Stigma in the Clinic Strongly Predicts HIV Treatment Interruption in Kenya

Antiretroviral therapy has transformed HIV from a fatal diagnosis into a manageable chronic condition, but the benefits of treatment depend entirely on people taking their medication consistently over a lifetime. A new study from Kenya, published in BMC Infectious Diseases, adds sobering quantitative weight to a message that clinicians and advocates have long voiced anecdotally: stigma, in its many forms, is not merely a social inconvenience but a measurable driver of treatment interruption. Drawing on data from more than 2,100 people living with HIV across eight regions of the country, researchers found that more than one in five participants had interrupted or stopped their antiretroviral therapy at some point in their lives, and that the probability of interruption rose sharply with the level of stigma they had experienced or anticipated.

The investigation was conducted as part of the Kenya Country Assessment under the People Living with HIV Stigma Index 2.0, a standardized, community-led surveillance instrument coordinated globally by networks of people living with HIV. Between February and March 2021, the study enrolled 2,125 participants drawn from both rural and urban settings across Kenya. Because the Stigma Index is administered by and for people living with HIV, it is designed to capture experiences of discrimination and self-stigma that participants might be reluctant to disclose in clinical settings, making it a uniquely sensitive tool for measuring the social environment surrounding treatment.

The research team, led by Yuanqi Mi of the Johns Hopkins Bloomberg School of Public Health together with colleagues at Kenyan community organizations including the International Community of Women Living with HIV, Women Fighting AIDS in Kenya, and the National Empowerment Network of People Living with HIV and AIDS, focused on three distinct forms of stigma. Internalized stigma refers to the adoption of negative beliefs about HIV by people living with the virus themselves, manifesting as shame, self-blame, or a decision to conceal one’s status. Healthcare-related enacted stigma, sometimes called experienced stigma, captures concrete discriminatory behaviors encountered in clinics, such as verbal abuse, denial of care, or breaches of confidentiality. Healthcare-related anticipated stigma measures the expectation that such discrimination will occur, whether or not it actually has. For each participant, the researchers calculated composite scores for each of the three stigma types by summing responses to stigma-specific survey items, and then categorized scores as low, moderate, or high.

The primary outcome was self-reported lifetime interruption of antiretroviral therapy, defined as ever having interrupted or stopped treatment. Of the 2,064 participants with complete data on this outcome, 456 individuals, or 22.1 percent, reported a lifetime interruption. This figure is striking in a country that has made enormous strides in expanding access to treatment, and it underscores the gap between the availability of medication and the consistent use of it. Interrupted therapy carries direct virological consequences: lapses in adherence allow viral replication to resume, driving viral load up, weakening immune recovery, increasing the risk of onward transmission, and creating conditions under which drug resistance can emerge.

To quantify the relationship between stigma and interruption, the researchers used Poisson regression with robust variance estimation, an approach well suited to common binary outcomes because it yields adjusted prevalence ratios that are directly interpretable as relative measures of risk. The models adjusted for potential confounders and compared each level of stigma against the low-stigma reference category. The results were consistent in direction across all three stigma domains. Moderate levels of internalized stigma were associated with a more than doubling of the prevalence of treatment interruption, with an adjusted prevalence ratio of 2.20, while high internalized stigma carried an adjusted prevalence ratio of 2.59, both statistically significant with confidence intervals comfortably excluding the null value.

The strongest signal, however, belonged to anticipated stigma in healthcare settings. Participants reporting anticipated healthcare-related stigma had an adjusted prevalence ratio of 4.09 for treatment interruption, meaning that, on average, the prevalence of interruption was roughly four times higher among those who expected discrimination from health workers compared with those who did not. Experienced healthcare-related stigma also doubled the prevalence of interruption, with an adjusted prevalence ratio of 2.16. The magnitude of the anticipated stigma estimate is the study’s most consequential finding, because it suggests that the fear of mistreatment, even before any actual mistreatment occurs, is enough to keep people away from the clinics and pharmacies where their medication is dispensed.

A central design question of the study was whether these relationships differed across the adult lifespan. Young people living with HIV face a disproportionate burden of new infections and consistently report high levels of stigma, which has led many programs to assume that stigma operates most powerfully on the young. The researchers therefore treated age as an effect measure modifier and stratified the analysis into three groups: adults aged 18 to 34, those aged 35 to 49, and those aged 50 and older. The stratified results showed that the associations between stigma and treatment interruption were generally consistent across age groups, with the single exception of moderate internalized stigma among participants above 50 years of age, where the pattern differed from the other strata.

Crucially, formal statistical interaction tests provided no evidence of effect measure modification by age for any of the three stigma measures. In epidemiological terms, this means the data do not support the idea that stigma drives treatment interruption only, or primarily, among younger adults. Older adults in the study were similarly vulnerable, and the authors conclude that stigma is significantly associated with HIV treatment outcomes across all age groups in Kenya. For program designers, this is an important corrective: interventions to reduce stigma cannot be confined to adolescent- and youth-friendly services but must address the clinical environments that people of all ages navigate.

The study’s authors argue that these findings reveal sustained challenges in achieving the consistent treatment uptake required for long-term viral suppression, a cornerstone of both individual health and population-level epidemic control under the UNAIDS treatment targets. They also point out that measurement of specific types of stigma remains limited in Kenya, which has constrained the ability of programs to target interventions precisely. The pattern of results, with anticipated stigma showing the strongest association, suggests that efforts should focus on the clinical encounter itself. The researchers highlight tailored approaches such as toolkits designed for healthcare providers to reduce healthcare-related stigmas, arguing that such tools may represent a critical component of optimizing HIV treatment programs in the country.

Like all observational, cross-sectional research, the study cannot establish temporality, since stigma and interruption were both measured at a single point in time and interruption was reported over a lifetime. Self-reported outcomes are also subject to recall and disclosure biases, although the community-led Stigma Index methodology is specifically intended to mitigate underreporting. Nevertheless, the size of the enrolled sample, its coverage of rural and urban settings across eight regions, and the consistency of associations across three distinct stigma constructs lend considerable weight to the conclusions. As Kenya and other high-burden countries pursue the final miles of epidemic control, this study makes clear that viral suppression is decided not only in laboratories and pharmacies but in the daily judgments of people weighing whether the clinic will treat them with dignity.

Subject of Research: The association between HIV-related stigma and antiretroviral therapy interruption among adults in Kenya

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

Article References: Mi, Y., Lyons, C., Turpin, G., Dunaway, K., Brion, S., Kibunja, P., Onyango, D., Otwoma, N., Oketch, B., Looze, P., Chiu, F., Anoubissi, J., Syarif, O., Baral, S., & Rao, A. (2026). Assessing the relationship between HIV-related stigma and antiretroviral therapy interruption among older and younger adults in Kenya. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14397-x

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14397-x

Keywords: HIV, antiretroviral therapy, stigma, Kenya, treatment interruption, internalized stigma, healthcare stigma, anticipated stigma, Stigma Index 2.0, viral suppression, epidemiology, BMC Infectious Diseases