Background: The AIDS epidemic is global in its span; a particularly heavy burden has fallen rnon Sub-Saharan Africa. The consequences of the African AIDS epidemic are growingâ€”not onlyrnjust in sizeâ€”but in complexity. These consequences are no longer just biological; increasingly,rnthey are also behavioural, social and cultural. rnIt is well-known that 84% of the population in Ethiopia lives in rural areas relying on thernagricultural sector which plays the central role in the countryâ€™s economy. However efforts tornconduct HIV related studies in rural areas of the country remain extremely patchy. So far, therernhave been few studies concerning the nature of HIV infection in rural areas resulting in meagre rninformation on how HIV spreads from urban to the rural areas and how local people perceive the rnepidemic and protect themselves from risk factors. The rural people in Bure Woreda are not anrnexception. rnThe negative influences of migration, fertility intentions and other socio-cultural factors in thernspread of HIV in the Amhara region in general and in the present study area in particular are notrnknown, moreover, overlooked social activities such as leisure activities which may be linked tornHIV risk behaviours among the study population of the rural to urban migrants and non-migrantsrnin Bure Woreda, North West Ethiopia require due attention and a thorough investigation. Thernway in which migration contributes to the spread of HIV risk is complex and not wellrnunderstood. Previous studies have focused on the destinations of migrants, or, less often, on thernareas from which migrants come. In this study exploring both ends of migration routes inrnatypical rural areas is fundamental for successful interventions rnAlthough subsistence agriculture is the major economic activity in Ethiopia; parents want to havernlarge numbers of children for assistance in farming activities as well as economic support duringrnold age. In the rural areas, womenâ€™s fertility and HIV infection are not independent of onernanother. Conditions and behaviours resulting in high levels of fertility are also likely to impactrnupon womens' likelihood of acquiring HIV. rnWomen and men desire children for their utilitarianâ€“economic, social, and psychological values, rnwhereas fertility is on the decline primarily due to changes in economic development. Differentrnsegments of the population are at different stages of this transition with different valuesrnattributed to children at each stage. The challenge is will women take measures to prevent HIV infection in themselves and their babies if they perceive themselves at high risk of HIV infection,rnor will endeavour to fulfill the utilitarianâ€“economic, social, or psychological dictates ofrnchildbearing. rnObjectives: The general objective of this study was to assess and explore the role of rural tornurban migrants (potential bridging population) and socio-cultural factors (including high fertilityrnintentions) in the transmission and spread of HIV risk to the rural community of Bure Woreda. rnMethods: In order to address this general objective, the study assessed factors that affect thernsexual behaviours of rural to urban migrants and non-migrants (rural residents) by comparing thernlink between predisposing, and enabling factors with the sexual risk behaviours among rural tornurban migrants and non-migrants and by investigating the leisure activities which are associatedrnwith different levels of likelihood to engage in HIV risk behaviours among rural to urbanrnmigrants and non-migrants. Moreover other sexual and cultural practices of the rural people inrnrelation to HIV risks including the association of fertility intention (the desire to have children)rnwith HIV risk were investigated. In this study, HIV-related sexual risk behaviours among rural tornurban migrants and non-migrants is compared and the role of migration in HIV transmission andrnsocio-cultural practice and norms for the spread of the virus in the rural areas of Bure Woreda isrnexplored. The detailed methodology included two components: The first one was a quantitativerncross-sectional study which involved 1,310 men (655 men rural to urban migrants, 655 non-rnmigrants) and 1,380 married women aged 18 to 49 years. The second component was arnqualitative study which consisted of 8 focus group discussions and 25 key informant interviews. rnI) Quantitative study: Radom sampling technique was applied to select the required studyrnunits from the rural- urban migrants (road construction sites (Cobble stone), Ethiopian rnCommodity Exchange (ECX), commercial agricultural farm employees and rural residents fromrnthe rural kebeles of Bure Woreda. rnA total of 2,751 participants, 667 rural men and 1,418 rural married women were drawn from thern23 rural kebeles of Bure Woreda while the remaining 666 rural to urban migrants were takenrnfrom Bure and around Bure town. Because the present study had a number of different outcomernvariables so it was necessary to calculate the respective sample sizes separately with different rnassumptions. Structured questionnaires were used to collect the quantitative data. rnrnThe questionnaires were tested prior to collecting the actual data in order to standardize the flowrnand content of the questions. Accordingly, amendments were made depending on the results ofrnthe pre-test