HIV

If you ask most people in the UK about the top three health issues in Africa, they are likely to name HIV/AIDS as one of them (and I suspect malaria and malnutrition as the other two). This is true, but with the widespread availability of HAART (highly active anti-retro viral therapy) HIV can be regarded more as a chronic disease than an immediately fatal diagnosis than most would expect. The local population in Zambia is thought to have a prevalence of HIV of around 16%. In the terminal phases of the disease, they do present with classical opportunistic diseases (certain infections and cancers have a particular affinity for people with the form of immunodeficiency seen in AIDS), but they also suffer from all the other diseases found everywhere in the world.

This means that a large number of my surgical patients have diagnosed HIV and are either on, or awaiting the start of, treatment. A significant number will also have undiagnosed HIV. Interestingly, there does not appear to be a huge stigma attached to the diagnosis of HIV here. It is a routine part of any consultation to ask about someone's HIV status or suggest they get tested (it is referred to as VCT, or voluntary counselling and testing) and they will often answer honestly despite there being other patients or relatives in earshot. Having said that, the doctors working on the medical wards, who deal with a lot of advanced HIV and related deaths, say that families are often very resistant to having HIV written on a death certificate.

The reality, or possibility of HIV infection, does render the job of surgery very different here as opposed to the UK. Firstly, we have to consider a completely different set of differential diagnoses for patients with presentations like enlarged lymph nodes or abdominal masses. These could commonly be TB, lymphoma, late-presenting abdominal or breast cancers or indeed just enlarged nodes because of HIV. Whilst doing a biopsy could be academically interesting, the lack of available treatment for most of those conditions does mean we have to have good reason for operating.

Secondly, HIV infection does affect the prognosis of other diseases. Acute infections, like osteomyelitis or soft tissue infections, are likely to be more virulent. Cancers tend to present with widespread metastases, although this may also be due to the lack of primary health care and late presentation. We recently palliated a relatively young man with advanced HIV, a blocked stomach outlet due to cancer and liver metastases. While there was an argument for inserting a feeding tube, the terminal HIV would have made it a futile gesture.

Thirdly, the impaired wound healing seen by many of these patients increase the risk of complications of routine surgery. One of the licentiates had listed a patient for examination under anaesthetic and removal of a painful haemorrhoid. On examination she had a small skin tag and very small pile, both of which I left alone as her (treated) HIV would have made post operative infection a significant risk.

Fourth, we must consider a patient's long-term prognosis when planning time-consuming treatment. Earlier this week we elected to amputate the leg of a man who we felt had a shorter prognosis from his HIV than it would have taken to repair his multiple open leg fractures using surgical fixation. He will be better off at home with an amputation than spending the last year of his life in and out of hospital with a useless leg.

Finally, we must consider the risk to ourselves. HIV can be transmitted by body fluid exposure in the course of patient care. While it will not pass through intact skin, a needlestick injury carries a 1/300 chance of catching HIV and a splash to the eye a 1/1000 risk. This can be reduced to near zero if a month's course of medication is started immediately on exposure, however for patients with unknown HIV status a very tricky risk / benefit analysis must be undertaken, as the medications are not without complications. I have not been exposed to this point, but have operated on plenty of HIV positive patients, several being extremely high risk because of their advanced disease. I have found myself examining both sets of gloves (I double glove) when I remove them for any evidence of holes. Indeed, there are instances in operations where you pick up a sharp instrument, or slip when suturing (the needles and needle holders we have aren't the best) where you have to be extremely careful. I doubt I'll completely lose that paranoia in the next few months, despite the fact that I would feel it if I was cut in the hand while operating!

Crucially, now HIV is a chronic disease, it is important to make funding available for the other, perhaps more run of the mill, diseases that people living with HIV will encounter. This was a big reason behind our cost effectiveness research, as it is very possible that somewhat neglected procedures, like hernia repairs, caesarean sections and the management of fractures, could turn out to be essential, and relatively cheap, to the health of this part of the world.