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Epidemics of HIV in men who have sex with men (MSM) continue to expand in most countries. We sought to understand the epidemiological drivers of the global epidemic in MSM and why it continues unabated. We did a comprehensive review of available data for HIV prevalence, incidence, risk factors, and the molecular epidemiology of HIV in MSM from 2007 to 2011, and modelled the dynamics of HIV transmission with an agent-based simulation. Our findings show that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiological data show substantial clustering of HIV infections in MSM networks, and higher rates of dual-variant and multiple-variant HIV infection in MSM than in heterosexual people in the same populations. Prevention strategies that lower biological transmission and acquisition risks, such as approaches based on antiretrovirals, offer promise for controlling the expanding epidemic in MSM, but their potential effectiveness is limited by structural factors that contribute to low health-seeking behaviours in populations of MSM in many parts of the world.
In 2012, men who have sex with men (MSM) are at substantial risk for HIV infection in virtually every context studied (panel 1).1,3,4 This risk has been present since the syndrome now known as AIDS was first described in previously healthy homosexual men in Los Angeles (CA, USA) in 1981.5–7 Despite decades of research and community, medical, and public health efforts, high HIV prevalence and incidence burdens have been reported in MSM throughout the world.8 In many high-income settings—including Australia, France, the UK, and the USA—overall HIV epidemic trends are in decline except in MSM, where they have been expanding in the era of highly active antiretroviral therapy (HAART) in what have been described as re-emergent epidemics in MSM.9,10 In the USA, HIV infections in MSM are estimated to be increasing at roughly 8% per year since 2001.9 And in much of Africa, Asia, and Latin America, the highest rates of HIV infection in any risk group are in these men.8
Men who have sex with men (MSM) is a term introduced in 1992 to attempt to capture a range of male–male sexual behaviours and avoid characterisation of the men engaging in these behaviours by sexual orientation (homosexual, bisexual, heterosexual, or gay) or gender identity (male, female, transgender, queer).1 MSM includes gay-identified men, heterosexually identified men who have sex with men, bisexual men, male sex workers who can have any orientation, men engaging in these behaviours in all male settings, such as prisons, and the rich and wide array of traditional identities and terms for these men across cultures and subcultures. Biological men who choose female identities are generally referred to in work on HIV as transgender or transgender women if they have undergone gender-reassignment surgery. Transgender people born male might share some biological risks with MSM, most importantly receptive anal intercourse, but their female gender identity places them in quite different categories from MSM; hence they are not included as a subgroup of MSM in this Series.
Scientific work suggests that sexual orientation in men represents a lifelong preference for sexual and romantic partners of the opposite, same, or both sexes.2 MSM is a broader category and includes non-gay-identified MSM, those married to women, and other subgroups who might be more hidden, difficult to reach for surveillance, and less willing to disclose sexual practices than gay-identified men, challenging epidemiological characterisation and HIV responses. This is particularly true in contexts where same-sex behaviour is stigmatised or criminalised. Nevertheless, MSM has become the standard term in the work on HIV. We use the term recognising its shortcomings.
However, our understanding of worldwide epidemiology is far from complete. By the end of 2011, 93 of 196 countries had not reported on HIV prevalence in MSM in the previous 5 years.11 In several regions, notably the Middle East, north Africa, and sub-Saharan Africa, data for HIV infections in MSM are only emerging.12,13 Data gaps and challenges to HIV research, surveillance, and epidemiological characterisation in MSM are largely the result of the hidden and stigmatised nature of MSM populations in much of the world, and of ongoing criminalisation of homosexuality and other forms of same-sex behaviour.11 These structural realities have limited our understanding, and might also have crucial roles in the vulnerability of MSM to HIV.14,15 We review the global epidemiology and disease burden of HIV infection in MSM; individual-level, couple, and network-level risks for HIV acquisition and transmission; biological aspects of anorectal HIV transmission; and molecular epidemiology advances, with the aim of understanding why MSM continue to bear such disproportionate burdens of HIV. We also developed and report on stochastic agent-based simulation models of HIV transmission to further clarify the drivers of HIV spread in MSM.16 Finally, we discuss the public health importance of our emerging understanding of the epidemiology of HIV in MSM.
We did a comprehensive search for HIV burden and risks in MSM from Jan 1, 2007, to June 30, 2011 (search criteria in the appendix). We retrieved 2105 unique citations, and we identified and reviewed 68 additional surveillance studies in the public domain. We included country progress reports submitted to the UN General Assembly Special Session on HIV/AIDS (UNGASS). We obtained data from 82 peer-reviewed publications on disease burden of HIV in MSM, from 12 of the 68 surveillance reports, and from 38 of 186 country progress reports submitted to UNGASS in 2010.
Figure 1 shows aggregate HIV prevalence estimates in MSM by region derived from the comprehensive search (references in the appendix). Pooled HIV prevalence ranged from a low of 3·0% (95% CI 2·4–3·6) in the Middle East and north Africa region to a high of 25·4% (21·4–29·5) in the Caribbean. The CIs for these pooled estimates must be interpreted with caution, since they only account for sampling variation and not the inherent biases of non-representative samples, and so undoubtedly underestimate actual variances. Nevertheless, HIV prevalences were relatively consistent across North, South, and Central America, south and southeast Asia, and sub-Saharan Africa (all within the 14–18% range). Comparing HIV infection levels in MSM with UNAIDS 2009 estimates of general population adult male HIV prevalence shows that levels in MSM are substantially higher in every context (figure 2).18 Most countries worldwide had not reported HIV rates in the previous 5 years in MSM, so these are aggregate regional values of available and present data. Figure 2 depicts HIV prevalence in MSM in countries where prevalence data could be obtained through peer-reviewed publications, behavioural surveillance reports, or UNGASS reports.
Figure 3 shows HIV incidence in MSM, which was available from 27 peer-reviewed publications. Data were reported from 15 countries overall; reports included nine from the USA, three from Europe, six from Asia, six from Latin America, two from Australia, and one from Africa (Kenya; references in the appendix). Overall incidences show sustained epidemic patterns, with no evidence of declines. The two Asian states for which incidence was available, China and Thailand, both show rising rates of HIV infection. Kenya, the only African country with an incidence report, had the very high rate of greater than 20% annual incidence in a selected sample of men who have sex with men only, in Mombasa.19
These findings suggest several important patterns for epidemiology in MSM. First, incidence continues to be sustained at levels sufficient for epidemics in the MSM population to continue, and, in some settings, expand. The available incidence data from Thai, Chinese, and Kenyan samples of MSM suggest these epidemics are in rapid expansion phases. With only one African incidence report, it is clear that more work needs to be done to understand the emerging HIV epidemics in African MSM.
The available epidemiological data must be interpreted with some caution. Probability and population-based sampling methods have been important in measuring HIV epidemics. Demographic and related household-based survey approaches have helped define HIV spread at community levels and provide important denominators for assessment of HIV prevalence and incidence densities.20,21 These approaches are problematic for hidden and stigmatised populations, and for measures of socially constrained behaviours. Many of the key epidemiological and population-based studies of HIV in developing countries collect no measures of male same-sex behaviour, restricting our understanding of this component of global HIV.11 When MSM risk assessment has been included, strong social response biases have often made such assessments unreliable. Size estimation of the numbers of MSM in any particular population have also been limited by the hidden nature of these men, heterogeneity in the populations, and low rates of participation (panel 2).31,32
In earlier years of the HIV epidemic, non-probability methods such as convenience and snowball sampling were commonly used for research and surveillance in men who have sex with men (MSM), injecting drug users, and sex workers.22 In convenience sampling, study participants are drawn from segments of the population accessible to researchers. During snowball sampling, individuals are asked to refer their peers with similar risk characteristics. Both methods are subject to selection bias and study results cannot be generalised. However, over the past two decades substantial progress has been made in creating alternative sampling frames that allow random sampling and can yield probability estimates of hard-to-reach population variables. Venue-day-time (VDT) sampling uses a sampling framework based on counts of venue visits of populations of interest (from MSM venues such as bars, clubs, saunas, and others) in specified timeframes.23 First, VDT units are randomly or otherwise selected, with subsequent random or other sampling of venue attendees for study purposes. Data obtained need adjustment for clustering effects and must be weighted for the frequency of venue attendance of enrollees.23
Respondent-driven (RD) sampling elaborates on traditional snowball sampling with several mathematical procedures.24 Although the sampling of participants is non-random, investigators have suggested that study results become generalisable when a sample reaches a specific equilibrium state, such that distributions on key variables of interest remain stable despite accrual of additional participants.25,26 At this equilibrium point, additional waves of recruitment will no longer change or add to the demographic composition of samples. Since RD sampling will generally oversample people with large network sizes, data should be weighted for individual network sizes of participants.25,26
More recently, the internet has provided ample opportunities to access and research previously hard-to-reach and hidden populations in relative privacy and anonymity. Both VDT and RD sampling and several other methods and approaches are being adapted at present for use via the internet.27–30 Nevertheless, the fundamental problems of research in hard-to-reach populations at risk for HIV infection remain, such as the absence of proper sampling frames, the lack of probabilistic sampling methods, and the resultant restricted generalisability of study findings.
These realities have led to many innovations in sampling, surveillance, and size estimation research in MSM. Past innovations have included the use of respondent-driven sampling, with its well described limitations, venue-day-time sampling, internet-based sampling, and the use of molecular methods for biological sampling. Size estimation approaches have included capture–recapture, multiplier methods, and the wisdom-of-the-crowd approach.14 Although no single method or approach is ideal or sufficient, the body of evidence on HIV in MSM is nevertheless substantial and growing.
Individual-level risks for HIV acquisition in MSM have been well documented, and include unprotected receptive anal intercourse, high frequency of male partners, high number of lifetime male partners, injection drug use, high viral load in the index partner, African- American ethnic origin (in the USA), and non-injection-drug use, including use of amphetamine-type stimulants (ATS).33–35 Recent data suggest individual-level risks might be insufficient to explain the high transmission dynamics evident in MSM outbreaks, and that biological, couple, network-level, and community-level drivers might be crucial to understand why HIV transmission rates remain so high in MSM populations.36 These factors might be crucial to understand why HIV prevalence rates in these men seem to have increased in the HAART era, both in settings where HIV epidemics are newly described or emerging and in settings where MSM have access to a broad range of HIV services, civil liberties, and organised and visible community structures.10,37–39 Present understanding of the role of HAART is that new infections should decline in populations where more people have reduced likelihood of transmission because of the effect of HAART on viral load.40
