) for SARS-CoV-2 seroprevalence by demographic characteristics, adjusting for the district. Result(s): A total of 5,351 women were enrolled at 29 study sites between September 2021 and September 2022. Participants' median age was 25 years (interquartile range: 21-30), 530 (9.9%) tested positive for HIV, and 101 (1.9%) reported a prior positive COVID-19 test. Overall, SARS-CoV-2 seroprevalence was 67%, and rose from 49% in September 2021 to 85% in September 2022 (Figure 1). The greatest increase in seroprevalence occurred during the 4th wave caused by the Omicron variant (48% in December 2021 to 63% in January 2022). Seroprevalence was significantly higher among women living in urban districts (Chipata and Lusaka) compared to rural Chongwe District (Chipata OR: 1.2, 95% confidence interval [CI]: 1.1-1.4;Lusaka OR: 1.7, 95% CI: 1.5-2.0). The age group was not significantly associated with seroprevalence after adjusting for the district (aOR: 1.1, 95% CI: 1.0-1.2). Seroprevalence was significantly lower among women living with HIV than women living without HIV (aOR: 0.8, 95% CI: 0.6-0.9). Conclusion(s): Overall, two-thirds of women in the three surveyed districts in Zambia had evidence of SARS-CoV-2 exposure, rising to 85% after the Omicron variant spread throughout the country. ANC clinics have a potential role in ongoing SARS-CoV-2 serosurveillance and can continue to provide insights into SARS-CoV-2 infection dynamics. Furthermore, they provide a platform for focused SARS-CoV-2 prevention messaging and COVID-19 management in pregnant women at higher risk of severe disease. (Figure Presented).

Acquired Hemophilia a Post-Covid-19 Vaccination Successfully Treated with Low Dose of Rituximab

Introduction: Acquired hemophilia A (AHA) is a rare autoimmune disease due to anti-factor VIII antibodies. It may be associated with infections and malignancies. The association with Covid vaccine is extremely rare. Immunosuppressive therapy with steroids, cytotoxic agents, is the traditionalmainstay for antibodies eradication. Rituximab standard doses have been used with success. There are few reports on low-dose Rituximab for AHA.We present a case of AHA post Covid-19 vaccination successfully treated with low dose of Rituximab. Method(s): case report Results: A non hemophilic 69-year-old male with no medical history consulted for multiple ecchymosis that spontaneously occurred with no context of trauma. Two months previously he received a second dose of CoronaVac-Sinovac vaccine. Coagulation tests revealed an isolated and prolonged aPTT (100 sec/30s;ratio=3.33) not corrected with normal plasma. The coagulation factors assay revealed an isolated decrease of factor VIII to 1% with a titer of 121 Bethesda units/ml confirming the diagnosis of AHA. Hepatitis B and C and HIV tests were negative. A full body-computed tomography scan was normal. Treatment with Prednisolone 1 mg/kg/d was started with tranexamic acid. Bypassing therapy was not considered because of the absence of life-threatening bleeding. Seventeen days after corticosteroid initiation, a worsening of the ecchymosis was noted with the non-improvement of the aPTT. A low-dose rituximab (100 mg/week) was added for 4 weeks. After 3 doses of Rituximab a complete clinical response was achieved. Factor VIII inhibitor was completely eradicated. Corticosteroid was discontinued. At 3-month follow-up the patient remains in remission without further treatment Discussion/Conclusion:More than 50 cases of AHA following COVID-19 vaccine have been reported. To our knowledge only 2 cases of AHA were successfully treated with low dose of rituximab. Low-dose Rituximab appears to be effective for Factor VIII inhibitor eradication in AHA with a lower cost.

Patient Satisfaction in HIV Counseling and Testing Services with the Importance-Performance Analysis (IPA) and Customer Satisfaction Index (CSI) Method

Provider Initiated HIV Testing and Counseling (PITC) is an HIV test offered by health professionals to patients as an initial diagnosis of HIV and a facility for obtaining HIV medication. Patient satisfaction helps assess the communication pattern between the client, the healthcare provider, and the healthcare manager. This study was conducted at 30 public health centres with 120 patients to determine patient Satisfaction concerning PITC, assessed through Customer Satisfaction Index (CSI) analysis. Then, the public health centre prioritized the importance-performance analysis (IPA) method in a Cartesian chart. The result obtained a 66,73% CSI value, meaning the PITC offered was relatively not good. The education level of patients and HIV test results correlate with patient Satisfaction with PITC services. Health professionals could optimize PITC service by improving the service quality by explaining that the HIV test was confidential, asking for the patient's consent before taking any action, and defining the phase of HIV growth thoroughly until it converted into AIDS.

