To explore the association of pre-exposure prophylaxis (PrEP) use with condomless sex and sexually transmitted infections (STIs) among gay, bisexual, and other men who have sex with men (MSM) in Washington, DC. Multivariate analysis of cross-sectional weighted survey data from 2014, 2017, and 2023 among MSM. Methods: This analysis used venue-based, time-space sampling to survey MSM about HIV-related behavioral risk factors, HIV testing, and use of prevention services. Chi-square tests and logistic regression were conducted to calculate adjusted prevalence ratios (aPR) and ascertain the association between the use of PrEP with condomless sex and having a bacterial STI in the past 12 months 774 MSM were surveyed during the three cycles in 2014, 2017, and 2023. The proportion of MSM reporting PrEP use, having a STI in the past 12 months, and condomless sex in the past 12 months increased over time from 2014 to 2023. MSM that used PrEP were more likely to report condomless sex (aPR = 1.33, 95

Older people who inject drugs (PWID) remain at risk for HIV, yet little is known about HIV risk behavior in this population. We investigated the prevalence and correlates of HIV risk behaviors among older PWID in Washington, DC. We conducted a cross-sectional analysis of self-reported survey data collected between June 2022 and June 2023 from adults recruited through community-based outreach at known drug use hotspots. Respondents who reported injection drug use in the past three months and were aged > 50 were included. We used simple and multivariable logistic regression to determine correlates of HIV risk behaviors in the last three months. Among 260 older PWID, 42

BACKGROUND:The HIV Prevention Trials Network 094 INTEGRA study sought to fill the gap in implementation science literature by exploring the delivery of integrated prevention and care for HIV and opioid use dependence (OUD) through mobile units to people who inject drugs (PWID). SETTING:Five U.S. INTEGRA sites with diverse implementation landscapes disproportionately affected by the HIV and opioid epidemics (New York, Philadelphia, Washington, DC, Houston, Los Angeles) . METHODS:In-depth qualitative interviews from an embedded implementation science evaluation were conducted with 37 clinical and research INTEGRA staff delivering integrated care through mobile units. Pragmatic qualitative analysis was guided by the PRISM framework to identify key implementation needs, challenges, and solutions for delivering the INTEGRA intervention via mobile units in local neighborhoods. RESULTS:Staff described how mobile delivery of INTEGRA reduced key barriers that limit PWID access to HIV and OUD services. Yet, they also detailed complex implementation needs, including the proactive coordination among staff to ensure sustained access to INTEGRA services, navigating internal and external spaces to deliver services, maintenance-related demands to keep the mobile unit's infrastructure operational, and interdependent efforts that bridged the mobile unit's service delivery within the extant health systems and community landscapes. CONCLUSION:Findings demonstrated that mobile integrated care models can reduce access barriers for PWID but require tailored implementation strategies to address operational, spatial, infrastructural, and community-level demands. Results may help inform an implementation blueprint for similar communities working to respond to the intersecting HIV and opioid epidemics affecting PWID across U.S. settings.

Background: Criminal legal involved (CLI) persons who use drugs (PWUD) are at high risk of exposure to HIV, yet few initiate pre-exposure prophylaxis (PrEP). Understanding interest in PrEP and the different formulations of PrEP may improve uptake in this population. Methods: Participants were CLI adults aged 18 or older, used opioids and/ stimulants, tested negative for HIV and met CDC PrEP eligibility criteria. Characteristics of persons interested in PrEP were compared to those who were not interested in PrEP at baseline. Among those interested in PrEP, characteristics were compared for those who preferred long-acting injectable (LAI) versus oral PrEP. Results: Of 566 persons enrolled, 35.1% (N=199) were interested in PrEP; of those, 60.8% (N=121) preferred LAI vs 39.1% (N=78) oral PrEP. PrEP interest was greater in persons from Texas (50%) vs Connecticut (18.3%). A significantly higher odds of being interested in PrEP was associated with having a methamphetamine use disorder and a higher self-perceived risk of HIV; and a history of sharing IDU equipment was associated with a higher odds of being interested in LAI vs. oral PrEP. Conclusions: Among CLI PWUD eligible for PrEP, persons in TX, were more interested in PrEP compared to persons in CT. Persons with a methamphetamine use disorder and a higher self-perceived risk of HIV were predictors of PrEP interest and sharing IDU equipment was a predictor of interest in LAI vs. oral PrEP. More research on patient choice and shared decision making should be included to improve PrEP initiation.

