Abdominal and anorectal surgery and the acquired immune deficiency syndrome in heterosexual intravenous drug users

Anorectal pathology amongst HIV infected patients attending the Douala General Hospital: a cross-sectional study

While gastrointestinal disease is common among HIV infected individuals, the prevalence and distribution of ano-rectal pathology has not been well studied in our setting. The objective of this study therefore was to determine the prevalence and determinants of ano-rectal pathology in HIV infected patients attending the Douala General Hospital HIV treatment centre. A hospital-based cross-sectional study was undertaken. We collected socio-demographic, clinical and laboratory data using a structured questionnaire and patients' files. Each study participant had a full physical and ano-rectal examination. We further studied factors associated with having at least one ano-rectal lesion by logistic regression reporting odds ratios (ORs) and their 95% confidence intervals (CI). We included 390 HIV infected patients. The mean age was 41 (SD: 8) years and 48% were men. Median duration since HIV diagnosis was 3 (interquartile range: 2-5) years and median CD4 cell count was 411 (interquartile range: 234-601) cells/mm³. Prevalence of ano-rectal pathology was 22.8% (95% CI: 18.7-27.3). Hemorrhoids and proctitis were most common lesions found; each in 10% of patients. From multivariate logistic regression, factors associated with ano-rectal pathology were CD4 < 350 cells/ml (OR: 2.1, 95% CI: 1.1-4.2), not on highly active antiretroviral therapy (OR: 2.2, 95% CI: 1.1-4.6), inpatient (OR: 2.3, 95% CI: 1.2-4.3), ano-rectal intercourse (OR: 5.0, 95% CI: 1.7-15.1), and more than one sexual partner (OR: 2.4, 95% CI: 1.3-4.2). Ano-rectal pathology is common amongst HIV infected patients. Care givers should actively investigate and treat them as this will improve the quality of life of people living with HIV/AIDS.

Comparison of perianal diseases in HIV-positive patients during periods before and after protease inhibitors use: what changed in the 21st century

PURPOSE

Highly active antiretroviral therapy has enabled better control over HIV infection. Thus, the immunologic status of such patients has been improving and we believe that changes in their perianal diseases also have been occurring. This study was designed to compare anorectal disease incidence among HIV-positive patients attended in two eras: prehighly active antiretroviral therapy and highly active antiretroviral therapy.

METHODS

We examined 5,660 HIV-positive patients with anorectal diseases, divided into two groups: 1,860 treated during 1989 to 1995 (Group 1), and 3,800 during 1996 to 2005 (Group 2).

RESULTS

In Group 1, the most common diseases were condylomas (24.7 percent), ulcers (21.8 percent), and anal fistulas (19.7 percent). Tumors occurred in 2.5 percent, with Kaposi's sarcoma in 51.1 percent, and squamous-cell carcinoma in 27.6 percent. In Group 2, the most common anorectal lesions were condylomas (75.6 percent), ulcers (17 percent), and fistulas (12.1 percent). The tumor incidence was 1.8 percent, with squamous-cell carcinoma in 59.4 percent and Kaposi's sarcoma in 23.2 percent. Changes in incidence were statistically significant for the increase in condylomas and fissures, and for the decrease in ulcers, fistulas, and Kaposi's sarcoma among Group 2 patients.

CONCLUSION

Anorectal disease incidences have changed in the highly active anti-retroviral therapy era.

[Anorectal lesions in HIV-positive patients using highly active antiretroviral therapy]

Anorectal lesions are common in patients with human immunodeficiency virus (HIV). Highly active anti-retroviral therapy (HAART) has little influence on the progression of anal neoplasms. The prevalence of anorectal lesions in 88 HIV-positive patients attended at the infectious diseases service of the University Hospital of Brasília who were using HAART was studied. Sociodemographic data were collected using a pre-prepared questionnaire and then the patients underwent proctological examination. Around 71% of the patients said they practiced anal intercourse. 30.7% were using a protease inhibitor. The prevalence of anorectal lesions was 36.4%, and condyloma acuminata and anal fissure were the most frequent of these. Condyloma acuminata was the most prevalent anorectal lesion and was strongly associated with the use of lopinavir/ritonavir. Screening for anorectal lesions caused by human papillomavirus in HIV/AIDS patients who use protease inhibitors is suggested.

