Secondary Logo

Journal Logo

Epidemiology and Social

Has the employment status of people living with HIV changed since the early 2000s?

Annequin, Margota,b; Lert, Francec,d; Spire, Brunoe,f,g; Dray-Spira, Rosemarya,b the VESPA2 Study Group

Author Information
doi: 10.1097/QAD.0000000000000722

Abstract

Introduction

In the general population, work constitutes a central dimension of individuals’ living conditions by providing them with financial support, social status, and identity [1]. In addition, employment status and, for those employed, working conditions and organization have major effects on health [2,3]. Among people living with HIV (PLWHIV) as well, employment status has been shown to be an independent predictor of adherence to treatment, morbidity, and mortality [4–7].

Studies conducted in various Western countries in the early 2000s provided evidence that early in the combined antiretroviral therapy (cART) era, HIV infection negatively affected individual chances of maintaining in and accessing/returning to employment [8–12]. This deleterious effect of HIV infection on employment was shown to occur from the very first months following disease onset [13] through various mechanisms including disease severity and HIV-related discrimination [14]. As in the general population, sociodemographic characteristics including age, sex, education, country of citizenship, and family status constitute major determinants of PLWHIV's position on the labor market [11,15]. HIV-infected women, migrants, and drug users are particularly disadvantaged compared with men who have sex with men (MSM) [11].

Major changes have occurred during the past decade, both in the field of HIV and in the broader general socioeconomic context, which may have resulted in changes in the burden of HIV infection on employment. First, the sustained use of cART has resulted in marked decreases in HIV-related morbidity and mortality [16,17], but also in a rise in the frequency of various non-AIDS-related conditions [18,19], which substantially affect PLWHIV's chances of maintaining in employment [15]. Second, in addition to PLWHIV's ageing, the changing face of the HIV epidemics in Europe has resulted in increasing proportions of persons with a disadvantaged position on the labor market among PLWHIV – especially women and migrants originating from sub-Saharan Africa [20,21]. Third, the economic crisis of 2008 has had severe and long-lasting effects on employment throughout Europe [22], and people affected by a chronic condition may be particularly affected [23–25].

In this changing context, the present study aimed at investigating changes in PLWHIV's situation regarding employment since the early 2000s in France. More specifically, our objectives were to measure changes over time in (1) PLWHIV's rates of employment, unemployment and inactivity and (2) early labor market transitions following HIV diagnosis, accounting for changes in individuals’ sociodemographic determinants of position on the labor market and health status. We hypothesized that the potentially beneficial effects of recent HIV care improvements on PLWHIV's situation regarding employment may have been counterbalanced by concurrent changes in the characteristics of the HIV epidemics and the general socioeconomic context.

Methods

Study design

The study was based on the VESPA (VIH: Enquête Sur les Personnes Atteintes) study, a repeated cross-sectional survey conducted among two large nationally representative samples of HIV-infected people followed at hospital in France in 2003 and 2011, with the primary aim of assessing the various dimensions of socioeconomic conditions and health of PLWHIV in France in their diversity and their changes over time. Both surveys were conducted among random samples of hospital outpatients aged 18 or older, diagnosed HIV-infected for at least 6 months, and either French citizens or immigrants living in France for at least 6 months. The VESPA-2003 survey was conducted between December 2002 and September 2003 among 2932 PLWHIV recruited in 102 hospital departments in mainland France. Its methodology has been extensively described elsewhere [26]. The VESPA-2011 survey was conducted between April 2011 and January 2012 among 3022 PLWHIV recruited in 73 hospital departments in mainland France, using a similar design as detailed elsewhere [27]. In both surveys, participants answered a standardized questionnaire administered face-to-face by a trained interviewer, including detailed questions on sociodemographic characteristics, living conditions, health, and healthcare. To allow comparisons, a number of key questions were kept the same between surveys. Participants were additionally asked to complete a self-administered questionnaire including an assessment of health-related quality of life (HRQL) using generic scales from the Medical Outcomes Study: the 36-item Short-Form health survey instrument (SF-36) [28] in VESPA-2003 and its 12-item subset (SF-12) [29] in VESPA-2011. Both scales have been shown to have discriminant validity and to provide appropriate measures of HRQL. Clinical and laboratory information were documented from medical records.

Data were weighted to account for sampling design and nonparticipation. Details about the weighting procedure are provided elsewhere [27]. Both surveys received approval from the French Advisory Committee on Information Processing in Material Research in the Field of Health and met the ethical requirements of the French National Commission for Computing and Liberties.

Variables of interest

Employment status at the time of interview was documented for all participants, based on similar questions in both surveys. In line with the definition of the International Labour Organization, employment status was categorized in two steps as follows. First, participants were considered employed if they reported having a job (either paid or voluntary), regardless of professional status and working time (full time/part time), or if they were on sick leave for less than 6 months. Then, among participants who were not employed, individuals were categorized as either unemployed if they reported having actively sought work within the preceding 3 months or inactive otherwise, including students, retirees, people on disability (recipients of a disability benefit or on sick leave for more than 6 months), and those with family responsibilities. In addition, employment status at the time of HIV diagnosis (employed or not) was documented for respondents diagnosed HIV-infected within the 36 months preceding the survey.

