The Role Of Culture In The Spread Of Hiv/Aids Amongst The

The Role Of Culture In The Spread Of Hiv/Aids Amongst The Luo People Of Kenya

Lewnida Sara

In partial fulfilment for the award of masters of art degree in disaster management

Date of submission:

Table of Contents

INTRODUCTION……………………………………………………………………………………………………………………………………………………….. 3

Background…………………………………………………………………………………………………………………………………………………………. 3

The Kenyan HIV Context…………………………………………………………………………………………………………………………………… 6

     HIV Prevalence rate in Kenya, by region…………………………………………………………….…………..……….. 7

The Study Context………………………………………………………………………………………………………………………………………….. 12

Objectives of the Study…………………………………………………………………………………………………………………………………… 15

Research Questions…………………………………………………………………………………………………………………………………………. 16

Problem Statement………………………………………………………………………………………………………………………………………….. 17

RISK FACTORS SPREADING HIV/AIDS IN NYANZA PROVINCE………………………………………………………………………….. 20

Gender Inequity and HIV prevalence…………………………………………………………………………………………………………… 21

Poverty and HIV Prevalence…………………………………………………………………………………………………………………………. 25

Widow Inheritance………………………………………………………………………………………………………………………………………… 26

Widow Cleansing…………………………………………………………………………………………………………………………………………… 30

Male Circumcision…………………………………………………………………………………………………………………………………………. 33

Polygamy………………………………………………………………………………………………………………………………………………………… 38

Cultural Interactions……………………………………………………………………………………………………………………………………… 40

Culture as a Positive Influence on HIV/AIDS..…………………………….…………………………………………………….. 42

METHODOLOGY……………………………………………………………………………………………………………………………………………………… 44

Study Design and Variables…………………………………………………………………………………………………………………………… 46

Cultural Factors Influencing the Prevalence of HIV…………………………………………………………………………………….. 47

Exercise of Authority /influence on inter partner /inter-spouse Sexuality………………………………………………. 47

Existing HIV policies and Programmes………………………………………………………………………………………………………… 48

Study Area…………………………………………………………………………………………………………………………………………………………. 48

Target Population……………………………………………………………………………………………………………………………………………. 49

Sampling Frame……………………………………………………………………………………………………………………………………………….. 49

Sampling……………………………………………………………………………………………………………………………………………………………. 50

Data Collection methods………………………………………………………………………………………………………………………………… 51

Ethical Considerations……………………………………………………………………………………………………. 52

Data Analysis……………………………………………………………………………………………………………………………………………………. 53

Study Limitations and Constraints……………………………………………………………………………………………………………….. 53

BIBLIOGRAPHY……………………………………………………………………………………………………………… 54

 

 

Chapter 1: INTRODUCTION

1.1. Background

UNDP (2004) define disasters as a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses, which exceed the ability of the affected community, or society to cope using its own resources. Of all the disasters that Africa has had to deal with, the worst that the continent has experienced to date is the HIV/aids scourge, as Cohen (1999) has noted.

HIV and AIDS have fronted a multi-pronged attack, damaging the continent’s social fabric, its economy, health systems, and its workforce, amongst other sectors. It is widely believed that about 30 million people are HIV positive in the world, with an estimated 22 million coming from Sub-Saharan Africa. According to UNAIDS (2008), an estimated 1.9 million people from Sub-Saharan Africa got infected with the disease in 2007 alone. During the same year, an estimated 1.5 million Africans succumbed to the illness. Overall, the AIDS pandemic has left behind more than 11.6 million orphans as observed by Avert, (2008).

For Africa, already affected by a plethora of challenges, HIV/AIDS has had devastating effects with a far-reaching impact on all spheres of life on the African continent. Households, hospitals, workplaces, schools, and economies have all been significantly affected. For instance, hospitals are overwhelmed by the high demand for care for people living with HIV. Households are disintegrating as parents die, leaving behind siblings who are barely old enough to care for themselves. These children are forced to undergo hardships and trauma because AIDS forces the children to take on the extra responsibilities of earning an income and heading households. In some instances, the disease has damaged the education sector to a point of collapse, thereby entrenching the cycle of poverty. (Avert 2008).

Some analysts and stakeholders, especially in the Western world, argue that the root cause of the above effects is the deep-seated cultural practices found among the African communities (Fauci et al 1998). According to these sources, for the war against the AIDS pandemic in the African continent to be won, communities have to fight such cultural practices as female genital mutilation (FGM), wife exchange and sexual cleansing, as these have been seen to contribute to the high prevalence rates of HIV/Aids in Africa.

On the other hand, other observers hold the view that targeting the apparently harmful traditional practices of these communities is the wrong way to go about HIV/AIDS prevention programs, because the eradication of such practices would not in any way ensure the protection of communities, and because they are not incompatible with a safer behaviour (National AIDS Control Council 2000). In any case, the West itself has some high-risk behaviour such as homosexuality and what would be termed “serial monogamy” as opposed to Africa’s outright polygamy.

Notwithstanding the different opinions offered, what cannot be debated is that the AIDS scourge has continued to wreak havoc, particularly in Sub-Saharan Africa. However, both the numbers of people dying from AIDS and HIV prevalence rates, vary greatly amongst countries located in this region. According to the Avert report (2008), HIV prevalence in Senegal and Somalia is below one percent of the adult population. A confounding factor in the culture debate is that both these nations, being largely Moslem, permit polygamy (up to four wives). Senegal is also the only country in Africa to have legalized prostitution. In Kenya, for instance, the lowest HIV prevalence rate is found in the North Eastern Province, a province that is mainly Moslem. Could religion perhaps be a key factor that influences the spread of HIV and AIDS?

In South Africa, Namibia, Zimbabwe and Zambia, approximately 15-20 percent of the adult population is infected with HIV. Swaziland is presumed to have the highest national adult HIV prevalence rate, at 26.1 percent, then Botswana, at 23.9 percent, and Lesotho, with 23.2 percent (CIA Factbook 2008), as indicated by the table below.

Table 1: HIV/AIDS prevalence by country for the year 2008

Source: CIA Factbook (2008)

Some of the socio-cultural practices and attitudes mentioned above are responsible for the high HIV prevalence rates recorded in these countries.  In addition to the said harmful cultural practices, the situational analysis also identified inhumane burial rites and practices that deny girls and women their rights to education and economic development as key contributing factors to the high HIV prevalence rate in Sub-Sahara Africa. Accordingly, those responsible for managing the scourge must make all efforts to ensure that such practices are changed (CAPA 2008).

1.2. the kenyan context – AN OVERVIEW

 Kenya is one of the Sub-Saharan Africa countries that have been hardest hit by HIV and AIDS. At its onset, HIV was not considered a serious threat to the nation. However, the AIDS pandemic began to spread rapidly in the early 1990s. To date, approximately 2 million Kenyans have been infected by the disease. About 1 million of the HIV-positive people are women, with children accounting for nearly 180 000 people. It is estimated that the scourge has decimated approximately 130 000 people in Kenya, leaving behind around 1.4 million orphans (Avert 2008).

When the virus was identified in this East African nation in the mid-eighties, scholars and researchers loudly dismissed it as a “disease of the West invented to scare Africa” (Nzioka & Ramos 2008: 27). During the initial stages, HIV/AIDS was associated with homosexuality and commercial sex workers. These groups of people were viewed by society as lacking in morals, and thus it was justified for them to pay back for their sins through contracting the disease. At no point in time did heterosexuals believe that they could become victims of the scourge, and that its prevalence rate would be so great. According to Kaiser Daily HIV/AIDS Report (2008:12), prevalence is “a measure of the total burden of disease including new and old infections”.. Prevalence can decrease or increase based on a number of factors including the mortality rate, the rate of new infections, and the length of time individuals are able to survive the infection based on available treatments.

After the first HIV-related case was reported in Kenya in 1985, the government moved with speed to form the National AIDS Committee in 1986, charged with the responsibility of advising the minister of health (MOH) on issues related to HIV/AIDS management and control (Nzioka & Ramos 2008). During the same year, the MOH came up with policy guidelines on blood safety that were previously non-existent. However, the Seventh National Development Plan of 1994 was the government’s major policy paper on HIV/AIDS in Kenya after the scourge started to spread at an alarming level. The section on HIV/AIDS was mainstreamed in all district development plans. In September 1997, a national HIV/AIDS policy /sessional paper No. 4 (1997) was launched.

When the scourge threatened to spill out of control, particularly in Nyanza province, former President Daniel Arap Moi, in November 1999, declared HIV/AIDS a national disaster , consequently unlocking national and international efforts to combat the disaster. Due to concerted efforts made by the government and donors, the trend stabilized at the turn of the Millennium, and in fact dropped to 6.7 percent as shown by the Kenya Demographic and Health Survey conducted in 2003 (Okwemba 2008). Extensive campaigns that encouraged abstinence, faithfulness and condom use were conducted throughout the country from informal settings like open-air markets to the more formal ones such as institutions of higher learning to create awareness and to educate the communities on the dangers of practicing unsafe sex. The campaigns indeed bore fruit when a study conducted in 2006 demonstrated that the national HIV prevalence rate had dropped to 5.1 percent. Prior to this announcement, awareness campaigns were being poorly managed and coordinated, and people feared to talk about the disease in public. AIDS patients were being stigmatized by society and therefore feared to come forward to reveal their status. When declaring AIDS as a national disaster, the former Head of State proposed that AIDS education be offered in schools and colleges to create awareness among students.  Free television and radio time was also to be offered for AIDS awareness broadcasts. However, the government was at that time reluctant to promote condom use as a preventive measure (National AIDS Control Council 2000).

