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 LaRon E. Nelson, Leo Wilton, Thomas Agyarko-Poku, Nanhua Zhang, Marilyn Aluoch, Chia T. Thach, Samuel Owiredu Hanson, Yaw Adu-Sarkodie
Correspondence to: LaRon E. Nelson E-mail: [email protected] LaRon E. Nelson Dean’s Endowed Fellow in Health Disparities & Assistant Professor School of Nursing University of Rochester 601 Elmwood Ave., Box SON Rochester, NY 14642 Leo Wilton Associate Professor Department of Human Development State University of New York at Binghamton Binghamton, NY Lecturer Faculty of Humanities University of Johannesburg Auckland Park, South Africa Thomas Agyarko-Poku Lecturer School of Medical Sciences Kwame Nkrumah University of Science & Technology Kumasi, Ghana Nanhua Zhang Assistant Professor Department of Biostatistics & Epidemiology Cincinnati Children’s Hospital Medical Center Cincinnati, OH
Note: Additional authors are listed on the last page.
C
2015 Wiley Periodicals, Inc.
Abstract: Ghanaian men who have sex with men (MSM) have a high HIV seroprevalence, but despite a critical need to address this public health concern, research evidence has been extremely limited on influences on sexual risk behavior among MSM in Ghana. To investigate associations between HIV/STD knowledge, HIV stigma, and sexual behaviors in a sample of MSM in Ghana, we conducted a secondary data analysis of cross-sectional survey data from a non-probability sample of Ghanaian MSM (N ¼ 137). Nearly all the men (93%) had more than one current sex partner (M ¼ 5.11, SD ¼ 7.4). Of those reported partners, the average number of current female sexual partners was 1.1 (SD ¼ 2.6). Overall, knowledge levels about HIV and STDs were low, and HIV stigma was high. There was no agerelated difference in HIV stigma. Younger MSM (25 years) used condoms less often for anal and vaginal sex than did those over 25. Relative frequency of condom use for oral sex was lower in younger men who had higher STD knowledge and also was lower in older men who reported high HIV stigma. Knowledge and stigma were not associated with condom use for anal or vaginal sex in either age group. These descriptive data highlight the need for the development of intervention programs that address HIV/STD prevention knowledge gaps and reduce HIV stigma in Ghanaian communities. Intervention research in Ghana should address age-groupspecific HIV prevention needs of MSM youth. ß 2015 Wiley Periodicals, Inc. Keywords: MSM; HIV; STI; Ghana; West Africa; condom use; HIV knowledge; adolescents; health disparities Research in Nursing & Health, 2015, 38, 194–206 Accepted 28 January 2015 DOI: 10.1002/nur.21650 Published online 23 March 2015 in Wiley Online Library (wileyonlinelibrary.com).
Nearly three-fourths of the global distribution of HIV is concentrated in sub-Saharan Africa (Joint United National Programme on HIV/AIDS [UNAIDS], 2012; Kenyon, Buyze & Colebunders, 2014; Population Reference Bureau, 2012). HIV prevalence among men who have sex with men (MSM) is more than triple the HIV prevalence for the general population (5% vs. 17.9%) in the sub-Saharan African region (Beyrer et al., 2012; UNAIDS, 2012) and higher than any other region in the world but the Caribbean (Beyrer et al., 2012; UNAIDS, 2010). Ghana is a democratic republic situated on the Gulf of Guinea in West Africa. While the HIV prevalence in the general population in Ghana decreased from 2.3% to 1.5% between 2010 and 2012 (Ghana AIDS Commission, 2012), the prevalence for MSM at the same time was estimated to be 17% (Beyrer et al., 2012; Ghana AIDS Commission, 2012). Young
KNOWLEDGE, HIV STIGMA, AND SEX BEHAVIORS IN GHANAIAN MSM/ NELSON ET AL.
men may be at particular risk. Major shifts in the age distribution curve for new HIV infections among MSM occur at age approximately age 25, with younger MSM disproportionately represented in new infections (Hall et al., 2008; Lieb et al., 2011; Prejean et al., 2011). Like many other African nations, Ghana still maintains colonial-era anti-sodomy laws that criminalize sexual practices between men and impose penalties on people who engage in same-gender sexual practices. Current statutes also criminalize sexual practice among people living with HIV, by, for example, making it illegal to have safer sex (e. g., using latex condoms) without first disclosing one's HIV seropositive status to a sexual partner. In this context, Ghanaian MSM must make informed decisions about sexual behaviors within a context where homophobia is the norm, and HIV stigma is high and is directed at them regardless of their HIV status. The research evidence on HIV stigma in Ghana is based on data from Ghanaian heterosexuals (Mwinituo & Mill, 2006; Poku, Linn, Fife, Azar, & Kendrick, 2005; Stephenson, 2009; Ulasi et al., 2009). There is limited evidence regarding HIV stigma in MSM, its correlation with HIV/STD knowledge to accurately assess sexual risks and make informed decisions, or the association of stigma or knowledge with sexual behavior in younger and older MSM in Ghana. The purpose of this study was to investigate associations between HIV/STD knowledge, HIV stigma, and sexual behaviors in a sample of MSM in Ghana and determine whether those associations differed in younger and older men.
