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Articles tagged as "HIV Treatment"
The third 90—ensuring adherence to ART needs approaches tailored to the clinical and social context of individuals
Editor's notes: The third 90, ensuring that people who are on antiretroviral therapy are supported to adhere well enough to suppress their viral load, is key to preventing drug resistance and to ensuring efficiency of resources as treatment is scaled up to all people living with HIV. Previous studies have demonstrated how useful SMS reminders can be for many people taking ARV medicines, and this evidence is now incorporated into WHO guidance on ART. However, a randomized trial by Linnemayr and colleagues among adolescents and young adults in Kampala, Uganda found no benefit after one year of either a weekly reminder or a weekly reminder with the option to respond. There are no magic bullets to ensure adherence. SMS reminders may well suit some individuals, whereas others will need different approaches. The differentiated care approach to ART emphasizes the need to develop the best treatment and support service for each individual, according to their specific social context and clinical situation.
Text messaging for improving antiretroviral therapy adherence: no effects after 1 year in a randomized controlled trial among adolescents and young adults.
Linnemayr S, Huang H, Luoto J, Kambugu A, Thirumurthy H, Haberer JE, Wagner G, Mukasa B. Am J Public Health. 2017 Dec;107(12):1944-1950. doi:10.2105/AJPH.2017.304089. Epub 2017 Oct 19.
Objectives: To assess the effectiveness of Short Message Service (SMS) reminder messages on antiretroviral and cotrimoxazole prophylaxis adherence among HIV-positive youths as well as the relative effectiveness of SMS with and without a response option.
Methods: Eligible HIV-positive patients aged 15 to 22 years at 2 HIV clinics in Kampala, Uganda, participated in a year-long parallel individual-randomized controlled trial and were assigned in a 1-to-1-to-1 ratio to a weekly SMS message group, weekly SMS message with response option group, or a usual-care control group.
Results: We enrolled 332 participants. Electronically measured mean adherence was 67% in the control group, 64% in the 1-way SMS group (95% confidence interval [CI] = 0.77, 1.14), and 61% in the 2-way SMS group (95% CI = 0.75, 1.12) in an intent-to-treat analysis. Results for secondary outcomes and complete-case analysis were similarly statistically insignificant across groups.
Conclusions: Despite previous evidence that interventions using SMS reminders can promote antiretroviral therapy adherence, this study shows that they are not always effective in achieving behavior change. More research is needed to find out for whom, and under what conditions, they can be beneficial.
Categories: HIV Treatment
Related Regions: Africa
Related Countries: Uganda
Women at substantial risk of HIV infection can and should take PrEP
Editor's notes: PrEP is now generally accepted to be one of the major reasons that the number of new infections among gay men and other men who have sex with men is falling in urban centres in Europe and the USA. The PROUD and Ipergay randomized trials demonstrated efficacy of over 85%. This proved conclusively that among men who were motivated to take tablets either every day or around the time of sex, PrEP could be highly effective. The data for vaginal rather than anal sex is less straightforward. The Partners PrEP trial and Demonstration project also showed high efficacy among both men and women in serodiscordant couples. However, several studies among women at high risk of acquiring HIV showed no effect overall, because women were not taking the tablets for a variety of reasons. Pharmacokinetic studies show that tenofovir-emtricitabine (the most widely used and recommended medicines for PrEP) reaches considerably higher levels in the rectal tissues than in the vagina. As a result, we know that PrEP adherence is vital to achieve protective levels for vaginal sex, and daily dosage rather than an 'on demand' regimen is still recommended. The ADAPT trial in Cape Town has now published its final results. In this trial, young South African women were given daily PrEP in a controlled setting for four weeks before being randomized to three different regimens. One group took PrEP every day, one group took PrEP before and after sex and the third group took two tablets each week with an additional dose after sex. Adherence was measured using an electronic device that recorded when the pills were accessed, as well as self-report. Drug levels were also measured. Although this is a somewhat artificial situation involving only 59 or 60 women in each group, the results are important and confirm that for women, only daily PrEP should be recommended. The trial also shows that women were able to adhere well, with 75% adherence and 75% of sex acts covered by PrEP among women taking the medicines every day during the follow-up period. Neither of the other two regimens provided adequate coverage and all four incident infections occurred in these two groups (although the numbers are too small to draw reliable conclusions about the efficacy).
Daily and non-daily pre-exposure prophylaxis in African women (HPTN 067/ADAPT Cape Town Trial): a randomised, open-label, phase 2 trial.
Bekker LG, Roux S, Sebastien E, Yola N, Amico KR, Hughes JP, Marzinke MA, Hendrix CW, Anderson PL, Elharrar V, Stirratt M, Rooney JF, Piwowar-Manning E, Eshleman SH, McKinstry L, Li M, Dye BJ, Grant RM; HPTN 067 (ADAPT) study team. Lancet HIV. 2017 Oct 3. pii: S2352-3018(17)30156-X. doi: 10.1016/S2352-3018(17)30156-X.
Background: The relative feasibility and acceptability of daily versus non-daily dosing of oral HIV pre-exposure prophylaxis (PrEP) among women are unknown. We aimed to investigate the feasibility of non-daily PrEP regimens in adult women.
Methods: We did a randomised, open-label, phase 2 clinical trial (HPTN 067/ADAPT) of oral PrEP with emtricitabine plus tenofovir disoproxil fumarate at a research centre in Cape Town, South Africa. Participants were adult women (age ≥18 years) who received directly observed dosing once a week for 5 weeks followed by random assignment (1:1:1) at week 6 to one of three unblinded PrEP regimens for self-administered dosing over 24 weeks: daily; time-driven (twice a week plus a post-sex dose); or event-driven (one tablet both before and after sex). Primary outcomes were PrEP coverage (at least one dose within the 4 days before sex and one dose within 24 h after sex), pills needed or used to achieve regimen-specific adherence and coverage, and symptoms and side-effects. All analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01327651; the trial is completed, and this report presents the final analysis.
Findings: Between Sept 12, 2011, and Oct 3, 2012, 191 women were enrolled to the trial. 178 (93%) completed directly observed dosing and were randomly assigned one of the three PrEP regimens for the self-administered phase: 59 were allocated the daily regimen, 59 the time-driven regimen, and 60 the event-driven regimen. Median age of women was 26 years (IQR 21-37; range 18-52). In women allocated the daily regimen, 1459 (75%) of 1952 sex events were covered by PrEP, compared with 599 (56%) of 1074 sex events among those assigned the time-driven regimen (odds ratio [OR] 2·35, 95% CI 1·43-3·83; p=0·0007) and 798 (52%) of 1542 sex events among those allotted the event-driven regimen (2·76, 1·68-4·53; p<0·0001). Fewer pills were needed for complete adherence in women allocated non-daily regimens (vs daily regimen, relative mean 2·53 [95% CI 2·39-2·69] for the time-driven regimen and 4·16 [3·59-4·82] for the event-driven regimen; p<0·0001). Side-effects were uncommon. Eight HIV seroconversions occurred overall, with four documented during the self-administered phase (two with the time-driven regimen and two with the event-driven regimen). Adherence to the assigned regimen was 75% (7283 of 9652 doses taken) for women allocated the daily regimen compared with 65% for those assigned the time-driven regimen (2367 of 3616 doses taken; p=0·0028) and 53% for those allotted the event-driven regimen (1161 of 2203 doses taken; p<0·0001). When sex was reported in the previous week, PrEP drugs were detected (above the lower limits of quantification) more frequently in women assigned the daily regimen (73 [68%] of 107 samples) than in those allocated the time-driven regimen (42 [58%] of 72 samples) and the event-driven regimen (41 [41%] of 99 samples).
Interpretation: Daily PrEP dosing resulted in higher coverage of sex events, increased adherence to the regimen, and augmented drug concentrations than did either time-driven or event-driven dosing. These findings support recommendations for daily use of PrEP with oral emtricitabine plus tenofovir disoproxil fumarate in women.
Categories: Clinical trial retention, HIV Treatment, Sexual transmission and prevention
Related Countries: South Africa
Although people living with HIV should have near normal life expectancy, far too many still die prematurely
Editor's notes: The scale up of antiretroviral therapy (ART) is the most important development in the past decade of the HIV response. Not only do antiretroviral medicines prevent death and prevent the immune destruction that HIV causes, but they also prevent transmission to sexual partners. Nonetheless, the challenges of reaching everyone living with HIV are enormous and Young and colleagues' study from the city of Nairobi highlights that we still have some distance to go. The authors estimated that 74% of adults living with HIV were receiving ART and among women, the figure was even higher and was estimated to have reached more than the UNAIDs target of 81%. The authors collected data from the two largest mortuaries in Nairobi, where most deaths that occur in the city are registered. With approximately 80% of all deaths in the city being registered, the authors believe that their study is reasonably representative of the adult population of the city. They found that among 807 people who died in Nairobi during the recruitment period, HIV was greatly over-represented. They calculated that around 16% of adult deaths in the city were attributable to HIV, and that, when adjusted for age and sex, death rates among people living with HIV were more than four times higher than the rate among HIV-negative people. The authors point out that these proportions and rates are much lower than they were at the peak of the epidemic, but they do show that in Nairobi we still have some distance to go to ensure that people living with HIV have the same life expectancy as those who are HIV-negative.
HIV-associated mortality in the era of antiretroviral therapy scale-up – Nairobi, Kenya, 2015
Young PW, Kim AA, Wamicwe J, Nyagah L, Kiama C, Stover J, Oduor J, Rogena EA, Walong E, Zielinski-Gutierrez E, Imbwaga A, Sirengo M, Kellogg TA, De Cock KM. PLoS One. 2017 Aug 2;12(8):e0181837. doi: 10.1371/journal.pone.0181837. eCollection 2017.
Background: Declines in HIV prevalence and increases in antiretroviral treatment coverage have been documented in Kenya, but population-level mortality associated with HIV has not been directly measured. In urban areas where a majority of deaths pass through mortuaries, mortuary-based studies have the potential to contribute to our understanding of excess mortality among HIV-infected persons. We used results from a cross-sectional mortuary-based HIV surveillance study to estimate the association between HIV and mortality for Nairobi, the capital city of Kenya.
