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African Journal of AIDS Research 2014, 13(4): 383–391 Printed in South Africa — All rights reserved

AJAR

ISSN 1608-5906 EISSN 1727-9445 http://dx.doi.org/10.2989/16085906.2014.985238

Practice of sumo kodhi among the Luo and implications for HIV transmission in western Kenya Charles Omondi Olang’o1,2,*, Erick Nyambedha1,2 and Jens Aagaard2 Sociology And Anthropology, Maseno University, PO Box 333, Maseno, Kenya Steno Health Promotion Center, Steno Diabetes Center, Steensens Vej 8 DK-2820, Gentofte, Copenhagen, Denmark *Corresponding author, email: [email protected]

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This paper discusses the practice of sumo kodhi among the Luo ethnic group and its implications for spread of HIV in western Kenya. Sumo kodhi is a practice in which a woman arranges to have sex with a man other than her legitimate sexual partner (husband or levir/inheritor) to give birth to children with specific qualities she wants in them. Data were drawn from a 16-month ethnographic study on reproductive aspirations of women living with HIV/AIDS (WLWHA). The study found that WLWHA engaged in sumo kodhi as they believe they will get gender balanced, beautiful, and academically talented and healthy children who are free from HIV. The WLWHA targeted agnates of their husbands living in distant villages, former boyfriends (before marriage) and other men who were new in the area such as civil servants, employees in local institutions and businessmen who would not suspect their HIV status. These WLWHA kept their HIV status secret and exposed the targeted men to the risk of being infected with HIV. It can be deduced that having knowledge of HIV status does not always translate into taking action towards protecting sexual partner(s). Moreover, continued childbearing is not always as a result of unmet contraceptives needs. It is apparent from this study that social factors sometimes overrule health considerations. The study recommends that further research be conducted among other ethnic groups to gauge whether they also have a practice similar to sumo kodhi. Women living with HIV/AIDS should be involved in HIV/AIDS control and prevention strategies. There is also need for an intervention that would ensure that WLWHA meet their reproductive aspirations without putting their sexual partners at risk of contracting HIV. Keywords: HIV/AIDS, pressure, reproduction, risk, societal

Introduction ‘I desire to give birth to another child, although I haven’t got the right man. Currently, I have only one child. But having one child is like being with “one eye’, if he dies, I remain with nothing. I don’t want to get a child with my current sexual partner because I don’t like his demeanor. I want a child with good qualities’ (Atieno, 28-year-old HIV-positive woman). The quote draws attention to the practice of sumo kodhi among the Luo of western Kenya. In Dholuo, a language spoken by the Luo ethnic group, sumo is derived from the word kisuma, which literally refers to going to beg for foodstuff from a relative or friend in a different region when one is faced with food shortage (Odaga 1997). Kodhi means ‘seed’ (Odaga 1997). Sumo kodhi, in the context of getting a child, has been defined by Ng’wena (2012) as a deliberate sexual encounter arranged between a married woman and a man other than the husband with the intention of conceiving. However, this definition given by Ng’wena (2012) may be limiting as it excludes widows who engage in a similar practice. In this paper, sumo kodhi refers to a practice where a woman deliberately arranges to have sex with a man other than her legitimate sexual

partner (husband or levir/inheritor) to get a child with certain qualities she desires for them. Traditionally, sumo kodhi among the Luo ethnic group is carried out under specific circumstances, namely: when (1) a family suffers from chronic hereditary diseases; (2) a woman continuously gives birth to girls; (3) a woman consistently experiences stillbirths; (4) the husband is impotent (bwoch); and (5) a woman desires some special qualities not found in her husband (Ocholla-Ayayo 1976, Ng’wena 2012). Similar practice is also found in other ethnic communities in Kenya. According to Mbiti (1969), in the Akamba ethnic community, a woman is encouraged to get at least one child outside marriage if the family is known to have a history of mental illness, genetic disorders or if a man is cursed by his father and there is a possibility that the curse could result in the death of the entire family. So, it was necessary to have a child from a different man to ensure that such a child survives for the continuity of that family. Within the Luo ethnic group, in sumo kodhi, a woman is advised by her kin members, especially her mother-in-law, to “talk well with her brothers’ or cousins’-in law (ywoche)” to sire children with her (Ocholla-Ayayo 1976: 141, Ng’wena

