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.

High-strain composites and dual-matrix composite structures

Most space applications require deployable structures due to the limiting size of current launch vehicles. Specifically, payloads in nanosatellites such as CubeSats require very high compaction ratios due to the very limited space available in this typo of platform. Strain-energy-storing deployable structures can be suitable for these applications, but the curvature to which these structures can be folded is limited to the elastic range. Thanks to fiber microbuckling, high-strain composite materials can be folded into much higher curvatures without showing significant damage, which makes them suitable for very high compaction deployable structure applications. However, in applications that require carrying loads in compression, fiber microbuckling also dominates the strength of the material. A good understanding of the strength in compression of high-strain composites is then needed to determine how suitable they are for this type of application.

The goal of this thesis is to investigate, experimentally and numerically, the microbuckling in compression of high-strain composites. Particularly, the behavior in compression of unidirectional carbon fiber reinforced silicone rods (CFRS) is studied. Experimental testing of the compression failure of CFRS rods showed a higher strength in compression than the strength estimated by analytical models, which is unusual in standard polymer composites. This effect, first discovered in the present research, was attributed to the variation in random carbon fiber angles respect to the nominal direction. This is an important effect, as it implies that microbuckling strength might be increased by controlling the fiber angles. With a higher microbuckling strength, high-strain materials could carry loads in compression without reaching microbuckling and therefore be suitable for several space applications.

A finite element model was developed to predict the homogenized stiffness of the CFRS, and the homogenization results were used in another finite element model that simulated a homogenized rod under axial compression. A statistical representation of the fiber angles was implemented in the model. The presence of fiber angles increased the longitudinal shear stiffness of the material, resulting in a higher strength in compression. The simulations showed a large increase of the strength in compression for lower values of the standard deviation of the fiber angle, and a slight decrease of strength in compression for lower values of the mean fiber angle. The strength observed in the experiments was achieved with the minimum local angle standard deviation observed in the CFRS rods, whereas the shear stiffness measured in torsion tests was achieved with the overall fiber angle distribution observed in the CFRS rods.

High strain composites exhibit good bending capabilities, but they tend to be soft out-of-plane. To achieve a higher out-of-plane stiffness, the concept of dual-matrix composites is introduced. Dual-matrix composites are foldable composites which are soft in the crease regions and stiff elsewhere. Previous attempts to fabricate continuous dual-matrix fiber composite shells had limited performance due to excessive resin flow and matrix mixing. An alternative method, presented in this thesis uses UV-cure silicone and fiberglass to avoid these problems. Preliminary experiments on the effect of folding on the out-of-plane stiffness are presented. An application to a conical log-periodic antenna for CubeSats is proposed, using origami-inspired stowing schemes, that allow a conical dual-matrix composite shell to reach very high compaction ratios.

Advancing EDL technologies for future space missions : from ground testing facilities to ablative heatshields

Motivated by recent MSL results where the ablation rate of the PICA heatshield was over-predicted, and staying true to the objectives outlined in the NASA Space Technology Roadmaps and Priorities report, this work focuses on advancing EDL technologies for future space missions.

Due to the difficulties in performing flight tests in the hypervelocity regime, a new ground testing facility called the vertical expansion tunnel is proposed. The adverse effects from secondary diaphragm rupture in an expansion tunnel may be reduced or eliminated by orienting the tunnel vertically, matching the test gas pressure and the accelerator gas pressure, and initially separating the test gas from the accelerator gas by density stratification. If some sacrifice of the reservoir conditions can be made, the VET can be utilized in hypervelocity ground testing, without the problems associated with secondary diaphragm rupture.

The performance of different constraints for the Rate-Controlled Constrained-Equilibrium (RCCE) method is investigated in the context of modeling reacting flows characteristic to ground testing facilities, and re-entry conditions. The effectiveness of different constraints are isolated, and new constraints previously unmentioned in the literature are introduced. Three main benefits from the RCCE method were determined: 1) the reduction in number of equations that need to be solved to model a reacting flow; 2) the reduction in stiffness of the system of equations needed to be solved; and 3) the ability to tabulate chemical properties as a function of a constraint once, prior to running a simulation, along with the ability to use the same table for multiple simulations.

Finally, published physical properties of PICA are compiled, and the composition of the pyrolysis gases that form at high temperatures internal to a heatshield is investigated. A necessary link between the composition of the solid resin, and the composition of the pyrolysis gases created is provided. This link, combined with a detailed investigation into a reacting pyrolysis gas mixture, allows a much needed consistent, and thorough description of many of the physical phenomena occurring in a PICA heatshield, and their implications, to be presented.

Through the use of computational fluid mechanics and computational chemistry methods, significant contributions have been made to advancing ground testing facilities, computational methods for reacting flows, and ablation modeling.

A. An investigation of the relation between the tensile strength and (Brinell) hardness of non-ferrous alloys. B. A design of a fatigue testing machine for a college laboratory

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Commercial testing of concrete

The material included within this report is the result of a series of tests of concrete specimens taken during the construction of various buildings in the cities of Pasadena and Los Angeles over a period of eight months.

The object of the problem is to determine the effect of the water ratio on the ultimate strength of the concrete as obtained from data observed and recorded from specimens taken from actual building practice rather than that from laboratory specimens made under ideal, or at least more nearly standard conditions.

Wave-front analysis method of circular aperture sampling for collimation testing

A new type of wave-front analysis method for the collimation testing of laser beams is proposed. A concept of wave-front height is defined, and, on this basis, the wave-front analysis method of circular aperture sampling is introduced. The wave-front height of the tested noncollimated wave can be estimated from the distance between two identical fiducial diffraction planes of the sampled wave, and then the divergence is determined. The design is detailed, and the experiment is demonstrated. The principle and experiment results of the method are presented. Owing to the simplicity of the method and its low cost, it is a promising method for checking the collimation of a laser beam with a large divergence. © 2005 Optical Society of America.