A discussion on the clinical evaluation and management of an HIV positive surgical patient. Also gives insight on the problems of the HIV patient and management of needle stick injury.

1. APPROACH TO AN HIV POSITIVE
SURGICAL PATIENT
Dr Itaman, Usifoh
Surgery Registrar
Presented 0n 17/12/2019 to the Urology Unit,
Department of Surgery, ISTH, as part of the requirements
for the Part 1 Post-graduate Training Programme in Surgery

2. OUTLINE
• INTRODUCTION
• EPIDEMIOLOGY
• MICROBIOLOGY
• PATHOGENESIS
• CLINICAL PRESENTATION
• PROBLEMS OF HIV PATIENT
• PERIOPERATIVE MGT
PREOP
INTRAOP
POST OP
• MGT OF AN EXPOSURED HCP
• ANTIRETROVIRAL THERAPY
• FUTURE TRENDS
• CONCLUSION

3. INTRODUCTION
• HIV infection is a common cause of morbidity
and mortality. This is particularly true for the
developing world where it is a leading cause of
death.
• HIV in patients now run a chronic course due to
availability of effective treatment. As such they
will develop and present with surgical problems
that will require treatments
• Such Surgical treatments will be for problems
both related and unrelated to HIV infection

4. EPIDEMIOLOGY
• First report of HIV/AIDS was in 1981. The virus
was discovered in 1983.
• Over 40million people living with HIV globally.
• 90% of cases are in Subsaharan Africa.
• About 3million PLWHA in Nigeria.
• 20 to 25% of HIV positive patients will require
surgery in their lifetime.
• Almost half (41.5%) of the surgeons had operated
on a known HIV/AIDS infected individuals

5. RISK FACTORS
• HOMOSEXUALS
• UNPROTECTED HETEROSEXUAL EXPOSURE
• UNSAFE BLOOD TRANSFUSION
• INTRAVENOUS DRUG ABUSE
• LIVING IN ENDEMIC AREAS
• HEALTH CARE WORKERS

6. MODES OF TRANSMISSION
• SEXUAL
• BODY FLUIDS
Blood and blood products, semen, vaginal
secretions, milk, CSF, peritoneal, pleural, pericardial
and synovial fluids.
• PERINATAL TRANSMISSION
NB: TEARS, SWEAT, URINE, FECES, SALIVA ARE NOT
CONSIDERED MEDIA FOR TRANSMISSION UNLESS
BLOOD STAINED

7. MICROBIOLOGY
• HIV is a retrovirus of the Lenti-virus family
• The viral particle consist of a core of 2 single
stranded RNA, reverse transcriptase enzyme,
core proteins and an envelope containing
glycoproteins (gp120 and 41).

9. PATHOGENESIS

11. CLINICAL PRESENTATION

12. DIAGNOSIS
• RAPID TEST STRIPS/ CASSETTES
• ELISA
• WESTERN BLOT
• PCR

13. CDC CLASSIFICATION
CLASS CD4 COUNT
1 GREATER THAN 500
2 200 – 500
3 LESS THAN 200

14. PROBLEMS OF HIV/AIDS
• MALNUTRITION
• IMMUNOSUPRESSION
• POOR WOUND HEALING
• OPPORTUNISTIC INFECTIONS
• ELECTROLYTE DERANGEMENT
• HEPATIC, RENAL AND CARDIAC INSUFFICIENCY
• ATYPICAL PRESENTATIONS
• RISK OF TRANSMISSION
• PSCHYCOSOCIAL PROBLEMS

15. INDICATIONS FOR SURGERY IN THE HIV
INFECTED PATIENT
• FOR DIAGNOSIS OF HIV RELATED INFECTION
AND NEOPLASM
• THERAPEUTIC FOR SURGICAL COMPLICATIONS
OF AIDS
• FOR OTHER INDICATIONS AS IN GENERAL
POPULATION.

16. PERIOPERATIVE MANAGEMENT

17. PRE OP
HISTORY:
• DURATION OF DISEASE
• RISK FACTORS
• FEATURES OF OPPORTUNISTIC INFECTONS
• TREATMENTS/SIDE EFFECTS
• CO MORBIDITIES
• LATEST CD4 COUNT/VIRAL LOAD

18. PRE OP: EXAMINATION
• GENERAL STATE OF THE PATIENT
• NUTRITIONAL STATUS
• VITAL SIGNS
• SYSTEMIC EXAMINATION IN SEARCH OF
OPPORTUNISTIC INFECTIONS, NEOPLASM
AND CO MORBIDITIES

19. PRE OP: INVESTIGATIONS
• CD4 COUNT
• VIRAL LOAD
• FBC
• EUCR
• URINALYSIS
• LFT
• CXR
• ECG, ECHO (ESP IF GREATER THAN 45%)
• IMAGING AS RELEVANT

20. CD4 COUNT AND VIRAL LOAD
• CD4 counts determine staging of HIV disease
and need for treatment
• Viral Loads determine effectiveness of ARV
treatment.
• Higher complication rates are seen if CD4
<200cell/mm³ and post operative viral load >
10000 copies/ml.

