When I started massage school, I bought a used medical dictionary to have on hand for those pre-Google moments when I might need to look up something. After all, how often does medical terminology change, right?
The terms HIV and AIDS do not appear in that 1981 text.
In fact, the term AIDS wasn’t even proposed by the Centers for Disease Control and Prevention until September 1982. Since then, the virus has killed hundreds of thousands of Americans, and millions of people around the world.
In this Pathology Perspectives column, we will review the basic technical information about how infection with the human immunodeficiency virus (HIV) leads to a disease called acquired immune deficiency syndrome (AIDS). We’ll look at how these conditions are treated and where massage therapy fits in these contexts. A more philosophical discussion about these conditions, persistent myths about them, and their interface with the massage therapy profession can be found in “HIV/AIDS: Today’s Truths for MTs” (page 52).  
DEFINITION: WHAT IS IT?
HIV is a pathogen—a retrovirus called human immunodeficiency virus. A retrovirus is a virus built around RNA (ribonucleic acid), rather than DNA (deoxyribonucleic acid). Retroviruses have to transcribe into DNA before they can replicate inside a host cell, a fact that turns out to be very important in HIV and AIDS treatment.
AIDS is a collection of signs and symptoms related to a failure of some specific immune system responses. This condition is the eventual consequence of infection with HIV, if viral replication is not interrupted adequately.
By the Numbers
Worldwide, almost 38 million people are HIV positive and almost 2 million of those infections are in children, who were probably infected prenatally or shortly postpartum.  
About 2.1 million new infections occur around the globe, and about 150,000 of those are in young children. Each year, we see some 1.5 million deaths around the world.
In the United States, about 1.2 million people are HIV positive, but about 13 percent of those don’t know their status. An estimated 40,000 new infections occur each year in this country (a decrease of 19 percent since 2005), and this infection leads to some 12,000 deaths each year.
Gay and bisexual men are the most-affected group, comprising about 67 percent of all diagnoses in the United States. Gay and bisexual men who are also racial minorities are particularly at risk: diagnoses among African Americans in this group have leveled off, but among Latinos, rates have risen.
Heterosexual contact is a factor in about 24 percent of new HIV diagnoses each year, and injected drug use accounts for 6–9 percent of new diagnoses.
How Does HIV Progress?
HIV enters the body by way of an intimate fluid: blood, semen, breast milk, or vaginal secretions. This usually happens in the context of sexual activity, mother-to-child transmission, or through the use of contaminated needles or other skin-piercing equipment. Another avenue that was once a significant problem was the transmission of HIV through infected donated blood, blood products, or organ tissue. Strict screening now prevents this transmission route in the United States and most other countries.
If the virus gains access through sexual activity, it bonds with epithelial cells in the genitourinary tract or the digestive tract. If it enters through maternal infection or the use of a contaminated needle or other implement, it is loose in the interstitial fluid or in the bloodstream. Either way, the virus then looks for cells with a particular marker on their cell membrane. This marker is a glycoprotein called CD4, and cells that have these markers are called CD4 cells.
Here’s the tricky part: most CD4 cells work for the immune system. This means that while HIV is looking for them, the CD4 cells are looking for any foreign material—like stray viruses. Monocytes and macrophages, the nonspecific white blood cells that constantly scan the body for invaders, are exactly the cells HIV is hoping to encounter, and they have the CD4 marker.
When a monocyte picks up the invader, where does that monocyte go? To the nearest lymph nodes, of course—which is just what the HIV pathogen wants. Lymph nodes are home to many, many CD4 cells. Within the lymph nodes, the virus can invade latent T cells and stay there, literally for years, only to become active when those T cells are recruited to help fight off an infection.
Attentive readers might wonder: why doesn’t the body raise the alarm when its cells have been invaded? One of the things that makes HIV so horribly successful is that it manages to interfere with its host cell’s alarm system, at least for a while. So, it can enter its target cells—monocytes, macrophages, T cells, and others—and begin replicating and spreading through the body without creating an immediate immune system response.
The immune system does eventually wise up and fight back, but the individual loses valuable weeks or months while the virus is able to invade cells, damage tissues, and spread to other people before they know anything might be amiss. This also means that a blood test to look for antibodies to HIV may be inaccurate for up to six months after exposure and infection.
HIV has two mechanisms for moving through a body. It invades its host cells and turns them into virus factories, so those cells now churn out copies and copies of HIV, or it can move directly from one CD4 cell to another, destroying the cells along the way. This happens in lymph nodes where lymphocytes congregate, and also among the microglial cells, which are the resident macrophages in the central nervous system.
Progression and Symptoms
So far, we have looked at how HIV enters a host and moves through the body. Now we’ll look at the phases of HIV infection.
Phase 1  
Phase 1 of an HIV infection is the time between when the virus enters the body and when the immune system finally realizes that something is wrong and begins to fight back. This is sometimes called the window period.
During this time, the virus is accumulating in the white blood cells, but it suppresses immune system responses. This means no antibodies are in production yet, so blood tests are negative, and no symptoms are present. But during this time, it is spreading through the body, and it is communicable to other people. This phase lasts from a few weeks to six months.  
Phase 2
Phase 2 is called the acute primary phase, and it brings the first symptoms of infection. At this point, the immune system has caught on to the fact that an invader is present, and it launches a counterattack. The appropriate T cells and B cells get busy, and soon HIV antibodies are in the blood, so blood tests are now accurate.
Many people have only minor symptoms during this phase, but some have fever and fatigue that look like flu or mononucleosis for a couple of weeks.
Phase 3
Phase 3 of an HIV infection is called the asymptomatic phase, or the clinical latency stage.  
