Operations Research Among Key Populations in Ghana
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BACKGROUND: A common misconception about HIV/AIDS in Africa is that the epidemic is similar across the continent. Nothing could be further from truth. While the virus affects a large proportion of the heterosexual adult population in East and Southern Africa, in West Africa the epidemic (with the exception of Nigeria) is smaller, slower, and largely concentrated in highly vulnerable populations. While only 1.3% of the adult population is infected in Ghana, HIV prevalence within some key populations is much higher. For example, the Ghanaian government estimates that HIV prevalence among female sex workers, men who have sex with men (MSM), and prisoners is 13%, 18%, and 6% respectively. These highly vulnerable populations were the focus of research at the BU Center for Global Health and Development (CGHD) that was conducted in partnership with Ghanaian collaborators at Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi. In a multi-study project funded by the United States Agency for International Development (USAID), CGHD and KNUST collected detailed qualitative information from young sex workers, MSM, prisoners, injection drug users, students, and people living with HIV to better understand their specialized needs. Our goal through this collection of studies was to provide information to the Ghanaian government, donors, and service providers who design and implement programs aimed at preventing HIV infection and providing appropriate services for these key populations.
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Item Program brief: HIV vulnerability and prevention needs of young female sex workers in Kumasi, Ghana(USAID Project SEARCH, 2013) Adhiambo Onyango, Monica; Sylvester, Joy; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, JenniferAdult HIV prevalence in Ghana in 2013 has been estimated at 1.31%.1 Among female sex workers (FSW), prevalence is, however, much higher at 12.9%, compared to 2.2% in the general female population. HIV prevalence among FSW in the Ashanti region is 13%, the second highest FSW prevalence after the Greater Accra Region (16.3%).2 Sex work plays a significant role in HIV transmission, with 2.4% of sex workers, 13.2% of male clients, and 22.2% of clients’ partners contributing to new HIV infections.2 While recent national and regional prevalence and behavior data on FSWs are available, little qualitative research has been published on sex workers in Kumasi, and specifically on younger sex workers. This qualitative study was conducted by Boston University’s Center for Global Health and Development and the Kwame Nkrumah University of Science and Technology with funding from the United States Agency for International Development (USAID)/Ghana. The study objectives were to: (1) investigate knowledge about and perceptions of HIV among young FSW in Kumasi, capital of the Ashanti region and second largest city in Ghana; (2) explore their HIV risk behaviors; and (3) identify their HIV prevention needs. Focus group discussions and in-depth interviews were done with 48 FSW Ten key informant interviews were held with health care providers at local clinics.Item Research report: "It’s all about making a life": young female sex workers vulnerability to HIV and prevention needs in Kumasi, Ghana(USAID Project SEARCH, 2012) Adhiambo Onyango, Monica; Sylvester, Joy; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, JenniferThis report presents findings from a qualitative study examining the vulnerability to HIV of young female sex workers (FSW) in Kumasi, Ghana and their prevention needs. The study was conducted by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) as part of the Project SEARCH Program funded by PEPFAR and the United States Agency for International Development Ghana. The objectives of this study were to: 1) Investigate knowledge about and perceptions of HIV in young FSW in the Kumasi Metropolitan area, 2) Explore their risk behaviors, and 3) Identify their most urgent prevention needs. A secondary objective was to provide foundational knowledge to inform the design of future studies of girls and young women engaging in sex work in Ghana.Item "I can decide to use the property I have to make money": HIV vulnerability of bar workers and bar patrons in Kumasi, Ghana(USAID Project SEARCH, 2014) Messersmith, Lisa; Longobardi, Dana; Asafo, Mabel; Agyarko‐Poku, Thomas; Corneliess, Caitlin; Daube, Elizabeth; Adu‐Sarkodie, Yaw; Beard, Jennifer; Ashigbie, Paul; Falconer, ArielThis report provides the findings from a qualitative study exploring the social, economic and behavioral vulnerability to HIV of women working in bars and restaurants in Kumasi, Ghana’s second largest city. This research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) School of Medical Sciences. It is one of nine studies under the Operations Research on Key Populations project funded by the United States Agency for International Development (USAID). The study was designed and carried out in collaboration with the Ghana AIDS Commission (GAC). Reducing vulnerability to HIV infection among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. While a number of studies have explored HIV risk behaviours among self-identified female sex workers and their partners in Ghana, little is known about the vulnerability of women working in small