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Health and Economic Outcomes Associated With COVID-19 in Women at High Risk of HIV Infection in Rural Kenya

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To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  How have COVID-19 lockdowns factored into the economic well-being, food security, and sexual behavior of vulnerable populations in low- and middle-income countries?

Findings  In this survey study of 1725 women at high risk of HIV infection in rural Kenya, COVID-19 lockdowns were associated with declines in employment, income, and numbers of sexual partners and transactional sex partners. Respondents also reported high levels of food insecurity.

Meaning  These findings suggest that COVID-19 lockdowns may negatively impact the economic well-being of vulnerable populations with limited access to social services but may also temporarily reduce the risk of HIV transmission in these high-risk populations.


Importance  COVID-19 lockdowns may affect economic and health outcomes, but evidence from low- and middle-income countries remains limited.

Objective  To assess the economic security, food security, health, and sexual behavior of women at high risk of HIV infection in rural Kenya during the COVID-19 pandemic.

Design, Setting, and Participants  This survey study of women enrolled in a randomized trial in a rural county in Kenya combined results from phone interviews, conducted while social distancing measures were in effect between May 13 and June 29, 2020, with longitudinal, in-person surveys administered between September 1, 2019, and March 25, 2020. Enrolled participants were HIV-negative and had 2 or more sexual partners within the past month. Surveys collected information on economic conditions, food security, health status, and sexual behavior. Subgroup analyses compared outcomes by reliance on transactional sex for income and by educational attainment. Data were analyzed between May 2020 and April 2021.

Main Outcomes and Measures  Self-reported income, employment hours, numbers of sexual partners and transactional sex partners, food security, and COVID-19 prevention behaviors.

Results  A total of 1725 women participated, with a mean (SD) age of 29.3 (6.8) years and 1170 (68.0%) reporting sex work as an income source before the COVID-19 pandemic. During the pandemic, participants reported experiencing a 52% decline in mean (SD) weekly income, from $11.25 (13.46) to $5.38 (12.51) (difference, −$5.86; 95% CI, −$6.91 to −$4.82; P < .001). In all, 1385 participants (80.3%) reported difficulty obtaining food in the past month, and 1500 (87.0%) worried about having enough to eat at least once. Reported numbers of sexual partners declined from a mean (SD) total of 1.8 (1.2) partners before COVID-19 to 1.1 (1.0) during (difference, −0.75 partners; 95% CI, −0.84 to −0.67 partners; P < .001), and transactional sex partners declined from 1.0 (1.1) to 0.5 (0.8) (difference, −0.57 partners; 95% CI, −0.64 to −0.50 partners; P < .001). In subgroup analyses, women reliant on transactional sex for income were 18.3% (95% CI, 11.4% to 25.2%) more likely to report being sometimes or often worried that their household would have enough food than women not reliant on transactional sex (P < .001), and their reported decline in employment was 4.6 hours (95% CI, −7.9 to −1.2 hours) greater than women not reliant on transactional sex (P = .008).

Conclusions and Relevance  In this survey study, COVID-19 was associated with large reductions in economic security among women at high risk of HIV infection in Kenya. However, shifts in sexual behavior may have temporarily decreased their risk of HIV infection.

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Article Information

Accepted for Publication: April 18, 2021.

Published: June 17, 2021. doi:10.1001/jamanetworkopen.2021.13787

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kavanagh NM et al. JAMA Network Open.

Corresponding Author: Harsha Thirumurthy, PhD, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Dr, Philadelphia, PA 19104 (hthirumu@pennmedicine.upenn.edu).

Author Contributions: Dr Thirumurthy and Mr Kavanagh had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Marcus, Otieno, Agot, Thirumurthy.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Kavanagh, Marcus, Thirumurthy.

Critical revision of the manuscript for important intellectual content: Kavanagh, Bosire, Otieno, Bair, Agot, Thirumurthy.

Statistical analysis: Kavanagh, Bair.

Obtained funding: Thirumurthy.

Administrative, technical, or material support: Marcus, Bosire, Otieno, Agot.

Supervision: Otieno, Agot, Thirumurthy.

Conflict of Interest Disclosures: None reported.

Funding/Support: This research was supported by the National Institutes of Health (grant No. 5R01MH111602) and the Leonard Davis Institute for Health Economics at the University of Pennsylvania.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank all the participants involved in this study, collaborators, and research teams at Impact Research and Development Organization.

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