HIV/AIDS AND TRAUMA

TAOLE MOKOENA MBChB (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 CD4 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 procedures1) Nose Nose D V et al. AIDS 1998; 12 : 2243 – 22512) Ayers J et al. Chest 1993; 103 : 1800 - 18073) Franz J et al. Infect Dis Obstet & Gynecol 2005; 13 : 167 – 169

• Certain categories of surgery show higher morbidityeg 1) Abdominal aortic surgery - Lin P H et al. Am J

Surg 2004; 188 ; 690 – 697eg 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 CD4 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 post-

op complications and apply prophylaxis generously