African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

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2012: 38). Ocholla-Ayayo (1976) writes that the woman then identifies one brother-in-law or cousin-in-law to cohabit with so she can conceive. The woman is not supposed to change from one man to another to avoid shame for the family. The situation is kept secret and traditionally does not involve the neighbours (libamba) for fear that they could reveal such secrets during conflicts or during social gatherings such as traditional beer parties (Ochola-Ayayo 1976, Ng’wena 2012). A woman engaged in sumo kodhi is not supposed to disrespect her husband or make such a relationship routine (Ocholla-Ayayo 1976, Ng’wena 2012). Where the husband is not impotent but the woman bears children with another man, she must be cautious not to let the husband know that he is not the biological father (Ng’wena, 2012). A child born out of such sexual liaison grows up in the family without any discrimination (Ng’wena 2012). Ng’wena (2012) adds that in cases where sumo kodhi is arranged to look for a particular gender, for example a boy, and the woman succeeds, it is believed that luck will befall her and the subsequent children born to the real husband would be boys. This means that after getting a boy child, the woman is advised to cease such external sexual liaisons and try her luck with her husband in subsequent births. On the part of widows, levirate unions were not only for cleansing purposes but also to bear children for continuity of the deceased husband’s lineage (Potash 1986, Weisberg 2009). Traditionally, a widow chooses a levir among the deceased husband’s brothers or his agnates but in rare cases extends beyond family relations (Potash 1986, Prince 2004, Weisberg 2009). Potash (1986) writes that Luo widows maintain high degree of autonomy in their choice of sexual partners. Although a Luo widow is supposed to get children with her legitimate sexual partner (levir/inheritor), she may still engage in sumo kodhi just like married women. While the practice of sumo kodhi exists among the Luo community (Ocholla-Ayayo 1976, Potash 1986, Ng’wena 2012), its implication on the spread of HIV has not been studied. Even though Delvaux and Nostlinger (2007) observed that assisted reproduction techniques can help prevent HIV transmission from women living with HIV/AIDS (WLWHA) to their male sexual partners, this may be difficult in low socio-economic settings. For example, in Kenya few hospitals provide assisted reproductive technology services and the cost is very high for local standards, approximately US$4 000 per trial (Murage et al. 2011). Thus, WLWHA may be left with no option but to have unprotected sex in order to become pregnant. This paper describes the practice of sumo kodhi among WLWHA and its implications for the spread of HIV among the Luo of western Kenya. Methodology The study setting The study was conducted in two sub-locations, West Migwena and Nyang’oma, of Central Sakwa location, Nyang’oma division, Bondo sub-county in western Kenya. Central Sakwa location is situated along the shores of Lake Victoria and is inhabited mainly by the Luo ethnic group. The area receives unreliable rainfall and is food insecure (Nyambedha 2006, Olang’o et al. 2012). The Luo ethnic

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group is patrilineal (Ocholla-Ayayo 1976, Nyambedha 2006). The study community mainly practises subsistence farming, fishing and small-scale gold prospecting (Nyambedha 2006). The Luo community has been severely hit by the HIV/ AIDS pandemic. Although the recent Kenya AIDS Indicator Survey (KAIS) of 2012 indicates a decline in the national HIV/AIDS prevalence of 7.8% in 2007 to 5.6% in 2012 for people aged 15–49 years, the former Nyanza province in which the Luo is a dominant ethnic group continues to record high HIV/AIDS prevalence of 17.6% for women and 13.4% for men within the same age category (NASCOP 2014). The high prevalence of HIV/AIDS among the Luo is attributed to widow inheritance (Agot et al. 2010), non-circumcision of Luo men (Bailey et al. 2007) and ‘jaboya system’, a practice where women fishmongers offer sex to the fishermen in return for fish (Nyambedha 2006). The high prevalence is also attributed to sexual practices of long-distance truck drivers from the port of Mombasa through Luo land into the landlocked countries of Eastern Africa (NACC and NASCOP 2012). When the truck drivers stop to rest in the towns in Luo land, they are reported to engage in casual sex with multiple sexual partners, propelling the spread of HIV in the area (NACC and NASCOP 2012). Data collection methods This was an ethnographic study conducted between May 2010 and August 2011. The duration of the study was necessary to provide ample time to observe the dynamics in the reproductive life of WLWHA. These included dynamics in their reproductive aspirations, observation of pregnancy and birth cases and their practice of prevention of motherto-child transmission (PMTCT) of HIV. Purposive sampling was used to select the study participants. The selection first began with identifying 32 key informants, who were in 2 categories. One category of key informants consisted of individuals selected by virtue of being in charge of the HIV/ AIDS patient support programmes in the study area. These included five officials from non-governmental organisations (NGOs), two nurses, one clinical officer and two voluntary counselling and testing (VCT) counsellors from the two healthcare facilities. The two NGOs and two healthcare facilities were then asked to give a list of their most active community health workers (CHWs) in their home-based care programmes. The lists were then compared and 12 CHWs were obtained. These key informants provided data on counselling services offered to WLWHA and what motivates their reproductive aspirations. Another category of key informants were 10 elderly persons aged over 65 years old selected because of their cultural knowledge. They were identified by asking CHWs and local administration such as chiefs and their assistants to name elderly individuals in their clustered villages who are often consulted for their cultural knowledge. In the 2 sub-locations there were 24 clustered villages. The 10 elderly persons gave information on why and how the practice of sumo kodhi has always been conducted in the community. The CHWs were then asked to help locate WLWHA aged 18–49 years, who would voluntarily participate in the study. They identified 39 WLWHA out of whom 23 were selected

