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Career issues and concerns for persons living with HIV/AIDS.

As the perception of HIV/AIDS continues to shift from a terminal illness to a manageable disease, persons living with HIV/AIDS (PLWHAs) are able to reenter the work force or remain in their current jobs for a longer period of time. Although this change is positive, it also raises many career concerns for PLWHAs. Using an ecological approach and the theory of work adjustment (Lofquist & Dawis, 1969, 1991), the authors provide suggestions for working with PLWHAs on career-related issues. A case vignette is presented to demonstrate how this approach may he applied.


With the advent of highly active antiretroviral therapy (HAART), HIV/AIDS is now regarded as a chronic, but manageable, illness (Goldblum & Kohlenberg, 2005). As the perception of HIV/AIDs as a fatal disease changes, the helping professional's view of how to treat persons living with HIV/AIDS (PLWHAs) must also change. Because PLWHAs are now living longer, career issues related to this increased longevity have surfaced. Potential career implications include how HIV/AIDS may affect current jobs, consideration for future employment, discrimination in the workplace, and managing medical needs at the workplace. It is important for career counselors working with PLWHAs to be cognizant of such factors when developing treatment plans or therapeutic interventions associated with career concerns (Barrio & Shoffner, 2005).

PLWHAs who seek assistance in considering their work options often find a gap between vocational services and AIDS service organizations (ASOs). ASOs are community-based groups working to treat and prevent HIV and AIDS. Services offered by ASOs include case management, educational services, housing and transportation assistance, financial assistance, and legal services (, n.d.). Although an ASO may provide adequate medical and psychosocial information, ASO providers typically do not provide vocational counseling. Conversely, the experiences of PLWHAs regarding work have received little re search, and career counselors may have limited knowledge about the specific issues pertaining to living with HIV/AIDS in the workplace (Werth, Borges, McNally, Maguire, & Britton, 2008). Career counselors will need to balance traditional vocational concerns with the unique needs of PLWHAs who are considering entering, returning, or staying in the workplace (Werth et al., 2008). Through the case vignette of John (a fictional client), we address the many career issues and concerns of PLWHAs from ecological (Barrio & Shoffner, 2005; Cook, Heppner, & O'Brien, 2002) and theory of work adjustment (Lofquist & Dawis, 1969, 1991) perspectives and suggest possible treatment interventions. We chose this combination of perspectives because both approaches allow for the consideration of the individual and environmental/systemic factors and together they facilitate the integration of PLWHAs' career and health concerns in the context of societal attitudes toward PLWHAs.

Case Vignette of John

John is a 42-year-old White man who currently lives in an urban city in the Midwest. Five years ago, John began to show signs of flu-like symptoms. Soon afterward, he was diagnosed as HIV positive. Following the diagnosis, John reported experiencing a wide range of emotional experiences, such as feeling numb, denial, guilt for past actions, depression, and suicidal ideation. At. the time of his diagnosis, John was working as an electrician for a local, midsize company. Financially, it was important for John to keep his job, and he assumed that if he disclosed his diagnosis he would be fired. Although he never disclosed his health status to his employer, John's employment was terminated 2 years ago. Although John does not have documented evidence, he believes that he was terminated because of his HIV status. John suspected that his frequent visits to the doctor's office and increased sick leave caused suspicion at his midsize company. Additionally, because of a change in his treatment regimen, John developed lipodystrophy, a syndrome characterized by dramatic changes in body composition and lipid abnormalities causing wasting of the arms, legs, and face, but obesity-type changes around the torso and breasts. Not sure what direction to take concerning future employment options, John has sought out career counseling.

