| Abstract|| |
Though surgeons are not primarily responsible for the treatment of patients with human immunodeficiency virus (HIV) infection, the disease influences the performance and outcome of surgery. Surgeons may be called upon to operate for the diagnosis of an infection, for an unrelated condition, or for one of the surgical complications of acquired immunodeficiency syndrome (AIDS). This article reviews in brief the etiology, pathogenesis, and natural history of HIV and AIDS, the signs and symptoms which may help in recognizing HIV disease especially in emergency situations, the clinical presentations from a surgical point of view and their management, controversial issues related to the management of AIDS patients, and finally the guidelines for the precautions to be taken to reduce the potential risk of transmission of infection from patient to a health care workers and the postexposure prophylaxis. Methods: Literature review was conducted by the way of relevant English articles obtained from National Library of Medicine's Pubmed database with the key words as mentioned below. Additional articles were obtained from the reference lists of key articles and recent reviews.
Keywords: Acquired immunodeficiency syndrome, human immunodeficiency virus, management, prevention of transmission, postexposure prophylaxis, surgery.
|How to cite this article:|
Bhattacharjee PR. Human immunodeficiency virus from the surgeons' viewpoint. Ann Trop Med Public Health 2008;1:35-42
|How to cite this URL:|
Bhattacharjee PR. Human immunodeficiency virus from the surgeons' viewpoint. Ann Trop Med Public Health [serial online] 2008 [cited 2020 Apr 10];1:35-42. Available from: http://www.atmph.org/text.asp?2008/1/1/35/43078
| Introduction|| |
On June 5, 1981, the morbidity and mortality weekly report (MMWR) of the U.S. Centers for Disease Control and Prevention (CDC), published a report of opportunistic infection with Pneumocystis carinii in five previously healthy homosexual males in Los Angeles, California.  Shortly afterward, a rare and often rapidly fatal malignancy, Kaposi's sarcoma, in association with the depletion of T-lymphocytes, were reported in 26 previously healthy homosexual males in New York and Los Angeles.  Very soon, the same disease was also described among injection drug users (IDUs) and in hemophiliacs who received blood transfusions.  These cases were later recognized as the first reported cases of acquired immunodeficiency syndrome (AIDS) in United States.
The exact cause of this condition was not known at that time. Two years later, in 1983, human immunodeficiency virus (HIV)  was isolated from a patient with lymphadenopathy  and a year later it was established to be the causative agent of AIDS. 
Over the next two decades, AIDS has been recognized globally as a major public health challenge which has assumed the proportion of a modern day pandemic eating into the resources of both the developing and the developed countries.
Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated 14,000 new infections, occurring in 2003 alone, with 90% of them being reported from developing countries.  It is the fourth leading cause of mortality worldwide, having claimed the lives of more than 22 million people (more than 500,000 in United States) in the year 2003 alone. ,
Through aggressive public health education and preventive measures, more widespread use of prophylactic therapies, which delay the onset of AIDS, and the use of highly effective antiretroviral therapy early in the course of HIV infection, the number of new AIDS cases and its mortality have decreased considerably. The current projections suggests that by 2010, an additional 45 million people in 126 low- and middle-income countries (>40% of those would be in the Asia and Pacific) will become infected with HIV unless drastic and expanded global preventive measures are undertaken.  The 2005 annual sentinel surveillance conducted by National AIDS Control Organization, Ministry of Health and Family Welfare, Government of India, estimated number of adults, in the age group of 15-49 years living with HIV worked out to be 52.06 lakhs, giving an adult prevalence of 0.91% in the country.  In 2006, more than 1 million people were living with HIV/AIDS in United States alone,  while approximately 40 million people are infected with HIV worldwide. 
| Etiology, Pathophysiology, and Natural History of AIDS|| |
HIV is a retrovirus of the lentivirus family. The virus contains a core containing RNA, reverse transcriptase (RNA dependent DNA polymerase), and core proteins. The envelope of the virus contains a glycoprotein (GP120). This glycoprotein has an affinity for the T-lymphocytes expressing CD4 antigen (helper/inducer lymphocytes).
Once the virus attaches to the host CD4+ receptors on the helper lymphocytes, after gaining access into the blood stream, they are phagocytosed and uncoated to release the viral RNA. The reverse transcriptase then incites the cell to synthesize copies of DNA (cDNA) complementary to the viral RNA. The cDNA then migrates into the nucleus of the infected cell and become a part of the host genome. The infected lymphocyte, manufactures in large numbers, new viral particles which after their lysis gets released into the blood stream to infect more CD4+ lymphocytes, a process which goes on for the rest of the patient's life leading to a chronic and usually fatal infection characterized by progressive immunodeficiency and opportunistic infection.
