Introduction:

A significant large body of literature documents that Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) is one of the most devastating epidemics that continue to impact different populations worldwide (Molato, Moloko-Phiri, Koen & Matsipane, 2025). One of such populations is children below the age of 18 years. Globally, an estimated 15 million children under 18 years of age have lost one or both parents to an AIDS-related cause (Nabunya, 2023), and over 75% of these orphans live in sub-Saharan Africa (SSA) (Matshepete, Makhado & Mashau, 2025; UNICEF, 2022). Described as children who have lost one or both parents - often the family breadwinners - orphans often encounter difficulties adapting to their new reality, grappling with the emotional turmoil resulting from the loss of parental support (Benthall, 2019; Jaffer et al, 2023). In addition, most orphans in SSA are forced to live under the care of their elderly grandparents, thereby reversing the role of child caregiving to elderly kinships (Kyomuhendo, Boateng & Agyemang, 2023). Nevertheless, the AIDS and orphan literature has predominantly looked at the economic burden and human costs of fostering an orphan, downplaying the benefits and their contribution (Fauk, Mwakinyali, Putra & Mwanri, 2017; Matshepete et al, 2025; Skovdal, 2010). Moreover, focus on how uptake of HIV treatment is affected by masculinity-constructed breadwinner role by orphaned adolescent boys has remained downplayed by AIDS and orphan literature.

One of the factors that have been documented as affecting men’s health is masculinity constructions (Courtenay, 2000). Within a framework of social construction, masculinities are viewed as a set of practices put into action by individuals interacting with others in their environment and not as the biological essence of an individual (Exner-Cortens, Wright, Claussen & Truscott, 2021). Men, who are frequently regarded as the heads of the household, decision-makers, and family breadwinners, have been burdened by masculinity (Rata Mohan, 2025). Traditionally, the term "breadwinner" referred to the individual, often the father or husband, responsible for earning the primary income to support the family (Thomas, 2026). During economic hardships and declining employment opportunities, fulfilling "breadwinner" role piles immense pressure upon men, resulting into stress and unhealthy behaviour such as alcohol consumption and drug abuse (Etienne, 2018). Nevertheless, such understanding should be extended towards unearthing the implications of "breadwinner" role on viral load suppression among orphaned adolescent boys on Ante-Retroviral Therapy (ART) living under caregivers.

Literature Review

In the era of HIV and AIDS pandemic in the SSA, extant literature illustrate how the burden of caregiving has been transferred to mothers and grandparents after the demise of paternal (or both) parents due to the epidemic (Akimanimpaye, Bimerew & Petlhu, 2024; Mudavanhu, Segalo & Fourie, 2008; Nyambedha, Wandibba & Aagaard-Hansen, 2003). These caregivers have, however, often faced enormous challenges in the line of care such as lack of support and resources including food and finance for upkeep (Molato et al, 2025; Nyasani, Sterberg & Smith, 2009). Conversely, studies (Olang'o, Nyamongo, & Nyambedha, 2012; Skovdal, 2010; Skovdal & Ogutu, 2009) have revealed changing patterns in Western Kenya where orphaned children have turned to be carers of their caregivers who are affected by either HIV or old age. Fulfilling the responsibilities of caregiving is noted to have profound repercussions for the children's lives, including psychological distress, physical burden, dropping out of school, participation in wage labour (Olang'o et al, 2012; Skovdal, 2010). Be that as it may, limited information is available regarding implications of caregiver role among orphaned adolescent boys on ART – who might be subscribing to masculinity constructions – on their viral load suppression.

Ending the HIV/AIDS epidemic by 2030 is one of the Sustainable Development Goals (SDG 3) (UN, 2017). The international community launched the "95-95-95" policy target, which aims to test 95% for HIV, place 95% of HIV-positive patients on antiretroviral therapy (ART), and guarantee that 95% of those on ART achieve viral suppression within six months of starting treatment, in order to meet this challenging goal (Oryokot et al, 2020). A patient with a lowered viral load is less likely to spread HIV to others and is shielded from opportunistic infections or illnesses linked to acquired immune deficiency syndrome (AIDS) (Natukunda et al., 2019). A key sign of a successful HIV therapy response is VL suppression. Men have been shown to perform worse over time in terms of healthcare outcomes, such as viral load suppression (Natukunda et al, 2019). VL suppression in adolescents has been shown to be hampered by a number of factors, including pill burden, medication taste, secrecy/stigma, drug toxicity and resistance, clinic-related problems, maternal loss, strong religious beliefs, and a lack of awareness about HIV (Galea et al, 2018). However, it appears that little research has been done on how the aforementioned elements interact with orphanood, the duty to care for others, and the position of breadwinner to affect VL suppression in teenage boys receiving ART. Such insight was considered vital in a context that experience high HIV prevalence such as Siaya County of Western Kenya.

