Anticipating anthropogenic threats in acquiring new protected areas.

Biodiversity continues to decline despite protected area expansion and global conservation commitments. Biodiversity losses occur in existing protected areas, yet common methods used to select protected areas ignore postimplementation threats that reduce effectiveness. We developed a conservation planning framework that considers the ongoing anthropogenic threats within protected areas when selecting sites and the value of planning for costly threat-mitigating activities (i.e., enforcement) at the time of siting decisions. We applied the framework to a set of landscapes that contained the range of possible correlations between species richness and threat. Accounting for threats and implementing enforcement activities increased benefits from protected areas without increasing budgets. Threat information was valuable in conserving more species per spending level even without enforcement, especially on landscapes with randomly distributed threats. Benefits from including threat information and enforcement were greatest when human threats peaked in areas of high species richness and were lowest where human threats were negatively associated with species richness. Because acquiring information on threats and using threat-mitigating activities are costly, our findings can guide decision-makers regarding the settings in which to pursue these planning steps.

Anticipación de las amenazas antropogénicas durante la adquisición de áreas protegidas nuevas Resumen La biodiversidad sigue declinando a pesar de la expansión de áreas protegidas y los compromisos mundiales con la conservación. La pérdida de la biodiversidad ocurre en las áreas protegidas existentes, y todavía los métodos comunes usados para seleccionar las áreas protegidas ignoran las amenazas posteriores a la implementación, las cuales reducen la efectividad. Desarrollamos un marco de planeación de la conservación que considera las amenazas antropogénicas actuales dentro de las áreas protegidas durante la selección de sitios y el valor de la planeación de actividades mitigantes costosas, como la aplicación, al momento de decidir. Aplicamos nuestro marco a un conjunto de paisajes que comprende el rango de correlaciones posibles entre las amenazas y la riqueza de especies. Si consideramos las amenazas y la implementación de actividades de aplicación, los beneficios de las áreas protegidas incrementan sin incrementar el presupuesto. La información sobre las amenazas fue importante para la conservación de especies por nivel de gasto incluso sin la aplicación, especialmente en paisajes con amenazas distribuidas de forma azarosa. Los beneficios de incluir la información sobre las amenazas y la aplicación fueron mayores cuando las amenazas humanas llegaron a su tope en áreas con gran riqueza de especies y alcanzaron su punto más bajo cuando las amenazas humanas estaban asociadas negativamente con la riqueza de especies. Ya que es costoso adquirir información sobre las amenazas y mitigar las amenazas con actividades, nuestros descubrimientos pueden informar a los tomadores de decisiones con respecto al entorno para seguir los pasos de la planeación.

Clinical Outcomes in a Randomized Controlled Trial Comparing Point-of-Care With Standard Human Immunodeficiency Virus (HIV) Viral Load Monitoring in Nigeria.

BACKGROUND: Point-of-care (POC) viral load (VL) tests provide results within hours, enabling same-day treatment interventions. We assessed treatment outcomes with POC vs standard-of-care (SOC) VL monitoring. METHODS: We implemented a randomized controlled trial at an urban and rural hospital in Nigeria. Participants initiating antiretroviral therapy (ART) were randomized 1:1 for monitoring via the POC Cepheid Xpert or SOC Roche COBAS (v2.0) HIV-1 VL assays. Viral suppression (VS) and retention in care at 12 months were compared via intention-to-treat (ITT) and per-protocol (PP) analyses. Post-trial surveys for POC patients and healthcare workers (HCWs) evaluated acceptability. RESULTS: During April 2018-October 2019, 268 SOC and 273 POC patients enrolled in the trial. Viral suppression at <1000 copies/mL at 12 months was 59.3% (162/273) for POC and 52.2% (140/268) for SOC (P = .096) in ITT analysis and 77.1% (158/205) for POC and 65.9% (137/208) for SOC (P = .012) in PP analysis. Retention was not significantly different in ITT analysis but was 85.9% for POC and 76.9% for SOC (P = .02) in PP analysis. The increased VS in the POC arm was attributable to improved retention and documentation of VL results. POC monitoring was preferred over SOC by 90.2% (147/163) of patients and 100% (15/15) of HCWs thought it facilitated patient care. CONCLUSIONS: POC VL monitoring did not improve 12-month VS among those with results but did improve retention and VS documentation and was preferred by most patients and HCWs. Further research can inform best POC implementation conditions and approaches to optimize patient care. CLINICAL TRIALS REGISTRATION: NCT03533868.

