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Kisumu town is found by the shores of Lake Victoria, is the capital of Nyanza province and the third largest town in Kenya. It is one of the most HIV/AIDS affected areas in Nyanza with a prevalence of 18.5% . Nyanza province, in general, is the most severely affected, with HIV rates as high as 15%, which is double the national average [6,7]. Studies conducted in Kisumu in the late nineties show that HIV prevalence among girls was very high compared to boys (age group 15-19 years 23% versus 4%; age group 20-24 years 40% versus 13%) . HIV prevalence among female sex workers was also very high, at 75% . Although more recent figures for Kisumu are slightly lower, the numbers are still alarmingly high, and higher than in other parts of the country [9,6]. High HIV prevalence rates (30%) as well as very high rates of STIs have been noted among fishing communities along the shores of Lake Victoria [10,11]. These high rates of HIV/AIDS in Luo Nyanza have left 40% of children under 18 without one parent, and 11% without both parents [6,12]. Cultural norms such as wife inheritance and widow cleansing, polygamy, "jaboya" (in which female fishmongers develop sexual relationships with fishermen and middlemen in exchange for fish), and "chira" (a curse that comes from breaking certain taboos and traditions), continue to have a powerful hold on people in this lakeside province [10,13,14].
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For the in-depth interviews, a convenience sample of 75 boys and 75 girls aged 15-20 years were interviewed at their households. Using the sampling framework of the multicentre study, quota sampling was used to ensure diversity in age, socio economic status (SES) of household, and education . A qualitative interview guide was developed in English and translated into Swahili and Luo. Trained fieldworkers pre-tested the guide in communities neighboring the study sites. The interviews were held in Luo, Swahili or English by same-sex interviewers, and tape-recorded; they took about 45 minutes to one hour. Prior to the in-depth interviews, verbal informed consent/assent was obtained from all adolescents, in addition to parental consent for minors.
Four focus group discussions (FGDs) were held by same-sex interviewers in preparation for the in-depth interviews (i.e. with in-school males, in-school females, out-of-school males, out-of-school females). A topic guide was used, that was pre-tested for face and construct validity. The FGDs mainly focused on youth's attitudes, risk perception and socio-cultural norms regarding sexuality. Each FGD had 8 to 12 participants aged 15-20, and the discussions took about one and half hour.
Of the youth interviewed, 79% of boys and 49% of girls reported they ever had had sex. Of these, 37% of boys (22/59) and 59% of girls (22/37) had their first sexual intercourse at age 15 or younger. A 15-year-old girl from a low-SES area stated: "In this area of ours, many girls...get pregnant while they are very young because of starting sexual relationships very early, maybe like my age, you will find one has a boyfriend and later on she is made pregnant and then she is left which is not good."
Most girls reported a large age difference with first and current partners. Sixteen of the 28 girls who mentioned the age of their first partner reported that he was 25 years or older. All girls with a current partner had a partner who was over 20 years old (ranging from 2 to 17 years older). One girl stated: "...well if I am 20 I will go for a guy who is older than me by six years or something like three... because you cannot move [date] a guy who is the same age as you...." Older men were preferred, as they proved to be more mature, could provide for their needs, and offer advice to solve problems. During the observations, older men were often seen with girls as young as 15.
Of the sexually active adolescents, over half of the girls reported having had 2-3 partners; over half of the boys indicated having had 3-5 partners and about a third reported more than 10 girlfriends. A few boys found it difficult to count all sexual partners: "Some you can meet, you talk, have sex, then it just ends there so remembering them is difficult". Some of the bicycle taxi transporters reportedly had sex daily, with different partners. Girls mostly reported serial monogamy and rarely stated outright that they had concurrent partners. In contrast, many sexually active boys casually reported having overlapping partnerships: "...the first is the one we talked about, ...the second is the one who was here, and the third is the one I connect with at the video hall." Even among young men with a steady partner, it was common to have brief sexual encounters on the side, for example while at the video halls or attending a disco funeral. These 'disco funerals' are parties held by the relatives of a person recently deceased, in order to raise funds for the funeral. The disco funerals are characterised by loud music, singing, dancing, bidding games and risky sexual behaviour. Because we have described these events (in which Kisumu youth engage in risky sexual behaviour) in a separate paper, we do not elaborate on it here .
