2. OUTLINE
• Introduction
• Epidemiology
• Pathophysiology
• Clinical manifestation
• Diagnosis
• Surgical issues of HIV pt
• Complications of surgery
• Prevention of disease transmission
• Post Exposure prophylaxis
• Conclusion
3. Introduction
• AIDS is a disease of the human immune
system caused by the HIV.
• AIDS was first reported in the United States
in 1981 and the HIV virus isolated in 1983, it
has since become a worldwide epidemic.
• The AIDS epidemic is progressing and is
associated with opportunistic infections and
unusual malignancies.
4. • These may mimic acute or chronic surgical
conditions.
• An awareness and understanding of the
disease processes distinctive to HIV
patients is essential for surgeons so that:
– appropriate care can be planned for their
patients ,
– and they can protect themselves and fellow
health care team members at the same time.
5. Epidemiology
• 4th leading cause of mortality in the world
• The greatest infectious health problem threatening
the human race
• Greatest burden is in subsaharan Africa
• Nigeria has the 2nd largest number of infected
people
• Prevalence rate in 2016 (2.9%)
• 3.2 million people
7. Routes of transmission
• horizontal -Sexual intercourse (vaginal and
anal), transfusion and organ donations.
Contaminated needles (IV drug misuse,
needle stick injuries.)
• Vertical ; mother - child (transplacental,
breastfeeding )
• Doubtful ; saliva, urine ,aersolization (bone
saws, electrocautery ,high speed drills)
8. AT RISK GROUPS
The major group of people at risk are:
➢injection drug users,
➢ recipients of blood products,
➢people with multiple sexual partners,
➢commercial sex workers and their partners,
➢ gay-men,
➢healthcare workers etc.
➢Babies born to HIV positive mothers
9. Structure of HIV
• Formerly HTLV-III
• Oncovirus
• Lentivirus group of
retrovirus family.
• 2types : HIV-1 & HIV-
2
• HIV-2 ( West Africa)
• Two molecules of
single stranded RNA
within the nucleus.
10. Structure of HIV
• gp 120 –cell surface
glycoprotein binds to
CD4 receptor.
• gp41 – transmembr
protein- infectivity &
cell fusion.
• Reverse transciptase.
• p24 (core protein)
• p17 ( matrix protein)
11. Pathophysiology
• AIDS is caused by the (HIV) which
progressively reduces the effectiveness of the
immune system and leaves individuals
susceptible to opportunistic infections and
tumors.
• It progressively destroys the body's ability to
fight infections and certain cancers.
• 15% of HIV (+) patients and 30-50% of
patients with AIDS developed cancer.
12. Pathogenesis
• It infects vital organs of the human immune
system i.e CD4+ T cells, macrophages and
dendritic cells.
• It directly and indirectly destroys CD4+ T cells.
• New T cells are continuously produced by the
thymus to replace lost ones but the regenerative
capacity of the thymus is destroyed by direct
infection of its thymocytes by HIV.
• Once HIV has killed so many CD4+ T cells that
there are fewer than 200 of these cells per
microlitre (µL) of blood, cellular immunity is lost.
13. Clinical Expressions of HIV
1. Asymptomatic (seronegative) virus-
positive:
– The 2-4 weeks following infection are usually silent
clinically and serologically.
– Infective but not detectable by current antibody
screening methods.
2. Asymptomatic antibody positive:
Seroconversion.
– Takes about 6 weeks to 6 months after infection to
occur.
– Characterized by a "flu"-like or glandular fever-like
illness.
– The virus systematically destroys the T- helper
lymphocytes leading to a breakdown of cellular
immunity.
14. 3.Persistent Generalized
Lymphadenopathy (PGL)
– Often symmetrical.
– Defined as the presence of lymph nodes of ≥
1 cm for at least 3 months in 2 or more
extrainguinal sites.
– The mean duration of lymphadenopathy is 18
months.
– There may be constitutional symptoms like
unexplained fatigue, fever, night sweats,
weight loss and diarrhoea.
15. 4. AIDS Related Complex(ARC)
The symptoms and signs of this stage of HIV
infection are:
– a) Severe malaise and lethargy.
– b) Weight loss >10% of body weight.
– c) Unexplained Diarrhoea of >1 month duration.
– d) Night sweats ≥ month or more.
– e) Unexplained fever of long standing.
– f) Oral thrush.
– g) Splenomegaly .
