hiv and surgeons

1. HIV AND SURGEON

2. HIV - SURGEON
•INTRODUCTION
•SURGICAL ASPECTS OF HIV
•HIV-AS A OCCUPATIONAL HAZARD
•UNIVERSAL PRECAUTIONS
• POST CONTAMINATION
•HIV-INFECTION BY SURGEON.
•CONCLUSIONS

3. Acquired immunodeficiency
syndrome (AIDS)
 Defined as a syndrome in which a person has a reliably diagnosed
disease that is least moderately indicative of an underlying cellular
immune deficiency but who, at the same time ,has no underlying
cause of cellular immune deficiency or any other cause of reduced
resistance reported to be associated with the disease.(essentials of
surgery by alfred cusheri ,George B Hanna)

4.  First virus isolated in france from a patient with lymphadenopathy
and was called lymphadenopathy associated virus.
 1981In U.S., cluster of Pneumocystis and Kaposi's sarcoma in
young homosexual men discovered. The men showed loss of
immune function.
 1983Discovery of virus causing loss of immune function.
It was isolated and named human T-cell lymphotrophic virus type 111
 International agreement that term HIV should be used to describe
agents responsible for AIDS and allied conditions(PGL,ARC)

5.  Persistent generalised lymphadenopathy(PGL):lymphadenopathy at
two or more non contagious ,non inguinal sites for 3 months or
longer in the absence of any current illness or medication know to
cause enlarged lymphnode
 AIDS-related Complex (ARC): weight loss of more than 10%
,intermittent fever of more than 38,intermittent or continous
diarrhoea, fatique and malaise ,night sweats and PGL
 More recently,a variant , HIV-2 have been isolated from african
patient but there does not appear to be any material difference in
the disease potential between these two viruses and a collective
term HIV IS recommended for either

6. Acquired Immunodeficiency
Syndrome (AIDS)

7.  Retrovirus
 Family: retroviridae
 Sub family: lentivirinae
 Has Reverse transcriptase enzyme
 RNA dependent DNA polymerase
 Normally DNA-RNA-proteins BUT in HIV RNA – DNA-mRNA-
proteins

8. HIV Infection

9. HIV Infection
Figure 13.19
Retrovirus penetrates
host cell.
Virion penetrates
cell and its DNA is
uncoated
The new viral DNA is
tranported into the host cell’s
nucleus and integrated as a
provirus. The provirus may
divide indefinitely with the
host cell DNA.
1
2
3
DNA
Transcription of the
provirus may also occur,
producing RNA for new
retrovirus genomes and
RNA that codes for the
retrovirus capsid and
envelope proteins.
4
Mature
retrovirus
leaves host
cell, acquiring
an envelope as
it buds out.
5
CapsidReverse
transcriptase
Virus Two identical + stands of RNA
DNA of one of the host
cell’s chromosomes
Provirus
Host
cell
Reverse
transcriptase
Viral RNA
RNA
Viral proteins
Identical
strands of
RNA

10. HIV Infection
Figure 19.13

11. HIV Infection
Figure 19.14

12.  Category A Asymptomatic or persistent
lymphadenopathy
 Category B Persistent Candida albicans
infections
 Category C Clinical AIDS. CMV, TB,
Pneumocystis, toxoplasmosis,
Kaposi's sarcoma
The Stages of HIV Infection

13. WHO staging system for HIV disease (determines the stage of HIV infection
based on
clinical symptoms)
 Stage I: HIV disease is asymptomatic and not categorized as AIDS.
 Stage II: includes minor mucocutaneous manifestations and
recurrent upper respiratory tract infections.
 Stage III: includes unexplained chronic diarrhoea for longer than a
month, severe bacterial infections and pulmonary tuberculosis.
 Stage IV: includes toxoplasmosis of the brain, candidiasis of the
oesophagus, trachea, bronchi or lungs and
 Kaposi’s sarcoma; these diseases are used as indicators

14. The Stages of HIV Infection
Figure 19.15

15. Some Common Diseases Associated
with AIDS

16.  Seroconversion takes up to 3 months
 HIV antibodies detected by ELISA
 HIV antigens detected by Western blotting
 Plasma viral load is determined by PCR or nucleic acid hybridization
Diagnostic Methods

