In 1988, the prevailing wisdom was thatby 1991 AIDS would be the number oneproblem facing the workplace as medicalcosts and a decimated work force batteredbusinesses and job discrimination and theloss of medical benefits threatened thesecurity of employees.

Thus far, experience has not matchedthese fears. Drug abuse, not AIDS, remainsthe primary preventable health problemfacing workplaces in the United States.HIV-related medical costs remain manage-able. Diligent efforts have forestalleddiscriminatory legislation and the recentlyenacted Americans with Disabilities Actaccords federal protection to people withHIV disease. However, more subtle issues—for example, negotiating “reasonableaccommodation,”* and dealing with theemotional responses of co-workers toseropositive employees—have emerged asbusinesses have continued to grapple withHIV disease.

In addressing these issues, corporationshave developed two critical tools: a clearand comprehensive HIV policy and a well-informed, clinically trained Employee Assis-tance Program (EAP) staff. The first providesthe structure and guidelines through whichcompanies can work when dealing withHIV disease; the second, a mechanism forcreatively implementing these guidelines.

Typically, EAPs offer clinical services toemployees and their families (sometimesincluding their unmarried partners), aswell as consultation with supervisors andmanagers when medical and behavioralproblems occur in the workplace. Theyidentify trends, recommend policies,

conduct trainings, and intervene toresolve conflicts. A trained EAP staffbecomes a liaison between HIV antibodypositive employees and virtually everyaspect of their lives at work.

Any business executive who seeks areasonable way to handle HIV disease inthe workplace asks: How can I maintainemployee productivity while ensuring thatemployees feel well-compensated, ade-quately covered by medical insurance,valued in their diversity, and supported if they become seriously ill? How can thiscompany address complex issues such ashomophobia, employee rights, employerliability, and the supervisor-employeerelationship while continuing to functionas a profitable and efficient business? Thewise executive responds to these ques-tions by adopting what has become thestandard approach to HIV disease.

Devising a Corporate PolicyThis approach can be summarized in

five steps. First, establish a policy thatclearly states how the company will andwill not react to employees with HIV dis-ease. This might include, for example,details regarding equal treatment andfreedom from discrimination, reasonableaccommodation, and HIV-related educa-tion of the work force.

To develop a policy, convene represen-tatives from key internal departmentssuch as Law, Benefits, Medical, EAP,Human Resources, and Labor Relations.While policies vary among companies—reflecting the type of business in which a company is engaged, the company’sproduct, and the duties of employees—a review of the policies of other organiza-tions is helpful. Prior to drafting the poli-cy, the group may consult medical, AIDS,and other experts outside the company.Once sufficient research is finished, thegroup develops the policy.

OOCCUUVolume 7 Number 3 February 1992

FF A Guide toAIDSResearch and Counseling

SS

*Laws like theAmericans withDisabilities Act and Section 504 of the Rehabilitation Actof 1973 prohibitdiscrimination againstdisabled employees, including people with HIV disease. A crucial part of this protection is embodied in theconcept of reasonable accommodation,which requiresemployers to seekways to modify a job’sduties or schedule so that an employeewho becomes disabled may fulfill them.

The Workplace Response to HIV DiseaseJude Sharp, PhD

Second, give each employee a copy ofthe policy and include with it the rationalefor its existence. Third, educate allemployees about HIV disease, its preven-tion, and its implications for the work-place, and about the purpose for thecompany’s policy. Emphasize the continu-ing education of managers and supervi-sors, who play a key role in determiningthe atmosphere of a workplace.

Fourth, make confidential counselingavailable through the EAP. The EAP shouldbe a primary resource to respond to ques-tions, expressions of concern, and resis-tance to the policy. Fifth, keep currentabout HIV disease, modify the HIV policyaccordingly, and notify employees aboutnew information.

Special ConcernsSome of the more difficult issues for

employers to handle and about whichemployees have the greatest concerns are:the maintenance of comprehensive healthcoverage, the effects of HIV disease on job

performance, the stigmatization of HIV-infected employees, the threat of HIVtransmission in the workplace, and HIVantibody testing as a condition of employ-ment. Fears about health, job security, andstigmatization may lead HIV-infectedemployees to isolate themselves, and thismay further complicate the EAP responseto these issues.

