The relationship between migration and the spread of HIV has been determined in multiple contexts [1-3]. This connection may be due to frequent travel between work and home country, with an increased risk of sexual behaviour with multiple concurrent partners [4,5]. The term ‘mobile men with money’ is one of the latest risk categories to enter into HIV prevention discourse. Used in countries in Asia, the Pacific and Africa, it refers to diverse groups of men (e.g., businessmen, miners and itinerant wage labourers) who, in contexts of high population movement and economic disparity, find themselves at heightened risk of HIV as members of a ‘most-at-risk population’, or render others vulnerable to infection [6-8].
Fisherfolks in Sub-Saharan Africa are highly vulnerable to HIV and AIDS . A combination of high-risk behaviour, poor health and sanitation, high mobility within generally isolated areas and a lack of services renders fisherfolk increasingly vulnerable to HIV and other [10,11]. Studies in the Lake Victoria region, where HIV and AIDS had a devastating impact, have provided insight into the environmental, structural and social factors that contribute to vulnerability in a livelihood sector that is crucial to the food and nutrition security of millions of people . However, mobile populations are known to engage in high risk-behaviour, such as having unprotected sex with multiple sexual partners. A study in Kenya by Ombere et al., has shown correlations between HIV and migration status of circumcised fishermen . However, to date, sexual behaviours of circumcised fishermen have not been fully explored to find out other existing sexual behaviours that may lead to HIV infections.
Averagely, Kenya is one of the six HIV high burden countries in Africa and has a HIV prevalence rate of 6%, and with about 1.6 million people living with HIV infection . The western part of the country through Homabay, Siaya and Kisumu are the most affected with HIV rates of population of reproductive age at 25.7%, 23.7% and 19.3% respectively . The promotion of VMMC in Kenya is linked to a broader intervention by the World Health Organization (WHO) and the joint United Nations Programme for HIV/AIDS (UNAIDS) to encourage medical Male Circumcision (MC) for HIV prevention in 14 priority countries with high HIV prevalence and low MC rates . VMMC was launched in the wake of evidence from three large Randomized Controlled Trials (RCTs) involving over 11,000 participants, which suggested the procedure could reduce female-to-male transmission of HIV by up to 60% [16-18]. This does not guarantee real protection since circumcised men also get infected even a demographic impact since fully circumcised ethnic groups have the same HIV epidemics than others.
Kenya adopted VMMC program in 2008. Since then, the program has been scaled up from about 8,000 VMMCs performed annually in 2008 to 190,000 in 2013 . Over this five years period, about 670,000 VMMCs were performed against a target of 860,000; which means 77% achievement of the target. About 50% of the males circumcised were aged 15-19 years and about 80% of the VMMCs were conducted in Nyanza region. The overall coverage of circumcision among men aged 15-49 in the country is estimated at 91% . Nyanza region had the highest increase in the number of VMMC from 48% to 66% between 2009 to 2015 however, Nyanza still records a high number of HIV infections. Currently, sustaining Voluntary Medical Male Circumcision (VMMC) among traditionally non-circumcising communities forms part of the National AIDS Strategic Framework 2015-2019 [13,14,19].
In some African countries, Voluntary Medical Male Circumcision (VMMC) has been scaled up as a partial HIV protection for men and by extension protection to their sexual partners. It has been introduced into settings where male circumcision existed, either for religious reasons (in the case of Islam, for example) or as a rite of passage marking the transition from boyhood to manhood . Traditional circumcision rituals have been subject to change because of the missionary, colonial and post-colonial influences, including the introduction of medical male circumcision [21-23]. While VMMC may not be seen as a substitute for traditional circumcision practices because of the value placed on a ritual which tests the bravery of the boys, a shift towards VMMC because of safety concerns is being observed in some settings .
