**1.3 General principles of antiretroviral therapy**

Antiretroviral therapy (ARVT) was introduced in the early nineties with the aim to act against the multiplication of the HIV and therefore, to stop the destruction of the CD4 lymphocytes and subsequent immune depression. The drugs are numerous, but have been considered based on their action into 3 main classes which are: antiproteasis, nucleoside inhibitor of reverse transcriptases and non nucleoside inhibitor of reverse transcriptase. Into the middle of the decade, it clearly appeared that none of these classes could solely stop the viral replication and that, in the contrary, the triple combination was efficient. Shortly after, the common presentation became a triple antiretroviral fixed combination drugs commonly named TRITHERAPY.

There are two most common combinations that are: Efavirenz, Zidovudine and Lamivudine into one hand, and on the other hand, Niverapine, Stadivudine and Lamivudine. In case of drug resistance, a second line combination of Indinavir, Zidovudine and Lamivudine is proposed. The first line treatment, which is commonly used, has shown that besides few sides effects seen at the beginning of the treatment, that combination is usually well tolerated thereafter and it is efficient. In a large majority of patients the CD4 level will rise above 500/ML after weeks to months and the virus will be undetectable in the peripheral blood, making them significantly less contagious to their sexual partners. Many institutions in our country give drugs only to severely immune depressed carriers defined as AIDS patients. Moderately immune depressed and non immune depressed carriers are not treated. Therefore, it remained a question weather this policy does not favor the spreading of the disease through the world? Anyway, whenever an arhtroplasty is demanded by a HIV carrier, a different protocol of ARVT should be associated.

### **1.4 Antiretroviral therapy in HIV carriers demanding arthroplasty**

Finally, 5 types of HIV carriers have been considered among arthroplasty demanders; they may need a similar number of protocols regarding ARVT.


Arthroplasty in HIV/SCD Carriers 489

4. A2 patients should start the ARVT and the arthroplasty delayed when they cross the

5. A3 patient should first be treated for their opportunist disease and later on managed

With these measures, we think that the results of arthroplasty in HIV carriers should be

YES NO YES

YES NO YES

Definition ARVT? PABT? PPABT?

B1 HIV +, under ARVT YES YES NO B2 HIV+, CD4>500 NO YES NO A1 HIV+, 300<CD4<500 YES NO YES

Table 1. Summarizing the use of ARVT, PABT, & PPABT in the five type HIV carriers

SCD is a chronic hemolytic hemoglobinopathy that is genetically transmitted. During a crisis, red blood cells become sickle-shaped increasing blood viscosity, slowing blood flow, and consequently plugging small blood vessels creating widespread thromboembolic tissue

This genetic disease which is the most frequent genetic disease in black people, is also the most common cause of femoral head necrosis in them. In fact, SCD touches up to 0·74% of the births in sub-Saharan Africa, while this number is 10-20 times less in Europe and North America. In Nigeria, an estimated 45,000 to 90,000 babies are born each year with SCD. The African blacks are the main victims but the disease is also distributed in the south of Italy, Greece, Turkey, the Arabian Gulf, especially Saudi Arabia, and the Indian subcontinent. In the United States SCD occurs in approximately 1 out of every 500 African American births. People in the USA with sickle-cell disease number 90,000 of which 80,000 are black and 10,000 are Hispanic. The state with the highest sickle-cell population was New York with 8000, followed by Florida with 7500, and Texas with 6700 people with SCD. FLOUZAT-LACHANIETTE et al. report a series of SCD patients developing secondary avascular

300 line in their CD4 count; the surgery should be protected by a PPABT.

as A2.

comparable to HIV seronegative counterparts.

A2 HIV+, CD4<300 no

demanders of arthroplasty

Section B summary

infarction.

Definition & history of SCD

**2.1 Definition & history of SCD** 

Diagnosis and classification of SCD

A3 HIV+,CD4<300 & some

**2. Section B: Arthroplasty in SCD carriers** 

opportunist infection-

opportunist infection

Physiopathology of SCD & related secondary avascular necrosis

Work-up and management of SCD systemic acute complications

according to the protocol of their physicians. Into our own practice, they will be operated with no ARVT and will be placed on treatment only if the CD4 count fall below 500/ML during the follow-up. After they have started with ARVT, they will continue it forever.