Timeliness of Point-of-Care Viral Load Results Improves Human Immunodeficiency Virus Monitoring in Nigeria.

BACKGROUND: Human immunodeficiency virus (HIV) viral load (VL) monitoring is critical for antiretroviral therapy (ART) management. Point-of-care (POC) VL testing has been reported to be feasible and preferred over standard-of-care (SOC) testing in many low- and middle-income country settings where rapid results could improve patient outcomes. METHODS: The timeliness of receipt of VL results was evaluated in an open-label, randomized, controlled trial among patients newly initiating ART. Clinical outcomes with POC VL monitoring using Cepheid Xpert vs SOC VL at Jos University Teaching Hospital and Comprehensive Health Centre Zamko in Nigeria were assessed. We determined time between specimen collection and recording of VL in patient charts, receipt of results, and ART switch for those who met virologic failure criteria. RESULTS: Between April 2018 and October 2019, we screened 696 ART-naive individuals; 273 were randomized to POC and 268 to SOC HIV-1 VL testing. Participants in the POC arm received VL results significantly faster than those in the SOC arm (0.1 median days, interquartile range [IQR], 0.1-0.2 vs 143.1 days, IQR, 56.0-177.1, respectively; P < .0001). Participants in the POC arm with confirmed virologic failure vs those in the SOC arm were switched more rapidly to a second-line regimen (0 median days, IQR, 0-28 vs 66 days, IQR, 63-123, respectively; P = .03). CONCLUSIONS: POC VL testing resulted in significant improvement in the timeliness of VL result receipt by patients and use for effective HIV clinical management. In patients experiencing VL failure, POC monitoring enabled prompt switching to second-line ART regimens. CLINICAL TRIALS REGISTRATION: NCT03533868.

Environmental Discourse Exhibits Consistency and Variation across Spatial Scales on Twitter.

Social media platforms, such as Twitter, are an increasingly important source of information and are forums for discourse within and between interest groups. Research highlights how social media communities have amplified movements such as the Arab Spring, #MeToo, and Black Lives Matter. But environmental digital discourse remains underexplored. In the present article, we apply automated text analysis to 200,000 Twitter users in several countries following leading environmental nongovernmental organizations. Some issues such as public action to decarbonize society or species conservation were discussed more intensely than agriculture or marine conservation. Our results illustrate where environmental discourse diverges and converges on Twitter across countries, states, and characteristics, such as political ideology. Using the coterminous United States as a case study, we observed that the prominence of issues varies across states and, in some cases, covaries with political ideology across counties. Our findings show paths forward to characterizing environmental priorities across many issues at unprecedented scale and extent.

Safety and efficacy of rifabutin among HIV/TB-coinfected children on lopinavir/ritonavir-based ART.

BACKGROUND: TB is the leading cause of death among HIV-infected children, yet treatment options for those who require PI-based ART are suboptimal. Rifabutin is the preferred rifamycin for adults on PI-based ART; only one study has evaluated its use among children on PIs and two of six children developed treatment-limiting neutropenia. METHODS: Since 2009, rifabutin has been available for HIV/TB-coinfected children requiring PI-based ART in the Harvard/APIN programme in Nigeria. We retrospectively analysed laboratory and clinical toxicities at baseline and during rifabutin therapy, and examined HIV/TB outcomes. RESULTS: Between 2009 and 2015, 48 children received rifabutin-containing TB therapy with PI (lopinavir/ritonavir)-based ART: 50% were female with a median (IQR) baseline age of 1.7 (0.9-5.0) years and a median (IQR) CD4+ cell percentage of 15% (9%-25%); 52% were ART experienced. Eighty-five percent completed the 6 month rifabutin course with resolution of TB symptoms and 79% were retained in care at 12 months. Adverse events (grade 1-4) were more common at baseline (27%) than during rifabutin treatment (15%) (P = 0.006). Absolute neutrophil count was lower during rifabutin compared with baseline (median = 1762 versus 2976 cells/mm3, respectively), but only one instance (2%) of grade 3 neutropenia occurred during rifabutin treatment. CONCLUSIONS: With clinical and laboratory monitoring, our data suggest that rifabutin is a safe option for TB therapy among children on PI-based ART. By contrast with the only other study of this combination in children, severe neutropenia was rare. Furthermore, outcomes from this cohort suggest that rifabutin is effective, and a novel option for children who require PI-based ART. Additional study of rifabutin plus PIs in children is urgently needed.

