HIV AND SURGEON

HIV and SURGEON : 

HIV and SURGEON Department of surgery gomco patiala

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The acquired immunodeficiency syndrome (AIDS) was first recognised in United States in the summer of 1981 when Centres for Disease Control and Prevention (CDC) reported unexplained Pneumocystis carinii pneumonia in 5 previously healthy homosexual men .

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In 1983 Human Immunodeficiency Virus (HIV) was isolated from a patient with lymphadenopathy and by 1984 it was demonstrated to be the causative agent of AIDS.

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The HIV infection/AIDS has assumed magnitude of global epidemic with estimated 40 million cases worldwide. In India alone there are 5.2 million cases.

ETIOLOGIC AGENT : 

ETIOLOGIC AGENT The etiology of AIDS is HIV which belongs to the family of human retroviruses and sub family of lentiviruses (slow viruses). HIV is an RNA virus that contains reverse transcriptase which transcribes viral RNA into DNA of host genome.

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Based on molecular and antigenic differences two types of HIV have been recognised : HIV-1 and HIV-2.

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HIV-2 is more closely related to Simian Immunodeficiency Virus than to HIV-1. It is also much less virulent and confined mainly to West Africa and South India.

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HIV has a cell surface glycoprotein gp 120 that recognises and binds to receptors on several types of human cells, particularly the CD4 receptors found in high density on surface of helper T lymphocytes.

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Other reservoirs of HIV infection are :- Macrophages Neural cells Renal cells Epithelial cells.

TRANSMISSION : 

TRANSMISSION The most certain mode of transmission is by infected blood. The HIV virus is considerable less infectious : 1ml of infected blood containing 50 HIV particles in contrast to 1000000000 hepatitis B particles. Besides blood other body fluids rich in virus particles are genital fluids and CSF. Breast milk and saliva have varying number while other fluids such as sweat, urine, faeces and tears have low viral content.

MODES OF TRANSMISSION : 

MODES OF TRANSMISSION Inoculation of infected blood or body fluids Penetrative sexual intercourse Vertical transmission from mother to child.

Efficiency of different routes of transmission : 

Efficiency of different routes of transmission

Contribution to total number of cases : 

Contribution to total number of cases

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Thus the most efficient vehicle is blood. However the risk of infection via blood transfusion is low due to strict HIV screening of donated blood. The most common route is unprotected penetrative sexual intercourse

PATHOGENESIS : 

PATHOGENESIS HIV upon entry into blood stream predominantly binds to CD4 receptors on T lymphocytes which bear strong affinity for virus surface protein gp 120.

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Reverse transcriptase mediated Reverse transcription Single Stranded DNA Double Stranded or Proviral DNA synthesis Integration with host cell DNA Viral protein synthesis Virus assembly and budding Destruction of CD4 cells Reinfection of new CD4 T lymphocytes

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Destruction of CD4 lymphocytes in main feature responsible for effects of HIV infection. This in turn leads to: Decreased CMI Disorders of antibody production Delayed hypersenstivity Depletion of Ig-A

NATURAL HISTORY OF HIV DISEASE : 

NATURAL HISTORY OF HIV DISEASE Acute HIV infection Following infection by the HIV into the blood there in a brief sero-conversion illness that is characterised by flu like symptoms and lymphadenopathy. Such symptoms are observed within 3 to 6 weeks of infection.

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Latent infection This phase lasts for about 10 years after 1st contact with HIV virus. In this phase, virus multiplication steadly goes on with progressive destruction of CD4 lymphocyte although the patient remain asymptornatic

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Persistent generalised LAP This has been defined as the presence of enlarged lymph nodes at least 1 cm in diameter in two or more non contiguous extrainguinal sites, that persist for at least 3 months in absence of any current illness.

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ARC – AIDS related complex This group includes patients with considerable immunodeficiency suffering from various constitutional symptoms or minor opportunistic infections.

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AIDS This is end stage disease representing the irreversible breakdown of immune defence mechanisms with patient succumbing to various opportunistic infections and malignancies.

Clinical Stages of HIV Disease : 

Clinical Stages of HIV Disease

DIAGNOSTIC TESTS : 

DIAGNOSTIC TESTS Viral entry into the body leads to a period of plasma viraemia and P24 antigenemia. However the levels of these components come down with concomitant immune response. Humoral response is evidenced by formation of antibodies of different classes. The antibodies appear in blood within 2-8 weeks after infection but usually become detectable after 3-12 weeks with the assays available presently. This period following the entry of HIV into the body and the appearance of detectable levels of antibodies with the available test kits is called the Window Period. During this period the patient is infected, infectious but non-reactive with the antibody detection tests.

