Surgical issues in HIV infection

INTRODUCTION — Antiretroviral therapy has significantly increased longevity among patients with HIV. As this population grows older, the need for surgical interventions, such as coronary revascularization, will likely increase. (See "HIV infection in older adults".)

This topic review will address issues surrounding HIV infection in the patient who needs surgery, including morbidity and mortality, preoperative assessment, and perioperative and postoperative management. This topic will also address concerns regarding HIV transmission during surgical procedures. Discussions of postexposure prophylaxis after potential HIV exposures are discussed elsewhere. (See "Management of health care personnel exposed to HIV".)

HIV INFECTION AND SURGICAL MORBIDITY AND MORTALITY — With the widespread use of antiretroviral therapy (ART) in patients with HIV, generally favorable surgical outcomes have been reported for a wide range of procedures [1-19]. However, many [4,9-14,17,20], but not all [2,7,8], studies have shown slightly greater morbidity and mortality compared with uninfected populations, especially in patients who have AIDS-related complications or lower CD4 cell counts.

●In a retrospective study of United States veterans who underwent inpatient surgery, 30 day postoperative mortality was higher among 1641 patients with HIV compared with 3282 procedure-matched, uninfected controls (3.4 versus 1.6 percent) [12]. Although lower CD4 cell counts were associated with higher mortality, the mortality difference between patients with and without HIV persisted at all CD4 cell count strata. Hypoalbuminemia and older age were also independently associated with mortality.

●In another retrospective study of surgical outcomes, patients with HIV were matched 1:1 by type of surgery, year of intervention, sex, and age with patients without HIV [2]. Clinical outcomes, length of stay, and number of postoperative visits were similar among the 332 matched patient pairs. Various complications were no more frequent among patients with HIV, except for pneumonia.

●In a retrospective cohort study of hospitalized patients who underwent emergency surgery (appendectomy, cholecystectomy, or colon resection), patients with HIV and an AIDS diagnosis were more likely to die during their hospital stay (4.4 versus 1.6 percent) [21]. Asymptomatic patients with HIV had outcomes similar to those of seronegative individuals.

Observational data are also conflicting as to whether there is a higher risk of postoperative complications (eg, wound infection, endometritis, pneumonia) [3-7]. One retrospective study cited a higher risk of pulmonary complications and pneumonia among patients with HIV who underwent surgery for lung cancer compared with patients without HIV [11]. In another retrospective study, short-term outcomes after lung cancer surgery did not differ significantly by HIV status [22]. In the retrospective study of emergency surgery described above, patients with an AIDS diagnosis had increased odds of postoperative complications, including pneumonia, urinary tract infection, sepsis, acute renal failure, and need for blood transfusion [21].

PREOPERATIVE ASSESSMENT — The general approach to the patient with HIV in need of surgery is similar to that used for any other patient in this setting.

General health status — Estimation of cardiac and pulmonary risk is important to review. Observational data suggest an increased risk of coronary artery disease among patients with HIV compared with those without HIV, which may be related to ongoing chronic inflammation, despite viral suppression [23,24]. Patients with HIV are also at risk for chronic pulmonary disease since the prevalence of smoking is high (over 40 percent) and the likelihood of cessation less than in the general population [25]. As noted above, patients with HIV and lung cancer have a higher risk of pulmonary complications from surgery [11]. Preoperative evaluation with a diffusion capacity of lung for carbon monoxide may be helpful for patient selection.

Compared with patients without HIV, the prevalence of insulin resistance, diabetes mellitus, and hypercholesterolemia is higher among those with HIV, which may be partly related to adverse events of certain antiretroviral medications, lifestyle habits, immunologic dysfunction and HIV itself [24]. (See "Epidemiology of cardiovascular disease and risk factors in patients with HIV", section on 'Dyslipidemia' and "Evaluation of cardiac risk prior to noncardiac surgery" and "Evaluation of perioperative pulmonary risk".)

HIV disease status — Past medical history should elicit any history of opportunistic diseases or other complications related to HIV infection. A CD4 cell count and HIV viral load should be performed if not available within the preceding three months. Clinicians should be aware that acute medical conditions may transiently decrease the CD4 cell count and increase the viral load, so HIV parameters should be interpreted cautiously in this setting. (See "Techniques and interpretation of measurement of the CD4 cell count in people with HIV" and "Techniques and interpretation of HIV-1 RNA quantitation".)

The CD4 cell count is a surrogate marker for degree of immune function and is used to determine whether prophylaxis against various opportunistic infections is indicated. (See "Overview of prevention of opportunistic infections in patients with HIV".)

