Major advances in highly active antiretroviral therapy (HAART) have dramatically altered the nature and duration of HIV/AIDS caregiving in the United States. Although scientists have not yet discovered a drug combination that can completely eradicate the virus, the new HAART regimens are helping many HIV-positive individuals live longer and enjoy a better quality of life. Marked declines in rates of opportunistic infections and deaths have brought the hope that HIV can be managed as a chronic disease.

The populations that require HIV management also are changing. Growing numbers of HIVpositive Americans are poor, marginalized, and uninsured or publicly insured.¹ African Americans and Latinos now represent the majority of new AIDS cases and people living with AIDS in the United States.² Women and youth are experiencing rapid rates of increase in HIV infection.³ HIV incidence remains high among men who have sex with men (MSM) and injection drug users, with young African American MSM experiencing particularly high rates of new infections.^{3, 4}

The changing demographics of the HIV epidemic, along with the growing complexity of medical care, have created major challenges for the health professionals who provide curative and palliative care and the informal caregivers who provide emotional and practical support to relatives and friends living with the disease. Although an estimated two-thirds of U.S. adults living with HIV infection are aware of their serostatus, only one-third are receiving regular medical care.^{5, 6} For those who are in care, decisions must be made on when to start antiretroviral therapy, which drug combinations to use, and how to manage viral resistance and drug-specific toxicities. Therapeutic regimens often must be adapted to meet the needs of homeless individuals and patients with comorbidities, such as mental illness and chemical dependence.

As treatment options have expanded, so have the stresses experienced by caregivers. The prolongation of the disease course, uncertainty about overall prognosis, and a “roller coaster” pattern of repeated exacerbations and remissions in later stages of HIV disease have intensified the emotional and physical demands of caregiving. In-home caregivers increasingly are being asked to help patients manage sizable pill burdens, frequent and complicated dosing schedules, and therapy-related side effects. Many of these caregivers face the added burdens of poverty, inadequate housing, and lack of knowledge about available resources. Some are themselves HIV-positive. These developments underscore the importance of recognizing and meeting the needs of HIV/AIDS caregivers over the long term—both for their benefit and for the well-being of people in their care.

This chapter discusses the challenges of providing HIV/AIDS care and ways of helping caregivers manage stress and maintain quality of life. The first section describes the types and prevalence of HIV/AIDS caregiving. The next two sections examine the burdens and rewards of caregiving and factors that contribute to burnout. The last two sections discuss strategies for preventing and managing burnout among informal and formal caregivers. While this chapter focuses on HIV/AIDS caregiving in the United States, the burdens experienced by caregivers are of worldwide concern. Many of the suggestions for counteracting burnout in informal caregivers may prove useful in resource-limited countries where family caregivers have little or no access to formal support systems.

Two types of caregivers provide clinical care and supportive services to people with HIV/AIDS. Formal caregivers include health professionals, behavioral health specialists, and social workers who are trained and compensated for their caregiving activities. The trained volunteers and spiritual counselors associated with AIDS service organizations, AIDS care teams, and hospice programs also fall in this definitional category. Informal caregivers include relatives, spouses/partners, and friends who provide in-home care – usually on an unpaid basis. These caregivers vary in the types of tasks performed, the amount of time devoted to caregiving, and living arrangements (i.e., same or separate household).

More than 54 million people – 27% of the adult U.S. population – served as informal caregivers for people with chronic illnesses or disabilities between August 1999 and September 2000.⁷ Fiftysix percent of these caregivers were female, and 37 percent lived in the same household as the care recipient. As compared to the total U.S. population, informal caregivers were more likely to have annual household incomes of less than $30,000 (43% vs. 35%).

No current data are available on the proportion of U.S. adults providing in-home care to people with HIV/AIDS. However, telephone interviews conducted with a probability sample of U.S. adults between June 1990 and February 1991 found that three percent of all adults and six percent of central-city residents were caring for HIV-positive relatives or friends.⁸ Nationally, 59 percent of these caregivers were female, and 22 percent were people of color. The vast majority were under age 40 (74%) and heterosexual (90%). Thirty percent had annual household incomes of $20,000 or less.

