lecture for medical students

1. human immunodeficiency
virus
(HIV)
by
Dr.Tarig Mahmoud Ahmed
MD SUDAN
HAIL UNIVERSITY KSA

2. The HIV virus is an RNA retrovirus

3. Transmission
 Horizontal: transmitted through sexual
contact, blood and blood products
 Vertical (mother-to-child).
 Peri natal: occurs in the late third
trimester, during labour or delivery ---80%
 breastfeeding --28%
 Most of the pregnant women with HIV have
acquired their infection through
heterosexual exposure.

4. Screening
 Routine antenatal screening has increased
detection rates and new treatments have
increased life expectancy.
 all pregnant women should be offered
screening in pregnancy because antenatal
interventions can reduce maternal-to-child
transmission of HIV infection from 25 to
30% to less than 2 %.

5. counselling
 Ensure that the woman understands the
reasons for screening.
 Appropriate interventions would be of
benefit to her baby.
 Reassured about confidentiality and
support,
If she be positive.
 Disclosure of the HIV diagnosis to her
partner should be handled with sensitivity.

6. Clinical features
 Infection with HIV begins with an
asymptomatic stage with gradual
compromise of immune function eventually
leading to acquired immunodeficiency
syndrome (AIDS).
 The time between HIV infection and
development of AIDS ranges from a few
months to as long as 17 years in untreated
patients.

7. Factors Increased risk of transmission to
child
 Advanced maternal HIV disease.
 High maternal plasma viral load.
 Low CD4 lymphocyte counts.
 Prolonged rupture of membranes.
 Chorioamnionitis.
 Preterm delivery.
 Obstetric interventions such as FBS or fetal
scalp electrodes.
 Coexisting viral infections e.g. herpes and
hepatitis C.
 Breastfeeding doubles transmission rate.

8. Management
Interventions to reduce the risk of HIV
transmission are:
 Low or undetectable viral counts at time
of delivery.
 Anti-retroviral therapy, given antenatally
and intrapartum to the mother and to the
neonate for the first 4–6 weeks of life.
 Delivery by elective Caesarean section.
 Avoidance of breastfeeding.

9.  Women who do not require HIV treatment
for their own health require antiretroviral
therapy to prevent mother-to-child
transmission usually commenced between 28
and 32 weeks of gestation and should be
continued intrapartum.

10.  Lactic acidosis is a recognized complication
of highly active antiretroviral therapy
(HAART) regimens and may mimic the
symptoms and signs of pre-eclampsia.
 Where this condition is suspected, liver
function tests and blood lactate should be
monitored.

11. Mode of delivery
 An elective vaginal delivery is an option for
women taking triple drug antiretroviral
therapy who have a viral load below 50
copies/mL at the time of delivery.
 Women who planned for vaginal delivery
should have their membranes left intact for
as long as possible.
 Use of fetal scalp electrodes and fetal blood
sampling should be avoided.

12. Caesarean section
 A Caesarean delivery is recommended if a
woman is taking monotherapy, or if viral load
is above 50 copies/mL at the time of delivery.
 A Caesarean delivery should be recommended
for women with hepatitis C co infection as the
risk of transmission is higher.

13. Management of infants
 Cord should be clamped as early as possible
after delivery and the baby should be bathed
immediately after the birth.
 NO breast feeding.
 All infants born to women who are HIV
positive should be treated with antiretroviral
therapy from birth for 4–6 weeks.
 PCR is used for the diagnosis of infant
infection, typically, tests are carried out at
birth, then at 3 weeks, 6 weeks and six months.

14. Hepatitis B

15. The hepatitis B virus (HBV) is a DNA virus

16. Transmission
Transmitted:
 mainly in blood
 other body fluids such as saliva, semen and
vaginal fluid.

17. Lab results
The presence of antibodies to the hepatitis B
surface antigen represents immunity
resulting either from previous infection or
from immunization and should not cause
concern
The presence of the surface antigen itself, or
the ‘e’ antigen, represents either a recent
infection(HbeAg) or carrier status(HbsAg).

18. Screening
 screening for HBV should be offered to all
pregnant women so that effective post-natal
intervention can be offered to infected
women to decrease the risk of mother-to-
child transmission.
 85 % of babies born to mothers who are
positive for the hepatitis e antigen (HBeAg)
will become HBsAg carriers and
subsequently become chronic carriers,
compared with 31% of babies who are born to
mothers who are HBeAg negative.

19.  Mother-to-child transmission of the HBV is
approximately 95 % cent preventable through
administration of vaccine and
immunoglobulin to the baby at birth.

20. Clinical features
 Hepatitis B is a virus that infects the liver,
but many people with hepatitis B viral
infection have no symptoms.
 The HBV has an incubation period of 6 weeks
to six months.

21. Management
 Women who screen positive for hepatitis B
should be referred to a hepatologist .
 To prevent vertical transmission of
hepatitis B, a combination of hepatitis B
immunoglobulin and hepatitis B vaccine
may be given.

22.  The passive immunoglobulin provides
immediate protection against any virus
transmitted to the baby from contact with
blood during delivery,
 The active vaccine provides ongoing protection
from subsequent exposure in the household.
 The active vaccine is given in three doses: at
birth, at one month and at six months of age.

23. Mode of delivery
 Mode of delivery does not appear to have a
significant effect on vertical transmission
 Manage delivery to minimize risk of vertical
transmission by avoiding fetal blood sampling
and fetal scalp electrodes where possible.
 Breastfeeding is not a risk factor for mother-
to-child transmission of hepatitis B virus.

24. Hepatitis C

25. Hepatitis C is a RNA virus

26. Transmission
 Transmitted through infected blood
products and injection of drugs.
 It can also occur with tattooing and body
piercing.
 Mother-to-child transmission can occur
due to contact with infected maternal blood
around the time of delivery, and the risk is
higher in those co infected with HIV.
 Sexual transmission is extremely rare.

27. Screening
 Current recommendations are that
pregnant women should NOT be offered
routine screening for HCV, because there is
a lack of evidence-based effective
interventions for the treatment of HCV in
pregnancy, and a lack of evidence about
which interventions reduce vertical
transmission of HCV from mother to child.

28. Clinical features
 It is one of the major causes of liver
cirrhosis, hepatocellular carcinoma and
liver failure. Following initial infection,
only 20% of women will have hepatic
symptoms, 80% being asymptomatic.
 The majority of pregnant women with
hepatitis C will not have reached the phase
of having the chronic disease, and may be
unaware that they are infected.

29. Management
 Testing for HCV involves detection of anti-
HCV antibodies in serum with subsequent
confirmatory testing by PCR for the virus, if
a positive result is obtained.
 Upon confirmation of a positive test, a
woman should be offered post-test
counselling and referral to a hepatologist
for management and treatment of her
infection.

30.  In non-pregnant adults, interferon and
ribavirin can be used to treat hepatitis C
infection, but these are contraindicated in
pregnancy.

31. mode of delivery
 There is no strong evidence regarding mode
of delivery in women with hepatitis C.
 elective Caesarean section NOT
recommended for all women with hepatitis C,
although it is recommended if the woman is
also HIV positive.
 Breastfeeding is not a risk factor for mother-
to-child transmission of hepatitis c virus.

32. Thank you for your attention