A framework for characterising HIV epidemics in MSM in wider epidemiological contexts has been proposed.8 This approach described four epidemiological scenarios for epidemics in MSM in low-income and middle-income countries. The first, primarily in South America, was characterised by MSM predominance— these men were the largest contributors to HIV prevalence in general populations with very low rates of infection. In the second scenario, which was found in eastern Europe and central Asia, epidemics in MSM were within HIV epidemics primarily driven by injection drug use. Epidemics in MSM during widespread epidemics in heterosexual people were generally evident in southern and eastern Africa, and here men had substantial HIV acquisition risks both from female and male partners. And finally epidemic contexts where heterosexual spread, sex work, MSM risks, and injection drug use were all contributors to HIV spread were evident in the complex epidemics of south and southeast Asia.
The role that sex with female partners might have in HIV risks for MSM has been studied in several populations. By contrast with widely held views, the data suggest that men who have sex with men and women have somewhat lower rates of HIV infection than men who only report sex with men.41 These men might be more likely to use condoms with male partners than other MSM, or they might be less likely to engage in receptive anal intercourse than men who are willing to report exclusively male sex partners.41–44
ATS have been widely reported as risk factors mediating higher risk sexual practices in MSM, including recent reports from San Francisco (CA, USA)45 and Bangkok (Thailand).46 San Francisco MSM who self-reported stimulant use during sex were much more likely to report serodiscordant unprotected anal inter course (UAI) compared with when no drug use.45 In Bangkok, MSM reporting ATS use increased significantly from 3·6% in the previous three months in 2003 to 17·5% in 2005, and 20·8% in 2007 (p for trend <0·001). HIV prevalence in this cohort increased from 17·3% in 2003, to 28·3% in 2005, and 30·8% in 2007 (p for trend <0·001).46 Of 595 young MSM in the USA aged 12–24 years, greater than 10% (64 of 595) reported recent ATS use.47 Young MSM reporting drug use also reported higher risk sexual practices including serodiscordant sex, sex with an injecting drug user, and more sexual partners.47
Seroadaptation, including serosorting and strategic or seropositioning, are strategies MSM have used as prevention approaches based on self and partner HIV status.48 Serosorting refers to choosing HIV-concordant sex partners, whereas seropositioning refers to a choice of sex acts based on serostatus. These behaviours have not been rigorously assessed as HIV prevention approaches, and some might pose unintended risks for MSM when partner or sex-act choices reduce condom use.49 It is well established that people with acute and early HIV infection are highly infectious, so men with a recent HIV negative test, yet newly infected, might be risky partners. Deliberate avoidance of condoms, or barebacking, is also a concern.
Barebacking was defined in 2004 as "intentional condomless anal sex in HIV-risk contexts".50 Reports from US and UK studies, primarily through analysis of internet barebacking sites, suggested that some MSM, including men living with HIV, were deliberately seeking anal sex without condoms.51,52 Barebacking in HIV concordant sex partners was associated with trans mission of other sexually transmitted infections (STIs) and with superinfection of HIV-positive MSM—transmissions that might include drug-resistant HIV variants.53,54 A 2009 meta-analysis of US studies55 identified that most MSM who were aware of their HIV status protected partners from HIV infection, but that condomless sex was more common between HIV-positive partners, at some 30% (95% CI 25–36). A consistent finding across US studies has been that ethnic minority MSM are less likely to engage in these risk behaviours than are other MSM.55
In MSM, sexual-network-level risks can be both important drivers of HIV spread and key entry points for the delivery of interventions.56–58 Larger networks can provide more opportunity for exposure to varied sexual practices and HIV-positive potential partners. In a study of Australian MSM,59 the number of reported anal sex partners was higher with increased size and decreased network density (odds ratio [OR] 0·014, 95% CI 0·002–0·008). Larger sexual networks have also been associated with increased reporting of UAI in MSM in Shanghai, China.60,61 These findings are consistent with studies of US MSM where social networks have been associated with a greater number of male partners (p=0·03) and transactional sex (p=0·0009).62 These network-level risks might have particularly important roles for ethnic and racial minority MSM communities, including black MSM in Canada, the UK, and the USA.47
Structural factors can also mediate risks for HIV acquisition and transmission in MSM. Although structural risk factors are the least studied of risk factors for HIV in epidemiological assessments, they are relevant targets for prevention in many contexts.37 In many high-income settings, ethnic and racial minority MSM carry a disproportionate burden of HIV.63 These issues are explored in the fifth report in The Lancet HIV in MSM Series,64 which shows that the increased burden of disease is not explained by higher risk sexual practices in these men.65,66 Rather, black MSM seem to have higher rates of untreated STIs (OR 1·64, 95% CI 1·07–2·53), and HIV-positive black MSM are less likely to be aware of their serostatus and less likely to be taking antiretrovirals (0·43, 0·30–0·61) compared with white MSM.63,67,68 Since antiretroviral use and access is low in black MSM, we would expect mean community viral load to be higher in sexual networks in black MSM compared with those in white MSM. Also, higher rates of untreated STIs within these sexual networks would facilitate transmission in cases of similar levels of condom use. Higher prevalence of STIs and undiagnosed HIV infection are markers of suboptimum access to health care.69 The lack of access to clinically competent and appropriate health care has also been noted to reduce HIV-related health-seeking behaviour in African MSM. In a study of MSM in Botswana, Malawi, and Namibia,70 any interaction with health care was associated with MSM reporting fear of seeking health care (2·6, 1·6–3·9), having been denied health-care services (6·4, 2·5–16·1), and having been blackmailed (2·1, 1·4–3·2).70 Decreases in health-seeking behaviour because of human rights abrogation have also been reported from Lesotho, Senegal, and South Africa.71–73
The biology of anal sex, the gut tropism of HIV-1,74 and the practices and behaviours associated with anal sex, might at least partly explain the high transmission efficiency of HIV infection for this practice. A recent systematic review and meta-analysis of HIV transmission risks in anal sex24 reported a 1·4% per-act probability (95% CI 0·2–2·5) of transmission for anal sex and a 40·4% per-partner probability (6·0–74·9).24 Per-act probabilities did not differ for MSM or heterosexual anal sex. The 1·4% per-act probability is roughly 18-times greater than that which has been estimated for vaginal intercourse.75 This review also noted that per-partner risks for infection were similar for people reporting exclusive unprotected receptive anal intercourse and both unprotected receptive and insertive anal intercourse— common behavioural patterns for most MSM worldwide. Only self-reporting of exclusive unprotected insertive anal intercourse had lower, but still substantial, per-partner risks: 21·7% (0·2–43·3).24
In addition to the high per-act and per-partner probability of infection noted in receptive anal sex, the likelihood that significant proportions of MSM engage in both receptive and insertive anal sex might have a crucial role in enhancing the efficiency of HIV spread within MSM networks, as opposed to heterosexual ones.75,76 In networks of heterosexual spread, insertive and receptive roles are biologically determined and trans mission probabilities from women to men might be lower, and can be reduced further with male circum cision. For MSM, uniquely, the relatively low HIV acquisition probability for insertive anal sex can be overcome in MSM populations since individual MSM can become infected through receptive sex and then transmit through insertive sex. It might also be relevant that substantial proportions of MSM—including high-risk subsets such as young MSM, men who use stimulants or alcohol with sex, and MSM who trade or sell sex—might have more partners than is common in other sexually active groups.4 High rates of acute HIV infection in MSM might further drive incidence, since acute and recently infected people can be more infectious.77 And male dyads might have substantial rates of extra-dyadic sex partners.34
STIs have also been associated with biological risk for HIV infection in MSM, notably syphilis and infection with herpes simplex virus type 2, and more recently, anal infection with human papillomavirus.78 For MSM, oropharyngeal and anal STIs can also be associated with HIV infection. Infection with hepatitis C virus is also sexually transmitted between men, and might be facilitated by HIV co-infection in MSM.79 The hidden and stigmatised nature of male same-sex behaviour in many settings might limit access to STI treatment and care for MSM and exacerbate the biological role of undiagnosed and untreated STIs.70 Higher rates of undiagnosed and untreated syphilis have been reported,63 and associated with the substantially higher rates of HIV infection noted in US black MSM.63 Fear of discrimination and blackmail has been associated with reducing willingness to seek care for STIs in MSM in a three-country study in southern Africa.70
Adult-male circumcision has been shown to reduce men's risk of acquiring HIV infection from women by roughly 60% in three African trials.80–82 The epidemiological evidence for circumcision and HIV risk in MSM has been inconsistent.83,84 This is presumably because receptive anal intercourse, where a man's own circumcision status is irrelevant, has such a higher per-act transmission probability than anal or vaginal insertive sex.24 MSM who engage only in insertive sex with other men are a minority, but such practice might plausibly lower their risk of HIV acquisition if circumcised. No trial of circumcision in MSM has been done. One large prospective study in MSM in the USA85 recorded lack of circumcision associated with incident HIV infection after adjustment for sexual practices and substance use (adjusted OR 2·0, 95% CI 1·1–3·7), but a large study of black and hispanic MSM in the USA did not identify any protection in circumcised MSM.86 The Sydney Health in Men cohort study87 also did not identify differences in HIV acquisition by circumcision status in homosexual men.87 In a subsequent analysis of these data assessing men with higher insertivity ratios (a higher proportion of reported insertive sex) a slight protective effect was noted for circumcision.88 In the only African study of circumcision status and HIV risk in MSM,89 the investigators reported lower HIV prevalence in circumcised MSM (adjusted OR 0·2, 95% CI 0·1–0·2); however, most also reported female sex partners.
Recent reports from molecular epidemiology, phylodynamic studies, and HIV virology are providing insights into transmission and acquisition risks for MSM, transmission dynamics in MSM networks, and challenges to HIV prevention for these men. In a 2008 report on HIV transmission dynamics across the city of London,38 episodic bursts of transmission in large linked clusters were identified as characteristics of transmission within MSM populations.38 About 25% of all HIV infections in MSM were linked to one of several clusters. Later work noted that only 5% of infections in UK heterosexuals were similarly linked, and that infections were spreading much more slowly within heterosexual networks than homo sexual ones.90 Investigators who used single-genome amplification and a model of viral evolution in a cohort of acutely infected US MSM91 noted that MSM were more than twice as likely as heterosexually exposed people to be infected with multiple HIV viruses (p=0·042). They also reported on the other available studies (n=5), which showed that this substantially higher rate of multiple-variant transmission held for MSM compared with heterosexual samples (p=0·008), and that 38% of acutely infected MSM had multiple variants. The investigators attributed this higher rate to the epidemiological risks these men reported: receptive anal intercourse with many partners and the differing anatomical and immunohistological characteristics of the male and female genital tracks and the lower gastrointestinal tract.91 Greater genetic variation in infection, faster spread in networks, and clustering of HIV infections in high-transmission bursts are clearly features of real relevance for understanding the epidemiology of HIV in MSM.
Figure 4 shows the results of a HIV-1 molecular epidemiology search in MSM (search strategy in appendix). HIV-1 subtype data were available for MSM samples in 14 countries, including at least three in Africa, the Americas, Asia, and western Europe. For North and South America, and for western Europe, subtype B continues to predominate in MSM (figure 4). This seems to be the case despite many reports of increasing non-B subtype variants in heterosexual transmission cases in Europe, largely attributable to HIV cases in African migrant populations to Europe.90,92 Several reports from Europe, the UK, and the USA noted high levels of clustering of MSM sequences, suggesting dense networks of spread.38,90,91 Clustering of infections has been significantly associated with visiting bath houses,93 group sexual exposures,91 homosexual versus heterosexual network membership,94,95 and younger age.95
