Growing attention on men often converge with studies on male power and practices of masculinity, characterized by sexuality and sexual- and gender-based violence (see Connell, 2005; Gough, Milnes & Turner-Moore, 2021; Maclean, 2016). The concept of masculinity postulates that gender is socially constructed; whereby men are expected to adopt particular behavior that are culturally imposed rather than by biological attributes (John, et al 2017).

Main elements of the dominant mode of masculinity are heterosexuality and fearlessness or risk-taking: to wit, a real male is not a sissy; a man is defined by having sex with women; and a man is afraid of nothing (Shefer, 2007). However, despite adolescents constituting majority of the world population, little focus has been directed at understanding how masculinity formulation of sexuality affects adolescent boys across different contexts especially in the wake of HIV/AIDS pandemic.

This insight is critical given that adolescence is a phase involving physical development shifts from puberty to sexual and reproductive maturity, identity formation to identity development, and economic dependency to independence (Dara & Arora, 2023; Kågesten et al, 2021)

Extant literature on masculinities demonstrates that there are undeniable pressures on adolescent boys, in a wide variety of contexts, to be like other, older males (Amin, Kågesten, Adebayo & Chandra-Mouli, 2018; Bell, Rosenberger & Ott, 2015; Connell, 2005). While there is pressure on all males to conform to the prevailing dominant mode of masculinity, expectations of adolescent boys have traditionally tended to demand that they take all manner of risks including sexual risks, risks related to drug use, and engaging in sexual violence and other violent behaviours (Bhana & Chen, 2020; Klingemann, & Klingemann, 2023; Messerschmidt, 2017). Similarly, while enactment of masculinity has been highlighted as a set-back in men’s HIV-care continuum (Brown, Sorrell & Raffaelli, 2005; Lindegger & Quayle, 2009; Wyrod, 2011), its influence on viral load suppression among adolescent boys on Ante-Retroviral Therapy (ART) has received limited attention.

Viral load suppression is a critical indicator of success in HIV treatment (UNAIDS, 2022). Suppression of viral load among patients on ART is noted on improved prognosis evident in reduced rate of disease occurrence and decreasing VL counts, progression and mortality (Waju, Dube, Ahmed & Assefa, 2021). A patient attains viral suppression when his or her viral load falls below the detectable threshold of <1,000 copies/mL of HIV (Waju et al, 2021). Unsuppressed VL, on the other and, pose the risk of increased vulnerability to opportunistic infections, HIV morbidity and mortality, thereby hampering achieving UNAIDS agenda of suppressing viral load to 95% among all HIV patients on ART by 2030 (Chowdhury et al, 2023; Cuadros et al, 2023; UNAIDS, 2022). Viral load suppression amongst adolescents is a serious concern for practitioners and policy makers since AIDS-related deaths of this population continue to rise globally, despite reduction being observed in other age groups (Cuadros et al, 2023; UNAIDS, 2023). The UNAIDS (2021) statistics demonstrate that mortality among adolescent rose from 18,000 deaths per annum in 2010 to 41,000 deaths in 2020, with adolescent boys constituting 69% of the deaths. Understanding causes to non-viral load suppression among adolescents especially boys will therefore be an essential step towards finding a solution to barriers to VL suppression amongst members of this cohort.

Drug resistance, non-adherence to ART, non-honoring of clinic appointments, and reduced access to medical services probably due to social, economic, and cultural problems, are some of the barriers listed by UNAIDS (2020) to VL suppression attainment. Similarly, age and gender of the patient as well as mode of delivery of ART drugs are also some of the social factors noted as compromising VL suppression, with males, aged 15 – 19, being at the highest risk (Tomescu et al, 2022). Significant attention has lately been directed at adolescents with regards to VL suppression due to the fact that globally, approximately 150 of this population die daily due to AIDS-related ailments (Bulage et al, 2017; Oryokot et al, 2020). According to Mushy et al (2024), the transitional phase of development from puberty to legal adulthood among adolescents is accompanied by different risks associated with behavioural changes capable of interrupting ART adherence and delaying the achievement of the “Third 95” target. However, whereas conformity to masculinity has been associated with negative health outcomes among adult men (Etienne, 2018; McGraw, White & Russell-Bennett, 2021; Olanrewaju et al, 2019; Wong, Ho, Wang & Miller, 2017), dearth of information exist regarding how sexuality formulation based on masculinities also influence VL suppression among adolescent boys. This information is vital for tailored response in HIV high prevalence areas such as Siaya County in Western Kenya.