Health Insurance. For obvious reasons,it is crucial for employees with HIV dis-ease to maintain the insurance coveragethey receive as an employment benefit.For their part, employers fear increasedinsurance costs, and if self-insured,increased medical costs. There is no evi-dence, however, that companies wouldsave money if they avoided hiring peoplewith HIV disease.

Many large corporations are self-insured for medical coverage. This prac-tice provides considerable flexibility, butalso requires that corporate managers payclose attention to medical expenditures.In concert with benefits departments and

FOCUS2 February 1992

Most of us work because wehave to support ourselves. Butthe emotional fabric of the work-place is never simply defined byour salaries and job duties. Workcarries with it everything fromultimate fears of unemploymentand homelessness to ultimatehopes of fame, fortune, security,and fulfillment. For most, it isnever more or less than a bal-ancing act between meetingfinancial and social needs andgetting as much satisfaction aswe can from our jobs.

The workplace—the setting inwhich most adults spend mostof their time—is an environmentheavy with roles and expecta-tions, a central experience yetone that is often dismissed as“just a job.” It is also where wemost often submit to the con-straints of a hierarchy andrules—sometimes arbitrary andsometimes patently unfair—over which we have no control.

In this charged atmosphere,neither employees nor theirsupervisors can deal with HIV

infection free from stress. But,as both articles in this issue ofFOCUS suggest, employers cananticipate the complicationsrelated to accommodatingemployees with HIV disease. Byimplementing fair and consis-tent policies, and HIV-relatedemployee education, they canreasonably and without greatexpense meet the obligations of both law and ethics.

Satisfaction and ProductivityEmployers, wary of the bot-

tom line, must also remindthemselves about the centralplace of employee satisfaction inmaintaining productivity. Clear,consistent, and equitable com-pany policies foster a sense ofsecurity among employees andgo a long way toward guarantee-ing productivity. Secretive, arbi-trary, and ambiguous policiespromise the converse—suspi-cion, dissatisfaction, fear, anddisloyalty—and most important-ly, do not forestall conflict. Acompany that fails to communi-

cate openly finds that employeeconcerns get suppressed until avolatile mix of rumor, exaggera-tion, and frustration ignite intoconflict magnified far beyondthe original concerns.

Mental health and medicalpractitioners—particularly pri-vate practitioners used to thecontrol of being their own boss-es—must remind themselvesabout this situation and aboutthe constraints of the workplace.They must learn more aboutworkplace issues and policies to help clients interpret work-related experiences and navigateworkplace procedures.

Work often gets reduced totwo things: the quality of anorganization’s “product” and thefinancial success of the compa-ny and its employees. Oftenignored is the central role workplays in maintaining mentalhealth. The presence of HIVdisease in the workplace chal-lenges employers and employ-ees to reach beyond simplifieddefinitions of work and toacknowledge their expectationsof each other and develop newapproaches to resolve the potential conflicts.

Editorial: 9 to 5 to 9 to 5 to . . .Robert Marks, Editor

FOCUS3 February 1992

managed care providers, EAPs often takeon the role of case manager, monitoringcare to make sure it is medically appropri-ate and cost effective, and when it is not,recommending alternatives. In this role,EAPs must remain aware of treatmentalternatives and how to access them, andin communities where resources are

scarce, may advocatefor and develop them.

Job Performance.For employers, it iswhen it affects jobperformance that HIVdisease becomes ofgreatest concern. Howand when shouldreasonable accommo-dation be negotiated?How can and shouldsupervisors maintainwork goals while theyassuage the guilt andfrustration of co-workers?

For employees withHIV disease, job per-formance raisesissues in two con-

texts. First, when HIV-related conditionsweaken, but do not disable employees,they may feel discomfort, frustration, andfear about their diminished output. Theymay also fear that employers will try topressure them to resign or accept reas-signment. Second, HIV-associated demen-tia may lead to mental incompetence,sometimes so subtle that HIV-infectedemployees may be unaware of their inca-pacity. EAPs address performance-relatedissues by assessing to what extentemployees are disabled, what tasks theycan perform, and in what ways reasonableaccommodation is an appropriate course.

