Social, economic and food insecurity among people living with HIV in Kenya during coinciding public health and environmental emergencies: a mixed-methods study.

Introduction: During the COVID-19 response, Kenya experienced widespread regional floods, resulting in the displacement of communities and agricultural loss. This study aimed to characterise food insecurity and other social and economic impacts of these emergencies on people living with HIV and to investigate whether and how existing microfinance activities in place before the events influenced social and economic instability. Methods: We used sequential explanatory mixed methods guided by a conceptual model. Interviewer-administered surveys (n=200) and follow-up in-depth interviews (n=40) were conducted by phone with people living with HIV in Busia and Trans Nzoia counties between October and December 2020. Socioeconomic factors (microfinance participation, income and social support) and food insecurity were examined with Poisson regression using survey data. Qualitative data were analysed using content analysis to contextualise quantitative findings. Results: Among 200 participants, 59.0% were female, median age was 45 years and 73.0% reported being severely food insecure. Microfinance participation was not associated with severe food insecurity (adjusted prevalence ratio, aPR 0.98; 95% CI 0.82, 1.18), but income loss (aPR 1.94; 95% CI 1.13, 3.30; p=0.015) and loss of social support (aPR 1.48; 95% CI 1.18, 1.84; p=0.001) were associated with severe food insecurity. Three main themes emerged: compounding effects of COVID-19 and flooding on food and economic insecurity are early indicators of upstream barriers to HIV treatment; microfinance groups may not have mitigated socioeconomic consequences of COVID-19 and flooding because of unexpected income loss and limits on gathering and displacement; and social support bolsters mental health and medication adherence among microfinance members despite lack of in-person activities. Conclusions: In the context of coinciding public health and environmental emergencies, people living with HIV in Kenya experienced widespread food insecurity. Programmatic efforts to support HIV treatment disbursement, coverage and adherence alone are not sufficient during an economic crisis affecting food insecurity. Integrating antiretroviral therapy (ART) dispensing efforts alongside interventions to support food security for people living with HIV could improve ART adherence and reduce mortality during widespread emergencies.