A livelihood intervention improved nutritional, mental health and sexual health outcomes among HIV-affected adolescents in western Kenya: results from the Shamba Maisha randomised controlled trial

Introduction Adolescent girls and young women (AGYW), aged 15–24 years, are disproportionately at risk of acquiring HIV in sub-Saharan Africa (SSA). Women and girls accounted for 63% of all new HIV infections in SSA in 2021, with around 4000 AGYW acquiring an infection weekly.1 Girls account for six out of seven new infections among adolescents aged 15–19, and AGYW are three times more likely to be living with HIV compared with similarly aged young men.1 Evidence-based HIV prevention interventions, including providing access to condoms and daily oral HIV pre-exposure prophylaxis, HIV risk reduction counselling and routine testing for HIV and sexually transmitted infections (STIs), have not meaningfully reduced HIV incidence among AGYW at the population level in many countries, including Kenya.2 These clinic-based interventions are unable to address upstream factors that shape the risk context for AGYW, highlighting an opportunity for additional multipronged HIV prevention approaches that meet the needs of AGYW and thereby support UNAIDS targets to end the HIV epidemic by 2030.3 The gender disparity in HIV vulnerability among adolescents is strongly shaped by household and structural factors, chief among them food insecurity (FI), poverty and gender inequality.4 5 Food-insecure and impoverished AGYW are more likely to be disempowered and to have worse sexual and reproductive health (SRH) outcomes, including higher rates of early sexual debut, inconsistent condom use, transactional sex, forced sex, STIs, HIV and unintended pregnancies.4 6–11 Living in an HIV-affected household is also associated with HIV-related and other health risks; adolescents that have lost one or both parents to AIDS or reside with an adult caregiver with HIV/AIDS are more likely to experience poverty,12 sexual risks13 and poor psychological well-being.14 Poverty and FI are both highly prevalent in SSA, with an estimated 490 million people living on less than US$1.90 a day,15 and over 60% of the population facing moderate or severe constraints on their ability to obtain sufficient food.16 A growing FI gap by gender highlights that this situation is especially acute among women and girls, particularly those from poor households and those living with HIV and in HIV-affected households.17 18 This body of research reinforces that upstream risk drivers, such as poverty and FI, are important targets of intervention to improve SRH and other health outcomes among AGYW. Recent systematic reviews and studies have demonstrated the need for a shift towards multilevel interventions and away from individual-centred interventions, given that the latter has a limited ability to change the underlying context that shapes vulnerability and risk.19–22 For adolescents, intervening on the risk context may be especially effective at the household level since they may have little power over their decisions on how to use household resources.23 Yet, few multicomponent interventions to improve adolescent girls’ SRH and reduce their HIV risk have been implemented at the household level, and limited research has examined interventions with combined FI and livelihood components. Many structural interventions with economic components among adolescent girls have combined skills training with economic empowerment, with mixed results. While some showed positive impacts on SRH-related outcomes, including reduced sexual risk-taking intentions,24 25 HIV infection,26 unprotected sex,27 28 unintended pregnancy and transactional sex,27 and others showed no impact on sexual risk intentions29 or on HIV/STI infections.30 31 Some also reported adverse effects, including increased sexual coercion and physical abuse.32 33 This highlights the potential hazards of promoting individual asset building with AGYW in precarious economic environments without considering the supports they may need from their household and community. Structural interventions that stimulate income growth at the household level may therefore be ideally suited to support vulnerable AGYW and allow them to realise the full benefits of multicomponent interventions. Since FI in many regions of SSA is shaped by the combined effects of extreme poverty, environmental change and insufficient agricultural output and distribution, agricultural interventions hold particular promise as a way to improve household FI and wealth.34 35 This may be especially so as climate change impacts become more widespread and severe in SSA and increase the risk of substantial agricultural and livelihood disruptions among already vulnerable populations, chiefly the women who constitute almost 50% of the agricultural labour force and largely work as smallholder farmers.36 To our knowledge, the impacts of an agricultural and livelihood intervention on SRH risk-related outcomes among AGYW have not yet been evaluated. Our study was a cluster randomised control trial (RCT) that evaluated the effects of Shamba Maisha (SM), a climate-adaptive agricultural livelihood intervention aimed at improving HIV-related health outcomes among adults living with HIV in western Kenya. We examine whether this intervention improved the FI and mental health of AGYW-caregiver pairs and the SRH of the AGYW living in SM households. We hypothesised that AGYW living in households participating in the intervention would experience improvements in FI, mental health and SRH.