HIV/AIDS Family Interventions Discussion

DISCUSSION PAPER
A discussion of HIV/AIDS family interventions: implications for
family-focused nursing practice
Rosemary W. Eustace
Accepted for publication 11 August 2012
Correspondence to R.W. Eustace:
e-mail: rosemary.eustace@wright.edu
Rosemary W. Eustace PhD RN PHCNS-BC
Assistant Professor
College of Nursing and Health, Wright
State University, Dayton, Ohio, USA
E U S T A C E R . W . ( 2 0 1 2 ) A discussion of HIV/AIDS family interventions: implica-
tions for family-focused nursing practice. Journal of Advanced Nursing 00(0),
000–000. doi: 10.1111/jan.12006
Abstract
Aim. This article presents a discussion on the role of family interventions in HIV/
AIDS disease prevention and care.
Background. Although HIV/AIDS epidemic and its impact on the society
traditionally has been measured in terms of individual risk behaviours and
individual-level HIV prevention, HIV/AIDS family-focused prevention and
management strategies are increasingly becoming a priority. However, little is
known as to what constitutes a HIV/AIDS family intervention.
Data sources. The search was limited to English and published literature starting
in the year 1983 to date. CINAHL and PubMed were emphasized using a
combination of text words and subject headings. Cochrane Library, PsycInfo,
Scopus, and the ISI Web of Science databases were also searched using keywords
and in the case of PsycInfo, subject headings were used. The main keywords were
‘nurse’, or ‘nursing’, ‘HIV/AIDS’, ‘family interventions’, ‘family support’ and
‘family education’, and/or ‘family subsystems’.
Discussion. The process of theorizing about ‘family interventions’ and ‘HIV/
AIDS-family interventions’ is critical for putting forth essential components
unique for designing culturally specific HIV/AIDS family interventions. In
addition, any proposed design of HIV/AIDS family intervention should consider
the impact of HIV/AIDS on the family across the family life span, disease
trajectory, and from an interdisciplinary perspective.
Conclusion. Training needs of family nurses should be met when designing
multidisciplinary HIV/AIDS-FIs. Furthermore, nurses should be proactive in
advocating for HIV/AIDS family intervention and HIV/AIDS family policies to
improve outcomes in family functioning, processes, and relationships. More needs
to be done in regard to research on families, family interventions, effectiveness,
and cost of family-focused approaches.
Keywords: conceptual definition, disease trajectory, family, family interventions,
family nursing practice, HIV/AIDS
© 2012 Blackwell Publishing Ltd 1
JAN JOURNAL OF ADVANCED NURSING

Introduction
The global HIV/AIDS epidemic and its impact on societies
has been traditionally measured in terms of individual risk
behaviours and individual-level HIV prevention interven-
tions. Contemporary efforts, however, demonstrate a push
for family-focused prevention and management strategies
(Belsey 2005, Tomlinson 2010) that capture the increased
incidence and prevalence of multiple HIV-related diagnosis,
illness, and AIDS death among household members and
their extended families (Hosegood et al. 2007). The affected
family members usually represent a range of family constel-
lations, such as couples, parents, grandparents, cousins,
daughters, sons, and/or siblings. The shared experiences
among affected families comprise of issues such as appre-
hension about disclosure, stigmatization, ill-health and suf-
fering, the costs and burdens of treatment, loss of income,
and need for care and support. Hence, it is essential for
researchers and practitioners to effectively manage family
processes that modify risks and promote protective factors
at all levels of prevention (i.e. primary, secondary, and ter-
tiary prevention) as part of the HIV/AIDS control and man-
agement efforts. This article presents a discussion of the
role of family interventions in HIV/AIDS prevention and
care. The major questions that inspired this discussion
include: (1) what is a family intervention? (2) What is a
HIV/AIDS Family Intervention (HIV/AIDS-FI); and (3)
What HIV/AIDS-FI(s) are appropriate across the HIV/AIDS
disease trajectory? This information is vital in the develop-
ment of future interventions for evidence-based HIV/AIDS
family-focused nursing practice.
