Real news in the last days!
And there will be SIGNS in the sun, in the moon, and in the stars; and on the earth distress of nations, with perplexity, THE SEA AND THE WAVES ROARING; men's hearts failing them from fear and for looking at the things that are coming upon the earth, for the powers of the heavens will be shaken. THEN THEY WILL SEE THE SON OF MAN COMING IN A CLOUD WITH POWER AND GREAT GLORY. Now when these things begin to come to happen, look up and lift up your heads, because your redemption draws near" (Luke 21:25-28).
. . . . .Are the end times in the here and now?.
The videos above does not neccessarily express the views of All of the Answers Ministry entirely, but represents a good compilation of the news reports.
Nicholas Sarkozy - Does He fit into END TIME NEWS?
Above article a must read!!!!!!!!
Verichip Video above is only the potential technology that the Beast System would use let's examine it scripturally.
this video is to show how it will be done, how easy it is to do, and how it will be come an accepted procedure to perform.
This chip may or not be the mark of the beast implant but something along these lines will occur when the antichrist has assumed power.
The Harvest begins - Muslims coming to Christ!
The candidate Red Heifer needed for Jewish Temple Sacrifice is alive now!
Rapture Survival Guide - no Kidding!
WHAT REALLY HAS HAPPENED IN THE MIDDLE EAST?


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The community around LifterLMS is clearly helpful, sensitive, and of above average intelligence. I finally found a education entrepreneur community that gets me.
With LifterLMS as an all-in-one solution I can finally stop stringing together all these different products made by different companies that don't always work well together. No separate third party membership, ecommerce, or gamification tools are required!
It's obvious this software is made by course creators and membership site builders. It's like LifterLMS knows what I need next before I do.
I chose LifterLMS for the flexibility and scalability. I can easily validate my course or membership idea through pre-selling, then launch one course, launch more courses, add a membership, add coaching, add community, build a multi-instructor online school, and much, much more.
It's like LifterLMS cares about my students' results and completion rates as much or even more than I do.
LifterLMS just works. I dropped in my course content and had my first course up for sale very quickly.


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The annual wrap event of the Festival sees Chefs, Restaurants, Food Outlets and producers complete for the coveted winners 'Plate'.
An Púcán presents an evening of delectable food and drink pairings in association with Kalak Irish Vodka.
Join Chef Jonathan Keane for Easter Rising Centenary 4 course Lunch at the Lodge at Ashford Castle. Lunch begins at 2.30pm followed by Trad on the Prom at 6pm.
Join us for an afternoon of Music, Tapas, Sangria & Spanish cocktails. Prices Vary.


text:
Q: Creating a post request including a multipart file upload I am writing a simple snippet which sends a simple post request.
Currently I am building the request like so:
    // Construct data
    String data = URLEncoder.encode("param1", "UTF-8") + "=" + URLEncoder.encode("val1", "UTF-8");
    data += "&" + URLEncoder.encode("param2", "UTF-8") + "=" + URLEncoder.encode("val2", "UTF-8");

    // Send data
    URL url = new URL("http://server:8080/servlet/upload");
    URLConnection conn = url.openConnection();
    conn.setDoOutput(true);
    OutputStreamWriter wr = new OutputStreamWriter(conn.getOutputStream());
    wr.write(data);
    wr.flush();

    // do stuff with response....

This works, as of now. But I need to add a file upload as a multipart POST request.
How can I do this? I would like to avoid using HttpClient from commons if possible.

A: Currently, you aren't using HTTP at all. If you intend to do a POST, the first thing you need to do is make sure you send the correct headers and such, so you are actually engaging in an HTTP connection. The you need to follow RFC 1867 ( https://www.rfc-editor.org/rfc/rfc1867 ) to properly encode the file contents into your POST. This is not easy, which is why there are libraries out there which do this for you. So I have to ask: why avoid HttpClient? I've always used it for this purpose. It's reliable, complete and performant. Are you short on (memory/disk) space?

A: To the point, you need to construct an outputstream with data in the format as specified in RFC 1687 and RFC 2388. It's a lot of work, I am not going to post a kickoff code example, sorry :) The RFC however contains clear information and several examples how the data should look like. It is absolutely doable.

A: Try this as this worked in my case
File f = new File(filePath);
PostMethod filePost = new PostMethod(url);
Part[] parts = { new FilePart("file", f) };
filePost.setRequestEntity(new MultipartRequestEntity(parts,
filePost.getParams()));
HttpClient client = new HttpClient();
status = client.executeMethod(filePost);
logger.info("upload status: " + status);

A: This code snippet served me well: Upload files by sending multipart request programmatically
It does not have any external dependencies, is only ~ 150 lines of code including comments and is IMHO even easier to handle than the Apache HttpClient library.

redpajama_set_name: RedPajamaStackExchange


text:
Q: How to solve a stochastic differential equation? This is a stochastic differential equation,
$$ dx(t) = -x(t)dt + e^{(-t)} dw(t)$$
I am not able to determine the next steps to solve this equation.

A: Something like this?
procx = ItoProcess[\[DifferentialD]x[t] ==
    x[t]*\[DifferentialD]t + Exp[-t]*\[DifferentialD]w[t],
   x[t], {x, 0}, t, {w \[Distributed] WienerProcess[]}];

datax = RandomFunction[procx, {0, 5, 0.1}, Method -> "StochasticRungeKutta"];

ListLinePlot[datax]


text:
The Mission of the 2018 Young Lawyers Division Earnings Survey was to compile and assess, data concerning Florida young lawyer earnings, to allow the Young Lawyers Division Board of Governors to better understand financial issues affecting its members, so it could then shape programing, initiatives, and resources to address those issues.
The 2018 Young Lawyers Division Earnings Survey was sent to a random sample of 3,754 young lawyers. Of those, 503 young lawyers responded giving the survey a margin of error of plus or minus 4%. All Florida lawyers under the age of 36 and new Florida Bar members for the first 5 years in good standing are automatically members of the YLD.
Key takeaways of the responses include:
75% of respondents reported having outstanding student loans.
The median reported outstanding student loan amount was $150,000.
82% of female young lawyers reported outstanding student loans compared to 67% for male young lawyers.
Median income reported for male young lawyers was $80,000 compared to $70,000 for female young lawyers.
Download Complete Survey Results
The Young Lawyers Division Board of Governors produced a report on one aspect of the survey results that included recommendations concerning law student debt. The YLD will continue to assess this data and modify its programs, initiatives, and resources to address the earnings issues facing Florida young lawyers.
Download "Increasing Law School Transparency: Tackling the Mountain of Debt faced by Young Lawyers"
View Florida Bar News Article "YLD takes a hard look at law school debt"
YLD President: Christian George
YLD President-Elect: Santo DiGangi
Chair: Adam White
Co-Chair: Cullan Jones
Sub-Committee Members with Substantial Contributions: Annika E. Ashton, Alex Palermo, and Celia Thacker Dorn

