title: HIV and pregnancy

text:
HIV in pregnancy is the presence of an HIV/AIDS infection in a woman while she is pregnant. There is a risk of HIV transmission from mother to child in three primary situations: pregnancy, childbirth, and while breastfeeding. This topic is important because the risk of viral transmission can be significantly reduced with appropriate medical intervention, and without treatment HIV/AIDS can cause significant illness and death in both the mother and child. This is exemplified by data from The Centers for Disease Control (CDC): In the United States and Puerto Rico between the years of 2014–2017, where prenatal care is generally accessible, there were 10,257 infants in the United States and Puerto Rico who were exposed to a maternal HIV infection in utero who did not become infected and 244 exposed infants who did become infected.

The burden of the HIV/AIDS pandemic, including mother-to-child transmission of HIV, disproportionately affects low- and middle-income countries, in particular the countries of Southern Africa.  The World Health Organization (WHO) estimates that 1.3 million women and girls living with HIV become pregnant each year.

The risks of both neonatal HIV infection and maternal illness are reduced by appropriate prenatal screening, treatment of the HIV infection with antiretroviral therapy (ART), and adherence to  recommendations after birth. Notably, without antiretroviral medications, obstetrical interventions, and breastfeeding recommendations, there is approximately a 30% risk of mother-to-child HIV transmission. This risk is reduced to less than 1% when the previously mentioned interventions are employed. The American College of Obstetrics and Gynecology (ACOG) therefore recommends HIV testing as a routine component of both pre-pregnancy and first trimester prenatal care to ensure expedient and appropriate interventions.

HIV infection is not a contraindication to pregnancy. Women with HIV may choose to become pregnant if they so desire, however, they are encouraged to talk with their doctors beforehand. Notably, 20-34% of women in the United States living with HIV are unaware of their diagnosis until they become pregnant and undergo prenatal screening.

Mechanism of transmission
HIV can be transmitted from an infected mother to the neonate in three circumstances: across the placenta during pregnancy (in utero), at birth due to fetal contact with infected maternal genital secretions and blood, or postnatally through the breast milk. This type of viral transmission is also known of as vertical transmission. It is thought that mother-to-child HIV transmission most commonly occurs at the time of delivery when the baby comes into direct contact with the mother's infected blood or genital secretions/fluid in the birth canal. Maternal treatment with ART therapy prior to delivery decreases the viral load, or the amount of virus present in the mother's blood and other body fluids, which significantly reduces the chance of viral transmission to the fetus during labor.

Signs or symptoms

Maternal
HIV infections in adults typically follow a 3-stage course, as described below:

Early, acute stage The early stage of an HIV infection involves rapid viral replication and infection. This stage typically lasts for 2–4 weeks following an infection and subsequently resolves spontaneously. Between 50 and 90% of adults experience symptoms during this phase of infection. At this time, women can experience fever, sore throat, lethargy, swollen lymph nodes, diarrhea, and a rash. The rash is described as maculopapular, which means it is composed of flat and raised skin lesions, and it appears on the trunk, arms and legs but does not appear on the palms of the hands or sole of the feet.
Middle, chronic/latent stage The middle stage of an HIV infection can last for 7–10 years in a patient who is not being treated with ART therapy. During this time, the virus itself is not latent or inactive, but it is sequestered inside of the lymph nodes, where it is replicating at low levels. Women are generally asymptomatic during this period but some can experience persistent fevers, fatigue, weight loss, and swollen lymph nodes, which is known as the AIDS-related complex (ARC).
Late, advanced/immunodeficient stage AIDS is caused by the progressive destruction of CD4 T-helper cells of the immune system by the HIV virus. AIDS is defined by either a CD4 cell count of less than 200 cells per microliter (which is indicative of severe immunodeficiency), or the development of an AIDS-specific condition. Because they are immunocompromised, women in this stage are at risk for serious, opportunistic infections that the general population either does not contract or contracts very mildly. These types of infections cause significant illness and death in patients with HIV/AIDS. People with such advanced HIV infections are also at greater risk for developing neurological symptoms (for example dementia and neuropathy), and certain cancers (for example Non-Hodgkin's B-Cell Lymphoma, Kaposi's Sarcoma, and HPV-associated cancers including anal, cervical, oral, pharyngeal, penile and vulvar cancer).

Infant

The clinical presentation of HIV in untreated infants is less predictable and specific than that of an adult infection. Notably, if an HIV diagnosis is diagnosed and appropriately treated, symptoms and complications in the infant are rare. Without ART therapy, infants born with HIV have a poor prognosis. If symptoms develop, the most common include persistent fevers, generalized lymph node swelling, enlarged spleen and/or liver, growth failure, and diarrhea. These children can also develop opportunistic infections, notably including recurrent oral thrush (Candidiasis) and/or Candida diaper rash, pneumonia, or invasive bacterial, viral, parasitic, or fungal infections. Neurologic symptoms, particularly HIV encephalopathy, are common in infants with untreated HIV.

Diagnosis/screening

Pregnancy planning
The main factors to consider in pregnancy planning for HIV positive individuals are the risk of disease transmission between the sexual partners themselves and the risk of disease transmission to the fetus. Both risks can be mitigated with appropriate perinatal planning and preventative care.

ACOG and the National Institutes of Health (NIH) recommends all couples in which one or both partners are HIV positive seek pre-pregnancy counseling and consult experts in Obstetrics and Gynecology, Infectious Disease, and possibly reproductive endocrinology and infertility to ensure couples are getting appropriate, individualized guidance based on their specific disease states and weighing the risks to the fetus associated with taking ART medications.

Couples in which only one partner is HIV positive are at risk of transmitting HIV to the uninfected partner. These couples are known as serodiscordant couples. The CDC reports that HIV positive people who are able to sustain undetectable viral loads while taking ART therapy have a negligible risk of transmitting HIV to their partner through sex based on observational data from multiple large scale studies, most notably the HPTN052 clinical trial, the PARTNER study, the PARTNER2 study, and the Opposites Attract Study. The NIH therefore advises that HIV positive people who maintain an undetectable viral load via adherence to long-term ART therapy can attempt conception via condomless sex with minimal risk of disease transmission to the HIV negative partner. The NIH further recommends that aligning condomless sex with peak fertility, which occurs at ovulation, via ovulation test kits and consultation with clinical experts can maximize the chance for conception.

When the HIV positive individual in a serodiscordant partnership has not achieved viral suppression or his or her viral status is unknown, there are other options for preventing transmission amongst partners. The first option includes administering Pre-Exposure Prophylaxis ART Therapy (PrEP) to the HIV negative partner, which involves once daily dosing of a combination drug to prevent the transmission of HIV following condomless sex. The NIH advises administering PrEP to serodiscordant couples who are going to attempt conception via condomless sex, however, they emphasize that adherence is absolutely necessary to effectively protect the HIV negative partner. The other option for achieving conception while simultaneously preventing HIV transmission amongst partners is reproductive assistance. When the female attempting to conceive is HIV positive, she can undergo assisted insemination with semen from her partner to reduce the risk of transmission. When the man in the partnership is HIV positive, the couple can choose to use donor sperm or utilize sperm preparation techniques (for example, sperm washing and subsequent viral testing of the sample) and intrauterine or in vitro fertilization to achieve conception to reduce the risk of transmission to his partner.

In couples where the male and female are both HIV positive, conception may occur normally without concern for disease transmission amongst each other. However, it is vital for any HIV positive mother to initiate and maintain appropriate ART therapy under the guidance of an HIV expert prior to and throughout pregnancy to reduce the risk of perinatal transmission to the fetus.

Although assisted reproductive techniques are available for serodiscordant couples, there are still limitations to achieving a successful pregnancy. women with HIV have been shown to have decreased fertility, which can affect the available reproductive options. women with HIV are also more likely to be infected with other sexually transmitted diseases, placing them at higher risk for infertility. Males with HIV appear to have decreased semen volume and sperm motility, which decreases their fertility. ART may also affect both male and female fertility and some drugs can be toxic to embryos.

Testing in pregnancy

Early identification of maternal HIV infection and initiation of ART in pregnancy is vital in preventing viral transmission to the fetus and protecting maternal health, as HIV-infected women who do not receive testing are more likely to transmit the infection to their children.  The CDC, NIH, ACOG, and American Academy of Pediatrics each recommend first trimester HIV testing for all pregnant women as a part of routine prenatal care. The NIH further elaborates on this recommendation, indicating that HIV testing should be conducted as early as possible wherever a woman seeks care and initially determines she is pregnant (for example, in the Emergency Department). First trimester HIV testing is conducted simultaneously with other routine, early pregnancy lab work in the United States, including: a complete blood count, blood typing and Rhesus factor, urinalysis, urine culture, rubella titer, hepatitis B and C titers, sexually transmitted infection testing, and tuberculosis testing.  ACOG advises that prenatal caregivers repeat third trimester HIV testing prior to 36 weeks gestation for the following women: those who remain at high risk for contracting an HIV infection, those who reside in areas with a high incidence of HIV infection in pregnancy, those who are incarcerated, or those with symptoms suggestive of an acute HIV infection. For women who have not received prenatal care or who have not been previously tested for HIV infection during pregnancy, ACOG and the NIH suggest performing rapid HIV screening in the labor and delivery unit prior to delivery or immediately postpartum.