VARIOUS TESTS PERFORMED ON SUSPECTED PATIENTS ARE : : 

VARIOUS TESTS PERFORMED ON SUSPECTED PATIENTS ARE : Antibody Detection Tests Screening tests – ELISA RAPID SIMPLE

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Supplemental test :- These are done to confirm positivity of E.R.S. tests i.e. to defect false positive cases. The patient is labeled as a case of HIV only if any of these tests are positive. Western Blot Test – Regarded as the gold standard in confirming the diagnosis of HIV infection. The seropositivity is diagnosed when antibodies against both the env and gag proteins are detected. HIV proteins are separated by their electrophoric mobility.

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ELISA – It is the most commonly performed screening test with high % of sensitivity and specificity. It is cost effective and can be employed for mass screening purposes. Results are available in 2-3 hours. It detects IgG antibodies against HIV which remain throughout the course of disease from phase of seroconversive illness onwards.

Microplate ELISA : Coloured wells indicate reactivity : 

Microplate ELISA : Coloured wells indicate reactivity If test serum contains anti HIV antibodies a photometrically detectable colour change occurs in test well, which can be read by special ELISA readers. ELISA is simple and relatively in expensive but false positive reactions are not uncommon particularly with sera containing rheumatoid factor, anti- lymphocyte or other autoantibodies.

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RAPID - It is a visual test in which result is displayed in minutes. It is a dip stick test.

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SIMPLE - Are agglutination tests which are very easy to perform i.e. require no special skill. Results are displayed in ½ hour.

Antigen Detection Tests : 

Antigen Detection Tests These tests are positive in 2 weeks after acquiring HIV infection. These tests are positive in seroconversion phase of illness and are used to screen blood donors along with ELISA test.

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Detection of HIV nucleic acid (RNA and DNA) It is the most sensitive and specific test and has become gold standard for diagnosis in all stages of HIV infection. Two forms of PCR are used – DNA PCR and RNA PCR. It is useful in – 1. Window period

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2. Detection of infection in newborn 3. Resolution of indeterminate ELISA/Westernblot tests (Partially reactive). PCR tests are complex and costly and used only when other tests are equivocal or non-informative.

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Surrogate Markers of Disease Progression These markers are linked with disease progression and are :- CD4 cell count P24 Ag B2 microglobulin P24 antibody.

Out of which CD4 counts are most useful : : 

Out of which CD4 counts are most useful :

PRESENTATION TO A SURGEON : 

PRESENTATION TO A SURGEON 1. Lymphadenopathy 2. HIV associated thrombocytopenic purpura 3. Anal diseases

Anal diseases : 

Anal diseases Warts Perianal Sepsis (Perianal abscess and fistual) Anorectal ulceration Anal neoplasia Faecal incontinence

HIV AND SURGEON : 

HIV AND SURGEON Dr.Sunil Kumar Goyal

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Acute Abdomen 1. Appendicitis 2. Infective colitis 3. NHL

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Cholangitis Lymphoma Intracranial Mass Lesion Thoracic Surgery Solid Organ Transplantation

Surgery in the Management of Clinical Problems of HIV Infection : 

Surgery in the Management of Clinical Problems of HIV Infection Lymphadenopathy Most common presentation to a general surgeon. Seen in cases of :- Opportunistic infections Secondary lymphomas.

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Procedure : FNAC of enlarged lymphnodes Excision biopsy – done when FNAC report is negative or if LN’s continue to enlarge.

2. Thrombocytopenic purpura : 

2. Thrombocytopenic purpura This is common condition seen in asymptomatic HIV infected patients or patients with advanced HIV disease. It is a refractory condition and does not respond to steroids and other medical treatment. Procedure – Splenectomy.

3. Anal diseases : 

3. Anal diseases Warts :- These are usually sexually transmitted through anoreceptive intercourse. They are caused by human papilloma virus – HPV and in presence of reduced immunity as in HIV infection lead to early neoplastic changes in anal epithelium – AIN. Treatment – Local application of podophyllin Local excision Destruction by lasers / diathermy.