redpajama_set_name: RedPajamaCommonCrawl


text:
Court Blocks Healthcare Vaccine Mandate Across the Nation: A Game Plan for Healthcare Employers
Lisa Nelson December 2, 2021, 1:38 pm December 2, 2021 0
Originally published by Fisher Phillips, Leavitt Group's preferred partner for employment law. Republished with permission. Some content provided by Leavitt Group Employee Benefits Compliance. Your Trusted Partner for compliance.
Not 24 hours after a Missouri federal court temporarily blocked the Centers for Medicaid and Medicare Services (CMS) from enforcing its COVID-19 vaccine mandate in 10 states, a Louisiana federal court took one giant step further and blocked the rule from taking effect in any healthcare facility across the country not covered by the Missouri decision. The judge's 34-page order issued late Tuesday contends that the federal government does not have the authority to implement the vaccine mandate, effectively putting the entire rule on ice for the time being. But with a January 4, 2022 deadline looming for covered workers to be vaccinated (and a December 6 deadline for accommodation requests and the first vaccine dose), as well as the ever-present threat that this court order could be overturned by an appeals court or the Supreme Court, what should healthcare employers do while waiting for a final decision?
Here's a quick timeline of critical events to catch you up to speed:
CMS issued a rule on November 5 requiring various Medicare and Medicaid certified providers and suppliers to implement a workplace vaccine mandate if they want to remain in the Medicare/Medicaid programs. The mandate would require employees, volunteers, students, contractors, and other "staff" (broadly defined) who provide services within covered facilities be fully vaccinated against the COVID-19 virus by January 4, 2022. It also set a December 6 deadline for accommodation requests and the first vaccine dose. Importantly, the mandate did not include a testing option as does OSHA's nationwide ETS (also currently enjoined).
On November 11, a collection of 10 states (Alaska, Arkansas, Iowa, Kansas, Missouri, Nebraska, New Hampshire, North Dakota, South Dakota, and Wyoming) filed a complaint in a Missouri federal court challenging the enforceability of the CMS mandate. Two days ago, that court granted the states' request to block the rule – but that order only applies to healthcare facilities in those 10 states.
Separately, another 14 states filed a similar action in Louisiana: Arizona, Alabama, Georgia, Idaho, Indiana, Kentucky, Louisiana, Mississippi, Montana, Ohio, Oklahoma, South Carolina, Utah, and West Virginia. It's that lawsuit that led to yesterday's nationwide order blocking the CMS vaccine mandate for all healthcare employers across the country not already covered by the Missouri ruling.
What did the Louisiana Court Say?
Just as in the Missouri case, the Louisiana federal court entered a preliminary injunction against the CMS vaccine mandate, holding that the 14 states demonstrated a likelihood of success on the merits and established that they would suffer immediate and irreparable harm in the absence of an injunction. It made five key findings to conclude that the states would likely prevail in any litigation attacking the mandate:
Federal Authorities Didn't Follow Standard Process
It first faulted CMS for not following the standard notice-and-comment period that would have allowed interested parties to weigh in and provide their opinions on the rule. Although the federal agency claimed it had "good cause" to issue the rule without that typical process, the court disagreed. It cited to the fact that CMS took almost two months to prepare the interim final rule, which is longer than a normal notice-and-comment period.
CMS Doesn't Have Authority to Issue Mandate
The court said that the separation of powers principle weighed in favor of striking down the rule because a "major question" such as a vaccine mandate impacting millions of workers should have been reserved for federal lawmakers and not federal bureaucrats in the executive branch. "There is no question that mandating a vaccine to 10.3 million healthcare workers is something that should be done by Congress, not a government agency," said the court. "It is not clear that even an Act of Congress mandating a vaccine would be constitutional. Certainly, CMS does not have this authority by a general authorization statue."
The Vaccine Mandate is Contrary to Law
The judge cited to further provisions of law that were not followed in implementing the vaccine mandate, including one related to the typical administration of the Social Security Act (failing to advise state agencies before rolling out the rule, among other things). It also pointed out that CMS failed to conduct an initial regulatory analysis on the impact the mandate would have on small rural hospitals, positing that loss of workers not complying with the mandate and/or the loss of federal funds could be "significant."
The Rule is "Arbitrary and Capricious"
The court contended that CMS didn't follow reasoned decision making when it issued the rule, and for that reason was arbitrary and capricious. "The goal of the CMS Mandate is to increase individual vaccine rates," the court noted, but according to the judge "will actually have the effect of harming patient well-being due to staff shortages of providers and suppliers. This is backed up by a number of declarations of various individuals that verify healthcare worker shortages, a significant number of healthcare workers that remain unvaccinated, and the harm that will be caused to these facilities in the event that even a few of the unvaccinated healthcare workers quit or are fired as a result of the CMS Mandate." Additionally, the court chided CMS for failing to consider (or arbitrarily rejecting) "obvious" alternatives to the vaccine mandate, such as daily or weekly COVID-19 testing, wearing masks or shields, natural immunity, and social distancing.
The Mandate Violates Various Constitutional Principles
Finally, the court cited various constitutional provisions such as the Spending Clause, the Tenth Amendment, and the Anti-Commandeering Doctrine for further justification as pressing pause on the vaccine mandate.
Scope of Decision
In addressing the geographic scope of the preliminary injunction, the judge noted a nationwide injunction was necessary due to the need for uniformity since the CMS mandate has a nationwide scope of the CMS Mandate. Therefore, the scope of this injunction is nationwide except for those employers in states covered by the Missouri ruling: Alaska, Arkansas, Iowa, Kansas, Missouri, New Hampshire, Nebraska, North Dakota, South Dakota, and Wyoming.
Where Does This Leave Healthcare Employers?
For all intents and purposes, healthcare employers covered by the CMS vaccine mandate in all locations across the country have been granted a temporary reprieve. The problem is that we do not know how "temporary" this reprieve will be, and how soon you may need to ramp up your compliance efforts if new life is breathed into the rule. Therefore, you may want to take a cautious approach and perform some behind-the-scenes actions to prepare for a possible resurrected vaccine mandate without unfurling major initiatives. Some steps to consider include:
Establish a compliant written policy on vaccines and determine how you will enforce it should the CMS rule come back on line.
Evaluate your company culture and how employees will react to a vaccine mandate. Do you know current site vaccination rates? Have you offered incentives and were they effective?
Plan for how to handle temporary and long-term employee loss.
Provide information to employees on vaccines and their safety and effectiveness.
Determine "how" to explain the pending court litigation and pending appeal(s), because many employees may assume that the CMS rule is dead if they just glanced at headlines.
Build a process (committee, outside providers, etc.) to evaluate requests for medical and religious accommodations.
Recognize Collective Bargaining obligations if you are unionized.
Finally, it is critically important to keep an eye on state and local laws for two critical reasons.
Some local laws may impact any self-imposed vaccine mandates you may have in place. Without the CMS rule in effect, any of your mandatory vaccine policies likely must comply with state laws that otherwise would have been preempted by the CMS rule. For example, Kansas and North Dakota recently passed laws that impact vaccine mandates and what exemptions must be considered, and the Arkansas legislature recently passed a bill that is expected to become law in the coming months.
At the same time, just because the federal healthcare mandate is on ice does not mean you can let your guard down. You may operate in a state or local jurisdiction that already has a vaccine mandate for healthcare workers in place – and those laws were not impacted by yesterday's decision.
The only practical distinction that may exist between employers operating in the Missouri decision's 10 states and the remainder of employers is if one of these two decisions is overturned while the other remains in place. In such a situation, it is possible that you may have different obligations to comply with a resurrected CMS vaccine mandate while other employers would be spared compliance obligations. And in such a situation, employers with multi-state operations may have a patchwork of rules to follow. You will thus need to monitor these separate pieces of litigation, and the best way to stay on top of these developments is to subscribe to Leavitt Group news.
Where this litigation goes next is anyone's guess. As challenges against the CMS rule have also been filed in other states as well, we could see further court decisions further muddying the waters. And we could see a federal appeals court weigh in to overturn these preliminary injunctions at any moment. Given the varied rulings in play, we could see the Multidistrict Litigation Panel once again be called upon to break out its trusty raffle wheel and ping-pong balls to assign this controversy to one federal appeals court for an overall ruling as happened several weeks ago with OSHA's mandate-or-test ETS. And, of course, a trip to the Supreme Court for an ultimate decision is not out of the question.
Covid-19employee benefits compliance
Supreme Court Revives Nationwide CMS Vaccination Mandate: A 4-Step Priority List for Healthcare Employers
Supreme Court Strikes Down OSHA's Vaccine ETS: An Employer's 6-Step Priority List
Group Health Plans Mandated to Cover At-Home COVID-19 Tests
Vaccine Showdown at the Supreme Court: Preview and Predict Outcome of Pivotal Battle on Jan 7th 2022
Federal Appeals Court Reinstates OSHA's Vaccine Mandate-or-Test ETS: An Employer's 5-Step Compliance Plan
OSHA's Vaccine ETS Halted Longer as Appeals Court Extends Stay on Vaccine Mandate – How Can Employers Make a Smooth Landing?
This information is educational only, and not intended to be legal or financial advice. Please consult with your own legal professional to ensure compliance with all applicable law.
Permission is granted to reprint this bulletin, as long as you credit The Leavitt Group/LGAA, Inc with authorship. This bulletin is general in nature and is not intended or provided as legal advice or opinion in any particular case. IRS Circular 230 disclosure: To ensure compliance with requirements imposed by the IRS, we inform you that any tax advice contained in this communication, unless expressly stated otherwise, was not intended or written to be used, and cannot be used, for the purpose of (i) avoiding tax-related penalties under the Internal Revenue Code or (ii) promoting, marketing, or recommending to another party any tax-related matter(s) addressed herein.


Please use this thread for all posts relating to our Premier League match against QPR at Loftus Road, before, during and after the game.
Moderators and our legal people will be keeping an eye on things. Keep it intelligent.
The match is scheduled to kick off at 13:30, Sunday 11th April, 2015.
I'm not sure which would be more valuable in view of the next few games: three points or Matic and Fabregas not getting booked.
Part of me is quite pleased that Costa is out for a few weeks because I think Remy deserves a run in the team. Please...... no Drogba!
I think we'll go with the same side we saw against Stoke. However, I'd like to think Oscar takes a place on the pine, Willian moves central, and either start Cuadrado or Ramires on the wing. Can't see any other hostile changes being made.
Cutoff date is next Sunday. It wont matter about being booked after that.
That's what I mean. If viewed only in the context of the QPR game then the three points are all that matter, but getting booked in that game will have consequences for the two games after that.
This game will either make or break our season.
The crowd will be vocal and a strong ref will be required, I expect they'll stitch us up one way or another.
A homer ref and we'll be lucky to survive with 11 players on the pitch and one point.