HIV testing in the United States is currently offered on an opt-out basis, per the CDC's recommendation. Opt-out testing involves educating the patient on the impact of an HIV infection on pregnancy, notifying the patient that HIV screening is recommended for all pregnant women, and informing her that she will automatically receive the test with her other routine lab work unless she explicitly declines the test and signs a consent form to have it removed from her lab panel. The alternative model, known as the opt-in model, involves counseling women on HIV testing, following which they elect to receive the test by signing a consent form. The opt-in model is not recommended by the CDC, as it is associated with lower testing rates.

If a woman chooses to decline testing, she will not receive the test. However, she will continue to receive HIV counseling throughout pregnancy so that she may be as informed as possible about the disease and its potential impact. She will be offered HIV testing at all stages of her pregnancy in case she changes her mind.

The most updated HIV testing protocols recommend using the HIV-1 and HIV-2 antigen/antibody combination immunoassay as the initial screening test for an HIV infection. This blood test assesses whether or not the mother has created antibodies, which are disease-fighting proteins of the immune system, against the HIV-1 and HIV-2 viruses. These antibodies will only be present if the patient has been exposed to HIV, therefore, they act as a marker of infection. This test also detects a protein called p24 in maternal blood, which is a specific component of the HIV virus itself and also acts as an early marker of an HIV infection. If this test is positive, the CDC recommends performing follow-up testing using a test called the HIV-1/HIV-2 antibody differentiation immunoassay that both confirms the diagnosis and determines the specific type of HIV infection the patient has to specifically tailor further management of the patient.

Sometimes, however, a person may be infected with HIV but the body has not produced enough antibodies to be detected by the test. If a woman has risk factors for HIV infection or symptoms of an acute infection but tests negative on the initial screening test, she should be retested in 3 months to confirm that she does not have HIV, or she should receive further testing with an HIV RNA assay, which can be positive earlier than the antibody/antigen immunoassay. Antiretroviral medications should be initiated at the time of maternal HIV diagnosis and they should be continued indefinitely.

Treatment/management

Prenatal care

Prevention of mother-to-child transmission
The risk of HIV transmission from mother to child is most directly related to the plasma viral load of the mother. Untreated mothers with a high  (HIV RNA greater than 100,000 copies/mL) have a transmission risk of over 50%. For women with a lower viral load (HIV RNA less than 1000 copies/mL), the risk of transmission is less than 1%. In general, the lower the viral load, the lower the risk of transmission. For this reason, ART is recommended throughout the pregnancy so that viral load levels remain as low as possible and the risk of transmission is reduced. The usage of ART drugs that effectively cross the placenta can also act as pre-exposure prophylaxis for the infant, as they can achieve adequate ART drug levels in the fetus to prevent acquisition of the viral illness. Finally, it is recommended that ART drugs be administered to the infant following birth to continue to provide protection from the virus that the infant could have been exposed to during labor and delivery.

All pregnant women who test positive for HIV should begin and continue ART therapy regardless of CD4 counts or viral load to reduce the risk of viral transmission. The earlier ART is initiated, the more likely the viral load will be suppressed by the time of delivery. Some women are concerned about using ART early in the pregnancy, as babies are most susceptible to drug toxicities during the first trimester.  However, delaying ART initiation may be less effective in reducing infection transmission.

Antiretroviral therapy is most importantly used at the following times in pregnancy to reduce the risk of mother-to-child transmission of HIV:
 During pregnancy: pregnant women infected with HIV receive an oral regimen of at least three different anti-HIV medications.
 During labor and delivery: pregnant women infected with HIV who are already on triple ART should continue with their oral regimen. If their viral load is high (HIV RNA greater than 1,000 copies/mL), or there is question about whether medications have been taken consistently, then intravenous zidovudine (AZT) is added at the time of delivery. Pregnant women who have not been on ART prior to delivery or who have been on ART for less than four weeks should also be given intravenous AZT or a single dose of nevirapin (sdNVP), tenofovir (TDF) and emtricitabine (FTC) and a three-hourly dose of AZT.
According to current recommendations by the WHO, CDC and U.S. Department of Health and Human Services (DHHS), all individuals with HIV should begin ART as soon as they are diagnosed with HIV. The recommendation is stronger in the following situations:
 CD4 count below 350 cells/mm3
 High viral load (HIV RNA greater than 100,000 copies/mL)
 Progression of HIV to AIDS
 Development of HIV-related infections and illnesses
 Pregnancy

Labor and delivery
Women should continue taking their ART regimen on schedule and as prescribed throughout both the prenatal period and childbirth. The viral load helps determine which mode of delivery is safest for both the mother and the baby.

According to the NIH, when the mother has been receiving ART and her viral load is low (HIV RNA less than 1000 copies/mL) at the time of delivery, the risk of viral transmission during childbirth is very low and a vaginal delivery may be performed. A cesarean delivery or induction of labor should only be performed in this patient population if they are medically necessary for non-HIV-related reasons.

If the maternal viral load is high (HIV RNA greater than 1000 copies/mL) or if her HIV viral load is unknown around the time of delivery (more than 34 weeks gestation), it is appropriate to schedule a cesarean delivery at 38 weeks to reduce the risk of HIV transmission during childbirth. In these situations, this is the appropriate management guideline regardless of whether or not the mother has taken prenatal ART.

Sometimes, women who have a high viral load who should receive a caesarean delivery will present to the hospital when their water breaks or they are in labor, and management for these patients is specific to each patient and will be determined at the time of presentation, as a cesarean delivery may not significantly reduce the risk of infection transmission. The NIH recommends that healthcare providers in the United States contact the National Perinatal HIV/AIDS Clinical Consultation Center at 1-888-448-8765 for further recommendations in these situations.

All women who present to the hospital in labor and their HIV status is unknown or they are at high risk of contracting an HIV infection but have not received repeat third trimester testing should be tested for HIV using a rapid HIV antigen/antibody test. If the rapid screening is positive, intravenous (IV) zidovudine should be initiated in the mother immediately and further confirmatory testing should be performed.

IV Zidovudine is an antiretroviral drug that should be administered to women at or near the time of delivery in the following situations:
 High viral load (HIV RNA greater than 1000 copies/mL)
 Unknown viral load
 Clinical suspicion for maternal noncompliance with prenatal ART regimen
 Positive rapid HIV antigen/antibody test at labor or prior to a scheduled caesarean delivery

Administration of IV Zidovudine can be considered on a case-by-case basis for women who have a moderate viral load (HIV RNA greater than or equal to 50 copies/mL AND less than 1000 copies/mL) near the time of delivery. IV Zidovudine is only not administered if women are both compliant with their prescribed ART regimen throughout pregnancy and have maintained a low viral load near the time of delivery (HIV RNA less than 50 copies/mL between 34 and 36 weeks gestation).

Further considerations for managing HIV positive women during labor and delivery include the following recommendations to reduce the risk of HIV transmission:
 Avoid fetal scalp electrodes for fetal monitoring, particularly if the maternal viral load is greater than 50 copies/mL.
 Avoid artificial rupture of membranes and operative vaginal delivery (using forceps or a vacuum extractor) if at all possible, particularly in women who have not achieved viral suppression. If these methods need to be employed, they should be conducted carefully and following obstetric standards.
 The potential interactions between the specific ART drugs taken by the mother and those administered during labor should be considered by healthcare providers prior to drug administration.

Immunizations
All pregnant women should receive the inactivated influenza vaccine and the TdaP vaccine, which covers tetanus, diphtheria, and pertussis (whooping cough) during the first trimester, regardless of their HIV status. If a pregnant woman tests positive for HIV, she should also be administered the pneumococcal vaccine, meningococcal vaccine, and Hepatitis A vaccine and Hepatitis B vaccine following a conversation with her provider. Vaccination is important to prevent serious infectious complications associated with the aforementioned diseases, which patients with HIV are at higher risk of contracting.

Pregnant women should notably not receive live vaccines, including the Human papilloma virus (HPV) vaccine, measles mumps and rubella (MMR) vaccine, live influenza vaccine, and varicella (Chicken pox) vaccine regardless of their HIV statuses, as these vaccines can potentially harm the fetus.

