text:
- Research article
- Open Access
- Open Peer Review
Effect of home-based interventions on virologic outcomes in adults receiving antiretroviral therapy in Africa: a meta-analysis
© Chishinga et al.; licensee BioMed Central Ltd. 2014
- Received: 8 April 2013
- Accepted: 27 February 2014
- Published: 7 March 2014
The success of adherence to combination antiretroviral therapy (ART) in sub-Saharan Africa is hampered by factors that are unique to this setting. Home based interventions have been identified as possible strategies for decentralizing ART care and improving access and adherence to ART. There is need for evidence at individual- or community-level of the benefits of home-based interventions in improving HIV suppression in African patients receiving ART.
We conducted a systematic review and meta-analysis of the literature to assess the effect of home-based interventions on virologic outcomes in adults receiving ART in Africa.
A total of 260 publications were identified by the search strategy, 249 were excluded on initial screening and 11 on full review, leaving 5 publications for analysis. The overall OR of virologic suppression at 12 months after starting ART of home-based interventions to standard of care was 1.13 (95% CI: 0.51–2.52).
There was insufficient data to know whether there is a difference in HIV suppression at 12 months in the home-based arm compared with the standard of care arm in adults receiving ART in Africa. Given the few trials conducted from Africa, there is need for further research that measures the effects of home-based models on HIV suppression in African populations.
- Virologic outcomes
- Home-based interventions
- Antiretroviral therapy
- Meta-analysis
- Sub-Saharan Africa
Successful HIV treatment programmes depend largely on adherence of patients to combination antiretroviral treatment (ART). Several studies have demonstrated that adherence to ART is an important predictor of viral suppression [1–4], antiretroviral resistance [1, 5, 6], progression to AIDS [1], and death [7, 8]. However, there are still challenges of improving adherence to ART in Africa [9]. Home based interventions have been identified as possible strategies of decentralizing ART care and promoting task shifting to improve access and adherence to ART. In this meta-analysis we searched for randomised trials from Africa that used home-based strategies to improve virologic outcomes in patients receiving ART to provide evidence on the feasibility of using this intervention on African populations. The reason for choosing studies from Africa is that unlike developed countries, the success of adherence to ART in sub-Saharan Africa is hampered by factors that are unique to this setting. The magnitude of HIV-related complications is becoming too great for existing clinic infrastructures in Africa. Most public health facilities in sub-Saharan Africa rely on self-presentation of patients to the ART clinic for group counselling on ART adherence and collection of monthly stocks of antiretroviral drugs (ARVs). This strategy risks failing because amidst the rapid scale-up of ART there are severe shortages of suitably skilled health professionals in public health facilities [10].
Existing systematic reviews and meta-analyses on home-based interventions [11] and directly observed therapy for ART [12, 13] have few studies from Africa. There are significant new data from trials in Africa on which to update these reviews. We perform a meta-analysis on the effect of home-based interventions on virologic outcomes in adults receiving ART in Africa.
Eligibility criteria
- 1.
were randomised controlled trials (RCT) or cluster randomised trials (CRT) of patients receiving ART, because these are considered the gold standard for assessing the effects of an intervention;
- 2.
included virologic outcomes, and
- 3.
reported on home-based interventions in Africa that used either family or lay and/or professional people to provide all forms of treatment, care or support in the HIV-infected person's home, as compared with hospital or health facility-based care; even though (i) patients still had to visit the clinic from time to time and (ii) the clinic remained responsible for the prescription of anti-retroviral regimen and changing the therapy.
Search methods for identification of studies
The following data sources were searched in May 2010, September 2011 and the search repeated in December 2012 for updates: PubMed/Medline from 2001 to 2012 and EMBASE from 2001 to 2012. Additional studies not indexed in PubMed/Medline and EMBASE were searched from abstracts presented at the Conference on Retroviruses and opportunistic Infections (CROI) from 2001 to 2012 and the International AIDS Society/International AIDS (IAS/AIDS) conferences from 2000 to 2012. Also, cross references were searched from the published systematic reviews and meta-analyses discussed above.
Database search terms
1. Randomized controlled trial.pt.
2. Controlled clinical trial.pt.
3. Randomized.ab.
4. Placebo.ab.
5. Drugtherapy.fs.
6. Randomly.ab.
7. Trial.ab.
8. Groups.ab.
9. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8
10. Exp animals/not humans.sh.
11. 9 not 10
12. (cluster$ adj6 randomi$).mp.
13. ((communit$ adj6 intervention$) or (communit$ adj6 randomi$)).mp.
14. group$ randomi$.mp.
15. cluster-randomi$.mp.
16. 12 or 13 or 14 or 15
17. 11 or 16
18. ((direct$ adj6 observ$) or (treat$ adj6 partner$) or (treat$ adj6 support$) or (patient$ adj6 support$) or (patient$ adj6 select$) or (peer adj6 health$) or (peer$ adj6 deliver$)).mp.
19. (Home based care or (facilit$ adj6 base$)).mp.
20. 18 or 19
21. Exp antiretroviral therapy, highly active/
22. Hiv treatment.mp.
23. Hiv care.mp.
24. 21 or 22 or 23
25. ((viral load) or (HIV viral load) or (virologic$ adj6 fail$) or (virologic$ adj6 outcome$) or (treat$ adj6 fail$) or (treat$ adj6 success$)).mp.
26. 24 or 25
27. 20 and 26
28. 17 and 27
29. Exp africa/
30. 28 and 29
1. Double-blind:.mp. or placebo.tw. or blind:.tw.
2. (Cluster: adj6 randomi:).mp.
3. ((communit: adj6 intervention:) or (communit: adj6 randomi:)).mp.
4. Group: randomi:.mp.
5. Cluster-randomi:.mp.
6. 2 or 3 or 4 or 5
7. 1 or 6
8. ((direct: adj6 observ:) or (treat: adj6 partner:) or (treat: adj6 support:) or (patient: adj6 support:) or (patient: adj6 select:) or (peer adj6 health:) or (peer: adj6 deliver:)).mp.
9. (Home based care or (facility: adj6 base:)).mp.
10. 8 or 9
11. Exp antiretroviral therapy, highly active/
12. Hiv treatment.mp.
13. Hiv care.mp.
14. 11 or 12 or 13
15. ((viral load) or (HIV viral load) or (virologic: adj6 fail:) or (virologic: adj6 outcome:) or (treat: adj6 fail:) or (treat: adj6 success:)).mp.
16. 14 or 15
17. 10 and 16
18. 7 and 17
19. exp africa/
20. 18 and 19
Data collection and analysis
Selection of studies
- 1.
Study design (RCT or CRT)
- 2.
The setting (primary or tertiary level of care) and type of intervention (including frequency and duration of the intervention) vs. the standard care at the clinic.
- 3.
The sample size of each trial
- 4.
Characteristics of the trial participants (including mean age distribution, gender and marital status)
- 5.
Virologic outcomes.
Data extraction and management
The data was extracted following the search terms. The outcome of interest for this meta-analysis was HIV suppression (dichotomous outcome) in adult Africans at 12 months after starting ART. Summary data was collected for each intervention group in a study and entered in STATA version 11 (STATA corp., Texas, USA).
Assessment of risk of bias in included studies
The risk of bias (methodological quality) of the extracted studies was assessed using the Cochrane Collaboration's 'Risk of bias' tool [14]. This checks whether the trials reported on sequence generation, allocation of concealment, blinding, incomplete outcome data of patients lost to follow-up (i.e., missing at follow-up as equal to virologic failure) and other biases. The following were considered as other biases: (i) recruitment bias; (ii) baseline imbalances. In addition, the following were assessed in CRTs (iii) loss of clusters; and (iv) incorrect analysis; and comparability with individually randomised trials [14]. In CRTs, individual patient assignment of the intervention was assumed to be by the allocation of the intervention to the cluster in which the individuals resided. A 'Risk of bias' graph was then produced using RevMan version 5.0 (Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration, 2008).
Measures of treatment effect and unit of analysis
The measure of effect is the odds ratio (OR) of HIV suppression in the home-based to the health facility-based group. If the data in the articles was measured using rate ratios, the rate ratio was used to estimate the OR [16]. In order to combine the effects of RCT and CRT, the OR of HIV suppression and the 95% confidence interval (CI) were used to calculate the log odds ratio (loge OR) and its standard error (SE (logeOR)). Because the unit of allocation in CRTs is a cluster, the cluster-adjusted risk ratio and rate ratios from each CRT were used as estimates of cluster-adjusted OR and the loge OR and the SE (loge OR).
