India is the highest TB burden country in the world & accounts for nearly 1/5th (20 per cent) of global burden of tuberculosis, 2/3rd of cases in SEAR. Every year approximately 1.8 million persons develop tuberculosis, of which about 0.8 million are new smear positive highly'- infectious cases.Annual risk of becoming infected with TB is 1.5 % and once infected there is 10 % life-time risk of developing TB disease
HIV (Human Immunodeficiency Virus) infects cells of the immune system and destroys or impairs their function.
Infection progressive deterioration of the immune system breaking down the body's ability to fight out infections & diseases by opportunistic bacteria, viruses and fungi.
AIDS (Acquired Immune Deficiency Syndrome) refers to the most advanced stages of HIV infection and a collection of signs and symptoms caused by more than 20 opportunistic infections or related cancers.
e632 www.thelancet.comhiv Vol 6 September 2019ViewpoiAlyciaGold776
e632 www.thelancet.com/hiv Vol 6 September 2019
Viewpoint
The disconnect between individual-level and population-level
HIV prevention benefits of antiretroviral treatment
Stefan Baral, Amrita Rao, Patrick Sullivan, Nancy Phaswana-Mafuya, Daouda Diouf, Greg Millett, Helgar Musyoki, Elvin Geng, Sharmistha Mishra
In 2019, the HIV pandemic is growing and soon over 40 million people will be living with HIV. Effective population-
based approaches to decrease HIV incidence are as relevant as ever given modest reductions observed over the past
decade. Treatment as prevention is often heralded as the path to improve HIV outcomes and to reduce HIV
incidence. Although treatment of an individual does eliminate onward transmission to serodifferent partners
(unde tectable=untransmittable or U=U), population-level observational and experimental data have not shown a similar
effect with scale-up of treatment on reducing HIV incidence. This disconnect might be the result of little attention given
to heterogeneities of HIV acquisition and transmission risks that exist in people at risk for and living with HIV, even in
the most broadly generalised epidemics. Available data suggest that HIV treatment is treatment, HIV prevention is
prevention, and specificity of HIV treatment approaches towards people at highest risk of onward transmission drives
the intersection between the two. All people living with HIV deserve HIV treatment, but both more accurately estimating
and optimising the potential HIV prevention effects of universal treatment approaches necessitates understanding who
is being supported with treatment rather than a focus on treatment targets such as 90-90-90 or 95-95-95.
Introduction
In 2019, we are at a pivotal time in the global HIV response
in that many people believe that the HIV pandemic is
over given the advances in HIV treatment.1 Yet the HIV
pandemic continues to grow as defined by numbers of
people living with HIV. Specifically, given the encouraging
decreases in overall mortality among people living with
HIV, in the context of universal treat ment as prevention,
approximately 930 000 more people annually (1·7 million
new infections minus 770 000 deaths of people living with
HIV) require anti retroviral therapy (ART) and many more
would need to change ART regimens. At the current rate
of new infections, over 40 million people will be living
with HIV by 2025.2 The global optimism about the HIV
pandemic has not been matched by decreases in new
HIV infections. New infections have declined by less than
2% per year since 2005, which means that between
1·8 and 2·5 million people acquired HIV in 2017.2,3 To
date, just over 60% of the 37·9 million people living with
HIV are on ART; of those 37·9 million, just over half
(20·1 million) are estimated to have achieved viral sup
pression.2 Taken together, these data suggest that an
estimated 18 million people living with HIV require ART
or improved ART regimens giv ...
India is the highest TB burden country in the world & accounts for nearly 1/5th (20 per cent) of global burden of tuberculosis, 2/3rd of cases in SEAR. Every year approximately 1.8 million persons develop tuberculosis, of which about 0.8 million are new smear positive highly'- infectious cases.Annual risk of becoming infected with TB is 1.5 % and once infected there is 10 % life-time risk of developing TB disease
HIV (Human Immunodeficiency Virus) infects cells of the immune system and destroys or impairs their function.
Infection progressive deterioration of the immune system breaking down the body's ability to fight out infections & diseases by opportunistic bacteria, viruses and fungi.