We considered sociodemographic characteristics (age, sex, citizenship, educational level, and household composition) and lifetime history of intravenous drug use as indicators of sociodemographic determinants of individuals’ position on the labor market. Educational level was measured using maximum attained level of education in VESPA-2003 and highest diploma obtained in VESPA-2011, and dichotomized as low (primary or secondary education in VESPA-2003; high school diploma or lower in VESPA-2011) or high (higher education in VESPA-2003; tertiary degree in VESPA-2011). Health status characteristics documented from medical records included indicators of HIV disease advancement (duration since HIV diagnosis at the time of the survey; immune status at the time of diagnosis; status regarding cART and HIV viral load at the time of the survey) and information on history of hepatitis C. For participants who completed the self-administered questionnaire, the physical component summary for physical HRQL and the mental component summary for mental HRQL were computed using the 12 items common to the SF-12 and the SF-36 scales. These scores range from 0 to 100, with higher values denoting better HRQL. Impaired physical or mental HRQL was defined by a score below the first quartile of the distribution by age and sex in the French general population of, respectively, the physical component summary and the mental component summary [30].

Statistical analyses

Analyses included participants of the VESPA-2003 and VESPA-2011 surveys of working-age (25–64 years old) at the time of the survey and diagnosed HIV-infected in 1996 or later, that is, in the era of cART availability. Individuals with missing information for variables with less than 1% missing values were excluded.

Employment, unemployment, and inactivity rates (each expressed as a percentage of the whole study population) were estimated in 2003 and in 2011, overall and according to individuals’ sociodemographic determinants of position on the labor market and health status characteristics. Adjusted prevalence rate ratios (aPRRs) comparing overall employment, unemployment and inactivity rates between 2003 and 2011 were assessed using three separate multivariate Poisson regression models with a robust variance estimator [31]. Each model considered the whole study population and compared the probability of being, respectively, employed (versus unemployed or inactive), unemployed (versus employed or inactive), or inactive (versus employed or unemployed) in 2011 versus 2003. In a first step, models were adjusted for individual sociodemographic determinants of position on the labor market, thus providing estimates of the comparison of PLWHIV's employment status between 2003 and 2011 controlling for changes in individuals profile over time. Then, in order to estimate whether changes in PLWHIV's health contributed to differences in employment status between 2003 and 2011, additional adjustment for health status characteristics was performed.

Labor market transitions following HIV diagnosis were assessed among the subsample of participants diagnosed HIV-infected within the 36 months preceding the survey in VESPA-2003 and VESPA-2011. Rates of work cessation (distinguishing between transitions from employment to unemployment and inactivity) and access to work (transition from non-employment to employment) between HIV diagnosis and survey time were compared between 2003 and 2011, using multivariate Poisson regression models adjusted for individual sociodemographic determinants of position on the labor market and health status characteristics.

Individuals with unknown CD4+ at the time of diagnosis or unknown viral load at the time of the survey and those who did not complete the self-administered questionnaire were included in the analyses using missing categories for immune status at diagnosis, status regarding cART and viral load at the time of the survey, and HRQL, respectively. Because these information may not be missing at random, we conducted sensitivity analyses assigning all participants with missing data for each of these three covariates to either the least favorable (i.e., <200 CD4+ cells/μl or AIDS; not on ART; impaired physical and mental HRQL, respectively) or the most favorable situation (i.e. ≥500 CD4+ cells/μl; on ART and viral load < 400 copies/ml; normal physical and mental HRQL, respectively) in separate analyses.

All analyses were performed using Stata 12 (Stata Corporation, College Station, Texas, USA) and accounted for the complex sampling design and data weighting so that estimates are representative of the whole population of HIV-infected people followed at hospital in France.

Results

Characteristics of the study population

Of a total of 2676 participants (1010 participants of VESPA-2003 and 1666 participants of VESPA-2011) of working-age at the time of interview and diagnosed HIV-infected in 1996 or later, 16 individuals with missing information on educational level (n = 3) or hepatitis C history (n = 13) were excluded. The 2660 participants included were predominantly men (64.8%); 28.0% were citizens of a country of sub-Saharan Africa and more than one-third (36.2%) were MSM. As shown in Table 1, sociodemographic and health characteristics of PLWHIV differed between 2003 and 2011. As compared to 2003, in 2011 PLWHIV were older (median age: 43 versus 39 years, P < 0.001) and more frequently women (37.2 versus 32.1%, P = 0.05) and citizens of a country of sub-Saharan Africa (31.0 versus 22.9%, P < 0.001). In addition, in 2011 PLWHIV had been diagnosed HIV-positive for a longer time than in 2003 (median time since HIV diagnosis: 7.4 versus 3.8 years, P < 0.001), their CD4+ cell count at diagnosis was higher (median: 358 versus 303, P < 0.001) and they were more frequently in virological success (83.2 versus 62.3%, P < 0.001).

Table 1
Table 1:
Participants’ sociodemographic determinants of position on the labor market and health status characteristics, VESPA-2003 and VESPA-2011 surveys.

Employment status at the time of the survey

Overall, approximately six PLWHIV out of 10 were employed in both surveys (60.9% in VESPA-2003 and 59.6% in VESPA-2011, P = 0.56). Among them, 6.2 and 4.7%, respectively, were on sick leave at the time of interview. The rate of unemployment increased by 3.2 points, from 12.6% in 2003 to 15.8% in 2011 (relative change: +25.2%, P = 0.04) and the rate of inactivity decreased by 1.9 points, from 26.5 to 24.6%, respectively (relative change: −7.2%, P = 0.34). Main reasons for inactivity were disability (almost half of the inactive in 2003 and 2011 – 47.0 and 48.4%, respectively, P = 0.76) and retirement (10.2 and 25.6%, respectively, P = 0.001).