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for this study after indicating that they still had reproductive aspirations. The other 16 WLWHA did not to continue with reproduction after knowing their HIV status. The 23 WLWHA were interviewed in-depth and followed over the entire study period. During the long-term follow-up, informal visits were paid to their homes monthly during which they discussed their reproductive aspirations. Five focus group discussions (FGDs) were conducted at the initial stages to help obtain information that would also be used to design interview questions for WLWHA. Two FGDs were conducted with CHWs who were basically women since they were the majority in community health work in the study area (see Olang’o et al. 2010). One FGD consisted of the elderly persons aged over 65 years. The aim of this FGD was to obtain the opinion of the elderly on how sumo kodhi has been conducted over time. The last two FGDs were conducted with young adults within reproductive age bracket (20–49 years of age); each gender was interviewed separately. Each of the FGD sessions had eight participants. The FGDs lasted one hour and were moderated by the principal investigator. The FGDs were tape-recorded and notes were taken by a research assistant. The tape-recorded data were transcribed in readiness for analysis. The data were read and themes were identified from repeated issues. The identified themes were put in different categories. These were: factors motivating sumo kodhi, the categories of men targeted to sire children, adherence to PMTCT of HIV and concern about the genitors’ HIV risk of HIV infection. Selected verbatim quotes from informants have also been used to illustrate the identified themes. Interviews were conducted in the local language, Dholuo, transcribed and then translated to English. The study was approved by the Maseno University Ethics Review Committee, after which a research permit was sought from the Ministry of Higher Education, Science and Technology. Informed consent was obtained from all informants after they had been provided with full information regarding the study. The informed consent was verbal. The principles of confidentiality and anonymity were observed. The names included in this paper are pseudonyms and not in any way linked to the details of the individual participants. Results Socio-demographic characteristics of the women living with HIV/AIDS As Table 1 shows, the study incorporated 23 WLWHA aged between 19 and 49 years. Most (16) of these WLWHA were 20–29 years of age; the other 6 were aged 30–39 years. Only 1 WLWHA was below 20 years (18 years) of age. Whereas 6 out of the 23 WLWHAs never completed primary education, 13 completed but never proceeded to secondary education. One WLWHA joined secondary education but dropped out at form two (lower secondary) while two completed upper secondary and obtained a certificate. All the WLWHA in the study relied on informal small-scale businesses such as selling fish, firewood and charcoal burning.

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Twelve out of the 23 WLWHA were married and 9 were widowed; the remaining 2 were separated. The total number of children each woman had is shown in Table 2 . A total of 17 of the WLWHA gave birth after starting ART; the remaining 6 had aspired to give birth but had not succeeded by the end of the study. In the process of aspiring to get more children, 11 of the 17 WLWHAs who had given birth after starting ART engaged in sumo kodhi. The remaining 6 gave birth with their legitimate sexual partners (husbands or inheritors) and never engaged in sumo kodhi. Sumo kodhi among women living with HIV/AIDS The FGDs conducted confirmed that: ‘Sumo kodhi is a practice that has been there from time immemorial. It still continues today. It is secretly conducted and a woman engaged in the practice keeps it, hence the common say among the Luo that “it is the mother who knows the father of her children”. She chooses the qualities she wants and identifies a man to give her that baby. For men, it is a source of pride for having been chosen to sire the baby — meaning he is socially highly valued. Such a child was never discriminated. In most cases, such children excelled in life — economically and even politically. They include even some prominent politicians among the Luo community today. You only hear people mention about them during political rallies when attacking on one’s personality’ (FGD with elderly persons aged 65 years and above). As previously indicated, 11 WLWHA in this study engaged in sumo kodhi. They were motivated several factors. Firstly, gender of children. Three WLWHA aspired to bear a boy child. The three WLWHA wanting boys were widows. They were under pressure from parents-in-law to give birth to boys who would ensure the continuity of the lineage of their deceased husbands:

Table 1: Age of the women living with HIV/AIDS participating in the study Age categories (years) ≤19 20–29 30–39 40–49 Total

Frequency 1 16 6 0 23

Table 2: Number of living children for the women living with HIV/AIDS participating in the study Number of children 0 1 2 3 4 5 Total

Frequency 2 5 7 4 4 1 23

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Interviewee: ‘I decided to give birth because my husband died when I had only one child and she is a girl. Now, my parents-in-law started telling me to look for a man and give birth to a boy to name after my late husband. They made it like a song where every day they talked about it, albeit my HIV status which, of course, I had told them. I said, for the sake of peace, I just do it. So, I got this boy. He is now six months old.’ Interviewer: Were you inherited?’ Interviewee: ‘Yes, but I didn’t like him. You know, when your husband dies, circumstances can force you to get any man no matter his social status. This inheritor was just a shepherd employed by somebody in this village. I didn’t want to have a child with him. Even my parents-in-law didn’t like him. So, I had to look for another man with better qualities to have a child with. That is, how I got my son’ (Adipo, a 25-year-old HIV-positive widow). This child was six months when the study began. By the end of the study, he was two months away from his second birthday. Apart from pressure from parents-in-law, there were three WLWHA who aspired to bear a girl child for support in household duties. Below is an example: Interviewer: ‘You have said you aspired to get another child; did you prefer a particular gender?’ Interviewee: ‘Of course, I didn’t mind getting a boy or girl, but I really longed to have a girl child.’ Interviewer: ‘Why did you long for a baby girl and not a boy?’ Interviewee: ‘I already had two boys, so I wanted a girl to balance them… [laughs]. You know, boys are often on the side of the father, so I also needed someone like me. A girl can help me cook but boys can’t. When they mature, a girl knows what a mother wants. [She lowers her tone] I want a beautiful baby girl… [Laughs again].’ Interviewer: ‘[laughs too].The way you have presented it, it means the issue of beauty was so much into your heart.’ Interviewee: ‘Yes [laughs softly]. In fact, now that my husband had refused, I got a handsome man to father my baby. I know I am dark. I had to look for a brown handsome man. I assured myself, I would get one very soon.’ Interviewer: ‘Now that you got a baby girl will you still look for additional child?’ Interviewee: ‘No. I rested my case there. Life has become difficult. The three are enough for me’ (Maria, a 26-year-old HIV-positive, discordant woman). Secondly, beauty of children was mentioned as motivating factors to sumo kodhi as contained in the interview with Maria above. Three other WLWHA also held this same aspiration, as Apiyo says: ‘In the family of my husband, they are very dark and their eyes are red, which I don’t like for a baby girl. So, when my husband died, I decided to go for a special quality, brown complexion. You see [she points], look at this my baby girl; she is cute and active like the father. She is a girl that men will

