Dilemma of HIV status disclosure among sexually active 14-19-year-old adolescent boys and its effects on viral load suppression in Siaya County, Kenya

INTRODUCTION

Globally, adolescents constitute an increasing share of people living with HIV. The United Nations International Children's Emergency Fund (UNICEF) reports among 480,000 of adolescents who were newly infected in 2022, approximately 140,000 were 10-19 years old.¹ Adolescent boys, according to the report, lag behind in HIV treatment continuum compared to girls. The report shows that in the past 12 months, 25% of girls aged 15-19 in eastern and southern Africa have been tested for HIV and received the test results compared to 17% of boys. Similarly, of the 1.8 million adolescents aged 10-19 living with HIV globally in 2020, approximately 1.5 were from sub-Saharan Africa.² While 54% of adolescents living with HIV (ALHIV) have been initiated on ART, this group has poorer treatment adherence and viral suppression, and higher mortality rates compared to children and adults.³ According to UNAIDS, a person living with HIV who has attained undetectable virology level is described as a virally suppressed patient.⁴ A virally suppressed patient is a person whose viral load is less than 1000 copies/ml after at least six months of first-line ART treatment.⁵ Such patients have lower risks of morbidity and mortality, and less likely to transmit the same to sexual partners.⁶ Persistent adherence to ART among ALHIV is therefore critical for VL suppression to be attained. While stigma related to HIV status exposure has been associated with poor treatment seeking among people living HIV, paucity of information exist on how this affects adolescent boys’ ART adherence and consequently VL suppression more than their female counterparts.

Practitioners highlight that HIV-related stigma forms a major challenge to the successful provision of care to these patients.^7,8 According to Kip et al, stigma is when a person is negatively viewed by others because of certain attributes such as ailing from particular diseases.² In the context of AIDS, stigma is based on the wrong beliefs that one has acquired the disease because of certain misconduct or misbehaviour.⁹ HIV-related stigma exists in diverse forms such as enacted, anticipated, and internalized stigma.² Enacted stigma is experienced when one is stereotyped, excluded or discriminated against due to one’s HIV status. Internalized stigma is experienced out of the belief that the negative stereotypes about their status are true, and in turn, this results into psychological distress and helplessness among persons living with HIV. Anticipated stigma, on the other hand, anticipated stigma occurs when a person develops fear of negative outcomes if his/her HIV status is disclosed.¹⁰ With regards to gender, females have been found to be more likely to internalise HIV stigma than their male counterparts especially in Africa.¹¹ However, while a number of previous studies have documented that men are unlikely to seek for healthcare than women, there is a dearth of literature on how this is related to stigma associated with HIV status disclosure particularly among adolescent boys.^12,13

Disclosure of HIV status has been considered as an important step in controlling the spread of HIV especially among sexual partners because it enables enactment of protective measures between the couples.¹⁴ Obiero explains that disclosure of HIV status involve telling one’s HIV-positive status to a health care worker, sexual partner(s) family members, or other people in the society.¹⁵ Disclosure process occurs in two ways: vertical and horizontal.¹⁶ Vertical occurs when a caregiver or a biological parent tells a child or adolescent about their positive HIV status. On the other hand, horizontal disclosure is when an HIV-positive individual tells others (a sexual partner of a friend) about his/her status.¹⁷ A number of reasons have been given as explanations to low HIV status disclosure among adolescents in the developing and middle-income countries. Surti et al reports that fear of losing friends is the main reason for non-disclosure of HIV status among adolescents aged 13-19 years.¹⁸ Stigma and social exclusion are mentioned as reasons why adolescents aged 10-24 years will not disclose their HIV status in Nigeria and South Africa.^7,19 Two studies done in Kenya and Nigeria among adults by Kingori et al and Tshweneagae et al in South Africa found that stigma is the main reason for non-disclosure to sexual partners, with the latter specifying that men were more unlikely than women to disclose their HIV status to their partners.^14,20 While it is reported in Obiero that HIV disclosure rate among adolescents in Kenya in 2022 was as low as 36.6% compared to the global rate of 69%, how this has remained prevalence among adult men and boys still remains underexplored.¹⁵

