Guidelines For Selecting HIV Positive Patients For Genital Reconstructive Surgery

by Sheila Kirk, MD

Citation: Kirk S., M.D. (1999) Guidelines For Selecting HIV Positive Patients For Genital Reconstructive Surgery. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/kirk.htm

• Introduction
• Guidelines
• Contacts with the Primary Physician
• Evaluation of Transferred Medical History
• Analysis of Lab Data
• Our own personal experience
• Conclusion
• Bibliography
    

Introduction
Surgery is often thought of in two distinctly different contexts—surgical procedures that are indicated and surgery that is designated as elective. Indicated surgery carries inherent in it the concept of a need, based on emergency or urgency, and is an approach to a cure or that which has capacity to restore to health or as close to it as possible. Elective procedures in surgery particularly in some specialties have not so vigorous a need and may even have a need that can be delayed or put off indefinitely. Urgency is not something associated with the word elective.

When we apply the words "indicated" and "elective" to the transgender community, particularly the transsexual person, we could draw argument from a number of people. Transsexuals both male-to-female and female-to-male will refuse to accept the term elective. For them it is never elective but always indicated. And in many respects they are correct. Genital Reconstruction Surgery (GRS) to accomplish congruity between mind, spirit and body, between identity and anatomy is truly indicated in my view as well, but not so in the opinion of many professionals. Many caretakers think of it as an option and not a necessity. This concept is quite different from the opinions of surgery-seeking transsexuals. Fixing one’s nose or jaw, reshaping the torso or the hairline could much more probably be considered elective in most individuals’ thinking including my own. I raise these points in consideration of the transsexual because there are a percentage of transsexual individuals who are in an area of ill health that is particularly grave. I refer to the transsexual who is a very apt candidate for genital reconstructive surgery from a psychologic standpoint but who is HIV positive. While I believe them to have a place in the indicated surgical patient group and not belonging to an elective surgical group, they do have an underlying health concern that needs to be looked at importantly, with not only great consideration and planning but with the cooperative effort and expertise of a number of professionals.

There is very little in the surgical literature about transgendered persons who are HIV positive having genital reassignment. One has to read surgical reports of non-transgendered HIV positive individuals having surgery and usually surgery performed for emergency or urgency reason. Hence guidelines for pre-operative assessment of the HIV positive trans person are not discussed in the literature to any extent. It is very important to establish some criteria even at the risk of my being somewhat academic. It’s important to establish a pre-operative protocol because I’m aware of two deeply concerning ideas that are somewhat evident in some surgeon’s view. First, the opinion of many is that HIV positive patients are to be considered just the same as anyone else hence special precaution with selection of procedure, allowing heavy acute blood loss, management of intra-operative and post-operative infection, are no more a consideration than for anyone else. In my view, that can be a dangerous idea. HIV positive patients deserve to be treated as normal it’s true. But they can’t be altogether because of the nature of the virus they carry and its potential for serious consequence. The second practice many surgeons have has to do with discontinuance of anti-retroviral therapy before surgery and the casual and often delayed return to the therapeutic regimen that was in use before the procedure. This is an observed practice of some surgeons who performed surgery of various kinds for HIV positive individuals. It came to my attention while serving in a large HIV medical practice. The nature of the medical regimen is often ignored with no realization that some anti-retrovirals can’t be discontinued for more than a day or two for fear of viral strain resistance i.e. Crixivan (Indinivir Sulfate^1,2). This basic ignorance in these two areas leads one to believe that other nuances and refinements in readying a patient for a three to four hour procedure such as a vaginoplasty for a male-to-female individual, are not known. In addition, while post-reassignment convalescence can be most often uncomplicated, the threat of pulmonary, operative site, and urinary tract infections exists even more so in this population. These individuals if not stable and well-controlled in their HIV status are very susceptible and can develop serious post-operative complications. With that thought in mind, it is important to consider some guidelines that should be a part of the pre-operative evaluation of the HIV infected transsexual. The gathering of information about an HIV infected patient can be somewhat involved but it harkens back to a very important concept that must never be forgotten in surgery. Pre-operative selection and preparation has very great influence on surgical outcome. When we are dealing with patients who have excellent reason for having their surgery but don’t have to rush to it until they are properly assessed and prepared-—the concept becomes even more cogent.
  

