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

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

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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.
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ORIGINAL ARTICLE
Changes in Health and Antiretroviral Adherence Among HIV-
Infected Adults in Kenya: Qualitative Longitudinal Findings
from a Livelihood Intervention
Sheri D. Weiser
1,2
Abigail M. Hatcher
1,2,3
Lee L. Hufstedler
1
Elly Weke
4
Shari L. Dworkin
2,5
Elizabeth A. Bukusi
4,6
Rachel L. Burger
6
Stephen Kodish
7
Nils Grede
8
Lisa M. Butler
9
Craig R. Cohen
2,6
Published online: 16 September 2016
Springer Science+Business Media New York 2016
Abstract 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.
Resumen Este estudio cualitativo longitudinal trato
´de
comprender por que
´y de que
´manera una intervencio
´n
sustento impacto
´la salud y los comportamientos de salud
de adultos kenianos infectados por el VIH. La intervencio
´n
incluyo
´un pre
´stamo de microfinanzas, capacitacio
´n agrı
´-
cola y financiero, y una bomba de agua de propulsio
´n
humana. En dos puntos se llevaron a cabo entrevistas en
profundidad con participantes de la intervencio
´n y del
grupo del control, y el personal del programa. Doble-co-
dificamos las entrevistas (n =117) y utilizamos un ana
´lisis
de contenido tema
´tico para las transcripciones, segu
´nun
enfoque inductivo-deductivo integrado. Participantes de la
intervencio
´n describieron mejor salud del VIH, recuentos
de CD4 aumentados, mayor energı
´a, mejor supresio
´n viral,
y menos sı
´ntomas de enfermedad asociados con el VIH.
Mejor salud estaba vinculada a mejor asistencia clı
´nica y
cumplimiento de la terapia antiretroviral a trave
´s de varios
mecanismos: 1) la reduccio
´n de la inseguridad alimentaria
y el hambre extrema; 2) mejor estabilidad financiera; 3)
mejor productividad, que aumento
´apoyo social; 4) mejor
control sobre situaciones laborales; y, 5) deseos renovados
de priorizar a su propia salud. Intervenciones sustentos
pueden mejorar la salud por influir los niveles iniciales de
&Sheri D. Weiser
Sheri.Weiser@ucsf.edu
1
Division of HIV, ID, and Global Medicine, Department of
Medicine, University of California San Francisco (UCSF),
Box 0874, 995 Potrero Avenue, San Francisco, CA 94110,
USA
2
Center of Expertise in Women’s Health & Empowerment,
University of California Global Health Institute,
San Francisco, CA, USA
3
School of Public Health, Faculty of Health Sciences,
University of the Witwatersrand, Johannesburg, South Africa
4
Centre for Microbiology Research, Kenya Medical Research
Institute (KEMRI), Nairobi, Kenya
5
Department of Social and Behavioral Sciences and Center for
AIDS Prevention Studies (CAPS), UCSF, San Francisco, CA,
USA
6
Department of Obstetrics, Gynecology & Reproductive
Sciences, UCSF, San Francisco, CA, USA
7
Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD, USA
8
World Food Program, San Salvador, El Salvador
9
Institute for Collaboration on Health, Intervention, and
Policy, University of Connecticut, Storrs, CT, USA
123
AIDS Behav (2017) 21:415–427
DOI 10.1007/s10461-016-1551-2
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Often cited in the literature is the impact of worries about taking ART on an empty stomach. [32][33][34][35][36][37][38][39] The fear of adverse side-effects linked to food insecurity was also noted as an important barrier to adherence in both quantitative and qualitative studies. [40][41][42][43][44][45][46][47][48][49] Study participants attributed side-effects such as hallucinations, drowsiness, and sickly feelings to taking ART with insufficient food, or on an empty stomach. ...
