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

OBJECTIVE: HIV stigma undermines antiretroviral treatment (ART) adherence and viral suppression. Livelihood interventions may target drivers of negative attitudes towards people living with HIV (PLHIV) by improving their health and strengthening their economic contributions. We examined the effects of a multisectoral agricultural livelihood intervention on HIV stigma among PLHIV 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 ≥18 years old, on ART >six months, and moderately-to-severely food insecure. We measured internalized, anticipated, and enacted HIV stigma semiannually over two years using validated scales. In blinded intent-to-treat analyses, we compared changes in scores over 24 months, by study arm, using longitudinal multi-level difference-in-differences linear regression models that accounted for clustering. RESULTS: Of 720 enrolled participants (354 intervention), 55% were female, and the median age was 40 years (interquartile range 34-47 years). Two-year retention was 94%. Compared to the control arm, the intervention resulted in significant decreases (p < 0.001) of 0.42 points (95% confidence interval (CI) -0.52, -0.31) in internalized stigma, 0.43 points (95% CI -0.51, -0.34) in anticipated stigma, and 0.13 points (95% CI -0.16, -0.09) in enacted stigma over 24 months. CONCLUSIONS: The agricultural livelihood intervention reduced HIV stigma among PLHIV. 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.

Comparing the effect of a multisectoral agricultural intervention on HIV-related health outcomes between widowed and married women.

INTRODUCTION: Widowed women make up 18-40% of the 12 million women living with HIV in eastern and southern Africa. Widowhood has also been associated with greater HIV morbidity and mortality. We compared the effectiveness of a multisectoral climate adaptive agricultural livelihood intervention (called Shamba Maisha) on food insecurity, and HIV related health outcomes among widowed and married women living with HIV in western Kenya. METHODS: We implemented Shamba Maisha (NCT02815579) using a cluster-randomized control trial design. The intervention arm received an US$175 in-kind loan to purchase a micro-irrigation pump, seeds, and fertilizer, and received eight training sessions on sustainable agriculture and financial management. Study outcomes were measured every 6 months over a 24-month follow-up period and trends in outcomes assessed using multilevel mixed-effects models. RESULTS: The trial enrolled 232 (61.5%) married and 145 (38.5%) widowed women. Widowed women (mean age 42.8 ± 8.4 years) were older than married women (35.8 ± 9.0 years) (p < 0.01). Almost all widowed women (97.2%) self-identified as household heads compared to 10.8% of married women. Comparing widowed vs married women, reduction in food insecurity (-3.13, 95%CI -4.42, -1.84 vs. -3.08, 95%CI -4.15, -2.02), depressive symptoms (-0.21, 95%CI -0.36, -0.07 vs. -0.19, 95%CI -0.29, -0.08), internalized stigma (-0.33, 95%CI -0.55, -0.11 vs. -0.38, 95%CI -0.57, -0.19), and anticipated stigma (-0.46 95%CI -0.65, -0.28 vs. -0.35, 95%CI -0.50, -0.21) was similar for both groups. In contrast, improvements in social support (-2.22, 95%CI -3.85, -0.59 vs. -4.00, 95%CI -5.16, -2.84; p = 0.08) and reduction in enacted stigma (0.01, 95%CI -0.06, 0.08 vs. -0.14, 95%CI -0.20, -0.09; p < 0.01) were weaker for widowed than married women. CONCLUSIONS: Our study is among the first comparing the effect of a livelihood intervention on HIV health outcomes among widowed and married women. Widowed women experienced similar benefits as married women on individual-level outcomes, but weaker benefit on outcomes dependent on their external environment like enacted stigma and social support. Future trials and programs targeting widowed women should bolster stigma reduction and social support.

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.

Perceived impacts of a pilot agricultural livelihood and microfinance intervention on agricultural practices, food security and nutrition for Kenyans living with HIV.

