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Given the large numbers of people with HIV (PWH) with Medicaid coverage, it is important to understand the patient experience with Medicaid. Understanding experiences with and attitudes around the program have important policy and clinical implications. The objective was to understand the patient perspective of PWH in Virginia, who transitioned to Medicaid in 2019 due to Medicaid expansion. English-speaking PWH who gained Medicaid due to Medicaid expansion in 2019 were recruited at one Virginia Ryan White HIV/AIDS Program clinic. The goal was to enroll33% of those who newly were on Medicaid for 2019. Participants were surveyed about demographic characteristics, and semistructured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using qualitative description and an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (

Insurance enrollment is complex for people living with HIV (PLWH) and people at increased risk for HIV, in part, owing to needing to ensure access to adequate provider networks and appropriate formularies. Insurance for PLWH facilitates access to HIV care/treatment and, ultimately, viral suppression, which has the individual benefit of longevity and the public health benefit of decreased HIV transmission. For people at increased risk for HIV, access to insurance facilitates improved access to HIV biomedical prevention, which has the individual benefit of elimination of transmission risk and the public health benefit of decreased HIV transmission. The objective of this study was to explore perceptions of priorities related to plan navigation, barriers and facilitators for enrolling and maintaining insurance coverage, and questions related to regional, state, and federal policies impacting plans provided both on and off the Affordable Care Act (ACA) marketplace. We interviewed a national sample of assisters (n = 40), who specialize in insurance plan selection for these populations. We found that assisters tailor their approaches to HIV-specific and person-specific concerns by navigating challenges related to affordability, formularies, and provider networks. In a complex coverage landscape during a time of uncertainty about the long-term future of the ACA, assisters have mastered the ability to simplify the insurance selection process for a vulnerable population. Assisters have excelled at incorporating insurance literacy education and encouraging client engagement in the process. Assisters play an essential role in the current complicated and fragmented United States' health care delivery system for PLWH and people at increased risk for HIV and could be incorporated into the Ending the HIV Epidemic initiative.

Background Most people diagnosed with hepatitis C virus (HCV) have not linked to care, despite the availability of safe and effective treatment. We aimed to understand why people diagnosed with HCV have not pursued care in the non-urban Southern United States. Methods We conducted a survey and semi-structured interview with participants referred to an HCV clinic who did not attend an appointment between 2014 and 2018. Our clinic is located in a non-urban region of Virginia at a university hospital. Qualitative data collection was guided by the Health Belief Model (HBM). Data was analyzed using qualitative content analysis to identify key factors influencing patient perceptions regarding HCV and pursuit of care. Results Over half of previously referred patients (N = 200) could not be reached by phone. Eleven participants enrolled, including 7 men and 4 women. Based on survey responses, unreliable transportation, unstable housing, substance use, and lack of insurance were common. Participants demonstrated good knowledge of HCV disease, complications, and treatment. On qualitative analysis of semi-structured interviews, final themes emerged from within and between HBM constructs. Emerging themes influencing patient perceptions included (1) structural barriers, (2) stigma, (3) prior experiences of HCV disease and treatment, (4) discordance between the recognized severity of HCV and expected impacts on one’s own health, and (5) patient-provider relationship. Substance use was not identified to be a barrier to care. Conclusions Participants perceived individual and structural barriers to linking to care. A strong HCV knowledge base was not sufficient to motivate pursuit of care. Efforts to improve linkage to care must address barriers at multiple levels, and system-level changes are needed. As the majority of previously referred patients could not be contacted by phone, current approaches to patient engagement are not effective for reaching these populations. Expansion of HCV care to primary care settings with an established patient-provider relationship or co-located treatment within substance use treatment programs may serve to increase access to HCV treatment.

Background Healthcare delivery changes associated with viral suppression (VS) could contribute to the United States’ “Ending the HIV Epidemic” (EtHE) initiative. This study aims to determine whether Qualified Health Plans (QHPs) purchased by AIDS Drug Assistance Programs (ADAPs) are associated with VS for low-income people living with HIV (PLWH) across 3 states. Methods A multistate cohort of ADAP clients eligible for ADAP-funded QHPs were studied (2014–2015). A log-binomial model was used to estimate the association of demographics and healthcare delivery factors with QHP enrollment prevalence and 1-year risk of VS. A number needed to treat/enroll (NNT) for 1 additional person to achieve viral suppression was calculated. Results Of the cohort (n = 7776), 52% enrolled in QHPs. QHP enrollment in 2015 was associated with QHP coverage in 2014 (adjusted PR [aPR], 3.28; 95% confidence intervals [CIs], 3.06–3.53) and engagement in care in 2014 (aPR, 1.16; 1.04–1.28). PLWH who were engaged in care (n = 4597) and had QHPs had a higher VS rate than those who received medications from Direct ADAP (86.0% vs 80.2%). QHPs’ NNT for an additional person to achieve VS is 20 (14.1–34.5). Starting undetectable (adjusted risk ratio [aRR], 1.39; 1.28–1.52) and enrolling in QHPs in 2015 (aRR, 1.06; 0.99–1.14) was associated with VS. Conclusions Once enrolled in ADAP-funded QHPs, ADAP clients stay enrolled. Enrollment is associated with VS across states/demographic groups. ADAPs, especially in the South and in Medicaid nonexpansion states, should consider investing in QHPs because increased enrollment could improve VS rates. This evidence-based intervention could be part of EtHE., In a multistate cohort, Qualified Health Plans (QHPs) are associated with viral suppression for AIDS Drug Assistance Program (ADAP) clients. State ADAPs, especially those without Medicaid expansion, should consider investing in QHPs as an evidence-based intervention to improve viral suppression.

