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ISSUE NO. 38

www.HIVLine.com

This newsletter is supported through an independent educational grant from GlaxoWellcome

Managing Work and HIV
Helping Clients Achieve a Productive and Rewarding Working Life
efore the advent of highly active antiretroviral therapy (HAAR"f), a diagnosis of HIV/AIDS meant leaving
the workplace, often permanently. HIV-infected individuals who were symptomatic frequently went on
permanent disability, and most of them went home to die. Now, thanks to effective combination therapies, broadened medical knowledge, and improved prophylactic treatments, many people can continue
to work, with few or no absences related to their illness. Those who have left the workplace temporarily are able to
return to their old jobs or seek new ones.
Nonetheless, managing HIV at work presents unique problems and issues, with implications in the legal, medical,
and psychosocial arenas as well as real challenges to time-management skills. Counselors have an important role
to play when their clients express the desire to continue working or return to work after a diagnosis of HIV disease.
This issue of HIV Frontline looks at HIV and the challenges it can bring to the workplace.
foster a sense of normalcy for many HIV-infected individuals. For people whose illness has put parts of their lives on
The Medical Issue
hold, returning to work can be a milestone on the road to
Steve had been teaching for 20 years when he took medical leave,
recovery. This achievement can improve the patient's mentoo ill from HIV to cope with a roomful of kids. He's been out of
tal
health and self-esteem.
the classroom for 5 years, but he's feeling much stronger, thanks
to his combination therapy. It has been more than 1 year since Work is often a source of stress, however, difficult for even
he's had any symptoms. He thinks he's ready to go back to work healthy people to manage. A recent study conducted by Dr
and believes it is essential to his emotional and physical well- Jane Lesserman, psychiatric researcher at the University of
being. He talked to his healthcare provider, who gave him the North Carolina, found that stress may speed the progres"OK" to return to work but emphasized the importance of contin- sion from HIV to AIDS. The report noted that men in stressuing the therapy that has made this possible. He will need to ful situations with little social support were two to three
adhere strictly to his regimen, get regular medical checkups times more likely to develop full-blown AIDS than individ(including viral load monitoring and CD4 counts), and follow a uals with lower stress and more support.
healthy diet and lifestyle.
Work-related stress, combined with continued concern
For many people with HIV/ AIDS, caring for their health is, about their health and about disclosure of their HIV status,
in itself, a full-time job and should be considered the can be especially harmful to HIV-infected employees.
Number One priority. Although financial need may be People with HIV/ AIDS need to take special care to minia concern, the question of whether their health can be mize stress in their lives.
properly managed along with full- or part-time work is first
and foremost a question to discuss with medical providers. 1111 Keeping Benefits: Safety Net
for HIV-Infected People in
In Steve's case, the healthcare provider assessed his current
the Workplace
medical status, the drugs and other therapies he was taking,
his cognitive status (that is, his memory and attention Tony worked at a succession of unskilled jobs before he left work
span), his stamina, and the effect the stress of work might on disability because of HIV/AIDS. He's been pretty healthy for
have on his medical status.
the past 2 years, and his combination therapy has driven his
viral
load below detectable levels; however, he feels useless;
For a person who is physically healthy enough to work, the
except
for his clinic visits, he has no reason to get out of bed in
benefits can be psychological as well as financial. For some,
work is empowering and a potential source of dignity and the morning. Someone in his support group suggested that he
pride. Work gets a person out of the house; activity and look for work, but Tony doesn't know where to begin. His last
time spent around people in the work environment can job-moving boxes around a warehouse-was meaningless, and

1111 To Work or Not to Work:

• Managing Work and HIV • Letters to the Editor
• Focus on Tuberculosis, Part II • HIV News Briefs
September/October 1999

HIYEc 0 otline
Editorial
Richard S. Ferri, PhD,
ANP, ACRN

HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts

-

Michele Fontaine, MA, CASAC

Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York
Susan M. Gallego, MSSW,
LMSW-ACP

-

Private Practitioner/Consultant
Austin, Texas
Vincent J. Lynch, DSW

Director
National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts

-

John G. O'Brien, PharmD

Assistant Clinical Professor
University of California, San Francisco
HIV Pharmacist Specialist
Ira Greene Positive PACE Clinic
San Jose, California
George Perez, MD

Director of Virology
St Michael's Medical Center
Medical Director
North Jersey Community
Research Initiative
Newark, New Jersey
Michael E. Sheran, MD

Assistant Professor of Medicine
New York Medical College
Associate Attending Physician
Department of Medicine
St Vincent's Hospital
New York, New York

-

Angela Shiloh-Cryer, MSW

Director
Office of Health Policy and
AIDS Funding
New Orleans, Louisiana

-

Barry Zevin, MD

Medical Director
Tom Waddell Health Center
San Francisco, California
This newsletter is published by World Health CME, a division of World Health Communications Inc., and is supported through an independent educational grant from
Glaxo WeUcome. The Views and opinions expressed
herein do not necessarily reflect those of Glaxo Wellcome,
World Health CME, or the Editorial AdVisory Board.
Statements regarding drugs, (josages, and procedures are
not meant to serve as guidelines in the treatment of
patients. Please see the full prescribing information before
using any agent mentioned in this publication.
© 1999, World Health CME. All rights reserved. Printed in
the USA. Pennl5sion granted for .noncommercial reproduction of this material.

Managing Work and HIV
besides, it's long gone. Tony figures he'll lose his government benefits if he returns to
work, and what if he gets sick again? Tony never expected to live long enough to worry
about questions like this_
Tony is a classic example of the "Lazarus syndrome"; he's an HIV-infected person who thought he had no future, only to find himself faced with an extended
one and the problem of how to live it. His work life before contracting HIV
wasn't fulfilling, and his current prospects for employment are slim. It is likely
that any work he could get would not provide him with enough income to
cover his considerable medical costs.
Tony could benefit from exploring vocational training. He may be able to enter
a vocational-training program, get paid, and still receive his full benefits. What
benefits he is eligible for and is able to maintain after employment can depend
on whether he receives Supplemental Security Income or Social Security
Disability Insurance (SSDI) through the Social Security Administration. Once he
gets a job, he will retain his full SSDI during a trial work period (TWP) totaling
12 months (9 months followed by review and 3 months of additional coverage,
regardless of income). In addition, his Medicare coverage will continue for at
least 39 months after the TWP. After that, if his job does not provide comparable
or better health insurance, Tony can buy his own Medicare coverage on a
monthly basis. Because of his HIV status, he is still considered disabled under
Medicare, whether or not he is able to work.
After the TWP, Tony's benefits will end only when his monthly earnings reach
the level of substantial gainful activity (SGA). The amount so defined changes
periodically and is currently $500 per month for a person with a disability and
$1110 per month for a person who is blind. Clients with cytomegalovirus retini-

Letters to the Editor

~

tn your article on Why Getting Tested ts So Important (Getting Tested for HIV,
June/July 1999) you wrote about early treatment with HMRT after an
~
individual tests HIV positive. How can I explain the benefits of HMRT to
HIV-positive clients who are asymptomatic?
.
.

Experts caution that early initiation of HAART in asymptom~tic patients has bot~ benefits and
risks. Benefits include control of viral ~eplication a~~ ':1~tation, /owe: Iev_els of vzral load, and
prevention ofprogressive immunodeficzency. Early mztiation may m~mtazn or r~store a n~rmal
immune system, delay progression to AIDS, prolong life, decrease nsk o( sele~tion of resistant
virus, and lower the risk of drug toxicity due to treating an asymptomatic patient.
While this information may confuse clients, counselors can explain these be_ne~ts better _by
using a metaphor/analogy. Counselors have found that metaphors are effective zn educating
their clients about the positive effects of initiating HAART. A commonly used metaphor
describes a "battle scene" in which CD4 cells fight the virus. For example, ~ou may ~ant to
start by explaining to your clients that the imm~ne system, like a fortres~, zs respon?ble for
keeping the body healthy. Although the fortress zs usually capable of keepzng most of zts enemies at bay successfully, the HIV-virus army is virulent enough to threaten the health of t~e
CD4 army. To help prevent attack, the CD4 army should arm itself with the best weapons, ze,
combination therapy.
This metaphor is one method that can be used to describe the benefits of therapy for the asymptomatic client; however, both the benefits and the risks of initiating HAART early should be
considered before a decision is made.
Questions or comments about the " back to work " issue? Please write to Frontline_Editor via fax at (212) 481-8~32,
E-mail at fronteditor@whcom .com or snail mail at World Health CME, Attention: Front/m e Editor, 41 Madison
Avenue, 41st Floor, New York, NY 10010-2202.

HIVfrontline
Managing Work and HIV
tis may fall into the latter category. Work expenses that are
related to Tony's impairment will be deducted from his
earnings when it is determined whether he exceeds this
level. These include any specialized equipment he may
need, possibly even transportation to and from work, and,
most importantly, the antiretroviral medication that makes
it possible for him to keep a job.
With his counselor's help, Tony got involved with the
Social Security Administration's Plan for Achieving SelfSupport (PASS) program. Under PASS, he can direct some of
his income and assets toward his approved plan, further
extending the time during which his income remains
below the SGA cutoff.
Tony worries that his good health might not last. If he has a
temporary health setback and his earnings fall below the
SGA, his benefits will resume. This safety net is available for
up to 36 months after Tony's TWP ends. If he is unable to
work after that, his disability status and full SSDI benefits
can be restored.

.. Sticking It Out: HIV on the Job
Eva, a cashier at a large chain variety store, has never felt ill. To
put her mind at ease, however, she had an HIV-antibody test
and discovered she was positive. At her physician's recommendation, she has begun ART. The only trouble is, her work and
medication schedules are not compatible. Her break time does
not coincide with when she needs to take her pills, and there is
no refrigerator available in the store for her medications. So far,
she has been able to schedule clinic visits during her time off, but
she worries that her shift might change to a time that would
interfere with clinic appointments. She is afraid to talk to her

HIV and the Americans
with Disabilities Act (ADA)
The employment provisions of the ADA make it unlawful to
discriminate against people who have or are perceived to have
disabilities. A disability is defined as a "physical or mental
impairment that substantially limits one or more major life
activities." The ADA also protects individuals with histories of
such disabilities or who are perceived by employers as having
disabilities.
The ADA, which applies to public- and private-sector employers with 15 or more employees, covers HIV-infected individuals, even when they are asymptomatic.
Job seekers are protected against questions during
interviews about the existence, nature, or severity of
disabilities. Prior to making a job offer, the employer

manager about her needs, because she fears he will be hostile
and may even fire her if he knows the truth.
Eva may not consider herself disabled by her infection, but
she is protected under the ADA (see sidebar on page 3).
Although she is asymptomatic, her need to take life-sustaining medication and to receive regular medical care
qualifies her for reasonable accommodations. She knows
that if her supervisor becomes aware of her illness, any discrimination that results from his perception of a disability
will be regarded as unlawful.
With her counselor's help, Eva learned about how the ADA
applies to her. She asked her physician for a letter outlining
the accommodations she requires: a change in her work
schedule on days when she has clinic appointments, break
times to coincide with her medication schedule, and installation of a small refrigerator in a storage area at the back of
the store where she can keep her pills. As long as she
remains well and her drug regimen is effective, these are all
the accommodations Eva needs. If at some point in the
future her needs change, she can request further accommodations. If, for example, she needs an extended period off
for illness, she can ask for an extension of 12 weeks' unpaid
leave under the Family and Medical Leave Act.
Eva still has not decided whether to disclose her condition
at work. On one hand, she hates the idea of keeping a
secret from her coworkers, many of whom have become
her friends. On the other hand, she knows how gossip
spreads and fears that not only her boss but some of the
regular customers will treat her differently if they know. To
address this fear, her counselor will need to examine Eva's
communication and negotiation skills, possibly including
a role-play exercise involving Eva talking to her boss.

cannot mandate a medical examination, and if the offer
depends on the satisfactory results of a postoffer examination,
that examination requirement must apply to all potential
employees in the same category.
At no time during the hiring process may an employee be
required to disclose details of a disability. Any information the
employer may have about the disability must be held in the
strictest confidence.
Disabled persons have the right to request and be granted
"reasonable accommodations" that will enable them to participate in the application process and/or to perform functions
essential to the job. Reasonable accommodations might
include adjustments or modifications to the job or work environment such as tailoring schedules to employees' needs and
providing specialized equipment or modifying existing equipment.

