text: Cost-Effectiveness of Alternative Strategies for Initiating and Monitoring Highly Active Antiretroviral Therapy in the Developing WorldVijayaraghavan, Arthi MS*; Efrusy, Molly Bates MPH*; Mazonson, Peter D MD, MBA*; Ebrahim, Osman MD, PhD†; Sanne, Ian M MD‡; Santas, Christopher C MBA*JAIDS Journal of Acquired Immune Deficiency Syndromes: 1 September 2007 - Volume 46 - Issue 1 - pp 91-100 doi: 10.1097/QAI.0b013e3181342564 Epidemiology and Social Science Abstract Author Information Article Outline Objective: Determine the cost-effectiveness of initiating and monitoring highly active antiretroviral therapy (HAART) in developing countries according to developing world versus developed world guidelines. Design: Lifetime Markov model incorporating costs, quality of life, survival, and transmission to sexual contacts. Methods: We evaluated treating patients with HIV in South Africa according to World Health Organization (WHO) "3 by 5" guidelines (treat CD4 counts ≤200 cells/mm3 or patients with AIDS, and monitor CD4 cell counts every 6 months) versus modified WHO guidelines that incorporate the following key differences from developed world guidelines: treat CD4 counts ≤350 cells/mm3 or viral loads >100,000 copies/mL, and monitor CD4 cell counts and viral load every 3 months. Results: Incorporating transmission to partners (excluding indirect costs), treating patients according to developed versus developing world guidelines increased costs by US $11,867 and increased life expectancy by 3.00 quality-adjusted life-years (QALYs), for an incremental cost-effectiveness of $3956 per QALY. Including indirect costs, over the duration of the model, there are net cost savings to the economy of $39.4 billion, with increased direct medical costs of $60.5 billion offset by indirect cost savings of $99.9 billion. Conclusions: Treating patients with HIV according to developed versus developing world guidelines is highly cost-effective and may result in substantial long-term savings. From *Mosaic Health Care Consultants, Larkspur, CA; †Brenthurst Clinic, Parktown, Johannesburg, South Africa; and ‡Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa Received for publication October 10, 2006; accepted June 5, 2007. Funded by an unrestricted educational grant from Roche Molecular Systems, Pleasanton, CA. Presented at the International AIDS Conference, Toronto, Ontario, Canada, August 15, 2006. All authors have received honoraria or consultancy fees from Roche Molecular Systems. Reprints: Arthi Vijayaraghavan, MS, 15 Hillcrest Avenue, Larkspur, CA 94939 (e-mail: firstname.lastname@example.com). Abstract METHODS Background and Objectives Decision Model Patient Population HIV Disease Progression Treatment of HIV Infection Transmission of HIV Quality of Life Costs Role of Funding Source RESULTS Model Validation Benefit of Treating and Monitoring According to US Departme... Impact of US Department of Health and Human Services Guidel... Indirect Costs Sensitivity Analyses DISCUSSION ACKNOWLEDGMENTS REFERENCES Cited By The "3 by 5" initiative, launched by the World Health Organization (WHO) and the Joint United Nations Program on HIV/AIDS (UNAIDS) in December 2003, was designed to mobilize the world to provide highly active antiretroviral therapy (HAART) to 3 million people in low- and middle-income countries by the end of 2005.1,2 Although this goal was not fully reached, the plan resulted in a large increase in HAART programs throughout the developing world. As HAART programs gain momentum in resource-limited settings, questions remain about the best way to select patients to receive HAART and to monitor these patients. The WHO "3 by 5" guidelines recommend initiating HAART for patients with CD4 counts ≤200 cells/mm3 or for patients with AIDS (defined as WHO stage IV HIV disease) and monitoring treatment with CD4 cell counts every 6 months.3 The WHO guidelines differ from many developed world guidelines, such as those prepared by the United States Department of Health and Human Services (US DHHS),4 which recommend initiating HAART at a CD4 count of ≤350 cells/mm3, at a viral load of >100,000 copies/mL, or for patients with AIDS and monitoring with CD4 cell counts and viral load every 3 months. There are a number of arguments for starting HAART earlier or later in the course of the disease. Arguments in favor of starting HAART earlier include preventing opportunistic infections, decreasing constitutional symptoms and thereby improving quality of life, preserving HIV-specific cellular responses, and reducing disease progression and associated viral virulence. Arguments for starting HAART later include preventing short- and long-term toxicity, decreasing the development of resistant strains attributable to poor adherence to complex HAART regimens, and preserving the possibility of treating with novel and more effective future therapies in treatment-naive patients.5 To our knowledge, no studies have comprehensively compared the health and economic impact of implementing developed versus developing world guidelines in the developing world. We selected US DHHS guidelines for use in this model as an example of developed world guidelines. Therefore, the objective of our analysis was to evaluate the cost-effectiveness of initiating and monitoring treatment in the developing world according to US DHHS versus WHO guidelines. We also sought to assess how incorporating the costs and benefits associated with reductions in HIV transmission would influence the cost-effectiveness of HAART programs in developing countries. Back to Top | Article Outline METHODS Background and Objectives We developed a lifetime Markov model of direct and indirect costs, quality of life, survival, and transmission to sexual contacts associated with treating patients with HIV according to US DHHS versus WHO guidelines. We adhered to the recommendations of the Panel on Cost-Effectiveness in Health and Medicine for conducting cost-effectiveness analyses.6 Back to Top | Article Outline Decision Model We developed a lifetime Markov Monte Carlo simulation model (TreeAge Pro 2005, release 1.5; TreeAge Software, Williamstown, MA). The Markov model contains 38 mutually exclusive health states defined by patients' current viral loads, CD4 cell counts, and treatment status (Fig. 1). Transition probabilities determine which health states patients transition to during each cycle of the model. Whenever possible, we based our probability estimates on high-quality published studies (Table 1). When published data were not available, we relied on the judgment of clinical experts and tested a range of values in sensitivity analyses. We analyzed the model using a Monte Carlo simulation with 10,000 patients. Figure 1 Table 1 Table 1 Back to Top | Article Outline Patient Population The target population for our analysis was HIV-positive adults in South Africa. The age at which patients entered our model (26 years of age) and the initial distribution of CD4 cell counts and viral loads were based on data from a community-based treatment-naive population of HIV-positive patients in South Africa (Dr. Bertran Auvert, personal communication, September 2005).7 We chose South Africa for our base case because it has a larger total number of HIV-positive individuals than any other country.30 South Africa is considered an upper-middle-income economy; as such, it is comparable to other upper-middle-income countries like Botswana, Malaysia, Mexico, and the Russian Federation.38 Back to Top | Article Outline HIV Disease Progression Risk of disease progression was based on patients' viral load and CD4 cell counts. For patients with an unsuppressed viral load, CD4 cell counts declined based on the viral load level.12,13 We used natural history data to estimate the rates of disease progression without therapy.8,13,17-21 As the patients' viral load or CD4 cell count changed, so did their risk of AIDS or death (see Table 1). Patients could die during any cycle of the model from non-AIDS-related causes.39 We assumed that all HIV-related deaths occurred among individuals with AIDS. Back to Top | Article Outline Treatment of HIV Infection Patients in the WHO group who enter the model with a CD4 count ≤200 cells/mm3 or WHO stage III or IV disease begin HAART immediately. The remaining patients initiate HAART once their CD4 count drops to ≤200 cells/mm3 or they develop AIDS. Patients in the US group who enter the model with a CD4 count ≤350 cells/mm3, a viral load >100,000 copies/mL, or WHO stage III or IV disease begin HAART immediately. The remaining patients initiate HAART once their CD4 count drops to ≤350 cells/mm3, their viral load increases to >100,000 copies/mL, or they develop AIDS. Patients were able to receive first-line and second-line HAART. As recommended in the WHO guidelines, first-line HAART consisted of stavudine, lamivudine, and nevirapine (for women) or efavirenz (for men). Second-line HAART consisted of tenofovir, didanosine, and ritonavir-boosted lopinavir. Patients in the WHO and US arms of the model received the same drug regimens. After starting a HAART regimen, patients in whom virologic replication was suppressed had an increase in their CD4 cell count (see Table 1). Each month, patients with virologic suppression could have continued virologic suppression, treatment-related toxicity, or virologic rebound. CD4 cell counts declined in patients experiencing virologic rebound. Patients who had drug-related toxicity switched to an alternate WHO-recommended antiretroviral regimen. Patients in the WHO group with incompletely suppressed viral loads could be identified when their CD4 cell counts were tested every 6 months. Based on WHO guidelines, these patients were switched to a second-line regimen if their CD4 count fell to lower than 50% of its peak value or to <200 cells/mm3. In the US group, treatment failure was identified when patients' viral load was tested every 3 months. These patients were switched to a second-line regimen if their viral load was >400 copies/mL. Patients in both groups also changed HAART regimens if they developed AIDS. We assumed that the probability of achieving a successful virologic response decreased after virologic failure but not after changing antiretrovirals because of toxicity (see Table 1).13,14,40 If resistance developed to second-line HAART, we assumed that only partial virologic suppression was possible.13 We assumed that this partial suppression was sustained until patients discontinued HAART because of the development of toxicity or death. All patients received opportunistic infection prophylaxis when appropriate. Back to Top | Article Outline Transmission of HIV Sexual transmission of HIV depended on the infected patient's gender, number of sexual partners, and viral load (see Table 1). We assumed that everyone in the population was heterosexual and used HIV transmission rates from a predominantly heterosexual population in Africa.9 We assumed that reductions in viral load reduced transmission (see Table 1). As their CD4 cell counts decreased, newly infected patients initiated HAART based on the US or WHO guidelines, depending on whether the person who infected them was in the US or WHO arm of the model, respectively. To incorporate the impact of the newly infected partners' HIV disease on the overall cost-effectiveness in the model, the newly-infected partners' life expectancy and lifetime costs were attributed to the index patients who infected them. Back to Top | Article Outline Quality of Life HIV/AIDS can markedly affect a patient's quality of life. Accordingly, we incorporated adjustments for quality of life in our analysis (see Table 1). In the absence of quality-of-life data for South African HIV/AIDS patients across all CD4 cell counts, we used quality-of-life data for HIV/AIDS patients in the United States.13 The utilities were similar to those collected for patients with CD4 counts <200 cells/mm3 at baseline in South Africa, however.32 Back to Top | Article Outline Costs We assumed a societal perspective and, as such, included direct costs of medical care and indirect costs resulting from HIV/AIDS morbidity (incorporated as utilities) in the base-case analysis. Resource