17. Parameters of AIDS, persistent generalized lymphadenopathy (PGL) and
AIDS-related complex (ARC)
 Decreased CD4+ lymphocytes and lymphopenia
 Decreased ratio CD4:CD8 lymphocytes
 Reduced cytotoxic response
 Reduced monocyte function
 Increased immunoglobulins
 Decreased blastogenic response of lymphocytes to mitogens
 Cutaneous anergy to multiple skin test antigens
 Increased levels of circulating immune complexes

18.  HIV survives 6 hours outside a cell
 HIV survives >1.5 days inside a cell
 Infected body fluids transmit HIV via:
 Sexual contact
 Breast milk
 Transplacental infection of fetus
 Blood-contaminated needles
 Organ transplants
 Artificial insemination
 Blood transfusion
HIV Transmission

19. Modes of HIV Transmission

20. Transmission of human immunodeficiency virus
infection
 The proven vehicles of infection are blood, semen and vaginal
secretions.
 The disease is transmitted by penetrative unprotected sexual
intercourse (homosexual and heterosexual),needle sharing by drug
misusers and blood products.
 Prior to the introduction of HIV testing of donors, a large proportion
of haemophiliacs were infected by contaminated clotting factor
concentrates, as were a few patients who received blood
transfusion to cover surgical procedures, especially cardiac
operations.
 With the introduction of testing of blood donations, this route of
transmission has now been eliminated but regrettably many of the
infected haemophiliacs have died of AIDS and some have
transmitted the disease to their sexual partners.

21.  The largest two groups contracting HIV infection are still active
homosexuals (especially those with multiplepartners) and drug
addicts and users, in whom HIV is spread by sharing contaminated
needles.
 Babies of HIV-positive mothers have a 25% risk of contracting the
infection in utero or perinatally and by breast feeding.
 Oral zidovudine during late pregnancy and labour reduces the rate
of mother to child transmission of HIV by 51%.The longer course
reduces it by 67%.
 Breast feeding with the short remains a problem, as this is
responsible for one-third of the maternal transmission. Thus, in
short-course prevention,breast feeding has to be replaced by
formula feeding.
 Transmission by human bites is possible and occurs if blood is
transmitted.

22. The risk of transmission to healthcare
workers is due to certain mishaps:
 direct percutaneous inoculations of infected blood, e.g. accident
bysharps (needle pricks, scalpel stab injuries, etc.)
 spillage of infected blood onto skin may introduce infection through
minute scratches or abrasions
 contamination of mucosal surfaces by infected blood, e.g.
accidental splashing of eyes
 transfer of infected material via environmental surfaces, e.g. blood
contaminated equipment and instruments.

23.  U.S., Canada, western Europe, Australia, northern Africa, South
America
 Injecting drug use, male-to-male sexual contact
 Sub-Saharan Africa
 Heterosexual contact
 Eastern Europe, Middles East, Asia
 Injecting drug use, heterosexual contact
 NEPAL : approx 50000 ; IDU ,female sex worker,transgender, some
migrant to high risk districts in india
AIDS Worldwide

24. AIDS Worldwide

25. Indicator diseases for case definition of AIDS for surveillance purposes
with laboratory evidence regarding HIV infection (Centers for Disease Control,
Atlanta, Georgia)
 Bacterial infections, multiple or recurrent (any combination of at
least two within a 2 year period), of the following types affecting a
child <13 years old: septicaemia, pneumonia, meningitis, bone or
joint infection, or abscess of an internal organ or body
cavity(excluding otitis media or superficial skin or mucosal
abscesses),
 caused by Haemophilus, Streptococcus or other pyogenic bacteria
 Coccidioidomycosis, disseminated (at a site other than or in
addition to lungs or cervical or hilar lymph nodes)
 HIV encephalopathy (HIV/AIDS dementia)
 Histoplasmosis, disseminated (at a site other than or in addition to
lungs or cervical or hilar lymph nodes)
 Isosporiasis with diarrhoea persisting >1 month
 Kaposi’s sarcoma at any age
 Primary lymphoma of the brain at any age

26.  Other non-Hodgkin’s lymphoma of β-cell or unknown
immunological phenotype
 Any mycobacterial disease caused by mycobacteria other than
M.tuberculosis, disseminated (at a site other than or in addition to
lungs, skin, or cervical or hilar lymph nodes)
 Disease caused by M. tuberculosis, extrapulmonary (involving at
least one site outside the lung, regardless of whether there is a
concurrent pulmonary involvement)
 Salmonella (non-typhoid) septicaemia, recurrent
 HIV wasting syndrome (emaciation, slim disease)