– h) Skin rashes.
• About 25 % of these patients develop full-blown
AIDS within 5 years.
16. 5. AIDS
• Clinically, the patient has ARC plus the features of
invasive opportunistic infections such as:
– pneumocystis carinii,
– toxoplasma,
– cmv
– candida,
– mycobacterium,
– varicella
– cryptococcus.
– Cryptosporidium
– Histoplasmosis
– strongyloides
17. HIV AND MALIGNANCY
• Increased incidence of several cancers due
to coinfection with oncogenic DNA virus .
• Kaposi's sarcoma (KS) is the most common
tumor in HIV-infected patients.
• High-grade B cell lymphomas such as
Burkitt's lymphoma by EBV.
• Cervical cancer by HPV,
• Hodgkins and NHLymphomas
• Anal and Rectal carcinoma.
• Primary CNS Lymphoma
18. DIAGNOSTIC TESTS
• The window period is the time from
infection until a test can detect any change.
• Detection of HIV antibody in serum.
– ELISA ( 22days)
– Western blot
– immunofluorescence assay
• Polmerase chain reaction. (16days)
– DNA and RNA reverse transcriptase
– During window period
• HIV P24 antigen.
• Nucleic acid tests (12days)
19. CD4 Count test
• Procedure where the number of CD4 T-
cells in the blood is determined.
• It is used to monitor immune system function
in HIV-positive people.
• Normal CD4 counts are between 500 and
1500 CD4+ T cells/microliter.
• In HIV-positive people, AIDS is officially
diagnosed when the count drops below 200
cells/μL .
20. SURGICAL NEEDS
• Surgical decision-making can be complex if
a patient has HIV infection.
• HIV infection affects the differential
diagnosis of surgical disease, nutritional
status and life expectancy.
• Some have suggested that HIV infection
may also influence postoperative wound
healing and complication rates.
21. SURGICAL PRESENTATION
• Group 1): Unconfirmed patients who present with
surgical diseases unrelated to HIV
• Group 2) :confirmed patients who present with
surgical diseases unrelated to HIV
• Group 3) :unconfirmed patients who present with
surgical diseases related to HIV
• Group 4 )confirmed patients presenting with HIV
related surgical diseases
22. Group 1
• This group highlight the importance of
universal precautions
• Its easy to be CAREFREE while treating these
patients
• its particularly precarious when patients are in
the window period
• Every patient should thus be assumed to be
HIV positive
23. Group 2
- HIV (+) patients are not at increased risk for
complications, unless their medical indices are
poor,
- CD4 < 200/ mm3,
- Post op Viral load > than 10,000 copies/ml.
- Poor nutritional status (↓Albumin)
- Other comorbidities
- Absence of HAART
- In era of HAART, surgical outcomes in HIV (+)
patients has been excellent.
- There is no data to suggest that major surgery
influences HIV disease progression.
24. Group 3
• This may herald the diagnosis of HIV
• Patients who present with the diseases already
highlighted should have voluntary testing and
counseling
• Baseline nutritional and virological markers
• Screen for opportunistic infections
• Reconfirm diagnosis
25. Group 4
• Specific conditions associated with HIV/AIDS
require surgical intervention
• Many AIDS defining illnesses manifest with
surgical diseases
• HIV/AIDS could also have implications on the
outcome of surgical diseases
• Some common surgical diseases could result
from diverse etiologic factors in HIV positive
patients
26. Kaposi sarcoma
• Caused by Kaposi's sarcoma
herpes virus (KSHV)
• Purplish nodules on the skin,
Mouth, GIT, and lungs.
• GI KS is associated with
hemorrhage, obstruction and
intussusception.
• More aggressive in AIDS.
• Treatment with local
rariotherapy.
28. Gastrointestinal
• Acute abdomen
– Intussusceptions are associated with KS lesions or
lymphoid hyperplasia.
– GI perforation ; CMV,Mycobacterium avium
intracellulare can cause ileocolitis with ulceration which
may progresss to ulceration
– GI bleeding ; ulcers from kaposi sarcoma,CMV and
MAI
– Intestinal obstruction ; MAI ,Kaposi sarcoma ,non
Hodgkins lymphoma and from intra and retroperitoneal
lymphadenopathy
30. Condyloma Acuminata
• Wart-like growths around the
anus, vulva, or tip of the penis
caused by HPV.