Joint Australasian Sexual Health and HIV and AIDS Conferences

The proceedings contain 22 papers. The topics discussed include: heard but not seen: experiences of telehealth by people living with HIV (PLHIV) in COVID times;clinical guidelines: their influence on HIV-related legal proceedings;examining HIV anxiety in gay men as an embodied response to the AIDS crisis;weight and lipid changes in phase 3 cabotegravir and rilpivirine long-acting trials;comparison of viral replication for the 2-drug regimen (2DR) of dolutegravir/lamivudine;lifetime cost of HIV management in Australia: a modelling study;Intentions for future use of PrEP following COVID-19 restrictions: results from the Flux Study of gay and bisexual men in Australia;associations between social capital and HIV risk-taking behaviors among men who have sex with men in Japan;HIV testing, treatment and viral suppression among men who have sex with men (MSM) in five countries: results of the Asia Pacific MSM Internet Survey;sustained higher levels of intracellular HIV-1 RNA transcript activity in viral blip patients;and lost in translation: preventing the meanings of sexual and reproductive health from being lost during the translation of national surveys.

HIV Testing Rates in NC Emergency Departments Before and During Covid Mitigation

Background. During the early stages of the COVID-19 pandemic, non-emergent services were limited or suspended in multiple ways. Restrictions in primary care may have limited STI testing, such as HIV, where timely access to testing and care is critical to mitigation efforts. Conversely, Emergency Departments (ED) operated with fewer restrictions and more in-person options. Even though patient census numbers decreased in some areas from those seen pre-covid lockdown, EDs and hospitals often became overwhelmed with patients seeking care for both severe acute illness but just importantly services that might normally have been received in outpatient settings. Methods. Observational study of HIV screening year-over-year in four EDs that are part of a large healthcare system located in the Southeast. Screenings of individuals 18 and over seen in the EDs were normalized per 1000 patients. Rates were also compared to two primary care clinics, located in the same metropolitan area, serving mainly Medicaid and uninsured patients. Results. From March 2019 through February 2020 there were 33.47 tests per 1000 patients at two community clinics and 7.79 tests per 1000 patient at four EDs located in the same region during that span. From March 2020 to February 2021, screening numbers in the primary care clinics dropped to an average of 22.7/1000;however, screenings in the ED remained stable and slightly increased to 10.7/1000. From March 2021 to February 2022, screenings in the primary care clinics returned to an average 36.9/1000 with screenings in the ED still above pre-covid levels at 9.48/1000. These trends in the ED screening remained consistent across gender, race, and ethnicity. Patient census at four ED sites located in the southwestern region of North Carolina dropped significantly during the first year of physical distancing covid-19 mitigation measures when compared to the two years prior. These census numbers increased during the second year of covid-19 but failed to return to previous levels. During the first year of physical distancing covid-19 mitigation measures HIV testing rates in the emergency department remained constant, and even increased in more urban areas, despite the significant decrease in overall patient census. Conclusion. With the observation that HIV screening decreased in primary care settings during the beginning of the covid-19 pandemic, there exists the possibility that new HIV infections may yet remain undiagnosed. That HIV testing remained constant in the ED, however, reinforces the importance of having embedded procedures in place for screening and linking both newly positive and at-risk patients into care to help mitigate the HIV epidemic. (Figure Presented).