text:
Week 11: Packers at Washington
Packers-Washington Q&A: Kirk Cousins 2016 backslide not as steep as advertised
Alex Rowsey of SB Nation's Washington blog Hogs Haven answers our questions about Kirk Cousins, the state of the NFC East, and what he expects from Green Bay vs. Washington.
By Jason B. Hirschhorn@by_JBH Nov 18, 2016, 2:00pm CST
Share All sharing options for: Packers-Washington Q&A: Kirk Cousins 2016 backslide not as steep as advertised
Photo by Rob Carr/Getty Images
On Sunday night, the Green Bay Packers travel to the nation's capitol for a rematch of last year's wild-card playoff game. Alex Rowsey of Hogs Haven was kind enough to answer some of our questions about Washington and provide insight into its strengths and weaknesses.
APC: Washington won a weak NFC East a season ago, but now the division looks like the most competitive in the conference. Besides the addition of the rookie quarterbacks, what changed this season?
That's a huge question. Washington's only slightly better than last year. Continuity helped them. Besides Dak Prescott, Dallas hit a HR with Zeke and their OL has gelled. The Giants improved their defense significantly through FA and Philly got rid of Chip Kelly. I don't know how much detail you're looking for, but I could probably write a book on the NFCE. For Washington, it's come down to building their team the right way. They've drafted well for 2-3 straight years now and are being frugal in FA. They have a solid GM with a proven track record. Also, Josh Norman's pretty damn good and the secondary went from one of the team's biggest weaknesses to one of their biggest strengths.
APC: Kirk Cousins finished 2015 on one of the hottest streaks for any quarterback in football, but he hasn't quite matched that level this season. What factors have affected his play in 2016, and what do you expect from him the rest of the way?
While Kirk hasn't managed what he did the latter half of last season, he's been very good for most of this year so far. His completion percentage is still great and he's throwing for even more yards this year. The INTs have remained pretty constant from last year and the TDs are down a touch, but he's still thrown twice as many TDs as INTs. Really, this year has been very comparable to last year for him, it's just that last year was split so extremely between a below average first half and a dynamite second half. He's brought both of those extremes more to the middle ground this year and has landed into a pretty consistent, very good place. He struggled a little bit the first couple weeks and I think that may have been expectations weighing on him some, but he's found himself lately and is playing great football. The running game improvement this year has certainly helped him but missing Jordan Reed and/or DeSean Jackson for games at a time has hurt him a little bit. Really, he hasn't been much different this year from last year aside from the fact that he's gotten more consistent it seems. I see no reason why he won't continue this same level of play the remainder of the year and am even a little hopeful that he can still play better. He seems to have gotten better as the season goes on both last year and again so far this year.
APC: Josh Norman joined Washington late in free agency and immediately became the new No. 1 corner. How do you evaluate his performance this year?
I evaluate it as very, very good. He's pretty much been a stud. He's a true #1 CB and QB typically avoid throwing towards him. He's given up some yards this year (particularly to OBJ and A.J. Green), but for the most part, he's shut guys down. He struggled a bit with Green. Beckham got good yardage on him, but Norman held up when it really counted most, clearly got into Beckham's head, and came out with the W. No one else has given him much trouble at all. More times than not, he takes his guy out of the game and he's been an excellent tackler in run support as well as an overall teammate that the rest of the guys really seem to like. I think he's made guys better. He has a good attitude and is a baller. Money well spent. Clearly Carolina misses him...
APC: How would you game plan against Washington's offense? Its defense?
I'd focus on taking away the Redskins running game. When this team is balanced, they usually win. When they go all one-dimensional (whether by their own doing or because of outstanding defensive play) and put it all on Kirk's shoulder and make him throw it a million times, they usually lose. It's really that simple. It's incredible. They've kind of beaten themselves a couple of times this year (especially in the first couple of games) by simply throwing it like 80% of the time for no reason. They have an excellent OL and when they run the ball and set up a lot of PA, this offense is one of the best in the league. So play the run. The passing game is too strong and has too many weapons to really focus on for most defenses. Also, if you really tighten up in the red-zone, things will be much better for you. For as great as the Redskins offense is between the 20s, they're pretty bad in the red-zone. If your defense bends but doesn't break, and makes the Redskins settle for FGs, then you'll be in it. The Redskins are great at getting a ton of yards and FGs. Keep them out of the end-zone even if they get close and it'll make a bigger difference than it would against most teams.
When you're on offense, run, run, run. Don't stop running. The Redskins have a relatively weak DL and are inconsistent tacklers. Their secondary is strong as is their pass rush. They play the passing game very well. But, they can be run on, especially right up the middle. The defense has pretty good speed, but they lack size and strength at some key spots in the middle of the field. They can be run on.
APC: Finally, it's prediction time. Which team wins on Sunday and why?
The Redskins are going to win 26-23. They're at home and GB is slumping hard. The Redskins running game has been on point the past few weeks and their passing game has been excellent almost all year. Their defense has improved drastically as the year goes on and STs have been great all year (their K, Dustin Hopkins, could be a Pro Bowler this year). It's hard to rule out a team with Aaron Rodgers, but something's clearly off with GB as they've lost a few in a row. Not sure why they'd just snap out of it all of a sudden. I'll say it's close just because Washington hasn't proven they can put a team away yet really and I haven't forgotten the playoffs last year. Rodgers can beat people. I've seen it so many times. Just don't think it's likely right now.
We'd like to thank Alex and Hogs Haven for answering our questions. Be sure to check out our Q&A session over there, as well as their fantastic coverage of all things Washington. As always, keep your internet machines tuned to Acme Packing Company this Sunday for our comprehensive game-day coverage of Green Bay vs. Washington.
Jason B. Hirschhorn is an award-winning journalist and Pro Football Writers of America member. He covers the NFL for Sports on Earth and SB Nation. He also serves as the senior writer and editor for Acme Packing Company, a Green Bay Packers blog.
Follow @by_JBH
Friday Cheese Curds: Who should be the Packers' biggest free agent priority? Choose your fighter in the comments.
Packers' Romeo Doubs was the most productive Day 3 rookie WR, despite injury Doubs brought in 42 receptions for 425 yards and three touchdowns in 2022.
NFL Conference Championship Game Picks: Who heads to Super Bowl LVII? Will the top-seeded Eagles and Chiefs advance, or is an upset brewing in either conference?


