Why we shouldn't say we have a "cure" for HIV until it's really true

The Berlin patient, Timothy Ray Brown, is historically unique - he is the only person ever truly cured of HIV. 

But in recent years scientific journals and the popular press alike have published multiple claims of HIV cures. From the French "functional cure" to the Mississippi baby, we have seen the word "cure" used a lot -- as well as vague synonyms for it like "cleared" and "HIV-free" -- and yet each time we've had to walk the hype back. 

Check out my new post over at The Conversation on why we shouldn't overhype HIV "cures."

Posted on December 16, 2014 .

Doctors Should Not Deny Ebola Patients CPR

The first time I did CPR, coagulated blood spurted onto my new white coat from a wound in the patient’s chest. Another time a patient’s urine soaked through the knees of my pants as I knelt at his side.

Even in the best of conditions, cardiopulmonary resuscitation (CPR) is a spit-smeared, bloody business that can expose health care workers to all kinds of body fluids. Like all health care workers, I put on gloves and a game face and accept such things as part of patient care.

The 2014 Ebola outbreak changes all that. It is much more dangerous for clinicians to resuscitate patients with Ebola. As a result, should we skip CPR altogether? Bioethicist Joseph Fins of the Weill Medical College of Cornell University recently suggested we should.

I disagree. See my rebuttal at Health Affairs. What do you think?

Posted on December 11, 2014 .

Top 10 trends in HIV this year

This year we have seen palpable progress in the fight against AIDS, and also some astonishing hucksterism. In celebration of World AIDS Day 2014, here are 10 of the most influential trends in HIV this year. 

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1. The cure, and its pretenders. To date only one person has ever been cured of HIV infection: Timothy Ray Brown, a resident of Berlin who received a CCR5-deleted bone marrow transplant while on potent anti-HIV medications. Recently we heard the word "cure" applied frequently but ultimately falsely to the Mississippi baby and some patients given ordinary bone marrow transplants. Everyone but Timothy has relapsed. Next year let's use the "C" word with caution, and for a great book on the search for a cure, try Cured: How the Berlin Patients Defeated HIV and Forever Changed Medical Science by Nat Holt. 

2. A new model for AIDS. As I summarized in the Scientific American, Warner Greene's lab unleashed simultaneous papers in Science and Nature in late 2013 that upend how we understand the pathogenesis of AIDS. Through a stroke of luck reminiscent of the early identification of AZT - in which a promising new drug was already sitting on the shelf as a result of unrelated cancer research - Greene's group even moved a promising new approach to HIV treatment into clinical trials.

3. Better ART. Speaking of antiretroviral therapy (ART), the three-in-one antiretroviral drug Atripla has long been king of the HIV treatment hill. This changed with the late 2013 publication of the SINGLE trial in which a new combination drug (dolutegravir/abacavir/lamivudine) was safer and more effective than Atripla. This - and other similar studies in new HIV treatment options - has driven yet another shift in HIV treatment as patients have more and more ways of living long lives on good HIV medicine. This is cause for celebration, but we should not forget that most people with HIV can't access these treatments for one reason or another.

4. Do we really need all those CD4's? For years doctors have checked CD4 counts with every clinical visit, and patients have grown accustomed to that regular gauge on how they're doing. Yet as life expectancy on antiretroviral therapy gets longer and clinical visits become less frequent, many HIV docs have realized those faithfully-plotted CD4 counts aren't guiding our decisions for patients with suppressed HIV viral loads and strong immune systems. As a result, new guidelines make CD4 count monitoring "optional" for some patients - and I think it should be optional for more. 

5. Hope for hepatitis C. HIV treatment successes weren't the only reason for hope this year. Drug development for hepatitis C has also progressed dizzyingly quickly. Multiple new effective regimens have been released recently, including some with equivalently near-perfect efficacy in people with HIV. Treatment is still complicated, but when the smoke clears and we work out the considerable financial obstacles to widespread treatment, many expect these potent new drugs to put a huge dent in the hepatitis C epidemic.