Over the years, Siaya County of Western Kenya has recorded the highest prevalence rates of HIV in Kenya. Healthcare records from the facilities indicate that despite being started on ART, 250 of the 12,253 juveniles in Siaya County—which had the highest incidence rate of 21.45% between 2015 and 2020—died in 2018 from AIDS-related illnesses (150 men and 100 females) (NASCOP, 2022). This tends to be at odds with current patterns among ART patients in nearby counties like Kisumu (120 deaths: 75 males; 45 females) or Homa Bay (190 deaths: 110 males; 80 females). This demonstrates that, in comparison to other counties with reported high HIV and AIDS prevalence, Siaya has a greater gender disparity in the number of young people who die from HIV and AIDS complications while receiving antiretroviral therapy (ART).

Research Question:

What are the implications of breadwinner role on viral load suppression among orphaned young boys on HIV treatment in Siaya County, Kenya?

Theoretical Framework

In order to comprehend how different masculine factors interact within each patient's unique socioeconomic situation to shape viral load suppression among adolescent males living with HIV and AIDS in Siaya County, intersectionality theory founded by Kimberlé Williams Crenshaw in 1989 (Crenshaw, 1989), is pertinent to this study. Furthermore, intersectionality theory is highly relevant in comprehending how different factors interact to influence teenage boys' health outcomes during adolescence (Galambos, Berenbaum & McHale, 2009; Kågesten et al, 2016; Kar, Choudhury & Singh 2015).

According to the social factor tenet of intersectionality, social categories are inextricably linked to broader geographical, institutional processes/practices, and structural systems. This means that constructed identities have both individual and contextual aspects (Al-Faham, Davis & Ernst, 2019; Atewologun, 2019). Else-Quest and Hyde (2016) assert that in order to overcome the limitations imposed upon them by those categories and associated injustices, many social categories overlap and are produced by and within power relations and groups.

Intersectionality theory is highly pertinent to comprehending how different factors interact to influence teenage boys' health outcomes. In addition to navigating biological, psychological, social, and cognitive changes (Kar et al, 2015), boys learn to negotiate and construct their masculinity—qualities typically associated with men—during adolescence (Galambos et al, 2009; Kågesten et al, 2016). Adolescents' decisions to seek medical attention are influenced by a number of interrelated social and structural factors.

Methodology

Research Design

The study used cross-sectional qualitative survey design to collect and analyse data. A cross-sectional qualitative survey collects data from a population at a single point in time to explore perceptions, attitudes, or experiences (Zuleika & Siswo, 2022). This observational approach was chosen because it is a fast and cost-effective way to gather detailed, thematic insights.

Study Setting

Six medical facilities in Western Kenya—Ambira, Bondo, Yala, Madiany, Ukwala, Got-Agulu, and Siaya County—were involved as locations for data collection for the study. This region is inhabited by an ethnic minority whose cultural customs, like wife inheritance and disco Matanga (nighttime music parties at funerals), are often seen as harmful to health in light of the HIV and AIDS pandemic (Oluoch & Wesonga, 2013; Perry et al, 2014). According to Kayongo-Male and Onyango (1984), adolescents are required by the community's cultural norm to sleep at a residence apart from their parents, either inside or outside the immediate family homestead. The majority of individuals think that this increases the risk of HIV and AIDS in youths (Juma et al., 2014). Additionally, the culture teaches teenage boys to be resilient, strong, and unafraid of difficult circumstances like traveling to unfamiliar locations, even at night (Ocholla-Ayayo, 1976).

Study population and sampling strategy

Target population comprised of  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.

 Instrumentation, Validity and Reliability

Focused Group Discussions (FGDs) guide and In-depth Interviews (IDI) were used to collect data from the orphaned adolescent boys. In addition, FGD guide and Key Informant Interviews (KII) were respectively used to gather information from comprehensive care-in charge (CCC) and Public Benefit Organizations (PBO) officials, as well as the County AIDS/HIV and STI Coordinator (CASCO), and the Sub County AIDS Coordinators (SCACOs).

