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HIV and Surgeon’s Perspective

This article discusses the surgical aspects of HIV, including screening, occupational hazards, and universal precautions. It also highlights the potential risk of HIV transmission to surgeons and provides recommendations for post-contamination management. The article emphasizes the importance of HIV awareness and prevention in surgical settings.

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HIV and Surgeon’s Perspective

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  1. HIV and Surgeon’s Perspective Dr.Bujjibabu Vijayawada

  2. HIV - SURGEON • INTRODUCTION • SURGICAL ASPECTS OF HIV • SCREENING • HIV-AS A OCCUPATIONAL HAZARD • UNIVERSAL PRECAUTIONS • POST CONTAMINATION • HIV-INFECTION BY SURGEON. • CONCLUSIONS

  3. Acquired Immunodeficiency Syndrome (AIDS) • 1981 In U.S., cluster of Pneumocystis and Kaposi's sarcoma in young homosexual men discovered. The men showed loss of immune function. • 1983 Discovery of virus causing loss of immune function.

  4. Acquired Immunodeficiency Syndrome (AIDS) Figure 19.12a

  5. The Origin of AIDS • Crossed the species barrier into humans in Africa in the 1930s • Patient who died in 1959 in Congo is the oldest known case • Spread in Africa as a result of urbanization • Spread in world through modern transportation and unsafe sexual practices • Norwegian sailor who died in 1976 is the first known case in Western world

  6. HIV Infection Figure 19.12b

  7. HIV Infection Capsid Reverse transcriptase DNA Virus Two identical + stands of RNA 1 Retrovirus penetrates host cell. Host cell DNA of one of the host cell’s chromosomes 5 Mature retrovirus leaves host cell, acquiring an envelope as it buds out. Reverse transcriptase 2 Virion penetrates cell and its DNA is uncoated Viral RNA Identical strands of RNA 4 Transcription of the provirus may also occur, producing RNA for new retrovirus genomes and RNA that codes for the retrovirus capsid and envelope proteins. Viral proteins RNA 3 The new viral DNA is tranported into the host cell’s nucleus and integrated as a provirus. The provirus may divide indefinitely with the host cell DNA. Provirus Figure 13.19

  8. HIV Infection Figure 19.13

  9. HIV Infection Figure 19.14

  10. The Stages of HIV Infection • Category A Asymptomatic or persistent lymphadenopathy • Category B Persistent Candida albicans infections • Category C Clinical AIDS. CMV, TB, Pneumocystis, toxoplasmosis, Kaposi's sarcoma

  11. The Stages of HIV Infection Figure 19.15

  12. Some Common Diseases Associated with AIDS Table 19.5

  13. Diagnostic Methods • Seroconversion takes up to 3 months • HIV antibodies detected by ELISA • HIV antigens detected by Western blotting • Plasma viral load is determined by PCR or nucleic acid hybridization

  14. HIV Transmission • HIV survives 6 hours outside a cell • HIV survives >1.5 days inside a cell • Infected body fluids transmit HIV via: • Sexual contact • Breast milk • Transplacental infection of fetus • Blood-contaminated needles • Organ transplants • Artificial insemination • Blood transfusion

  15. Modes of HIV Transmission Figure 19.17

  16. AIDS Worldwide • U.S., Canada, western Europe, Australia, northern Africa, South America • Injecting drug use, male-to-male sexual contact • Sub-Saharan Africa • Heterosexual contact • Eastern Europe, Middles East, Asia • Injecting drug use, heterosexual contact

  17. AIDS Worldwide Figure 19.16

  18. Prevention of AIDS • Use of condoms and sterile needles • Health-case workers use universal precautions • Wear gloves, gowns, masks, goggles • Do not recap needles • Risk of infection from infected needlestick injury is 0.3%

  19. Chemotherapy • Nucleotide Reverse Transcriptase Inhibitors • Non- Nucleoside Reverse Transcriptase Inhibitors • Protease Inhibitors • Virus decoys

  20. Highly Active Antiretroviral Therapy (HAART): • Combinations of nucleoside reverse transcriptase inhibitors + • Non-nucleoside reverse transcriptase inhibitor or • Protease inhibitor

  21. Post Exposure Prophylaxis Is the source material blood, bloody fluid, or other potentially Infectious material or an instrument contaminated with one of these substances NO No PEP needed Yes Blood or bloody material What type of exposure has occurred? Mucous memb.or Skin with Evidence of dermatitis ,abrasion or Open wound Intact skin Per cutaneous exposure Severity Normally no PEP needed Volume

  22. Post Exposure Prophylaxis Severity Volume More severe Small( e.g. few drops, short Duration) Negligible risk: risk of drug toxicity may outweigh benefit of PEP regimen If source HIV titer is high Or unknown Recommend expanded PEP regimen Large( several drops, major Blood splash or longer duration PEP regimen