The infected CD4+ cells cannot carry out their normal functions and over a period of time get progressively depleted in number from 500/mm 3 to <200/mm 3 . This corresponds to profound immunosuppression and development of opportunistic infections with low virulence pathogens (pneumocystis pneumonia) and neoplasms (Kaposi's sarcoma and B-cell lymphomas) - the clinical manifestations of AIDS which develops 7-9 years after HIV infection. Patients with CD4+ cell count >500/mm 3 should have normal immune function. Counts of 500-200 CD4+ lymphocytes/mm 3 show some degree of immune compromise; while counts <200 indicate severe loss of immune function. A low CD4+ count is the best guide to the likely future clinical events or death while plasma viral load a guide to the rate of depletion of CD4+ cells and hence to the prognosis of the illness. 
The progress of HIV infection follows distinct stages. In the first stage, occurring 1-4 weeks after viral transmission, the individual manifests with symptoms of acute nonspecific viral infection such as fever, chills, and malaise. Initially, serological examination demonstrates high HIV RNA in the absence of HIV antibody. Seroconversion (positive HIV-antibody test) almost invariably occurs within 6 months of acute infection. This is followed by a variable period of asymptomatic HIV infection lasting 8-10 years when the viral load remains stable while the CD4+ cells are depleted. Symptomatic HIV infection follows next, manifesting symptoms of persistent generalized lymphadenopathy (PGL), oral/vaginal cadidiasis, recurrent episodes of herpes zoster, diarrhea, low-grade fever, significant weight loss (>10% body weight) - defined as AIDS-related complex . The final stage is the onset of the AIDS defining clinical conditions in a HIV-positive individual characterized by CD4+ cell count of <200/mm 3 with opportunistic infections (pneumocystis pneumonia, cryptococcal meningitis, CNS toxoplasmosis, histoplasmosis, cryptosporidiosis, Candida esophagitis, tuberculosis, etc.), and neoplasm (Kaposi's sarcoma, non-Hodgkin's lymphoma). Without treatment, the average time from acquisition of HIV to an AIDS defining opportunistic infection is about 10 years; patients usually survive for an average of 1-2 years thereafter.
The likelihood of developing AIDS has been reduced by highly active antiretroviral (HAART) therapy which is capable of inhibiting viral replication and clearing the virus from both the plasma and lymph nodes.  HAART and chemoprophylaxis against opportunistic infections have markedly improved the overall prognosis of HIV disease.
| Mode of Transmission and High-Risk Groups|| |
Though HIV has been isolated from blood and various other body fluids like tear, saliva, sputum, breast milk, synovial fluid, semen, vaginal secretions, CSF, and amniotic fluid; only blood and blood products, semen, vaginal secretions, and breast milk have been related to its transmission.  The commonest mode of transmission in India and around the world is heterosexual contact; while that in north-east India is intravenous drug use. Recipients of blood from HIV-positive donors have 95% chances of contacting HIV infection; though with the practice of mandatory testing of donors the risk of such transmission has been reduced to 1 in 725,000 to 1 in 835,000.  With an AIDS epidemic looming large the Government of India has put in place number of measures to check transmission through contaminated blood. It has made HIV screening mandatory at all blood banks, banned professional blood donations, established National and State Blood Transfusion councils to oversee all aspects of blood safety program, and launched program to modernize and strengthen the management of blood banks.  It is only pertinent to mention that screening of donors for HIV antibody does not totally exclude the possibility of transmission of HIV antigen because those in the seronegative window will test negative. The window period may last as long as 3 years in some patients,  although 95% seroconvert within 6 months. 
Health care workers (HCWs) are at risk of acquiring HIV through occupational percutaneous exposure to body fluids of HIV-infected patients. The risk of such transmission after a single encounter is 1 in 300 as against 1 in 150 following needle sharing, 1 in 300-1000 following receptive anal intercourse, 1 in 500-1250 with receptive vaginal intercourse.  Transmission risk increases with the number of encounters, a large inoculum and with a larger HIV RNA plasma levels. 
Groups which have the highest risk of seroprevalance are: 
- Homosexual and bisexual men (highest risk of transmission follows unprotected receptive anal or vaginal intercourse during menses or that in presence of genital ulcers). 