For Africa, where data were restricted to Kenya, Senegal, and South Africa, the mix of HIV variants in MSM seemed similar to those variants circulating in the wider population of those at risk in each country, which suggested local spread.96,97 In the multiethnic MSM population of Cape Town (South Africa) and surrounding township communities, an early segregation of HIV subtypes by race and risk group was reported in the 1980s, with B-clade infection recorded in white gay men, and C-clade infections in African heterosexual populations. This segregation seems to have changed. Reports on subtypes in Cape Town MSM identified clade-C variants in 92% of black MSM, 69% of so-called Cape Coloured MSM, and 36% of white MSM, suggesting substantial bridging across these populations.97
For Asia the situation is somewhat more complex. Subtype B predominated in Mongolia, in Beijing in 2007, and in Taiwan,93,98,99 but more recent reports from China suggested an increase in non-B-clade infections in MSM with an increase in the CRF01_AE subtype predominant in southeast Asia.100 In Thailand and in Singapore, the CRF01_AE virus predominates in all populations, and also accounted for most infections in MSM.95,96 Although subtype C predominates in India, there have been no recent reports that disaggregated HIV variants by risk group for that large population.
Taken together, these notably incomplete findings suggest several patterns for MSM. First, in the northern hemisphere, and in the Americas overall, subtype B continues to predominate in MSM and to circulate with substantial clustering in large MSM networks. In Africa and Asia, outbreaks in MSM seem more embedded within wider epidemic contexts, with the subtypes in MSM generally related to the diversity of epidemic contexts, with some variation in proportions of infections by risk category.
We developed a stochastic agent-based network simulation model of HIV transmission to show the size of some key drivers of HIV epidemics for MSM discussed above (details given in the appendix). These drivers include the high per-act transmission rate for anal sex relative to vaginal sex; the unique ability for MSM to be role versatile within high-transmission acts; and the existence of high numbers of partners within a subset of the population. The model thus shares some goals of previous work (Goodreau SM, unpublished), but extends it into a much more detailed modelling framework for both the underlying biology and behaviour. This framework was originally developed and parameterised for the Prevention Umbrella for MSM in the Americas (PUMA) project (Goodreau SM, unpublished). Since some of these are inherent to MSM, the model is not meant to be an explicit representation of any specific intervention. Rather, it is structured as a counterfactual experiment—eg, if anal sex were as infectious as vaginal sex, with all other things being equal, how much smaller would the HIV epidemic be in specific populations of MSM? Country-specific model inputs include demo graphics: sexual behaviours within main and casual partnerships, circumcision prevalence, testing frequencies, and existing treatment levels. The model was first parameterised with multiple datasets from urban USA (a high-income country) and urban Peru (a middle-income country). We then considered additional scenarios in which testing and treatment were both much less common (both at a third of present levels), as an attempt to roughly represent the situation in low-income countries with low access or use of health services by MSM. We ran all models with an initial prevalence of 15%, similar to worldwide HIV prevalence for MSM. We repeated the exercise for other initial prevalence values, with qualitatively similar results (not shown). Initial population size for all runs was 5000 men in each country.
We computed the cumulative number of infections over a 5 year period for our baseline model, and for each counterfactual scenario. We then calculated the fraction of infections attributable to each factor by comparing the proportion reduction in cumulative incidence from baseline to counterfactual. Specific scenarios we considered were those in which transmission rates for unprotected anal sex were lowered to match those for unprotected vaginal sex; scenarios where all men were restricted to a specific role (50% insertive and 50% receptive); the combination of these first two scenarios; and a scenario where all casual UAI was replaced by an equal amount of UAI within the setting of new main partnerships, the duration and UAI frequency for these new main partnerships matched values noted in the main partners data, and the number of partnerships added was that needed to maintain the overall amount of UAI from baseline. We summarise our findings in figure 5.
The greatest reductions were associated with the scenarios that entailed reducing transmission probabilities to those of vaginal intercourse; in all settings, this quickly reduced incidence by greater than 80%, and in some by as much as 98%. This emphasises that the biological factors specific to anal sex have a fundamental effect in driving HIV epidemics in MSM worldwide. The ability of MSM to be role versatile also predisposes them to large epidemics—removing this practice so as to mimic a heterosexual population in this regard reduced incidence by 19–55%, although we recognise that changing sexual practices on the scale needed to see these effects is an unrealistic prevention goal. This metric revealed major differences by setting, since role versatility is much more prevalent in US MSM than Peruvian MSM. The existence of high casual numbers of UAI partners for some men also facilitates HIV transmission, but to a lower extent than the specific biological factors of anal sex, and about as much as the existence of role versatility. Converting all casual UAI into the same amount of UAI within long-term main partnerships reduced HIV prevalence by 29–51%. Here too there were regional differences, with HIV prevalence dropping more in the high prevalence Peru scenario than the US one, since a higher proportion of UAI happens within the context of casual contacts in Peru than in the USA.
Our findings on the epidemiology of HIV in MSM have many implications for HIV prevention, treatment, and care. The second101 and third102 reports in this Series will address these implications in detail and propose a targeted set of interventions for prevention for these men. First, the high transmission probability, high force of infection, and the potent effect of prevalent HIV infections in networks clearly suggest that interventions to reduce infectiousness, such as HAART for HIV-positive MSM, will probably be essential to achieve control of these epidemics. Our modelling outputs suggest that even substantial behaviour change, such as reductions in extra-primary partnerships, would not reduce transmission frequency enough to control HIV incidence in MSM networks. Interventions that reduced the probability of acquisition for men engaging in unprotected receptive anal intercourse, such as oral pre-exposure prophylaxis, rectal microbicide, or successful treatment for prevalent HIV infections, will probably be key. The high burden of infections in MSM demands more vigorous and scientifically informed responses, and the development and implementation of strategies to address the high biological risks associated with anal sex.
The molecular epidemiology of HIV in MSM also has several important implications for public health. An HIV vaccine based on subtype B (assuming subtypes, as currently understood, have roles in vaccine design) would have wide applicability in Europe, North and South America, and parts of Asia. This reality has already been of proven use to HIV vaccine trials.85 The CRF01_AE component, proposed for trials in MSM in Thailand, would protect against an additional and substantial proportion of infections in MSM in Asia. The apparent clustering of transmission events in MSM, the speed with which HIV can move through MSM networks, and the reported high heterogeneity of HIV in acute infections in MSM might be a challenge to HIV vaccines for this route of exposure. That daily oral pre-exposure prophylaxis with a combination of emtricitabine and tenofovir disoproxil fumarate is so far the only biomedical intervention with evidence for efficacy in MSM102 suggests that this intervention might address these dynamics and might eventually be combined with vaccine strategies. Viral suppression within high-density networks of MSM might also be an approach fit to the molecular epidemiology of MSM transmission.
However, the public health importance of our new understanding might be affected by several important factors. First, the available data for HIV prevalence and incidence in MSM remain incomplete, with only one incidence estimate from Africa, two from Asia, and very few prospective cohorts of MSM in any setting. More than 30 years after the discovery of a viral infection in this population, 93 countries have no available reports on MSM in the past 5 years. What data we do have are hampered by the lack of population-based measures of the prevalence of same-sex behaviours in men, the size of the populations at risk, and the great diversity of these populations in differing social, cultural, and political contexts. Social response biases against reporting some behaviours, including receptive anal sex, are likely to affect risk factor assessment.
Improved size estimation approaches are urgently needed. Encouragingly, these limitations have led to a range of innovations in epidemiology and are proving of use to the description of other hidden, stigmatised, or otherwise hard-to-reach populations.103,104
Other biases in the global evidence base include the disproportionate urban sampling of MSM populations, the relative lack of data from the Middle East and north African region, and the lack of data for adolescents in sexual and gender minorities, who are systematically undersampled in most contexts. What data are available on younger MSM suggest that they are high-incidence groups in need of targeted interventions, and that waiting until they are aged 18 years, or older, is, as with girls in many high-risk transmission contexts, inadequate to protect them against early acquisition of HIV.105
If HIV infection in MSM is heavily biologically determined, do present approaches to HIV programming for MSM, which rely heavily on information, education, and behaviour change strategies, make sense? The epidemiology suggests that urgent reform is needed. Programmes and research efforts need to be informed by the realities of HIV transmission risks for MSM. The reduction of those risks will probably need combination approaches, the use of antiretrovirals for both treatment and prevention, and much greater understanding of why these men, their networks, and their communities, continue to bear such heavy burdens of HIV. HIV remains uncontrolled in MSM in 2012. This reality demands reinvigorated effort, new approaches grounded in biology and epidemiology, and concerted effort to reduce the structural risks that aid and abet HIV spread in these men.
This report was supported by grants to the Center for Public Health and Human Rights at Johns Hopkins from amfAR the Foundation for AIDS Research and from the Bill & Melinda Gates Foundation. The Johns Hopkins Center for AIDS Research (NIAID, 1P30AI094189-01A1) provided partial support to CB. We thank Marco Ambrosio, Shirina Kakayeva, Madeleine Schlefer, and Darrin Adams for the data extraction from the comprehensive searches for this report. We also thank Susan Buchbinder and colleagues for assistance with the modelling, which was based on work done for their Prevention Umbrella for MSM in the Americas (PUMA; NIAID, R01-AI083060).
ContributorsCB, RB, and FvG designed the study. SDB, ALW, and CB searched for and reviewed published work. ALW and SDB produced the figures. SDB and ALW assessed the systematic review. SMG did the mathematical modelling. CB, RB, and FvG were involved in the interpretation and writing of the report.
Conflicts of interest
We declare that we have no conflicts of interest.
See Online for appendix
Prof. Chris Beyrer, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Stefan D Baral, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Frits van Griensven, Institute of Global Health, University of California at San Francisco, CA, USA.
Steven M Goodreau, Department of Anthropology, University of Washington, Seattle, WA, USA.
Prof. Suwat Chariyalertsak, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand. Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
Andrea L Wirtz, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Prof. Ron Brookmeyer, Department of Biostatistics, University of California Los Angeles, CA, USA.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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Find the best La Gaude vacation rentals with Tripping.com. Choose from 13481 rentals, from studio apartments to luxurious condos to entire cabin homes. Book in advance or book instantly with properties marked as "Instabook," with prices ranging from $25 a night to $25648 a night.
Our Tripping.com vacation rentals will save you hundreds, offering more amenities than the average hotel room. Going on a business trip? 10011 of homes in La Gaude offer high-speed wifi internet so you won't miss a beat. Travelling with kids? Have them splash around in any of the 3673 rentals with pool or jacuzzi, or relax with the family in one of the 9648 homes with cable TV.
For all those dog lovers and cat lovers, La Gaude offers 2267 pet-friendly vacation rentals at an affordable price. Book the perfect vacation home that best matches your budget and accommodation style. For the ultimate stay, check out our listings now to grab the latest deals.Search properties from 17 rental sites in La Gaude where the top providers in that area are HomeAway, TripAdvisor, and Booking.com. There are 5726 HomeAway rentals, 2920 TripAdvisor short term rentals and 1923 Booking.com vacation rentals.