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scramble for and will fetch me good bride price. I love her so much’ (Apiyo, a 33-year-old HIV-positive widow). When Apiyo was asked why she did not consider such a trait of brown complexion before she got married to her late husband, she mentioned that she was still too young and could not gather courage to address that. She got married when she was 17 years old. Thirdly, three WLWHA considered good academic performance as a factor for sumo kodhi. According to these WLWHA, this was because their husbands’ lineages had not produced people who perform well in school. Even the children they already had exhibit poor performance in school: ‘The lineage of my husband is known to be heavy in class [meaning, not academically gifted]. Even the children I have already don’t perform well in class. So, I didn’t want to zero graze [not mate with a man from the same family]. I have to get a child who will be sharp in class. Even if I die, I know a bright child will never fail to get a sponsorship’ (Anyango, a 33-year-old HIV-positive widow). The fourth reason for sumo kodhi was to bear ‘strong, active and healthy children’. Two widows living with HIV/ AIDS believed that when they had a child with a man who is also HIV-positive, the baby would be so weak and possibly HIV infected. They believed that a man’s sperm cells are not only weakened by HIV, but carry the virus that can infect the child: Interviewer: ‘Do you still intend to give birth?’ Interviewee: ‘Yes. I have only one child. I am keenly looking for a man who will give me a strong and healthy baby. But I don’t want to get a weak child.’ Interviewer: ‘How?’ Interviewee: ‘I am HIV-positive, but I don’t want to give birth with a man with a similar problem. I am afraid that his sperm cells are already weak and can pass the virus to my baby.’ Interviewer: ‘Will you take the man for HIV test for you to know if he is fit to give you a baby?’ Interviewee: ‘No. But I will know before I move in with him for the baby’ (Atieno, a 28-year-old HIV-positive widow). The other widow said she lost a child she bore when her husband was bedridden. As a result, she did not want to give birth with a sexual partner who is HIV-positive because she is afraid she would again give birth to a weak or HIV infected child. The fathers of the children As shown in Table 3, three categories of men were targeted to sire children. The first category was husbands’ agnates targeted by three women (two widows and one married woman). Even the widows never went for these men to inherit them. Rather, all three women simply approached and asked the agnates to sire children with them because of their own qualities which they wanted to have in their own children too. These agnates welcomed the idea. The second category was that of the women’s boyfriends before marriage. Among the WLWHA who approached these former boyfriends, two were married and two were

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widowed. They rekindled their former love to obtain kodhi. According to these WLWHA, since they did not marry each other initially, coming back for kodhi was an indication to these former boyfriends that they highly valued them. Whenever they were told about siring a child, they simply laughed and quickly accepted, as Adongo puts it: ‘It was long after we parted ways with my former boyfriend. So, when my husband refused to give me a baby, I looked for the contact for my former boyfriend and one day I called him. He got shocked. But I just told him, I still have him in my heart and I have to go back to get his child that will help me remember him throughout my life. You know, I knew he loved me so much but my dad refused to let me marry him. So, when I told him about this baby, he just laughed and told me to plan and go. On that day, I told my husband I was going to visit my mother for two days and he accepted. When I went, the man met with joy and we had sex. That is how I got this my beautiful baby girl. She has light complexion that I had desired from the man. She is like him… [laughs]’ (Adongo, 26-year-old HIV-positive, discordant woman). Among the widows, one went back to her former boyfriend because she had had a baby with him before she got married. She had liked his qualities, especially academic capability. So, despite being in a leviratic union with another man, she went back to her former boyfriend and told him that she needed another child and the man agreed. The last category was that involving four men who had come to work within and around the study area as civil servants, home guards, shepherds, gold prospectors or businessmen. These workers came from different places, namely Ugenya constituency in the northern part of Siaya county. Other places were Kiambu and Homa Bay counties. For example, a man from Kiambu county sired Atieno’s child. The man had come to do business in Bondo town. Apart from one shepherd approached by one of the widows, the rest of the men were met in social pubs as they drank beer. As acquaintances of such social places, they started developing intimate relations and in the process engaged in sumo kodhi. Adherence to prevention of mother to child transmission of HIV The WLWHA who engaged in sumo kodhi adhered to the required safety practices by strictly following PMTCT of HIV programmes to ensure that their quality children escaped HIV infection. These included regular attendance

Table 3: Categories of the men selected by the WLWHA to father their babies Categories Husbands’ agnates Former boyfriends (before marriage) Men from far places, but work in the area (civil servants, shepherds, gold miners) Total

