An agricultural livelihood intervention is associated with reduced HIV stigma among people with HIV.

OBJECTIVE: HIV stigma undermines antiretroviral treatment (ART) adherence and viral suppression. Livelihood interventions may target drivers of negative attitudes towards people with HIV (PWH) by improving their health and strengthening their economic contributions. We examined the effects of a multisectoral agricultural livelihood intervention on HIV stigma among PWH in western Kenya. DESIGN: Sixteen health facilities were randomly allocated (1 : 1) to intervention or control arms in Shamba Maisha , a cluster randomized controlled trial that aimed to improve HIV-related health through behavioral, mental health, and nutritional pathways. METHODS: The intervention included a farming loan and agricultural and financial training. Participants had access to farmland and surface water and were at least 18 years old, on ART for more than 6 months, and moderately-to-severely food insecure. We measured internalized, anticipated, and enacted HIV stigma semiannually over 2 years using validated scales. In blinded intent-to-treat analyses, we compared changes in scores over 24 months by study arm, using longitudinal multilevel difference-in-differences linear regression models that accounted for clustering. RESULTS: Of 720 enrolled participants (354 intervention), 55% were women, and the median age was 40 years [interquartile range 34-47 years]. Two-year retention was 94%. Compared with the control arm, the intervention resulted in significant decreases ( P  < 0.001) of 0.42 points [95% confidence interval (CI) -0.52 to -0.31) in internalized stigma, 0.43 points (95% CI -0.51 to -0.34) in anticipated stigma, and 0.13 points (95% CI -0.16 to -0.09) in enacted stigma over 24 months. CONCLUSION: The agricultural livelihood intervention reduced HIV stigma among PWH. Poverty-reduction approaches may be a novel strategy for reducing HIV stigma.

Impact of a livelihood intervention on gender roles and relationship power among people with HIV.

OBJECTIVE: To evaluate the impact of an agricultural livelihood intervention on gender role conflict and sexual relationship power among people with HIV (PWH) in western Kenya. DESIGN: Study participants were enrolled in Shamba Maisha , a cluster randomized controlled trial of an agricultural intervention conducted among PWH across 16 health facilities during 2016-2020. Intervention participants received a water pump, seeds, and agricultural and financial training; control participants received standard of HIV care. METHODS: We assessed men's views on masculinity and gender roles via the validated gender role conflict score (GRCS; range 18-78, higher = greater gender role conflict). We measured gender power imbalances among women via the validated Sexual Relationship Power Scale (SRPS), which combines subscales of relationship control and decision-making dominance (range 1-4, higher = female holds more power). We compared changes over the study period by arm using longitudinal multilevel difference-in-difference linear regression models accounting for clustering of facilities using the intention-to-treat cohort. RESULTS: We enrolled 720 participants (366 intervention, 354 control); 2-year retention was 94%. Median age was 40 and approximately 55% of participants were female. Among men, after 24-months the decrease in GRCS scores was 4.3 points greater in the intervention than the control arm ( P  < 0.001). Among women, the intervention resulted in 0.25 points greater increase in the SRPS compared to the control arm ( P  < 0.001). CONCLUSIONS: Shamba Maisha resulted in less gender role conflict in men and greater sexual relationship power for women. Agricultural livelihood interventions may be a powerful tool to improve gender power imbalances, which may subsequently mitigate poverty and food insecurity.

Transforming masculine norms to improve men's contraceptive acceptance: results from a pilot intervention with men in western Kenya.

