This document discusses HIV/AIDS and considerations for surgery in HIV-infected patients. It covers the epidemiology and transmission of HIV, surgical procedures commonly performed in HIV patients like draining abscesses, anorectal surgeries, and managing acute abdominal issues. Occupational risks for surgeons are addressed, including post-exposure prophylaxis guidelines. Universal precautions like barriers, vaccination, and waste disposal are emphasized to prevent transmission during procedures.

1. Dr. ANSHUMAN AASHU
1ST YEAR PGT

2.  GENERAL EPIDEMIOLOGY OF AIDS
 SURGERY IN HIV INFETED PATIENTS
 OCCUPATIONAL RISK OF HIV TRANSMISSION
IN SURGEONS
 PRECAUTIONARY MEASURES
 MANAGEMENT STRATEGY IN EVENT OF
EXPOSURE.

3.  AIDS is a viral disease caused by a retrovirus
of lentivirus family called HIV.
 Contains a core containing two single
stranded RNA, Reverse Transcriptase enzyme,
and core proteins.
 The envelope contains a glycoprotien (gp120)
– affinity for CD4 antigens.
 CD4+ cells are the target for HIV infection,
most commonly being the T-helper cells.
 Also involves macrophages, dendritic cells
etc.

4. Structure of the HIV

5.  After infecting the CD4+ cells, leads to the
rapid destruction of such cells leading to
different manifestations.
 Most common cell involved being T-helper
cells, leads to immunodeficiency and hence
several opportunistic infections.
 Some neoplasms (Kaposi’s sarcoma and
Lymphoma) also associated with HIV
infection.

6. Prodromal flu-like
illness
(1-4 weeks)
Seroconversion
(6 months)
Asymptomatic
phase
(8-10 yrs)
AIDS related
complex
AIDS
defining
illness

7.  Sexual.
 Body fluids.
◦ Blood and blood products.
◦ Semen, vaginal secretions.
◦ Saliva.
◦ Milk.
◦ Peritoneal, pleural and pericardial fluids.
◦ Synovial fluids.
◦ CSF.
◦ Urine, vomit, tears, sweat, feces (lower risk).
 Perinatal transmission.

8.  For diagnosis of AIDS related infection or
neoplasm.
 For surgical complications of AIDS.
 For other indications as in general
population.

9.  Lymph nodes almost always show follicular
hyperplasia, so not reliable for diagnosis.
 Excision/Incision biopsy of lymph node or
soft tissues required for diagnosis of
lymphoma, sarcoma, tuberculosis etc.
 Due to the risk of transmission, FNAC should
be considered first and surgical biopsy be
reserved for inconclusive FNAC reports.

10.  Abscesses.
 Ano-rectal diseases.
 Acute abdominal emergencies.
 Hepato-biliary and splenic disorders.
 Neoplasms.
 Intracranial SOLs.

11.  With profound immunodeficiency, abscesses
are common presentations in HIV+ patients.
 Young adult patients of either sex with
pyomyositis are particulary likely to have
AIDS.
 Treatment consists of simple Incision &
Drainage as in normal conditions.

12.  Most frequent reason for surgical
interventions in HIV+ patients.
 HIV+ male homosexuals have higher
incidence of such disorders than other HIV+
patients.
 Perianal sepsis, Fissures, Fistula, Warts,
Squamous cell carcinoma commonly seen.
 Large perianal incisions and division of
internal anal sphincter should be avoided.
Setons are ideal for fistulas.

13.  Anal warts are mostly resistant to medical
therapy with podophyllin. So electrocautery or
laser should be used.
 Other conditions may mimic perianal sepsis
like:-
◦ Massive ulceration following Herpes simplex.
◦ Kaposi’s sarcoma presenting as bleeding
hemorrhoids.
◦ Lymphoma as perianal abscess.
◦ Chronic indolent ulcer caused by M. avium
intracellulare.

17.  Acute abdomen may be a presentation in
about 12-45% of AIDS patients but surgery is
required in only upto 5% cases mainly for
appendicitis, obstruction or perforation.
 CMV infection, Kaposi’s sarcoma, Lymphoma
all may present with bowel obstruction or
perforation or even obstructive appendicitis.
 Requires laparotomy for perforations and
acute obstructions.
 30% of all acute appendicitis are related to
AIDS related illness. Requires appendectomy.

18.  Appendicitis carries higher risk of perforation
and abscess formation.
 Typhlitis common presentation in AIDS
patients.
 Other opportunistic infections of GIT may
also present as acute abdominal
emergencies.

