Presentation on theme: "HIV and the Surgeon Paul MacPherson PhD, MD, FRCPC Assistant Professor of Medicine Division of Infectious Diseases Ottawa Hospital, General Campus University."— Presentation transcript:
HIV and the Surgeon Paul MacPherson PhD, MD, FRCPC Assistant Professor of Medicine Division of Infectious Diseases Ottawa Hospital, General Campus University of Ottawa
Summary 1.HIV today 2.HIV infection and natural history 3.Current treatments for HIV infection 4.Indications for surgery in HIV+ patients 5.Surgical outcomes for HIV+ patients 6.Needlestick injuries
HIV: A Global Pandemic
Current Demographics in Canada
Demographic Trends 1. HIV+ tests (all ages) highest in 1995 at 2,990 lowest in 2000 at 2,106 increased in 2001 and 2002 and then plateaued at 2, Increasing among older adults (age >40 yrs) 3. HIV+ tests among MSM: increasing since Steady decline among injection drug users 5. Steady increase among Heterosexuals 68% increase in Ontario over the past 5 years (11%/yr)
HIV Epidemiology Developing World –Heterosexual men and women –Children Developed World –Men who have sex with men –People from endemic countries –Aboriginals –People who use injection drugs –Heterosexual men and women
Transmission 1.Sexual contact with exchange of bodily fluids –Exposure of mucous membranes 2.Sharing injection drug paraphernalia –Needles, snorting straws 3.Transfusion of infected blood or blood products –Currently 1 in 500,000 4.Mother to child (vertical) –Perinatal and breast feeding
Sexual Transmission of HIV: HIV is contained in: –Semen –Vaginal secretions –Rectal secretions –(Saliva at very low levels)
Exposure to HIV In these fluids: 1.HIV is present as free virus 2.HIV is contained in infected CD4 cells
Mucous Membranes: the target Mucous membranes are the moist epithelial linings of body cavities including the: –oral cavity –rectum –vagina and cervix –inner foreskin Live cells line the surface.
Mucous Membrane: the target Only 2% of the body’s immune cells circulate in the blood 98% of the body’s immune cells are located in the lymph nodes and the mucous membranes Mucous membranes are rich in T-cells and macrophages to provide defence The majority of these cells are organized into “lymphoid follicles” just under the surface of the mucosal membrane
Mucous Membrane: rectum Lymphoid follicles: 15/cm 2 in the colon and increase to 25/cm 2 in the rectum.
Mucous Membrane: the target M-cells transport HIV directly into the lymphoid follicle Owen, RL. Pathobiology, 1998.
Mucous Membrane: cervix Lymphoid follicle in the cervix. CD4 cells are stained brown. Kobayashi, Am J Pathology, 2002
Mucous Membrane: the target Hladik F. Immunity, McCoombe. AIDS, 2006.
Transmission: Injection drug paraphernalia Sharing injection drug paraphernalia Access to clean needles Drug rehabilitation programs
Transmission: Blood transfusion Transfusion of infected blood or blood products Screening donated blood –ELISA: 2-3 month window period –PCR: essentially no window period
Transmission: Mother to child Mother to child (vertical) In utero (trans-placental) Peri-natal accounts for majority of cases –By blood-blood mixing Breast feeding.
Human Immunodeficiency Virus
HIV and Immunology
Immunologic: Peripheral Blood CD4 T-cells: infected, decrease, dysfunction, alterations in subsets CD8 T-cells: dysfunction, anergic, alterations in subsets Macrophages: infected, dysfunction NK cells: dysfunction B-cells: dysfunction- polyclonal hypergammaglobulinemia Cytokine dysregulation Lymph Nodes Hyperplastic and eventually fibrotic
Natural History of HIV Disease
HIV Disease HIV enters the body and slowly destroys the immune system without treatment, HIV is continuously active without treatment, the average length of time between infection and the onset of symptomatic disease is years the competency of the immune system is reflected by the CD4 count
Viral Load What is the viral load? How much virus per ml of blood Range 100’s to >500,000 Viral load and progression are roughly correlated Each patient has their own “set-point”
CD4 Count What is the CD4 count? is normal >500 no worry a bit of a gray zone. <200 at risk <50 at significant risk
Risk of Illness based on CD4 Count >500:usually no symptoms. May have fever, night sweats, lymphadenopathy, weight loss : recurrent HSV, zoster, sinusitis, pneumonia candidiasis (oral, vaginal), lymphoma <200: PCP, Toxo, KS, Cryptococcus <50: MAC, CMV, PML, dementia, wasting
Eosinophilic Folliculitis CD4 < 200 Waxing and waning Moderate to severe pruritis 90% occur above T2 Rx: topical steroids
Seborrheic dermatitis Erythematous plaques with greasy scales Face, ears, scalp, axilla Topical steroids with or without ketoconazole
HIV-Associated Wasting Syndrome
Antiretroviral Therapy The new era
Antiretrovirals Save Lives
Antiretrovirals reduce the rate of progression years No treatment Antiretrovirals
Why Antiretroviral Therapy?