Stigmatization. On hearing that anemployee is seropositive, co-workers’responses may range from sympatheticand supportive to rejecting and fearful.Both responses set infected employeesapart. Sympathetic co-workers may dis-play an outpouring of inappropriate senti-ment or concern, focusing unwantedattention on seropositive employees anddemoralizing them by treating them asterminally ill. Through their reluctance tointeract, fearful or judgmental co-workersmay evoke anger or sadness among infect-ed employees. Upon disclosure, the workgroup itself may be emotionally affectedin unanticipated ways; anxiety, depres-sion, irritability, illness, and accidentsmay all increase among co-workers.

A sound corporate policy should antici-pate the possibility that seropositiveemployees may isolate themselves andthat their co-workers may stigmatizethem. HIV policies should articulate theconsequences for employees who discrim-inate or, in the absence of a threat oftransmission, refuse to work with HIV-infected co-workers. EAPs can work againststigma by providing HIV education—particularly about the difficulty of HIVtransmission in the workplace—and coun-seling, through which EAP clinicians canacknowledge employees’ concerns, helpresolve them, and reiterate company policy.

Antibody Testing. Employees fear testingas an unwarranted invasion of their priva-cy. Some executives believe that mandato-ry HIV antibody testing of employees andjob applicants will enable their companiesto avoid HIV-related problems. Most largecompanies, however, have rejected testing,and in some states, mandatory testing isillegal. Since disabling HIV disease may notemerge for 10 years or more, test resultsare irrelevant to successful job perfor-mance, and since there is virtually notransmission risk in most jobs, test re-sults will not protect co-workers from HIV.

EAP InterventionsA good corporate HIV policy will

encourage employees with HIV disease to seek EAP help as soon as possible todevelop strategies for dealing with theshort- and long-term outcomes of theirmedical status. When no formal EAPexists, but an HIV policy is in place, acompany should consider retaining theservices of a mental health professional inthe community for guidance and ongoingassistance.

In a typical case, 28-year-old Carl, whodoes a combination of physical and cleri-cal work calls Susan, an EAP counselorwhom he trusts. Two months ago Carlbroke up with his lover of almost a year;10 days ago he learned he was HIV infect-ed. Shocked, frightened, and unable tofocus on work, Carl has told nobody thisnews. Although he is well-liked and com-petent at work, he has no close co-workersin whom he can confide.

During initial EAP sessions, Carl willneed time and encouragement to expresssadness, anger, and fear. Susan must allowCarl to ventilate these feelings, but shemust also address practical concerns. HasCarl accepted his condition and started toplan appropriate action? Does he haveaccess to medical care from an AIDS-knowledgeable physician? Is his current

ReferencesGeneral AccountingOffice. Coping withAIDS in the GAOWorkplace: The Task Force Report.Washington, D.C.: U.S. GeneralAccounting Office,December 1987.

Puckett S, Emery A.Managing AIDS in theWorkplace. Reading,Mass.: Addison-Wesley,1988.

Rubenstein N. AIDS in the workplace.Electric Perspectives.Spring 1988: 16-24.

An effective Employee Assistance

Program provides the mechanism needed to creatively implement

the guidelines outlined by a clear

and comprehensivecompany HIV policy.

AuthorsJude Sharp, PhD is the Administrator of the EmployeeAssistance Program at Pacific Gas &Electric Company in San Francisco. She is a psychologist,teacher, and consul-tant, who for threeyears served on theboard of the SanFrancisco AIDSFoundation.

social and emotional support systemadequate? Has he considered joining anHIV support group?

The scenario described above is ideal:Carl seeks help immediately, before ill-ness and impaired job performance com-plicate the picture. Carl and Susan caneventually develop an action plan basedon the flexibility of Carl’s current jobduties, whether and when he wishes toinform his supervisor and co-workersabout his condition, and the progressionof Carl’s illness. Susan might also consid-er: negotiating with the company benefitsdepartment and health plan to expediteCarl's treatment; beginning to assessreasonable accommodations should theybe needed in the future; anticipating andresponding to problems within Carl’s workgroup; and acting as a support and infor-mation resource for Carl.