As shown in Table 2, in 2003 and 2011 employment status markedly differed according to sociodemographic characteristics. Employment rates were the highest among men (67.0% in VESPA-2003 and 64.7% in VESPA-2011), French nationals (67.6% and 63.9%, respectively), individuals aged 40–49 years (65.3 and 64.5%, respectively), those highly educated (72.5 and 71.6%, respectively) and those living in cohabiting partnership without children (71.6 and 66.1%, respectively). Unemployment was particularly high among women (16.4 and 21.0%, respectively, in 2003 and 2011), individuals aged less than 40 years (14.9 and 22.5%, respectively) and those originating from sub-Saharan Africa (22.8 and 26.5%, respectively). Inactivity was particularly frequent among women (35.7 and 28.0%, respectively), non-African immigrants (42.2 and 35.1%, respectively), individuals aged 50 years or more (42.3 and 40.2%, respectively) and those low-educated (31.9 and 28.5%, respectively). History of intravenous drug use was also associated with high rates of inactivity (53.4 and 50.0%, respectively). Employment status additionally differed according to health status characteristics, with higher employment rates among individuals with the most favorable indicators regarding HIV disease advancement, comorbidity and HRQL.

Table 2
Table 2:
Employment status according to participants’ sociodemographic determinants of position on the labor market and health status characteristics, VESPA-2003 and VESPA-2011 surveys.

Adjusting for sociodemographic determinants of position on the labor market, the employment rate of PLWHIV was not different in 2011 as compared to 2003 [aPRR: 1.03, 95% confidence interval (95% CI): 0.96 to 1.10]. Nonetheless, the rate of inactivity significantly decreased between 2003 and 2011 (aPRR: 0.83, 95% CI: 0.72 to 0.96), and the rate of unemployment significantly increased (aPRR: 1.28, 95% CI: 1.04 to 1.57) (Tables 3 and 4).

Table 3
Table 3:
Prevalence rate ratio of inactivity in 2011 versus 2003, adjusted for individual sociodemographic determinants of position on the labor market (Model 1) and additionally for health status characteristics (Model 2).
Table 4
Table 4:
Prevalence rate ratio of unemployment in 2011 versus 2003, adjusted for individual sociodemographic determinants of position on the labor market (Model 1) and additionally for health status characteristics (Model 2).

After additional adjustment for health status characteristics, the difference in inactivity rate between 2003 and 2011 was no longer significant (aPRR: 0.89, 95% CI: 0.77 to 1.03). In contrast, the unemployment rate remained significantly higher in 2011 compared to 2003 (aPRR: 1.55, 95% CI: 1.24 to 1.93). These results remained consistent in sensitivity analyses.

Labor market transitions following HIV diagnosis

A total of 427 participants in VESPA-2003 and 366 participants in VESPA-2011 had been diagnosed as HIV-infected within the 36 months preceding the interview. These recently diagnosed individuals did not differ between 2003 and 2011 regarding sociodemographic determinants of position on the labor market (supplementary Table S1, http://links.lww.com/QAD/A703); nonetheless compared with 2003 those included in 2011 were less likely to have reached an advanced stage of HIV disease at the time it was diagnosed (29.1 versus 37.6%, P = 0.06) and to have a history of hepatitis C (3.0 versus 6.0%, P = 0.06), and more likely to be in virological success (69.7 versus 57.1%, P = 0.007).

Among recently diagnosed participants employed at the time of HIV diagnosis, 10.1% in VESPA-2003 and 19.2% in VESPA-2011 had turned unemployed by the time of interview (P = 0.01); and 14.8 and 15.4%, respectively, had become inactive (P = 0.88) (Fig. 1). Adjusting for individuals’ sociodemographic determinants of position on the labor market and health status characteristics, the rate of transition from employment to unemployment between times of HIV diagnosis and interview tended to be higher among participants of VESPA-2011 compared with participants of VESPA-2003 (aPRR: 1.58, 95% CI: 0.92 to 2.68). The rate of transition from employment to inactivity did not differ between participants of both surveys (aPRR: 1.05, 95% CI: 0.63 to 1.76).

Fig. 1
Fig. 1:
Labor market transitions following HIV diagnosis among participants of the VESPA-2003 and VESPA-2011 surveys diagnosed HIV-infected within the 36 months preceding interview. VESPA, VIH: Enquête Sur les Personnes Atteintes.

Among recently diagnosed participants not employed at the time of HIV diagnosis, the proportion who had accessed employment by the time of interview was 29.0% in VESPA-2003 and 21.2% in VESPA-2011 (Fig. 1). Adjusting for individuals’ sociodemographic determinants of position on the labor market and health status characteristics, the rate of access to work between times of HIV diagnosis and interview was significantly lower among participants of VESPA-2011 compared with participants of VESPA-2003 (aPRR: 0.54, 95% CI: 0.32 to 0.90). These results remained consistent in sensitivity analyses.

