HIV virus is composed of single stranded RNA
Contains a variety of genes
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
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
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
Two groups of Pathology occurring in HIV/AIDS
Diseases with a definitive association to HIV
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.
Issues to consider:
operative risk in
occupational risk to
the health care workers
When a doctor proposes a surgical intervention, informed
consent is an
absolute necessity. Three new aspects have arisen during the
the HIV pandemic.
Firstly, HIV/AIDS patients fear social recognition and
frequently request doctors to perform unnecessary surgery
removal of ‘tell-tale’ cervical lymph nodes or parotidectomy
for Diffuse infiltrative lymphocytosis syndrome
The second aspect of informed consent pertains to the
terminal HIV/AIDS patients. Some patients (and their
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 <2.5g/dL) have been found to be more reliable predictors of surgical outcome than CD4 count or viral load in HIV-infected patients (4-7) Viral suppression also has not been conclusively shown to improve surgical outcomes; however, in the setting of elective surgery, it is still recommended that ART be optimized preoperatively Surgical risk assessment for HIV-infected individuals is highly individualized, and all aspects of the HIV-infected patient's clinical profile, including the indication for surgery, should be evaluated and discussed with the patient Early disease Pateints with early HIV infection have an operative risk similar to HIV negative patients and can be subjected to any major surgery Advanced disease Pathophysiological consequences immunosuppression, malnutrition, infections and neoplasms could dictate that the magnitude of the surgery Can be down scaled to an acceptable and safe level.
Four factors have
been found to increase operative morbidity and mortality in HIV/AIDS patients:
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
emergency surgery as
opposed to elective procedures
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.
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
thrombocytopenia side effects of zidovudine
P.I’s can affect
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
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).
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
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
All bodily fluids of all patients should be regarded
as hazardous substances.
Barrier protection is
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 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%
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).
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
practitioner responsible for the treatment of a person may undertake a HIV test
in respect of that person without consent of the person if:
person is unconscious and unable to give consent and:
medical practitioner believes that such a test is clinically necessary or
desirable or in the interest of that person.
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.
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
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
CA, Derr R, Anderson J. Operative complications in HIV-infected women
undergoing gynecologic surgery. J Reprod Med 2001;46:199-204.
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.
TE, Muckart DJJ, Thomson SR. Human immunodeficiency disease: How should it
affect surgical decision-making? World J Surg2009;33:899-909.
L, Pettorino R, Ashikari A. Emergency abdominal operations in the patient
with acquired immunodeficiency syndrome. J Am Coll Surg1995;180:205-209.
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
HW, Schecter WP. Surgical risk assessment and management in patients with
HIV disease. Gastroenterol Clin North Am 1997;26:377-391.