title: Super Bowl XV

text: Oakland became only the second wild card team to make it to the Super Bowl and the first to come away victorious. The Super Bowl IV champion Kansas City Chiefs are often thought of as a "wild-card team," but they were not; during 1969, the season before the 1970 AFL-NFL Merger, the second-place finishers in both divisions of the American Football League qualified for the playoffs. Flores became the first person to be a member of a Super Bowl winning team as a player and head coach. He was a member of the Chiefs in Super Bowl IV, but did not play in the game.


title: Super Bowl XV

text: Sources: NFL.com Super Bowl XV, Super Bowl XV Play Finder Oak, Super Bowl XV Play Finder Phi, Super Bowl XV Play by Play


title: Super Bowl XV

text: The following records were set in Super Bowl XV, according to the official NFL.com boxscore and the ProFootball reference.com game summary.


title: Super Bowl XV

text: Dooley, Graf, Kelleher and Veteri wore #7 at their respective officiating positions during 1979-81 (except Dooley was promoted to Referee for 1981, wearing #19), but Kelleher had priority on the number for the Super Bowl, due to his seniority. Kelleher and Veteri became the third and fourth officials to work four Super Bowls, joining Jack Fette and Stan Javie.


title: Exuma

text: The largest of the cays is Great Exuma, which is 37 mi (60 km) in length and joined to another island, Little Exuma, by a small bridge. The capital and largest town in the district is George Town (population 1,437). It was founded 1793 and located on Great Exuma. Near the town, but on Little Exuma, the Tropic of Cancer runs across Pelican Beach lending it another name: Tropic of Cancer Beach. Its white sand and turquoise waters make it a world-famous destination. The entire island chain is 130 mi (209 km) long and 72 sq mi (187 km²) in area. Great Exuma island has an area of 61 sq mi (158 km²) while Little Exuma has an area of 11 sq mi (29 km²).


title: Exuma

text: Between 2000 and 2010, the population of Exuma more than doubled, reflecting the construction of large and small resort properties and the related direct air traffic to Great Exuma from locations as distant as Toronto, Ontario, Canada. The population in 2010 was 6,928.


title: Exuma

text: Exuma was settled in or around 1783 by American colonial loyalists fleeing the Revolutionary War. The expatriates brought a cotton plantation economy to the islands. George Town was named in honour of George III, to whom the settlers maintained their loyalty. A few smaller cays still remain partially or wholly privately owned, albeit they are still referred to as part of the Exuma–Bahamas Cays; they are distinguished by a three-digit suffix number. The best known examples are adjoined cays Exuma 642 and 643, which are suffering from receding shorelines.


title: Exuma

text: John Rolle, 1st Baron Rolle, a Loyalist settler of the Exumas, is a major figure in the islands' heritage. Upon his death in 1842, he bestowed all of his significant Exuma land holdings to his slaves. As a result, towns on Great Exuma such as Rolleville and Rolletown were named after him.


title: Exuma

text: The islands are a popular spot for yachting, sailing, diving, and coral reef and cave exploring. Many of the unnamed beaches and coves of the islands, including extensive offshore reef areas, are included in the protected Exuma National Land and Sea Park or the Moriah Harbour Cay National Park of the Bahamas National Trust. Some of the islands on which there are permanent residents and resorts include Great Exuma, Little Exuma, Stocking Island, Staniel Cay (home of the Staniel Cay Yacht Club, a fixture in the Exumas), Fowl Cay, Musha Cay and Iguana Cay. Thunderball Grotto, located just a few hundred yards off Staniel Cay, is one location where the James Bond film "Thunderball" was filmed. Sandy Cay, just a short boat ride from Little Exuma was the location used for filming the "Pirates of the Caribbean" beach scenes and a Shell commercial. The novel "Wind from the Carolinas" was set in Great Exuma.


title: Exuma

text: The Exumas are the historic home of the Lucayan Natives, who were wholly enslaved in the 16th century, leaving the islands uninhabited until the 18th century. In the intervening period, the Exumas provided many hideouts and stashes for pirates. Elizabeth Harbour was allegedly a favorite lair of Captain Kidd.


title: Exuma

text: In 2017, it was the site of the Fyre Festival, a luxury music festival which became notorious online and in the media for its shambolic organization, and the numerous lawsuits that followed.


title: Exuma

text: Exuma International Airport serves the city of George Town directly from Nassau, Miami, Atlanta, Fort Lauderdale, Charlotte, and Toronto. Staniel Cay also has a small airstrip commercially served by charter or scheduled charter airlines. A number of other cays have small airstrips, both private and public. Boat travel from Nassau to the Northern Exuma Cays is approximately one hour.


title: Exuma

text: The Exumas are known for fresh food and cultural significance to The Bahamas. Sea life regularly caught for commercial purpose include barracuda, bonefish, conch, grouper, jack, lobster, marlin, sailfish, snapper, tarpon, tuna and wahoo.


title: Exuma

text: The George Town Fish Fry is a collection of businesses, some of which are only open at night serving a variety of cuisine. It is popular among local residents and tourists alike.


title: Exuma

text: The capital, George Town, is home to government offices, shops and services that serve both the traveling public and residents of the islands. As of 2020 there were 2 banks, a police station, 2 grocery stores, 3 liquor stores, a gas station and 1 hotel within the town proper although there are a few other businesses nearby that are typically associated as being in George Town due to proximity.


title: Exuma

text: There are a number of restaurants throughout Exuma, the majority of which serve variations of local cuisine, and a some that serve other cuisines such as Italian.


title: Exuma

text: Fishing is a part of both the local and tourism economies of Exuma. Visitors may fish on their own, hire a fishing guide or charter for sport while the local fishing economy primarily supports the local population's food supply. Locals can be often seen fishing from shore and bridges presumably for their own food, often using a hand line.


title: Exuma

text: Known as the "Grey Ghost", bonefish can be found in the flats areas covered by as little as one foot of water, or less. Their fair colouration is perfectly adapted as camouflage against the sandy ocean bottom, making the fish difficult to spot in spite of the clear Bahamian waters. Anglers may employ spin casting equipment, but more often opt for fly-fishing in their hunt for bonefish. Other flats fish targets may include permit and tarpon.


title: Exuma

text: Fishing in Exuma is primarily separated into two broad regions, the shallower southern or western side and the deep water of Exuma Sound, although some inshore fishing grounds exist such as in Moriah Harbour National Park. These areas are habitat for other types of fish including various snapper, grunts, jacks, grouper are possible to be caught throughout the fishing areas in Exuma while pelagic species like wahoo, mahi-mahi, barracuda, marlin, tuna, sailfish and more are primarily caught in Exuma Sound.


title: Exuma

text: The telephone area code for the island is 242, which is the same as the rest of the Bahamas. There are 2 main telecommunication providers that cover most of the Exuma cays, Aliv and BTC Bahamas.


title: Exuma

text: High-speed internet is available from both providers with varying technologies such as DSL, cellular and fiber optic cable becoming available.


title: Exuma

text: The annual Bahamian Music and Heritage Festival, Regattas, Junkanoo and various "homecoming" events held in smaller settlements are highly anticipated in The Exumas by tourists and islanders alike. These festivals may focus on the food, sailing competition, arts, and music of the local culture.


title: Exuma

text: Because the population is so tiny, there is a small traditional media industry. The Bahamas is served by many newspapers, radio stations and web sites, whereas the local media in George Town consists of The Blaze 98.3 FM. "The Chain" is a free newspaper published monthly and is the "one source for current and accurate information" on the chain of islands.


title: Exuma

text: Some books have been written about living in Exuma including Life on a Rock and This Sweet Place; Island Living and Other Adventures.


title: Exuma

text: St. John's Baptist Church was built in 1892; St. Theresa's Church was built in 1960; St. Andrews Anglican Parish is the oldest church in Georgetown.


title: Exuma

text: The Baptist church of Farmer's Hill ordained Rev. Stephen Smith in 2015. Rev. Smith 'superseded' Dr. Irvin Clarke Sr., who had been pastor for the previous 45 years. The culvert at Farmer's Hill is being repaired, with sustainable development by an islands construction company.


title: Exuma

text: Sandals Emerald Bay has an 18-hole golf course designed by professional golfer, Greg Norman. Emerald Bay hosts the Great Exuma Classic on the Web.com Tour.


title: Exuma

text: Sailing is a popular sport in Exuma and with many competitions year-round. The Family Island Regatta in George Town is a recurring event at the beginning of every year. Others include the George Town Cruising Regatta and Black Point Regatta.


title: Exuma

text: Rowing is being developed in Exuma with the aim of developing the island as an outlet for competitive and recreational rowing.


title: Exuma

text: The main island has been a haven for celebrities for years. Until recently, the tourist population on the island was extremely minimal, allowing anonymity for anyone escaping the spotlight. Frequent visitors included Princess Margaret, Countess of Snowdon, who stayed at the Goat Cay home of Babbie Holt, Jackie Onassis, Jessica Tandy and Hume Cronyn, and Sigourney Weaver, who vacationed there with her family. More recently, the islands were used by John McAfee, founder of McAfee Software, who conducted his brief 2020 presidential campaign from a boat moored in the harbour.


title: Exuma

text: The Bahamian tax structure may be an advantage for some with the desire to establish residency, while others may purchase homes for private use or investment. Some have purchased private islands, while others have purchased more common homes. A number of well known people own islands or residences in the Exumas. These include Aga Khan, Nicolas Cage, David Copperfield, Ali Daei, Johnny Depp, Faith Hill and Tim McGraw, Ali Karimi, Eddie Murphy, Eddie Irvine, Tyler Perry and Jena Sims.


title: Éliphas Lévi

text: Éliphas Lévi Zahed, born Alphonse Louis Constant (8 February 1810 – 31 May 1875), was a French esotericist, poet, and author of more than 20 books on magic, Kabbalah, alchemical studies, and occultism. He pursued an ecclesiastical career in the Catholic Church until, after great personal struggle, at the age of 26, he abandoned the Catholic priesthood. At the age of 40, he began professing knowledge of the occult, and becoming a reputed ceremonial magician.


title: Éliphas Lévi

text: The pen name "Éliphas Lévi", was a transliteration of his given names "Alphonse Louis" into Hebrew. Levi gained renown as an original thinker and writer, his works attracting attention in Paris and London among esotericists and artists of romantic or symbolist inspiration. He left the Grand Orient de France (the French Masonic organization that originated Continental Freemasonry) in the belief that the original meanings of its symbols and rituals had been lost. "I ceased being a freemason, at once, because the Freemasons, excommunicated by the Pope, did not believe in tolerating Catholicism ... [and] the essence of Freemasonry is the tolerance of all beliefs."