Men's adherence to constraining male gender norms can lead them to resist contraceptive use. Very few interventions have attempted to transform masculine norms to encourage greater contraceptive acceptance and gender equality. We designed and evaluated a small-scale community-based intervention targeting the masculine norms tied to contraceptive resistance among partnered men (N = 150) in two western Kenya communities (intervention vs. control). Pre-post survey data fit to linear and logistic regression models evaluated differences in post-intervention outcomes, accounting for pre-intervention differences. Intervention participation was associated with increases in contraceptive acceptance scores (adjusted coefficient (aß) 1.04; 95% confidence interval (CI) 0.16, 1.91; p = 0.02) and contraceptive knowledge scores (aß 0.22; 95% CI 0.13, 0.31; p < 0.001) and with contraceptive discussions with one's partner (adjusted Odds Ratio (aOR) 3.96; 95% CI 1.21, 12.94; p = 0.02) and with others (aOR 6.13; 95% CI 2.39, 15.73; p < 0.001). The intervention was not associated with contraceptive behavioural intention or use. Our findings demonstrate the promise of a masculinity-driven intervention on increasing men's contraceptive acceptance and positive contraceptive involvement. A larger randomised trial is needed to test the effectiveness of the intervention among men as well as among couples.

Relationship Power, Antiretroviral Adherence, and Physical and Mental Health Among Women Living with HIV in Rural Kenya.

Little is known about the association of gender-based power imbalances and health and health behaviors among women with HIV (WWH). We examined cross-sectional baseline data among WWH in a cluster-randomized control trial (NCT02815579) in rural Kenya. We assessed associations between the Sexual Relationship Power Scale (SRPS) and ART adherence, physical and mental health, adjusting for sociodemographic and social factors. SRPS consists of two subscales: relationship control (RC) and decision-making dominance. Women in the highest and middle tertiles for RC had a 7.49 point and 8.88 point greater Medical Outcomes Study-HIV mental health score, and a 0.27 and 0.29 lower odds of depression, respectively, compared to women in the lowest tertile. We did not find associations between SPRS or its subscales and ART adherence. Low sexual relationship power, specifically low RC, may be associated with poor mental health among WWH. Intervention studies aimed to improve RC among WWH should be studied to determine their effect on improving mental health.

RESUMEN: Poco se sabe acerca de su asociación con los desequilibrios de poder basados en el género y los comportamientos de salud y salud entre las mujeres con Virus de Inmunodeficiencia Humana (VIH). Examinamos los datos de referencia transversales entre mujeres con VIH en un ensayo de control aleatorizado por grupos (NCT02815579) en las zonas rurales de Kenia. Evaluamos las asociaciones entre la Escala de Poder de Relación Sexual y la adherencia a la Terapia Antirretroviral (TAR), la salud física y mental, ajustando por factores sociodemográficos y sociales. La Escala de Poder de Relación Sexual consiste de dos subescalas: control de relaciones y dominio en la toma de decisiones. Las mujeres en los terciles más alto y mediano para control de relaciones tenían una puntuación de salud mental de 7.49 puntos y 8.88 puntos mayor en el Medical Outcomes Study HIV Health Survey (MOS)-HIV, y una puntuación de salud mental de 0.27 y 0.29 menores probabilidades de depresión, respectivamente, en comparación con las mujeres en el tercil más bajo. El bajo poder de relación sexual, específicamente el control de relaciones bajo, puede estar asociado con una salud mental deficiente entre las mujeres con VIH. Se deben estudiar estudios de intervención destinados a mejorar el control de relaciones entre mujeres con VIH para determinar su efecto en mejorar la salud mental.

The Impact of Land Tenure Security on a Livelihood Intervention for People Living with HIV in Western Kenya.

Few studies have explored land access, a structural driver of health, and women's participation in livelihood interventions to improve food security and HIV outcomes. This qualitative study, embedded within Shamba Maisha (NCT02815579)-a randomized controlled trial (RCT) examining the impact of a multisectoral intervention among farmers living with HIV in western Kenya-sought to explore the influence of perceived access to and control of land on agricultural productivity, investments, and benefits. Thirty in-depth interviews (IDIs) were conducted with purposively sampled men and women, 3 to 6 months after receiving intervention inputs; data were deductively and inductively coded and analyzed. Farming practices and participation in Shamba Maisha were dependent on land tenure and participants' perceived strength of claim over their land, with participants who perceived themselves to be land insecure less likely to make long-term agricultural investments. Land tenure was influenced by a number of factors and posed unique challenges for women which negatively impacted uptake and success in the intervention. Data underscore the importance of secure land tenure for the success of similar interventions, especially for women; future interventions should integrate land security programming for improved outcomes for all.

