Beyond adherence: exploring the persistent role of stigma and disclosure in HIV care in Machakos County, Kenya

Abstract Aim . This study aimed to investigate the levels of HIV-related stigma and discrimination among people living with HIV (PLHIV) in Machakos County, Kenya, and examine their association with adherence to antiretroviral treatment (ART) and HIV status disclosure, with a focus on the social dimensions influencing HIV care and well-being. Methods . A cross-sectional study was conducted in four sub-counties in Machakos County among PLHIV receiving care at project-supported health facilities. Multilevel logistic regression models were applied to evaluate associations between stigma, discrimination, ART adherence, and HIV status disclosure. Results . A total of 1810 PLHIV were included (median age 43.0, IQR: 26.0–53.0; 67.5% female). Overall, 76.7% experienced some form of stigma, with internalized stigma being the most common, particularly among younger individuals, and 19.1% reported discrimination, including within healthcare settings. ART adherence was relatively high (82.6%), and 64.9% reported having disclosed their HIV status to someone. In multilevel logistic regression analysis, stigma and discrimination were negatively associated with ART adherence. In contrast, both stigma and discrimination were associated with a higher likelihood of disclosure. Engagement in positive actions was associated with increased odds of adherence and disclosure. Conclusion . HIV-related stigma and discrimination remain persistent in Machakos County and continue to undermine optimal treatment outcomes and social well-being among PLHIV. Although ART adherence was relatively high, younger individuals and males showed lower adherence to treatment. Stigma—particularly internalized stigma—and discrimination, including within healthcare settings, were negatively associated with adherence. The relationship between disclosure and stigma appeared complex and context-dependent, reflecting both increased vulnerability and potential access to social support. These findings highlight the need for comprehensive and community-responsive interventions addressing stigma in both healthcare and social settings, while strengthening youth-responsive services and supportive environments for PLHIV.