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Biomedical Interventions: Post-exposure Prophylaxis (PEP)
I. Definition of the Prevention Area
Antiretroviral post-exposure prophylaxis (PEP)—short-term antiretroviral therapy initiated soon after known or suspected exposure to HIV—aims to prevent the establishment of HIV infection in an exposed person.
PEP has become the standard of care to prevent acquisition of HIV infection after occupational exposure to blood or other bodily fluids of people infected with HIV. There is less of a consensus regarding the administration of PEP after nonoccupational exposure. While PEP is part of the package of post-sexual assault care in most countries, the use of nonoccupational PEP, outside of rape or isolated incidents of exposure, is more controversial—particularly when the HIV status of the source case is unknown. The World Health Organization (WHO) and the U.S. Department of Health and Human Services offer guidelines for nonoccupational PEP.
II. Epidemiological Justification for the Prevention Area
Each day, new HIV infections occur among health care workers, sexual assault victims, and other individuals following known or suspected exposure to HIV in blood or genital secretions. PEP is generally considered appropriate for people with occasional high-risk exposure to HIV (such as health care workers exposed to bodily fluids of patients with HIV or people sexually assaulted by a person with documented HIV infection). It may also be appropriate following occasional accidental exposure in serodiscordant partnerships (such as when a condom breaks during sex). In other cases of possible exposure, PEP may not be warranted unless there is a strong likelihood that the source of the exposure is HIV-positive.
Evidence suggests that a simple, relatively nontoxic and effective antiretroviral PEP regimen could prevent some of these new HIV infections. Although the degree of protection offered by PEP cannot be established in placebo-controlled trials because of ethical issues, studies of people who had a known exposure to HIV and were administered PEP suggest that PEP is about 80 percent effective in preventing establishment of HIV infection. Data from macaque studies suggest that PEP is protective when administered as soon as possible after exposure and that the effect degrades over time. Thus, in order to be effective, PEP should ideally begin within 48 hours of exposure and at least within 72 hours, and PEP should continue for 28 days. Cases of seroconversion despite PEP have been documented after occupational and nonoccupational exposure to HIV.
III. Core Programmatic Components
Successful implementation of occupational or nonoccupational PEP depends on the following: 1) identification (usually self-identification) of people at risk of exposure; 2) counseling PEP candidates on the implications of seroconversion and, if they are not infected with HIV, on risk reduction to lower the odds of recurrent exposure; 3) informed determination of the exposure risk on a case-by-case basis, including HIV testing of the source, if possible; 4) HIV testing of the PEP candidate before and after completion of PEP; 5) selection of an appropriate PEP regimen; 6) initiation of PEP within at least 72 hours of exposure; and 7) completion of a 28-day PEP course.
IV. Current Status of Implementation Experience
WHO strongly advises national authorities to establish PEP guidelines, especially in countries with a high HIV prevalence. Studies of individuals who have undergone PEP regimens suggest which antiretroviral combinations may be most tolerable as PEP. Tenofovir and emtricitabine have attracted research attention as PEP agents because of their tolerability, once-daily administration as a single pill, and high concentration in the female genital tract. Whether three-drug regimens hold an advantage over two-drug regimens remains uncertain, but U.S. health authorities recommend a three-drug regimen. As with any antiretroviral use, PEP poses some risk of resistance.
Despite the cost of PEP, it has been successfully implemented in low-income countries, such as Kenya (for occupational and nonoccupational exposures) and Malawi (for sexually exposed children). An analysis of four studies suggests that PEP could be cost-effective when following exposure to blood and/or body fluids known to contain HIV. PEP has been used in children and adolescents after sexual assault in both high- and low-income settings. Some work indicates higher toxicity rates and worse adherence in children and adolescents than in adults.
Tenofovir DF Plus Lamivudine or Emtricitabine for Nonoccupational Postexposure Prophylaxis (NPEP) in a Boston Community Health Center
Mayer, K. H., Mimiaga, M. J., Cohen, D., et al. Journal of Acquired Immune Deficiency Syndromes (2008), Vol. 47 No. 4, pp. 494–9.
Completion rates for NPEP are known to be low (less than 50 percent). This may be due, in part, to adverse side effects associated with the use of ZDV either alone, or in combination with 3TC, the regimen recommended by the U.S. Public Health Service. This article describes the results of two trials conducted at the Fenway Community Health Center in Boston that examine Tenofovir DF (TDF) in combination with either 3TC or emtricitabine (FTC) for NPEP. The study looked at the side effects, adherence to treatment, and completion rates of men treated with one or the other TDF combinations (combined n = 112) and compared outcomes with 241 men who received NPEP regimens of ZDV in combination with one or two other drugs during an earlier period at the center. Results demonstrate that both TDF regimens produced milder side effects, better adherence, and high completion rates (73 percent for TDF/FTC and 88 percent for TDF/3TC) compared to ZDV regimens, where side effects were thought to have affected completion rates, which were significantly lower: 39 and 42 percent for ZDV/3TC and ZDV/3TC + third drug, respectively. Although the sample is small, the findings warrant reconsideration of recommended NPEP regimens by the U.S. Public Health Service.
Tolerability of HIV Post-Exposure Prophylaxis With Tenofovir/Emtricitabine and Lopinavir/Ritonavir Tablet Formulation
Tosini, W., Muller, P., Prazuck, T., et al. AIDS (2010), Vol. 24 No. 15, pp. 2375-2380.
According to this study, the standard of care for post-exposure prophylaxis should be a combination of tenofovir/emtricitabine and the tablet formulation of lopinavir/ritonavir, as it is better tolerated, easier to use and has higher rates of continuation than other drug regimens. Once the participants who did not need post-exposure prophylaxis were excluded, more than four fifths continued with the treatment for 28 days. The authors suggest that completion rates could be higher if preventive measures were taken against common adverse events—diarrhea, weakness, nausea and headache, with women worse affected than men.
Prevention of Vaginal Simian Immunodeficiency Virus Transmission in Macaques by Postexposure Prophylaxis with Zidovudine, Lamivudine and Indinavir
Bourry, O., Brochard, P., Souquiere, S., et al. AIDS (2009), Vol. 23 No. 4, pp. 447–54.
The study shows that a triple-antiretroviral (ARV) regimen can protect macaque monkeys from vaginal exposure to the simian immunodeficiency virus (SIV), in some conditions. Three groups of six macaques (n = 18) were vaginally inoculated with SIV. A combination of three ARVs—zidovudine (ZDV), lamivudine (3TC), and indinavir (IDV)—were administered to the experimental groups. One group received ZDV and 3TC orally and the same two drugs were administered to the second group by subcutaneous injection. Both groups received the third drug (IDV) orally; however, the subcutaneous group received a higher dose (60 mg/kg) than the oral group (20 mg/kg). Animals in the control group received placebos and all six became infected. Four of six monkeys in the subcutaneous group were afforded medium-term (230 days) protection, as compared to just one animal in the oral group. The results indicate that administering ARVs to macaques by injection versus mouth was more effective in preventing transmission of SIV; however, the reasons why some animals in both groups were protected and some were not remain unclear.
Non-occupational Postexposure Prophylaxis for HIV: A Systematic Review.
Bryant, J., Baxter, L., & Hird, S. Health Technology Assessment (2009), Vol. 13 No. 14, pp. 1–82.
This document reports on a comprehensive review of selected studies that examine clinical effectiveness and cost-effectiveness of post-exposure prophylaxis (PEP) for HIV. The cost-effectiveness chapter identified four assessments that were selected for inclusion because they detailed all monetary costs of PEP treatment and conducted sensitivity analyses on cost-effectiveness measures for a range of different assumptions (i.e., hypothetical PEP effectiveness rates; high and low transmission probabilities). None of the studies included actual clinical effectiveness as an outcome measure. Instead, they used rates derived from occupational PEP effectiveness studies that were found to be about 80 percent effective for a single ARV regimen (not standard protocol for nonoccupational exposure). Overall, the studies showed PEP programs to be most cost-effective in cases where exposure to HIV occurs among men who have unprotected sex (of all types) with men. Cost savings were less evident for injecting drug users and women who had unprotected vaginal sex, unless there was a very high probability (greater than 73 percent) that a male partner was infected. The authors caution that it would be difficult to generalize results based on these four studies done in the United States and France to other contexts where HIV incidence and cost structure are likely to be quite different.
The Structure and Outcomes of a HIV Postexposure Prophylaxis Program in a High HIV Prevalence Setup in Western Kenya
Siika, A. M., Nyandiko, W. M., Mwangi, A., et al. Journal of Acquired Immune Deficiency Syndromes (2009), Vol. 51 No. 1, pp. 47–53.
A program that provided PEP for HIV was first set up in Western Kenya (Eldoret) at the Moi Teaching and Referral Hospital in 2001. All patients who were referred for PEP during the first five years of the program (November 2001 through December 2006) were studied retrospectively using electronic medical records. The algorithm adopted for evaluating all referrals required a test for HIV status before initiating full treatment. Of the total number who originally referred (n = 446), 19 of the 91 occupational exposures (health workers) and 55 of the 355 nonoccupational exposures (82 percent were victims of sexual assault), refused testing. The PEP regimen adopted initially (in 37 percent of the sample) was a three-drug combination (stavudine/3TC/nevirapine) that may have contributed to a hepatitis-induced patient fatality. Risk of toxicity and hepatitis is known to be associated with nevirapine. In subsequent patients treated (63 percent), the regimen used was ZDV/3TC/lopinavir-ritonavir. No differences in reported side effects or treatment completion rates were found between the two regimens. However, the completion rate for the nonoccupational cohort was less than half that (35 percent) of health workers (76 percent). The authors suggest that efforts to strengthen adherence and completion of PEP programs are necessary to improve outcomes.
