Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2021 Mar 1.
Published in final edited form as: AIDS Care. 2019 Oct 10;32(3):330–336. doi: 10.1080/09540121.2019.1675858

Knowledge and Acceptability of HIV pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) in Ghana

Adedotun Ogunbajo 1, Natalie M Leblanc 2, Sameer Kushwaha 3, Francis Boakye 4, Samuel Hanson 5, Martez DR Smith 2, LaRon E Nelson 2,6
PMCID: PMC6980967  NIHMSID: NIHMS1054761  PMID: 31597455

Abstract

In Ghana, men who have sex with men (MSM) are disproportionately affected by HIV. Pre-exposure prophylaxis (PrEP) is an intervention that reduces risk for HIV infection but is not currently available in Ghana. This paper explores knowledge and acceptability of HIV PrEP among Ghanaian MSM. Qualitative content analysis was conducted on 22 focus group discussions(N=137) conducted between March-June 2012 in Accra, Kumasi, and Manya Krobo. Overall, participants reported low knowledge of PrEP. However, once information about PrEP was provided, there was high acceptability. The primary reason for acceptability was that PrEP provided an extra level of protection against HIV. Acceptability of PrEP was conditioned on it having minimal side effects, being affordable and efficient in preventing HIV infection. No acceptability of PrEP was attributed to limited knowledge of side effects and perceived lack of effectiveness. The reasons provided to utilize PrEP and condoms was condoms protect against other STIs, and sexual partner factors. This is the first known study to explore PrEP knowledge and acceptability among Ghanaian MSM. It is important that key stakeholders preemptively address potential barriers to PrEP acceptability, uptake, and adherence, especially among MSM, once PrEP becomes available in Ghana.

Keywords: PrEP, Ghana, MSM, Acceptability, HIV, Africa

Introduction

In Ghana, men who have sex with men (MSM) are disproportionately affected by HIV. Although MSM make up an estimated 1% of Ghana’s population (Service, 2013, 2016), they account for 17.5% of people living with HIV (UNAIDS, 2018). In Ghana, men and are less likely than women to be tested for HIV(Sano et al., 2016; Yawson et al., 2014), and engage in HIV treatment(Dako-Gyeke, Snow, & Yawson, 2012; Kumar et al., 2015). A study of MSM living with HIV in Ghana found that 25% had never been linked to treatment (Nelson, Adu-Sarkodie, McMahon, Zhang, & Mayer, 2015) and barriers to care among Ghanaian MSM include stigma, financial difficulties, and healthcare system challenges (A. Ogunbajo et al., 2017).

The disparity in HIV prevalence and gaps in linkage to care place Ghanaian MSM at an increased risk for HIV infection. High HIV prevalence among MSM, low condom usage, and small sexual networks, increases the likelihood of HIV infection (Nelson, Wilton, Agyarko-Poku, Zhang, Zou, et al., 2015; Schneider et al., 2012). Gaps in linkage to HIV care contributes to persistently detectable community viral loads, which increases likelihood of HIV transmission (Herbeck & Tanser, 2016; Kelley et al., 2012; Miller, Powers, Smith, & Cohen, 2013; Tanser et al., 2017). Pre-exposure prophylaxis (PrEP) is a biomedical intervention that reduces risk for HIV infection but is not currently available in Ghana.

Oral PrEP is a medication with demonstrated efficacy to reduce risk for acquiring HIV when taken daily (Donnell et al., 2014; Grant et al., 2010; Smith, Herbst, & Rose, 2015). In 2012, the WHO released guidelines that recommended PrEP for MSM globally (Organization, 2012). Research in the United States has demonstrated willingness to use and uptake of PrEP among MSM (Cohen et al., 2015; Hood et al., 2016; Mimiaga, Case, Johnson, Safren, & Mayer, 2009). The state of the science on HIV PrEP include a large body of research on its efficacy and the central role of adherence to achieving and maintaining protective effect (Murnane et al., 2013; Paltiel et al., 2009). Given its’ proven efficacy, PrEP has the potential to reduce new HIV infections among Ghanaian MSM. However, to effectively implement PrEP, in Ghana—where stigma and social hostility to MSM is high (Kushwaha et al., 2017; Logie et al., 2017; Nelson, Wilton, Agyarko-Poku, Zhang, Aluoch, et al., 2015; Nyblade et al., 2017; Risher et al., 2013; Soto, Komaie, Neilands, & Johnson, 2013)—understanding knowledge and acceptability of PrEP among MSM is crucial. The current study aimed to gain understanding of knowledge and acceptability of PrEP among Ghanaian MSM.