27. Alternative useful clinical classification of HIV infection
Group Definition
 I Acute infection: infectious mononucleosis-type illness
 II Asymptomatic infection: asymptomatic HIV-positive subjects
 III Persistent generalized lymphadenopathy (PGL)
 IV
A Constitutional disease: fever, diarrhoea and weight loss lasting
>1month
B Neurological disease: dementia, myelopathy and
peripheralneuropathy
C Secondary infectious disease: opportunistic
C1 Specified in US Centers for DiseaseControl surveillance
definition ofAIDS
C2 Other infections: oral hairy leucoplakia, nocardiosis, oral
candidiasis,etc.
D Secondary cancers: Kaposi’s sarcoma, non-Hodgkin’s
lymphomas,
primary cerebral lymphoma
E Other conditions: other disorders attributable to HIV infection

28. Antiviral therapy for acquired
immunodeficiency syndrome
 combination of three or more anti-HIV drugs, sometimes
referred to as
highly active antiretroviral therapy (HAART), is compatible
with long-term survival with the HIV virus.
 The classes of antiretroviral drugs used in AIDS are:
 Nucleoside/nucleotide reverse transcriptase
inhibitors:(NRTIs) interfere with the action of an HIV protein
called reverse transcriptase, which the virus needs to make
newcopies of itself.
 Non-nucleoside reverse transcriptase inhibitors
(NNRTIs):also stop HIV from replicating within cells by
inhibiting the reverse transcriptase protein.
 Protease inhibitors (PIs) inhibit protease, another protein
involved in the HIV replication process.

29.  Fusion or entry inhibitors prevent HIV from binding to or entering
human immune cells.
 Integrase inhibitors interfere with the integrase enzyme,which
HIV needs to insert its genetic material into human

30.  NRTIs: lamivudine, abacavir, zidovudine, didanosine, emtricitabine.
 NNRTIs: delavirdine, efavirenz, etravirine, nevirapine, rilpivirine,
atazanavir.
 PIs: amprenavir, fosamprenavir, atazanavir, darunavir, indinavir,
ritonavir, saquinavir, maraviroc.
 Fusion or entry inhibitors: enfuvirtide.
 Integrase inhibitors: raltegravir

31. Surgeons….
 With the development of rapid diagnostic tests and the recognition
of opportunistic infections involving GIT made the surgeons involve
in the management of AIDS disease.
 And the surgeons are placed at high risk of acquiring HIV as there
is direct contact with blood of the HIV infected individuals.
 The risk of potential transmission from highest to lowest -
percutaneous injuries, mucus membrane & skin contact.
 According to Centers of Disease Control & Prevention - blood and
certain other body fluids, all visibly bloody body fluids and tissue
from all patients should be considered as potentially infected with
blood borne pathogens.

32. Surgical aspects of HIV
 GI disease in HIV pts
 To provide venous access for chemotherapy for infections (CMV
retinitis) /neoplasms.
 LN excision biopsy : to diagnose specific infection, lymphoma/
Kaposi’s sarcoma
 indications-lymphadenopathy with constitutional
symptoms
 splenomegaly
 cytopenia
 oral candidiasis
 hilar lymphadenopathy.
 or a solitary LN enlarged disproportionately.

33. GI disease in HIV:
 Oral cavity- thrush, hairy leukoplakia, aphthous ulcers & Kaposi’s
sarcoma.
 Oesophagus- monilial oesophagitis, lymphoma &Kaposi’s sarcoma.
 Stomach & duodenum-bleeding, abdominal pain, gastric outlet
obstruction and/or perforation.
 Kaposi’s sarcoma- most common cause of bleeding ,
occasionally outlet obst.
 NHL- usually presents as bleeding, but obstruction and
perforation can also occur.
 CMV- one of the more common cause of the gastritis,
gastric& duodenal ulcers.