  23. With the development of rapid diagnostic tests and the recognition of opportunistic infections involving GIT made the surgeons involve in the management of AIDS disease. And the surgeons are placed at high risk of acquiring HIV as there is direct contact with blood of the HIV infected individuals. The risk of potential transmission from highest to lowest - percutaneous injuries, mucus membrane & skin contact. According to Centers of Disease Control & Prevention - blood and certain other body fluids, all visibly bloody body fluids and tissue from all pts should be considered as potentially infected with blood borne pathogens. INTRODUCTION:

  24. GI disease in HIV pts To provide venous access for chemotherapy for infections (CMV retinitis) /neoplasms. LN excision biopsy : to diagnose specific infection, lymphoma/ Kaposi’s sarcoma indications-lymphadenopathy with constitutional symptoms splenomegaly cytopenia oral candidiasis hilar lymphadenopathy. or a solitary LN enlarged disproportionately. Surgical aspects of HIV

  25. Oral cavity- thrush, hairy leukoplakia, aphthous ulcers & Kaposi’s sarcoma. Oesophagus- monilial oesophagitis, lymphoma &Kaposi’s sarcoma. Stomach & duodenum-bleeding, abdominal pain, gastric outlet obstruction and/or perforation. Kaposi’s sarcoma- most common cause of bleeding , occasionally outlet obst. NHL- usually presents as bleeding, but obstruction and perforation can also occur. CMV- one of the more common cause of the gastritis, gastric& duodenal ulcers. GI disease in HIV:

  26. Small and large bowel disease- the most significant problem. GI disease contd... HIV-enteropathy- > 1month without cause specific infections-bacterial, fungal and viral (severe bloody colitis) • diarrhoea • abdominal pain • fever & wt.loss • bleeding • obstruction • & perforation. • jaundice • ascites Kaposi’s sarcoma &NHL-small bowel

  27. Appendicitis- obstructed due to Kaposi’s / NHL secondary deposits / perforated. Anorectal lesions- Pancreas- drug toxicity spleen- thrombocytopenic purpura Liver- HBV(85%) Biliary tract Contd… Warts -( intra epithelial neoplasia) perianal sepsis anorectal ulceration anal neoplasia fecal incontinence Acalculous cholecystitis papillary stenosis sclerosing cholangitis

  28. Acute abdomen- seen in 10% of all AIDS pts. Only 5% require emergency surgery Appendicectomy. Total colectomy in cases of Infective colitis with bleeding/ perforation. Laparotomy when small bowel obstruction /perfotration +. Excision of warts. Splenectomy -to correct auto-immune thrombocytopenia. LN excision biopsy- useful in later part of disease. CVP line placement. Surgical procedures in HIV patient:

  29. No. of retrospective studies -(Robinson et al, Ferguson,Wakeman & Miles et al) Reports suggest -increased risk of P.O.complications in HIV pts. But, the effect on survival rates were not assessed. 51 HIV pts. Underwent 73 surgical procedures for anorectal disease. 22pts died within 6 months and 45pts (88%) had poor wound healing at 30 days. Outcome of surgery:

  30. SCREENING Repeat ELISA + HIV-1 WB + Diagnosis of HIV-1 infection _ + _ indeterminate HIV-2 ELISA HIV-1/HIV-2 ELISA Repeat in 4-6 weeks _ + _ indeterminate Retest in 3-6 months if clinically indicated HIV-2 WB + Diagnosis of HIV-2 infection

  31. ELISA -Sensitivity 99.5% positive-highly reactive negative -non reactive indeterminate - partially reactive. In low risk individuals only 13% of ELISA positive actually had HIV infection. Common causes of false positive results: class II antigens autoantibodies hepatic disease recent influenza vaccination. Screening contd…. -Polymerase chain reaction-to detect HIV earlier

  32. Western Blot- multiple HIV antigens having different mol.wt.elicit production of specific antibodies Positive- +ve for >2 of gene products indeterminate- a) cross reacting antibodies with proteins of HIV (p24/p55) b)in the process of mounting a classic antibody response. To repeat twice at 3 month intervals / test for p24 antigen on HIV RNA. Negative- ELISA is false positive. False positive Western blot-20-30% , due to cross reacting antibodies. Alternative tests - Viral culture, PCR & p24 antigen assay Contd…

  33. surgeons, physicians , nursing staff , lab.technicians and other health care workers. Extent of the risk - ( American & European countries- 30 yr career in place where HIV is highly prevalent-1 in 800 chance of acquiring) In Africa - risk is 1in 4. Source of infection: Skin perforation with hollow needle containing infected blood. (also reported with solid needle, but the risk is 10 fold less) Extensive splashes of blood on mucous membrane and skin. HIV- as an occupational hazard: • prevalence of HIV in pt.population • no.of procedures carried out by the surgeon, • & length of the period of risk

  34. After infection with HIV initial acute rise in viable virus in circulation - fall - later increase during AIDS phase. CD4 cells/cmm months

  35. Large institutional studies showed - risk following skin puncture from a needle /sharp object contaminated from a HIV pt- 0.3%.( risk of Hepatitis B is 20-30%) Transmission through intact skin is not documented. Survey studies - percutaneous injuries -5.6% of operations.and 86 % of surgeons report at least 1 injury per year. risk of transmission through mucus memb.-0.1%. Occupational hazard -contd.. • Factors - • unusually large volume of blood • prolonged contact • a potential portal of entry.