Methods

Design

This was a qualitative descriptive study using data from twenty-two focus group discussions (FGDs) conducted across Ghana in Accra (8 FGDs; n = 53), Kumasi (8 FGDs; n = 51), and Manya Krobo (6 FGDs; n = 33) with a total of 137 participants between March and June 2012. A comprehensive report of the recruitment methodology has been published (Kushwaha et al., 2017; Nelson, Wilton, Agyarko-Poku, Zhang, Zou, et al., 2015). At each step of the study, various stakeholders with expertise in HIV prevention among MSM in Ghana were consulted.

Sample and Recruitment

Inclusion criteria were: 1) 18 years or older; 2) birth-assigned male; 3) cis-gender man; and 4) anal sex with another cis-gender man in past 6 months. Outreach workers and popular-opinion leaders who self-identified as MSM were trained as research assistants (RAs). The RAs recruited participants using a chain-referral method. They initially recruited MSM within their networks and those individuals invited peers. Prior to the FGDs, RAs explained the study purpose to prospective participants, who subsequently provided informed consent through digital signatures on a secure iPad-based platform. Participants received 25 Ghana Cedis (about 12 US dollars) for participation.

Data Collection

All FGDs facilitators were trained in qualitative data collection and followed a semi-structured interview guide (Kushwaha et al., 2017). Data collection occurred in the private offices of the partner community-based organizations. All FGDs were audio-recorded and lasted about 1.5 hours.

This analysis focuses on the discussions pertaining to PrEP. Participants were provided with the following information about PrEP: “A recent study indicated that people without HIV who took one daily dose of an anti-HIV pill were able to reduce their chance of getting HIV. This concept, called “PrEP”, is very new and is not something that is currently available in Ghana but we would like to know your thoughts about its use as a prevention tool.” Detailed interview questions are provided in Table 1. Professional transcriptionists from Ghana used Transcriva (V. 2.016) to create written transcripts.

Table 1:

Discussion topics, questions, and sample prompts from MSM focus groups

Topic Domain Question Sample Prompts
Healthcare seeking attitudes; Attitudes about PrEP If PrEP were available here in Ghana, would you use it?

  • What would you need to know about PrEP before using it?

  • What have you already heard about PrEP?

  • What would prevent you from using it?

  • What would prevent you from using it daily?
Condom and PrEP use attitudes Tell us about how often you use condoms now during sex.

  • How do you feel about using condoms during sex? With men? With women?

  • Imagine for a moment that you were taking PrEP; please describe what your condom use would be like with men? For anal sex? For oral sex?
Open in a new tab

Data Analysis

The authors performed qualitative content analysis of data pertaining to PrEP. We approached the analysis with the following three questions as our frame of reference: “What is the knowledge of PrEP among MSM?”, “What factors affect whether PrEP is acceptable?” and “What are their perspectives on condom use with PrEP?” This analytic process involved extracting and categorizing all relevant data and iteratively developing conclusions based on the implicit and explicit meanings of the texts. NVivo for Mac (V. 10.2.1) was used to manage transcripts. Two authors independently read and reviewed all transcripts and extracted the data into preliminary categories. These findings were reviewed with the larger team, who provided insight into the meaning of the text. This process continued until the authors concluded that no new themes were emerging that addressed the research questions.

Ethical Considerations

The study was approved by the Kwame Nkrumah University of Science and Technology Committee on Human Research Publication and Ethics board.

Results

Key demographic characteristics are presented in Table 2. Participant quotations are marked with abbreviation of the study site (ACC= Accra; KUM= Kumasi; Manya Krobo= MAK) and FGD number.

