STANDARD OPERATION PROCEDURE (SOP) TREATMENT OF HIV / AIDS, WHEN DO SURGERY
HIV infection is a viral infection that progressively destroys white blood cells and causes AIDS (Acquired Immunodeficiency Syndrome). (10) AIDS was first discovered in 1981. (1)
Transmission of HIV infection from mother to child is a major cause of HIV infection in children under 15 years of age. Since HIV became pandemic in the world, an estimated 5.1 million children in the world are infected with HIV. Most of the patients are infected through mother-to-child transmission. Each year, an estimated more than 800,000 infants become infected with HIV as a result of transmission from mother to child. And followed a child about 610,000 deaths from the virus. (10)
In Indonesia, according to PPM and PL DG Health Department recorded 3568 cases of HIV / AIDS at the end of December 2002. There were 20 children with HIV infection were infected mothers. Research conducted by Yayasan Pelita Science and obstetrics section Faculty of medicine / RSCM during the 1999-2001 examination on 558 pregnant women in poor areas in Jakarta, showed as many as 16 people (2.86%) suffering from HIV infection. (10)
Women often acquired HIV infection through heterosexual relations with an infected partner or through the use of drugs, increasing HIV infection in children is due to a result of transmission during perinatal (the period of pregnancy, during and after childbirth). Perinatal HIV transmission is a major cause of pediatric AIDS mother - mothers who transmitted HIV is usually good and have a number of CD 4 T lymphocytes are normal and do not know if they are infected with HIV. More than 90% of AIDS in children were reported in 1994 occurred due to transmission from mothers to children. (10)
Transmission to the baby can occur during pregnancy, labor or postnatally through breast milk. The incidence of mother-to-child transmission is estimated at 20% - 30%. Transmission of HIV to the fetus if no intervention is reported to range between 155-45%. (10)
The risk of transmission in developing countries about 21% - 43%, higher than the risk of transmission in developed countries about 14% -26%. Transmission can occurs during pregnancy, intrapartum, and postpartum. Highest risk of infection transmission occurs during labor by 18%, in the content of 6% and 4% postpartum.
Definition and Etiology
HIV infection is a viral infection that progressively destroys white blood cells and causes AIDS (Acquired Immunodeficiency Syndrome). There are 2 types of the virus that causes AIDS, namely HIV-1 and HIV-2.
HIV-1 is most prevalent in the west, Europe, Asia and Central Africa, South and East. HIV-1 infects mainly CD4 + T lymphocytes. Discharging CD4 + lymphocytes cause immunodeficiency. (1), (2) HIV-2 is primarily found in West Africa. (1)
Once infected, a person may look and feel healthy up to ten years or more before signs of AIDS appear. However, at this time the blood test can show the presence of HIV. This is referred to as "HIV positive" people who are HIV positive despite the look and feel healthy, can spread it to others. (5)
AIDS is a fatal disease which is an advanced stage of HIV infection. Infection with HIV usually results in damage to the immune system progressively, leading to opportunistic infections and certain cancers (especially in adults).
People who have HIV or AIDS called PLWHA (People Living with HIV / AIDS).
• By doing vaginal, anal, or oral sex unprotected with people who are HIV positive.
• By using shared needles or syringes with an HIV positive person.
• During pregnancy, birth, or breastfeeding, or from an infected mother to her baby. (5)
Body fluids from an infected person who has HIV is:
3. Vaginal Fluid
4. Mother's Milk (5)
HIV is not transmitted through casual contact or close contact of a sexual nature that are not at work, school or at home.
Has never been reported cases of HIV transmission through coughing or sneezing of people and through mosquito bites. Transmission from a doctor or dentist who infected the pasennya also very rare.
HIV is a human retrovirus that included sub lentivirinae family. Retrovirus containing inner capsid composed of protein structure referenced in size. Major structural protein, p24, was detected in the serum of patients infected with high loads. (2)
Infection to occur, the virus must enter the cell, in this case the white blood cells called lymphocytes. Viral genetic material is inserted into the DNA of infected cells. Inside the cell, the virus multiply and eventually destroy the cell and release of new viral particles. The new virus particles then infect other lymphocytes and destroy it. (8)
Viruses attach to lymphocytes have a receptor protein called CD4, which is present in the outer membrane.
