HIV and AIDS: An Introduction
Ian Hodgson, Lecturer in Nursing
School of Health Studies, University of Bradford
Created September 1998
[updated February 2000]
This handout covers the following aspects of HIV and AIDS:
2. Modes of transmission
3. Progress of the virus
4. The nurses role (safe practice, universal precautions, issues surrounding attitudes and prejudice
5. References/recommended reading (general; social and political; attitudes of health care workers) - you are strongly advised to peruse at least the core sources to enhance your knowledge further
NB: please visit HIV/AIDS Information and Links for more detailed information and resources
1.1 - Terminology
H.I.V. = human immunodeficiency virus. Probably leads to AIDS, although the timescale is variable, and depends upon numerous factors, including: treatment regimes; infections to which the person is exposed. Essentially, HIV attacks and disables a group of cells in the immune system, the CD4 cells. These are necessary for defending the person against cell mediated infections (eg. TB).
A.I.D.S. = acquired immune deficiency syndrome. A term used to describe the presence of specific infections that indicate end stage immune system breakdown. The onset of AIDS is manifested by the appearance of 2 major opportunistic infections: Kaposis sarcoma, pneumocystis carinii pneumonia (P.C.P.) - see the section below for more information on the virology of HIV.
Words/phrases anomalous or now out of vogue:
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. There have been many plagues and wars in history; yet always plagues and wars take people equally by surprise. (Camus, 1971, p 34).
The last major world wide epidemic was in 1918/1919, when an influenza virus killed 20m people, and large numbers of brain damaged survivors were left.
The African Connection - The source of HIV is a topic of hot debate. It is now thought that HIV lived for many years (along with other apocolyptic viruses such as Ebola and Lassa) in central Africa in a pre-epidemic state (Anderson and May, 1992; Wills, 1997). Factors that precipitated the current epidemic include: military and civil unrest in many African states; shifting national borders as a result; economic exploitation; increasing international travel (see Wills, 1997, for more detail).
The dangers of this thesis are obvious: dangers of inciting racism; the definition of AIDS in Africa is not clear [in the absence of expensive tests, many manifestations of TB mimic the symptoms of AIDS]. As mentioned above, the mode of transmission in Africa is predominantly heterosexual, perhaps connected with the high incidence of untreated sexually transmitted diseases (STDs), especially syphilis and gonorrhea. These often manifest as open sores, providing an ideal route for HIV transmission.
Timetable of events:
1954 - currently, the earliest date that a person is thought to have died of an AIDS type syndrome. The victim was a young rent-boy in New York.
1959 - the earliest that a person in the UK is thought to have had the virus - a sailor from Manchester.
1981 - 20 cases of Kaposis sarcoma appeared in young men NOT of middle eastern origin (where the condition is more common). The individuals were found to have damaged immune-systems.
Also, other (homosexual) young men were found to have acquired unusual fungal and parasitic infections. Initially, this led the (US) authorities to cite the appearance of a gay plague. However, once the tumours and other infections appeared in heterosexual drug users and spouses/sexual partners of people with AIDS, the virus was seen not to be confined to just one group.
1983 - The Pasteur institute in Paris isolated a virus in the lymph glands of an individual thought to have the new virus - they called the virus lymphadenopathy associated virus (LAV).
1984 - Robert Gallo in the USA isolated a retrovirus and antibodies that matched a virus in people with AIDS - HIV had been finally discovered.
NB. Montagnier of the Pasteur institute and Gallo were, until recently, hauling each other through the courts, each battling to be recognised as the discoverer of the HIV.
HIV viral particles
1.3 - Current statistics (as at December 1999)
United Kingdom - over 37000 people with HIV have been reported since records began in 1984. See the Public Health Laboratory Service (PHLS) for more information
World - approx. 33.3m people in the world are living with HIV. See the UNAIDS site for more information
In the UK, 60% of HIV diagnoses are from homosexual or bisexual men. Heterosexual intercourse accounts for 19% of HIV. Other routes (intravenous drug use, mother to child transmission, etc.) account for the remainder.
