HIV/AIDS issue paper
INTRODUCTION
Few issues in the twentieth century have created a unanimous concern all around the world, affecting and modifying the lives of people as has HIV and AIDS. The disease has a 100% fatality rate, a long infection period and a high propensity to mutate forming drug resistant strains. Health costs of nations have spiraled as present modalities of treatment remain out of reach for lower socioeconomic strata, which ironically is the most affected part of the population. Social stigma attached to the disease persists even after two decades and having a sexual mode of spread, the disease is still treated as a curse owing to one’s perversion. The HIV virus was never bereft of controversy and will rarely be.
HISTORY OF HIV/AIDS
The disease was first identified in March, 2001 when around this date a number of cases of a rare lung disorder, Pneumocystis Carnii pneumonia (PCP) were reported in both California and New York (Avert.org, 2007). There were also cases of Kaposi’s sarcoma (KS) reported in gay men in New York although the disease till then was one of old age. By April of the same year, CDC had noticed this increase and on June 5, 1981 published a report about the occurrence, without identifiable cause of PCP in 5 men who were homosexuals in Los Angeles (MMWR Weekly, 1981). This is touted as the “beginning” of AIDS.
When first identified AIDS was known to affect only gay men and so came to be known as “Gay Related Immune Disorder” (Brennan, R.O. and Durack, D.T., 1981). In fact in July, 1981 Dr Curran of CDC went ahead and stated that, “there was no apparent danger to non-homosexuals from the contagion….. no cases have been reported to date outside the homosexual community or women” (Altman, L.K, 1981). Just five months later in December, 1981 first cases of PCP were reported outside the homosexual community in intravenous drug users (IDU). With the occurrence of disease in non-homosexuals the name of “Gay Related Immune Disorder” became redundant. The acronym AIDS was suggested at a meeting in July and the CDC properly defined it in September, 1982 (Avert.org, 2007).
Early years were rife with rumors about AIDS, originating out of lack of understanding about the disease. Even the mode of transmission was debatable. In March, 1983 CDC defined people at high risk and included homosexuals, heterosexuals with multiple partners, hemophiliacs, IV drug users, Haitian immigrants and sexual partners of a person with AIDS or at risk of AIDS (MMWR Weekly, 1983). The inclusion of Haitians was just the first event of stigmatization. Social Security administration was accused of interviewing patients on phone rather than face to face while gays faced social discrimination owing to the disease’s dubious mode of spread (Enlow, R., 1984). The causative agent was identified by French in May 1983 and named lymphadenopathy- associated virus (LAV) (Connor S. and Kingman S., 1988, p.35), however the Americans identified a year later and named it as HTLV-III (Willis C., 1986). The confusion was resolved in May, 1986 when a new name, HIV (human immunodeficiency virus) was adopted.( Coffin J. et al, 1986).
Nevertheless, it was not until six years from the first reported case of AIDS that any significant development was made on the front of treatment. It was in September, 1986 that the first clinical trials for Azidothymidine (AZT) as a candidate for AIDS drug were started (Fischl M. A. et al, 1987). In March, 1987 it was approved by FDA as the first anti-retroviral drug for treatment of AIDS (‘Approval of AZT', 1987). However, by January, 1993 first strains of AZT resistant strains of HIV were reported. By the middle of 1996 a multiple drug treatment strategy named as HAART therapy came into being and additions to the regimen are still being made as newer drugs and substitutes are identified (‘History of HIV/AIDS’, 2007).
POPULATION & GEOGRAPHY OF HIV/AIDS
The HIV epidemic is disproportionate in its affect, severely impacting some regions and populations than others. Sub-Saharan Africa will account for 22.5 million cases living with HIV (69% of the total cases worldwide) by the end of year 2007, 61% of which will be females. (‘2007 AIDS Epidemic Update’, UNAIDS, 2007) Ironically, in USA 77% of a total of 437,982 people living with HIV in 2005 were males (‘Cases of HIV infection and AIDS in the United States and Dependent Areas-2005’ (AIDSUSDA), CDC, 2007). The three states of California, New York and Florida have accounted for 43% of cumulative total number of AIDS/HIV cases reported in USA till the end of year 2005 (CDC Wonder Database, 2007). A total of 36% of a total of 40,608 new cases of HIV reported in 2005, were from these three states. Missouri reported 386 new cases of HIV in 2005 (AIDSUSDA, 2007).
During the 1980s, there were rapid increases in the number of AIDS cases and deaths of people with AIDS. Cases peaked with the 1993 expansion of the case definition to a high of 104,713 cases in 1993, and then declined. With the widespread use of HAART, drops in both cases and deaths began in 1996 (Surveillance Data for 1981-2002, CDC WONDER On-line Database, December 2005(CDC)). The rate of decrease in AIDS diagnoses slowed in the late 1990s reaching a plateau, the number of diagnoses increased slightly each year from 2000 to 2002, reaching 43,950 in 2002 and fell to 40,608 in 2005. The number of deaths among people with AIDS has remained relatively stable since 1999; there were an estimated 17,011 deaths in 2005 (CDC, 2007).
During the 1990s, the epidemic showed a growing proportion of AIDS cases among black people and Hispanics and in women, and toward a decreasing proportion in MSM, although this group still remains the largest single exposure group. Black people and Hispanics have been disproportionately affected since the early years of the epidemic. In absolute numbers, blacks have outnumbered whites in new AIDS diagnoses and deaths since 1996, and in the number of people living with AIDS since 1998. (Surveillance Data for 1981-2002)
From 2000 to 2005, the estimated number of new AIDS cases increased in all racial/ethnic groups. Over the same period, the estimated number of new AIDS diagnoses increased by 17% among women and by 16% among men. The number of new cases probably due to heterosexual contact grew by 42%; cases probably due to sex between men grew by 24%; and the number among injecting drug users fell by less than 1% (AIDSUSDA, 2007; CDC, 2007)
During 2005 there were an estimated 58 pediatric AIDS diagnoses, compared to 187 in 1999 and 799 in 1994. The decline in pediatric AIDS incidence is associated with more HIV testing of pregnant women and the use of Zidovudine (AZT) by HIV-infected pregnant women and their newborn infants (AIDSUSDA, 2007; Surveillance Data for 1981-2002).
The age group 35-44 years accounted for 38% of all AIDS cases diagnosed in 2005. At the end of 2005, the CDC estimates that there were 433,760 people living with HIV/AIDS in the 37 areas that have a history of confidential name-based HIV reporting, based on reported diagnoses and deaths (AIDSUSDA, 2007). However, the total number of people living in the USA with HIV/AIDS is thought to be between 1,039,000 and 1,185,000. The discrepancy between these figures is due to several factors including (CDC, 2007):
• Confidential name-based reporting of HIV diagnoses has not yet been implemented in all states. (33 states are included)
• Anonymous tests, including home tests, are excluded from case reports
• One in every four people living with HIV has not even had their infection diagnosed, let alone reported.
Within Missouri State the racial disparity is less pronounced as whites accounted for 53.8% cases, but gender differences are wider as 83.8% cases were in males (new cases in 2005). Most of these cases occur in urban settings- Saint Louis city, Saint Louis County and Kansas City accounting for 69% of 415 cases of HIV diagnosed in 2005. MSM were the most affected with 72.9% cases and another 2.9% in MSM using IV drugs while heterosexual contact accounting for 21%. It’s heartening to know that only 12 cases were due to IV drug use and none due to Blood transfusion (MICA, 2007).
PRESENT CHALLENGES AND PROBLEMS
ASSESSMENT
The CDC has a HIV/AIDS surveillance program which collects data from the 37 areas (33 states and 4 U.S. dependent areas) that have had confidential name-based HIV infection reporting since 2001.The method of applying the serological testing algorithm for recent HIV seroconversion (STARHS) to the serum specimens from which the diagnosis of HIV infection was made helps in differentiating between recent infection and infections occurring some time in the past.(CDC, 2007) However, recent estimates using a new diagnosis technique may raise the numbers upwards by 50% from the previous incidence rates for 2001-2005 (Harris, G., 2007) .
Recently The United Nations’ UNAIDS agency reported that it had overestimated Global AIDS numbers and that improved survey methods used have brought down the estimated figure of people living with HIV/AIDS to 33.2 million from the previous 39.5 million (‘U.N. Overestimated Global AIDS Numbers’, November 20, 2007).
POLICY CHALLENGES
IV drug use is a well known route of HIV transmission, yet injection drug use (IDU) contributes to the epidemic’s spread far beyond the circle of those who inject. IDU behavior, having sex with an IDU or being born of mother who contracted HIV from IDU behavior, all have accounted for around 1/3rd of all cases till date. Although Drug abuse treatment program is the ideal way for HIV prevention, the present health system does not have the capacity to provide it. In this scenario, using sterile syringes only once remains the safest and most effective way of preventing transmission. However sterile syringe exchange programs and laws authorizing needle exchange are present in only 28 states as of 2005 (Update: Syringe Exchange Programs-United States-2005, MMWR, 2007).
The approach to HIV/AIDS prevention strategy cannot be more ironic than in the case of educational programs. In spite HIV being classified as an STD by most, only 35 states + DC have mandated STI/HIV education in schools. Most states, including some that do not mandate the instruction itself, also place requirements on how abstinence or contraception should be handled when included in a school district’s curriculum. This guidance is heavily weighted toward stressing abstinence; in contrast, while many states allow or require that contraception be covered, none requires that it be stressed. Further affecting whether students receive instruction on sex or STIs/HIV are parental consent requirements or the more frequent “opt-out” clauses, which allow parents to remove students from instruction the parents find objectionable (Sex and STD/HIV Education, State Policies in Brief, 2005).
Around 20% of people living with HIV/AIDS are uninsured. Some of them are eligible for the federally sponsored schemes but are not covered under any insurance scheme owing to the long administrative delays before a person can be enrolled in either of the scheme. The implementation of the new citizenship and identity documentation requirement set forth in the Deficit Reduction Act, 2005 has further increased administrative delays in processing applications and renewals resulting in postponement and denial of coverage often for individuals otherwise eligible for the program (The Centers for Medicare and Medicaid Services (CMS), 2004; Committee on Public Financing and Delivery of HIV care (CPFDH), 2005).
ASSURANCE
Knowledge about the disease and advancement in treatment in the form of HAART therapy has changed the perception of HIV/AIDS as an acutely fatal infectious disease to a chronic one. The near constant incidence rate and declining mortality rate of HIV further indicate that more people are living with HIV/AIDS. Today Americans with HIV can expect to live 24 years as against a survival rate of 10 years in the 90s (Mike Stobbe, 2006). Nevertheless, this comes at a cost of $600,000 for health care over those two decades. In spite of federal spending of $8.7 billion dollars on health care for HIV/AIDS (CMS, 2004), spiraling costs have left big lacunae in the present health coverage which will increase as the number of people living with HIV/AIDS keeps on rising.
In 1980s HIV was perceived to be affecting only MSM and even after two decades of the disease, the picture hasn’t changed much. After showing a decline in the 1990s, there has been a recent rise in the number of new cases reported for MSM. In 2002 they accounted for 71% of all infections even though only 5% to 7% of adult males identify themselves as MSM. It is unclear whether the recent rise in infection rates in MSM is due to more testing or is it due to a rise in infection (Surveillance Data for 1981-2002).
Populations of minority races and ethnicities continue to be disproportionately affected by the HIV epidemic. African Americans are the hardest hit race. According to the 2000 census, blacks make up approximately 13% of the US population. However, in 2005, blacks accounted for 49% of new HIV/AIDS diagnoses in the USA (Surveillance Data for 1981-2002; AIDSUSDA, 2007). The reasons are not directly related to race or ethnicity, but rather to some of the barriers faced by many African Americans. These barriers can include poverty, sexually transmitted diseases, and stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who do things that might put them at risk for HIV).
The HIV/AIDS epidemic is a serious threat to the Hispanic/Latino community. Although they made up only about 13% of the population of USA, they accounted for 16% (155,179) of the estimated 952,629 AIDS cases diagnosed since the beginning of the epidemic (Surveillance Data for 1981-2002). In addition to being a population seriously affected by HIV, Hispanics/Latinos continue to face challenges in accessing health care, prevention services, and HIV treatment. The migration patterns, social structure, language barriers, and lack of access to regular health care among transient Hispanic/Latino immigrants amplify the problem.