Coinciding with the declaration was the establishment of the National AIDS Control Council (NACC), charged with the responsibility of overseeing overall leadership, management, and coordination of all efforts geared towards curtailing the spread of the pandemic in a multi-sectoral response (Nzioka & Ramos 2008). Its immediate task was to prepare the Kenya National HIV/AIDS Strategic Plan that was later published in December 2000. According to Nzioka and Ramos (2008: 68), the Plan “provided a sound institutional framework for integrating the HIV/AIDS issues into all core processes of government in Kenya.” The primary targets of the Marshall Plan included:

  • Reduction of HIV/AIDS prevalence rate by 20-30 percent by the end of 2005.
  • Increased access to care and support for individuals infected or affected by the disaster.
  • Reinforced institutional capacity and coordination to respond to HIV/AIDS at all levels across the nation.

The NACC’s mission seems to have been achieved relatively well. By the end of 2007, 95 percent of the adult population in the country knew the basics of HIV and its modes of transmission. By January 2006, 65 000 HIV positive patients were receiving free antiretroviral therapy, up from a meagre 2 000 recorded in 2003. This was made possible through government funding, together with other international donors like the Global Fund to Fight AIDS, TB and Malaria (GFATM), President’s Emergency Plan for AIDS Relief (PEPFAR), and the Clinton Foundation (Nzioka & Ramos 2008). The national HIV prevalence rate dropped from a high of over 10 percent in 1997 to a low of 5.1 percent in 2006 (Okwemba 2008). However, surprisingly, the gains made over the years were reversed when the Kenya AIDS Indicator Survey [KAIS] conducted in 2007 showed that Kenya’s national HIV/ AIDS prevalence rate had indeed increased to nearly 8 percent, with Nyanza recording the highest provincial prevalence rate of 15.3 percent.

To date, the Kenyan government through NACC, MOH, and other interested parties continue to advocate four HIV management approaches, popularly known as “ABCC” (Okwemba 2008): Abstinence, Being faithful, Condom use, and Circumcision. The latter approach, circumcision, was incorporated into the mainstream HIV management approaches in 2008, and a policy paper drafted calling on all willing males to undergo the procedure. In the circumcision policy, the government stressed that circumcision should be considered as part of a comprehensive prevention package and should not in any way replace the other effective HIV prevention and management strategies. Regarding condom use, the government met with a lot of resistance in its promotion as an effective HIV prevention method especially from religious leaders (Mbugua et al. 2005). However, condom use remains one of the most widely used HIV prevention strategies in Kenya today.

1.2.1 HIV Prevalence rate in Kenya

Kenya is made up of eight provinces, namely Rift Valley, Western, Eastern, Nyanza, Central, North Eastern, Coast and Nairobi, which amongst them are home to about 42 ethnic communities. According to the recent KAIS survey (cf. Figure 1.0), Nyanza leads in HIV prevalence rate, with 15.3 percent of the people testing HIV positive, followed by Nairobi (9.3%), Coast (7.9%), Rift Valley (7.0%), Eastern (4.7%), Central (3.8%), and North Eastern (1.0%).

Figure 1.0: HIV Prevalence rate in Kenya by province for 2007

                                                  Source: KAIS (2007)

In terms of gender, females between 15-64 years of age recorded a HIV prevalence rate of 8.7 percent compared to 5.6 percent among males in the same age group, in 2007.  In urban areas, females between 15-49 years of age had a HIV prevalence rate of 11.1 percent, far outrunning their male counterparts who recorded a 6.4 percent prevalence rate. In the rural parts of Kenya, the same trend was noted, with females leading with 8.7 percent compared to males on a 5.7 percent HIV prevalence rate. Uncircumcised men were 3 to 5 times more likely to have HIV than circumcised men of between 15-64 years of age (Kaiser Daily HIV/AIDS Report 2008).

Table 1.0 shows HIV prevalence rates in Kenya by sex and marital status. (For men and women who were tested)

 

Table 2: HIV Prevalence Rates among Kenyans aged between 15-64 years by sex and marital status by 2007

Marital Status

(15-64 yrs)

Female

(% rate)

Male

(% rate)

Total

(% rate)

Currently in union

Monogamous

Polygamous

7.8

7.1

11.2

7.4

7.0

11.4

7.6

7.1

11.3

 Currently not in union

Currently widowed

Currently divorced/ separated

10.3

20.7

17.1

3.2

19.3

6.4

7.1

20.5

13.7

Never in Union

Ever had sex

Never had sex

4.7

7.3

1.8

2.2

2.8

1.1

3.3

4.6

1.5

                                                  Source: KAIS (2007)

 

An immediate interpretation of the information above conveys the findings that the main medium of transmission of HIV in Kenya is through sex, amongst males and females that are not in union. When interpreted along gender lines, women are at a higher risk given their physiological nature and harmful traditional practices such as widow inheritance, as one man can infect several women, especially when seen against the background of widow inheritance.

1.2.2 Study Context

Of the approximately 42 ethnic communities to be found in Kenya, the Luo form the 3rd largest, after the Kikuyu and the Luhya, thereby comprising approximately 12 percent of the national population of Kenya, as shown by the table below:

Table 3: Main Kenyan ethnic groups, along with population estimates 2007

Percent of population
Kikuyu 22
Luhya 14
Luo 13
Kalenjin 12
Kamba 11

                       Source: Library of Congress, Country Profile: Kenya (2007)

Kenya undertakes a population census every 10 years, with the next one due in August 2009.Going by the 1999 national census projections, the Luo may be numbering approximately 3.5 million (Daily Nation 2000). The Luo tribe has spread its populace beyond Kenya, into neighbouring Sudan, Uganda, and Tanzania. The main economic activity among the Luo revolves around fishing, though many have now taken on farming activities to supplement the income they get from fishing.  On the Kenyan side, the majority of community members reside in Nyanza province, one of the eight provinces of Kenya. The administrative centre of the province is Kisumu City, the third largest city in Kenya after Nairobi and Mombasa.

The Luo, who belong to the Nilotic group, migrated from Sudan into present-day Kenya and Tanzania between 1500 and 1800 A. D, and settled in the area on the banks of Lake Victoria (Cohen & Odhiambo 1989: 33). Formally pastoral nomads, the Luo today are agriculturalists and fishermen, who depend on the lake for their daily bread. There is evidence to underscore the strong association of the Luo to both river and lake (Onyango-Ogutu & Roscoe 1974: 15) and their use of descriptive words such as nyarnam (daughter of the Lake) to distinguish themselves from others. The mainstream language in the area is known as Dholuo.  The Luo are known to be a proud people who value their language and culture. This is juxtaposed with the fact that Luo Nyanza boasts a large proportion of the most widely read and acclaimed personalities in the nation. The community holds formal education in high esteem, and boasts a significant proportion of medical and philosophical doctors, professors, teachers, nurses, and other white-collar jobholders. It does not think much of blue-collar occupations, and endeavours to send its children to achieve as high a formal educational level as possible, with a view to securing top white-collar jobs. This view of the Luos’ high estimation of education is supported by a study conducted by Parkin who states that “Luo families have been urged to seek salvation through education, with entrepreneurship increasingly ruled out as a possibility in Nairobi” (Odundo & Owino 2004: 27). Those who have managed to pursue their education to university level, especially overseas universities and in particular, the United Kingdom and the United States, are especially revered.  This reverence of education dates back generations, as can be attested to by Parkin, who further states of the Luo: “when we compare the families of other ethnic groups in Kaloleni, we see how pronounced is the Luo propensity to locate their children in Nairobi, primarily to give them education and training” (2004: 47). Nevertheless, contrary to expectations, these high education levels have not diminished much the hold of cultural practices and reverence of tradition. Without the advent of HIV, this reverence of tradition is not in itself a negative attribute – to the contrary, it should be upheld. However, since the advent of HIV, stakeholders involved in the fight against the disease have painstakingly attributed the high prevalence rate witnessed in the region to harmful cultural practices that the Luo continue to espouse. By 1997, the HIV prevalence rate within Kisumu city had surpassed 26 percent (Glynn et al. 2007).

1.3 Objectives of the Study

1.3.1. Overall Objective

The study sets out to establish the socio-cultural factors responsible for the continued rapid spread of HIV/AIDS in Nyanza Province in Kenya, which may be negatively impacting the effectiveness of HIV management and control programmes in the region.

The specific objectives of the study are to:

  1. identify the socio-cultural factors which contribute to the high HIV/AIDS prevalence rate in Nyanza Province;
  2. evaluate knowledge levels of the local population towards harmful cultural practices that are popular in the region;
  3. determine the vulnerable and affected groups by age, gender, and level of education.

1.4. Research Questions

The study will be guided by the following research questions

  • What are the attitudes and perceptions held by the Luo on their deep attachment to tradition and cultural practices?
  • What is the nature of Luo cultural practices and what role do these practices play in the spread of HIV/Aids in the region?
  • What is the level of awareness of the methods of transmission, management, and mitigation of HIV/AIDS amongst members of the Luo?
  • How may improved knowledge and understanding of the local cultural practices contribute to the management of HIV/AIDS as a national disaster in Kenya?

