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Little is understood about how people perceive or experience the mechanisms by which extreme weather events affect the health of people living with HIV (PLHIV). We conducted a qualitative study using in-depth, semi-structured interviews with 40 PLHIV enrolled in a cluster randomized clinical trial that included 8 pairs of health facilities in rural Western Kenya, who were 18 years or older, receiving ART for &gt;\u20096 months; had moderate to severe food insecurity; and practiced smallholder farming with access to surface water or aquifers. Intervention participants received a loan to purchase an irrigation pump and farming inputs and were provided climate-responsive, sustainable agriculture and financial literacy training. This study did not evaluate the impacts of the clinical trial. We aimed to understand participant perceptions of how climate change impacted their HIV health, and associated pathways for these impacts. Interviews were transcribed, translated, and double coded using an inductive-deductive-abductive thematic content approach. Almost all participants noted that droughts, flooding, and elevated temperatures had serious negative impacts on their health and wellbeing. Extreme weather negatively impacted their health via five key pathways, with the first being most prominent: (1) decreases in agricultural yields and income; (2) increased food insecurity and undernutrition; (3) medication non-adherence, missed clinic visits, and infrastructure erosion; (4) increased infections, and (5) displacement and forced migration. Several pathways were interrelated, with decreased agricultural yields and income being proximal to most other pathways. Participants perceived pathways by which severe weather negatively impacted their HIV health, and these pathways were bi-directional and reinforcing. Food and livelihood sources were devastated, and housing and infrastructure were negatively affected, causing a cascade of nutrition and health vulnerabilities. Understanding the contexts in which PLHIV are vulnerable to impacts of climate change will be essential to establish climate-responsive policies that can interrupt the pathways identified here. Cross-sector collaboration between the Kenyan Ministries of Agriculture and Health to develop climate-responsive policies to support PLHIV should be prioritized. The clinical trial start date was June 23, 2016. Trial Registration: Registered with ClinicalTrials.gov Identifier: NCT02815579.<\/jats:p>","DOI":"10.1038\/s41598-026-52085-7","type":"journal-article","created":{"date-parts":[[2026,5,8]],"date-time":"2026-05-08T14:06:18Z","timestamp":1778249178000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Pathways between climate change and HIV health in rural Kenya: a qualitative analysis"],"prefix":"10.1038","volume":"16","author":[{"given":"Tammy M.","family":"Nicastro","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gladys","family":"Odhiambo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stanley","family":"Jawuoro","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elly","family":"Weke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth A.","family":"Bukusi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yihui A.","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helen A.","family":"Harris-Fry","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Suneetha","family":"Kadiyala","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheri D.","family":"Weiser","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,5,8]]},"reference":[{"key":"52085_CR1","unstructured":"Hallegatte, S. et al. 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