Appendix D
Literature Tables

METHODS

A review of published literature was conducted related to disability and HIV/AIDS to examine current evidence of related employment capability. Extensive search terms were used, yielding initial results of 9,295 studies published between January 1993 and October 2009. The studies were reviewed, analyzed, and categorized (see Box D-1). The most relevant studies were identified as Category 1, totaling 32 articles for more detailed review. The topics of these studies include return to work for people living with

BOX D-1

Definitions of Categories

  • Category 1: Studies on clinical measures of treatment outcomes, diagnostic techniques, or health status indicators as they relate to employment capability (i.e., return to work, employability) for U.S.-based populations with HIV/AIDS.

  • Category 2: Studies on one or more parameters of disability (e.g., comorbid conditions, quality of life, morbidity, mortality) as they affect functional capacity for populations with HIV/AIDS.

  • Category 3: Studies on disability or employment factors, but which do not explicitly address, measure, or estimate medical treatment or functional capacity of populations with HIV/AIDS.

  • Category 4: Studies not related to HIV disability and employment.



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Appendix D Literature Tables METHODS A review of published literature was conducted related to disability and HIV/AIDS to examine current evidence of related employment capability. Extensive search terms were used, yielding initial results of 9,295 studies published between January 1993 and October 2009. The studies were re- viewed, analyzed, and categorized (see Box D-1). The most relevant studies were identified as Category 1, totaling 32 articles for more detailed review. The topics of these studies include return to work for people living with BOX D-1 Definitions of Categories • Category 1: Studies on clinical measures of treatment outcomes, diagnos- tic techniques, or health status indicators as they relate to employment capability (i.e., return to work, employability) for U.S.-based populations with HIV/AIDS. • Category 2: Studies on one or more parameters of disability (e.g., comorbid conditions, quality of life, morbidity, mortality) as they affect functional capacity for populations with HIV/AIDS. • Category 3: Studies on disability or employment factors, but which do not explicitly address, measure, or estimate medical treatment or functional capacity of populations with HIV/AIDS. • Category 4: Studies not related to HIV disability and employment. 

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4 HIV AND DISABILITY HIV/AIDS, the neuropsychological symptoms of HIV infection, and effect of combination antiretroviral therapy on vocational rehabilitation. Search Strategy The strategy of the literature review searched four databases: Medline, EMBase, Web of Science, and PsychINFO. Together these databases access information related to medicine, nursing, health care delivery, psychiatry, sociology, and psychology. Search strategies were developed for each da- tabase using text terms and Medical Subject Headings focused on eight subject areas, including HIV/AIDS, disability, employment, quality of life, functional capacity, treatment outcomes, severity of impairment, and co- morbidities. Distinct terms were identified in each subject area to yield as many unique results as possible. Strategy parameters included limiting the search to human subjects, the English language, and studies published from 2004 to 2009. This time period was chosen to focus the studies on the most recent medical and scientific literature. Preliminary Analysis and Results A rigorous review of titles and abstracts determined which studies met the inclusion criteria. Each study was coded according to the category sys- tem. The preliminary results include 32 Category 1 articles, which focus on study populations with HIV/AIDS and employment capability. Table D-1 provides a detailed review of all Category 1 studies. An additional 331 arti- cles were identified as Category 2 articles, which inform broader parameters potentially affecting functional capacity of populations with HIV/AIDS. These parameters include relative quality of life (with specific measurements for health-related quality of life), comorbid conditions, gender comparisons, and assessments of treatments for HIV/AIDS, or associated conditions that may lead to disability or impairment. The remaining 8,932 studies were categorized as either Category 3 or Category 4 studies. Category 3 studies informed background research during report writing. Category 4 studies did not meet the inclusion criteria and were not included in the study.

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 APPENDIX D Table D-1 starts on the following page.