Assessment of heterogeneity
The between-study heterogeneity variance of the loge ORs, tau-squared (I2), was used to measure heterogeneity between trials. An I2 ≥ 30% and χ2 p-value < 0.10 were used test for evidence of heterogeneity [14]. Also, a visual check of confidence intervals of individual studies (depicted by horizontal lines on the forest plot) was used; if the confidence intervals poorly overlapped, this would indicate presence of heterogeneity.
Assessment of reporting biases
A 'funnel plot' of standard error vs. effect size estimate of the intervention on virologic suppression was created to visually assess for asymmetry as an indication of publication bias.
Data synthesis
The loge OR and SE (loge OR) for the RCTs and CRTs were combined using the inverse-variance method for meta-analysis in metan (STATA corp. version 11, Texas, USA) to produce a forest plot. An OR > 1 indicated HIV suppression favouring the home-based group. All P-values were two sided; at 5% significance level (except in the testing for heterogeneity where a χ2 p-value of 10% was used as discussed above).
Sensitivity analyses
As a priori, a sensitivity analysis was going to be performed only when there was evidence of heterogeneity between studies. The sensitivity analysis would be performed by including and excluding studies based on indicators in the Cochrane Collaboration's 'Risk of bias' tool listed above of reporting (i) sequence generation, (ii) allocation of concealment, (iii) blinding, (iv) incomplete outcome data of patients lost to follow-up (i.e., missing at follow-up as equal to virologic failure) and (v) other biases.
Description of studies
Characteristics of included studies
Characteristics of included studies
Study duration
Inclusion and exclusion criteria
Sample size analysed
Interval to viral load measure
HIV viral load outcomes
Jaffar et al. [37]
Cluster randomised trial: Equivalence trial
36 months
Home and Outpatient clinics in Jinja district, Uganda
Included: 1. Patients >18 years old; 2. Starting ART for the first time. Excluded: Patients living 100 km away from the ART clinic, where the provision of the home-based intervention was not possible.
Mean age in intervention arm 37 years (range 32–44); Mean age in control arm 38 years (range 33–44)
73% Female (625/859) in intervention arm; 68% Female (406/594) in control arm
n = 1212: 729 (22 clusters) in intervention arm; 483 (22 clusters) in control arm
Intervention arm: monthly visits to a patient's home by field staff to deliver ARVs and monitor signs and symptoms of drug toxicity or disease progression, and provide adherence support. Control arm: Standard care provided at the clinic.
Viral load measured at 6, 12, 18, 24,30 and 36 months
Time to RNA viral load >500 copies/ml. "Home-based HIV care was as effective as was facility-based care."% of persons with undetectable viral load at 12 months in intervention arm = (729–117)/729 = 84.0%;% of persons with undetectable viral load at 12 months in control arm: (483–80)/483 = 83.4%. Rate ratio 1 · 04 (95% CI: 0 · 78 – 1 · 40; equivalence shown). Odds Ratio = 1.04 (95% CI: 0.78 – 1.40) §
Nachega et al. [35]
Randomised controlled trial: Superiority trial
24 months
Home and Public clinic in Cape Town, South Africa
Included: 1. Male or non-pregnant female ≥18 years old; 2. HIV infection documented by two serologic tests; 3. Eligible to start ART (CD4 ≤ 200 cells/μL or WHO Clinical Stage IV disease); 4. Living in the study site catchment area at a stable address; 5. Willing to disclose HIV status to a treatment supporter; 6. Signed informed consent. Excluded: 1. Patients with prior ART use; 2. Life expectancy <6 months; 3. Karnofsky Performance Score <60; 4. Serious liver disease; or 5. History of single dose nevirapine for prevention of mother to child transmission of HIV infection.
Mean age in intervention arm 35.7 years (SD 9.7); Mean age in control arm 36.7 years (SD 9.2)
57.7% female in intervention arm; 57.7% female in control arm
n = 272: 136 in intervention arm; 136 in control arm
Intervention arm: In addition to standard care at the clinic, trained treatment supporters provided ART adherence support, observed at least one medication dose daily and documented it on a study adherence chart. Control arm: Standard care provided at the clinic.
Viral load measured at 12 and 24 months
RNA viral load <400 copies/ml. "DOT-ART showed no effect on virologic outcomes".% of persons with undetectable viral load at 12 months in intervention arm = 99/(99 + 37) = 72.8%;% of persons with undetectable viral load at 12 months in control arm = 93/(93 + 43) = 68.4%. Odds Ratio of HIV suppression at 12 months = (99/37)/ (93/43) = 1.24 (95% CI: 0.73 – 2.09)
Chang et al. [38]
Cluster randomised trial: Superiority trial
48 months
Home and Public clinics in rural Rakai District, South West Uganda
Included: All adult patients who were either already on ART at the start of the trial or were started on ART at any time during the trial.
Mean age in intervention arm 35.5 years (range 15–76); Mean age in control arm 34.0 years (range 17–70)
65.8% female in intervention arm; 67.5% female in control arm
n = 620: 456 (10 clusters) in intervention arm; 164 (5 clusters) in control arm
Intervention arm: Standard care of ARV delivery at the clinic plus biweekly home-based review by a peer health worker who checked for symptoms of treatment failure; patient self-report of adherence; pill count and provision of counselling and education in ART adherence and general HIV/AIDS-related issues. Control arm: Standard ART care provided at the clinic.
Viral load measured at 6, 12, 18, 24,30, 36, 42, 48 months
RNA viral load >400 copies/ml. At 12 months (48 weeks), no significant differences were found between the intervention and control arm.% of persons with undetectable viral load at 12 months in intervention arm = (456–42)/456 = 90.8%;% of persons with undetectable viral load at 12 months in control arm = (164–18)/164 = 89.0%. Risk Ratio 0.83 (95% CI: 0.47 – 1.48). Odds Ratio of HIV suppression at 12 months = 1/0.83 = 1.20 (95% CI: 0.68 – 2.13)
Taiwo et al. [36]
Randomised controlled trial: Superiority trial
12 months
Home and Tertiary Hospital HIV clinic in Jos, Nigeria
Included: 1. HIV-1-infected; 2. Treatment-naïve; 3. Age >15 years; 4. Eligible for ART (clinical diagnosis of AIDS, CD4 count <350 cells/μL with HIV-related symptoms or CD4 count <200 cells/μL regardless of symptoms); 5.Willingness and ability to select a treatment partner. Excluded: Patients with severe illness.
Mean age 34.2 years (SD 8.9)
66.1% female in intervention arm; 63.3% in control arm
n = 499: 248 in the intervention arm; 251 in the control arm
Intervention arm: In addition to standard care at the clinic, a treatment partner residing in same house or close proximity observed the ingestion of ARVs at least once daily. The treatment partner reported adverse effects and reminded participants of drug pick-up at the hospital. Control arm: Standard care provided at the Hospital HIV clinic.
Viral load measured at 6 and 12 months
RNA viral load <400 copies/ml. At 12 months (48 weeks), no significant differences were found in HIV suppression between the intervention and control arm. % of persons with undetectable viral load at 12 months in intervention arm = 162/248 = 65.3%;% of persons with undetectable viral load at 12 months in control arm = 149/251 = 59.4%. Odds Ratio = 1.28 (95% CI: 0.89 – 1.84)
Matovu et al. [17]
Randomised controlled trial: Non-inferiority trial
12 months
Home and PMTCT follow-up clinic, Mulago National Referral Hospital in Kampala, Uganda
Included: 1. Female; 2. Age ≥18 years; 3. Provision of written informed consent; 4. ≥36 weeks of gestation; 5. Eligible for ART (WHO Clinical Stage II/IV or CD4 counts <200 cells/μL); 6. Demonstrated compliance with ART screening visits; 7. Residence in a stable home within 15 km of Mulago Hospital; 8. Willing and able to come to the clinic regularly without transport reimbursement; 9. Willing to be home visited.
Mean age in intervention arm 27.8 years (SD 4.9); Mean age in control arm 27.0 years (SD 5.4)
All Females
n = 85: 45 in the intervention arm; 40 in the control arm
Intervention arm: Involved peer counsellors and home visiting, combined with nurses providing care at routine visits, and longer intervals between scheduled visits. Control arm: Standard care provided at the Hospital promoted adherence through routine counselling at each scheduled visit, care provided by a medical officer at each visit, and shorter intervals between visits.
Viral load measured at 6 and 12 months
RNA viral load <400 copies/ml.% of persons with undetectable viral load at 12 months was similar in the intervention (= 88%) and control (= 91%) arm. Odds Ratio of HIV suppression at 12 months = (0.88/ (1–0.88)) / (0.91/ (1–0.91)) = 0.73 (95% CI: 0.18 – 2.96)
Risk of bias in included studies
Risk of bias in included studies
Adequate sequence generated?
Allocation concealment?