Further evaluation
The following monitoring tests are recommended for women who are diagnosed with HIV prior to or during pregnancy:
 HIV Viral Load (via HIV RNA Levels) at the initial prenatal visit, 2–4 weeks after starting or changing ART, monthly until viral load is undetectable, at least every 3 months subsequently throughout pregnancy, and between 34 and 36 weeks to inform decisions regarding labor and delivery.
 CD4 Count at the initial prenatal visit. This lab should be repeated every 3 months for pregnant women have been on ART for less than 2 years, have inconsistent ART compliance, CD4 counts less than 300 cells per millimeter cubed, or a high viral load. Otherwise, CD4 count does not need to be monitored following the initial visit.
 HIV Drug Resistance Testing should be performed prior to initiating ART in any pregnant woman including those who have and have not taken antiretroviral medications before, and when modifying failing ART regimens for pregnant women. Note, ART should be initiated prior to receiving the results of drug resistance testing.
 Standard Glucose Screening to monitor for gestational diabetes.
 Liver Function Tests within 2–4 weeks after initiating or changing ART drugs and every 3 months subsequently.
 Monitoring for ART Toxicities based on the specific drugs that have been prescribed.
 Aneuploidy Screening should initially be offered via noninvasive methods. If these tests are abnormal or an abnormal ultrasound is performed, invasive testing via amniocentesis or chorionic villus sampling can be performed once an ART has been initiated and the HIV viral load is undetectable.
 Hepatitis A, B, and C Screening should be performed in all pregnant women with HIV because coinfection is common.
 Further Sexually Transmitted Infection (STI) Screening should be performed as HIV positive women are at a higher risk for co-infection than the general population, and exposure to other STIs is associated with stillbirth, preterm delivery, low birth weight, and other complications. Screening should include syphilis, gonococcal, chlamydial, and trichomonal infection.
 Tuberculosis Testing as HIV positive patients are at high risk for developing active tuberculosis.
 Testing for prior Toxoplasma Exposure should be performed in HIV infected pregnant women, as reactivation of Toxoplasma gondii infection can occur with a low CD4 count (less than 100 cells per microliter), and has the potential to cause congenital toxoplasmosis in the fetus, which has many associated birth complications.
 Testing for Cytomegalovirus (CMV) Exposure should similarly be performed, as CMV is the most common congenital infection and is associated with congenital hearing loss, major handicaps, and death in exposed infants.

Antiretroviral medications
The goals of antiretroviral administration during pregnancy are to reduce the risk of transmission of HIV from mother to child, to slow maternal disease progression, and to reduce the risks of maternal opportunistic infection and death. It is important to choose medications that are as safe as possible for the mother and the fetus, and are effective at decreasing the total viral load. Certain antiretroviral drugs carry a risk of toxicity for the fetus. However, the overall benefits of an effective ART regimen outweigh the risks and all women are encouraged to use ART for the duration of their pregnancy. It is important to note that the associations between birth defects and antiretroviral drugs are confounded by several important factors that could also contribute to these complications, for example: exposure to folate antagonists, nutritional and folate status, and tobacco, alcohol, and drug use during pregnancy.

The recommended ART regimen for HIV-positive pregnant women is similar to that of the general population. In the United States, the favored ART regimen is a three-drug routine in which the first two drugs are NRTIs and the third is either a protease inhibitor, an integrase inhibitor, or an NNRTI.
 Nucleoside reverse transcriptase inhibitors (NRTIs) are considered the "backbone" of ART and 2 of these medications are generally used in combination.
 Due to its known safety profile and extensive use in pregnant patients, zidovudine-lamivudine is the preferred choice as the NRTI backbone. Zidovudine may worsen anemia so anemic patients are advised to use an alternative agent.
 For women who are coinfected with hepatitis B, tenofovir with either emtricitabine or lamivudine is the preferred NRTI backbone.
 NRTI use may cause a life-threatening complication called lactic acidosis in some women, so it is important to monitor patients for this problem. Deaths from lactic acidosis and liver failure have been primarily associated with two specific NRTIs, stavudine and didanosine. Therefore, combinations involving these drugs should be avoided in pregnancy.
 Protease inhibitors (PIs) have been studied extensively in pregnancy and are therefore the preferred third drug in the regimen. Atazanavir-ritonavir and darunavir-ritonavir are two of the most common PIs used during pregnancy.
 There is conflicting data regarding the association between protease inhibitors with preterm births. Boosted lopinavir has the strongest correlation with this outcome, so women who are at a high risk for premature delivery are advised not to use this drug.
 Some PIs have been associated with high blood sugar (hyperglycemia) but is unclear whether or not they contribute to the development of gestational diabetes.
 Some PIs have been noted to cause hyperbilirubinemia and nausea, so these side effects should be monitored for closely.
 Integrase inhibitors (IIs) are generally the third drug in the regimen when a PI cannot be used. They rapidly reduce the viral load and for this reason, they are often used in women who are diagnosed with HIV late in their pregnancy. Raltegravir (RAL) is the most commonly used.
 Non-nucleoside reverse transcriptase inhibitors (NNRTIs) may be used during pregnancy, however, there are significant toxicities associated with their use. NNRTIs are therefore them less desirable options for ART. The most commonly administered NNRTIs in pregnancy are efavirenz (EFV) and nevirapine (NVP).

Pre-exposure prophylaxis (PrEP)

Pre-Exposure Prophylaxis (PrEP) should be offered in the form of oral combination tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) to patients who are at risk of acquiring HIV and are trying to become pregnant, who are pregnant, who are postpartum/breastfeeding. People who are considered at risk for developing HIV are those who participate in condom-less sex with a partner who is HIV positive, patients who have been diagnosed with a recent sexually transmitted infection (STI), and patients who engage in injection drug use. PrEP is notably optional if a patient's HIV positive partner has been reliably on ART and has an undetectable viral load. PrEP can reduce the risk of both mother and fetal acquisition of HIV. Patients who take PrEP should be counseled on the importance of strict medication adherence and tested for HIV every three months and be aware of the symptoms of an acute HIV infection in case of viral contraction.

Nutritional supplements
Vitamin A plays a role in the immune system and has been suggested as a low-cost intervention that could help with preventing mother-to-child transmission of HIV. However, analysis of 5 large studies that utilized Vitamin A supplementation to prevent HIV transmission showed that said supplementation likely has little or no effect on transmission of the virus in pregnant women. Vitamin A supplementation has been largely superseded by antiretroviral therapy on a global basis. Furthermore, high doses of natural Vitamin A can be toxic to the fetus, which is important to consider in management of HIV in pregnant women.

Postnatal care

Maternal follow-up
The most important component of maternal follow-up for HIV positive mothers in the postnatal period is ART. All mothers should continue their antiretroviral medications following hospital discharge, and any changes to their regimens should be made in consultation with the physicians who coordinate their HIV care. The NIH also advises that providers should be wary of the unique challenges to medication compliance that mothers face in the postpartum period when designing a discharge ART regimen for their patients.

Infant Treatment and Follow-Up
All newborns who were exposed to HIV in utero should receive postpartum antiretroviral drugs within 6 hours of delivery, and their dosing should be based on the newborn's gestational age. Premature newborns should only receive zidovudine, lamivudine, and/or nevirapine based on toxicity testing.

Newborns who were exposed to HIV in utero and whose mothers were on ART prior to and during pregnancy and achieved viral suppression by delivery should be administered zidovudine for 4 weeks to continue preventing HIV transmission following delivery. If a pregnant woman presents in labor with an unknown HIV status and a positive rapid HIV test result or an infant has a high risk of HIV transmission in utero (for example, the mother was not taking antiretroviral drugs in the pre-pregnancy period or during pregnancy, the mother had not achieved viral suppression, or the mother experienced an acute HIV infection during pregnancy or while breastfeeding), the infant should be started on a presumptive three drug ART regimen for treatment of the infection until the infant's test results are available. If the infant has a documented HIV infection after birth, they should be started on 3-drug ART at treatment doses that will be continued indefinitely.

In infants younger than 18 months, HIV testing must consist of virologic assays that directly detect the HIV virus, not HIV antibody testing, as it is less reliable in the postpartum period. The results of these tests can be affected by antiretroviral drugs, so they should be repeated. All infants exposed to HIV in utero should be tested at three ages: 14–21 days, 1–2 months, and 4–6 months. Any positive HIV testing should be repeated as soon as possible. HIV cannot be excluded as a diagnosis in an HIV-exposed, non-breastfed infant until the infant has had either two or more negative virologic tests at at least 1 month and 4 months of age, or two negative HIV antibody tests at at least 6 months of age.

