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Background In 2018, Philadelphia identified an outbreak of new human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Although conventional HIV surveillance systems capture individual-level behavioral risk, they are not able to capture the social and environmental factors contributing to rapid transmission. Methods HIV surveillance data were used to assess demographic, clinical, and behavioral factors for PWID with HIV diagnosed during 2017 and 2018. Social factors such as homelessness, disruption of encampments, and trends in sexual behaviors, drug use and syringe availability among PWID were captured through National HIV Behavioral Surveillance, routine hepatitis and sexually transmitted infection surveillance, and shelter and homeless outreach data. Results In 2018, there were 71 new infections among PWID, an increase of 115% since 2016. During this time, opioid overdose deaths peaked at 59 deaths per 100 000 persons, 85% of which involved the use of fentanyl. While overall reported homelessness increased, rates of those living unsheltered rose by 13%. The Philadelphia Department of Public Health identified increased injection frequency, encampment closures, and lack of syringe access as promoters of continued HIV transmission. Conclusion The use of conventional surveillance methods only is inadequate for determining HIV risk during outbreaks. Incorporation of individual and aggregate level data on social and environmental determinants is necessary to develop effective outbreak response interventions.

In May 2018, a study of birth defects in infants born to women with diagnosed human immunodeficiency virus (HIV) infection in Botswana reported an eightfold increased risk for neural tube defects (NTDs) among births with periconceptional exposure to antiretroviral therapy (ART) that included the integrase inhibitor dolutegravir (DTG) compared with other ART regimens (1). The World Health Organization* (WHO) and the U.S. Department of Health and Human Services† (HHS) promptly issued interim guidance limiting the initiation of DTG during early pregnancy and in women of childbearing age with HIV who desire pregnancy or are sexually active and not using effective contraception. On the basis of additional data, WHO now recommends DTG as a preferred treatment option for all populations, including women of childbearing age and pregnant women. Similarly, the U.S. recommendations currently state that DTG is a preferred antiretroviral drug throughout pregnancy (with provider-patient counseling) and as an alternative antiretroviral drug in women who are trying to conceive.§ Since 1981 and 1994, CDC has supported separate surveillance programs for HIV/acquired immunodeficiency syndrome (AIDS) (2) and birth defects (3) in state health departments. These two surveillance programs can inform public health programs and policy, linkage to care, and research activities. Because birth defects surveillance programs do not collect HIV status, and HIV surveillance programs do not routinely collect data on occurrence of birth defects, the related data have not been used by CDC to characterize birth defects in births to women with HIV. Data from these two programs were linked to estimate overall prevalence of NTDs and prevalence of NTDs in HIV-exposed pregnancies during 2013-2017 for 15 participating jurisdictions. Prevalence of NTDs in pregnancies among women with diagnosed HIV infection was 7.0 per 10,000 live births, similar to that among the general population in these 15 jurisdictions, and the U.S. estimate based on data from 24 states. Successful linking of data from birth defects and HIV/AIDS surveillance programs for pregnancies among women with diagnosed HIV infection suggests that similar data linkages might be used to characterize possible associations between maternal diseases or maternal use of medications, such as integrase strand transfer inhibitors used to manage HIV, and pregnancy outcomes. Although no difference in NTD prevalence in HIV-exposed pregnancies was found, data on the use of integrase strand transfer inhibitors in pregnancy are needed to understand the safety and risks of these drugs during pregnancy.

While there are both ethical and practical imperatives to address health inequity issues related to chronic disease management for persons with social complexity, existing programs often do not appropriately address the needs of these individuals. This leads to low levels of participation in programs, suboptimal chronic disease management, and higher health-care utilization. The aims of this project were to describe the challenges related to availability, accessibility, and acceptability faced by socially complex patients with Chronic Obstructive Pulmonary Disease (COPD) who were eligible, but declined enrollment in a traditional Chronic Disease Management Program (CDMP). Using a qualitative descriptive study approach informed by a health equity lens, interviews with participants, managers, and a focus group with providers were used to gather data addressing the above aims. Qualitative data were analyzed using Braun and Clarke’s theoretical thematic analysis approach. The ability of participants to manage chronic disease was profoundly influenced by contextual and personal factors, such as poverty, disability, personal attitudes and beliefs (including shame, mistrust, and hopelessness), and barriers inherent in the organization of the health-care system. The existing chronic disease management program did not adequately address the most critical needs of socially complex patients. Challenges with accessibility and acceptability of chronic disease management and health services played important roles in the ways these socially complex participants managed their chronic illness. The individualistic approach to self-management of chronic illness inherent in conventional CDMP can be poorly aligned with the needs, capacity, and circumstances of many socially complex patients. Innovative models of care that promote incremental and guided approaches to enhancing health and improving self-efficacy need further development and evaluation.

Background Ending the HIV Epidemic (EHE) requires prompt diagnosis and treatment of HIV to reduce transmission. Delayed HIV diagnosis and late entry into care remain challenging. Strategic deployment of testing resources may leverage both targeted and universal testing to accomplish the timely diagnosis of HIV infection. Methods We extracted data from the City of Philadelphia’s Enhanced HIV/AIDS Reporting System for 3,856 individuals diagnosed with HIV infection in Philadelphia, PA from 2012-2018, to determine characteristics associated with delayed diagnosis, defined as: AIDS diagnosed within 90 days of HIV or date of AIDS diagnosis prior to HIV diagnosis. Independent variables included: time since HIV diagnosis, age category, birth sex, current gender, race/ethnicity, transmission risk, insurance status, and receipt of care from Ryan White medical provider. We used Chi-square and multivariate logistic regression to assess factors associated with delayed diagnosis. Results From 2012 to 2018, the number of HIV diagnoses declined from 731 to 422; those with delayed diagnosis declined from 28% to 18%. Age category of 25-34 years comprised the majority of HIV diagnoses N=1402 (36%). The majority were: born male (78%), current gender male (76%), black (69%), MSM (51%), insured (54%), and participating in Ryan White care (71%). In multivariate regression, current gender male, heterosexual transmission, race/ethnicity Asian, American Indian, Alaska Native, or Multi-race, unknown insurance status, and receipt of care from a Ryan White medical provider were 3.7 (95%CI, 1.2-11.4), 1.3 (1.0-1.7), 1.8 (1.2-2.8), 5.9 (4.9-7.1), and 1.4 (1.2-1.7) times as likely to have delayed diagnosis, respectively, after adjustment for time since diagnosis, age category, and birth sex. Participants’ Characteristics and Logistic Regression Results Conclusion EHE will only be successful by reaching all people living with HIV and creating opportunities for early diagnosis. Routine opt-out universal screening combined with repeated, targeted testing will allow for identification and early treatment of HIV infection. As a medical care safety net, Ryan White program provides care to a disproportionate number of people with delayed diagnosis of HIV. By diagnosing HIV as early as possible, we may eliminate delayed diagnosis and reduce the risk of AIDS-related events or death. Disclosures All Authors: No reported disclosures

Information hierarchies are difficult to express when real-world space or time constraints force traversing the hierarchy in linear presentations, such as in educational books and classroom courses. We present booc.io , which allows linear and non-linear presentation and navigation of educational concepts and material. To support a breadth of material for each concept, booc.io is Web based, which allows adding material such as lecture slides, book chapters, videos, and LTIs. A visual interface assists the creation of the needed hierarchical structures. The goals of our system were formed in expert interviews, and we explain how our design meets these goals. We adapt a real-world course into booc.io, and perform introductory qualitative evaluation with students.