CROI 2019 Abstract eBook

Abstract eBook

Poster Abstracts

888 HIV PHYLODYNAMIC ANALYSIS CORRELATES WITH TRENDS IN ILLICIT OPIOID TRADE IN PAKISTAN Francois Cholette 1 , Jeffrey Joy 2 , Yann Pelcat 3 , Laura Thompson 4 , Richard Pilon 1 , John Ho 3 , Rupert Capina 3 , Chris Archibald 1 , James F. Blanchard 4 , Faran Emmanuel 4 , Tahira Reza 4 , John Kim 3 , Paul Sandstrom 3 1 Public Health Agency of Canada, Winnipeg, MB, Canada, 2 British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada, 3 National Microbiology Laboratory, Winnipeg, MB, Canada, 4 University of Manitoba, Winnipeg, MB, Canada Background: Pakistan is considered to have transitioned from a “low prevalence, high risk” epidemic to a “concentrated” HIV epidemic owing primarily to a rapid rise in infections among people who inject drugs (PWID). Prevalence among the country’s nearly 105,000 PWID is estimated to be 37.8% but has been shown to be higher in several large urban centers. Here we evaluate the molecular characteristics of HIV sequences from PWID in several Pakistani cities to examine transmission dynamics and the association between rates of HIV transmission with regards to regional trends in opioid trafficking. Methods: Tip-to-tip (patristic) distance based phylogenetic cluster inferences and BEAST2 Bayesian Markov Chain Monte Carlo phylodynamic analyses of time-stamped data were performed on HIV pol sequences generated from dried blood spots collected from 1,453 PWID as part of a cross-sectional survey conducted in Pakistan during 2014/2015. Results: In total, we were able to amplify 290 pol sequences of the 367 HIV positive specimens. Overall, subtype A1 strains were dominant (75.2%) followed by CRF02_AG (14.1%), recombinants (7.2%), CRF35_AD (2.1%), G (1.0%) and C (0.3%). Nearly a quarter (n=72) of the PWID HIV sequences belonged to one of four distinct phylogenetic clusters. The largest cluster (n=53) mainly consisted of individuals who did not seek help injecting which was previously identified as a strong correlate of HIV infection. Spikes in estimated HIV population sizes coincided with increases in opium poppy cultivation in Afghanistan, Pakistan’s western neighbor. Structured coalescent analysis was undertaken in order to investigate the spatial relationship of HIV transmission among the various cities under study. In general terms, our analysis placed the city of Larkana at the center of the PWID HIV epidemic in Pakistan which is consistent with previous epidemiological data. Conclusion: The current epidemic among PWID is no longer dominated by transmission of a limited number of subtype A1 founder viruses as reported previously. The greater subtype diversity is consistent with sexual and/or drug injecting networks between PWID and other most at-risk populations. Although it is evident that unsafe injection behaviors played a significant role in driving the rise in HIV prevalence among PWID, local trends in opioid trafficking may have influenced injection behavior and facilitated HIV-1 transmission as a result. 889 IMPROVING CHRONIC OPIOID THERAPY AMONG PEOPLE LIVING WITH HIV: A CLINICAL RCT Jeffrey H. Samet 1 , Jane Liebschutz 2 , Debbie Cheng 1 , Jonathan Colasanti 3 , Judith I. Tsui 4 , Marlene C. Lira 5 , Leah S. Forman 1 , Christopher W. Shanahan 1 , Meg Sullivan 1 , Christin Root 3 , Carly Bridden 5 , Christine Capozzi 5 , Wendy S. Armstrong 3 , Alexander Y. Walley 1 , Carlos del Rio 3 1 Boston University, Boston, MA, USA, 2 University of Pittsburgh, Pittsburgh, PA, USA, 3 Emory University, Atlanta, GA, USA, 4 University of Washington, Seattle, WA, USA, 5 Boston Medical Center, Boston, MA, USA Background: Chronic pain is highly prevalent among people living with HIV (PLWH); managing pain with chronic opioid therapy (COT) is common. HIV physicians often diverge from opioid prescribing guidelines. Methods: The Targeting Effective Analgesia in Clinics for HIV (TEACH) study was a 2-arm cluster randomized trial to assess whether a collaborative care intervention increased guideline-concordant care for COT compared to standard practice among PLWH. From 2015-2016 we recruited HIV care providers who prescribed COT and their patients from two safety-net hospital-based HIV clinics. We randomized 41 providers, in a 1:1 ratio, to receive either the TEACH intervention (an IT-enabled nurse care manager; education and academic detailing; and access to addiction specialists) or the control condition (educational brochure). We assessed: a) ≥2 urine drug tests (UDTs) (primary); b) any early COT refills (primary); c) having an opioid treatment agreement (OTA); d) virologic suppression (VS); and e) provider’s routine use of prescription monitoring programs (PMP). An intention-to-treat analysis was conducted using generalized estimating equations (GEE) logistic regression models. Results: The 41 providers and their 187 COT patients had the following baseline characteristics: providers - 34%male; age 46 years; 63%white; 78%MDs; 12%