195
2000; Carey, Morrison-Beedy, & Johnson, 1997; Fisher & Fisher, 1992). It is established that HIV stigma is a major obstacle to both primary and secondary HIV prevention in Ghana (Bosu, Yeboah, Gurumurthy, & Atuahene, 2009; Makofane, Beck, & Ayala, 2014; Sabin et al., 2013). Hostile attitudes regarding same-sex behavioral practices are common in Ghana and are intertwined with beliefs that HIV infection is punishment for engaging in same-sex behaviors (Sabin et al., 2013). In this context, MSM need not be infected with HIV to experience HIV stigma because MSM are believed to be the vectors of HIV. Knowledge and stigma may work differently for adolescent and adult MSM. Adult maturation of the dorsal lateral prefrontal cortex (the region of the brain responsible for regulating behavioral impulse) occurs around age 25 (Casey, Giedd, & Thomas, 2000; Giedd, 2004; Mills, Goddings, Clasen, Giedd, & Blakemore, 2014; Spear, 2000), and adult cognitive and behavioral development does not correspond with socio-legal criteria for adulthood (i.e., ages 18 and 21 years). Differences in knowledge, stigma, or sexual risk behavior between adolescent and adult MSM have not previously been studied in Ghana. Very little is known about HIV knowledge, stigma, and sexual behavior in adolescent or adult Ghanaian MSM. This study represented an initial effort to explore these factors in this high-risk group.
Methods Design and Study Context
Influences on HIV Risk Behaviors HIV risk is influenced by the intersection of psychological (e. g., HIV/STD knowledge), biological (e.g., cognitive development, untreated STDs), environmental (e.g., HIV stigma, institutionalized homophobia), and behavioral (e.g., sexual behavior, condom use) factors (Crepaz & Marks, 2001; Tucker, Simpson, Huang, Roth, & Stewart, 2013). In settings across sub-Saharan Africa, behavioral risk factors influencing HIV infection included substance use, number of sex partners, untreated STDs, unprotected anal intercourse, commercial sex work, and unprotected sex with known HIVpositive partners (Gilbert et al., 2013; Merrigan et al., 2011; Sabin et al., 2013). Other teams across the globe have identified similar risk behavior patterns (Koblin et al., 2003; Ma et al., 2007; Millett, Flores, Peterson, & Bakeman, 2007). HIV/STD knowledge is a foundational component of people's capacities to accurately assess their sexual behavioral risks and to develop informed menus of risk-reduction options (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999; Johnson et al., 2008; Ng et al., 2012; Nunn et al., 2011). Yet, there is overwhelming evidence that greater HIV/STD knowledge alone is insufficient to predict sexual risk-reduction behavior such as condom use (Carey,
Research in Nursing & Health
The present report is of a secondary analysis of cross-sectional survey data generated from the Kumasi & Accra Project to Prevent AIDS (KAPPA). The KAPPA study was an embedded multiple-case study of the structure, psychosocial characteristics, and function of MSM peer networks across three community contexts. The KAPPA study included focus group discussions, one-on-one interviews with peer network leaders, community leaders, and health care providers, and a cross-sectional survey of MSM peer network members. In the survey, we assessed sexual behavior and a range of psychosocial variables including HIV stigma, HIV knowledge, and STD knowledge. The KAPPA study was conducted between January 2012 and July 2012. The Kwame Nkrumah University of Science & Technology (Ghana) Committee on Human Research, Ethics and Publications and the University of Toronto HIV Research Ethics Board approved this study.