Findings from the HIV Cost and Services Utilization Study (HCSUS), a nationally representative sample of U.S. adults receiving medical care for HIV disease, indicate that 21 percent used inhome nursing and supportive services during early 1996.⁹ AIDS-diagnosed individuals were much more likely to use home care services than people in earlier stages of disease (40% vs. 10%). Of the home care users with AIDS, 42 percent used unpaid (informal) care only, 35 percent used paid (formal) care only, and 23 percent used both types of care. The most common sources of unpaid care were family members other than a spouse or partner (38%) and friends (27%). While most AIDS-diagnosed individuals relied upon relatives and friends for help with household tasks and personal care, 22 percent received in-home nursing services (e.g., injections, infusion therapy, parenteral nutrition) from informal caregivers.

Two studies offer important insights on the economic value of informal caregiving. The first study¹⁰ estimated the national economic value of all informal care provided to people with chronic illnesses or disabilities during 1997. Using a midrange estimate of caregiving prevalence (25.8 million), a national average of 17.9 hours per week spent on informal caregiving, and a wage rate of $8.18 per hour, the researchers determined that this care was worth $196 billion, an amount equivalent to 18% of total health care spending.

An older study¹¹ estimated the economic value of housework and personal care tasks performed by HIV/AIDS caregivers during 1990. The informal caregivers in this study reported spending an average of 8.5 hours per day on personal care tasks (e.g., meal preparation, bathing and toileting, companionship) and 19 hours per week on housework. Based on the market value of these services, the researchers estimated the annual per capita value of informal HIV care to be $25,858.

Informal caregivers perform a variety of roles that help people with HIV/AIDS adhere to treatment regimens, avoid unnecessary hospital admissions, reduce reliance on formal caregivers, remain at home longer, and maintain quality of life. Traditionally, family members have served as the primary caregivers for seriously ill individuals. Because HIV care involves more diverse social networks, many HIV-positive individuals have redefined family boundaries to include lovers, friends, and other “chosen kin.” ^{12, 13}

Findings from a 1997 national survey indicate that the typical caregiver devotes more than 20 hours per week to caregiving tasks.¹⁴ These tasks may include:

• Emotional support (e.g., comforting, empathizing, and providing encouragement)
• Help with activities of daily living (e.g., feeding, bathing, dressing, and toileting)
• Help with instrumental activities of daily living (e.g., cleaning the house, running errands, providing transportation)
• Management of financial and legal matters
• Health care advocacy (e.g., linking the care recipient with formal and informal services, communicating with health professionals)
• Nursing care (e.g., dispensing medications and monitoring use, administering injections, inserting catheters)

Although informal caregivers increasingly are being asked to administer pain medications, manage epidural catheters and home infusions, and provide wound care, relatively few studies have examined their contributions to palliative care. Informal caregivers can play an important role in identifying and managing symptoms and side effects, yet most are thrust into these roles with little or no training.¹⁵

Psychologists use the term “caregiver burden” to describe the physical, emotional, financial, and social problems associated with caregiving.¹⁶ Burden can be assessed in terms of objective or subjective impact. Objective burden assesses the extent to which caregiving disrupts daily routines and social relationships and negatively affects resources.^{17, 18} Examples include forced changes in household routines, missed days of work, family frictions, reduced social contacts, loss of income, and/or reduced energy. Subjective burden assesses the caregiver’s perceptions of and reactions to caregiving demands.^{17, 19} Caregivers with high levels of subjective burden may report “feeling trapped,” “feeling nervous or depressed about their relationship with the care recipient,” or “resenting caregiving tasks” even when their objective burden is relatively low.