utilization was based on WHO and South African treatment guidelines.3,34 Additional resource utilization and unit cost data were obtained from a South African cost-effectiveness study.32 South African rand costs were adjusted for inflation to 2005 values using the implicit gross domestic product (GDP) price deflator and were converted to US dollars.37,41 In a separate analysis, we included the indirect costs resulting from early mortality attributable to HIV/AIDS for index patients and their sexual partners. For the index patients, we identified the average age at which patients in the WHO and US groups died. South African GDP per capita was used to assign a monetary value to the years of life lost in the WHO group compared with the US group.42 GDP per capita was calculated across the lifetimes of the index patients and their sexual partners based on projected real GDP growth rates and was discounted at 3%.41,43,44 For newly infected sexual partners of the index patients, we first determined the number of HIV transmissions that would be prevented by treating patients according to US versus WHO guidelines. We then determined the difference in life expectancy between patients treated according to WHO guidelines and the general population in South Africa.45 The additional years of life saved for patients who did not contract HIV were valued using GDP per capita. Back to Top | Article Outline Role of Funding Source Roche Molecular Systems was not involved in the design, conduct, or writing of this manuscript. The authors had full editorial independence, including the decision about whether to publish the manuscript. Back to Top | Article Outline RESULTS Model Validation Most Monte Carlo analyses are based on a simulation cohort of 10,000 patients. We assessed the margin of error in the base-case analysis using a sequence of 10 simulations with 10,000 patients each. Across the 10 simulations, the average lifetime cost per patient changed by <0.6% and the average life expectancy changed by <0.4%. The margin of error in analyzing a group of 100,000 versus 10,000 patients was <0.5% for effectiveness and cost per patient. Back to Top | Article Outline Benefit of Treating and Monitoring According to US Department of Health and Human Services Versus World Health Organization Guidelines When we considered only the benefit to index patients, we found that initiating HAART at a CD4 count of 350 cells/mm3 as opposed to 200 cells/mm3, incorporating viral load testing, and testing more frequently increased life expectancy by 1.89 years, or 1.83 quality-adjusted life-years (QALYs), at an incremental lifetime cost of $9725, for an incremental cost-effectiveness ratio (ICER) of $5314 per QALY (Table 2). Table 2 Back to Top | Article Outline Impact of US Department of Health and Human Services Guidelines on Reduced Transmission of HIV We then determined the impact on the transmission of HIV of treating patients earlier in the course of their disease (CD4 count ≤350 cells/mm3 instead of CD4 count ≤200 cells/mm3) and treating patients with a high viral load (>100,000 copies/mL) regardless of CD4 cell count. Treating all HIV-infected adults in South Africa (assuming a population of 5.1 million30) according to US versus WHO guidelines would reduce the number of HIV transmissions to sexual partners by 137,000 over the lifetime of the currently infected patients. Of this overall decrease, 35% of the reduction in transmission is attributable to initiating treatment at a higher CD4 count (CD4 count ≤350 cells/mm3 vs. CD4 count ≤200 cells/mm3), 60% is attributable to inclusion of viral load testing (treating patients with viral load of >100,000 copies/mL and testing viral load every 6 months), and 5% is attributable to more frequent testing (every 3 months vs. every 6 months). Incorporating the impact of transmission to partners, we estimated that treating patients according to US versus WHO guidelines cost $11,867 more and increased life expectancy by 2.58 years, or 3.00 QALYs, for an incremental cost-effectiveness of $3956 per QALY (see Table 2). Seventy percent of the differential increase in life expectancy was attributable to initiating treatment at a higher CD4 count, 28% to inclusion of viral load testing, and 2% to more frequent testing (Table 3). Looked at separately, the ICERs of each of these 3 strategies were $1168, $7860, and $41,286, respectively (see Table 3). Table 3 Over a 5-year period, treating and monitoring all adult HIV-positive patients in South Africa according to US versus WHO guidelines would increase direct costs by $14 billion but result in approximately 370,000 fewer deaths, 1 million fewer new AIDS cases, and 290,000 fewer new cases of HIV. Back to Top | Article Outline Indirect Costs We conducted a separate analysis to determine the indirect costs resulting from early mortality attributable to HIV/AIDS for the index patients and the partners to whom they transmitted HIV. The incremental indirect cost per patient was $16,778 for the index patient and $101,265 for their sexual partners. The indirect cost for the sexual partners is considerably higher because of the expectation that the GDP net of inflation is going to rise rapidly over the next 50 years in South Africa.44 For South Africa, based on our modeling assumptions, treating all HIV-positive patients according to US versus WHO guidelines would result in cost savings of $39.4 billion over the lifetime of all currently infected adult patients and the partners to whom they transmit HIV (approximately 38 years). Increased direct medical costs of $60.5 billion would be more than offset by indirect cost savings of $99.9 billion across the index patients and their sexual partners. Back to Top | Article Outline Sensitivity Analyses We conducted 1-way sensitivity analyses to determine the effect of individual parameters in the model on the stability of the cost-effectiveness results. The results are presented as a Tornado diagram (Fig. 2). The ICER comparing the US versus WHO guidelines is displayed on the horizontal axis, with each bar representing the range of ICERs generated by varying the related variable. A wide bar indicates that the associated variable has a large effect on the results of the model. The bars are arranged in order, with the widest bar (the most critical uncertainty) at the top. Figure 2 Results were most sensitive to clinical variables, such as the effect of changes in CD4 cell count on the risk of progression to AIDS and the probability of virologic rebound, as well as to the quality-of-life variables. The major cost variables to which the model was sensitive were the cost of viral load testing and the cost of second-line and alternate second-line HAART regimens (see Fig. 2). Results were also sensitive to the discount rate. The transmission variables to which the model was most sensitive included the effect of changes in viral load on the risk of transmission, the viral load level at which baseline transmission occurred, the annual rates of transmission, and the number of susceptible partners at risk. We also conducted a multiway sensitivity analysis on the 3 variables the model was most sensitive to: impact of CD4 cell count on progression to AIDS, quality of life, and the cost of measuring viral load. ICERs ranged from $3100 to $10,700, indicating that the results remained cost-effective in multiway sensitivity analysis, even when the values for all 3 variables were at the upper end of the sensitivity range. Back to Top | Article Outline DISCUSSION In addition to the devastating impact of HIV/AIDS on affected individuals and their families, the impact on the economies of sub-Saharan Africa has been staggering. A recent South African study claimed that by the year 2010, the national GDP could be lower by 17% because of HIV/AIDS.46 Our base-case analysis, which included the impact of treatment on transmission of HIV but did not include indirect costs, demonstrated that treating patients according to US guidelines costs $3956 for every QALY saved. When the indirect costs attributable to early mortality from HIV/AIDS are considered, our model results indicate that treating HIV-positive patients according to US guidelines may be cost-saving. In South Africa, treating all adult HIV-positive patients according to US guidelines could result in net savings to the economy of $40 billion over the next 38 years. According to the Commission on Macroeconomics and Health,47 interventions with an ICER that is between 1 and 3 times the GDP per capita are considered cost-effective. Interventions with an ICER that is less than the GDP per capita are considered "very cost-effective".48 Our base-case result of $3956 per QALY (not including indirect costs) is less than the GDP per capita for South Africa ($4900 in 200549); as such, it is considered a highly cost-effective result. Throughout the sensitivity analyses, the cost per QALY for the US guidelines group remained less than $10,700, indicating that the results are cost-effective across all ranges of the parameters that we tested. Furthermore, for the base-case model, including transmission, we isolated the incremental cost-effectiveness of the individual components of the developed world versus developing world guidelines. Based on this analysis, the strategy of treating patients with CD4 counts ≤350 cells/mm3 was found to be highly cost-effective and using viral load testing was found to be cost-effective. The WHO "3 by 5" program is a major advance in the treatment of HIV/AIDS in the developing world, and significant progress has been made to date. Despite this progress, there are a number of potentially significant benefits to treating patients in the developing world according to developed world (eg, US) guidelines. First, by initiating treatment at a higher CD4 cell count, people can begin life-saving HAART before severe immunologic damage occurs. Patients initiating HAART at lower CD4 cell counts are less likely to respond to treatment, more likely to progress to AIDS and die,50-52 and more likely to experience immune reconstitution inflammatory syndrome (IRIS).53 A recent cohort study in South Africa found that 24% of deaths while on HAART were attributable to IRIS.51 Second, by initiating treatment for patients with viral loads >100,000 copies/mL regardless of CD4 cell count, patients who are likely to progress most quickly to AIDS and die instead initiate HAART before their CD4 cell counts decline significantly.54 Third, using the viral load to monitor patients on HAART allows clinicians to identify treatment failure more quickly and to switch antiretroviral therapy, slowing disease progression, improving treatment outcomes, and reducing transmission of HIV. Finally, patients with viral loads >100,000 copies/mL are much more likely to transmit HIV than patients with lower viral loads.9 Implementation of WHO guidelines, with the exclusion of viral load testing, does not specifically target this group of highly efficient transmitters of HIV. Treating this group of efficient transmitters would reduce the HIV transmission rates as a result of the decreased viral load during HAART.55 Other techniques that have been proven to decrease HIV transmission (eg, education, voluntary counseling and testing programs) are also critically important. All these approaches improve the chances of gaining control of this epidemic. Our results are similar to those of recently published studies that evaluated the cost-effectiveness of early versus late initiation of antiretrovirals in South Africa.56,57 Bachmann56 found that initiating HAART at a CD4 count of 350 versus 200 cells/mm3 increased life expectancy by 2.3 years compared with 1.9 years in our model. His incremental costs were significantly higher than ours ($8936 vs. $2350 in our model), resulting in a somewhat higher ICER ($3885 per life-year gained versus $1270 in our model [calculated using Bachmann's assumptions]). Badri et al57 found a similar increase in life expectancy (2.2 years) but had a somewhat lower incremental cost ($1650) and ICER ($766 per life year saved). The difference in cost between our study and Bachmann's is most likely attributable to the inclusion