Methods and Findings: HIV seropositivity in cadavers measured at the two largest mortuaries in Nairobi was used to estimate HIV prevalence in adult deaths. Model-based estimates of the HIV-infected and uninfected population for Nairobi were used to calculate a standardized mortality ratio and population-attributable fraction for mortality among the infected versus uninfected population. Monte Carlo simulation was used to assess sensitivity to epidemiological assumptions. When standardized to the age and sex distribution of expected deaths, the estimated HIV positivity among adult deaths aged 15 years and above in Nairobi was 20.9% (95% CI 17.7-24.6%). The standardized mortality ratio of deaths among HIV-infected versus uninfected adults was 4.35 (95% CI 3.67-5.15), while the risk difference was 0.016 (95% CI 0.013-0.019). The HIV population attributable mortality fraction was 0.161 (95% CI 0.131-0.190). Sensitivity analyses demonstrated robustness of results.
Conclusions: Although 73.6% of adult PLHIV receive antiretrovirals in Nairobi, their risk of death is four-fold greater than in the uninfected, while 16.1% of all adult deaths in the city can be attributed to HIV infection. In order to further reduce HIV-associated mortality, high-burden countries may need to reach very high levels of diagnosis, treatment coverage, retention in care, and viral suppression.
Categories: HIV Treatment, People living with HIV
Related Countries: Kenya
HIV testing and the HIV epidemic –vitally important to prevent HIV becoming endemic
Editor's notes: Epidemics refer to situations where the number of infections rises (and subsequently falls) more quickly than might be expected compared to a disease that is endemic. Endemic implies a stable situation, with natural fluctuations in the number of cases. Medley and Vassal have written a provocative article in Science that considers how differently individuals, communities and society react to epidemic rather than endemic diseases. They choose to call HIV in 2017 endemic, which carries a serious risk. As the authors state, "The contained public response, and the concurrent shift of responsibility to individuals to protect themselves from risk, means that endemic disease embeds itself further, as those at risk are often the very same people who do not have the private resources to avoid risk or access treatment." There are in fact multiple separate epidemics of HIV in different regions and in different populations. Some are rising and some are falling. The latest UNAIDS' report emphasizes the heterogeneity of HIV infections in the world. New HIV infections have fallen by 29% since 2010 in East and Southern Africa, the region with the highest rates. On the other hand, new HIV infections have risen by an alarming 60% in Eastern Europe and Central Asia over the same period, albeit from a much lower baseline. There is widespread political consensus to pursue the UN agenda endorsed at the High Level Meeting on Ending AIDS in New York last year. Let's not throw in the towel too soon!
HIV testing services remain central to the HIV strategy and, as usual, this month there are several important papers on aspects of HIV testing, many of which illustrate challenges that need to be overcome.
There are several reasons to encourage people living with HIV to know their status. First and foremost, we know that the earlier treatment is started in the course of HIV, the better the outlook for the individual. People who start treatment become much less likely to transmit HIV infection to sexual partners. People who know their HIV status are also able to make informed decisions about their lives and their partnerships. A study this month by Escudero et al. from New York City used agent-based modelling to understand the testing and care continuum for people who inject drugs. Their results remind us of the key role of HIV testing. They estimated that 53% of the HIV transmission events from people who inject drugs arose from people who did not know their status, and a further 37% from people who had not been started ART. In other words, they estimate that only 10-11% of infections from people who inject drugs could be prevented by improving quality of care for people on treatment. The need to find effective ways to encourage people at risk to know their status and start treatment is stark.
Guanzhou is one of the largest cities in China, with a high population of migrants both national and international. It is among the most prosperous regions of Guangdong province and has the highest rates of HIV. Chen et al. added some HIV testing related questions to a wider population based health survey in two districts and showed that approximately a quarter of adults had previously been tested for HIV. HIV testing was almost all provided through free government facilities or blood transfusion centres. Despite early steps to make HIV self-testing more available, none of the 666 participants who answered the relevant questions in the survey had used a self-test. Distance from an HIV testing site was a key determinant of the likelihood of getting tested. It was not clear that people who might be at higher risk were more likely to be tested, although the numbers and sampling focused on the general population rather than people at special risk.
Wang et al. explored the different HIV test kits used in the first line screening in Xi'an. In line with Chinese guidelines, but not in line with WHO guidance on HIV testing algorithms for low prevalence settings, they used third- or fourth-generation rapid tests and repeated the positive tests. WHO's algorithm for low prevalence settings includes three different rapid tests based on different antigens. Among 665 people found to be positive on rapid tests, only 559 were confirmed to be HIV-positive by Western blotting. Subsequent follow up with additional Western blots showed that two of the individuals in whom the first Western blot was indeterminate were seroconverting but the other 104 were HIV-negative and had had false-positive results on the original rapid tests. False positives were more likely with the fourth-generation test (22% of positive tests) compared to the various third-generation tests used (9-11% of positive tests). Fourth-generation assays are known to be more sensitive, detecting people with HIV around a week or two earlier in the window period than third-generation assays. However, the authors point out that in low prevalence settings like Xi'an, the known lack of specificity of fourth-generation assays means that they may not provide sufficient advantages to be used as the first line test. Overall, the paper emphasizes the importance of using clearly defined algorithms. The WHO algorithms no longer use Western blots, but do recommend using multiple tests based on different antigens for testing people at low risk of infection, and at least two different tests with different antigens for testing people at high risk of infection. Everyone should have additional confirmatory tests done prior to starting ART.
Harbertson et al. also focused on the accuracy of rapid diagnostic tests. They screened samples from 459 military personnel in seven African countries who had reported that they were HIV-positive. Using the WHO algorithm, they compared the results of quality assured HIV testing to the self-reported HIV status of the participants. They found that, in different country surveys, between three and 91% of people who said that they were living with HIV were in fact HIV-negative. The authors point out that several studies have demonstrated the importance of following the WHO guidance, and that the positive predictive value of a test (or algorithm) will always fall as the overall prevalence falls. They discuss possible limitations such as misunderstanding the question or the terminology used, but discount these possibilities as causing many of the false-positive reports, particularly given the highly variable results across different countries. There was a strong association between the likelihood of a false positive report and lower education level. People whose understanding of HIV was less good were also more likely to report themselves to be positive falsely. Overall, the authors assume that quality of testing services needs to be an important priority, while not discounting the challenges of using self-reports to collect information about HIV status.
As more and more people chose to know their HIV status, it may be possible to use routine data from the health service to track the epidemiology of HIV, rather than to use special surveys. Traditionally surveys of antenatal mothers have been used to monitor trends in the HIV epidemic over time. With the widespread adoption of routine testing for mothers, a large proportion of women have an HIV test. However, the assays used vary. For surveillance purposes, samples are often stored and transported as dried blood spots and assays are run in batches using automated ELISA technology. Routine testing (as discussed above) is often done using an algorithm based on a number of different rapid tests. Pereira et al. have explored the differences between these approaches among almost 40 000 Brazilian mothers who participated in the antenatal surveillance exercise. They interviewed mothers and linked their routine ANC results to the surveillance database. Overall the prevalence of HIV among expectant mothers in Brazil was similar whichever approach was used (0.36% or 0.38%). However, there were interesting differences. The performance accuracy in those found positive in the surveillance exercise (which was taken as the gold standard) was only 84% overall and varied between regions from 43% to 100%. So these 14 false negative results among the 88 individuals who were truly positive were compensated for in the overall prevalence estimates by a similar number (18) of false positive results among around 30 000 individuals who were truly negative. This highlights the challenges of providing accurate results to people in low prevalence settings. The 13% of mothers who slipped through the routine services and were not tested or refused to be tested were significantly more likely to be HIV-positive (0.56%), reinforcing the potential biases involved. Finding 90% of people living with HIV will require considerable attention to the detail and the quality of HIV testing services.
Adolescents are often a population left behind, and regular reports show that adolescents living with HIV are less likely to know their status or to be on treatment or virally supressed. Simms et al. used provider initiated testing and counselling (PITC) in primary care clinics in Harare, Zimbabwe. For two years, the research team supported the routine offer of HIV testing to all six to 15 year olds presenting to seven clinics in a well-defined area of Harare. The authors then conducted a population-based survey to find out how many eight to 17 year olds (who had had two years of exposure to the intervention) were aware of their status. 141 (2.6%) were living with HIV and more than one-third of these were undiagnosed. Some had rarely been to the clinic, and others had been taken to the clinic by a guardian who was unable to consent to HIV testing on behalf of the child or the child's parents. Others had slipped through the PITC net, possibly because, as Lightfoot et al. in an accompanying comment suggest, providers still find it hard to offer HIV tests to everyone, as they assume that people living with HIV will not appear healthy. This fits with the researchers' findings that adolescents living with HIV who were currently healthy, had no skin or other problems and had parents who were alive were less likely to be diagnosed. Both papers suggest that community based testing is needed to find adolescents. However, this also raises challenges in settings with lower prevalence than the high-density suburbs of Harare chosen for this project. As prevalence falls lower than the 2.6% observed, a huge testing effort is needed, with attendant costs, but also (as explored above) with the risks of inaccurate results and of the very people that we want to find most, not being around for testing at the right moment.
When an emerging disease becomes endemic.
Medley GF, Vassall A. Science. 2017 Jul 14;357(6347):156-158. doi: 10.1126/science.aam8333.
