Awareness, willingness, and uptake of pre-exposure prophylaxis (PrEP) among men who have sex with men in Ghana

Abstract

Background

HIV prevalence among men who have sex with men (MSM) in Ghana is 18.1% as compared to 1.6% in the general population. Pre-exposure Prophylaxis (PrEP) is recommended by the World Health Organization (WHO) for people who are HIV-negative and at high risk of acquiring HIV. Since PrEP introduction in Ghana in 2020, little is known nationally about the level of awareness, uptake, and willingness to take PrEP among MSM. This study aims to generate estimates on PrEP awareness, uptake and willingness to use among MSM in Ghana.

Methods

We conducted a bio-behavioral survey among MSM aged 18 years and above in all the 10 traditional regions in Ghana from August 2022 to July 2023 using respondent-driven sampling (RDS). RDS-Analyst was used to compute weights based on the participants’ network. Data analysis was restricted to MSM who were HIV-negative and sexually active to estimate the prevalence of awareness, willingness, and uptake of PrEP. A multivariable logistic regression model was used to assess the factors influencing these outcomes.

Results

Out of the 3,420 total MSM surveyed, 2,627 were HIV negative and were included in the analysis, Out of which 44.5% (95% CI: 42.0–47.0) were aware of PrEP, 90.4% (95% CI: 88.0–92.3) were willing to take PrEP and 17.8% (95% CI: 16.0 – 19.8) had ever taken PrEP. In the regression analyses, PrEP awareness was 5-fold higher among those who completed tertiary education (aOR: 5.56, 95% CI: 2.87–10.78, p < 0.001) and 4-fold among those who interacted with peer educators (aOR: 3.78, 95% CI: 2.52–5.67, p < 0.001). In terms of uptake, the odds were almost 9 times among those who had experienced forced sex (aOR: 8.88, 95% CI: 1.42–55.47, p = 0.02). MSM aged 25–34 were less willing to take PrEP (aOR:0.21, 95% CI 0.07–0.65, p = 0.006) and PrEP use was also less likely among those who consumed high alcohol (aOR:0.42, 95% CI 0.19–0.92, p = 0.03) and never tested for HIV (aOR: 0.44, 95% CI” 0.25–0.88, p = 0.017).

Conclusion

In Ghana, awareness and willingness to take PrEP to prevent HIV is high, but uptake is low. These results highlight the need for interventions to improve the overall uptake of PrEP among MSM in Ghana, especially among those aged 25–34, high alcohol consumers and those who have never screened for HV. Effective implementation of these findings into the national policies can enhance access and encourage PrEP use, ultimately reducing HIV incidence in Ghana among MSM.

Background

Human Immunodeficiency Virus (HIV) remains a global public health issue. In 2022, about 39 million people globally were living with HIV [1]. There were 1.3 million new infections and 630,000 deaths from Acquired Immune Deficiency Syndrome (AIDS) related illness in the same year [1]. Among these cases, sub-Saharan Africa (SSA) alone accounts for the highest burden of the HIV epidemic [1]. The prevalence is higher among key populations (KP). These include men who have sex with men (MSM), transgender people, female sex workers (FSW), and others. Key populations account for 70% of the global HIV burden with infection risk of 28 times higher than the general population [1]. Globally, MSM experienced a 25% increase in HIV infection between 2010—2019 [1]. The situation is not different in Ghana, where MSM are 11 times more likely to be living with HIV than the general population [2]. Given the high prevalence, the initiatives to curb this epidemic in SSA have increased [3–5]. In Ghana, HIV prevalence and access to PrEP vary significantly by region and socio-demographic factors. Urban areas like Greater Accra (2.4% HIV prevalence) and Ashanti (2.3%) have better access to healthcare compared to rural regions such as the Northern region (0.2%) [6].

Acknowledging the evidence of low condom use among MSM [2, 7, 8], the World Health Organization (WHO) has recommended Pre-exposure Prophylaxis (PrEP) as an additional preventive measure for both KP and the general population [9]. PrEP has proven to be effective in reducing HIV transmission [10]. PrEP reduces the chance of HIV transmission through sex by 99% or injectable drug use by 74% [11, 12]. PrEP has been mainly administered through daily oral medication [13]. Injectable PrEP offers a promising solution for MSM in Ghana, addressing adherence challenges associated with daily oral medication. Administered every two months, it reduces stigma and fear of disclosure linked to pill use. This long-acting alternative could enhance uptake among MSM facing social barriers to HIV prevention [14]. The scientific evidence of PrEP efficacy as a robust HIV prevention tool has gained additional impetus from recent studies. Initial randomized clinical trial data reported efficacy ranging from 44%-75% [15]. As of 2021, 144 countries globally reported to have adopted the WHO recommendations on oral PrEP in their national guidelines [16]. Despite its potential, PrEP implementation faces multiple barriers at different levels, including the healthcare system, providers, and patients [17, 18] Globally, especially in LMICs, the uptake of PrEP as a preventive measure for HIV remains low [19, 20].

Research from countries with similar sociocultural, legal and healthcare challenges like Nigeria and Kenya shows the need to improve PrEP implementation among MSM. In Kenya national PrEP rollout has indicated the need to address, structural barriers and stigma, healthcare workers’ attitudes to improve PrEP uptake. Kenya HIV Prevention Revolution Road Map is focused on making PrEP accessible for MSM in medium to high-risk areas [21]. Similarly, studies in Nigeria has also highlighted stigma, cost, access, lack of interest, and side effects to be the key barriers to PrEP uptake [22, 23]. In Ghana, stigma towards MSM and PrEP usage has been shown to discourage enrollment, with additional barriers including limited access to healthcare facilities and negative healthcare experiences [24].

In 2019, the Ghana National AIDS/STI Control Program (NACP) included PrEP delivery in the consolidated Guidelines for HIV in Ghana, enabling PrEP delivery to KPs in August 2020, focusing on MSM [25]. Before the rolling out of PrEP in Ghana, research identified a lack of awareness and knowledge among MSM as the major barrier to its acceptance [26].

Previous research has also analyzed several aspects of PrEP following enrollment in Ghana. A study conducted on the attitude of policymakers and healthcare providers on PrEP for KPs found substantial support for PrEP rollout by policymakers and healthcare workers. Key concerns raised include cost, long-term financial implications, and stigma [24]. A study has also shown that MSM are motivated to take PrEP based on the type of sexual activity and history of being negative HIV [27]. Distance and healthcare facilities were found to be the major barriers for PrEP uptake and access [27].

Previous studies in Ghana have mostly focused on urban areas, our study extends to all the ten traditional regions in Ghana, providing nationally representative data. Also, this study includes other distinctive variables such as peer educator contact, comprehensive HIV education, influence of forced sex encounters on PrEP which have been underexplored in previous research.

Despite the increasing burden of HIV infection among MSM in Ghana, there is a dearth of national evidence on the awareness, uptake, and willingness to take PrEP among this population. Previous studies in Ghana on PrEP have focused on specific cities and urban areas, not reaching the country’s broader demographic and geographic diversity. While PrEP has been shown to be highly effective in reducing HIV transmission by up to 99% [28], research in Ghana has shown several barriers to PrEP implementation which potentially affect uptake [29]. Stigma towards MSM and PrEP uptake discourages MSM from enrolling on PREP. Given the varying demographics and intensity of interventions across different regions of Ghana, it is essential to assess the contribution of PrEP to HIV prevention among MSM nationwide. This study aims to estimate PrEP awareness, uptake and willingness to use among MSM in Ghana. This study will also identify predictive factors and provide evidence for tailored interventions to increase PrEP uptake among Ghana’s MSM.

Methods

Survey design

This cross-sectional survey used Respondent Driven Sampling (RDS). Enrollment started with purposeful seed selection. Seeds were identified during the pre-survey assessment.

