a power point on HIV and surgery

1. HIV and the Surgeon
Dr Okpako Isaac Oghenero
Senior Registrar Plastic and Reconstructive surgery
Department of surgery
University of Abuja Teaching Hospital Gwagwalada
14/11/2023

2. Outline
• Introduction
• Historical perspective
• Epidemiology
• Structure
• Life cycle
• Pathophysiology
• HIV and the surgeon
• Management
• Factors affecting transmission
• Risk of transmission
• How to handle needle prick/ body fluid contact
• Use of Post exposure prophylaxis
• Current trend
• Conclusion

3. Introduction
• HIV – human immunodeficiency virus is a retro virus that is known to
be destructive to T cells
• By destroying T cells they alter the immune system and makes the
body prone to opportunistic infections

4. Historical perspective
• First known AIDS patient died.(1976)
• First human retrovirus isolated (HTLV-1) (1980).
• Named HIV-1 & later HIV-2.(1986)

5. Epidemiology
• Nigeria is the most populous country in Africa with an estimated
population of over 200 million.
• First reported AIDS case in the country was in 1986.
• Estimated number of affected person in 2006 was 2.9million (female
predominance).
• It is estimated that there are about 1.8 million people in Nigeria living
with HIV in 2019

6. Structure
• HIV is a retrovirus of the lentivirus family
• It is an RNA virus
• It has a cylindrical core containing the RNA genome, reverse
• transcriptase, and some core proteins
• The virus envelope is derived from the host cell membrane,
• The envelope has a protein called GP 120 which has affinity for CD4
bearing cell chief of which is the T helper cell

8. Life cycle
• It has seven phases
• Binding
• Fusion
• Reverse transcription
• Integration
• Replication
• Assembly
• Budding

10. Pathophysiology
• Mode of transmission
• Unprotected sexual contact with an infected person (oral, analor
vaginal) (75%)
• Vertical transmission
• Exposure to infected blood/blood products e.g. needle pricks sharing
of needles by intravenous drug abusers
• Transfusions and Blood Products: Hemophiliac population

11. Pathophysiology
• Mode of transmission
• About 378,000 - 756,000 needle sticks occur every year.
• 30% are due to recapping,
• 30% are due to improper disposal, and
• 30% are due to unexpected movement of patient or another worker

12. Pathophysiology
• Seroconversion / window period
• This is the period from inoculation to when an individual produces
sufficient antibodies to be able to test positive to the disease
• Usually within 6 to 12 weeks
• Most people by 3 months would have seroconverted hence 3 months
is generally used as the window period

13. Pathophysiology
• AIDS
• With HIV infection, there is continuous destruction of the helper T cells and
replication of more viruses within the dying Helper T cells
• Helper T cells are necessary for amplification of immune responses among other
functions
• The consequent production of more viruses and destruction of helper T cells would
eventually lead to a state of weakened immunity referred to as AIDS with resultant
opportunist infections
• Median progression rate (HIV to AIDS) is about 10 years

14. Pathophysiology
• Criteria for diagnosis of AIDS
• Less than 200 CD4+ T cells per cubic millimeter of blood, compared with about 1,000
CD4+ T cells for healthy people
• CD4+ T cells accounting for less than 14 percent of all lymphocytes
• One or more of the following
• Candidiasis of bronchi, esophagus, trachea or lungs
• cervical cancer that is invasive
• Coccidioidomycosis that has spread
• Cryptococcosis that is affecting the body outside the lungs
• Cryptosporidiosis affecting the intestines and lasting more than a month
• Cytomegalovirus disease outside of the liver, spleen or lymph nodes
• Cytomegalovirus retinitis that occurs with vision loss
• Encephalopathy that is HIV-related
• Herpes simplex including ulcers lasting more than a month or bronchitis, pneumonitis or
esophagitis
• Histoplasmosis that has spread

15. Pathophysiology
• CD4 counts determine staging of HIV disease and need for treatment.
• Viral Loads determine effectiveness of ARV treatment.
• Increased risk of opportunist infection if CD4 <200cell/mm³
• If Viral load > 10000 copies/ml suggest that ARV is no longer
effective.