Blinding of participants and personnel?
Blinding of viral load assessment?
Incomplete outcome data addressed? (Missing at follow up = treatment failure)
Free of other bias?
Jaffar et al. [37]
Cards were sealed in advance and labelled with stratum numbers and placed into a box
Sealed cards were drawn from a concealed box.
The study was cluster randomized trial; researchers and participants knew which clusters were receiving the interventions.
Probably done, because Blood taken for viral load testing was for research purposes; the testing was done in batches rather than in real-time.
"Those who withdrew or were lost to follow-up before 12 months were excluded from the primary endpoint analysis…"
The two groups were well balanced according to baseline characteristics apart from CD4-cell count, which was lower in the home-based than in the facility-based group [39]. There were no losses of clusters. The analysis adjusted for the effect clustering
Nachega et al. [35]
Probably done, because there was sequential allocation concealment
"[T]reatment assignments were placed in opaque envelopes, which were sequentially opened by the study coordinator at enrolment."
The study was an open-label, randomized controlled trial; both the researchers and the participants knew which intervention was being administered.
Measurement of viral loads performed was every 6 months as part of routine monitoring
Missing viral load values were considered detectable.
Trial terminated early for futility by an independent Data and Safety Monitoring Board
Chang et al. [38]
An allocation sequence was generated
Random allocation was by drawing of lots.
The study was cluster randomized trial; researchers and participants knew which clusters were receiving the interventions.
"Viral loads … were performed every 24 weeks on all patients as part of routine patient monitoring procedures."
Those who died or were lost to follow-up were excluded from the analysis of shorter-term virologic outcomes
Contamination in the control arm was reported in subsequent evaluation study [40].
Taiwo et al. [36]
"Using a computer-generated allocation sequence, randomization was performed …"
Probably done, because there was computer-generated allocation sequence.
"The study pharmacist, who was blinded to treatment arm, provided one-on-one reinforcement of the education provided by the adherence counsellor plus information specific to each participant's regimen."
Probably not done because patients who had detectable viral loads at week 24 underwent intensive adherence retraining with the adherence counsellor.
"[P]articipants who were missing virologic indicators and were reported to have died were counted as failures."
There were no significant differences between treatment groups at baseline.
Matovu et al. [17]
Probably done, because patients were randomly allocated.
Insufficient information to permit judgement of "Yes" or "No".
The study was an open randomized non-inferiority intervention trial.
Insufficient information to permit judgement of "Yes" or "No".
Patients lost to follow-up were excluded from the analysis.
Baseline viral load was adjusted for. This means there were significant differences in viral loads between intervention groups at baseline.
Effect of intervention
The I2 showed no heterogeneity between trials (I2 = 0.0%, p = 0.998). Therefore no sensitivity analyses were performed to assess differences in the studies.
Detecting publication bias
No statistical tests for funnel plot asymmetry were performed because at least 10 studies are required to be included in the meta-analysis for these tests to be performed. When there are few studies, the power of the tests is too low to distinguish chance from real asymmetry [14].
Summary of results
Neither superiority nor non-inferiority of the home-based interventions compared with standard of care has been clearly demonstrated with existing interventions to date. Based on the overall 95% confidence interval in this meta-analysis, it is conceivable that the effect of the home-based care does lead to an almost 2-fold worse outcome of unsuppressed HIV (OR 0.51) or that it is a lot better than the clinic-based care (OR 2.52) - but this meta-analysis is underpowered (by the few studies included) to demonstrate superiority of the home-based over the clinic-based care model. In addition, the home-based model in practice depends on clinic-based activities (including laboratory tests, monitoring of drug toxities and changing of ART regimen). Despite one study (by Jaffar and colleagues) being an equivalence trial, another (by Matovu and colleagues) being a non-inferiority trial and the other three being superiority trials, this did not affect the overall result (i.e. no evidence of heterogeneity).
Overall completeness and applicability of evidence
The studies included in this meta-analysis were conducted in sub-Saharan countries; where the challenge of shortages of health workers and increased demand for care at the clinic is apparent. Home-based interventions for ART may still have the potential of complementing existing health facility-based care in reducing the burden of HIV care. Home based interventions can potentially be delivered with minimum laboratory tests at the clinic. This is substantiated by a randomised non-inferiority trial conducted in Uganda and Zimbabwe that demonstrated that ART can still be delivered safely without routine laboratory monitoring at the clinic of toxic ART effects [41].
However, for home-based interventions to be successfully rolled out in an African setting, there would still be need for long-term management of HIV patients using culturally acceptable approaches that promote adherence to ART; that can also be easily integrated into public health models of ART care [42]. As demonstrated by Chang and colleagues in 2009 and 2010 [38, 43] and recently by Arem and colleagues in 2011 [40], this can be achieved through training of HIV patients (nominated by fellow patients) to provide HIV care in homes. Consequently, this may provide long-term benefits of adherence to ART and retention in care [37].
Jaffar and colleagues in 2009 demonstrated that the costs of health services for ART care is similar in the home-based intervention and the health facility-based group (US$793 in the home-based intervention group and US$838 in the health facility-based group) [37]. However, for the home-based intervention to be sustainable, there is need for ongoing support, training and consistent remuneration for the home-based workers from existing health systems [44].
Quality of the evidence
Only five trials were found to have met the study inclusion criteria and the combined sample size analysed was 2 688. Each study was assessed for its methodological limitation. The study by Matovu and colleagues [17] showed the highest risk of bias due to failure of this study to meet most of the criteria in the 'Risk of bias' assessments.
Two [35, 36] of the five studies included used intention-to-treat analyses with losses to follow-up treated as virologic failures. Like most prospective studies, losses-to-follow-up can be a source of selection bias; as it is not known what the true outcome of those lost to follow-up is i.e. whether they died as a result failing treatment or as a result of another competing cause of death or were still alive at the end of follow-up but moved out of study site and were thus not available for measuring the outcome at the end of the study. With such losses to follow-up it was hard to ascertain with certainty what the true outcomes were at study completion for the patients in these trials. For example, in the trial by Taiwo and colleagues, 14 out of 248 in the home-based group and 34 out of 251 in the health facility-based group were not found at the end of the study and were treated as failures [36]. These 14 losses in the home-based group and 34 in health facility-based group might have influenced the results differently in the Taiwo and colleagues' study. Also, after an evaluation of the CRT by Chang and colleagues [38], Arem and colleagues [40] contended that direct and indirect contamination in the health facility-based arm could have reduced the ability of the CRT to detect home-based intervention effects, and may explain why no differences were seen in early virologic outcomes between arms or in cumulative risk of virologic outcomes. Direct contamination occurred when some patients in the health facility-based arm started volunteering to take up tasks that were similar to those of the peer health workers in the home-based intervention arm. Indirect contamination occurred through task shifting which resulted in overall gains in the quality of the ART program during the study period [40].
Potential biases in the review process
The search for studies was performed in MEDLINE and EMBASE. Additional articles were identified from abstracts presented at the CROI and IAS conferences. It is likely that all relevant articles from Africa were identified and that there are few randomised studies that have been conducted in Africa on the effect of home-based interventions on virologic outcomes in patients receiving ART.
Agreements and disagreements with other studies or reviews
The meta-analysis by Ford and colleagues [12] also found a lack of effect of the directly observed ART intervention; the risk ratio was 1.04 (95% CI: 0.91 to 1.20). As noted by Hart and colleagues [13] this effect estimate in the study by Ford and colleagues was smaller than their finding of RCTs despite also not being significant; risk ratio 1.18 (95% CI: 0.99 to 1.42). This was also the case in this meta-analysis where we found the overall risk OR to be higher than that of Ford and colleagues', though with wider 95% confidence intervals; risk OR 1.13 (95% CI: 0.51 to 2.52). The reason for this difference may be that Ford and colleagues included estimates from the post intervention period; during which the efficacy of the intervention may have waned [13], unlike in this meta-analysis where the duration considered for the analysis was shorter .i.e., 12 months from starting ART. If the effects of directly observed ART intervention are not durable .i.e., once people graduate from the directly observed ART intervention there is no benefit on adherence to ART, there may be need for directly observed ART interventions that are repetitive [45, 46] or ongoing [47].
There was insufficient data to know whether there is a difference in HIV suppression at 12 months in the home-based arm compared with the standard care arm in adults receiving ART in Africa. However, given the high shortages of health workers in public health facilities in Africa, home-based interventions for ART, in addition to other approaches that have been proven to be effective such as use of mobile phone short message service [30, 48] and use of "buddies" to provide adherence support [49], may complement existing health facility-based care in reducing the burden of care. By task shifting HIV care to peer workers in the community that visit, provide ARVs and witness the dosing of ARVs, adherence can be promoted and this would not lead to poorer virologic response to ART in African settings.
