Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums—BSGH-005

Abstract

Despite significant progress in Ghana’s HIV response, disparities in HIV prevalence persist among different populations. Gays, bisexuals, and other men who have sex with men (GBMSM) in the country remain vulnerable to HIV infection due to high levels of stigma and discrimination, limited access to healthcare services, and low HIV knowledge levels. While limited studies focus on HIV prevention and care in the Ghanaian GBMSM context, we did not find studies on GBMSM in slums. We, therefore, explored stigma and motivations of HIV testing among GBMSM in slums. In collaboration with our community partners, we recruited and conducted face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi, Ghana. Our multiple-reviewer summative content analysis identified the following: under HIV stigma, we identified two categories, avoidance of GBMSM living with HIV and fear of testing positive for HIV. Under motivations for HIV testing, we identified three categories; HIV vulnerability, knowing one’s HIV status, and positive messaging about HIV. Our findings provide valuable insights into stigma and motivations for HIV testing among GBMSM in Ghanaian slums. They also highlight the importance of targeted HIV education interventions to empower GBMSM to take responsibility for their sexual health and address the unique challenges they face accessing HIV testing services.

Introduction

Sub-Saharan Africa (SSA) carries over two-thirds of the world’s burden of HIV, yet, HIV testing and related services remain underutilized due to several factors such as insufficient knowledge, low-risk perception, and increased stigma [1,2]. Despite programmatic efforts in SSA, the burden of HIV and the factors (e.g., stigma) that hinder access to HIV testing remain a significant obstacle to HIV testing among HIV key populations such as gays, bisexuals, and men who have sex with men (GBMSM) [3–6].

Although Ghana has made significant strides in its HIV response, disparities persist in HIV prevalence between different populations, with GBMSM carrying a disproportionate burden, 18% compared to that of the general population, 1.7%% [7–9]. Efforts to increase HIV testing and prevention among GBMSM continue, yet reports indicate suboptimal testing rates in this group in the country due to individual, interpersonal, and environmental barriers [6–8,10,11]. At the individual level, such factors include low-risk perception, low HIV knowledge, and fear of rejection [3,12]. At the environmental level, factors include healthcare facility-level stigma, inadequate access to testing, and community stigma among others [12–15]. At the peer level, interpersonal HIV stigma affects interest in testing as some GBMSM discriminate against their peers living with HIV [3,12].

While limited studies explore stigma and testing practices among GBMSM in Ghana, no known studies have focused explicitly on GBMSM in Ghanaian slum communities. However, in SSA, studies have highlighted the association of low HIV knowledge and low HIV testing to persons with low socioeconomic status [16,17]. Slums also remain associated with high-risk behaviors such as transactional sex, inconsistent condom use, and increased HIV prevalence [18–20]. Emerging findings as from 2010 in eastern Africa show that GBMSM in slums have low-risk perception, increased risk behaviors, and low access to HIV testing and prevention services [21,22]. In 2012, HIV rates among slum residents in Kenya were notably higher at 12%, compared to 5% among non-slum urban residents and 6% among rural residents [22]. Also, out of 4028 youth sampled in Kenyan slums, only 27% had ever tested for HIV, and over 90% had low HIV risk perception. Of those who tested, over 90% reported being required to take the test [21].

Whereas no specific studies exist among GBMSM in Ghana’s slums, previous studies among slum communities in Ghana report increased HIV risk behaviors and higher HIV prevalence among slum residents [19,23,24]. Communities with increased HIV prevalence and risk also have poorly resourced infrastructure and health facilities which contributes to poor health outcomes [25,26]. Urban areas such as the Accra and Kumasi larger regions present the highest prevalence rates of HIV, 2.47% and 1.98%, respectively, compared to the other 16 regions [9]. These two cities and their surrounding areas also record high prevalence among GBMSM, Accra (42%) and Kumasi (25%), compared to the national GBMSM rate of 17.5% [7]. Thus, placing GBMSM living in urban slums at increased risk of HIV infection than other populations.

The current study seeks to understand GBMSM slum-specific HIV stigma manifestation and motivation for testing in Accra and Kumasi, Ghana. Understanding stigma and motivations for HIV testing is critical to reducing HIV transmission and improving health outcomes for this population.

Self Determination Theory (SDT)

The Self Determination Theory (SDT) explains, individuals’ innate psychological needs inform their wellbeing and quality of life within a social context [27,28]. The various components of SDT (the basic psychological need for autonomy, competence, and relatedness) could help explain the importance of HIV testing motivations among GBMSM in slums. Per the psychological need for autonomy, the barriers faced by GBMSM in slums can undermine the autonomy and restrict their ability to make informed HIV testing [12,13,29–31]. On the psychological need for competence, the low levels of HIV knowledge can affect GBMSM’s proficiency to make informed decisions regarding HIV testing [29,32].

The theory also offers insight into HIV stigma by GBMSM. Being stigmatized can affect the autonomy GBMSM have over their ability to test for HIV due to the potential threat of disclosure of their sexual orientation without their consent. This perceived threat may lead to the reluctance of GBMSM to seek HIV testing. GBMSM may be affected by negative stereotypes and misconceptions about homosexuals and HIV. These misconceptions may lead to situations where GBMSM feel ashamed, have self-doubts, or have low self-esteem, affecting their chances of testing for HIV. The stigma and discrimination faced by GBMSM can also negatively impact the relatedness aspect of SDT, which emphasizes the need for individuals to feel connected and supported in their social environments. Creating supportive and inclusive environments, reducing stigma, and improving access to healthcare services are crucial for promoting relatedness and encouraging GBMSM to seek HIV testing [33–35].

