Quantcast

Subscribe to:
POZ magazine
E-newsletters
Join POZ: Facebook MySpace Twitter Pinterest
Tumblr Google+ Flickr MySpace
POZ Personals
Sign In / Join
Username:
Password:
Welcome, Guest. Please login or register.
September 18, 2014, 08:11:56 AM

Login with username, password and session length


Members
  • Total Members: 23495
  • Latest: kylebam
Stats
  • Total Posts: 639209
  • Total Topics: 48519
  • Online Today: 176
  • Online Ever: 585
  • (January 07, 2014, 02:31:47 PM)
Users Online

Welcome


Welcome to the POZ/AIDSmeds Community Forums, a round-the-clock discussion area for people with HIV/AIDS, their friends/family/caregivers, and others concerned about HIV/AIDS.  Click on the links below to browse our various forums; scroll down for a glance at the most recent posts; or join in the conversation yourself by registering on the left side of this page.

Privacy Warning:  Please realize that these forums are open to all, and are fully searchable via Google and other search engines. If you are HIV positive and disclose this in our forums, then it is almost the same thing as telling the whole world (or at least the World Wide Web). If this concerns you, then do not use a username or avatar that are self-identifying in any way. We do not allow the deletion of anything you post in these forums, so think before you post.

  • The information shared in these forums, by moderators and members, is designed to complement, not replace, the relationship between an individual and his/her own physician.

  • All members of these forums are, by default, not considered to be licensed medical providers. If otherwise, users must clearly define themselves as such.

  • Forums members must behave at all times with respect and honesty. Posting guidelines, including time-out and banning policies, have been established by the moderators of these forums. Click here for “Am I Infected?” posting guidelines. Click here for posting guidelines pertaining to all other POZ/AIDSmeds community forums.

  • We ask all forums members to provide references for health/medical/scientific information they provide, when it is not a personal experience being discussed. Please provide hyperlinks with full URLs or full citations of published works not available via the Internet. Additionally, all forums members must post information which are true and correct to their knowledge.

  • Product advertisement—including links; banners; editorial content; and clinical trial, study or survey participation—is strictly prohibited by forums members unless permission has been secured from POZ.

To change forums navigation language settings, click here (members only), Register now

Para cambiar sus preferencias de los foros en español, haz clic aquí (sólo miembros), Regístrate ahora

Finished Reading This? You can collapse this or any other box on this page by clicking the symbol in each box.

Poll

Should HIV treatment naive people have a PEP available in case of sexual exposure of their sexual partner ?

Yes
16 (51.6%)
No
13 (41.9%)
Other
0 (0%)
Neutral
2 (6.5%)

Total Members Voted: 31

Author Topic: Reducing the HIV infection rate  (Read 14403 times)

0 Members and 1 Guest are viewing this topic.

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Reducing the HIV infection rate
« on: November 26, 2008, 11:07:13 AM »
I'm still wondering why most of us haven't available at home a PEP in case of condom failure for e.g.

This would allows to reduce the time to get the PEP, and so the reduce the nochance to infect our partner.

The cost shouldn't be an issue, as if the PEP could reduce the risk of infection by at least let say 80% (as taken few minutes after the exposure), it will allow to save then a life treatment.
Typically, a treatment expiration date is of 2 years.

But till now, this measure isn't standard.

I would have prefer that it is, for those who are asking for.
Of course, if the PEP should be given to the partner, the latter would still have let say to see an ID doc to review the need of the treatment for e.g.

As this is not a standard measure, I'm creating this poll to get some feedback on that questions and see why this could or not be a good idea
« Last Edit: November 26, 2008, 12:09:52 PM by John2038 »

Offline Moffie65

  • Member
  • Posts: 1,755
  • Living POZ since 1983
Re: Reducing the new HIV infection rateS
« Reply #1 on: November 26, 2008, 11:30:07 AM »
Being that this is a Capitalistic Democracy, and we are all free to act accordingly; it would behoove all who are fearful of this scenario to go ahead and purchase PEP if they feel it is important to them.  If we lived in a socialist democracy, then the government would then be the one to ask for such a thing, however I doubt any legislator would vote to approve such an expense. 
The Bible contains 6 admonishments to homosexuals,
and 362 to heterosexuals.
This doesn't mean that God doesn't love heterosexuals,
It's just that they need more supervision.
Lynn Lavne

Offline Basquo

  • Member
  • Posts: 3,257
Re: Reducing the HIV infection rate
« Reply #2 on: November 26, 2008, 12:44:12 PM »
Without a diagnosis, how am I supposed to get PEP for my partner? Go to a doctor? Get a prescription? and even if that were to happen, how am I going to pay for it? Insurance isn't going to pay without a diagnosis or a visit to the ER, so I'd rather not have a few thousand dollars worth of meds waiting around to expire instead of in the bank earning interest.  I also don't understand why the poll specifies for treatment-naive patients.

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #3 on: November 26, 2008, 12:59:55 PM »
Without a diagnosis, how am I supposed to get PEP for my partner? Go to a doctor? Get a prescription? and even if that were to happen, how am I going to pay for it? Insurance isn't going to pay without a diagnosis or a visit to the ER, so I'd rather not have a few thousand dollars worth of meds waiting around to expire instead of in the bank earning interest. 

In 2007, 2.7 mio have been newly infected, 77'000 in the UK only, more than ever before.
Maybe the insurance will agree to prescribe an emergency PEP, that your doc will anyway prescribe to your partner (or probably the hospital emergency) if you come to them saying that you are s+ and that your partner have take a sexual risk with you.

In more, we can imagine that the PEP can be returned to the pharmacy, sealed, with a sticker green if the storage temperature haven't exceed the normal range (red otherwise), to be exchanged by another box. So the returned box could be reuse by someone else.
Hey hey, just few idea, I haven't say it is realistic
But 30 days of Kaletra + Truvada cost 1000 euros in the EU as far as I know, against 100 euros in South Africa. I guess the insurance can negociate a better price with the pharma for this kind of prescription.

I also don't understand why the poll specifies for treatment-naive patients.
 

Because I was expecting non naive patients with virological, immunological success to give their own meds and go to the emergency unit afterward.