People who inject drugs (PWID) are frequently hospitalized with acute infections. Patient-directed discharge (PDD) is common among people with injection-related infections and is associated with rehospitalization and death. Opioid withdrawal and pain are common reasons for PDD among PWID but approaches to reduce PDD among people with injection-related infections are lacking. To measure if inpatient treatment of opioid use disorder (OUD) and opioid withdrawal is associated with lower PDD rates among people hospitalized with infections from injection drug use. Multisite retrospective observational cohort. Multivariable Poisson regression models were used to compute adjusted incidence rate ratio (aIRR) for factors associated with PDD. Adults hospitalized for ≥ 2 days at four academic medical centers for a bacterial or fungal infection caused by injection opioid use between January 1, 2018, and March 31, 2023. Drug toxicology testing, presence of opioid withdrawal, treatment of opioid withdrawal, receipt of medication for OUD (MOUD; buprenorphine or methadone), duration of hospitalization, and discharge type (planned or patient-directed). PDD occurred in 25

Stimulant use among men who have sex with men (MSM) can contribute to HIV risk and care challenges. Monitoring and responding to local trends are critical for Ending the HIV Epidemic (EHE) initiatives. We assessed stimulant use patterns in Baltimore, Philadelphia, and Washington, DC from 2008 to 2023 using National HIV Behavioral Surveillance data. We collected cross-sectional data in each city using venue-based sampling in 2008, 2011, 2014, 2017, and 2023. We estimated average predicted probabilities of methamphetamine, powder cocaine, and crack cocaine use, and evaluated differences in prevalence of stimulant use overall and by race/ethnicity. In DC, stimulant use was stable or declined. Methamphetamine use remained stable overall (8

Hospitalization provides an opportunity to improve the Hepatitis C Virus (HCV) cascade of care among people who inject drugs. Little is known about whether this potential opportunity is utilized. We conducted a retrospective chart review at four U.S. academic medical centers among patients hospitalized between 1/1/2018-3/ 31/2022 with ICD-10 diagnosis codes for both opioid use disorder and acute bacterial or fungal infection. Electronic medical records were reviewed manually to confirm injection drug use-related infection for inclusion in the study. Data abstracted from medical records included baseline HCV status at the time of admission; whether HCV antibody screening and confirmatory viral load testing were performed during hospitalization, and their results; follow up for HCV treatment within the same medical system after discharge; and response to treatment. A total of 1651 patients were included. Seventy-five percent of patients with unknown HCV status at the time of admission were screened for HCV during hospitalization, of whom 66% screened positive. Of those with a confirmatory ribonucleic acid (RNA) test, 62% had a detectable viral load (VL). Seventeen percent of those with detectable VL attended a follow up appointment within 12 months. Fifty-five percent of patients with known prior HCV infection were RNA tested, and 65% of those tested had detectable virus. Results revealed sizeable attrition along the entire HCV cascade of care and missed opportunities to engage people who inject drugs in follow up during hospitalization for other infections. Hospitalized individuals who inject drugs need targeted interventions to improve HCV screening, diagnosis, and care linkage.