Sustained Specific and Cross-Reactive T Cell Responses to Zika and Dengue Virus NS3 in West Africa.

Recent studies on the role of T cells in Zika virus (ZIKV) infection have shown that T cell responses to Asian ZIKV infection are important for protection, and that previous dengue virus (DENV) exposure amplifies the protective T cell response to Asian ZIKV. Human T cell responses to African ZIKV infection, however, remain unexplored. Here, we utilized the modified anthrax toxin delivery system to develop a flavivirus enzyme-linked immunosorbent spot (ELISPOT) assay. Using human ZIKV and DENV samples from Senegal, West Africa, our results demonstrate specific and cross-reactive T cell responses to nonstructural protein 3 (NS3). Specifically, we found that T cell responses to NS3 protease are ZIKV and DENV specific, but responses to NS3 helicase are cross-reactive. Sequential sample analyses revealed immune responses sustained many years after infection. These results have important implications for African ZIKV/DENV vaccine development, as well as for potential flavivirus diagnostics based on T cell responses.IMPORTANCE The recent Zika virus (ZIKV) epidemic in Latin America and the associated congenital microcephaly and Guillain-Barré syndrome have raised questions as to why we have not recognized these distinct clinical diseases in Africa. The human immunologic response to ZIKV and related flaviviruses in Africa represents a research gap that may shed light on the mechanisms contributing to protection. The goal of our study was to develop an inexpensive assay to detect and characterize the T cell response to African ZIKV and DENV. Our data show long-term specific and cross-reactive human immune responses against African ZIKV and DENV, suggesting the usefulness of a diagnostic based on the T cell response. Additionally, we show that prior flavivirus exposure influences the magnitude of the T cell response. The identification of immune responses to African ZIKV and DENV is of relevance to vaccine development.

The role of point-of-care viral load monitoring in achieving the target of 90% suppression in HIV-infected patients in Nigeria: study protocol for a randomized controlled trial.

BACKGROUND: The Joint United Nations Programme on HIV/AIDS 90-90-90 goal envisions 90% of all people receiving antiretroviral therapy to be virally suppressed by 2020. Implied in that goal is that viral load be quantified for all patients receiving treatment, which is a challenging undertaking given the complexity and high cost of standard-of-care viral load testing methods. Recently developed point-of-care viral load testing devices offer new promise to improve access to viral load testing by bringing the test closer to the patient and also returning results faster, often same-day. While manufactures have evaluated point-of-care assays using reference panels, empiric data examining the impact of the new technology against standard-of-care monitoring in low- and middle-income settings are lacking. Our goal in this trial is to compare a point-of-care to standard-of-care viral load test on impact on various clinical outcomes as well to assess the acceptability and feasibility of using the assay in a resource-limited setting. METHODS: Using a two-arm randomized control trial design, we will enroll 794 patients from two different HIV treatment sites in Nigeria. Patients will be randomized 1:1 for point-of-care or standard-of-care viral load monitoring (397 patients per arm). Following initiation of treatment, viral load will be monitored at patients' 6- and 12-month follow-up visits using either point-of-care or standard-of-care testing methods, based on trial assignment. The monitoring schedule will follow national treatment guidelines. The primary outcome measure in this trial is proportion of patients with viral suppression at month 12 post-initiation of treatment. The secondary outcome measures encompass acceptability, feasibility, and virologic impact variables. DISCUSSION: This clinical trial will provide information on the impact of using point-of-care versus standard-of-care viral load testing on patient clinical outcomes; the study will also supply data on the acceptability and feasibility of point-of-care viral load monitoring in a resource-limited setting. If this method of testing is acceptable and feasible, and also superior to standard of care, the results of the trial and the information gathered will inform future scaled implementation and further optimization of the clinic-laboratory network that is critical for monitoring achievement of the 90-90-90 goals. TRIAL REGISTRATION: US National Institutes of Health Clinical Trials.gov: NCT03533868 . Date of Registration: 23 May 2018. Protocol Version: 10. Protocol Date: 30 March 2018.