PUBLIC HEALTH SYSTEM RESPONSE
FEDERAL LEVEL
The three basic tenets of public health are met by the approach of federal government towards the HIV/AIDS health issue. The CDC HIV/AIDS surveillance program collects data for both HIV infections and AIDS rates. Surveillance data on HIV infections provide a more complete picture of the epidemic and the need for prevention and care services than does the picture provided by AIDS data alone. The National HIV Behavioral Surveillance (NHBS) System, CDC collects risk behavior data from three populations at high risk for HIV infection: men who have sex with men (MSM), injection-drug users, and heterosexual adults in areas in which HIV is prevalent.
The federal programs that provide care to people living with HIV/AIDS operate through two financing mechanisms: mandatory annual spending and discretionary annual funding for specific services. These financing mechanisms include federal spending on Medicare, Medicaid, Ryan White CARE act, SAMHSA funding, HOPSA funding, CDC HIV/AIDS funding and OMH funding. It spent $18 billion in fiscal year 2004 for research, prevention, care and assistance, and international programs and activities. In the year 2002, $14.7 billion were spent of which 51.7% ($7.6 billion) were spent mandatory services for people with HIV/AIDS (CPFDH, 2005).
A large proportion of people with HIV/AIDS are low-income or below low-income and disabled; thus, Medicaid forms an important source of insurance coverage accounting for 43% of them. The federal government spent $4.2 billion on Medicaid related AIDS services while $3.5 billion was pooled in by individual states. Overall the program covers 44 percent of people living with HIV, 55% of people living with AIDS and 90% of children with AIDS. The federal guidelines require all states to provide mandatory services which include hospital, physician, lab and X-ray, home health, and nursing services (CPFDH, 2005).
The Federally sponsored Medicare covers 6% of the population with HIV/AIDS. It includes services for the elderly and those who are permanently disabled. Through its three ‘Parts’, Medicare covers for hospital care, physician, hospice, nursing, home health, medical equipment & supplies, and prescription drugs. The Ryan White CARE act addresses the gaps in financing care for HIV/AIDS and to provide financial support to cities that bear disproportionate burden of HIV/AIDS cases (CPFDH, 2005; CMS, 2004).
The federal Government has tried to integrate services for high risk groups through SAMHSA and OMH funding. Substance Abuse and Mental Health Services Administration (SAMHSA) works on decreasing transmission of HIV in IV drug users by providing mental health and substance abuse prevention and treatment services.
CDC has developed effective intervention strategies for high risk groups like Peers Reaching Out and Modeling Intervention Strategies (PROMISE) and Many Men, Many Voices for MSM. It works in collaboration with states and counties to develop these HIV/AIDS programs tailored to a region/ population.
MISSOURI STATE LEVEL
The Medicaid works on a sharing basis; the federal government provides matching funds for state funds. The state of Missouri was matched $4 million in federal grant for $2.3 billion for all services included in Medicare in the year 2004. States are allowed broad flexibility in designing their Medicaid programs, and consequently there is significant variation in eligibility, benefits, provider payments, and other aspects of the program at state level. Thus, a person may be eligible in one state may not be in the other owing to wide variation in policies. Most adults with HIV/AIDS who qualify for Medicaid do so because they meet the disability and income criteria of the federal Supplemental Security Income program. Some adults may qualify for Medicaid through a state’s medically needy program. For those who are not covered under Medicaid and Medicare the Governor’s Plan for Uninsured provides coverage (CPFDH, 2005).
With limited funding dedicated to HIV prevention efforts, CDC requires states to prioritize prevention dollars to those populations that are most epidemiologically at risk for infection. Given Missouri’s rates, the priority populations are White MSM, African American MSM and African American Women. IV drug users and Hispanics do not account for a significant proportion of HIV/AIDS patients in Missouri; nevertheless efforts are being made to prevent any rise among them (Sandra Hentges, personal communication, November 29, 2007). Missouri State has a policy in place which authorizes needle exchange program under the Department of Health. Issues of privacy and confidentiality have been addressed by closing all identifying records under this program ("SB 0166, Establish a Needle Exchange Program within the Department of Health," 2003).
“The MSM population has been the focus of over 60% of our prevention efforts for a number of years” says Sandra Hentges (November 29, 2007). Through community-based organizations as well as local health agencies, intensive, science-based interventions are provided to this population that promotes behavior change. However, with that said, this population is getting younger and younger and many of the youngest MSM have not had to live through the traumatic years of watching their friends and lovers die from HIV disease. It has now become a chronic health condition and people with HIV are living longer productive lives so the risk of contracting this disease doesn’t seem to be motivating the younger generation to protect themselves. In addition, they are tired of hearing the same messages in the same way about HIV. The state is currently working with CDC to provide interventions that are new and innovative to spark the attention of a generation who isn’t worried about contracting this still deadly virus (Sandra H, 2007).
Evidence based public health interventions have added a new dimension to the present public health programs. Of note here is the L.I.F.E. program which is striving to combine conventional measures of prevention and treatment with psychological and social aspects ("Shanti L.I.F.E. Program,").
LOCAL
The Saint Louis County and City have a combined METRO program for HIV, STD and Hepatitis. The program receives funding from the state and also through Title funds under the Ryan White CARE act as the city is included in EML list. The program focuses on increasing HIV testing rates amongst high risk groups besides integrating health services for STDs and Hepatitis with HIV care. Given Saint Louis’ case rates, African Americans and MSM are the most affected population. HIV testing services are offered directly by the department and indirectly through private organizations. IV drug users don’t form a significant population in Saint Louis HIV region; however efforts are being made to restrict the numbers before they become a problem (Wrigley D., Personal Communication, November 27, 2007).
One of the most significant problems being faced at local level is case management. At present the transition from HIV detection to treatment program takes anywhere between 2 weeks to 2 months. Approximately 50% of cases detected on HIV screening tests are lost before they can be started on medication by attaching them to a curative service. To address this particular issue the city is going to launch a new program from January 1, 2008 by having a provision of temporary case managers. They will follow the patient right from detection to the point where the person is either inducted in a treatment program or attached to a permanent case manager (Wrigley, 2007)
Saint Louis County’s STD department tries to integrate services for both STDs and
HIV. They offer voluntary HIV testing. An estimated 25%-30% of syphilis cases from this year were co-infected with HIV. This proves to be a very challenging factor due to the compromised immune system of these patients and the lack of obvious symptoms for this infection. Many of these patients find out about their syphilis infection because their providers are running routine screening test during their exam. Whenever a patient is diagnosed with a secondary infection, partner notification is offered for all infections as well as information on the patient’s rights and responsibilities (Whittington R., Personal Communication, November 29, 2007).
PRIVATE
Not for profit organizations like Saint Louis Effort for AIDS, The AIDS Foundation of Saint Louis and Red Cross work as an important link between the government and HIV/AIDS patients. These community organizations have expertise in delivery of health services like HIV testing and are more favored by at-risk individuals owing to privacy and confidentiality issues, and stigma attached with government services. Thus, Saint Louis Metro AIDS/HIV project works in close conjunction with these organizations and outsource its work to them by giving grants.
These organizations offer HIV testing at the center and also run mobile HIV testing vans. These vans offer door to door testing and confidentiality is maintained by two separate cabins for testing (Cheryl R. Oliver, Personal Communication, November 28, 2007). If an MSM is diagnosed with HIV, his contacts are offered HIV testing and counseling about their rights at any place of their choice. They also offer case management and work with the city health department in ensuring that a HIV diseased individual is covered under some form of insurance (Cheryl, 2007).
RECOMMENDATIONS
The ‘Committee on Public Financing and Delivery of HIV Care’, acknowledged that the present HIV/AIDS care system requires fundamental redesign, not just minor corrections. It implies that allocating more funds to the present system will not necessarily achieve better results, what is required is a change in the design of the delivery system and a redesigned financing system (CPFDH, 2005).
The present Medicare guidelines are designed such that if a low income person cannot avail funds if he is not disabled, although the same funds could have prevented a disability. This policy of treating a disease and not preventing it is pervasive throughout the public health system and is flawed in its ideology itself.
HAART therapy has worked in terms of increasing the survival time and quality of life of HIV diseased. However, the high cost of this treatment regimen has been blamed for funding deficits. What is required are ways of decreasing the cost of drugs and treatments by measures to discontinue current patents on these life saving drugs. A federal ceiling of drug prices used in some other federal programs can also work towards lowering the cost.
Uniformity in policy amongst all states is required. The present laws on needle sharing programs and Sex education programs in schools are two areas of prime concern. It has to be realized that these are practical options to decrease HIV/AIDS rates in the present scenario. Also stress needs to be placed on contraception than abstinence in states which already have laws.
At local level, more preventive measures have to be taken. HIV testing is far-reaching in its scope, yet it cannot be classified as a preventive tool as it does not affect risky behavior among individuals. More educational services and community interventions have to be implemented.
REFERENCES
‘2007 AIDS Epidemic Update’, UNAIDS. Retrieved November, 2007, from http://www.unaids.org/en/HIV_data/2007EpiUpdate/default.asp
AIDS, S. L. E. f. (2005). About HIV/AIDS. Retrieved November,25, 2007, from http://www.stlefa.org/About_HIV_AIDS.php
Altman, L.K, (1981) 'Rare cancer seen in 41 Homosexuals', the New York Times, July 3
‘Approval of AZT', News release, March 20, 1987, Public Health Service, http://fda.gov/bbs/topics/NEWS/NEW00217.html
Avert.org. (2007, June 26,2007). The history of AIDS. 1981-1986. Retrieved November, 2007, from http://www.avert.org/his81_86.htm
Avert.org. (2007, June 26,2007). The history of AIDS, 1993 - 1997. Retrieved November, 2007, from http://www.avert.org/his93_97.htm
Avert.org. (2007). The History of AIDS. 1987-1992. Retrieved November, 2007, from http://www.avert.org/his87_92.htm
Avert.org. (2007). The history of AIDS. 1998-2002. Retrieved November, 2007, from http://www.avert.org/his98_99.htm
Brennan, R.O. and Durack, D.T., (1981) 'Gay compromise syndrome', the Lancet, 2 1338-1339:
Burris, S. et al., "The Legality of Selling or Giving Syringes to Injection Drug Users", Journal of the American Pharmaceutical Association, 42(6), Supp.2: S13-18, 2002
Connor S. and Kingman S. (1988), 'The search for the virus, the scientific discovery of AIDS and the quest for a cure' Penguin Books, p.35
Coffin J., Haase A., Levy J.A., Montagnier L., Oroszlan S., Teich N., Temin H., Toyoshima K., Varmus H., Vogt P., Weiss R.A., (1986) 'What to call the AIDS virus?', (Letter), Nature, 321:10
Centers for Disease Control and Prevention. Update: Syringe Exchange Programs-United States, 2005. MMWR 2007; 56(44): 1164-1167. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a4.htm , accessed November 2007.
Committee on Public Financing and Delivery of HIV care, B. o. H. P. a. D. P., Institute of Medicine. (2005). Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White.: The National Academic Press, Washington D.C.
Daniel McGinn, 'MSNBC: AIDS at 20: Anatomy of a Plague; an Oral History', Newsweek Web Exclusive
Darrow, W.W (1991) 'AIDS: Socioepidemiologic responses to an epidemic', in 'AIDS and the social sciences, common threads', edited by Ulack, R. and Skinner, W.F., 1991,The University Press of Kentucky
Enlow, R.(1984), 'Special session', in Acquired Immune Deficiency Syndrome, Annals of the New York Academy of Science, Volume 437, edited by Selikoff I.J, Teirstein A.S. and Hirschman S.Z., The New York Academy of Sciences, p.291
Fischl M. A., Richman D. D., Grieco M. H., Gottlieb M. S., Volberding P. A., Laskin O. L., Leedom J. M., Groopman J. E., Mildvan D., Schooley R. T., et al. (1987)''The Efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex, a double-blind, placebo-controlled trial', The New England Journal Of Medicine, Vol. 317: 185-191, Number 4
Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference; June 2005; Atlanta
HARRIS, G. (December 2, 2007). Figures on H.I.V. Rate Expected to Rise. New York Times. Retrieved December 2, 2007, from http://www.nytimes.com/2007/12/02/health/02aids.html?th&emc=th
Mann J. M (1989) 'AIDS: A worldwide pandemic', in Current topics in AIDS, volume 2, edited by Gottlieb M.S., Jeffries D.J., Mildvan D., Pinching, A.J., Quinn T.C., John Wiley & Sons
Mike Stobbe Associated Press "Americans with HIV can expect to live 24 years, study says". Deseret News (Salt Lake City). Nov 12, 2006. FindArticles.com. 05 Dec. 2007.
