SURGICAL PROTOCOLS IN THE ERA OF HIV INFECTION

Dr. K. Lakshman,
FRCS Consultant Surgeon
58, 1st Main, 1st Block, Thyagaraja Nagar
Bangalore 560 028
Tel; 6676870 Fax: 6618525
E-Mail - lman@vsnl.com

Introduction

Human Immunodeficiency Virus (HIV) infection and Acquired Immuno Deficiency Syndrome (AIDS) is a pandemic. The large majority of patients suffering from this infection reside in developing countries. In this part of the world, India and Thailand show the highest number of cases1,2. It is also clear that the clinical cases seen are only the tip of the literal iceberg of cases. Under these circumstances, surgeons in India are likely to see many patients with HIV or AIDS coming for treatment of surgical diseases.

A logical and scientifically sound strategy to deal with this problem is the need of the hour. The reaction of society in general and the health care workers (HCW) in particular, has been, unfortunately, based on emotions and paternalistic, judgmental decisions, rather than sound thinking3. In contrast, a few well-designed programmes have been instituted to deal with HIV subjects even in this country4. We must remember that patients with HIV and AIDS are just that - patients. They have their rights and privileges and their needs. It is our moral and ethical duty to meet these needs. This paper outlines one model of the strategy to be adopted when we see a patient with established or suspected HIV or AIDS. Indeed the issues raised are applicable when dealing with all surgical patients. The paper discusses three aspects of this problem:

1. HIV / AIDS testing of surgical patients
2. Universal precautions to be adopted by surgeons
3. Post Exposure prophylaxis
4. Unique surgical features in AIDS patients.

Testing for HIV / AIDS in surgical patients

The social consequences and repercussions to a patient on testing positive for HIV are enormous. Hence this test cannot be seen on par with an average laboratory test like the haemoglobin or blood sugar, wherein the consent for getting such a test is presumed to be given implicitly by the patient. Hence, an explicit and a clear consent for doing the HIV test has to be obtained from the patient. The consent request has to be accompanied by a pretest counselling and the results of the test have to be conveyed to the patient with another session of counselling, called the post-test counselling5,6. Lack of awareness or the low educational status of the average patient cannot be quoted as a reason for bypassing adequate counselling and obtaining an informed consent7.

The pre-test counselling should stress the following points:

u A negative rapid test almost rules out HIV positivity; the ‘window period’ (the period during which, the patient is infected and infective but tests negative for HIV) is the only limitation.

u A positive test needs further confirmation with other tests; this may take a further two weeks for confirmation; The WHO now considers using three different kits for the tests as adequate; a Western Blot test confirmation is not mandatory.

u Use this opportunity to delineate risk behaviours and educate the patient about safe practices.

The post-test counselling addresses the following points:

1. If the test is negative

u Explain the ‘window period’ and the need for repeat testing in patients with high risk behaviour
u Review and correct, aspects of risk behavior

2. If the test is positive

u Explain that HIV infection is very likely to be present
u Explain the need for confirmatory tests
u Plan out a voluntary disclosure strategy
u Describe the methods to minimize spread of infection
u Obtain a contact address to pursue surveillance

While a formal counselling programme needs committed personnel, a surgeon can institute most of these measures at a personal level without having to depend on a team of counsellors. The most important need for this is a strong motivation in the surgeon. While no law in this country is enforcing this, HCWs should take the lead in voluntarily carrying out this exercise.

The present common practice of getting HIV tests done as a routine before every surgical procedure should be given up for the following reasons:

u The patient may be in the “Window period” - a negative test gives a false sense of security. This period may last for 6 months and in some isolated cases, may even be one year8.

u Routine testing is not cost effective in small subgroups of the population, even in the rich developed countries9; the situation can only be more unsuitable in our socio-economic milieu when applied to the whole population of patients.

u Studies have shown that the outcome in terms of practice and risk are unaltered by the presence or absence of preoperative testing, when universal precautions are followed as a routine

10. Universal Precautions

Universal precautions are a set of measures designed to eliminate the risk of acquiring HIV, Hepatitis B and C and other blood borne diseases by HCWs during the course of their ministrations to an infected patient. They replace the barrier and reverse barrier nursing strategies that were being followed previously. The precautions do not apply to other body fluids like urine, faeces and saliva, unless these are contaminated with blood. As of December 1996, the Centers for Disease Control and Prevention (CDC) had reported 52 documented and 111 possible cases of HCWs who have acquired HIV in the workplace. The majority of documented occupational transmissions occurred in clinical laboratory technicians and nurses. Forty-five of the cases involved percutaneous exposure, while 5 involved muco-cutaneous exposure11.

The basic principle of Universal Precautions is to prevent the contact of the infected patient’s blood or blood contaminated body fluid with the HCWs’ blood. Contamination through intact skin does not occur. Contamination through intact mucous membrane is more contentious. Transmissions through conjunctiva and oral mucosa have been recorded12.