Content validity index (CVI) was utilised to check 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 as stipulated by Davis (1992):

Data Collection Process

Focus Group Discussions

Twelve focus group discussions were held in Alego, Bondo, Gem, Rarieda, Ugunja, and Ugenya. The first one took place on December 6, 2024, at Yala Sub-county Hospital with teenage boys and PBO officials; two more FGDs with seven participants each were held at RERA KMTC with teenage boys and PBO officials; two more FGDs with twelve teenage boys and eight PBOs were held at AYP, Rarieda, on December 10 and 11, respectively, with adolescent boys and PBO officials at Ugenya and Ugunja Sub County hospitals; and the final FGD with eight teenage boys on ART at Uyawi Sub-county hospital.

When the researcher saw that further discussions were not yielding any new insights—a sign of data saturation—he stopped part of the conversations (Aldiabat & Le Navenec, 2018).

In-depth interviews (IDIs)

To "find the adolescent boys’ own framework to meanings" (Rutledge & Hogg, 2020; Mwilongo, 2025), in-depth interviews were conducted. Twelve purposefully chosen teenage boys on ART—two from each of the six Sub-Counties—were the subjects of individual in-depth interviews, or IDIs. On December 6, 2024, the first IDI was conducted at Yala Sub-county Hospital. IDIs were also carried out at RERA KMTC, AYP in Rarieda, Bondo Sub County, Uyawi Sub-County Hospital, Sega Mission Hospital in Ugunja Sub County, and Ukwala Sub County Hospital in Ugenya over the course of the following five days.

Key-informant interviews

The County AIDS/HIV and STI Coordinator (CASCO) and Sub County AIDS Coordinators (SCACOs), two government representatives in charge of HIV and AIDS treatment in the County, were chosen as key informants due to their extensive knowledge and experience working with adolescent boys receiving HIV and AIDS treatment (Jiménez & Orozco, 2023). Additionally, three CCCs, three SCACOs, and seven key informant interviews were conducted with the CASCO. The interview schedule was structured around three themes: breadwinner obligations for adolescent boys; HIV and AIDS treatment obligations, and masculinity expectations of the adolescent boys. To get as much information as possible, extensive probing was conducted (Aldiabat & Le Navenec, 2018; Fusch & Ness, 2015).

Data Analysis and Presentation

Key points were extracted from each FGD and in-depth interview through a preliminary analysis, which guided the following data collection (Brailas, Tragou & Papachristopoulos, 2023). In order to preserve an audit trail and encourage accountability and transparency for both the researchers and potential users, the framework approach was employed (Smith & Firth, 2011). The researcher was able to capture a variety of people's realities by combining multiple data sources (government officials, Public Benefit Organizations, and teenage boys themselves) with triangulation techniques (in-depth and key-informant interviews and FGDs). This helped to ensure the interpretation was thorough (Onwuegbuzie, Leech & Collins, 2012).

Ethical Considerations

For ethical reasons, the researchers sought approval to perform the field study from Maseno University Scientific and Ethics Review Committee (MUSERC) and the National Commission for Science, Technology and Innovation (NACOSTI). The teenage boys under the age of eighteen created and signed an assent form, and their parents or guardians signed consent forms. Participants were asked not to remove their identities from the research equipment in order to maintain anonymity.

Results

Characteristics of the Participants

Findings showed that 53.6% of the teenage boys in the sample had lost one or both parents. Of these, 26.2% have lost their fathers and are living solely with their moms, while 18.3% have lost both parents and only 9.1% have fathers. The results also show that the majority of teenage boys (57.4%) do not live with both parents because they have either lost their father or mother. Of them, 26.6% live with their mothers and 15.2% with their grandmothers.

These results show that the research area has a high rate of orphaned teenagers. The fact that more fathers (male parents) have passed away than their female counterparts is also noteworthy from these statistics. Adolescent boys in this study are also subject to the construction of gender roles because their female caregivers are ill and unable to provide for the family, which forces the boys to take on the role of breadwinner. This was brought up during FGD with some PBO officials, where a female officer stated:

              The majority of the boys have lost their fathers, who were employed and supported the family. The majority of these fathers were salaried workers in large cities like Nairobi. They pass away after suffering for extended periods of time, leaving unemployed mothers to care for their kids. Due to their illness (HIV positive), the mothers are unable to carry out physically demanding tasks. As a result, they have little support for     the children's maintenance and live in extreme poverty. The boys, would often accept hard labor to support family food stock, the situation is pitiful (FGD discussant, PBO Official).

Poverty and disease burden in the family interact with the need to adhere to ART as well as school attendance and to satisfy socially constructed masculinity norms which seem to jeopardize the boys’ VL suppression endeavors.

