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The Ending the HIV Epidemic initiative aims to decrease new HIV infections and promote test-and-treat strategies. Our aims were to establish a baseline of HIV outcomes among newly diagnosed PWH in Washington, DC (DC), a ‘hotspot’ for the HIV epidemic. We also examined sociodemographic and clinical factors associated with retention in care (RIC), antiretroviral therapy (ART) initiation and viral suppression (VS) among newly diagnosed PWH in the DC Cohort from 2011–2016. Among 455 newly diagnosed participants, 92% were RIC at 12 months, ART was initiated in 65% at 3 months and 91% at 12 months, VS in at least 17% at 3 months and 82% at 12 months and 55% of those with VS at 12 months had sustained VS for an additional 12 months. AIDS diagnosis was associated with RIC (aOR 2.99; 1.13–2.28), ART initiation by 3 months (aOR 2.58; 1.61–4.12) and VS by 12 months (aOR4.87; 1.69–14.03). This analysis contributes to our understanding of the HIV treatment dynamics of persons with recently diagnosed HIV infection in a city with a severe HIV epidemic.

Pre-exposure prophylaxis (PrEP) for HIV is highly effective, yet uptake has been limited. We measured PrEP knowledge, eligibility, and referral willingness among patients receiving emergency or acute care in Washington, DC. We surveyed HIV-negative patients with STI-related complaints on HIV risk behaviors, PrEP knowledge, eligibility, and willingness for PrEP referral. Among 174 participants, 70% were PrEP unaware and 33% were PrEP eligible. Most participants (81%) supported learning more, 64% would consider taking PrEP, and 28% agreed to immediate referral. Willingness to learn more about PrEP suggests referral from non-traditional settings may increase uptake. Further evaluation of this approach is warranted.

Unmet needs can impede optimal care engagement, impacting the health and well-being of people living with HIV (PLWH); yet, whether unmet needs differ by care engagement status is not well understood. Using surveys and qualitative interviews, we examined and compared unmet needs for PLWH (n = 172) at different levels of care engagement. Unmet needs varied only slightly by care status. Survey findings revealed that provision of housing, emergency financial assistance, employment assistance, and food security were the greatest unmet need; for those in care, housing was the greatest unmet need, whereas for those sporadically in care or out of care, employment assistance was the greatest unmet needs. Qualitative interviews likewise illustrated that a lack of financial resources including insurance, housing, employment, and transportation presented barriers to care engagement across all care groups. Our findings indicate that unmet needs among PLWH are complex and multi-faceted across care engagement status.

Pre-exposure prophylaxis (PrEP) is an effective method to prevent HIV acquisition in high-risk individuals. This cross-sectional survey study estimated the proportion of patients who were PrEP eligible among a targeted sample of emergency department (ED) patients with chief complaints indicative of HIV risk. Research assistants screened a convenience sample of adult patients who presented to two hospital EDs in Washington, DC, during a 6-month period with genitourinary, substance use, or intentional injury-related complaints. Patients with these complaints who reported being sexually active within the past 6 months and HIV negative completed a computer-assisted survey that included questions on sexual practices and partners, substance use, and attitudes and knowledge about PrEP. We used the Centers for Disease Control and Prevention (CDC) clinical guidelines to determine whether PrEP use was indicated. We report differences in PrEP eligibility by demographic characteristics, knowledge, and attitudes. Of the 410 participants, the majority were black (85%), and heterosexual females (72%). PrEP use was indicated in 20% (N = 84), most commonly because of condomless sex with a person of unknown HIV status (82%) and/or a sexually transmitted infection (STI) diagnosis (41%). One-third (34%) of participants had heard of PrEP. Overall, 36% of the sample (N = 148) wanted to learn more about PrEP while in the ED. The percentage who wanted to learn more about PrEP was higher among PrEP-eligible patients (52%) compared with PrEP-ineligible patients (32%). Using CDC criteria, targeted screening identified that a substantial proportion of ED patients are PrEP eligible based on their self-reported behaviors.

Background The Undetectable = Untransmittable (U = U) campaign advances the goal of ending the HIV epidemic by promoting durable viral suppression and therefore reducing sexual transmission. We used geospatial analysis to assess the potential for sexual HIV transmission by ZIP code of residence in the District of Columbia (DC) using data from the DC Cohort Longitudinal HIV Study (DC Cohort), a city-wide cohort of persons with HIV (PWH). Methods DC Cohort participants aged ≥13 years were included in the study period between April 1, 2016, and March 31, 2018. Potential for sexual HIV transmission was defined as the proportion of participants with incident sexually transmitted infection (STI; gonorrhea, chlamydia, syphilis) and with HIV RNA ≥200 copies/mL from 9 months before to 3 months after STI diagnosis. We performed geographic information system (GIS) analysis to determine the ZIP codes with the highest potential for sexual HIV transmission. Results Of 3467 participants, 367 (10.6%) had at least 1 incident STI, with 89.4% residing in 11 of the 20 residential ZIP codes in DC. Of the 367 participants with an incident STI, at least 1 HIV RNA was available for 348 (94.8%). Ninety-seven (27.9%) individuals with an incident STI had HIV RNA ≥200 copies/mL in the defined time window. Of these 97, 66 (68.0%) resided in 5 of the 20 DC ZIP codes. Conclusions In DC, 5 ZIP codes of residence accounted for the majority of the estimated potential for HIV transmission among participants in the DC Cohort. These results support focused neighborhood-level interventions to help end the HIV epidemic.

