Prospective memory deficits are associated with unemployment in persons living with HIV infection.

Early in the human immunodeficiency virus (HIV) epidemic, the life expectancy for infected individuals who had received an AIDS diagnosis was only approximately one year (e.g., Lemp et al., 1990). However, since the introduction and widespread use of combined antiretroviral therapies (cART) in 1996, survival rates have improved dramatically (Centers for Disease Control [CDC] and Prevention, 2007) and many individuals are now living for decades with chronic HIV infection (The Antiretroviral Therapy Cohort Collaboration, 2008). Thus, although HIV remains a significant cause of death (CDC, 2007), it is increasingly perceived as a manageable, chronic medical condition akin to diabetes or hepatitis C infection. Although cART has greatly reduced mortality and improved systemic HIV disease outcomes (Kitahata et al., 2009), daily functioning capabilities (Goldman & Bao, 2004), and quality of life (Parsons, Braaten, Hall, & Robertson, 2006), individuals with chronic HIV infection nevertheless experience the burdens of a host of medical (e.g., cardiovascular disease, hepatitis C co-infection), neuropsychiatric (e.g., mood disorders, neurocognitive impairment), and psychosocial (e.g., functional independence, stigma) difficulties that are increasingly relevant to rehabilitation psychologists. Unemployment is one such psychosocial problem that is highly prevalent among individuals living with HIV. It is estimated that one-half to two-thirds of the HIV infected population in the United States are unemployed (e.g., CDC, 2010), which is six times higher than the estimates for the general U.S. population. When considered alongside data on the adverse influence of unemployment on health-related quality of life (e.g., Blalock, McDaniel, & Farber, 2002), such high prevalence estimates underscore the potential importance of identifying novel and potentially remediable predictors of unemployment in persons living with HIV. Research to date has identified a number of important risk factors for unemployment. For example, individuals with lower CD4 cell counts (Blalock et al., 2002; Lem et al., 2005), AIDS diagnoses, and physical disabilities (Rabkin, McElhiney, Ferrando, van Gorp, & Lin, 2004) are all at greater risk for unemployment. Demographic characteristics, including older age (e.g., Burns, Young, & Maniss, 2006) and lower levels of education (Fogarty, Zablotska, Rawstorne, Prestage, & Kippax, 2007), as well as psychiatric comorbidities, such as histories of major depression (Rabkin et al., 2004) or alcohol and substance use disorders (e.g., Lem et al., 2005; van Gorp et al., 2007) have also been associated with a reduced likelihood of employment in HIV. HIV-associated neurocognitive impairment is another important risk factor for unemployment (e.g., Heaton et al., 1994). Approximately 30-50% of persons living with HIV infection demonstrate global impairment in neurocognitive functioning, which – consistent with the primarily frontostriatal neuropathogenesis of HIV – is most commonly evident in executive functions, psychomotor speed, working memory, and the strategic aspects of episodic memory (e.g., Heaton et al., 2010). In their seminal study, Heaton and colleagues (1994) reported that individuals with global HIV-associated neurocognitive impairment were nearly twice as likely to be unemployed as compared to persons with normal neurocognitive performance. Subsequent studies in the pre-cART (e.g., Albert et al., 1995) and cART (e.g., Heaton et al., 2004; Twamley et al., 2006) eras have demonstrated similar adverse effects of global HIV-associated neurocognitive impairment on vocational outcomes, including return to work (e.g., van Gorp et al., 2007; cf. Chernoff, Martin, Schrock, & Huy, 2010). At the level of specific cognitive domains, HIV-infected individuals with deficits in psychomotor skills (van Gorp, Baerwald, Ferrando, McElhiney, & Rabkin, 1999; van Gorp et al., 2007), executive functions (van Gorp et al., 1999; Rabkin et al., 2004; Chernoff et al., 2010), or episodic memory (van Gorp et al., 1999; 2007) appear to be at particular risk of being unemployed. In an effort to extend this literature, the goal of the current study was to investigate the relationship between deficits in prospective memory (ProM) and unemployment in individuals living with HIV. ProM is a form of episodic memory that describes one's ability to successfully execute a delayed intention, or “remember to remember.” In other words, ProM describes the complex cognitive process of forming an intention to carry out a specific behavior at a particular future occasion (e.g., take a medication after dinner), maintaining that intention while engaged in other activities (e.g., normal daily life), detecting the proper cue for intention retrieval (e.g., dinner), and retrieving and executing the correct intention (e.g., taking the medication) (Kliegel Jager, Altgasen, & Shum, 2008). Apparent in this description of the construct is the ubiquitous nature of ProM to daily life; in fact, it has been argued that ProM may be more relevant to many aspects of everyday functioning than other cognitive constructs, such as retrospective memory (i.e., recollection of past events) or executive functions (Woods, Iudicello, et al., 2008). It is therefore reasonable to posit that ProM may play a key role in vocational functioning, including acquisition and maintenance of paid employment. ProM would be relevant to, for example, submitting job applications, attending interviews, arriving at work on time, and carrying out many assigned work tasks. Yet we are unaware of any prior studies that have examined the association between employment and ProM in HIV disease (or in any other clinical sample, for that matter). This is a relevant undertaking because individuals living with HIV infection report frequent ProM failures in their daily lives (e.g., Woods et al., 2007) and evidence deficits in time- and event-based ProM in the laboratory (e.g., Carey et al., 2006; Martin et al., 2007), the profile of which is suggestive of deficits in strategic encoding and retrieval (e.g., Carey et al., 2006). Moreover, HIV-associated ProM impairment is singly dissociable from deficits in other cognitive functions, including retrospective memory (e.g., list learning) and executive functions. Evidence for the separability of ProM from cognitive (Gupta et al., 2010), neurobiological (Woods, Morgan et al., 2006), and functional (e.g., Woods, Iudicello, et al., 2008) studies. For example, Woods et al. (2006) reported that ProM, but not RetM, was associated with specific biomarkers of HIV neuropathogenesis, including tau. Of particular relevance to the present investigation, several studies now show that ProM provides incremental value over standard neurocognitive tests, psychiatric factors, and disease severity in predicting everyday functioning outcomes in HIV, including dependence in instrumental activities of daily living (Woods, Iudicello et al., 2008) and medication management (e.g., Contardo, Black, Beauvais, Dieckhaus, & Rosen, 2009; Woods, Moran, Carey, et al., 2008; Woods et al., 2009). The current study was therefore designed to test the hypothesis that ProM deficits confer an increased risk of unemployment in persons living with HIV infection. It was expected that HIV-infected individuals who were unemployed would report more frequent ProM complaints and demonstrate worse performance on a standardized laboratory measure of ProM. It was also hypothesized that the relationship between HIV-associated ProM impairment and unemployment could not be better explained by other neurocognitive deficits, HIV disease severity, or psychiatric factors.