AIDS first described in 1981, HIV identified in 1986.
2/3 new cases in USA associated with MSM, 24 % heterosexual transmission, 6 % IVDU.
HIV is a retrovirus (RNA virus) which binds to CD4 molecule on T lymphocytes – HIV viral RNA then replicates and is incorporated into host DNA, causing suppression of T lymphocyte CD4 count and immune suppression.
HIV has been identified in all kinds of fluids including saliva, breast milk, amniotic fluid, CSF and tears, but transmission has only been evidenced in blood, semen, vaginal secretions and breastmilk.
Falling CD4 counts corresponds to increasing risk of opportunistic infection and malignancy. RCTs have shown best outcomes with initiation of anti-retroviral therapy at diagnosis cf. waiting for falling counts.
Anti-retrovirals have significantly improved the prognosis of HIV from a terminal illness to chronic condition.
Transmission and testing
HIV is transmitted through bodily fluids – sexual contact responsible for majority.
No reported transmission in urine.
Compliance with ART, low viral load counts and absence of other STIs reduces risk of HIV transmission.
Most people who contract HIV will test positive within 2 – 6 weeks of index exposure – but can take up to 3 months to generate antibodies for positive antibody test (sero-conversion).
- Modern testing will often identify earlier but cannot definitively call negative until 3 month test.
HIV infection clinical features
Stage 1 – acute flu-like illness 2 – 4 weeks after infection – high viral load at this stage but often test negative.
Stage 2 – clinical latency – asymptomatic or chronic HIV infection with slow replication of virus, often over years
Stage 3 – AIDS – CD4 counts less than 200 cells/mm3 or AIDS-defining condition.
- Urological AIDS-defining illnesses are chronic HSV ulcers > 1 month, TB and Kaposi’s sarcoma.
Urological implications of HIV
Infectious:
- Higher risk of urinary infection with lower CD4 counts
- Usual organisms but also Salmonella and higher rates of Pseudomonas in lower UTI
- Consider atypical organisms like Candida, cryptococcus, toxoplasma, especially in upper tract infections
- Higher rates of prostatitis cf. normal population, esp if AIDS, and higher rates of progression to abscess
- Fournier’s more common
- Much higher rates of urogenital TB in those infected with HIV
- STI rates higher
- 20 % of HIV patients have genital warts / HPV – these can grow large to giant condylomata
Malignancy:
- Higher rates of seminoma, unknown mechanism
- Higher rates of penile cancer and PeIN, both HPV related and not
Voiding dysfunction:
- HIV and AIDS independent risk factor for bothersome LUTS
- Multiple potential mechanisms
- Recurrent / persistent UTI and prostatitis
- Central nervous system disturbances – HIV encephalitis, toxoplasmosis, CMV polyradiculopathy)
- Side effects of ART
- Be particularly aware of neurogenic causes of neurological infection like CMV
Other:
- Renal dysfunction can be due to both the disease and ART
- Recurrent infections, nephrotoxic medications including ART/Abx/antivirals, intrinsic HIV associated nephropathy, obstruction from infections or stones
- Increased life expectancy with HIV has revealed higher rates DM and CKD
- ED rates much higher in HIV population
- Multifactorial – neurological effects of HIV, potential organic vascular contribution, ART likely contributes including contributing to incr BMI, plus depression
- Stones
- Indinavir not often used but had very high rates of stone formation
- Other protease inhibitors less so but still may increase stone risk
- Dehydration and chronic illness and some medications may still contribute to stone risk
Operating on HIV positive patients
- As above – risk of transmission from needlestick injury 1 in 300 – 1 in 450 – and these rates in individuals not on ART. Mucus membrane exposure risk < 1 in 1000 if source not on ART.
- Assume risk even lower on ART or with low viral counts.
- Staff should be aware and follow standard precautions.
- Follow normal needlestick protocols if injury and wash wounds.
- Aust guidelines – PEP commenced if known HIV positive patient, with 2 or 3 drugs depending on viral load of source, commenced within 72 hours, continuing for 28 days.
ASHM guidelines – there has only been one case of occupational HIV transmission in the US since 1999.