Three years later, Carl has his first HIV-related medical crisis, which requires himto take sick leave and impairs his abilityto work. He and Susan agree that it is timeto inform his supervisor. They rehearsewhat Carl should say, anticipate his super-visor’s reaction, define the outcome Carldesires, and decide what role Susan willplay in the interaction.

With the cooperation of Carl’s doctor,Susan will also assess whether Carl cancontinue to perform his regular duties. Ifhe cannot, Susan, Carl, Carl’s supervisor,and other company representatives canexplore reasonable accommodation.

Negotiating reasonable accommodationis a complex task that requires the com-bined efforts of the employee, and theEAP, Human Resources, Labor Relationsdepartments. There is, unfortunately, nocookbook solution for reasonable accom-modation, and successful accommodationrequires anticipatory planning and ongo-

ing review. Central to the accommodationsolution are: the company’s size; thenature of the employee’s work require-ments and their flexibility; employee andwork group morale; and the openness ofcommunication within the work group.There will be times when accommodationwill be impossible to achieve, but employ-ers should not assume this outcomebefore making good faith efforts toresolve the problem.

When employees are disabled with HIV-related conditions, virtually everyonerelies on the EAP for guidance: the illemployee seeking reassurance; the workgroup seeking support; and the supervisorseeking advice. Avoiding the concerns ofany of these parties can lead to absen-teeism, lowered productivity, illness,accidents, poor morale, and transferrequests. Supervisors in particular arecritical in this process and have a respon-sibility to balance compassion, fairness,and respect with productivity.

ConclusionAIDS and work are no longer mutually

exclusive conditions. As the two coexist,mental health and medical practitionerswill become more involved in negotiatingthe conditions by which some employeeswith HIV disease can remain productivejust as others become disabled and mustleave. In this traditional work setting,where emotional issues are often ignored,AIDS has forced us to confront sexuality,drug use, disability, death, and grief—issues typically denied straightforwarddiscussion at work. While even the mostcompassionate corporate efforts will leadto painful encounters, a sensitive HIVpolicy and the intervention of a well-trained EAP staff can shift the odds infavor of constructive results.

FOCUS4 February 1992

ReferencesBarr JK, Waring JM, Warshaw LJ.Employees’ sources of AIDS informa-tion: the workplace as a promisingeducational setting. Journal of Occupa-tional Medicine. 1991; 33(2): 143-147.

Bible JD. When employers look forthings other than drugs: the legality ofAIDS, genetic, intelligence, and honestytesting in the workplace. Labor LawJournal. 1990; 41(4): 195-213.

Centers for Disease Control. AIDS andthe Workplace: Resources for Workers,Managers, and Employers, July 1990.Atlanta: Centers for Disease Control,1990.

Cohen CF, Cohen ME. AIDS in theworkplace: legal requirements andorganizational responses. Labor LawJournal. 1989; 40(7): 411-418.

Lamm SH, Brewer TF, Crutcher JM. AIDSin the workplace—a summary of risks

and responses. American IndustrialHygiene Association Journal. 1991;52(2): A112-A115.

Landsbergis PA, Caplan RL, GreenbergM. AIDS and employment policies: therole of labor unions. AIDS & PublicPolicy Journal. 1991; 6(2): 76-82.

Temple TE. Employers prepare: hopefor AIDS victims means conflict in yourworkplace. Labor Law Journal. 1990;41(10): 694-699.

Special PublicationsThe National AIDS Clearinghouse isexpanding its “Business Responds to

Clearinghouse: HIV in the Workplace

The specter of HIV-associated dementia,a condition of declining cognitive andintellectual capacity, may raise concernsabout the competence ofemployees with HIVdisease. This articledefines HIV-associateddementia, reviews relat-ed issues for employers,and offers recommenda-tions for businesses onhow to approach thissituation.

Practitioners base adiagnosis of HIV-associ-ated dementia on psy-chological assessmentor on behavioral evi-dence of cognitive diffi-culties. This clinicaldiagnosis is necessarysince there is no fail-proof method—no labo-ratory test orprocedure—to detect the condition.