text:
Research Article| Volume 81, P225-230, April 2019
Post Option B+ implementation programme in Nigeria: Determinants of adherence of antiretroviral therapy among pregnant women with HIV
Olumuyiwa Omonaiye
Corresponding author at: Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, 221 Burwood Highway, Melbourne Campus at Burwood, Victoria, 3125, Australia.
Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Faculty of Health, Deakin University, Melbourne, Victoria, Australia
Snezana Kusljic
Department of Nursing, School of Health Sciences, The University of Melbourne, Melbourne, Australia
Pat Nicholson
Mohammadreza Mohebbi
Elizabeth Manias
Open AccessPublished:February 18, 2019DOI:https://doi.org/10.1016/j.ijid.2019.02.014
Previous ArticleEpidemiological analyses of regional and age differences of HIV/AIDS prevalence in China, 2004–2016
Next ArticleAccess to second-line drug susceptibility testing results among patients with Rifampicin resistant tuberculosis after introduction of the Hain® Line Probe Assay in Southern provinces, Zimbabwe
Of surveyed pregnant women in Nigeria, about one-third self-reported taking all their ART doses in the past 96 h.
Disclosure of HIV status to anyone was associated with ART adherence during pregnancy.
Among pregnant women, previous prevention of MTCT was associated with ART adherence.
An increased level of education among pregnant women was associated with ART adherence.
Nigeria has the highest rate of mother to child transmission of HIV (MTCT) in the world. By 2015, all Global Plan priority countries, except Nigeria, had adopted the Option B+ programme. Nigeria finally adopted Option B+ in 2016 with full implementation reported in 2017. We examined adherence to antiretroviral therapy (ART) among pregnant women since the rollout of Option B+ in Nigeria.
A cross sectional approach was adopted that involved dissemination of a survey (Adult AIDS Clinical Trial Groups [AACTG] standardised survey) to HIV positive pregnant women, to assess adherence to ART. This study was conducted from February to June, 2018 in four health care sites in Akwa Ibom State, in the South-South region of Nigeria. Bootstrapping was used to estimate the 95% confidence interval of the prevalence of adherence. Bivariate associations between patient demographic characteristics and medication taking behaviours, and the outcome variable of ART adherence were examined using Chi-square tests. Multivariable logistic regression was used to identify factors independently associated with adherence.
Of the 275 women (response rate = 92.6%), 32.7% (95% CI: 26.9–38.5) self-reported taking all ART doses in the past 96 hours. In the multivariable logistic regression analyses, there were positive associations between an increased education level (OR = 1.7, p = 0.006) and disclosure of HIV status (OR = 2.3, p = 0.024), and medication adherence. For women who had previous prevention of MTCT exposure, the odds of medication adherence were 2.5 times higher compared with those with no previous MTCT exposure (OR = 2.5, p = 0.005).
Adherence to ART among pregnant women in Nigeria is low. There is a need to improve adherence during pregnancy under the Option B+ programme in Nigeria.
Antiretroviral therapy
Prevention of-mother-to-child transmission
Globally, Nigeria has the highest burden of mother to child transmission (MTCT) of the human immunodeficiency virus (HIV) (
Nigeria National Agency for the Control of AIDS (NACA), 2016
Nigeria National Agency for the Control of AIDS (NACA)
Fact sheet: prevention of mother-to-child transmission of HIV (PMTCT).
). This country is therefore an important target in the current global efforts towards eliminating MTCT of HIV. Approximately 180,000 HIV-positive pregnant women require prevention of MTCT services every year in Nigeria (
), with 37,000 new paediatric HIV infections reported in 2016 (
United nations joint programme on HIV/AIDS (UNAIDS), 2017
United nations joint programme on HIV/AIDS (UNAIDS). Nigeria:Overview. 2017. http://www.unaids.org/en/regionscountries/countries/nigeria. [Accessed 10 November 2018].
). The Global Plan towards the elimination of new HIV infections among children by 2015 and keeping their mothers alive (Global Plan) prioritised 22 countries that, in 2009, accounted for 90% of the global number of pregnant women living with HIV who were in need of services to prevent MTCT (
United nations joint programme on HIV/AIDS (UNAIDS), 2016a
United nations joint programme on HIV/AIDS (UNAIDS)
On the fast-track to an AIDS-free generation.
http://www.unaids.org/sites/default/files/media_asset/GlobalPlan2016_en.pdf
). Nigeria is at the top of this list of high-HIV burden priority countries in sub-Saharan Africa (
). Based on the Joint United Nations Programme on HIV/AIDS (UNAIDS) final accountability report of the Global Plan that was released in 2016, some countries still face significant challenges, which includes Nigeria. This is because between 2009 and 2015, only a 21% reduction in new pediatric HIV infection in Nigeria has been achieved compared with other priority countries such as Uganda, South Africa, Burundi, Swaziland, Namibia and Mozambique, which have achieved 86%, (Burundi and South Africa-84%), 80%, 79% and 75% reductions within the same time frame respectively.(
Prior to 2010, the Nigerian national guidelines on preventing MTCT recommended the Option A regimen to the World Health Organization (WHO), which included administration of maternal zidovudine during pregnancy, and short-term single-dose of nevirapine, zidovudine, and lamivudine at delivery and at one week postpartum (
Federal Ministry of Health Nigeria (FMOH), 2007
Federal Ministry of Health Nigeria (FMOH)
National guidelines for prevention of mother-to-child transmission of HIV.
Federal Ministry of Health Nigeria, Abuja, Nigeria2007
). In 2010, the revised guidelines recommended antiretroviral therapy (ART) for pregnant women in compliance with the WHO Option B regimen (
World Health Organization (WHO), 2010
Antiretroviral drugs for treating pregnant women and preventing HIV Infection in infants-towards universal access: recommendations for a public health approach.
). This regimen involved continuing postpartum maternal ART until one week after cessation of breastfeeding for women who did not meet eligibility criteria for CD4 count and WHO clinical staging, as detailed under Option B (
). However, healthcare facilities, such as primary health care centres with low technical capability for implementing Option B, were required to continue implementation of Option A (
). The 2014 Nigerian national guidelines endorsed Option B for preventing MTCT and expanded this treatment option to all healthcare facilities (
Federal Ministry of Health Nigeria, 2014
Federal Ministry of Health Nigeria
Nigeria F.M.o.H. Integrated national guidelines for HIV prevention, treatment and care. Federal Ministry of Health Nigeria, Abuja, Nigeria2014
). This endorsement was in contrast to the 2013 WHO consolidated guidelines, which recommended life-long ART for all HIV-infected women after delivery, using the Option B+ regimen (
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach.
). By 2015, all Global Plan priority countries, except Nigeria, had adopted Option B+. Under this treatment regimen, pregnant women are offered lifelong ART from the time of HIV diagnosis, regardless of the gestational age, and irrespective of their WHO HIV clinical staging and CD4 cell count (
Ebuy et al., 2015
Ebuy H.
Yebyo H.
Alemayehu M.
Level of adherence and predictors of adherence to the Option B+ PMTCT programme in Tigray, northern Ethiopia.
Int J Infect Dis. 2015; 33: e123-e129
). Nigeria finally adopted Option B+ in 2016 with full implementation in 2017 (
US President Emergency Plan for AIDS Relief (PEPFAR), 2017
US President Emergency Plan for AIDS Relief (PEPFAR). Nigeria Country Operational Plan (COP) 2017 Strategic Direction Summary. https://www.pepfar.gov/documents/organization/272254.pdf. [Accessed 30 October 2018].
Extensive evidence demonstrates the importance of medication adherence, and its crucial role in influencing treatment outcomes in the general population (
Brown and Bussell, 2011
Brown M.T.
Bussell J.K.
Medication adherence: WHO cares?.
Mayo Clin Proc. 2011; 86: 304-314
). In the face of high MTCT burden in Nigeria, there has been a dearth of research specifically examining whether Nigerian women take their medications during pregnancy, and the complex factors that influence their decision to take ART. This study is the first to examine adherence to ART among pregnant women since the rollout of Option B+ in Nigeria.
Study design and participants
A cross sectional approach was adopted that involved dissemination of the Adult AIDS Clinical Trial Groups [AACTG] standardised survey (
Chesney et al., 2000
Chesney M.A.
Ickovics J.R.
Chambers D.B.
Gifford A.L.
Neidig J.
Zwickl B.
Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG).
AID Care. 2000; 12: 255-266
) to HIV positive pregnant women, to assess adherence to ART. Information about their health behaviours and practices associated with this treatment was also obtained. This survey has been widely used in assessing adherence to ART among the general adult HIV positive population in sub-Saharan Africa, such as South Africa and Uganda (
Nachega et al., 2004
Nachega J.B.
Stein D.M.
Lehman D.A.
Adherence to antiretroviral therapy in HIV-infected adults in Soweto: South Africa.
AIDS Res Hum Retroviruses. 2004; 20: 1053-1056
Byakika-Tusiime et al., 2005
Byakika-Tusiime J.
Oyugi J.H.
Tumwikirize W.A.
Katabira E.T.
Mugyenyi P.
Bangsberg D.R.
Adherence to HIV antiretroviral therapy in HIV+ Ugandan patients purchasing therapy.
Int J STD AIDS. 2005; 16: 38-41
) and in particular among HIV positive pregnant women in Zambia (
Okawa et al., 2015
Okawa S.
Chirwa M.
Ishikawa N.
kapyata H.
Msiska C.Y.
Syakantu G.
Longitudinal adherence to antiretroviral drugs for preventing mother-to-child transmission of HIV in Zambia.
BMC Pregnancy Childbirth. 2015; 15: 258
). This study was conducted from February to June of 2018 in Akwa Ibom State, in the South-South region of Nigeria. Among the six regions of Nigeria, the South-South region has the highest HIV prevalence rate (5.5%) with the prevalence of HIV reported to be 6.5% in the Akwa Ibom State, which is higher than the national HIV prevalence (3.4%) (
National Agency for the Control of AIDS (NACA), 2012
National Agency for the Control of AIDS (NACA). Nigeria Prevalence Rate. 2012. https://naca.gov.ng/nigeria-prevalence-rate/. [Accessed 23 November 2018].
). The study was conducted in four health facilities, which are among the highest volume of HIV/AIDS treatment centres in the state, with over 2,000 patients on ART including adult and children. These health facilities offer free comprehensive HIV/AIDS services, including prevention of MTCT. Following status determination, every HIV positive pregnant and breastfeeding woman is started on lifelong ART (same-day ART initiation) with a single fixed-dose combination tablet, regardless of their clinical status or CD4 count. HIV positive pregnant women receive at least one viral load estimate prior to delivery of their baby to determine whether the resultant HIV exposed infant is high risk and eligible for enhanced ART prophylaxis (
). Prior to ART commencement, HIV positive pregnant women undergo adherence counseling, provided by nurses and midwives in the antenatal clinic. Subsequently, ongoing group and individualised adherence counseling is provided at every refill visit (usually every month) by doctors, nurses, midwives, trained adherence counselors and pharmacy personnel before ART is dispensed.
The minimum sample size (N) was determined by using the WHO statistical formula of estimating population proportion with absolute precision in health studies (
Lwanga and World Health Organization, 1991
Lwanga S.K.a.L.
Sample size determination in health studies:a practical manual/S. K. Lwanga and S. Lemeshow.
World Health Organization, Geneva1991
N = Z21-α⁄2 P (1-p)/d2
The following parameters were used to calculate the sample size for the prevalence of adherence to ART: Z = Normal deviant at the portion of 95% confidence interval = 1.96, (P) proportion of adherence among HIV positive pregnant women based on two previous studies conducted in Nigeria (
Igwegbe et al., 2010
Igwegbe A.O.
Ugboaja J.O.
Nwajiaku L.A.
Prevalence and determinants of non-adherence to antiretroviral therapy among HIV- positive pregnant women in Nnewi, Nigeria.
Int J Med Med Sci. 2010; 2: 238-245
Ekama et al., 2012
Ekama S.O.
Herbertson E.C.
Addeh E.J.
Gab-Okafor C.V.
Onwujekwe D.I.
Tayo F.
Pattern and determinants of antiretroviral drug adherence among Nigerian pregnant women.
J Pregnancy. 2012; 2012: 2-6
) (i.e. mean value of 79.6%), an absolute precision (d) of 5% and the 95% confidence interval level. This calculation gave a sample size of 250. The sample size was adjusted by 10% to compensate for a potential non-response rate of 10%, which increased the sample size to approximately 275.
HIV positive pregnant women were eligible to participate if they were aged 18 years or older, had received ART for at least one month and could provide informed consent. HIV positive pregnant women who were judged by clinic health professionals to be too ill to participate were excluded.
In each of the four health facilities, HIV positive pregnant women received their ART refill monthly on specific clinic days and recruitment occurred while women were seated in the pharmacy waiting area before receiving their ART refills. Hence, all women available on each of the clinic days had an equal chance of being selected to participate. Information about the study was placed on a notice board within the dispensing area. Additionally, during the group adherence session facilitated by the nurses and adherence counselors in the pharmacy waiting area, information about the study and the potential benefits and risks of participating were provided. Once women indicated their willingness to participate to the nurse in the clinic, they were approached by a researcher who sought written informed consent. Women completed the AACTG standardised survey anonymously and placed it in a secured box positioned on the pharmacy counter.
A record was kept reflecting the number of women scheduled to attend the clinic, the ones who did not attend and those who attended. These numbers were used to determine the response rate for the study. Ethical approval for this study was granted by the Akwa Ibom State Ministry of Health, Nigeria and Deakin University Human Research Ethics Committee.
A questionnaire with two parts was used to collect data about adherence to ART. Part one of the questionnaire was used to collect socio-demographic and pregnancy details, and HIV and treatment related characteristics of participants. If a consented woman was unable to provide HIV and treatment related information, one of the researchers, together with the medical record staff in the hospital, obtained this information from the woman's medical record by using the patient identification number provided on the questionnaire. Part two included the AACTG standardised survey (
) comprising six sections. Section one measures adherence based on a four-day recall method, with sections two and three assessing adherence to the medication regimen, and special instructions on how to take ART. Sections four and five assess whether the ART medication was not taken in the previous weekend and when the medication was last missed, with section six exploring the reasons for missed dosages.
Definition of the study outcome
This study examined adherence to ART (dose adherence) as the primary outcome. The prevalence of self-reported 100% adherence to ART doses in the previous four days was estimated using the AACTG standardised survey. Dose adherence has been found to be the best predictor of recent and durable viral suppression (
Beer and Skarbinski, 2014
Beer L.
Skarbinski J.
Adherence to antiretroviral therapy among HIV-infected adults in the United States.
AIDS Educ Prev. 2014; 26: 521-537
). Therefore, a respondent was considered adherent if she had not missed taking any doses over the four-day period. Missing at least one dose over the four-day period prior to the day of a survey was considered as non-adherent.
Survey data were entered into an IBM SPSS software database (Version 25, Chicago). Means and standard deviations, or medians and inter-quartile ranges were used to describe continuous variables. Categorical variables were described using summary counts and percentages. The prevalence estimation method was used to determine adherence prevalence. The ART adherence prevalence proportion was calculated and the bootstrap technique was used to calculate prevalence at 95% confidence intervals. Bivariate associations between patient characteristics and medication-taking behaviours, and the outcome variable of ART adherence were examined using Chi-square tests. Multivariable logistic regression was used to identify factors independently associated with adherence, using a backward elimination variable selection strategy with p< 0.10 inclusion and p< 0.05 retention criteria. In addition the Akaike information criterion (AIC) and the Bayes information criterion (BIC) were compared between the nested models and the model with optimal (i.e. smaller) goodness of fit index was selected as the final multivariable model (
Zucchini, 2000
Zucchini W.
An introduction to model selection.
J Math Psych. 2000; 44: 41-61
). Model adjusted odds ratios (adjusted OR) and 95% confidence intervals (CI) were reported.
Role of the funding source