Background
The role of family in HIV/AIDS
Definition of the family
‘Family’ and ‘family intervention’ are key concepts in the
family nursing literature. Although there is no standard def-
inition of family, one of the earliest definitions describes the
family as a group of persons united by ties of marriage,
blood, or adoption (Eshleman & Bulcroft 2009). This tradi-
tional definition has been utilized in various governmental
entities for programmatic purposes. In other situations,
however, family has been defined more broadly to include
self-defined two or more individuals, who depend on one
another for emotional, physical, and economical supports
(Hanson 2005). For instance, the global community of
HIV/AIDS professionals broadly defines family to include
committed relationships between individuals who fulfil the
family functions (Richter 2010). These functions may be
linked to economic, emotional, health care, reproductive,
and socialization issues (Friedman et al. 2003). Thus, fol-
lowing the above conceptual definitions, it is apparent that
the term ‘family’ has ‘multiple meanings’, a defining charac-
teristic that is currently well embraced by contemporary
family theorists (Bengtson et al. 2005). For the purpose of
this discussion, ‘family’ is conceptualized as what the indi-
vidual client/patient says it is (Kaakinen et al. 2011).
HIV/AIDS as a family disease
As a life stressor, HIV/AIDS is a prevalent and chronic dis-
ease that occurs in the context of family. Once it occurs,
the disease has an impact on individuals and families by
disrupting the family structure and processes. For example,
the family’s sexual and reproductive health processes are
usually affected creating a major concern. For the majority
individuals, especially those who live in highly affected
areas, the HIV/AIDS diagnosis usually happens through
antenatal screening or after a family member has fallen sick
(Miller & Murray 1999). Once identified as HIV positive,
clients are expected to adhere and cope with the use of
highly active antiretroviral therapy (also known as
HAARTs) (Byakika-Tusiime et al. 2009) and in some situa-
tions, safety infant feeding to reduce the risk of further HIV
infection (Carr & Gramling 2004). Family sexual behav-
iours frequently change because of fear of infection and
shame (Cowgill et al. 2008).
Furthermore, dysfunctional family interpersonal relation-
ships and communication processes may occur, especially
with disclosure issues and negotiation about decision-mak-
ing and sexual behaviour (Porter et al. 2004, Arnold et al.
2008, Eustace & Ilagan 2010). Family members may choose
to delay disclosure because of lack of trust, fear, or worry of
information leakage to others (Corona et al. 2006, Murphy
2008). Moreover, in communities where gender ratio and
power imbalances are prominent, there may be increased
female vulnerability related to safer sex negotiation power
(Wingood et al. 2000, McNair & Prather 2004). Women
may be forced into unprotected sex to maintain partner sta-
bility, hope, intimacy, and sensuality (Oliver 2007). The risk
of transmission is even higher when there is domestic vio-
lence or abuse (Maher et al. 2000, Witte et al. 2004, Miner
et al. 2006). For older women and those in monogamous
relationships, chances of contracting HIV maybe higher
because of lower perceived risk and lesser sexual assertive-
ness in using protection (Stampley et al. 2005, Corneille
et al. 2008). Similarly, variations in family members’ knowl-
edge and attitudes about HIV/AIDS prevention and manage-
ment can also be a challenge (Fisher et al. 1993).
2 © 2012 Blackwell Publishing Ltd
R.W. Eustace

In addition, the burden of HIV in terms of households’
morbidity, poverty, and food insecurities is usually evident
(Hosegood et al. 2004, Wyss et al. 2004, Thangata et al.
2007). Families may be forced to engage in risky behav-
iours out of desperation of making ends meet (Anema et al.
2009). For those who are already infected, co-morbidity
with other diseases and conditions such as malnutrition,
substance abuse, tuberculosis (TB), and viral hepatitis can
have a huge negative impact in the body systems. Conse-
quently, the family has to bear the greatest care giving and
support burden when a family member becomes ill and can
no longer be a productive family member (Manopaiboon
et al. 1998, Vithayachockitikhun 2006). Children may be
forced to cope with informal/formal foster care or reconsti-
tuted family situations following divorce or death of their
parent(s) (Kimuna & Makiwane 2007). Grandparents usu-
ally become the second line of defence (Bock & Johnson
2008), whereas in other families, children and youths
assume the unexpected adult caregiver role, which may
result into emotional distress (Carr & Gramling 2004). This
is worsened when families encounter social stigma (Gilbert
& Walker 2010), social isolation and discrimination from
other family members, friends (Shang 2009, Eustace &
Ilagan 2010), and/or healthcare providers (Thomas et al.
2009).
