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Feminist Social Work Practice
Cheryl A. Hyde
Feminist social work practice is based on principles derived from the political and social analyses of the women's movement. As a practice approach, feminism emphasizes gendered analyses and solutions, democratized structures and processes, diversity and inclusivity, linking personal situations with political solutions, and transformation at all levels of intervention. Feminist practice is in concert with a multisystemic approach; it complements and extends strength-based social work. It requires of the practitioner, regardless of method, to be relational and open to other ways of knowing and understanding.
Gay Men: Overview
James I. Martin
This entry explains who gay men are, how gay identity constructions have evolved since their inception, and how they continue to evolve. It also describes the health and mental health problems that gay men may present to social work practitioners. In addition, it identifies several social policies that are relevant to gay men. The entry argues that a systemic perspective that takes into account the social, political, and cultural influences on gay men is necessary for understanding the problems that such men commonly experience.
Gay Men: Practice Interventions
Robert L. Miller Jr.
This chapter explores salient concepts of social work practice with gay men. These concepts are described within a life cycle context. The illuminated concepts have been identified based on the biopsychosocial and spiritual developments in the social work literature related to this population since the printing of the 19th edition of the Encyclopedia of Social Work.
HIV/AIDS: Practice Interventions
Kosta N. Kalogerogiannis, Richard Hibbert, Lydia M. Franco, Taiwanna Messam, and Mary M. McKay
For over 20 years, social workers have been involved in service delivery for HIV and AIDS infected and affected individuals. It is estimated that more than 1 million people are living with HIV or AIDS in the United States. The rates of HIV infections continue to rise, with more than 40,000 individuals being diagnosed each year in the United States. This entry explores the current trends in HIV primary prevention, secondary prevention, and counseling and psychotherapy services for people living with or affected by HIV/AIDS.
Lesbians: Practice Interventions
Deana F. Morrow
This entry will provide an overview of psychosocial issues and social work intervention relevant to working with lesbians. Practice issues related to the impact of heterosexism, coming out, lesbian identity development, and lesbian couple and family formation will be discussed. Assessment and intervention methods appropriate for social work practice with lesbians will be addressed.
Men: Practice Interventions
Robert Blundo
A consistent theme for the majority of men in the United States remains the code of manhood. Men are expected by society to be stoic in the face of danger and to play out, in all aspects of life, the idea of the rugged individual going it alone, even in the face of a quickly changing world. Whereas social-work theorists and practitioners talk about male aggression, sexuality, intimacy, depression, anxiety, addiction, ageing, and work-related concerns, most men are less likely to view these as problems. If they do enter into counseling or treatment, they are less likely to remain for any length of time. Faced with these issues, practitioners are challenged to find ways of engaging men and forming successful collaboration and meaningful outcomes.
Sexual Assault
Judy L. Postmus
Sexual assault or rape affects millions of women and men in the United States; however, it is only in the last 30 years that it is being considered a social problem. During this period, many policies at the state and federal levels have attempted to address sexual assault and provide legal remedies for victims. However, sexual assaults are still the most underreported crime in the United States and are accompanied by bias and misinformation that plague our response. Social workers play a crucial role in offering services to survivors and advocating for more education and awareness in our communities and universities.
Transgender People
M. J. Gilbert
In this entry, transgender is defined in the context of ethnomethodology and social construction of gender. A history of the role of transgender people in the gay, lesbian, and bisexual rights movement is presented, including tensions concerning the role of transgender people in this movement. Issues regarding social work practice related to transgender issues on the micro, mezzo, macro, and meta levels are discussed.
Women: Practice Interventions
Josefina Figueira-McDonough
Gender hierarchy is the most pervasive source of inequality in the world. In view of the commitment of social work to the goal of justice, redressing the consequences of inequality among the most disenfranchised should be at the core of professional intervention. Rather than discussing the merits of specific types of practice intervention adopted by social workers, I focus on strategies and knowledge-gathering techniques relevant to empowering women, with an emphasis on five social work methods.


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Howlin Wolf
A big, imposing man with a voice to match.
Even Howlin' Wolf's six foot three frame couldn't contain his unrestrained vocals and larger than life stage presence. The Chicago blues icon is revered by the likes of the Rolling Stones and Eric Clapton.
Howlin' Wolf ranks among the most electrifying performers in blues history, as well as one of its greatest characters.
He was a ferocious, full-bodied singer whose gruff, rasping vocals embodied the blues at its most unbridled.
A large man who stood more than six feet tall and weighed nearly three hundred pounds, Howlin' Wolf cut an imposing figure, which he utilized to maximum effect when performing. In the words of blues historian Bob Santelli, "Wolf acted out his most potent blues, becoming the living embodiment of its most powerful forces." Howlin' Wolf cut his greatest work in the Fifties and early Sixties for the Chicago-based Chess Records.
Many songs with which he is most closely identified—"Spoonful," "Back Door Man," "Little Red Rooster" and "I Ain't Superstitious"—were written for him by bluesman Willie Dixon, a fixture at Chess Records who also funneled material to Wolf's main rival, Muddy Waters. Howlin' Wolf himself was an estimable songwriter, responsible for such raw classics as "Killing Floor," "Smokestack Lightning" and "Moanin' at Midnight."
Howlin' Wolf was born Chester Arthur Burnett on June 10, 1910 on a plantation between West Point and Aberdeen, Mississippi. "Howlin' Wolf" was a nickname he picked up in his youth. He was exposed to the blues from an early age through such performers as Charley Patton and Willie Brown, who performed at plantation picnics and juke joints. Wolf derived his trademark howl from the "blue yodel" of country singer Jimmie Rodgers, whom he admired. Although he sang the blues locally, it wasn't until he moved to West Memphis in 1948 that he put together a full-time band. Producer Sam Phillips recorded Howlin' Wolf at his Memphis Recording Service (later Sun Records) after hearing him perform on radio station KWEM. Some of the material was leased to Chess Records, and in the early Fifties Howlin' Wolf signed with Chess and moved to Chicago.
His Chess recordings include such classics as "Sitting on Top of the World," "Spoonful," "Smokestack Lightnin'," "Little Red Rooster," "I Ain't Superstitious," "Back Door Man," "Killing Floor" and "How Many More Years." Howlin' Wolf was a major influence on such blues-based rock musicians as the Rolling Stones and Eric Clapton. In fact, he recorded a pair of albums—The London Howlin' Wolf Sessions (1971) and London Revisited (1974)—with his British disciples in the early Seventies. Howlin' Wolf's distinctive vocal style and rough-hewn approach to the blues can also be heard in the work of such diverse artists as Captain Beefheart and His Magic Band and Led Zeppelin. In 1971 Wolf received an honorary doctorate from Columbia College in Chicago.
Slowed down for much of the Seventies due to serious internal injuries suffered in an automobile accident, Howlin' Wolf gave his last performance in Chicago in November 1975 with fellow blues titan B.B. King. He died of kidney failure two months later, on January 10, 1976.
Inductee: Chester Arthur Burnett a.k.a. Howlin' Wolf (born June 10, 1910, died January 10, 1976)

subset: commoncrawl


text:
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People think that ice is unyielding, but if you're precise, if you're focused and calm, it can give your skates wings.
Juneau, AK
Sergei Maslov
Viktor Bartók
Ethan Pasternak was born on November 1, 1998 in Juneau, Alaska and learned to skate at the tender age of two. His parents, Fiona and Piotr, brought him to the city rink during summers and Mendenhall Lake in the winter. A child prodigy, Ethan surprised all the local skate club instructors when he performed a double axel at only five years of age. Mrs. Pasternak has often recalled that Ethan seemed more comfortable on skates than on his feet. Ethan was always dedicated to the sport, spending up to six hours each day skating.
He drew the attention of renowned coach Sergei Maslov as the youngest competitor in the 2010 Pacific Northwest Skating Championships. Under Mr. Maslov's training, Ethan has become widely recognized as one of the world's most talented young skaters to date. Ethan enjoys traveling and competing, but loves coming back home to skate by the Juneau Ice Fields. His fondest and earliest memory is skating on Mendenhall Lake in late January 2002. Weaving figure-eights at dusk, he listened to his skates echo against the calm, ancient glacier. From that moment forward, Ethan never wanted to leave the ice.