bars and restaurants who may be involved in transactional sex. Further, we have little information about how best to reach this population with services that will enable them and their clientele to protect themselves from HIV and reduce other vulnerabilities related to their health and well-being. To address this gap, this study aimed to explore behavioural, social, and economic factors that contribute to HIV vulnerability; types and extent of transactional sex; the relationship between alcohol/drug use, unsafe sex and transactional sex; and the health and social service needs of this population. The study findings are meant to inform the development and implementation of HIV prevention programs for bar workers and bar patrons.Item Attitudes and behaviors among older MSM in Ghana(USAID Project SEARCH, 2013) Sabin, Lora; Ashigbie, Paul; Hollenbeck‐Pringle, Danielle; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, Jennifer; Bachman DeSilva, Mary; Green, Kimberly; Wambugu, Sam; Ahmed Abdul Rahman, YussifMen who have sex with men (MSM) are a particularly stigmatized group in Ghana. Male-tomale sex is viewed as “unnatural” and therefore illegal. MSM are a critical, though difficult, population to reach with HIV-related services. Preventing HIV among key populations is a goal of the National AIDS Control Program (NACP) and the Ghana AIDS Commission (GAC).1 Until recently, specific data on MSM in the country were limited. The Ghana Men’s Study (GMS), which collected information from 1,302 MSM in five regions in 2011, provides detailed data on HIV and sexually transmitted infection (STI) prevalence and risk behaviors among MSM. Whereas adult HIV prevalence in Ghana has been estimated 1.31% in 2013,2 the GMS documented a nationwide average prevalence in 2011 of 17.5% among MSM, with the rate in Accra estimated at 34.3% and 13.7% in Kumasi.3 Boston University’s Center for Global Health and Development (BU CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST), in collaboration with the GAC and FHI 360, conducted a qualitative study to examine HIV vulnerability among “older” MSM in Kumasi, Ghana’s second largest urban area. It is the second of two studies focusing on MSM in Ghana undertaken by CGHD/KNUST. The first, “Exploring the beliefs, attitudes, and behaviors of MSM engaged in substance use and transactional sex in Ghana,”4 focused on adolescent and young adult MSM aged 15 to 29 years. This companion study included MSM aged 30 years and above. The research is designed to complement and supplement information on MSM obtained by the GMS. The study’s goal was to collect and analyze data to improve the outreach and effectiveness of local programs that aim to reach older MSM with important HIV prevention and treatment information and with services appropriate to their needs. In-depth interviews (IDIs) and focus group discussions (FGDs) were used to collect data from two MSM groups: those aged 30 to 39 years and those aged forty and older. A total of 44 MSM participated in the study, 22 in each age group.Item Attitudes and behaviors among older MSM in Ghana(USAID Project SEARCH, 2013) Sabin, Lora; Ashigbie, Paul; Hollenbeck‐Pringle, Danielle; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, Jennifer; Bachman DeSilva, Mary; Green, Kimberly; Wambugu, Sam; Ahmed Abdul Rahman, YussifThis report provides the findings of a qualitative study that explored vulnerability to HIV of men who have sex with men (MSM) in Kumasi, Ghana. It is the second of two related studies focusing on MSM. The first study, “Exploring the beliefs, attitudes, and behaviors of MSM engaged in substance use and transactional sex in Ghana,”1 focused on adolescent and young adult MSM aged 15 to 29 years. This companion study focused on ‘older MSM’, encompassing individuals aged 30 years and above. This research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST). The team conducted this research in Kumasi, Ghana’s second largest urban center. It is a component of the ‘Operations Research for Key Populations in Ghana’ Program funded by the United States Agency for International Development (USAID). We designed and carried out the study in collaboration with FHI 360, an organization based in the capital of Accra that operates programs targeting MSM and other high‐risk individuals in Ghana, as well as the Ghana AIDS Commission (GAC). Reducing vulnerability to HIV infection among high‐risk populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. MSM are highly stigmatized in Ghana, in part because male‐to‐male sex is illegal. This makes it extremely challenging to understand the challenges these men face and ensure that they have access to HIV‐ and AIDS‐related services. We designed this qualitative study to add to what is known about the beliefs, attitudes, and behaviors of older MSM in Ghana. We focused on two groups among older MSM: those aged 30‐39 years and those aged 40 years and above. Given the need for more data on these groups to better reach them with effective HIV prevention and treatment information, the study aimed to explore: 1) How older MSM find their sex partners; 2) Their views of HIV risk; 3) Their risky behaviors, including those situations in which they are most likely to engage in risky sex; 4) HIV‐related services they receive; and 5) What services would be most helpful to them. The broad goal of the study was to collect and analyze in‐depth data in order to