The Surgeon and HIV Infection

Educational disclaimer. This article is for clinician and student education. It is not medical advice, does not establish a clinician-patient relationship, and does not replace individualized assessment by a licensed physician or an infectious disease specialist. Drug regimens, exposure response, and screening recommendations evolve; consult the current versions of the U.S. Department of Health and Human Services (DHHS) Adult and Adolescent ARV Guidelines, U.S. Public Health Service occupational PEP guidance, U.S. Centers for Disease Control and Prevention (CDC) HIV Nexus resources, and the relevant national society guidance before clinical decision-making.

Introduction

Human immunodeficiency virus (HIV) is a retrovirus that selectively depletes CD4+ T lymphocytes, producing progressive immunodeficiency if untreated. HIV is transmitted through sexual contact, sharing of injection equipment, transfusion of infected blood and blood products, organ transplantation, vertical (perinatal) exposure, and percutaneous or mucosal exposure to infected body fluids (CDC HIV Basics).

Populations most affected in the United States include men who have sex with men, people who inject drugs, transgender women, Black and Hispanic/Latino communities, people in custodial settings, infants exposed perinatally, and sexual partners of people with HIV (CDC HIV Surveillance). Person-first language (“people with HIV,” “men who have sex with men,” “people who inject drugs”) is now the professional standard and replaces older labels such as “high-risk groups” and “AIDS patients” (HIV.gov Stigma Language Guide).

Surgeons and other health care personnel may encounter HIV in the operating room, the emergency department, and inpatient services. With modern antiretroviral therapy (ART), HIV is a chronic, manageable condition rather than a uniformly fatal illness, and most surgical patients with HIV who are virally suppressed have outcomes comparable to those without HIV (Marcus et al., JAMA Network Open 2020; DHHS Adult and Adolescent ARV Guidelines). Ethical, legal, and infection-control questions raised by the case presented are instructive and are discussed below.

Case report

One year, 11 months old SK was brought to hospital by her mother. The child’s history was three weeks of fever, poor appetite, diarrhoea, cough and cold. Of significance in her antenatal history was that her mother had been transfused one unit of blood. She had no other relevant history. On examination the child was found to have an apathetic facies, papules over the trunk and limbs, generalized lymphadenopathy, oral thrush and pale mucous membranes. She was malnourished with sparse, discolored hair. Her weight-for-age was less than 60% of normal and weight-for-height was 66% of normal. She was tachypnoeic with bilateral basal pulmonary crackles and had hepatosplenomegaly. Her haemoglobin concentration was 6 gm/dL, and white blood cell count 16×10⁹/L. Chest x-ray showed nodular opacities over both lung fields but her Mantoux test was negative. A cervical lymph node was biopsied and this showed reactive hyperplasia. Liver biopsy showed changes of non-specific hepatitis. Subsequently her ELISA was found to be strongly positive. The patient remained afebrile but failed to thrive despite appropriate nutritional therapy. Auscultation of the chest showed an increase in the area of distribution of crackles and repeat chest x-ray showed progression of the pulmonary nodular opacification. Open left lung biopsy via an anterolateral thoracotomy was performed. Lung biopsy showed pulmonary lymphoid hyperplasia consistent with the lymphocytic interstitial pulmonary complex. The patient was therefore placed and maintained on prednisolone. Out-patient follow-up was undertaken by a pediatrician.

Evidenced considerations

This child on presentation with this clinical picture is screened with a pediatric HIV diagnostic algorithm: HIV-1/2 antigen/antibody immunoassay confirmed by an HIV-1/HIV-2 antibody differentiation assay, with reflex HIV-1 RNA testing for indeterminate results or suspected acute infection. In infants under 18 months, maternal antibodies cross the placenta, so diagnosis is made with HIV nucleic acid testing (DNA or RNA) at defined time points (CDC Quick Reference Guide: HIV Laboratory Testing Algorithm; DHHS Perinatal HIV Guidelines). The child’s mother would also be tested, and the transfusion source investigated. Lymphocytic interstitial pneumonitis (LIP) remains a recognized AIDS-defining condition in children, but the priority shift in 2026 is rapid initiation of combination ART, which often leads to substantial improvement in pulmonary disease and growth (DHHS Pediatric ARV Guidelines; WHO Consolidated Guidelines on HIV 2021, updated 2024). Lung biopsy is rarely required when the clinical and radiologic picture is consistent and other infections are excluded. Residual transfusion-transmitted HIV risk in screened blood supplies is now approximately 1 in 1.5–2 million units in resource-rich settings owing to nucleic acid testing of donations (AABB / FDA Blood Supply Safety).