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About AWE
About AWE
The Atomic Weapons Establishment (AWE) Aldermaston has been at the centre of Britain's nuclear weapons production since 1950. Then called the Atomic Weapons Research Establishment (AWRE), it replaced Fort Halstead where Britain's research on atomic weapons began in 1947. AWE Burghfield, where warheads are assembled, was opened at the same time.
The first atomic bomb, the "Blue Danube", tested off Australia in June 1952, was built at Aldermaston. In 1955 work started on the first thermo-nuclear or hydrogen bombs which were were tested in the Pacific, including at Christmas Island, in 1957.
These were the last "independent" nuclear weapons built at Aldermaston. From 1958 onwards, under the Mutual Defence Agreement, the UK and the US agreed to exchange information on "atomic weapon design, development, and fabrication capability".
Since 1958 all of the UK's nuclear weapons have been designed, tested and built (in collaboration with the US) at Aldermaston: the WE177, deployed on RAF and Royal Navy planes from 1966; the submarine-launched Polaris warhead, deployed from 1968, and the successor Chevaline warhead deployed from 1982.
All of these warheads were tested at the US underground test site in Nevada, on the land of the Western Shoshone people.
The warheads for the current Trident system were built at Aldermaston, and they are refurbished at AWE Burghfield. Since 2002, the government has invested in building new facilities at AWE, and recruited new staff to test, design and build the next generation of nuclear warheads.
AWPC is calling for an end to the production of nuclear warheads at Aldermaston, the decommissioning of the current stockpile, and AWE's expertise to be used for worldwide nuclear disarmament.
Developments at AWE
- In 2002, AWE Aldermaston and Burghfield embarked on a massive building programme which will equip the UK government to design, test and build a new generation of nuclear warheads;
- Since 2002, AWE have built the new "Orion" laser and the Gemini office complex; a massive supercomputer, essential to the design of new warheads, has been installed. A new High Explosives Fabrication Facility and several other buildings are under currently construction;
- At AWE Burghfield work is underway on a new Warhead Assembly Facility and supporting builings;
- Up to 1,500 new staff, including specialist warhead engineers, have been recruited;
- These developments started well before parliament voted in March 2007 to replace the current Trident system.
- Further planning applications for new buildings, including a new Uranium Enrichment Facility, are envisaged in the Site Development Strategy Plan;
- For a detailed chronology of construction and related events, see ...here;
- When Parliament voted in March 2007 to replace the current Trident system, they only agreed to new submarines and missiles.They did not vote to replace the warheads.
- Since 2007 the government have continued to claim that they have not yet made in a decision to replace the current warhead system, however continued building work at Aldermaston and other evidence suggests that this decision has already been made.
WMD profiteers
AWE Aldermaston and Burghfield are managed for the Ministry of Defence by AWE Management Ltd (AWE ml), by a consortium of three companies: the US arms giant Lockheed Martin, the British-based company SERCO and since December 2008, Jacobs Engineering, another US company with interests in the US nuclear industry.


