Program Brief

The Evolution of HIV Education for Nurses

in Australia
Judith Dean, RN, RM, BN, MPHTM
Shaun Staunton, BS (Psychology), MCCJ
Stephen Lambert, BE, MPH
Mary Batch, RN, BH (Nursing), MNL, PhD
Warren Fitzgerald, RN, BA Bus (Health Admin), MPH
Joanne Leamy, RN, BA (Soc Sci), MA (Nursing)
Key words: education, HIV, nursing roles,
professional development

he number of people living with HIV infection

(PLWH) in Australia is growing due to a gradually
rising annual incidence of new HIV diagnoses
(The Kirby Institute, 2012) along with an increasing
life expectancy as a result of improved therapies
and access to evidence-informed models of care
(Savage, Crooks, & McLean, 2009). HIV is no longer
an acute infectious disease requiring only prevention
and management but an emerging chronic lifelong
health issue that is continually evolving and increasing in management complexity. This evolution
and complexity is apparent in many different spheres.
For example, male-to-male transmission remains the
predominant mode of HIV transmission in Australia;
however, rates of newly acquired HIV diagnoses attributed to heterosexual transmission have
gradually increased and now account for 10% of
newly acquired HIV each year (The Kirby Institute,
2012). Despite the changes to affected population
profiles over the last decade, there continues to be
lower awareness of womens risks and needs among
health care workers in Australia (Commonwealth of
Australia, 2010).
Another aspect of change is that the majority of
new diagnoses attributed to heterosexual transmissions are occurring in people from or with partners
from high prevalence countries (The Kirby Institute,
2011). HIV nurses in Australia have, therefore,
been required to develop greater understanding of

global HIV epidemiology, along with cultural awareness and competence to meet the needs of the diverse
and continually changing community of PLWH.
These and other pressures have placed significant
demands on educators to ensure that nurses across
a broad spectrum of settings have the awareness,
knowledge, and skills to provide best practice,
gender, sexuality, and culturally appropriate, clientcentered care to PLWH.
In Australia, HIV models of care vary across the
states and territories, but clinical services are
predominately provided in publicly funded sexual
health clinics, specialist HIV services, and primary
health care general practice settings (Savage et al.,
Judith Dean, RN, RM, BN, MPHTM, is the Sexual Health
Program Convenor, School of Nursing and Midwifery,
Griffith University and State Nurse Educator, Sexual
Health & HIV Service, Queensland Health, Australia.
Shaun Staunton, BS (Psychology), MCCJ, is the Chief
Executive Officer, Tasmanian Council on AIDS, Hepatitis
and Related Diseases, Hobart, Tasmania, Australia. Stephen Lambert, BE, MPH, is a Research Coordinator, HIV
& HCV Education Projects, School of Medicine, The
University of Queensland, Brisbane, Australia. Mary
Batch, RN, BH (Nursing), MNL, PhD, is a Clinical Nurse
Consultant, Infectious Diseases Unit, Royal Brisbane and
Womens Hospital, Queensland Health, Brisbane,
Australia. Warren Fitzgerald, RN, BA Bus (Health Admin),
MPH, is a Community Nurse, Positive Directions, Gold
Coast, Australia. Joanne Leamy, RN, BA (Soc Sci), MA
(Nursing), is a Clinical Nurse Consultant, Cairns Sexual
Health Service, Queensland Health, Australia.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. -, No. -, -/- 2013, 1-7
http://dx.doi.org/10.1016/j.jana.2013.07.007
Copyright 2013 Association of Nurses in AIDS Care