 

 

1.5 Problem statement

HIV/AIDS has become a serious threat to the socio-economic prosperity and human capital of many developing nations around the world. The HIV virus is known to affect individuals during their most economically productive years, at an age when they are most needed for raising their children, with implications extending well into the future (UNAIDS/ UNESCO 2000). For the last two decades, many nations have committed enormous resources to scientific research in efforts aimed at finding a lasting solution to the menace.

UNAIDS/ UNESCO (2000) gives one of the best outlines of the interactions between culture and development. The report quotes the anthropological definition of culture used by UNESCO: “…a set of distinctive, spiritual and material, intellectual and emotional characteristics, which define society or social group…it encompasses ways of life, the fundamental rights of the person, value systems, traditions and beliefs” (UNAIDS/UNESCO 2000: 12). More importantly, the joint report  further points out that with regard to HIV/AIDS prevention and care, “a cultural approach means that any population’s cultural specificities: ways of life, value systems, traditions and beliefs…will be considered as key references for policy and planning in prevention and care”. And further, that the said cultural specificities “…will be seen as resources and a framework for action, in order to obtain in-depth and long-term changes in people” (UNAIDS/UNESCO 2000: 8). In Kenya, the Government, together with other interested stakeholders. have been involved in the search for a vaccine and multidisciplinary programmes aimed at containing the spread of the disease. Since the search for a viable cure has not borne fruit, the most commonly used strategies include advocacy for behaviour change and sensitization programmes for awareness creation. As a direct result of the campaign programmes, 95 percent of Kenyans are aware of the nature of HIV and its modes of transmission (UNAIDS/ UNESCO).

What is worrying is that these behaviour change campaigns have not yielded much in Nyanza province as evidenced by the stark difference in prevalence rates between Nyanza province and the other seven provinces of the country.   The situation has drawn the interest of many scholars, researchers, and analysts. Various studies indicate that over 80 percent of the HIV transmissions in Kenya occur through sexual contact (Odundo & Owino 2004: p7). Yet, for local communities such as the Luo and Kuria, sex as a ritual is deeply entrenched in culture. For example, among the Luo, the start of every planting season, or the move to a new home, is marked by sexual intercourse between the man and his first wife. In Kenya, different ethnic groups exhibit diverse cultural beliefs and practices. Some of these practices such as widow cleansing, widow inheritance, male and female circumcision, and polygamy encourage behaviours that put people at risk of contracting and transmitting HIV (Njeru, Mwangi, & Ndunge 2004:1; Ntozi et al. 1999).  According to Ocholla-Ayayo and Muganzi (2003), in order to understand the spread of HIV/AIDS better, it is imperative to examine socio-cultural attributes such as types and forms of sexual association, marriage patterns, widow inheritance, socio-economic aspects, and power relations among men and women, especially regarding negotiation for safer sex.

Even though the pandemic has attracted multidisciplinary studies and multicultural responses, information on socio-cultural reasons for the lack of behaviour change, especially in Nyanza Province, remains scanty. Furthermore, few studies have assessed the effectiveness of the policies and management of the HIV disaster in Nyanza Province, including the recently launched policy on male circumcision. In other words, very few studies have been conducted to assess the effectiveness of intervention programmes already on the ground. Based on this, sentinel surveillance statistics provided by the government and other local NGOs are not adequate to guide informed project or programme design decisions. Proper understanding of the socio-cultural attributes of the communities in Nyanza is indispensable for effective programmes that can promote behaviour change aimed at reducing the HIV disaster in the region. It is this gap that the study seeks to fill.

Chapter 2: Risk Factors Spreading HIV/AIDS in Nyanza Province 

In the social sciences circles, culture, in its broadest definition, is a way of life practiced by a group of individuals –the beliefs, behaviours, values, and symbols that they generally accepted, and that are passed along by imitation and communication from one generation to the next (Li & Karakowsky 2001). According to Owino (1998), culture is a learned and shared symbolic system of beliefs, values, and attitudes that shapes and influences the behaviour and perception of a group of people. It must therefore be studied by looking at the customs, behaviour, language, and the material culture of the group of individuals. Culture is learned through a process known as enculturation. Culture must be shared by members of a particular community. Culture must also be patterned, mutually constructed through a steady progression of social interaction, and symbolic. It must also be internalized and arbitrary considering that it is created by humans according to their desires rather than according to natural laws.

As stated earlier, many researchers have taken the influential view of culture, which highlights the role traditional cultural practices and institutions play in moulding behaviours that lead to rapid HIV infection rates. According to NASCOP (1999:11), “particular rights and ceremonies … are incongruent with the modern way of life and observance of which tend to enhance the contraction, containment, and spread of AIDS.”

According to Matlin and Spence (2000), cultural factors in Africa, including wife inheritance, gender inequality, and sexual practices need to be better understood or changed if the fight against the disease is to be more effective. According to the report, many societies especially in Africa find it uncomfortable and challenging to discuss and act on some cultural issues and practices, which nevertheless determine the spread of HIV/AIDS, and undermine the effectiveness of national management responses put in place by governments and other stakeholders. However, not all cultural traditions and practices are bad. Some cultural practices such as male circumcision have been found to have a positive impact on curtailing the spread of HIV/AIDS (UNAIDS 2008). The section below details the socio-cultural factors that have fuelled HIV/AIDS within Nyanza province, while drawing on similarities to be found in other regions of the continent.

2.3.1. Gender Inequality and HIV Prevalence

Cultural traditions that fail to recognize the value of women have contributed to the high prevalence of HIV in Africa, from Botswana to Swaziland to Kenya and Uganda (Morris 2006). Policy experts and scholars in Africa have devoted much of their time to study the role of gender in relation to the spread of HIV/AIDS. There is an assertion that the low status and marginal position of women in many communities prevent them from protecting themselves from HIV[1] (Male Circumcision and HIV Fact Sheet 2007). According to the Director of the Women and AIDS Support Network (WASN) of Zimbabwe, Ms. Priscilla Misihairabwi, women continue to be socially and economically dependent on men as they continue to get poorer and poorer by the day. This is evidenced by the fact that women have less control over when and whether to engage in sex with their husbands, a situation that has increased the spread of HIV (Opportunity International 2007).  Most husbands, especially in Africa, do not stick to one spouse. Indeed, the 2007 KAIS study in Kenya revealed that a higher percentage of Kenyans aged between 30-34 years are currently infected with the HIV pandemic than in any other age category (Kaiser Daily HIV/AIDS Report 2008). This age category is largely composed of married couples, and thus the high prevalence rate can partly be attributed to the marginalization of married women and the promiscuity of married men. It is therefore imperative that marginalized African women be given both HIV/AIDS education and economic empowerment if they are to significantly reduce their vulnerability to high-risk sexual behaviour.

Many previous studies point to the connection between gender, high-risk behaviour, poverty, and the prevalence of HIV. Adams and Trost (2005:5) argue that the social structure of most Kenyan communities, including the Luo, guarantees a gendered division of responsibilities and roles. These communities are known to be patrilocal and patrilineal in that, residence and inheritance are at the core of male lineage. Sexual division of labour is such that the women are charged with the responsibility of overseeing food production for the whole family, maintaining the domestic sphere, and caring for children (Shipton 1989). On the other hand, men are engaged in formal employment and have the rights to land ownership. Due to such division of labour, women are faced with a lot of hurdles when they try to access finance to start up an enterprise. In most instances, men are in total control of economic power and command over household resources, thereby making women more susceptible to the pandemic. Besides controlling wealth and property, men are the major decision-makers (Cohen & Adhiambo 1989). These social cultural structures leave the women with no authority at all to guide their decision making. Indeed, bride wealth is exchanged by husbands and families upon marriage in compensation for the productive and reproductive capabilities of the women (Ntonzi et al 1999).

In Luo Nyanza, the traditional major sources of income are fishing and subsistence farming (Kenya Information Guide 2009). In farming, women are involved in planting, weeding, and harvesting the crop, while their male counterparts are engaged in land preparation. Luo women are today also engaged in small-scale business activities such as selling mitumba[2] food and other commodities. The money they get from these ventures is meant to meet their most basic needs. However, their productive power is very limited due to the fact that traditional Luo customs do not give the Luo women any chance of pursuing economic channels or even owning property. (Gray et al 2002). Women therefore turn to men for financial support since they are left with very limited means of earning adequate financial resources. Women must plead with men to be given money for school fees, medical payments, and capital to start some small businesses (Shipton 1989).

These gender inequalities and biases are not limited to the Luo, but are widespread in Africa. They vary from the mundane and inconsequential, to the life-threatening inequalities. In some communities in Uganda, for example, women are never allowed by their male counterparts to eat chicken wings due to the fear that they would fly like birds and refuse to be submissive in bed (Halperin & Bailey 1999).  In West Africa, some cultures have the tradition of beating women at least once in three months to make them submissive, and discipline them. More serious examples include Somalia, where women have to go through female genital mutilation (FGM) to prevent them from becoming sexually promiscuous. FGM has many times resulted in threatening the very life of the woman undergoing it. While the women are being “tamed”, their husbands roam the streets with any woman they desire (Kawango 1995). Such cultural practices aim at marginalizing women to the periphery of existence so that they are fully dependent on their male counterparts, and consequently, more vulnerable to HIV infection.