Determinants of High-risk Sexual Behavior during Post-Exposure Prophylaxis to Prevent HIV Infection
Golub, S. A., Rosenthal, L., Cohen, D. E., et al. AIDS Behavior (2008), Vol. 12 No. 6, pp. 852–9.
The Centers for Disease Control and Prevention (CDC) guidelines recommend providing behavioral counseling to decrease sexual risk behavior in conjunction with PEP. This study examined the sexual risk behaviors of 89 men who have sex with men (MSM) and receive PEP in Boston, Massachusetts, and specifically asked about their high-risk sexual behavior in the six months prior to PEP and during the 28-day PEP period. Nineteen men (21 percent) reported unprotected anal intercourse (UAI) during PEP; and ten of these men reported UAI with partners of positive or unknown HIV status (11 percent of the overall population). In multivariate analysis, those men with higher depression scores and histories of engagement with HIV service organizations (e.g., receiving services from an HIV-related agency, donating money to HIV-related causes, etc.) were more likely to report UAI with high-risk partners. The investigators postulated that patients engaged with HIV service organizations may be more likely to believe they are protected from HIV by PEP, and thus more willing to engage in risky sexual behavior. These results highlight the need for integration of behavioral counseling for MSM receiving PEP.
Antiretroviral Drug Exposure in the Female Genital Tract: Implications for Oral Pre- and Post-exposure Prophylaxis
Dumond, J. B., Yeh, R. F., Patterson, K. B., et al. AIDS (2007), Vol. 21 No. 14, pp. 1899–907.
PEP for women is most likely to be effective when it is initiated early with a drug that quickly and effectively concentrates in the genital tract. This study examined the pharmacokinetics of oral ARV drugs in female genital secretions. Blood and cervicovaginal fluid samples were taken from 27 women on the day they started PEP, three weeks later, and then monthly for six months. All of the 11 ARV drugs examined in this study achieved detectable concentrations in genital secretions within four hours after the first dose. Of the nucleoside analogs, ZDV, TDF, 3TC, and FTC achieved higher steady-state levels in the genital tract than in the blood. The protease inhibitors studied, lopinavir and atazanavir, achieved only moderate to low concentrations in the genital secretions compared to levels in the blood; as did efavirenz, the only non-nucleoside agent studied. These findings support the use of 3TC, ZDV, TDF and FTC, nucleoside, and nucleotide reverse transcriptase inhibitors for PEP.
Assessment of Adverse Events Associated with Antiretroviral Regimens for Post-exposure Prophylaxis for Occupational and Nonoccupational Exposures to Prevent Transmission of Human Immunodeficiency Virus
Luque, A., Hulse, S., Wang, D., et al. Infection Control and Hospital Epidemiology (2007), Vol. 28 No. 6, pp. 695–701.
The goal of this study was to assess adverse events associated with different antiretroviral therapy (ART) regimens for PEP with a particular focus on TDF-containing regimens. The investigators performed a retrospective chart review of 113 health care workers who received occupational PEP between 1999 and 2004, and 87 patients who received NPEP between 2002 and 2004. Nausea was reported by the majority of patients and health care workers who received ZDV-3TC-TDF (66 percent) or ZDV-3TC-IDV (54 percent), but less than half of those who received ZDV-3TC (29 percent) or ZDV-3TC-nelfinavir (NFV; 40 percent). Subjects who received ZDV-3TC-TDF were less likely to complete PEP than subjects who received treatment with ZDV-3TC-IDV or ZD-3TC. This study underscored the impact of adverse side effects on the completion of PEP in both occupational and nonoccupational settings.
The Public Health Impact of Widespread Availability of Non-Occupational Post-Exposure Prophylaxis Against HIV
Poynten, I. M., Smith, D. E., Cooper, D. E., et al. HIV Medicine (2007), Vol. 8 No. 6, pp. 374–81.
The use of PEP is accepted and practiced widely in Australia, particularly among MSM. Only registered providers can prescribe ART, which allowed the authors of this study to identify and prospectively follow the cohort who received PEP from 1998 to 2004. Most of the 1,552 patients were male (95 percent), and the majority of sexual exposures were male-to-male (87 percent). PEP was initiated in 92 percent of patients within 72 hours. Of the 1,146 patients who returned for evaluation four weeks after starting PEP, 86 percent had completed the original or a modified regimen. Three subjects seroconverted within six months after PEP, all of whom had ongoing sexual risk behaviors in the time during and after PEP. Based on epidemiologic data, the investigators estimated that only between one and nine HIV infections were averted in the study population. This relatively small effect is attributed to the low likelihood of transmission in any one sexual encounter and the fact that many, or most, of the exposure sources were not actually infected with HIV.
Seroconversion Following Non-Occupational Post-Exposure Prophylaxis against HIV
Roland, M. E., Neilands, T.B., Krone, M. R., et al. Clinical Infectious Diseases (2005), Vol. 41, pp. 1507–13.
In San Francisco, a feasibility study of PEP was conducted in which subjects were offered the drug treatment (either ZVD-3TC, stavudine-3TC, or stavudine-didanosine) and counseling sessions. Participants were part of a 52-week assessment on medication initiation, adherence, side effects, and seroconversion. Those who knew that their HIV-infected source partner had a detectable viral load on ART were also given NFV. Most of the subjects were male (95 percent), and the majority had had sexual exposure to HIV (96 percent). Seven seroconversions occurred in 702 subjects (1 percent) and these individuals started PEP significantly later than subjects who did not seroconvert (median 45.5 hours versus 32.5 hours). Three of the seroconverters started PEP more than 45 hours after exposure; and three reported missing several doses of medication. This study demonstrated that PEP is not 100 percent effective. To increase its chances of effectiveness, it must be started as quickly as possible and the importance of complete adherence must be emphasized to patients.
Introduction of HIV Post-exposure Prophylaxis for Sexually Abused Children in Malawi
Ellis, J. C., Ahmad, S., & Molyneux, E. M. Archives of Disease in Childhood (2005), Vol. 90 No. 12, pp. 1297–9.
This program was designed to improve the care of victims of child sexual abuse (CSA) in Malawi by routinely assessing eligibility for PEP, and to investigate the feasibility, safety, and efficacy of such treatment in a pediatric emergency department. Sixty-four children seen at Queen Elizabeth Central Hospital and Blantyre between January 2004 and December 2004 were assessed for eligibility for HIV PEP and followed prospectively for six months. Among these 64, all of whom presented a history of alleged CSA in the 12-month period, 17 were offered PEP. The remainder were not offered PEP due to the absence of physical signs of abuse (sample size, n = 20), delay in presentation beyond 72 hours from assault (n = 11), repeated sexual abuse in the preceding six months (n = 15), and HIV infection found on initial testing (n = 1). No family refused an HIV test, and no ART-related side effects were reported. Of the 17 children who commenced PEP, 1 returned for a follow-up at one month, 7 returned at three months, and 2 of 15 returned at six months post-assault. None of those who returned for a follow-up seroconverted. The authors concluded that in a resource-poor setting with a high HIV prevalence, PEP following CSA is acceptable, safe, and feasible. The authors recommended that HIV PEP be incorporated into national guidelines in countries with a high community prevalence of HIV infection.
Efficacy of Postexposure Prophylaxis after Intravaginal Exposure of Pig-Tailed Macaques to a Human-Derived Retrovirus (Human Immunodeficiency Virus Type 2)
Otten, R. A., Smith, D. K., Adams, D. R., et al. Journal of Virology (2000), Vol. 74 No. 20, pp. 9771–5.
This study investigates the critical window for initiating PEP using an animal model (macaque monkeys). The methodology was a departure from other animal studies in that vaginal exposure with a human HIV retrovirus (HIV 2), as opposed to SIV, was used. A control group (n = 4) was compared with three experimental groups (n = 4 each) that varied by treatment initiation times (12, 24, and 72 hours). The treatment regimens for the experimental groups were identical and employed a single ARV [(R)-9-(2-phosphonylmethoxypropyl) adenine (PMPA)] for 28 days. Three animals in the control group seroconverted (one, inexplicably, did not convert). All eight animals in the 12- and 24-hour treatment initiation groups were protected. The 72-hour group had mixed results: one animal converted, one died of a cause unrelated to treatment, and two remained healthy. The researchers suggest that initiating therapy sooner than the 72-hour window generally used as a cutoff in national guidelines is likely to improve the effectiveness of treatment. The authors consider the study results to represent "proof of concept" for PEP in humans.
Prevention of SIV Infection in Macaques by (R)-9-(2-phosphonylmeth-oxypropyl)adenine
Tsai, C. C., Follis, K. E., Sabo, A., et al. Science (1995), Vol. 270 No. 5239, pp. 1197–9.
There is an urgent need for identifying effective and well tolerated ARVs that can be used to prevent HIV infection post exposure. Drugs currently being used therapeutically, such as ZDV, often produce adverse side effects. A study that used an animal model (long tail macaques) to examine the efficacy and toxicity of a new drug showed that PMPA, a reverse transcriptase inhibitor, prevented SIV in 100 percent of the exposed animals (n = 15), regardless of whether they received pre- (48 hours prior to inoculation with SIV) or post-exposure treatment (4 hours and 24 hours after inoculation). In contrast, all animals in the control group developed SIV within a one- to three-week period. The dose given to animals in the pre-exposure group was lower (20 mg/day) than those treated post-exposure (30 mg/day). None of the animals in the treatment group were observed to have had adverse effects. The results suggest that PMPA is a promising candidate for use in PEP regimens, although the efficacy of the drug in combination with others that are used in treating humans must be conducted.
