Evaluation of chitosan nanoformulations as potent anti-HIV therapeutic systems

Background: Antiretroviral Therapy (ART) is currently the major therapeutic intervention in the treatment of AIDS. ART, however, is severely limited due to poor availability, high cytotoxicity, and enhanced metabolism and clearance of the drug molecules by the renal system. The use of nanocarriers encapsulating the antiretroviral drugs may provide a solution to the aforementioned problems. Importantly, the application of mildly immunogenic polymeric carrier confers the advantage of making the nanoparticles more visible to the immune system leading to their efficient uptake by the phagocytes. Methods: The saquinavir-loaded chitosan nanopartides were characterized by transmission electron microscopy and differential scanning calorimetry and analyzed for the encapsulation efficiency, swelling characteristics, particle size properties, and the zeta potential. Furthermore, cellular uptake of the chitosan nanocarriers was evaluated using confocal microscopy and Flow cytometry. The antiviral efficacy was quantified using viral infection of the target cells. Results: Using novel chitosan carriers loaded with saquinavir, a protease inhibitor, we demonstrate a drug encapsulation efficiency of 75% and cell targeting efficiency greater than 92%. As compared to the soluble drug control, the saquinavir-loaded chitosan carriers caused superior control of the viral proliferation as measured by using two different viral strains, NL4-3 and Indie-C1, and two different target T-cells, Jurkat and CEM-CCR5. Conclusion: Chitosan nanoparticles loaded with saquinavir were characterized and they demonstrated superior drug loading potential with greater cell targeting efficiency leading to efficient control of the viral proliferation in target T-cells. General significance: Our data ascertain the potential of chitosan nanocarriers as novel vehicles for HIV-1 therapeutics. (C) 2013 Elsevier B.V. All rights reserved.

Evaluation of airline exercises prescribed to avoid deep vein thrombosis using fiber Bragg grating sensors

Various leg exercises have been recommended to prevent deep vein thrombosis (DVT), a condition where a blood clot forms in the deep veins, especially during long-haul flights. Accessing the benefit of each of these exercises in avoiding the DVT, which can be fatal, is important in the context of suggesting the correct and the most beneficial exercises. Present work aims at demonstrating the fiber Bragg grating (FBG)-based sensing methodology for measuring surface strains generated on the skin of the calf muscle to evaluate the suggested airline exercises to avoid DVT. As the dataset in the experiment involves multiple subjects performing these exercises, an inertial measurement unit has been used to validate the repetitiveness of each of the exercises. The surface strain on the calf muscle obtained using the FBG sensor, which is a measure of the calf muscle deformation, has been compared against the variation of blood velocity in the femoral vein of the thigh measured using a commercial electronic-phased array color Doppler ultrasound system. Apart from analyzing the effectiveness of suggested exercises, a new exercise which is more effective in terms of strain generated to avoid DVT is proposed and evaluated. (C) 2013 Society of Photo-Optical Instrumentation Engineers (SPIE)

Biodiesel Exhaust Treatment with Dielectric Barrier Discharges Coupled with Industrial Waste Byproducts

Biodiesel run engines are gaining popularity since the last few years as a viable alternative to conventional petro-diesel based engines. In biodiesel exhaust the content of volatile organic compounds, oil mist, and mass of particulate matter is considerably lower. However, the concentration of oxides of nitrogen (NOx) is relatively higher. In this paper the biodiesel exhaust from a stationary engine is treated under controlled laboratory conditions for removal of NOx using dielectric barrier discharge plasma in cascade with adsorbents prepared from abundantly available industrial waste byproducts like red mud and copper slag. Results were compared with gamma-alumina, a commercial adsorbent. Two different dielectric barrier discharge (DBD) reactors were tested for their effectiveness under Repetitive pulses /AC energization. NOx removal as high as 80% was achieved with pulse energized reactors when cascaded with red mud as adsorbent.

Biodiesel Exhaust Treatment with HFAC Plasma supported by Red Mud: Study on DeNOx and power consumption

The concentration of Nitrogen Oxides (NOx) in engines which use biodiesel as fuel is higher compared to conventional diesel engine exhaust. In this paper, an attempt has been made to treat this exhaust using a combination of High frequency AC (HFAC) plasma and an industrial waste, Red Mud which shows proclivity towards Nitrogen dioxide (NO2) adsorption. The high frequency AC source in combination with the proposed compact double dielectric plasma reactors is relatively more efficient in converting Nitric Oxide (NO) to NO2. It has been shown that the plasma treated gas enhances the activity of red mud as an adsorbent/catalyst and about 60-72% NOx removal efficiency was observed at a specific energy of 250 J/L. The advantage in this method is the cost effectiveness and abundant availability of the waste red mud in the industry. Further, power estimation studies were carried out using Manley's equation for the two reactors employed in the experiment and a close agreement between experimental and predicted powers was observed. (C) 2015 The Authors. Published by Elsevier Ltd.