Impact of highly active antiretroviral therapy on outcome of cholecystectomy in patients with human immunodeficiency virus infection

BACKGROUND

Highly active antiretroviral therapy (HAART) reduces virus proliferation and significantly decreases the rate of septic and opportunistic complications in patients infected with human immunodeficiency virus (HIV). Although surgery is performed routinely on patients receiving HAART, the effect of this treatment on surgical outcome has not been examined in detail.

METHODS

This retrospective study reviewed 54 consecutive patients with HIV infection who underwent surgical cholecystectomy: 31 patients were on HAART, 13 on nucleoside analogue reverse transcriptase inhibitors (NRTIs) and ten were receiving no specific therapy. Characteristics of HIV-1 infection, laboratory investigations, characteristics of the gallbladder disease, type of operation, postoperative course, morbidity and mortality were recorded. Univariable analysis and unconditional logistic regression were performed to determine factors related to postoperative complications and death.

RESULTS

The three groups were similar in terms of HIV-1 infection characteristics. In univariable analysis HAART and laparoscopic cholecystectomy were associated with a significantly lower complication rate, whereas only HAART was shown to be protective by logistic regression analysis. A low HIV RNA load and a high CD4(+) cell count were significant predictors of uncomplicated surgical outcomes.

CONCLUSION

HAART significantly reduces the risk of complications after cholecystectomy in patients with HIV infection or acquired immune deficiency syndrome.

Incidence of acquired immune deficiency syndrome (AIDS)-related disorders at laparotomy in patients with AIDS

BACKGROUND

Patients with acquired immune deficiency syndrome (AIDS) present for surgical management of abdominal conditions that are complications of advanced human immunodeficiency virus (HIV) infection or that are caused by other disease not related to AIDS. This study compared the clinical details and postoperative outcomes of patients with AIDS-related diseases found at laparotomy with those of patients with non-AIDS-related disorders.

METHODS

The medical records of 30 consecutive patients with AIDS who underwent laparotomy were examined retrospectively.

RESULTS

Fourteen patients had AIDS-related pathologies found at laparotomy, 13 had disease processes that were not AIDS related and three had no abnormal findings at laparotomy. Patients with AIDS-related conditions at laparotomy had lower mean body-weight, serum albumin concentration and CD4 lymphocyte count, and required a longer hospital admission than those who had non-AIDS-related disease. The duration of HIV infection and the number of complications and deaths were similar in the two groups. Complications occurred in 21 patients and there were five deaths (30-day mortality rate 17 per cent).

CONCLUSION

AIDS-related pathologies are commonly found at laparotomy in patients with HIV/AIDS. An AIDS-related diagnosis does not confer a greater risk of complication or postoperative death than other conditions.

A comparison of biomechanical properties of excised mature scars from HIV patients and non-HIV controls

BACKGROUND

Patients with human immunodeficiency virus (HIV) infection have been found to have impaired wound healing. This study aimed to determine whether the healed wounds from these patients have an impaired intrinsic strength.

METHODS

The healed wounds of patients with HIV infection who were undergoing a subsequent surgical procedure were excised and examined immediately by tensionometry. A non-HIV group with wounds of the same range of maturity were used as controls.

RESULTS

The wounds of 11 patients with HIV were compared with those of 11 controls. There was no significant difference between the groups' preoperative hemoglobin or albumin; however, the white cell count was lower in the HIV group (P = 0.005). When examined biomechanically, wounds of the HIV group had a lower resilience (P = 0.0138), toughness (P = 0.0138), and maximum extension (P = 0.0235) compared with the control group.

CONCLUSIONS

The wounds of patients with HIV infection when measured biomechanically are weaker than those of normal non-HIV controls.

Predictors of operative outcome in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome

BACKGROUND

Plasma viral load has recently been associated with clinical outcome in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). We hypothetized that, in addition to CD4 lymphocytes, plasma HIV-1 RNA counts are predictive of postoperative outcome.

METHODS

HIV-infected and AIDS patients admitted to a major teaching hospital requiring invasive or surgical procedures were retrospectively analyzed for postoperative outcome. Preoperative and postoperative immune cell counts including plasma HIV-1 RNA counts were recorded. Chi-square analysis, Fisher's exact test, and multivariate regression were performed with statistical significance P </=0.05.