Table 2:

Sample Characteristic (N=137)

Demographics n (%)
Age (years)
18–24 81 (59.1)
25–34 51 (37.3)
35–44 4 (2.8)
45 and over 1 (0.7)
Ethnicity
Asante 56 (40.9)
Ga 26 (19.0)
Krobo 24 (17.5)
Multi-Ethnic 7 (5.1)
Ewe 6 (4.4)
Hausa 4 (2.9)
Akuapem 3 (2.2)
Akyem 3 (2.2)
Fante 2 (1.5)
Community of Residence
Accra 53 (38.7)
Kumasi 51 (37.2)
Manya Krobo 33 (25.2)
Housing Status
Living with parents 65 (47.4)
Renting 39 (28.5)
Boarding house 24 (17.5)
Living in own home 8 (5.8)
Squatting 1 (0.7)
HIV Status
Seronegative 102 (75.0)
Seropositive 1 (0.7)
HIV status unknown 31 (23.0)
Decline to answer 3 (2.0)
Marital Status
Not married 132 (96.4)
Married 5 (3.6)
Sexual Attraction
Men only 78 (56.9)
Women only 1 (0.7)
Men and women 58 (42.3)
Lifetime STI History
Yes 38 (28.0)
No 99 (72.0)
Open in a new tab

PrEP Knowledge

Across all FGDs, a majority of participants reported no knowledge of PrEP (three participants had previously heard of PrEP and only two were able to accurately explain what PrEP is used for). Almost all participants responded to the question about whether they had ever heard of PrEP with: ‘I haven’t heard anything about PrEP.’ (ACC, 3). One participant described hearing about it from someone in a different country: ‘I have heard of it, I have this gay partner abroad and he once told me about the drug.’ (KUM, 1)

Only two participants were able to provide detailed knowledge of PrEP. This participant explained learning about PrEP through the internet: ‘I read something about it on the internet. It is used to prevent HIV infection.’ (KUM, 7)

PrEP Acceptability

A majority of participants expressed acceptability to PrEP. The primary reason for PrEP acceptability was that it provided protection from HIV infection. One participant explained: ‘I will use it since it’s going to reduce my chances of being infected [with HIV]. I would love to take it because nobody wants to have HIV. I don’t want to die.’ (ACC, 2). Another participant added that despite his dislike for medications, he still found PrEP acceptable: ‘I am not a fan of drugs but considering what this drug is being made for, I think I might use it because the drug is going to prevent me from getting HIV.’ (KUM, 7)

Some participants stated that they would require certain criteria to be met before becoming acceptable to PrEP. The first condition was the need to be informed about common side effects as this participant describes: ‘Before using it, I would want to know the long and short-term side effects.’ (KUM 7). Other participants accepted PrEP, with the contingency that there are no side effects and that it was affordable: ‘I would accept it if it has no side effects and will like to know the cost. I need to know whether it’s expensive and I will see if I can buy it.’ (ACC 6).

Another condition for acceptability was proof of PrEP’s effectiveness in preventing HIV. One participant said: ‘I would want to know its’ effectiveness. When I take it today, how long will it protect me from the getting HIV?’ (KUM, 5). Another participant expressed the need for personal testimony about its’ effectiveness: ‘If someone testifies of its’ potency, I would accept it.’ (MAK, 6)

No acceptability of PrEP

A few participants expressed no acceptability of PrEP. The reasons provided included the expectation of harmful side effects as one participant mentioned: ‘I am not interested [in PrEP] due to the harmful health effects it could have on me.’ (KUM, 6). Others were concerned due to limited knowledge about possible side effects: ‘I don’t know the side effects of the drug, so I won’t use it.’ (MAK, 3) Another reason given was perceived low efficacy of PrEP against HIV infection: ‘I will not use it because it is not 100%. It is used to prevent not to eradicate.’ (KUM, 6)

Condom Use with PrEP

Many participants described plans to utilize condoms with PrEP. The reasons for utilizing both was because condoms help prevent against other STIs, and sexual partner factors. Some participants expressed no interest in using both condoms and PrEP due to perceived redundancy and condoms possibly being cheaper than PrEP.