A key concern since the outset of the epidemic has been that population mobility may be responsible for the onward transmission of HIV . This may be especially true of fishing communities whose members migrate seasonally in pursuit of their occupation. While away from home, the social power structures that guide sexual norms may no longer be felt [24,25]. On the beach and in other settings where fishermen work, social ties are based more on economic relationships and occupational peer-group interactions, providing less restricted sexual and behavioural norms [11,26]. For this reason, a fishing community lifestyle, therefore, has been cited as one of the reasons for high rates of HIV infection in Nyanza region [8,27]. Additionally, mobile populations are known to engage in high risk behaviour, such as having unprotected sex with multiple sexual partners. Studies in different parts of Sub-Saharan Africa have found strong correlations between HIV and migration status [8,11]. Luo fishermen in western Kenya, as in many other parts of the world, are highly mobile, often staying away from their families for long periods and interacting with women who trade in fish. Few studies describe the details of sexual behaviour of fishermen, even after medical circumcision.
Although studies in Kenya have shown that among other factors the time fishermen spend away from home looking for fish offshore has acted as one of the catalyst to HIV infections among the non-circumcised and migrating circumcised fishermen, there is a gap in explaining when and how this risky sexual behaviours begins and how it can lead to high rates of HIV infections . Therefore, in this paper sex in green lodge which refers to a night sexual intercourse in the bushes at the lake shore mainly between fishermen and female fishmongers, exposes when the risky sexual behaviour among circumcised fishermen is likely to begin. It is sometimes also referred to as ‘quick sex’ by the fishermen. After medical male circumcision, men’s sexual behaviour change may be either protective against HIV, or it may provide a greater risk for HIV transmission when they engage in unprotected sex with multiple partners of the opposite sex. Bailey et al., noted that in Kenya, more circumcised men reported having two or more sexual partners at six months after voluntary medical male circumcision and more unprotected intercourse at 24 months . However, Bailey et al., noted increase in risky sexual behaviour following medical circumcision among men, showed that VMMC did not lead to risky sexual behaviour . Notably, the foregoing studies did not focus on sexual behaviour of medically circumcised fishermen. Therefore, in this paper we sought to address this complex set of concerns by looking at the practice of sex in the green lodging as a risk sexual behaviour pattern among medically circumcised fishermen on the shores of Lake Victoria in western Kenya. Sex in green lodging refers to sexual intercourse that occurred in the bushes at the lake shore.
The study was conducted out in Usenge Sub-Location situated in Siaya County in Western Kenya. The sub-Location has an estimated population of about 21,931 out of which 11,027 are male and 10,904 are female . The area is mainly inhabited by the Luo people ethnic group. Out of 6200 male adults aged 15 years and above, approximately 2,100 were circumcised by the end of the year 2015 (Bondo District AIDS/STD Control Records, 2015). The study area is situated along the fish landing beach line on the shores of Lake Victoria. However, being a fishing community, there are different ethnic groups from Kenya and neighbouring countries as people come to look for economic opportunities. It is a region with high HIV prevalence due to activities related to fishing and low condom use [13,29,30]. Within the Sub-Location, three beach settings (Usenge, Uhanya and Anyanga beaches) were purposively selected for this study because they had high activities related to fishing and low male condom use . However, out of eighteen villages in Usenge Sub-Location, eight villages linked to fish landing beaches also formed the study area. The eight villages had busy markets for fish from the selected fish landing beaches and also had entertainment places used by local residents and fishermen.
According to Central Bureau of Statistics (CBS), the primary economic activity in the study area is fishing which also provides some manual jobs for local people and also acts as a source of livelihood . The inhabitants also practice subsistence farming while young men sometimes engage in touting, bicycle and motorcycle Boda boda taxi business . Local people and emigrants from other parts of Kenya also run small-scale businesses such as small retail shops, pubs, local brews and food kiosks.
This study was conducted between August 2013 and January 2014 to explore the socio-cultural context and its relationship to circumcised men’s sexual behaviour after VMMC. Qualitative methods were employed. We used a cross-sectional study design to obtain a snapshot picture of what was happening in the study area hence was useful in capturing information within a short period. Thirty in-depth interviews were conducted with medically circumcised fishermen who were purposively selected based on the nature of their economic activity (fishing) which had been cited as one of the predisposing factors to HIV and AIDS in the lake region . A VMMC mobiliser who had worked for Nyanza Reproductive Health (a non-governmental organization doing medical male circumcision) and knew majority of medically circumcised fishermen (circumcised during the VMMC program scale up) in the region helped during the recruitment of legible respondents. In-depth interviews were followed by key informant interviews with beach leaders in the three selected beaches and Focus Group Discussions (FGDs) with circumcised fishermen. The FGDs comprised 7-12 recently circumcised fishermen in each of the sessions. The focus-group sessions were arranged in convenient and neutral spaces suggested by the fishermen. All participants provided informed consent and were reassured about the confidentiality of their entire involvement in the study. No participants declined to participate or withdrew from the study. The researchers led a team of two research assistants in conducting thirty in-depth interviews, three key informant interviews and six FGDs. The interviews were audio taped. The interviews were mainly done in Dholuo (the local language) and the responses from the respondents were back-translated to English.
