"It pains me because as a woman you have to breastfeed your baby": decision-making about infant feeding among African women living with HIV in the UK

OBJECTIVES: UK guidance advises HIV-positive women to abstain from breast feeding. Although this eliminates the risk of postnatal vertical transmission of HIV, the impact of replacement feeding on mothers is often overlooked. This qualitative study examines, for the first time in the UK, decision-making about infant feeding among African women living with HIV. METHODS: Between 2010 and 2011, we conducted semistructured interviews with 23 HIV-positive African women who were pregnant or had recently given birth. We recruited participants from three HIV antenatal clinics in London. RESULTS: Women highlighted the cultural importance of breast feeding in African communities and the social pressure to breast feed, also describing fears that replacement feeding would signify their HIV status. Participants had significant concerns about physical and psychological effects of replacement feeding on their child and felt their identity as good mothers was compromised by not breast feeding. However, almost all chose to refrain from breast feeding, driven by the desire to minimise vertical transmission risk. Participants' resilience was strengthened by financial assistance with replacement feeding, examples of healthy formula-fed children and support from partners, family, peers and professionals. CONCLUSIONS: The decision to avoid breast feeding came at considerable emotional cost to participants. Professionals should be aware of the difficulties encountered by HIV-positive women in refraining from breast feeding, especially those from migrant African communities where breast feeding is culturally normative. Appropriate financial and emotional support increases women's capacity to adhere to their infant-feeding decisions and may reduce the emotional impact

Pregnancies in older women living with HIV in the UK and Ireland.

OBJECTIVES: The aim of the study was to compare maternal characteristics and pregnancy outcomes in women aged < 40 years and ≥ 40 years in a large unselected population of HIV-positive women delivering in the UK and Ireland between 2000 and 2014. METHODS: Comprehensive population-based surveillance data on all HIV-positive pregnant women and their children seen for care in the UK and Ireland are collected through the National Study of HIV in Pregnancy and Childhood. All singleton and multiple pregnancies reported by the end of June 2015 resulting in live birth or stillbirth to women diagnosed with HIV infection before delivery and delivering in 2000-2014 were included. Logistic regression models were fitted in analyses examining the association between older maternal age and specific outcomes (preterm delivery and stillbirth). RESULTS: Among 15 501 pregnancies in HIV-positive women, the proportion in older women (≥ 40 years) increased from 2.1% (73 of 3419) in 2000-2004 to 8.9% (510 of 5748) in 2010-2014 (P < 0.001). Compared with pregnancies in younger women, those in older women were more likely to result in multiple birth (3.0 vs. 1.9% in younger women; P = 0.03), stillbirth (adjusted odds ratio 2.39; P = 0.004) or an infant with a chromosomal abnormality (1.6 vs. 0.2%, respectively; P < 0.001). However, there was no increased risk of preterm delivery, low birth weight or mother-to-child HIV transmission among older mothers. CONCLUSIONS: There has been a significant increase over time in the proportion of deliveries to women living with HIV aged ≥ 40 years, which has implications for pregnancy management, given their increased risk of multiple births, stillbirth and chromosomal anomalies, as also apparent in the general population

Rubella infection in pregnancy and congenital rubella in United Kingdom, 2003 to 2016

