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okay. Makes it two lovely big announcement when it does that that with me was gonna admit everyone. Now. Hello, guys. Good evening. I hope your Oh, well, So I think that's pretty much everyone in. And so we have a doctor on low on the dust do with us today who is going to be doing a session on chronic HIV infection on AIDS on. She ran the procession on HIV. I'm so she's come back with us today. I want to give us another brilliant session. So And as you'll know, the 1st 40 minutes, all the first kind of not like 35 ish minutes will be teaching time on. Then the last 15, 20 minutes will be for any questions. If you do have any questions and put them in the chat box on 100 will see you now, Doctor. I think I'll just muted Doctor, I fabulous. Hi. Thank you again for the kind introduction. Onda, Thank you for having me back. Um, they felt that, um, this session would write an opportunity to build on the what you learned in the previous session. Um, Onda kind of use the response in the feet back uh, that was given to see how we can best support it. I suppose what I should also call it is management or supportive. Care for the person living with HIV said to recap some of the stuff we did last time. So these are the objectives of this. This, um this lectures a brief revision off the previous one. The approach with people living with HIV. Very cursory. Look at opportunistic infection. Think is in on those ones that are kind of Coleman serious and severe. Um, that people often this other HIV pathology that is worth there in in mind there was living with HIV on the approach to listing management. So to recap the previous session, these were the objectives. We had a kind of a brief look at the history of HIV from kind of discovery and where we are now, the epidemic situation around the world, the etiology and pathogenesis of HIV infection, the classification of clinical stages testing and diagnosis. The principal for into retroviral introduction. Um, monitoring on the care continue and social determinants. I'm sorry to interrupt, Doctor Thie. The preview mowed the view mode for your power points now on. So We're just We're still looking at the first slide of the moment. Oh. Uh huh. Uh, it's on May. Should we try that again? Um, how is it now? And I was still looking at the non presentation mode. Okay, I will. Are you on the Requip? Ah, slide daughter. Yeah. Yeah, you can see that. Oh, okay. Yeah, that that's that's Yeah. I think we agreed at the start that we got said that, um you don't want to go into presented mode, that it was better like their speaker's and you having some issues with it last time. So we're going to just be sticking with the presentation like this today, guys. So what? What can you see? We can see exactly what you Conceicao. So, um, so you know, if you like the little bit Bharat, this heart, it just means that the slide on full screen, but we can still see the slides. Okay. Okay. I think I I'm on a Mac say, I think I am on the equivalent of presenter, but, um, I didn't appreciate. Can you guys see my notes and Yeah, Yeah, we can see. Oh, no, it was Yeah. Okay. They didn't appreciate that, because that's quite dense. There's quite a lot in it. I would not. Let's try that again. So if you click to the top on top are on click slideshow, it's like a yeah on. Then I think it's a little bit of a lag. And then I think it's like few slides a while back with me One moment. Say clinic slides. It's if you actually select. Yes, so click on that and let's see what it Sayers on. Then say play from the start or play from Cook current slight. Say play from the start. You've got me on play for the start. Yeah, I think that might be a bit of a lot cars, so we might have to stick to it this way. Yeah, he's obviously absolutely fine, Mrs. Perfectly fine. We couldn't see the screen. Absolutely fine. Don't worry about it. I get a I'll take it if you can only see my um Yeah, I do that. That is perfect, actually. Yeah, that's lovely. Make it a bit better. Yeah. Thank you so much. No, it's okay. It's okay. I have a completely different beauty. You guys. So I I can I can see. I can see it a subfalcine thing. All writing is so going back. So this is the recaps so that but sort of will run through in the last session. And then this session, which is looking at that aspect of the continued that we didn't we didn't really look at in much detail. So we kind of started people on HRT yet highly until a highly active antiretroviral therapy on. But then we didn't talk about this section, which is really the kind of what people often associate with HIV is the kind of AIDS epidemic and what happened after and just take read. It's rate that HIV does not always need to progress to AIDS. That timeline is on average on that timeline off. This graph you can see is with someone who has not started on two retroviral therapy. Say when we talk. When we looked at a stage in last time, we