Background Using the results of a site assessment survey performed at clinics throughout Washington, DC, we studied the impact of clinic-level factors on antiretroviral therapy (ART) initiation and viral suppression (VS) among people living with human immunodeficiency virus (HIV; PLWH). Methods This was a retrospective analysis from the District of Columbia (DC) Cohort, an observational, clinical cohort of PLWH from 2011–2018. We included data from PLWH not on ART and not virally suppressed at enrollment. Outcomes were ART initiation and VS (HIV RNA < 200 copies/mL). A clinic survey captured information on care delivery (eg, clinical services, adherence services, patient monitoring services) and clinic characteristics (eg, types of providers, availability of evenings/weekends sessions). Multivariate marginal Cox regression models were generated to identify those factors associated with the time to ART initiation and VS. Results Multiple clinic-level factors were associated with ART initiation, including retention in care monitoring and medication dispensing reviews (adjusted hazard ratios [aHRs], 1.34 to 1.40; P values < .05 for both). Furthermore, multiple factors were associated with VS, including retention in HIV care monitoring, medication dispensing reviews, and the presence of a peer interventionist (aHRs, 1.35 to 1.72; P values < .05 for all). In multivariable models evaluating different combinations of clinic-level factors, enhanced adherence services (aHR, 1.37; 95% confidence interval [CI], 1.18–1.58), medication dispensing reviews (aHR, 1.22; 95% CI, 1.10–1.36), and the availability of opioid treatment (aHR, 1.26; 95% CI, 1.01–1.57) were all associated with the time to VS. Conclusions The observed association between clinic-level factors and ART initiation/VS suggests that the presence of specific clinic services may facilitate the achievement of HIV treatment goals.

Integrase inhibitors (INSTIs) are recommended by expert panels as initial therapy for people with HIV. Because there can be disparities in prescribing and uptake of novel and/or recommended therapies, this analysis assessed potential INSTI prescribing disparities using a combined data set from the Johns Hopkins HIV Clinical Cohort and the DC Cohort. We performed multivariable logistic regression to identify factors associated with ever being prescribed an INSTI. Disparities were noted, including clinic location, age, and being transgender. Identifying disparities may allow clinicians to focus their attention on these individuals and ensure that therapy decisions are grounded in valid clinical reasons., We assessed INSTI prescribing disparities using Johns Hopkins HIV Clinical Cohort/DC Cohort data. Disparities were noted, including clinic location, age, and being transgender. Clinicians should focus their attention on these individuals and make therapy decisions grounded in valid clinical reasons.

We conducted a retrospective analysis of 38 children and youth with human immunodeficiency virus (aged 0–19 years) in the United States and report an increased rate of change of BMI-for-age z score after initiating integrase strand transfer inhibitors (+0.19 z score units/year [95% confidence interval, .01–.37]; P = .036) for a median follow-up of 527.5 days., Children and youth with HIV in the United States (n=38) have an increased rate of change of BMI-for-age z-score (+0.19 z-score units/year) after initiating integrase strand transfer inhibitors for a median follow-up of 527.5 days.

Molecular epidemiology (ME) is one tool used to end the HIV epidemic in the United States. We combined clinical and behavioral data with HIV sequence data to identify any overlap in clusters generated from different sequence datasets; to characterize HIV transmission clusters; and to identify correlates of clustering among people living with HIV (PLWH) in Washington, District of Columbia (DC). First, Sanger sequences from DC Cohort participants, a longitudinal HIV study, were combined with next-generation sequences (NGS) from participants in a ME substudy to identify clusters. Next, demographic and self-reported behavioral data from ME substudy participants were used to identify risks of secondary transmission. Finally, we combined NGS from ME substudy participants with Sanger sequences in the DC Molecular HIV Surveillance database to identify clusters. Cluster analyses used HIV-Transmission Cluster Engine to identify linked pairs of sequences (defined as distance ≤1.5%). Twenty-eight clusters of ≥3 sequences (size range: 3–12) representing 108 (3%) participants were identified. None of the five largest clusters (size range: 5–12) included newly diagnosed PLWH. Thirty-four percent of ME substudy participants (n = 213) reported condomless sex during their last sexual encounter and 14% reported a Syphilis diagnosis in the past year. Seven transmission clusters (size range: 2–19) were identified in the final analysis, each containing at least one ME substudy participant. Substudy participants in clusters from the third analysis were present in clusters from the first analysis. Combining HIV sequence, clinical and behavioral data provided insights into HIV transmission that may not be identified using traditional epidemiological methods alone. Specifically, the sexual risk behaviors and STI diagnoses reported in the substudy survey may not have been disclosed during Partner Services activities and the survey data complemented clinical data to fully characterize transmission clusters. These findings can be used to enhance local efforts to interrupt transmission and avert new infections.