RESULTS

Fifty-five consecutive patients between 14 and 62 years of age were admitted in a 1-year period and underwent 64 diagnostic and therapeutic procedures. Fourteen (22%) postoperative infections and 18 (28%) complications other than infection, with an overall mortality of 11%, were documented. Total preoperative white blood cell count ([WBC] P <0.01), preoperative percent lymphocyte count (P <0.01), absolute postoperative CD4 lymphocyte count (P <0.01), and postoperative plasma viral load (P <0.0001) are associated with mortality. Multivariate regression indicated that postoperative percent CD4 lymphocyte count is an independent predictor of both postoperative infection and other complications (P <0.05, R = 0.848, power = 0.9911), while the decrement in percent CD4 lymphocyte count is an independent predictor of postoperative complications other than infection (P <0.05, R = 0.596, power = 0.7838).

CONCLUSIONS

In accordance with the medical literature for clinical outcome in HIV-infected and AIDS patients, both immune cell counts and HIV-1 RNA counts were found to associate with postoperative mortality. However, the postoperative and decrement in percent CD4 lymphocyte proved to be the independent predictors of postoperative complications.

Prospective study of healing time after hemorrhoidectomy: influence of HIV infection, acquired immunodeficiency syndrome, and anal wound infection

PURPOSE

Hemorrhoids and rectal diseases are very frequent in HIV-positive patients, especially in those with homosexual habits. This study was designed to compare posthemorrhoidectomy healing time in such patients, and evaluate the role of various factors related to their HIV-positive status.

METHODS

The study involved a prospective series of 48 male patients (32 HIV-seropositive and 16 with acquired immunodeficiency syndrome) who underwent hemorrhoidectomy between 1992 and 1996; 20 age-matched and gender-matched seronegative patients were retrospectively identified as controls. Healing times, postoperative complications, and wound infections were recorded, and the delaying effect of CD4+, Karnofsky Index scores, and HIV-ribonucleic acid were evaluated. Between-group differences were analyzed using Cox's model, Student's t-test, chi-squared test, and Fisher's exact probability test. P values of <0.05 were considered statistically significant.

RESULTS

Cox's model revealed that HIV positivity and the presence of acquired immunodeficiency syndrome significantly delayed wound healing, which also correlated with the presence of infection. The healing rate in HIV-positive patients was 66 percent after 14 weeks and 100 percent after 32 weeks; the corresponding figures for patients with acquired immunodeficiency syndrome were 0 and 50 percent. All of the controls were healed after 14 weeks (P < 0.01 vs. both the patients with acquired immunodeficiency syndrome and HIV+ patients). Centers for Disease Control and Prevention HIV-positive status (including CD4+ counts) and the performance status proved to be of prognostic value.

CONCLUSIONS

Our data suggest that the indications for hemorrhoidectomy in patients with acquired immunodeficiency syndrome need to be considered extremely carefully because of the high incidence of delayed wound healing.

Perianal diseases in HIV-positive patients compared with a seronegative population

PURPOSE

The aim of this report was to present our cases showing the prevalence and cause of perianal diseases in human immunodeficiency virus-positive patients.

METHODS

We compared 1,860 human immunodeficiency virus-positive patients to 1,350 human immunodeficiency virus-negative outpatients with perianal diseases, examined from January 1989 to December 1996, and the results obtained with the treatment methods for seropositive patients. Among them, 88.7 percent were males, mostly in the age range from 30 to 50 years old.

RESULTS

Condylomas, ulcers, hemorrhoids, fistulas, fissures, abscesses, and tumors were the most frequently diagnosed diseases. Two or more anal diseases occurred in 16.7 percent of patients. Among the human immunodeficiency virus-negative patients we noticed the same incidence of gender, and most were in the age range of 40 to 60 years old. Hemorrhoids, fistulas, skin tags, and fissures were diagnosed.

CONCLUSIONS

From statistical analysis we may conclude that human immunodeficiency virus-positive patients have more condylomas, ulcers, tumors, fistulas, and abscesses than human immunodeficiency virus-negative patients, who have more hemorrhoids. Incidence of fissures was similar in the two groups.