HIV/AIDS and Psychosocial Concerns

Receiving an HIV/AIDS diagnosis can result in emotions of intense fatalism; numbness; guilt and remorse for past actions; denial; suicidal ideation; and, conversely, a sense of optimism regarding today's medical processes (Anderson & Rowe, 2006). Disclosure of the diagnosis may also result in vulnerability to violence, loss of employment, loss of relationships with significant others, exposure to societal prejudice, and stigmatization (Anderson & Rowe, 2006; Werth et al., 2008). Additionally, the decline of viral counts, hospital stays, deaths of fellow patients with AIDS, and confronting one's own mortality create another set of concerns and stress (Anderson & Rowe, 2006; Fisher, Fisher, Amico, & Harman, 2006; Joyce, Chan, Orlando, & Burnam, 2005; Mendias & Paar, 2007).

A diagnosis of HIV/AIDS has social as well as individual ramifications. Many people sec PLWHAs as morally suspect and at fault for their circumstances. PLWHAs may face additional discrimination in the form of denial of insurance, scrutiny on housing and employment applications, and denial of entry into the U.S. military (Anderson & Rowe, 2006). PLWHAs experience many prejudicial and discriminatory events that are both life-altering and demoralizing. PLWHAs must cope with individuals, employers, fellow coworkers, organizations, and policies that can threaten their professional careers; concerns regarding gaps in their employment histories; living arrangements; financial solvency; and ability to participate in social and professional organizations (Brooks, Martin, Ortiz, & Veniegas, 2004; Maguire, McNally, Britton, Werth, & Borges, 2008; Martin, Brooks, Ortiz, & Veniegas, 2003). Unfortunately, many PLWHAs even experience hostile and violent actions carried out by people or groups who harbor profound and unsubstantiated hate or fear (Heckman, 2003). Thus, PLWHAs are considered to be members of disenfranchised and discriminated groups and frequently experience career barriers on the basis of stigma, prejudice, and discrimination (Werth et al., 2008). Because of these psychosocial concerns and the dearth of theory-based literature related to career issues and HIV/AIDS, we believe it is important for researchers to specifically focus on PLWHAs and their career concerns (Maguire et al., 2008; Werth et al., 2008).

Career Issues and Concerns for PLWHAs

For PLWHAs, the introduction of HAART medications significantly improved overall health and quality of life (Hunt, Jaques, Niles, & Wierzalis, 2003; Weaver et al., 2005). As a result, clients such as John are likely to be able to stay in the workforce longer. Nevertheless, HAART requires near-perfect regimen adherence to receive the maximum benefit and avoid treatment failure. Dose regimens often require PLWHAs to take up to 22 pills a day. Even the most modest deviation from the daily pill schedule can greatly diminish the effects of the treatment (Gonzalez et al., 2004). HAART can also cause significant side effects such as nausea, vomiting, diarrhea, fatigue, malaise, headaches, lipodystrophy, peripheral neuropathy, kidney stones, liver toxicities, diabetes, and severe rashes (Averitt, 2000). Experiencing such side effects can require additional medical visits and employment flexibility, making treatment adherence and maintaining employment difficult.

Another factor that contributes to the difficulty of treatment adherence and the importance of employment is the cost associated with HAART. Protease inhibitors and the other supplemental drugs that must be taken with them can cost between $10,000 and $15,000 per year. This annual cost does not include regular visits to the doctor's office, emergency hospital visits, or lab tests. Furthermore, the majority of these costs ac cumulate when PLWHAs are symptomatic or later in the disease process when having HIV/AIDS can be the most severe and stressful (Kalichman, 1998; Werth et al., 2008). One of John's greatest concerns might be maintaining his health benefits. If he earns more than a specified amount, he might move into a higher income bracket and lose eligibility for government-subsidized health benefits.. If government benefits are lost, the income from a newly acquired job is frequently not enough to cover the cost of HIV/AIDS treatments (Brooks & Klosinski, 1999). Therefore, to provide effective career counseling, John's counselor needs to learn the medical aspects of HIV/AIDS and its treatment as well as how those medical issues interact with workplace requirements.