Other important testing for newborns includes a complete blood count at birth to determine a baseline for the infant's blood cell numbers. The infant should then be followed with appropriate laboratory monitoring based on their gestational age and clinical condition, and both the fetal and maternal drug regimens. Important hematologic anomalies being monitored include anemia and neutropenia. If either of these complications occur, the infant may need to discontinue their ART regimen under physician supervision. Infants exposed to HIV in utero should also be receive preventative drugs against Pneumocystis jirovecii pneumonia between 4–6 weeks old after completing their 4-week course of antiretroviral medications, as this is a life-threatening complication of HIV.

Although the risk is very low, HIV can also be transmitted to a baby through food that was previously chewed by a mother or caretaker infected with HIV. To be safe, babies should not be fed pre-chewed food.

Breastfeeding
While maternal compliance with ART reduces the chance of HIV transmission to the infant, there is still a risk of viral transmission via the breastmilk. Furthermore, there is concern that maternal antiretroviral drugs can enter the breastmilk and cause toxicity issues in the infant or future drug resistance. For these reasons, the NIH, CDC, and the AAP each discourage breastfeeding amongst HIV-positive women in the United States and other developed nations because there are safe, affordable feeding alternatives and clean drinking water. In fact, ACOG lists maternal HIV infection as one of very few contraindications to breastfeeding.

Despite these recommendations, some women in developed countries chose to breastfeed. In these situations, it is important that mothers adhere strictly to their ART regimens and it is advised that infants are administered antiretroviral drugs for the prevention of possible viral transmission for at least 6 weeks. Notably, when mothers do not comply with their ART regimens, there is a 15-20% risk of infant HIV acquisition from breastfeeding over 2 years. Both infants and mothers should be regularly tested every throughout breastfeeding to ensure appropriate viral suppression and lack of HIV transmission. Maternal monitoring should be done with an assessment of HIV viral load, and infant testing should be done with virologic HIV testing.

The WHO dictates that in developing nations, the decision about whether or not mothers breastfeed their infants must weigh the risk of preventing HIV acquisition in the infant against the increased risk of death from malnutrition, diarrhea, and serious non-HIV infection if the infant is not breastfed. In developing nations, clean water and formula are not as readily available, therefore, breastfeeding is often encouraged to provide children with adequate food and nutrients because the benefit of nourishment outweighs the risk of HIV transmission. The WHO's 2010 HIV and Infant Feeding Recommendations intend to increase the rate of HIV-survival and reduce non-HIV related risk in infants and mothers, and they include the following:
 National health authorities in each country should recommend one, specific, universal infant feeding practice for mothers with HIV, as mothers will need persistent counselling while feeding their infants and this is better promoted when national authorities are unified in the guidance they administer. The choices for feeding include either breastfeeding while receiving antiretroviral medications or avoidance of all breastfeeding.
 When national health authorities chose the feeding practice they intend to promote and determine how to implement it, they should consider HIV prevalence, infant and child mortality rates due to non-HIV causes, current infant and young child feeding, the nutritional status of children, water quality, sanitation resources, and quality of health services.
 women who breastfeed while receiving ART should exclusively breastfeed their infants for 6 months and then continue breastfeeding for until the infant is 12 months of age. They used to be advised to discontinue breastfeeding at 6 months, however, this recommendation has been changed to improve long-term nutritional outcomes.
 Mixed feeding (when a baby is fed formula and breastmilk) should be avoided to reduce the risk of HIV transmission and avoid diarrhea and malnutrition.

In developing nations, If the mother has a high HIV viral load (HIV RNA more than 1000 copies/L), replacement feeding with formula is only initiated as per the UNAIDS guidelines, termed the AFASS criteria, "where replacement feeding is acceptable, feasible, affordable, sustainable, and safe.":95-6 A mother should only give infant formula, as explained by the WHO, if the following conditions are met:
 "Safe water and sanitation are assured at the household level and in the community; and
 the mother or other caregiver can reliably provide sufficient infant formula milk to support the normal growth and development of the infant; and
 the mother or caregiver can prepare it cleanly and frequently enough so that it is safe and carries a low risk of diarrhea and malnutrition; and
 the mother or caregiver can exclusively give infant formula milk in the first six months; and
 the family is supportive of this practice; and
 the mother or caregiver can access health care that offers comprehensive child health services."

Societal impacts

Discrimination
Despite advances made in preventing transmission, HIV-positive women still face discrimination regarding their reproductive choices. In Asia, it was found that half the women living with HIV were advised not to have children and as many as 42% report being denied health services because of their HIV status.

Compulsory sterilisation in an attempt to limit mother-to-child transmission has been practiced in Africa, Asia, and Latin American. women are forced to undergo sterilisation without their knowledge or informed consent, and misinformation and incentives are often used in order to coerce them into accepting the procedure. The forced sterilisation of HIV-positive women is internationally recognized as a violation of human rights.

Legal advocacy against this practice has occurred in some countries. In Namibia, litigation was brought against the government by three HIV-positive women who claimed they were coerced during labour into signing consent forms that gave permission for the hospital to perform a sterilisation. The LM & Others v Government of Namibia case is the first of its kind in sub-Saharan African to deal with coerced sterilisation of HIV-positive women. The court ruled that these women were sterilised without their consent but failed to find that this was due to their HIV status. A 2010 case in Chile have also aimed to seek government accountability for violation of sexual and reproductive rights of women living with HIV.

Health considerations
Pregnant women with HIV may still receive the trivalent inactivated influenza vaccine and the tetanus, diphtheria, and pertussis (Tdap) vaccination during pregnancy.

Many patients who are HIV positive also have other health conditions known as comorbidities. Hepatitis B, hepatitis C, tuberculosis and injection drug use are some of the most common comorbidities associated with HIV. women who screen positive for HIV should also be tested for these conditions so that they may be adequately treated or controlled during the pregnancy. The comorbidities may have serious adverse effects on the mother and child during pregnancy, so it is extremely important to identify them early during the pregnancy.

Health disparities
There are well documented disparities with regards to who is affected by HIV/AIDS during pregnancy. For example, a study of Florida births from 1998 to 2007 showed parents who were identified as Hispanic or Black in the medical records were more likely to have HIV during pregnancy. Though more research is needed, poverty is a significant structural inequity that can drive these differences in HIV rates. Furthermore, there are large disparities in access to antiretroviral therapies, medications important in preventing the transmission of HIV from parent to child. Not receiving antiretroviral therapies was significantly associated with restricted Medicaid eligibility. This data suggests that improved insurance coverage to diagnose, screen, and treat pregnant individuals with HIV would help increase access to essential medications and reduce transmission of HIV from parent to child.

Support groups

Bateganya et al. studied the impact of support groups for people living with HIV and found that 18/20 (90%) of papers reviewed showed support groups had a significant positive outcome. Studies show that support groups reduce morbidity (having disease or symptoms of disease), reduce mortality (likelihood of dying), increase quality of life, and increase use of healthcare. There is also research showing that support groups, in the short term, have a significant positive impact for pregnant women living with HIV. Mundell et al. showed that pregnant women enrolled in a support group had 1) improved self-esteem, 2) a greater ability to cope with their medical diagnoses, and 3) were more likely to follow up with healthcare services and share their HIV diagnosis with others than those not enrolled in a support group. This research suggests pregnant women living with HIV may benefit from peer support groups.

References

External links
 aidsinfo.nih.gov

HIV/AIDS
Midwifery


title: Mounir Bouziane

text:
Mounir Bouziane (born 5 February 1991) is a French professional footballer who most recently played as a forward for Eintracht Trier.

Career
Born in Saint-Louis, Haut-Rhin, Bouziane started his career with local club Saint-Louis Neuweg before joining the youth ranks of RC Strasbourg. In 2009, he made the switch to German football, joining SC Freiburg's reserve team in the Regionalliga. In 2013, Bouziane moved to Mainz 05 II, signing a one year contract with the club. On 26 July 2014, he made his 3. Liga debut for Mainz, scoring a goal against Arminia Bielefeld in the opening match of the season.

On 22 January 2017, he made his Bundesliga debut for Mainz 05 in a 0–0 draw against 1. FC Köln, when he came on as a substitute for Jairo Samperio in the 77th minute.

Personal life
Born in France, Bouziane is of Algerian descent. In summer 2022 he married German footballer Chiara Bouziane (née Loos).

Career statistics

References

External links

1991 births
Living people
Footballers from Haut-Rhin
French men's footballers
French sportspeople of Algerian descent
Men's association football forwards
Bundesliga players
3. Liga players
Regionalliga players
SC Freiburg II players
1. FSV Mainz 05 II players
FC Energie Cottbus players
FC Energie Cottbus II players
1. FSV Mainz 05 players
FC Hansa Rostock players
SV Waldhof Mannheim players
Türkgücü München players
FC 08 Homburg players
SV Eintracht Trier 05 players
French expatriate men's footballers
French expatriate sportspeople in Germany
Expatriate men's footballers in Germany


title: James Sinclair, 12th Earl of Caithness

text:
James Sinclair, 12th Earl of Caithness (1766–1823) was a Scottish noble, Earl of Caithness and chief of the Clan Sinclair, a Highland Scottish clan.

