HIV virus is composed of single stranded RNA Contains

 

 

HIV virus is composed of single stranded RNA

Contains a variety of genes

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Gag,pol,vif,rev,nef env,tat, vpu,vpr

The pol gene encodes reverse transcriptase

Reverse transciptase is na enzyme  necessary to copy the viral RNA into DNA

Integrase incorporates the newly copied DNA into the hosts
genome

HI Virus is covered by a lipid bilayer that contains the
envelop proteins gp 120 and gp40

HIV has tropism for CD4 herlper T cells. The CD4 helper has
ahigh affinity for the viral gp120 glycoprotein

Binding to the CD4 molecule is not sufficient for infection

The binding of coreceptors CCR5 CxCR4 is required

In early infectionthe CCR5 tropic molecules dominate

As the disease progresses a rapid decline in Tcell counts is
associated with a switch from CCR5 tropic viruses to CXCR4

 

 

 

 

Two groups of HIV patients

 

Patients with HIV infection only

Patients with AIDS

 

Patients with HIV infection only have less operative risk
and are less contagious

 

Notes:

HIV/AIDS patients are
not a homogeneous group. For clinical purposes it is imperative to stratify
them into two groups (Table I). Patients with HIV infection only (A1, B1, A2,
B2) have a lower operative risk and are less contagious. Patients with AIDS
(C1, C2, C3, A3, B3) are more prone to operative complications and are more
contagious.

 

Two groups of Pathology occurring in HIV/AIDS

 

Diseases with a definitive association to HIV

Coincidental diseases

 

 

Notes:

Pathology occurring
in HIV/AIDS patients can be classified into two groups: diseases with a
definitive association with HIV and coincidental diseases. Examples of diseases
associated with HIV solely, disintegrating perineum syndrome and diffuse
infiltrative lymphocytosis syndrome (DILS),

The second group of
patients are those with HIV/AIDS who develop the ‘normal’ type of pathologies
as are seen in the general population.

 

 

 

Surgical treatment

 

Issues to consider:

Informed consent

informed consent

operative risk in
HIV/AIDS patients

occupational risk to
the health care workers

universal and
specific precautions

variations in
operative technique

ethics

 

Notes:

When a doctor proposes a surgical intervention, informed
consent is an

absolute necessity. Three new aspects have arisen during the
course of

the HIV pandemic.

Firstly, HIV/AIDS patients fear social recognition and
rejection and

frequently request doctors to perform unnecessary surgery
such as

removal of ‘tell-tale’ cervical lymph nodes or parotidectomy
for Diffuse infiltrative lymphocytosis syndrome

The second aspect of informed consent pertains to the
management of

terminal HIV/AIDS patients. Some patients (and their
families) refuse

surgery in desperate situations (such as bowel perforation)
as they want

an end to the suffering.

 

Operative risk In HIV patient

Established in the same way as in a HIV negative patient

Use risk factor scores- ASA, POSSUM, APACHE

Consider Pathophysiological state of the patient vs
magnitude of the procedure

Although the relative risk of surgery in
HIV-infected patients has been debated in the literature, retrospective studies
have indicated favorable outcomes despite HIV serostatus and regardless of
extent or duration of surgery 1-3. 

 

Neither CD4 cell count nor HIV viral load should
be used as sole determinants of a given patient’s surgical risk (4)

Overall health, particularly the presence or
absence of organ failure, and nutritional state (albumin

 

 

Four factors have
been found to increase operative morbidity and mortality in HIV/AIDS patients:

a compromised
physiological state – the best predictors of perioperative morbidity and
mortality appear to be scores that measure general health such as ASA (American
Society of Anesthesiology) risk classes

physiologically
demanding surgery

emergency surgery as
opposed to elective procedures

operations in
contaminated fields, e.g. anorectum or oral cavity.

Studies of the value
of viral loads and CD4 counts (alone or in combination) in predicting operative
morbidity and mortality did not produce conclusive results.

 

 

Intraop
considerations

The anaesthetist
should be aware of any possible drug interactions with the ARV’s

Presence of a
myopathy or neuropathy may alter the anaesthetic technique

HIV infected patients
have a greater risk for bleeding

 

Notes:

Anaemia and
thrombocytopenia side effects of zidovudine

P.I’s can affect
glucose metabolism

Foscarnet and P.Is
can cause renal toxicity

Fsocarnet can alter
calcium and magnesium levels

 

Occupational risk to
the health care workers

Although all exposure
to contaminated bodily fluid carries a risk, the risk of HIV transmission

increases
particularly in the following circumstances:

if the penetrating needle-stick
injury occurred with a hollow as opposed to a solid needle,

if the needle injury
was a deep soft-tissue penetration, if there was visible

blood on the needle,

if the patient is in
the early viraemia stage or the patient has advanced AIDS (both have high viral
loads) and in case of prolonged exposure (blood inside a glove).