Setting Our study was focused within three specific Ghanaian communities. We selected three communities in order to compare the structure and functions of peer networks and the ways in which the networks regulation of sexual behavior
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differed across the communities. We selected Accra, Kumasi, and Manya Krobo/Koforidua (Manya Krobo) for their social and cultural diversity and because they are the three communities with the highest prevalence of HIV in MSM. Accra is the administrative and commercial capital of Ghana and its largest city with approximately 2.3 million residents. It is an international city of culturally and ethnically diverse neighborhoods with high percentages of ex-patriot residents from Europe, the Middle East, and United States. Accra is understood to be more liberal than most Ghanaian communities—a likely product of the multicultural influence of foreign nationals living in Accra. Accra also has the highest prevalence of HIV (34%) among MSM—twice the national HIV prevalence in MSM (Ghana AIDS Commission, 2012). Kumasi is Ghana's second largest city and, like Accra, an urban metropolis. Kumasi is a major trading post of domestically produced goods due to its geographic location in the center of the country. Kumasi is also the seat of the Asante Kingdom, the largest ethnic group in Ghana. It is popularly known as the cultural capital of Ghana, due to the dominance of Asante cultural norms and institutions. Manya Krobo is a rural area in the eastern region. Its history as a thriving agricultural community was undermined by the construction of the Akosomba Dam, which resulted in severe flooding and forced displacement of farmers. Over time, Manya Krobo developed a disproportionately high prevalence of HIV (Suavé et al., 2002) and an unwelcome reputation for exporting commercial sex workers to the “big city” (Accra), believed to be a survival strategy to make up for revenue losses caused by the destruction of the Krobo farmlands. The HIV prevalence in MSM in Kumasi (14%) and Manya Krobo (11%) is lower than the national average for MSM—but nearly 10 times higher than the prevalence in the general population (Ghana AIDS Commission, 2012).
Research Team This study was conducted in collaboration with the Centre for Popular Education & Human Rights Ghana, a local community-based organization (CBO) providing health education and advocacy for lesbian, gay, bisexual and transgender (LGBT) Ghanaians. We also collaborated with the Otumfuo Osei Tutu II Foundation, which is the charitable organization of King Otumfuo Osei Tutu II, the current leader of the Asante Kingdom. The research assistants (RAs) for this study were affiliated with these local stakeholder organizations. All RAs were Ghanaian men who had experience working with MSM in healthcare and research settings. All RAs participated in a 4-day research training on human subjects research ethics, informed consent, research equipment use, emergency procedures, and other specifics of the research protocol. The RAs in turn educated the investigator team on best practices for engaging and interacting with MSM in the local Ghanaian context. The
Research in Nursing & Health
RAs were multilingual, proficient in Ghanaian local languages (e.g., Twi, Ga, Hausa, Krobo), and familiar with core Ghanaian cultural worldviews, values, and linguistic frameworks in the communities where the study was conducted. Most of the RAs were themselves MSM. This reciprocal training practice led to improvements in study recruitment and screening procedures.
Sampling, Recruitment, and Enrollment The sampling strategy for the parent study (KAPPA) was to tap into 6–8 MSM peer networks in each of the three sites. We used a chain-referral sampling method, in which initial recruits, or seeds, were identified by the peer outreach staff serving as RAs. The RAs leveraged their experiences working with local MSM to identify venues where seeds could be recruited. RAs also used their current portfolios of MSM clients as a source for directly identifying potential seeds or indirectly identifying potential seeds through referrals. RAs provided potential seeds with information about the study's purpose and procedures and screened those interested for preliminary eligibility. To be eligible for the study, seeds had to: be 18 years or older, Ghanaian, male at birth, currently self-identify as a man, and report sexual contact with another man at least once within the past 6 months. In this study, we focused our recruitment on behavioral criteria and not on sexual orientation, so men did not need to identify as gay or report only having sex with other men to be in the study. If the individual-level focused screening criteria were satisfied, seeds proceeded to a peer-network-focused screening. The RA briefly screened the seeds to determine the extensiveness (e.g., How many MSM friends do you have?) and characteristics (e.g., Are your MSM friends “out” to one another regarding their same-gender sexual behaviors?) of their peer networks. Seeds were excluded from recruiting their MSM peer network if their self-reported network size was less than eight MSM or if they reported that the peers in their network had not disclosed their sexuality to other peers in their network. This exclusion criterion was used to prevent focus group participants from involuntarily or implicitly disclosing their same-gender sexual practices to friends to whom they had not previously disclosed. If a network met the inclusion criteria, the seed was asked to invite up to 12 of its members to participate in a focus group. A peer network was included only if at least four members agreed to participate in the focus group. Because the RAs were peer outreach workers, they were already familiar with many of the men who presented for study participation. Figure 1 illustrates the cascade of peer network recruitment and enrollment in the KAPPA study. Due to widespread economic and material deprivation in Ghanaian communities, research studies' monetary and material participation incentives can be attractive opportunities for young men to generate income by feigning eligibility criteria. Our local CBO partners had many years of
KNOWLEDGE, HIV STIGMA, AND SEX BEHAVIORS IN GHANAIAN MSM/ NELSON ET AL.