Concerning reproduction, many African communities, including the Luo, expect their women to give birth to a lot of children, and at regular intervals (Shipton 1989). To carry on the male-dominated lineage, women are especially expected to give birth to boys. According to Kawango (1995), sub-fertility or infertility, including giving birth to girl children alone is viewed as a disgrace to the society by the Luos. Marrying of other wives in such a case was permitted in order to sire sons.

Property ownership is yet another manifestation of gender bias and inequality. Few communities in Africa permit women to own property, especially land. On the contrary, the women themselves are regarded as property, and it therefore baffles their male counterparts how a property can own property (Bailey et al 2002). Local women in Luo Nyanza are still perceived as property (Odundo & Owino 2004).  In a typical rural Luo household, a housewife will never complain when her husband comes home with another woman as she has been conditioned to believe that husbands must have extramarital affairs (Odundo & Owino 2004).  The foregoing reveals deep-rooted gender inequality in the region, with the resultant risks and vulnerabilities to HIV infection.

2.3.2. Poverty and HIV Prevalence

Abject poverty has been blamed for the swift spread of HIV in many African nations. In Nyanza province, Kenya, a government survey released in 2005 revealed that 65 percent of the local population mainly composed of the Luos, lives below the poverty line. In rural areas, households were living on US$ 17 per month, whereas those in towns had to live on US$ 35 per month. This led many stakeholders working in the region to argue that there is a correlation between poverty and HIV/AIDS. In addition to lack of good quality education, women start having sex far much earlier in poorer areas. Studies have revealed that women who go to school have a lower HIV prevalence rate than their counterparts who fail to attend school (Cohen 2005). Poor women are also more likely to engage in sex for money or get married at an early age to escape the poverty dragnet. These are major risk factors that expose the women to HIV infection.

Though needy populations account for most of the HIV related cases in Africa, it is not automatic that the infection is confined to the poorest (Cohen 1999). There exists partial evidence for a socio-economic inclination to HIV infection. It therefore follows that the association between HIV prevalence and poverty is neither direct nor simple, and more complex influences are at work than just the forces of poverty alone. Indeed, many rich Africans adopt flashy lifestyles that directly expose them to the risks of HIV infection. Rich Luos are known to love this kind of lifestyle (Njeru et al 2004).                                                                                     

 

2.3.3. Widow Inheritance

Widow inheritance is a marriage arrangement whereby a widow marries a kinsman of her deceased husband. This could be a brother to the deceased or a close member of his family (Stephen 1997). Male mortality in African countries is higher than in many industrialized countries around the world. This means that more African women are widowed at a more tender age than their Western counterparts (Njeru et al 2004). Traditionally, to deal with such frequent occurrences, social institutions such as wife inheritance came into play. Though the widows took on an even bigger role in their families’ welfare, inheritance failed to offer them the same level of support and companionship that marriage offered. Traditionally, inheritance enabled the widows to remain reproductively active and economically productive.

Though levirate or widow inheritance has waned elsewhere, it continues to be widely practiced among the Luo of Kenya. The practice is entrenched in the Luo culture and a widow who refuses to be inherited is threatened that chira[3], an indigenous disease that functions to safeguard Luo moral standards, will strike her or members of her own family (Ntonzi et al 1999). The Luo tradition demands that a widow must be inherited by her deceased husband’s brother or another close male relative some months after the burial of her husband (Njeru et al 2004). According to Njeru and colleagues (2004), basically the idea is to ensure that the widows remain under the custody of men. It is like a remarriage in that the wife is supposed to be sexually satisfied by the inheritor alone. The inheritor serves as a husband, standing in for the deceased in all ceremonies and rituals, and also serving as the father of the widow’s children during marriage. Potash (1986) argued that Luo widows were never allowed to formally remarry or engage in sex with other partners apart from the inheritor. According to Obbo (1986) and Ndenda (2002), the widows’ union with their departed husbands was supposed to continue hence the name mond liel – “wives of the grave.”

There are two schools of thought regarding widow inheritance among the Luo. There is the one view – unpopular among the Luo – that widow inheritance is to be blamed for the increase in the spread of HIV in the region. This is because many of the widows’ husbands are AIDS victims and therefore ‘forcing’ the widows into new relationships in the name of maintaining the family lineage unwittingly helps to spread the disease. In the hope of aping their forefathers and fathers who inherited widows without contracting HIV, some even inherit widows knowing fully well that their spouses died of the disease (IRIN PlusNews 2009). The inheritors contract the virus and go ahead to infect their own wives. According to this school of thought, these interactions explain the vicious circle of HIV prevalence in Nyanza province

There are individuals who advocate for the maintenance of what others may term harmful cultural practices traditions to persist. According to Adetunji and Oni (1999), widow inheritance obstructs the spread of the infection instead of exacerbating it. The infection of HIV is therefore localized to a few households basically because the infected woman is emotionally and sexually involved with a single inheritor rather than mingling freely amongst men in the society. This school of thought argues that wife inheritance contains the spread of disease from getting to the whole population, while risking “only” the life of the inheritor. The argument finds favour in the assertion that unmarried women are likely to have many sexual partners since they rely on men for financial support. The unmarried women often engage in unsafe sexual behaviours with numerous partners for financial gain (NACC 2000; MOH 1998). In order to support themselves financially, widows who are not inherited and who no longer receive any kind of assistance may likely find themselves engaging in high risk behaviours with numerous male partners (Caldwell et al. 1994).

Sanctions, dictated by traditions, still exist to ensure that traditions are honoured and obligations fulfilled. The widow who refuses to be inherited is threatened with chira, an indigenous disease whose symptoms includes a wasting away of the sufferer. In Luoland, AIDS is often misconstrued as Chira, or a curse that the almighty God bestows on anyone who willingly or unwillingly offends the customs of their ancestors or breaks a taboo. An individual who has been possessed by Chira is supposed to experience weight loss, mysterious illness, weakness, and eventual death. In the thinking of the local Luo community, AIDS and Chira look the same, so they must be treated as one. (Swan 2008)Even today, some people dismiss AIDS as nothing but chira– the wasting away that befalls someone who has failed to honour a traditional rite. To observers, the role of chira is to ensure maintenance of cultural practices through instilling fear (Sindiga 1995: 68). If the cultural transgression is not identified and treated using cleansing traditional concoctions, it is believed that the victim’s body will waste away slowly and eventually die. Chira can affect anyone from the offending victim to other family members and as such, people are pressured to maintain cultural practices irrespective of the harm caused to them.

Due to the unequal status of the women in relation to men in Luo Nyanza, many widowed women turn to men inheritors in the hope of being supported materially and financially[4] (IRIN PlusNews 2009). Although such an objective may have been socially beneficial, the advent of HIV has changed the whole scenario. Gender inequality has served to perpetuate demeaning attitudes towards women, denying the women their dignity and value. The demeaning attitudes have brought about increased levels of domestic violence, physical and sexual abuse to women, and myths about women, which contribute to higher HIV prevalence levels among women than men (IRIN PlusNews (2009).

A comparator is to be found in Botswana and Swaziland, where some church pastors put aside their Christian doctrines and faith in order to inherit the wife and properties of a deceased brother in the name of cultural heritage (IRIN PlusNews 2009).  Even if men have prior knowledge that the individual died of HIV/AIDS, they would rather die of the disease than break their cultural tradition. The result is that these two nations have the highest adult HIV prevalence rates in Africa, with Swaziland leading with 26.1 percent, and Botswana closely following with 23.9 percent (Avert 2008). In Malawi, though the practice of wife inheritance has come under heavy criticism from the Malawian government and AIDS networks operating in the country, it continues unabated in some communities. The government believes that this practice has a lot to do with the high adult HIV prevalence rate of about 14 percent, with ten people dying every hour due to the pandemic (Avert 2008). It therefore follows that a strong correlation between the cultural practice of wife inheritance and high HIV prevalence levels really does exist.

2.3.4. Widow Cleansing

This is another ritual that is closely associated with widow inheritance. According to Robson

(2006), after the death of a spouse, the widow is often looked at negatively as ‘unclean.’ After the burial of her husband, the woman must undertake the cleansing ritual for her to be accepted back into the community[5]. This basically entails a ritual sexual intercourse between the inheritor and the widow at the onset of the inheritance arrangement. The cleansing is performed in conjunction with other rituals such as preparation of a meal for the inheritor and shaving of the widow’s head IRIN PlusNews (2009).

In the society, widows are identified as a source of HIV due to the widely held fear that their spouses may have perished due to the infection.  Widow “cleansing” and wife inheritance practices amongst some African communities play a role in spreading HIV (Gable 2007: 146).

Hypothetically, women be able to decline engaging in such activities – practically, however, they are usually under intense social pressure to comply. Hence such widows engage in unprotected sex either as a cleansing ritual, or following their inheritance, their chances of acquiring HIV infection increases. In response to these life-threatening practices, many scholars, researchers, and policy makers have continued to campaign for change. People are being encouraged to abandon “abhorrent cultural practices” so that the HIV epidemic can be effectively stemmed (NACC 2000:19; Kiragu 1996).