Selection of Study Participants
The study employed purposive and snowball sampling methods to access the circumcised men. A VMMC mobiliser who had worked for Nyanza Reproductive Health (a non-governmental organization providing medical circumcision in the study area) and knew majority of circumcised fishermen in the study area helped recruit the study participants aged between 15 to 49 years. The three beach leaders were also purposively selected to provide their opinion on sexual behaviour of fishermen in the beach.
Data analysis began while the fieldwork was in progress. The researchers took note of emerging themes and how these developed in the course of the research. Data from in-depth interviews, key informant interviews and focus group discussions were analyzed through a contextualized content analysis by the first author who transcribed the data and a data analyst who had a solid foundation in qualitative methods had helped in identifying the emerging themes. All transcripts were verified by a second member of the research team against the audio recording for accuracy and any discrepancies were reconciled. Qualitative inquiry enabled the participants to present their perspectives and views in their own voices, which is very important when exploring an individual’s sexual behaviour. Qualitative data is presented here in the form of textual descriptions and illustrations using verbatim quotes.
Ethical permission for the study was obtained from Ethical Review Committee at Maseno University. Research participants were informed about the nature of the study, that participation in the study was entirely voluntary, and that they could stop the interviews at any time. Informed consent was obtained before data collection from all participants and the respondents were assured of confidentiality. Respect for human privacy and dignity was maintained throughout data collection and analysis. Informants are given pseudonyms in this paper to protect confidentiality and anonymity. A summary of the study findings was made available to the participants in a dissemination process through Usenge Sub-Location assistant chief’s baraza or formal community meeting, after the study.
A total of 30 circumcised fishermen were recruited to participate in this study. Out of 30 circumcised fishermen 21 were married while 9 had girlfriends. Averagely, there were at least 9-10 men who were circumcised fishermen in the six focus group discussions. However, participants were recruited who differed with respect to ethnic group, age and county of origin. The results of the analysis are presented below. Respondents have been allocated pseudonyms to ensure confidentiality. The primary goal of VMMC is to reduce heterosexual transmission of HIV and AIDS. Therefore, before and after circumcision men receive risk reduction counseling and that getting circumcised is instrumental in changing their sexual behaviour. However, despite the fact that the respondents in this study were circumcised fishermen who were suppose to adapt safe sexual behaviour, they still engage in high-risk sexual behaviours that place them and their partners at risk for HIV. Sex in the bush emerged as one of the leading risk sexual behaviour that fishermen engage in. Sex in the bushes is an existing transactional sex and sex outside of the fishermen’s primary relationships that acted as a risk factor for HIV infections. Sexual intercourse occurs at dawn when women come to collect fish from the fishermen.
During dawn, sex is done in a hurry and, in most cases there are infrequent uses of condoms. Moreover, fish were given to the women who engage in such risky sexual practices at a subsidised price compared to other women. Fishermen also noted that sex in the bush was a secret of fishermen or a fishing crew both circumcised and non-circumcised. Fishermen noted that it was a way of catching up with the married female fishmongers whose husbands were strict on them. Married fishermen reported not using a condom in their primary relationship while fishermen who were single noted that they do not use condoms consistently during sexual intercourse because they were circumcised and according to them this acted as a safe ‘backup’ against HIV infections.
