New Jersey FQHC Process Improvement Increases Oral Health Access for HIV Patients

Introduction: Patients living with HIV/AIDS (PLWHA) have more unmet oral health care needs than the general population, outpacing unmet medical needs [1]. Poor oral health can impact a person’s confidence and ability to speak, eat, work, sleep, and socialize [2]. Lack of access to dental care is a national issue for HIV patients; providing access is a challenge faced by many health centers and practices, including Zufall Health in New Jersey, a federally qualified health center (FQHC). In collaboration with Northeast/Caribbean AIDS Education and Training Center (NECA AETC), Zufall embarked on an initiative to improve access to quality dental care for PLWHA. AETC is the training component of the Ryan White Program, a federally funded program that provides medical care, support services, and medications for PLWHA who are low income, uninsured, or underserved [3-5]. Materials and Methods: In 2019, Zufall Health launched a quality improvement project to increase oral health access and services for Ryan White patients by integrating all partners involved in providing health care: medical, dental, psychological, behavioral, and HIV/AIDS providers and case managers. The project goal was to increase the number of patients receiving dental care to improve oral and overall health. Results/Observations: As a result of the project, there were significant quantitative and qualitative improvements in the oral health and quality of life of PLWHA: more dental encounters, a higher percentage of patients with a dental home, and the surpassing of the project goal of a 10% increase in dental referrals.

Social Determinants of Health Among Those With and Without HIV Infection in NYC, the Epicenter of the U.S. Crisis

The COVID-19 pandemic in NYC, the epicenter of the US crisis, revealed indisputable evidence that social determinants of health (SDoH, e.g., racism, crowded housing, employment risks) and disparities in comorbid health risk factors produce higher burdens of disease and death among racial and ethnic populations. We conducted a needs assessment of SDoH among 1400 patients in several ambulatory care clinics to explore the impact among older adults, across different clinical populations. Among older adults with HIV (OAH), we found lower rates of food and housing insecurity compared to older adults without HIV. Despite higher levels of COVID knowledge and prevention adherence, we also found significantly higher levels of isolation, loneliness, depressive symptoms, and anxiety among OAHs compared to those without HIV. Access to Ryan White entitlements did buffer some impacts but preexisting high burdens of mental health issues were exacerbated, perhaps due to heightened perceptions of increased vulnerability to COVID-19.

894. Trend of Transmitted Resistance Associated Mutations in People Living with HIV (PLWH) in a Large Southeastern U.S. Ryan White Clinic

Background Department of Health and Human Services (DHHS) guidelines recommend integrase strand transfer inhibitors (INSTIs) as the backbone of preferred initial antiretroviral (ART) regimens (1). Baseline mutation rates for the INSTI class is 0.8% compared with an overall rate of 19% for all ART classes, based on Centers for Disease Control and Prevention (CDC) U.S. data from 2013-16 (2). First-generation INSTIs (raltegravir and elvitegravir) have a lower genetic barrier to resistance compared with newer, second generation INSTIs (bictegravir and dolutegravir) (3, 4). DHHS guidelines do not currently recommend routine HIV genotypic resistance testing to INSTIs prior to ART initiation (1). Our study seeks to determine the current prevalence of transmitted INSTI and overall resistance in a large southeastern U.S. Ryan White clinic. Methods This was a single-center, retrospective analysis of treatment naïve PLWH presenting for care from January 1, 2017 to December 31, 2020. Of these, 164 had a baseline genotype performed by one of two commercially available assays – Vela Genomics or ViroSeq. Subsequent interpretations were based on Stanford HIV Drug Resistance Database. Results 65 patients (39.6%) had at least one transmitted resistance associated mutation (RAMs). Of these, 24 (36.9%) had an INSTI RAM. Baseline PI, NRTI, and NNRTI RAMs declined during the four-year interval (2017-2020), while the rate of INSTI RAMs increased from 11.1% to 19%; all conferred resistance to the first generation INSTIs with one also conferring resistance to second generation INSTIs. INSTI Resistance Associated Mutation Prevalence 2017-2020 Frequency of Antiretroviral Therapy Class Mutations Per Year Trend of INSTI Mutations and Resistance Associated Mutations 2017-2020 Conclusion Unlike the CDC data which showed the overall prevalence of INSTI RAM transmission rates during 2013-2016 to be 0.8%, our data suggests a higher rate of INSTI RAMs (14.6%) with overall ART RAM transmission of 39.6%. This increase in baseline resistance to the INSTI class, which occurred over time, mimics the historical development of RAMs seen in the earlier ART classes. Though suboptimal adherence in the population promotes development of RAMs, increased frequency of INSTI RAMs may be due to a lower barrier to resistance of first generation INSTIs. Should our observed trend continue, routine baseline INSTI resistance testing may need to be considered prior to ART initiation. Disclosures Cheryl Newman, MD, Gilead (Scientific Research Study Investigator)GSK/ViiV (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker’s Bureau)Janssen (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)