Substance use disorders (SUDs) are common among people with HIV and can prevent achievement of optimal health outcomes. Using data from a longitudinal HIV cohort study in the District of Columbia (2011-2018), we calculated the prevalence and correlates of SUD (alcohol, stimulant, and/or opioid use disorders) and determined the association of SUD with engagement in HIV care, ART prescription, viral suppression, and mortality. Of 8420 adults, 3168 (37.6%) had a history of any SUD, most commonly history of alcohol use disorder (29.6%). SUDs disproportionately affected Black individuals (aOR 1.33) and heterosexuals (aOR 1.18), and women had a lower risk of SUD (aOR 0.65). SUD was not associated with engagement in care, ART prescription, or viral suppression. SUD was associated with mortality (aHR 1.31). Addressing alcohol use disorder and preventable causes of death among people with HIV and substance use disorders should be priorities for clinical care and public health.Los trastornos por uso de sustancias (TUS) son comunes entre las personas con VIH y pueden impedir el logro de resultados óptimos de salud. Utilizando datos de un estudio sobre VIH de cohorte longitudinal en el Distrito de Columbia (2011–2018), calculamos la prevalencia y los correlatos de TUS (trastornos por consumo de alcohol, estimulantes y/o opioides) y determinamos la asociación de los TUS con la vinculación a cuidado de VIH, prescripción de terapia antirretroviral, supresión viral y mortalidad. De 8420 adultos, 3168 (37.6%) tenían historial de algún TUS, más comúnmente historial de trastorno por consumo de alcohol (29.6%). Los TUS afectaron de manera desproporcionada a las personas negras (aOR 1.33) y a los heterosexuales (aOR 1.18) y las mujeres tenían un riesgo menor de TUS (aOR 0.65). TUS no tuvo asociación estadísticamente significativa con la vinculación a cuidado de VIH, la prescripción de terapia antirretroviral o la supresión viral. TUS se asoció con mortalidad (aHR 1.31). Abordar el trastorno por consumo de alcohol y las causas prevenibles de muerte entre personas con VIH y trastornos por consumo de sustancias debe ser una prioridad para el cuidado clínico y la salud pública.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the cause of COVID-19, was first detected in China in December 2019 and has rapidly spread throughout the world. Globally, the impact of COVID-19 has been severe with more than half a million deaths over 6 months; in contrast, the HIV pandemic has resulted in over 32 million deaths worldwide over 40 years. This paper reviews the current epidemiology of COVID-19, summarizes its relationship to HIV, identifies synergies in our response, and suggests actions that can be taken to curtail the spread of COVID-19 among persons living with HIV (PLWH). Our understanding of the epidemiology, clinical presentation, prevention, and treatment of COVID-19 has evolved rapidly as they did with HIV. Epidemiologically, there are similarities between the two viruses including asymptomatic spread, disproportionate impact on persons of color, need for rapid diagnostic testing, and lack of a cure or vaccine. PLWH do not appear generally to have an increased incidence of COVID-19 infection or a more severe course of disease. Clinical trials to identify potential treatment and prevention options for COVID-19 have included antiretrovirals used to treat HIV that have not been efficacious. Public health responses overlap between the two pandemics including the need for behavior change and containment strategies such as contact tracing. As the SARS-CoV-2 pandemic evolves, the path forward to controlling, preventing, and treating COVID-19 can be informed by lessons learned from HIV as we seek to control the spread of both viral pandemics.

BACKGROUND: Optimal management of noncommunicable diseases, including diabetes mellitus (DM), is crucially important as people with HIV (PWH) live longer with antiretroviral therapy. Our objective was to assess patient-level and clinic-level factors associated with achieving hemoglobin A1c (HbA1c) ≤7.0% among PWH and DM. SETTING: The DC Cohort, an observational clinical cohort of PWH, followed from 2011 to 2019 at 12 sites in Washington, DC. METHODS: Among PWH with diagnosed DM and elevated HbA1c (>7.0%), we examined the association between achieving HbA1c ≤7.0% and demographic and clinical factors, including time-updated medication data, and clinic-level factors related to services and structure. A multilevel marginal extended Cox regression model was generated to identify factors associated with time to HbA1c ≤7.0%. RESULTS: Over half (52.3%) of 419 participants achieved HbA1c ≤7.0%. Individual-level factors associated with HbA1c ≤7.0% included a diagnosis of DM after enrollment and a longer time since HIV diagnosis [hazard ratio (HR) = 2.65 and 1.13, P < 0.05 for both]. Attending a clinic with an endocrinologist was associated with the outcome [adjusted HR (aHR) = 1.41 95% confidence interval (CI): (1.01 to 1.97)]. In addition, comparing clinics that treat everyone, refer everyone or have a mix of treating and referring, showed an association between attending a clinic that treats everyone [aHR = 1.52 95% CI: (1.21 to 1.90)] or a clinic that refers everyone [aHR = 2.24 95% CI: (1.63 to 3.07)] compared with clinics with a mix in achieving glycemic control. CONCLUSION: Multiple factors are associated with achieving glycemic control in an urban cohort of PWH. Determining if specific services or structures improve DM outcomes may improve health outcomes for PWH and DM.