6. The high potential and personal politics of PrEP. A key recent boon to the fight against AIDS has been the discovery that HIV drugs can safely protect many high risk people from HIV infection. In a huge boon to HIV prevention, pre-exposure prophylaxis (PrEP) has been proven to protect men who have sex with men, heterosexual men and women, and people who inject drugs from HIV. Recent WHO guidelines suggested "All men who have sex with men should have the opportunity to choose PrEP if they feel that it meets their HIV prevention needs" whereas the CDC guidelines recommended PrEP to groups that hew more closely to populations in whom PrEP showed proven protection. Political commentary has been plentiful, and new clarified WHO guidelines are due out soon, so the PrEP conversation is sure to rage on.

7. A shot in the arm for vaccines. Many HIV vaccine candidates have fizzled out in clinical trials, including the much-lauded Merck adenovirus vaccine which may have increased the risk of HIV infection. Fortunately the 2009 Rv144 trial showed a protective HIV vaccine is possible, and subsequent studies showed that certain antibody levels correlated with HIV protection among vaccine recipients. This has fueled a new phase of HIV vaccine research, with many new candidates now in clinical trials built on what we have learned in the past few years.

8. Stagnant funding. For years the United States has been the major funder of the global HIV response. Yet on the heels of the global financial crisis, and a diversification of PEPFAR funds, HIV funding has stagnated and experts fear there is a growing gap between the global HIV need and our ability to address it. Will we look at this year as the beginning of the end of HIV, or the year we started to turn away from the dream of zero HIV?

9. Progress for children. Children are our most precious resource. We have a long way to go, but everybody welcomed the wonderful news from UNICEF that new HIV infections in children have dropped by 40%. Hallelujah! 

10. A PROMISE for pregnant women. There was good news this year for both children and mothers with HIV. This fall, a pivotal clinical trial called PROMISE was closed early when it showed that full antiretroviral therapy is better for new mothers with HIV. It also surprised many of us by showing a dark horse regimen was best. The ethics of the trial were hotly contested, as I wrote recently in Health Affairs, but ultimately the results of the PROMISE study will help drive global HIV policy in the right direction for years to come.

2014 was a great year for HIV. We saw real progress, we made startling new discoveries, and the HIV community remains as vibrant as ever. Would you have chosen the same top 10 trends in HIV for 2014?

 

 

Posted on December 1, 2014 .

Is a clinical trial of therapy for mothers with HIV unethical?

A global health controversy erupted this summer when the prominent scientific journal Nature ran an article entitled “HIV trial attacked.” Within, commentators squared off over whether a huge ongoing study provides suboptimal and thus unethical treatment options to mothers with HIV in the developing world.

To read more, see my new post at Health Affairs.

Posted on October 1, 2014 .

How Hospitals Are Getting Safer for American Children

I could tell I was being watched as I walked into the neonatal intensive care unit.

I took off my white coat, folded my stethoscope in a pocket, and hung the coat in a closet. In a nearby sink I washed my hands for a full minute, scrubbing between each finger before drying my hands.

I approached a high-tech isolette and leaned in to examine my patient, the pink baby within.

A voice stopped me: “Doctor!”

There were footsteps behind me. I pulled back and thought, what did I miss? I retraced each step. Coat. Stethoscope. Hands.

The desk clerk pointed a finger. “Your ring, doctor. You forgot to take off your wedding ring.”

She was right. I rolled my eyes, pocketed my ring, washed again, and went back to my little patient.

Small interactions like these make hospitals safer for children by reducing rates of hospital-acquired infections. Now a new article shows exactly how much safer.

To read more, click on my story over at The Atlantic.

Posted on September 10, 2014 .

Are sugar daddies to blame for HIV in Africa?

Messaging about the prevention of HIV transmission is the ultimate act of cross-cultural communication. In our haste to save lives, it can be easy to make blunders.

Recently, a cross-cultural assumption about African sexual practices that was the focus of prevention messaging has been called into question. That assumption has to do with intergenerational sex, and on closer scrutiny we are reminded about how important it is to be modest in the face of cross-cultural communications.  

Read more in my new post at Scientific American guest blogs.

