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Since 2003, the HIV Voluntary Counselling and Testing (VCT) has been identified as one of the key strategies in the HIV/AIDS prevention, control and care programmes in Ghana. However, utilization of …

Since 2003, the HIV Voluntary Counselling and Testing (VCT) has been identified as one of the key strategies in the HIV/AIDS prevention, control and care programmes in Ghana. However, utilization of this service is low among Ghanaian youth. This study examined predictors associated with VCT utilization among youth in Ghana. This study utilized quantitative and qualitative data in a cross-sectional survey in three sub-metropolitan areas in Kumasi. Using a multi-variate regression, evidence from 120 respondents showed potential factors associated with VCT utilization. The qualitative data were subjected to a content analysis through direct quotes. The results suggest that less than 30% of the youth had ever tested for HIV through VC. Women were more likely to avail themselves for counselling testing than men. Psychological and emotional trauma experienced by the seropositive, lack of confidentiality, proximity to VCT sites, HIV-related stigma inter alia, were found to be strongly associated with HIV VCT in the study prefecture. VCT utilization among the youth in Ghana was low and affected by HIV/AIDS-related stigma and residence. In order to increase VCT acceptability, HIV/AIDS prevention and control programs in the country should focus on reducing HIV/AIDS-related stigma.

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  • 2. 1. IntroductionSub-Saharan Africa continues to bear a disproportionate share of the global HIV burden. Inmid-2010, about 68% of all people living with HIV resided in sub-Saharan Africa, a regionwith only 12% of the global population (WHO/UNAIDS, 2012). HIV/AIDS pandemicsignificantly and unabatedly continues to spread in many parts of Africa. Ghana is identifiedas one of the countries with the lowest official HIV prevalence rate of 1.9%, where anestimated 260,000 Ghanaians were living with HIV/AIDS by the end of 2009, whilst 23,236new infections occurred in the same year (WHO/UNAIDS, 2012). Notwithstanding, theprevalence rate among Ghanaian youth (15 – 24 year olds) increased from 1.9% in 2008 to2.1% in 2009 (GHS and MoH, 2009). Moreover, AIDS has been identified as one of thehighest causes of mortality in Ghana, claiming about 21,000 lives in 2007 (UNAIDS, 2008).The Ghana AIDS Commission (2010) estimated that about 1.2 million of the projected 25million Ghanaians will be living with HIV/AIDS by the end of 2014.This HIV/AIDS prevalence and mortality rates pose a great threat to Ghana‘s developmentagenda. The pressure on Government of Ghana (GoG) to develop the country is exacerbated,considering the amount of resources being channelled to HIV/AIDS prevention andtreatment. In 2008, for instance, the GoG spent $38,850,940 on HIV/AIDS and the annualcost of treating HIV/AIDS opportunistic infections is also expected to triple by the year 2014(MoH, 2001; Ghana AIDS Commission, 2010; 2008). Barnett and Whiteside (2006) havealso indicated that Ghana and other countries, south of Sahara are not likely to meet thehealth-related Millennium Development Goals (MDGs)1 by 2015 because HIV/AIDS-induced infant, mother-to-child-transmission and child mortality will continue to increase inthe years ahead. Consequently, the Ghana AIDS Commission (2010) has identified the need1 The three health-related MDGs include goals 4, 5 and 6 of reducing infant mortality, improving maternalhealth and combating HIV/AIDS, malaria and other diseases respectively. 2
  • 3. for a combination of evidence informed and targeted interventions in HIV programme as keyfor effective HIV prevention and treatment. In this regard, the GoG adopted Counselling andTesting (CT) in 2003 as a conduit to complement ongoing ABC HIV prevention campaigns(UNAIDS, 2000). HIV CT is the process by which an individual undergoes confidentialcounselling, enabling him or her to cope with stress and make an informed choice aboutbeing tested for HIV and to take appropriate action thereof (UNAIDS, 2000; UNFPA andIPPF, 2004).In recent years, testing for HIV, in combination with pre- and post-test counselling, hasbecome increasingly important in national and international prevention and care efforts. CThas been recognized as the crux of HIV surveillance, prevention and treatment programs(WHO/UNAIDS, 2009). The benefits of HIV CT are manifold and well documented in theliterature. Denison et al., (2008), in their study on the voluntary counselling and testing andbehavioural risk reduction in developing countries, point out that CT serves as an effectiveprevention strategy for HIV-1 since the combined effect of one‘s knowledge of their HIVstatus and counselling under CT helps individuals change their behaviour to skirmish furthertransmission of the virus. Additionally, when an individual tests seronegative high qualitycounselling helps them to maintain a lifestyle that will keep them seronegative (Denison etal., 2008; Wolitski et al., 1997; Baggaley, 2001; de Paula et al., 2008; 2010). Baggaley(2001) has explicated the need for HIV prevention to address injecting drug use andhomosexual transmission. Individuals who test HIV positive after an HIV CT have thechance to access medical treatment that can prevent mortality. This is a way of ensuring thatHIV seropositive people stay longer to contribute their quota to the development agenda oftheir countries and the world at large (Baggaley, 2001). Moreover, knowledge of serostatusthrough CT can be a motivating force for HIV-positive and-negative people alike to adopt 3