Reports of forced sex were many: 15 of 37 sexually active interviewed girls reported some degree of force/persuasion during first sex. Some girls were lured into secluded places such as a boy's cube [separate living quarter for boys], and were forced to have sex: "This boy told me to visit him so when I went, he put the radio on... then later he just held me by force." A 17-year-old boy reported: "Say you've been dancing with her and you've told her that thing [sex] and she has refused, you just hold her and pull her by force till you go with her... to the bush or darkness where people don't go to..." Another girl said that a boy grabbed and pinned her down and forced her to have sex at age 13. Some boys were said to waylay prostitutes and force them to have sex: "Especially when it is night you meet a lot of girls hijacked by a group of men, being pulled to some place... they know these girls are prostitutes, they sell for money. But these groups of boys don't have any cash, they just get them and hijack them yah," (FGD, out-of-school boys).
Few adolescents reported condom use at first sex (12 girls and 15 boys out of 96 sexually active adolescents). Condom use was neither common nor consistent: "I have four girlfriends...I use a condom but not every time." Reasons cited by boys for non-use included trust, discomfort, reduction of pleasure, and not having any condoms. For most girls, non-use was related to their limited ability to request condom use, ideals of intimacy and pleasure, and mixed messages about safety: "Well... some don't use condoms because they tend to say that they will have side effects". Some young people also held the belief that very young boys and girls could not have STIs. Some adolescents only used condoms during the unsafe period in the menstrual cycle. Others reported they usually stop using condoms in a new relationship when they have become more used to each other or, as a few reported, after getting a negative HIV test.
There are a number of limitations that should be considered when interpreting the results. Because we used purposive quota sampling, it cannot be concluded that our results are fully representative for the total Kisumu youth population. Age was difficult to estimate from observation. We relied on participants' self-reports and there is a possibility of social desirability bias particularly among girls who may have underreported sexual experiences . Caution is also suggested when generalizing our findings to other settings and populations, because the urban environment may have influenced youth norms regarding sexuality. Despite these limitations, the study was able to generate rich, descriptive data obtained through method triangulation, including new knowledge on a previously unstudied aspect of HIV risk- pornographic video shows. The high number of interviews held and the use of quota sampling ensured that the views of diverse youth (both girls and boys, in and out-of-school, in different SES) were incorporated.
Our findings point to gender-related power differences that expose young girls to HIV risk. Power-related differences manifest themselves not only in relationships, but also in the belief and structure of society . For example, pre-marital and multi-partner sex, while typically portrayed (in Kisumu and elsewhere) as a breach of social norms, is also said to be a fundamental dimension of gendered social organization . Men in settings like Kenya generally are expected to conform to a range of behavioural norms that confirm the hegemonic masculinity . People consider it as a right and necessity, and part of the tradition, that men have more than one partner . Pressure to be sexually adventurous and aggressive to prove manhood is quite pervasive in Africa. These norms allow men to have more sexual partners than women, encourage older men to have sexual relations with younger women, and increase the acceptance and justification of violence against women. It is not surprising therefore that our findings show that male partners force sex, perform gang rape, and have multiple concurrent relationships. Such norms and societal power relations consistently tend to disadvantage young women, as evidenced by the high incidence of transactional and coerced sex in many sub-Saharan countries .
The subordinate position of women, including the lack of control over finances and resources, has motivated girls to engage in multiple concurrent partnerships primarily for economic reasons, but at times the desire for love and sexual pleasure contributes to these partnerships [29-31]. Girls look at these partnerships in light of future plans, hoping for a steady relationship or marriage with an affluent older man. But also young men have a stronger socio-economic position than young women, enabling them to use money/gifts as leverage for sex. The material exchange accompanying sexual encounters may be interpreted as a loving gesture, but it may also express an unloving and calculating relationship. 041b061a72