1.4 - A brief virology of HIV
The immune system is essentially composed of three branches, each of which has a specific role in defending the body against bacterial and viral attack: the non-specific branch (e.g. ear wax, gastric acid, saliva); the cell-mediated branch (using various types of T cells to attack organisms that enter cells); the humoral branch (based on the action of antibodies).
HIV attacks and invades cells within the cell mediated branch of the immune system - specifically the CD4 (or T4) cells. Their task is to switch on that branch of the system. HIV is a retrovirus - that is, information the virus holds about itself is stored in the form of RNA (ribonucleic ac id), as opposed to DNA (deoxyribonucleic acid). Once inside the T4 cell, the HIV takes on the DNA configuration of the host, and is then replicated within the cell, and also whenever the body demands more CD4 cells (see diagram below).
All effected CD4 cells are inactivated once invaded, and the person becomes more open to infections such as: candida (thrush); T B; certain cancers; toxoplasmosis; cytomegalovirus (CMV) that can cause blindness; cryptosporidiosis (leading to severe diarrhoea and weight loss). Due to some crossover between the cell-mediated immune system and the humoral based (antibody) immune system, the latter is also (eventually) affected. In addition, there are similar cells within the nervous system, and therefore people with the HIV are likely to develop neurological complications as well (memory loss, slurring of speech, and encephalitis).
As the number of effective CD4 cells declines, the person becomes more prone to opportunistic infections, and the number of active CD4 cells is often taken as a marker as to when anti-viral treatment should be commenced.
As with the transmission of any organism, there are 3 important elements to consider - the quantity, the quality, and the route of transmission. With the HIV, there are 5 specific routes through which the virus can be spread:-
Initially, there will be a short period of feeling unwell and experiencing flu like symptoms. There may be a slight rash, and swelling of the lymph nodes in the groin, armpits and neck. In this first period, the person is extremely infectious. At this stage (up to 3 months), an HIV test will show negative - the HIV test is specifically designed to look for antibodies against HIV [looking for the virus bodies themselves are expensive and the test inaccurate].
Therefore, a negative test does not mean the person is infection free, unless there is an absolute guarantee that the individual has not been exposed to the virus within the previous 3 - 6 months.
There then follows a time when the person is symptomless. The timescale between infection and the onset of minor opportunistic infections such as thrush, general malaise, persistent generalised lymphadenopathy (PGL), meningitis (rare) is variable - in the elderly, it is much shorter (sometime 6 months) than in others (currently up to 19 years). Certain precipitating factors can hurry the preaches, e.g. pregnancy, and age (the elderly have a weaker immune system due to the ageing process.
Once the number of CD4 cells in the cell-mediated immune system begin to fall, there will be an increase in the number of minor opportunistic infections, as well as the more serious, specific infections that are used to diagnose the onset of AIDS (not now referred to an full blown).
Universal precautions assume that anybody is potentially a carrier of a blood borne virus - and therefore all people in hospital are treated identically. They apply whenever contact with blood, semen, cerebro-spinal fluid [usually from around the spinal cord], vaginal secretions, pericardial fluid [from around the heart] or amniotic fluid.
Initially, an appropriate risk assessment should be carried out. Then, precautions can be taken which could entail any of the following:
Two final recommendations:
The Department of Health (1997) has recently published guidelines for the action required if a health care worker is exposed to HIV - this includes commencing anti-viral treatment immediately, and it is recommended all centres have a pack available for immediate use.
4.2 - Attitudes and prejudice
The unsafe behaviour that produces AIDS is judged to be more than just weakness - it is indulgence, delinquency - addictions to chemicals that are illegal and sex regarded as deviant (Sontag, 1991).
There is much research that identifies nurses as being significantly prejudiced against people with the HIV, or who are deemed to be at risk [see reference list 3]. For example, Akinsanya (1992) found that: 13% of staff thought there was a risk from sharing crockery with an infected individual; 23% felt that people with AIDS should be nursed in isolation from other patients; 27% agreed that all people should be tested for HIV on admission to hospital; 32% were concerned about infection from donating blood.
Much of the prejudice is based on: a flawed knowledge base; a fear of catching the virus though accidental injury; inherited/personal value system. Significantly, 75% of one sample stated that the health care worker should be aware of the diagnosis (Burtis and Evangelista, 1992).