Dementia symptomsmay vary over time. Inthe early stages, motorproblems may predomi-nate: patients may havetrouble with balance, clumsiness, and legweakness. They may also demonstratebehavioral changes, including social with-drawal and generalized apathy, a slowingof mental function, and diminished pow-

ers of concentration and memory. In peo-ple with severe dementia, successfullycompleting daily tasks of living—forexample, cooking, cleaning, and dress-ing—may become difficult, and eventuallypatients may become bedridden andrequire 24-hour care. According to morethan a dozen studies from around theworld, dementia occurs most often inpeople already diagnosed with AIDS,

particularly in the laterstages of disease, and itrarely occurs amongasymptomatic seropositivepeople.

Dementia on the JobDespite the rarity of

HIV-associated dementia inthe working population,cases do occur, and theincidence may increase aspeople with HIV diseasecontinue to live longer.While they may be confi-dent that most HIV-infect-ed employees will remainmentally competent,employers should preparefor the possibility of dis-abling HIV-associateddementia.

People with HIV-associ-ated dementia most oftenhave two types of employ-ment-related problems.First, mental slowing,impaired concentration

and memory, and mental inflexibility canresult in difficulties for those employeesresponsible for making higher-level or quick deci-sions. Planning and organizational skills

FOCUS5 February 1992

Most HIV-infected

employees will remain

mentallycompetent,

but employersshould prepare

for the possibility of disabling

dementia in the workplace.

AIDS Resource Service” with a kit of 11new books and brochures. Among thebooks are: Small Business and AIDS:How AIDS Can Affect Your Business;Developing an HIV/AIDS Policy for YourBusiness; and The Profiles Project:Common Features and Profiles of AIDSin the Workplace Programs. The kit isexpected to be available at the end ofMarch. For more information, contact:the National AIDS Clearinghouse at(800) 458-5231.

The Compliance Guide to the Americanswith Disabilities Act is a 35-page hand-book that includes a discussion of thelegislation’s impact on HIV disease in

the workplace. To order a copy, send$16.00, including shipping, to: SmallBusiness Legislative Council, 115615th Street, N.W., Suite 510,Washington, DC, 20005.

The San Francisco AIDS Foundationproduces a series of workplaceresources including: AIDS Education inthe Workplace: An Educational Guidefor Managers (1987, 68 pages, $40.00),The Next Step: HIV in the 1990s, AManagement Guide to AIDS (1990; 97pages, $50.00), and An Epidemic ofFear: AIDS in the Workplace (1987;videotape, 25 minutes, $150). To learnmore, call or write Impact AIDS: (415)

861-3397, 3692 18th Street, SanFrancisco, CA 94110.

ContactsJames W. Dilley, MD, UCSF AIDS HealthProject, Box 0884, San Francisco, CA94143-0884, (415) 476-6442.

Alan Emery, PhD, Alan Emery Consult-ing, 360 Church Street, Suite G, SanFrancisco, CA 94114, (415) 864-1227.

Jude Sharp, PhD, Pacific Gas & ElectricCompany, 333 Market, Suite A325/S,San Francisco, CA 94105, 415-973-2634.

See also references cited in articles in this issue.

HIV-Associated Dementia and the WorkplaceJames W. Dilley, MD

might also suffer as the ability to attendto a range of complex issues declines.Furthermore, failing memory and inatten-tion to detail can result in an apatheticapproach to job-related tasks.

Second, dementia is frequently assoc-iated with the diminishment of fine motorskills and, in some studies, with reducedreaction time (the amount of time it takesa person to respond physically to verbalor visual cues). This may compromise theabilities of employees such as word pro-cessors, key-punch operators, graphicsdesigners, and artists. It should bestressed that whether deterioration iscognitive or motor-related, new or unfa-miliar tasks are likely to be the most difficult for people with HIV-associateddementia.

Because the impairment associated withdementia is difficult to recognize and haspotentially serious consequences—forexample, legal liability and customerdissatisfaction—employers motivated byfear may react inappropriately. They mayinterpret HIV disease as equivalent to HIV-associated dementia and take unnecessaryand premature action regarding asymp-tomatic seropositive employees.Conversely, they may deny cognitivedisability when it occurs in order to avoidwhat may seem to be punitive, hostile, or discriminatory responses, or becausethey overidentify with an employee’sstruggle with HIV disease.