Nonoccupational HIV Post-exposure Prophylaxis: A 10-year Retrospective Analysis
Tissot, F., Erard, V., Dang, T., et al. HIV Medicine (2010), Vol. 11 No. 9, pp. 584–92.
This retrospective study, conducted in Switzerland, is the largest account of the precipitating circumstances, clinical procedures, and outcomes associated with NPEP of HIV. Of 1068 referrals for PEP, 910 eligible records were identified for the study: 734 reported sexual exposures and 179 reported nonsexual exposures, the latter were primarily users of illicit drugs who were sharing drug injecting equipment. The sample is unusual because the large majority of exposures were heterosexual (77 percent). Research reported in the literature focuses on MSM or assault victims. Following established Swiss national guidelines, if the HIV status of the source person or object is unknown or uncertain, an attempt to find the source and determine and confirm status is made. In 72 percent of the cases, the source was not known. However, 298 sources (42 percent) were found and 178 tested negative, thereby reducing the number of unnecessary PEP treatments in 31 percent of the group (n = 283). An additional 11 individuals from high-risk groups were found to be living with HIV. Of the 710 people who initiated PEP, 423 completed treatment, 108 discontinued when the source was determined to be HIV-negative, 39 dropped out because they could not tolerate the drug regimen, and a high number of 117 people (16 percent) were lost to follow-up. The researchers conclude that tracking and testing the source for the exposure is not only good clinical practice, but also cost-effective.
Postexposure Prophylaxis for HIV Infection
Landovitz, R. J., & Currier, J. S. New England Journal of Medicine (2009), Vol. 361, pp. 1768–75.
Although evidence of the efficacy of PEP for HIV has not been established in clinical trials due to cost and ethical issues, guidelines have emerged from a host of smaller studies that provide reliable parameters for when exposure indicates treatment for different exposure types (occupational and nonoccupational) and cases that have the highest risk for transmission. Elapsed time from exposure to treatment (no more than 48 hours), the duration of treatment (4 weeks), risks and benefits associated with different drug combinations, and requisite adherence to regimens are considered in turn. Useful tables on two- and three-drug combinations and laboratory tests recommended for persons exposed and treated are also included. The authors conclude that although PEP is considered to be effective when certain conditions are met, ultimately, it is the degree of risk aversion on the part of the doctor and the patient that will dictate whether PEP is initiated and completed.
Occupational and Nonoccupational Postexposure Prophylaxis for HIV in 2009
Landovitz, R. J. Topics in HIV Medicine (2009), Vol. 7 No. 3, pp. 104–8.
This article reviews treatment protocols and new studies on combination drug regimens for HIV PEP. Guidance on elapsed times from exposure to initiation of treatment in nonoccupational cases, a critical variable in success, ranges from 36 (U.S. state of New York) to 72 hours (CDC, WHO, and others). The rationale for the differences is discussed. The author also includes useful tables with doses and common side effects of the most commonly used two-drug regimen (e.g., 3TC/ZDV) and more recent ones (TDF/FTC) as compared to triple combinations (e.g., 3TC/ZDV plus IDV or NFV). Two-drugs are better tolerated, although three-drugs are indicated when significant ARV drug resistance or high-risk exposure has been identified. Patients referred for PEP must be assessed for transmission risk (minimal to moderate). A collateral benefit of providing PEP to patients is that, in the author's view, it can be used as a valuable educational moment, an opportunity to discuss behavioral risks and suggest referrals for additional screening and counseling.
Post-exposure Prophylaxis (PEP) to Prevent HIV Infection: Guidelines on the Use of Treatment Starter Kits
United Nations Organization. (n.d.).
This document provides explicit procedures that are to be adopted in any type of PEP for HIV experienced by U.N. personnel or family members who work and live in regions where medical treatment may not be immediately available. Starter kits with five days worth of a three-drug combination ARV for PEP, in addition to emergency contraception for possible pregnancy, are made available to team leaders. Rationale for the steps to be followed and information for local doctors or medical staff who may be unfamiliar with PEP are also given.
Engendering Health Sector Responses to Sexual Violence and HIV in Kenya: Results of a Qualitative Study
Kilonzo, N., Taegtmeyer, M., Molyneux, C., et al. AIDS Care (2008), Vol. 20 No. 2, pp. 188–90.
Societal norms underlie sexual violence perpetrated on women, but these attitudes are poorly understood and rarely discussed in African countries. To inform HIV prevention programs being set up for victims of sexual abuse in three districts in Kenya, researchers conducted 16 focus groups and 34 key informant interviews with adult and adolescent men and women, counselors, members of the police, religious organizations, and legal advocates. Results reveal that what people think constitutes consensual and coerced sex, both within and outside marriage, is ambiguous. Both men and women said that women and girls who say "no" to sex do not necessarily mean it. Counselors and police said they felt unprepared to discuss rape and provide adequate support to victims of sexual violence. In addition, there was very little awareness of the availability of PEP, what it entailed, and its value in preventing HIV. The researchers recommend that community outreach about PEP and gender training for heath sector staff and others who interact with rape victims should be integral components of prevention and treatment programs.
Delivering Post-rape Care Services: Kenya's Experience in Developing Integrated Services
Kilonzo, N., Theobald, S. J., Nyamato E., et al. Bulletin of the World Health Organization (2009), Vol. 87 No. 7, pp. 555–9.
Offering integrated services for rape victims that include PEP is difficult everywhere in the world but presents significant challenges in resource-limited settings. This article describes the process used in three districts in Kenya to initiate a comprehensive sexual assault and PEP program. Based on two waves of formative research, the district health management teams, in collaboration with a Kenyan nongovernmental organization, trained personnel in hospital or clinic emergency units. The teams developed, and providers successfully used, an algorithm that detailed triage and standards of care for a full range of services for victims (clinical exam, PEP eligibility and treatment, test for HIV status, trauma counseling, emergency contraception, treatment of sexually transmitted infection, legal support, and post-treatment testing). The program provided PEP to 84 percent of the 784 rape victims referred for treatment in the three districts between 2003 and 2007. The estimated per patient cost for services (PEP, labs, and staff) was $27. The authors believe that the model can be replicated in other resource-poor locales, and provide recommendations and lessons learned based on their experience.
Post-exposure Prophylaxis for HIV Infection After Sexual Assault: When is It Indicated?
Fong, C. Emergency Medicine Journal (2001), Vol. 18, pp. 242–5.
Determining whether to offer emergency PEP to victims of sexual violence requires doctors to rapidly assess multiple factors. The effectiveness of NPEP is not known because clinical trials have not been conducted; therefore, decisions to offer PEP treatment must be made by judging the evidence for each case individually. The author presents a three-step decision tree for assessing who should receive PEP. The three factors are the following: 1) the actual or likely HIV status of the perpetrator (if known or determinable); 2) the probable risk that the assault would lead to HIV; and 3) considerations that affect treatment effectiveness (e.g., time elapsed since the attack, trauma, likelihood of completing treatment, special needs groups such as pregnant women and children). Despite the issues outlined, the author concludes that even when the risk of transmission is small, offering victims of assault PEP may well be justifiable.
HIV PEP Guidelines After Sexual Assault
Harborview Medical Center. (2007).
These guidelines for PEP, revised in April 2010, describe three levels of risk for HIV based on the type of perpetrator (e.g., HIV-positive, MSM), extent of injury and/or type of assault (e.g., vaginal, rectal, oral), and elapsed time since the event. Considered together, the three indicators are used to determine likelihood of transmission and the type of PEP treatment (none, basic, or expanded) that would be recommended. Useful case management guidance and additional guidance on determining PEP eligibility is also given in the appendix, which details five case examples of sexual assault and risk.
HIV Post-Exposure Prophylaxis in an Urban Population of Female Sex Workers in Nairobi, Kenya
Izulla, P., L.R. McKinnon, J. Munyao, et al. 2012. Journal of Acquired Immune Deficiency Syndromes. [Epub ahead of print].
Post-exposure prophylaxis (PEP) is a potential HIV prevention strategy among high-risk groups such as sex workers (SWs). The study examined how PEP was used, its adherence levels, and HIV incidence among SWs in Nairobi, Kenya. Non-infected participants were selected from among those who were enrolled in a prevention and care program for sex workers from 2008 to 2010. Eleven percent (n = 326) of SWs requested PEP after it was offered in 2009. Those who did not use PEP were a natural control group (n = 2,570). PEP users received risk reduction counseling, HIV counseling and testing, Combivir twice a day for 28 days, emergency contraception, and sexually transmitted infection prophylaxis. A physical exam and blood work were given to all those who requested PEP as well as a questionnaire to document demographic, behavior, and PEP use information. It was found that there were no HIV seroconversions among the PEP users while 2.2 percent of non-users seroconverted. PEP users were found to be in sex work for a shorter amount of time, less likely to have a regular partner, more likely to use a condom 100 percent of the time with causal clients, and more likely to be tested for HIV prior to the study compared to non-users. Most requests for PEP came after sex with a first time causal client (69.2 percent). The most common reasons for seeking PEP were not trusting the client and not knowing the client's HIV status. It is recommended that PEP use be within the first twenty-four hours after exposure, and the median time from possible exposure to HIV and PEP use was 18 hours. However, one-fourth of the SWs initiated PEP after thirty-six hours, which is longer than recommended. Fifty-six percent returned to the clinic for their final PEP dose; therefore, adherence needs to be improved. The authors recommend that guidelines for PEP use need to be developed for this population.