Recruitment

The team started the sampling procedure with seeds that were as different as possible from one another. This was expected to help not only to optimize the implementation of RDS but also to maximize the diversity of the participants and to ensure a fair chance of participation among all potential participants. Five to seven seeds at each site received 3 coupons and were trained to share the coupons with members of their social network who were also MSM. The site supervisor provided education to the seeds about the basic details of the survey and promoted a feeling of survey ownership and enthusiasm.

Seed selection

With the support of Stakeholders, Non-Government Organizations (NGO’S), Civil Society Organizations (CSO’s) and Community-Based Organizations (CBO’s), and key population implementing partners, seeds were recruited on the basis that they were;

1. well-connected within their social networks (among their peers)

2. well-regarded by their peers

3. supportive of the survey’s goals

4. in separate social networks (that is, did not know each other)

5. not members of CBO or NGO (to prevent oversampling of CBO / NGO member networks).

Survey procedures

Interviewers/ field enumerators

Most of the interviewers were selected from the MSM community with the help of CSOs and CBOs, gatekeepers, and community leaders. For a member to be qualified, he/she must have at least a Higher National Diploma (HND) certificate. The selected field enumerators were all trained in building rapport, interviewing skills, and research ethics.

Training field supervisors and enumerators

At every phase of the survey (formative assessment, mapping and population size estimation, and bio-behavioral survey), field staff were trained for that phase considering the objectives of that phase and the processes and tools involved. Training for each phase ranged between 2 to 5 days per session and was organized in all three zones (Southern, Middle, and Northern).

Data collection

Trained interviewers conducted face-to-face interviews with the respondents using a mobile data collection software called Research Electronic Data Capture (REDCap). The use of the mobile application helped reduce the time in data collection and processing and facilitated real-time monitoring of the data collection. Data quality issues were identified by trained data monitors in real-time and data cleaning occurred simultaneously with data collection. All research assistants received adequate training in using the data collection tools and the mobile application.

Pre-testing

The questionnaire was pre-tested within the Greater Accra region to ensure that questions were easy to understand, appropriate level of sensitivity, and acceptable duration of the interview. Interviewers reported all issues encountered to the project team and suggested modifications were made to improve clarity. An electronic finger-coding scanner was used. This ensured that participants who took part in the pre-testing survey did not take part in the main survey.

First visit

All potential recruits presented a valid coupon at the survey office. This enabled a staff member to assess whether the recruit was eligible using a screening tool designed by the survey team. Those eligible were then provided with a more thorough description of the survey and procedures using the informed consent form. When recruits provided consent, they did so for both questionnaire and biomarker testing. Trained laboratory technicians collected blood samples to conduct onsite rapid testing for HIV, hepatitis B and syphilis. Specimen collection for HIV, HBV, and syphilis was collected after pre-test counseling then followed by the face-to-face administration of the survey questionnaire. After responding to the quantitative questions, survey participants went to the survey counselor for the laboratory results. The counselor provided the results and post-test counseling. Participants whose HIV test result was positive received counseling and were linked to an antiretroviral therapy (ART) site and those who tested positive for HBV and syphilis were also referred to an appropriate health facility for treatment at the end of the first visit. After this process, the counselor referred the participant to the coupon manager, who then trained the participant on peer recruitment. They were given three coupons each to recruit peers and schedule a second visit to the survey site. Survey participants received their primary compensation before exiting.

Unique identification of participants

Each participant was uniquely identified to prevent participants from taking part in the survey more than once. When participants consented to enroll in the survey, they had 4 fingers scanned (index and middle of both hands) through a biometric fingerprint scanner. In situations where one of these fingers could not be scanned, the rest of the three were used. The scanner did not store an image of the fingerprint but rather converted it into a unique participant code (UPC) for each participant. In addition to the biometric scanner, each participant was also given a unique participant ID and Coupon Number. The Participants’ ID and the Coupon Number were customized for each survey site.

Study settings and sample size

The study was conducted in Ghana’s 10 traditional regions (Western, Central, Eastern, Greater Accra, Volta, Ashanti, Brong Ahafo, Northern, Upper East and Upper West). Ghana is a West African country on the Coast of Guinea, bordered by Cote d’Ivoire to the west, Burkina Faso to the north, and Togo to the East. It has a population of about 32.8 million [30].

The sample size was calculated with an expected change in the indicator of consistent condom use (48.2%) among MSM [2] and detecting a change of 15%with an alpha of 5% and 80% power. A design effect of 1.5 was factored in and a nonresponse rate of 10%. This resulted in an average sample size of 342 participants per site. After adjusting for strata [10], the final sample size amounted to 3420 participants for the entire survey.

Target populations

The study included MSM, defined as biologically born males who self-reported consensual anal sex with another man within the last 12 months. All MSM must be at least 18 years of age at the time of enrolment in the survey and could communicate in English or any other Ghanaian language.

Data collection and management

The study utilized a structured questionnaire to obtain information from the participants. The questionnaire was adapted from the WHO, Joint United Nations Programme on HIV/AIDS (UNAIDS), Family Health International (FHI) 360, Centers for Disease Control and Prevention (CDC), and US President’s Emergency Plan for AIDS Relief (PEPFAR) biobehavioral survey guidelines for the population at risk of HIV [31]. Trained interviewers conducted face-to-face interviews with the respondents using a mobile data collection software called Research and Electronic Data Capture (REDCap). Data quality issues were identified by trained data monitors in real-time, and data cleaning co-occurred with data collection.

Study variables

Outcome variables

The first outcome of the study was awareness of PrEP. The question for awareness of PrEP was “Have you ever heard of PrEP where a yes response implied ever and no otherwise.

The other outcomes of the study were willingness to take PrEP to prevent HIV and ever taken PrEP. The question for willingness of PrEP was “Would you take PrEP to prevent HIV?" where a yes response implied ever and no otherwise and forever taken PrEP was "Have you ever taken PrEP?" where the yes response implied ever and no otherwise.

Predictor variables

The questionnaire in the study included sociodemographic, behavioral, and biological variables such as age, education, marital status, region, monthly income, currently living with a partner, sex most attracted to, history of vaginal sex, alcohol consumption, contact with a peer educator, ever tested for HIV, experienced stigma, forced sex, comprehensive knowledge in HIV, and HIV rapid testing. For comprehensive Knowledge, it was estimated using a series of questions on various HIV transmission modes, preventive measures, HIV transmission myths and misconceptions.

Statistical analysis

The study adopted both descriptive and inferential statistical methods. Prevalence of each outcome (PrEP awareness, willingness to take PrEP, and ever taken PrEP) was estimated. Frequencies and percentages (sociodemographic and clinical factors) and odds ratios (sociodemographic and clinical factors) were reported at 5% significance level. Simple binary logistic regression was used to determine the existence of a relationship between the outcome variables (PrEP awareness, willingness to take PrEP, and ever-taken PrEP) and the predictor variables. A hybrid approach was used for model selection. Statistically significant variables (p-value < 0.05) in the simple binary logistic regression were included in the multivariable logistic regression models. Additionally, variables were identified from the literature as important predictors of PrEP outcomes. Predictor variables like age [32, 33], education level [33, 34], HIV testing history [33, 35], and contact with peer educators [36], currently living with a partner [37] were included at the multivariable level regardless of their statistical significance. This ensured that the model accounted for both statistically relevant and theoretically informed predictors. All analyses in this study were carried out using weight. The weight of each participant was calculated based on their personal network size using RDS Analyst software. All statistical analysis was done in STATA 16, and a P-value of 0.05 was considered statistically significant.