Epidemics, such as HIV in the early 1980s and Ebola in 2014, inspire decisive government investment and action, and individual and societal concern, sometimes bordering on panic. By contrast, endemic diseases, such as HIV in 2017 and tuberculosis, struggle to maintain the same attention. For many, the paradox is that endemic disease, in its totality, continues to impose a far higher public health burden than epidemic disease. Overall, the swift political response to epidemics has resulted in success. It has proven possible to eradicate epidemic diseases, often without the availability of vaccines and other biomedical technologies. In recent times, only HIV has made the transition from epidemic to endemic, but diseases that have existed for centuries continue to cause most of the infectious disease burden.
The risk of HIV transmission at each step of the HIV care continuum among people who inject drugs: a modeling study.
Escudero DJ, Lurie MN, Mayer KH, King M, Galea S, Friedman SR, Marshall BL. BMC Public Health. 2017 Jul 25;17(1):614. doi: 10.1186/s12889-017-4528-9.
Background: People who inject drugs (PWID) are at continued risk for HIV in the U.S., and experience disparities across the HIV care continuum compared to other high-risk groups. Estimates of the risk of HIV transmission at each stage of the care continuum may assist in identifying public health priorities for averting incident infections among PWID, in addition to transmissions to sexual partners of PWID.
Methods: We created an agent-based model simulating HIV transmission and the HIV care continuum for PWID in New York City (NYC) in 2012. To account for sexual transmission arising from PWID to non-PWID, the simulation included the entire adult NYC population. Using surveillance data and estimates from the National HIV Behavioral Surveillance system, we simulated a dynamic sexual and injecting network. We estimated the proportion of HIV transmission events attributable to PWID in the following categories, those: without an HIV diagnosis ('Undiagnosed'); diagnosed but not on antiretroviral therapy (ART) ('Diagnosed - not on ART'); those who initiated ART but were not virally suppressed ('Unsuppressed'); and, those who achieved viral suppression ('Suppressed').
Results: We estimated HIV incidence among PWID to be 113 per 100 000 person-years in 2012, with an overall incidence rate for the entire adult NYC population of 33 per 100 000 person-years. Despite accounting for only 33% of the HIV-infected PWID population, the Undiagnosed were associated with 52.6% (95% simulation interval [95% SI]: 47.1-57.0%) of total transmission events. The Diagnosed - not on ART population contributed the second-largest proportion of HIV transmissions, with 36.6% (95% SI: 32.2-41.5%). The Unsuppressed population contributed 8.7% (95% SI: 5.6-11.8%), and Suppressed 2.1% (95% SI: 1.1-3.9%), relatively little of overall transmission.
Conclusion: Among PWID in NYC, more than half (53%) of transmissions were from those who were unaware of their infection status and more than 36% were due to PWID who knew their status, but were not on treatment. Our results indicate the importance of early diagnosis and interventions to engage diagnosed PWID on treatment to further suppress population-level HIV transmission. Future HIV prevention research should focus on the elimination of identified and potential barriers to the testing, diagnosis, and retention of PWID on HIV treatment.
Is there a relationship between geographic distance and uptake of HIV testing services? A representative population-based study of Chinese adults in Guangzhou, China.
Chen W, Zhou F, Hall BJ, Tucker JD, Latkin C, Renzaho AMN, Ling L. PLoS One. 2017 Jul 20;12(7):e0180801. doi: 10.1371/journal.pone.0180801. eCollection 2017.
Achieving high coverage of HIV testing services is critical in many health systems, especially where HIV testing services remain centralized and inconvenient for many. As a result, planning the optimal spatial distribution of HIV testing sites is increasingly important. We aimed to assess the relationship between geographic distance and uptake of HIV testing services among the general population in Guangzhou, China. Utilizing spatial epidemiological methods and stratified household random sampling, we studied 666 adults aged 18-59. Computer-assisted interviews assessed self-reported HIV testing history. Spatial scan statistic assessed the clustering of participants who have ever been tested for HIV, and two-level logistic regression models assessed the association between uptake of HIV testing and the mean driving distance from the participant's residence to all HIV testing sites in the research sites. The percentage of participants who have ever been tested for HIV was 25.2% (168/666, 95%CI: 21.9%, 28.5%), and the majority (82.7%) of participants tested for HIV in Centres for Disease Control and Prevention, public hospitals or STIs clinics. None reported using self-testing. Spatial clustering analyses found a hotspot included 48 participants who have ever been tested for HIV and 25.8 expected cases (Rate Ratio = 1.86, P = 0.002). Adjusted two-level logistic regression found an inverse relationship between geographic distance (kilometers) and ever being tested for HIV (aOR = 0.90, 95%CI: 0.84, 0.96). Married or cohabiting participants (aOR = 2.14, 95%CI: 1.09, 4.20) and those with greater social support (aOR = 1.04, 95%CI: 1.01, 1.07) were more likely to be tested for HIV. Our findings underscore the importance of considering the geographical distribution of HIV testing sites to increase testing. In addition, expanding HIV testing coverage by introducing non-facility based HIV testing services and self-testing might be useful to achieve the goal that 90% of people living with HIV knowing their HIV status by the year 2020.
The characteristics of screening and confirmatory test results for HIV in Xi'an, China.
Wang L, Zhou KH, Zhao HP, Wang JH, Zheng HC, Yu Y, Chen W. PLoS One. 2017 Jul 7;12(7):e0180071. doi: 10.1371/journal.pone.0180071. eCollection 2017.
Objectives: Individuals with recent or acute HIV infection are more infectious than those with established infection. Our objective was to analyze the characteristics of detection among HIV infections in Xi'an.
Methods: A 4th-generation kit (Architect HIV Ag/Ab Combo) and three 3rd-generationEIA kits (WanTai, XinChuang and Livzon) were used for HIV screening. Overall, 665 individuals were identified as positive and were tested by western blotting (WB). The characteristics of the screening and confirmatory tests were analyzed, including the band patterns, the early detection performance and the false-positive rates.
Results: In total, 561 of the 665 patients were confirmed as having HIV-1 infection, and no HIV-2 specific band was observed. Among these 561 WB-positive cases, reactivity to greater than or equal to 9 antigens was the most commonly observed pattern (83.18%), and the absence of reactivity to p17, p31 and gp41 was detected in 6.44%, 5.9% and 2.86% of the cases, respectively. Two cases were positive by the 4th-generation assay but negative by the 3rd-generation assay for HIV screening and had seroconversion. The false-positive rate of the Architect HIV Ag/Ab Combo (22.01%) was significantly higher than those of WanTai (9.88%), XinChuang (10.87%) and Livzon (8.93%), p<0.05
Conclusion: HIV infection in Xi'an is mainly caused by HIV-1, and individuals are rarely identified at the early phase. Although the false-positive rate of the 4th-generation assay was higher than that of the 3rd-generation assay, it is still recommended for use as the initial HIV screening test for high-risk individuals. In Xi'an, a 3rd-generation assay for screening could be considered.
Self-reported HIV-positive status but subsequent HIV-negative test result using rapid diagnostic testing algorithms among seven sub-Saharan African military populations.
Harbertson J, Hale BR, Tran BR, Thomas AG, Grillo M, Jacobs MB, McAnany J, Shaffer RA. PLoS One. 2017 Jul 7;12(7):e0180796. doi: 10.1371/journal.pone.0180796. eCollection 2017.
HIV rapid diagnostic tests (RDTs) combined in an algorithm are the current standard for HIV diagnosis in many sub-Saharan African countries, and extensive laboratory testing has confirmed HIV RDTs have excellent sensitivity and specificity. However, false-positive RDT algorithm results have been reported due to a variety of factors, such as suboptimal quality assurance procedures and inaccurate interpretation of results. We conducted HIV serosurveys in seven sub-Saharan African military populations and recorded the frequency of personnel self-reporting HIV positivity, but subsequently testing HIV-negative during the serosurvey. The frequency of individuals who reported they were HIV-positive but subsequently tested HIV-negative using RDT algorithms ranged from 3.3 to 91.1%, suggesting significant rates of prior false-positive HIV RDT algorithm results, which should be confirmed using biological testing across time in future studies. Simple measures could substantially reduce false-positive results, such as greater adherence to quality assurance guidelines and prevalence-specific HIV testing algorithms as described in the World Health Organization's HIV testing guidelines. Other measures to improve RDT algorithm specificity include classifying individuals with weakly positive test lines as HIV indeterminate and retesting. While expansion of HIV testing in resource-limited countries is critical to identifying HIV-infected individuals for appropriate care and treatment, careful attention to potential causes of false HIV-positive results are needed to prevent the significant medical, psychological, and fiscal costs resulting from individuals receiving a false-positive HIV diagnosis.
Transitioning from antenatal surveillance surveys to routine HIV testing: a turning point in the mother-to-child transmission prevention programme for HIV surveillance in Brazil.
Pereira GFM, Sabidó M, Caruso A, Benzaken AS. BMC Infect Dis. 2017 Jul 5;17(1):469. doi: 10.1186/s12879-017-2540-4.
Background: In Brazil, due to the rapid increase in programmes for the prevention of mother-to-child transmission (PMTCT), routine programme data are widely available. The objective of this study was to assess the utility of programmatic data to replace HIV surveillance based on the antenatal care (ANC) surveillance survey (SS).
Methods: We analysed ANC SS data from 219 maternity service clinics. PMTCT variables were extracted from the ANC SS data collection form, which allowed us to capture and compare the ANC SS data and PMTCT HIV test results for each pregnant woman who completed the ANC SS. Both the PMTCT programme and the ANC SS tested for HIV using sequential ELISA and western blot for confirmation. We assessed the completeness (% missing) of the PMTC data included in the ANC SS.
Results: Of the 36 713 pregnant women who had ANC SS HIV tests performed, 30 588 also underwent PMTCT HIV testing. The HIV prevalence rate from routine PMTCT testing was 0.36%, compared to 0.38% from the ANC SS testing (relative difference -0.05%; absolute difference -0.02%). The relative difference in prevalence rates between pregnant women in northern Brazil and pregnant women central-west Brazil was -0.98 and 0.66, respectively. Of the 29 856 women who had HIV test results from both the PMTCT and ANC SS, the positive percent agreement of the PMTCT versus the surveillance test was 84.1% (95% confidence interval [CI]: 74.8-91.0), and the negative percent agreement was 99.9% (95% CI: 99.9-100.0). The PMTCT HIV testing uptake was 86.4%. The ANC SS HIV prevalence was 0.33% among PMTCT non-refusers and 0.59% among refusers, with a percent bias of -10.80% and a differential prevalence ratio of 0.56. Syphilis and HIV testing results were complete in 98% and 97.6% of PMTCT reports, respectively. The reported HIV status for the women at clinic entry was missing.
Conclusion: Although there were consistent HIV prevalence estimates from the PMTCT data and the ANC SS, the overall positive percent agreement of 84.1% falls below the World Health Organization benchmark of 94.7%. Therefore, Brazil must continue to reinforce data collection practices and ensure the quality of recently introduced rapid HIV testing before replacing the PMTCT data with surveillance techniques. However, some regions with better results could be prioritized to pilot the use of PMTCT data for surveillance.