HIYfcontline
Managing Work artd HIV
Eva knows that what laws mandate and what actually happens in the workplace are not always the same. Although she
has worked at the store for 3 years and has always received
good reports from her supervisor, there is the chance that
knowing she has HIV will change his attitude. He might
exert subtle pressure and make demands that undermine her
morale. Some employees who believe that they are subject to
unlawful discrimination resort to legal action, but others are
reluctant to add the stress of a lawsuit to the strain of living
with a serious illness. For them, looking for a new job in a
more HIV-friendly workplace may be a better option.

1111 Staying Healthy: Adhering to

ART and Medical Appointments

HIV-infected workers need to be doubly vigilant about
their health. They must take care not to overcompensate,
immersing themselves in their work so deeply that they
become exhausted; not to neglect their medical and personal needs; and not to allow themselves to be overwhelmed by stress.
Continued strict adherence to drug regimens is of paramount importance. Employees should discuss with their
medical teams how to make their medication and work
schedules compatible. It may be necessary to modify their
1111 Making a Change:
prescriptions.
To allow more user-friendly dosing at work
Job Seekers Living With HIV
and to minimize side effects, HAART regimens may need to
Helen is a reporter for a daily newspaper. HIV positive for 4 be simplified by a reduction in the number of pills and freyears, she is doing well on HAART, but she is exhausted most of quency of dosing.
the time and knows that that could spell disaster. To make matters worse, a new city editor is making the staffprove themselves Simplified regimens are more likely to increase adherence.
against long odds. Most of her buddies are tuning up their They also help reduce the numbers of breaks required durresumes and looking for new jobs, and they have urged Helen to ing the workday. Newly approved antiretroviral agents,
do the same; but she worries about losing her benefits, about such as abacavir (a nucleoside reverse transcriptase
answering questions that reveal her status, and about asking for inhibitor [NRTI]), amprenavir (a protease inhibitor), and
accommodations that would make it possible for her to work in efavirenz (a nonnucleoside RTI [NNRTI]), offer potent treatthis environment. She feels miserable at her current job and ment options with lighter dosage schedules. According to
the May 1999 US Department of Health and Human
scared to look for another, and the stress is getting to her.
Services HIV-treatment guidelines, examples of simplifiedLike Eva, Helen can and should avail herself of protections
dosing combinations include lamivudine/zidovudine plus
guaranteed under the ADA. As a job seeker, she is not
efavirenz
(two NRTls plus one NNRTI) or lamivudine/
required to disclose her illness, and she does not have to
zidovudine
plus abacavir (three NRTis).
mention her need for accommodations until she has
received and accepted a job offer. Nevertheless, finding a Keeping medical appointments, including regular viral
new job is rarely easy, and Helen needs as much help as she load and CD4 cell testing to monitor health status, is also
essential. If medication schedules and/or alleviation of
can get.
Fortunately, Helen's counselor was able to link her with an drug-related side effects require special accommodations
employment counselor who specializes in HIV- and ADA- on the job, workers should ask their care providers for letrelated job searches. They have put together a winning ters to employers explaining what modifications are
resume and sent it to newspapers, magazines, and other needed. Time off for medical appointments can also
media known to be HIV friendly. The employment coun- be requested as a reasonable accommodation under
selor has been coaching Helen on how to navigate the the ADA.
interview minefield, and Helen has enlisted friends to HIV-infected workers need emotional support-to deal
rehearse "killer" interviews with her.
with stress, to discuss work issues, to engage in and enjoy
In looking for a new job, Helen also needs to consider med- recreational activities, to stay connected with people who
ical and other benefits. Will she get the same or better cover- know about their illness and who support them, and to
age for her substantial medical and pharmaceutical bills? deal with the strain of disclosure.
Will there be a gap because she has a preexisting condition?
Medical insurance policies differ widely on these extremely 1111 What Counselors Can Do
important details. Fortunately, the Health Insurance Counselors whose clients wish to remain in or return to the
Portability and Accountability Act was designed to remedy workforce should educate themselves as completely as posthe problem, and it may help in Helen's case. Another sible about benefits and legal protections applicable to their
option would be to pay for continuation of old coverage clients. They should build referral networks of experts in
through COBRA (the Consolidated Omnibus Budget the many complex areas related to HIV/ AIDS in the workReconciliation Act) until her new insurance is fully in effect. place. Counselors can also help their clients by

H IVFrontl i ne
Managing Work and HW
• Discussing the many aspects of the "to work or not to
work" question-Urge clients to talk to their physicians,
recommend specific benefits and job counselors, and
arrange for peer and other types of support, regardless of
what decision is made. This is an ongoing process, and
the issue may have to be revisited as a client's health status changes
• Identifying accommodations that will make it possible for
them to work-For clients who believe they have been or
fear they may be subjected to disability-related job discrimination, provide referrals for legal advice and assistance
• Providing support and referrals to help clients decide
whether, when, and how to disclose their HIV status at
work-Counselors should help clients manage stress that
is associated with disclosure
• Discussing the pros and cons of a job change and helping
coordinate the job search-This might include exploring
options for health insurance and benefits and making
referrals to support groups, employment counselors, and
service agencies that specialize in HIV- and ADA-related
job candidates

Counselor-to-Counselor
The Back to Work Issue
By Sue Gallego, MSSW, LMSW-ACP*
Michael Sherrill, a veteran of 9 years in HIV case management in
Austin, Texas, told me he responds to each client who contemplates returning to work in a "supportive, enthusiastic, and realistic" manner. So when my client, Bob, visited my office excited
about feeling much better and wanting to return to his old job,
that's how I approached the subject. Bob had been on Social
Security disability income for 3 years and had become restless
and bored at home. Bob was dearly a person whose identity had
been tied to his work and career and who had difficulty adjusting to a "disabled lifestyle."
It was important to acknowledge how much healthier Bob was
feeling, looking, etc, and to support the potential of new possibilities opening up for him. We focused on walking him through,
step by step, what it would be like to return to work. It's easy to
forget all the details of "work life" when you've been unemployed for 3 years. We talked about what working again would
entail: getting up at 8:00 AM 5 days a week (even when he felt
nauseous), checking the status of his car, making extra income,
having additional expenses, changing to an evening support
group, meeting and talking to new people at work, and experiencing exhaustion.
It was important to approach these steps in a nonjudgmental
and supportive manner. Equally significant, was ensuring that
information provided on Social Security disability income and
Medicare was accurate and realistic.

• Working with clients and medical teams to optimize
adherence to ART regimens at work
• Providing support and referrals to help clients manage
stress and other threats to health at work
• Providing continued psychosocial support and exploring
transitional options for clients who are not yet ready to
rejoin the workforce
Counselors can help clients better understand their
health benefits by
• Examining the medical benefits, preexisting-illness
clauses, length of time after employment coverage begins,
etc
• Determining whether a change in health coverage due to
employment will require that the client change healthcare providers, therapists, hospitals, pharmacies, etcand, if these changes will be required, process the pros
and cons with the client, care providers, etc
• Working with the client's current health benefits and medical providers to ensure that there are no gaps in coverage
during the transition period, that prescriptions have been
filled, and that "stopgap" measures have been taken II
Bob needed to be aware that he would probably lose his assistance from the State HIV Medication Program and might have to
deal with a "preexisting medical condition" clause with his new
employer's health-benefit plan. He also had to think through the
pressures of the job, learning new guidelines, using new office
equipment, and being the "new guy" again. We discussed what
it might be like to leave the job at some point if he became ill
again. Some of our clients talk about "going through it all over
again"-that is, working for a year and then becoming ill or too
exhausted to continue-in other words, reliving the feelings of
grief and loss, saying good-bye to a working lifestyle, and having
to reapply for Social Security and live on a fixed income.
Bob was lucky in that his past employer was glad to have him
back, and they decided on a flexible part-time schedule that
allowed Bob to focus on his health and maintain his Social
Security benefits.
As counselors, we know that some clients may have more issues
to consider than Bob did. Those who don't have employers
welcoming them back will need to consider disclosure concerns,
difficult medication schedules, side effects, and the total loss of
disability benefits. While Bob had resumed a desk job, other
clients, especially those with little work experience and limited
education, may seek work that is physically intense-and therefore in not very healthy working environments.
Counselors need to consider the type of work clients are seeking,
since it is an important factor in foreseeing potential adherence
difficulties (due to hectic and/or inconvenient schedules).
*Sue Gallego is a private practitioner/consultant in Austin, Texas and
a member of the HIV Frontline Editorial Advisory Board.

HIYfrogtlige
HIV-RELATED CONDITIONS

Focus On: Tuberculosis
(Second in a two-part series)

The subject of last issue's article was tuberculosis (TB): signs and symptoms, mode of transmission, and epidemiology, especially within
HIV-infected populations. TB in HIV-infected individuals is ofparticular concern, not only because of the inaeased risk for developing active
disease but also because ofproblems inherent in diagnosing and treating TB in conjunction with HIV. Part II of our focus on TB will examine the issues related to diagnosis, prophylaxis, and treatment.
Diagnosis
TB can be difficult to diagnose in HIVinfected individuals because of the
impaired immunity that characterizes
HIV and the overlapping clinical signs
of the two diseases. The key to early
diagnosis of TB in HIV-infected individuals is to be vigilant in looking for
signs and symptoms. According to
Michael L. Tapper, MD, Chief of
Infectious Diseases at Lenox Hill
Hospital, New York, providers must
always "think TB."
Anyone with HIV should be screened
for TB. For high-risk populations, 6
months is the recommended interval
between TB screenings. The standard
TB screen is the Mantoux skin test, in
which a small amount of purified protein derivative is injected just below
the skin. Within 48 to 72 hours, an
individual with prior exposure to
Mycobacterium tuberculosis will present
with some hardening (induration) at
the site of infection. This reaction is
evidence of infection, not necessarily
of active disease. A person with
advanced HIV disease whose immune
system is so damaged that it cannot
mount a reaction to the skin test may
yield a false-negative result.
Anyone who tests positive should be
given a chest X-ray. Chest X-ray is also
recommended for HIV-infected individuals who test negative but have
clinical signs of active TB. Additional
tests include sputum smear and culture, in which a specimen coughed or
aspirated from the lungs is cultured in
the laboratory and examined for evidence of M tuberculosis. If extrapulmonary disease is suspected, other
tests that are appropriate for the probable sites may be performed. Drug-susceptibility tests on an active bacterial

culture are used for treatment planning, to determine whether the strain
of TB is resistant to one or more of the
standard drugs used.

Latent TB Infection:
Prophylaxis
The latent phase of TB infection refers
to infection in which clinical disease is
inapparent, yet infection of the host
has been established. Although people
with latent TB infection are not ill and
cannot infect others, they require prophylactic treatment to ensure that the
disease is not activated. This is particularly important for HIV-infected
patients, since the virus puts them at
high risk for developing active-often
aggressively active-disease.
The Centers for Disease Control and
Prevention (CDC) recommends TB
prophylaxis for all HIV-infected individuals with positive skin tests.
Recommendations are for a 9- to 12month course of the anti-TB agents
isoniazid and pyridoxine. Shorter
courses of a two-drug combination
(rifampin and pyrazinamide) are
sometimes used. Adding preventive
treatment for TB infection to an existing HIV-treatment regimen, as well as
coping with potential drug-related
side effects, may be difficult for some
patients. It is essential, nonetheless,
that the full course of medication be
taken faithfully to avoid the development of active disease.
Active Disease:
Treatment
When an HIV-infected person has
active TB, treatment should be initiated as quickly as possible, since the
course of TB in the presence of HIV is

swift and often deadly.
Combining ART and anti-TB drug
therapy is a complex matter. From a
practical point of view, the number of
pills that should be taken faithfully
and on schedule can be daunting. Side
effects may be difficult to tolerate, and
interactions between drugs may interfere with their effectiveness. In particular, rifampin and its "cousin"
rifabutin have known interactions
with
methadone,
hormonal
contraceptives, several antifungals,
coumadin, protease inhibitors, and
NNRTis. According to Dr Tapper,
"[Treating] the coinfected patient
involves the adroit management of
several different classes of drugs and
requires a clinician experienced in
both diseases."

