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The majority of the sentiments regarding the news of Robin Williams' passing have been positive. We all remember laughing at the Genie in Aladdin…and seeing the extreme love of a father in Mrs. Doubtfire. And being moved to tears while being taught by Dr. Keating. It's important in the aftermath of any death, whether a celebrity or a relative, to remember the good times. Many of the comments have been more serious…encouraging others to seek help if they're hurting and lamenting the devastating toll that mental illness takes. However, some of the more callous comments have indicated that suicide is an act of a selfish coward who takes the easy way out. Or that he should have just "manned up" since this was somehow his choice.
Looking back through my childhood, adolescence, and college years, I can see signs of something dark blooming in me. Despite what most people know about me, my very early childhood was unstable, violent, and frightening. How my mom survived the things we suffered early in my life is beyond me. I felt by adolescence that I had made peace with it…and to some extent, I was right. But loneliness and the effects of trauma manifest themselves in strange ways. I remember taking a trip in middle school to go snow skiing. It was my first big trip away from home. I got so homesick after the first day that I just wanted to hole up in my room and cry. From the age of around 7 through leaving home, life was fairly stable and there were no major traumatic events that stick out. But I still felt the darkness manifest itself in small things like being nostalgic or homesick.
In college, it manifested itself in stress. I worked mostly full-time to pay the bills and took a somewhat full load of classes (some semesters anyway). But if a class was especially hard or if a job had crazy demands, I would quit the job or drop the class and I was able to escape. Then came adulthood. My son was born right as I was finishing at UGA and shortly thereafter, I got my first real job in Atlanta. I had a new family, a good job, and plenty of things to be happy about. And mostly, I was happy. But some days, sitting at my desk, the stress overwhelmed me. And driving home from work in heavy traffic, I felt nostalgic and longed for the simpler days of childhood…when I didn't have to spend 3 hours in traffic or get yelled at by my boss for things I couldn't control. I wanted nothing more than to just disappear and be back at my grandparents' house during the summer without a care in the world. Then it progressively got worse. As the months passed by, I found myself sneaking away to the bathroom stall to cry for no apparent reason. I couldn't get anything done at work or home because my own overwhelming sense of ill-health impaired me from doing anything about it. Normally, at this point, I would just quit my job, give up some responsibilities, and move on to something less stressful. But here I was with a family to provide for and a very real, very heavy burden to provide for them and be a good husband/ dad. My coping mechanisms were overloaded. I was surrounded by people, but I felt so alone.
After about a year, I saw my doctor and I was prescribed an antidepressant. At the time, this made a world of difference. The depression and anxiety were mostly under control and I felt like I was able to not only survive, but thrive. For 3 or 4 years, I felt great and optimistic about the future. Then in the span of a few years, we lost everything we owned in a house fire and I went through a heart-wrenching divorce. Suddenly, the darkness was more overwhelming than I had ever experienced. Once again, I felt useless and ill-equipped to fight against it.
I feel fortunate that I have never struggled with addictions or thoughts of suicide (I'm also fortunate that my dark passenger is not the same as Dexter's). Some of my closest friends fight these demons every day and I'm amazed at their courage. I am a father, son, brother, boyfriend, colleague, and friend. I've been successful in my career and I feel like I'm a pretty good dad. However, I constantly struggle with guilt. I feel like I could be more if I didn't feel sick every day. Most of the people around me don't know that it takes a fiery pep talk inside my head for me to get out of bed every morning. And I have to repeat this to myself several times a day to keep going. I strain myself to the point of exhaustion just to muster the willpower to perform daily tasks. There are days when getting a shower, brushing my teeth, cooking supper, and washing the dishes feels like running a marathon. I get anxious about the most inconsequential details. The anxiety leads to depressed behavior. Which leads to more anxiety and it creates a vicious loop. It's also difficult to enjoy things I used to love. I rarely experience joy or pleasure from doing things that would typically lift my spirits. It's an overwhelming numbness that just wears you out. Even on the good days, I feel like my dark passenger is still waiting around the corner, ready to pounce.
9 years ago, my medical diagnosis was Major Depressive Disorder with Agorophobic Panic. The first 5 years of treatment were fairly successful, but the last 4 have been a mixed bag. I never stopped taking medication, attending therapy, or trying to get better. But all my efforts haven't been able to quite get me back and sustain my health at baseline. Ironically, many of the things I need to do to feel better are things my dark passenger works hard to discourage me from doing. Don't get me wrong—there have been a lot of very good days. But I haven't felt well for an extended time in years. Every day is a battle. A fight against the darkness that distorts my view of every other facet of my life.
I'm speaking out now because I've read and heard so many misguided viewpoints about mental illness recently. There is an unfortunate social stigma that exists with admitting it or seeking help. It makes people uncomfortable, causes them to question faith, and some people that I highly respect otherwise give their non-medical opinion that I don't need medication. Enough is enough. If you haven't lived with the darkness or have a half-informed opinion, please keep it to yourself. It's a matter of life and death for some people that you do. Your snarky comments and judgement help maintain the stigma associated with the treatment of a very real disease. It may cause someone to avoid treatment and internalize their pain until it becomes too much to bear. You would never ridicule someone for accepting medical treatment of kidney problems or a broken bone, so why should a mental medical condition be any different?
I often wonder why I feel depressed. I have a great career, 2 amazing kids, a caring family, great friends, and I'm in a relationship with the most wonderful person I've ever met. But what I think I'm learning is that depression isn't a reaction to circumstances, necessarily. It's like the weather. I have listed a few traumatic events that served as triggers for major depressive episodes for me, but sometimes I'm depressed for no reason at all. It just comes and goes. That's not to say that I can't fight it or learn to cope with the symptoms. But many days, I feel like the fight is just wearing me out. So to say that Robin Williams was a selfish coward is ignoring the mountain of courage that he had to muster every day to fight his demons. From what I've heard, he won the battle most days. For 30 years he fought. But it only took 1 lost battle for his demons to destroy him. RIP, Robin Williams.
If you are hurting, don't be ashamed to seek help. 1 in 4 Americans are affected by mental illness. There are a lot of us out there. Despite the social stigma, you are not alone and there are resources that will help you get better. Call your doctor if you can. If you can't afford a doctor, go to www.nami.org and find the resources to get help. The National Suicide Hotline is 800-273-8255. If you're stuck or frustrated, message me and I'll help you find help. If you're not hurting, keep an eye on those around you. Even if things seem alright, get to know them deeply. Learn their struggles. Be there for them to come through the other side. Also be aware that typically, in the wake of a celebrity suicide, some people are at a higher risk for copycat suicide. This risk is especially high for young people. It is difficult and not rewarding at all to be a friend to a depressed person, but it is unbelievably kind and noble.


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Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States
The information in the brief version is excerpted directly from the full-text guidelines. The brief version is a compilation of the tables and boxed recommendations.
Management of Infants Born to Women with HIV Infection
Antiretroviral Management of Newborns with Perinatal HIV Exposure or Perinatal HIV
Last Updated: December 7, 2018; Last Reviewed: December 7, 2018
|Panel's Recommendations
|Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion
General Considerations for Antiretroviral Management of Newborns Exposed to HIV or Born with HIV
All newborns with perinatal exposure to HIV should receive antiretroviral (ARV) drugs in the neonatal period to reduce perinatal transmission of HIV, with selection of the appropriate ARV regimen guided by the level of transmission risk. The most important factors that influence the risk of HIV transmission to a newborn exposed to HIV are whether the mother has received antepartum/intrapartum antiretroviral therapy (ART) and her viral load. The risk of transmission is increased in the absence of maternal ART or if maternal antepartum/intrapartum treatment was started after early pregnancy or was ineffective in producing virologic suppression; higher maternal viral load, especially in later pregnancy, correlates with higher risk of transmission. There is a spectrum of transmission risk that depends on these and other maternal and infant factors, including mode of delivery, gestational age at delivery, and maternal health status. HIV transmission can occur in utero, intrapartum, or during breastfeeding.
Historically, the use of ARV drugs in the newborn period was referred to as ARV prophylaxis since it primarily focused on protection against newborn perinatal acquisition of HIV. More recently, clinicians have begun to identify newborns at highest risk for HIV acquisition and initiate three-drug ARV regimens as empiric treatment of HIV. In this guideline, the following terms will be used:
- ARV Prophylaxis: The administration of ARV drugs to a newborn without documented HIV infection to reduce the risk of HIV acquisition. ARV prophylaxis includes administration of a single agent, usually zidovudine, as well as combinations of two or three ARV drugs.
- Empiric HIV Therapy: The administration of a three-drug ARV regimen to newborns at highest risk of HIV acquisition. Empiric HIV therapy is intended to be early treatment for a newborn who is later documented to have acquired HIV, but also serves as ARV prophylaxis against HIV acquisition for those newborns who are exposed to HIV in utero, during the birthing process, or during breastfeeding and who do not acquire HIV.