Many AIDS drug assistance programs (ADAPs) purchased Affordable Care Act (ACA) qualified health plans (QHPs) for low-income people living with HIV. To date, little has been written about this from the client perspective. The study's objective was to gain information about the experience of Virginia ADAP-funded QHP enrollment and the impact of this change. English-speaking clients who were eligible for ADAP-funded QHPs were recruited at three HIV clinics in Virginia. The goal was to enroll ≥5% of those who were eligible for ADAP-funded QHPs in two Virginia Department of Health planning districts. Participants were surveyed about demographic characteristics, and semi-structured interviews were performed. Descriptive analyses were performed for cohort characteristics. Using an open coding strategy, codebooks were generated for the interviews and themes were identified. The cohort (n = 53) met our recruitment goal. Two-thirds gained their ACA knowledge at HIV clinics from case managers and social workers. Many barriers to enrollment were identified, including internet access/literacy. Almost 9 out of 10 participants had concerns about privacy, which centered on QHP's mandated use of mail-order pharmacies. Except for medication concerns, most participants had positive perceptions of the impact of QHP enrollment on their health care. HIV clinic case managers and social workers are often the primary source of knowledge for patients about insurance options and their assistance is crucial for QHP enrollment. Our findings indicate that reducing identified barriers and addressing privacy concerns by allowing people to opt out of mail order pharmacies may encourage QHP enrollment.

Retrospective analysis of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) use among individuals with PrEP indications demonstrates worsening disparities in uptake between early- and late-adopting states from 2014 to 2018. To end the HIV epidemic, federal and state governments must close gaps by translating successful policies from early-adopting states to late-adopting states.

Background: Latinx people in the United States are disproportionately diagnosed with HIV and are more likely to experience worse HIV-related health outcomes. Although m-health has demonstrated success in improving HIV care, a gap remains in the development of m-health platforms tailored to Latinx populations. Methods: We conducted formative study to guide the adaptation of an evidence-based m-health intervention, PositiveLinks (PL), for Spanish-speaking Latinx people living with HIV (PLWH). Spanish-speaking Latinx PLWH in the nonurban Southern United States completed semistructured interviews and viewed a demo version of the m-health intervention. Qualitative analysis was performed using a grounded theory approach. Emerging themes were identified in four topic areas: (1) prior experiences with technology, (2) desired m-health features, (3) experiences with prototype app, and (4) iteration of prototype. Results: All PLWH who participated (n = 22) were born outside the continental United States. Participants included 10 men, 10 women, and 2 transgender participants. Mean age was 41.1 years (standard deviation 11.6 years). Participants expressed concerns about privacy, a need for reliable information, and interest in practical m-health features such as appointment and medication reminders. After trialing the Spanish-language PL prototype, participants reported that peer support and positive reinforcement were strong motivators to use the app. The ability to individualize the app to meet one's own needs was also considered important. Conclusion: This formative study provides baseline attitudes about m-health among Latinx PLWH as well as desired m-health features. m-Health interventions are acceptable to Spanish-speaking PLWH and involving the target population in a user-centered formative process led to improvements in app accessibility and usability.

Background Age-related chronic conditions are becoming more concerning for people with human immunodeficiency virus (PWH). We aimed to identify characteristics associated with multimorbidity and evaluate for association between multimorbidity and human immunodeficiency virus (HIV) outcomes. Methods Cohorts included PWH aged 45–89 with ≥1 medical visit at one Ryan White HIV/AIDS Program (RWHAP) Southeastern HIV clinic in 2006 (Cohort 1) or 2016 (Cohort 2). Multimorbidity was defined as ≥2 chronic diseases. We used multivariable logistic regression to assess for associations between characteristics and multimorbidity and between multimorbidity and HIV outcomes. Results Multimorbidity increased from Cohort 1 (n = 149) to Cohort 2 (n = 323) (18.8% vs 29.7%, P < .001). Private insurance was associated with less multimorbidity than Medicare (Cohort 1: adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI] = 0.02–0.63; Cohort 2: aOR = 0.53, 95% CI = 0.27–1.00). In Cohort 2, multimorbidity was associated with female gender (aOR, 2.57; 95% CI, 1.22–5.58). In Cohort 1, black participants were less likely to be engaged in care compared with non-black participants (aOR, 0.72; 95% CI, 0.61–0.87). In Cohort 2, participants with rural residences were more likely to be engaged in care compared with those with urban residences (aOR, 1.23; 95% CI, 1.10–1.38). Multimorbidity was not associated with differences in HIV outcomes. Conclusions Although PWH have access to RWHAP HIV care, PWH with private insurance had lower rates of multimorbidity, which may reflect better access to preventative non-HIV care. In 2016, multimorbidity was higher for women. The RWHAP and RWHAP Part D could invest in addressing these disparities related to insurance and gender., At one HIV clinic, multimorbidity prevalence increased among older people with HIV from 2006 to 2016. Private insurance was associated with decreased multimorbidity compared with Medicare in 2006 and 2016, which may reflect better access to preventative non-HIV care.

Coronavirus disease 2019 negatively impacts social determinants of health that contribute to disparities for people with human immunodeficiency virus (HIV). Insecurity of food, housing, and employment increased significantly in April 2020 among patients with lower incomes at a Ryan White HIV/AIDS program clinic in the Southern United States.

BackgroundHepatitis C virus (HCV) and the opioid epidemic disproportionately affect the Appalachian region. Geographic and financial barriers prevent access to specialty care. Interventions are needed to address the HCV-opioid syndemic in this region.MethodsWe developed an innovative, collaborative telehealth model in Southwest Virginia featuring bidirectional referrals from and to comprehensive harm reduction (CHR) programs and office-based opioid therapy (OBOT), as well as workforce development through local provider training in HCV management. We aimed to (1) describe the implementation process of provider training and (2) assess the effectiveness of the telehealth model by monitoring patient outcomes in the first year.ResultsThe provider training model moved from a graduated autonomy model with direct specialist supervision to a 1-day workshop with parallel tracks for providers and support staff followed by monthly case conferences. Forty-four providers and support staff attended training. Eight providers have begun treating independently. For the telehealth component, 123 people were referred, with 62% referred from partner OBOT or CHR sites; 103 (84%) attended a visit, 93 (76%) completed the treatment course, and 61 (50%) have achieved sustained virologic response. Rates of sustained virologic response did not differ by receipt of treatment for opioid use disorder.ConclusionsProviders demonstrated a preference for an in-person training workshop, though further investigation is needed to determine why only a minority of those trained have begun treating HCV independently. The interdisciplinary nature of this program led to efficient treatment of hepatitis C in a real-world population with a majority of patients referred from OBOTs and CHR programs.

