Surgeons championing the cause of treating people living with HIV

Despite evidence to prevent occupational exposure to HIV for surgeons and other healthcare providers, people living with HIV (PLHIV) requiring surgical procedures for treatment often face heightened stigma and get discriminated within healthcare settings. But all is not that black and there are surgeons who have championed the cause of treating PLHIV without stigma and challenged discrimination in healthcare settings as well. Few of these surgeon-heroes were sharing their experiences of over 20 years in treating PLHIV at the 6th National Conference of AIDS Society of India (ASICON 2013).

Dr Keki Turel, a senior neurosurgeon at Department of Neurosurgery, Bombay Hospital Institute of Medical Sciences, had performed his first surgery on a PLHIV in August 1989. The HIV-positive patient was referred to Dr Turel by Dr Maniar and Dr Saple, two noted HIV physicians in India. This patient was of 17 years and due to advancing diseases, weighed only 17 kgs. She was working in Kamathipura, a sex work area in Mumbai, and clinically had full-blown AIDS. Her CT scan showed post-TB meningitis hydrocephalous (collection of fluid in the brain). Best way to relieve the pressure in the brain was by placing a stent. Dr Turel performed this surgery successfully in JJ Hospital in August 1989. All disposable items used in this operation were made of plastic and clothes used for the operation were burnt, said Dr Turel.

Recollecting the experience 24 years back, Dr Turel said that she was given a bed in one corner of the ward. Very few doctors or nurses or other healthcare providers wanted to attend to her with a majority of them staying away. Dr Maniar had established an AIDS Ward in GT Hospital where this patient stayed for over 5 years with dignity.

Dr Turel’s did his second surgery on a HIV-positive patient in September 1990. This patient had meningitis and brain abscess. But Bombay Hospital refused to let this surgery take place in its operation theatre to avoid getting branded as a hospital for PLHIV. Such was the stigma that blocked access to healthcare for PLHIV in one of the most progressive cities of India (Mumbai!). So this patient was transferred to JJ Hospital were Dr Turel had earlier operated upon a PLHIV too. But this time AIDS-related stigma was lurking in JJ Hospital too where all of the 8 anaesthetists who were on duty declined. They gave reasons for declining this surgery on health grounds such as diarrhoea, diabetes, a cut in their hand, etc. The Dean of JJ Hospital called upon Dr Turel to persuade him not to go ahead with this surgery as it poses a HIV transmission risk for other team members too. This Dean only receded when Dr Turel insisted to go ahead with the surgery unless the Dean gives a written order not allowing Dr Turel to do this surgery (this order never came so Dr Turel could go ahead with this surgery). Finally by 9pm the same day, a young anaesthetist who was not on duty that day came forward to help Dr Turel do this successful neurosurgery on a HIV-positive patient.

Surgeons who plan treatment of PLHIV must weigh the risk to the patient against the potential benefits of surgery. Dr Turel shared arguments put forth by doctors who are avoiding to treat PLHIV such as: ‘surgeons have a right to choose if they want to treat PLHIV’ or ‘it is a traditional right of doctors to decline to treat certain patient as long as prompt referral to another doctor is made’ or ‘surgeons also have a responsibility to protect themselves, their families, and their co-workers against occupationally-acquired illnesses’. Dr Turel said that health professionals who are privileged to be members of the surgical team have a professional responsibility to provide the highest possible quality of care for their patients, including PLHIV.  “Let’s do what is right for everyone,” said Dr Turel.

“Surgery in HIV patients has become common place today. No need for any eyeballs to be raised” said Dr Turel.

Dr Turel said that there are four methods to prevent perioperative HIV transmission.
1) Infection control
2) Changes in surgical techniques
3) Mandatory HIV preoperative testing of the patient
4) Non-operative treatment of HIV infected patients

The World Health Organization (WHO) advisory for the protection of the surgical and other healthcare providers from occupational exposure to HIV suggest the following:
-    Quarantine the operation theatre
-    Restrict movements of personal engaged in surgery within the confines of this operation theatre until the procedure is over
-    Protect all personnel with disposable boot leggings, gown, cap, mask, goggles and two gloves - second glove should be half-size more than the first (comprehensive HIV kit should be available for everyone inside operation theatre)
-    Carefully and separately dispose-off (incinerate) all non-metallic materials used in surgery
-    Clean the floor of operation theatre and walls with antiseptics and soda-bi-carb

New guidelines of US Public Health Service have refined the approach to protect healthcare workers who get exposed to HIV on the job. Healthcare personnel who are exposed to HIV in the workplace should immediately begin post-exposure prophylaxis (PEP) with at least 3 antiretroviral (ARV) medicines to prevent HIV infection.

Dr Gaurang Shah, a senior Urologist at JJ Hospital is another champion surgeon who has sensitively and humanely treated PLHIV in-need. Dr Shah said that urological needs are often very common in PLHIV with sexually transmitted infections (STIs) which lead to urogenital diseases (commonest being stricture urethera). Also exposure to blood at times is very high in endo-urological surgeries “where up to 30 litres of blood-stained fluid drains over the operating urologist.”

Dr Shah said that “a urological or renal surgeon who sustains 3 percutaneous injuries over 12 months and does not take PEP after each injury has 1 in 2,000,000 annual risk of HIV transmission. But the same risk for general surgeons, gynaecologists, obstetricians, ENT surgeons among others is lower at 1 in 200,000. If we administer PEP after each injury then it will reduce the HIV transmission risk to 1 in 10,000,000.”

Dr Shah said that “disposable materials used in urological surgeries are very costly. Also endourology instruments require thorough sterilization to prevent infection to other patients.” Some hospitals have a policy to allow surgery in PLHIV at the very last in the operation theatre. This practice needs to stop because half-hour fumigation (or cleaning with hydrochloride solution) of operation theatre table is all what is required to make it ready for next surgery.

Kidney transplants have been accepted in PLHIV with no difference in transplant outcomes if compared to HIV-negative patients, said Dr Shah. “Take out the ‘H’ out of ‘THREAT’ and just TREAT” said Dr Shah.

Dr Ravi Pendkar, a senior cardiothoracic surgeon, is another champion surgeon who has been at the forefront of relieving PLHIV in-need. “When every PLHIV has a right to antiretroviral therapy (ART) then they also have a right to access other healthcare needs such as cardiothoracic care needs. Once a patient is on ART then HIV transmission rates are negligible. These patients should not be denied treatment” said Dr Pendkar. Dr Pendkar has successfully done many open heart surgeries too on PLHIVs.

Bobby Ramakant, Citizen News Service - CNS
December 2013