Discussion

Our results indicate that in France, the employment rate of PLWHIV has remained consistently low during the past decade. Nonetheless, this apparent stability masks diverging trends over time in the labor market position of PLWHIV who are out of employment. Indeed, we found that between 2003 and 2011, although economic inactivity decreased, unemployment increased. This suggests that despite the major improvements in HIV care and treatments occurred during the past decade, the employment of PLWHIV, a population that is mainly made of working-age people, still remains problematic in the current context and therefore deserves special attention.

The VESPA-2003 and VESPA-2011 studies, because they were conducted at two different time points using similar study design and questions, provide unique datasets to investigate changes in PLWHIV health and living conditions over a period marked by major changes both in the field of HIV and more broadly in terms of socioeconomic, political, and social context. The national-representative nature of the two datasets constitutes a major strength of our study, as well as the availability of detailed individual information allowing distinguishing between unemployment and economic inactivity and accounting for changes over time in PLWHIV's sociodemographic and health profiles. However, it should be acknowledged that the study is restricted to HIV-infected people attending hospital for HIV care. Nevertheless, HIV care is essentially provided at hospital in France and since 2006 the experts have recommended that all PLWHIV have at least an annual checkup at hospital [32], suggesting that our estimates are likely to apply to the vast majority of PLWHIV in care in France. In addition, the causal interpretation of our findings on changes over time should remain cautious, especially because analyses consisted of comparisons between two cross-sectional surveys rather than on individual longitudinal data. Furthermore, the changes we report among PLWHIV may partly reflect changes occurred more generally in the French general population. Investigating the proper role of HIV infection on these changes would have required a control group of HIV-negative individuals.

The employment rates of approximately 60% we report among PLWHIV in 2003 and 2011 are much lower than the corresponding rates in the French general population aged 20–64 years (69.7% in 2003 and 69.3% in 2011) [33]. This is consistent with previous studies, which reported a lower employment rate among PLWHIV compared with the general population in France [15] as well as in other European countries including Denmark [34], Belgium [35], Spain [36], or UK [37]. In contrast, our findings provide evidence of high rates of both economic inactivity and unemployment among PLWHIV. The inactivity rates we report are substantially higher among PLWHIV aged 25–49 years compared with the French general population of similar age range (23% in 2003 and 18% in 2011 versus 12 and 11%, respectively, in the general population [38]), while among people aged 50–64 years figures appear less contrasted, reaching more than 40% of individuals in this age category both among PLWHIV and in the general population (42 and 40% versus 43 and 41% [38], respectively). Even in the era of highly potent antiretroviral treatments, inactivity appears to be primarily driven by disability among PLWHIV, probably as a consequence of HIV disease itself but also comorbidities. Similarly, disability retirement was reported to be increased among PLWHIV compared with the general population in Denmark [34]. By providing evidence of high rates of unemployment among PLWHIV (12.6% in 2003 and 15.8% in 2011, compared with 5.7 and 6.1%, respectively, in the general population [38]), our results additionally suggest that the low employment rate of PLWHIV results not only from their exclusion from the labor market but also from a decreased employability of those who remain in the labor force.

We found that controlling for individual sociodemographic determinants of position on the labor market, the inactivity rate of PLWHIV, although persistently high, significantly decreased between 2003 and 2011. This decrease was no longer significant after accounting for health status characteristics, suggesting that it likely results from improvements in HIV care occurred during the study period. Such a finding, by providing evidence for PLWHIV's increased ability to work, is consistent with previous findings supporting the ‘normalization’ of PLWHIV's life in the era of cART [39]. This decrease may also reflect changes in eligibility requirements for disability introduced in France in 2005 [40], which may have resulted in reduced access to disability benefits for PLWHIV. Yet, among participants of the VESPA studies the proportion of recipients of a disability benefit did not decrease between 2003 (15.7%) and 2011 (18.1%), suggesting that such changes are unlikely to explain the decrease in inactivity we report.

In contrast with inactivity figures, unemployment significantly increased between 2003 and 2011. Previous reports showed that adverse employment outcomes arise very early in the course of HIV disease [9,10,13,15,34]. Our results on early labor market transitions (i.e., within the first 36 months) following HIV diagnosis confirm the high frequency of such early changes; and furthermore suggest that the increase in unemployment we report is likely to result from lower chances of both maintaining in employment and accessing (or returning) to work in 2011 compared with 2003. This may be related to various underlying mechanisms. First, the increase we report in terms of adverse labor market transitions may result from the overall deterioration of the economic situation generally affecting the French labor market since 2008 [38]. Second, this may reflect the increasing burden of comorbidities, including cardiovascular disease or depression, which have been shown to impair PLWHIV's employment status [15]. Indeed, in our study although analyses were adjusted for health status as measured by HIV disease advancement, hepatitis C coinfection and HRQL, differences in comorbidities over time could not be accounted for because the information was not available in the 2003 survey. Third, experiences of discrimination related either to HIV status or other characteristics of the individuals, which constitute independent predictors of employment loss among PLWHIV [14], were very frequent in France in 2011. Indeed, 24% of the VESPA-2011 respondents having applied for a job reported having been discriminated against when seeking a job in the past 2 years, and 6% of the participants reported experiences of discrimination in their work environment (if any) [41]. However, because comparable figures were not available in the VESPA-2003 study, we were not able to measure their contribution to the reported trends.

In conclusion, our study suggests that improvements in HIV care occurred since the early 2000s have not translated into improvements in PLWHIV's situation regarding employment. Although PLWHIV have seen their ability to work increased in recent years, these improvements appear to have been offset by increasing barriers to maintain in and/or access to employment. The respective roles of socioeconomic recession, comorbidities, and discrimination deserve to be further investigated to help address the issue of employment of PLWHIV in the current context.