Posted on September 4, 2014 .

Is HIV superinfection unhealthy?

People who contract HIV once can contract it again, often through the same risk behaviors that led to the initial infection. A long-standing question has been whether getting infected with a second strain of HIV leads to more rapid HIV disease progression than infection with a single strain.

To this point, a 24-year-old man who has sex with men recently asked me, "Doc, I already rang the bell, why do I care if I get HIV again?"

My answer is at TheBodyPro.

Posted on August 15, 2014 .

The Paranoid Hypochondriac's Guide to Ebola

The Internet has lit up with news of a burgeoning Ebola virus outbreak in western Africa and the few cases that have trickled through to the United States.

This weekend, TV helicopters beat the air above the ambulance of a US doctor stricken with Ebola and transferred to Emory's high tech containment center for care. Viewers worldwide surely struggled to figure out how this was interesting, and why they were suddenly thinking about OJ Simpson.

Was this the beginning of the end? We'd all seen Gwenyth expire in Contagion so were we next?

Fortunately card-carrying epidemiologists have come to the rescue not with wonder drugs or martial law, but with the facts of the situation: this is a small epidemic largely confined to the developing world and unlikely to be a big deal in the US. It is, however, another reminder that the public health infrastructure in Africa has been neglected. They tried valiantly to placate, to reassure, and to divert the public's fickle attention back to the scarier infectious epidemics that afflict millions every year.

Amid the hubbub, I was proud to be quoted in Erin Gloria Ryan's new Jezebel piece, "The Paranoid Hypochondriac's Guide to the Ebola Outbreak." Should I be worried that the other folks quoted in the article chose to remain anonymous? Heck no! I'm going to go enjoy my ten seconds of fame, knowing full well the firestorm of corrections and trolling will begin soon. Ten. Nine. Eight...

Posted on August 4, 2014 .

How to Read Education Data without Jumping to Conclusions

Education has entered the era of Big Data. The Internet is teeming with stories touting the latest groundbreaking studies on the science of learning and pedagogy. Education journalists are in a race to report these findings as they search for the magic formula that will save America's schools. But while most of this research is methodologically solid, not all of it is ready for immediate deployment in the classroom.

To read the rest of my new article, written with the lovely and talented education writer Jessica Lahey, visit The Atlantic.

Posted on July 8, 2014 .

Bearing the weight of mistakes

I stopped breathing when the syringe filled with bubbles. The resident and I stood silently for a couple of breaths, watching the syringe fill with more pink bubbles each time the patient’s chest filled with air.

“Shit,” said the resident, taking the syringe from my hand. He withdrew the syringe from the vein, and applied pressure with a gloved hand. I watched, my own carotid pulsing at my chin.

A STAT chest x-ray confirmed our worst fears...

To read more, visit my article in the Living Hand medical humanities section of the Journal of General Internal Medicine.

Posted on June 27, 2014 .

Hospitals Are Ground Zero

The MERS coronavirus has now spread from the Middle East to home town USA.

Since both US victims of this resurgent respiratory virus - one in Indiana and another in Florida - are healthcare workers, all eyes have turned to nosocomial transmission. In some locales nosocomial transmission has outpaced the former frontrunner for the MERS transmission prize: camel spit.

Proper infection control, therefore, is hugely important. The CDC recommends special airborne infection rooms, masks, eye protection, gowns and gloves. I remember taking these precautions when the SARS epidemic came through town. In some cases, patients were incredibly sick and it was scary; other times folks with SARS had the sniffles and we made a big deal over very little. Let's hope that as we learn more about MERS, the early reports of 30% case fatality will turn into less sobering statistics. 

Along the way, it's good that the macho culture of medicine has been changing. When I was in training, it was common and even admirable for doctors to work sick. I remember idolizing a medicine resident who did morning rounds with an IV pole at his side. Yet now we know - how could we not have clued in then?!  - that this risks spread of infectious diseases to our fragile patients.

In a nice story just out today titled "Second MERS Case Shows Hospitals Are Ground Zero for MERS," Maggie Fox of CBS News quoted me and others about MERS infection control. 