Offline MarcoPoz

  • Member
  • Posts: 396
Re: Reducing the HIV infection rate
« Reply #4 on: November 26, 2008, 02:20:29 PM »
I don't think PrEP is the singular answer.  I do however see it as one possible tool in a continuum of prevention possiblities.

Offline David_CA

  • Member
  • Posts: 3,246
  • Joined: March 2006
Re: Reducing the HIV infection rate
« Reply #5 on: November 26, 2008, 03:36:42 PM »
I obviously know what PEP is, but what drugs are generally used?  What doses? 
Black Friday 03-03-2006
03-23-06 CD4 359 @27.4% VL 75,938
06-01-06 CD4 462 @24.3% VL > 100,000
08-15-06 CD4 388 @22.8% VL >  "
10-21-06 CD4 285 @21.9% VL >  "
  Atripla started 12-01-2006
01-08-07 CD4 429 @26.8% VL 1872!
05-08-07 CD4 478 @28.1% VL 740
08-03-07 CD4 509 @31.8% VL 370
11-06-07 CD4 570 @30.0% VL 140
02-21-08 CD4 648 @32.4% VL 600
05-19-08 CD4 695 @33.1% VL < 48 undetectable!
08-21-08 CD4 725 @34.5%
11-11-08 CD4 672 @39.5%
02-11-09 CD4 773 @36.8%
05-11-09 CD4 615 @36.2%
08-19-09 CD4 770 @38.5%
11-19-09 CD4 944 @33.7%
02-17-10 CD4 678 @39.9%  
06-03-10 CD4 768 @34.9%
09-21-10 CD4 685 @40.3%
01-10-11 CD4 908 @36.3%
05-23-11 CD4 846 @36.8% VL 80
02-13-12 CD4 911 @41.4% VL<20
You must be the change you want to see in the world.  Mahatma Gandhi

Offline skeptik73

  • Member
  • Posts: 24
  • switch (zero)
Re: Reducing the HIV infection rate
« Reply #6 on: November 26, 2008, 04:00:21 PM »
Because I was expecting non naive patients with virological, immunological success to give their own meds and go to the emergency unit afterward.

Um.  Well I guess desperate times do call for desperate measures.  But geez.  I don't think that's the right approach at all. Even if it turned out to be a GOOD idea, I think you're probably one of the few with that level of audacity.  And personally, I think it sounds like a BAD idea.

But then again what do I know.  I get chewed up by Ann for suggesting the HIV window period is six months.

Offline Miss Philicia

  • Member
  • Posts: 24,082
  • celebrity poster, faker & poser
Re: Reducing the HIV infection rate
« Reply #7 on: November 26, 2008, 04:12:21 PM »
Ann corrected you, not "chewed" you up.
"I’ve slept with enough men to know that I’m not gay"

Offline red_Dragon888

  • Member
  • Posts: 2,811
  • Love and Be Love in Return
Re: Reducing the HIV infection rate
« Reply #8 on: November 26, 2008, 10:53:48 PM »
If I was a betting man I would buy stock in PEP and push the public to use it before, during and after sex.  Or before I had sex and was negative, I would insist that my partner to go with me and get tested for HIV every month for six months then have sex but by then I would not want to take the chance.
« Last Edit: November 27, 2008, 01:43:47 PM by red_Dragon888 »
http://www.youtube.com/watch?feature=player_embedded&v=I3ba3lnFHik

“Neither look forward where there is doubt nor backward where there is regret. Look inward and ask not if there is anything o

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #9 on: November 27, 2008, 10:38:17 AM »
I obviously know what PEP is, but what drugs are generally used?  What doses? 

The most frequently prescribed PEP is

KALETRA 200/50 mg (lopinavir + ritonavir)
2 caps per 12h

+

Truvada 200/300 mg (emtricitabine + tenofovir)
1 caps per 24h

Offline Moffie65

  • Member
  • Posts: 1,755
  • Living POZ since 1983
Re: Reducing the HIV infection rate
« Reply #10 on: November 27, 2008, 12:37:28 PM »
John said, "But 30 days of Kaletra + Truvada cost 1000 euros in the EU as far as I know, against 100 euros in South Africa. I guess the insurance can negociate a better price with the pharma for this kind of prescription."


I say, if a person who is going to need PEP, is not going to go out and spend $1,475 dollars on such a thing to have in the home, "just in case".  Sorry John, you are living in a fantasy land that obviously isn't on this planet.  :)
The Bible contains 6 admonishments to homosexuals,
and 362 to heterosexuals.
This doesn't mean that God doesn't love heterosexuals,
It's just that they need more supervision.
Lynn Lavne

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #11 on: November 27, 2008, 01:14:29 PM »
I think the insurance will pay if they can expect less infection.
I think avoiding new infection is a huge priority, could it be through such measures
I think that if the PEP is returned let says 1 year before it's expiration date, and then reused, it will still haven't cost 1 penny
I think that anyway, if you go to the emergency unit, they will prescribe you a PEP anyway, so better save time as much as possible
In more, those who needs a PEP won't maybe get it, just being too lazy to go to the hospital.

Saving life is something possible on the Earth, without having to feel to live in a fantasy land  ;)
« Last Edit: November 29, 2008, 12:29:01 AM by John2038 »

Offline fearless

  • Member
  • Posts: 2,191
Re: Reducing the HIV infection rate
« Reply #12 on: November 27, 2008, 06:20:11 PM »
I'm all for people having access to PEP but I'm curious why you would suggest the poz person keep it just in case a condom breaks etc.

I don't believe your proposal is feesible - for the same reason I don't keep snake bite antivenom handy, just in case. But, even if it were, why the shouldn't the sexually active neg person be responsible for keeping PEP handy. I'm sick and tired of us poz people being made to shoulder all the responsibility for trying to minimize the spread of HIV. It's about time, those who are neg took responsibility for trying to stay neg.

my two cents...
Be forgiving, be grateful, be optimistic

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #13 on: November 28, 2008, 12:21:15 PM »
Vivarium got antivenom.

Your solution is not cost-effective.