16. HIV and the surgeon

17. Relationship
• Patients who require surgery for complications of HIV/AIDS
• HIV patient who require surgery for other surgical condition not
related to HIV/AIDS
• Asymptomatic HIV patient who require surgery for other non
HIV/AIDs related conditions

18. Patients who require surgery for complications of
HIV
• Some examples of surgery in this categories are
• Biopsies e.g lymph nodes ulcers
• Kaposi sarcoma
• Venous cut down
• Cryptosporidial acute cholangitis
• Cytomegalovirus induced gastrointestinal bleeding & perforation
• Gastrointestinal obstruction from Gastrointestinal stroma tumor

19. HIV patient who require surgery for other surgical
condition not related to HIV/AIDS
• Wound debridement for Road traffic accident
• Organ transplantation
• Acute appendicitis
• External/internal fixation of a fracture

20. Asymptomatic HIV patient who require surgery for
other non HIV/AIDs related conditions
• They may look more healthy than many people and this makes
suspicion less likely among hospital personnel and thus increases the
chances of transmission.

21. Management
• Preoperative
• Intraoperative and
• Post operative

22. Management
• Preoperative
• History taking
• Ensure the following are evaluated in the history
• Knowledge of HIV status
• Medication being taken and adherence to medication and hospital care
• progression to AIDS and complication arising from use of HAART
• comorbidities (e.g. diabetes, asthma, hypertension, sickle cell anemia among
others) and if present their management

23. Management
• Preoperative
• Examination
• General physical examination
• Anemia, jaundice, BMI, level of hydration and lymphadenopathy
• Systemic examination
• Presence of and character of ulcers
• Presence of and character of tumors in all systems
• Presence of and character of deformity, malformation

24. Management
• Preoperative
• Investigation
• Confirmation of diagnosis
• Retroviral screening
• To know extent of disease progression
• CD count
• Viral load
• To prepare patient for surgery
• Fbc
• Eucr
• gxm

25. Management
• Handing of HIV patient fluids
• Adopt universal precautions

26. Management
• Intraoperative
• Adopt universal precautions
• The scrub-up ritual
• Double gloves
• Use of face mask
• Use of Eye protection
• Waterproof gown, shoes, and aprons
• No hand-to-hand passage of sharps
• No re-sheathing of Needles
• Finger not to be used as needle guide
• Correct disposal of sharps

27. management
• Post operative
• Adopt universal precaution
• Use of gloves face mask
• Avoid contact with patient body fluid
• recommencement of HAART

28. Factors affecting transmission
• Amount of blood involved in exposure
• Amount of virus in patient’s blood at time of exposure
• Post-exposure prophylaxis usage

29. • Risk of transmission
• Percutaneous- 0.3%
• Mucous membrane-0.1%
• Non-intact skin-< 0.1%
• The risk of HIV transmission (without prophylaxis) is 0.3%
• (3/1,000) from percutaneous injury and 0.09% (9/10,000)
• from mucocutaneous exposure

30. Risk of transmission
• Highest Risk
• deep parenteral inoculation via hollow needle
• parenteral inoculation with high viral titters
• Less Risky
• small volume via non-hollow needle
• mucosal exposure/non-intact skin exposure
• Risk not identified
• intact skin exposure
• exposure to urine, saliva, tears, sweat

31. How to handle needle prick/ body fluid
contact
• Percutaneous:
• Remove gloves
• Remove foreign materials
• Do not squeeze, allow blood or secretions flow freely
• wash needle pricks and cuts with soap and water
• on-intact skin exposure:
• wash with soap and plenty of water or antiseptic
• Mucous membrane
• flush, mouth or skin with plenty of water
• irrigate eyes with clean water, sterile saline

32. Use of Post exposure prophylaxis
• Evaluation
• If patient is negative no need for PEP but do repeat in 3 months
• Health personal positive – commence HAART
• Patient is positive and health personnel is negative commence Post
exposure prophylaxis
• If no possibility for testing assume positive and commence PEP and monitor
• PEP should be given less than 72 hrs at best within 1 hr of exposure and for
4 weeks with 3 drug combination
• AZT, lamivudine & indinavir

33. Current trend
• Endoscopy
• Telemedicine
• Robotic medicine

34. Conclusion
• HIV affects the surgeon in various ways as he/she would have to
operate on them either for conditions relating to the HIV or non
related HIV condition or even for patients who do not manifest
symptoms of the disease but need surgery

35. •Thank you