title: Éliphas Lévi

text: Many authors influenced Levi's political, occultic and literary development, such as the French monarchist Joseph de Maistre, whom he quotes in many parts of his "Dogme et Rituel de la Haute Magie", Paracelsus, Robert Fludd, Swedenborg, Fabre d'Olivet, the Rosicrucians, Plato, Raymond Lull, and other esoterics.


title: Éliphas Lévi

text: Constant was the son of a shoemaker in Paris. In 1832 he entered the seminary of Saint Sulpice to study to enter the Roman Catholic priesthood, as a sub-deacon he was responsible for catechism, later he was ordained a deacon, remaining a cleric for the rest of his life. One week before being ordained to the priesthood, he decided to leave the priestly path, however the spirit of charity and the life he had in the seminary stayed with him through the rest of his life, later he wrote that he had acquired an understanding of faith and science without conflicts.


title: Éliphas Lévi

text: In 1836, on leaving the priestly path, he provoked his superiors' anger. He had committed to permanent vows of chastity and obedience as a sub-deacon and deacon, so returning to civil life was particularly painful for him; he continued to wear the clerical clothes, the cassocks, until 1844.


title: Éliphas Lévi

text: The possible reasons that saw Levi's departure from the Saint-Sulpice seminary, in 1836, are expressed in the following quote, by A. E. Waite: "He [Levi] seems, however, to have conceived strange views on doctrinal subjects, though no particulars are forthcoming, and, being deficient in gifts of silence, the displeasure of authority was marked by various checks, ending finally in his expulsion from the Seminary. Such is one story at least, but an alternative says more simply that he relinquished the sacerdotal career in consequence of doubts and scruples."


title: Éliphas Lévi

text: He had to obviate extreme poverty by working as a tutor in Paris. Around 1838, he met and was influenced by the views of the mystic Simon Ganneau, and it may have been through Ganneau's meetings that he also met Flora Tristan. In 1839 he entered the monastic life in the Abbey of Solesmes, but he could not maintain the discipline so he quit the monastery.


title: Éliphas Lévi

text: Upon returning to Paris, he wrote, "La Bible de la liberté" (The Bible of Liberty), which resulted in his imprisonment in August 1841.


title: Éliphas Lévi

text: The Eliphas Levi Circle ("(Association law 1901) was set up on April 1 1975") gives the following summary of Levi's marriage and paternity: "At the age of 32 he met two young girls who were friends, Eugénie C and Noémie Cadiot. Despite his preference for Eugenie he also fell under the spell of Noémie whom he was obliged to marry in 1846 in order to avoid a confrontation with the girl’s father. Seven years later Noémie ran away from the marital home to join the marquis of Montferriet and in 1865 the marriage was annulled. Several children issued from this marriage, in particular twins who died shortly after birth. None of these children reached adult age, little Marie for example, who died when she was seven. Lévi had an illegitimate son with Eugénie C, born 29 September 1846, but the child never bore Lévi’s name. However he did know his father, who saw that he was educated. We know from reliable sources that the descendants of this son are living among us in France today."


title: Éliphas Lévi

text: Writing at the beginning of the 20th century, A. E. Waite depicts Levi's marriage, perished offspring, and (possible) violation of the Saint Sulpice seminary rule, as follows:


title: Éliphas Lévi

text: Unexpectedly, in 1850, at the age of 40, Levi succumbed to a period of heightened financial and spiritual crisis, leading him, more profoundly, to find refuge in the milieu of mid-19th-century esotericism and the occult.


title: Éliphas Lévi

text: In December 1851, Napoleon III organized a coup that would end the Second Republic and give rise to the Second Empire. Constant saw the emperor as the defender of the people and the restorer of public order. In the "Moniteur parisien" of 1852, Constant praised the new government's actions, but he soon became disillusioned with the rigid dictatorship and was eventually imprisoned in 1855 for publishing a polemical chanson against the Emperor. What had changed, however, was Constant's attitude towards "the people." As early as in "La Fête-Dieu" and "Le livre des larmes" from 1845, he had been skeptical of the uneducated people's ability to emancipate themselves. Similar to the Saint-Simonians, he had adopted the theocratic ideas of Joseph de Maistre in order to call for the establishment of a "spiritual authority" led by an élite class of priests. After the disaster of 1849, he was completely convinced that the "masses" were not able to establish a harmonious order and needed instruction.


title: Éliphas Lévi

text: Constant's activities reflect the struggle to come to terms, both with the failure of 1848 and the tough repressions by the new government. He participated on the "Revue philosophique et religieuse", founded by his old friend Fauvety, wherein he propagated his "Kabbalistic" ideas, for the first time in public, in 1855-1856 (notably using his civil name).


title: Éliphas Lévi

text: Lévi began to write "Histoire de la magie" in 1860. The following year, in 1861, he published a sequel to "Dogme et rituel", "La clef des grands mystères" ("The Key to the Great Mysteries"). In 1861 Lévi revisited London. Further magical works by Lévi include "Fables et symboles" ("Stories and Images"), 1862, "Le sorcier de Meudon" ("The Wizard of Meudon", an extended edition of two novels originally published in 1847) 1861, and "La science des esprits" ("The Science of Spirits"), 1865. In 1868, he wrote "Le grand arcane, ou l'occultisme Dévoilé" ("The Great Secret, or Occultism Unveiled"); this, however, was only published posthumously in 1898.


title: Éliphas Lévi

text: The thesis of magic propagated by Éliphas Lévi was of significant renown, especially after his death. That Spiritualism was popular on both sides of the Atlantic from the 1850s contributed to this success. However, Lévi diverged from spiritualism and criticized it, because he believed only mental images and "astral forces" persisted after an individual died, which could be freely manipulated by skilled magicians, unlike the autonomous spirits that Spiritualism posited.


title: Éliphas Lévi

text: In regard to the purported supernatural occurrences reported by the practitioners of spiritualism, Levi was obviously credulous. He explained: "The phenomena which quite recently have perturbed America and Europe, those of table-turning and fluidic manifestations, are simply magnetic currents at the beginning of their formation, appeals on the part of Nature inviting us, for the good of humanity, to reconstitute great sympathetic and religious chains."


title: Éliphas Lévi

text: His magical teachings were free from obvious fanaticisms, even if they remained rather obscure; and he had nothing to sell (notwithstanding his publications). He did profess himself to be: "A poor and obscure scholar [who] has found the lever of Archimedes, and he offers it to you for the good of humanity alone, asking nothing whatsoever in exchange." He did not pretend to be the initiate of some ancient or fictitious secret society. He incorporated the Tarot cards into his magical system, and as a result the Tarot has been an important part of the paraphernalia of Western magicians.


title: Éliphas Lévi

text: He had a deep impact on the magic of the Hermetic Order of the Golden Dawn and later on ex–Golden Dawn member Aleister Crowley. He was also the first to declare that a pentagram or five-pointed star with one point down and two points up represents evil, while a pentagram with one point up and two points down represents good. Lévi's ideas also influenced Helena Blavatsky and the Theosophical Society.


title: Éliphas Lévi

text: Of his initial experience with British esotericists, in 1854, Levi wrote: "I had undertaken a journey to London, that I might escape from internal disquietude and devote myself, without interruption, to science. [...] They asked me forthwith to work wonders, as if I were a charlatan, and I was somewhat discouraged, for, to speak frankly, far from being inclined to initiate others into the mysteries of Ceremonial Magic, I had shrunk all along from its illusions and weariness. Moreover, such ceremonies necessitated an equipment which would be expensive and hard to collect. I buried myself therefore in the study of the transcendent Kabalah, and troubled no further about English adepts."


title: Éliphas Lévi

text: It did not take long after his arrival in England, however, before his skills as a reputed magus were earnestly courted; and Levi obliged: An elderly British woman, who, on the agreement to strictest secrecy, "rigorous amongst adepts," provided him with "a complete magical cabinet" containing the necessary paraphernalia to apply his theories to the practice of magic in England.


title: Éliphas Lévi

text: In the preface to "The History of Magic" (translator, A. E. Waite), enumerates (what he believed to be) the nine key tenets of magic as codified in Levi's earlier work, "Doctrine and Ritual of Transcendental Magic".


title: Éliphas Lévi

text: The three chief components of Levi's magical thesis were: Astral Light, the Will and the Imagination. Levi did not originate any of these as occult concepts.


title: Éliphas Lévi

text: Concerning the "Astral Light", Waite noted: "the Astral Light, which is neither more nor less than the odylic force of Baron Carl Reichenbach, as the French writer [Levi] himself admits substantially, [...]" and: "This force he [Levi] usually terms the Astral Light, a name which is borrowed from Saint-Martin and the French mystics of the eighteenth century."


title: Éliphas Lévi

text: "Astral Light" was also indebted to the ideas of 18th-century proto-hypnotist, Franz Mesmer: "[Mesmer] evolved the theory of “animal magnetism.” This he held to be a fluid which pervades the universe, but is most active in the human nervous organization, and enables one man, charged with the fluid, to exert a powerful influence over another."


title: Éliphas Lévi

text: Astral is an adjective meaning: "Connected to, consisting of, stars." Levi used the term "Astral", not only as a synonym for "psychic force", but because he believed in the ancient and medieval practice of astrology. As Levi wrote himself: "Nothing is indifferent in Nature, a pebble more or less upon a road may crush or profoundly alter the fortunes of the greatest men and even of the greatest empires, much more then the position of a particular star can not be indifferent to the destinies of the child who is being, and who enters by the fact of his birth into the universal harmony of the sidereal [astrological] world."


title: Éliphas Lévi

text: "Will" and "Imagination", as magical agents, were asserted three centuries before Levi, by Paracelsus:


title: Éliphas Lévi

text: Eliphas Levi cautioned: "The operations of [magic] science are not devoid of danger. Their result may be madness for those who are not established on the base of the supreme, absolute, and infallible reason. They may over-excite the nervous system, producing terrible and incurable diseases." "Let those, therefore, who seek in magic the means to satisfy their passions, pause in that deadly path, where they will find nothing but death or madness. This is the significance of the vulgar tradition that the devil finished sooner or later by strangling the sorcerers."