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Seeds Assessed for Preliminary Eligibility (n=33)
Excluded (n=3) Did not meet inclusion criteria (n=2) Declined to participate (n=1)
Seeds Assessed for Network Eligibility (n=30)
Excluded (n=2) Did not meet network size criteria (n=2)
Number of Seeds Activated to Recruit (n=28)
Accra Seeds (n=11)
Kumasi Seeds (n=10)
Networks Excluded (n=3) Network 25 years (older) and 25 years (younger) based on past evidence. In addition to descriptive statistics, we calculated relative frequency of condom use (rel. f ¼ f/n) by dividing the number of sexual episodes (n) into the number of times that condoms were used (f). We performed chi-square and t-tests to assess age-related differences in variable frequencies and means for men in both age groups. We conducted multivariate regression analyses to determine which variables, or combination of variables, predicted relative frequency of condom use for anal, oral, and vaginal sex in each age group. Interactions among predictors were examined and significant interaction terms, if any, included in the analyses. HIV
KNOWLEDGE, HIV STIGMA, AND SEX BEHAVIORS IN GHANAIAN MSM/ NELSON ET AL.
knowledge, STD knowledge, and HIV stigma were entered simultaneously as predictors into the regression model.
Results Demographics A full summary of selected demographic variables is presented in Table 1. The men (N ¼ 137) ranged in age from 18 to 55. The sample was primarily comprised of adolescents and young adult MSM, with approximately 60% under age 25 and 96% under age 35. Three ethnic groups (Asante, Ga, and Krobo) accounted for more than three-quarters (77.4%) of the sample. The remaining quarter was composed of six other ethnic groups. The men were predominantly educated at or beyond primary grade 12 (65.5%). The mean age at first sexual intercourse was 15.8 (SD ¼ 3.6) years. Twothirds of the men reported that they had been tested for HIV at least once in their lifetime. The majority (86%) had been tested for HIV in the past 12 months.
HIV Knowledge The mean score for HIV knowledge was low (M ¼ 12 out of a possible 18, SD ¼ 3.71), or 67%. Overall, the lowest percentages of correct responses were for items related to women's anatomy and physiology and items that suggested water had a role in the facilitation or prevention of HIV transmission. The men had the highest percentages of correct responses for items regarding the use of condoms to prevent HIV transmission. Younger men were less knowledgeable about HIV (Table 2) and had more incorrect responses than older men on four items. The items for which younger men were less knowledgeable were about women, HIV post-exposure risk reduction, and the window period for detection of HIV antibodies in a screening test.
STD Knowledge The mean score for STD knowledge also was low and substantially lower than HIV knowledge (M ¼ 12.2 [SD ¼ 5.7] out of a possible 27, or 45%). On the STDKQ scale, the men had the lowest percentage of correct responses on items pertaining to viral infection and transmission in women. Additionally, the men had very low knowledge pertaining to onset, infectious stages, and immunity to STIs (e. g., a person develops open sores on his or her genitals soon after infection; a person who had gonorrhea in the past is immune). Overall, the men had the highest percentages of correct responses on items related to condom use. Younger men had more incorrect responses on one-third of the STDKQ items. Most of these items also pertained to onset, infectious stages, and immunity of STDs. However, younger men had more correct responses on STDKQ items regarding whether HPV causes genital warts and leads to cancer, and whether gonorrhea is a curable infection.
Research in Nursing & Health
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Table 1. Characteristics of Participants (N ¼ 137) Characteristic Age (years) 35 Highest level of education 21 years Used drugs in past 3 months Yes No I do not want to answer Used drugs in past 12 months Yes No
n
%
19 75 39 4
14 55 28 3
28 18 32 22 37
20 13 24 16 27
103 1 33
75 1 24
93 43
69 31
88 2 3
95 2 3
23 36 21 12
25 39 22 14
21 46 44 17 9
15 34 32 12 7
12 122 3
89 9 2
10 127
7 93
HIV Stigma HIV stigma was high among this sample (M ¼ 24.1, SD ¼ 7.3), which represented 73% of the total possible score. There was no difference in HIV stigma between older and younger MSM (Table 2). A higher proportion of older men felt that most people in their community attributed shame, disgust, and dishonor to HIV-positive serostatus and reported that most people in their community stigmatized having an HIV-positive person participate in interactions involving the preparation and serving of food (e.g., people would not want an HIV-infected person cooking for them, people would not want an HIV-infected person to hold or feed their children). For the item specifically pertaining to MSM, 50% of the men strongly agreed that people in their
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Table 2. Mean HIV Knowledge, STD Knowledge, and HIV Stigma Scores in Younger and Older MSM Younger (n ¼ 94)
HIV knowledge STD knowledge HIV stigma
Older (n ¼ 43)
M
SD
M
SD
t(df 135)
p
12.5 13.2 23.3
3.5 5.6 7.1
10.9 10.0 25.9
3.9 5.2 7.5
2.39 3.12 1.93
Correspondence to: LaRon E. Nelson E-mail: [email protected] LaRon E. Nelson Dean’s Endowed Fellow in Health Disparities & Assistant Professor School of Nursing University of Rochester 601 Elmwood Ave., Box SON Rochester, NY 14642 Leo Wilton Associate Professor Department of Human Development State University of New York at Binghamton Binghamton, NY Lecturer Faculty of Humanities University of Johannesburg Auckland Park, South Africa Thomas Agyarko-Poku Lecturer School of Medical Sciences Kwame Nkrumah University of Science & Technology Kumasi, Ghana Nanhua Zhang Assistant Professor Department of Biostatistics & Epidemiology Cincinnati Children’s Hospital Medical Center Cincinnati, OH
Note: Additional authors are listed on the last page.