that was conducted in the nearby similar areas. Data collection was carried out byrntwenty diploma holders who were given three-days of intensive training with practical exercises.rnFour health officers/sanitarians were assigned to supervise the data collection process and therndata was analyzed using SPSS version 17 statistical software. The, chi-square test and binaryrnlogistic regression were used to see the association of variables. rnII) Qualitative study: This part of the study was aimed at substantiating and complementingrnthe quantitative study. The selection of participants and formation for focus group discussions rn(FGD) were facilitated by the community leaders of the respective kebeles under consideration. rnFour rural kebeles were identified for the 8 FGDs and 25 in-depth interviews. rnThe main data analysis took place on completion of each interview. In this regard, the usualrnprinciples guiding qualitative analysis were taken into account and sequences of interrelatedrnsteps (reading, coding, displaying, data reduction and interpreting) were employed whilernanalyzing the data. In short, as can be noted from the above explanations, the procedure used tornprocess the raw data for the purposes of classification, summarization and tabulation wasrnthematic content analysis. The basic idea here was to identify the extracts of data that wererninformative in some way and to sort out the important messages hidden in the mass of each keyrninformant interview and FGD. rnResults: A total of 2,690 participants (response rate, 97.7 %) responded to the questionnaire onrnHIV risk behaviours, leisure activities and fertility intention. This study consisted of two groups rn655 male rural to urban migrants working in Bure town and rural residents (655 male nonmigrantsrnandrn1,380rnmarriedrnwomen).rnrnWhen the two groups (rural to urban migrants and non-migrants) are compared in terms ofrnpracticing sexual risk behaviours i.e. having of multiple sexual partners, practicing sex with rncommercial sex workers, contracting sexual transmitted infections and practicing premarital sexrnthere is a difference between them. The proportions of rural to urban migrants vs non- migrantsrnwho had multiple sexual partners (31.4 % vs 7.4 %), practiced sex with commercial sex workers rn(22.3% vs 13.3%), contracted sexual transmitted infections (11.7% vs 3.2%) and practicedrnpremarital sex (20.8% vs 14.2 %) were significantly higher in rural to urban migrants than nonmigrants.rnAmongrnthosernwhornhad multiplernsexualrnpartners,rnonlyrn12.7rn%rnof ruralrnto urbanrnmigrantsrnrnand 9.8 % of non-migrants reported consistent condom use with sexual partners other than theirrnspouse. rnIn addition, the findings of the study indicated that both migrants and non-migrants werernengaged in different leisure activities when they did not have work. The first three leisurernactivities with the highest rates of participation among migrants were visiting entertainmentrninstallments (76.3%), chatting (64.9%), and listening to radio (31.5%). On the other hand, doingrnchores (71.6%), visiting entertainment installments (30.7%) and chatting (29.2%) were amongrnthe activities in which non- migrants were participating most often. The differences notedrnbetween the two groups in terms of the types of leisure activities were statistically significantrn(P=0.001). Multiple logistic regression analysis was also done to explore the association betweenrnthe eleven leisure activities and each of the five HIV risk behaviours among migrants and nonmigrants.rnAmongrnmigrants,rnwatchingrnTV, readingrn(includingrnnon migrants),rnchatting,rnwatchingrnrnvideos,rnwanderingrnon streetsrn(includingrnnon-migrants),rnandrnvisitingrnentertainmentrnfacilitiesrnwerernrnpositivelyrnassociatedrnwithrnmostrnofrnthernfivernHIVrnriskrnbehaviours.rnListeningrnto radiornforrnmigrantsrnrnandrnchattingrnand doingrnchoresrninrnnonrnmigrantsrnwerernnegativelyrnassociatedrnwithrnsomernofrnthernHIVrnrnriskrnbehaviours.rnrnrnThe association of rural married women to HIV perceived risk, child mortality and desire to havernchildren and the link to HIV risk was assessed. Overall, 32.8 % of subjects expressed desire forrnfuture pregnancy, 8.8 % perceived themselves at high risk for HIV infection and 26.7% reportedrnthe death of at least one child in the past five years. In multiple logistic regression analysis,rnreporting at least one child's death (OR=6.92; 95% CI=4.91 to 9.47) was significantly associatedrnwith a higher desire higher to become pregnant. Furthermore perceived high risk for HIVrninfection (OR=2.08; 95% CI= 1.35 to 3.19) was found to be associated with the desire to getrnpregnant. Being currently married, having no education, being of low parity and having lowrnhousehold expenditure were significantly associated with having the desire for more children. rnThe qualitative part of this study identified a number of social factors and cultural norms andrnpractices that impact on HIV/AIDS. The first category consists of factors that were said tornpromote the spread of HIV/AIDS such as alcohol drinking and drunkenness. To that effect, allrnsocial and cultural functions that involve large gatherings such as holidays and wedding rnceremonies, alcohol drinking and dancing were seen to greatly contribute to the spread ofrnHIV/AIDS. rnrnThe second category is of factors influencing