Effect of a Multisectoral Agricultural Intervention on HIV Health Outcomes Among Adults in Kenya: A Cluster Randomized Clinical Trial.

Importance: Food insecurity and HIV health outcomes are linked through nutritional, mental health, and health behavior pathways. Objective: To examine the effects of a multisectoral agriculture and livelihood intervention on HIV viral suppression and nutritional, mental health, and behavioral outcomes among HIV-positive adults prescribed antiretroviral therapy (ART). Design, Setting, and Participants: This cluster randomized clinical trial was performed in 8 pairs of health facilities in Kenya. Participants were 18 years or older, living with HIV, and receiving ART for longer than 6 months; had moderate to severe food insecurity; and had access to arable land and surface water and/or shallow aquifers. Participants were followed up every 6 months for 24 months. Data were collected from June 23, 2016, to June 13, 2017, with follow-up completed by December 16, 2019. Data were analyzed from June 25 to August 31, 2020, using intention-to-treat and per-protocol methods. Interventions: A loan to purchase a human-powered irrigation pump, fertilizer, seeds, and pesticides combined with the provision of training in sustainable agriculture and financial literacy. Main Outcomes and Measures: The primary outcome was the relative change from baseline to the end of follow-up in viral load suppression (≤200 copies/mL) compared between study groups using difference-in-differences analyses. Secondary outcomes included clinic attendance, ART adherence, food insecurity, depression, self-confidence, and social support. Results: A total of 720 participants were enrolled (396 women [55.0%]; mean [SD] age, 40.38 [9.12] years), including 366 in the intervention group and 354 in the control group. Retention included 677 (94.0%) at the 24-month visit. HIV viral suppression improved in both groups from baseline to end of follow-up from 314 of 366 (85.8%) to 327 of 344 (95.1%) in the intervention group and from 291 of 353 (82.4%) to 314 of 333 (94.3%) in the control group (P = .86). Food insecurity decreased more in the intervention than the control group (difference in linear trend, -3.54 [95% CI, -4.16 to -2.92]). Proportions of those with depression during the 24-month follow-up period declined more in the intervention group (from 169 of 365 [46.3%] to 36 of 344 [10.5%]) than the control group (106 of 354 [29.9%] to 41 of 333 [12.3%]; difference in trend, -0.83 [95% CI, -1.45 to -0.20]). Self-confidence improved more in the intervention than control group (difference in trend, -0.37 [95% CI, -0.59 to -0.15]; P = .001), as did social support (difference in trend, -3.63 [95% CI, -4.30 to -2.95]; P < .001). Conclusions and Relevance: In this cluster randomized trial, the multisectoral agricultural intervention led to demonstrable health and other benefits; however, it was not possible to detect additional effects of the intervention on HIV clinical indicators. Agricultural interventions that improve productivity and livelihoods hold promise as a way of addressing food insecurity and the underpinnings of poor health among people living with HIV in resource-limited settings. Trial Registration: ClinicalTrials.gov Identifier: NCT02815579.

Measuring Men's Gender Norm Beliefs Related to Contraception: Development of the Masculine Norms and Family Planning Acceptance Scale.

Male partner resistance is identified as a key factor that influences women's contraceptive use. Examination of the masculine norms that shape men's resistance to contraception-and how to intervene on these norms-is needed. To assess a gender-transformative intervention in Kenya, we developed and evaluated a masculinity-informed instrument to measure men's contraceptive acceptance-the Masculine Norms and Family Planning Acceptance (MNFPA) scale. We developed draft scale items based on qualitative research and administered them to partnered Kenyan men (n = 150). Item response theory-based methods were used to reduce and psychometrically evaluate final scale items. The MNFPA scale had a Cronbach's α of 0.68 and loaded onto a single factor. MNFPA scores were associated with self-efficacy and intention to accept a female partner's use of contraception; scores were not associated with current contraceptive use. The MNFPA scale is the first rigorously developed and psychometrically evaluated tool to assess men's contraceptive acceptance as a function of male gender norms. Future work is needed to test the MNFPA measure in larger samples and across different contexts. The scale can be used to evaluate interventions that seek to shift gender norms to increase men's positive engagement in pregnancy spacing and prevention.

