With the wide prevalence of individuals living with the human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), it is essential for massage therapists to understand the etiology, pathogenesis and treatment trends of the disease. It is likely that a person living with HIV/AIDS is, or at some point will be, under a massage therapist's care. The importance of understanding HIV/AIDS in massage therapy practice is reiterated by its inclusion in the curriculum for continuing education and maintenance of a license.

Epidemiology: The first AIDS case was reported in the United States 24 years ago. Since then, the Centers for Disease Control (CDC) reports HIV infection leading to AIDS is the fifth leading cause of death in people between the ages of 35-44, and AIDS is the leading cause of death among African-Americans ages 35-44.¹ Moreover, data recently presented at the 2005 National HIV Prevention Conference in Atlanta, Ga., reports that more than 1 million Americans currently are infected with HIV.² Each year, 40,000 new cases are diagnosed in the U.S. alone.³ A person infected with HIV does not always transition to the AIDS phase.

Pathogenesis: The etiological agent of acquired immunodeficiency virus (AIDS) is the human immunodeficiency retrovirus (HIV). The virus primarily targets the CD4+ T-lymphocyte, because of the affinity of the virus to the CD4+ T CELL surface marker. The clinical categories of HIV infection are: Category A, which includes asymptomatic or acute HIV infection; Category B, symptomatic conditions not included in Category C; and Category C, clinical conditions associated with AIDS.⁴ (For more information on clinical categories, visit www.cdc.gov.)

Current treatments: Since there is no cure for HIV, the current medical treatment is to inhibit replication of the virus and thus prevent it from causing AIDS. The virus is transmitted through direct blood contact with an infected person; the most common method of transmission is through sexual contact. Other modes of transmission include needle sharing, blood transfusions and the birth of a child to an infected mother.

Antiretroviral medications (ART) are used to inhibit the spread of HIV at various sites of activity. The ART medications are used alone or in a combination known as a "cocktail," a highly active retroviral therapy (HAART). General classification of drug therapies includes:

• Protease inhibitors - inhibit the enzyme protease, which the HIV needs to mature and replicate.
• Nucleoside Reverse Transcriptase Inhibitors (NRTIs) - inhibit the reverse transcriptase enzyme that is essential in the HIV replication through changing of its single-stranded RNA to the double-stranded DNA.
• Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs) - inhibit the non-nucleoside reverse transcriptase enzyme from converting from RNA to DNA in the HIV.

Massage Therapy Research

Some research on the efficacy of massage on HIV/AIDS patients includes the following:

• Scafidi & Field studied HIV-positive babies; the mother of each child served as the massage therapist. The babies who received massage therapy gained significant weight in comparison to the control group babies that did not receive any massage therapy. The massaged babies also presented with lower stress behaviors. As a contributing variable, the mothers showed reduced anxiety and lower stress levels.⁵
• Ironson and Field conducted a study in 1996 on the effect of massage therapy on the immune system. This study was performed on 23 HIV-positive and 10 HIV-negative men. The men received a month of daily 45-minute massages and alternately a month without massage. The massage group showed significant increases in natural killer (NK) cell cytotoxicity (p<0.01), cytotoxic T-cells (p<0.05), and relaxation levels, and significant decreases in urinary cortisol and states of anxiety (p<0.01). NK cells have shown to be highly protective in HIV-positive patients, thus massage therapy could prove significant. The role of NK also might be significant in other diseases such as cancer. The study was done on a small sample; a larger study with a larger sample is recommended.⁶
• Seventy three HIV-positive men were studied by Antoni, et al., to determine how cognitive-behavioral stress management (including massage therapy) affected anxiety, T-cytotoxic/suppressor cells and 24-hour urinary norepinephrine output. The results showed significant reduction in anxiety, anger, total mood disturbance and perceived stress, and lowered norepinephrine output. Even after six to 12 months, there was a significant increase in T-cytotoxic/suppressor (CD4+CD8+) lymphocytes.⁷

Massage Therapy on HIV/AIDS Patients

Massage therapists play a role in the lives of those infected with HIV and AIDS by complementing the patient's medical team. Massage therapy plays a vital role in helping patients cope with the various symptoms of HIV/AIDS and indirectly boosts the immune system at the same time. The factors that seemed to contribute to immune enhancement were pressure strokes, dosage and period of massage therapy. A single massage dose on a healthy person indicated substantial increases in the NKCA. The effect on the immune system was even more intense when pressure was applied with multiple-dose massages lasting for a longer duration of time. Deep strokes, pressure points and trigger-point massage improved immune function in those living with HIV/AIDS.⁸ For the treatment to prove beneficial, it is recommended that the therapist use a full-body stress management approach. The technique should include pressure strokes, such as acupressure, trigger-point therapy and deep strokes, which should last approximately one hour and be performed at least once or twice weekly over an extended period of months for immune-enhancing results.