improve the outreach and effectiveness of local programs that aim to reach older MSM with important HIV prevention and treatment information and with services appropriate to their needs.Item Program brief: Exploring the beliefs, attitudes, and behaviors of msm engaged in substance use and transactional sex in Ghana(USAID Project SEARCH, 2013) Sabin, Lora; Bachman DeSilva, Mary; Green, Kimberly; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, Jennifer; Wambugu, Sam; Esang, Michael; Ashigbie, Paul; Ahmed Abdul Rahman, YussifPreventing HIV among key populations is a goal of the National AIDS Control Program (NACP) and the Ghana AIDS Commission (GAC).1 Men who have sex with men (MSM) are a particularly stigmatized group in Ghana, in part because male-to-male sex is viewed as “unnatural” and therefore illegal. MSM are a critical though difficult population to reach with HIV-related services. Until recently, specific data on MSM in the country were limited. The Ghana Men’s Study (GMS), which collected data from 1,302 MSM in five regions in 2011, has detailed information on HIV and sexually transmitted infection (STI) prevalence and risk behaviors among MSM. Whereas adult HIV prevalence in Ghana has been estimated at 1.31% in 2013,2 the GMS documented a nationwide average prevalence in 2011 of 17.5% among MSM, with the rate in Accra estimated at 34.3% and 13.7% in Kumasi.3 This qualitative study was designed to complement and supplement quantitative findings about MSM from the GMS. It was conducted by Boston University’s Center for Global Health and Development and the Kwame Nkrumah University of Science and Technology (KNUST) in collaboration with FHI 360 and with funding from the United States Agency for International Development (USAID)/Ghana. It is the first of two qualitative studies focusing on MSM in Ghana. The objectives were to explore: (1) the types and extent of substance use by MSM; (2) the overlap between substance use and transactional sex among MSM; (3) the beliefs and attitudes related to substance use and transactional sex; and (4) knowledge and risk behaviors of both subgroups. In-depth interviews (IDI) and focus group discussions (FGD) were used to collect data from four participant groups: two age groups, adolescent MSM (aged 15-17 years) and young adult MSM (aged 18-29 years), with each group including men who consume high levels of alcohol and/ or use drugs and men who engage in transactional sex (TS). Transactional sex is defined here as self-reported sex with another man in exchange for money, gifts, or favors.Item Research report: Exploring the beliefs, attitudes, and behaviors of MSM engaged in substance use and transactional sex in Ghana(USAID Project SEARCH, 2013) Sabin, Lora; Bachman DeSilva, Mary; Green, Kimberly; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, Jennifer; Wambugu, Sam; Esang, Michael; Ashigbie, Paul; Ahmed Abdul Rahman, YussifThis report presents findings from a qualitative study examining the vulnerability to HIV of young men who have sex with men (MSM) in Kumasi, Ghana, and their prevention needs. The study was jointly conducted in Kumasi, Ghana’s second largest urban center, by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST). It was carried out as a component of Project SEARCH funded by the United States Agency for International Development. The study was designed and conducted in collaboration with FHI 360 (formerly Family Health International (FHI)), an international non‐governmental organization based in the capital city of Accra which operates programs targeting MSM and other key populations in Kumasi, and the Ghana AIDS Commission (GAC). Preventing HIV among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC.1 MSM are a particularly stigmatized population in Ghana, in part because male‐to‐male sex has traditionally been viewed as illegal, making them a difficult yet critical to reach population with HIV/AIDS‐related services. This qualitative study was conducted in order to enhance understanding of the beliefs, attitudes, and behaviors of adolescent and young MSM (aged 15‐29). In this population, we particularly sought to focus on two sub‐groups: MSM who engage in transactional sex and those who use alcohol or illicit substances (hereinafter “substances”). The specific objectives were to explore: 1) the types and extent of substance use by MSM; 2) the overlap between substance use and transactional sex among MSM; 3) the beliefs and attitudes related to substance use and transactional sex; 4) knowledge and risk behaviors of both subgroups. The study’s broader goal was to collect and analyze in‐depth data that can be used to improve the outreach and effectiveness of local programs that aim to reach these groups with important HIV prevention and treatment information and with services appropriate to their needs.Item The Ghana retention on ART study (ROARS): keeping HIV-positive patients on antiretroviral therapy(USAID Project SEARCH, 2014) Sabin, Lora; Longobardi, Dana; Abacan, Allyssa; Agyarko‐Poku, Thomas; Myint Zu Kyaw, Mya; Falconer, Ariel; Kissiwah Asafo, Mabel; Messersmith, Lisa; Adu‐Sarkodie, Yaw; Beard, JenniferThis report presents the findings of a study that employed qualitative research methods to explore the beliefs, attitudes, and behaviors of people living with HIV (PLHIV) in Ghana who are either in care and on antiretroviral therapy (ART), or are no longer in care and