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the safest way for magnetic couple to bear childen.
This question comes up frequently. (See below.) The safest way involves sperm washing (if the future dad is HIV positive) and in vitro fertilization.
Dr. Bob
Pregnancy and Sperm Washing (POSITIVE MALE, NEGATIVE FEMALE) May 5, 2008
Hi Dr. Frascino,
Firstly, thank you for all your great answers and expertise.
I have spent the past year researching safe ways for me to get pregnant. My husband is positive, I am negative. Sadly we cannot afford IVF and do not live in a city up North where certain studies are being conducted in IUI sperm washing. I think it is really sad that there are so many of us wanting to have a child so badly that we are willing to put ourselves at risk. I feel I am playing russian roulette with my life and wish I could find an alternative solution to this. The only thing that keeps playing at the back of my mind is the study I saw of couples that used the Prep and did not convert over. I have contacted local labs to see whether they could help with sperm washing but have not had any luck. The only way is to pay over $3000 to send the sperm overnight to a facility that will process the sperm and check if it is undetectable and have it send back, then an additional $10,000+ for IVF. Since this is not an option - ncxt cycle I will use HIV meds and take my chances.....
Response from Dr. Frascino
You are not alone in trying to navigate these tricky waters. (See below.) I would suggest you to discuss your plan with your husband's HIV specialist and also with an HIV-knowledgeable obstetrician. You should make certain your husband's plasma viral load is suppressed to undetectable levels. The specialists will also help you select the safest antiretrovirals for PrEP (pre-exposure prophylaxis). Some antiretrovirals should not be used during pregnancy.
Good luck.
Dr. Bob
Want a baby, discordant couple Apr 29, 2008
Hi there, hope u can help. I'm a 32yr old lady, HIV+ and my husband is HIV-, we want a baby desperately, what options do we have to conceive except IVF, we cannot afford the cost of insemination. Thanks.
Response from Dr. Frascino
At present in vitro fertilization is the safest way for an HIV-positive woman and HIV-negative man to conceive a child. If that is not available or feasible, other options could be considered. They would include driving your HIV plasma viral load down to undetectable levels with antiretroviral drugs that can safely be used during pregnancy and possibly having your husband use antiretrovirals as well. This would be considered a form of PrEP (Pre-exposure prophylaxis). These techniques have not been completely tested in clinical trials, but there is at least theoretical and suggestive evidence they may significantly decrease HIV-transmission risk while you attempt to conceive "naturally." I would certainly consult an HIV-knowledgeable obstetrician as you begin this undertaking and have him or her confer with your HIV specialist. You should also be advised exactly when during your cycle you are most fertile (likely to conceive) so that your husband can decrease his unprotected exposures while maximizing your chances for pregnancy. I'll reprint some information about magnetic couples and pregnancy below for our readers.
Good luck!
Dr. Bob
Children and aids (SPERM WASHING) (PREGNANCY) (POSITIVE PREGNANCY) Mar 24, 2008
I was wondering if a man who has AIDs is able to impregnate his wife safely
Response from Dr. Frascino
Yes. A variety of techniques have been developed to significantly reduce the possibility of transmitting HIV to a wife or fetus. These techniques involve sperm washing and in vitro fertilization. See below.
Good luck.
Dr. Bob
Please help me (PREGNANCY) Feb 23, 2008
I leave in Ethiopia. I am male living with HIV. My CD4 is now 800 and viral load less than 40 in ML. My problem is I have a wife who is HIV negative, who want to have a baby from me only with sexual intercourse know the baby can be safe with proper medicine but I am worrying that my wife will be infected. How much is the risk of transmission from me to her and is their any possible way decrease the risk and make my wife have baby from me. Please help me what I can do? In my country sperm washing cant work. Please, advise me.
Response from Dr. Frascino
Certainly sperm washing and in vitro fertilization would be the safest way for a magnetic couple to conceive. If that is not an option and you are determined to begin a family, I would suggest you work closely with an HIV/AIDS specialist as well as an HIV/AIDS-knowledgeable obstetrician. The risk of HIV transmission can be very significantly reduced if you have had an undetectable HIV plasma viral load on your HIV medications for the past six months. You should also be screened for any other potential STDs before attempting to conceive. In addition you can discuss with your doctors the best time during your wife's monthly cycle to attempt conception. This would hopefully decrease her exposure and allow for the best chance for pregnancy to occur.
Good luck to you both.
Dr. Bob
What I Can do (SPERM WASHING) (PREGNANCY) Feb 16, 2008
I am male living with HIV. I am takink the ARV therapy before four Years My CD4 is now 896 and undetectable viral load(less than 40 in ML). My problem is I have a wife who is HIV negative, who want to have a baby from me only with sexual intercorse.I know the baby can be safe with proper medicine but I am woring that my wife will be infected . How much is the risk of transmission from me to her and is their any possible way decrease the risk and make my wife have baby from me. Please help me what i can do
Response from Dr. Frascino
I've discussed this topic many times in this forum. See below.
Dr. Bob
Discordant couple wanting a baby (SPERM WASHING) Jan 29, 2008
Dear Dr. Frascino:
Four months ago my husband tested positive for HIV-1 and started treatment right away. Fortunately for me, I tested negative after two years of unprotected sex and really trying hard for a baby. Now that were finally getting used to these big changes that HIV news brought with it, the baby question came back. Were exploring some avenues for having a baby together in the safest way possible. I love my husband to death but Im EXTREMELY worried about catching the virus even if the chance is close to zero. Recently, as I was searching the internet, I found this article Complete removal of HIV-1 RNA and proviral DNA from semen by the swim-up method: assisted reproduction technique using spermatozoa free from HIV-1 published by the Japanese scientists. Unfortunately, I didnt seem to find any follow up articles on this topic by the same group of scientists. I was wondering:
a.Have you heard about this study? b.Do you know if they made any further progress in Japan? Money is not an issue for us and were willing to travel as far as Japan to have the procedure done if that means no risk for me or my baby. c.Do you think there is any prospect of US adopting that procedure? d.What do you think of the current methods available in the US for HIV discordant couples?
Doctor Frascino, I love you!!! Thank you for being there for all of us!!!
Response from Dr. Frascino
a) Yes, and I posted information about it in the archives. (See below.)
b) I know other centers are using similar swim-up techniques successfully. I'm fairly sure there have been reports from Hôpital Paul de Viguier in Toulouse among others. I don't know where you are writing from, but your husband's HIV specialist should be able to refer you to the best and closest medical center experienced in these procedures.
c and d) Yes, I believe this or similar techniques are being used in the U.S. You can check with some of the resources listed below in Dr. Lee's response from the archives.
Good luck with your upcoming new addition!
Dr. Bob
sperm washing .... and Bush Jul 24, 2006
Dr. Bob,
I'm part of a magnetic couple here in NYC. What's the latest on my chances to conceive a bambino safely with my HIV positive hubby?
I'm not a Bush fan but don't you think the homeland security department are makng good decisions to keep us safe?
Times Square Sally
Response from Dr. Frascino
Hey Times Square Sally,
I'll post a question from the archives below that addresses this topic.
In addition, there has been a report from Japanese researchers recently describing an improvement in the method of sperm-washing that appears to remove even the theoretical risk of HIV infection for an HIV-negative woman wanting to conceive a child with an HIV-positive guy. The report appeared a few months ago in the medical journal "AIDS." The researchers revised the "swim-up" method of sperm washing and designed an Ultrasensitive HIV RNA/DNA test to confirm that the sperm of all 48 HIV-positive men in the study was completely free of HIV, including the proviral HIV DNA that we had previously theorized could pose a risk for HIV transmission. So this is great news! Your husband's HIV specialist would be able to provide you with a referral to an HIV-knowledgeable OB/GYN specialist to help organize the sperm washing and in vitro fertilization procedures.
Now, turning to the homeland security issue, do you really feel safe with Michael Chertoff in charge??? Yikes!!! Have you seen Chertoff's current list of potential terrorist targets??? Guess which state has the absolute most number of potential terrorist targets in the newly released 2006 National Asset Database, according to the Department of Homeland Security??? Give up? It's Indiana!!!! Yep, Indiana! Indiana clocked in with 8,591 potential terrorist targets!!! My favorite on that list is the Amish Country Popcorn Factory! (Honest! It's really on there!) Now take a look at the number of potential targets in New York State. It registered only 5,687. And what about my state, California, the most populous state in the nation? Well, we only rated 3,212 potential targets.
So, um, Times Square Sally, if you really want the Department of Homeland Security to protect you, you better consider moving to the Amish Country Popcorn Factory in Indiana because guess what?!? Times Square in New York City didn't even make the terrorist target list! Oh yea, that Chertoff is doing a hell of a job.
So bottom line: In vitro fertilization and sperm washing for magnetic couples wanting to conceive is safe! But the United States of America, under Dubya and Chertoff, is anything but safe (unless you happen to like Amish popcorn).
Stay well.
Dr. Bob
Want to NOT end this...
Jul 1, 2006
Dear Dr Bob,
I posted on June 18 a rather bleak outlook for my newly HIV positive life. I took your advice and now I feel great. I found comfort in reading the 'Just Diagnosed' section of this website.
My psychiatrist hooked me up with a paedeatric oncologist - I think that basically means a doctor who deals with children who have cancer. I was taken through the wards and all of a sudden my problems seemed completely insignificant.
My psychiatrist also hooked me up with a great HIV specialist doc - she really knows her stuff and was really supportive. My initial numbers indicate that I am 'progressing normally'. So far I don't require medicine and she said probably not for a while!!
I found a new employer and even ennrolled in college. My family is taking me on a trip to NYC as well and my girlfriend and I are back to talking.
I have realised that there is still a great deal I want to do with this life like travel, career, charity work, even have a family (my HIV doc says this is possible - though I don't see how if my semen is infected won't my child and / or wife be as well - please explain?).
I now feel as though there is not enough time on the planet rather than before when I dreaded every future moment with anxiety and a 'feel sorry for myself' attitude.
So thank you because you, at least in part, got me motivated enough to start this new 'virally enhanced' life!!!
Peace out - David.
Response from Dr. Frascino
Hey David!
Welcome back! Looks like you not only took my advice, but also that of Patti Labelle! Remember her song "New Attitude?"
"I'm feelin' good from my head to my shoes Know where I'm goin' and I know what to do I tidied up my point of view I got a new attitude Runnin' hot, runnin' cold I was runnin' into overload It was extremes, ex-ex-ex-ex-ex-extreme It took it so high, so low So low, there was nowhere to go Like a dream Somehow the wires uncrossed, the tables were turned Never knew I had such a lesson to learn I'm feelin' good from my head to my shoes . . . ."
And I think there are a lot of ooh, ooh, ooh, oohs in there as well . . . .
At any rate, I'm delighted with your new positive outlook on being positive!
As for the feasibility of your having a family, your HIV doctor is correct. With new sperm washing techniques coupled with in vitro fertilization, there is no reason why you should have to forgo the pleasures of fatherhood! I'll repost a question from the archives that addresses this topic.
Be well. Stay well, David!
Dr. Bob
HIV+ person wants children Mar 13, 2006
Hey Dr. Bob I have a client who found out recently that his boyfriend is HIV+. He asked me a question about the possibility of his boyfriend having children in the future. I told him that because it would probably be in vitro fertilization and a surrogate mother I couldn't see much risk of the child being +. Then I realized that I didn't really know what I was talking about so I decided to ask you. Can you clear this up for us? Health Educator in DC
Response from Dr. Frascino
Hi DC Health Educator,
The issue of HIV+ men wanting to conceive children safely and decrease the likelihood their mate or offspring will acquire the virus is a complex topic. I'll repeat a question from the archives that summarizes our current recommendations.
Dr. Bob
HIV + male HIV - female Feb 12, 2006
Dr. I have a question concerning having children. I have asked my HIV specialist and I am getting mixed answers. I am HIV pos and my wife is HIV neg. we really want to have a child, is it really possible to have a child without endangering her life and the child life. We decided against adoption and artificial reproduction (sperm banks). These were options to us. Is it really safe? Please give a yes or no answer if possible. I haven't received an answer.
Response from Dr. Frascino
I'll repost a response form Dr. Sharon Lee below that addresses this problem.
Good luck!
Dr. Bob
Resources for Positive Men & Negative Women Who Want a Baby Oct 16, 2004 Response from Dr. Lee
Several people have written recently asking for information about sperm washing and their hopes about having a baby when the man is positive and the woman is negative. There are a growing number of places that provide information and that provide these services. Here is a comment and list of general resources:
Studies have suggested that HIV is not present in the sperm themselves but it is in the fluid which surrounds them (Semen). Sperm washing consists of removing the semen (and presumably the HIV) from the sperm and then using the "washed" sperm for insemination. There are currently three ways to attempt pregnancy using washed sperm. A common method used for years is intravaginal insemination, which involves holding a cervical cap full of live sperm near a woman's cervix and allowing them to swim into the uterus. Another is to directly insert the washed sperm into the uterus through a cannula (or plastic tube) placed through the cervix into the uterus. The safest method is in vitro fertilization, which only exposes the woman to fertilized eggs, and not to live sperm cells. In this technique the sperm cells and the egg are brought together in a laboratory and the fertilized eggs are implanted directly into the woman's uterus.
Sperm-washing combined was reported to be the source of one man passing the virus to his partner, though it remains unclear whether her infection was caused by the procedure. (A lawsuit is underway.) Health care professionals willing to undertake the sperm-washing venture are quick to remind their patients that it is only a risk-reduction method, and that no procedure is entirely risk-free. There are several places in the United States that utilize sperm washing. However, due to quite variable policies, you will need to contact fertility specialists in your individual area to find a doctor or to be referred.
American Society for Reproductive Medicine. Visit www.asrm.org.
Bay Area Perinatal AIDS Center (BAPAC), at the University of California, San Francisco's (UCSF) Positive Health Program in San Francisco General Hospital. Offers pre-conception counseling and infertility work-up to seroconcordant and discordant couples (both partners positive or one partner is positive). Also conducts prenatal care to HIV-positive women. Call (415) 206-8919. Visit http://php.ucsf.edu/bapac.
Center for Women's Reproductive Care, at Columbia University in New York City. Conducts IVF for serodiscordant couples. Call (646) 756-8282.
Duncan Holly Biomedical. Operates the Special Program of Assisted Reproduction (SPAR), started in 1994 as a support group for couples living with incurable sexually transmitted virus diseases such as HIV. Developed a mail-in product for shipping sperm-washed samples to fertility clinics around the country, as well as an HIV testing kit for sperm that can be mailed to you at home. Complete details and in-depth articles available on its Web site, including the story of Baby Ryan, the first baby conceived through SPAR. Call (781) 665-0750 or (617) 623-7447, or visit www.duncanholly.com/idi/spar/spar_main.html
Reproductive Lab Service, 233 East Erie St. Suite 309, Chicago, IL 60611. Call toll-free: (877) REPROLAB (737-7652). Visit www.reprolab.org
SMART (Sisterhood Mobilized for AIDS/HIV Research & Treatment), New York City, provides treatment and prevention education and support for women impacted by HIV/AIDS. Call (917) 593-8797, write email@example.com or visit www.smartuniversity.org.
"Sperm Washing: Reducing the Risk of Father-to-Mother Transmission." Comprehensive article, although written in 2001. Visit http://hivinsite.ucsf.edu.
Women Organized in Response to Life-Threatening Diseases (WORLD), 414 13th Street, 2nd floor, Oakland, CA 94612. Call (510) 986-0340. Visit www.womenhiv.org. Unfortunately, not all copies of their excellent newsletter and articles are available on-line. However, an abbreviated version of their article "Reducing the Risks of Conception: Getting Pregnant When One or Both Partners is HIV positive," is available at www.PositiveWords.com. The article is very easy to understand and extremely detailed.
To each of the couples who are concerned about this issue: our best wishes for wellness for you and your families!
Doc Can I be a daddy??? May 25, 2003
Hi Doctor Bob
I've been reading this board for over 2 months and I'd like to say i think... i mean I know you are one of theeeee smartest and wittiest Docs around to be honest most are quite the zzzzzzzzzzzzzzzz.
Anyhow... is it at all possible for a HIV POZ man to ever become a father without infecting the mother or the baby????
Thanks a billion and keep being YOU.
Response from Dr. Frascino
Hey possible future Dad,
I'm glad you don't find this forum a zzzzzzzzzzzz!
Is it possible for us positoids to be dads without infecting the mom or baby? Yes, it's possible, but it's not completely without risk. It involves a medical technique called "sperm washing." Now before you start thinking about having sex in your Maytag, let me explain. Using various techniques, sperm can be separated from the other fluids in cum. These other fluids carry the vast majority of HIV. The washed sperm is then used for artificial insemination or in-vitro fertilization. This technique drastically reduces the risk of HIV transmission. There are a variety of medical centers around the world studying this technique (Milan, Italy, for example). In the US, there are programs at Tufts University/New England Medical Center in Boston. Although it's a bit dated, check out the article in the Washington Post called "Seeking a Safe Path Toward Fatherhood." It can be found at http://washingtonpost.com/wp-dyn/articles/A99181-1999Apr18.html
Good luck! If it's a boy, can you name him Dr. Bob?
Dr. Bob
Response from Dr. Frascino
For additional recent information see below.
European Alternative to Sperm Washing Feb 3, 2008
Hi Dr. Frascino:
There have been so many sperm washing questions recently and since the fertility rates go down so much and it costs so much per try, I was wondering what you thought of the study below by Vernazza: and also this study: Safety and efficacy of sperm washing in HIV-1-serodiscordant couples where the male is infected: results from the European CREAThE network. Louis Bujan, Lital Hollander, Mathieu Coudert, Carole Gilling-Smith, Alexandra Vucetich, Juliette Guibert, Pietro Vernazza, Jeanine Ohl, Michael Weigel, Yvon Englert, Augusto E. Semprini, for the CREAThE network. AIDS. September 2007;21(14):1909-1914
Pietro Vernazza, a physician at the Cantonal Hospital in St. Gallen, Switzerland, is going to talk a little bit about his poster, which is very interesting. Dr. Vernazza, could you tell me a little bit about why you decided to do this poster?
Yes. We have been involved in the past 10 years in insemination with processed semen from [serodiscordant] couples who wanted to conceive a child. Now, we also have studied, together with colleagues in the United States, the risk of transmission as a function of HIV viral load and semen. What I realized from 2000 onwards: All these couples that came in for treatment were very select couples, where the male [HIV-positive] partner was on a fully suppressive treatment. When we measured HIV in their semen, it was not existent at all. We couldn't find it. So I knew the risk of a transmission is very, very low.
Now, when we sent them, then, to the infertility clinic, this is a procedure that is quite time consuming. It's also costly. I started to ask myself whether this process is actually ethically correct. Then, in addition, I talked to Enrico Semprini, who was the first who started with the insemination [click here to view some of Semprini's publications].
Is this in Italy?
This is in Milan. And he followed ... About one third of the women who came for the first consultation would never show up for an insemination. And within Europe, all the centers have about one third no-shows, [these are people] who just don't follow up. Semprini followed up with them. And among the 500 couples, 250 are parents now.
So we realized we are giving a treatment for two thirds of the couples. About one third, or 40%, will get a baby. But the rest will do it [have unprotected sexual intercourse in order to conceive] by themselves.
We were sort of accepting that a major group of these clients, and all those outside of the program, were taking the risk and having unprotected sex. So we thought: It's okay. The risk is very, very low. It's probably in the range of one in 100,000, or one in one million. That's about the risk that you take when you mount an airplane.
We thought: Could we help these couples to reduce this, even very, very little risk? It's like wearing a seatbelt. We give them an additional safety. The additional safety is that we teach them just to have sex at the right time, when ovulation is happening (with a urine test).
Second thing: We make sure they don't have some asymptomatic chlamydia or other sexually transmitted diseases, because that increases the risk of transmission.
Then we make sure they are really stable, under a suppressive HAART. And the fourth point, which is probably the most important: We give a pre-exposure prophylaxis to the woman prior to the sexual contact -- the unprotected sexual act to conceive the baby.
We give them two doses of tenofovir [brand name: Viread; also known as TDF] at the time. When the urine test is positive [for ovulation], the next day, then the same evening, they have sex. Interestingly, the pregnancy rate in these couples is exceedingly high. After three unprotected acts, it's more than 50%. And it goes to a maximum, to a plateau, at around 70 to 75%.