title: Éliphas Lévi

text: It was long believed that the socialist Constant disappeared with the demise of the Second Republic and gave way to the occultist Éliphas Lévi. However, according to Julian Strube, this narrative was constructed at the end of the 19th century in occultist circles and was uncritically adopted by later scholars. Strube argues that Constant not only developed his "occultism" as a direct consequence of his socialist and post-clergical ideas, but he continued to propagate the realization of "true socialism" throughout his entire life.


title: Éliphas Lévi

text: According to the occultist Papus (Gérard Encausse) and the occultist biographer Paul Chacornac, Constant's turn to occultism was the result of an "initiation" by the eccentric Polish expatriate Józef Maria Hoene-Wroński. The two did know each other, as evidenced in Constant's 6 January 1853 letter to Hoene-Wroński, thanking him for including one of Constant's articles in Hoené-Wroński's 1852 work, "Historiosophie ou science de l’histoire". In the letter Constant expresses his admiration for Hoené-Wroński's "still underappreciated genius" and calls himself his "sincere admirer and devoted disciple." Nonetheless, Strube argues that Wronski's influence had been brief, between 1852 and 1853, and superficial. He criticizes Papus and his companions' research based on Papus' attempts to contact Constant on 11 January 1886 - 11 years after Constant's death.


title: Éliphas Lévi

text: Later on, the construction of a specifically French esoteric tradition, in which Constant was to form a crucial link, perpetuated this idea of a clear rupture between the socialist Constant and the occultist Lévi. Strube in 2016 wrote that a different narrative was developed independently by Arthur Edward Waite, who was a near contemporary of Lévi. Strube opined that A. E. Waite knew insufficient details of Constant's life.


title: Éliphas Lévi

text: Furthermore, Strube proposes that Lévi contemplated "magic" as a "new order" - an ideology (potentially a politically useful superstition (?)) by which a new hierarchy would be articulated, as he interpret from Levi's statement: "Hereunto therefore we have made it plain, as we believe, that our Magic is opposed to the goetic and necromantic kinds. It is at once an absolute science and religion, which should not indeed destroy and absorb all opinions and all forms of worship, but should regenerate and direct them by reconstituting the circle of initiates, and thus providing the blind masses with wise and clear-seeing leaders." Strube argues that "A journey to London that Lévi made in May 1854, did not cause his preoccupation with magic", and that "even though Lévi professed involvement in magical ritual. Instead, it was the aforementioned socialist-magnetistic dialectic that compassed Lévi's interest in magic.". Despite so, it is clear that Lévi's statement limits itself to magic and its kinds, where Lévi proposes to have merged science and religion and promotes his own methods by claiming to have applied a scientific approach in his research, contrasting it against the Goetic and Necromantic methods.


title: Paul Bremer

text: Lewis Paul Bremer III (born September 30, 1941) is an American diplomat. He led the Coalition Provisional Authority (CPA) following the 2003 invasion of Iraq by the United States, from May 2003 until June 2004.


title: Paul Bremer

text: Born on September 30, 1941, in Hartford, Connecticut, Bremer was educated at New Canaan Country School, Kent School, and Phillips Academy Andover. Bremer's father was president of the Christian Dior Perfumes Corporation in New York and his mother was a lecturer in art history at the University of Bridgeport.


title: Paul Bremer

text: Bremer graduated from Yale University in 1963 and went on to earn an MBA from Harvard University in 1966. He later continued his education at the Institut d'études politiques de Paris, where he earned a Certificate of Political Studies (CEP).


title: Paul Bremer

text: That same year he joined the Foreign Service, which sent him first to Kabul, Afghanistan, as a general services officer. He was assigned to Blantyre, Malawi, as economic and commercial officer from 1968 to 1971.


title: Paul Bremer

text: During the 1970s, Bremer held various domestic posts with the U.S. State Department, including posts as an assistant to Henry Kissinger from 1972 to 1976. He accompanied Kissinger on shuttle diplomacy missions to Israel, Syria, and Egypt to resolve the Yom Kippur War in 1973. He was Deputy Chief of Mission in Oslo, Norway, from 1976 to 1979, returning to the United States to take a post of Deputy Executive Secretary of the Department of State, where he remained from 1979 until 1981. In 1981, he was promoted to Executive Secretary and Special Assistant to Alexander Haig.


title: Paul Bremer

text: Ronald Reagan appointed Bremer as Ambassador to the Netherlands in 1983 and Ambassador-at-Large for Counterterrorism and Coordinator for Counterterrorism in 1986.


title: Paul Bremer

text: Bremer retired from the Foreign Service in 1989 and became managing director at Kissinger and Associates, a worldwide consulting firm founded by Henry Kissinger. A career member of the Senior Foreign Service, class of Career Minister, Bremer received the State Department Superior Honor Award, two Presidential Meritorious Service Awards, and the Distinguished Honor Award from the Secretary of State. Before rejoining government in 2003, he was chairman and CEO of Marsh Crisis Consulting, a risk and insurance services firm which is a subsidiary of Marsh & McLennan Companies.


title: Paul Bremer

text: He also served as a trustee on the Economic Club of New York, and a board member of Air Products and Chemicals, Inc., Akzo Nobel NV, the Harvard Business School Club of New York and the Netherland-America Foundation. He served on the International Advisory Boards of Komatsu Corporation and Chugai Pharmaceuticals.


title: Paul Bremer

text: Bremer and 1,700 of the employees of Marsh & McLennan had offices in the World Trade Center. Bremer's office was in the North Tower. In an interview with CNN after the September 11 attacks, he stated that their office was located "above where the second aircraft hit". On September 11, he was interviewed in Washington on WRC-TV at 12:30pm in-studio.


title: Paul Bremer

text: Bremer and his wife were the founders of the Lincoln/Douglass Scholarship Foundation, a Washington-based nonprofit that provides high school scholarships to inner-city youths.


title: Paul Bremer

text: Bremer was appointed Chairman of the National Commission on Terrorism by House Speaker Dennis Hastert in 1999. The report, "Countering The Changing Threat of International Terrorism", was published in June 2000. He also served on the National Academy of Sciences' Committee on Science and Technology for Countering Terrorism, which authored a 2002 report called "Making the Nation Safer: The Role of Science and Technology in Countering Terrorism".


title: Paul Bremer

text: Bremer was appointed by President Bush as Presidential Envoy to Iraq on May 9, 2003. His appointment declared him subject to the "authority, direction and control" of Secretary of Defense Donald Rumsfeld.


title: Paul Bremer

text: Bremer arrived in Iraq in May 2003. On May 11 he replaced Lt. General Jay Garner as Director of the Office for Reconstruction and Humanitarian Assistance. In June, the Office was transformed into the Coalition Provisional Authority, and Bremer became the country's chief executive authority. As the holder of the "most powerful foreign post held by any American since Gen. Douglas MacArthur in Japan", he compared himself to MacArthur as well as General Lucius Clay, who was in charge of the American zone in Germany following its defeat in World War II.


title: Paul Bremer

text: As the top civilian administrator of the Coalition Provisional Authority, Bremer was permitted to rule by decree. Among his first and most notable decrees were Coalition Provisional Authority Order 1, which banned the Ba'ath party in all forms and Coalition Provisional Authority Order 2, which dismantled the Iraqi Army.


title: Paul Bremer

text: On July 13, 2003, Bremer approved the creation of an Iraqi Interim Governing Council with the stated mission of "ensuring that the Iraqi people's interests are represented." The council members were chosen by Bremer from among groups and individuals which had supported the American invasion of Iraq. Bremer retained veto power over the council's proposals. The council was authorized to select a limited number of delegates to key Coalition Provisional Authority committees, like the Program Review Board.


title: Paul Bremer

text: Bremer also empowered the CPA to develop and implement the Iraqi constitution. The constitution became controversial when the first draft submitted by the CPA suggested banning political parties opposed to the U.S. occupation from participating in elections; privatizing much of Iraq's industries and natural resources; and allowing the unelected Iraqi Interim Governing Council to sign a binding Status of Forces Agreement between Iraq and the United States. On March 1, 2004, after several hours of negotiations, the Iraqi Interim Governing Council resolved the council members' disagreements with clauses in the constitution. A formal signing ceremony was scheduled for March 5, 2004. As the guests waited and the orchestra played, the signing was canceled due to mass demonstrations. Finally, on March 8, 2004, an interim constitution was signed. It was to be revised or replaced by a second constitution after Iraqi elections.


title: Paul Bremer

text: On June 28, 2004, at 10:26 am local time, the U.S.-led Coalition Provisional Authority formally transferred limited sovereignty of Iraqi territory to the Iraqi Interim Government, two days ahead of schedule. Bremer departed from the country on the same day. In his farewell speech, broadcast on Iraqi television, he said, "I leave Iraq gladdened by what has been accomplished and confident that your future is full of hope. A piece of my heart will always remain here in the beautiful land between the two rivers, with its fertile valleys, its majestic mountains and its wonderful people".


title: Paul Bremer

text: Bremer's office was a division of the U.S. Department of Defense, and as Administrator he reported directly to the United States Secretary of Defense and the President of the United States. His senior adviser Dan Senor served as coalition spokesman, working with military spokesman Mark Kimmitt.


title: Paul Bremer

text: Bremer's role as the head of the CPA is notable for being the subject of much criticism. Large sums of money have been reported to have gone missing under Bremer's leadership. Bremer's attempts at privatizing much of Iraq's infrastructure and mineral wealth were also highly criticized and the decision, apparently formulated in the office of the Secretary of Defense, to disband the Iraqi Army is widely blamed for fueling the Iraqi insurgency against the American occupation.


title: Paul Bremer

text: After his return from Iraq, Bremer engaged in a few speaking tours. On December 14, 2004, Bremer was awarded the Presidential Medal of Freedom by President Bush, America's highest civil award for "especially meritorious contributions to the security or national interests of the United States, to world peace, or to cultural or other significant public or private endeavors". "He was also presented with the Department of Defense award for Distinguished Public Service and the Nixon Library honored him with the "Victory of Freedom Award" for "demonstrating leadership and working towards peace and freedom".


title: Paul Bremer

text: Bremer's April 18, 2005, visit to Clark University as a guest speaker led to protests against his role in the Iraq War. Dissatisfied with Bremer's speech and answers, several students also voiced disappointment at the university for having paid him $40,000. Another appearance, scheduled for the public library of his hometown, New Canaan, Connecticut, on January 18, 2006, was moved to the private St. Luke's School in the same town for fear for protests. During a February 27, 2006 public appearance at Lynchburg College, where his sister-in-law is an assistant dean, Bremer insisted that his decision to disband the Iraqi Armed Forces was the correct one.