- Intravenous drug abusers.
- Persons with hemophilia or blood disorders requiring repeated transfusion.
- Sexual partners of the above.
- Children born to HIV-positive mothers.
- Persons coming from high prevalence areas
Surgeons and their team should be alert while dealing with such high-risk groups to reduce the risk of transmission of HIV to the HCWs.
| Clinical Evaluation for HIV Disease|| |
While every patient cannot be tested for HIV before surgical treatment; even if it was practicable, a proportion of patient in the window period would test negative (the viral titres are at their highest and the individual probably most infectious during this initial "seroconversion" and in the late AIDS phase of the illness). Hence, all surgical staff should after a quick and thorough clinical assessment be able to recognize symptoms and signs of HIV disease, especially in an emergency situation. In an elective setting clinical assessment for HIV infection may be supplemented by serological tests whereby undiagnosed HIV-related illness can be discovered at the time of surgery. This will help in obtaining an informed consent explaining the extra complications of HIV disease and also influence the choice of treatment in certain situations, e.g., open lymph node biopsies may be largely replaced by fine needle aspiration cytology (FNAC) (an experienced cytologist may easily differentiate between reactive hyperplasia, tuberculosis, Kaposi's sarcoma, and metastasis), or an internal fixation of a fracture may be replaced by closed reduction and immobilization were feasible.
Clinical assessment - History:
- Recurrent upper respiratory tract infections.
- Fever, weight loss, or persistent diarrhea.
- Other HIV-related infections like tuberculosis, herpes zoster.
- Hepatitis B (HBV) and hepatitis C (HCV) which are common co-infections. 
- Risk factors: sexual practices, intravenous drug abuse.
Clinical assessment - Examination of the mouth, skin, and lymph nodes: 
- Faucial inflammation, hairy leukoplakia of tongue, candidiasis or purple staining, or raised plaques of oral Kaposi's sarcoma involving palate and gums, periodontitis, and aphthous ulcers.
- Scars of herpes zoster or furunculosis (pigmented circle around a depigmented central scar).
- Symmetrical enlargement of posterior cervical, axillary, or epitroclear nodes.
- Asymmetrical lymphadenopathy is seen with HIV-related tuberculosis, lymphoma, and Kaposi's sarcoma.
It is pertinent to mention that occasionally the depressed host immune response may obscure the presentation resulting in delayed or missed diagnosis.
| Surgery in HIV-infected Patients|| |
With new HIV infections occurring worldwide and better availability of low cost antiretroviral drugs, the number of the HIV-positive people in the population is steadily increasing. Surgeons will be increasingly called upon for consultation and surgical interventions for either routine surgical conditions or for AIDS-related complications. Surgical management of such patients obviously carries some risk of contracting this lethal infection and this fear has some direct and indirect influence on the psychologic, social, and professional life of the concerned surgeon. It has been estimated that a surgeon working in an area with high prevalence of HIV over a career span of 30 years has as high as 1:4 chance of acquiring the infection.  Surgeons have been found to have a higher rate of percutaneous exposure than other specialists and operations such as lymph node biopsy, soft-tissue-mass excision, and abscess drainage (commonly assigned to inexperienced trainee surgeons) have carried the greatest risk of infection. 
Patients with HIV infection may require surgery for:
- Diagnosis of an AIDS-associated infection and neoplasm.
- Treatment of surgical complications of AIDS.
- The same reasons that anyone else may require surgery.
Such patients do not require any special preoperative preparation, but HCWs need to adopt safe techniques during surgery and while handling wounds, drains, and body fluids to avoid accidental transmission.
CD4 counts and plasma viral loads, in addition to the standard laboratory tests, are useful in determining the prognosis in AIDS patients. Reduction of the HIV viral load in the plasma prior to high-risk interventions like cardiothoracic and orthopedic surgery have been tried to ensure the safety of the operating team.  Postoperative CD4 counts of 200 cells/mm 3 or less are associated with higher-mortality rate.  Obtaining these values within the time frame required to plan definitive management may be difficult. As a rule, the number of CD4 cells is roughly 10% of the lymphocyte count  and total lymphocyte count >2000 cells/mm 3 are usually associated with a CD4 count of >200 cells/mm 3 while a total lymphocyte count <1000 cells/mm 3 is associated with a CD4 count <200 cells/mm 3 .  Similarly, postoperative viral loads >75,000 RNA copies/ml are associated with a higher complication and mortality rates. 