looked at kind of Stage four with a CD four count below 200 on the occurrence of specific diseases associated with a try being, and we briefly mentioned some of thumb can any can people think just just right in the chat. Any ideas or opportunistic infections or infections that associated with HIV? So in the town, we have candida PCP. Okay, Composes sarcoma. STDs. What it? Sorry. What is the STD standing for? Is that for sexually transmitted diseases? But I'm not cream for something else. I I want to make any assumptions. Is there's injectable and seeding. I remember staying off iris. Respect your infections yet? Sexually transmitted diseases. Yeah. So, uh yeah. So I'm thinking, um, specific infections. So Epstein Barr is correct. CNBC's a BG candidate, or, um so AIDS is an interesting answer because acquired immunodeficiency syndrome is not what you'd consider necessarily. It's not an infection. HIV is is the human immunodeficiency virus is the thing that caused the infection. AIDS is a syndrome. So it's a collection off symptoms that can present in many, many different ways, depending on who has independent of contacts, depending on other quick mobility of factors. Um, so that that's an important distinction to kind of delineate. Yes, say, But I want I want how much of these are going to come up. So yeah, these days is kind of the stuff with thinking off. So it's important to think about the things that are common in people with HIV because they appear very differently in people in HIV. But also people with HIV will have the things that are common already in the population because of that immuno suppressed state that we have, um, TV is a very interesting one, and we will have will have a bit more of over over deep dive into into TB opportunistic infections as we've mentioned infections that occur more often, or a more severe in people with weakened immune system, those with healthy immune systems on the other things that we can your immune system other than HIV. Um, so anyone familiar with any other conditions with diseases that leads Teo Immunosuppression? I, um, me a Tradjenta Klay or or otherwise, yeah, yeah, lymphoma has been something in particular that weaken your immune system. I mean, that's the whole idea of lymphoid generated, um, liver generated cancers. That's one Many chronic diseases will do the same thing on, but it's worth remembering that people who had organ transplantations to kidney liver on immunosuppression will also will have weakened immune system's. So you can see these is just working your differential diagnosis is being aware of that and that you can see this. But a lot of chronic disease is a lot of cancers. Some estrogenic in me and suppression will really too similar presentations. So it's a piece a couple of the stuff we wanted to talk about, a said with for the sake of time, because I'm very whether we have around last time too significantly shortened. This is to look at these things that are common on these things that I missed and it's worth thinking about. So we'll focus predominantly on the respiratory system, the G I trapped under neurological systems because sometimes this presentations could be very nebulous and then on special relationships. So the first is the respiratory system. So I know some of you have already mentioned most of these. So we're going to some going to go straight to this slide rather than our ski. Which disease is a common within that the HIV immunosuppressed people say we go to back loose is we've gotten you Mr Stick pneumonia. We've got histoplasmosis and we've got other community acquired pneumonia. So whatever pneumonia is going about in, you know your general area, either it's worth thinking about. Uneven. Aged. If someone with HIV has been in the hospital recently, can anyone think of which pneumonia, which is not on the list? We might be thinking off? Yeah, Which one's a common? Which, which Norgle ISMs common cause is in in your hospital through your institutions? Yes, that that's not sadness. Yeah. Say thinking about drug resistance and off drug, wrist and causes of pneumonia would be a good good idea for whatever is going on in your in your place. Yeah, Yeah, we call that say respectfully looking at TB now, TB is fascinating because the relationship between HIV and TB is a very symbiotic one. The infects say that this diagram is sort of highlighting on this. The paper in the references really is is really good read. I do recommend it is highlight in the relationship between HIV and TB infection on the theories on how together they worsen outcomes than what you do is you. If you had HIV infection alone or if you had TB infection alone. So the mycobacterium, when it infects the resident of your macrophages, produces increased level off lows of sight, a kind on achieving a crisis factors and interleukins, and that leads to unenhanced mint of the HIV off HIV virus. Replication on those, uh, those macrophages that affected with both