Cook et al. (2002) suggested that the implementation of an ecological model (i.e., Bronfenbrenner's model) might be helpful in meeting the needs of career clients such as John whose career development paths may be complicated by the challenges presented with an HIV/AIDS diagnosis. Bronfenbrenner's (1977) widely recognized Ecological Model encompasses four subsystems that influence human behavior and directly relate to career concerns: (a) microsystems include interpersonal relation ships at home, school, and work settings; (b) mesosystems consist of interactions between microsystems (e.g., one's school interacting with the work environment); (c) exosystems are subsystems that indirectly influence the individual; and (d) macrosystems are ideological components within a given society (e.g., work values, norms, and attitudes toward disenfranchised groups).

Regarding the exo-and macrosystem levels, understanding state, local, and federal employment discrimination laws is important in helping John cope with work-related issues. Knowledge of these ecological influences can assist John in areas such as Social Security Disability Insurance, Supplemental Security Income, and private disability insurance (Brooks & Klosinski, 1999; Werth et al., 2008). The career counselor also needs to assist John in recognizing and addressing discrimination and harassment. Examples of discrimination may include isolation from other coworkers, termination, or a reduction in responsibilities (Kalichman, 1998). It is also important to help John understand the range of legal definitions for disability in federal, state, local, and private insurance terms and the implications the different definitions have on work-related activities. For example, a company's insurance policy may permit John to experiment with returning to work without permanently jeopardizing his disability coverage. Understanding legal rights pertaining to the Americans With Disabilities Act of 1990 (1991), including asking for accommodations and knowing how to protect one's privacy in a job interview, may help to empower John in his attempts to reenter the workforce. Nevertheless, it is also important to educate John on the limits of these protections and the need for appropriate interpersonal skills when working with an employer regarding workplace accommodations (Goldblum & Kohlenberg, 2005). On the basis of these multifaceted issues, the career counselor can use an ecological perspective to inform interventions when working with John on issues such as discrimination, disability' insurance, and harassment in the workplace. In addition, through a collaborative relationship, the career counselor can assist John in challenging institutional and societal barriers that may impede his vocational and personal-social development (Maguire et al., 2008).

Work Adjustment Theory With PLWHAs

With an understanding of the exo-and macrosystem influences on the client, the career counselor can now shift focus to the micro-and mesosystem levels and address specific career decisions. Work adjustment theory provides an excellent approach for integrating PLWHAs' work abilities and values, medical and career-related concerns, and the environmental context. Work adjustment theory was first described by Lofquist and Dawis in 1969 and more recently in 1991 when they referred to it as person-environment-correspondence counseling. Work adjustment is the effort of the client to maintain correspondence between the workplace environment and the work personality. Work personality is defined in terms of abilities, vocational needs, and personality style, whereas work environments are described in terms of work reinforcers provided by the job and ability requirements. Worker satisfaction is a function of the correspondence between the work reinforcers of the environment and the individual's needs, and worker satisfactoriness is a function of the person's abilities and the work environment's ability requirements. By considering environmental reinforcers and individual reinforcement needs, the counselor can incorporate issues related to working with PLWHAs into career counseling.

An important first step in working with John is to conduct a thorough intake that specifically addresses the medical and systemic influences described earlier. During the intake, key information regarding medical status (e.g., current T-cell counts, physical condition), current medication treatments, emotional state, experiences of harassment or discrimination, employment history, and legal or disability issues needs to be gathered. Investigating these areas will help identify the needs that might be important for John to have met in his new job.

According to work adjustment theory, once the identification of systemic considerations is complete, the career counselor should then help John assess his current abilities and the values that would be important for him to fulfill through his work. The results of these assessments allow John to see how his set of skills and values matches with specific occupations or career areas and can assist him in exploring work-related values, past work and educational achievements, and current vocational aptitudes (Goldblum & Kohlenberg, 2005). John can then explore new or alternative career options on the basis of values and skills as well as consider what will be required for him to be a satisfactory worker (Lofquist & Dawis, 1991).