have been lost to follow-up. The study was designed to deepen our understanding of the challenges ART patients face in continuing on ART in Ghana and to contribute information with the potential to improve retention in care and outcomes for PLHIV in Ghana.This study was carried out by a collaborative team of researchers based at Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology’s (KNUST) School of Medical Sciences. The team conducted this research in Kumasi, Ghana’s second largest urban center. It is a component of the ‘Operations Research among Key Populations in Ghana’ project funded by the United States Agency for International Development (USAID). We designed and conducted the research in collaboration with the Ghana AIDS Commission (GAC).Expanding access to ART among HIV-positive individuals has been a major goal of the Ghana AIDS Commission and Ghana Health Service. Since 2005, Ghana has scaled up ART rapidly; by 2011, 150 health facilities were providing ART to over 60,000 people, an increase from fewer than 5,000 just six years earlier. At the same time, like in most countries in sub-Saharan Africa, ensuring that those who begin ART remain on treatment has proven a major challenge. Previous studies suggest that retention in care for 12 months or longer is approximately 70-80% in Ghana, similar to the rate in many other low-resource settings. While research elsewhere in sub-Saharan Africa indicates that a number of barriers affect retention in care, little research on this topic has been conducted in Ghana. Given that ART is currently the only known way to prolong life for PLHIV, it is critical to identify barriers that affect different groups of patients and to find ways to support them in remaining on treatment.This study was motivated by a desire to increase understanding of the challenges of and facilitators to retention in care among individuals on ART in Kumasi, Ghana. We conducted it in collaboration with the Suntreso Government Hospital, one of Kumasi’s largest medical facilities, and specifically with the hospital’s STI (sexually transmitted infection)/HIV clinic, which has experienced high levels of patient dropout from care and treatment. Together with staff at the clinic, we designed this research with the aim of contributing to understanding of the range of barriers PLHIV in Ghana experience trying to stay on treatment, the reasons they default, and the types of supports they believe would help themselves and other patients remain on or return to treatment if they do default. Our hope is that the study’s findings will add in a meaningful way to the evidence base on strategies and approaches for improving retention in treatment, thereby maximizing the potential benefits of ART, for PLHIV in Ghana.Item HIV vulnerability of men and women who inject drugs in Kumasi, Ghana(USAID Project SEARCH, 2014) Messersmith, Lisa; Adjei, Rose; Longobardi, Dana; Agyarko‐Poku, Thomas; Falconer, Ariel; Sabin, Lora; Adu‐Sarkodie, Yaw; Beard, JenniferReducing vulnerability to HIV infection among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. While a number of studies have explored HIV risk behaviours among several key vulnerable populations in Ghana including female sex workers, men who have sex with men, and prisoners, little is known about the drug use and sexual vulnerability of people who inject drugs (PWID). In addition, no programs have been implemented to reduce the vulnerability among this population. This report provides the findings from a qualitative study that aimed to understand the social, economic and behavioral vulnerability to HIV of PWID in Kumasi and to inform the development and implementation of HIV prevention programs for this population. The research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) School of Medical Sciences. It is one of nine studies under the Operations Research on Key Populations project funded by the United States Agency for International Development (USAID). The study was designed and carried out in collaboration with the Ghana AIDS Commission (GAC).Item Program brief: "Using what you have to get what you want: HIV vulnerability and prevention needs of female post‐secondary students engaged in transactional sex in Kumasi, Ghana(USAID Project SEARCH, 2013) Baba‐Djara, Monita; Brennan, Alana; Corneliess, Caitlin; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, JenniferHIV prevalence among young Ghanaian men and women aged 15–24 years old is estimated at 1.7%.1 HIV prevalence in the specific population of female post-secondary students is unknown. The Ghana AIDS Commission (GAC) recognizes the need for further research in communities participating in less well-defined risky sex practices. This study was conducted by Boston University’s Center for Global Health and Development and the Kwame Nkrumah University of Science and Technology with funding from the United States Agency for International Development/Ghana. The objective was to provide academic institutions, the GAC, the National AIDS Control Program, donors, and other stakeholders with data to inform research and programmatic efforts in Kumasi, specifically, as well as academic institutions, in general. Study participants were recruited from five post-secondary institutions in the greater Kumasi area. Data were collected on students’ perceptions of transactional sex (TS) on campus, individual and structural HIV vulnerabilities, and