The cells that have CD4 receptors are usually called cells or CD4 + T helper lymphocytes.
T helper lymphocyte activating and regulate other cells of the immune system (eg B lymphocytes, macrophages and cytotoxic T lymphocytes), all of which help destroy malignant cells and foreign organisms.
HIV infection destroys helper T lymphocytes, causing weakness in the body's system to protect themselves against infection and cancer.
A person infected with HIV will lose helper T lymphocytes through 3 stages for several months or years:
1. Healthy person has a CD4 lymphocyte count as much as 800-1300 cells / mL of blood. In the first few months after infection with HIV, the numbers decreased by 40-50%. During these months the patient could transmit HIV to others because many virus particles present in the blood. Although the body tries to fight the virus, but the body is not able to relieve the infection.
2. After about 6 months, the number of virus particles in the blood reached a stable level, which is different in every patient. The destruction of CD4 + cells and the spread of disease to others continues.
High levels of viral particles and CD4 + lymphocyte levels were low assist physicians in determining people at high risk of suffering from AIDS.
3. 1-2 years before the onset of AIDS, CD4 + lymphocyte count is usually decreased dramatically. If the level reaches 200 cells / mL of blood, the patient becomes susceptible to infection. (8)
HIV infection also causes interference with the function of B lymphocytes (lymphocytes that produce antibodies) and often leads to excessive production of antibodies. These antibodies are mainly directed against HIV and infections experienced by patients, but these antibodies are not much help in the fight against various opportunistic infections in AIDS. At the same time, the destruction of CD4 + lymphocytes by virus leads to reduced ability of the immune system to recognize organisms and new targets should be attacked.
A. Effect of HIV in pregnant women
Pregnant women who are HIV positive can pass to the fetus or baby. However, the risk can be minimized. Having children is something every couple. But when his wife, who turned out to contain HIV positive, they must be prepared for the possibility the baby is infected. In pregnancy, HIV does not cause abnormal 'congenital'. However, there is a trend of failure risk of pregnancy, such as miscarriage, increases. the possibility that spontaneous abortion may occur due to other comorbidities, or because the pregnancy has caused HIV to become more progressive way, both early and advanced stage of HIV disease (4)
Transmission of HIV from mother to the fetus is called vertical transmission. But pregnant women with HIV, not 100% passing the virus to their fetuses, therefore, as a result she does not think to immediately terminate the pregnancy. That, most importantly, the mother should pay attention to diet and regularly during their pregnancy. The possibility of having other infections must be avoided. Because immune mothers with HIV are very low. When exposed to infection, such as flu, may be more severe than the common cold. A lot of rest, and avoid disease transmission around it. (9) In women who are infected with HIV, the virus was found in 21% of vaginal fluid. Maternal disease state will also be considered for HIV-infected mothers have a higher risk of death from non-breast-feeding.
Risk of HIV-infected women, 2-4 times greater than men. Because:
• The surface of the female genitals larger than males. The possibility of infection through semen during intercourse, greater.
• The concentration of HIV in semen is higher than the concentration in vaginal fluid. In fact, spermalah into the woman's body during intercourse.
• Women bear the risks of anal sex (which should not be done) which damages the anus. Viruspun into the body.
Both men and women can be infected with both HIV and other STIs, many of whom gave serious consequences and the long term, especially for women for example, inflammatory pelvic disease, tubal pregnancy / ectopic, sterility. (5)
Women are at greater risk of contracting STIs than men as more likely to get HIV or STDs from one sexual exposure. Women can have a difficult asinptomatik STIs diagnosed, but increases the risk of HIV. Women often are not on the beneficiaries on sexual negotiation and the object of sexual violence. (5)
The patient may show symptoms of HIV infection within a few years prior to the infection or tumor which is typical for AIDS. Symptoms - symptoms of AIDS from HIV infection itself, as well as opportunistic infections and cancers.