of overhead in his cost estimates (because this study was conducted from the perspective of a tax-funded health service) and higher drug prices. Our finding that treating patients with a high viral load (>100,000 copies/mL) increased life expectancy compared with treating patients based on CD4 cell counts alone is consistent with a recent analysis by Bogaards et al.58 In a community-based setting in sub-Saharan Africa, selecting patients for treatment based on plasma viral load in addition to CD4 cell counts was the most efficient treatment initiation strategy and resulted in a larger reduction in the 1-year AIDS incidence rate than selecting based on CD4 cell counts alone. Our analysis has several limitations. First, an inherent limitation of modeling is that data were combined from multiple sources with varied study designs. We obtained data from the best available published literature, however, and where such data were not available, we based any assumptions on the advice of clinical experts and varied all estimates widely in sensitivity analyses. Second, there were a few parameters for which data from the developing world were not available, and we had to rely on data from the developed world or make simplifying assumptions. We limited the use of developed world data to natural history or clinical parameters that are thought to be similar across countries. Third, with regard to indirect costs, it is possible that AIDS patients receiving HAART are sicker than the average adult (working or nonworking and HIV-positive or HIV-negative) and that, as a result, GDP per capita may not be an entirely accurate reflection of incremental productivity in this group. Fourth, it is possible that the real GDP in South Africa may grow more slowly than predicted, although we took our estimate from an authoritative source.44 Fifth, our analysis was limited to sexual transmission of HIV and did not incorporate the impact of mother-to-child transmission (MTCT). MTCT is an important problem, but the guidelines for treating pregnant women and their infants are quite different than the overall WHO "3 by 5" guidelines and warrant a separate analysis. Sixth, we have assumed that the infrastructure to conduct CD4 cell count and viral load testing exists in South Africa. This seems reasonable, because real-time viral load and CD4 cell count testing are available at all government sites in the HIV treatment program, which encompasses approximately 260 treatment sites and more than 30 laboratories (Dr. Ian Sanne, personal communication, May 10, 2007). Finally, regardless of the finding that treating patients according to developed world guidelines is highly cost-effective in the short-term and cost-saving in the long-term, some governments may not be able to afford to follow these guidelines without outside financial assistance. However, the main goal of cost-effectiveness analyses is to highlight interventions that result in the greatest clinical gain for a given investment of resources. In that context, we have demonstrated that treating HIV patients according to developed world guidelines should be prioritized highly from the perspectives of both cost and effectiveness. Our analysis indicated that treating patients in the developing world according to developed world (US DHHS) guidelines is more effective than treating patients according to developing world (WHO) guidelines. Including the impact of HIV/AIDS on direct and indirect costs, this approach is cost-saving for the economy as a whole. Even without the inclusion of indirect costs, the cost-effectiveness of this approach is well within the range of cost-effective interventions outlined by the Commission on Macroeconomics and Health. These findings suggest that in many upper- to middle-income countries in the developing world, treating patients according to developed world guidelines can provide important health benefits for a reasonable investment in health care resources. Back to Top | Article Outline ACKNOWLEDGMENTS The authors are grateful to Bertran Auvert for providing data on the distribution of CD4 cell counts and viral load levels among patients in South Africa. They also thank Nicholas Hellmann for clinical advice and comments on the paper and Gillian Sanders for advice on HIV cost-effectiveness modeling and her comments on the paper. Back to Top | Article Outline REFERENCES1. Boerma JT, Stanecki KA, Newell ML, et al. Monitoring the scale-up of antiretroviral therapy programmes: methods to estimate coverage. Bull World Health Organ. 2006;84:145-150. Cited Here... | PubMed | CrossRef 2. World Health Organization and Joint United Nations Program on HIV/AIDS. Treating 3 Million by 2005: Making It Happen. 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Accessed November 4, 2005.32. Cleary S, Boulle A, McIntyre D, et al. Cost-Effectiveness of Antiretroviral Treatment for HIV-Positive Adults in a South African Township. Cape Town, South Africa: Health Systems Trust, Medecins Sans Frontieres, University of Cape Town; March 2004. Available at: http://www.epi.uct.ac.za/. Accessed March 13, 2006. Cited Here... 33. Bozzette SA, Joyce G, McCaffrey DF, et al. Expenditures for the care of HIV-infected patients in the era of highly active antiretroviral therapy. N Engl J Med. 2001;344:817-823. View Full Text | PubMed | CrossRef 34. National Department of Health, South Africa. National Antiretroviral Treatment Guidelines. Johannesburg, South Africa: Jacana; 2004. Available at: http://www.doh.gov.za/docs/factsheets/guidelines/artguidelines04/. Accessed March 6, 2006. Cited Here... 35. Medecins Sans Frontieres (MSF). Untangling the Web of Price Reductions: a Pricing Guide for the Purchase of ARVs for Developing Countries, 8th ed. MSF, Geneva, Switerland; June 2005. Available at: www.accessmed-msf.org. Accessed December 2, 2005.36. Rosen S, Vincent JR, MacLeod W, et al. The cost of HIV/AIDS to businesses in southern Africa. AIDS. 2004;18:317-324. View Full Text | PubMed | CrossRef 37. Tan-Torres Edejer T, Baltussen R, Adam T, et al, eds. Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis. Geneva, Switzerland: World Health Organization; 2003. Cited Here... 38. The World Bank Group. Country groups, 2006. Available at: http://web.worldbank.org/WBSITE/EXTERNAL/DATASTATISTICS/0,contentMDK:20420458∼menuPK:64133156∼pagePK:64133150∼piPK:64133175∼theSitePK:239419,00.html. Accessed April 21, 2006. Cited Here... 39. Dorrington R, Bradshaw D, Budlender D, et al. The current state and future projections of the HIV/AIDS epidemic in South Africa. SADJ. 2002;57:449-450. Cited Here... | PubMed 40. Casado JL, Perez-Elias MJ, Antela A, et al. Predictors of long-term response to protease inhibitor therapy in a cohort of HIV-infected patients. AIDS. 1998;12:F131-F135. Cited Here... | View Full Text | PubMed | CrossRef 41. International Monetary Fund, South Africa. Staff Report for the 2005 Article IV Consultation. Pretoria and Cape Town, South Africa: International Monetary Fund; 2005. Available at: http://www.finance.gov.za/documents/imf/2005/. Accessed November 14, 2005. Cited Here... 42. Ojo K, Delaney M. Economic and demographic consequences of AIDS in Namibia: rapid assessment of the costs. Int J Health Plann Manage. 1997;12:315-326. Cited Here... | PubMed 43. Oanda Corp. Fx historical currency converter. Available at: http://www.oanda.com/convert/fxhistory. Accessed March 20, 2006. Cited Here... 44. Wilson D, Purushothaman R. Dreaming with BRICs: the path to 2050. Goldman Sachs Global Economics Paper No. 99. October 1, 2003. Available at: http://www.gs.com/insight/research/reports/report6.html. Accessed March 16, 2006. Cited Here... 45. World Health Organization Statistical Information System (WHOSIS). Life table for South Africa, 2001. Available at: http://www3.who.int/whosis/menu.cfm?path=whosis,life&language=english. Accessed March 13, 2006. Cited Here... 46. Forsythe S. How does HIV/AIDS affect African businesses? In: State of the Art: AIDS and Economics. POLICY Project, Washington, DC, and Merck & Company; 2002:30-37. Available at: http://www.iaen.org/library/statepidemic/chapter5.pdf. Accessed April 28, 2006. Cited Here... 47. World Health Organization (WHO). Macroeconomics and Health: Investing in Health for Economic Development: Report of the Commission on Macroeconomics and Health. Geneva, Switzerland: WHO; 2001. Available at: http://www.cid.harvard.edu/cidcmh/CMHReport.pdf. Accessed April 28, 2006. Cited Here... 48. Murray CJ, Lauer JA, Hutubessy RC, et al. Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular-disease risk. Lancet. 2003;361:717-725. Cited Here... | PubMed | CrossRef 49. The World Bank Group. South African data profile from World Development Indicators database, August 2005. Available at: http://devdata.worldbank.org/external/CPProfile.asp?PTYPE=CP&CCODE=ZAF. Accessed March 13, 2006. Cited Here... 50. Braitstein P, Brinkhof MWG, Dabis F, et al, for the Antiretroviral Therapy in Lower Income Countries (ART-LINC) Collaboration. ART Cohort Collaboration (ART-CC). Mortality of HIV-1-infected patients in the first year of antiretroviral therapy: comparison between low-income and high-income countries. Lancet. 2006;367:817-824. Cited Here... | PubMed 51. Lawn SD, Myer L, Orrell C, et al. Early mortality among adults accessing a community-based antiretroviral service in South Africa: implications for programme design. AIDS. 2005;19:2141-2148. Cited Here... | View Full Text | PubMed | CrossRef 52. Merito M, Pezzotti P, for the ICONA Study Group. Comparing costs and effectiveness of different starting points for highly active antiretroviral therapy in HIV-positive patients: evidence from the ICONA cohort. Eur J Health Econ. 2006;7:30-36. Cited Here... | PubMed | CrossRef 53. Shelburne SA, Montes M, Hamill RJ. Immune reconstitution inflammatory syndrome: more answers, more questions. J Antimicrob Chemother. 2006;57:167-170. Cited Here... | View Full Text | PubMed | CrossRef 54. Wood E, Hogg RS, Yip B, et al. Impact of baseline viral load and adherence on survival of HIV-infected adults with baseline CD4 cell counts ≥200 cells/μl. AIDS. 2006;20:1117-1123. Cited Here... | View Full Text | PubMed | CrossRef 55. Castilla J, del Romero J, Hernando V, et al. Effectiveness of highly active antiretroviral therapy in reducing heterosexual transmission of HIV. J Acquir Immune Defic Syndr. 2005;40:96-101. Cited Here... | View Full Text | PubMed | CrossRef 56. Bachmann MO. Effectiveness and cost effectiveness of early and late prevention of HIV/AIDS progression with antiretrovirals or antibiotics in Southern African adults. AIDS Care. 2006;18:109-120. Cited Here... | PubMed | CrossRef 57. Badri M, Cleary S, Maartens G, et al. When to initiate highly active antiretroviral therapy in sub-Saharan Africa? A South African cost-effectiveness study. Antivir Ther. 2006;11:63-72. Cited Here... | PubMed 58. Bogaards JA, Jan Weverling G, Zwinderman AH, et al. Plasma HIV-1 RNA to guide patient selection for antiretroviral therapy in resource-poor settings: efficiency related to active case finding. J Acquir Immune Defic Syndr. 2006;41:232-237. Cited Here... | View Full Text | PubMed | CrossRef Cited By: This article has been cited 2 time(s). JAIDS Journal of Acquired Immune Deficiency SyndromesPooled Nucleic Acid Testing to Identify Antiretroviral Treatment Failure During HIV InfectionMay, S; Gamst, A; Haubrich, R; Benson, C; Smith, DMJAIDS Journal of Acquired Immune Deficiency Syndromes, 53(2): 194-201.10.1097/QAI.0b013e3181ba37a7 PDF (715) | CrossRef JAIDS Journal of Acquired Immune Deficiency SyndromesLaboratory Monitoring to Guide Switching Antiretroviral Therapy in Resource-Limited Settings: Clinical Benefits and Cost-EffectivenessKimmel, AD; Weinstein, MC; Anglaret, X; Goldie, SJ; Losina, E; Yazdanpanah, Y; Messou, E; Cotich, KL; Walensky, RP; Freedberg, KA; for the CEPAC-International Investigators, JAIDS Journal of Acquired Immune Deficiency Syndromes, 54(3): 258-268.10.1097/QAI.0b013e3181d0db97 PDF (457) | CrossRef Back to Top | Article Outline Keywords: cost-effectiveness; developing countries; guidelines; highly active antiretroviral therapy; transmission; viral load © 2007 Lippincott Williams & Wilkins, Inc.