A large volume of literature on adolescents demonstrates that boys and girls are often socialised to endorse certain sexual behaviour so as to conform to social and cultural expectations. For instance, boys are expected to prove their toughness and sexual prowess by seducing as many girls as possible at the on-set of puberty, besides shunning emotions associated with femininity (Blum, Mmari & Moreau, 2017). Adolescent boys residing in slum settings often engage in premarital sex at earlier ages than those living in formal settlements (Maina, Nyakangi, Mbuthia & Bangha, 2020). In the Luo community context where the current research was done, Ocholla-Ayayo (1976) 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. 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) (Blommaert, 2014). In one of the sub counties forming Siaya County, Ombere, Nyambedha and Bukachi (2018) 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. 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 masculinity has influenced sexuality and, consequently, viral load suppression among adolescent boys.

In a region that is witnessing higher HIV-related deaths among adolescent boys on ART, probably due non-viral load suppression, 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. The Kenya Population-based HIV impact Assessment (KENAPHIA, 2022), the body responsible for monitoring HIV and AIDS-related cases including VL status among patients, Siaya County was one of the areas with the very high HIV prevalence in the country at 15.3% by end of 2022. This is substantially higher than the national estimate of 4.9% (Awuoche et al, 2024). The statistics (KENAPHIA, 2022) further shows that the gender differences between youths who succumb to HIV and AIDS complications despite being on ART is higher in Siaya in favour of females as compared to other counties with reported high HIV and AIDS prevalence. The report additionally highlights that as at December 2020, under 14 – 19 HIV positive cases were 1641 (Females=846; Males=795) and 248 HIV related deaths. This article aims at providing additional insights on unique factors which hinder the achievement of the global goals in the HIV treatment continuum especially among key populations such as adolescent boys.

Methods and Materials

Research Design

The study used cross-sectional survey design with mixed-methods involving collection and analyses of both quantitative and qualitative data. This design enabled the researchers to use quantitative approach to measure particular aspects of the phenomenon under study and qualitative methods for others, as proposed by Dawadi, Shrestha and Giri (2021). This, according to Shorten and Smith (2017), has the advantage of providing complementarity in data collection, analysis and interpretation (Shorten & Smith, 2017).

Study Setting

The study was done in Siaya County, located in the Lake region of Kenya. The study was carried out in six Sub-County health facilities: Ambira, Bondo, Yala, Madiany, Ukwala, Got-Agulu, and Siaya County. This area is dominated by the Luo ethnic community with cultural practices that are widely regarded as health-undermining especially in the wake of HIV and AIDS pandemic such as wife inheritance and disco Matanga (night music parties in funerals) (Oluoch & Wesonga, 2013; Perry et al, 2014). The culture guiding sleeping arrangements as practiced by the community, where adolescents are socialised to sleep at a house separate from their parents, either within or outside the immediate family homestead, has also been described as predisposing the adolescents to HIV and AIDS (Kayongo-Male & Onyango, 1984; Juma et al, 2013). The culture also socialises the adolescent boys to be tough, strong, and not to fear challenging situations such as venturing unknown places even at night (Ocholla-Ayayo, 1976).

Study population and sampling strategy

Target population comprised of 795 adolescent boys with high viral load aged 14 – 19 years, 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. To obtain the sample size of adolescent boys, this study adopted Yamane’s (1967) formula as:

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) as illustrated in Table 1. Similarly, the study purposively selected healthcare practitioners and government officials for interviews and Focus Group Discussions until saturation was attained.