| Surgery for Diagnosis of an AIDS-associated Infection and Neoplasm|| |
Histopathology report of the lymph nodes nearly always reveals benign reactive follicular hyperplasia and as such is of no use for diagnostic purpose.  Excision biopsy of lymph node/soft tissue mass may occasionally be required for the diagnosis of tuberculosis, lymphoma, or sarcoma, though most of the time the diagnosis may be arrived at without the help of surgical biopsy. However, with the increasing awareness regarding the risk of transmission, FNAC should be considered first and open biopsy reserved for situations where FNAC is inconclusive in a clinically suspicious node, when it is associated with signs and symptoms of systemic illness, such as fever and weight loss, or when the nodes begin to enlarge, become fixed, or coalesce, and when it is required to classify a lymphoma diagnosed on FNAC. 
| Surgery for Treatment of Surgical Complications of AIDS|| |
Abscesses are common in HIV-positive patients. Young adult patients of either sex with pyomyositis (especially of the large striated muscles of the trunk and limbs) are particularly likely to have HIV disease. 
Acute abdominal emergencies ,,
Patient with HIV infection may present with features of acute abdomen for conditions like acute appendicitis, bowel perforation, or bowel obstruction. Abdominal pain which requires medical evaluation is a feature in 12-45% of the patients with HIV infection, but only 5% of this need a surgical intervention. Acute abdominal pain in HIV infection may occur due to various reasons, e.g., in advanced AIDS, CMV infection may cause ischemic bowel perforation and peritonitis (due to arteriolar involvement of the intestine) - terminal ileum and colon being the commonest sites; obstructive appendicitis leading to appendicular perforation may result due to lymphoid hyperplasia following CMV infection. In advanced stages of HIV infection, Kaposi's sarcoma can cause bowel obstruction, perforation, and acute obstructive appendicitis. Though the previously high incidences of bowel perforation due to CMV infection and Kaposi's sarcoma has decreased somewhat following the use of anti-retroviral drugs it is now more common in patients with disseminated tuberculosis and lymphomas. Bowel perforation signifies an advanced stage of HIV infection. Similarly gastrointestinal hemorrhage may be a presentation of both CMV infection and Kaposi's sarcoma.
Only 30% of acute appendicitis in HIV infection is caused by complications of AIDS-related conditions. Characteristically, HIV/AIDS patients with acute appendicitis presents with low or normal white blood cell (WBC) count (though it is elevated over the chronically low WBC count of such patients). The misleading blood picture along with delayed or absent features of peritoneal inflammation may delay the diagnosis and may indirectly be responsible for increased rate of appendicular perforation and abscess formation in such patients. 
Profound immunosuppression in AIDS can result in normal gut flora causing inflammation of the cecum and appendix, i.e., typhlitis, mimicking appendicitis. Surgery in such patients is not only unnecessary, but also carries risk of increased postoperative morbidity. So, some recommends that a computed tomography (CT) scan or even laparoscopy should be performed prior to decision of surgical intervention in AIDS patients. 
Patients with advanced HIV infection are susceptible to opportunistic infection of the gastrointestinal tract (GIT) with Clostridium difficile to repeated hospitalization and antibiotic therapy. Toxic megacolon may ultimately result in advanced cases. A conservative approach by medical management and colonoscopic decompression has been associated with a more acceptable outcome than emergency colectomies. 
Hepatobiliary and splenic disease ,,
Chronic hepatitis B and C infections share common routes of transmission with HIV. Hepatobiliary opportunistic infections with CMV and fungi like Cryptococcus neoformans , Histoplasma capsulatum , Candida albicans , etc. are features of patients with severe immunosuppression, having CD4 counts <100 cells/mm 3 , who present with multiple small liver abscess.
Mechanical obstruction of the bile ducts may result from enlarged lymph nodes at the porta hepatis or rarely due to AIDS-associated sclerosing chlongiopathy due to Cryptosporidium species, CMV and Microsporidia. Acute acalculous cholecystitis occurs at a higher frequency in HIV-infected patients and requires cholecystectomy.
Splenomegaly is a common finding in patients with AIDS, due to infections with CMV, Mycobacterium tuberculosis , and Pneumocystis carinii . Splenic abscess, lymphoma, and Kaposi's sarcoma are other causes. Splenectomy may be required for traumatic or spontaneous rupture of spleen. Splenectomy may also be required to increase the platelets count in immunodeficiency-associated thrombocytopenic purpura who respond poorly to steroids.