- HIV Therapy: The administration of a three-drug ARV treatment regimen to newborns with documented HIV (see Diagnosis of HIV Infection). HIV therapy is lifelong.
The terms ARV prophylaxis and empiric HIV therapy describe the clinician's intent in prescribing ARV drugs and may be overlapping. For example, an empiric HIV therapy regimen also provides ARV prophylaxis for a newborn. However, two-drug (and some three-drug) ARV prophylaxis regimens, notably those that use prophylactic rather than therapeutic dosages of nevirapine, are not considered empiric HIV therapy.
The interval during which newborn ARV prophylaxis or empiric HIV therapy can be initiated and still be beneficial is undefined; however, most studies support providing ARVs as early as possible after delivery.1-6
Table 8 provides an overview of neonatal ARV management recommendations according to risk of perinatal transmission of HIV to the newborn and Table 9 summarizes the dosing recommendations for ARV dosing in newborns. Additional information about dose selection for newborns, including premature infants (<37 weeks gestational age), can be found in Pediatric Antiretroviral Drug Information. In addition, the National Perinatal HIV Hotline (888-448-8765) is a federally funded service providing free clinical consultation for difficult cases to providers caring for pregnant women living with HIV and their newborns, and can provide referral to local or regional pediatric HIV specialists.
Table 8. Newborn Antiretroviral Management According to Risk of HIV Infection in the Newborn
Drug selection and dosing considerations are related to the age and gestational age of the newborn. Consultation is available through the National Perinatal HIV Hotline (888-448-8765).
|Neonatal ARV Management
|Low Risk of Perinatal HIV Transmission
|ZDV for 4 weeks
|Higher Risk of Perinatal HIV Transmissiona,b
|2-drug ARV prophylaxis (NICHD-HPTN 040/PACTG 1043 regimen) with 6 weeks ZDV and 3 doses of NVP (prophylactic dosage, with doses given within 48 hours of birth, 48 hours after first dose, and 96 hours after second dose)
Empiric HIV therapy using either ZDV, 3TC, and NVP (treatment dosage) or ZDV, 3TC, and RAL administered from birth to age 6 weeks.d
|Presumed Newborn HIV Exposure
|ARV management as above (for higher risk of perinatal HIV transmission).
Infant ARVs should be discontinued immediately if supplemental testing confirms that the mother does not have HIV.
|Newborn with HIVe
|3-drug ARV regimen using treatment dosages
|a See text for evidence supporting a 2-drug ARV prophylaxis regimen and empiric HIV therapy.
b See the Intrapartum Care section for guidance on indications for scheduled cesarean delivery and intrapartum IV ZDV to reduce the risk of perinatal HIV transmission for mothers with an elevated viral load at delivery.
c Most Panel members would opt to administer empiric HIV therapy to infants whose mothers had acute HIV during pregnancy because of the higher risk for in utero transmission. If acute HIV is diagnosed during breastfeeding, mother should stop breastfeeding.
d The optimal duration of empiric HIV therapy in newborns at higher risk of perinatal HIV transmission is unknown. Some Panel members opt to discontinue NVP, RAL, and/or 3TC when a birth NAT returns negative, while others would continue empiric HIV therapy for infants at highest risk of HIV acquisition for 6 weeks. In all cases, ZDV should be continued for 6 weeks. It is recommended that providers consult with an expert in pediatric HIV infection to determine therapy duration based on case-specific risk factors and interim HIV NAT results.
e Most Panel members do not recommend delaying the initiation of ART pending results of the confirmatory HIV NAT, given low likelihood of a false-positive HIV NAT.
Note: ARV drugs should be initiated as close to the time of birth as possible, preferably within 6 to 12 hours of delivery. See Table 9 for dosing specifics.
Key to Acronyms: 3TC = lamivudine; ART = antiretroviral therapy; ARV =antiretroviral; IV = intravenous; NAT = nucleic acid test; NVP = nevirapine; the Panel = Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission; RAL = raltegravir; ZDV = zidovudine
|Newborns at Low Risk of Perinatal HIV Transmission
|Recommended Regimen
|Recommended Duration
|Newborns at Higher Risk of Perinatal HIV Transmission
|Recommended Regimen
|Recommended Duration
|Newborns with HIV Infection
|Recommended Regimen
|Recommended Duration
|Low Risk Prophylaxis
|Higher Risk Prophylaxis: 2-Drug
|Higher Risk Prophylaxis:
Empiric and HIV Therapy
Note: For newborns unable to tolerate oral agents, the IV dose is 75% of the oral dose while maintaining the same dosing interval.
|≥35 Weeks Gestation at Birth:
|≥35 Weeks Gestation at Birth
Birth–4 Weeks:
|≥30 to <35 Weeks Gestation at Birth
Birth to Age 2 Weeks:
|≥30 to <35 Weeks Gestation at Birth
Birth to Age 2 Weeks:
|<30 Weeks Gestation at Birth
Birth to Age 4–6 Weeks:
|<30 Weeks Gestation at Birth
Birth to Age 4 Weeks:
|≥32 Weeks Gestation at Birth
Birth to Age 4 Weeks:
|≥32 Weeks Gestation at Birth:
|≥37 Weeks Gestation at Birth
Birth to Age 4 Weeks:
Birth to Age 1 Week:
Note: If the mother has taken RAL 2–24 hours prior to delivery, the neonate's first dose of RAL should be delayed until 24–48 hours after birth; additional ARVs should be started as soon as possible.
|≥37 Weeks Gestation at Birth and Weighing ≥2 kgc
Birth to Age 6 Weeks:
|a The optimal duration of empiric HIV therapy in newborns at higher risk of perinatal HIV transmission is unknown. Some Panel members opt to discontinue NVP, RAL, and/or 3TC when birth NAT returns negative, while others would continue empiric HIV therapy for infants at the highest risk of HIV acquisition for 6 weeks. In all cases in which the newborn is at higher risk of HIV acquisition, ZDV should be continued for 6 weeks. Consultation with an expert in pediatric HIV to select a therapy duration based on case-specific risk factors and interim HIV NAT results is recommended.
b Investigational NVP treatment dose recommended by the Panel; FDA has not approved a dose of NVP for infants <1 month of age.
c RAL dosing is increased at 1 and 4 weeks of age because metabolism by UGT1A1 is low at birth and increases rapidly during the next 4 to 6 weeks of life. No dosing information is available for preterm or low birthweight infants.
Key to Acronyms: 3TC = lamivudine; ARV =antiretroviral; BSA = body surface area; FDA = Food and Drug Administration; IV = intravenous; N/A = no recommendation; NAT = nucleic acid test; NVP = nevirapine; the Panel = the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission; RAL = raltegravir; UGT1A1 = uridine diphosphate glucotransferase; ZDV = zidovudine
Recommendations for Antiretrovirals in Specific Clinical Situations
In the following sections and Table 8, the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission (the Panel) presents available data and recommendations for management of newborns with documented HIV and newborns born to mothers who:
- Received antepartum/intrapartum ARV drugs with effective viral suppression
- Are at higher risk of transmitting HIV to their newborns, including mothers who:
- Received neither antepartum nor intrapartum ARV drugs
- Received only intrapartum ARV drugs, or
- Received antepartum and intrapartum ARV drugs but who had detectable viral load near delivery, particularly if delivery was vaginal
- Have acute or primary HIV infection during pregnancy or breastfeeding
- Have unknown HIV status
- Have known ARV drug-resistant virus
Newborns Born to Mothers Who Received Antepartum/Intrapartum Antiretroviral Drugs with Effective Viral Suppression
The risk of HIV acquisition in newborns born to women who received ART regimens during pregnancy and labor and had undetectable viral loads at delivery is <1%. In the PACTG 076 study, zidovudine alone was shown to effectively reduce perinatal HIV transmission and is recommended as prophylaxis for neonates whose mothers received ART that resulted in consistent virologic suppression during pregnancy. The optimal minimum duration of neonatal zidovudine prophylaxis has not been established in clinical trials. A 6-week newborn zidovudine regimen was studied in PACTG 076. However, in the United Kingdom and many other European countries, where a 4-week neonatal zidovudine prophylaxis regimen has been recommended for newborns born to mothers who have received ART regimens during pregnancy and have viral suppression, there has been no apparent increase in the overall HIV perinatal transmission rate.7,8 Compared with the 6-week zidovudine regimen, a 4-week zidovudine regimen has been reported to allow earlier recovery from anemia in otherwise healthy newborns.9
Therefore, the Panel now recommends a 4-week neonatal zidovudine prophylaxis regimen for newborns if the mother has received ART during pregnancy with viral suppression (usually defined as confirmed HIV RNA level below the lower limits of detection of an ultrasensitive assay) at or after 36 weeks gestation, and there are no concerns related to maternal adherence. Dosing recommendations for zidovudine are available for premature newborns and an intravenous preparation is available. Table 9 shows recommended neonatal zidovudine dosing based on gestational age and birthweight.
