CROI 2018 Abstract eBook

Abstract eBook

Poster Abstracts

1119 IS CLINICAL STABILITY STABLE? MULTI-STATE SURVIVAL ANALYSIS OF HIV PATIENTS IN ZAMBIA Monika Roy 1 , Charles B. Holmes 2 , Izukanji Sikazwe 3 , Theodora Savory 3 , Mwanza wa Mwanza 3 , Carolyn Bolton Moore 3 , Nancy Czaicki 1 , David Glidden 1 , Nancy Padian 4 , Elvin Geng 1 1 University of California San Francisco, San Francisco, CA, USA, 2 Johns Hopkins University, Baltimore, MD, USA, 3 Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, 4 University of California Berkeley, Berkeley, CA, USA Background: Differentiated service delivery (DSD) models increase the efficiency of HIV services by de-intensifying contact with the health system for clinically stable patients. Although a large proportion of patients may be clinically stable at any given time, the durability of clinical stability under routine care will influence the potential Impact of these models. We used a multi-state survival analysis to describe the rate of becoming stable on treatment after enrollment in care and the dynamics of becoming unstable to assess the durability of clinical stability. Methods: We evaluated visit data in a cohort of HIV-infected adults who made at least one visit between March 1, 2013 and February 28, 2015 at 56 clinics in Zambia. Clinical, laboratory, and visit data were collected from an existing electronic medical record system. Definition of stability was based on Zambian guidelines and WHO criteria for stability in the absence of viral load. We developed a 6-state model: States 1: never stable on ART; 2: lapse in care before stable on ART; 3: stable on ART; 4: previously stable on ART; 5: lapse in care after stable on ART; 6: death. Cumulative incidence and Incidence rates for transitions between states (from time from enrollment) were calculated overall and by gender, age, and time. Results: Among 160,487 patients, cumulative incidence of stability on ART was 39.6% (95% CI: 39.3-39.8) 12 months post-enrollment. However, among those who had achieved stability, only 39%were still stable on ART, 54% had already become unstable, and 7.8% had lapsed in care at 12 months. Once stable, the rate of becoming unstable was highest in the first two years post-enrollment (45 and 37 events per 100 person years (pyrs) in Years 1 and 2 respectively) but remained greater than 20 events per 100pyrs thereafter. Rates for lapse in care after being stable on ART were similar regardless of gender, age, or time period, ranging from 45 to 58 events per 100 pyrs. Rate of lapse in care was greater before becoming stable on ART compared to after becoming stable on ART (118 vs 51 events per 100pyrs). Conclusion: Although most patients became clinically stable shortly after enrollment, many stable patients subsequently became unstable or experienced lapses in care. DSD models targeting stable patients need to account for transient clinical stability among enrollees. Robust systems to detect and react to clinical instability (including viral load testing) will strengthen DSD models.

impact of $30 million in Malawi and $228 million in SA (6.6% and 2.3% increases in total health expenditures in these populations). Conclusion: Urine-based TB screening for hospitalized PWH would increase life expectancy and is cost-effective in resource-limited settings.

1118 HIGH RATES OF VIRAL RESUPPRESSION ON FIRST-LINE ART AFTER INITIAL VIROLOGICAL FAILURE Lucas E. Hermans 1 , Hugo Tempelman 2 , Sergio Carmona 3 , Monique Nijhuis 1 , Diederick Grobbee 1 , Douglas D. Richman 4 , Michelle A. Moorhouse 5 , Willem D. Venter 5 , Annemarie Wensing 1 1 University Medical Center Utrecht, Utrecht, Netherlands, 2 Ndlovu Care Group, Groblersdal, South Africa, 3 National Health Laboratory Service, Johannesburg, South Africa, 4 VA San Diego Healthcare System, San Diego, CA, USA, 5 Wits Reproductive Health and HIV Institute, Johannesburg, South Africa Background: ART achieves viral suppression in the majority of HIV infected patients in low and middle-income countries. WHO guidelines recommend annual viral load (VL) monitoring with confirmatory VL testing in case of a VL ≥1000 copies/mL (c/mL), and switch to second-line ART without resistance testing if virological failure (VF) is confirmed. However, challenges exist regarding clinical follow-up of VL results, prompting discussion around the criteria for VF and switch to second-line ART. Methods: Patients from 19 urban and 38 rural South African HIV treatment sites were studied. Adult patients on first-line ART for ≥20 weeks and with ≥1 VL performed ≥20 weeks after start of ART were included. Proportions of viremia ≥1000 c/mL, confirmed VF (>1 VL ≥1000 c/mL) on first-line ART, likelihood of switch to second-line ART, and resuppression on first-line ART were analyzed. Results: 69,454 patients were included. 20.7% of patients (14,380/69,454) had ≥1 VL ≥1000 c/mL during 209,638 patient years of first-line ART. After 1 year of ART, 88.3% of patients achieved viral suppression <1000 c/mL. Patients with a VL ≥1000 c/mL were more often male (35.6% vs 31.2%), younger (34.9 vs 36.0 years), and had a lower baseline CD4-count (159 vs 193 cells/uL). Of 9,351 patients with a VL ≥1000 c/mL and ≥1 subsequent VL result during first-line ART, VF was not confirmed in 44.8% (4,186/9,351) of patients, with 90.4% (3,785/4,186) of these patients achieving resuppression <50 c/mL without switch to second-line ART. In patients with confirmed VL ≥1000 c/mL, resuppression without switch occurred in 15.9% (581/3,649), but they remained at increased risk of subsequent VF. Median time between first detection of a VL ≥1000 c/mL and confirmation of VF was 30 weeks [IQR: 17 - 53]. Median time between first detection of VF and switch was 67.7 weeks [35 - 124]. Conclusion: In this large cohort of patients on first-line ART monitored according to WHO guidelines, viral resuppression occurred in just under half of cases after a single VL ≥1000 c/mL, and in a considerable number of cases after VF was confirmed. Confirmation of VF and switch to second-line ART was performed after significant delay, allowing for prolonged episodes of viremia and potential onward HIV transmission. These data confirm the relevance of timely confirmatory VL testing, and suggest that once virological failure is confirmed, diagnostic tools to discriminate between non-adherence and loss of drug activity may prevent unnecessary switches to second-line ART.

Poster Abstracts

1120 COMPARING TIME TO VIRAL SUPPRESSION AMONG ACUTE AND NON- ACUTE HIV IN NORTH CAROLINA Nicole Dzialowy Adams 1 , Anna Cope 2 , Brad Wheeler 1 , Victoria L. Mobley 1 , John Barnhart 1 , Joann D. Kuruc 3 , Cynthia L. Gay 3 , Lindsey M. Filiatreau 3 , Rhonda Ashby 1 , Erika Samoff 1 1 North Carolina Division of Public Health, Raleigh, NC, USA, 2 CDC, Atlanta, GA, USA, 3 University of North Carolina Chapel Hill, Chapel Hill, NC, USA Background: North Carolina (NC) has had statewide screening for acute HIV infection (AHI) since 2002. The program involves a coordinated effort between

CROI 2018 431