Condom use with PrEP was endorsed by several participants. Many mentioned that the availability of PrEP would not alter their current condom use behavior. This participant expressed that the inability for PrEP to protect against STIs, other than HIV, was his motivation for wanting to use both condoms and PrEP: ‘Condoms and PrEP is the best thing to use because it’s not only HIV you can get from sex. You can get gonorrhea, hepatitis B and other things. The medicine is just for HIV. You still have to use the condoms.’ (ACC, 2)

Two participants expressed that their decision of whether or not to use condoms together with PrEP was dependent on the nature of their sexual partnerships. One expressed that if they trusted a sexual partner, they would use only one mode of protection and lack of trust meant utilizing both condoms and PrEP: ‘It may depend on the person I’m having sex with. If I don’t trust the person then I will take the PrEP and use the condom at the same time but if I trust the person, I will take one.’ (ACC, 4) Another participant described plans to use only PrEP with an exclusive partner and PrEP and condoms with casual partners: ‘With my exclusive sexual partners, I will use the PrEP without the condom but with a casual partner, I will use the PrEP and the condom at the same time.’ (ACC, 4)

A few participants expressed no interest in utilizing PrEP with condoms. The major reason provided was that using condoms with PrEP was redundant as they both aim to prevent HIV transmission: ‘No… Because both of them are for HIV prevention so there is no need for me to use the two. If you use one, it’s the same as using the other.’ (KUM, 2). Another participant expressed that they would use condoms exclusively and not PrEP due to costs: ‘Since condom is cheaper, there would be no need for me to buy PrEP.’ (KUM, 3)

Discussion

Our findings indicate that while Ghanaian MSM had low knowledge of PrEP, once information about PrEP was provided, there was high acceptability.

We found that Ghanaian MSM expressed low knowledge of PrEP. This finding is expected as data collection occurred between March and June 2012. Low PrEP knowledge is consistent with other studies on PrEP knowledge among MSM in the Americas (United States and Canada (Bauermeister, Meanley, Pingel, Soler, & Harper, 2013; Eaton, Driffin, Bauermeister, Smith, & Conway-Washington, 2015; Krakower et al., 2012; Leonardi, Lee, & Tan, 2011), Europe (Ferrer et al., 2016; J. Frankis, Young, Flowers, & McDaid, 2016; J. S. Frankis, Young, Lorimer, Davis, & Flowers, 2016), and Asia (Lim et al., 2017; Zhang et al., 2013; Zhou et al., 2012). This is in contrast to a recent study that found high PrEP knowledge (64%) among Kenyan MSM (Adedotun Ogunbajo et al., 2019). This finding underscores the need for a comprehensive, multimedia awareness campaign that provides evidence-based information about PrEP, when it becomes available. Additionally, key stakeholders such as MSM community opinion leaders, community-based organizations, and MSM-friendly health providers should serve as channels for dissemination of information about PrEP to Ghanaian MSM.

We found that participants expressed conditional acceptability of PrEP. The participants’ concerns about the side effects of PrEP is consistent with previous studies that showed side effects as a major barrier intention to use and current PrEP use among MSM (Galea et al., 2011; Goedel, Halkitis, Greene, & Duncan, 2016; Golub, Gamarel, Rendina, Surace, & Lelutiu-Weinberger, 2013; Mimiaga et al., 2009; Yi et al., 2017). It is important to ensure Ghanaian MSM are aware of potential side effects and course of action if side effects persist. Another condition for acceptability was that PrEP be affordable. Previous studies have shown cost to be a major barrier to PrEP uptake among MSM(Brooks et al., 2011; Galea et al., 2011; Yi et al., 2017). To maximize PrEP uptake among Ghanaian MSM, PrEP should be offered at little to no cost. This will alleviate the financial barrier of accessing PrEP. Lastly, proven effectiveness of PrEP to prevent HIV was a conditional factor for PrEP acceptance. Prior work has demonstrated that doubt of PrEP effectiveness is associated with reduced willingness to use PrEP(Yi et al., 2017). Providing Ghanaian MSM with easily understood data on the effectiveness of PrEP might assuage some of their fears around how effectively PrEP prevents HIV.

Finally, data from our study suggests that while Ghanaian MSM expressed the combination of condom and PrEP use as acceptable, a few participants expressed usage of both as redundant and costly. Previous studies have demonstrated that MSM are not likely to significantly decrease condom use while on PrEP(Golub, Kowalczyk, Weinberger, & Parsons, 2010; Holt et al., 2012), debunking the argument that risk compensation (increased sexual risk) might occur upon PrEP uptake. However, it is important to stress that PrEP only protects against HIV and no other STIs. Reminders about the need to use both PrEP and condoms should be expressed to individuals on PrEP during follow-up clinical visits.