Seems you don't care at all, I don't see others possibilities.
It's your choice, definitely not mine.

Offline Moffie65

  • Member
  • Posts: 1,755
  • Living POZ since 1983
Re: Reducing the HIV infection rate
« Reply #14 on: November 28, 2008, 06:21:22 PM »
I think the insurance will pay if they can expect less infection.

Please forward to me the necessary money for me to be able to buy insurance and my sweetie and I will surely ask them to spend the $1500 for us to keep it in our fridge.

I haven't been able to afford insurance for about 20 years now.  Seems the best I can do for insurance rates are now about $2300 a month.  AHEM, can you please wire the $27,600 to me, and if you really care, an extra $27,600 for my sweetie.  Then in December of next year, please don't forget to send it again.... Blue Cross Blue Shield won't insure if you don't pay. 

Wake up please John; your world is not my world. 
The Bible contains 6 admonishments to homosexuals,
and 362 to heterosexuals.
This doesn't mean that God doesn't love heterosexuals,
It's just that they need more supervision.
Lynn Lavne

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #15 on: November 29, 2008, 12:39:44 AM »
Please forward to me the necessary money for me to be able to buy insurance and my sweetie and I will surely ask them to spend the $1500 for us to keep it in our fridge.

I haven't been able to afford insurance for about 20 years now.  Seems the best I can do for insurance rates are now about $2300 a month.  AHEM, can you please wire the $27,600 to me, and if you really care, an extra $27,600 for my sweetie.  Then in December of next year, please don't forget to send it again.... Blue Cross Blue Shield won't insure if you don't pay. 

Wake up please John; your world is not my world. 

I do not want to argue the point of view that each of us has the right to have.

But I must say that you seems to look for argument against such idea, and I don't believe that the cost is the real reason for you.

Because you are not looking for solutions (about these costs) but problems.
As such, you aren't considering the arguments provided above and saying that such cost could be very low if for e.g. the PEP is returned enough long time before its expiration date, so it can be reused.
Or admitting the fact that if you present yourself to the emergency unit, they will prescribe you the PEP, if you have take a risk. I don't know who pay in the US, but in EU, it's the insurance.

The insurance can negotiate the price with the Pharma.

Someone infected will have to take dugs for let says 40 years.
That 40x12 = 480 PEP equivalent (without counting associated cost such as labs etc)

So just if such measure could prevent more  1 of 500 infection to occurs, it will cost less money.
I'm not trying to convince you, but I found your arguments very light, and I am wondering why.

The world you are describing is a worst world, not a better world. And it's up to each of us to build the world we want.

Offline Ann

  • Administrator
  • Member
  • Posts: 28,140
  • It just is, OK?
    • Num is sum qui mentiar tibi?
Re: Reducing the HIV infection rate
« Reply #16 on: November 29, 2008, 07:21:12 AM »
I cannot see this concept working as a blanket solution. PEP consists of heavy-duty drugs that should not be given out without a doctor's say so.

However, I can see a modified version working in a long-term committed relationship, where the negative partner has been to see the prescribing doctor and all the ins and outs of PEP treatment have been thoroughly explained. The instances in which the drugs should be taken should also be thoroughly explained - otherwise, you'd have people taking the drugs over no-risk events. Guaranteed.

And the main modification is this - a whole months worth of PEP doesn't need to be kept on hand. A couple days would suffice, giving the person plenty of time to get in to see a doctor, who would then confirm the need, and make sure there are no contraindications that hadn't come up at the initial consultation when the PEP was originally prescribed, and to then prescribe the rest of the course of treatment - or not, depending on actual need.

But to just hand out a month's worth of PEP willy-nilly? No way.

Ann
Condoms are a girl's best friend

Condom and Lube Info  



"...health will finally be seen not as a blessing to be wished for, but as a human right to be fought for." Kofi Annan

Nymphomaniac: a woman as obsessed with sex as an average man. Mignon McLaughlin

HIV is certainly character-building. It's made me see all of the shallow things we cling to, like ego and vanity. Of course, I'd rather have a few more T-cells and a little less character. Randy Shilts

Online Dachshund

  • Member
  • Posts: 5,957
Re: Reducing the HIV infection rate
« Reply #17 on: November 29, 2008, 08:16:59 AM »
So tiresome.

We already know of the best and most cost efficient way to reduce the spread of HIV. Education and condoms. The holes in this silly theory are too numerous to mention. Reverse the abstinence only policy of the Bush administration and you'll reduce infection faster than you can say PEP. In order for this nonsense to be effective you'd need to identify all the HIV infected people in the world. This pink Unicorn view of how easy this could be accomplished, proves once again a thread started just for argument sake. Serious replies met with patronising derision and simplistic, childish solutions.

But while you're negotiating, see if you can get Agribusiness to end world hunger.

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #18 on: November 29, 2008, 08:22:14 AM »
Hi Ann,

I think you made valid comments.
I like especially the idea to get a regimen for just enough days to see a doctor, in order to validate the PEP, despite globally you are against the idea.

Dachshund, no comments, I have no interests reading such posts.

Offline Moffie65

  • Member
  • Posts: 1,755
  • Living POZ since 1983
Re: Reducing the HIV infection rate
« Reply #19 on: November 29, 2008, 08:31:35 AM »
John 2038 Signature Quote:  "Disclaimer: I'm a physicist, not a physician nor an aids scientist.
Take my postings with a grain of salt."

I'm sorry John, I thought you were actually serious, and I never noticed your signature block.  Sorry for commenting on this thread to nowhere!  In the future I won't waste my time or yours, which is obvously far more valuable that the rest of ours.
The Bible contains 6 admonishments to homosexuals,
and 362 to heterosexuals.
This doesn't mean that God doesn't love heterosexuals,
It's just that they need more supervision.
Lynn Lavne

Online Dachshund

  • Member
  • Posts: 5,957
Re: Reducing the HIV infection rate
« Reply #20 on: November 29, 2008, 10:34:50 AM »
And it's up to each of us to build the world we want.

On the off chance you're reading this post ;), you might want to try becoming the change you seek. While obsessing over theory you could actually be doing something practical. Start with volunteering, or maybe educating others in HIV prevention. Just think, even a small dose of some real-time activism might prevent others from infection. It does require action over words, but in the end it really is the only way to "build the world you want."

