Culture, Health & Sexuality An International Journal for Research, Intervention and Care
ISSN: 1369-1058 (Print) 1464-5351 (Online) Journal homepage: http://www.tandfonline.com/loi/tchs20
Wimbo: implications for risk of HIV infection among circumcised fishermen in Western Kenya Stephen Okumu Ombere, Erick Otieno Nyambedha & Salome Atieno Bukachi To cite this article: Stephen Okumu Ombere, Erick Otieno Nyambedha & Salome Atieno Bukachi (2015) Wimbo: implications for risk of HIV infection among circumcised fishermen in Western Kenya, Culture, Health & Sexuality, 17:9, 1147-1154, DOI: 10.1080/13691058.2015.1018949 To link to this article: http://dx.doi.org/10.1080/13691058.2015.1018949
Published online: 16 Mar 2015.
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Date: 06 November 2015, At: 01:21
Culture, Health & Sexuality, 2015 Vol. 17, No. 9, 1147–1154, http://dx.doi.org/10.1080/13691058.2015.1018949
SHORT REPORT Wimbo: implications for risk of HIV infection among circumcised fishermen in Western Kenya Stephen Okumu Omberea*, Erick Otieno Nyambedhaa and Salome Atieno Bukachib a
Department of Sociology and Anthropology, Maseno University, Maseno, Kenya; bInstitute of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya
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(Received 14 August 2014; accepted 10 February 2015) Medical male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60% in three randomised controlled trials. However, not much anthropological literature exists to provide a holistic understanding of sexual behaviour among migrating fishermen who have been circumcised. This qualitative study used cultural ecology theory and anthropological methods to develop a more holistic understanding of Luo fishermen’s sexual behaviour after circumcision when they migrate (wimbo) to islands in western Kenya. Results from focus-group discussions show that during wimbo there is a deviation from community norms governing sexual expression, influenced by the belief that circumcision provides protection against HIV infection. Through the exchange of sex for fish, circumcised men access new sexual partners in the destination beaches and engage in risky sexual behaviours without any HIV prevention measures. The processes and practices associated with wimbo may therefore help explain why rates of HIV infection are increasing among fisherfolk despite new interventions to combat HIV. These results have relevant implications for HIV-related intervention and policy in sub-Saharan Africa. Keywords: HIV; fishermen; male circumcision; risky sexual behaviour; wimbo
Introduction The term ‘mobile men with money’ is one of the latest 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 (Aggleton, Bell, and Kelly-Hanku 2014). However, to date the concept has not been utilised to look at circumcised Kenyan fishermen’s migratory patterns and how these may lead to the transmission of HIV. High rates of heterosexual transmission of HIV in sub-Saharan Africa, often in the presence of risk-related sexual behaviour and low condom use, are increasing the pressure to find cheap and effective HIV control interventions. Male circumcision is performed for cultural, ritual, religious and medical reasons (Halperin and Bailey 1999). Recent epidemiological studies have shown fairly convincingly that in high-risk populations in sub-Saharan Africa, male circumcision is associated with a reduced risk of HIV infection (Weiss, Quigley, and Hayes 2000).
*Corresponding author. Email: [email protected] q 2015 Taylor & Francis
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Despite high rates of medical male circumcision in some parts of sub-Saharan Africa, there are signs of an increase in risky sexual behaviour in several countries (UNAIDS 2013). Recent evidence indicates a significant increase in the number of sexual partners in certain countries, including Burkina Faso, Congo, Cote d’Ivoire, Ethiopia, Gabon, Guyana, Rwanda, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe, as well as a decline in condom use (UNAIDS 2013). Notably, in Cameroon, Guinea, Haiti, Lesotho, Malawi, Niger, Rwanda, Senegal, Tanzania and Zimbabwe, HIV prevalence is higher among circumcised than non-circumcised men (Mishra et al. 2009). This provokes questions about the potential effects of voluntary medical male circumcision, which has previously been reported to be a means of protection against HIV despite the fact that male circumcision is common in some African countries and is almost universal in North Africa and most of West Africa (World Health Organization and UNAIDS 2011). Kenya is one of the global leaders in efforts to scale up voluntary medical male circumcision for adult men. For instance, over a two-year period between 2008 and 2010, more than 230,000 men are reported to have been medically circumcised, with more than 60% of these being adult males in Nyanza Province (NACC 2012). Voluntary medical male circumcision has been reported to reduce the risk of female-to-male HIV transmission by up to 60% (NACC 2012). However, male circumcision does not provide complete protection against HIV infection because circumcised men can still become infected with the virus (UNAIDS 2013). The Kenya AIDS Indicator Survey (KAIS) (2012) reveals that HIV prevalence among adult men aged 15 to 64 years decreased nationally from 7.2%, as measured in KAIS 2007, to 5.6% in 2012 (NACC 2012). While the country’s HIV prevalence rate is estimated to be 5.6%, Nyanza region, which is predominantly inhabited by members of the Luo people, had a prevalence rate of approximately 14.9% in 2007, which increased to 15.1% in 2012. There are several reasons for the high HIV prevalence in this region and among the Luo ethnic group despite the fact that this same region recorded a high increase in voluntary medical male circumcision rates between 2007 – the time when it was adopted as an additional HIV preventive measure – and 2012 (NACC 2012). 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 (Kwena et al. 2013). While away from home, the social power structures that guide sexual norms may no longer be felt (Seeley and Allison 2005). 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 (Kissling et al. 2005). 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 (Gordon and Ann 2005; Nyambedha 2007). 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 (Kwena et al. 2013). Vulnerability to HIV stems from complex, interacting causes that include the mobility of many fisherfolk and the time fishermen spend away from home looking for fish offshore, a concept locally known as wimbo. This practice has been suggested as a catalyst to the spread of HIV among the Luo fishermen (Kwena et al. 2013). Given the lack of existing research, a deeper understanding is needed of the relational factors influencing sexual behaviour among men who move in search of money and greater opportunity.