Human immunodeficiency virus and the trauma patient: factors influencing postoperative infectious complications

OBJECTIVE

While immunosuppression 2 degrees to human immunodeficiency virus (HIV) infection should logically render HIV+ trauma victims more prone to infection after injury, little data is available regarding trauma outcome in this group of patients. Since the helper CD4+ lymphocyte count is a marker for progression of HIV-associated diseases, we examined the relationship between CD4+ counts, Injury Severity Score (ISS), and bacterial infectious complications in HIV+ trauma patients.

METHOD

Retrospective review of 56 consecutive HIV+ trauma patients treated at a Level I trauma center.

RESULTS

Nine patients (15%) developed significant infectious complications (four pneumonias, three soft-tissue infections, one urinary tract infection, one wound infection) with no pattern to the causative agents. Evaluation of CD4+ counts, white blood cell counts, serum albumin levels, blood transfusion requirements, and ISS revealed that only the ISS was associated with infectious complications.

CONCLUSION

Despite the profound immunosuppression in this group of patients, the incidence of bacterial infectious complications was independent of the CD4+ count (p = 0.958), but was associated with increases in the ISS (p = 0.003).

Severe complications of perianal sepsis in patients with human immunodeficiency virus

Fifty human immunodeficiency virus (HIV)-infected patients with perianal sepsis were studied. Seven (14 per cent) had serious septic complications, four patients with severe necrotizing gangrene, and three with abscesses in the mediastinum, liver and brain respectively. CD4+ lymphocyte counts were significantly lower in patients with severe septic complications as compared with those with uncomplicated perianal sepsis (P < 0.05). In patients with HIV presenting with rare (metastatic) abscesses, perianal sepsis must always be kept in mind as a possible focus. Although HIV-infected patients have a limited life expectancy perianal fistulas and abscesses should be aggressively treated, because of the high risk of severe complications.

Should HIV status alter indications for hemorrhoidectomy?

PURPOSE

There is a widespread belief that performing hemorrhoidectomy on a patient infected with human immunodeficiency virus (HIV) is an invitation for disaster. Aim of this study was to compare morbidity of hemorrhoidectomy in HIV-positive (HIV+) with HIV-negative (HIV-) patients.

METHODS

Charts of 27 HIV+ and 30 HIV- male patients less than age 50 years who underwent hemorrhoidectomy were reviewed.

RESULTS

Mean age of the 57 study group patients was 38 years. Open hemorrhoidectomy was performed in 26 patients (46 percent), and a closed technique was used in 31 patients (54 percent). HIV+ and HIV- patient groups were well matched to all preoperative and intraoperative variables. Mean T-cell helper count in the HIV+ patient group was 301 (range, 9-1,040) cells/microliter. There were no deaths, and complications were seen in 15 patients (26 percent). There was no difference in overall complication rates between HIV+ and HIV- patient groups. Urinary retention was seen in ten patients (18 percent), three of whom were HIV+ (11 percent) vs. seven of whom were HIV- (23 percent) (P = not significant). Although no patient required reoperation for bleeding, postoperative hemorrhage was seen in three patients (1 HIV+, 2 HIV-). None of the patients developed fecal incontinence. Mean time to complete wound healing was 6.8 (range, 4-12) weeks for HIV+ patients vs. 6.6 (range, 4-14) weeks for HIV- patients (P = not significant).

CONCLUSIONS

These data suggest that HIV status of a patient should not alter indications for surgical management of hemorrhoidal disease.

Anorectal surgery in human immunodeficiency virus-infected patients. Clinical outcome in relation to immune status

PURPOSE

Anorectal disease is commonly found in human immunodeficiency virus (HIV)-infected patients. The aim of this study was to determine the spectrum of anorectal disease, its surgical treatment, clinical outcome, and its relation to immune status.

METHODS

Medical records of all HIV-infected patients with anorectal pathology that required surgical treatment from January 1984 to January 1994 were retrospectively reviewed. Patients were divided into five different groups: common anorectal pathology (hemorrhoids, polyps, Group A); condylomata acuminata (Group B); perianal sepsis (abscesses, fistulas, Group C); anorectal ulcers (Group D); malignancies (Group E).