Determination of sampling weights

Sampling weights were determined using RDS-Analytics. Data for each region was loaded into RDS-A using the following information: Coupon IDs, participant IDs, network size, and estimated population size. Network size was determined using the following five questions: “How many people (MSM) do you currently know who are community members?”; “Of these (MSM you know), how many live, work or socialize in this area?”; “Of these (MSM who live around this area), how many are aged 18 and above?”; “Of these (MSM 18 years and above), how many have you seen in the last 30 days?”; Of these (MSM seen in the last 30 days), how many have you spoken within the last two weeks?” and finally, “Of these (MSM you spoke with within the last two weeks), how many would you consider inviting to participate in this survey? The answer to the last question was used as the network size question.

Results

Characteristics of study participants

Among 2,627 participants who tested negative and had complete data, half were between the ages 20–24, with a small fraction of 2% aged 35 and above. The majority (71.6%) have completed at least senior high school, with about nine out of ten being single and never married. A significant portion (85.6%) were not living with a partner. Geographically, participation varied, with the lowest participants observed from the Upper East (3.4%) and Upper West (3.2%) regions. Half of the participants have encountered a peer educator in the past year, with a slightly higher proportion (61.4%) reported ever being tested for HIV. Less than half of the participants (44.3%) demonstrated comprehensive knowledge. A similar proportion (41.2%) reported monthly earnings below GHS 500.00 (Table 1).

Table 1.

Socio- demographic characteristics of study participants (N = 2627)

	Weighted		Unweighted
Variable	Frequency	Percentage	Frequency	Percentage
Age Group
18–19	348	13.25	378	14.4
20–24	1333	50.73	1,284	48.9
25–34	872	33.18	881	33.5
≥ 35	72	2.75	82	3.1
Nonresponse	3	0.1	2	0.1
Education
Basic (None/Primary)	120	4.58	129	4.9
Junior high school	627	23.85	592	22.5
Senior High School	1424	54.22	1,425	54.2
Tertiary	454	17.29	480	18.3
Nonresponse	2	0.06	1	0.0
Marital Status
Single, never married	2457	93.54	2,438	92.8
Married/cohabiting	140	5.31	154	5.9
Separated/divorced/widowed	24	0.92	25	1.0
Nonresponse	6	0.23	10	0.4
Currently living with a partner
No	2249	85.61	2,214	84.3
Yes	374	14.24	406	15.5
Nonresponse	4	0.15	7	0.3
Region
Greater Accra	427	16.25	434	16.5
Ashanti	305	11.63	360	13.7
Volta	235	8.96	197	7.5
Western	453	17.25	286	10.9
Eastern	272	10.35	221	8.4
Central	267	10.18	274	10.4
Brong Ahafo	327	12.44	262	10.0
Northern	168	6.4	190	7.2
Upper East	89	3.37	200	7.6
Upper West	83	3.17	203	7.7
Sex Attracted to Most
Only Male	703	26.77	664	25.3
Mostly Male	895	34.09	927	35.3
Equally Male and Female	806	30.7	823	31.3
Mostly Female	206	7.85	184	7.0
Nonresponse	16	0.59	29	1.1
History of Vaginal Sex
None	605	23.02	576	21.9
1 Woman	583	22.21	573	21.8
2 women	338	12.87	352	13.4
3 + Women	506	19.26	489	18.6
Never had vaginal sex with a woman	571	21.74	589	22.4
Nonresponse	24	0.9	48	1.8
Sexual Partners
1 Partners	563	21.42	581	22.1
2 Partners	679	25.85	708	27.0
3 Partners	451	17.16	470	17.9
4 + Partners	932	35.49	865	32.9
Nonresponse	2	0.08	3	0.1
Alcohol Consumption
Never	1523	57.99	1,615	61.5
Moderate	861	32.78	784	29.8
High	241	9.16	226	8.6
Nonresponse	2	0.07	2	0.1
Contact with Peer Educator In the past year
No	1297	49.39	1,141	43.4
Yes	1316	50.08	1,458	55.5
Nonresponse	14	0.54	28	1.1
Ever Tested for HIV
Yes	1614	61.44	1,472	56.0
No	1002	38.14	1,137	43.3
Nonresponse	11	0.42	18	0.7
Experienced Stigma and discrimination for being an MSM
Yes	309	11.75	307	11.7
No	2298	87.48	2,293	87.3
Nonresponse	20	0.77	27	1.0
Comprehensive Knowledge
Yes	1165	44.33	1,222	46.5
No	1462	55.67	1,405	53.5
Forced Sex
Never	2,354	89.61	2,361	89.9
Once	55	2.11	64	2.4
A few times	38	1.43	39	1.5
Often	4	0.14	6	0.2
Does not apply because no one knows	173	6.6	150	5.7
Nonresponse	3	0.11	7	0.3
Income
< Ghc500.00	1081	41.17	1,099	41.8
Ghc500-999.00	740	28.18	736	28.0
Ghc1000-1999.00	500	19.03	474	18.0
Ghc2000.00 +	263	10	275	10.5

Out of the 2,627 MSM who tested negative for HIV, 44.5% (95% CI: 42.0–47.0) reported being aware of PrEP. The majority (67.6%) who were aware of PrEP had completed tertiary education. Volta was the region with the highest proportion of participants who reported PrEP awareness (68.5%), followed by Brong Ahafo (57.5%), Ashanti (49.5%), Western (44.8%) and Greater Accra (44.3%) (Fig. 1).

Fig. 1.

Flowchart of analyzed sample from the survey

History of ever taken PrEP was 17.9% (95% CI: 16.0 – 19.8). Almost one third of those who reported having tertiary education or below reported to have ever taken PrEP. Volta was the region with the highest proportion of MSM who had ever taken PrEP with (28.5%, followed by Northern (25.6%), Greater Accra (23%), Brong Ahafo (22.3%) and Ashanti region (22%) (Fig. 2). Also, 22.8% of those who had encountered peer educators in the previous year had ever taken PrEP, 23.5% of those who had never had sex with women, and 34.5% of those who had experienced forced sex had ever taken PrEP (Table 2).

Fig. 2.

Percentage distribution of PrEP awareness, willingness to take PrEP and ever taken PrEP among Men who have sex with men across the 10 traditional regions in Ghana

Table 2.