Multiple factors contribute to caregiver burden. First, caregiving usually comes as an unexpected role, one for which people are neither socialized nor prepared.²⁰ To assume this new role, caregivers must restructure preexisting role obligations and social activities and the ways in which they relate to the care recipient.^{20, 21} Interpersonal strains may intensify as the caregiver and care recipient attempt to resolve issues of autonomy and reciprocity within the context of an increasingly asymmetrical relationship.²² Progressive enlargement of the caregiver’s role over the course of illness may require further adjustments in family, work, and social commitments.²³

The physical demands of informal caregiving also contribute to burden. Unlike formal caregivers, the relatives and friends providing in-home care often are “on call” 24 hours a day.²⁴ While working this 24-hour shift, caregivers may be required to perform multiple, and sometimes conflicting roles.²⁵ Those who have never cared for a seriously ill person must learn basic nursing skills, often under extremely stressful circumstances. They must also find ways to oversee complex medication schedules while meeting their own home and work obligations. Some have the added burden of caring for entire families infected/affected by HIV disease.

The emotional issues surrounding caregiving are a third source of burden. Because HIV is most prevalent among people under age 40, the caregivers also tend to be relatively young.^{22, 24} The non-normative experience of caring for someone with a terminal illness can be a major source of stress for these young adults.⁸ For people of all ages, HIV/AIDS caregiving creates the emotional strain of dealing with an unpredictable and currently incurable disease.²⁶ Some caregivers are burdened by fears of contracting HIV even when they know there is little basis for concern.²⁷ Those who are already infected may worry that no one will be around to care for them when they become ill.²⁴ Adjusting to disease progression can be especially difficult for caregivers who have experienced multiple losses and the attenuation of social support networks.⁸

The financial impact of caregiving can be a major source of burden. Many families suffer severe economic hardships when a key wage earner is forced to reduce work hours or leave paid employment to care for a sick partner or relative.²⁸ As bills accumulate, the family’s most basic needs may go unmet. The loss of income also makes it difficult for caregivers to access formal resources, such as home health and respite care, that could make their tasks more manageable.

A final source of burden is the stigma surrounding HIV disease. Community rejection of HIVpositive individuals because of their disease or the mode of transmission often extends to the relatives and friends who provide care.^{28, 29} Rather than face stigmatization, some caregivers try to conceal their caregiving activities by withdrawing from social relationships. Those who do acknowledge their caregiving status may find it difficult to obtain support from familial or social networks.^{8, 22}

HIV-positive parents face additional challenges that increase their sense of burden.^{30, 31} These challenges include arranging for guardianship of the children, balancing the needs of “sick” and “healthy” family members, and helping their children cope with the disease and possible discrimination.²⁵ If a child is HIV-positive, the mother’s guilt about transmitting the virus can be overwhelming.³² HIV-positive parents also may have unmet needs for social support. For example, in one multi-city study, only 30 percent of the HIV-positive mothers were aware of childcare services, and only 8 percent had used these services.³³ In another study of African-American and Latino families with HIV-positive children, seropositive parents reported more isolation and fewer financial and support resources than uninfected caregivers.³⁴

Many of the burdens experienced by formal and informal caregivers are the same. For example, fear of exposure is a major source of stress for some health professionals.^{35, 36} Formal caregivers may experience a lack of support from their families and professional colleagues due to concerns about contagion or “stigma by association.” ^{25, 37} They also may share the informal caregiver’s emotional distress about not being able to “cure” the disease.

The unpredictable course of HIV disease and the wide range of potential complications can create significant burden, particularly for clinicians with limited HIV management experience. While attempting to control chronic symptoms and conditions, clinicians also must be prepared to treat episodes of acute illness and therapy-related side effects. Additional sources of burden include repeated exposure to the death of young patients, ethical dilemmas, and finding the time to counsel and support informal caregivers.^{38, 39} Formal caregivers also may be burdened by workplace-related stressors, such as work overload, unrealistic expectations of what can be accomplished, lack of decisionmaking autonomy, communication problems and role conflicts, and inadequate medical resources and referral arrangements.^{35, 40, 41}