I felt that is very interesting. It's certainly better than with the insemination practice, where we reach 40%. So I felt we should let people know about this experience.
Why did you choose tenofovir when the latest studies with chimpanzees showed FTC [generic name: emtricitabine; brand name: Emtriva] and tenofovir was better, or seemed to be a better prevention? My second question is: Why two doses, and not more, for a week? I know there are two days of ovulation, but it gives them more freedom.
Tenofovir has the advantage of a very, very long intracellular half-life that is about a week. So it is taken up over one or two days, and then it remains there at the place of action within the cells for a week. So that covers the risk period completely.
The question I have been asked at the poster discussion is: Why do you give it at all, since the risk is so low? I think that is probably the more relevant question. I think we give it to give a sort of psychological, additional argument, but I agree it's really a theoretically miniscule risk. And it's probably psychological. That would be the reason why I wouldn't go directly to a combination with FTC. But if you want to be more safe, safer than safe, that's fine.
I see. Because in actuality, we don't know whether the tenofovir did help at all in these couples. There's no way of teasing that out.
Of course. Right. We'll never find out.
How many couples did you do this with?
The ones that I recorded here [in this poster] are 22 couples. I also have, now, a collaboration with other clinics in Austria and Munich and in London. They are reporting that we're trying to get together a group of 35 or 40 couples. But it will never prove that there is no risk, because to prove that there is no risk is almost impossible, since we don't see any transmission from individuals with fully suppressed virus to the steady partner. There has been not a single case report worldwide.
But there haven't been any studies, so you can't ...
That's right. We know in the Swiss HIV cohort that approximately 150 to 200 [serodiscordant] couples always have unprotected sex, with fully suppressed virus, and they don't transmit.
In the Swiss cohort.
Yes. I'm sure it's the case with many, many other people. They just have sex. We see many new cases of HIV infection, but none of these new cases are associated with a sexual exposure to a partner on HAART with fully suppressed HIV.
Can you describe some of the illustrations in your poster?
Sperm washing. Reprinted with permission from Pietro Vernazza, M.D., et al. The first illustration shows a little bit of the technique that was developed by Semprini, where there is a two-step technique with a density gradient, where the larger cells, where the lymphocytes are, remain in the upper gradient of the centrifugation and then you collect the motile sperm in the pellet and do a second procedure, where you have a swim-up, where the sperm swim against gravity. And then you remove the upper layer, and that is used for the procedure.
Now, through this procedure you get about 1% of the motile sperm, which also explains a little bit why this method doesn't work as well as natural conception. There are also other reasons.
Pregnancy rates with natural conception. Reprinted with permission from Pietro Vernazza, M.D., et al. Right. Is this what we call sperm washing?
That is sperm washing. In the other graph, I show the number of cycles, and the number of couples. All of the couples started with the first cycle, and 20% of the women got pregnant after one exposure or sexual contact. Then after three [cycles] it's 50%, and it mounts to the plateau of about 70 to 75%. Then even after repeated exposures, you see that these couples very rarely get pregnant. It would mean, probably, that these [couples] have other fertility issues. That also needs to be addressed. I think it's important. All the fertility clinics in Europe that have now gained experience with HIV-positive individuals, they actually can also help them [these infertile couples]. I think there is still a role for fertility clinics to teach HIV-discordant couples. But for the majority of couples who just want to conceive a child, the natural way is much simpler.
A question related to this concerns stigma in Europe. I know in the United States a lot of fertility clinics do not want to publicly acknowledge that they help discordant couples. Is this similar in Europe, or is it more open?
I think it's more open, but there is still this stigma around, and there are still some people who think HIV-positive people, or discordant couples, should not have a child. It's sort of a belief ... or, I don't know ... it may also have to do with punishment. They are responsible for their disease, and they should get punished. It's not the way we think about people who smoke. It's very special for HIV. I think we should try to work against this stigmatization.
I think you're definitely helping with this study, and with explaining how couples do not, necessarily, need the help of fertility clinics to have a baby.
One interesting experience I had during the interviews with the couples: When I asked the couples, "What do you think is the risk of transmission when you have sex tonight?" Their estimate was in the range between 5 and 100%, a little bit higher for the women than for the men. So we haven't really properly informed these couples about the very, very low risk.
Of unprotected sex when one partner who is HIV positive is undetectable.
Exactly. Exactly. They still keep this high risk in their brain, and we haven't really openly talked about the changes in the risk of transmission, which we obviously observe. I think it wasn't a favor to them, because we sent them to the infertility clinics. They had to go through all this trouble. But on the other hand, we know it's not necessary, but we don't tell them. So that, during these interviews, causes a lot of questions, like, "Why I haven't I been told?" It also helps when I can reassure the couple that the question of sexual transmission risk is something that I have been involved with for the past 15 years. I have studied that and done research on that. Otherwise it would probably be a little bit difficult.
But within a few years, I'm sure that knowledge will disseminate, and it will change the habit of everybody.
So what's the reluctance, do you think? In the United States HIV specialists feel reluctant to say that. I have heard them say, "Well, I know the risk is minimal, but I ..." Because I guess they fear being responsible if a transmission occurs. Also, I guess, the second issue is: What if the positive partner becomes detectable? If I'm negative and my partner is positive, and even though he was undetectable the last time he went to the doctor, there is a possibility that he was not adherent and there was some viral breakthrough, so that he becomes detectable. But I believe he's still undetectable. And he doesn't have to go to the doctor for another month.
I think that's a very good point, and that's why I think this discussion about risk and behavior -- how do we make decisions about our sexual life -- is something that belongs in a steady partnership. The program that I'm talking about here is for steady partnerships. It's not about just in general. If I'm living with a partner and she takes drugs for HIV, I know exactly her adherence. I know exactly her virus. I have been talking with her doctor and herself.
So that is a little bit different situation than having sex with a partner who just tells me, "I'm suppressed." So I think it would be smart to restrict unprotected intercourse to couples where the partners know each other very well. I think that's important.
Click here to view Dr. Vernazza's study abstract.
Click here to view the slides from Dr. Vernazza's presentation.
Response from Dr. Frascino
I believe this is very encouraging data, but that the conclusions are premature. I certainly hope the follow-up studies confirm the preliminary results. That would truly be a wonderful advance for magnetic couples wishing to conceive. This report is generating considerable discussion. Stay tuned to The Body as the story evolves.
Dr. Bob
Positive Pregnancy
By Vaughn Taylor and Hanna Tessema
Winter 2007
Many HIV-positive women are reluctant to become pregnant because they fear they will pass the virus to their fetuses or that they will become too sick or disabled to care and provide for their children properly. But with counseling and guidance, along with comprehensive healthcare and treatment, many HIV-positive women can have healthy, HIV-negative children.
The key to a successful pregnancy is the health of the mother-to-be. The HIV-positive woman who is pregnant -- or is considering having children -- has an additional reason to take care of herself. Living well with HIV isn't just about antiretrovirals -- it's also about adequate nutrition, quitting smoking, getting enough exercise, and not using recreational drugs (especially those that involve needles). These recommendations will become even more vital during pregnancy, and will be joined by others -- avoiding alcohol and caffeine, for example. The aim is a healthy pregnancy, an HIV-negative baby, and a long, healthy life as a caring mother.
The prospective mother needs to learn everything she can about risks to the fetus during pregnancy and to the baby after delivery. She needs to discuss her options with both her HIV specialist and her obstetrician (and later her baby's pediatrician), in order to determine the choices that are best for her. This article will explore some of those options.
The Importance of Prenatal Care and Counseling Researchers are not sure exactly when HIV is transmitted during pregnancy. While some fetuses can be infected with HIV while developing inside their mothers' uteruses (wombs), the vast majority of infections occur during labor (the time of delivery) or after the baby is born and is breastfed by an HIV-infected mother.
Ideally, preparation for reducing risks to mother and child begins before conception, when the woman and her partner are deciding if, when, and how to have a baby. Without treatment, there is a 25% to 30% chance of an HIV-positive woman passing the virus to her child -- so-called "vertical transmission." Risk of mother-to-child transmission is generally dependent on the pregnant woman's viral load -- the higher the amount of virus during pregnancy and delivery, the greater the higher the chance of transmitting the virus to her baby.
Throughout pregnancy, a developing fetus has its own blood supply. In other words, the developing fetus generally does not come into contact with the blood of the mother. This helps protect the fetus from infections, such as HIV, in the mother's blood. Developing fetuses do, however, receive nutrients and various proteins, such as immune system antibodies, from their mothers. While a mother's HIV may not enter the fetus, her antibodies to the virus will. These antibodies cannot harm the fetus, but will cause the baby to test "positive" to an HIV antibody test at birth.
At the time of birth (labor), a baby often comes into contact with his or her mother's blood. If the mother's blood enters the baby's body, HIV can be transmitted. But with good prenatal care and antiretroviral treatment, the risk of transmission can be reduced to less than 2%.
Sperm Washing Sperm washing is a process that was developed to reduce risk of transmission from an HIV-positive man to his HIV-negative partner, and subsequently to the fetus, while enabling them to conceive a child. If both partners are positive, sperm washing also reduces the risk of cross-infection with a different strain of HIV.
HIV is carried primarily in the seminal fluid rather than in the sperm itself. Sperm washing involves separating the sperm from the seminal fluid, then using it to impregnate the woman when she is ovulating and most likely to become pregnant, or to fertilize her egg through in vitro fertilization.
Integrated Pregnancy Care A comprehensive approach to care is the most effective way for a pregnant woman with HIV infection to have a healthy pregnancy and delivery. While an obstetrician and an HIV specialist are safely and effectively managing the woman's pregnancy, she should also be provided with professional support to help manage psychological, social, and economic challenges should they arise. This might include assistance from a social services agency to help her with counseling, housing, food, and childcare needs, both during pregnancy and after delivery.
Professional counseling before pregnancy can also be extremely helpful. Working closely with her healthcare provider, an HIV-positive women and her partner can learn a great deal about the risks and benefits associated with pregnancy, including treatment options, and different ways of achieving conception.
Antiretroviral Therapy Women who are HIV positive can drastically reduce the risk of transmitting HIV to their babies with the use of antiretroviral drug treatment during pregnancy and at the time of delivery. Deciding when to begin antiretroviral therapy during pregnancy, however -- if it's not already being taken -- and which medications to use can be confusing.
Working with a healthcare provider, HIV-positive women can make important perinatal treatment decisions that best suit their individual needs, while at the same time following state-of-the-art recommendations from the U.S. Department of Health and Human Services (DHHS), the federal agency responsible for setting healthcare policies in the United States. The most recent version of the agency's guidelines, entitled Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States, was published on November 2, 2007.
When to Use Treatment During Pregnancy Generally speaking, if an HIV-positive woman requires treatment to protect her own health -- if her CD4 cell count is below 350, for example -- she should not be denied therapy, regardless of whether she is pregnant or plans to become pregnant.
There are lingering questions about the safety of antiretrovirals when used during the first three months (first trimester) of pregnancy, when a developing fetus is believed to be most susceptible to drug toxicity. According to the DHHS, antiretrovirals can be avoided during this three-month period provided the woman does not require treatment to maintain her own health. Otherwise, HIV treatment should be continued throughout pregnancy.
HIV-positive pregnant women who do not require antiretroviral therapy to maintain their own health may be able to stop treatment after giving birth -- a decision that should only be made in consultation with her healthcare team.
Which HIV Drugs to Use During Pregnancy As for specific HIV medications, the DHHS guidelines spell out a number of important considerations that HIV-positive pregnant women and their healthcare providers should be aware of.
First, the nucleoside reverse transcriptase inhibitor (NRTI) Retrovir (zidovudine) has been studied extensively in HIV-positive pregnant women and has been shown to be safe and effective at reducing the transmission of HIV from mother to fetus. In turn, it is almost always recommended as a treatment component during pregnancy and delivery (and given to the infant after birth), even when the woman has HIV that is resistant to it.
The non-nucleoside reverse transcriptase inhibitor (NNRTI) efavirenz, found in Sustiva and Atripla, should not be used by pregnant women and only cautiously by women who might become pregnant. Because efavirenz may cause birth defects if taken during the first trimester -- the first three months of pregnancy -- it is recommended that HIV-positive women have a pregnancy test before starting efavirenz and use adequate birth control while using the drug.
The NNRTI Viramune (nevirapine) has been shown to reduce the risk of mother-to-child HIV transmission, but it is recommended only for women with CD4 counts below 250 cells. There is a higher risk of serious allergic reactions, including liver damage, occurring in women who start Viramune with CD4s higher than 250.
The protease inhibitor Viracept (nelfinavir) should also be avoided during pregnancy, until further notice. In September 2007, Pfizer reported the discovery of a manufacturing impurity, ethyl methanesulfonate (EMS), in U.S. batches of Viracept. As EMS has been found to be cancerous and capable of causing birth defects in animals, the U.S. Food and Drug Administration (FDA) recommends avoiding Viracept during pregnancy until Pfizer has found a way to remove EMS from the drug.
It is also a good idea to switch off medications known to cause serious side effects in women during pregnancy. For example, the FDA has warned that HIV-positive pregnant women should not take Zerit (stavudine) and Videx (didanosine) at the same time. Some pregnant women who took these drugs together developed lactic acidosis -- a serious and sometimes fatal buildup of lactic acid in the blood, which can cause fatigue, nausea/vomiting, painful inflammation of the pancreas, and liver damage.
Other Considerations During Pregnancy It is important to remember that pregnancy-related complications typically seen in women who are not living with HIV, such as hypertensive disorders, ectopic pregnancy, gestational diabetes, psychiatric illness, preterm delivery, and STDs, also can occur in pregnant women living with HIV.
Finally, there are some aspects of typical prenatal care that might not be suitable for HIV-positive pregnant women. For example, amniocentesis, used to test for genetic defects in the baby, is done with a needle that passes through the mother's abdomen and into the womb. While this test may be necessary to look for any genetic problems that a developing baby may have, it can also increase the risk of transmitting HIV. Before undergoing amniocentesis, HIV-positive pregnant women may want to discuss its benefits and risks with their healthcare provider.
Labor and Delivery Labor and delivery are believed to be riskiest time for HIV transmission during pregnancy, as babies are most likely to be exposed to their mother's blood during the birthing process. To reduce this risk, healthcare providers should avoid performing amniotomies -- intentionally rupturing the amniotic sac to "make the water break" and induce labor. The risk of transmission increases by 2% for every hour after membranes have been ruptured.
An episiotomy -- a surgical incision through the perineum made to enlarge the vagina and assist childbirth -- can also expose the infant to the mother's blood and increase the danger of transmission. What's more, the use of birthing instruments and common procedures, such as forceps/vacuum extractors, scalp electrodes, scalp blood sampling, and internal fetal monitoring, can cause small tears in the baby's skin and increase the risk of transmission further.
Cesarean Sections vs. Vaginal Delivery A Cesarean section -- also referred to as C-section -- is delivery via a surgical incision through the maternal abdomen and uterus. It is one of the oldest documented surgical procedures. A C-section is performed when a vaginal birth is not possible or is not safe for the mother or child. Because of a variety of medical and social factors, C-sections have become fairly common -- about 26% of all births in the United States in 2002 were C-sections.
C-sections can greatly reduce an HIV-positive woman's risk of passing along the virus to her baby at the time of birth, as they greatly reduce the amount of time a baby remains in contact with his or her mother's blood and other fluids during delivery. It is still not known, however, if C-sections are any more effective than if the woman takes a powerful combination of antiretroviral drugs throughout her pregnancy. It is also not known if a woman who takes a powerful HIV drug combination and has a C-section has a lower chance of passing along the virus to her baby than a woman who takes HIV drugs and has a vaginal delivery.
Some experts do not like the idea of C-sections used solely to reduce the risk of mother-to-child HIV transmission. Because C-sections are a type of surgery, there are risks of infection and other complications. In fact, HIV-positive women may be at a higher risk for infection while undergoing C-section delivery or other complications than HIV-negative women. It is also important to remember that combination HIV treatment might do a better job of stopping transmission than a C-section. According to some studies, in HIV-positive pregnant women who have an undetectable viral load at the time of birth, the risk of delivering a baby infected with the virus is less than 2%, even with vaginal delivery. It is not known if C-sections reduce this risk further.
In its perinatal treatment guidelines, the DHHS says that C-sections are only recommended for the purpose of reducing the risk of mother-to-child HIV transmission when the mother's viral load is higher than 1,000 at week 36 of the pregnancy. A woman with a viral load below 1,000 should be counseled that her risk of transmitting the virus to her baby is low and that there is currently no information concluding that performing a scheduled cesarean section will lower her risk further. DHHS also says that, if C-section delivery is chosen, it should be scheduled for week 38 of the pregnancy.
Postnatal Treatment The months following delivery of a baby by an HIV-positive woman are also crucial to keeping the risk of vertical transmission to a minimum.
After the baby is born, the doctor will likely advise that he or she take anti-HIV drugs for four to six weeks, usually a liquid form of Retrovir taken two or four times a day, possibly in combination with other HIV medications. Studies suggest that the use of antiretroviral treatment during the first few weeks of life plays a role in further lowering the risk of HIV infection in a newborn baby. No significant side effects of Retrovir have been observed, other than a mild anemia in some infants that cleared up when the drug was stopped. Follow-up studies show that the HIV-negative treated babies continued to develop normally.
Learning the Baby's HIV Status An HIV-positive new mother usually wants to know right away whether her baby is infected. It can take several months to learn definitively the HIV status of a newborn. Moreover, it is important to keep in mind what an HIV test is. The standard test looks for antibodies to HIV; it does not look for the virus itself. Because a fetus is exposed to the mother's HIV antibodies, the baby will automatically test "positive" after birth. These antibodies can remain in the baby's body for more than 18 months after birth.
Most hospitals now conduct nucleic acid testing, which looks for the virus itself, on babies born to HIV-infected women. This test can be performed within a few days after delivery and looks for HIV itself in a blood sample collected from the baby. If the test is negative, it should be repeated within a few months after the birth.
Breastfeeding Breast milk also carries HIV, and breastfeeding adds considerable risk of transmission. As with transmission via blood, there's some indication that risk increases along with viral load (the amount of HIV in the mother's blood). So far, research shows that the risk of breast milk transmission is highest in the first six months of life. There's no threshold, however, or point beyond which it becomes absolutely safe to breastfeed.
Wherever clean water and formula are available, it is recommended that HIV-positive women exclusively formula feed their infants.
In recent years, studies have also looked at breast milk pasteurization, a procedure that allows women to express their breast milk and treat it themselves so that it becomes safe for their infants to drink. Right now, these studies have been done in resource-poor settings; your doctor may have more information about this strategy.
Vaughn Taylor is Manager and Hanna Tessema Associate Manager of ACRIA's Older Adults Training and Technical Assistance Program.
This article was provided by AIDS Community Research Initiative of America. It is a part of the publication ACRIA Update.