Symptoms - symptoms:
• Swollen Lymph Nodes
• Weight loss
• intermittent fever
• Feeling unwell
• Diarrhea recurrent
• Thrush (yeast infection in the mouth) (8)
Some opportunistic infections and cancers are characteristic of the emergence of AIDS:
Candida yeast overgrowth in the mouth, vagina or esophagus, usually an infection that first appears.
Recurrent vaginal yeast infections are often difficult to treat early symptoms of HIV in women. But this kind of infection can also occur in healthy women due to various factors such as birth control pills, antibiotics and hormonal changes.
2. Pneumonia pneumokistik. Fungus Pneumocystis carinii pneumonia is an opportunistic infection that is often repeated in patients with AIDS.
The infection is often a serious opportunistic infection first appears and before it found the treatment and prevention, a common cause of death in patients with HIV infection
Chronic infection by Toxoplasma often since childhood, but the symptoms only occur in a small group of people with AIDS.
If there pengaktivan back, then Toxoplasma can cause severe infections, particularly in the brain.
Tuberculosis in patients with HIV infection, is more common and more deadly.
Mycobacteria other types of Mycobacterium avium, is a cause of the onset of fever, weight loss and diarrhea in patients with advanced tuberculosis. Tuberculosis can be treated and prevented with anti-tuberculosis drugs commonly used.
5. Gastrointestinal infections. Gastrointestinal infection by the parasite Cryptosporidium is often found in people with AIDS. These parasites may be obtained from food or water contaminated. Symptoms include diarrhea, abdominal pain and weight loss.
6. Progressive multifocal Leukoensefalopati. Progressive multifocal Leukoensefalopati is a viral infection of the brain that can affect the neurological function of the patient. Initial symptoms usually an arm or leg strength loss and loss of coordination or balance.
In a few days or weeks, the patient was unable to walk and stand and usually a few months later the patient will die.
7. Infection by cytomegalovirus. Repeat infections tend to occur at an advanced stage and often attack the retina of the eye, causing blindness.
Treatment with anti-viral drugs to control cytomegalovirus.
8. Kaposi's sarcoma. Kaposi's sarcoma is a tumor that is not painful, red to purple, a prominent patches on the skin.
These tumors are particularly common in homosexual men.
It may also happen lymph node cancer (lymphoma), which first appeared in the brain or internal organs. Women with AIDS tend to develop cervical cancer. Homosexual men are also susceptible to cancer of the rectum. (8)
B. Effect of HIV on the Fetus and Newborn
Estimates medicine or HIV transmission process has been going on since the baby in the womb, through placenta. However, the greatest risk of transmission occurs during labor and after childbirth. This is because the virus thrives in areas barkembang Vagina. At birth the baby has a close contact with the vagina as the path is born. Blood ejected during labor would be the baby's body. "If there is injury to the baby, the virus (from the mother's blood can enter through wounds.) After the birth of any baby could still be infected with HIV. Via breast milk. (1) (2) (3) (9) To that mothers with HIV are advised not to give milk, because the HIV virus is also present in breast milk (3), to reduce the risk of transmission from mother to child when safe alternatives are available, accessible, and acceptable.
Not easy to make sure babies are born infected with HIV or not. Only be known after the 18 month old child. (9) Babies who are infected can not be recognized clinically until there is severe or chronic problems to arise. Common symptoms are common in children are prolonged diarrhea, infection or fever often have long, growing fungus in the mouth, the more body lean and continuous weight loss.