RESULTS

Eighty-three patients needed 204 surgical consultations (13 percent conservative, 87 percent operative) for 170 anorectal diseases. Fifty-one patients had multiple anorectal pathology. Operative intervention resulted in adequate wound healing and symptom relief in 59 percent of patients, adequate wound healing without relief of symptoms in 24 percent of patients, and disturbed wound healing was related to type of anorectal disease (P < 0.001) and to preoperative CD4(+)-lymphocyte counts (P < 0.01). Disturbed wound healing and most insufficient immune status were encountered in Groups C, D, and E. Within these groups low CD4(+)-lymphocyte counts were a risk factor for disturbed wound healing (P = 0.004). Median postoperative survival was highest (4.7 years) in Group A, lowest (0.6 years) in Groups D and E, and related to type of anorectal disease (P = 0.0001).

CONCLUSIONS

The spectrum of anorectal disease is complex. Type of anorectal disease is strongly related to immune status, wound healing, and postoperative survival.

Surgery for anal lesions in HIV-infected patients

Anorectal manifestations are commonplace in patients with HIV infection. However, standardized or rational treatment of these conditions has not been proposed and many patients are denied adequate treatment based on fear of complications. This review looks critically at the available literature to draw conclusions about treatment, results and complications of surgery for anorectal problems in these patients.

Local excision and mucosal advancement for anorectal ulceration in patients infected with human immunodeficiency virus

In patients infected with human immunodeficiency virus (HIV) no effective surgical procedure has been described for anorectal ulceration that is resistant to medical therapy. This study was designed to determine the effectiveness of surgical excision of anorectal ulcers, with or without mucosal advancement. The medical records of patients with HIV and anorectal pathology diagnosed between 1984 and 1994 were reviewed. Patients with anorectal ulcers were divided into group A which was treated only with excision and group B in which excision was combined with mucosal advancement. Surgical treatment was considered successful if relief of symptoms was achieved within 4 weeks of the operation. Excision of anorectal ulcers was successful in seven of 16 patients (44 per cent) in group A. Relief of symptoms was achieved in 12 of 13 patients (92 per cent) in group B when surgical excision was combined with mucosal advancement, which is significantly better than the results in group A (P = 0.02). This non-randomized study indicates that after unsuccessful medical treatment persistent symptomatic ulcers should be treated operatively by excision with mucosal advancement.

Emergent abdominal surgery in AIDS: experience in San Francisco

Several recent reviews have suggested that aggressive surgical intervention can reduce morbidity and mortality associated with intra-abdominal crises in AIDS patients. We reviewed our experience with 57 AIDS patients with 63 emergent laparotomies performed at 4 hospitals affiliated with the University of California in San Francisco. Fifty-five patients (96%) were homosexual men. Thirty-nine (68%) had been treated for an opportunistic infection. Indications for exploration included right lower quadrant pain consistent with appendicitis in 24 patients (38%), visceral perforation or obstruction in 11 (17%), right upper quadrant pain in 9 (14%), diffuse peritonitis in 8 (13%), and uncontrollable hemorrhage in 8 (13%). Perioperative mortality was 12% (7/57). Fifteen patients (26%) suffered major complications including pneumonia, sepsis, multi-organ failure, and intra-abdominal abscess. Forty-five of 50 survivors (90%) were receiving some type of chronic antimicrobial or antineoplastic chemotherapy, compared to only 2 of the 7 patients who died (28.6%) (P < 0.001). Lack of ongoing prophylactic treatment for AIDS-related disease, active opportunistic infections, Walter Reed VI classification, and ongoing sepsis at the time of exploration were noted to be associated with increased morbidity and mortality.

Ulcerative disease of the anorectum in the HIV+ patient

Ulcerative processes are the most disabling of anal diseases in HIV+ patients. The spectrum ranges from "benign" fissures to invasive ulcerative processes. It is important to recognize their salient features in order to effectuate proper management. Since 1989, 74 HIV+ patients with ulcerative anal disease were evaluated. Of 33 patients with benign fissures, 13 had sphincterotomy, with symptomatic relief in 12 and healing in 11. Ten had improvement with standard conservative treatment, and 10 did not return for re-evaluation. Of 41 patients with "idiopathic" anal ulcers, 34 underwent operative evaluation, biopsy, viral culture, and debridement. Thirty had significant pain relief, and 17 showed variable evidence of healing. Four patients with intractable pain had injection of Depo-Medrol (The Upjohn Co., Kalamazoo, MI) into the bed of the ulcer with significant pain relief. One patient was diverted. We propose that anal ulcerative disease be classified as benign lesions and therefore treated as if the patient were HIV negative. In those patients with HIV-associated anal ulcers, evaluation under anesthesia, biopsy, culture, and debridement should be performed and therapy directed against any neoplastic or viral agents found. Those patients with no identifiable agents may be helped with aggressive debridement or intralesional steroid therapy. This approach allows safe and effective treatment in most patients.