Anorectal disease ,
This has become the most frequent reason for surgical intervention in HIV-positive patients. Perianal sepsis, fissure, fistulas, anal warts and even squamous cell carcinoma of the anus are commonly encountered in patients with AIDS. A considerable number (13-15%) of HIV-positive male homosexuals reports with anorectal diseases while only 4% of other patients with HIV infection are likely to be affected. , In this context, it is only apt to mention that HIV-positive individuals may present with a variety of conditions mimicking perianal sepsis, e.g., massive anal ulceration due to Herpes simplex, Kaposi's sarcoma of anal canal presenting as bleeding hemorroids, Hodgkin's lymphoma as perianal abscess, or chronic indolent abscess due to Mycobacterium avium intracellulare.
Large perianal incisions and division of internal anal sphincter should be avoided; setons are preferable for managing fistulae.
Condylomata acumiata caused by human papilloma virus are large or extensive in nature and generally resist medical therapy with podophyllin. They are also more aggressive and dysplastic in nature. Surgical treatment with electrocautery or laser is effective in eradicating them.
Kaposi's sarcoma may be found to involve the skin, GIT, liver, lungs, and even heart.  There has been a decline in its incidence after the wide spread use of antiretroviral therapy.
Colorectal adenocarcinomas have been diagnosed in more advanced stage and at an earlier age group of patients in HIV-positive patients. 
Surgery for these is limited to that for diagnostic purpose (FNAC/biopsy), management of complications or palliative interventions for events like obstruction, bleeding, or perforation.
Non-Hodgkin's lymphoma, commonly affecting GIT, is another common malignancy in patients with AIDS and is commonly undifferentiated and aggressive in nature. It needs to be primarily managed by chemotherapy.
Vascular diseases ,
Necrotizing arteriopathy leading to vascular aneurysm and progressive granulomatous vasculitits leading to fibroproliferative aortoiliac occlusive disease are entities associated with HIV infection. Salmonella More Details have been shown to have an affinity for atherosclerotic plaques in such patients leading to Salmonella arteritis; an invasive form of this infection can lead to pseudoaneurysm formation. Infected pseudoaneurysm with common bacteria is seen among IVDUs. Surgical management in the form of arterial reconstruction may avoid the potentially fatal rupture.
| Occupational Risk of HIV Transmission and its Implication for Surgeons|| |
Surgeons and his team operating on a patient with known HIV infection or on potentially infected patients should be aware of the risk of transmission of infection and the precautions to be taken to prevent it. Many a time, especially in emergency settings, surgeons operate on patients without knowing their HIV status. Hence precautions must always be taken to prevent or minimize the risk of transmission of HIV as well as hepatitis B and C viruses among medical staff. In 1987, the CDC issued guidelines for minimizing the risk of HIV transmission in health care setting, which have come to be called the "Universal Precautions." It involves the use of protective barriers (gloves, gowns, masks, etc.) to prevent transmission of HIV, while dealing with potentially infectious materials like blood, other body fluids containing visible blood, semen, and vaginal secretions, cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Protective barriers and precautions are needed to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.
Universal precautions do not apply to feces, nasal secretions, sputum, saliva sweat, tears, urine, and vomitus unless they contain visible blood.
The basic idea is to assume all patients to be potentially infectious irrespective of their serological status and always take precautionary measures to avoid accidental transmission.
The following conditions are associated with the increased likelihood of HIV transmission following percutaneous exposure: deep injuries (needle stick, cut with sharp objects), visible blood on the device, procedures involving direct placement of a needle into a vein or artery, dealing with terminally ill HIV-infected patients and where postexposure prophylaxis (PEP) has not been taken [Table 1]. The risk of HIV infection to the surgeon is the highest when the viral load is increased, i.e., during the earlier (when seroconversion is occurring) and in later stages (uncontrolled AIDS).