MMWR Weekly (1982) 'Epidemiologic Notes and Reports Possible Transfusion-Associated Acquired Immune Deficiency Syndrome, AIDS- California', December 10, 31 (48); 652-4
MMWR Weekly (1981) 'Pneumocystis Pneumonia- Los Angeles', June 5, 30 (21); 1-3
MMWR Weekly (1983) 'Current trends prevention of Acquired Immune Deficiency Syndrome (AIDS): Report of Inter-Agency Recommendations', March 4, 32(8);101-3
Personal Communication, Hentges S., Department of Health and Human Services, Missouri, November 29, 2007.
Personal Communication, Whittington R., Disease Intervention Supervisor, Saint Louis County Department of Health, November 29, 2007.
Personal Communication, Wrigley D., Metro Center for HIV,STD and Hepatitis, St. Louis City Health Department, November 27,2007.
Personal Communication, Cheryl R. Oliver, Executive Director, Saint Louis Effort for AIDS, November 28, 2007.
SB 0166, Establish a Needle Exchange Program within the Department of Health, (2003).
Sex and STD/HIV Education, State Policies in Brief, Guttmacher Institute, http://www.guttmacher.org/statecenter/spibs/spib_SE.pdf, accessed November-2007.
Shanti L.I.F.E. Program. Retrieved November, 2007, from http://www.shanti.org/life/index.html
Substance Abuse & Mental Health Services Administration, U. S. D. o. H. a. H. S. (FY 2006 and FY 2007). SAMHSA Action Plan: HIV/AIDS & Hepatitis. Retrieved. from http://www.samhsa.gov/Matrix/SAP_HIV.aspx.
The Centers for Medicare and Medicaid Services (CMS) Health Care Financing Review Medicare and Medicaid Statistical Supplement, 2004, http://www.cms.hhs.gov/MedicaidBudgetExpendSystem/02_CMS64.asp#TopOfPage accessed December 5, 2007.
Total HIV/AIDS Federal Funding, FY2006. Retrieved December,4, 2007, from http://statehealthfacts.org/comparetable.jsp?ind=528&cat=11&yr=29&typ=4&o=d&sort=840
U.N. Overestimated Global AIDS Numbers. (November 20, 2007). Retrieved November, 30, 2007, from http://www.poz.com/articles/un_numbers_overestimate_1_13536.shtml
US Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for HIV, STD and TB Prevention (NCHSTP), AIDS Public Information Data Set (APIDS) US Surveillance Data for 1981-2002, CDC WONDER On-line Database, December 2005. Accessed at http://wonder.cdc.gov/aids-v2002.html on Dec 5, 2007 12:54:16 AM.
US Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for HIV, STD and TB Prevention (NCHSTP), Cases of HIV infection and AIDS in the United States and Dependent Areas. Accessed at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/default.htm on Dec 5, 2007 11:51:56 AM.
' Willis C. (1986) 'A different kind of AIDS fight', Time Magazine, May 12
Few issues in the twentieth century have created a unanimous concern all around the world, affecting and modifying the lives of people as has HIV and AIDS. The disease has a 100% fatality rate, a long infection period and a high propensity to mutate forming drug resistant strains. Health costs of nations have spiraled as present modalities of treatment remain out of reach for lower socioeconomic strata, which ironically is the most affected part of the population. Social stigma attached to the disease persists even after two decades and having a sexual mode of spread, the disease is still treated as a curse owing to one’s perversion. The HIV virus was never bereft of controversy and will rarely be.
HISTORY OF HIV/AIDS
The disease was first identified in March, 2001 when around this date a number of cases of a rare lung disorder, Pneumocystis Carnii pneumonia (PCP) were reported in both California and New York (Avert.org, 2007). There were also cases of Kaposi’s sarcoma (KS) reported in gay men in New York although the disease till then was one of old age. By April of the same year, CDC had noticed this increase and on June 5, 1981 published a report about the occurrence, without identifiable cause of PCP in 5 men who were homosexuals in Los Angeles (MMWR Weekly, 1981). This is touted as the “beginning” of AIDS.
When first identified AIDS was known to affect only gay men and so came to be known as “Gay Related Immune Disorder” (Brennan, R.O. and Durack, D.T., 1981). In fact in July, 1981 Dr Curran of CDC went ahead and stated that, “there was no apparent danger to non-homosexuals from the contagion….. no cases have been reported to date outside the homosexual community or women” (Altman, L.K, 1981). Just five months later in December, 1981 first cases of PCP were reported outside the homosexual community in intravenous drug users (IDU). With the occurrence of disease in non-homosexuals the name of “Gay Related Immune Disorder” became redundant. The acronym AIDS was suggested at a meeting in July and the CDC properly defined it in September, 1982 (Avert.org, 2007).
Early years were rife with rumors about AIDS, originating out of lack of understanding about the disease. Even the mode of transmission was debatable. In March, 1983 CDC defined people at high risk and included homosexuals, heterosexuals with multiple partners, hemophiliacs, IV drug users, Haitian immigrants and sexual partners of a person with AIDS or at risk of AIDS (MMWR Weekly, 1983). The inclusion of Haitians was just the first event of stigmatization. Social Security administration was accused of interviewing patients on phone rather than face to face while gays faced social discrimination owing to the disease’s dubious mode of spread (Enlow, R., 1984). The causative agent was identified by French in May 1983 and named lymphadenopathy- associated virus (LAV) (Connor S. and Kingman S., 1988, p.35), however the Americans identified a year later and named it as HTLV-III (Willis C., 1986). The confusion was resolved in May, 1986 when a new name, HIV (human immunodeficiency virus) was adopted.( Coffin J. et al, 1986).
Nevertheless, it was not until six years from the first reported case of AIDS that any significant development was made on the front of treatment. It was in September, 1986 that the first clinical trials for Azidothymidine (AZT) as a candidate for AIDS drug were started (Fischl M. A. et al, 1987). In March, 1987 it was approved by FDA as the first anti-retroviral drug for treatment of AIDS (‘Approval of AZT', 1987). However, by January, 1993 first strains of AZT resistant strains of HIV were reported. By the middle of 1996 a multiple drug treatment strategy named as HAART therapy came into being and additions to the regimen are still being made as newer drugs and substitutes are identified (‘History of HIV/AIDS’, 2007).
POPULATION & GEOGRAPHY OF HIV/AIDS
The HIV epidemic is disproportionate in its affect, severely impacting some regions and populations than others. Sub-Saharan Africa will account for 22.5 million cases living with HIV (69% of the total cases worldwide) by the end of year 2007, 61% of which will be females. (‘2007 AIDS Epidemic Update’, UNAIDS, 2007) Ironically, in USA 77% of a total of 437,982 people living with HIV in 2005 were males (‘Cases of HIV infection and AIDS in the United States and Dependent Areas-2005’ (AIDSUSDA), CDC, 2007). The three states of California, New York and Florida have accounted for 43% of cumulative total number of AIDS/HIV cases reported in USA till the end of year 2005 (CDC Wonder Database, 2007). A total of 36% of a total of 40,608 new cases of HIV reported in 2005, were from these three states. Missouri reported 386 new cases of HIV in 2005 (AIDSUSDA, 2007).
During the 1980s, there were rapid increases in the number of AIDS cases and deaths of people with AIDS. Cases peaked with the 1993 expansion of the case definition to a high of 104,713 cases in 1993, and then declined. With the widespread use of HAART, drops in both cases and deaths began in 1996 (Surveillance Data for 1981-2002, CDC WONDER On-line Database, December 2005(CDC)). The rate of decrease in AIDS diagnoses slowed in the late 1990s reaching a plateau, the number of diagnoses increased slightly each year from 2000 to 2002, reaching 43,950 in 2002 and fell to 40,608 in 2005. The number of deaths among people with AIDS has remained relatively stable since 1999; there were an estimated 17,011 deaths in 2005 (CDC, 2007).
During the 1990s, the epidemic showed a growing proportion of AIDS cases among black people and Hispanics and in women, and toward a decreasing proportion in MSM, although this group still remains the largest single exposure group. Black people and Hispanics have been disproportionately affected since the early years of the epidemic. In absolute numbers, blacks have outnumbered whites in new AIDS diagnoses and deaths since 1996, and in the number of people living with AIDS since 1998. (Surveillance Data for 1981-2002)
From 2000 to 2005, the estimated number of new AIDS cases increased in all racial/ethnic groups. Over the same period, the estimated number of new AIDS diagnoses increased by 17% among women and by 16% among men. The number of new cases probably due to heterosexual contact grew by 42%; cases probably due to sex between men grew by 24%; and the number among injecting drug users fell by less than 1% (AIDSUSDA, 2007; CDC, 2007)
During 2005 there were an estimated 58 pediatric AIDS diagnoses, compared to 187 in 1999 and 799 in 1994. The decline in pediatric AIDS incidence is associated with more HIV testing of pregnant women and the use of Zidovudine (AZT) by HIV-infected pregnant women and their newborn infants (AIDSUSDA, 2007; Surveillance Data for 1981-2002).
The age group 35-44 years accounted for 38% of all AIDS cases diagnosed in 2005. At the end of 2005, the CDC estimates that there were 433,760 people living with HIV/AIDS in the 37 areas that have a history of confidential name-based HIV reporting, based on reported diagnoses and deaths (AIDSUSDA, 2007). However, the total number of people living in the USA with HIV/AIDS is thought to be between 1,039,000 and 1,185,000. The discrepancy between these figures is due to several factors including (CDC, 2007):
• Confidential name-based reporting of HIV diagnoses has not yet been implemented in all states. (33 states are included)
• Anonymous tests, including home tests, are excluded from case reports
• One in every four people living with HIV has not even had their infection diagnosed, let alone reported.
Within Missouri State the racial disparity is less pronounced as whites accounted for 53.8% cases, but gender differences are wider as 83.8% cases were in males (new cases in 2005). Most of these cases occur in urban settings- Saint Louis city, Saint Louis County and Kansas City accounting for 69% of 415 cases of HIV diagnosed in 2005. MSM were the most affected with 72.9% cases and another 2.9% in MSM using IV drugs while heterosexual contact accounting for 21%. It’s heartening to know that only 12 cases were due to IV drug use and none due to Blood transfusion (MICA, 2007).
PRESENT CHALLENGES AND PROBLEMS
ASSESSMENT
The CDC has a HIV/AIDS surveillance program which collects data from the 37 areas (33 states and 4 U.S. dependent areas) that have had confidential name-based HIV infection reporting since 2001.The method of applying the serological testing algorithm for recent HIV seroconversion (STARHS) to the serum specimens from which the diagnosis of HIV infection was made helps in differentiating between recent infection and infections occurring some time in the past.(CDC, 2007) However, recent estimates using a new diagnosis technique may raise the numbers upwards by 50% from the previous incidence rates for 2001-2005 (Harris, G., 2007) .
Recently The United Nations’ UNAIDS agency reported that it had overestimated Global AIDS numbers and that improved survey methods used have brought down the estimated figure of people living with HIV/AIDS to 33.2 million from the previous 39.5 million (‘U.N. Overestimated Global AIDS Numbers’, November 20, 2007).
POLICY CHALLENGES
IV drug use is a well known route of HIV transmission, yet injection drug use (IDU) contributes to the epidemic’s spread far beyond the circle of those who inject. IDU behavior, having sex with an IDU or being born of mother who contracted HIV from IDU behavior, all have accounted for around 1/3rd of all cases till date. Although Drug abuse treatment program is the ideal way for HIV prevention, the present health system does not have the capacity to provide it. In this scenario, using sterile syringes only once remains the safest and most effective way of preventing transmission. However sterile syringe exchange programs and laws authorizing needle exchange are present in only 28 states as of 2005 (Update: Syringe Exchange Programs-United States-2005, MMWR, 2007).
The approach to HIV/AIDS prevention strategy cannot be more ironic than in the case of educational programs. In spite HIV being classified as an STD by most, only 35 states + DC have mandated STI/HIV education in schools. Most states, including some that do not mandate the instruction itself, also place requirements on how abstinence or contraception should be handled when included in a school district’s curriculum. This guidance is heavily weighted toward stressing abstinence; in contrast, while many states allow or require that contraception be covered, none requires that it be stressed. Further affecting whether students receive instruction on sex or STIs/HIV are parental consent requirements or the more frequent “opt-out” clauses, which allow parents to remove students from instruction the parents find objectionable (Sex and STD/HIV Education, State Policies in Brief, 2005).
Around 20% of people living with HIV/AIDS are uninsured. Some of them are eligible for the federally sponsored schemes but are not covered under any insurance scheme owing to the long administrative delays before a person can be enrolled in either of the scheme. The implementation of the new citizenship and identity documentation requirement set forth in the Deficit Reduction Act, 2005 has further increased administrative delays in processing applications and renewals resulting in postponement and denial of coverage often for individuals otherwise eligible for the program (The Centers for Medicare and Medicaid Services (CMS), 2004; Committee on Public Financing and Delivery of HIV care (CPFDH), 2005).