Studies focusing on adolescents have demonstrated that both boys and girls have been socialised to enact certain sexual behaviour. Blum, Mmari and Moreau, in a study done among 15 countries (one of them being Kenya) showed that at the on-set of puberty, boys are expected to prove their toughness and sexual prowess by seducing as many girls as possible.²¹ Adolescent boys particularly those living in slum settings have been found to engage in premarital sex at earlier ages than those living in formal settlements.²² In the Luo community context where the current research was conducted, Ocholla-Ayayo documents that boys were culturally socialised to be brave (Thuon), and not to be fond of telling people about whatever situations that they were going through: boys were expected to be able to solve their challenges without seeking for help from anywhere.²³ In Siaya County, the location of the current research, disco Matanga (Disco music at funerals) is a common practice where youths get involved in multiple sexual intercourse in the grass under the influence of chang’aa (local brew) and bhang (cannabis sativa).²⁴ In one of the sub counties forming Siaya County, Ombere et al revealed in a study that adolescent boys and young men have the habit of performing hurried sexual intercourse in the grass without protection along the beaches of Bondo Division.²⁵ These studies provide evidence that adolescent boys in Kenya have been socialised to adopt particular sexual behaviour by the society. However, the aforementioned studies have not highlighted how enactment (or non-enactment) of these types of behaviour associates with HIV-related stigma and, consequently, adherence to ART and viral load suppression among adolescent boys. In contexts where HIV-related deaths among adolescent boys on ART probably due non-viral load suppression have been relatively higher than other area such as Siaya County in Kenya, understanding the role played by adoption of particular sexual behaviour desired or articulated by existing traditional culture remains critical.

Continuous adherence to the required dosage of ART has been articulated as significant in the achievement of VL suppression among people living with HIV.²⁶ However, while extant literature has highlighted a number of factors which determine HIV status disclosure and stigma among adolescents in Kenya, how the same (disclosure and stigma) relate with adherence to ART and consequently VL suppression among boys more than girls remain understudied. For instance, caregiver factors such as school nurse’s friendliness were noted to be affecting disclosure of HIV status among adolescents on ART in boarding schools in Kenya.²⁷ Similarly, negative experiences following HIV status self-disclosure, a strong desire for secrecy, restrictive school policies, and health education focused on sexual transmission of HIV were found to affect ART adherence among adolescents initiated into treatment in a health facility in Kenya.²⁸ Marital status of the care-giver, care-givers who are biological parents and care-givers who have educational background on HIV were found to enhance HIV disclosure among HIV-positive adolescents.¹⁵ The aforementioned studies highlight the nexus between HIV stigma, disclosure, and adherence to ART among adolescents in the Kenyan context. However, little effort has been made to explore whether adolescent boys on ART in areas such as Siaya County of Kenya have been affected by these factors (HIV disclosure and stigma) more than their female counterparts, in turn leading to their non-adherence to ART and consequently unsuppressed VL. This understanding was considered necessary due to the fact that 68% of adolescents who succumbed to HIV-related deaths in the county over the years were boys, according to the Kenyan National AIDS Control Program.²⁹ This study therefore endeavoured to explore how stigma related to HIV status disclosure among 14-19-year-old adolescent boys with sexually active partners affects viral load suppression in Siaya County, Kenya.

METHODS

Research design

This study used cross-sectional design with mixed-methods, utilizing both quantitative and qualitative methods of data collection and analysis. This approach was adopted so that quantitative method is used to measure some aspects of the phenomenon under study and qualitative methods for others.

Study population and sample

The study targeted 795 adolescent boys with high viral load aged 14-19 years as contained in NASCOP (2023) records as at December 2022, alongside seven comprehensive care-in charge (CCC), the County AIDS/HIV and STI coordinator (CASCO), 6 Sub County AIDS coordinators (SCACOs), and fourteen Public Benefit Organizations (PBO) officials.

This study adopted Yamane’s formula to calculate the sample size of adolescent boys as shown below:³⁰

Where:

n = the sample size,

N = the population size, and

e is the level of precision (0.05).

The calculated sample size for adolescent boys with high viral load on ART was 265. Using stratified proportional technique, the adolescent boys were distributed in each of the six sub-counties based on each administrative unit’s population (of the adolescent boys under ART). Similarly, the study purposively selected healthcare practitioners and government officials for interviews and focus group discussions until saturation was attained.

Instrumentation, validity and reliability

The study administered structured questionnaires to collect data from the sampled adolescent boys. Similarly, in-depth interviews and focused group discussions (FGDs) guide were also used to gather additional information from randomly selected adolescent boys. In addition, interview schedule as well as FGD guide was also used for gathering information from care-givers as well as government officials in charge of HIV and AIDS treatment in the county.

This study used content validity index (CVI) to enhance the validity of the study instruments. In this regard, ratings of four experts based on item relevance were used to measure constructs of the study variables. The ratings adopted a 4-point ordinal scale of 1-4 for not relevant to highly relevant using the formula of item content validity index (I-CVI) stipulated by Davis:³¹

I-CVI = (agreed item)/(number of expert)

The calculated rating of the four experts generated a CVI of 0.88. This was considered to be highly relevant by the researchers.