Factors associated with ever taken PrEP among MSM in Ghana

	Ever taken PrEP		Binary logistic regression model of factors associated with Ever Taken of PrEP
			Unadjusted model		Adjusted model
Characteristics	n/N (%)	P-value	cOR [95% CI]	P-value	aOR [95% CI]	P-value
Age group		0.009
18–19	38 /348 (10.9)		1.00 [reference]		1.00 [reference]
20–24	239 /1333 (17.9)		1.85 [1.21, 2.82]	0.004	1.22 [0.71, 2.12]	0.473
25–34	172 /872 (19.7)		2.14 [1.40, 3.29]	< 0.001	1.20 [0.67, 2.14]	0.533
≥ 35	20 /72 (27.8)		2.06 [1.12, 3.80]	0.020	1.60 [0.62, 4.17]	0.333
Nonresponse	0 /3 (0.0)		-		-
Education		< 0.001
Basic (None/Primary)	9 /120 (7.5)		1.00 [reference]		1.00 [reference]
Junior high school	75 /627 (12.0)		1.86 [1.02, 3.38]	0.042	1.56 [0.66, 3.73]	0.314
Senior High School	263 /1424 (18.5)		2.72 [1.56, 4.72]	< 0.001	2.44 [1.07, 5.53]	0.033
Tertiary	122 /454 (26.9)		3.87 [2.18, 6.89]	< 0.001	2.72 [1.15, 6.44]	0.023
Nonresponse	0 /2 (0.0)		-
Marital status		0.585
Single, never married	438 /2457 (17.8)		-		-
Married/cohabiting	27 /140 (19.3)		-	-	-	-
Separated/divorced/widowed	2 /24 (8.3)		-	-	-	-
Nonresponse	2 /6 (33.3)		-	-	-	-
Currently living with a partner		0.975
No	402 /2249 (17.9)		1.00 [reference]		1.00 [reference]
Yes	67 /374 (17.9)		1.23 [0.94, 1.62]	0.136	0.96 [0.64, 1.44]	0.855
Nonresponse	0 /4 (0.0)		-		-
Region		< 0.001
Greater Accra	98 /427 (23.0)		1.00 [reference]		1.00 [reference]
Ashanti	67 /305 (22.0)		1.02 [0.73, 1.42]	0.928	0.85 [0.52, 1.39]	0.516
Volta	67 /235 (28.5)		1.18 [0.79, 1.75]	0.420	1.09 [0.66, 1.81]	0.745
Western	66 /453 (14.6)		0.67 [0.44, 1.01]	0.055	0.66 [0.37, 1.18]	0.160
Eastern	18 /272 (6.6)		0.51 [0.31, 0.85]	0.009	0.38 [0.16, 0.88]	0.024
Central	31 /267 (11.6)		0.48 [0.30, 0.77]	0.002	0.51 [0.28, 0.95]	0.033
Brong Ahafo	73 /327 (22.3)		0.91 [0.61, 1.34]	0.616	1.19 [0.67, 2.08]	0.554
Northern	43 /168 (25.6)		1.24 [0.81, 1.89]	0.315	1.74 [0.99, 3.06]	0.054
Upper East	0 /89 (0.0)		-		-
Upper West	5 /83 (6.0)		0.21 [0.11, 0.43]	< 0.001	1.10 [0.40, 3.02]	0.846
Sex Attracted to Most		0.171
Only Male	136 /703 (19.3)		-		-
Mostly Male	177 /895 (19.8)		-	-	-	-
Equally Male and Female	130 /806 (16.1)		-	-	-	-
Mostly Female	24 /206 (11.7)		-	-	-	-
Nonresponse	1 /16 (6.3)		-	-	-	-
History of Vaginal Sex		0.006
None	111 /605 (18.3)		1.00 [reference]		1.00 [reference]
1 Woman	111 /583 (19.0)		1.04 [0.76, 1.43]	0.805	0.98 [0.62, 1.53]	0.916
2 women	51 /338 (15.1)		0.74 [0.50, 1.08]	0.119	0.82 [0.50, 1.35]	0.435
3 + Women	62 /506 (12.3)		0.68 [0.47, 0.98]	0.040	0.66 [0.41, 1.08]	0.097
Never vaginal anal sex with a woman	134 /571 (23.5)		0.96 [0.71, 1.29]	0.786	1.33 [0.88, 2.03]	0.177
Nonresponse	0 /24 (0.0)		-	-	-
Sexual Partners		0.405
1 Partner	118 /563 (21.0)		-		-
2 Partners	115 /679 (16.9)		-	-	-	-
3 Partners	77 /451 (17.1)		-	-	-	-
4 + Partners	158 /932 (17.0)		-	-	-	-
Nonresponse	0 /2 (0.0)		-
Alcohol Consumption		0.112
Never	257 /1523 (16.9)		-		-
Moderate	176 /861 (20.4)		-	-	-	-
High	35 /241 (14.5)		-	-	-	-
Nonresponse	1 /2 (50.0)		-	-	-	-
Contact with Peer Educator in the previous year		< 0.001
No	35 /725 (4.8)		1.00 [reference]		1.00 [reference]
Yes	434 /1902 (22.8)		4.56 [2.96, 7.03]	< 0.001	2.70 [1.35, 5.38]	0.005
Nonresponse	0 /1 (0.0)		-		-
Ever Tested for HIV		< 0.001
Yes	437 /1614 (27.1)		1.00 [reference]		1.00 [reference]
No	31 /1002 (3.1)		0.08 [0.05, 0.12]	< 0.001	0.11 [0.07, 0.17]	< 0.001
Nonresponse	0 /11 (0.0)		-	-	-	-
Experienced Stigma and discrimination For being MSM		0.001
Yes	85 /309 (27.5)		1.00 [reference]		1.00 [reference]
No	380 /2298 (16.5)		0.59 [0.45, 0.77]	< 0.001	0.80 [0.54, 1.18]	0.261
Nonresponse	3 /20 (15.0)		-	-	-	-
Comprehensive Knowledge		0.001
Yes	259 /1165 (22.2)		1.00 [reference]		1.00 [reference]
No	209 /1462 (14.3)		0.61 [0.49, 0.76]	< 0.001	0.74 [0.54, 1.00]	0.053
Forced Sex		0.014
Never	423 /2354 (18.0)		1.00 [reference]		1.00 [reference]
Once	19 /55 (34.5)		2.12 [1.28, 3.51]	0.003	1.67 [0.72, 3.87]	0.228
A few times	10 /38 (26.3)		1.26 [0.48, 3.29]	0.643	1.27 [0.38, 4.30]	0.695
Often	1 /4 (25.0)		0.27 [0.03, 2.21]	0.223	8.88 [1.42, 55.47]	0.020
Does not apply because no one knows	15 /173 (8.7)		0.56 [0.30, 1.04]	0.068	0.50 [0.22, 1.13]	0.096
Nonresponse	1 /3 (33.3)		-	-	-	-
Income		0.008
< Ghc500.00	157 /1081 (14.5)		1.00 [reference]		1.00 [reference]
Ghc500-999.00	138 /740 (18.6)		1.31 [0.99, 1.73]	0.060	1.10 [0.74, 1.62]	0.638
Ghc1000-1999.00	118 /500 (23.6)		1.83 [1.37, 2.45]	< 0.001	1.26 [0.84, 1.88]	0.270
Ghc2000.00 +	48 /263 (18.3)		1.32 [0.93, 1.88]	0.116	0.91 [0.56, 1.46]	0.688
Nonresponse	7 /43 (16.3)

n/N (%): Frequency Ever taken PrEP/Total frequency (Percentage)

COR crude odds ratio, aOR adjusted odds ratio, CI confidence interval

Prevalence of awareness, willingness, and uptake of PrEP among MSM in Ghana

Awareness of PrEP among MSM was 44.5% (95% CI: 42.0%—47.0%), while willingness to take PrEP among MSM who had never taken PrEP was 90.8% (95% CI: 88.0%—92.3%) and ever taken PrEP was 17.8% (95% CI: 16.0%—19.8%) (Fig. 3).

Fig. 3.

Prevalence of awareness, willingness, and ever taken PrEP among MSM in Ghana

Factors associated with PrEP awareness among MSM in Ghana

From the Bivariate analysis, PrEP awareness was high among MSM aged 35 and above, those who have completed Tertiary education, reside in Volta region and have ever tested for HIV. Additionally, participants who have comprehensive knowledge of HIV, those who have experienced forced sex once were significantly associated with awareness. Awareness was also low among those aged 18–19, those with basic education, reside in Upper West region, and earn less than GHC 500.00 monthly. From the multivariable logistic regression model, MSM who had completed tertiary education had five times the odds of being aware of PrEP compared to MSM with basic or non-primary educations (aOR: 5.56, 95% CI: 2.87–10.78, p < 0.001). When compared to Greater Acccra, participants from Brong Ahafo and Volta regions had 2 and 3 times the odds of being aware of PrEP. MSM who encountered peer educators had higher odds (aOR: 3.78, 95% CI: 2.52–5.67, p < 0.001) of being aware of PrEP than those who hadn’t. MSM who had not tested ever for HIV were 77% less likely than those who had tested for HIV to be aware of PrEP (aOR: 0.23, 95% CI: 0.17–0.30, p < 0.001). Finally, MSM who did not have comprehensive knowledge of HIV were32% less likely to be aware of PrEP than those who had comprehensive HIV knowledge (aOR: 0.68, 95% CI 0.52–0.88, p < 0.003) (Table 3).

