A systematic review of risk of HIV transmission through biting or spitting: implications for policy.

OBJECTIVES: The perceived threat of HIV transmission through spitting and biting is evidenced by the increasing use of "spit hoods" by Police Forces in the UK. In addition, a draft parliamentary bill has called for increased penalties for assaults on emergency workers, citing the risk of communicable disease transmission as one justification. We aimed to review literature relating to the risk of HIV transmission through biting or spitting. METHODS: A systematic literature search was conducted using Medline, Embase and Northern Lights databases and conference websites using search terms relating to HIV, AIDS, bite, spit and saliva. Inclusion and exclusion criteria were applied to identified citations. We classified plausibility of HIV transmission as low, medium, high or confirmed based on pre-specified criteria. RESULTS: A total of 742 abstracts were reviewed, yielding 32 articles for full-text review and 13 case reports/series after inclusion and exclusion criteria had been applied. There were no reported cases of HIV transmission related to spitting and nine cases identified following a bite, in which the majority occurred between family (six of nine), in fights involving serious wounds (three of nine), or to untrained first-aiders placing fingers in the mouth of someone having a seizure (two of nine). Only four cases were classified as highly plausible or confirmed transmission. None related to emergency workers and none were in the UK. CONCLUSIONS: There is no risk of transmitting HIV through spitting, and the risk through biting is negligible. Post-exposure prophylaxis is not indicated after a bite in all but exceptional circumstances. Policies to protect emergency workers should be developed with this evidence in mind.

Specialist care of older adults with HIV infection in the UK: a service evaluation.

OBJECTIVES: There is a clear trajectory towards cohort ageing in the UK. HIV infection is associated with an increased prevalence of traditionally age-related comorbidities and geriatric syndromes. Some HIV services have been proactive in innovating models that cater for adapting needs. We aimed to describe how widespread this practice is and what form such services take. METHODS: We conducted an evaluation of the perceived need for and current provision of specialist ageing services, and the need for formal guidance on monitoring or treatment of older adults with HIV infection. A web-based questionnaire was sent to the audit lead at every British HIV Association (BHIVA)-registered HIV clinic. RESULTS: A total of 102 clinics responded, with a broad geographical spread. Five of the 102 clinics have a clinician with an interest in ageing. Two dedicated HIV ageing services exist, practising different models. A quarter (23 of 98; 23%) of clinics reported a need for an ageing service, with three in development. The majority (65 of 95; 68%) supported dedicated guidance for monitoring in older adults, but fewer (39 of 94; 41%) felt that dedicated guidance on treatment was necessary. CONCLUSIONS: We identified two existing and three proposed HIV ageing services. Another 20 clinics (20%) reported an unmet need for a specialist ageing service, suggesting that complex older adults may pose a management challenge. This is the first survey of its kind to attempt to describe the current landscape and opinion around such services. HIV-infected cohorts will continue to age and current models of care may be insufficient, which should prompt services, their users and commissioners to consider what models may best fit current and future demand.

Achilles tendinopathy following Kaletra (lopinavir/ritonavir) use.

A multitude of rheumatologic manifestations have been associated with HIV infection and protease inhibitors use. We describe two cases that display a temporal relationship between initiating Kaletra and developing Achilles tendinopathy. Immediate and dramatic resolution of symptoms occurred on switching from Kaletra to an alternative agent. Clinicians may want to consider a trial of an alternative agent in individuals on Kaletra who experience Achilles tendinopathy. Adverse events must be formally reported so that our understanding of antiretrovirals may continually evolve and aid decisions about antiretroviral prescribing.

Creutzfeldt-jakob disease as a cause of cognitive decline and seizures in the elderly: diagnostic pointers and strategy for investigation.

Cognitive decline affects one in twenty people over the age of 65. There is often a paucity of clues as to the underlying pathology, and while the diagnosis will usually prove to be either Alzheimer's disease or vascular dementia, there may be clinical features suggesting rarer alternatives. This case of a 71-year-old lady with a 3-month history of progressive cognitive decline illustrates clinical features suggestive of Creutzfeltd-Jakob disease such as rapid decline in conscious level and myoclonic jerking. Diagnosis was confirmed by 3 means: (1) Electroencephalogram demonstrating periodic sharp wave complexes, (2) MRI brain showing cortical ribboning and high signal in the caudate nucleus, and (3) presence of protein S100 and protein14-3-3 in the cerebrospinal fluid. Postmortem brain histology confirmed a typical spongiform encephalopathy. Establishing an underlying aetiology is dementia is important not only for prognostic reasons but in order to detect potentially reversible causes. In cases of an atypical dementing illness our proposed investigations may assist in confirming or excluding underlying Creutzfeltd-Jakob disease.

Differential Ingestion and Digestion of Bivalve Larvae by the Scyphozoan Chrysaora quinquecirrha and the Ctenophore Mnemiopsis leidyi.

We investigated predation on bivalve veligers by the scyphozoan Chrysaora quinquecirrha and the ctenophore Mnemiopsis leidyi. We found that the medusa stage of C. quinquecirrha captures, but does not digest, veliger larvae: 99% of oyster veligers (Crassostrea virginica) caught by medusae were egested alive within 7 h of capture, and 98% survived for 24 h after egestion; 98% of oyster, mussel (Mytilus edulis), and clam (Mulinia lateralis) veligers placed on the oral arms of medusae were rejected; all bivalve veligers in field-collected medusae were closed and full of tissue. Our laboratory evidence suggests that the shell of larval bivalves probably offers protection from medusae: 23% of dead, open veligers were ingested by medusae compared with 0.7% of live, closed veligers; open veligers were retained longer than closed veligers; and tissue excised from recently settled oyster larvae was ingested and digested. Freeswimming C. quinquecirrha ephyrae ingested but did not digest veligers. By contrast, the benthic scyphistoma stage ingested 69% of veligers that contacted their tentacles and digested 48% of those ingested. Each scyphistoma consumed an average of 1 veliger/day at densities of 0.3 veligers ml-1. However, larval settlement was not reduced on oyster shells bearing scyphistomae. By contrast to the results on C. quinquecirrha, ctenophores egested only 4% of veligers alive, and 25% of the veligers in their gut contents were digested. Predation on veligers by ctenophores was estimated to be 0.2 to 1.7%/day in Chesapeake Bay. We conclude that C. quinquecirrha medusae are not important predators of bivalve veligers, but rather may reduce their mortality by consuming ctenophores, which do eat veligers.