BACKGROUND: Data on integrase strand transfer inhibitor (INSTI) use in children, adolescents, and young adults with HIV are limited. We evaluated virologic and safety outcomes following INSTI initiation among treatment-experienced children, adolescents, and young adults. METHODS: The DC Cohort is a multi-center observational study of individuals receiving HIV care in Washington, DC. This analysis included treatment-experienced participants aged 0-24 years who initiated an INSTI during 2011-2017. Viral suppression (VS) and safety outcomes were quantified. Differences in VS by age, sex, and CD4 count were assessed using Kaplan-Meier curves. RESULTS: Of 141 participants (median age 20 years; 35% 500) cells/μL were less likely to achieve VS (p

To explore reasons for the disproportionate metabolic and cardiovascular disease burdens among older HIV-infected persons, we investigated whether associations of CD4 count and HIV viral load (VL) with non-high-density lipoprotein cholesterol (non-HDL-C) and high-density lipoprotein cholesterol [HDL-C] differed by age. Longitudinal clinical and laboratory data were collected between 2011 and 2016 for HIV-infected outpatients in the DC Cohort study. Using data for patients aged ≥21 years with ≥1 cholesterol result and contemporaneous CD4/VL results, we created multivariable linear regression models with generalized estimating equations. Among 3,912 patients, the median age was 50 years, 78% were male, 76% were non-Hispanic black, 93% were using antiretroviral therapy, 8% had a CD4 count 500) cells/μL and VL ≥200 copies/mL were associated with lower non-HDL-C concentrations (p 500 cells/μL [β = −2.2 (95% CI: −3.7 to −0.8)] (CD4–VL interaction, p

Statin coverage has been examined among HIV-infected patients using Adult Treatment Panel III (ATP III) and American College of Cardiology/American Heart Association (ACC/AHA) guidelines, although not with newer National Lipid Association (NLA) guidelines. We investigated statin eligibility, prescribing practices, and therapeutic responses using these three guidelines. Sociodemographic, clinical, and laboratory data were collected between 2011 and 2016 for HIV-infected outpatients enrolled in the DC Cohort, a multi-center, prospective, observational study in Washington, DC. This analysis included patients aged ≥21 years receiving primary care at their HIV clinic site with ≥1 cholesterol result available. Of 3312 patients (median age 52; 79% black), 52% were eligible for statins based on ≥1 guideline, including 45% (NLA), 40% (ACC/AHA), and 30% (ATP III). Using each guideline, 49% (NLA), 56% (ACC/AHA), and 73% (ATP III) of eligible patients were prescribed statins. Predictors of new prescriptions included older age (aHR = 1.16 [1.08-1.26]/5 years), body mass index ≥30 (aHR = 1.50 [1.07-2.11]), and diabetes (aHR = 1.35 [1.03-1.79]). Hepatitis C coinfection was inversely associated with statin prescriptions (aHR = 0.67 [0.45-1.00]). Among 216 patients with available cholesterol results pre-/post-prescription, 53% achieved their NLA cholesterol goal after 6 months. Hepatitis C coinfection was positively associated (aHR = 1.87 [1.06-3.32]), and depression (aHR = 0.56 [0.35-0.92]) and protease inhibitor use (aHR = 0.61 [0.40-0.93]) were inversely associated, with NLA goal achievement. Half of patients were eligible for statins based on current US guidelines, with the highest proportion eligible based on NLA guidelines, yet, fewer received prescriptions and achieved treatment goals. Greater compliance with recommended statin prescribing practices may reduce cardiovascular disease risk among HIV-infected individuals.

Background Central to measuring the impact of the COVID-19 pandemic on HIV is understanding the role of loss of access to essential HIV prevention and care services created by clinic and community-based organization closures. In this paper, we use a comprehensive list of HIV prevention services in four corridors of the US heavily impacted by HIV, developed as part of a large RCT, to illustrate the potential impact of service closure on LGBTQ+ youth. Methods We identified and mapped LGBTQ+ friendly services offering at least one of the following HIV-related services: HIV testing; STI testing; PrEP/PEP; HIV treatment and care; and other HIV-related services in 109 counties across four major interstate corridors heavily affected by HIV US Census regions: Pacific (San Francisco, CA to San Diego, CA); South-Atlantic (Washington, DC to Atlanta, GA); East-North-Central (Chicago, IL to Detroit, MI); and East-South-Central (Memphis, TN to New Orleans, LA). Results There were a total of 831 LGBTQ+ youth-friendly HIV service providers across the 109 counties. There was a range of LGBTQ+ youth-friendly HIV-service provider availability across counties (range: 0–14.33 per 10,000 youth aged 13–24 (IQR: 2.13), median: 1.09); 9 (8.26%) analyzed counties did not have any LGBTQ+ youth-friendly HIV service providers. The Pearson correlation coefficient for the correlation between county HIV prevalence and LGBTQ+ youth-friendly HIV service provider density was 0.16 (p = 0.09), suggesting only a small, non-statistically significant linear relationship between a county’s available LGBTQ+ youth-friendly HIV service providers and their HIV burden. Conclusions As the COVID-19 pandemic continues, we must find novel, affordable ways to continue to provide sexual health, mental health and other support services to LGBTQ+ youth.