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 HIV AND DISABILITY TABLE D-1 Literature Review on Employment Capability and HIV Time Study Study Purpose Study Type Frame Disability Anandan, N., B. Navaraj, B. Determines occupational Observational N/A Braveman, G. Kielhofner, and functioning required for K. Forsyth. 2006. Impairments various activities and and perceived competence in describes impairments persons living with HIV/AIDS. prevalent in HIV/ Work 27(3):255–266. AIDS population; examines impact of these impairments on individuals’ perceived occupational competence Cade, W. T., L. Peralta, and Examines the biological Review N/A R. E. Keyser. 2004. Aerobic factors possibly limiting exercise dysfunction in human the oxidative metabolic immunodeficiency virus: A response to physical potential link to physical activity for people with disability. Physical Therapy HIV 84(7):655–664. Levin, M., G. Kielhofner, B. Determines the utility Observational 9 months Braveman, and L. Fogg. 2007. of the narrative slope Narrative slope as a predictor in predicting vocational of work and other occupational outcomes of individuals participation. Scandinaian with HIV/AIDS Journal of Occupational Therapy 14(4):258–264.

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 35 • Convenience • Occupational Self- • Impairments most commonly sample from the Assessment (OSA) identified by participants: ongoing federally • Sign and Symptom - Fatigue funded research Checklist - Fear/worries project: Enabling (SSC-HIV) - Difficulty concentrating Self-Determination - Muscle aches (ESD) for Persons - Depression Living with • Primary areas of occupational HIV/AIDS functioning where individuals reported moderate to severe impairment: managing finances and physical activities N/A N/A N/A Physical functional disability measured by: • Fatigue • Diminished capacity to engage in peak aerobic exercise capacity • Inability to engage in instrumental activities of daily living 65 • SSC-HIV Narrative slope • Positive narrative slope • Occupational measure of predictive of employment Performance employment status or engagement in other History Interview or other productive productive activity (OPHI-II) includes: activity at 3- and 6- • Relationships were statistically - Occupational month follow-up significant at 3- and 6-month identity scale follow-up; 9-month follow-up - Occupational not statistically significant competence scale - Occupational behavior settings scale • Model of Human Occupation continued

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 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Employment Arns, P., D. Martin, Examines a population Observational January and R. Chernoff. 2004. entering a vocational 1997– Psychosocial needs of HIV- rehabilitation program December positive individuals seeking designed for individuals 1999 workforce re-entry. AIDS Care with HIV, examining the 16(3):377–386. population’s indicated objective and subjective needs to gain employment Braveman, B., G. Kielhofner, Examines and describes Observational 12 G. Albrecht, and C. Helfrich. the efforts of 12 men months 2006. Occupational identity, living with AIDS to occupational competence reestablish a role in the and occupational settings workforce following the (environment): Influences completion of a vocational on return to work in men rehabilitation program living with HIV/AIDS. Work 27(3):267–276. Braveman, B., M. Levin, G. Reviews literature Review 1995– Kielhofner, and M. Finlayson. on employment and 2005 2006. HIV/AIDS and return combination antiretroviral to work: A literature review therapy one-decade post-introduction of combination therapy (HAART). Work 27(3):295–303. Burns, S. M., L. R. Young, and Explores the relationship Observational N/A S. Maniss. 2006. Predictors between employment of employment and disability and disability as well as among people living with selected demographic, HIV/AIDS. Rehabilitation biological, and Psychology 51(2):127–134. functionality variables for people living with HIV/AIDS Conover, C. J., P. Arno, M. Examines the labor Observational 2000– Weaver, A. Ang, and S. L. market outcomes of 2002 Ettner. 2006. Income and individuals diagnosed with employment of people living HIV, mental disorders, with combined HIV/AIDS, and substance abuse chronic mental illness, and disorders substance abuse disorders. Journal of Mental Health Policy and Economics 9(2):71–86.