Background The Affordable Care Act’s (ACA’s) major reforms started in 2014. In addition to assessing HIV clinicians’ ACA knowledge and attitudes, this study aims to evaluate HIV clinicians’ perspectives on whether the ACA has impacted the quality of HIV care and whether it addresses the main barriers to HIV care. Methods HIV clinicians were emailed a survey weblink in 2018. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results Of the 211 survey participants, the majority (70%) answered all 4 knowledge questions correctly. About 80% knew correctly whether their state had expanded Medicaid. Participants from Medicaid expansion states were more likely to report an improved ability to provide high-quality care compared with participants from Medicaid nonexpansion states (50% vs 34%; P = .01). The average response to whether the ACA addresses the main barriers to HIV care was neutral and did not differ based on Medicaid status. The top 3 main barriers to HIV care cited were mental health, substance use, and transportation. Conclusions HIV clinicians in Medicaid expansion states were more likely to report an improved ability to provide high-quality care since ACA implementation compared with those in Medicaid nonexpansion states. However, HIV clinicians across the United States are concerned that the ACA does not address the main barriers to HIV care. To be successful, the “Ending the HIV Epidemic” initiative should address these identified barriers.

Background The Affordable Care Act (ACA) affects United States’ healthcare by offering Medicaid expansion and tax subsidies to persons with low incomes, and its interaction with the current human immunodeficiency virus (HIV) healthcare delivery system is complex. The objective was to explore HIV medical providers’ knowledge and attitudes about the ACA. Methods HIV medical providers were emailed a weblink to a survey. Descriptive statistics, Mann-Whitney U tests, and binary logistic regression were performed. Results Of the 253 survey participants, the majority (61%) answered all 4 knowledge questions correctly. About 70% knew whether or not their state had decided to expand Medicaid. About 1 in 10 did not know if the ACA eliminated the Ryan White Program. When rating whether the ACA would improve their patients’ HIV outcomes from 1–5 with 5 as “strongly agree,” the providers’ mean responses varied by state Medicaid status: 3.78 (standard deviation [SD], 0.83) for Medicaid expansion compared with 3.37 (SD, 1.00) for Medicaid nonexpansion (P = .002). Adjusting for medical provider type, years of HIV practice, and sources of ACA information, correct ACA knowledge was associated with providing care in a Medicaid nonexpansion state (adjusted odds ratio [aOR], 2.07; 95% confidence interval [CI], 1.11–3.88), obtaining knowledge from case managers (aOR, 1.89; 95% CI, 1.03–3.48), and obtaining knowledge from newspapers/magazines (aOR, 1.94; 95% CI, .99–3.81). Conclusions Medical providers in Medicaid expansion states were more optimistic about the ACA’s likelihood to improve their patients’ HIV outcomes. There are gaps in HIV medical providers’ understanding of the ACA. Education could enhance systems-based practice., HIV medical providers in Medicaid expansion states were more optimistic about the Affordable Care Act’s (ACA) likelihood to improve their patients’ HIV outcomes. There are knowledge gaps in providers’ understanding of the ACA. Education should be disseminated to enhance systems-based practice.

The nature of the HIV epidemic in the United States and Canada has changed with a shift toward rural areas. Socioeconomic factors, geography, cultural context, and evolving epidemics of injection drug use are coalescing to move the epidemic into locations where populations are dispersed and health care resources are limited. Rural–urban differences along the care continuum demonstrate the implications of this sociogeographic shift. Greater attention is needed to build a more comprehensive understanding of the rural HIV epidemic in the United States and Canada, including research efforts, innovative approaches to care delivery, and greater community engagement in prevention and care.

Background For comprehensive care, it is recommended that people living with HIV who are sexually active have annual multisite testing for gonorrhea and chlamydia. Appropriate testing is defined by testing at all sites of sexual exposure (urogenital, pharyngeal, rectal). In the first year of 3 site testing at our HIV clinic, we aimed to describe (1) the rate of appropriate sexually transmitted infection (STI) testing, (2) the factors associated with STI diagnosis, and (3) the percentage of extragenital STIs that would have been missed with only urogenital testing. Methods Participants were > 14 years old with > 1 in-person medical visit at the Ryan White HIV/AIDS Program clinic in 2019. We collected demographics, reported sexual activity, and STI test dates and results. Controlling for number of sites tested, a log-binomial model was used to estimate the association of different characteristics with an STI diagnosis. Results For this cohort (n=857; Table 1), 44% reported sexual activity, 34% reported no sexual activity and 22% had no sexual activity information recorded. Of 1185 STI tests performed for 491 participants, 51 STIs were diagnosed in 33 participants. One STI was diagnosed for a female (0.7%). Overall, 68% (253/375) received appropriate urogenital testing, 63% (85/134) received appropriate pharyngeal testing and 69% (72/105) received appropriate rectal testing. For male participants with > 1 STI test (n=347), Hispanic ethnicity was associated with an STI diagnosis (Table 2). Of those with concurrent extragenital and urogenital tests, 96% of people with an STI (n=26) were positive at only an extragenital site. Table 1: Study Participants’ Characteristics Table 2: Factors Associated with Being Diagnosed With a Sexually Transmitted Infection for Men Living With HIV: Frequencies and Results of Univariable and Multivariable Log-binomial Model Conclusion Nearly a quarter of participants had no sexual activity information recorded in the year, which is an area for improvement. Despite newly adopting 3 site testing, appropriate extragenital and urogenital testing rates were similar and were high compared with national averages. There was no obvious clinician/patient bias against extragenital testing. Hispanic male participants’ higher STI diagnosis rate may point to more condomless sex in this population. Based on the identification of many infections exclusively at extragenital sites, we likely missed STIs previously. This highlights the importance of 3 site testing availability and testing at all appropriate sites. Disclosures Kathleen A. McManus, MD, MSCR, Gilead Sciences, Inc (Research Grant or Support, Shareholder)