Methodology

Study design

The study used a qualitative interview [36] to collect data from GBMSM living in slum communities in Ghana. This approach allowed researcher in this study gather firsthand experiences of GBMSM around HIV stigma and motivations for HIV testing for those living in slum communities within the Accra, and Kumasi cities in Ghana.

Sampling and recruitment procedure

Using the time location sampling (TLs) technique, we reached and recruited GBMSM in slum communities in collaboration with our community partners in Accra and Kumasi. Research assistants working with our community partner organizations in Accra. community partner organizations screened and invited GBMSM to take part in interviews sessions during one of the organizations’ activities when GBMSM visited the site. We have worked with these community partners in previous studies [10,11]. Although we originally intended to purposively include 19 participants in this study, we reached saturation of information after the eight interviews. When responses from study participants were found to be consistent by the research assistants, an additional four transcripts were included to ensure complete information saturation, bringing the total number of transcripts to twelve.

Study setting

Ghana is a country located in West Africa and the main religions practiced are Christianity (71%), Islam (18%), and African Traditional Religion (5%) [37]. The education statistics show that the majority of children (71%) complete primary education, but the percentages decrease (47%) for lower secondary school, and upper secondary school (35%) [38]. A study conducted on MSM (transgender, gay, bisexual, and straight) in Ghana revealed that over half (52.2%) of them are educated, with around 16.8% of them having tertiary or higher educational qualifications [7]. Additionally, the study highlighted that nearly half (44.1%) of the MSM were employed and had never been married [7]. The official language spoken in Ghana is English, but there are several indigenous languages such as Twi, Ewe, and Fante that are spoken more frequently [39].

Inclusion criteria

Participants in the study had to be at least 18 years old and live in a slum community in Accra, Ghana’s Greater Accra regional capital, or Kumasi, Ghana’s Ashanti regional capital. Additionally, the individual identity had to be a cisgender man who self-identifies as gay, bisexual, or pansexual or engage in sexual intercourse with another cis-gender man for reasons other than sexual orientation. The person must have been sexually active during engagement and must have had sexual intercourse with another cis-gender man within the previous six months.

Data collection procedure

Procedure.

To gather information from the participants, we conducted in-depth face-to-face interviews. Following the screening, participants were given consent forms by the research assistants to review. Research assistants (EYZ, OWS) engaged in data collection had prior and extensive research training from working with these populations in the past. We also utilized the expertise of these researchers in our past studies, with similar populations, hence, the familiarity and experience engaging our participants [23,24,40–44]. The research assistants also read the consent forms out loud and provided extra explanations to ensure everything was understood. They answered the participants’ queries before the interviews started, collected signatures confirming GBMSM’s agreement to participate in the study, and allow for audio recording. The community partners’ private spaces were used for all interviews. All but four interviews were in English, the other four in Twi, a local Ghanaian language that some participants found more conversant. Data collected in Twi were translated and transcribed into the English Language. Data were collected from participants in January 2022, and lasted for 10 days.

Nature of questions.

The research assistants were trained to conduct qualitative interviews using the study’s checklist as a guide in collecting information on HIV stigma and motivations for testing among GBMSM living in Ghanaian slum communities. In line with our design, the checklist allowed a more transparent and open discussion rather than the traditional question-and-answer interview structure. Participants were asked to share their experiences of HIV testing, their knowledge, and what motivated or affected their interest in testing.

Analytical strategy.

Trained research assistants deidentified the transcripts after translating the audio interview recordings verbatim. We performed a summative content analysis on the transcripts with multiple reviewers [11]. Our team has successfully used this analytical method to comprehend crucial components in participant accounts [11]. Each transcript received at least two reviewers. Each reviewer independently read the transcripts to identify the most statements made by the participants. They then reported these statements in between 100 and 200 words. The principal authors reviewed each summary to find clusters and recorded the elements frequently appearing in transcripts and summaries in a data spreadsheet. We identified several clusters and classified them under categories that outlined participant experiences, perceptions, and motivations for HIV testing. Each area that was reported appeared in both peer reviewers’ summaries.

Ethical considerations.

Ethical approval was received from the Ghana Health Service Ethics Committee (GHS-ERC 011/10/21) and the Institutional Review Board Committee (IRES IRB) of Yale University (IRES IRB #RNI00002010). The interviewers in this study ensured that each participant had read and understood the informed consent form thoroughly before any data was collected, and afterward, they obtained written consent.

Findings

Description of participants

The 12 participants identified as cis-gender men and had sexual intercourse within the previous six months with another cis-gender man. Six participants identified as Christians, four as Muslims, and two as both Muslims and Christians. Five participants accomplished tertiary education, and six concluded senior high school while one didn’t complete Junior High school education.

Description of findings

Findings from the data collected and analyzed revealed two categories; 1) HIV stigma and 2) motivations for HIV testing. Under HIV stigma: avoidance of GBMSM living with HIV, and fear of testing positive for HIV. Under the category motivations for HIV testing: HIV vulnerability, sexual health decision-making, and knowing one’s HIV status.

HIV stigma

Avoidance of GBMSM living with HIV.