Adherence to HIV Post-Exposure Prophylaxis in Victims of Sexual Assault: A Systematic Review and Meta-Analysis
Chacko, L., N. Ford, M. Sbaiti, et al. 2012. Sexually Transmitted Infections Vol. 88 No. 5, pp. 335-41.
The review and meta-analysis explored post-exposure prophylaxis (PEP) access rates and levels of adherence among adults and children after they were sexually assaulted in both developed and developing countries. All observational and experimental studies that addressed the topic of PEP adherence among sexual assault victims were included in the analysis. The authors reviewed data on the study's characteristics, indicators on the quality of the studies, and outcome data. They also distinguished between those who were adherent to the PEP regimen, those who refused PEP treatment, and those who defaulted on the regimen. Twenty-four studies met the inclusion criteria. The studies included both adults and children, and about half were from sexual assault services. Eight of the studies were conducted in developing countries. The majority of studies did not report how adherence was measured, and the studies varied on the PEP regimens that were prescribed. There was a wide range of reported adherence in the cohort studies, from about 12 percent to 74 percent. The pooled proportion was about 40 percent, and this figure was somewhat higher compared to what was found in the randomized controlled trial. Adherence in developing countries was higher than in developed countries. For defaulters in the cohort studies, the range was from about 3 percent to 76 percent, with the pooled proportion at about 41 percent. In the cohort studies, the pooled proportion of clients who refused PEP was about 29 percent, and about one-third did not complete the full PEP regimen. In conclusion, there is a need to standardize PEP treatment among sexual assault victims as well as to increase activities and research to improve adherence.
Post-exposure Prophylaxis to Prevent HIV Infection: Joint WHO/ILO Guidelines on Post-exposure Prophylaxis (PEP) to Prevent HIV Infection.
World Health Organization (WHO), & International Labor Organization (ILO). (2007).
These are joint WHO and ILO guidelines on PEP to prevent HIV infection. They aim to provide a unified framework to guide both PEP policy development and the implementation of services for occupational and nonoccupational HIV exposures, with a focus on occupational exposure and exposure through sexual assault. This document does not provide detailed guidance relating to exposure through injecting drug use or through consensual sex.
Management of Non-Occupational Post Exposure Prophylaxis to HIV (NONOPEP): Sexual, Injecting Drug User or Other Exposures.
European Project on Non-Occupational Post Exposure Prophylaxis (EURO-NONOPEP). (n.d.).
EURO-NONOPEP is a collaboration of 14 European countries. The goals of the collaboration are to collect and describe the PEP guidelines of all participants to evaluate PEP-related knowledge among patients and providers, and to maintain a registry of nonoccupational HIV exposures.
Antiretroviral Post-exposure Prophylaxis After Sexual, Injection-Drug Use, Or Other Nonoccupational Exposure to HIV in the United States: Recommendations from the U.S. Department of Health and Human Services.
CDC. MMWR (2005), Vol. 54, pp. 1–20.
The CDC recommends prompt initiation of PEP with highly active ART (HAART) for persons who seek care within 72 hours after a nonoccupational exposure to infectious body fluids of a person with known HIV infection, if the exposure event presents a substantial risk for transmission. HAART should be continued for 28 days. Exposures are defined as "any direct mucosal, percutaneous, or intravenous contact with potentially infectious body fluids that occurs outside perinatal or occupational situations. Potentially infectious body fluids are blood, semen, vaginal secretions, rectal secretions, breast milk, or another body fluid that is contaminated with visible blood." When the HIV status of the source is not known and the patient seeks care within 72 hours after exposure, the CDC does not recommend for or against PEP but encourages clinicians and patients to weigh the risks and benefits on a case-by-case basis. When the transmission risk is negligible or when patients seek care more than 72 hours after a substantial exposure, PEP is not recommended. However, clinicians might consider prescribing PEP for patients who seek care more than 72 hours after a substantial exposure if, in their judgment, the diminished potential benefit of PEP outweighs the potential risk for adverse events from ARV medications.
Post Exposure Prophylaxis Guidelines for Occupational Exposure
National AIDS Control Organisation (NACO)-India. (n.d.).
This document gives NACO's clear and concise guidelines for preventing and responding to occupational injuries that expose hospital workers and others to HIV. Separate flow charts detailing the differential levels of risk associated with types of injuries and the HIV status of the exposure source were developed to evaluate whether PEP would be recommended, and if so, the type of regimen that is most appropriate.
Offering HIV Post-Exposure Prophylaxis (PEP) Following Non-Occupational Exposures: Recommendations for Health Care Providers in the State of California
California Task Force on Non-Occupational PEP & California Department of Health Services. (2004).
This document offers a comprehensive discussion of the critical issues that medical providers must consider before offering PEP for HIV in cases of nonoccupational exposure. Areas covered include the elapsed time from the event to referral, type of exposure and its associated risk (e.g., receptive/insertive anal or vaginal intercourse; shared needle), and the actual or likely HIV status of the source person or instrument. A summary of key studies on these issues and research on drug regimens used in different circumstances provides good background information for providers. Also useful are the patient information sheets on frequently asked questions, patient information forms, and provider scripts on topics that should be discussed with patients, which are provided in appendices.
HIV PEP: Now There is a Treatment that May Prevent HIV Infection After the Virus has Entered the Body
Terrence Higgins Trust. (2004).
This colorful five-page booklet is intended to raise awareness among MSM about the availability of emergency PEP for HIV. Using a question and answer format ("We had unsafe sex . . . the condom broke. . . is it worth asking for PEP?"), and written in plain, nontechnical language, the pamphlet describes the who, what, where, and when of PEP—namely, eligibility, factors affecting success, how and where treatment is administered, and possible side effects.
PEP Online Self-Assessment
Terrence Higgins Trust. (2004).
This website offers a brief online questionnaire that assesses eligibility for PEP. A series of questions establish when the exposure occurred and the actual or likely HIV status of the partner and recommends whether PEP is indicated or not. The site also offers links to a sexual assault hotline, how to find PEP administration centers, and easily accessible information about PEP that can be downloaded.
Development of Guidelines on Nonoccupational HIV Postexposure Prophylaxis for the State of Rhode Island
Merchant, R. C., Mayer, K. H., & Browning, C. A. Public Health Reports (2004), Vol. 119, pp. 136–40.
This article describes the history of the U.S. state of Rhode Island's developing PEP guidelines. Rhode Island was the first state to establish such guidelines, which were disseminated in 2002. The key elements of the guidelines (context, timing, consent and testing, and recommended regimens) are summarized. However, the information in the guidelines is not as clear, nor as comprehensive, as guidelines that were published subsequently by the U.S. Government or by international organizations. Also, the drug regimens do not take into account recent research on adverse side effects associated with some multidrug regimens.
Antiretroviral Agents Used by HIV-Uninfected Persons for Prevention: Pre- and Postexposure Prophylaxis
Grant, R. M. Clinical Infectious Diseases (2010), Vol. 50 Suppl. 3, pp. S96–101.
The author reviews the range of biomedical prevention therapies from prevention of mother-to-child transmission to pre-exposure prophylaxis (PrEP) and PEP. The author also discusses issues that challenge research on new prophylactic approaches and individual and societal barriers that affect provision and use. PEP is not commonly offered where resources are scarce because questions about treatment efficacy and regimen safety prevail. The author also considers issues that have been raised with respect to PrEP (a daily oral dose of a single ARV or in combination) and microbial (ARV in gel form) prevention approaches for high-risk populations. A concern raised is that prevention options like these confer safety from HIV and may lead individuals to believe that they can engage in risky sexual behavior. Clinical trials currently underway will provide answers to some of these concerns and will help inform decisions by implementers and policymakers in determining what programs are offered in resource-poor locales. The author cautions that community acceptance and support for biomedical approaches like these are critical to adherence and successful outcomes.
Narrative Review: Antiretroviral Therapy to Prevent the Sexual Transmission of HIV-1
Cohen, M. S., Gay, C., Kashuba, A. D. M., et al. Annals of Internal Medicine (2007), Vol. 146 No. 8, pp. 591–601.
This summary focuses on the findings of prevention studies for PrEP and PEP within the larger literature review covered by the article. The rationale for PEP is based on a series of studies conducted with rhesus and macaque monkeys that provide the critical parameters of treatment—namely, beginning ARVs not later than 72 hours after exposure and continuing with the regimen for 28 days. The limitations of animal studies for PEP reflect shortcomings of studies conducted with humans. Rigorous trials have not been carried out because they require very large samples and are prohibitively expensive or face ethical dilemmas. Therefore, studies use small samples and do not address long-term patient outcomes. In fact, only one study with humans has proven that PEP is effective in preventing HIV. This was a retrospective case control study of medical accidents with sharps (n = 679). An 81 percent reduction in risk was registered when ZDV (or another ARV drug) was administered to workers who were exposed. Protocols and guidelines used worldwide are based on this research and the series of animal studies. The authors discuss a number of potentially harmful consequences if widespread use of ART for prevention is adopted, including increased high risk behaviors on the part of people who believe themselves to be safe, emergence of drug resistance strains, and provision of ARVs to those with low probability for HIV transmission.
National HIV/AIDS Clinicians' Consultation Center
University of California, San Francisco. (2010).
This U.S.-based center hosts a PEP hotline for providers seeking clinical guidance related to the treatment occupational exposure to HIV.