The funder had no role in the design, collection of data, data analysis, interpretation, or writing of the report. The corresponding author had full access to all data in the study and had final responsibility for the decision to submit the manuscript for publication.
Of 297 women who attended the health facilities, 275 women responded to the survey, resulting in a response rate of 92.6% (Figure 1). The demographic profile of women who did not respond to the survey was similar to those who participated. An overwhelming majority of the women (274 out of 275) were on a fixed dose combination of Tenofovir 300 mg (TDF) + Lamivudine 300 mg (3TC) + Efavirenz 600 mg (EFV), taken once a day at night. One woman was on a fixed dose combination of Zidovudine (300 mg) (ZDV) + Lamivudine 150 mg (3TC) + Nevirapine 200 mg (NVP), taken twice daily (12 hourly). The median age of responding women was 27 years (interquartile range [IQR] 24–29). In all, 117 (42.5%) had completed primary school education, and 239 (86.9%) were married and living with a spouse or a partner (Table 1). More than half (54.5%) of the women lived in a rural area and 178 (64.7%) of the women reported that it takes less than an hour for them to get to the health facility (Table 1). More than half of the women (53.5%) had not disclosed their HIV infection status to anyone. With respect to timing of diagnosis, 65.8% of the women were newly diagnosed as HIV positive in the current pregnancy. Of all the women, 199 (72.4%) reported not having a treatment supporter (who was a family member or friend nominated by the women to support medication adherence) with 57.1% stating they did not know the HIV status of their spouse or partner (Table 2). Just over one-third of women (36.4%) commenced ART during the second trimester of their current pregnancy, while 209 women (76%) had not previously received preventive MTCT therapy (Table 1, Table 2).
Figure 1Study flow chart.
Table 1Socio-demographic characteristics of HIV positive pregnant women by adherence status.
Overall (N = 275)
Dose adherent (n = 90; 32.7%)
p-value for chi-square test.
95% CI: (26.9–38.5)
95% CI
Age (Median, IQR
IQR: interquartile range.
) 27 (24-29)
18–24 115 (41.8) 38 33 24.3 to 42.6 0.746
25–29 109 (39.6) 35 32.1 22.9 to 41.3
30–34 43 (15.6) 13 30.2 16.3 to 44.2
35+ 8 (2.9) 4 50 12.5 to 87.2
Married and living with spouse 182 (66.2) 59 32.4 24.7 to 39.0 0.848
Married not living with spouse 23 (8.4) 6 26.1 8.7 to 43.5
Single but living with partner 57 (20.7) 20 35.1 22.8 to 47.4
Others 13 (4.7) 5 38.5 15.4 to 69.2
Educational level completed
None 24 (8.7) 5 20.8 8.3 to 37.5 < 0.001
Primary school 117 (42.5) 19 16.2 10.3 to 23.1
Secondary school 100 (36.4) 44 44 35.0 to 54.0
Tertiary 34 (12.4) 22 64.7 47.1 to 79.4
Rural 150 (54.5) 33 22 15.3 to 28.7 < 0.001
Urban 125 (45.5) 57 45.6 37.6 to 54.4
Full time house wife 35 (12.7) 9 25.7 11.4 to 42.9 0.072
Trader 71 (25.8) 20 28.2 18.3 to 39.3
Civil servant 18 (6.5) 11 61.1 38.9 to 83.3
Self employed 71 (25.8) 23 32.4 21.1 to 43.7
Unemployed 79 (28.7) 26 32.9 22.8 to 44.3
Travel time to hospital
Less than one hour 178 (64.7) 59 33.1 26.4 to 40.4 0.841
More than one hour 97 (35.3) 31 32 22.7 to 41.2
* p-value for chi-square test.
a IQR: interquartile range.
Table 2Pregnancy and HIV related treatment, care and support characteristics by adherence status.
Overall (N = 275)
Dose adherent (n = 90; 32.7%)
95% CI: (26.9 to 38.5)
Disclosure of HIV status
Disclosure to someone (spouse, partner, family, friend, religious leader) 128 (46.5) 64 50.0 41.4 to 58.6 <0.001
Disclosure to no one all 147 (53.5) 26 17.7 11.6 to 24.5
HIV status of partner
HIV positive 40 (14.5) 20 50 35.0 to 65.0 0.001
HIV negative 78 (28.4) 33 42.3 30.8 to 53.8
Unknown 157 (57.1) 37 23.6 16.6 to 29.9
Treatment supporter <0.001
Yes 76 (27.6) 47 61.8 51.3 to 72.4
No 199 (72.4) 43 21.6 16.1 to 27.6
WHO clinical stage
Clinical stage 1 244 (88.7) 82 33.6 27.9 to 39.8 0.383
Clinical stage 2 31 (11.3) 8 25.8 12.9 to 41.9
Timing of HIV diagnosis
Before getting pregnant 94 (34.2) 49 52.1 42.6 to 62.8 <0.001
During this pregnancy 181 (65.8) 41 22.7 17.1 to 28.7
Couple/partner HIV testing and counseling
Received 25 (9.1) 16 64 44.0 to 80.0 <0.001
Never received 250 (90.9) 74 29.6 24.4 to 35.6
0 22 (8.0) 9 40.9 18.2 to 59.1 0.551
1-2 212 (77.1) 66 31.1 25.0 to 37.7
More than 2 41 (14.9) 15 36.6 22.0 to 51.2
Number of children that have died
0 220 (80.0) 75 34.1 28.2 to 40.0 0.443
1-2 53 (19.3) 15 28.3 17.0 to 41.5
More than 2 2 (0.7) 0
Previous PMTCT experience
Yes 66 (24.0) 42 63.6 51.5 to 74.2 <0.001
Timing of ART initiation
Before conception 94 (34.2) 48 51.1 41.5 to 60.6 <0.001
First trimester 68 (24.7) 21 30.9 20.6 to 42.6
Second trimester 100 (36.4) 19 19.0 12.0 to 28.0
Third trimester 13 (4.7) 2 15.4 0 to 38.5
Of the women, 32.7% (95% CI: 26.9–38.5) self-reported taking all ART doses in the past 96 h, while during the same time frame, 67.3% (95% CI: 61.5–73.1) did not take all their ART doses. In the bivariate analyses, there were significant associations between the women's educational level (p < 0.001) and place of residence (p < 0.001), to adherence to ART during pregnancy (Table 1). In addition, pregnancy and HIV related treatment, care and support characteristics, such as disclosure of HIV status, HIV status of partner and treatment supporter, demonstrated a significant association with adherence to ART (Table 2). Furthermore, couple/partner HIV counseling and testing, previous prevention of MTCT experience, and timing of ART initiation all showed a significant relationship with ART adherence among the pregnant women (Table 2). In the multivariable logistic regression analyses, education and place of residence were significantly associated with medication adherence among the women. For every level increase in education status, there was 70% increase in odds of medication adherence (OR = 1.7, p = 0.006). The odds of medication adherence were two times higher in women living in rural areas compared with urban regions (OR = 2.0, p = 0.019) (Table 3). In addition, disclosure of HIV infection status and previous prevention of MTCT experience were significantly associated with adherence to ART in the multivariable analyses. The odds of medication adherence were 2.3 times higher for participants who disclosed their HIV status compared with those with no HIV status disclosure (OR = 2.3, p = 0.024). For the women who had previous PMTCT exposure, the odds of medication adherence was 2.5 times higher compared with those with no previous MTCT exposure (OR = 2.5, p = 0.005) (Table 3). In the final logistic regression model, there was a trend towards a significant association between having a treatment supporter and adherence to ART (OR = 2, 95% CI: [1.0–4.4], p = 0.084).
Table 3Determinants of adherence in multivariable logistic regression model.
Adjusted OR
95% C.I
Wald (df)
Education completed (ordinal strata) 1.7 1.1–2.5 7.6 (1) 0.006
Having previous PMTCT exposure 2.5 1.2–5.1 6.6 (1) 0.010
Disclosure of HIV status to anyone 2.3 1.1–4.6 5.1 (1) 0.024
Place of residence (rural) 2.0 0.3–0.9 5.5 (1) 0.019
*AIC and BIC for initial model included all factors significant at 0.1, and were 254.2 and 312.1 respectively. These indexes changed to 84.8 and 102.9 in the final selected model.
In this study, 32.7% of the HIV positive pregnant women self-reported 100% dose adherence to ART over a recall period of four days, whereas 67.3% had missed at least one dose within the same time frame. These results show a poor level of adherence to ART during pregnancy in this study population. Current evidence involving general patients situated in developed countries suggests that an adherence level lower than 95% may be sufficient for viral load suppression in populations using the newer non-nucleoside reverse transcriptase inhibitors (NNRTI) formulations (
Viswanathan et al., 2015
Viswanathan S.
Justice A.C.
Alexander G.C.
Brown T.T.
Gandhi N.R.
McNicholl I.R.
Adherence and HIV RNA. Suppression in the current era of highly active antiretroviral therapy.
J Acquir Immune Defic Syndr. 2015; 69: 493-498
Kobin and Sheth, 2011
Kobin A.B.
Sheth N.U.
Levels of adherence required for virologic suppression among newer antiretroviral medications.
Ann Pharmacother. 2011; 45: 372-379
), as compared with the near perfect adherence of 95% or greater required when using the early ART regimens(
Nelson et al., 2010
Nelson M.
Girard P.M.
Demasi R.
Chen L.
Smets E.
Sekar V.
Suboptimal adherence to darunavir/ritonavir has minimal effect on efficacy compared with lopinavir/ritonavir in treatment-naive, HIV-infected patients: 96 week ARTEMIS data.
J Antimicrob Chemother. 2010; 65: 1505-1509
Paterson et al., 2000
Paterson D.L.
Swindells S.
Mohr J.
Brester M.
Squier C.
Wagener M.M.
Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.
Ann Intern Med. 2000; 133: 21-30
). However, health care professionals must continue to support patients to achieve perfect adherence. This is because missed ART in pregnancy may lead to virologic failure, increased risk of MTCT, and potential transmission of drug resistant virus to the unborn child (
Bailey et al., 2018
Bailey H.
Zash R.
Rasi V.
Thorne C.
HIV treatment in pregnancy.
Lancet HIV. 2018; 5: e457-e467
). The results of this study underscore the recent report from the United Nations Joint Programme on HIV/AIDS (UNAIDS), which showed that Nigeria has the highest rate of MTCT among the Global Plan priority countries compared to other Global Plan countries, including South Africa, Uganda, Swaziland, Mozambique and Malawi, with MTCT rates that vary between 2 and 7% (
United nations joint programme on HIV/AIDS (UNAIDS), 2016b
UNAIDS global plan country fact sheet.
http://www.unaids.org/en/resources/campaigns/globalplan/factsheets
). The MTCT rate in Nigeria is 13% at the first six weeks following childbirth and increases to 23% at the end of breastfeeding (
). A major contributing factor to this high MTCT rate in Nigeria, particularly in the first six weeks of life, could be poor medication adherence during pregnancy, as exemplified in this study. The level of ART adherence during pregnancy has implications for HIV transmission in-utero, during delivery and in the early postpartum period. Additionally, our results showed that 65.5% of the women commenced ART after conception with more than half initiating ART for the first time during the second trimester of their current pregnancy. This result could also be another contributing factor to the high MTCT rate in Nigeria, as research has shown that ART started before conception, and continued throughout pregnancy, is linked with exceptionally low rates of MTCT (
Uthman et al., 2017
Uthman O.A.
Anderson J.
Kanters S.
Mills E.J.
Renaud F.
Timing of initiation of antiretroviral therapy and adverse pregnancy outcomes: a systematic review and meta-analysis.
Lancet HIV. 2017; 4: e21-e30
In multivariable analyses, disclosure of HIV status to anyone was significantly associated with an increased level of adherence. Past studies conducted in other sub-Saharan African countries showed that disclosure of HIV infection status to partners, family and friends was associated with good maternal adherence(
Kirsten et al., 2011
Kirsten I.
Sewangi J.
Kunz A.
Dugange F.
Ziske J.
Jordan-Harder B.
Adherence to combination prophylaxis for prevention of mother-to-child-transmission of HIV in Tanzania.
PLoS One. 2011; (e21020–e)
Hampanda, 2016
Hampanda K.M.
Intimate partner violence and HIV-positive women's non-adherence to antiretroviral medication for the purpose of prevention of mother-to-child transmission in Lusaka, Zambia.
Soc Sci Med. 2016; 153: 123-130
) while non-disclosure was linked with non-adherence as shown by a study conducted in Rwanda (
). A previous study conducted in Nigeria reported a relationship between disclosure of a partner's HIV status and women's adherence to medication, especially if the spouse was also HIV positive (
Our results also showed that previous prevention of MTCT exposure was independently associated with adherence to ART during pregnancy. A qualitative study in Kenya, using in-depth interviews, found that women who gave birth previously had successfully accessed prevention of MTCT services. These women lived a healthy life with children who were HIV negative and were better equipped and more compliant with taking ART in their current pregnancy (
Murithi et al., 2015
Murithi L.K.
Masho S.W.
Vanderbilt A.A.
Factors enhancing utilization of and adherence to prevention of mother-to-child transmission (PMTCT) service in an urban setting in Kenya.
AIDS Behav. 2015; 19: 645-654
The findings from this study allude to two important areas where urgent attention is needed. First, the issues surrounding the disclosure of HIV status by women should be addressed. As shown in this study, more than half of women had not disclosed their HIV infection status to anyone. According to the WHO, pregnant women in sub-Saharan Africa have the lowest rate of HIV status disclosure to their partners in the world (
HIV status disclosure to sexual partners: rates, barriers and outcomes for women.
). As shown in our study, women who had disclosed their HIV status to someone were more than two times as likely to adhere to ART than women who had not disclosed their HIV status. Without partner support, it is often challenging for women to adhere to ART (
Walcott et al., 2013
Walcott M.M.
Hatcher A.M.
Kwena Z.
Turan J.M.
Facilitating H.I.V.
Facilitating HIV status disclosure for pregnant women and partners in rural Kenya: a qualitative study.
BMC Public Health. 2013; 13: 1115
). There is a need for government and non-government organisations supporting HIV service implementation in Nigeria to ensure the active implementation of the WHO recommended voluntary assisted partner notification services (
HIV testing services: WHO recommends assistance for people with HIV to notify their partners.
) at all health care facilities providing HIV treatment. These voluntary assisted partner notification services should be offered as part of a comprehensive package for pregnant women during HIV testing and counseling in antenatal clinics, to facilitate safe and comfortable disclosure of HIV status to partners. Second, late initiation of ART by pregnant women should also be addressed. About two-thirds of women were made aware of their HIV status during an antenatal care visit and were required to commence ART. It is therefore pertinent that Nigeria works towards the attainment of the 90-90-90 UNAIDS target, particularly in this case to reach the first 90 goal, that is, diagnosing 90% of people with HIV who do not know their HIV status. According to the UNAIDS, only 3 out of every 10 pregnant women living with HIV in Nigeria access ART to prevent MTCT (
). Early diagnosis may help to facilitate early initiation of ART in women of reproductive age, thus increasing the likelihood of HIV positive women commencing ART before conception and improving adherence during pregnancy.
The strengths of this study include utilisation of a tool with proven validity and reliability to assess adherence. Many previous studies on adherence in pregnant women in sub-Saharan Africa used self-reporting measures to assess medication adherence without identifying the tools used (
Omonaiye et al., 2018
Omonaiye O.
Nicholson P.
Kusljic S.
Manias E.
A meta-analysis of effectiveness of interventions to improve adherence in pregnant women receiving antiretroviral therapy in sub-Saharan Africa.
Int J Infect Dis. 2018; 74: 71-82
). The anonymous collection of adherence information may have improved accurate reporting by eliminating social desirability bias. Our study was a multicentre study with a relatively high sample size. A key limitation of the study was inability to correlate the level of adherence with the viral load of women. Viral load coverage for patients in most health facilities in Nigeria remains very low, the turnaround time for viral load test results also remains unacceptably high, and significant viral load results released by the laboratories are not filed in the patients' medical records.
In summary, the proportion of women who were adherent to ART was low. The factors relating to women's education level, living in a rural area, having a previous experience with prevention of MTCT and disclosing HIV status to someone were significantly associated with improved adherence. It is crucial that ART adherence is improved among pregnant women in Nigeria, for the country to be well positioned for elimination of MTCT of HIV.
O.O., S.K., P.N. and EM conceptulised and designed the study. O.O., M.M, S.K, P.N., E.M. analysed and interpreted data. O.O., M.M and E.M. did the statistical analysis. O.O. wrote the first and second draft of the manuscript with input from S.K., P.N., M.M. and EM. All authors read and approved the final manuscript.
We declare no competing interests.
We acknowledge the funding received in form of an International PhD scholarship from the Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Deakin University.
2016 (https://naca.gov.ng/fact-sheet-prevention-mother-child-transmission-pmtct-2016/. [Accessed 14 November 2018])
2016 (accessed 25 January 2017)
2016 (accessed 12 November 2018)
2004 (http://apps.who.int/iris/bitstream/10665/42717/2/9241590734_summary.pdf. [Accessed 24 November 2016])
2010 (http://www.who.int/hiv/pub/mtct/antiretroviral2010/en/. [Accessed 29 October 2018])
2013 (http://www.who.int/hiv/pub/guidelines/arv2013/en/. [Accessed 10 December 2018])
2016 (http://apps.who.int/iris/bitstream/handle/10665/251548/WHO-HIV-2016.22-eng.pdf;jsessionid=EB50A9D6363A8FD7273D92008A5982D0?sequence=1. [Accessed 3 December 2018])
Accepted: February 13, 2019
Received in revised form: February 12, 2019
Received: January 3, 2019
Corresponding Editor: Eskild Petersen, Aarhus, Denmark
Crown Copyright © 2019 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.