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These companies, which have recently repurchased shares, offer attractive dividend yields and generous payment growth. Jack Hough reports. Photo: Getty Images.
This transcript has been automatically generated and may not be 100% accurate.
... I ... talk about the potential of you out there Friday already and dividend stocks but it cannot be thinking aiming to supplement to be interested in ... Barron's Jack Kallis here with some ... interesting ideas on the dividend for the month sold on the dividend story Jack and I that I ... think it's the way to go demand for dividends is off the charts you look at the at the income tables and the economists look at ... interest income is way down dividend income is way up and investors have to do something with bank rates this low ... and companies are delivering the other is in the SB five are set to make record payouts this year was reason given ... but investors sometimes ignore small companies ... fell forty percent of the Russell two thousand index now pays dividends ... interesting study by a bank for men and that's unusual ... yet it's it's the highest since two thousand and six ... I'm back to America did it did a study on this may find that ... small companies that pay dividends outperform ones that don't buy the five percentage points the year as interesting as investors often make a small companies this ... year where everything is about growth the dress I wore their money back in the business but it turns out it's for some pre well for investment from a small company pays ... a dividend and a rising demand so he opposed both worlds yes yes on the farm on top of column right ... do I ... get so Epic Systems ... epic with a Q and you know that makes them cool one this fall than in the queue ... this is the technology company makes software allows the searches for legal documents things like that they're taking the place of ... of junior lawyers in the discovery process for the law ... firm's ... saving comp is Lamar and I wana do some other things they'd handle ... a class action lawsuit slow things to related regulations ... on the on the business is good right now ... blessed are the people is their dividend payment by eighty percent ... campaigned for special events are ... the nightmares as a real weirdo yielded two point seven percent you get you get on them so that ... I think it'd be a good growth in the stock is well over a good growth healthy override the remembers important ... on Northwest Bancshares is no one was the regional background Pennsylvania Ohio other businesses around the sun Marcellus shale where the water drilling activity spreading these little via a small local ... economic booms ... that's good for reform the mortgage business and non interest income was up ... eight percent last quarter that are doing a lot of ... a lot of mortgages so you know this is about its up fast grower ... the study growing get ready at three point eight percent dividend yield the bank is well capitalized ... aam and if Islanders Fred's which is the ... term general merchandise store that about seven hundred stores ... this is not a top performer but by any stretch but the key here is that ... this company only turns about two cents of each sales dollar into operating profit versus like Opinion nickel for of for CBS maybe seven cents for Family Dollar so this is a company that ... is right ... for some sort of improvement ... management has some ideas now the relocating more than a hundred stores to try to boost sales per square foot ... ah maybe that'll work maybe you want they're all sorts of opportunities for this come on who remain tales that we don't ... we tell Suffern what are they pay a ... dividend yield there is one point seven percent ... but if this company it doesn't need a big sales boost all it needs is to get its margins in order ... to cover the can earn twice as much as it does now that you just achieve some the same ... efficiencies as some the other chains that so ... I ... check out excellent stuff as always I ... think you're a much