C
2015 Wiley Periodicals, Inc.
Abstract: Ghanaian men who have sex with men (MSM) have a high HIV seroprevalence, but despite a critical need to address this public health concern, research evidence has been extremely limited on influences on sexual risk behavior among MSM in Ghana. To investigate associations between HIV/STD knowledge, HIV stigma, and sexual behaviors in a sample of MSM in Ghana, we conducted a secondary data analysis of cross-sectional survey data from a non-probability sample of Ghanaian MSM (N ¼ 137). Nearly all the men (93%) had more than one current sex partner (M ¼ 5.11, SD ¼ 7.4). Of those reported partners, the average number of current female sexual partners was 1.1 (SD ¼ 2.6). Overall, knowledge levels about HIV and STDs were low, and HIV stigma was high. There was no agerelated difference in HIV stigma. Younger MSM (25 years) used condoms less often for anal and vaginal sex than did those over 25. Relative frequency of condom use for oral sex was lower in younger men who had higher STD knowledge and also was lower in older men who reported high HIV stigma. Knowledge and stigma were not associated with condom use for anal or vaginal sex in either age group. These descriptive data highlight the need for the development of intervention programs that address HIV/STD prevention knowledge gaps and reduce HIV stigma in Ghanaian communities. Intervention research in Ghana should address age-groupspecific HIV prevention needs of MSM youth. ß 2015 Wiley Periodicals, Inc. Keywords: MSM; HIV; STI; Ghana; West Africa; condom use; HIV knowledge; adolescents; health disparities Research in Nursing & Health, 2015, 38, 194–206 Accepted 28 January 2015 DOI: 10.1002/nur.21650 Published online 23 March 2015 in Wiley Online Library (wileyonlinelibrary.com).
Nearly three-fourths of the global distribution of HIV is concentrated in sub-Saharan Africa (Joint United National Programme on HIV/AIDS [UNAIDS], 2012; Kenyon, Buyze & Colebunders, 2014; Population Reference Bureau, 2012). HIV prevalence among men who have sex with men (MSM) is more than triple the HIV prevalence for the general population (5% vs. 17.9%) in the sub-Saharan African region (Beyrer et al., 2012; UNAIDS, 2012) and higher than any other region in the world but the Caribbean (Beyrer et al., 2012; UNAIDS, 2010). Ghana is a democratic republic situated on the Gulf of Guinea in West Africa. While the HIV prevalence in the general population in Ghana decreased from 2.3% to 1.5% between 2010 and 2012 (Ghana AIDS Commission, 2012), the prevalence for MSM at the same time was estimated to be 17% (Beyrer et al., 2012; Ghana AIDS Commission, 2012). Young
KNOWLEDGE, HIV STIGMA, AND SEX BEHAVIORS IN GHANAIAN MSM/ NELSON ET AL.
men may be at particular risk. Major shifts in the age distribution curve for new HIV infections among MSM occur at age approximately age 25, with younger MSM disproportionately represented in new infections (Hall et al., 2008; Lieb et al., 2011; Prejean et al., 2011). Like many other African nations, Ghana still maintains colonial-era anti-sodomy laws that criminalize sexual practices between men and impose penalties on people who engage in same-gender sexual practices. Current statutes also criminalize sexual practice among people living with HIV, by, for example, making it illegal to have safer sex (e. g., using latex condoms) without first disclosing one's HIV seropositive status to a sexual partner. In this context, Ghanaian MSM must make informed decisions about sexual behaviors within a context where homophobia is the norm, and HIV stigma is high and is directed at them regardless of their HIV status. The research evidence on HIV stigma in Ghana is based on data from Ghanaian heterosexuals (Mwinituo & Mill, 2006; Poku, Linn, Fife, Azar, & Kendrick, 2005; Stephenson, 2009; Ulasi et al., 2009). There is limited evidence regarding HIV stigma in MSM, its correlation with HIV/STD knowledge to accurately assess sexual risks and make informed decisions, or the association of stigma or knowledge with sexual behavior in younger and older MSM in Ghana. The purpose of this study was to investigate associations between HIV/STD knowledge, HIV stigma, and sexual behaviors in a sample of MSM in Ghana and determine whether those associations differed in younger and older men.
