CROI 2019 Abstract eBook

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Poster Abstracts

737LB WITHDRAWN / INTENTIONALLY UNASSIGNED 738 RIFAMPIN-RESISTANT TUBERCULOSIS IN THE UNITED STATES, 1998–2014 Lisa Sharling 1 , Suzanne Marks 1 , Terence Chorba 1 , Sundari Mase 2 1 CDC, Atlanta, GA, USA, 2 WHO South-East Asia, New Delhi, India Background: Rifampin is the backbone of the standard regimen for tuberculosis. Monoresistance to rifamycins necessitates longer and more toxic regimens and is a precursor to multidrug resistance. We examined characteristics and mortality associated with rifampin-monoresistant TB (RMR) in the United States. Methods: We analyzed Mycobacterium tuberculosis culture-positive cases reported to the National TB Surveillance System (excluding California because HIV infection of TB cases was not reported to CDC during 2005-2010) between 1998 and 2014. We defined: (1) RMR-TB found on initial drug susceptibility testing, and (2) possible acquired rifampin-resistantTB (ARR). We assessed temporal trends in RMR-TB. We calculated adjusted risk ratios (adjRR) and 95% confidence intervals (CI) for social and clinical characteristics associated with RMR-TB, mortality with RMR-TB, ARR-TB, and mortality with ARR-TB compared to drug susceptible TB (DS) in multivariable models. Time to sputum culture conversion was assessed using medians and interquartile ranges (IQR). Results: Of 180,329 TB cases, 136,561 (76%) were eligible for analysis, with 359 (0.26%) of eligible cases reported as RMR. Similar to the decline in HIV/TB over the period, the percentage of RMR cases with HIV declined significantly over time. Persons with HIV and prior TB were more likely to have RMR (adjRR=8.8, CI=5.2-14.8) as were persons with HIV and no prior TB (adjRR=3.1, CI=2.4-4.1), versus those without either characteristic, controlling for age ≥ 65 (adjRR=0.4, CI=0.3-0.6) and black race (adjRR=0.7, CI=0.5-0.9). RMR cases had significantly greater mortality (adjRR=1.4, CI=1.04-1.8), controlling for HIV (adjRR=2.9, CI=2.7-3.0), directly observed therapy (DOT; adjRR=0.79, CI=0.76-0.82), and other variables. Persons with HIV also had greater risk of ARR than persons without HIV (adjRR=9.6, CI=6.9-13.3). ARR was also associated with increased mortality (adjRR=2.4, CI=1.8-3.4), controlling for DOT (adjRR=0.5, CI=0.4-0.6) and other variables. There was a significant (P<0.01) delay in sputum culture conversion for RMR cases (median 60 days, IQR 38-95 days) compared with median time for DS cases (49 days, IQR 26-77 days), and for ARR cases (median 190 days, IQR 75-362 days) compared with that of rifampin- and isoniazid- susceptible cases (median 76, IQR 53-110 days). Conclusion: All forms of rifampin resistance were positively associated with HIV co-morbidity, delayed culture conversion, and increased mortality (controlling for HIV, and age, and DOT). 739 GLOBAL DISPARITIES IN PRICES OF KEY MEDICINES FOR MULTIDRUG- RESISTANT TUBERCULOSIS Andrew Hill 1 , Dzintars Gotham 2 1 University of Liverpool, Liverpool, UK, 2 Independent, Boston, MA, USA Background: Worldwide, 245,000 people with HIV died from TB coinfection in 2016, with 30,000 of those deaths due to drug-resistant TB. Multidrug-resistant (MDR) TB is increasing in prevalence, but only 54% of notified MDR-TB cases are

736 MORTALITY AFTER PRESUMED TB TREATMENT COMPLETION IN PERSONS WITH HIV IN LATIN AMERICA Serena Koenig 1 , Ahra Kim 2 , Bryan E. Shepherd 2 , Carina Cesar 3 , Valdilea Veloso 4 , Claudia P. Cortes 5 , Denis Padgett 6 , Brenda Crabtree-Ramírez 7 , Eduardo Gotuzzo 8 , Catherine McGowan 2 , Timothy R. Sterling 2 , Jean William Pape 9 , for the The Caribbean, Central and South America Network for HIV Epidemiology (CCASAnet) 1 Brigham and Women’s Hospital, Boston, MA, USA, 2 Vanderbilt University, Nashville, TN, USA, 3 Fundación Huésped, Buenos Aires, Argentina, 4 Institute Nacional de Infectologia Evandro Chagas (INI/Fiocruz), Rio de Janeiro, Brazil, 5 Fundación Arriarán, Santiago, Chile, 6 Hospital Escuela Universitario, Tegucigalpa, Honduras, 7 Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, 8 Universidad Peruana Cayetano Heredia, Lima, Peru, 9 GHESKIO, Port-au-Prince, Haiti Background: Several studies in HIV-negative cohorts have suggested that the risk of mortality is increased after tuberculosis (TB) cure, compared to individuals without TB. Data are limited on long-term survival after TB cure among people living with HIV (PLWH). Methods: The study cohort included PLWH who were ≥18 years of age and who were ART-naïve at first clinic visit at a CCASAnet clinical site in Brazil, Chile, Haiti, Honduras, Mexico, or Peru from 2006 to 2015. Baseline TB was defined as TB diagnosed within 30 days before or after enrollment. Follow-up started at 9 months after enrollment or date of TB diagnosis, as a proxy for TB treatment completion in those with baseline TB. We compared time to death among patients with and without baseline TB, using Kaplan-Meier analysis and the log-rank test. We estimated predictors of mortality with univariable and multivariable Cox models, stratified by site and adjusting for baseline TB, sex, mode of transmission, education, age, year of enrollment, and CD4 count. Results: Of 19,197 patients, 1306 (6.8%) were diagnosed with TB at baseline. Of these, 15,999 patients remained in care 9 months after enrollment and were included in the analysis; 1051 (6.6%) had baseline TB. Patients with TB were more likely to be male, older, less educated, with lower CD4 counts, and residing in Haiti or Peru. Starting 9 months after enrollment (Figure 1), patients with a history of baseline TB had higher long-termmortality compared with those without baseline TB (p-value <0.001). The unadjusted 5-year mortality (measured from 9 months after enrollment) was 10.0% for patients with baseline TB vs. 5.6% in those without baseline TB; 10-year mortality was 19.1% vs. 10.5%, respectively. In multivariable Cox models, increased mortality was associated with baseline TB (hazard ratio [HR]=1.53, 95% confidence interval [CI]: 1.21-1.93), lower CD4 count (100 vs. 350 cells/mm3: HR=1.59, 95% CI: 1.45-1.76; 500 vs. 350 cells/mm3: HR=0.89, 95% CI: 0.81-0.99), older age (age 55 vs. 35: HR=1.52, 95% CI: 1.29-1.79), and lower education (none vs. at least secondary: HR=1.21, 95% CI: 0.90-1.64). Conclusion: PLWH who present with baseline TB have an elevated risk of long- termmortality, even after TB treatment completion. Further study is necessary to understand the long-term clinical impact of TB disease in PLWH.

Poster Abstracts

CROI 2019 284