Development and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults.

PURPOSE: We developed and validated a measure that assesses the latent construct of sexual and reproductive empowerment among adolescents and young adults. A specific measure for this group is critical because of their unique life stage and circumstances, which often includes frequent changes in sexual partners and involvement from parents in decision-making. METHODS: After formative qualitative research, a review of the literature, and cognitive interviews, we developed 95 items representing nine dimensions of sexual and reproductive empowerment. Items were then fielded among a national sample of young people aged 15-24 years, and those who identified as sexually active completed a 3-month follow-up survey. We conducted psychometric analysis and scale validation. RESULTS: Exploratory factor analysis on responses from 1,117 participants resulted in the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults, containing 23 items captured by seven subscales: comfort talking with partner; choice of partners, marriage, and children; parental support; sexual safety; self-love; sense of future; and sexual pleasure. Validation using logistic regression demonstrated that the subscales were consistently associated with sexual and reproductive health information and access to sexual and reproductive health services measured at baseline and moderately associated with the use of desired contraceptive methods at 3-month follow-up. CONCLUSIONS: The Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults is a new measure that assesses young people's empowerment regarding sexual and reproductive health. It can be used by researchers, public health practitioners, and clinicians to measure sexual and reproductive empowerment among young people.

Impacts of Men's Gender-transformative Personal Narratives: A Qualitative Evaluation of the Men's Story Project.

Gender-transformative interventions have been found to help ameliorate gender-inequitable norms and improve health outcomes for women and men. While narrative-based strategies are increasingly being used in public health programs, no evaluation publications exist to date for gender-transformative programming that employs men's public narrative-sharing as a central means for promoting healthy masculinities. The Men's Story Project (MSP) creates live productions in which diverse men publicly perform personal narratives that challenge hegemonic masculinity, promote gender equality, and highlight intersections of masculinity with other social identities. This study draws upon six focus groups with thirty-one audience members (AMs), two weeks after an MSP production at a US public university. The MSP led AMs to reevaluate key pillars of hegemonic masculinity, including a singular conception of masculinity, essentialist notions of gender, restricted emotional expression, and use of violence; AMs also gained an expanded understanding of intersectionality. Directions for future research are discussed.

Gendered health institutions: examining the organization of health services and men's use of HIV testing in Malawi.

INTRODUCTION: Men in sub-Saharan Africa are less likely to use HIV testing services than their female counterparts. Norms of masculinity are frequently cited as the main barrier to men's use of HIV testing services, but very little is known about how health institutions are organized to facilitate or impede men's care. We examined the organization of health institutions in Malawi, and implications for men's use of HIV testing services. METHODS: A mixed methods ethnography was conducted in Malawi between October 2013 and September 2014. National Ministry of Health guidelines from 2012 to 2014 were analysed, counting the frequency of recommended preventative services by sex. In-depth interviews were conducted with 18 healthcare workers and 11 national key informants (29 total). Five rural health facilities participated in direct observation and 52 observational journals were completed to document the structure and implementation of HIV services within local facilities. All data were analysed using the theory of gendered organization. Findings were grouped into one of the three theoretical levels of organization: (1) organizational policy; (2) organizational practice; and (3) structure of gendered expectations. RESULTS: Health institutions were gendered across three levels. Organizational policy: National guidelines omitted young and adult men's health during reproductive years (176-433 recommended visits for women vs. 32 visits for men). Health education strategies focused on reproductive and child health services, with little education strategies targeting men. Organizational practice: HIV testing was primarily offered during reproductive and child health services and located near female-focused departments within health facilities. As these departments were women's spaces, others could easily tell that men were using HIV services. Structure of gendered expectations: Clients who successfully accessed HIV testing services were perceived as exemplifying characteristics that were traditionally considered feminine: compliance (obeying instructions without explanation); deference (respecting providers regardless of provider behaviour); and patience ("waiting like a woman"). CONCLUSIONS: Health institutions in Malawi were organized in ways that created substantial, multilevel barriers to men's HIV testing and reinforced perceptions of absent, difficult men. Future research should prioritize a gendered organization framework to understand and address the complex realities of men's constrained access to HIV services.