Gender Roles and Masculinity Messaging

Having established that mothers and grandmothers form majority of the caregivers of the orphaned adolescent boys, the study proceeded to reveal the role played by female family members in socialisation of adolescent boys in the society. In a FGD with chosen boys, the predominance or presence of women in the lives of the sampled young adolescents was also emphasized. A 15-year-old boy stated:

My mother as played a significant role making me to become strong in the wake of my ailment. My mother was the one who informed me of my status. She informed me   that I had the condition from birth and that if I took these drugs regularly, I would get well soon. As a 15-year-old boy FGD participant, my mother and grandma frequently inspire me to be bold and maintain my strength as a man.

The sentiment made by the 15-year-old youngster demonstrates the emotional dedication that mothers and grandmothers have to a pertinent family issue: the existence of a sick child (an HIV-positive boy) who need critical support to receive medical care.

Breadwinner Role and VL Suppression

The study also aimed to determine the relationship between the orphaned teenage boys under investigation's breadwinner status and VL suppression. The results indicate that most of the teenage boys in the sample do not always show up for their VL test sessions since the testing procedures implemented by the medical facility that treats them do not favor them. Qualitative findings from IDIs with a portion of the boys supported this conclusion; one 16-year-old boy said:

VL testing appointments are sometimes ……. difficult to honour. You find long  queues at the facility, and you can take a whole day queuing. ……. After testing, you are again given another appointment to come for your results………….. This will also  involve queuing with old women and men, as well as children and young girls.……At the same time, my friends would sometime invite me for a mjengo (manual labour at a construction site) or ywayo sut (fishing expedition). ……… I would skip            some of these VL testing appointments for purposes of undertaking some manual   labour which are often critical for subsidizing family food stock (a 16 year-old IDI  interview).

This IDI highlights patient-related and facility-level social factors as major obstacles to VL testing uptake among ART-treated adolescent boys. Even if the boys are ill and orphans, they are expected to fulfill the gender duties of finding food and supporting their families, but they also have to wait in long lines at the medical facilities. A male Sub County AIDS Coordinator (SCACO) said:

Most adolescent boys often get lost from treatment cascades. Most of them barely show up for VL testing visits, and often fail to pick up their medications from the clinics. After passing the KCPE exam in class 8, the majority of the guys would begin  going on fishing trips. These youngsters are motivated to engage in income-generating  activities because poverty is pervasive in their homes. Most of these boys have lost  their parents and live with their grandparents who are old and poor. Conversely, the community expects the sons to look after the elderly grandparents. According to the   male Sub County AIDS Coordinator [SCACO], these circumstances put the boys' health and education at risk because they will be less likely to attend school and comply to their medication regimens.

Moreover, an excerpt drawn from FGD sessions with adolescent boys also illustrated circumstances that have often led to failure in honouring medication appointments. A commonly mentioned situation was highlighted in one of the FGDs by a 17-year-old boy as:

              It can be challenging for us to regularly attend medical appointments. I am always asked to provide a lot of support to the family because my grandma, with whom I live,  does not have a reliable source of income. I frequently participate in income-generating activities that help us buy food, especially when I'm not in school. I'm frequently invited to a mjengo (manual labor at a construction site) by a family friend  who recognizes and sympathizes with our living circumstances. I will accept this invitation without a doubt, even if it falls on the day I have a doctor's appointment for a VL test, as this type of work will make meals available to the family. On the day you are scheduled to visit the health institution for your medication or VL testing, you may occasionally receive an invitation to go on a ywayo sut (fishing expedition) in Lake Victoria. In this instance, postponing the doctor's appointment becomes a crucial choice since going fishing will guarantee that the family has fish to eat and I will also make some money to assist the family (17-year-old FGD discussant)..

The aforementioned verbatim quote from the SCACO and the teenage boy demonstrates how the teenage boys assume the duty of providing for their families and earning a living.

Discussions

The majority of the boys are being cared for by their moms or grandmothers, according to this study, which highlights the importance of women in this field of study. These findings concur with earlier research done in a different context by Jacobson, Parker, Cadel, Mansfield and Kuluski (2025) which revealed that societal expectations require women to perform caregiving roles to older adults ageing family members in Canada. Similarly, Bardhan (2025) also established that women's involvement in caregiving activities is considered in Bangladesh as the primary responsibility of their lives. Examining the role of gender in family caregiving to AIDS patients in Uganda, Kipp, Tindyebwa, Karamagi and Rubaale (2006) also revealed that women are overburdened with the family care of AIDS patients compared to men. As confirmed in the current research, caregiving role taken up by mothers and grandmothers signifies gender constructions that apportion homecare duties to women and breadwinner burden to men.