  • 4. safer sexual behaviour, which enables seropositive people to prevent their sexual partnersfrom getting infected and those who test seronegative to remain negative (Ghana StatisticalService [GSS], 2008; UNAIDS, 2001; WHO/UNAIDS, 2007; UNFPA and IPPF, 2004).Lack of knowledge of serostatus by people living with HIV is a major obstacle to actualizingthe goal of universal access to treatment and prevention. A significant proportion of peopleliving with HIV continues to present late for treatment because they are unaware that they areseropositive (Cohen, 2008; UNFPA, 2002), thus reducing the effectiveness of antiretroviraltherapy on morbidity, survival and preventing HIV infection.Since 2003, GoG has launched a number of HIV prevention and treatment programsincluding CT services (Koku, 2010). In the face of these efforts vis-avis the benefits of CT,desire for and uptake of HIV testing remains disproportionately low. The GhanaDemographic and Health Survey found that 14% of men and 21% of women aged, 15-49have ever undergone HIV CT. Moreover, only 7% and 4% of women and men respectively ofthose recently tested have received results (GSS, 2008). The relatable factors that influencethe decision to accept CT are mixed and still far from comprehension. Studies have correlatedpoor intention of testing in general to such psycho-social and physical factors aspsychological and emotional trauma experienced by the seropositive individual or the fear oftesting outcomes, lack of confidentiality, proximity and access to CT site and HIV-relatedstigmatization and discrimination experienced by seropositive people leading to loss offamily and employment (Koku, 2010; Mansergh et al., 1998; Dannenbueg et al., 1996;Maman et al., 2000 and Yeager et al., 2000; Nuwaha et al., 2002; Kalichman and Simbayi,2003). Others include socio-demographic and economic determinants such as age (Shisana etal, 2005; Hutchinson and Mahlalela, 2006; Ma et al, 2007; Wringe et al, 2008; Bwambale et 4
  • 5. al, 2008) marital status, educational level, occupation, household wealth, and area ofresidence (Hutchinson and Mahlalela, 2006; Wringe et al, 2008; Gage and Ali, 2005; Haile etal, 2008).Research has shown that the introduction of routine testing has particularly increased testingexperience among women through prevention of mother-to-child transmission programs(Byamugisha et al, 2010a; Chandisarewa et al, 2007). Conversely, men are reluctant and thusdo not show up to the antenatal clinics with their wives for CT (Falnes et al, 2011;Byamugisha et al, 2010b; Theuring et al, 2009). Improving CT utilization by men has thepotency to influence directly or indirectly women’s CT utilization (Demissie et al, 2009; Lataet al, 2012). There is thus urgent need to understand the predictors of acceptability anduptake of HIV CT by men since it connotes with nitty-gritty for designing policy measuresand options to stem future spread of HIV infections and foster its treatment, care and support.The 2009 national Official HIV Sentinel Survey conducted by Ghana AIDS Commissionrevealed that the Ashanti Region recorded 3.0% prevalence rate of HIV with 4.0% in thecapital city, Kumasi (Ghana AIDS Commission, 2010). What makes the situation morelooming is the fact that most of the young people in the area are express little willingness toaccept and uptake HIV CT to ascertain their HIV serostatus. Campaigns that entreat them toknow their status have been coldly and grimly embraced, and CT services that are taken tothe various communities have recorded minimal turn out rates. The possible consequence ofthis is that most of these young folks ignorantly spread the disease. Nevertheless, studies onHIV CT in Ghana have focused on the other side of the subject; see Wyss et al. (2007),Holmes et al. (2008), Appiah et al. (2009) and Koku (2010). This informed the thesis and thelocus of this research and the selection of Kumasi Metropolis as the study prefecture. 5