ASSURANCE
Knowledge about the disease and advancement in treatment in the form of HAART therapy has changed the perception of HIV/AIDS as an acutely fatal infectious disease to a chronic one. The near constant incidence rate and declining mortality rate of HIV further indicate that more people are living with HIV/AIDS. Today Americans with HIV can expect to live 24 years as against a survival rate of 10 years in the 90s (Mike Stobbe, 2006). Nevertheless, this comes at a cost of $600,000 for health care over those two decades. In spite of federal spending of $8.7 billion dollars on health care for HIV/AIDS (CMS, 2004), spiraling costs have left big lacunae in the present health coverage which will increase as the number of people living with HIV/AIDS keeps on rising.
In 1980s HIV was perceived to be affecting only MSM and even after two decades of the disease, the picture hasn’t changed much. After showing a decline in the 1990s, there has been a recent rise in the number of new cases reported for MSM. In 2002 they accounted for 71% of all infections even though only 5% to 7% of adult males identify themselves as MSM. It is unclear whether the recent rise in infection rates in MSM is due to more testing or is it due to a rise in infection (Surveillance Data for 1981-2002).
Populations of minority races and ethnicities continue to be disproportionately affected by the HIV epidemic. African Americans are the hardest hit race. According to the 2000 census, blacks make up approximately 13% of the US population. However, in 2005, blacks accounted for 49% of new HIV/AIDS diagnoses in the USA (Surveillance Data for 1981-2002; AIDSUSDA, 2007). The reasons are not directly related to race or ethnicity, but rather to some of the barriers faced by many African Americans. These barriers can include poverty, sexually transmitted diseases, and stigma (negative attitudes, beliefs, and actions directed at people living with HIV/AIDS or directed at people who do things that might put them at risk for HIV).
The HIV/AIDS epidemic is a serious threat to the Hispanic/Latino community. Although they made up only about 13% of the population of USA, they accounted for 16% (155,179) of the estimated 952,629 AIDS cases diagnosed since the beginning of the epidemic (Surveillance Data for 1981-2002). In addition to being a population seriously affected by HIV, Hispanics/Latinos continue to face challenges in accessing health care, prevention services, and HIV treatment. The migration patterns, social structure, language barriers, and lack of access to regular health care among transient Hispanic/Latino immigrants amplify the problem.
PUBLIC HEALTH SYSTEM RESPONSE
FEDERAL LEVEL
The three basic tenets of public health are met by the approach of federal government towards the HIV/AIDS health issue. The CDC HIV/AIDS surveillance program collects data for both HIV infections and AIDS rates. Surveillance data on HIV infections provide a more complete picture of the epidemic and the need for prevention and care services than does the picture provided by AIDS data alone. The National HIV Behavioral Surveillance (NHBS) System, CDC collects risk behavior data from three populations at high risk for HIV infection: men who have sex with men (MSM), injection-drug users, and heterosexual adults in areas in which HIV is prevalent.
The federal programs that provide care to people living with HIV/AIDS operate through two financing mechanisms: mandatory annual spending and discretionary annual funding for specific services. These financing mechanisms include federal spending on Medicare, Medicaid, Ryan White CARE act, SAMHSA funding, HOPSA funding, CDC HIV/AIDS funding and OMH funding. It spent $18 billion in fiscal year 2004 for research, prevention, care and assistance, and international programs and activities. In the year 2002, $14.7 billion were spent of which 51.7% ($7.6 billion) were spent mandatory services for people with HIV/AIDS (CPFDH, 2005).
A large proportion of people with HIV/AIDS are low-income or below low-income and disabled; thus, Medicaid forms an important source of insurance coverage accounting for 43% of them. The federal government spent $4.2 billion on Medicaid related AIDS services while $3.5 billion was pooled in by individual states. Overall the program covers 44 percent of people living with HIV, 55% of people living with AIDS and 90% of children with AIDS. The federal guidelines require all states to provide mandatory services which include hospital, physician, lab and X-ray, home health, and nursing services (CPFDH, 2005).
The Federally sponsored Medicare covers 6% of the population with HIV/AIDS. It includes services for the elderly and those who are permanently disabled. Through its three ‘Parts’, Medicare covers for hospital care, physician, hospice, nursing, home health, medical equipment & supplies, and prescription drugs. The Ryan White CARE act addresses the gaps in financing care for HIV/AIDS and to provide financial support to cities that bear disproportionate burden of HIV/AIDS cases (CPFDH, 2005; CMS, 2004).
The federal Government has tried to integrate services for high risk groups through SAMHSA and OMH funding. Substance Abuse and Mental Health Services Administration (SAMHSA) works on decreasing transmission of HIV in IV drug users by providing mental health and substance abuse prevention and treatment services.
CDC has developed effective intervention strategies for high risk groups like Peers Reaching Out and Modeling Intervention Strategies (PROMISE) and Many Men, Many Voices for MSM. It works in collaboration with states and counties to develop these HIV/AIDS programs tailored to a region/ population.
MISSOURI STATE LEVEL
The Medicaid works on a sharing basis; the federal government provides matching funds for state funds. The state of Missouri was matched $4 million in federal grant for $2.3 billion for all services included in Medicare in the year 2004. States are allowed broad flexibility in designing their Medicaid programs, and consequently there is significant variation in eligibility, benefits, provider payments, and other aspects of the program at state level. Thus, a person may be eligible in one state may not be in the other owing to wide variation in policies. Most adults with HIV/AIDS who qualify for Medicaid do so because they meet the disability and income criteria of the federal Supplemental Security Income program. Some adults may qualify for Medicaid through a state’s medically needy program. For those who are not covered under Medicaid and Medicare the Governor’s Plan for Uninsured provides coverage (CPFDH, 2005).
With limited funding dedicated to HIV prevention efforts, CDC requires states to prioritize prevention dollars to those populations that are most epidemiologically at risk for infection. Given Missouri’s rates, the priority populations are White MSM, African American MSM and African American Women. IV drug users and Hispanics do not account for a significant proportion of HIV/AIDS patients in Missouri; nevertheless efforts are being made to prevent any rise among them (Sandra Hentges, personal communication, November 29, 2007). Missouri State has a policy in place which authorizes needle exchange program under the Department of Health. Issues of privacy and confidentiality have been addressed by closing all identifying records under this program ("SB 0166, Establish a Needle Exchange Program within the Department of Health," 2003).
“The MSM population has been the focus of over 60% of our prevention efforts for a number of years” says Sandra Hentges (November 29, 2007). Through community-based organizations as well as local health agencies, intensive, science-based interventions are provided to this population that promotes behavior change. However, with that said, this population is getting younger and younger and many of the youngest MSM have not had to live through the traumatic years of watching their friends and lovers die from HIV disease. It has now become a chronic health condition and people with HIV are living longer productive lives so the risk of contracting this disease doesn’t seem to be motivating the younger generation to protect themselves. In addition, they are tired of hearing the same messages in the same way about HIV. The state is currently working with CDC to provide interventions that are new and innovative to spark the attention of a generation who isn’t worried about contracting this still deadly virus (Sandra H, 2007).
Evidence based public health interventions have added a new dimension to the present public health programs. Of note here is the L.I.F.E. program which is striving to combine conventional measures of prevention and treatment with psychological and social aspects ("Shanti L.I.F.E. Program,").
LOCAL
The Saint Louis County and City have a combined METRO program for HIV, STD and Hepatitis. The program receives funding from the state and also through Title funds under the Ryan White CARE act as the city is included in EML list. The program focuses on increasing HIV testing rates amongst high risk groups besides integrating health services for STDs and Hepatitis with HIV care. Given Saint Louis’ case rates, African Americans and MSM are the most affected population. HIV testing services are offered directly by the department and indirectly through private organizations. IV drug users don’t form a significant population in Saint Louis HIV region; however efforts are being made to restrict the numbers before they become a problem (Wrigley D., Personal Communication, November 27, 2007).
One of the most significant problems being faced at local level is case management. At present the transition from HIV detection to treatment program takes anywhere between 2 weeks to 2 months. Approximately 50% of cases detected on HIV screening tests are lost before they can be started on medication by attaching them to a curative service. To address this particular issue the city is going to launch a new program from January 1, 2008 by having a provision of temporary case managers. They will follow the patient right from detection to the point where the person is either inducted in a treatment program or attached to a permanent case manager (Wrigley, 2007)
Saint Louis County’s STD department tries to integrate services for both STDs and
HIV. They offer voluntary HIV testing. An estimated 25%-30% of syphilis cases from this year were co-infected with HIV. This proves to be a very challenging factor due to the compromised immune system of these patients and the lack of obvious symptoms for this infection. Many of these patients find out about their syphilis infection because their providers are running routine screening test during their exam. Whenever a patient is diagnosed with a secondary infection, partner notification is offered for all infections as well as information on the patient’s rights and responsibilities (Whittington R., Personal Communication, November 29, 2007).
PRIVATE
Not for profit organizations like Saint Louis Effort for AIDS, The AIDS Foundation of Saint Louis and Red Cross work as an important link between the government and HIV/AIDS patients. These community organizations have expertise in delivery of health services like HIV testing and are more favored by at-risk individuals owing to privacy and confidentiality issues, and stigma attached with government services. Thus, Saint Louis Metro AIDS/HIV project works in close conjunction with these organizations and outsource its work to them by giving grants.
These organizations offer HIV testing at the center and also run mobile HIV testing vans. These vans offer door to door testing and confidentiality is maintained by two separate cabins for testing (Cheryl R. Oliver, Personal Communication, November 28, 2007). If an MSM is diagnosed with HIV, his contacts are offered HIV testing and counseling about their rights at any place of their choice. They also offer case management and work with the city health department in ensuring that a HIV diseased individual is covered under some form of insurance (Cheryl, 2007).
RECOMMENDATIONS
The ‘Committee on Public Financing and Delivery of HIV Care’, acknowledged that the present HIV/AIDS care system requires fundamental redesign, not just minor corrections. It implies that allocating more funds to the present system will not necessarily achieve better results, what is required is a change in the design of the delivery system and a redesigned financing system (CPFDH, 2005).
The present Medicare guidelines are designed such that if a low income person cannot avail funds if he is not disabled, although the same funds could have prevented a disability. This policy of treating a disease and not preventing it is pervasive throughout the public health system and is flawed in its ideology itself.
HAART therapy has worked in terms of increasing the survival time and quality of life of HIV diseased. However, the high cost of this treatment regimen has been blamed for funding deficits. What is required are ways of decreasing the cost of drugs and treatments by measures to discontinue current patents on these life saving drugs. A federal ceiling of drug prices used in some other federal programs can also work towards lowering the cost.
Uniformity in policy amongst all states is required. The present laws on needle sharing programs and Sex education programs in schools are two areas of prime concern. It has to be realized that these are practical options to decrease HIV/AIDS rates in the present scenario. Also stress needs to be placed on contraception than abstinence in states which already have laws.
At local level, more preventive measures have to be taken. HIV testing is far-reaching in its scope, yet it cannot be classified as a preventive tool as it does not affect risky behavior among individuals. More educational services and community interventions have to be implemented.
REFERENCES
‘2007 AIDS Epidemic Update’, UNAIDS. Retrieved November, 2007, from http://www.unaids.org/en/HIV_data/2007EpiUpdate/default.asp
AIDS, S. L. E. f. (2005). About HIV/AIDS. Retrieved November,25, 2007, from http://www.stlefa.org/About_HIV_AIDS.php
Altman, L.K, (1981) 'Rare cancer seen in 41 Homosexuals', the New York Times, July 3
‘Approval of AZT', News release, March 20, 1987, Public Health Service, http://fda.gov/bbs/topics/NEWS/NEW00217.html
Avert.org. (2007, June 26,2007). The history of AIDS. 1981-1986. Retrieved November, 2007, from http://www.avert.org/his81_86.htm
Avert.org. (2007, June 26,2007). The history of AIDS, 1993 - 1997. Retrieved November, 2007, from http://www.avert.org/his93_97.htm
Avert.org. (2007). The History of AIDS. 1987-1992. Retrieved November, 2007, from http://www.avert.org/his87_92.htm
Avert.org. (2007). The history of AIDS. 1998-2002. Retrieved November, 2007, from http://www.avert.org/his98_99.htm
Brennan, R.O. and Durack, D.T., (1981) 'Gay compromise syndrome', the Lancet, 2 1338-1339:
Burris, S. et al., "The Legality of Selling or Giving Syringes to Injection Drug Users", Journal of the American Pharmaceutical Association, 42(6), Supp.2: S13-18, 2002
Connor S. and Kingman S. (1988), 'The search for the virus, the scientific discovery of AIDS and the quest for a cure' Penguin Books, p.35
Coffin J., Haase A., Levy J.A., Montagnier L., Oroszlan S., Teich N., Temin H., Toyoshima K., Varmus H., Vogt P., Weiss R.A., (1986) 'What to call the AIDS virus?', (Letter), Nature, 321:10
Centers for Disease Control and Prevention. Update: Syringe Exchange Programs-United States, 2005. MMWR 2007; 56(44): 1164-1167. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5644a4.htm , accessed November 2007.