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #21 on: November 29, 2008, 11:08:34 AM »
Moffie65 seems you have miss critical information ! Wowow

Offline Peter Staley

  • Member
  • Posts: 1,337
  • Founder & Advisory Editor, AIDSmeds.com
    • AIDSmeds.com
Re: Reducing the HIV infection rate
« Reply #22 on: November 29, 2008, 11:44:57 AM »
So tiresome.

We already know of the best and most cost efficient way to reduce the spread of HIV. Education and condoms. The holes in this silly theory are too numerous to mention. Reverse the abstinence only policy of the Bush administration and you'll reduce infection faster than you can say PEP. In order for this nonsense to be effective you'd need to identify all the HIV infected people in the world. This pink Unicorn view of how easy this could be accomplished, proves once again a thread started just for argument sake. Serious replies met with patronising derision and simplistic, childish solutions.

But while you're negotiating, see if you can get Agribusiness to end world hunger.

Hal -- you're on a roll these past few days.  Please stop with the patronizing posts. If you find this thread useless, then you have a simple solution -- don't post to it.  Instead, you chose to post flamebait.

Don't post in this thread again.

Peter

Offline gerry

  • Member
  • Posts: 522
  • Joined AM Feb 2003
Re: Reducing the HIV infection rate
« Reply #23 on: November 29, 2008, 04:33:14 PM »
I obviously know what PEP is, but what drugs are generally used?  What doses? 

It can be a two-drug (such as Combivir or Truvada) or a three-drug (like any of the triple drug combos already used for treatment) regimen depending on the exposure risk.  The doses are standard ARV doses and the duration is 4 weeks generally.

As some have already mentioned, cost is very prohibitive.  I got a call last week from a local shelter administrator asking for help about a client who was raped, went to the ED, and was given a PEP prescription.  The client had no insurance and the administrator had a sticker shock when she realized how much the regimen was going to cost.  She called us to find out if we had any ideas how to get it filled and I had to say no we don't.  We really don't have that type of funding and even if we were able to procure the meds for her at a discount (which some community health centers are able to do), it would still amount to several hundred dollars at least.


Offline hotpuppy

  • Member
  • Posts: 555
Re: Reducing the HIV infection rate
« Reply #24 on: November 29, 2008, 11:06:15 PM »
Heck, from what I understand Kaletra is almost a sentence to the bathroom.  A friend of mine takes it and has to eat immodium like candy.

I think there does need to be an efficient way to get someone started on PEP.  If you were stupid (or had a condom break) on a Friday evening it might potentially be 48 to 72 hours before you could get into see a doc.  At which point it might be too late.  I don't know enough about initial infective stages.

I do know that an entry inhibitor like Selzentry (mariviroc) or Vicriviroc is a very good PEP candidate.  They have few documented side effects and Vicriviroc in particular is particular tenacious.  150mg daily would work fine without Norvir and could be taken solo until the doc decided if a PI was appropriate.

Based on the mechanism of action, it would be completely feasible to use entry inhibitors as a prophylatic.  I'm not saying it would stop all infections, but if you could cut 70% of them (the estimated number of R5 tropic infections) isn't that worth considering? 

It's an interesting discussion anyway you look at it.  I personally am pretty harsh with my friends who are HIV neg.  Not mean, just blunt about reminding them to play safe.  I've had one or two who say they don't care, and I've offered to help them through the paperwork and initial clinic visits for bloodwork.  That normally tends to sober them up.  If that doesn't than I ask them if they would rather have diarrhea, nausea, bad dreams, food restrictions, or yellow eyes.  Which invariably elicits a "why?" to which i reply that those are the side effects and that is the price life has when you are HIV poz.  That always stops them in their tracks.
Don't obsess over the wrong things.  Life isn't about your numbers, it isn't about this forum, it isn't about someone's opinion.  It's about getting out there and enjoying it.   I am a person with HIV - not the other way around.

Offline komnaes

  • Member
  • Posts: 1,893
Re: Reducing the HIV infection rate
« Reply #25 on: November 30, 2008, 10:33:12 AM »
Moffie65 seems you have miss critical information ! Wowow

It is a bit rude isn't it?

I find the title a bit misleading - I thought it was about broader educational efforts, etc. Surely if a person needs PEP it means to me that s/he has already been infected, but taking the meds in time to arrest it so it won't spread.

I really don't believe in self-medication. If a situation arises PEP is needed, it should only be decided by a doctor.
Aug 07 Diagnosed
Oct 07 CD4=446(19%) Feb 08 CD4=421(19%)
Jun 08 CD4=325(22%) Jul 08 CD4=301(18%)
Sep 08 CD4=257/VL=75,000 Oct 08 CD4=347(16%)
Dec 08 CD4=270(16%)
Jan 09 CD4=246(13%)/VL=10,000
Feb 09 CD4=233(15%)/VL=13,000
Started meds Sustiva/Epzicom
May 09 CD4=333(24%)/VL=650
Aug 09 CD4=346(24%)/VL=UD
Nov 09 CD4=437(26%)/VL=UD
Feb 10 CD4=471(31%)/VL=UD
June 10 CD4=517 (28%)/VL=UD
Sept 10 CD4=687 (31%)/VL=UD
Jan 11 CD4=557 (30%)/VL=UD
April 11 CD4=569 (32%)/VL=UD
Switched to Epizcom, Reyataz and Norvir
(Interrupted for 2 months with only Epizcom & Reyataz)
July 11 CD=520 (28%)/VL=UD
Oct 11 CD=771 (31%)/VL=UD(<30)
April 12 CD=609 (28%)/VL=UD(<20)
Aug 12 CD=657 (29%)/VL=UD(<20)
Dec 12 CD=532 (31%)/VL=UD(<20)
May 13 CD=567 (31%)/VL=UD(<20)
Jan 14 CD=521 (21%)/VL=UD(<50)

Offline thunter34

  • Member
  • Posts: 7,314
  • His name is Carl.
Re: Reducing the HIV infection rate
« Reply #26 on: November 30, 2008, 07:55:04 PM »
*sigh*  And while we're convincing insurance to magically pick up the tab for all of this, how about for those of us who are already having to jump through hoops just to get pills for OURSELVES via ADAP?