Most studies have found that the incidence of postoperative bacterial complications and sepsis is increased in patients with lower CD4 cell counts, although some have yielded contrary results [2,8-10,21,26]. One study found that a viral load of 30,000 copies/mL or greater was associated with a threefold increased risk of complications [2]. Thus, for elective surgery, it is preferable to work with the patient's HIV clinician to achieve viral suppression in advance of the planned procedure [27]. (See 'HIV infection and surgical morbidity and mortality' above.)

Starting ART in the treatment-naïve patient or modifying an ineffective regimen should be made in consultation with an HIV clinician or infectious diseases specialist. (See "Selecting antiretroviral regimens for treatment-naïve persons with HIV-1: General approach".)

Medication history — The United States Department of Health and Human Services (DHHS) recommends that ART be initiated in all patients with HIV, regardless of CD4 cell count [28]. Most patients who are aware of their HIV status and in care are taking ART, although some people with HIV infection remain undiagnosed [29]. (See "When to initiate antiretroviral therapy in persons with HIV".)

Protease inhibitors and non-nucleoside reverse transcriptase inhibitors have significant drug-drug interactions with many other agents. A review of potential drug interactions with antiretroviral medications should be performed during the inpatient hospitalization, particularly in preparation for induction of sedation and anesthesia. Detailed information on drug interactions can be found in the drug interaction program within UpToDate.

Past medical history — Specific questions should be asked of the patient regarding a history of viral hepatitis, tuberculosis exposure, and alcohol and substance use, since these issues are prevalent in patients with HIV. A detailed history of sexually transmitted diseases is especially important in females undergoing surgery for possible tuboovarian abscess. Pregnancy testing should also be performed in females of childbearing age who are undergoing surgery.

Nutritional status — Nutritional status should be assessed by recent dietary history and comparison of body weights over time. Patients with AIDS are at risk for wasting and nutritional deficiencies.

Lipoatrophy, such as thinning of the extremities and malar atrophy, is also prevalent in patients with longstanding HIV infection on ART and needs to be differentiated from wasting secondary to advanced HIV infection [30]. Lipoatrophy may also be accompanied by areas of lipodeposition (eg, cervicodorsal region, visceral adiposity), which may be mistaken for simple obesity [31]. (See "Epidemiology, clinical manifestations, and diagnosis of HIV-associated lipodystrophy" and "Overview of perioperative nutrition support", section on 'Nutritional assessment in the surgical patient' and "Clinical assessment and monitoring of nutrition support in adult surgical patients", section on 'Initial assessment of nutritional status'.)

Laboratory assessment — Routine baseline laboratory studies should include a complete blood count; serum blood urea nitrogen (BUN), glucose, and creatinine; liver function tests; and prothrombin and partial thromboplastin times.

Pancytopenia may be seen in patients with HIV with advanced immunosuppression related to HIV-related myelodysplasia, opportunistic infections or neoplasms, or other causes [32].

Any mild abnormality of serum creatinine should be accompanied by urinalysis to screen for proteinuria to determine if the patient may have HIV-associated nephropathy [33]. In addition, tenofovir disoproxil fumarate (TDF), a commonly used nucleotide reverse transcriptase inhibitor, has been associated with tubular dysfunction and renal insufficiency, particularly in patients with diabetes mellitus or hypertension [34]. Tenofovir alafenamide (TAF) appears to have less renal toxicity. (See "Overview of kidney disease in patients with HIV".)

Determination of platelet count and prothrombin time are important in assessing risk of bleeding, particularly in those patients who have advanced liver disease secondary to hepatitis C or hepatitis B infection. Thrombocytopenia may also be immune-mediated (ITP) related to underlying HIV infection, usually seen in untreated patients with advanced immunodeficiency. HIV-related ITP is usually manifested by mild to moderate thrombocytopenia, but occasionally platelet counts can drop below 10,000 to 20,000/microL with an associated increased risk of bleeding. (See "HIV-associated cytopenias".)

Advance directives — Medical directives and health care proxy status should be discussed with the patient prior to surgery. (See "Advance care planning and advance directives".)

PERIOPERATIVE MANAGEMENT — Antiretroviral medications should generally be continued through the perioperative period when feasible [27]. However, if clinically necessary, stopping antiretroviral medications for a few days should not have a deleterious impact on their effectiveness. Viral resistance is more likely to occur when doses of some medications are intermittently missed over an extended period.