Frequency 3 4 4 11

of prenatal clinic and delivering at a health facility to ensure that the baby is given treatment against HIV at birth. It also included exclusive breast feeding for the first six months after birth. All the children, except one, tested HIV-negative. The children were frequently tested for HIV and by 18 months, they were confirmed free from HIV infection. These details were not only confirmed by the mothers, but also verified from health records where they attended the PMTCT programmes. The child that tested HIV-positive belonged to a HIV discordant couple. After testing HIV discordant, the husband stopped engaging in sexual intercourse with her. He even stopped supporting her financially. When the woman became pregnant, definitely the husband knew it was out of wedlock. This worsened his hatred for the discordant woman. He remarried and moved to Siaya town about 30 kilometres from the study area and left this HIV-positive discordant wife at home. This discordant woman explained she did not manage to practise exclusive breastfeeding and she it might have led to the transmission of HIV to the child. This child died towards the end of the study period. Risk of HIV transmission to men involved in sumo kodhi The WLWHA targeted men who were HIV-negative. According to these WLWHA, HIV weakens sperms, so having a child with such a man would bring result in a weak child. In the process, none of these WLWHA disclosed her HIV status to the men they engaged in sumo kodhi. Furthermore, these men were new while others lived in distant places and could not suspect these women’s HIV status. When these WLWHA were asked about the risk of transmitting the virus to the men who sired their children; five did not answer that question. The remaining six said they did not care, what they wanted was a baby: ‘Today, everyone knows about HIV/AIDS. The moment a man accepts to have sex without protection, he must be aware he is HIV positive and thinks he has got another volunteer to die with him. So, whether they get infected, I don’t care. What I want is a baby’ (Adongo, a 26-year-old HIV-positive, discordant woman). After some time, Atieno’s and Adongo’s male sexual partners were notified by some of their friends that those women are HIV-positive. When they asked, these two WLWHA strongly denied it. For example, Atieno told her male sexual partner, ‘don’t listen to villagers; they are jealous about our love. But if you doubt, we can go for test.’ This convinced the man that Atieno was being honest with him. For Atieno, this was a psychological game, knowing very well that when the man heard about going for test he would definitely get frightened and fail to go. When Atieno was pregnant, the man accompanied her to the hospital where he was asked to undergo HIV test. Atieno pretended she had not known her HIV status before. Both of them were counselled and tested together. As they waited for the results, the man told Atieno that if he was HIV-positive, he would never return to their home in Kiambu county (in central Kenya) because he would be rejected by his family members. ‘Back there, stigma is still high’, he explained

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to Atieno. Luckily, the man was HIV-negative. Although they were given post-test counselling, Atieno said the man almost went mad. When they returned home, the man slept the whole day and did not get up to eat. The following day he packed his things and left without saying goodbye. He neither called nor took Atieno’s calls thereafter. But according to Atieno, this was not a loss because she had achieved her goal, a beautiful brown baby girl. Similarly, Adongo never disclosed her HIV status to her male sexual partner (her former boyfriend) when they engaged in sumo kodhi. However, later, this man was notified by a friend that Adongo is HIV-positive and they accessed ART at the same health facility. When he called and asked Adongo, she denied it. He asked Adongo to go for the test together, but she refused. He even asked her for the child’s clinic card to see if there would be a clue about her status, but Adongo said she forgot the card at the hospital. After one week of bitter exchange via mobile phone, Adongo’s husband who had noticed what was going on, secretly took the man’s number from Adongo’s phone and wrote him a short text message telling the boyfriend to stop interfering with his family. Since that incident, Adongo stopped going to her maternal home for fear that the former boyfriend might meet and kill her. Adongo secretly monitored the health of this former boyfriend and his family. She sent her brother’s wife (sister-in-law) to spy on them. Adongo’s maternal home and that of the former boyfriend are close to each other, though they belong to different clans. Every time he left for work, Adongo’s sister-in-law went to see his wife. After some time, his wife fell sick and tested HIV-positive. This, for Adongo, was a bargaining point. She called and told him she was now ready for test. However, the man did not reply. Adongo later told him via a text message that he should never allege that she infected him, yet the reverse may be true. She then told him that he is the one who infected her. Because of the risk of HIV transmission, healthcare providers felt sumo kodhi should not be practised any more. Healthcare providers felt that it would be better if WLWHA stopped having children: ‘Inasmuch as I know giving birth is their right, we should not let them put to risk other people’s lives. This is unacceptable and against the law. They already know their HIV status, yet they still do unprotected sex in the name of looking for children. There are those WLWHAs who have children but they don’t want to stop further reproduction. We talk and give them condoms but you only get shocked to see them pregnant’ (A female health care provider). The CHWs, the elderly and young community members who participated in the FGDs also expressed their views. They said that sumo kodhi is still okay, but should not be practised by those already infected with HIV to avoid spreading it to other people. Discussion Several themes have emerged from the data, showing why and how WLWHA went about sumo kodhi and the implications for HIV and AIDS infection. Thus, sumo kodhi among WLWHA and its implications for the spread of HIV can be