prevention needs through in-depth interviews with seven female post-secondary students involved in TS and focus groups with twenty-nine female and male students. Key informant interviews were also conducted with faculty, residence hall matrons, and hotel staff. Non-commercial transactional sex is defined here as engaging in sex for the purposeof obtaining material goods, financial support, or grades.Item Research report: "Using what you have to get what you want": Vulnerability to HIV and prevention needs of female post‐secondary students engaged in transactional sex in Kumasi, Ghana(USAID Project SEARCH, 2013) Baba‐Djara, Monita; Brennan, Alana; Corneliess, Caitlin; Agyarko‐Poku, Thomas; Akuoko, Kofi; Baffuor Opoku, Kofi; Adu‐Sarkodie, Yaw; Beard, JenniferThis report presents findings from a qualitative study examining vulnerability to HIV of female post‐secondary students engaged in transactional sex in Kumasi, Ghana and their prevention needs. The study was conducted by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) as part of Project SEARCH funded by the United States Agency for International Development Ghana. Participants were recruited from five post‐secondary institutions in the greater Kumasi area. Our objective is to provide academic institutions, the Ghana AIDS Commission (GAC), the National AIDS Control Program, donors, and other stakeholders with rich data to inform research and programmatic efforts in Kumasi specifically, as well as academic institutions in general. We set out to document what forms of transactional sex female students are engaging in, who their partners are, and what motivates them to participate. We asked students about the individual and structural vulnerabilities for HIV reported by female post‐secondary students involved in transactional sex and what their prevention needs are. We also interviewed a small sample of faculty, residence hall matrons, and hotel staff to get their perspective on the behavior of female students practicing transactional sex that might put them at risk for HIV. The findings of this study can be used as well to inform the design of future studies of young women engaging in transactional sex in Ghana. With such limited understanding of HIV transmission among young female post‐secondary students engaged in transactional sex, research is needed to determine how this group contributes to the overall HIV epidemic. The Ghana AIDS Commission has recognized the need for further research among communities engaged in less well‐defined risky sex practices in the National Strategic Plan for Most‐at – Risk Populations (MARP) 2011‐2015.4 This study attempts to fill in gaps in the research regarding transactional sex, taking into account the complexities and nuances of the practice, in addition to examining the needs of female students for targeted HIV prevention programs.Item Understanding the relationship dynamics between female sex workers and their intimate partners in Kumasi, Ghana(USAID Project SEARCH, 2014) Adhiambo Onyango, Monica; Adjei, Rose; Green, Kimberly; Agyarko‐Poku, Thomas; Wambugu, Sam; Falconer, Ariel; Adu‐Sarkodie, Yaw; Hunsberger Kopelman, Carol; Beard, JenniferThis report presents findings from a qualitative study examining vulnerability to HIV and the prevention needs of men involved in intimate relationships with female sex workers (FSW) in Kumasi, Ghana. The study was conducted by a collaborative team of researchers from Boston University’s Center for Global and Health and Development (CGHD), Kwame Nkrumah University of Science and Technology (KNUST), and FHI 360. It is the last of nine small qualitative studies conducted under the Operations Research among Key Populations in Ghana project designed to gather in-depth, personal information from members of key populations about their vulnerability to HIV and other threats to their health and well-being. This project was funded by the United States Agency for International Development Ghana in collaboration with the Ghana AIDS Commission (GAC). The findings will be used to strengthen harm reduction interventions for sex workers and their intimate partners. Intimate partners of FSW are a population of growing interest in Ghana, where interventions focused on sex workers and both their paying and non-paying partners are being implemented by FHI 360 and other local organizations with support from the GAC and USAID. In 2012 Boston University and KNUST conducted a qualitative study looking at the backgrounds, living conditions, vulnerabilities, and HIV prevention needs of young female sex workers in Kumasi. Most (22/24) of the young women participating in in-depth interviews reported having a boyfriend or intimate partner, and half reported either never or only sometimes using condoms with these partners (1). In addition, quantitative data from two previous integrated bio-behavioral surveillance studies (IBBSS) conducted in 2009 and 2011 provide critical data showing the degree to which these men and their female partners (both those involved in sex work and others) are highly vulnerable to HIV and other sexually transmitted infections. The specific objectives were to: explore the emotional, financial and other power dynamics within these relationships; describe the sexual behaviors and HIV knowledge and vulnerabilities of both partners; and document the perceived availability and accessibility of social support and health services.