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Perianal Sepsis – Anorectal ulcerations, abscess and fistula – The condition is due to trauma to anal canal due to anoreceptive sex in homosexuals. – Perianal healing is reduced in patients with advanced HIV diseases associated with low CD4 counts. Treatment - CD4 count >100 – conventional treatment count <100–conservative approach eg. Seton

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Anal neoplasia :- HIV infected individuals have much higher percentage of anal neoplasm than non infected individuals. The common malignancies seen are : Squamous cell carcinoma Kaposi’s sarcoma Perirectal/perianal NHL.

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Lymphoma can produce a tense, painful swelling in the ischiorectal fossa that may be mistaken for perianal sepsis. Therefore needle aspiration is must before I & D in suspected ischiorectal abscess in HIV positive patients.

Treatment : : 

Treatment : AIN - Simple excision, excision with grafting, laser ablation, cryoablation or application of 5-FU cream. Sq cell CA – on anal verge – wide local excision –extensive – Abdominal perineal resection.

Acute Abdomen in AIDS : 

Acute Abdomen in AIDS Abdominal pain occurs in over 10% of all AIDS patients. However only 5% required surgery and this includes a small group of patients in whom emergency surgery is necessary eg. Appendicitis Infective colitis – usually from CMV in immuno compromised patient and results in - Bloody colitis - Toxic megacolon - Colonic perforation

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NHL - Occasionally patients undergoing chemotherapy for NHL develop acute abdominal symptoms due to small bowel perforation at the site.

Treatment : 

Treatment Appendicetomy for acute appendicitis. Laprotomy for gut perforation

Cholangitis : 

Cholangitis Some patients with advanced HIV disease develop liver dysfunction consistent with cholangitis. Etiology is not clearly defined but it is thought to have an infective basis probably CMV. Procedure ; ERCP. Changes are usually similar to sclerosing cholangitis. Endoscopic sphincterotomy in ampullary stenosis.

Intracranial Mass Lesion : 

Intracranial Mass Lesion In HIV positive patients, toxoplasmosis causes brain abscess. If medical treatment fails then CT guided stereotatic needle aspiration.

Thoracic Surgery : 

Thoracic Surgery It is most commonly performed for emphyema or pneumothorax. Treatment - ICCD with water seal is usually sufficient. Trans bronchial biopsy in cases of NHL of lung

Solid Organ Transplantation : 

Solid Organ Transplantation Relatively new field involving a surgeon. Initially HIV infected patients were excluded from list of solid organ transplantation due to fear of subsequent immunosupression associated with medication in organ transplantation. However due to decrease in morbidity and mortality in HIV patients such cases are common recipients for liver, kidney and eye transplantations. Patients with HIV are commonly infected with hepatitis C and B virus because of their similar routes of transmission. As a result end stage liver disease is common resulting in need of liver transplantation.

ESTIMATION OF OPERATIVE MORBIDITY/MORTALITY : 

ESTIMATION OF OPERATIVE MORBIDITY/MORTALITY Studies show same rate of post-operative complications in HIV positive as with asymptomatic HIV negative patients. - Incidence of infection after anorectal surgery in HIV positive patients is independent of CD4 cell counts. - Relation between viral load and post operative infection is still under trial.

RISK OF TRANSMISSION OF HIV DISEASE : 

RISK OF TRANSMISSION OF HIV DISEASE FROM PATIENT TO SURGEON

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The surgeon is regularly exposed to blood, which is the most infective medium for HIV transmission. Incidence of accidental exposure to infected patients blood is 6.4%.

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Risk is greater when there are more HIV particles in blood i.e. during the earliest and later stages of the disease. The extent of risk to the surgeon depends on - Prevalence of HIV in patient population. - Number of procedures carried out by the surgeon. - Length of the period of risk. Risk of infection with percutaneous needle stick injury is 0.3 – 0.4% . Risk of transmission of HIV in surgery is 1 in 28000 – 50000 per hour of operations.

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Risk of infection is more When surgery lasted for > 3 hours. > 300ml blood loss present during surgery. In major vascular, intra-abdominal and gynaecological surgeries

Risk of infection from needles is more with : : 

Risk of infection from needles is more with : 5 fold increased risk if there is either visible blood on the needle or the procedure involved placement of the needle in an artery or vein. 6 fold increased risk if needle stick injury was in above mentioned patient with advanced AIDS. 10 fold increased risk with hollow needles – large inoculation of blood products. 16 fold increased risk with deep penetration

PRECAUTIONS : 

PRECAUTIONS In HIV infection risk to the surgeon is greatest at the times of seroconversion and uncontrolled AIDS, when the viral load in blood is most increased. Patients, even those within a high risk group, cannot be identified at the time of ‘seroconversion’ and rigorous application of Universal Precautions offers the best protection to the surgeon with Additional Precautions where a procedure is undertaken in a known HIV infected patient.

