Important note: Information in this article was accurate in March 2004. The state of the art may have changed since the publication date. 
Treatment Issues: Newsletter of Current Issues in HIV/AIDS - Volume 18, Number 3 & 4, March / April 2004
Karen Escovitz
Project KEEP was a three-year demonstration project to identify and develop service strategies for overcoming barriers to obtaining and maintaining employment for persons living with HIV/AIDS. After an initial community consultation and design phase to identify real and perceived barriers, comprehensive employment support services were provided to unemployed adults living with HIV/AIDS during a two-and-a-half year period. In order to reflect the demographics of HIV/AIDS in urban settings, participants were recruited from Empowerment Zone areas of Philadelphia.
Description
Project KEEP implemented services based on vocational rehabilitation practices proven effective in helping people with psychiatric disabilities to achieve and maintain employment. The components of such supported employment programs typically include:
In keeping with these principles of a supported employment program, Project Keep did not emphasize job readiness training, but rather assisted "all who say they want to work" to find employment in the competitive job market. The rapid attachment approach, along with comprehensive individualized supports, allowed participants to use real-world work experience as an opportunity to develop job maintenance and coping skills.
|
Participant Demographics |
|
| Number of participants Age, mean (range) |
N=148 38 years (20–65) |
| Gender | |
| Male Female Transgender |
60% 38.5% 1.5% |
| Race/Ethnicity | |
| African American Latino White Other |
72.8% 19.7% 6.8% 0.7% |
| Education | |
| No high school diploma High school grad Post high school |
29.3% 53% 17.7% |
Methods
Baseline interviews were conducted by research staff and follow-up interviews were collected at six-month intervals. Employment tracking data was collected at job start, at any significant change in job characteristics, and at job end. Time spent in each service category was tracked. Services and support were available to participants throughout the project duration with at least monthly follow-up by support counselors. Counselors were available to be reached by pager when problems occurred on the job. Services provided included:
The target of 100 participants was rapidly enrolled and dropouts replaced from a waiting list. During the course of the project, 148 individuals obtained services.
|
Baseline Characteristics |
|
| Years since HIV diagnosis, mean (range) HIV+/AIDS HIV+/No AIDS |
5 (2.0–16.4) 26% 74% |
| Comorbidities | |
| Concurrent psychiatric disability Substance abuse treatment in prior month |
34.5% 31.0% |
| Any employment experience Months unemployed, mean (range) |
92% 33.7 (1–300) |
| Social Security status | |
| SSDI SSI Both |
18.2% 20.2% 9.5% |
| Other benefits | |
| Public assistance No cash benefits |
34.5% 17.5% |
General Findings
Best practices for helping people with psychiatric disabilities find employment were effective in this population.
There were few significant correlations between medical indicators (CD4 count, AIDS status, recent hospitalization) and employment outcomes.
Individuals with longer periods of unemployment and those with concurrent psychiatric diagnosis tended to take longer to find a first job, although these factors were not correlated with overall employment rate, which suggests that effective employment support enables people to overcome these barriers. Medical indicators, low education level and self esteem were not associated with time to the first job.
Findings Related to Benefits:
Employment rates were similar for those receiving SSI and SSDI, although those receiving disability benefits worked fewer hours than those not receiving benefits.
Participants who stated they were not afraid of losing benefits (53%) were more likely to become employed and work more hours than those who said they were afraid of benefit loss.
|
Correlations with Total Hours Worked |
||
|
Corr |
Sig |
|
| Overall functioning score at baseline Received offsite vocational counseling* Received onsite job support** |
.18 .571 .26 |
.03 .001 .01 |
| *primarily post-employment job-related problem solving, disability management and coping skills development. | ||
| **primarily mediating misunderstandings between employer and employee |
||
Discussion
The majority of participants in this demonstration project were people of color and people from impoverished backgrounds and neighborhoods; they were representative of the populations in which HIV is spreading most rapidly in U.S. urban areas. Most participants experienced barriers to employment in addition to HIV/AIDS, including psychiatric disability, substance abuse, domestic violence, low education levels, history of incarceration, and unstable housing. Despite multiple disadvantages, Project KEEP participants provided with access to comprehensive and proactive individualized supports were able to achieve a high rate of employment and retention in competitive jobs.
It is important to note that Project KEEP participants were self-selected individuals actively seeking to explore employment possibilities and were therefore likely to represent community members who are most motivated to work or those who have less medical impairment. Furthermore, over 90 percent of participants had some work history. This supports recent findings that even limited prior work experience is a good indicator of capacity for vocational success.
|
Results |
|
| Outcomes | |
| Some employment No employment Hourly wages, mean (range) Participants remaining in job >= 90 days Total jobs held (per employed participant) Jobs held >= 90 days |
114/148 (77%) 24/148 (23%) $8.49 ($2.50 – $44.23) 63% 278 (2.4) 52% |
| Job characteristics | |
| Full time Part time Reported income Under-the-table income Jobs with benefits Jobs without benefits |
54.3% 45.7% 79.5% 20.5% 12.6% 87.4% |
It should also be noted that the services demonstrated to be most effective were not necessarily those traditionally associated with "back-to-work" programs or vocational services for persons with disabilities. These programs typically stress pre-employment activities such as job readiness and job-seeking skills (resume writing and interview techniques, etc.), rather than the job-keeping skills that will help individuals manage work in their lives once they become employed. Follow-along services are generally limited or unavailable once a person becomes employed. Project KEEP findings strongly support the value of a service approach that emphasizes post-employment support, including disability management and job-related problem solving. It is also critical that the ongoing services be available as needed to support individuals when changes occur in medical condition, job situation or life circumstances.
The type of back-to-work efforts most common in the HIV community often emphasize benefits counseling and decision-making about financial and legal issues and typically lead participants through a cost/benefit analysis of their options. These programs, while addressing important components of transitioning to work, may not adequately consider the intangible benefits, such as alleviating boredom and gaining a sense of purpose and social integration.
Karen Escovitz, MSS, is a Project Director at the Matrix Center @ Horizon House, Inc., in Philadelphia. For more detailed information about Project KEEP or for training/technical assistance regarding employment for people with HIV/AIDS, she can be reached at: karen.escovitz@hhinc.org
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