Limitations

This study has several limitations. While only one participant reported living with HIV, 24% opted to not report their HIV status, meaning that HIV status could have been underestimated in the sample. Consequently, information about PrEP knowledge and acceptability may have been garnered from participants who would not qualify for PrEP due to HIV seropositivity. Also, data collection occurred in 2012, and while PrEP is still not available in Ghana, information and guidelines on PrEP are more widely available today and could influence how participants would answer the study questions. Nonetheless, this study provides critical information needed to guide successful implementation of PrEP among Ghanaian MSM in the near future.

Conclusions

This is the first known study to explore PrEP knowledge and acceptability among MSM in Ghana. As Ghana consider incorporating PrEP into their HIV prevention toolkit, we recommend that eligible MSM should be a priority group for PrEP and it should be offered at little to no cost.

Acknowledgments

First, we will like to thank all the research participants who shared their insight. We thank all the local community partners in Ghana: Otumfuo Osei Tutu II Charity Foundation, Centre for Popular Education & Human Rights Ghana, Priorities on Rights and Sexual Health, Suntreso Government Hospital, Asesewa Government Hospital, Eastern Region HIV/STI program, Ashanti Region HIV/STI program, and the Office of the Konor of Manya Krobo Traditional Area. We thank Dr. Vanessa Apea (Barts & The Royal London Hospital), Nene Sakite II Konor of Manya Krobo, Nene Kwasi Kafele (York University), Dr. Francis Addai (Ghana Health Services), Dr. Francis Arko Akoto-Ampaw (Ghana Health Services), Enock Amankwah (University of South Florida) Nana Yaw Atakora-Yeboah and Sulaimon O. Giwa (York University).

Funding

Direct expenses for this research was primarily provided by Grand Challenges Canada grant CRS0024–0101. Additionally, this research was supported, in part, by the National Institute of Mental Health under R25MH083620 (principal investigator [PI]: Amy Nunn, PhD) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development P2C HD041020 (PI: Susan Short, PhD), for which the first author is a trainee but did not support project-specific expenses. This work was also supported by the Robert Wood Johnson Foundation Health Policy Research Scholars Program, for which the first author is a scholar but did not support project-specific expenses. The University of Rochester School of Nursing Dean’s Endowed Fellowship in Health Disparities supports LN. This publication was also made possible through core services supported by grant P30 AI078498 to the University of Rochester Center for AIDS Research (CFAR) from the National Institute of Allergy & Infectious Diseases, which supports LN.