When altered mental status or gastrointestinal tract dysfunction interfere with the ability of the patient to take or absorb oral medications, all antiretroviral drugs should be held. Parenteral alternatives should be sought for agents used for prophylaxis for opportunistic infections (eg, intravenous trimethoprim-sulfamethoxazole) if it is anticipated that the patient will be unable to have oral intake for an extended duration of time. (See "Overview of prevention of opportunistic infections in patients with HIV".)

Liquid preparations are available for many antiretroviral agents for patients who may have difficulty swallowing. (See "Overview of antiretroviral agents used to treat HIV", section on 'Protease inhibitors (PIs)' and "Overview of antiretroviral agents used to treat HIV", section on 'Patients who have trouble swallowing tablets'.)

POSTOPERATIVE MANAGEMENT — Most postoperative complications, including delayed healing, wound infection, and bacterial sepsis, occur in patients with HIV and advanced immunosuppression (as manifested by low CD4 cell count), poor nutrition (as manifested by low serum albumin), and/or neutropenia (eg, absolute neutrophil count <500 cells/microL). One study conducted in 1996 identified HIV infection as a risk factor for unplanned postoperative admission to a critical care unit for mechanical ventilation [35]. However, in the era of potent antiretroviral therapy (ART), patients with HIV who have achieved immune reconstitution appear to have excellent outcomes [1].

Nutrition — Nutritional consultation may be warranted postoperatively if oral intake is inadequate.

Hypoadrenalism — The stress of surgery may unmask previously unsuspected hypoadrenalism, which is seen more commonly in patients with advanced HIV disease who have smoldering infections with Mycobacterium avium complex or cytomegalovirus. Many of the symptoms of adrenal dysfunction are nonspecific. Electrolyte changes (eg, hyponatremia or hyperkalemia) or hypotension may raise suspicion of the presence of hypoadrenalism in the postoperative setting; a cosyntropin stimulation test is indicated in this circumstance. (See "Clinical manifestations of adrenal insufficiency in adults" and "Determining the etiology of adrenal insufficiency in adults" and "Pituitary and adrenal gland dysfunction in patients with HIV".)

Postoperative fever — The approach to the patient with HIV and postoperative fever is determined by the presence and nature of accompanying symptoms and the level of immunodeficiency as measured by CD4 cell count (table 1).

Common causes — Most postoperative fevers in patients with HIV disease are from common causes, such as a surgical site infection, Clostridioides difficile infection, intravascular catheter site, pneumonia, urinary tract infection, thrombophlebitis, and drug toxicity. In addition to a thorough history and physical examination, evaluation should include a complete blood count with differential, liver function tests, two blood culture sets, urinalysis, and a chest x-ray. (See "Fever in the surgical patient".)

Opportunistic infections — Consideration should be given to an opportunistic infection in the febrile patient with a CD4 cell count less than 200/microL. In such patients, routine blood cultures and isolator tubes for Mycobacterium avium complex infection should be performed in addition to the testing noted above. Symptoms of dyspnea or headache may also direct additional evaluation for pneumocystis pneumonia or cryptococcal meningitis, respectively. (See "Epidemiology, clinical manifestations, and diagnosis of Cryptococcus neoformans meningoencephalitis in patients with HIV", section on 'Clinical manifestations' and "Epidemiology, clinical presentation, and diagnosis of Pneumocystis pulmonary infection in patients with HIV".)

It is also important to remember that patients with HIV and pre-existing leukopenia may not mount a leukocyte response despite the presence of serious infection or bacteremia. An infectious disease consult should be considered for assistance in the diagnostic evaluation.

Pneumonia — Pneumonia is among the most frequently encountered postoperative infections in HIV disease. The patient with HIV who has dyspnea or cough should undergo a careful assessment guided by the clinical presentation and CD4 cell count. An infectious diseases consultation should be considered for assistance in the evaluation and management of fever and pulmonary infiltrates in the immunosuppressed patient.

The clinical presentation and radiologic appearance of bacterial pneumonia in the patient with HIV and a CD4 cell count >200 cells/microL are generally similar to those in immunocompetent patients. A complete blood and differential count, two blood culture sets, chest x-ray, and oximetry should be performed. If the chest x-ray reveals lobar or segmental infiltrates, induced sputum examination for Gram stain and culture should be ordered and empiric therapy for bacterial pneumonia should be started, pending results. (See "Evaluation of pulmonary symptoms in persons with HIV" and "Bacterial pulmonary infections in patients with HIV".)

Patients with AIDS and neutropenia are at risk for invasive bacterial pneumonia related to nosocomial pathogens, such as Staphylococcus aureus and gram-negative organisms, including Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter species [36-38]. (See "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults".)