1. Contact with primary physician caring for patient’s HIV Disease
2. Evaluation of medical history of the disease in the patient
3. Evaluation of lab data
4. Evaluation of most recent treatment regimen and the patient’s response

Contacts with the Primary Physician
Identifying the medical physician who cares for the HIV patient seeking genital reconstruction is most important. In-depth conversation with this professional is vital. That doctor can trace the history of this patient’s infection giving important information about opportunistic illness, infections, other sexually transmitted diseases and sarcoma, treatment plans that have failed and that have been replaced and those that have been effective. He or she can give important information about recent laboratory data and in the process of information exchange give insight into the patient’s reliability to keep appointments, follow instructions in treatment regimens and very important—insight into behavioral changes that lead to good health practices. It’s a striking phenomena that develops sometimes when patients exercise denial of their disorder and stop treatment or when their use of alcohol and other organ damaging substances continues and/or gets worse. It’s particularly upsetting to observe patients take a new lover who is also HIV positive and then abandon not only safe sexual practice but even the anti-retroviral regimens that have been so effective, believing nothing more can take place to worsen this or any other disease process. (Patients can develop new strains of virus resistant to the previously successful regimen just cohabiting with someone infected with different strains, when neither uses safe sexual practices.⁶). This health care provider is essential in the circle of care to be established before a surgical date is determined. After that initial conversation is established others will follow and requests should be made for transfer of records at least for the past year and if possible for years before if there is need.
  

Evaluation of Transferred Medical History
Upon receipt of medical records, which should include both office and relevant hospital records, the task to evaluate can become difficult yet it must be thorough! Pertinent information must include the following:

• The time interval since diagnosis was first made to the present with pertinent medical/surgical events detailed.
• The kinds of infection experienced in that time. Modes of treatment along with levels of response and success in treatment are most necessary.
• Details of hospitalizations with diagnosis of illnesses, treatment and response
• Anti-retroviral regimens in the past. Their success or failure as indicated by patient’s health status and lab data in those time periods must be included.
• Details of current anti-retroviral regimen; how long in place, viral loads and CD4 counts with this particular regimen.
• A review of CD4 counts and viral load counts for the past 6 months to a year is helpful to the evaluation of the patient.
• Details about other systems involvement i.e. central nervous system, liver function, as well as eye or pulmonary dysfunction or infections.⁴
• What other medications are in use? How effective are they? Is the patient on antibiotic prophylaxis, psychotropic medication, androgens, marinol, etc.?
• What is the level of activity this patient is engaged in daily, employed or not, in therapy, engaged in volunteer work, etc.?

Analysis of Lab Data
Looking at liver and kidney function testing for the past year and to the present time is very helpful. Subtle trends can be seen and any patient demonstrating even gradual failure in these systems may not be a candidate for Genital Reconstruction Surgery. Special liver and kidney studies may be indicated including needle biopsy and if there is a history of alcohol abuse and/or hepatitis, these studies are mandatory.

A detailed evaluation of CD4/CD8 cells is most important as an indicator of T cell resilience and capacity to return to acceptable levels. Has the patient had inability to maintain red blood cell counts and proper indices in different regimens? What has been the response to treatment? What is the current viral load? Is there a positive trend? Is it in the undetectable range i.e. below 400 copies, and with refined viral measurement technique, what is the actual count below 400? Have viral loads been effectively lowered with change in anti-retroviral medication in the past and if so for how long?^3,4 What anti-retrovirals have been used in the natural history of the infection in a particular patient and with what success for the patient’s quality of health and longevity of life. One may need a full year of laboratory studies to formulate a pattern for patient stability.
  