Failing to PrEPare is PrEParing to Fail: Advocating for PWID PrEP Inclusion

Background. The CDC recommends that PrEP be offered to anyone with a history of injection drug use, with a particular focus on those that have injected in the past 6 months, shared injection equipment, or have sexual risk factors. Yet, PrEP remains underutilized. The SARS-CoV2 pandemic introduced additional barriers to HIV testing and substance use treatment. We sought to develop a specialty pharmacydriven program to minimize barriers and increase education surrounding PrEP in PWID in patients admitted to the hospital with IV drug use related complications. Patients identified by the ID consultant or stewardship team were offered enrollment in the program as part of a comprehensive harm reduction strategy. Upon referral, specialty pharmacists provided phone counseling, prescribed TDF/FTC, and conducted laboratory monitoring. Methods. From November 2020 through March 2022, we collected data on our accepted referrals including number of refills, laboratory appointments, reason for discharge, duration of retention in the program, and injection-related emergency department visits and hospital admissions for 90 days after program discharge. Results. During the eighteen month period, 23 patients accepted referral into the program. The median age was 42 years and 47.8% were male. Despite accepting the initial referral while inpatient, 87% (n=20) of patients did not remain in the program to receive the first month's supply of TDF/FTC once discharged. Sixteen (69.6%) were not able to be contacted on the phone number provided despite multiple attempts. Four (17.4%) declined ongoing IV drug use. Eight patients (35%) had an injection related ED visit or hospitalization within 90 days of program discharge. Conclusion. In conclusion, high risk PWID admitted to the hospital who agreed to PrEP with daily TDF/FTC had a low retention rate after discharge. PWID need to be included in future research studies, especially studies involving novel PrEP treatments.

Risk Factors for COVID-19 Infection and Outcomes in People Living with HIV

Background. As the risk for concomitant COVID-19 infection in people living with HIV (PLHIV) remains largely unknown, we explored a large national database to identify risk factors for COVID-19 infection among PLHIV. Methods. Using the COVID-19 OPTUM de-identified national multicenter database, we identified 29,393 PLHIV with either a positive HIV test or documented HIV ICD9/10 codes. Using a multiple logistic regression model, we compared risk factors among PLHIV, who tested positive for COVID-19 (5,134) and those who tested negative (24,259) from January 20, 2020, to January 20, 2022. We then compared secondary outcomes including hospitalization, Intensive Care Unit (ICU) stay, and death within 30 days of test among the 2 cohorts, adjusting for COVID-19 positivity and covariates. We adjusted all models for the following covariates: age, gender, race, ethnicity, U.S. region, insurance type, adjusted Charlson Comorbidity Index (CCI), Body Mass Index (BMI), and smoking status. Results. Among PLHIV, factors associated with higher odds for acquiring COVID-19 (Figure 1) included lower age (compared to age group 18-49, age groups 50-64 and >65 were associated with odds ratios (OR) of 0.8 and 0.75, P= 0.001), female gender (compared to males, OR 1.06, P= 0.07), Hispanic White ethnicity/race (OR 2.75, P=0.001),Asian (OR 1.35, P=0.04), and AfricanAmerican (OR1.23, P=0.001) [compared to non-Hispanic White], living in the U.S. South (compared to the Northeast, OR 2.18, P= 0.001), being uninsured (compared to commercial insurance, OR 1.46, P= 0.001), higher CCI (OR 1.025, P= 0.001), higher BMI category (compared to having BMI< 30, Obesity category 1 or 2,OR 1.2 and obesity category 3,OR1.34, P=0.001), and noncurrent smoking status (compared to current smoker, OR 1.46, P= 0.001). Compared to PLHIV who tested negative for COVID-19, PLHIV who tested positive, had an OR 1.01 for hospitalization (P = 0.79), 1.03 for ICU stay (P=0.73), and 1.47 for death (P=0.001). Conclusion. Our study found that among PLHIV, being Hispanic, living in the South, lacking insurance, having higher BMI, and higher CCI scores were associated with increased odds of testing positive for COVID-19. PLHIV who tested positive for COVID-19 had higher odds of death. (Figure Presented).

Brief Educational and Process Change Quality Improvement Intervention Increases HIV, Hepatitis C, and Syphilis Screening in Psychiatric Inpatients Admitted from a Psychiatric Emergency Service