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 235 • Questionnaires • Employment status • Employed participants of individuals • Education exhibited a marked decline in recruited from • Finances vocational functioning relative local health care • Housing to pre-HIV status, with related agencies, HIV • Access to health and accompanying financial mental health care declines programs, HIV • Health status case management programs 12 • OPHI-II • Employment • Resumption of roles and • Completion of history before engagement in new activities Employment and after onset of resulted in increased Options Program disability confidence in occupational • Narratives identity, competence, and • Narrative slope setting analysis N/A N/A N/A • Employment is a possibility for HIV-infected people, but many face multiple challenges, including: • Side effects of treatment • Ongoing social stigma • Psychological burden associated with the disease 152 • Questionnaire • Age • Significant predictors of • Clinical markers employment: • Race - Minority race • Time since - Higher CD4 count diagnosis - Higher mental health or physical health functioning 1,138 • Interviews • HIV transmission • Less than 15 percent of risk activities sample employed, including • Medication both full- or part-time adherence • High education levels and • Employment better physical health were • Source of income indicators for employment • More than 33 percent reported not working due to a permanent disability continued

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0 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Conyers, L. M. 2004. The Explores the perceptions Observational N/A impact of vocational services of 25 individuals with and employment on people HIV/AIDS who engage with HIV/AIDS. Work in vocational services in 23(3):205–214. attempt to return to work Conyers, L. M. 2008. HIV/ Reviews three articles Review N/A AIDS and employment research: on HIV/AIDS and A need for an integrative employment that approach. The Counseling recommend future Psychologist 36(1):108–117. directions for theory integration, HIV health outcomes, and interdisciplinary approaches Escovitz, K., and K. Donegan. The Kirk Employment Observational 36 2005. Providing effective Empowerment Project months employment supports for (KEEP), a 3-year persons living with HIV: demonstration project, The KEEP project. Journal identified effective employment service of Vocational Rehabilitation 22(2):105–114. strategies for individuals with HIV/AIDS Goldman, D. P., and Y. Bao. Examines whether Observational 24 2004. Effective HIV treatment combination antiretroviral months and the employment of HIV(+) therapy helps HIV-infected adults. Health Serices Research patients return to work, 39:1691–1712. remain employed, or maintain hours of work

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 25 • Focus groups • Impact of • Vocational rehabilitation vocational services led to the following: rehabilitation - Improved confidence • Programmatic - Higher motivation qualities of - Increased skills vocational services - Increased self-respect • Impact of - Diversion from HIV employment - Improved health • Vocational services engender the following among participants: - Individualized approach to HIV management - Peer support N/A N/A N/A • Integrating multiple disciplines—such as psychology, vocational rehabilitation, and community development—in addition to approaches to clinical care are important for helping individuals with HIV/AIDS return to work 148 • Focus groups • Employment status • Most participants experienced • Interviews at 6- • Motivation to the following barriers to month intervals work employment: • Quality of life - Psychiatric disability - Substance abuse - Domestic violence - Low education levels - Incarceration history - Unstable housing 2,864 • Interviews • Return to work • Beginning treatment at less • Multistage within 6 months advanced stages of infection sampling frame of treatment leads to greatest gain in • Remaining employment status employed within • Employed patients are more 6 months of likely to remain employed treatment because of therapy • Hours at work continued

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 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Gorman, A. A., J. M. Foley, Reviews the implications Review N/A M. L. Ettenhofer, C. H. of HIV-associated Hinkin, and W. G. van neuropsychological Gorp. 2009. Functional disorders (HAND) consequences of HIV-associated neuropsychological impairment. Neuropsychology Reiew 19(2):186–203. Hergenrather, K. C., S. D. Explores factors Observational N/A Rhodes, and G. Clark. 2005. influencing the job-seeking The employment perspectives behaviors of individuals study: Identifying factors living with HIV/AIDS, influencing the job-seeking using the planned behavior of persons living with behavior theory HIV/AIDS. AIDS Education & Preention 17(2):131–142. Maguire, C. P., C. J. McNally, Provides in-depth Observational N/A P. J. Britton, J. L. Werth Jr., and descriptions of vocational N. J. Borges. 2008. Challenges experiences of individuals of work: Voices of persons with with HIV HIV disease. The Counseling Psychologist 36(1):42–89. Martin, D. J., P. G. Arns, Compares factors Observational 1997– R. A. Chernoff, and M. influencing individuals 2001, Steckart. 2004. Working with with HIV/AIDS who 24-month HIV/AIDS: Who attempts attempt workforce periods workforce reentry following reentry; at entry to the disability? Journal of Applied program, participants were unemployed and Rehabilitation Counseling 35(3):28–38. disabled Martin, D. J., R. A. Chernoff, Reviews three vocational Review N/A and M. Buitron. 2005. Tailoring rehabilitation programs a vocational rehabilitation to better understand the program to the needs of people workforce-reentry process with HIV/AIDS: The Harbor– for individuals living with UCLA experience. Journal HIV/AIDS of Vocational Rehabilitation 22(2):95–103.

