Suboptimal uptake, retention, and adherence of daily oral PrEP among people with OUD receiving HCV treatment

Background

Daily oral preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) prevents human immunodeficiency (HIV) among people who inject drugs (PWID). Despite rising HIV incidence and injection drug use (IDU), PrEP use remains low and there is limited research about uptake, adherence, and retention among PWID.

Methods

The ANCHOR investigation evaluated a community-based care model collocating hepatitis C virus (HCV) treatment, medication for opioid use disorder (OUD), and PrEP in individuals in Washington, DC, and Baltimore, Maryland. PrEP counseling was conducted from HCV treatment day 0 until week 24. Subjects could start any time during this window, were followed for 48 weeks, and were assessed for adherence by self-report and dried blood spot TDF analysis.

Results

One hundred ninety-eight participants were enrolled, of whom 185 (93%) were HIV negative. Twenty-nine individuals (15.7% of HIV-negative cohort) initiated PrEP. One hundred sixteen participants (62.7%) met 2014 Centers for Disease Control and Prevention (CDC) PrEP criteria due to IDU (82 [44.3%]), sex (9 [4.9%]), or both practices (25 [13.5%]). Providers recommended PrEP to 94 individuals (50.8%), and recommendation was associated with PrEP uptake. Median treatment duration was 104 days (interquartile range, 28–276 days), with 8 participants retained through week 48. Adherence was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Conclusions

This cohort of people with HCV and OUD experienced low uptake of PrEP despite the majority meeting CDC criteria. High rates of disruption and discontinuation, compounded by variable adherence, made TDF/FTC a suboptimal prevention strategy. Emerging modalities like long-acting formulations may address these barriers, but PWID have been excluded from their development to date.

859. Suboptimal Uptake, Retention, and Adherence of Daily Oral PrEP Among People with OUD Receiving HCV Treatment

Background

Daily oral pre-exposure prophylaxis (PrEP) with tenofovir/emtricitabine (TDF/FTC) effectively prevents HIV among people who use drugs (PWUD). Despite rising rates of HIV incidence and injection drug use, PrEP use remains low and limited research exists on PrEP adherence and retention in this population.

Methods

Based in Washington, DC and Baltimore, the ANCHOR investigation evaluated a community-based model of care collocating hepatitis C (HCV) therapy, medication for opioid use disorder (OUD), and PrEP in people with chronic HCV, OUD, and drug use within 1 year. PrEP counseling was offered from HCV treatment Day 0 until Week 24 and subjects could start any time during this window. PrEP patients were followed for 48 weeks and assessed for adherence by self-report and dried blood spot analysis of TDF.

ANCHOR PrEP study enrollment and participant retention along the PrEP continuum.

Results

198 participants enrolled in ANCHOR, of whom 185 (93%) were HIV-negative. 29 subjects (16% of HIV-negative group) initiated PrEP. 116 subjects (63%) met 2014 CDC criteria for PrEP initiation due to IDU (82, 44%), sex (9, 5%), or both (25, 14%). Those who initiated were more likely to meet both CDC sexual and IDU risk criteria than those who declined PrEP (P=0.006). Providers recommended PrEP to 94 subjects (51%), which was associated with uptake (P=0.02). While median treatment duration was 104 days (IQR 28, 276), only 8 subjects were retained through Week 48. The most common reason for discontinuation was side effects in 7 subjects or 24% of PrEP subgroup. Treatment interruptions occurred in one-third of the PrEP subgroup. Adherence of 4 to 7 pills per week was variable over time by self-report and declined by TDF analysis. No HIV seroconversions occurred.

Demographic and epidemiological background of the ANCHOR study population.

Total duration, in days, on PrEP in the ANCHOR study. Discontinued participants are grouped by reason for cessation of therapy.

PrEP Adherence

Adherence to PrEP by ANCHOR study timepoint, assessed via self-report (above) and dried bloodspot analysis of tenofovir level (below).