Other challenges may include disparities in family access
and utilization of healthcare services. For example, lack of
family-centred services may have a negative impact on fam-
ilies with HIV-positive children and adults (Tolle 2009).
At-risk family members who lack accessibility and utiliza-
tion of HIV services may also have a high chance of trans-
mitting HIV to others because they may be unaware of
their HIV status (Hall et al. 2008). For those who have a
confirmed HIV-positive status, navigating the systems may
also be overwhelming and frightening. In addition, fear and
despair resulting from poor quality of health care is not
uncommon, especially in resource-limited regions (D’Cruz
& Arora 2010).
In summary, the above evidence demonstrates that HIV/
AIDS is a chronic disease that has an impact on the individ-
ual and family system(s). Therefore, strategies that promote
family processes and functioning may be of value for HIV/
AIDS prevention and care across the family life cycle and
disease trajectory.
Data sources
To identify interventions for families affected by HIV/AIDS,
a literature search was performed. The search was limited
to English and published literature starting in the year 1983
to date. CINAHL and PubMed, Cochrane Library, Psy-
cInfo, Scopus, and the ISI Web of Science databases were
searched using keywords and subject headings. The main
key phrases used included ‘nurse’ or ‘nursing’, ‘HIV/AIDS’,
‘family interventions’, ‘family support’, ‘family education’,
and/or family subsystems (e.g. ‘spouses’, ‘caregivers’, child’,
‘siblings’, ‘parents’, and ‘family’). The search strategy
yielded a list of 1002 citations. The following discussion
was informed by the review of relevant research evidence
related to the role of the family in HIV/AIDS. The major
outcome was related to the concepts central to ‘family
intervention’, in particular potential HIV/AIDS-FIs across
the disease trajectory.
Discussion
Conceptualizing family intervention
The theorizing process of ‘family interventions’ continues to
be one of the priorities in the family literature (e.g. Camp-
bell 2003, Mattila et al. 2009, Kaakinen et al. 2011).
According to the Merriam–Webster Dictionary (n.d.), the
term ‘intervention’ is simply defined as the ‘act or fact or a
method of interfering with the outcome or course especially
of a condition or process’. Family scholars offer varied defi-
nitions of family interventions. For instance, Berkey and
Hanson (1991) conceptualizes family interventions by
examining the three levels of prevention, namely, primary
(e.g. family education, providing information, and encour-
agement), secondary (e.g. helping families handle their
problems, providing referrals, and intervening in family cri-
sis), and tertiary interventions (e.g. coordination of care
after family is discharged). Feetham (1992), on the other
hand, defines family intervention as the direct activities per-
formed by the practitioner to affect family function and/or
structure in collaboration with the individual family mem-
bers and/or the family system. Similarly, Snyder (1992)
equated family interventions as nursing actions performed
to achieve positive patients’ outcomes in the realm of nurs-
ing. These actions may include family nurturing, support,
and socialization (Niska 1999). Moreover, Campbell (2003)
conceptualizes family interventions across three different
dimensions, namely, family education and support, family
psycho-educational, and family therapy. The first two cate-
gories are conceptualized as either knowledge, behavioural
(e.g. skill training, health-seeking behaviours), or psychoso-
cial (e.g. coping skills, conflict resolutions, problem-solv-
ing). Family therapy, on the other hand, focuses on
dysfunctional families rather than on diseases and illnesses
(Campbell 2003). In addition, Svavarsdottir (2006)
JAN: DISCUSSION PAPER HIV/AIDS family interventions

supports that offering educational information and normali-
zation were examples of specific nursing interventions for
Nordic families with chronic illnesses. Furthermore, Wright
and Leahey (2009) developed the Calgary Family Interven-
tion Model and conceptualized family interventions across
three domains that promote family functioning, namely,
cognitive (knowledge and information), affective (emo-
tional), and behavioural (skills) domains. More recently,
Myers-Walls et al. (2011) conceptualized the major
domains of family health practice to include family life edu-
cation, family support, family therapy/psychotherapy, and
family case management.