Background: Psychiatric disorders increase risk for infection with human immunodeficiency virus (HIV), hepatitis C virus (HCV), and syphilis, and these infections carry implications for psychiatric symptoms and treatment (Campos, 2008). At the University of New Mexico Psychiatric Center (UNMPC), no standardized protocol existed for HIV, HCV, and syphilis screening among patients admitted for psychiatric hospitalization. Method(s): In January 2020, residents and faculty at UNMPC began a quality improvement intervention aimed at increasing screening rates of HIV, HCV, and syphilis among patients admitted for hospitalization from the psychiatric emergency service. The intervention consisted of four components: Safe Zone training for residents;addition of HIV, HCV, and syphilis testing prompts to the admission orders in the electronic health record (EHR);resident education about screening and consent;and posted reminders at resident workstations. Retrospective evaluation of de-identified EHR admissions data compared screening rates over the nine months post-intervention versus the nine months pre-intervention. Secondary evaluations investigated whether onset of the COVID-19 in New Mexico in March 2020, or the start of the new resident class in July 2020, affected screening rates post-intervention. Pearson chi-square analyses tested for screening rate differences. This study was approved by the UNM Human Research Protections Office. Result(s): Screening rates for all conditions increased post-intervention. HIV screening increased from 7.7 to 14.4%, X2 (1, 1838) = 20.89, p <.001, HCV from 4.9 to 15.3% X2 (1, 1838) = 54.66, p <.001, and syphilis from 15.6 to 21.5%, X2 (1, 1838) = 10.60, p =.001. Neither COVID-19, X2 (1, 488) = 0.31, p =.579, nor start of the new resident class, X2 (1, 679) = 0.03 p =.863, impacted screening rates post-intervention. Discussion(s): This brief quality improvement intervention significantly increased screening rates for HIV, HCV, and syphilis in psychiatric inpatients admitted from the psychiatric emergency service. However, even post-intervention, screening rates remained low. These findings mirror previously published data on the impact of a low-intensity administrative advocacy and in-service training intervention on HIV screening rates in psychiatric inpatients (Shumway, 2018). Conclusion/Implications: In light of the bidirectional risks of psychiatric disorders and infection with HIV, HCV, and/or syphilis, and in keeping with United States Preventive Service Task Force guidelines pertaining to screening for these infectious diseases, further quality improvement initiatives remain necessary for increasing screening amongst persons admitted for psychiatric hospitalization (USPSTF, 2022). References: Campos LN, Guimaraes MD, Carmo RA, et al. HIV, syphilis, and hepatitis B and C prevalence among patients with mental illness: a review of the literature. Cad Saude Publica. 2008 24(Suppl 4):s607-20 Shumway M, Mangurian C, Carraher N, et al. Increasing HIV testing in inpatient psychiatry. Psychosomatics 2018 59(2):186-192 United States Preventive Services Taskforce. (n.d.). Retrieved April 3, 2022, from Copyright © 2022

A LESSON ON ANCHORING BIAS DURING A PANDEMIC: A CASE PRESENTATION

SESSION TITLE: Cases of Overdose, OTC, and Illegal Drug Critical Cases Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Anchoring bias is a cognitive bias where one relies too heavily on initial information early on in the decision making process, affecting subsequent decisions due to future arguments being discussed in relation to the "anchor. Overemphasis on COVID-19 due to the pandemic has impacted the timely diagnosis and treatment of other diseases. CASE PRESENTATION: A 39-year-old man with a past medical history of COVID 19 in 12/2020 presents to the ED with increasing weakness, chest pain, recurrent fevers, diarrhea, and cough. CXR revealed bilateral infiltrates suggestive of pneumonia/pulmonary edema. Patient was empirically started on ceftriaxone. CT chest was suspicious of COVID-19;however repeat testing was negative. Diarrhea did not improve. Patient later admitted to recent travel to Jamaica. Ova and parasite, C-difficile, and stool culture were negative. On hospital day 8, the patient was intubated and placed on mechanical ventilation for worsening hypoxic respiratory failure Infectious disease was consulted for recurrent fevers of unknown origin and diarrhea with recent travel. Testing for typhoid fever, hantavirus, malaria, HIV, zika virus, chikungunya, dengue, and yellow fever were performed. Consent was obtained for HIV testing. HIV antibody tests were positive, CD4 count of 7, and viral load greater than 900k. Since a new diagnosis of AIDS with a CD4 count of 7 was obtained, the patient was subsequently tested for opportunistic infections such as TB. TB sputum PCR testing was positive but AFB smear was negative for TB. Antiretroviral and tuberculosis treatments were initiated. DISCUSSION: Anchoring bias can delay critical diagnoses and impede patient care if it is not recognized. According to Watson et. al, one way physicians circumvent the thought of pretest probability when ordering tests based on patient history and the subsequent list of differential diagnoses is anchoring bias. Bypassing the pretest probability also alters the sensitivity and specificity of testing because results that do not confirm or rule out a top differential diagnosis are thought to be inaccurate and are then repeated attributing the initial result to a bad specimen or an improper collection of the specimen. CONCLUSIONS: The case presented exemplifies clearly the concept of anchoring bias. Upon initial presentation, the patient had nonspecific symptoms such as weakness, chest pain, recurrent fevers, diarrhea, and cough, all of which can be symptoms of COVID 19 in the setting of a global pandemic. It is clear that the initial diagnosis based on these symptoms was COVID 19. When initial testing was negative, anchoring bias still played a role in the decision to test the patient once again, despite the first negative test. Repeat testing still did not support the diagnosis of COVID 19, which expanded the differential diagnosis and ultimately led to the correct diagnosis of AIDS with concomitant TB infection. Reference #1: Saposnik, et. Al. Cognitive Biases Associated with Medical Decisions: A Systematic Review. BMC Med Inform Decis Mak. 2016 Nov. 3. PMID: 27809908 Reference #2: Harada, et. al. COVID Blindness: Delayed Diagnosis of Aseptic Meningitis in the COVID-19 Era. Eur J Case Rep Intern Med. 2020 Oct 23. PMID: 33194872. Reference #3: Singh, et. al. The Global Burden of Diagnostic Errors in Primary Care. BMJ Qual Saf. 2016 Aug 16. PMID: 27530239. DISCLOSURES: No relevant relationships by Sagar Bhula