Occupational risk of HIV transmission depends on the local seroprevalence rates, nature, and length of period of exposure number of procedures carried out by the surgeon and the susceptibility of the HCW.  Commonest mode of HIV infection in HCWs is by percutaneous injuries with hollow needle (greatest risk) containing HIV-infected blood (most important source). The average risk of HIV transmission after percutaneous exposure to HIV-infected blood (risk is 10-fold more following injuries with hollow needle)  ; is approximately 0.3%; and approximately 0.09% after mucous membrane exposure.  The risk following non-intact skin exposure has been estimated to be less than the risk of mucous membrane exposure while those following exposure to other fluids and body tissue are overall lower than that of exposure to blood. Contact with normal skin with no injury is not a risk for HIV transmission.  As of January 1, 2002, 57 HCWs in the United States had been documented as having seroconverted to HIV following occupational exposure; 26 have developed AIDS.  These included 19 laboratory workers, 24 nurses, 6 physicians, 6 technicians, and 2 housekeeper /maintenance workers. The exposures included 48 percutaneous (puncture/cut injury), 5 mucocutaneous (mucous membrane and/or skin), 2 both percutaneous and mucocutaneous, and 2 unknown route of exposure. 
| Preoperative Testing for HIV Status|| |
Testing for HIV status is required for the management of HCWs exposed to blood or body fluids of HIV-infected patients and for diagnosis and management in a suspected case. In India, political and social constraints do not permit routine preoperative serological screening of all patients for HIV.
The revised CDC recommendations for HIV testing  in the health care settings and for screening pregnant women are as follows:
- HIV screenings is recommended for patients in all health care settings including pregnant women after the patient is notified that the testing will be performed unless the patient declines (opt-out testing).
- Persons at high risk for HIV infection should be screened for HIV at least annually.
- Written informed consent from the individual should not be required; general consent for medical care is sufficient and encompasses consent for HIV testing.
- HIV screening should be included in the routine panel of prenatal screening for pregnant women.
- HIV diagnostic testing as part of prevention counseling associated with controlling HIV transmission or as part of HIV screening program is not required.
| Precautionary Measures|| |
Unfortunately, in spite of the oft repeated recommendations regarding Universal Precautions, noncompliance with the same in an emergency setting is as high 84%.  Some basic and standard precautions need to be universally followed like wearing gloves while drawing blood or inserting cannula, while catheterizing or passing an endotracheal tube, and various endoscopic examinations. These are often forgotten while dealing with emergency patients. However, gloves are not worn while examining HIV-infected patient without any open wound.
Accidental prick with blood filled hypodermic needles and cannulas are an important cause of seroconversion among HCWs. Needles must always be disposed off into puncture resistant sharp's box after use and not recapped or bent. The puncture-resistant containers should be located as close as practical to the use area. All reusable needles (disposable needles are always preferable) should be placed in a puncture-resistant container for transport to the reprocessing area.
Wastes contaminated with blood or bloody fluids need to be safely disposed.
Disposable instruments are used wherever possible, otherwise instruments and other equipment needs proper disinfection.
Additional precautions are used while operating on a known HIV-infected patient. OT gowns should have waterproof sleeves and front, surgeons and assistant should wear visor to protect the eyes, boots (instead of open toed slippers), and face shields. Use of double gloves (fivefold reduction of risk of skin contamination) , or special prick proof gloves  help in preventing needle pricks or pricks from sharp bone fragments or snagged wires. Use of blunt needles for some routine surgical steps like fascial closure could reduce the risks of needle related injury. Passing the needle back to the assistant with the holder clamped on to the suture rather than the needle is an effective way of preventing accidental needle stick injuries. 
As far as operative techniques are concerned, undue haste should be avoided during surgery, number of assistants to be kept minimum, skin incisions should be large so that the assistant need to use minimum retraction and his hands are as far away from the operative field as possible. , Surgery should be done in an orderly fashion with meticulous attention to avoid sudden rapid bleeding thereby avoiding rapid movements and its attended risk of inadvertent injuries. Perhaps the most effective strategy is to transfer sharp instruments on a kidney dish and not directly from hand-to-hand.  Use of Mayo's table can lead to accidental injuries and should preferably be avoided. These surgical principles may be followed as a routine in all cases irrespective of their HIV status.
| Management Strategy in the Event of Exposure|| |
In the event of significant accidental exposure to a HIV-infected source the following guidelines are to be followed:
Treatment of the exposure site:
Skin : Through wash with soap and water
Eyes: Irrigation of eyes with water
Oral exposure: Spit out immediately and rinse mouth several times
Prompt assessment of the risk, i.e., the source, recipient, and the nature of exposure.
- Source: HIV testing after proper consent. If known to be HIV positive then assess the health status and the possibility of drug resistance if on anti retro-viral therapy
- Recipient: Baseline serological testing for HIV, HBV, and HCV.
