Purpose of This Guideline
Date of current publication: May 9, 2022
Lead author: Lily Yan, MD, MSc, Weill Cornell Medicine, NY, NY
Contributors: Tanya Ellman, MD, MSc, and Margaret McNairy, MD, MSc, Weill Cornell Medicine, NY, NY
Writing group: Joseph P. McGowan, MD; Steven M. Fine, MD, PhD; Rona M. Vail, MD; Samuel T. Merrick, MD; Asa E. Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD
Committee: Medical Care Criteria Committee
Date of original publication: November 16, 2021
This guideline was developed by the New York State Department of Health AIDS Institute (NYSDOH AI) Clinical Guidelines Program to assist clinicians in perioperative care management for adults with HIV, which is largely the same as for adults without HIV. The guideline focuses on concerns specific to patients with HIV. The goals of this guideline are to:
- Make clear that HIV is not a contraindication to surgery.
- Advise that HIV does not increase surgical risk in virally suppressed patients and that HIV transmission to the surgical team is eliminated in virally suppressed patients.
- Provide guidance for managing risks of elective surgery in patients who are not virally suppressed.
- Emphasize that interruptions in antiretroviral therapy and opportunistic infection prophylaxis or treatment should be avoided.
The guideline is intended to supplement, not replace, routinely used perioperative protocols that cover stabilization of active medical conditions and risk stratification.
Note on “experienced” and “expert” HIV care providers: Throughout this guideline, when reference is made to “experienced HIV care provider” or “expert HIV care provider,” those terms are referring to the following 2017 NYSDOH AI definitions:
- Experienced HIV care provider: Practitioners who have been accorded HIV Experienced Provider status by the American Academy of HIV Medicine or have met the HIV Medicine Association’s definition of an experienced provider are eligible for designation as an HIV Experienced Provider in New York State. Nurse practitioners and licensed midwives who provide clinical care to individuals with HIV in collaboration with a physician may be considered HIV Experienced Providers as long as all other practice agreements are met (8 NYCRR 79-5:1; 10 NYCRR 85.36; 8 NYCRR 139-6900). Physician assistants who provide clinical care to individuals with HIV under the supervision of an HIV Specialist physician may also be considered HIV Experienced Providers (10 NYCRR 94.2)
- Expert HIV care provider: A provider with extensive experience in the management of complex patients with HIV.
HIV-Specific Perioperative Considerations
RECOMMENDATIONS |
Emergency and Urgent Surgery
Elective Surgery: Determine HIV Clinical Status
Continue HIV Medications
Evaluate for Potential Drug-Drug Interactions
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Abbreviations: ART, antiretroviral therapy; NNRTI, non-nucleoside reverse transcriptase inhibitor; OI, opportunistic infection; PI, protease inhibitor. Note:
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KEY POINTS |
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Emergency and Urgent Surgery
Consistent with operative standards of care, emergency and urgent surgeries should not be delayed in patients with HIV for preoperative evaluation and risk stratification, including CD4 count and HIV viral load testing. CD4 count testing can often take many days to complete.
Elective Surgery: Determine HIV Clinical Status
Preoperative evaluation: All standard preoperative assessments should be performed in patients with HIV, including cardiovascular and pulmonary evaluations such as the Revised Cardiac Risk Index (RCRI) and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator scores. Individuals with HIV tend to have earlier and more comorbidities than those without HIV, including coronary artery disease, thromboembolic events, and pulmonary complications. As with all patients, a detailed assessment of social support, housing, and food security is required to determine the level of assistance needed for optimal postoperative recovery.
In patients with HIV, clinicians should review the most recent CD4 cell count and HIV viral load test results as part of the preoperative evaluation. If recent test results (6 months for HIV viral load; 12 months for CD4 count) are available in the patient’s medical records, retesting before surgery is unnecessary. For most individuals taking ART, the current recommendation is to perform CD4 count testing every 12 months if a patient’s CD4 count is <350 cells/mm3 and HIV viral load testing at least every 6 months. In those with viral suppression and a CD4 count >350 cells/mm3, CD4 count monitoring is optional.
