Although HIV/AIDS management has advanced, surgeons must maintain vigilance
Since HIV was first documented in the United States in 1981, great strides have been made in the prevention of transmission and the management and treatment of HIV/AIDS. Still, an estimated 1.2 million persons aged 13 years or older are living with HIV infection in the country. Approximately 156,300 (12.8 percent) are unaware of their infection. An estimated 50,000 new HIV infections are diagnosed each year, with new cases disproportionately represented by persons in certain high-risk groups and geographically in coastal and urban regions.
Within those regions, trauma centers report that 10 percent of their patients are HIV-infected, including many who are unaware of the diagnosis. All orthopaedic surgeons should be mindful of considerations for risk, management, and perioperative decision making in the care of patients with HIV/AIDS. An article in the August issue of the Journal of the American Academy of Orthopaedic Surgeons reviews various clinical issues specific to HIV in the orthopaedic setting.
Authors Gregory Grabowski, MD, and his colleagues at the University of South Carolina note that since the initiation of universal precautions by the Centers for Disease Control and Prevention (CDC) in 1987 and the implementation of standard precautions in 1995, reported cases of occupationally acquired HIV infection have been low. From 1985 through 2013, 58 confirmed cases were recorded, with just one case reported since 1999.
The sharp decrease in occupational transition is a positive development. Nonetheless, the authors caution, "This decline in documented incidents does not minimize the assumed risk to surgeons when treating HIV-positive patients." The United States does not have a standard or mandate for preoperative HIV screening for patients undergoing an emergent or elective procedure, even though screening would "provide a level of reassurance among healthcare workers and surgeons." However, financial considerations work against universal implementation, including for the 5 million orthopaedic procedures performed annually in the United States.
According to the authors, although a surgeon may "expect that persons with compromised immunity are at risk for various complications, including poor wound healing, infection, and malnutrition," the orthopaedic literature does not uniformly support this assumption. A study of HIV-positive individuals treated for open fractures suggested that HIV was not a contraindication to either internal or external fixation and indicated no markedly increased risk of acute wound or implant infection.
With the improvements seen in outcomes in the HIV-infected population stemming from effective antiretroviral agents, the authors note that complication rates associated with orthopaedic surgery procedures in this population may resemble those of unaffected patients. Nonetheless, in addition to the usual comprehensive medical screening, clinicians should assess known HIV-affected patients for conditions that are more prevalent in that population, including hepatic and renal dysfunction, coronary artery disease, malnutrition, coagulopathy and pancytopenia, substance abuse, and history of opportunistic infections. For example, patients with a history of Pneumocystis carinii pneumonia are at increased risk of intraoperative or postoperative spontaneous pneumothorax.
Immune function should be assessed in the HIV-infected patient to determine which preoperative interventions, if any, should be used to reduce viral load. Implementation and timing of such interventions should be coordinated with the patient's infectious disease specialist.
In an interview with AAOS Now, one of the article's coauthors, Alexis Pilato, MD, addressed the issues and considerations that arise in the orthopaedic care of the patient with HIV.
AAOS Now: What prompted you to undertake this review?
Dr. Pilato: At this juncture, the literature reviewing the HIV-infected patient in the setting of orthopaedic surgery is limited. During the past decade, several advancements have been made in the treatment of HIV, resulting in near-normal life expectancy and limited sequalae of disease; however, there is a paucity of data on current outcomes in orthopaedic surgery. We thought that it would be beneficial to review and analyze all available data as an updated resource for the currently practicing orthopaedist.
AAOS Now: What is your own and your coauthors' experience with and exposure to patients with HIV or with profiles of higher risk for HIV-infected status?
Dr. Pilato: Working at a large, Level-1 trauma center, which acts as a tertiary care center for the region, we take care of a wide demographic of patients, including both high risk and HIV-infected patients. I imagine that our facility (in Columbia, S.C.) is comparable to any large trauma center, which cares for the underserved population of the region, and I believe that our patient population mirrors that of any large, urban trauma center. Our experience and exposure is likely representative of most major health systems in the country.