In summary, the above family interventions can be
defined as those acts or strategies that facilitate the process
of healthy changes and stability in the family (Kaakinen
et al. 2011). These interventions include concepts such as
information, psychosocial, and behavioural support. How-
ever, to better understand family interventions, it is also
important to take a closer look at the target audiences, dos-
ages, methods, programme administration credibility, and
outcomes as critical components of any intervention (Issel
2009). Based on the review of literature, family interven-
tions are believed to vary across studies, family subsystems,
or disease/illness conditions (Mattila et al. 2009). For
example, some interventions may be directed either towards
the family as a whole or towards its subsystems (Hopia
et al. 2005, von Essen et al. 2001). For the majority of
interventions, the focus is on patients and/or families that
deal with different chronic diseases, such as cancer, obesity,
diabetes, asthma, disabled, schizophrenia, and HIV/AIDS
(Mattila et al. 2009). In terms of the intervention dosage,
most family interventions are reported to take more than
13 weeks to complete (Mattila et al. 2009). The methods
of delivery include home visits, personal meetings, phone
calls, group meetings, or a combination of methods (Mattila
et al. 2009). These methods can take place in the home,
hospital, clinic, or combinations of settings.
Furthermore, to maintain programme administration
credibility, a multidisciplinary healthcare team is desirable
with respect to levels of educational qualifications/prepara-
tions and expertise (Friedman et al. 2003, Kaakinen et al.
2011). Expertise in the fields of family sciences, psychology,
mental health, nursing, public health, and social sciences
are essential as they provide theoretical foundations for
family interventions. Some of the commonly utilized family
theories include structural–functional theory, systems the-
ory, developmental theory and health belief model and ill-
ness theory, communication theory, and change theory.
The structural–functional theory explains family health
outcomes through the examination of family structural
components (i.e. roles, power and decision-making, com-
munication patterns, and values) (Friedman et al. 2003).
The family function component examines the reproductive,
health care, economics, socialization, and affection func-
tions (Friedman et al. 2003, Kaakinen et al. 2011). The sys-
tems theory examines the interactions in and between the
family members, subsystems, and suprasystem. The devel-
opmental theory calls attention to the chronological life
events that take place in a family (Friedman et al. 2003).
Conversely, communication theory represents how family
members interact while change theory focuses on the ripple
effect of change from one family member to the other
(Kaakinen et al. 2011).
In terms of assessing the efficacy of family interventions,
challenges still exist because of the lack of clarity on the
meaning of ‘family outcomes’ (Feetham 1992). However,
lessons can be learnt from other disciplines such as the field
of mental health. For instance, psychosocial family out-
comes may include lowering the emotional climate in the
family by reducing stress and burden on relatives, enhance-
ment of the capacity of relatives to anticipate and solve
problems, reduction in expressions of anger and guilt,
maintenance of reasonable expectations for patient perfor-
mance, and encouragement of relatives to set/keep appro-
priate limits (Pharoah et al. 2006). Other potential family
outcomes include the patient’s physiological measures of
disease processes (e.g. CD4 counts), functional health status
such as health behaviour changes (e.g. smoking, exercising,
dieting), and emotional health (e.g. family functioning, mar-
ital satisfaction, family criticism/conflict) (Campbell 2003),
parental coping (Puotiniemi et al. 2001), enhanced family
nurturing, support and socialization (Niska 1999), family
members’ general well-being and health, quality of life, life
satisfaction, preparedness, overall healthcare service utiliza-
tions, cost-effectiveness (e.g. a reduction in the number of
hospital days) (Mattila et al. 2009), and family caregiving
practices (Vithayachockitikhun 2006). Knafl (2011) also
proposes resilience, role strain, ambiguity, cohesiveness,
and adaptability as useful family concepts for evaluating
the overall outcome of family functioning.
Conceptualizing HIV/AIDS-FIs
Despite limited translational/intervention research on HIV/
AIDS-FIs, the ongoing accumulated evidence supports the
need of developing cost-effective intervention packages in
family-focused HIV/AIDS care (Rotheram-Borus et al.
2010, Li et al. 2011). Simply, HIV/AIDS-FIs packages can
be conceptualized as strength-based family interventions
designed to improve family functioning outcomes among
R.W. Eustace

families affected with HIV/AIDS while recognizing the
social ecology of the family system. The ecological
approach is beneficial in HIV/AIDS care because it provides
a useful way of conceptualizing the interrelationship
between systems (i.e. individual, family, and the larger sys-
tems) (Decosas 2002). HIV/AIDS-FIs are based on several
sound and theoretical approaches mentioned earlier in this
discussion. These theories facilitate the selection of family-
related constructs that are believed to impact individuals
and family outcomes. Although pharmacotherapy is
essential for positive physiological health outcomes, the
focus of HIV/AIDS-FIs is on informational, psychosocial,
and behavioural interventions. The outcomes may include
psychological, physiological, spiritual, and relational com-
ponents. Hence, to effectively design culturally appropriate
interventions, it is important to make sure that any pro-
posed HIV/AIDS-FIs reflect the impact of HIV/AIDS across
the family life cycle and across the disease/illness trajectory.
