Assessing the relationship between HIV-related stigma and antiretroviral therapy interruption among older and younger adults in Kenya

Stigma has been consistently shown to be associated with suboptimal HIV treatment outcomes among people living with HIV (PLHIV). Young people face a disproportionate risk of new infections and report high levels of stigma. However, there has been limited study in Kenya evaluating associations between stigma and antiretroviral therapy (ART) interruption and how these relationships vary by age. In response, we aimed to describe the relationships between internalized stigma, healthcare-related enacted stigma, and healthcare-related anticipated stigma with ART interruption including differences by age among PLHIV in Kenya. Data were collected as part of the Kenya Country Assessment under the People Living with HIV (PLHIV) Stigma Index 2.0. 2,125 PLHIV from rural and urban settings across eight regions in Kenya were enrolled from February to March, 2021. The primary outcome was self-reported lifetime ART interruption defined as ever having interrupted or stopped ART treatment. Composite scores for the three primary exposures: internalized, healthcare-related anticipated, and healthcare-related experienced stigma were calculated as the sum of responses to stigma-specific items. Age was treated as an effect measure modifier and people were categorized into 3 groups: 18–34, 35–49 and 50 + years old. Poisson regression models with robust variance estimation for the relationship between the three HIV-related stigma indicators and antiretroviral treatment interruption were conducted overall and stratified by age group. More than 1 in 5 (22.1%, 456/2,064) PLHIV experienced a lifetime ART interruption in our study. Overall, moderate (adjusted prevalence ratio, aPR = 2.20; 95% CI: 1.81, 2.68) and high (aPR = 2.59; 95% CI: 2.12, 3.17) levels of internalized stigma were positively associated with ART interruption compared with low internalized stigma. Healthcare-related anticipated stigma (aPR = 4.09; 95% CI: 3.55, 4.72) and healthcare-related experienced stigma (aPR = 2.16; 95% CI: 1.84, 2.53) were also positively associated with ART interruption. In analyses stratified by age, associations were generally consistent across age groups, with the exception of moderate level of internalized stigma among participants aged above 50 years. Formal interaction tests provided no evidence of effect measure modification by age for any of the three stigma measures. These data suggest sustained challenges in facilitating consistent treatment among PLHIV as a means of achieving long-term viral suppression. Internalized stigma, healthcare-related anticipated and experienced stigma all are significantly associated with HIV treatment outcomes for PLHIV across all age groups in Kenya, with healthcare-related anticipated stigma showing the strongest association. Measurement of specific types of stigma remains limited in Kenya, which highlight the importance of addressing multiple forms of HIV-related stigma, with particular attention to anticipated stigma within healthcare settings. Tailored approaches like toolkits designed for healthcare providers to reduce healthcare-related stigmas may represent a critical part of optimizing HIV treatment programs in Kenya.