Sage Journals: Discover world-class research

Abstract

Introduction: Research has begun to examine human immunodeficiency virus (HIV) prevention strategies within the Ghanaian context. Still, little is known about specific populations such as gay, bisexual, and other cisgender men who have sex with men (GBMSM) living in slum communities. We studied HIV prevention strategies such as condoms and preexposure prophylaxis (PrEP) in slum communities and the awareness and willingness to use these choices among GBMSM. This qualitative study examines HIV prevention strategies, specifically examining PrEP and condom use behaviors among GBMSM in Ghana. Methods: We conducted in-depth face-to-face interviews among 12 GBMSM from slums in Accra and Kumasi cities in Ghana. Data were analyzed through a summative content analysis with multiple reviewers to develop codes. Data were collected from participants in January 2022. Results: We found the fear and perceived risk of infection were motivators for consistent condom use, especially during anal sex. GBMSM living with HIV receiving antiretroviral therapy were more inclined to use condoms. We found motivations for using PrEP were influenced by the type of sexual activity and a history of negative HIV status. Also, the barriers to PrEP for GBMSM included limited access to healthcare facilities and the distance to these facilities. Conclusions: To improve condom and PrEP access and uptake, we recommend addressing structural barriers by increasing the number of health facilities and implementing targeted interventions to address the lack of information on HIV awareness and prevention. Involving peer educators may also effectively promote HIV prevention strategies, especially in communities with limited access to healthcare such as slums. Overcoming these access constraints could significantly enhance awareness and prevention of HIV, leading to improved health outcomes for GBMSM living in slum communities.

Keywords

bisexual condom HIV PrEP gay

Introduction

Globally, strategies to prevent human immunodeficiency virus (HIV) have been a significant focus in many countries.^1–4 According to the World Health Organization [WHO]⁵, the number of people living with HIV at the close of 2021 reached an estimated 38.4 million with 0.7% of this population aged 15–49 years. While this number continues to rise over the years, the WHO (2022) report shows the African continent has been severely affected with an estimated (3.4%) 1 in 35 adults living with HIV. These projections position the African continent to account for two-thirds of all cases worldwide. Within Africa, the Sub-Saharan region is known to have the highest affected rate of HIV infection, accounting for an estimated 70% of HIV globally.^6,7 Given these statistics, the calls for strategic steps to curb the high epidemic incidence have increased, particularly within Africa's Sub-Saharan region.^8–10

Like many other African countries, Ghana has adopted some intervention strategies into its policy such as The U.S. President Emergency Plan For AIDS Relief (PEPFAR) and the (UNAIDS) 90–90-90 to reduce the epidemic spread of HIV.^11–13 PEPFAR was a United States-funded initiative to support and expand Ghana's efforts to prevent the spread of HIV/AIDs, care for persons living with HIV, and provide support to improve coverage of the country's response to the epidemic.^11,14–16 Ghana adopted the (UNAIDS) 90-90-90 achieve the United Nations Programme (90% of all people who are HIV-positive know their status, 90% of those diagnosed with HIV are on treatment, and 90% of those diagnosed with HIV are virally suppressed).^12,17–19 These policy efforts among other efforts from the Ministry of Health, Ghana AIDS Commission and other community and nongovernmental organization have contributed to the low-level epidemic rate in the country.

Among many interventional strategies to prevent the spread of HIV, administering preexposure prophylaxis (PrEP) has been identified as a practical way to reduce incidence.^20–22 PrEP can be presented as a daily medication to prevent a diagnosed HIV-negative person from getting infected.²³ PrEP is the use of antiretrovirals in individuals who do not have HIV to prevent infection. PrEP is taken in anticipation of exposure to HIV and is mainly recommended for individuals at increased risk of exposure.²⁴ PrEP comes in many forms and can be administered (oral or injectable) through various therapeutic options such as using tenofovir/emtricitabine in combination with maraviroc, using long-acting rilpivirine administered every 8 weeks, using cabotegravir/vocabria, which is an Integrase Strand Transfer Inhibitor, and using VRC-HIVMAB060-00-AB.²⁵ Effective administration of antiretrovirals can support individuals living with HIV to achieve a state where the virus has been suppressed to undetectable levels, low enough to prevent transmission.^26,27 Meaning the virus cannot be transmitted through sexual contact.^26–29 This scientific evidence is based on the concept of U = U (undetectable equals untransmittable).^26–30 Despite the evidence showing U = U significance in reducing the risk of transmission, many have stressed that it does not eliminate the risk of infection completely, emphasizing the need for regular testing and safer sexual practices such as condom use.^31,32 U = U significance has also been questioned, as it does not prevent other sexually transmitted infections.^31–33

While the PrEP strategy has proven effective in controlling the spread of HIV, it comes with many challenges. Awareness and usage of PrEP have been reportedly low in certain contexts,^24,34–36 particularly among low- and middle-income countries.^37,38 The uptake of antiretrovirals as an effective means of preventing the spread of HIV is reported to be globally low.^20,39–41 Many other barriers to PrEP implementation and antiretroviral usage are seen in the stigma surrounding its use among individuals at increased risk of HIV, the possible drug-to-drug interaction, the risk of sexually transmitted infection, the cost of antiretrovirals, and its reported side effects.^41–43

Additionally, the cost of antiretrovirals has been shown to significantly affect PrEP implementation among key Ghanaian population.⁴⁴ Barriers related to the cost of antiretrovirals among key Ghana populations have been associated with long-term financial implications and poor health insurance coverage.44 Other cost barriers related to antiretrovirals were associated with those incurred by the patients such as laboratory fees, travel-related expenses, and testing for sexually transmitted diseases.^44–46 Recommendations to improve antiretrovirals uptake in Ghana include the government subsidizing the cost of the medication, or including it in the National Health Insurance Scheme.⁴⁴

Past studies have also shown insufficient knowledge of PrEP among MSM as a primary reason for its low acceptability, even when the antiretrovirals are presented as a reliable means of preventing the spread of HIV.^47–49 In Ghana, available research indicates that PrEP rejection is high among individuals at an increased risk of infection.²⁰ According to Dako-Gyeke et al⁵⁰ and Kumar et al⁵¹, MSM in Ghana form a significant population (17.5%) of people living with HIV in the country and have a higher chance of not getting tested or engaging in HIV-related in treatment. These studies highlight an increasing need for MSM to explore preventive strategies when engaged in activities that increase their risk of infection. While PrEP implementation is coupled with many challenges within Sub-Saharan Africa,⁴⁸ understanding perceptions, awareness and preferences among MSM is crucial to PrEP acceptance as a reliable strategy of HIV prevention.^52–54 Given Ghana's conscious efforts to present PrEP as an alternative strategy to preventing the spread of HIV, leaders in the implementation drive remain hesitant due to the lack of context-based evidence from data to support a scale-up of antiretrovirals in the country.^55,56

Similarly, condom use as an intervention technique against the spread of HIV has been emphasized in many countries, especially within sub-Saharan Africa, where HIV continues to be high among sexual minorities.^48,49,57,58 Condom use has been identified as one of the most effective means of preventing the spread of HIV.^59,60 According to the United States Agency for International Development⁶¹, condoms are effective when used correctly to reduce HIV transmission by 90%. Among key populations such as gay men, condoms effectively reduce the spread of HIV by 70% for individuals with HIV-positive partners who reported consistent use, 72% for those who indicated they were bottoming, and 63% for those who were topping.⁶² Hence, many health providers and promoters urged its use, especially among individuals at an increased risk of infection.^63–65 Several interventions have been employed in Ghana to encourage condom use.^{48,49,63,66,67} One of the major intervention approaches in the country to increase condom use, especially among individuals who are at an increased risk of infection in Ghana is the Ghana Nation Condom and Water Based Lubricant Programming Strategy 2014–2019. The intervention was a conscious approach by the government in collaboration with multiple nongovernmental and community-based organizations to identify barriers within Ghana that impacted condom use and employ strategies that addressed the needs of different segments of the Ghanaian population.⁶⁶ The report captures key populations (23%) as the second largest group in HIV new infection in the country.⁶⁶

Despite employing strategies such as the Ghana Nation Condom and Water Based Lubricant Programming Strategy 2014–2019, the National HIV and AIDS Strategic Plan (2011-2015), and the Ghana MARP Strategic Framework 2011–2015, among others, HIV among key populations, particularly MSM in Ghana continue to record increasing rate of infection.⁶⁸ The USAID recommends HIV prevention services such as condom use and PrEP be combined to maximize the odds of viral transmission since no barrier method can guarantee 100% prevention.

