Examining pathways between stigma, extreme weather exposure, resource insecurities and ART adherence among young men who have sex with men and female sex workers living with HIV in Kampala, Uganda

Objectives Stigma is multidimensional and undermines HIV care. We examined socio‐environmental pathways linking HIV‐related stigma, everyday discrimination and structural stigma to antiretroviral therapy (ART) adherence among men who have sex with men (MSM) and female sex workers (FSW) living with HIV in Kampala, Uganda. Methods We conducted a cross‐sectional survey (06/2024–02/2025) among MSM and FSW aged 18–35 receiving HIV services from a key population clinic in Kampala. ART adherence was assessed using the Wilson 3‐item adherence scale. We conducted stratified multivariable linear regression and multi‐group structural equation modelling (SEM) to estimate direct and indirect associations from stigma to adherence through socio‐environmental stressors (traumatic exposure severity to extreme weather [TESS], food insecurity, water insecurity), adjusted for socio‐demographic variables. Results Participants included MSM ( n = 225, mean age: 27.65, standard deviation [SD] = 3.54) and FSW ( n = 240, mean age: 25.68, SD: 2.90). SEM showed acceptable fit. In adjusted SEM analyses (a) among MSM, higher TESS, HIV‐related stigma and everyday discrimination were directly associated with lower ART adherence and (b) among FSW, higher TESS, HIV‐related stigma, water and food insecurity were directly associated with lower ART adherence. There were significant indirect associations between HIV‐related stigma and ART adherence via TESS for FSW and MSM, and between everyday discrimination and structural stigma with ART adherence via TESS for MSM. Conclusions Stigma and socio‐environmental stressors, including traumatic exposure to extreme weather events, were associated with reduced ART adherence among MSM and FSW participants. Population‐tailored HIV care interventions may benefit from integrating intersectional stigma reduction with economic and disaster preparedness supports.