SIMILAR, YET SO DIFFERENT: A TALE OF TWO DISEASES

SESSION TITLE: COVID-19 Case Report Posters 3 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumocystis Pneumonia (PCP) is an opportunistic infection caused by a yeast-like fungus pneumocystis jirovecii. It is characterized by hypoxemia and increased inflammatory markers with elevated lactate dehydrogenase (LDH) often used as a clinical indicator of possible infection. COVID-19 is a viral infection caused by severe acute respiratory syndrome coronavirus and presents with a variety of symptoms, pneumonia being the most frequent and serious manifestation. Common laboratory markers include lymphopenia, elevated LDH and inflammatory markers. CASE PRESENTATION: Our patient is a 54 yo African American male with an unremarkable history who presented to our facility from an outside hospital (OH) for worsening respiratory failure in the setting of a large left pulmonary artery thrombosis. He was infected with COVID-19, four months prior and had experienced worsening weakness, SOB and anorexia two months before admission. Work up at OH revealed the large pulmonary emboli as well as extensive multifocal opacities consistent with prior COVID infection and described as post- COVID fibrosis. His sputum also tested positive for pseudomonas aeruginosa and mycoplasma pneumoniae for which he was treated. Unfortunately his hypoxemia worsened and he required intubation;prompting transfer to our facility for hopes of thrombectomy. He continued with hypoxemic, hypercarbic respiratory failure and underwent a bronchoscopy which was grossly normal. As serology indicated lymphopenia and paraprotein gap > 4, we decided to order HIV RNA PCR, which came back positive (CD4 count 11cells/ mm3). One week later, pneumocystis jirovecii was identified from an immunohistochemical stain from bronchial alveolar lavage (BAL). DISCUSSION: PCP is a common opportunistic infection in patients with human immunodeficiency virus, generally presenting when CD4 counts decrease below 200 cells/ mm3. Along with similar symptoms and elevated inflammatory markers, COVID-19 and PCP share common radiographic findings of ground glass opacities. In addition to his compromised lung (from COVID-19) and prolonged hospitalization, the positive cultures of m. pneumoniae and p.aeruginosa were originally misleading. Although cases of co-infection of PJP and COVID-19 exist, our case demonstrates that having a broad differential after recovery from COVID-19 continues to be necessary. CONCLUSIONS: PCP and COVID-19 pneumonia share similarities in radiographic and laboratory findings proving difficult to differentiate from each other. This case highlights the importance of assessing the immunological status of patients with unknown HIV history especially in a time where considering different etiologies of pneumonia have taken the backseat in the height of the COVID-19 pandemic Reference #1: Anggraeni AT, Soedarsono S, Soeprijanto B. Concurrent COVID-19 and Pneumocystis jirovecii pneumonia: The importance of radiological diagnostic and HIV testing. Radiol Case Rep. 2021;16(12):3685-3689. Published 2021 Oct 2. doi:10.1016/j.radcr.2021.09.002 Reference #2: Analysis of underlying diseases and prognosis factors associated with Pneumocystis carinii pneumonia in immunocompromised HIV-negative patients. Roblot F, Godet C, Le Moal G, Garo B, Faouzi Souala M, Dary M, De Gentile L, Gandji JA, Guimard Y, Lacroix C, Roblot P, Becq-Giraudon B. Eur J Clin Microbiol Infect Dis. 2002;21(7):523. DISCLOSURES: No relevant relationships by Cynthia Espinosa No relevant relationships by Jason Kovacevic No relevant relationships by Laura Mendez Morente No relevant relationships by Zuleikha Muzaffarr