Adherence
Shortly after beginning anti-TB therapy, the patient will no longer be
infectious. Symptoms will disappear,
and the patient will feel markedly better. Improvement may also cause
patients to stop treatment, however,
which can result in a relapse and the
possible development of drug-resistant disease.
Drug regimens for both prevention
and treatment of TB can be arduous,
particularly for individuals coinfected
with HIV, and adherence is a major
challenge. It is believed that the development of drug-resistant strains of TB,
which coincided with the high point
of the TB epidemic of the mid-1990s,
was largely caused by poor adherence.
DOT (directly observed therapy) was
developed to improve adherence and
eliminate the specter of multidrugresistant TB. It is now among the CDC
(continued on page 8)

HIVFrontline
H·l·V
■

N·E·W·S

B·R·l·E·F·S

HN-Preventlon Conference, Atlanta, G~ia, ~ust 29-September 1
Despite the continued decline in the incidence of AIDS-associated deaths and a decrease in the number of new HIV cases, morbidity and mortality continue to strike disproportionately in certain populations. Reports from the first National HIV
Prevention Conference, sponsored by the CDC, focus on an ongoing state of emergency in specific groups. Studies released at
the conference indicated elevated annual rates of HIV infection among prison inmates, young gay men, people with other
sexually transmitted diseases (STDs), intravenous-drug users, women, and minorities.
• Inmates at Correctional Facilities: The prevalence of AIDS among US prisoners is five times higher than that in the general
population. There are between 35,000 and 47,000 HIV-infected inmates, of whom approximately 8900 have AIDS.
• African Americans: The rate of new AIDS cases among African Americans is 10 times higher than that among whites. The
incidence of AIDS-associated deaths in 1998 was nearly 10 times higher among African Americans, representing 49% of all
deaths from the disease.
• Young Gay Men: A survey conducted in Baltimore, Dallas, Los Angeles, Miami, New York, San Francisco, and Seattle found
a 7% infection rate among gay men between the ages of 15 and 22, with a 3% annual increase in the incidence of new
infections. Young African Americans and those of mixed race were particularly affected. Failure to follow safe sex practices
appears to be a major factor.

■

Transmission Decline
The CDC reported significant declines in the incidence of perinatal HIV infection in the wake of United States Public Health
Service recommendations regarding prenatal HIV testing and zidovudine therapy. According to the report, cases of perinatal
AIDS reached a high point in 1992 and dropped a total of 67% through 1997. During that period, the percentage of HIVinfected women who received zidovudine increased from 7% to 91 %. Implementation of zidovudine therapy and elective
cesarean delivery provide hope for the elimination of vertical transmission of HIV in the United States.
Nonetheless, a CDC study found that HIV-infected women in the United States receive substandard prenatal care. The study
reported that 68% of women with HIV had inadequate or no prenatal care from 1987 to 1996.
In developing nations, where access to antiretroviral drugs is limited by economics as well as by other factors affecting continual care, a new, simplified, and cost-effective strategy for preventing mother-infant transmission of HIV may provide an
answer. Researchers in the United States and Uganda found that a single dose of the NNRTI nevirapine given to the mother
during labor and to the infant after birth was highly effective in reducing the incidence of perinatal HIV infection.

■

In 1998, 18,361 cases of active TB disease were reported in the United States, an 8% decline from 1997. This overall decline
for the sixth straight year provides continued evidence that the United States has recovered from the resurgence of TB that
began in the 1980s. These trends point, nonetheless, to a number of remaining challenges for the next era of TB elimination.
These include the impact of the global TB epidemic in the United States and multidrug-resistant TB, of which 45 states
reported cases between 1993 and 1998. According to the CDC, effectively addressing these concerns will require specific
approaches for identifying and treating those populations at greatest risk, as well as a sustained US commitment and increased
global collaboration.
■

A study by researchers at The Johns Hopkins University School of Medicine in Baltimore, Maryland, published in the Annals
of Internal Medicine, compared the progress of people receiving HAART as outpatients with that of participants in clinical trials. After 1 year of therapy, researchers reported that HAART appears to be more effective in clinical trials than in the real world.
The difference was attributed to missed clinic visits, which physicians said was the most frequent causal factor in reducing the
effectiveness of HAART.
VISIT OUR INFORMATIVE, CME-ACCREDITED WEBSITE FOR DAILY AND WEEKLY UPDATES ON HIV DISEASE.

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CME-accredited programs updated bimonthly, including

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HIVfrogtl ioe
HIV-RELATED CONDITIONS

Counseling Implications

with m ai n taini n g h ig h levels of
knowledge and awareness of the signs
and sympt oms of TB and working
with clients and medical providers to
ensure that all clients have regular TB
skin tests. For clients with latent infection, counse lors sho ul d p romote
adherence to preventive therapy and
ensure that the importance of comp leti n g the cou rse of treatment is
u nderstood. For clients with active
disease, t h e need for adherence is
especially important.

Counselors play a key role regarding
TB in HIV-in fected clients. It begins

The health and lifestyle complications
of coin fect ion will n ecessitate addi-

recommendations for all people with
active TB . DOPT (directly observed
preventive therapy) has been adopted
in some localities for individuals with
latent infection . .DOT/DOPT can take
various forms and be performed in a
variety of location s. Basically, people
receive an ti-TB th erapy in the presence of trained healthcare workers to
ensure that medications are taken regularly and in the prescribed dosage.

tional su pport and services . Legal
issu es such as contact notification
and, for nonadh erent patients, involuntary isolation may require counselor intervention. Coordination with
the treatment team can help clients
deal with the substantial burdens of
HIV /TB coinfection.
Counsel ors sho ul d be aware of
their own occupational risk and be
screene d for TB every 6 months.
Regu lar screenings are especially
critical for HIV-positive counselors.

Managing Work and HIV
Resources

Benefits

Returning to Work
National AIDS Fund Return-to-Work Initiative
The National AIDS Fund

AIDS Benefits Handbook: Everything You Need to Know to
Get Social Security, Welfare, Medicaid, Food Stamps,
Housing, Drugs and Other Benefits, by Thomas P.
McCormack, Yale University Press, 1990

1400 I Street NW, Suite 1220
Washington, DC 20005-2208
(202) 408-4848; www.aidsfund.org
Includes "Medical Checklist and Return to Work Issues
for Persons Living with HIV and AIDS: A Personal Assessment
Tool"

Americans with Disabilities Act
Equal Employment Opportunity Commission
1801 L Street NW
Washington, DC 20507
(800) 669-3362; (800) 800-3302 (TDD); www.eeoc.gov
ADA Helpline: (800) 669-4000; (800) 669-6820 (TDD)
Job Accommodation Network: (800) 232-9675
(voice and TDD)

Office on the Americans with Disabilities Act
Civil Rights Division
US Department of Justice
PO Box 66118
Washington, DC 20035-6118
(202) 514-0301; (202) 514-0383 (TDD)

Social Security Administration
Office of Public Inquiries
6401 Security Boulevard
Room 4-C-5 Annex
Baltimore, MD 21235-6401
(800) 772-1213; TTY: (800) 325-0778; www.ssa.gov
Social Security Administration publications: "Disability," Pub
#05-10029; "SSI," Pub #05-11000; "Working While
Disabled-How Can We Help,"
Pub #05-10095; "Working While Disabled: A Guide to Plans
for Achieving Self-Support (PASS)," Pub #05-11017

Online
Websites with valuable information on benefits,
discrimination, and other employment issues:

Gay Men's Health Crisis (GMHC): www.gmhc.org
AIDS Project Los Angeles: www.apla.org
The Body: www.thebody.org

To add your name to the mailing list for this publication, please send your request to
HIV Frontline, World Health CME, 41 Madison Avenue, New York, New York 10010-2202. HIV Frontline is also
available on the World Wide Web, through the HIV Information Network1M at http://www.HIVLine.com.



Property of the Center

ISSUE NO. 38

www.HIVLine.com

This newsletter is supported through an independent educational grant from GlaxoWellcome

Managing Work and HIV
Helping Clients Achieve a Productive and Rewarding Working Life
efore the advent of highly active antiretroviral therapy (HAAR"f), a diagnosis of HIV/AIDS meant leaving
the workplace, often permanently. HIV-infected individuals who were symptomatic frequently went on
permanent disability, and most of them went home to die. Now, thanks to effective combination therapies, broadened medical knowledge, and improved prophylactic treatments, many people can continue
to work, with few or no absences related to their illness. Those who have left the workplace temporarily are able to
return to their old jobs or seek new ones.
Nonetheless, managing HIV at work presents unique problems and issues, with implications in the legal, medical,
and psychosocial arenas as well as real challenges to time-management skills. Counselors have an important role
to play when their clients express the desire to continue working or return to work after a diagnosis of HIV disease.
This issue of HIV Frontline looks at HIV and the challenges it can bring to the workplace.
foster a sense of normalcy for many HIV-infected individuals. For people whose illness has put parts of their lives on
The Medical Issue
hold, returning to work can be a milestone on the road to
Steve had been teaching for 20 years when he took medical leave,
recovery. This achievement can improve the patient's mentoo ill from HIV to cope with a roomful of kids. He's been out of
tal
health and self-esteem.
the classroom for 5 years, but he's feeling much stronger, thanks
to his combination therapy. It has been more than 1 year since Work is often a source of stress, however, difficult for even
he's had any symptoms. He thinks he's ready to go back to work healthy people to manage. A recent study conducted by Dr
and believes it is essential to his emotional and physical well- Jane Lesserman, psychiatric researcher at the University of
being. He talked to his healthcare provider, who gave him the North Carolina, found that stress may speed the progres"OK" to return to work but emphasized the importance of contin- sion from HIV to AIDS. The report noted that men in stressuing the therapy that has made this possible. He will need to ful situations with little social support were two to three
adhere strictly to his regimen, get regular medical checkups times more likely to develop full-blown AIDS than individ(including viral load monitoring and CD4 counts), and follow a uals with lower stress and more support.
healthy diet and lifestyle.
Work-related stress, combined with continued concern
For many people with HIV/ AIDS, caring for their health is, about their health and about disclosure of their HIV status,
in itself, a full-time job and should be considered the can be especially harmful to HIV-infected employees.
Number One priority. Although financial need may be People with HIV/ AIDS need to take special care to minia concern, the question of whether their health can be mize stress in their lives.
properly managed along with full- or part-time work is first
and foremost a question to discuss with medical providers. 1111 Keeping Benefits: Safety Net
for HIV-Infected People in
In Steve's case, the healthcare provider assessed his current
the Workplace
medical status, the drugs and other therapies he was taking,
his cognitive status (that is, his memory and attention Tony worked at a succession of unskilled jobs before he left work
span), his stamina, and the effect the stress of work might on disability because of HIV/AIDS. He's been pretty healthy for
have on his medical status.
the past 2 years, and his combination therapy has driven his
viral
load below detectable levels; however, he feels useless;
For a person who is physically healthy enough to work, the
except
for his clinic visits, he has no reason to get out of bed in
benefits can be psychological as well as financial. For some,
work is empowering and a potential source of dignity and the morning. Someone in his support group suggested that he
pride. Work gets a person out of the house; activity and look for work, but Tony doesn't know where to begin. His last
time spent around people in the work environment can job-moving boxes around a warehouse-was meaningless, and

1111 To Work or Not to Work:

• Managing Work and HIV • Letters to the Editor
• Focus on Tuberculosis, Part II • HIV News Briefs
September/October 1999

HIYEc 0 otline
Editorial
Richard S. Ferri, PhD,
ANP, ACRN

HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts

-

Michele Fontaine, MA, CASAC

Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York
Susan M. Gallego, MSSW,
LMSW-ACP

-

Private Practitioner/Consultant
Austin, Texas
Vincent J. Lynch, DSW

Director
National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts

-

John G. O'Brien, PharmD

Assistant Clinical Professor
University of California, San Francisco
HIV Pharmacist Specialist
Ira Greene Positive PACE Clinic
San Jose, California
George Perez, MD

Director of Virology
St Michael's Medical Center
Medical Director
North Jersey Community
Research Initiative
Newark, New Jersey
Michael E. Sheran, MD

Assistant Professor of Medicine
New York Medical College
Associate Attending Physician
Department of Medicine
St Vincent's Hospital
New York, New York

-

Angela Shiloh-Cryer, MSW

Director
Office of Health Policy and
AIDS Funding
New Orleans, Louisiana

-

Barry Zevin, MD

Medical Director
Tom Waddell Health Center
San Francisco, California
This newsletter is published by World Health CME, a division of World Health Communications Inc., and is supported through an independent educational grant from
Glaxo WeUcome. The Views and opinions expressed
herein do not necessarily reflect those of Glaxo Wellcome,
World Health CME, or the Editorial AdVisory Board.
Statements regarding drugs, (josages, and procedures are
not meant to serve as guidelines in the treatment of
patients. Please see the full prescribing information before
using any agent mentioned in this publication.
© 1999, World Health CME. All rights reserved. Printed in
the USA. Pennl5sion granted for .noncommercial reproduction of this material.

