CROI 2018 Abstract eBook

Abstract eBook

Poster Abstracts

in an oral self-testing study and linked them to preventive care. We collected sociodemographic, sexual orientation, gender identity, and risk behavior data, and retested all men for HIV-1 using rapid tests. We assessed PrEP interest and calculated HIV-1 incidence since the 2016 study. We also conducted 3 focus group discussions (FGD) to characterize potential PrEP users’ perspectives on perceived challenges and outcomes of PrEP use and adherence. Results: During May-July 2017, 168 (74.4%) GBMSMwere tested for HIV-1, including 112 men who have sex with men and women (MSMW) and 42 men who have sex with men exclusively (MSME) and 14 TGW. Overall, the median age was 26 years (interquartile range: 23-30). A total of 130 (59.1%) participants reported either primary schooling or no education, and 51 (30.4%) reported transactional sex in the past 6 months. Nine new HIV-1 infections were detected: 2 in MSMW, 4 in MSME, and 3 in TGW for an estimated HIV-1 incidence of 4.5 (95% confidence interval: 1.1-18.2), 3.4 (95% CI: 1.2-9.2), and 20.6 (95% CI: 6.6-63.8) per 100 person years, respectively. All but two participants were interested to start PrEP. Ten MSMW, 11 MSME, and 7 TGW participated in three separate FGD. MSME felt PrEP offered protection for receptive anal sex, MSMW perceived less need for taking PrEP, and TGW felt that PrEP may encourage condomless transactional sex. GBMSM and TGW criticized the integration of PrEP services in public hospital HIV clinics as undesirable due to stigma. Conclusion: We demonstrated PrEP interest among GBMSM and estimated a very high HIV-1 incidence in a small group of TGW, who have received no attention in PrEP programming in Kenya. TGWmay have been misclassified as MSME in previous HIV-1 incidence reports. Tailored PrEP messages and adherence support is needed for specific key population sub-categories. 1041 SEROCONVERSION ON PrEP: A PROTOCOL FOR UNTANGLING ADHERENCE VS RESISTANCE FAILURE Joshua T. Thaden 1 , Monica Gandhi 2 , Karen Kuncze 2 , Alexander Louie 2 , Hideaki Okochi 2 , Christopher B. Hurt 3 , Mehri McKellar 1 1 Duke University, Durham, NC, USA, 2 University of California San Francisco, San Francisco, CA, USA, 3 University of North Carolina Chapel Hill, Chapel Hill, NC, USA Background: PrEP with emtricitabine (FTC)/tenofovir (TFV) disoproxil fumarate (TDF) reduces risk of HIV acquisition with adequate adherence. Here, we describe a case of seroconversion with multidrug resistant (MDR) HIV despite good adherence, complicated by inappropriate prescribing practices and follow-up. Methods: History was obtained from patient and records. PrEP adherence was assessed via self-report, pharmacy records, and measuring TFV/FTC levels with LC-MS/MS in plasma and hair. Segmental hair analysis was performed to assess PrEP adherence over prior months. Genotypic resistance was evaluated. Results: A 34 year-old white MSM started daily FTC 200 mg/TDF 300 mg in 2/2016 after a non-reactive antigen/antibody test in 12/2015; he had no interim sexual activity. He reported full adherence to FTC/TDF from February to May 2016. He self-discontinued PrEP fromMay-July due to perceived lack of risk, and restarted 7/2016-4/2017. At PrEP initiation, he was prescribed 30 days of FTC/ TDF with 11 refills by an ID specialist. He was told to return in 1 month and 6 months for HIV and renal testing, but no visits occurred. In 3/2017, he developed fevers, chills, myalgias and had a negative rapid influenza A/B test at an urgent care site. No HIV test was performed. In 4/2017, an antigen/antibody HIV test was reactive at an evaluation for anal condylomata (day 0). He was seen in an HIV clinic on day 2. FTC/TDF was stopped; no additional therapy was yet started. HIV-1 RNA was 27,316 copies/mL and genotyping revealed M184V, K65R, and K103N mutations. Day 2 plasma revealed TFV and FTC levels of 75 ng/mL and 281 ng/mL, respectively, consistent with recent dosing. To evaluate adherence over preceding months, a hair sample was collected at day 27 and segmental analysis of TFV/FTC levels performed in 1 centimeter segments from the scalp. Hair drug levels were commensurate with consistently high PrEP adherence over the last 3 months (Figure). Conclusion: Acquisition of MDR HIV despite excellent PrEP adherence has been described in 3 prior reports. Though exact time of acquisition is unknown, our case acquired a virus with at least K103N; subsequent development of K65R and M184V from consistent FTC/TDF use is epidemiologically most likely. This study employs segmental analysis of PrEP drug levels for the first time to assess adherence over preceding months. Proper PrEP prescribing and follow-up would have allowed for quicker identification of HIV and possible prevention of further drug resistance in this individual.