34. GI disease contd...
 Small and large bowel disease- the most significant problem.
HIV-enteropathy- > 1month
without cause
specific infections-bacterial, fungal
and viral (severe
bloody colitis)
diarrhoea
abdominal pain
fever & wt.loss
bleeding
obstruction
& perforation.
jaundice
ascites
Kaposi’s sarcoma
&NHL-small bowel

35. Contd…
 Appendicitis- obstructed due to Kaposi’s / NHL secondary deposits / perforated.
 Anorectal lesions-
 Pancreas- drug toxicity
 spleen- thrombocytopenic purpura
 Liver- HBV(85%)
 Biliary tract
Warts -( intra epithelial neoplasia)
perianal sepsis
anorectal ulceration
anal neoplasia
fecal incontinence
Acalculous cholecystitis
papillary stenosis
sclerosing cholangitis

36. Outcome of surgery:
 No. of retrospective studies -(Robinson et al,
Ferguson,Wakeman & Miles et al)
 Reports suggest -increased risk of P.O.complications in HIV
pts. But, the effect on survival rates were not assessed.
 51 HIV pts. Underwent 73 surgical procedures for
anorectal disease. 22pts died within 6 months and 45pts
(88%) had poor wound healing at 30 days.

37. HIV- as an occupational hazard:
 surgeons, physicians , nursing staff , lab.technicians and other health care
workers.
 Extent of the risk -
 ( American & European countries- 30 yr career in place where HIV is highly
prevalent-1 in 800 chance of acquiring)
 In Africa - risk is 1in 4.
 Source of infection: Skin perforation with hollow needle containing infected
blood.
 (also reported with solid needle, but the risk is 10 fold less)
 Extensive splashes of blood on mucous membrane and skin.
•prevalence of HIV in pt.population
•no.of procedures carried out by the surgeon,
•& length of the period of risk

38. Occupational hazard -contd..
 Large institutional studies showed - risk following skin puncture from a needle
/sharp object contaminated from a HIV pt- 0.3%.( risk of Hepatitis B is 20-30%)
 Transmission through intact skin is not documented.
 Survey studies - percutaneous injuries -5.6% of operations.and 86 % of
surgeons report at least 1 injury per year.
 risk of transmission through mucus memb.-0.1%.
 Transmission by other body fluids- no evidence that saliva can transmit although
HIV can be isolated from small percentage of infected individuals
Factors -
•unusually large volume of blood
•prolonged contact
•a potential portal of entry.

39. Precautions -
 before surgery-
 screening of all patients esp.
high risk group.
 Universal precautions
Homosexual men,
IV drug abusers,
Hemophiliacs,
residents of central Africa
sexual partners of the above
children of infected mothers.
•Wearing safety spectacles
•waterproof gown
•Boots rather than open shoes
•Double gloves- 5-fold reduction in
contamination

40. Universal precautions against the spread
of AIDS
These apply to all patients irrespective of risk category or HIVstatus
(known or unknown)
• Care in the handling of sharps: needles, scalpels, sharpinstruments,
etc.
• All cuts and abrasions on patients and staff should be coveredwith a
waterproof dressing. Personnel should wear plastic aprons and
disposable gloves when dealing with blood or secretions
• Parenteral procedures should be kept to a minimum
• External surfaces of equipment and bench surfaces which mayhave
been contaminated by blood and other secretions should be wiped with a
fresh preparation of sodium hypochlorite solution 1% (10â•›000â•›p.p.m.
available chlorine) or 2% activated
glutaraldehyde.
•Contaminated gloves, paper tissues and cottonwool should be
incinerated

41. • In the event of the death of a person with AIDS, the body should be
wrapped in impermeable plastic sheeting or a polythene cadaver bag
before coffining
• Equipment being sent for maintenance and servicing should be
disinfected with glutaraldehyde before leaving the ward or theatre
• Disposable equipment should be used wherever possible, and reusable
equipment immersed in 2% glutaraldehyde for 1 hour before being
returned for processing
• Walls and floor should be cleaned with soap and water

42. Post contamination:
 when exposed to infected blood-
 Zidovudine post exposure prophylaxis to be given.
 a case control study showed- 79% decrease in the risk
of seroconversion after exposure.
 even if it fails to prevent seroconversion, decrease the
initial burst of viremia which has long term benefit.
 current recommendation - a combination of Zidovudine,
Lamivudine& Indinavir.
 this should be started as soon as possible after the
injury(within 1-2 hrs)
-immediate washing under running
water.
-status not known- HIV test
-hepatitis prophylaxis
-base line HIV test.
-re testing after 12 weeks
Zidovudine 200mg 4hrly
for28-42days.