... Statistical evidence (and good qualitative narratives from some of these studies) of associations between health systems interventions and positive adherence outcomes among patients have been found in quantitative studies. 38,100 This means that changes in medication (ART) regimens, improved policy guidelines for patients' handling or engagement (targeted at care providers and facilities), sentiments of trust towards care providers, and the effectiveness of counselling and support groups and e366 www.thelancet.com/planetary-health Vol 6 April 2022 Review community or lay health workers signalled improvements in adherence outcomes in the reviewed literature. ...
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Climate change is directly and indirectly linked to human health, including through access to treatment and care. Our systematic review presents a systems understanding of the nexus between drought and antiretroviral therapy (ART) adherence in HIV-positive individuals in the African setting. Narrative synthesis of 111 studies retrieved from Web of Science, PubMed/MEDLINE, and PsycINFO suggests that livelihoods and economic conditions, comorbidities and ART regimens, human mobility, and psychobehavioural dispositions and support systems interact in complex ways in the drought–ART adherence nexus in Africa. Economic and livelihood-related challenges appear to impose the strongest impact on human interactions, actions, and systems that culminate in non-adherence. Indeed, the complex pathways identified by our systems approach emphasise the need for more integrated research approaches to understanding this phenomenon and developing interventions.
... and/or "what remains the same?" (Saldañ a, 2003). LQR designs have been applied in a variety of research areas including, transitions in human development (Schmidt et al., 2019), the experiences of incarceration (Cooper et al., 2015), aging (Oosterveld-Vlug et al., 2013) and the progression of chronic illness (Namukwaya et al., 2017), as well as behavioral research investigating medication adherence (Salter et al., 2014;Weiser et al., 2017) and breastfeeding (Doherty et al., 2006;Jardine et al., 2017). LQR may be applied to understand any human experience, as well as its sequalae and is particularly well suited for studying transition periods and developmental or behavioral changes across time. ...
... Meanwhile, Corepal et al. (2018) used their qualitative study to better understand how and why an intervention designed to promote physical activity was effective among a group of adolescents. Findings from another LQR study among people living with HIV in Kenya provided key information to understand how and why a livelihood intervention impacted health behaviors (Weiser et al., 2017). LQR may also identify changes in needs or levels of stress that can in turn be used to inform the development of supportive interventions (Murray et al., 2009). ...
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Longitudinal qualitative research (LQR) is an emerging methodology in health behavior and nursing research. Researchers are turning to LQR to understand experiences across time as well as identify facilitators and inhibitors of health/illness behaviors and transitions. Currently, a lack of information exists to guide researchers on LQR techniques and considerations. Our objective was to provide a methodological resource for health behavior and nursing researchers conducting LQR. LQR may be applied to understand any human experience, as well as the sequalae of the experience and is well suited for studying transitions and developmental or behavioral changes. Conducting LQR is resource intensive and requires flexibility and complex analyses. We discuss multiple components of LQR such as design considerations, analysis options, and our lessons learned. Despite complexities, LQR provides the opportunity to understand experiences across time within an individual and among a group resulting in holistic, in-depth understandings beyond a cross-sectional time point.
... There is a growing consensus that theory-informed livelihood interventions can improve mental and physical well-being of persons living with HIV (PLWH) (Tsai et al., 2017;Weiser et al., 2017). The demands of managing poverty and HIV illness in resource-limited contexts such as India can contribute to increased morbidity, diminished quality of life, and heightened stigma (Kang et al., 2016;Schensul et al., 2009;Zelaya et al., 2012). ...
... This paper presents findings from an ethnographic process evaluation of Kirana theory-informed programme aimed to improve mental well-being among women affected by HIV in Delhi by supporting means to improve their economic livelihood. The theory underlying the intervention was that mental and physical wellbeing is improved by reducing economic insecurity (Kang et al., 2016;Tsai et al., 2017;Weiser et al., 2017) and strengthening personal agency and life purpose (Hatcher et al., 2020;Weiser et al., 2011). Longitudinal, qualitative methodology may help clarify how livelihood interventions potentially affect mental wellness among PLWH (Hatcher et al., 2020). ...
