894. Trend of Transmitted Resistance Associated Mutations in People Living with HIV (PLWH) in a Large Southeastern U.S. Ryan White Clinic

Abstract Background Department of Health and Human Services (DHHS) guidelines recommend integrase strand transfer inhibitors (INSTIs) as the backbone of preferred initial antiretroviral (ART) regimens (1). Baseline mutation rates for the INSTI class is 0.8% compared with an overall rate of 19% for all ART classes, based on Centers for Disease Control and Prevention (CDC) U.S. data from 2013-16 (2). First-generation INSTIs (raltegravir and elvitegravir) have a lower genetic barrier to resistance compared with newer, second generation INSTIs (bictegravir and dolutegravir) (3, 4). DHHS guidelines do not currently recommend routine HIV genotypic resistance testing to INSTIs prior to ART initiation (1). Our study seeks to determine the current prevalence of transmitted INSTI and overall resistance in a large southeastern U.S. Ryan White clinic. Methods This was a single-center, retrospective analysis of treatment naïve PLWH presenting for care from January 1, 2017 to December 31, 2020. Of these, 164 had a baseline genotype performed by one of two commercially available assays – Vela Genomics or ViroSeq. Subsequent interpretations were based on Stanford HIV Drug Resistance Database. Results 65 patients (39.6%) had at least one transmitted resistance associated mutation (RAMs). Of these, 24 (36.9%) had an INSTI RAM. Baseline PI, NRTI, and NNRTI RAMs declined during the four-year interval (2017-2020), while the rate of INSTI RAMs increased from 11.1% to 19%; all conferred resistance to the first generation INSTIs with one also conferring resistance to second generation INSTIs. INSTI Resistance Associated Mutation Prevalence 2017-2020 Frequency of Antiretroviral Therapy Class Mutations Per Year Trend of INSTI Mutations and Resistance Associated Mutations 2017-2020 Conclusion Unlike the CDC data which showed the overall prevalence of INSTI RAM transmission rates during 2013-2016 to be 0.8%, our data suggests a higher rate of INSTI RAMs (14.6%) with overall ART RAM transmission of 39.6%. This increase in baseline resistance to the INSTI class, which occurred over time, mimics the historical development of RAMs seen in the earlier ART classes. Though suboptimal adherence in the population promotes development of RAMs, increased frequency of INSTI RAMs may be due to a lower barrier to resistance of first generation INSTIs. Should our observed trend continue, routine baseline INSTI resistance testing may need to be considered prior to ART initiation. Disclosures Cheryl Newman, MD, Gilead (Scientific Research Study Investigator)GSK/ViiV (Scientific Research Study Investigator, Advisor or Review Panel member, Speaker’s Bureau)Janssen (Scientific Research Study Investigator)Merck (Scientific Research Study Investigator)


Session: P-51. HIV: Treatment
Background. Department of Health and Human Services (DHHS) guidelines recommend integrase strand transfer inhibitors (INSTIs) as the backbone of preferred initial antiretroviral (ART) regimens (1). Baseline mutation rates for the INSTI class is 0.8% compared with an overall rate of 19% for all ART classes, based on Centers for Disease Control and Prevention (CDC) U.S. data from 2013-16 (2). First-generation INSTIs (raltegravir and elvitegravir) have a lower genetic barrier to resistance compared with newer, second generation INSTIs (bictegravir and dolutegravir) (3, 4). DHHS guidelines do not currently recommend routine HIV genotypic resistance testing to INSTIs prior to ART initiation (1). Our study seeks to determine the current prevalence of transmitted INSTI and overall resistance in a large southeastern U.S. Ryan White clinic.
Methods. This was a single-center, retrospective analysis of treatment naïve PLWH presenting for care from January 1, 2017 to December 31, 2020. Of these, 164 had a baseline genotype performed by one of two commercially available assays -Vela Genomics or ViroSeq. Subsequent interpretations were based on Stanford HIV Drug Resistance Database.
Results. 65 patients (39.6%) had at least one transmitted resistance associated mutation (RAMs). Of these, 24 (36.9%) had an INSTI RAM. Baseline PI, NRTI, and NNRTI RAMs declined during the four-year interval (2017-2020), while the rate of INSTI RAMs increased from 11.1% to 19%; all conferred resistance to the first generation INSTIs with one also conferring resistance to second generation INSTIs.

Trend of INSTI Mutations and Resistance Associated Mutations 2017-2020
Conclusion. Unlike the CDC data which showed the overall prevalence of INSTI RAM transmission rates during 2013-2016 to be 0.8%, our data suggests a higher rate of INSTI RAMs (14.6%) with overall ART RAM transmission of 39.6%. This increase in baseline resistance to the INSTI class, which occurred over time, mimics the historical development of RAMs seen in the earlier ART classes. Though suboptimal adherence in the population promotes development of RAMs, increased frequency of INSTI RAMs may be due to a lower barrier to resistance of first generation INSTIs. Should our observed trend continue, routine baseline INSTI resistance testing may need to be considered prior to ART initiation.
Disclosures Background. Telemedicine (TM) has been seldom used for the care of persons with HIV. However, the COVID-19 pandemic has forced HIV clinics to rapidly scale TM resources. With the increase of TM, the impact on HIV patient care remains uncertain. The purpose of this study is to examine the effects of TM on HIV care and retention at a Ryan White-funded clinic.
Methods. This was a retrospective study of patients seen at an academic clinic in Pittsburgh, PA between 1/1/20 -12/31/20. Encounter information was extracted from the clinic electronic health record. Primary outcomes were viral load (VL) suppression (< 200 copies/ml) and retention in care for persons seen via TM (phone, video +/-in person) vs those seen in-person. Secondary outcomes included flu vaccination and STI screening rates.
Results. Amongst 1414 patients, 608 patients had at least one scheduled TM visit, with 97 seen exclusively via TM, and 806 were scheduled for only in-person visits. In those with at least one TM visit, 92.72% had a suppressed VL. 89.69% of those with only TM visits were suppressed. 92.43% were suppressed in the in-person group. Average show rate amongst patients who had at least one TM visit was 60.39% (+0.96% from 2019, +1.71% from 2018), vs 64.38% amongst patients who only had in-person visits. Amongst patients who were only scheduled for TM visits, show rate was 83.97%. 40.18% of patients who had at least one TM visit received their flu vaccine in 2020 (-37.45% from 2019, -36.72% from 2018) vs 37.62% who were only seen in-person. Amongst patients who had at least one TM visit, syphilis screening rate was 43.09% (-7.64% from 2019, -8.55% from 2018) vs 43.51% for those seen only in-person. Gonorrhea and chlamydia screening rates were both 42.91% (+9.46% from 2019, +15.27% from 2018 for chlamydia screening; +8.36% from 2019, +14.73% from 2018 for gonorrhea screening). Amongst patients who were exclusively seen in-person gonorrhea screening rate was 48.24% and chlamydia screening rate was 47.57%. Conclusion. VL suppression rates were similar across both groups, but retention in care was highest in the TM-only group. Flu vaccination rates and STI screening were lower in the groups that included TM. TM is an effective method for maintaining VL suppression and retention in care but has room for improvement with provision of preventative services. Disclosures.