Related Prevention Knowledge Base Interventions
Related AIDSTAR-One Publications


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This Plain Style Stainless Steel Cross Pendant is meaningful and beautiful, as well as being subtle. This Stainless Steel cross necklace had traditionally detailed points on the cross, adding a little detail without making this piece overly ornate or gawdy. Have the plain Cross pendant delivered on a 18, 20 or 24 inch curb chain. This 1.25 by 1 inch cross plain necklace is a perfect way to express your faith in style.
Eve's Addiction.com wants you to be a happy customer. We want you to be completely satisfied with the sterling silver jewelry that you receive from us, as we only sell high quality silver and cubic zirconia cz jewelry. We do understand that you may not like your purchase for some reason.
You may return or exchange your jewelry within 60 days of purchase if you are not satisfied with it. The jewelry must be returned in its original condition for a refund or exchange. Engraved, personalized, photo, monogram, name and initial, chocolate and clearance items are not returnable or exchangeable.

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text: Honduras is a democratic republic in Central America. It was formerly known as Spanish Honduras to differentiate it from British Honduras (now Belize). Archaeologists have demonstrated that Honduras had a rich, multi-ethnic prehistory. An important part of that prehistory was the Mayan presence around the city of Copán in western Honduras, near th ...e Guatemalan border. A major Mayan city flourished during the classic period (150-900) in that area. It has many carved inscriptions and stelae. In the northeastern region of La Mosquitia lies the Río Plátano Biosphere Reserve, a lowland rainforest which is home to a great diversity of life. The reserve was added to the UNESCO World Heritage Sites List in 1982. Honduras has rain forests, cloud forests (which can rise up to nearly three thousand meters above sea level), mangroves, savannas and mountain ranges with pine and oak trees, and the Mesoamerican Barrier Reef System. In the Bay Islands there are bottlenose dolphins, manta rays, parrot fish, schools of blue tang and whale shark.Show More


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Chengguan - Fushun, China
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Folding Knives
Columbia River
Priceless than $25
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Recent Folding Knife Reviews
Gerber Obsidian
I like this knife for a number of reasons. Notably it has a double lock mechanism so it will never shut on my fingers. The compact size means it doesn't take up valuable space and it weighs very little – 124 gms. The open design allows dirt and grit to fall through and not jam it up. The blade is 7cm or 2.75" in the old scale, the steel holds an edge well and cuts everything I've needed to date — opening dehydrated meal packets, cutting rope, fishing line and fruit. Additionally, there is… Full review
EKA Swede 8 Wood
The Eka 8 is a Swedish folding knife with Sandvik 12c27 blade. 8 stands for 8 cm (3.15") Just enough for everyday use. The geometry of the blade is good for the hunter and the camper. Not the best wood carving knife, but that's kind of obvious with this blade. Light to carry. Ease of Use: Smooth opening, great lock, sharp and easy to sharpen steel. Features: Hole for cord. A short leather cord with a knot is great for getting it out of the pocket and gives some extra control when hands are bloody… Full review
Benchmade Mini-Griptilian
Custom Mini-Griptilian (S30V): Well constructed, factory sharp knife. Handle gives good grip, and the opening hole (Pardue) is more comfortable than any other design. Purchased this through Benchmade's "custom" ordering process. The order was easy to specify precisely what blade, steel, and grips I wanted. Overall, the knife is light but well put together. It's sharp and the S30V steel will keep its edge longer over other steels. My only complaint is that the handle is not "open" to allow dust and… Full review
Fällkniven PXLwh
Does exactly what I want and need for what I consider to be an essential hiking tool. Safe, reasonably light, durable, and sharp. For those who want a folding knife with a clip, look elsewhere. I consider a good knife to be one of the essential tools of the trade for hiking. There are lots of great options; this one is particularly useful. Basic Information This knife weighs about 4 1/2 ounces, and the blade is about 3 1/2 inches long. It's a folding knife — the blade folds away when you don't… Full review
Gerber EVO Jr.
Accessible, rugged protection. The reason I bought this knife is the pocket clip, which makes the knife easily and readily accessible when I experience drunks or hostile people or dogs while riding my bicycle. I clip it either onto the loop of my shoulder strap on my daypack, or onto the front pocket of my sport shirt while riding. Actually, I take it with me when walking, too, because you never know what kind of people/dogs you are going to encounter. It beats carrying a handgun, which I would… Full review
Kershaw Chill
Fantastic knife that won't break the bank, or your heart, if you lose it. I've had a knife in my pocket since Junior High. I see them as tools and use them daily at work, so my EDC knife is usually one of my five Swiss Army knives. When backpacking, however, I usually take a locking blade. Twenty years ago, that was the standard Buck. About five years ago, I began adding to my collection, and believe I have found (at least for me) what I consider to be the perfect knife. I've been drooling over… Full review
Spyderco Kiwi
A very lightweight, high-quality folding knife with a blade that's excellent for cutting things and good for food prep. I like knives, and I'm always on the lookout for good backpacking knives. A backpacking knife needs to be light, strong, well constructed and functional. A folding knife for backpacking should have a sturdy pocket clip so that it can be securely carried. The Spyderco Kiwi 4 meets all these criteria. Version 4 of the Spyderco Kiwi is a significant upgrade to the Kiwi line of knives. Full review
Kershaw Half Ton
OK knife for EDC or the pack, but there are much better knives out there. I bought this knife on a whim at my local Lowes for $20. First the pros: It has a fairly stout, drop point, c8CR13MOV stainless steel blade that is easily sharpened. The blade doesn't have much recurve. The thumb stud allows for quick, easy deployment. The liner lock seems to lock solidly. Conversely, the handle just didn't feel right. The knife felt very heavy in my hand, unlike some of the other knives I own. The wrench… Full review
Opinel No. 9 Folding Knife
The proven simple and dependable design for over 100+ years. I purchased the #9 model from its indigenous country, France, during a conference meeting I was attending. I have known the knife for some time and wanted to add one into my gear arsenal. The sizes vary from ridiculously small to unnecessarily large. I picked the #9, a little bit larger than the popular #7 or #8. The first thing noticeable is the fact that it is light, almost feather-like. For those of you minimalist guys, I can definitely… Full review
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The soft shimmer on our Frosted Silver Steel Bangle Bracelet makes this classic style an undeniably chic addition to your jewelry collection. The smooth stainless steel inner surface of the bangle lies comfortably against the skin, while the frosted outer surface draws the eye with its subtle yet lovely glow. The inner circumference of the bangle is a full 8 inches, making this bangle wearable for most women. You won't regret adding this lovely bangle bracelet to your next outfit!
Eve's Addiction.com wants you to be a happy customer. We want you to be completely satisfied with the sterling silver jewelry that you receive from us, as we only sell high quality silver and cubic zirconia cz jewelry. We do understand that you may not like your purchase for some reason.
You may return or exchange your jewelry within 60 days of purchase if you are not satisfied with it. The jewelry must be returned in its original condition for a refund or exchange. Engraved, personalized, photo, monogram, name and initial, chocolate and clearance items are not returnable or exchangeable.


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Barn quilts are gaining popularity in Surry and Yadkin counties.
The colorful, wooden quilt blocks adorning barns, sheds, and even houses are adding interest along county roads. Surry Community College is offering two barn quilt classes at the Elkin Center, 1461 N. Bridge St. in Elkin.
The first class will meet on Friday, March 8 from 9 a.m. to 3 p.m. The second class is scheduled for Friday, April 19 from 9 a.m. to 3 p.m.
Students may make a 2' x 2', 3' x 3', or 4' x 4' wooden barn quilt block. Each class is limited to six students. Interested persons should call Terri Cockerham at (336) 386-3244 or Sonnie Hardy (336) 386-3229.
Barn quilt trails are becoming tourist attractions. Recently, the Yadkin Arts Council established a Yadkin County Quilt Trail with 30 locations on the trail. For more information, go to www.yadkinarts.org.
About Surry Community College
Surry Community College was founded in 1964 and is located in Dobson, North Carolina. As one of the state's 58 community colleges, it serves Surry and Yadkin counties. Currently, Surry offers27 degree programs, 16 diploma programs, and 22 certificate programs, with hundreds of continuing education courses and seminars.


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Derek Jeter Big Head: Now you can get your head in the game with your very own cut out of Derek Jeter's face. Unlike giant head posters or other player head photos, MLB Big Heads are sturdy and big enough to stand out in any crowd. There's no better way to prove you're a fan than with an officially licensed MLB Fathead Big Head.
Team: New York Yankees
Position: Shortstop
Born: June 26, 1974 in Peqaunnock Township, New Jersey
Turned Pro: 1995
Awards / Notes: Jeter is a 13 time All-Star selection (1998-2002, 2004, 2006-2012), a 5 time World Series Champion (1996, 1998-2000, 2009), a 5x Gold Glove Award winner (2004-2006, 2009, 2010) and a 5 time Silver Slugger Award winner (2006-2009, 2012). On July 9th, 2011, Derek Jeter made his 3,000th hit, becoming the first Yankee to reach that milestone. In 2000, he was named All-Star Game MVP, World Series MVP and he won the Roberto Clemente Award.
What Are Fathead Big Heads?: Fathead Big Heads are portable cutouts of players' heads or your own head (we make Custom Big Heads too). That's right, the head and nothing but the head (well the face actually). Fathead Big Heads are printed on high density foam core and die cut around the face. They are meant to be held up and displayed with the kind of passion that would lead you to buy someone's head at ten times normal size. Which is not normal, but is very Fathead. Fathead Big Heads fully embrace the saying, "Get Your Head in the Game!"