subset: commoncrawl


text: Blog, NHN Couture, Spotted in NHN Couture How to rock Neniesville [Queen and Bone Series] Jewelry Collection on Different Outfits August 30, 2015 nhncouture This content is restricted to site members. If you are an existing user, please log in. New users may register below. Existing Users Log InUsernamePassword Remember Me New User RegistrationChoose a Username*First Name*Last Name*Address 1*Address 2City*State*Zip*Country*Day Phone*Email**Required field


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Recent Posts
Monthly Archives: May 2015
Recap: Volusia County Update
Leading the nation in job growth last year isn't the only topic of discussion in Volusia County these days. With a major renovation of an iconic race track underway, cutting-edge research in aviation, and important infrastructure improvements in the works, ULI members and other attendees flocked to Daytona last week to hear the latest county news directly from the experts. The ULI Signature Event: Volusia County Update was held on April 30th at the Daytona International Speedway, drawing nearly 100 guests from around Central Florida and kicking off with a … Read More
Posted in Events Tagged daytona, daytona international speedway, embry riddle, florida, Infrastructure, urban planning, volusia county Leave a comment


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January 30th, 2011
Part 1 about scarf This winter is said to be the coldest one in last 20 years, so the first thing that we have to do is keeping ourselves warm. But young girls can not tolerate the tragedy that they must sacrifice the opportunity of showing their lovely figure for fat and clumsy clothes which just aim to keep warm. Therefore, big and warm scarf has become the new favorite fashion this season. An assortment of scarf has broadened our horizon, bib, carves, shawl and so on. Wearing a scarf can make your ordinary wear turn into fashionable style instantly, and taking color, shape and size of scarf into consideration, you absolutely don't worry about putting on repetitious clothes everyday. In the final analysis, scarf is definitely the most worthy of gorgeous accessories this season.
Part 2 about boots Faced with the extreme cold winter weather, many beauties have come up with smart tricks to respond to it. That is so thick fur boots, which can let our legs and feet warmer. This year, the fashionable trend is Arctic style that marked by all kinds of thick fur boots. Wearing exaggerated and warm boots to get cold weather under control is indeed a warm and consistent trends way. The role of shoes is not only comfortable, but also a good tool to dress for your body's overall. Another popular element is tassel, you can choose ankle boots, clogs. Rivets and feathers can add tassel shoes style in the most appropriate method. At the same time, national print dresses, lace, motorcycle vest has always been the most popular stuff that make us vogue.
In closing, I'd like to call your mention that no matter what others tell you about the things that are worthy to buy, you have to decide whether it is fit for you or not. Be a smart consumer, you will get a lot of fun.


text: Thomas is Managing Director of Rebate Networks, a German venture investor. Over the last years he has been involved in building up several e-commerce companies in South East Asia and Eastern Europe. Thomas started his internet career in 2000 as Co-Founder of yousmile.de AG and Mentasys GmbH, which became one of Germany's leading online price comparison service provider and which has subsequently been sold to a subsidiary of Bertelsmann AG. Prior to Rebate Networks he was managing director and CFO of studiVZ, Europe's largest social network at that time. Thomas is currently also involved in several start-ups in Europe, the US and Asia as business angel and advisor. He likes running marathons.