title: Paul Bremer

text: Among other things, Bremer repeatedly asserted that when he came to Iraq, the Iraqi army had abandoned its barracks, and therefore "there was no army to disband". He also repeatedly defended his decision to expel Ba'ath Party members from government posts by comparing Saddam Hussein to Adolf Hitler.


title: Paul Bremer

text: On February 6, 2007, Bremer appeared before a congressional committee investigating fraud and abuse and was questioned about missing funds during his tenure as head of the CPA and a January 2005 audit that found $8.8 billion in unaccounted for funds.


title: Paul Bremer

text: In 2006 Bremer published a memoir called "My Year in Iraq: The Struggle to Build a Future of Hope", which has been described as "an almost day-by-day narrative that sticks to what Bremer was doing and with whom he was interacting, without providing much analysis or introspection". Michiko Kakutani of "The New York Times" characterized it as "an amalgam of spin and sincerity, is partly an explanation (or rationalization) of actions Mr. Bremer took as America's man in Baghdad, partly an effort to issue some 'I told you so's' to administration colleagues, and partly an attempt to spread (or reassign) responsibility (or blame) by tracing just who in the White House, Pentagon and State Department signed off on or ordered critical decisions made during his tenure".


title: Paul Bremer

text: His media commentary is generally critical of the Obama administration for not devoting more effort to promoting democracy overseas. He is also a consistent advocate for continued U.S. presence in Iraq. On the other hand, while many other conservatives began advocating for a withdrawal from Afghanistan, Bremer endorsed the administration's new strategy in 2010, describing it as "reasonable" and giving Obama "credit for deciding to replicate President Bush's Iraq strategy by sending more troops to the fight in Afghanistan". He has also endorsed Samuel P. Huntington's "clash of civilizations" thesis, stating: "It is a fact of history that Europe is based on Judeo-Christian values. But Europe seems unwilling, or perhaps afraid, to acknowledge this reality."


title: Paul Bremer

text: After taking art lessons at a school in Glen Echo, Maryland, in 2007, Bremer began doing oil paintings of New England country landscapes, which he sells through his company Bremer Enterprises. What he sells proceeds to the historical societies of Chester and Grafton in Vermont, where he moved after his public retirement. He has self-mockingly described his style of painting as "evolving American primitive".


title: Paul Bremer

text: The Bremer Enterprises website also provides links to books by Bremer and his wife Frances Winfield Bremer. In addition to his 2006 memoir, in September 2011 Bremer published "From Sea to Shining Sea: Biking Across America with Wounded Warriors", on Amazon.com's Kindle platform via Bremer Enterprises.


title: Paul Bremer

text: During his time in Iraq, he opened the country's first ski resort. Bremer has worked for several seasons as a ski instructor at Okemo Mountain Resort in Vermont.


title: Paul Bremer

text: He also engages in consulting work and serves on a number of boards. Bremer currently serves on the board of directors of BlastGard International, a Florida-based company that manufactures materials to mitigate the impact of explosions.


title: Paul Bremer

text: In November 2010, Bremer joined World T.E.A.M. Sports, a Holbrook, New York-based nonprofit, as CEO and President. Bremer also served as a member of the organization's board of directors. He retired from the organization in March 2012 and as of 2015 was listed as a 'Special Advisor'.


title: Paul Bremer

text: Bremer formerly served as a member of the board of directors of the International Republican Institute.


title: Paul Bremer

text: Bremer appears in a viral internet meme, where his phrase "Ladies and gentlemen, we got him" following the capture of Saddam Hussein is used to accompany someone getting 'busted' or exposed, often with Breakbot's "Baby I'm Yours" playing in the background. After his granddaughter informed him of the trend, he was fascinated by it and hoped it would increase people's interest in Iraq's recent events.


title: Paul Bremer

text: On May 23, 2003, Bremer issued "Order Number 2", in effect dissolving the entire former Iraqi army and putting 400,000 former Iraqi soldiers out of work.


title: Paul Bremer

text: The move was widely criticized for creating a large pool of armed and disgruntled youths for the insurgency. Former soldiers took to the streets in mass protests to demand back pay. Many of them threatened violence if their demands were not met.


title: Paul Bremer

text: It was widely asserted within the White House and the CPA that the order to disband the Iraqi Army had little to no practical effect, since it had "self-demobilized" in the face of the oncoming invasion force.


title: Paul Bremer

text: Bremer was later heavily criticized for officially disbanding the former Iraqi Army. Bremer, however, contends that there were no armies to disband, despite the fact that American commanders at that time were negotiating with senior Iraqi army officers on how to use the Iraqi army for security purposes. He claimed that many soldiers simply left after the fall of Baghdad; some to protect their own families from the rampant looting. Critics claimed his extreme measures, including the firing of thousands of school teachers and removing Ba'ath Party members from top government positions, helped create and worsen an atmosphere of discontent. As the insurgency grew stronger, so did the criticisms. Bremer was also in personal danger because of Iraqi perceptions of him and was henceforth heavily guarded. Attempts to assassinate him took place on numerous occasions—one of the more publicized events occurred on December 6, 2003, when his convoy was driving on the dangerous Baghdad Airport Road while returning to the fortified Green Zone. The convoy was hit by a bomb and gunfire, with the rear window of his official car blown away and as bullets flew, Bremer and his deputies ducked below their seats. No injuries or casualties were reported and news of the attack on Bremer was not released until December 19, 2003, during his visit to Basra.


title: Paul Bremer

text: During Bremer's stay in Iraq, Osama bin Laden allegedly placed a bounty of 10,000 grams of gold on Bremer, the equivalent of US$125,000 at the time.


title: Paul Bremer

text: Despite the messages the CIA reportedly communicated to the Iraqi army, the argument was still ventured that by the time Baghdad fell on April 9, 2003, the previous Army had demobilized, or as Bremer puts it, "had simply dissolved". However, as Mark Danner reports in an essay in "The New York Review of Books" entitled "Iraq: The War of Imagination" and dated September 21, 2006, American agents—including one colonel and a number of CIA operatives—had already begun meeting regularly with Iraqi officers in order to reconstitute the army as a working force. Implied in this is the notion that the army, temporarily "demobilized" or not, did in fact continue to exist as a coherent entity, indeed coherent enough that it could be consulted and negotiated with. This seems to concur with the position of the first Director of the Office of Reconstruction and Humanitarian Assistance (ORHA), retired U.S. Army Lieutenant General Jay Garner, who Bremer had replaced. As Bob Woodward reports in "State of Denial", Garner, upon hearing of the order to disband the army, attempted to convince Bremer to rethink the dissolution. Bremer was reported as saying: "The plans have changed. The thought is we don't want the residuals of the old army. We want a new and fresh army." To this, Garner replied: "Jerry, you can get rid of an army in a day, but it takes years to build one."


title: Paul Bremer

text: The issue of disbanding the old Iraqi Army found itself, once again, the center of media attention with two articles explaining why Bremer ostensibly did not make the decision on his own. The first press release by "The New York Times" included a letter written by Bremer to President Bush dated May 20, 2003, describing the progress made so far since Bremer's arrival in Baghdad, including one sentence that reads "I will parallel this step with an even more robust measure dissolving Saddam's military and intelligence structures to emphasize that we mean business."


title: Paul Bremer

text: The second press release dated September 6, 2007, was submitted by Bremer as a "New York Times" op-ed. Titled "How I Didn't Dismantle Iraq's Army", Bremer says he did not make the decision on his own, and that the decision was reviewed by "top civilian and military members of the American government" including the then-USCENTCOM Commander, General John Abizaid, who briefed officials in Washington that there were no more "organized Iraqi military units".


title: Paul Bremer

text: Bremer's article goes into further detail about how the Coalition Provisional Authority considered two alternatives: To recall the old army or to rebuild a new army with "both vetted members of the old army and new recruits". According to Bremer, Abizaid preferred the second.


title: Paul Bremer

text: Bremer also details the situation he and the major decision makers faced; especially when the large Shiite majority in the new army could have had problems with the thought of having a former Sunni officer issuing orders.


title: Paul Bremer

text: Furthermore, a memo from U.S. Secretary of Defense Donald Rumsfeld on May 8, 2003, that said "the coalition 'will actively oppose Saddam Hussein's old enforcers—the Baath Party, Fedayeen Saddam, etc ... 'we will make clear that the coalition will eliminate the remnants of Saddam's regime'" was sent to both National Security Adviser Condoleezza Rice and Secretary of State Colin Powell.


title: Paul Bremer

text: After two protesters were killed by U.S. troops, the CPA agreed to pay up to 250,000 former soldiers a stipend of $50 to $150 a month. Conscripts were given a single severance payment. Many of the former soldiers found this to be grossly inadequate.


title: Paul Bremer

text: Charles H. Ferguson, director of critically acclaimed "No End in Sight", created a video response to Bremer's op-ed on September 6, 2007. (This was the very first "New York Times" video op-ed in history.)


title: Paul Bremer

text: Saddam Hussein's ruling Ba'ath Party counted among its members a majority of Iraq's governmental employees, including educational officials and some teachers, though as of 2003 members of the Ba'ath Party had constituted only around 10% of the Iraqi population. By order of the CPA, the top 1% of Iraqi Ba'ath Party members were forbidden from holding government positions, but were still permitted to open businesses and work at newspapers, and all public sector employees affiliated with the Ba'ath Party were to be removed from their positions and be banned from any future employment in the public sector. When the CPA turned over enforcement of de-Ba'athification to Iraqi politicians, however, these rules were broadly expanded and used to punish political opponents, including nearly 11,000 teachers who were dismissed from the party and removed from government—a phenomenon which Bremer worked with the then-Education Minister to fix. Critics claim these measures helped to create and worsen an atmosphere of discontent among Iraqis and that de-Ba'athification, coupled with the disbandment of the Iraqi military, if not created then at least fueled the insurgency against Coalition Forces. This policy of "de-Ba'athification" was reversed in January 2008.


title: Paul Bremer

text: Bremer was once again warned of the harm his actions would have. According to Woodward, when Garner asserted that none of the ministries would be able to function after this order, Bremer asked the Baghdad station chief for his thoughts. "If you put this out ... you will put 50,000 people on the street, underground, and mad at Americans", he replied. Woodward: "And these 50,000 were the most powerful, well-connected elites from all walks of life".