For John, exploring work values may be one of the most important factors in the career counseling process. The Minnesota Importance Questionnaire (MIQ; Rounds, Henly, Dawis, Lofquist, & Weiss, 1981) is frequently used to identify an individual's career-related values and needs. The MIQ assesses 20 needs that can be clustered into six values of achievement, comfort, status, altruism, safety, and autonomy. The Work Importance Locator and the Work Importance Profiler, available from the Occupational Information Network Resource Center (, provide similar information on work values. Each of these work values could increase or decrease in saliency for John at various times in his illness process. Comfort, for example, may be extremely important during a time when his T-cell counts are low and he needs to reduce his activity levels at work. Safety is likely to be another area that may be important for John. Because of the stigmatization associated with HIV/AIDS, John may need to be careful when choosing a new work environment. Additionally, safety may pertain to potential job loss. HIV/AIDS treatments can cause severe side effects, and the illness may result in hospital stays, frequent doctor visits, and absences related to HIV/AIDS conditions. These fluctuations would require a flexible work schedule, the ability to work part time, or jobs that allow for short or extended absences. Safety may also be an important component to consider regarding disability services. Too much income may result in the loss of much-needed services that cover the expensive drug treatments and overall medical care.

Additionally, it may be appropriate for John to assess his needs and values as they change over the course of his illness. Work adjustment theory conceptualizes the person-environment fit as dynamic such that as the client's work personality and the work environment change, the correspondence between the two must be renegotiated. This is clearly the case with HIV/AIDS in that symptoms can fluctuate, forcing the client and career counselor to reevaluate salient needs and abilities. HIV/AIDS is different from many disabilities (e.g., cerebral palsy) that often stabilize over time (Goldblum & Kohlenberg, 2005). Therefore, PLWHAs such as John who wish to reenter the workforce can learn time management skills to accommodate a strict medication schedule and adopt coping skills for managing work-related stress while also generating the strength and resilience necessary to return to work (Maguire et al., 2008). These new skills can be a source of strength that may be used for coping with a range of oppressive scenarios (Maguire et al., 2008).

Work adjustment theory also emphasizes the client's abilities and considers how they match with the skills required in different job settings. Here, too, John's health status may alter some of his previously established skills (e.g., loss of muscular strength, concentration difficulties). Although there are hundreds of work skills, most ability assessments measure factors that are common to many skills and give information on a smaller number (approximately 10) of ability dimensions (e.g., verbal, mathematical, spatial relations). The General Aptitude Test Battery (U.S. Department of Labor, 1982) is often used with work adjustment theory because it measures a broad base of abilities.

Increasing job awareness for John may be another critical aspect of career counseling. Prior to the new medical treatments, PLWHAs frequently perceived that working was no longer an option. Nevertheless, in what is often termed the Lazarus syndrome, PLWHAs who once thought that keeping a steady job was not possible are now realizing that they can reenter the workplace (Barrio & Shoffner, 2005). Although this is a positive step, PLWHAs who did not believe that they could continue working or work again may have removed themselves from the career development process and therefore possess limited knowledge of the types of jobs that may be suitable for them. Thus, John may need assistance to identify the types of work that seem appropriate, locate any necessary funding sources for vocational training, develop interview skills, or address gaps in his resume (Barrio & Shoffner, 2005).

An additional useful tool in working with PLWHAs is the Chronic Illness Quality of Life (CIQOL) scale (Heckman, 2003). The CIQOL scale assesses life satisfaction on the basis of five factors: AIDS-related discrimination, barriers to health care, physical well-being, social support, and engagement coping. Many of these ecological factors are often overlooked when considering the stress associated with an HIV or AIDS diagnosis. AIDS discrimination has been shown to be related to poorer overall well-being, which may be attributed to poor health care delivery or discriminatory practices performed by the health care providers (Heckman, 2003). This assessment may be extremely valuable in working within the micro-, meso-, exo-, and macrosystem domains of the psychosocial and medical concerns for John.