  • 6. 2. Methods2.1 Study settingThe study will be conducted between December, 2012 and March, 2013 in the KumasiMetropolitan District of Ashanti Region, Ghana. This is one of the 27 political andadministrative districts in the Ashanti Region with Kumasi as capital. The Metropolis islocated in the transitional moist semi-deciduous forest zone and spans an area of 254km2forming approximately 1.04% of the total landmass of the region. It is located in the south-central portion of Ashanti Region. The Metropolis shares boundaries with Afigya Kwabreand Kwabre East Districts to the North, Ejisu-Juaben to the East, Atwima Kwanwoma to thesouth and Atwima Nwabiagya District to the West. Specifically, the Metropolis stretchesbetween latitude 6.35o – 6.40o and longitude 1.30o – 1.35o, an elevation which rangesbetween 250 – 300 metres above sea level (see figure 1) (KMA/Ghana District, 2012). Thepredominant economic activities in the Metropolis are trading, commerce and other services.The unique centrality of Kumasi as a traversing point from all parts of the country makes it aspecial place for many to migrate to. Kumasi is the most populous district in the region andaccounts for almost a third of the region’s population. According to the 2010 Population andHousing Census Report, Kumasi accommodates a total of 2,035,064 people, reflecting aninter-censal growth rate of 5.4% (GSS, 2012).The Metropolis is made up of 10 Sub-Metros with 189 health facilities. It is worth noting thatthe private sector operates a significant number by taking over 90% share of the facilities.Komfo Anokye Teaching Hospital (KATH), 1 of the national autonomous hospitals, issituated in Kumasi Metropolis. There are other 4 quasi-government health institutions, 172private health institutions and 3 CHAG in the Metropolis (Kumasi Metropolitan HealthDirectorate, 2012). These health institutions are evenly distributed across the district to 6
  • 7. enhance easy access and use of health care services. The common diseases in the Metropolisinclude malaria, diarrhoea, HIV/AIDS, tuberculosis, hypertension and diabetes mellitus.Septic abortion and road traffic accidents also constitute another major challenge to the healthsector (Kumasi Metropolitan Health Directorate, 2012).Among other services, CT provided at 10 health facilities videlicet, Kumasi South, Suntreso,Tafo, Manhyia, Bomso Clinic, Aninwaa Medical Centre, KNUST hospital, Kwadaso,Seventh Day Adventist Hospital and KATH whilst Anti retroviral treatment is provided at theKATH, the Kumasi South Hospital and the Bomso Clinic only (Kumasi Metropolitan HealthDirectorate, 2012).2.2 Study design and samplingThis retrospective cross-sectional survey will employ triangulation of both quantitative andqualitative approaches of research. Individuals, both male and female between the agebrackets of 15-29 found in the selected communities in the study prefecture will constitute thestudy sample. The target population from which the sample will be drawn is 601,336. Asample size of 360, representing .061% of the population will be used. A multi-stagestratified cluster and simple random sampling technique will be utilised to select 6 Sub-Metros and 12 study settlements from the Metropolis for the study. The selected Sub-Metroswill be Asokwa, Subin, Manhyia, Nhyiaeso, Kwadaso and Oforikrom.Two communities will be selected randomly from each Sub-Metro for the study. The researchcommunities will include: Atonsu, Kaase, Asafo, Amakom, Krofrom, Ashanti New Town,Ayigya, Kotei, Ahodwo, Fankyinebra, Kwadaso and Asuoyeboa (see figure 1). The sub-sample for each community will be proportionately determined based on population size. 7
  • 8. Unit of analysis will be households and one (1) respondent will be selected from eachhousehold through systematic random sampling method. The sample interval of thecommunities will base on the density of houses and households and that the intervals will bepegged at 5 for communities with high density of houses and 3 for research settlements withlow house densities. The underpinning factor in the selection of these communities is toensure fair and adequate coverage of the Metropolis to boost accuracy and representativenessof research findings.2.3 Data collectionPrimary data will be sourced and collected from households in the various selected studycommunities for this research. In-depth interviews and questionnaire instruments willrespectively be considered in obtaining qualitative and quantitative data in the primary datacollection. The illiterate and semi-literate respondents who find it relatively difficult to readand interpret the questionnaire guide will be interviewed. However, some literates will havethe option to be interviewed so as to play down possible challenges of call-backs. Thequestionnaire and interviews will be translated into Twi, the major language spoken in thestudy prefecture and verified by a second translator. Where inconsistencies are found, thesewill be corrected. Pre-testing of the questionnaire will be completed with 5 qualified personsbut not be included in the study. However, English will be used to administer the interviewswhere necessary. Besides, secondary information will be utilised to place the study in thecontext of scholarly world.Ethical approval will be obtained from the Committee on Human Research and PublicationEthics, School of Medical Sciences, Kwame Nkrumah University of Science andTechnology, Kumasi prior to the data collection exercise. Israel and Hay (2006) have 8