Community burden of undiagnosed HIV infection among adolescents in Zimbabwe following primary healthcare-based provider-initiated HIV testing and counselling: A cross-sectional survey.
Simms V, Dauya E, Dakshina S, Bandason T, McHugh G, Munyati S, Chonzi P, Kranzer K, Ncube G, Masimirembwa C, Thelingwani R, Apollo T, Hayes R, Weiss HA, Ferrand RA. PLoS Med. 2017 Jul 25;14(7):e1002360. doi: 10.1371/journal.pmed.1002360. eCollection 2017 Jul.
Background: Children living with HIV who are not diagnosed in infancy often remain undiagnosed until they present with advanced disease. Provider-initiated testing and counselling (PITC) in health facilities is recommended for high-HIV-prevalence settings, but it is unclear whether this approach is sufficient to achieve universal coverage of HIV testing. We aimed to investigate the change in community burden of undiagnosed HIV infection among older children and adolescents following implementation of PITC in Harare, Zimbabwe.
Methods and Findings: Over the course of 2 years (January 2013-January 2015), 7 primary health clinics (PHCs) in southwestern Harare implemented optimised, opt-out PITC for all attendees aged 6-15 years. In February 2015-December 2015, we conducted a representative cross-sectional survey of 8-17-year-olds living in the 7 communities served by the study PHCs, who would have had 2 years of exposure to PITC. Knowledge of HIV status was ascertained through a caregiver questionnaire, and anonymised HIV testing was carried out using oral mucosal transudate (OMT) tests. After 1 participant taking antiretroviral therapy was observed to have a false negative OMT result, from July 2015 urine samples were obtained from all participants providing OMTs and tested for antiretroviral drugs to confirm HIV status. Children who tested positive through PITC were identified from among survey participants using gender, birthdate, and location. Of 7146 children in 4251 eligible households, 5486 (76.8%) children in 3397 households agreed to participate in the survey, and 141 were HIV positive. HIV prevalence was 2.6% (95% CI 2.2%-3.1%), and over a third of participants with HIV were undiagnosed (37.7%; 95% CI 29.8%-46.2%). Similarly, among the subsample of 2643 (48.2%) participants with a urine test result, 34.7% of those living with HIV were undiagnosed (95% CI 23.5%-47.9%). Based on extrapolation from the survey sample to the community, we estimated that PITC over 2 years identified between 18% and 42% of previously undiagnosed children in the community. The main limitation is that prevalence of undiagnosed HIV was defined using a combination of 3 measures (OMT, self-report, and urine test), none of which were perfect.
Conclusions: Facility-based approaches are inadequate in achieving universal coverage of HIV testing among older children and adolescents. Alternative, community-based approaches are required to meet the Joint United Nations Programme on HIV/AIDS (UNAIDS) target of diagnosing 90% of those living with HIV by 2020 in this age group.
Categories: HIV modelling, HIV testing, HIV testing and counselling, HIV testing and treatment, HIV Treatment, Injecting drug use and HIV prevention, Key populations
Related Regions: Africa, Asia, Latin America, Northern America
Related Countries: Brazil, China, United States of America, Zimbabwe
Old fashioned AIDS is still with us – shocking in 2017
Editor's notes: The term AIDS refers to advanced HIV disease with a CD4 count below 200 cells per microl. or with one of several typical opportunistic infections. It is more than twenty years since the revolutionary discovery of highly active combination antiretroviral therapy. While deaths due to HIV have fallen steadily over the past two decades, it is shocking that so many people are still dying from AIDS. In part this is due to the same issues of HIV testing discussed above. The Centers for Disease Control and Prevention (CDC) published their most recent report on surveillance in the United States of America (USA). The authors show very gradual progress in the right direction. But, still more than 20% of people are diagnosed with HIV infection in the USA when they already have AIDS. In fact, in a further 20% of people, the stage of infection was not reported to CDC, so as a proportion of those with a known stage at diagnosis, as many as one quarter were diagnosed with AIDS. As might be expected, there are disparities between states with District of Columbia and California doing a little better. There are big disparities by age (with over one third of people diagnosed at age greater than 45 years having AIDS) but surprisingly little difference by ethnicity.
Médecins sans Frontières (MSF) recently released a report highlighting the challenge of advanced disease, which was picked up in a commentary in the British Medical Journal by Cousins. The report points out that in hospital settings in Democratic Republic of Congo, Guinea, Kenya, and Malawi, MSF are still seeing an alarmingly high mortality rate, with one third of deaths occurring within the first 48 hours of admission. As many as three quarters of the patients had been on antiretroviral therapy (ART), suggesting that their advanced disease was not a consequence of late presentation, but rather of failure of the health system to deliver quality care. The importance of detecting treatment failure early and changing to effective second (or third) line ART was emphasized. Once patients do present to hospital with advanced HIV disease, it is a clinical emergency and urgent effective care may make a big difference. WHO has recently issued guidance on managing advanced HIV disease, and the Journal of the International AIDS Society has recently released a useful supplement on Differentiated Care and HIV.
Back in the USA, Braunstein et al. used existing laboratory and other data to construct a retrospective analysis of what happened in the intervenable period during which different treatment approaches might have prevented more than 11 000 people from dying with HIV between 2007 and 2013. The intervenable period was defined as the 12 months before the last three months of life. The authors pointed out that in the last three months of life, people might be in care that was not typical of their engagement during the preceding year. So the intervenable period is therefore more important to see where change could happen. Like the MSF team, they found that a substantial proportion of people were not properly treated, as shown by the finding that 60% of people did not have a suppressed viral load in the period analysed. This was despite 98% having some engagement with the health system as shown by laboratory records, 80% being defined as linked to care, and 76% being prescribed ART. The challenge seemed to be to provide high quality care with continuity of care and decisions made promptly according to the findings in the laboratory.
The package of interventions recommended by WHO in their guidance for people presenting with advanced HIV disease includes screening, treatment and/or prophylaxis for major opportunistic infections, rapid ART initiation and intensified adherence support interventions. Additional support for this approach comes from the REALITY randomized trial conducted by Hakim and colleagues in Uganda, Zimbabwe, Malawi, and Kenya. In this trial, people with advanced HIV infection, judged by their CD4 count, were randomized in a factorial design. 1805 participants were randomized to different ART regimens; to nutritional support or not; and to a package of prophylaxis. This paper reports on the differences seen according to whether or not participants were randomized to receive the enhanced prophylaxis. The package consisted of at least 12 weeks of co-trimoxazole (against pneumocystis, malaria, and various bacterial and protozoal infections), co-formulated with isoniazid and pyridoxine (against tuberculosis), along with fluconazole (against cryptococcus, candida and other fungi) also for 12 weeks and azithromycin (against a broader range of invasive bacteria including salmonella) for five days. The enhanced prophylaxis led to a 27% reduction in mortality six months after entering the study, and there was still a clear difference after one year, by when 127 people had died in the standard of care group compared to 98 in the enhanced prophylaxis group. Nonetheless, the death rate was still considerable. It is also worth noting that many of the people in whom the CD4 count was extremely low did not complain of any symptoms. So CD4 testing is still needed at the point of clinical care to determine who needs urgent differentiated care for advanced HIV infection.
The final paper in this section is a randomised trial from GHESKIO in Haiti (Koenig et al.). The investigators randomized 701 people diagnosed with HIV, to start ART on the same day as their diagnosis, or to wait for three weeks, as is standard of care at the centre. 12 months later, viral suppression was somewhat better in people who started ART on the same day (61% vs. 52% at a cut-off of 1000 copies per ml.). The authors point out that this was a single centre study, and results from GHESKIO might not be generalizable to other treatment sites in Haiti. Although there were still substantial losses to follow up, there was clearly no evidence that the policy to start people on HIV treatment immediately was too hasty.
Missed opportunities: adapting the HIV care continuum to reduce HIV-related deaths
Braunstein SL, Robbins RS, Daskalakis DC. J Acquir Immune Defic Syndr. 2017 Jul 26. doi: 10.1097/QAI.0000000000001509. [Epub ahead of print]
Introduction: With advances in HIV care, persons with HIV/AIDS (PWHA) can lead healthy lives, but avoidable, HIV-related deaths continue to occur in New York City (NYC).
Methods: We selected PWHA from our surveillance registry who died between 2007-2013, resided in NYC, and survived ≥15 months post-diagnosis to generate an HIV Mortality Reduction Continuum of Care (HMRCC) describing pre-death care patterns among PWHA. We used HIV laboratory test reports to measure care outcomes during an "intervenable period" (IP) during which deaths may have been avoided. The continuum was stratified by underlying cause of death (COD) (HIV-related vs. other), and the HIV-related HMRCC was stratified by demographic characteristics.
Results: 11 187 analysis-eligible PWHA died during 2007-2013. 98% linked to care; 80% were retained in care during the IP; 66% were prescribed ART; 47% had VL≤1500 copies/mL; 40% achieved viral suppression (VS). Half (47%) of deaths were HIV-related. Retention was higher among HIV-related COD (83% vs. 78%), but VS was lower (34% vs. 46%). The HIV-related HMRCC revealed disparities in VS. Despite comparable retention rates, Whites had the highest VS (42%, vs. 32% Blacks and 33% Latinos/Hispanics). Additionally, retention and VS increased with increasing age. People with a history of injection drug use had relatively high rates of retention (88%) and VS (37%).
Discussion: The HMRCC is a novel framework for evaluating pre-death care patterns among PWHA and identifying opportunities to reduce preventable deaths. In NYC, reducing mortality will require increasing VS among those already in care, particularly for Blacks and Latinos/Hispanics.
Enhanced prophylaxis plus antiretroviral therapy for advanced HIV infection in Africa
Hakim J, Musiime V, Szubert AJ, Mallewa J, Siika A, Agutu C, Walker S, Pett SL, Bwakura-Dangarembizi M, Lugemwa A, Kaunda S, Karoney M, Musoro G, Kabahenda S, Nathoo K, Maitland K, Griffiths A, Thomason MJ, Kityo C, Mugyenyi P, Prendergast AJ, Walker AS, Gibb DM; REALITY Trial Team. N Engl J Med. 2017 Jul 20;377(3):233-245. doi: 10.1056/NEJMoa1615822.
Background: In sub-Saharan Africa, among patients with advanced human immunodeficiency virus (HIV) infection, the rate of death from infection (including tuberculosis and cryptococcus) shortly after the initiation of antiretroviral therapy (ART) is approximately 10%.
