Risk Factors

Risk Factors for Transmission

People most affected by HIV

Canada has identified 8 vulnerable populations most affected by the effects of HIV². These include:

1. Gay men
2. People who inject drugs
3. Aboriginal people
4. Prison inmates
5. Youth at risk
6. Women
7. People from countries where HIV is endemic
8. People currently living with HIV/AIDS

Stigma is one of the biggest barriers to fighting HIV effectively.
Individuals from these populations may not only have a higher risk of contracting HIV, but may also experience more stigma and discrimination. Nurses need to be aware of these vulnerable populations in order to provide proper care and treatment and to avoid stigmatization and discrimination. As front-line workers, it is imperative that nurses contribute to an environment where people living with HIV/AIDS feel safe to seek help rather than feel fear of rejection.

HIV is a virus that can affect anyone.
Even though certain vulnerable populations are more susceptible to HIV, it is important to remember that HIV is a virus that can affect anyone, regardless of age, sexual orientation, ethnicity, or socio-economic background.

Question: You are a nurse working in a primary care setting. During a health history interview, a patient discloses that he uses intravenous drugs. How should you respond?

1. Recognize that IV drug users are at higher risk for contracting HIV.
   Continue the health history after you have donned gloves, goggles, and a gown to protect yourself.


2. Recognize that IV drug users are at higher risk for contracting HIV.
   Obtain an order from the physician to test for HIV.


3. Recognize that IV drug users are at higher risk for contracting HIV.
   Educate the patient on HIV transmission through sharing IV needles and ask the patient if he would like to be tested.

How is HIV transmitted?

HIV is primarily transmitted through unprotected sexual intercourse (almost 90%)³

Other modes of transmission include:

• mother to child transmission;
• blood products contaminated with HIV; and
• needles contaminated with HIV.

Fact: Canada tests 100% of blood products for HIV⁴. (Did you know less than 3.7% of people in Canada donate blood? Click here to donate!

These 2 conditions need to be present for HIV infection to occur:

1. Exposure to bodily fluids with high levels of HIV.
2. A way for HIV to enter the bloodstream.

Condition 1. Exposure to bodily fluids with high levels of HIV.

HIV is found in blood and bodily fluids.

The following fluids contain high levels of HIV:

• blood
• semen and vaginal fluids
• breast milk
• cerebrospinal fluid
• amniotic fluid

These bodily fluids do not contain enough HIV to infect, unless: 1) They are visibly contaminated by blood; and 2) There is significant and direct contact⁵.

• urine and feces
• sweat, tears, nasal secretions
• saliva, sputum
• emesis

Question: What PPEs would you want to wear in each of the following nursing care activities for an HIV positive patient who is on treatment?

1. Giving a bed bath	Gloves	Gown	Mask	Others:
2. Changing adult pads soiled with urine and feces	Gloves	Gown	Mask	Others:
3. Changing linens soiled with blood	Gloves	Gown	Mask	Others:
4. Giving an injection	Gloves	Gown	Mask	Others:
5. Withdrawing blood	Gloves	Gown	Mask	Others:
6. Changing a wound dressing	Gloves	Gown	Mask	Others:

See the answer.

Condition 2. A way for HIV to enter the blood stream.

Being exposed to bodily fluids with high levels of HIV (for example, blood splashes on clothing) will not result in infection unless HIV can enter the blood stream. HIV can enter the blood stream through breaks in the skin or through mucous membranes. Mucous membranes that are thin are more susceptible to HIV because it is easier for HIV to cross the membrane and because thin membranes are more likely to tear.

Mucous Membranes

The membrane lining of the anus and cervix are composed of simple columnar epithelium that are one cell layer thick thus make it easy for HIV to cross the membrane. In addition, the mucous membrane of the anus is more susceptible to tearing because it does not produce lubrication to reduce friction during sexual intercourse - making unprotected anal sexual intercourse the riskiest type of sexual behavior.⁶

The foreskin of the penis (the inner layer) is also a mucous membrane that is more susceptible to HIV infection. Although this area is composed of stratified epithelium with many cell layers, it has many immune cells, called dendritic cells, that HIV binds to in order to enter the body. In fact, circumcision has been found to reduce the chance of acquiring HIV by almost 50%.⁷

The mouth is also a mucous membrane where HIV can enter the body, although sexual intercourse still carries the highest risk for HIV infection. Factors that can increase the risk of contracting HIV through the oral mucosa include:

• poor oral health, such as gum disease or cuts/sores in the mouth;
• brushing or flossing, which can cause minor cuts, abrasions, and inflammation; and
• smoking, which can damage the mucous membrane in the mouth.

You cannot get HIV from:

Coughing or sneezing Insect bites Touching or hugging Kissing Public baths/swimming pools Handshakes Sharing utensils

Inflammation increases risk of HIV transmission.

In a person who is HIV positive: Inflammation can increase the viral load in certain bodily fluids because inflammation activates the immune system, which causes infected CD4+ cells to produce more copies of HIV, thus increasing the viral load.

In a person who is HIV negative: Inflammation and the resulting accumulation of CD4+ cells (helper T cells) in the area will make it easier for HIV to come into contact with non-infected CD4+ cells.

Question: You are caring for a young adult who has been diagnosed with gonorrhea - a bacterial infection that is transmitted sexually and causes inflammation of the penis and vagina. Through the health history, you learn that this patient has engaged in unprotected sex with multiple partners. What patient teaching would you provide in regards to the link between sexually transmitted diseases (STDs) and HIV?

1. The risk of infection for HIV is lower for someone with an STD because STDs cause your body to produce an immune response that can also fight off HIV.
2. The risk of infection for HIV is higher for someone with an STD because the partner who was the source of infection probably also has HIV.
3. The risk of infection for HIV is higher for someone with an STD because STDs can often cause inflammation - giving HIV easier access to the CD4 cells that respond to the site of inflammation.

Next Page: Occupational Risk for Nurses

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Sorry, wrong answer. Try again. :)

That's correct! Good job.

As a nurse, you recognize that IV drug users are at a higher risk for contracting HIV. Combined with a thorough health history including engagement in risky behaviors will inform you as to whether or not to refer the patient for HIV testing. Avoid stigmatization by assuming that everyone from a high risk population needs to be tested for HIV.

PPEs are usually not necessary during a health history interview. Over-protection may contribute to stigmatization of people living with HIV/AIDS by health care professionals. Consent is also necessary in order to refer a patient for HIV testing.

Go back to the question

Sorry, wrong answer.Try again. :)

That's correct! Good job.

STDs can cause inflammation, resulting in activation of CD4 cells - HIV's favorite target. An individual with inflammation from STDs who engages in unprotected sex has a higher risk of contracting HIV.
Wrong answers: The immune response to inflammation will not prevent HIV infection and it is incorrect to assume that someone with a sexually transmitted disease also has HIV.

Go back to the question.

Next Page: Occupational Risk for Nurses
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Answer. There is no right or wrong answer. As a health care professional, you can use any type of PPEs you feel is necessary to protect yourself. However, you should be knowledgeable about the risks involved with the nursing care activities you undertake and keep in mind that when working with people who have experienced stigma and discrimination, over-protecting yourself may contribute to their negative experiences.

How do you balance protecting yourself with not contributing to stigmatization of people living with HIV/AIDS by over-protecting yourself and making patients feel like they cannot be touched? Comment on our wiki using Moodle

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