INTRODUCTION: Agriculture is the primary source of income and household food for >75% of rural Kenyans, including people living with HIV (PLHIV), making agricultural yields an important factor in food security and nutrition. Previous studies have shown the interconnectedness of food insecurity, malnutrition, and poor HIV health by elucidating that having one of these conditions increases the likelihood and severity of having another. However, few studies have explored the linkages between agricultural practices, food security and nutrition for PLHIV, or how agricultural livelihood interventions may affect these domains. This study aimed to examine the mechanisms through which an agricultural livelihood intervention can positively or negatively affect agricultural practices, food security, and nutrition for PLHIV. METHODS: From July 2012-August 2013, we interviewed participants with HIV on antiretroviral therapy (ART) enrolled in a pilot randomized controlled trial (RCT) of an agricultural livelihood and finance intervention to understand the mechanisms through which the intervention may have affected HIV health outcomes. The intervention included agricultural and finance training and a microfinance loan to purchase the MoneyMaker hip pump, a human-powered water pump, seeds, and other farming implements. A purposive sample of 45 intervention and a random subset of 9 control participants were interviewed at 12-month endline visit with a subset of 31 intervention participants interviewed longitudinally at both the 3- and 12-month visits. Transcripts were double coded using an inductive-deductive approach and analyzed for impacts of the intervention on agricultural practices, food security, and nutrition using analytic reports for each key theme. RESULTS: All intervention participants described improvements in agricultural practices and yields attributed to the intervention while many also described improvements in income; these changes in turn contributed to improved HIV health, including suppressed viral loads, and a few people noted improved immunologic parameters. Key mechanisms included the knowledge gained from agricultural training which led to improved yields and access to new markets. The use of the irrigation pump was also identified as an additional, lesser important mechanism. All intervention participants reported sustained improvements in food security and nutrition through increased yields and income from the sale of excess crops used to purchase food, and diversification of fresh fruits and vegetables consumed through agricultural production. This led to self-reported weight gain which was a nutritional mechanism towards improved health. CONCLUSIONS: Agricultural and finance interventions that improve farming practices could lead to improved health outcomes through the pathways of improved food security, income, and diversified diet. The results from this study helped the team to enhance the intervention prior to implementation of the larger cluster RCT (cRCT). By understanding how agricultural livelihood interventions act upon pathways towards improved health, policy options can be developed and implemented to include components that are needed to achieve sustainable outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT01548599.

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.

Water Insecurity is Associated with Lack of Viral Suppression and Greater Odds of AIDS-Defining Illnesses Among Adults with HIV in Western Kenya.

Reliable access to safe and acceptable water in sufficient quantities (i.e., water security) is important for medication adherence and limiting pathogen exposure, yet prior studies have only considered the role of food security as a social determinant of HIV-related health. Therefore, the objective of this analysis was to assess the relationships between household water insecurity and HIV-related outcomes among adults living with HIV in western Kenya (N = 716). We conducted a cross-sectional analysis of baseline data from Shamba Maisha (NCT02815579), a cluster randomized controlled trial of a multisectoral agricultural and asset loan intervention. Baseline data were collected from June 2016 to December 2017. We assessed associations between water insecurity and HIV-related outcomes, adjusting for clinical and behavioral confounders, including food insecurity. Each five-unit higher household water insecurity score (range: 0-51) was associated with 1.21 higher odds of having a viral load ≥ 1000 copies/mL (95% CI 1.07, 1.36) and 1.26 higher odds of AIDS-defining illness (95% CI 1.11, 1.42). Household water insecurity was not associated with CD4 cell count (B: 0.27; 95% CI -3.59, 13.05). HIV treatment and support programs should consider assessing and addressing water insecurity in addition to food insecurity to optimize HIV outcomes.