Available anthropological research reveals that the practice of widow cleansing continues unabated in Nyanza as the population strongly wishes to avoid chira. A cultural study conducted in 2005 revealed that over three-quarters (77.0%) of local Luos were more frightened of Chira than they were of AIDS (Robson 2006). This strange disease had the power to afflict any close relative of the widow who refused to be cleansed. If the widow refused to be cleansed, the community would chase her away for fear that chira would bring disaster to the community. This left the widow with no alternative but to agree to be cleansed by a brother to the deceased or a close relative.

The results of these rituals are there for all to see. In some parts of Nyanza province, one in every four individuals is affected by the pandemic. According to IRIN PlusNews (2009: 9) “around the village of Orongo, 10km from Kisumu city…the effects of AIDS mark the landscape: homesteads stand derelict while herds of goats graze on the grass that covers scores of unmarked graves.” It is against this backdrop, and to the credit of the community, that elders saw the need to replace the rite of intercourse with other substitutes such as the inheritor hanging his coat in the house of the widow to be cleansed or placing his legs on the widow’s thigh (Robson 2006). However, such alternative rituals have not been fully embraced by the community, with many members still preferring the traditional way, despite their wide exposure and the expected corrosion of their culture by education.

Another comparable example is to be found in Zambia, where for some communities, funeral rites must be concluded with a final ritual – sex between the deceased’s widow and at least one of her husband’s close relatives. According to tradition, this is apparently done to break the bond with the deceased husband’s spirit, and is done to save the widow and the villagers from disease or insanity (Glynn et al 2001). This tradition of widow cleansing is largely endorsed by traditional leaders, and widows have long tolerated it. A recent study commissioned by Women and Law in Southern Africa found out that sexual cleansing is found in one-third of the nation’s provinces. According to Lafraniere, widow cleansing in Zambia is responsible for the high HIV prevalence level, which stood at 20 percent of the adult population in 2005.

 

2.3.5. Male Circumcision

According to compelling epidemiological evidence, there is a significant association between HIV infection and lack of circumcision. The XIII International AIDS Conference held in Durban in July 2000 came up with evidence that supported circumcision as “risk-lowering factor for HIV transmission” (Matlin, & Spence 2000: 1). In 2005, results from a randomized controlled trial conducted over a period of 20 years of observational studies in South Africa confirmed that the practice of male circumcision could protect males against acquiring HIV through heterosexual intercourse by 60 percent (Rennie, Muula, & Westreich 2007).  Male circumcision is a highly effective HIV prevention intervention in clinical trial settings where transmission is predominantly heterosexual, and initial research indicates that it is highly cost-effective. Circumcision in younger males prior to sexual activity may increase efficacy. The potential for increased risk behaviour in circumcised men, however, is a concern, and must be monitored closely as protective effects of male circumcision become more widely known.

Bailey and colleagues (2007) offer strong evidence that significantly connects male circumcision with reduced risk in terms of HIV infection rates. In this regard, a number of large clinical trials whose intention was to validate this connection have already been carried out. For example, Bailey and others (2007) talk of RCTs (Randomized Controlled Trials) which have already been carried out in Kenya. Other RCTs have also been conducted in Uganda (Grey et al 2002), as well as in South Africa (Puree et al 2002). Furthermore, the RCTs conducted in Uganda tested prior conclusions which offered the suggestion that the female partners of men already infected with HIV, and who underwent male circumcision, could be protected from acquiring HIV infection. At the moment, the aforementioned studies have ended, following vast evidence to the effect that male circumcision indeed offers protection, in as far as being infected with HIV is concerned.

The RCT in Kenya were conducted under the UNIM Project, and took place in Kisumu, Kenya, a city whose population is predominantly Luo. Historically, Luos did not practice male circumcision, as a rite of passage. Scientific evidence obtained from the UNIM Project indicated that the infection rates for HIV/AIDS fell drastically, by 54 percent, following the circumcision of the study’s participants (Bailey 2007). On the basis of a strong association between on the one hand, reduced HIV infection risk and on the other hand, male circumcision, WHO (the World Health Organization), along with a number of other international health organizations, support prevention measures which provide and promote male circumcision (Bailey 2007).

Male circumcision, and more so within the context of those communities that do not practice this ritual, appears to be a practice of high risk, in as far as HIV/AIDS spreading is concerned (Caldwell 1996). The Luo is a big, traditionally non-circumcising tribe. Traditionally, the Luo practiced the rite of passage into adulthood through knocking off six teeth, three from each jaw (Malungo 2001:27).

Priscilla Reining, an anthropologist from the United States, undertook a study in 1989 (Reining1989) that sought to draw a correlation between those cities in the African continents that bore the highest HIV/AIDS prevalence rates and those that had predominantly embraced circumcision as a cultural practice. The findings of this correlation were such that HIV appears to spread fast amongst those towns and cities that were not routinely performing the act of circumcision.

Caldwells (1996) obtained similar findings, when it was found that amongst the areas that the AIDS epidemic was severe, there was also a correspondingly higher number of males that were not circumcised. Moses and colleagues (1998) have also cited connection between high rates of HIV infection and male circumcision. On the basis of such research findings, it may be inferred that the prevalence rates of HIV/AIDS in Luo Nyanza, more than in any other region could be higher due to the combined effect of a high number of uncircumcised males, in addition to such cultural practices as wife inheritance and polygamy.

A research concluded in the year 2000 revealed that male circumcision had the ability to reduce the chances for contracting HIV by 60 percent among males (National AIDS Control Council 2000). In another much recent research, 3 000 HIV negative men underwent circumcision and were then monitored for a period of up to five years. Among the respondents, 54 percent tested HIV negative after the five years. In South Africa, 60 percent tested negative, with similar results being reflected in Rakai, Uganda (Male Circumcision and HIV Fact Sheet 2007).  The findings necessitated the Kenya government to recommend male circumcision as a strategy for fighting HIV infection among males in areas where circumcision is not practiced and HIV transmission is predominantly through heterosexual relationships. In April 2008, the government, through the ministry of Health, commenced a five-year pilot programme covering Kisumu-West, Kisumu-East, and Nyando districts of Nyanza Province (Nduri & Akoko 2008). Under the new policy, a task force will be established to direct circumcision efforts around the country and health personnel will be offered intensive training on male circumcision. The exercise will be conducted free-of-charge under conditions of confidentiality, informed consent, safety, and risk reduction counselling by well trained practitioners in antiseptic settings (Kaiser Daily HIV/AIDS Report 2008)

However, Kenyan public officials warned that male circumcision does not in any way fully protect males against HIV infection though it had proved effective in preventing the spread of the pandemic. According to a National AIDS Control Council (NACC), male circumcision is an effective HIV/AIDS management strategy, but should be practiced with caution as the new policy may end up encouraging circumcised males to engage in unprotected sexual intercourse. As such, the programme needs very cautious implementation, and educating the population is vital as people need to be told that circumcision does not guarantee protection from HIV. As a HIV management strategy, circumcision will be part of the government’s new “ABCC” approach but will not in anyway replace other prevention methods. This approach accentuates HIV prevention through abstinence, being faithful, circumcision, and condom use (Kaiser Daily HIV/AIDS Report 2008)

Despite its beneficial inputs of better genital hygiene and reduced risk of HIV infection, circumcision is still finding resistance from traditional bigwigs who view the practice as alien to Luo cultural traditions. The Luo Council of Elders’ Chairman has been quoted saying that the government’s policy on male circumcision can never be implemented without consultations. He has warned that no NGO would be allowed to implement the government’s policy without consulting the locals (Nduri & Akoko 2008). Apart from cultural restrictions, some people also fear the practice due to the pain and excessive bleeding involved.  Others, including the current Kenyan Prime Minister Mr. Raila Odinga, have been in the forefront in advocating for this intervention. (Okwemba 2008: 5). The practice of male circumcision in Kisumu has become popular in many parts of Nyanza after previous research findings indicated that the practice reduces HIV infection rates among men (Menya & K’aluoch 2008: 2). The districts, which have recorded high numbers of people seeking circumcision, are Kisumu, Nyando, and Homabay.

2.3.6. Polygamy

Polygamy is one of the cultural practices found in some African traditions that continue to pose high potential risk of HIV infection. Polygamy is an institutionalized multi-spouse arrangement, where males are permitted to get two or more wives depending on their quest for social capital and resource capacity (Njeru, Mwangi & Ndunge 2004). Though a long-standing tradition through the ages and in many cultures, today’s society views the structure of polygamy as limiting the choice of women and culturally binding them to submit to the sexual advances of the male custodians of such cultural practices.

Polygamy is practiced by many people in Kenya, even though it is only sanctioned by traditional customary law and Muslim religion. Christian churches prohibit the custom. According to previous studies, Nyanza province is the hotbed of polygamy. A study conducted in the region revealed that most Luo women felt polygamy could be a beneficial and happy experience if the co-wives could cooperate with each other. The study also revealed that traditional uneducated women carried polygamy with esteem more than their educated counterparts (Male Circumcision and HIV Fact Sheet 2007).

The consequence of a polygamous union is such that sexual partners increase in number. In this case, chances are that HIV infections rates amongst such partners could increase, in the event that one of the partners turns unfaithful. The Luo community has traditionally been practicing polygamy (Stephen 1997). This, along with the practice of wife inheritance, may act to enhance HIV transmission, when we have the partners engaging in unprotected sex.