REFERENCES

  1. Bauermeister JA, Meanley S, Pingel E, Soler JH, & Harper GW (2013). PrEP awareness and perceived barriers among single young men who have sex with men in the United States. Current HIV research, 11(7), 520. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Brooks RA, Kaplan RL, Lieber E, Landovitz RJ, Lee SJ, & Leibowitz AA (2011). Motivators, concerns, and barriers to adoption of preexposure prophylaxis for HIV prevention among gay and bisexual men in HIV-serodiscordant male relationships. AIDS Care, 23(9), 1136–1145. doi: 10.1080/09540121.2011.554528 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Cohen SE, Vittinghoff E, Bacon O, Doblecki-Lewis S, Postle BS, Feaster DJ,…Estrada Y (2015). High interest in pre-exposure prophylaxis among men who have sex with men at risk for HIV-infection: baseline data from the US PrEP demonstration project. Journal of acquired immune deficiency syndromes (1999), 68(4), 439. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Dako-Gyeke P, Snow R, & Yawson AE (2012). Who is utilizing anti-retroviral therapy in Ghana: an analysis of ART service utilization. International journal for equity in health, 11(1), 62. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Donnell D, Baeten JM, Bumpus NN, Brantley J, Bangsberg DR, Haberer JE,…Celum C (2014). HIV protective efficacy and correlates of tenofovir blood concentrations in a clinical trial of PrEP for HIV prevention. J Acquir Immune Defic Syndr, 66(3), 340–348. doi: 10.1097/QAI.0000000000000172 [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Eaton LA, Driffin DD, Bauermeister J, Smith H, & Conway-Washington C (2015). Minimal awareness and stalled uptake of pre-exposure prophylaxis (PrEP) among at risk, HIV-negative, black men who have sex with men. AIDS patient care and STDs, 29(8), 423–429 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Ferrer L, Folch C, Fernandez-Davila P, Garcia A, Morales A, Belda J,…Casabona J (2016). Awareness of pre-exposure prophylaxis for HIV, willingness to use it and potential barriers or facilitators to uptake among men who have sex with men in Spain. AIDS and Behavior, 20(7), 1423–1433 [DOI] [PubMed] [Google Scholar]
  8. Frankis J, Young I, Flowers P, & McDaid L (2016). Who Will Use Pre-Exposure Prophylaxis (PrEP) and Why?: understanding PrEP awareness and acceptability amongst men who have sex with men in the UK–A mixed methods study. PLoS One, 11(4), e0151385. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Frankis JS, Young I, Lorimer K, Davis M, & Flowers P (2016). Towards preparedness for PrEP: PrEP awareness and acceptability among MSM at high risk of HIV transmission who use sociosexual media in four Celtic nations: Scotland, Wales, Northern Ireland and The Republic of Ireland: an online survey. Sex Transm Infect, 92(4), 279–285 [DOI] [PubMed] [Google Scholar]
  10. Galea JT, Kinsler JJ, Salazar X, Lee S-J, Giron M, Sayles JN,…Cunningham WE (2011). Acceptability of pre-exposure prophylaxis as an HIV prevention strategy: barriers and facilitators to pre-exposure prophylaxis uptake among at-risk Peruvian populations. International journal of STD & AIDS, 22(5), 256–262 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Goedel WC, Halkitis PN, Greene RE, & Duncan DT (2016). Correlates of awareness of and willingness to use pre-exposure prophylaxis (PrEP) in gay, bisexual, and other men who have sex with men who use geosocial-networking smartphone applications in New York City. AIDS and Behavior, 20(7), 1435–1442 [DOI] [PubMed] [Google Scholar]
  12. Golub SA, Gamarel KE, Rendina HJ, Surace A, & Lelutiu-Weinberger CL (2013). From efficacy to effectiveness: facilitators and barriers to PrEP acceptability and motivations for adherence among MSM and transgender women in New York City. AIDS patient care and STDs, 27(4), 248–254 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Golub SA, Kowalczyk W, Weinberger CL, & Parsons JT (2010). Preexposure prophylaxis and predicted condom use among high-risk men who have sex with men. Journal of acquired immune deficiency syndromes (1999), 54(5), 548. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Grant RM, Lama JR, Anderson PL, McMahan V, Liu AY, Vargas L,…iPrEx Study T. (2010). Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med, 363(27), 2587–2599. doi: 10.1056/NEJMoa1011205 [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Herbeck J, & Tanser F (2016). Community viral load as an index of HIV transmission potential. Lancet HIV, 3(4), e152–154. doi: 10.1016/S2352-3018(16)00036-9 [DOI] [PubMed] [Google Scholar]