Background Most people diagnosed with Hepatitis C virus (HCV) have not linked to care. The patient perspective on decision-making regarding linkage to care (LTC) in the direct acting antivirals treatment era is limited. We assess perceptions that impacted the choice not to pursue care among non-urban patients in the South who failed to attend an HCV clinic appointment. Methods We conducted a demographic survey and semi-structured interview with participants referred to our HCV clinic between 2014 and 2018 who did not attend an appointment. Data collection and analyses were guided by the Health Belief Model. Results Twelve participants enrolled, including 7 men and 5 women. Barriers to care were common including being uninsured (33%), having unreliable transportation (42%), unstable housing (33%), and a history of substance use disorder requiring treatment (58%). Participants demonstrated good knowledge of HCV disease, complications, and treatment. Emerging themes regarding failure of LTC included: (1) ambivalence due to uncertainty regarding the impact of HCV on one’s own health, (2) logistical barriers such as financial concerns, lack of insurance, transportation, scheduling conflicts, (3) prior negative experiences with HCV care resulting in hesitance to seek care, (4) stigma, and (5) patient-provider relationships as a barrier when the relationship is poor and a facilitator when good. Conclusions A strong HCV knowledge base was not sufficient for participants to seek care. Strategies to increase treatment uptake by changing patient perceptions include addressing the uncertainty of how HCV impacts one’s health, acknowledging challenges with HCV treatment in the past, eliminating stigma in health care settings, and promoting education regarding treatment ease and availability. Expanding access to Medicaid may overcome perceived financial barriers. Providing HCV care in settings with an established patient-provider relationship may increase treatment uptake.

Background. Many AIDS Drug Assistance Programs (ADAPs) purchased Affordable Care Act (ACA) Qualified Health Plans (QHPs) for low-income people living with HIV (PLWH). To date, little has been published about PLWH’s perspective on the ACA. We explored ACA knowledge, HIV stigma, trust in the healthcare system, and ACA attitudes among PLWH with ADAP-funded QHPs in Virginia. Methods. Participants were surveyed about demographic characteristics, ACA knowledge, HIV stigma, trust in various healthcare and government entities, and attitudes toward the ACA. Descriptive statistics were used. We assessed for associations (1) between baseline characteristics and correct ACA knowledge, HIV-related stigma, trust, and ACA attitudes and (2) between correct ACA knowledge and the following data: sources of ACA knowledge, HIV stigma, and trust. Results. Participants (n = 53) were a vulnerable population based on the assessment of social determinants of health, and 30% had correct ACA knowledge. Almost three-fourths of participants used HIV clinic case managers for ACA information. Participants who used websites for ACA information had correct ACA knowledge more often compared to those that did not (71% vs. 15%; p = 0.001). Those with correct ACA knowledge had lower stigma scores compared to those without correct ACA knowledge (93.8; SD: 15.4 vs. 108; SD: 20.3; p = 0.01). Participants trusted HIV clinicians more than general clinicians and insurance companies. No association was found between having correct ACA knowledge and endorsing having enough information about the ACA to understand how it will impact their HIV care. Conclusions. Websites imparted accurate ACA information. HIV clinic case managers were the most used source, and HIV clinicians were a trusted source of information. HIV clinicians and case managers should consider disseminating information about the ACA and its impact on HIV care delivery via internet videos. Lack of internet and stigma are a threat to PLWH gaining actionable healthcare information.

Background: Direct acting antivirals (DAAs) have simplified and expanded access to Hepatitis C virus (HCV) treatment. Only 17% of the 2.4 million Americans with HCV have linked to HCV care. We aimed to evaluate linkage to care (LTC) in a non-urban HCV referral clinic with a nurse navigator model and identify disparities in LTC.Methods: A single-center retrospective cohort analysis was performed among all patients referred to an infectious diseases HCV clinic between 2014 and 2018. The primary outcome was LTC, defined as attendance at a clinic appointment. A multivariable Poisson regression model estimated the association of variables with LTC.Results: Among 824 referred patients, 624 (76%) successfully linked to care and 369 (45%) successfully achieved sustained virologic response. Forty-six percent of those referred were uninsured. On multivariable analysis, LTC rates were higher among women (Incidence Rate Ratio [IRR] 1.11, 95% CI 1.03–1.20, p-value = 0.01) and people with cirrhosis (IRR 1.20, 95% CI 1.11–1.30, p-value < 0.001). Lower LTC rates were found for young people (

Background An academic Ryan White HIV/AIDS Program clinic increased co-located mental health care (MH) services in 2013. The study objectives were to characterize the changing demographics of the people living with HIV (PLWH) who initiated MH and to determine MH initiation’s association with HIV outcomes. Methods The cohort included PLWH who received clinic-based MH services from 2012 to 2014. Cohorts A and B initiated MH before or during 2012 and during 2013–2014, respectively. Demographics were compared for the 2 cohorts, and for Cohort B, pre/post–MH initiation clinical outcomes were compared. Results Compared with Cohort A (n = 130), Cohort B (n = 181) had 3 times the participants with CD4 counts

With the implementation of the Affordable Care Act (ACA) in 2014, many safety net resources, including state AIDS Drug Assistance Programs (ADAPs), incorporated ACA Qualified Health Plans (QHPs) into their healthcare delivery model. This article highlights the benefits of the ACA for persons living with HIV. It also describes the range of strategies employed by state ADAPs to enroll patients in QHPs. The Virginia ADAP ACA implementation experience is described to illustrate one ADAP's shift to purchasing QHPs in addition to providing direct medications. Virginia ADAP is in a Medicaid nonexpansion state and funds the full costs of the QHP premiums, deductibles, and medication copayments. Virginia's experience is applicable to other Medicaid nonexpansion states and to state ADAPs in Medicaid expansion states, who are looking for options for their Medicaid ineligible clients. This article provides practical details of Virginia ADAP's ACA implementation as well as insights and best practices at both the state and clinic level.