title: Paul Bremer

text: Bremer was accountable to the Secretary of Defense for the actions he took. But, since his authority spent Iraq's oil revenue derived from United Nations Resolution 1483, he was also accountable to the United Nations. The authority he derived from the UN to spend Iraq's oil revenue bound him to show that:


title: Paul Bremer

text: One of the concerns the IAMB raised repeatedly was that the CPA had repaired the well-heads and pipelines for transporting Iraq's oil, but they had stalled on repairing the meters that were necessary to document the shipment of Iraqi oil, so it could be demonstrated that none of it was being smuggled.


title: Paul Bremer

text: The CPA has acknowledged that the failure to meter the oil shipments resulted in some oil smuggling—an avoidable loss of Iraq's oil that was Bremer's responsibility. Neither Bremer nor any of his staff has offered an explanation for their failure to repair the meters.


title: Paul Bremer

text: Under Bremer's stewardship the CPA requested $12 billion in cash from the U.S. Treasury. Under Bremer's stewardship the CPA paid out $12 billion in cash. The external auditors management notes point out that the CPA didn't perform a cash reconciliation until April 2004, eleven months into Bremer's mandate, when they started their work. See Congressional hearing when Ambassador Paul Bremer and Stuart Bowen, the Special Inspector General for Iraq Reconstruction, testified on management of U.S. funds in Iraq.


title: Paul Bremer

text: In his second regulation, Bremer committed the Coalition Provisional Authority to hire a reputable firm of certified chartered accountants, to serve as internal auditors, to help make sure the Coalition's finances were administered according to modern accounting principles. These internal auditors would be separate and distinct from the external auditors who would report to the International Advisory and Monitoring Board. Bremer did not make sure the CPA hired internal auditors, however.


title: Paul Bremer

text: When the external auditors arrived, they learned that Bremer had not made sure the CPA lived up to the commitment to hire internal auditors to help set up a reliable accounting system. On the contrary they learned that a single contracted consultant kept track of the CPA's expenditures in a series of spreadsheets.


title: Paul Bremer

text: The external auditors reported that rather than use a modern double entry accounting system the CPA used what they described as "a single-entry, cash-based transaction list".


title: Paul Bremer

text: On January 30, 2005, an official report by Special Inspector General for Iraq Reconstruction Stuart Bowen cited by "Time" stated that $9 billion for the reconstruction of Iraq might have disappeared in fraud, corruption, and other misbehavior. On one particular salary register, only 602 names among 8,206 could be verified. As another cited example, the Coalition Authority authorized Iraqi officials to postpone declaring the reception of $2.5 billion, which the provisional government had received in spring through the Oil for Food program.


title: Paul Bremer

text: Bremer wrote an eight-page reply to deny the accusations and stated that, during the IG's inquiry, Bowen's people refused to interview Bremer's deputies, and the IG's report failed to mention that Bremer and his people worked under extraordinary conditions, faced a high turnover rate, and had insufficient number of personnel to carry out their rebuilding and humanitarian relief efforts.


title: Paul Bremer

text: Bremer's claim that Bowen's staff made no attempt to interview his staff is at odds with the detailed account of the external auditors, of their attempts to meet with Bremer and his staff. In their management notes they describe how some of the CPA's senior staff, including Bremer himself, just would not make themselves available to meet with the auditors. Others, like George Wolfe, the CPA's de facto treasurer, showed a total lack of cooperation.


title: Paul Bremer

text: This issue also became a topic of discussion during some of Bremer's Q&A sessions with students who attended Bremer's presentations during Bremer's campus speaking tours. Some questioned Bremer if he could have done things differently in Iraq, but were notably disappointed when he avoided the question. Bremer allegedly responded to one such question with, "I will tell you what I told them, I'm saving that for my book ... I need more time to reflect".


title: Paul Bremer

text: One of the CPA's most important tasks was the reconstruction of Iraq's infrastructure. Compared to the rapid repair of Iraq's oil infrastructure – with the notable exception of the meters—the progress of reconstruction on Iraq's potable water, sewage, and electricity systems was extremely slow. Defenders argued that this was due to the unanticipated volume and fierceness of those resisting the Coalition's occupation. Critics blame the CPA's preference for contracts with connected US firms; only 2% of the reconstruction contracts in 2003 were awarded to Iraqi firms.


title: Paul Bremer

text: On March 28, 2004, Bremer ordered the 759th Military Police Battalion to shut down controversial Iraqi newspaper "al-Hawza" for two months. This move was widely criticized as running directly counter to the Bush administration's announced goal of helping transform Iraq into a modern, democratic state. This move was even criticized by members of Bremer's own appointees on the Iraqi Governing Council.


title: Paul Bremer

text: "Al-Hawza" started after the removal of Saddam Hussein and was considered a mouthpiece for Shi'ite cleric Muqtada al-Sadr. It was shut down by the United States-led administration headed by Bremer on March 28, 2004, after being accused of encouraging violence against Coalition troops. There was discussion with Sir Jeremy Greenstock (UK's Special Representative for Iraq), about preparations to arrest al-Sadr, who by early March 2004 had increased his militia following, the Mahdi army, from about 200 followers to some 6,000, in seven months. Bremer wrote in his book that "Greenstock said that this would be a difficult time to go after him ... I first urged [his] arrest last August".


title: Paul Bremer

text: Iyad Allawi, leader of the interim government, explicitly gave "al-Hawza" permission to re-open on July 18, 2004.


title: Paul Bremer

text: Two days before he left Iraq, Bremer signed Coalition Provisional Authority Order 17, which gave everyone associated with the CPA and the American government immunity from Iraqi law. One of his former top aides is quoted as saying that Bremer "wanted to make sure our military, civilians and contractors were protected from Iraqi law." This stipulation was later incorporated into Iraqi law.


title: Paul Bremer

text: Since then, violent events in Iraq involving American security companies such as Blackwater have triggered great resentment among Iraqi citizens, who view them as private armies acting with impunity.


title: Paul Bremer

text: Bremer's early departure was a complete surprise. But the turnover of political power a couple of days earlier was suggested by members of the Bush Administration to thwart any plans the insurgency may have had for June 30.


title: Paul Bremer

text: U.S. intelligence sources had monitored chatter that suggested resistance elements were planning demonstrations, or outright attacks, to coincide with the time of the official handover. An early handover would preempt the plans of resistance elements.


title: Paul Bremer

text: His early departure was disruptive to the smooth transition of authority, as the KPMG audit of the Development Fund for Iraq made clear. In their management notes the external auditors describe trying to meet with Bremer, and being very surprised by his early departure.


title: Paul Bremer

text: Many of Bremer's senior staff left when he did, meaning that important documents required for the completion of the audit could not be signed by the appropriate staff members.


title: Paul Bremer

text: Former Speaker of the House Newt Gingrich called Bremer "the largest single disaster in American foreign policy in modern times", stating that he should have been relieved of his duties "no later than" September 2003.


title: Turtle shell

text: The turtle shell is a shield for the ventral and dorsal parts of turtles (the order Testudines), completely enclosing all the vital organs of the turtle and in some cases even the head. It is constructed of modified bony elements such as the ribs, parts of the pelvis and other bones found in most reptiles. The bone of the shell consists of both skeletal and dermal bone, showing that the complete enclosure of the shell likely evolved by including dermal armor into the rib cage.


title: Turtle shell

text: The turtle's shell is an important study, not just because of the apparent protection it provides for the animal but also as an identification tool, in particular with fossils, as the shell is one of the likely parts of a turtle to survive fossilization. Hence understanding the shell structure in living species provides comparable material with fossils.


title: Turtle shell

text: The shell of the hawksbill turtle, among other species, has been used as a material for a wide range of small decorative and practical items since antiquity, but is normally referred to as tortoiseshell.


title: Turtle shell

text: The turtle shell is made up of numerous bony elements, generally named after similar bones in other vertebrates, and a series of keratinous scutes which are also uniquely named. Some of those bones that make the top of the shell, carapace, evolved from the scapula rami of the clavicles along with the dorsal and superficial migration of the cleithra. The ventral surface is called the "plastron". These are joined by an area called the bridge. The actual suture between the bridge and the plastron is called the anterior bridge strut. In Pleurodires the posterior pelvis is also part of the carapace, fully fused with it. This is not the case in Cryptodires which have a floating pelvis. The anterior bridge strut and posterior bridge strut are part of the plastron. On the carapace are the sutures into which they insert, known as the Bridge carapace suture.


title: Turtle shell

text: In the shell there is a turtle's epidermis layer. This layer is important to the strength of the shell surrounding it. In an international study, the layer can be as thick as two to four cells. Even with such a small thickness, the epidermis allows the deformation the shell can experience and provides the shell more support. The epidermis layer is apparent in both sections of the shell, carapace, and plastron, and is thicker in critical areas. A thicker epidermis allows a higher stress force to be experienced without permanent deformation or critical failure of the shell.


title: Turtle shell

text: The shape of the shell is from its evolutionary process, which caused many microstructures to appear to aid survival and motion. Shell shape allows the animal to escape predatory situations. Microstructures can include the scutes mentioned prior or the ribs found internally of the shell. Many ribs can be found within the shell and throughout the shell. The rib structures provide extra structural support but allows the shells to deform elastically depending on the situation the turtle is in (i.e., predatory escape). Nonstructural mechanisms have also been in the turtle shell that aids the turtle during locomotion. A mucus film like is covering parts of the shell, allowing like friction and drag.


title: Turtle shell

text: The bones of the shell are named for standard vertebrate elements. As such the carapace is made up of eight pleurals on each side, these are a combination of the ribs and fused dermal bone. Outside of this at the anterior of the shell is the single nuchal bone, a series of twelve paired periphals then extend along each side. At the posterior of the shell is the pygal bone and in front of this nested behind the eighth pleurals is the suprapygal.


title: Turtle shell

text: Between each of the pleurals are a series of neural bones, which although always present are not always visible, in many species of Pleurodire they are submerged below the pleurals. Beneath the neural bone is the Neural arch which forms the upper half of the encasement for the spinal cord. Below this the rest of the vertebral column. Some species of turtles have some extra bones called mesoplastra, which are located between the carapace and plastron in the bridge area. They are present in most Pelomedusid turtles.


title: Turtle shell

text: The skeletal elements of the plastron are also largely in pairs. Anteriorly there are two epiplastra, with the hyoplastra behind them. These enclose the singular entoplastron. These make up the front half of the plastron and the hyoplastron contains the anterior bridge strut. The posterior half is made up of two hypoplastra (containing the posterior bridge strut) and the rear is a pair of xiphiplastra.