Slums in Ghana are known to be under-resourced, evident in the lack of health facilities, leading to adverse health outcomes.⁶⁹ Slums in Ghana are characterized by poor access to drinking water, schools, transportation services, and inadequate housing settlements.^70–74 The individual or combination of these slum characteristics can affect how gay, bisexual and other cisgender men who have sex with men (GBMSM) access HIV prevention services. Understanding how these implications manifest for highly stigmatized groups such as GBMSM is imperative when suggesting interventions to increase HIV prevention strategies, particularly concerning PrEP, and condom use. This research was conducted in selected slum communities due to lacking information on HIV prevention strategies for GBMSM living in these areas. We attempt to use this study to understand the current state of HIV prevention strategies for GBMSM in these slum communities and how the unique characteristic of slums in Ghana affects the utilization of HIV prevention strategies among GBMSM.

Ghana has been described as a country where the safety of GBMSM cannot be guaranteed as the laws of the country do not provide protection for LGBTQ groups or individuals or groups advocating for their wellbeing.⁷⁵ Ghana's laws currently criminalize same-sex penetrative behaviors.^76,77 The country's current legislation on sexuality is vague; hence, the policing of sexual activities, particularly among GBMSM is left to the discretion of law enforcement officers.^76,78 Ghanaian criminal law is fraught with ambiguity, resulting in individuals and law enforcement officials resorting to personal interpretation to determine its application to people in the LGBTQ community.⁷⁶ The phrase “unnatural carnal knowledge,” found in the Ghanaian Criminal Code Amendment Act of 2003, does not explicitly reference LGBTQ individuals.⁷⁶ However, it has been invoked to justify criminal assaults and the perpetuation of stigmatization against members of these communities.^76,79,80

The current stigmatizing climate in Ghana towards LGBTQ or individuals in close relation to these groups translates into challenges in health services.^81,82 Accessing preventive services such as PrEP can be discouraging for these groups of individuals due to the stigma they face at the health facilities.⁸¹ Though calls have been made for the Government of Ghana to subside these rates or include them fully into the National Health Insurance Policy, the fear associated with high stigma may prevent GBMSM from accessing these services.⁴⁴

Methods

Research Design

The research used qualitative interviews⁸³ to understand the lived experiences of GBMSM in Ghanaian slum communities. We collected first-hand accounts from participants about their day-to-day experiences of HIV prevention strategies related to condoms and PrEP use in the slum communities. We also investigated how they interpreted their experiences concerning their sexual orientation and the barriers or willingness to HIV prevention.

Sampling and Recruitment Procedure

To reach and recruit GBMSM in slum communities, we partnered with our community organizations in Accra and Kumasi, using the time location sampling method.⁸⁴ A sampling method that has been proven effective in researching similar populations in the past.^85–87 The time location sampling method in this study was purposively used due to the stigmatizing nature of GBMSM in Ghana. This approach allowed researchers reach the sample at locations and times that provided them the maximum amount of safety. Aside from providing security, the time location sampling method ensured diversity as GBMSM were randomly chosen from these secured locations, ensuring equal chances of being included in the study. Additionally, multiple visits from the researchers to recruit participants at times that were not chosen by the research team increased the likelihood of recruiting a diverse pool of respondents into the study. Community partners and research assistants came from PORSH (Priorities on Rights and Sexual Health) in Accra and YAHR (Youth Alliance on Health and Human Rights) in Kumasi. Research assistants working with our community partner organizations screened and invited GBMSM to participate in interview sessions during one of the organizations’ activities when GBMSM visited the site at times and locations that had been previously determined as safe. We have a long history of partnering with these two organizations to recruit participants and conduct studies among GBMSM in Ghana.^48,49,88 Initially, we had planned to recruit 19 participants, but after the eighth interview, we reached saturation in responses to fill the information gap. We continued to capture four more participants to ensure complete saturation, bringing the final number of transcripts to 12. We decided not to conduct further interviews with our samples when we realized the data were repetitive, and information received from GBMSM were recurring, similar to those from previous participants. Participants who participated in the study were given 80 Ghana Cedis each as compensation to cater for their transportation to and from the interview site.

Inclusion Criteria

Before enrollment, all participants were 18 years or older and resided in a slum community within Ghana's Greater Accra regional capital. Participants self-identified as a cisgender man and fell under the GBMSM category having had sexual relations with other cisgender men for reasons other than sexual orientation in the past 6 months. The HIV status of participants did not affect their eligibility to be included in this study.

Data Collection

Procedure

We conducted in-depth face-to-face interviews to collect participant data.⁸⁹ Following screening, research assistants gave participants consent forms to read. The research assistants read the consent forms aloud to ensure clarity and gave additional explanations. Before beginning the interviews, research assistants responded to participants’ questions and obtained their signatures to confirm their consent to participate and enable audio recording. All conversations took place in private spaces owned by the community partners. Four interviews were recorded in a local Ghanaian language called Twi because some participants found it challenging to communicate in English; all other interviews in the study were conducted in English. Data were collected in January 2022.

Nature of Questions

The checklist created for the study served as the basis for the qualitative interview training given to the research assistants. Consistent with our design, the checklist encouraged free and open discussion over the more conventional question-and-answer interview format. Participants were invited to share personal narratives about their background and family, sex and gender expectations, experiences of stigma within the family, openness about sexuality and sexual behavior, acceptance within the family, and how they deal with stigma or live as GBMSM.

Analytical Strategy

The audio interview recordings were directly transcribed verbatim by trained research assistants, who also deidentified the transcripts by removing details that could be used to identify the participants. After that, we conducted a summative content analysis with multiple reviewers on the transcripts.⁹⁰ We have effectively used this analytical procedure to understand essential elements in participant accounts.⁴⁹ We allocated at least two reviewers to each transcript. Each reviewer examined the interview checklist before reviewing the transcripts to find the most important points brought up by the participants, which they then independently reported in between 100 and 200 words. The first author went over each summary and compiled its key points into a data spreadsheet, which helped identify clusters in the qualitative data and highlighted the factors that frequently came up in transcripts and summaries.

Ethical Approval and Informed Consent

IRB approvals were obtained from the University of Rochester (IRES IRB #RNI00002010) and the Ghana Health Service (GHS-ERC 001/10/21) approved the study. Before any information was collected, the study's interviewers ensured that every participant had read and understood the informed consent form and given approval for information to be collected on HIV prevention strategies in condom use and PrEP.