Background:Adolescents and young adults account for a disproportionate number of new HIV diagnoses in the United States due to missed opportunities for education, testing, and prevention. Objective:We tested the efficacy of an interactive life-simulation gaming intervention to provide HIV education and improve HIV testing uptake and preventive services among youths ages 13-24 years in the Washington, DC area. Methods:We conducted a parallel randomized controlled trial testing the efficacy of an HIV-focused gaming intervention app to a control app in increasing HIV testing uptake. Participants were recruited via social media and peer referral. Eligible participants were randomized 1:1 by age (13-17 vs 18-24 years) and sexual orientation (lesbian, gay, bisexual, or "other" vs heterosexual). Participants accessed their assigned app for 3 months and completed baseline, 1-, 3-, and 6-month surveys. The primary outcome was self-reported HIV testing within 6 months after enrollment; secondary outcomes included intent to test for HIV, HIV knowledge, and intention to start pre-exposure prophylaxis (PrEP). Analyses were conducted as intent-to-treat and stratified by sexual orientation. Results:From November 2023 to May 2024, we randomized 309 participants (intervention: n=156; control: n=153) with 80% and 88% retention at 6 months, respectively. Among the analyzed participants (intervention: n=150; control: n=149), the mean age was 20.7 (SD 1.84) years, 49% (145/299) were women, and 34% (103/299) were non-Hispanic White. Overall, 53% (158/299) self-reported as gay, lesbian, bisexual, or "other" sexual orientation. A total of 48% (144/299) had previously tested for HIV. Compared to the control app, game participants were 32% less likely to test for HIV within 6 months (relative risk 0.68, 95% CI 0.47-0.98). The two groups showed no statistically significant differences regarding their intention to get tested for HIV or to start PrEP. A significantly higher difference in mean HIV knowledge scores at 3 months (0.99, 95% CI 0.33-1.65; P<.01) and 6 months (0.81, 95% CI 0.14-1.48; P=.02) was observed in the game arm compared to the control arm. Additionally, heterosexual participants in the game arm had statistically significant increases in PrEP intention (0.53, 95% CI 0.05-1.00; P=.03) across all time points compared to controls. Conclusions:Our interactive gaming app was less effective than an information control app in increasing HIV testing and changing testing and prevention intentions among adolescents and young adults. In the game arm, we did observe increased HIV knowledge and increased PrEP intention among heterosexual adolescents and young adults. Few life-simulation apps integrating HIV testing and prevention features have been rigorously tested among adolescents and young adults. Our efficacy findings suggest that while these interventions are feasible and acceptable to adolescents and young adults, they require additional tailoring to improve their reach, use, and potential effectiveness in real-world settings.

Importance:In the US, the overdose crisis continues to be driven by fentanyl, xylazine, and stimulant-involved polysubstance use among people who inject drugs, especially those who are not engaged in medical care. Objective:To estimate the overall prevalence of illicit drugs detected among people who inject drugs in 5 US cities by city and sociodemographic characteristics and assess trends in drug detection over a 2-year period. Design, Setting, and Participants:This cross-sectional study included data from individuals enrolled in HIV Prevention Trials Network (HPTN) 094, a randomized clinical trial to evaluate an integrated mobile unit engaging adults aged 18 years or older who inject drugs in HIV services between June 2021 and September 2023 in New York City; Houston, Texas; Los Angeles, California; Philadelphia, Pennsylvania; and Washington, DC. All analyses were completed between August 2021 and August 2025. Main Outcomes and Measures:Baseline prevalence of toxicologic detection was assessed using liquid chromatography-high-resolution mass spectrometry. Differences in toxicologic detection by sociodemographic characteristics (age, race and ethnicity, housing status, and incarceration history), study site, and illicit drug type over time were analyzed using generalized linear models. Results:Across 444 participants, 303 (68.2%) were male, 267 (60.1%) were aged 30 to 49 years, 203 of 440 (46.1%) were unhoused, and 91 of 442 (20.6%) had a recent incarceration history. In all, 414 participants (93.2%) tested positive for fentanyl, 328 (73.9%) for cocaine, 299 (67.3%) for amphetamine-type stimulants, and 234 (52.7%) for xylazine. Nearly all participants (421 [94.8%]) tested positive for polysubstance drugs (fentanyl or opioids with stimulants, benzodiazepines, cocaine, and/or xylazine). Fentanyl detection was high across all sites; xylazine was most common in New York City (68 of 94 [72.3%]), Philadelphia (111 of 112 [99.1%]), and Washington, DC (31 of 41 [75.6%]). Every 6 months, xylazine detection increased in New York City by 10.3% (95% CI, 4.0%-16.5%; P = .001), and its prevalence stayed high in Philadelphia. Amphetamine-type stimulant detection increased in Washington, DC, by 15.0% (95% CI, 2.9%-27.1%) every 6 months over the enrollment period (P = .02). Across all sites, cocaine prevalence was higher among unhoused than housed participants (difference, 11.4%; 95% CI, 3.6%-19.2%; P = .004), and stimulant detection was elevated among those recently incarcerated vs not (difference, 9.9%; 95% CI, 1.4%-18.5%; P = .02). Conclusions and Relevance:This cross-sectional study found widespread fentanyl and polysubstance detection, with rising xylazine and stimulant detection that varied by sociodemographic and structural vulnerabilities and may be due to adulteration within the unregulated drug supply. These findings highlight urgent public health needs for real-time drug supply surveillance, targeted harm-reduction services, and integrated treatment approaches to reduce overdose risk and address social and structural vulnerabilities.