- Nature of exposure
Counseling and antiretroviral therapy
- Pretest counseling to the exposed individual.
- Baseline test for HIV, HBV, and HCV.
- PEP with antiretroviral medicines should be started within an hour of the injury where possible when the source patient is known to be HIV positive or comes from a high-risk group and the HIV status is unknown and the exposure is of high or intermediate risk in nature. PEP may also be considered for those presenting 72 or more after exposure after explaining the risk/benefit.
Current recommendations are to use two drugs or three drugs (expanded regime) depending on the nature of exposure. For low-risk exposure two drugs basic regime (backbone) with nucleoside reverse transcriptase inhibitors (NsRTIs) with Zidovudine (AZT) 250 mg b.d. and Lamivudine (3TC) 150 mg b.d. may be recommended. Sometimes PEP is not recommended following such exposures considering the low risk of HIV transmission as against the risk and side effects of PEP. For intermediate- or high-risk exposures a three drug regimen, i.e., dual nucleoside component as above combined with Indinavir (Protease inhibitor) 800 mg t.d.s. The treatment needs to be continued for 28 days.
- If the individual is not immunized to HBV consider HBV immunoglobulin and HBV vaccine (the risk of developing hepatitis is greater after contamination with infected blood).
- Counseling regarding the need for practicing safe sex, avoiding blood donation, breast feeding, and to adopt the necessary safety precautions while taking injections especially during the first 6-12 weeks postexposure.
- Post-test counseling and declaration of the base line results.
- HIV test should be repeated after 6 weeks, 12 weeks, and 6 months postexposure to know whether seroconversion has occurred or not.
Reporting and documentation of the event
- Record date/time of exposure and details of the event.
- Details of the exposure source if known.
- Details of the PEP treatment if given.
- Follow-up and outcome.
| References|| |
|1.||Centers for Disease Control (CDC). Pneumocystis pneumonia-Los Angeles. MMWR Morb Mortal Wkly Rep 1981;30:250-2. [PUBMED] |
|2.||Anthony SF, Clifford HL. Human immunodeficiency virus disease: AIDS and related disorders. In: Dennis LK, Eugene B, Anthony SF, Stephen LH, Dan L, Larry JJ, editors. Harrison's principles of internal medicine. 16 th ed. New York: McGraw-Hill Publications; 2005. p. 1076-139. |
|3.||Barre-Sinoussi F, Chermann JC, Rey F. Isolation of T-lymphotropic retrovirus from a patient at risk for acquired immune deficiency syndrome (AIDS). Science 1983;220:868-71. |
|4.||Joint United Nations Programme on HIV/AIDS (UNAIDS): AIDS Epidemic Update, December, 2003. |
|5.||Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, et al. Revised recommendations for HIV testing of adults, adolescents and pregnant women in health care settings. MMWR Morb Mortal Wkly Rep 2006;55:1-17. |
|6.||UNAIDS. Report on the global HIV-AIDS epidemic. 2002. UNAIDS/02.26E. Available from: http://www.naco.nic.in/indianscene/esthiv.htm. |
|7.||National AIDS Control Organization, April 2006 report. HIV/AIDS epidemiological Surveillance and Estimation report 2005. Available from: http://www.nacoonline.org/fnl_april06rprt.doc. |
|8.||Centers for Disease Control (CDC). Twenty-five years of HIV-AIDS - United States, 1981-2006. MMRW Morb Mortal Wkly Rep 2006;55:RR-21. |
|9.||Sax PE. HIV infection. In: Cunha BA, editor. Antibiotic essential. 4 th ed. New York: Physician's Press; 2005. p. 226-67. |
|10.||Allen-Mersh TG. Acquired immunodeficiency syndrome. In: Russel RC, Williams NS, Bulstrode CJ, editors. Bailey and Love's short practice of surgery. 24 th ed. London: Arnold; 2004. p. 175-82. |
|11.||World Bank, India's National AIDS Control Program. [cited on 1999 Sep]. Available from: http://wbln1018.worldbank.org/sar/sa.nsf/all/oc8b13c927927ca3852567f4005394fc?opendocument. |