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Poverty-alleviation programmes aimed to improved mental well-being among persons living with HIV (PLWH) in low and middle income countries have underscored the importance of understanding how and why such programmes work. We present findings from a six-month ethnographic process evaluation of Kiran, an economic livelihood programme locally designed to improve mental well-being among women affected by HIV in Delhi, India. In addition to benefits of improved economic standing, we found that supportive relationships cultivated among participants (n = 9) and with providers (n = 3) provided respite from worry about their illness and reframed what was relationally and practically possible in the context of living with HIV. In acquiring marketable craft skills with peers, participants challenged internalized scripts of being socially devalued and regained agency about their abilities to contribute to their community and support their children’s immediate and future needs. We found that the benefits of Kiran weighed less on the direct alleviation of mental distress and more on the instillation of hope for their children. Our findings exemplify the importance of re-visiting a priori theories that inform interventions for PLWH and highlight the methodological merits of ethnographic approaches that underscore how theory and intervention praxis are bidirectionally informed.
... A pilot of the Shamba Maisha randomized controlled trial (RCT) conducted at 2 facilities in the Nyanza Region found significant improvements in the proportion virally suppressed [comparative improvement in the proportion suppressed of 33% (OR: 7.6; 95% CI: 2.2, 26.8)], CD4 count level, and food security in the intervention arm as compared with the control arm (28). Qualitative pilot data suggest that there were several key pathways through which the intervention improved HIV health, including improved nutrition, income, empowerment, mental health, and adherence to care (28)(29)(30). The intervention was implemented as a cluster RCT in 16 paired facilities in western Kenya from 2016 to 2019. ...
... In addition, questions were developed to explore the pathways through which the Shamba Maisha intervention may exert its impact on health outcomes; the guide therefore included sections on mental health, empowerment, and relationship power. The questions were developed based on previous literature, including our prior qualitative research conducted during the Shamba Maisha pilot study (29)(30)(31). Intervention participants were asked additional questions about their experiences and perceptions of the intervention; therefore, interviewers were not blinded to the intervention or control status of interviewees. The guide was modified and further developed through an iterative process based on interviewer feedback and review of early transcripts. ...
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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.
... Such an initiative also brought about significant mental and behavioral changes, specifically concerning perceptions about health status. Participants stated that their increased food intake made them feel healthier and more able to process the medicine, providing the motivation to be diligent with treatment regimens; some claimed that their weight gain boosted their social image, increasing their confidence and willingness to continue treatment [28]. Similarly, the UHANFS intervention, whose participants were food insecure from the onset, saw indirect effects of microfinance on improved food security, implying a mutually beneficial, connected mechanism [9]. ...
... The social support provided through these groups is crucial to cultivating a sense of identity, motivation, and communal drive for success-all factors that may be crucial to changing behaviors like adherence, ultimately impacting HIV treatment outcomes [8]. The group nature of these interventions provides potential pathways through which individuals can find solidarity and enforce positive self-perceptions [28]. ...
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... Higher economic vulnerability might, in turn, lead to lower adherence to ART. A longitudinal qualitative study on HIV-infected Kenyan adults showed that livelihood interventions such as a microfinance loan or agricultural and financial training improved food security and poverty and consequently led to improved ART adherence, VS and CD4 + T-lymphocyte counts (47,48). This observation underscores the need for economic empowerment for women since economic insecurity is a major barrier to HIV treatment adherence. ...