OBJECTIVES:To describe HPTN 094 study's peer navigation (PN) intervention, implemented in 5 urban US cities among people who inject drugs (PWID) at risk for or living with HIV, including guiding theories, core components, navigator training, available services, implementation challenges, and implications for future PN intervention research dissemination. METHODS:This 2-arm, randomized, open-label study assessed outcomes for PWID receiving integrated care services delivered in a mobile health unit that provided medication for opioid use disorder (MOUD), HIV prevention/treatment, and other health care in addition to PN to community services compared with PN to community services alone. Participants were PWID with opioid use disorder (OUD) not receiving MOUD and were either at risk for HIV or living with HIV. The PN model was grounded in 5 complementary theories addressing individual, interpersonal, social, systemic, and structural determinants of care. Variables used to measure PN intervention utility were number of sessions attended, session length, session topics, and in-person versus remote navigation sessions. RESULTS:Across study sites, participants without HIV (PWOH; n = 409) completed 3390 PN sessions and participants with HIV (PWH; n = 38) completed 365 PN sessions; the median number of sessions per participant was 6 in both groups. Most sessions were conducted in person and commonly addressed MOUD, HIV prevention or HIV care, and other medical or social service needs. These findings support the feasibility of delivering a flexible, theory-informed PN model for urban PWID and help characterize how peer navigation was used to address substance use, HIV, and broader service needs within HPTN 094. CONCLUSIONS:The PN model is acceptable with urban PWID and potentially for people with other public health concerns in underserved communities. The findings have implications for future research examining the effectiveness and dissemination of the PN intervention.

People who inject drugs (PWID) experience high rates of serious injection-related bacterial and fungal infections (SIRI), including cellulitis, osteomyelitis, and endocarditis. These infections often require prolonged antibiotic treatment and result in frequent rehospitalizations, with over 50

OBJECTIVES:People who inject drugs (PWID) face elevated risks of hospitalizations and readmissions due to serious injection-related infections, yet few evidence-based interventions exist to prevent readmissions. This study aimed to explore factors contributing to rehospitalization among PWID, potential strategies, and assess the acceptability of 2 proposed interventions and implementation considerations. METHODS:We conducted 22 semistructured interviews with 36 health care providers and staff across 4 study sites in Georgia, Maryland, the District of Columbia, and West Virginia from June 2023 to September 2023. Participants were purposively sampled to represent diverse roles in providing or overseeing care to PWID. Interviews explored barriers to care, challenges contributing to rehospitalization, and perceptions of 2 proposed interventions: (1) integrated care for addiction and infectious diseases, and (2) patient navigation to support linkage to care postdischarge. Data were analyzed using rapid qualitative analysis informed by framework and thematic approaches. RESULTS:Three main themes emerged regarding rehospitalization factors (unaddressed structural, health system, and social determinants; gaps in addiction care training; and continuity of care). Participants expressed high acceptability toward the proposed interventions. Three main themes emerged as recommendations for the implementation of the proposed interventions (organizational needs and capacity; leveraging existing resources; patient engagement and retention). CONCLUSIONS:Reducing readmissions among PWID requires addressing provider training gaps, care fragmentation, and structural barriers. Both proposed interventions were deemed acceptable by health care team members. Key implementation factors include strengthening organizational capacity, leveraging existing resources effectively, and using person-centered approaches to build trust and maintain patient engagement and retention.