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Although studies in Kenya (Agot et al. 2007; Bailey et al. 2007) and in Uganda (Gray et al. 2007) as well as Swaziland (Grund and Hennink 2011) have failed to identify risk compensation among men following medical male circumcision, there exists debate about the different responses men may make to the procedure. Following 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. (2007) 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 (Bailey et al. 2007). This paper sought to address this complex set of concerns by looking at the practice of wimbo, and its implications for risk of HIV infection, among medically circumcised fishermen in western Kenya. Study setting and methodology Study setting The study was conducted in Usenge sub-location, which is situated in Siaya County in western Kenya. The sub-location has an estimated population of about 21,931, of which 11,027 are male and 10,904 are female (Central Bureau of Statistics 2010). The area is mainly populated by Luo people. The study area is situated along the fish landing beachline on the shores of Lake Victoria. It is a region with very high HIV prevalence (Government of Kenya 2002; Republic of Kenya 2005). Within the sub-location, three beach settings (Usenge itself, together with Uhanya and Anyanga) were purposively selected for this study. However, of 18 villages in Usenge sub-location, 8 villages linked to fish landing beaches were also included in the study area. According to Central Bureau of Statistics (2010), the main economic activity in the study area is fishing, which also provides a source of livelihood and some manual jobs for local people. The inhabitants also practise subsistence farming, while young men sometimes engage in touting, bicycle and motorcycle boda boda (taxi business) (Nyambedha 2000). Local people also run small-scale businesses such as small retail shops and food kiosks. Methods Four months fieldwork took place exploring the sociocultural context and its relationship to circumcised men’s sexual behaviour after voluntary medical circumcision. The study was cross-sectional in design and involved both qualitative and quantitative research techniques. Data collection took place in two phases, lasting two months each. The first two months involved administering 101 semi-structured questionnaires and conducting 10 in-depth interviews with circumcised fishermen who were purposively selected based on their long-term experience of migration to other beaches. This was followed by a second two-month period that involved conducting key-informant interviews with ‘beach leaders’ in the three selected beaches and four focus-group discussions with circumcised men who were fishermen. The focus-group discussions comprised 7– 12 recently circumcised men in each of the sessions. The researcher led a team of two research assistants in conducting in-depth interviews, key-informant interviews and focus-group discussions. Selection of study participants The study employed purposive and snowball sampling methods to access the men. A voluntary medical male circumcision mobiliser who had worked for Nyanza Reproductive
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Health (a non-governmental organisation providing medical circumcision) in the study area helped recruit the study participants. The three beach leaders were also purposively selected to provide information on what happens when fishermen migrate to a new beach. Data analysis
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Data analysis began while the field work was in progress. The researcher took note of emerging themes and how these developed in the course of the research. Data from indepth interviews, key-informant interviews and focus-group discussions were analysed through content analysis by the first author, who also transcribed the data. The second author, who had a solid foundation in qualitative methods, helped in identifying the emerging themes. Qualitative data is presented here in the form of in textual descriptions and illustrations using verbatim quotes. Ethical considerations Ethics 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 completely 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 project findings was made available to the participants in a dissemination process through the Usenge sub-location assistant chief’s baraza, or formal community meeting, after the study. Findings Results from in-depth interviews, key-informant interviews and focus-group discussions point to the importance of mobility as an influence on fishermen’s sexual behaviour. Beach leaders indicated that fishermen’s movement in search of fish – known locally as wimbo – caused men to travel to beaches situated far away from the home beach. Wimbo was reported to influence men’s sexual behaviour in a number of ways. On arrival at destination beaches, men frequently took new sexual partners. Moreover, while mobile fisherman were away from their primary partner and from social monitoring and family and community norms, the non-mobile partner was freed from the protective watch of the spouse. A key factor influencing men’s sexual behaviour away from home was the need to obtain new customers for their fish. Sexual transactions provided access to new customers who, in the long run, benefited from getting fish from the fishermen. Additionally, women whose husbands were away targeted men who land on the home beach for economic gain, having temporary sexual relationships with these men until their husbands came back home. As one beach leader explained: In every society, there are values and norms guiding issues of sex and human behaviour. Circumcised men along Lake Victoria, who are fishermen, migrate to other beaches in search of a huge fish catch and, from my experience, some of these men stay for long in the destination beaches like for weeks, months or even a year. When at the destination beaches, their sexual behaviour changes in order to adapt to the new environment. These men get a lot of money which they do not remit to their families back at home . . . some consume a lot of alcohol and the majority get new sexual partners. That is beach culture. However, men who migrate to these beaches are targeted by women whose husbands have migrated to other
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beaches, and they get married temporarily until the time their husbands come back from wimbo. Beyond any reasonable doubt with the kind of sexual relationships in these beaches, our circumcised men rarely use condoms and on most occasions after adapting to the new environment, they tend to have multiple sexual partners . . . . Curbing this is very difficult because I cannot follow these men and women all the time. (Opija, beach leader, 49 years old)