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discussed under different themes: (1) factors motivating sumo kodhi; (2) men targeted by WLWHA to father their children; (3) adherence to PMTCT of HIV programmes; and (4) how HIV status is concealed from them. Factors motivating sumo kodhi The results showed that there were both cultural and individual reasons for sumo kodhi among WLWHA. Gender of children emerged as a cultural reason behind sumo kodhi among WLWHA in the study. Some WLWHA wanted boys and others wanted girl children. This depended on the expected roles that these children would play in the home. For example, boys were desired particularly to continue the lineage. This was not just a concern for WLWHA but also for their parents-in-law, who despite being aware that the daughters-in-law were HIV-positive, still put pressure on them to look for men to sire male heirs. This is because the Luo ethnic community, like most other African communities, is patrilineal and continuity of the lineage is appreciated through the male child (Mburugu and Adams 2004). It is also the male child that inherits parents’ property such as land (Ocholla-Ayayo 1976). Hence, a family without a male child has low social status in the Luo community (OchollaAyayo 1976, Mburugu and Adams 2004). However, girls were desired by other WLWHA so that when they become of age they would assist with household duties such as cooking and fetching water. In African society, girls remain around their mothers helping with chores (Erchak 1998). In addition, WLWHA desire girl children who would in future understand and address their material needs, especially clothing seeing as they are of the same gender. The WLWHA desired beautiful girl children. Although beauty may be difficult to define, some of the attributes WLWHA considered include brown complexion and good facial looks. According to the WLWHA, these attributes would make the girls attractive and highly valued. Among the Luo, girls who are not good looking or who have any deformities do not command high bride wealth (OchollaAyayo 1976). They often are married to men of low social status or as second or third wives (Ocholla-Ayayo 1976). This explains why WLWHA in this study aspired to bear girl children with good looks so that in adulthood they would attract men of high social status. Women living with HIV/AIDS were keen to bear children with men from families known to perform well in academics. Good academic performance is an indication of a bright future for the children. This is because good education will give the children good job opportunities. Since colonial times, the Luo community has embraced Western education (formal education) because it leads to good employment opportunities outside home (Cohen and Atieno-Odhiambo 1989, Prince 2004). Cohen and Atieno-Odhiambo (1989) describe how educated labour migrants (jopango) were highly regarded and important ideas were associated with them. So, high intellectual capability remains a highly regarded resource a parent, especially WLWHA, desires in a child. Besides, WLWHA aspire to have bright children who attract scholarships to enable them to pursue their education. Currently, several educational foundations in Kenya, such as the Equity Bank

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Group Foundation, support students who perform well in academics. In addition, the health of their children was a concern for the WLWHA. They wanted children who are strong and healthy, which they believe may only be possible with HIV-negative men. The WLWHA believe that if they had a child with a man who was HIV-positive, the child would be weak and might be HIV infected. As Ocholla-Ayayo (1976) writes, the Luo highly regard children with physical fitness as it determines their performance of the roles expected of them. Weak children or those with health complications are often disregarded. The fathers of the children The study has shown that WLWHA targeted husbands’ agnates, boyfriends they had before marriage and men who had come to work within and around the study area. Although these categories of men were targeted because of their qualities, they were taken advantage of because they could not suspect the HIV status of these women since they were either from far away or new to the area. The men’s cultural knowledge of sumo kodhi also made them complaisant for the idea of sumo kodhi. They considered the love and high regard for their qualities, rather than the health implications. They felt proud to be chosen to sire children, hence willingly engaged in sumo kodhi. Adherence to prevention of mother to child transmission of HIV According to the Ministry of Health (2012), mother to child transmission (MTCT) is the predominant mode of transmission of HIV in infants and young children. Without any intervention, up to 40% of HIV-positive mothers transmit HIV to the children. This transmission occurs during pregnancy, labour and delivery and, among breastfed babies in the post-partum period (Ministry of Health 2012). With the increasing access to PMTCT of HIV programmes, WLWHA have had hope and are beginning to see fruits of strictly following recommended practices because many of their children are testing HIV-negative. The child who got infected is an isolated case and shows that total support for such children is necessary to ensure that the child escapes infection. Risk of HIV transmission to men involved in sumo kodhi In as much as sumo kodhi has served a purpose since time immemorial, in this era of HIV/AIDS, the practice may contribute to continued new infections in the area since the women mainly targeted men who are not yet HIV infected. This follows their fear that giving birth with a HIV infected man would lead to a weak child. Although WLWHA have reproductive rights (UNAIDS 2006, Segurado and Paiva 2007, UNAIDS 2012), access to assisted reproductive technology services that would ensure no transmission of HIV occurs to their sexual partners remains a challenge. In Kenya few hospitals provide assisted reproductive technology services and those that do are too expensive for poor families to access (Murage et al. 2011). Other alternatives would include provision of pre-exposure prophylaxis (PrEP) and post-exposure