Committee on Public Financing and Delivery of HIV care, B. o. H. P. a. D. P., Institute of Medicine. (2005). Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White.: The National Academic Press, Washington D.C.
Daniel McGinn, 'MSNBC: AIDS at 20: Anatomy of a Plague; an Oral History', Newsweek Web Exclusive
Darrow, W.W (1991) 'AIDS: Socioepidemiologic responses to an epidemic', in 'AIDS and the social sciences, common threads', edited by Ulack, R. and Skinner, W.F., 1991,The University Press of Kentucky
Enlow, R.(1984), 'Special session', in Acquired Immune Deficiency Syndrome, Annals of the New York Academy of Science, Volume 437, edited by Selikoff I.J, Teirstein A.S. and Hirschman S.Z., The New York Academy of Sciences, p.291
Fischl M. A., Richman D. D., Grieco M. H., Gottlieb M. S., Volberding P. A., Laskin O. L., Leedom J. M., Groopman J. E., Mildvan D., Schooley R. T., et al. (1987)''The Efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex, a double-blind, placebo-controlled trial', The New England Journal Of Medicine, Vol. 317: 185-191, Number 4
Glynn M, Rhodes P. Estimated HIV prevalence in the United States at the end of 2003. National HIV Prevention Conference; June 2005; Atlanta
HARRIS, G. (December 2, 2007). Figures on H.I.V. Rate Expected to Rise. New York Times. Retrieved December 2, 2007, from http://www.nytimes.com/2007/12/02/health/02aids.html?th&emc=th
Mann J. M (1989) 'AIDS: A worldwide pandemic', in Current topics in AIDS, volume 2, edited by Gottlieb M.S., Jeffries D.J., Mildvan D., Pinching, A.J., Quinn T.C., John Wiley & Sons
Mike Stobbe Associated Press "Americans with HIV can expect to live 24 years, study says". Deseret News (Salt Lake City). Nov 12, 2006. FindArticles.com. 05 Dec. 2007.
MMWR Weekly (1982) 'Epidemiologic Notes and Reports Possible Transfusion-Associated Acquired Immune Deficiency Syndrome, AIDS- California', December 10, 31 (48); 652-4
MMWR Weekly (1981) 'Pneumocystis Pneumonia- Los Angeles', June 5, 30 (21); 1-3
MMWR Weekly (1983) 'Current trends prevention of Acquired Immune Deficiency Syndrome (AIDS): Report of Inter-Agency Recommendations', March 4, 32(8);101-3
Personal Communication, Hentges S., Department of Health and Human Services, Missouri, November 29, 2007.
Personal Communication, Whittington R., Disease Intervention Supervisor, Saint Louis County Department of Health, November 29, 2007.
Personal Communication, Wrigley D., Metro Center for HIV,STD and Hepatitis, St. Louis City Health Department, November 27,2007.
Personal Communication, Cheryl R. Oliver, Executive Director, Saint Louis Effort for AIDS, November 28, 2007.
SB 0166, Establish a Needle Exchange Program within the Department of Health, (2003).
Sex and STD/HIV Education, State Policies in Brief, Guttmacher Institute, http://www.guttmacher.org/statecenter/spibs/spib_SE.pdf, accessed November-2007.
Shanti L.I.F.E. Program. Retrieved November, 2007, from http://www.shanti.org/life/index.html
Substance Abuse & Mental Health Services Administration, U. S. D. o. H. a. H. S. (FY 2006 and FY 2007). SAMHSA Action Plan: HIV/AIDS & Hepatitis. Retrieved. from http://www.samhsa.gov/Matrix/SAP_HIV.aspx.
The Centers for Medicare and Medicaid Services (CMS) Health Care Financing Review Medicare and Medicaid Statistical Supplement, 2004, http://www.cms.hhs.gov/MedicaidBudgetExpendSystem/02_CMS64.asp#TopOfPage accessed December 5, 2007.
Total HIV/AIDS Federal Funding, FY2006. Retrieved December,4, 2007, from http://statehealthfacts.org/comparetable.jsp?ind=528&cat=11&yr=29&typ=4&o=d&sort=840
U.N. Overestimated Global AIDS Numbers. (November 20, 2007). Retrieved November, 30, 2007, from http://www.poz.com/articles/un_numbers_overestimate_1_13536.shtml
US Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for HIV, STD and TB Prevention (NCHSTP), AIDS Public Information Data Set (APIDS) US Surveillance Data for 1981-2002, CDC WONDER On-line Database, December 2005. Accessed at http://wonder.cdc.gov/aids-v2002.html on Dec 5, 2007 12:54:16 AM.
US Department of Health and Human Services (US DHHS), Centers for Disease Control and Prevention (CDC), National Center for HIV, STD and TB Prevention (NCHSTP), Cases of HIV infection and AIDS in the United States and Dependent Areas. Accessed at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2005report/default.htm on Dec 5, 2007 11:51:56 AM.
' Willis C. (1986) 'A different kind of AIDS fight', Time Magazine, May 12
We love to laugh at the nouveau riche and the silly way in which they flaunt their baubles: driving up in a flashy red sports car, wiping themselves with branded toilet paper, wearing ice-cubes on their chunky fingers, and most depressing of all, dropping names like so much dandruff. Sure they may have arrived but they can't stop jingling their moneybags and getting the world to take notice.
India, on the road to being a global power, seems to be suffering from this disease. The most tiresome symptom being the unthinking way in which we appropriate any achiever with even the most tenuous connection to the motherland as Indian. It makes us feel better, bigger, first-world and truly global. There is not so much as a prickle of shamefacedness at the fact that India has done little to further their careers or their talents. In the last couple of years, at regular intervals, the media has been choking with reports about "Indians such as Bobby Jindal, Norah Jones, Sanjaya Malakar, Sunita Williams, etc who have all done the country proud in the USA or in space. Indian schoolchildren light diyas (lamps) or fast, villages and towns in remote corners of India distribute sweets, dance in joy, and the cameras chase the drivers, aunties, uncles and village postmen for sound bytes, all because the son or a daughter of a former resident who quit the country fifty years ago has achieved a modicum of success thousands of kilometers away.
But, at some point, reality bites. Louisiana governor Bobby Jindal's father, Amar Jindal, left Maler Kotla in Punjab for the United States almost 40 years ago and settled in Baton Rouge, Louisiana. Bobby Jindal, 36, has never visited his ancestral home and has no plans to. Nora Jones who grew up in Texas with a white mother said after winning the Grammy that if anything, she felt more Texan than New Yorker (India did not figure). In fact, Geethali Norah Jones Shankar dropped the first and last extensions of her name when she turned 16. Sanjaya Malakar, the American Idol contestant whose father was an Indian, thanked his maternal Italian grandfather in his interviews. Sunita Williams was born in the USA to an Indian father (who became an American) and a mother of Slovenian heritage (the Slovenian press reproduced articles about how India was trying to appropriate their daughter of the soil).
Historian Ramachandra Guha says he is revolted by this craven desire of Indians to shine in reflected glory. There is something lopsided and imbalanced in all of this, he says. It is nothing but pathetic insecurity and an inferiority complex. I blame the rudderless trans-national middle class for such hype. In Delhi, Professor Mushirul Hassan, the vice-chancellor of Jamia Millia Islamia endorses Guha's view that this is nothing but the urge of a middle-class keen to join the rat race to prove itself. It is a way of saying we have arrived. An expression of new-found confidence. And when there not enough persons in India, you look outside, he says.
Equus CEO and advertising professional Suhel Seth calls it a reverse globalisation. India is very territorial in its emotions. We want to capture territories overseas. For us Indians, the grass is not only greener but sweeter outside India. We have shifting sands of respect and shifting sands of recognition. We seek role models from outside India and appropriate them even when they are not comfortable. Take Amarnath Bose (of Bose Electronics). I don't think he wants to be called an Indian.
There is certainly something surreal about the whole hysteria, agrees Sunil Khilnani, professor and director of South Asian Studies, Johns Hopkins University, and the author of the acclaimed The Idea of India. This is not a healthy sign our admiration and adulation for the overseas success of whomever we can claim (however tenuously) our own: its perhaps quaint, but also self-delusional, he says. We should perhaps think harder, focus more closely, on the many millions of those whom we condemn to failure, who really are our 'own' fellow, though far from equal, citizens.
What really grates is that much greater achievement within the country goes unnoticed or is downplayed. But once the West gives its seal of approval, the drum roll just won't stop. “Indian scientists who were ignored in India suddenly get talked about if they get recognised abroad. Even Mother Teresa became Indian only after she got the Nobel. We are a land of hypocrites. R K Pachauri suddenly shot to fame only after he got the Nobel Peace Prize. Till then very few would even give him appointment. And now suddenly he has become an Indian scientist, says Seth.
Prof Hassan adds that success is always seen as suspect: We don't recognise the worth of person who has achieved something or done something worthwhile. We attribute it to tikdam (machinations). We don't think that it could be an intrinsic part of the person or hard work that has contributed to his/her success. When I go abroad, people talk about how Indian scholars, historians are making great advances. But here we don't talk about them. We are in awe of someone who has studied in Cambridge but the moment you say you have studied in India, the interest wanes. This is an inferiority complex.
Guha blames the media for feeding this kind of false pride. The media should not be so obsequious about the West, he says. A few years ago, a magazine said that they did not put Vishwanathan Anand on the cover because he came second in the world championship. Bismillah Khan's death and even M S Subbulakshmis death were covered sparsely. Sunita Williams got ten times that coverage in the media. If great artistes like Bismillah Khan or M S had died in France, there would be half-hour programmes every day for a week if not more. Look at the way they covered Pavarotti's death. And here in India we cover our national heroes death while reading out what the President of India has said about him or her. But Bobby Jindal wins the governorship of a small state in the US and he gets excessive coverage.
Congress MP Milind Deora says that before celebrating the success of Indians abroad their Indianness needs to be verified. Take the example of Arnold Schwarzenegger. Austria celebrates his success and that is genuine because he was born there and grew up in Austria before migrating to the USA, says Deora. We celebrate these achievements because we have a certain affinity for them. The affinity is not derived from citizenship or from accent. America is full of immigrants but one does not find Europe celebrating each and every success of an American who is of European descent.
Another Indian who only has nasty things to say about India is V S Naipaul, who was born in Trinidad and lives in England. India counts Naipaul amongst its Nobel winners. Naipaul, who hates to be asked what he considers home says, I refuse to answer that question one more time, he snapped at Crosswords in Mumbai has this to say about the three countries he is associated with. India is unwashed, Trinidad is unlearned and England is morally bankrupt. The criticism is evenly handed out but perhaps we should reflect on what the Indian achievers across the pond think of the country before we roll out the red carpet and smother them in it.
India, on the road to being a global power, seems to be suffering from this disease. The most tiresome symptom being the unthinking way in which we appropriate any achiever with even the most tenuous connection to the motherland as Indian. It makes us feel better, bigger, first-world and truly global. There is not so much as a prickle of shamefacedness at the fact that India has done little to further their careers or their talents. In the last couple of years, at regular intervals, the media has been choking with reports about "Indians such as Bobby Jindal, Norah Jones, Sanjaya Malakar, Sunita Williams, etc who have all done the country proud in the USA or in space. Indian schoolchildren light diyas (lamps) or fast, villages and towns in remote corners of India distribute sweets, dance in joy, and the cameras chase the drivers, aunties, uncles and village postmen for sound bytes, all because the son or a daughter of a former resident who quit the country fifty years ago has achieved a modicum of success thousands of kilometers away.
But, at some point, reality bites. Louisiana governor Bobby Jindal's father, Amar Jindal, left Maler Kotla in Punjab for the United States almost 40 years ago and settled in Baton Rouge, Louisiana. Bobby Jindal, 36, has never visited his ancestral home and has no plans to. Nora Jones who grew up in Texas with a white mother said after winning the Grammy that if anything, she felt more Texan than New Yorker (India did not figure). In fact, Geethali Norah Jones Shankar dropped the first and last extensions of her name when she turned 16. Sanjaya Malakar, the American Idol contestant whose father was an Indian, thanked his maternal Italian grandfather in his interviews. Sunita Williams was born in the USA to an Indian father (who became an American) and a mother of Slovenian heritage (the Slovenian press reproduced articles about how India was trying to appropriate their daughter of the soil).
