The entire Kenyan shoreline of Lake Victoria all its inhabited islands on the Kenyan waters (Wayasi, Sifu, Ndeda, Oyamo, Sukru, Kibwogi, Ngodhe, Rusinga, Ringiti, Mfangano, Remba and Kiwa) form a zigzag shoreline approximately 760 km long. About 700km of this shoreline lies in Nyanza Province. The lake is the main source of livelihood for a population stretching about 490 p/km sq. (2009 census) of the lake. Nyanza Province has the highest HIV prevalence in Kenya among adults aged 15 to 64 years at 14.9% compared to the national prevalence of 7.1% (KAIS 2007). The second highest prevalence is from Nairobi Province at 8.8%. When Foundation of People Living with HIV/AIDS in Kenya (FOPHAK0 established an office at Luanda Kotieno Beach in 2007, it was motivated by this high prevalence rate.
Although no outstanding contributory factors to the high prevalence have been authoritatively isolated, it is assumed that a number of reasons contribute to this. Top on the list is the Luo tradition, the predominant ethnic group in the region, of no-circumcision, tero (wife heritance), poligamy and general sexual promiscuity and secondly, the geographical disposition of the province within proximity of the lake. It is estimated that there are over 208 commercial fish-landing posts along the shoreline in Nyanza and Western provinces. Of these 187 posts or 90% are on the Nyanza side of the lake distributed in the counties of Kisumu (32), Siaya (46) and Homa Bay (109). Commercial fish landing and other fish related businesses contribute an estimated Kshs 12 billion annually to the national economy making fishing a lucrative venture to the people of the region.
FOPHAK selected Luanda Kotieno Beach, a strategic fish landing post in Siaya County, to undertake HIV interventions targeting fisher folks under Global Fund Round 7, in partnership with CARE International in Kenya. The office was meant to serve the entire Rarieda District with a total of 17 beaches and the hinterland. The fish-for sex exchange has been highlighted as a major factor in the spread of HIV/AIDS among fishermen and female fish mongers in what the fisher community have christened 'jaboya system'. (Jaboya means the owners or operators of fishnets and floating gears used for catching fish). This system has survived and thrived among fisher folks over the years due to ignorance about HIV, migratory practices of fishermen (most of whom do not live with their families) from beach to beach and poverty. Women fishmongers, most of whom are widowed by HIV/AIDS and young and vulnerable female orphans, in an effort to improve their chances of obtaining fish from fishermen often offer sex favors to the fishermen (joboya) in exchange for the best catch and best bargains. It does not end there. For those who need space in the local buses and matatus (which always have limited space) to transport their fish to other markets, the sex offer is extended to the turn-boys and drivers to reserve space. The sex-chain is thus extended with multiple partners irrespective of one's HIV status and more often than not, without protection.
Sensitization meeting for fisherfolks attended by CARE and PriceWaterHouse Cooper representatives
FOPHAK'S main intervention for this community has been to sensitize the fisher folks on counselling and testing and increase uptake of ART among those who are already infected. Sensitization was carried out in a number of beaches within Uyoma and Asembo locations of Rarieda District using DASCO accredited facilitators, working with positives and use of strong mobilization teams which included carefully selected mobilizers, beach leaders and local community leaders. FOPHAK also worked with other partners to address some of the challenges such as long distances to the available VCT centres and health facilities which inhibited treatment, counselling and testing. Madiany District Hospital, the nearest health facility is situated in the hinterland some 18kms from Luanda Kotieno. A number of moonlight VCT sessions were carried out by Tuungane Group and KEMRI-CDC both of Kisumu at FOPHAK centre; including advocacy for voluntary medical male circumcision, referrals for TB and other opportunistic infections diagnostics) and treatment for Sexually Transmitted Infections. Migratory lifestyle of fishermen, poverty, illiteracy and retrogressive cultural practices like wife inheritance also presented serious challenges. Mr. Oguda, the Beach Leader for Luanda Kotieno indicated that 80% of the fishermen residing at Luanda Kotieno were from outside Rarieda district. Most of the homes in the area were headed either by widows or widowers and at least 5 out of 10 homes by orphans with one or both grandparents as care givers. Records at Madiany District Hospital indicated that 6 out of 10 cases referred for VCT tested HIV positive.
The organization's centre operated as an open friendly and accommodating office working 7 days a week from 8 am to 9 pm daily where the fisher community would present HIV related issues. This strategy appeared to work very well as the organization gained foothold and popularity with the people. At the end of Phase I of the programme, the organization had reached a total of 367 fisher folks of which 186 or 51% were males and 181 or 49% females against a target of 468 over an 18 month implementation period. With concerted effort from the organization, at least 172 or 47% attended VCT and an increased uptake of counselling and testing was realized. It was also noted that prior to the arrival of FOPHAK in the area, there were no serious HIV interventions other than casual announcements in the chief's barazas.
Major lessons learnt were that the fisher folks are highly engaged, busy people who are driven by the urge to make money every day by either being in the lake fishing or trying to get markets for the catch and hence have no time to visit VCT centres located long distances away. Fish is carried out throughout the night and landings done in the morning meaning, during the day most of them take rest by either sleeping or preparing their boats and fishing gear. That is why in effort to attract as many of them as possible, the organization had to leave its doors open for longer working hours. There was noted substantial reduction of stigma as many were willing to share their activities and were willing to undergo testing after sensitization. Moonlight VCTs had overwhelming response.
It is important to maintain the tempo of sensitization of fisher folks since they form the majority of the residents and have contributed to the spread of the HIV pandemic hinterland.
Foundation of People Living with HIV/AIDS in Kenya