This phase has no specific symptoms, and the opportunistic diseases that we associate with AIDS are not active. The infection is progressing, but the immune system is able to keep up, so circulating CD4 cells are at normal or nearly normal levels.
The drug therapies currently used for HIV infections work to keep people in this asymptomatic phase for as long as possible. These drugs don’t eradicate the virus from the body, but they can interfere with the transcribing of the RNA into DNA that has to happen for the virus to replicate.
It’s unclear how long the asymptomatic phase might last, because some very successful treatment options exist right now. Without treatment, it usually lasts less than 10 years. But with treatment, many patients persist in the asymptomatic phase for decades.
Phase 4
Phase 4 of HIV is the transition from a person being HIV positive to having AIDS. The line in the sand is when circulating CD4 cells drop below 200 units per cubic millimeter. (That’s down from normal levels of 800–1,200 circulating CD4 cells per cubic millimeter of blood.)
Complications
When circulating levels of CD4 cells drop below 200 per cubic millimeter of blood, some of the complications related to a weakened immune system—the diseases and infections that develop when so many immune system cells have been destroyed—begin to arise. These are sometimes called “indicator diseases,” and here are some of the most typical ones:
• Cytomegalovirus: this is a common member of the herpes family that is typically not threatening to people with healthy immune systems. In those who are immune-compromised, it can cause gastroenteritis, retinitis with a risk of blindness, and other complications.
• Herpes simplex and herpes zoster (shingles) are infections that are common in the general population, but occur more frequently, and possibly more severely, in people who have compromised immune systems.
• Kaposi sarcoma: this is a type of cancer that is linked to infection with human herpesvirus 8. It can affect any part of the body. It is most easily seen in the skin, but most dangerous when it affects the lungs, lymph nodes, or intestines.
• Lymphoma, especially Hodgkin’s and non-Hodgkin’s lymphoma: these are cancers that begin in lymph nodes and affect lymphocytes (one of the types of cells most aggressively targeted by HIV).
• Oral thrush: this is a version of candidiasis, in which internal yeasts become prevalent. It is marked by white lesions inside the mouth; if it also invades the esophagus, trachea, bronchi, and lungs, it can be a serious problem.
• Pneumocystis jiroveci pneumonia (also known as pneumocystis carinii pneumonia or PCP): this is a fungal infection of the lungs, and it is almost unknown outside of people who are severely immune-compromised.
• Toxoplasmosis: toxo is an infection caused by a parasite that is carried by mammals (including cats) and excreted in their feces. This is why people who are HIV positive or otherwise immune-suppressed need to take extra care in changing their cats’ litter boxes. Toxo is also found in beef and pork: meats need to be frozen for at least 24 hours and/or cooked to an internal temperature of at least 150 degrees Fahrenheit to kill these pathogens.
Prevention
Prevention begins with avoiding high-risk behaviors. High-risk behaviors include unprotected sexual activity with someone who might be HIV positive (including oral sex) and the use of contaminated needles or other skin-piercing equipment.  
Pre-exposure prophylaxis (PrEP) is a drug protocol for someone who is not HIV positive, but is at high risk for infection—maybe because they have sexual partners who are HIV positive or because they are an injected drug user. PrEP is effective at reducing the risk of HIV transmission, but it should still be used with barrier methods for safe sex.     
Treatment
The mainstay of HIV and AIDS treatment is called ART (antiretroviral therapy), or HAART (highly active antiretroviral therapy). This is a combination of medications that interfere with the process of viral replication by inhibiting the necessary enzymes. Unlike AIDS treatments from even just a few years ago, ART can now be administered in a single daily pill, with little risk of developing resistance to the drug.
AIDS medications can be extremely effective, but they also have some potential side effects including fatigue, nausea, diarrhea, and rashes.
Some of the more serious side effects of the ART protocol include:
• Bone thinning.
• Fat lipodystrophy (fat cells decrease in some areas and increase in others).
• High cholesterol.
• Insulin resistance.
• Low blood cell count.
• Pancreatitis.
• Peripheral neuropathy.
The good news is that most of these problems are manageable, and several options in ART are now available so people can find the strategy that is best suited for a long-term treatment.
Most experts agree that starting ART as soon after a diagnosis as possible is important for longevity and disease management, and it has the added benefit of reducing the risk of transmission of the infection to others or from mother to child.
Implications for Massage
When a massage therapist and a client who is HIV positive meet, one person is at higher risk for picking up a new infection than the other—and it’s not the massage therapist. Our clients who are HIV positive may be immune-compromised, so these are the people who really need us to be healthy when we see them.
It is possible for a person with AIDS to have a complicating infection that could be spread by way of casual contact—herpes simplex is an example. This is really the only way a massage therapist is at risk for picking up a new infection in an interaction with a client who is HIV positive.
And a final risk is that the medication for HIV and AIDS can create some side effects for the client that might change how we work. Peripheral neuropathy, bone thinning, or kidney stress are situations that demand some adaptation in massage, so we need to be sure to have a complete picture of all our clients’ medication-related challenges.
On the other hand, it is difficult to overstate what a gift we can bring to the experience of a person who is living with HIV, or who is in end-stage AIDS. When this disease was first widely identified and publicly discussed in the 1980s, it carried a huge social stigma that meant many patients lived in isolation and rejection. That stigma has not entirely lifted, and massage therapy, with our welcomed touch and the unconditional positive regard that we bring to every interaction, can be an especially powerful intervention, as long as we adjust our work to the resilience of our clients. This will range from people who are active and healthy to people who are frail and dying—we need to be ready to meet them all.
For resources for this column, please see page 58.

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.