Methods: In this factorial open-label trial conducted in Uganda, Zimbabwe, Malawi, and Kenya, we enrolled HIV-infected adults and children 5 years of age or older who had not received previous ART and were starting ART with a CD4+ count of fewer than 100 cells per cubic millimeter. They underwent simultaneous randomization to receive enhanced antimicrobial prophylaxis or standard prophylaxis, adjunctive raltegravir or no raltegravir, and supplementary food or no supplementary food. Here, we report on the effects of enhanced antimicrobial prophylaxis, which consisted of continuous trimethoprim-sulfamethoxazole plus at least 12 weeks of isoniazid-pyridoxine (co-formulated with trimethoprim-sulfamethoxazole in a single fixed-dose combination tablet), 12 weeks of fluconazole, 5 days of azithromycin, and a single dose of albendazole, as compared with standard prophylaxis (trimethoprim-sulfamethoxazole alone). The primary end point was 24-week mortality.
Results: A total of 1805 patients (1733 adults and 72 children or adolescents) underwent randomization to receive either enhanced prophylaxis (906 patients) or standard prophylaxis (899 patients) and were followed for 48 weeks (loss to follow-up, 3.1%). The median baseline CD4+ count was 37 cells per cubic millimeter, but 854 patients (47.3%) were asymptomatic or mildly symptomatic. In the Kaplan-Meier analysis at 24 weeks, the rate of death with enhanced prophylaxis was lower than that with standard prophylaxis (80 patients [8.9% vs. 108 [12.2%]; hazard ratio, 0.73; 95% confidence interval [CI], 0.55 to 0.98; P=0.03); 98 patients (11.0%) and 127 (14.4%), respectively, had died by 48 weeks (hazard ratio, 0.76; 95% CI, 0.58 to 0.99; P=0.04). Patients in the enhanced-prophylaxis group had significantly lower rates of tuberculosis (P=0.02), cryptococcal infection (P=0.01), oral or esophageal candidiasis (P=0.02), death of unknown cause (P=0.03), and new hospitalization (P=0.03). However, there was no significant between-group difference in the rate of severe bacterial infection (P=0.32). There were nonsignificantly lower rates of serious adverse events and grade 4 adverse events in the enhanced-prophylaxis group (P=0.08 and P=0.09, respectively). Rates of HIV viral suppression and adherence to ART were similar in the two groups.
Conclusion: Among HIV-infected patients with advanced immunosuppression, enhanced antimicrobial prophylaxis combined with ART resulted in reduced rates of death at both 24 weeks and 48 weeks without compromising viral suppression or increasing toxic effects.
Same-day HIV testing with initiation of antiretroviral therapy versus standard care for persons living with HIV: A randomized unblinded trial
Koenig SP, Dorvil N, Dévieux JG, Hedt-Gauthier BL, Riviere C, Faustin M, Lavoile K, Perodin C, Apollon A, Duverger L, McNairy ML, Hennessey KA, Souroutzidis A, Cremieux PY, Severe P, Pape JW. PLoS Med. 2017 Jul 25;14(7):e1002357. doi: 10.1371/journal.pmed.1002357. eCollection 2017 Jul.
Background: Attrition during the period from HIV testing to antiretroviral therapy (ART) initiation is high worldwide. We assessed whether same-day HIV testing and ART initiation improves retention and virologic suppression.
Methods and Findings: We conducted an unblinded, randomized trial of standard ART initiation versus same-day HIV testing and ART initiation among eligible adults ≥18 years old with World Health Organization Stage 1 or 2 disease and CD4 count ≤500 cells/mm3. The study was conducted among outpatients at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic infections (GHESKIO) Clinic in Port-au-Prince, Haiti. Participants were randomly assigned (1:1) to standard ART initiation or same-day HIV testing and ART initiation. The standard group initiated ART 3 weeks after HIV testing, and the same-day group initiated ART on the day of testing. The primary study endpoint was retention in care 12 months after HIV testing with HIV-1 RNA <50 copies/ml. We assessed the impact of treatment arm with a modified intention-to-treat analysis, using multivariable logistic regression controlling for potential confounders. Between August 2013 and October 2015, 762 participants were enrolled; 59 participants transferred to other clinics during the study period, and were excluded as per protocol, leaving 356 in the standard and 347 in the same-day ART groups. In the standard ART group, 156 (44%) participants were retained in care with 12-month HIV-1 RNA <50 copies, and 184 (52%) had <1000 copies/ml; 20 participants (6%) died. In the same-day ART group, 184 (53%) participants were retained with HIV-1 RNA <50 copies/ml, and 212 (61%) had <1000 copies/ml; 10 (3%) participants died. The unadjusted risk ratio (RR) of being retained at 12 months with HIV-1 RNA <50 copies/ml was 1.21 (95% CI: 1.04, 1.38; p = 0.015) for the same-day ART group compared to the standard ART group, and the unadjusted RR for being retained with HIV-1 RNA <1000 copies was 1.18 (95% CI: 1.04, 1.31; p = 0.012). The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain.
Conclusions: Same-day HIV testing and ART initiation is feasible and beneficial in this setting, as it improves retention in care with virologic suppression among patients with early clinical HIV disease.
Categories: HIV testing, HIV testing and treatment, HIV Treatment, People living with HIV
Related Regions: Africa, Latin America, Northern America
Related Countries: Haiti, Kenya, Malawi, Uganda, United States of America, Zimbabwe
Women know what they want, but need more reproductive health choices
Editor's notes: Eliminating new HIV infections among children is often seen as a useful barometer of the overall success of the health systems as it relates to HIV. Combination prevention approaches that include structural, behavioural and biomedical elements reduce the chance of women becoming HIV-positive. Effective provision of a range of choices of modern contraceptive technology allow women to choose whether and when to have babies. The option B+ approach should ensure that all pregnant women living with HIV are offered lifelong ART, which minimises the chance of mother to child transmission of HIV infection. Continuing ART treatment for life keeps the mother healthy and allows her to support the development of her infant.
New HIV infections in children have declined by 46% since 2010, but there were still an estimated 160 000 new infections in 2016. We know that in many settings the health system barometer is still forecasting plenty of clouds among the bright spells. This month saw a range of papers describing reproductive health choices and HIV, as well as reflections on how option B+ is working, now that it is standard of care.
Contraceptive choices for women at high risk of HIV or living with HIV are complicated. WHO recently reclassified long-acting progestin injections, such as DMPA, for women at high risk of HIV infection as category 2 in the Medical Eligibility for Contraception guidance. Category 2 means that, although the method is generally safe to use, clinical judgment and careful follow up may be required. While the evidence comes from meta-analyses of observational studies, with inherent limitations, there is a reliable association between new HIV infection and the use of injectable progestins. The ongoing randomized ECHO trial will provide higher quality evidence of causality, but results will not be reported until 2019.
Mayhew et al. found that women living with HIV attending clinics in Kenya, were quite clear about their fertility intentions. Many did not want more children, although they acknowledged pressure from partners and others. Stigma around breast-feeding, worries about money and about possible health consequences of pregnancy were all reasons to decide not to have further children. The large majority used various sorts of contraception, but despite this 40% of pregnancies during the study were unintended. The authors felt that the advice given by the clinics was not adequate and that choice of contraceptive method was limited. In particular reliable long-acting methods, both reversible and not, were rarely taken up by the younger women. Overall 16% of women used long-acting methods, and no pregnancies occurred in this group.
Chanda et al. focused on female sex workers in Zambia and found similar results. Almost half the women had had terminations of pregnancies, and 62% of pregnancies were not planned. Interestingly the availability of condoms at their places of work reduced the chances of unwanted pregnancy. Approximately 39% used injectable long-acting contraceptives and only 18% used dual protection with a barrier in addition to a non-barrier method. Less than one-third of the women reported that condoms were available often or always at work, and 23% reported using no contraception. Providing access to condoms for sex workers in the highest transmission areas of countries like Zambia seems such an obvious pre-requisite for HIV programmes that it is extraordinary that in 2017 we still do not manage to do so.
Finally on this theme, Salters et al. demonstrate that contraceptive choice for women living with HIV is not only a challenge in sub-Saharan Africa. The authors followed women in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study and showed that 61% of reported pregnancies were unintended. Women with unintended pregnancies tended to be younger, single and born in Canada compared to women with planned pregnancies. To support the second prong of the strategy to eliminate HIV infections in children, we need to improve on the integration between services for sexual and reproductive health and rights and services for women living with HIV.
Once women living with HIV are pregnant, the focus shifts to the third and fourth prong – preventing transmission to the infant and keeping the mother and infant healthy. Option B+ has transformed the approach in most antenatal clinics with high rates of coverage of HIV testing and most women receiving ART during pregnancy. In the One Stop Clinic in Ifakara, Tanzania, Gamell et al. show that almost all pregnant women, who do not already know that they are living with HIV, are offered an HIV test and that 94% accept it. Retesting late in pregnancy is not yet routine, and only 3% were re-tested, of whom one (2%) had seroconverted. Since acute HIV infection has such an important impact on the risk of transmission, re-testing later in pregnancy is now routine in many countries. Coverage is far from complete, so it is not always clear whether the high rates of seroconversion observed reflect a selection bias in choosing women who are at particularly high risk. This is an important area for research if we are to continue to drive down the already low transmission rates. Similarly the authors found that women who slipped through the net and presented in labour, were not always tested and did have a higher prevalence of infection - 5.2% vs. 3.1%. The other significant finding in Ifakara was that, as in many cohort studies, women were happy to take ART during pregnancy to protect their infants, but retention in care thereafter was much less impressive. Of women newly diagnosed with HIV infection during pregnancy, 27% were lost to follow up at the time of the analysis.
Chadambuka et al. used qualitative methods to understand what impact the shift to option B+ has had in their study area in Zimbabwe. Overall, the women interviewed were very positive about treatment. They believed that it was good for their babies and also good for them, making them look healthy and thus avoiding stigma. However, women pointed out that their male partners are not exposed to as much information at the clinic or in the community. As a result, many men are less keen to be tested and sometimes not keen for their partners to be taking medicine despite appearing healthy. As one woman put it: "Very few men are supportive. You have to be strong. The men base their judgment on how healthy you appear to be as you carry yourself around and he also compares to how healthy he feels and opts to delay testing. But delaying only brings further harm. So when those men tell you to stop taking your medication, you need to tell them that they can stop if they want to, whilst you continue with your treatment." Within the power dynamics of many relationships, such a forthright approach may not be easy for all women. So we need continued attention on how to engage men in the process and how to empower women to act as agents of change within their communities.