Participants in the study indicated they were afraid and had negative feelings about people living with HIV. One person, Participant K, mentioned they were scared to be near someone because of fear of a potential HIV infection. According to the participants, this fear of HIV stemmed from simple things like eating, sleeping in the same room, and bathing with persons living with HIV. Others, such as Participant F, thought that only people who have a lot of sex are likely to get HIV. They believed that married people were less likely to get the virus because they weren’t promiscuous but had sex with only their marriage partners. However, not everyone felt this way. Some participants were well informed about how HIV is transmitted and were comfortable with being around people who have HIV. Participant E, for example, said they would do things like eat or hang out with someone who has HIV, but they wouldn’t have sex with persons living with HIV.

I’m scared of them. I will be scared to eat with the person infected with HIV. Bath with the person or even live in the same area with the person. Because I don’t want to get close to the person, maybe because my thoughts are that the person may transfer it to me at any moment, so I will neglect the person (GBMSM participant K).

They do much of sex, they are sex addicts. Because when you don’t have sex, you won’t get infected. And married people usually don’t get infected in my community (GBMSM participant F).

I wouldn’t mind eating with the person because I was told you can only get infected through sex, deep kissing and sharing sharps. So I will treat the person like an ordinary person. Sex will be the only thing I wouldn’t have with this person. I am nondiscriminatory; that’s why my friends came to me and told me they were positive (GBMSM participant E).

Fear of testing positive for HIV.

Participants mentioned they were really scared about getting tested for HIV. One person, Participant B, felt nervous about telling others their HIV status and was scared at the idea of getting tested. They worried that they might test positive for HIV. Another person, Participant E, said getting tested for HIV was scary at first because they were afraid of testing positive and what would happen next. However, both participants talked about how they learned to deal with their fears. Participant B said it was important to encourage themselves and think positively about the testing process. Participant E said they used to find HIV testing scary, but now they see it as a regular thing, like other medical tests. The participants indicated the importance of clearing up any wrong ideas and stigma about HIV testing so people won’t be so scared and will be more open to getting tested.

It’s scary. I have tested for HIV, but I wouldn’t like to share my status now. Being in the house, I encourage myself to go and get tested. However, when I get there, it’s scary. What if it comes out positive? But rather, I should be thinking the other way that it should be negative (GBMSM Participant B).

It’s very scary going for HIV testing, but when you encourage yourself to do the test, you realize it’s not that scary but just like the normal tests that we do. But because of the mentality that if you test, you will come out positive and the ARV and other stuff, its scary (GBMSM Participant E).

Motivations for HIV testing among GBMSM

HIV vulnerability.

Some GBMSM were motivated to test for HIV due to their HIV high-risk awareness, as being a sexually active GBMSM poses a higher risk of getting HIV because of the increased HIV prevalence compared to the general population. Participant A mentioned it was really important for MSM to get tested for HIV for these reasons. Even though they were scared, some participants understood that it was imperative to know if they had HIV to stay healthy. According to Participant D, they were scared to get tested, but they knew it was necessary to prevent getting sick. They were worried about having past unprotected sex and wanted to make sure they were safe by getting tested for HIV. Other participants indicated how they regularly get tested for HIV to stay healthy. Participant C said they never know what might happen during sex and they could catch HIV without knowing it. They wanted to be careful and make sure they stayed healthy, so they made sure to get tested regularly.

Yes, there’s the need to test for HIV…because men who have sex with men have a higher rate of getting HIV infections compared to men having sex with ladies. So, it’s very good for any MSM to get tested (GBMSM participant A).

It is very scary when I am going to test. But I feel it’s very important for me to know my status to prevent me from getting sick. So, it’s very important for me to test for HIV. I test for HIV sometimes because maybe I’ve had raw sex with someone, and I don’t trust the person (GBMSM participant D).

I do test for HIV because it’s an opportunistic infection. And you will not know when you might contract it, so I have to test for it to know my status…the sex doesn’t always go as planned…and risky behaviors. I have had some infections some time ago. And now I prefer to be extra careful (GBMSM participant C).

Knowing one’s HIV status.

GBMSM participants shared their thoughts about why HIV testing was important, pointing out different reasons related to their health and wellbeing. According to Participant Z, getting tested for HIV is important for knowing one’s status and making informed decisions. They were assured that medications are available to treat HIV and allow one to live a long and healthy life if diagnosed early. Participant F emphasized the urgency of HIV testing to prevent complications and the progression to AIDS. They stressed the risks of delayed testing and the importance of acting quickly to avoid negative health outcomes. Similarly, Participant I mentioned the importance of timely HIV testing after potential exposure to HIV. They described feeling uneasy after sexual encounters and felt it was necessary to get tested promptly to address any risks.

Of course, it is necessary to get tested because it will help you to know your status and decision-making. If I test positive for HIV, there are medications to help me live long (GBMSM participants Z).

It’s important for me to test for HIV…because you have to know your status. Knowing your status allows you to know what to do. The more you keep on delaying, the more the thing (HIV) too gets worse. Because maybe you are HIV positive, you aren’t on drugs, and if you delay, it might turn into something else (AIDS). And that can cause your death (GBMSM participant F).

I feel it’s important to test for HIV because sometimes you feel like you’ve been exposed (to HIV). Sometimes after having sex, you feel as if you should go, and your body isn’t feeling too well. These thoughts just run through my head, so I go and test because I’m not comfortable with that. So, the earlier you get tested, the better (GBMSM participant I).

Positive messaging about HIV.

Several participants shared their experiences and views on HIV testing, revealing a range of motivations and beliefs related to health. Participant O took a proactive approach to HIV testing, stressing the importance of knowing one’s status in light of growing awareness about HIV transmission. They described their decision to get tested and their relief at receiving a negative result. Participant O also showed knowledge of HIV treatment options, highlighting the potential for achieving an undetectable viral load with proper medication adherence and emphasizing the overall benefit of HIV testing for health management.