Managing Work and HIV
besides, it's long gone. Tony figures he'll lose his government benefits if he returns to
work, and what if he gets sick again? Tony never expected to live long enough to worry
about questions like this_
Tony is a classic example of the "Lazarus syndrome"; he's an HIV-infected person who thought he had no future, only to find himself faced with an extended
one and the problem of how to live it. His work life before contracting HIV
wasn't fulfilling, and his current prospects for employment are slim. It is likely
that any work he could get would not provide him with enough income to
cover his considerable medical costs.
Tony could benefit from exploring vocational training. He may be able to enter
a vocational-training program, get paid, and still receive his full benefits. What
benefits he is eligible for and is able to maintain after employment can depend
on whether he receives Supplemental Security Income or Social Security
Disability Insurance (SSDI) through the Social Security Administration. Once he
gets a job, he will retain his full SSDI during a trial work period (TWP) totaling
12 months (9 months followed by review and 3 months of additional coverage,
regardless of income). In addition, his Medicare coverage will continue for at
least 39 months after the TWP. After that, if his job does not provide comparable
or better health insurance, Tony can buy his own Medicare coverage on a
monthly basis. Because of his HIV status, he is still considered disabled under
Medicare, whether or not he is able to work.
After the TWP, Tony's benefits will end only when his monthly earnings reach
the level of substantial gainful activity (SGA). The amount so defined changes
periodically and is currently $500 per month for a person with a disability and
$1110 per month for a person who is blind. Clients with cytomegalovirus retini-

Letters to the Editor

~

tn your article on Why Getting Tested ts So Important (Getting Tested for HIV,
June/July 1999) you wrote about early treatment with HMRT after an
~
individual tests HIV positive. How can I explain the benefits of HMRT to
HIV-positive clients who are asymptomatic?
.
.

Experts caution that early initiation of HAART in asymptom~tic patients has bot~ benefits and
risks. Benefits include control of viral ~eplication a~~ ':1~tation, /owe: Iev_els of vzral load, and
prevention ofprogressive immunodeficzency. Early mztiation may m~mtazn or r~store a n~rmal
immune system, delay progression to AIDS, prolong life, decrease nsk o( sele~tion of resistant
virus, and lower the risk of drug toxicity due to treating an asymptomatic patient.
While this information may confuse clients, counselors can explain these be_ne~ts better _by
using a metaphor/analogy. Counselors have found that metaphors are effective zn educating
their clients about the positive effects of initiating HAART. A commonly used metaphor
describes a "battle scene" in which CD4 cells fight the virus. For example, ~ou may ~ant to
start by explaining to your clients that the imm~ne system, like a fortres~, zs respon?ble for
keeping the body healthy. Although the fortress zs usually capable of keepzng most of zts enemies at bay successfully, the HIV-virus army is virulent enough to threaten the health of t~e
CD4 army. To help prevent attack, the CD4 army should arm itself with the best weapons, ze,
combination therapy.
This metaphor is one method that can be used to describe the benefits of therapy for the asymptomatic client; however, both the benefits and the risks of initiating HAART early should be
considered before a decision is made.
Questions or comments about the " back to work " issue? Please write to Frontline_Editor via fax at (212) 481-8~32,
E-mail at fronteditor@whcom .com or snail mail at World Health CME, Attention: Front/m e Editor, 41 Madison
Avenue, 41st Floor, New York, NY 10010-2202.

HIVfrontline
Managing Work and HIV
tis may fall into the latter category. Work expenses that are
related to Tony's impairment will be deducted from his
earnings when it is determined whether he exceeds this
level. These include any specialized equipment he may
need, possibly even transportation to and from work, and,
most importantly, the antiretroviral medication that makes
it possible for him to keep a job.
With his counselor's help, Tony got involved with the
Social Security Administration's Plan for Achieving SelfSupport (PASS) program. Under PASS, he can direct some of
his income and assets toward his approved plan, further
extending the time during which his income remains
below the SGA cutoff.
Tony worries that his good health might not last. If he has a
temporary health setback and his earnings fall below the
SGA, his benefits will resume. This safety net is available for
up to 36 months after Tony's TWP ends. If he is unable to
work after that, his disability status and full SSDI benefits
can be restored.

.. Sticking It Out: HIV on the Job
Eva, a cashier at a large chain variety store, has never felt ill. To
put her mind at ease, however, she had an HIV-antibody test
and discovered she was positive. At her physician's recommendation, she has begun ART. The only trouble is, her work and
medication schedules are not compatible. Her break time does
not coincide with when she needs to take her pills, and there is
no refrigerator available in the store for her medications. So far,
she has been able to schedule clinic visits during her time off, but
she worries that her shift might change to a time that would
interfere with clinic appointments. She is afraid to talk to her

HIV and the Americans
with Disabilities Act (ADA)
The employment provisions of the ADA make it unlawful to
discriminate against people who have or are perceived to have
disabilities. A disability is defined as a "physical or mental
impairment that substantially limits one or more major life
activities." The ADA also protects individuals with histories of
such disabilities or who are perceived by employers as having
disabilities.
The ADA, which applies to public- and private-sector employers with 15 or more employees, covers HIV-infected individuals, even when they are asymptomatic.
Job seekers are protected against questions during
interviews about the existence, nature, or severity of
disabilities. Prior to making a job offer, the employer

manager about her needs, because she fears he will be hostile
and may even fire her if he knows the truth.
Eva may not consider herself disabled by her infection, but
she is protected under the ADA (see sidebar on page 3).
Although she is asymptomatic, her need to take life-sustaining medication and to receive regular medical care
qualifies her for reasonable accommodations. She knows
that if her supervisor becomes aware of her illness, any discrimination that results from his perception of a disability
will be regarded as unlawful.
With her counselor's help, Eva learned about how the ADA
applies to her. She asked her physician for a letter outlining
the accommodations she requires: a change in her work
schedule on days when she has clinic appointments, break
times to coincide with her medication schedule, and installation of a small refrigerator in a storage area at the back of
the store where she can keep her pills. As long as she
remains well and her drug regimen is effective, these are all
the accommodations Eva needs. If at some point in the
future her needs change, she can request further accommodations. If, for example, she needs an extended period off
for illness, she can ask for an extension of 12 weeks' unpaid
leave under the Family and Medical Leave Act.
Eva still has not decided whether to disclose her condition
at work. On one hand, she hates the idea of keeping a
secret from her coworkers, many of whom have become
her friends. On the other hand, she knows how gossip
spreads and fears that not only her boss but some of the
regular customers will treat her differently if they know. To
address this fear, her counselor will need to examine Eva's
communication and negotiation skills, possibly including
a role-play exercise involving Eva talking to her boss.

cannot mandate a medical examination, and if the offer
depends on the satisfactory results of a postoffer examination,
that examination requirement must apply to all potential
employees in the same category.
At no time during the hiring process may an employee be
required to disclose details of a disability. Any information the
employer may have about the disability must be held in the
strictest confidence.
Disabled persons have the right to request and be granted
"reasonable accommodations" that will enable them to participate in the application process and/or to perform functions
essential to the job. Reasonable accommodations might
include adjustments or modifications to the job or work environment such as tailoring schedules to employees' needs and
providing specialized equipment or modifying existing equipment.

HIYfcontline
Managing Work artd HIV
Eva knows that what laws mandate and what actually happens in the workplace are not always the same. Although she
has worked at the store for 3 years and has always received
good reports from her supervisor, there is the chance that
knowing she has HIV will change his attitude. He might
exert subtle pressure and make demands that undermine her
morale. Some employees who believe that they are subject to
unlawful discrimination resort to legal action, but others are
reluctant to add the stress of a lawsuit to the strain of living
with a serious illness. For them, looking for a new job in a
more HIV-friendly workplace may be a better option.

1111 Staying Healthy: Adhering to

ART and Medical Appointments

HIV-infected workers need to be doubly vigilant about
their health. They must take care not to overcompensate,
immersing themselves in their work so deeply that they
become exhausted; not to neglect their medical and personal needs; and not to allow themselves to be overwhelmed by stress.
Continued strict adherence to drug regimens is of paramount importance. Employees should discuss with their
medical teams how to make their medication and work
schedules compatible. It may be necessary to modify their
1111 Making a Change:
prescriptions.
To allow more user-friendly dosing at work
Job Seekers Living With HIV
and to minimize side effects, HAART regimens may need to
Helen is a reporter for a daily newspaper. HIV positive for 4 be simplified by a reduction in the number of pills and freyears, she is doing well on HAART, but she is exhausted most of quency of dosing.
the time and knows that that could spell disaster. To make matters worse, a new city editor is making the staffprove themselves Simplified regimens are more likely to increase adherence.
against long odds. Most of her buddies are tuning up their They also help reduce the numbers of breaks required durresumes and looking for new jobs, and they have urged Helen to ing the workday. Newly approved antiretroviral agents,
do the same; but she worries about losing her benefits, about such as abacavir (a nucleoside reverse transcriptase
answering questions that reveal her status, and about asking for inhibitor [NRTI]), amprenavir (a protease inhibitor), and
accommodations that would make it possible for her to work in efavirenz (a nonnucleoside RTI [NNRTI]), offer potent treatthis environment. She feels miserable at her current job and ment options with lighter dosage schedules. According to
the May 1999 US Department of Health and Human
scared to look for another, and the stress is getting to her.
Services HIV-treatment guidelines, examples of simplifiedLike Eva, Helen can and should avail herself of protections
dosing combinations include lamivudine/zidovudine plus
guaranteed under the ADA. As a job seeker, she is not
efavirenz
(two NRTls plus one NNRTI) or lamivudine/
required to disclose her illness, and she does not have to
zidovudine
plus abacavir (three NRTis).
mention her need for accommodations until she has
received and accepted a job offer. Nevertheless, finding a Keeping medical appointments, including regular viral
new job is rarely easy, and Helen needs as much help as she load and CD4 cell testing to monitor health status, is also
essential. If medication schedules and/or alleviation of
can get.
Fortunately, Helen's counselor was able to link her with an drug-related side effects require special accommodations
employment counselor who specializes in HIV- and ADA- on the job, workers should ask their care providers for letrelated job searches. They have put together a winning ters to employers explaining what modifications are
resume and sent it to newspapers, magazines, and other needed. Time off for medical appointments can also
media known to be HIV friendly. The employment coun- be requested as a reasonable accommodation under
selor has been coaching Helen on how to navigate the the ADA.
interview minefield, and Helen has enlisted friends to HIV-infected workers need emotional support-to deal
rehearse "killer" interviews with her.
with stress, to discuss work issues, to engage in and enjoy
In looking for a new job, Helen also needs to consider med- recreational activities, to stay connected with people who
ical and other benefits. Will she get the same or better cover- know about their illness and who support them, and to
age for her substantial medical and pharmaceutical bills? deal with the strain of disclosure.
Will there be a gap because she has a preexisting condition?
Medical insurance policies differ widely on these extremely 1111 What Counselors Can Do
important details. Fortunately, the Health Insurance Counselors whose clients wish to remain in or return to the
Portability and Accountability Act was designed to remedy workforce should educate themselves as completely as posthe problem, and it may help in Helen's case. Another sible about benefits and legal protections applicable to their
option would be to pay for continuation of old coverage clients. They should build referral networks of experts in
through COBRA (the Consolidated Omnibus Budget the many complex areas related to HIV/ AIDS in the workReconciliation Act) until her new insurance is fully in effect. place. Counselors can also help their clients by

