Social Health Authority Insurance Uptake among PLHIV in Machakos, Kenya: Determinants and Barriers

Abstract

People living with HIV (PLHIV) face high healthcare needs, yet many lack financial protection. Kenya’s Social Health Authority (SHA) insurance program was established to improve access and reduce out-of-pocket costs for vulnerable groups including PLHIV. However, uptake of SHA among PLHIV has remained suboptimal in some regions, limiting the benefits of HIV care programs. This study examined the extent of SHA uptake among PLHIV in Machakos Sub-County and identified factors influencing enrollment. A cross-sectional mixed-methods study was conducted with 386 PLHIV in public health facilities. Quantitative data were collected via structured questionnaires and analyzed for associations between SHA enrollment and socio-demographic factors using chi-square tests and logistic regression. Qualitative interviews with key informants explored barriers to utilization. SHA enrollment was 81.4% (314/386). Uptake was significantly higher among participants with greater socioeconomic resources including higher education, formal employment, and middle-income levels (p<0.01). For example, 94.7% of formally employed PLHIV were enrolled vs. 58.2% of unemployed (p<0.001). Primary self-reported barriers to enrollment were financial constraints (34.0%) and lack of knowledge about SHA (24.0%). Qualitative findings revealed stigma and misconceptions (e.g. viewing SHA as a corrupt or “political” scheme) that discouraged some PLHIV from enrolling. Despite a relatively high coverage in this cohort, socioeconomic disparities and informational barriers limit full utilization of SHA. Targeted interventions such as premium subsidies for low-income PLHIV and community education to raise awareness are recommended to bolster insurance uptake. Strengthening SHA enrollment among PLHIV will support Kenya’s progress toward universal health coverage and improved health outcomes in this population.