RESUMEN: El acceso seguro al agua potable en cantidades suficientes (es decir, seguridad hídrica) es importante para la adherencia a la medicación y para limitar la exposición a patógenos; sin embargo, estudios anteriores solo han considerado el papel de la seguridad alimentaria como un determinante social de salud relacionado con el VIH. Por lo tanto, el objetivo de este análisis fue evaluar las relaciones entre la inseguridad hídrica en hogares y los resultados relacionados con el VIH en adultos que viven con VIH en el oeste de Kenia (N = 716). Realizamos un análisis transversal de los datos basales de la iniciativa Shamba Maisha (NCT02815579), un ensayo controlado aleatorio por conglomerados de una intervención multisectorial de créditos para insumos agrícolas. Los datos basales se recopilaron de junio de 2016 a diciembre de 2017. Evaluamos las asociaciones entre la inseguridad hídrica y resultados relacionados con el VIH, ajustando por factores de confusión clínicos y conductuales, incluyendo inseguridad alimentaria. Cada cinco unidades superiores de puntajes de inseguridad hídrica doméstica (rango: 0-51) fue asociado con 1.21 mayores probabilidades de tener una carga viral más alta ≥ 1000 copias / ml (CI 95%: 1,07-1,36) y con 1.26 mayores probabilidades de factores determinantes del SIDA (CI 95%: 1,11-1,42). La inseguridad de hídrica doméstica no se asoció con el recuento de células CD4 (B: −0,27; CI 95%: -13,59-13,05). Los programas de tratamiento y de apoyo al VIH deben considerar evaluar y abordar la inseguridad hídrica además de la inseguridad alimentaria para optimizar los resultados del VIH.

Household Water and Food Insecurity Are Positively Associated with Poor Mental and Physical Health among Adults Living with HIV in Western Kenya.

BACKGROUND: Household food insecurity (FI) and water insecurity (WI) are prevalent public health issues that can co-occur. Few studies have concurrently assessed their associations with health outcomes, particularly among people living with HIV. OBJECTIVES: We aimed to investigate the associations between FI and WI and how they relate to physical and mental health. METHODS: Food-insecure adult smallholder farmers living with HIV in western Kenya were recruited to participate in a cluster-randomized controlled trial of a multisectoral agricultural and asset loan intervention. We used baseline data on experiences of FI (using the Household Food Insecurity Access Scale, range: 0-27) and WI (using a modified scale developed for this region, range: 0-51) in the prior month (n = 716). Outcomes included probable depression (using the Hopkins Symptom Checklist), fatigue and diarrhea in the prior month, and overall mental and physical health (using the Medical Outcomes Study HIV Health Survey, range: 0-100). We first assessed Pearson correlations between FI, WI, and sociodemographic characteristics. We then developed 3 regressions for each health outcome (control variables and FI; control variables and WI; control variables, FI, and WI) and compared model fit indexes. RESULTS: Correlations between household FI, WI, and wealth were low, meaning they measure distinct constructs. FI and WI were associated with numerous physical and mental health outcomes; accounting for both resource insecurities typically provided the best model fit. For instance, when controlling for FI, each 10-point higher WI score was associated with a 6.42-point lower physical health score (P < 0.001) and 2.92 times greater odds of probable depression (P < 0.001). CONCLUSIONS: Assessing both FI and WI is important for correctly estimating their relation with health outcomes. Interventions that address food- and water-related issues among persons living with HIV concurrently will likely be more effective at improving health than those addressing a single resource insecurity. This trial was registered at clinicaltrials.gov as NCT02815579.

Food Insecurity and Intimate Partner Violence Among HIV-Positive Individuals in Rural Kenya.

INTRODUCTION: Intimate partner violence and food insecurity are both structural drivers of HIV acquisition, care, and treatment, but little is known about how the 2 conditions intersect in the lives of those already living with HIV. METHODS: This study examined cross-sectional baseline data (collected in January 2016-December 2017) from an ongoing trial in southwestern Kenya. Trained interviewers asked enrolled participants living with HIV aged 18-60 years about household food insecurity (using the Household Food Insecurity Access Scale), intimate partner violence (using an adapted WHO multicountry study instrument), and sociodemographics. Negative binomial regression was used to examine the association between food insecurity and partner violence victimization (among women) or perpetration (among men). Secondary data were analyzed in August 2019-March 2020. RESULTS: Of 720 participants, more than half of women reported experiencing intimate partner violence (57.6%) and most men reported perpetrating it (58.4%). Participants reporting any partner violence had higher Household Food Insecurity Access Scale scores (21.8) compared with those reporting no violence (21.3, p=0.02). Each categorical change in food insecurity (mild, moderate, severe) was associated with a 41% increased risk of an additional partner violence episode. In models controlling for relationship status, wealth, season of interview (lean versus not lean), and baseline physical health, each 1-point increase in food insecurity was associated with a 6% higher risk of violence victimization among women and 4% greater risk of men perpetrating partner violence. CONCLUSIONS: This study highlights the interconnected nature of intimate partner violence and food insecurity among women and men living with HIV. This relationship suggests that enhancing food security may be a useful intervention strategy to prevent intimate partner violence and improve HIV-related health outcomes.