title: Turtle shell

text: Overlying the boney elements are a series of scutes, which are made of keratin and are a lot like horn or nail tissue. In the center of the carapace are five vertebral scutes and out from these are four pairs of costal scutes. Around the edge of the shell are 12 pairs of marginal scutes. All these scutes are aligned so that for the most part the sutures between the bones are in the middle of the scutes above. At the anterior of the shell there may be a cervical scute (sometimes incorrectly called a nuchal scute) however the presence or absence of this scute is highly variable, even within species.


title: Turtle shell

text: On the plastron there are two gular scutes at the front, followed by a pair of pectorals, then abdominals, femorals and lastly anals. A particular variation is the Pleurodiran turtles have an intergular scute between the gulars at the front, giving them a total of 13 plastral scutes. Compared to the 12 in all Cryptodiran turtles.


title: Turtle shell

text: The carapace is the dorsal (back), convex part of the shell structure of a turtle, consisting of the animal's ossified ribs fused with the dermal bone. The spine and expanded ribs are fused through ossification to dermal plates beneath the skin to form a hard shell. Exterior to the skin the shell is covered by scutes, which are horny plates made of keratin that protect the shell from scrapes and bruises. A "keel", a ridge that runs from front to the back of the animal is present in some species, these may be single, paired or even three rows of them. In most turtles the shell is relatively uniform in structure, species variation in general shape and color being the main differences. However, the soft shell turtles, pig-nose turtles and the leatherback sea turtle have lost the scutes and reduced the ossification of the shell. This leaves the shell covered only by skin. These are all highly aquatic forms.


title: Turtle shell

text: The evolution of the turtle's shell is unique because of how the carapace represents transformed vertebrae and ribs. While other tetrapods have their scapula, or shoulder blades, found outside of the ribcage, the scapula for turtles is found inside the ribcage. The shells of other tetrapods, such as armadillos, are not linked directly to the vertebral column or rib cage allowing the ribs to move freely with the surrounding intercostal muscle. However, analysis of the transitional fossil, "Eunotosaurus africanus" shows that early ancestors of turtles lost that intercostal muscle usually found between the ribs.


title: Turtle shell

text: The plastron (plural: plastrons or plastra) is the nearly flat part of the shell structure of a turtle, what one would call the belly or ventral surface of the shell. It also includes within its structure the anterior and posterior bridge struts and the bridge of the shell. The plastron is made up of nine bones and the two epiplastra at the anterior border of the plastron are homologous to the clavicles of other tetrapods. The rest of the plastral bones are homologous to the gastralia of other tetrapods. The plastron has been described as an exoskeleton, like osteoderms of other reptilians; but unlike osteoderms, the plastron also possesses osteoblasts, the osteoid, and the periosteum.


title: Turtle shell

text: The evolution of the plastron has remained more mysterious, though Georges Cuvier, a French naturalist and zoologist in the 19th century, wrote that the plastron developed primarily from the sternum of the turtle. This fits well with the knowledge obtained through embryological studies, showing that changes in the pathways of rib development often result in malformation or loss of the plastron. This phenomenon occurs in turtle development, but instead of experiencing complete loss of the sternum the turtle body plan repurposes the bone into the form of the plastron, although other analyses find that the endochondral sternum is absent and replaced by the exoskeletal plastron. The ventral ribs are effectively not present, replaced by the plastron, unless the gastralia from which the plastron evolved were once floating ventral ribs. During turtle evolution, there was probably a division of labor between the ribs, which specialized to stabilize the trunk, and the abdominal muscles, which specialized for respiration, and these changes took place 50 million years before the shell was fully ossified.


title: Turtle shell

text: The discovery of an ancestral turtle fossil, "Pappochelys rosinae," provides additional clues as to how the plastron formed. "Pappochelys" serves as an intermediate form between two early stem-turtles, "E. africanus" and "Odontochelys," the latter of which possesses a fully formed plastron. In place of a modern plastron, "Pappochelys" has paired gastralia, like those found in "E. africanus". "Pappochelys" is different from its ancestor because the gastralia show signs of having once been fused, as indicated by the fossil specimens which show forked ends. This evidence shows a gradual change from paired gastralia, to paired and fused gastralia, and finally to the modern plastron across these three specimens.


title: Turtle shell

text: In certain families there is a hinge between the pectoral and abdominal scutes allowing the turtle to almost completely enclose itself. In certain species the sex of a testudine can be told by whether the plastron is concave, male or convex, female. This is because of the mating position; the male's concave plastron allows it to more easily mount the female during copulation.


title: Turtle shell

text: The plastral scutes join along a central seam down the middle of the plastron. The relative lengths of the seam segments can be used to help identify a species of turtle. There are six laterally symmetric pairs of scutes on the plastron: gular, humeral, pectoral, abdominal, femoral, and anal (going from the head to the tail down the seam); the abdominal and gular scute seams are approximately the same length, and the femoral and pectoral seams are approximately the same length.


title: Turtle shell

text: The "gular scute" or "gular projection" on a turtle is the most anterior part of the plastron, the underside of the shell. Some tortoises have paired gular scutes, while others have a single undivided gular scute. The gular scutes may be referred to as a gular projection if they stick out like a trowel.


title: Turtle shell

text: The plastral formula is used to compare the sizes of the individual plastral scutes (measured along the midseam). The following plastral scutes are often distinguished (with their abbreviation):


title: Turtle shell

text: Comparison of the plastral formulas provides distinction between the two species. For example, for the eastern box turtle, the plastral formula is: .


title: Turtle shell

text: Turtle plastrons were used by the ancient Chinese in a type of divination called plastromancy. See also Oracle bones.


title: Turtle shell

text: The turtle's shell is covered in scutes that are made of keratin. The individual scutes as shown above have specific names and are generally consistent across the various species of turtles. Terrestrial tortoises do not shed their scutes. New scutes grow by the addition of keratin layers to the base of each scute. Aquatic chelonii shed individual scutes. The scute effectively forms the "skin" over the underlying bony structures; there is a very thin layer of subcutaneous tissue between the scute and the skeleton. The scutes can be brightly colored in some species, but the basal color is a grey to dark brown color dorsally; the plastral scutes are often white to yellow in base color. Moustakas-Verho and Cherepanov's embryological study reveals that the patterning of the plastral scutes appear independent from the patterning of carapacial scutes, suggesting that the carapace and plastron evolved separately.


title: Turtle shell

text: The appearance of scutes correlates to the transition from aquatic to terrestrial mode of life in tetrapods during the Carboniferous period (340 Ma). In the evolution from amphibians to terrestrial amniotes, transition in a wide variety of skin structures occurred. Ancestors of turtles likely diverged from amphibians to develop a horny cover in their early terrestrial ancestral forms.


title: Turtle shell

text: The carapacial ridge plays an essential role in the development of the turtle shell. Embryological analyses show that the carapacial ridge initiates the formation of the turtle shell. It causes axial arrest which causes the ribs to be dorsalized, the shoulder girdle to be rearranged and encapsulated in the rib cage, and the carapace to develop. "Odontochelys semitestacea" presents evidence of axial arrest that is observed in embryos but lacks fan-shaped ribs and a carapace. This suggests that the primitive carapacial ridge functioned differently and must have gained the function of mediating the ribs and carapace development later. The "Pax1" and "Sonic hedgehog gene" ("Shh") serve as key regulators during the development of the vertebral column. "Shh" expression in the neural tube is essential for the maintenance of "Pax1" expression in the ventral sclerotome and thus plays a key role in carapacial rib development. Genetic observations of "Pax1" and "Shh" further provide an understanding in key gene expression that could potentially be responsible for changing turtle morphology.


title: Turtle shell

text: During the development of the turtle embryo, the ribs grow sideways into the carapacial ridge, unique to turtles, entering the dermis of the back to support the carapace. The development is signalled locally by fibroblast growth factors including FGF10.


title: Turtle shell

text: Zoologists have sought to explain the evolutionary origin of the turtles, and in particular of their unique carapace. In 1914, J. Versluys proposed that bony plates in the dermis, osteoderms, fused first to each other and then to the ribs beneath them. The theory persisted into the 21st century, when Olivier Rieppel proposed a hypothetical turtle precursor, its back covered by bony armour plates in the dermis, which he called the "Polka Dot Ancestor". Michael Lee proposed that the transformation of the carapace began with an unarmoured parareptile and then an armoured pareiasaur, and ended with modern turtles with a fully developed carapace and a relocated rib cage. The theory accounted for the evolution of fossil pareisaurs from "Bradysaurus" to "Anthodon", but not for how the ribs could have become attached to the bony dermal plates.


title: Turtle shell

text: Recent stem-turtle fossil discoveries provide a "comprehensive scenario" of the evolution of the turtle's shell. A fossil that may be a stem-turtle from the Permian of South Africa, "Eunotosaurus", some 260 million years ago, had a short broad trunk, and a body-case of broadened and somewhat overlapping ribs, suggesting an early stage in the acquisition of a shell. The fossil has been called "a diapsid reptile in the process of becoming secondarily anapsid". Olivier Rieppel summarizes the phylogenetic origins of the ancestral turtles: ""Eunotosaurus" is placed at the bottom of the stem section of the turtle tree, followed by "Pappochelys" and "Odontochelys" along the turtle stem and on to more crown-ward turtles".


title: Turtle shell

text: Tyler Lyson and colleagues suggest that "Eunotosaurus" might imply a fossorial origin for the turtles. During the Permian, the broadened ribs may have provided great stability in burrowing, giving a body shape resembling the extant fossorial gopher tortoise, with strong shoulders and forelimbs, and increased muscle attachment structures such as their tubercle on the posterior coracoid and their large and wide terminal phalanges creating shovel-like "hands". Fossoriality may have helped "Eunotosaurus" survive the global mass extinction at the end of the Permian period, and could have played an essential role in the early evolution of shelled turtles.


title: Turtle shell

text: A stem-turtle from the Middle Triassic of Germany, some 240 million years ago, "Pappochelys", has more distinctly broadened ribs, T-shaped in cross-section. They vary in shape along the spine.


title: Turtle shell

text: A Late Triassic stem-turtle from Guizhou, China, "Eorhynchochelys", is a much larger animal, up to long, with a long tail, and broadened but not overlapping ribs; like the earlier fossils, it has small teeth.