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West Wallsend High School, New South Wales - Secondary School
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What program did you use? What dataset? And could you post the results? With standard errors and such?North Ukrainian R1a-M417 sample I6561 (dated to approximately 3,960 BC) gives a different picture of R1a-M417 Corded Ware, as Corded Ware seems to have directly descended from its community, without the need for any additional Steppe DNA insertion from later Yamnaya or EEF DNA insertion from Neolithic North European communities.
It perhaps indicates that Corded Ware populations were tightly-knit - largely genetically uninfluenced not only by Yamnaya on the paternal side (unsurprisingly, as they had virtually wholly different yDNA), but also by EEF Neolithic communities on the maternal side. It looks like Corded Ware was both of uniform paternal lineage and largely endogamous - its best fit contribution from the EEF groups that it replaced (Funnel Beaker, GA and Baalberge etc.) looks to be about 2% on average, so I cannot see that its men took in too many outsider women as it expanded.
One possibly interesting aspect is that North Eastern Corded Ware (Latvia and Lithuania) is a little different in that it does appear to have a Yamnayan element - a 95% best-fit contribution in one Latvian sample, and a 17% average contribution in Lithuanian samples generally. It is perhaps striking that these North Eastern Corded Ware (Yamnayan-admixed) R1a populations were the only ones that survived and thrived in Europe after Corded Ware's collapse.