  16. Holt M, Murphy DA, Callander D, Ellard J, Rosengarten M, Kippax SC, & de Wit JB (2012). Willingness to use HIV pre-exposure prophylaxis and the likelihood of decreased condom use are both associated with unprotected anal intercourse and the perceived likelihood of becoming HIV positive among Australian gay and bisexual men. Sex Transm Infect, 88(4), 258–263 [DOI] [PubMed] [Google Scholar]
  17. Hood JE, Buskin SE, Dombrowski JC, Kern DA, Barash EA, Katzi DA, & Golden MR (2016). Dramatic increase in preexposure prophylaxis use among MSM in Washington state. Aids, 30(3), 515–519 [DOI] [PubMed] [Google Scholar]
  18. Kelley CF, Rosenberg ES, O’Hara BM, Frew PM, Sanchez T, Peterson JL,…Sullivan PS (2012). Measuring population transmission risk for HIV: an alternative metric of exposure risk in men who have sex with men (MSM) in the US. PLoS One, 7(12), e53284. doi: 10.1371/journal.pone.0053284 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Krakower DS, Mimiaga MJ, Rosenberger JG, Novak DS, Mitty JA, White JM, & Mayer KH (2012). Limited awareness and low immediate uptake of pre-exposure prophylaxis among men who have sex with men using an internet social networking site. PloS one, 7(3), e33119. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Kumar N, Reece R, Norman B, Kwara A, Flanigan T, & Rana A (2015). Delayed entry to care by men with HIV infection in Kumasi, Ghana. Pan African Medical Journal, 22(1) [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Kushwaha S, Lalani Y, Maina G, Ogunbajo A, Wilton L, Agyarko-Poku T,…Nelson LE (2017). “But the moment they find out that you are MSM…”: a qualitative investigation of HIV prevention experiences among men who have sex with men (MSM) in Ghana’s health care system. BMC Public Health, 17(1), 770. doi: 10.1186/s12889-017-4799-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Leonardi M, Lee E, & Tan D (2011). Awareness of, usage of and willingness to use HIV pre-exposure prophylaxis among men in downtown Toronto, Canada. International journal of STD & AIDS, 22(12), 738–741 [DOI] [PubMed] [Google Scholar]
  23. Lim SH, Mburu G, Bourne A, Pang J, Wickersham JA, Wei CKT,…Azwa I (2017). Willingness to use pre-exposure prophylaxis for HIV prevention among men who have sex with men in Malaysia: Findings from an online survey. PloS one, 12(9), e0182838. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Logie CH, Lacombe-Duncan A, Brien N, Jones N, Lee-Foon N, Levermore K,…Newman PA (2017). Barriers and facilitators to HIV testing among young men who have sex with men and transgender women in Kingston, Jamaica: a qualitative study. J Int AIDS Soc, 20(1), 21385. doi: 10.7448/IAS.20.1.21385 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Miller WC, Powers KA, Smith MK, & Cohen MS (2013). Community viral load as a measure for assessment of HIV treatment as prevention. Lancet Infect Dis, 13(5), 459–464. doi: 10.1016/S1473-3099(12)70314-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Mimiaga MJ, Case P, Johnson CV, Safren SA, & Mayer KH (2009). Preexposure antiretroviral prophylaxis attitudes in high-risk Boston area men who report having sex with men: limited knowledge and experience but potential for increased utilization after education. Journal of acquired immune deficiency syndromes (1999), 50(1), 77–83 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Murnane PM, Celum C, Nelly M, Campbell JD, Donnell D, Bukusi E,…Thomas KK (2013). Efficacy of pre-exposure prophylaxis for HIV-1 prevention among high risk heterosexuals: subgroup analyses from the Partners PrEP Study. AIDS (London, England), 27(13) [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Nelson LE, Adu-Sarkodie Y, McMahon J, Zhang N, & Mayer KH (2015). Exploring Stigmas and HIV Diagnosis Delay, Linkage and Retention for MSM in Ghana (Vol. $275,000). Ghana: National Institute of Mental Health. [Google Scholar]
  29. Nelson LE, Wilton L, Agyarko-Poku T, Zhang N, Aluoch M, Thach CT,…Adu-Sarkodie Y (2015). The Association of HIV Stigma and HIV/STD Knowledge With Sexual Risk Behaviors Among Adolescent and Adult Men Who Have Sex With Men in Ghana, West Africa. Res Nurs Health. doi: 10.1002/nur.21650 [DOI] [PubMed] [Google Scholar]
  30. Nelson LE, Wilton L, Agyarko-Poku T, Zhang N, Zou Y, Aluoch M,…Adu-Sarkodie Y (2015). Predictors of Condom Use among Peer Social Networks of Men Who Have Sex with Men in Ghana, West Africa. PLoS One, 10(1), e0115504. doi: 10.1371/journal.pone.0115504 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Nyblade L, Reddy A, Mbote D, Kraemer J, Stockton M, Kemunto C,…Barker C (2017). The relationship between health worker stigma and uptake of HIV counseling and testing and utilization of non-HIV health services: the experience of male and female sex workers in Kenya. AIDS Care, 29(11), 1364–1372. doi: 10.1080/09540121.2017.1307922 [DOI] [PubMed] [Google Scholar]