AAOS Now: In what ways might orthopaedic surgeons be more likely to encounter patients who are HIV positive? What are the implications?
Dr. Pilato: When an orthopaedic surgeon encounters a patient with HIV, it is more often than not a scenario of urgency such as a trauma situation or a patient who may have come through the emergency department. In these circumstances, it is not always known prior to surgical intervention that the patient may be HIV positive, if it is ever discovered at all. That said, there is also an element of outpatient care in which patients are forthcoming with their diagnosis. I believe a stigma still exists with respect to a diagnosis of HIV, and therefore patients may be apprehensive to divulge this information unless they are asked about it.
It is very important to be thorough in preoperative evaluation of patients. The implications may be significant if a needle stick injury is sustained; however, regardless of preoperative knowledge of the diagnosis, protocol will ultimately have both patient and surgeon undergo appropriate testing and treatment in the event of a sharps injury. With that said, there may be some element of extra protection employed if the patient is known to be HIV positive—for instance, utilizing Kevlar gloves.
AAOS Now: In the practical terms of clinical medicine, how would you characterize the transmission risk of HIV and should there be any concern about complacency?
Dr. Pilato: As our article states, the transmission rate is quite low for HIV following needle stick injuries. With that said, there is still an element of anxiety that exists surrounding potential transmission. Although HIV has ultimately become a manageable disease, the eventual consequence of the impact on the individual should not be taken lightly. Patients with HIV submit to a lifelong medication regimen to maintain normalcy, which is not without side effects, and it affects the lives of their spouses and future offspring. Although the perception of HIV/AIDS has transformed over the years, the consequence of transmission should not be taken lightly.
AAOS Now: Regarding the lack of standards or mandates for HIV screening for patients undergoing either emergent or elective surgery, you write, "One might conclude that, since universal precautions have been implemented for all patients, such information is superfluous." Might this mean that standards for screening are warranted? Does this situation set up the potential for complacency?
Dr. Pilato: At this time, there is no mandate that patients undergo HIV testing preoperatively, and patients may, in fact, refuse to do so, unless in an emergency department setting. If a patient has participated in high-risk behavior such that he or she may have been exposed, it should be the responsibility of the patient to seek testing. This may not always be the case. In a scenario in which the physician believes that HIV testing is warranted, it would be ideal for such a standard to be in place.
With that said, every patient should be treated with universal precautions. I do not believe that preoperative screening would allow potential for complacency, because each patient would still be treated the same with regard to contact with bodily fluid. Preoperative screening, however, may allow the surgeon to take extra measures such as reinforced surgical gloves as an added element of protection in case an accidental breach in universal precautions occurs.
AAOS Now: What are the main considerations that arise in orthopaedic management of patients with HIV and antiviral therapies? Are they all warranted? The article mentions that surgeons may be hesitant to employ internal fixation on patients with HIV infection.
Dr. Pilato: Overall, the considerations that arise are ultimately patient outcomes in the areas of fracture healing, wound healing, and risk of infections. Often patients with HIV who are not medically optimized with regard to their viral load and overall clinical health may have healing issues. This may be related to decreased immunity due to the disease itself or to sequalae of the disease such as malnutrition or anemia.
The goal is to take good care of our patients and successfully treat their musculoskeletal problems to allow them stable function and mobility, devoid of complications such as infection, wound breakdown, and fracture healing. Our hope is that the article provides a basic foundation of information and a framework from which to provide successful perioperative care in the setting of HIV, while minimizing potential complications.
The other authors of "HIV in Orthopaedic Surgery" are Caroline Clark, MMS, PA-C, and J. Benjamin Jackson III, MD.J Am Acad Orthop Surg 2017;25:569-576.
Terry Stanton is the senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org.