Although rubella is usually a mild, sometimes asymptomatic illness in childhood, the consequences of rubella infection in pregnancy can be devastating. In 2010, the Pan American Health Organisation announced that the Region of the Americas had eliminated rubella and congenital rubella syndrome (CRS) [1,2]. In the same year all 53 Member States of the World Health Organization (WHO) European Region committed to the goal of eliminating endemic transmission of measles and rubella, initially by 2015 and later revised to 2020. For the elimination of rubella and congenital rubella, high coverage of a two-dose childhood vaccination programme of a rubella-containing vaccine must be sustained [3]. Rubella can be easily mistaken for a number of other viral infections, and in order to monitor progress towards elimination it is essential that countries across Europe have robust surveillance systems in place to identify all suspected cases and reliably confirm or exclude rubella and congenital rubella infection (CRI) using appropriate laboratory methods [4]. Surveillance systems and laboratory confirmation of rubella and congenital rubella cases vary across Europe. Despite the elimination goals set for the WHO European Region, three of 28 European Union (EU) countries do not have national surveillance systems for all rubella cases [5,6]. In 2016, only 5% of all cases reported to the European Centre for Disease Prevention and Control (ECDC) were laboratory-confirmed. The United Kingdom (UK) vaccination strategy and programme surveillance is very similar to other western European countries and is based on laboratory-confirmed cases. It is, however, the only country to perform routine IgM confirmatory testing of oral fluid of notified cases (since 1994), which has strengthened surveillance and improved ascertainment [7-9]. The consequences of rubella infection in the first 20 weeks of pregnancy, and the relationship between gestational week of exposure and likelihood of fetal loss or features of congenital rubella syndrome, have been well documented [10,11]. With the introduction of effective vaccination strategies in the UK, the incidence of rubella has decreased dramatically and the last large outbreak of rubella occurred in 1995–96. Most clinicians who have qualified in this country in the past 20 years will never have seen a case of rubella, rubella infection in pregnancy or congenital rubella. Before routine vaccination was introduced, rubella was a common childhood disease in the UK with 80% of adults having evidence of prior infection [12]. Rubella vaccination was introduced for susceptible women and girls aged 11–14 years in 1970 with the aim of allowing most girls to acquire natural immunity in earlier childhood [13,14]. Non-immune women of child-bearing age were also targeted following the introduction of antenatal screening for rubella susceptibility based on rubella IgG testing throughout the UK in the early 1970s. The main programme aim was to ensure women of childbearing age were immune to rubella and thus prevent primary infection in pregnancy. This strategy successfully increased the proportion of women with antibodies to rubella from 85–90% in 1970 to 97–98% in 1987 [15]. Surveillance of CRS and CRI infections was established in the UK in 1971 to monitor the effectiveness of the vaccination programme [16]. While programmes to directly protect women of childbearing age against rubella successfully reduced cases of congenital rubella and terminations following rubella infection in pregnancy [16,17], the disease continued to circulate among young children, who were a potential source of infection to any women who remained susceptible. In 1988, a combined measles-mumps-rubella (MMR) vaccination was introduced into the routine childhood schedule at 12–15 months of age. The rubella component of MMR vaccine is highly effective and a single dose of a rubella-containing vaccine confers around 95–100% protection; the measles and mumps components require two doses to reach high levels of effectiveness [10,18]. A successful mass school-based measles-rubella immunisation campaign targeting all children aged 5–16 years was conducted in 1994 to prevent a predicted measles epidemic and to address continuing high levels of rubella susceptibility in school-aged children, particularly among boys [15]. To ensure continued high population protection, a routine second dose of MMR for 3–4-year-olds was introduced from 1996, when selective immunisation of schoolgirls ended. Uptake of the two-dose schedule by fifth birthday in the UK reached 75% by June 2005 [19] and was 88.5% in October to December 2016 [20]. MMR first-dose coverage by fifth birthday reached the 95% WHO elimination target for the first time in 2016. Determination of rubella susceptibility is not straightforward. The widespread use of an ELISA cut-off value of 10IU/ml, generally accepted as evidence of immunity, is based on levels following vaccination [21]. Vaccine-induced rubella antibody levels, while protective, appear to be lower at a population level than those resulting from naturally acquired infection. With an increasing proportion of UK-born women acquiring immunity through vaccination rather than natural infection and the absence of circulating rubella in the UK, reported antenatal susceptibility rates have increased in recent years based on this cut-off value [9]. In 2013, 27% of all births in England were to women born outside the UK, with geographical variation peaking in London at 58% [22]. Many of these women are likely to have come from rubella-endemic countries, with no or disrupted routine immunisation against rubella. A higher proportion of non-UK-born mothers, particularly those from sub-Saharan Africa and south-east Asia were more likely to be seronegative than UK-born women or white British women [23], [24] and analysis of antenatal rubella susceptibility data from London suggested that between 16% and 65% of non-UK-born women were susceptible in 2007 [25]. This paper summarises cases of laboratory-confirmed rubella infection in pregnancy (IIP), CRI and CRS reported to Public Health England (PHE) and other national surveillance programmes in the UK between 2003 and 2016