The initial clinical signs include diarrhea can be mild and long (> 1 month), oral kanidiasis protracted, lymphadenopathy, hepatomegaly, or a decrease in the growth rate. Otitis media is often repeated mild clinical signs. At the next level of severity, the patient may present with severe life-threatening infections, including pneumonia or septicemia. Chronic Sinusitis in infants can merupkan main sign of immune dysfunction. (2)
Acute clinical signs caused by virulent organisms limfopeni in patients with HIV-infected CD4 + 1 is referred to as opportunistic infections "determinants of AIDS". Opportunistic infections are the most frequent and deadly is pneumonia P. carini (PPC). Clinical signs such as severe respiratory imfeksi with cough, tachypnea, dyspnea, and hypoxemia with blood gas pointing towards the alveolar capillary blockade (eg inflammation interstisil). Rontenogram chest showed diffuse bilateral pneumonitis with dafragma flat. Diagnosis is confirmed by bronchoscopy and bronchoalveolar washings with staining for cysts and trophozoites. Lactate levels also rose. (2)
Infants and children are infected most often suffer Hipergammaglobulinemia (> 1.750 g / L) with high levels of anti-HIV-1 antibody. It could also be anemia (<8g/dL), neutropenia (<1000/mm3) and thrombocytopenia (<100.000/mm3). (2)
Detection of HIV-1 antibody is highly sensitive and specific. However, maternal IgG in infants tranplasenta obscure use of antibody screening to diagnosis except in older children and adolescents. Maternal IgG has a half-life of 20-28 days and in most infants infected with HIV -1 humoral response develops at the age of 4-6 months. After 6 months, the antibody can be detected by immunosorbent assay. (1), (2) The number of CD4 + less than 200U / L can also be a diagnosis for AIDS (1).
Direct detection of viral proteins or nucleic acids are less sensitive but very specific. If available, recommended untukm direct detection or confirmation of diagnosis. The most sensitive test is a PCR for the detection of nucleic acid sequences and direct virus isolation (culture) from peripheral blood. (2) (3) Sensitivity of PCR and virus isolation will increase sharply when performed at 1 week old baby who is not breastfed. In infants aged 1 month sensitivity of PCR and viral culture bias reaches 90% even more. (3) Assay of protein p-24 is less sensitive but fast and easily available, especially in the State without the facility for PCR testing and viral culture. To confirm the diagnosis, positive results from two blood samples with one or a combination of tests (PCR, culture or p-24 test). (3)
Anti-retroviral drugs to pregnant women chosen to serve to prevent transmission from mother to child. The drugs that have proven effective include ZDV (zidovudine), ZDV/3TC (Lamivudine), and NVP (Nevirapine). (6) ZDV empirically, is a drug with the highest efficacy and safe for both mother and fetus. Therefore, if possible, a first-line option for pregnant women including ZDV. (1) (2) (6) Combination ZDV/3TC is the first choice for pregnant women, with a dose of ZDV, 100 mg, 5 times daily, (1) starting at 14-34 mg gestation and continued throughout pregnancy. (1) Anti- retroviral drugs for pregnant women should be continued during labor, usually fixed using a combination of therapies. (1) (6) NFV (Nelfinavir) is well tolerated by pregnant women and is the drug of first choice from among PI (protease inhibitor) for pregnant women. 2x1250mg doses per day resulted in drug levels in the blood are sufficient. (6)
Women in the first trimester of pregnancy may consider delaying therapy until the age of 10-12 weeks of pregnancy because of potential teratogenic ART (anti-retroviral). Usually non-emergency treatment needs. But if the woman is ill PLWHA, given as early as possible therapeutic benefits are greater than the theoretical risk for fetusnya, especially if treatment begins with medications that have been reported empirically safety for pregnancy (such as ZDV, 3TC, NVP or NFV). (6)
Prevention of Opportunistic Infections
We can provide Hepatitis B vaccination, influenza and pneumonia. If CD4 + under 200/uL, prophylaxis for P carinii pneumonia is recommended for granted, namely sulfamethoxazole-trimethoprim DS (1 tablet daily) or Pentamidine aerosol. (1)
Prevention of HIV transmission to infants
Prevention may be a provision of antiretroviral (ART), delivery by SC (Sectio cesarian), and delaying breastfeeding. (1) The Anti retroviral therapy typically use a combination of (ZDV/3TC) (1). According to the study, the anti-retroviral drugs should be given at 14 weeks of pregnancy. However, other studies merekomondasikan to 8 weeks of pregnancy. With Anti retroviral, the possibility of transmission can be reduced about 8-15 percent. (9)
The process of cesarean delivery / also thought to reduce the risk of transmission. In the process the baby does not 'direct contact' with the birth canal (vagina). Nor is there likely aids infant injured in childbirth. Even if the treatment according to the mother of taking anti-retroviral drugs and gave birth to a cesarean, the possibility of HIV transmission can be reduced to 1%.
