This cross-sectional study evaluated epidemiologic characteristics of persons living with HIV (PWH) coinfected with Trypanosoma cruzi in Cochabamba, Bolivia, and estimated T. cruzi parasitemia by real-time quantitative polymerase chain reaction (qPCR) in patients with and without evidence of reactivation by direct microscopy. Thirty-two of the 116 HIV patients evaluated had positive serology for T. cruzi indicative of chronic Chagas disease (27.6%). Sixteen of the 32 (50%) patients with positive serology were positive by quantitative polymerase chain reaction (qPCR), and four of the 32 (12.5%) were positive by direct microscopy. The median parasite load by qPCR in those with CD4+ < 200 was 168 parasites/mL (73-9951) compared with 28.5 parasites/mL (15–1,528) in those with CD4+ ≥ 200 (P = 0.89). There was a significant inverse relationship between the degree of parasitemia estimated by qPCR from blood clot and CD4+ count on the logarithmic scale (rsBC= –0.70, P = 0.007). The correlation between T. cruzi estimated by qPCR+ blood clot and HIV viral load was statistically significant with rsBC = 0.61, P = 0.047. Given the significant mortality of PWH and Chagas reactivation and that 57% of our patients with CD4+ counts < 200 cells/mm3 showed evidence of reactivation, we propose that screening for chronic Chagas disease be considered in PWH in regions endemic for Chagas disease and in the immigrant populations in nonendemic regions. Additionally, our study showed that PWH with advancing immunosuppression have higher levels of estimated parasitemia measured by qPCR and suggests a role for active surveillance for Chagas reactivation with consideration of treatment with antitrypanosomal therapy until immune reconstitution can be achieved.

Historically, the role of the emergency physician in HIV care has been constrained to treating sick patients with opportunistic infections and postexposure prophylaxis for occupational exposures. However, advances in HIV care have led to medications that have substantially fewer issues with toxicity and resistance, opening up an exciting new opportunity for emergency physicians to participate in treating the HIV virus itself. With this new role, it is crucial that emergency physicians be familiar with the advances in testing and medications for HIV prevention and treatment. To our knowledge, to date there has not yet been an article addressing this expansion of practice. We have compiled a summary of what the emergency physician needs to know, including misconceptions associated with antiretroviral therapy, medication complexity, toxicity, resistance, and usability. Additionally, we review potential indications for prescribing these drugs in the emergency department, including the role of the emergency physician in postexposure prophylaxis, preexposure prophylaxis, and treatment of acute HIV, as well as how emergency physicians can engage with chronic HIV infection.

Earlier intervention in acute HIV infection limits HIV reservoirs and may decrease HIV transmission. We developed criteria for empiric antiretroviral therapy (ART) in an emergency department (ED) routine HIV screening program. We assessed the feasibility and willingness of patients with suspected acute HIV infection in the ED to begin ART. A suspected acute HIV infection was defined as a positive HIV antigen antibody combination immunoassay with pending HIV-antibody differentiation test results and HIV RNA viral load. During the study period, there were 16 confirmed cases of acute HIV infection: 11 met our criteria for empiric ART and agreed to treatment, 10 were prescribed ART, and 1 left the ED against medical advice without a prescription for ART. Eight patients completed at least one follow-up visit. Empiric HIV treatment in an ED is feasible, well received by patients, and offers a unique entry point into the HIV care continuum.

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BackgroundAtlanta, GA ranks third in the nation for highest rates of new HIV diagnoses, disproportionally affecting Black men and women. Pre-exposure prophylaxis (PrEP) is underutilized in this population due to multiple barriers to uptake, including limited access to PrEP delivery programs. The advantages of a primary pharmacy-led PrEP program include: relatively low service fees, perform and assess point-of-care testing, and provide adherence counseling. Similar programs across the United States have been shown to effectively increase PrEP uptake and optimize retention in care. Grady Health System (GHS), the fifth largest public hospital system in the United States, is located at the epicenter of the HIV epidemic: downtown Atlanta. It encompasses 11 different primary care clinics, accounting for 850,000 outpatient visits per year. In August 2018, we launched a developmental pilot of a GHS pharmacy-based tele-PrEP program, aiming to optimize PrEP access for vulnerable populations who would otherwise not be able to obtain it. PrEP services are provided directly to the community and through a consultative support program for all clinical sites within the GHS system. The key pilot interventions included developing a user-friendly electronic medical record (EMR)-based PrEP order sets and brief provider education interventions in 6 GHS primary care clinics, to increase PrEP awareness among non-HIV clinicians.MethodsWe conducted a retrospective process evaluation of the pilot PrEP program based on the PrEP continuum of care.ResultsOver 9 months, 95 referrals were received from providers within the GHS clinics. Of the 95 patients referred, 56 (59%) started PrEP. Two patients were started on post-exposure prophylaxis prior to initiation of PrEP. Forty-five patients (81%) remain on PrEP as of April 2019. Six clients were diagnosed with 9 STIs on screening (4 syphilis, 2 gonorrhea, 2 chlamydia, 1 lymphogranuloma venereum). There have been no HIV seroconversions in patients on PrEP.ConclusionUtilizing a pharmacy-based PrEP program to train and support clinical providers in a large, hospital system can facilitate PrEP uptake and retention for patients in primary care.Disclosures All authors: No reported disclosures.