• Lesions can be removed with
a scalpel, cautery, laser
ablation, liquid nitrogen or
podophyllin.
• Extensive anal condylomata
predispose to development of
squamous cell carcinoma of
the anus.
31. Peri-anal sepsis
• Anal fistula
• fissure in ano
• Ischiorectal abscess
• Pruritus ani
• Anorectal ulcerations (HSV)
32. BRAIN
• Advanced HIV patients may develop
intracranial mass lesions due to
toxoplasmosis, brain abscess, or primary
(CNS) lymphoma.
• Toxoplasma abscesses are the commonest
lesions.
• A 3-week empiric trial of pyrimethamine and
sulfadiazine for patients with intracranial mass
lesions is the first step.
• Brain surgery should only be performed if the
potential health benefits outweigh the risks.
33. Spleen
• ITP occurs in AIDS patients
– due to deposition of circulating immune complex
on platelet.
– 75% may show some degree of improvement
following surgery.
• In marked Splenomegaly
– splenectomy results in significant rise in platelet
and CD4-cell count.
34. Chest
• Lung infections, caused by Pneumocystis
jirovecii ( carinii) pneumonia.
– CXR – Bilateral perihilar interstitial shadowing.
– Sputum m/c/s – may show p.jirovecii.
• To differentiate this from Tuberculosis, MAC
and other fungal infections, they may require
invasive diagnostic procedures like:
– Bronchoalveolar lavage
– Transbronchial Biopsy
– Open Lung Biopsy
35. MUSCULOSKELETAL
• Osteomyelitis:
– Most frequently distal femur and proximal
tibia are common sites for hematogenous
osteomyelitis in adult HIV patients.
– Usually the disease is bilateral.
– Causative organism usually
Staphylococcus and bowel flora.
– This is a very difficult disease to treat and
only amputation will remove the infection.
36. BILIARY TRACT
• Opportunistic infections with salmonella,
cryptosporidium, CMV , MAC can involve the
GB and CBD of HIV patients.
• Most HIV patients with biliary tract disease
have cholelithiasis.
• Extrahepatic biliary obstruction from external
compression of the CBD by enlarged portal
lymph nodes or lymphoma of the CBD.
37. ORGAN TRANSPLANT
• Patients with HIV were traditionally excluded
from solid organ transplantation
• It was assumed that they had shorter life
expectancies and lower survival rates than
other patients.
• However, HIV patients are living longer lives,
• With improvements in effective prophylaxis
against opportunistic infections many groups
are reconsidering that HIV patients should be
transplant candidates.
38. VASCULAR ACCESS
• Long term venous access are needed:
– for treating fungal infections,
– Long term chemotherapy,
– providing nutritional support in pt with debilitating
diarrhoeal syndromes.
• Tunneled Silastic catheters can be placed
percutaneously or by cutdown into the subclavian
or Int Jugular Vein.
• Catheter related infections occur in abt 30% of
AIDS patient.
39. Management
• Aim is to prevent transmission ,as well as
prevent other complications that may arise
• Appropriate voluntary testing and counseling
with commencement of HAART and
chemoprophylaxis for opportunistic infections
improves outcome
40. Pre-operative care
• Pre-op care is similar to that of HIV negative
patient with a few considerations
• Established indication
• Minimal access surgeries
• Pre-op plan for accidental fluid exposure
• Screening high risk
• Screen for and treat opportunistic infections
• Adequate nutrition(serum albumin)
• CD4
41. Pre-op
• FBC
• PCV up to 30%(anaemia e.g from AZT)
• WBC up to 3000 (stavudine,AZT -marrow
suppression)
• Platelets
• LFT (NNRTI cause hepatotoxic)
• E/U/Cr -( NRTIs and lactic acidosis
• Lipid profile - (stavudine)
42. INTRA - OP CONSIDERATIONS
• Universal precautions must be adopted
• All appropriate staff must be made aware of
the patients high risk status
• Limit movement and personnel
• All staff with open wound prohibited
• Anaesthesia - disposable endotracheal tube ,
use of dedicated anesthetic machine
43. Intra - op
• Dressing -face mask, goggles, boots, water proof
garments(disposable),double gloving
• use tourniquet to reduce bleeding
• Meticulous attention hemostasis and asepsis
• Operation should proceed in a slow, careful and
methodical manner
• Large incisions
• Suctions available
44. • Surgeon to pick-up instrument himself
from a sharps tray. Avoid hand-to-hand
transmission of instruments.
