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152 HIV/AIDS and the Paediatric Surgeon

Confirmation of HIV infection in babies can be difficult because 3. The patient may be referred for assistance in diagnosis of lymph
routine antibody tests may detect a maternally derived antibody that node enlargement, particularly the differentiation between lymphoma
can persist for up to 18 months in the absence of active viral disease, and tuberculosis in an HIV-infected individual.
and therefore polymerase chain reaction (PCR) testing is necessary. 23 4. The patient may present de novo with an AIDS-defining pathology,
In many countries, blood transfusion remains a hazard due to such as spontaneous rectovaginal fistula, 33,34 or neonatal CMV
inadequate screening of donors, and children requiring multiple enteritis, among others.
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transfusions of blood or blood products (e.g., haemophiliacs or
sicklers), are at particular risk. 24, 25 5. The patient may be a neonate with an emergency condition, born
In addition, a myth that HIV can be cured by having sex with young girls to an HIV-infected mother, in whom the HIV status cannot be rapidly
has increased the spread of the virus through rape and other sexual abuse. 26 determined, or may be an older child with an emergency in whom the
status cannot be determined.
Risk to Health Workers The merit of the dictum that all patients, irrespective of age or
Occupational infection with HIV is rare amongst health care workers. clinical diagnosis, should be regarded as HIV positive is clear, and
Certain categories of health workers (e.g., surgeons, dentists, and oper- “universal precautions” against needle-stick and contact with body
ating theatre staff) are at greater risk, but even following documented fluids should become routine.
needle stick injury and exposure to blood from HIV positive patients It is apparent that asymptomatic HIV-infected individuals carry no
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this risk is small. This is not to say that sensible precautions should greater surgical risk than noninfected patients, either in the general ward
not be taken. The risk of seroconversion can be minimised by postexpo- or the intensive care unit (ICU). Other than referral for subsequent
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sure prophylaxis with zidovudine. Employers are required to provide antiviral treatment no modification of surgical protocol is required.
adequate protection to employees, and all staff should be aware of the In symptomatic patients, it is important to remember that it is the
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local policy for postexposure prophylaxis and report all injuries. patient who requires treatment, not merely his surgical pathology.
Stages of the Disease Any treatment plan must be modified according to the clinical and
Like many malignant diseases the principles of management depend haematological status of the patient, but it is the clinical status of the
patient that should determine the management approach, not the patient’s
upon the stage of disease. In HIV/AIDS, the stage of disease is deter- HIV status. Patients in a poor clinical condition should not undergo
mined by CD4 counts, the percentage of the total lymphocyte count elective surgery, no matter what their HIV status. Patients who are well
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represented by CD4 cells, the viral load, and, most important, the gen- should be offered surgery as needed, no matter what their HIV status.
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eral condition of the patient. It must be remembered that children nor- Symptomatic HIV-infected patients exhibit a spectrum of clinical
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mally have higher CD4 counts than adults, but this count declines with conditions from apparently well to moribund. Generally speaking, the
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age, making absolute numbers difficult to interpret; thus, the count is least possible surgical intervention should be performed that “buys
usually expressed as a percentage of the total lymphocyte count. HIV- time” for the patient’s general condition to be improved by medical
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infected children may be identified by a low CD4 count and decreasing interventions. Surgeons have been making these determinations for
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percentage count as early as 3 months after birth. 31 generations, long before the HIV pandemic arose; however, a new
The formal diagnosis of AIDS requires the application of criteria critical factor in management decisions is the availability of antiviral
established by the World Health Organization (WHO; see Table 24.1) therapy for the patient. Untreated AIDS remains a lethal disease.
or the Centers for Disease Control and Prevention (CDC). In children, Thus, an asymptomatic HIV-infected individual with an
unfortunately, these criteria are neither precise nor predictive, and uncomplicated inguinal hernia would be a candidate for an immediate
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they are constantly being revised to include both clinical and laboratory herniotomy. A similar patient who has AIDS, severe wasting, candidiasis,
parameters. Resources for the laboratory confirmation of HIV infection encephalopathy, and any other comorbidity might be better served by a
are not universal in developing countries, however, so a clinical period of medical treatment that may include antiviral treatment.
approach is more generally useful, although difficult to quantify.
Antiviral Treatment
Table 24.1: World Health Organization temporary definition of AIDS in
developing countries (the Bangui definition). Antiviral treatment is not without hazard, which is why it should be
offered only within a structured programme that includes long-term
Major criteria Minor criteria follow-up and continued supervision. It should be remembered that
Weight loss or slow weight gain Generalised lymphadenopathy HIV treatment is lifelong; this fact must be emphasized to caregivers
Chronic diarrhoea (more than 1 Oro-pharyngeal candidiasis who tend to discontinue treatment when wellness has been achieved.
month) Repeated common infections (e.g., otitis) Failure to continue with treatment may increase the incidence of viral
Fever (more than 1 month) Persistent cough resistance to therapy, and this fear forms the basis for the strict criteria
Pruritic dermatitis with which patients must comply before starting therapy. 37
Confirmed maternal HIV infection Each of the commonly used antiviral drugs has a specific toxicity
profile, and continued surveillance for toxic effects is mandatory.
Initiation of treatment may also result in clinical deterioration due to
Surgical Approach the immune reconstitution inflammatory syndrome (IRIS). Whilst
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The paediatric surgeon may encounter HIV positive patients in a num- the exact pathogenesis of IRIS is unknown, it is clearly related to the

ber of scenarios: severity of immunosuppression at the time of the initiation of antiviral
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therapy. As the patient’s immune function is restored, the CD4
1. The patient may present with an unrelated pathology such as count rises, the viral load falls, and there is restoration of pathogen-
inguinal hernia, and may be coincidentally HIV infected. The specific immunity. This may recognise viable organisms, particularly
immediate management of the patient will depend upon the stage of tuberculosis, but also other pathogens, and in some patients an
the HIV disease.
associated inflammatory response results in rapid clinical deterioration
2. The patient may present, unaware of his or her HIV status, for and, in some cases, death. This condition was well recognised by
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management of a disorder that is likely to be HIV related, such as physicians managing patients with disseminated tuberculosis in the pre-
tuberculosis or fasciitis. Such patients should be offered serological AIDS era, but appears to be more common in HIV-infected individuals.
testing so that antiviral therapy can be provided if necessary. In HIV-infected patients with tuberculosis, it is recommended that