text: Reductionism—breaking things into their component parts to study how they work—is an effective tool in physics. But many real-world challenges resist this approach. All too often, large scale behavior emerges in ways that are difficult to predict from the behavior of individual components. When the computational requirements are too massive or the theories that govern the component parts are inadequate, many complex systems have yielded to the physics of emergence, which seeks organizing principles at the system level. Find out how many different phenomena—superconductors, hydrodynamics, and even the formation of structure in the universe—are all fruitful areas where the physics of emergence is leading to new understanding.


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- Washing dishes by hand uses less energy than running an electric dishwasher.
This is one instance where the modern machine beats the old-fashioned method: hand washing generally uses more hot water per load than using a dishwasher. The key to maximizing energy savings is to use the dishwasher efficiently. Most modern dishwashers don't require pre-rinsing of dishes; and according to Consumer Reports, this practice wastes up to 20 gallons of water per load without getting dishes any cleaner.
Don't bother with the "rinse hold" on your machine, for the same reason. Wait to run the dishwasher until you have a full load of dishes, but don't overload the machine. The energy-saving control offered on many dishwashers will turn off the heat during the drying cycle, which will also help keep the kitchen cooler in the summer.
Opening the door after the rinse cycle and letting the dishes air dry is another way to save energy. {full article}


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I was called in to look into noise complaints in a large law library. A Trane heat pump above the ceiling in the stacks was making horrible rattling noises. Most of it was caused by tubing banging into adjacent tubing and devices within the unit. Several of the tubes had noticeable divots in the copper - including one in the hot gas line. It wouldn't have been long before that unit was oil-drenched inside.
I've never seen any other WSHP units that have so many problems with this.


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Jörg Heiser
|Mario PfeiferReconsidering The new Industrial Parks near Irvine, California by Lewis Baltz, 1974
by Mario Pfeifer, 2009
With texts by Chris Balaschak, Lewis Baltz, Martin Hochleitner, Julia Moritz, Vanessa Joan Müller, and a conversation between Lewis Baltz and Mario Pfeifer
The book discusses Mario Pfeifer's recent 16mm film installation Reconsidering The new Industrial Parks near Irvine, California by Lewis Baltz, 1974. This installation, consisting of two synchronized, looped, and parallel projected films, takes its point of departure from the first monograph of Baltz's work, published by Castelli Graphics, New York in 1974.
Over the last four decades, Lewis Baltz has continuously produced highquality photographic books. This publication functions as a critical reader, reevaluating "New Topographics" as representations of landscapes. Looking at Pfeifer's installation, which re-visits a Baltz's photographic site, Vanessa Joan Müller negotiates the terms realism / reality and the way Pfeifer discovers the mis-representation of a modern industrial building in Irvine's Industrial Park in 2009. Martin Hochleitner contextualizes Pfeifer's film installation within the context of the original "New Topographics" exhibitions (1975), which, since 2009, are being shown throughout the United States and Europe. In addition, this publication consists of film stills, production stills, and a rare interview by Mario Pfeifer with Lewis Baltz. It was published on the occasion of Mario Pfeifer's contribution for the "New Topographics" exhibitions at Los Angeles County Museum of Art and Landesgalerie Linz in 2010.


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Class details
Champion Boxing & Fitness has one of the largest amateur boxing teams in the metropolitan area. We are a member of the Potomac Valley Region of USA Boxing, which is the national governing organization that sponsors local, regional and national amateur boxing events in the United States. Our coaching staff, headed by Coach Bruce Babashan,has grown the program to more than 50 men and women over the age of 13. The team is comprised of beginner, intermediate, and experienced amateurs with members of our team competing each year in the Golden Gloves Tournament (members of our boxing team are not required to compete). Stop by and talk to Coach Bruce at the gym to learn more about our boxing team.
Class Trainer
Bruce Babashan


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Richard A. Bailey, Race and Redemption in Puritan New England, Religion in America Series (New York: Oxford University Press, 2011).
This fascinating monograph began as a dissertation at the University of Kentucky. In it, Bailey, an alumnus of the Southern Baptist Theological Seminary currently teaching history at Canisius College (Buffalo), highlights the contradictory and sometimes even hypocritical manner in which Puritans like Edwards sought the spiritual redemption of the African and Native American people they enslaved.
Most historians identify the rise of what we call "race," racialized ways of viewing the world, and the practices of racism, at least in British America, with the late eighteenth century. Bailey shows that the Puritans used racialized categories and expressed racist views much earlier than that—indeed, soon after they rowed ashore.
His book explores what he refers to as "the intersections between the religious frontier that was colonial New England and the racial frontiers pioneered by white colonists as they ordered colonial society," paying most of its attention "to the ways New England puritans socially, culturally, intellectually, legally, and theologically ordered and attempted to control their experiences with New Englanders of color" (pp. 6-7). Bailey's thesis is rather vague and usually difficult to follow, perhaps because he is eager to foreground its poignant paradox: "race was created, at least in part, out of the spiritual freedoms offered by New England Puritanism" (p. 7); or, in other words, colonial Americans "constructed race from the spiritual freedoms found in the redemption being offered by puritans of all persuasions, tying race and redemption" close together (p. 14). But the real strength of the book is not its thesis anyway, but the evidence it offers of the racialized perceptions of New Englanders like Edwards.
Those who think that I was wrong, or simply too harsh, for criticizing Edwards as "something of a racist" (Jonathan Edwards and the Ministry of the Word, p. 180) really need to read this book. I recommend it most highly to anyone interested in Edwards, Edwards' world, and its socio-cultural legacies.
–By Douglas Sweeney, Director of the JEC at TEDS


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The 19th Indiana were part of what the confederates called "That d*mned Black Hat brigade!" before everyone began calling them the "Iron Brigade" because of their Iron resolve not to back down from the enemy even when under intense fire or pressure. This resolve almost lead to their utter destruction at Gettysburg where it suffered 1200 killed & wounded out of 1900 engaged with some regiments hitting 75% and 80% casualties. Although the brigade was arguably the Unions finest brigade that was ever in the field and sustained more causalities then any other in the course of the war to back that up one must say after Gettysburg the brigade was never quite the same again, however even after that it did still remain an elite formation until the end of the war.
The 19th like the rest of the brigade was composed of western state soldiers that instead of fighting in the west fought in the east wearing the distinctive Hardee hat, frock coats and white gaiters that made them stand out in the army of the Potomac where sack coats and kepi's were the norm.
The 19th Indiana was mustered into service on July 29th, 1861 at Camp Morton in Indianapolis Indiana. The regiment served in numerous campaigns and battles including Brawner Farm, 2nd Bull Run, South Mountain, Antietam(suffered heavily here), Fredericksburg, Fitzhugh's Crossing, Gettysburg, Wilderness, Laurel Hill, North Anna, Cold Harbor, Petersburg and it's sieges, Weldon Road and Yellow House. Not including those lost from sickness and disease the regiment lost 5 officers and 194 enlisted men killed/wounded from battle before being mustered out on July 28th, 1864 with those remaining joining the 20th Indiana.
A monument to the regiment can be seen here:
More info. on the 19th Indiana:
Home page of the Iron Brigade:
The Iron Brigade as a whole consisted of the 2nd Wisconsin, 6th Wisconsin, 7th, Wisconsin, 19th Indiana and the 24th Michigan. I probably will do another regiment from them with my eye on the Sash and Saber version in the future.
The miniatures are from Redoubt which I believe make the best ACW miniatures on the market followed by Sash and Saber and Perry. While the Perry's probably make the most proportionally correct ACW mini's they are not very painter friendly and sometimes can be a bit static and this is where Redoubt really excels in that their miniatures are not only painter friendly but really pack tons of character as do Sash and Saber which I happen to really like!
I tried a few new things out with these. The first being the coat which I used Foundry Union Blue A, B but then used Deep Blue C for a final highlight as I felt Union Blue C was too dark. I saw Giles do something similar with his French and liked it. The other thing is a tried a new base color as the reddish brown wasn't working for me any more.This new base is more of a grey earth tone and I quite like it. I'm going to also try out a real earthy brown on another regiment and see how it works.
I was just able to finish this unit tonight in time to have my desk cleared off for tomorrow which kicks off Curt's painting competition where I already have a unit primed and ready to go!
As always thanks for viewing!
Miniature Company- Redoubt


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Kai Budde defeated Dan Clegg in a final pairing that spanned five formats and an exhausting seven and a half hours. Tied 2-2 in the formats, the final match was to be decided by the competitors playing their 5-Color decks. Budde won in a close and very exciting final game that lasted only two turns. Clegg had a hand capable of winning via Hatred on turn 3, but Budde was able to cast Tinker to find Jeweled Bird, reducing the value of his ante enough to where Clegg could no longer win the match. Budde now added an Invitational win to his amazing resume, and still remains the most successful player in the game's recent history.
Grand Prix Cape Town Coverage