Posted on May 14, 2014 .

A Positive Partnership

In a new blog post at the HIV-related web site The Body, I recall the last few years with an HIV-positive patient, Steve. Steve and I started out with the treatment of sexually transmitted diseases and delicate discussions of safer sex. Now, Steve is on effective HIV treatment and we talked most recently about his honeymoon plans. It has been really fun to watch Steve grow, and change, and thrive.

Posted on May 10, 2014 .

A Watchful Eye in Hospitals

DESPITE the intensely personal moments that happen in hospitals, patient privacy can be elusive. Hospitals are multimillion-dollar corporations that look like shopping malls and function like factories. Doctors knock on exam room doors to signal they are about to enter — not to ask permission. The curtain that encircles the hospital bed always lets in a crack of light.

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Yet we do expect some degree of privacy in hospitals. We trust doctors with our secrets in part because they take a 2,000-year-old Hippocratic oath to respect our privacy, an oath enforced by laws like the Health Insurance Portability and Accountability Act. But sometimes, doctors have to weigh patients’ privacy against their health and safety, and that’s when things get complicated.

My hospital, where I am chairman of the bioethics committee, recently wrestled with the question of where patient and family privacy ends. Nurses in the neonatal intensive care unit (N.I.C.U.) worried that a premature infant, whom I’ll call Rickie to protect his identity, was being harmed by his parents.

Read my full op ed at The New York Times

Posted on February 16, 2014 .

Changing the Water in Which We Swim

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As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Read the rest of my blog at Health Affairs. It is a response to a very nice article by Liao et al in the January issue of that same journal.

Posted on January 31, 2014 .

This just in: how HIV kills

New findings by researchers at the Gladstone Institute of Virology at the University of California at San Francisco (UCSF) have upended how we understand the pathogenesis of the acquired immunodeficiency syndrome (AIDS). 

Enter Warner Greene, a dapper white-haired professor of medicine at UCSF and its Gladstone Institute of Virology. In a feat of scientific hutzpah sure to trigger fits of envy among other scientific heavy-hitters, Greene shattered the existing model of AIDS pathogenesis in two simultaneous groundbreaking articles in the prestigious journals Science and Nature in late December 2013.

Greene’s team made multiple seminal observations. Their key findings were ...

Read my new post at Scientific American guest blogs to learn more

 

Posted on January 17, 2014 .

Protect Thy Neighbor

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We are now deep into flu season. Forty states are reporting widespread influenza, and the number of deaths is greater thane expected.

Hospitalized patients are among the most vulnerable people in flu season. Immune systems already weakened by kidney failure or another major illness, hospitalized patients contract influenza from loved ones and - most ironically - from hospital workers. From doctors to nurses and beyond, a coughing caregivers can be the worst kind of medicine for vulnerable hospitalized patients.

Should hospital employees be obligated to get a flu shot to protect vulnerable hospitalized patients? Some hospitals - including mine - require employees to get flu shots or else suffer consequences such as mandatory masks, furlough and firing. Is this an unjustified infringement on personal liberty, or a thoughtful way to protect the health of our most vulnerable? 

Ethicist Bill Nelson and I explore this controversial issue in a recent issue of Healthcare Executive.

Posted on January 17, 2014 .

Toward fewer demons

My New Year's resolution 2014: fewer demons.

There were a lot of demons in 2013. Some like Typhoon Haiyan were faceless, and not of our making. Most demons, though, were human, and their demonism was a false and human creation. 

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2013 saw many people treated like demons: Ted Cruz, Barack Obama, Justine Sacco, Miley Cyrus, gays, the GOP, Paula Deen, Pope Francis. The list goes on*. I revere some of these demonized people, and others I don't. But inarguably these people and many others like them have fallen prey to our abbreviated, stereotyped, uncharitable understanding of the Other. The Other is, like us, flawed. Capable of great sin, even. But when we sit in judgment of them, dispassionately, unforgivingly, we commit a second sin of our own. 