OBJECTIVE: To evaluate associations of mood, anxiety, stress-/trauma-related, and psychotic disorders, both treated and untreated, with duration of unsuppressed HIV viral load (VL) among persons living with HIV (PLWH). SETTING: The DC Cohort, an observational clinical cohort of PLWH followed from 2011–2018 at 14 sites in Washington, DC. METHODS: Among PLWH ≥18 years old who received primary care at their HIV clinic, we determined in a time-updated manner whether participants had diagnoses and pharmacologic prescriptions for mood, anxiety, stress-/trauma-related, and/or psychotic disorders. Associations between psychiatric disorders/treatments and the proportion of subsequent days with VL ≥200 copies/mL were assessed using multivariable Poisson regression with generalized estimating equations. RESULTS: Among 5,904 participants (median age 51; 70% male; 82% Black), 45% had ≥1 psychiatric disorder, including 38% with mood disorders (50% treated), 18% with anxiety or stress-/trauma-related disorders (64% treated), and 4% with psychotic disorders (52% treated). Untreated major depressive disorder (adjusted rate ratio=1.17; 95% confidence interval: 1.00–1.37), untreated other/unspecified depressive disorder (1.23; 1.01–1.49), untreated bipolar disorder (1.39; 1.15–1.69), and treated bipolar disorder (1.25; 1.02–1.53) (vs. no mood disorder) predicted more time with VL ≥200 copies/mL. Treated anxiety disorders (vs. no anxiety disorder) predicted less time (0.78; 0.62–0.99). Associations were weaker and non-significant for treated depressive disorders (vs. no mood disorder) and untreated anxiety disorders (vs. no anxiety disorder). CONCLUSIONS: PLWH with depressive and bipolar disorders, particularly when untreated, spent more time with unsuppressed VL than PLWH without a mood disorder. Treatment of mood disorders may be important for promoting sustained viral suppression.

Background Improved detection and linkage to care of previously undiagnosed HIV infections require innovative approaches to testing. We sought to determine the feasibility of targeted HIV testing in geographic areas, defined by continuum of care parameters, to identify HIV-infected persons needing linkage or engagement in care. Methods Using HIV surveillance data from Washington, DC, we identified census tracts that had an HIV prevalence >1% and were either above (higher risk areas-HRAs) or below (lower risk areas-LRAs) the median for 3 indicators: monitored viral load, proportion of persons out of care (OOC), and never in care. Community-based HIV rapid testing and participant surveys were conducted in the 20 census tracts meeting the criteria. Areas were mapped using ArcGIS, and descriptive and univariate analyses were conducted comparing the areas and participants. Results Among 1471 persons tested, 28 (1.9%) tested HIV positive; 2.1% in HRAs vs. 1.7% in LRAs (P = 0.57). Higher proportions of men (63.7% vs. 56.7%, P = 0.007) and fewer blacks (91.0% vs. 94.6%, P = 0.008) were tested in LRAs vs. HRAs; no differences were observed in risk behaviors between the areas. Among HIV-positive participants, 54% were new diagnoses (n = 9) or OOC (n = 6), all were Black, 64% were men with a median age of 51 years. Conclusions Although significant differences in HIV seropositivity were not observed between testing areas, our approach proved feasible and enabled identification of new diagnoses and OOC HIV-infected persons. This testing paradigm could be adapted in other locales to identify areas for targeted HIV testing and other reengagement efforts.

As the HIV epidemic passes its 35 years mark, the role of multidisciplinary approaches to HIV research has become increasingly important. Development of diverse, cross-cutting research teams has been found to be key to engaging and retaining participants in population-based studies; it is also a crucial component of designing studies capable of examining the sensitive and nuanced issues that surround HIV related risk and adherence behavior. Expanding our understanding of these issues is central to being able to overcome them and ultimately to the development of best practices for translation of research discovery into improvements in prevention and care. The objectives of this paper are to characterize the importance of multidisciplinary teams in HIV research where they are critical to gaining information that can have a positive impact on the epidemic and to propose specific methods for creating teams to conduct research with optimal public health impact.

Distance to HIV care may be associated with retention in care (RIC) and viral suppression (VS). RIC (≥ 2 HIV visits or labs ≥ 90 days apart in 12 months), prescribed antiretroviral therapy (ART), VS (

Background Agents from the integrase inhibitor (INSTI) therapeutic class only are recommended as initial therapy for most patients with HIV. Clinicians now face a decision when treating ART-experienced patients on non-INSTI regimens: continue current therapy or switch to INSTI. Multiple factors may be considered in this decision: clinician/patient preference, comorbidities, tolerability, and resistance history. The objective of this analysis was to examine patient factors associated with currently taking an INSTI-based regimen. Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants in the sample had ≥ 1 encounter between 4/1/17 and 3/1/18, were aged ≥ 18 years and were ART experienced. Participants were classified as currently, previously, or never on an INSTI. Independent variables included demographics, clinical characteristics, alcohol/tobacco use, HBV/HCV status and HIV-related variables (recent CD4 and HIV RNA, presence of resistance mutations). Multivariable multinomial logistic regression was used to identify factors associated with INSTI use status. Results Among 4584 participants (58.2% aged 50+ years; 69.4% male; 2.5% transgender; 80.3% Black; 36% MSM), most (65.0%) were current INSTI users; however, a sizeable proportion (28.3%) were never users and 6.7% were former users. Current and previous INSTI users were more likely to have a major NRTI, NNRTI or PI mutation compared with never users (see Table 1). Transgender participants (compared with males), were less likely to be current (vs. never) users (adjusted odds ratio (aOR) 0.48, 95% CI 0.32, 0.72). Younger participants (18–24 vs 50+ years) were more likely current users (aOR 1.90, 95% CI 1.18, 3.06), as were Hispanic participants (aOR 1.39, 95% CI 1.05, 1.84). Conclusion The majority of active DC Cohort participants were using INSTI-based therapy. Transgender and older individuals were less likely to be on INSTIs, indicating that they are more likely to be on PI-based or NNRTI-based therapy or not on therapy. Further research should explore whether this is detrimental for long-term HIV outcomes in these patient groups. Additionally, these results suggest resistance history as an important driver of INSTI prescription. Disclosures All authors: No reported disclosures.