BACKGROUND With the Patient Protection and Affordable Care Act, many state AIDS Drug Assistance Programs (ADAPs) shifted their healthcare delivery model from direct medication provision to purchasing qualified health plans (QHPs). The objective of this study was to characterize the demographic and healthcare delivery factors associated with Virginia ADAP clients' QHP enrollment and to assess the relationship between QHP coverage and human immunodeficiency virus (HIV) viral suppression. METHODS The cohort included persons living with HIV who were enrolled in the Virginia ADAP (n = 3933). Data were collected from 1 January 2013 through 31 December 2014. Multivariable binary logistic regression was conducted to assess for associations with QHP enrollment and between QHP coverage and viral load (VL) suppression. RESULTS In the cohort, 47.1% enrolled in QHPs, and enrollment varied significantly based on demographic and healthcare delivery factors. In multivariable binary logistic regression, controlling for time, age, sex, race/ethnicity, and region, factors significantly associated with achieving HIV viral suppression included QHP coverage (adjusted odds ratio, 1.346; 95% confidence interval, 1.041-1.740; P = .02), an initially undetectable VL (2.809; 2.174-3.636; P < .001), HIV rather than AIDS disease status (1.377; 1.049-1.808; P = .02), and HIV clinic (P < .001). CONCLUSIONS QHP coverage was associated with viral suppression, an essential outcome for individuals and for public health. Promoting QHP coverage in clinics that provide care to persons living with HIV may offer a new opportunity to increase rates of viral suppression.

This cross-sectional study investigates whether there are regional disparities in prior authorization requirements for combined tenofovir disoproxil fumarate and emtricitabine with qualified health plans and assesses if any qualified health plan characteristics explain the disparities., Key Points Question For qualified health plans in the 2019 Affordable Care Act Health Insurance Marketplace in the United States, are there regional disparities in prior authorization requirements for HIV pre-exposure prophylaxis? Findings Among 16 853 qualified health plans in this cross-sectional study, the proportion of qualified health plans in the South that required prior authorization for HIV pre-exposure prophylaxis was 37% compared with 13% in the Midwest, 6% in the West, and 2% in the Northeast. Meaning High rates of required prior authorization are a possible barrier to HIV pre-exposure prophylaxis access in the South, which is the region of the United States with the most annual new HIV infections., Importance With the goal of ending the HIV epidemic in the United States, access to HIV pre-exposure prophylaxis (PrEP) is essential to help curb new HIV infections. There has been differential uptake of PrEP by region, with the South lagging behind other regions. Discriminatory benefit design (benefit design that prevents or delays people with complex or expensive conditions from obtaining appropriate treatment) through prior authorization requirements could be a systemic barrier that contributes to the decreased PrEP uptake in the South. Objectives To investigate whether there are regional disparities in prior authorization requirements for combined tenofovir disoproxil fumarate and emtricitabine for qualified health plans (QHPs) and to assess whether any QHP characteristics explain the disparities. Design, Setting, and Participants This design was a cross-sectional study of QHPs offered in the 2019 Affordable Care Act Marketplace. The QHPs studied included all Affordable Care Act–compliant individual and small-group market plans in the United States. Exposures The primary exposure was the 4 census regions (Northeast, West, Midwest, and South). Additional covariates included other plan characteristics. Main Outcomes and Measures Prior authorization requirement for combined tenofovir disoproxil fumarate and emtricitabine at the QHP level. Results In total, 16 853 QHPs were analyzed (18.2% in the Northeast, 19.5% in the West, 25.0% in the Midwest, and 37.3% in the South). Overall, 18.9% of QHPs required prior authorization for combined tenofovir disoproxil fumarate and emtricitabine. This percentage varied by region, with 2.3%, 6.2%, 13.3%, and 37.3% of plans requiring prior authorization in the Northeast, West, Midwest, and South, respectively. Compared with QHPs in the Northeast, QHPs in the South were 15.89 (95% CI, 12.57-20.09) times as likely to require prior authorization, whereas the Midwest and West were 5.69 (95% CI, 4.45-7.27) and 2.65 (95% CI, 2.02-3.47) times as likely, respectively. Other plan characteristics did not account for the regional variation. Conclusions and Relevance Compared with QHPs in the Northeast, QHPs in the South were almost 16 times as likely to require prior authorization for PrEP, and the reasons for these disparities are unknown. The prior authorization requirement is a possible barrier to PrEP access in the South, which is the region of the United States with the most annual new HIV diagnoses. There is limited regulation of QHPs’ prior authorization requirements. Federal- or state-level health policy laws may be necessary to remove this system-level barrier to ending the HIV epidemic in the United States.

Background Hepatitis C is now curable for most individuals, and national goals for elimination have been established. Transmission persists, however, particularly in nonurban regions affected by the opioid epidemic. To reach goals of elimination, barriers to treatment must be identified. Methods In this open cohort of all individuals diagnosed with active hepatitis C from 2010 to 2016 at a large medical center, we identified patient and clinic characteristics associated with our primary outcome, sustained virologic response (SVR). We performed a subgroup analysis for those with documented substance misuse. Results SVR was achieved in 1544 (41%) of 3790 people with active hepatitis C. In a multivariable Poisson regression model, SVR was more likely in individuals diagnosed outpatient (incident rate ratio [IRR], 1.7; 95% confidence interval [CI], 1.5–2.0), living in close proximity to the medical center (IRR, 1.2; 95% CI, 1.1–1.3), with private insurance (IRR, 1.1; 95% CI, 1.0–1.3), and with cirrhosis (IRR, 1.4; 95% CI, 1.3–1.5). Achieving SVR was less likely in those qualifying as indigent (IRR, 0.8; 95% CI, 0.8–0.9) and those with substance misuse (IRR, 0.8; 95% CI, 0.7–0.9). In the subgroup analysis of those with substance misuse, SVR rates were higher in those linked to the infectious diseases clinic, which has embedded support services, than those linked to the gastroenterology clinic, which does not (IRR, 1.4; 95% CI, 1.1–1.9). Conclusions Social determinants of health including proximity to care and poverty impacted achievement of SVR. Those with substance misuse, a high-priority population for treatment of hepatitis C, had better outcomes when receiving care in a clinic with embedded support services.