Discussion

1. Diagnosis, staging, and the current testing algorithm

Acute HIV infection is often clinically silent or presents as a nonspecific viral syndrome with fever, lymphadenopathy, pharyngitis, and rash; suspicion should be high in any febrile illness with relevant exposure history (DHHS Adult and Adolescent ARV Guidelines, Acute HIV Infection).

The current laboratory diagnostic algorithm for adults and adolescents, established by the CDC and the Association of Public Health Laboratories (APHL) in 2014 and updated, is:

  1. Fourth-generation HIV-1/2 antigen/antibody combination immunoassay as the initial test, capable of detecting infection earlier than older antibody-only tests because it detects p24 antigen.
  2. HIV-1/HIV-2 antibody differentiation immunoassay for confirmation and to distinguish HIV-1 from HIV-2.
  3. HIV-1 nucleic acid (RNA) test as a reflex when the differentiation assay is negative or indeterminate, to identify acute infection.

The historical ELISA-plus-Western-blot algorithm has been retired (CDC/APHL Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations). Rapid fourth-generation point-of-care tests are widely available and useful in emergency departments, labor and delivery, and operating room settings (CDC HIV Testing for HCP; Branson et al. updated guidance and reviews).

Staging now follows the 2014 CDC HIV surveillance case definition, which uses CD4 count or CD4 percentage to assign Stage 0 (acute infection), Stage 1, Stage 2, Stage 3 (AIDS), or Stage Unknown, and a list of Stage 3-defining opportunistic illnesses without the age cut-offs that appeared in the 1987 definition (for example, the under-60 age limit for Kaposi sarcoma and primary CNS lymphoma was removed) (CDC. Revised Surveillance Case Definition for HIV Infection — United States, 2014. MMWR 2014;63(RR-03):1–10). The older Groups I–IV classification used in the original article has been superseded.

A confirmed diagnosis is communicated to the patient with prompt linkage to HIV care, partner-services referral, and offer of rapid ART initiation, often on the same day as diagnosis (DHHS Adult and Adolescent ARV Guidelines, Rapid ART; IAS-USA 2024 Recommendations, Gandhi et al., JAMA).

2. Prognosis, ART, and U=U

The original claim that AIDS carries 100% mortality with no current cure no longer reflects clinical reality. Combination ART has transformed HIV into a chronic, manageable condition. Adults who start ART promptly and remain virally suppressed have life expectancy approaching that of HIV-negative peers (Marcus et al., JAMA Network Open 2020; DHHS Adult and Adolescent ARV Guidelines).

ART is recommended for all people with HIV regardless of CD4 count. Preferred initial regimens are integrase strand transfer inhibitor (INSTI)–based, typically bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) or dolutegravir-based regimens, with two-drug options such as dolutegravir/lamivudine for selected patients, and long-acting injectable cabotegravir + rilpivirine as a maintenance option in eligible adults (DHHS Adult and Adolescent ARV Guidelines, What to Start; IAS-USA 2024 Recommendations, Gandhi et al., JAMA; BHIVA Treatment Guidelines 2025 Interim Update; EACS Guidelines v13.0, 2025).

A central public health concept is Undetectable = Untransmittable (U=U): a person with HIV who achieves and maintains a sustained undetectable viral load on ART cannot sexually transmit HIV to partners. This is endorsed by the CDC and major international bodies and has direct implications for both patient counseling and occupational risk assessment (CDC U=U Resource Guide, 2024; DHHS Adult and Adolescent ARV Guidelines).

3. Routine HIV screening

In the United States, the U.S. Preventive Services Task Force recommends routine opt-out HIV screening for all adolescents and adults aged 15–65 (Grade A), and screening of all pregnant persons at every pregnancy (USPSTF, HIV Screening). The CDC similarly recommends opt-out screening of patients aged 13–64 in health care settings (CDC HIV Screening Recommendations; WHO Consolidated Guidelines on HIV Testing Services, 2024). The original article’s selective testing of “high-risk” surgical patients has been replaced by universal opt-out screening with patient notification, but a surgeon may still identify and recommend testing for individual patients whose history suggests recent exposure or undiagnosed acute infection. HIV testing of a patient must remain voluntary and confidential; mandatory preoperative testing for the surgeon’s protection alone is not supported by major guidelines, because infection control depends on Standard Precautions applied to every patient, not on knowing each patient’s status (CDC Standard Precautions).

4. Protecting patients: blood supply, organ donors, and the surgeon’s role

The residual risk of transfusion-transmitted HIV in jurisdictions with nucleic acid testing of donations is approximately 1 in 1.5–2 million units (AABB / FDA Blood Supply Safety). Modern blood banks combine donor risk-history questionnaires (now using individual donor assessment in many countries, including the United States), serologic testing, and nucleic acid amplification testing of donations. Solid organ and tissue donors are likewise screened, and HIV is no longer an absolute contraindication for organ donation under the HOPE Act, which authorizes transplantation of organs from donors with HIV into recipients with HIV under research and increasingly under standard-of-care protocols (U.S. HOPE Act Final Rule, HRSA).