It should also be borne in mind that the patient being treated by a HIV infected surgeon is also at risk of getting the disease from the surgeon. While this risk is extremely small, the present consensus is that HIV positive HCWs should refrain from undertaking invasive procedure on patients13.

The Universal precautions described in the CDC documents13, 14 form the basis of the following recommendations. These precautions have to be applied to every single patient, at all times. While the principles are maintained, the recommendations take into account the socio-economic and medical situation in our country and suitable modifications have been incorporated.

1. Washing Hands - One of the most important requirements and the one that is most commonly ignored is washing hands, before and after seeing a patient. Doctors seem to be the most culpable. Strict adherence to washing hands with ordinary soap clearly reduces the risk of transmission of HIV and many other infectious agents15.

2. Wearing Gloves - A pair of disposable plastic gloves have to be worn whenever the potential for a contact with the patient’s body fluid exists. At surgery, where there is a risk of injury from sharp objects, double gloving with good quality latex gloves are recommended. Fortified gloves that reduce chances of injury from sharps are not universally available and are also expensive16.

3. Eye Glasses/Cap/Mask - The eyes are to be protected from split secretions by wearing goggles; the conventional glasses worn for correction of eyesight defects are open in the sides; but nevertheless give acceptable protection. The cap and mask protect the head and face from being exposed to spillage.

4. Foot Wear - The feet are notorious for little cuts and abrasions that may be contaminated by body fluids. Gumboot types of footwear are to be worn to avoid this.

5. Impervious Gown - While disposable impervious gowns are available, the cost may not be justifiable. For our conditions, use of a plastic apron under the conventional operating gown will serve the purpose.

6. Needles and Sharps - Manipulation of needles like bending and re-sheathing should be avoided. The used needles are to be deposited in thick walled puncture resistant containers for later incineration. We use thick cardboard boxes discarded in our pharmacy, for this purpose. A small square hole is made in the top for deposition of the needles. It is sent for incineration when two thirds full.

7. Surgical technique - Risk from needle prick injuries are greatest when working in depths like in the pelvis, the diaphragmatic hiatus or the chest. The use of the hand to direct the passage of needles is to be avoided. While blunt needles have been shown to drastically reduce injuries17, they are expensive and are not universally available.

8. Soiled linen - Soaking soiled linen for 30 minutes in 1:100 bleach solution (hypochlorite solution) kills the HIV virus completely. These can then be processed normally with washing and autoclaving as usual.

9. Metal Instruments - Metal instruments are washed with soap and water. They are then soaked in 2% Glutaraldehyde solution for 30 mins. This will kill the virus. The sharp instruments are transfered to another container with fresh glutaraldehyde and soaked for a further six hours. The other instruments are autoclaved.

10. Plastic tubings - The anaesthetic tubings, tubings used for suction and those used in rotary pumps are all soaked in 2% Glutaraldehyde for six hours after cleaning with soap and water. Where available, these can also be subjected to ethylene oxide sterilization.

Unfortunately a lot of hype is created, particularly in the lay press, regarding the conduct of surgical procedures on AIDS patients. Special scheduling during weekends, summary disposal of ‘’costly’’ instruments and linen are all quoted as safety measures. A pragmatic view of the situation should convince us that operating on an AIDS patient is practically no different from operating on any other patient, if following the universal precautions really becomes universal.

Post Exposure Prophylaxis (PEP)

In spite of all the precautions taken, it is likely that a surgeon or a HCW will be subjected to an accidental needle prick or exposure to the infected body fluid of a patient, in the line of his work. This section deals with the quantification of the risk of infection and the measures to be taken to minimise this risk.

The risk of HIV infection from a single needle stick injury is 0.31% (1 in 325)18. The risk from a hollow needle is worse than that from a solid surgical needle. This is in keeping with the viral load that the inoculum places on the recipient of the injury. It is to be noted that the risk of acquiring Hepatitis B from such a needle prick is much worse, as Hepatitis B is 10 times more infective and 100 times more prevalent than HIV19. Hence, the prevention of needle stick injury also guards against Hepatitis B and C infections, apart from HIV infection. A corollary of this observation is that the PEP should also include prophylaxis against Hepatitis B and C.

The rationale for instituting PEP hinges on using the ‘window of opportunity’. After the inoculum, the virus stays in the dendritic cells of the skin and the regional nodes for 24-48 hours, before entering the general circulation20. This coupled with the proven success of control of perinatal transmission21 with Zidovudine prophylaxis, has made it clear that prompt institution of antiretroviral drugs after an exposure prevents sero-conversion to a large extent.

The institution of PEP involves the following steps. This is a modification of the steps outlined by the CDC8:

1. Reporting of an injury and the mechanism for its evaluation by an expert.
2. Stratification of the exposure and the need for prophylaxis.
3. Administration of the drugs for prophylaxis.