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Under Armour Printed Layered Up Storm Jacket
Product description
- Fitted: Next-to-skin without the squeeze.
- UA Storm technology repels water but stays soft & breathable for superior comfort
- Lightweight woven fabric delivers superior comfort & durability
- Princess seams create a slimmer, more streamlined silhouette
- Generous scuba hood with adjustable bungee drawcords
- Back mesh vent for extra breathability
- Full zip front for easy layering
- Slight asymmetrical hem
- Zippered hand pockets
- Reflective logos & details deliver greater visibility on low-light runs
- Allover seasonal printed body
- Polyester
- ALLSEASONGEAR: When the sun's blazing, ordinary fabrics heat up quick, meaning you sweat harder, fatigue faster & lose focus.
- UA STORM: A tiered system of water and wind protection that keeps you dry in any wet weather situation. UA Storm1: Water-Resistant UA Storm2: Highly Water-Resistant & Windproof UA Storm3: Waterproof & Windproof
- REFLECTIVE: High visibility solution for running before dawn and after dark.
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First line modern house for sale in Playa de la Malvarrosa, Valencia, with fantastic sea views
- Bedrooms 4
- Bathrooms 5
- Size 300m²
- Plot size 550m²
Contact Lucas Fox Valencia today and speak to an advisor about this propertyRequest information
Modern house with a swimming pool in Playa de la Malvarrosa with wonderful sea views, situated close to the centre of the city and within walking distance of the marina.
This is one of the few houses located on the first line of the beach in Valencia.
The property has been recently built and boasts a modern interior.
On the ground floor there is a living/dining room, a kitchen, a WC and a terrace with a swimming pool and decked area. The first floor offers 3 en-suite bedrooms. On the top floor there is a large attic room with spectacular sea views.
The property offers a lift, a swimming pool and underfloor heating. It also boasts 2 large terraces on the ground floor, one at the entrance where you can enjoy a welcome breeze during the spring and summer months, and a larger one at the back and in the swimming pool area.
There is also space for parking.
- Swimming pool
- Waterfront
- Sea views
- Lift
- Terrace
- Garden
- Rental licence
- Fireplace
- Underfloor heating
- Parking
Ground floor:
- Living/dining room
- Kitchen
- Terrace with a decked area and swimming pool
First floor:
- 3 en-suite bedrooms with sea views
Top floor:
- Large attic
- 2 terraces, one at the entrance and one at the back in the swimming pool area
- Parking
- High quality finishes
This excellent urban beach of fine golden sands is located in the north of the municipal district between the town of Alboraya and Calle Acequia de la Cadena.
Playa de la Malvarrosa is serviced by lifeguards and offers sun beds, sports activities such as a lively beach volleyball club and many beach bars. It also has numerous amenities available all year round including supermarkets, medical services, pharmacies, restaurants, ice cream shops and a gym.
One of its main attractions is the Paseo Marítimo and its many restaurants and cafés. Of note is the impressive Hotel Balneario Las Arenas, located on the waterfront, where you can enjoy fantastic facilities including a spa and beauty centre.
Situated 10 minutes from the centre, Playa de la Malvarrosa is well connected with the rest of the city via bus, tram, taxi and the Valenbisi bike rental service.
Similar properties for sale in Valencia City
Valencia City, Eixample
- Bedrooms 3
- Built size 211m²
Valencia Inland, Godella / Rocafort
- Bedrooms 7
- Built size 496m²
- Plot size 764m²
Valencia Inland, Godella / Rocafort
- Bedrooms 5
- Built size 700m²
- Plot size 2,100m²
Valencia Inland, Monasterios / Puzol
- Bedrooms 4
- Built size 603m²
- Plot size 1,000m²
Reduced Price
Valencia Inland, Godella / Rocafort
- Bedrooms 3
- Built size 537m²
- Plot size 1,385m²
Valencia Inland, Monasterios / Puzol
- Bedrooms 6
- Built size 500m²
- Plot size 903m²


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Austin Area Geocaching Awards event Saturday
Expand Messages
- If you're looking for something to do this weekend, come to the 2011 Austin Area Geocaching Awards Ceremony! (GC3EXJY http://www.geocaching.com/seek/cache_details.aspx?guid=fa5587bc-06e3-442d-ac9e-dca2ccdffcd0) We are celebrating the excellent Austin Area hides of 2011. Come support your friends, hang out, and make new ones!
Hope to see you there,
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The man without the Spirit does not accept the things that come from the Spirit of God, for they are foolishness to him, and he cannot understand them, because they are spiritually discerned.
The Daily Bible Promise provides you with a daily Bible passage delivered via Twitter, Email, RSS or the Web. [ More about the DailyBiblePromise.com ]
Suggestions are welcome via DM on Twitter or through the feedback form.


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Luck spells
Banishing bad luckPublished by on
You will need:
12 white tea lights
Picture or ornament of a white unicorn
On the first night of a new moon, place the candles in a circle on the kitchen table. Inside the circle, put the unicorn image or ornament. Light the candles and say the following three times:
'Take forth this ill luck and bring peace to its space,
Magnificent moon, engulf and embrace.
Angel of harmony, shine magical power,
All that is harmful be gone in this hour.'
Boosting your luckPublished by on
You will need:
Several white tea lights
Some salt
Start by having a good spring clean in your home. Get in every nook and cranny, and don't forget lampshades and windows, as a build-up of dirt and dust can trap negative energies. In the evening, light a tea light in every room of the house and sprinkle a little salt (to help spiritually cleanse) on the floor in each as you recite these words:
'Ill fate be gone,
I shall have none.'
Removing negative energyPublished by on
You will need:
This site will be taken down for a short while to perform an upgrade.


text: Write the first paragraph of your page here. Section headingEdit Write the first section of your page here. Section headingEdit Write the second section of your page here. Retrieved from "http://lesharo.wikia.com/wiki/Transmission_(4_Speed_Manual)?oldid=4057" Ad blocker interference detected! Wikia is a free-to-use site that makes money from advertising. We have a modified experience for viewers using ad blockers Wikia is not accessible if you've made further modifications. Remove the custom ad blocker rule(s) and the page will load as expected. Categories: Chassis Transmission Add category Cancel Save


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Back Home at a Ghost Town
Credits & Info
- Uploaded
- May 11, 2010 | 10:17 AM EDT
- File Info
- Song
- 1 min 15 sec
- Score
- 3.97 / 5.00
Related Content
You might also enjoy:
Licensing Terms
Please contact me if you would like to use this in a project. We can discuss the details.
- Score:
- Rated 3.97 / 5 stars
- Plays & Downloads:
- 1,164 Plays | 62 Downloads
- Share Links:
- Genres:
- Other - Miscellaneous
- None
Author Comments
Rated 4.5 / 5 stars
strip it chill it
haha i dissagre totaly i think it needs to be striped down, yet i can see pileing it on being good too i think it's not chilled enuff and yet not the other it's too interesting to not like tho
Rated 5 / 5 stars
Needs more background synth/strings and a larger running time. The baby or whatever it is, is good. It's just placed in the background so you kind of hear it without really noticing it's arrival.
Ah yeah maybe if I do another in this style I'll try and add more synth, I can kinda see where your coming from :) cheers man.
Not many people seemed to like this one from the score, but it's one of my favourites haha


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The closer we come to Thanksgiving celebrations next week the more it seems we think about giving thanks and showing our gratitude. Yet, we can count these blessings every day, and for me doing so has sharpened my senses to the many small things I often overlook as gifts from God. This last week it's been impossible not to give thanks:
184. Ann's writing of their Compassion International experiences.
185. Compassion International and the work they do around the world.
186. Freedoms fought for by our veterans and current military.
187. Nature's fall decorations.
188. Calls from our kids.
189. My husband's slow, loving smile.
190. Time with friends sharing a meal.
191. Breakfast out.
192. Mosaic seen in leaf-covered sidewalks and roads.
193. Children singing and playing bells in church.
194. God's incredible fall palette.