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings N/A N/A N/A • Patients with HAND have limited or challenged ability to engage and persist in employment, driving, medication adherence, mood, fatigue, and interpersonal functioning 54 • Focus groups • Responses elicited • Work perceived as having • Planned behavior from individuals value model on interest in and • Participants expressed need potential barriers for assistance to address to employment barriers to employment such as education/training or social stigma 93 • Focus groups • Responses elicited • Primary areas of concern for • Grounded theory from individuals participants: approach on interest in and - Employment potential barriers - Community to employment - Health 235 • Questionnaire • Income and source • Individuals who attempted • Short Form 36 • Employment status return to work showed more (SF-36): Evaluates • CD4 count improved health status (i.e., individuals on • Viral load higher CD4 counts, fewer eight domains of • History of opportunistic infections, functioning opportunistic higher SF-36 scores for infections physical functioning, among other measures) N/A N/A N/A • Continuing need for workforce reentry programs exists • Population affected by HIV shifts; programs should reflect this change • Full-time employment may not be an appropriate goal for individuals with HIV/AIDS continued

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4 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Martin, D. J., M. J. Steckart, Studies the workforce- Observational 24 and P. G. Arns. 2006. Returning reentry process for months to work with HIV/AIDS: individuals with A qualitative study. Work HIV/AIDS 27(3):209–219. Rabkin, J. G., M. McElhiney, S. Identifies patterns and Observational 30 J. Ferrando, W. van Gorp, and predictors of work status months S. Hsing Lin. 2004. Predictors and number of hours of employment of men with employed in a group of HIV/AIDS: A longitudinal men with HIV/AIDS study. Psychosomatic Medicine 66(1):72–78. Razzano, L. A., and M. M. Evaluates two issues Observational N/A Hamilton. 2005. Health-related identified in previous barriers to employment among research on HIV/AIDS people with HIV/AIDS. Journal and employment: health perceptions and sources of Vocational Rehabilitation 22(3):179–188. of insurance and health benefits Razzano, L. A., M. M. Focuses on the factors Observational 6 months Hamilton, and J. K. Perloff. related to employment 2006. Work status, benefits, status, sources of health and financial resources among benefits, and entitlements people with HIV/AIDS. Work among people with HIV/ 27(3):235–245. AIDS; results demonstrate differences in work status, benefits, and financial support received based on gender

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 104 • Questionnaire • Income • Employment barriers include: • Health indexes - Poor physical health - CD4 count - Poor mental health - Viral load - Education deficiencies • Work in the past - Lack of motivation month - Social barriers - Cognitive deficits - Substance abuse - Incarceration history 141 • Beck Depression • Medical measures • 20 percent of men were Inventory (CD4 count, viral continuously employed full • Axis I diagnosis load, physical time of lifetime and limitations) • 9 percent of men were current depressive • Hours employed: continuously employed part disorders (full or part time, time unemployed) • 40 percent of men were • Financial measures continuously unemployed (SSI, SSDI) • Barriers to work included: • Neuropsych- - Structure of disability ological measures benefits (seven tests—not - Depressive disorder listed) - Physical limitations - Cognitive impairment 63 • Beck Depression • Functional status • Patients faced health-related Inventory • Well-being barriers to employment, • Medical Outcome - Pain including personal concerns of Survey-HIV Health - Mental health health and functional status Survey (MOS-HIV) - Energy/fatigue • Depression affected the ability - Health distress to consider or continue work - Quality of life • Physical impairments • Changes in health remained despite higher CD4 status (i.e., CD4 counts count, viral load) 98 • Medication • Employment status • More men than women Adherence Program • Health benefit reported working at 6-month Study sources follow-up (MAPS protocol) • Medication • Men receive higher Social adherence Security Disability Insurance • Alcohol or drug benefit based on higher use average lifetime earnings • Physical and • Employment and gender mental health affect amount of benefits indicators and financial resources • Employment status for individuals living with • Financial status HIV/AIDS continued