The following section is an attempt to conceptualize the
HIV/AIDS-FIs across the disease trajectory.
Conceptualizing the HIV/AIDSs disease trajectory
According to Merriam–Webster Dictionary (n.d), the term
‘trajectory’ means ‘a path, progression or line of develop-
ment resembling a physical trajectory’. According to the
work of Glaser and Strauss (1970), a disease trajectory is a
series of events/situations that occur and are experienced by
the family system during an illness. The Family Cycle of
Health and Illness Model developed by Danielson et al.
(1993) was one of the earliest disease illness trajectory
models. This model was based on Doherty and McCubbin’s
(1985) work. The model describes the cyclic and progres-
sion of family events and experiences of a disease through
eight different phases from when a family is healthy to
when the family gets sick and ends in recovery or death.
Belsey (2005) produced a similar conceptual argument of a
chronic disease trajectory, which was specific to the HIV/
AIDS disease trajectory. Four phases instead of eight phases
were used to contextualize the HIV/AIDS disease trajectory.
The following section uses Belsey’s (2005) trajectory per-
spective to describe how family nurses can identify appro-
priate HIV/AIDS-FIs to meet the needs of the affected
individual family member(s) and their families at each
phase:
Phase I: Before a family member is infected with HIV but when cir-
cumstances are such that a family is vulnerable to HIV and family
members are likely to engage in HIV risk behaviors or may be sub-
jected to exploitation or abuse, increasing the risk of HIV exposure
At this phase, it is important to recognize the family as
the primary socializer in health beliefs, attitudes, and prac-
tices (Lesser et al. 1999). The primary goal of HIV/AIDS-
FIs is to promote primary prevention strategies among
high-risk families. Wellness-checks for anticipatory
guidance, health education, risk reduction strategies, and
positive family processes such as relationships and commu-
nication should be emphasized. For instance, relationship-
based interventions that promote healthy relationships
through quality communication, positive sexual negotiation
skills (avoidance of unhealthy sexual relationships), empow-
erment, and problem-solving skills are critical to behaviour-
al change (Lawrence et al. 2001, Kyomugisha 2006). For
example, interventions that have a family communication
component (e.g. Koniak-Griffin et al. 2003, Dancy 2006,
Dancy et al. 2006, 2009, Wamoyi et al. 2010) have the
likelihood of motivating family members to adopt preven-
tive behaviours (Perrino et al. 2000, Kohler et al. 2007)
and raise self-esteem among women dealing with childhood
trauma (Lesser et al. 2003, 2007). Secondary prevention
HIV/AIDS-FIs may be designed to promote couples’ HIV
testing (Mlay et al. 2008, Ganguli et al. 2009). Likewise,
HIV/AIDS-FIs with a focus on tertiary prevention may be
helpful for high-risk individuals or families dealing with
mental health issues related to life vulnerabilities and stres-
sors that put them at increased risks of acquiring HIV. Ter-
tiary interventions may include offering family counselling/
therapy and support. For example, families dealing with
sexual identity crisis may benefit from family counselling
and coping strategies (Meyer & Champion 2010). It is
equally important to incorporate family advocacy as a pri-
mary preventive measure in all of the HIV/AIDS-FIs across
the diseases trajectory because high-risk families often rep-
resent the face of vulnerability in terms of poverty, hope-
lessness, and powerlessness:
Phase II: When the first asymptomatic HIV positive family member
has informed one or more other family members of his or her HIV
Status
Primary, secondary, and tertiary preventions are also
crucial during this phase. The ultimate outcome for HIV/
AIDS-FIs in phase II is to prolong the productive life of
the person living with HIV. This can be accomplished by
implementing strategies that minimize HIV transmission,
promote, and strengthen social and family capital. Strate-
gies to enrich family capacity and functioning include risk
assessments for intimate partner violence, attention to
mental health issues, and integration of parenting practices
for families with children (Betancourt et al. 2010). Pri-
mary prevention of HIV/AIDS-FIs should be tailored

towards health eating, food security, and ‘prevention for
positive’ strategies. In particular, prevention and manage-
ment of co-morbidities (e.g. substance abuse) should be a
priority (Mitrani et al. 2009, 2010), especially among fam-
ilies living in poverty (Bhana et al. 2010). Secondary pre-
vention should focus on screening at-risk family members
(e.g. spouse). To promote and maximize the role of prena-
tal HIV/AIDS diagnoses, maternal and child health centres
should be utilized as venues for implementing HIV/AIDS-
FIs (Tarwireyi 2004). This is important given earlier argu-
ments that majority of the families usually learn about
their diagnosis during prenatal screening. It is also impor-
tant to involve fathers in preconception counselling,
mother-to-child transmission (PMTCT) counselling, infant
feeding counselling, and general decision-making processes
(Sherr 2010).