Abstract Background People who inject drugs hospitalized with severe injection-related infections (SIRI) face barriers to antibiotic treatment completion and remain at risk for new infections due to ongoing injection drug use. We explored risk factors for SIRI readmission and whether readmissions were caused by the index SIRI or a new SIRI. Methods CHOICE+ is a retrospective cohort study of adults hospitalized with SIRI due to injection opioid use at 4 hospital systems between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the medical record. Primary outcomes were readmission for SIRI within 1 year and time to readmission. Categorical variables were analyzed by chi-square, Fischer exact test, and multivariate logistic regression. Time to readmission was compared by the Mann-Whitney test. Results Of 1618 patients discharged alive, 439 (27%) had ≥1 readmission for SIRI. Unstable housing, patient-directed discharge, and not finishing planned intravenous antibiotics in the hospital were associated with increased risk for SIRI readmission (Table 2). Risk of SIRI readmission was not associated with addiction or psychiatry consultation, discharge on medication for opioid use disorder (MOUD), or type of MOUD. The cause of readmission in 238 (54%) was the index SIRI and in 201 (46%) was a new SIRI. Median time to readmission was shorter for those readmitted with index SIRI compared to a new SIRI (10 v. 126 days, p < 0.0001, Figure 1) and for those who did not complete treatment for the index SIRI compared to those who completed treatment (7 v. 78 days, p < 0.0001, Figure 2). Conclusion In this large, representative study, readmission for SIRI occurred frequently for both problems related to the index SIRI as well as development of new SIRI. Readmission for index SIRI occurred earlier than for new SIRI, especially for those who did not complete antibiotic treatment. Notably, readmission for SIRI was not associated with inpatient interventions to address addiction during the index hospitalization. Therefore, prioritizing completion of treatment of the index SIRI may be critical for reducing early readmissions. In contrast, prevention of new SIRI, by longitudinally addressing addiction, social determinants of health, and harm reduction, may be necessary to reduce later readmissions. Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Abstract Background Injection-related skin ulcers (IRSU) are a cause of acute bacterial infection among people who inject drugs (PWID). We aimed to measure the prevalence, characteristics, and risk factors for IRSU, and the risk of readmission, among a cohort of PWID hospitalized for infections. Table 1 SD, standard deviation. Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized at four healthcare systems with infections due to injection opioid use between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the electronic medical record and were analyzed by chi-square, multivariable logistic regression, and unpaired t-test. Factors statistically significant for IRSU in bivariate analysis were examined by multivariate logistic regression. Detailed data on IRSU were recorded from the Baltimore site. Table 2 GWU, George Washington University; MOUD, medication for opioid use disorder; UMB, University of Maryland Baltimore; WVU, West Virginia University. Results Of 1652 included patients, 221 (13%) had a documented IRSU. Key demographics were similar between those with and without IRSU (Table 1). The odds of IRSU were higher among those who were positive for fentanyl and older age (Table 2). Baseline IRSU was associated with increased odds of readmission (aOR 1.4, p = 0.02) and a greater number of readmissions within 1 year (1.2 v. 0.9, p = 0.01, Figure 1). Among 116 patients from Baltimore with documented IRSU and detailed data, IRSU was the primary reason for admission in 66%. Xylazine use was not noted in any records. Most patients had < 4 ulcers and ulcers < 10 cm. 13% of patients received sharp debridement and 6% were treated with limb amputation. IRSU was more frequently addressed in the discharge note if IRSU was the primary reason for admission (71% v 50%, p < 0.05). Only 16 (14%) patients were advised or scheduled to attend an outpatient wound care appointment; only 3 (3%) did so within 30 days of discharge (Figure 2). Figure 1 **, p=0.01. Conclusion Among PWID hospitalized for infection, IRSU were common, especially among older patients and those testing positive for fentanyl. Xylazine exposure was likely under-assessed. Importantly, IRSU was associated with an increased risk of hospital readmission, but outpatient planning and follow up were rare. Clinicians caring for PWID must address IRSU alongside other infectious diseases, addiction, and harm reduction interventions. Figure 2 Discharge planning and outpatient care within 30 days of discharge. DC, discharge; *, p=0.048) Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Justice-involved individuals have many cooccurring socioeconomic and medical needs. Here, we characterize the needs of justice-involved individuals with substance use history at risk for or living with human immunodeficiency virus (HIV) in Texas (TX) and Connecticut (CT). All participants are part of a larger trial linking justice-involved people to community-based substance use and HIV services. Comprehensive baseline needs were assessed; frequencies of needs were quantified and compared using chi-square analysis. Participants (N = 356) reported greater socioeconomic than medical needs in both TX (n = 198) and CT (n = 158). Housing, transportation, food, employment, and financial benefits were endorsed by more than 60% of participants. Health needs were emphasized in both states. Demand in TX was higher for health insurance (52.0% vs. 26.6%, p < .01) and identification/documentation (60.6% vs. 46.2%, p < .01), but not naloxone access (25.3% vs. 38.6%, p < .01). Substance use treatment/harm reduction and HIV preexposure prophylaxis were low priorities overall. The prioritization of socioeconomic over medical needs suggests a hierarchy of needs and resources. State-specific differences may reflect different sociopolitical environments and resources. Despite the high risks of living with or acquiring HIV and overdose, most participants reported low need for HIV and/or substance use services.