Another beach leader had this to say:
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Sex-for-fish is a common practice along the lake region. Circumcision targeted noncircumcising communities with a relatively high incidence of HIV/AIDS. Usenge sublocation is one of such areas . . . [but] our circumcised men still face the risk of contracting HIV because circumcision does not alter beach culture . . . in my opinion we still need to come up with ways of educating these men on the importance of condom use when on shore and offshore. (Opete, beach leader, 55 years old)
During focus-group discussions, circumcised men revealed that crew members had at least one or two sexual partners on every beach they moved to, and that in most cases they rarely used condoms and other HIV preventive measures. It was commonly said by respondents that circumcised men do not care about the HIV status of their new sexual partners in the destination islands and beaches because they know they are going to stay on these islands for a while depending on the fish catch. While fishing has been an economic activity on the lake since ancient times, a new trend, referred to as jaboya (new girlfriends), has emerged on the beaches of the Nyanza region. One participant thus observed: Fishing is a good occupation. It exists among the river lake Nilotes . . . we get a lot of cash and women are at our disposal. Sincerely, during wimbo, we become unfaithful to our spouses, we get new girlfriends in the destination beaches or islands, and the relationship may be terminated when fish catch goes down and we move to the next beach where we also get new girlfriends or jaboya. In my crew, for instance, almost all the men are circumcised but I tell you these men’s sexual behaviour in the destination beaches is a risky one. They change women like dresses and am very sure that these men do not use condoms because our main objective during wimbo is fishing. In addition, we don’t even bother to know the HIV status of these women. This is a risky behaviour but we cannot change it since it is the beach culture. In cases where the jaboya is married, sex occurs in hurry and there is no room for negotiation for condom use . . . . After all I am circumcised! (Oonglo, in-depth interview respondent, 27 years old)
Another man explained: We are mobile and our next destination is determined by the bountiful fish catch in these beaches . . . you know I cannot stay for a period of three weeks in the cold nights in the islands without warmth from a woman, so I must get one. Moreover, these women love circumcised men and money, so the more they praise me to be good in bed or good at sex, the more I befriend many of them – but in different beaches. Money is not a problem, the lake is my bank so I spend all the money I have to pay for these women’s upkeep depending on which beach I am on. However, the behaviour patterns among circumcised men who are fishermen in this region can facilitate HIV transmission . . . for instance, I don’t bother to ask these women their HIV status and I rarely use condoms so to some extent I feel to be at risk while sometimes I am confident that I have a hardened dick so I just work on them mercilessly, but my wife [she] has to remain faithful until I go back home. (Nyuok, male focus-group discussion participant, 39 years old)
Discussion The study findings reveal that fishermen in Nyanza, as in other parts of the world, are highly mobile in search of large catches of fish. Often, men stay away from their families for long periods and interact with women who trade in fish. On destination beaches and islands, condom use is reportedly very low. Opportunities to participate in transactional
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sex, isolation from communities of origin and home and the desire for unique experiences all enhance the likelihood of men having sexual experiences while on beaches and islands away from home (c.f. Ward and Plourde 2006). Evidence from this study suggests, however, that mobility alone is less of a risk factor for HIV than mobility and its correlates, including the disruption of family bonds, the use of alcohol and other substances and a culture of risk-taking (NACC 2012). Research in the fishing communities around Lake Victoria 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 (Kissling et al. 2005). One of the key drivers of HIV in fishing communities is fish-for-sex networks in which women fish traders exchange sex with fishermen for access to or more favourable prices of fish. Among some men at least, voluntary medical circumcision seems associated with the belief that condom use or other protective measures are no longer necessary, implying that newly circumcised men along Lake Victoria region are still at substantial risk of HIV infection. These findings have important implications for the design of future HIV preventive measures and the need to encourage realistic appraisals of vulnerability following voluntary medical male circumcision in populations at heightened risk. Acknowledgements We are grateful to the study participants who gave of their time to contribute to the study.
Disclosure statement No potential conflict of interest was reported by the authors.
Note 1.
The names allocated to respondents are fictitious to protect confidentiality.
References Aggleton, P., S. A. Bell, and A. Kelly-Hanku. 2014. “‘Mobile Men with Money’: HIV Prevention and the Erasure of Difference.” Global Public Health 9 (3): 257– 270. Agot, K. E., J. N. Kiarie, H. Q. Nguyen, J. O. Odhiambo, T. M. Onyango, and N. S. Weiss. 2007. “Male Circumcision in Siaya and Bondo Districts, Kenya.” JAIDS Journal of Acquired Immune Deficiency Syndromes 44 (1): 66 – 70. Bailey, R. C., S. Moses, C. B. Parker, K. Agot, I. Maclean, J. N. Krieger, C. F. Williams, R. T. Campbell, and J. O. Ndinya-Achola. 2007. “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial.” The Lancet 369 (9562): 643– 656. Central Bureau of Statistics. 2010. Bondo District Development Plan. Nairobi: Government Printer. Gordon, J., and E. Ann. 2005. HIV/AIDS in the Fisheries Sector in Africa. Cairo, Egypt: World Fish Center Limited. Government of Kenya. 2002. Bondo District Developmet Plan. Nairobi: Government printer. Gray, R. H., G. Kigozi, D. Serwadda, F. Makumbi, S. Watya, F. Nalugoda, and M. J. Wawer. 2007. “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial.” The Lancet 369 (9562): 657– 666. Grund, M., and M. Hennink. 2011. “A Qualitative Study of Sexual Behavior Change and Risk Compensation Following Adult Male Circumcision in Urban Swaziland.” AIDS Care 24 (2): 245– 251. Halperin, D. T., and R. C. Bailey. 1999. “Male Circumcision and HIV Infection: 10 Years and Counting.” The Lancet 354 (9192): 1813– 1815.
