Both social and medical factors predict unemployment in people with HIV

Unemployment amongst HIV-positive men in Australia needs to be understood within a combined social and medical context, according to a study published in a supplement to the January 2^nd edition of AIDS. The investigators, from the ongoing Positive Health Study, found that although medical factors such as longer duration of HIV infection and poorer self-rated health predicted unemployment, social factors, including age and education, acted as independent predictors of unemployment. The investigators also found that participation in support groups for HIV-positive individuals also predicted unemployment, and suggest that this factor merits further research.

Employment prospects have been a concern for people with HIV since the disease was first identified. Many HIV-positive individuals have left employment because of ill health. However, effective antiretroviral therapy can mean that the health of people with HIV remains sufficiently robust to sustain employment or to return to the job market. Nevertheless, studies have found ongoing rates of high unemployment (as high as 66%) amongst people with HIV.

Studies exploring unemployment have tended to focus on the relationship between single factor and unemployment including health-related barriers to employment; the role of antiretroviral therapy; mental health; and, sociodemographic factors. These studies have often yielded conflicting results.

Investigators from the longitudinal Positive Health Study therefore conducted a study to clarify the relationship between sociodemographic and health factors and unemployment in a large cohort of HIV-positive men.

Recruitment to the study started in 1999 and it included a little over 700 men, 91% of whom were gay with a mean age of 46. Five separate waves of annual interviews were conducted. Three major groups of factors predicting unemployment were analysed: sociodemographic variables; physical health; and, mental health.

Results of the investigators’ initial analysis were not altogether surprising.

First, the investigators looked at sociodemographic factors. They found that unemployment was lower amongst individuals who had received a university education (37%) than those who had not (54%), and that those with an income over AU$ 22,000 per annum were less likely to be unemployed (13%) compared to those with lower incomes (53%). Increasing age was also related with unemployment, with 36% of those under 40 out of work compared to 55% of the over-50s.

The investigators’ first set of analysis also revealed that unemployment was also related to physical and mental ill health. Over two-thirds of individuals who rated their health as “poor” were unemployed compared to only 30% of those who rated their health as “excellent.” Unemployment was also higher amongst those with lower CD4 cell counts (below 200 cells/mm³, 67%, versus 42% with higher CD4 cell counts); those whose who had been diagnosed with HIV for longer (diagnosed before 1987, 565 unemployment, versus 27% unemployment diagnosed as 1996); and, amongst people who had or were taking anti-HIV therapy (45% versus 30%).

As regards the relationship between mental health and unemployment, the investigators found that 52% of those who had sought help for mental health problems in the past year were unemployed compared to 38% those who had not sought such help. They also found that those scored highest on the Kessler score for psychological distress were more likely to be out of work (70%) than those with the lowest scores (34%) and that individuals with the greatest number of self-reported symptoms of depression and psychological distress also had a higher prevalence of unemployment than those with the fewest (69% versus 26%).

The investigators then conducted multivariate analysis to see if there was any relationship between the sociodemographic and physical and mental health factors related to unemployment revealed by the first set of analysis.

This analysis revealed a significantly higher likelihood of unemployment amongst individuals who had been ill because of HIV; had a higher Kessler score of psychological distress; and were older. It also showed that there was a lower likelihood of unemployment amongst individuals who rated their health as “good” or “excellent”; had been living with HIV for a short amount of time; and who had a university education.

Although the investigators did not provide statistical analysis for this, their research also showed that individuals who used HIV support groups were more likely to be unemployed. They suggest that this factor merited further research.

“Our findings show that aspects of both physical and mental health as well as sociodemographic factors are major predictors of unemployment among PLWHA, and that sociodemographic factors remain independent of health factors”, write the investigators. They add that, “these results indicate that a person’s demographic background or social standing is as important to unemployment as their mental or physical health.”

They conclude by recommending that “a shift away from a single focus on antiretroviral therapy as a reason for unemployment would improve the employment prospects for PLWHA.”