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Background: People with HIV (PWH) have a higher risk of COVID-19 morbidity and mortality. SARS-CoV-2 vaccination is highly effective in preventing severe COVID-19, although medical mistrust may contribute to vaccine hesitancy among PWH. Method(s): PWH from 8 sites in the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) completed the clinical assessment of patient-reported outcomes including a vaccine hesitancy instrument as part of routine care from 2/21-4/22. Participants were defined as vaccine hesitant if they had not yet received the SARS-CoV-2 vaccine and would probably or definitely not receive it. We assessed factors associated with SARS-CoV-2 vaccine hesitancy using logistic regression, and adjusted for demographics, unsuppressed viral load >200 copies/mL, calendar month and time on ART. Result(s): Overall, 3,278 PWH with a median age of 55 responded;19% were female sex at birth;93% were virally suppressed. At the time of survey, 27% reported they had not received the SARS-CoV-2 vaccine, of whom 27% (n=242;7% overall) reported vaccine hesitancy. Of these 242, 82% expressed concerns about vaccine efficacy;86% about side effects;38% reported distrust of healthcare, 53% reported concerns about vaccine contents (i.e. trackers, live virus);and 24% did not perceive risk from COVID-19. Factors associated with vaccine hesitancy included female sex (Adjusted Odds Ratio [AOR] 2.0;95% Confidence Interval (CI): 1.5-2.8;Table), Black vs. White race (AOR 1.8;95% CI: 1.3-2.5), age< 30 years (AOR 2.8;95% CI: 1.5-5.2), South/Midwest vs. Northeast region (AOR 1.7;95% CI: 1.2-2.4), years on ART (0.8;0.7-0.9) and unsuppressed viral load (AOR 2.2;95% CI: 1.4-3.5). Hesitancy decreased over time (AOR 0.9 per month;95% CI: 0.8-0.9). Vaccine side effects were the primary concern for women;vaccine contents for Black PWH and those who were unsuppressed;and lack of perceived COVID-19 risk for youth. Conclusion(s): Vaccine hesitancy was reported by approximately 7% of a U.S. multi-site cohort of PWH, and it was more prevalent among Black PWH, women, youth, those with unsuppressed viral loads, and residents of the South/ Midwest. The association between virologic non-suppression and vaccine hesitancy highlights the intertwined challenge of medical mistrust for both HIV and COVID-19. Although vaccine hesitancy decreased over time, renewed efforts will be needed to address concerns of PWH about the COVID-19 vaccine, given the ongoing need for revaccination with the evolution of the pandemic.
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Background: Disruptions in clinical services during the COVID-19 pandemic could compromise past progress towards meeting U.S. Ending the HIV Epidemic (EHE) goals. We examined changes in the proportion with virologic suppression (VS) before and since the onset of COVID-19 in a multi-site U.S. cohort of people with HIV (PWH) using an interrupted time series design. Method(s): We assessed VS (< 200 copies/mL) trajectories 1/1/2018-1/1/2022, comparing trends before and after March 21, 2020 at 8 HIV clinics within the U.S. Center for AIDS Research Network of Integrated Clinical Systems (CNICS'). Hierarchical mixed-effects logistic regression and interrupted time series analyses examined changes in the trend (i.e., slope) of VS over time, and maximum likelihood estimation was used to account for missing VS data among those lost to follow-up (LTFU) post-COVID-19. Analyses were adjusted for demographics, site, CDC transmission group, CD4 nadir, VS, time on ART. Result(s): Data from 17,999 participants were included, providing a total of 120,918 VS assessments. Median age was 53 (interquartile range 42-61);19% were female sex at birth;the mean time on ART was 9.5 years;18% were unsuppressed at any point;17.7% were LTFU. Among the overall population, prior gains in VS slowed during COVID-19 (adjusted odds ratio [AOR] 0.93 per quarter-year;95% CI: 0.88-0.98;p=0.004;Figure). Greater impacts occurred among women (AOR 0.90;95% CI 0.81-0.99;p=0.05), persons with a history of injection drug use (PWID) (AOR 0.77 95% CI: 0.66-0.90;p=0.001), and Black PWH (AOR 0.90;95% CI: 0.84-0.96;p=0.001) in whom prior positive VS trends plateaued or began to reverse (Figure). VS remained lower among those with unstable housing (AOR 0.44;95% CI: 0.40-0.50;p< 0.001) but stayed unchanged from the pre-pandemic period. Conclusion(s): Previous gains in VS slowed during the COVID-19 pandemic among PWH in a multi-site network of U.S. HIV clinics. Known disparities in VS according to housing status remain unchanged, but VS disparities worsened for PWH who were women, PWID, or Black. Changes in VS trends could be related to socioeconomic impacts of the pandemic, insurance lapses, reduction of in-person clinic services, fear of coming to clinics, or other factors. Renewed investment in HIV public health and clinical services will be vital to achieve the U.S. EHE goals following COVID-19, with additional targeted interventions to support key populations with persistent or worsening disparities needed.