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Kissling, E., E. H. Allison, J. A. Seeley, l. S. Russel, M. Bachmann, D. Stanley, and H. Simon. 2005. “Fisherfolk are among Groups Most at Risk of HIV: Cross-Country Analysis of Prevalence and Numbers Infected.” AIDS 19 (17): 1939– 1946. Kwena, Z. A., C. S. Camlin, C. A. Shisanya, I. Mwanzo, E. A. Bukusi, and J. Tang. 2013. “ShortTerm Mobility and the Risk of HIV Infection among Married Couples in the Fishing Communities along Lake Victoria, Kenya.” PLoS ONE 8 (1): e54523. Mishra, V. A., R. Medley, Y. Hong, Y. Gu, and B. Robey. 2009. Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. Calverton, Maryland, USA: Macro International. NACC (National AIDS Control Council and National AIDS and STI Control Programme). 2012. Kenya AIDS Epidemic Update 2011. Nairobi, Kenya: NASCOP Press. Nyambedha, E. O. 2000. “Support System for Orphaned Children in Nyang’oma Sub-location, Bondo District, Western Kenya.” Unpublished M.A. thesis, Institute of Anthropology and African Studies, Nairobi: University of Nairobi. Nyambedha, E. O. 2007. “Children and HIV/AIDS: Questioning Vulnerability in Western Kenya.” Unpublished PhD thesis. Department of Anthropology, University of Copenhagen: Copenhagen. Republic of Kenya. 2005. BONDO District Strategic Plan 2005– 2010 for Implementation of the National Population Policy for Sustainable Development. Nairobi: National Coordination Agency for Population and Development Ministry of Planning and National Development. Seeley, J. A., and E. H. Allison. 2005. “HIV/AIDS in Fishing Communities: Challenges to Delivering Antiretroviral Therapy to Vulnerable Groups.” AIDS Care 17 (6): 688– 697. UNAIDS. 2013. Report of the Global AIDS Epidemic. 2013. Geneva: UNAIDS. Ward, B. J., and P. Plourde. 2006. “Travel and Sexually Transmitted Infections.” Journal of Travel Medicine 13 (5): 300– 317. Weiss, H. A., M. A. Quigley, and R. J. Hayes. 2000. “Male Circumcision and Risk of HIV Infection in Sub-Saharan Africa: A Systematic Review and Meta-Analysis.” AIDS 2000 14: 2361 –2370. Accessed November 22, 2014. www.ncbi.nlm.nih.gov/pubmed/11089625 World Health Organization and UNAIDS. 2011. Circumcision for HIV Prevention in Eastern and Southern Africa: Focus on the Delivery. Geneva: WHO Press.
Re´sume´ Trois e´tudes randomise´es ont de´montre´ que la circoncision masculine me´dicale peut re´duire de 60 % le risque de la transmission he´te´rosexuelle du VIH. Cependant il existe peu de donne´es anthropologiques permettant une compre´hension holistique des comportements sexuels des peˆcheurs migrants ayant e´te´ circoncis. Cette e´tude qualitative a employe´ la the´orie de l’e´cologie culturelle et des me´thodes anthropologiques pour amener a` une compre´hension holistique des comportements sexuels des peˆcheurs luos ayant e´te´ circoncis, alors qu’ils migrent (wimbo) vers les ˆıles de l’ouest du Kenya. Les donne´es extraites des groupes de discussion the´matique montrent que pendant le wimbo, des e´carts se produisent par rapport aux normes communautaires de l’expression sexuelle. Ces e´carts sont dus a` la croyance selon laquelle la circoncision est un moyen de protection contre le VIH. En raison de la transaction « sexe contre poisson », les hommes circoncis rencontrent de nouvelles partenaires sexuelles sur les plages de leurs destinations et adoptent des comportements sexuels a` risque, non prote´ge´s par des me´thodes de pre´vention du VIH. Les processus et les pratiques associe´s au wimbo pourraient contribuer a` la compre´hension de l’augmentation des taux d’infection a` VIH parmi les peˆcheurs, en de´pit des nouvelles interventions pour combattre le VIH. Ces re´sultats ont des implications importantes pour les interventions et les politiques concernant le VIH en Afrique subsaharienne.
Resumen A trave´s de tres ensayos controlados aleatorios se demostro´ que la circuncisio´n me´dica masculina (CMM) reduce hasta en 60% el riesgo de transmisio´n del VIH en las relaciones heterosexuales establecidas por los hombres. Sin embargo, existe escasa literatura antropolo´gica que analice y permita comprender de manera integral el comportamiento sexual de los pescadores migrantes circuncisos. Apoya´ndose en la teorı´a cultural ecolo´gica y en me´todos antropolo´gicos, el presente estudio cualitativo se oriento´ a construir una comprensio´n completa del comportamiento sexual manifestado por los pescadores luo circuncisos a la hora de migrar (wimbo) hacia las islas de Kenia
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Occidental. Los hallazgos surgidos de las conversaciones llevadas a cabo en grupos de enfoque dan cuenta de que, durante el wimbo, se presenta una desviacio´n de las normas comunitarias en torno a la expresio´n sexual, en la que incide la conviccio´n de que la circuncisio´n brinda proteccio´n frente a la infeccio´n por el VIH. Debido a la pra´ctica de intercambiar pescado por relaciones sexuales, los hombres circuncisos se relacionan sexualmente con parejas diferentes que habitan en las playas de destino, participando a la vez en arriesgadas pra´cticas sexuales sin utilizar medida alguna de prevencio´n del VIH. Como consecuencia de lo sen˜alado, los procesos y las pra´cticas asociados con el wimbo podrı´an explicar las razones por las cuales las tasas de infeccio´n de VIH entre los pescadores continu´an eleva´ndose, aun a pesar de las acciones emprendidas para combatirlo. Los resultados de este estudio conllevan importantes implicaciones para las intervenciones y las polı´ticas ´ frica subsahariana. instrumentadas con el fin de prevenir el VIH en el A
ISSN: 1369-1058 (Print) 1464-5351 (Online) Journal homepage: http://www.tandfonline.com/loi/tchs20
Wimbo: implications for risk of HIV infection among circumcised fishermen in Western Kenya Stephen Okumu Ombere, Erick Otieno Nyambedha & Salome Atieno Bukachi To cite this article: Stephen Okumu Ombere, Erick Otieno Nyambedha & Salome Atieno Bukachi (2015) Wimbo: implications for risk of HIV infection among circumcised fishermen in Western Kenya, Culture, Health & Sexuality, 17:9, 1147-1154, DOI: 10.1080/13691058.2015.1018949 To link to this article: http://dx.doi.org/10.1080/13691058.2015.1018949
Published online: 16 Mar 2015.