H IVFrontl i ne
Managing Work and HW
• Discussing the many aspects of the "to work or not to
work" question-Urge clients to talk to their physicians,
recommend specific benefits and job counselors, and
arrange for peer and other types of support, regardless of
what decision is made. This is an ongoing process, and
the issue may have to be revisited as a client's health status changes
• Identifying accommodations that will make it possible for
them to work-For clients who believe they have been or
fear they may be subjected to disability-related job discrimination, provide referrals for legal advice and assistance
• Providing support and referrals to help clients decide
whether, when, and how to disclose their HIV status at
work-Counselors should help clients manage stress that
is associated with disclosure
• Discussing the pros and cons of a job change and helping
coordinate the job search-This might include exploring
options for health insurance and benefits and making
referrals to support groups, employment counselors, and
service agencies that specialize in HIV- and ADA-related
job candidates

Counselor-to-Counselor
The Back to Work Issue
By Sue Gallego, MSSW, LMSW-ACP*
Michael Sherrill, a veteran of 9 years in HIV case management in
Austin, Texas, told me he responds to each client who contemplates returning to work in a "supportive, enthusiastic, and realistic" manner. So when my client, Bob, visited my office excited
about feeling much better and wanting to return to his old job,
that's how I approached the subject. Bob had been on Social
Security disability income for 3 years and had become restless
and bored at home. Bob was dearly a person whose identity had
been tied to his work and career and who had difficulty adjusting to a "disabled lifestyle."
It was important to acknowledge how much healthier Bob was
feeling, looking, etc, and to support the potential of new possibilities opening up for him. We focused on walking him through,
step by step, what it would be like to return to work. It's easy to
forget all the details of "work life" when you've been unemployed for 3 years. We talked about what working again would
entail: getting up at 8:00 AM 5 days a week (even when he felt
nauseous), checking the status of his car, making extra income,
having additional expenses, changing to an evening support
group, meeting and talking to new people at work, and experiencing exhaustion.
It was important to approach these steps in a nonjudgmental
and supportive manner. Equally significant, was ensuring that
information provided on Social Security disability income and
Medicare was accurate and realistic.

• Working with clients and medical teams to optimize
adherence to ART regimens at work
• Providing support and referrals to help clients manage
stress and other threats to health at work
• Providing continued psychosocial support and exploring
transitional options for clients who are not yet ready to
rejoin the workforce
Counselors can help clients better understand their
health benefits by
• Examining the medical benefits, preexisting-illness
clauses, length of time after employment coverage begins,
etc
• Determining whether a change in health coverage due to
employment will require that the client change healthcare providers, therapists, hospitals, pharmacies, etcand, if these changes will be required, process the pros
and cons with the client, care providers, etc
• Working with the client's current health benefits and medical providers to ensure that there are no gaps in coverage
during the transition period, that prescriptions have been
filled, and that "stopgap" measures have been taken II
Bob needed to be aware that he would probably lose his assistance from the State HIV Medication Program and might have to
deal with a "preexisting medical condition" clause with his new
employer's health-benefit plan. He also had to think through the
pressures of the job, learning new guidelines, using new office
equipment, and being the "new guy" again. We discussed what
it might be like to leave the job at some point if he became ill
again. Some of our clients talk about "going through it all over
again"-that is, working for a year and then becoming ill or too
exhausted to continue-in other words, reliving the feelings of
grief and loss, saying good-bye to a working lifestyle, and having
to reapply for Social Security and live on a fixed income.
Bob was lucky in that his past employer was glad to have him
back, and they decided on a flexible part-time schedule that
allowed Bob to focus on his health and maintain his Social
Security benefits.
As counselors, we know that some clients may have more issues
to consider than Bob did. Those who don't have employers
welcoming them back will need to consider disclosure concerns,
difficult medication schedules, side effects, and the total loss of
disability benefits. While Bob had resumed a desk job, other
clients, especially those with little work experience and limited
education, may seek work that is physically intense-and therefore in not very healthy working environments.
Counselors need to consider the type of work clients are seeking,
since it is an important factor in foreseeing potential adherence
difficulties (due to hectic and/or inconvenient schedules).
*Sue Gallego is a private practitioner/consultant in Austin, Texas and
a member of the HIV Frontline Editorial Advisory Board.

HIYfrogtlige
HIV-RELATED CONDITIONS

Focus On: Tuberculosis
(Second in a two-part series)

The subject of last issue's article was tuberculosis (TB): signs and symptoms, mode of transmission, and epidemiology, especially within
HIV-infected populations. TB in HIV-infected individuals is ofparticular concern, not only because of the inaeased risk for developing active
disease but also because ofproblems inherent in diagnosing and treating TB in conjunction with HIV. Part II of our focus on TB will examine the issues related to diagnosis, prophylaxis, and treatment.
Diagnosis
TB can be difficult to diagnose in HIVinfected individuals because of the
impaired immunity that characterizes
HIV and the overlapping clinical signs
of the two diseases. The key to early
diagnosis of TB in HIV-infected individuals is to be vigilant in looking for
signs and symptoms. According to
Michael L. Tapper, MD, Chief of
Infectious Diseases at Lenox Hill
Hospital, New York, providers must
always "think TB."
Anyone with HIV should be screened
for TB. For high-risk populations, 6
months is the recommended interval
between TB screenings. The standard
TB screen is the Mantoux skin test, in
which a small amount of purified protein derivative is injected just below
the skin. Within 48 to 72 hours, an
individual with prior exposure to
Mycobacterium tuberculosis will present
with some hardening (induration) at
the site of infection. This reaction is
evidence of infection, not necessarily
of active disease. A person with
advanced HIV disease whose immune
system is so damaged that it cannot
mount a reaction to the skin test may
yield a false-negative result.
Anyone who tests positive should be
given a chest X-ray. Chest X-ray is also
recommended for HIV-infected individuals who test negative but have
clinical signs of active TB. Additional
tests include sputum smear and culture, in which a specimen coughed or
aspirated from the lungs is cultured in
the laboratory and examined for evidence of M tuberculosis. If extrapulmonary disease is suspected, other
tests that are appropriate for the probable sites may be performed. Drug-susceptibility tests on an active bacterial

culture are used for treatment planning, to determine whether the strain
of TB is resistant to one or more of the
standard drugs used.

Latent TB Infection:
Prophylaxis
The latent phase of TB infection refers
to infection in which clinical disease is
inapparent, yet infection of the host
has been established. Although people
with latent TB infection are not ill and
cannot infect others, they require prophylactic treatment to ensure that the
disease is not activated. This is particularly important for HIV-infected
patients, since the virus puts them at
high risk for developing active-often
aggressively active-disease.
The Centers for Disease Control and
Prevention (CDC) recommends TB
prophylaxis for all HIV-infected individuals with positive skin tests.
Recommendations are for a 9- to 12month course of the anti-TB agents
isoniazid and pyridoxine. Shorter
courses of a two-drug combination
(rifampin and pyrazinamide) are
sometimes used. Adding preventive
treatment for TB infection to an existing HIV-treatment regimen, as well as
coping with potential drug-related
side effects, may be difficult for some
patients. It is essential, nonetheless,
that the full course of medication be
taken faithfully to avoid the development of active disease.
Active Disease:
Treatment
When an HIV-infected person has
active TB, treatment should be initiated as quickly as possible, since the
course of TB in the presence of HIV is

swift and often deadly.
Combining ART and anti-TB drug
therapy is a complex matter. From a
practical point of view, the number of
pills that should be taken faithfully
and on schedule can be daunting. Side
effects may be difficult to tolerate, and
interactions between drugs may interfere with their effectiveness. In particular, rifampin and its "cousin"
rifabutin have known interactions
with
methadone,
hormonal
contraceptives, several antifungals,
coumadin, protease inhibitors, and
NNRTis. According to Dr Tapper,
"[Treating] the coinfected patient
involves the adroit management of
several different classes of drugs and
requires a clinician experienced in
both diseases."

Adherence
Shortly after beginning anti-TB therapy, the patient will no longer be
infectious. Symptoms will disappear,
and the patient will feel markedly better. Improvement may also cause
patients to stop treatment, however,
which can result in a relapse and the
possible development of drug-resistant disease.
Drug regimens for both prevention
and treatment of TB can be arduous,
particularly for individuals coinfected
with HIV, and adherence is a major
challenge. It is believed that the development of drug-resistant strains of TB,
which coincided with the high point
of the TB epidemic of the mid-1990s,
was largely caused by poor adherence.
DOT (directly observed therapy) was
developed to improve adherence and
eliminate the specter of multidrugresistant TB. It is now among the CDC
(continued on page 8)

HIVFrontline
H·l·V
■

N·E·W·S

B·R·l·E·F·S

HN-Preventlon Conference, Atlanta, G~ia, ~ust 29-September 1
Despite the continued decline in the incidence of AIDS-associated deaths and a decrease in the number of new HIV cases, morbidity and mortality continue to strike disproportionately in certain populations. Reports from the first National HIV
Prevention Conference, sponsored by the CDC, focus on an ongoing state of emergency in specific groups. Studies released at
the conference indicated elevated annual rates of HIV infection among prison inmates, young gay men, people with other
sexually transmitted diseases (STDs), intravenous-drug users, women, and minorities.
• Inmates at Correctional Facilities: The prevalence of AIDS among US prisoners is five times higher than that in the general
population. There are between 35,000 and 47,000 HIV-infected inmates, of whom approximately 8900 have AIDS.
• African Americans: The rate of new AIDS cases among African Americans is 10 times higher than that among whites. The
incidence of AIDS-associated deaths in 1998 was nearly 10 times higher among African Americans, representing 49% of all
deaths from the disease.
• Young Gay Men: A survey conducted in Baltimore, Dallas, Los Angeles, Miami, New York, San Francisco, and Seattle found
a 7% infection rate among gay men between the ages of 15 and 22, with a 3% annual increase in the incidence of new
infections. Young African Americans and those of mixed race were particularly affected. Failure to follow safe sex practices
appears to be a major factor.

■

Transmission Decline
The CDC reported significant declines in the incidence of perinatal HIV infection in the wake of United States Public Health
Service recommendations regarding prenatal HIV testing and zidovudine therapy. According to the report, cases of perinatal
AIDS reached a high point in 1992 and dropped a total of 67% through 1997. During that period, the percentage of HIVinfected women who received zidovudine increased from 7% to 91 %. Implementation of zidovudine therapy and elective
cesarean delivery provide hope for the elimination of vertical transmission of HIV in the United States.
Nonetheless, a CDC study found that HIV-infected women in the United States receive substandard prenatal care. The study
reported that 68% of women with HIV had inadequate or no prenatal care from 1987 to 1996.
In developing nations, where access to antiretroviral drugs is limited by economics as well as by other factors affecting continual care, a new, simplified, and cost-effective strategy for preventing mother-infant transmission of HIV may provide an
answer. Researchers in the United States and Uganda found that a single dose of the NNRTI nevirapine given to the mother
during labor and to the infant after birth was highly effective in reducing the incidence of perinatal HIV infection.

■

In 1998, 18,361 cases of active TB disease were reported in the United States, an 8% decline from 1997. This overall decline
for the sixth straight year provides continued evidence that the United States has recovered from the resurgence of TB that
began in the 1980s. These trends point, nonetheless, to a number of remaining challenges for the next era of TB elimination.
These include the impact of the global TB epidemic in the United States and multidrug-resistant TB, of which 45 states
reported cases between 1993 and 1998. According to the CDC, effectively addressing these concerns will require specific
approaches for identifying and treating those populations at greatest risk, as well as a sustained US commitment and increased
global collaboration.
■

A study by researchers at The Johns Hopkins University School of Medicine in Baltimore, Maryland, published in the Annals
of Internal Medicine, compared the progress of people receiving HAART as outpatients with that of participants in clinical trials. After 1 year of therapy, researchers reported that HAART appears to be more effective in clinical trials than in the real world.
The difference was attributed to missed clinic visits, which physicians said was the most frequent causal factor in reducing the
effectiveness of HAART.
VISIT OUR INFORMATIVE, CME-ACCREDITED WEBSITE FOR DAILY AND WEEKLY UPDATES ON HIV DISEASE.