UNIVERSAL PRECAUTIONS : 

UNIVERSAL PRECAUTIONS Wearing either safety spectacles or a face mask and a gown that provides water proof protection to surgeons anterior trunk and arms. Boots rather than open toed shoes should be worn to protect the feet when something sharp gets accidently dropped. Using 2 pair of gloves whenever direct contact with blood/bloody fluids is expected-wearing the larger sized glove on the inside next to the skin and a half size smaller glove worn as the outer second layer.

BEHAVIOUR MODIFICATION : 

BEHAVIOUR MODIFICATION Although universal precautions are an important element of risk prevention, they do not prevent exposure that is associated with routine procedures in the hospital. The following behaviour modifications are

IN OPD : 

IN OPD Wash hands before and after contact with all patients. Wear gloves for potential contact with blood/body fluids. Use of water proof, strongly adhesive plastic dressings for sealing off break in skin and areas that are oozing blood.

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For non-invasive procedures like vaginal, anal and rectal examinations, prostatic massage and oral examination wear gloves and wash hands thoroughly after removal of gloves. Immediately after use, the instruments (like proctoscope, vaginal speculum etc.) should be immersed in suitable disinfectant for 20 minutes and then auto claved / boiled for 20-30 minutes.

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FNAC should be carried out carefully, stabilising the mass with other hand and putting the needle in such a way that it does not injure the fingers.

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Wound dressings should be done with gloved hands and instruments used during dressing must also be decontaminated and sterilized before next use.

IN WARD : 

IN WARD Wash hands before and after contact with patients. Wear gloves while collecting blood samples. Handle the blood of all patients as potentially infectious. Place used syringes immediately in nearby permeable container. Do not recap or manipulate needles in any way. Wash hands after collection of blood sample.

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Do not soil the test request forms with blood. For this seal the vials and preferably send them in small plastic bags. Injection of antibiotics should be avoided if an equally effective oral preparation is available or if one injection can be given instead of multiple doses. There is no need to wear gloves when giving injections.

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Decontamination and washing of mattresses. It is advisable to cover all mattresses with waterproof synthetic material like rexene/plastic. In case of accidental spill of potentially infected material 1% Sodium hypochlorite solution must be poured on and around the spill area and covered with paper for 10 minutes.

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Waste disposal in the ward should be done as per recommendations of NACO. Using different coloured containers for different types of waste material.

IN THEATRE : 

IN THEATRE Routine double gloving in the operating room to be encouraged which decreases the risk of perforation and in the event of perforation is associated with a decreased inoculum size. This reduces risk of exposure from 17% to 5%.

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Surgical assistants should be kept to minimum. The procedure should be performed in slow and methodical manner. Meticulous attention should be given to haemostasis. One’s hands should not be used to palpate sharps during suturing

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Instruments should be used to hold suture needles at all times. Wound retraction should be performed with instruments only. Gloved hands should not be used for wound retraction. Instrument tray should be positioned between the scrub nurse and surgeon so that sharps can be placed on a tray instead of passing directly.

FOR THEATRE STAFF : 

FOR THEATRE STAFF High degree of theatre discipline. Use of highly experienced staff. Unnecessary instruments to be removed from field to avoid contamination.

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Endoscopes to be decontaminated with 2% Gluteraldehyde for 30 min followed by 3-4 rinsings with sterile water. Usage of disposable instruments which are to be disposed in a well marked container after use. Non sterilized instruments should be handled carefully after use and sterilized carefully. Well marked bags to be used for collection of waste from theatre.

MANDATORY PRE-OPERATIVE HIV TESTING : 

MANDATORY PRE-OPERATIVE HIV TESTING Pre-operative HIV testing to know the potential risk for exposure to HIV positive patients after informed consent is must.

MANAGEMENT OF ACCIDENTAL EXPOSURE : 

MANAGEMENT OF ACCIDENTAL EXPOSURE Immediately following an exposure to blood Needle stick injuries and cuts should be washed with soap and water. Splashes to the nose, mouth or skin should be flushed with water. Eyes should be irrigated with clean water or saline. Pricked finger never to be put in mouth reflexly.