buprenorphine waivered; patients - 72%male; age 54 years; 28%white; 91% with undetectable HIV viral load; 15%with history of injection drug use. COT prescribers (n=21 with 87 patients) were randomized to the intervention arm. At 12-month follow up, the intervention arm had higher odds of ≥2 UDTs (70% vs. 18%, adjusted odds ratio [AOR]: 15.46, 95% confidence interval [CI]: 7.29- 32.79; p<0.0001) and OTAs (75% vs. 11%, AOR: 128.21, 95% CI: 22.85-719.30, p<0.0001). We did not detect a difference in early refills (21% vs. 29%, AOR: 0.57, 95% CI: 0.26-1.24, p=0.15), routine use of PMP (55% vs. 25%, AOR: 3.65, 95% CI: 0.94-14.19, p=0.06), or HIV VS (88% vs. 84%, AOR: 1.14, 95% CI: 0.63- 2.04, p=0.67) between the two arms. Conclusion: Participants in the TEACH intervention had higher odds of following 2 important guidelines for COT: ≥2 urine drug tests and treatment agreements. We did not detect significant differences in early refills, use of prescription monitoring programs, or viral suppression. The TEACH intervention is a promising strategy to improve adherence to guidelines for COT and does not appear to compromise viral suppression.

890 HIV CARE OUTCOMES AMONG SUBSTANCE USERS IN PUERTO RICO FOLLOWING HURRICANE MARIA Diana Hernandez 1 , Lisa R. Metsch 1 , Pedro C. Castellón 1 , Sandra Miranda de Leon 2 , Glenda O. Davila-Torres 3 , Yue Pan 4 , Allan Rodriguez 4 , Iveth G. Yanez 1 , Mariela Maisonet Alejandro 5 , Wilmarie L. Calderón Alicea 3 , Gabriel Cardenas 4 , Héctor J. Meléndez-González 5 , Lauren Gooden 1 , Daniel J. Feaster 4 , Jorge L. Santana 5 1 Columbia University Medical Center, New York, NY, USA, 2 Puerto Rico Department of Health, San Juan, PR, USA, 3 Iniciativa Comunitaria de Investigación, San Juan, Puerto Rico, 4 University of Miami, Miami, FL, USA, 5 University of Puerto Rico, San Juan, Puerto Rico Background: In 2017, Hurricane Maria (HM) caused devastation to Puerto Rico and its residents. Based on an ongoing cohort study in San Juan, Puerto Rico (Proyecto PACTo), we examined the effects of HM on HIV care outcomes among people living with HIV (PLWH) and with a history of substance use. Methods: We measured differences in HIV care outcomes - viral load, viral suppression, and CD4 counts - before and after HM using assessments conducted in 6-month intervals. Data are based on blood collected to measure CD4 and viral load and a social and behavioral assessment completed through a computer-assisted personal interview. Factors associated with HIV care outcomes were evaluated using generalized estimating equations to take into account repeated measures per individual. Results: 219 participants completed a follow-up visit within the 9-month period before and after HM. The mean post-HM viral load was 2.3 log10 copies/ ml (se=0.09), significantly higher compared to pre-HM (2.1 log10 copies/ml, se=0.08). CD4 counts also were lower post-HM (mean=553 cells/ul, se=23.2) compared to pre-HM (mean=589 cells/ul, se=24.7) (Figure). Viral suppression (<200 copies/ml) was 72% pre-HM compared to 65% post-HM. After controlling for age, gender, income, health insurance, incarceration history, homelessness, history of living in the mainland United States, severe drug use, and depression at baseline, there was a 9% reduction for viral suppression between pre- and post-HM time points (aIRR=0.91, 95% CI 0.84-0.98). Also, age (aIRR=1.01, 95% CI 1.00-1.02) and homelessness (aIRR=0.78, 95% CI 0.62-0.98) were independent predictors of viral suppression. Conclusion: PLWH and with a history of substance use in San Juan, Puerto Rico demonstrated an increase in viral load and decrease in both viral suppression and CD4 counts following HM, critical factors in determining disease outcome and potential community transmission. Further post-HM research will focus on the barriers and facilitators related to accessing healthcare and resources and the effects of post-traumatic stress disorder, which may explain long-term HIV care outcomes.

Poster Abstracts

CROI 2019 346