text:
Cumulonimbus calvus
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Cumulonimbus calvus is a moderately tall cumulonimbus cloud that is capable of precipitation but has not yet reached the tropopause, which is the height of stratospheric stability at which cumulonimbus forms into cumulonimbus capillatus (fibrous-top) or cumulonimbus incus (anvil-top). Cumulonimbus calvus develops from cumulus congestus, and its further development, under auspicious conditions, will result in cumulonimbus incus.
Cumulonimbus calvus, with probable cumulonimbus incus in background over Milan Malpensa Airport, Milan, Italy
Cb cal
Cumulonimbus (heap, rain)
Calvus (bald)
Family C (Low-level)
Dark-based storm cloud capable of impressive vertical growth without cirriform, hairless.
Very common Rain, Snow, Snow pellets or Hail, heavy at times
This cloud consists mainly of water droplets. By definition of cumulonimbus cloud, at its top water droplets are transformed into ice crystals. But for cumulonimbus calvus, content of ice crystals are meager and polar are in early stage, so cloud tops still look round and puffy.
Cumulonimbus calvus is characterized by distinctive (between other types of cumulonimbus cloud) rounded shape and relatively sharp edges of its top area, unlike cumulonimbus incus or cumulonimbus capillatus, which have cirriform tops. Developing cumulonimbus calvus lose sharp outlines of the top as more water droplets transform into ice crystals. Strong updrafts may form pileus or thin vertical stripes may protrude upwards out of the cloud. When upper parts of the cloud freeze to a greater extent and clearly visible cirriforms appear, cumulonimbus calvus metamorphoses into another species of cumulonimbus.
Cumulonimbus calvus arcus is a sub-form of cumulonimbus calvus, which has arcus cloud ahead of cloud's front.
HazardsEdit
Like other cumulonimbus clouds, cumulonimbus calvus can cause severe weather conditions including:
Lightning; these clouds produce lightning.
Wind; these clouds may produce strong winds especially during a downburst
Hail; these clouds can sometimes produce hail
The cumulonimbus calvus can further grow larger if the updraft is strong. It can form into a cumulonimbus incus, and bring more severe thunderstorms that can cause constant cloud-to-ground lightning, extensive wind damage, microbursts, hail, and occasionally a tornado.
Cumulonimbus calvus cloud with precipitation over the Gulf of Mexico in Galveston, Texas
Cumulonimbus calvus with cloud-to-cloud lightning
Wikimedia Commons has media related to Cumulonimbus calvus.
This cloud–related article is a stub. You can help Wikipedia by expanding it.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Cumulonimbus_calvus&oldid=1106500521"