Treatment Goals Maximal viral suppression (VL<50) Undetectable does not mean absent Durable suppression Restoration and preservation of immune function Improved quality of life Reduction in morbidity and mortality Current projected life-expectancy from time of diagnosis: 43 years!
Adverse Effects: Lipodystrophy Syndrome 1.Hyperlipidemia: Total cholesterol, LDL and triglycerides Risk of atherosclerosis Pravastatin, Crestor and Fibrates are drugs of choice 2.Lipodysmorphic Features –Fat atrophy of face and limbs –Fat accumulation dorsocervical pad, stomach, breasts 3.Insulin Resistance May consider metformin
Mother to child transmission
Transmission of HIV from mother to infant occurs predominantly at the time of delivery.
Women and Infant Transmission Study, 1999 Viral LoadTransmission < 10000% 1000 – 10, % 10,000 – 50, % 50,000 – 100, % > 100, % Average risk of transmission to the infant: 30%
ACTG 076 Study (1994) Protocol: AZT given IV during labour AZT to the infant for 6 weeks Success: 67.5% reduction in transmission From 30% to 8.3%
Reducing Mother to Child Transmission: If mother not diagnosed previously: perinatal AZT and C-section (risk < 5%) If mother known HIV+: antiretroviral therapy beginning week 28 If mother known HIV+ and on antiretroviral therapy: continue therapy (change if on EFV) If maternal VL < 50, then risk of perinatal transmission < 1% Breast feeding only if no access to formula
Indications for surgery in HIV+ patients
Indications for Surgery: not on therapy Intracranial lesion –Primary CNS lymphoma –Toxoplasma –TB –Gumma –PML –Bacterial abscess Stereotactic needle biopsy
Indications for Surgery: not on therapy Lymph node biopsy –lymphoma, TB, MAC Cholecystitis –Cholelithiasis –Crytosporidium, CMV, MAC
Indications for Surgery: on therapy Coronary by-pass –Antiretrovirals associated with increased lipids –50% of HIV+ individuals smoke cigarettes –Increased rates of CVD Resection of malignancies –Cervical cancer (HPV) –Anal cancer (HPV) –Lymphoma –Hepatoma –(No increase in breast or lung cancer)
HIV and Surgical Outcomes
HIV + ARV = excellent surgical outcomes
ARV and Surgery Impact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection. Department of S. Siro Clinical Institute, University of Milan, Milan, Italy. Br J Surg Nov; 93(11): HAART was shown to be protective. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes. CONCLUSION: HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection.
ARV and Surgery Outcomes of hysterectomy in HIV-seropositive women compared to seronegative women. Department of Gynecology and Obstetrics, Emory University, Atlanta, USA. Infect Dis Obstet Gynecol Sep;13(3): No significant differences in complication rates were found among HIV-infected women compared with uninfected women.
ARV and Surgery HIV-positive renal recipients can achieve survival rates similar to those of HIV- negative patients. Terasaki Foundation Laboratory, Los Angeles, CA, USA. Transplantation Jun 27;81(12): Although not statistically significant, graft survival was higher among HIV-positive patients compared with their negative controls, as was patient survival. –Graft survival: 76.1% vs. 65.1% at 5 years (p=0.21) –Patient survival: 91.3% vs. 87.3% at 5 years (p=0.72)
ARV and Surgery Excellent outcomes of cardiac surgery in patients infected with HIV in the current era. Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York Clin Infect Dis Aug 15;43(4): The surgeon and AIDS: twenty years later. Department of Surgery, Medical Center, University of California-Irvine, CA Arch Surg Oct;140(10): Since the first reports on indications and outcome for abdominal procedures in the HIV/AIDS patient were published 20 years ago, the epidemiology and presentation of surgical illness have changed remarkably with the advent of new antiviral regimens.