Despite a thorough literature search, only five studies were identified to have met the inclusion criteria in this meta-analysis. This shows that there are few randomized trials on home-based interventions on HIV suppression that have been conducted and reported in Africa. There is need for further research in Africa that measures the effects of home-based models on HIV suppression at population level.
This article is an output from a PhD that was supported by projects funded by the UK Department for International Development (DFID) for the benefit of developing countries, and the Bill and Melinda Gates Foundation (Grant No. 19790.01). The views expressed in this article are not necessarily those of DFID or the Bill and Melinda Gates Foundation.
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- Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, Jack W, Habyarimana J, Sadatsafavi M, Najafzadeh M, Marra CA, Estambale B, Ngugi E, Ball TB, Thabane L, Gelmon LJ, Kimani J, Ackers M, Plummer FA: Effects of a mobile phone short message service on antiretroviral treatment adherence in Kenya (WelTel Kenya1): a randomised trial. Lancet. 2010, 376 (9755): 1838-1845. 10.1016/S0140-6736(10)61997-6.View ArticlePubMedGoogle Scholar
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- Collier AC, Ribaudo H, Mukherjee AL, Feinberg J, Fischl MA, Chesney M, Adult AIDS Clinical Trials Group 746 Substudy Team: A randomized study of serial telephone call support to increase adherence and thereby improve virologic outcome in persons initiating antiretroviral therapy. J Infect Dis. 2005, 192 (8): 1398-1406. 10.1086/466526.View ArticlePubMedGoogle Scholar
- Birbeck GL, Chomba E, Kvalsund M, Bradbury R, Mang'ombe C, Malama K, Kaile T, Byers PA, Organek N, RAAZ Study Team: Antiretroviral adherence in rural Zambia: the first year of treatment availability. Am J Trop Med Hyg. 2009, 80 (4): 669-674.PubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/239/prepub
Pre-publication history
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.


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Course News & Downloads
- Bear Mountain Golf and Country Club - Mountain Course Overview Page
- Bear Mountain Golf and Country Club - Mountain Course Scorecard
- Stellar field of PGA TOUR Champions stars set to tee off today in the Pacific Links Bear Mountain Championship on the Nicklaus-designed Mountain Course
- Pacific Links International Announces Partnership With Bear Mountain Golf Resort and Spa In Victoria, British Columbia
- Weir wins $270,000 in Telus Skins
- Camilo Villegas and Fred Couples Added to Field For 2010 Telus World Skins Game
- Ian Poulter and Retief Goosen Round Out the Field For 2010 Telus World Skins Game
- Westin Bear Mountain Victoria welcomes Telus World Skins Game
- Mike Weir headlining 2010 TELUS World Skins Game
- Bear Mountain doubles its pleasure
- TELUS World Skins Game coming to Victoria and Bear Mountain Resort
- Bear Mountain adds a gentler touch
Bear Mountain Golf and Country Club - Mountain Course News
March 13, 2009
With the June opening of its Valley Course, Bear Mountain Resort becomes Canada's first to feature 36 holes of Nicklaus Design golf
Bear Mountain Resort is putting Vancouver Island on the map as the next golf destination, with its rugged alpine setting and temperate climate. Jutting rocks, roaring rivers, majestic valleys, lush forests and distant white-capped mountain peaks provide the ideal backdrop for the first and only offering in Canada of 36 holes of Nicklaus Design golf—all within minutes of the beautiful seaside harbour of Victoria, British Columbia.
The developers at Bear Mountain Resort were the first to bring a Nicklaus Design course to Victoria. Originally introduced in 2003, the cornerstone of the Bear Mountain Resort community is the Jack and Steve Nicklaus co-designed Mountain Course, a 19-hole beauty that is the first Jack and Steve Nicklaus co-designed course on Vancouver Island. The Mountain Course is a masterpiece, offering challenging terrain and spectacular natural beauty. A par 72 playing at 7,212 yards, the course takes full advantage of its setting atop a 1,100-foot mountain, exhibiting dramatic elevation changes and awe-inspiring views. The course has been assigned a slope rating of 152 from the back Golden tees, making it one of the most inspiring courses in North America. From the Grizzly tees, the course plays 6,744 yards, the Black Tees play 6,345 yards, the Spirit tees play 5,783 yards and the Cinnamon tees play 5,014 yards.
The Valley Course debuts in June and the 18-hole, par-71 Nicklaus Design championship course will measure approximately 6807 yards. The Valley Course will play at a lower elevation than the Mountain Course and alternate between 300 and 400 feet above sea level. Coupled with the uniquely challenging course terrain and unsurpassed natural beauty, Bear Mountain Golf and Country Club assures its stature among the most sought-after golf destinations in the Americas.
"From the outset, my vision for Bear Mountain Resort centered around offering a world-class golf experience with the most notable designers behind it," said Len Barrie, president and CEO of Bear Mountain Resort. "While our community offers the best in resort accommodations and residential living, our goal has always been to create the West's most renowned golf destination."

subset: commoncrawl


text: By Sondra Whitt Ever feel like you're stuck when you need to make a decision and don't know what to do? Unfortunately, our emotions often cloud our thinking when faced with the pressure of making a big decision. To make wise choices and avoid acting on impulse we need to engage in a logical thought process. So, think about this. If your life was a movie how would you write the script? This is one of the methods that Dr. Henry Cloud, author of 9 Things You Simply MUST DO to Succeed in Love and Life, has found that successful… Read More


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👋🏼 I'm Taylor, 23 years old 📍living in St. Louis Missouri with my soulmate Dalton. I am a full time Neuro Nurse at Barnes Jewish Hospital + I am a Double Diamond leader with It Works Global. I will be approaching my 2 year mark of my journey with this health and wellness company in July. 💉i started this business before my last semester of nursing school. I wanted to lose 20 lbs & thought "if I can make an extra income from my phone in between classes AND lose weight....." WHY NOT TRY. I had never tried a product, I didn't research this company, I knew nothing about the products I just said YES after being approached with this opportunity. Worst case scenario i was going to lose weight if this business didn't work out for me... 🔥 I found my passion for this company, the products, the people very quickly after joining. I saw the diamond and above leaders and thought I would never be that successful with this. It seemed so out of reach. 😭 it blows my own damn mind that here I am sitting as a double diamond. My nursing salary is now my extra income and this business has completely changed things for me my family. We have #freedom. We have amazing #friends that we have gained because I said yes. We have #goals that are so big that they make us cry thinking of them. We will be a work from home Full time family 🏡 we will continue to pour our faith into the big man upstairs because we know that he blesses our check every single month and that he puts people in our line of vision everyday. We continue doing what we do so we can help more people have this freedom. To have the ability to dream again. To live the life you want doing the things you love. If your ready for a change in your life then I want to talk to you. 📱217-619-2468 text OPPORTUNITY for details
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I had loads of FUn at The Marble Slab Creamery Ottawa (MSCOttawa)!
|These are what SuperFit calls my...
SuGaRy EyEs!
They open up wider than my head!
I was beyond thrilled when MSCOttawa contacted me and gave me the SwEeT OpPorTunItY to create a *CaNdY FiT* FUlavored Slab!
There was absolutely no way I could or would pass up on this ofFUr! (And based on my last experience, I'd be FU'in insane to do so!)
Like I mentioned in my previous post...
I saved the date FU this SwEeT Occasion post-FUtoshoot! (That way I could take FUll advantage of all the sweet everythings MSCottawa had in store!)
So until that day...
I prepared a list of Slabs and Toppings I knew I'd
like love! (Of course I did! Have you seen their options?! The possibilities are endless!)
|I came up with 5!
With your help...
I was able to come up with something that far surpassed what I ever imagined creating! (I went beyond the list! lol)
Thanks to MSCOttawa...
|These words brought a BIG smile to my face :)
I was able to treat myself and satisfy my SweEt ToOth beyond what my pallet could have ever thought possible! (Oh my yes!!!!)
BeFUre we got down to Slabbing business...
I did an hour on my CycleOps Bike trainer! (Nothing out of the ordinary on a Saturday morning!)
I trained Arms with SuperFit! (Biceps and Triceps!)
Once we were done...
We made our way to the MSCOttawa in the Glebe!
I was excited...
|Who wouldn't be?!
It's Ice Cream!!! ;)
That being said though...
I had no idea what to pick and choose the moment I got there! (I thought I had a pretty good idea up until I stepped FU't in the door! Then the options made me go in all directions! lol)
|What the FU am I going to do!
I was so relieved when I got help from the Owner herself!!! (She and her Husband are absolutely the FUrendliest people ever!!! I could have stayed there all day!)