organisms are also less prone, so they're less likely to undergo TNF dependent a pop Tosis. So if you remember last time we talked about the host immune response to do any type of affected cell being to have it filled on, that that that's less likely to happen if you have an HIV and TB co infection rather than the singular infection, Um, on D, the HIV infection or so induces the expression of beer markers, which then we can your T cell response to TB. So together they have a really good relationship, which further compromise is the host. So in coming in in countries and situations where you where you have a high prevalence of either or so context like, um, prisons, um, it's it's really it makes it more difficult to get hold off all to get hold off on Outbreak or an infection, it becomes more difficult to successfully treat people on. Do you get situations where more to drug resistance develops quite quickly, so that's worth knowing on also because both infections our office and present with quite constitutional symptoms who not very clear, precise symptoms. You know TB has its chronic cough, but for some people, that isn't always as obvious. It's lost to the very long time. Um, it makes it also difficult to delineate it so often in places where there's high prevalence, where we have a lot of the population suffering from either or if you are. You know, if you diagnosed, um, with TB, you review them the HIV. You could diagnose someone with HIV. You review that before TV when, as you said in the previous lecture, what paper mentioned. But HIV, a sexually transmitted infection hunts impact with other sexually transmitted infection. So it really depends on your contacts in your situation. If there's a high prevalence of syphilis or family or gonorrhea, if I'm doing one HIV test, my eyes will do all the other test for the other infections to see when you look at TV, A lot of the symptoms tend to be constitutional. People in the chapped mention or think off what people with TB often present with people with TB HIV combination problem, the ones I'm giving. Yeah, yes. Good tech. See, a weight loss might slip for Have CVA? Yep. Keeper. Yeah, these would be your constitutional very general eye symptoms and depending on the state of people. But a lot of the presentation is usually about point where they're becoming a Texas on where we investigate often. Now, you're very, very good point of care tests. So we use gyn expert, um, usually on, but you can use, um, Italy TB. Um, the these tests are a lot. They're standardized. They're easily available worldwide. Um, at least better than they used to be on. They don't require the kind of specialist, um, skill set that you need for something like microscopy, culture and sensitivity or added fast bacilli test. I'm staying in. And in terms of management, we say a B C D E management people know what I mean by that. Or did these acronyms start stand for? Yeah, sweet. We got back. Um, So yeah, so prioritizing. Kind of stabilizing that person, getting getting them in a position where you know you can you can actually have some interventions on starting that. You're long your very long time TV treatment. So usually the acronym. I used to remember what TB treatment is, what we've been using for a very long time, especially when your jinaek spurt hasn't told you that there's resistance is ripe to reform. Person denies it. Pyrazinamide on the computer There's a lot of eyes anizers resistance in this summer campus in resistance around. So it's always worth doing something like genetic spurt, which can tell you they if there's a resistant and you can cause the dirt, um, using the W two protocol to change your treatment. So the next respiratory one is Pneumocystis pneumonia? Um, yes, well, not always. Usually, if you take a good history, you should be able to delineate, um, between a side effect on hematuria. But it's raised a very good point, which are kind of ever speaking about it's what having a look at the medications and know in the side effects because patients lack of a deer in on stopping treatment. A lot of that is influenced by the fact that they are not counseled, um, appropriately before the start of treatment, said Pneumocystis pneumonia, which is another very indicative pathogen that doesn't tend to affect us until wait mean it's suppressed, say often the main side effects for this. The main presenting complaint is shortness of breath on on examination, the attack picnic on their pox. Sick. But often you don't have very clear you didn't have very clear clinical signs on your chest. X rays or your CT's can shoot diffuse interstitial infiltrates. You can do a PCR. You know why there's a rock. See, the the management is similar. So looking at maybe CD stabilizing that patient with that respiratory problem and then co-trimoxazole if you didn't know someone with any of these infections, it is worse again. Which is I'm going to reach rate if you send this feud, um, sample or if