Negotiation of risk in sexual relationships and reproductive decision-making amongst HIV sero-different couples

The paper focuses on the ways in which medical discourses of HIV transmission risk, personal bodily meanings and reproductive decision-making are re-negotiated within the context of sero-different relationships, in which one partner is known to be HIV-positive. Eighteen in-depth interviews were conducted with 10 individuals in Northern Ireland during 2008–2009. Drawing on an embodied sociological approach, the findings show that physical pleasure, love, commitment, a desire to conceive without medical interventions and a dislike of condoms within regular ongoing relationships, shaped individuals' sense of biological risk. In addition, the subjective logic that a partner had not previously become infected through unprotected sex prior to knowledge of HIV status and the added security of an undetectable viral load significantly impacted upon women's and, especially, men's decisions to have unprotected sex in order to conceive. The findings speak to the importance of reframing public health campaigns and clinical counselling discourses on HIV risk transmission to acknowledge how couples negotiate this risk, alongside pleasure and commitment within ongoing relationships.

Creating continuity out of the disruption of a diagnosis of HIV during pregnancy

AIM: To understand the uniqueness of the experience of testing HIV positive from the perspective of pregnant women.

BACKGROUND: As more people learn of their HIV diagnosis through routine screening processes, it is timely to reflect on the impact of receiving an unexpected positive result.

DESIGN: A prospective qualitative study.

METHODS: This paper draws on the case studies of four women who were participating in a larger prospective qualitative study of reproductive decision-making, pregnancy and childbirth following HIV diagnosis. Multiple interviews were conducted following diagnosis during pregnancy, and, after the birth of their babies. Thematic data analysis was undertaken.

RESULTS: Drawing on Becker's theory of disruption, we document the 'sudden disjuncture' of their antenatal diagnosis and the embodied emotional struggle the women engaged in to create continuity in their lives. A diagnosis of HIV disrupted the women's biographies in terms of their health, relationships and social identity. As pregnant women, the threat of HIV was experienced most significantly in relation to their unborn child. However, their narratives also revealed how a diagnosis of HIV in the context of pregnancy, whilst traumatic, provided a focus for regaining continuity in their lives, as the baby became a metaphor for hope and orientation toward the future.

CONCLUSIONS: As HIV testing becomes more 'routine', the findings of this study serve to remind health professionals that a positive diagnosis continues to constitute a major trauma to individuals and families.

RELEVANCE TO CLINICAL PRACTICE: We propose that appropriately educated nursing and midwifery staff could facilitate the 'meaning making' process that is required for newly diagnosed HIV positive persons to find a subjective sense of well-being in their lives.

Expression of toll-like receptors by human muscle cells in vitro and in vivo:TLR3 is highly expressed in inflammatory and HIV myopathies, mediates IL-8 release and up-regulation of NKG2D-ligands

The particular microenvironment of the skeletal muscle can be the site of complex immune reactions. Toll-like receptors (TLRs) mediate inflammatory stimuli from pathogens and endogenous danger signals and link the innate and adaptive immune system. We investigated innate immune responses in human muscle. Analyzing TLR1-9 mRNA in cultured myoblasts and rhabdomyosarcoma cells, we found constitutive expression of TLR3. The TLR3 ligand Poly (I:C), a synthetic analog of dsRNA, and IFN-gamma increased TLR3 levels. TLR3 was mainly localized intracellularly and regulated at the protein level. Poly (I:C) challenge 1) activated nuclear factor-kappaB (NF-kappaB), 2) increased IL-8 release, and 3) up-regulated NKG2D ligands and NK-cell-mediated lysis of muscle cells. We examined muscle biopsy specimens of 6 HIV patients with inclusion body myositis/polymyositis (IBM/PM), 7 cases of sporadic IBM and 9 nonmyopathic controls for TLR3 expression. TLR3 mRNA levels were elevated in biopsy specimens from patients with IBM and HIV-myopathies. Muscle fibers in inflammatory myopathies expressed TLR3 in close proximity of infiltrating mononuclear cells. Taken together, our study suggests an important role of TLR3 in the immunobiology of muscle, and has substantial implications for the understanding of the pathogenesis of inflammatory myopathies or therapeutic interventions like vaccinations or gene transfer.