Newborns Born to Mothers Who Have Received No Antepartum or Intrapartum Antiretroviral Drugs, Who Have Received Intrapartum Antiretroviral Drugs Only, Who Have Received Antiretroviral Drugs and Do Not Have Viral Suppression Near Delivery, or Who Have Acquired HIV During Pregnancy or Breastfeeding
All newborns born to mothers with detectable viral load at the time of delivery, who received only intrapartum ARV drugs, or who have received no ARV drugs during pregnancy or delivery, are at higher risk of HIV acquisition and should receive a multi-drug ARV prophylaxis regimen or empiric HIV therapy.5,10-14 The experience with these regimens is described below. Currently, the optimal duration of an empiric HIV therapy regimen in newborns at higher risk of perinatal HIV transmission is unknown. When birth HIV nucleic acid test (NAT) returns negative, some Panel members would opt to discontinue nevirapine, raltegravir, and/or lamivudine, while others would continue empiric HIV therapy for 6 weeks. In all cases in which the newborn is at higher risk of HIV acquisition, zidovudine should be continued for 6 weeks. Consultation with an expert in pediatric HIV is recommended to select a duration of therapy based on case-specific risk factors and interim HIV NAT results.
For those women who received ARV drugs during pregnancy but have a detectable viral load near delivery (on or after 36 weeks gestation), the level of maternal viremia that would trigger the use of a multi-drug ARV prophylaxis regimen or empiric HIV therapy is not definitively known. In two large observational studies of women on combination antenatal ARV drugs, perinatal transmission rates were 0.05% and 0.3% when the mother had viral load measurements <50 copies/mL at delivery. Rates of transmission in these studies increased to 1.1% and 1.5% when viral load measurements were 50 to 399 copies/mL and 2.8% and 4.1% when viral load measurements were >400 copies/mL.15,16 However, there has been no study to compare the relative efficacy of a multi-drug ARV prophylaxis regimen or empiric HIV therapy to standard newborn prophylaxis at these different thresholds of maternal viremia. While some Panel members would recommend a multi-drug ARV prophylaxis regimen or empiric HIV therapy with any level of detectable viremia, others reserve multi-drug ARV prophylaxis regimens and empiric HIV therapy until higher levels of maternal viral load are documented. The decision whether to initiate a multi-drug ARV prophylaxis regimen or empiric HIV therapy should be made following discussion with the parents weighing the risks and benefits of the proposed regimen.
Primary or acute HIV infection during pregnancy is associated with an increased risk of perinatal transmission of HIV. A multi-drug ARV prophylaxis regimen or empiric HIV therapy should be administered to the infant until maternal HIV can be confirmed or ruled out. (see Acute HIV Infection).
In summary, in these scenarios where the infant is at higher risk of HIV transmission, the Panel recommends either a multi-drug ARV prophylaxis regimen, specifically the NICHD-HPTN 040/PACTG 1043 regimen, or empiric HIV therapy. The data supporting the use these regimens are summarized below. Choosing between these regimens will depend on clinician assessment of the likelihood of HIV transmission.
Multi-Drug Antiretroviral Prophylaxis
There is a paucity of data from randomized clinical trials to guide the optimal selection of a newborn multi-ARV prophylaxis regimen. To date, the NICHD-HPTN 040/PACTG 1043 trial is the only randomized clinical trial of multi-ARV prophylaxis in newborns at higher risk of HIV acquisition. In this study, 1,746 formula-fed infants born to women with HIV who did not receive any ARV drugs during pregnancy were randomized to 1 of 3 newborn prophylaxis regimens: the standard 6-week zidovudine regimen; 6 weeks of zidovudine plus three doses of nevirapine given during the first week of life (first dose at birth–48 hours, second dose 48 hours after the first dose, and third dose 96 hours after the second dose); and 6 weeks of zidovudine plus 2 weeks of lamivudine/nelfinavir. Forty-one percent of the mothers received zidovudine during labor. The risk of intrapartum transmission was significantly lower in the 2- and 3-drug arms (2.2% and 2.5%, respectively, vs. 4.9% for 6 weeks of zidovudine alone; P = 0.046 for each experimental arm vs. zidovudine alone).5 The NICHD-HPTN 040/PACTG 1043 regimen was associated with nucleoside reverse transcriptase inhibitor (NRTI) resistance in 3 of 53 (5.7%) participants with in utero infection who were treated with zidovudine alone, and in 6 of 33 (18.2%) participants treated with zidovudine plus nevirapine (P > 0.05). In addition, the third drug in the three-arm regimen was nelfinavir, which has highly variable pharmacokinetics (PKs) in this age group and did not reach the nelfinavir target plasma concentration in 46% of study participants.17 Although transmission rates with the two regimens were similar, neutropenia was significantly more common with the three-drug regimen than with the two-drug or zidovudine-alone regimen (27.5% vs. 15%, P < 0.0001).
Data from Europe and the United States indicate increasing use of multi-drug ARV prophylaxis regimens in newborns exposed to HIV. In the United Kingdom and Ireland, use of the regimens increased from 9% of newborns exposed to HIV between 2001 to 2004 to 13% between 2005 to 2008 and, in a poll of 134 U.S.-based providers, 62% reported using multi-ARV prophylaxis regimens in high-risk newborns.18-20 However, interpretation of these observational studies is complicated by the definition of ARV prophylaxis, use of prophylaxis versus treatment dosing of nevirapine, and combining multiple different ARV prophylaxis regimens to compare safety and efficacy with zidovudine monotherapy. Many studies include single-dose nevirapine combined with another ARV, usually zidovudine, as two-drug HIV prophylaxis. Most do not report whether nevirapine was administered at the recommended prophylaxis dose or at a higher dose as part of empiric HIV therapy. So, despite increasing use of various ARV prophylaxis regimens, comprehensive data on efficacy and safety are lacking. For newborns at higher risk of HIV acquisition (Table 8), the Panel recommends the NICHD-HPTN 040/PACTG 1043 2-drug regimen of 6 weeks of zidovudine plus 3 doses of nevirapine as an option for management.
Empiric HIV Therapy
The other option that the Panel recommends for newborns at higher risk of perinatal acquisition of HIV is a three-drug ARV empiric HIV therapy regimen consisting of zidovudine, lamivudine, and either nevirapine (at treatment dosage) or raltegravir.
Enthusiasm for the three drug approach followed a case of a "functional cure" of HIV in an newborn reported in 2013.21 The newborn was born by vaginal delivery at 35 weeks' gestation to a woman who received no prenatal care and whose HIV infection was diagnosed by expedited testing during labor; delivery occurred before maternal intrapartum ARV drugs could be given. When the newborn was 30 hours old, a regimen of zidovudine, lamivudine, and nevirapine (the latter drug administered at a higher treatment dose rather than standard prophylactic dosing) was initiated. The newborn was found to have a positive HIV DNA polymerase chain reaction (PCR) in a sample obtained at age 30 hours and an HIV RNA level of 19,812 copies/mL on an HIV RNA PCR assay performed at age 31 hours. Based on these test results, the newborn was continued on treatment for HIV, thought to be acquired in utero. At age 18 months, the mother discontinued the child's ART; levels of plasma RNA, proviral DNA, and HIV antibodies remained undetectable in the child for >2 years without ART. Unfortunately, virologic rebound was identified shortly before the child turned 4 years of age. Of interest is the subsequently reported case of an infant treated from birth and virologically suppressed for 4 years who had virologic rebound within days of ART discontinuation.22
Further support of empiric HIV therapy comes from Canadian investigators who have reported outcomes in 136 newborns considered at higher risk of HIV acquisition (i.e., born to women with HIV who had detectable viral loads and/or poor adherence to therapy prior to delivery) who received a triple-ARV regimen within 72 hours of birth. Of these 136 newborns, 12 (9%) were found to be have acquired HIV and no major regimen-related toxicities were identified.23 However, there was no control group to permit comparison of safety or efficacy of this approach relative to single-drug or two-drug regimens. Another Canadian study compared the safety of empiric HIV therapy in 148 newborns with high-risk exposure (i.e., incomplete maternal virologic suppression at delivery or, in the absence of maternal viral load results, a maternal history of incomplete adherence or non-adherence to ART, or late pregnancy initiation of ART) to zidovudine alone in 145 low-risk newborns in a control group. Thirteen newborns in the empiric HIV therapy group acquired HIV, including five with a positive HIV NAT within the first 48 hours of life, suggesting in utero infection. No newborn in the low-risk zidovudine-only group acquired HIV. Non-specific signs and symptoms (e.g., vomiting, diarrhea, rash, jitteriness, irritability) potentially attributable to medication-related adverse effects were reported among the newborns receiving empiric HIV therapy but not among those receiving zidovudine only (10.2% vs. 0%, P < 0.001). ARV drugs were also more likely to be discontinued prematurely in the newborns receiving empiric HIV therapy than in those receiving only zidovudine (9.5% vs. 2.1%, P = 0.01).24
Empiric HIV therapy in newborns is consistent with the Centers for Disease Control and Prevention's recommendations for occupational and non-occupational HIV post-exposure prophylaxis in adults, circumstances in which the risk of infection is often lower than for newborns at higher risk of HIV acquisition.25,26 The use of empiric HIV therapy in newborns was limited until the availability of new PK and safety information about ARVs in the neonatal period. Although the use of nevirapine to prevent perinatal transmission has been found to be safe in neonates and low-birthweight newborns, these prophylaxis-dose regimens target trough drug levels are ≥10-fold lower than targeted therapeutic levels. However recent studies of therapeutic dosages of nevirapine and raltegravir have established safe doses that achieve targeted PK parameters.27-31
At this time, if an empiric HIV therapy regimen is selected, the Panel recommends a combination of zidovudine, lamivudine, and nevirapine (treatment dosage) or zidovudine, lamivudine, and raltegravir (see Tables 8 and 9). The optimal duration of empiric HIV therapy in newborns at higher risk of perinatal HIV transmission is unknown. Some Panel members opt to discontinue additional medications if returned birth NAT results are negative, while others would continue empiric HIV therapy for 6 weeks depending on risk for HIV transmission. In all cases, zidovudine should be continued for 6 weeks. Consultation with an expert in pediatric HIV to select a therapy duration based on case-specific risk factors and interim HIV NAT results is recommended.