Background In individual states, the Patient Protection and Affordable Care Act has been associated with improved viral suppression (VS) rates for AIDS Drug Assistance Program (ADAP) clients or low-income people living with HIV (PLWH). This study aims to assess whether this association is consistent in multiple states (Nebraska, South Carolina, Virginia). Methods The multistate cohort included ADAP clients who were eligible for ADAP-funded Qualified Health Plans (QHPs). Data were collected from 2014 through 2015. A log-binomial model was used to estimate the association of demographics (age, race/ethnicity, sex, AIDS, rurality, HIV risk factor, previous VS) and healthcare delivery factors (income, previous ADAP plan, previous HIV care engagement) with QHP enrollment prevalence and 1-year risk of VS. Results For the cohort (n = 7,800; 5% NE, 36% SC, 59% VA), 52% enrolled in ADAP-funded QHPs with enrollment ranging from 35% to 63% by state. Enrollment in ADAP-funded QHPs in 2015 was higher for those who had ADAP-funded QHPs in 2014 (adjusted prevalence ratio [aPR] 3.28; 95% confidence interval [CI] 3.21–3.35) and those who were engaged in care in 2014 (aPR 1.16; 95% CI 1.05–1.27), and it was lower for those with a rural residence (aPR 0.91; 95% CI 0.81–1.00). Of those who were consistently engaged in care (n = 4,597), as defined by one viral load in 2014 and one viral load in 2015 separated by at least 180 days, those who received medications from Direct ADAP had a VS rate of 80.2% and those with ADAP-funded QHPs had a VS rate of 86.0%. The number needed to enroll in ADAP-funded QHPs for an additional PLWH to achieve VS is 18. Those who achieved VS in 2014 (adjusted risk ratio [aRR] 1.39, 95% CI 1.30–1.48) and those who enrolled in QHPs in 2015 (aRR 1.06, 95% CI 0.99–1.13) were more likely to achieve/maintain VS. Conclusion Additional efforts should be made to reach rural PLWH for QHP enrollment. State ADAPs, especially those in the South and those in states without Medicaid expansion, should consider investing in purchasing QHPs for PLWH because increased enrollment could improve VS rates. This evidence-based intervention could be a part of “Ending the HIV Epidemic.” Once ADAP clients are enrolled in ADAP-funded QHPs, they stay enrolled, and QHP enrollment is associated with VS across states and demographic groups. Disclosures All Authors: No reported Disclosures.

Background Direct-acting antivirals (DAAs) have simplified and expanded access to Hepatitis C virus (HCV) treatment. Only 17% of the estimated 2.4 million Americans currently infected with HCV have linked to HCV specialty care. We evaluated linkage to care (LTC) in a non-urban hepatitis C referral clinic with a nurse navigator model of care and identified disparities in LTC during the DAA era. Methods A single-center retrospective cohort analysis was performed among all patients referred to an infectious diseases HCV clinic between 2014 and 2018. The primary outcome was LTC, defined as attendance at a clinic appointment. A multivariable Poisson regression model estimated associations of patient characteristics with LTC. Results Among 824 referred patients, 624 (76%) successfully linked to care and 369 (45%) achieved sustained virologic response. The mean age was 48.5 years (SD 13.5 years) and 46% (382 of 824) were uninsured. Common reasons for failure of LTC included no-shows (26.5%), could not be contacted (20.5%) and incarceration (10%). On multivariable analysis, LTC rates were higher among women (incidence rate ratio (IRR) 1.11, 95% CI 1.03–1.20, P = 0.01) and those with cirrhosis (IRR 1.20, 95% CI 1.11–1.30, P < 0.001). Lower rates of LTC were seen for young people (< 40 years old) (IRR 0.88, 95% CI 0.79–0.98, P = 0.02) and uninsured people (IRR 0.85, 95% CI 0.77–0.94, P = 0.002). Race, proximity to care, substance use, and HIV status were not associated with differences in LTC rates. Conclusion In an embedded nurse navigator model of care, a high rate of LTC was achieved despite the prevalence of barriers, including a high uninsured rate. LTC was the biggest drop-off in the cascade. Disparities in LTC based on age, sex, and insurance status are present. Substance use was not associated with differences in LTC, supporting current recommendations to provide treatment to all patients with HCV. No-shows were common, potentially due to lack of reliable contact information or lack of transportation. Qualitative work exploring patients’ experiences leading to failure of LTC would be helpful. Future interventions to improve care could include expanded access to insurance, affordable medical tests, and programs bridging care for incarcerated populations. Disclosures All authors: No reported disclosures.

