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 (see the NYSDOH guideline Comprehensive Primary Care for Adults With HIV > Box 1:
Conditions With Higher Incidence in People With HIV and Selected
Citations). 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, current guidelines recommend 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 (see the NYSDOH AI guideline Virologic and Immunologic Monitoring > Monitoring
Intervals). 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).
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 (see the NYSDOH AI guideline
When to Initiate ART, With Protocol for Rapid
Initiation). 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.
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.