887. Implementation of Long-acting Injectable Cabotegravir/Rilpivirine for HIV-1 Treatment at a Ryan White-funded Clinic in the U.S. South

Background In January 2021, the first ever long-acting injectable (LAI) antiretroviral therapy (ART), cabotegravir/rilpivirine (CAB/RPV), was approved for maintenance HIV-1 treatment in select patients with virologic suppression. LAI-ART has the potential to improve ART adherence, reduce HIV stigma, and promote equity in care outcomes, however, implementation in real-world settings has yet to be evaluated. Methods We launched a pilot LAI-ART program at the largest Ryan White-funded HIV clinic in the Southeast. From 4/14/21 to 5/14/21, providers referred patients interested and willing to switch to LAI-CAB/RPV who met screening criteria. Our interdisciplinary LAI team (Clinician-Pharmacy-Nursing) verified clinical eligibility (HIV-1 < 200 c/ml ≥6 months and no history of virologic failure, resistance to either drug, or chronic HBV infection) and pursued medication access for 28-day oral lead-in and monthly injectable CAB/RPV. We describe demographic and clinical variables of referred PWH and early outcomes in accessing LAI-ART. Results Among 42 referrals, median age was 40.5 (Q1-Q3, 32-52) years, 83% were men, and 76% Black. Payor source distribution was 26% Private, 19% Medicare, 10% Medicaid, and 45% ADAP. At the time of referral, median CD4 count was 583 (Q1-Q3, 422-742) cells/mm3 and median sustained HIV-1 RNA < 200 c/ml was 1427 (Q1-Q3, 961-2534) days. A total of 35 patients (74%) met clinical eligibility for LAI-CAB/RPV, including 4 patients who required a transition off proton pump inhibitor therapy to accommodate oral RPV. Ineligible PWH were excluded due to evidence of RPV resistance (n=5), possible RPV hypersensitivity (n=1), and HIV non-suppression (n=1). The table summarizes the process of pursuing LAI-ART access for the initial 10 enrollees by insurance status. Conclusion Our experience implementing LAI-ART at a Ryan White-funded HIV clinic in the Southern U.S. has been challenged by substantial human resource capital to attain drug, delayed therapy initiation due to insurance denials, and patient ineligibility primarily due to concern for potential RPV resistance. These barriers may perpetuate disparities in ART access and virologic suppression among PWH and need to be urgently addressed so that LAI-ART can be offered equitably. Disclosures Lauren F. Collins, MD, MSc, Nothing to disclose Bradley L. Smith, Pharm.D., AAHIVP, Gilead Sciences, Inc (Advisor or Review Panel member) Wendy Armstrong, MD, Nothing to disclose Jonathan Colasanti, MD, Integritas CME (Consultant, develop and deliver CME content around Rapid Entry/Rapid ART)

831. Hepatitis C Virus Micro-elimination Within a Human Immunodeficiency Virus Clinic: Challenges in the Home Stretch

Background Hepatitis c virus (HCV) eradication among persons with HIV (PWH) is alluring since DAAs efficacy is high regardless of HIV status and PWH in care are usually screened for HCV. Despite the potential, barriers to care have prevented many from achieving sustained virologic response (SVR). We performed a pharmacist-led campaign to reduce the proportion of PWH with active HCV and describe the barriers to care. Methods This retrospective review evaluated patients receiving care at a Ryan White-funded clinic from 07/2018 to 12/2020. Patients were eligible if HCV diagnosed ≥1 year and receiving HIV care. The primary endpoint was to compare the prevalence HCV before and after a pharmacy initiative to target the remaining patients at the clinic not treated during first 3 ½ year period of oral DAA therapy availability. Secondary analysis was to identify barriers to care, measure the proportion of patients in each step of the HCV care cascade, and determine predictors of SVR. Among barriers to care, inconsistent engagement was defined as patients with habitual missed appointments. Logistic regression and Chi-square tests were performed. Results 46 of 1,100 PWH had active HCV for ≥1 year. Median age, years since HIV and HCV diagnoses were 58.5 years of age, 17 years, and 11.5 years, respectively. Most patients were male (70%), Black (61%), Latinx (28%), HCV genotype 1 (90%), had an HIV RNA < 200 copies/mL (72%), & had Medicaid (87%). 32/46 patients agreed to therapy, with all getting insurance approval and DAAs delivered. Glecaprevir/pibrentasvir (73%) was the preferred by payors, followed by sofosbuvir/velpatasvir (15%). Eight remained with active HCV and 19 achieved SVR. The prevalence rate dropped from 4.2% to 0.7% (P < 0.0001). Active drug use, inconsistent engagement, mental health disorder and nonadherence were initial barriers to care. After multivariate analysis, patients with inconsistent engagement continued to be less likely achieve SVR compared to those we remained consistently in care (aOR: 0.062, 95 CI: 0.009-0.421). HCV care cascade in PWH within a Ryan White-funded clinic Active HCV includes 46 patients with chronic HCV infection receiving HIV in care at clinic, DAA approval process describes patients agreeing to HCV treatment along a continuum of pending laboratory results or pending prior authorization requests, DAA procurement depicts patients that have received approval and delivery of medications, DAA initiation describes patients who started treatment (27 patients), and SVR documented defines patients with an undetectable HCV RNA 12 weeks after therapy (19 patients). Conclusion Pharmacists can impact the burden of HCV among PWH receiving care. The HCV care cascade remains tied to the HIV continuum of care, with disengagement from care remaining an important rate-limiting step impeding micro-elimination. Disclosures All Authors: No reported disclosures