Introduction Preexposure prophylaxis (PrEP) is a promising approach to reducing HIV incidence. So, garnering the support of HIV providers, who are most familiar with antiretrovirals and likely to encounter patients in HIV serodiscordant relationships, to scale-up PrEP implementation is essential. We sought to determine whether certain subgroups of HIV providers were more likely to intend to prescribe PrEP. Methods Surveys were administered to HIV providers in Miami, Florida and Washington, District of Columbia. Composite scores were developed to measure PrEP knowledge, experience, and likelihood of prescribing. Latent class analysis was used to stratify provider attitudes toward PrEP. Results Among 142 HIV providers, 73.2% had cared for more than 20 HIV-infected patients in the previous 3 months; 17% had ever prescribed PrEP. Latent class analysis identified 2 classes of providers (entropy, 0.904); class 1 (n = 95) found PrEP less effective and perceived barriers to prescribing it; class 2 (n = 47) perceived PrEP as moderately effective and perceived fewer barriers to prescribing it. Compared with class 2, class 1 had significantly less experience with PrEP delivery (t(22.7) = 2.88, P = 0.009) and was significantly less likely to intend to prescribe to patients with multiple sex partners (20% vs. 43%, P = 0.04) and those with a drug use history (7% vs. 24%, P = 0.001). Conclusions Although most HIV providers found PrEP to be effective, those considering it less effective had limited knowledge and experience with PrEP and had lesser intentions to prescribe. Provider training regarding whom should receive PrEP and addressing potential barriers to PrEP provision are needed if this HIV prevention method is to be optimized.

Background Indicators for determining one's status on the HIV care continuum are often measured using clinical and surveillance data but do not typically assess patient perspectives. We assessed patient-reported care status along the care continuum and whether it differed from medical records and surveillance data. Methods Between June 2013 and October 2014, a convenience sample of clinic-attending HIV-infected persons was surveyed regarding care-seeking behaviors and self-perceived status along the care continuum. Participant responses were matched to DC Department of Health surveillance data and clinic records. Participants' care patterns were classified using Health Resources Services Administration-defined care status: in care (IC), sporadic care (SC), or out of care (OOC). Semistructured qualitative interviews were analyzed using an open coding process to elucidate relevant themes regarding participants' perceptions of engagement in care. Results Of 169 participants, most were male participants (64%) and black (72%), with a mean age of 50.7 years. Using self-reported visit patterns, 115 participants (68%) were consistent with being IC, 33 (20%) SC, and 21 (12%) OOC. Among OOC participants, 52% perceived themselves to be fully engaged in HIV care. In the previous year, among OOC participants, 71% reported having a non-HIV-related medical visit and 90% reported current antiretroviral use. Qualitatively, most SC and OOC persons did not see their HIV providers regularly because they felt healthy. Conclusions Participants' perceptions of HIV care engagement differed from actual care receipt as measured by surveillance and clinical records. Measures of care engagement may need to be reconsidered as persons not receiving regular HIV care maybe accessing other health care and HIV medications elsewhere.

Background Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5–4.1); age 18–34 years, 10.8 (95% CI, 9.7–12.0); transgender women, 9.9 (95% CI, 6.9–14.0); Hispanics, 9.2 (95% CI, 7.2–11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1–8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation.

This article presents an overview of pre-exposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) prevention. The authors describe the past animal and human research that has been conducted that informs our current understanding of PrEP; summarize ongoing research in the area, including describing new regimens and delivery mechanisms being studied for PrEP; and highlight key issues that must be addressed in order to implement and optimize the use of this HIV prevention tool.

Background Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control were compared using an LME model with random slopes and random intercepts, adjusted for sex, BMI, nadir CD4, a history of AIDS, or cancer diagnosis. Results Among 554 participants (median age 53.5; 70.8% male; 82.7% Black), there were 5,138 total CD4 count measurements. In unadjusted analysis, participants with moderate or uncontrolled HbA1c had higher mean CD4 counts over the follow-up period than those with strict HbA1c control (strict: 690 cells/μL, moderate: 712 cells/μL uncontrolled: 711 cells/μL; P = 0.0156 strict vs. moderate, 0.049 strict vs. uncontrolled). All DM control groups had a similar temporal increase over time in CD4 count (P = 0.46). In multivariate analysis, only moderate vs. strict control showed a significant difference in CD4 count (mean difference=18.1; P = 0.02). Results showed CD4 count change was not affected by the duration of HIV diagnosis or diabetes diagnosis. See Table 1 for additional results. Conclusion PLWH and DM with moderate HbA1c control had higher CD4 counts than those with strict HbA1c control and similar CD4 counts compared with those with uncontrolled HbA1c levels, while the rate of increase in CD4 count was similar in the three groups. These results show that moderate DM control may benefit CD4 count, which should be considered when revising DM control guidelines for PLWH. Disclosures All authors: No reported disclosures.