Polygamy has been found to contribute to the high level of HIV prevalence in the lake basin. In some areas of Nyanza, HIV infection rates are as high as one person in every four. If this is the scenario, it means that out of every four wives you get, at least one will be infected. The HIV-positive wife will infect her husband who in turns will affect the other three wives unknowingly. This perhaps explains the higher prevalence of HIV/AIDS in regions where such cultural practices are still prevalent.

2.4. Cultural Interactions

There are a lot of activities that go on within and around Nyanza province on a daily basis. First, the province is home to Kisumu, the third largest city in Kenya. Due to its proximity to Lake Victoria, the world’s largest freshwater lake, the region attracts many visitors ranging from fishermen, tourists, fish traders, commercial sex workers, and truck drivers (Glynn et al. 2001:72)

The high number of visitors into Nyanza province is both beneficial and harmful. It is beneficial because of the fact that the region has been opened up for trading activities with other parts of the country and the East African region. Fish traders traverse the region daily in search of fish and markets. To transport the fish to Nairobi city and other areas around the country, the services of truck drivers must be enlisted. Due to the free circulation of money generated by the fish trade, various groups of people have been attracted to the region in the hope of finding a niche for themselves. Traders have set up businesses in the region. As a result, fish traders, truck drivers, middlemen, commercial sex workers have all camped in the region in the hope of making some money (NACC 2000).

All the above groups of people come from various cultures. Though these people visit the lake side region for beneficial purposes, their interactions with the locals is often viewed as a major contributor to the high HIV prevalence rates in the region. According to Stuart and colleagues (2007), these groups of people are highly mobile. Quite often, mobile persons are not accompanied by regular sex partners, thus exposing them to the risk of multiple partners. The risk of a mobile person is further aggravated by poverty (in the case of commercial sex workers), feelings of loneliness and anonymity in the new environments. These strangers end up engaging in sex with the locals, thereby exposing them to the risk of contracting HIV/AIDS (NACC 2000).

According to Glynn et al. (2001), the spread of HIV/ AIDS in the lake basin can be analyzed in the context of risks and vulnerabilities. Risk factors relate to individual behaviours, whereas vulnerability is due to external factors beyond the control of the individual.

2.5 Culture as a Positive Influence on HIV/AIDS

What then can be deduced from the foregoing? Is culture to be demonized as the propagator of HIV? Singhal & Rogers (2003) differ, and point out that HIV prevention programs may be failing due to a simplistic, bio-medical approach that does not take into consideration the socio-cultural construction of sexuality. Moreover, they point out that the campaigns target the individuals instead of taking a multi-level, cultural and contextual angle (Singhal & Rogers 2003: 214).

Indeed, there are aspects of Luo culture that may be harnessed to rein in the run-away HIV/AIDS prevalence rates in the region. The Luo are a deeply spiritual people with great reverence for ancestors and a healthy fear of death and the dead. This spirituality, and the call to do what is right, can be used as a deterrent to promiscuity.

Singhal & Rogers also advocate for a change from the prevention strategies that do not acknowledge the cultural concept of sex as “pleasurable”, and instead take on a condemning tone. Most African societies, the Luo included, are male-dominated and focus on the pleasures of the man. Are there any approaches to HIV prevention that would enhance the pleasure concept whilst advocating for caution and common sense? Instead of using the commonplace medium of communication such as newspapers and radio, can prevention campaigns strengthen the previously existing cultural communication channels, such as communicating through the respected aunties and uncles who are charged with providing sexual information to the youth?

And for the Luo who are yet to fully embrace circumcision, proper education can be provided to deter against the common use of a single blade to circumcise a large number of initiates, which has been a cause of the spread of HIV amongst traditionally-circumcising communities.

To further the debate on the positive aspects of culture in the fight against HIV and AIDS, is the fact that culture can be tapped as a coping mechanism when dealing with the mortality that eventually results from full-blown AIDS. The Luo in particular are a close community that believe in consanguine ties and for whom everyone is their brother’s keeper. Properly harnessed, the cultural tradition of collective responsibility can be used to offset the increased dependency from the increasing number of orphans and vulnerable children, funeral expenses, and general hopelessness.

 

Chapter 3: METHODOLOGY

3.1 Conceptual Framework

This study utilized a proximate determinants model for investigating the various socio-cultural routes to HIV infection. The model endeavoured to bring together all the cultural factors accountable for risk taking behaviour among the Luo and successive infection.

Conceptually, the proximate determinants model “identifies a set of proximate variables through which social and economic variables operate to give rise to morbid conditions or death” (Njeru, Mwangi, & Ndunge 2004:17). For the purposes of this study, these proximal factors include cultural aspects of wife inheritance, wife cleansing, polygamy, and lack of male circumcision.

The proximate determinants model maps out the conduits through which factors such as poverty, culture, and gender inequality lead to engagement of high-risk behaviours. Cultural practices, gender inequality manifested in double sexual standards for females and males intermarried with the general susceptibility of women have surfaced as some of the aspects increasing the prevalence of HIV/AIDS infection in Africa as a whole (Njeru, Mwangi, & Ndunge 2004: 17). The lack of male circumcision in some communities is also viewed as a possible reason for the elevated HIV levels in these communities.  Different communities in Africa practice the said socio-economic and cultural aspects differently. Some communities like the Luo and Luhya in Kenya are completely entangled in observing cultural practices, while others like the Kikuyu have shed the cultural cocoon. There is a resonate gap of HIV prevalence rates between the communities which continue to observe cultural practices and communities which have discarded many cultural practices and embraced modernity (Standing & Kisseka 1989). In the former, HIV prevalence is higher than in the latter. Put in this context, the proximate determinants model is best illustrated by the diagram below.

Figure 2.0: Routes to HIV infection

Exposure to risk
Socio-cultural factors, beliefs, practices, norms, gender, roles, and responsibilities

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source: Adapted from Njeru, Mwangi, and Ndunge (2004)

 

3.2: Study Design and Variables

This study utilised triangulation, both quantitative and qualitative research methodologies, to establish the relationship between the cultural traditions practiced by the Luo and the prevalence of HIV/AIDS in the lake basin region. According to Hopkins (2000), the aim of quantitative research is to determine the association between one item (independent variable) and another (outcome or dependent variable). Quantitative study designs are either experimental (subjects are measured before and after the treatment) or descriptive (subjects usually measured once). An experiment establishes causality while a descriptive study establishes associations only between the independent and the dependent variables. This study is a descriptive study designed to measure the association between the Luo cultural practices and the prevalence of HIV in the region.

The study utilized the qualitative research design in its attempt to generate descriptive information about peoples’ behaviours, actions, experiences, and intentions in a group, place, community, or programme. This design came in handy in trying to understand the Luos’ interpretation of the Behaviour Change Campaigns (BCC) that has been undertaken in the area in relation to HIV/AIDS. It also proved useful in understanding the peoples’ understanding and interpretation of the various cultural practices accused of worsening the HIV/AIDS situation in the area. Data are reported in words rather than numbers.

 

3.2.1. Cultural Factors Influencing the Prevalence of HIV

These variables were measured through the existence of the cultural practices in the lake basin region. The indicators under scrutiny included cultural practices such as wife inheritance, wife cleansing, and polygamy, lack of male circumcision, occupation and gender roles. The attitudes and knowledge levels towards these practices were also sought to measure if people are still bound by the traditions. People’s interpretation of these practices was also measured to reflect how they are likely to be swayed by cultural practices to engage in high-risk behaviours. According to IRINPlus News (2009), the situation in rural Nyanza is that individuals, especially women, are obliged to have sex to keep up with the cultural traditions. The cultural hold on women is so strong such that they end up having sex with partners that they know could be infected with HIV, but they are not in a position to refuse. Gender roles and responsibilities vary between cultures and can change over time. In almost all societies, women’s roles tend to be undervalued (WHO 1998:56).

3.2.2: Exercise of Authority/ Influence on Inter-partner/ Inter-spouse Sexuality

The aspect of unequal power relations was measured through assessing the partner/ spouse who makes decisions about money, sex, investments, using protection, being inherited, and other related issues. Poverty was also measured using the same indicators. The weakening ability to protect women from HIV/AIDS can be explained by their low status and marginal location in society (KashKooli 2008). Women have been denied dignity and value due to the demeaning attitudes brought about by gender inequality. This has brought about increased levels of domestic violence, physical and sexual abuse to women, and myths about women, which contribute to high HIV prevalence levels among women than men (Bailey et al 2001).

3.2.3. Existing HIV Policies and Programmes

Indicators used to measure the above variable included the level of VCT uptake among respondents, knowledge about HIV and the modes of transmission among respondents, interviews with local officials of local NGO’s offering HIV related programmes, interviews with the local district hospital’s HIV and STD coordinator, opinion leaders, and distance to health facilities offering VCT/HIV related services.

3.3. Study Area

Although Nyanza province has 12 districts, with an estimated population of 4 700 000 (as of 2008) within a locale of 16 162 km2 this study was only limited to Rongo Division of Migori district of Nyanza province. In this area, cultural practices of widow inheritance, widow cleansing, gender inequality, polygamy, and lack of male circumcision are still prevalent, and these are cultural practices that have earlier been cited as contributing to the increase in the prevalence rates for HIV infection. The district is located in the south-western part of Kenya, and measure approximately 2 005 km2. During the 1999 official census, the district registered a population of 514 897 (Nation Master 2005). The district has four administrative constituencies, namely Migori, Uriri, Nyatike, and Rongo. It is in the latter constituency that the study will be conducted, in an administrative division that goes by the same name. During the 1999 census, the division had a population of 79 817, and an urban population of 2 918, with a population density of 376. Recent projections estimate that the population of the area may have gone up by at least 30%, bringing it to an estimated to 103 770.