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Aims: To describe longitudinal associations between health-related quality of life (HR-QoL) scores and demographic, clinical, and health behavioral characteristics in a multisite U.S. cohort of adults in HIV care. Method(s): People with HIV (PWH) completed an electronic assessment of patient-reported outcomes (PROs) as part of routine clinical care between 2016 and 2021 including measures for HR-QoL (EQ-5D-3L), substance use (ASSIST, AUDIT/AUDIT-C), smoking, and HIV stigma, among others. We used generalized linear latent and mixed models with nonparametric random effects for the intercept term to accommodate repeated measures on individuals to examine longitudinal factors associated with HR-QoL overall and stratified by birth-sex. Result(s): PWH (n = 10,559, median age at first assessment = 49, 17.8% cis-gender women, 1.4% transgender women;68.3% non-White) completed 33,866 assessments. Lower HR-QoL scores were associated with increasing age (p <= 0.0001);identifying as female (cis or transgender) compared to cisgender male (p <= 0.0001, p = 0.005, respectively);living in the Southeast or Western US relative to Northeast (both p <= 0.0001);identifying as a sexual orientation other than gay (heterosexual p = 0.03, bisexual p = 0.009, other p <= 0.0001);higher internalized HIV stigma (p <= 0.0001);current or former smoking (both p <= 0.0001);past methamphetamine use (p = 0.015) and current cocaine/crack, methamphetamine, opioid and cannabis use (p <= 0.0001 for each except cannabis, which was p = 0.007). Higher HR-QoL scores were associated with race/ethnicities other than White (Black: p = 0.002, Hispanic: p = 0.002, other: p <= 0.0001);the COVID-19 pandemic period (March 2020-December 2021) (p <= 0.0001);and increased AUDIT/AUDIT-C score (p = 0.001). In sex stratified models men (n = 8666) had higher HR-QoL scores among non-white compared to white (Black p = 0.0006, Hispanic p = 0.007, Other p <= 0.0001);and during the COVID period (p <= 0.0001). Men had lower HR-QoL scores among heterosexual and bisexual men relative to gay (p = 0.004, p = 0.005), if they were a former smoker (p <= 0.0001), and among past or current methamphetamine users relative to nonusers (p = 0.002, p <= 0.0001). Women (n = 1893) had higher HR-QoL scores if in care longer (p = 0.005), and lower HR-QoL if in the South (p <= 0.0001), if previously used cocaine/crack (p <= 0.0001), or if currently uses marijuana (p = 0.001). Conclusion(s): Our findings describe HR-QoL and its associations among a large diverse cohort of PWH, identifying potentially modifiable factors to improve HR-QoL, such as substance use, smoking, and impact of HIV-related stigma.
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Background/Case Studies: Our system has consistently purchased a higher percentage of O-negative (O-) and O-positive (O+) RBCs than other hospitals serviced by our blood supplier. Our patients' ABORh types do not mirror the US donor base. Our patients are more likely to be type O and Rh-positive due to the racially diverse population we serve. We have tried to alter the ordering practices of the transfusion services (TSs) using data sharing (DS) and monitoring. The COVID-19 pandemic created blood shortages, which severely impacted blood availability. We sought to determine whether the severe shortage of O- and O+ RBCs altered our TSs' inventory management. Study Design/Methods: Well Sky Transfusion reports for RBC transfusions from calendar years 2017 (baseline), 2019 (DS & monitoring) and 2021 (during COVID-19 with significant supply problems) were run. The ABORh of RBCs issued to patients by ABORh type were analyzed. Statistical analysis was performed using the Student's t-test. Results/Findings: The number O+ RBCs Txed to O+ patients increased significantly from 2017 (p-value 0.031) to 2019 (p-value 0.0061) and 2021 (p-value 0.0224). The number of O- RBCs Txed to O- patients increased 6.7%. Total RBC Tx increased from 17.1% from 2017 to 2021 (p-value 0.0155). Emergency issued RBCs rose 62.7% from 2017 to 2021 (p-value 0.0097). Tx of O- RBCs to non-O- patients decreased by 10.9% and total O- RBC usage decreased by 5.1%. Tx of O+ RBCs to non-O+ patients increased 32.9% while total O+ RBCs usage increased by 8.9%. Conclusion(s): Although voluntary change is possible, difficult times force behavioral changes. Shortages of type O- and type O+ RBCs forced the TSs to order more type A and type B RBCs so that they could preserve the type O RBCs for type O patients. TSs can play a role in managing blood shortage solution by trying to preferentially issued type specific RBCs when possible.