Breadwinner Role

Research results also highlight that adolescent boys in this study are subject to the creation of gender roles since their female caregivers are unable to provide for the family due to their poor health, which forces the boys to take on the position of breadwinner. The results also show how the family's poverty and illness load interact with the need to follow ART, attend school, and conform to socially created masculinity norms, all of which appear to compromise the boys' efforts to repress their VL. The adolescent boys' pursuit of VL suppression gave rise to various and overlapping identities that align with the principles of Kimberlé Crenshaw's intersectionality theory (Crenshaw, 1989). According to the idea, marginalized and disadvantaged groups of persons with complex multiple and overlapping social identities face significant social and health disparities (Bowleg, 2012; Larson et al., 2016).

Similarly, several prior studies in the HIV treatment literature have discovered a variety of social factors that hinder VL suppression among adolescents in the study location. According to Owoko et al. (2019), double and maternal orphanhood presented obstacles to appropriate medication adherence, and schools frequented by teenagers did not offer a proper and safe atmosphere that supported ART adherence. Adino (2020) also found that Siaya County drug adherence is hampered by the cost of transportation to the facility and paying for nourishment.

Implications on VL Suppression

The finding shows that a majority of the sampled adolescent boys do not always honour VL test appointments because testing processes put in place by the health facility providing them with care do not favour them. Even if the boys are ill and orphans, they are expected to fulfill the gender duties of finding food and supporting their families, but they also have to wait in long lines at the medical facilities. These boys appear to have accepted the responsibility of providing for their families financially, but they are also required to keep their doctor's appointments. Henceforth, the boys tend to bear several social identities at the same time, which interact with the disadvantages associated with male adolescence that permeate health systems, particularly in underdeveloped nations like Kenya (Larson et al., 2016). These identities include being young and inexperienced, having HIV, which is stigmatized in society, having to support the construction of a true "man" by supporting their families, and having to endure long lines at the medical facility.

It is also found that the migration of teenage boys to other fishing beaches after form four for fishing expeditions was one of the reasons given for the low awareness of the significance of knowing VL counts. Furthermore, it is revealed that majority of teenage boys who have been started on ART rarely show up for their prescription appointments, according to discussions with several government officials in the study area. Rather, they participate in a variety of income-generating enterprises, particularly on the county's fish landing beaches. In this context, the result demonstrates how the teenage boys assume the duty of providing for their families and earning a living. Even while the conditions that lead to such occupations make it challenging to adhere to VL suppression, it is a means of exhibiting masculinity and complies with societal expectations around gender roles. These results are consistent with earlier research on gender role creation conducted by different sociologists (Amin et al., 2018; Kågesten et al., 2016; Ocholla-Ayayo, 1976). Additionally, Ayieko (2003) found in Kisumu that children left orphaned by AIDS had taken on the role of head of home in many households. Therefore, it should be concluded that the orphaned teenage boys' adoption of HIV and AIDS treatment in Siaya County, western Kenya, has been significantly hampered by their adoption and performance of the gender role of breadwinner.

Conclusions

The study concludes that masculinity constructions that define gender roles obligates mothers and grandmothers the role of caregiving to the orphaned adolescent boys in the study area. Consequently, the existing poverty in the area makes performance of this role to be a big challenge to the mothers and grandmothers since they themselves are respectively ailing (with HIV and AIDS) and aging.

The study also concludes that, in light of poverty encountered by households fostering the orphaned adolescent boys, they (adolescent boys) choose to engage in income-generating activities such as ywayo sut (fishing expeditions), kunyo mula (mineral mining), or mjengo (menial labour in construction sites). The boys take up these duties to fulfill their masculinity-oriented gender role of breadwinner, as expected of them in the absence of paternal parent (or head of the family).

Additionally, the study concludes that the obligation to fulfill gender role of breadwinner is a stumbling block honoring of medical appointments including requisite VL tests, thereby hampering their medication as required by HIV and AIDS regime. Migration to various fishing beaches and construction sites make the boys to skip required medication consequently leading to negative implication in as far as VL suppression is concerned.

Acknowledgement

Every participant who freely gave the information needed to compile this report is acknowledged by the researcher. These include the PBO officials, CASO and SCASOs, and the teenage boys on ART; I sincerely hope that the situations of the teenage boys who were the study's main respondents will improve beyond human comprehension.

Conflict of Interest:  No Conflict of Interest

Funding:  No funding received for this work