Recommendations for ManagementWhen dementia-related difficulties are

significant enough to impair performance,businesses must find ways of fulfillinglegal obligations to reasonably accommo-date disabled employees as well as ethicalobligations to avoid abandoning them.While cognitive impairment is unlikely tobe a common reason for a decline in workperformance among people with HIV dis-ease, the following guidelines may helpevaluate dementia-associated concerns.

1. Focus on the employee’s abilities toperform specific job tasks, not on the factthat he or she is HIV-infected. When work-ers raise the issue of HIV infection andcomplain of problems concentrating, theyshould be referred to HIV-knowledgeablepsychiatrists. Neuropsychological testingcan help to identify HIV-associateddementia and quantify the degree ofimpairment, or help identify some othercause for the impairment, such as depres-sion or anxiety. Be aware that some fac-tors—such as stress, prescription druguse, and recreational drug use—may

exacerbate dementia. Changes in anemployee’s habits regarding these factorsshould also be discussed with the employ-ee’s primary care physician.

2. Evaluate the HIV-infected employee’sjob performance as you would that of anyother employee. Focusing on job perfor-mance helps to keep unrelated emotionalissues from obscuring appropriateresponses. The key to any effective jobevaluation is the articulation of clearexpectations and the maintenance ofregular performance documentation. Theemphasis must be on successful comple-tion of assigned tasks and not on thepotential for problems.

3. If a problem in performance is identified, act immediately. Employeeconferences and actions to assess thesituation should begin promptly. Obtainprofessional advice and evaluations in away consistent with usual and customarycompany standards. Should HIV-relatedcognitive impairment be suggested bycompany consultants, supervisors shouldmove rapidly to secure the employee’scooperation in making appropriate job changes. Since impairment tends to advance, and dementia may affectmood and perception, a timely responseensures that a mutually acceptable resolution can be achieved.

Conclusion HIV disease generally progresses slowly

enough to give employers and employeestime to plan for any eventuality. Withcompany assurances that employees willnot be abandoned and with safeguards in place to protect health and disabilitybenefits, it is likely that employees willcome forward and work with theiremployers to develop mutually beneficialplans. Companies that implement suchemployee-centered policies will not only

FOCUS6 February 1992

ReferencesWorld Health Organ-ization. World HealthOrganization consul-tation on the neuro-psychiatric aspects ofHIV-1 infection. AIDS.1990; 4: 935-936.

AuthorsJames W. Dilley, MD is Associate Clinical Professor of Psychiatry at the University of California SanFrancisco, Director of the UCSF AIDSHealth Project, andExecutive Editor ofFOCUS. He is also thePrincipal Investigatorof a longitudinalstudy of the neuro-psychiatric aspects of HIV infection at San Francisco General Hospital.

Comments and Submissions We invite readers to send letters

responding to articles published inFOCUS or dealing with current AIDSresearch and counseling issues. Wealso encourage readers to submit arti-cle proposals, including a summary ofthe idea and a detailed outline of thearticle. Send correspondence to:

Editor, FOCUSUCSF AIDS Health Project, Box 0884San Francisco, CA 94143-0884

Developing Workplace PoliciesHeacock MV, Orvis GP. AIDS in the workplace:public and corporate policy. Harvard Journal of Law& Policy. 1991; 13(2): 689-713. (University ofAlabama at Birmingham.)

About 10 percent of U.S. corporationshave developed AIDS policies for theiremployees. A review of corporate respons-es to HIV disease found that these policiesaddress financial issues most prominent-ly, in addition to legal concerns, employeetraining, and employee rights, such asprotection from workplace discriminationand employer-mandated antibody testing.

Companies with AIDS policies acknowl-edge from the outset that comprehensiveeducational programs and confidentialityfor people with HIV disease are necessarycomponents of an AIDS policy. In addition,most firms with policies have establishedplans—such as case management foremployees with AIDS—that seek to mini-mize HIV-related costs. These programsmobilize medical, psychological, andsocial workers who help employees, theirfamilies, and physicians determine appro-

priate care. Casemanagementincludes monitoringcourse of illness,supervising andauthorizing neces-sary medical ser-vices, andproviding outpa-tient, home, andhospice care. Itsaves money inemployee andemployer healthcare costs andinsurance premi-ums by keepingworkers out of thehospital.