Occupational Exposures Pietrabissa et al (1997) - surveyed 15,375 procedures in 39 hospitals by 122 surgeons over 6 months: a) 3.9% of procedures had percutaneous or eye exposures b) needle sticks accounted for 84% of injuries c) 58% occurred at wound closure d) direct correlation between length of procedure and number of injuries
Occupational Exposures Prospective surveillance of HCW exposed to HIV conducted by CDC from 1983 to 1992: 89% percutaneous 5% mucous membrane Of Percutaneous: 34% by syringe needles 40% by suture needles 4% by scaples 2% by lancets 4% other
Needle stick Injuries
What do we worry about? 1) Hepatitis B: 30% risk - chronic hepatitis, cirrhosis, carcinoma 2) Hepatitis C: 3% risk - chronic hepatitis, cirrhosis, carcinoma 3) HIV: 0.3% risk
What do I do ? 1) Don’t panic! 2) Dispose of the needle in a sharps container 3) Express blood from the wound 4) Clean thoroughly with Providone iodine, or chlohexidine, or soap and water 5) If eyes or mucous membranes: lots of water 6) Go to the Emergency Dept.
Risk Assessment: 1) You 2) The patient 3) The Injury
You: 1) Are you vaccinated against HepB? 2) Are you immune to HepB? Get your titers measured! 3) General health 4) Blood work: CBC, lytes, liver function
The Patient: 1) HIV status 2) HepB status 3) HepC status Don’t Know? Then request: 1) HIV test STAT, with consent from patient 2) HBsAg, HBsAb 3) HCV-Ab and PCR
The Patient: Do know: 1) HIV: what is the viral load? how sick is the patient? 2) HepB: is he/she sAg+
The Injury: Risk Factors: depth of skin invasion? Exposure to broken skin? hollow bore or suture needle? did the needle enter a blood vessel of the pt? visible blood on the needle? were you wearing gloves?
Post Exposure Prophylaxis
HIV Post Exposure Prophylaxis There is minimal evidence for PEP: 1) case controlled study of HCW 2) ACTG 076, perinatal HIV transmission 3) Animal models
HIV Post Exposure Prophylaxis AZT 300 mg BID 3TC 150 mg BID Kaletra II tabs BID should begin ASAP, within 48 hours of injury total course = 28 days side effects: nausea, vomiting, diarrhea, headache, fatigue, anemia, drug interactions
HIV Post Exposure Prophylaxis Seen in clinic within 2 days Repeat HIV tests at 1, 3 and 6 months use condoms with all sex partners do not donate blood cost: $1200 for one month supply
Hepatitis B You should be vaccinated! If not vaccinated and not immune, liver function tests HBIG and HepB vaccination HBsAg and HBsAb at 1, 3 and 6 months
Hepatitis C Takes up to three months to develop antibodies HCV RNA detectable in blood within days
Hepatitis C Recent trial of 44 health care workers exposed to HCV via needle sticks received IFN daily for 1 month followed by IFN 3x per week for 5 months 95% response rate
Infection Control and HIV
Protecting Yourself and Others What body fluids contain HIV?
Protecting Yourself and Others What body fluids contain HIV? Blood semen vaginal fluids
Protecting Yourself and Others What body fluids do not contain HIV? SalivaTears SweatUrine Stool/diarrheaVomit *unless contaminated with blood
Protecting Yourself and Others Wear gloves for venipuncture Wear gloves for cleaning up any body fluids Carefully dispose of sharps!! Bedding, towels, etc stained with blood or vaginal fluids are laundered normally No gowns! No masks! (except for bloody procedures)
Protecting the Patient Do Not isolate because of HIV!!! HIV+ individuals deserve your respect If you don’t know about HIV, learn something Maintain confidentiality!!