  36. Transmission by other body fluids- no evidence that saliva can transmit although HIV can be isolated from small percentage of infected individuals. (secretory leukocyte protease inhibitor in the saliva possesses anti-HIV-1 activity in vitro.) A case report- 91 yr old man was bitten during a robbery attempt by HIV infected person. Seroconversion is reported. ( source of infection - human bite, and actual infection transmitted via blood as the person had bleeding gums.) though virus can be isolated from any body fluid, transmission does not occur through tears, sweat and urine. Isolated cases reported. A case of mother contracted HIV from her child who had colostomy, former is exposed to the potentially infected material from colostomy , blood as well as nasal secretions. Contd...

  37. before surgery- screening of all patients esp. high risk group. Universal precautions Precautions - Homosexual men, IV drug abusers, Hemophiliacs, residents of central Africa sexual partners of the above children of infected mothers. • Wearing safety spectacles • waterproof gown • Boots rather than open shoes • Double gloves- 5-fold reduction in contamination

  38. needle prick injuries to the index finger and palm adjacent to the thumb of the non dominant hand. During surgery- procedure carried out in orderly manner. Assistants should be minimum and movement should be minimum. Procedure - to go in methodical manner with meticulous hemostasis. Unexpected bleeding changes the tempo of the procedure and increases the risk of inadvertent injury to operators. Sharp instruments - passed in a dish. After surgery- cleaned with soap and water, then autoclaved in a separate bag. Precautions contd…

  39. Safety devices to minimize injury- preliminary analysis revealed Contd.. • Blunt tipped suture needles • finger protective strips • magnetic passing trays • shielded scalpels • cushions to hold needles Percutaneous injury: blunt tipped-0 standard suture needle-2.1 straight needle-14.2 HIV test soon after exposure. -re tested at 6wk, 12wk, 6months When exposed to HIV infecte blood,

  40. by 1997-52 well documented seroconversions in health care workers. In 111 HW, no risk other risk A sero prevalence survey of 3420 orthopedic surgeons, practicing in high prevalent areas - 39% had per cutaneous exposure involving suture needle, failed to reveal occupational infection- lower risk of solid needle Contd…. 47-blood 1-pleural fluid 1-unspecified 3-conc.virus stocks • 45 due to percutaneous exposure • 5 -mucous memb. • 1-both percut,& mucus memb • 1-route of exposure not known

  41. when exposed to infected blood- Zidovudine post exposure prophylaxis to be given. a case control study showed- 79% decrease in the risk of seroconversion after exposure. even if it fails to prevent seroconversion, decrease the initial burst of viremia which has long term benefit. current recommendation - a combination of Zidovudine, Lamivudine& Indinavir. this should be started as soon as possible after the injury(within 1-2 hrs) Post contamination: -immediate washing under running water. -status not known- HIV test -hepatitis prophylaxis -base line HIV test. -re testing after 12 weeks Zidovudine 200mg 4hrly for28-42days.

  42. development o f safe& effective vaccine - difficult due to high mutability of virus infection can be transmitted by cell free or cell associated virus need for the development of effective mucosal immunity. clinical trials of candidate vaccines in humans- both recombinant envelop proteins and recombinant viruses expressing a no.of HIV proteins- demonstrated to be safe and immunogenic in healthy uninfected workers. Vaccines:

  43. In 1990,HIV infected dentist in Florida had transmitted HIV to 5 of his pts while undergoing minor invasive procedure. Occurred through HIV contaminated instruments supposedly used the same instruments on himself. A break down of sterile procedures was suspected. Several epidemiological studies - >8000 pts.who received care from HIV infected dentists, surgeons, physicians and obstetricians. Not a single case could be linked. No reported case of pt.undergoing general surgical procedure acquiring HIV from surgeon. Risk -is very low, about < 1/10,00,000. 1/2 of the risk of transfusion related HIV inf. 1/100 of risk of dying from GA. Infection of patient by surgeon:

  44. High risk group should be identified. Causative agent can be rapidly detectable even in the window period by antigen tests -hence, high risk pts.should be subjected to HIV test. If Universal precautions are followed strictly , occupational risk can be reduced to a minimum. Risk of infection is maximum in the acute phase and in the advanced phase. Risk of infection after needle puncture is 0.3% Zidovudine - prophylactic, decreases seroconversion. CONCLUSIONS:

  45. Conclusions • Surgeons should have the ethical obligations to render care to • HIV infected patients as they have to care for other pts. 2.Surgeons should utilize the highest standards of infection control involving the most effective known sterile barriers ,universal precautions, and scientifically accepted infection control practices. 3. Based on current literature ,HIV infected surgeon may continue to practice and perform invasive procedures and surgical operations. 4. Post exposure prophylaxis with antiretroviral chemotherapy is recommended 5. Surgeons should know their own status for HIV infection 6. Committees should continue to consider the concerns & problems of HIV infected Surgeons and their families

  46. Stopping the virus

  47. Esophageal candidiasis

  48. Candidiasis

  49. Thank You

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