Participant D also talked about their changing understanding of HIV and the significance of everyone getting tested. They explained how learning about HIV shifted their perceptions of its severity compared to other diseases, like malaria. They also emphasized the right to life for people living with HIV and spoke out against stigma and discrimination. Participant C reechoed the idea of proactive testing and understanding treatment options. They mentioned the reassurance of treatment availability as a reason for regularly getting tested.

Lately, I have been hearing a lot about HIV and how it’s spreading. I went and took the test. And I found out I’m negative. It is always good to know your status. When I was admitted to college, I had my test before I started lectures. Even if you test positive there are treatment options for you and I learned if you take your medication well, you will achieve the undetectable stage. So, I believe is good to test for HIV (GBMSM Participant O).

I thought HIV was so deadly until I started reading about it. I learned that malaria is even more dangerous than HIV, so I think everyone should test and know their status. And I believe persons living with HIV have the right to life, and they shouldn’t be stigmatized or discriminated against… I’ve learned that there are drugs they give to them when they have HIV. And when they give it to them and take it as prescribed, you will be ok and fine (GBMSM participant D).

I was told that if I should test positive for HIV, there were treatment options and other medications which would prolong my life. So, I always test when it’s time for me to test (GBMSM participant C).

Discussion

Despite the heightened stigma, elevated vulnerability to HIV, and low rates of HIV testing among GBMSM and residents of slums, there is a lack of research exploring HIV testing among GBMSM, particularly within slum communities in Ghana [11,45–47]. The SDT theory was useful in the context of this study to highlight the psychological needs for autonomy, competence, and relatedness for GBMSM in HIV testing, or how this affects the motivation for testing. The theory sheds light on the barriers and facilitators of HIV testing that’ could affect GBMSMS living in the slum communities. The theory also improved our understanding of HIV stigma and how it impacts autonomy considering that the fear of negative stereotypes impedes uptake of testing. GBMSM stigma around HIV testing may affect testing knowledge or proficiencies. Stigma also affects relatedness, which is a crucial component of social support.

The present study qualitatively describes GBMSM level stigma and their motivations for HIV testing in Ghana’s slums. Whereas some GBMSM demonstrated an understanding and acceptance of people living with HIV, others avoided their peers living with HIV and had fears of testing for HIV. The need to test was driven by factors such as perceived HIV vulnerability, need to know one’s HIV status for sexual health reasons, and positive messaging about HIV-informed motivations for HIV testing. These findings emphasize the necessity for interventions that enhance HIV awareness and capitalize on existing motivation to enhance HIV testing rates among GBMSM residing in slum areas [4,48–51].

Although this is one of the early studies to explore GBMSM level HIV stigma in slum communities, the findings remain consistent with literature reported among GBMSM and other populations in Ghana and other SSA [4,48–53]. Consistent with previous findings and aligned with key components of autonomy and competence in the SDT, HIV stigma undermines HIV testing decisions among GBMSM as they fear testing for HIV due to the stigma associated with testing positive [10,52–54]. Thus, it remains imperative for interventions to address HIV stigma to improve testing [10,54,55]. The present study findings of participants projecting stigma towards their peers living with HIV by avoiding them, refusing them sex, and labelling them as sexually promiscuous was also reflected in our previous findings among other GBMSM. Such labeling and avoidance of others living with HIV reflect our previous findings among other GBMSM in Ghana [10,30,48,54,56]. Such behavior poses a significant challenge for testing and the willingness of GBMSM who test positive to disclose their status and even adhere to care as they will not want to be isolated by their peers [56–58]. This finding is also imperative in understanding the relatedness component of the SDT framework that explains HIV stigma from peers may lead to avoidance or social isolation leading to the reluctance to seek social support services.

Despite the stigma shown by others, findings around motivations for HIV testing provide opportunities for encouraging GBMSM in slums to improve HIV knowledge and testing among their peers [11,12,45]. As shown in the results, some GBMSM understand the basics of HIV, especially around risk behaviors, and respond to such risk by testing for HIV, which remains consistent with previous research that shows that the awareness of increased vulnerability among GBMSM encouraged them to test [13,48,59]. Consistent with the SDT and prior literature, the participants’ responses show that increased knowledge of HIV will increase their self-determination for testing. GBMSM did not only consider HIV testing as a path to knowing their HIV status but as an essential means for knowledge acquisition about their health to enable them take meaningful steps like seeking care and adopting behavior changes to ensure their wellbeing. Whereas no previous studies focused on GBMSM in slums, earlier studies among GBMSM in Ghana showed that some GBMSM acknowledged the importance of HIV testing, as it enabled them know their status and make important sexual health choices [13,45,48].

Providing information on how HIV is transmitted, participants’ accounts show that positive messaging about HIV, instead of negative messaging can encourage HIV testing. Others informing participants about how HIV is transmitted and treated, including stages such as undetectable status motivated them to test for HIV. Previous studies reported similar findings among GBMSM [10,52,54]. In one of the studies on HIV health promotion, after attending a workshop where GBMSM peer groups discussed and learned about HIV, they observed an increase in HIV testing from 4% to 17% within a week post-intervention [10].