CRYPTIC CRYPTO: PULMONARY CRYPTOCOCCOSIS IN AN IMMUNOCOMPETENT HOST

SESSION TITLE: Uncommon Presentations and Complications of Chest Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Cryptococcus is a ubiquitous fungus in the environment. Infections can occur in humans when Cryptococcus is aerosolized and inhaled. Severity of clinical presentation varies from asymptomatic pulmonary colonization to disseminated life-threatening infection such as meningitis. These infections usually occur with deficiencies in T-cell-mediated immunity, including those with HIV/AIDS and immunosuppression due to transplantation. Herein we present a case of isolated pulmonary cryptococcosis in an immunocompetent host. CASE PRESENTATION: The patient is a 36-year-old never-smoker male with history of recurrent left spontaneous pneumothorax status post VATS blebectomy, negative for alpha-1 antitrypsin deficiency and cystic fibrosis. A year later, he presented with fatigue, shortness of breath, and dry cough after a recent trip to Ohio. Viral panel including COVID-19 was negative. A chest x-ray showed a new 4 cm rounded opacity in the right middle lobe (RML). A CT scan of the chest showed 2 mass-like and nodular areas of consolidation with surrounding GGOs within the RML (Figure 1). He underwent navigational bronchoscopy with transbronchial biopsy (TBBx) of RML, BAL, and EBUS with transbronchial needle aspiration (TBNA). Cytology was negative for malignant cells. BAL showed rare yeast. Pathology of the TBBx showed the airway wall with chronic inflammation including granulomatous inflammation, positive for yeast, most consistent with Cryptococcus with positive Grocott methenamine silver (GMS) stain (Figure 2). Culture of the TBNA grew C. neoformans var. grubii. Other cultures were negative. Serum Cryptococcal antigen was positive. HIV test was negative. He started treatment with oral fluconazole with improvement of symptoms. DISCUSSION: Clinical presentation of pulmonary cryptococcosis can include a variety of symptoms in which immune status is critical for determining the course of infection. Infection can vary from asymptomatic infection to severe pneumonia and respiratory failure, and meningitis. Similarly, imaging findings can also vary and be characterized as pulmonary nodules, consolidations, cavitary lesions, and/or a diffuse interstitial pattern. The diagnosis of Cryptococcus is made using histology, fungal cultures, serum cryptococcal antigen, and radiography in the appropriate clinical and radiological context. Treatment recommendations are determinant on immune status of the patient as well as symptoms. Asymptomatic and localized disease in immunocompetent patients can be monitored and mild/moderate disease can be treated with fluconazole. Those with severe or disseminated infection warrant induction therapy with an amphotericin B and flucytosine CONCLUSIONS: Clinical and radiological presentation of cyptococcosis varies depending on immune status. Disease can occur in both immunocompromised and competent hosts. Immune status determines disease course and treatment. Reference #1: Huffnagle GB, Traynor TR, McDonald RA, Olszewski MA, Lindell DM, Herring AC, et al. Leukocyte recruitment during pulmonary Cryptococcus neoformans infection. Immunopharmacology. 2000 Jul 25;48(3):231–6. Reference #2: Kd B, Jw B, Pg P. Pulmonary cryptococcosis. Semin Respir Crit Care Med [Internet]. 2011 Dec [cited 2022 Apr 2];32(6). Available from: https://pubmed.ncbi.nlm.nih.gov/22167400/ Reference #3: Ms S, Rj G, Ra L, Pg P, Jr P, Wg P, et al. Practice guidelines for the management of cryptococcal disease. Infectious Diseases Society of America. Clin Infect Dis Off Publ Infect Dis Soc Am [Internet]. 2000 Apr [cited 2022 Apr 1];30(4). Available from: https://pubmed.ncbi.nlm.nih.gov/10770733/ DISCLOSURES: No relevant relationships by Mina Elmiry No relevant relationships by Brenda Garcia No relevant relationships by Zein Kattih no disclosure on file for Priyanka Makkar;No relevant relationships by Jonathan Moore

