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Background: Food insecurity and HIV viral suppression are linked through nutritional, mental health, and health behavior pathways. We examined the effects of a multisectoral agriculture and livelihood intervention on HIV viral suppression and nutritional, mental health, and behavioral outcomes among HIV-positive adults prescribed antiretroviral therapy (ART) in rural Kenya.

Methods: We randomly allocated 8 pairs of health facilities in western Kenya to intervention or control arms. The intervention included a bank loan to purchase farming commodities, including a human-powered irrigation pump, fertilizers and seeds, and training in sustainable agriculture and financial literacy. Eligible participants were≥ 18 years old, living with HIV and on ART> 6 months, and moderately-to-severely food insecure, with access to arable land and surface water. Participants were followed every 6 months for 24 months. The primary outcome was the relative change from baseline to endline in viral load suppression (≤ 200 copies/mL), compared between arms using difference-in-differences analyses. Secondary outcomes included clinic attendance, ART adherence, food insecurity, depression, self-confidence, and social support.

Findings: Between June 2016 and December 2017, we enrolled 366 and 354 participants in the intervention and control arms, respectively. Approximately 55% of participants were female. Retention was 94.0% at the 24-month visit. HIV viral suppression improved in both arms from baseline to endline: intervention 87.9% to 96.2% and control 82.4% to 94.3%(p= 0.86 for difference in differences). The proportion of participants with a …