title: Turtle shell

text: Also in the Late Triassic, some 220 million years ago, the freshwater "Odontochelys semitestacea" of Guangling in southwest China has a partial shell, consisting of a complete bony plastron and an incomplete carapace. The fossil showed that the plastron evolved before the carapace. Like crown turtles, it lacked intercostal muscles, so rib mobility was limited. The ribs were laterally expanded and broadened without ossification, like the embryos of modern turtles.


title: Turtle shell

text: The development of a shell reaches completion with the late Triassic "Proganochelys" of Germany and Thailand. It lacked the ability to pull its head into its shell, and had a long neck and a long, spiked tail ending in a club, somewhat like an ankylosaur.


title: Turtle shell

text: Pyramiding is a shell deformity of captive tortoises, in which the shell grows unevenly resulting in a pyramid shape underlying each scute. Factors which may contribute to pyramiding include inadequate water supply; the consumption of excessive animal or vegetable protein; inadequate calcium, UVB and/or vitamin D3; poor nutrition.


title: Plain

text: In geography, a plain is a flat expanse of land that generally does not change much in elevation, and is primarily treeless. Plains occur as lowlands along valleys or at the base of mountains, as coastal plains, and as plateaus or uplands.


title: Plain

text: In a valley, a plain is enclosed on two sides, but in other cases a plain may be delineated by a complete or partial ring of hills, by mountains, or by cliffs. Where a geological region contains more than one plain, they may be connected by a pass (sometimes termed a gap). Coastal plains mostly rise from sea level until they run into elevated features such as mountains or plateaus.


title: Plain

text: Plains are one of the major landforms on earth, where they are present on all continents, and cover more than one-third of the world's land area. Plains can be formed from flowing lava; from deposition of sediment by water, ice, or wind; or formed by erosion by the agents from hills and mountains. Biomes on plains include grassland (temperate or subtropical), steppe (semi-arid), savannah (tropical) or tundra (polar). In a few instances, deserts and rainforests may also be considered plains.


title: Plain

text: Plains in many areas are important for agriculture because where the soils were deposited as sediments they may be deep and fertile, and the flatness facilitates mechanization of crop production; or because they support grasslands which provide good grazing for livestock.


title: Plain

text: Erosional plains have been leveled by various agents of denudation such as running water, rivers, wind and glacier which wear out the rugged surface and smoothens them. Plain resulting from the action of these agents of denudation are called "peneplains" (almost plain) while plains formed from wind action are called "pediplains".


title: Plain

text: Structural plains are relatively undisturbed horizontal surfaces of the Earth. They are structurally depressed areas of the world that make up some of the most extensive natural lowlands on the Earth's surface.


title: Pre-exposure prophylaxis

text: Pre-exposure prophylaxis (PrEP) is the use of medications to prevent the spread of disease in people who have not yet been exposed to a disease-causing agent, usually a virus. The term typically refers to the use of antiviral drugs as a strategy for the prevention of HIV/AIDS. PrEP is one of a number of HIV prevention strategies for people who are HIV negative but who have a higher risk of acquiring HIV, including sexually active adults at increased risk of contracting HIV, people who engage in intravenous drug use (see drug injection), and serodiscordant sexually active couples.


title: Pre-exposure prophylaxis

text: When used as directed, PrEP has been shown to be highly effective, reducing the risk of acquiring HIV by up to 99%.


title: Pre-exposure prophylaxis

text: , the World Health Organization (WHO) recommends two drug combinations for the use as PrEP for HIV/AIDS: the combination of tenofovir disoproxil and emtricitabine (Truvada), or the combination of tenofovir disoproxil and lamivudine (Cimduo).


title: Pre-exposure prophylaxis

text: In October 2019, the US Food and Drug Administration (FDA) approved the combination of emtricitabine and tenofovir alafenamide (Descovy) to be used as PrEP in addition to Truvada, which provides similar levels of protection.


title: Pre-exposure prophylaxis

text: In December 2021, the FDA approved cabotegravir (Apretude), which is an injectable form of PrEP manufactured by ViiV, a pharmaceutical company that specializes in HIV drugs. Regulators believe it will improve medication adherence because it only has to be taken once every two months, and will also widen adoption as it eliminates the need to hide pills or pharmacy visits for discretion.


title: Pre-exposure prophylaxis

text: In the United States, federal guidelines recommend the use of pre-exposure prophylaxis (PrEP) for HIV-negative adults with the following characteristics:


title: Pre-exposure prophylaxis

text: In the United Kingdom the "BHIVA/BASHH guidelines on the use of HIV pre-exposure prophylaxis (PrEP) 2018" recommend:


title: Pre-exposure prophylaxis

text: Other government health agencies from around the world have devised their own national guidelines for how to use PrEP to prevent HIV infection in those at high risk, including Botswana, Canada, Kenya, Lesotho, South Africa, Uganda, the Zambia, and Zimbabwe.


title: Pre-exposure prophylaxis

text: Often, laboratory testing is required before starting PrEP, including a test for HIV. Once PrEP is initiated, individuals are asked to see their healthcare provider at least every three to six months. During those visits, providers may want to repeat testing for HIV, test for other sexually transmitted infections, monitor kidney function, and/or test for pregnancy. Individuals must test negative for HIV prior to PrEP initiation because persons infected with HIV taking PrEP medication are at risk for becoming resistant to emtricitabine. Consequently, people with HIV infection and resistance to emtricitabine will have fewer options for selecting HIV treatment medications.


title: Pre-exposure prophylaxis

text: PrEP has been shown to be effective at reducing the risk of acquiring HIV in individuals at increased risk. However, PrEP is not 100% effective at preventing HIV, even in people who take the medication as prescribed. There have been several reported cases of people who acquired HIV despite taking PrEP. People taking PrEP may use combination prevention strategies along with PrEP, like condoms. If someone on PrEP acquires HIV, they may experience the signs and symptoms of HIV/AIDS.


title: Pre-exposure prophylaxis

text: PrEP is typically taken continuously and daily following potential exposure. The CDC recommends follow-up visits at least every three months to provide HIV tests, medication adherence counseling, behavioral risk reduction support, side effect assessment, STI symptom assessment, and STI testing for sexually active individuals with symptoms of a current infection. Pregnancy tests should also be done every three months for woman who may become pregnant. At three months and every six months thereafter, renal function and presence of bacterial STI is assessed. Effectiveness of PrEP is associated with adherence, with effectiveness decreasing with suboptimal adherence.


title: Pre-exposure prophylaxis

text: Although the daily, oral dosing schedule is still recommended for all individuals taking PrEP medication for HIV infection prevention, event-driven pre-exposure prophylaxis, or ED-PrEP, is an option for men who have sex with men. ED-PrEP is also referred to as "2+1+1" dosing, because the dosing regimen involves a person taking two pills two to twenty-four hours prior to sex, one pill twenty-four hours after taking the first two pills, and a last pill taken forty-eight hours after taking the first two pills. This dosing regimen was first proven effective to reduce the relative risk of HIV infection by 86% in the IPERGAY randomized clinical trial performed in Canada and France in 2015. This has only been evaluated with Truvada and not other drugs. According to the WHO, ED-PrEP should be considered for HIV infection prevention in men who have sex with men who have relatively infrequent sex, who are able to plan sex or delay sex for about two hours, and who find this dosing schedule convenient. ED-PrEP is not recommended for use in other populations, such as cisgender or transgender women and men who have vaginal and/or anal sex with women, due to the lack of safety and efficacy data available studying ED-PrEP in these populations. ED-PrEP can be beneficial to help reduce the pill burden for people and decrease costs, as fewer pills are needed.


title: Pre-exposure prophylaxis

text: In 2016, the World Health Organization (WHO) consolidated guidelines regarding the use of antiretroviral drugs for treatment and prevention of HIV infection support the use of PrEP in pregnant and breastfeeding women who are at continued and substantial risk of HIV infection. In clinical PrEP trials, exposure to TDF-containing PrEP during the first trimester of pregnancy was not associated with adverse pregnancy or infant outcomes. The increased risk of mother-to-child HIV transmission outweighs any potential risks of PrEP. The guidelines also note the need for continued monitoring of pregnant and breastfeeding women receiving PrEP. However, global PrEP accessibility for women, including those who are either pregnant or breastfeeding, is limited. Efforts to increase accessibility to women who are at risk for HIV are necessary for reducing rates of global HIV infections.


title: Pre-exposure prophylaxis

text: Truvada and Descovy are contraindicated for use as pre-exposure prophylaxis (PrEP) in individuals who have an unknown or positive HIV status. HIV positive or negative status must be determined before someone begins the use of either of these medications as PrEP. Additionally, any hypersensitivity or severe allergy to any ingredient, emtricitabine, tenofovir disoproxil, or tenofovir alafenamide is a contraindication for continued use of these medications.


title: Pre-exposure prophylaxis

text: Research shows that pre-exposure prophylaxis (PrEP) is generally safe and well tolerated for most individuals, although some side effects have been noted to occur. Some people experience a "start-up syndrome" involving nausea, headache, and/or stomach issues, which generally resolve within a few weeks of starting the PrEP medication. Research has shown that the use of Truvada as PrEP has been associated with mild to moderate declines in kidney function, mostly associated with older people over 50, those with predisposing conditions such as diabetes, or glomerular filtration rate lower than 90. These declines were usually of no concern, stabilized after several weeks of being on the drug, and reversed once the drug was discontinued. However, these side effects were serious enough for several people on PrEP to file lawsuits against the makers of Truvada as well as the makers of other similar drugs.


title: Pre-exposure prophylaxis

text: Osteopenia or bone loss has been reported in clinical studies. Bone loss was not seen as a major concern for ending the service since bone loss was considered minimal and did not lead to osteoporosis. When comparing bone fractures between active participants and control there was no major difference in bone fractures.


title: Pre-exposure prophylaxis

text: Fat redistribution and accumulation was more commonly seen in individuals receiving antiretroviral therapy, particularly older antiretrovirals, for the treatment of HIV. No significant changes in fat redistribution or change in fat had been noted when used as a pre-exposure prophylaxis. Research and study outcome analysis suggests that emtricitabine/tenofovir does not have a significant effect on fat redistribution or accumulation when used as pre-exposure prophylaxis in HIV negative individuals. As of early 2018 these studies have not assessed in detail subtle changes in fat distribution that may be possible with the drug when used as PrEP, and statistically significant – though transient – weight changes have been attributed to detectable drug concentrations in the body.


title: Pre-exposure prophylaxis

text: Other potential serious side effects of Truvada include acute exacerbations of hepatitis B in individuals with HBV infection, lactic acidosis, and severe hepatomegaly with steatosis.