Results

Description of Participants

Six GBMSM reported being Christian, two were Muslim, and the remaining four practiced a combination of both religions. Concerning formal education, only one had an education level below a Junior High School, six had completed Senior High School Education, and five had earned a university degree. Six participants reported being unemployed, while the other six worked part-time or full-time jobs.

Description of Categories and Subcategories

Two categories emerged from the study. The first category was condom use determinants. Under this category were subcategories: (a) familiarity, trust, and longevity, (b) fear and perceived risk of infection, and (c) preventing HIV transmission to others. The second category our data analyzed was PrEP use determinants. Subcategories under this team were (a) motivators to use PrEP and (b) access constraints to PrEP.

Condom Use Determinants

We categorized condom use drivers into three subcategories. The first was familiarity, trust, and longevity, the second was the fear and perceived risk of infection, and the third was preventing HIV transmission to others.

Familiarity, Trust, and Longevity. Our interviews with participants indicated the decision to use condoms was complex and influenced by various factors, including familiarity with partners, trust, and longevity with an intimate partner. Participants reported they prioritize safety and use condoms mostly. Still, they may be persuaded to have sex without condoms if they have been with the same partner for a while and the partner convinces them to trust them. Another participant shared that they sometimes chose not to use condoms when they were strongly attracted to someone and wanted a more intimate experience.

For safety measures, I use condoms mostly, but when I have sex continuously, and the person is trying to tell me to trust him because he's not flirting around, then I give in for raw sex (GBMSM participant I).

Sometimes but not always, though. It gets to when you are attracted to someone you really like and want to feel the person. That's when I decide not to use the condom. But not everyone I allow to go raw like that (GBMSM participant H).

Fear and Perceived Risk of Infection. Participants expressed a strong commitment to condom use, stating they use condoms every time they engage in anal sex. However, some participants reported using condoms only when necessary, as they had regular partners and did not engage in high-risk sexual behaviors. The risk of sexual infections also motivated participants to consistently use condoms during anal sex, citing previous experiences with gonorrhea as a motivator for consistent condom use.

I always use condoms and I use them every time. I engage in anal sex. But during sex, what I ensure that the sex is safe for me without any harm, is that I use condoms. I usually will use condoms. But let me say I will give it like 80% condom use. Because the world is a little scary, you don’t know when you will contract something. (GBMSM participant A)

I engage in anal sex. I’m always on top. I actually use a condom. But I don’t move around a lot. I have a regular partner (GBMSM participant F)

I always go for a condom during sex. I do anal sex. There was a time I ended up having gonorrhea and from that time no matter what you claim to be, whoever you are, you have to wear a condom. (GBMSM participant C)

Preventing HIV Transmission to Others. The results showed some participants who reported being HIV-positive still used condoms during intimate relationships. Participants who disclosed their HIV-positive status mentioned using condoms consistently after learning about their situation and being advised by a healthcare provider on the risk of spreading HIV. Participants mentioned insisting on using a condom when their intimate partners wanted to engage in condomless sex. Results also showed participants preferred to move away from current intimate partners who were insisting on condomless sex to those who preferred condoms use for the sole purpose of preventing further infections.

I love sex. At first, not so much, but now yes, Because I am on ARTs, I use condoms. If I am with someone who doesn’t want condoms, I will leave and do it with another person who is okay with condoms. As for condom use, 100%. (GBMSM participants G)

Because I am on ARTs, we use condoms. We use gold circles (condom brand). Previously, I had sex with no condoms depending on my partner. When I got to know my status, I was always advised by a health person to use a condom and I have been practicing that. (GBMSM participant B)

PrEP use Determinants

The results show PrEP presented a significant role in HIV prevention for GBMSM. Determinants of PrEP use were captured within two subcategories. The first was the motivators to use PrEP. The second was Access constraints to PrEP use.

Motivators to use PrEP. GBMSM were motivated to adhere to PrEP due to the nature of sex they engaged with their intimate partners. Other actors, such as peer educators in the lives of GBMSM were instrumental in how they decided to adhere to PrEP use by encouraging them to get tested for HIV to keep being eligible for PrEP. Other reasons cited by GBMSM were the nature of how they engaged in sexual activities and the associated risk of acquiring HIV.

I have engaged in anal sex, hence, take PrEP every day. I’m a top now even though I used to be at the bottom, you don’t know when you will contract something. (GBMSM participant D)

I’m HIV-negative, hence, use PrEP. I have a peer educator in my community which I have been randomly doing tests with him. And I’m on the safe side. (GBMSM participant E)

Yes, I’d like to be on it because of how rough I can be at times during sex. I’m not on PrEP. But I know what PrEP is and would like to be on it. (GBMSM participant K)

Access Constraints to PrEP use. GBMSM indicated structural barriers such as the lack of health facilities and distance to a health facility limited their PrEP access. Responses from our participants show if these structural challenges were tackled adequately, it would go a long way to encourage access and adherence to PrEP. GBMSM also indicated that additional constraints connected to time prevented them from accessing antiretrovirals from individuals who had the drug available. According to participants, the inability to find the time for medication pickups meant staying on other sexual protective mechanisms to prevent infection. Another significant finding from GBMSM showed the challenge of not knowing where to go for PrEP presented as a constraint GBMSM living in slums mentioned as a reason for not taking the medication.

I used to be on PrEP but I have stopped because of the distance to the health facility. I will continue if there is a facility close by to pick up the drug. (GBMSM participant N)

I know PrEP. A friend told me about it when I was in school. I thought he could get some for me, but he said unless I come there. But I haven’t had time to go, so I make sure I protect myself. I know my status. (GBMSM participant K)

I’m not on PrEP. But I know what PrEP is and would like to be a part of it. I have

heard about it, but I don’t know how to get some. (GBMSM participant J)

Discussion

Living in slums are filled with multiple challenges.^70,91,92 Empirical information in Ghana on PLHIV in slums is not extensive, making it difficult to understand the recent experiences of PLHIV and HIV prevention strategies among GBMSM. This study revealed GBMSM familiarity, trust, longevity with intimate partners, the fear and perceived risk of infection and preventing HIV transmission to others significantly affected condom use. The study also identified GBMSM engaging in anal sex and a history of testing negative for HIV as motivations for PrEP use. Structural barriers such as inadequate health facilities, the limited proximity to services, and time constraints associated with obtaining PrEP limited its use.^45,46

Previous studies in Africa have shown that strong relationships may affect condom use negotiations due to the desire to seek emotional intimacy with a partner.^93,94 During our interviews, we found familiarity, trust, and longevity emerging as significant determinants when deciding whether or not to use a condom. This finding was similar to those by Peasant et al⁹⁵, who found that self-sacrificing was a strategy to earn a partner's trust, or nurture a romantic relationship that could result in less condom use among sexually active partners. Other studies have found proposing condom use, especially among gay men can be perceived as less romantic, with condomless sex seen as a way of showing trust and emotional connection.^94,96 Though not a focus in this study, familiarity, and trust has emerged as a significant factor in HIV transmission, especially in the areas of U = U (undetectable = untransmittable) with findings showing 42.3% trusted it, 19.8% did not trust it, and 38.0% were not sure.^30,97,98 We found condoms use in Ghanaian slum communities was also determined by the longevity with intimate partners, the sexual attractiveness of the partner, and the partner's characteristics. Participants who engaged in sexual activity consistently with a partner were likely to develop trust and stop using condoms. Our findings highlight the role of familiarity, trust, and longevity in condom use decisions among GBMSM. Our results also suggest consistent condom use may be challenging for individuals engaged in long-term relationships or regular partners. Findings on familiarity, trust, and longevity to consistent condom use and long-term support the call by earlier researchers to investigate the attitudes of GBMSM when considering interventions in HIV/STI in the country.^10,68,99,100