Table 3.

Factors associated with awareness of PrEP among MSM in Ghana

	PrEP Awareness		Binary logistic regression model of PrEP Awareness among MSM
			Unadjusted model		Adjusted model
Characteristics	n/N (%)	P-value	cOR [95% CI]	P-value	aOR [95% CI]	P-value
Age group		< 0.001
18–19	106 /348 (30.5)		1.00 [reference]		1.00 [reference]
20–24	610 /1333 (45.8)		2.08 [1.55, 2.80]	< 0.001	1.19 [0.77, 1.84]	0.425
25–34	412 /872 (47.2)		2.53 [1.86, 3.43]	< 0.001	1.07 [0.66, 1.72]	0.792
≥ 35	39 /72 (54.2)		3.26 [1.98, 5.37]	< 0.001	0.95 [0.36, 2.52]	0.923
Nonresponse	2 /3 (66.7)		-	-	-
Education		< 0.001
Basic (None/Primary)	28 /120 (23.3)		1.00 [reference]		1.00 [reference]
Junior high school	210 /627 (33.5)		1.72 [1.06, 2.79]	0.027	1.72 [0.92, 3.20]	0.087
Senior High School	623 /1424 (43.8)		2.61 [1.65, 4.12]	< 0.001	2.33 [1.28, 4.22]	0.006
Tertiary	307 /454 (67.6)		7.70 [4.70, 12.61]	< 0.001	5.56 [2.87, 10.78]	< 0.001
Nonresponse	2 /2 (100.0)		-
Marital status		0.0924
Single, never married	1093 /2457 (44.5)		1.00 [reference]		-
Married/cohabiting	69 /140 (49.3)		1.31 [0.91, 1.89]	0.141	-	-
Separated/divorced/widowed	5 /24 (20.8)		0.40 [0.17, 0.96]	0.041	-	-
Nonresponse	3 /6 (50.0)		-	-	-	-
Currently living with a partner		0.2170
No	987 /2249 (43.9)		1.00 [reference]		-
Yes	180 /374 (48.1)		1.39 [1.09, 1.76]	0.007	-	-
Nonresponse	2 /4 (50.0)		-	-	-	-
Region		< 0.001
Greater Accra	189 /427 (44.3)		1.00 [reference]		1.00 [reference]
Ashanti	151 /305 (49.5)		1.04 [0.77, 1.39]	0.814	1.12 [0.75, 1.68]	0.570
Volta	161 /235 (68.5)		1.89 [1.30, 2.74]	0.001	2.50 [1.51, 4.15]	< 0.001
Western	203 /453 (44.8)		0.75 [0.55, 1.04]	0.084	1.22 [0.77, 1.92]	0.403
Eastern	92 /272 (33.8)		0.58 [0.41, 0.82]	0.002	1.76 [0.97, 3.19]	0.063
Central	102 /267 (38.2)		0.66 [0.47, 0.93]	0.016	0.98 [0.60, 1.59]	0.929
Brong Ahafo	188 /327 (57.5)		1.18 [0.83, 1.67]	0.347	3.07 [1.86, 5.08]	< 0.001
Northern	66 /168 (39.3)		0.55 [0.38, 0.80]	0.002	0.98 [0.61, 1.58]	0.936
Upper East	7 /89 (7.9)		0.07 [0.04, 0.12]	< 0.001	0.42 [0.19, 0.95]	0.036
Upper West	10 /83 (12.0)		0.12 [0.07, 0.20]	< 0.001	0.69 [0.33, 1.43]	0.317
Sex Attracted to Most		0.003
Only Male	344 /703 (48.9)		1.00 [reference]		1.00 [reference]
Mostly Male	407 /895 (45.5)		0.80 [0.64, 0.99]	0.045	1.14 [0.80, 1.62]	0.471
Equally Male and Female	355 /806 (44.0)		0.69 [0.55, 0.87]	0.002	1.20 [0.81, 1.77]	0.361
Mostly Female	59 /206 (28.6)		0.38 [0.25, 0.58]	< 0.001	0.89 [0.47, 1.68]	0.727
Nonresponse	5 /16 (31.3)		-	-	-	-
History of Vaginal Sex		0.017
None	284 /605 (46.9)		1.00 [reference]		1.00 [reference]
1 Woman	275 /583 (47.2)		0.88 [0.68, 1.14]	0.337	0.97 [0.67, 1.38]	0.852
2 women	137 /338 (40.5)		0.63 [0.46, 0.85]	0.003	0.79 [0.51, 1.23]	0.299
3 + Women	182 /506 (36.0)		0.52 [0.39, 0.69]	< 0.001	0.70 [0.47, 1.06]	0.094
Never had vaginal sex with a woman	288 /571 (50.4)		1.03 [0.80, 1.32]	0.802	1.41 [0.97, 2.07]	0.073
Nonresponse	3 /24 (12.5)		-	-	-	-
Sexual Partners		0.3014
1 Partner	276 /563 (49.0)		1.00 [reference]		-
2 Partners	299 /679 (44.0)		0.84 [0.65, 1.08]	0.166	-	-
3 Parteners	196 /451 (43.5)		0.84 [0.64, 1.11]	0.231	-	-
4 + Partners	397 /932 (42.6)		0.86 [0.68, 1.08]	0.192	-	-
Nonresponse	0 /2 (0.0)		-	-	-	-
Alcohol Consumption		0.017
Never	635 /1523 (41.7)		1.00 [reference]		1.00 [reference]
Moderate	428 /861 (49.7)		1.47 [1.21, 1.78]	< 0.001	1.03 [0.77, 1.37]	0.840
High	105 /241 (43.6)		1.18 [0.87, 1.61]	0.294	0.88 [0.57, 1.35]	0.555
Nonresponse	2 /2 (100.0)		-		-
Contact with Peer Educator in the previous year		< 0.001
No	148 /725 (20.4)		1.00 [reference]		1.00 [reference]
Yes	1021 /1902 (53.7)		4.60 [3.63, 5.82]	< 0.001	3.78 [2.52, 5.67]	< 0.001
Nonresponse	0 /1 (0.0)		-	-	-	-
Ever Tested for HIV		< 0.001
Yes	970 /1614 (60.1)		1.00 [reference]		1.00 [reference]
No	194 /1002 (19.4)		0.13 [0.10, 0.16]	< 0.001	0.23 [0.17, 0.30]	< 0.001
Nonresponse	5 /11 (45.5)		-	-	-	-
Experienced Stigma and discrimination for being MSM		< 0.001
Yes	173 /309 (56.0)		1.00 [reference]		1.00 [reference]
No	991 /2298 (43.1)		0.54 [0.42, 0.70]	< 0.001	0.76 [0.52, 1.11]	0.160
Nonresponse	5 /20 (25.0)		-	-	-	-
Comprehensive Knowledge		< 0.001
Yes	624 /1165 (53.6)		1.00 [reference]		1.00 [reference]
No	545 /1462 (37.3)		0.48 [0.41, 0.58]	< 0.001	0.68 [0.52, 0.88]	0.003
Forced Sex		0.016
Never	1021 /2354 (43.4)		1.00 [reference]		1.00 [reference]
Once	37 /55 (67.3)		2.61 [1.61, 4.22]	< 0.001	2.38 [1.14, 4.95]	0.021
A few times	22 /38 (57.9)		2.14 [1.04, 4.39]	0.038	1.87 [0.72, 4.89]	0.200
Often	1 /4 (25.0)		1.25 [0.31, 5.06]	0.756	10.40 [1.55, 69.88]	0.016
Does not apply because no one knows	86 /173 (49.7)		1.05 [0.70, 1.57]	0.816	2.14 [1.26, 3.60]	0.005
Nonresponse	1 /3 (33.3)		-	-	-	-
Income		0.002
< Ghc500.00	429 /1081 (39.7)		1.00 [reference]		1.00 [reference]
Ghc500-999.00	336 /740 (45.4)		1.34 [1.07, 1.66]	0.010	1.01 [0.74, 1.38]	0.940
Ghc1000-1999.00	267 /500 (53.4)		1.85 [1.45, 2.36]	< 0.001	1.26 [0.90, 1.78]	0.176
Ghc2000.00 +	122 /263 (46.4)		1.55 [1.17, 2.06]	0.003	0.88 [0.58, 1.31]	0.522
Nonresponse	15 /43 (34.9)

n/N (%): Frequency aware of PrEP/Total frequency (Percentage)