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Background Achieving and maintaining viral suppression (VS) in people living with HIV/AIDS on antiretroviral therapy (ART) remains a crucial clinical goal, more so in pregnancy to prevent mother-to-child-transmission (MTCT). There is a need to understand VS kinetics and barriers to achieving it in order to meet the target of eliminating HIV-MTCT by 2030. Methods HIV-infected pregnant women ≥20 weeks of gestation with different durations of Tenofovir/Lamivudine/Efavirenz exposures seeking antenatal care services at four primary health centres in high-density residential areas in Harare, Zimbabwe were enrolled in the University of Zimbabwe Birth Cohort Study. Plasma viral load (VL) was quantified by reverse transcriptase–polymerase chain reaction. Demographic, clinical, socio-economic and HIV- and ART-related factors were tested in multivariable logistic regression analyses as potential predictors for VS and undetectable VL. Results From March 2016 to June 2019, 608 HIV-infected pregnant women were enrolled. 63 (10.4%) were self-reported-ART-naïve; 324 (53.3%) and 221 (36.3%) initiated ART pre- and post-conception, respectively. Time from ART initiation to VS (VL ≤ 1,000 copies/ml) in 95% of the women was 126 days. Overall lack of VS (VL > 1,000 copies/ml) was observed in 133 (21.9%) women being 76.2, 27.4 and 7.7% in self-reported-ART-naïve, post-conception and pre-conception groups, respectively. Undetectable VL (≤ 50 copies/ml) was observed in 371 (61.2%) and low-level viremia (51–1,000 copies/ml) in 102 (16.8%) women. In multivariable models for all participants regardless of ART exposure, being on ART was the strongest predictor for both VS and undetectable VL (odds ratio 95% confidence interval, OR (CI): 8.9(4.2–19.5) and 8.1(3.2–24.4), respectively). For women on ART, duration of ART use >126 days was the strongest predictor with OR (CI): 6.7(3.3–14.0) for VS and 8.5(5.6–13.1) for undetectable VL. Other relevant predictors for favourable virological outcomes were older maternal age, HIV-status disclosure, absence of ART side effects and self-reported depression. Having a spouse/intimate partner on ART predicted a 4 times higher likelihood for VS. Discussion Lack of VS was frequently observed in this Harare cohort of pregnant women, mainly due to new HIV diagnosis, hence not being on ART and suboptimal duration of ART exposure. Since VS for 95% of women needed about 4 months of ART exposure, eliminating HIV-MTCT will require timely screening and commencing women together with their spouses/intimate partners on ART before pregnancy or early after conception. Clinical Trial Registration www.ClinicalTrials.gov , identifier: NCT04087239.
... Given that FI is dependent upon local food availability, 61 we controlled for month of interview in our models to account for seasonal fluctuations in food production and harvest. Month of interview, however, may not have adequately captured other key community and environmental determinants of FI. ...
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Background Food insecurity (FI) is common globally and can have lifelong consequences. However, few studies have longitudinally examined how FI varies across gestation and the postpartum period (“the first 1000 days”); none have explored this in sub-Saharan Africa or in the context of HIV. Objective To assess the prevalence and covariates of FI in the first 1000 days among Kenyan women. Methods All pregnant women attending 7 clinics in western Kenya (n = 1247) were screened for HIV and FI (Individual Food Insecurity Access Scale) between September 2014 and June 2015. A subset of women (n = 371) was recruited into an observational cohort study and surveyed 11 times through 2 years postpartum (NCT02974972, NCT02979418). Data on FI, sociodemographics, and health were repeatedly collected. Severe FI was modeled using multilevel, mixed-effects logistic regressions (n = 346). Results Of the 1247 pregnant women screened, 76.5% were severely food insecure in the prior month. Further, the prevalence of severe FI was higher among women living with HIV than those without (82.6% vs 74.6%, P < .05). In the cohort, the odds of being severely food insecure decreased monotonically after delivery. Each point higher on the Center for Epidemiologic Studies-Depression scale was associated with 1.08 times greater odds of being severely food insecure (95% CI: 1.05-1.10); each point higher on the Duke/UNC Functional Social Support Scale was associated with 0.97 lower odds of severe FI (95% CI: 0.94-0.99). Conclusions Severe FI is prevalent during the first 1000 days in western Kenya. Services to mitigate the far-reaching consequences of this modifiable risk should be considered.
... The study revealed that peer support for adherence had a positive effect on immunological restoration in functioning families and had a negative effect in dysfunctional families [47]. Similar studies indicate that attention to the family dynamics, rather than simply engaging all families, and building networks of support among HIV-positive peers, may help improve ART adherence for older adolescents going forward [48,49]. ...
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