Submit your article to this journal
Article views: 58
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=tchs20 Download by: [Universite Laval]
Date: 06 November 2015, At: 01:21
Culture, Health & Sexuality, 2015 Vol. 17, No. 9, 1147–1154, http://dx.doi.org/10.1080/13691058.2015.1018949
SHORT REPORT Wimbo: implications for risk of HIV infection among circumcised fishermen in Western Kenya Stephen Okumu Omberea*, Erick Otieno Nyambedhaa and Salome Atieno Bukachib a
Department of Sociology and Anthropology, Maseno University, Maseno, Kenya; bInstitute of Anthropology, Gender and African Studies, University of Nairobi, Nairobi, Kenya
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(Received 14 August 2014; accepted 10 February 2015) Medical male circumcision has been shown to reduce the risk of heterosexual transmission of HIV infection in men by up to 60% in three randomised controlled trials. However, not much anthropological literature exists to provide a holistic understanding of sexual behaviour among migrating fishermen who have been circumcised. This qualitative study used cultural ecology theory and anthropological methods to develop a more holistic understanding of Luo fishermen’s sexual behaviour after circumcision when they migrate (wimbo) to islands in western Kenya. Results from focus-group discussions show that during wimbo there is a deviation from community norms governing sexual expression, influenced by the belief that circumcision provides protection against HIV infection. Through the exchange of sex for fish, circumcised men access new sexual partners in the destination beaches and engage in risky sexual behaviours without any HIV prevention measures. The processes and practices associated with wimbo may therefore help explain why rates of HIV infection are increasing among fisherfolk despite new interventions to combat HIV. These results have relevant implications for HIV-related intervention and policy in sub-Saharan Africa. Keywords: HIV; fishermen; male circumcision; risky sexual behaviour; wimbo
Introduction The term ‘mobile men with money’ is one of the latest 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 (Aggleton, Bell, and Kelly-Hanku 2014). However, to date the concept has not been utilised to look at circumcised Kenyan fishermen’s migratory patterns and how these may lead to the transmission of HIV. High rates of heterosexual transmission of HIV in sub-Saharan Africa, often in the presence of risk-related sexual behaviour and low condom use, are increasing the pressure to find cheap and effective HIV control interventions. Male circumcision is performed for cultural, ritual, religious and medical reasons (Halperin and Bailey 1999). Recent epidemiological studies have shown fairly convincingly that in high-risk populations in sub-Saharan Africa, male circumcision is associated with a reduced risk of HIV infection (Weiss, Quigley, and Hayes 2000).
*Corresponding author. Email: [email protected] q 2015 Taylor & Francis
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Despite high rates of medical male circumcision in some parts of sub-Saharan Africa, there are signs of an increase in risky sexual behaviour in several countries (UNAIDS 2013). Recent evidence indicates a significant increase in the number of sexual partners in certain countries, including Burkina Faso, Congo, Cote d’Ivoire, Ethiopia, Gabon, Guyana, Rwanda, South Africa, Uganda, the United Republic of Tanzania and Zimbabwe, as well as a decline in condom use (UNAIDS 2013). Notably, in Cameroon, Guinea, Haiti, Lesotho, Malawi, Niger, Rwanda, Senegal, Tanzania and Zimbabwe, HIV prevalence is higher among circumcised than non-circumcised men (Mishra et al. 2009). This provokes questions about the potential effects of voluntary medical male circumcision, which has previously been reported to be a means of protection against HIV despite the fact that male circumcision is common in some African countries and is almost universal in North Africa and most of West Africa (World Health Organization and UNAIDS 2011). Kenya is one of the global leaders in efforts to scale up voluntary medical male circumcision for adult men. For instance, over a two-year period between 2008 and 2010, more than 230,000 men are reported to have been medically circumcised, with more than 60% of these being adult males in Nyanza Province (NACC 2012). Voluntary medical male circumcision has been reported to reduce the risk of female-to-male HIV transmission by up to 60% (NACC 2012). However, male circumcision does not provide complete protection against HIV infection because circumcised men can still become infected with the virus (UNAIDS 2013). The Kenya AIDS Indicator Survey (KAIS) (2012) reveals that HIV prevalence among adult men aged 15 to 64 years decreased nationally from 7.2%, as measured in KAIS 2007, to 5.6% in 2012 (NACC 2012). While the country’s HIV prevalence rate is estimated to be 5.6%, Nyanza region, which is predominantly inhabited by members of the Luo people, had a prevalence rate of approximately 14.9% in 2007, which increased to 15.1% in 2012. There are several reasons for the high HIV prevalence in this region and among the Luo ethnic group despite the fact that this same region recorded a high increase in voluntary medical male circumcision rates between 2007 – the time when it was adopted as an additional HIV preventive measure – and 2012 (NACC 2012). 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 (Kwena et al. 2013). While away from home, the social power structures that guide sexual norms may no longer be felt (Seeley and Allison 2005). 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 (Kissling et al. 2005). 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 (Gordon and Ann 2005; Nyambedha 2007). 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 (Kwena et al. 2013). Vulnerability to HIV stems from complex, interacting causes that include the mobility of many fisherfolk and the time fishermen spend away from home looking for fish offshore, a concept locally known as wimbo. This practice has been suggested as a catalyst to the spread of HIV among the Luo fishermen (Kwena et al. 2013). Given the lack of existing research, a deeper understanding is needed of the relational factors influencing sexual behaviour among men who move in search of money and greater opportunity.