Studies in Africa have shown that HIV-positive individuals appear to use condoms more consistently after knowing their status, with the main aim of not getting new infections or transmitting to their intimate partners.^101,102 Previous research has also indicated that GBMSM were more likely to use condoms if they knew about their HIV-positive status, were directed by health professionals, or knew where to access condoms.^103,104 Our participants on antiretroviral therapies (ARTs) appeared to be more consistent with condom use after learning about their HIV-positive status. They also assumed the responsibility of ensuring no further infections of HIV by either insisting on condom use with their partners or breaking off with individuals who did not want to engage in condomless sex. Consistent condom use among HIV-positive GBMSM was also driven by advice from healthcare professionals as a critical step in preventing the spread of HIV. When paying attention to the lack of infrastructure in health facilities and services (counseling, HIV testing, condom provision, and use education) and health personnel for GBMSM in HIV prevention, we find these results informative in tailoring interventions for HIV prevention among GBMSM living in Ghanaian slum communities.

Previous research has shown that individuals who are at an increased risk of infection, such as men who have sex with men stand a higher chance of HIV transmission through sexual intercourse.^105–107 Studies have also indicated anal sexual intercourse has higher chances of transmitting HIV compared to vaginal sex.^107,108 While highlighting the risk of anal sex in HIV transmission, some studies show other infections, such as gonorrhea, can present during sexual activities among sexual minorities.¹⁰⁹ In our study, the risk of HIV infection through anal sex for GBMSM came up as a vital determinant for condom use. Anal intercourse for GBMSM was perceived as a sexual activity that could put one at significant risk of HIV infection. The fear associated with infection and further spread of HIV through anal sexual intercourse among GBMSM reportedly showed consistent condom use among participants. Some participants also indicated that the high rates of HIV infections globally put enough fear in them to encourage consistent condom use. Closely related to this finding was GBMSM history of STI and constant use of condoms. Our finding suggests a historical experience of an STI such as gonorrhea can have profound implications on sexual practices, leading to a more cautious and protective sexual lifestyle.¹¹⁰ Our findings demonstrate that the lack of health facilities and personnel for GBMSM living in slum communities could increase the risk of HIV infection if interventions are not tailored, providing these amenities and making them accessible to these populations. Given the stigmatized context of slum communities,¹¹¹ sensitization campaigns surrounding condom use in anal sex activities must be prioritized to sustain our current finding.^48,49 We also urge bringing on board community stakeholders such as community religious leaders and political heads to reduce stigma and discrimination when these educational programs are organized around condom use and HIV prevention.^112–114

Safer sex practices in previous research among sexual minorities, particularly HIV-positive MSM, are primarily concerned with exposing other intimate partners to the risk of HIV infection.^115,116 Our findings show having casual and/or multiple sex partners, the risk of contracting, and the fear of infecting a partner encouraged consistent condom use among GBMSM who engaged in sexual intimacy. According to Serovich et al¹¹⁷, personality traits among sexual minorities with HIV-positive status who had casual intimate partners played a significant role when insisting on or not using a condom for sexual intimacy. Our findings show GBMSM interviewed had developed a sense of personal responsibility to prevent their partner from contracting HIV and used condoms. These findings demonstrate to some extent how individual personality traits can play a role in condom use among GBMSM. The results also indicate higher condom use preference when the risk of infecting others or being infected is high among GBMSM. For GBMSM living in slum communities, the resource constraint of these areas, especially regarding health facilities and personnel could hinder services such as HIV/STI counseling in promoting favorable attitudes towards condom use in HIV prevention.

For GBMSM, PrEP uptake is a recommended preferred means of HIV prevention as PrEP effectively reduces the risk of HIV infection, especially among GBMSM.^47,118 Whereas no studies were conducted in Ghana among GBMSM in slums on PrEP, the only study in the country on PrEP among the GBMSM showed a high willingness to take up PrEP.⁴⁷ This willingness has been further highlighted in research among MSM, who suggest antivirals be subsidized by the Government of Ghana or included fully in the National Health Insurance policy.⁴⁴ Consistently the GBMSM participants in our study were motivated to accept PrEP because of the HIV risk associated with same-sex sexual activities and the belief in the efficacy of antiretrovirals in preventing HIV infection.

Participants also described the role of peer educators as crucial in antiretroviral uptake and adherence through HIV testing to remain eligible for the drug. The role of peer educators has been stressed in multiple studies in PrEP follow-ups and uptake among at-risk individuals.^119–121 Although no published work on PrEP and peer mentors in slums exist in Ghana, GBMSM peers have played a critical role in previous interventions that address HIV prevention and linkage to care GBMSM in Ghana.^{9,48,49,67,88} Despite the favorable attitude toward PrEP uptake among our participants, we urge the training of more peer educators to strengthen use and adherence. Due to the location of this study, we propose peer educators be trained from within the slum to reduce accessibility challenges, increase relatability and trust, and facilitate linkage to care for GBMSM in HIV prevention and care services.⁴⁸

Challenges associated with PrEP use are complex and range within the individual, community, and health systems.^122,123 Our results about PrEP access and use were closely aligned with the challenges surrounding health systems.⁹ We found the proximity of PrEP access points limited access and use. Ahouada et al (2020) also arrived at these conclusions, indicating distance and sites for PrEP distribution significantly affected PrEP access and use in HIV prevention. Though we couldn’t find previous literature on the case of GBMSM living in Ghanaian slums, we trust that properly addressing health system challenges could promote PrEP access and adherence in these communities.

Conclusion

Our findings show familiarity, trust, and the attractiveness and characteristics of GBMSM intimate partners influenced condom use in HIV prevention. Fear and perceived risk of infection came up as motivators for consistent condom use, particularly when the mode of sexual intimacy was primarily anal sex. Our findings also revealed GBMSM with HIV-positive status and receiving ARTs were inclined to condom use. The study shows motivations for PrEP use were influenced by the nature of sex GBMSM engaged in and a history of HIIV negative status. PrEP use barriers included limited access to healthcare facilities and the distance to these facilities.

Our findings suggest that efforts to improve PrEP access and uptake among GBMSM should prioritize addressing structural barriers, such as increasing the number of health facilities providing PrEP and developing targeted interventions to address time constraints and lack of information about antiretrovirals. Additionally, engaging peer educators may effectively promote PrEP use among GBMSM, especially in communities with limited access to health facilities. Addressing these access constraints could significantly enhance the uptake and adherence to PrEP to improve HIV prevention outcomes among GBMSM living in slum communities.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Yale University FLAGS grant,

ORCID iDs

Osman Wumpini Shamrock

Amos Apreku

LaRon E. Nelson

References

Excler

Robb

Kim

. Prospects for a globally effective HIV-1 vaccine. Vaccine. 2015;33. doi:10.1016/j.vaccine.2015.03.059

Gartner

Roche

Churchill

Gorry

Flynn

. Understanding the mechanisms driving the spread of subtype C HIV-1. EBioMedicine. 2020;53. doi:10.1016/j.ebiom.2020.102682

Mahamboro

Fauk

Ward

Merry

Siri

Mwanri

. HIV stigma and moral judgement: qualitative exploration of the experiences of HIV stigma and discrimination among married men living with HIV in Yogyakarta. Int J Environ Res Public Health. 2020;17(2): 636. doi:10.3390/ijerph17020636

Rotheram-Borus

Davis

Rezai

. Stopping the rise of HIV among adolescents globally. Curr Opin Pediatr. 2018;30(1): 131. doi:10.1097/MOP.0000000000000580

World Health Organization. Data on the size of the HIV epidemic.