Acknowledgements

The authors are deeply grateful to people living with HIV who agreed to participate in the ANRS-VESPA2 study and to all investigators in participating hospitals.

The authors also thank Yann Le Strat (InVS, Saint-Maurice), Lise Cuzin (Hopital Purpan, Toulouse), and Laurence Meyer (INSERM UMR-S 1018, Le Kremlin Bicêtre) for their methodological support; and the community-based organizations AIDES and Act-Up Paris for their ground support in the implementation of the ANRS-VESPA2 study.

The VESPA-2003 and VESPA-2011 surveys were sponsored and funded by the ANRS (Agence Nationale de Recherches sur le SIDA et les Hépatites Virales). M.A. is the recipient of a PhD grant from EHESP (Ecole des Hautes Etudes en Santé Publique) – School of Public Health, Rennes.

M.A., F.L., and R.D.S. contributed to the study design, data interpretation and manuscript preparation. M.A. conducted statistical analyses. M.A. and R.D.S. drafted the manuscript. F.L. and B.S. critically revised the manuscript.

Members of the ANRS-VESPA2 Study Group

F.L. (INSERM UMR-S 1018) and B.S. (INSERM UMR-S 912/ORS PACA), scientific coordinators; Patrizia Carrieri (INSERM UMR-S 912/ORS PACA), R.D.-S. (INSERM UMR-S 1136), Christine Hamelin (University Versailles Saint-Quentin-en-Yvelines), Nicolas Lorente (INSERM UMR-S 912/ORS PACA), Marie Préau (INSERM UMR-S 912/ORS PACA), Marie Suzan-Monti (INSERM UMR-S 912/ORS PACA); with the collaboration of Marion Mora (INSERM UMR-S 912/ORS PACA).