Despite having my list of Ice Creams (yes, I brought the list with me lol)...
I had to try them all just to be sure!!! (Okay, well 95% of the FUlavors!)
I Tested the:
Red Velvet, Vanilla Bean, Apple 'N Spice, Peanut Butter, Cotton *CaNdY*, Birthday Cake,
Peppermint, White Chocolate, Double Dark Chocolate, Cheese Cake and Swiss Chocolate.
I FUnally decided on two FUlavors:
1. Peanut Butter (There was no escaping it!); and
2. Swiss Chocolate! (The best combo ever!)
As soon as my decision was made...
Then came the scooping action!
|I was ready to go!
I'll tell you one thing...
I quickly learned scooping is a workout in itself!!! (I could have skipped on my morning training session .... Notttt lol!)
Once scooped up...
I placed the ice cream balls on the Cold Marble Slab and FUlattened it up! (So as to make lots of room FU the mixings I was about to add!)
I got two (not one!) thumbs up! ;)
Her left hand is clearly a thumbs up! lol
|The Slabs were waiting to get topped with the...
SwEeT Mixings!
Let me tell you...
I had such a difFUcult time making up my mind! (Again, I thought I knew what I wanted but then there were too many good things to pick from!)
This is going to be FU'in hard!
I took a handFUl of M&Ms to help me think it through...
|Just one...
|They were sure to help!
|I think she knew I simply wanted to eat *CaNdY* lol
We then decided to take out my list and look through the array of options I had listed!
The M&Ms did come in handy in my decision-making!
I went with a FU mixings from each of the slab options I had written out! (Fair compromise! I'd get the best of all creations!)
The Mixings included:
1. FUdge;
2. 1 Brownie Piece mushed up;
3. FUresh Strawberries;
4. Sliced Bananas;
5. Marshmallows (SuperFit's advice turned out to be the secret weapon of this Slab! I was weary about adding them, but it turned out to be a huge success!); and
6. Pecans to top!
6. Pecans to top!
|Placing the mixings on the ice cream.
|Smushing the Brownie!
|About to turn it over like an Egg White Omelette.
|I was having way too much FUn!
I couldn't stop giggling!
Once mixed...
It was time to decide on a WafFUl bowl!
Decisions, Decisions!
I could have gone with a cone but I like the bowls!
I went with the Dark Chocolate WafFUl! (It didn't take me very long to pick which one I wanted!)
The next was to...
Scoop up the mixed slab and gently place it in the edible bowl!
Scoop up the mixed slab and gently place it in the edible bowl!
We had to top my Slab with a Cherry! (I mean, is that even a question?!)
We had to top my Slab with a Cherry! (I mean, is that even a question?!)
|Can I eat it now?!
We ended up calling it the *CaNdY FiT* SuGaR RuSh!!! (And that it was! I was bouncing off the walls lol)
|Once again, I found...
Happiness Within!
Did I ever!!!
|It was edible and enjoyed...
Not only by me but by both of us! lol
To be honest...
It wasn't as heavy as I thought it would be (or looked!)!
It was both sastisFUying and PerFUctly Balanced (to my liking)!
I ate it all.
Since SuperFit wouldn't stop digging into mine...
We told him to make his own! (And he did!!!)
It's called the...
SuperFit Sugar Shock!!!
SuperFit Sugar Shock!!!
His Slab included:
1. Swiss Chocolate Ice Cream;
2. Strawberry Ice Cream;
3. Marshmallows;
4. FUdge;
5. FUresh Strawberries; and
6. Sliced Bananas!
He had it in the same WafFUl bowl as me!
|He may have been just as excited as I was ;)
|I had 2 spoonFUls of his.
It was super good too!
Not only did we get to indulge in our amazing delights, but...
My sister Kiki and Mr. FUntastic came to join in on some Slabbing good FUn too! (My brother had just come back a day earlier from out West, so this was the FUrst time I'd seen him since the last! That dates back a couple of months!)
|He was thrilled at the idea of making a Slab!
|They too would have to pick and choose from the array of options.
FU Kiki, well...
It was an easy decision!
She got the *CaNdY FiT* SuGaR RuSh!!! (She was the FUrst patron to test it out!)
|We both love our SwEeTs!
|She loved it and FUnished it all!!!
|I was happy!
As FU Mr. FUntastic...
He got what I thought he would! (Something simple yet so delicious!)
It included:
1. Chocolate Hazelnut Ice Cream;
2. Praline Ice Cream;
3. Sliced Almonds;
4. Pecans;
5. FUresh Raspberries; and
6. Sliced Bananas!
Of course...
I made it FU him as well! (I swear, I could have made Slabs all day!)
Of course...
I made it FU him as well! (I swear, I could have made Slabs all day!)
|Applying all the skills I learned.
|I had a big smile on my face every step of the way!
|It looked heavenly.
|I think he also found Happiness Within his cup!
He did, he loved his creation!
After an awesome day spent with the Crew at the Marble Slab Creamery Ottawa...
My shift was over! (It was hard leaving my creative and Slabbing post!)
All in all...
We had an amazing time!
I am so very grateFUl FU the SwEeT OpPoRtUnItY I was given in making a *CaNdY FiT* FUlavored Slab!!!
Thank you to MSCOttawa FU a perFUct treat in your warm and ever so SwEeT Creamery!!!
That being said...
Be sure to order your *CaNdY FiT* SuGar RuSh or SuperFit SuGar Shock when visiting MSCottawa! (It will be posted in case you FUrget the names or mixings! FU those outside the Ottawa area, you can simply write down the creations! But, I'm sure you knew that lol)
|SuperFit and *CaNdY FiT*...
Finding Happiness Within.
Oh and how could I FUrget...
The lucky MSCOttawa Giveway Winner is: Pierrette J.! (Check your mailbox FU your gift card to treat yourself to a yummy Slab!)
And make sure to post your creation on my FB page!
I can't wait to see what you come up with!!!
Stay Tuned FU more on *CaNdY FiT*


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With a nod to the Keepall, this multi-purpose bag is styled in Monogram canvas. It offers a spacious interior and a padlockable closure. It is ideal as a sports or weekend bag.
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Slithering Snake Stories
One day Israel Johnson was out walking near his mill pond in the Oconee District of Laurens County when he observed a moccasin crawling out of a hole. Johnson reached for the nearest stick and impaled the water loving serpent right there on the spot. In a moment, another moccasin came slithering out of the same hole. Then came another and then another. This went on until Johnson's pile of dead moccasins totaled thirty-four, all about fourteen inches in length. Macon Telegraph, Sept. 17, 1887.
When most people go out into the woods, one of the reasons they wear boots is to keep snakes from biting their feet. W.H. McLendon, of Rockledge, had his boots on when he went out squirrel hunting with some of his friends. At the end of a successful day, McLendon, who had felt something in his boot but ignored it, noticed a small hole in one of his boots. Just then, a small snake, several inches in length, came squirming out of his boot. Atlanta Constitution, Oct. 25, 1942.
C.G. Gunnin was proud of his snake. He brought it into the offices of the Courier Herald to show it off. Killed near Norristown in Emanuel County, the snake had a short hard point on its tail shaped like a rattler's fangs, instead of the normal horn. The people in Norristown said the snake used its tail to kill its prey. Similar in appearance to a rattler, the snake was more than five feet long. Atlanta Constitution, May 21, 1914.
Smith Williams was proud of his snakes too. He put three of the rattlers in his suit case and headed from Wrightsville to the District Fair in Dublin to show them off. One was five feet long with eight rattles, while the other two were much smaller. Williams had raised the snakes from neonates. Although he removed the fangs from the largest rattler, the younger vipers were capable of deadly bites. On the trip, the bouncing passenger car annoyed one of the smaller snakes. Its defiant rattling caused much consternation among the passengers until they discovered that the snakes were confined to William's securely locked baggage. No one asked to see inside.
To keep the snakes company, Williams brought along a five-year-old dog and six-month-old fox. Williams had also raised them from birth. Now, you might say what is unusual about a dog and a fox. The fox, one of the grey variety, was said to be tame and possessed the ability to understand his name when called. Well, the dog was just a dog, but when Williams put his five animals on display, the crowd got a chance to see the canines play with each other like puppies. Macon Telegraph, Nov. 5, 1913.
In the category of "Maybe I should move," J.C. Jones told another true tale about another snake he found in his yard. One of his most valuable hounds was bitten by a rattler. In order to save the dog, Jones drenched its wound in kerosene. The old remedy worked and the dog survived. Apparently Jones had not learned his lesson as it was the fiftieth time in three years that a rattlesnake was killed inside his dog pen. Macon Telegraph, June 28, 1886.