• Used needle should not be re-capped,
but put in sharps bin. (60% of needle
stick occurs during recapping)
• Grasp suture needles with a needle
holder or forceps.
• When possible, avoid use of needles.
Use blunt suture needles or skin
staplers .
• Use electrocautery and scissors instead
of scapels (if possible).
√
X
45. post -op
• All surfaces should be decontaminated with
hypochlorite (1/10)
• Clean and autoclave surgical equipments
• Incinerate disposable materials
• Anticipate likely post-op problems
• 1)reduced resistance to infection (SSI, post-op
abscess,
• 2)reduction in wound healing
• 3)they develop more lung complications
46. Disinfection and sterilization
• Effective cleaning of instruments .
• Endoscopes should receive high level
disinfection using Glutaraldehyde(2%),
hydrogen peroxide ( 3-6%) or formaldehyde(1-
8%)
• Wash other instruments and soak in 1:10
dilution of (5.25%) sodium hypochlorite
(bleach) for about 10 minutes before sterilizing.
• Bleach, however, is corrosive to metals
(especially aluminum) and should not be used
to decontaminate medical instruments with
metallic parts.
48. HAART
• Although treatments for AIDS and HIV can slow
the course of the disease, there is currently no
vaccine or cure.
• The standard treatment for HIV infection is called
HAART
• Reduces the mortality and the morbidity of HIV
infection & increase survival by 4-12years.
• The development of drug resistance is reduced by
using a combination of drugs which usually includes
– 2 nucleoside reverse transcriptase inhibitors with either a
non-nucleoside reverse transcriptase inhibitor or 1 or 2
protease inhibitors.
50. PEP
• CLASS 1- Exposure to blood of asymptomatic
patient or known viral load <1500 copies/ml
• Class 2: exposure to symptomatic patient,
high viral load,AIDS
51. RISK OF INTRA-OP EXPOSURE
• 1. Risk great if procedure longer than 3hrs.
• 2. Bloody surgery greater than 300mls
• 3. Major vascular, intra-abdominal,
• 4. Emergency
• 5. Single gloving – 17.5% risk of perforation
while wearing two pairs of latex gloves
reduces the risk to 5%.
• Needle type -deep/superficial, hollow /solid
52. • Extent of risk to surgeons depends on
Prevalence of HIV in the population, number
of procedures carried out by the surgeon
• Needle stick injury risk (0.3%)
• Index finger of non- dominant hand most
involved
53. • Decontaminate using soap and water or bleach. If in mucous
membrane, use sterile saline or water.
• Test Surgeon and Patient for HIV and HBV.
• If patient is HBV +ve, immunize Surgeon for HBV if not already
immunized.
• Baseline investigation, follow-up serology test for HIV at 6wks,
3mths, 6mths, and 1yr.
• Counsel the health worker if the patient has AIDS.
• Commence Anti-Retroviral Therapy early
• within hours
• course for ~4/52
• ~80% reduction in transmission
55. Doctor to patient transmission
Only Two cases reported worldwide
• Dentist in Florida (1990)
– six patients identified by DNA sequencing as
source of HIV
• French orthopaedic surgeon (1995)
– one patient infected
• Estimated risk of transmission from HCW
to patient is between 1 in 2.4-24 million
56. Doctor Responsibility
• Surgeons should know their own status for
HIV infection.
• Annual serological testing for HIV, HCV
• Immunization for HBV
• Doctors who are HIV positive may not
perform invasive procedures
57. Mandatory Pre-op HIV Testing
• In the debate surrounding the question of
preoperative HIV testing of patients,
– Opponents were concerned about civil rights
implications of a positive HIV test result and
feared that HIV-positive patients would receive
different (i.e, substandard) treatment.
– Supporters argued that members of the surgical
team had the right to know of a potential risk for
acquiring a fatal infection after exposure to a
patient's blood.
58. Conclusion
• An in depth understanding of HIV/AIDS
and its implications in a surgical
perspective is vital
• this ensures excellent outcome for these
patients and prevention of transmission to
health care personnel and other patients.
59. References
• Schwartz ,Principles of surgery
• Bailey and love ,short practice of surgery
• Robbins and cotran, pathologic basis of
disease,7th edition
• SRB manual surgery, sri Ram bhatt, 4th edition
• Manual of HIV and surgery, James
hemsworth,2016
