HIV care engagement and ART adherence among Kenyan gay, bisexual, and other men who have sex with men: a multi-level model informed by qualitative research

ABSTRACT

Gay, bisexual, and other men who have sex with men (GBMSM) are highly stigmatized and male–male sex is often criminalized in sub-Saharan Africa, impeding access to quality care for sexual health, HIV prevention, and treatment. To better understand HIV care engagement and antiretroviral therapy (ART) adherence among GBMSM in this context, a conceptual model incorporating sociocultural factors is needed. We conducted a qualitative study of barriers to and facilitators of HIV care engagement and ART adherence among Kenyan GBMSM, informed by a conceptual model based on an access, information, motivation, and behavioral skills (access-IMB) model, with trust in providers and stigma and discrimination as a priori factors of interest. We conducted 30 semi-structured interviews with HIV-positive Kenyan GBMSM, of whom 20 were taking ART and 10 had not yet initiated treatment. A deductive approach was used to confirm the relevance of basic concepts of the access-IMB model, while an inductive approach was used to identify content that emerged from men’s lived experiences. Access-related information, motivation, and behavioral skills appeared relevant to HIV care engagement and ART adherence, with stigma and discrimination appearing consistently across discourse exploring facilitators and barriers. Trusted providers and supportive family and friends helped many men, and resilience-related concepts such as selective disclosure of GBMSM status, connection to lesbian, gay, bisexual, and transgender (LGBT) organizations, self-acceptance, goal-setting, social identity and altruism emerged as important facilitators. Findings suggest a need to increase support from providers and peers for Kenyan GBMSM living with HIV infection. In addition, they point toward the potential value of interventions that provide opportunities to build or enhance one’s sense of community belonging in order to improve HIV care engagement and promote ART adherence for this vulnerable population.

KEYWORDS:

• HIV/AIDS
• men who have sex with men
• antiretroviral therapy
• treatment adherence
• social stigma
• social discrimination
• resilience

Acknowledgements

First and foremost, we thank our study participants for their contribution to a better understanding of their lived experiences. We thank the staff of the HIV/STI project at the KEMRI-Wellcome Trust Research Programme in Kilifi for their commitment to serving GBMSM. We are also grateful for support and guidance provided by the KWRTP to carry out research with stigmatized and vulnerable populations. The views expressed in this publication are those of the authors and do not necessarily represent the official views the United States Government. This report was published with permission from the Director of the KEMRI-Wellcome Trust Research Programme.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Susan M. Graham http://orcid.org/0000-0001-7847-8686

Additional information

Funding

Support for this study was provided by NIH [grant number R34MH099946] (PI: SMG). JMS was supported by NIH [grant number K24 MH093243] (https://projectreporter.nih.gov/project_info_description.cfm?aid=8698463&icde=40900088&ddparam=&ddvalue=&ddsub=&cr=5&csb=default&cs=ASC&pball=). DO was supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development [grant number R24 HD07796]. The KWRTP at the Centre for Geographical Medicine Research-Kilifi is supported by core funding from the Wellcome Trust [grant number #203077/Z/16/Z]. Additional infrastructure funding was provided by the University of Washington Center for AIDS Research, an NIH funded program [grant number P30 AI027757] supported by the following NIH Institutes and Centers (National Institute of Allergy and Infectious Diseases (NIAID), National Cancer Institute (NCI), National Institute of Mental Health (NIMH), National Institute on Drug Abuse (NIDA), National Institute of Child Health and Human Development (NICHD), National Heart, Lung, and Blood Institute (NHLBI), National Institute on Aging (NIA), National Institute of General Medical Sciences (NIGMS), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)). Our work with GBMSM has also been funded by the International AIDS Vaccine Initiative (IAVI) with the generous support of The U.S. Agency for International Development and other donors; a full list of IAVI donors is available at http://www.iavi.org/what-we-do/partner/donors.