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Background. Little is known about how race and ethnicity, imperfect (albeit accessible) proxies for structural racism, impact COVID-19 incidence among people with HIV (PWH). We report the cumulative incidence and incidence rate ratios (IRR) for COVID-19 in a long-term multi-site cohort of PWH across the US Figure 1. Cumulative incidence of COVID-19 in the CNICS cohort Methods. We examined COVID-19 cumulative incidence and IRR among PWH in care between 3/1/2020 and 12/31/2020 at seven sites in the CFAR Network of Integrated Clinical Systems (CNICS) cohort. We define COVID-19 incident case as having a laboratory-confirmed (RT-PCR/Ag) SARS-CoV-2 positive result or diagnosis verified by chart review. Reinfections were excluded. Results are presented as monthly and quarterly cumulative incidence and IRR with 95% CI stratified by CD4 count, self-reported race/ethnicity, and site. Follow-up was censored on the earliest of diagnosis of COVID-19 disease, loss to follow up, or 12/31/2020 Results. Among 15,780 PWH in care in the CNICS cohort during the study period, 62% were non-white, with a median (IQR) age of 52 (IQR 40-59), 95% were on antiretroviral therapy, 17% had a CD4 count less than 350, and 6% less than 200. Overall, 651 PWH tested positive for COVID-19 for a cumulative incidence of 4.13%. COVID-19 cumulative incidence increased from 0.77% at the end of the first quarter to 4.12% by the end of December 2020. At the peak of the pandemic in December 2020, the cumulative incidence in Black PWH was 1.68 fold higher than in white PWH (p=.033) and 2.35 fold higher in Hispanics than in whites (P< .0001), figure 1. Similarly, the IRR for COVID-19 was 1.71 (95% CI 1.42-2.07) for Black and 2.40 (95% CI 1.91-3.01) for Hispanic PWH relative to white. Although there was variation across sites, reflecting geographic differences in pandemic waves and access to COVID-19 testing, overall individual trends remained the same. COVID-19 cumulative incidence was similar across CD4 cell count strata Conclusion. Our results suggest effects of structural racial disparities on COVID-19 incidence in this diverse population of PWH across the US, with higher and disproportionate rates of COVID-19 in Black and Hispanic PWH. Incidence estimates are conservative because testing was not uniform, and no systematic testing was conducted.
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Title: Comparison of Clinical and Thrombotic Outcomes in SARS-CoV-2- Pneumonia versus Other Viral Pneumonia in an Urban Academic Medical Center Objective: To compare clinical and thrombotic outcomes in SARS-CoV-2 pneumonia versus other viral pneumonias. Introduction: Viral pneumonia (PNA) causes oxidative stress to the pulmonary vasculature, triggering endothelial dysfunction and activation of the coagulation cascade. Elevations in coagulation markers, including d-dimer and fibrinogen, have been observed. Recent studies indicate that SARS-CoV-2 infection causes endothelial cell injury, with activation of the coagulation cascade, and a high frequency of systemic thrombotic events. It remains unclear whether it is viral pneumonia itself, a specific viral strain (and/or viral load) that drives the clinical and thrombotic outcomes. Furthermore, limited data is available regarding clinical outcomes in a diverse patient population hospitalized with SARS-CoV-2 infection. This study is from a single urban medical center in Chicago, Illinois. Study Design: A retrospective cohort study evaluating the medical records of hospitalized adult patients admitted to University of Illinois Hospital and Health Sciences System (UIHHSS) with SARS-CoV-2 pneumonia or other viral (H1N1 or H3N2) pneumonia between 10/01/2017 and 09/01/2020. Methods: Patients were included if ≥18 years old, hospitalized, with a primary confirmed diagnosis of viral pneumonia (SARS-CoV-2, H1N1 or H3N2) based on ICD-10 code, viral diagnostic testing, diagnosis description, and appropriate clinical characteristics/imaging studies. Past medical history, inpatient medications, coagulation parameters, arterial/venous thrombotic outcomes, and other clinical outcomes (renal replacement therapy, mechanical ventilation, co-infection) were ed from UIHHSS electronic health record database. Results: Medical records of 257 patient with a primary diagnosis of pneumonia were reviewed, 199 patients with SARS-CoV-2 PNA (95 male, average age 58 years, 52% Hispanic, 37% non-Hispanic Black) and 58 patients with other viral PNA (24 male, average age 63 years, 21% Hispanic, 55% non-Hispanic Black;34 with H3N2, 24 with H1N1). Coagulation parameters (maximum D-dimer, fibrinogen, INR) were similar in both groups;average D-dimer was >3x ULN. Anticoagulation therapy was similarly prescribed