Agricultural Intervention for Food Security and HIV Health Outcomes in Kenya
Condition: HIV
Study type: Interventional

Summary: 
      The purpose of this study is to determine whether this multisectoral agricultural and
      microcredit loan intervention improves food security, prevent antiretroviral treatment
      failure, and reduce co-morbidities among people living with HIV/AIDS.
    

Detailed description: 
      Despite major advances in care and treatment for those living with HIV, morbidity and
      mortality among people living with HIV/AIDS (PLHIV) remains unacceptably high in sub-Saharan
      Africa (SSA), largely due to the parallel challenges of poverty and food insecurity.[1] In
      the Nyanza Region of Kenya, 15.1% of the adult population is infected by HIV,[2] and over 50%
      of the rural population is food insecure, primarily due to unpredictable rainfall and limited
      irrigation.[3,4] The investigators have previously shown that food insecurity delays
      antiretroviral therapy (ART) initiation, reduces ART adherence, contributes to worse
      immunologic and virologic outcomes, and increases morbidity and mortality among PLHIV.[5-16]
      There has been increasing international recognition that improved food security and reduced
      poverty are essential components for a successful global response to the HIV epidemic.[17-21]
      Yet, to date few studies have systematically evaluated the impacts of sustainable food
      security interventions on health, economic, and behavioral outcomes among PLHIV. Agricultural
      interventions, which have potential to raise income and bolster food security, are an
      important but understudied route through which to sustainably improve nutritional and HIV
      outcomes in SSA, including Kenya where agriculture accounts for > 75% of the total workforce,
      and 51% of the gross domestic product.[22]

      Building on the investigators successful completion of the pilot intervention trial in Kenya
      and the investigators collective experience studying structural barriers to HIV care in SSA,
      the investigators plan to test the hypothesis that a multisectoral agricultural and
      microcredit loan intervention will improve food security, prevent ART treatment failure, and
      reduce co-morbidities among PLHIV. The investigators' intervention was co-developed with
      KickStart, a prominent non-governmental organization (NGO) based in SSA that has introduced a
      human-powered pump, enabling farmers to grow high yield crops year-round. This technology has
      reduced food insecurity and poverty for 800,000 users in 22 countries in the subcontinent
      since 1991.[23] The investigators' intervention includes: a) a loan (~$175) from a
      well-established Kenyan bank for purchasing agricultural implements and commodities; b)
      agricultural implements to be purchased with the loan including the KickStart treadle pump,
      seeds, fertilizers and pesticides; and c) education in financial management and sustainable
      farming practices occurring in the setting of patient support groups. This study is a cluster
      randomized controlled trial (RCT) of this intervention with the following specific aims:

      Aim 1: To determine the impact of a multisectoral agricultural intervention among
      HIV-infected farmers on ART on HIV clinical outcomes. The investigators hypothesize that the
      intervention will lead to improved viral load suppression (primary outcome) and changes in
      CD4 cell count, physical health status, WHO stage III/IV disease, and hospitalizations
      (secondary outcomes) in the intervention arm compared to the control arm.

      Aim 2: To understand the pathways through which the multisectoral intervention may improve
      HIV health outcomes. Using the investigator's theoretical model,[1,24] the investigators
      hypothesize that the intervention will improve food security and household wealth, which in
      turn will contribute to improved outcomes through nutritional (improved nutritional status
      measured with Body Mass Index), behavioral (improved ART adherence, and retention in care),
      and mental health (improved mental health/less depression, improved empowerment) pathways
      (secondary outcomes).

      Aim 3: To determine the cost-effectiveness of the intervention and obtain the information
      necessary to inform scale-up in Kenya and similar settings in SSA. The investigators will
      quantify the cost per disability-adjusted life year averted, and identify lessons to inform
      successful scale-up.

      To accomplish Aims 1 & 2, the investigators will randomize 8 matched pairs of health
      facilities in the Nyanza Region in a 1:1 ratio to the intervention and control arms, and
      enroll 44 participants per facility (total n=704). All participants will be followed for 2
      years. Impacts of the investigator's intervention on primary health outcomes and mediators
      will be investigated to provide definitive data of direct and indirect intervention effects.
      To accomplish Aim 3, the investigators will: a) conduct a cost-effectiveness analysis; b)
      identify the characteristics of individuals most likely to benefit from the intervention
      (e.g., gender, educational attainment, family size, wealth, risk tolerance, and
      entrepreneurial ability); and c) perform a mixed-methods process evaluation with study
      participants, staff, and various stakeholders to determine what worked and did not work to
      guide future scale-up efforts of the intervention.

      The investigator's ultimate goal is to develop and test an intervention to reverse the cycle
      of food insecurity and HIV/AIDS morbidity and mortality in SSA.
    

Intervention name(s): Shamba Maisha Intervention
Intervention type(s): Other
Intervention description(s): A) A loan (~$175) B) Agricultural implements to be purchased with the loan C) Education in financial management and sustainable farming practices
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Other
Keywords: HIV; Food insecurity; Microcredit loan; Agriculture; Livelihoods