Our own personal experience
The author is a surgeon in a surgical center known as the Transgender Surgical and Medical Care Center (TSMC) located in Pittsburgh, Pennsylvania and is administrator for the center as well. To date, TSMC has performed Genital Reassignment Surgery for 5 HIV positive male-to-female transsexuals. In addition to genital reassignment, one of the group had breast augmentation as well. None had facial cosmetic surgery. The series is small, without doubt, but experience with them has served strongly to formulate our evaluative policy for this very deserving portion of our T patient caseload. We have followed the guidelines outlined to the letter and this very carefully observed policy has led to completely uncomplicated intra-operative experience and particularly a complication free post-operative course both in the acute as well as the intermediate post-operative period. None of our patients have received blood or developed infection. Our plan though detailed is a simple one. It means being meticulous and willing to exchange with the health care provider who is actively managing the patient applying to us. Our goal was to determine that these patients experienced stability, good health and acceptable laboratory values before surgery for a significant period of time. Their CD4 cells had to be at least 200 cell/mm and preferably 300 or more. Viral loads had to be 400 copies/ml. or below and these studies had to be at these levels for at least 3 months on the current anti-retroviral regimen. These patients demonstrated excellent liver and kidney function for at least a year and in that year opportunistic disease did not occur or if so was perhaps no more than mild herpes simplex or zoster outbreaks. Our first patient is now about 9 months post-operative—very well and very stable in her disease. The others report good stable health patterns although more time will be necessary for adequate follow-up.

One of our very important approaches was to re-institute the pre-operative anti-retroviral regimen as quickly as possible after surgery. The last pre-operative dosage is given about four hours before the usual morning administration time and well before the surgical start time. The next dosage is given with no more delay than six hours after the usual midday or late in the daytime dose. Regimens currently are three-drug therapy requiring specific times for taking each day. Some drugs are once a day regimens facilitating the continuance of the therapy. On the day of surgery after the procedure, the medical physician "at home," responsible for HIV care is called and given report. Another report is made to that doctor within 48 hours. There is a highly skilled team of HIV specialists in the city of Pittsburgh, with whom the author of this paper practiced for 2 years, who can be consulted, should there be additional need. Our hope is not to ever have that need.

We ask our patients to bring their own medication, the entire daily regimen and most importantly the antiviral medications. Once they are judged able to begin taking their own medications, we entrust them to re-institute the program of self-medication as determined by their "at-home" medical doctor. Our nursing staff generally doesn’t administer except for one or two occasions after the operation although they keep track to be sure the patient has not omitted any part of the regimen. By allowing our patients to begin to self-administer their medication regimen again quickly encourages them to take responsibility for their wellness and well being. ⁶
  

Conclusion
Because a patient is HIV positive the door need not be closed to possibility of bringing congruency through genital surgery to a transsexual. Even surgery for facial or body contouring could be considered at some later time in our continued experience, though not at this time.⁷ The word "elective" is not an appropriate one, in our view, when considering the needs of the transperson for candidacy in our surgical center. What is appropriate is thoroughness in evaluation and to be as assured as can be possible that the surgical candidate will not suffer increased harm due to their HIV disease if human endeavor can in any way prevent it. Heretofore, surgeons performing surgery for the transsexual have eliminated the HIV positive person from consideration. This should not be so. Granted not all will be candidates but thoughtful selection can be applied and can change some individual’s crushed dreams to quality living and fulfillment.

At the Harry Benjamin International Gender Dysphoria Associations’s symposium held in Vancouver in September 1997, members endorsed a policy that favored surgery for the HIV- infected transsexual. No guidelines were formulated then or since. Our hope is that the precepts outlined in this paper will fortify that policy and help GRS surgeons consider this special population for the treatment and care they deserve.

ã 1998 Sheila Kirk, MD

Bibliography

1. Personal Communication Merck an Co. Pharmaceuticals, Research Division Director
2. Personal Communication DuPont Pharmaceuticals, Research Director
3. Mellor JW et al, Plasma viral load and CD4 lymphocytes as prognostic markers of HIV-1 infection. Ann Intern Med. 1997;126;946-94
4. Changes in Plasma HIV-1 RNA and CD4 Lymphocyte Counts and the Risk of Progression to AIDS, O’Brien WA et al, N Engl J. Med. 1996; 334:426-431
5. O’Brien WA et al. Changes in plasma HIV-1 RNA and CD4 lymphocyte Counts and the Risk of Progression to AIDS, N Engl J. Med. 1996;334:426-431.
6. Condra JH et al. In vivo emergence of HIV-1 variants resistant to multiple protease inhibitors. Nature. 1995;374:569-571
7. Rhinoplasty, a part of gender confirming surgery in Male Transsexuals. Basic considerations and clinical experience, Hage JJ et al, Ann Plast Surg. 1997;Sept 39 (3) 266-71