in both groups (SARS-CoV-2, 95% vs 84%, H1N1 or H3N2), with prophylactic dose anticoagulation prescribed most frequently (73% vs 62%) and with high average compliance rates (89% vs 83%). Admission to the intensive care unit (ICU;32% vs 29%) and the median length of stay (10 vs 4 days) was similar in both groups. Thrombotic events (n = 6, 3%) occurred only in SARS-CoV-2 PNA patients in the ICU: 3 pulmonary embolism (PE), 1 distal lower extremity deep vein thrombosis (DVT), 2 non-ST elevated myocardial infarctions (NSTEMI). There was a significantly higher incidence of use of renal replacement therapy (8.5% vs 0%, p=0.016) and mortality (15.6% vs 3.4%, p=0.048) in the SARS-CoV-2 PNA group compared to the H3N2/H1N1 PNA group. There were no differences in the rates of mechanical ventilation, the incidence of major bleeding or co-infection. In a multivariable logistic regression analysis, age (aOR 1.07), the presence of SARS-CoV-2 PNA (aOR 11.37), and ICU admission (aOR 41.95) were significantly associated with risk of mortality during hospitalization. Race and ethnicity were not associated with mortality. Conclusion: The overall incidence of thrombotic events was low and occurred only in the SARS-CoV-2 PNA group. The low rate of venous thrombosis detected in this group, especially in the ICU setting, is likely related to the reduced use of diagnostic studies during the first COVID-19 pandemic in 2020 and to the high rates of anticoagulation prophylaxis orders and compliance. SARS-CoV-2 PNA was associated with a higher rate of renal failure and mortality compared to patients with H3N2/H1N1 viral pneumonia. There was no difference in mortality rates between Hispanic and non-Hispanic and between Black and non-Black patients. This study suggests that SARS-CoV-2 pneumonia leads to greater endothelial dysfunction than that observed in H3N2/H1N1 viral pneumonia and that race/ethnicity does not drive mortality outcomes. Disclosures: Benken: BMS: Research Funding;CareDx: Research Funding;Transplant Genomics: Research Funding;Daiichi Sankyo: Research Funding;Verici Dx: Research Funding.
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Background/Case Studies: The COVID-19 pandemic has dramatically impacted hospital operations forcing the expansion of overall hospital capacity and the number of ICU beds to meet care demands. On 3/1/20 the first case of COVID-19 was confirmed in our state. On March 4, 2020 our local blood center announced an urgent need for blood and platelet donors and later reported that 75% of the incoming blood supply would be interrupted. As the number of cases rose, to preserve the blood supply and availability of hospital beds, NYC DOHMH ordered that all elective surgery be canceled effective March 16, 2020. We sought to evaluate the impact of the COVID-19 pandemic on blood product usage at our hospital. Study Design/Methods: Total daily and weekly blood product transfusion reports were run from HCLL Transfusion from March to May 2020 and 2019 for comparison data. Means, sums, and standard deviations were calculated. Statistical significance was assessed using the Student's T-test. Results/Findings: From 3/1/20 to 5/31/20, 1734 RBCs, 194 plasmas, 260 SDPs, and 535 patients were transfused. From 3/1/19 to 5/31/19, 1392 RBCs, 202 plasmas, 264 SDPs, and 481 patients were transfused. The weekly mean transfusions from 3-5/20 versus 3-5/19 were statistically higher for RBCs at 132.2 vs 98.7 units (pvalue= 0.007) and were fractionally lower for plasmas at 15.8 vs 14.7 and for SDPs at 20.1 vs 19.6. There was an initial downward trend in RBC usage in March 2020 which was rapidly reversed as COVID-19 patients remained hospitalized longer and underwent more invasive treatments including ECMO. Despite the initial drop in RBC transfusions in March 2020, there was a statistically significant increase in the number of RBCs trans-fused during the peak period of COVID-19 admissions in NYC (p-value=0.02) when compared to pre-COVID numbers. Weekly mean RBCs transfusions pre-COVID were 110.4 vs 132.2 during the peak and 135.6 while elective surgery was canceled. As the peak ended in NYC and elective surgery was able to be safely resumed, the mean weekly RBC transfusions returned to 106.8 units. Weekly mean plasma and SDP transfusions were essentially unchanged due to COVID-19. Conclusions: The cancelation of elective surgery and other procedures likely to require blood or admission to the hospital resulted in fewer transfusions in March 2020 but as COVID-19 patients remained hospitalized longer and underwent more invasive treatments including ECMO, RBC transfusions exceeded baseline levels. Critically ill COVID-19 patients required transfusion support and necessitated maintaining pre-pandemic blood product inventory levels.