And given how some people already attempt to use PEP along with their party drugs when they plan on "hitting it raw", is it really gonna help when we have all these other pills on hand for just such situations? (Though come to think of it, given that mentality, I'll bet I could trade my supplemental stash for a SWEET sack of tina...good plan, John!)
AIDS isn't for sissies.

Offline komnaes

  • Member
  • Posts: 1,893
Re: Reducing the HIV infection rate
« Reply #27 on: November 30, 2008, 09:35:03 PM »
And given how some people already attempt to use PEP along with their party drugs when they plan on "hitting it raw", ...

Bull eyes!

If the thread is about under what specific circumstances PEP should be made more readily available, there's something I can understand and participate. We discussed this topic in one of our support groups, and we went through several "tricks" we could try to convince hesitating doctors in ER, day clinics to prescribe enough PEP for as long as someone can sign up with one of the HIV clinics to get proper medical attention.

Since we are fortunate enough to have universal health care, there's also the option of going to the few private doctors to get just a few days of supply, which will be costly but still affordable for most. But in all those cases the PEP is still given out by doctors. Not one of us, including our counselors, suggested that we should try self medication.

I do just it as my responsibility though to learn all about those options, i.e. which ER to go to if I need to, say, at 2am in the morning, which doctor to call, etc to protect a neg partner. Other than that I don't see the point of keeping PEP myself or should any negative persons be carrying them "just in case".
Aug 07 Diagnosed
Oct 07 CD4=446(19%) Feb 08 CD4=421(19%)
Jun 08 CD4=325(22%) Jul 08 CD4=301(18%)
Sep 08 CD4=257/VL=75,000 Oct 08 CD4=347(16%)
Dec 08 CD4=270(16%)
Jan 09 CD4=246(13%)/VL=10,000
Feb 09 CD4=233(15%)/VL=13,000
Started meds Sustiva/Epzicom
May 09 CD4=333(24%)/VL=650
Aug 09 CD4=346(24%)/VL=UD
Nov 09 CD4=437(26%)/VL=UD
Feb 10 CD4=471(31%)/VL=UD
June 10 CD4=517 (28%)/VL=UD
Sept 10 CD4=687 (31%)/VL=UD
Jan 11 CD4=557 (30%)/VL=UD
April 11 CD4=569 (32%)/VL=UD
Switched to Epizcom, Reyataz and Norvir
(Interrupted for 2 months with only Epizcom & Reyataz)
July 11 CD=520 (28%)/VL=UD
Oct 11 CD=771 (31%)/VL=UD(<30)
April 12 CD=609 (28%)/VL=UD(<20)
Aug 12 CD=657 (29%)/VL=UD(<20)
Dec 12 CD=532 (31%)/VL=UD(<20)
May 13 CD=567 (31%)/VL=UD(<20)
Jan 14 CD=521 (21%)/VL=UD(<50)

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #28 on: December 01, 2008, 05:48:19 AM »
Getting a 4 days prescription available, as usually prescribed by hospital emergency unit across the EU still sound cost effective and very useful, in case of sexual exposure.

The 4 days treatment allows to get the time to see an ID doc, who will among others things, review the risk, evaluate the side effects.

In the EU, the PEP is prescribed based on recommendations.
Most of the insurances are covering its cost.

It seems that the problem is very different in the richest country of the World.

Finally, we all know at least 4 things:

1) With the PEP, the faster the better (especially in the next few minutes after the exposure), despite the fact that it is prescribed up to 72h after the last risk.
2) An accident (exposure) can occurs.
3) Going to the emergency unit will lead to a 4 days prescription anyway in most case matching the EU recommendations for the PEP
4) Nobody want to infect someone else
5) The costs is NOT the question, when in the balance is either to be HIV free or HIV infected. In the latter scenario, there will be real cost.

Based on these arguments, I still don't see why a PEP is not available for most of us, in case of accident.

Offline Moffie65

  • Member
  • Posts: 1,755
  • Living POZ since 1983
Re: Reducing the HIV infection rate
« Reply #29 on: December 01, 2008, 10:13:08 AM »
5) The costs is NOT the question, when in the balance is either to be HIV free or HIV infected. In the latter scenario, there will be real cost.

Based on these arguments, I still don't see why a PEP is not available for most of us, in case of accident.


John, I am still waiting for you to send me my $27,600, so that I can afford the Health Insurance Policy you so dearly and urgently cling to.  For me, health care is not affordable, and for most here, I suspect that without Employer paid health insurance; they wouldn't be able to afford it either.  Hell John, can you afford nearly $30,000 a year to get Health Care?  I think not, or else you wouldn't have even started this thread.
The Bible contains 6 admonishments to homosexuals,
and 362 to heterosexuals.
This doesn't mean that God doesn't love heterosexuals,
It's just that they need more supervision.
Lynn Lavne

Offline Grasshopper

  • Member
  • Posts: 451
Re: Reducing the HIV infection rate
« Reply #30 on: December 01, 2008, 11:11:57 AM »

Hell John, can you afford nearly $30,000 a year to get Health Care?  I think not, or else you wouldn't have even started this thread.

I understand where John is comming from, however IF his plans are to become reality, healthcare would certainly become prohibitively expensive.

In the Netherlands you pay a fixed percentage of your gross income (6,5%) to the state for healthcare. In addition to that an additional nominal premium of € 1150,= per annum. This is enough to cover all basic care + prescribed medicines. You can upgrade your coverage to cover extra's and supplement payments vary between € 96  and € 450 (per annum).

The sum of my nominal premium and supplements is  € 1600,=  per year , and that covers me to max for EVERYTHING medically related.