Table 1: Distribution of Sample Size

Structured questionnaire was used to collect data from the sampled adolescent boys. The questionnaire consisted of both closed ended and open ended questionnaire to enable collection of both qualitative and quantitative data. Questionnaire method was chosen because it enabled the researcher to gather rue amount of data within a short duration of time. Similarly, in-depth interviews and Focused Group Discussions (FGDs) guide were also used to obtain qualitative information from randomly selected adolescent boys. In addition, interview schedule as well as FGD guide was also used for gathering information from care-givers, being comprehensive care-in charge (CCC) and Public Benefit Organizations (PBO) officials, as well as  government officials in charge of HIV and AIDS treatment in the County: the County AIDS/HIV and STI Coordinator (CASCO), Sub County AIDS Coordinators (SCACOs)

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 (Dawadi et al, 2021). 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 (1992):

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. The instrument was therefore considered as reliable in collecting the required data since the reliability coefficient surpassed the threshold of 0.70 (Nunnally, 1978).

Data Analysis and Presentation

Data obtained using questionnaire was analyzed via descriptive and inferential statistics with the aid of SPSS version 25. Descriptive statistics enabled generation of frequencies and percentages which was essential for interpretation of quantitative results. On the other hand, Pearson correlation was used to analyse the relationships between HIV status disclosure, multiple sexual partners, and VL suppression. 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. For purposes of confidentiality, participants were asked not to exclude their identities from the research instruments.

Results

Socio-demographic Characteristics of the respondents

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. Table 1 presents the demographic information of the sampled adolescent boys.

Table 1: Demographic Information of Respondents

Results presented in Table 4.1 illustrate that of the boys who participated in the study, most

Similarly, results on the socio-demographic information also illustrate that 86.3% of the adolescent boys were perinatally infected, while 4.2% were behaviourally infected. The remaining 9.5% of them did not know how they were infected with HIV. It is also indicated that majority of the adolescent boys (87.5%) have been on ART for more than one year, whereas 12.5% of them have been on treatment for one year and below. Findings further showed that majority 53.6% (n=141) of the sampled adolescent boys have lost either one parent or both parents. Of these, 26.2% (n=69) have lost their fathers and are remaining with mothers only while 18.3% (n=48) have lost both parents. The Table additionally shows that majority (57.4%; n=151) of the adolescent boys do not live with both parents, having lost either the mother or the father. Among them, 26.6% (n=70) live with their mothers while 15.2% (n=40) live with their grandmothers.

Masculinity Formulations

To establish the masculinity formulations ratified by the primary respondents, the study enquired from the sampled adolescent boys whether they have ever been called upon to behave in certain ways to be viewed as real men in the society. Table 2 summarizes the computed results.

Additional enquiry by means of the open-ended questionnaire revealed that those with whom the adolescent boys closely interact with almost on a daily basis formed the bulk of them including:

My grandmother, my mother, my uncle, my father, my care-giver, and the person delivering ARVs to me

The family, especially parents, is responsible for conveying masculine messages to the adolescent boys. Moreover, the role of women in inculcating masculinity values among children and young adolescents was also highlighted in an FGD done with selected boys, where a 15-year-old boy said:

It is my mother who informed me of my status. She told me that I was born with the           disease and that if I continue taking these drugs without skipping, I will soon heal. My      mother and grandmother often encourage me to be fearless and remain strong as a         man. My mother has been telling me that men should be tough and fearless. In most               cases, my mother reminds me of the time required for taking up the drugs and when to   honour medical appointment at the facility (15-year-old boy FGD discussant).

These findings demonstrate critical features of masculinity formulations in the light of expression of emotions and deep feelings towards a pertinent issue in the family, being that there is a sick child (HIV positive boy) in need of critical help and the person who takes the responsibility to seek for healthcare.  The study thereafter proceeded to explore masculinity formulation of sexuality relates wit viral load suppression amongst the adolescent boys.