text: Pinch to zoom Rose Quartz Handmade Statement Gemstone Bracelet by Poppy Jewellery £595$1043.21€694.18$792.18 Made to order free gift wrap Favourite Favourite View your favourites quantity personalise & pay PRODUCT DETAILS exclusive free gift wrap ask seller a question save for later Stunning Rose Quartz bracelet set with rough cut gemstones in Rose Quartz set in a brushed sterling silver setting. Made to order Rose Quartz statement bracelet in gorgeous shades of pale pink this statement gemstone silver bracelet is one of a kind. Hallmarked at the Edinburgh Assay Office. This beautiful bracelet is handmade, our natural rough semi precious gemstones are hand selected for quality and colour ensuring every piece of jewellery is unique. This bracelet is made to order and while the design is based on bracelet shown the design/layout and gemstones will vary slightly in size, shape and colour. Please allow up to 6 - 8 weeks for it to be handmade and hallmarked. All our jewellery is carefully hand wrapped in tissue and provided in a jewellery box. made from: Brushed sterling silver with semi precious rough gemstones of Rose Quartz As with all silver gemstone jewellery, avoid all chemicals and cleaning products dimensions: Length including silver chain is approx 18.2cm and width is approx 2.5cm. This bracelet is adjustable with three silver rings to suit fit. product code: 482025 DELIVERY This product is dispatched to you by Poppy Jewellery. RETURNS You have 28 days, from receipt of cancellable goods, to notify the seller if you wish to cancel your order or exchange an item. Please note: goods that are personalised, bespoke or made-to-order to your specific requirements, perishable products and personal items sold with a hygiene seal (cosmetics, underwear) in instances where the seal is broken are non-refundable, unless faulty. Read more about our returns policy.Should you choose to return or exchange your order you will need to deliver the item(s) to the UK, where this seller is based. Poppy Jewellery's return policy Please see notonthehighstreet.com's returns policy.