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Although studies in Kenya (Agot et al. 2007; Bailey et al. 2007) and in Uganda (Gray et al. 2007) as well as Swaziland (Grund and Hennink 2011) have failed to identify risk compensation among men following medical male circumcision, there exists debate about the different responses men may make to the procedure. Following 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. (2007) 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 (Bailey et al. 2007). This paper sought to address this complex set of concerns by looking at the practice of wimbo, and its implications for risk of HIV infection, among medically circumcised fishermen in western Kenya. Study setting and methodology Study setting The study was conducted in Usenge sub-location, which is situated in Siaya County in western Kenya. The sub-location has an estimated population of about 21,931, of which 11,027 are male and 10,904 are female (Central Bureau of Statistics 2010). The area is mainly populated by Luo people. The study area is situated along the fish landing beachline on the shores of Lake Victoria. It is a region with very high HIV prevalence (Government of Kenya 2002; Republic of Kenya 2005). Within the sub-location, three beach settings (Usenge itself, together with Uhanya and Anyanga) were purposively selected for this study. However, of 18 villages in Usenge sub-location, 8 villages linked to fish landing beaches were also included in the study area. According to Central Bureau of Statistics (2010), the main economic activity in the study area is fishing, which also provides a source of livelihood and some manual jobs for local people. The inhabitants also practise subsistence farming, while young men sometimes engage in touting, bicycle and motorcycle boda boda (taxi business) (Nyambedha 2000). Local people also run small-scale businesses such as small retail shops and food kiosks. Methods Four months fieldwork took place exploring the sociocultural context and its relationship to circumcised men’s sexual behaviour after voluntary medical circumcision. The study was cross-sectional in design and involved both qualitative and quantitative research techniques. Data collection took place in two phases, lasting two months each. The first two months involved administering 101 semi-structured questionnaires and conducting 10 in-depth interviews with circumcised fishermen who were purposively selected based on their long-term experience of migration to other beaches. This was followed by a second two-month period that involved conducting key-informant interviews with ‘beach leaders’ in the three selected beaches and four focus-group discussions with circumcised men who were fishermen. The focus-group discussions comprised 7– 12 recently circumcised men in each of the sessions. The researcher led a team of two research assistants in conducting in-depth interviews, key-informant interviews and focus-group discussions. Selection of study participants The study employed purposive and snowball sampling methods to access the men. A voluntary medical male circumcision mobiliser who had worked for Nyanza Reproductive
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Health (a non-governmental organisation providing medical circumcision) in the study area helped recruit the study participants. The three beach leaders were also purposively selected to provide information on what happens when fishermen migrate to a new beach. Data analysis
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Data analysis began while the field work was in progress. The researcher took note of emerging themes and how these developed in the course of the research. Data from indepth interviews, key-informant interviews and focus-group discussions were analysed through content analysis by the first author, who also transcribed the data. The second author, who had a solid foundation in qualitative methods, helped in identifying the emerging themes. Qualitative data is presented here in the form of in textual descriptions and illustrations using verbatim quotes. Ethical considerations Ethics 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 completely 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 project findings was made available to the participants in a dissemination process through the Usenge sub-location assistant chief’s baraza, or formal community meeting, after the study. Findings Results from in-depth interviews, key-informant interviews and focus-group discussions point to the importance of mobility as an influence on fishermen’s sexual behaviour. Beach leaders indicated that fishermen’s movement in search of fish – known locally as wimbo – caused men to travel to beaches situated far away from the home beach. Wimbo was reported to influence men’s sexual behaviour in a number of ways. On arrival at destination beaches, men frequently took new sexual partners. Moreover, while mobile fisherman were away from their primary partner and from social monitoring and family and community norms, the non-mobile partner was freed from the protective watch of the spouse. A key factor influencing men’s sexual behaviour away from home was the need to obtain new customers for their fish. Sexual transactions provided access to new customers who, in the long run, benefited from getting fish from the fishermen. Additionally, women whose husbands were away targeted men who land on the home beach for economic gain, having temporary sexual relationships with these men until their husbands came back home. As one beach leader explained: In every society, there are values and norms guiding issues of sex and human behaviour. Circumcised men along Lake Victoria, who are fishermen, migrate to other beaches in search of a huge fish catch and, from my experience, some of these men stay for long in the destination beaches like for weeks, months or even a year. When at the destination beaches, their sexual behaviour changes in order to adapt to the new environment. These men get a lot of money which they do not remit to their families back at home . . . some consume a lot of alcohol and the majority get new sexual partners. That is beach culture. However, men who migrate to these beaches are targeted by women whose husbands have migrated to other
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beaches, and they get married temporarily until the time their husbands come back from wimbo. Beyond any reasonable doubt with the kind of sexual relationships in these beaches, our circumcised men rarely use condoms and on most occasions after adapting to the new environment, they tend to have multiple sexual partners . . . . Curbing this is very difficult because I cannot follow these men and women all the time. (Opija, beach leader, 49 years old)