What It's Made Of: A Fathead Big Head is printed on high density 3/16 inch foam core and die cut around the player's face. They are not wall graphics or self-adhesive.
Suggested Uses: Fathead Big Heads are designed so you can take them with you. Hold up a Fathead Big Head at the big game to psych out the opposing team! Make a Custom Big Head of your child and show your support at their sporting event! Fathead Big Heads are also perfect for birthday and office parties. However you choose to use them, they are meant to stand out in a crowd.
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Comments about Fathead Derek Jeter Big Head:
I purchased both Derek Jeter and Alex Rodriguez Fatheads and hung them in the classroom. I am using them in "Voice" writing lessons. Students take on the persona of the player and write dialogues of what they might say to each other,or during a press interview or internal dialogues, such as what they are thinking at any given moment during a game. I will also use them for Math lessons. Students can create and solve their own Math problems using baseball statistics, etc.They are definitely a homerun!!
Applying REAL.BIG. Fathead decals that require the rub on transfer application requires patience and a strict observance of the installation steps. Unlike our standard peel and stick wall decals, they are not movable or reusable so it's very important to follow the instructions and do it right the first time. Instructions are included with the product, but if you'd like a preview of how to install one, or if you need to print a copy, please click on one of the buttons below:
*Valid only at www.fathead.com. Does not apply to gift cards or already discounted items. Cannot be combined with other offers or applied to previous purchases. Discount will be applied evenly across all qualifying items at checkout. A minimum purchase of $50 is required to apply 15% off when using promotion code 1550 at checkout. A minimum purchase of $100 is required to apply 20% off with free standard shipping within the 48 contiguous United States when using promotion code 20100FREE at checkout. The amount applied for free standard shipping will vary based on your order total. A minimum purchase of $100 is required to apply 20% off when using promotion code 20100FREE at checkout. Offer ends 8/5/2015 at 11:59 P.M. Pacific time.
*Valid only at www.fathead.com. This offer does not apply to gift cards or already discounted items and cannot be applied to previous purchases or combined with any other offer.


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Following in the footsteps of McFarlane's Military 3 and Redeployed Series 2, our Military Series 4 had some big shoes to fill. And we believe we've done it. Six new modern military soldiers are ready to report for duty.
ARMY RANGER ARCTIC OPERATIONS: Rangers Lead the Way! Whether it is in the scorching heat of the desert or the frozen winter air of snow-covered peaks, Army Rangers are trained, equipped and ready for the mission.
ARMY INFANTRY: Trained for both large-scale assaults and more intimate, close quarters combat; the infantryman remains the backbone of any military fighting force.
ARMY SPECIAL FORCES OPERATOR: When they are not training for a mission, the Army Special Forces, also known as Green Berets, are conducting worldwide, real-world missions ranging from humanitarian efforts to counterterrorism and unconventional warfare.
AIR FORCE COMBAT ENGINEER: Responsible for the detection and removal of battlefield hazards, as well as the laying of landmines and road and bridge construction. It is a combat engineer's task to aid in the movement of allied troops while hindering the progress of enemy forces.
NAVY SEAL SNIPER: Sea. Air. Land. Navy SEAL teams are elite combat forces highly trained for combat in all terrains. Combining intense SEAL training with the "one shot, one kill" mentality of a sniper creates one of modern military's most focused and lethal soldiers.
NAVY FIELD MEDIC: Trained medical specialists who provide emergency care and first aid to personnel while in the field, Field Medics are responsible for the care and treatment of injuries whether in a field treatment facility or in the heat of combat.
McFarlane's Military Series 4 is scheduled for deployment to stores in October.
>> McFARLANE'S MILITARY SERIES 4


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Rhinestone Baseball Cap
Style # 215596
Top your weekend look with this cute bebe baseball hat, featuring rhinestone logo across front and a classically-cool style.
- Made in USA with imported materials
Rhinestone Baseball Cap 5 5
Love it! My hat came packaged nicely and I couldn't wait to wear it. A few of the rhinestones were missing around the second "e" in "bebe" but it's hardly noticeable. I love the variety of rhinestones used to create the name. In an effort to preserve its beauty I am very gentle with handling the hat. August 14, 2013
Bebe Hat The hat looks like a Bebe knockoff cheap hat....but it will be ok for now. July 27, 2013
I loved it It fitted very nice on me. I purchase both white and black and up to this point Im happy with my purchase... July 12, 2013
Cheap! This hat looks like a free hat you get from a vendor with bebe sparkles ironed on. the front has some kind of cheap cardboard in it and it was smashed and bent when I got it in the mail. Not happy with the quality for the price at all. June 10, 2013
Stones are not sold black. Nice cap but I return the cap because the stone were not solid black. March 19, 2013
1-5 of 5


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Texas on the Potomac
Washington news with a Texas accent
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TexMessage: Sheila Jackson Lee says Obama should increase debt ceiling by executive order
Sheila Jackson Lee wants President Obama to unilaterally act to raise the debt ceiling. Louie Gohmert doesn't care if John Boehner is mad at him about his vote against the Speaker's debt ceiling plan. And Ron Paul says the U.S. already is bankrupt — even before Congress finally acts (or doesn't). That and more in today's TexMessage. [Read More]


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Kevin Borseth a Laker Alumni from 1976 was recently named head coach of the Women's Basketball team at Michigan. Read more
(photo courtesy of U of M)
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Majoring in Sociology...
Carrie McBride
Caro, MI
I love the small tight-knit community on campus.You always see someone you know while walking to class.Your professors know you on a first name basis. [ more ]


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Whether you group is 20 or 200, our Group Sales Team will take care of your every need. We'll assign a dedicated sales associate to personally help you prepare the perfect plan for a trip your members will talk about for years to come. Park City Mountain Resort offers the greatest variety of terrain. One hundred runs, with up to fifty of them groomed each day. Jupiter Bowl with its rugged appeal and scenic view. The country's best terrain parks and superpipe. Take your pick, or try them all. That's the great thing about Park City Mountain Resort.
For complete details, contact Groups & Corporate Sales at
1-800-222-PARK (7275) or 1-435-647-5453
Email us at or fill out our Bid Request Form
Numerous details go into planning a successful trip and our Group Sales team is skilled in providing you with one-stop shopping. Let us provide you with a package quote for whatever combination of lodging, airfare, transfers, lift tickets, meetings and mountain activities. Call us at 1-800-222-PARK (7275) for a proposal designed to meet your group's specific needs.
Group Policies
Group rates and policies begin with a minimum of 20 participants. Group lift tickets must be pre-purchased in one order for the same starting date in order to qualify for the group discount. Special rates on air, lodging and ground transfers are also available.
Your trip package or lift ticket order should be confirmed at the earliest possible date to facilitate arrangements. No lodging or air can be guaranteed until the receipt of timely deposits. To order lift tickets only, place the order by phone and then confirm it with full pre-payment (two weeks or more in advance of start date is optimal).
Form of Payment
Checks or credit cards (VISA, MasterCard, Discover, American Express) are welcome.
Lift Ticket Add-Ons and Refunds
Group lift ticket orders should be as firm as possible when the order is placed. However, we understand the challenges involved and allow some flexibility. Add-ons at the group rate will be permitted when made by the group leader (no individual members can purchase separately at the group rate).
Our extraordinary mountain professionals are ready to help your group enjoy its best trip ever. Most groups embark on an initial mountain tour on their first day of skiing and have a race day near the end of the trip. Race events should be booked up to six months in advance to ensure availability. Lesson vouchers at group discounts can be arranged for group members. Many groups also hold an on-mountain picnic or BBQ. We'll be happy to provide you with delectable menus. We can also arrange for group parties, dinner and après-ski activities.
Free Mountain Tour!
Be sure to book a free, two-hour all-mountain tour for your intermediate or advanced skiers and boarders with our Sales Department. Due to the great popularity of group tours, your reservation should be made well in advance. Availability of group tours is on a first-come, first-served basis. Credit Card required to hold a tour reservation and a $30 charge will be applied to cancelled reservations.
Race on the 2002 Olympic Winter Games Courses
The Eagle Race Arena boasts superb Slalom and Giant Slalom race courses, which have hosted annual World Cup races and the 2002 Giant Slalom and Snowboard HalfPipe. Groups can rent space if available (call for rates). In addition, NASTAR racing is available every Wednesday through Sunday on our Blanche run and groups can arrange special runs on the NASTAR course.
Park City Mountain Resort's World-Class Ski and Snowboard School
Group discounts are available on adult group lessons. (Sorry, not available for Private or Kid's Mountain School lessons). Every level of skier or rider, from beginner to advanced, can gain confidence and improve their technique to take things to the next level.
Off-Mountain Activities
Many groups like to offer some off-mountain options to add variety to the trip. Park City boasts a remarkable array of options, including snowmobiling, sleigh rides, cross-country skiing, heli-skiing, snow cat skiing and balloon rides.
Park City Mountain Resort
1345 Lowell Ave
PO Box 39
Park City, UT 84060
(435) 649–8111
© Park City Mountain Resort
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*image shown is 5 x 8 or larger rug
*smaller sizes will not show complete pattern, will be scaled down to fit.