So perhaps that's why "some" may talk lightly about having insurance covering expenses.
« Last Edit: December 01, 2008, 11:25:47 AM by Grasshopper »

Offline Miss Philicia

  • Member
  • Posts: 24,082
  • celebrity poster, faker & poser
Re: Reducing the HIV infection rate
« Reply #31 on: December 01, 2008, 11:35:01 AM »
I don't understand the argument of the OP -- if John's idea came to fruition how many people would pop pills needlessly that were sitting idly by at home, before discussing their exposure with a professional?  All you have to do is glance at the "Am I Infected" and the endless, obsessive compulsive crowd that parades through that hell hole daily to get an idea of the numbers of people that would take PEP for a paper cut they got while paying a bill at the local stripper club in Bangkok.  Seriously, this would spiral out of control very quickly cost wise.

I must be missing something because I don't see why this idea would be entertained by anyone.
"I’ve slept with enough men to know that I’m not gay"

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #32 on: December 01, 2008, 11:36:06 AM »
Does it means that in the US, if you go to the hospital emergency unit, the insurance won't cover the cost of the PEP ?

If they will, then what is the issue ? If they do not cover pro-actively the risk, then the risk to get new infection will be necessarly higher, as the sooner the PEP is prescribed, the better it is.

Again, there is the idea to prescribe a PEP just for 3-4 days, the time to see an ID doc.
(In the EU, you are see by an urgentist which just follow treatments guidelines).

So if the cost of a treatment in the US should be of 1000 euro,  a 4 days treatment will cost almost 134 euros.

Better than a life treatment no ?

Note
If the PEP exist, it is supposed to be useful. Starting from there, again, we know that the earlier it is prescribed, the better it is.

Offline RapidRod

  • Member
  • Posts: 15,288
Re: Reducing the HIV infection rate
« Reply #33 on: December 01, 2008, 12:02:47 PM »
By going to an ER the doctor's looks at this risk of exposure and weighs the risk of taking meds, they obtain a medical history, get information on your allergies, they draw a baseline blood test. They don't just write a script.

Offline MarcoPoz

  • Member
  • Posts: 396
Re: Reducing the HIV infection rate
« Reply #34 on: December 01, 2008, 01:01:06 PM »
Maybe a bit of a hijack here--and something that may make the waters even more murky, however I don't think a discussion of PrEP (PRE-exposure prophylaxis) out of line here.

http://www.sciam.com/article.cfm?id=daily-hiv-prevention-pill


Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #35 on: December 01, 2008, 01:10:27 PM »
Hi MarcoPoz,

if only the PrEP could work, it would be a wonderful news.

This study have already shows that among 21 couples willing to conceive (while the man was undetectable and the woman taking TDF at -36h and -12h before attempting to conceive), no mother nor babies have been infected.

It doesn't really demonstrate that infection may be prevented with a once-daily pill, but at least doesn't contradict the idea. A much larger study is on-going to validate this small study.

Offline MarcoPoz

  • Member
  • Posts: 396
Re: Reducing the HIV infection rate
« Reply #36 on: December 01, 2008, 01:18:40 PM »
I know the limitations that PrEP has--at least the limitations that I can undersatand not being a scientist, but I think PEP and PrEP can fall into their respective places along the HIV prevention continuum.  Yes, more data is needed, but I don't off-handedly think ideas like these are non-starters.  Then again, I support sterile syringe distribution, access to any and all HIV prevention tools and or interventions regardless if you are injecting, having unprotected sex, doing one or both while in prison, exchanging sex for money/drugs or anything else...etc etc etc.

Just my uninformed and personal opinion that there could be more lives saved if we deployed ALL possible prevention measures---maybe let the science lead the process and remove politics from the equation.  I know--I'm still a dreamer ;-)

Just my simpl opinion--your mileage may vary. 

Offline jkinatl2

  • Member
  • Posts: 6,007
  • Doo. Dah. Dipp-ity.
Re: Reducing the HIV infection rate
« Reply #37 on: December 01, 2008, 01:23:54 PM »
Quote
Does it means that in the US, if you go to the hospital emergency unit, the insurance won't cover the cost of the PEP ?

The insurance? There are literally thousands of different insurance policies, each with different rules and restrictions. Some will pay for PEP, depending on how the doctor words the request. Many will not. And then there are the issues of deductibles and co-pays. And this, of course, presupposes that the patient has any insurance at all. Many Americans between 18-35 do not have insurance. Actually, to be fair, many Americans of any age do not have insurance.

Perhaps someday, when the cost of certain drugs that carry minimal side effects (such as entry inhibitors) come drastically down, such an idea might be feasible. As it stands today and in the foreseeable future, meds used for PEP are statistically aborted well before the month supply is taken. This has much to do with the reality of taking a strict regimen of pills every day, and often enduring nasty side effects in the process.

Sadly, the reality of HIV and AIDS has changed the impetus to prevent infection, or to suffer during PEP. Death rates have plummeted. Illnesses are becoming less and less common. The spectre of death is no longer looming over the western world.  HIV is a serious illness, but it is no longer the burglar of youth that it was in the 1980s and 1990s. And that, beyond anything else, makes for a far more relaxed attitude towards infection.

It's odd that we still endure the stigma of having HIV, but the fear of getting HIV seems to have diminished greatly.
"Many people, especially in the gay community, turn to oral sex as a safer alternative in the age of AIDS. And with HIV rates rising, people need to remember that oral sex is safer sex. It's a reasonable alternative."

-Kimberly Page-Shafer, PhD, MPH

Welcome Thread

Offline Moffie65

  • Member
  • Posts: 1,755
  • Living POZ since 1983
Re: Reducing the HIV infection rate
« Reply #38 on: December 01, 2008, 03:22:46 PM »
Quote
Does it means that in the US, if you go to the hospital emergency unit, the insurance won't cover the cost of the PEP ?

John if you are a physicist, then you obviously do understand the english language, and I will repeat it again. 

If you go to the emergency room in the United States, where hospitals are run by SHAREHOLDERS, since they are ultimately the owners of these profit making establishments; then YOU are responsible for the bill.  If you have insurance which you must purchase on your own, it might cover PEP, but probably not since having the need for PEP was caused by you. 

Ultimately if you own anything like a home or a car, they can be taken to pay for the emergency room visit, which is now about $5,000 to $7,000 per visit, that is if you don't have to have anything done other than "take these pills".  If you must see a doctor, then it costs much more.  If you don't pay, then your credit is ruined for life. 