Mechanisms and perceived mental health changes after a livelihood intervention for HIV-positive Kenyans: Longitudinal, qualitative findings.

While food insecurity and poverty worsen mental health outcomes among people living with HIV/AIDS (PLHIV), few intervention studies have targeted poverty and food insecurity as a way to improve mental health. Among HIV-positive patients, addressing such upstream determinants may prove crucial to ensure better mental health and HIV clinical outcomes. We integrated longitudinal, qualitative research into a randomized trial of a livelihood intervention to understand processes and mechanisms for how the intervention may affect mental health among HIV-infected Kenyan adults. In-depth interviews were conducted with intervention participants (n = 45) and control participants (n = 9) at two time-points (after intervention start and upon intervention end). Interviews (n = 85) were translated, double-coded, and analyzed thematically using an inductive-deductive team approach. Participants reported numerous mental health improvements post-intervention including reduced stress, fewer symptoms of anxiety, improved mood, lower depressive symptoms, fewer repetitive and ruminating thoughts, and more hopefulness for the future. Improvements in mental health appear to occur via several mechanisms including: 1) better food security and income; 2) increased physical activity and ability to create fruitful routines around farm work; and, 3) improved sense of self as an active member of the community. Qualitative, longitudinal interviews may help identify intervention mechanisms for improved mental health, but additional research is required to confirm self-reports of mental health changes. These findings suggest that livelihood interventions may improve mental health in multi-faceted ways, and help PLHIV better integrate with their communities. Trial registered at ClinicalTrials.gov: NCT01548599.

Gender-Transformative Approaches to Engaging Men in Reducing Gender-Based Violence: A Response to Brush & Miller's "Trouble in Paradigm".

Brush and Miller's paper is critical of gender-transformative interventions and they believe that the paradigm is in trouble. In this response, we examine the body of evidence and the conceptual frames that undergird gender-transformative interventions, along with the emergence of these interventions and their efficacy. We argue here that it is reductionist to state either (a) that gender-transformative programs do not work, or (b) that gender-transformative programs only rely on social norms theory. We reveal how these claims omit important developments emerging from research on homophobia, feminist thought, and intersectionality that have made their way into gender-transformative interventions in several countries. We show that the implementation of gender-transformative interventions is far from uniform and we examine how changing power relations, relationships, communities, and masculinities, as well as other structures and practices that negatively influence health and well-being are integrated into this large body of work. We highlight how gender-transformative interventions show solid promise on balance, as measured in several evaluation studies in several settings, when implemented well and sustained. Overall then, gender-transformative interventions represent a tremendous advance over the previous "risk group-focused," single-topic approaches with men that have been implemented in public and global health interventions.

A scoping review on the role of masculine norms in men's engagement in the HIV care continuum in sub-Saharan Africa.

Men living with HIV/AIDS in sub-Saharan Africa are less likely than women to be engaged at each stage of the HIV care continuum. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV care engagement in sub-Saharan Africa. Our review yielded a total of 17 qualitative studies from 8 countries. Six major themes emerged that demonstrated how norms of masculinity create both barriers and facilitators to care engagement. Barriers included the exacerbating effects of masculinity on HIV stigma, the notion that HIV threatened men's physical strength, ability to provide, self-reliance, and risk behavior, and the belief that clinics are spaces for women. However, some men transformed their masculine identity and were motivated to engage in care if they recognized that antiretroviral therapy could restore their masculinity by rebuilding their strength. These findings demonstrate masculinity plays an important role in men's decision to pursue and remain in HIV care across sub-Saharan Africa. We discuss implications for tailoring HIV messaging and counseling to better engage men and an agenda for future research in this area.