For nearly fifty years, it was said that a huge rattlesnake lived in the cliffs of Jennie's Creek in Johnson County. Many people tried to find the legendary rattler and kill it. No one succeeded until one day when a cow, belonging to Mr. Dan Davis, was found to be bitten by a large rattler. Davis offered a handsome reward of $25.00 to anyone who would bring him the lifeless corpse of the dastardly diamondback. One of his farm hands fetched two .38 caliber pistols and set out to follow the distinct trail of the snake back to its den. The man climbed a tree in front of the cave where he suspected the snake to be resting. He waited. After a four-hour stakeout, the snake appeared. The man fired nine shots into the venomous monster. After making sure it was dead, the bounty hunter measured his prize to be eighteen feet in length and twenty-nine inches in circumference. The rattle end of its tail measured two feet long and was eight inches wide. Senior citizens of the area remarked that they had heard of the monster reptile since their childhood. I am not saying that Mr. Davis and his friends were exaggerating, but my research indicates that the largest Eastern Diamondback rattlesnake ever found measured only eight feet in length. Maybe this was a freak of nature. Who knows? But, if I see a rattlesnake which is at least eight feet long, it won't matter at all if he has another ten more feet of tail added on. I am out of there! Atlanta Constitution, Sept. 16, 1897.
In a more believable story, Nannie Rushton, of Laurens County, killed a seven-foot rattler with eighteen rattlers in the fall of 1908. Washington Post, Oct. 25, 1908.
There were plenty of reports of people getting bit by snakes and dying from their wounds, but undoubtedly the most tragic story came in the spring of 1887. Two miles below Dublin a man was out working in the field. He discovered a large copperhead snake. Afraid of an up close and arms length attack on the snake, he ran back to his home to fetch a pistol. His niece, Ella Griffin, ran back with him to watch her uncle shoot the snake. When the copperhead was aroused, it maneuvered itself into position to attack. This frightened the little girl who ran toward her uncle for safety. Just as the man fired, the girl ran straight into the path of the bullet, which struck her in the abdomen and inflicted severe internal bleeding which was thought to have been ultimately fatal. Atlanta Constitution, May 25, 1887.
Jess Jones and Henry Barry, Jr. were in the swamps of Gum Creek squirrel hunting one day when they noticed a peculiar squirrel running up and down the side of a tree. Every time the squirrel went down the tree, it would go a little closer to the ground. Their curiosity aroused, the boys moved in closer to investigate. At the base of the tree, the hunters found two large rattlers eyeing their supper. The boys shot the snakes and the squirrel lived to tell its own snake story. Washington Post, Sept. 28, 1913.
Usually, snakes are charmed by gifted and misguided snake charmers. But over in Dodge County, there was a story about the snake being the charmer and Giles Melton's ol' dog being the charmed and last victim of a devilish rattler. Melton noticed his dog approaching him in an unusual manner. The dog was crouching down, whining, and refusing to notice his master as it was slowly moving away. Melton noticed that his dog was slowly creeping toward a coiled rattlesnake. He had seen his dog kill snakes before, but he had never seen it trembling and mindlessly drifting toward a deadly snake. As the dog got within striking range, Melton feared that it was being charmed by the snake. So, Melton fired his gun and killed the snake. The dog collapsed to the ground and began to foam at the mouth. It eventually recovered, but the next morning Melton found his prized dog in an advanced state of hydrophobia. He had no choice. "Mad dogs" had to be killed. Atlanta Constitution, Sept. 22, 1888.
So watch where you step, even after Dog Days are gone. Snakes don't go blind and strike at anything just during Dog Days which end on August 11. They don't watch the calendar. They are watching you!


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'Sweatshop Conditions' Zing - Obama may not be preparing any "zingers" for the debate Wednesday night, but Zing!, his new ad accusing, without any hard evidence, uses the words "sweat shop conditions" in close proximity to Romney and Bain and China. It's a doozy. More from Devin Dwyer - http://abcn.ws/SULCHA
Happy October! - Imagining this year's surprise with Russell Goldman - "Imagine the impact on the polls if just days before Election Day, negotiations between the president and Iran dramatically broke down, intensifying an already volatile situation and fueling rumors that his Republican challenger cut a deal with a hostile enemy power to influence the election. Would you be surprised?" Go back to 1980. http://abcn.ws/UCf41k
W hat we'll be watching tonight? - Warren / Brown Debate 2
What we'll be watching tomorrow? - Colbert guest-hosting GMA
Fact or Fiction? - Jonathan Karl will helm our robust debate "Fact or Fiction" operation - A taste - candidates on social security - abcn.ws/RuTo8N
Debate Camp - Greg Krieg lays out the day - "President Obama and Mitt Romney are going camping. With less than 72 hours to go until Wednesday night's debate, the candidates have retreated from the campaign trail, gathering with top advisers to prepare for the first of three scheduled primetime meetings. "For Obama, this will be the final "debate camp" of a political career that's seen him move from the Illinois state house to the White House in less than five years. Now, with his first term nearing an end, he'll spend the next three days honing his case for another four years during closed sessions at a lakeside resort in Henderson, Nev., 20 miles outside of Las Vegas.
"Romney left Boston, Mass., for the Rockies this afternoon, having spent most of the morning and at least three hours Sunday being drilled by his own debate team, with Ohio Sen. Rob Portman standing in as Obama during sparring sessions. He will hold one more rally, tonight in Denver, before leaving the stump for a final round of preparations."
To the Tapes - Obama Team Studies Romney Tapes as Debate Camp Begins - President Obama convened the final debate camp of his political career here on Sunday, huddling with top advisers at a posh lakeside resort 20 miles east of the Strip for a three-day crash course on Republican rival Mitt Romney. http://abcn.ws/PFHbeZ (Devin Dwyer)
Debate Cringes Through History - If, as the Romney Folks Expect, Debates are About Moments, the ones that stick with us are often the cringe-inducing ones. From Gerald Ford's Poland brain freeze to Al Gore's sighs, here are 12 - http://abcn.ws/OzF14K
Meet the Australian behind viral U.S. Political Videos - http://yhoo.it/StWc73
Ryan Says Obama Plan Risks U.S. Troops in Afghanistan - Shush Walshe reports that as U.S. casualties cross the grim benchmark of 2,000, Paul Ryan accuses President Obama of endangering Americans: "Paul Ryan charged today that President Obama is risking the lives of U.S. soldiers in Afghanistan by making a political calculation to drawdown U.S. troops just before the election rather than listen to military commanders in the field.
"They just pulled about 22,000 troops in September, which to me is a political decision to have a draw down before the election, but we're still giving our soldiers the same mission, the same counter-insurgency mission, but we're sending fewer people out to do the same job," Ryan said. Ryan continued, saying the "politicization of these decisions is something we would never do."
"We would never put politics ahead of what our commanders say is necessary to do the job and keep our soldiers as safe as possible when they're prosecuting this war," Ryan said.