subset: commoncrawl


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Quite a good location of this hotel. There's a big ASDA and Next just next to the hotel where you get do some quick shopping easily. It's within 10 minutes' walk to the high street. The staff in the hotel are very nice and delivered...More
21 - 25 of 497 reviews
Quite a good location of this hotel. There's a big ASDA and Next just next to the hotel where you get do some quick shopping easily. It's within 10 minutes' walk to the high street. The staff in the hotel are very nice and delivered...More
Hi, Thank you for your feedback. We are pleased that our great location was a highlight during your stay. You are right in thinking that you have confused us with the other brand of hotel, but the great thing when staying with us is that...More
Can't fault the staff from Reception, bar to breakfast staff. Friendly, accommodating, polite, chatty and accommodating. It's not my usual hotel in that area, but I will be back. Well done to local manager, they have a very good team. We loved Anthony on the...More
Hello mikeeff, Thank you for your kind words regarding your recent stay with us. It is fantastic to read that you were impressed by the staff within the building and that you were attended to well by Anthony, he will be delighted with your comments....More
we used the hotel for a day at Hamilton races. When we entered the postcode in the sat nav it did take some getting to through the one way system. Please note that you have to park at the retail park and that is simple...More
Hello daltonblue, Thank you so much for providing us with your review. It is great to read that you find us to be ideally situated and that you will be returning to us when next in the area. We have added a video to our...More
Checked in late to break journey. Staff on reception very friendly and accommodating. Room comfortable and clean, newly refurbished. Fan, hairdryer and iron in room together with TV. Breakfast nice too. Good selection of cooked and cold options. Parking available next to hotel. Best thing...More
Hello Bob, Many thanks for leaving the hotel a five star review regarding all aspects of your recent stay. I am glad to hear you found all of our team to be both friendly and helpful throughout your stay. Our updated breakfast options including bacon...More
Typical of this type of hotel, clean and convenient. Where it was not quite as good as others was the breakfast. Yes it was self-service but the choice was limited. Note that the free parking is in the small shopping/entertainment area next to the hotel....More
Hi Carol, Thank you for your feedback, I am sorry to hear that you found our breakfast disappointing. We have recently changed our breakfast variety and strive to offer a tasty, fresh breakfast to all of our guests, with the bonus of our breakfast being...More
"We had 3rd floor room overlooking Bins/Air Conditioning Units. So not a room at the back"


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About the Illustrators
Kaaren Pixton is a fine artist and childrens educator who has been making art with children for thirty years. As an artist-in-residence at local schools she has been responsible for over a hundred permanent art installations - murals and sculptural pieces - created by the children themselves. She was born in Dublin, Ireland and currently lives in Portland, OR with her husband. She is the mother of seven and the grandmother of twelve.
Jonas Sickler lives in Syracuse, NY with his wife Kelly and two boys Gabe and Oliver. When he is not shoveling snow, he is in the studio of his 1924 bungalow making art. His bold and whimsical illustrations are created with acrylic paint and collage. Jonas draws inspiration from old cartoons, vintage childrens books, and all kinds of music. He always creates a musical score for his illustrations before he begins sketching because it helps to set the scene of the story.
Jonas has created numerous illustrations for Cricket, Spider and Cicada magazines. He has now moved into the childrens book market with three imaginative nursery rhyme books published by Workman Publishing Company called Indestructibles. Currently Jonas is working on three more books in the Indestructibles series, as well as paintings for The Land of Nod. Jonas is a member of SCBWI.
See all the artwork for Jonas' Indestructibles series HERE.