Presence of Older Adolescents in the Household is Associated with Depressive Symptoms Among Women Living with HIV in Kenya.

The objective of this study was to determine the association between the number of adolescents in a household and depressive symptoms among adult caregivers living with HIV. We examined cross-sectional baseline data among adults enrolled in the Shamba Maisha multisectoral agricultural intervention (n = 705) in the Nyanza region of Kenya (NCT02815579). Each additional adolescent 15-19 years in a household was associated with a 1.35 (95% CI 1.06-1.71) higher odds of depressive symptoms among women, but not men, adjusting for potential confounders. Interventions to support the mental health of adults living with HIV may target women caring for dependent adolescents 15-19 years.

"When I Eat Well, I Will Be Healthy, and the Child Will Also Be Healthy": Maternal Nutrition among HIV-Infected Women Enrolled in a Livelihood Intervention in Western Kenya.

BACKGROUND: Food insecurity remains a major obstacle to achieving health and well-being for individuals living with HIV in western Kenya. Studies have shown that pregnant women are vulnerable to experiencing food insecurity worldwide, with significant consequences for both maternal and child health. The Shamba Maisha cluster randomized controlled trial in western Kenya (which means "farming for life" in Swahili) tested the effects of a multisectoral livelihood intervention consisting of agricultural and finance trainings, farm inputs, and a loan on health and food security among 746 farmers living with HIV in Kisumu, Homa Bay, and Migori Counties. OBJECTIVES: We conducted a qualitative substudy within the Shamba Maisha trial to understand the experiences and perspectives of pregnant women living with HIV enrolled in the trial. METHODS: Thirty women who had experienced a pregnancy during the Shamba Maisha study period, comprising 20 women in the intervention arm and 10 women in the control arm, completed in-depth interviews using a semistructured interview guide. RESULTS: Intervention participants interviewed noted improvements in maternal nutrition compared with previous pregnancies, which they attributed to the livelihood intervention. Key identified pathways to improved nutrition included improved access to vegetables, increased variety of diet through vegetable sales, and improved nutritional awareness. Women in the intervention arm also perceived increased weight gain compared with prior pregnancies and increased strength and energy throughout pregnancy. CONCLUSIONS: Livelihood interventions represent a promising solution to alleviate food insecurity for pregnant women in order to improve maternal and child health outcomes.This trial was registered at clinicaltrials.gov as NCT02815579.

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.

Development and Piloting of a Home-Based Couples Intervention During Pregnancy and Postpartum in Southwestern Kenya.

Engaging both partners of a pregnant couple can enhance prevention of mother-to-child transmission of HIV and promote family health. We developed and piloted an intervention to promote couple collaboration in health during pregnancy and postpartum in southwestern Kenya. We utilized formative data and stakeholder input to inform development of a home-based couples intervention. Next, we randomized pregnant women to intervention (n = 64) or standard care (n = 63) arms, subsequently contacting their male partners for enrollment. In the intervention arm, lay health workers conducted couple home visits, including health education, couple relationship and communication skills, and offers of couple HIV testing and counseling (CHTC) services. Follow-up questionnaires were conducted 3 months postpartum (n = 114 women, 86 men). Baseline characteristics and health behaviors were examined by study arm using t-tests, chi-square tests, and regression analyses. Of the 127 women randomized, 96 of their partners participated in the study. Of 52 enrolled couples in the intervention arm, 94% completed at least one couple home visit. Over 93% of participants receiving couple home visits were satisfied and no adverse social consequences were reported. At follow-up, intervention couples had a 2.78 relative risk of having participated in CHTC during the study period compared with standard care couples (95% confidence interval: 1.63-4.75), and significant associations were observed in other key perinatal health behaviors. This pilot study revealed that a home-based couples intervention for pregnant women and male partners is acceptable, feasible, and has the potential to enhance CHTC and perinatal health behaviors, leading to improved health outcomes.

Men's hopes, fears and challenges in engagement in perinatal health and the prevention of mother-to-child transmission of HIV in rural Kenya.