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Background/Case Studies: The COVID-19 (C-19) pandemic has altered almost everything. The first case of C- 19 was confirmed in New York (NY) on 3/1/20. As of 6/30, there were >212,000 confirmed cases, >50,000 patients hospitalized, and >18000 confirmed and >4600 probable deaths in NYC. Quarantines diminished the blood supply, and all elective surgery was canceled effective 3/16. We sought to assess the transfusion needs of hospitalized C-19 patients in our system. Study Design/Methods: After obtaining IRB approval, an EMR report to identify all patients, who had a positive SARS-CoV-2 PCR test result and were transfused between 3/1/20 and 6/30/20, was created to identify howmany C-19 patients had been transfused and the number and type of blood products they received. Results/Findings: From 3/1-6/30, 12973 confirmed patients had been admitted to the hospital and transfused a total of 4297 blood products. Of the admitted confirmed patients, 1024 patients were transfused at least one blood product. A MTP was activated on 12 patients, and 9 were placed on ECMO. 3644 RBCs, 267 SDPs, 339 plasmas, and 47 pooled CRYO were transfused to C-19 patients. Table 1 depicts the mean number, range, and percent of transfusions by product type administered. Table 2 shows the data for patients who required intubation. Patients who died in the hospital were more likely to be transfused than those who had a routine discharge (13.1% vs 9.2%). 39 patients who required intubation and died in the hospital received a RBC transfusion. Conclusions: 1024 COVID-19 patients were transfused a total of 4297 blood products. 22.7% of all blood products during the period were transfused to C-19 patients. C-19 patients received 26.9% of RBCs, 9.1% of plasmas, 20.8% of SDPs, and 15.4% of pooled CRYO transfused in the hospital. An ample blood inventory is required to support the care of C-19 patients especially those requiring ECMO and intubation.
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Background/Case Studies: The COVID-19 pandemic has altered almost everything. The first case of COVID-19 was confirmed in New York (NY) on 3/1/20. As of 6/30, there were >212,000 confirmed cases, >50,000 patients hospitalized, and >18000 confirmed and >4600 probable deaths in NYC. The governor declared a state of emergency on 3/7. Social distancing and mandatory quarantines implemented on 3/12 have resulted in dramatic reductions in the blood supply. To preserve the blood supply and available hospital beds, all elective surgery was canceled effective 3/16. I sought to assess the usage of blood products in our hospitalized confirmed and suspected COVID-19 patients. Study Design/Methods: After obtaining IRB approval, an Epic report to identify all patients, who had a positive SARS-CoV-2 PCR test result and were transfused from 3/1/20 to 6/30/20, was created to identify how many COVID-19 patients had been transfused and the number and type of blood products they received. Results/Findings: From 3/1-6/30, 993 patients tested positively for COVID-19. 1669 confirmed and suspected patients had been admitted to the hospital, 1361 had been discharged (excluding deaths), and 253 had died. Of the admitted confirmed COVID-19 patients, 121 patients were transfused at least one blood product. A massive transfusion protocol was activated on 3 patients. A total of 519 RBCs, 78 SDPs, 40 plasmas, and 15 pooled cryoprecipitate (CRYO) units were transfused to COVID-19 patients. Table 1 depicts the mean number, range, and percent of transfusions by product type administered to COVID-19 patients. Conclusions: 121 COVID-19 patients were transfused a total of 652 blood products. 21.8% of all blood products during the period were transfused to COVID-19 patients. COVID-19 patients received 23.6% of RBCs, 16.8% of plasmas, 24.2% of SDPs, and 21.4% of pooled CRYO transfused in the hospital. Although their needs were only a portion of the hospital's overall blood usage, maintaining an ample blood inventory is required to support the care of COVID-19 patients especially those requiring ECMO and long-term mechanical ventilation.