Diabetes, high blood pressure increase risk of unemployment for people with HIV

Large numbers of patients are leaving employment in the years following their diagnosis with HIV, French investigators report in the online edition of AIDS. The five-year probability of work cessation was 35%, and there was little evidence that this was a consequence of a positive choice, for example to retrain.

Neither antiretroviral therapy nor the severity of HIV disease were associated with an increased risk of withdrawing from employment. However, some of the comorbidities that occur in patients with HIV, especially diabetes and hypertension and to a lesser extent, depression, were associated with leaving work.

“Our results provide evidence for the existence of a phenomenon of work cessation starting after the very first months following HIV diagnosis and persisting during the five subsequent years,” comment the investigators. “Comorbidities frequently associated with HIV disease including diabetes, hypertension and depression substantially affect the chances of maintaining employment.”

Employment is a major factor in maintaining levels of income and living standards. Moreover, unemployment has also been associated with poor outcomes, including an increased risk of illness and death.

A number of studies have shown that chronic conditions such as cardiovascular disease increase the risks of unemployment. Research conducted soon after the introduction of effective antiretroviral therapy showed that patients had a high risk of unemployment in the years immediately following their diagnosis with HIV.

Since then there have been major improvements in HIV treatment and care and the prognosis of many HIV-infected patients is now near normal. However, it is well recognised that individuals with HIV have an increased risk of other illness which in themselves can increase the risk of unemployment.

Investigators from the French ANRS-CO-9-COPANA cohort study wanted to establish the risks of work cessation for patients with HIV and the factors associated with this.

They therefore designed a prospective study involving 622 patients who received HIV care between 2004 and 2010.

At baseline and then at annual intervals the patients were asked about their employment status. Information was obtained from medical records about the patients’ demographics, CD4 cell count and viral load, the use of antiretroviral therapy and the presence of comorbidities.

The patients enrolled in the study were a representative sample of the HIV-affected population in France. Approximately a third were women, 41% were migrants and 45% were infected with HIV via sex with another man.

Overall, 367 patients (60%) were employed at baseline. Individuals in employment were older (36 vs. 33) than those who were not employed. They also had a better level of education. Employed individuals were also more likely to live with their partner (58% vs. 51%) and to have disclosed their HIV status to family, friends or colleagues (79% vs. 59%).

Differences in health status were also apparent between employed and unemployed patients. Those in employment were less likely to have AIDS (5% vs. 10%), a CD4 cell count below 200 cells/mm³ (15% vs. 23%) or a viral load above 5 log₁₀ copies/ml (22% vs. 29%).

Rates of hepatitis B or C co-infection were also lower in the employed patients than in those who were out of work. (2% vs. 9%), and economically active individuals were also less likely to have depression (32% vs. 43%).

Over the course of the study a total of 67 patients who were in employment at baseline stopped working before the official retirement age of 60.

This included 58 patients who became unemployed, four individuals who were medically retired, three who took long-term sick leave, and two who returned to education or undertook further training. However, 24 individuals subsequently returned to work meaning that 47 (13%) were still out of employment at the end of follow-up.

The investigators therefore believe that they found little evidence of “employment discontinuation from reasoned choice”.

Work cessation occurred a median of 20 months after entry into the study.

The cumulative probability of work cessation was 5% after twelve months, increasing to 14% after 24 months and 35% after five years.

Patients aged 30 to 39 had a higher risk of leaving employment than those in their 40s (adjusted hazard ratio [aHR] = 3.1; 95% CI, 1.5-6.5). The risk of work cessation was also higher for those with lower levels of education compared to patients who had attended college or university (aHR = 2.6; 95% CI, 1.0-6.7). Women and migrants had a higher risk of work cessation, but this ceased to be significant after controlling for levels of education.

Medical conditions associated with an increased risk of leaving employment included diabetes (aHR = 5.6; 95% CI, 1.7-18.5) and hypertension (aHR = 3.1; 95% CI, 1.5-6.4). There was also a trend approaching significance for depression (aHR = 1.7; 95% CI, 0.9-2.9).

In contrast, neither HIV disease progression nor CD4 cell count and viral load increased the risk of work cessation. Nor was the risk of leaving employment associated with starting HIV therapy.

“Comorbidities constitute major barriers to continued employment among HIV-infected people,” comment the authors.

They conclude, “The risk of work cessation during the course of HIV infection has remained substantial. Social and economic consequences for patients, employers and society are likely to be important and should be addressed at different levels including clinical settings, employers and social workers.” The researchers add: “Particular attention should be paid to prevent HIV-infected patients affected by comorbidities from leaving employment.”