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CISWH Study Shows Anticipation of Stigma Can Limit Employment for Persons with HIV

Wednesday, September 01, 2021

Employment is a significant social determinant of health, particularly important for the financial and mental well-being of persons with HIV (PWH). Researchers at the Center for Innovation in Social Work & Health (CISWH), Serena Rajabiun (co-PI, now at UMass Lowell) and Jessica Flaherty (project director), and co-authors, examined the barriers to employment for those with HIV.  Due to effective medical treatments, PWH are expected to live 43.1 years longer than individuals with HIV just 20 years ago. This increased life expectancy gives PWH the opportunity to retain or gain employment and live a life similar to those not infected with HIV. The study’s goal, recently published in the PLOS ONE journal, is to better understand and address what limits PWH from achieving employment and housing and to develop interventions that can improve those outcomes. 

In previous studies, unemployment was linked to mental health disorders such as depression and suicidal ideation — PWH are no exception. The researchers explain that “In fact, greater quality of life is associated with paid employment and a higher level of income among PWH. Employment may prevent disease progression by increasing one’s sense of belonging, access to health care, and medication adherence. Interventions to increase employment and income are needed for PWH.”

Professor Christina Lee, CISWH Research Core director, emphasizes that “As part of CISWH’s research core initiative to focus on health equity among vulnerable groups, this study is a perfect illustration of how, by addressing structural barriers like unemployment among marginalized populations, we can improve outcomes.”

Currently, there are approximately 1.2 million individuals with HIV in the United States, with 45–65% unemployed and 10–20% homeless. In 2011, among PWH, the majority were living at or below the federal poverty level, leaving this disadvantaged group with limited resources. 

The researchers found that stigma and discrimination are significant barriers to employment for PWH.  While 74% of unemployed PWH were thinking of returning to work, 66% fear workplace discrimination as a potential barrier. The study focuses specifically on understanding the associations between internalized and anticipated HIV stigma and employment barriers. 

Stigma & Discrimination

Previous research findings show that among some employers, fear of contagion and HIV-related stigma are factors in their decisions to hire PWH. HIV stigma includes negative attitudes, judgments, and discriminatory behaviors directed towards those at risk for or with HIV. Internalized HIV stigma is a negative self-perception of self-image due to HIV and is linked to poor physical, mental, and cognitive health, and poor antiretroviral adherence. 

A gap in the literature exists for studying an individual’s perception of HIV stigma and employment barriers, especially in populations that experience housing instability. This prompted the researchers to highlight the relationship between anticipated stigma and employment among people living with HIV. 

This study suggests that for people with HIV, especially those from low-income, racial and ethnic minority communities, addressing the underlying consequences of stigma is essential to support not only physical and mental health but also economic well-being. 


The study funded 12 sites to deliver interventions focused on connecting PWH to employment opportunities. All sites were located in urban areas with interventions based at outpatient HIV clinics or hospitals, city or county health departments, or AIDS Service Organizations. Common elements of the interventions included:

  • Employing navigators as part of the care team to support participants with obtaining necessary housing, employment, and other social services
  • System-level coordination with formal meetings between housing, employment, and medical providers to share and exchange information and support referrals

The researchers concluded that internalized stigma may not play as large of a role in employment as anticipated stigma, noting that stigma reduction interventions focused on communities and employers are essential to improving employment opportunities for PWH.

Study co-authors include Howard J. Cabral of the BU School of Public Health, Joseph S. Lightner of the University of Missouri – Kansas City, Ronald Brooks of The Center for HIV Identification, Prevention, and Treatment Services (CHIPTS) at UCLA, and Jamie Shank of HIV Services, Kansas City Health Department.

The HIV, Housing & Employment Project at CISWH

The Health Resources & Services Administration (HRSA), HIV/AIDS Bureau, through its Special Projects of National Significance (SPNS) Program, has funded a national initiative to support the design, implementation, and evaluation of interventions that coordinate HIV care and treatment, housing, and employment services to improve health outcomes for people living with HIV. Boston University and its partners are working as the Evaluation and Technical Assistance Provider (ETAP) for this 3-year project to promote access to housing, employment, and HIV care for people from low-income and racial and ethnic minority communities.