the reduction in the risk of HIV transmission suchrnas promotion of virginity and arranged marriages. Interestingly, some of the main social factors,rncultural norms and practices that increase the risk of HIV transmission were seen to also playrnsignificant roles in risk reduction; church gatherings, weddings, and burials were singled out asrnmajor avenues for promoting positive sexual behaviours while some people use them to engagernin risky behaviours. rnHIV/AIDS and the social and cultural set-up of communities have impacted upon each other. Inrnthe context of HIV/AIDS, social and cultural practices play dual roles, on one side enhancingrnHIV transmission while on the other facilitating reduction in incidence. However, social factors,rncultural norms and practices were seen more as facilitators than inhibitors of HIV transmission,rnwhile low awareness about HIV/AIDS and lack of supportive services such as VCT andrnknowledge of condoms remain major limitations to sustain behaviour change. Accessibility tornthese services is also limited to the majority in the rural areas rnConclusions: As both rural to urban migrants and non-migrants are at risk for HIV infection,rnintervention program targeting both groups are recommended. However, in order to contain the rnbridging effect on HIV transmission from urban to rural areas particular attention should berngiven for the rural to urban migrant population. rnEffective HIV prevention programming must reach and serve populations at risk. This studyrnshows that male migrants are at high risk of HIV due to risky sexual partnerships and lowrncondom use. Additionally, their high mobility and multiple partnerships potentially contribute tornthe spread of HIV to the rural areas. Sero-prevalence data should be collected to complementrnbehavioural data and enable tailored programming to reach this vulnerable group. Employersrnshould be engaged in HIV prevention for this population. rnSocially desirable and constructive leisure activities such as listening to the radios amongrnmigrants and doing chores and chatting among non-migrants may prevent them from being rnengaged in HIV risk behaviours while leisure activities such as visiting entertainmentrninstallments and watching videos may increase the odds for migrants to be engaged in HIV riskrnbehaviours. However the evidence in this study strongly suggest that migrants who are detached rnfrom family and home environment may be exposed to leisure activities possibly associated withrnHIV risk behaviours. Therefore, given the high mobility of migrants, it is very important tornstrengthen work place intervention in their destination places rnrnHigh perceived risk of HIV infection was associated with high desire for future pregnancy.rnMoreover women seem to have a higher desire for a future pregnancy to replacing a dead childrnthat may have lost its life as a result of HIV infection. This finding indicated the crucial role ofrndesire for fertility by a married woman irrespective of the risk for acquiring HIV infection. Thisrnimplies that there should be further research to address the issue and the utilitarian-economic,rnsocial, and psychological values attributed to children by both women and their male sex partners.rnThe involvement of men as partners in childbearing should be explored, as their desire for childrenrnmay be the primary barrier to protective behavioural change among women. In order to changernrural Ethiopian parentsâ€™ perception of values of children, child education needs to be compulsoryrnso the cost of raising children will increase and inhibit a further high desire for pregnancy. rnIn the area the prevailing cultural practices and norms encourage large families and discourage thernuse of condoms. In such settings, there is the need to find appropriate mechanisms that could helprnincrease the use of all types of contraceptives. As contraceptive use increases, it is likely that thernuse of condoms for AIDS prevention and also for family planning purpose would increase.. rnAccording to the qualitative findings some striking characters were noted - these are the mobilityrnof commercial sex workers from large town to small towns such as Bure or adjust rural villages inrnorder to attract a wider or different client base, for adventure and to conceal illnesses which mightrnbe associated with HIV/AIDS, drinking alcohol while on ART drugs to pretend as HIV free andrninvolve in sexual activity, desired to be considered as a HIV positive in order to get the supportrngiven to PLHI, underline the needs for further investigation due to their possible contribution forrnsustaining the HIV epidemic. Although there are some prevention activities to fight HIV/AIDS inrnthe rural areas, most of them were inappropriate in terms of convenience in time, place and targetrngroups. For instance, HIV educations are given only in weekends, holidays and around the churchrnareas where most of the young people are not available. The finding has programmaticrnimplications as it misses the young who are vulnerable to HIV infections. The needs and prioritiesrnin prevention of HIV/AIDS are two fold: to enable community members to be fully informedrnabout the disease and reduce potentially risky behaviour; and to secure viable rural livelihoodsrnwhich would reduce the need for people to move into potentially HIV-risky environments.