Human Immunodeficiency Virus Infection (HIV)

Two very different patients share one diagnosis - Ask for the most recent CD4 count, the viral load, and the ART regimen. Suppressed virus with CD4 above 500 means you plan around the surgery, not the HIV. CD4 under 200 means opportunistic infection, malignancy, and organ dysfunction are all live possibilities. If no CD4 is available, the CBC differential substitutes: an absolute lymphocyte count below 950 cells/mm³ suggests a CD4 under 200.

Continue the antiretrovirals - ART is lifelong therapy and interrupting it risks resistance and viral rebound. Keep it running through the perioperative period. If the patient cannot take it orally, get pharmacy and infectious disease involved rather than simply holding it.

Protease inhibitors and boosters inhibit CYP3A4 - Ritonavir and cobicistat are added to regimens specifically as pharmacokinetic enhancers, and protease inhibitors are potent CYP3A4 inhibitors — enough that buprenorphine levels rise measurably in patients taking them. Assume anything you give that depends on 3A4 for clearance will run higher and longer. Read the regimen against your drug list before induction, not after.

Cardiovascular disease is the main killer now - With ART, cardiovascular disease has overtaken opportunistic infection as the leading cause of death in HIV, and it is unclear whether the driver is the virus, the drugs, or an associated metabolic syndrome. Work it up on merit: history of chest pain, dyspnea, or exertional fatigue, a baseline ECG, and echocardiography when the exam or history points at valvular or pericardial disease. Do not discount ischemic symptoms because the patient is young.

Pericardial disease and tamponade - Purulent pericarditis and tamponade from Mycobacterium tuberculosis are AIDS-related possibilities. Hypotension with jugular venous distension and muffled heart sounds in a patient with advanced disease is Beck's triad — get an echo before you induce, not after.

Pulmonary reserve - HIV predisposes to upper respiratory infection and bronchitis even without AIDS, and to Kaposi sarcoma, non-Hodgkin lymphoma, sarcoidosis, lung cancer, and emphysema. Watch the work of breathing and auscultate before induction; get a chest radiograph when the history points at a pulmonary process. Anyone with signs suggesting tuberculosis goes into respiratory isolation before the confirmatory test returns.

Cytopenias are common - Anemia, thrombocytopenia, and leukopenia come from both the virus and the marrow toxicity of ART and prophylactic drugs. Get a CBC — the platelet count decides the neuraxial conversation and the hemoglobin decides the transfusion plan.

Peripheral neuropathy is the most common neurologic complication - Distal sensory polyneuropathy, mononeuritis multiplex, progressive polyradiculopathy, and autonomic neuropathy all occur, and advancing age, obesity, and diabetes add to the risk. Document the pre-existing deficit in the record before any block or any position that could later be blamed for it, and pad accordingly.

New neurology needs imaging before a needle - Meningitis, focal demyelinating lesions, and primary CNS lymphoma present as headache, altered mental status, focal weakness, or seizures. In advanced disease, a head CT comes before lumbar puncture or a neuraxial technique. On fundoscopy, fluffy white perivascular lesions with surrounding hemorrhage are CMV retinitis.

Hepatic and pancreatic drug injury - ART causes pancreatitis, hepatic steatosis, and hepatotoxicity, and co-infection with hepatitis B or C is common. Send LFTs and a lipase when the history fits, and dose hepatically cleared drugs against what comes back. Patients with lower CD4 counts are also prone to acalculous cholecystitis.

Renal function and tenofovir - Tenofovir-based regimens are the ones to watch renally; check a creatinine and avoid stacking nephrotoxins in the same anesthetic. Tenofovir disoproxil fumarate is also associated with reduced bone mineral density, which is worth a thought when you position and pad.

Needlestick math - A single percutaneous stick from an HIV-positive source carries roughly 0.3% transmission risk, higher with a large-bore hollow needle, a deeper injury, a high source viral titer, or a source who recently seroconverted. Gloves cut the inoculated viral load by more than half. Report it immediately — the CDC algorithm decides whether post-exposure antiretrovirals start, and they are time-sensitive.

PrEP is a medication like any other - Patients on pre-exposure prophylaxis are taking the same drug classes, most often tenofovir-based. No anesthetic agent is contraindicated, and current evidence supports continuing PrEP perioperatively. Ask about it neutrally alongside other medications and in a private setting, because it only helps you if the patient actually discloses it.

Human immunodeficiency virus (HIV) is an enveloped RNA retrovirus that binds CD4 plus a chemokine co-receptor (CCR5 or CXCR4), reverse-transcribes its genome into host DNA, and destroys CD4 T lymphocytes. Untreated, the CD4 count falls roughly 50 to 80 cells/µL per year and faster once it drops below 200. A CD4 under 200 or an AIDS-defining illness marks acquired immunodeficiency syndrome (AIDS), and with it opportunistic infection and malignancy.

Antiretroviral therapy (ART) has changed the patient you actually meet in the holding area. Someone with a suppressed viral load and a CD4 over 500 has close to normal life expectancy, and cardiovascular disease — not opportunistic infection — is now the leading cause of morbidity and mortality. What remains for anesthesia is a chronic multisystem disease plus a drug regimen with real interaction potential.