-w-wvv. HIVLi ne.com
The Clinician's Educational Resource

CME-accredited programs updated bimonthly, including

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HIVfrogtl ioe
HIV-RELATED CONDITIONS

Counseling Implications

with m ai n taini n g h ig h levels of
knowledge and awareness of the signs
and sympt oms of TB and working
with clients and medical providers to
ensure that all clients have regular TB
skin tests. For clients with latent infection, counse lors sho ul d p romote
adherence to preventive therapy and
ensure that the importance of comp leti n g the cou rse of treatment is
u nderstood. For clients with active
disease, t h e need for adherence is
especially important.

Counselors play a key role regarding
TB in HIV-in fected clients. It begins

The health and lifestyle complications
of coin fect ion will n ecessitate addi-

recommendations for all people with
active TB . DOPT (directly observed
preventive therapy) has been adopted
in some localities for individuals with
latent infection . .DOT/DOPT can take
various forms and be performed in a
variety of location s. Basically, people
receive an ti-TB th erapy in the presence of trained healthcare workers to
ensure that medications are taken regularly and in the prescribed dosage.

tional su pport and services . Legal
issu es such as contact notification
and, for nonadh erent patients, involuntary isolation may require counselor intervention. Coordination with
the treatment team can help clients
deal with the substantial burdens of
HIV /TB coinfection.
Counsel ors sho ul d be aware of
their own occupational risk and be
screene d for TB every 6 months.
Regu lar screenings are especially
critical for HIV-positive counselors.

Managing Work and HIV
Resources

Benefits

Returning to Work
National AIDS Fund Return-to-Work Initiative
The National AIDS Fund

AIDS Benefits Handbook: Everything You Need to Know to
Get Social Security, Welfare, Medicaid, Food Stamps,
Housing, Drugs and Other Benefits, by Thomas P.
McCormack, Yale University Press, 1990

1400 I Street NW, Suite 1220
Washington, DC 20005-2208
(202) 408-4848; www.aidsfund.org
Includes "Medical Checklist and Return to Work Issues
for Persons Living with HIV and AIDS: A Personal Assessment
Tool"

Americans with Disabilities Act
Equal Employment Opportunity Commission
1801 L Street NW
Washington, DC 20507
(800) 669-3362; (800) 800-3302 (TDD); www.eeoc.gov
ADA Helpline: (800) 669-4000; (800) 669-6820 (TDD)
Job Accommodation Network: (800) 232-9675
(voice and TDD)

Office on the Americans with Disabilities Act
Civil Rights Division
US Department of Justice
PO Box 66118
Washington, DC 20035-6118
(202) 514-0301; (202) 514-0383 (TDD)

Social Security Administration
Office of Public Inquiries
6401 Security Boulevard
Room 4-C-5 Annex
Baltimore, MD 21235-6401
(800) 772-1213; TTY: (800) 325-0778; www.ssa.gov
Social Security Administration publications: "Disability," Pub
#05-10029; "SSI," Pub #05-11000; "Working While
Disabled-How Can We Help,"
Pub #05-10095; "Working While Disabled: A Guide to Plans
for Achieving Self-Support (PASS)," Pub #05-11017

Online
Websites with valuable information on benefits,
discrimination, and other employment issues:

Gay Men's Health Crisis (GMHC): www.gmhc.org
AIDS Project Los Angeles: www.apla.org
The Body: www.thebody.org

To add your name to the mailing list for this publication, please send your request to
HIV Frontline, World Health CME, 41 Madison Avenue, New York, New York 10010-2202. HIV Frontline is also
available on the World Wide Web, through the HIV Information Network1M at http://www.HIVLine.com.



Property of the Center

ISSUE NO. 38

www.HIVLine.com

This newsletter is supported through an independent educational grant from GlaxoWellcome

Managing Work and HIV
Helping Clients Achieve a Productive and Rewarding Working Life
efore the advent of highly active antiretroviral therapy (HAAR"f), a diagnosis of HIV/AIDS meant leaving
the workplace, often permanently. HIV-infected individuals who were symptomatic frequently went on
permanent disability, and most of them went home to die. Now, thanks to effective combination therapies, broadened medical knowledge, and improved prophylactic treatments, many people can continue
to work, with few or no absences related to their illness. Those who have left the workplace temporarily are able to
return to their old jobs or seek new ones.
Nonetheless, managing HIV at work presents unique problems and issues, with implications in the legal, medical,
and psychosocial arenas as well as real challenges to time-management skills. Counselors have an important role
to play when their clients express the desire to continue working or return to work after a diagnosis of HIV disease.
This issue of HIV Frontline looks at HIV and the challenges it can bring to the workplace.
foster a sense of normalcy for many HIV-infected individuals. For people whose illness has put parts of their lives on
The Medical Issue
hold, returning to work can be a milestone on the road to
Steve had been teaching for 20 years when he took medical leave,
recovery. This achievement can improve the patient's mentoo ill from HIV to cope with a roomful of kids. He's been out of
tal
health and self-esteem.
the classroom for 5 years, but he's feeling much stronger, thanks
to his combination therapy. It has been more than 1 year since Work is often a source of stress, however, difficult for even
he's had any symptoms. He thinks he's ready to go back to work healthy people to manage. A recent study conducted by Dr
and believes it is essential to his emotional and physical well- Jane Lesserman, psychiatric researcher at the University of
being. He talked to his healthcare provider, who gave him the North Carolina, found that stress may speed the progres"OK" to return to work but emphasized the importance of contin- sion from HIV to AIDS. The report noted that men in stressuing the therapy that has made this possible. He will need to ful situations with little social support were two to three
adhere strictly to his regimen, get regular medical checkups times more likely to develop full-blown AIDS than individ(including viral load monitoring and CD4 counts), and follow a uals with lower stress and more support.
healthy diet and lifestyle.
Work-related stress, combined with continued concern
For many people with HIV/ AIDS, caring for their health is, about their health and about disclosure of their HIV status,
in itself, a full-time job and should be considered the can be especially harmful to HIV-infected employees.
Number One priority. Although financial need may be People with HIV/ AIDS need to take special care to minia concern, the question of whether their health can be mize stress in their lives.
properly managed along with full- or part-time work is first
and foremost a question to discuss with medical providers. 1111 Keeping Benefits: Safety Net
for HIV-Infected People in
In Steve's case, the healthcare provider assessed his current
the Workplace
medical status, the drugs and other therapies he was taking,
his cognitive status (that is, his memory and attention Tony worked at a succession of unskilled jobs before he left work
span), his stamina, and the effect the stress of work might on disability because of HIV/AIDS. He's been pretty healthy for
have on his medical status.
the past 2 years, and his combination therapy has driven his
viral
load below detectable levels; however, he feels useless;
For a person who is physically healthy enough to work, the
except
for his clinic visits, he has no reason to get out of bed in
benefits can be psychological as well as financial. For some,
work is empowering and a potential source of dignity and the morning. Someone in his support group suggested that he
pride. Work gets a person out of the house; activity and look for work, but Tony doesn't know where to begin. His last
time spent around people in the work environment can job-moving boxes around a warehouse-was meaningless, and

1111 To Work or Not to Work:

• Managing Work and HIV • Letters to the Editor
• Focus on Tuberculosis, Part II • HIV News Briefs
September/October 1999

HIYEc 0 otline
Editorial
Richard S. Ferri, PhD,
ANP, ACRN

HIV/AIDS Nurse Practitioner
Crossroads Medical
Harwich, Massachusetts

-

Michele Fontaine, MA, CASAC

Senior Vocational Counselor
Next Step Program
Project Renewal
New York, New York
Susan M. Gallego, MSSW,
LMSW-ACP

-

Private Practitioner/Consultant
Austin, Texas
Vincent J. Lynch, DSW

Director
National Research
and Training Center on
Social Work and HIV/AIDS
Boston College
Graduate School of Social Work
Chestnut Hill, Massachusetts

-

John G. O'Brien, PharmD

Assistant Clinical Professor
University of California, San Francisco
HIV Pharmacist Specialist
Ira Greene Positive PACE Clinic
San Jose, California
George Perez, MD

Director of Virology
St Michael's Medical Center
Medical Director
North Jersey Community
Research Initiative
Newark, New Jersey
Michael E. Sheran, MD

Assistant Professor of Medicine
New York Medical College
Associate Attending Physician
Department of Medicine
St Vincent's Hospital
New York, New York

-

Angela Shiloh-Cryer, MSW

Director
Office of Health Policy and
AIDS Funding
New Orleans, Louisiana

-

Barry Zevin, MD

Medical Director
Tom Waddell Health Center
San Francisco, California
This newsletter is published by World Health CME, a division of World Health Communications Inc., and is supported through an independent educational grant from
Glaxo WeUcome. The Views and opinions expressed
herein do not necessarily reflect those of Glaxo Wellcome,
World Health CME, or the Editorial AdVisory Board.
Statements regarding drugs, (josages, and procedures are
not meant to serve as guidelines in the treatment of
patients. Please see the full prescribing information before
using any agent mentioned in this publication.
© 1999, World Health CME. All rights reserved. Printed in
the USA. Pennl5sion granted for .noncommercial reproduction of this material.

Managing Work and HIV
besides, it's long gone. Tony figures he'll lose his government benefits if he returns to
work, and what if he gets sick again? Tony never expected to live long enough to worry
about questions like this_
Tony is a classic example of the "Lazarus syndrome"; he's an HIV-infected person who thought he had no future, only to find himself faced with an extended
one and the problem of how to live it. His work life before contracting HIV
wasn't fulfilling, and his current prospects for employment are slim. It is likely
that any work he could get would not provide him with enough income to
cover his considerable medical costs.
Tony could benefit from exploring vocational training. He may be able to enter
a vocational-training program, get paid, and still receive his full benefits. What
benefits he is eligible for and is able to maintain after employment can depend
on whether he receives Supplemental Security Income or Social Security
Disability Insurance (SSDI) through the Social Security Administration. Once he
gets a job, he will retain his full SSDI during a trial work period (TWP) totaling
12 months (9 months followed by review and 3 months of additional coverage,
regardless of income). In addition, his Medicare coverage will continue for at
least 39 months after the TWP. After that, if his job does not provide comparable
or better health insurance, Tony can buy his own Medicare coverage on a
monthly basis. Because of his HIV status, he is still considered disabled under
Medicare, whether or not he is able to work.
After the TWP, Tony's benefits will end only when his monthly earnings reach
the level of substantial gainful activity (SGA). The amount so defined changes
periodically and is currently $500 per month for a person with a disability and
$1110 per month for a person who is blind. Clients with cytomegalovirus retini-

Letters to the Editor

~

tn your article on Why Getting Tested ts So Important (Getting Tested for HIV,
June/July 1999) you wrote about early treatment with HMRT after an
~
individual tests HIV positive. How can I explain the benefits of HMRT to
HIV-positive clients who are asymptomatic?
.
.

Experts caution that early initiation of HAART in asymptom~tic patients has bot~ benefits and
risks. Benefits include control of viral ~eplication a~~ ':1~tation, /owe: Iev_els of vzral load, and
prevention ofprogressive immunodeficzency. Early mztiation may m~mtazn or r~store a n~rmal
immune system, delay progression to AIDS, prolong life, decrease nsk o( sele~tion of resistant
virus, and lower the risk of drug toxicity due to treating an asymptomatic patient.
While this information may confuse clients, counselors can explain these be_ne~ts better _by
using a metaphor/analogy. Counselors have found that metaphors are effective zn educating
their clients about the positive effects of initiating HAART. A commonly used metaphor
describes a "battle scene" in which CD4 cells fight the virus. For example, ~ou may ~ant to
start by explaining to your clients that the imm~ne system, like a fortres~, zs respon?ble for
keeping the body healthy. Although the fortress zs usually capable of keepzng most of zts enemies at bay successfully, the HIV-virus army is virulent enough to threaten the health of t~e
CD4 army. To help prevent attack, the CD4 army should arm itself with the best weapons, ze,
combination therapy.
This metaphor is one method that can be used to describe the benefits of therapy for the asymptomatic client; however, both the benefits and the risks of initiating HAART early should be
considered before a decision is made.
Questions or comments about the " back to work " issue? Please write to Frontline_Editor via fax at (212) 481-8~32,
E-mail at fronteditor@whcom .com or snail mail at World Health CME, Attention: Front/m e Editor, 41 Madison
Avenue, 41st Floor, New York, NY 10010-2202.