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prophylaxis (PEP) for HIV to prevent risk of HIV in sexual partners involved in sumo kodhi. Pre-exposure prophylaxis refers to use of antiretroviral drugs by a HIV uninfected individual before HIV exposure to prevent acquisition of HIV (Ministry of Health and NASCOP 2014). PEP refers to the use antiretroviral drugs by an uninfected individual soon after potential HIV exposure to prevent the likelihood of infection (WHO 2007). Although the use of these prophylaxes has been widely accepted in other countries for use beyond occupational settings (WHO 2007, SharifiAzad and Rizzolo 2011), in Kenya PEP is mainly administered to those exposed to HIV at work or have been sexually assaulted and PrEP is restricted for use only within research settings (Ministry of Health and NASCOP 2014). Therefore unprotected sex remains the only way out for WLWHAs to bear children. To succeed, these WLWHA did not disclose their HIV status. They also targeted men who were new to the area or who came from far away to avoid any suspicion about their HIV status. Although, in certain instances, these WLWHA seemed not to care about the risk they predispose the genitors to, they kept their HIV status secret purely to avoid rejection and possible failure of their reproductive targets. This corresponds to the findings from other studies such as Aggleton et al. (2005) and Turan et al. (2011) which have shown that the fear of experiencing violence, loss of intimacy, ostracism, and discrimination inhibit disclosure of HIV-positive status, thus contributing to spreading the virus. This practice of sumo kodhi therefore potentially carries the risk of transmission of HIV to the genitors. It is unclear whether involvement of WLWHA in HIV control and prevention would help address the cases of their involvement in risky sexual encounters for the sake of sumo kodhi. Such a possibility might need further exploration. Limitations of the study The results of this study should be interpreted with caution due to the limitations. The sample size was small and did not include views of those men who took part in sumo kodhi. These men were not interviewed to avoid suspicion because WLWHA had not disclosed their HIV status to them. Moreover, some of these men, especially former boyfriends lived far away from the study area. The WLWHA also refused to participate in FGDs because they considered the information personal and did not want people to know their family secrets. So, information from WLWHA had limited triangulation. However, reliability of data was still ensured through other methods such as participant observation, in-depth interview and key informant interview. Finally, the study explored the situation in one geographical area and was culture specific and may not apply in other areas. Conclusion and recommendations This paper illustrates that sumo kodhi exists among WLWHA who participated in the study. The WLWHA engaged in the practice, as they hoped to get gender balanced, beautiful, academically talented and strong healthy children. They targeted husbands’ agnates, former

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boyfriends and men who had come to work in the area. The successes of adherence to PMTCT of HIV were becoming evident as most of the children tested HIV-negative. However, these WLWHA engaged in sumo kodhi despite their knowledge of the potential risk their actions carry. This implies that the need to fulfil social needs carries more weight than the consideration of disease transmission. It thus, contradicts the popular notion that having knowledge of HIV status translates into taking action towards protecting sexual partners. Similarly, it contradicts the view that continued pregnancies among PLWHA are a result of unmet need for contraceptives. Therefore studies need to go beyond recommending HIV awareness and the view that continued pregnancies among PLWHA are the result of unmet contraceptives needs. We recommend that these issues are taken seriously and that tailored interventions be developed that take into consideration human rights issues and individuals’ aspirations as well as public health priorities including protection of the general population — all seen in the complex context of real life. Further, research should be conducted among other ethnic groups in Africa and elsewhere, to gauge whether sumo kodhi is a socio-biological phenomenon that persists only among the Luo ethic group. Acknowledgements — We are indebted to the Department of Sociology and Anthropology, Maseno University, for the invaluable contribution towards the development of this work. We thank DBL—Center for Health Research and Development, Faculty of Life Sciences, University of Copenhagen for the funds that facilitated fieldwork. We also thank the people of Nyang’oma for their hospitality and willingness to take part in the study. The authors — Charles Omondi Olang’o is a tutorial fellow at Maseno University, Kenya. He teaches anthropology. His research interests are in HIV/AIDS, culture and sexuality. Erick Otieno Nyambedha, an Associate Professor of Anthropology, works at Maseno University, Kenya. He teaches anthropology. His research interests are in HIV/AIDS and children. Jens Aagaard-Hansen is a senior researcher at Steno Health Promotion Center, Steno Diabetes Center, Denmark.

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