Early treatment for the infected family members should
also be part of secondary prevention. Thus, HIV/AIDS-FIs
should be designed to enhance adherence to medication and
improve healthy self management practices (e.g. Kamenga
et al. 1991, Tsertsvadze et al. 2008, Ferguson et al. 2009).
Interventions that provide information and referrals about
complimentary or alternative medication (MacIntyre &
Holzemer 1997, Andrade & Anderson 2008) may be help-
ful to families struggling with common uncertainties and
transitional patterns (Knafl 2011).
Tertiary prevention of HIV/AIDS-FIs should focus on
topics such as building hope (Klotz 2010), coping skills,
empowerment (Hulme 1999, Kmita et al. 2002), communi-
cation, stress appraisal, and social support (Fife et al.
2008). In particular, empowerment strategies may prove
useful in helping families develop coping skills that can
facilitate the provision of better care and access to resources
for their infected loved ones (Kmita et al. 2002). Case man-
agement programmes designed to provide continuity of care
should also be emphasized (e.g. Miles et al. 2003, Parrish
et al. 2003). The research evidence has consistently demon-
strated a positive link between family support and emo-
tional well-being (Kennedy 1995, Kalichman 2003,
Schrimshaw 2003, Dyer et al. 2012), positive sexual behav-
iours (Kimberly & Serovich 1999), financial assistance,
activities of daily living (Li et al. 2006), medication adher-
ence (Burgoyne 2005), and disclosure process (Sethosa &
Peltzer 2005). Hence, promising family support and coun-
selling interventions are beneficial especially for families
dealing with depression resulting from denial, shame, sense
of loss, and death anxiety. Furthermore, it is important to
offer HIV/AIDS-FIs with a disclosure component during
this phase and in the next phase, especially for those who
have delayed telling (Nelms & Zeigler 2008). Positive
impacts of disclosure include strengthening family relations
and helping with medical care and counselling, whereas
negative impacts include fear, isolation, avoidance, and psy-
chological burden (Li et al. 2007). Family interventions that
educate the family on how to deal with stigma and discrim-
inations should also be initiated (e.g. Krauss et al. 2006).
The interventions should promote family caregiver practices
that influence positive client’s health outcomes (Wacharasin
& Homchampa 2008), such as medication compliance and
access to care:
Phase III: When the HIV-positive family member, whose serostatus
may or may not have been known becomes symptomatic with
AIDS, an AIDS-related illness, or another illness and is less able to
engage in productive labor activities and fulfill expected family
roles and functions
During this phase of the disease process, the goal of
promoting the family quality of life by preventing or
reducing additional health risks, maintaining levels of well-
ness and therapeutic care routines is still a priority. Thus,
the proposed HIV/AIDS-FIs in phases I and II above are
also applicable in this phase, especially for families that
have not yet disclosed their status and are dealing with
stigma. However, it should be noted that during this time,
families are overwhelmed with role overload and caregiv-
ing burden (O’Donnell & Bernier 1990) as the patient
may be in and out of the hospital or rehabilitation ser-
vices. Family caregivers usually experience feelings of lone-
liness, abandonment, sadness, and physical exhaustion.