19.  Chronic hepatits B and C infections are
common co-infections with AIDS.
 Small liver abscesses secondary to infections
with cryptococcus, histoplasma, candida etc
are common.
 Acute acalculous cholecystitis more common
in AIDS patients. Require cholecysectomy.
 Biliary obstruction due to compression by
enlarged portal lymph node or due to
infection with cryptosporidium, CMV or
mirosporidium may be seen.

20.  Multiple splenic abscesses leading to
splenomegaly is common.
 Splenectomy may be required for traumatic or
spontaneous rupture of spleen found to be
more common in patients with AIDS.
 May also be required for associated
thrombocytopenia.

21.  Kaposi’s sarcoma and Non Hodgkin’s
lymphoma common neoplasms associated
with AIDS infection.
 Surgery often required for biopsy purposes or
for other complications.

22.  In HIV positive patients, toxoplasmosis
causes brain abscess. If medical treatment
fails then CT guided stereotatic needle
aspiration.

23.  Necrotizing arteriopathy leading to aneurysm
formation common in HIV infected patients.
 Salmonella arteritis especially common
leading to pseudoaneurysm.
 Infected pseudoaneurysms also common in IV
drug abusers (high risk group for HIV
infection).
 Vascular reconstructions usually helpful.

24.  Studies show same rate of post-operative
complications in HIV positive as with
asymptomatic HIV negative patients.
 Incidence of infection after anorectal surgery
in HIV positive patients is independent of
CD4 cell counts.
 Relation between viral load and post
operative infection is still under trial.

25.  The surgeon is regularly exposed to blood,
which is the most infective medium for HIV
transmission. Incidence of accidental
exposure to infected patients blood is 6.4%.
 Risk is greater when there are more HIV
particles in blood i.e. during the earliest
and later stages of the disease.
 Risk with needle stick injury is 0.3%
 Risk of transmission in surgery is 1 in
28000-50000 per hour of operations.

26.  Extent of risk of infection to the surgeons
depends on:
◦ Prevalence of HIV in patient population.
◦ Number of procedures carried out by the
surgeon.
◦ Length of the period of risk.
 Risk is more when
◦ When surgery lasted for > 3 hours.
◦ > 300ml blood loss present during surgery.
◦ In major vascular, intra-abdominal and
gynaecological surgeries.

27.  Most common mode
 Risk of HIV:- 0.3%
 1ml of infected blood has
50 HIV RNA compared
with 109 HBV particles
 Hollow needles 10 times
more dangerous than
solid needles
 Most of needle
injuries(27%) occurs from
improper disposal.

28.  Deep injury.
 Visible blood on instrument.
 Prick directly into vein or artery.
 High viral load.
 Hollow needle > solid needle
 Large diameter needles.

29.  Recommended by CDC (USA) in 1987.
 Every patient to be treated and precautions
observed as if he/she has the infection.
 Use of protective barriers while dealing with
body fluids like blood, semen, vaginal
secretions, CSF, synovial fluid, pleural,
pericardial, peritoneal and amniotic fluids.
 Feces, sweat, tear, saliva, urine, vomitus,
nasal secretions not included.

30.  Corner stone of any precautionary program.
 All HCWs should be trained and educated
about different aspects of the infection that
include:
◦ Mode of transmission.
◦ Standard precutionary guidelines.
◦ Method of disposal.
◦ Social stigma and discrimination issues.
◦ Posting of warning signs for others.

31. Screening of patients
 Screening of patients for HIV,
HBV, HCV is very important
 Even if HIV test is negative, it
is not 100% sure that patient
is not infected.
 Patient may be in window
period when HIV antibodies
have not yet formed in the
patient (detected by the HIV
test kits)
 So precautionary measures
are very important.

32.  Revised CDC reommendations (2006) for HIV
testing in health care settings and screening
pregnant women:
◦ HIV screenings is recommended for patients in all health
care settings including pregnant women after the patient
is notified that the testing will be performed unless the
patient declines (opt-out testing).
◦ Persons at high risk for HIV infection should be screened
for HIV at least annually.
◦ Written informed consent from the individual should not
be required; general consent for medical care is
sufficient and encompasses consent for HIV testing.
◦ HIV screening should be included in the routine panel of
prenatal screening for pregnant women.
◦ HIV diagnostic testing as part of prevention counseling
associated with controlling HIV transmission or as part
of HIV screening program is not required.