Newborns Born to Mothers with Unknown HIV Status at Presentation in Labor
Expedited HIV testing is recommended during labor for women with unknown HIV status and, if not performed during labor, as soon as possible after birth for the mothers and/or their newborns (see Identification of Perinatal Exposure). Expedited test results should be available within 60 minutes. If maternal or infant expedited testing is positive, the newborn should be immediately initiated on a multi-drug ARV prophylaxis regimen or empiric HIV therapy, without waiting for the results of supplemental tests. Expedited HIV testing should be available on a 24-hour basis at all facilities with a maternity service and/or neonatal intensive care unit or special care or newborn nursery.
A positive initial test result in mothers or newborns should be presumed to indicate maternal HIV until supplemental testing clarifies maternal and newborn status. If appropriate test results for a mother (or newborn) are negative, newborn ARV drugs can be discontinued. Clinicians should be aware of their state laws, as there is variability in the HIV testing allowed without parental consent.
A nursing mother who is suspected of having HIV based on an initial positive antibody or antibody/antigen test result should stop breastfeeding until HIV is confirmed or ruled out. Pumping and temporarily discarding or freezing breast milk can be recommended. If HIV is ruled out, breastfeeding can resume. If HIV is confirmed, breastfeeding should be discontinued permanently.32
Newborns Born to Mothers with Antiretroviral Drug-Resistant Virus
The optimal ARV regimen for newborns delivered by women with ARV drug-resistant virus is unknown. It is also unknown whether resistant virus in the mother increases the risk of HIV acquisition by the infant. The ARV regimen for newborns born to mothers with known or suspected drug resistance should be determined in consultation with a pediatric HIV specialist before delivery or through consultation via the National Perinatal HIV Hotline (888-448-8765). However, there is no evidence that neonatal prophylaxis regimens customized based on presence of maternal drug resistance are more effective than standard neonatal prophylaxis regimens.
Data from the WITS study suggest that, in women who have mixed zidovudine-resistant and zidovudine-sensitive viral populations, the zidovudine-sensitive virus may be preferentially transmitted.33,34 Thus, the selection of the newborn ARV regimen should be based on other risk factors (Table 8).
Some studies have suggested that ARV drug-resistant virus may have decreased replicative capacity (reduced viral fitness) and transmissibility.34 However, perinatal transmission of multidrug-resistant virus has been reported both in the United States and in international settings.35-39
Newborns with HIV Infection
Until recently, neonatal ARV regimens were designed for prophylaxis against perinatal HIV transmission and to be as simple as possible for practical use. There was little reason to develop ARV regimens for treatment of neonates, as the long turnaround times to receive HIV NAT results meant that neonatal infections were generally not diagnosed in the first weeks of life. HIV NAT results are now available within a few days and HIV in newborns is being diagnosed as early as the first days of life. A positive HIV NAT must be repeated to confirm HIV. However, most Panel members do not recommend delaying the initiation of ART while waiting for the results of the confirmatory HIV NAT, given the low likelihood of a false-positive HIV NAT. However, evidence that very early treatment (before age 2 weeks) will lead to prolonged remission or better outcomes in newborns with HIV is lacking. Earlier diagnosis of HIV in newborns and the increasing use of empiric HIV therapy in newborns at higher risk for HIV acquisition have necessitated investigation of dosing and safety of ARV drugs in term and preterm newborns. Although still incomplete, especially for preterm newborns, PK and safety profiles of ARV drugs are increasingly available. As already noted, the recommended neonatal ARV doses for prophylaxis and for treatment are the same with the important exception of nevirapine (see Pediatric Antiretroviral Drug Information).
Sufficient data exist to provide dosing recommendations appropriate for the treatment of HIV in neonates using the following medications (see Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection):
- From birth in term and preterm newborns: zidovudine, lamivudine, nevirapine
- From birth in term newborns: emtricitabine, raltegravir
- From age 2 weeks in term newborns: lopinavir/ritonavir (LPV/r)
Dosing recommendations for premature newborns are available for zidovudine, lamivudine, and nevirapine only. Neonatal dosing advice, including for premature newborns, is summarized in Table 9. For more detailed information about neonatal dosing recommendations and considerations of these drugs, please see the Pediatric Antiretroviral Drug Information.
Newborns of Mothers Diagnosed with HIV while Breastfeeding
Women with suspected HIV (e.g., a positive initial screening test) should stop breastfeeding until HIV is ruled out. Pumping and temporarily discarding or freezing breast milk can be recommended to mothers who are suspected of having HIV but whose HIV serostatus is not yet confirmed and who want to continue to breastfeed. If HIV is ruled out, breastfeeding can resume. Breastfeeding is not recommended for women with confirmed HIV in the United States, including those receiving ART (see Guidance for Counseling and Managing Women Living with HIV in the United States Who Desire to Breastfeed).40
The risk of HIV acquisition associated with breastfeeding depends on multiple newborn and maternal factors, including maternal viral load and CD4 T lymphocyte (CD4) cell count.41 Newborns of women who develop acute HIV while breastfeeding are at greater risk of acquiring HIV than are those whose mothers have chronic HIV infection42 because acute HIV infection is accompanied by a rapid increase in viral load and a corresponding decrease in CD4 cell count.43
Other than discontinuing breastfeeding, optimal strategies for managing a newborn who was breastfed by a mother with HIV (often because the mother just learned of her own HIV diagnosis) have yet to be defined. Some Panel members would consider the use of post-exposure prophylaxis in newborns for 4 to 6 weeks after cessation of breastfeeding. Post-exposure prophylaxis, however, is less likely to be effective in this circumstance than with other non-occupational exposures because the exposure to breast milk is likely to have occurred during a prolonged period rather than a single exposure to the virus.44
Several studies of newborns breastfed by women with chronic HIV infection in low-resource settings have shown that daily newborn nevirapine, lamivudine, LPV/r, or nevirapine plus zidovudine can reduce the risk of postnatal infection during breastfeeding.45-49 No trials have evaluated the use of multi-ARV regimens to prevent transmission after cessation of breastfeeding in mothers with acute HIV infection.
Given the higher risk of postnatal transmission from a breastfeeding woman with acute HIV infection, an alternative approach favored by some Panel members would be to offer empiric HIV therapy until infant HIV status can be determined. If the infant's initial HIV NAT is negative, the optimal duration of empiric HIV therapy is unknown. A 28-day course may be reasonable based on current recommendations for non-occupational HIV exposure.44 As in other situations, decisions regarding ARV management should be accompanied by consultation with a pediatric HIV specialist and maternal counseling on the potential risks and benefits of this approach. The National Perinatal HIV Hotline (888-448-8765) is a federally funded service providing free clinical consultation for difficult cases to providers caring for pregnant women living with HIV and their newborns, and can provide referral to local or regional pediatric HIV specialists.
Newborns should be tested for HIV prior to initiation of empiric HIV therapy, 4 to 6 weeks and 4 to 6 months after diagnosis of maternal HIV infection and cessation of breastfeeding to determine their HIV status. An additional virologic test should be performed 2 to 4 weeks after discontinuation of empiric HIV therapy (see Diagnosis section). If a newborn is already receiving an ARV prophylaxis regimen other than empiric HIV therapy and is found to have HIV, prophylaxis should be discontinued and treatment for HIV initiated. Resistance testing should be performed, and the ART regimen modified if needed (see the Pediatric Antiretroviral Guidelines).
Short-Term Antiretroviral Drug Safety
Newborn prophylaxis with zidovudine has been associated with only minimal toxicity, consisting primarily of transient hematologic toxicity (mainly anemia), which generally resolves by age 12 weeks (see Initial Postnatal Management). Data on toxicities in newborns exposed to multiple ARV drugs are limited.