text: Vendeur: discountleisureproducts (153.026) 99.9%, Lieu où se trouve: Spalding, Lieu de livraison: Worldwide, Numéro de l'objet: 181283105879 Discount Leisure ProductsHigh Quality Jebao UV BulbThese bulbs are a high quality branded lamp to fit a wide range of pond and aquarium UVC systems including the Hozelock Easyclear Filter rangeThis is a Multi Listing - Please select the wattage lamp you require from the drop down options above It is important you check your old uv lamp before purchasing. From 2012 Hozelock started making the Easyclear 9000 with a Twin Lug Lamp connection.Standard size lamps(select wattage from options) to fit a wide range of pond UV clarifiers such as the Tropical Marine Centre Pond Clear and Pro Clear(TMC), Hozelock Eco Power box filters, Fish Mate, Yamitsu Algae Master UVs from Kockney Koi and many other brands. Please contact us if unsureA UV bulb should be replaced every 6 to 12 months to ensure optimum performance and clarity.Discount Leisure Products can now be found on social media sites. Please check out Facebook or twitter for product updates and any special offers'Like' us on Facebook'Follow' us on Twitter @discountleisureDispatch InformationWe will generally dispatch your item the same day if ordered are placed before 12 noon.Items under 2Kg are usually dispatched via Royal Mail 1st & 2nd class deliveries which covers all UK address with a postcode including Northern IrelandIf the selected postage option is Royal Mail 1st or 2nd Class then on average delivery times are between 2 to 7 working daysPlease allow up to 10 working day on Royal Mail deliveries as delay do happen. Please also check at your Local Royal Mail collection office, with your neighbour and at the post office before getting in contact with us. Many items are being left in these places and calling cards are not being left behind.We offer a courier delivery which is a tracked and signed service with 48 & 24hr options.Please provide a mobile number for delivery notifications, we will send day of dispatch notification texts on courier order offering the option to change delivery daysOur courier pass on zonal surcharges for certain UK postcodes, please check for your postcode below as there may be additional charges if item is shipped via courier is the selected delivery method.Courier Deliveries to the following postcode will incur an additional charge of £6.00 IV,HS, KA27-28, KW, PA20-49, PA60-78, PH17-26, PH30-44, PH49-50, ZECourier Deliveries to the following postcodes will incur an additional charge of £9.00 BT, IM, TR21-25Courier deliveries to the Channel Islands will incur a £9.00 additional chargeCourier Deliveries to the Republic of Ireland will incur a £14.00 additional chargeIsle of Wight delivery via Courier will incur a £7.00 additional chargeFeel free to Contact us with any questions through eBay messages Type: UV Replacement Bulb, Brand: JEBAO, MPN: Does Not Apply


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Beautiful 3 b / 2 b - Beach Block - single family home. Steps to the Beach. Ocean views from kitchen & living room. New kitchen, appliances & flooring. Granite countertops. Furnished. Lots of natural light from plenty of windows. Entire property is fenced in - Front yard - chain link - Backyard - white privacy fencing - patio - gas grill, outside shower. Large garage in backyard is not included in rent but maybe added at additional cost. Winter rental only. Avail from Sept 2017 to May 2018. Unit rents weekly in season for $2800 per week. Perfect for staff, facility of Stockton University, Tech Center, those working in AC area. Pet considered.
Listing Courtesy of WEICHERT REALTORS BRIGANTINE REALTY


text:
Desk Analyst jobs in Leinster
Stanley Steemer International, Inc. Direct Employer12 Aug
Help Desk Analyst
The Help Desk Analyst role will provide first level technical support and troubleshooting to Franchise, Branch...
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...Service Desk Analyst Global financial services and advisory client are seeking an experienced Service Desk...
Confidencial Direct Employer19 Aug
Service Desk Analyst
...The Service Desk Analyst role comprises of both customer service and support responsibilities within company ITIL...
The Panel03 Aug
Operational Management Desk Analyst
Operational Management Desk Analyst REF J37602 Location: Dublin City Employment Type: Permanent Salary: Negotiable I am...
Irish Jobs Direct Employer22 Jul
Service Desk Analyst
Financial Services company now has a vacancy for a Service Desk Analyst /Network Administrator . Responsibilities...
Singlepoint18 Aug
Service Desk Analyst
...the initial engagement. The Service Desk Analyst role comprises of both customer service and support responsibilities...


text: S&W K-22 1947 mfg For Sale from Gun Emporium | Positive feedback: 100% View | Verified Seller | 16 Completed Sales View Sellers Items /UserImages/103495/917700915 9909705.jpg Description: 90% condition, just reduced thus price is firm. Read More Condition: Used, Minor Wear Brand: SMITH & WESSON INC UPC: K-22 Caliber: .22 Long Rifle Location: AZ Trades Accepted: US Postal money orders only. Read More FFL since 1988 in Scottsdale, AZ.Shipping as shown does not include insurance. If you want insurance it is $2/$100 of value & you must purchase it before an item is shipped. Shipping Notes: $25 basic USPS Read More Share Item Item #: 917700915 Gun Emporium Seller Since: Jan. 2009 Seller Level: Verified This seller is an FFL City: Scottsdale State: AZ This seller requires that you use our Verified Address Page to confirm your basic identity before any contact regarding this listing. Price: $795.00 Add To Cart Please Login/Register to Order Login or Register to buy Shipping: $25.00 (or Arrange local transfer) Accepted Payment Methods: Returns: No Returns Your Recently Viewed Items


text:
my site is temporary out -
Expand Messages
- Hi there,
I don't know what happened but the server I was using is not updating my site any longer...it must be due to some technical problems.
I was feeling so frustated that I decided to delete it all and put all back there again, but guess what it didn't work. The only way it seems to work is buy uploading the files manually, and I do not feel like it. I transfered all my stuff to naother server. I just hope that my old one will be beack in business soon...
meanwhile the photostory can be checked here: http://virtual-waters.tripod.com/photostories.htm
My Blog & Site
Get amazing travel prices for air and hotel in one click on Yahoo! FareChase
[Non-text portions of this message have been removed]
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text:
About me
A little about me: My name is Preston de Guise, and I've been working in primarily consulting roles since 1996 – whether that be customer-facing consulting, back-end outsourcing administration, customer support or training. I've dealt with a large variety of enterprise environments ranging from primary industries (mining, exploration, etc.) through to health, finance and banking, manufacturing, sales and importing. I'm the author of Enterprise Systems Backup and Recovery: A corporate insurance policy, and wrote that book based on the lessons I've learned over the years dealing with a plethora of backup implementations, policies, administrators and managers. I started in Unix system administration, managing multiple backup servers across Australia for a multinational company, so I approach customers with a healthy understanding of the need for availability and prioritisation of issue resolution.
In my spare time, I write, read, get ruled over by a couple of cats, spend time with my partner, dabble with photography, potter with programming and pugnaciously procrastinate.
Oh, and I'm utterly terrified of zombies. As soon as a movie or story has zombies in it, I'm off watching or reading something else. If you know the official phobia name for that, I'd appreciate you letting me know 🙂
About NetWorker
EMC NetWorker (formerly Legato NetWorker) is an enterprise class data protection product that I've been using since 1996. It is not by any means the only backup product that I've used, but for various functionality reasons, it is certainly one of my preferred.
I'm not by any means in this blog advocating that you should be using NetWorker yourself – each backup product has to be deployed against the requirements of an individual environment, and I don't know your environment. If however you're looking at deploying an enterprise backup product, it's certainly one to consider.
16 Responses to "About"
Love your blog! Keep it up … thanks!
Hi Preston,
very good blog! I am also working with networker and would like to share my knowledge. Do you accept guest acticles?
Hi Ronny,
I had not thought of guest articles when I setup the blog. Let me think about it over the next couple of days and get back to you. I'll email you directly.
Really like this blog, I'm pretty new to NetWorker but this blog has helped me alot during my year of NetWorking..
Thanks for all your helpful posts on the networker listserv list at temple.edu!
I'm glad to be able to help where I can, which is why I still contribute to the NetWorker listserv as well as doing this blog. Thanks for the feedback!
Hi Preston,
I would like to know if you know a way to automatize with a batch file the instalation of agents on both Windows and Linux Environments?
Thanks for your attention!
Hi Erick – you probably should check out the article on the NetWorker software distribution system — that's probably about the closest thing to what you sound to be after. It's at http://nsrd.wordpress.com/2009/08/05/using-the-networker-software-distribution-functionality/
Thank you so much for your help, i appreciate it.
"Oh, and I'm utterly terrified of zombies. As soon as a movie or story has zombies in it, I'm off watching or reading something else. If you know the official phobia name for that, I'd appreciate you letting me know :-)"
I have found this, but it is from the Urban Dictionary, so you can use it or not:
Kinemortophobia: The fear of the undead.
Just received a copy of your book. Very good! Oh, the blog's really great too 😉
Hi Alex – thanks for the great feedback, and I hope you enjoy the book!
My pleasure!
I gave it a thumbs-up on my LinkedIn profile too, free ads just because I really like it 🙂
Hi Alex – that's great, thank you!
Your Blog is really very helpful . I refer this for almost all my doubts in networker
Great blog thanks.
Really helping out with my first implementation of NW.
My management are wondering how I picked it up so quick 😉
On a side note Kinemortophobia is the correct term for your phobia.
Keep up the great work.