"Despite the harsh words, Ryan conceded as he has before that he agrees with the president's date of a pull out of troops by 2014. Romney and Ryan disagree with making that date public." http://abcn.ws/QHsknm (Shushannah Walshe)
Supreme Court Debates Whether US Courts Can Take Human Rights Cases Overseas - Hoffman appeared before the Justices last February on behalf of 12 Nigerian plaintiffs who are seeking to sue a subsidiary of Shell Petroleum for allegedly aiding and abetting human rights violations in Nigeria between 1992 and 1995. At issue was whether corporations can be held liable in U.S. courts for human rights violations allegedly committed abroad. http://abcn.ws/P6QzMU (Ariane DeVogue) Jets Lose Again: Owner Woody Johnson Puts Romney First - New York Jets owner Woody Johnson said today he'd take a Mitt Romney victory on Election Day over a winning season for his "Gang Green" football team. http://abcn.ws/QSUh8B (Greg Krieg)
With Congress on Break, Pols Blast Dysfunction - Despite having left Washington more than a week ago for a six-week campaign recess that lasts until after the election, lawmakers on both sides of the aisle have used the legislative lull to draw attention to the stalemate in the divided Congress. http://abcn.ws/UCv8jx (John Parkinson)
Pelosi a Zombie Leader in New Attack Ad - Nancy Pelosi's challenger John Dennis (in a re-match of a futile 2010 effort) uses a different tact - zombies. There's also a sacrificial lamb and an over-the-top impersonation of Pelosi. http://abcn.ws/P6Is2I (Kyle Blaine)
Hackers Hit White House Computer Network - The Obama administration has confirmed a report that unidentified hackers targeted an unclassified computer network for the White House Military Office in an cyber attack last month. http://abcn.ws/PoabXf (Devin Dwyer)
Aurora Survivor Pushes Romney, Obama To End Gun Violence - Days before President Obama and Mitt Romney take the stage at the University of Denver for their first debate, a survivor of the deadly shooting that took place just 10 miles away in suburban Aurora, Colo., is demanding the candidates deliver more precise plans on how they'd combat gun violence. http://abcn.ws/V7c0yV (Greg Krieg)
Spanish Language Campaign Ad Spending Lags - Courting the Hispanic vote may be an integral part of both Republicans and Democrats campaign strategies this cycle, but Spanish language ads don't appear to be a key part of their financial expenditures. http://abcn.ws/PSfKjd (Elizabeth Hartfield) A Deep Dive into the Air War on Spanish Language - From Univision's Jordan Fabian - http://abcn.ws/PSfKjc
More 'Fast and Furious' Guns Linked to Mexican Crimes - A new report by our partners at Univision has found additional links between violent crimes in Mexico and guns involved in the Obama administration's flawed "Fast and Furious" operation. http://abcn.ws/UCjWDH (Jake Tapper)
Confused by the various allegations against David Rivera? Jordan Fabian has a timeline - http://abcn.ws/V6v7ZK
Arnold Schwarzenegger Undecided on Romney vs. Obama - He's still a Republican but Arnold Schwarzenegger told George Stephanopoulos he doesn't know who he will vote for in the presidential election next month. http://abcn.ws/U0H7Nh
Arnold Schwarzenegger on Affair: 'Worst Thing I've Ever Done' - "It's just one of the disastrous situations I've created and the worst thing that I've ever done," former California Gov. Arnold Schwarzenegger told George Stephanopoulos. http://abcn.ws/P674Zq
The Man Behind the "MC 'Bama" Video - A little comic relief on our Yahoo! News/ABC News digital show http://abcn.ws/STcqIo (Jake Tapper)Also Read
Source: http://news.yahoo.com/pm-note-sweatshop-zinger-debate-camp-envisioning-october-225053403--abc-news-politics.html
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In the chaos that characterizes any crisis, explanations increase as so many attempts to impose their vision of the world where the stake is world domination. The chaotic "gap[1] » opened by a crisis is also a narrative war zone whose winners will be either the strongest (for a short period of time), or the most coherent (for a long period).
For the everyday citizen or player, the great difficulty is not to lose one's head in the middle of these countless story-tellings. The GEAB's mission since January 2006 is precisely this: helping its readers to look beyond the obvious and the dominant noise and try to get closer to the reality of profound changes. This work is important individually, in the decisions that everyone must continue to make in an unstable environment, but it's even more important on a collective basis because the choice of narrative is of course a choice for the future. Yet between the narrative imposed by force and that by reality, a society can lock itself into an ideological system or resolutely commit itself to an open world.
In the 20th century, the people who swung to ideological systems disconnected from reality probably had little choice. Today, ultra-connected and multi-informed societies have a real responsibility in the choice of their future. This is why the GEAB and political anticipation, without claiming to be always right, is offering a summary of the narratives attempting to maximize objectivity and help its readers to keep as much distance as possible from events, to distinguish between factual information and opinion, between false and reliable information, and provide the tools to forge and have confidence in one's own opinion.
We have already mentioned the fact that 2015 would be characterized by a "monstrous overlap" between the world before and the world afterwards, where the two worlds appear to be equal: one by the strength of the tools of power at its disposal and which are still operational (media, armies, finance…), the other by its intrinsic strength.
In reality, the world before is henceforth eminently weakened and its residual domination is no more than the fruit of its superhuman efforts to make its tools of power "speak" in its place, an effort in which it is exhausting itself, much as the URSS exhausted itself in the arms race.
Our team has decided to make public the first part of the Perspectives section, about the tools of power in crisis, knowing that the second part of the section proposes some analyses on the European QE and the euro-dollar rate.
Four tools of power in crisis
Let's look for a moment where the world before's famous tools of power are:
. open questioning of the media's objectivity, their professionalism, their added value, etc… with the Charlie affair an illustrative event of this deep questioning: the contrast between editorial chiefs with ultra-authoritarian methods suddenly proud to wear the "I am Charlie" badge didn't fail to examine whole classes of journalists, but also citizens, ... Read


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Everything You Need to Know.
In just nine short days my family will be travelling to WaltDisneyWorld in Orlando, Florida. It is known as the Happiest Place on Earth…and also one of the busiest.
While my daughter lingers behind me like a shadow, my son is more likely to wander off, deep in thought and mesmerized by the sights and sounds of the Magic Kingdom. At two and a half, he actually has a somewhat astounding vocabulary. The glitch is that he's only understandable to the average person about 50% of the time. The thought of him becoming separated from us and being unable to communicate simple details like his name is maddening.
Fortunately, the kind people at My Precious Kid, Child Safety Products, offered to send me a free Kid's Dog Tag to review. I chose the blue tag with the little boy (pictured above), and utilized the eight customizable lines of type on the opposite side to list my son's name, my cell phone number, my husband's cell phone number, and our home phone number. The dog tag arrived to my home incredibly fast after I placed my order, and not only is the information printed on the tag very clearly, but I was especially impressed out how light the tag is. I plan on hooking the dog tag to my son's belt loop or windbreaker zipper, and I know that if the tag were heavy and bulky, he would attempt to remove it from his clothing.
Thank you to the folks at My Precious Kid for allowing me to test this child safety item. Please visit their site to check out their other great products including shoe ID tags, disposable ID bracelets, and fingerprint kits.
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TV To Go
FLO TV Personal Television Giveaway!
This contest is now over. A winner has been announced here. Thanks to everyone who entered!
FLO TV Personal Television. It's a 5 ounce TV streaming machine that gives you five hours of access to 20 channels including CBS, Comedy Central, Discovery, ESPN, FOX, MTV, NBC, and The Food Network. What's better than that? Well, how about your very own FLO TV Personal Television? Yup, that's what we thought.
To Win: Become a Gear Patrol Facebook fan here or use the handy new widget to the right. Don't use Facebook? Leave a comment with your Super Bowl prediction: Saints or Colts. Want to up your chances with another entry? Tweet: Gimme A #FLOTV @gearpatrol! http://bit.ly/biamwA. Boom goes the dynamite.
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|Project by harshest
|posted 12-31-2012 04:06 PM
|1777 views
|1 time favorited
|7 comments
I made this for my wifes grandfather who served in the Army in WWII. He made it through the entire war. I believe he landed in France just after D Day and traveled all the way into Germany. I don't have the exact dates in front of me now.
Anyways he just now filled out the paper work to get his medals. When he finally got them he would always mention to me that he wanted to get a shadow box for them to be displayed. Not wanting to put and American Hero's medals in some cheap piece of Chinese crap I made him a box using only vintage US made tools.
I did a full size drawing, just because, and still made measuring mistakes. I cut the sides two short, I didn't take into consideration the thickness of the top and bottom for the trough dovetails. Somehow I split one of the side pieces with the tails on it, usually I split the pin pieces. Also I changed the design since I could not get the 45 miters lined up (I need a new shootingboard). I just did a simple half lap for the joints of the frame. The space under the main viewing are is for the original boxes the Medals cam in. This was a fun project using only had tools.
I retrospect i think I made the box a little to deep, but he loved it so that is all that counts.
7 comments so far
#1 posted 12-31-2012 04:27 PM
Great work! The box, also.
-- Interested in Oregon property? Visit me at http://www.willamettepropertiesgroup.com
#2 posted 12-31-2012 04:51 PM
Very nice ,a good way to honor your grandfather and a American hero.
-- https://www.artisticwoodstudio.com/videos wood crafting & woodworking classes
#3 posted 12-31-2012 04:54 PM
A wonderful way to honor our heroes. My day entered the war at Omaha beach shortly after D-Day and made it into Belgium and the Bulge. He was wounded in Belgium and came home from there.
#4 posted 12-31-2012 06:31 PM
Honors to your Grandfather, "Thank You for your Service".
"Special mention for your Honor to his Legacy".
Very nice Tribute Case, I'm certain he is proud of your gift.
Work Safely and have Fun. – Grandpa Len.
-- Mother Nature should be proud of what you've done with her tree. - Len ...just north of a stone's throw from the oHIo, river that is, in So. Indiana.
#5 posted 12-31-2012 09:51 PM
Great way to honor his time served.
-- Chris L. "Don't Dream it, Be it."- PortablePastimes.com (Purveyors of Portable Fun and Fidgets)
#6 posted 01-01-2013 02:14 AM
Nicely done. I am sure your wife's grandfather is very proud of your work.
-- -Al, Chesapeake, VA
#7 posted 01-01-2013 02:28 AM
Nice job and great idea for storage of the presentation boxes.