Corporate policies also seek to reflectappropriate worker protection laws, suchas those that relate to employee dismissaland accommodation. It is only in rarecases that an employee can be dismissedbecause of HIV infection. An employermay reject a worker or job applicant ifthere is a “bona fide occupational qualifi-cation” that workers be free of infection;the employer would have to prove, howev-er, that there was “a reasonable probabili-ty of substantial harm” if workers wereinfected, a difficult standard to meet.

A Model Workplace PolicyCrutcher JM. AIDS policy for the workplace: a casestudy of Baltimore city policy. American IndustrialHygiene Association Journal. 1991; 52(1): A10-A13. (United States Navy.)

The city of Baltimore has developed acomprehensive policy that outlines exist-ing laws that protect workers with HIVinfection and then details ways in whichits own response goes beyond these laws.

The policy covers a work force of40,000 people, including both employeeswhose work puts them at risk of HIVtransmission as well as those who areunlikely to contract HIV on the job.

The article uses Baltimore’s policy as a basis from which to discuss legal issuesaffecting employees with HIV infection.The policy, developed in 1987 by repre-sentatives of 10 city departments andagencies, relates to both hiring and con-tinued employment, and to client service.Its major topics include: knowledge of HIVtransmission, discrimination in servingclients or working with HIV-infected co-workers, discrimination in hiring andfiring, antibody testing, employee confi-dentiality, and education.

Employees who refuse to work with HIV-infected co-workers or to provide servicesto HIV-infected clients may be subject todisciplinary action. Employees who refuseto work in what they consider an unsafeenvironment, however, may have legalprotection from disciplinary action.

HIV antibody testing should not be usedas a condition of initial or continuedemployment or for receiving city services.Because this policy may have been incon-sistent with the city’s policy regardingother diseases, Baltimore re-evaluated andchanged its entire policy on medicalscreening of job applicants.

HIV Knowledge and Training at WorkFeldmann TB, Bell RA, Purifoy FE, et al. Outcomesof AIDS training for supervisory and nonsupervisorypersonnel in the workplace. Journal of OccupationMedicine, 1990; 32(2): 103-109. (University ofLouisville, Louisville-Jefferson County Board ofHealth, American Red Cross—Louisville AreaChapter.)

A large 1988 survey found that employ-ees in Louisville, Kentucky showed signifi-cant increases in HIV knowledge andconfidence in responding to HIV infectionafter a one-hour workplace training.

Nearly three-quarters of the 3,834 par-ticipants were nonsupervisors. Super-visors were more likely than nonsuper-visors to be men, to be older, and to becollege graduates.

FOCUS7 February 1992

Most companies with AIDS policies

acknowledge that HIV

education,confidentiality,

and case managementare necessary elements.

Recent Reports

*Editor’s Note: Someinformation in “AIDSin the Workplace:Public and CorporatePolicy” —particularlyrelating to medicalaspects and thespectrum of HIVdisease—is dated.

FOCUS8 February 1992

Executive Editor; Director,AIDS Health ProjectJames W. Dilley, MD

EditorRobert Marks

Staff WriterJohn Charles Tighe

Founding Editor; AdvisorMichael Helquist

Medical AdvisorStephen Follansbee, MD

MarketingPaul CauseyRichard McCormack

DesignSaul Rosenfield

ProductionJoseph WilsonStephan PeuraRoger Scroggs

CirculationSandra Kriletich

FOCUS is a monthly pub-lication of the AIDSHealth Project, affiliatedwith the University ofCalifornia San Francisco.

Twelve issues of FOCUSare $36 for U.S. residents,$24 for those with limitedincomes, $48 for individu-als in other countries, $90for U.S. institutions, and$110 for institutions inother countries. Makechecks payable to “UCRegents.” Address sub-scription requests and cor-respondence to: FOCUS,UCSF AIDS HealthProject, Box 0884, SanFrancisco, CA 94143-0884. Back issues are $3each: for a list, write to theabove address or call(415) 476-6430.

To ensure uninterrupteddelivery, send your newaddress four weeks beforeyou move.

Linotronic plates partiallydonated by Design & Type,San Francisco. Printed onrecycled paper.