Historian Ramachandra Guha says he is revolted by this craven desire of Indians to shine in reflected glory. There is something lopsided and imbalanced in all of this, he says. It is nothing but pathetic insecurity and an inferiority complex. I blame the rudderless trans-national middle class for such hype. In Delhi, Professor Mushirul Hassan, the vice-chancellor of Jamia Millia Islamia endorses Guha's view that this is nothing but the urge of a middle-class keen to join the rat race to prove itself. It is a way of saying we have arrived. An expression of new-found confidence. And when there not enough persons in India, you look outside, he says.
Equus CEO and advertising professional Suhel Seth calls it a reverse globalisation. India is very territorial in its emotions. We want to capture territories overseas. For us Indians, the grass is not only greener but sweeter outside India. We have shifting sands of respect and shifting sands of recognition. We seek role models from outside India and appropriate them even when they are not comfortable. Take Amarnath Bose (of Bose Electronics). I don't think he wants to be called an Indian.
There is certainly something surreal about the whole hysteria, agrees Sunil Khilnani, professor and director of South Asian Studies, Johns Hopkins University, and the author of the acclaimed The Idea of India. This is not a healthy sign our admiration and adulation for the overseas success of whomever we can claim (however tenuously) our own: its perhaps quaint, but also self-delusional, he says. We should perhaps think harder, focus more closely, on the many millions of those whom we condemn to failure, who really are our 'own' fellow, though far from equal, citizens.
What really grates is that much greater achievement within the country goes unnoticed or is downplayed. But once the West gives its seal of approval, the drum roll just won't stop. “Indian scientists who were ignored in India suddenly get talked about if they get recognised abroad. Even Mother Teresa became Indian only after she got the Nobel. We are a land of hypocrites. R K Pachauri suddenly shot to fame only after he got the Nobel Peace Prize. Till then very few would even give him appointment. And now suddenly he has become an Indian scientist, says Seth.
Prof Hassan adds that success is always seen as suspect: We don't recognise the worth of person who has achieved something or done something worthwhile. We attribute it to tikdam (machinations). We don't think that it could be an intrinsic part of the person or hard work that has contributed to his/her success. When I go abroad, people talk about how Indian scholars, historians are making great advances. But here we don't talk about them. We are in awe of someone who has studied in Cambridge but the moment you say you have studied in India, the interest wanes. This is an inferiority complex.
Guha blames the media for feeding this kind of false pride. The media should not be so obsequious about the West, he says. A few years ago, a magazine said that they did not put Vishwanathan Anand on the cover because he came second in the world championship. Bismillah Khan's death and even M S Subbulakshmis death were covered sparsely. Sunita Williams got ten times that coverage in the media. If great artistes like Bismillah Khan or M S had died in France, there would be half-hour programmes every day for a week if not more. Look at the way they covered Pavarotti's death. And here in India we cover our national heroes death while reading out what the President of India has said about him or her. But Bobby Jindal wins the governorship of a small state in the US and he gets excessive coverage.
Congress MP Milind Deora says that before celebrating the success of Indians abroad their Indianness needs to be verified. Take the example of Arnold Schwarzenegger. Austria celebrates his success and that is genuine because he was born there and grew up in Austria before migrating to the USA, says Deora. We celebrate these achievements because we have a certain affinity for them. The affinity is not derived from citizenship or from accent. America is full of immigrants but one does not find Europe celebrating each and every success of an American who is of European descent.
Another Indian who only has nasty things to say about India is V S Naipaul, who was born in Trinidad and lives in England. India counts Naipaul amongst its Nobel winners. Naipaul, who hates to be asked what he considers home says, I refuse to answer that question one more time, he snapped at Crosswords in Mumbai has this to say about the three countries he is associated with. India is unwashed, Trinidad is unlearned and England is morally bankrupt. The criticism is evenly handed out but perhaps we should reflect on what the Indian achievers across the pond think of the country before we roll out the red carpet and smother them in it.
Most Addictive Games
Very rarely will a teenager that comes in to a treatment facility for excessive videogame use be there because he just can’t get enough of a puzzle videogame. They may have spent some time on the game, and maybe even an above average amount of time on a puzzle game. But, rarely will they have reached the level of “addiction” usage. This is because puzzle games do not lend themselves to those types of gaming habits. Thus, it becomes necessary for parents to become familiar with the different types of games available to their children, and most importantly, those games that have the most potential to become addictive. The following is a list of the current types of video games available to children today. The game types are listed in order of least (1) addictive to most (7) addictive types.
1) Educational - Games that are found only on the systems built specifically for learning. Unfortunately these systems are currently all designed for younger children. Examples of these educational systems are Leapster and Pixter.
2) Party Games are games designed to get people together playing lots of fast-paced mini-games one after another. Each party game can contain up to 150 mini-games in which everyone in the same room has a controller and plays the mini-game at the same time. Each mini-game lasts about 2 minutes. Games in this category would include Mario Party, and Shrek Party Blast.
3) Physical - The latest addition to videogames is the advent of the physical games in which the player’s physical movements move the character on the screen. In a baseball game, the player swings the remote. When this happens, the character on the screen swings the bat. These games currently are the newest and hottest thing around, hopefully pointing toward greater physical health of gamers in the long run. Games in this category include Wii Sports and the Bigs.
4) Puzzle – These games are typically abstract games of logic with no theme or characters. They can be games in which you must line up blocks or games in which you solve math problems. These games are simple to learn, and simple to play. They usually hit the broadest age demographics. Examples of puzzle games include Tetris, Brain Age, and Bejeweled.
5) Racing – These are simply games in which one player races one or more other racers to the finish line. They come in a variety of race types and courses, but in general it is always a race to the finish. The draw in these types of games is making your car better every time you win, or unlocking new cars and tracks as you win. Examples of this type of game are Need for Speed and Mario Kart.
6) Sports games are any game that is a sport in real life. There are even professional (NBA) and college (NCAA) level games of some of the major American Sports (basketball and football). Some people play this for a one-time fun game, and other people like to create a player or team and take them through an entire season, improving their player along the way.
7) Fighting - The vast majority of these games are one fighter versus another fighter. The draw here is the brutality of the fighting, and the learning of fighting moves. These games often take a lot of playing in order to master all of the moves of a given fighter. Yet again, an argument could be made for saying it takes strategy and planning to know which moves to use when.
8) Platformer - These games are action oriented logic games with a main character. They usually involve a simple story line in which the hero of the story must complete each level by jumping from platform to platform, jumping on or shooting the bad guy. These games are rarely violent or gory. Most of the time, the main character and levels are more akin to a cartoonish, Looney Toons look and feel. Some levels are tricky to get to the end and take some trial and error to complete, thus the logic comes into play. Examples of these types of games are Super Mario and Crash Bandicoot.
9) Third person action - These games are similar to the platformer in almost every way, accept they have a more mature theme. Whereas in the platformer, the hero is a cartoon, in the third-person action game, the hero is an realistic looking action star. These games are usually in realistic settings, with more realistic violence, and much harder logic puzzles. Examples of this type of game include Splinter Cell and Tomb Raider.
10) Role-Playing Games (RPG’s) - These games are very similar to the MMORPG’s listed below accept these games are usually designed for only one player, and they have an ending. Depending on how you play the game, the ending is often different. The more you play, the deeper you get into the story, and the more powers your character gains. Examples of this type of game are Final Fantasy and Knights of the Old Republic.
11) Real-time strategy - Games that are basically a fast paced chess game without the turn-taking component. In these games, you are responsible for controlling and commanding an army you have built from scratch. You must face off with whomever you opponent is and try to be the last man standing. Examples of these games include Starcraft and Command and Conquer.
12) First Person Shooters (FPS) - These are games where you are the hero. All you can see on the screen is your gun directly in front of you. bad guys attack you, and you must shoot them. These games are all about the guns. Throughout the games, you get bigger and better guns and must kill bigger and “badder” enemies, adding a very addicting macho (power) factor to the games. Recently, a lot of these games have taken more historical spins, allowing you to be a soldier in Vietnam or WWII. Examples of these games include Halo and Call of Duty.
13) Massively Multiplayer Online Role-Playing Games (MMORPG). These are epic games with an everlasting storyline. These games do not have an ending. They are designed to play forever. MMORPG’s are usually played with thousands of other players online at the same time, adding a highly addictive social component to the game. Lastly, these games are designed so that the more you play, the more powerful and well respected you are by everyone playing. Examples of this type of game are Everquest, and the infamous World of Warcraft.
Source- http://www.aspeneducationgroup.com/gameaddiction/most_addictive_games.asp
1) Educational - Games that are found only on the systems built specifically for learning. Unfortunately these systems are currently all designed for younger children. Examples of these educational systems are Leapster and Pixter.
2) Party Games are games designed to get people together playing lots of fast-paced mini-games one after another. Each party game can contain up to 150 mini-games in which everyone in the same room has a controller and plays the mini-game at the same time. Each mini-game lasts about 2 minutes. Games in this category would include Mario Party, and Shrek Party Blast.
3) Physical - The latest addition to videogames is the advent of the physical games in which the player’s physical movements move the character on the screen. In a baseball game, the player swings the remote. When this happens, the character on the screen swings the bat. These games currently are the newest and hottest thing around, hopefully pointing toward greater physical health of gamers in the long run. Games in this category include Wii Sports and the Bigs.
4) Puzzle – These games are typically abstract games of logic with no theme or characters. They can be games in which you must line up blocks or games in which you solve math problems. These games are simple to learn, and simple to play. They usually hit the broadest age demographics. Examples of puzzle games include Tetris, Brain Age, and Bejeweled.
5) Racing – These are simply games in which one player races one or more other racers to the finish line. They come in a variety of race types and courses, but in general it is always a race to the finish. The draw in these types of games is making your car better every time you win, or unlocking new cars and tracks as you win. Examples of this type of game are Need for Speed and Mario Kart.
6) Sports games are any game that is a sport in real life. There are even professional (NBA) and college (NCAA) level games of some of the major American Sports (basketball and football). Some people play this for a one-time fun game, and other people like to create a player or team and take them through an entire season, improving their player along the way.
7) Fighting - The vast majority of these games are one fighter versus another fighter. The draw here is the brutality of the fighting, and the learning of fighting moves. These games often take a lot of playing in order to master all of the moves of a given fighter. Yet again, an argument could be made for saying it takes strategy and planning to know which moves to use when.
8) Platformer - These games are action oriented logic games with a main character. They usually involve a simple story line in which the hero of the story must complete each level by jumping from platform to platform, jumping on or shooting the bad guy. These games are rarely violent or gory. Most of the time, the main character and levels are more akin to a cartoonish, Looney Toons look and feel. Some levels are tricky to get to the end and take some trial and error to complete, thus the logic comes into play. Examples of these types of games are Super Mario and Crash Bandicoot.
9) Third person action - These games are similar to the platformer in almost every way, accept they have a more mature theme. Whereas in the platformer, the hero is a cartoon, in the third-person action game, the hero is an realistic looking action star. These games are usually in realistic settings, with more realistic violence, and much harder logic puzzles. Examples of this type of game include Splinter Cell and Tomb Raider.
10) Role-Playing Games (RPG’s) - These games are very similar to the MMORPG’s listed below accept these games are usually designed for only one player, and they have an ending. Depending on how you play the game, the ending is often different. The more you play, the deeper you get into the story, and the more powers your character gains. Examples of this type of game are Final Fantasy and Knights of the Old Republic.
11) Real-time strategy - Games that are basically a fast paced chess game without the turn-taking component. In these games, you are responsible for controlling and commanding an army you have built from scratch. You must face off with whomever you opponent is and try to be the last man standing. Examples of these games include Starcraft and Command and Conquer.
12) First Person Shooters (FPS) - These are games where you are the hero. All you can see on the screen is your gun directly in front of you. bad guys attack you, and you must shoot them. These games are all about the guns. Throughout the games, you get bigger and better guns and must kill bigger and “badder” enemies, adding a very addicting macho (power) factor to the games. Recently, a lot of these games have taken more historical spins, allowing you to be a soldier in Vietnam or WWII. Examples of these games include Halo and Call of Duty.
13) Massively Multiplayer Online Role-Playing Games (MMORPG). These are epic games with an everlasting storyline. These games do not have an ending. They are designed to play forever. MMORPG’s are usually played with thousands of other players online at the same time, adding a highly addictive social component to the game. Lastly, these games are designed so that the more you play, the more powerful and well respected you are by everyone playing. Examples of this type of game are Everquest, and the infamous World of Warcraft.