Caring for an individual with a chronic disease, such as HIV/AIDS, leaves little time or energy for self-care. The multiple tasks performed by caregivers may cause them to neglect nutrition, exercise, socialization, and sleep.⁴² One study of women caring for people with physical or mental disabilities found that caregivers with high levels of subjective burden were less likely to eat balanced diets, exercise, and participate in stress management and health-promoting activities.¹⁸ Another study of women caring for HIV-positive relatives and friends found that almost two-thirds had experienced at least one chronic physical symptom.²⁷ A third study of Latinas caring for family members with HIV/AIDS documented high levels of physical health problems and affective disorders.⁴³

Caregiver burden often produces high levels of chronic stress. The literature on caregiving distinguishes between two types of stress.^{20, 44} Primary stressors arise from the actual tasks of caregiving. These stressors may result from caregiving demands (i.e., number and intensity of caregiving activities), role overload, and/or the sense of being coerced into caregiving. Secondary stressors are influenced by the caregiving role but arise outside that role. For example, caregiving may adversely affect outside employment, exacerbate family frictions, and/or reduce social contacts.

Caregivers under stress exhibit a wide range of signs and symptoms (Table 20-1). The extent to which caregivers experience these symptoms depends on their personalities, belief systems, health and energy levels, and coping skills.⁴² Additional factors affecting caregivers’ response to stress include the severity of the care recipient’s illness, the duration of caregiving, and the accessibility of social support and financial resources.^{20, 27, 45}

Although studies of caregiving tend to focus on the “burden” of caring, there also are many rewards. When asked about the positive aspects of providing HIV/AIDS care, informal caregivers cite opportunities to:

• Bring mission and purpose to one’s life^{25, 46}
• Develop empathy and self-knowledge^{12, 37}
• Gain a sense of personal effectiveness by demonstrating competence under very difficult circumstances^{25, 37}
• Experience the positive feelings associated with loving, caring, and feeling needed^{24, 37}

One study suggests that helping caregivers define the meaningful and valued aspects of their roles and become more attuned to “brief human moments” that create positive feelings can enhance both physical and psychological well-being.²⁴

Finding rewards in caregiving does not necessarily make these activities less stressful. A high degree of involvement, whether positive or negative, can produce stress. The term “burnout” is used to describe the process in which everyday stressors that are not addressed gradually undermine the caregiver’s mental and physical health.²⁸

Psychologists define burnout in terms of three components: emotional exhaustion, depersonalization, and reduced personal accomplishment.⁴⁷ Emotional exhaustion represents the basic stress dimension of burnout. This condition is characterized by feelings of being emotionally overextended and lacking enough energy to face another day. Depersonalization represents the interpersonal dimension of burnout. Feeling drained and “used up,” the caregiver develops an emotional buffer of detached concern and interacts with others in a negative and callous manner. Reduced personal accomplishment represents the self-evaluation dimension of burnout. This dimension is characterized by a growing sense of inadequacy and may result in a self-imposed verdict of failure.

The literature on caregiving suggests that both individual and situational factors increase the risk of burnout (Table 20-2). Empirical research suggests that situational factors are more strongly predictive of burnout than individual characteristics.^{47, 50, 51} Caregivers experiencing work overload and interpersonal conflict over an extended period of time are particularly vulnerable to burnout.⁴⁷

Caregiver burnout has serious consequences for the caregiver, care recipient, and health care system. Caregivers typically experience burnout in stages.⁴⁸ Early warning signs may include feeling less motivated, putting in more hours with poorer results, and/or voicing complaints about the caregiving role. During later stages, caregivers develop many of the physical, psychological, and behavioral problems listed in Table 20-1. Because burnout occurs gradually, caregivers tend to keep working until the downward spiral goes too far and the costs in performance and well-being become unacceptably high.⁴⁷

Care recipients suffer when burnout leads to lower-quality care. Caregivers struggling with emotional exhaustion often become less sensitive to the care recipient’s feelings and needs. This “compassion fatigue” increases the likelihood that the care recipient will be neglected; treated in a detached, mechanical fashion; or even subjected to mental/physical abuse.^{42, 52} Burnout symptoms, such as decreased judgmental ability and difficulty focusing on tasks, make it more difficult for caregivers to competently perform clinical roles. As these changes occur, care recipients may be at increased risk for disrupted care or placement in a long-term care facility.^{50, 52}

The health care system is negatively affected when burnout depletes the supply of experienced caregivers and creates a need for continual training of replacements. Burnout among caregivers who remain in the system may require greater commitments of resources for their physical and mental health care.¹⁰ The health care system incurs additional costs when relatives and family members become too exhausted to provide in-home care and responsibility shifts to formal service providers.