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 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Timmons, J. C., and S. L. Fesko. Reveals the value Observational N/A 2004. The impact, meaning, and and significance of challenges of work: Perspectives employment for of individuals with HIV/ individuals with HIV/ AIDS. Health & Social Work AIDS, concerns related to 29(2):137–144. Social Security benefits van Gorp, W. G., J. G. Followed individuals with Observational 24 Rabkin, S. J. Ferrando, J. HIV/AIDS who initiated months Mintz, E. Ryan, T. Borkowski, return to work processes and M. McElhiney. 2007. to identify existing Neuropsychiatric predictors of supports or barriers to return to work in HIV/AIDS. employment Journal of the International Neuropsychological Society 13(1):80–89.

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 29 • Focus groups • Employment status • The loss of Social Security • Perceptions and benefits was a notable intentions of concern for participants who participants considered returning to work 118 • Neuropsychological • Financial status • Predictors of employments: tests: • Health status - Younger age - Wechsler Adult • Neuropsych- - Reporting higher quality of Intelligence Scale ological measures life III • Psychiatric/ - Performing significantly - Wide Range psychosocial better on timed motor Achievement measures measure with dominant Test-3 • Employment status hand - Trail Making assessed at each - Evidence of better learning Test I and II 6-month follow-up and recall on recognition - California Verbal and learning memory Learning Test measures - Faces I and III - Stroop Color Interference Test - California Computerized Assessment Package - Wisconsin Card Sorting Test • Structured Clinical Interview for DSM (SCID) • Beck Depression Inventory • Endicott Quality of Life Enjoyment and Satisfaction Questionnaire • Wortman Social Support Scale continued

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 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Functional Capacity Bernell, S. L., and J. A. Analyzes the determinants Observational 1996, Shinogle. 2005. The relationship of combination 2 months between HAART use and antiretroviral therapy use employment for HIV-positive and employment status individuals: An empirical for individuals who are analysis and policy outlook. infected with HIV Health Policy 71(2):255–264. Berry, J. D., and B. Hunt. Provides an overview of Review N/A 2005. HIV/AIDS 101: A primer medical and psychosocial, for vocational rehabilitation information on HIV/AIDS counselors. Journal of related to vocational rehabilitation Vocational Rehabilitation 22(2):75–83. Conyers, L., and P. Datti. Discusses unique needs Observational N/A 2008. The unmet vocational of women with HIV/ rehabilitation needs of women AIDS and their needs for with HIV/AIDS. Work vocational rehabilitation 31(3):277–290. services

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 2,864 • HIV Cost and • Employment status • Fully or partially employed Services Utilization • Combination individuals were more likely Study: A test of antiretroviral to be on therapy (26 versus 22 independence therapy percent) between individuals • Covariates: • Individuals on therapy were on therapy and - Comorbidities less likely to have difficulties those not, and - Injection drug with activities of daily living unemployed use (7 versus 26 percent) and employed - Mental health individuals status N/A N/A N/A • Vocational rehabilitation may include: - Training for employers to reduce stigma or discrimination of the individual with HIV/AIDS - Address employment gaps for individuals with HIV/AIDS - Improve job seeking and interviewing skills 122 • National Working • Economic • 59 percent of study Positive Coalition and health respondents were employed Employment characteristics and at time of survey (compared Needs Survey how they differ by to 68 percent at time of (NWPC-ENS) employment status diagnosis) • Patterns of • Maintaining or increasing employment and income was cited as the use of employment most important incentive for services of employment NWPC-ENS • 70 percent of employed • Incentives to work individuals self-reported they and effect of loss were mostly to very healthy, of employment compared to 49 percent of unemployed participants continued