Rating: 4.00
Read 6 Reviews >>
Name: #U14090
Manufacturer: Oriental Weavers
Material: Polypropylene
Construction: Machine Made
Colors: Tans/Browns/Rusts , Greens/Olives
Origin: Egypt
Description: This collection boasts a wonderful new coloration with cross woven construction with up to 36 colors in each design. The new color palette includes reds, greens, browns, and plums that vary from soft to deep tones. Designs range from transitional to traditional and tribal to contemporary. This collection is sure to add beauty and interest to any decor. (#U14090)
Other Related Patterns You Will


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Vacuum Parts
Vacuum Cleaner Parts and Accessories: Find the Best For Your Cleaning System.
Cleaning homes is a task that most people dread. Busy schedules leave most of us with little or no time to clean homes on a daily basis. Vacuuming is a must at least once a week. Technology has revolutionized the types of vacuum cleaning systems being made available today, and they are now able to vacuum all the floors in your home and their parts and accessories also make it possible to dust and tidy furniture and other sections of your home. Again, the type of vacuum cleaning system and accessories you choose will depend on the pets and allergy prone members of your family. You might require parts such as HEPA filters to ensure that up to 99.97% of the allergens are kept at bay. Pollen and grass cutting seasons will require frequent vacuuming and probably require you to replace the parts of your vacuum cleaner including belts, bags, fans, switches, hoses and much more.
GoVacuum carries the largest selection of vacuum cleaning systems and accessories from all the major brands. You can shop and buy accessories to enhance the cleaning ability of your vacuum. Be it vacuum bags, vacuum filters, vacuum hoses, vacuum cleaner parts and other accessories, we stock a huge selection and even let you find the perfect accessory for you based on brand, price, etc. You can match the parts you need using our detailed parts diagrams. Save money and time by choosing to shop online for your vacuum cleaner parts and accessories. We offer free shipping and guaranteed low prices on all these parts and accessories so you can enjoy the best prices on vacuum accessories online.
Perfect Backpack Sponge Exhaust Filter Part Number PB-15.$34.99This is the sponge exhaust filter for the Perfect commercial backpack vacuum cleaners models PB1001, and PB1006. The filter is on the very bottom of the vacuums casing, and also is used to help muffle the motor. Perfect recommends to replace this filter Learn More
Perfect Commercial Back Pack Power Nozzle Kit$169.00
Perfect backpack vacuums are the recommended choice for cleaning millions of square feet per day at retail stores and big companies over the world, well-known for their ability to handle touch cleaning tasks without any down time. Additional tools such as the hose, wands and power nozzle are great addons for any commercial backpack from this brand, and if you use the PB1001 (10qt.) and the PB1006 (6 qt.) models, here is a kit which offers just that. Commercial cleaning is important at it keeps your place of business presentable to customers and your employees as well. Aside from disposing trash in a responsible manner, you should keep dirt, germs and allergens at bay, and the usage of a nozzle kit for your Perfect commercial backpack will effectively "clean" your business set up.
At GoVacuum, we take pride is selling only the best vacuum cleaners from various brands. We undertake research to ensure your online purchase of vacuum cleaners or replacement parts is smooth and hassle free. Why hop from store to store when you can order top-rated vacuum cleaners from the comfort of your home or office. We also provide superior customer service to all our customers and help them find the model that is right for them.
Product Features: • Fits the PB1001 (10qt.) and the PB1006 (6 qt.) models • Includes electrical hose, wands, and power nozzle unit
Perfect Backpack Suction Hose Part PB-19, 100505.$39.95This is the replacement hose for the Perfect Backpack vacuum cleaners models PB1001, and PB1006. Hose includes both swivel ends, black in color. Perfect part number PB-19.This hose will also fit Oreck Commercial Backpack vacuums models XLPRO6A, XLPRO6, Learn More
Perfect Commercial Backpack 14" Bare Surface Floor Brush Fits All 1.5" Hose Backpacks, Part CM-8502.$17.95This is a 14" wide deluxe bare surface floor brush for all commercial backpack vacuum cleaners. Soft Nylon brushes prevent scratching of high finish floors. Fits all backpack vacuum cleaners using 1.5" hoses. Genuine Perfect Part Number CM-8502, Fits P Learn More
Perfect Backpack 2 Piece 1.5" Wand Assembly Part CM-8563B$59.44This is the replacment two piece wand assembly for the Perfect commercial backpack vacuum cleaners. The two wands connect together using a button lock system in the middle of the wands, and together measure 56" in length. Wands include the coupling at t Learn More
Perfect Backpack PB1001, PB1006 50ft Extension Cord Part CD-7212.$39.49This is the replacement electrical extension cord for the Perfect, Oreck, and ProTeam Backpack vacuum cleaners. Learn More
Perfect Backpack Vacuum 14 Inch Carpet / Rug Tool Part CM-8503.$21.99This is a 14 inch rug / carpet tool for the Perfect Commercial Backpack Vacuum. Learn More
Perfect Backpack Vacuum PB1001 On / Off Switch Assembly Part PB-09$42.35This is the main On / Off switch for the Perfect Commercial backpack vacuum cleaner models PB1001, and PB1006. Switch includes entire box assembly and lead wires. Sold as a complete assembly only. Genuine Perfect Part PB-09.Also Fits Oreck commerical b Learn More
Perfect Backpack Harness Assembly Complete Part PB-07$41.50This is the complete harness assembly including the shoulder straps and the waist strap for the Perfect commercial backpack vacuum cleaner models PB1001, and PB1006. Also included is the plastic part that secures the harness to the body of the vacuum cle Learn More
Perfect Backpack 12 AMP Motor Assembly Part PB-09OS$122.50This is the suction motor for the Perfect commercial backpack vacuum cleaner models PB1001 and PB1006. Vacuum motor is 12 AMPS. Perfect Part Number PB-09OS.Also fits Oreck Commercial Backpack vacuums XLPRO6A, XLPRO6Z, and XLPRO10. Oreck part number 10- Learn More
Perfect Commercial Backpack Replacement Sponge Exhaust Filter PB-15 +$22.83This is the sponge exhaust filter for the Perfect commercial backpack vacuum cleaners models PB1001, and PB1006. The filter is on the very bottom of the vacuums casing, and also is used to help muffle the motor. Perfect recommends to replace this filter once every six months to get better performance.This Filter also fits Oreck Commercial backpack vacuum models XLPRO6, XLPRO6A, XLPRO6Z, and XLPRO10. Genuine Oreck Dual Cell Noise Filter Part Number 10-0019, as well as Proteam part number 100597. Learn More
2 For Kenmore Vacuum Cleaner Pet Grooming Groomer Attachments; Perfect for Dogs & Cats$20.47Unwanted Pet Hair Goes Into Your Vacuum Cleaner Before it Has a Chance to Settle Around your Home! With this pet grooming vacuum brush kit, you get 2 pet grooming vacuum attachments for the price of just 1! You receive a stiff-bristled vacuum pet attachment for getting tough tangles out, and you also get a softer vacuum pet brush we know your pet will love! Do you want to keep your dog and cat hairs off of your furniture, couch, carpets, bed sheet, and clothes, then this is YOUR vacuum pet grooming tool.These pet grooming brushes fit on most standard vacuum cleaner hoses. More specifically, the main pet grooming vacuum brush attachment fits 1 1/4 inch wands and hoses.This is a standard attachment connection that will hook up to just about any central vacuum system as well as most standard 1 1/4" hoses or wand connectors with an outside measurement of 1 1/4". Some of the compatible brands of vacuums cleaner this will fit are KIRBY, EUREKA, ELECTROLUX, HOOVER, Uprights, including the Progressive, Intuition, and Whispertone models, as well as Canister vacuum Cleaners all models. Learn More
Perfect Vacuum Cleaner Floor Brush$12.35Works with: Perfect DES-FB4764 Learn More
Perfect Backpack Vacuum PB1001 On / Off Switch Assembly Part PB-08$42.35Perfect Backpack Vacuum PB1001 On / Off Switch Assembly Part PB-08 Learn More
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Friday, March 15, 2013
In less than 30 days Rotarians from District 7770 will converge on Myrtle Beach for their annual district conference. The district, more than 4,100 Rotarians strong, is comprised of the eastern portion of South Carolina and is represented by 79 clubs, 10 of which are located in the Myrtle Beach area.
According to Rotary District Governor Ed Duryea, the choice to host the conference in Myrtle Beach was an easy decision. "Not only is Myrtle Beach a beautiful area, but there are numerous activities which will provide a great atmosphere for those Rotarians who wish to bring their families.
Slated for March 22-24 at the Marriott Resort, conference planners led locally by chair, Dr. William Fox of the Carolina Forest Sunrise Club, have been at work for more than a year selecting the theme, venues and working with officials throughout the area to ensure that the Rotary experience is a positive one.
The purpose of the District Conference is to provide opportunities for networking, inspirational addresses and discussions of Rotary-related matters. It recognizes the service programs, projects and public relations achievements in the district in order to inspire Rotarians to become more involved in service above self.
According to District Governor Duryea, "Many Rotarians have said that they were never truly enthusiastic about Rotary until they saw an inspirational presentation at a District Conference."
This year's theme, "Rotary Roundup," offers numerous opportunities for Rotarians to not only network and learn more about Rotary, but to work hand-in-hand on a district-wide service project. Partnering with Help 4 Kids (Backpack Buddies), the group expects to prepare 2,400 - 3,000 backpack meals for needy children in Horry County. "While this may sound like a lot of meals, it actually only fulfills about a week's worth of needs," Duryea said.
"It is through projects such as this that our clubs continue to make their communities stronger and make me, along with my fellow Rotarians, proud to be part of this great service organization," he concluded.
Rotarians may register for the conference at www.rotary7770.org or are encouraged to inquire through their home club.