title: Pre-exposure prophylaxis

text: Descovy research and data from public use has shown similar "start-up" effects; however, some data indicates that Descovy is better for one's kidneys and for those with a diagnosis of osteoporosis. The DISCOVER trial that compared descovy versus truvada for PrEP showed that descovy produced safer kidney and bone outcomes.


title: Pre-exposure prophylaxis

text: Both Truvada and Descovy carry a black box warning for the combination of emtricitabine/tenofovir, as this combination of drugs can result in the acute worsening of hepatitis B infection when discontinued. This combination of drugs is also known to increase HIV resistance to these medications when used as pre-exposure prophylaxis (PrEP) in individuals who have already (recently) been infected with HIV. It is recommended that individuals continue to periodically get tested to determine their HIV status to ensure proper continuing use of these medications for PrEP.


title: Pre-exposure prophylaxis

text: Truvada was previously only approved by the U.S. Food and Drug Administration (FDA) to treat HIV in those already infected. In 2012, the FDA approved the drug for use as pre-exposure prophylaxis (PrEP), based on growing evidence that the drug was safe and effective at preventing HIV in populations at increased risk of infection. The FDA has approved two additional medications for PrEP since then, approving Descovy in 2019 and cabotegravir (Apretude) in 2021.


title: Pre-exposure prophylaxis

text: In 2012, the World Health Organization (WHO) issued guidelines for PrEP and made similar recommendations for its use among men and transgender women who have sex with men. The WHO noted that "international scientific consensus is emerging


title: Pre-exposure prophylaxis

text: that antiretroviral drugs, including PrEP, significantly reduce the risk of sexual acquisition and transmission of HIV regardless of population or setting." In 2014, on the basis of further evidence, the WHO updated the recommendation for men who have sex with men to state that PrEP "is recommended as an additional HIV prevention choice within a comprehensive HIV prevention package." In November 2015 the WHO expanded this further, on the basis of further evidence, and stated that it had "broadened the recommendation to include all population groups at substantial risk of HIV infection" and emphasized that PrEP should be "an additional prevention choice in a comprehensive package of services."


title: Pre-exposure prophylaxis

text: , numerous countries have approved the use of PrEP for HIV/AIDS prevention, including the United States, South Korea, France, Norway, Australia, Israel, Canada, Kenya, South Africa, Peru, Thailand, the European Union and Taiwan.


title: Pre-exposure prophylaxis

text: New Zealand was one of the first countries in the world to publicly fund PrEP for the prevention of HIV in March 2018. Funded access to PrEP will require that people undergo regular testing for HIV and other sexually transmitted infections, and are monitored for risk of side effects. People taking funded PrEP will receive advice on ways to reduce the risk of HIV and sexually transmitted infections.


title: Pre-exposure prophylaxis

text: In Australia, the country's Therapeutic Goods Administration approved the use of Truvada as PrEP in May 2016, allowing Australian providers to legally prescribe the medication. On March 21, 2018, the Federal Minister for Health announced that PrEP will be subsidized by the Australian Government through the Pharmaceutical Benefits Scheme (PBS) from April 1, 2018.


title: Pre-exposure prophylaxis

text: Within the United States, Truvada and Descovy are brand name products of Gilead Sciences that cost around $2200/month (a 30-day supply) at wholesale price. In other countries around the world, generic Truvada is available for a much lower price. Expected fall of 2020, Teva Pharmaceuticals will begin producing a generic version of Truvada within the United States; however, it has been reported that the details surrounding the rights to the patent are unclear, which makes it difficult to predict if this will increase access to the medications. In the meantime, there are several assistance programs at the local, state, and national level for gaining access to PrEP at reduced costs. Gilead has an "advancing access" co-pay coupon program that can be accessed by individuals and providers alike to help cover some of the monthly costs of these medications. It is recommended to discuss other available options with a community pharmacist or physician.


title: Pre-exposure prophylaxis

text: In December 2019, the U.S. announced the "Ready, Set, PrEP" program to provide free PrEP to the uninsured through major drugstore chains. The Ready, Set, PrEP program is led by the U.S. Department of Health and Human Services (HHS) and allows qualifying individuals to fill their prescription for PrEP medication free of cost at their choice of participating pharmacies or through the mail.


title: Pre-exposure prophylaxis

text: NPIN PrEP Provider Data and Locator Widget was launched on the CDC website to provide a comprehensive, national directory of public and private providers in the U.S. that offer pre-exposure prophylaxis (PrEP) to prevent HIV infection. The database includes over 1,800 PrEP providers from all 50 U.S. states as well as U.S. territories.


title: Pre-exposure prophylaxis

text: Beginning in January 2020, after California Governor Gavin Newsom signed Senate Bill 159 (SB159) in late 2019, licensed pharmacists in California are authorized to initiate and dispense a 30 to 60 day supply of pre-exposure prophylaxis (PrEP) or the full course of post-exposure prophylaxis (PEP) without a doctor's prescription, given certain clinical criteria of the individual are met. The bill acts as an extension of Medi-Cal benefits (the Medicaid program in the state of California). The law is recognized by pharmacist organizations, health providers, legislators, and the general public to be the removal of a barrier to direct and time-dependent access to these medications, especially for those in communities most affected by HIV/AIDs.


title: Pre-exposure prophylaxis

text: Since the FDA approval of PrEP for the prevention of HIV, moves toward greater adoption of PrEP have been met some issues, especially around the overall public health effect of widespread adoption, the cost of PrEP and associated disparities in availability and access. Many public health organizations and governments have embraced PrEP as a part of their overall strategy for reducing HIV. For example, in 2014 New York state governor Andrew Cuomo initiated a three-part plan to reduce HIV across New York that specifically emphasized access to PrEP. Similarly, the city of San Francisco launched a "Getting to Zero" campaign. The campaign aims to dramatically reduce the number of new HIV infections in the city and relies on expanding access to PrEP as a key strategy for achieving that goal. Public health officials report that since 2013 the number of new HIV infections in San Francisco has decreased almost 50% and that such improvements are likely related to the city's campaign to reduce new infections. Additionally, numerous public health campaigns have been launched to educate the public about PrEP. For instance, in New York City in 2016 Gay Men's Health Crisis launched an ad campaign in bus shelters across the city reminding riders that adherence to PrEP is important to ensuring the regimen is maximally effective. In Washington, D.C., a PrEP campaign was launched to increase the number of D.C. residents taking PrEP. Social media pushes, such as an ad campaign called "PrEP for Her", targeted African-American women, who, along with gay and bisexual African-American men, are at high risk of infection in the district. Other states and cities that have initiated "Getting to Zero" campaigns include Massachusetts, Connecticut, Illinois, San Diego, Silicon Valley/Santa Clara, and Miami-Dade.


title: Pre-exposure prophylaxis

text: Despite those efforts, PrEP remains controversial among some who worry that widespread PrEP adoption could cause public health issues by enabling risky sexual behaviors. For instance, AIDS Healthcare Foundation founder and director Michael Weinstein has been vocal in his opposition to PrEP adoption, suggesting that PrEP causes people to make riskier decisions about sex than they would otherwise make. Some researchers, however, believe that there is insufficient data to determine whether or not PrEP implementation has an effect on the rate of other sexually transmitted infections. Other critics point out that despite implementation of PrEP, significant disparities exist. For example, some point out that African Americans bear a disproportionate burden of HIV infections but may be less likely than whites to access PrEP. Still other critics of PrEP object to the high cost of the regimen. For example, the U.K.'s NHS initially refused to offer PrEP to individuals citing concerns about cost and suggested that local officials ought to bear the responsibility of paying for the drug. However, following significant advocacy efforts, the NHS has started to offer PrEP to people in the UK in 2017.


title: Pre-exposure prophylaxis

text: PrEP is used predominantly by men who have sex with men, often as an alternative to condoms. For the first time since the outbreak of the AIDS crisis, PrEP makes somewhat HIV-protected sex without condoms possible, and since its availability, sex without condoms has increased. PrEP does not prevent the transmission of sexually transmitted infections other than HIV, and is not 100% effective.


title: Pre-exposure prophylaxis

text: PrEP is underused. A systematic review of 76 peer-reviewed articles and 28 conference abstracts of values and preferences among global populations who might benefit from PrEP found that awareness of PrEP is low, but individuals were receptive to use when presented with information. Common barriers to PrEP use include lack of communication between an individual and their doctor, stigmatization, concerns about safety, side effects, and cost and effectiveness. Transgender women are disproportionally affected by HIV/AIDS, and PrEP is often underused. Barriers for PrEP use and access for transgender women include concerns about side effects, cost, hormone therapy, adherence, PrEP-related stigma and interaction with healthcare workers.


title: Pre-exposure prophylaxis

text: Studies evaluating PrEP efficacy to reduce risk of HIV infection found a linear relationship between adherence and effectiveness of medication. This means that the more closely people follow recommended dosing of PrEP, the more effective the medication is at preventing infection.


title: Pre-exposure prophylaxis

text: Most PrEP studies use the drug tenofovir or a tenofovir/emtricitabine combination (Truvada) that is delivered by mouth. Initial studies of PrEP strategies in non-human primates showed a reduced risk of infection among animals that receive ARVs prior to exposure to a simian form of HIV. A 2007 study at UT-Southwestern (Dallas) and the University of Minnesota showed PrEP to be effective in "humanized" laboratory mice. In 2008, the iPrEx study demonstrated 42% reduction of HIV infection among men who have sex with men, and subsequent analysis of the data has suggested that 99% protection is achievable if the drugs are taken every day. Below is a table summarizing some of the major research studies that demonstrated PrEP with Truvada to be effective across different populations.


title: Pre-exposure prophylaxis

text: PrEP approaches with agents besides Truvada are being investigated. On December 20, 2021, the FDA approved cabotegravir (Apretude), which was the first injectable drug for PrEP that's taken every two months. There has been some evidence that other regimens, like ones based on the antiretroviral agent Maraviroc, could potentially prevent HIV infection. Similarly, researchers are investigating whether drugs could be used in ways other than a daily pill to prevent HIV, including taking a long-acting PrEP injection, PrEP-releasing implants, or rectally administered PrEP. However, it is important to keep in mind that , major public health organizations such as the U.S. Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend only daily Truvada for use as PrEP.


title: Pre-exposure prophylaxis

text: Data on efficacy and safety of PrEP in adolescents are insufficient. Risks and benefits of PrEP use should be considered for adolescents.