In the next phase of the work adjustment theory approach, the career counselor uses these assessment tools to help the client match client abilities with job requirements and client needs and values with workplace reinforcers. The Ecological Model (Bronfenbrenner, 1977) allows for the incorporation of macro- and mesosystem forces into the therapeutic work. Knowing how John's needs and abilities might change as a result of his changing health status emphasizes the responsibility of the career counselor and John to maintain an awareness of his inputs and work with potential employers on clarifying how alterations to job requirements and workplace conditions could be made to increase client-workplace correspondence. Additionally, increasing John's awareness and exploring his own responsibility in assessing employment needs can greatly increase the likelihood of his job success in the future. These developmental, future-oriented, and strength-based interventions are consistent with a paradigm of helping clients such as John to respond in an adaptive fashion, appraise and adjust problem-solving skills, and adapt to life's challenges (Maguire et al., 2008).

Moving Beyond the Traditional Career Counseling Role

Career counselors may also have to step outside their traditional counseling role in other areas when working with clients such as John. It is important for the counselor to assist in ensuring that appropriate medical care is being received, that psychological and physical needs are being addressed, and that treatment decisions and career options are evaluated in conjunction with each other (Anderson & Rowe, 2006; Israel, 2000). Interventions for clients such as John may also include linking clients with an ASO for support and services. The career counselor might also assist in locating child care services, transportation, and other practical services that will facilitate resumed employment (Barrio & Shoffner, 2005). In compliance with the ACA Code of Ethics (American Counseling Association, 2005), counselors must strive to provide the best service possible for their clients. The counselor's work might also have a psychoeducational focus on providing John with information concerning Social Security Disability Insurance, Supplemental Security Income, and private disability insurance (Brooks & Klosinski, 1999) or on providing referrals to those professionals who can address these issues. Interventions may require the career counselor to receive additional legal training or to work as an advocate for John by finding appropriate (e.g., pro bono) legal representation.

Integrating an ecological approach with work adjustment theory can assist career counselors in conceptualizing the individual and systemic needs and concerns of clients such as John. Counselors may need to take an active role in educating the local ASO in their area concerning PLWHAs' vocational concerns. Additionally, a career counselor may need to educate the local vocational rehabilitation organizations on the psychological concerns often associated with PLWHAs who are attempting to enter or reenter the workforce. An integrated approach to career counseling increases the likelihood that PLWHAs will receive more holistic and comprehensive care within their communities.

Finally, career counselors have the potential to influence federal, state, and local institutional policies. As we have discussed in this article, providing comprehensive and effective care for PLWHAs requires an understanding of the complex and multifaceted issues related to career and HIV/AIDS. With an understanding of this illness and the corresponding psychosocial concerns, career counselors are in an excellent position to inform and educate local and national legislative bodies (Gebbie, 1995) as well as businesses and organizations within the community. Legislators and business owners may be unaware of the challenges of managing HAART medication regimens and that simple accommodations such as flextime might allow for PLWHAs to maintain higher levels of work quality and productivity. Similarly, policy makers working on health care legislation might benefit from a greater understanding of PLWHAs' struggles to balance the desire to be employed with the fear of losing medical benefits. Career counselors can also engage in a wide range of activities from developing relationships with local employers and legislators to lobbying for specific HIV/AIDS policies or laws. Additionally, through the Ryan White Comprehensive AIDS Resources Emergency Act (1990), mental health care professionals are able to conduct qualitative and quantitative studies and provide need assessments, develop comprehensive treatment plans, and identify gaps in HIV/AIDS service delivery. These data can then be used to obtain additional state and federal funding to support HIV/AIDS research and improve the availability and quality of care for PLWHAs (Hayes, Gambrell, Young, & Conviser, 2005). Therefore, continued documentation of the career concerns for PLWHAs can be used to provide a road map for developing a system of care for mental health providers, legislators, and government agencies.


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David T. Dahlbeck and Suzanne H. Lease, Department of Counseling, Educational Psychology and Research, University of Memphis. Correspondence concerning this article should be addressed to David T. Dahlbeck (e-mail:
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Title Annotation:Effective Techniques
Author:Dahlbeck, David T.; Lease, Suzanne H.
Publication:Career Development Quarterly
Geographic Code:1USA
Date:Jun 1, 2010
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