If records indicate that a patient has undetectable HIV RNA but has not had recent CD4 count testing, a CD4 count can be ordered, though it is not necessary and should not delay surgery. If no records are available, preoperative CD4 count and HIV viral load tests should be ordered. Other laboratory test results to consider for patients with HIV include complete blood count (CBC), basic metabolic panel (BMP), liver function tests (LFTs), and prothrombin time (PT)/partial thromboplastin time (PTT).
KEY POINT |
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Risk factors for surgical complications: In general, in patients with HIV, the combination of a low CD4 count and an uncontrolled viral load is associated with an increased risk for postoperative mortality and complications. If surgery is elective and the patient has a viral load level ≥200 copies/mL or CD4 count ≤200 cells/mm3, clinicians should consult with the patient’s primary care provider or an experienced HIV care provider.
Several studies have shown that a diagnosis of AIDS (CD4 count ≤200 cells/mm3) is associated with increased postoperative mortality Horberg et al. 2006; King et al. 2015; Naziri et al. 2015; Gahagan et al. 2016; Sandler et al. 2019. This finding was consistent across multiple sites for emergency general surgery Sandler et al. 2019, total hip arthroplasty Naziri et al. 2015, and all types of surgery at a Kaiser Permanente Medical Care Program in Northern California Horberg et al. 2006.
One study found a slightly higher mortality rate among people with controlled HIV (CD4 count >200 cells/mm3) compared to those without HIV King et al. 2015, but 2 studies found no increased mortality Gahagan et al. 2016; Sandler et al. 2019. In a systematic review and pooled analysis of outcomes after cardiac surgery, investigators found that mortality in patients with HIV was similar to that in those without HIV (odds ratio 0.89, 95% confidence interval 0.72-1.12, P = 0.32) Dominici and Chello 2020. Evidence is mixed on an association between low CD4 count and postoperative complications, such as infections and poor wound healing Tran et al. 2000; Cacala et al. 2006; Horberg et al. 2006; Guild et al. 2012; Sharma et al. 2018; Sandler et al. 2019; Lin et al. 2020; Zhao et al. 2021. One study found that a viral load >30,000 copies/mL, but not CD4 count, was associated with an increased risk of surgical complications Horberg et al. 2006.
The results of these studies can be difficult to interpret because the studies were conducted during different periods, and most did not evaluate the effect of HIV RNA level. However, the evidence points to an increased risk of surgical complications in patients with HIV who have low CD4 counts, almost certainly in combination with viremia and AIDS-related comorbidities.
Not all patients with HIV RNA levels ≥200 copies/mL and CD4 count ≤200 cells/mm3 are at increased risk for surgical complications. Some patients may have stable, low-level viremia and additional time on ART or changing the ART regimen is unlikely to reduce the viral load or change clinical stability. For these patients, it is reasonable for surgery to proceed. Input from the patient’s primary care doctor or an experienced HIV care provider is essential to help guide this decision. Other patients who are taking ART may have an undetectable HIV viral load for many years but have incomplete immune reconstitution, and therefore low CD4 counts. In this circumstance, delaying surgery is unlikely to lead to CD4 count recovery.
If initiating or changing ART has the potential to reduce the risk of surgical complications, clinicians should engage the patient in shared decision-making regarding the risks and benefits of delaying elective surgery long enough to initiate or adjust ART. The decision to delay surgery involves nuance and a balance of risks and benefits for the individual patient. Factors to consider include the patient’s clinical stability, purpose of surgery (emergency vs. elective), risk of delaying surgical intervention, likelihood that the patient will return for surgery, and likelihood that the patient’s clinical status will improve during the delay.