Ssentongo

Sznajder

. Prevalence, behavioral and socioeconomic factors associated with human immunodeficiency virus in Ghana: a population-based cross-sectional study. J Glob Health Rep. 2019;3, doi:10.29392/joghr.3.e2019092.

Joint United Nations Programme on HIV/AIDS. Global Report: UNAIDS Report on the Global AIDS Epidemic 2010. https://unaids-test.unaids.org/sites/default/files/unaids/contentassets/documents/unaidspublication/2010/20101123_globalreport_en%5b1%5d.pdf

Abubakari

Dada

Nur

, et al. Intersectional stigma and its impact on HIV prevention and care among MSM and WSW in sub-Saharan African countries: a protocol for a scoping review. BMJ Open. 2021;11(8):e047280. doi:10.1136/bmjopen-2020-047280

Nelson

LRE

Nyblade

Torpey

, et al. Multi-level intersectional stigma reduction intervention to increase HIV testing among men who have sex with men in Ghana: protocol for a cluster randomized controlled trial. PLoS One. 2021;16(11 November). doi:10.1371/journal.pone.0259324

10.

Nelson

Ogunbajo

Abu-Ba’are

, et al. Using the implementation research logic model as a lens to view experiences of implementing HIV prevention and care interventions with adolescent sexual minority men—A global perspective. AIDS Behav. 2022;27:128-143.

11.

Ali

Amoyaw

Baden

, et al. Ghana’s HIV epidemic and PEPFAR’s contribution towards epidemic control. Ghana Med J. 2019;53(1): 59-62. doi:10.4314/gmj.v53i1.9

12.

UN Joint Programme on HIV/AIDS (UNAIDS). 90-90-90 An ambitious treatment target to help end the AIDS epidemicto help end the AIDS epidemic. United Nations. 2014. Published online 2014.

13.

Owusu

Enimil

. Prevalence and determining factors of HIV infection among HIV exposed infants in a teaching hospital in Ghana. Afr J Curr Med Res. 2022;5(1). doi:10.31191/afrijcmr.v5i1.91

14.

Cantelmo

Lee

Dutta

. Smart cascades: using cost analysis to improve HIV care and treatment interventions to achieve global 95–95–95 goals. Afr J AIDS Res. 2019;18(4): 350-359. doi:10.2989/16085906.2019.1679201

15.

Nkrumah

van der Puije

Bekoe

, et al. Building local human resources to implement SLMTA with limited donor funding: the Ghana experience. Afr J Lab Med. 2014;3(2): 1-7. doi:10.4102/ajlm.v3i2.214

16.

Kaiser Family Foundation. The US President’s Emergency Plan for AIDS Relief (PEPFAR) Fact Sheet, 2015. 2015;(December). https://www.kff.org/global-health-policy/fact-sheet/the-u-s-presidents-emergency-plan-for-aids-relief-pepfar/

17.

UNAIDS. UNAIDS Goal 90-90-90: An ambitious treatment target to help end the AIDS epidemic. https://www.unaids.org/en/resources/909090#:~:text=Powerful%20momentum%20is%20now%20building,will%20receive%20sustained%20antiretroviral%20therapy. Published online 2014.

18.

UNAIDS. To help end the AIDS epidemic. United Nations. 2014. Published online 2014.

19.

Joint United Nations Program on HIV/AIDS. To help end the AIDS epidemic. United Nations. 2014. Published online 2014.

20.

Guure

Afagbedzi

Torpey

Chaurasia

. Willingness to take and ever use of preexposure prophylaxis among female sex workers in Ghana. Medicine (United States). 2022;101(5). doi:10.1097/MD.0000000000028798

21.

Eakle

Venter

Rees

. Preexposure prophylaxis (PrEP) in an era of stalled HIV prevention: can it change the game? Retrovirology. 2018;15(1): 1-10. doi:10.1186/s12977-018-0408-3

22.

Mimiaga

Case

Johnson

Safren

Mayer

. 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. J Acquir Immune Defic Syndr (1988). 2009;50(1): 77-83. doi:10.1097/QAI.0b013e31818d5a27

23.

Weitzman

Zhou

Kogelman

Rodarte

Vicente

Levkoff

. MHealth for preexposure prophylaxis adherence by young adult men who have sex with men. Mhealth. 2021;7, doi:10.21037/mhealth-20-51.

24.

Collins

. Preexposure prophylaxis (PrEP) and ‘risk’ in the news. J Risk Res. 2022;25(3): 379-394. doi:10.1080/13669877.2021.1894470

25.

Landovitz

. Preexposure prophylaxis for HIV prevention: what we know and what we still need to know for implementation. Top Antivir Med. 2015;23(2): 85.

26.

Coyne

Walsh

Noone

. Awareness, understanding and HIV stigma in response to undetectable = untransmittable messages: findings from a nationally representative sample in the United Kingdom. AIDS Behav. 2022;26(12): 85. doi:10.1007/s10461-022-03710-9

27.

Huntingdon

De Wit

Duracinsky

Juraskova

. Belief, covariates, and impact of the “Undetectable = Untransmittable” message among people living with HIV in Australia. AIDS Patient Care STDS. 2020;34(5): 205-212. doi:10.1089/apc.2019.0300

28.

Sauermilch

Siegel

Hoppe

Roth

Meunier

. Attitudes toward HIV-positive status disclosure among U=U-aware sexual and gender minority individuals in the USA: a consensual qualitative research approach. Sex Res Soc Policy. 2023;20(2): 692-704. doi:10.1007/s13178-022-00710-1

29.

Agaku

Nkosi

Gwar

Tsafa

. A cross-sectional analysis of U=U as a potential educative intervention to mitigate HIV stigma among youth living with HIV in South Africa. Pan Afr Med J. 2022;41. doi:10.11604/pamj.2022.41.248.33079

30.

MacGibbon

Bavinton

Broady

, et al. Familiarity with, perceived accuracy of, and willingness to rely on undetectable=untransmittable (U=U) among gay and bisexual men in Australia: results of a national cross-sectional survey. Sex Health. 2023. Published online 2023;20(4): 373-373. doi:10.1071/sh23050

31.

Behrens

GMN

Aebi-Popp

Babiker

. Close to zero, but not zero: what is an acceptable HIV transmission risk through breastfeeding? J Acquir Immune Defic Syndr (1988). 2022;89(4). doi:10.1097/QAI.0000000000002887

32.

Ngure

Ongolly

Dolla

, et al. I just believe there is a risk” understanding of undetectable equals untransmissible (U = U) among health providers and HIV-negative partners in serodiscordant relationships in Kenya. J Int AIDS Soc. 2020;23(3). doi:10.1002/jia2.25466

33.

Kowalska

Krankowska

Wróblewska

Firląg-Burkacka

. Undetectable HIV equals untransmittable HIV (U = U) statement in women. Are we there yet? Acta Scientific Women’s Health. 2022;4:44–48. Published online June 1, 2022. doi:10.31080/aswh.2022.04.0374

34.