Step1:

Every institution must put in place a mechanism wherein an injury at work can be readily reported by a HCW in the institution. A detailed history of the circumstances of the injury is to be recorded. The HIV status of the patient whose blood, the HCW was exposed to is to be determined after adequate counselling of the patient. If the patient refuses to have the test done, at least a good history of possible risk behavior has to be obtained. A registry of such injuries has to be maintained.

Step 2: Exposure of intact skin to blood and body fluids does not warrant prophylaxis. The intermediate group consists of percutaneous or mucous membrane exposure to blood from patients who have no known risk factors for HIV or have not indulged in any risk behaviour in the previous weeks have minimal risks of acquiring HIV. Such HCWs must be offered the choice of prophylaxis.

The high-risk groups have exposure to known HIV positive or AIDS patients; additionally large volume inoculums in the high infective stage (early viraemia and end stage AIDS) of the disease may have occurred. Such HCWs are recommended to take the prophylaxis.

This brief outline does not define all possible scenarios of exposure that are possible. With these broad generalizations, each case has to be assessed individually before the decision to institute drug therapy is taken.

Step 3: Once the decision to give prophylaxis is taken, the sooner it is given the better it is for the HCW. While institutions in the West have mechanisms to start this prophylaxis within 1 to 2 hours of the exposure through 24-hour Pharmacy outlets, it may be difficult in our setup to do this. Administration within 24 to 36 hours is acceptable. The present recommendation is to give three drugs for the high-risk group and two drugs for the intermediate risk group, for one month22.

The two-drug regime includes:

Zidovudine 300 mg twice daily +

Lamivudine 150 mg twice daily

The three-drug regime includes:

The two drug regime +

Indinavir 800 mg or Nelfinavir 750 mg thrice daily.

An institution of this policy has shown a 79% reduction in the seroconversion rate of HCWs who have received the prophylaxis23.

Unique features of surgical conditions in AIDS

This section briefly outlines some of the unique features seen in HIV and AIDS.

1. There is a recrudescence of tuberculosis after the advent of HIV24. This has manifestations in the form of increased incidence of lymphadenopathy, pleural disease and abdominal disease. Primary HIV lymphadenopathy and that associated with Kaposi’s sarcoma can also occur; even though the latter is uncommon in our country.

2. The acute abdominal pain in a patient with HIV poses a great challenge. Apart from the usual inflammatory/infective conditions, esoteric infections of the biliary tract and the gut can occur with Cytomegalovirus, cryptosporidosis etc. Kaposi’s sarcoma and non-Hodgkin’s lymphoma are other considerations25. While perforations or hemorrhage need surgery, many times conservative treatment is to be preferred for some of these conditions.

3. Common sites of fulminant sepsis are the female genital tract, joints and necrotising fascitis cased by synergistic infection. In view of the severity of the sepsis, these need prompt debridement26.

4. Perianal disease is common in these patients. They range from condylomata to ulceration, fistulation and neoplasms including Bowen’s disease, Kaposi’s disease and lymphoma. The perianal disease seems to be a result of immunosuppression and occurs independent of anal intercourse. Wound healing after surgery is delayed. Nevertheless, all painful lesions need the appropriate surgical intervention27.

Our experience

We do not practice routine preoperative testing for HIV but rather rely on universal precautions. A general surgical unit in the city, which does undertake screening tests, had an incidence of 4 positives out of 1000 tests done. A cardiac unit had one positive out of 700 cases tested.

It is clear that even in developed countries, breach of universal precautions occur. The knowledge and practice of UP in our setup leaves much to be desired. Nevertheless, our effort should be concentrated on educating the HCW about UP. Routine testing without UP would lead to many tragedies.

We have undertaken the following surgical procedures on HIV/AIDS patients in the previous 24 months. All the patients (except the cholecystectomy and one endoscopy) were known HIV/AIDS patients.

Lymph node biopsies	5 Males	4 Females
Esophageal candidiasis	3 Males	2 Female
Cholecystitis	1 Male
Perianal abscess	5 Males
Thrombosed hemorrhoids	3 Males
Pseudopancreatic cyst	1 Male
Papillary carcinoma thyroid	1 Female
Total		25 cases

This excludes the patients with AIDS who did not need any procedures done. No special complications occurred in these patients. Only three of these 15 patients were on antiretroviral therapy.

Conclusion:

HIV and AIDS are here to stay. Surgeons will be asked to treat surgical problems in this group of patients. Ethical and moral considerations demand that surgeons do not shy away from this responsibility. The risks of surgeons acquiring HIV from the patients is very small. Routine, mandatory testing of patients before operative procedures is to be discouraged. However, testing may be undertaken for medical reasons after due counselling. Universal precautions can be applied universally without incurring any great increase in expenditure. If one gets exposed to HIV through accidental injury, PEP is an effective means of very substantially reducing the risk of acquiring the infection.

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