2 JANAC Vol. -, No. -, -/- 2013

2009). Queensland has 16 HIV care service

providers, the majority being publicly funded
specialist sexual health and HIV services (Mijch &
Vujovic, 2009). And while these services provide
integrated and coordinated holistic continuity of
care using a multidisciplinary client-centered model,
the evolution of HIV infection has increased the need
to move to share care models accessible across a wide
range of settings (Hopwood et al., 2013). The move
from acute clinical models of care to chronic disease
and community-based primary health care models
has further influenced the roles of nurses within the
HIV multidisciplinary team. Regardless of these
changes, HIV nurses continue to play an integral
role in providing optimal care to people living with
and affected by HIV (Association of Nurses in
AIDS Care [ANAC] and American Nurses Association [ANA], 2007; Rowe, 2009).
Nurses who specialize in HIV in Queensland
have access to high-quality tertiary and continuing
professional development education. However, there
is limited understanding about HIV knowledge,
awareness, and the education needs of other nurses,
who are not considered HIV specialists, providing
care for HIV-infected populations. As the HIV
epidemic continues to evolve and PLWH are aging
and living longer with complex health issues, there
will be an increasing need for all nurses to be aware
and knowledgeable about HIV in the context of their
areas and scopes of practice (Bradley-Springer,
Stevens, & Webb, 2010). Consequently, educators
and employers will also need to ensure that all nurses
and other health care workers are educationally
prepared to provide optimal care to PLWH in a range
of health care settings. Vast differences in international, national, and local educational curricula
related to HIV education, at all levels, has led to enormous knowledge disparities in relation to HIV and
other sexual health-related issues as well as to nurses
willingness and preparation to provide care to PLWH
(Nyamathi et al., 2008; Pickles, King, & Belan, 2009;
Williams et al., 2006). Entry into practice nurses will
also need to be considered, as limited education is
a factor underpinning the apparent widespread
negative attitudes and beliefs that nursing students
hold about providing care to PLWH (Pickles, King,
& Belan, 2012; Relf, Laverriere, Devlin, & Salerno,
2009).

National education and regulatory changes in

nursing, including the introduction of a Nursing and
Midwifery Board of Australia, came into effect in
Australia in July 2010 under the Australia Health
Practitioner Regulation National Law Act of 2009
(Australian Health Practitioner Regulation Agency
[AHPRA], 2011). These changes included the introduction of national standards of practice and accreditation of education, and they have the potential to
improve outcomes for PLWH when they support
practice and education opportunities that incorporate
knowledge and awareness of HIV as a core component of all undergraduate, postgraduate, and vocational nursing education programs (AHPRA, 2011).
While beyond the scope of this paper, addressing
the HIV education needs at entry to practice and for
the generalist nurse is a growing area of interest to
educators in Queensland.
Specifically, our paper explores how the role of
HIV nursing and associated education is changing
in response to the evolving HIV epidemic. A subjective review of literature from on-line article databases
and government reports published after 2000 using
the key words HIV, nursing, education, role change,
and evolution, shows how the changing HIV profile
has led to the need to reflect on what underpins
nursing roles within models of HIV care and the
accompanying education necessary to prepare nurses
to practice in the evolving era of the HIV pandemic.
Some of the steps taken to assist nurses in Queensland to obtain the necessary education to prepare
them to practice will be presented in this paper. Our
discussions will also use findings from an external
review of the Queensland University School of Medicine HIV and HCV Education Project, conducted in
2009, to identify gaps and future directions for HIV
nursing education in Queensland (Mijch & Vujovic,
2009).

HIV Nursing is Changing

The specialty of HIV nursing emerged due to the
recognition of HIV as a global health concern in the
early 1980s (ANAC & ANA, 2007). In the early
HIV era, nurses working in acute inpatient hospital
environments were best placed to provide quality
care and role modeling. With the changing profile

Dean et al. / Evolution of HIV Education for Nurses in Australia

of HIV in Australia, specialist units and services

have decreased due to improvements in all aspects
of testing and treatment. However, decreasing
services has also led to the decline of acute
HIV nursing roles (Hodgson, 2006). A survey of
Australian and New Zealand nurses working in HIV
conducted in 1999 by Dobson and Loewenthal
(2001) indicated that the advent of highly active antiretroviral therapy (ART) in the late 1980s had significantly impacted the roles and skills of HIV nurses.
Prior to improvements in therapy, nurses predominately provided inpatient care to PLWH, but with
the introduction of combined ART and resultant
reductions of opportunistic infections and other
AIDS-defining illnesses, acute HIV-related hospitalizations have decreased and client care has moved
from specialist outpatient ambulatory into primary
health care settings (Dobson & Loewenthal, 2001;
Savage et al., 2009). Better treatment has improved
the overall health and well-being of PLWH, leading
to more PLWH who are living longer and experiencing normal stages of aging and conditions associated with a chronic illness (Bradley-Springer et al.,
2010). Chronic health care problems are frequently
complex, requiring coordination between home,
community, primary health, and tertiary health
services (Savage, 2009). HIV nurses, therefore,
need to obtain the necessary knowledge and skills
to practice within a coordinated collaborative primary
health care model while retaining skills and knowledge to address the acute needs of PLWH.
HIV nursing needs to be responsive to contemporary evidence and practice changes, along with the
physical, psychological, spiritual, and social concerns
of PLWH. The HIV nurses role can range from
prevention and testing to providing care, support,
and advocacy for PLWH from being newly diagnosed
through to learning to live well with HIV.
Respect for diversity is essential to the role of HIV
nursing and, while the ability to practice effectively
within a multidisciplinary team is important, the HIV
specialist nurse also needs to have the knowledge,
skill, and confidence to practice autonomously. The
individual scope of HIV nursing practice depends
on the context of practice, and the knowledge, skill,
and educational preparation of the individual nurse,
but generally their roles include screening and
serological monitoring; treatment support such as