Another beach leader had this to say:
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Sex-for-fish is a common practice along the lake region. Circumcision targeted noncircumcising communities with a relatively high incidence of HIV/AIDS. Usenge sublocation is one of such areas . . . [but] our circumcised men still face the risk of contracting HIV because circumcision does not alter beach culture . . . in my opinion we still need to come up with ways of educating these men on the importance of condom use when on shore and offshore. (Opete, beach leader, 55 years old)
During focus-group discussions, circumcised men revealed that crew members had at least one or two sexual partners on every beach they moved to, and that in most cases they rarely used condoms and other HIV preventive measures. It was commonly said by respondents that circumcised men do not care about the HIV status of their new sexual partners in the destination islands and beaches because they know they are going to stay on these islands for a while depending on the fish catch. While fishing has been an economic activity on the lake since ancient times, a new trend, referred to as jaboya (new girlfriends), has emerged on the beaches of the Nyanza region. One participant thus observed: Fishing is a good occupation. It exists among the river lake Nilotes . . . we get a lot of cash and women are at our disposal. Sincerely, during wimbo, we become unfaithful to our spouses, we get new girlfriends in the destination beaches or islands, and the relationship may be terminated when fish catch goes down and we move to the next beach where we also get new girlfriends or jaboya. In my crew, for instance, almost all the men are circumcised but I tell you these men’s sexual behaviour in the destination beaches is a risky one. They change women like dresses and am very sure that these men do not use condoms because our main objective during wimbo is fishing. In addition, we don’t even bother to know the HIV status of these women. This is a risky behaviour but we cannot change it since it is the beach culture. In cases where the jaboya is married, sex occurs in hurry and there is no room for negotiation for condom use . . . . After all I am circumcised! (Oonglo, in-depth interview respondent, 27 years old)
Another man explained: We are mobile and our next destination is determined by the bountiful fish catch in these beaches . . . you know I cannot stay for a period of three weeks in the cold nights in the islands without warmth from a woman, so I must get one. Moreover, these women love circumcised men and money, so the more they praise me to be good in bed or good at sex, the more I befriend many of them – but in different beaches. Money is not a problem, the lake is my bank so I spend all the money I have to pay for these women’s upkeep depending on which beach I am on. However, the behaviour patterns among circumcised men who are fishermen in this region can facilitate HIV transmission . . . for instance, I don’t bother to ask these women their HIV status and I rarely use condoms so to some extent I feel to be at risk while sometimes I am confident that I have a hardened dick so I just work on them mercilessly, but my wife [she] has to remain faithful until I go back home. (Nyuok, male focus-group discussion participant, 39 years old)
Discussion The study findings reveal that fishermen in Nyanza, as in other parts of the world, are highly mobile in search of large catches of fish. Often, men stay away from their families for long periods and interact with women who trade in fish. On destination beaches and islands, condom use is reportedly very low. Opportunities to participate in transactional
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sex, isolation from communities of origin and home and the desire for unique experiences all enhance the likelihood of men having sexual experiences while on beaches and islands away from home (c.f. Ward and Plourde 2006). Evidence from this study suggests, however, that mobility alone is less of a risk factor for HIV than mobility and its correlates, including the disruption of family bonds, the use of alcohol and other substances and a culture of risk-taking (NACC 2012). Research in the fishing communities around Lake Victoria 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 (Kissling et al. 2005). One of the key drivers of HIV in fishing communities is fish-for-sex networks in which women fish traders exchange sex with fishermen for access to or more favourable prices of fish. Among some men at least, voluntary medical circumcision seems associated with the belief that condom use or other protective measures are no longer necessary, implying that newly circumcised men along Lake Victoria region are still at substantial risk of HIV infection. These findings have important implications for the design of future HIV preventive measures and the need to encourage realistic appraisals of vulnerability following voluntary medical male circumcision in populations at heightened risk. Acknowledgements We are grateful to the study participants who gave of their time to contribute to the study.
Disclosure statement No potential conflict of interest was reported by the authors.
Note 1.
The names allocated to respondents are fictitious to protect confidentiality.
References Aggleton, P., S. A. Bell, and A. Kelly-Hanku. 2014. “‘Mobile Men with Money’: HIV Prevention and the Erasure of Difference.” Global Public Health 9 (3): 257– 270. Agot, K. E., J. N. Kiarie, H. Q. Nguyen, J. O. Odhiambo, T. M. Onyango, and N. S. Weiss. 2007. “Male Circumcision in Siaya and Bondo Districts, Kenya.” JAIDS Journal of Acquired Immune Deficiency Syndromes 44 (1): 66 – 70. Bailey, R. C., S. Moses, C. B. Parker, K. Agot, I. Maclean, J. N. Krieger, C. F. Williams, R. T. Campbell, and J. O. Ndinya-Achola. 2007. “Male Circumcision for HIV Prevention in Young Men in Kisumu, Kenya: A Randomised Controlled Trial.” The Lancet 369 (9562): 643– 656. Central Bureau of Statistics. 2010. Bondo District Development Plan. Nairobi: Government Printer. Gordon, J., and E. Ann. 2005. HIV/AIDS in the Fisheries Sector in Africa. Cairo, Egypt: World Fish Center Limited. Government of Kenya. 2002. Bondo District Developmet Plan. Nairobi: Government printer. Gray, R. H., G. Kigozi, D. Serwadda, F. Makumbi, S. Watya, F. Nalugoda, and M. J. Wawer. 2007. “Male Circumcision for HIV Prevention in Men in Rakai, Uganda: A Randomised Trial.” The Lancet 369 (9562): 657– 666. Grund, M., and M. Hennink. 2011. “A Qualitative Study of Sexual Behavior Change and Risk Compensation Following Adult Male Circumcision in Urban Swaziland.” AIDS Care 24 (2): 245– 251. Halperin, D. T., and R. C. Bailey. 1999. “Male Circumcision and HIV Infection: 10 Years and Counting.” The Lancet 354 (9192): 1813– 1815.