Other than zidovudine, lamivudine is the NRTI with the most experience in use for neonatal prophylaxis. In early studies, neonatal exposure to combination zidovudine/lamivudine was generally limited to 113,50,51 or 2 weeks.5 Six weeks of newborn zidovudine/lamivudine exposure has also been reported. These studies suggest that hematologic toxicity may be greater with zidovudine/lamivudine than with zidovudine alone, although the newborns in these studies also had in utero exposure to maternal HIV therapy that may have contributed to the toxicity.
In a French study, more severe anemia and neutropenia were observed in newborns exposed to 6 weeks of zidovudine/lamivudine for prophylaxis plus maternal antepartum zidovudine/lamivudine than in a historical cohort of newborns exposed only to maternal and newborn zidovudine. Anemia was reported in 15% and neutropenia in 18% of newborns exposed to zidovudine/lamivudine, with 2% of newborns requiring blood transfusion and 4% requiring treatment discontinuation for toxicity.52 Similarly, in a Brazilian study of maternal antepartum and 6-week newborn zidovudine/lamivudine prophylaxis, neonatal hematologic toxicity was common, with anemia seen in 69% and neutropenia in 13% of newborns.53
Experience with other NRTI drugs for neonatal prophylaxis is more limited.54,55 Hematologic and mitochondrial toxicity may be more common with exposure to multiple NRTI drugs than to a single NRTI.52,56-59
In rare cases, chronic multiple-dose nevirapine prophylaxis in pregnant women has been associated with severe and potentially life-threatening rash and hepatic toxicity.60 These toxicities have not been observed in newborns receiving prophylactic dosing with single-dose nevirapine, the two-drug zidovudine regimen plus three doses of nevirapine in the first week of life in NICHD-HPTN 040/PACTG 1043), or in breastfeeding newborns receiving nevirapine prophylaxis daily for 6 weeks to 18 months to prevent transmission of HIV via breast milk.5,45-47,49,61
The Food and Drug Administration (FDA) recently approved infant dosing of raltegravir for term neonates ≥37 weeks gestation at birth and weighing ≥2 kg. Dosing information is not available for preterm or low birthweight infants. Infant raltegravir dosing needs to be increased at 1 week and 4 weeks of age. Raltegravir is metabolized by UGT1A1, the same enzyme responsible for the elimination of bilirubin. UGT enzyme activity is low at birth, and raltegravir elimination is prolonged in neonates. In addition, bilirubin and raltegravir may compete for albumin binding sites, and extremely elevated neonatal plasma raltegravir concentrations could pose a risk of kernicterus.62 IMPAACT P1110 is a Phase 1, multicenter trial enrolling full-term neonates exposed to HIV and who are at risk of acquiring perinatal HIV-1-infection, with or without in utero raltegravir exposure. Daily raltegravir was safe and well tolerated during the first 6 weeks of life. Infants were treated for ≤6 weeks from birth and followed for 24 weeks. There were no drug-related clinical adverse reactions observed and only three laboratory adverse reactions: one case of Grade 4 transient neutropenia in an infant receiving zidovudine-containing regimen; and two cases of bilirubin elevations (one each, Grade 1 and Grade 2) that were considered non-serious and did not require specific therapy63 (see Pediatric Antiretroviral Drug Information for additional information).
The safety and PK data about daily dosing from P1110 are from raltegravir-naive infants whose mothers did not receive raltegravir; data collection from infants born to mothers who were receiving raltegravir is ongoing. However, the Panel believes that the FDA-approved dosing of raltegravir, delaying the first dose for infants born to mothers who received raltegravir, is reasonable based on current data about clearance of the drug in premature and raltegravir-exposed infants.
Of the protease inhibitors, pediatric drug formulations are available for LPV/r, ritonavir, darunavir, tipranavir, and fosamprenavir, but their use in neonates in the first weeks of life is not recommended given the lack of dosing and safety information. In addition, LPV/r oral solution contains 42.4% alcohol and 15.3% propylene glycol, and enzymes that metabolize these compounds are immature in neonates, particularly preterm newborns. Four premature newborns (two sets of twins) started on LPV/r from birth, developed heart block that resolved after drug discontinuation.64,65 In studies of adults, both ritonavir and LPV/r cause dose-dependent prolongation of the PR interval, and cases of significant heart block, including complete heart block, have been reported. Elevation of 17-hydroxyprogesterone and dehydroepiandrosterone-sulfate has also been associated with administration of LPV/r in the neonatal period, an association not found with zidovudine. Levels of 17-hydroxyprogesterone were greater in newborns who were also exposed to LPV/r in utero than in those exposed only in the neonatal period. Term newborns were asymptomatic but three premature newborns experienced life-threatening symptoms compatible with adrenal insufficiency, including hyponatremia and hyperkalemia with, in one case, cardiogenic shock.66 On the basis of these and other post-marketing reports of cardiac toxicity (including complete atrioventricular block, bradycardia, and cardiomyopathy), lactic acidosis, acute renal failure, adrenal dysfunction, central nervous system depression, respiratory complications leading to death, and metabolic toxicity,67 predominantly in preterm neonates, the FDA now recommends that LPV/r oral solution not be administered to neonates before a postmenstrual age (first day of the mother's last menstrual period to birth plus the time elapsed after birth) of 42 weeks and a postnatal age of ≥14 days.68 However, a recent study (ANRS 12174) randomized 1,273 newborns, 615 assigned to LPV/r and 621 assigned to lamivudine, as prophylaxis during breastfeeding in women with CD4 counts above the local threshold for treatment at the time. Newborn study prophylaxis was initiated at 7 days of life and only newborns >2 kg were randomized. Clinical and biological severe adverse events did not differ between groups suggesting that LPV/r is safe in term newborns, 7 days of age and older.69 At this time, the Panel does not recommend the use of LPV/r before a postmenstrual age of 42 weeks and a postnatal age of ≥14 days.
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- McArthur MA, Kalu SU, Foulks AR, Aly AM, Jain SK, Patel JA. Twin preterm neonates with cardiac toxicity related to lopinavir/ritonavir therapy. Pediatr Infect Dis J. 2009;28(12):1127-1129. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19820426.
- Simon A, Warszawski J, Kariyawasam D, et al. Association of prenatal and postnatal exposure to lopinavir-ritonavir and adrenal dysfunction among uninfected infants of HIV-infected mothers. JAMA. 2011;306(1):70-78. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21730243.
- Boxwell D, Cao K, Lewis L, Marcus K, Nikhar B. Neonatal toxicity of Kaletra oral solution: LPV, ethanol or prophylene glycol? Presented at: 18th Conference on Retroviruses and Opportunistic Infections. 2011. Boston, MA.
- Food and Drug Administration. FDA drug safety communication: serious health problems seen in premature babies given kaletra (lopinavir/ritonavir) oral solution. 2011; http://www.fda.gov/Drugs/DrugSafety/ucm246002.htm.
- Nagot N, Kankasa C, Tumwine JK, et al. Extended pre-exposure prophylaxis with lopinavir-ritonavir versus lamivudine to prevent HIV-1 transmission through breastfeeding up to 50 weeks in infants in Africa (ANRS 12174): a randomised controlled trial. Lancet. 2016;387(10018):566-573. Available at: http://www.ncbi.nlm.nih.gov/pubmed/26603917.
Download Guidelines
- Section Only PDF (1.5 MB)
- Full Guideline PDF (3 MB)
- Recommendations Only PDF (211 KB)
- Tables Only PDF (388 KB)
Related Content
- AIDSinfo Drug Database
- AIDSinfo Patient Materials: Preventing Mother-to-Child Transmission of HIV
- AIDSinfo Patient Materials: HIV Medicines During Pregnancy and Childbirth
- AIDSinfo Patient Materials: Protecting Baby from HIV
- AETC National HIV Curriculum
- How to Cite These Guidelines
- Perinatal Guidelines Archive

subset: commoncrawl


text:
WARNING: "For the Grown and Cake Lovers Only"
I am a chocolate beauty queen, the same chocolate beauty queen that is to die for. But yet I am worthless. Same chocolate beauty queen that is richly chocolate and moist in all the right places! With flavor to savory, every bite is a private party on repeat.
I want your buttercream. Every drop. Fill my center with all of your cookies n' cream. Make mine extra creamy in the center. Work it, work it out! I want to enjoy this to the fullest. Get the most out of it.
Put it all on me. Do not hesitate I can take it. I came to be fully submerged into you. No less! I came to get my cake! Level me off! OH, YEAH!! YES! That is it….
Watch the video below on how this chocolate beauty was created.