AIDS (Acquired Immune Deficiency Syndrome) refers to the most advanced stages of HIV infection and a collection of signs and symptoms caused by more than 20 opportunistic infections or related cancers.
e632 www.thelancet.comhiv Vol 6 September 2019ViewpoiAlyciaGold776
e632 www.thelancet.com/hiv Vol 6 September 2019
Viewpoint
The disconnect between individual-level and population-level
HIV prevention benefits of antiretroviral treatment
Stefan Baral, Amrita Rao, Patrick Sullivan, Nancy Phaswana-Mafuya, Daouda Diouf, Greg Millett, Helgar Musyoki, Elvin Geng, Sharmistha Mishra
In 2019, the HIV pandemic is growing and soon over 40 million people will be living with HIV. Effective population-
based approaches to decrease HIV incidence are as relevant as ever given modest reductions observed over the past
decade. Treatment as prevention is often heralded as the path to improve HIV outcomes and to reduce HIV
incidence. Although treatment of an individual does eliminate onward transmission to serodifferent partners
(unde tectable=untransmittable or U=U), population-level observational and experimental data have not shown a similar
effect with scale-up of treatment on reducing HIV incidence. This disconnect might be the result of little attention given
to heterogeneities of HIV acquisition and transmission risks that exist in people at risk for and living with HIV, even in
the most broadly generalised epidemics. Available data suggest that HIV treatment is treatment, HIV prevention is
prevention, and specificity of HIV treatment approaches towards people at highest risk of onward transmission drives
the intersection between the two. All people living with HIV deserve HIV treatment, but both more accurately estimating
and optimising the potential HIV prevention effects of universal treatment approaches necessitates understanding who
is being supported with treatment rather than a focus on treatment targets such as 90-90-90 or 95-95-95.
Introduction
In 2019, we are at a pivotal time in the global HIV response
in that many people believe that the HIV pandemic is
over given the advances in HIV treatment.1 Yet the HIV
pandemic continues to grow as defined by numbers of
people living with HIV. Specifically, given the encouraging
decreases in overall mortality among people living with
HIV, in the context of universal treat ment as prevention,
approximately 930 000 more people annually (1·7 million
new infections minus 770 000 deaths of people living with
HIV) require anti retroviral therapy (ART) and many more
would need to change ART regimens. At the current rate
of new infections, over 40 million people will be living
with HIV by 2025.2 The global optimism about the HIV
pandemic has not been matched by decreases in new
HIV infections. New infections have declined by less than
2% per year since 2005, which means that between
1·8 and 2·5 million people acquired HIV in 2017.2,3 To
date, just over 60% of the 37·9 million people living with
HIV are on ART; of those 37·9 million, just over half
(20·1 million) are estimated to have achieved viral sup
pression.2 Taken together, these data suggest that an
estimated 18 million people living with HIV require ART
or improved ART regimens giv ...
ONLINE FUZZY-LOGIC KNOWLEDGE WAREHOUSING AND MINING MODEL FOR THE DIAGNOSIS A...ijcsity
The need for a reliable and efficient way of storing and mining data about people living with HIV/AIDs with the intent to monitor the health status for effective therapy is on the increase. This paper presents a model of a web-based system for knowledge warehousing and mining of diagnosis and therapy of HIV/AIDs using Fuzzy Logic and data mining approach. A model was developed, using the predictive modeling technique, for predicting HIV/AIDs and monitoring of patient health status. The fuzzy inference
rule and a decision support system based on cognitive filtering was employed to determine the possible course of action to be taken. A case study of some data of PLWH was used and the result obtained shows that the developed system is efficient. The system uses XAMP on Windows OS platform. The system was tested and evaluated with satisfactory results
Design of a Clinical Decision Support System Framework for the Diagnosis and ...Editor IJCATR
This paper proposes an adaptive framework for a Knowledge Based Intelligent Clinical Decision Support System for the
prediction of hepatitis B which is one of the most deadly viral infections that has a monumental effect on the health of people afflicted
with it and has for long remained a perennial health problem affecting a significant number of people the world over. In the framework
the patient information is fed into the system; the Knowledge base stores all the information to be used by the Clinical Decision
Support System and the classification/prediction algorithm chosen after a thorough evaluation of relevant classification algorithms for
this work is the C4.5 Decision Tree Algorithm with its percentage of correctly classified instances given as 61.0734%; it searches the
Knowledge base recursively and matches the patient information with the pertinent rules that suit each case and thereafter gives the
most precise prediction as to whether the patient is prone to hepatitis B or not. This approach to the prediction of hepatitis B provides a
very potent solution to the problem of determining if a person has the likelihood of developing this dreaded illness or is almost not
susceptible to the ailment.