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- Uncle Jon's Store
- >
- Shaving Supplies
- >
- Unbreakable Pocket Comb
Unbreakable Pocket Comb
1.5 10 $1.50 - $10.00
This little beauty has been around a long time..and, with good reason! The choice of wide teeth or narrow and the size (5 inches) makes this comb one of the best choices for carrying in your pocket, purse or carry-on! Great for beards too!


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Help make a child's Christmas brighter!
At the Bay Area Crisis Nursery, all of the families who receive our services are remembered during the holiday season. Please help us make their Christmas a little brighter, a little more peaceful and full of smiles.
Below is our annual Christmas wish list with AmazonSmile links. If you shop Amazon, using AmazonSmile allows you to designate the Bay Area Crisis Nursery as your charity. As a result, AmazonSmile will donate 0.5% of the price of your eligible AmazonSmile purchases to the Bay Area Crisis Nursery. Don't shop AmazonSmile? Click here to download this year's list.
Gifts collected from November 15, 2016 – January 15, 2017
Giving Guidelines
- New toys, clothes and gifts should be delivered to the Bay Area Crisis Nursery, 1506 Mendocino Drive, Concord, CA.
- No war, violent toys, guns or violent action figures.
- Only G rated DVD's and E rated game cartridges.
Bay Area Crisis Nursery Annual Christmas Wish List
African American Dolls: Luv Snuggle Baby, You and Me Comfort Care, Cabbage Patch, Little Hugs plush dolls
Hispanic Dolls: La Baby Doll, Hispanic Lil Hugs Doll, You&Me , Ethnic Babies
Doll Clothes: strollers and accessories
Action Figures: Superman, Spiderman, Batman, Star Wars figures, Teen Age Mutant Ninja Turtles, Power Rangers, Transformers
Indoor play for boys and girls of all ages: DVD's (G rated), Aqua Doodle, Arts & Craft Kits, Science Kits, Lego Kits, trains, fire trucks, police cars, puzzles for all ages, kitchen play sets, tea sets
Sports Equipment: footballs, baseballs, bats & gloves, basket balls, soccer balls size 4, soccer balls size 5
Teen Items: Make up sets, bath sets, manicure sets, model cars, board games, Apples to Apples, Twister, Monopoly, purses, wallets, jewelry, watches, scooters with helmets
Clothes for all ages: sports clothes (A's, Giants, Raiders 49er's) sweaters, holiday outfits, shirts, pants, dresses, sweat shirts, sweatpants.
Books: All age groups are needed from the soft baby books, children's books to the latest teen books.
Favorite movies and themes: Star Wars, Inside Out, Frozen, Dora the Explorer, Toy Story, Sponge Bob, All Disney Princess', Thomas the Train
Toys for babies 2 and under: Fisher Price, Winnie-the-Pooh and Tigger Too!, Laugh and Learn tool bench, music to dance and sing, activity blankets, See and Say toys, Elmo, Sesame Street.


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Defence depleted for Magpies
Newcastle boss Chris Hughton will be without first-choice central defenders Fabricio Coloccini and Mike Williamson for Sunday's Barclays Premier League clash with Chelsea.
Both men begin three-match suspensions, the Argentinian following his red card in the 5-1 defeat at Bolton last weekend and his English team-mate after his ban on video evidence for violent conduct against Johan Elmander in the same game.
Sol Campbell and Steven Taylor are set to deputise, although neither has started a Premier League game yet this season.
Joey Barton completes his own three-match ban, but Cheik Tiote is back after missing the game at the Reebok Stadium having earlier picked up his fifth booking of the campaign.
Steve Harper (shoulder) and Leon Best (ankle) are closing in on returns, but Ryan Taylor (ankle ligaments), Dan Gosling (knee) and Hatem Ben Arfa remain on the sidelines.
Provisional squad: Krul, Soderberg, Simpson, Perch, Ferguson, Enrique, S. Taylor, Campbell, Kadar, Tiote, Smith, Routledge, Gutierrez, Guthrie, Vuckic, Tavernier, Donaldson, Nolan, Carroll, Ameobi, Lovenkrands, Ranger, Xisco.
Press Association


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Wednesday 25th January 2017
Join Us To Celebrate The Birth Of Our Nation's Famous Poet.
Our ceremonial, wild Highland haggis will be piped in at 7.30pm, and the traditional "Address To The Haggis" will be given at 8.15pm.
We'll have live music from 8.30pm – 11.30pm with Edinburgh's favourite singer/guitarist Jamie Scott, covering some traditional Scottish numbers alongside her usual stellar classics!
We'll also be adding traditional Haggis, Neeps & Tatties (plus the all important dram!) to our menu at a special price of just £12 – or splash out and enjoy a special three course Burns Supper for just £22 per person!


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Don't miss out on your free vbook!
Mindset Hacks: A Cheat Sheet on Positive Thinking
Click below to sign up & receive your "vBook" of shortcuts to your most powerful entrepreneurial mindset.
April 27, 2017
What is it about the lyrics of great musical compositions?
My guess is you are no different than the rest of us when it comes to being grabbed by the words in your favorite songs. In some cases, the rhythmic flow of those words have been with you for decades. They have become a part of who you are!
One of the challenges you have in being who you are is realizing your full potential during your life. It's not easy climbing the metaphoric "Stairway to Heaven"—AKA achieving all you can be, do, or have.
But it can become easier and more certain if you learn to follow the advice shared by the Beatles in one of their iconic songs penned over 50 years ago. A half century has not reduced the resonance of the lyrical message.
In the following video, I build on the power of their message to help you successfully live your life.
What are you going to do to encourage your life to reveal itself to you?
Please share your thoughts by commenting below.
Share this information with others by following the social media links at the top or bottom of this post. Thank you.
Mindstate mentor, author, trainer and speaker, Gary Greenfield (@LifeRider) helps organizations with inspirational insight and concise business ideas to help improve mindstate and minimize stress. He believes a mindstate that is positive and stress that is minimized helps people better profit through performance.


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Contact Info / Websites
Entry #3
One day I wanted to play ShellShock by inviting someone so I went into the chat and it works! Just be sure that you search in the search bar chat and that you're not clicking the chat at the top of the page. Can't wait to see you guys there!
- 1 comment
You must be logged in to comment on this post.
2011-03-21 05:22:39
What is your shelshock live username?
mine is cyborg3000
shadowfan246 responds:
ultramagnus12345 is my shellshock username. I'll be sure to look for you in the shellshock and newgrounds chat rooms.