Development and Validation of the Power Imbalance in Couples Scale.

Few researchers have quantitatively explored the relationship power-HIV risk nexus in same-sex male couples. We developed and validated the Power Imbalance in Couples Scale (PICS) to measure relationship power among men in same-sex, committed relationships and its association with sexual risk behaviors. We recruited three independent and diverse samples of male couples in the greater San Francisco and New York City metropolitan areas and conducted qualitative interviews (N1 = 96) to inform item development, followed by two quantitative surveys (N2 = 341; N3 = 434) to assess the construct, predictive, convergent, and discriminant validity of the PICS. Exploratory factor analysis of the first survey's data yielded four factors-overtly controlling partner, supportive partner, conflict avoidant actor, and overtly controlling actor-that accounted for more than 50% of the shared variance among the PICS items. Confirmatory factor analysis (CFA) of the second survey's data supported these four factors: χ2(1823) = 2493.40, p < .001; CFI = .96, RMSEA = .03 and WRMR = 1.33. Strong interfactor correlations suggested the presence of a higher-order general perception of power imbalance factor; a higher-order factor CFA model was comparable in fit to the correlated lower-order factors' CFA: χ2(2) = 2.00, p = .37. Internal reliability of the PICS scale was strong: α = .94. Men perceiving greater power imbalances in their relationships had higher odds of engaging in condomless anal intercourse with outside partners of discordant or unknown HIV status (OR 1.27; 95% CI 1.01-1.60; p = .04). The PICS is an important contribution to measuring relationship power imbalance and its sequelae among male couples; it is applicable to research on relationships, sexuality, couples, and HIV prevention.

Couple-Level Dynamics and Multilevel Challenges Among Black Men Who Have Sex with Men: A Framework of Dyadic HIV Care.

The primary romantic relationship may offer critical opportunities for improving HIV care among key populations affected by high rates of HIV infection and low rates of care engagement, such as black men who have sex with men. A conceptual framework is needed to identify dyadic processes involved in addressing challenges in retention in care and adherence to antiretroviral therapy. This study conducted dyadic and individual-level qualitative analyses of individual interviews with men living with HIV from 14 black gay couples (n = 28). Interviews explored each partner's perspectives on challenges to and supportive strategies for retention in care and medication adherence. Findings highlighted challenges at various levels of care engagement and patterns of dyadic interactions that impeded or facilitated HIV care. Couple-level processes (i.e., couple's resilience, interdependence) underlined a joint problem-solving approach toward addressing challenges in care engagement. Findings support a conceptual framework of dyadic HIV care that highlights the impacts of dyadic and individual factors on coordination of care and treatment to influence retention and adherence. The generalizability of study findings is limited by the small sample size. Implications for intervention design include leveraging drivers of partner support, including couples' resilience, in enhancing joint problem-solving in HIV care among black gay couples.

What Role Do Masculine Norms Play in Men's HIV Testing in Sub-Saharan Africa?: A Scoping Review.

Men living with HIV/AIDS in sub-Saharan Africa are less likely to test for HIV than women. We conducted a scoping review in May of 2016 to identify how masculine norms influence men's HIV testing in sub-Saharan Africa. Our review yielded a total of 13 qualitative studies from 8 countries. Masculine norms create both barriers and facilitators to HIV testing. Barriers included emotional inexpression, gendered communication, social pressures to be strong and self-reliant, and the fear that an HIV positive result would threaten traditional social roles (i.e., husband, father, provider, worker) and reduce sexual success with women. Facilitators included perceptions that HIV testing could restore masculinity through regained physical strength and the ability to re-assume the provider role after accessing treatment. Across sub-Saharan Africa, masculinity appears to play an important role in men's decision to test for HIV and further research and interventions are needed to address this link.

Relationship Power Among Same-Sex Male Couples in New York and San Francisco: Laying the Groundwork for Sexual Risk Reduction Interventions Focused on Interpersonal Power.