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The Art of Cheerfulness
M.V. Moorhead March 15, 2001 4:00AM
Even though it's a weekday, Phoenix Art Museum is packed. I'm there with an artist, and an internationally acclaimed artist at that, but the crowds aren't there to see his work. They've turned out in the thousands to see the works of Norman Rockwell. Sculptor Larry McLaughlin and I haven't gone there to look at the paintings; we're there for lunch.
McLaughlin does, however, share in the admiration of the Americana painter. "I was looking at photographs of some of the stuff he did in a catalogue, and it was amazing," he says. "It might seem funny, someone who does the kind of stuff I do saying that, but it really was amazing."
The reason it might seem funny is that Larry McLaughlin's work is just about as physically dissimilar to Rockwell's as could be imagined. Most of his more noted sculptures are large figures, vaguely human in shape -- potbellied torsos and limbs -- but with a rough mud-doll texture. They look to me like human beings crossed with radishes, and as we sit down to lunch in the PAM Cafe, I make bold enough to tell him so.
He laughs good-naturedly at the description, and if he's offended he doesn't show it. It's hard to imagine McLaughlin being offended by anything. He's an ebulliently cheerful person. He may be in a better mood than anyone I've ever met. A woman I know says McLaughlin reminds her of Mary Tyler Moore: He can turn the world on with his smile.
She's right -- our waitress seems harried as she gives us our menus, but within seconds McLaughlin has her wrapped around his finger, teasing and trading quips with her as if they're old school chums. We both order prickly pear iced tea, from which the waitress promises she will carefully skim out all the spines.
I don't know art, but I don't have a moment's doubt that McLaughlin's a major talent, because he's the opposite of the brooding, intense poseur-artist. If he wasn't the Real Thing, the art community never would have been able to take this big, bespectacled, effusively genial man with his sweet toothy grin seriously.
His manner shows up in his work, too. His art -- most popular in France and in Northern California, though examples of it may be seen locally in the permanent collection on the grounds of Shemer Art Center -- does share with Rockwell's a vibrant, amused, life-affirming sensibility.
McLaughlin decides on the meat loaf sandwich. "I want something squashy," he declares gleefully. "I want meat! I have to eat meat, 'cause I'm leaving the country next week. I have a client in San Francisco, and she's going to be over there, too, and I'm meeting her in Geneva. And she said to me, 'You've got to eat as much meat as you can while you're in the States!' She said she won't eat any meat in Europe because of Mad Cow Disease."
He's managed to make the meat loaf sandwich sound like such a national blessing that I can't help it -- I order the same thing. After the waitress leaves, I ask McLaughlin how he stays so upbeat.
"To tell you the truth, I do yoga," he says. "I've done it ever since I was at UC-Santa Cruz; in those days, at Santa Cruz, you could just about major in yoga. That was one of the best things about it, is you didn't have to do sports, you know, those sports where you have to knock everybody over. You could just do yoga."
McLaughlin went to the University of California at Santa Cruz after growing up on a family farm in the small town of Litchfield, Minnesota -- the accent can still be heard in his vowels. Accordingly, he says, his influences include "a lot of Minnesota kitsch. I remember when I was about 10 years old, I went with my family to an auction, and I got a lamp that was a female figure. And I put it in the backyard with water coming out of its head. That was my first fountain, I guess."
He left Bullwinkle country behind for college. By majoring in art history and French studies, McLaughlin was able to spend a lot of time bumming around Europe, soaking up art. "Santa Cruz is such an independent school that every year I could pretty much make up my own proposal for a class," he says. He did design work for a firm in London, and in 1985 was accepted to the prestigious Ecole Nationale Superieure des Beaux Arts (First National School for Fine Arts) in Paris.
"They charge you nothing to go to this school; they provide you with all the materials. You're in a socialist country. And you get to exhibit in the school's own gallery, which is right in downtown Paris. It's like, even though you're a student, you're taken seriously as an artist. That's what gave me the courage to keep doing this."
We get our meat loaf sandwiches, served with French fries, onion and a special ketchup. We've both requested mayonnaise on the side, and the waitress, who now seems to count McLaughlin among her dearest friends, has been happy to oblige. McLaughlin takes a bite of his sandwich, and with characteristic reserved understatement leans toward me across the table and says, "Mmmmmmmmmmmm!"
He likes it, I guess. I take a bite, and yes, it is pretty darn good at that.
Since McLaughlin completed his studies in Paris, his work has found its way into numerous museums, commercial properties and private collections, ranging from the Musée de l'Art Brut in Auxerre to the collections of Arnold Schwarzenegger and Maria Shriver and Linda Evangelista. For the last four years, he's divided his time between a house and studio he keeps in France's Loire Valley and a second house here in the Valley of the Sun, purchased as an affordable home base when California real estate proved too pricey.
We finish our sandwiches, and decide to splurge on dessert -- McLaughlin orders the chocolate layer cake with caramel, while I opt for the Key lime pie with real chantilly cream. We share, and once again, from across the table: "Mmmmmmmm!"
I ask McLaughlin what he can tell me, if anything, about what he's trying to express in his art. "Marianne Mittelholzer Leuenberger wrote about that in the catalogue," he says. "A lot of what she wrote is very spiritual, and I suppose unconsciously, that's true." As is usual for visual artists, though, he can't put a specific meaning of his works into words himself. "In the big fat pieces, my intent is just a presence, you know, a physical presence. People will see an embracing couple, or they'll see" -- he gestures at me -- "a radish!" He laughs. "If people look at my stuff and don't say, 'What the hell is that?' I'm happy."
As we're leaving, walking through the courtyard at PAM, McLaughlin is telling me about a Mexican restaurant with mariachi music he's planning to visit that weekend. A middle-aged couple who look like tourists overhear him, and ask where the place is. He stops and explains it to them in detail, as comfortably as if he used to go over to their house as a kid for lemonade and cookies. Then, as we head for the parking lot, he calls warmly to them over his shoulder:
"See you there!"
M.V. Moorhead
Contact: M.V. Moorhead
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text:
I've been married for 14 years. My wife has told me she no longer wants to have sex. She says she doesn't love me any more. She has stopped going to mikveh, so it is not possible for us to engage in sex. I am not satisfied with the situation. What does halacha say about this? Am I required to give her a get (divorce bill) and divorce her? Is it permissible that I do so? Would it be right to do so?
Click here for a(n) Conservative answer by Rabbi Joshua Heller (Emeritus)
First of all, let me express to you my sympathy at this difficult time where your marriage has broken down. One cannot legislate love and feelings, only actions. Our tradition offers specific legal rulings and ethical principles with regard to the expectations of sexual relations in the context of marriage, but the pain of each broken relationship is unique.
The Jewish tradition does describe a mutually gratifying sexual relationship as one of the expected criteria for married life. While neither partner must be available to the other at all times or in all ways (indeed, this is one of the effects of the system of "Taharat Hamishpacha" the monthly cycle of abstention, mikvah and intimacy among those who observe it), the expectation is that both partners will make a good faith effort to maintain the physical aspect of the relationship on a regular basis.
According to the classical sources, from the Mishnah onward, if one of the partners is not able to meet the reasonable need of the other partner for physical intimacy, that is considered grounds for divorce. One source which lays out these criteria is the Shulchan Aruch. One subsection (Even Ha-ezer 76:1-13, 77:1) lays out the grounds for the husband's responsibility to provide for the physical gratification of his wife, even going to the level of specifying the frequency of relations based on his occupation and travel.
The following section (Even Ha'ezer 77:2-5) describes the wife's parallel responsibilities to her husband. It defines the category of a Moredet- a woman who refuses to engage in sexual relations with her husband over an extended period of time. It specifies a very detailed process for the Beit Din, the Jewish court, to work with the couple, over periods of at least a month, and up to a year, but if the couple are not reconciled, then divorce (through the husband's granting of a "get" ) is the result. It is worth noting that a husband does not grant a "get" unilaterally. A Beit Din is involved to ensure that the proper procedures are followed.
A husband is permitted to initiate this process, but not required to do so. There may be extenuating circumstances. To take an example not relevant to your situation: while some couples remain sexually active into old age, others reach a point where their physical capabilities, or mutual expectations of the relationship no longer include sex, though they may still enjoy other forms of physical affection. Such couples are not required to seek a divorce just because neither of them desire continued sexual activity, and typically other factors maintain the strength of the relationship. Other couples may chose to stay together for financial reasons or "for the sake of the children." However, it is not healthy for a person to be denied a safe outlet for appropriate sexual desires, nor, more importantly, to be in relationship with a partner who is actively antagonistic. A marriage where one partner desires physical intimacy and the other does not, or where one partner dislikes the other, is likely to be harmful to both partners and to those around them.
Therefore, according to Jewish ethics, if your wife states that she does not love you and no longer wishes to be intimate with you over an extended period of time, you would be permitted to initiate the process that might end with a divorce carried out through the "get," and through whatever civil procedures might be appropriate where you reside. Throughout the divorce process, there are Jewish ethical obligations that apply (for example,the oblgation to care for any children in the family, and the prohibition on Lashon Harah, gossip). I would recommend a book by my colleague, Rabbi Perry Netter, called "Divorce is a Mitzvah" which covers these and many related topics.
Whether divorce is "right" or not depends on the outcome of that process, where other resources might be brought to bear. The Shulchan Aruch, cited above, notes that part of the process of "moredet" involves inquiring of the woman why she no longer desires intimacy with her husband, and the code suggests a range of possible causes that must be explored. To list a few examples: she may no longer find him attractive, he may have been abusive or hurtful , or another party may be involved. Some are the "fault" of one partner or the other, others may be beyond human control. What unites them is that often a breakdown in physical intimacy is preceded by a breakdown in emotional intimacy, and resolution of the emotional issues could lead to resolution of the physical issues.
I would therefore encourage you, or any couple whose relationship has reached this stage, to seek professional guidance together. Depending on the circumstances, you might choose a rabbi with expertise in couples and relationship counseling, or a professional counselor who is sensitive to Jewish values. With their assistance you could determine what factors in your relationship that have led to this impasse, and whether they still might be resolved successfully. If such counsel does not bring about reconciliation, or if your partner is unwilling to seek such assistance, then you would be within your rights to pursue a divorce.
Answered by: Rabbi Joshua Heller (Emeritus)
Click here for a(n) Orthodox answer by Rabbi Sanford Shudnow
The issue of marriage and refusal of one partner or the other to have sexual relations is well founded in Rabbinic sources, based on passages in the Torah.
The situation is a difficult and painful one. In today's world most rabbis, I included, advise couples to seek competent couples counseling and therapy. It often takes time to find the right mix of therapist and couple.
Marriage is a vital part of Judaism and life. It is not to be dissolved unless absolutely necessary. But Judaism unlike some other religions believes that not all unions are meant to last and gives individuals the tools to bring such troubled unions to a reasonably equitable conclusion through the gerushin or gittin procedures (delivery of a Get or divorce document).
The major source for divorce in Judaism is in the Book of Deuteronomy, Chapter 24, verse 1: "When a man marries a woman or possesses her, if she is displeasing to him [or] if he has evidence of sexual misconduct on her part, he shall write her a bill of divorce and place it in her hand, thus releasing her from his household."
The procedure of giving and obtaining a Get written by a sofer (scribe) in accordance with the halakhah (Jewish Law) as determined by a recognized beit din (Rabbinic Court) is well-known. I will not deal with these laws here.
Rather, I would like to address the laws pertaining to a mored (m.) or moredet (f.) in a marriage. These are partners who do not provide the normally expected conjugal rights that are considered a vital part of what kiddushin (marriage) is all about.
While one might imagine that Judaism defines this from the masculine perspective, with a wife withholding pleasure from her husband; the Rabbinic sources deal with the issue from both perspectives—a woman withholding sex from the man or a man withholding sex from his wife.
The sources are so explicit that they deal exactly with your case. Please realize, as I began, it is always recommended to do all in one's power to bring a happy resolution through counseling and therapy.
After doing everything in one's power and it still does not work, then and only then is a divorce warranted. It should be noted, however, that if both parties decide to divorce, a Get would normally be granted, even without counseling.
According to the Shulkhan Arukh, the Code of Jewish Law, if a wife refuses to have intercourse for a period of one year or more, then a Jewish divorce is appropriate. There is, however, a distinction to be made between a moredet—a woman whose refusal is based in spite and a woman whose husband has become loathsome to her.
Naturally, a husband whose manners, hygiene, etc. are unbecoming needs to be dealt with, as through therapy.
As with so many aspects of life, it is easy to interpret matters only from one's own perspective. We all need to move beyond our own selves and determine whether or not "I could be causing her to refuse me."
If after all the work necessary has been done in endeavoring to bring the marriage back to the way it had been before and it is seen that there is no resolution, a Get would be sought through an authorized beit din and mesader gittin (Rabbinical Court and Master of Divorce Documents).
It is understood that life under the described circumstances is unlivable and when living in accordance with Torah and Mitzvot (commandments) requires immersion in the mikvah (ritual bath), a divorced is warranted, albeit, sadly.
According to the circumstances that you outlined, it appears that you are halakhically within you rights to have a Get issued and given to your wife. (Shulkhan Arukh, Even Ha-Ezer, Section 77)
As with all questions of halakhah, a competent Rav must be consulted. What I have written does not constitute a specific decision in your case. I have only given direction in the matter as presented.
Answered by: Rabbi Sanford Shudnow
Click here for a(n) Reform answer by Rabbi Daniel Plotkin
As a Reform Rabbi, I will leave the technical aspects of Halacha to my Conservative and Orthodox Colleagues and focus instead on the values involved.
It is unfortunate that your marriage has fallen into this state. The fact is that it happens and we can be thankful that Jewish law and custom give us a way to deal with the situation in a manner that is both dignified and lays the groundwork for a healthy friendship following.
Rabbi Heller was correct in advising you to seek counseling before anything else. But ultimately both you and your wife are within your rights. She is right in letting you know her feelings on both sex and the relationship, and you are right in wanting something more than companionship from your marriage.
If approached in a mature and open way, then even if you are unable to resolve your differences through counseling (and there are many couples who cannot), then you can end your marriage through both Jewish and secular processes, in a way that will enable you to be cordial and respectful to one another, and have as little impact on your children (if there are any) as possible.
While the Reform movement does not require anything more than a civil divorce, many within the movement have developed rituals for couples going through divorce that would go along with the formal signing of a Get. This can make the moment of divorce, usually painful and filled with regret, into a moment that also has God present. I encourage you to visit ritualwell.org to see some of the beautiful ceremonies that lend dignity and beauty to a process that is all too often anything but dignified and beautiful. Most of the rituals there can work in the strict Halachic framework I suspect you will seek.
The worst outcome is for you to stay in a marriage that is not fulfilling to you and then to seek that fulfillment in ways that would be immoral or illegal. Therefore I encourage you to seek counseling to see if your marriage can be saved, but ultimately do what is best for yourself.
Answered by: Rabbi Daniel Plotkin


