Promoting employment in persons living with HIV/AIDS

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Abstract Many persons living with HIV/AIDS (PLWHA) are unemployed, with estimates indicating rates as high as 60%. Unemployment results in lower quality of life, greater depression and substance use, and it is associated with morbidity and mortality. Although PLWHA face substantial challenges in obtaining and maintaining jobs, interventions based upon behavior analytic and behavioral economics principles can be applied alongside best practices employment services to enhance behavior change and improve outcomes. These interventions involve provision of monetary-based reinforcers for objective evidence of behavior change. They can successfully enhance job-seeking activities, even in highly marginalized and disenfranchised populations. This study will examine the efficacy of reinforcing job-acquisition activities for improving employment outcomes in PLWHA who desire to return to the workforce in part- or full-time capacity. In total, this study will randomly assign 144 unemployed PLWHA to one of two interventions. All participants will receive usual unemployment services with an emphasis on specific issues related to HIV/AIDS, plus encouragement for completing activities geared toward employment readiness and acquisition. The enhanced intervention will involve that same treatment plus chances to win prizes ranging from $1 to $100 for engaging in job-related activities each week. Participants will receive study treatments for 16 weeks and complete follow- up evaluations throughout 18 months. Structured evaluations will assess employment outcomes, quality of life indices, physical and cognitive functioning, psychological symptoms, viral loads, and drug use and risk behaviors. The hypothesis is that participants reinforced for completing job-related activities will transition to employment at higher and faster rates and work more often than those who are not reinforced for job-related activities. We also expect the reinforcement intervention will increase quality of life, reduce depressive symptoms, and improve medical outcomes. Compared to the standard care condition, it may also maintain or improve cognitive functioning and medication adherence and reduce risk behaviors that spread infectious diseases. We will evaluate moderators and mediators of key employment and health outcomes, with an emphasis on exploring the extent to which work conditions (temporary, under the table, physically or emotionally demanding jobs etc.) impact psychosocial and physical health. We will conduct cost-effectiveness analyses to estimate the potential for wide scale dissemination of this intervention if efficacious. !