In all the cases, prophylactic antibiotic therapy should also be considered.

### **1.5 Prophylactic antibiotic therapy in HIV carriers undergoing arthroplasty**

The aim of classical **prophylactic antibiotic therapy** (**PATB**) is to keep the surgical site under antibiotic protection during the short period of decrease immune response around the perioperative period. This period, which is less than 72 hours in a normal individual, may be prolonged in cases of immune depressed HIV carriers. Our previous study has shown that there is no significant difference in rates of post-operative infections between immune depressed and non immune depressed patients when we extend **PATB** to 10 ten days ,what we call **prolonged prophylactic antibiotherapy**, (**PPATB)** as one would expect. Although there were only few cases of arthroplasty in this serie. Finally, as far as arthroplasty demanders are concerned, two different regiments of prophylactic antibiotic therapy are to be considered, that is:


### **1.6 Section A summary**

Finally, combined protective measures of HIV carriers demanding atrhroplasty may be summarized as follow ( table I), depending of their classification:


3. Type **A1** patients, (HIV carriers with 300 to 499 CD4 lymphocytes/ML), as they are moderately immune depressed, should be placed on ARVT shortly after the CD4 count results and they should undergo surgery without delay. Although it is not recommend by the official policy, we believe that they do need treatment before they undergo major

5. Type **A3** arthroplasty demanders (HIV carriers with less than 300 CD4 lymphocytes/ML, but with an opportunistic disease) are first treated for their opportunistic disease, various prophylaxes, ARVT and the surgery postponed as above.

The aim of classical **prophylactic antibiotic therapy** (**PATB**) is to keep the surgical site under antibiotic protection during the short period of decrease immune response around the perioperative period. This period, which is less than 72 hours in a normal individual, may be prolonged in cases of immune depressed HIV carriers. Our previous study has shown that there is no significant difference in rates of post-operative infections between immune depressed and non immune depressed patients when we extend **PATB** to 10 ten days ,what we call **prolonged prophylactic antibiotherapy**, (**PPATB)** as one would expect. Although there were only few cases of arthroplasty in this serie. Finally, as far as arthroplasty demanders are concerned, two different regiments of prophylactic antibiotic therapy are to

1. The classical regiment of PATB with intravenous cefuroxime (or any other second generation cephalosporin); 1.5g at the anesthesia induction, followed by 750 mg every 12h within not more than 72 hours. This is indicated for class B arthroplasty demanders. 2. The extended regiment of **PPATB** into which the above regiment is maintained during

Finally, combined protective measures of HIV carriers demanding atrhroplasty may be

1. B2 patients should continue their previous ARVT and, get normal PABT during the

2. B1 may wait to start ARVT when the CD4 count will cross the 500 line; they should

3. A1 patients should start an ARVT and get their arthroplasty not delayed but under

In all the cases, prophylactic antibiotic therapy should also be considered.

10 days. This is indicated for all class A arthroplasty demanders.

summarized as follow ( table I), depending of their classification:

undergo normal PABT and their arthroplasty with no delay.

arthroplasty which should not be delayed.

**1.5 Prophylactic antibiotic therapy in HIV carriers undergoing arthroplasty** 

surgery to give them a protection which may be needed anyway in the future. 4. Type **A2** arthroplasty demanders (HIV carriers with less than 300 CD4 lymphocytes/ML , but with no opportunistic disease), who are by definition asymptomatic, but severely immune depressed, are placed on ARVT and their surgery postponed for a few weeks till the CD4 lymphocytes/ML above 300 is obtained. Exceptionally in the emergency setting, the arthroplasty should not be postponed but the patient must be protected by a prolonged antibioprophylaxis which is actually an

continue it forever.

antibiotherapy.

be considered, that is:

**1.6 Section A summary** 

protective PPABT.

according to the protocol of their physicians. Into our own practice, they will be operated with no ARVT and will be placed on treatment only if the CD4 count fall below 500/ML during the follow-up. After they have started with ARVT, they will


With these measures, we think that the results of arthroplasty in HIV carriers should be comparable to HIV seronegative counterparts.


Table 1. Summarizing the use of ARVT, PABT, & PPABT in the five type HIV carriers demanders of arthroplasty