Participating hospitals and investigators: Aix-en-Provence, CH Pays d’Aix (T. Allègre, P. Mours, J.M. Riou, M. Sordage); Angers, CHU Hôtel-Dieu (J.M. Chennebault, P. Fialaire, V. Rabier); Annemasse, CH Alpes-Léman (M. Froidure, D. Huguet, D. Leduc); Avignon, Hôpital Henri Duffaut (G. Pichancourt, A. Wajsbrot); Besançon, Hôpital Saint-Jacques (C. Bourdeaux, A. Foltzer, B. Hoen, L. Hustache-Mathieu); Bobigny, Hôpital Avicenne (S. Abgrall, R. Barruet, O. Bouchaud, A. Chabrol, S. Mattioni, F. Mechai); Bondy, Hôpital Jean Verdier (V. Jeantils); Bordeaux, Hôpital Saint-André (N. Bernard, F. Bonnet, M. Hessamfar, D. Lacoste, D. Malvy, P. Mercié, P. Morlat, F. Paccalin, M.C. Pertusa, T. Pistone, M.C. Receveur, M.A. Vandenhende); Boulogne-Billancourt, Hôpital Ambroise Paré (C. Dupont, A. Freire Maresca, J. Leporrier, E. Rouveix); Caen, Hôpital Clémenceau (S. Dargere, A. de la Blanchardière, A. Martin, V. Noyon, R. Verdon); CH de Chambéry (O. Rogeaux); Clermont-Ferrand, CHU Gabriel Montpied (J. Beytout, F. Gourdon, H. Laurichesse); Colombes, Hôpital Louis-Mourier (F. Meier, E. Mortier, A.M. Simonpoli); Creil, CH Laennec (F. Cordier); Créteil, CHIC (I. Delacroix, V. Garrait, B. Elharrar), Hôpital Henri Mondor (S. Dominguez, A.S. Lascaux, J.D. Lelièvre, Y. Levy, G. Melica); Dijon, Hôpital du Bocage (M. Buisson, L. Piroth, A. Waldner); Eaubonne, Hôpital Simone Veil (N. Gruat, A. Leprêtre); Garches, Hôpital Raymond-Poincaré (P. de Truchis, D. Le Du, J.Cl. Melchior); CH de Gonesse (R. Sehouane, D. Troisvallets); CHU de Grenoble (M. Blanc, I. Boccon-Gibod, A. Bosseray, J.P. Brion, F. Durand, P. Leclercq, F. Marion, P. Pavese); La Rochelle, Hôpital Saint- Louis (E. Brottier-Mancini, L. Faba, M. Roncato-Saberan); La Roche-sur-Yon, CHD Les Oudairies (O. Bollengier-Stragier, J.L. Esnault, S. Leautez-Nainville, P. P erré); CH de Lagny Marne-la-Vallée (E. Froguel, M. Nguessan, P. Simon); Le Chesnay, CH de Versailles (P. Colardelle, J. Doll, C. Godin-Collet, S. Roussin-Bretagne); Le Kremlin-Bicêtre, Hôpital de Bicêtre (J.F. Delfraissy, M. Duracinsky, C. Goujard, D. Peretti, Y. Quertainmont); CH du Mans (J. Marionneau); Lens, CH Dr Schaffner (E. Aissi, N. Van Grunderbeeck); Limoges, CHU Dupuytren (E. Denes, S. Ducroix-Roubertou, C. Genet, P. Weinbreck); Lyon, Hôpital de la Croix-Rousse (C. Augustin-Normand, A. Boibieux, L. Cotte, T. Ferry, J. Koffi, P. Miailhes, T. Perpoint, D. Peyramond, I. Schlienger); Hôpital Édouard-Herriot (J.M. Brunel, E. Carbonnel, P. Chiarello, J.M. Livrozet, D. Makhloufi); Marseille, Hôpital de la Conception (C. Dhiver, H. Husson, A. Madrid, I. Ravaux, M.L. de Severac, M. Thierry Mieg, C. Tomei), Hôpital Nord (S. Hakoun, J. Moreau, S. Mokhtari, M.J. Soavi), Hôpital Sainte Marguerite (O. Faucher, A. Ménard, M. Orticoni, I. Poizot-Martin, M.J. Soavi); Montpellier, Hôpital Gui de Chauliac (N. Atoui, V. Baillat, V. Faucherre, C. Favier, J.M. Jacquet, V. Le Moing, A. Makinson, R. Mansouri, C. Merle); Montivilliers, Hôpital Jacques Monod (N. Elforzli); Nantes, Hôtel-Dieu (C. Allavena, O. Aubry, M. Besnier, E. Billaud, B. Bonnet, S. Bouchez, D. Boutoille, C. Brunet, N. Feuillebois, M. Lefebvre, P. Morineau-Le Houssine, O. Mounoury, P. Point, F. Raffi, V. Reliquet, J.P. Talarmin); Nice, Hôpital l’Archet (C. Ceppi, E. Cua, P. Dellamonica, F. De Salvador-Guillouet, J. Durant, S. Ferrando, V. Mondain-Miton, I. Perbost, S. Pillet, B. Prouvost-Keller, C. Pradier, P. Pugliese, V. Rahelinirina, P.M. Roger, E. Rosenthal, F. Sanderson); Orléans, Hôpital de La Source (L. Hocqueloux, M. Niang, T. Prazuck), Hôpital Porte Madeleine (P. Arsac, M.F. Barrault-Anstett); Paris, Hôpital Bichat – Claude-Bernard (M. Ahouanto, E. Bouvet, G. Castanedo, C. Charlois-Ou, A. Dia Kotuba, Z. Eid-Antoun, C. Jestin, K. Jidar, V. Joly, M.A. Khuong-Josses, N. Landgraf, R. Landman, S. Lariven, A. Leprêtre, F. L’hériteau, M. Machado, S. Matheron, F. Michard, G. Morau, G. Pahlavan, B.C. Phung, M.H. Prévot, C. Rioux, P. Yéni), Hôpital Cochin-Tarnier (F. Bani-Sadr, A. Calboreanu, E. Chakvetadze, D. Salmon, B. Silbermann), Hôpital européen Georges-Pompidou (D. Batisse, M. Beumont, M. Buisson, P. Castiel, J. Derouineau, M. Eliaszewicz, G. Gonzalez, D. Jayle, M. Karmochkine, P. Kousignian, J. Pavie, I. Pierre, L. Weiss), Hôpital Lariboisière (E. Badsi, M. Bendenoun, J. Cervoni, M. Diemer, A. Durel, A. Rami, P. Sellier), Hôpital Pitié-Salpêtrière (H. Ait-Mohand, N. Amirat, M. Bonmarchand, F. Bourdillon, G. Breton, F. Caby, J.P. Grivois, C. Katlama, M. Kirstetter, L. Paris, F. Pichon, L. Roudière, L. Schneider, M.C. Samba, S. Seang, A. Simon, H. Stitou, R. Tubiana, M.A. Valantin), Hôpital Saint-Antoine (D. Bollens, J. Bottero, E. Bui, P. Campa, L. Fonquernie, S. Fournier, P.M. Girard, A. Goetschel, H.F. Guyon, K. Lacombe, F. Lallemand, B. Lefebvre, J.L. Maynard, M.C. Meyohas, Z. Ouazene, J. Pacanowski, O. Picard, G. Raguin, P. Roussard, M. Tourneur, J. Tredup, N. Valin); Hôpital Saint-Louis (S. Balkan, F. Clavel, N. Colin de Verdière, N. De Castro, V. de Lastours, S. Ferret, S. Gallien, V. Garrait, L. Gérard, J. Goguel, M. Lafaurie, C. Lascoux-Combe, J.M. Molina, E. Oksenhendler, J. Pavie, C. Pintado, D. Ponscarme, W. Rozenbaum, A. Scemla), Hôpital Tenon (P. Bonnard, L. Lassel, M.G. Lebrette, T. Lyavanc, P. Mariot, R. Missonnier, M. Ohayon, G. Pialoux, M.P. Treilhou, J.P. Vincensini); Hôtel-Dieu (J. Gilquin, B. Hadacek, L. Nait-Ighil, T.H. Nguyen, C. Pintado, A. Sobel, J.P. Viard, O. Zak Dit Zbar); Perpignan, Hôpital Saint-Jean (H. Aumaître, A. Eden, M. Ferreyra, F. Lopez, M. Medus, S. Neuville, M. Saada); Pontoise, CH René Dubos (L. Blum); Quimper, Hôpital Laennec (P. Perfezou); Rennes, Hôpital de Pontchaillou (C. Arvieux, J.M. Chapplain, M. Revest, F. Souala, P. Tattevin); Rouen, Hôpital Charles-Nicolle (S. Bord, F. Borsa-Lebas, F. Caron, C. Chapuzet, Y. Debab, I. Gueit, M. Etienne, C. Fartoukh, K. Feltgen, C. Joly, S. Robaday-Voisin, P. Suel); Saint-Denis, CH Delafontaine (M.A. Khuong, J. Krausse, M. Poupard, G. Tran Van); Saint-Étienne, CHU Nord (C. Cazorla, F. Daoud, P. Fascia, A. Frésard, C. Guglielminotti, F. Lucht); Strasbourg, Nouvel hôpital civil (C. Bernard-Henry, C. Cheneau, J.M. Lang, E. de Mautort, M. P artisani, M. Priester, D. Rey); Suresnes, Hôpital Foch (C. Majerholc, D. Zucman); Toulon, CHI Chalucet (A. Assi, A. Lafeuillade), Hôpital Sainte-Anne (J.P. de Jaureguiberry, O. Gisserot); Toulouse, Hôpital de La Grave (C. Aquilina, F. Prevoteau du Clary), Hôpital Purpan (M. Alvarez, M. Chauveau, L. Cuzin, P. Delobel, D. Garipuy, E. Labau, B. Marchou, P. Massip, M. Mularczyk, M. Obadia); Tourcoing, CH Gustave Dron (F. Ajana, C. Allienne, V. Baclet, X. de la Tribonnière, T. Huleux, H. Melliez, A. Meybeck, B. Riff, M. Valette, N. Viget); Tours, CHRU Bretonneau (F. Bastides, L. Bernard, G. Gras, P. Guadagnin); Vandoeuvre-lès-Nancy, CHU Brabois (T. May, C. Rabaud); Vannes, CH Bretagne Atlantique (A. Dos Santos, Y. P oinsignon); Villejuif, Hôpital Paul-Brousse, (O. Derradji, L. Escaut, E. Teicher, D. Vittecoq); CHI de Villeneuve-Saint-Georges, (J. Bantsima, P. Caraux-Paz, O. Patey).

