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

Key Points

Question

Does a multisectoral, climate-adaptive, agricultural livelihood intervention improve health outcomes for individuals living with HIV and food insecurity?

Findings

In this cluster randomized clinical trial of 720 participants, the intervention did not lead to improvements in HIV viral suppression for adults living with HIV and receiving antiretroviral therapy. Viral suppression approached the UNAIDS goal of at least 95% in both study groups in the setting of widespread test and treatment policies launched during the study, and the intervention led to improvements of predefined secondary outcomes, including food security, mental health, self-confidence, and social support.

Meaning

In the setting of high-quality HIV service delivery, a multisectoral agricultural and livelihood intervention did not affect viral suppression.

Abstract

This cluster randomized clinical trial assesses whether a multisectoral agricultural livelihood intervention improves viral load suppression, reduces food insecurity, and improves nutrition, mental health, and empowerment indicators among people living with HIV in sub-Saharan Africa.

Abstract

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