1042 A PUBLIC HEALTH APPROACH TO VIREMIC INDIVIDUALS WITH PrEP- RESISTANT VIRUS Susan E. Buskin 1 , Richard Lechtenberg 1 , Matthew R. Golden 2 , Mark J. Fleming 1 , Julia C. Dombrowski 2 1 Public Health–Seattle & King County, Seattle, WA, USA, 2 University of Washington, Seattle, WA, USA Background: King County public health HIV control efforts include tracking viremia and drug resistance, and promotion of antiretroviral adherence and reduction of viremia among people living with HIV (PLWH). A possible transmission of a tenofovir (TDF)/emtricitabine (FTC) resistant virus to a PLWH reporting good adherence to pre-exposure prophylaxis (PrEP, comprised of TDF and FTC) in 2016 initiated interventions with viremic PLWH with TDF/ FTC resistant virus to help prevent transmission of an HIV strain potentially rendering PrEP ineffective. Methods: HIV genotypic and viral load (VL) data from King County HIV surveillance were used to identify viremic PLWH with TDF/FTC resistant HIV. Resistance was defined by the Stanford database algorithm and based on any reported genotypic test. Resistance to TDF/FTC was defined by intermediate to high level resistance to both components. Viremia was defined as a most recent (within 2 years) plasma VL 1,000+ copies per mL. The Care and Antiretroviral Promotion Project (CAPP) investigated two prior viremic TDF/FTC resistant cohorts, working with individuals who are poorly engaged in HIV care to overcome barriers to care and antiretroviral adherence. Results: Of 6,798 King County PLWH, genotypic sequences were reported for 3,892 (57%). Intermediate to high level TDF/FTC resistance was found for 251 (6%). We identified 368 PLWH (6% excluding 422 with no VL in 2 years) with viremia, and 8 had TDF/FTC resistance. Including 17 PLWH with no reported VL testing in two years and TDF/FTC resistance, 25 PLWH had TDF/FTC resistance and either viremia or no recent VL (corresponding to 0.4% of PLWH). Assuming the 43% of individuals with no reported genotype had similar levels of resistance we estimate that an additional 17 PLWH (42 total) may have no VL or viremia and TDF/FTC resistance, corresponding to 0.6% of PLWH. Investigation outcomes are summarized in the figure, and include (1) that nearly half of individuals without a VL were from a facility not reporting VL, all were virally suppressed or relocated and (2) at least 7 had previously completed the CAPP intervention and remained viremic or without VL, including 2 referred to a clinic providing extensive support to PLWH unable to achieve viral suppression. Conclusion: FTC/TDF drug resistance among viremic PLWH in King County, WA remains rare, estimated in 0.4-0.6% of PLWH. We have developed outreach programs for these persons, designed to promote care and prevent transmission of HIV with TDF/FTC resistance.

Poster Abstracts

CROI 2018 399