Unworthy: Neoliberal Moral Values in Hiv Care for the Homeless

HIV among homeless populations is an important public health issue. Researchers have estimated that three to twenty percent of homeless individuals are HIV-positive, a rate 9-10 time higher than the public at large. However, aspects of the medical institution are often resistant to treat this intersectionally-oppressed population. This thesis searches for the reason for this resistance, arguing that the collective moral leanings of the medical institution are often based in neoliberal, free-market capitalism and that this morality has been instrumental in establishing and perpetuating the healthcare disparity between homeless and housed populations. I suggest that aspects of public health and medicine reflect neoliberal morals and conclude that health programs for the homeless must counter the moral judgments that the homeless have traditionally faced

Incentivizing optimal risk map use for Triatoma infestans surveillance in urban environments.

In Arequipa, Peru, a large-scale vector control campaign has successfully reduced urban infestations of the Chagas disease vector, Triatoma infestans. In addition to preventing new infections with Trypanosoma cruzi (etiological agent of Chagas disease), the campaign produced a wealth of information about the distribution and density of vector infestations. We used these data to create vector infestation risk maps for the city in order to target the last few remaining infestations, which are unevenly distributed and difficult to pinpoint. Our maps, which are provided on a mobile app, display color-coded, individual house-level estimates of T. infestans infestation risk. Entomologic surveillance personnel can use the maps to select homes to inspect based on estimated risk of infestation, as well as keep track of which parts of a given neighborhood they have inspected to ensure even surveillance throughout the zone. However, the question then becomes, how do we encourage surveillance personnel to actually use these two functionalities of the risk map? As such, we carried out a series of rolling trials to test different incentive schemes designed to encourage the following two behaviors by entomologic surveillance personnel in Arequipa: (i) preferential inspections of homes shown as high risk on the maps, and (ii) even surveillance across the geographical distribution of a given area, which we term, 'spatial coverage.' These two behaviors together constituted what we termed, 'optimal map use.' We found that several incentives resulted in one of the two target behaviors, but just one incentive scheme based on the game of poker resulted in optimal map use. This poker-based incentive structure may be well-suited to improve entomological surveillance activities and other complex multi-objective tasks

The impact of the COVID-19 pandemic on rabies reemergence in Latin America: The case of Arequipa, Peru.

In Latin America, there has been tremendous progress towards eliminating canine rabies. Major components of rabies elimination programs leading to these successes have been constant and regular surveillance for rabid dogs and uninterrupted yearly mass dog vaccination campaigns. Unfortunately, vital measures to control COVID-19 have had the negative trade-off of jeopardizing these rabies elimination and prevention activities. We aimed to assess the effect of interrupting canine rabies surveillance and mass dog vaccination campaigns on rabies trends. We built a deterministic compartment model of dog rabies dynamics to create a conceptual framework for how different disruptions may affect rabies virus transmission. We parameterized the model for conditions found in Arequipa, Peru, a city with active rabies virus transmission. We examined our results over a range of plausible values for R0 (1.36-2.0). Also, we prospectively evaluated surveillance data during the pandemic to detect temporal changes. Our model suggests that a decrease in canine vaccination coverage as well as decreased surveillance could lead to a sharp rise in canine rabies within months. These results were consistent over all plausible values of R0. Surveillance data from late 2020 and early 2021 confirms that in Arequipa, Peru, rabies cases are on an increasing trajectory. The rising rabies trends in Arequipa, if indicative to the region as whole, suggest that the achievements made in Latin America towards the elimination of dog-mediated human rabies may be in jeopardy

Progression of Friedreich Ataxia: Quantitative Characterization over 5 Years

Objective Friedreich ataxia (FRDA) is a progressive neurodegenerative disorder of adults and children. This study analyzed neurological outcomes and changes to identify predictors of progression and generate power calculations for clinical trials. Methods Eight hundred and twelve subjects in a natural history study were evaluated annually across 12 sites using the Friedreich Ataxia Rating Scale (FARS), 9-Hole Peg Test, Timed 25-Foot Walk, visual acuity tests, self-reported surveys and disability scales. Cross-sectional outcomes were assessed from recent visits, and longitudinal changes were gaged over 5 years from baseline. Results Cross-sectional outcomes correlated with measures of disease severity. Age, genetic severity (guanine-adenine-adenine [GAA] repeat length), and testing site predicted performance. Serial progression was relatively linear using FARS and composite measures of performance, while individual performance outcomes were nonlinear over time. Age strongly predicted change from baseline until removing the effects of baseline FARS scores, when GAA becomes a more important factor. Progression is fastest in younger subjects and subjects with longer GAA repeats. Improved coefficients of variation show that progression results are more reproducible over longer assessment durations. Interpretation While age predicted progression speed in simple analyses and may provide an effective way to stratify cohorts, separating the effects of age and genetic severity is difficult. Controlling for baseline severity, GAA is the major determinant of progression rate in FRDA. Clinical trials will benefit from enrollment of younger subjects, and sample size requirements will shrink with longer assessment periods. These findings should prove useful in devising gene therapy trials in the near future

Progression of Friedreich Ataxia: Quantitative Characterization over 5 Years

Objective Friedreich ataxia (FRDA) is a progressive neurodegenerative disorder of adults and children. This study analyzed neurological outcomes and changes to identify predictors of progression and generate power calculations for clinical trials. Methods Eight hundred and twelve subjects in a natural history study were evaluated annually across 12 sites using the Friedreich Ataxia Rating Scale (FARS), 9-Hole Peg Test, Timed 25-Foot Walk, visual acuity tests, self-reported surveys and disability scales. Cross-sectional outcomes were assessed from recent visits, and longitudinal changes were gaged over 5 years from baseline. Results Cross-sectional outcomes correlated with measures of disease severity. Age, genetic severity (guanine-adenine-adenine [GAA] repeat length), and testing site predicted performance. Serial progression was relatively linear using FARS and composite measures of performance, while individual performance outcomes were nonlinear over time. Age strongly predicted change from baseline until removing the effects of baseline FARS scores, when GAA becomes a more important factor. Progression is fastest in younger subjects and subjects with longer GAA repeats. Improved coefficients of variation show that progression results are more reproducible over longer assessment durations. Interpretation While age predicted progression speed in simple analyses and may provide an effective way to stratify cohorts, separating the effects of age and genetic severity is difficult. Controlling for baseline severity, GAA is the major determinant of progression rate in FRDA. Clinical trials will benefit from enrollment of younger subjects, and sample size requirements will shrink with longer assessment periods. These findings should prove useful in devising gene therapy trials in the near future