Conclusion

In this cohort of people with OUD and HCV, 16% of subjects started PrEP. While clinical recommendation was associated with uptake, high rates of disruption and discontinuation, compounded by variable pill adherence, made daily oral TDF/FTC a suboptimal preventive strategy in this cohort. Emerging PrEP modalities like long-acting injectables have potential to address these barriers, but PWUD have been excluded from their research and development to date. Additional work to identify vulnerable individuals and to promote use, adherence, and retention will be critical in implementing PrEP more effectively in this key population.

Disclosures

Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

844. High Risk Behaviors, Suboptimal HIV Viral Suppression, and Limited PrEP Use among People Who Engage in Transactional Sex

Background

In the United States, high rates of HIV transmission persist, particularly due to sexual transmission in marginalized populations. Transactional sex (TS) is a known risk factor for HIV transmission, yet risk behaviors and engagement in HIV treatment and prevention among those who have TS are poorly understood.

Methods

GRAVITY is cross-sectional investigation of people living with HIV (PLWH) or HCV in Washington, DC and Baltimore, MD. Epidemiologic survey data were collected at a single timepoint. Patients who endorsed previous year sex in exchange for drugs, money, or shelter were considered positive for TS. Fisher’s exact test was used for statistical analysis.

Results

Of 500 participants, 81(16%) endorsed TS, the majority of whom were HIV+ (51, 63%) and used drugs daily or more (57,70%; see Table 1). PLWH with TS were more likely to be Black (44, 86%, p= 0.05) and Trans female (17, 33%, p<0.01) than HIV- participants with TS. In the TS cohort, PLWH were more likely to engage in anal sex (38, 75%, p< 0.01), have sex weekly or more (46, 90%; p< 0.01), have sex with more than 2 partners (27, 77%, p=0.03), and have a history of syphilis (14, 27% p= 0.04) compared to HIV- participants. Only 21% and 35% of PLWH and 17% and 22% of HIV- always used condoms in vaginal sex and anal sex, respectively (p >0.05). Though 41 (80%) PLWH took ART, only 19 (41%) reported viral suppression. Of HIV- participants, 59% had interest in starting Pre-Exposure Prophylaxis (PrEP), but few had been offered (3,10%), or ever taken PrEP (2,7%).

Table 1: Participant Characteristics and Associations with Transactional Sex and HIV Status

Conclusion

In this cohort of people with TS, there were high rates of HIV and racial, sexual, and gender minorities. Notably, PLWH had higher rates of frequent sex, multiple partners, and anal sex, as well as suboptimal viral suppression and condom use during anal sex. As such, PLWH +TS may be a consequential part of HIV transmission networks. While those without HIV also had frequent sex and suboptimal condom use, PrEP experience was limited. As the majority had interest in PrEP, targeted strategies to initiate and maintain PrEP in people with TS may be critical in preventing HIV acquisition. Interventions to identify TS, address high-risk behaviors, achieve and maintain viral suppression amongst +TS PLWH, and connect +TS HIV- individuals to PrEP are key to a comprehensive strategy to end the HIV epidemic.

Disclosures

Sarah Kattakuzhy, MD, Gilead Sciences (Scientific Research Study Investigator, Research Grant or Support) Elana S. Rosenthal, MD, Gilead Sciences (Research Grant or Support)Merck (Research Grant or Support)

Maternal cecal microbiota transfer rescues early-life antibiotic-induced enhancement of type 1 diabetes in mice

Early-life antibiotic exposure perturbs the intestinal microbiota and accelerates type 1 diabetes (T1D) development in the NOD mouse model. Here, we found that maternal cecal microbiota transfer (CMT) to NOD mice after early-life antibiotic perturbation largely rescued the induced T1D enhancement. Restoration of the intestinal microbiome was significant and persistent, remediating the antibiotic-depleted diversity, relative abundance of particular taxa, and metabolic pathways. CMT also protected against perturbed metabolites and normalized innate and adaptive immune effectors. CMT restored major patterns of ileal microRNA and histone regulation of gene expression. Further experiments suggest a gut-microbiota-regulated T1D protection mechanism centered on Reg3γ, in an innate intestinal immune network involving CD44, TLR2, and Reg3γ. This regulation affects downstream immunological tone, which may lead to protection against tissue-specific T1D injury.