Fertility intentions and contraceptive practices among clinic-users living with HIV in Kenya: a mixed methods study
Mayhew SH, Colombini M, Kimani JK, Tomlin K, Warren CE; Integra Initiative, Mutemwa R. BMC Public Health. 2017 Jul 5;17(1):626. doi: 10.1186/s12889-017-4514-2.
Background: Preventing unwanted pregnancies in Women Living with HIV (WLHIV) is a recognised HIV-prevention strategy. This study explores the fertility intentions and contraceptive practices of WLHIV using services in Kenya.
Methods: Two hundred forty women self-identifying as WLHIV who attended reproductive health services in Kenya were interviewed with a structured questionnaire in 2011; 48 were also interviewed in-depth. STATA SE/13.1, Nvivo 8 and thematic analysis were used.
Results: Seventy one percent participants did not want another child; this was associated with having at least two living children and being the bread-winner. FP use was high (92%) but so were unintended pregnancies (40%) while living with HIV. 56 women reported becoming pregnant "while using FP": all were using condoms or short-term methods. Only 16% participants used effective long-acting reversible contraceptives or permanent methods (LARC-PM). Being older than 25 years and separated, widowed or divorced were significant predictors of long-term method use. Qualitative data revealed strong motivation among WLHIV to plan or prevent pregnancies to avoid negative health consequences. Few participants received good information about contraceptive choices.
Conclusions: WLHIV need better access to FP advice and a wider range of contraceptives including LARC to enable informed choices that will protect their fertility intentions, ensure planned pregnancies and promote safe child-bearing.
Trial registration: Integra is a non-randomised pre-post intervention trial registered with Current Controlled Trials ID: NCT01694862.
Contraceptive use and unplanned pregnancy among female sex workers in Zambia
Chanda MM, Ortblad KF, Mwale M, Chongo S, Kanchele C, Kamungoma N, Barresi LG, Harling G, Bärnighausen T, Oldenburg CE. Contraception. 2017 Sep;96(3):196-202. doi: 10.1016/j.contraception.2017.07.003. Epub 2017 Jul 12.
Objectives: Access to reproductive healthcare, including contraceptive services, is an essential component of comprehensive healthcare for female sex workers (FSW). Here, we evaluated the prevalence of and factors associated with contraceptive use, unplanned pregnancy, and pregnancy termination among FSW in three transit towns in Zambia.
Study design: Data arose from the baseline quantitative survey from a randomized controlled trial of HIV self-testing among FSW. Eligible participants were 18 years of age or older, exchanged sex for money or goods at least once in the past month, and were HIV-uninfected or status unknown without recent HIV testing (<3 months). Logistic regression models were used to assess factors associated with contraceptive use and unplanned pregnancy.
Results: Of 946 women eligible for this analysis, 84.1% had been pregnant at least once, and among those 61.6% had an unplanned pregnancy, and 47.7% had a terminated pregnancy. Incarceration was associated with decreased odds of dual contraception use (aOR=0.46, 95% CI 0.32-0.67) and increased odds of unplanned pregnancy (aOR=1.75, 95% CI 1.56-1.97). Condom availability at work was associated with increased odds of using condoms only for contraception (aOR=1.74, 95% CI 1.21-2.51) and decreased odds of unplanned pregnancy (aOR=0.63, 95% CI 0.61-0.64).
Conclusions: FSW in this setting have large unmet reproductive health needs. Structural interventions, such as increasing condom availability in workplaces, may be useful for reducing the burden of unplanned pregnancy.
Pregnancy incidence and intention after HIV diagnosis among women living with HIV in Canada
Salters K, Loutfy M, de Pokomandy A, Money D, Pick N, Wang L, Jabbari S, Carter A, Webster K, Conway T, Dubuc D, O'Brien N, Proulx-Boucher K, Kaida A; CHIWOS Research Team. PLoS One. 2017 Jul 20;12(7):e0180524. doi: 10.1371/journal.pone.0180524. eCollection 2017.
Background: Pregnancy incidence rates among women living with HIV (WLWH) have increased over time due to longer life expectancy, improved health status, and improved access to and HIV prevention benefits of combination antiretroviral therapy (cART). However, it is unclear whether intended or unintended pregnancies are contributing to observed increases.
Methods: We analyzed retrospective data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS). Kaplan-Meier methods and GEE Poisson models were used to measure cumulative incidence and incidence rate of pregnancy after HIV diagnosis overall, and by pregnancy intention. We used multivariable logistic regression models to examine independent correlates of unintended pregnancy among the most recent/current pregnancy.
Results: Of 1165 WLWH included in this analysis, 278 (23.9%) women reported 492 pregnancies after HIV diagnosis, 60.8% of which were unintended. Unintended pregnancy incidence (24.6 per 1000 women-years (WYs); 95% CI: 21.0, 28.7) was higher than intended pregnancy incidence (16.6 per 1000 WYs; 95% CI: 13.8, 20.1) (Rate Ratio: 1.5, 95% CI: 1.2-1.8). Pregnancy incidence among WLWH who initiated cART before or during pregnancy (29.1 per 1000 WYs with 95% CI: 25.1, 33.8) was higher than among WLWH not on cART during pregnancy (11.9 per 1000 WYs; 95% CI: 9.5, 14.9) (Rate Ratio: 2.4, 95% CI: 2.0-3.0). Women with current or recent unintended pregnancy (vs. intended pregnancy) had higher adjusted odds of being single (AOR: 1.94; 95% CI: 1.10, 3.42), younger at time of conception (AOR: 0.95 per year increase, 95% CI: 0.90, 0.99), and being born in Canada (AOR: 2.76, 95% CI: 1.55, 4.92).
Conclusion: Nearly one-quarter of women reported pregnancy after HIV diagnosis, with 61% of all pregnancies reported as unintended. Integrated HIV and reproductive health care programming is required to better support WLWH to optimize pregnancy planning and outcomes and to prevent unintended pregnancy.
Prevention of mother-to-child transmission of HIV Option B+ cascade in rural Tanzania: the One Stop Clinic model
Gamell A, Luwanda LB, Kalinjuma AV, Samson L, Ntamatungiro AJ, Weisser M, Gingo W, Tanner M, Hatz C, Letang E, Battegay M; KIULARCO Study Group. PLoS One. 2017 Jul 12;12(7):e0181096. doi: 10.1371/journal.pone.0181096. eCollection 2017.
Background: Strategies to improve the uptake of Prevention of Mother-To-Child Transmission of HIV (PMTCT) are needed. We integrated HIV and maternal, newborn and child health services in a One Stop Clinic to improve the PMTCT cascade in a rural Tanzanian setting.
Methods: The One Stop Clinic of Ifakara offers integral care to HIV-infected pregnant women and their families at one single place and time. All pregnant women and HIV-exposed infants attended during the first year of Option B+ implementation (04/2014-03/2015) were included. PMTCT was assessed at the antenatal clinic (ANC), HIV care and labour ward, and compared with the pre-B+ period. We also characterised HIV-infected pregnant women and evaluated the MTCT rate.
Results: 1579 women attended the ANC. Seven (0.4%) were known to be HIV-infected. Of the remainder, 98.5% (1548/1572) were offered an HIV test, 94% (1456/1548) accepted and 38 (2.6%) tested HIV-positive. 51 were re-screened for HIV during late pregnancy and one had seroconverted. The HIV prevalence at the ANC was 3.1% (46/1463). Of the 39 newly diagnosed women, 35 (90%) were linked to care. HIV test was offered to >98% of ANC clients during both the pre- and post-B+ periods. During the post-B+ period, test acceptance (94% versus 90.5%, p<0.0001) and linkage to care (90% versus 26%, p<0.0001) increased. Ten additional women diagnosed outside the ANC were linked to care. 82% (37/45) of these newly-enrolled women started antiretroviral treatment (ART). After a median time of 17 months, 27% (12/45) were lost to follow-up. 79 women under HIV care became pregnant and all received ART. After a median follow-up time of 19 months, 6% (5/79) had been lost. 5727 women delivered at the hospital, 20% (1155/5727) had unknown HIV serostatus. Of these, 30% (345/1155) were tested for HIV, and 18/345 (5.2%) were HIV-positive. Compared to the pre-B+ period more women were tested during labour (30% versus 2.4%, p<0.0001). During the study, the MTCT rate was 2.2%.
Conclusions: The implementation of Option B+ through an integrated service delivery model resulted in universal HIV testing in the ANC, high rates of linkage to care, and MTCT below the elimination threshold. However, HIV testing in late pregnancy and labour, and retention during early ART need to be improved.
Acceptability of lifelong treatment among HIV-positive pregnant and breastfeeding women (Option B+) in selected health facilities in Zimbabwe: a qualitative study
Chadambuka A, Katirayi L, Muchedzi A, Tumbare E, Musarandega R, Mahomva AI, Woelk G BMC Public Health. 2017 Jul 25;18(1):57. doi: 10.1186/s12889-017-4611-2.
Background: Zimbabwe's Ministry of Health and Child Care (MOHCC) adopted 2013 World Health Organization (WHO) prevention of mother-to-child HIV transmission (PMTCT) guidelines recommending initiation of HIV-positive pregnant and breastfeeding women (PPBW) on lifelong antiretroviral treatment (ART) irrespective of clinical stage (Option B+). Option B+ was officially launched in Zimbabwe in November 2013; however the acceptability of life-long ART and its potential uptake among women was not known.
Methods: A qualitative study was conducted at selected sites in Harare (urban) and Zvimba (rural) to explore Option B+ acceptability; barriers, and facilitators to ART adherence and service uptake. In-depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with PPBW, healthcare providers, and community members. All interviews were audio-recorded, transcribed, and translated; data were coded and analyzed in MaxQDA v10.
Results: Forty-three IDIs, 22 FGDs, and five KIIs were conducted. The majority of women accepted lifelong ART. There was however, a fear of commitment to taking lifelong medication because they were afraid of defaulting, especially after cessation of breastfeeding. There was confusion around dosage; and fear of side effects, not having enough food to take drugs, and the lack of opportunities to ask questions in counseling. Participants reported the need for strengthening community sensitization for Option B+. Facilitators included receiving a simplified pill regimen; ability to continue breastfeeding beyond 6 months like HIV-negative women; and partner, community and health worker support. Barriers included distance of health facility, non-disclosure of HIV status, poor male partner support and knowing someone who had negative experience on ART.
Conclusions: This study found that Option B+ is generally accepted among PPBW as a means to strengthen their health and protect their babies. Consistent with previous literature, this study demonstrated the importance of male partner and community support in satisfactory adherence to ART and enhancing counseling techniques. Strengthening community sensitization and male knowledge is critical to encourage women to disclose their HIV status and ensure successful adherence to ART. Targeting and engaging partners of women will remain key determinants to women's acceptance and adherence on ART under Option B+
Categories: Biomedical interventions, HIV Treatment, Key populations, People living with HIV, Preventing HIV infection in children
Related Regions: Africa, Northern America
Related Countries: Canada, Kenya, United Republic of Tanzania, Zambia, Zimbabwe