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Kissling, E., E. H. Allison, J. A. Seeley, l. S. Russel, M. Bachmann, D. Stanley, and H. Simon. 2005. “Fisherfolk are among Groups Most at Risk of HIV: Cross-Country Analysis of Prevalence and Numbers Infected.” AIDS 19 (17): 1939– 1946. Kwena, Z. A., C. S. Camlin, C. A. Shisanya, I. Mwanzo, E. A. Bukusi, and J. Tang. 2013. “ShortTerm Mobility and the Risk of HIV Infection among Married Couples in the Fishing Communities along Lake Victoria, Kenya.” PLoS ONE 8 (1): e54523. Mishra, V. A., R. Medley, Y. Hong, Y. Gu, and B. Robey. 2009. Levels and Spread of HIV Seroprevalence and Associated Factors: Evidence from National Household Surveys. Calverton, Maryland, USA: Macro International. NACC (National AIDS Control Council and National AIDS and STI Control Programme). 2012. Kenya AIDS Epidemic Update 2011. Nairobi, Kenya: NASCOP Press. Nyambedha, E. O. 2000. “Support System for Orphaned Children in Nyang’oma Sub-location, Bondo District, Western Kenya.” Unpublished M.A. thesis, Institute of Anthropology and African Studies, Nairobi: University of Nairobi. Nyambedha, E. O. 2007. “Children and HIV/AIDS: Questioning Vulnerability in Western Kenya.” Unpublished PhD thesis. Department of Anthropology, University of Copenhagen: Copenhagen. Republic of Kenya. 2005. BONDO District Strategic Plan 2005– 2010 for Implementation of the National Population Policy for Sustainable Development. Nairobi: National Coordination Agency for Population and Development Ministry of Planning and National Development. Seeley, J. A., and E. H. Allison. 2005. “HIV/AIDS in Fishing Communities: Challenges to Delivering Antiretroviral Therapy to Vulnerable Groups.” AIDS Care 17 (6): 688– 697. UNAIDS. 2013. Report of the Global AIDS Epidemic. 2013. Geneva: UNAIDS. Ward, B. J., and P. Plourde. 2006. “Travel and Sexually Transmitted Infections.” Journal of Travel Medicine 13 (5): 300– 317. Weiss, H. A., M. A. Quigley, and R. J. Hayes. 2000. “Male Circumcision and Risk of HIV Infection in Sub-Saharan Africa: A Systematic Review and Meta-Analysis.” AIDS 2000 14: 2361 –2370. Accessed November 22, 2014. www.ncbi.nlm.nih.gov/pubmed/11089625 World Health Organization and UNAIDS. 2011. Circumcision for HIV Prevention in Eastern and Southern Africa: Focus on the Delivery. Geneva: WHO Press.
Re´sume´ Trois e´tudes randomise´es ont de´montre´ que la circoncision masculine me´dicale peut re´duire de 60 % le risque de la transmission he´te´rosexuelle du VIH. Cependant il existe peu de donne´es anthropologiques permettant une compre´hension holistique des comportements sexuels des peˆcheurs migrants ayant e´te´ circoncis. Cette e´tude qualitative a employe´ la the´orie de l’e´cologie culturelle et des me´thodes anthropologiques pour amener a` une compre´hension holistique des comportements sexuels des peˆcheurs luos ayant e´te´ circoncis, alors qu’ils migrent (wimbo) vers les ˆıles de l’ouest du Kenya. Les donne´es extraites des groupes de discussion the´matique montrent que pendant le wimbo, des e´carts se produisent par rapport aux normes communautaires de l’expression sexuelle. Ces e´carts sont dus a` la croyance selon laquelle la circoncision est un moyen de protection contre le VIH. En raison de la transaction « sexe contre poisson », les hommes circoncis rencontrent de nouvelles partenaires sexuelles sur les plages de leurs destinations et adoptent des comportements sexuels a` risque, non prote´ge´s par des me´thodes de pre´vention du VIH. Les processus et les pratiques associe´s au wimbo pourraient contribuer a` la compre´hension de l’augmentation des taux d’infection a` VIH parmi les peˆcheurs, en de´pit des nouvelles interventions pour combattre le VIH. Ces re´sultats ont des implications importantes pour les interventions et les politiques concernant le VIH en Afrique subsaharienne.
Resumen A trave´s de tres ensayos controlados aleatorios se demostro´ que la circuncisio´n me´dica masculina (CMM) reduce hasta en 60% el riesgo de transmisio´n del VIH en las relaciones heterosexuales establecidas por los hombres. Sin embargo, existe escasa literatura antropolo´gica que analice y permita comprender de manera integral el comportamiento sexual de los pescadores migrantes circuncisos. Apoya´ndose en la teorı´a cultural ecolo´gica y en me´todos antropolo´gicos, el presente estudio cualitativo se oriento´ a construir una comprensio´n completa del comportamiento sexual manifestado por los pescadores luo circuncisos a la hora de migrar (wimbo) hacia las islas de Kenia
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Occidental. Los hallazgos surgidos de las conversaciones llevadas a cabo en grupos de enfoque dan cuenta de que, durante el wimbo, se presenta una desviacio´n de las normas comunitarias en torno a la expresio´n sexual, en la que incide la conviccio´n de que la circuncisio´n brinda proteccio´n frente a la infeccio´n por el VIH. Debido a la pra´ctica de intercambiar pescado por relaciones sexuales, los hombres circuncisos se relacionan sexualmente con parejas diferentes que habitan en las playas de destino, participando a la vez en arriesgadas pra´cticas sexuales sin utilizar medida alguna de prevencio´n del VIH. Como consecuencia de lo sen˜alado, los procesos y las pra´cticas asociados con el wimbo podrı´an explicar las razones por las cuales las tasas de infeccio´n de VIH entre los pescadores continu´an eleva´ndose, aun a pesar de las acciones emprendidas para combatirlo. Los resultados de este estudio conllevan importantes implicaciones para las intervenciones y las polı´ticas ´ frica subsahariana. instrumentadas con el fin de prevenir el VIH en el A