management of side effects, adherence, and information about starting and/or switching ART; patient
education; and professional development and education of other nurses (Griffiths et al., 2006). They also
play a major role in providing advocacy and social
support for PLWH, a role that improves the ability
of an individual (and affected others) to cope with
a new diagnosis, adhere to treatment, and achieve
and maintain sexual, psychological, and emotional
well-being as s/he learns to live with HIV (National
AIDS Trust, 2011).
Research is also a core role for the HIV nurse.
While well placed to facilitate recruitment to clinical
research including trials related to HIV pharmaceutical management, the HIV nurse also plays
a fundamental role in advocating for the protection
of PLWH participating in various research programs
(ANAC & ANA, 2007). HIV nurse participation in
multidisciplinary collaborative models of research
is important for client outcomes, and HIV nurse-led
and focused research is essential in the evolving
era of HIV. Nurse-led and focused research will
ensure that HIV nursing models of care and supporting education is evidence informed and continues
to improve to meet the needs of HIV specialist nurses
and their clients, as well as generalist nurses providing care and support to PLWH accessing mainstream health care services (Rowe, 2009; Trimble,
2009).
While the role of HIV nurses is continually
evolving to meet changing HIV epidemic and resultant client needs, the physical, psychological, spiritual, and social concerns remain core to providing
client-centered care and positive outcomes. The
HIV nurse needs the knowledge and skill to provide
care to PLWH across a diverse range of health care
settings ranging from acute hospital inpatient, longterm palliative care, and outpatient ambulatory
management environments, through to communitybased nursing in settings such as home care, corrections facilities, and remote regional settings (ANAC
& ANA 2007; Trimble, 2009).
Exploring models of care that take the full scope of
HIV nursing practice and contemporary nursing theories into account is essential if services and education
programs are to successfully continue to evolve in
order to continue to meet the changing physical,
social, and cultural needs of PLWH. Nurse-based

4 JANAC Vol. -, No. -, -/- 2013

initiatives aimed at increasing access to clinical

services along with community-based programs that
enhance client independence and quality of care
are emerging as key components of the evolving
models of HIV care in Australia. These changes
and emerging roles led educators in Queensland to
reflect on what would constitute best practice HIV
education and how the current programs and education pathways compared.

Characteristics of an Effective HIV Education

Program
An appropriately educated and trained workforce
is critical to the success of any service (Mijch &
Vujovic, 2009). Nursing education at the emergence
of the HIV pandemic focused predominantly on pathophysiology and nursing processes such as standard
precautions and transmission prevention while addressing affective issues such as stigma and fear
of providing care for PLWH (Corless & Nokes,
1996). With the emergence of specialist HIV nursing
roles, education and professional development
courses emerged to address the expanding skills and
knowledge needed to practice within the changing
and advancing scope of practice. However, with the
continually changing profile and demographics of
PLWH, educators need to ensure that programs
and courses also evolved to meet the changing education needs of HIV specialist nurses as well as those
practicing across a diverse range of health care
and community-based settings. All nurses, whether
community or hospital based, should be knowledgeable and comfortable when discussing HIV with
clients (Bradley-Springer et al., 2010). Education,
therefore, needs to be inclusive and responsive to
the needs of nurses from all areas of practice and
levels of skill.
Providing appropriate, evidence-informed, effective HIV education that addresses a basic introduction
to HIV through to the rapidly evolving complex treatment and social issues associated with management
of a lifelong chronic disease is an ongoing challenge.
Nyamathi et al. (2008) agreed that a comprehensive
HIV program should include HIV epidemiology
and etiology, infection control, psychosocial support,
counseling, modes of transmission, natural history of