Taken together, the central takeaway from the findings on stigma and motivation for HIV testing lies in the importance of empowering GBMSM to take charge of their sexual health and make informed decisions about HIV testing, as this may help in reducing barriers to testing and promote self-efficacy. By enhancing their sense of competence and autonomy, tailored interventions can motivate GBMSM living in Ghanaian slums to overcome barriers to HIV testing and take control of their sexual health. A popular intervention that could help reduce HIV stigma at the individual and interpersonal level is the Many Men Many Voices (3MV) [10,54,60]. The intervention addresses stigma, HIV risk, transmission, testing, and treatment among GBMSM in Black communities. When adapted to Ghana, we found that GBMSM improved their understanding of HIV, formed community, and improved their HIV testing behaviors [54].

Conclusion

Despite the important findings, research needs to consider the study limitations when interpreting these study findings. As a qualitative study, which recruited from two regions in Ghana, the findings may not apply to all GBMSM in slums across Ghana. We therefore recommend using this study’s findings in conjunction with other studies from Ghana to draw conclusions about HIV stigma and testing among GBMSM. Future studies could include GBMSM from other regions and consider targeting specific age groups, as this formative work did not have any specific age brackets and may not fully represent people in different age groups.

In conclusion, our findings contribute to the existing knowledge and provide insights for policymakers, healthcare providers, and researchers to develop effective strategies and programs aimed at reducing HIV disparities and improving HIV testing among GBMSM in slums. While stigma can undermine HIV testing, some GBMSM are highly motivated to test for HIV as such positive messaging about HIV should be encouraged and leveraged to increase HIV self-testing among GBMSM in Ghana’s slums.

Citation: Abu-Ba’are GR, Shamrock OW, Zigah EY, Ogunbajo A, Dakpui HD, Agbemedu GRK, et al. (2024) Qualitative description of interpersonal HIV stigma and motivations for HIV testing among gays, bisexuals, and men who have sex with men in Ghana’s slums—BSGH-005. PLoS ONE 19(6): e0289905. https://doi.org/10.1371/journal.pone.0289905

About the Authors:

Gamji Rabiu Abu-Ba’are

Roles: Conceptualization, Formal analysis, Funding acquisition, Methodology, Visualization, Writing – original draft, Writing – review & editing

Affiliations: Behavioral, Sexual and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana, Department of Public Health Sciences, University of Rochester, Rochester, New York, United States of America, School of Nursing, Yale University, New Haven, Connecticut, United States of America, Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria, Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana

ORICD: https://orcid.org/0000-0002-1718-0381

Osman Wumpini Shamrock

Roles: Conceptualization, Methodology, Visualization, Writing – original draft, Writing – review & editing

E-mail: [email protected]

Affiliations: Behavioral, Sexual and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana

ORICD: https://orcid.org/0000-0003-3127-9596

Edem Yaw Zigah

Roles: Conceptualization, Investigation, Writing – original draft, Writing – review & editing

Affiliations: Behavioral, Sexual and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana

Adedotun Ogunbajo

Roles: Methodology, Writing – original draft, Writing – review & editing

Affiliation: Us Helping Us People into Living, Washington, DC, United States of America

Henry Delali Dakpui

Roles: Conceptualization, Methodology, Visualization, Writing – original draft

Affiliations: Behavioral, Sexual and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana

ORICD: https://orcid.org/0009-0005-8364-1253

George Rudolph Kofi Agbemedu

Roles: Conceptualization, Investigation, Methodology, Visualization, Writing – original draft

Affiliations: Behavioral, Sexual and Global Health Lab, School of Nursing, University of Rochester, Rochester, New York, United States of America, Behavioral, Sexual and Global Health Lab, Jama’a Action, West Legon, Accra, Ghana

ORICD: https://orcid.org/0000-0003-1759-715X

Donte T. Boyd

Roles: Formal analysis, Writing – original draft, Writing – review & editing

Affiliation: College of Social Work, Ohio State University, Columbus, Ohio, United States of America

ORICD: https://orcid.org/0000-0001-9952-3116

Oliver C. Ezechi

Roles: Methodology, Visualization, Writing – original draft, Writing – review & editing

Affiliation: Clinical Sciences Department, Nigerian Institute of Medical Research, Lagos, Nigeria

LaRon E. Nelson

Roles: Investigation, Visualization, Writing – original draft, Writing – review & editing

Affiliations: School of Nursing, Yale University, New Haven, Connecticut, United States of America, Center for Interdisciplinary Research on AIDS, School of Public Health, Yale University, New Haven, Connecticut, United States of America

Kwasi Torpey

Roles: Supervision, Writing – original draft, Writing – review & editing

Affiliation: Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana

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References

1. Poteat T, Ackerman B, Diouf D, Ceesay N, Mothopeng T, Odette KZ, et al. HIV prevalence and behavioral and psychosocial factors among transgender women and cisgender men who have sex with men in 8 African countries: A cross-sectional analysis. PLoS Med. 2017;14(11). pmid:29112689

2. Ahouada C, Diabaté S, Mondor M, Hessou S, Guédou FA, Béhanzin L, et al. Acceptability of pre-exposure prophylaxis for HIV prevention: Facilitators, barriers and impact on sexual risk behaviors among men who have sex with men in Benin. BMC Public Health. 2020;20(1). pmid:32819335

3. Abubakari GM, Dada D, Nur J, Turner D, Otchere A, Tanis L, et al. Intersectional stigma and its impact on HIV prevention and care among MSM and WSW in sub-Saharan African countries: a protocol for a scoping review. BMJ Open. 2021 Aug 6;11(8):e047280. pmid:34362801