895. Impact of Telemedicine on HIV Care and Prevention Services at an Academic Ryan White-Funded Clinic

Background Telemedicine (TM) has been seldom used for the care of persons with HIV. However, the COVID-19 pandemic has forced HIV clinics to rapidly scale TM resources. With the increase of TM, the impact on HIV patient care remains uncertain. The purpose of this study is to examine the effects of TM on HIV care and retention at a Ryan White-funded clinic. Methods This was a retrospective study of patients seen at an academic clinic in Pittsburgh, PA between 1/1/20 – 12/31/20. Encounter information was extracted from the clinic electronic health record. Primary outcomes were viral load (VL) suppression (< 200 copies/ml) and retention in care for persons seen via TM (phone, video +/- in person) vs those seen in-person. Secondary outcomes included flu vaccination and STI screening rates. Results Amongst 1414 patients, 608 patients had at least one scheduled TM visit, with 97 seen exclusively via TM, and 806 were scheduled for only in-person visits. In those with at least one TM visit, 92.72% had a suppressed VL. 89.69% of those with only TM visits were suppressed. 92.43% were suppressed in the in-person group. Average show rate amongst patients who had at least one TM visit was 60.39% (+0.96% from 2019, +1.71% from 2018), vs 64.38% amongst patients who only had in-person visits. Amongst patients who were only scheduled for TM visits, show rate was 83.97%. 40.18% of patients who had at least one TM visit received their flu vaccine in 2020 (-37.45% from 2019, -36.72% from 2018) vs 37.62% who were only seen in-person. Amongst patients who had at least one TM visit, syphilis screening rate was 43.09% (-7.64% from 2019, -8.55% from 2018) vs 43.51% for those seen only in-person. Gonorrhea and chlamydia screening rates were both 42.91% (+9.46% from 2019, +15.27% from 2018 for chlamydia screening; +8.36% from 2019, +14.73% from 2018 for gonorrhea screening). Amongst patients who were exclusively seen in-person gonorrhea screening rate was 48.24% and chlamydia screening rate was 47.57%. Table 1. Characteristics of Patients Seen in 2020 Table 2. Primary and Secondary Outcomes for Patients Seen in 2020 Conclusion VL suppression rates were similar across both groups, but retention in care was highest in the TM-only group. Flu vaccination rates and STI screening were lower in the groups that included TM. TM is an effective method for maintaining VL suppression and retention in care but has room for improvement with provision of preventative services. Disclosures All Authors: No reported disclosures

869. A Qualitative Review of Social Barriers Impeding Retention in HIV Care at a Ryan White Clinic

Background Ending the HIV Epidemic: A Plan for America aims to decrease new HIV diagnoses 75% by 2025 and 90% by 2030. To achieve this, we identified patients unable to achieve viral suppression with social-behavioral needs deemed ‘high-hanging fruit.’ Via extensive outreach efforts and creation of shared problem solving, we pursued the goals of rapid and effective treatment leading to viral suppression and prevention of HIV transmission. We (1) exhausted all avenues of outreach to re-engage patients in HIV care and (2) identified personal or social characteristics related to difficulties in visit retention and achieving viral suppression. Methods Of 446 Ryan White-eligible patients seen in an urban, academic medical center, 46 did not achieve and/or maintain viral suppression, and qualified for the study. We conducted a mixed methods survey comprised of both multiple choice and open-ended questions to ascertain what barriers patients face to continuous engagement in care and to achieving viral suppression. We developed a re-engagement outreach cycle which included: text messages and phone calls, electronic messages via patient portal or email, phone call to pharmacy to cross-check contact information, outreach to patients’ emergency contact, and sending a letter by mail. Results Of 46 participants, 32 were reached and 14 were not found. Sixteen re-engaged in care and of these, 14 completed the survey (see Figure). Those who completed the survey noted the following barriers to care: poor mental health, financial issues, problems committing to an appointment due to work/family/transportation, and COVID-19. Out of all 46 participants, the 14 who were not found had an overall a higher index of chaos. This index of chaos included, but was not limited to: homelessness, IV drug use, domestic violence, and stigma. Outreach to re-engage in HIV care A. Participants in study, B. Outreach outcomes, C. Common survey themes Conclusion Intensive efforts are required to re-engage patients, counsel on adherence, and achieve viral suppression. The reasons for lack of engagement in care are real and challenging. Multiple cycles of continuous outreach serve to establish trust, address barriers, and connect to HIV care. Disclosures All Authors: No reported disclosures