As one respondent explained: Yes, fishing is good. We have sex in the green lodging; I mean the bushes at the lake shore. First, I agreed with the woman on how we will do it. Because today fish is scarce, so the woman agrees to my terms. So our usual time is between 4.30 am to 5 am. We meet here at the shore and the first thing is to go to a nearby bush have sex then she comes for her fish. And we do it in a hurry no time for romance. Some of these women are married and their husbands who are busy out there are very strict on their movement, but I manage to get them. However, sex in the bush is practiced by both circumcised and non-circumcised fishermen. After all we are circumcised and at least protected against HIV and AIDS (Opija, unmarried, in-depth interview respondent, 29 years old).
Another man explained: It is something we had agreed on, so she comes and quickly we go to the bush do it faster. Being that am also circumcised I don't use a condom. By the way, you know during that time I am cold, and she is warm and I had spent my night in the cold, so everything is like an automatic car. I mean we become ready instantly. Sex in the bush is a secret that most fishermen cannot tell you. During the day we assume nothing happens but at dawn am the darling when she comes at the shore. So whether the husband is strict, I know when to get her. Maybe somebody might also be doing that with my wife when am in the lake, but she is not a fishmonger anyway. (Omid, married, in-depth interview respondent, 40 years old).
Migration and staying away from home beaches also emerged as an issue that encouraged sex outside primary relationships while for single fishermen it was an opportunity to explore and get new sexual partners. Unmarried fishermen noted that during migration from one beach to another, they built their sexual networks. From in-depth interviews, it also emerged that unmarried fishermen’s sexual networks in the destination beaches acted as a way of obtaining new customers for their fish and that transactional sex provided access to new customers who later on benefited from getting fish from the fishermen at the shore. From in-depth interviews, key informant interviews and FGDs, it emerged that sex-for-fish is a common practice along the fish landing beaches in the study area. Moreover, it was commonly mentioned by respondents that in the destination beaches, circumcised men quickly got into sexual relationships and they don't care to know their new sexual partners HIV status. Despite the fact of getting into short-term relationships in these beaches, some men still had sexual partners to meet at dawn at the lake shore.
As one beach leaders explained: You know these beaches I cannot deny, men and women form relationships mainly on some benefits like one give fish and the other gives sex. But they are consenting adults and as beach authority, I cannot follow them everywhere including where they migrate. I know that VMMC is good, but there is still need for more sensitization and education specifically to our fishermen on other HIV prevention measures. Even if you go to nearby beach sex between fishermen and the female fishmongers is not something strange though some of them are secretly done. I don't know what can be done to minimize the spread of HIV along lake regions in Nyanza region (Ogwal, beach leader, 50 years old).
Another man explained: Due to the scarcity of fish in Lake Victoria, we have to move to new beaches looking for more fish. In those beaches, we get new girlfriends whom we sometimes stay with and sometimes they are just hit and run. So most of my crew members have at least one or two sexual partners who give them warmth when they feel cold. But sex for fish is there. I give you fish you give me sex. However, some crew members have secret lovers who are married and the meeting time is usually at dawn when the woman comes to collect fish at the shore. They rush to a nearby bush and do their things (referring to sex) then come back. However, we keep it secret because we are like brothers here. (Madhar, head of fishing crew, in-depth interview respondent, 40 years old).
Another man added: Am not hiding anything, we are all circumcised here. If you give fish and expect sex later during the day I tell you, it will not be possible. But it is our secret, some women are married, some from town, some are widows and some are single. We know each other’s ‘girlfriend’ so when giving out fish or omena (another species of fish) ‘girlfriend’ has to get more and that is well known. But when we migrate to new beaches there everyone tries to get a new catch which is not a difficult task anyway. In the near future, I think we will need condoms in our boats because I hear HIV is very high along the lake. In the new beaches, we don't even bother to go to VCT first to know our status with new ‘girlfriends.... no time for VCT (Kiwilra, male focus group discussion participant, 30 years old).
