Cultural traditions fuel the spread of HIV/AIDS

When Pamela Dola's brother-in-law died in 1995, the tradition of her Luo ethnic group dictated that her husband "inherit" his brother's widow, a responsibility he assumed as a matter of course. Three months after George Dola inherited her, his second wife died. He was soon taken ill and did not last long. "Before he died in 1997, he tested positive for HIV. So I knew he had died of AIDS," said Pamela Dola, who is HIV-positive and takes antiretroviral (ARV) medications. Despite her illness, she single-handedly shoulders the responsibility of raising eight children, including the five orphans left behind by her brother-in-law and his wife. Traditions For members of the Luo community who inhabit the Lake Victoria region of Nyanza Province in western Kenya, customs like wife inheritance and widow cleansing threaten to extinguish a vast majority of the population. Both practices have been cited as contributing factors to the high HIV/AIDS prevalence rate in the province. Nyanza has an average HIV/AIDS infection rate of 14.7 percent, compared with Kenya's national average of 9 percent. Alarmingly, the rate varies by as much as 30 percent across the province: In Suba district, for example, it is as high as 41 percent, according to Lennah Nyabiega, a health ministry official in charge of facilitating access to antiretroviral therapy (ART) in the province. According to Leonard Oloo, chief coordinator of Rural AIDS Prevention and Development Organisation (RAPADO), an NGO working in Nyanza's Migori district, wife inheritance is just one manifestation of the importance of sex in Luo culture. Custom also dictates that because a widow is "unclean" she is obliged to undergo a cleansing ritual immediately after her husband's death. Luo women who refuse to have intercourse with another man are thought to be unlucky or cursed and are usually ostracised by the community. Sex is not exclusively linked to death, however. According to Grace Ayieko of Community AIDS International, an NGO working with AIDS orphans in Bondo district in Nyanza Province, sex is almost sacred among the Luo. "A man has to have sex with his wife before cultivating his field. It is a ritual that has to take place at every stage of the farming process," she said. Oloo pointed out that many of life's milestones, like moving to a newly constructed home, are preceded by sex. "In the Luo society, sex seems to be more rooted in tradition," he observed. The sex act is believed to have protective powers as well. "If your parent dies, you have to have sex with your wife before you can leave your home. If you don't, there is a belief that you could die of chira [a curse]," explained Ayieko. Identifying risk factors In addition to harmful cultural practices, the lower status of women, the social stigma surrounding HIV/AIDS and poverty all conspire against communities in Nyanza Province. To curb the rampant spread of HIV/AIDS in the region, members of the Kenyan government and international aid organisations are working together to address factors that place communities at risk. Oloo called for a societal review of traditions that may be contributing to the spread of HIV/AIDS in Nyanza Province. "We have a situation in which people, especially women, are culturally obliged to have sex," he said. "The woman may not like it because she knows that the partner could be infected, but the cultural hold is so strong on her, she is unable to say No." Bernard Oduor Olayo, a health systems analyst with the Nairobi-based Millenium Development Goals Centre, previously worked as a doctor in Nyanza. He surmised that the low status of most Luo women could be linked to the high incidence of HIV in the community. "By and large women are still seen as property. Typically, in a rural Luo family the woman will not even complain when the husband brings another woman home. They have been inculcated to accept the fact that husbands are going to have extramarital affairs," he observed. "Among polygamous people there is a tendency of men having significant extramarital affairs. That is what you observe when you live among them. Polygamy on its own has not been documented in any literature as a risk factor on its own, but the man has several sexual partners who are not necessarily his wives," he added. Olayo maintained that social stigma and a tendency to deny the problem hindered efforts to control the spread of the virus. "There is a big number of number of people who do not want to go through VCT [voluntary counselling and testing centres], who do not utilise the antiretroviral programmes that are already in place in Nyanza. In fact, they do not want even to know what killed people," he said. "People continue interacting sexually with these women even after their husbands have died of HIV/AIDS," Olayo observed. "Alternative explanations are given for every death. It is either a neighbour's witchcraft, or chira, or something else." Extreme poverty also played a role in the rapid spread of HIV/AIDS. The findings of a government survey released in early November showed that 65 percent of the inhabitants of Nyanza Province lived below the poverty line, which was calculated at 1,239 Kenyan shillings (US $17) per month in rural areas and 2,648 shillings ($35) in towns. "Poverty has a causal relationship to HIV/AIDS," explained Olayo. "In poorer areas women start having sex much earlier. They do not have good education. Women who do not go to school have been studied and found to have higher HIV prevalence than their counterparts who do go to school." The poor were also more likely to have sex for money or marry at a younger age. They lacked access to good nutrition, healthcare and other services available to other HIV/AIDS-affected people. "The poor also carry a bigger burden - like deaths from HIV/AIDS - and were more likely to engage in sex as a source of income," Olayo said. "Even young men - there are women who have been widowed by HIV/AIDS and tend to migrate to fish-trading areas. These women generally give young boys money and keep them as sex partners." The fact that the Luo as a community do not practise circumcision is also considered a factor in the high incidence of HIV/AIDS in Nyanza. According to a study carried out in Gauteng Province in South Africa and whose results were presented at the 3rd International AIDS Society Conference on HIV Pathogenesis and Treatment in Brazil in July 2005, male circumcision showed promising results in reducing HIV acquisition. The Joint United Nations Programme on HIV/AIDS (UNAIDS), however, cautioned that more research was needed to confirm the findings of the study in South Africa. "If you look at the Luo community as a whole - even those living away from the lake - it has been observed that they tend to have a relatively higher HIV prevalence," Olayo said. "One key feature of the Luo culture that has been studied and documented is the lack of circumcision. Lack of circumcision is a significant risk factor for contracting HIV/AIDS." Working towards change Oloo said that people in Nyanza province were conscious of HIV/AIDS, but they "are not changing their sexual behaviour despite the HIV pandemic." Awareness campaigns by groups like RAPADO were beginning to bear fruit, however. "People are now open. They can speak out," observed Oloo. "More and more people are coming to our mobile VCT, saying they want to know their [HIV] status. Last year alone we received 844 people." The government had also set up its own VCTs and made ARV medications available in the main hospitals and health centres in the area. Oloo, however, criticised the administration for its initial slow response to the pandemic. Lazarus Ouma, a community volunteer health worker in Bondo district, said people were beginning to realise that some of their cultural traditions were outmoded and potentially deadly within the context of HIV/AIDS. "There are some people who criticise when we discourage wife inheritance. They will say, 'You are cheating people. Death has always been there [death predates HIV/AIDS].’ But generally people are beginning to understand [that HIV/AIDS is a reality]," said Ouma. In the Wawai village of Bondo district, women who have been widowed by AIDS and rejected wife inheritance have established a support group. "Wife inheritance is bad. It is because of it that I am now HIV-positive. Were it not for it, I still would be a healthy person," said Felista Aluoch, 37, who believed she was infected by her late husband, who took his sister-in-law as his second wife after his brother died. Aluoch said she was "deserted" by her brothers-in-law after she refused to be inherited. She now raises seven children on her own, despite the fact that she relies on free ARVs provided by a government clinic in Bondo town, 58 km away. Aluoch, who ekes out an income fetching water for neighbours, selling firewood and raising a few chickens, said she sometimes lacks the 300 Kenya shillings ($4) in bus fare to travel to Bondo town to pick up a month's supply of ARVs. The National AIDS Control Council, a government agency, has in its strategic plan acknowledged that although HIV/AIDS awareness in the country was high, people have been slow in changing their behaviour where sexuality was closely linked to traditional beliefs and cultural practices. [HIV/AIDS a major health issue in western region]