If patients are not taking ART, clinicians should refer them to an HIV care provider who can initiate ART. If a patient has a high viral load and low CD4 count and chooses not to take or change ART, clinicians should explain the potential risk of surgical complications and engage the patient in a discussion of the risks and benefits of planned elective surgery.
Perioperative antibiotic prophylaxis: As noted above, evidence is mixed regarding an association between lower CD4 count and postoperative infections. Some studies found a positive association in multiple types of surgeries Sandler, et al. 2019; Liu, et al. 2012; Zhang, et al. 2012; Tran, et al. 2000 and orthopedic traumas Zhao, et al. 2021; Guild, et al. 2012, while others found no association across multiple types of surgeries Cacala, et al. 2006, including total hip arthroplasties Lin, et al. 2020. One study found that higher viral loads, but not low CD4 cell counts, were associated with postoperative complications, including infections across multiple types of surgery Horberg, et al. 2006. Taken together, the evidence suggests that use of pre-operative antibiotic prophylaxis is reasonable in patients with low CD4 cell counts or high viral loads to decrease the chance of post-operative surgical site infections and sepsis.
Continue HIV Medications
ART and OI prophylaxis should be continued throughout the perioperative period, especially in patients with HIV/hepatitis B virus (HBV) coinfection in whom cessation of ART can lead to an HBV flare Perrillo 2001. If patients have difficulty swallowing or nasogastric tubes, clinicians can offer equivalent doses of ART in liquid formulations or pediatric pill sizes and advise patients which ART medications can be crushed. For all forms of ART (oral, injection, infusion), the timing of elective surgery should be coordinated with the timing of ART administration to avoid missed doses.
If a patient cannot eat or drink due to the surgical procedure and ART interruption is necessary, all medications in the regimen should be held. If a patient is taking prophylaxis for HIV-related OIs, clinicians should consult an infectious disease specialist if medication interruption or dosing adjustments are required.
Evaluate for Drug-Drug Interactions With Antiretroviral Medications
There is increased potential for drug-drug interactions in patients taking ART due to cytochrome P450 interactions with PIs, NNRTIs, and regimens boosted with ritonavir or cobicistat. Table 1, below, lists common perioperative medications that may interact with ART. It is essential to check up-to-date resources for potential interactions (see Resources: HIV Drug-Drug Interactions, below) or consult with an experienced HIV care provider. If there is an unavoidable drug-drug interaction, clinicians should consult an experienced HIV care provider before surgery to plan medication management and dosing.
Abbreviations: ART, antiretroviral therapy; AUC, area under the curve; CYP3A4, cytochrome P450 3A4; CYP450, cytochrome P450; FDA, U.S. Food and Drug Administration; NSAID, nonsteroidal anti-inflammatory drug; PI, protease inhibitor; QTc, corrected QT interval.
Notes:
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Table 1: Potential Drug-Drug Interactions Between Medications Commonly Used in Perioperative Management and Antiretroviral Agents (also see drug package inserts) | |
Perioperative Medication or Class | Antiretroviral Medication or Class |
Anesthetics [a] | |
Fentanyl |
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Lidocaine |
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Paralytics and Reversal Agents [c] | |
Rocuronium |
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Sedatives | |
Haloperidol | See NYSDOH AI guideline ART Drug-Drug Interactions > Antipsychotics. |
Midazolam |
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Olanzapine |
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Miscellaneous short-acting antipsychotics (risperidone, ziprasidone, quetiapine) |
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Miscellaneous, Other | |
Ondansetron | No interactions expected. No dose adjustment required. |
Acid-reducing agents | See NYSDOH AI guideline ART Drug-Drug Interactions > Acid-Reducing Agents. |
Anticoagulants | See NYSDOH AI guideline ART Drug-Drug Interactions > Anticoagulants. |
Nonopioid analgesics | See NYSDOH AI guideline ART Drug-Drug Interactions > Nonopioid Pain Medications for potential interactions between NSAIDs and tenofovir disoproxil fumarate. |
Opioid analgesics | See NYSDOH AI guideline ART Drug-Drug Interactions > Opioid Analgesics and Tramadol. |
RESOURCES: HIV DRUG-DRUG INTERACTIONS |
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Manage Postoperative Care
There is a greater risk of venous thrombosis in patients with HIV than those without HIV Shen and Frenkel 2004; Malek et al. 2011; Bala et al. 2016. Thus, it is essential to mobilize patients with HIV as soon as medically feasible after surgery and initiate pharmacologic prophylaxis. People with a long history of HIV, low CD4 count, or exposure to boosted regimens and glucocorticoids are at increased risk for hypoadrenalism, which the stress of surgery can unmask Makaram et al. 2018. This possibility should be considered in assessing postoperative hypotension.