3.4. Target Population

The target population for this study included women of child-bearing age of between 14 and 49 years, who are single, married, widowed, or inherited. This category has borne the brunt of cultural practices that are still practiced in the area and within the larger Nyanza province (IRINPlus News 2009).The study population also included males of the same age-group. Another target group selected for this study were the opinion leaders or village elders within the division. This group facilitated in offering a proper insight into the cultural practices that are still rampant in the area. Officials from the local sub-district hospital and local NGO networks operating in the area formed the last category for this particular study. This category offered useful insights into HIV/AIDS management strategies and awareness campaigns that have been undertaken in the area, and if indeed they have bore fruits. This category is important for such type of study as it is the custodian of the fact sheets that document the extent and spread of the pandemic (Odundo & Owino 2004).

3.5. Sampling Frame

According to Abowd and Woodcock (2004) a sampling frame is a register of all individuals of a population used as a foundation for sampling. The sample for this study was selected from the sampling frame known as National Sample Survey and Evaluation Programme III (NASSEP III), used and maintained by the Kenya Bureau of Statistics to undertake household based sample surveys (Njeru et al 2004). The sample frame was developed from the 1999 national census and contains 1 133 clusters in total. Rongo division was chosen to be one of 930 rural clusters and 203 urban clusters. The Rongo cluster has 108 households. Each household is recognized by a number, the exact village location, and the name of the household head. The researcher utilised the maps under the custody of the District’s Statistical Officer (DSO) at Migori District to locate the households.

3.6. Sampling

The baseline study was based on a purposive sample. Respondents were selected on the basis of falling within known categories of individuals included in the study population. After the desired categories were identified, simple random sampling technique was employed in the administration of questionnaires. This was with a view to ensuring that all the categories/ subsets of the sample frame are given equal probability. Each element of the frame therefore had equal probability of selection (Odundo et al. 2003). The researcher intended to get the names of the village elders from the administrative Division’s Office. The division has three locations, and each location is represented by 2 village elders. The study wished to get views from all the six elders, and therefore, no sampling was required. The same case applied to the NGO networks and officials from the MOH at the local sub-district hospital.

The table below depicts the breakdown of the sample groups in terms of the relevant biographic categories and data collection methods.

Table 4: Breakdown of sample size in terms of biographic categories and methods of data collection

Sex Age-group Category Sample size Data collection Method
Female 14-49 Women of child bearing age 40 Personal-administered questionnaires
Male 14-49 Circumcised and uncircumcised 30 Personal-administered questionnaires
Any >45 years Village elders/ opinion leaders 6 In-depth interviews
Any >21 years NGO officials 5 In-depth interviews
Any >21 years MOH officials 2 In-depth interviews
N/A N/A HIV Awareness campaigns/ Cultural practices/ NGO’s N/A Covert Observation

Table 2: Breakdown of sample size in terms of biographic categories and methods of data collection

3.7. Data Collection Methods

The study used both primary and secondary methods of data collection. Primary data was collected through the use of covert observation, personal-administered questionnaires, and in-depth interviews. Observation is a way of gathering information by noting physical characteristics, behaviour, and events in a natural setting. Given that the researcher is Luo herself, she had ample time and opportunity to quietly observe the practice of the NGO networks in the area and many cultural practices under study, as they unfold in their natural setting. The author had the added advantage of not requiring interpretation, which may sometimes give a slightly altered angle to the goings-on.

Primary data was also collected through personally-administered questionnaires. The questionnaires contained both structured and unstructured questions. The questionnaires were administered to women of reproductive age and males, and focused on capturing quantitative data about the various cultural practices found in the area, HIV/AIDS knowledge levels among the respondents, and poverty levels in the area. They were also aimed at capturing gender inequality levels and VCT uptake.   Personalized in-depth interviews were also conducted for the purposes of collecting primary data. The interviews were administered to opinion leaders, officials of local NGO networks, and officials of MOH from the local sub-district hospital. The focus was to know the HIV management practices in the area, level and uptake of HIV awareness campaigns, and the burden of the cultural practices on HIV/AIDS preventive strategies in the area. Village elders also helped in shedding light on some of the cultural practices rampant in the area. Both qualitative and quantitative data were collected from the personalized in-depth interviews. Secondary data was obtained from the review of related literature and fact sheets that are to be provided by the NGO and MOH officials detailing the extent and spread of the HIV infection in the area.

3.8. Ethical Considerations

Consent was sought from the Luo clan elders and religious leaders in the area. Information about the research and its objectives was also provided to the household heads so that they could allow their wives to participate in the research study. Respondents were made aware that the information obtained would be confidential. Furthermore, the information obtained as a result of the interviews was utilized only for the purposes of this research. Besides, no participant was coerced to take part in the research study, as participation was on voluntary basis.

3.9: Data Analysis

3.10. Study Limitations and Constraints

Although all the cultural practices under study are to be found in all the 12 districts of the expansive Nyanza province, nevertheless the study was limited to Rongo Division of Migori district. This is due to the constraints of time and travelling costs. Therefore, while the design may have provided the basis for generalization of the study findings with regard to Rongo Division, the same cannot be done to the rest of Nyanza province. A more comprehensive study may shed more light on the relationship between cultural practices and HIV prevalence within the region in particular and within the country in general. Also, a more detailed study may shed more light on effective HIV management practices that can be replicated elsewhere in the fight against the pandemic.

Bibliography

Abowd, J. M. and Woodcock, S. D. (2004). Multiply-Imputing Confidential Characteristics and
       File Links in Longitudinal Linked Data. Privacy in Statistical Databases. New York:
       Springer Verlag

Adetunji, J., & Oni, J. (1999). Rising Proportion of Young Widows and the AIDS Epidemic in

Africa. Paper Presented at the Annual Meeting of the American Sociological Association, August 6-10. Chicago.

Al-Bayati, M.A. (1999). Get All The Facts: HIV does not Cause AIDS. Dixon, California: Sage

Publishers

Avert (2008). Number of people living with AIDS. Retrieved December 14, 2008, from

http://www.avert.org/worlstatinfo.htm

Bailey, R.C, R. Muga, R. Poulusen and H. Abicht (2002). The acceptability of Male

Circumcision to Reduce HIV Infections in Nyanza Province, Kenya. AIDS CARE, Vol. 14,

No. 11 Pp 27-40

Buckley, S 1997. “Wife Inheritance Spurs AIDS Rise in Kenya.” Washington Post Foreign

Service. November 8

Caldwell, J.C., Caldwell, P., & Quiggin, P 1994. “The Social Context of AIDS in Sub-Saharan

Africa.” In L.O. Orubuloye, John C. Caldwell, Pat Caldwell, and Gigi Santow, eds. Sexual Networking and AIDS in Sub-Saharan Africa: Behavioural Research and the Social Context. Canberra: Publisher?

Caldwell, J.C. and Caldwell, P. (1996). The African AIDS Epidemic. Scientific American, Vol.

274, pp. 62-68

Central Intelligence Agency (2008). CIA World Factbook (2008). HIV adults’ prevalence rates.

Retrieved November 28, 2008, from

https://www.cia.gov/library/publications/the-world-factbook/rankorder/2157rank.html

Cohen, D 1999. Poverty and HIV/AIDS in Sub-Sahara Africa, UNDP publication. Issue

paper No. 27

Cohen, D.W., & Odhiambo E.S.A 1989. Siaya: The Historical Anthropology of an African

Landscape. London: James Currey.

Daily Nation 2000. “We are 28 Million.’ Daily Nation (Kenya). February 17.

Fauci A.S. Braunwald, E, Isslbacher, K.J., et al. Harrison’s. (1998). Principles of Internal

Medicine. (14th Ed.). New York: McGraw-Hill Companies.

Gable, L, 2007, Legal aspects of HIV/AIDS: a guide for policy and law reform. Washington, D.

C.: World Bank Publications.

Glynn, J.R., Careal, M., Kahindo, M., Chege, J., Musonda, R., Kaona, F., & Buve, A 2001. Why

do Young Women Have a Much Higher Prevalence of HIV than Young Men? A Study in Kisumu, Kenya and Ndola, Zambia. AMREF

Gray, R, Wawer, M.  Serwadda, D.  (2002). Randomized Trial of Male Circumcision for HIV

Prevention, Rakai, Uganda. Paper presented at a special meeting on Male Circumcision:

Current Epidemiological.