Background While morbidity and mortality related to HIV are decreasing, age-related chronic conditions are becoming more common in people living with HIV (PLWH). We hypothesized that multimorbidity prevalence among PLWH would increase from 2006 to 2016 and that multimorbidity would be associated with demographic and healthcare system-level factors. Methods Cohorts included PLWH aged 45–89 who received care at the University of Virginia (UVA) Ryan White HIV clinic in 2006 (Cohort 1) and 2016 (Cohort 2). Multimorbidity was defined as the co-occurrence of ≥2 age-related chronic diseases. Demographics, HIV-specific clinical characteristics and multimorbidity were compared between the cohorts using a generalized linear model fit using a generalized estimating equation that accounted for repeated measures. Within each cohort, multivariable binary logistic regression was used to assess the association between participants’ characteristics and multimorbidity. Results Cohort 1 had 198 participants, and Cohort 2 had 378 participants. Cohort 1 represented 33% of the 2006 clinic population, and Cohort 2 represented 54% of the 2016 clinic population. Less Cohort 2 participants were uninsured (5% vs. 22%, P < 0.001) and more had private insurance (44% vs. 26%, P < 0.001). The prevalence of multimorbidity was higher in Cohort 2 (28% vs 21%, P < 0.001). For Cohort 1, multimorbidity was less likely for those with private insurance (8%, adjusted Odds Ratio [aOR] 0.81, 95% Confidence Interval [CI] 0.69–0.90) compared with those with Medicare (32%). For Cohort 2, multimorbidity was more likely for those with incomes < 100% Federal Poverty Level (FPL; 34%) compared with those with incomes 101–250% FPL (27%, aOR 0.86, 95% CI 0.74–1.00) and 251–500% FPL (21%, aOR 0.78, 95% CI 0.64–0.95). For Cohort 2, multimorbidity was associated with female sex (40%, aOR 1.21, 95% CI 1.01–1.45) compared with male sex (24%). Conclusion Older PLWH represented an increasing proportion of the studied Southeastern clinic population. Multimorbidity prevalence was higher in 2016 compared with 2006. Insurance status was associated with multimorbidity for Cohort 1. For Cohort 2, incomes < 100% FPL and female sex were associated with increased likelihood of multimorbidity. Future research will need to assess the reasons for these disparities. Disclosures All authors: No reported disclosures.

Background Immune reconstitution inflammatory syndrome (IRIS) can manifest with initiation or reintroduction of antiretroviral therapy (ART) in persons living with HIV (PLWH). In 2012, updated United States treatment guidelines recommended initiation of ART for all PLWH regardless of CD4 count. The objectives of this study were to quantify hospital usage attributable to IRIS and assess the reasons for hospitalization in PLWH before and after the guideline update. Methods Subjects were PLWH between 18–89 years of age who were hospitalized between November 1, 2009 and July 31, 2014. Equivalent time periods before and after updated treatment guidelines were considered, and designated as Time Period 1 and Time Period 2, respectively. IRIS-attributable hospitalizations were identified by ICD9 codes and electronic medical record searches with subsequent review and confirmation. For hospitalizations that were not confirmed as being IRIS-attributable, primary discharge diagnoses were reviewed. Results A total of 278 PLWH were hospitalized 521 times throughout the study period. Time Period 1 had 9 PLWH with 12 IRIS-attributable hospitalizations while Time Period 2 had 6 PLWH with 9 IRIS-attributable hospitalizations. A larger proportion of IRIS-attributable hospital days was observed in Time Period 1 compared to Time Period 2 (7.5 vs 4.2%; p

AIDS Drug Assistance Programs, enacted through the Ryan White Comprehensive AIDS Resources Emergency Act of 1990, are the “payer of last resort” for prescription medications for lower income, uninsured, or underinsured people living with HIV/AIDS. ADAPs face declining funding from the federal government. State funding of ADAP is discretionary, but some states increased their contributions to meet the gap in funding. The demand for ADAP support is increasing as people living with HIV are living longer; the antiretroviral therapy (ART) guidelines have been changed to recommend initiation of treatment for all; the United States is increasing HIV testing goals; and the recession continues. In the setting of increased demand and limited funding, ADAPs are employing cost containment measures. Since 2010, emergency federal funds have bailed out ADAP, but these are not sustainable. In the coming years, providers and policy makers associated with HIV care will need to navigate the implementation of the Affordable Care Act (ACA). Lessons learned from the challenges associated with providing sustainable access to ART for vulnerable populations through ADAP should inform upcoming decisions about how to ensure delivery of ART during and after the implementation of the ACA.

Acute HIV infection (AHI) is often marked by nonspecific and vague complaints, which make detection difficult. An 18-year-old man presented with one week history of subjective fevers with chills, nonproductive cough and generalized body aches. He was found to have rhabdomyolysis due to AHI. This report adds the most thoroughly investigated case of AHI-associated rhabdomyolysis to date, having ruled out erlichia, legionella, parainfluenza, adenovirus, enterovirus, metapneumovirus, RSV and DILS.

People living with human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) often are uninsured or underinsured, and they may benefit from the Patient Protection and Affordable Care Act (PL 111-148) and its improved access to medical care. Safety net programs, such as AIDS Drug-Assistance Programs (ADAPs) funded through the Ryan White HIV/AIDS Program, which serve low-income people living with HIV, are incorporating Patient Protection and Affordable Care Act Marketplace–qualified health plans (QHPs) and helping to fund patients' participation. This changing landscape differs from state to state, and one main element contributing to the differing situations is whether a state elected to expand Medicaid. This review examines QHP enrollment of ADAP clients in Virginia, a Medicaid nonexpansion state, and explores some issues that affect people living with HIV in other Medicaid nonexpansion states. Virginia is a leader in the shift of ADAP healthcare delivery from direct medication provision to purchasing QHPs. Virginia ADAP clients accounted for approximately 2% of ADAP clients nationally, but they represent 17% of ADAP clients enrolled in QHPs nationwide. Ensuring good HIV care of the ADAP population is important to each patient's personal longevity, the public health, and the efficient use of healthcare dollars. As healthcare delivery models shift, the effects on patients and health outcomes achieved should be monitored, particularly for chronic diseases such as HIV.

We report fMRI findings in 3 asymptomatic cases of agenesis of the corpus callosum, the largest white matter bundle in the brain, which is responsible for interhemispheric transfer of information. Sensory information was presented to 1 hemisphere, and the patients had to generate a motor response governed by the contralateral hemisphere. Enhanced ipsilateral motor pathways have been suggested as a compensation method for people with agenesis of the corpus callosums; our functional magnetic resonance imaging data did not support this theory.