The Physical Costs and Psychosocial Benefits of Travel Aids for Persons who are Visually Impaired Or Blind

This study investigated the musculoskeletal consequences of using travel aids, particularly white canes and dog guides, as perceived by 21 individuals, aged 27 to 68 years, who are visually impaired or blind. These individuals experienced a variety of negative physical effects that they either denied, ignored, or minimized because of the fundamental biophysical, psychological, and social benefits derived from being independently mobile and because of the need to attend to environmental cues to ensure safe travel. The implications of these findings for mobility training and future research are discussed.

Pharmacokinetics/genotype associations for major cytochrome P450 enzymes in native and first- and third-generation Japanese populations: comparison with Korean, Chinese, and Caucasian populations

Application of foreign clinical data across geographic regions can accelerate drug development. Drug disposition can be variable, and identification of factors influencing responsible pharmacokinetic/pharmacogenomic approaches could facilitate the universal application of foreign data and reduce the total amount of phase III clinical trials evaluating risks in different populations. Our objective was to establish and compare genotype (major cytochrome P450 (CYP) enzymes)/phenotype associations for Japanese (native and first- and third-generation Japanese living abroad), Caucasian, Chinese, and Korean populations using a standard drug panel. The mean metabolic ratios (MRs) for the four ethnic groups were similar except for a lower activity of CYP2D6 in Caucasians and CYP2C19 in Asians. Genotype, not ethnicity, impacted the MR for CYP2C9, CYP2C19, and CYP2D6; neither affected CYP1A2, CYP2E1, and CYP3A4/5 activities. We conclude that equivalent plasma drug concentrations and metabolic profiles can be expected for native Japanese, first- and third-generation Japanese, Koreans, and Chinese for compounds handled through these six CYP enzymes.

Expression of PTHrP and the PTH/PTHrP receptor in growing red deer antler

Antler growth is highly co-ordinated, so that trabecular bone and antler skin (velvet) develop together, at a rapid rate and in a manner reminiscent of their development in the fetus. Parathyroid hormone-related peptide (PTHrP) is expressed in both bone and skin, and is therefore a candidate to effect co-ordination between these tissues. The aim of this study was to localize the expression of PTHrP and its principal receptor, the parathyroid hormone/parathyroid hormone-related peptide receptor (PTH/PTHrPR), in antler ("spiker") of one-year-old red deer. Using immunohistochemistry and in situ hybridization, intense and overlapping expression of PTHrP and its receptor was seen in developing osseocartilaginous structures and in the underlying layers of velvet epidermis. PTHrP was located on both the cell surface and within the nuclei. Our results strongly suggest that PTHrP, acting via the PTH/PTHrPR and possibly other intracrine mechanisms, plays a central role in the co-ordinated regulation of cell division and differentiation of developing antler bone and skin.

Postures and repetitive movements during use of a long cane by individuals with visual impairment

STUDY DESIGN

Descriptive.

OBJECTIVE

To describe upper body postures and movements that occur when an individual with visual impairment uses a cane to explore the environment while walking.

BACKGROUND

Previous research revealed self-reported neuromusculoskeletal problems related to cane use in individuals with visual impairments. No research, however, is available correlating neuromusculoskeletal problems with specific strategies of cane use or describing what movements and postures actually occur during cane use.

METHODS AND MEASURES

Twenty-eight individuals with visual impairment who had been walking independently with a long cane for >1 year were videotaped walking with their canes. Subjects included 16 men and 12 women with a mean age of 39.8 +/- 15.2. Postures and movements of the head and neck, trunk, and each upper extremity body segment were analyzed using videotape.

RESULTS

Thirty-nine categories of postures or repetitive joint movements were observed. Half of the subjects lacked intersegmental movement of the head, trunk, and shoulder girdles during walking. The repetitive movements used to manipulate the cane occurred at the forearm or wrist. Intrasubject variability of postures and movements was low.