'Every pregnant woman needs a midwife'--the experiences of HIV affected women in maternity care

TITLE: 'Every pregnant woman needs a midwife'-the experiences of HIV affected women in Northern Ireland.

OBJECTIVE: to explore HIV positive women's experiences of pregnancy and maternity care, with a focus on their interactions with midwives.

DESIGN: a prospective qualitative study.

SETTING: regional HIV unit in Northern Ireland.

PARTICIPANTS: 22 interviews were conducted with 10 women at different stages of their reproductive trajectories.

FINDINGS: the pervasive presence of HIV related stigma threatened the women's experience of pregnancy and care. The key staff attributes that facilitated a positive experience were knowledge and experience, empathy and understanding of their unique needs and continuity of care.

KEY CONCLUSIONS: pregnancy in the context of HIV, whilst offering a much needed sense of normality, also increases woman's sense of anxiety and vulnerability and therefore the need for supportive interventions that affirm normality is intensified. A maternity team approach, with a focus on providing 'balanced care' could meet all of the woman and child's medical needs, whilst also emphasising the normalcy of pregnancy.

Explanations for child sexual abuse given by convicted offenders in Malawi:no evidence for "HIV cleansing"

OBJECTIVE: A commonly cited, but unproven reason given for the rise in reported cases of child sexual abuse in Sub-Saharan Africa is the "HIV cleansing myth"-the belief that an HIV infected individual can be cured by having sex with a child virgin. The purpose of this study was to explore in Malawi the reasons given by convicted sex offenders for child sexual abuse and to determine if a desire to cure HIV infection motivated their offence.

METHODS: Offenders convicted of sexual crimes against victims under the age of 18 were interviewed in confidence in Malawi's two largest prisons. During the interview the circumstances of the crime were explored and the offenders were asked what had influenced them to commit it. Each participant was asked the closed question "Did you think that having sex with your victim would cure or cleanse you from HIV?"

RESULTS: 58 offenders agreed to participate. The median (range) age of offenders and victims was 30 (16-66) years and 14 (2-17) years, respectively. Twenty one respondents (36.2%) denied that an offence had occurred. Twenty seven (46.6%) admitted that they were motivated by a desire to satisfy their sexual desires. Six (10.3%) stated they committed the crime only because they were under the influence of drugs or alcohol. None of the participants said that a desire to cure or avoid HIV infection motivated the abuse.

CONCLUSION: This study suggests that offenders convicted of a sexual crime against children in Malawi were not motivated by a desire to be cured or "cleansed" from HIV infection. A need to fulfil their sexual urges or the disinhibiting effect of drugs or alcohol was offered by the majority of participants as excuses for their behaviour.

Lights and Shadows about the Effectiveness of IVF in HIV Infected Women: A Systematic Review

Background. HIV infected women have higher rates of infertility. Objective. The purpose of this literature review is to evaluate the effectiveness of fresh IVF/ICSI cycles in HIV infected women. Materials and Methods. A search of the PubMed database was performed to identify studies assessing fresh nondonor oocyte IVF/ICSI cycle outcomes of serodiscordant couples with an HIV infected female partner. Results and Discussion. Ten studies met the inclusion criteria. Whenever a comparison with a control group was available, with the exception of one case, ovarian stimulation cancelation rate was higher and pregnancy rate (PR) was lower in HIV infected women. However, statistically significant differences in both rates were only seen in one and two studies, respectively. A number of noncontrolled sources of bias for IVF outcome were identified. This fact, added to the small size of samples studied and heterogeneity in study design and methodology, still hampers the performance of a meta-analysis on the issue. Conclusion. Prospective matched case-control studies are necessary for the understanding of the specific effects of HIV infection on ovarian response and ART outcome.

The new EASL guidelines for the management of chronic hepatitis B infection adapted for Swiss physicians.