The surgeon’s role in protecting patients is no longer focused on “informing patients of HIV-positive status”. Current guidance from the Society for Healthcare Epidemiology of America (SHEA) and the American College of Surgeons (ACS) is that a surgeon with HIV who maintains an undetectable plasma HIV RNA and complies with an expert review panel‘s oversight may perform the full range of procedures, including exposure-prone procedures, without routine prospective disclosure of HIV status to patients. Disclosure is required only in defined circumstances, for example after a documented exposure incident (SHEA Guideline for Management of Healthcare Personnel with HIV, HBV, or HCV, Henderson et al. 2020; American College of Surgeons Statement on the Surgeon and HIV Infection). The historical recommendations that HIV-positive surgeons should refrain from pelvic and orthopaedic procedures are not consistent with current evidence on transmission risk from suppressed health care workers.

5. Protecting the surgical team: Standard Precautions and engineering controls

The term Universal Precautions has been superseded by Standard Precautions since 1996, broadened to include all body fluids regardless of whether blood is visible and to address mucous membrane and non-intact skin exposure, hand hygiene, respiratory hygiene/cough etiquette, safe injection practices, and use of personal protective equipment based on anticipated exposure (CDC Standard Precautions for All Patient Care; CDC HICPAC Guideline to Prevent Transmission of Pathogens, 2024 draft; OSHA Bloodborne Pathogens Standard, 29 CFR 1910.1030). The earlier concept of targeted precautions based on perceived risk group is no longer endorsed because perceived risk identifies HIV status unreliably and reinforces stigma.

Surgical-site engineering controls and safer-sharps practices for which there is good evidence include:

These controls apply to all patients as Standard Precautions, not selectively. A pregnant surgeon, junior trainee, or volunteer is not required to be excluded from an operation simply because the patient has HIV; assignment decisions should be based on institutional policy, anticipated exposure risk, and the trainee’s competence, with engineering controls available to all.

6. Occupational exposure: immediate steps and current post-exposure prophylaxis

When percutaneous, mucous-membrane, or non-intact-skin exposure to potentially infectious body fluid occurs, the response is:

  1. Immediate site care: wash percutaneous wounds with soap and water; flush mucous membranes and eyes with copious water or sterile saline. Do not apply caustic agents or attempt to “squeeze” wounds aggressively.
  2. Report to the institution’s occupational health or designated exposure service immediately for risk assessment and source-patient evaluation. Document the device involved, depth and type of injury, fluid involved, and source patient’s known viral load and ART status if available.
  3. Source-patient testing, ideally with a rapid fourth-generation HIV antigen/antibody test, with consent under local law. In many jurisdictions, expedited testing of a source patient is permitted in occupational exposure scenarios.
  4. Risk-based initiation of HIV post-exposure prophylaxis (PEP) as soon as possible, ideally within hours and not later than 72 hours from exposure.

Current U.S. Public Health Service recommendation (Kuhar et al., 2025) is a three-drug regimen of:

  • Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) or dolutegravir plus tenofovir disoproxil fumarate/emtricitabine (or TAF/FTC), for 28 days.
  • Follow-up HIV testing at baseline and at 12 weeks post-exposure using a fourth-generation antigen/antibody assay (which generally permits discontinuation of follow-up earlier than the 6-month schedules used previously).
  • Shared decision-making about whether to start or continue PEP when the source patient is known to be on suppressive ART with a documented undetectable viral load.

Zidovudine (AZT) monotherapy is no longer appropriate (Kuhar DT, et al. Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis, 2025. Infection Control & Hospital Epidemiology; CDC HIV Nexus, Post-Exposure Prophylaxis Clinical Guidance). Hepatitis B and hepatitis C status of both the exposed worker and the source patient must also be assessed, with appropriate vaccination, immune globulin, or treatment according to current CDC guidelines.

Counseling addresses adherence, common side effects, drug interactions, behavioral precautions during the follow-up window (safer sex, avoidance of blood donation, breast-feeding considerations), and psychological support. Reporting to institutional infection control and (where applicable) state occupational health authorities is required under OSHA’s bloodborne pathogen standard (OSHA 29 CFR 1910.1030).