Source- http://www.aspeneducationgroup.com/gameaddiction/most_addictive_games.asp
Video Gaming- BOON or BANE?
I was reading the newspaper the other day when I happened to glance upon a particularly interesting piece of news. A man in China dropped dead after a 3-day gaming binge. I can sense some eyebrows raising of those who are ardent video game supporters, questioning the validity of the news article and its pertinence over here. Just to qualms any doubts, I am an ardent video gamer myself, though nothing in the league of professional players, so I shared the same amount of skepticism as anyone belonging to the posse. As for people who have been criticizing the games since its inception, it was a feast and a valid point in the direction of showing where the gaming industry is leading us. The nebulous cloud of thoughts that were traversing my neural circuit could only be laid to rest if I was able to take one side, so I thought I should better investigate the case myself before I choose to take sides. This blog thus, from hereon will be dedicated to my findings about the pros and cons in order to characterize video gaming as a BOON or BANE.
My first mugging
USA is a new world in itself, everything different from India so still
figuring out things. like the other day I took a metro shuttle- a bus
that takes u to the closest metro station. knowing not what to do I
just went inside and sat. the driver- a black lady asked me to come
back and get a ticket. I said k so they don't have a conductor. so how
much for a ticket, she said two dollars. I said k- I gave her a
twenty- she looked back at me and said that the machine will not give me any change back so I needed to tender the exact change. I didn't have any so she asked if
some one in the bus had a change for twenty. Everyone was looking around but none
had it so she said- k i'll give u a free ride. I said thanks n was
going back when a white lady in the back just took out two dollars and
gave it to me, asking me to keep it when i offered her the twenty dollar bill. however, what this whole episode did was bring me in notice of a lot of black fellows inside the bus. They started saying things to me, but thanks to their accent I couldn't get a word of what they were saying and I maintained my calm- smiling back at them. Once at the metro station I got off only to find them following me. I hurried downstairs but they caught with me soon and then started saying things. All I could get of the melee was that they were asking for my twenty dollar bill.
I was shit scared- they were four, heavily built and with the stories of guns being so easily available in USA- I literally froze for a moment. But i kept moving and thank god none came in my way allowing me to rush things up. Once on to the platform I kept on walking till I saw a white cop and went straight to him. I
asked him how to get a ticket. He led me to the counter and assisted me
there. Meanwhile the blacks did come over but the cop sensed their
intentions and asked them to move away. Soon the metro was there and I
got lost in its crowd.....
my first near mugging.
now I didn't go looking for trouble but it caught on to me.
figuring out things. like the other day I took a metro shuttle- a bus
that takes u to the closest metro station. knowing not what to do I
just went inside and sat. the driver- a black lady asked me to come
back and get a ticket. I said k so they don't have a conductor. so how
much for a ticket, she said two dollars. I said k- I gave her a
twenty- she looked back at me and said that the machine will not give me any change back so I needed to tender the exact change. I didn't have any so she asked if
some one in the bus had a change for twenty. Everyone was looking around but none
had it so she said- k i'll give u a free ride. I said thanks n was
going back when a white lady in the back just took out two dollars and
gave it to me, asking me to keep it when i offered her the twenty dollar bill. however, what this whole episode did was bring me in notice of a lot of black fellows inside the bus. They started saying things to me, but thanks to their accent I couldn't get a word of what they were saying and I maintained my calm- smiling back at them. Once at the metro station I got off only to find them following me. I hurried downstairs but they caught with me soon and then started saying things. All I could get of the melee was that they were asking for my twenty dollar bill.
I was shit scared- they were four, heavily built and with the stories of guns being so easily available in USA- I literally froze for a moment. But i kept moving and thank god none came in my way allowing me to rush things up. Once on to the platform I kept on walking till I saw a white cop and went straight to him. I
asked him how to get a ticket. He led me to the counter and assisted me
there. Meanwhile the blacks did come over but the cop sensed their
intentions and asked them to move away. Soon the metro was there and I
got lost in its crowd.....
my first near mugging.
now I didn't go looking for trouble but it caught on to me.
Food worries
Today I made my first indian recipe. aalo ki sabzi with rice, and the good part is it was palatable.
usually we get processed food and eat that -like beritos, pizza ya aisa hi kuch. but since it was a week of free lunches and dinner for me, owing to the orientation, I didn't have to fend for food more than a couple of times. As for breakfast well its
cornflakes most of the time. We have bread but the taste is so
different from what we have in india. We usually get our groceries from shnucks- if you can call processed food, garlic paste, tomato puree as groceries! Have been to walmart- some stations away from where I live- an there I could see why everybody keeps flocking to this store. They have sell stuff which is cheap by a margin!
Another strange habit I have developed now is that now whenever I pick up an item, I tend to look at the nutrition facts printed on the same. I even looked up for nutrition facts on a packet of potatoes, but what left me startled was they had printed one on that too!
The american diet is low on fiber so whatever u do, try having more fibre
as raw vegetables else u will get constipated soon, especially if you come from India.
usually we get processed food and eat that -like beritos, pizza ya aisa hi kuch. but since it was a week of free lunches and dinner for me, owing to the orientation, I didn't have to fend for food more than a couple of times. As for breakfast well its
cornflakes most of the time. We have bread but the taste is so
different from what we have in india. We usually get our groceries from shnucks- if you can call processed food, garlic paste, tomato puree as groceries! Have been to walmart- some stations away from where I live- an there I could see why everybody keeps flocking to this store. They have sell stuff which is cheap by a margin!
Another strange habit I have developed now is that now whenever I pick up an item, I tend to look at the nutrition facts printed on the same. I even looked up for nutrition facts on a packet of potatoes, but what left me startled was they had printed one on that too!
The american diet is low on fiber so whatever u do, try having more fibre
as raw vegetables else u will get constipated soon, especially if you come from India.
my flight journey and first days in USA
I am still settling here in USA. The orientation program takes nearly all my
day. It starts at 8 in the morning with the breakfast and goes up till
dinner- so not much time to go around and look. Also once the
orientation ends i would be able to go to an Indian center to get a
calling card so that i can call back home. This weekend perhaps.
have to buy a laptop and also need to shift into a new apartment this
weekend. Food has not been a problem till now as all my meals are
being provided by the university itself thanks to the orientation
stuff...
Till now i have found the Americans to be very helpful, punctual
and carefree as far as dressing goes. The streets are sparkling and
the outside atmosphere or temperature has no bearance on you are in an
air conditioned environ for most part of the day- including my room,
the apartment lobby, the bus, the metro, the school the classes... you
name it and they have it.
The journey was good. Saw what traveling across time lines means... it
was day for the most part of my 32 hour journey leaving me totally
disoriented. still have a bit of jet lag left which surfaces
especially if i get some time during the day to sleep- leaving me
awake in the night...
The air hostess on Lufthansa were good but one was a stunner. Other
than that there was plenty of material available left right and center
to keep me awake through my journey- especially at the Frankfurt
airport. six hours of complete bliss. the people, the shops the luxury
and all. I was bowled over. then the trip to Denver was ok. nothing
great about it except that i had a lot of booze...
At Denver it was a complete dressing down to your basics for a
complete security check in person and of the luggage.
On the flight from Denver to Saint Louis was THE air hostess. boy. she
just had a single garment on her. nothing beneath it too. so tightly
hugging her curvaceous body and the lapels of her apparel gave you a
deep view into her inner assets- especially when she came asking sir
would u like something....
It was in Denver itself that I first saw the colors of America- a
mouth to mouth kiss in wide public view was my first, but by the time
i had reached home along with gangwani bhai- hardly 3 hours later- i had been
witness to three. Hard to keep your eyes off all those and it is thus
nothing strange that i find myself staring blankly at people. the
chicks are hot- and what makes them so is the way they dress... boy o
boy.
At the first day of orientation i saw a stunner- pity that she
belongs to a totally different course and I would hardly see her, but
it was better the next day as I had some classes and I got to share a
laptop with another whooper from health administration. and this time it was more
than just me ogling, I talked to her and had my eyes all over her.
alas a lot happening here
day. It starts at 8 in the morning with the breakfast and goes up till
dinner- so not much time to go around and look. Also once the
orientation ends i would be able to go to an Indian center to get a
calling card so that i can call back home. This weekend perhaps.
have to buy a laptop and also need to shift into a new apartment this
weekend. Food has not been a problem till now as all my meals are
being provided by the university itself thanks to the orientation
stuff...
Till now i have found the Americans to be very helpful, punctual
and carefree as far as dressing goes. The streets are sparkling and
the outside atmosphere or temperature has no bearance on you are in an
air conditioned environ for most part of the day- including my room,
the apartment lobby, the bus, the metro, the school the classes... you
name it and they have it.
The journey was good. Saw what traveling across time lines means... it
was day for the most part of my 32 hour journey leaving me totally
disoriented. still have a bit of jet lag left which surfaces
especially if i get some time during the day to sleep- leaving me
awake in the night...
The air hostess on Lufthansa were good but one was a stunner. Other
than that there was plenty of material available left right and center
to keep me awake through my journey- especially at the Frankfurt
airport. six hours of complete bliss. the people, the shops the luxury
and all. I was bowled over. then the trip to Denver was ok. nothing
great about it except that i had a lot of booze...
At Denver it was a complete dressing down to your basics for a
complete security check in person and of the luggage.
On the flight from Denver to Saint Louis was THE air hostess. boy. she
just had a single garment on her. nothing beneath it too. so tightly
hugging her curvaceous body and the lapels of her apparel gave you a
deep view into her inner assets- especially when she came asking sir
would u like something....
It was in Denver itself that I first saw the colors of America- a
mouth to mouth kiss in wide public view was my first, but by the time
i had reached home along with gangwani bhai- hardly 3 hours later- i had been
witness to three. Hard to keep your eyes off all those and it is thus
nothing strange that i find myself staring blankly at people. the
chicks are hot- and what makes them so is the way they dress... boy o
boy.
At the first day of orientation i saw a stunner- pity that she
belongs to a totally different course and I would hardly see her, but
it was better the next day as I had some classes and I got to share a
laptop with another whooper from health administration. and this time it was more
than just me ogling, I talked to her and had my eyes all over her.
alas a lot happening here
my visa interview on 2nd of August
The visa was scheduled for 0915 in the morning. I reached there at 8 am in the morning. It was raining heavily en route and i was thanking that I asked my brother to drop me at the counslate. After standing in the line for more than hour finally my documents were received at the counter outside and I was asked to go inside. After depositing my mobile and a security check I was inside the arena. First up was the finger prints counter- done up with it in a flash I was asked to go and stand in the second row- there were 6 candidates in front of me. In the other row- only 2, while a no of them were kept seated waiting their arrival- the immigrant visa row.
With in 5 mins I found myself at the front of the row guessing who was it going to be.
I was called for the interview in the corner most window- the guy who was handling the emergency appointments.
VO- YA (young guy, looks harried, probably missed his early morning coffee)
ME- Good Morning Sir
VO- Your papers.....
ME- (Gawd this man is in a foul mood)
VO- Why do you want to go to USA?
ME- Sir, I want to pursue Masters in public health from Saint Louis University.
VO- Are you practicing?
Me- No Sir
VO- Were you working before this?
Me- Yes sir
VO- Where?
ME- Sir, I was working as a Research physician in Alembic pharmaceuticals.
VO- So, you want to do research
Me- NO sir....(before i could say anything else)
VO- Which all universities did you apply to?
ME- pardon me
VO- (repeats question)
ME- Sir I applied to University of Pittsburgh, Boston University, Yale University, Saint Louis University, University of South Florida, U MASS at Amherst.
VO- Which was your priority university
ME- Saint Louis University
VO- (surprised) over Yale University?
ME- (taken aback) No sir, but I got rejected from Yale university
VO- prove it to me that Saint Louis university is the best.
Me- Sir, the university is highly acclaimed and the school of public health
specially is well known. Moreover my course in epidemiology is.....
VO- (interrupts in between, looks perplexed) What's Epidedmiology.
ME- (I knew I had my chance-the guy knew nothing about epidemiology) Sir Epiemiology is....( and I started ranting- all medical lingo)
VO- K, who's going to sponsor your education
ME- Sir My father
VO- Whats his annual Income.
ME- (I have been half guessing his questions as the sound quality was pathetic) SIR?
VO- your father's annual income?
ME- Four lakhs (not exact so I thought I should consult my papers for the exact figure)
VO- What is the net worth of your fathers liquid assets.
ME- (Still consulting the papers)
VO- I don't want to see your papers.