Since the arrival of several new antivirals and due to the growing molecular and clinical knowledge of hepatitis B virus (HBV) infection, therapy of hepatitis B has become complex. Clinical guidelines aim at streamlining medical attitudes: in this respect, the European Association for the Study of the Liver (EASL) recently issued clinical practice guidelines for the management of chronic hepatitis B. Guidelines made by international experts need however to be adapted to local health care systems. Here, we summarise the EASL guidelines with some minor modifications in order to be compatible with the particular Swiss situation, while discussing in more detail some aspects. Chronic hepatitis B is a complex disease with several phases where host and viral factors interact: the features of this continuous interplay need to be evaluated when choosing the most appropriate treatment. The EASL guidelines recommend, as first-line agents, using the most potent antivirals available with the optimal resistance profile, in order to abate HBV DNA as rapidly and as sustainably as possible. Once therapy has been started, the infection evolves and resistant viral strains may emerge. Rescue therapy needs to be started early with more potent agents lacking cross-resistance.

Common genetic variation and the control of HIV-1 in humans.

To extend the understanding of host genetic determinants of HIV-1 control, we performed a genome-wide association study in a cohort of 2,554 infected Caucasian subjects. The study was powered to detect common genetic variants explaining down to 1.3% of the variability in viral load at set point. We provide overwhelming confirmation of three associations previously reported in a genome-wide study and show further independent effects of both common and rare variants in the Major Histocompatibility Complex region (MHC). We also examined the polymorphisms reported in previous candidate gene studies and fail to support a role for any variant outside of the MHC or the chemokine receptor cluster on chromosome 3. In addition, we evaluated functional variants, copy-number polymorphisms, epistatic interactions, and biological pathways. This study thus represents a comprehensive assessment of common human genetic variation in HIV-1 control in Caucasians.

Parents living with HIV in a high-income country: do patients need specific support?

The number of HIV-infected persons with children and caregiving duties is likely to increase. From this statement, the present study was designed to establish how HIV infected caregivers organise their parenting routines and to determine their support needs. A further aim was to ascertain caregivers' perception of conspicuous behaviours displayed by their children. Finally, it sought to determine the extent to which the caregivers' assessment of their parenting activity is influenced by the required support and their children's perceived conspicuous behaviours. The study design was observational and cross-sectional. Sampling was based on the 7 HIV Outpatient Clinics associated with the national population-based Swiss HIV Cohort Study. It focused on persons living with HIV who are responsible for raising children below the age of 18. A total of 520 caregivers were approached and 261 participated. An anonymous, standardised, self-administered questionnaire was used for data collection. The data were analysed using descriptive statistical procedures and backward elimination multiple regression analysis. The 261 respondents cared for 406 children and adolescents under 18 years of age; the median age was 10 years. The caregivers' material resources were low. 70% had a net family income in a range below the median of Swiss net family income and 30% were dependent on welfare assistance. 73% were undergoing treatment with 86% reporting no physical impairments. The proportion of single caregivers was 34%. 92% of the children were living with their HIV infected caregivers. 80% of the children attended an institution such as a school or kindergarten during the day. 89% of the caregivers had access to social networks providing support. Nevertheless, caregivers required additional support in performing their parenting duties and indicated a need for assistance on the material level, in connection with legal problems and with participation in the labour market. 46% of the caregivers had observed one or more conspicuous behaviours displayed by their children, which indicates a challenging situation. However, most of these caregivers assessed their parenting activity very favourably. Backward elimination multiple regression analysis indicated that a smaller number of support needs, younger age of the eldest child and fewer physical impairments on the part of the caregiver enhance the caregivers' assessment of their parenting activity. Physicians should speak to caregivers living with HIV about their parenting responsibilities and provide the necessary scope for this subject in their consultation sessions. Physicians are in a position to draw their patients' attention to the services available to them.

HIV-1 vaccines and adaptive trial designs.