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text:
Submit your review
The kit is well made and easy to assemble, even for anyone without any electronic experience. It is affordable and also ideal for electronic technicians who might not have the time to do the development themselves. The assembly manual is easy to follow and any questions are answered by Bozidar promptly. Overall, a good buy, deserving 5 stars!
Excellent product at a great price. Only just started using this so can't comment yet on how effective the therapy is. Only comment is that the electrodes require wrapping in gauze and soaking in saline solution which is a pain. To improve on this, I have purchased from amazon some reusable 25mm diameter adhesive electrodes normally used for tens machines. These have a 2mm connection and perfectly connect to the Bob Beck device. Seems to work well. If 25mm is too large they can easily be trimmed down with a pair of scissors.
hi. i received my device 4 days after purchase. very good little gadget. i would recomend this seller/ thanks
Thanks Glen.
Maybe I spoke too soon. After posting the previous negative review (and admittedly not attempting to resolve with an email), I did receive an email with shipping confirmation. I'll post another review after I receive and try the unit.In my humble opinion, 2-3 days to ship is kind of the norm and that was what I expected. I guess that's what I get from having expectations.At this point, I will recommend you order from this site. Sorry to be so quick to allow my stress to get the best of me. Perhaps it's a symptom of what I am looking for a cure for in your device. 🙂
Thanks for honesty Chuck. Be well.
I promptly received an email after ordering over a week ago, stating the order was received. Still no email to say it shipped. I've been had, don't let it happen to you too.
Huh, after 18 years in hypnotherapy i am still impressed about people negativity. Chuck, the time you have spent with this review, you could spend it to send me an email to resolve the situation. I had too many orders and i have sent yours with delay. Sorry. Anyway, the device is on its way to you.
Be positive 🙂
Fantastic little device well built thank you very much all good except the electrodes could do with being a little longer as only half an inch long but other than that very happyThanks again
Thanks Nick, yeah...electrodes. After so many time i finally developed new type of electrodes and they will be ready till end of january. Will let you know.
The product came in good shape and I could feel the difference after using it for a few days. Unfortunately somehow it stopped working after a while, probably due to something in the machine got displaced. Emailed Mr Bozidar and he kindly sending a new one as replacement. Thank you Mr Bozidar. Great work and service.
Many thanks for the Bob Beck Purifier. This is a very professionally made unit in a strong custom case, and is working perfectly. Bozidar has created an impressive web site to sell his products which shows his commitment to providing a first class service.
Thanks Adrian, Merry christmas and a great 2017 🙂
Emailed Boozier three times with no response. I ordered one of these units thirteen days ago and he has my money, but no unit yet. I've contacted him three times and he has yet to reply.
In the meantime we resolved the issue. The problem was in emails. I will definitely answer your emails, but sometimes my reply goes to SPAM folder and unfortunatly a lot of people doesn't check SPAM folder. Don't allow Google to manage your life. A lot of usefull stuff goes to Spam, because of Gmail and similar filters.
When you order the device, i'll send you an email you that i received your order, and the next email when the device was dispatched.
If you don't hear from me, please check your SPAM folder.
Enjoy the summer
P.S. The device was already at her place...this is USPS notice from the tracking number 🙁
July 22, 2016 , 11:39 am Notice Left (No Authorized Recipient Available)
Received in Romney, WV, USA 4 days after Paypal payment. Wrapped very securely. Very appreciated. Thanks for all you do!
Thanks 🙂


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American Cancer Society
11000 North MoPac Expressway
Suite 100
Austin, TX 78759
Our goal is to provide pro bono estate planning legal services to the cancer community.
We are local professionals who care about the cancer community. We are attorneys, paralegals, notaries, community and business leaders, and other volunteers. We are supported by the Austin Bar Association, Austin Bar Foundation, local law firms, as well as local cancer community professionals.
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Born in Lisbon, Portugal in 1980 and raised in the green valley of Alenquer, the village that saw him fall in love with things, from the multicoloured river pebbles, to the abandoned mills that rest on the top of the mountains, to the roads painted in autumnal colours, by the leaves blown away by the wind, to the sweet music of the night.
After he finished the 5 years degree in industrial and interior design, at Universidade Lusófona de Humanidades e Tecnologias, in Lisbon, Portugal, he was granted with the Leonardo da Vinci scholarship. He moved to Barcelona, Spain, to do an internship at Estudio Mariscal, where he stayed working after the 6 months internship, making part of the department of industrial design, in 2007/2008. In November 2008, he collaborated in the studio of Martín Azúa.
"...from the multicoloured river pebbles, to the abandoned mills that rest on the top of the mountains..."


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What's Lost When We Photograph Life Instead Of Experiencing It?
- Details
- Category: Art & Culture
- Published: Wednesday, December 28, 2016
Rebecca Macmillan, University of Texas at Austin
At a conference on June 14, Facebook executive Nicola Mendelsohn predicted that the social networking site would be "all video" within five years.
"We're seeing a year-on-year decline of text," she said. "If I was having a bet, I'd say: video, video, video."


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Awd! Want to stretch your purchasing power? Well take a look at this superb 2014 Acura MDX. This is one luxurious ride, but don't just take my word for it. Come on down and EXPERIENCE it for yourself. You won't be disappointed. See why our dealership is the Largest Certified Acura Dealership in Central PA!
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**note** My apologies for the lack of a baby in the picture. None of the ones I drew actually looked like a fetus, so I gave up.
Placenta previa is a very dangerous condition for both the mother and the baby. It occurs when the placenta covers the cervix — causing either complete previa or partial previa (fairly self explanatory) — or when the placenta is very close to the cervix, causing marginal previa. A recent study published in AJOG found that, in cases of marginal previa, at least two-thirds of women with a placenta farther than 10 millimeters were able deliver vaginally without increased risk of hemorrhage. The study is very small, though, and I would have liked to see a third group with normal placentas as a control. In any case, when it comes to complete or partial previa, good outcomes for both infant and mother depend on prenatal diagnosis and cesarean delivery before the membranes rupture. If not, they are at risk for some very nasty complications, including preterm delivery, blood clots, infection, placental abruption, hemorrhage of both the fetus and the mother, shock, and death. Placenta previa is not a joke.
This is why it is unconscionable for Unhindered Living to continue publishing the page Handling Placenta Previa At Home.
A few choice bits:
It seems like she realizes it's terrible advice, because she's qualifying every other statement, yet she still gives it! Placenta previa is NOT a "variation of normal," so if you are diagnosed and it continues late in your pregnancy, please do not consider that page as a justification for a home birth. **Note** An early diagnosis of placenta previa (with the anatomy scan, 20ish weeks) may resolve itself as the uterus grows, and if that is the case, you would not need a c-section for previa. However, this is something that should be taken care of between you and your doctor or midwife, not by taking advice from websites.


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I was told that Singapore men cannot wear long hair. I was even told that they will ask the male tourists with long hair to cut off their hair before they enter the country. Is it true or just another misinformation?
I was told that Singapore men cannot wear long hair. I was even told that they will ask the male tourists with long hair to cut off their hair before they enter the country. Is it true or just another misinformation?
whoever told u that is pulling ur leg. But seriously, do u think this to be true ?
SIN may be known as a police state but it is mainly the drug law that launched this nick. the media (esp. American ones) loves to blow it out of proportion when they report anything about SIN. The chewing gum ban is a good example. Media tells the world that it is banned but not why (the hazards and ugliness it caused when not disposed properly - under tables, between train doors, floors, etc) and how (u can still chew gum in the country if u brought in a few for personal consumption, u just cant find any local retailers selling any).
lol, i cant believe u fall for that.... hahaha.
actually, this would be a wonderful idea. we have a lot of unemployment now, so if we introduce this long hair law, then we can create a lot of jobs for barbers at the airport, sea port and causeway.
hair can also be used as biomass fuel.
sorry, its been a long day...i needed the relief...
I heard this was true back in 1970s and 1980s. They had barber at the airport to do haircuts for male tourists with long hair.
Thanks for all the responses. I didn't think it was true, but the person who told me had actually been to Singapore and have a sister that lives there. I'm glad that's all clear up. Thanks!
As everyone has mentioned, this is not true, but I think that Kitaro or Yanni (can't remember which one) was not allowed to enter Singapore some time back because of his long hair. He was told that he had to cut it if he wanted to perform in Singapore. So he didn't perform in Singapore.
However, do be mentally prepared in case they search your luggage at the airport. They usually go guys with long hair as the officials may think that it's not very presentable.
Hello Cindy
Just wanted to tell you that you're being misguided and misinformed. Singapore is an small but nice country to visit and truly one of the cleanest. I worked there for about 3 years. They are somehow strict on certain things like chewing gum, smoking, littering. You can get fined if got caught littering, or chewing gum and not disposed of properly.
Otherwise, Singaporeans are very nice, polite, and respectable. You'll difinitely have a wonderful time. Good Luck and Have a safe and enjoyable trip.
Cheers .... Lyn
Hi Cindy
We were in Singapore for 3 nights in February & I spent a large (6 years) portion of my childhood growing up there. I heard this story nearly 30 years ago when hippies were popular. I believe that the immigration authorities back then were difficult to & in some cases prevented men entering the country whose hair was longer than collar length. At that time they associated long hair with hippies & associated hippies with drugs, but who didn't back then. That was 30 years ago though. This an old story re-surfaced.
On my recent visit I saw plenty of men with long hair, both Singaporeans & tourists. Singapore has an unfair reputation of being almost totalitarian; this is completely untrue. I love Singapore & its citizens. They are pleasant, helpful & polite. It is probably the cleanest city in the world & quite naturally it wants to stay that way. I have never been anywhere in the world that provides ashtrays on the roadside. I can only applaud their efforts. If only things were similiar here in the UK. What a contrast to arrive back in London to see the huge amount of litter laying by the roadside right outside Heathrow Airport. If I could get a work position, visa & work permit I'd move there in a heartbeat!