ME- Sir 50,000 US $
VO- In Rupees...
ME- 16 lakhs
VO- Is that enough for your education?
ME- Sir I have a loan of 25000 US $, I mean 10 lakh Rupees
VO- K *@$@@(&($@&($&@$&(@&$(@&$^&*&)(&(
ME- (in my mind- Whats he saying now. K he's kept my passport. means I would get the visa I presume) Thank you sir.
picked up my bag and went out with a smile on my face and a purpose in my walk.
I am going to USA!!!
With in 5 mins I found myself at the front of the row guessing who was it going to be.
I was called for the interview in the corner most window- the guy who was handling the emergency appointments.
VO- YA (young guy, looks harried, probably missed his early morning coffee)
ME- Good Morning Sir
VO- Your papers.....
ME- (Gawd this man is in a foul mood)
VO- Why do you want to go to USA?
ME- Sir, I want to pursue Masters in public health from Saint Louis University.
VO- Are you practicing?
Me- No Sir
VO- Were you working before this?
Me- Yes sir
VO- Where?
ME- Sir, I was working as a Research physician in Alembic pharmaceuticals.
VO- So, you want to do research
Me- NO sir....(before i could say anything else)
VO- Which all universities did you apply to?
ME- pardon me
VO- (repeats question)
ME- Sir I applied to University of Pittsburgh, Boston University, Yale University, Saint Louis University, University of South Florida, U MASS at Amherst.
VO- Which was your priority university
ME- Saint Louis University
VO- (surprised) over Yale University?
ME- (taken aback) No sir, but I got rejected from Yale university
VO- prove it to me that Saint Louis university is the best.
Me- Sir, the university is highly acclaimed and the school of public health
specially is well known. Moreover my course in epidemiology is.....
VO- (interrupts in between, looks perplexed) What's Epidedmiology.
ME- (I knew I had my chance-the guy knew nothing about epidemiology) Sir Epiemiology is....( and I started ranting- all medical lingo)
VO- K, who's going to sponsor your education
ME- Sir My father
VO- Whats his annual Income.
ME- (I have been half guessing his questions as the sound quality was pathetic) SIR?
VO- your father's annual income?
ME- Four lakhs (not exact so I thought I should consult my papers for the exact figure)
VO- What is the net worth of your fathers liquid assets.
ME- (Still consulting the papers)
VO- I don't want to see your papers.
ME- Sir 50,000 US $
VO- In Rupees...
ME- 16 lakhs
VO- Is that enough for your education?
ME- Sir I have a loan of 25000 US $, I mean 10 lakh Rupees
VO- K *@$@@(&($@&($&@$&(@&$(@&$^&*&)(&(
ME- (in my mind- Whats he saying now. K he's kept my passport. means I would get the visa I presume) Thank you sir.
picked up my bag and went out with a smile on my face and a purpose in my walk.
I am going to USA!!!
Two days from now I will be appearing for my Visa Interview. The mocks have been going on well. My counselor, Mr Himish Bhatnagar says I am well prepared- there's fluency, coherence of thought and my explanations are logical. Add to it the paper work- which is also complete- though I had it done is a different story. I had to dig deep down in to all the financial assets my father had, or held- find which is still in his name- their net market worth and get them confirmed with the experts in the respective field. Seems easy but the problem was the first step itself, how do I locate what all my father has in his name. I asked him but he had little idea except for the ones in bank. Looked up all the audit reports of yester years but to no avail. Thereafter it was plain gong through every document i could lay my hands on in my home.
With the counselor seeming confident, I think it should not be a worry for me to get a Visa but one thing that keeps on lingering in my mind is after all I am a doctor who is going for a Public health degree in USA. Usually the visa authorities think otherwise and see MPH as a pretext of entering USA to give USMLE later. Talk of it, I have never had plans of pursuing anything clinical post my MBBS. I would love to hold on to the doctor against my name- but I think the PhD route would be better suited to me now. Alas, its time again to go for another mock, so will end it up here.
With the counselor seeming confident, I think it should not be a worry for me to get a Visa but one thing that keeps on lingering in my mind is after all I am a doctor who is going for a Public health degree in USA. Usually the visa authorities think otherwise and see MPH as a pretext of entering USA to give USMLE later. Talk of it, I have never had plans of pursuing anything clinical post my MBBS. I would love to hold on to the doctor against my name- but I think the PhD route would be better suited to me now. Alas, its time again to go for another mock, so will end it up here.
Damn Protests!!!!
I have reached delhi but not via the route I had planned. I was in udaipur when I heard the news of violent protests and riots in eatern parts of gujarat. I thought all this was not going to affect me as I was going through a route much less in confrontation with the same. I was wrong. By next morning news was out that the rioters had laid siege to the capital and anyway in and out of Jaipur was blocked by them. Moreso the protest had turned violent with destruction of Governmnet property and no of people dead. By afternoon news of the protest spreading nearly all across rajasthan and cancellation of trains on various lines was enough to put doubt in my mind, and so I decided to stay put to get a better account of the situation lest I run into trouble. All my efforts of trying to find an alternate route were in vain- finally accedeing defeat on the hands of man and not nature, I had to return back. The return back was as horrible as it could be, I wasnt able to wake up early. Got on the road by 11am- the sun was high and blazing- the air hot. Though I was able to enter ahmedabad by 1630hrs, the whole journey in the heat and left me sapped. The head was splitting and my ego bruised, sun burns on my hand and face. At various points through the trip I felt like running away from this, it was too damn hot, I kept talking to myself that I had no option but to drive back- that I couldnt leave it half way. May sound too bombastic but I was on the near edge of breaking down- if not my bike.
The yamaha though fared good enough and never once complained though I tested its nerve- speeding at 70-80 and never offering it a rest of more than 5 mins- in that heat. Have left my bike at ahmedabad and I am in delhi fro now. But if time and weather permit I would take up the endeavour once again!!!!
The yamaha though fared good enough and never once complained though I tested its nerve- speeding at 70-80 and never offering it a rest of more than 5 mins- in that heat. Have left my bike at ahmedabad and I am in delhi fro now. But if time and weather permit I would take up the endeavour once again!!!!
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Ahemdabad to Udaipur
Reached udaipur at 11 am after moving from ahemdabad at 5am. Getting out of ahemdabad itself tooka na hour since to avoid the confusing city routes i took the outer ring road which took me an extra 15-20 kms. However once on the road- It was a smooth drive. Great road- four lane and without a blemish on the surface throughout the route. With the rains lashing the ahmedabad district last night- the weather was cool in the early morning, so was able to cover most of the disttance without a problem. One problem the route faces is lack of good quality dhabas enroute- had a make do with a bad tasting idli as my breakfast. As the sun started rising so did the heat and I could feel the sweat dripping down my collar. However the twisting and turning road gleaming through the hills kept my attention. It was such an exhillarating experience that I switched off my ipod to get back to driving without any distractions whatsoever. Once in udaipur, I was able to locate Kumbha palace- good afforadable rooms. Have driven arund 250 kms today- but on the whole- even at 11 am could do more.
Ahmedabad
I did pack in a lot of socialising for 1 day in ahmedabad, and so I faced the consequences- couldnt get up in time to start off for uaipur. Thus, another day at ahmedabad- saw back to back movies- shootout and spiderman-3. I t has rained here in ahemdabad today-its raining right now. I wonder what its going to be further up north. Any rain up ahead spells problems galore for me on the highway but alternatively the weather could just remain overcast and not rain. All in all the trip hasnt as yet kicked much yet there are things coming up. I like it that way.
Baroda - Ahmedabad
The trial run from Baroda to Ahemdabad was coverered without any glitches. Started at 0615am instead of 4am, got delayed as always coz i had left my packing up for the last hour. However, I was able to enter ahemdabad by 0800 hrs. Though the sun was up and beating on my back. Wasnt a tiring experience considering that I took only one break from baroda to ahemdabad at anand- and to keep me company was Dhanraj- so couldn't test what being alone would do to me. That is up for tomorrow- when i drive to Udaipur. Hoping i will be able to start off by 4am morrow.
One thing I learnt on my trip- beware of the dogs- nearly met an accident save that I was able to break my speed well in time to avoid it.
One thing I learnt on my trip- beware of the dogs- nearly met an accident save that I was able to break my speed well in time to avoid it.
The penultimate day
Alas, the penultimate day and tomorrow I am going to commence on my journey. Off to ahemdabad before the day break.
Plenty of people did come to know of this eccentric idea of mine and leave a few quarters most expressed doubt. Nevertheless, they were wishing well for me.
But as headstrong a person I am, I choose not to listen to them and continue with the stupidity.
I am also leaving Baroda finally- its been a home for me. Everytime I return to the city- a sudden calm descends on me- a calm that I know the whole place as the back of my hand- it's my den.
The past six years have allowed me to come in touch with many people who's company I cherish. All my colleagues- who have been in the thick and thin with me- most of the muck being created by me. My juniors- awesome- I wish they all have as good juniors as I have had. Of course my mentor and friend Dr Ranjit Kadam- a guardian away from home. One more person I have shared a strange chemistry with is our Dean - Dr Kamal Pathak- though the guy has scolded and reprimanded me on most occasions- he still has been providing support where necessary...
I WILL MISS BARODA!!!!!
Plenty of people did come to know of this eccentric idea of mine and leave a few quarters most expressed doubt. Nevertheless, they were wishing well for me.
But as headstrong a person I am, I choose not to listen to them and continue with the stupidity.
I am also leaving Baroda finally- its been a home for me. Everytime I return to the city- a sudden calm descends on me- a calm that I know the whole place as the back of my hand- it's my den.
The past six years have allowed me to come in touch with many people who's company I cherish. All my colleagues- who have been in the thick and thin with me- most of the muck being created by me. My juniors- awesome- I wish they all have as good juniors as I have had. Of course my mentor and friend Dr Ranjit Kadam- a guardian away from home. One more person I have shared a strange chemistry with is our Dean - Dr Kamal Pathak- though the guy has scolded and reprimanded me on most occasions- he still has been providing support where necessary...
I WILL MISS BARODA!!!!!
The supposed Itinerary
28th morning- start for ahemdabad
28th afternoon- reach ahemdabad
29th morning- start for udaipur
29th evening- reach udaipur
30th roam through udaipur
31st 6am - start for chittaurgarh
31st 10 am - reach chittaurgarh, roam around
31st 6pm - start for bhilwara
31st night - reach bhilwara
1st - stay at bhilwara
2nd - morning start for jaipur
2nd - evening reach jaipur
3rd- stay at jaipur
4th - morning start for delhi
4th - evening reach delhi
28th morning- start for ahemdabad
28th afternoon- reach ahemdabad
29th morning- start for udaipur
29th evening- reach udaipur
30th roam through udaipur
31st 6am - start for chittaurgarh
31st 10 am - reach chittaurgarh, roam around
31st 6pm - start for bhilwara
31st night - reach bhilwara
1st - stay at bhilwara
2nd - morning start for jaipur
2nd - evening reach jaipur
3rd- stay at jaipur
4th - morning start for delhi
4th - evening reach delhi
There's a decision to be made.
Of course I can take my bike back to my home via transport- the routine mundane way. Alternatively, I could ride it back home.
I know riding a bike for 1500 kms is not a joke, it will be very tiring. Add to it the fact that I will be doing it alone, braving the hot winds and the terrain for which rajasthan is famous for.
I can easily send my bike via transport, from Baroda to Kanpur- easy, no tiring journey, no loneliness to face, no hot air blowing into my face and of course easy on my pocket.
And that is reason enough why I wont do it- its too easy!!!!
I will drive my bike all the way to my home. I know people would tell me that this is a plain stupid idea and I would be foolish to think that I would be able to complete the whole journey in one piece. They would try to deter me from my stand point- and its very easy to be swayed away from all this- they have 7 days for this.
I hope next sunday I will be writing my last blog before i commence on my journey.
Of course I can take my bike back to my home via transport- the routine mundane way. Alternatively, I could ride it back home.
I know riding a bike for 1500 kms is not a joke, it will be very tiring. Add to it the fact that I will be doing it alone, braving the hot winds and the terrain for which rajasthan is famous for.
I can easily send my bike via transport, from Baroda to Kanpur- easy, no tiring journey, no loneliness to face, no hot air blowing into my face and of course easy on my pocket.
And that is reason enough why I wont do it- its too easy!!!!
I will drive my bike all the way to my home. I know people would tell me that this is a plain stupid idea and I would be foolish to think that I would be able to complete the whole journey in one piece. They would try to deter me from my stand point- and its very easy to be swayed away from all this- they have 7 days for this.
I hope next sunday I will be writing my last blog before i commence on my journey.
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