James Sinclair was born at Barrogill Castle (Castle of Mey) on 31 May 1766. He was the son of Sir John Sinclair of Mey, Baronet who he succeeded in the baronetcy in 1774. He succeeded as 12th earl of Caithness in 1789, as nearest lawful male heir of William Sinclair, 2nd Earl of Caithness. His claim to the peerage was sustained by the House of Lords.

In 1811 he was appointed Deputy Postmaster General of Scotland in place of Francis Gray, 14th Lord Gray. Following his death on 16 July 1823 the post was filled by Sir David Wedderburn, 1st Baronet.

He was lord-lieutenant of the county of Caithness and lieutenant-colonel of the Ross-shire militia.

He married at Thurso Castle on 2 January 1784 Jane, second daughter of Alexander Campbell of Bareldine who was deputy governor of Fort George. They had the following children:

John Sinclair, Lord Berriedale who died in 1802 aged 14.
Alexander Sinclair, 13th Earl of Caithness.
Four other sons and three daughters.

See also

Barony of Roslin
Lord Sinclair
Lord Herdmanston

References

Lord-Lieutenants of Caithness
Earls of Caithness
1823 deaths
Clan Sinclair
1766 births


title: Superstition (The Birthday Massacre album)

text:
Superstition is the sixth studio album by Canadian electronic rock band The Birthday Massacre, released on November 11, 2014 through Metropolis Records. The album was funded through PledgeMusic. To promote the album, a subsequent North America tour and music video for "Beyond" followed the album's release.

Background
In 2015, Chibi admitted that the band had initially been hesitant to produce an album through crowd funding, but were glad they made the choice. In Fireworks Magazine Online, she said: "We really wanted it to be worthwhile for the fans... It was incredible to reach our goal so quickly; the campaign definitely brought to us an awareness of how supportive our fans can be. We’re so grateful for everything they’ve done for us."

Regarding the album's themes and lyrics, Chibi has said "I was in a darker place and sort of looking for spiritual comfort, which naturally just brings up confusion and even more questions, so there are more of those lyrical themes on this record. I suffered a few losses in the last year which sent me looking for comfort; a sort of “what is beyond all of this” kind of thing. We started looking at legends, religions, ideas, what other cultures look to, what images and ideas from those explorations appealed to us and working those themes in. Ultimately, spiritual and religious beliefs are basically just “superstitions”, and thus, that became the theme of the album."

During interviews, the band stated that the themes of the album came from their recurring element of water, mythology and world cultures' different views on religion, mortality, loss, and the unknown nature of the afterlife.

Release and promotion
In mid 2013, the band officially announced that they were working on a new album. On February 5, 2014, the band announced that their next album would partly be funded by a crowdfunding project on PledgeMusic in cooperation with their label, Metropolis Records. The project launched on February 7, 2014, offering pledgers a number of incentives and bundles in return for their support. In under 24 hours, the band was able to meet their goal. On June 29, 2014, via PledgeMusic, the band's manager Terry McManus announced the album is set to be released November 11, 2014, with a supporting North American tour in Fall 2014 a Brazilian tour in January 2015 and a UK tour beginning February 2015. On July 30, 2014, it was revealed by the band's manager via the band's Facebook that the album name would be Superstition. The track Beyond was the album's lead single, with an accompanying music video as well. At the campaign's end, the band achieved 312% of its goal. Superstition was released November 11, 2014.

Almost a year after the album's release, the band uploaded a performance music video for the title track, "Superstition", on September 24, 2015. The video was filmed in their rehearsal space.

On November 9, 2014, the band began their North America tour with New Years Day and The Red Paintings.

Reception
Superstition received mostly positive reviews.

Sputnikmusic summarized the album as: "A little less darkness, a little more synth pop", and stated that "The Birthday Massacre is a massively underrated band, and it's an absolute joy watching them further developing their sound with each passing album." Kathy Nichols of The Spill Magazine called the album "enjoyable in its entirety" but found Chibi's growls on tracks such as "Divide" and "Destroyer" to be creepy and "the weakest link" on the album. Ilker Yücel from ReGen Magazine noted the use of ambience in "Surrender" and "The Other Side", and said "Unlike the previous album’s sense of urgency and speed, Superstition allows each song to breathe." Their final comment called Superstition one of their "most powerfully engaging and darkly melodic albums to date." Rafi Shlosman from Cryptic Rock described the programming and synth on the album able to "induce the same fear and euphoria one experiences having a nightmare or dream" and called Superstition "one of 2014’s best albums."

Some reviews criticized particular tracks for having repetitive lyrics and melodies, despite enjoyable instrumentals.

Track listing

Notes
 "Superstition" was credited as "Written by 'Wight Eyes' - (Rainbow and Aaron Cunningham)".

Personnel
Superstition album personnel adapted from CD liner notes.

Chibi - songwriter, performance
Michael Rainbow - songwriting, performance, production, mixing, album cover design
Michael Falcore - songwriting, performance, production, mixing
Aaron Cunningham - songwriter on "Superstition", album design and artwork
Nathaniel Radmacher - additional bass
Nik Pesut - additional percussion
Dave Ogilvie - mix engineer, mixing at Hipposonic Studios, Vancouver, British Columbia, Canada
Karl Dicaire - assistant mix engineer
Noah Mintz - mastering at Lacquer Channel, Toronto, Ontario, Canada
Terry McManus - management
Owen MacKinder - album cover design
Andrew Rainbow - album cover photography

Charts

References

External links

2014 albums
The Birthday Massacre albums
Metropolis Records albums
Albums recorded at Hipposonic Studios


title: César (footballer, born 1992)

text:
César Bernardo Dutra (born 27 January 1992), simply known as César, is a Brazilian professional footballer who plays as a goalkeeper for Primeira Liga club Boavista.

Career

Flamengo
César debuted for Flamengo on 7 December 2013 in the last match of the 2013 Brazilian Série A against Cruzeiro at Maracanã Stadium, the match ended 1-1.

On 18 May 2018 César extended his contract with Flamengo until April 2022.

Ponte Preta (loan)
In February 2016 César moved to Ponte Preta on loan hoping to gain more experience, although he didn't play a single match during the 2016 season.

Ferroviária (loan)
On 29 December 2016 César moved again on loan, this time to Ferroviária to play in the 2017 São Paulo State League. Shortly after he returned to Flamengo.

Career statistics

Honours

Club
Flamengo
Copa Libertadores: 2019
Recopa Sudamericana: 2020
Campeonato Brasileiro Série A: 2019, 2020
Supercopa do Brasil: 2020, 2021
Copa do Brasil: 2013
Campeonato Carioca: 2014, 2019, 2020, 2021

International
Brazil U-20
FIFA U-20 World Cup: 2011

References

External links

1992 births
Living people
Footballers from Rio de Janeiro (city)
Brazilian men's footballers
Brazil men's under-20 international footballers
Men's association football goalkeepers
Campeonato Brasileiro Série A players
Primeira Liga players
CR Flamengo footballers
Associação Atlética Ponte Preta players
Associação Ferroviária de Esportes players
Esporte Clube Bahia players
Boavista F.C. players
Copa Libertadores-winning players
Brazilian expatriate men's footballers
Expatriate men's footballers in Portugal
Brazilian expatriate sportspeople in Portugal


title: Black Harmony

text:
Black Harmony is a Lugbara music duo based in Arua (Northwestern Uganda). It comprises Emmanuel Ledra who sings and raps while Robert Adima provides the "reggae flavour".

History
Emmanuel first did music in 2003. He formed a club called Street Culture but waited two years to produce his first song "Isabella". Then in 2006, the duo came up with "Leta" and "Munyu Munyu" which was a very powerful hit (actually added as a ringtone by Uganda telecom). This song talks about men spending their money all night with prostitutes and it made a runaway husband return to Uganda to the four women each of whom he had left behind with a kid.

A female artist named Lady Shadia doing music in Kampala once came to Arua to see how she could take her music to the next level and united with Black Harmony. They produced a quadrilingual hit called "Shadia (Baby Gal)" which was chosen as a live performance during the 2008 Bell PAM (Pearl of Africa Music) Awards. The collaboration actually scooped the preliminary 2008 Regional Award for West Nile though Dogman won the final award. "Shadia" is the second last song on the "Leta" Album, "Bacaku" which some call "Skulu" is the last one.

The third album is called "Ti Icita" meaning "Unity" in Lugbara and includes other languages like Lingala, Swahili, plus English.

The duo sing about love, community development, parental affection, hard work, procreation and AIDS Prevention.