Background In 2019, the US Administration announced the Ending the HIV Epidemic plan to decrease new infections. A key component is the Test and Treat plan to diagnose early, treat rapidly and achieve viral suppression (VS) among persons living with HIV (PLWH). We assessed retention in care (RIC), antiretroviral therapy (ART) initiation and VS among newly diagnosed PLWH in Washington, DC. Methods We conducted a cross-sectional analysis using data from the DC Cohort, an observational longitudinal cohort of PLWH in care in 14 clinics in DC. We included participants enrolled from 2011 to 2016 whose HIV diagnosis was within 1 year of enrollment and with at least 12 months follow-up. RIC was defined as ≥2 visits or HIV lab results 90 days apart in the first year of follow-up. ART initiation was defined as being prescribed ART, VS was defined as HIV RNA Results Among the 455 newly diagnosed participants (6% of all enrollees), median age was 33 years (IQR 25, 45), 69% were Black, 79% male, 60% MSM. Median duration of HIV at enrollment was 4.9 months (IQR 2.3, 7.7). Median nadir CD4 count was 346 cells/μL (IQR 224, 494). Of the 455, 38% had a history of AIDS, 92% were RIC, 65% initiated ART by 3 months and 17% had VS by 3 months. There were no differences by sex or race for RIC, ART initiation and VS. An AIDS diagnosis at enrollment was associated with RIC (aOR 2.28; 1.01–5.15), ART initiation by 3 months (aOR 2.41; 1.54–3.76), and VS by 12 months (aOR 1.92; 1.06–3.46). Lower nadir CD4 (aOR 0.89 per 50 cell increase; 0.84–0.94) and younger age (aOR 0.747 per 10-year increase; 0.584–0.995) were associated with ART initiation by 12 months. Conclusion Although the majority of newly diagnosed PLWH were RIC, fewer started ART or achieved VS. With a large proportion of our sample having an AIDS diagnosis at enrollment, we illustrate the ongoing challenge of late HIV diagnosis in DC. Those with AIDS at diagnosis were more likely to initiate ART within the first 3 months. As same-day ART initiation is scaled up in DC, future research can evaluate if all PLWH, regardless of AIDS status, will achieve this milestone earlier. Disclosures All authors: No reported disclosures.

Introduction:In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care pr

We sought to benchmark the quality of HIV care being received by persons living with HIV in care in Washington, DC and identify individual-level and structural-level differences. Data from the DC Cohort, an observational HIV cohort of persons receiving outpatient care in DC, were used to estimate the Institute of Medicine (IOM) and Department of Health and Human Services (HHS) quality of care measures. Differences in care by demographics and clinic type were assessed using χ2 tests and multivariable regression models. Among 8,047 participants, by HHS standards, 69% of participants were retained in care (RIC), 95% were prescribed antiretroviral therapy (ART), and 84% were virally suppressed (VS). By IOM standards, 84% were in continuous care; and 78% and 80% underwent regular CD4 and VL monitoring, respectively. Screening for syphilis, chlamydia, and gonorrhea was 51%, 31%, and 26%, respectively. Older participants were 1.5 times more likely to be RIC compared to younger participants (OR: 1.5; 95% CI: 1.3, 1.8). Participants enrolled in community-based clinics were more likely to be RIC (OR: 1.7; 95% CI: 1.4, 2.0) versus those enrolled at hospital-based clinics. Older participants were more likely to achieve VS than younger participants (OR: 1.8; 95% CI: 1.5, 2.2) while Black participants were less likely compared to white participants (OR: 0.4; 95% CI: 0.3, 0.5). Despite high measures of quality of care, disparities remain. Continued monitoring of the quality of HIV care and treatment can inform the development of public health programs and interventions to optimize care delivery.

The District of Columbia launched a routine HIV testing initiative in 2006. We examined HIV testing behaviors among heterosexuals at risk for HIV over time using CDC National HIV Behavioral Surveillance data from Washington, DC for the heterosexual cycles from 2006-7 (“Cycle 1”) and 2010 (“Cycle 2”). Past year and past two-year HIV testing across study cycles were compared using chi-square tests. Weighted multivariable logistic regression identified correlates of past year testing. The majority of participants across both cycles were black and female. Cycle 1 participants were significantly more likely to have ≥4 partners in the past year, casual sex partners, and have anal sex at last sexual encounter (p

Between 2000 and 2005, 84 HIV-infected children were referred to Children's National Medical Center; 28 were born to immigrant mothers, 89% of whom were of African descent. Rates of antiretroviral prophylaxis were low regardless of maternal origin. Nonimmigrant mothers (30.4%) used illicit drugs (P < 0.001), and 50% of immigrant mothers breast-fed their children (P < 0.001). These data can guide intervention strategies.

Background The District of Columbia Department of Health funds facilities to provide HIV medical case management (MCM), inclusive of linkage, engagement in care, and treatment adherence support. The objective of this analysis was to identify the differences in the clinical outcomes among HIV-infected persons receiving care at MCM-funded facilities compared with those in nonfunded facilities. Methods Newly diagnosed and prevalent HIV-infected persons were identified from the District of Columbia Department of Health surveillance system. Clinical outcomes of interest were linkage, retention in care, and viral suppression. Bivariate analyses and random effects logistic regression were used to examine the differences in demographics and clinical outcomes of persons receiving care at MCM-funded and nonfunded facilities. Results Among 5631 prevalent cases, 56.7% received care at MCM-funded facilities of which 76.2% were retained in care, and 70.6% achieved viral suppression. Those receiving care in MCM-funded facilities were significantly more likely to be retained in care [adjusted odds ratio (aOR) 4.13; 95% confidence interval (CI): 1.93 to 8.85] and as likely (aOR 1.06; 95% CI: 0.68 to 1.62) to be virally suppressed than persons receiving care in nonfunded facilities. Among 789 newly diagnosed persons, those diagnosed in MCM-funded facilities were not significantly more likely to be linked to care within 3 months (aOR 0.50; 95% CI: 0.21 to 1.18) than those diagnosed in nonfunded facilities. Discussion This study provides evidence that MCM may be beneficial to HIV-infected persons in DC by improving retention in care. Further identification of the specific services providing the most benefit to clients is needed, including a better understanding of the complex relationship between retention and viral suppression.