Halperin, D.T and R.C Bailey (1999). Male Circumcision and HIV Infection: Ten Years and

Counting. The Lancet, Vol. 354, pp. 1813-15

Hammel, E.A 1990. “A Theory of Culture for Demography.” Population and Development

Review, 16(3): pp 455-485

Hopkins, W. G. (2000). Qualitative research design. Retrieved February 09, 2009, from

http://www.sportsci.org/jour/0001/wghdesign.html

IRIN PlusNews (2009). Kenya: from the classroom to the bedroom. Retrieved March 31, 2009,

from http://www.kaisernetwork.org/daily_reports/rep_ghr_recent_rep.cfm?dr_

cat=4&show=yes&dr_DateTime=03-31-09

Kaiser Daily HIV/AIDS Report (2008). Global Challenges:  Kenya’s HIV Prevalence Increases

to 7.8% in 2007, Report Finds. Thursday, July 31. Retrieved November 19, 2008, from

http://kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=53611&dr_cat=1

Kashkooli, K. (2008).  “Gender Inequality and HIV/AIDS in sub-Saharan Africa.”

Submitted to Population and Development Review. New York, New York.

Kawango, E.A 1995. “Ethno medical Remedies and Therapies in Maternal and Child Health

among the Rural Luo”. In Isaac Sindiga, eds. Traditional Medicine in Africa. Nairobi: East African Educational Publishers.

Kenya Information Guide (2009). The Luo tribe: the lake and fishing tribe of Kenya. Retrieved

April 24, 2009, from http://www.kenya-information-guide.com/luo-tribe.html

Kenya: Cultural traditions that fuel the spread of HIV/AIDS 2007. [Online]. Retrieved from:

http://www.plusnews.org/report.aspx?reportid=39201  [11 June 2008]

Kiragu, J 1996. HIV Prevention and Women Rights: Working for One Means Working for Both

AIDS Captions. Regal Publishing Press

Li & Karakowsky. (2001). Do We See Eye-to-Eye? Implications of Cultural Differences for

Cross-Cultural Management Research and Practice. The Journal of Psychology, Vol. 135,

No.5, pp. 501-517.

Male Circumcision and HIV (Fact Sheet) 2007. [Online]. Retrieved from:

http://data.unaids.org/Publications/Fact-Sheets04/FS_Male_circumcision_26Jul05_en.pdf [2008, [11 June 2008]

Matlin, S., & Spence, N 2000. “The gender Aspects of HIV/AIDS Pandemic.” Expert

Group Meeting on the HIV/AIDS Pandemic and its Gender Implications. New York-Geneva: Division for the Advancement of Women, WHO and (UNAIDS)

Ministry of Health (MoH) 1996. Sessional Paper No. 4 on AIDS in Kenya. Nairobi, Ministry of

Health.

Ministry of Health (MOH) 1997. Sessional Paper no. 4 of 1997 on AIDS in Kenya. Nairobi,

Ministry of Health

Moses, S, Bailey, R. C. and A.R. Ronald (1998). Male Circumcision: Assessment of Health

Benefits and Risks. Sexually Transmitted Infections, Vol. 74, pp. 368-373.

NASCOP and Ministry of Health (MOH) 1998. Report of the Second National HIV/AIDS/STD

Conference: Lessons Learned. Nairobi

National AIDS Control Council 2000. The Kenya National HIV/AIDS Strategic Plan.

NACC Popular Version 2000-2005, Nairobi.

National AIDS Control Council (NACC) 2000. Kenya National HIV/AIDS Strategic Plan 2000-

  1. 2005. Nairobi, Office of the President and NACC

New Data on Male Circumcision and HIV Prevention: Policy and Programme Implications

  1. [Online]. Retrieved from: http://data.unaids.org/pub/Report/2007/mc_recommendations_en.pdf

[11 June 2008]

Njeru, H.N., Mwangi, P., & Ndunge, M 2004. Gender Aspects in HIV/AIDS infection and

Prevention in Kenya, IPAR. ISBN: 9966948775

Ntonzi, J.P.N., Ahimbisibwe, F.E., Ayuiga, N., Adwee, J.O., & Okurut, F.N 1999. “The Effects

of the AIDS Epidemic on Widowhood in Northern Uganda.” In L.O. Orubuloye, Responses and Coping Strategies. Canberra: Health Transition Centre, National Centre for Epidemiology and Population Health.

Ocholla-Ayayo, A.B.C (1976). Traditional Ideology and Ethics among the Southern Luo,

Uppsala: Scandinavian Institute of African Studies

Odundo, P, Owino P, Ochola, P, Ndolo, M, Ombija O. and Korir, J. (2003). Mainstreaming

Gender in Managing HIV/AIDS Pandemic in Nyanza: Cultural Practices, Poverty, and Policy. IPAR Discussion Paper.

Odundo, P & Owino, O 2004. HIV/AIDS Scourge in Nyanza Province: Culture, Poverty and

Behaviour Change.  Nairobi: Regal Press Kenya Ltd.

Onyango-Ogutu, B & Roscoe, A. A 1974. Keep My Words. Nairobi:  East African Educational

Publishers Ltd.

Opportunity International (2007). 43.7 million People stand against poverty. Retrieved

December 14, 2008, from

http://www.opportunity.org.au/home.asp?pageid=B91F4CEF9C01A1FF&

pressid=11CF1D76742F9847

Owino, J. P.  (1998). Wife inheritance and ‘Chira’ cultural impediments in HIV and AIDS

control, prevention and management: a case study of Luo community in Kenya.

Int Conf AIDS, Vol. 12, No. 474, pp. 8-13.

Pala, A.O 1979. “Women in the Household Economy: Managing Multiple Roles.” Studies in

Family Planning. 10(11/12): pp 337-343

Palloni, A., & Lee, J.Y 1990. Families, Women, and HIV/AIDS in Africa. CDE Working

Paper, 90-32, Madison: University of Wisconsin.

Peter, C.B 1994. A Guide to Academic Writings. Nairobi: Kijabe Printing Press.

Purée, A, Taljaard, D, Auvert, B. (2002). Male Circumcision Randomized Controlled Trial,

Johannesbourg – South Africa. Paper presented at a special meeting on Male Circumcision:

Current Epidemiology

Reining, P. (1989). Africa: A Comparison of Ethnographic Data on Circumcision and HIV

Seroprevalence. Paper presented at the Annual meeting of the American Anthropological

Association, Washington, D.C

Robson, A. (2006). The greatest need. The Guardian, Saturday 12. Retrieved January 19,

2009, from http://www.guardian.co.uk/news/2006/aug/12/guardianextra.guardianspecial53

Shipton, P 1989. Bitter Money: Cultural Economy and Some African Meanings of Forbidden

Commodities. American Ethnological Society Monograph Series No. 1

Singhal, A & Rogers, E.M. (2003). Combating AIDS: Communication Strategies in Action. New Delhi: Sage Publications India Pvt Ltd.

Standing, H., & Kisseka, M.N 1989. Sexual Behaviour in Sub-Sub-Saharan Africa: A Review

       and Annotated bibliography. London: Overseas Development Administration.

Stephen, B 1997. “Wife Inheritance Spurs AIDS Rise in Kenya.” Washington Post Foreign

Service

Stuart Rennie, S, Muula, S, & Westreich, D. (2007). Male circumcision and HIV

prevention: ethical, medical and public health tradeoffs in low-income countries
J Med Ethics, Vol. 33, pp. 357-361

UNAIDS/UNESCO 2000. A Cultural Approach to HIV/AIDS Prevention and Care.  Proceedings

of the Nairobi International Conference.

UNAIDS and World Health Organization 2002. AIDS Epidemic Update. Geneva

USAID AIDSCAP/Family Health International 1996. AIDS in Kenya: Socioeconomic Impact

and Policy Implications.

UNAIDS (2008). Sub-Saharan Africa: AIDS epidemic update (regional summary)

April 16, 2008. Retrieved November 19, 2008, from

http://data.unaids.org/pub/Report/2008/JC1526_epibriefs_subsaharanafrica_en.pdf

UNDP (2004). Reducing Disaster Risk – A challenge for Development. New York. Sage

Publishers.

[1] There is a case of a nineteen year old Ugandan school girl who was lured into unprotected sex by a wealthy man on the promise that he would pay her school fees. The girl ended up getting infected with HIV. Cases like these are very common in Africa due to women’s marginalization. (Opportunity International 2007)

[2] The term “mitumba” refers to second-hand clothes, popular among the Kenyan impoverished population. A mtumba dress can retail for less than a dollar.

[3] In Luoland, AIDS is often misconstrued as Chira, or a curse that the almighty God bestows on anyone who willingly or unwillingly offends the customs of their ancestors or breaks a taboo. An individual who has been possessed by Chira is supposed to experience weight loss, mysterious illness, weakness, and eventual death. In the thinking of the local Luo community, AIDS and Chira look the same, so they must be treated as one. (Swan 2008)

[4] “Three months after George Dola inherited me due to financial constraints, his second wife died. He was soon taken ill and did not last long. Before he died in 1997, he tested positive for HIV. So I knew he had died of AIDS.” –Pamela Dola, a HIV positive widow from Bondo, Nyanza Province. She now has the responsibility of feeding eight children (Plus News 2005).

[5] “In the hours after James Mbewe was laid to rest three years ago, in an unmarked grave not far from here, his 23-year-old wife, Fanny, neither mourned him nor accepted visits from sympathizers. Instead, she hid in his sister’s hut, hoping that the rest of her in-laws would not find her. But they hunted her down…and insisted that if she refused to exorcise her dead husband’s spirit, she would be blamed every time a villager died. So she put her two children to bed and then forced herself to have sex with James’s cousin.” – Case in Zambia reported by Lafraniere (2005)

CategoriesUncategorized