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My trip to the United States Holocaust Memorial Museum was a powerful reminder of how this kind of polarization and demonization can lead to evil. One large portion of the determination it took to build that institution came from one of my favorite Georgetown professors, Michael Berenbaum. Berenbaum was an inspirational teacher at Georgetown, and in between classes he flew frequently to Europe to collect artifacts for the Holocaust Memorial Museum. A student once asked Berenbaum how he accomplished so much. Berenbaum paused at the front of the class, silent for a moment with his tie torn in honor of his recently deceased father. He had bags under his eyes from a recent transatlantic flight. "You know how you doubt yourself?" he asked, "You spend time asking, 'Can I do this?' or saying to yourself, 'I'm not smart enough?'" He said he used the time most spend on self-doubt to accomplish a little more of his life mission. In his case that mission was to help avert future evil through the remembrance of the Shoah, but whatever your mission, that there is sound advice.

So: in 2014, I will debate the issues, perhaps even loudly, but I will try my best to be civil and respectful and not to make a demon out of anyone. This is especially important precept to follow amid strong disagreement. Along the way, as much as I can, I will keep my focus on achieving my mission and not on how great or poorly I am looking along the way. 

In a related vein, critic Frank Bruni had a timely message recently: Tweet less, read more. Bruni argues that in the Age of Twitter we are too apt to make snap judgments without letting the full complexity of the situation "steep" in the way it may when we take time to ponder. As we do when reading fiction. Amen, I say, amen! Hallelujah! 

Prohibitions like these - don't hate, don't fear - are good, but they don't fill me up. As a result, I will keep this photograph in mind as well. 

Photo by Sergey Ponomarev for The New York Times (Copyright 2013)

Photo by Sergey Ponomarev for The New York Times (Copyright 2013)

Taken from the Year in Pictures at The New York Times, this is an Afghan schoolgirl, reading. Considering how hard-won the freedom to read a few words of text can be in towns like hers, this powerful reminder of the preciousness of learning and education will be one guide for me through the challenges of 2014.

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Gratitude, too, will guide me. I am grateful for the connections I made in 2014: my wonderful patients, an inspiring troupe of medical educators, our vibrant hospital ethics committee, and a motley cast of Twitter characters. I cannot imagine better company in 2014.

Happy New Year!

 

 

* PS Shortly after I posted this article, I was pained to see a crowd of science writers whom I respect sit in rather snarky judgment of another excellent writer (and my former editor), Bora Zivkovic.

Way back in 2013, Zivkovic had apologized (imperfectly) when accused of sexual harassment by more than one female science writer. As New Year's Day unfolded, Zivkovic's story looked like a hunk of red meat amid a pack of wolves. Much as it had in fall 2013.

There were many reasonable-sounding justifications for the public flogging: sexual harassment must be stomped out, Zivkovic appeared to want to make a fresh start without making enough apologies to satisfy everyone, this was a pattern that exemplifies the male power structure in science, etc etc.

What reasonable person would argue these points? What emerging science writer would dare raise his or her voice amid all that certainty, and blood? Such a person risks being lumped with perpetrators, surely.

Yet silence is not always golden. What was lost amid the din was the idea that there are more effective and more humane ways of rectifying such wrongs than a Twitter hanging. Some writers wrote they were done hearing from not only Zivkovic but a friend who supported him. "They're dead to me," that writer and her supporters seemed to say. Others, most of them not at least publicly victims of the behavior of which Zivkovic is accused, critiqued whether his apology felt ... apologetic enough.

For all involved, I hope this private problem can have a private fix. I just don't see how this public excoriation helps anybody. Certainly decrying sexual harassment in public can do good: it may well discourage other perpetrators and help define what is and what is not harassment. This is the core story to which the public dialog should hew. But this public mastication and remastication of one man's sin went beyond PSA - it looked to me like bloodlust and distracted from the main story.

Instead, private apologies and a private plan for prevention seem the way to salvage some good from this story. Most importantly, any victims (identified in public or not) should have the opportunity to hear an apology and some assurances that harassment will not recur. I get the sense from Zivkovic's writing that he is willing to make such amends and hope this indeed occurs at least to some degree of satisfaction of those he harmed.