On the other hand, the study used data collected from a pilot study involving randomly selected 79 adolescent boys on ART who were thereafter excluded from the main study to check reliability of the study instrument. With the aid of Statistical Package for the Social Sciences (SPSS) version 21 tool, Split-half method was used to calculate correlation coefficients of 0.83 and 0.84 for stigma in HIV status disclosure and multiple sexual partners respectively.

Data analysis

Data obtained using questionnaire was analyzed via descriptive and inferential statistics with the aid of SPSS version 25. Similarly, thematic analysis was used to analyze qualitative data obtained from open ended questions in the questionnaire, interviews and focus group discussions.

Ethical considerations

For ethical considerations, the researchers obtained clearance to conduct the field study from Maseno University Scientific and Ethics Review Committee (MUSERC) and the National Commission for Science, Technology and Innovation (NACOSTI). An assent form was designed and signed by the adolescent boys who were under 18 years old while their parent/guardian signed consent forms.

RESULTS

The researchers were able to process 263 completely filled in out of expected 265 questionnaires from the sampled adolescent boys. Out of this, 23.1% of the boys were 14 years old; 18.9% were 15 years old; 18.6% were 16 years old, and 14.4% were 17 years old. The remaining 25% were aged between 18 and 19 years old. Similarly, 53.8% of them had lost either one parent or both, meaning that they are orphans in one way or the other.

Participation in sexual activities

To determine the extent to which the sampled adolescent boys were sexually active, the respondents were asked to state whether they have been sexually active (participating in sexual intercourse) and whether they have ever had a sexual partner since their initiation into ART (Table 1).

A majority (72.3%) of the sampled adolescent boys as shown in Table 1 had not participated in sexual intercourse. At the same time, majority of the adolescent boys (73.5%) have not had a sexual partner ever since their initiation into ART. The boys who indicated that they have not participated in sexual intercourse stated that the reason for this is because they were still young and are not ready for such an activity. This theme emerged in the qualitative data during IDIs, where a statement from a 14-year-old boy at a health centre stated:

Having a girlfriend at this moment is not a priority to me. In any case, I am still young and would wish to concentrate in my education. Similarly, I do not have any money for the upkeep of a girlfriend, and my grandmother whom I leave with does not have money to support me in doing things such as the upkeep of a girlfriend.

The statement attributed to the 14-year-old boy demonstrates that poverty experienced in the households in which a number of these boys live is a factor that determines the active participation in sexual activities. The study proceeded to explore the extent to which the adolescent boys who engage in sexual intercourse had multiple sexual partners.

Multiple-sexual behaviour

The second aim of the study was to assess the sexual behaviour of the sampled adolescent boys in terms of multiple sexual partnerships (Table 2).

Table 2 illustrates that the sampled adolescent boys do not restrict themselves to one sexual partner even after initiation into ART (55.6%). However, the boys do not know of reactive adolescent boys on ART who have multiple sexual partners (58.7%). They also seldom easily get new sexual partners in replacement of departing ones since their initiation into ART (57.1%).

The observations made from findings in Table 2 on multiple sexual partners also arose during IDIs with part of the adolescent boys under the study. This is a statement obtained from a 17 years old boy in one of the IDIs:

Most sexually active adolescent boys had multiple sexual partners. Others, however, did not have. You find that a person meets a girl today, after a few days, he finds yet another one who he feels is better than the first one and the behavior develops like that. They did not stay indoors when evening approaches; they were looking for girls, while it is mostly not easy to get the girls. The boys ‘comb’ the village every evening in search of girls.

Because of the existing peer pressure and societal socialization to sexually conquer as many females as possible so as to be seen as real men, the adolescent boys who are sexually active under the current study are ever out-door on search of females to prove their sexual prowess.

Disclosure of HIV status

Another objective of the study aimed at the extent of disclosure of HIV status among the sampled adolescent boys (Table 3).

Table 3 illustrates that the sampled adolescent boys seldom disclose their HIV status to their partners (65.1%) and do not take ART drugs with the knowledge of their sexual partners (60.3%). However, the sampled adolescent boys often use condoms for protection during sexual intercourse (57.1%). This perspective also emerged during focus group discussions with selected adolescents where various reasons were given for non-disclosure of HIV status. One 18-year-old boy stated that:

Disclosing your HIV status is like committing suicide: the partner might end up leaving you forever. Worse still, she might end up telling everyone about your sickness. In the end, every chic in the town/village will know about you and it will be your end in as much as winning ‘chics’ is concerned.

