Perioperative Care in Adults With HIV

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.

RECOMMENDATIONS
Emergency and Urgent Surgery Clinicians should not delay an emergency or urgent surgical procedure to determine a patient’s CD4 count or HIV viral load. (A*) Elective Surgery: Determine HIV Clinical Status As part of the standard preoperative evaluation for patients with HIV, clinicians should review the medical record for results of an HIV viral load test within the previous 6 months and CD4 count within the previous 12 months; if one or both results are not available, the clinician should order laboratory testing to evaluate the patient’s HIV clinical status. (A3) If a patient is taking ART and has an HIV viral load <200 copies/mL and a CD4 count >200 cells/mm3, the clinician should proceed with the surgical plan as with a patient who does not have HIV [a]. (A2) If a patient’s HIV clinical status suggests an increased risk of surgical complications (e.g., unsuppressed HIV viral load or low CD4 count), the clinician should consult with an experienced HIV care provider to formulate a plan to optimize the patient’s HIV treatment and to estimate the likely timeline for improvement in HIV clinical status. (A3) Clinicians should refer patients who are not taking ART to an experienced HIV care provider who can promptly initiate ART. (A1) If optimized ART is likely to improve the patient’s clinical status within an acceptable amount of time, then the clinician should inform the patient of the benefits and any potential risks of delaying elective surgery and engage the patient in shared decision-making regarding when to proceed. (A3) If the patient chooses not to pursue a change in HIV treatment or the benefit of surgery will be compromised by waiting, the clinician should explain the potential surgical risks associated with immunosuppression and uncontrolled viremia and engage the patient in shared decision-making regarding when to proceed with elective surgery. (A3) Continue HIV Medications Clinicians should consult with an experienced HIV care provider before interrupting a patient’s ART during the pre- and postoperative period if interruption cannot be avoided. (A1) Clinicians should consult with an experienced HIV care provider before interrupting a patient’s treatment or prophylaxis for OIs if interruption cannot be avoided. (A3) Evaluate for Potential Drug-Drug Interactions Clinicians should evaluate potential drug-drug interactions with any surgery-associated medications, with particular attention to drug-drug interactions with PIs, NNRTIs, and boosters such as ritonavir or cobicistat. (A*)
Abbreviations: ART, antiretroviral therapy; NNRTI, non-nucleoside reverse transcriptase inhibitor; OI, opportunistic infection; PI, protease inhibitor. Note: Patients who are taking ART and have had an undetectable HIV viral load for many years may have incomplete immune reconstitution and a low CD4 count. In this circumstance, delaying surgery is unlikely to lead to CD4 count recovery.

KEY POINTS

The risk of HIV transmission from patient to healthcare worker during surgical procedures is extremely low; from 1985 to 1999, 2 surgical technicians and no surgeons reported occupational HIV transmission to the Centers for Disease Control and Prevention, with none since 1999 Joyce et al. 2015. When performing surgery on patients with HIV, clinicians should employ standard universal surgical precautions to prevent exposure to blood and bodily fluids. If exposure to the blood or body fluids of a patient with HIV occurs, follow standard institutional protocols and consult the NYSDOH AI guideline PEP to Prevent HIV Infection.

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

In individuals with controlled HIV and higher CD4 counts, the risk of surgical complications and postoperative mortality is approximately the same as in individuals without HIV.

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.

RESOURCES: HIV DRUG-DRUG INTERACTIONS

NYSDOH AI resource ART Drug-Drug Interactions University of Liverpool HIV Drug Interactions Prescribers Digital Reference U.S. Department of Health and Human Services Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents Living With HIV

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: PERIOPERATIVE CARE IN ADULTS WITH HIV
Emergency and Urgent Surgery Clinicians should not delay an emergency or urgent surgical procedure to determine a patient’s CD4 count or HIV viral load. (A*) Elective Surgery: Determine HIV Clinical Status As part of the standard preoperative evaluation for patients with HIV, clinicians should review the medical record for results of an HIV viral load test within the previous 6 months and CD4 count within the previous 12 months; if one or both results are not available, the clinician should order laboratory testing to evaluate the patient’s HIV clinical status. (A3) If a patient is taking ART and has an HIV viral load <200 copies/mL and a CD4 count >200 cells/mm3, the clinician should proceed with the surgical plan as with a patient who does not have HIV [a]. (A2) If a patient’s HIV clinical status suggests an increased risk of surgical complications (e.g., unsuppressed HIV viral load or low CD4 count), the clinician should consult with an experienced HIV care provider to formulate a plan to optimize the patient’s HIV treatment and to estimate the likely timeline for improvement in HIV clinical status. (A3) Clinicians should refer patients who are not taking ART to an experienced HIV care provider who can promptly initiate ART. (A1) If optimized ART is likely to improve the patient’s clinical status within an acceptable amount of time, then the clinician should inform the patient of the benefits and any potential risks of delaying elective surgery and engage the patient in shared decision-making regarding when to proceed. (A3) If the patient chooses not to pursue a change in HIV treatment or the benefit of surgery will be compromised by waiting, the clinician should explain the potential surgical risks associated with immunosuppression and uncontrolled viremia and engage the patient in shared decision-making regarding when to proceed with elective surgery. (A3) Continue HIV Medications Clinicians should consult with an experienced HIV care provider before interrupting a patient’s ART during the pre- and postoperative period if interruption cannot be avoided. (A1) Clinicians should consult with an experienced HIV care provider before interrupting a patient’s treatment or prophylaxis for OIs if interruption cannot be avoided. (A3) Evaluate for Potential Drug-Drug Interactions Clinicians should evaluate potential drug-drug interactions with any surgery-associated medications, with particular attention to drug-drug interactions with PIs, NNRTIs, and boosters such as ritonavir or cobicistat. (A*)
Abbreviations: ART, antiretroviral therapy; NNRTI, non-nucleoside reverse transcriptase inhibitor; OI, opportunistic infection; PI, protease inhibitor. Note: Patients who are taking ART and have had an undetectable HIV viral load for many years may have incomplete immune reconstitution and a low CD4 count. In this circumstance, delaying surgery is unlikely to lead to CD4 count recovery.

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 2Weill Cornell Medicine, New York City, NY 3Weill 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	Medical Care Criteria 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	Michelle S. Cespedes, MD, MS, Icahn School of Medicine at Mount Sinai Susan Olender, MD, MSc, New York-Presbyterian/Columbia University Irving Medical Center
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

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