"The Best Music is Live Music," Emmanuel confesses and they have performed with Wenge Musica from DR Congo besides his own project called "Amangonde". Other songs by Black Harmony include "Ewa Be Ma Ra", "Lucky", "Etoo", "Adiaa", "Ti Icita" (Title Track for their 3rd Album), "Jua Kali", "Anga Azi Avasi" plus "Silimu".

On Friday 5 May 2023, Black Harmony held its maiden concert called Ti Echita at Capital One in Arua City. That same year, they released a new song entitled "Isa Ma Raka" about avoiding conflicts and fights.

Awards
During the inaugural West Nile Music Awards (WEMA) at Hill View Inn Arua in 2007, Black Harmony won two accolades: Song of the Year (for Munyu Munyu, off their debut six-track album) and Best Upcoming Artiste.

Partnerships
In 2019, Black Harmony teamed up with Monopoly, a Lugbara artiste, to produce "Tap Tap". Arufu Records in Arua wants to sign Black Harmony to their label. Robert Bob Adima works at Radio Pacis in Ediofe Suburb of Arua City. With a plan to release new videos and songs including Gospel by the end of 2020, BH teamed up with Ivan G (Trojan Sound) to sing "Uganda (Pearl Of Africa)". They also produced a traditional blend of "Yenge Yenge" and "Endika Endika" about the plight of the girl child during the COVID-19 pandemic. "Pataa" is a Gospel tune they also worked on. In February 2022, they released a party jam collaboration with Jayharryboui ESB entitled "Ayiko" which means Happiness in Lugbara.

References

Arua District
Reggae musical groups
Ugandan musical groups


Caroline Now!: The Songs of Brian Wilson and the Beach Boys is a 2000 tribute album devoted to songs by the Beach Boys, consisting of cover versions recorded by independent artists. The chosen material focuses on rarities by the group, some of them available only as bootleg recordings such as Adult/Child and Sweet Insanity. The album took nearly three years to produce, with sunshine pop outfit the Free Design reuniting to contribute one track after a three-decade absence from recording.

Reception

Jason Ankeny of AllMusic wrote in a mostly positive review, "by and large, the disc boasts an artistry and consistency most tributes lack, thanks as much to the brilliance of its subject as to the torch-carrying affections of its contributors." Uncut magazine named it their album of the month, while NME named it their compilation of the month.

Track listing

 Eugene Kelly: "Lady"
 Alex Chilton: "I Wanna Pick You Up"
 June & The Exit Wounds: "All I Wanna Do"
 Katrina Mitchell & Bill Wells: "Wind Chimes"
 The High Llamas: "Anna Lee, The Healer"
 Souvenir: "Ne Dis Pas (Girl Don't Tell Me)"
 Duglas T. Stewart: "Lines"
 Camping: "Busy Doin' Nothin'"
 Stevie Jackson: "Good Time"
 The Free Design: "Endless Harmony"
 The Pearlfishers: "Go Away Boy"
 Saint Etienne: "Stevie"
 The Radio Sweethearts: "Honkin' Down The Highway"
 Eric Matthews: "Lonely Sea"
 Kle: "Rainbow Eyes"
 Chip Taylor & Evie Sands: "Let's Put Our Hearts Together"
 Peter Thomas Sound Orchestra: "Pet Sounds"
 Malcolm Ross: "Heroes and Villains"
 Norman Blake: "Only With You"
 The Aluminum Group: "Caroline, No"
 Jad Fair: "Do Ya"
 The Secret Goldfish: "Big Sur"
 David Ritchie Coalition: "Good Timin'"
 Kim Fowley: "Almost Summer"

See also
List of cover versions of Beach Boys songs

References

The Beach Boys tribute albums
Brian Wilson
2000 compilation albums
Indie rock compilation albums


title: Sofía dame tiempo

text:
Sofía dame tiempo, was a Colombian telenovela produced by RTI for Caracol Televisión and Telemundo in 2003. It was a remake of the telenovela El último beso.

Cast
 Karen Martínez as Sofía Santero
 Rafael Novoa as Santiago Rodríguez Salazar
 Ana María Trujillo as Francesca Sabina
 Alejandro López as Nicolás Pardo
 Orlando Fundichely as Antonio 'Toño' Rivas
 Ana Laverde as Valeria Sabina
 Mayte Vilán as Victoria Guerrero
 Salvo Basile as Salvatore Sabina
 Marcela Gallego as Fabiola de Neira
 Pedro Mogollón as Santos Neira
 Katherine Vélez as Adela Salazar viuda de Rodríguez
 Víctor Cifuentes as Gregorio Manrique
 Carlos Hurtado as Dairo García
 Astrid Hernández as Marilyn Monroy
 Orlando Lamboglia as Teodolindo 'Teo' Caro
 Cecilia Navia as Rosa Torres
 Claudia Liliana Gonzalez as Pilar Amaya
 Claudia Arroyave as Juliana Rodríguez Salazar
 Saín Castro as Aníbal Zapata
 Salvatore Cassandro as Chancho Panza
 Ramiro Meneses as Teniente Pinzón
 Santiago Alarcón as Rodrigo
 Juan del Mar as Diosdao
 Julio del Mar as José 'Pepe' Pardo
 Rosa Garavito as Ubaldina
 María José Martínez as Tatiana Neira
 Toto Vega as Sargento Díaz
 Rolando Tarajano as Manuel Manrique

External links
 Sofía dame tiempo, en Terra
 Sofía dame tiempo en Colarte

Telemundo telenovelas
Caracol Televisión telenovelas
2003 telenovelas
2003 American television series debuts
2003 American television series endings
2003 Colombian television series debuts
2003 Colombian television series endings
Spanish-language telenovelas
Television shows set in Bogotá


title: Jesse Were

text:
Jesse Jackson Were (; born 19 April 1989) is a Kenyan professional footballer who plays as a striker for Zambia Super League club Kansanshi Dynamos F.C. and the Kenya national team. He previously played for Mathare United and Tusker F.C.
Joined Kansanshi dynamos in 2021

Club

References

External links

1989 births
Living people
Footballers from Nairobi
Kenyan men's footballers
Men's association football forwards
Mathare United F.C. players
Tusker F.C. players
Kenyan Premier League players
ZESCO United F.C. players
Kenya men's international footballers


title: Stephen Robbins

text:
Stephen Robbins  (born 1953) is a British Church of England priest and former British Army officer. He is bishop's chaplain to Nick Holtam, Bishop of Salisbury. He was previously the most senior military chaplain in the British Army, serving as Chaplain-General from 2008 to 2011.

Honours and decorations
Robbins was awarded the Queen's Commendation for Valuable Service 'in recognition of gallant and distinguished services in Northern Ireland during the period 1 October 1998 to 31 March 1999'. In the 2011 New Years Honours, Robbins was appointed Companion of the Order of the Bath (CB), military division.

References

Living people
20th-century English Anglican priests
21st-century English Anglican priests
Chaplains General to the Forces
Companions of the Order of the Bath
Recipients of the Commendation for Valuable Service
Church of England archdeacons (military)
1953 births


title: La ley del silencio

text:
La ley del silencio is an American telenovela produced by Telemundo in 2003.

Cast

 José Ángel Llamas - Padre Javier Castro
 Flora Martínez - Natalia Aguirre
 Rodrigo de la Rosa - Fernando Cardenas
 Jullye Giliberti - Magdalena Aguirre
 Alejandro Chabán - Tomás
 Joaquín Garrido - Pedro
 Lumi Cavazos - Clemencia
 Omar Fierro - Francisco
 Issabella Camil - Julia
 Fernanda Romero - Virginia
 Lilian Tapia - Guadalupe
 Henry Zakka - Luis Alberto
 Julio Bracho Castillo - Ángel
 Liz Gallardo - Manuela
 Chela Arias - Clotilde
 Mónica Lopera - Adela
 José Bardina - Arturo
 Eliana H. Alexander - Amparo
 Sergio Romero - Sebastián
 Cora Cardona - Mercedes
 Mara Croatto - Isabel
 Roger Cudney - Meyer
 Juan Pablo Gamboa - Leopoldo
 Marlon Lara - Jimmy
 Mauricio Ripke - Sata
 Leticia Alaniz - Laura / Recepcionista
 Joe Arquette - Topo
 Ricardo Azulay - Dr. Clark
 Glenn Bradley - Miembro de banda
 Dan Burkarth - Policia & Chofer
 Javier Castillo - Jerry García
 Édgar Castuera - Bombero
 Gerardo Dávila - Manager de restaurante
 Gigi Erneta - Jane
 Carlos Girón - Ramiro
 Rodrigo Gómez - Poncho
 Julián Guevara - Sweety
 Tony Helling - Paulina
 Andrea León - Apache
 John Nikitin - Agente Counts
 Mónica Peña - Enfermera Svenson
 J.R. Ramírez - Mr. A
 Raymond Rivera - Travolta
 Germán Santiago - Tomás
 Mark-Brian Sonna - Dr. José Luis Monsalve
 Craig Taylor - Patrón
 Carolina Vengoechea - Jennifer González
 Ted West - Basura

References

Telemundo telenovelas
2005 telenovelas


title: Tirli

text:
Tirli is a village in Tuscany, central Italy, administratively a frazione of the comune of Castiglione della Pescaia, province of Grosseto. At the time of the 2001 census its population amounted to 284.