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0 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Kielhofner, G., B. Braveman, Describes the Observational N/A M. Finlayson, A. Paul-Ward, L. development, Goldbaum, and K. Goldstein. implementation, and 2004. Outcomes of a vocational outcomes of a program program for persons with of vocational services AIDS. American Journal for individuals with HIV/AIDS of Occupational Therapy 58(1):64–72. O’Brien, K. K., A. M. Bayoumi, Develops a conceptual Observational N/A C. Strike, N. L. Young, and framework of disability A. M. Davis. 2008. Exploring from the perspective disability from the perspective of adults living with of adults living with HIV/AIDS: HIV/AIDS Development of a conceptual framework. Health & Quality of Life Outcomes 6(76). Paul-Ward, A., B. Braveman, G. Details the development Observational 12 Kielhofner, and M. Levin. 2005. of employment and months Developing employment services independent living services for individuals with HIV/AIDS: of a 3-year federally Participatory action strategies funded demonstration at work. Journal of Vocational project: Enabling Self- Rehabilitation 22(2):85–93. Determination (ESD) for Persons Living with AIDS

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 129 • OPHI-II • Other physical • Significant outcomes included • Narrative slope diagnoses besides return to work, school, or HIV or AIDS volunteer or intern activities: • Mental health - 60 participants successfully history completed the program • Substance abuse - 30 participants did not history successfully complete the • Incarceration program because they did history not return to work or seek • OPHI-II scale education or volunteer scores opportunities • Narrative slope • An additional 39 individuals dropped out of the program prior to its completion: reasons included becoming sick, deciding vocational goals were not realistic, relapse into substance abuse, or difficulty maintaining a routine to come to the program; 39 individuals did not complete the program 38 • Focus groups • Health-related • Participants’ concepts • Grounded theory challenges of disability emerged as techniques • Physical, social, multidimensional and episodic and psychological • Disability spanned physical, areas of life mental, and psychological affected domains • Overall impact on • Inability to access needed health services (e.g., housing, medications) reduced the individual’s ability to participate in society 14 • Survey • OPHI-II Intensive, personalized, • Focus groups • MOS-HIV coordinated independent living • HIV impairment services positively affect the checklist lives of individuals living with • The Worker HIV/AIDS: Role (structured • Two clients obtained part-time interview) jobs • One client returned to school • One client enrolled in a full-time technical training program • One client transitioned to independent living continued

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 HIV AND DISABILITY TABLE D-1 Continued Time Study Study Purpose Study Type Frame Quality of Life Martin, D. J., P. B. Arns, P. J. Predicts the likelihood Observational 24 Batterham, A. A. Afifi, and M. of return to work of months J. Steckart. 2006. Workforce individuals living with reentry for people with HIV/ HIV/AIDS participating in AIDS: Intervention effects and a specialized program predictors of success. Work 27(3):221–233. Ryu, E., S. G. West, and K. Examines the relationships Observational 1992– H. Sousa. 2009. Mediation among symptoms, 1994 and moderation: Testing functional capacity, relationships between symptom and quality of life for status, functional health, and individuals living with quality of life in HIV patients. HIV/AIDS Multiariate Behaioral Research 44(2):213–232. Severity of Impairment Vetter, C. J., and J. P. Donnelly. Reviews literature Review N/A 2006. Living long-term with addressing medical, HIV/AIDS: Exploring impact psychological, and in psychosocial and vocational psychosocial challenges domains. Work 27(3):277–286. related to living with HIV/AIDS

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 APPENDIX D Sample Size (Persons) Method Outcome Measures Relevant Findings 235 • Questionnaire • Income and • Participants receiving Social income source Security Disability Income • Current benefits were less likely to employment status return to work • Health status: • Participants with higher - CD4 count income levels prior to study - Viral load were less likely to return to - History of work than those with low opportunistic income levels infections • Those with higher health - SF-36 status were more likely to return to work 956 • Questionnaire • Symptoms • Symptom status has an • Functional health indirect relationship to quality • Health-related of life quality of life • Relationship partially mediated by functional health: having more symptoms increases disability (i.e., decreases functional health) and lowers quality of life N/A N/A N/A • In 5 of 10 reviewed studies, respondents cited loss of medical benefits through Social Security as a barrier to seeking or resuming employment • Social stigma cited as a barrier to employment • Receiving support services after attaining employment were cited as important in one study

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