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Last call for "old" SHS uniforms (blue). We will continue collecting until August 3rd, end of day.
Additionally, we would ask for any volunteers (adults and older children) to sort, organize and box uniforms to ship off to our orphanage and school in the Philippines. We will be in the cafeteria at school on August 3rd,Thursday from 6:30pm on.
We appreciate any help in advance!
Lois Kosc
Yeah! Last week of school is upon us!!
A few reminders and announcements …
Mega 50/50 tickets are SOLD OUT!! Many thanks to all the hard work of Chris Guanci!
Ice Cream Social is this Thursday, June 15th at 7pm. Come celebrate the end of the year, find out who won the $5,000 Mega Raffle and DO a good deed ….
What good deed??? Being all your OLD SHS school uniforms (the blue ones). All articles accepted … shorts, pants, dresses, shirts, gym, etc, etc. We are asking that you wash each article of clothing you plan to donate. There is a Catholic orphanage and school in the Philippines who are anxiously awaiting their arrival. They have never had school uniforms and many of the children have never had clothing of their own!!! SHS can truly "Pay It Forward" by donating these items to this very worthy cause. We look forward to posting pictures of these grateful children wearing our uniforms next school year.
HSA announcements to be made at Ice Cream Social.
Happy Summer!
You can be the lucky winner of $5,000!!!
Don't miss the opportunity to purchase a Mega Raffle Ticket.
$50 buys you the chance to win a summer vacation!
One fundraising point per ticket …. and you can use this year OR credit it towards next school year! Start September with a point!
You have to be in it to win it!!
Details in Thursday Folder …. but act fast ….. less than 20 tickets left!
Once they are gone ….. so is your $5,000:(
LOL. The end of the school year is fast approaching!
With only a few weeks left before our Ice Cream Social, your chance to win the Sacred Heart School Vacation Fund Mega 50/50 is slipping away. There are only about 50 tickets left. Once they are gone, there are no more. Take a chance to win $5,000. Every ticket purchased earns you a point! What could be better?
Click this image to print the order form and send yours in TODAY!
The HSA meeting that had been scheduled for Wednesday, May 17th has been canceled.
We all have ONE MORE DAY to pack up all our clutter and donate to the SHS Clothing (et al) drive!
WEDNESDAY, MAY 3rd from 7-11am in church parking lot! DROP AND GO !!!
Accepting clothing, coats, boots, shoes, toys, blankets, quilts, curtains, towels ….. PURGE AWAY AND HELP OUR SCHOOL!
This is the most painless fundraiser ever!!
PLEASE ….. 3 bags a family would increase our fundraising "pot" tremendously!
Hand out a plastic bag to each family member NOW!
See you Wednesday!! Drive in and drive out! Super easy!! Send a family member if you can't make the times!
Thanks 🙂
Hoping everyone had a wonderful weekend!
John Khin has contacted me for HELP! Our Annual Track Meet is in need of volunteers.
This is a unique opportunity at Sacred Heart …. because YOU decide if you want to use your fundraising point for this year , OR defer it until the next year (1017/18). You can start the year off in the positive!!
It's a long day so there are many time schedules available …. get done early or come in after spending your day elsewhere.
This is huge event and we cannot pull this off without a large volunteer core.
Please consider helping John and our Sacred Heart School Track Team!
Below is the link for online signup!
Many thanks for your dedication to our kids!
Hoping everyone had a wonderful weekend!
John Khin has contacted me for HELP! Our Annual Track Meet is in need of volunteers.
This is a unique opportunity at Sacred Heart …. because YOU decide if you want to use your fundraising point for this year , OR defer it until the next year (1017/18). You can start the year off in the positive!!
It's a long day so there are many time schedules available …. get done early or come in after spending your day elsewhere.
This is huge event and we cannot pull this off without a large volunteer core.
Please consider helping John and our Sacred Heart School Track Team!
Below is the link for online signup!
Many thanks for your dedication to our kids!
Clean out those closets and make room for summer clothes!
Our Spring Clothing Drive is Wednesday, May 3rd!
Remember …. it's not just clothing …. shoes, boots, stuffed animals, toys, linens, coats, etc, etc
Help your house while supporting our school! It's a WIN-WIN fundraiser!
Last fall I challenged everyone to ONE BAG …. well the goal is increased … TWO BAGS EACH FAMILY! Who can't rustle up two bags of "goods"?? Come on!
Drop off anytime between 7-10 am in church parking lot … we will even empty the bags from your car … DRIVE THRU SERVICE!
Volunteers, please contact Diana Gray directly at 201-240-8932 or email@example.com
In an effort to "Pay It Forward" and help the underprivileged, we have found a home for our "old" Sacred Heart School uniforms!
The blue uniforms, which are being replaced, will be donated with love to a Catholic orphanage and school in the Philippines.
To that end, we are asking that you launder and bag any "gently used" uniforms. They will be able to use all sizes and types. Dresses, pants, tops, vest, sweaters, shorts, polos, gym shorts/pants, tee shirts, sweatshirts ….. EVERYTHING!
I will send out information about collection after Easter Break. We will continue to collect through the early summer before we ship out.
The children at this orphanage and school are very excited and thrilled to receive our school's uniforms. They have very little clothes and school uniforms will be a first for them!
It's humbling and heartwarming to be able to help such grateful children.
I sincerely appreciate the efforts you'll make to help our "uniform drive" a success!
Wishing everyone a blessed and peaceful Easter!
Help support our school and enjoy a dinner out (or take home to enjoy in your house)!
Ticket forms on Thursday Folder!
Don't miss out on all the fun and delicious food! Chicken is also available for you landlubbers:)
Send your form in tomorrow morning!!
Looking forward to seeing everyone on Friday night!
How many of you are cooking dinner right now? Or shopping aimlessly in the grocery store looking for "What to cook"? Or calling the local take out for delivery?
GUESS WHAT??? You won't be doing ANY of that this friday, April 7Th!
Get your tickets for our Lenten Fish Fry and ….. LEAVE IT TO US!! Eat in (no mess to clean up) or Take Out (eat in PJ's in front of TV)!
Tickets still available!! Food is delicious …. The Thistle Inn is cooking for us! Cheaper than going out OR ordering out!
Support our children's school! Please help us to reach our goal!
Enjoy a family night!
And if you need it ….. fundraising points are still able to be earned … call me! (973-800-9601)
Ticket forms on Thursday Folder!
Good Morning!
Spring is springing …. and our school year is ticking down.
Most of you who still owe points should have received a letter with your tally YTD.
To that end, we have many more opportunities to earn those points! Don't be left with a bill at the end of the year 🙁
I will post a total list of remaining opportunities next week. However, I am reaching out today for help with our Lenten Fish Fry.
The event is Friday, April 7th in the cafeteria. The flier and form are in the Thursday Folder.
I am in need of help to set up, serve and clean up at the event. We would need you between the hours of 4-8 or 5-9 on that Friday. (Anyone already signed up will receive a text this weekend)
Additionally, WE NEED BAKERS! Cakes, cupcakes, cookies, etc. If you can please find the time to bake an item and/or purchase one, please text me (973-800-9601). Items can be dropped off to the main office anytime during the school day on 4/7 or they can be delivered to the cafeteria from 3-5pm.
Lastly, please support this event by purchasing tickets and talking it up outside of school. We have advertised in most church bulletins, the senior centers and the local supermarkets. This can be a very successful fundraiser if supported. It's an opportunity to make this a family event. Bring your extended families and friends …. enjoy an evening out ….. cheaper than a restaurant …. and help OUR SCHOOL!
Thanks! (and don't forget the BUNNY is hopping his way to SHS … get your tickets!)
The Easter Bunny is on his way … THIS SATURDAY, APRIL 1ST …. at SHS cafeteria!
Decorations, food, volunteers and bunny are all ready!
HOWEVER …. very few tickets have been sold:(
PLEASE print the flier off the Thursday Folder and get your ticket requests in.
The Bunny will be very sad if we need to cancel his trip to SHS!!
Happy Spring Everyone!
Just a quick reminder that tonight is our HSA Meeting at 7pm in the school cafeteria.
There will be a fashion show of the new uniforms, fundraising point opportunities and many updates!
Don't forget …. FREE TAG DAY for all children of parents who attend:)
Babysitting will be available!
Coffee and sweets!
What more could you want? LOL
See you there …. Lois
We are all hoping that winter is in our rear view mirror …. finally!
To that end, let's get into Spring and support our Track Team!
Please come out and enjoy some family fund while helping to fundraise for our team!
Please read (CLICK) the below message from Chris Guanci.
It would be very much appreciated if you could support this fundraiser. In addition to showing support for your child/children, it is a source of advertising for our school. The signs are extremely resilient. Ours has been on our lawn all winter, through rain, snow and wind… it's still standing strong!
Lois Kosc
Please read (CLICK) the below message from Chris Guanci.
It would be very much appreciated if you could support this fundraiser. In addition to showing support for your child/children, it is a source of advertising for our school. The signs are extremely resilient. Ours has been on our lawn all winter, through rain, snow and wind… it's still standing strong!
Lois Kosc
The Sacred Heart Cafeteria will be transformed into a majestical castle THIS FRIDAY, MARCH 10TH!!
Don't miss out on the fun!
Calling all Pre-K through 2nd grade Pirates and Princesses! Come dance the night away and make all your dreams come true!
Crafts, Food, Dancing, Photos by the Castle!
***SPECIAL PRIZE OPPORTUNITY FOR PARENTS DRESSED AS PIRATES OR PRINCESSES*** (Win a magical night out donated by Luna Restaurant in Nutley!)
Tickets available through Bridget Saoud (6A) ; see thursday folder for order form
Don't let your little one miss out on their first magical dance …. send forms in ASAP!
Good evening and THANK YOU!!
From the very bottom of my heart, I thank our SHS Family! Today's event was a HUGE success! I have yet to count our profits and find out "bottom-line" but regardless of the finances, I was inspired and heart warmed to experience the love and fun and spirit today! The kids were inspiring as they danced and sang …. and I saw many parents going in! It was truly a great day with our SHS family! It was a rousing success from a spiritual and community perspective! THANK YOU!!!
My "Last Minute" alert tonight is that we will hold an impromptu CUPCAKE SALE TOMORROW!! Fifty cents … sold at lunches!!
If anyone is around during lunchtime to help me, I'd appreciate it! Good news is our cupcakes are baked and all ready! (973-800-9601)
reminder … tomorrow is LAST CHANCE to order Hot Pretzel and Soup for Thursday Lunch! (Dips cost money …. many people aren't sending money for them, check your order …. no money, no dip!)
It's almost here! ARRAY OF HOPE 2017!
We will be selling tickets at the door so don't let that stop you from joining your Sacred Heart Family on Sunday, January 29th, 4-6:30pm in the Auditorium!
Ticket sales have soared and we are expecting over 350 people!!
Food, drinks, fun, music, dancing and tons of great prizes ….. signed sports memorabilia, tons of kids toys and games, gift certificates and even a drone!
Don't miss out on the fun …. and remember, every family ticket purchased gets u into the raffle for 2 FREE family school registrations!
We can still use some help on Sunday during the event so please consider earning a fundraising point while helping us with this large fundraiser (973-800-9601). It would be most appreciated.
Lastly …. our HSA hot pretzel and soup lunch in celebration of Catholic Schools Week will extend its order date until Monday, January 30th. Last chance …. NO HOT LUNCH will be provided that day …. so order from us! Order form in Thursday Folder!
Thanks for all your support … looking forward to seeing everyone on Sunday!!
Hello All!
Our "Array of Hope" concert is quickly approaching! This is the grand kickoff to our Catholic Schools Week 2017! It is an interactive family event filled with music, comedy, food, raffles, sports memorabilia, games and tons of FUN!!
Organizing and presenting an event of this magnitude takes a huge amount of work. I was lucky enough to have a very dedicated and hard – working committee at my side over these past months. However, we cannot set up, run and break down this event without more dedicated and kind volunteers.
We will be awarding Fundraising Points for your hours "worked". Basically, 4 hours = 1 point.
So …. below is a list of "holes" which we need filled in order to run this event smoothly. We are striving to be very organized and efficient so things should move quickly as long as we have people helping.
I would very much appreciate if willing volunteers contacted me, directly, via text @ 973-800-9601. This will expedite things and improve rapid communication.
Get those points out of the way …. the opportunities to earn them dwindle as the school year progresses!!
SATURDAY, JANUARY 28TH 10:00 am
I truly appreciate any and all help you can assist with. Many hands can make these tasks go extremely quickly!
Ticket sales are increasing …. the Praybill has gone to print with over 25 ads …. food vendors are ready to cook ….. tricky tray items are being wrapped and will appeal to all the kids (child and adult! LOL) … the entertainers are coming from across several states …. our Instagram contest is rocking the internet tonight …. and if my prayers for volunteers are answered, all will be successful!!
Hoping to hear from you soon …. Lois
Good Morning!
I met with the school assembly this morning to announce an HSA contest for the middle school students. I fully explained it to them but would like to share the details with you.
Grades 5-8 are welcome to participate in an Array of Hope Instagram Contest.
Contest runs from 6pm today, January 23rd through 6pm Friday, January 27th.
Students participating need to go to the SHS website and screen shot the Array of Hope flier with the details of the concert. Then they will post it to their Instagram Account with a "#arrayofhopeshs". They can post as often as they like throughout the five days of the contest.
At the conclusion of the contest (Friday, 1/27, 6pm), the number of posts and "likes" will be tabulated per grade.
The middle school grade (not class) with the most amount of "likes" will win a free pizza, drink and ice cream lunch!
Good luck and happy posting!
Sacred Heart School will be on the radio!
Friday, January 20th @ 10:05am, The SHS Array of Hope Concert will be advertised on the Catholic Radio Station, "Relevant Radio" !
Tune in …. 1430 AM WNSW …. 10:05 AM …. Friday, January 20th!
Do you dread that question? I know I do!!
Well guess what? On Sunday, January 29th, nobody has to cook!!
Come out to the SHS ARRAY OF HOPE CONCERT ….. we will have available for purchase the following menu items (and maybe more):
-hot dogs, hamburgers
-fried chicken
-candy, chips
Make it a fun filled family night … and leave the cooking to someone else!
Tickets available ….. see thursday folder or contact me directly 973-800-9601
Thanks for supporting our school and instilling Christian values into our families!
Lois Kosc
Hello again !
It's me …. talking about "Array of Hope" …. again!
Our deadline for Praybill ads is fast approaching. I need all ads (via pdf or jpeg file) but THIS FRIDAY, JANUARY 20TH.
Many of you took forms at the HSA meeting but I've only received one ad from that.
The Praybill will be widely distributed and will be seen by potential "customers" from all of Bergen County and parts of Hudson. It is a rather inexpensive opportunity to advertise for businesses, corporations, physicians, restaurants, high schools, etc. There is also an opportunity for a coupon to be built into the ad which should, in fact, increase the likelihood of receiving a return on the investment. Encourage the potential advertisers to utilize this option when designing their ad.
We have secured a decent amount of sponsors for the Praybill. However, with ticket sales at a lower number than expected, this book has the potential of securing a successful fundraiser.
I would humbly ask each of you to try to solicit at least one ad before Friday. Your employer? Dentist? Dry Cleaners? Pizza place? Bakery?
I appreciate any and all assistance!
Forms are available, if necessary, text, call or email me!
Many thanks, Lois
On behalf of the entire HSA, I would like to send out a huge shout out and a heartfelt thank you to Patty Pavlica!
Once again, she pulled off a spectacularly successful Tricky Tray 2017 !!
I am most humbly announcing that Patty's Event raised a whopping $34K ! Actually, it was dollars away from $35K!!!
Patty, your tireless efforts and endless work is much appreciated!
This financial winner has put us over $50K YTD raised ……and halfway to our yearly goal!
Thank you Patty, and thank you for all the volunteers, attendees and supporters!
Lois Kosc
2 FREE giveaways ….
I received several Praybill ads today and I am most grateful! Many of you took forms last evening so please, try to solicit some ads over the weekend.
Ticket sales are still floundering. Father Jim and Mrs Durocher are supporting this event. This was their wish to bring a family centered, Christian event to our school. Please help this event succeed. It's success is synonymous with our school's success. A family ticket is $30. Forms are on the Thursday Folder.
Looking forward to lots of ticket sales, Praybill ads and enthusiasm!
**Special shout out to the 6th grade parents ….. a record number of attendees from this class at last night's meeting …. more than 40 parents:) Thank You!!!
Tomorrow, January 10th is our HSA meeting at 7pm in school cafeteria. Free tag day will be awarded for children of all attendees.
Our Agenda will include feedback to the school survey which was completed on-line prior to the holidays. Mrs. Durocher will be addressing every issue raised, suggestions and criticisms. This will be the ONLY source of feedback. You need to attend meeting to hear the school's responses. In addition, this is the time and place to address any concerns you may have with tuition, fundraising, etc. Parking lot and social media discussions do not reap answers. Come and let your voice be heard and listen to the feedback.
In addition, presentation of the remaining fundraisers for the year will take place. You will have the opportunity to secure your chance to earn fundraising points.
I am looking for help with coffee service, if possible, please contact me via cell (973)800-9601.
Lastly, more Spirit Wear orders went home on Friday, January 6th. These were orders placed after December 1st. They contained all items which we had "in stock". The remaining items were ordered and will be delivered within 2 weeks. Hence, many of you received partial orders. We are aware and will deliver the rest upon receiving.
Thanks you for your ongoing support. I am eagerly awaiting ticket orders for our "Array of Hope" fundraiser. Your children will be watching DVD's and listening to CD's of the musical program from now until concert. They will be excited and eager to come. Please support this family event.
Good evening and Happy New Year!
I am hoping that each of you and your families had wonderful and memorable holidays!
January is a time of renewed hope, goals and dreams!
To that end, I am hoping and praying that this special month of "new" things can bring the Sacred Heart Family together for a common purpose and goal.
Our fundraiser set for January 29th is "Array of Hope; Awakening Hearts". It is a family oriented, Christian based musical program. It is interactive, modern, lively and professional. The singers and entertainers are coming from all over the country and have followings among the Christian music community. This is a quality, proven event which is designed to bring families and communities closer under Christian values.
I am reaching out to each and everyone of you this evening with multiple requests (don't I always… LOL)
First, and most importantly, I am pleading with you to consider purchasing a family ticket to this event for your "crew". The cost of a family ticket is $30 ($10 individual) and I dare say that it is quite cheaper than a night out at the movies for ANY family?! How can we not feel good about spending 2 hours with our SHS family? This is our "kick off" event for Catholic Schools Week 2017. All of us send our children to SHS and struggle to do so financially for a reason. Hopefully, that reason is the Catholic, Christian atmosphere they experience. That atmosphere and philosophy carries beyond the school day and weekday. It needs to be carried out at home and in our community. SHS is our community. Let's strengthen those values outside the classroom, among our Catholic family.
Secondly, I am asking each and every one of us to approach our bosses, companies, businesses we frequent (restaurants, dry cleaners, doctors, etc) to take an ad out in our "PRAYBILL". This is a booklet which will be distributed at the event, similar to a Broadway Playbill. This is a prime source of fundraising for this event. Our community expands much farther than Lyndhurst these days, so please, bring the attached paperwork to all your "favorite" vendors and companies. You would be surprised at the people who are willing to advertise. You can assure them that the exposure will be vast and spared to people all over Bergen County.
Lastly, I ask that you try to solicit items for our Silent Auction as well as items to be used in Tricky Tray baskets. I am proud and thrilled to advise you that we have already secured the following items which will be auctioned off that night:
– Kicks mini basketball signed by Kristaps Porzingis
– Rangers hockey stick signed by Mats Zuccarello (and a signed picture)
– Signed pictures of Khris Kreider, Derek Stepan, Rick Nash (Rangers, all with stats on back, 5X7)
– Signed picture of Walt Frazier (Knicks)
– Rangers golf shoe bag, golf balls
– Rangers practice shirt
– Knicks practice shirt
– Red Bulls jersey signed by entire team
– Devils memorabilia
So, thanks for sticking with this long email, thanks for helping, thanks for supporting!
The forms for tickets, Praybill ads and a video about the event are all attached for your perusal and action!
I know we can pull this event off ….. nothing is beyond the capability of a determined group of Sacred Heart families, teachers, administrators!
I sincerely thank you from the bottom of my heart!
Lois Kosc
Array of Hope PROMOTIONAL VIDEO:
Copyright © 2017 Sacred Heart School · Log in