7. The duty to treat

Refusing to provide indicated medical or surgical care to a patient solely because that patient has HIV is unethical and, in many jurisdictions, unlawful as disability-based discrimination (American Medical Association, Code of Medical Ethics Opinion 8.4; U.S. Department of Justice, ADA and HIV). The duty to treat is reinforced by the World Medical Association and national bodies including the General Medical Council (UK) and the College of Physicians and Surgeons of the relevant Canadian province (WMA Statement on HIV/AIDS and the Medical Profession).

Pelvic, orthopaedic, and emergency surgery do not present “excessive risk”. Therefore, there is no reason to limit treatment of patients with HIV. Documented occupational HIV seroconversion among surgeons is rare, especially with Standard Precautions, engineering controls, and modern PEP. Similarly, it is professionally unethical for a pregnant surgeon to “forego treatment” of a patient because of fetal risk. Institutions provide engineering controls, reasonable accommodations, and case-by-case risk assessment in line with occupational health and disability law. Reasonable limits on a surgeon’s obligation still apply when an intervention is medically futile or when the procedure would offer no net benefit to the patient, but these limits are framed by clinical judgment about the patient’s condition, not by the patient’s HIV status.

8. Surgical procedures and outcomes

The majority of operations in people with HIV today are general surgical and trauma procedures unrelated to HIV — appendicitis, cholecystitis, hernia repair, oncologic resections, fracture fixation, obstetric procedures — and outcomes for virally suppressed patients are similar to those in patients without HIV after controlling for comorbidities (systematic reviews and recent cohort analyses summarized in DHHS Adult and Adolescent ARV Guidelines). HIV status alone is not a contraindication to indicated elective surgery.

Diagnostic procedures historically performed during the AIDS era — open lung biopsy and broad lymph-node biopsy — have largely been replaced by:

  • High-resolution chest CT plus bronchoalveolar lavage and molecular diagnostics for opportunistic pulmonary infection (for example, Pneumocystis jirovecii, renamed in 2002 from P. carinii) (CDC Pneumocystis jirovecii Pneumonia).
  • Image-guided percutaneous biopsy of lymph nodes or masses where tissue is required.
  • Anorectal screening with high-resolution anoscopy for anal high-grade squamous intraepithelial lesions in people with HIV, given elevated anal cancer risk; the ANCHOR trial demonstrated that treatment of anal HSIL reduces progression to anal cancer in people with HIV, and the National Cancer Institute and ASCCP have updated screening guidance accordingly (Palefsky et al., ANCHOR trial, N Engl J Med 2022; International Anal Neoplasia Society Consensus Guidelines).
  • Endoscopy with biopsy for suspected opportunistic gastrointestinal infections or malignancy.

Indications for splenectomy in ART-naïve immune thrombocytopenia have largely been displaced by ART initiation (which often resolves HIV-associated thrombocytopenia) and by current second-line ITP therapies such as thrombopoietin-receptor agonists; splenectomy is reserved for refractory cases per general ITP guidelines, not as HIV-specific therapy (American Society of Hematology ITP Guidelines, 2019, with subsequent updates; DHHS Opportunistic Infections Guidelines).

Operative decision-making for a person with advanced HIV who is not yet on ART, with a high opportunistic infection burden, still requires individualized assessment of life expectancy, anesthetic risk, and goals of care, in coordination with infectious disease, hematology/oncology, and palliative care.

9. Prevention beyond the operating room: PrEP and population strategy

Surgeons may not prescribe HIV pre-exposure prophylaxis (PrEP), but should be aware of and able to refer for it. PrEP options include daily oral emtricitabine/tenofovir disoproxil fumarate, daily oral emtricitabine/tenofovir alafenamide for selected groups, and long-acting injectable cabotegravir, each with USPSTF Grade A or strong CDC/IAS-USA endpoint recommendations (USPSTF PrEP Recommendation, Grade A; CDC PrEP Clinical Practice Guideline 2021/2023 Update; IAS-USA 2024 Recommendations). For non-occupational post-exposure prophylaxis (nPEP) after sexual or injection-drug exposure, the same urgency and regimens as occupational PEP generally apply (CDC nPEP Guidance).

Conclusion

Surgeons now work in a clinical landscape transformed by antiretroviral therapy: HIV is a chronic condition, viral suppression prevents sexual transmission (U=U), routine opt-out screening identifies most undiagnosed infections, modern post-exposure prophylaxis is highly effective when initiated rapidly, and engineering controls in the operating room substantially reduce occupational risk. The duty to treat is unambiguous and reinforced by professional, statutory, and human-rights frameworks. The surgeon’s task is to provide care of the highest standard to every patient — including patients with HIV and patients with unknown HIV status — while applying Standard Precautions to all, supporting safer-sharps engineering, ensuring access to rapid PEP, and respecting the dignity, confidentiality, and rights of patients and colleagues with HIV.

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