  • 9. reverberated that Social Scientists do not have an inalienable right to conduct researchinvolving other people. The opinion leaders, household heads and respondents in eachselected community will be notified and briefed on the objectives of the research and bemade to sign consent form before the commencement of the data collection. Questionnairewill be anonymised, with no personal identifying information recorded on them. Also,contributions made by participants will be treated anonymous and confidential. Besides, arespondent will reserve the right to withdraw at any point in time or deny certain informationin the course of the interview. Each interview will approximately last for 45 minutes.Detailed notes will be taken and those in local dialect then translated and back translated intoEnglish for analysis.2.4 Outcome measuresRespondents will be interviewed with an anonymously structured questionnaire that requestsinformation on demographic variables, socioeconomic status, knowledge of HIV, HIV riskhistory, impact of HIV, HIV CT history and knowledge and determinants of intension toaccept and utilise CT (Peltzer et al, 2009).The survey will include questions concerning history of HIV antibody testing. Thesemeasures will be used to classify participants into groups based on whether they had beentested for HIV and know their results. Participants who will report having been tested forHIV will be made to indicate their HIV awareness status of their most recent test, or that theydid not know the results.To assess HIV risk history, participants will indicate the number of sex partners they had inthe previous 12 months, had symptoms of a sexually transmitted infection, and whether they 9
  • 10. have ever used a condom, a condom with their last sexual partner and their last sexual non-regular partner. All responses will be dichotomous indicating the occurrence or non-occurrence of each risk factor. A 4-item HIV knowledge test will be used; e.g. is it possible totransmit HIV through unprotected sex? Response options will be “Yes”, “No”, and “Does notknow”. “Does not know” responses will be scored as “No”; CT knowledge will be assessedwith one item: “Have you ever heard about test for people with HIV called HIV CT?”Response options will be “Yes” or “No”. A 3-item will be used to measure HIV impactitems; thus, Has anyone in the household ever been diagnosed with HIV/AIDS, is there aperson in the household who is bed-ridden with an AIDS related illness and past yearoccurrence of AIDS-related death of household member. Response options will be “Yes” or“No”. For AIDS stigma attitudes, 4-AIDS-stigma items will be used; “Would you be willingto care for a family member with AIDS”. Response options were, “Yes”, “No”, or “Do notknow”.Demographic and social variables linked to HIV CT will be included in the survey. Thesewill include sex, age, marital status, ethnic background, religious affiliation, and place ofresidence whist socioeconomic status included will be household income standing, formaleducation completed and employment status.2.5 Data AnalysisData analysis will be performed using Predictive Analytic Software (PASW) for Windowssoftware application program version 17.0. Data will be ordered, edited, coded, and enteredinto the software and analysed quantitatively using multiple regression. Stepwise method willbe employed to determine the relative strengths of the independent variables on HIV CT. Themultiple regression analysis will be preceded by a bivariate correlation matrix to examine the 10
  • 11. strength of associations between the dependent variable HIV CT utilization and relevantpotential predictor variables. The probability (p) value less or equal to 0.05 will be used toindicate statistical significance in the regression model. Frequencies, means, and standarddeviations will be computed to describe the sample. The qualitative data will be subjected toa content analysis. The analysis will be done using the grounded-theory approach. Thismethod is based on techniques to systematically discover categories, themes or patterns thatemerge from the data, through coding and categorisation of information into manageableunits (Strauss and Corbin, 1998). In this respect, the categories for analysis will be drawnfrom the interview guides and then, themes and patterns emerge after reviewing the datawithin and across groups of respondents (Carey, 1994; Charmaz, 1990). Results will bepresented through direct quotes.ReferencesAppiah, L. T., Havers, F., Gibson, J., Kay, M., Sarfo, F. and Chadwick, D. (2009). Efficacy and acceptability of rapid, point-of-care HIV testing in two clinical settings in Ghana. AIDS Patient Care & STDs, 23(5). Pp. 365 - 9Baggaley, R. (2001). Voluntary counselling and testing (VCT). Paper for the UNAIDS expert panel on HIV testing in United Nations peacekeeping operations. 17-18th September 2001, New York.Barnett, T. and Whiteside, A. (2006). AIDS in the twenty-first century: disease and globalization. New York: Palgrave Macmillan.Bwambale, F. M., Ssali, S. N., Byaruhanga, S., Kalyango, J. N. and Karamagi, C. A. (2008) Voluntary HIV counselling and testing among men in rural western Uganda: implications for HIV prevention. BMC Public Health, 30(8):263.Byamugisha, R., Tumwine, J. K., Semiyaga, N., Tylleskar. T. (2010a). Determinants of male 11
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