Prompt exposure report : 

Prompt exposure report Date and time of exposure. Detail of procedure performed. Detail of the type of fluid and amount exposed. Prompt reporting is essential because in some cases, HIV PEP (Post exposure prophylaxis) may be recommended and it should be started as soon as possible preferably within 2 hrs. This is because the success of PEP therapy is maximal when started within a matter of hrs. after exposure.

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Basline testing of the source (patient) and the exposed HCW (Health care worker) for HIV, HBs Ag & HCV.

Treatment of HCW’s with PEP : 

Treatment of HCW’s with PEP Since most occupational exposures do not lead to HIV infection, the chances of possible toxicity from drugs used to prevent infection may be much greater than the chance of HIV infection from such exposures. Therefore both risk of infection and possible side effects of drugs should be carefully considered when deciding whether to take post exposure treatment or not.

The decision to start PEP is taken after deciding : 

The decision to start PEP is taken after deciding The Severity of exposure (EXPOSURE CODE) HIV status of infecting source (STATUS CODE)

Determine the PEP recommendation for treatment : 

Determine the PEP recommendation for treatment

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Basic Regimen : - Zidovudine 300 mg. BD - Lamivudine 150 mg. BD× 28 days. Expanded Regimen :- Basic Regimen + Saquivnanir 600 mg TDS (or any one protease inhibitor × 28 days

Pregnant HCW’s : 

Pregnant HCW’s Based on limited information, ZDV taken in II and III trimester has not caused serious side effects in mother or infants. There is very little information on the safety of ZDV taken during I trimester or on the safety of other antiretroviral drugs taken during pregnancy.

Monitoring of PEP toxicity :- : 

Monitoring of PEP toxicity :- Complete blood counts RFT’s - Baseline Hepatic function tests - Two weeks after starting PEP

Follow up of HCW :- : 

Follow up of HCW :- Done at 6 weeks, 12 weeks, 6 months following exposure by subjecting to HIV tests.

TREATMENT OF HIV POSITIVE PATIENTS : 

TREATMENT OF HIV POSITIVE PATIENTS Reverse Transcriptase inhibitors Nucleoside analogue RT inhibitors (NRTI) Zidovudine Lamivudine Didanosine Zalcitabine Stavudine

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Non Nucleoside analogue RT inhibitors (NNRTI) Nevirapine Delavirdine Effavirenz

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Protease inhibitors(P I) Saquinavir Ritonavir Indinavir Nelfinavir

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It is recommended that HIT THE VIRUS EARLY AND HIT IT HARD

HIT THE VIRUS EARLY : 

HIT THE VIRUS EARLY START ART IN; Acute HIV or less than 6 months after sero conversion Symptomatic patients Asymptomatic Patients with CD4 counts <500 Per mm3

HIT IT HARD ........ : 

HIT IT HARD ........ HAART (HIGHLY ACTIVE ANTIRETROVIRAL THERAPY) Is the Internationally recommended therapy. It is Three drug therapy (combination therapy) Combination of…… 2 NRTI + 1 PI OR 2 NRTI + 1 NNRTI OR 1 NRTI + NNRTI + 1 PI

HOW LONG TO GIVE ART : 

HOW LONG TO GIVE ART CD4 Count and Viral Load estimation are the markers to determine efficacy and end point of therapy. Ideally, the aim of therapy is to bring down viral load to undetectable levels i.e. <50 copies/ml but one has to remember that hidden compartments --- LN’s and Bone marrow are sanctuaries for non-replicating virus. So treat for atleast 1-2 years after plasma viral load becomes undetectable and remains so.

RISK OF TRANSMISSION OF HIV DISEASE FROM HCW’s TO PATIENT : 

RISK OF TRANSMISSION OF HIV DISEASE FROM HCW’s TO PATIENT Various studies have shown a risk of less than 1/1,000,000 during an exposure prone procedure. This is one half the risk that a given unit of screened blood is HIV positive and 1/100 the risk of dying from G.A. Thus, this level of risk seems acceptable and is within the scope of other risks taken by patients in the context of receiving health care. Theoretically, the same universal precaution that are used to protect the HCW from HIV infected patient will also protect the patient from HIV infected HCW.

CONCLUSION : 

CONCLUSION Education, Counseling and Behaviour modification are the cornerstones of HIV prevention strategy which is the only strategy currently available to prevent AIDS.

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THANX