Join Us:
Want to learn the basic of cake decorations? Tired of your cake sticking to the pan?? Join Chantal the 2017 America's Best Bakers Ohio Queen; when you book a Bake With Me Workshop. These workshops are fun and perfect for that person looking to do something different. Regardless, if you are hosting a club, event, party, or business event; Bake With Me Workshop offers standard and custom themed workshops. You gather your friends and come ready for good old fashion fun; you know the kind before cell phones and the internet, lol. We will bring all the baking supplies. Bake with Me Workshops is baking for the entire family. Now Booking 2017- 2018.
About Chantal:
Chantal considers herself the "Soul Baker". She is a baker, mother, cook, poet, instructor and 2017 Ohio America's Best Baker Ohio Queen! Cakes By Chantal L.L.C specializes in creating custom designed cakes and cupcakes, with the highest quality ingredients; with old fashion elbow grease and love; for your special event! As a child, her favorite tradition was hearing people sing "Happy Birthday" with the cake and candles. She did not care about presents.
Chantal has been baking for about 7 years. As a single mother she wanted to make a difference in her and her daughter's lives. Chantal obtained 2 Computer Science degrees while taking care of her daughter. After graduating she was offered a position in her field of study. After many prayers, she took the step of faith and started Cakes By Chantal.


text:
"A Movie Magic "I Do"
Romantic sunsets, strangely beautiful black beaches and a unique Caldera landscape. The pure blue sea, the white-washed houses and picturesque Greek chapels….. That is why Santorini is one of the world's most unforgettable wedding destinations.
What better way to express your eternal love than while silhouetted by the sunset with the subtle taste of salty sea mist setting your soul free.
Beyond the stunning backdrop, soft Aegean breeze, historic ruins and a treasure trove of wedding traditions, there is an army of reasons why Santorini is the ultimate destination for your dream wedding.
Customize your dream wedding and allow the Special Events Team at Sophia Luxury Suites to organize everything, abiding by your wishes, with care to detail and a background of know-how experience.
We will stand discreetly by your side, every step of the way, to help arrange your destination wedding and really make it your special day.
There's simply no denying that the rocky Cycladic cliff tops, the Aegean Blues and the volcano as a back drop are a match made in heaven for a destination wedding.
We offer an array of luxury services and wedding packages, to suit all styles and preferences. Propose to your other half in the destination setting you have imagined, have your wedding on a white washed chapel overlooking the endless Caldera cliffs with views of a shimmering pink sunset as a backdrop to your perfect day.
With our passion for romance, our great care for our guests, our expertise in destination weddings and our knowledge of Santorini Island, we can blend and combine the right amount of elements to create a day that you will forever hold dear to your hearts."


text:
I have a problem configuring my server to authenticate users that are members of a nested AD group. I have a 'group1' that includes 'group2' with the user account I'm trying to authenticate.
When configured as on the example below users that are members of 'group1' are authenticated successfully but members of a nested AD group 'group2' are not.
Code: Select all
# Base DN
BaseDN "OU=Users,DC=example,DC=com"
# User Search Filter
SearchFilter "(sAMAccountName=%u)"
# Require Group Membership
RequireGroup true
BaseDN "OU=Security Groups,DC=example,DC=com"
SearchFilter "(cn=group1)"
MemberAttribute Member
Based on this https://msdn.microsoft.com/en-us/librar ... s.85).aspx article SearchFilter can be configured to perform recursive query that 'walks the chain of ancestry in objects' until it finds the user. However, when I configure the SearchFilter like that authentication fails completely and the server logs "TLS Auth Error: Auth Username/Password verification failed for peer" event.
What am I doing wrong? Does anyone have an example of working config that does what I need? Any help will be much appreciated.
Code: Select all
SearchFilter (&(objectClass=*)(objectCategory=person)(memberof:1.2.840.113518.104.22.1681:=CN=group1,OU=Security Groups,DC=example,DC=com))


text:
Ye! Child & Youth Finance International held the Dutch launch of Ye! - an online platform for young entrepreneurs – in Amsterdam, the Netherlands, on Wednesday, December 10th . The global platform was launched to an audience of young entrepreneurs, investors, established entrepreneurs and representatives from the Netherlands Ministry of Foreign Affairs, and, the event's hosts, De Autoriteit Financiële Markten (AFM).
2015 – The Year of the Start-Up
The launch is timely as 2015 is set to be a tipping point for entrepreneurs in the Netherlands with ex-EU Commissioner Neelie Kroes being announced as the Dutch Special Envoy for Start-Ups, and the new law coming into act as of January 1, 2015, which will make it easier for international entrepreneurs to launch their business in the Netherlands.
Entrepreneurs Pitch to Investors
During the event 10 young entrepreneurs from around the world pitched their ventures to investors and key-stakeholders from the Netherlands:
- VACSE: Shadi Al-Hakimi has developed a search engine which searches the content of videos and audio
- I Hate Statistics:Pim Belling will turn your hate for statistics into love
- Bonsum:Frederik Betz makes shopping sustainably easy and rewarding (for the earth and for you)!
- Swapp:Want to swop your jacket for her shoes? Lonneke Boonzaaijer's interactive app will do just that
- The Dev School: Martha Chelimo is teaching African youth to code and become tech entrepreneurs themselves
- Crystal Shower:Wouter Chömpff wants people to get unlimited shower time with just 1 bucket of water
- Huishuai: Huishuai Li brings Asia from your browser to your door
- Thinking Green: Marwan Ma'som powers street-kiosks in Malaysia with sunshine
- Shoemates: Obaid Rahimi ensures your good fashion choices will benefit a family in need
- FGE Exports: Senai Wolderufael is ensuring that the world gets their kick from ethically sourced Ethiopian coffee
Sustainable Businesses
"The AFM supports Ye! due to our commitment to financial education and financial inclusion, and building fair and transparent markets. Young people can bring this change as young entrepreneurs predominantly start businesses which are unlike the old way of doing things – they are new and fair and they...bring a positive change in the world."Annemiek Hoogenboom representing the players of Nationale Postcode Loterij and Energo Foundation, a main sponsor of the Ye! online platform, underlined this socially conscious characteristic which the majority of the young entrepreneurs pitching at the event shared. She highlighted that in her experience young people tend to have more sustainable and socially aware solutions – their ideas are green from the get-go.
Theodor Kockelkoren, AFM Executive Board member.
Start-Up Coach
Duke Urbanik, private investor and YES!Delft strategy coach, heeded this with a warning that the commonality of young entrepreneurs to be hyper socially-conscious may lead them to live in an idealist bubble. For an investor to take notice of a young entrepreneur they have to see an attainable goal. This is where the Ye! coaching platform will be useful to young entrepreneurs as the coaches will hold a mirror up to the entrepreneur and hold them accountable to their goals helping to ensure that they don't become unrealistic and unattainable.
International Markets
Mr. Kockelkoren emphasized the important role which Ye! will play in welcoming young entrepreneurs from international markets to the Netherlands, and vice versa. Ms. Hoogenboom echoed the importance of this international platform: "Young people think internationally automatically. If they want to make a difference and earn money then they don't just think "hey, let's do this in the Netherlands," they think "hey, let's do this in the Netherlands, the US, and China!" This is important for the growth of their business and national economies, and Ye!'s international resources makes it easier for them to do this.
Jeroen Roodenburg, the Ambassador for the Private Sector and International Cooperation from the Netherlands Ministry of Foreign Affairs, announced that they are working closely with the private sector to ensure that the Post-2015 Sustainable Development Goals (to be established in September 2015) will result in the eradication of extreme poverty. In light of this, encouraging investment in young entrepreneurs, especially enterprises in the supply chain which links developing markets to developed ones, is a top priority.
Entrepreneurship Top Tip
Perseverance was the word of the evening, with established and young entrepreneurs alike repeating that their top tip for any budding entrepreneur is to persevere! Gert-Jan van der Hoeven CEO and co-founder of H2 Equity Partners, a leading Western-European hands-on investment firm, shared jokingly that being an entrepreneur is what gave him grey hair but encouraged the young entrepreneurs to ride out the tough times and stick to their guns – it's all worth it in the end.
Jeroo Billimoria, serial social entrepreneur and Managing Director of Child & Youth Finance International, said that the only reason that Ye! is in existence is because her team believed whole-heartedly in the idea and persevered against all odds.
International Resource Hub
"Ye! will make it so much easier for young entrepreneurs to find the advice and resources that they need" said Angelien Kemna, Chief Finance & Risk Officer of the APG Group, and Chairman of the Supervisory Board of Yellow and Blue, a Dutch venture capital firm in the field of renewable energy. She went on to say that "we all need to work together to build up enterprises and economies."
About Ye!
Ye! will be the biggest online community for young entrepreneurs. It supports entrepreneurs between the age of 16 and 30. By joining the community, they can get in touch with peers and obtain support through sharing knowledge, a free coaching service from international and local experts, and funding opportunities. Young people can use these resources to become more knowledgeable entrepreneurs and grow their business.