© 1992 UC Regents: All rights reserved.

ISSN 1047-0719

FOCUSA Guide toAIDSResearch and Counseling

T H E

AIDSHEALTHPROJECT

While supervisors had generally higherHIV knowledge levels than nonsupervi-sors, only 36 percent of supervisors,compared to 30 percent of nonsupervi-sors, knew that HIV could not be contract-ed through the air. After training, bothgroups—76 percent of supervisors, and 66 percent of nonsupervisors—answeredthis question correctly, and respondedsignificantly better to other knowledgequestions. Researchers attributed groupdifferences largely to the higher educa-tional levels of supervisors, but this wasnot always the reason.

Supervisors scored no better than non-supervisors in their ability to respond tothe disease. Before training, 67 percent ofnonsupervisors, compared to 63 percent ofsupervisors, expressed confidence in theirability to seek confidential testing andhandle an AIDS-related situation at work.After training, 88 percent of both supervi-sors and nonsupervisors expressed confi-dence about dealing with such a situation.

Trainings consisted of a brief history ofthe epidemic, and discussion of methodsof transmission, precautions to take whengiving first aid, high-risk behaviors, signsand symptoms of disease, and where to go for more information. Researchers saidthe training’s broad and basic nature wasnecessary because initially workers dis-played low levels of knowledge and camefrom a variety of skill, educational, andsocioeconomic backgrounds.

DementiaMaj M. Organic mental disorders in HIV-1 infec-tion. AIDS. 1990; 4:831-840. (World HealthOrganization.)

Basic questions about the cause andprogression of HIV-associated dementiaremain unanswered and highlight the lack of knowledge surrounding the syn-drome, its treatment, and its management,according to a review article of mentaldisorders associated with HIV infection.The article also summarizes the literatureregarding other mental disorders—includ-ing mild cognitive impairment, delirium,organic schizophrenia-like disorders, andorganic affective disorders—that occur inpeople with HIV disease.

The causes of HIV-associated dementiaare largely unknown. In at least somecases, the syndrome is believed to be theresult of direct HIV infection of the brain.Marked immunosuppression also seems tobe necessary for dementia to develop. Alarge prevalence study found dementia in6.5 percent of adults with AIDS. In 3 per-cent of the sample, dementia was the only

early manifestation of AIDS. Dementia ratesappear to increase significantly with age.

The course of dementia is variable, andthere is no way to predict the speed of itsprogression. It may progress rapidly todeterioration and death, but it may alsostabilize, or fluctuate and result inreversible deterioration. A study of 132patients showed that 25 percentprogressed from a subclinical stage to a symptomatic stage of dementia within37 weeks of initial detection, and half ofall patients progressed to this stage within 59 weeks.

Studies have found that people withHIV-associated dementia who take zidovu-dine (ZDV; AZT) show improvement onmeasures of mental awareness and per-ception. A preliminary report has suggest-ed that didanosine (ddI; dideoxyinosine) isalso effective in diminishing symptoms ofdementia. However, the long-term impactof these drugs is not known. Patients withdementia who demonstrate retardation ofmotor skills or apathy may benefit fromshort-term use of psychostimulants. Anti-depressants may provoke or exacerbatedelirium and therefore should be usedwith caution in people with dementia.

Next MonthHIV disease has cut a swath across

age, gender, sexual orientation, andclass categories within the AfricanAmerican community and left Blacksoverrepresented among people withAIDS. In the March issue of FOCUS,Michael T. Myers, Jr., MD, an inter-nal medicine physician at theMassachusetts Institute of Technologyand former Chair of the Task Force onAIDS Education of the MassachusettsMedical Society, outlines the epidemi-ology of HIV disease among AfricanAmericans and describes differencesin the way HIV infection manifests andis treated in this population.

For another perspective on ethnicdifferences and HIV disease, MindyThompson Fullilove, MD of the HIVCenter at Columbia University and for-merly of the University of CaliforniaSan Francisco Center for AIDSPrevention Studies, reports on theAIDS in Multi-Ethnic NeighborhoodsStudy (AMEN), which examines the dis-tribution of HIV infection and riskbehaviors in groups defined by race,gender, and sexual orientation.

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