COR crude odds ratio, aOR adjusted odds ratio, CI confidence interval

Factors associated with willingness to take PrEP to prevent HIV

Among MSM who were aware of PrEP, nine out of ten (90.4%) reported their willingness to take PrEP to prevent HIV. From the adjusted model, MSM between 25–34 years were 79% less willing to take PrEP to prevent HIV compared to those aged 18–19 (aOR:0.21, 95% CI 0.07–0.65, p = 0.006). Those aged 20–24 were also 70% less willing to take PrEP (aOR: 0.30, 95% CI: 0.10–0.86, p = 0.026). MSM who were married or cohabiting were 80% less willing to take PrEP compared to single and never married MSM. MSM in Western and Volta had the highest likelihood of willingness to take PrEP (aOR 3.79, 95% CI 1.37–10.48, p = 0.001) and (aOR: 2.91, CI: 95% 1.17–7.26, p = 0.022), respectively. Additionally, MSM who reported high alcohol consumption were 58% less likely to report willingness take PrEP (aOR: 0.42 CI: 95% 0.19–0.92, p = 0.03). Those who had never tested for HIV were 53% less likely to report willingness to take PrEP (aOR:0.47, CI 95% 0.25–0.88, p = 0.017) (Table 4).

Table 4.

Factors associated with willingness to take PrEP to prevent HIV among MSM in Ghana

	Willingness to take PrEP		Binary logistic regression model
			Unadjusted model		Adjusted model
Characteristics	n/N (%)	P-value	cOR [95% CI]	P-value	aOR [95% CI]	P-value
Age Group		0.178
18–19	95 /99 (96.0)		1.00 [reference]		1.00 [reference]
20–24	518 /571 (90.7)		0.53 [0.24, 1.16]	0.111	0.30 [0.10, 0.86]	0.026
25–34	339 /386 (87.8)		0.38 [0.17, 0.82]	0.014	0.21 [0.07, 0.65]	0.006
≥ 35	35 /36 (97.2)		0.76 [0.28, 2.09]	0.600	0.85 [0.16, 4.68]	0.856
Nonresponse	1 /1 (100.0)		-		-
Education		0.243
Basic (None/Primary)	25 /26 (96.2)		1.00 [reference]		1.00 [reference]
Junior high school	170 /196 (86.7)		0.81 [0.21, 3.11]	0.754	0.26 [0.03, 2.23]	0.221
Senior High School	537 /583 (92.1)		1.63 [0.44, 6.08]	0.468	0.51 [0.06, 4.35]	0.534
Tertiary	255 /287 (88.9)		1.23 [0.32, 4.66]	0.762	0.39 [0.05, 3.38]	0.393
Nonresponse	1 /1 (100.0)		-		-
Marital Status		0.029
Single, never married	932 /1023 (91.1)		1.00 [reference]		1.00 [reference]
Married/cohabiting	50 /64 (78.1)		0.47 [0.24, 0.88]	0.020	0.20 [0.07, 0.56]	0.002
Separated/divorced/widowed	4 /4 (100.0)		0.28 [0.06, 1.36]	0.115	0.23 [0.03, 1.78]	0.160
Nonresponse	3 /3 (100.0)		-	-	-
Currently living with a Partner		0.204
No	829 /923 (89.8)		1.00 [reference]		1.00 [reference]
Yes	158 /169 (93.5)		1.09 [0.69, 1.71]	0.713	3.55 [1.41, 8.89]	0.007
Nonresponse	2 /2 (100.0)		-	-	-	-
Region		0.002
Greater Accra	149 /177 (84.2)		1.00 [reference]		1.00 [reference]
Ashanti	120 /141 (85.1)		0.72 [0.44, 1.18]	0.191	0.68 [0.34, 1.35]	0.268
Volta	141 /151 (93.4)		2.25 [1.17, 4.34]	0.015	2.91 [1.17, 7.26]	0.022
Western	183 /190 (96.3)		2.16 [1.07, 4.36]	0.031	3.79 [1.37, 10.48]	0.010
Eastern	78 /86 (90.7)		1.81 [0.81, 4.01]	0.146	1.42 [0.46, 4.36]	0.543
Central	84 /96 (87.5)		0.84 [0.46, 1.54]	0.571	1.30 [0.49, 3.41]	0.597
Brong Ahafo	165 /176 (93.8)		4.19 [1.86, 9.43]	0.001	2.02 [0.78, 5.23]	0.149
Northern	57 /62 (91.9)		2.32 [0.93, 5.79]	0.072	2.15 [0.70, 6.64]	0.183
Upper East	4 /7 (57.1)		0.28 [0.09, 0.93]	0.037	0.32 [0.08, 1.25]	0.101
Upper West	9 /9 (100.0)		2.37 [0.70, 8.03]	0.167	1.53 [0.42, 5.63]	0.519
Sex Attracted to Most		0.051
Only Male	294 /322 (91.3)		-		-
Mostly Male	328 /381 (86.1)		-	-	-	-
Equally Male and Female	310 /332 (93.4)		-	-	-	-
Mostly Female	52 /55 (94.5)		-	-	-	-
Nonresponse	4 /5 (80.0)		-	-	-	-
History of Vaginal Sex		0.326
None	236 /266 (88.7)		-		-
1 Woman	241 /258 (93.4)		-	-	-	-
2 women	120 /128 (93.8)		-	-	-	-
3 + Women	149 /171 (87.1)		-	-	-	-
Never had vaginal sex with a woman	240 /269 (89.2)		-	-	-	-
Nonresponse	3 /3 (100.0)		-
Sexual Partners		0.816
1 Partner	236 /258 (91.5)		-		-
2 Partners	254 /280 (90.7)		-	-	-	-
3 Partners	168 /184 (91.3)		-	-	-	-
4 + Partners	331 /372 (89.0)		-	-	-	-
Nonresponse			-
Alcohol Consumption		0.039
Never	539 /594 (90.7)		1.00 [reference]		1.00 [reference]
Moderate	368 /400 (92.0)		1.24 [0.84, 1.83]	0.274	1.11 [0.61, 2.02]	0.723
High	79 /98 (80.6)		0.69 [0.40, 1.18]	0.175	0.42 [0.19, 0.92]	0.030
Nonresponse	2 /2 (100.0)		-		-
Contact with Peer Educator in the previous year		0.837
No	126 /139 (90.6)		-		-
Yes	862 /955 (90.3)		-	-	-	-
Nonresponse	-		-		-	-
Ever Tested for HIV		0.012
Yes	830 /908 (91.4)		1.00 [reference]		1.00 [reference]
No	156 /182 (85.7)		1.23 [0.71, 2.11]	0.457	0.47 [0.25, 0.88]	0.017
Nonresponse	2 /4 (50.0)		-	-	-	-
Experienced Stigma and Discrimination for being MSM		0.815
Yes	146 /162 (90.1)		-		-
No	838 /927 (90.4)		-	-	-	-
Nonresponse	5 /5 (100.0)		-	-	-	-
Comprehensive Knowledge		0.108
Yes	537 /584 (92.0)		-		-
No	451 /510 (88.4)		-	-	-	-
Forced Sex		0.155
Never	855 /956 (89.4)		-		-
Once	32 /35 (91.4)		-	-	-	-
A few times	20 /20 (100.0)		-	-	-	-
Often	1 /1 (100.0)		-		-	-
Does not apply because no one knows	79 /81 (97.5)		-	-	-	-
Nonresponse	1 /1 (100.0)		-
Income		0.711
< Ghc500.00	361 /401 (90.0)
Ghc500-999.00	281 /314 (89.5)		-	-	-
Ghc1000-1999.00	231 /250 (92.4)		-	-	-	-
Ghc2000.00 +	105 /114 (92.1)		-	-	-	-
Nonresponse	11 /14 (78.6)		-	-	-	-

n/N (%): Frequency Willingness to take, PrEP /Total frequency (Percentage)