43. Action in the event of an accident involving
possible
transmission
 The rate of transmission resulting from accidental inoculation of
healthcare workers with blood from individuals known to be infected
has been reported to be of the order of 0.13–0.55, i.e. 1:770 to
1:200 chance of infection as a result of any single event. When
such an accident occurs, the following procedure is necessary:
 • Contaminated areas (spillage and splashes) or injury site
(from sharps)should be immediately and thoroughly washed with
soap and water.
 If the HIV status of the source patient is not known, the patient
consent’s for HIV testing is obtained. This is usually forthcoming,
but, if the patient declines consent, the statement by the General
Medical Council becomes relevant: ‘Only in the most exceptional
circumstances, where a test is imperative in order to secure the
safety of persons other than the patient, and where it is not possible
for the prior consent of the patient to be obtained, can testing
without explicit consent be justified.’

44.  In such a difficult situation, this statement implies that HIV testing of
a blood specimen that had previously beenobtained from the patient
for other purposes is permissible.
 • The exposed health worker should be counselled and expert
advice sought.
 Consent for HIV testing from the individual concerned should be
obtained, in which event, an immediate specimen (baseline)
followed by others at intervals are necessary.
 Seroconversion usuallyoccurs within 3 months.
 when exposed to infected blood : HIV test soon after exposure and
 Retest after 6wks ,12wks and 12 months

45. Guidelines for operating theatre
staff
IT is s justifiable to set aside a theatre and staff solely for HIV positive
patients
 Shaving should be avoided
 The anaesthetic room staff should wear disposable masks, plastic
aprons, gloves and overshoes
 The anaesthetic machine and work surfaces should be stripped of all
but essential equipment
 All theatre staff should wear impermeable overshoes, which must not
be taken out of the theatre
 All staff, scrubbed and unscrubbed, should wear disposable gowns,
plastic aprons, goggles and gloves (double for the surgeons and scrub
nurse)
 Disposable drapes should be used. Swabs should be counted on a
polythene sheet on the floor, not on the swab rack
 Only disposable scalpels are used. All instruments should be handed
to and from the surgeon on a tray such that the surgeon or nurse picks
the instrument without any direct transfer from nurse to surgeon and
vice versa

46.  Suction bottles should be half filled with freshly prepared 2%
glutaraldehyde solution
 Spilt blood or body fluids must be diluted with fresh 2%
glutaraldehyde and mopped up with white paper towels.
 All consumables should be placed in a watertight bag for plastic
incineration
 Splashes of blood or body fluids or accidental puncture wounds
should be immediately and thoroughly washed with soap and water
and the consultant should then inform the occupational health
service of such an incident
 the operating nurse must ensure that the patient’s skin is completely
free of blood after the operation
 The patient should wear a clean operating gown before transfer
back to the ward

47. Infection of patient by surgeon:
 In 1990,HIV infected dentist in Florida had transmitted HIV to 5 of his pts
while undergoing minor invasive procedure.
 Occurred through HIV contaminated instruments supposedly used the same
instruments on himself.
 A break down of sterile procedures was suspected.
 Several epidemiological studies - >8000 pts.who received care from HIV
infected dentists, surgeons, physicians and obstetricians.
 Not a single case could be linked.
 No reported case of pt.undergoing general surgical procedure acquiring HIV
from surgeon.
 Risk -is very low, about < 1/10,00,000.
 1/2 of the risk of transfusion related HIV inf.
 1/100 of risk of dying from GA.

48. CONCLUSIONS:
 High risk group should be identified.
 Causative agent can be rapidly detectable even in the
window period by antigen tests -hence, high risk pts.should
be subjected to HIV test.
 If Universal precautions are followed strictly , occupational
risk can be reduced to a minimum.
 Risk of infection is maximum in the acute phase and in the
advanced phase.
 Risk of infection after needle puncture is 0.3%
 Zidovudine - prophylactic, decreases seroconversion.

49. Conclusions
1. Surgeons should have the ethical obligations to render care to
HIV infected patients as they have to care for other pts.
2.Surgeons should utilize the highest standards of infection control
involving the most effective known sterile barriers ,universal
precautions, and scientifically accepted infection control practices.
3. Based on current literature ,HIV infected surgeon may continue
to practice and perform invasive procedures and surgical operations.
4. Post exposure prophylaxis with antiretroviral chemotherapy is
recommended
5. Surgeons should know their own status for HIV infection
6. Committees should continue to consider the concerns & problems
of HIV infected Surgeons and their families

50.  ….Thank
you