Determinants, mechanisms, and association of water insecurity with HIV treatment outcomes among adults on art In Kisumu county, Kenya

Abstract

Despite progress in HIV management, resource insecurities threaten the gains made with antiretroviral therapy (ART) among adults globally. Water insecurity, a common problem in high HIV burden regions, has not received much attention despite its important role in HIV treatment outcomes. Kisumu County has a high HIV prevalence (11.7%), a 17% viral suppression gap, and only 42% water access, however, the relationship of water insecurity with HIV outcomes among ART clients is not adequately understood. This study, in line with the Sustainable Development Goals (SDGs) 3 and 6, had the general objective of establishing the determinants, the mechanisms, and the association of water insecurity with HIV treatment outcomes among adults on ART in Kisumu County. The specific objectives were 1) to estimate the prevalence and characterize the drivers and dimensions of water insecurity; 2) to explore the lived experiences of water insecurity and elucidate pathways from water insecurity to HIV treatment outcomes, and 3) to determine the association of water insecurity with HIV treatment outcomes among adults on ART and assess whether sex modified this association. An integrated multiphase mixed-methods design was employed. In Phase I, a baseline cross-sectional study of 434 randomly selected adults addressed the first objective, with a nested water quality sub-study. In Phase II, water insecure participants were purposively selected to explore the lived experiences of water insecurity. In Phase III, a matched case–control study of 356 randomly selected adults was conducted to determine the association between water insecurity and HIV treatment outcomes and assess sex as an effect modifier. Quantitative data were analyzed using descriptive and inferential statistics (α = 0.05). Qualitative data were analyzed using inductive thematic analysis, followed by framework analysis to develop a novel conceptual model. Baseline household water insecurity prevalence was 64%. Determinants of water insecurity included socio-structural factors, communal, and individual factors. Female sex (OR = 4.88; 95% CI: 3.11–7.67; p < 0.001; AOR = 3.65; 95% CI: 2.02–6.58; p < 0.001), and microbial contamination (OR = 10.04, 95% CI: 5.94–16.95, p < 0.001; AOR = 3.96, 95% CI: 2.07–7.59, p < 0.001) were independent predictors of water insecurity. Water sources had widespread microbial (76.5%) and physicochemical (94%) contamination. The lived experiences revealed challenges with availability, access and quality, resulting in HIV treatment interruptions. Physical health, psychosocial, resource insecurity, and water-dependent dosing mechanistic pathways linked water insecurity to HIV treatment outcomes. In the case–control study, water insecurity was strongly associated with poor HIV treatment outcomes (OR = 3.18, 95% CI: 1.95–5.17; p <0.001; AOR = 3.66, 95% CI: 2.13–6.29, p < 0.001), with no evidence that sex modified the association. Increasing severity of water insecurity was associated with higher odds of poor HIV treatment outcomes, with each 5-point increase in the water insecurity score doubling those odds (OR = 2.05, 95% CI 1.72–2.44; p < 0.001). Water insecurity was highly prevalent among adults on ART and increased the risk of poor HIV treatment outcomes. Multi-sectoral collaboration for strengthening water infrastructure, governance, and adaptive capacities may reduce water insecurity and downstream health impacts. Integrated patient-provider strategies can help sustain HIV care engagement despite structural barriers to treatment continuity. Institutionalization of water insecurity interventions within HIV care may mitigate its impact on HIV treatment outcomes in Kisumu County, while contributing to the global SDGs efforts of eradicating HIV.