Hepatitis C elimination in HIV-infected men who have sex with men: reality and challenges
Edward Cachay MD, MAS
February 23rd, 2018
UCSD HIV & Global Health Rounds
Global Medical Cures™ | HIV TESTING IN USA
DISCLAIMER-
Global Medical Cures™ does not offer any medical advice, diagnosis, treatment or recommendations. Only your healthcare provider/physician can offer you information and recommendations for you to decide about your healthcare choices.
Trevor Hawkins, M.D., M.P.H. of the Univeristy of New Mexico and Southwest CARE Center, presents "Top Ten HIV Clinical Controversies 2014" at AIDS Clinical Rounds
Katherine Promer Flores, MD (she/her)
Staff Physician
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California San Diego
Daniel Lee, MD
Clinical Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Leandro Mena, MD, MPH
Chair and Professor of Population Health Science
Department of Population Health Science
University of Mississippi Medical Center
Maile Young Karris, MD
Associate Professor
Co-Director San Diego Center for AIDS Research Clinical Investigations Core
Divisions of Infectious Diseases & Global Public Health and Geriatrics & Gerontology
Department of Medicine
University of California San Diego
Edward Cachay, MD, MAS
Professor of Medicine
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Gabriel Wagner, MD
Associate Clinical Professor
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Jocelyn Keehner, MD
Infectious Disease Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Richard Garfein, PhD, MPH
Professor
Herbert Wertheim School of Public Health and Human Longevity Science
Adjunct Professor
Division of Infectious Disease and Global Public Health
Department of Medicine
University of California, San Diego
Laura Bamford, MD, MSCE
Associate Professor of Medicine
Medical Director, Owen Clinic
Division of Infectious Diseases and Global Public Health
Department of Medicine
University of California, San Diego
Davey Smith, MD, MAS
Professor of Medicine
Chief, Division of Infectious Diseases and Global Public Health
Co-Director, San Diego Center for AIDS Research (CFAR)
Department of Medicine
University of California, San Diego
Elliot Welford, MD
Infectious Diseases Fellow
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Darcy Wooten, MD
Assistant Professor of Medicine
Associate Program Director, Infectious Diseases Fellowship
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
Amutha Rajagopal, MD
Associate Physician Diplomate
Division of Infectious Diseases & Global Public Health
Department of Medicine
University of California, San Diego
More from UC San Diego AntiViral Research Center (20)
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
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AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
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Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
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The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
Strategies for HIV Epidemic Control
1. The UC San Diego AntiViral Research Center sponsors weekly
presentations by infectious disease clinicians, physicians and
researchers. The goal of these presentations is to provide the most
current research, clinical practices and trends in HIV, HBV, HCV, TB
and other infectious diseases of global significance.
The slides from the AIDS Clinical Rounds presentation that you are
about to view are intended for the educational purposes of our
audience. They may not be used for other purposes without the
presenter’s express permission.
AIDS CLINICAL ROUNDS
2. Susan Little, M.D.
Professor of Medicine
University of California San Diego
Strategies for HIV Epidemic Control
7/18/141
3. Epidemic spread of infection
Understanding the spread of infectious diseases in
populations is key to controlling them.
Epidemic disease spread determined by properties of the
pathogen (contagiousness, the length of the infection
period, severity, etc.) and network structures within the
population.
An understanding of these issues may provide insights for
preventing the spread of disease.
7/18/142
4. Epidemic Disease Control
Infection control options
Treatment as prevention/Universal test and
treat
Network-focused interventions
Improved methods to guarantee privacy
7/18/143
5. Strategies to prevent/control infectious diseases
7/18/14
Reduce contact rate (case finding & isolation, contact tracing &
quarantine, behavior change)
Reduce infectiousness (treatment, vaccination)
Reduce susceptibility (vaccination, immune globulin)
Interrupt transmission (infection control)
Identify and control reservoir/source (pest/vector control,
environmental disinfection)
Reduce prevalence of infectious sources (identify and control
infectious sources)
Reduce duration of infectiousness (treatment, vaccination)
Increase herd immunity (vaccination)
4
6. Strategies to prevent/control HIV
7/18/14
Reduce contact rate (case finding & isolation, contact tracing &
quarantine, behavior change)
Reduce infectiousness (treatment, vaccination)
Reduce susceptibility (vaccination, immune globulin)
Interrupt transmission (infection control ≈ treatment)
Identify and control reservoir/source (pest/vector control,
environmental disinfection)
Reduce prevalence of infectious sources (identify and control
infectious sources)
Reduce duration of infectiousness (treatment, vaccination)
Increase herd immunity (vaccination)
5
7. Summary of HIV prevention options
7/18/14
Case finding (testing)
Contact tracing (partner services for recently infected)
Behavior change (durable?)