Objectives: Recent data suggest that community viral load (CVL) can be used as a population-level biomarker for HIV transmission and its reduction may be associated with a decrease in HIV incidence. Given the magnitude of the HIV epidemic in Washington, District of Columbia, we sought to measure the District of Columbia’s CVL. Design: An ecological analysis was conducted. Methods: Mean and total CVL were calculated using the most recent viral load for prevalent HIV/AIDS cases reported to District of Columbia HIV/AIDS surveillance through 2008. Univariate and multivariable analyses were conducted to assess differences in CVL availability, mean CVL, proportion of undetectable viral loads, and 5-year trends in mean CVL and new HIV/AIDS diagnoses. Geospatial analysis was used to map mean CVL and selected indicators of socioeconomic status by geopolitical designation. Results: Among 15 467 HIV/AIDS cases alive from 2004 to 2008, 48.2% had at least one viral load reported. Viral load data completeness increased significantly over the 5 years (P < 0.001). Mean CVL significantly decreased over time (P < 0.0001). At the end of 2008, the mean CVL was 33 847 copies/ml; 57.4% of cases had undetectable viral loads. Overlaps in the geographic distribution of CVL by census tract were observed with the highest means observed in areas with high poverty rates and low high school diploma rates. Conclusion: Mean and total CVL provide markers of access to care and treatment, are indicators of the population’s viral burden, and are useful in assessing trends in local HIV/AIDS epidemics. Measurement of CVL is a novel tool for assessing the potential impact of population-level HIV prevention and treatment interventions. 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2012, 26:345–353

Introduction : Changes in combination antiretroviral therapy (cART) throughout childhood challenge the continuity of paediatric HIV treatment. This study aimed to evaluate the prevalence of treatment interruption (TI), including lamivudine (3TC) monotherapy, and the relationship of TI to virologic and immunologic parameters in HIV-infected paediatric patients. Methods : Nested within a prospective observational study of a city-wide cohort of HIV-infected persons in the District of Columbia, this sub-study collected retrospective data on antiretroviral therapy, enrolment (endpoint) and historic (lifelong) CD4 counts and HIV RNA viral load (VL) of the paediatric cohort. TI was defined as interruption of cART ≥4 consecutive weeks. Data on TI, including 3TC monotherapy TI (MTI), were collected. Descriptive statistics and univariate testing were used to compare children with TI and MTI to children on continuous treatment (CT). Results : Thirty-eight (28%) out of 136 enrolled children (median age=12.9 years) experienced TI, with 14 (37%) of those placed on 3TC MTI. Significantly lower endpoint median CD4 counts (598 cells/mm 3 vs. 815 cells/mm 3 ; p= 0.003) and CD4% (27.5% vs. 33%; p =0.006) were observed in the TI cohort as compared to the CT cohort. The median endpoint VL in the overall TI cohort was ~4 times higher than among the CT cohort (1427 copies/mL vs. 5581 copies/mL; p

Background Although funding has supported the scale up of routine, opt-out HIV testing in the US, variance in implementation mechanisms and barriers in high-burden jurisdictions remains unknown. Methods We conducted a survey of health care organizations in Washington, DC and Houston/Harris County to determine number of HIV tests completed in 2011, policy and practices associated with HIV testing, funding mechanisms, and reported barriers to testing in each jurisdiction and to compare results between jurisdictions. Results In 2012, 43 Houston and 35 DC HIV-testing organizations participated in the survey. Participants represented 85% of Department of Health-supported testers in DC and 90% of Department of Health-supported testers in Houston. The median number of tests per organization was 568 in DC and 1045 in Houston. Approximately 50% of organizations in both DC and Houston exclusively used opt-in consent and most conducted both pre- and post-test counseling with HIV testing (80% of organizations in DC, 70% in Houston). While the most frequent source of funding in DC was the Department of Health, Houston organizations primarily billed the patient or third-party payers. Barriers to testing most often reported were lack of funding, followed by patient discomfort/refusal with more barriers reported in DC. Conclusions Given unique policies, resources and programmatic contexts, DC and Houston have taken different approaches to support routine testing. Many organizations in both cities reported opt-in consent approaches and pre-test counseling, suggesting 2006 national HIV testing recommendations are not being followed consistently. Addressing the barriers to testing identified in each jurisdiction may improve expansion of testing.

Background Washington, DC (DC) has one of the highest HIV/AIDS rates in the U.S and cancer is the second leading cause of death among DC residents. This study sought to examine the demographic characteristics and survival of persons with AIDS defining cancers (ADCs) compared to those with non-AIDS defining cancers (NADCs) between the early HAART era (1996-2001) and the late HAART era (2002-2006) in DC.