HIVfrontline
Managing Work and HIV
tis may fall into the latter category. Work expenses that are
related to Tony's impairment will be deducted from his
earnings when it is determined whether he exceeds this
level. These include any specialized equipment he may
need, possibly even transportation to and from work, and,
most importantly, the antiretroviral medication that makes
it possible for him to keep a job.
With his counselor's help, Tony got involved with the
Social Security Administration's Plan for Achieving SelfSupport (PASS) program. Under PASS, he can direct some of
his income and assets toward his approved plan, further
extending the time during which his income remains
below the SGA cutoff.
Tony worries that his good health might not last. If he has a
temporary health setback and his earnings fall below the
SGA, his benefits will resume. This safety net is available for
up to 36 months after Tony's TWP ends. If he is unable to
work after that, his disability status and full SSDI benefits
can be restored.

.. Sticking It Out: HIV on the Job
Eva, a cashier at a large chain variety store, has never felt ill. To
put her mind at ease, however, she had an HIV-antibody test
and discovered she was positive. At her physician's recommendation, she has begun ART. The only trouble is, her work and
medication schedules are not compatible. Her break time does
not coincide with when she needs to take her pills, and there is
no refrigerator available in the store for her medications. So far,
she has been able to schedule clinic visits during her time off, but
she worries that her shift might change to a time that would
interfere with clinic appointments. She is afraid to talk to her

HIV and the Americans
with Disabilities Act (ADA)
The employment provisions of the ADA make it unlawful to
discriminate against people who have or are perceived to have
disabilities. A disability is defined as a "physical or mental
impairment that substantially limits one or more major life
activities." The ADA also protects individuals with histories of
such disabilities or who are perceived by employers as having
disabilities.
The ADA, which applies to public- and private-sector employers with 15 or more employees, covers HIV-infected individuals, even when they are asymptomatic.
Job seekers are protected against questions during
interviews about the existence, nature, or severity of
disabilities. Prior to making a job offer, the employer

manager about her needs, because she fears he will be hostile
and may even fire her if he knows the truth.
Eva may not consider herself disabled by her infection, but
she is protected under the ADA (see sidebar on page 3).
Although she is asymptomatic, her need to take life-sustaining medication and to receive regular medical care
qualifies her for reasonable accommodations. She knows
that if her supervisor becomes aware of her illness, any discrimination that results from his perception of a disability
will be regarded as unlawful.
With her counselor's help, Eva learned about how the ADA
applies to her. She asked her physician for a letter outlining
the accommodations she requires: a change in her work
schedule on days when she has clinic appointments, break
times to coincide with her medication schedule, and installation of a small refrigerator in a storage area at the back of
the store where she can keep her pills. As long as she
remains well and her drug regimen is effective, these are all
the accommodations Eva needs. If at some point in the
future her needs change, she can request further accommodations. If, for example, she needs an extended period off
for illness, she can ask for an extension of 12 weeks' unpaid
leave under the Family and Medical Leave Act.
Eva still has not decided whether to disclose her condition
at work. On one hand, she hates the idea of keeping a
secret from her coworkers, many of whom have become
her friends. On the other hand, she knows how gossip
spreads and fears that not only her boss but some of the
regular customers will treat her differently if they know. To
address this fear, her counselor will need to examine Eva's
communication and negotiation skills, possibly including
a role-play exercise involving Eva talking to her boss.

cannot mandate a medical examination, and if the offer
depends on the satisfactory results of a postoffer examination,
that examination requirement must apply to all potential
employees in the same category.
At no time during the hiring process may an employee be
required to disclose details of a disability. Any information the
employer may have about the disability must be held in the
strictest confidence.
Disabled persons have the right to request and be granted
"reasonable accommodations" that will enable them to participate in the application process and/or to perform functions
essential to the job. Reasonable accommodations might
include adjustments or modifications to the job or work environment such as tailoring schedules to employees' needs and
providing specialized equipment or modifying existing equipment.

HIYfcontline
Managing Work artd HIV
Eva knows that what laws mandate and what actually happens in the workplace are not always the same. Although she
has worked at the store for 3 years and has always received
good reports from her supervisor, there is the chance that
knowing she has HIV will change his attitude. He might
exert subtle pressure and make demands that undermine her
morale. Some employees who believe that they are subject to
unlawful discrimination resort to legal action, but others are
reluctant to add the stress of a lawsuit to the strain of living
with a serious illness. For them, looking for a new job in a
more HIV-friendly workplace may be a better option.

1111 Staying Healthy: Adhering to

ART and Medical Appointments

HIV-infected workers need to be doubly vigilant about
their health. They must take care not to overcompensate,
immersing themselves in their work so deeply that they
become exhausted; not to neglect their medical and personal needs; and not to allow themselves to be overwhelmed by stress.
Continued strict adherence to drug regimens is of paramount importance. Employees should discuss with their
medical teams how to make their medication and work
schedules compatible. It may be necessary to modify their
1111 Making a Change:
prescriptions.
To allow more user-friendly dosing at work
Job Seekers Living With HIV
and to minimize side effects, HAART regimens may need to
Helen is a reporter for a daily newspaper. HIV positive for 4 be simplified by a reduction in the number of pills and freyears, she is doing well on HAART, but she is exhausted most of quency of dosing.
the time and knows that that could spell disaster. To make matters worse, a new city editor is making the staffprove themselves Simplified regimens are more likely to increase adherence.
against long odds. Most of her buddies are tuning up their They also help reduce the numbers of breaks required durresumes and looking for new jobs, and they have urged Helen to ing the workday. Newly approved antiretroviral agents,
do the same; but she worries about losing her benefits, about such as abacavir (a nucleoside reverse transcriptase
answering questions that reveal her status, and about asking for inhibitor [NRTI]), amprenavir (a protease inhibitor), and
accommodations that would make it possible for her to work in efavirenz (a nonnucleoside RTI [NNRTI]), offer potent treatthis environment. She feels miserable at her current job and ment options with lighter dosage schedules. According to
the May 1999 US Department of Health and Human
scared to look for another, and the stress is getting to her.
Services HIV-treatment guidelines, examples of simplifiedLike Eva, Helen can and should avail herself of protections
dosing combinations include lamivudine/zidovudine plus
guaranteed under the ADA. As a job seeker, she is not
efavirenz
(two NRTls plus one NNRTI) or lamivudine/
required to disclose her illness, and she does not have to
zidovudine
plus abacavir (three NRTis).
mention her need for accommodations until she has
received and accepted a job offer. Nevertheless, finding a Keeping medical appointments, including regular viral
new job is rarely easy, and Helen needs as much help as she load and CD4 cell testing to monitor health status, is also
essential. If medication schedules and/or alleviation of
can get.
Fortunately, Helen's counselor was able to link her with an drug-related side effects require special accommodations
employment counselor who specializes in HIV- and ADA- on the job, workers should ask their care providers for letrelated job searches. They have put together a winning ters to employers explaining what modifications are
resume and sent it to newspapers, magazines, and other needed. Time off for medical appointments can also
media known to be HIV friendly. The employment coun- be requested as a reasonable accommodation under
selor has been coaching Helen on how to navigate the the ADA.
interview minefield, and Helen has enlisted friends to HIV-infected workers need emotional support-to deal
rehearse "killer" interviews with her.
with stress, to discuss work issues, to engage in and enjoy
In looking for a new job, Helen also needs to consider med- recreational activities, to stay connected with people who
ical and other benefits. Will she get the same or better cover- know about their illness and who support them, and to
age for her substantial medical and pharmaceutical bills? deal with the strain of disclosure.
Will there be a gap because she has a preexisting condition?
Medical insurance policies differ widely on these extremely 1111 What Counselors Can Do
important details. Fortunately, the Health Insurance Counselors whose clients wish to remain in or return to the
Portability and Accountability Act was designed to remedy workforce should educate themselves as completely as posthe problem, and it may help in Helen's case. Another sible about benefits and legal protections applicable to their
option would be to pay for continuation of old coverage clients. They should build referral networks of experts in
through COBRA (the Consolidated Omnibus Budget the many complex areas related to HIV/ AIDS in the workReconciliation Act) until her new insurance is fully in effect. place. Counselors can also help their clients by

H IVFrontl i ne
Managing Work and HW
• Discussing the many aspects of the "to work or not to
work" question-Urge clients to talk to their physicians,
recommend specific benefits and job counselors, and
arrange for peer and other types of support, regardless of
what decision is made. This is an ongoing process, and
the issue may have to be revisited as a client's health status changes
• Identifying accommodations that will make it possible for
them to work-For clients who believe they have been or
fear they may be subjected to disability-related job discrimination, provide referrals for legal advice and assistance
• Providing support and referrals to help clients decide
whether, when, and how to disclose their HIV status at
work-Counselors should help clients manage stress that
is associated with disclosure
• Discussing the pros and cons of a job change and helping
coordinate the job search-This might include exploring
options for health insurance and benefits and making
referrals to support groups, employment counselors, and
service agencies that specialize in HIV- and ADA-related
job candidates

Counselor-to-Counselor
The Back to Work Issue
By Sue Gallego, MSSW, LMSW-ACP*
Michael Sherrill, a veteran of 9 years in HIV case management in
Austin, Texas, told me he responds to each client who contemplates returning to work in a "supportive, enthusiastic, and realistic" manner. So when my client, Bob, visited my office excited
about feeling much better and wanting to return to his old job,
that's how I approached the subject. Bob had been on Social
Security disability income for 3 years and had become restless
and bored at home. Bob was dearly a person whose identity had
been tied to his work and career and who had difficulty adjusting to a "disabled lifestyle."
It was important to acknowledge how much healthier Bob was
feeling, looking, etc, and to support the potential of new possibilities opening up for him. We focused on walking him through,
step by step, what it would be like to return to work. It's easy to
forget all the details of "work life" when you've been unemployed for 3 years. We talked about what working again would
entail: getting up at 8:00 AM 5 days a week (even when he felt
nauseous), checking the status of his car, making extra income,
having additional expenses, changing to an evening support
group, meeting and talking to new people at work, and experiencing exhaustion.
It was important to approach these steps in a nonjudgmental
and supportive manner. Equally significant, was ensuring that
information provided on Social Security disability income and
Medicare was accurate and realistic.

• Working with clients and medical teams to optimize
adherence to ART regimens at work
• Providing support and referrals to help clients manage
stress and other threats to health at work
• Providing continued psychosocial support and exploring
transitional options for clients who are not yet ready to
rejoin the workforce
Counselors can help clients better understand their
health benefits by
• Examining the medical benefits, preexisting-illness
clauses, length of time after employment coverage begins,
etc
• Determining whether a change in health coverage due to
employment will require that the client change healthcare providers, therapists, hospitals, pharmacies, etcand, if these changes will be required, process the pros
and cons with the client, care providers, etc
• Working with the client's current health benefits and medical providers to ensure that there are no gaps in coverage
during the transition period, that prescriptions have been
filled, and that "stopgap" measures have been taken II
Bob needed to be aware that he would probably lose his assistance from the State HIV Medication Program and might have to
deal with a "preexisting medical condition" clause with his new
employer's health-benefit plan. He also had to think through the
pressures of the job, learning new guidelines, using new office
equipment, and being the "new guy" again. We discussed what
it might be like to leave the job at some point if he became ill
again. Some of our clients talk about "going through it all over
again"-that is, working for a year and then becoming ill or too
exhausted to continue-in other words, reliving the feelings of
grief and loss, saying good-bye to a working lifestyle, and having
to reapply for Social Security and live on a fixed income.
Bob was lucky in that his past employer was glad to have him
back, and they decided on a flexible part-time schedule that
allowed Bob to focus on his health and maintain his Social
Security benefits.
As counselors, we know that some clients may have more issues
to consider than Bob did. Those who don't have employers
welcoming them back will need to consider disclosure concerns,
difficult medication schedules, side effects, and the total loss of
disability benefits. While Bob had resumed a desk job, other
clients, especially those with little work experience and limited
education, may seek work that is physically intense-and therefore in not very healthy working environments.
Counselors need to consider the type of work clients are seeking,
since it is an important factor in foreseeing potential adherence
difficulties (due to hectic and/or inconvenient schedules).
*Sue Gallego is a private practitioner/consultant in Austin, Texas and
a member of the HIV Frontline Editorial Advisory Board.