21. ISSUES
• ROUTINE TESTING
• CONSENT
• CONFIDENTIALITY
• NUTRITION
• IMMUNE STATUS
• OPERATIVE RISK OF PATIENT
• ANTI-RETROVIRAL AGENTS

22. INTRA OP
• All staff must be made aware of patient’s status
• ANAESTHESIA
Regional preferred to GA.
Dedicated circuits.
Potential for drug-drug interaction
• PROPHYLATIC ANTIBIOTICS

23. INTRA-OP
PREVENT HCP EXPOSURE
• Proper barrier protective devices (disposable
Scrubs, aprons, gowns, goggles, face mask,
impervious boots, gloves)
• Prevention of needle-stick injuries
-Experienced surgeon and assistant
-Double glove
-Minimal access surgeries preferred
-Diathermy preferred to scalpels
-Slow and careful techniques
-Avoid handling needles/blades
-Cutting needles from sutures before tying a knot
-Use of staplers

24. ISSUES
• HCP EXPOSURE
• SURGEON TO PATIENT INFECTION

26. POST OP
• WOUND CARE
• REMOVAL OF SUTURES
• ANTIBIOTICS
• ANTIRETROVIRAL AGENTS
• PROPHYLAXIS AGAINST OPPORTUNISTIC
INFECTION
• PREVENTION OF HCP EXPOSURE
• FOLLOW UP

27. PREDICTORS OF OPERATIVE OUTCOME
• ANAESTHESIST RISK CLASS.
• CD4 <200CELL/MM³ (INFECTION RISK)
• POST-OP CD4 COUNT.
• PRE TO POST-OP CHANGE IN CD4.
• Becker et al: reported successful surgical
outcome rate of 79% (range: 68%-90%) without
any significant increase of mortality or morbidity
in HIV infection

28. ANTIRETROVIRAL THERAPY
• Nucleoside Reverse Transcriptase Inhibitor(NRTI)
• Non-Nucleoside Reverse Transcriptase
Inhibitor(NNRTI)
• Protease Inhibitors (PI)
• Integrase inhibitors eg dolutegravir
• Fusion inhibitors eg enfurvitide
• Entry inhibitors eg ibalizumab
• Chemokine receptor antagonist eg maraviroc

30. HEALTHCARE PRACTICIONER (HCP) EXPOSURE
• DEFINED AS CONTACT WITH BLOOD AND OTHER
FLUIDS/TISSUES OF AN HIV POSITIVE PATIENT IN
MANNERS THAT CREATES A RISK FOR
TRANSMISSION.
• EXPOSURE RATES 2-6%
• RISKS:
Endemic areas, surgery longer than 3hrs, blood
loss > 300ml, pelvic surgeries.

31. • TYPES OF EXPOSURE:
Needle stick injury
Mucosal
Cutaneous
• RISK FOR TRANSMISSION 0.03% - 0.3%
Depends on:
• Type of needle (Hollow/Large bore needle)
• Depth of injury
• Quantity of blood
• Disease status of source patient
• Host defenses
• Post-exposure prophylaxis

32. MGT OF AN EXPOSURED HCP
• TREATMENT OF EXPOSED LOCAL SITE:
SKIN: allow to bleed freely, wash with soap
and running water for 30mins.
EYES: irrigate with fresh water
ORAL CAVITY: spit out immediately. Rinse
mouth.
• PROMPT EXPOSURE REPORTING.

33. • PROMPT RISK ASSESSMENT:
o SOURCE:
HIV testing after obtaining consent.
If known to be positive, assess health status and
possibility of drug resistance.
o RECIPIENT:
Baseline serological testing for HIV, HBV, HCV
o NATURE OF EXPOSURE

34. POST EXPOSURE PROPHYLAXIS
• USE OF ARVs TO PREVENT INFECTION
FOLLOWING EXPOSURE.
• Decision to start PEP depends on:
Severity of exposure and HIV status of the
patient
• Best commenced 1-2hrs after exposure. Less
efficacy after 72hrs.
• Duration of 4weeks
• Not 100% guarantee, risk must be balanced with
toxicity

35. REGIMEN
BASIC:
• 2 NRTI FOR 1MONTH
Tenofovir+ emtricitabine
Zidovudine + lamivudine
Zidovudine + stavudine
Didanosine + stavudine
EXTENDED
• 2NRTI + 1 PI

37. • TESTING done at 6wk, 12wk and 6month
• Follow up every 1-2 wk for side effects
• Advise:
Have safe sex (use barrier methods),
Do not donate blood or organs.

39. LOCAL CHALLENGES
• LACK OF DATA
• NON AVAILABILITY OF NEWER DRUGS
• LACK OF LAID DOWN PROCTOCOL FOR
MANAGING EXPOSURES.
• SOCIAL STIGMATISATION OF PLWHA
• IGNORANCE

40. FUTURE TRENDS
• DEPOT ANTI RETROVIRAL INJECTABLES
• VACCINES

41. CONCLUSION
• Doctors are bound by ethics of duty to
manage all patients, including PLWHA.
• Availability of effective treatment for HIV
means that surgeons will operative on more
persons living with HIV/AIDS.
• The surgeon must therefore be abreast of the
principles of mgt and the prevention of
exposure transmission.
• PREVENTION IS BETTER THAN CURE.

42. REFERENCES
1. Smit S. Guidelines for surgery in the HIV patient. CME J.2010;
28(8):356-8.
2. Irowa O.OHIVJAIDS, Surgical Complications and Challenges,
The Nigerian Experience. Benin Journal of Postgraduate
Medicine. 2007:9(1:55-572 Centers for Disease Control.
Morbidity and Mortality Weekly Report.
3. Kosmidis C, AnthimidisG, Vasiliadou. Acute abdomen and
HIV infection. https://cdn.intechopen.com/pdfs-
wm/23598.pdf219

43. THANK YOU FOR LISTENING.