Appendicitis in acquired immunodeficiency syndrome

Reports in the surgical literature are few regarding common intra-abdominal disease processes, such as gallstone disease or appendicitis, in patients with AIDS and instead have focused on AIDS-related intra-abdominal diseases that infrequently require surgical intervention unless complicated by bleeding, obstruction, or perforation. A literature review for appendicitis in AIDS patients revealed only 30 well-documented cases drawn from 13 studies, with a 40% perforation rate and frequent delays and errors in diagnosis. A 7-year experience with 28 patients with appendicitis and AIDS from 4 urban San Francisco hospitals is reviewed. There were no perioperative deaths and an 18% postoperative complication rate. Five patients (18%) were found to have normal appendices with other intra-abdominal pathology, and an AIDS-related etiology for appendicitis was discovered in 7 of 23 patients with appendicitis (30%). With the exception of diffuse versus localized abdominal pain, no preoperative symptom or sign was useful in differentiating AIDS-related and non-AIDS-related disease. Aggressive use of ultrasound and abdominal computed tomographic scanning, along with early surgical intervention, is recommended.

Healing after dental extractions in men with HIV infection

To determine the incidence of delayed healing after dental extractions in men with HIV infection, a retrospective audit was conducted of all extractions performed in a dedicated dental clinic over a 26-month period. The incidence of delayed healing in patients with HIV was compared with the incidence in those patients without HIV. Eighty men with HIV had 163 teeth extracted, which resulted in five dry sockets (3.01%). Thirty-six men thought not to have HIV had 70 extractions and three dry sockets (4.28%). All three dry sockets in the control group occurred in men who had tested negative for HIV antibodies in the year before their extraction. There were no other incidents of delayed healing. These findings contrast with other reports since they reveal no increase in delayed healing after extractions in men with HIV and do not support recommendations that prophylactic antimicrobials are required for extractions in this group of patients.

Common complications of wound healing. Prevention and management

The culmination of any operation is a healed wound. Failure of a wound to heal increases time spent in the hospital and the expense, and may start a cascade of progressive complications. Thus, it is important to optimize as many factors as possible before operation and to have the knowledge and resources to deal with wound problems should they occur. This approach involves understanding basic wound healing with its multiple factors, including nutrition, and knowing how to deal with potential adverse factors in wound healing, such as chemotherapy, corticosteroids, and radiation.

Sexually transmitted diseases of the colon, rectum, and anus. The challenge of the nineties

During the past two decades, an explosive growth in both the prevalence and types of sexually transmitted diseases has occurred. Up to 55 percent of homosexual men with anorectal complaints have gonorrhea; 80 percent of the patients with syphilis are homosexuals. Chlamydia is found in 15 percent of asymptomatic homosexual men, and up to one third of homosexuals have active anorectal herpes simplex virus. In addition, a host of parasites, bacterial, viral, and protozoan are all rampant in the homosexual population. Furthermore, the global epidemic of AIDS has produced a plethora of colorectal manifestations. Acute cytomegalovirus ileocolitis is the most common indication for emergency abdominal surgery in the homosexual AIDS population. Along with cryptosporidia and isospora, the patient may present to the colorectal surgeon with bloody diarrhea and weight loss before the diagnosis of human immunodeficiency virus (HIV) disease. Other patients may present with colorectal Kaposi's sarcoma or anorectal lymphoma, and consequently will be found to have seropositivity for HIV. However, in addition to these protean manifestations, one third of patients with AIDS consult the colorectal surgeon with either condylomata acuminata, anorectal sepsis, or proctitis before the diagnosis of HIV disease. Although aggressive anorectal surgery is associated with reasonable surgical results in some asymptomatic HIV positive patients, the same procedures in AIDS (symptomatic HIV positive) patients will often be met with disastrous results. It is incumbent upon the surgeon, therefore, to recognize the manifestations of HIV disease and diagnose these conditions accordingly.