Background Hepatitis C virus (HCV) infection is now curable for most individuals and national goals for elimination have been established. Transmission remains ongoing, particularly in non-urban regions affected by the opioid epidemic. To reach elimination goals, barriers to treatment must be identified with a priority placed on those with substance abuse. Methods In this retrospective cohort study of all individuals with chronic HCV from 2010 to 2016 at a large medical center serving a predominately non-urban population, we identified patient and clinic characteristics associated with our primary outcome, sustained virologic response (SVR). We performed a subgroup analysis for those with documented substance abuse. Results SVR was achieved in 1,544 (41%) of 3,790 people with chronic HCV (Figure 1). In a multivariate Poisson regression model adjusted for patient demographics and year of diagnosis, SVR was less likely in those with substance abuse (IRR 0.8, 95% CI 0.7–0.9). In the subgroup analysis of those with substance abuse (N = 682), SVR rates were higher in those linked to the infectious diseases clinic, which has embedded support services, than in those linked to gastroenterology, which does not (IRR 1.4, 95% CI 1.1–1.9) (table). Higher SVR rates were driven by an increased rate of medication prescribing in those linked to infectious diseases (IRR 1.3, 95% CI 1.1–1.6) (Figure 2). Conclusion Those with substance abuse, a high priority population for treatment of HCV, had better outcomes when receiving care in a clinic with embedded support services. Figure 1. Hepatitis C cascade of care. Table. Factors Associated with SVR in a Multivariable Poisson Regression Model Among Those with Substance Abuse Linked to Care (N = 458) Incidence Rate Ratio* (95% CI) P Hepatitis C clinic Gastroenterology 1 (ref) - Infectious diseases 1.4 (1.1–1.9) 0.01 Diagnosis characteristics Outpatient diagnosis 1.5 (1.1–2.1) 0.01 * Incidence rate ratios are adjusted for patient demographics (age, sex, race, proximity to medical center, financial status, insurance type), diagnosis year and comorbidities (cirrhosis, hepatocellular carcinoma, HIV, hepatitis B) in addition to variables shown in table above. Figure 2. HCV cascade of care for those with substance abuse linked to care. Disclosures All authors: No reported disclosures.

Clostridium perfringensbacteremia is an uncommon yet serious clinical syndrome that typically arises from a gastrointestinal source. However, clinicians should consider nongastrointestinal sources as well. We present a rare case ofC. perfringensbacteremia of urinary origin that required surgical intervention for definitive treatment. A 61-year-old male presented with acute nausea and vomiting, altered mental status, and chronic diarrhea. His physical exam revealed right costovertebral tenderness and his laboratory work-up revealed acute renal failure. Percutaneous blood cultures grewC. perfringens. Cross-sectional imaging revealed a right-sided ureteral stone with hydronephrosis, which required nephrostomy placement. On placement of the nephrostomy tube, purulent drainage was identified and Gram stain of the drainage revealed Gram-variable rods. A urinary source ofC. perfringenswas clinically supported. Although it is not a common presentation, nongastrointestinal sources such as a urinary source should be considered inC. perfringensbacteremia because failure to recognize a nongastrointestinal source can delay appropriate treatment, which may include surgical intervention.

anaging a patient with chronic alcohol abuse who is beginning to withdraw is a situation in which to expect the unexpected. A 61-year-old man with a 40-year history of alcohol abuse was admitted to the hospital after presenting with a 6-month history of weakness and increasing frequency of falls, as well as a 2-day history of myalgias and fatigue. He had anorexia and chronic diarrhea, and he reported an unintentional 100-lb weight loss over the past year. He consumed at least three to five alcoholic drinks daily, including a daily “eye-opener,” and his diet was essentially devoid of meat, bread, fruits, and vegetables. His last drink had been on the morning of admission. On physical examination, his vital signs were no-table for marked orthostatic hypotension. He had an-gular cheilitis, an erythematous, scaly facial rash, and poorly healing severe sunburn on the dorsal surface of the left forearm, acquired 1 month earlier after mini-mal sun exposure while driving his car (

To evaluate Gd-DTPA contrast enhancement of brain tumors over time and to describe the dispersion of contrast into the zone of peritumoral edema. We performed MR imaging with a dose of 0.4 mmol Gd-DTPA/kg on eleven patients diagnosed with 5 different supratentorial tumors. MR imaging was done at five intervals between 5 min and 6 h. The change in zone of enhancement was measured for each time point, and a linear measurement was made of the furthest dispersion of contrast from the original volume of enhancement. An increase in the zone of enhancement over time was seen for all tumors; the average increase in volume of contrast was 14.76 +/- 3.35 cm(3) (mean +/- standard deviation). The largest changes in the zone of contrast enhancement, 18.6 +/- 4.63 cm(3), were seen in glioblastoma multiforme. The expansion of contrast enhancement assumed the morphology of the surrounding edema. The dispersion of Gd-DTPA over time into the zone of peritumoral edema is a potential source of error in clinical settings when there is a delay between Gd-DTPA injection and scanning.

Objectives: To describe the impacts of Virginia AIDS Drug Assistance Program’s elimination of diabetes and hyperlipidemia medication on disease outcomes in people living with HIV. Methods: Data were collected on two groups of people living with HIV who were prescribed medications for diabetes and/or hyperlipidemia; one group received medications from AIDS Drug Assistance Program (ADAP) and the other group received medications from another source. Data were collected for 13 months before and after the policy change. Diabetes, hyperlipidemia, and HIV control were compared using standard laboratory measures. Results: During the pre-policy-change time period, non-ADAP patients had better diabetes control than ADAP patients, but with multivariate analysis, ADAP status was no longer a statistically significant predictor. Otherwise, no significant differences between groups were identified. Discussion: ADAP patients had worse diabetes control compared to the non-ADAP group before the policy change. It is possible that this is due to the AIDS Drug Assistance Program population’s poor access to non-HIV primary care, including care for diabetes. It is reassuring that, even during a time of flux in AIDS Drug Assistance Program resources, the AIDS Drug Assistance Program patients’ co-morbid and HIV outcomes were not negatively impacted.