Raman and infra-red microspectroscopy: towards quantitative evaluation for clinical research by ratiometric analysis

Biomolecular structure elucidation is one of the major techniques for studying the basic processes of life. These processes get modulated, hindered or altered due to various causes like diseases, which is why biomolecular analysis and imaging play an important role in diagnosis, treatment prognosis and monitoring. Vibrational spectroscopy (IR and Raman), which is a molecular bond specific technique, can assist the researcher in chemical structure interpretation. Based on the combination with microscopy, vibrational microspectroscopy is currently emerging as an important tool for biomedical research, with a spatial resolution at the cellular and sub-cellular level. These techniques offer various advantages, enabling label-free, biomolecular fingerprinting in the native state. However, the complexity involved in deciphering the required information from a spectrum hampered their entry into the clinic. Today with the advent of automated algorithms, vibrational microspectroscopy excels in the field of spectropathology. However, researchers should be aware of how quantification based on absolute band intensities may be affected by instrumental parameters, sample thickness, water content, substrate backgrounds and other possible artefacts. In this review these practical issues and their effects on the quantification of biomolecules will be discussed in detail. In many cases ratiometric analysis can help to circumvent these problems and enable the quantitative study of biological samples, including ratiometric imaging in 1D, 2D and 3D. We provide an extensive overview from the recent scientific literature on IR and Raman band ratios used for studying biological systems and for disease diagnosis and treatment prognosis.

Evaluation of bioactive sphingolipids in 4-HPR-resistant leukemia cells

Background -- N-(4-hydroxyphenyl)retinamide (4-HPR, fenretinide) is a synthetic retinoid with potent pro-apoptotic activity against several types of cancer, but little is known regarding mechanisms leading to chemoresistance. Ceramide and, more recently, other sphingolipid species (e.g., dihydroceramide and dihydrosphingosine) have been implicated in 4-HPR-mediated tumor cell death. Because sphingolipid metabolism has been reported to be altered in drug-resistant tumor cells, we studied the implication of sphingolipids in acquired resistance to 4-HPR based on an acute lymphoblastic leukemia model. Methods -- CCRF-CEM cell lines resistant to 4-HPR were obtained by gradual selection. Endogenous sphingolipid profiles and in situ enzymatic activities were determined by LC/MS, and resistance to 4-HPR or to alternative treatments was measured using the XTT viability assay and annexin V-FITC/propidium iodide labeling. Results -- No major crossresistance was observed against other antitumoral compounds (i.e. paclitaxel, cisplatin, doxorubicin hydrochloride) or agents (i.e. ultra violet C, hydrogen peroxide) also described as sphingolipid modulators. CCRF-CEM cell lines resistant to 4-HPR exhibited a distinctive endogenous sphingolipid profile that correlated with inhibition of dihydroceramide desaturase. Cells maintained acquired resistance to 4-HPR after the removal of 4-HPR though the sphingolipid profile returned to control levels. On the other hand, combined treatment with sphingosine kinase inhibitors (unnatural (dihydro)sphingosines ((dh)Sph)) and glucosylceramide synthase inhibitor (PPMP) in the presence or absence of 4-HPR increased cellular (dh)Sph (but not ceramide) levels and were highly toxic for both parental and resistant cells. Conclusions -- In the leukemia model, acquired resistance to 4-HPR is selective and persists in the absence of sphingolipid profile alteration. Therapeutically, the data demonstrate that alternative sphingolipid-modulating antitumoral strategies are suitable for both 4-HPR-resistant and sensitive leukemia cells. Thus, whereas sphingolipids may not be critical for maintaining resistance to 4-HPR, manipulation of cytotoxic sphingolipids should be considered a viable approach for overcoming resistance.

