CROI 2018 Abstract eBook

Abstract eBook

Oral Abstracts

62 HIV CARE ENGAGEMENT: MAXIMIZING INDIVIDUAL AND POPULATION HEALTH Michael J. Mugavero , University of Alabama at Birmingham, Birmingham, AL, USA Enhancing engagement in care represents the greatest opportunity to achieve the individual and population health benefits afforded by scientific advances in HIV prevention and treatment science. In the era of HIV treatment as prevention (TasP), with robust scientific evidence substantiating PLWH with sustained undetectable viral loads cannot sexually transmit the virus (U=U), there is optimism towards ‘bending the curve’ via achievement of global targets for HIV testing, treatment, and viral suppression (90:90:90). However, effective implementation of innovative technologies and low tech strategies to optimize progression across the care continuum are hampered by disjointed delivery of supportive and treatment services within the fragmented U.S health care system. This presentation will review the current evidence for approaches to improve care engagement for PLWH, with particular emphasis on early retention in HIV medical care, and attention towards unique geographical considerations, with review of best evidence models and programs spanning clinical, community and public health agencies. 63 SYSTEMS OF CARE FOR VULNERABLE POPULATIONS IN THE UNITED STATES Julia C. Dombrowski , University of Washington, Seattle, WA, USA Maintaining continuous care engagement and viral suppression among persons living with HIV (PLWH) is a central goal of HIV care and prevention. However, many individuals fall out of care or sporadically engage in care. An effective population-based approach to improving retention in HIV care and viral suppression among PLWH requires a combination of strategies with varying intensity. Some patients who have disengaged from HIV care can be effectively re-engaged with low-intensity assistance or additional support services and case management outreach. However, individuals with extensive barriers to care – particularly unstable housing, substance use disorders, and untreated mental health conditions – may be unable or unwilling to engage in HIV care as it is traditionally organized. Unmet social needs compete with patients’ ability to prioritize and access health care, and health systems factors such as the need for advanced scheduling, limited appointment availability, and uncoordinated services exacerbate the problem. Alternate models of care are needed to effectively care for high-need individuals within the fragmented U.S. healthcare system. This presentation will review the current evidence for approaches to identify and re-engage out-of-care PLWH, elements of an effective population- based approach to re-engaging out-of-care individuals in HIV care, and effective models of care for high-need patients with complex medical and social needs. 64 THE VAGINAL MICROBIOME AND ACQUISITION OF HIV INFECTION Nichole Klatt , University of Washington, Seattle, WA, USA More than one million women are infected with HIV annually. However, the biological mechanisms associated with transmission in women are not well understood. One factor that has consistently been associated with increased acquisition of HIV in women is imbalanced vaginal bacteria, i.e. vaginal microbiome dysbiosis. Lack of healthy Lactobacillus bacteria, but increased anaerobic bacteria and higher diversity of the microbiome in the female reproductive tract has been associated with clinical vaginosis, inflammation, and increased HIV infection. We recently demonstrated that dysbiotic vaginal bacteria can also alter the efficacy of topical pre-exposure prophylactic (PrEP) strategies. We found the mechanism by which dysbiotic bacteria decrease efficacy of topical antiretroviral-based PrEP is by direct metabolism of the drugs by bacteria. Here we will summarize what is currently known about vaginal microbial dysbiosis and HIV infection, and the potential mechanisms of how vaginal bacteria may influence HIV transmission in women. 65 ADDRESSING MENTAL HEALTH: A CRUCIAL COMPONENT TO ENDING THE HIV EPIDEMIC Robert H. Remien , New York State Psychiatric Institute and Columbia University, New York, NY, USA Mental health problems including substance abuse are one of the most significant areas of co-morbidity for people living with HIV/AIDS (PLWHA) worldwide and are more prevalent among PLWHA than the general population. An estimated 50% of PLWH meet criteria for one or more mental or substance use disorders, which are associated with suboptimal HIV treatment outcomes