SERRATIA MARCESCENS CAVITARY PNEUMONIA FOLLOWING COVID-19 INFECTION IN A YOUNG IMMUNOCOMPETENT HOST

SESSION TITLE: Complications of Thoracic Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Serratia marcescens is a gram negative bacteria known to colonize the human GI tract. While infections of urinary tract, respiratory tract, and CNS can occur, it is usually associated with immunocompromised hosts or patients who undergo invasive procedures or surgeries. Here, we present a 21-year-old immunocompetent male with Serratia marcescens cavitary pneumonia following COVID-19 infection. CASE PRESENTATION: A 21-year-old obese male with no past medical history presented with shortness of breath, cough and fevers for one week. In the emergency department (ED), he was febrile to 38.8°C, tachycardic, saturating 90% on room air. He was recently admitted to an outside hospital two weeks prior with COVID-19 pneumonia. He was treated with Remdesivir and decadron and discharged after five days. No invasive procedures were performed during his hospital stay and he never required advanced oxygen support other than simple nasal cannula. CTA of his chest in the ED showed thick walled bilateral lower lobe cavitary lesions and multifocal ground glass alveolar opacities. No pulmonary embolism was seen. Sputum cultures were collected but inadequate. Bronchoscopy with bronchoalveolar lavage (BAL) was performed and fluid studies showed white blood cell count of 70,029 cell/uL, with 94% neutrophils. BAL fluid cultures grew Serratia marcescens. He was originally placed on vancomycin and cefepime and discharged on oral Levaquin for four weeks based on sensitivities. HIV testing was negative. DISCUSSION: Serratia is a rod shaped gram negative bacteria found in soil, water, and human gut flora. It is known to be an opportunistic pathogen that can cause urinary, respiratory, CNS and blood stream infections in immunocompromised patients. Infections in immunocompetent are usually associated with invasive devices such as mechanical ventilation or central venous catheters. While superimposed bacterial infections in COVID-19 illness are well known, they are usually seen in patients with severe disease requiring mechanical ventilation and prolonged hospitalization. Those with underlying systemic illness, advanced age and impaired immune systems are particularly susceptible. Our patient was young, immunocompetent and only required minimal oxygen support while hospitalized for COVID-19. CONCLUSIONS: Serratia marcescens pneumonia is rarely seen in immunocompetent hosts, but should remain on the differential in patients with recent hospitalization and COVID-19 infection, regardless of severity of disease. Reference #1: Hidron, A., Quiceno, W., Cardeño, J. J., Roncancio, G., & García, C. (2021). Post-COVID-19 Necrotizing Pneumonia in Patients on Invasive Mechanical Ventilation. Infectious Disease Reports, 13(3), 835–842. https://doi.org/10.3390/idr13030075 Reference #2: Fazio, G., Galioto, F., Ferlito, A., Coronella, M., Palmucci, S., & Basile, A. (2021). Cavitated pulmonary nodules in a female patient with breast cancer: Keep in mind Serratia marcescens’ infections. Respiratory Medicine Case Reports, 33, 101441. https://doi.org/10.1016/j.rmcr.2021.101441 Reference #3: Jose, M., & Desai, K. (2020). Fatal Superimposed Bacterial Sepsis in a Healthy Coronavirus (COVID-19) Patient. Cureus. https://doi.org/10.7759/cureus.8350 DISCLOSURES: No relevant relationships by Lucy Checchio No relevant relationships by Syeda Hassan No relevant relationships by Jaclyn Rosenzweig No relevant relationships by Stephanie Tzarnas No relevant relationships by Laura Walters