Health professionals historically have been trained to focus on the clinician-patient relationship, with little attention to the needs of the informal caregiver.⁴⁸ Newer educational models encourage health professionals to develop “partnerships” with informal caregivers that include periodic assessment of the caregiver and the patient.⁵³ By assessing the causes and levels of stress in informal caregivers, health professionals can more effectively tailor interventions to meet their needs.

Some informal caregivers accompany HIV-positive patients to medical appointments and can be easily identified. If a patient’s sources of emotional and practical support are not known, this question should be asked when taking the family and social history. Once informal caregivers are identified, their level of perceived burden and the presence of affective disorders, such as depression and anxiety, should be assessed.⁵² The availability, accessibility, and appropriateness of social support resources also should be evaluated.³² Because caregiver burden tends to intensify over time, particularly among caregivers with the fewest personal and material resources, health professionals should periodically reassess each caregiver’s problems and needs.⁴⁵

The early detection of caregiver burden conserves resources by preventing or reducing medical visits for psychosomatic complaints.⁵⁴ In many cases, health professionals can assess the degree of burden by asking just a few questions. Parks and Novielli offer the following examples:⁵²

• Do you feel you are currently under a lot of stress?
• What aspects of your day are the most stressful?
• Have you been feeling down or blue lately?
• Have you been feeling more anxious or irritable lately?
• Do your friends and family watch the care recipient for you so that you have time for yourself?
• Do you have any outside help?
• What do you do to relieve your stress and tension?

Information on caregiver stress and burden also can be obtained from self-administered questionnaires. For example, the American Medical Association has developed a caregiver self-assessment questionnaire for use in physician offices.⁵³ This questionnaire contains 16 yes/no items and 2 global scale items designed to measure indices of emotional and physical distress. Health professionals can use the caregiver’s total score or scores on individual questions to assess the need for medical or counseling interventions and to recommend appropriate community resources.

Information gained from the systematic assessment of caregiver burden places health professionals in a stronger position to help informal caregivers cope with stressors. Time should be set aside during each medical appointment to discuss what is happening in caregivers’ lives and to give them a chance to express their feelings.³² In addition to serving as empathic listeners, clinicians may be able to offer practical suggestions for eliminating or better managing stressors. They also can help caregivers recognize and build on aspects of their lives that contribute to physical, psychological, and social well-being.⁵⁵

Caregivers of HIV-positive children require comprehensive assessments of emotional burden and social support.³² One study of parents, relatives, and friends caring for HIV-positive children³¹ identified six psychosocial needs:

1. Need to Maintain Physical Integrity
   (i.e., desire to be knowledgeable about the modes of HIV transmission and ways of protecting the infected child from opportunistic infections)
2. Need to Learn
   (i.e., desire to know the different roles of the health professionals with whom they interact, to receive information on new HIV/AIDS treatments, to have their questions answered honestly, and to learn how to deal with stress)
3. Need to Act According to a Set of Beliefs and Values
   (i.e., desire to have health professionals respect them for doing what they believe is “right”)
4. Need to Communicate
   (i.e., desire to be kept informed on the condition of the child and to be able to express their feelings. Desire for greater support from their informal social networks)
5. Need to Feel Worthwhile and Useful
   (i.e., desire to be supported by health professionals throughout the course of disease)
6. Need for Continuity of Care
   (i.e., desire to develop and maintain relationships with the same group of health professionals)

Caregivers experiencing guilt, hopelessness, or spiritual distress may need to be referred for religious or spiritual counseling. Discussions with clergy, hospital/hospice chaplains, or other spiritual counselors can help caregivers find comfort and peace even in the absence of strong religious or philosophical belief systems.⁵⁶ Caregivers with affective disorders or high levels of burden should be referred to mental health professionals for assessment and counseling.