Evaluation of wheat or corn dried distillers' grains with solubles on performance and carcass characteristics of feedlot steers

[EN]A study was conducted on crossbred steers (n=275; 376±924 kg) to evaluate performance and carcass quality of cattle fed wheat or corn dried distillers’ grains with solubles (DDGS). The control ration contained 86.6% rolled barley grain, 5.7% supplement and 7.7% barley silage (DM basis). The four treatments included replacement of barley grain at 20 or 40% of the diet (DM basis) with wheat or corn DDGS. Steers were slaughtered at a common end weight of 645 kg with 100 steers randomly (n=20 per treatment) selected for determination of the retail yield of sub-primal boneless boxed beef (SPBBB). Data were analyzed as a completely randomized design using pen as the experimental unit. Feeding increasing levels of wheat DDGS led to a quadratic increase in dry matter intake (DMI) (P<0.01), whereas increasing levels of corn DDGS led to a quadratic decrease in DMI (P=0.01). Average daily gain was not influenced (P=0.13) by feeding wheat or corn DDGS, but cattle fed corn DDGS exhibited a quadratic increase (P=0.01) in gain:feed. As a result, a quadratic increase (P<0.01) in calculated NEg of the diet was observed as corn DDGS levels increased. A linear decrease (P=0.04) in days on feed (169, 166 and 154 d) was noted when increasing levels of wheat DDGS (0, 20 and 40%) were fed. Dressing percentage increased in a linear fashion with wheat DDGS (P<0.01) inclusion level and in a quadratic fashion (P=0.01) as corn DDGS inclusion level increased although other carcass traits were not affected (P=0.10) by treatment. The results indicate that replacement of barley grain with corn or wheat DDGS up to 40% of the diet (DM) can lead to superior performance (improved gain:feed or reduced days on feed, respectively) with no detrimental effect on quality grade or carcass SPBBB yield.

Evaluation of Several Commercial Algicides for Control of Odor-producing Cyanobacteria

The production of certain odorous metabolites is an undesirable attribute of cyanobacteria (blue-green algae) growth in aquaculture ponds [e.g., channel catfish(Ictalurus punctatus)] and in drinking water reservoirs. The most common odorous compounds encountered in catfish aquaculture are geosmin (trans-1,10-dimethyltrans-9-decalol) and 2-methylisoborneol(exo-1,2,7,7-tetramethylbicyclo[2.2.1]heptan-2-ol). These compounds are also frequently encountered worldwide in reservoirs and aqueducts used for municipal drinking water systems(Schrader et al. 2002). In this study, several algicides were evaluated using a rapid bioassay to determine their effectiveness in controlling the MIB-producing cyanobacterium Oscillatoria perornata from a west Mississippi catfish pond and the MIBproducing Pseudanabaena sp. (strain LW397) from Lake Whitehurst, Virginia, used as a city water supply reservoir. The cyanobacterium Oscillatoria agardhii , not a MIB-producer, and the green alga Selenastrum capricornutum , found in catfish ponds in the southeastern United States, were included in the bioassay to help determine potential broad-spectrum toxicity of the commercial products. (PDF has 3 pages.)

Endothall species selectivity evaluation: northern latitude aquatic plant community

Species selectivity of the aquatic herbicide dipotassium salt of endothall (Aquathol® K) was evaluated on plant species typically found in northern latitude aquatic plant communities. Submersed species included Eurasian watermilfoil (Myriophyllum spicatum L.), curlyleaf pondweed (Potamogeton crispus L.), Illinois pondweed (Potamogeton illinoensis Morong.), sago pondweed (Potamogeton pectinatus L.), coontail (Ceratophyllum demersum L.), elodea (Elodea canadensis Michx.) and wildcelery (Vallisneria americana L.). Emergent and floating-leaf plant species evaluated were cattail (Typha latifolia L.), smartweed (Polygonum hydropiperoides Michx.), pickerelweed (Pontederia cordata L.) and spatterdock (Nuphar advena Aiton). The submersed species evaluations were conducted in 7000 L mesocosm tanks, and treatment rates included 0, 0.5 1.0, 2.0, and 4.0 mg/L active ingredient (ai) endothall (dipotassium salt of endothall). The exposure period consisted of a 24-h flow through half-life for 7 d. The cattail and smartweed evaluation was conducted in 860 L mesocosm tanks, and the spatterdock and pickerelweed evaluations were conducted in 1600 L mesocosm tanks. Treatment rates for the emergent and floating-leafed plant evaluations included 0, 0.5, 2.0 and 4.0 mg/L ai endothall, and the exposure period consisted of removing and replacing half the water from each tank, after each 24 h period for a duration of 120 h. Biomass samples were collected at 3 and 8 weeks after treatment (WAT). Endothall effectively controlled Eurasian watermilfoil and curlyleaf pondweed at all of the application rates, and no significant regrowth was observed at 8 WAT. Sago pondweed, wildcelery, and Illinois pondweed biomass were also significantly reduced following the endothall application, but regrowth was observed at 8 WAT. Coontail and elodea showed no effects from endothall application at the 0.5, 1.0, and 2.0 mg/L application rates, but coontail was controlled at 4.0 mg/L rate. Spatterdock, pickerelweed, cattail, and smartweed were not injured at any of the endothall application rates.