UK national clinical audit: Management of pregnancies in women with HIV

BACKGROUND: The potential for HIV transmission between a pregnant woman and her unborn child was first recognized in 1982. Since then a complex package of measures to reduce risk has been developed. This project aims to review UK management of HIV in pregnancy as part of the British HIV Association (BHIVA) audit programme. METHODS: The National Study of HIV in Pregnancy and Childhood (NSHPC), a population-based surveillance study, provided data for pregnancies with an expected delivery date from 1/1/13 - 30/6/14. Services also completed a survey on local management policies. Data were audited against the 2012 BHIVA pregnancy guidelines. RESULTS: During the audit period 1483 pregnancies were reported and 112 services completed the survey. Use of dedicated multidisciplinary teams was reported by 99% although 26% included neither a specialist midwife nor nurse. 17% of services reported delays >1 week for HIV specialist review of women diagnosed antenatally. Problematic urgent HIV testing had been experienced by 9% of services although in a further 49% the need for urgent testing had not arisen. Delays of >2 h in obtaining urgent results were common. Antiretroviral therapy (ART) was started during pregnancy in 37% women with >94% regimens in accordance with guidelines. Late ART initiation was common, particularly in those with a low CD4 count or high viral load. Eleven percent of services reported local policy contrary to guidelines regarding delivery mode for women with a VL <50 copies/mL at ≥36 weeks. According to NSHPC reports 27% of women virologically eligible for vaginal delivery planned to deliver by CS. CONCLUSIONS: Pregnant women in the UK are managed largely in accordance with BHIVA guidelines. Improvements are needed to ensure timely referral and ART initiation to ensure the best possible outcomes

CD4 cell count and the risk of AIDS or death in HIV-Infected adults on combination antiretroviral therapy with a suppressed viral load: a longitudinal cohort study from COHERE.

BACKGROUND: Most adults infected with HIV achieve viral suppression within a year of starting combination antiretroviral therapy (cART). It is important to understand the risk of AIDS events or death for patients with a suppressed viral load. METHODS AND FINDINGS: Using data from the Collaboration of Observational HIV Epidemiological Research Europe (2010 merger), we assessed the risk of a new AIDS-defining event or death in successfully treated patients. We accumulated episodes of viral suppression for each patient while on cART, each episode beginning with the second of two consecutive plasma viral load measurements 500 copies/µl, the first of two consecutive measurements between 50-500 copies/µl, cART interruption or administrative censoring. We used stratified multivariate Cox models to estimate the association between time updated CD4 cell count and a new AIDS event or death or death alone. 75,336 patients contributed 104,265 suppression episodes and were suppressed while on cART for a median 2.7 years. The mortality rate was 4.8 per 1,000 years of viral suppression. A higher CD4 cell count was always associated with a reduced risk of a new AIDS event or death; with a hazard ratio per 100 cells/µl (95% CI) of: 0.35 (0.30-0.40) for counts <200 cells/µl, 0.81 (0.71-0.92) for counts 200 to <350 cells/µl, 0.74 (0.66-0.83) for counts 350 to <500 cells/µl, and 0.96 (0.92-0.99) for counts ≥500 cells/µl. A higher CD4 cell count became even more beneficial over time for patients with CD4 cell counts <200 cells/µl. CONCLUSIONS: Despite the low mortality rate, the risk of a new AIDS event or death follows a CD4 cell count gradient in patients with viral suppression. A higher CD4 cell count was associated with the greatest benefit for patients with a CD4 cell count <200 cells/µl but still some slight benefit for those with a CD4 cell count ≥500 cells/µl

Young people in the United Kingdom and Ireland with perinatally acquired HIV: The pediatric legacy for adult services