COR crude odds ratio, aOR adjusted odds ratio, CI confidence interval

Factors associated with ever taken PrEP among MSM in Ghana

On bivariate analysis, factors associated with ever taken PrEP among MSM were age group, education, region, monthly income, history of vaginal sex, contact with a peer educator, ever tested with HIV, experienced stigma, comprehensive knowledge of HIV, and forced sex were significantly associated with ever taken of PrEP. In the adjusted model. MSM who had completed secondary or tertiary education had more than twice the likelihood of ever taken PrEP compared to those with basic (none or primary) education. MSM living in the Eastern and Central region less likely to ever take PrEP compared to MSM from the Greater Accra (aOR: 0.38, 95% CI: 0.16–0.88, p = 0.024) (aOR: 0.51, 95% CI 0.28–0.95, p = 0.033). The odds of ever taking PrEP were 3 times higher among MSM who had encountered peer educators in the previous year (aOR: 2.70, 95% CI: 1.35–5.38, p = 0.005). Additionally, MSM who had never tested for HIV were 89% less likely to take PrEP (aOR: 0.11, 95% CI: 0.07–0.17, p < 0.001) (Table 2).

Discussion

Globally, PrEP has demonstrated effectiveness in controlling the transmission of HIV. In line with the WHO recommendations, Ghana adopted PrEP as an additional preventive measure since 2020, with a focus on key populations vulnerable to HIV transmission. To our knowledge, this is the first study exploring PrEP awareness, willingness and ever taken among MSM in Ghana. Using data from the 2023 Biobehavioral survey among MSM in Ghana, we estimated that among the 2,627 HIV negative MSM surveyed in ten regions, 44.5% (95% CI: 42.0–47.0) were aware of PrEP, 90.4% (95% CI: 88.0–92.3) were willing to take PrEP, and 17.8% (95% CI: 16.0 – 19.8) had ever taken PrEP. Awareness, willingness and ever taken PrEP varied by region. Using multivariable analysis, we identified multiple factors that were associated with awareness of PrEP, willingness to take PrEP, and ever taken PrEP.

Among those who were aware of PrEP, a majority had completed tertiary education, with a significant proportion hailing from the Volta and Brong Ahafo regions, followed by Ashanti, Western, and Greater Accra regions. The high level of PrEP awareness in these regions may be attributed to the availability of intervention programs and their effectiveness by stakeholders in those areas. Local health programs in the Volta and Brong Ahafo region, such as community-based HIV prevention campaigns and active peer educator networks, likely played a pivotal role in driving awareness and willingness among MSM. Similarly, these findings are consistent with earlier studies [19, 38] that have linked higher education levels to a greater likelihood of PrEP awareness. Additionally, highly educated participants may have better access to awareness materials, this might also be mediated by access to the internet and exposure to community groups and health campaigns. However, regions like the Upper West and Eastern exhibited lower levels of PrEP uptake, which could be attributed to limited healthcare infrastructure, higher stigma levels, or a lack of HIV prevention services. Future programs should address these disparities by targeting regions with low uptake through tailored interventions and resource allocation. Specifically, enhancing healthcare infrastructure and expanding peer education programs in low-uptake regions like the Upper West and Eastern could significantly improve PrEP awareness and accessibility. The influence of stigma on PrEP uptake cannot be overlooked. Societal and healthcare-related stigma may discourage MSM from seeking PrEP or disclosing their status. Stigma affects access, willingness, and uptake of PrEP by creating fear of judgment or discrimination. Mitigating stigma through public awareness campaigns and training healthcare workers to provide non-discriminatory care is critical to improving uptake. A similar study conducted in Ghana in 2020 among FSW revealed that 20.8% of HIV negative FSW were aware of PrEP, which is lower than our recent findings [39]. Levels of PrEP awareness are consistent with a study conducted among key populations in Nigeria, which found PrEP awareness among MSM to be 47.9% [40]. While our results indicate lower PrEP awareness compared to Spanish-speaking Latinos in Los Angeles (85%) [38], they surpass PrEP knowledge and awareness reported in Similar studies in China 11.6% and 24.7% [41, 42]. Additionally, our findings surpass the 29.7% reported in a systematic review in Low- and middle-income countries (LMIC) [19] and 39.4% reported in young men in South Africa [43].

The difference in our findings compared to another study could be attributed to the difference in sociocultural, structure of PrEP awareness programs, accessibility and the stigma associated with PrEP usage. In Ghana, research has found the role of Peer educators has played a significant role in PrEP awareness and uptake [44, 45].

The legal and social context in Ghana which is currently characterized by the proposed anti-LGBTQ bill in Ghana which intends to intensify punishment presents potential significant challenges to the uptake to HIV prevention options such as PrEP [46, 47] Unlike other African countries, South Africa has improved laws on the same sex, and the recognition of same-sex relationship. Though the success of some PrEP interventions is not directly linked to these laws, research has found promising results of PrEP uptake in South Africa. The Sibanye Health Project demonstrated relatively high initial PrEP uptake among men who have sex with men (MSM) and transgender women, with 61% of eligible participants initiating PrEP [48].

Overall, our study findings established a higher awareness of PrEP among MSM in Ghana compared to various international studies especially in LMIC, suggesting a potential hike in current PrEP awareness interventions among key populations in Ghana.

In line with previous research conducted in Ghana [39], our study is consistent with the geographical variability observed in previous research. on PrEP awareness.

Interestingly, unlike a study on PrEP awareness among MSM in Brazil [49], which found a lower likelihood of awareness among those aged 18–24 and those aged 36 years and above, our findings suggest no significant association between age and PrEP awareness in the Ghanaian context which is consistent with results from Zimbabwe [50] among MSM and transgender women.

Furthermore, contact with peer educators, comprehensive knowledge of HIV, and previous HIV testing, particularly among MSM who have experienced forced sex, were significantly associated with PrEP awareness. Individuals who had contact with peer educators demonstrated a higher likelihood of being aware of PrEP, potentially due to the educational interventions they received through peer education. Additionally, individuals with comprehensive knowledge of HIV have a higher likelihood of being aware of PrEP. HIV education may encompass information about PrEP as a preventive measure. Conversely, MSM who have never been tested for HIV exhibited a lower likelihood of being aware of PrEP, possibly indicating a lack of concern about infections and a reluctance to seek information. The association between experiences of sexual violence and higher PrEP use (aOR: 8.88) highlights the psychological and social impacts of trauma on health-seeking behavior. Survivors may prioritize PrEP uptake due to heightened perceived vulnerability to HIV, driven by their traumatic experiences. Additionally, outreach through trauma-informed care programs may enhance access to PrEP by addressing the unique needs of this population and fostering trust in healthcare systems.