Male involvement in antenatal care has been shown to improve health outcomes for women and infants. However, little is known about how best to encourage male partners to support essential perinatal health activities. We explored men's perceptions of facilitators and barriers to involvement in antenatal care and HIV prevention including fears, hopes and challenges. Forty in-depth interviews were conducted with the male partners of HIV-positive and HIV-negative pregnant women in southwest Kenya. Most male partners believed engaging in pregnancy health-related activities was beneficial for keeping families healthy. However, thematic analysis revealed several obstacles that hindered participation. Poor couple relationship dynamics seemed negatively to influence male engagement. Some men were apprehensive that clinic staff might force them to test for HIV and disclose the results; if HIV-positive, men feared being labelled as 'victimisers' in situations of serodiscordancy, and described fears of abandonment by their wives. Some men avoided accompanying their wives, citing local culture as rationale for avoiding the 'effeminate' act of antenatal care attendance. Amidst these obstacles, some men chose to use their partners' HIV status as proxy for their own. Findings suggest that improving male engagement in essential maternal and child health-related activities will require addressing both structural and interpersonal barriers.

Implementation of repeat HIV testing during pregnancy in southwestern Kenya: progress and missed opportunities.

INTRODUCTION: Repeat HIV testing during the late antenatal period is crucial to identify and initiate treatment for pregnant women with incident HIV infection to prevent perinatal HIV transmission and keep mothers alive. In 2012, the Kenya Ministry of Health adopted international guidelines suggesting that pregnant women be offered retesting three months after an initial negative HIV test. Our objectives were to determine the current rate of antenatal repeat HIV testing; identify successes, missed opportunities and factors associated with retesting; and estimate the incidence of HIV during pregnancy. METHODS: Retrospective analysis of longitudinal data was conducted for a cohort of 2145 women attending antenatal care clinic at a large district hospital in southwestern Kenya. Data were abstracted from registers for all women who attended the clinic from the years 2011 to 2014. RESULTS: Although 90.2% of women first came to clinic prior to their third trimester and 27.5% had at least four clinic visits, 58.0% of all women went to delivery without a retest. Missed opportunities for retesting included not returning to clinic at all, not returning when eligible, or late gestational age (>28 weeks) at first clinic visit making them ineligible for retesting (accounting for 14.2%, 26.8% and 9.6% of all clinic attendees respectively); and failure to be retested even when eligible at one or more visits (accounting for 73.2% of eligible returnees). Being unmarried and aged 20 or younger was associated with an increase in mean gestational age of first visit by 2.52 weeks (95% CI: 1.56, 3.48) and a 2.59 increased odds (95% CI: 1.90, 3.54) of failing to return to clinic, compared to those who were married and over 20 years of age. On retest, two women tested HIV positive, suggesting an incidence rate of 4.4 per 100 person-years. After adjusting for potential confounders, only later year of last menstrual period (2013 vs. 2012 and 2011) was associated with retesting. CONCLUSIONS: Adoption of retesting guidelines in 2012 appears to have successfully increased retesting rates, but missed opportunities to identify incident HIV infection during pregnancy may contribute to continuing high rates of perinatal HIV transmission in southwestern Kenya.

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.

Changes in Health and Antiretroviral Adherence Among HIV-Infected Adults in Kenya: Qualitative Longitudinal Findings from a Livelihood Intervention.

This longitudinal qualitative study sought to understand how and why a livelihood intervention affected the health and health behaviors of HIV-infected Kenyan adults. The intervention included a microfinance loan, agricultural and financial training, and a human-powered water pump. In-depth interviews were conducted at two time points with intervention and control participants and program staff. We double coded interviews (n = 117) and used thematic content analysis of transcripts following an integrative inductive-deductive approach. Intervention participants described improvements in HIV health, including increased CD4 counts and energy, improved viral suppression, and fewer HIV-related symptoms. Better health was linked to improved clinic attendance and ART adherence through several mechanisms: (1) reductions in food insecurity and abject hunger; (2) improved financial stability; (3) improved productivity which enhanced social support; (4) better control over work situations; and, (5) renewed desire to prioritize their own health. Livelihood interventions may improve health by influencing upstream determinants of health behavior including food security and poverty.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya.

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.