BMP treatment technologies, monitoring needs, and knowledge gaps: status of the knowledge and relevance within the Tahoe Basin

This Technical memorandum fulfills Task 2 for Agreement 03-495 between El Dorado County and the Office of Water Programs at California State University Sacramento and their co-authors, Bachand & Associates and the University of California Tahoe Research Group: 1) a review of current stormwater treatment Best Management Practices (BMP) in the Tahoe Basin and their potential effectiveness in removing fine particles and reducing nutrient concentrations; 2) an assessment of the potential for improving the performance of different types of existing BMPs through retrofitting or better maintenance practices; 3) a review of additional promising treatment technologies not currently in use in the Tahoe Basin; and 4) a list of recommendations to help address the knowledge gaps in BMP design and performance. ... (PDF contains 67 pages)

Fish Habitat Utilization Patterns and Evaluation of the Efficacy of Marine Protected Areas in Hawaii: Integration of NOAA Digital Benthic Habitat Mapping and Coral Reef Ecological Studies

Over the past four decades, the state of Hawaii has developed a system of eleven Marine Life Conservation Districts (MLCDs) to conserve and replenish marine resources around the state. Initially established to provide opportunities for public interaction with the marine environment, these MLCDs vary in size, habitat quality, and management regimes, providing an excellent opportunity to test hypotheses concerning marine protected area (MPA) design and function using multiple discreet sampling units. NOAA/NOS/NCCOS/Center for Coastal Monitoring and Assessment’s Biogeography Team developed digital benthic habitat maps for all MLCD and adjacent habitats. These maps were used to evaluate the efficacy of existing MLCDs for biodiversity conservation and fisheries replenishment, using a spatially explicit stratified random sampling design. Coupling the distribution of habitats and species habitat affinities using GIS technology elucidates species habitat utilization patterns at scales that are commensurate with ecosystem processes and is useful in defining essential fish habitat and biologically relevant boundaries for MPAs. Analysis of benthic cover validated the a priori classification of habitat types and provided justification for using these habitat strata to conduct stratified random sampling and analyses of fish habitat utilization patterns. Results showed that the abundance and distribution of species and assemblages exhibited strong correlations with habitat types. Fish assemblages in the colonized and uncolonized hardbottom habitats were found to be most similar among all of the habitat types. Much of the macroalgae habitat sampled was macroalgae growing on hard substrate, and as a result showed similarities with the other hardbottom assemblages. The fish assemblages in the sand habitats were highly variable but distinct from the other habitat types. Management regime also played an important role in the abundance and distribution of fish assemblages. MLCDs had higher values for most fish assemblage characteristics (e.g. biomass, size, diversity) compared with adjacent fished areas and Fisheries Management Areas (FMAs) across all habitat types. In addition, apex predators and other targeted resources species were more abundant and larger in the MLCDs, illustrating the effectiveness of these closures in conserving fish populations. Habitat complexity, quality, size and level of protection from fishing were important determinates of MLCD effectiveness with respect to their associated fish assemblages. (PDF contains 217 pages)

A review of the ecological effectiveness of subtidal marine reserves in Central California, Part I: Synopsis of scientific investigations