Given a C-section is expensive and can not reach people in remote areas, usually the doctor will 'eradicate' HIV from the birth canal. Prior vaginal delivery the nesting virus, cleaned with antiseptic, every 6 or 8 hours. (1) (3) (9)
PLWHA women are breastfeeding should avoid to reduce the risk of transmission from mother to child when safe alternatives are available, accessible, and acceptable. But the alternative of safe breast milk substitutes are often not available in resource-limited countries. In such conditions, it is recommended that breast milk exclusively for the first 6 months of baby's life. Women who require ART and are breast-feeding should continue ARTnya regimen. But the efficacy of antiretroviral therapy to prevent post natal transmission through breast milk is unknown. (6)
CONCLUSIONS AND RECOMMENDATIONS
• HIV infection due to HIV-1 or HIV-2. It can be transmitted from mother to baby.
• Transmission of HIV can be through a variety of ways, the most important is through body fluids. The most common is through sexual intercourse.
• Transmission of the HIV virus in infants can occur during pregnancy, during delivery and after delivery.
• HIV infection will be severe when it develops into AIDS, dangerous for both mother and baby. Because it will lower the immune system, making it susceptible to various diseases and opportunistic infections.
• Therapy for the treatment of HIV infection and AIDS can get by using a variety of anti-retroviral drugs such as zidovudine and others.
• Hepatitis B vaccination as recommended and the other to be given to infants, especially to prevent opportunistic infections.
• Prevention by using ART, SC or by delaying breastfeeding, should be performed in women who have or are at risk of HIV infection.
• treatment during surgery for people with HIV / AIDS need special handling.
• Should be done for HIV screening in couples who are getting married, although these tests are expensive and taboo thing to do.
• Prevention of HIV infection should be taken to prevent transmission to the baby, with no contact with people with HIV / AIDS can be sexual intercourse, blood transfusion, needle exchange and the other related to the patient's body fluids.
• Women who have HIV should use ART to prevent transmission to their babies.
• Do also counseling for mothers with HIV / AIDS about the dangers of HIV / AIDS on herself and her baby.
• People with HIV / AIDS should not we stay away and isolate, because HIV / AIDS is not transmitted through social contact.
• Management of HIV / AIDS in pregnancy and after childbirth requires approaches and cooperation from various parties as well as possible.
• The management of medical, obstetric and pediatric good will hopefully bring down maternal and infant mortality rates of HIV / AIDS.
• When performing surgery on people with HIV / AIDS by using a standard glass eyes wide and meetings. Double surgical gloves and blunt suture needles yng (blunt)
1. Cunningham F.G.; Obstetri Williams. 21st edition. Chapter 57, “Sexually Transmitted Diseases.”
2. Nelson Ilmu Kesehatan Anak Vol. 2. edisi 15 (cetakan 1 2000) : oleh Behrman, Kliegman, Arvin.
3. Catherine Peckham, M.D. and Diana Gibb, M.D. “Mother to child transmission of the human immunodeficiency virus”. www.nejm.org.
4. HIV berpengaruh terhadap kesuburan. www. Suara Merdeka.com.
5. Mempelajari pencegahan HIV dan isu - isu perubahan perilaku. www. Certi.org.
6. Tata laksana ODHA wanita. www.aids-rspiss.com.
7. Komisi penanggulangan AIDS. “Terapi HIV/AIDS semakin memberi harapan”. www.aids-rspiss.com dan www.aidsI ndonesia.or.id
8. Infeksi HIV. www.medicastore.com
9. “AIDS dan kehamilan”. Tabloid Ibu dan Anak.