Children with perinatally acquired HIV-1 infection are surviving into adolescence and increasingly transitioning toward adult services. Planning appropriate services in adult life requires an understanding of their progress through pediatric care. We describe the demographic features, disease progression, antiretroviral therapy (ART), and resistance in young people aged 10 years or more living in the United Kingdom and Ireland reported to the National Study of HIV in Pregnancy and Childhood (NSHPC) with prospective annual follow-up in the Collaborative HIV Paediatric Study (CHIPS) between 1996 and September 2007. Six hundred fifty-four perinatally infected young people were identified; 76% black African, 57% born abroad. Median age at presentation and duration of follow-up was 1 and 11 years, respectively, if born in the United Kingdom/Ireland, and 8 and 5 years if born elsewhere. One hundred sixty-nine (26%) ever had an AIDS-defining illness. Ten died during adolescence. At last follow-up, 64% were on ART, 18% off treatment having previously received ART and 18% were ART naive. Of 518 who had received highly active antiretroviral therapy (HAART), 47% were triple class experienced. At last follow-up 77 (12%) had CD4 counts less than 200 per microliter; of those on HAART, 78% had HIV-1 RNA <= 400 copies per milliliter, median CD4 count 554 (interquartile range [IQR] 324-802). Among 166 with resistance assays on HAART, 52% and 12% had dual- and triple-class HIV-1-associated resistance mutations, respectively. One hundred three (16%) young people had transferred to adult services. Young adults with perinatally acquired HIV-1 infection require coordinated multidisciplinary transitional care services and careful long-term follow-up in adult life

Sick building syndrome: are we doing enough?

Health and well-being are vitally important aspects of people centric building design and are the roots of productivity. Sick building syndrome (SBS) is a collection of factors that can negatively affect physical health in several ways. Besides physical health is also related to psychological well-being because the human body is one interactive biological system. This paper focuses on reviewing the current state of knowledge on building sickness syndrome which has been prevalent as a building illness since the 1970s especially in offices and schools. While the concepts of intelligent, smart and sustainable buildings have gained considerable attention during recent decades, there is now increasing attention being given to designing healthy buildings. This study provides a review about SBS symptoms. Several negative effects of SBS are identified and potential solutions are advocated. Finally, the study stresses the role of built environment and concludes that ongoing research towards tackling SBS and developing healthy indoor environments should not be limited to a single formula as any health-related building design approach is dependent on several interacting factors

Glucosinolates, myrosinase hydrolysis products, and flavonols found in rocket (Eruca sativa and Diplotaxis tenuifolia)

Rocket species have been shown to have very high concentrations of glucosinolates and flavonols, which have numerous positive health benefits with regular consumption. In this review we highlight how breeders and processors of rocket species can utilize genomic and phytochemical research to improve varieties and enhance the nutritive benefits to consumers. Plant breeders are increasingly looking to new technologies such as HPLC, UPLC, LC-MS and GC-MS to screen populations for their phytochemical content to inform plant selections. Here we collate the research that has been conducted to-date in rocket, and summarise all glucosinolate and flavonol compounds identified in the species. We emphasize the importance of the broad screening of populations for phytochemicals and myrosinase degradation products, as well as unique traits that may be found in underutilized gene bank resources. We also stress that collaboration with industrial partners is becoming essential for long-term plant breeding goals through research

Overview of T and D-T results in JET with ITER-like wall

In 2021 JET exploited its unique capabilities to operate with T and D–T fuel with an ITER-like Be/W wall (JET-ILW). This second major JET D–T campaign (DTE2), after DTE1 in 1997, represented the culmination of a series of JET enhancements—new fusion diagnostics, new T injection capabilities, refurbishment of the T plant, increased auxiliary heating, in-vessel calibration of 14 MeV neutron yield monitors—as well as significant advances in plasma theory and modelling in the fusion community. DTE2 was complemented by a sequence of isotope physics campaigns encompassing operation in pure tritium at high T-NBI power. Carefully conducted for safe operation with tritium, the new T and D–T experiments used 1 kg of T (vs 100 g in DTE1), yielding the most fusion reactor relevant D–T plasmas to date and expanding our understanding of isotopes and D–T mixture physics. Furthermore, since the JET T and DTE2 campaigns occurred almost 25 years after the last major D–T tokamak experiment, it was also a strategic goal of the European fusion programme to refresh operational experience of a nuclear tokamak to prepare staff for ITER operation. The key physics results of the JET T and DTE2 experiments, carried out within the EUROfusion JET1 work package, are reported in this paper. Progress in the technological exploitation of JET D–T operations, development and validation of nuclear codes, neutronic tools and techniques for ITER operations carried out by EUROfusion (started within the Horizon 2020 Framework Programme and continuing under the Horizon Europe FP) are reported in (Litaudon et al Nucl. Fusion accepted), while JET experience on T and D–T operations is presented in (King et al Nucl. Fusion submitted)