195
2000; Carey, Morrison-Beedy, & Johnson, 1997; Fisher & Fisher, 1992). It is established that HIV stigma is a major obstacle to both primary and secondary HIV prevention in Ghana (Bosu, Yeboah, Gurumurthy, & Atuahene, 2009; Makofane, Beck, & Ayala, 2014; Sabin et al., 2013). Hostile attitudes regarding same-sex behavioral practices are common in Ghana and are intertwined with beliefs that HIV infection is punishment for engaging in same-sex behaviors (Sabin et al., 2013). In this context, MSM need not be infected with HIV to experience HIV stigma because MSM are believed to be the vectors of HIV. Knowledge and stigma may work differently for adolescent and adult MSM. Adult maturation of the dorsal lateral prefrontal cortex (the region of the brain responsible for regulating behavioral impulse) occurs around age 25 (Casey, Giedd, & Thomas, 2000; Giedd, 2004; Mills, Goddings, Clasen, Giedd, & Blakemore, 2014; Spear, 2000), and adult cognitive and behavioral development does not correspond with socio-legal criteria for adulthood (i.e., ages 18 and 21 years). Differences in knowledge, stigma, or sexual risk behavior between adolescent and adult MSM have not previously been studied in Ghana. Very little is known about HIV knowledge, stigma, and sexual behavior in adolescent or adult Ghanaian MSM. This study represented an initial effort to explore these factors in this high-risk group.
Methods Design and Study Context
Influences on HIV Risk Behaviors HIV risk is influenced by the intersection of psychological (e. g., HIV/STD knowledge), biological (e.g., cognitive development, untreated STDs), environmental (e.g., HIV stigma, institutionalized homophobia), and behavioral (e.g., sexual behavior, condom use) factors (Crepaz & Marks, 2001; Tucker, Simpson, Huang, Roth, & Stewart, 2013). In settings across sub-Saharan Africa, behavioral risk factors influencing HIV infection included substance use, number of sex partners, untreated STDs, unprotected anal intercourse, commercial sex work, and unprotected sex with known HIVpositive partners (Gilbert et al., 2013; Merrigan et al., 2011; Sabin et al., 2013). Other teams across the globe have identified similar risk behavior patterns (Koblin et al., 2003; Ma et al., 2007; Millett, Flores, Peterson, & Bakeman, 2007). HIV/STD knowledge is a foundational component of people's capacities to accurately assess their sexual behavioral risks and to develop informed menus of risk-reduction options (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999; Johnson et al., 2008; Ng et al., 2012; Nunn et al., 2011). Yet, there is overwhelming evidence that greater HIV/STD knowledge alone is insufficient to predict sexual risk-reduction behavior such as condom use (Carey,
Research in Nursing & Health
The present report is of a secondary analysis of cross-sectional survey data generated from the Kumasi & Accra Project to Prevent AIDS (KAPPA). The KAPPA study was an embedded multiple-case study of the structure, psychosocial characteristics, and function of MSM peer networks across three community contexts. The KAPPA study included focus group discussions, one-on-one interviews with peer network leaders, community leaders, and health care providers, and a cross-sectional survey of MSM peer network members. In the survey, we assessed sexual behavior and a range of psychosocial variables including HIV stigma, HIV knowledge, and STD knowledge. The KAPPA study was conducted between January 2012 and July 2012. The Kwame Nkrumah University of Science & Technology (Ghana) Committee on Human Research, Ethics and Publications and the University of Toronto HIV Research Ethics Board approved this study.