4. Hagopian A, Rao D, Katz A, Sanford S, Barnhart S. Anti-homosexual legislation and HIV-related stigma in African nations: what has been the role of PEPFAR? Glob Health Action. 2017 Jan 5;10(1):1306391. pmid:28580879

5. Price MA, Rida W, Mwangome M, Mutua G, Middelkoop K, Roux S, et al. Identifying at-risk populations in kenya and south africa: HIV incidence in cohorts of menwho report sex with men, sex workers, and youth. J Acquir Immune Defic Syndr (1988). 2012;59(2). pmid:22227488

6. Abu-Ba’are GR, Torpey K, Nelson L, Conserve D, Jeon S, McMahon J, et al. Adaptation and feasibility of Many Men Many Voices (3MV), an HIV prevention intervention to reduce intersectional stigma and increase HIVST among YSMM residing in Ghanaian slums–A clustered pre-post pilot trial protocol. 2024. Available from:

7. Phaswana-Mafuya , Simbayi L, Wabiri N, Cloete A, Ghana AIDS Commission. “The Ghana men’s study II: mapping and population size estimation (MPSE) and integrated bio-behavioral surveillance survey (IBBSS) amongst men who have sex with men (MSM) in Ghana.” 2020. Available from: http://hdl.handle.net/20.500.11910/15238.

8. Ghana AIDS Commission. President’s Emergency Plan for AIDS Relief, US Centers for Disease Control, University of California San Francisco. The Ghana Men’s Study: Integrated biological-behavioral surveillance surveys and population size estimation among men who have sex with men in Ghana. Accra, Ghana; 2013. Available from: http://hdl.handle.net/20.500.11910/15238.

9. Ghana National AIDS Control Programme. National HIV prevalence & AIDS estimates report, 2012–2013. Accra, Ghana; 2016. Available from: https://www.unaids.org/sites/default/files/country/documents/file,94605,es..pdf.

10. Abubakari GMR, Nelson LRE, Ogunbajo A, Boakye F, Appiah P, Odhiambo A, et al. Implementation and evaluation of a culturally grounded group-based HIV prevention programme for men who have sex with men in Ghana. Glob Public Health. 2021;16(7). pmid:33050773

11. Abubakari GMR, Turner DA, Ni Z, Conserve DF, Dada D, Otchere A, et al. Community-Based Interventions as Opportunities to Increase HIV Self-Testing and Linkage to Care Among Men Who Have Sex With Men–Lessons From Ghana, West Africa. Front Public Health. 2021;9. pmid:34178919

12. Abubakari GM, Owusu-Dampare F, Ogunbajo A, Gyasi J, Adu M, Appiah P, et al. HIV Education, Empathy, and Empowerment (HIVE3): A Peer Support Intervention for Reducing Intersectional Stigma as a Barrier to HIV Testing among Men Who Have Sex with Men in Ghana. Int J Environ Res Public Health. 2021 Dec 12;18(24):13103. pmid:34948712

13. Kushwaha S, Lalani Y, Maina G, Ogunbajo A, Wilton L, Agyarko-Poku T, et al. “But the moment they find out that you are MSM ⋯”: a qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana’s health care system. BMC Public Health. 2017;17(1). pmid:28974257

14. Ogunbajo A, Oke T, Okanlawon K, Abubakari GM, Oginni O. Religiosity and Conversion Therapy is Associated with Psychosocial Health Problems among Sexual Minority Men (SMM) in Nigeria. J Relig Health. 2022;61(4). pmid:34455514

15. Gyamerah AO, Taylor KD, Atuahene K, Anarfi JK, Fletcher M, Raymond HF, et al. Stigma, discrimination, violence, and HIV testing among men who have sex with men in four major cities in Ghana. AIDS Care. 2020 Aug 2;32(8):1036–44. pmid:32362131

16. Darteh EKM, Kumi-Kyereme A, Awusabo-Asare K. Perception of risk of HIV among adolescents’ living in an Urban Slum in Ghana. Afr J Reprod Health. 2016;20(1). pmid:29553178

17. Musinguzi G, Bastiaens H, Matovu JKB, Nuwaha F, Mujisha G, Kiguli J, et al. Barriers to condom use among high risk men who have sex with men in Uganda: A qualitative study. PLoS One. 2015;10(7). pmid:26172374

18. Engstrom R, Pavelesku D, Tanaka T, Wambile A. Mapping poverty and slums using multiple methodologies in Accra, Ghana. In: 2019 Joint Urban Remote Sensing Event, JURSE 2019. 2019.

19. Esantsi SF, Onyango F, Asare GQ, Kuffour E, Tapsoba P, Birungi H, et al. Understanding the reproductive health needs of adolescents in selected slums in Ghana: a public health assessment. Ghana; 2015.

20. Osman Wumpini Shamrock, Henry Delali Dakpui, George Rudolph Kofi Agbemedu, Donte T Boyd, Kharul Islam, Ibrahim Wunpini Mashoud, et al. “I’m scared of the nurses telling other people I am a transwoman”: Disclosure and nondisclosure of gender identity among trans women in Ghana’s urban slums–BSGH010 [Internet]. 2024 Apr [cited 2024 Apr 19]. Available from: https://doi.org/10.21203/rs.3.rs-4243840/v1.