To learn more about Rotary, visit www.Rotary.org.
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Worx JawSaw™
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Exclusive | Worx Electric JawSaw™: Power and Safety in One Hardworking Tool
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A weekly series for web designers who want to enhance their design, software, and general freelance business skills and streamline their workflow. Get a new tip every Thursday.
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The influential web designer and founder of A List Apart talks about developing the web standards that shaped the Internet we know today, fostering community, and educating the next generation of designers.
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Kyle Lovern
Sports Editor
NAUGATUCK – The Lady Panthers of Tug Valley pushed back the Lady Tide of Sherman 73-41 Thursday night at the TVHS gym.
Junior Hannah Armstrong flipped in 21 points and pulled down 10 rebounds to lead the way for Tug Valley. Senior point guard Adreana Vance fired in 14 points and had seven rebounds.
Whitney Evans-Kirk added 10 points and dished out six assists for coach Okey Smith's team. Amber Linville, Katie Robinson and Briana Shrum scored six points each for TVHS.
Jordon Lewis led Sherman with 18 points, while Nikki Santonia added seven points.
"First I would like to congratulate Whitney Evans-Kirk on going over the 1,000 point mark during the first quarter tonight. Whitney has played through a lot of injuries this season but, she is a tough girl and I knew there was no way I was gonna keep her off the court on Senior Night," said coach Smith. "She also stepped up and played the point for us some during the game when Adreana had to sit with foul problems. Amber Linville, our other senior also finished her regular season career for us tonight and she put up good numbers for us too."
"I am not sure if anyone knows what the record is for blocked shots at Tug Valley but, I know she has had a bunch for us over the last four years. Hannah (Armstrong) continues her strong comeback from her injury and Adreana (Vance) had another fine game at the point for us tonight."
Smith also praised the play of freshmen Katie Robinson, Emily Baisden and Cassidy Runyon.
"We will be back in the gym tomorrow getting ready for sectional play next week. The girls are excited about the tournament and I am excited about our chances of performing well during the tournament season," Smith added.
Tug Valley finishes the regular season with a 13-8 record. They will play the winner of the Greater Beckley Christian at Montcalm game at 7:00 on Tuesday at home. Sherman finishes the regular season with a 8-13 record. They will begin sectional play on Monday playing Van at 7:00 at home.
Score by quarters:
Tug Valley (13-8) - Armstrong 21, Vance 14, Evans-Kirk 10, Linville 6, Robinson 6, Shrum 6, Baisden 4, Runyon 4,, Griffith 1, Stacy 1.
Sherman (8-13) - Lewis 18, Santonia 7, Massey 6, Kinder 4, Davis 2, Smith 1, Chapman 1, Skinner 1, Miller 1.


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Stadium: MP's furious attack on 'humiliating shambles'
Last updated at 16:45, Thursday, 26 April 2012
COPELAND MP Jamie Reed has launched a furious attack on local government regeneration chiefs after West Cumbria lost the chance to host 2013 Rugby League World Cup games due to plans for a new £5.5 million stadium stalling.
The bombshell was dropped on Wednesday when stadium development partners declared that building at Pow Beck was not cost- effective and they had finally pulled out of tortuous negotiations with the Whitehaven Miners' Welfare over land access.
Now they say they are exploring other options still to build at Pow Beck but there is no chance of staging the allocated World Cup matches featuring Scotland, Italy and Tonga.
Hosting the games was seen as a great showcase for West Cumbria and its announcement by the Rugby Football League was toasted with champagne.
Copeland MP Jamie Reed has called the situation a "humiliating shambles" and has warned Copeland and Cumbria County Council they are in danger of squandering a historic opportunity for an economic renaissance in west Cumbria on the back of the £2bn Britain's Energy Coast plan.
"Britain's Energy Coast is the best hope we've got of delivering on our ambitions for west Cumbria," he said. "Those in local government, whether in the borough or county council, need to be honest about what they can achieve. There's no place for amateurism in the development of west Cumbria. Those not up to it should get out of the way and leave it to those who know how to do it.
"I think the stadium will happen, but we are going to miss the World Cup which would have brought real recognition and investment to the area. The chance has been squandered and people will want to know why.
"It's about credibility. I believe that all partners involved have to look at themselves and admit why this went wrong and ensure it doesn't happen again.
"This is the last chance saloon and more embarrassments like this will not be tolerated."
The scheme's backers – Copeland Borough Council, Whitehaven Rugby League Club and Whitehaven Amateur Football Club – insist the idea is not dead and the stadium could still be built. But they say it is not "feasible or affordable" to continue with negotiations with the Whitehaven Miners' Welfare Association about an access route to the stadium across land the miners own. The miners say they are not to blame and have called for an inquiry.
The Pow Beck stadium saga has dragged on for 10 years and one of its most outspoken critics has called for the scheme to be scrapped altogether and attention switched to Hensingham's Copeland Stadium – a Cumbria Centre for Sporting Excellence – as a possible alternative.
Coun David Moore, opposition Tory group leader on Copeland Council, said: "It is a complete and utter embarrassment. Too many people have chosen to ignore advice, with the result that we have now lost hundreds of thousands of pounds, not only that but two prestigious World Cup matches.
"On numerous occasions I have asked for information to show it would be financially viable and to pull back until proved otherwise.
"We should now start with a blank sheet and have a complete evaluation which would bring back into play the possibilities of moving the project to Copeland Athletics Stadium, which already has fine sporting facilities and room for expansion.
"I take little satisfaction in being vindicated over this but have never wavered from my stance. I have never seen any evidence to show that Pow Beck would be sustainable – but as I say, too many peopled have chosen to ignore advice at some considerable cost.
"Now we have an opportunity to look somewhere else such as Copeland Stadium – but not Pow Beck."
In a joint statement, the Pow Beck stadium partners – Copeland Borough Council, Whitehaven Rugby League Club and Whitehaven Amateur Football Club – said: "Following a meeting last night [Tuesday] we have agreed unanimously that it is no longer affordable nor feasible to continue negotiations with the Whitehaven Miners' Welfare Organisation and will instead look to develop the stadium in a new direction.
"The partners will continue to work together to move the stadium forward but will no longer be exploring the option of access over the Whitehaven Miners' land. Positive discussions about other options for the development have already taken place and the partners are pleased to now be moving forward.
"Partners recognise that their new approach will lead to a delay in the project being completed but believe that it will ultimately help secure the sustainability of the project.
"As a result of this decision the opportunity to bring the 2013 Rugby League World Cup to Whitehaven is lost and the RFL has been advised of this.
"The partners are pleased that Britain's Coast continues to support the stadium and look forward to working more closely with them, our nuclear partners and the RFL to make the stadium a reality."
Even the Whitehaven Miners were shocked to learn that it was all off. Secretary Brian Birkett, who has been heavily involved in negotiations, said: "We are absolutely astounded. There have been no discussions or recent negotiations going on. All we asked for lately was clarification on 38 points over what they wanted to do on our land - all mundane matters.
"We didn't ask for any money. What I've since heard is that what we are asking was going to cost £250,000 but I couldn't see anything that was going to cost.
"We dispute that we have made any demands. We'd already agreed the price for selling access for the stadium and that was it."
Mr Birkett said the original sum reported of £750,000 was rubbish. The settlement was much less. The Miners' were still prepared to talk further if the stadium partners wanted to re-consider. "Our door is always open. We have members who are die hard Whitehaven rugby league fans. We have all wanted the new stadium to be built and for the World Cup matches to go ahead."
He added that his organisation resented being cast as "scapegoats".
The Rugby Football League said: "Despite much hard work and dialogue with the partners Copeland Council are no longer able to guarantee the building of Pow Beck stadium within the timescale required by the tournament."
Sally Bolton, World Cup 2013 general manager, added: "When selecting Copeland as a host, the selection committee were very supportive of the idea of building a new stadium in Whitehaven as a way of growing the game in West Cumbria.
"The fact that Copeland Borough Council are no longer able to deliver that is disappointing primarily for the people of West Cumbria who will not benefit from being part of RLWC2013, the biggest sporting event in the UK to take place after London 2012.
"As the Copeland bid was predicated on the building of a new stadium, our strategy always included a robust contingency plan which has now been put in place and we will announce the replacement venues shortly."
Most of the £5.5 million was coming through Britain's Energy Coast funding obtained from Nuclear Management Partners.
BEC chairman Brian Wilson said: "Our support for this project has been unswerving and we share in the disappointment about the immediate implications of this decision.
"However the funding remains in place whenever a revised project emerges. In the meantime we will give as much practical support as possible in order to advance that objective."
First published at 14:36, Wednesday, 25 April 2012
Published by http://www.whitehavennews.co.uk
Have your say
Shouldn't the MP be supporting or giving some more spin for the the Council instead distancing himself? The Council have made a difficult decision and must feel let down by the comments in this article.
I cant understand why if a new stadium will result in a super rugby leage team why not develop the football team into a premier leage outfit? Just imagine Whitehaven v Manchester United. Cumbria may produce good players who go on to play for clubs in Lancashire and Yorkshire but two little towns will never provide the gate income that will support a super league side. The whole thing is a pipe dream supported by people who have something to gain from a council who hope a stadium would keep them in employment to a nuclear industry which hopes to sweeten the population and allow them to treat the area as a dump.
The only people to blame are the council who failed to oversee the development. They have people in planning departments and solicitors who should have seen this outcome and planned for it from the beginning. As the Labour MP says, as he quickly puts space between himself and the Labour council, the whole thing has been an amaturish fiasco.
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