the disease, symptoms of early and late disease, diagnostic testing and legal and ethical issues (p. 433).
Education also needs to encourage examination of
personal and cultural values. Relf et al. (2009) highlighted the need to imbue a clear understanding of the
professional ethical principles of autonomy, beneficence, non-maleficence and justice, in the context of
testing, confidentiality, disclosure, and the environment of care related to HIV and AIDS (p. 1453)
right from a nursing students entry to practice
studies. Education courses should also include information surrounding pharmaceutical developments
and current treatment options, drug side effects, the
importance of medication adherence, drug resistance,
and the role of good nutrition.
Along with an education program that encompasses the topics outlined above, HIV education
programs today need to incorporate the principles
of chronic disease management. Inclusion of these
principles will help nurses develop the knowledge
and skills needed to work within the coordinated,
multidisciplinary, patient-focused approaches necessary to address complex physical, psychological,
spiritual, social, and chronic HIV issues while
enhancing client independence and improving the
quality of life for PLWH, their care providers, and
families, and preventing avoidable hospitalizations
(Savage et al., 2009).
Education is an important feature of developing
sound attitudes and values (Pickles et al., 2009;
Relf et al., 2009) and improved nursing care
(Thompson, 2009). The education needs of nurses
providing care to people living with or at risk of
acquiring HIV will always vary from context to
context, from hospital to community setting, and
from beginner to expert. Maintaining currency of
scientific information is essential (Mijch & Vujovic,
2009). However, the challenge is to ensure that
learning is appropriate to the context and standards
of local nursing practice and has the capacity to
continually evolve to address the changing profile
of HIV. Collaboration between multidisciplinary
service providers and education networks is essential
to support continued advanced learning. Education
should be delivered in an interactive case-based
format and aim to empower participants to develop
skills and knowledge that enables them to easily
update and access support (Mijch & Vujovic, 2009).

Dean et al. / Evolution of HIV Education for Nurses in Australia

HIV Nursing Education in Queensland

The Queensland University School of Medicine
HIV and HCV Education Projects commenced
training in HIV for nurses, physicians, community
workers, counselors, and other allied health care
professionals in 1998. A range of courses (Education
Course in HIV Medicine, Prescribers Course, and
HIV Nursing Practice Course) have been offered
and, since inception, have provided basic-toadvanced HIV education to more than 6,200 participants (Mijch & Vujovic, 2009). The HIV Nursing
Practice course originally aimed to provide education
and support to those nurses practicing in high HIVcaseload settings. But with time and key stakeholder
advice, the course has evolved into a course designed
to enhance and maintain a competent, advanced level
of knowledge and skill in the treatment and management of HIV among nurses working in HIV settings
as well as a diverse range of other clinical and
community-based services that provide care and
support to PLWH. An advisory committee of nurses
with expertise in HIV, education, and advanced practice in both acute and community settings has
supported the nursing program. The curriculum is reviewed annually to incorporate cutting-edge evidence
and emerging issues, thereby reflecting the diversity
of the HIV nursing community and changing clinical
practice to meet the needs of PLWH.
The HIV and HCV Education Project has provided
other HIV introductory and professional development
courses to address contemporary and emerging HIV
practice issues. These include: annual HIV nursing
updates; HIV and mental health, nutrition, and wellness; working overseas in HIV; and motivational
interviewing. These courses, delivered by a multidisciplinary team of expert HIV clinicians, have had
the flexibility to incorporate emerging issues and
evidence specific to the Queensland context. The
course format has facilitated timely modification
to meet local needs and has been delivered in a
range of metropolitan, regional, and remote locations
around Queensland a state covering an area of
more than 1,727,000 square kilometers (Queensland
Government, 2013).
Evaluation of the program in 2009 by two independent HIV education experts demonstrated that the