21. Kabiru CW, Beguy D, Crichton J, Zulu EM. HIV/AIDS among youth in urban informal (slum) settlements in Kenya: What are the correlates of and motivations for HIV testing? BMC Public Health. 2011 Dec 3;11(1):685. pmid:21888666

22. Madise N J., Ziraba AK, Inungu J, Khamadi SA, Ezeh A, Zulu EM, et al. Are slum dwellers at heightened risk of HIV infection than other urban residents? Evidence from population-based HIV prevalence surveys in Kenya. Health Place. 2012;18(5). pmid:22591621

23. Shamrock OW, Abu-Ba’are GR, Zigah EY, Apreku A, Agbemedu GRK, Boyd DT, et al. Family rejection of non-hetero sexuality–Sexual orientation and behavior anonymity among sexual minority men in slum communities-BSGH 001. PLOS Global Public Health 3: e0001659 2023 Dec 1; pmid:38039264

24. Abu-Ba’are GR, Shamrock OW, Apreku A, Agbemedu GRK, Zigah EY, Ezechi OC, et al. Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay, Bisexual, and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004. Journal of the International Association of Providers of AIDS Care (JIAPAC) [Internet]. 2023;22:23259582231209650. Available from: pmid:37933162

25. Amoako C, Cobbinah PB. Slum improvement in the Kumasi metropolis,Ghana—a review of approaches and results. Journal of Sustainable Development in Africa. 2011;13(8).: 150–170.

26. Snyder RE, Boone CE, Cardoso CAA, Aguiar-Alves F, Neves FPG, Riley LW. Zika: A scourge in urban slums. PLoS Negl Trop Dis. 2017 Mar 23;11(3):e0005287. pmid:28333922

27. Teixeira PJ, Marques MM, Silva MN, Brunet J, Duda JL, Haerens L, et al. A classification of motivation and behavior change techniques used in self-determination theory-based interventions in health contexts. Motiv Sci. 2020;6(4).

28. Ryan RM, Deci EL. Intrinsic and extrinsic motivation from a self-determination theory perspective: Definitions, theory, practices, and future directions. Contemp Educ Psychol. 2020;61.

29. Nelson LE, Wilton L, Agyarko-Poku T, Zhang N, Aluoch M, Thach CT, et al. The Association of HIV Stigma and HIV/STD Knowledge With Sexual Risk Behaviors Among Adolescent and Adult Men Who Have Sex With Men in Ghana, West Africa. Res Nurs Health. 2015 Jun;38(3):194–206. pmid:25809638

30. Nelson LRE, Wilton L, Agyarko-Poku T, Zhang N, Aluoch M, Thach CT, et al. The Association of HIV Stigma and HIV/STD Knowledge With Sexual Risk Behaviors Among Adolescent and Adult Men Who Have Sex With Men in Ghana, West Africa. Res Nurs Health. 2015;38(3). pmid:25809638

31. Dakpui HD, Shamrock OW, Aidoo-Frimpong G, Zigah EY, Agbemedu GR, Ahmed A, et al. A qualitative description of HIV testing and healthcare experiences among trans women in Ghanaian urban slums BSGH-011. 2024. https://doi.org/10.21203/rs.3.rs-4390892/v1.

32. Faust L, Yaya S. The effect of HIV educational interventions on HIV-related knowledge, condom use, and HIV incidence in sub-Saharan Africa: A systematic review and meta-analysis. Vol. 18, BMC Public Health. 2018. pmid:30424761

33. Mbeda C, Ogendo A, Lando R, Schnabel D, Gust DA, Guo X, et al. Healthcare-related stigma among men who have sex with men and transgender women in sub-Saharan Africa participating in HIV Prevention Trials Network (HPTN) 075 study. AIDS Care—Psychological and Socio-Medical Aspects of AIDS/HIV. 2020;32(8). pmid:32500722

34. Luvuno ZP, Mchunu G, Ncama B, Ngidi H, Mashamba-Thompson T. Evidence of interventions for improving healthcare access for lesbian, gay, bisexual and transgender people in South Africa: A scoping review. Afr J Prim Health Care Fam Med. 2019;11(1). pmid:31296011

35. Keuroghlian AS, Mujugira A, Mayer KH. Healthcare worker training to improve quality of care for sexual and gender minority people in sub-Saharan Africa: learning from efforts in Uganda. Vol. 24, Journal of the International AIDS Society. 2021. pmid:34189872

36. Colorafi KJ, Evans B. Qualitative Descriptive Methods in Health Science Research. HERD: Health Environments Research & Design Journal. 2016 Jul 19;9(4):16–25. pmid:26791375

37. Shamrock OW. Disability, Religion and Work among Vulnerable Populations: An Inquiry of Women Experiences and Perspectives [Doctoral Dissertation]. [Binghamton]: State University of New York at Binghamton; 2022. Available from: https://ezp.lib.rochester.edu/login?url=https://www.proquest.com/dissertations-theses/disability-religion-work-among-vulnerable/docview/2692119036/se-2

38. UNICEF. Ghana Education Facts 2020-Analyses for learning and equity using MICS data. Ghana; 2020. Available from: https://www.researchgate.net/publication/347955695_Ghana_Analyses_for_learning_and_equity_using_MICS_data.