Identify and treat infectious sources
Identify and treat susceptible recipients
6
8. HIV Intervention Strategies
7/18/14
Universal test and treat strategies: theoretically plausible
Acceptability: issues of stigma
Feasibility: model presumes annual testing
Resources: estimated costs are greater initially
ARTAccess: by 2012,ART accessed by 65% of 15 million global “target”
Acute Infection: 20-50% of transmission may occur in setting of acute HIV
(not captured by routineAb screening).
Targeted strategies
How to prioritize target populations?
Will locally effective interventions translate to success at the population
level?
7
9. Epidemic Disease Control
Infection control options
Treatment as prevention/Universal test and
treat
Network-focused interventions
Improved methods to guarantee privacy
7/18/148
10. Treatment as Prevention
A strategy that considers “universal” HIV
testing with immediate antiretroviral therapy
(ART) with the goal of reducing HIV
transmission (HIV incidence) and eventual
“elimination” of disease
9 7/18/149
11. This image cannot currently be displayed.
0.00
0.05
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0.15
1980 1990 2000 2010 2020 2030 2040 2050
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0.01
0.02
0.00
0.05
0.10
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1980 1990 2000 2010 2020 2030 2040 2050
0.00
0.01
0.02
0.00
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1980 1990 2000 2010 2020 2030 2040 2050
0.00
0.01
0.02
Current phase Roll out
Elimination
Prevalence
Incidence
Mortality
On ART
7/18/1410
12. Conclusions from modeling exercise
Universal and annual voluntary HIV testing followed by
immediate ART (irrespective of CD4 cell count and combined
with other prevention interventions) could:
Eliminate HIV transmission in 5-10 years
Eliminate HIV infection in 40 years
Initial resources would be higher but over time, given the
reduction in HIV incidence, this approach may provide cost
savings
Estimated costs are within UNAIDS estimates for universal
access for a population this size
7/18/14Granich, et al. Lancet 200911
13. Treatment as Prevention: HPTN 052
Sheth PM, et al. AIDS. 2009;23:2050-2054. 7/18/14
Cohen M. NEJM 2011
1,763 sero-discordant couples (97% heterosexual)
HIV infected partners: 890 men, 873 women
I-ART
(CD4 350-550)
D-ART
(CD4 <250, >200)
39 Transmissions
28 Linked 11 Unlinked
I-ART:
1 Transmission
D-ART:
27 Transmissions
96% Protection
Associated with
Immediate ART
12
14. Test and Treat (Treatment as Prevention)
Studies (1)
HPTN 071 (PopART): Richard Hayes/Sara Fidler, n=1.2 million
3 arm, 2-country (Zambia & S.Africa) cluster-randomized trial:
Full combination prevention and immediate ART
Combination prevention with SOC ART (CD4<350)
SOC
Endpoint: HIV incidence (at 36 months)
Botswana combination prevention program (BCPP): Max Essex
Pair-matched, community-randomization design (30 villages)
Interventions: enhanced HTC (>90%), MC (>80%), PMTCT, improved
LTC/treatment (>90%/60%),ART for those withVL ≥ 10,000 (regardless of
CD4)
Endpoint: HIV incidence (within 3 years) 7/18/1413
2013/4 International HIV Treatment as Prevention Workshop
15. SEARCHTrial: Diane Havlir/Moses Kamya, Uganda and Kenya
Clustered, community-randomized trial (32 pair-matched communities of
10,000 each)
Intervention:ART access w/optimized LTC and streamlined care vs. SOC
Outcome: cumulative 3 and 5-year HIV incidence
MaxART:Velephi Okello (Swaziland – In country study)
Regional access to immediateART and various PMTCT options
Médecines Sans Frontières (MSF) Implementation: RogerTeck
Promote community scale ofART and PMTCT
CombinationTrials in SouthAfrica & Uganda: Ruanne Barnabas
Promote testing, LTC, male circumcision
7/18/1414
Test and Treat (Treatment as Prevention)
Studies (2)
2013/4 International HIV Treatment as Prevention Workshop
16. TasP is biologically plausible, but…
Massive mobilization of resources necessary
No specific recommendations for sex workers, drug users, or
MSM
Retrospective analyses of HIV transmission and ART are mixed.