Setting Our study was focused within three specific Ghanaian communities. We selected three communities in order to compare the structure and functions of peer networks and the ways in which the networks regulation of sexual behavior
196
RESEARCH IN NURSING & HEALTH
differed across the communities. We selected Accra, Kumasi, and Manya Krobo/Koforidua (Manya Krobo) for their social and cultural diversity and because they are the three communities with the highest prevalence of HIV in MSM. Accra is the administrative and commercial capital of Ghana and its largest city with approximately 2.3 million residents. It is an international city of culturally and ethnically diverse neighborhoods with high percentages of ex-patriot residents from Europe, the Middle East, and United States. Accra is understood to be more liberal than most Ghanaian communities—a likely product of the multicultural influence of foreign nationals living in Accra. Accra also has the highest prevalence of HIV (34%) among MSM—twice the national HIV prevalence in MSM (Ghana AIDS Commission, 2012). Kumasi is Ghana's second largest city and, like Accra, an urban metropolis. Kumasi is a major trading post of domestically produced goods due to its geographic location in the center of the country. Kumasi is also the seat of the Asante Kingdom, the largest ethnic group in Ghana. It is popularly known as the cultural capital of Ghana, due to the dominance of Asante cultural norms and institutions. Manya Krobo is a rural area in the eastern region. Its history as a thriving agricultural community was undermined by the construction of the Akosomba Dam, which resulted in severe flooding and forced displacement of farmers. Over time, Manya Krobo developed a disproportionately high prevalence of HIV (Suavé et al., 2002) and an unwelcome reputation for exporting commercial sex workers to the “big city” (Accra), believed to be a survival strategy to make up for revenue losses caused by the destruction of the Krobo farmlands. The HIV prevalence in MSM in Kumasi (14%) and Manya Krobo (11%) is lower than the national average for MSM—but nearly 10 times higher than the prevalence in the general population (Ghana AIDS Commission, 2012).
Research Team This study was conducted in collaboration with the Centre for Popular Education & Human Rights Ghana, a local community-based organization (CBO) providing health education and advocacy for lesbian, gay, bisexual and transgender (LGBT) Ghanaians. We also collaborated with the Otumfuo Osei Tutu II Foundation, which is the charitable organization of King Otumfuo Osei Tutu II, the current leader of the Asante Kingdom. The research assistants (RAs) for this study were affiliated with these local stakeholder organizations. All RAs were Ghanaian men who had experience working with MSM in healthcare and research settings. All RAs participated in a 4-day research training on human subjects research ethics, informed consent, research equipment use, emergency procedures, and other specifics of the research protocol. The RAs in turn educated the investigator team on best practices for engaging and interacting with MSM in the local Ghanaian context. The
Research in Nursing & Health
RAs were multilingual, proficient in Ghanaian local languages (e.g., Twi, Ga, Hausa, Krobo), and familiar with core Ghanaian cultural worldviews, values, and linguistic frameworks in the communities where the study was conducted. Most of the RAs were themselves MSM. This reciprocal training practice led to improvements in study recruitment and screening procedures.
Sampling, Recruitment, and Enrollment The sampling strategy for the parent study (KAPPA) was to tap into 6–8 MSM peer networks in each of the three sites. We used a chain-referral sampling method, in which initial recruits, or seeds, were identified by the peer outreach staff serving as RAs. The RAs leveraged their experiences working with local MSM to identify venues where seeds could be recruited. RAs also used their current portfolios of MSM clients as a source for directly identifying potential seeds or indirectly identifying potential seeds through referrals. RAs provided potential seeds with information about the study's purpose and procedures and screened those interested for preliminary eligibility. To be eligible for the study, seeds had to: be 18 years or older, Ghanaian, male at birth, currently self-identify as a man, and report sexual contact with another man at least once within the past 6 months. In this study, we focused our recruitment on behavioral criteria and not on sexual orientation, so men did not need to identify as gay or report only having sex with other men to be in the study. If the individual-level focused screening criteria were satisfied, seeds proceeded to a peer-network-focused screening. The RA briefly screened the seeds to determine the extensiveness (e.g., How many MSM friends do you have?) and characteristics (e.g., Are your MSM friends “out” to one another regarding their same-gender sexual behaviors?) of their peer networks. Seeds were excluded from recruiting their MSM peer network if their self-reported network size was less than eight MSM or if they reported that the peers in their network had not disclosed their sexuality to other peers in their network. This exclusion criterion was used to prevent focus group participants from involuntarily or implicitly disclosing their same-gender sexual practices to friends to whom they had not previously disclosed. If a network met the inclusion criteria, the seed was asked to invite up to 12 of its members to participate in a focus group. A peer network was included only if at least four members agreed to participate in the focus group. Because the RAs were peer outreach workers, they were already familiar with many of the men who presented for study participation. Figure 1 illustrates the cascade of peer network recruitment and enrollment in the KAPPA study. Due to widespread economic and material deprivation in Ghanaian communities, research studies' monetary and material participation incentives can be attractive opportunities for young men to generate income by feigning eligibility criteria. Our local CBO partners had many years of
KNOWLEDGE, HIV STIGMA, AND SEX BEHAVIORS IN GHANAIAN MSM/ NELSON ET AL.