Health professionals sometimes overlook the importance of extending counseling into the bereavement period.⁵⁷ If the relatives and friends providing care had a close relationship with the care recipient, grief may extend for two or more years after death.⁵⁸ Bereavement counseling can help caregivers mourn appropriately, cope with the changes resulting from their loss, and plan for the future. (See Chapter 16: Grief and Bereavement.)

The literature on caregiving describes a wide variety of strategies for preventing and managing burnout. Most of these strategies focus on ways of managing the caregiving situation rather than on eliminating or reducing stressors in the caregiving environment.⁵⁹ Caregivers are advised to reevaluate caregiving demands and resources, clarify values and priorities, and adopt coping strategies that match the nature of the stressors. Anecdotal reports from informal caregivers suggest that many of these strategies are effective; however, relatively few studies have been conducted to assess actual outcomes.⁴⁷ Six approaches to counteracting burnout and promoting self-care receive frequent mention in the literature:

1. Use Problem-Focused Strategies to Cope with Stress.
   
   

   Research suggests that caregivers who use problem-focused strategies to cope with stressful situations are less likely to experience burnout than those who use emotion-focused strategies.^{16, 41, 60} Problem-focused strategies include gathering information, planning, and taking direct action. Emotion-focused strategies include efforts to escape or avoid problems, emotional outbursts, and self-accusation. Health professionals often can assess informal caregivers’ risk for burnout by asking hypothetical questions about coping strategies.⁵² For example, an emotion-focused response to the question, “When something goes wrong with your partner’s care, how would you react?,” may signal a need for further assessment and counseling.

   Specific examples of problem-focused approaches to stress can help caregivers move toward more active, engaged forms of coping. Books and web sites for caregivers offer the following suggestions: (See Table 20-3 for additional web sites.)

   • Educate yourself about your care recipient’s condition. Try to read at least one new resource on HIV/AIDS and/or caregiving each week. Understanding the disease process and caregiving issues will make it easier to deal with day-to-day problems.⁶¹
   • Ask questions. When accompanying the care recipient to a medical appointment, don’t be afraid to ask questions or to admit that you don’t understand what the health professional is saying.⁶¹ Use a journal to note changes in the care recipient’s health so that you can confidently discuss these concerns during medical appointments.⁶²
   • Keep a daily journal to record the events that cause stress in your life. After several weeks, you should be better prepared to identify problems, evaluate the criticality of the situation, and weigh possible solutions.⁴⁸
   • Discuss your problems with someone else. In addition to learning how others deal with similar problems, you may be able to help them manage stress.⁶³
   • If your coping strategies are not working, seek professional help. A mental health counselor may be able to help you better understand your feelings and needs and suggest new ways of managing stress.⁴⁸
2. Change Caregiving Patterns.
   
   

   Informal caregivers sometimes get so involved with their work that they lose all perspective and burn out quickly.²⁸ This situation can be avoided by helping caregivers establish realistic goals based on an honest assessment of what they can and cannot do. Once goals are established, caregiving patterns can be changed by:

   • Breaking down tasks into small acts of care⁶⁴
   • Learning how to adjust the pace of caregiving⁶⁵
   • Asking others to help with caregiving tasks^{61–63, 66}
   • Encouraging the care recipient to help with tasks and continue self-care as long as possible²¹

   Caregivers with high levels of subjective burden should be reminded that no one expects them to be perfect. A “level of care prescription” from the physician may help them achieve a better balance between caregiving responsibilities and their own physical and mental health needs. One guide for caregivers offers the following advice:

   Let go. No one person can do it all. Acknowledge that as a human you have limitations just like everyone else. Allow others to help you; delegate responsibilities. Practice asking for help and saying no once in awhile. Lower your expectations and tolerate that things might not get done perfectly. . . . Prioritize tasks and learn to manage your time.⁴⁸

3. Adopt Relaxation Techniques.
   
   

   Many caregivers use relaxation techniques to manage stress and prevent burnout. These techniques should fit with the individual caregiver’s interests, time, and resources. Some caregivers may wish to learn yoga or tai chi, while others may prefer to take a walk, listen to music, or soak in a warm bath. Armstrong describes a visualization technique in which caregivers close their eyes and imagine a scene of beauty and tranquility into which they project themselves. She also suggests reserving ten minutes each day for a “worry break.” ²⁸ The idea is to consolidate all worries into this period and then to set them aside until the next day. Additional relaxation techniques recommended by caregivers include meditation, deep-breathing exercises, massage therapy, gardening, exercising, reading, and socializing with friends.

4. Strive for Good Health.
   
   

   Healthful lifestyles play an important role in burnout prevention. By eating three balanced meals each day, engaging in regular physical activity, and sleeping 7 to 9 hours each night, caregivers can increase their capacity to manage stress. In addition to promoting cardiovascular fitness and building muscular strength, exercise programs increase energy and provide a needed outlet for pent-up emotions. These programs may involve vigorous workouts, but significant health benefits also can be gained from just walking 20 to 30 minutes each day. One study of informal caregivers of HIV-positive minority women suggests that maintaining a regular exercise regimen, along with a spiritual focus, can be an effective coping strategy.⁶⁷

   Some caregivers react to stress by engaging in unhealthful behaviors such as smoking, drinking, and drug misuse. While these chemicals may provide a “quick fix,” their long-term use is likely to increase anxiety and health problems – particularly among caregivers who are not eating or sleeping properly. Caregivers should be informed of the harmful effects of these behaviors and encouraged to participate in counseling and/or treatment programs. Alternative and complementary therapies, such as acupuncture, aromatherapy, acupressure, and massage, also may help to relieve stress.

5. Maintain a Life outside the Caregiving Role.
   
   

   Caregivers often respond to stress by becoming over-involved with caregiving duties.²⁸ The constant demands of the job may cause caregivers to neglect friends, interests, and activities that once gave them pleasure. Health professionals should encourage caregivers to take regular breaks and to keep up with their interests and hobbies as best they can.⁶² For some caregivers, outside employment may provide relief from everyday tensions. Others may simply need to get away for a few hours. Health professionals can help caregivers “jump-start” the self-renewal process by linking them with social support resources.

6. Build a Support Network.
   
   

   Although U.S. cultural norms emphasize self-sufficiency,⁶⁸ empirical studies suggest that caregivers with higher levels of social support are less likely to experience negative outcomes.⁶⁹ Social resources can provide emotional comfort and practical support; reduce social isolation; and offer humor, recognition, and encouragement.⁴⁷ They also can be a valuable source of new information and insights.⁵⁹

   Social support resources should be explored if the caregiver’s answers to screening questions suggest a need for outside assistance. Formal sources of social support include:

   • AIDS service organizations (provide supportive services such as buddy/companion programs, case management, emergency financial support, food banks, housing assistance, nutritional counseling, and transportation assistance)
   • Home health agencies (provide skilled nursing care, homemaker and personal care services, and rehabilitation services)
   • Home-delivered meal programs
   • Hospice programs (provide in-home or residential palliative and supportive care services for patients in the terminal stages of illness)
   • Respite care programs (provide short-term, temporary nonmedical care for people with disabilities and chronic or terminal illnesses)

Informal sources of social support include:

• Family members, other relatives, and friends
• Other caregivers who are willing to rotate caregiving responsibilities
• Faith communities
• Caregiver support groups

Many of the stressors contributing to caregiver burnout are caused by misinformation or the lack of useful information. After assessing the caregiver’s level of knowledge about HIV/AIDS and the types of tasks performed, health professionals should offer appropriate education. The educational topics may include:

• Modes of HIV transmission
• Effects and side effects of medications
• Drug-taking schedules and strategies for improving adherence
• Basic information on nutrition
• Symptoms and problems to expect as the disease progresses

Informal caregivers also may benefit from instruction on infection control, pain and symptom management, and simple nursing techniques (e.g., administering injections, cleaning and dressing ulcers).