39. USAID. Ghana- Education. Ghana; 2023 Oct. Available from: https://www.usaid.gov/ghana/education.

40. Zigah EY, Abu-Ba’are GR, Shamrock OW, Dakpui HD, Apreku A, Boyd DT, et al. “For my safety and wellbeing, I always travel to seek health care in a distant facility”—the role of place and stigma in HIV testing decisions among GBMSM–BSGH 002. Health Place. 2023 Sep;83:103076. pmid:37423093

41. Shamrock OW, Abu-Ba’are GR, Zigah EY, Dakpui HD, Adjaka G, LeBlanc NM, et al. Community stigma, victimization, and coping strategies among gay, bisexual, and other cis-gender men who have sex with men in slum communities in Ghana. BSGH-003. BMC Public Health. 2024 Apr 5;24(1):966. pmid:38580970

42. Dada D, Abu-Ba’are GR, Turner D, Mashoud IW, Owusu-Dampare F, Apreku A, et al. Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa. BMJ Open. 2024;14(2):e078794. pmid:38346887

43. Abu-Ba’are GR, Aidoo-Frimpong G, Stockton M, Zigah EY, Amuah S, Amu-Adu P, et al. “I told myself, be bold and go and test”: Motivators and barriers to HIV testing among gay, bisexual, and other cis-gender men who have sex with men in Ghana ‒ West Africa. PLOS Global Public Health. 2024 Jan 11;4(1):e0002231. pmid:38206889

44. Gamji Rabiu Abu-Ba’are Gloria Aidoo-Frimpong, Prince Amu-Adu Edem Yaw Zigah, Stockton Melissa, Amuah Samuel, et al. “One pastor advised him to stop taking HIV medication”: Promoters and barriers to HIV care among gay, bisexual, and men who have sex with men living with HIV in Ghana. BMC Public Health. 2024 Mar 22. pmid:38562846

45. Nelson LRE, Nyblade L, Torpey K, Logie CH, Qian HZ, Manu A, et al. Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: Protocol for a cluster randomized controlled trial. PLoS One. 2021;16(11 November). pmid:34843529

46. Haruna U. Stirring the Hornet’s Nest: a Study of Student’s Awareness, Perception and Tolerance of Homosexuality in a Ghanaian University. Journal of Sociological Research. 2015;6(1).

47. Adua JY. Religion and Homosexuality in Ghana: Assessing the Factors Constraining the Legalisation of Homosexuality in Ghana: A Study of the Klottey Korle Sub-Metropolitan Area. of Accra. University of Ghana; 2018. Available from: https://ugspace.ug.edu.gh/handle/123456789/30142?show=full.

48. Ogunbajo A, Kershaw T, Kushwaha S, Boakye F, Wallace-Atiapah ND, Nelson LE. Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM). AIDS Behav. 2018 Mar 26;22(3):829–39. pmid:28550380

49. Girault P, Green K, Clement NF, Rahman YAA, Adams B, Wambugu S. Piloting a Social Networks Strategy to Increase HIV Testing and Counseling Among Men Who Have Sex with Men in Greater Accra and Ashanti Region, Ghana. AIDS Behav. 2015;19(11). pmid:25903507

50. Ghana AIDS Commission. Ghana AIDS Commission (2016). National HIV/AIDS strategic plan (2016–2020).Available from: https://www.ghanaids.gov.gh/mcadmin/Uploads/ABRIDGED%20NSP%202016-2020.pdf.

51. Ali H, Amoyaw F, Baden D, Durand L, Bronson M, Kim A, et al. Ghana’s HIV epidemic and PEPFAR’s contribution towards epidemic control. Ghana Med J. 2019 Mar 10;53(1):59. pmid:31138945

52. Abubakari GM, Smith MDR, Boyd DT, Raquel Ramos S, Johnson C, Benavides JL, et al. Assessing Different Types of HIV Communication and Sociocultural Factors on Perceived HIV Stigma and Testing among a National Sample of Youth and Young Adults. Int J Environ Res Public Health. 2022;19(2). pmid:35055823

53. Boyd DT, Waller B, Quinn CR. Reimaging an AIDS free generation: Examining youth and young adults’ personal agency and its association with HIV testing. Prev Med Rep. 2021;22. pmid:33680722

54. Abubakari GM, Turner D, Nelson LE, Odhiambo AJ, Boakye F, Manu A, et al. An application of the ADAPT-ITT model to an evidence-based behavioral HIV prevention intervention for men who have sex with men in Ghana. International Health Trends and Perspectives. 2021;1(1).

55. Boyd D, Lea CH, Gilbert KL, Butler-Barnes ST. Sexual health conversations: Predicting the odds of HIV testing among black youth and young adults. Child Youth Serv Rev. 2018;90.

56. Nelson LE, Ogunbajo A, Abu-Ba’are GR, Conserve DF, Wilton L, Ndenkeh JJ, et al. Using the Implementation Research Logic Model as a Lens to View Experiences of Implementing HIV Prevention and Care Interventions with Adolescent Sexual Minority Men—A Global Perspective. AIDS Behav. 2022 Aug 10; pmid:35947235

57. Logie CH, Newman PA, Chakrapani V, Shunmugam M. Adapting the minority stress model: Associations between gender non-conformity stigma, HIV-related stigma and depression among men who have sex with men in South India. Soc Sci Med. 2012;74(8). pmid:22401646

58. Saalim K, Amu-Adu P, Amoh-Otu RP, Akrong R, Abu-Ba’are GR, Stockton MA, et al. multi-level manifestations of sexual stigma among men with same-gender sexual experience in Ghana. BMC Public Health. 2023 Jan 24;23(1):166. pmid:36694150

59. Estem KS, Catania J, Klausner JD. HIV Self-Testing: a Review of Current Implementation and Fidelity. Vol. 13, Current HIV/AIDS Reports. 2016. pmid:26879653

60. Wilton L, Herbst JH, Coury-Doniger P, Painter TM, English G, Alvarez ME, et al. Efficacy of an HIV/STI prevention intervention for black men who have sex with men: findings from the many men, many voices (3MV) project. AIDS Behav. 2009;13(3). pmid:19267264