Developing a vaccine against the human immunodeficiency virus (HIV) poses an exceptional challenge. There are no documented cases of immune-mediated clearance of HIV from an infected individual, and no known correlates of immune protection. Although nonhuman primate models of lentivirus infection have provided valuable data about HIV pathogenesis, such models do not predict HIV vaccine efficacy in humans. The combined lack of a predictive animal model and undefined biomarkers of immune protection against HIV necessitate that vaccines to this pathogen be tested directly in clinical trials. Adaptive clinical trial designs can accelerate vaccine development by rapidly screening out poor vaccines while extending the evaluation of efficacious ones, improving the characterization of promising vaccine candidates and the identification of correlates of immune protection.

Will the "fight" ever end? : a critical reading of the metaphors and discourses that construct HIV/AIDS in an African context

In this thesis, I critically examine the discourses that inform how we conceptualise HIV/AIDS in Sub-Saharan Africa as they are produced in a sample of Canadian news articles, two nonfiction texts - Stephanie Nolen's 28 Stories of AIDS in Africa and Jonathan Morgan and the Bambanani Women's Group's Long Life ... Positive HIV Stories - as well as two literary texts - John Le Carre's popular fiction novel The Constant Gardener and an anthology of stories and poems from Southern Africa titled Nobody Ever Said AIDS, compiled and edited by Nobantu Rasebotsa, Meg Samuelson and Kylie Thomas. Paying particular attention to the role of metaphor in discursive formation, I have found that military metaphors, usually used in conjunction with biomedical discourses, continue to dominate what is said about HIV/AIDS. However, the use of military metaphors to conceptualise HIV/AIDS contributes to stigma and limits the effectiveness of responses to the pandemic. I argue that accessing alternative metaphors and discourses, such as biopsychosocial discourse, can lead to a more layered - and more beneficial - conceptualisation of HIV/AIDS, encouraging a more active response to the pandemic.

An educator's perspective of Dr. Feingold's K-P (Kaiser- Permanents) elimination diet for hyperkinetic children and others

Do evaluation of the literature and a regional observational report support Dr. Feingold's claim that the K-P (Kaiser-Permanente) elimination diet improves the behaviours of hyperkinetic children, and others? Dr. Feingold suggests that some hyperkinetic children, and other children as well, are genetically predisposed to intolerance of food additives, particularly food colours and flavours. He claims that the K-P diet, that eliminates salicylates and artificial food colours and flavours, improves the hyperkinetic child's behaviour, muscle co-ordination, and scholastic performance. Public acceptance of the K-P diet has outstripped acceptance in the medical and scientific communities. Evaluation of available data and additional studies are needed to arrive at a conclusion of acceptance or rejection of the K-P diet for hyperkinetic children and others. My interest in the K-P elimination diet for hyperkinetic children is educational. My experience as an elementary school teacher in special education and in the classroom from K-8 has taught me that attentiveness is crucial to learning. Hyperkinesis appears to impair a child's ability to attend. Learning problems appear, followed by behavioural and social problems. l If we accept the possibility of a relationship between diet and attentiveness, and attentiveness and school behaviours, then the diet-behaviour link could be of lay importance. For instance, if a diet such as the K-P diet could do what is claimed, substantial benefits could accrue to the child. One could, for example, improve a child's behaviours. One could identify attending disturbances early in the child's education, possibly minimizing, or eliminating future difficulties in school. Finally, the greatest benefit may be the fulfillment of the basic goal of our Ontario schools, that the eh~ld-,lIla1p.evelop happily and competently within our educational framework. 2 This thesis reports evidence from the literature and from a regional observational investigation to determine the possibility of a link between the behaviours of children and Dr. Feingold's K-P elimination diet. The literature research examines (1) Dr. Feingold's concept of H-LD, (2) his K-P elimination diet, and (3) the response from three sectors, medicine, science, and the public. The regional investigation examines the observed behaviours of nine children in Regional Niagara during a nine-month period on the K-P diet.

Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation - a factorial survey of medical students in China

Background
HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.

Methods
The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis (AIDS, leukaemia, or no disease) and a co-characteristic (IDU, CS, commercial blood donation (CBD), blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.

Results
Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.

Conclusion
The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context.