Should I shoot or should I go? Simple rules for prey selection in multi-species hunting systems.

Across the tropics, unregulated hunting targeting many different species presents a major conservation challenge. Prioritizing resources for monitoring and enforcement is difficult when multiple prey species are exploited. However, identifying which prey species are subject to hunting pressure can be achieved with diet choice models. We evaluate hunter diet sets using data from Southwest China and compare two diet choice models: optimal foraging theory and a relatively new diet model originating from economic optimal stopping problems. The optimal stopping diet choice model required fewer field parameters than optimal foraging models and more accurately reflected hunter catch in Southwest China. The optimal stopping model also indicated that hunters should be less selective when they experience a larger opportunity cost for their time. Finally, we illustrate a new method to evaluate harvest impact from single sites with limited data using dietary thresholds. This technique could be used to evaluate whether or not the community of exploited wildlife has shifted in its trait distribution, providing a means to anticipate trait-biased defaunation from minimal data.

Examining conservation compliance with randomized response technique analyses.

Understanding violations of laws or social norms designed to protect natural resources from overexploitation is a priority for conservation research and management. Because direct questioning about stigmatized behaviors can produce biased responses, researchers have adopted more complex, indirect questioning techniques. The randomized response technique (RRT) is one of the most powerful indirect survey methods, yet analyses of these data require sophisticated statistical models. To date, there has been limited user-friendly software to analyze RRT data, particularly for models that combine information from multiple RRT questions. We developed an R package, zapstRR (ZoologicAl Package for RRT) that provides functions for 3 RRT models that can be applied to single or multiple RRT questions. With these functions, researchers can estimate the prevalence of conservation noncompliance, determine the number of violations by individuals, perform regressions for univariate and multivariate RRT data, and correct prevalence estimates for evasive-response bias. We illustrate the use of these estimators for RRT data through an examination of 2 case studies: illegal bird hunting where the interview consisted of a standard RRT question design and a novel implementation designed to offer further anonymity to respondents and reveal the impact of educational interventions on illegal bushmeat consumption. The case studies demonstrate how the models can work in tandem to uncover distinct patterns within RRT data sets. The case studies also show how several assumptions are central to the application of the multivariate models.

Continued Transmission of Zika Virus in Humans in West Africa, 1992-2016.

First identified in 1947 in Uganda, Zika virus (ZIKV) has remained largely unstudied until the recent outbreak in Latin America. This study aimed to measure the prevalence of ZIKV in febrile patients in Senegal and Nigeria in samples collected from 1992 to 2016. The seroprevalence of ZIKV was 6.2% based on ZIKV immunoglobulin M and negative for dengue reactivity. ZIKV envelope was amplified from 4 samples. Phylogenetic analysis showed that the ZIKVs belonged to the African lineage, grouping with either the Nigerian or MR766 sublineages. This study provides evidence that ZIKV has been silently circulating in West Africa for 2 decades.

The pleasure of pursuit: recreational hunters in rural Southwest China exhibit low exit rates in response to declining catch.

Hunting is one of the greatest threats to tropical vertebrates. Examining why people hunt is crucial to identifying policy levers to prevent excessive hunting. Overhunting is particularly relevant in Southeast Asia, where a high proportion of mammals and birds are globally threatened. We interviewed hunters in Southwest China to examine their social behavior, motivations, and responses to changes in wildlife abundance. Respondents viewed hunting as a form of recreation, not as an economic livelihood, and reported that they would not stop hunting in response to marked declines in expected catch. Even in scenarios where the expected catch was limited to minimal quantities of small, low-price songbirds, up to 36.7% of respondents said they would still continue to hunt. Recreational hunting may be a prominent driver for continued hunting in increasingly defaunated landscapes; this motivation for hunting and its implications for the ecological consequences of hunting have been understudied relative to subsistence and profit hunting. The combination of a preference for larger over smaller game, reluctance to quit hunting, and weak enforcement of laws may lead to hunting-down-the-web outcomes in Southwest China.

Community-Based Participatory Research Conceptual Model: Community Partner Consultation and Face Validity.