In patients with HIV and postoperative fever, common causes of fever, including urinary tract infections, pneumonia, venous thromboembolism, wound infections, or Clostridioides difficile if antibiotics were administered, should be considered before HIV-related causes. If the patient has a CD4 count ≤200 cells/mm3, clinicians should consult an infectious disease specialist and consider OIs.
If ART or OI prophylaxis is discontinued, clinicians should ensure the patient restarts the medication(s) as soon as possible.
All Recommendations
ALL RECOMMENDATIONS: PERIOPERATIVE CARE IN ADULTS WITH HIV |
Emergency and Urgent Surgery
Elective Surgery: Determine HIV Clinical Status
Continue HIV Medications
Evaluate for Potential Drug-Drug Interactions
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Abbreviations: ART, antiretroviral therapy; NNRTI, non-nucleoside reverse transcriptase inhibitor; OI, opportunistic infection; PI, protease inhibitor. Note:
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Guideline Information and Updates
Guideline Information | |
Intended users | New York State clinicians who provide perioperative care for adults with HIV |
Last reviewed and updated | May 09, 2022 |
Lead author(s) |
Lily Yan, MD, MSc1; Tanya Ellman, MD, MSc2; Margaret McNairy, MD, MSc3 1Weill Cornell Medicine, New York City, NY |
Original publication | November 2021 |
Writing group |
Joseph P. McGowan, MD; Steven M. Fine, MD, PhD; Rona M. Vail, MD; Samuel T. Merrick, MD; Asa E. Radix, MD, MPH, PhD; Christopher J. Hoffmann, MD, MPH; Charles J. Gonzalez, MD |
Committee | |
Developer and funding |
New York State Department of Health AIDS Institute (NYSDOH AI) |
Development |
See Guideline Development and Recommendation Ratings Scheme, below. |
Peer Reviewers |
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Updates | |
May 09, 2022 |
Lily Yan, MD, MSc, with the MCCC: Added discussion of perioperative antibiotic prophylaxis, noting that the evidence suggests that use is reasonable in patients with low CD4 counts or high viral loads to decrease the chance of post-operative surgical site infections and sepsis |
November 16, 2021 |
Comprehensive update of original 2012 guideline |
Guideline Development: New York State Department of Health AIDS Institute Clinical Guidelines Program | |
Program Manager | Clinical Guidelines Program, Johns Hopkins University School of Medicine, Division of Infectious Diseases. See Program Leadership and Staff. |
Mission | To produce and disseminate evidence-based, state-of-the-art clinical practice guidelines that establish uniform standards of care for practitioners who provide prevention or treatment of HIV, viral hepatitis, other sexually transmitted infections, and substance use disorders for adults throughout New York State in the wide array of settings in which those services are delivered. |
Expert Committees | The NYSDOH AI Medical Director invites and appoints committees of clinical and public health experts from throughout New York State to ensure that the guidelines are practical, immediately applicable, and meet the needs of care providers and stakeholders in all major regions of New York State, all relevant clinical practice settings, key New York State agencies, and community service organizations. |
Committee Structure |
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Disclosure and Management of Conflicts of Interest |
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Evidence Collection and Review |
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Recommendation Development |
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Review and Approval Process |
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External Reviews |
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Update Process |