Tirli is about 28 km from Grosseto and 18 km from Castiglione della Pescaia, and it is situated on a hill next to the top of Poggio Ballone.

History
The village dates back to the Early Middle Ages, as it was mentioned in a document of 814. Destroyed by the Turks in the 16th century, it was then part of the Principality of Piombino.

Main sights

 Church of Sant'Andrea Apostolo (17th century), main parish church of the village, it was consecrated in 1674. The former convent of Sant'Agostino is situated next to the church.
 Hermitage of San Guglielmo di Malavalle (13th century), situated in the woods near the village. It was built between 1230 and 1249 as a sanctuary where saint William of Maleval was buried.
 Hermitage of Sant'Anna (17th century), located in the woods of Tirli.
 Palazzo Pretorio (18th century).

References

Bibliography
 Bruno Santi, Guida storico-artistica alla Maremma. Itinerari culturali nella provincia di Grosseto, Siena, Nuova Immagine, 1995, pp. 83–84.
 Enrico Collura, Mario Innocenti, Stefano Innocenti, Comune di Castiglione della Pescaia: briciole di storia, Grosseto, Editrice Innocenti, 2002, pp. 176–187.
 Fiorenzo Corsali, Storia della Maremma. Castiglione della Pescaia e il suo territorio, Roma, Aldo Sara Editore, 2008, pp. 65–69, 103–106.

See also
 Buriano, Castiglione della Pescaia
 Pian d'Alma
 Pian di Rocca
 Punta Ala
 Roccamare
 Rocchette
 Vetulonia

Frazioni of Castiglione della Pescaia


title: Oats (horse)

text:
Oats (27 April 1973 – 13 January 1990) was an Irish-bred, British-trained Thoroughbred racehorse and sire. He showed promise as a two-year-old before establishing himself as one of the best British colts of his generation in the following year when he won the Blue Riband Trial Stakes and finished third in The Derby. As a four-year-old he won the Jockey Club Stakes and the Ormonde Stakes before his career was ended by injury. After his retirement he became a very successful sire of National Hunt horses.

Background
Oats was a "strong, attractive" bay horse with a small white star bred in Ireland by T E Kelly. He was from the first crop of foals sired by Northfields, an American horse whose biggest win came in the Louisiana Derby in 1971, before spending most of his stud career in Europe. His other winners included Northjet, Northern Treasure (Irish 2,000 Guineas), No Pass No Sale (Poule d'Essai des Poulains) and North Stoke (Joe McGrath Memorial Stakes). Oats' dam Arctic Lace finished third in the 1969 Irish 1,000 Guineas and was a granddaughter of Fair Alycia, whose other descendants included Bold Lad (IRE).

As a yearling, the colt was offered for sale and bought for 7,000 guineas by David Oldrey. Oats was sent into training with Peter Walwyn at Lambourn in Berkshire.

Racing career

1975: two-year-old season
In 1975, Walwyn made no secret of the high regard in which he regarded Oats, describing him as "a real beauty". When the colt made his racecourse debut in September, he started favourite for a maiden race over six furlongs at Goodwood Racecourse but finished seventh behind the Clive Brittain-trained filly Petalca. On his only other appearance of 1975, Oats started the 9/4 favourite for the second division of the Westley Maiden Stakes over seven furlongs at Newmarket Racecourse in October. He was among the leaders from the start and drew away in the closing stages to win by five lengths from the Henry Cecil-trained filly Helcia.

1976: three-year-old season
Oats began his three-year-old season by finishing second to the Irish-trained Malinowski in the Craven Stakes over the Rowley Mile course at Newmarket in April. Two weeks later in the Group Three Blue Riband Trial Stakes over eight and a half furlongs at Epsom Downs Racecourse he took the lead two furlongs from the finish and won from Navigator and All Hope. On 2 June, Oats started at odds of 10/1 for the 197th running of The Derby. Ridden by Pat Eddery, he was in sixth place on the final turn and made steady progress in the straight without ever looking likely to win and finished third, beaten three lengths and a head by Empery and Relkino.

After an eight-week absence, Oats returned in the Gordon Stakes at Goodwood Racecourse in late July. Ridden again by Eddery, he was under pressure throughout the closing stages, and although he made progress in the straight he narrowly failed to catch the Dick Hern-trained Smuggler. In August, the colt was matched against older horses in the Geoffrey Freer Stakes over thirteen and a half furlongs at Newbury Racecourse. He finished second, beaten a head by the five-year-old gelding Swell Fellow after a prolonged struggle over the final quarter mile. In the St Leger Stakes at Doncaster Racecourse in September, Oats started the 6/1 co-favourite, alongside Crow and General Ironside. He finished fourth of the fifteen runners behind Crow, Secret Man and Scallywag.

1977: four-year-old season
On his first appearance as a four-year-old, Oats won by ten lengths from weak opposition over ten furlongs at Doncaster and then started at odds of 11/4 for the Jockey Club Stakes over one and a half miles at Newmarket. His opponents for his second race included Smuggler, Swell Fellow, Malinowski and Grey Baron. Oats tracked the leaders before going to the front three furlongs from the finish and maintained a narrow advantage to win from Smuggler. In the Ormonde Stakes over thirteen furlongs at Chester Racecourse in May Oats started the 7/4 favourite. Eddery adopted new tactics, sending the colt into the lead from the start. and Oats won by three lengths from Decent Fellow, with Gunner B in third place. Undefeated in three races in 1977, Oats was regarded as potentially the best older horse in Britain over middle distances, but sustained a serious leg injury when being prepared for the Coronation Cup and did not race again.

Assessment
There was no International Classification of European two-year-olds in 1975: the official handicappers of Britain, Ireland and France compiled separate rankings for horses which competed in those countries. In the British Free Handicap, Oats was allotted a weight of 113 pounds, twenty pounds below the top-rated Wollow. The independent Timeform organisation gave Oats a rating of 101 p, the "p" indicating that he was likely to make more than normal progress. In their annual Racehorses of 1975 Timeform commented that "the best of Oats is yet to come". In the following year he was rated eleven pounds behind Vitiges in the official British handicap for three-year-olds. He was given a rating of 126 by Timeform in 1976, nine pounds behind their Horse of the Year Youth, and was described as "a tough horse, but lacks a turn of foot". As a four-year-old, Oats was rated 124 by Timeform, thirteen pounds behind their top-rated horse Alleged. In the inaugural International Classification he was given a rating of 86, eight pounds behind the top-rated older horse Balmerino.

Stud record
Oats was retired from racing to become a breeding stallion at the Ardenode Stud in Ireland, at an initial fee of £1,500. Oats had little success as a sire of flat racers, but became a very good sire of National Hunt horses. The best of his progeny included the Cheltenham Gold Cup winner Master Oats, the Champion Hurdler Flakey Dove and the Hennessy Gold Cup winner Couldn't Be Better. Oats died on 13 January 1990.

Pedigree

Oats was inbred 4 × 4 to Nearco, meaning that this stallion appears twice in the fourth generation of his pedigree.

References

1973 racehorse births
1990 racehorse deaths
Racehorses bred in Ireland
Racehorses trained in the United Kingdom
Thoroughbred family 2-e


title: Olyva

text:
Olyva (; ; ) is a rural settlement in the Yalta Municipality of the Autonomous Republic of Crimea, a territory recognized by a majority of countries as part of Ukraine and annexed by Russia as the Republic of Crimea.

Olyva is located on Crimea's southern shore at an elevation of . The settlement is located  southwest from Foros, which it is administratively subordinate to. Its population was 98 in the 2001 Ukrainian census. Current population:

References

Rural settlements in Crimea
Yalta Municipality


title: Program equilibrium

text:
Program equilibrium is a  game-theoretic solution concept for a scenario in which players submit computer programs to play the game on their behalf and the programs can read each other's source code. The term was introduced by Moshe Tennenholtz in 2004. The same setting had previously been studied by R. Preston McAfee, J. V. Howard and Ariel Rubinstein.

Setting and definition

The program equilibrium literature considers the following setting. Consider a normal-form game as a base game. For simplicity, consider a two-player game in which  and  are the sets of available  strategies and  and  are the players'  utility functions. Then we construct a new (normal-form) program game in which each player  chooses a computer program . The payoff (utility) for the players is then determined as follows. Each player's program  is run with the other program  as input and outputs a strategy  for Player . For convenience one also often imagines that programs can access their own source code. Finally, the utilities for the players are given by  for , i.e., by applying the utility functions for the base game to the chosen strategies.

