Urologic Aspects of AIDS and HIV Infection

•       HIV : retrovirus, replicates and kills T-helper cells

•       HIV-1

•       HIV-2 : less transmitted, less virulent

•       AIDS : development of opportunistic infections, neoplasms, other life-threatening conditions resulting from immunosuppression caused by HIV infection

•       HIV transmission

•       Unprotected intercourse (semen, vaginal discharge) : men à female, circumcision decrease risk

•       Contact with blood

•       Mother to child transmission

•       Screening : anti HIV-1 and anti HIV-2 antibodies

•       Infection phase :

•       Primary infection

•       Chronic asymptomatic : slow progress à > 15 yrs (5-15 % pts)

•       Overt AIDS : rapid progress à < 5 yrs (10-20 % pts)

•       Tissue sanctuary :

•       Lymphoid system

•       Urogenital organ

•       Nervous system

TESTS TO DIAGNOSE AND MONITOR HIV INFECTION

•       History : first isolated HIV 1983, first diagnostic test marketed 1985

•       Detection :

•       2 days in lymphoid system

•       12 days in RNA HIV

•       21 days in antibody

•        Predictor of disease progress : RNA HIV viral load ↑ à treatment failure

UROLOGIC MANIFESTATIONS OF HIV INFECTION

•       Nonmalignant Conditions

•       Primary HIV Infection

•       Sexually Transmitted Infections : Herpes simplex virus (HSV), Human Papillomavirus, Syphilis, Chancroid, Urethritis, Molluscum Contagiosum.

•        HIV-Related Genitourinary Tract Infections : Renal Infections, Prostatitis, Epididymitis and Orchitis à testicular atrophy, Impetigo, Abscesses, Cellulitis, Lymphadenitis, and Necrotizing Fasciitis. Therapy : antibiotics + HAART

•       Voiding Dysfunction ß infection, obstruction, neurologic disorders

•       Urinary retention (54%)

•       Detrusor hyperreflexia (27%)

•       Outflow obstruction (18%)

•       Urolithiasis :

•       Indinavir : protease inhibitor à minimal finding in NCCT, developing at pH 7

                                   conservative : hydration, analgesics, temporary cessation of indinavir

  

•       HIV-Associated Nephropathy (10-30% on patients with HIV)

•       More common in black patients

•       Oedem, hypertension, anemia

•       Renal insufficiency

•       Massive proteinuria in the nephrotic range (>3.5 g/day)

•       Ultrasound : echogenic kidney with preserved size

•       Neoplasms

•       Kaposi’s Sarcoma : co-infection HIV + Human Herpes Virus 8

•       Non-Hodgkin Lymphoma

•       Squamous Genital Cancers

•       Testicular Cancer (seminoma)

OCCUPATIONAL RISKS FOR HIV INFECTION IN UROLOGY

•       Exposures on seroconverted worker :

•       84% percutaneous (puncture/cut injury) à needle stick injury

•       9% mucocutaneous (mucous membrane and/or skin)

•       4% both percutaneous and mucocutaneous

•       4% unknown route

•       Risk factors for occupational infection

•       deep + superficial exposure (P < .0001)

•       blood visible on the device causing the exposure (P = .0014)

•       placement of the device in a source-patient’s vein or artery (P = .0028)

•       death of the source-patient within 60 days of the exposure (P = .0011),

•       and no post exposure chemoprophylaxis with zidovudine

Interventions to Decrease Occupational Risk

•       Wounds should be washed with soap and water and then irrigated with sterile saline, a disinfectant, or other suitable solution

•       Postexposure chemoprophylaxis 

•       Severe : 3 drug regimens (zidovudine, lamivudine, other drug)

•       Lesser exposure : 2 drug regimens (zidovudine + lamivudine, or zidovudine + other drug)

•        Vaccines to Prevent HIV Infection : in progress