If possible,
postponing elective operations with the aim of starting the patient on
antiretroviral medication should be encouraged: operating on a healthier
patient with a lower viral load and higher CD4 count is advantageous for both
patient and surgeon

 

Notes

In case of exposure,
the post-exposure prophylaxis (PEP) should be taken as early as possible. It is
wise for doctors to have a personal PEP kit readily available. The relative
cumulative seroconversion risk for surgeons in tropical Africa is estimated to
be 15 times higher than in Western countries.4

 

Universal and
specific precautions

 All bodily fluids of all patients should be regarded
as hazardous substances.

Barrier protection is
key.

Protective eyewear,
gloves and water-impermeable gowns are essential.

The use of
high-quality latex gloves should be mandatory

Wearing two pairs of
gloves reduces the risk of exposure, as 98% of blood from the penetrating
needle will be removed and it will also compensate for defects in the fabric of
the gloves.

The outer glove
should be half a size bigger than the inner glove.

The risk of
contracting HIV from a simple needle stick injury of an instrument infected
with HIV is 0.3%

 

Variations in
operative technique Simple techniques to reduce occupational hazards include: cutting
with electrocautery, avoidance of hand-to-hand passage of sharps and the dogma
that hands should never be used as tissue retractors. Contemporary to the HIV
pandemic, and partially due to it, less invasive and non-operative management
of surgical conditions has literally exploded. Laparoscopic surgery has obvious
advantages for both patients (less invasive, fewer wound complications) and
health care workers (less time consuming, less exposure).

 

 

 

 

 

Ethics

If a doctor proposes
an operation, the risks to the patient must be weighed against the potential
benefits of surgery.

With HIV there is an
additional variable: the risk to the surgical team

If a patient who is
to undergo surgery refuses HIV testing, Is it ethical to still test the patient
for the safety of the surgical team?

 

Laws of Kenya

HIV and AIDS
Prevention and control act

Part IV Section 14 C
States:

A medical
practitioner responsible for the treatment of a person may undertake a HIV test
in respect of that person without consent of the person if:

     
i.        
The
person is unconscious and unable to give consent and:

    
ii.        
The
medical practitioner believes that such a test is clinically necessary or
desirable or in the interest of that person.

 

Notes:

This is considered
with the knowledge that PEP should only be taken when source patients are HIV
positive or have high risk factors for HIV. 
Initiating PEP when source patients are uninfected puts exposed persons
at risk from taking toxic dugs with no added benefit.Forgoing PEP if the source
is infected results in increased risk of acquiring HIV.

 

 

 

HIV/AIDS patients
presenting with surgical disease may be divided into two clinical categories: •
life-threatening surgical correctable disease • surgical interventions intended
for diagnosis, prophylaxis, or palliation. The consensus opinion is that in the
first instance surgical intervention is obligatory. In the second instance,
alternatives to surgery can be contemplated

 

 

 

Guth
AA, Hofstetter SR, Pachter HL. Human immunodeficiency virus and the trauma
patient: Factors influencing post operative infectious
complications. J Trauma 1996;41:251-255. PubMed
Sewell
CA, Derr R, Anderson J. Operative complications in HIV-infected women
undergoing gynecologic surgery. J Reprod Med 2001;46:199-204.

PubMed
Jones
S, Schechter CB, Smith C, et al. Is HIV infection a risk factor for
complications of surgery? Mt Sinai J Med 2002;69:329-333.

PubMed
Madiba
TE, Muckart DJJ, Thomson SR. Human immunodeficiency disease: How should it
affect surgical decision-making? World J Surg2009;33:899-909.

PubMed
Bizer
L, Pettorino R, Ashikari A. Emergency abdominal operations in the patient
with acquired immunodeficiency syndrome. J Am Coll Surg1995;180:205-209.

PubMed
Yii
MK, Saunder A, Scott DF. Abdominal surgery in HIV/AIDS patients:
Indications, operative management, pathology and outcome. Aust N Z
J Surg1995;65:320-326. PubMed
Harris
HW, Schecter WP. Surgical risk assessment and management in patients with
HIV disease. Gastroenterol Clin North Am 1997;26:377-391.

PubMed