Abstract Background People who inject drugs have high rates of patient directed discharge (PDD). In a cohort of patients hospitalized for serious injection related infections (SIRI), we aimed to assess the factors leading to PDD and the influence of PDD on rehospitalization. Characteristics of study participants Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized at four healthcare systems with SIRI due to injection opioid use between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the electronic medical record and were analyzed by chi-square and multivariable logistic and linear regression. Factors associated with patient directed discharge Results Of 1645 patients, 1180 (72%) had a planned discharge and 465 (28%) had a PDD. PDD was associated with younger age (p< 0.001), white race (p=0.018), and documented opioid withdrawal (p< 0.001). PDD was less likely in patients on medication for opioid use disorder (MOUD) during hospitalization (p< 0.001) or who received consultations by infectious diseases (p< 0.001), social work (p=0.04), or addiction medicine (p=0.003). Compared to those with planned discharge, patients with PDD were less likely to have completed antibiotics at the time of discharge (7% vs 60%; p< 0.001), and 64% left without a plan for antibiotic completion. Patients with PDD were more likely to be readmitted within a year (57% vs 52%; p=0.015), and more likely to have a first readmission due to an infection (81% vs 56%; p< 0.001). Time to readmission was significantly shorter among patients with PDD (15 vs 65d; -41.5 days, p< 0.001). Post-Hospitalization Antibiotic Plan by Discharge Status Conclusion Among people hospitalized with SIRI, we found high rates of PDD associated with insufficient treatment of OUD, evidenced by withdrawal, lack of MOUD, and not receiving an addiction consultation. PDD was consequently associated with higher rates of readmission due to infection and shorter time to readmission, possibly due to discharge without a plan to complete antibiotics. To improve outcomes and reduce readmissions among people with SIRI, efforts to address OUD during hospitalization are crucial, and could reduce PDD. Regardless, given high rates of PDD in this population, strategies to facilitate continuity of antibiotics - including contingency plans for oral or long-acting regimens - may be critical to ensuring resolution of SIRI and improving long-term outcomes. Risk of Readmission within 1-Year Based on Discharge Status Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Abstract Background Harm reduction for persons who inject drugs (PWID) has many components, including HIV testing and Pre-exposure Prophylaxis (PrEP). However, despite the increasing evidence of effectiveness, PrEP remains highly underutilized in these patients at high-risk for infection and subsequent transmission risk to others. Our aim is to identify the gaps in HIV prevention care among a hospitalized PWID population.Table 1:Demographics and Clinical Characteristics Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized with infectious complications of active injection opioid use between 1/1/2018 and 3/31/2022 at four US medical centers. Data were collected by abstraction of the electronic medical record and analyzed by chi-square and multivariate logistic regression.Table 2:Multivariate Analysis of Factors Associated with HIV Screening Results 1168 (74%) adults with unknown HIV status underwent HIV screening during sentinel admission. For risk comparison, 48% of this cohort had active HCV infection. HIV screening was less likely to occur in PWID who were male (69% vs 78% females), Black (51% vs 78% White), hospitalized < 3 days (56%), on non-medical services (62% vs 75%), and without ID consult (56% vs 79%). Only 3 participants were referred for PrEP, and only 4 initiated PrEP within 1 year of discharge. Additionally, nearly half (49%) of this HIV (-) cohort did not have follow up HIV screening. There were 79 HIV (+) individuals: 66 known HIV (+) and 13 new diagnoses. Forty-five (57%) were on anti-retroviral therapy during hospitalization, 28 (35%) had CD4 < 200, 47 (59%) had detectable viral load, and 49 (62%) were referred for HIV care. However, only 37% were confirmed linked to care. Of those in care, 59% were virally suppressed within 12 months.Table 3:HIV Prevention Outcomes among HIV negative group within 12 months Conclusion In a cohort of high-risk PWID hospitalized with infectious complications of substance use, there were low rates of HIV screening, PrEP initiation, and referrals for treatment in HIV (-) individuals. The lack of PrEP initiation in this study is unsurprising; however, the absence of referring patients suggests a lack of awareness of increased PrEP availability. More concerning are the gaps in HIV screening among this high-risk cohort. Clinicians must capitalize on opportunities to provide this population with tools to reduce their risks, which includes HIV screening and PrEP.Figure 1:HIV Care Cascade Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support