A national community-based participatory research (CBPR) team developed a conceptual model of CBPR partnerships to understand the contribution of partnership processes to improved community capacity and health outcomes. With the model primarily developed through academic literature and expert consensus building, we sought community input to assess face validity and acceptability. Our research team conducted semi-structured focus groups with six partnerships nationwide. Participants validated and expanded on existing model constructs and identified new constructs based on "real-world" praxis, resulting in a revised model. Four cross-cutting constructs were identified: trust development, capacity, mutual learning, and power dynamics. By empirically testing the model, we found community face validity and capacity to adapt the model to diverse contexts. We recommend partnerships use and adapt the CBPR model and its constructs, for collective reflection and evaluation, to enhance their partnering practices and achieve their health and research goals.

Moving research to practice through partnership: a case study in Asphalt Paving.

BACKGROUND: Multi-stakeholder partnerships play a critical role in dissemination and implementation in health and safety. To better document and understand construction partnerships that have successfully scaled up effective interventions to protect workers, this case study focused on the collaborative processes of the Asphalt Paving Partnership. In the 1990s, this partnership developed, evaluated, disseminated, and achieved near universal, voluntary adoption of paver engineering controls to reduce exposure to asphalt fumes. METHODS: We used in-depth interviews (n = 15) and document review in the case study. RESULTS: We describe contextual factors that both facilitated and challenged the formation of the collaboration, central themes and group processes, and research to practice (r2p) outcomes. CONCLUSIONS: The Asphalt Paving Partnership offers insight into how multi-stakeholder partnerships in construction can draw upon the strengths of diverse members to improve the dissemination and adoption of health and safety innovations and build a collaborative infrastructure to sustain momentum over time.

Triage for action: Systematic assessment and dissemination of construction health and safety research.

BACKGROUND: Research translation too often relies on passive methods that fail to reach those who can impact the workplace. The need for better research to practice (r2p) approaches is especially pressing in construction, where a disproportionate number of workers suffer serious injury illness. METHODS: A triage process was designed and used to systematically review completed research, assess r2p readiness, establish priorities, and launch dissemination follow-up efforts. A mixed quantitative and qualitative approach was used. RESULTS: The process proved effective in ensuring that significant findings and evidence-based solutions are disseminated actively. Key factors emerged in the selection of follow-up priorities, including availability of partners able to reach end users, windows of opportunity, and cross-cutting approaches that can benefit multiple dissemination efforts. CONCLUSIONS: Use of a systematic triage process may have an important role to play in building r2p capacity in construction safety and health.

Wage theft as a neglected public health problem: an overview and case study from San Francisco's Chinatown District.

Wage theft, or nonpayment of wages to which workers are legally entitled, is a major contributor to low income, which in turn has adverse health effects. We describe a participatory research study of wage theft among immigrant Chinatown restaurant workers. We conducted surveys of 433 workers, and developed and used a health department observational tool in 106 restaurants. Close to 60% of workers reported 1 or more forms of wage theft (e.g., receiving less than minimum wage [50%], no overtime pay [> 65%], and pay deductions when sick [42%]). Almost two thirds of restaurants lacked required minimum wage law signage. We discuss the dissemination and use of findings to help secure and enforce a wage theft ordinance, along with implications for practice.

Evaluation of a pilot promotora program for Latino forest workers in southern Oregon.

BACKGROUND: Forest work, an occupation with some of the highest injury and illness rates, is conducted primarily by Latino immigrant workers. This study evaluates a pilot program where promotoras (lay community health educators) provided occupational health and safety trainings for Latino forest workers. METHODS: Evaluation methods included a focus group, post-tests, and qualitative feedback. RESULTS: Community capacity to address working conditions increased through (i) increased leadership and community access to information and resources; and (ii) increased worker awareness of workplace health and safety rights and resources. Fear of retaliation remains a barrier to workers taking action; nevertheless, the promotoras supported several workers in addressing-specific workplace issues. CONCLUSIONS: For working conditions to significantly improve, major structural influences need to be addressed. A long-term, organizationally supported promotora program can play a key role in linking and supporting change at the individual, interpersonal and community levels, contributing to and supporting structural change.

The HIV-2 proviral landscape is dominated by defective proviruses.