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Latest News
July e-Newsletter | Athletes & Blood Clots
Think you are too fit for a blood clot? Think again. Blood clots can happen to even the most active and physically fit people, including professional athletes and fitness enthusiasts alike. We at NBCA regularly hear from athletes who have experienced DVT and PE, even at the peak of physical fitness. The one thing that…
4th Annual Get in Rhythm. Stay in Rhythm.™ Atrial Fibrillation Patient Conference
The 2017 Get in Rhythm. Stay in Rhythm.™ Atrial Fibrillation Patient Conference, hosted by StopAfib.org, takes place this year, August 4-6, in Dallas, Texas. The conference will provide important information about the management of Afib, and bring patients and leading experts in the field together for a unique opportunity to engage and learn about living your best life…
Betrixaban: New Oral Blood Thinner Cleared by FDA
The U.S. Food and Drug Administration has granted Portola Pharmaceuticals permission to market a a new oral anticoagulant or "blood thinner"called betrixaban (BevyxXa®). The medication is indicated for use for the prevention of venous thromboembolism and pulmonary embolism in acutely ill patients who are not undergoing surgery, but are at risk for venous thromboembolism due…
NBCA Educational Materials Selected for Use in New Joint Commission Educational Effort
The National Blood Clot Alliance is pleased to announce that its website, as well as several of its educational products stemming from its cooperative agreement with the Division of Blood Disorders, National Center on Birth Defects and Development Disabilities, at the Centers for Disease Control and Prevention (CDC), have been chosen for use in a…
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2nd Annual Kicks for Clots tournamentCharlotte, North Carolina
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Chalet Tantalus Resort Lodge
Whistler Canada
Sleeps: 2-6
Property Description
These well established and spacious apartments are located only approx. 5 minutes walk from the heart of lively Whistler Village and the Whistler/Blackcomb lifts. The Tantalus Resort Lodge operate a free shuttle to and from the ski lifts.
Chalet Tantalus Resort Lodge
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( 74m²) Living/dining room with wood burning fireplace, TV, pay per view movies, telephone, balcony and double sofa bed. Master bedroom with queen size bed, second bedroom with two twin size beds; two full bathrooms with hairdryer. Full kitchen with 4 ring oven, fridge, toaster, coffee maker, microwave and dishwasher.
Features Included
Linen, towels, daily maid service and end of stay cleaning.
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Photos are representative of Tantalus Lodge - your accommodation may differ to those shown.
Other supplements may apply.


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What More Can I Do?
On Monday, August 8, I sat down for an in person job interview with St. Louis County Library for an Assistant Branch Manager position at their Daniel Boone library. I met with the Branch Manager and a woman from Human Resources. We spoke for approximately 30 minutes. It was all very pleasant. I stressed why…… Continue reading What More Can I Do?


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In parallel with the 67th Berlinale, Glashütte Original introduces the exclusive new limited edition range of five Sixties Square watches. Each of them is limited to 25 pieces worldwide. The collection is named the Glashütte Original Sixties Iconic Square, and each its dials is inspired by colors seen on watch dials first presented in a range of "Spezimatic" models produced by Glashütte Original in the 1960's. The distinctive dials of five square chronographs are made by the brand's own dial manufacture in Pforzheim, Germany.
Their square cushion shape, domed dials, curved hands, and characteristic Arabic numerals, distinguish the watches of the Spezimatic series, which still stands as the lasting icon of style. All of these recognizable design elements inspired the Sixties Iconic Square Collection. Five different dials give models their names: Sixties Iconic Forest, Sixties Iconic Ocean, Sixties Iconic Graphite, Sixties Iconic Tangerine and Sixties Iconic Fire.
Their vibrant watch faces are made by applying colored lacquers to achieve the precise hues and shading, lighter in the center and darker towards the perimeter – a finish known as the "dégradé effect." First, the dials are given a galvanic base coat before layers of colored lacquer are added by hand in a series of subsequent steps. In a final step, black lacquer is carefully applied to the dial using a spray gun to create a unique color gradient. The lacquered dials are then fired in an oven to burn in the colors.
The five models of the Original Sixties Iconic Square collection are presented with a distinctive square cushion shaped stainless steel case, measuring 41.35 x 41.35 mm. The manufactory automatic Calibre 39-34 chronograph, beating at a frequency of 28,800 vph, powers the watches. The movement is mounted on 51 jewel bearings, and it promises around 40 hours of power reserve. All watches are fitted with a matching Louisiana Alligator leather strap: brown for the models featuring forest green or tangerine colored dials, black for the watches with graphite grey, ocean blue or fiery red dials.
The Original Sixties Iconic Square collection is available in Glashütte Original Boutiques and selected retailers. Each of the five models, limited to 25 pieces, retails at $9,700 USD.
REF. 1-39-34-22-32-04 Sixties Iconic Ocean
REF. 1-39-34-23-32-04 Sixties Iconic Forest
REF. 1-39-34-24-32-04 Sixties Iconic Fire
REF. 1-39-34-25-32-04 Sixties Iconic Graphite
REF. 1-39-34-26-32-04 Sixties Iconic Tangerine
Photo copyright ©Glashütter Uhrenbetrieb GmbH
Glashutte Original collections
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This time, the successful model appears in a distinctive dark blue version, uniting fine watchmaking with a sense of refined elegance and masculine beauty. The chronometer watch is a term that characterizes only the most refined and precise time telling instruments. A watch can be called "chronometer" only if it has earned this title by complying normative standards of one of the authorized testing institutions. For Swiss watches, it is the Official Swiss Chronometer Testing Institute (COSC). This Swiss non-profit organization tests...
Glashütte Original the Sixties Iconic Collection Colored Dials
The house of Glashutte Original adds five new colorful dials to its famous Sixties Iconic Collection. This vintage-inspired collection, which is a tribute to the iconic timepieces from the 1960's, and particularly the Spezimatic – one of Glashütte Original's most famous creations. The Spezimatic, which was first introduced in 1964, is a series of automatic models, equipped with Calibers 74 or 75, and manufactured from 1964 to 1979. The special Sixties Icons Collection pays a tribute to this iconic era, while blending its unmistakable design sty...
Glashutte Original the Sixties
In 2015, the manufacture of Glashutte Original celebrates its 170th anniversary. At the same time, German reunification took place exactly 25 years ago, which opened another chapter in the history of Glashütte watchmaking. In this special year, the house of Glashütte Original celebrates several of its jubilees and anniversaries. For the occasion, the brand introduces the new "Sixties" model as a special tribute to the 1960s, which was one of the most productive periods in VEB Glashütter Uhrenbetriebe's history (the predecessor of Glashütte Orig...
Glashute Original Senator Cosmopolite
The Glashute Original Senator Cosmopolite watch is offered in two different renditions: one made from red gold, and the other one from white gold steel. Both watches are powered by the new automatic Calibre 89-02, which was entirely developed in Glashute Original's workshops. Designed with modern world travelers in mind, the Senator Cosmopolite simultaneously tracks time in two time zones. The time zone disc is printed with the official IATA location codes of 37 world time zones, each signifying a major international airport in the selected zon...
Glashutte Original PanoMaticLunar and PanoReserve for BaselWorld 2015
Two new timepieces are joining Glashutte Original's Pano Collection, in red gold styles with a matt black dial, and in polished/satin brushed stainless steel versions with a dark blue dial. Their exceptional deals are made in Glashütte Original's own dial manufactory in Pforzheim, by the Manufacture's best masters of the craft. Up to 40 separate operations are required to produce each and every one of these dials, while the application of the graphic elements goes over four different stages. The color of the dials is obtained from a special gal...
Glashutte Original Seventies Chronograph Panorama Date
As mentioned so many times during the last couple of weeks, Glashutte Original has finally unveiled its new in-house chronograph caliber 37, a movement that just made its debut in two new models: the sophisticated Senator Chronograph Panorama Date and more casual Seventies Chronograph Panorama Date. Both new models were officially unveiled a couple of days ago, at the Art of Chronograph event at the Sky Room of the New Museum in New York City (you can read our coverage of the event here). I have already introduced you with the Senator model, in...
Glashutte Original Art of the Chronograph Event in NYC
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Glashutte Original Senator Chronograph Panorama Date
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