The risk of acquiring the virus is small (as compared to hepatitis B). One paper (Marcus, 1988) surveyed 1201 health care workers in the USA exposed to HIV +ve blood. Four (4) seroconverted (ie became HIV +ve themselves). Two were exposed during resuscitation, and 1 from recapping a needle. 37% of the 1201 initially exposed to the virus could have prevented the incident. Vlahov and Polk (1987) stated that, following a needlestick injury, there is a 6-30% chance of acquiring hepatitis B, and a <1% chance of contracting HIV.
Ethically, and professionally, nurses cannot refuse to care for a person with the HIV or AIDS. Only in specific cases can individual cases be addressed - for example, it may be wise not to expose a pregnant nurse to toxoplasmosisis.
Like syphilis in the 1900s, AIDS has brought into play the attribution of moral meaning to biological phenomena (Brandt, 1988).
HIV has successfully established itself in all layers of human strata: health care workers and carers would be wise to consider HIV not as an infection confined to any particular social group, but to all the ages of man described by Shakespeare in As You Like it - from the infant mewing and puking in his mothers arms, through to second childishness and mere oblivion..sans teeth..sans everything (II, 7). As the world enters the third millenium, HIV, along with TB and enteric disease, will present health promotion and medicine with a continuing challenge.
General texts and articles
(core sources in bold)
Advisory Committee on Dangerous Pathogens (1996) - Protection against blood borne infections in the workplace: HIV and hepatitis. The Stationary Office, London
Anderson, R; May, R (1992) - Understanding the AIDS pandemic. Scientific American , May edition, pp 20-26 - covering the African connection
Brandt, A (1988) - The syphilis epidemic and its relation to AIDS. Science, 239, pp 58 - 63 - the similarities between the moral and social aspects of syphilis and AIDS are addressed
Camus, A. (1971) - The Plague. Penguin, London
Department of Health (1997) - Post exposure prophylaxis for health care workers exposed to HIV. HMSO, London
Flaskerud, J; Ungvarski P (1997) (3rd edition) - HIV/AIDS: A guide to Nursing Care Harcourt Brace, Philadelphia
Marcus, R (1988) - Surveillance of health care workers exposed to blood from patients infected with HIV New England Journal of Medicine , 319, pp 1118-1123
Pratt, R (1995) - HIV and AIDS: A Strategy for Nursing Care. Edwin Arnold, London
Sontag, S. (1991) - AIDS and its Metaphors. Penguin, London
Wills, R. (1997) - Plagues: Their Origin, History and Future. Flamingo, London -overview of plagues from prehistory to the present. Good chapter on HIV, and much useful information about other conditions, including syphilis. Very readable.
RECOMMENDED READING 
Social and Political Aspects
(core sources in bold)
Aggeleton, P; Hart, G; Davies, P (Ed) (1989) - AIDS: Social Representations and Social Practices. Falmer, London
Altman, D (1986) - AIDS and the New Puritanism. Pluto Press, London
Department of Health (1992) - The Health of the Nation. HMSO, London - target area for HIV and AIDS is interesting, but flawed due to the emphasis on behaviour alone, and use of other STDs as markers for HIV
Macintyre, S West, P (1993) - What does the phrase "safer sex" mean to you? - Understanding among Glaswegian 18-years-olds in 1990. AIDS, 7, pp 121 - 125
Marzuk, F; Tierney, H; Tardiff, K; Gross E; Morgan, E; Ming-Ann, H; Mann, J. (1988) - Increased risk of suicide in Persons with AIDS. Journal of the American Medical Association, 259 (9), pp 1333 - 1337
Moore, O. (1996) - PWA: Looking AIDS in the Face. Picador, London - excellent and moving book, compiled from the 'GuardianŽarticles published over the 2 years before Oscar died of an AIDS related illness
Shilts, R (1987) - And the Band Played on. Penguin, London - an American writers perception of the political and social intransigence that contributed towards the spread of the HIV
