HIVAIDS AND TRAUMA TAOLE MOKOENA MBCh B Natal

HIV/AIDS AND TRAUMA TAOLE MOKOENA MBCh. B (Natal) DPhil (Oxon) FRCS

TRANSMISSION OF HIV Major routes: • Sexual contact with infected person • Perinatal transmission from mother to child • Infusion or inoculation of infected blood eg BTF or shared needles especially drug addicts • Inoculation of blood through skin penetration by sharp instruments is major route in health care workers!

PROGRESSION OF HIV TO AIDS • Mean incubation period of HIV infection until AIDS symptoms is 8 – 11 years (without treatment) • Great variation in rate of progression to AIDS • Full Blown AIDS survival: - 1 year survival 49% - 5 year survival 15% - Mean survival with CD 4 count < 200 = 3, 7 years

TRANSMISSION OF HIV FROM PATIENT TO STAFF • Principally through contaminated hollow needle injuries • Mixing of blood during intra-operative injuries • Solid needles and intact mucus membrane transfer a distinct possibility but very low < 0. 09%. No hard data to support it • No documented seroconversion from solid needle or aerosolisation in OT • Testing patients for possible transfer not infallable because of window period • Seroconversion depends of viral load of inoculum • Current risk estimated at 0. 3% after percutaneous hollow needle injury

TRANSMISSION OF HIV FROM STAFF TO PATIENT • Early report of transmission from staff (dentist) to patient • Since HIV/AIDS awareness no further documentation of such transmission

PRECAUTIONS AND PROPHYLAXIS AGAINST OCCUPATIONAL HIV TRANSMISSION • Universal precautions - gloving always - double glove during surgery - waterproof apron - protective eye/face device • Extra precaution during procedures on known HIV patients • Post exposure prophylaxis - reduces risk of transmission by 80%

OUTCOME OF SURGERY IN HIV/AIDS PATIENTS • Generally morbidity and mortality in HIV infected patient comparable to uninfected for most surgical procedures 1) Nose D V et al. AIDS 1998; 12 : 2243 – 2251 2) Ayers J et al. Chest 1993; 103 : 1800 - 1807 3) Franz J et al. Infect Dis Obstet & Gynecol 2005; 13 : 167 – 169 • Certain categories of surgery show higher morbidity eg 1) Abdominal aortic surgery - Lin P H et al. Am J Surg 2004; 188 ; 690 – 697 eg 2) Obsteterics surgery (C/s) – Ferrero S & Bentivoglio. Arch Gynecol Obstet 2003; 268 : 268 - 273 eg 3) Gynaecological surgery – Grubert T A et al. Clin Infect Dis 2002; 34 : 822 – 830 • Therefore no patient must be denied deserved surgery

DETERMINANTS OF POST-OP OUTCOME IN HIV PATIENTS • Immune status - full blown AIDS - low CD 4 count • Poor nutrition • Main morbidity are post-op infections and wound breakdown • Antiretroviral treatment reverses high risk tendency

OUTCOME IN HIV PATIENTS AFTER TRAUMA • No specific studies • Emergency surgery in HIV patients generally shows similar outcomes to HIV naive patients • Therefore no trauma patient must be denied surgical intervention on account of HIV • Surgeon must however be more vigilent for postop complications and apply prophylaxis generously