education courses were of good quality and effectively delivered (Mijch & Vujovic, 2009). A literature
review of international and Australian evidence
helped to benchmark the existing program against
other available education. Analysis of data from
formative evaluation of the education activities and
a survey of past participants and stakeholders
involved in program delivery indicated that the
Nursing Practice Course provided high-quality
professional development to nurses in Queensland.
The use of a combination of lectures, skills practice,
interactive group work, and case discussions enabled
effective application of theory to practice.
The advisory committee of nurses and other
key local HIV experts has been actively involved in
developing, updating, and delivering the content,
and facilitating group work. The format has provided
flexibility to adapt content in response to emerging
issues and has facilitated application of knowledge
and theory to practice along with reiteration of key
points and sharing of experiences and practice tips.
The availability of a suite of courses has allowed
nurses to also participate in courses designed for
other health professionals, thus nurturing the development of multidisciplinary collaboration as participants from a range of practice areas and levels
actively engage in case scenarios and learning activities together. Advanced practice HIV nurses were
also able to participate in prescribers courses and,
although not eligible to prescribe drugs in Queensland, they developed advanced levels of knowledge
and skill necessary to meet the complex needs of
the aging PLWH population.
The Griffith University Graduate Sexual Health
Program commenced offering an online HIV course
as a core component of a Master in Advanced Practice (Sexual Health) in 2005. Instigated in 1998 in
response to changing legislative and practice standards for sexual health nurses in Queensland, the
evolution of this tertiary qualification in sexual health
and HIV reflected the changing nature of advanced
practice nursing and the need to support specialist
postgraduate levels of education (Queensland
Government, 2008). The HIV and HCV Education
Project has a long-established partnership with the
Griffith Graduate Sexual Health Program and, in
2008, a credit pathway was established between the
two programs, thereby providing opportunities for

6 JANAC Vol. -, No. -, -/- 2013

nurses who had completed the HIV and HCV Education Projects Education Course in HIV Medicine
and the HIV Nursing Practice Course to complete
an assessment challenge and gain credit toward the
core specialty HIV course of the Griffith Master in
Advanced Practice (Sexual Health). Unpublished
formative and informative feedback from successful
credit pathway applicants has indicated that the credit
pathway is a valuable addition to HIV education in
Queensland as it has encouraged nurses to not only
gain higher education qualification but has also
provided opportunities to develop advanced levels
of reflective practice and critical thinking knowledge
and skills (HIV and HCV Education Project, 2011).
These skills have helped nurses actively participate
in quality review and improvement of models of
nursing care that are responsive to contemporary
literature and the ever-evolving continuum of HIV
care and nursing frameworks.

Conclusion
Queensland has provided a model of HIV nursing
education that not only considered the changing
patterns of HIV epidemiology and management but
also the education needs of nurses across a diverse
range of health care settings and levels of practice.
HIV specialist nursing education has evolved to
address the change from acute clinical HIV management to ambulatory primary health care of an increasingly complex chronic infectious disease. The HIV
education framework in Queensland has prepared
nurses to practice within the current context of HIV
care while providing pathways to achieving higher
education qualification and academic skills. The
model has demonstrated that collaboration between
educators and clinical experts from a range of practice areas and professions can result in education
that is responsive to the changing HIV profile and
the evolution of HIV nursing.
Collaboration between the clinical and academic
sectors promotes development of reflective practice
and critical thinking that supports research to guide
evidence-informed models of care. But it is important that nurse-led/nurse-focused research be supported to guide practice and develop education
programs that address the current context and skill

mix of nurses providing care to PLWH. Ensuring

that evidence remains embedded within education
programs to prepare nurses to meet the evolving
needs of PLWH will also enable ongoing quality
improvement of clinical practice and models of
HIV nursing care.
Changing HIV models of care means that
education is needed for nurses practicing in a wide
range of practice settings, especially in general practice, as these nurses are increasingly involved in the
provision of care to PLWH. It is also important
to provide graduate nurses with HIV knowledge
and skills as they are the next generation of nurses
to provide care for PLWH. The continually evolving
era of HIV and scope of nursing practice, combined
with the paucity of current literature related to
HIV nursing in Australia, does present a challenge
for educators and service providers. Contemporary
research is needed on the role, practices, and education needs of nurses to ensure that nursing education and models of care can continue to evolve to
address the changing needs of nurses and PLWH in
Queensland.

Disclosures
The authors are the providers of the education
program described in this paper. The authors report
no real or perceived vested interests that relate to
this article that could be construed as a conflict of
interest.

Acknowledgments
Funding for the external evaluation of the Queensland University, School of Medicine, HIV and HCV
Education Project was provided by Queensland
Health. This funding was not used in relation to this
article.
The authors acknowledge the support and guidance provided by the Queensland University, School
of Medicine, HIV and HCV Education Projects staff,
and members of the Nursing Advisory Committee.
The authors also wish to thank the people who volunteer their time and expertise during the HIV Nursing
education courses.

Dean et al. / Evolution of HIV Education for Nurses in Australia

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