Please get it now, this has gone on for so long and you simply don't understand CAPITALISTIC HEALTH CARE. 


Grasshopper, thanks for the valuable explanation of healthcare costs in your neck of the woods, but mind you, your charges for health care are more than one third of my annual salary.  I live on Disability because I cannot work, therefore, I do qualify for our Ryan White program which is for poor people like me and many others in this thread.
The Bible contains 6 admonishments to homosexuals,
and 362 to heterosexuals.
This doesn't mean that God doesn't love heterosexuals,
It's just that they need more supervision.
Lynn Lavne

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #39 on: December 01, 2008, 03:41:36 PM »
Moffie65

it has been understood that YOU or YOUR insurance can't or won't pay the bill.

It doesn't means that YOU or YOUR insurance are right.

It doesn't means that having available a PEP immediately is a wrong idea.
It doesn't means that the only way to consider this question is on its cost perspective.

You are only talking about money,  but not about the different ways this issue can be solved such as getting the PEP sponsored by pharma, AIDS org, donation or whatever, recycling etc.

What you are saying is thatyou and your insurance are thinking:
better to save a PEP, but HAART for a life time.

The arguments I can more easily understand in this debate are those regarding the risk that the PEP might be given abusively.

But then again, an ID doc can still reconsider this PEP.

Another way could be to call a hotline before give the PEP, to get the approval from a doc.
FYI, in the EU, there are medical insurance plan that request you to call a hotline each time you plan have a medical problem, or want to see a doc, etc

We can also assume that the conditions under which the PEP can be given will be well explained to the one desiring to get one available.
« Last Edit: December 01, 2008, 05:41:49 PM by John2038 »

Offline Grasshopper

  • Member
  • Posts: 451
Re: Reducing the HIV infection rate
« Reply #40 on: December 01, 2008, 03:53:10 PM »

Grasshopper, ............. mind you, your charges for health care are more than one third of my annual salary. 

I am very much aware of what my charges for health care totals up to. I thank the powers that be for our system, and hope we never have to crawl & beg like loads of you have to.

I am on (insured)disablity and the amount I get is 80% of my last (working) earnings. Guess how much income taxes are being withheld :........  52% !!!  + 6,5% for health insurance + 3,5% mandatory unemployment insurance.

To embark on the road John2038 is suggesting would be the apocalypse for out healthcare system.
« Last Edit: December 01, 2008, 03:57:06 PM by Grasshopper »

Offline mecch

  • Member
  • Posts: 11,674
  • red pill? or blue pill?
Re: Reducing the HIV infection rate
« Reply #41 on: December 01, 2008, 05:12:28 PM »
The poll is strangely worded and has qualifications I, as well as others in this thread, do not understand...

Treatment naive??? why is this important?? you mean if the poz partner is not on treatment and/or is assumed to have a transmissable viral load?

I agree that a months treatment is not necessary. Just a few days. Maybe just a day or two, depending on where your live. If I had a steady, HIV- partner, i would sure as hell get my ID's ok that my treatment could serve as temporary PEP should my partner need it.  I think the ID should give the OK to take it, however. Otherwise as ANN says, everyone's gonna be popping PEP like viagra before and antioxidants after a night of partying.... 

But if I were travelling to a place that is remote, or too unknown for health care, I'd definately want to have enough pills to give to my partner if, god forbid, there was some ghastly risk, on the road... Cause I can imagine thousands of places where language barriers and health policies might make PEP access questionable and time-consuming...

So, yeah, a few days supply. I'm sure anyones combo is better than none, if there really was a transmission. Until you can get the proper combo.
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline mecch

  • Member
  • Posts: 11,674
  • red pill? or blue pill?
Re: Reducing the HIV infection rate
« Reply #42 on: December 01, 2008, 05:20:05 PM »
PS - I wonder about that idea that HIV negative people get nasty side effects from a months PEP.... Its tangential but someone mentioned it. 

It seems that in 2008, even many HIV+ people don't feel all that much when they first go on HAART....  So a previously HIV neg person who might be infected, going on HAART is probably in most cases not a nasty ride... now, in 2008. 

It seems to be a hold over fear from earlier times... I dunno.  Anyone know?

By the way, related, but tangential - NYC studied the idea of giving PRE EXPOSURE HAART to "high-risk" gay men and the study showed interesting benefits....  (Which means offering guys "likely" to contract HIV with HAART when they are negative, in order to stay negative.....)

http://www.aidsmap.com/en/news/F5A6E530-125B-4C32-B843-9F1122C81776.asp

Wild stuff, epidemiology....
« Last Edit: December 01, 2008, 05:24:56 PM by mecch »
“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline thunter34

  • Member
  • Posts: 7,314
  • His name is Carl.
Re: Reducing the HIV infection rate
« Reply #43 on: December 01, 2008, 07:38:26 PM »
Moffie65

it has been understood that YOU or YOUR insurance can't or won't pay the bill.

It doesn't means that YOU or YOUR insurance are right.

It doesn't means that having available a PEP immediately is a wrong idea.
It doesn't means that the only way to consider this question is on its cost perspective.

Unfortunately, yes....Yes, it does.  And it isn't just the awful old US of A.  It all boils down to cash the whole world over - and this little plan is just NOTfiscally viable...for all the reasons mentioned above and then some.  We're scrambling the world over to get needed meds in the hands of people who ALREADY need them.  Fat chance we're going to be able to hand them out like tic-tacs for everybody to have "just in case". 

If it's simply about ideas based solely on good intentions, let's just stem the infection rates with sunshine and puppies.

If anyone needs me, I'll be over here arguing with the wall.  I have a feeling I'll make more progress.
AIDS isn't for sissies.

Offline jkinatl2

  • Member
  • Posts: 6,007
  • Doo. Dah. Dipp-ity.
Re: Reducing the HIV infection rate
« Reply #44 on: December 01, 2008, 08:07:36 PM »
Quote
It seems that in 2008, even many HIV+ people don't feel all that much when they first go on HAART....  So a previously HIV neg person who might be infected, going on HAART is probably in most cases not a nasty ride... now, in 2008.