HIYfrogtlige
HIV-RELATED CONDITIONS

Focus On: Tuberculosis
(Second in a two-part series)

The subject of last issue's article was tuberculosis (TB): signs and symptoms, mode of transmission, and epidemiology, especially within
HIV-infected populations. TB in HIV-infected individuals is ofparticular concern, not only because of the inaeased risk for developing active
disease but also because ofproblems inherent in diagnosing and treating TB in conjunction with HIV. Part II of our focus on TB will examine the issues related to diagnosis, prophylaxis, and treatment.
Diagnosis
TB can be difficult to diagnose in HIVinfected individuals because of the
impaired immunity that characterizes
HIV and the overlapping clinical signs
of the two diseases. The key to early
diagnosis of TB in HIV-infected individuals is to be vigilant in looking for
signs and symptoms. According to
Michael L. Tapper, MD, Chief of
Infectious Diseases at Lenox Hill
Hospital, New York, providers must
always "think TB."
Anyone with HIV should be screened
for TB. For high-risk populations, 6
months is the recommended interval
between TB screenings. The standard
TB screen is the Mantoux skin test, in
which a small amount of purified protein derivative is injected just below
the skin. Within 48 to 72 hours, an
individual with prior exposure to
Mycobacterium tuberculosis will present
with some hardening (induration) at
the site of infection. This reaction is
evidence of infection, not necessarily
of active disease. A person with
advanced HIV disease whose immune
system is so damaged that it cannot
mount a reaction to the skin test may
yield a false-negative result.
Anyone who tests positive should be
given a chest X-ray. Chest X-ray is also
recommended for HIV-infected individuals who test negative but have
clinical signs of active TB. Additional
tests include sputum smear and culture, in which a specimen coughed or
aspirated from the lungs is cultured in
the laboratory and examined for evidence of M tuberculosis. If extrapulmonary disease is suspected, other
tests that are appropriate for the probable sites may be performed. Drug-susceptibility tests on an active bacterial

culture are used for treatment planning, to determine whether the strain
of TB is resistant to one or more of the
standard drugs used.

Latent TB Infection:
Prophylaxis
The latent phase of TB infection refers
to infection in which clinical disease is
inapparent, yet infection of the host
has been established. Although people
with latent TB infection are not ill and
cannot infect others, they require prophylactic treatment to ensure that the
disease is not activated. This is particularly important for HIV-infected
patients, since the virus puts them at
high risk for developing active-often
aggressively active-disease.
The Centers for Disease Control and
Prevention (CDC) recommends TB
prophylaxis for all HIV-infected individuals with positive skin tests.
Recommendations are for a 9- to 12month course of the anti-TB agents
isoniazid and pyridoxine. Shorter
courses of a two-drug combination
(rifampin and pyrazinamide) are
sometimes used. Adding preventive
treatment for TB infection to an existing HIV-treatment regimen, as well as
coping with potential drug-related
side effects, may be difficult for some
patients. It is essential, nonetheless,
that the full course of medication be
taken faithfully to avoid the development of active disease.
Active Disease:
Treatment
When an HIV-infected person has
active TB, treatment should be initiated as quickly as possible, since the
course of TB in the presence of HIV is

swift and often deadly.
Combining ART and anti-TB drug
therapy is a complex matter. From a
practical point of view, the number of
pills that should be taken faithfully
and on schedule can be daunting. Side
effects may be difficult to tolerate, and
interactions between drugs may interfere with their effectiveness. In particular, rifampin and its "cousin"
rifabutin have known interactions
with
methadone,
hormonal
contraceptives, several antifungals,
coumadin, protease inhibitors, and
NNRTis. According to Dr Tapper,
"[Treating] the coinfected patient
involves the adroit management of
several different classes of drugs and
requires a clinician experienced in
both diseases."

Adherence
Shortly after beginning anti-TB therapy, the patient will no longer be
infectious. Symptoms will disappear,
and the patient will feel markedly better. Improvement may also cause
patients to stop treatment, however,
which can result in a relapse and the
possible development of drug-resistant disease.
Drug regimens for both prevention
and treatment of TB can be arduous,
particularly for individuals coinfected
with HIV, and adherence is a major
challenge. It is believed that the development of drug-resistant strains of TB,
which coincided with the high point
of the TB epidemic of the mid-1990s,
was largely caused by poor adherence.
DOT (directly observed therapy) was
developed to improve adherence and
eliminate the specter of multidrugresistant TB. It is now among the CDC
(continued on page 8)

HIVFrontline
H·l·V
■

N·E·W·S

B·R·l·E·F·S

HN-Preventlon Conference, Atlanta, G~ia, ~ust 29-September 1
Despite the continued decline in the incidence of AIDS-associated deaths and a decrease in the number of new HIV cases, morbidity and mortality continue to strike disproportionately in certain populations. Reports from the first National HIV
Prevention Conference, sponsored by the CDC, focus on an ongoing state of emergency in specific groups. Studies released at
the conference indicated elevated annual rates of HIV infection among prison inmates, young gay men, people with other
sexually transmitted diseases (STDs), intravenous-drug users, women, and minorities.
• Inmates at Correctional Facilities: The prevalence of AIDS among US prisoners is five times higher than that in the general
population. There are between 35,000 and 47,000 HIV-infected inmates, of whom approximately 8900 have AIDS.
• African Americans: The rate of new AIDS cases among African Americans is 10 times higher than that among whites. The
incidence of AIDS-associated deaths in 1998 was nearly 10 times higher among African Americans, representing 49% of all
deaths from the disease.
• Young Gay Men: A survey conducted in Baltimore, Dallas, Los Angeles, Miami, New York, San Francisco, and Seattle found
a 7% infection rate among gay men between the ages of 15 and 22, with a 3% annual increase in the incidence of new
infections. Young African Americans and those of mixed race were particularly affected. Failure to follow safe sex practices
appears to be a major factor.

■

Transmission Decline
The CDC reported significant declines in the incidence of perinatal HIV infection in the wake of United States Public Health
Service recommendations regarding prenatal HIV testing and zidovudine therapy. According to the report, cases of perinatal
AIDS reached a high point in 1992 and dropped a total of 67% through 1997. During that period, the percentage of HIVinfected women who received zidovudine increased from 7% to 91 %. Implementation of zidovudine therapy and elective
cesarean delivery provide hope for the elimination of vertical transmission of HIV in the United States.
Nonetheless, a CDC study found that HIV-infected women in the United States receive substandard prenatal care. The study
reported that 68% of women with HIV had inadequate or no prenatal care from 1987 to 1996.
In developing nations, where access to antiretroviral drugs is limited by economics as well as by other factors affecting continual care, a new, simplified, and cost-effective strategy for preventing mother-infant transmission of HIV may provide an
answer. Researchers in the United States and Uganda found that a single dose of the NNRTI nevirapine given to the mother
during labor and to the infant after birth was highly effective in reducing the incidence of perinatal HIV infection.

■

In 1998, 18,361 cases of active TB disease were reported in the United States, an 8% decline from 1997. This overall decline
for the sixth straight year provides continued evidence that the United States has recovered from the resurgence of TB that
began in the 1980s. These trends point, nonetheless, to a number of remaining challenges for the next era of TB elimination.
These include the impact of the global TB epidemic in the United States and multidrug-resistant TB, of which 45 states
reported cases between 1993 and 1998. According to the CDC, effectively addressing these concerns will require specific
approaches for identifying and treating those populations at greatest risk, as well as a sustained US commitment and increased
global collaboration.
■

A study by researchers at The Johns Hopkins University School of Medicine in Baltimore, Maryland, published in the Annals
of Internal Medicine, compared the progress of people receiving HAART as outpatients with that of participants in clinical trials. After 1 year of therapy, researchers reported that HAART appears to be more effective in clinical trials than in the real world.
The difference was attributed to missed clinic visits, which physicians said was the most frequent causal factor in reducing the
effectiveness of HAART.
VISIT OUR INFORMATIVE, CME-ACCREDITED WEBSITE FOR DAILY AND WEEKLY UPDATES ON HIV DISEASE.

-w-wvv. HIVLi ne.com
The Clinician's Educational Resource

CME-accredited programs updated bimonthly, including

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• FAX NEWSLETTER PUBLICATION

HIVfrogtl ioe
HIV-RELATED CONDITIONS

Counseling Implications

with m ai n taini n g h ig h levels of
knowledge and awareness of the signs
and sympt oms of TB and working
with clients and medical providers to
ensure that all clients have regular TB
skin tests. For clients with latent infection, counse lors sho ul d p romote
adherence to preventive therapy and
ensure that the importance of comp leti n g the cou rse of treatment is
u nderstood. For clients with active
disease, t h e need for adherence is
especially important.

Counselors play a key role regarding
TB in HIV-in fected clients. It begins

The health and lifestyle complications
of coin fect ion will n ecessitate addi-

recommendations for all people with
active TB . DOPT (directly observed
preventive therapy) has been adopted
in some localities for individuals with
latent infection . .DOT/DOPT can take
various forms and be performed in a
variety of location s. Basically, people
receive an ti-TB th erapy in the presence of trained healthcare workers to
ensure that medications are taken regularly and in the prescribed dosage.

tional su pport and services . Legal
issu es such as contact notification
and, for nonadh erent patients, involuntary isolation may require counselor intervention. Coordination with
the treatment team can help clients
deal with the substantial burdens of
HIV /TB coinfection.
Counsel ors sho ul d be aware of
their own occupational risk and be
screene d for TB every 6 months.
Regu lar screenings are especially
critical for HIV-positive counselors.

Managing Work and HIV
Resources

Benefits

Returning to Work
National AIDS Fund Return-to-Work Initiative
The National AIDS Fund

AIDS Benefits Handbook: Everything You Need to Know to
Get Social Security, Welfare, Medicaid, Food Stamps,
Housing, Drugs and Other Benefits, by Thomas P.
McCormack, Yale University Press, 1990

1400 I Street NW, Suite 1220
Washington, DC 20005-2208
(202) 408-4848; www.aidsfund.org
Includes "Medical Checklist and Return to Work Issues
for Persons Living with HIV and AIDS: A Personal Assessment
Tool"

Americans with Disabilities Act
Equal Employment Opportunity Commission
1801 L Street NW
Washington, DC 20507
(800) 669-3362; (800) 800-3302 (TDD); www.eeoc.gov
ADA Helpline: (800) 669-4000; (800) 669-6820 (TDD)
Job Accommodation Network: (800) 232-9675
(voice and TDD)

Office on the Americans with Disabilities Act
Civil Rights Division
US Department of Justice
PO Box 66118
Washington, DC 20035-6118
(202) 514-0301; (202) 514-0383 (TDD)

Social Security Administration
Office of Public Inquiries
6401 Security Boulevard
Room 4-C-5 Annex
Baltimore, MD 21235-6401
(800) 772-1213; TTY: (800) 325-0778; www.ssa.gov
Social Security Administration publications: "Disability," Pub
#05-10029; "SSI," Pub #05-11000; "Working While
Disabled-How Can We Help,"
Pub #05-10095; "Working While Disabled: A Guide to Plans
for Achieving Self-Support (PASS)," Pub #05-11017

Online
Websites with valuable information on benefits,
discrimination, and other employment issues:

Gay Men's Health Crisis (GMHC): www.gmhc.org
AIDS Project Los Angeles: www.apla.org
The Body: www.thebody.org

To add your name to the mailing list for this publication, please send your request to
HIV Frontline, World Health CME, 41 Madison Avenue, New York, New York 10010-2202. HIV Frontline is also
available on the World Wide Web, through the HIV Information Network1M at http://www.HIVLine.com.