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text:
Een rolschaats is een schoen met wielen, waarmee vooruit gekomen kan worden door een schaatsbeweging te maken. De rolschaats werd voor het eerst in 1863 door zijn uitvinder James Plimpton aan het grote publiek getoond. Deze uitvinding is echter serieus te betwisten. Plimpton was degene die als eerste een patent nam. Een voorloper van de rolschaats was de in-line rolschaats, in 1743 uitgevonden door Jean-Joseph Merlin uit Hoei in Wallonië. Ook de Bruggeling Maxilimilien Van Lede en Garcin hadden al een rolschaats gecreëerd in resp. 1790 en 1815. In 1823 kwam de Brit Tyerin ook al met een rolschaats op de proppen. In 1824 bezat Londen al overdekte rolschaatsbanen. De opening van de baan in Cincinnati in 1867 luidde in de Verenigde Staten een bloeiperiode in.

Er zijn twee soorten rolschaatsen:
 De gewone rolschaats, met twee wielen voor, en twee wielen achter.
 De skeeler en de inline-skate, waarbij meerdere wielen achter elkaar staan (bij de skeeler vroeger 5, maar nu ook wel 4 en de in-line skate 4). Dat heeft het voordeel dat de voet ook schuin gehouden kan worden om af te zetten.

In het verleden zijn er hardrijkampioenschappen op gewone rolschaatsen gehouden. Een daarvan waren de Europese kampioenschappen te Madalena op het Azoreneiland Pico, ergens in de jaren 80.

Zie ook
 Roller derby
 Schoeisel
 Skaten

Sportschoeisel
Rolschaatsen

redpajama_set_name: RedPajamaWikipedia


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