Massage Therapy and Gloves

Using gloves to massage an HIV/AIDS patient is the preference of the caregiver and patient. There is no evidence showing a positive correlation between the transmission of HIV/AIDS and touching or therapeutic massage. In conversations with individuals living with HIV/AIDS, it was unanimously expressed that the use of gloves by a therapist was negative. HIV and AIDS patients routinely are victims of discrimination. Despite years of health education, the disease continues to be misunderstood. Is it paranoia?

Massage therapy is a health profession. As such, therapists will be exposed to various diseases. The motive for wearing gloves should be weighed. Protection is important, but not at the cost of harming the patient, harboring professional paranoia or discriminating against people living with HIV/AIDS. There might be times in which the use of gloves is warranted, but there is no reason for them to be worn customarily in providing therapy to the patient. Remember, there is greater danger that the patient might contract a pathogen from the therapist because of his or her compromised immune system. According to the CDC, "People living with AIDS can get very sick from common germs and infections. Hugging, holding hands, giving massages, and many other types of touching are safe for you, and needed by the person with AIDS. But you have to be careful not to spread germs that can hurt the person you are caring for."⁹ If you feel you must use gloves because of the presence of blood, it is recommended you inform the patient and get his or her consent prior to therapy. The safest gloves are latex and vinyl.

Below are some general guidelines massage therapists can follow when working with HIV/AIDS patients:

• Be educated about the disease.
• Perform a patient history.
• Survey the patient to ascertain there are no cuts, open wounds or bleeding.
• Survey your hands to ascertain there are no cuts, open wounds or bleeding.
• Keep your nails short so they don't accidentally scratch the patient.
• Wash your hands thoroughly with warm water and soap before and after massage.

The CDC also recommends: "To take gloves off, peel them down by turning them inside out. This will keep the wet side on the inside, away from your skin and other people. When you take the gloves off, wash your hands with soap and water right away."⁹

And finally, "If you get blood, semen, vaginal fluid, breast milk or other body fluid that might have blood in it in your eyes, nose or mouth, immediately pour as much water as possible over where you got splashed, then call the doctor, explain what happened, and ask what else you should do."⁹

Conclusion

Although most massage therapy research regarding HIV/AIDS is preliminary, the results in the studies that have been conducted are encouraging. As future studies reveal the benefits of the NK cells and their role in protecting patients with low CD4+ T-lymphocyte count, massage will become an integral part of the treatment of HIV/AIDS patients. As part of the medical team, massage therapists can greatly enhance the lives of people living with HIV/AIDS in the physical and psychological realms, by providing the personal touch other therapies do not generally provide.

References

1. Anderson, R. N. (2002). Centers for Disease Control and Prevention, national vital statistics report. Deaths: Leading Causes for 2000. www.cdc.gov/nchs/data/nvsr/nvsr50/nvsr50_16.pdf.
2. U.S. HIV cases pass 1 million mark for first time since 80's. June 14, 2005. MTV.com Headlines.
3. National Institute of Allergy and Infectious Diseases (July 2004). HIV/AIDS statistics. www.niaid.nih.gov/factsheets/aidsstat.htm.
4. Centers for Disease Control. 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR Morbidity Mortality Weekly Report, 1992;41(RR-17):1-19.
5. Scafidi F, Field T. Massage therapy improves behavior in neonates born to HIV-positive mothers. J Pediatr Psychol, 1996;21:889-897.
6. Ironson G, Field T, Scafidi F, Kumar M, Patarca R, Price A, Goncalves A, Hashimoto M, Kumar A, Burman I, Tetenman C, Fletcher MA. Massage therapy is associated with enhancement of the immune systems cytotoxic capacity. International Journal of Neuroscience, 1996;84:205-218.
7. Antoni MH, Curess DG, Curess S, Lutgendorf S, Kumar M, Ironson G, Klimas N, Fletcher MA, Schneiderman N. Cognitive-behavioral stress management intervention effects on anxiety, 24-hr urinary norepinephrine output, and t-cytotoxic/suppressor cells over time among symptomatic HIV-infected gay men. Journal of Consulting & Clinical Psychology, 2000;68(1):31-45.
8. Diego MA, Field T, Hernandez-Reif M, Shaw K, Friedman L, Ironson G. HIV adolescents show improved immune function following massage therapy. International Journal of Neuroscience, 2001;106:35-45.
9. Giving Care. Centers for Disease Control and Prevention, National Center for HIV, STD and TB Prevention. www.cdc.gov/hiv/pubs/brochure/care4.htm.