Conflicts of interest

The authors have no conflict of interest to disclose.

References

1. Berkman LF. Commentary: the hidden and not so hidden benefits of work: identity, income and interaction. Int J Epidemiol 2014; 43:1517–1519.
2. Bartley M, Sacker A, Clarke P. Employment status, employment conditions, and limiting illness: prospective evidence from the British household panel survey 1991–2001. J Epidemiol Community Health 2004; 58:501–506.
3. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality. Soc Sci Med 2011; 72:840–854.
4. International Labour Office (ILO). The impact of employment on HIV treatment adherence. 2013; Geneva: International Labour Organization, http://http://www.ilo.org/aids/Publications/WCMS_230625/lang--en/index.htm. [Accessed 28 November 2014].
5. Richardson LA, Milloy MJ, Kerr TH, Parashar S, Montaner JS, Wood E. Employment predicts decreased mortality among HIV-seropositive illicit drug users in a setting of universal HIV care. J Epidemiol Community Health 2014; 68:93–96.
6. Dray-Spira R, Gueguen A, Persoz A, Deveau C, Lert F, Delfraissy JF, et al. Temporary employment, absence of stable partnership, and risk of hospitalization or death during the course of HIV infection. J Acquir Immune Defic Syndr 2005; 40:190–197.
7. Delpierre C, Cuzin L, Lauwers-Cances V, Datta GD, Berkman L, Lang T. Unemployment as a risk factor for AIDS and death for HIV-infected patients in the era of highly active antiretroviral therapy. Sex Transm Infect 2008; 84:183–186.
8. Dray-Spira R, Lert F, Marimoutou C, Bouhnik AD, Obadia Y. Socio-economic conditions, health status and employment among persons living with HIV/AIDS in France in 2001. AIDS Care 2003; 15:739–748.
9. Goldman DP, Bao Y. Effective HIV treatment and the employment of HIV(+) adults. Health Serv Res 2004; 39:1691–1712.
10. Rabkin JG, McElhiney M, Ferrando SJ, Van Gorp W, Lin SH. Predictors of employment of men with HIV/AIDS: a longitudinal study. Psychosom Med 2004; 66:72–78.
11. Dray-Spira R, Lert F, Group VS. Living and working with HIV in France in 2003: results from the ANRS-EN12-VESPA Study. AIDS 2007; 21 (Suppl 1):S29–S36.
12. Dray-Spira R, Gueguen A, Ravaud JF, Lert F. Socioeconomic differences in the impact of HIV infection on workforce participation in France in the era of highly active antiretroviral therapy. Am J Public Health 2007; 97:552–558.
13. Dray-Spira R, Persoz A, Boufassa F, Gueguen A, Lert F, Allegre T, et al. Employment loss following HIV infection in the era of highly active antiretroviral therapies. Eur J Public Health 2006; 16:89–95.
14. Dray-Spira R, Gueguen A, Lert F, Group VS. Disease severity, self-reported experience of workplace discrimination and employment loss during the course of chronic HIV disease: differences according to gender and education. Occup Environ Med 2008; 65:112–119.
15. Dray-Spira R, Legeai C, Le Den M, Boue F, Lascoux-Combe C, Simon A, et al. Burden of HIV disease and comorbidities on the chances of maintaining employment in the era of sustained combined antiretroviral therapies use. AIDS 2012; 26:207–215.
16. Smith CJ, Ryom L, Weber R, Morlat P, Pradier C, Reiss P, et al. Trends in underlying causes of death in people with HIV from 1999 to 2011 (D:A:D): a multicohort collaboration. Lancet 2014; 384:241–248.
17. Morlat P, Roussillon C, Henard S, Salmon D, Bonnet F, Cacoub P, et al. Causes of death among HIV-infected patients in France in 2010 (national survey): trends since 2000. AIDS 2014; 28:1181–1191.
18. Mocroft A, Reiss P, Gasiorowski J, Ledergerber B, Kowalska J, Chiesi A, et al. Serious fatal and nonfatal non-AIDS-defining illnesses in Europe. J Acquir Immune Defic Syndr 2010; 55:262–270.
19. Hasse B, Ledergerber B, Furrer H, Battegay M, Hirschel B, Cavassini M, et al. Morbidity and aging in HIV-infected persons: the Swiss HIV cohort study. Clin Infect Dis 2011; 53:1130–1139.
20. Del Amo J, Likatavicius G, Perez-Cachafeiro S, Hernando V, Gonzalez C, Jarrin I, et al. The epidemiology of HIV and AIDS reports in migrants in the 27 European Union countries, Norway and Iceland: 1999–2006. Eur J Public Health 2011; 21:620–626.
21. Hamers FF, Downs AM. The changing face of the HIV epidemic in western Europe: what are the implications for public health policies?. Lancet 2004; 364:83–94.
22. European Commission. EU Employment and Social Situation. Quarterly Review. 2014; Luxembourg: Edited by European Union, http://ec.europa.eu/social/BlobServlet?docId=11565&langId=en. [Accessed 1 December 2014].
23. Reeves A, Karanikolos M, Mackenbach J, McKee M, Stuckler D. Do employment protection policies reduce the relative disadvantage in the labour market experienced by unhealthy people? A natural experiment created by the Great Recession in Europe. Soc Sci Med 2014; 121:98–108.
24. Minton JW, Pickett KE, Dorling D. Health, employment, and economic change, 1973–2009: repeated cross sectional study. BMJ 2012; 344:e2316.
25. Holland P, Burstrom B, Whitehead M, Diderichsen F, Dahl E, Barr B, et al. How do macro-level contexts and policies affect the employment chances of chronically ill and disabled people? Part I: the impact of recession and deindustrialization. Int J Health Serv 2011; 41:395–413.
26. Peretti-Watel P, Riandey B, Dray-Spira R, Bouhnik A, Sitta R, Obadia Y, et al. Surveying the HIV-positive population in France. The ANRS-EN12-VESPA 2003 Survey. Population 2005; 60:525–550.
27. Tron L, Lert F, Spire B, Dray-Spira R. Group AN-Vs. Tobacco smoking in HIV-infected versus general population in France: heterogeneity across the various groups of people living with HIV. PLoS One 2014; 9:e107451.
28. Leplege A, Ecosse E, Verdier A, Perneger TV. The French SF-36 Health Survey: translation, cultural adaptation and preliminary psychometric evaluation. J Clin Epidemiol 1998; 51:1013–1023.
29. Ware JEJ, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34:220–233.
30. Preau M, Marcellin F, Carrieri MP, Lert F, Obadia Y, Spire B. Health-related quality of life in French people living with HIV in 2003: results from the national ANRS-EN12-VESPA Study. AIDS 2007; 21 (Suppl 1):S19–S27.
31. Barros A, Hirakata V. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 2003; 3:21.
32. Morlat P. Medical care of people living with HIV. Guidelines of the experts group. 2013 Report [in French]. Paris: La documentation française; 2013.
33. EuroStat. Statistical Office of the European Union. http://ec.europa.eu/eurostat/web/labour-market/statistics-illustrated. [Accessed 1 December 2014]
34. Legarth R, Omland LH, Kronborg G, Larsen CS, Pedersen C, Pedersen G, et al. Employment status in persons with and without HIV infection in Denmark: 1996–2011. AIDS 2014; 28:1489–1498.
35. Pezeril C. First results of the survey on life condition of people living with HIV in Brussels and Wallonia [in French]. 2012; Bruxelles: Observatoire du sida et des sexualités, 28.
36. Oliva J. Labour participation of people living with HIV/AIDS in Spain. Health Econ 2010; 19:491–500.
37. Rodger AJ, Brecker N, Bhagani S, Fernandez T, Johnson M, Tookman A, et al. Attitudes and barriers to employment in HIV-positive patients. Occup Med (Lond) 2010; 60:423–429.
38. INSEE. National Institute of Statistics and Economic Studies. http://www.insee.fr/en/. [Accessed 12 December 2014]
39. Pierret J. An analysis over time (1990–2000) of the experiences of living with HIV. Soc Sci Med 2007; 65:1595–1605.
40. Ravaud JF. Definition, classification and epidemiology of disability [in French]. Rev Prat 2009; 59:1067–1074.
41. Marsicano E, Dray-Spira R, Lert F, Aubriere C, Spire B, Hamelin C, et al. Multiple discriminations experienced by people living with HIV in France: results from the ANRS-Vespa2 study. AIDS Care 2014; 26 (Suppl 1):S97–S106.
Keywords:

disability; employment status; France; HIV infection; socioeconomic factors

Supplemental Digital Content

Copyright © 2015 Wolters Kluwer Health, Inc.