you send some foot PCR, someone has name assisted. You should be thinking or checking for HIV. Okay, often times it's worth making sure that is, You know it's just good. It's good management policy, which opportunistic infections are fuss to appear in a try being, so it really it depends. It depends on which kind of coats your looking at it depends on which populations you're looking at, for example, in parts off sub Saharan Africa or like South Africa, Um, whether it is increase prevalence of HIV and TB. Then you often get people presenting with TB because you don't have to be a minister pressed to get TB right. Many people without without even a suppression can be positive for TB. Any few imprisoned situations and stuff like that before, in areas of the population or if you're in, You know, if you're more Western or or high income countries where the prevalence is not that high, you're the other genetic infections you get will be very different. Also, the computer system affection can different dependent on what's prevalent in your population. Onda what? Your exposure and rest of these things are safe, for example, um, looking at, you know, increase in people with increasing infections of molluscum. Contact us, um, in people with HIV boy, you're looking at increasing composes sarcoma among people with HIV. Those things are more prevalent in certain populations already. So if someone with in that population then gets an HIV infection, you want you present with, uh, the beginning is different. You have that makes sense. So the next one is gastrointestinal symptoms. So what gastrointestinal disease is? Are we thinking off when we think about, um, opportunistic infections. Okay, there we go. And dysentery and writers, Malaria, Peptic ulcer is so it's a busy thinking more in the terms off. What are you What are you thinking When someone presents who is HIV positive and what are the more likely to have? So, as we said before, the things that are going around in your population are going to be prevalent that a lot of the time you have you look at their symptoms on these the key ones that you wouldn't often get in immunocompetence. But if you get, you should be thinking I should be doing an HIV test. Is that is that kind of that does that diagnostic triage big sense. There we go for my good bacteria. Um avium complex. So this is a combination of off microbacterium in Tulsa. Little alright, Mycobacterium avium and the bacteria again have a very good symbiont IQ relationship on often the person presents with chronic non bloody diarrhea on on examination, you know, you you should you should be thinking about best. If someone has the diarrhea that is non bloody and has been around for more than a month, this should be top of your differential as well as that HIV test that we're going to do. It is the first presentation. Open an examination, you see wasting. Hello, Doctor. I think it looks like you paused. Can you hear us? Well, can you see anything? Okay, guys, I think we'll give and the doctor just a couple minutes. All right, baby, Don't suppose the recordings are? Yeah, that was sweet. I'm not sure where I lost. Um, afraid, um, muscle wasting three around the muscle wasting area. Uh, so, yeah, it's a general kind of general whole body wasting lymphadenopathy on a participant of meddling on often. Do you? Do you? Do you need to do that? Mike Rowe microscopy culture and sensitivity on this. This is a really good just to kind of give credit where credit's due. A lot of this microscopy slides are from the welcome trust collection. So they're open to the public, and they're really very useful to revise history, pathology and just kind of get your way around if you don't have. If you're not doing much practical work in labs what these things should look like, um, and management is usually as it through myself plus family. It'll the next one which again we often miss. That is, um it is common in those suffering. Oh, people living with HIV is cryptosporidiosis. Say this is why again your history. 80% of diagnosis you can usually get from If you're good history, take and your investigation students and examination Just help you confirm it did it when you're looking at someone with moderately watery diarrhea. So we're talking. We're not talking kind of the rice water stools off cholera, but we're talking about a water diarrhea that is non bloody, but it's quite profuse. Um, you you're thinking then because this because it's pretty, it's it's you're finding on examination, often quite nebulous. Um, on. You know, it doesn't always give you clarity, I'm afraid. Yeah, I think it, um I'm afraid my slides of swapped over, but you're the you're not doing the necessarily the same. Kind of you're not doing the same investigation protocol cryptosporidiosis ist So cryptosporidiosis is is a It's a brush border parasite or the that lives in the epithelial cells off the small intestine. So it's mainly you can see, I don't know, because