HIV incidence has not decreased in Canada, US, EU despite
improved access to testing and treatment
Marked increases in risk activity in SF are outpacing any decrease
in infectivity due to increasedART use
~4300 discordant HET couples in China (2006) – no difference in
seroconversion rates associated w/ART use
7/18/1415
Lu, et al. JAIDS 2010; Nguyen, et al. AIDS 2011
17. Universal Test and Treat: The Present
HIV testing is the foundation for all ART interventions.
Early treatment substantially reduces the risk of secondary HIV
transmission.
The prevention benefit of treatment requires linkage to and retention
in care, and adherence to ART (Gardner EM, et al. CID, 2011).
7/18/14
80
%
89
%
66
%
77
%
77
%
16
18. Epidemic Disease Control
Infection control options
Treatment as prevention/Universal test and
treat
Network-focused interventions
Improved methods to guarantee privacy
7/18/1417
19. 18
The Challenge….
7/18/14
“Because of the common route of transmission through sexual
networks, interventions against STIs need to be targeted to whole
populations.”
-World Health Organization,2012
“What network theory teaches us is that connections, even within the
most complex systems, are not random (that is, they are not
unpredictable). Instead, networks behave in ways that we can
theorize, model, and predict.”
The PLoS Medicine Editors
It's the Network,Stupid:Why Everything in Medicine Is Connected
PLoS Med 2008
20. Talking about networks…
Nodes (n): individuals in the network
Degree (d): connections between nodes
The degree or degree centrality of a node is the number of
connections (edges) the node has to other nodes in the network 7/18/1419
21. Network Topology
Scale Free
Real world networks: www, gang
networks, power grid, on-line gaming,
HIV, etc.
Large majority of nodes have low
degree, but small number (hubs)
have high degree.
Random
Cannot be used to model real
world networks
Nodes are connected (or not) with
independent probability: binomial
distribution (for large n)
7/18/1420
Degree distribution: the probability (P) that a randomly chosen node has k
connections: Pdeg(k)
22. Scale-free Networks: preferential attachment
Connectivity is maintained by a few highly connected “hubs”
Scale-free networks are vulnerable to coordinated attacks - when the
nodes with the highest number of edges are targeted, the network
breaks down faster than in the case of random node removal.
7/18/1421
Scale-free network (i.e. HIV)
Hubs
23. 7/18/14
HIV is transmitted along a complex contact network
Concept Contact Network Transmission network
Node Individual HIV+ individual
Edge A contact that could lead to HIV transmission, e.g.
sexual, shared needle
Transmission event
Degree = edges
connected to a node
Number of contacts associated with a node Number of transmissions associated with a node
Transmission network is a
subset of the contact network
22
Contact network
24. It pays to target highly connected nodes
Targeting a low degree
node has a local effect
Targeting a high degree
node has a global effect
7/18/1423
25. Example 1: Drug Trafficking Network
Simulation
Simulations of illicit networks (drug trafficking networks) to determine
areas of vulnerability and resilience.
Four intervention strategies:
1) Target most connected nodes (high degree centrality)
2) Target nodes which play most important roles
3) Target by a combination of degree centrality and role
4) Random selection
Quantify the extent of network disruption – the number of nodes in the
largest remaining connected component
7/18/1424 Bright et al, UNSW, Australia (2013)
26. Size of the largest connected component
7/18/1425
27. 7/18/1426
Example 2: Simulations of HIV network
Random vs. Preferential ART
• RandomART (red): 4.1%
fewer infected nodes than
without any intervention
• PreferentialART (black):
31.3% fewer infected nodes
after 3 years than random
ART.
• Highly connected nodes become
infected early and thus receive
ART earlier.
• These nodes are 96% less likely
to transmit to partners
NumberofInfected
Day
ART Non-targeted
ART Targeted
Trewick C, et al. Computational Social Science Society of the Americas, 2013
28. HIV Network Intervention Strategies
7/18/14
Studies of the UK national HIV database suggest that
random (i.e. uniformly applied) interventions will not be
sufficient to halt the epidemic.
Interventions must be targeted to high-degree nodes to be
effective.
San Diego: Dr. Smith working on an NIH funded study
to map HIV transmission dynamics in real time and direct
community specific prevention resources.
Leigh Brown, et al. JID 2011; Brenner et al. AIDS 2013
27
29. Degree Distribution of SDPIC Network
A small proportion of individuals
have many connections (high
degree)
7/18/1428
31. 30
Example 3: Retrospective Analysis of Self-Selected ART
ART naive
ART >30
days of EDI
ART ≤30
days of EDI
No data
7/18/14
32. Retrospective study of ART
Network statistic* shows that early (≤30 days since EDI)
treatment results in a significantly lower network
connectivity than does delayed treatment (p<0.05),
even with small samples (N=21 early, N=137 delayed).