Nine out of ten HIV negative MSM expressed their willingness to take PrEP to prevent HIV. All MSM from the Upper West region were willing to take PrEP to prevent HIV, closely followed by the Western region, Brong Ahafo, and Volta regions. This high PrEP willingness may be due to their awareness of PrEP, knowledge about HIV prevention, and individual motivation to stay healthy and HIV negative. Despite high willingness, low uptake suggests structural barriers such as limited healthcare access, restricted distribution to high-risk populations, and the unavailability of PrEP in certain areas. Addressing these issues through the integration of PrEP into primary healthcare services and expanding distribution points, particularly in underserved regions, could help bridge this gap. Additionally, ensuring a consistent supply and improving awareness campaigns tailored to high-risk populations may enhance uptake A similar study conducted in Ghana among FSWs reported 53.9% willingness to take PrEP to prevent HIV. While studies in some jurisdictions in China, Malaysia, and Thailand reported relatively low willingness among participants to take PrEP [51–53], subsequent research from other countries and different jurisdictions in China has shown an increasing trend. Studies from Taiwan, Myanmar, and other parts of China among MSM have reported moderate to high willingness, ranging from 56 to 91% [54–56]. These findings are consistent with our study and those from Brazil [57] where 82% of MSM reported their willingness, and 83.3% reported from Kenya [58]. The willingness is even higher in studies in Vietnam [59] and Peru [60] with 95.4% and 96.2% of the participants, respectively, indicating their willingness to take PrEP. Our findings and these high trends of willingness suggest that there is a significant level of interest in PrEP as a preventive measure against HIV transmission, and this willingness is not limited to a specific geographical region.

Despite the importance of PrEP in HIV prevention, only 17.82% have ever used PrEP, consistent with a study report that 6.4% of FSWs in Ghana have ever used PrEP [39] This current estimate, though low, is higher than estimated in China among Chinese gay bisexuals and MSM, which reported PrEP use to be 4% [61] and 0.7% [42]. The biobehavioral survey conducted in Nigeria among key populations also reported ever taken of PrEP to be 25.3% among MSM. Interestingly, the use of PrEP has been reported high (45%) in cross-sectional study among MSM in Rwanda [62].

Factors independently associated with ever taking PrEP among MSM included level of education, the region of residence, contact with peer educator, and HIV testing. Our findings suggest that the higher your education, the higher your likelihood of PrEP use, which is consistent with a study conducted in China [63] among MSM. They found that MSM with master’s degrees and higher had a high likelihood of PrEP use. A systematic review of 23 studies showed that age was a significant factor in PrEP uptake, in that younger MSM are more likely to take PrEP [64] which is in contrast with our findings where age was not a significant factor in ever taken of PrEP as well as studies conducted in the United States [65]. The current findings suggest that monthly income was not a significant factor in PrEP use among MSM in Ghana, which contradicts the study by Brooks et al. [38]; PrEP medication is currently not for sale in Ghana and thus cannot be entirely influenced by income. MSM who have never tested for HIV have less likelihood of using PrEP; this could be that such people do not care or may not have knowledge of HIV and prevention. This could also be as result of HIV testing being a pre-requisite for PrEP. Policy implications of these findings emphasize the need to expand PrEP education through peer-led initiatives, and ensure consistent availability to improve uptake. Integrating PrEP into routine healthcare services could also enhance accessibility and uptake.

Our findings provide valuable insights for improving PrEP awareness and uptake in Ghana. knowledge and campaigns could be improved in locations with poor knowledge and uptake by employing demographically targeted messages to combat misconceptions and stigma. Additionally, peer educators could be improved and expanded, perhaps increasing reach even for extremely hidden groups. PrEP has previously been implemented to some level in HIV prevention programs in Ghana; however, continuing to assess, improve, and ensure that services are consistently available, inexpensive, and accessible across all regions will raise awareness and adoption.

Limitation and strength

The participants may have exhibited social desirability bias because of shyness. We endeavored to reduce this bias by reassuring participants of the confidentiality and de-identified nature of the data. Also, the use of RDS, though one of the effective ways to reach hidden populations could introduce recruitment bias related to network characteristics of participants, preference from the seeds as well as the clustering effect of uneven chains. Our study did not capture drug use which has been reported in other studies to be associated with PrEP awareness, as results could not examine the relationship between drug use and Prep awareness, willingness and ever taken. Additionally, the operational definition of the main outcome was measured with a dichotomous variable, which does not capture other levels of awareness, willingness, or uptake. This is a secondary analysis of a nationwide study and qualitative data was not obtained which could have provided some in-depth reasons behind the attitude toward PrEP. Despite these limitations, our study is powered by a large sample size, samples from all ten traditional regions in Ghana. The study utilized a biometric device to avoid duplication. This study provides a comprehensive assessment of PrEP among MSM in Ghana, which provides national-level insight into its awareness, ever-taken and willingness.

Conclusion

This study revealed close to half of MSM are aware of PrEP with high proportion of MSM in Ghana being willing to take PrEP to prevent HIV. However, the actual uptake of PrEP remains low. Factors such as education, peer education, HIV testing, and experiences of forced sexual encounters among MSM have been identified as significant contributors to PrEP awareness, uptake, and willingness. Civil Society Organizations (CSOs) that engage with MSM communities could play a pivotal role in enhancing PrEP education and accessibility to HIV treatment and preventive services, including PrEP. Additionally, broader involvement from healthcare providers and the government is crucial for a comprehensive strategy to improve PrEP uptake. Stigma, a significant barrier, must be addressed through public health campaigns and healthcare provider training to ensure non-discriminatory care for MSM. Tailored communication strategies are vital for effective outreach. Expanding peer education programs and utilizing platforms like social media and in-person counseling can help engage diverse subgroups within the MSM community.

Policy measures such as ensuring consistent supply and integrating PrEP into primary healthcare services are recommended to improve access. These interventions should be guided by the regional disparities, with much focus on regions with less PrEP uptake like the Upper West and Eastern region.

The various outcomes and contributing factors identified in this research serve as a groundwork for stakeholders and implementers to design tailored interventions to improve the overall uptake of PrEP within this population.

Abbreviations

AIDS

Acquired Immune Deficiency Syndrome

CDC

Centers for Disease Control and Prevention

CSO

Civil Society Organization

ERC

Ethics Review Committee

FHI

Family Health International

FSW

Female Sex Workers

GHS

Ghana Health Service

HIV

Human Immunodeficiency Virus

IRB

Institutional Review Board

LMIC

Low- and Middle-Income Countries

MSM

Men who have sex with Men

NACP

National AIDS Control Programme

NMIMR

Noguchi Memorial Institute for Medical Research

PEPFAR

US President’s Emergency Plan for AIDS Relief

PrEP

Pre-exposure prophylaxis

RDS

Respondent Driven Sampling

REDCap

Research Electronic Data Capture

SQL

Structured Query Language

STATA

Statistics and Data

STI

Sexually Transmitted Infections

UNAIDS

Joint United Nations Programme on HIV/AIDS

WHO

World Health Organization

Authors’ contributions

CG, SD, SAA, KT conceived of the parent study. CG, SD, AA, YA Cleaned and analyzed the data, the current paper was conceptualized by CG, AA, SD, YA. The manuscript was drafted by AA, CG, YA. The manuscript was reviewed and revised by CG, SD, GRAB, AA, YA, SAA, KT.

Funding

The study was funded by the Global Fund through the National AIDS/STI Control Programme (NACP), Ghana Health Service.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to the high risk of persecution and severe adverse social consequences related to the socio-political sensitivity of the topic of same-sex behaviours in Ghana; however, data are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by two institutions namely: Ghana Health Service Ethics Review Committee (GHS-ERC:007/01/22) and the Noguchi Memorial Institute of Medical Research (NMIMR-IRB CPN 028/21–22). All participants in this study were required to sign an informed consent form. The study was voluntary, and the consenting process was explained to participants to willingly decide to partake in the study. Participants had the flexibility to withdraw at any time during the survey process.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.