Statistical and econometric analysis of the treatment of HIV/AIDS

The epidemic of HIV/AIDS in the United States is constantly changing and evolving, starting from patient zero to now an estimated 650,000 to 900,000 Americans infected. The nature and course of HIV changed dramatically with the introduction of antiretrovirals. This discourse examines many different facets of HIV from the beginning where there wasn't any treatment for HIV until the present era of highly active antiretroviral therapy (HAART). By utilizing statistical analysis of clinical data, this paper examines where we were, where we are and projections as to where treatment of HIV/AIDS is headed.

Chapter Two describes the datasets that were used for the analyses. The primary database utilized was collected by myself from an outpatient HIV clinic. The data included dates from 1984 until the present. The second database was from the Multicenter AIDS Cohort Study (MACS) public dataset. The data from the MACS cover the time between 1984 and October 1992. Comparisons are made between both datasets.

Chapter Three discusses where we were. Before the first anti-HIV drugs (called antiretrovirals) were approved, there was no treatment to slow the progression of HIV. The first generation of antiretrovirals, reverse transcriptase inhibitors such as AZT (zidovudine), DDI (didanosine), DDC (zalcitabine), and D4T (stavudine) provided the first treatment for HIV. The first clinical trials showed that these antiretrovirals had a significant impact on increasing patient survival. The trials also showed that patients on these drugs had increased CD4+ T cell counts. Chapter Three examines the distributions of CD4 T cell counts. The results show that the estimated distributions of CD4 T cell counts are distinctly non-Gaussian. Thus distributional assumptions regarding CD4 T cell counts must be taken, into account when performing analyses with this marker. The results also show the estimated CD4 T cell distributions for each disease stage: asymptomatic, symptomatic and AIDS are non-Gaussian. Interestingly, the distribution of CD4 T cell counts for the asymptomatic period is significantly below that of the CD4 T cell distribution for the uninfected population suggesting that even in patients with no outward symptoms of HIV infection, there exists high levels of immunosuppression.

Chapter Four discusses where we are at present. HIV quickly grew resistant to reverse transcriptase inhibitors which were given sequentially as mono or dual therapy. As resistance grew, the positive effects of the reverse transcriptase inhibitors on CD4 T cell counts and survival dissipated. As the old era faded a new era characterized by a new class of drugs and new technology changed the way that we treat HIV-infected patients. Viral load assays were able to quantify the levels of HIV RNA in the blood. By quantifying the viral load, one now had a faster, more direct way to test antiretroviral regimen efficacy. Protease inhibitors, which attacked a different region of HIV than reverse transcriptase inhibitors, when used in combination with other antiretroviral agents were found to dramatically and significantly reduce the HIV RNA levels in the blood. Patients also experienced significant increases in CD4 T cell counts. For the first time in the epidemic, there was hope. It was hypothesized that with HAART, viral levels could be kept so low that the immune system as measured by CD4 T cell counts would be able to recover. If these viral levels could be kept low enough, it would be possible for the immune system to eradicate the virus. The hypothesis of immune reconstitution, that is bringing CD4 T cell counts up to levels seen in uninfected patients, is tested in Chapter Four. It was found that for these patients, there was not enough of a CD4 T cell increase to be consistent with the hypothesis of immune reconstitution.

In Chapter Five, the effectiveness of long-term HAART is analyzed. Survival analysis was conducted on 213 patients on long-term HAART. The primary endpoint was presence of an AIDS defining illness. A high level of clinical failure, or progression to an endpoint, was found.

Chapter Six yields insights into where we are going. New technology such as viral genotypic testing, that looks at the genetic structure of HIV and determines where mutations have occurred, has shown that HIV is capable of producing resistance mutations that confer multiple drug resistance. This section looks at resistance issues and speculates, ceterus parabis, where the state of HIV is going. This section first addresses viral genotype and the correlates of viral load and disease progression. A second analysis looks at patients who have failed their primary attempts at HAART and subsequent salvage therapy. It was found that salvage regimens, efforts to control viral replication through the administration of different combinations of antiretrovirals, were not effective in 90 percent of the population in controlling viral replication. Thus, primary attempts at therapy offer the best change of viral suppression and delay of disease progression. Documentation of transmission of drug-resistant virus suggests that the public health crisis of HIV is far from over. Drug resistant HIV can sustain the epidemic and hamper our efforts to treat HIV infection. The data presented suggest that the decrease in the morbidity and mortality due to HIV/AIDS is transient. Deaths due to HIV will increase and public health officials must prepare for this eventuality unless new treatments become available. These results also underscore the importance of the vaccine effort.

The final chapter looks at the economic issues related to HIV. The direct and indirect costs of treating HIV/AIDS are very high. For the first time in the epidemic, there exists treatment that can actually slow disease progression. The direct costs for HAART are estimated. It is estimated that the direct lifetime costs for treating each HIV infected patient with HAART is between $353,000 to $598,000 depending on how long HAART prolongs life. If one looks at the incremental cost per year of life saved it is only $101,000. This is comparable with the incremental costs per year of life saved from coronary artery bypass surgery.

Policy makers need to be aware that although HAART can delay disease progression, it is not a cure and HIV is not over. The results presented here suggest that the decreases in the morbidity and mortality due to HIV are transient. Policymakers need to be prepared for the eventual increase in AIDS incidence and mortality. Costs associated with HIV/AIDS are also projected to increase. The cost savings seen recently have been from the dramatic decreases in the incidence of AIDS defining opportunistic infections. As patients who have been on HAART the longest start to progress to AIDS, policymakers and insurance companies will find that the cost of treating HIV/AIDS will increase.

Distributed Load Control in Multiphase Radial Networks

The current power grid is on the cusp of modernization due to the emergence of distributed generation and controllable loads, as well as renewable energy. On one hand, distributed and renewable generation is volatile and difficult to dispatch. On the other hand, controllable loads provide significant potential for compensating for the uncertainties. In a future grid where there are thousands or millions of controllable loads and a large portion of the generation comes from volatile sources like wind and solar, distributed control that shifts or reduces the power consumption of electric loads in a reliable and economic way would be highly valuable.

Load control needs to be conducted with network awareness. Otherwise, voltage violations and overloading of circuit devices are likely. To model these effects, network power flows and voltages have to be considered explicitly. However, the physical laws that determine power flows and voltages are nonlinear. Furthermore, while distributed generation and controllable loads are mostly located in distribution networks that are multiphase and radial, most of the power flow studies focus on single-phase networks.

This thesis focuses on distributed load control in multiphase radial distribution networks. In particular, we first study distributed load control without considering network constraints, and then consider network-aware distributed load control.

Distributed implementation of load control is the main challenge if network constraints can be ignored. In this case, we first ignore the uncertainties in renewable generation and load arrivals, and propose a distributed load control algorithm, Algorithm 1, that optimally schedules the deferrable loads to shape the net electricity demand. Deferrable loads refer to loads whose total energy consumption is fixed, but energy usage can be shifted over time in response to network conditions. Algorithm 1 is a distributed gradient decent algorithm, and empirically converges to optimal deferrable load schedules within 15 iterations.

We then extend Algorithm 1 to a real-time setup where deferrable loads arrive over time, and only imprecise predictions about future renewable generation and load are available at the time of decision making. The real-time algorithm Algorithm 2 is based on model-predictive control: Algorithm 2 uses updated predictions on renewable generation as the true values, and computes a pseudo load to simulate future deferrable load. The pseudo load consumes 0 power at the current time step, and its total energy consumption equals the expectation of future deferrable load total energy request.

Network constraints, e.g., transformer loading constraints and voltage regulation constraints, bring significant challenge to the load control problem since power flows and voltages are governed by nonlinear physical laws. Remarkably, distribution networks are usually multiphase and radial. Two approaches are explored to overcome this challenge: one based on convex relaxation and the other that seeks a locally optimal load schedule.

To explore the convex relaxation approach, a novel but equivalent power flow model, the branch flow model, is developed, and a semidefinite programming relaxation, called BFM-SDP, is obtained using the branch flow model. BFM-SDP is mathematically equivalent to a standard convex relaxation proposed in the literature, but numerically is much more stable. Empirical studies show that BFM-SDP is numerically exact for the IEEE 13-, 34-, 37-, 123-bus networks and a real-world 2065-bus network, while the standard convex relaxation is numerically exact for only two of these networks.

Theoretical guarantees on the exactness of convex relaxations are provided for two types of networks: single-phase radial alternative-current (AC) networks, and single-phase mesh direct-current (DC) networks. In particular, for single-phase radial AC networks, we prove that a second-order cone program (SOCP) relaxation is exact if voltage upper bounds are not binding; we also modify the optimal load control problem so that its SOCP relaxation is always exact. For single-phase mesh DC networks, we prove that an SOCP relaxation is exact if 1) voltage upper bounds are not binding, or 2) voltage upper bounds are uniform and power injection lower bounds are strictly negative; we also modify the optimal load control problem so that its SOCP relaxation is always exact.

To seek a locally optimal load schedule, a distributed gradient-decent algorithm, Algorithm 9, is proposed. The suboptimality gap of the algorithm is rigorously characterized and close to 0 for practical networks. Furthermore, unlike the convex relaxation approach, Algorithm 9 ensures a feasible solution. The gradients used in Algorithm 9 are estimated based on a linear approximation of the power flow, which is derived with the following assumptions: 1) line losses are negligible; and 2) voltages are reasonably balanced. Both assumptions are satisfied in practical distribution networks. Empirical results show that Algorithm 9 obtains 70+ times speed up over the convex relaxation approach, at the cost of a suboptimality within numerical precision.

Cryogenic Silicon Optical Reference Cavities

Thermodynamical fluctuations in temperature and position exist in every physical system, and show up as a fundamental noise limit whenever we choose to measure some quantity in a laboratory environment. Thermodynamical fluctuations in the position of the atoms in the dielectric coatings on the mirrors for optical cavities at the forefront of precision metrology (e.g., LIGO, the cavities which probe atomic transitions to define the second) are a current limiting noise source for these experiments, and anything which involves locking a laser to an optical cavity. These thermodynamic noise sources scale physical geometry of experiment, material properties (such as mechanical loss in our dielectric coatings), and temperature. The temperature scaling provides a natural motivation to move to lower temperatures, with a potential huge benefit for redesigning a room temperature experiment which is limited by thermal noise for cryogenic operation.

We design, build, and characterize a pair of linear Fabry-Perot cavities to explore limitations to ultra low noise laser stabilization experiments at cryogenic temperatures. We use silicon as the primary material for the cavity and mirrors, due to a zero crossing in its linear coefficient of thermal expansion (CTE) at 123 K, and other desirable material properties. We use silica tantala coatings, which are currently the best for making high finesse low noise cavities at room temperature. The material properties of these coating materials (which set the thermal noise levels) are relatively unknown at cryogenic temperatures, which motivates us to study them at these temperatures. We were not able to measure any thermal noise source with our experiment due to excess noise. In this work we analyze the design and performance of the cavities, and recommend a design shift from mid length cavities to short cavities in order to facilitate a direct measurement of cryogenic coating noise.

In addition, we measure the cavities (frequency dependent) photo-thermal response. This can help characterize thermooptic noise in the coatings, which is poorly understood at cryogenic temperatures. We also explore the feasibility of using the cavity to do macroscopic quantum optomechanics such as ground state cooling.