What should the rest of us do with our typing fingers while such things occur in private? Get a PSA out there, for sure. Learn. Listen. Consider if we could commit that same sin and how we might avoid it. Most of this can occur with mouths shut and fingers still. (See Bruni, above.) And then: we move forward. 

When identifying a sin such as Zivkovic's, it is too easy to think of him as equivalent to and nothing more than the sin itself. Without considering the full scope of his humanity and his personhood, we essentially commit a second sin. It's an easy sin - we make a joke, we pass judgment, we block a Twitter account. No one of these acts is a major problem. But I worry about a society build on such a foundation.

Some would say such protestations enable the original sin itself. That whatever is done in the defense of those wronged women is fair game. This is the game of empowered white men, goes the screed. They should be quiet and take their licks. It is the turn of the downtrodden to rise up and take the stage.

I disagree. Unless we are simply trading bad power for bad power, we who think of ourselves as good should be able to think with nuance, and to hold two ideas in our heads at once. A sinner can be wronged. A victim can do wrong. (Not to imply this has occurred; I'm saying we should be able to think in more than black and white.) It'd be great if the world were divided into good and evil but the truth is most of us fall somewhere in between. Sinners and pundits look quite a lot alike, it turns out. Perhaps it is the similarity that motivates the pundits to make a starker distinction than really exists? Or perhaps we forget our own troubles for a while when we decry someone else's?

I can only hope the virtual community erected on Twitter and on blogs can learn from the mistakes made in the corporeal society that preceded it. Yes, there are invidious power structures here and we should fight them. We too need justice. But, a system of justice build on vengeance and demonization will ultimately be the downfall of all our lofty ideals. We aren't being soft on crime - we are trying not to compound the original crime with a new one.

The way forward? The original victims should expect reparation. Absolutely. But those looking on from their typewriters, from their comfortable seats at the edge of the town square, should behave as gently and as humanely in their responses to this sinner - this man - as they would hope to be treated when they too walk out into the middle of the square with their sin in full view. We all have our day. What kind of people are we? Are we vengeful, or are we just? 

Posted on January 1, 2014 .

The ethics of research in low and middle income countries

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Many developed world academic institutions are forming international partnerships to improve clinical care, education and research in developing countries. This is a great development, and one I hope will last even when it is no longer trendy. But, particularly the conduct of research in developing world countries brings with it ethical complexities: it's cross-cultural, there are power gradients, and sometimes researchers are motivated more by pecuniary gain than true altruism. To help manage these risks, so our outreach can be most effective and least undermined by such factors, I wrote a review of the history and approach to the ethics of research in low and middle income countries

Posted on December 22, 2013 .

HIV doesn't happen here

The rural state of New Hampshire has some of the lowest HIV incidence and prevalence rates in the United States. That's great news, but it comes with a price. 

Many at risk people in New Hampshire think HIV is a third world or city problem and not something they need to worry about personally. That means they are less likely to take precautions against HIV. 

At the same time, people who have been diagnosed with HIV in New Hampshire face stigma from neighbors and friends who may be less familiar with HIV than people living in urban areas where the disease is more prevalent. Geography adds to those challenges: the ~650 people cared for at Dartmouth-Hitchcock HIV Program come from a much wider geographic area than patients in similarly sized clinics in metropolitan areas. That translates to longer travel times and more complicated access to care.

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Not surprisingly, HIV patients living in rural areas have been shown by Sam Bozzette and others to receive substandard care, probably because HIV experts are not sufficiently accessible.

In formal analyses at the Dartmouth-Hitchcock HIV Program, our HIV expert providers  delivered outstanding care equivalently to rural and urban patients  But despite this my colleagues and I showed that our rural patients have higher rates of depression and even higher mortality. New Hampshire might be a lovely place to live, but living with HIV infection anywhere is no walk in the park. 

Todd Bookman of NHPR touches on these and other issues in nice  radio story in which I was quoted. There are still plenty of battles remaining in the war against HIV in New Hampshire.

Posted on December 18, 2013 .