If the chest x-ray shows diffuse or patchy infiltrates in a patient with a CD4 cell count <200/microL, an induced sputum examination for Pneumocystis jirovecii, as well as for Gram stain, acid-fast bacilli stain, special stains for Legionella and fungi, and appropriate cultures should be performed. Treatment is generally based upon the results of these tests. However, if the patient with a CD4 cell count <200/microL appears acutely ill or is hypoxemic, empiric therapy for pneumocystis pneumonia should be initiated promptly; treatment started prior to the sputum examination will not adversely affect its sensitivity for this infection. (See "Treatment and prevention of Pneumocystis infection in patients with HIV".)

In a patient at risk for tuberculosis exposure, a PPD should be placed or interferon-gamma release assay performed, and multiple samples for acid-fast bacilli should be obtained. (See "Diagnosis of pulmonary tuberculosis in adults".)

ORGAN TRANSPLANTATION IN PATIENTS WITH HIV — Organ transplantation in patients with HIV has become more common with effective antiretroviral therapy and improvement in life expectancy [39-43]. Kidney transplantation from a donor with HIV is an option for patients with HIV and chronic renal disease [44]. Liver transplantation has also been successfully performed in patients with HIV and advanced liver disease [45-47]. These topics are discussed in detail elsewhere. (See "Kidney transplantation in adults: Kidney transplantation in patients with HIV" and "Liver transplantation in adults: Patient selection and pretransplantation evaluation".)

SURGERY AND HIV TRANSMISSION — There is no evidence that identifying the HIV status of patients prior to procedures reduces the chance of accidental blood exposures [48]. Routine preoperative screening for HIV infection in surgical patients is neither cost-effective nor a reasonable alternative to universal precautions [49].

Concerns regarding HIV transmission during surgery have been raised regarding transmission from a patient with HIV to an uninfected surgeon or from a surgeon with HIV to an uninfected patient, as discussed below.

Risk of HIV transmission from patient to health care worker — Measuring the true incidence of occupational exposure to infectious agents is difficult because an estimated 50 percent of events are unreported. Surgeons have approximately one dozen percutaneous blood exposures per person-year, which is the highest among health care workers, while inpatient nurses average one exposure per year.

Between 1981 and 2013, there were 58 documented seroconversions and 150 possible cases of occupationally acquired HIV infection in the United States (table 2) [50]. Of the 58 occupational HIV transmissions, there were two involving surgical technicians and none in surgeons. The most common route of exposure leading to HIV infection among these health care workers was percutaneous/puncture injury [50]. It is significant that only one documented case has occurred since 1999. However, the reporting system is voluntary so underreporting of cases is possible (figure 1).

All cases of suspected occupationally acquired HIV should be reported to state health department HIV surveillance staff and the CDC coordinator at 404-639-2050. In the event of any exposure, prompt postexposure prophylaxis is critically important. These issues are discussed in detail elsewhere. (See "Infection prevention: Precautions for preventing transmission of infection" and "Management of health care personnel exposed to HIV".)

Risk of HIV transmission from infected health care workers to patients

Large-scale look-back investigations — The overall risk of HIV transmission from a health care worker to a patient appears to be extremely low; only three cases resulting in eight infections have been documented globally [51,52]. In a widely publicized incident in 1990, a Florida dentist was identified by DNA sequencing as the source of HIV infection in six of his patients [53-55]. Despite intensive epidemiologic investigation, the mechanism of transmission was never established.

Following the incident involving the dentist, the Centers for Disease Control and Prevention (CDC) initiated 66 "look-back" investigations involving 22,759 patients who had invasive procedures performed by health care workers with HIV [56-58]. Only 113 (0.5 percent) were found to have HIV infection, most of whom were aware of their condition prior to the time of the procedure. In the other cases, none of the viral strains were found to be identical to those of the health care workers based on DNA sequencing. In reviewing the available data, the CDC has estimated that the risk of HIV transmission from a health care worker to a patient during a surgical procedure is between 1 in 2.4 million and 1 in 24 million.

Another investigation was performed in an Israeli cardiothoracic surgeon who was found to be infected with HIV in 2007 when he presented with unexplained fevers [59]. The surgeon had advanced HIV disease with a CD4 cell count of 49/microL and an HIV RNA level of >100,000 copies/mL. A look-back investigation was performed of all patients on whom he had operated during the previous 10 years. Of the 1669 patients identified, 545 (33 percent) underwent serologic testing; all were HIV seronegative. In addition, none of the patients' names have appeared on a national registry of known HIV-seropositive persons. This report adds to the existing body of data, which argue for a very low risk of practitioner-to-patient HIV transmission in the present era.