I don't know much conceive from that slide, but you can see that it's attached to the epidural yourselves on it's the membrane envelopes it. But the incident interest, Elena, but the extra cytoplasmic because these are your these the rest of your kind of cytoplasm or fat cell, they got quite a distinctive look on microscopy. If you haven't trouble kind of seeing that that mean I don't, um but yeah, but they they once you got that slide, not much else he looks like, Um um And then with that you thinking for treatment, you know, reiteration on supplementary Think Are you thinking of treatment in a similar way that you think off treatment for the other things that you get, like the viral gastroenteritis? Uh, I let norovirus rotovirus say you are supportive on with supper with with think, because think has a very good effect of stabilizing the got lining. So next phase is neurology. So some of the stuff you guys already mentioned cryptococcal meningitis, toxoplasmosis, tuberculosis, which can present urologically unsighted McCalla virus encephalitis on something quite distinct. So progressive multifocal leuko encephalopathy. We're going to you too, about the fast TV because it's sort of a problem third on. The thing to note with TB is that if you know people have disseminated TV to the brain, you are treat him for longer because of the effect of the blood brain barrier on how penetrative your TB medication is. Um, how easy it is to get that on. You might also want to tweak some of your medications, but that I would say consult your local guidelines and the W two guidelines if you don't have local. So grip took a cosis say, this is a very kind of because a lot of the symptoms you get when you're taking that history you're trying to decide. Have you got a focal neurological problems? Have you got a global neurological problems sake? And anyone kind of Can anyone describe Oh, type in the chat what a focal neurological problem would be. It's all right. The zinc stabilizes and supports the recovery of the gut. Yes, a broadly at sort of what? What I how I divide kind of symptoms. So something like left sided weakness or one I go blind or you know that that is focal because it's localized to a certain section of the brain. You can kind of go back to your new anatomy on Piece it together. We're at something like a seizure. Of course, with some seizures, you have a Jacksonian march, so you start off in a very vocal way on. Then it becomes generalized. But in terms of seizures, do to infection and bring both ology you. That's a more generalized symptoms rather than a local symptoms. So the Zomig sense if I can. If you have a symptom on, I can tell you exactly where it is in your brain. Then it is very much a local eye symptom. If I can tell clinically if you have a symptom and it's neurological like confusion or a personality change or headache, then I can't really pinpoint that to a specific location on when we think of signs of meninges. Um, what are we looking for? Yeah, so many names for many fancy kind of things. You can do that. A lot of it is, Yes. How are they when you try to put pressure on either the spinal cord said the neck. I'm pulling their legs and stuff like that. How are they with were resisting that? Yeah, the next one say this one. When will this is why we were talking about? I'm sorry. Did we go through? We didn't go through what you do. Say sorry, because this is a This is a more kind of generalized problem on the issue. Here is that days and increase in the intercranial pressure because off the because of the me in response to the infection because of the inflammatory response of the bacteria, what you also do is a bit different. So after you a B c D. And stabilizing them, you can do a therapeutic lumbar puncture. You really some of the CSF in order to support on do reduce the amount of pressure that is building up in the very closed space of the vault. You also consider starting with life of Soma Lampa terrorism be on my side to flights cytose in or flu cytosis. And then afterwards you have a very long protocol off spending time treating that with fluconazole. This you know that the trick treatment is almost minimum of a year. So it is. It's ah, it's a significant undertaken, Onda Most you know, you have quite a lot of people ending up with long term, you know, neurological problems, even if they do recover. So it's just what, very in mind, the amount of kind of disability, um, a long term disability. But this can cause even with recovery. So why it's important that we know the difference between are kind of more global on focal signs is because something like top toxic, which can affect any part of the brain and spinal cord, does all from cause vocal symptoms, whereas cryptococcus testicles global symptoms too, sometimes just peace. And together that differentiation can allow you to figure out what test you need to do next on how you need to start supported. So we talked a pass met. This