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Giardia lamblia (or Giardia intestinalis), the parasite that causes
giardiasis, is found in all parts of the world. But
your chances of becoming infected are highest in areas in which water treatment
facilities are limited or general sanitation is poor. When traveling in these
places or whenever you're uncertain about water quality, take these
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In September 2013, AWI received notification from USDA that it intends to act on AWI's petition and amend the regulations governing the export of animals to foreign countries. A proposed rule will be published for public comment, probably in 2014. AWI will continue to press USDA to strengthen the regulations to protect the welfare of animals transported to international markets.
Dear Humanitarian,
Two years ago, large numbers of animals—many of them pregnant dairy cattle—began leaving the United States to establish breeding herds in Turkey, Russia and Kazakhstan. Last year alone, about 100,000 cattle were shipped from the eastern U.S. coast on sea voyages lasting more than two weeks.
When these massive shipments began, AWI warned the U.S. Department of Agriculture (USDA) that the risk of injury and death during long-distance journeys was high. AWI requested that the agency, at a minimum, establish animal "fitness to travel" requirements. Unfortunately, USDA failed to act on AWI's petition.
AWI recently received word that 400 cattle, among a shipment of 3,900 animals, have died en route to Russia. The deaths have been attributed to a breakdown in manure removal and ventilation systems, causing the animals to suffocate on ammonia fumes.
Tell USDA that you expect it to ensure the well-being of animals being exported from the United States, and that if the agency is not capable of doing so, that exports involving long-distance transport should not be approved.
Please share this Dear Humanitarian eAlert with friends, family and coworkers, and ask them to do the same. As always, thank you for your continued and critical support on this important issue.
Dena Jones
Farm Animal Program Manager
P.S. Follow us on Facebook and Twitter for updates on the action above and other important animal protection news.


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(Phoenix, Ariz. -- Aug. 26, 2010) Attorney General Terry Goddard today announced that Edward L. Carpenter, 52, of Phoenix, a minister and former mortgage broker, has been found guilty by a Maricopa County Superior Court jury of 10 charges related to his operation of a fraudulent mortgage "rescue" business.
Carpenter was convicted on five counts of fraudulent schemes and artifices, all Class 2 Felonies, and five counts of fraudulent schemes and practices, all Class 5 Felonies.
The defendant contacted local homeowners, falsely stating he ran a "mortgage elimination" business that could legally remove the homeowners' names from their mortgages, giving them ownership of the properties free and clear. He charged up-front fees of $1,000 or more.
Utilizing his knowledge of the mortgage system and his religious influence, Carpenter used the homeowners to file fraudulent foreclosure paperwork with the Maricopa County Recorder's Office. These filings were designed to cloud the title, confuse title companies, and cause mortgage companies to fund loans, portions of which were obtained by Carpenter. He received more than $257,398 in illegal proceeds from this scheme.
"This case is particularly outrageous example of mortgage modification schemes," Goddard said. "Representing himself as a minister to gain the trust of homeowners, this fraud artist said he could have their mortgages forgiven and enable them now to own their properties free and clear. He then filed fraudulent paperwork that victimized mortgage companies, title companies and the consumers. I encourage all homeowners contacted by mortgage "rescue" operators to check out the claims carefully and not possibly lose the home that they are trying so hard to save."
Assistant Attorney General Yukiko Kuwata prosecuted the case in a six-day trial. The jury returned its verdict on Wednesday. Carpenter has been taken into custody and faces sentencing on October 7 before Judge Janet Barton. For sentencing purposes, the jury also found the State had proven two aggravating factors for each of the 10 counts.
A copy of the indictment and a photo of the defendant are attached. For more information, contact Press Secretary Molly Edwards at (602) 542-8019.


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Walt Weiss says not concerned about Todd Helton's start; Jordan Pacheco at 1B
SAN FRANCISCO — It would be difficult for Todd Helton to get off to a worse start, a slump magnified by his age (39) and his diminished production last season.
Helton is not starting in the series finale Wednesday against the Giants. Manager Walt Weiss said that was the result of a day game after a night game, and his desire to keep Jordan Pacheco, one of the team's better hitters, involved. Helton is hitless in his last 13 at-bats, and is 2-for-20 overall. The Rockies have protected him against left-handers (he's 0-for-1), which is another reason he's not starting against Barry Zito.
"I think it's just one of those times that you go through as a hitter. I don't think it has to do with his skills. We saw him swing the bat all spring and he was as good as he's ever been, so I don't have any doubt that it's still there," Weiss said.
Weiss also gave center fielder Dexter Fowler his first day off this season. He's been the Rockies' best player, leading the team with four home runs. He is 1-for-6 against lefties this year and is .217 hitter against Zito in 23 at-bats.
"Dexter isn't going to play 162 games. Dexter is one of he best in the game in center. But this seemed like a good day (to rest him)," Weiss said.
The Rockies are looking to avoid a sweep at AT&T Park. If that sounds familiar, it's because it is. The Rockies have dropped eight straight at China Basin. And they've lost eight consecutive overall to the Giants. Matt Belisle took the blame for Tuesday's loss, "saying this one is on me." But there was plenty of blame to assign given Juan Nicasio's five walks, including two to open the sixth when he lost the grip on his fastball, Adam Ottavino's meaty fastball to Brandon Crawford on a 2-0 count and the Rockies' meager four hits.
Weiss was clear on his goal Wednesday.
"I don't think there are moral victories. Playing well isn't enough. We need a W," Weiss said.
It won't be easy. The Giants have won the last 15 times Zito has started. The left-hander is 10-0 with a 3.18 ERA during this stretch, which includes the playoffs. The last time the Giants won 16 games started by the same pitcher was with Carl Hubbell from July 17-Sept. 30, 1936.
CF Young
2B Rutledge
LF Gonzalez
SS Tulowitzki
RF Cuddyer
C Rosario
1B Pacheco
3B Nelson
LHP Francis
CF Pagan
2B Scutaro
C Posey
RF Pence
3B Arias
1B Belt
LF Torres
SS Crawford
LHP Zito


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One of the British victims killed when Malaysia Airlines flight MH17 was shot down over Ukraine has been formally identified as former BBC journalist Glenn Thomas.
The 49-year-old, from Blackpool, was among the 298 passengers and crew aboard the doomed flight , which was downed by suspected pro-Russian separatists last month.
A Foreign Office spokesman today said: "We can confirm the formal identification of another British victim of Flight MH17 Glenn Thomas.
"His family have been informed. Our thoughts are with them at this difficult time. We continue to provide consular assistance to the family."
Mr Thomas' family are making plans for his body to be returned to his home town of Blackpool, according to reports on the BBC.
Mr Thomas worked as a media officer for the World Health Organisation (WHO) and was travelling to Australia for a conference on Aids when the plane crashed.
He was one of 10 Britons killed in the tragedy, and leaves behind his partner Claudio and sister Tracey.
At the time of his death WHO spokeswoman Fadela Chaib said: "We have lost a wonderful person and a great professional. Our hearts are broken. We are all in shock."
Tensions between the West and Russia have flared following the downing of the Boeing 777, which was flying from Amsterdam to Kuala Lumpur when it crashed on July 17.
Fighting has engulfed Ukraine's separatist east and its government has repeatedly accused Russia of stirring up trouble within its borders.
In the latest development, Ukraine security services has released a video of 10 Russian paratroopers it claimed were captured while fighting alongside pro-Moscow rebels in the east of the country.
However, Russia has always denied supporting and arming rebels in the region.


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Systems Research Lab
The Systems Research Lab (SRL) is part of the Jack Baskin School of Engineering at the University of California, Santa Cruz. The SRL is interested in a broad range of topics including real-time systems, performance management, and large-scale storage systems. We are particularly interested in the intersection of these topics, and in their application to problems requiring inter-disciplinary collaboration. The SRL is composed of a broad range of students and collaborators from industry, government research labs, and other universities.


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- Living Room
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Cloe Italian Room Divider Composition 230 by Tonin Casa
Made in Italy
The Cloe by Tonin Casa is a wooden traditionally styled room divider available in either lacquered or stained wood. Cloe line compositions feature an abundance of shelf inserts to provide you with an ergonomic system of storage. All the units of this line are fully finished making the units look the same from both sides. Cloe is a modular line that can be built according to your wish. Cloe offers lots of options on hight and width of this room divider, so it could fit any size of room with grace and elegance. The Cloe line consists of the next units: side panel, shelf panel and one- or two-side drawers that provide the hidden storage space. The process of customization of Cloe room divider is quite simple, just choose the quantaty and height of the side panels, then add the necessary amount of shelf panels for connecting the side panels together and having enough storage space and add some drawers if you want. The base panel is added automatically and is included in the price. The drawers are available with glass doors with lace serighraphy or wooden doors covered in vintage leather and depends on the version, can be open from just one or both sides of the room divider.
The starting price is for the Cloe Room Divider Composition 230 in L0110 White Lacquered finish with drawers in G11 Natural Walnut. The composition 230 includes: six side panels H74.8", thirty shelf panels and five two-side drawers with doors in glass with lace serigraphy.
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