|12.||Imagawa DT, Lee MH, Wolinsky SM, Sano K, Morales F, Kwok S, et al. Human Immunodeficiency Virus Type I infection in homosexual men who remain seronegative for prolonged periods. N Engl J Med 1989;320:1458-62. [PUBMED] |
|13.||Horsburgh CR Jr, Ou CY, Jason J, Holmberg SD, Longini IM Jr, Schable C, et al. Duration of Human Immunodeficiency Virus infection before detection of the antibody. Lancet 1989;2:637-40. [PUBMED] |
|14.||Regez RM, Kleipool AE, Speekenbrink RG, Frissen PH. The risk of needle stick accidents during surgical procedures: HIV-1 viral load in blood and bone marrow. Int J STD AIDS 2005;16:671-2. [PUBMED] [FULLTEXT]|
|15.||Poles MA, Dieterich DT. HIV and hepatitis virus infection. Cur Infect Dis Rep 2000;2:177-84. |
|16.||Weiss ES, Makary MA, Wang T, Syin D, Pronovost PJ, Chang D, et al. Prevalence of blood borne pathogens in an urban, University based general surgical practice. Ann Surg 2005;241:803-9. [PUBMED] [FULLTEXT]|
|17.||Savioz D, Chilcott M, Ludwig C, Savioz M, Kaiser L, Leissing C. Preoperative counts of CD4 T-lymphocytes and early postoperative infective complications in HIV-positive patients. Eur J Surg 1998;164:483-7. |
|18.||Blartt SP, Lucey CR, Butzin CA, Hendrix CW, Lucey DR. Total lymphocyte count as a predictor of absolute CD4+ count and CD4+ percentage in HIV infected persons. JAMA 1993;269:622-6. |
|19.||Shapiro NI, Karras DJ, Leech SH, Heilpern KL. Absolute lymphocyte count as a predictor of CD4 count. Ann Emerg Med 1998;32:323-8. [PUBMED] |
|20.||Tran HS, Monocure M, Tranoff M, Goodman M, Puc MM, Kroon D, et al. Predictors of operative outcome in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome. Am J Surg 2000;180:228-33. |
|21.||Saltzman DJ, Williams RA, Gelfand DV, Wilson SE. The surgeon and AIDS: Twenty years later. Arch Surg 2005;140:961-7. [PUBMED] [FULLTEXT]|
|22.||Barone JE, Gingold BS, Arvanitis ML, Nealon TF Jr. Abdominal pain in patients with acquired immunodeficiency syndrome. Ann Surg 1986;204:619-23. [PUBMED] [FULLTEXT]|
|23.||Yoshida D, Caruso JM. Abdominal pain in HIV infected patients. J Emerg Med 2002;23:111-6. [PUBMED] [FULLTEXT]|
|24.||Whitney TM, Macho JR, Russell TR, Bossart KJ, Heer FW, Schecter W. Appendicitis in acquired immune deficiency syndrome. Am J Surg 1992;164:467-71. |
|25.||Lowy AM, Barie PS. Laparotomy in patients infected with human immunodeficiency virus: Indications and outcome. Br J Surg 1994;81:944-5. |
|26.||Beaugerie L, Ngo Y, Goujard F. Etiology and management of toxic magacolon in patients with human immunodeficiency virus infection. Gastroenterology 1994;107:858-63. |
|27.||Miles AG, Mellor CH, Gazzard BG, Allen-Mersh TG, Wastell C. The surgical management of ano-rectal disease in HIV-positive homosexual. Br J Surg 1990;77:883-7. |
|28.||Yeguez JF, Martnez SA, Sands DR, Sands LR, Hellinger MD. Colorectal malignancies in HIV-positive patients. Am Surg 2003;69:981-7. |
|29.||Rhodes RS, Bell DM. Prevention of transmission of blood borne pathogens. Surg Clin North Am 1995;75:1047-218. |
|30.||Wright JG, Young NL, Stephens D. Reported use of strategies by surgeons to prevent transmission of bloodborne diseases. Can Med Assoc J 1995;152:1089-95. |
|31.||Patterson JM, Novak CB, Mackinnon SE, Patterson GA. Surgeons' concern and practices of protection against blood borne pathogens. Ann Surg 1998;228:266-72. [PUBMED] [FULLTEXT]|
|32.||Centers for Disease Control (CDC). Updated US public health services guidelines for the management of occupational exposures to HIV and recommendations for post exposure prophylaxis. MMWR Morb Mortal Wkly Rep 2005;54:1-17. |
Prosanta K R Bhattacharjee
Flat no 10-C, 9-Mandeville Gardens, Kolkata - 19, West Bengal
Source of Support: None, Conflict of Interest: None
Clinical trial registration None