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Altered immune Ambulatory Care. HIV infection has no cure, continues for life, causes physical disability, and contributes to impaired health. In many cases it can lead to death. HIV infection affects the entire range of a person's life from physical health to social, emotional, economic, and spiritual well-being. Stigma of HIV. HIV-infected patients share problems experienced by all individuals with chronic diseases, but these problems are exacerbated by negative social attitudes and beliefs surrounding HIV.[34] HIV-infected people may be thought to lack control over urges to have sex or use drugs. Some people conclude that people with HIV brought the disease upon themselves and deserve to be sick. Behaviors associated with HIV infection are viewed by some as immoral (e.g., homosexuality, promiscuity) and are sometimes illegal (e.g., using drugs, sex work). The fact that infected individuals can transmit HIV to others creates fear, which leads to stigma and discrimination in all facets of life. In the United States, HIV-infected people have lost jobs, homes, and insurance, although these forms of discrimination are prohibited by the Americans with Disabilities Act (ADA). HIV-related stigma is a global problem that is often more severe for women. Discrimination can lead to social isolation, dependence, frustration, low self-image, loss of control, and economic pressures. Disease and Drug Side Effects. Physical problems related to HIV or its treatment can interfere with the patient's ability to maintain a desired lifestyle. HIV-infected patients frequently experience anxiety, fear, depression, diarrhea, peripheral neuropathy, pain, nausea, vomiting, and fatigue. Nursing interventions for these symptoms are similar to what they would be for the patient who does not have HIV infection. For example, nursing management of diarrhea includes helping patients collect specimens, recommending dietary changes, encouraging fluid and electrolyte replacement, instructing the patient about skin care, and managing skin breakdown around the perianal area. Nursing approaches for fatigue in HIV include teaching patients to assess fatigue patterns; determine contributing factors; set activity priorities; conserve energy; schedule rest periods; exercise regularly; and avoid substances such as caffeine, nicotine, alcohol, and other drugs that may disturb sleep. Some HIV-infected patients, especially those who have been infected and on ART for a long time, may develop a set of metabolic disorders. These include (1) lipodystrophy (changes in body shape caused by a redistribution of fat in the abdomen, upper back, and breasts along with fat loss in the arms, legs, and face) (Fig. 14-9); (2) hyperlipidemia (elevated triglycerides, elevated low-density lipoproteins, and decreased high-density lipoproteins); (3) insulin resistance (4) hyperglycemia; (5) bone disease (osteoporosis, osteopenia, avascular necrosis); (6) lactic acidosis; (7) renal disease; and (8) cardiovascular disease.[35,36] FIG. 14-9 Lipodystrophy manifestations. It is still not clear why these disorders develop, but it is probably a combination of factors such as long-term infection with HIV, side effects of ART, genetic predisposition, and chronic stress. Management of metabolic disorders focuses on detecting problems early, dealing with symptoms, and helping the patient cope with emerging problems and changes to treatment regimens. It is important to recognize and treat these problems early, especially because cardiovascular disease and lactic acidosis are potentially fatal complications. A frequent first intervention is to change ART medications because some drugs are more often associated with these disorders. Lipid abnormalities are generally treated with lipid-lowering drugs (see Table 33-5), dietary changes, and exercise. Insulin resistance is treated with hypoglycemic drugs and weight loss. Bone disease may be improved with exercise, dietary changes, and calcium and vitamin D supplements. End-of-Life Care. Despite new developments in the treatment of HIV infection, many patients eventually experience disease progression, disability, and death. Sometimes these occur because treatments do not work for the patient. Sometimes the patient's HIV becomes resistant to all available drug therapies. In addition, ART is now allowing people living with HIV to live longer and to develop diseases of aging, such as cardiovascular and endocrine problems that lead to death. Nursing care during the terminal phase of any disease should focus on keeping the patient comfortable, facilitating emotional and spiritual acceptance of the finite nature of life, helping the patient's significant others deal with grief and loss, and maintaining a safe environment.[37] As a nurse, you are the pivotal care provider during this phase of illness, whether at home, through hospice, or in a health care facility. (End-of-life care is discussed in Chapter 9.)