Walsh-Buhi

Houghton

Lange

Hockensmith

Ferrand

Martinez

. Preexposure prophylaxis (PrEP) information on Instagram: content analysis. JMIR Public Health Surveill. 2021;7(7). doi:10.2196/23876

35.

Golub

Fikslin

Starbuck

Klein

. High rates of PrEP eligibility but low rates of PrEP access among a national sample of transmasculine individuals. J Acquir Immune Defic Syndr (1988). 2019;82(1). doi:10.1097/QAI.0000000000002116

36.

Parsons

Rendina

Lassiter

Whitfield

THF

Starks

Grov

. Uptake of HIV preexposure prophylaxis (prep) in a national cohort of gay and bisexual men in the United States. J Acquir Immune Defic Syndr (1988). 2017;74(3): 285-292. doi:10.1097/QAI.0000000000001251

37.

Tuot

Mwai

, et al. Awareness and willingness to use HIV preexposure prophylaxis among men who have sex with men in low- and middle-income countries: a systematic review and meta-analysis. J Int AIDS Soc. 2017;20(1). doi:10.7448/IAS.20.1.21580

38.

Young

McDaid

. How acceptable are antiretrovirals for the prevention of sexually transmitted HIV?: a review of research on the acceptability of oral preexposure prophylaxis and treatment as prevention. AIDS Behav. 2014;18(2):195–216. doi:10.1007/s10461-013-0560-7

39.

Ojikutu

Bogart

Mayer

Stopka

Sullivan

Ransome

. Spatial access and willingness to use preexposure prophylaxis among black/African American individuals in the United States: cross-sectional survey. JMIR Public Health Surveill. 2019;5(1). doi:10.2196/12405

40.

Poon

Han

, et al. Acceptability and willingness of HIV preexposure prophylaxis amongst female sex workers in China. AIDS Care - Psychol Socio-Med Aspects AIDS/HIV. 2019;31(12). doi:10.1080/09540121.2019.1612001

41.

Zhao

Sun

Xue

, et al. Acceptability of preexposure prophylaxis among female sex workers in Xinjiang. Zhejiang Da Xue Xue Bao Yi Xue Ban. 2011;40(3). doi:10.3785/j.issn.1008-9292.2011.03.009

42.

Jain

Strathdee

Patterson

, et al. Perceived barriers to preexposure prophylaxis use and the role of syndemic factors among female sex workers in the Mexico-United States border region: a latent class analysis. AIDS Care - Psychol Socio-Med Aspects AIDS/HIV. 2020;32(5): 557-566. doi:10.1080/09540121.2019.1626338

43.

Emmanuel

Folayan

Undelikwe

, et al. Community perspectives on barriers and challenges to HIV preexposure prophylaxis access by men who have sex with men and female sex workers access in Nigeria. BMC Public Health. 2020;20(1): 1-10. doi:10.1186/s12889-020-8195-x

44.

Nagai

Adiibokah

Tagoe

, et al. Policymakers’ and healthcare providers’ perspectives on the introduction of oral preexposure prophylaxis for key populations in Ghana. BMC Public Health. 2023;23(1): 1-9. doi:10.1186/s12889-023-15871-w

45.

Gomez

Borquez

Case

Wheelock

Vassall

Hankins

. The cost and impact of scaling up preexposure prophylaxis for HIV prevention: a systematic review of cost-effectiveness modelling studies. PLoS Med. 2013;10(3). doi:10.1371/journal.pmed.1001401

46.

van de Vijver

DAMC

Richter

Boucher

CAB

, et al. Cost-effectiveness and budget effect of preexposure prophylaxis for HIV-1 prevention in Germany from 2018 to 2058. Eurosurveillance. 2019;24(7). doi:10.2807/1560-7917.ES.2019.24.7.1800398

47.

Ogunbajo

Leblanc

Kushwaha

, et al. Knowledge and acceptability of HIV preexposure prophylaxis (PrEP) among men who have sex with men (MSM) in Ghana. AIDS Care - Psychol Socio-Med Aspects AIDS/HIV. 2020;32(3): 330-336. doi:10.1080/09540121.2019.1675858

48.

Abubakari

GMR

Nelson

LRE

Ogunbajo

, et al. Implementation and evaluation of a culturally grounded group-based HIV prevention programme for men who have sex with men in Ghana. Glob Public Health. 2021;16(7): 1028-1045. doi:10.1080/17441692.2020.1832555

49.

Abubakari

Turner

Nelson

, et al. An application of the ADAPT-ITT model to an evidence-based behavioral HIV prevention intervention for men who have sex with men in Ghana. Int Health Trends Perspect. 2021;1(1): 1-16. doi:10.32920/ihtp.v1i1.1412

50.

Dako-Gyeke

Snow

Yawson

. Who is utilizing antiretroviral therapy in Ghana: an analysis of ART service utilization. Int J Equity Health. 2012;11(1): 1-8. doi:10.1186/1475-9276-11-62

51.

Kumar

Reece

Norman

Kwara

Flanigan

Rana

. Delayed entry to care by men with HIV infection in Kumasi, Ghana. Pan Afr Med J. 2015;22. doi:10.11604/pamj.2015.22.107.7010

52.

Sun

Dai

, et al. Increasing awareness of HIV preexposure prophylaxis (PrEP) and willingness to use HIV PrEP among men who have sex with men: a systematic review and meta-analysis of global data. J Int AIDS Soc. 2022;25(3). doi:10.1002/jia2.25883

53.

Plotzker

Seekaew

Jantarapakde

, et al. Importance of risk perception: predictors of PrEP acceptance among Thai MSM and TG women at a community-based health service. J Acquir Immune Defic Syndr (1988). 2017;76(5): 473–481. doi:10.1097/QAI.0000000000001536

54.

Whitfield

Beauchamp

Fields

, et al. Risk compensation in HIV PrEP adherence among Black men who have sex with men in HPTN 073 study. AIDS Care - Psychol Socio-Med Aspects AIDS/HIV. 2021;33(5): 633-638. doi:10.1080/09540121.2020.1810618

55.

Nagai

Tagoe

Tun

, et al. Perspectives of policymakers on the introduction and scale-up of HIV self-testing and implication for national HIV programming in Ghana. Front Public Health. 2021;9. doi:10.3389/fpubh.2021.694836

56.

Koduah

Agyepong

van Dijk

. Towards an explanatory framework for national level maternal health policy agenda item evolution in Ghana: an embedded case study. Health Res Policy Syst. 2018;16(1): 1-16. doi:10.1186/s12961-018-0354-5

57.

Winskell

Sabben

. Sexual stigma and symbolic violence experienced, enacted, and counteracted in young Africans’ writing about same-sex attraction. Soc Sci Med. 2016;161: 143-150. doi:10.1016/j.socscimed.2016.06.004

58.

Beyrer

Baral

van Griensven

, et al. Global epidemiology of HIV infection in men who have sex with men. Lancet. 2012;380(9839): 367-377. doi:10.1016/S0140-6736(12)60821-6

59.

Wiyeh

Mome

RKB

Mahasha

Kongnyuy

Wiysonge

. Effectiveness of the female condom in preventing HIV and sexually transmitted infections: a systematic review and meta-analysis. BMC Public Health. 2020;20(1): 1-17. doi:10.1186/s12889-020-8384-7

60.

Giannou

Tsiara

Nikolopoulos

, et al. Condom effectiveness in reducing heterosexual HIV transmission: a systematic review and meta-analysis of studies on HIV serodiscordant couples. Expert Rev Pharmacoecon Outcomes Res. 2016;16(4): 489-499. doi:10.1586/14737167.2016.1102635

61.

