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.

Awakening a sleeping giant: The riddle of Latino political participation

For some time now, the Latino voice has been gradually gaining strength in American politics, particularly in such states as California, Florida, Illinois, New York, and Texas, where large numbers of Latino immigrants have settled and large numbers of electoral votes are at stake. Yet the issues public officials in these states espouse and the laws they enact often do not coincide with the interests and preferences of Latinos. The fact that Latinos in California and elsewhere have not been able to influence the political agenda in a way that is commensurate with their numbers may reflect their failure to participate fully in the political process by first registering to vote and then consistently turning out on election day to cast their ballots.

To understand Latino voting behavior, I first examine Latino political participation in California during the ten general elections of the 1980s and 1990s, seeking to understand what percentage of the eligible Latino population registers to vote, with what political party they register, how many registered Latinos to go the polls on election day, and what factors might increase their participation in politics. To ensure that my findings are not unique to California, I also consider Latino voter registration and turnout in Texas for the five general elections of the 1990s and compare these results with my California findings.

I offer a new approach to studying Latino political participation in which I rely on county-level aggregate data, rather than on individual survey data, and employ the ecological inference method of generalized bounds. I calculate and compare Latino and white voting-age populations, registration rates, turnout rates, and party affiliation rates for California's fifty-eight counties. Then, in a secondary grouped logit analysis, I consider the factors that influence these Latino and white registration, turnout, and party affiliation rates.

I find that California Latinos register and turn out at substantially lower rates than do whites and that these rates are more volatile than those of whites. I find that Latino registration is motivated predominantly by age and education, with older and more educated Latinos being more likely to register. Motor voter legislation, which was passed to ease and simplify the registration process, has not encouraged Latino registration . I find that turnout among California's Latino voters is influenced primarily by issues, income, educational attainment, and the size of the Spanish-speaking communities in which they reside. Although language skills may be an obstacle to political participation for an individual, the number of Spanish-speaking households in a community does not encourage or discourage registration but may encourage turnout, suggesting that cultural and linguistic assimilation may not be the entire answer.

With regard to party identification, I find that Democrats can expect a steady Latino political identification rate between 50 and 60 percent, while Republicans attract 20 to 30 percent of Latino registrants. I find that education and income are the dominant factors in determining Latino political party identification, which appears to be no more volatile than that of the larger electorate.

Next, when I consider registration and turnout in Texas, I find that Latino registration rates are nearly equal to those of whites but that Texas Latino turnout rates are volatile and substantially lower than those of whites.

Low turnout rates among Latinos and the volatility of these rates may explain why Latinos in California and Texas have had little influence on the political agenda even though their numbers are large and increasing. Simply put, the voices of Latinos are little heard in the halls of government because they do not turn out consistently to cast their votes on election day.

While these findings suggest that there may not be any short-term or quick fixes to Latino participation, they also suggest that Latinos should be encouraged to participate more fully in the political process and that additional education may be one means of achieving this goal. Candidates should speak more directly to the issues that concern Latinos. Political parties should view Latinos as crossover voters rather than as potential converts. In other words, if Latinos were "a sleeping giant," they may now be a still-drowsy leviathan waiting to be wooed by either party's persuasive political messages and relevant issues.

Death or taxes? The political economy of sanitation expenditure in nineteenth-century Britain

This thesis consists of three papers studying the relationship between democratic reform, expenditure on sanitation public goods and mortality in Britain in the second half of the nineteenth century. During this period decisions over spending on critical public goods such as water supply and sewer systems were made by locally elected town councils, leading to extensive variation in the level of spending across the country. This dissertation uses new historical data to examine the political factors determining that variation, and the consequences for mortality rates.

The first substantive chapter describes the spread of government sanitation expenditure, and analyzes the factors that determined towns' willingness to invest. The results show the importance of towns' financial constraints, both in terms of the available tax base and access to borrowing, in limiting the level of expenditure. This suggests that greater involvement by Westminster could have been very effective in expediting sanitary investment. There is little evidence, however, that democratic reform was an important driver of greater expenditure.

Chapter 3 analyzes the effect of extending voting rights to the poor on government public goods spending. A simple model predicts that the rich and the poor will desire lower levels of public goods expenditure than the middle class, and so extensions of the right to vote to the poor will be associated with lower spending. This prediction is tested using plausibly exogenous variation in the extent of the franchise. The results strongly support the theoretical prediction: expenditure increased following relatively small extensions of the franchise, but fell once more than approximately 50% of the adult male population held the right to vote.

Chapter 4 tests whether the sanitary expenditure was effective in combating the high mortality rates following the Industrial Revolution. The results show that increases in urban expenditure on sanitation-water supply, sewer systems and streets-was extremely effective in reducing mortality from cholera and diarrhea.

Report of an investigation of a plan of elimination of grade crossings on the A.T. & S.F. Ry. in the city of Pasadena, California

The problem of the Atchison, Topeka, and Santa Fe railroad in Pasadena is a very dynamic one, as is readily recognized by engineers, city officials, and laymen. The route of the railroad was first laid out in the eighties and because of certain liberal concessions granted by the City of Pasadena, the right-of-way was located through Pasadena, despite the fact that the grade coming into the city either from Los Angeles or San Bernardino was enormous. Some years later, other transcontinental routes of the Santa Fe out of Los Angles were sought, and a right-of-way was obtained by way of Fullerton and Riverside to San Bernardino, where this route joins the one from Los Angeles through Pasadena. This route, however, is ten miles longer than the one through Pasadena, which means a considerable loss of time in a short diversion of approximately only sixty miles in length.