Research is clear that power differentials between women and men shape women's human immunodeficiency virus (HIV) risks; however, little research has attempted to examine power differentials within same-sex male (SSM) couples and whether these influence sexual risk outcomes. To produce the first quantitative scale that measures power in SSM relationships, the current work was a Phase 1 qualitative study that sought to understand domains of relationship power and how power operated in the relationship among 48 Black, White, and interracial (Black-White) SSM couples recruited from San Francisco and New York. Interview domains were focused on definitions of power and perceptions of how power operated in the relationship. Findings revealed that couples described power in three key ways: as power exerted over a partner through decision-making dominance and relationship control; as power to accomplish goals through personal agency; and as couple-level power. In addition, men described ways that decision-making dominance and relationship control could be enacted in the relationship-through structural resources, emotional and sexual influence, and gender norm expectations. We discuss the implications of these findings for sexual risks and HIV care and treatment with SSM couples that are focused on closing gaps in power.

Jaboya ("Sex for Fish"): A Qualitative Analysis of Contextual Risk Factors for Extramarital Partnerships in the Fishing Communities in Western Kenya.

Extramarital partnerships exacerbate high HIV prevalence rates in many communities in sub-Saharan Africa. We explored contextual risk factors and suggested interventions to reduce extramarital partnerships among couples in the fishing communities on Lake Victoria, Kenya. We conducted 12 focus group discussions with 9-10 participants each (N = 118) and 16 in-depth interviews (N = 16) with fishermen and their spouses. Couples who participated were consented and separated for simultaneous gender-matched discussions/interviews. Interview topics included courtship and marriage, relationship and sexual satisfaction, extramarital relationships and how to intervene on HIV risks. Coding, analysis, and interpretation of the transcripts followed grounded theory tenets that allow analytical themes to emerge from the participants. Our results showed that extramarital partnerships were perceived to be widespread and were attributed to factors related to sexual satisfaction such as women needing more foreplay before intercourse, discrepancies in sexual desire, and boredom with the current sexual repertoire. Participants also reported that financial and sociophysical factors such as family financial support and physical separation, contributed to the formation of extramarital partnerships. Participants made suggestions for interventions that reduce extramarital partnerships to minimize HIV risks at the community, couple, and individual level. These suggestions emphasized improving community education, spousal communication, and self-evaluation for positive behavior change. Future studies can draw upon these findings as a basis for designing community-owned interventions that seek to reduce community-level HIV risk through a reduction in the number of sexual partners.

A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study.

The scale-up of effective treatment has partially reduced the stigma attached to HIV, but HIV still remains highly stigmatized throughout sub-Saharan Africa. Most studies of anti-HIV stigma interventions have employed psycho-educational strategies such as information provision, counseling, and testimonials, but these have had varying degrees of success. Theory suggests that livelihood interventions could potentially reduce stigma by weakening the instrumental and symbolic associations between HIV and premature morbidity, economic incapacity, and death, but this hypothesis has not been directly examined. We conducted a longitudinal qualitative study among 54 persons with HIV participating in a 12-month randomized controlled trial of a livelihood intervention in rural Kenya. Our study design permitted assessment of changes over time in the perspectives of treatment-arm participants (N = 45), as well as an understanding of the experiences of control arm participants (N = 9, interviewed only at follow-up). Initially, participants felt ashamed of their seropositivity and were socially isolated (internalized stigma). They also described how others in the community discriminated against them, labeled them as being "already dead," and deemed them useless and unworthy of social investment (perceived and enacted stigma). At follow-up, participants in the treatment arm described less stigma and voiced positive changes in confidence and self-esteem. Concurrently, they observed that other community members perceived them as active, economically productive, and contributing citizens. None of these changes were noted by participants in the control arm, who described ongoing and continued stigma. In summary, our findings suggest a theory of stigma reduction: livelihood interventions may reduce internalized stigma among persons with HIV and also, by targeting core drivers of negative attitudes toward persons with HIV, positively change attitudes toward persons with HIV held by others. Further research is needed to formally test these hypotheses, assess the extent to which these changes endure over the long term, and determine whether this class of interventions can be implemented at scale.