image is just showing that this is a cute, necrotizing toxoplasma, and so what it does. And you can see this is not a happy brain. And that swelling has got nowhere to go. Say this is a picture credited to radio Pedia on It's really, really good results again for looking at image is all images on just learning how to interpret those images on On cursory glance, I really highly recommend it, um, on this patient, I understood it was initially thought to have a glioma, um, and then open get into surgery. It was found to have quite severe toxic. And for this again, it's a B C D a. It's kind of stabilizing that either. I'm surprised this person wasn't suffering from seizures on, um then starting them on and biotics. Does anyone remember kind of the timeline that was we mentioned last last time for starting antiretroviral therapy. So when would you start antiretroviral therapy for patients with neurological? Same terms of AIDS. Only in the case of neuro symptoms don't we have to be careful because of the actual viral retroviral itself can cause the neurological symptoms as well like that. So then we have to kind of, like, stabilize that side before we start retriever. So when you say stabilized, what? What kind of what are you? What are you thinking? Like knowing exactly where the issue is on what it's related to specifically what the deficit is. Make sure it's unrelated to another medication or something else that's going on. So you actually know exactly what the problem is before we start anything else? Yes, definitely. That is, that is worth doing that with something like say TB, if I know that you've got pulmonary TB only, um, then I can I would I would start you as soon as possible on antiretroviral therapy, because often times people, sometimes you might only get that one chance to get that person. Teo, you know, they might come back. Um, todo clinic you're in. So you you you try and start a many of the medications you can assume as possible. So let's see, we've done everything and we know that this person has a neurological issue on a neurological is defined illness that we want to start, um, onto retroviral therapy is why that perhaps I need your question is why would I not start it immediately? Going back to something that featured in the last lesson? I think I'll so the positive speak earlier kind of hinted on this. So one of the potential complication off starting, highly hang active retroviral therapy on to recover therapy is the fact that you have a risk of an exaggerated immune response. So you're the person who's living with HIV as basically hot. The immune system shut down and it's been the sleep for a while. But, you know, it's been getting assaulted for a while. It's really very difficult then, when you really wake it in that immune system, there is so much around to fight on to deal with that the exaggerated response of your immune system can further compromise. You're you're that that inflammation on again in places like the brain where there isn't that much space for you to go to. If you start all kind of whole scale nuclear war bit because your immune system is restarted. That in itself can be a big problem, so patients can sometimes seem to be getting worse before they get better. So we say, usually with neurological issues, it is worth waiting 4 to 6 weeks whilst they you've treated some of that. So there's a dampening down of all those toxins and activating compounds and then start in the highly active, highly active interest of our therapy. Whereas for almost everything else off, um, you stopped as soon as as soon as you can, because sometimes that's your only chance to get that patient in that room. But often the patient in the state with the neurological issues, they're not going anywhere, you know by the time you've got this MRI scan you, you probably be be with us for a while. So this is the key things that one a common in people with a try. Be not as common in others or a very key Onda. You know, I felt that I often missed when people present and come in. There were other stuff that also common, but I'm very aware of the feedback last time that we around over time, say, I really think it's what having a look on, like exploring this in your own time, I really recommend the Oxford Handbook of Tropical Meds. Then it's brilliant on. I really recommend the wt guidance on managing people where they tried the, um because it's very, very well written on the and they got quite a few of them. They're also things that are not to do. So this is something that someone hinted on that or not to do. Um, altered handbook off tropical medicine. The fifth edition is out on. I understand that if you study in a lower middle income country, it is free. Um, but otherwise your institutions will have, um so they're also things that are worth kind of consider, and that ought to do with chronic, um, HIV infection, but no chronic age of infection, but not to do with other opportunistic infections. Right? So