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Recommendation Ratings Scheme | |||
Strength | Quality of Evidence | ||
Rating | Definition | Rating | Definition |
A | Strong | 1 | Based on published results of at least 1 randomized clinical trial with clinical outcomes or validated laboratory endpoints. |
B | Moderate | * | Based on either a self-evident conclusion; conclusive, published, in vitro data; or well-established practice that cannot be tested because ethics would preclude a clinical trial. |
C | Optional | 2 | Based on published results of at least 1 well-designed, nonrandomized clinical trial or observational cohort study with long-term clinical outcomes. |
2† | Extrapolated from published results of well-designed studies (including nonrandomized clinical trials) conducted in populations other than those specifically addressed by a recommendation. The source(s) of the extrapolated evidence and the rationale for the extrapolation are provided in the guideline text. One example would be results of studies conducted predominantly in a subpopulation (e.g., one gender) that the committee determines to be generalizable to the population under consideration in the guideline. | ||
3 | Based on committee expert opinion, with rationale provided in the guideline text. |
References
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Cacala S. R., Mafana E., Thomson S. R., et al. Prevalence of HIV status and CD4 counts in a surgical cohort: their relationship to clinical outcome. Ann R Coll Surg Engl 2006;88(1):46-51. [PMID: 16460640]
Dominici C., Chello M. Impact of human immunodeficiency virus (HIV) infection in patients undergoing cardiac surgery: a systematic review. Rev Cardiovasc Med 2020;21(3):411-18. [PMID: 33070545]
Gahagan J. V., Halabi W. J., Nguyen V. Q., et al. Colorectal surgery in patients with HIV and AIDS: trends and outcomes over a 10-year period in the USA. J Gastrointest Surg 2016;20(6):1239-46. [PMID: 26940943]
Guild G. N., Moore T. J., Barnes W., et al. CD4 count is associated with postoperative infection in patients with orthopaedic trauma who are HIV positive. Clin Orthop Relat Res 2012;470(5):1507-12. [PMID: 22207561]
Horberg M. A., Hurley L. B., Klein D. B., et al. Surgical outcomes in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. Arch Surg 2006;141(12):1238-45. [PMID: 17178967]
Joyce M. P., Kuhar D., Brooks J. T. Notes from the field: occupationally acquired HIV infection among health care workers - United States, 1985-2013. MMWR Morb Mortal Wkly Rep 2015;63(53):1245-46. [PMID: 25577991]
King J. T., Perkal M. F., Rosenthal R. A., et al. Thirty-day postoperative mortality among individuals with HIV infection receiving antiretroviral therapy and procedure-matched, uninfected comparators. JAMA Surg 2015;150(4):343-51. [PMID: 25714794]
Lin C. A., Behrens P. H., Paiement G., et al. Metabolic factors and post-traumatic arthritis may influence the increased rate of surgical site infection in patients with human immunodeficiency virus following total hip arthroplasty. J Orthop Surg Res 2020;15(1):316. [PMID: 32787972]
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Makaram N., Russell C. D., Roberts S. B., et al. Exogenous steroid-induced hypoadrenalism in a person living with HIV caused by a drug-drug interaction between cobicistat and intrabursal triamcinolone. BMJ Case Rep 2018;11(1):e226912. [PMID: 30567264]
Malek J., Rogers R., Kufera J., et al. Venous thromboembolic disease in the HIV-infected patient. Am J Emerg Med 2011;29(3):278-82. [PMID: 20825798]
Naziri Q., Boylan M. R., Issa K., et al. Does HIV infection increase the risk of perioperative complications after THA? A nationwide database study. Clin Orthop Relat Res 2015;473(2):581-86. [PMID: 25123240]
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