BackgroundTuberculosis (TB) is the most common opportunistic infection and the leading cause of death in HIV-positive people worldwide. Diagnosing TB is difficult, and is more challenging in resource-scarce settings where culture-based diagnostic methods rely on poorly sensitive smear microscopy by Ziehl-Neelsen stain (ZN).MethodsWe performed a cross-sectional study examining the diagnostic utility of Microscopic Observation Drug Susceptibility liquid culture (MODS) versus traditional Ziehl-Neelsen staining (ZN) and Lowenstein Jensen culture (LJ) of pulmonary tuberculosis (TB) and multidrug-resistant tuberculosis (MDRTB) in HIV-infected patients in Bolivia. For sputum scarce individuals we assessed the value of the string test and induced sputum for TB diagnosis. The presence of Mycobacterium tuberculosis (Mtb) in the sputum of 107 HIV-positive patients was evaluated by ZN, LJ, and MODS. Gastric secretion samples obtained by the string test were evaluated by MODS in 102 patients.ResultsThe TB-HIV co-infection rate of HIV patients with respiratory symptoms by sputum sample was 45 % (48/107); 46/48 (96 %) were positive by MODS, 38/48 (79 %) by LJ, and 30/48 (63 %) by ZN. The rate of MDRTB was 9 % (4/48). Median time to positive culture was 10 days by MODS versus 34 days by LJ (p < 0.0001). In smear-negative patients, MODS detected TB in 17/18 patients, compared to 11/18 by LJ (94.4 % vs 61.0 %, p = 0.03 %). In patients unable to produce a sputum sample without induction, the string test cultured by MODS yielded Mtb in of 9/11 (82 %) TB positive patients compared to 11/11 (100 %) with induced sputum. Of the 10 patients unable to produce a sputum sample, 4 were TB-positive by string test.ConclusionMODS was faster and had a higher Mtb detection yield compared to LJ, with a greater difference in yield between the two in smear-negative patients. The string test is a valuable diagnostic technique for HIV sputum-scarce or sputum-absent patients, and should be considered as an alternative test to induced sputum to obtain sample for Mtb in resource-limited settings. Nine percent of our TB+ patients had MDRTB, which reinforces the need for rapid detection with direct drug susceptibility testing in HIV patients in Bolivia.

Background HIV disproportionally affects transgender women (TGW) of color, with a prevalence of 26% and 44% among Latinx and Black TGW, respectively. Low medication adherence likely contributed to suboptimal pre-exposure prophylaxis (PrEP) efficacy among TGW in clinical trials, but real-world PrEP outcome data for TGW is limited. In this study, we developed the PrEP care continuum for TGW referred to a PrEP program at a large, safety-net urban hospital in the Southeast. Figure 1. PrEP care continuum of TGW referred a PrEP program. Referrals include all TGW referred to PrEP clinic, eligibility includes all those referred who were deemed eligible for PrEP, linkage refers to those eligible who had ongoing care at the PrEP clinic, prescription refers to those who received their first prescription of PrEP, initiation includes those who started taking the PrEP they were prescribed, and persistence includes those who had a visit within 6 months of study end. Methods We analyzed data for those referred to the PrEP program from 3/2018 to 2/2020. We determined the proportion of TGW who were linked to the program, provided a PrEP prescription, started PrEP, and persisted in PrEP care, defined as having at least one follow-up visit within 6 months. Using a multivariate regression model, including age, race, ethnicity, mental health co-morbidities, and substance use, we determined factors associated with persistence in PrEP care. We calculated rates of sexually transmitted infections (STIs) and HIV incidence. Results Of the 321 total referrals for PrEP, 42 (13%) were TGW. 81% of TGW were referred from a co-located gender clinic. Median age was 28.5 years (IQR 23-34), 62% were Black, 21% had mental health co-morbidities, 45% used substances, and 35% engaged in transactional sex. Of all TGW who were referred, 37 (88%) were eligible for PrEP and linked to care, 36 (85.7%) were prescribed and initiated PrEP, and 22 (52.4%) persisted in care at the end of the study period. There were no factors associated with persistence in PrEP care. The most common STIs during the first visit were pharyngeal gonorrhea (22.7%) and syphilis (16.7%). STI incidence was highest for rectal chlamydia (12.5%) and pharyngeal gonorrhea (6.5%). There was one HIV seroconversion during the study period. Conclusion In a public hospital-based PrEP clinic in Atlanta with a co-located gender clinic, TGW had high rates of linkage to care and PrEP prescription and initiation, despite high rates of mental health diagnoses and substance use. However, there was a significant drop-off in persistence. STI prevalence and incidence were high, but there was only one HIV seroconversion, highlighting the potential benefits of PrEP. Future studies are needed to assess interventions to optimize persistence in PrEP care among TGW. Disclosures Bradley L. Smith, PharMD, AAHIVP, Gilead Sciences, Inc (Advisor or Review Panel member)