Watney, S (1987) - Policing Desire: pornography, AIDS and the media. Methueu, London - main thesis is that the moral majority among the conservative party used the HIV to marginalise groups that did not fit with their view of normal'
RECOMMENDED SOURCES 
Attitudes of health care workers to
people with HIV and AIDS
(core sources in bold)
Akinsanya, J. & Rouse, P. (1992) - Who will care ?: A survey of the knowledge and attitudes of hospital nurses to people with HIV and AIDS. Journal of Advanced Nursing, 17 (3) pp 1068-1077
Breault, A. & Polifroni, C. (1992) - Caring for people with AIDS: nurses' attitudes and feelings. Journal of Advanced Nursing, 17 (1), pp 21-27
Burtis, R. & Evangelista, J.T. (1992) - Will universal precautions protect me ?: A look at Staff Nurses' attitudes. Nursing Outlook, 40 (3), pp 133-138
Clift, S., Stears, D., Legg, S., Memon, A. & Ryan, L. (1990) - Blame and young people's moral judgement about AIDS. In P. Aggleton and G. Hart (ed) - AIDS: Individual, Cultural and Policy Dimensions. Falmer Press: London
Cole, F. & Slocumb, E. (1994) - Mode of acquiring AIDS and nurses' intention to provide care. Research in Nursing and Health, 17, pp 303-309
Forrester, D. & Murphy, P. (1992) - Nurses attitudes towards people with AIDS and AIDS - related risk factors. Journal of Advanced Nursing, 17, pp 1260-1266
Gillespie, F. (1993) - Health care workers' attitudes to HIV infection and AIDS. British Journal of Nursing, 2 (10), pp 516-523
Goldenberg, D. & Laschinger, H. (1991) - Attitudes and normative beliefs of nursing students as predictors of intended care behaviours with AIDS patients: a test of the Ajzen-Fishbein theory of reasoned action. Journal of Nursing Education, 30 (3), pp 119-126
Henry, K., Campbell, S. & Willenbring, K. (1990) - A cross sectional analysis of variables impacting on AIDS related knowledge, attitudes and behaviours among employees of a Minnesota teaching hospital. AIDS Education and Prevention, 2 (1), pp 36-47
Hodgson, I. (1997) - Attitudes towards HIV and AIDS: entropy and health care ethics. Journal of Advanced Nursing, 26 (2), pp 283 - 288
Kerr, C. & Horrocks, M. (1990) - Knowledge, values, attitudes and behavioural intent of Nova Scotia nurses towards AIDS and patients with AIDS. Canadian Journal of Public Health, 81 (2), pp 125-8
Maj, M. (1991) - Psychological problems of families and health care workers dealing with people infected with HIV. Acta Psychiatrica Scandinavica, 83 (3), pp 161-168
Nemeroff, C., Brinkman, A. & Woodward, C. (1994) - Magical contagion and AIDS risk in a college population. AIDS Prevention and Education, 6 (3), pp 249-265
Peterson, C. (1993) - Structured controversy versus lecture on nursing students beliefs about attitudes towards providing care for persons with AIDS. Journal of Continuing Education in Nursing, 24 (2), pp 24-32
Roach, P., Fleming, C., Hagen, M. & Pauker, S. (1988) - Prostatic cancer in a patient with asymptomatic HIV infection: are some lives more equal than others ? Medical Decision Making, 8, pp 132-144 - NB - an old reference, but left in due to importance
Sims, J. (1992) - AIDS, nursing and occupational risk: an ethical analysis. Journal of Advanced Nursing, 17, pp 569-575
Snowden, L. (1997) - An investigation into whether nursing students alter their attitudes and knowledge levels regarding HIV infection following a 3 year programme leading to registration as a qualified nurse. Journal of Advanced Nursing, 25, pp 1167 - 1174
Wallack, J. (1991) - AIDS and the health care professional: evolving attitudes and strategies to effect change. Psychiatric Medicine, 9 (3), pp 483-501
Wiley, K., Heath, L. & Acklin, M. (1988) - Care of AIDS Patients: student attitudes. Nursing Outlook, 9, pp 244-245
Wilson, G. (1973) - The Concept of Conservatism. In: G. Wilson (ed.) - The Psychology of Conservatism. Academic Press: London
van Wissen, K. & Woodman, K. (1994) - Nurses' attitudes and concerns to HIV/AIDS: a focus group approach. Journal of Advanced Nursing, 20, pp 1141-1147
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