Marine reserves, often referred to as no-take MPAs, are defined as areas within which human activities that can result in the removal or alteration of biotic and abiotic components of an ecosystem are prohibited or greatly restricted (NRC 2001). Activities typically curtailed within a marine reserve are extraction of organisms (e.g., commercial and recreational fishing, kelp harvesting, commercial collecting), mariculture, and those activities that can alter oceanographic or geologic attributes of the habitat (e.g., mining, shore-based industrial-related intake and discharges of seawater and effluent). Usually, marine reserves are established to conserve biodiversity or enhance nearby fishery resources. Thus, goals and objectives of marine reserves can be inferred, even if they are not specifically articulated at the time of reserve formation. In this report, we review information about the effectiveness of the three marine reserves in the Monterey Bay National Marine Sanctuary (Hopkins Marine Life Refuge, Point Lobos Ecological Reserve, Big Creek Ecological Reserve), and the one in the Channel Islands National Marine Sanctuary (the natural area on the north side of East Anacapa Island). Our efforts to objectively evaluate reserves in Central California relative to reserve theory were greatly hampered for four primary reasons; (1) few of the existing marine reserves were created with clearly articulated goals or objectives, (2) relatively few studies of the ecological consequences of existing reserves have been conducted, (3) no studies to date encompass the spatial and temporal scope needed to identify ecosystem-wide effects of reserve protection, and (4) there are almost no studies that describe the social and economic consequences of existing reserves. To overcome these obstacles, we used several methods to evaluate the effectiveness of subtidal marine reserves in Central California. We first conducted a literature review to find out what research has been conducted in all marine reserves in Central California (Appendix 1). We then reviewed the scientific literature that relates to marine reserve theory to help define criteria to use as benchmarks for evaluation. A recent National Research Council (2001) report summarized expected reserve benefits and provided the criteria we used for evaluation of effectiveness. The next step was to identify the research projects in this region that collected information in a way that enabled us to evaluate reserve theory relative to marine reserves in Central California. Chapters 1-4 in this report provide summaries of those research projects. Contained within these chapters are evaluations of reserve effectiveness for meeting specific objectives. As few studies exist that pertain to reserve theory in Central California, we reviewed studies of marine reserves in other temperate and tropical ecosystems to determine if there were lessons to be learned from other parts of the world (Chapter 5). We also included a discussion of social and economic considerations germane to the public policy decision-making processes associated with marine reserves (Chapter 6). After reviewing all of these resources, we provided a summary of the ecological benefits that could be expected from existing reserves in Central California. The summary is presented in Part II of this report. (PDF contains 133 pages.)

Assessment of phytostabilization of Pb/Zn mine soils with organic amendments and a native metallicolous ecotype of Festuca Rubra l.: implications for amendment selection and recovery of soil health

La contaminación del suelo es una de las principales amenazas para los ecosistemas y la salud humana. Actualmente, desde un punto de vista tanto económico como ambiental, la fitoestabilización es la mejor tecnología para remediar suelos contaminados con elevadas concentraciones de metales como son los suelos mineros. La fitoestabilización asistida consiste en el empleo de plantas y enmiendas orgánicas y/o inorgánicas con el fin de reducir la movilidad y la biodisponibilidad de los contaminantes y recuperar la salud de suelo. En este trabajo se han realizado ensayos en microcosmos y en campo centrándonos en la salud del suelo minero contaminado con Pb y Zn durante un proceso de fitoestabilización empleando enmiendas orgánicas (purines vacunos, gallinaza, estiércol de oveja y lodos de papelera mezclados con gallinaza) y/o la especie metalífera Festuca rubra con el objetivo de (i) estudiar las interacciones suelo-enmienda responsables de los cambios inducidos por el proceso de quimioestabilización en las propiedades físicoquímicas y biológicas del suelo, (ii) evaluar la efectividad del proceso de fitoestabilización sobre suelos vegetados y de la revegetación sobre suelos desnudos (iii) valorar la idoneidad de distintos indicadores químicos y biológicos (parámetros microbianos y de la vegetación) para monitorizar la efectividad de la fitoestabilización asistida en términos de reducción de la biodisponibilidad de metales en el suelo, mejora de la vegetación y de la recuperación de la salud del suelo. La aplicación de enmiendas al suelo minero supone una entrada de materia orgánica y nutrientes que conduce a una disminución de la biodisponibilidad de metales, facilitando la colonización de las plantas y el crecimiento de la vegetación nativa, además de estimular la actividad microbiana del suelo. El pH del suelo es un factor crítico que condiciona la movilidad de los metales y la toxicidad del suelo. Las poblaciones microbianas de las enmiendas no modificaron la diversidad funcional de las comunidades microbianas nativas de la mina. Los purines vacunos y los lodos de papelera mezclados con gallinaza son los tratamientos más efectivos en el proceso de fitoestabilización asistida bajo condiciones de campo. La gallinaza fue el tratamiento que más estimuló el crecimiento de la vegetación nativa y la colonización en los suelos desnudos. El bioensayo de elongación radical de lechuga es un test sensible, sencillo y barato para evaluar la biodisponibilidad de metal y la ecotoxicidad del suelo. Los tocoferoles son biomarcadores de exposición a metales con potencial para su implementación en bioensayos de toxicidad. Este trabajo permite concluir que la población metalífera de F. rubra, combinada con enmiendas orgánicas, es una excelente candidata para los proyectos de fitoestabilización asistida. Además, la monitorización simultánea de los parámetros fisicoquímicos y microbiológicos del suelo y de su ecotoxicidad permite una evaluación adecuada de la salud del suelo, así como la selección de enmiendas apropiadas para el desarrollo de un proceso fitoestabilizador.

External Evaluation for the BCE-CT Project

Strand one: Effectiveness of project activities and processes

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.