The sentiment by the 18-year-old adolescent highlights the notion that these boys put a lot of effort to ensure that they conceal their health condition from the knowledge of their partners. The fear of being isolated should their HIV status be known is the driving force behind this effort.

Stigma of HIV status exposure and its effects on viral load suppression

For determining how stigma of HIV status disclosure influences VL suppression, the study first assessed the level of VL suppression among the sampled adolescents (Table 4).

Table 4 illustrates that 83.3% of the boys have suffered from a number of opportunistic diseases since their initiation to ART. The table also indicates that 67.3% of the adolescent boys have not been ready to honour appointments for VL test. It is further shown that 62.9% of them do not fully understand the importance of knowing their VL testing, and that they do not frequently get their VL counts tested and measured (50.5%). This is irrespective of the fact that 73.4% of the boys have indicated that they often get educated/sensitized on VL issues by caregivers.

To determine the influence that stigma of HIV status exposure has on VL suppression among the sampled adolescent boys, the authors run a Pearson Correlation analysis between the variables (disclosure of HIV status, multiple sexual partners’ behavior, and VL suppression through the aid of SPSS version 22 (Table 5).

Table 5 illustrates that the correlation between disclosure to partners and VL suppression (r=0.072; p=0.122) and multiple sexual partners and VL suppression (r=0.023; p=0.353) are not significant. However, the correlation between disclosure to partners and multiple sexual partners (r=0.391; p=0.000) is significant.

DISCUSSION

Disclosure of HIV status

Findings in this study reveal that the adolescent boys in this study majorly engage in sexual intercourse at older age (19) as compared to younger age (14), implying that the older they get, the more engagement in sexuality they become (Tables 2 and 3). Findings also illustrate that the adolescent boys keep secrecy their HIV status from their sexual partners and they also take ART drugs when their partners are not near them (Table 4). This is done out of fear of being ‘left’ should the partners become aware of their (the boys’) status, forms of enacted as well as anticipated stigma. Enacted stigma arises since the adolescent boy fear being stereotyped, excluded or being discriminated against because of their HIV status.²

The reluctance of the adolescents to disclose their HIV status in fear of being isolated in the sexual relationship circles has also been highlighted in some past studies. For instance, Tshweneagae et al found in a study done in South Africa that men are more reluctant to disclose to their sexual partners their HIV status for fear of rejection, while women were relatively more willing to disclose their HIV status to their sexual partners.¹⁴ The current study has also revealed that fear associated with stigma and isolation from ‘love-relations’ circle is the drive behind non-disclosure of HIV status among adolescent boys in Siaya County, Kenya.

Multiple sexual partners

The study has found that the adolescent boys in the current study have the habit of engaging in multiple sexual relationships (Table 5). Qualitative data has also shown that the adolescent boys often move around every evening in ‘search of girls’ while the girls are prohibited from freely roaming the village. This finding is in tandem with masculinity inclinations demonstrated in a previous study done in Kenya alongside other 15 countries by Blum, et al which showed that at the on-set of puberty, boys are expected to prove their toughness and sexual prowess by multiple sexual partners as much as possible, while girls are expected to preserve their sexuality.²¹ Another study done in Brazil also highlighted that adolescent boy living with HIV give preference to multiple sexual relationship without considering their HIV status for purposes of fulfilling their gender-induced prowess as constructed by the society.³² Likewise to different contexts, adolescent boys in the study area engage in multiple sexual relationships despite their health condition of being HIV positive and on ART treatment. They seem to give preference to masculinity obligations articulated by the culture of their community which view being a man as the ability to conquer as many sexual partners as possible.

The study reveals that the relationship between disclosure to partners and VL suppression, and multiple sexual partners and VL suppression are not significant (Table 5). However, the relationship between disclosure to partners and multiple sexual partners is significant. This implies that disclosure of HIV status (or non-disclosure) to partners has a direct and significant effect on multiple sexual partnership behaviour, which on its own a risky to VL suppression endeavours. The fear of being excluded from sexual relations circle due to exposure of their HIV status while it is their desire to own as many sexual partners as possible, boys in this current would rather keep their health conditions secret. This observation concurs with a finding in a previous study done in South Africa which showed that as opposed to females, males were more reluctant to disclose their HIV status to their sexual partners for fear of rejection, with such secrecy was commonly linked to sexual matters between the spouses.¹⁴

CONCLUSION

Findings from this study shows that the adolescent boys under ART start engaging in sexual intercourse at as early age as 14 years, and concentrate at 19 years. There is predominant non-disclosure attitude of HIV status among the adolescent boys due to fear of being rejected in the love-relationship circle.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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