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INTRODUCTION

The human immunodeficiency virus (HIV) has been described as causing the worst epidemic of the 20th century with over 35 million fatalities impacting every aspect of human life globally. At the end of 2018, it was estimated that about 38 million people were living with HIV worldwide. Of these, 79% were diagnosed, 62% were on antiretroviral treatment (ART), and 53% had achieved virological suppression.1

Thirty-eight percent of patients with HIV infection worldwide and 36% in the U.S. are untreated either because they are undiagnosed or because they have not been able to access care for a variety of reasons.2

The advent and evolution of effective antiretroviral therapy has led to a stark drop in mortality attributable to HIV infection. The downstream effect of better survival has been longer life spans such that persons living with HIV are increasingly likely to need surgical interventions similar to the general population.

PREOPERATIVE EVALUATION

Special Preoperative Considerations

In the U.S. 42% of patients diagnosed with HIV infection are not retained in care2 and so have suboptimal disease control which may be accompanied by poorly controlled acute or chronic comorbidities. It is thus necessary to determine the level and stability of virological suppression and immunological recovery prior to surgery. This can be accomplished by reviewing records for recent HIV viral load, CD4 count, and adherence to follow-up. Where this is not easily available electronically, the patient’s HIV clinician should be contacted directly for current status and HIV-specific perioperative recommendations. The consultant should keep in mind that frequency and type of monitoring varies based on level of control, ranging from annual viral load monitoring for the well-controlled patient with a track record of good adherence to monthly viral loads and CD4 counts for the newly diagnosed or those with recent deterioration of virological suppression.

It is also important to recognize that noninfectious comorbidities that impact anesthetic and surgical risk occur at a higher rate and younger age than in groups without HIV. The level of comorbidity control is variable but often correlates with level of HIV infection control due to overlap in medication and follow-up adherence. Key ones to keep in mind are diabetes mellitus, adrenal insufficiency, and cardiovascular, pulmonary, and renal disease.3 This is thought to be due to chronic inflammation, immune activation, or immunosenescence. It is not clear if the aging process is accelerated or if the infection makes the comorbid conditions more likely to emerge.4 Unfavorable lifestyle variables further compound this while ART attenuates but does not eliminate it.

Preoperative risk assessment, mitigation, and optimization should follow general principles with the addition of ensuring that HIV is maximally treated. Multiple studies have showed that when medically optimized prior to surgery, postoperative outcomes are no different between patients with and without HIV infection.5,6...

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