197
Seeds Assessed for Preliminary Eligibility (n=33)
Excluded (n=3) Did not meet inclusion criteria (n=2) Declined to participate (n=1)
Seeds Assessed for Network Eligibility (n=30)
Excluded (n=2) Did not meet network size criteria (n=2)
Number of Seeds Activated to Recruit (n=28)
Accra Seeds (n=11)
Kumasi Seeds (n=10)
Networks Excluded (n=3) Network 25 years (older) and 25 years (younger) based on past evidence. In addition to descriptive statistics, we calculated relative frequency of condom use (rel. f ¼ f/n) by dividing the number of sexual episodes (n) into the number of times that condoms were used (f). We performed chi-square and t-tests to assess age-related differences in variable frequencies and means for men in both age groups. We conducted multivariate regression analyses to determine which variables, or combination of variables, predicted relative frequency of condom use for anal, oral, and vaginal sex in each age group. Interactions among predictors were examined and significant interaction terms, if any, included in the analyses. HIV
KNOWLEDGE, HIV STIGMA, AND SEX BEHAVIORS IN GHANAIAN MSM/ NELSON ET AL.
knowledge, STD knowledge, and HIV stigma were entered simultaneously as predictors into the regression model.
Results Demographics A full summary of selected demographic variables is presented in Table 1. The men (N ¼ 137) ranged in age from 18 to 55. The sample was primarily comprised of adolescents and young adult MSM, with approximately 60% under age 25 and 96% under age 35. Three ethnic groups (Asante, Ga, and Krobo) accounted for more than three-quarters (77.4%) of the sample. The remaining quarter was composed of six other ethnic groups. The men were predominantly educated at or beyond primary grade 12 (65.5%). The mean age at first sexual intercourse was 15.8 (SD ¼ 3.6) years. Twothirds of the men reported that they had been tested for HIV at least once in their lifetime. The majority (86%) had been tested for HIV in the past 12 months.
HIV Knowledge The mean score for HIV knowledge was low (M ¼ 12 out of a possible 18, SD ¼ 3.71), or 67%. Overall, the lowest percentages of correct responses were for items related to women's anatomy and physiology and items that suggested water had a role in the facilitation or prevention of HIV transmission. The men had the highest percentages of correct responses for items regarding the use of condoms to prevent HIV transmission. Younger men were less knowledgeable about HIV (Table 2) and had more incorrect responses than older men on four items. The items for which younger men were less knowledgeable were about women, HIV post-exposure risk reduction, and the window period for detection of HIV antibodies in a screening test.
STD Knowledge The mean score for STD knowledge also was low and substantially lower than HIV knowledge (M ¼ 12.2 [SD ¼ 5.7] out of a possible 27, or 45%). On the STDKQ scale, the men had the lowest percentage of correct responses on items pertaining to viral infection and transmission in women. Additionally, the men had very low knowledge pertaining to onset, infectious stages, and immunity to STIs (e. g., a person develops open sores on his or her genitals soon after infection; a person who had gonorrhea in the past is immune). Overall, the men had the highest percentages of correct responses on items related to condom use. Younger men had more incorrect responses on one-third of the STDKQ items. Most of these items also pertained to onset, infectious stages, and immunity of STDs. However, younger men had more correct responses on STDKQ items regarding whether HPV causes genital warts and leads to cancer, and whether gonorrhea is a curable infection.
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Table 1. Characteristics of Participants (N ¼ 137) Characteristic Age (years) 35 Highest level of education 21 years Used drugs in past 3 months Yes No I do not want to answer Used drugs in past 12 months Yes No
n
%
19 75 39 4
14 55 28 3
28 18 32 22 37
20 13 24 16 27
103 1 33
75 1 24
93 43
69 31
88 2 3
95 2 3
23 36 21 12
25 39 22 14
21 46 44 17 9
15 34 32 12 7
12 122 3
89 9 2
10 127
7 93
HIV Stigma HIV stigma was high among this sample (M ¼ 24.1, SD ¼ 7.3), which represented 73% of the total possible score. There was no difference in HIV stigma between older and younger MSM (Table 2). A higher proportion of older men felt that most people in their community attributed shame, disgust, and dishonor to HIV-positive serostatus and reported that most people in their community stigmatized having an HIV-positive person participate in interactions involving the preparation and serving of food (e.g., people would not want an HIV-infected person cooking for them, people would not want an HIV-infected person to hold or feed their children). For the item specifically pertaining to MSM, 50% of the men strongly agreed that people in their
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Table 2. Mean HIV Knowledge, STD Knowledge, and HIV Stigma Scores in Younger and Older MSM Younger (n ¼ 94)
HIV knowledge STD knowledge HIV stigma
Older (n ¼ 43)
M
SD
M
SD
t(df 135)
p
12.5 13.2 23.3
3.5 5.6 7.1
10.9 10.0 25.9
3.9 5.2 7.5
2.39 3.12 1.93