Abstract Background Oral (PO) antibiotics are a convenient alternative to parenteral antibiotics and decrease the need for inpatient care. Increasing evidence shows PO antibiotics are effective even in severe infections. We aim to assess PO antibiotic use among hospitalized people who inject drugs (PWID). Methods CHOICE+ is a multisite retrospective cohort study of adults hospitalized at four healthcare systems with infections resulting from injection opioid use between 1/1/2018 and 3/31/2022. Data were collected by abstraction of the electronic medical record. Patients were categorized by intended route of the antibiotic course. Data were analyzed by the chi-square test, Fisher’s exact test, and multivariate logistic regression. PO, oral; SSTI, skin and soft tissue infection. Results 1631 patients had an intended treatment plan with either PO (17%) or parenteral (83%) (intravenous, long-acting infusion, or other) antibiotics (Table 1). There was no difference in PO antibiotic use based on gender or unstable housing. PO antibiotics were more likely to be used when planned antibiotic duration was ≤2 weeks (p< 0.0001) and when only skin and soft tissue infection (SSTI) was present (p< 0.0001, Table 2). Alternatively, infectious disease consultation was associated with lower use of PO antibiotics (p< 0.0001). From 2018 to 2022, PO antibiotic use decreased (p< 0.0001, chi-square for trend, Figure 1). Those treated with PO antibiotics were less likely to have ID follow-up scheduled (p=0.0002) and less likely to attend ID follow up (p=0.0024, Figure 2). PO, oral. Conclusion PO antibiotics were rarely used in this large multisite cohort of PWID, especially for infections other than SSTI. Surprisingly, use decreased over the study period, despite emerging evidence for PO antibiotics in complex infections for people who do not inject drugs. PWID with complex infections require long courses of antibiotics, but face barriers to prolonged hospitalization and outpatient infusions due to underinsurance, unstable housing, and untreated addiction. PO antibiotics may facilitate antibiotic completion while reducing patient-directed discharge, and therefore are likely underutilized for PWID. PO, oral. Disclosures Elana S. Rosenthal, MD, Gilead Sciences: Grant/Research Support|Merck: Grant/Research Support