One year after starting antiretroviral therapy (ART), 46% of HIV-positive people initially judged unable to work regained the ability to work full- or part-time, according to a 5800-person analysis of the Swiss HIV Cohort Study (SHCS). The proportion of people who regained the ability to work almost doubled from 1998-2001 to 2009-2012.
The newest antiretroviral combinations have increased the life expectancy of some HIV-infected groups to near-normal spans. But the impact of more robust health on ability to rejoin the work force remains poorly understood. To address that question, SHCS investigators conducted this prospective analysis of cohort members less than 60 years old who started ART from January 1998 through December 2012.
The researchers defined inability to work as "a medical judgment of the patient's ability to work as 0%," independent of the patient's opinion or current employment status. Partial ability to work meant a medical judgment that the patient had 1% to 99% ability to work part-time. Full work ability meant a medical judgment that the patient had 100% ability to work full time. The primary endpoint was the proportion of people unable to work at baseline who recovered the ability to work after one year of ART.
Of the 5800 study participants, 4382 (75.6%) had full ability to work at the baseline pre-ART visit, 471 (8.1%) had the ability to work part-time and 947 (16.3%) had no ability to work. Median age was slightly but significantly lower in people with 100% ability to work than in those with ability to work part-time and those unable to work (37 versus 38 versus 39 years, P < .001). The group fully able to work included a higher proportion of men than the groups partly able or fully unable to work (73.1% versus 62.2% versus 65.3%, P < .001). And the group fully able to work included a lower proportion of whites than the other two groups (73.3% versus 80.5% versus 81.6%, P < .001).
Among the 947 people fully unable to work at baseline, 508 (53.6%) remained fully unable after one year of ART, 310 (32.8%) regained full ability to work after one year of ART, and 129 (13.6%) regained partial ability to work. Among the 4382 people fully able to work at baseline, only 217 (5%) lost ability to work during the first year of ART.
Multivariate analysis identified five factors independently associated with higher odds of recovering full ability to work after one year of ART: nonwhite ethnicity, more education, CD4+ count at least 500 cells/mm3 (versus <200 cells/mm3), viral load <50 copies/mL and starting ART later in the study period. Three factors independently predicted lower odds of regaining full ability to work after one year of ART: older age, a psychiatric disorder and participating in an opiate substitution program. Six variables independently raised the odds of developing a new disability to work during the first year of ART: older age, female gender, coinfection with hepatitis C, prior AIDS disease, active intravenous drug use at baseline and a psychiatric disorder.
The overall proportion of people fully able to work rose after one year of ART from 64.4% in 1998-2001 to 85.9% in 2009-2012 (P < .001). Among the 947 people initially completely unable to work, the proportion fully able to work after one year of therapy rose from 24.0% in 1998-2001 to 41.2% in 2009-2012 (P = .001). Participants who regained the ability to work full- or part-time after one year of ART sustained that ability after five years of treatment. But the proportion of HIV-positive people fully capable of working for whom a job was their primary source of income did not increase over time, a result suggesting that "barriers for work reintegration of persons with HIV/AIDS still exist" in Switzerland.
The authors propose that ability to work in the study population depended mainly on reaching an undetectable viral load, on beneficial psychosocial factors and on absence of specific comorbidities. They suggest that reintegration of ART responders into the work force may improve with offers of modified work schedules to sick workers, training of supervisors and communication between employers and health care providers.