BACKGROUND: Compared with HIV-1 infection, HIV-2 infection is associated with a slower progression to AIDS. Understanding the persistence of HIV-2 infection might inform the mechanisms responsible for differences in the pathogenicity of HIV-2 versus HIV-1. METHODS: In this study, we analyzed the genetic composition of the proviral reservoir in archived blood samples collected from 13 untreated HIV-2-infected adults from Senegal. We used single-genome, near-full-length individual proviral sequencing (FLIP-Seq) to assess the relative frequency of intact and defective proviruses. RESULTS: Ten out of 13 (77%) study participants demonstrated virologic suppression (<90 HIV RNA copies/ml) while the remaining 3 (23%) had detectable HIV RNA. We obtained 363 proviral sequences from peripheral blood mononuclear cells (PBMCs) from the 13 study participants. Within these sequences, 342 (94%) defective proviruses were detected. Twenty-one (6%) intact proviruses were detected from three study participants, with one study participant displaying a large clone consisting of 16 genome-intact sequences. CONCLUSION: This data suggests that similar to HIV-1 infection, the proviral landscape of HIV-2 is dominated by defective proviruses.

Antiretroviral therapy retention, adherence, and clinical outcomes among postpartum women with HIV in Nigeria.

While research involving pregnant women with HIV has largely focused on the antepartum and intrapartum periods, few studies in Nigeria have examined the clinical outcomes of these women postpartum. This study aimed to evaluate antiretroviral therapy retention, adherence, and viral suppression among postpartum women in Nigeria. This retrospective clinical data analysis included women with a delivery record at the antenatal HIV clinic at Jos University Teaching Hospital between 2013 and 2017. Descriptive statistics quantified proportions retained, adherent (≥95% medication possession ratio), and virally suppressed up to 24 months postpartum. Among 1535 included women, 1497 met the triple antiretroviral therapy eligibility criteria. At 24 months, 1342 (89.6%) women remained in care, 51 (3.4%) reported transferring, and 104 (7.0%) were lost to follow-up. The proportion of patients with ≥95% medication possession ratio decreased from 79.0% to 69.1% over the 24 months. Viral suppression among those with results was 88.7% at 24 months, but <62% of those retained had viral load results at each time point. In multiple logistic regression, predictors of loss to follow-up included having a more recent HIV diagnosis, higher gravidity, fewer antenatal care visits, and a non-hospital delivery. Predictors of viral non-suppression included poorer adherence, unsuppressed/missing baseline viral load, lower baseline CD4+ T-cell count, and higher gravidity. Loss to follow-up rates were lower and antiretroviral therapy adherence rates similar among postpartum women at our study hospital compared with other sub-Saharan countries. Longer follow-up time and inclusion of multiple facilities for a nationally representative sample would be beneficial in future studies.

SARS-CoV-2 live virus culture and sample freeze-thaw stability.

The effect of freeze-thaw on SARS-CoV-2 viral viability is not well established. We isolated virus from 31 split clinical samples cultured fresh or after a 7- or 17/18-day freeze. We found that freeze-thaw did not significantly affect viral culture isolation. Therefore, frozen samples may be used to assess SARS-CoV-2 infectiousness.

Chikungunya virus antepartum transmission and abnormal infant outcomes in a cohort of pregnant women in Nigeria.

OBJECTIVES: Chikungunya virus (CHIKV), a reemerging global public health concern, which causes acute febrile illness, rash, and arthralgia and may affect both mothers and infants during pregnancy. Mother-to-child transmission (MTCT) of CHIKV in Africa remains understudied. METHODS: Our cohort study screened 1006 pregnant women with a Zika/dengue/CHIKV rapid test at two clinics in Nigeria between 2019 and 2022. Women who tested positive for the rapid test were followed through their pregnancy and their infants were observed for 6 months, with a subset tested by reverse transcription-polymerase chain reaction (RT-PCR) and neutralization, to investigate seropositivity rates and MTCT of CHIKV. RESULTS: Of the 1006, 119 tested positive for CHIKV immunoglobulin (Ig)M, of which 36 underwent detailed laboratory tests. While none of the IgM reactive samples were RT-PCR positive, 14 symptomatic pregnant women were confirmed by CHIKV neutralization test. Twelve babies were followed with eight normal and four abnormal outcomes, including stillbirth, cleft lip/palate with microcephaly, preterm delivery, polydactyly with sepsis, and jaundice. CHIKV IgM testing identified three possible antepartum transmissions. CONCLUSION: In Nigeria, we found significant CHIKV infection in pregnancy and possible CHIKV antepartum transmission associated with birth abnormalities.