Difference between the closing price (last trading price) of a security on a trading day and its closing price on the next trading day. Net change is published in the newspaper financial pages, usually as the last figure on the stock price list. In over-the-counter transactions, net change is the difference between the closing bids from one trading day to the next.


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A Fast Graphic Approach To Estimate Hole Cleaning for Directional Drilling
Feifei Zhang (University of Tulsa) | Stefan Miska (University of Tulsa) | Mengjiao Yu (University of Tulsa) | Evren Ozbayoglu (University of Tulsa) | Nicholas Takach (University of Tulsa)
https://doi.org/10.2118/173681-PA
SPE-173681-PA
Society of Petroleum Engineers
SPE Drilling & Completion
2017.Society of Petroleum Engineers
hole cleaning, graphic approach, directional drilling
SPE Member Price: USD 10.00
SPE Non-Member Price: USD 30.00
In this paper, a set of charts is developed to allow drilling engineers to quickly estimate the cuttings volumetric concentration in the wellbore. The most-important parameters for hole cleaning are divided into several ranges on the basis of their sensitivity to cuttings concentration in the wellbore. A series of charts is obtained by running a hole-cleaning simulator, which is based on a large number of experimental and modeling studies of cuttings transport. The difference between the charts' prediction results and experimental data is within 20%. Drilling engineers can quickly estimate the cuttings volumetric concentration by looking up the charts and conducting very-simple calculations.
File Size 745 KB Number of Pages 8
Adari, R. B., Miska, S., Kuru, E. et al. 2000. Selecting Drilling Fluid Properties and Flow Rates for Effective Hole Cleaning in High-Angle and Horizontal Wells. Presented at the SPE Annual Technical Conference and Exhibition, Dallas, 1–4 October. SPE-63050-MS. http://dx.doi.org/10.2118/63050-MS.
Bassal, A. A. 1996. The Effect of Drillpipe Rotation on Cuttings Transport in Inclined Wellbores. MS thesis, The University of Tulsa, Tulsa, Oklahoma (May 1996).
Bourgoyne, A. T., Millheim, K. K., Chenevert, M. E. et al. 1986. Applied Drilling Engineering, 113–189. Richardson, Texas: SPE.
Chien, S. F. 1969. Annular Velocity for Rotary Drilling Operations. Proc., SPE Fifth Conference on Drilling and Rock Mechanics, Austin, Texas, USA, 25–26 January. SPE-2786-MS. http://dx.doi.org/10.2118/2786-MS.
Doron, P. 1986. Hydraulic Transport of Solid Particles in Horizontal Pipes—Modeling Pressure Drop and Flow Patterns. MS thesis, Tel-Aviv University, Tel Aviv, Israel.
Duan, M. 2005. An Experimental Study of Small Sand-Sized Cuttings Transport in Horizontal and High Angle Boreholes. MS thesis, The University of Tulsa, Tulsa, Oklahoma (December 2005). https://books.google.com/books/about/An_Experimental_Study_of_Small_Sand_size.html?id=9m6XNwAACAAJ.
Erge, O., Ozbayoglu, E. M., Miska, S. Z. et al. 2014. Effect of Drillstring Deflection and Rotary Speed on Annular Frictional Pressure Losses. Journal of Energy Resources Technology 136 (4). http://dx.doi.org/10.1115/1.4027565.
Gavignet, A., Forex, S., and Sobey, I. 1989. Model Aids Cuttings Transport Prediction. J Pet Technol 41 (9): 916–921. SPE-15417-PA. http://dx.doi.org/10.2118/15417-PA.
Guo, Y., Bern, P. A., Chambers, B. D. et al. 1994. Simple Charts to Determine Hole Cleaning Requirements in Deviated Wells. Presented at the SPE/IADC Drilling Conference, Dallas, 15–18 February. SPE-27486-MS. http://dx.doi.org/10.2118/27486-MS.
Hashemian, Y., Yu, M., Miska, S. et al. 2014. Accurate Predictions of Velocity Profiles and Frictional Pressure Losses in Annular YPL-Fluid Flow. J Can Pet Technol 53 (6). SPE-173181-PA. http://dx.doi.org/10.2118/173181-PA.
Hopkins, C. J. and Leicksenring, R. A. 1995. Reducing the Risk of Stuck Pipe in the Netherlands. Presented at the SPE IADC Drilling Conference, Amsterdam, 29 February–2 March. SPE-29422-MS. http://dx.doi.org/10.2118/29422-MS.
Iyoho, A. W. 1980. Drilled-Cuttings Transport by Non-Newtonian Drilling Fluids Through Inclined, Eccentric Annuli. PhD dissertation, The University of Tulsa, Tulsa, Oklahoma.
Kulkarni, S., Jamison, D., and Teke, K. 2014a. Managing Suspension Characteristics of Lost-Circulation Materials in a Drilling Fluid. Presented at the SPE Deepwater Drilling and Completions Conference, Galveston, Texas, USA, 10–11 September. SPE-170271-MS. http://dx.doi.org/10.2118/170271-MS.
Kulkarni, S., Jamison, D., Teke, K. et al. 2014b. Modelling Suspension of Lost Circulation Materials in a Drilling Fluid. Presented at the AADE Fluids Technical Conference and Exhibition, Houston, 15–16 April. AADE-14-FTCE-24.
Larsen, T. F. 1990. A Study of the Critical Fluid Velocity in Cuttings Transport for Inclined Wellbores. MS thesis, The University of Tulsa, Tulsa, Oklahoma.
Li, J. and Luft, B. 2014. Overview of Solids Transport Studies and Applications in Oil and Gas Industry-Experimental Work. Presented at the SPE Russian Oil and Gas Exploration & Production Technical Conference and Exhibition, Moscow, 14–16 October. SPE-171285-RU. http://dx.doi.org/10.2118/171285-RU.
Massie, G. W., Castle-Smith, J., Lee, J. W. et al. 1995. Amoco's Training Initiative Reduces Wellsite Drilling Problems. Pet. Eng. Intl. 67 (3). United States, http://www.osti.gov/scitech/biblio/39900.
Nguyen, D. and Rahman, S. S. 1996. A Three-Layer Hydraulic Program for Effective Cuttings Transport and Hole Cleaning in Highly Deviated and Horizontal Wells. Presented at the 1996 Asia Pacific Drilling Technology, Kuala Lumpur, 9–11 September. SPE-36383-MS. http://dx.doi.org/10.2118/36383-MS.
Pigott, R. 1941. Mud Flow in Drilling. Drilling and Production Practice, 1 January, New York. API-41-091.
Saasen, A. and Løklingholm, G. 2002. The Effect of Drilling Fluid Rheological Properties on Hole Cleaning. Presented at the IADC/SPE Drilling Conference, Dallas, 26–28 February. SPE-74558-MS. http://dx.doi.org/10.2118/74558-MS.
Sifferman, T. R., Myers, G. M., Haden, E. L. et al. 1974. Drill-Cutting Transport in Full Scale Vertical Annuli. J Pet Technol 26 (11). SPE-4514-PA. http://dx.doi.org/10.2118/4514-PA.
Thomas, R. P. 1978. Drill Pipe Eccentricity Effect on Drilled Cuttings Behavior. MS thesis, The University of Tulsa, Tulsa, Oklahoma.
Williams, C. E. and Bruce, G. H. 1951. Carrying Capacity of Drilling Muds. J Pet Technol 3 (4). SPE-951111-G. http://dx.doi.org/10.2118/951111-G.
Wilson, K. C. 1976. A Unified Physically-Based Analysis of Solid-Liquid Pipeline Flow. Proc., the 4th International Conference on the Hydraulic Transport of Solids in Pipes, Banff, Alberta, Canada. Paper A1, pp. 1–16.
Zhang, F., Miska, S., Yu, M. et al. 2014. Application of Real-Time Solids Monitoring in Well Design, Annulus Pressure Control and Managed Pressure Drilling. Presented at the 2014 AADE Fluids Technical Conference and Exhibition, Houston, 15–16 April. AADE-14-FTCE-14.
Zhang, F., Miska, S., Yu, M. et al. 2015. Pressure Profile in Annulus: Solids Play a Significant Role. J. Energy Resour. Technol 137 (6). http://dx.doi.org/10.1115/1.4030845.
Zhang, F. 2015. Numerical Simulation and Experimental Study of Cuttings Transport in Intermediate Inclined Wells. PhD dissertation, The University of Tulsa, Tulsa, Oklahoma, USA. http://gradworks.umi.com/37/33/3733239.html.
Zhou, L. 2004. Cuttings Transport With Aerated Mud in Horizontal Annulus Under Elevated Pressure and Temperature Conditions. PhD dissertation, The University of Tulsa, Tulsa, Oklahoma, USA. http://www.worldcat.org/title/cuttings-transport-with-aerated-mud-in-horizontal-annulusunder-elevated-pressure-and-temperature-conditions/oclc/58965297.