text:
I try my hardest to schedule things on easy days (Mondays and Fridays) or on weekends when I have the entire day, but it's not always possible. I have to go to the doctor when they have space. Tomorrow at 3 I have to go to Geneva and get my bike fit done because that's when they could squeeze me in. Next week I have to pick Andy up from a doctor's appointment because he needs a ride home. All of these things are things in my life that I can't blow off, and I need to be able to work my training around them instead of freaking out. So tomorrow I will go to work early, get to Geneva by 3, do my fit, and then go to the gym late. I won't like it, but I need the fit to be done so I will do it.
I think I do things like marathons and Ironman because I am an introvert. I like to stay busy but I don't like to be around tons of people all the time. This way, I get my solitude with all of my training but I get human interaction with the best kind of people out there - other triathletes! And the few friends that I do see on a regular basis are people who are similar to me and who understand what I do and why I might have time constraints. And they don't constantly pester me to go clubbing or something else ridiculous that I would never do.


text:
Contact Customer Service – Contact Form or Call
Mail or Phone for Corporate Office
- AmeriTrade International, Inc.
- Brick Clip® Fasteners
- 1035 East Alpine Drive
- Alpine, Utah 84004
Toll free phone number: 1-800-756-8995 – Fax: 1-801-756-7506
Office hours: 9:00 AM – 5:00 PM (Mountain Time) Monday-Friday
For Canadian or orders outside the United States call: 1-801-756-8995
AmeriTrade International, Inc. is the official and only authorized manufacturer of the Brick Clip® Fastener. This product is made in the USA.
Please feel free to call our toll free number if you have any questions regarding this product.
Brick Clip® is a Registered U.S. and Canadian Trademark.
The Brick Clip® Shape and Configuration is a U.S. Trademark
Customer Service Number: 1-800-756-8995
Made In USA


text:
Wednesday, August 20, 2008
The Book is on the can!
The eagle has landed. The chair is on the wall. Circle takes the square. Starting in mid-June, the good folks at Hormel saw fit to put together a promotion for The Book of SPAM! How nice of them! Now you can see the book on the front and back of every SPAM can! It might take a while for them to get on the shelf at your local market, so here's all the info on how you can get your own special copy of The Book of SPAM:
"Just mail in 3 UPC codes from any 12 oz. SPAM® product and a check or money order for $8.95 made payable to: "The Book of SPAM" Offer, P.O. Box 10, Austin MN, 55912"
Now go on and get it! You probably have 10-12 empty SPAM cans laying around in the backyard right now! How easy is that?
Posted by The Book of SPAM at 3:12 PM
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text:
Drip for the hood, you know what I'm saying?
Burn up for the hood, you know what I'm saying?
Dipped it in the bowl, microwaved up the blunt
You know what I'm saying?
Burning that water
Also, you know what I'm saying, freeing up the soul for my brothers too, you know what I'm saying?
Get away from that bullshit, you know what I'm saying?
Waterfront, you know what I'm saying?
Real nigga, keep it wet all day
I know my position, you know what I'm saying?
I know my part
Man, it's lil b and niggas biting off my old shit
Nigga that's my old shit, I'm fresh like the ocean
I'm still up underwater, the goggles on my left side
Bitch, it's the west side, yeah, that's the best side
Sit up in the best rides, drivers gon' drive me home
You pussy niggas like roly polys, pissed on holes
I'm froze, bitch my cake right, eat steak every night
I'm deep like barry white
Girls wanna marry me, bitch you gotta pay the price
I'd rather fuck my jewelry than beat your pussy at night
Got fangs in my teeth, but I promise I don't bite
Yeah right, speak soft when the time right
Never been a sucker for dough, I'm finer than your nigga, bitch
Hate dealing with bitch niggas, suckers make a nigga sick
Maybe make a nigga split rounds like a fucking dick
Shh, you got a nigga pissed
But I'm scared and I ain't never piss
I make you drip, drip, drip, drip, drip nigga
I make you drip, drip, drip, drip, drip
I make you, drip, drip, drip, drip, bitch
Yeah, I make you, drip, drip, drip, drip, bitch
You getting money, yeah, you fucking hoes, what?
You a boss, slap backs lil nigga, yeah
This is shit on the right note
They all love a nigga now, cleaner than embro
Slob up on the knob, bopper do your job
Like young l said, I gotta improv
Bitch, where the scene? I'm dipped in butter
Bitch, I'm looking cream, lil nigga on his hustle
Riding with my niggas, hope you riding with the muscle
Bitches show up, I'm riding with a muzzle
Smoking on that russell, berkeley boys get it in
You stupid if you don't know that we with' it
Bitch, we winning, riding on doubles
Lil nigga's getting money cause a nigga won't fumble
Bet I won't drop it, bitch I'm rocking in a puddle
You niggas like puppies with them little nut huggers
Asking no questions, and I'm thinking nothing of it
I'm a real nigga, and naw, I'm not thuggin'
I'm just busting shit, I'll shoot you fuckers and your cousins
Playing games man? Um, nigga it's nothing
Got the gun from deezle, all my niggas love me
Bitch, I'm lil beezy, team knoc, what it do?
Technicians get dough, and believe, fan boys what it do?
Crack street, what it is?
Hey, all you street niggas, man, we out here
Hey man, I'm out here like a sports camp
You know what I'm saying?
We rocking man. Hey, salute all my real niggas to the top
Basedworld paradise man
I come from a different cloth, the classic shit
A lot of you niggas reppin' shit now, and I ain't understand it
Niggas done took everybody's shit, niggas done really fucked up the game, you know what I'm saying?
I'm a keep it 100. What is the mob, nigga?
Cause I see everybody claiming that
I know everybody can't be in it


text:
My recent conversation with celebrated comedian Ryan Singer about the importance of integrating science and the mysterious.
I recently experienced the good fortune of having an engaging and thought-provoking discussion with clever and daring comedian Ryan Singer on his "mindcast", Me and Paranormal You. Ryan is a gifted and insightful host and we had a stimulating conversation that explored vignettes from my life narrative and work as a psychotherapist, as well as my beliefs and experiences of the importance and benefits of integrating and balancing the energies of science with those of the mysterious and unknown.
Along with evidence-based practices supported by research, and scientific information about the functioning of the body and mind, in my private practice I often implement techniques like Tarot exploration that while effective, remain fairly enigmatic as to why they can produce such profound results. As all individuals are unique, I find this eclectic use of methods is conducive to a flexible and holistic lens and modality which fosters successful collaborations in therapy and consultation.
Hear more by listening to the mindcast on;
Ryan's website, ITunes, or SoundCloud
And learn more about Ryan at;
© 2017 Mark F. Barone, MA, LMHC
Catalyst Psychotherapy and Consulting
Seattle & West Seattle, WA
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March 2018


text:
Author: Amy Davis, Investigative Reporter/Consumer Expert, firstname.lastname@example.com
Cody Schultz, News Producer
HOUSTON – It's the three-digit number that can affect how much someone pays for a car, a house, even insurance. Credit scores dictate an incredible amount in our lives, yet errors can be hard to fix.
The website Annual Credit Report is key to deciphering credit problems. Experts recommend checking each item on a credit report. If any errors are found, consumers can dispute them by writing a letter to the bureau. The Federal Trade Commission even has a sample letter form to help people get started.
Proof is imperative when it comes to disputing a claim. Consumer attorney Dana Karni says if the dispute is denied, it can hurt a person's credit more than the original bad debt.
"I would encourage a consumer to add every bit of information that they can to support their claim," Karni explained. "If you do not have a good basis for a dispute, you're much better off just letting that listing on your report age. It will have much less of a detrimental effect on your credit score over the years."
After seven years, that old debt will fall off the credit report. If a consumer doesn't have that much time, like if they're buying a house, there's still a way to recoup money lost on a higher interest rate.
"If you feel like you're going to lose the home of your dreams because of this credit reporting dispute, go ahead with the closing and then turn around and assert your rights in court," Karni said.
In court, a judge could force the credit bureau or the company responsible for the bad information to cover the extra costs incurred because of the error. It's always best to consult an attorney before going through with a closing to ensure the case is strong enough to pursue.
Lastly, Karni suggests avoiding credit repair companies. They can stir up things on a credit report that were about to expire anyway. For instance, if there's a debt that's six years old, the credit repair company may try and dispute it, and the creditor can renew that debt, which would keep it on the record for another seven years.


text:
Monday, October 25, 2010
Juvenile Godwits Arrive
For more bird photos visit the Bird Photography Weekly.
16 comments:
my lake already started to freeze a bit. No birds, no kayaking. :(ReplyDelete
Take good care of the Godwits, please.
Mick, it was probably too cold during the blooming period of the rowan trees. No insects, no fruit. I´ve never seen them so empty. :(
Hi Mick. It still amazes me the distances that these waders make to complete their migration journey. Cheers FAB.ReplyDelete
Hi NatureFootstep it must be very cold up your way if the lake is freezing. Very interesting about the rowan trees and the cold weather effecting the setting of fruit. I hope the bird can find something else to eat.ReplyDelete
Hi Frank, the distances the birds travel are always astonishing and I especially think of these distances when I realize these young ones have come down here by themselves.