United States Agency for International Development. Condom Fact Sheet.; 2015. https://www.usaid.gov/sites/default/files/2022-05/condomfactsheet.pdf

62.

Barcavage

. How well do condoms protect gay men from HIV? https://www.sfaf.org/collections/beta/how-well-do-condoms-protect-gay-men-from-hiv/#:∼:text=They%20still%20have%20a%20role,i.e.%20breakage)%20resulting%20in%20infections.

63.

Ahinkorah

Hagan

Seidu

, et al. Understanding the association between exposure to family planning messages and consistent condom use among never married men in Ghana. PLoS One. 2021;16(8 August 2021). doi:10.1371/journal.pone.0255325

64.

Davis

Weller

. The effectiveness of condoms in reducing heterosexual transmission of HIV. Fam Plann Perspect. 1999;31(6): 272-279. doi:10.2307/2991537

65.

Wald

Langenberg

AGM

Link

, et al. Effect of condoms on reducing the transmission of herpes simplex virus type 2 from men to women. JAMA. 2001;285(24): 3100-3106. doi:10.1001/jama.285.24.3100

66.

Ministry of Health. Ghana National Condom and Water- Based Lubricant Programming Strategy-2014–2019. https://www.ccmghana.net/index.php/strategic-plans-reports?download%3D35:national-condom-and-lubricant-strategy-2014-2019&tbm=ilp&sa=X&ved=2ahUKEwjks8eDuf2BAxXaDFkFHbYBCukQv5AHegQIABAE

67.

Abubakari

GMR

Turner

, et al. Community-based interventions as opportunities to increase HIV self-testing and linkage to care among men who have sex with men – Lessons from Ghana, West Africa. Front Public Health. 2021;9. doi:10.3389/fpubh.2021.660256

68.

Nelson

LRE

Wilton

Agyarko-Poku

, et al. Predictors of condom use among peer social networks of men who have sex with men in Ghana, West Africa. PLoS One. 2015;10(1). doi:10.1371/journal.pone.0115504

69.

Srikrishnan

Sivaram

, et al. High HIV prevalence and risk behaviors in men who have sex with men in Chennai, India. J Acquir Immune Defic Syndr (1988). 2004;35(3): 314-319. doi:10.1097/00126334-200403010-00014

70.

Shah

. Characterizing slums and slum-dwellers: exploring household-level Indonesian data. University of California; 2012, Published online 2012.

71.

Appiah-Kubi

. Challenges encountered in community development in urban slums: a study of Ashaiman, Ghana. Int J Sci: Basic Appl Res 2018;4531(October 2018): 81-93.

72.

Jankowska

Weeks

Engstrom

. Do the most vulnerable people live in the worst slums? A spatial analysis of Accra, Ghana. Ann GIS. 2011;17(4): 221-235. doi:10.1080/19475683.2011.625976

73.

Owusu

Agyei-Mensah

Lund

. Slums of hope and slums of despair: mobility and livelihoods in Nima, Accra. Norsk Geografisk Tidsskrift. 2008;62(3): 180-190. doi:10.1080/00291950802335798

74.

Ezeh

Oyebode

Satterthwaite

, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet. 2017;389(10068): 547-558. doi:10.1016/S0140-6736(16)31650-6

75.

Zigah

Abu-Ba’are

Shamrock

, et al. For my safety and wellbeing, I always travel to seek health care in a distant facility—the role of place and stigma in HIV testing decisions among GBMSM – BSGH 002. Health Place. 2023;83:103076. doi:10.1016/j.healthplace.2023.103076

76.

Atuguba

. Homosexuality in Ghana: morality, law, human rights. J Pol & L. 2019;12:113:103076.

77.

Opoku

Manu

Appiah

. Same-sex marriage in Ghana: scripture, health law and bioethics. Developing Country Studies. 2021;11(4).

78.

Nartey

. Marginality and otherness: the discursive construction of LGBT issues/people in the Ghanaian news media. Media Cult Soc. 2022;44(4): 785-801. doi:10.1177/01634437211045552

79.

Oppong

. Examining attitudes and the law on homosexuality in non-Western Societies: the example of Ghana in West Africa. Polish Psychol Bullet. 2018;49(4): 416-423. doi:10.24425/119510

80.

Dai-Kosi

Asamani

Adomako

. Ghanaian perspectives on the present day dynamics of homosexuality. Afr Res Rev. 2016;10(5): 1-12. doi:10.4314/afrrev.v10i5.1

81.

Gyamerah

Kinzer

Aidoo-Frimpong

, et al. PrEP knowledge, acceptability, and implementation in Ghana: perspectives of HIV service providers and MSM, trans women, and gender diverse individuals living with HIV. PLOS Global Public Health. 2023;3(6). doi:10.1371/journal.pgph.0001956

82.

Laar

Debruin

. Key populations and human rights in the context of HIV services rendition in Ghana. BMC Int Health Hum Rights. 2017;17(1): 1-10. doi:10.1186/s12914-017-0129-z

83.

Colorafi

Evans

. Qualitative descriptive methods in health science research. Health Environ Res Design J. 2016;9(4):16–25. doi:10.1177/1937586715614171

84.

Leon

Jauffret-Roustide

Le Strat

. Design-based inference in time-location sampling. Biostatistics. 2014;16(3): 565-579. doi:10.1093/biostatistics/kxu061

85.

Trouiller

Velter

Saboni

, et al. Injecting drug use during sex (known as “slamming”) among men who have sex with men: results from a time-location sampling survey conducted in five cities, France. Int J Drug Policy. 2020;79. doi:10.1016/j.drugpo.2020.102703

86.

Zhao

Cai

Chen

, et al. A comparison between respondent-driven sampling and time-location sampling among men who have sex with men in Shenzhen, China. Arch Sex Behav. 2015;44(7): 2055-2065. doi:10.1007/s10508-014-0350-y

87.

Sommen

Saboni

Sauvage

, et al. Time location sampling in men who have sex with men in the HIV context: the importance of taking into account sampling weights and frequency of venue attendance. Epidemiol Infect. 2018;146(7): 913-919. doi:10.1017/S0950268818000675

88.

Abubakari

Owusu-Dampare

Ogunbajo

, et al. HIV Education, empathy, and empowerment (HIVE3): a peer support intervention for reducing intersectional stigma as a barrier to HIV testing among men who have sex with men in Ghana. Int J Environ Res Public Health. 2021;18(24):13103. doi:10.3390/ijerph182413103

89.

Cypress

. Qualitative research methods: a phenomenological focus. Dimens Crit Care Nurs. 2018;37(6): 302–309. doi:10.1097/DCC.0000000000000322

90.

Holloway

Freshwater

. Narrative Research in Nursing.; 2009. doi:10.1002/9781444316513.

91.

Unger

Riley

. Slum health: from understanding to action. PLoS Med. 2007;4(10):e295. doi:10.1371/journal.pmed.0040295

92.

Kshetrimayum

Bardhan

Kubota

. Factors affecting residential satisfaction in slum rehabilitation housing in Mumbai. Sustainability (Switzerland). 2020;12(6): 2344. doi:10.3390/su12062344

93.

Bell

Atkinson

Mosier

Riley

Brown

. The HIV transmission gradient: relationship patterns of protection. AIDS Behav. 2007;11(6):789–811. doi:10.1007/s10461-006-9192-5

94.