One has to further deal with the possibility that one of the programs  doesn't halt. One way to deal with this is to restrict both players' sets of available programs to prevent non-halting programs.

A program equilibrium is a pair of programs  that constitute a Nash equilibrium of the program game. In other words,  is a program equilibrium if neither player  can deviate to an alternative program  such that their utility is higher in  than in .

Different mechanisms for achieving cooperative program equilibrium in the Prisoner's Dilemma

Various authors have proposed ways to achieve cooperative program equilibrium in the Prisoner's Dilemma.

Cooperation based on syntactic comparison

Multiple authors have independently proposed the following program for the Prisoner's Dilemma:

 algorithm CliqueBot(opponent_program):
   if opponent_program == this_program then
     return Cooperate
   else
     return Defect

If both players submit this program, then the if-clause will resolve to true in the execution of both programs. As a result, both programs will cooperate. Moreover, (CliqueBot,CliqueBot) is an equilibrium. If either player deviates to some other program  that is different from CliqueBot, then the opponent will defect. Therefore, deviating to  can at best result in the payoff of mutual defection, which is worse than the payoff of mutual cooperation.

This approach has been criticized for being fragile. If the players fail to coordinate on the exact source code they submit (for example, if one player adds an extra space character), both programs will defect. The development of the techniques below is in part motivated by this fragility issue.

Proof-based cooperation

Another approach is based on letting each player's program try to prove something about the opponent's program or about how the two programs relate. One example of such a program is the following:

 algorithm FairBot(opponent_program):
   if there is a proof that opponent_program(this_program) = Cooperate then
     return Cooperate
   else
     return Defect

Using Löb's theorem it can be shown that when both players submit this program, they cooperate against each other. Moreover, if one player were to instead submit a program that defects against the above program, then (assuming consistency of the proof system is used) the if-condition would resolve to false and the above program would defect. Therefore, (FairBot,FairBot) is a program equilibrium as well.

Cooperating with ε-grounded simulation

Another proposed program is the following:

 algorithm GroundedFairBot(opponent_program):
   With probability :
     return Cooperate
   return opponent_program(this_program)

Here  is a small positive number.

If both players submit this program, then they terminate almost surely and cooperate. The expected number of steps to termination is given by the geometric series. Moreover, if both players submit this program, neither can profitably deviate, assuming  is sufficiently small, because defecting with probability  would cause the opponent to defect with probability .

Folk theorem

We here give a theorem that characterizes what payoffs can be achieved in program equilibrium.

The theorem uses the following terminology: A pair of payoffs  is called feasible if there is a pair of  (potentially mixed) strategies  such that  for both players . That is, a pair of payoffs is called feasible if it is achieved in some strategy profile. A payoff  is called  individually rational if it is better than that player's minimax payoff; that is, if , where the minimum is over all mixed strategies for Player .

Theorem (folk theorem for program equilibrium): Let G be a base game. Let  be a pair of real-valued payoffs. Then the following two claims are equivalent:
 The payoffs  are feasible and individually rational.
 There is a program equilibrium  that achieves payoffs .

The result is referred to as a folk theorem in reference to the so-called  folk theorems (game theory) for repeated games, which use the same conditions on equilibrium payoffs .

Notes

References

Game theory


title: W. N. T. Tam

text:
William Ngar-tse Thomas Tam, OBE. JP, (21 July 1900 – 8 April 1976) was a magistrate and member of the Legislative Council in Hong Kong.

Biography

W.N.Thomas Tam ( 譚雅士 ) was born in Hong Kong on 21 July 1900, to a native of Hoi-ping (開平 Kai-ping), named Tam Lung-foo (譚龍虎) alias Tam Bok-choi, who had laboured in California from the age of 16 for nearly 20 years, before relocating to Hong Kong.   His mother, Emma Tsang Fook (曾福), was the daughter of a merchant from Po On County.

He was junior to two fostered brothers, and was christened Willie Thomas (譚威利) by his western-orientated father, a Christian, who was to christen all his children with the surname of “Thomas”.  The only sibling who reverted to the original family name of “Tam 譚” was “Willie”, who formalised his name to William Ngar-tse Thomas Tam by Deed Poll in 1926 in the United Kingdom, and there-after was commonly addressed as “Thomas Tam” in English, and as 譚雅士 (Tam Ngar-tse) in Chinese.

Willie attended the Diocesan Boys School (1909-1916), and graduated from the University of Hong Kong (BA 1920).   In the same year, he was admitted to the Inner Temple, as well as the University College of the London University to read law (LLB 1923).   He was called to the bar by the Honourable Society of the Inner Temple in 1923.   He undertook pupillage in Chamber with Mr. F.G. Ennes.   Meanwhile, he had enrolled at Lincoln College Oxford in 1921, and was awarded a Diploma in Economics and Political Science in 1922.

While studying in London, he lived modestly in digs at 2 Holford Road in Hampstead, and integrated into British society with such fervour that, on returning to Hong Kong in 1926 with his impeccable English, he was regarded by the locals as an authority on anything English in the way of custom, etiquette, dress and language for rest of his life.  Immaculately and correctly attired as he ever was, nobody ever guessed that he was the owner of only  3 suits besides his dinner-suit and tails at any one time.

In Hong Kong he initially practiced as a barrister.   He was extrovert, eloquent and liked socialising.

His many public appointments included being a member of the Legislative Council of Hong Kong, a member of the Urban Council, a director of the Tung Wah Group of Hospitals, a Life Chancellor of Po Leung Kuk, and of many boards of education and charity.   He was made a Justice of peace in 1933.

During the war, he declined to accept any post in the Japanese administration, and was subjected to interrogations.   He was welcome back by the British administration after the war, and was appointed a magistrate at the Central Magistracy in 1947, heralding a first for an ethnic Chinese.   In 1951, he was appointed an Officer of the Order of the British Empire.

He was very active as a Freemason rising to the Grand Rank in the English Craft.

Thomas married Jessie To Pui-chun (杜佩珍 1909-1994) on 2 November 1929 at St. John's Cathedral.   Jessie was a daughter of Dr.To Ying-kwan (杜應坤), and a grand-daughter of the famous Dr.To Dao-ming (杜道明) an overseas Chinese missionary doctor of western medicine in Guangzhou in the 1880s, who had fled to Hong Kong, in order to avoid an imperial edict that he should serve the imperial family at the Forbidden City.  Her mother, Liao Xiang-nong (廖薌儂), was on close terms with her cousin Liao Zhong-kai (廖仲愷), a revolutionary of the 1920s.   Her father was a contemporary and friend of Dr Sun Yat-sen at Hong Kong University.

Between 1931 and 1971, Thomas and Jessie lived at Jessville, a house named after Jessie, built in the wilds of Pokfulam.   It was not only their marital home, but also home to their younger orphaned siblings.  The household at times totalled more than a dozen people as well as domestic staff.   The house had an aura of grandeur on the outside, but was gaunt and frugal on the inside.

Life for Thomas Tam and his family after the war was much more modest, and the income from his job as a magistrate supplemented the education of his children in England in the wake of the instability in Hong Kong as a result of the political upheaval across the border in 1949.

His daughter, Barbara (1931-2006), married Yang Ti-liang (楊鐵樑), who became Chief Justice of Hong Kong.  His son, William (1939), was an architect in Britain before relocating to Hong Kong in 1976 to revive  family assets.

The Honourable Mr W.N.Thomas Tam, OBE, JP, passed away after a stroke on 8 April 1976 at the age of 76.

The Jessie and Thomas Tam Charitable Foundation was founded in 1986 by his widow Jessie TO Pui-chun.

*(The above information was up-loaded by William Tam (his son) on 25th August 2020).

Legacy
The Jessie and Thomas Tam Charitable Foundation (established in 1986) has made significant donations to worthwhile causes including HK$5 million to the Hong Kong Cancer Society, £1 million for the 2012 NHS project, “Inflammatory Bowel Disease Registries in the United Kingdom and Hong Kong. A Comparative Study of Disease Pathogenesis in the Far East and West”, and through the Jessie and Thomas Tam Charitable Foundation a donation was made to the Oxford University in support of Chinese education at its Faculty of Oriental Studies.

References

1900 births
1976 deaths
Alumni of the University of Hong Kong
Alumni of University College London
Barristers of Hong Kong
Hong Kong collaborators with Imperial Japan
British Hong Kong judges
Members of the Legislative Council of Hong Kong
Members of the Urban Council of Hong Kong
Officers of the Order of the British Empire
Alumni of Lincoln College, Oxford