Which begs the question, why bother preventing infections at all? If, as John suggests, its merely a matter of getting cheap or free drugs to everybody, then petition or revolt or do whatever one does to convince the global community to make HIV drugs free and accessible to all.

As a manageable disease, whose meds often have negligible side effects, surely its inevitable that most people are going to get it anyhow. If that is, indeed, the message this thread seems to be sending. It's simply a matter of making the meds available, and cheap or free.

"Many people, especially in the gay community, turn to oral sex as a safer alternative in the age of AIDS. And with HIV rates rising, people need to remember that oral sex is safer sex. It's a reasonable alternative."

-Kimberly Page-Shafer, PhD, MPH

Welcome Thread

Offline fearless

  • Member
  • Posts: 2,191
Re: Reducing the HIV infection rate
« Reply #45 on: December 01, 2008, 09:29:53 PM »
So, my summary on where we have got to on all of this is that John is of the view that it is worth spending $millions to arm each and every one of us pozzies with some PEP just in case a condom breaks in order to reduce the HIV infection rate.

How many people are actually infected this way each year? i would guess very few when compared to the numbers infected each year through unprotected sex between individuals of unknown status.

Is there an alternative way to access PEP for ANYONE who supsects they may have been exposed. In many places, yes. Get your arse to emergency or a doc and get some prescribed.

Is John's proposal feasible, cost effective, and will it ultimately achieve his aim of reducing HIV infection rates - NO.
Be forgiving, be grateful, be optimistic

Offline mecch

  • Member
  • Posts: 11,674
  • red pill? or blue pill?
Re: Reducing the HIV infection rate
« Reply #46 on: December 02, 2008, 04:54:02 AM »
Which begs the question, why bother preventing infections at all? If, as John suggests, its merely a matter of getting cheap or free drugs to everybody, then petition or revolt or do whatever one does to convince the global community to make HIV drugs free and accessible to all.

As a manageable disease, whose meds often have negligible side effects, surely its inevitable that most people are going to get it anyhow. If that is, indeed, the message this thread seems to be sending. It's simply a matter of making the meds available, and cheap or free

Oh my, if that is how you interpret my post, I have written it quite wrongly!!  Do you really think I or anyone thinks HIV should not be prevented, just treated?  Come on....

Is is not I who investigated pre-exposure treatment.  I didn't make up this survey.  I was just saying that it would make sense, for example, if you are in a sero-discordant couple, to have PEP on hand. What if this couple were travelling in some exotic land, with inadequate health care, and there was a big "risk act"...

Its a good question, how to pay for UTT (universal testing and treatment) --- but tadvocating for LOTS of access to treatment is not the same as advocating for no prevention.....


“From each, according to his ability; to each, according to his need” 1875 K Marx

Offline John2038

  • Member
  • Posts: 1,529
  • Happiness is a journey, not a destination.
    • HIV Research News (Twitter)
Re: Reducing the HIV infection rate
« Reply #47 on: December 02, 2008, 05:24:46 AM »
Taking a simplistic cost perspective


An estimated 77,400 people were living with HIV in the UK at the end of 2007, of whom more than a quarter (28%) were unaware of their infection.
In 2007, there were at least 7,734 new diagnoses of HIV, contributing to a cumulative total of 97,423 reported by the end of June 2008.

Source


Let say in the UK, 55,000 people knows they are HIV positive in the UK, and that they are responsible of the infection of 62% of these 7,734 new diagnoses of HIV
(ONLY AN ILLUSTRATION)


Let says a PEP cost 1,000 USD, and that all of these 55k infected people got 1 in 2007.
The cost of the PEP for 2007 will have be of:

55k * 1000 = 55 mio USD

Let say the PEP allows to prevent 80% of the infection.
The number of people saved from the infection will have be of

80% 62% 7734= 3,836

A 1 year treatment for these people will have cost:

12 months x 1000 USD/month people x 3,836 people = 46 millions USD

Compared to the 55 mio spent on the PEP, the money saved is at least

46 - 55 = -9 mio USD

Including now the cost of doc, labs, etc the balance is almost 0.

But we have now 3,836 people free from the infection, and so, from others possible infection:
We have reduce the infection rate.
Those 3,836 will have also taken a treatment for life.

Now the real question in this kind of calculation is how much more efficient is a PEP taken in the next minute after the exposure, compared to the average time it is currently taken.
I guess that if taken in the minute after the infection, the success rate will be higher than 80%

NOTE
This calculation is NOT scientific, of course. Just a brief illustration.
I'm aware that many parameters haven't been taken in to account.

CONCLUSION
The PEP at home might still be cost effective, as it might lower the number of new infections, and so, the spread of HIV, and so new cost.

Now is this question a question of money ?
To the question: won't this measure explode the cost ?
The answer is probably no. Or it will cost almost nothing, but allows to save a let say 30 years of HAART to thousand of people per year. More important, it reduce the number of new infection, and the long term costs also.

About the question raised

If we are prescribing PEP, and if we knows that the sooner it is taken, the higher are the chance that it will save someone from the infection ,why don't we just give a 4 days PEP available to everyone who feel to need it ?
« Last Edit: December 02, 2008, 07:16:42 AM by John2038 »

Online BT65

  • Global Moderator
  • Member
  • Posts: 9,943
Re: Reducing the HIV infection rate
« Reply #48 on: December 02, 2008, 07:44:51 AM »
I was just saying that it would make sense, for example, if you are in a sero-discordant couple, to have PEP on hand.

Do you know how many worried wells would be popping those pills every time they got something they "suspected" was HIV? 
I've never killed anyone, but I frequently get satisfaction reading the obituary notices.-Clarence Darrow

Offline RapidRod

  • Member
  • Posts: 15,288
Re: Reducing the HIV infection rate
« Reply #49 on: December 02, 2008, 09:56:25 AM »
I guess no one has ever seen someone go into Anaphylactic shock from a medication reaction.

 


Terms of Membership for these forums
 

© 2014 Smart + Strong. All Rights Reserved.   terms of use and your privacy
Smart + Strong® is a registered trademark of CDM Publishing, LLC.