including late ART initiation and delayed viral suppression. Mortality rates for PLWHA having a Major Depressive Disorder (MDD) is twice as high as for those without a MDD. Positive mental health is associated with improved physical health outcomes across a range of chronic illnesses, but – in addition to negative psychological responses to an HIV diagnosis, disease progression, associated stigma, and loss of social support – the chronic inflammatory response to HIV infection is hypothesized to contribute to elevated rates of mental health problems among PLWHA. Further, HIV effects on the brain contribute to neuro-cognitive disorders as well as disturbed affect regulation among PLWHA. Unfortunately, the stigma embodied in discriminatory social structures, policy, and legislation, results in a disparity between physical and mental health care services, with lower availability, accessibility, and quality of services for the latter. Integration of services to screen and manage mental health and substance use disorders into HIV care settings is a promising strategy to improve mental health and HIV treatment outcomes among PLWHA, including in resource-constrained settings. A range of psychological interventions have been shown to improve mental health among PLWHA, including reducing depression and anxiety and increasing quality of life and psychological well- being. Further, treatment for mental disorders and behavioral (i.e., adherence) interventions has an additive effect, positively affecting HIV health outcomes. While significant challenges remain for meeting the high demand, especially in resource-constrained settings where HIV is most prevalent, addressing mental health co-morbidities (i.e., screening and treatment) in the context of HIV prevention and care is essential for achieving optimal outcomes along the HIV prevention and treatment continua. We may have the biological tools to “end AIDS,” however we will not be able to achieve “ending the epidemic” (EtE) goals, if we do not address mental health co-morbidities among our most vulnerable populations. 66 PERSISTENT DETECTION OF HIV RNA+ CELLS WITH ART STARTED IN FIEBIG 1&2 VS FIEBIG 3-5 Eugène Kroon 1 , Mark de Souza 1 , Suthat Chottanapund 1 , Jodi Anderson 2 , Sopark Manasnayakorn 3 , Siri Jorstad 2 , Caitlin David 2 , Adam Conner 2 , Erika Helgeson 2 , Cavan Reilly 2 , Merlin L. Robb 4 , Daniel Douek 5 , Jintanat Ananworanich 4 , Timothy Schacker 2 1 Thai Red Cross AIDS Research Center, Bangkok, Thailand, 2 University of Minnesota, Minneapolis, MN, USA, 3 Chulalongkorn University, Bangkok, Thailand, 4 US Military HIV Research Program, Silver Spring, MD, USA, 5 NIH, Bethesda, MD, USA Background: The reservoir of HIV DNA+ cells is stable during treatment of chronic HIV infection; however, it is unknown if treatment during acute HIV infection (AHI) will limit reservoir size or the pathology of virus replication in lymph nodes (LN). Methods: We obtained LNs from 2 groups enrolled into the RV254 study; 55 individuals sampled during AHI and 31 identified in acute infection but were sampled after a mean of 348 days of ART (range 269 – 849 days, Table). We analyzed LNs by in situ hybridization (ISH) to determine the frequency of viral RNA (vRNA+) and DNA (vDNA+) cells and by immunohistochemistry (IHC) to determine the extent of LN fibrosis as a marker of inflammatory damage. Results: Prior to ART, the mean frequency of vRNA+ and vDNA+ cells was 2.3 x 10 ... 5 cells/g LN (interquartile range 7.6 x 10 ... 4 - 4.1 x 10 ... 5) and 5.4 x 10 ... 5 cells/g LN (interquartile range 2.3 x 10 ... 5 – 1.5 x 10 ... 6), respectively with no significant effect of Fiebig stage at the time of diagnosis. In the group receiving ART, the mean frequency of detection of vRNA+ and vDNA+ cells was 0.0 cells/g (interquartile range 0, 4.7 x 10 ... 4) and 3.0 x 10 ... 5 cells/g (interquartile range 1.6 x 10 ... 5- 7.3 x 10 ... 5), respectively. However, 15/31 (48%) LNs did have vRNA+ detectable cells (mean 9.1 x 10 ... 4 cells/g, range 2.2 x 10 ... 3 – 2.4 x 10 ... 5 cells/g) and people initiating ART in F1 or F2 were significantly more likely to have vRNA+ cells (adjusted O.R. 6.48, p = 0.0354). There was no significant difference in vDNA+ cells/g in the group sampled during AHI or the group receiving ART. Significant collagen deposition into the parafollicular T cell zone (TZ) began as early as F1 and did not decay as a result of ART, however there was no significant increase over time. Conclusion: We found that the of reservoir of vDNA+ cells was established as early as F1 and did not decay with ART. Further, inflammatory damage occurred (as measured by TZ collagen) as early as F1 and did not appear to decrease if ART was started in acute infection, however it did not progress. Finally, the detection of persistent vRNA production in LNs in people treated very early suggests that interventions to both block viral replication and elicit immune clearance of infected cells in LNs will be important.

Oral Abstracts

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CROI 2018