CONCLUSIONS

A variety of sustained postures and repetitive movements occur among individuals using long canes. Each individual displays minimal variability in cane manipulation strategy when walking in an uncomplicated environment. Cane manipulation is accomplished by repetitive movements of wrist flexion/extension, wrist ulnar/radial deviation, or forearm pronation/supination. The remainder of the upper body maintains sustained postures, and more than half of long cane users lack the normal intersegmental movement that typically occurs in the neck, trunk, and shoulder girdle during walking. Further research is needed to determine whether particular cane manipulation strategies or sustained postures during cane use increase the risk of musculoskeletal pain syndromes.

Applications of random sampling to virtual screening of combinatorial libraries

We describe statistical techniques for effective evaluation of large virtual combinatorial libraries (> 10(10) potential compounds). The methods described are used for computationally evaluating templates (prioritization of candidate libraries for synthesis and screening) and for the design of individual combinatorial libraries (e.g., for a given diversity site, reagents can be selected based on the estimated frequency with which they appear in products that pass a computational filter). These statistical methods are powerful because they provide a simple way to estimate the properties of the overall library without explicitly enumerating all of the possible products. In addition, they are fast and simple, and the amount of sampling required to achieve a desired precision is calculable. In this article, we discuss the computational methods that allow random product selection from a combinatorial library and the statistics involved in estimating errors from quantities obtained from such samples. We then describe three examples: (1) an estimate of average molecular weight for the several billion possible products in a four-component Ugi reaction, a quantity that can be calculated exactly for comparison; (2) the prioritization of four templates for combinatorial synthesis using a computational filter based on four-point pharmacophores; and (3) selection of reagents for the four-component Ugi reaction based on their frequency of occurrence in products that pass a pharmacophore filter.

IcePick: a flexible surface-based system for molecular diversity

IcePick is a system for computationally selecting diverse sets of molecules. It computes the dissimilarity of the surface-accessible features of two molecules, taking into account conformational flexibility. Then, the intrinsic diversity of an entire set of molecules is calculated from a spanning tree over the pairwise dissimilarities. IcePick's dissimilarity measure is compared against traditional 2D topological approaches, and the spanning tree diversity measure is compared against commonly used variance techniques. The method has proven easy to implement and is fast enough to be used in selection of reactants for numerous production-sized combinatorial libraries.

Description of movement patterns of young adults moving supine from the foot to the head of the bed

BACKGROUND AND PURPOSE

The purpose of this study was to describe the movement patterns (MPs) in young adults moving supine from the foot to the head of a bed.

SUBJECTS

Thirty-six young adults, aged 19 through 44 years, participated in this study.

METHODS

Subjects were videotaped performing 10 trial of moving in bed. The MPs of 3 body regions were described and categorized.

RESULTS

Six MP categories were developed for the axial region, 8 MP categories were developed for the upper extremities, and 6 MP categories were developed for the lower extremities. Kappa values ranged from .81 to .90 for the 3 body regions, Fifty-nine different combinations of MPs were observed. The most common combination of MPs occurred in 21.2% of the trials, 3 times more frequently than any other combination.

CONCLUSION AND DISCUSSION

A variety of MPs are used by young adults for moving from the foot to the head of the bed. A symmetrical pattern of sitting up and pushing with both hands and both feet was found to be the most common pattern. [Cohen BG, Cardillo ER, Lugg D, et al. Description of movement patterns of young adults moving supine from the foot to the head of the bed.

A hirudin-sensitive, growth-related proteinase from human fibroblasts

We have identified a hirudin-sensitive proteinase from human fibroblasts. Inhibition of this enzyme results in partial inhibition of cell growth in culture. The enzyme has a molecular weight of about 38000, and can be isolated by affinity chromatography with a hirudin-agarose matrix. The enzyme is apparently not closely related to thrombin, but does show a high level of amino acid sequence homology with fragments of a protein isolated from the synovial fluid of rheumatoid arthritis patients, which acts as a mitogen for human T lymphocytes.