The overall objective of this study was to explore the socio-cultural context and its relationship to circumcised men’s sexual behaviour after VMMC. VMMC has been rolled out in many parts of Sub-Saharan Africa as part of HIV prevention initiatives. It is worth noting that VMMC has led to the reduction in the number of HIV infections in a many countries Kenya being one of them. The findings indicate that in their daily activities at the lake onshores and offshores, circumcised fishermen engaged in transactional sex a behaviour that other studies had identified as a catalyst to the spread of HIV along Lake Region . Sex in the green lodging has been a form of transactional sex, which other studies have not investigated but exposes circumcised fishermen to HIV infection. However, despite, the post-VMMC counseling received by circumcised fishermen, sexual intercourse in the bush, which was referred to as ‘green lodgings’ by the fishermen mainly occurred without any HIV prevention measure. Recent research among circumcised fishermen along Lake Victoria also indicated that some circumcised fishermen along Lake Victoria associated VMMC with the belief that it acted as a perfect protection therefore, condom use or other protective measures were no longer necessary . From this study it emerges that despite massive campaigns for VMMC targeting the most at-risk population such as the fisherfolks, the practice of sex in the bush along Lake Victoria region still put circumcised fishermen at substantial risk of HIV infection.
Apart from sex in the bush, overfishing and environmental changes have led to gradual diminishing in the fish population. This has resulted in low catch and increase in demand for fish . Therefore, domination of the fishing industry by gendered structure, where in most occasions men are involved in catching fish and women in purchasing and processing of fish, female fishmongers do not have alternatives but to engage in transactional sexual relationships to sustain fish supply continually . Notably, the gendered power balance acted as a driver for HIV vulnerability in circumcised fishermen. However, power balance is a risk for women, as it puts them at a disadvantaged position in negotiating condom use during transactional sex. Therefore, we argue that despite being circumcised, fishermen along fish landing beaches of Usenge sub location are still at substantial risk of HIV infection.
Previous studies on fishermen have also shown the association of little fish catch and high demand has resulted in increased risk of acquiring HIV and other sexually transmitted infections due to transactional sex [10,25,32,33]. Research in the fishing communities around Lake Victoria also indicates that upwards of 30% or more of fisherfolk are infected with HIV, a level of infection higher than those documented among fishing communities in other countries . From the study findings, it has also emerged that sexual intercourse occurred in a hurry and there was no time to negotiate for condom use and the participants viewed VMMC as an additional ‘backup’ against HIV infection. According to Dunkel et al., and Okumu having sex is not in itself risky, however lack of time and power to negotiate for condom use also catalyzes vulnerability to HIV infections [31,34]. Transactional sex has frequently been associated with intimate partner violence, situations in which women are often unable to negotiate condom use and intergenerational sex which further exacerbates power differentials over the terms and timing of sexual interactions . This could lead to the risk of HIV infections.
The study findings also reveal that just like in other parts of the world, fishermen in Nyanza, are highly mobile in search of large catches of fish. In most occasions, fishermen migrate to other nearby beaches where they interact with women who trade in fish. On destination beaches, fishermen get new sexual partners whose HIV status are unknown to them and condom use is reportedly very low. Migrating fishermen sometimes spend long periods away from their families and local communities . While away from home, the social structures and hierarchies that guide sexual norms are no longer observed and sometimes earning high incomes, they are more likely to engage in unprotected sex [11,24].
One major limitation of the study is as much as sex in the bush emerged as a risky behaviour based on views of circumcised fishermen, women’s perspectives were not sought to corroborate what circumcised fishermen had said. Moreover, views of uncircumcised fishermen were not sought. Additionally, these results are based on self-reported experiences. People are sometimes unwilling to share personal information concerning their sexual behaviours, therefore it is possible that some respondents fabricated their responses during the interviews.
Fishing communities have been recognized as a key population at higher risk particularly in Sub-Saharan Africa. In this study, circumcised fishermen described the nature and context of their sexual behaviour which compromised their ability to practice safer sex. Sex in the bush clearly facilitates the spread of HIV in the fishing communities. The study has also confirmed that HIV vulnerability among circumcised fishermen was also driven by high mobility and migration, transactional sex and gendered power imbalances. As such there should be an effective behaviour change communication targeting fishermen post-VMMC. Beyond effective behaviour change communication, including information about the dangers of HIV/AIDS, the lack of protection following circumcision and the importance of safe sex and condom use, fishermen should be provided with general education and empowering information on diversification of income generating activities during seasons of low fish catches.
Authors wish to Acknowledge research assistant Joram Ochieng and circumcised fishermen from Usenge Sub-Location for their time and contributions in this study. This study had no any source of funding.