Masculinity and Sexuality

The study further analysed how masculinity formulation of sexuality influence VL suppression. This was achieved by requesting the sampled adolescent boys to state the extent of their agreement with how their sexual behaviour has been influenced by particular masculinity conceptions presented by the researcher. Table 3 presents the findings on masculinity influences on sexual behaviour.

Table 3 illustrates that the sampled adolescent boys disagree that they always restrict themselves to one sexual partner since their initiation to ART (F=38; 52.1%), and that they do not know of reactive adolescent boys on ART who have multiple sexual partners (F=51; 69.9%). the respondents also indicated that do not always easily get a new sexual partner in replacement of a departing one since my ART initiation (F=38; 52.1), while 29 (39.7%) of the boys indicated that they do not often use a condom for protection during sexual intercourse. This finding demonstrates that while a number of these boys are involved in multiple partnerships, many of them do not use condoms during sexual intercourse. A cross tabulation was therefore conducted between ages of the respondents and sexual partnership behaviour. Table 4 presents the results.

Table 4: Cross-tabulation of Age and Multiple Sexual Partners

Most adolescents who are sexually active have multiple sexual partners. Others, however, do 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 do not stay indoors when evening approaches; they are        looking for girls, while it is mostly not easy to get the girls. This is because girls are often placed under intense restriction by guardians and parents (17year old IDI participant).

Peer pressure and prescribed societal norms which do not inhibit excesses in sexuality of males appear to be extended to adolescent boys in this area..

In some of the FGDs held with the adolescent boys, it emerged that the “roaming” boys sometimes come across “sugar mummies”, elderly women who are still stuck with youth-like sexual desires. These elderly women entice the boys with various gifts to make them (the boys) to remain “theirs” sexually.  Depicting this was a statement made by an 18-year old boy as:

Sugar mummies often look for young boys like us to meet certain sexual objectives   which do not usually seem to be in good faith. You know, these women have money: real money. As a young man you find that sometimes there is nothing at home and you need a good cloth for Christmas, you end up getting caught up in these relationships risking your life just for money. However, our parents perceive them as sluts. An old woman who does not respect herself and does not have good morals is a prostitute (18    year old FGD participant)

The predators, whom the society including their parents have allowed to roam the vicinities and conquer as many sexual preys as possible, seem to become the preys themselves based on the statement made by the 18-year old boy in the preceding paragraph. During KII with some of the clinical partners and PBO officers, it also emerged that a lot of efforts made by people close to the adolescents, such as teachers, parents, and caregivers, with regard to healthy behavior have been skewed towards girls more than boys. One female PBO officer put this narrative into the following perspective:

Girls are seen as vulnerable and in need of protection. Therefore, concerns regarding         safety of female sexuality and “reputational” risks compel most parents to tightly   control their daughters’ behaviour and freedom of movement (a female PBO interviewee).

The safety of the boys’ sexuality appears to be overlooked, based on the statement attributed by the female PBO officer.

Relationship between Masculinity Formulation of Sexuality and Viral Load Suppression

The researcher used stepwise multiple regression analysis to ascertain the type and direction of the relationship between masculinity formulation of sexuality variables and VL suppression among the adolescent boys in the sample. In order to determine how effectively the model (Y = β₀ + β₁X₁+ ε) could predict the influence of masculinity formulation of sexuality variables on VL suppression among the adolescent boys, an analysis of variance (ANOVA) was first computed. Table 5 presents the ANOVA.

a. Dependent Variable: VL suppression levels

b. Predictors: (Constant); Masculinity Formulations of Sexuality

Table 5 illustrates that masculinity formulation of sexuality variables under study are significant predictors of VL suppression among the sampled adolescent boys on ART {F _{(1, 260)} =96.493, P<0.05}. The significance value of F in this case is 0.000, which is less than 0.05 (P<0.05). The importance of masculinity formulation of sexuality variables in predicting VL suppression is presented in Table 6.

Table 6: Beta Coefficients for masculinity formulation of sexuality and VL Suppression