things like the things that you talked about so far, like toxic but toxoplasma aces. 40 to 60% of us have been infected with toxoplasmosis. It was one time, well, the other injured in the world. And sometimes they stayed dormant. It's a common disease in cats. It has no business in humans. We're not, um we're not. It's and host. It can't reproduce in humans. So if toxicity finds us after in a human, it's it's usually because it got lost. Whereas some things are just you to the effect that the HIV virus itself is having on yourselves on the cells of the person living with Try to be so. A lot of you know, HIV is safety. HIV advances and significantly increases the risk of dementia. Ah, lot of these effects are thought to be due to the chronic inflammatory nature of the foot on the blood vessels on on the cells. I know also, many of them had to do with, you know, diseases. Oh, anemias and pressures of chronic diseases say these things, I think really kind of worth considering the a lot of new wrist like car trick illness is a lot of depression. There are a lot of other things that occur with people with HIV that is really worth being aware of. There's open a chronic fatigue that occurs. There are also interesting pathologies again, due to that change in vasculature off that permanent or semi permanent inflammatory response for things like pulmonary arterial hypertension. So people with HIV really Do you know when when they say, Do you still need HIV doctors or do you still need specialist management? Well, yeah, even with HRT, we really do because although we've made a lot of success and a lot of progress, there are still you need someone who can see that whole picture and can look at the nuances off. Why that person's situation contextualized it, teo to HIV and the chronic, the chronic disease that's just idea off the other stuff that can occur out of HIV associated. Um, I said many do to the constant inflammation on the constant irritation of the blood vessels, so holistic management is really key on joined up management When you have different specialties and different silos, Um, I'm also thinking outside the box, just thinking a little bit differently. I'm thinking, Oh, what my, what else might this be? Or how else can we better support this person? I'm going to reiterate the fact that we really it's really important if we are to reverse the tide on this epidemic that we have on HIV care. Continue. It's really important that when people leave therapy, we welcome them back on. It's very important that as clinicians, we think about those other things that could be affecting their ability to engage with HIV treatment. I don't have many pictures in my slides because I'm never very sure about the consent process, especially when it comes to pictures of people. And I think it's very important to make sure that, you know, if you're sharing something, it's something but has permission. So just June was one of the few pictures I could find a line where the person that detail will the publisher detailed consent on. We really want to go from the picture. Your left two more of the picture on your right on. We can do that with I only have 200 of our therapy. Good. Follow up, clinicians. Who? You know, I think I saw the box and look holistically up the patient just to make you aware off the W two campaigns. You It was you on, detective. A viral load equals HIV is on transmittable, which is really one of the biggest benefits we having in terms of control in this on it's one of the main message is that you know, that'll be a choice trying to person put out there because there's very good evidence. If we can't detect your viral load, you're not going to transmit it to When he tried going to remind you guys of the free e book by Stephen Burger on you know the access to that Andi here is my baby. A graffiti. So that's the reference for the Oxford Handbook. Onda, though the other images, they have their own references on the pages they were at. But as I said, many of the microbiology slides where from the welcome collection. Thank you so so much doctor or a wonderful actor, we have one. Would it left. So I don't think that leaves of those with much time for questions. But you've handled on a lot of questions throughout the lecture anyway, on So thank you so much for that. And guys in relation to the E book. What we'll do is we'll get the link on. Do we'll make sure that it's distributed to the students so that everyone has access to it? And we'll, you know, we'll disseminate that information throughout how we normally do on our various platforms. Don't worry. We'll make sure that you get hold of it. Um, Thank you so much, Doctor. Thank you. Feel time. Thank you for having me take half of I. Okay, guys. So I was going to end this meeting now, but and we have our next lecture on nephrology starting in just a couple of minutes of just there with those Also get that set up that will be on acute and chronic kidney disease.