33.  Noncompliance with recommendations on
universal precautions amounts to upto 84% in
emergency conditions.
 Hence, certain basic standard precautions
must be observed like wearing gloved while
drawing blood or inserting cannula.
 Routine wearing of gloves for examination of
AIDS patients are not recommended unless
for open wounds.

34.  Needles and sharps must always be disposed
in puncture-proof containers.
 Such containers should be present as near as
practically possible.
 Proper waste disposal.
 Additional precautions are to be observed
while performing on HIV+ patients:
◦ Barrier method
◦ Methodical approach

35.  DOUBLE GLOVES
(reduces risk by 5
fold)
 CAP AND MASK
 EYE GLASSES OR
SHIELDS
 PLASTIC
APRON/GOWN
 FOOTWEAR(wellington
shoes)

36.  Undue haste should be avoided.
 Assistants and other staffs should be
minimum.
 Incisions should be large so as to have
minimal requirement of retraction by
assistants.
 Surgery should be done in orderly manner
with meticulous attention to avoid as much
blood loss as possible.
 Clumsy transfer of instruments should be
avoided. Sharps preferably be transferred in
kidney dishes.

37.  TREATMENT OF EXPOSED LOCAL SITE:
◦ Skin: thorough cleaning with soap water. Never put
fingers reflexly into mouth.
◦ Eyes: Irrigation with fresh water.
◦ Oral cavity: spit out immediately and rinse with
water several times.
 Prompt exposure report regarding the time,
nature etc of exposure should be reported.

38.  Source
◦ HIV testing after proper consent. If known to be HIV
positive then assess the health status and the
possibility of drug resistance if on anti retro-viral
therapy
 Recipient
◦ Baseline serological testing for HIV, HBV and HCV.
 Nature of exposure.

39.  Depending upon the risk and toxicity
balance.
 Decision to start PEP depends on:
◦ Severity of exposure (Exposure Code, EC)
◦ HIV status of source (Status Code, SC).
 If required, should be started within 2-24
hours of exposure and not later than 72
hours.
 Effectivity decreases with increasing duration
since exposure.

42. EC SC. PEP recommendation
1 1 PEP may not be warranted. NO known risk
1 2 Basic regimen. Negligible risk
2 1 Basic Regimen. Negligible risk
2 2 Expanded Regimen. Increased transmission
risk.
2/3 Unknown Basic Regimen

43.  Consists of two NRTIs for 1 month.
 Zidovudine 300mg BD+Lamivudine 150mg
BD.
 Zidovudine 300mg BD+Stavudine 40mg BD.
 Didanosine 200mg BD+Stavudine 40mg BD.

44.  Consists of 2 NRTIs+ 1 PI for 1 month.
 Any of the basic regimen+ any one of the
following:
◦ Indinavir 800mg TDS.
◦ Ritonavir 100mg BD.
◦ Saquinavir 1000mg BD.
◦ Lopinavir 400mg BD.

45. Side effects
 PEP is very toxic so its use is weighed against
toxicity
 Should not be used for exposure that poses
negligible risk
 Don’t use three drug regimen for all HIV exposure
 Most common is nausea and diarrhea
 Mild and reversible may be relieved by
domperidone and loperamide
 PIs cause peripheral neuropathy
 Indinavir:- Nephrolithiasis, Hyperbilirubinemia
 NRTI Abacavir causes hypersensitivity reaction
 NNRTI not used causes acute fulminant liver failure
 Efavirenz is teratogenic, Steven Johnson Syndrome,
dizziness, insomnia, psychiatric illness

46. Investigations before prescribing
PEP
 Full medical history
 Risk of pregnancy
 CBC
 LFT
 RFT
 Zidovudine + Lamivudine + Ritonavir are
safe in pregnancy
 Alone Zidovudine gives 80% protection.
Combinations provide extra protection

47. Follow up
 Perform baseline HIV test of HCW at the time
of exposure which will be negative then repeat
at 6 wk, 12wk and 6 month interval to see any
seroconversion
 Follow up every 1-2 wk to check side effects,
toxicity and adherence to regimen
 Instruct to seek medical advice immediately if
experiences acute viral symptoms
 Advise to:- have safe sex
 Use barrier methods during intercourse
 Don’t donate blood or organs during follow up
period
 Safe to continue performing exposure prone
procedure as risk of seroconversion is low and
the risk of onward transmission is remote