While encouraging, must still prove that such
interventions when delivered in a targeted fashion can
disrupt the entire network.
7/18/14*Wertheim, et al. PLoS One 201131
33. The Future…
Goal is a prospective, real-time, network informed (i.e., targeted
interventions) trial to evaluate impact of network HIV incidence
Objectives:
Infer the local HIV transmission network - estimate features of the
underlying infected population and efficacy of potential
interventions.
Assess the potential of molecular epidemiology and network
statistics to measure the efficacy of ART as a network-based
prevention intervention.
To develop and deploy privacy preserving methods for analysis and
release of network data. 7/18/1432
34. Hypothesis
We can control the San Diego HIV epidemic (i.e.,
reduce R0<1) by identifying high degree nodes or
“hubs” within the transmission network and
selectively interrupting transmission from these
clusters.
7/18/1433
35. Study Design
HIV EarlyTest Program – identify persons with HIV
Provide partner services for acutely and recently infected persons
Rapid linkage to care
UCSD AVRC – referral to primary care
Baseline HIV genotype and routine clinical laboratories
Universal access to immediateART –
elvitegravir/cobicistat/tenofovir/emtricitabine (Stribild) for 1-5
years
Compare network connectivity (transmission) in persons who
initiate ART within ≤30 days EDI vs >30 days.
7/18/1434
36. Epidemic Disease Control
Infection control options
Treatment as prevention/Universal test and
treat
Network-focused interventions
Improved methods to guarantee privacy
7/18/1435
37. 7/18/1436
HIV Transmission & The Law: USA
In 1990, Congress passed the RyanWhite CAREAct – mandated that
states criminalize the intentional transmission of HIV
In 2000, Congress reauthorized theAct, but removed the
criminalization requirement – many states kept their laws
32 States currently have laws that criminalize the transmission of HIV
25 States criminalize one or more behaviors that pose a low or negligible
risk for transmission
These laws perpetuate and condone stigma and discrimination against
persons with HIV
38. California (7/2010)
“Any person who exposes another to HIV by engaging in unprotected
sexual activity (anal or vaginal intercourse without a condom) when
the infected person knows at the time of the unprotected sex that he
or she is infected with HIV, has not disclosed his or her HIV-positive
status, and acts with the specific intent to infect the other person with
HIV, is guilty of a felony.”
7/18/1437
http://www.hivandhepatitis.com/hiv-policy-advocacy/3803-hiv-medicine-association-calls-for-repeal-of-hiv-
criminalization-laws
• The divisions between intentional, reckless, and accidental
transmission can be blurred
• The majority of criminal convictions involving sexual transmission
involve an HIV positive person not informing their negative partner
about their status
39. Rhoades vs. Iowa (2008)
Nick Rhoades (HIV+,VL undetectable) had sexual
encounter with another man – used a condom.
HIV transmission did not occur
Other man found out Rhoades was HIV infected, contacted police
Rhoades received maximum sentence – 25 years in prison and
lifetime registration as a sex offender.
Months later, sentence suspended – replaced with supervised
probation for 5 years
Iowa Supreme Court (6/13/14) - sentence reversed
7/18/1438
40. HIV Transmission & The Law: Africa
USAID has financed the
“Action forWestAfrica
Region HIV-AIDS
program” since 2004
Instrumental in
developing a model for
HIV-specific criminal law
27 African countries now
have active laws.
7/18/1439 http://www.change.org/petitions/demand-usaid-to-stop-funding-hiv-criminalization-laws-in-africa
41. Limitations of Phylogenetic Analysis
• Current techniques are NOT reliable enough to estimate the
direction of transmission with certainty.
• Similar strains may be found in many more than two individuals,
especially if they are part of the same transmission network.
7/18/14
A B C
E
D
F
G
H
?
?
40
42. Privacy Challenges
To develop and deploy privacy preserving methods for analyzing
network dynamics in order to share predictions about future
network growth with quantitative estimates of privacy risk.
7/18/1441
43. Phylogentics & Criminal Statutes
Plans
Assess consumer and provider knowledge and expectations
associated with phylogenetic analyses
Assess perceptions of acceptable risk and benefit for public health
and personal privacy
Public health use of these data requires decriminalization
of unintended HIV transmission during consensual
exposure.
7/18/1442