Cool shots of the Godwits Mick! I really like the second one with the lead bird's wings up.ReplyDelete
It is rather amazing that the juvies follow that much later than the adults.
Thanks Larry. I have read that the juveniles are not well developed enough or strong enough to migrate when the adults leave. There is not a lot of time in the very short arctic season.ReplyDelete
...beautiful birds. I also am amazed at their migration. I didn't realize the juveniles stayed back to mature and then flew on by themselves...ReplyDelete
Hi Kelly, - one of nature's marvels!ReplyDelete
Hi MickReplyDelete
Glad you can tell the bubs from the Mums 'n Dads.
I suppose you are wanting to find yourself another "flagged" one.
Re migrations, the adult Muttonbirds (which pretty much do the same trip in reverse as your beloved Godwits) also leave before the chicks, which have to navigate on instinct totally.
No-one to say "hurry up", or "turn left past Japan".
It is all so wondrous.
Thanks for the shots Mick. It's also amazing that bar tails are common in the UK, a widespread arctic species in fact.ReplyDelete
Hi Denis, it would be fantastic to see a flagged one as important as the one we found before! Thanks for the info re the Muttonbirds which I didn't know. Teens taking control and responsibility !!! Wonderful!!!!ReplyDelete
Hi Phil, I went and looked in my books as I hadn't realized you had Bar-tails up your way. Very interesting.
Awesome shots of the godwits, Mick! The juvenile's plumage really stands out from among the adults.ReplyDelete
I hope to see some godwits here in the Philippines soon.
Awesome, godwits!ReplyDelete
Ah those teenagers! Always have to be different. :)ReplyDelete
Thanks for commenting Bob, Zen and Halcyon. Bob, I hope you can see some Godwits over your way soon.ReplyDelete
Mick, do you get many juv Godwits coming through there?ReplyDelete
Hi Mark, yes quite a number but I have never done a count of them and I don't think anyone else has either. The Sandy Strait is a huge area - even just this southern portion - and we only count a couple of the roosts regularly. We need more counters - desperately!ReplyDelete


text:
Bill And Maria Barnes Found A Gem In This '70 GTX
It's strange when you think about the dichotomy of praise afforded to top cars in the Mopar hobby. On the one hand you've got the OEM restorations that receive the highest accolades from both judges and interested enthusiasts. Tons of money and often years of research and knuckle-busting wrenching goes into building these exquisite machines. And in the end their praise and notoriety are duly granted to their restorers.
On the other hand we find the unrestored iron. These mysterious specimens seem to have rolled through a time portal. These cars are celebrated not for their pristine paint job or their exquisite undercarriage detailing, but rather for their lack of attention. In fact, their appreciation is exponentially rated by how much their owners have stayed their restoration hand. The more warts, it would seem, the better.
One of these unrestored treasures which has surfaced during the last few years is a Burnt Orange '70 GTX currently owned by Bill and Maria Barnes of Hamler, Ohio. And like all unrestored classics there is a strange story behind its preservation.
Bill and Maria first spotted the GTX at the '96 Mopar Nationals in Indianapolis, and knew right away that they had stumbled across a rare find. One of the giveaways was the cardboard tag which was still attached to the 440's water pump. "I knew of only one other car that's still got that on there," says Bill. Another clue was the paint. "You know all the dirt that's in paint when they are original? It's just unbelievable how much dirt and specs are in the paint. I told my wife I know exactly what I'm looking at here that day we first saw the car."
For an unrestored car, the GTX was in remarkable condition. Although the expected dust and aged veneer was evident, the hardtop could just as easily have been sitting on a new car lot almost three decades earlier. The Burnt Orange vinyl interior was immaculate, as was the paint and uncommon Gator Grain vinyl roof. Only the odometer, sporting around 12,000 miles on the clock, belied the car's limited road exposure over the years.
Intrigued, and hoping to add this unusual piece of Mopar history to a collection that already included two '67 R/T convertibles, a '70 Superbird, a '70 Challenger convertible, and a '64 Polara convertible, Bill queried the owner about the possibility of selling him the car. Fortunately, Bill was the first person to approach the owner, a Minnesota resident, who had picked up the GTX from a collector in Illinois. The owner, Bill explained, had a bunch of GMs and Fords in his collection, but this was his first Mopar. He really wasn't a Mopar guy, but obtained the car because it was an original.
Bill figured his chances were slim that he would be able to take the GTX for his own, but about three months after the show the owner wrote him a letter saying that his wife "was hollering for him to get a 'Vette." After some negotiating, Bill and Maria had the pleasure of bringing the car into their collection.
"I've wiped the dust off. That's about all I've done to the thing," says Bill.
"I've completely left it exactly the way I found it. I got underneath and wiped the dust off. I took the drums off to look at the brakes at all four corners-and the brakes-I've never seen a set of brakes like this. They've got all the markings right on it-on the shoes. The springs and everything are just like new. None of them were leaking, so I blew them off and put the drums back on.
So how did Bill's GTX stay in such remarkable shape over the years? A letter to Bill from the original owner explaining the car's history provides some insight…
I bought the GTX in June or July of 1971 from Barnet Chrysler in White Bear Lake, Minnesota, brand new. I paid $3,500 for it…
When I sold the car it was 100-percent original, except for the Cragar SS Mags and the walnut steering wheel. It had been stored in a garage from the time that I bought it and was never driven in rain or snow. At the time, I also owned a '69 396 Chevelle with 4,000 miles on it. I decided to store the GTX and drive a beater to work and back.
As for the original Rally wheels, I also had a '70 Road Runner with plain rims and hubcaps. I put the Rally wheels on that. The only thing that I ever did to it was change the oil, filter, grease, air cleaner, and check the gears.
The car had one scratch on the right rear quarterpanel when I bought it. I never bothered to fix it, and am unsure if it is still there. The car was also always covered while in the garage.
Everything the original owner told Bill and the previous owners of the car seemed to verify the man's claims. For example, Bill says, "I know for sure that the original spark plugs are in the car because they are still painted engine color. I talked to Galen Govier on that, and he told me that they put covers over the plugs because they were already installed in the motor. It's absolutely amazing to me that he never had them changed."
Another verification can be found underneath the hardtop.
"One of the coolest things," says Bill, "is that he was legitimate when he said he never drove it in the rain, because the masking tape is still on the holes underneath where the seats bolt through. They're still hanging there like they did when they left the factory. It was 31/44-inch masking tape that they taped on there, sprayed the undercoat, then they shoved the seats through. To me that's pretty outstanding because it wouldn't take much of a rain shower to drive in and those would be gone.
Although the original owner swapped the stock rims and steering wheel (which has since been returned to the vehicle), interestingly enough he put the car's factory tires on the Cragars. While they are beginning to show some signs of dry rot, says Bill, they have been verified as the original tires for the car. The only other modification was the replacement of the tailpipes done by the Illinois collector. Bill says the guy added fresh pipes because the originals had holes in them, but that the stock muffler, clamps, and everything else is correct.
Obviously tooling around the show circuit with such a well-preserved classic invites studious inquiries from restorers.
"That is one of the main things about the car when we go to a show," explains Bill. "[People] are constantly wanting to lay under the car to check the shock absorbers, the springs, or the tires to document the dates-or, 'How was the undercoating applied?' Things like that. They even come to my shop."
Likewise, the offers to buy are endless.
"It doesn't really go anywhere without people going crazy over it. A lot of people talk about buying it, that's for sure. But we're Mopar lovers, and I really didn't buy it to make a buck on it or anything like that. I wanted something that I new was exactly right. When I restore cars-I've restored quite a few of them-I really love doing it, and they look beautiful. But there's just that thing about an original car that I really like."
From the sounds of it, Bill and Maria Barnes will continue to revel in their perfect original GTX for many years to come.


text:
Sold for $351,111
on Jun 30, 2017
This 5 bedroom, 3 1/2 bath, 4,043 square foot home in Lexington's Royal Creek neighborhood is immaculate inside and out! Main floor features include 2-story entry, formal dining with heavy molding and coffered ceiling, large open concept kitchen with granite counters and butler pantry, spacious great room with gas stack-stone fireplace and coffered box ceiling, and master bedroom with tray ceiling and large walk-in closet. Great room exits to screened-in porch, patio, and well manicured private fenced-in backyard. Second floor features 4 bedrooms - all with large closets, 1 full bath and a Jack & Jill bath, a great bonus or game room, and walk-in storage closet. Beautiful and private backyard. Lexington One Schools including River Bluff HS.
Patrick O'Connor
The #1 Coldwell Banker
Realtor in the Carolinas
Patrick O'Connor | 803-243-0224 | Email Patrick
Coldwell Banker Residential Brokerage | 5599 Sunset Blvd, Lexington, SC 29072
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