I wonder how many Vets have medals or accommodations they would like display and could use a great display case like this?
-- Do not be discouraged by those who don't. Be inspired by those who do.
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Additional navigation for pages within this section of the website
Don't Play Renovation Roulette With Asbestos
"Don't Play Renovation Roulette – Asbestos can be in any home built or renovated before 1987"
If you are thinking about renovating, you must be aware of asbestos. It is important for home owners and renovators to be aware of how to safely manage asbestos in and around the home.
Importantly, if you suspect you have asbestos in your home, Dont cut it! Don't drill it! Don't drop it! Don't sand it! Don't saw it! Don't scrape it! Don't scrub it! Don't dismantle it! Don't tip it! Don't waterblast it! Don't demolish it! And whatever you do… Don't dump it!
Asbestos fibres were used widely in building materials before the mid-1980s. If your house was built or renovated before the mid-1980s, it is likely to contain asbestos cement building materials.
You may be surprised at the various types of products that were made from bonded asbestos cement included fibro sheeting (flat and corrugated), water drainage and flue pipes, roofing shingles and guttering – even the backing of vinyl sheet floor coverings.
In NSW, the use of asbestos was discontinued in all fibro sheets and products by the mid-1980s. After this, asbestos continued to be used principally in friction products, for brake and clutch linings. The manufacture and use of asbestos products was banned nationally in Australia from 31 December 2003. Asbestos is still widely used in some countries. Despite being a prohibited import in Australia, goods containing asbestos are still being located at the Australian border.
For more information visit https://www.asbestossafety.gov.au/managing-importation-asbestos-australia
Or http://asbestosawareness.com.au
And for information regarding to health issues related to asbestos use please use the following link below. https://www.mesotheliomaprognosis.com/mesothelioma
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Earn MYER one points when you shop online with Myer.
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Product InfoGreat update for Carousel. Full leather lining. 4mm high density latex sock foam for added comfort.
Fabrication: Sheep leather
Lining: Pigsplit/4mm latex sock foam
Sole: Two colour rubber resin
Heel height: 15mm
Our No Regrets Returns Policy is all about making it easier for you to experiment and try something new, so we've made the process of returning purchases that are 'not quite right' as easy as possible.
You can return and exchange items at one of our 60+ store locations, or return items to us by mail.


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Ashley Tisdale: HSM3, Here I Come Again!
Ashley Tisdale and backup dancer boyfriend Jared Murillo arrive at LAX in Los Angeles on Saturday.
The couple caught a departing flight to Salt Lake City, Utah to finish filming High School Musical 3: Senior Year. Ashley made sure to bring along her pet pooch, Maui, who traveled like royalty in a Louis Vuitton pet carrier.
10+ pictures inside of Jashley looking pretty LAX…


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It is an quiet onsen resort which is located along the clear water of Shima River. The hot spring, which takes its name from the word "shima", meaning "40,000", is said to cure 40,000 types of illness. The traditional ambiance with a nostalgic charm is very popular among visitors. In recent years, Shima Onsen has become famous for its ryokan, which served as one of the models for the onsen ryokan in the full-length animated movie, "Spirited Away."
Source: http://www.visitgunma.jp


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Islamophobic comments made by the incumbent aimed at Dalia Kasseb probably played a role in Mike Floyd comfortably winning his Pearland ISD school race, and now we may have a replay happening in the runup to the June 10 Pearland mayoral and city council runoffs.
30 year old pharmacist Dalia Kasseb is making a historic run for a Pearland City Council seat as the first Muslim ever to run for office in Brazoria County. On May 6 topped a crowded field of candidates in the Position 7 council race to capture 41% of the vote to Owens 21%
She noted in a Houston Chronicle story that when they have met in person, he seemed cordial, but Owens' has been sharing anti- Muslim message and comments on his Facebook page,.
"Our few meetings have been very pleasant,"Kasseb said. "But for him to be sharing that stuff on Facebook shows what he really believes."
The controversy also has had an indirect impact on the Pearland mayor's race. Longtime Pearland Mayor Tom Reid is being challenged by 36 year old Quentin Wiltz, The 91 year old Reid has held the mayor's chair for a combined 34 years (1978-90, 1995-present), and publicly endorsed Owens on who served four terms on Pearland's city council, back on April 6.
Pearland is a fast growing southern suburb of Houston that has grown from a small town of less than 5,000 residents in the 1960's to over 130,000 people, and its population has tripled and gotten more diverse since 2000. It is currently 47% Anglo, 25% Latinx, 17% African American and 9% Asian .
But it seems as though some peeps either aren't aware of that or are being willfully ignorant about that fact, and the clock is ticking toward the June 10 conclusion of this runoff campaign.


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For an overview on travel beginning on or after April 1st, please review the CSUB Travel Policy.
Before you travel:
- American Express Corporate Card applications are available on our website under Travel Forms.
- The Travel Authorization Request Form should be completed and submitted to the appropriate administrator approving travel. This form authorizes the requestor to travel on official CSUB business. Once approved, the form must be attached to the travel claim.
- A Travel Advance may be requested to pay for registration fees directly to the vendor.
- A Charge Request Form - for rental car, local lodging or airfare. A Charge Request may be used to charge an airline ticket purchased through Uniglobe. The campus American Express business travel account (BTA) has been set up with Uniglobe, an authorized agency. All other authorized purchases or reservations must be made using your American Express Corporate Card to insure insurance coverage and reimbursement upon your return. Reimbursements will not be made for damage waivers.
- A defensive driving training course offered through CSUB Campus Safety must be completed once every 4 years if you drive on official state business more than one time in any given month.
- When making lodging reservations, inquire about a Claim for Exemption from Transient Occupancy Tax.
While you Travel:
- Meals will be reimbursed for actual expenses up to the daily maximum of $55.00 within the continuous 48 US States. Original itemized receipts are required for expenses of $25 or more. Incidentals will be reimbursed $7 per every 24 hour period (no receipts required), which starts on the second day. If traveling to Alaska, Hawaii, other US possessions, or out of the United States, the maximum daily allowance will be based on the Federal Per Diem Rates (http://www.defensetravel.dod.mil/site/perdiemCalc.cfm)
- Meal reimbursements for travel of less than 24 hours are reportable income.
Less than 12 hours:
- Breakfast - Reimburse if travel begins 2hrs before regular work hours (reportable as income).
- Lunch -- Not reimbursable.
- Dinner -- Reimburse if traveled 2 hours after regular work (reportable as income).
Less than 24 hours with overnight stay:
- Breakfast - Reimbursable (2nd day only)
- Lunch - Reimbursable
- Dinner - Reimbursable
- Lodging will be reimbursed based on length of stay and location:
- Less than 30 days
- Continental U.S., Alaska, Hawaii and U.S. Possessions - will be reimbursed for actual lodging costs with a maximum limit of $175.00 per night. Rates in excess of this amount must be pre-approved by a campus vice-president or designees in accordance with the campus approval process. Detailed folio must show a zero balance and last 4 digits of the credit card statement.
- International location - will be reimbursed based on Federal Per Diem rates by specific location.
- More than 30 days
- Continental U.S., Alaska, Hawaii and U.S. Possessions - will be reimbursed based on Federal Per Diem rates by specific location.
- International location - will be reimbursed based on per diem approved by authorized approver, up to 100% of Federal Per Diem rates by specific location.
Federal Per Diem rates are maintained by the Federal Department of Defense: http://www.defensetravel.dod.mil/site/perdiemCalc.cfm
- Less than 30 days
- The standard maximum mileage reimbursement rate is .575 cents per mile EFFECTIVE January 1, 2015.
- 56 cents per mile (January 1, 2012 thru December 31, 2014)
- Authorization To Use Privately-Owned Vehicles on State Business Form must be on file in the Accounting Office. No reimbursement will be made when the employee uses a privately owned motorcycle.
After you travel:
- If you do not have a receipt for any item over $25 additional documentation will be needed including your supervisors approval for the lost receipt.
- Fill out a Travel Expense Claim (Form 262) within 30 days after your return. Please submit all original itemized receipts for meals, lodging, airfare, car rental, gas, parking fees, etc. Provide a program, email invitation, agenda, flyer, or other document showing the purpose, location, and dates of the travel event.
- Travel Expense reimbursements take up 10 working days to process.
Good luck on your trip.
If you have specific issues you would like discussed contact either Accounts Payable (x6209) or Sally(x6207) by phone or email.
California State University, Bakersfield
9001 Stockdale Highway
Bakersfield, CA 93311
Phone: (661) 654-6209
Fax: (661) 654-2134
Office: Administration Building East
Hours: Mon-Fri 8:00 am to 5:00 pm