University of Louisville ThinkIR: The University of Louisville's Institutional Repository Electronic Theses and Dissertations 8-2009 Neuropsychiatric predictors of occupational persistence in HIV/ AIDS. Stephan L. Buckingham University of Louisville Follow this and additional works at: https://ir.library.louisville.edu/etd Recommended Citation Buckingham, Stephan L., "Neuropsychiatric predictors of occupational persistence in HIV/AIDS." (2009). Electronic Theses and Dissertations. Paper 174. https://doi.org/10.18297/etd/174 This Doctoral Dissertation is brought to you for free and open access by ThinkIR: The University of Louisville's Institutional Repository. It has been accepted for inclusion in Electronic Theses and Dissertations by an authorized administrator of ThinkIR: The University of Louisville's Institutional Repository. This title appears here courtesy of the author, who has retained all other copyrights. For more information, please contact [email protected]. NEUROPSYCHIATRIC PREDICTORS OF OCCUPATIONAL PERSISTENCE IN HIV/AIDS by Stephan L. Buckingham B.S., Murray State University, 1982 M.S.S.W., University of Louisville, 1983 A Dissertation Submitted to the Faculty of the Graduate School of the University of Louisville in Partial Fulfillment of the Requirements for the degree of Doctor of Philosophy Kent School of Social Work University of Louisville Louisville, Kentucky August 2009 Copyright 2009 by Stephan 1. Buckingham All rights reserved I NEUROPSYCHIATRIC PREDICTORS OF OCCUPATIONAL PERSISTENCE IN HIV/ AIDS by Stephan L. Buckingham B.S., Murray State University, 1982 M.S.S.W., University of Louisville, 1983 A Dissertation Approved on July 27, 2009 By the following Dissertation Committee: Anna ~ Fa~, Ph.D., Chair Ruth Huber, Ph.D. Christina R Studts, Ph.D. Wilfta:d G. van 60rp, Ph.D. 11 DEDICATION This dissertation is dedicated to people living with HIV /AIDS, and to my friends who died as a result of this epidemic. NECROLOGY TIM BOGUE BRUCE CAMPBELL CRAIG COWAN JEFF DEMLING MATTHEW GAREY STEVE GENDIN GARY HARRISON PATRICK HARRISON PAUL E. KEITH J. VICTOR LOPEZ RON LOYD PAUL ROTHMAN MICHAEL SHERNOFF JEFF TRIPLETT DANNY WARNER RICHARD WARNER CHARLES WILCOX JIM WILEY iii ACKNOWLEDGEMENTS First, I would like to thank Terry Singer and the University of Louisville Board of Trustees for naming me the Kent School of Social Work Alumni Fellow in 2005. This honor came along with discussion of my resuming doctoral studies. And so it was that I began this journey. Second, I would like to thank Chris Rice and Reuben Robbins for the countless times I telephoned, email ed, and sent text messages. Every request was enthusiastically accommodated and never a complaint or any sign of annoyance. They saved me countless times without knowing. Third, I want to thank Wilfred van Gorp for making my dissertation analysis possible. His support and unfailing belief in me, and our work together regarding the neuropsychiatric complications associated with HIV / AIDS, has defined, in large part, my professional career. Our collaboration is a point of great pride, and I look forward to our continued endeavors. Fourth, I would like to thank my committee members, Anna Faul, Ruth Huber, Terry Singer, Christina Studts, and Wilfred van Gorp. Each contributed in meaningful ways, and in the end, I am certain that I could not have accomplished this without each of them. Fifth, to my family, especially my sister Sharon, and my friends, most notably my fellow doctoral students, a special thank you. I know the experience was richer because , IV of them. Also, those special friends that accepted all manner of requests and expectations with unmerited favor-they know who they are-a very special thank you for their encouragement and support. Finally, I want to express my eternal gratitude to my chair and mentor, Anna Faul. Without her support, guidance, and patience this would not have been possible. She never gave up on me or let me give up on myself. She managed the most difficult situations with genuine interest, optimism, and humor. Through example, she showed me the kind of academic I aspire to become. It is impossible to express the depth of my appreciation. In closing, to quote a friend upon completing her doctorate, "I can die now." v ABSTRACT NEUROPSYCHIATRIC PREDICTORS OF OCCUPATIONAL PERSISTENCE IN HIV/AIDS Stephan L. Buckingham July 27, 2009 It is well established that HIV (human immunodeficiency virus), the virus responsible for AIDS, directly attacks the central nervous system, altering cognition, behavior, and affect, and can result in a full dementia syndrome. HIV -associated neurocognitive complications, along with a myriad of other health threats, resulted in significant disability and unemployment for those infected. However, the advent of more effective antiretroviral medications used in combinations, along with homologous improvements in morbidity and mortality, have allowed for people living with HIV / AIDS to return to work, albeit not without challenges. Even mild cognitive impairment has been shown to affect employability and level of occupational functioning. The focus of this dissertation was to develop an understanding of the impact of HIV -associated neurocognitive challenges, the most common neuropsychiatric expression of HIV, on occupational persistence. This study analyzed existing data from a parent study conducted in New York City. The sample consisted of 116 community dwelling HIV positive men and women who were actively seeking employment after being unemployed subsequent to learning of their HIV status. The research design was a VI longitudinal prospective cohort study testing a multilevel growth model with a two­ nested-level structure. The growth model examined individual differences in occupational persistence over a two year time period, testing multiple potential neuropsychological predictors and covariates. Changes in individual growth profiles were investigated, and possible explanations for observed differences were tested. The analysis found that memory is the most potent neuropsychological predictor of occupational success, both in terms of returning to work in the first six months of the study (event), as well as persisting on the job over time (two years). The second most influential neuropsychological predictor was executive functioning, which significantly influenced occupational persistence over time and an accelerated growth trajectory. These central findings along with other significant control interactions are discussed. The study limitations are discussed, along with opportunities for future research. The relevance of these findings is explored, specifically addressing the implications for social work practice and social work education. Vll TABLE OF CONTENTS CHAPTER I: PROBLEM STATEMENT ....................................................................... 1 Demographics of HIVI AIDS .................................................................................. 3 History of HIVIA IDS .............................................................................................. 5 The Central Nervous System and HIV/AIDS ......................................................... 8 HIV-Associated Neurocognitive Disorder ................................................. 10 Neuroanatomic and Clinical Features ............................................ 13 Nosology of HI V-Associated Neurocognitive Disorder ................ 16 Summary ................................................................................................................ 19 CHAPTER II: LITERATURE REVIEW ...................................................................... 21 Overview of the Literature Review ....................................................................... 21 HIV / AIDS and Return to Work ............................................................................ 22 Search Parameters and Process ................................................................. .22 Return to Work Literature .......................................................................... 23 HIV-Associated Neurocognitive Disorder ..................................... 25 Physical and Medical Issues .......................................................... 25 Mental and Emotional Issues ........................................................ .26 Education and Training Needs ...................................................... .26 Financial and Benefit Stability ....................................................... 27 HIV-Associated Neuropsychological Function and Employment ......................... 28 Vlll Theoretical Perspectives and Models ......................................................... 32 Model of Functional Psychosocial Adjustment Outcomes ............ 33 Model of Employment Outcomes .................................................. 37 Model of Directional Causal Relationships ................................... 39 Proposed Conceptual Model ........ .' ........................................................................ 40 Main Predictor ........................................................................................... 42 Neuropsychological Functioning .................................................. .42 Control Variables ....................................................................................... 42 Demographic and Life Characteristics ........................................... 42 Age ....................................................................................