Effect of practice of a throwing skill in one body position on performance of the skill in an alternate position

The effect of learning a throwing skill with the body in one position on performing the skill in a different position was investigated. 40 normal women, aged 20 to 34 years, were randomly assigned to experimental or control groups. Subjects threw darts from two positions, sitting on a Balans chair or reclined on a slanted table. Practice and transfer sessions each included 4 sets of 5 throws. Performance was significantly poorer after switching positions than when remaining in the same position. Performance after practice in an alternate position was significantly worse than performance after no practice. These findings suggest that practicing a skill in one position may not improve learners' ability to perform that skill in a different position.

Complete short-term correction of canine hemophilia A by in vivo gene therapy

Hemophilia A is a severe bleeding disorder caused by a deficiency in clotting factor VIII (FVIII). A canine model that closely mimics the human disease was used to determine if an adenoviral vector expressing a human FVIII cDNA could be used to correct the hemophilia A phenotype. Within 48 hours after peripheral vein administration of the vector to FVIII-deficient dogs, the hemophilic phenotype was corrected, based on determination of the activated clotting time, the activated partial thromboplastin time, and the cuticle bleeding time. Direct measurement of human FVIII in the dog plasma showed FVIII expression at amounts well above the human therapeutic level. FVIII expression in treated dogs was short-term, lasting 1 to 2 weeks, due to the development of a human FVIII-specific inhibitor antibody response. These data provide the first demonstration of in vivo gene therapy of hemophilia A.

The inability to name a child

A patient, whose presenting complaint is the inability to decide on a name for her child, is presented. A review of the literature on the significance of names is included, and comments are made on panelists from psychoanalytic and phenomenological perspectives. Management of the patient's depression is discussed.

Kluver Bucy syndrome with severe amnesia secondary to herpes encephalitis

The authors present a case of Kluver Bucy syndrome with severe amnesia secondary to herpes encephalitis. The clinical features, neuropsychological test results and magnetic resonance images in this case also elucidate important aspects of limbic system pathology that are discussed in light of the literature.

Effectiveness of visual vs kinesthetic instruction for learning a gross motor skill

The purpose of this study was to compare visual with kinesthetic instruction for learning a motor skill that is not visually monitorable. Previous studies comparing visual and kinesthetic information have all used arm tasks for which the nonvisual condition was artificial. 20 subjects were randomly assigned to either a kinesthetic or a visual instruction group. The task was to draw a horizontal line with the right foot while in a quadruped position. All subjects received visual knowledge of results. While performance improved over the course of the 10 instructional sessions and trials, no difference in performance was found between the two instructional groups. A follow-up study is required to determine whether this result was based on visual dominance. Understanding the effectiveness of the different modalities for teaching gross motor skills would be valuable to physical therapists, physical educators, and psychologists.

Is there genetic heterogeneity in Usher's syndrome?

Usher's syndrome is an autosomal recessive disease characterized by congenital sensorineural hearing loss and retinitis pigmentosa (RP). Evidence for genetic heterogenicity within a single pattern of transmission of RP, be it autosomal recessive, dominant or sex-linked recessive, has been demonstrated by clustering patterns within and between families of specific clinical parameter weightings. Fishman, et al have noted corresponding evidence for subtypes of Usher's Syndrome, of paramount importance in mounting molecular level studies elucidating pathogenesis and management. Our study is of 25 consecutive patients studied by clinical investigation, including audiometric, vestibular and electro-ocular tests. Evidence for and against horizontal as well as proximal to distal receptors is weighed against loss of both visual and cochleo-vestibular systems. The clinical relevance is discussed.

Controlled voltages for electroconvulsive therapy

A description is given for the design of an isolated output, servo-controlled voltage, electroconvulsive therapy (ECT) machine for the safe, controlled application of 60-Hz alternating current (ac) signals between 0 and 230 V rms for controlled periods ranging from 0.1 to 2 sec. Added safety is provided by current limiting in the range of 360 to 770 mA rms for patient impedances ranging from 500 to 50 omega. The use of this equipment has permitted a detailed description of the impedances characteristic of unilateral ECT.