After receipt of these results, an expert panel recommended allowing the surgeon to return to work with no restrictions on the types of procedures he performed, provided that the surgeon complete additional infection control instruction and adhere to routine HIV RNA monitoring to confirm ongoing viral suppression on antiretroviral therapy (ART).

Based on the investigation and the published literature, the panel did not require notification of prospective patients of the surgeon's HIV status because of the extremely low likelihood of transmission if these conditions were met.

Management of the health care worker with HIV — The Society for Healthcare Epidemiology of America (SHEA) has published guidelines for the management of health care workers who are infected with HIV and other bloodborne pathogens, such as hepatitis B and C viruses [60,61]. In general, SHEA states that health care practitioners with HIV should not be prohibited from participating in patient-care activities solely based on HIV status. Specific recommendations are made based upon the health care worker's viral burden and category of clinical activity. The three categories of procedures include:

●Category 1 – Those with minimal risk of blood transmission (eg, endoscopy, or routine rectal or vaginal examinations)

●Category 2 – Those with possible risk of blood transmission, but unlikely (eg, endodontic dental procedures, abscess drainage, biopsies under local anesthesia)

●Category 3 – Those with definite risk of blood transmission (eg, general surgery)

The guidelines recommend that health care practitioners with HIV should not be restricted from Category 1 or 2 procedures if they have a viral load assay below 200 copies/mL. Those with HIV RNA >200 copies/mL should refrain from category 3 procedures. Health care workers who have a viral load assay below 200 copies/mL may be allowed to engage in category 3 procedures if the following criteria have been met:

●The practitioner has not previously transmitted HIV to a patient.

●The practitioner obtains advice from an oversight panel about practices to minimize the risk of exposure events.

●The practitioner has twice-yearly follow-up regarding maintenance of viral suppression.

●The practitioner receives HIV care from an expert in the field, who communicates with the oversight panel regarding their clinical status.

SUMMARY AND RECOMMENDATIONS

●With widespread use of antiretroviral therapy (ART), generally favorable surgical outcomes have been reported among patients with HIV undergoing a wide range of surgical procedures. Most studies have shown slightly greater morbidity and mortality compared with uninfected populations, especially in patients who have AIDS-related complications or lower CD4 cell counts. (See 'HIV infection and surgical morbidity and mortality' above.)

●Preoperative screening in the patient with HIV is similar to any other patient and should include evaluation of cardiac and pulmonary status and routine laboratories, including complete blood count; serum blood urea nitrogen (BUN), glucose, and creatinine; liver function tests; and prothrombin and partial thromboplastin times. A CD4 cell count and HIV viral load should be performed if not available within the preceding three months. Measurement of the CD4 cell count is important since immunosuppression may increase the risk of postoperative infection. (See 'Preoperative assessment' above.)

●A review of potential drug interactions with antiretroviral medications should be performed in preparation for induction of sedation and anesthesia. (See 'Preoperative assessment' above.)

●When altered mental status or gastrointestinal tract dysfunction interferes with the ability of the patient to take oral medications, all antiretroviral drugs should be held. In the patient with AIDS, parenteral alternatives should be sought for agents used for prophylaxis against opportunistic infections if a prolonged duration of poor oral intake is anticipated. (See 'Perioperative management' above.)

●Most postoperative fevers in patients with HIV disease are from common causes, such as an infected intravascular catheter site, pneumonia, urinary tract infection, thrombophlebitis, and drug toxicity. However, the possibility of an opportunistic infection should be considered in the patient with advanced immunosuppression (eg, CD4 cell count <200 cells/microL). (See 'Postoperative management' above.)

●Routine preoperative screening for HIV infection in surgical patients is neither cost-effective nor a reasonable alternative to universal precautions. (See 'Preoperative assessment' above.)

●The risk of HIV transmission from a health care worker to a patient through a surgical procedure has been estimated to be extremely low, and few documented cases exist in the literature. Health care practitioners with HIV should not be prohibited from participating in patient-care activities solely based on their HIV status. (See 'Risk of HIV transmission from infected health care workers to patients' above.)

ACKNOWLEDGMENT — UpToDate gratefully acknowledges John G Bartlett, MD (deceased), who contributed as Section Editor on earlier versions of this topic and was a founding Editor-in-Chief for UpToDate in Infectious Diseases.