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I found out about the Norwegian painter Hans Fredrik Gude (1825-1903) through one of the art groups I follow on facebook, as another Norwegian digital artist (of whom I will talk about later) was doing some studies of his paintings and I thought they were amazing.
He was a romanticist and one of Norway's most important landscape painters. You can see an incredible clarity and level of detail in all of his paintings with a depth of color that I think no camera can match. Apart from that, the landscapes of his home country are simply stunning by themselves.
I would definitely encourage you to check some more of his artworks online and if you can go to the National Gallery of Norway in Oslo (which I would love to do) go check them out live.


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Contact Info / Websites
Recent Movie Reviews
Grandpa Moral Episode 2
Rated 4 / 5 stars
Good, short, and sick in a delicious way. Totally the good-old-fashioned newgrounds style! Make more, please.
Mystical Box
Rated 3 / 5 stars
One-Line-Summary Blank
Yo, I aint insulting you or anything, but I just don't get the point of this. It had no redeeming qualities, short, pointless, and akward. But I don't know if it's good or bad?
Cube 2 : Hypercube
Rated 0 / 5 stars
:( Boring
Nice idea, and awesome graphics, but the actual movie was queer. I think I heard something about this movie freaking me out? Yeah, mmmhmmm that sure as hell happened [MAJOR SARCASM]. Well, this is going on my favourites for queer movies.
Recent Game Reviews
Beat Tom Green (Fighting)
Rated 2.5 / 5 stars
I liked it
It was good, nice idea, but by the way, he gave out his personal email, NOT his phone number.
yeah and I made the intro voice myself.
Guardian Angel
Rated 5 / 5 stars
Wow... nice ass!!! lol.... how'd you do animate that anyways? Well, whatever. Anyways, this game is awesome. Ingenious idea. Really. You must have MX.... 245 kb??????? It was perfect, really perfect. The only thing I didn't like about it was how she screamed in like horror when she got killed. But don't think once about changing that cause it should be on there. This is going on my favourites, good for you.
Rated 4 / 5 stars
Good Game
Alright, so it was a little fun, but really, you should have made it more complicated. All you have to do is keep tapping your 3 fingers hard against the space bar. I never went under 6 health.


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Thank you Libby Francisco, Jamie Graber & Daniel Jones- from Moorpark College, studying environmental Science. You really helped us unload the steer maneure 🙂 !!
Also thank you Jesse and Bruce Shapiro from Crossroads School! What a beautiful bunch of Broccolini you harvested for us!
We hope to see you all back at the farm soon!!!


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We have all had those chaotic days when it appears like the schedule is quite recently never going to arrive at an end. Be that as it may, regardless of how bustling we get in our lives it is to even now feeble to adhere to our long haul objectives like losing a touch of weight. You see getting in shape is much similar to a plane taking off – it doesn't work if backs off toward the end!
In the meantime however, eating solid for weight reduction doesn't need to be entangled the length of we make a point to prepare and foresee the feverish days in our calendar. One helpful trap I have constantly utilized is to keep advantageous sound snacks with me! Along these lines I never feel the inclination to fling on superfluous abundance calories.
Here are 6 tips for solid dinners on occupied days:
Family time
Continuously ensure that you have no less than one supper of the day with your family that isn't surged. This advances family holding and let's be realistic, when you are not raced to get to your next arrangement it is less demanding to have a sound supper!
A family supper can be any feast of the day, not really just supper. Simply make certain to be adaptable with what time the dinner begins as not everybody will have a similar calendar each day!
Be readied
So as to spare time, cook ahead. Cook a few suppers ahead of time and keep them in the cooler until you require them! For instance you can simply cook pasta one night and have just a segment of it warm leaving the rest over for the following day as pasta serving of mixed greens.
Keep fixings that make basic suppers.
By keeping it basic when you don't have time, you won't have the inclination to purchase unfortunate garbage sustenance from a takeaway joint! Here are a few fixings that make basic suppers:
• 100 Percent entire wheat bread
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• Canned dried beans
• Low-fat or without fat yogurt and cheddar.
• Whole-wheat pasta
• Fresh and solidified vegetables
• Fresh and canned natural products
Accommodation and wellbeing
There is such an enormous wellbeing drive nowadays, that advantageous snacks that used to be pressed with calories are presently being supplanted with more beneficial choices! For instance on the off chance that you are feeling hungry you can simply get a protein bar at the shops that doesn't contain any fat at all!
Rearrange your life
Spare time amid dinner arrangements by keeping pre-cut products of the soil in the cooler. New natural product will dependably be the best choice be that as it may, canned organic product will work similarly too! Simply ensure that the canned natural product is not the sugary syrup kind, and wash the organic product before you devour it to diminish the sodium content.
Keep a menu of straightforward suppers
These dinners ought to take 20 minutes or less to get ready. This is a truly helpful thought when you don't have at whatever time amid your wild bustling days!
Loosing weight isn't something that you do just when you feel like it! It is something that you do each day, regardless of whether you feel like it or not! It is basic, set yourself up for accomplishment by preparing and you will be on the right way to lose that headstrong overabundance muscle to fat quotients.
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To commend, he has discharged his fresh out of the box new book, 'Fat Burning Furnace' for nothing temporarily as it were.


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MUMBAI - RBI Governor Raghuram Rajan to speak on capitalism, democracy and inequality at St Xavier's College annual festival - 0700 GMT. JAKARTA - Indonesia Central Bank holds Board of Governors Meeting. SEOUL - Bank of Korea holds Monetary Policy Committee Meeting. SANTIAGO - Central Bank of Chile holds monetary policy meeting. KAMPALA - Central Bank of Uganda announces Monetary Policy Statement.
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Find the best activities, restaurants and things to do in Taichung Commercial Bank, Taiwan. Explore Taichung Commercial Bank travel guide before you plan your trip here. This city is located in the close proximity of a major city Taipei, Taiwan. Take a short trip from Taichung Commercial Bank and set some time aside to explore the Taipei. Dotted with places like Yangmingshan National Park, Beitou Hot Springs, National Chiang Kai-shek Memorial Hall; it will definitely be a good idea. To reach Taichung Commercial Bank, hop on a flight to airport which is the nearest major Taipei Songshan Airport, Taiwan Taoyuan International Airport. Get in the character of the city, this city requires at least of 1 to 2 number of days of exploration.
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- Nearby Cities
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We don't know whether Shruti Haasan had under the knife for getting the lip job done or not, but we know that she had got her sensitive skin pricked for sporting tattoos. She revealed that she has five permanent tattoos on her body.
The actress is presently miffed with one of her tattoos which she got inked on her wrist. To cover up that particular tattoo, Shruti has to apply a lot of makeup, every time. Vexed, she says she is done with tattoos now. That means, no more tattoos on Shruti's body.
Recently, Shruti was trolled big time for the alleged lip job and also for gaining weight. She gave a damn to these online trolls and preferred not to give an explanation for the lip job rumour or her weight gain. Her recent Bollywood release 'Behen Hogi Teri' earned her any good reviews neither for performance nor for her looks.


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Executive Body
General Secretary
Prof. J.P.Sharma ( Punjab)
Founder General Secretary Since 1978.
Advisory Board :
Chief Advisor
Sh. Chander Sheikhar IPS (Chandigarh)
Chief Advisor
Sh. Jagdish Mittal IPS (Punjab)
Executive Council of ACKFI :
Vice President
C.P. Kaushal (Chandigarh)
Chief Legal Advisor
Mr. Gurinder Singh Gill (Senior Advocate Supreme Court)
Ved Ram Sharma (Haryana)
Legal Advisor
Sh. Aditya Sharma (Chandigarh)
Finance Advisor
Sh. Munish Arora (Chandigarh)
Vice President
Sh. N.D Parmar (Gujarat)
Joint Secretary
Sh. Santosh Singh (Himachal)
Joint Secretary
Sh. Ashok Dudhare (Maharastra)
Joint Secretary
Sh.A.P.Reddy (AndhraPradesh)
Joint Secretary
Sh. R.S. Gaur (Madhya Pradesh)
Joint Secretary
Sh.Sunil Kumar (Uttar Pradesh)
Secretary Organisation
Sh. Rishab Sharma (Chandigarh)
Executive Member
Sh. Sant Ram (Haryana)
Executive Member
Sh. Manu Dubey (Chandigarh)
Executive Member
Prof. R.P.Gupta (Chandigarh)
Executive Member
Dr. Mukesh Arora (Punjab)