  32. Ogunbajo A, Kang A, Shangani S, Wade RM, Onyango DP, Odero WW, & Harper GW (2019). Awareness and Acceptability of pre-exposure prophylaxis (PrEP) among gay, bisexual and other men who have sex with men (GBMSM) in Kenya. AIDS care, 1–8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Ogunbajo A, Kershaw T, Kushwaha S, Boakye F, Wallace-Atiapah ND, & Nelson LE (2017). Barriers, Motivators, and Facilitators to Engagement in HIV Care Among HIV-Infected Ghanaian Men Who have Sex with Men (MSM). AIDS Behav. doi: 10.1007/s10461-017-1806-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Organization WH (2012). Guidance on Pre-exposure oral prophylaxis (PrEP) for serodiscordant couples, men who have sex with men and transgender women at high risk of HIV in implementation research, Annexes [PubMed] [Google Scholar]
  35. Paltiel AD, Freedberg KA, Scott CA, Schackman BR, Losina E, Wang B,…Walensky RP (2009). HIV preexposure prophylaxis in the United States: impact on lifetime infection risk, clinical outcomes, and cost-effectiveness. Clinical Infectious Diseases, 48(6), 806–815 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Risher K, Adams D, Sithole B, Ketende S, Kennedy C, Mnisi Z,…Baral SD (2013). Sexual stigma and discrimination as barriers to seeking appropriate healthcare among men who have sex with men in Swaziland. J Int AIDS Soc, 16(3 Suppl 2), 18715. doi: 10.7448/IAS.16.3.18715 [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Sano Y, Sedziafa AP, Amoyaw JA, Boateng GO, Kuuire VZ, Boamah S, & Kwon E (2016). Exploring the linkage between exposure to mass media and HIV testing among married women and men in Ghana . AIDS care, 28(6), 684–688 [DOI] [PubMed] [Google Scholar]
  38. Schneider J, Kumar R, Dandona R, Kumar P, Kumar A, Lakshmi V,…Dandona L (2012). Social network and risk-taking behavior most associated with rapid HIV testing, circumcision, and preexposure prophylaxis acceptability among high-risk Indian men. AIDS Patient Care STDS, 26(10), 631–640. doi: 10.1089/apc.2012.0188 [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Service GS (2013). 2010 Population and Housing Census: National Analytic Report. Accra, Ghana: G. S. Service. [Google Scholar]
  40. Service GS (2016). 2010 Population Projection by Sex, 2010–2016. Accra, Ghana: G. S. Service. [Google Scholar]
  41. Smith DK, Herbst JH, & Rose CE (2015). Estimating HIV protective effects of method adherence with combinations of preexposure prophylaxis and condom use among African American men who have sex with men. Sex Transm Dis, 42(2), 88–92. doi: 10.1097/OLQ.0000000000000238 [DOI] [PubMed] [Google Scholar]
  42. Soto T, Komaie G, Neilands TB, & Johnson MO (2013). Exposure to crime and trauma among HIV-infected men who have sex with men: associations with HIV stigma and treatment engagement. J Assoc Nurses AIDS Care, 24(4), 299–307. doi: 10.1016/j.jana.2012.11.008 [DOI] [PubMed] [Google Scholar]
  43. Tanser F, Vandormael A, Cuadros D, Phillips AN, de Oliveira T, Tomita A,…Pillay D (2017). Effect of population viral load on prospective HIV incidence in a hyperendemic rural African community. Sci Transl Med, 9(420). doi: 10.1126/scitranslmed.aam8012 [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. UNAIDS, J. U. N. P. o. H. A. (2018). Country Fact Sheets, Ghana 2016. Geneva, Switzerland. [Google Scholar]
  45. Yawson AE, Appiah LK, Yawson AO, Bonsu G, Aluze-Ele S, Amanhyia NAO,…Beckwith C (2014). Sex differences in perceived risk and testing experience of HIV in an urban fishing setting in Ghana. International journal for equity in health, 13(1), 109. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Yi S, Tuot S, Mwai GW, Ngin C, Chhim K, Pal K,…Mburu G (2017). Awareness and willingness to use HIV pre‐exposure prophylaxis among men who have sex with men in low‐and middle‐income countries: a systematic review and meta‐analysis. Journal of the International AIDS Society, 20(1) [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Zhang Y, Peng B, She Y, Liang H, Peng H-B, Qian H-Z,…Huang A (2013). Attitudes toward HIV pre-exposure prophylaxis among men who have sex with men in western China. AIDS patient care and STDs, 27(3), 137–141 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Zhou F, Gao L, Li S, Li D, Zhang L, Fan W,…Yan L (2012). Willingness to accept HIV pre-exposure prophylaxis among Chinese men who have sex with men. PLoS One, 7(3), e32329. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES