How to Protect a Town with One of the Highest HIV Infection Rates

Homa Bay is both a bay and a town in Kenya. A visitor to the bay’s outskirts, standing atop the rugged Asego Hill, would see a place of golden sunsets and breathtaking scenery. But once he ventured down to the streets of the town, he would see a city struggling to find its infrastructural foothold—one in which one-fourth of residents are infected with HIV.

Homa Bay has one of the highest infection rates in the world. If grave-digging were a reputable profession here, the entrepreneurial and morbid could make a small fortune: As William Hennequin, Médecins Sans Frontières (MSF) head of mission observed, there are high rates of mortality among sick patients receiving hospital treatment. This prompted the international humanitarian NGO to initiate a pilot intervention program in an attempt to reverse the trend of the epidemic in Ndhiwa, a HIV hotspot in Homa Bay.

Homa Bay has been declared by the National AIDS Control Council of Kenya to be in the throes of a health crisis. But understanding why that is—why the HIV rate here soars as high as it does, and what convergence of factors makes it so—can help us understand HIV in 2015 more broadly.

Fish for Sex

Kenneth Otieno, a subsistence farmer, left his home for the lake to become a fisherman. Having no means to secure his own fishing vessel, he resorted to laboring for other boat owners for a paltry payment of a few pieces of fish for an entire night's drudgery. He could hardly sustain himself on this arrangement. Fishing was not as lucrative as he had anticipated, and, more often than not, he caught more water than fish. He almost called it quits until sheer desperation ensnared him in the murky world of ‘kept husbands.’

“I was desperate to make ends meet. In the process, I got introduced to a woman who offered me a fishing vessel to man. Hardly could I decline,” says Mr. Otieno in an interview. “Strangely, she was to later offer to cater for my other needs, including food, clothing and even rent! Before long our friendship blossomed into a ‘husband and wife’ arrangement. We still are, even though I have a wife at home.”

Because of the town’s proximity to Lake Victoria, its natives are predominantly fishermen. Consequently, decades of uncontrolled fishing has diminished the fish population. Competition is thus stiff for fishermen, and also for female fishmongers. As a result, some female fishmongers are known to ‘keep husbands,’ an arrangement that gives them preferential treatment in the supply of fish for trade. It’s not unusual for these highly mobile women to ‘keep’ more than one husband, in addition to their actual marriages.

On the flip side, local fishermen have also polished a culture of seeking sexual favors from female fishmongers. For the compensation of buying fish at a much lower price, the women grant sexual favors to the fishermen, a phenomenon that experts say has furthered the spread of HIV. Novices often have almost no hope of securing a basket of fish without (at least) one sexual liaison. But men and women alike end up with more than fish from the arrangement, as unprotected sex with multiple partners allows HIV to spread more, and more quickly. Mr. Otieno, who is now on HIV medication, admits that most people, especially fishermen, often have unprotected sex, thereby exposing them to HIV infections.

Wife Inheritance

Philomena Nyakundi lost her husband to a road accident in 2008. Village elders prevailed upon her to get inherited—that is, to become the wife of one of her late husband’s relatives, ostensibly in order to cleanse her of the curse of death—according to tradition. When she showed slight hesitation, her father-in-law directed her to adhere to their customs or hit the road. With no means to fend for her four children, she caved in to the demands of tradition and got inherited to a cousin of her deceased husband, whom, apart from his three actual wives, had two other inherited women. She is now 37 years old and living with HIV.

“About two years into my inheritance, frequent bouts of sickness became the norm for me. At one point, I became seriously sick; I got admitted at the hospital,” Nyakundi said. “I underwent several tests and was found HIV-positive. While I was at the hospital, one of my co-wives was also admitted and also confirmed positive. Unfortunately, she died.”

Tradition does not limit the number of widows a man can inherit. It is not uncommon for the so called ‘cleansers’ to inherit several widows at a time. With multiple sexual partners, this has become another conduit through which HIV has ravaged the local population. Pamela, a psychosocial counselor at the MSF clinic in Homa Bay, said that women often complain of being disadvantaged when it comes to the choice of having protected sex. “Women say their male partners have turned a deaf ear to the idea of using condoms. Broaching the subject has led to violence against some of the women, who eventually consent to unprotected sex.”

Circumcision and Condom Use

Mathews Nguka considers himself a strict traditionalist. Surprisingly alert for his age, the elderly man—he is 87 years old—bemoans the demise of tradition among the contemporary generation. Nguka insists that he is still opposed to the concept of VMMC, or Voluntary Medical Male Circumcision. “My people did not circumcise our males. Not as a rite of passage. Not on any grounds. Instead, we used to remove six lower teeth to mark the transition into adulthood. Circumcision was an outlandish practice common with other communities, like the Luhya. We were never circumcised!”

While male circumcision has been touted to reduce the risk of female-to-male transmission of HIV by 60 percent, the Luo community, including that which lives around Homa-Bay, does not circumcise their males as a rite of passage, as opposed to other communities in Kenya. As such, exposure to infection is comparatively high. Circumcision came with the dawn of VMMC campaigns in 2008, an exercise that still faces challenges. Men over the age of 25 are still reported to decline the cut.

Whilst specific data on condom use is not readily available, occasional condom shortages caused by erratic supplies are not uncommon. But even with condom availability, cases of unprotected sex, as well as early sexual debut, abound. In 2013, the media carried reports of 11 teenage girls between grades four and eight who became pregnant in the third term of school at a primary school in Ndhiwa sub-county of Homa Bay. The situation has been widespread in schools, prompting regional political leaders, including the County Governor himself, Hon. Cyprian Awiti, to agitate for stiffer penalties against culprits in an effort to curb the steady rise of school pregnancies. With a largely uncircumcised populace indulging in unprotected sex, it is not difficult to see why HIV infection has been high.

To Keep HIV at Bay

If there is a common theme to all of these stories, it is this: If communities in which the spread of HIV is particularly prevalent are to have a chance of surviving, they need to bring preventative progress—protected sex and agency for the unempowered, particularly women—into their tradition. Conversely, those outside the community who are actively attempting to thwart the spread of HIV need to understand the traditions of the communities with which they’re working. That won’t be easy for either party, but it’s necessary to keep those in towns like Homa Bay—those who cannot simply ascend back up to the golden sunset of Asego Hill and on to their next journey—alive.