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Q: destructure object if value of some key is possibly null I am destructuring an object in map function, object might contain value null for some keys of object. it is something like below:
{key1, key2} = {key1 : null,key2:'someval'}

I am seeing error saying key1 is not defined. What am I doing wrong?

A: You need to declare the variable using let or var like var {key1, key2}

var {key1, key2} = {key1 : null,key2:'someval'};
console.log(key1);
console.log(key2);

Using {key1, key2} will give you that error:

{key1, key2}

A: Without (or earlier) declaring and direct assignment, you need parentheses around the expression for destructuring to distinguish the objects brackets from a block statement.

({ key1, key2 } = { key1: null, key2: 'someval'});

console.log(key1, key2);

redpajama_set_name: RedPajamaStackExchange


text:
/**
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      return res.send(403);
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};

redpajama_set_name: RedPajamaGithub


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» Trophies will define Liverpool's season, not stats - Wijnaldum
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Trophies will define Liverpool's season, not stats - Wijnaldum
พนัน บอล ออนไลน์Liverpool's Premier League statistics this season make for impressive reading but the focus should be on delivering trophies at Anfield, according to midfielder Georginio Wijnaldum. The Merseyside club are second in the league after 12 matches with 30 points, two behind defending champions Manchester City. It is Liverpool's joint best start to a league season since the inception of the Premier League in 1992 and their unbeaten run has been built on solid foundations at the back.
The team has conceded five league goals -- the joint-best defensive record in the competition พนัน บอล ออนไลน์ alongside Manchester City. Wijnaldum, however, wants Liverpool, who have not won the league title since 1990 and whose last silverware came when they lifted the League Cup in 2012, to convert these milestones into tangible success. "It is good to hear, of course, but we are not playing for statistics -- we are playing to win games and at the end of the season, we hope we can win something," he told the club website .
"Of course it is something good when you don't concede goals because that makes it easier to win games and also suggests that we have defended well but I think you also need a little bit of luck. "Of course, those figures say something about our defensive qualities, particularly at home, but we have to make sure that we continue that now and go on a new run."
Wijnaldum has hailed fellow Dutchman Virgil van Dijk for พนัน บอล ออนไลน์ marshalling the defensive unit, which has kept seven clean sheets this season. "I think Virgil has made a difference in the last line because he is a good defender, a big defender. He is an extra man who can defend set-pieces as well," he said. "He is a leader in the last line who not only helps himself with his quality but also the players next to him and so he really helps the team."


Designing a kitchen is easy with free kitchen design software programs online that not only help you with the floor layout and appliance sizes, but also makes choosing paint colors and cabinet designs simple. Remodeling a kitchen back in the day required contractors and architects to create workable design plan for their clients. As a homeowner, we were lucky if our contractors actually shared drawings of their proposed layout. Most times we had trust them verbally and hope our new kitchen renovation successfully met our goals. With cabinet design software and kitchen remodeling tools we are very fortunate to have the do-it-yourself (diy) capability as a homeowner to draw luxury kitchen designs without any help from professionals. Top 10 kitchen design software reviews for multiple brands of paid-for and free drafting tools to help you find the CAD program to fit your needs.
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20 20 kitchen design software download is definitely the most premium brand of home remodeling programs available on the market. This brand of software is not ideal for a homeowner attempting to design a practical kitchen layout or other ideas for home remodeling as the learning curve is extremely high and so is the price. 20 20 is commercial kitchen design software and is best used by professional contractors and licensed architects. This home design software program not only makes it easy to redesign a kitchen remodel, but is also fantastic in producing feasible proposals with blueprints, 3D design plans, inventory lists, time and materials. If you're only looking for ideas for kitchen remodeling, then it would be cheaper to outsource the project to create a workable remodeling plan. Google Sketchup Pro 8 design tool is free to use and allows you draw a floor plan for any room in the house. Unfortunately, it's not focussed on home remodeling and lacks several key componenets for easy online kitchen design.
3D Home Architect Design Suite is a popular choice among homeowners to plan and design a new kitchen remodel. A benefit to this software is that it includes choices of u shaped cabinet layouts, countertops, floor options, new appliances, and lighting for kitchen designs. The 3D online design tool also includes an extensive free kitchen design photo gallery with ideas for small kitchen and larger homes. On the down-side, the software produces design plans that are low quality even for your own use, and not workable for an architect or contractor. Encore's 3D kitchen design program costs between $35-70 and has a free trial offer, which we highly recommend doing before spending the money. As a diy designer, our commonly shared goal is to save money. With that said, let's discuss one of the most popular 2017 program and by far our favorite 3D kitchen design software tools made by the technology giant Google. The software's capabilities are very limited and not specifically meant for house remodeling, but will definitely get the job done for free. The value of paid for software is in the skills need for kitchen remodeling.


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Q: Singular cohomology of complex projective space In the article "What is ... Equivariant Cohomology?" by Loring W. Tu (https://arxiv.org/abs/1305.4293), I read that
$H^*(\mathbb{C}P^{\infty},\mathbb{R})\simeq \mathbb{R}[u]$,
where $H^*()$ denotes the singular cohomology (functor), $\mathbb{C}P^{\infty}=\cup_n \mathbb{C}P^{n}$ and $\mathbb{R}[u]$ is the polynomial ring generated by an element $u$ of degree 2.
I don't see this equivalence. Can you explain me why it is so?