Therefore, tertiary prevention in terms of family caregiving
practices (e.g. Flaskerud et al. 2000, de Figueiredo & Tu-
rato 2001) and family caregivers’ outcomes usually
becomes a priority (e.g. Crandles et al. 1992, Hansell
et al. 1998, Pakenham et al. 2002). HIV/AIDS-FIs should
focus on family processes such as positive caregiving, sup-
port, care coordination/connectedness, and communication.
For example, family caregivers who are at risk of depres-
sion may benefit from guidance and assistance through
interventions that focus on stress management and coping
strategies to improve mental health. In addition, family
support in terms of family respite care may alleviate some
of the family stressors related to the family caregiving
role. Furthermore, family communication strategies may
be essential for effective family decision-making and prob-
lem-solving as the family learns how to cope with AIDS,
navigate the healthcare systems and deal with uncertain-
ties. At this point, it is vital that HIV/AIDS-FIs include
end-of life issues such as palliative care. Family counselling
should be emphasized especially when the family is
affected by depression and suicide thoughts related to
R.W. Eustace

death anxiety (Sherman et al. 2010). It may not be unsure
for families to experience emotional strains related to
advanced directives. Therefore, family interventions such
as end-of life communication protocols must be put in
place to facilitate informed medical decisions:
Phase IV: When a family experiences an AIDS death, particularly
when it is a parent who dies and dependent children are orphaned
During this phase, bereavement care is critical especially
for high-risk families prone to pathological grief associated
with the loss of a loved one and/or possible anger related to
HIV transmission (Sikkema et al. 2006). Bereavement inter-
ventions such as family counselling, family support, and
therapy are usually helpful (Forte et al. 2004). The pro-
posed HIV/AIDS-FIs should include coping strategies for
dealing with loss, separation, adoption or reconstituted
family structures, and resiliency (Danielson et al. 1993,
Demmer 2001). For example, support for family caregivers
is essential because they usually feel lonely, sad, and lost
following the demands of caregiving (Kaakinen et al.
2011). Furthermore, family resource management strategies
are helpful for a family facing burdens associated with buri-
als, funeral, and inheritance issues (Belsey 2005). Family
support interventions targeting orphaned children and adult
survivors with internalized and externalized distress related
to discrimination, regret, and stigmatization are equally
important during bereavement (Mizota et al. 2006, Cluver
et al. 2007).
In summary, the proposed HIV/AIDS-FIs span from
health promotion and prevention strategies to interventions
that promote family adjustments and adaptation across the
disease trajectory (Danielson et al. 1993). The proposed
interventions evidently reflect the current needs for psycho-
social and spiritual aspects in HIV/AIDS care (Alexander
et al. 2012). Therefore, the following implications can be
drawn from the above discussion.
Implications for culturally appropriate HIV/AIDS family
nursing practice
It is obvious that HIV/AIDS care includes disease manage-
ment, prevention, and health promotion HIV/AIDS-FI
strategies. These strategies may contain an educational
and/or psychotherapeutic component. To demonstrate
administrative credibility for any proposed HIV/AIDS-FIs
strategies, nurses should make sure that the delivery team
is knowledgeable and believable in the eyes of the con-
sumers. As the largest healthcare profession, nurses are
gatekeepers for patients with HIV/AIDS. They are a great
human resource to implement HIV/AIDS-FIs during their
practice. Therefore, apart from demonstrating profession-
alism, as they work with multiple family members and a
multidisciplinary team, family nurses should obtain the
necessary training and qualification to be able to practice
at various levels of family nursing practice. Appropriate
training should include a solid foundation of family
health sciences and potential family interventions in man-
aging chronic illnesses, such as family life education,
family case management, family therapy, family resource
management, and family financial planning. For example,
a novice baccalaureate family nurse can be trained to
conduct brief/short HIV/AIDS-FIs for high-risk families in
phase I of the disease trajectory, whereas advanced prac-
tice nurses can do so for high-risk families in phases II,
III, and IV.
In addition, knowledge about the different cultural
dimensions and how they apply to specific family groups
affected by HIV/AIDS is crucial in designing and imple-
menting culturally sensitive and appropriate HIV/AIDS-FIs
(Black 2008). Examples of cultural dimensions include
issues surrounding stigmatization of women, fertility, mar-
riage, child-rearing practices, health perceptions of illness
and dying, inheritance practices, gender roles, religious
practices (Belsey 2005), and healthcare delivery systems. It
is important for nurses to assess and evaluate individual
and family health outcomes in any proposed HIV/AIDS-FIs
(Martire et al. 2004).