As new treatments are discovered and standards of care change, informal caregivers need to receive ongoing education. Topics should be introduced slowly, over an extended period, since individuals under stress can process only small amounts of information at a given time.⁴² To the extent possible, these topics should be explained in nonmedical terms, with ample opportunity for caregivers to ask questions. The use of educationally and linguistically appropriate videos and written materials may help reinforce key concepts.

Counteracting burnout among formal caregivers requires a two-pronged approach. In addition to helping individual caregivers develop more effective coping strategies, interventions should target policies and practices in the workplace that create or exacerbate stress.²⁸ Formal caregivers can benefit from coping effectiveness training, but these techniques will be only partially effective if the work environment is not supportive.⁴⁷

Situational strategies attempt to reduce the incidence of burnout by eliminating or modifying worksite stressors. These strategies promote engagement with work (i.e., high energy, strong involvement, and a sense of self-efficacy) by:

• Establishing clear job descriptions and good referral mechanisms
• Setting realistic work targets
• Restructuring jobs to make workloads more manageable
• Providing training on HIV management, new approaches to pain and symptom management, and effective ways of communicating with patients and family members
• Offering on-site health promotion programs
• Encouraging staff to participate in policy decisions that affect their work
• Providing regular time off and appropriate rewards
• Scheduling regular memorial services for staff wishing to remember and grieve lost patients

Conflict among formal caregivers can be prevented, or at least managed, by scheduling regular forums for case discussion.⁴⁰ Although these sessions reduce the time available for direct service, they help promote collegiality, information sharing, and a consensual, comprehensive approach to care.^{40, 42} Case forums may need to be supplemented by support groups, where caregivers can openly acknowledge the stresses of their work and discuss ways of eliminating or coping with stressors.

Over the past decade, improved antiretroviral regimens, concerns about the costs of inpatient care, and consumer preferences have shifted HIV care from hospitals to home and communitybased settings.^{9, 71} This shift has placed heavy demands on the family and friends of HIV-positive individuals, many of whom have very little knowledge of HIV management or available resources. Formal caregivers also are faced with intense pressures as they struggle to keep pace with rapidly changing standards of HIV care.

Because informal caregivers experience varying types of burdens and have differential access to financial resources and social support, strategies for counteracting burnout and promoting selfcare must be tailored to their individual needs. Many of the strategies recommended in the caregiving literature assume that caregivers are middle-income, fairly well educated, and surrounded by family and friends who are willing to help. As HIV continues to penetrate poor and marginalized communities, new or modified approaches may be needed to help caregivers manage stress and maintain good physical and mental health. These strategies are likely to require family-centered case management and integrated primary care and behavioral health services for patients and caregivers.

Strategies for counteracting burnout among formal caregivers must address both individual and situational factors. Formal caregivers may be able to change the ways in which they deal with stressors by developing a better understanding of their personalities, values, and coping strategies. However, their efforts will be only partially effective if negative policies and practices in the workplace remain unchanged. Finding ways to enhance the working environment may ultimately prove more effective in preventing burnout than teaching caregivers how to manage stress.

Advances in HIV antiretroviral therapy are changing but not necessarily improving the conditions of caregiving. Although HIV-positive individuals are living longer, many are developing therapyrelated side effects that require monitoring and management in the home. By systematically assessing the causes and levels of stress in informal caregivers, health professionals can offer education and counseling that is more responsive to individual needs.

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2. Kaiser Family Foundation. The HIV/AIDS epidemic in the United States. June 2001.
3. CDC. HIV and AIDS - United States, 1981-2000. MMWR 50(21): 430-34, 2001.
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