Implications for HIV/AIDS family research
There is no doubt that more needs to be done about the
overall family-level intervention approaches (Bowen 2003,
Richter 2010) and family-related HIV/AIDS research (Jones
et al. 2003). Researchers should explore family protective
factors such as social relationships/networks as they are
beneficial in identifying how families function and thrive.
More research is needed to expand HIV/AIDS knowledge
on decision-making, especially about end-of life issues
(Gysels et al. 2011), disclosure and sexual negotiations.
Furthermore, the role of family subsystems needs to be
explored. For instance, kinship care systems should be
explored and understood in the context of family members’
coping behaviours across the disease trajectory and
throughout the life span. Furthermore, HIV/AIDS research
evidence should acknowledge the multiple meanings of fam-
ily. HIV/AIDS is colour blind – meaning that all family
structures can be impacted by the disease. Therefore,
recruitment of family systems into clinical trials research
and tracking any changes in family composition should be
emphasized (Mitrani et al. 2011). Moderating or mediating

factors that can influence intervention effects such as age
(Schrimshaw & Siegel 2003), gender (Mitra & Sarkar
2011), social class, and culture should also be addressed in
HIV/AIDS-FIs.
Although there is a strong emphasis of a multidisciplinary
and multilevel approach in designing HIV/AIDS-FIs
(Li et al. 2011), research is still needed on the development
of a multidisciplinary framework to guide the implementa-
tion of multi-component packages of HIV/AIDS-FIs. New
research ideas should be created to garner evidence on how
to alleviate the impact of HIV/AIDS on the family systems.
Moreover, it is also important to get a clear picture of how
nurses perceive family interventions, family outcomes, and
the overall meaning of family health nursing practice for
better innovative multidisciplinary interventions (Eustace
et al. 2012).
Implications for nursing
Nurses have a critical role to play when it comes to HIV/
AIDS family policy. Despite the fact that families are
usually not considered as the client in most healthcare set-
tings (Friedman et al. 2003, Mattila et al. 2009), family
nurses should continue to advocate for family-level care in
their practice (Saveman et al. 2005, Chia-Chen & Thomp-
son 2007). Therefore, nurses should be proactive in devel-
oping policies that promote HIV/AIDS-FIs with the purpose
of improving outcomes in family functioning, processes,
and relationships across the lifespan and chronic disease
trajectory (Belsey 2005). Nurses should be involved in mul-
tidisciplinary local, national, and global HIV/AIDS policy
development and analysis.
Conclusion
This study is important in confirming Wacharasin’s (2010)
assertion that family nursing interventions are promising in
promoting a healing power for families dealing with HIV/
AIDS. The review offers insights that include attention to
the role of the family system and its subsystems across the
chronic disease trajectory. Most important, the information
put forth in this discussion serves as a starting point for fur-
ther exploration of family outcomes and how they can be
perceived and measured in HIV/AIDS interventional
research.
Author contributions
All authors meet at least one of the following criteria
(recommended by the ICMJE: http://www.icmje.org/ethi-
cal_1author.html) and have agreed on the final version:
● substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
● drafting the article or revising it critically for important
intellectual content.
Acknowledgements
Special thanks go to Ms Ximena Chrisgaris, a nursing
librarian at Wright State University for her assistance with
the literature searches. Thanks to Dr Kristine Scordo for
providing constructive feedback during the conceptualiza-
tion process.
Funding
This research received no specific grant from any funding
agency.
What is already known about this topic
● HIV/AIDS is a family disease.
● Both individual and family-focused prevention and
management strategies are important in the prevention
and care of HIV/AIDS.
● There is no standard definition of the term ‘family’.
What this paper adds
● A conceptual definition of HIV/AIDS family interven-
tion
● A call for designing culturally appropriate HIV/AIDS
family interventions across the disease trajectory.
Implications for practice and/or policy
● Nurses should be proactive in developing HIV/AIDS
family interventions and HIV/AIDS family policies to
improve outcomes in family functioning, processes,
and relationship.
● A multidisciplinary approach in designing HIV/AIDS
family intervention should be encouraged.
● More research on families, family interventions, effec-
tiveness, and efficacy of family-focused approaches is
needed.
R.W. Eustace

Conflict of interest
There is no conflict of interest.
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