Skakoon-Sparling

Cramer

. Are we blinded by desire? Relationship motivation and sexual risk-taking intentions during condom negotiation. J Sex Res. 2020;57(5): 545-558. doi:10.1080/00224499.2019.1579888

95.

Peasant

Parra

Okwumabua

. Condom negotiation: findings and future directions. J Sex Res. 2015;52(4): 470-483. doi:10.1080/00224499.2013.868861

96.

Starks

Pawson

Stephenson

Sullivan

Parsons

. Dyadic qualitative analysis of condom use scripts among emerging adult gay male couples. J Sex Marital Ther. 2018;44(3): 470–483. doi:10.1080/0092623X.2017.1359713

97.

Smith

Buttenheim

Schmucker

Bekker

Thirumurthy

Davey

DLJ

. Undetectable=untransmittable (U=U) messaging increases uptake of HIV testing among men: results from a pilot cluster randomized trial. AIDS Behav. 2021;25(10):3128–3136. doi:10.1007/s10461-021-03284-y

98.

Carneiro

Westmoreland

Patel

Grov

. Awareness and acceptability of undetectable=untransmittable among a U.S. National sample of HIV-negative sexual and gender minorities. AIDS Behav. 2021;25(2):634–644. doi:10.1007/s10461-020-02990-3

99.

Saalim

Amu-Adu

Amoh-Otu

, et al. Multi-level manifestations of sexual stigma among men with same-gender sexual experience in Ghana. BMC Public Health. 2023;23(1):166. doi:10.1186/s12889-023-15087-y

100.

Nyblade

Stockton

Saalim

, et al. Using a mixed-methods approach to adapt an HIV stigma reduction intervention to address intersectional stigma faced by men who have sex with men in Ghana. J Int AIDS Soc. 2022;25(S1). doi:10.1002/jia2.25908

101.

Ali

. Prevalence and predictors of virological non-suppression among key populations on HIV treatment in Zanzibar. Muhimbili University of Health and Allied Sciences; 2019.

102.

Raiford

Wingood

DiClemente

. Correlates of consistent condom use among HIV positive African American women. Women Health. 2007;46(2-3): 41-58. doi:10.1300/J013v46n02_04

103.

Smith

Herbst

Zhang

Rose

. Condom effectiveness for HIV prevention by consistency of use among men who have sex with men in the United States. J Acquir Immune Defic Syndr (1988). 2015;68(3): 337-344. doi:10.1097/QAI.0000000000000461

104.

Manguro

Musau

Were

, et al. Increased condom use among key populations using oral PrEP in Kenya: results from large scale programmatic surveillance. BMC Public Health. 2022;22(1): 328-340. doi:10.1186/s12889-022-12639-6

105.

Dudley

Rostosky

Korfhage

Zimmerman

. Correlates of high-risk sexual behavior among young men who have sex with men. AIDS Educ Prev. 2004;16(4):328-340. doi:10.1521/aeap.16.4.328.40397

106.

Baral

Sifakis

Cleghorn

Beyrer

. Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000-2006: a systematic review. PLoS Med. 2007;4(12). doi:10.1371/journal.pmed.0040339

107.

Musinguzi

Bastiaens

Matovu

JKB

, et al. Barriers to condom use among high risk men who have sex with men in Uganda: a qualitative study. PLoS One. 2015;10(7). doi:10.1371/journal.pone.0132297

108.

Baggaley

White

Boily

. HIV transmission risk through anal intercourse: systematic review, meta-analysis and implications for HIV prevention. Int J Epidemiol. 2010;39(4):1048-1063. doi:10.1093/ije/dyq057

109.

Hui

Fairley

Chen

, et al. Oral and anal sex are key to sustaining gonorrhoea at endemic levels in MSM populations: a mathematical model. Sex Transm Infect. 2015;91(5): 365-369. doi:10.1136/sextrans-2014-051760

110.

Patel

Gutnik

Yoskowitz

O’Sullivan

Kaufman

. Patterns of reasoning and decision making about condom use by urban college students. AIDS Care - Psychol Socio-Med Aspects AIDS/HIV. 2006;18(8): 918-930. doi:10.1080/09540120500333509

111.

Kebaso JN. Levels of HIV/AIDS-Related Stigma and Its Association with Individual HIV Status in Nairobi City Slums. Order No. 10193765 ed. Loma Linda University; 2016. https://ezp.lib.rochester.edu/login?url=https://www.proquest.com/dissertations-theses/levels-hiv-aids-related-stigma-association-with/docview/2135749943/se-2

112.

Nyblade

Carr

. Towards a stronger response to HIV and AIDS: challenging stigma. International Center for Research on Women; 2004, Published online 2004.

113.

Hartwig

Kissioki

Hartwig

. Church leaders confront HIV/AIDS and stigma: a case study from Tanzania. J Community Appl Soc Psychol. 2006;16(6): 492-497. doi:10.1002/casp.897

114.

Surur

Kaba

. The role of religious leaders in HIV/AIDS prevention, control, and patient care and support: a pilot project in Jimma Zone. Northeast Afr Stud. 2000;7(2): 59-79. doi:10.1353/nas.2004.0021

115.

van Kesteren

NMC

Hospers

Kok

van Empelen

. Sexuality and sexual risk behavior in HIV-positive men who have sex with men. Qual Health Res. 2005;15(2):145–168. doi:10.1177/1049732304270817

116.

Van Kesteren

NMC

Hospers

Van Empelen

Van Breukelen

Kok

. Sexual decision-making in HIV-positive men who have sex with men: how moral concerns and sexual motives guide intended condom use with steady and casual sex partners. Arch Sex Behav. 2007;36(3): 437–449. doi:10.1007/s10508-006-9125-4

117.

Serovich

Oliver

Smith

Mason

. Methods of HIV disclosure by men who have sex with men to casual sexual partners. AIDS Patient Care STDS. 2005;19(12):823–832. doi:10.1089/apc.2005.19.823.

118.

Hillis

Germain

Hope

McVeigh

Van Hout

. Preexposure prophylaxis (PrEP) for HIV prevention among men who have sex with men (MSM): a scoping review on PrEP service delivery and programming. AIDS Behav. 2020;24(11):3056–3070. doi:10.1007/s10461-020-02855-9

119.

Sun

. Awareness and use of HIV preexposure prophylaxis and factors associated with awareness among MSM in Beijing, China. Sci Rep. 2023;13(1):554. doi:10.1038/s41598-023-27485-8

120.

Eubanks

Coulibaly

Keita

, et al. Loss to follow-up from HIV preexposure prophylaxis care in men who have sex with men in West Africa. Viruses. 2022;14(11): 2380. doi:10.3390/v14112380

121.

Atkins

Musau

Mugambi

, et al. Health system opportunities and challenges for PrEP implementation in Kenya: a qualitative framework analysis. PLoS One. 2022;17(10 October). doi:10.1371/journal.pone.0259738

122.

Ahouada

Diabaté

Mondor

, et al. Acceptability of preexposure prophylaxis for HIV prevention: facilitators, barriers and impact on sexual risk behaviors among men who have sex with men in Benin. BMC Public Health. 2020;20(1):1–17. doi:10.1186/s12889-020-09363-4

123.

Hannaford

Lipshie-Williams

Starrels

, et al. The use of online posts to identify barriers to and facilitators of HIV preexposure prophylaxis (PrEP) among men who have sex with men: a comparison to a systematic review of the peer-reviewed literature. AIDS Behav. 2018;22(4):1080–1095. doi:10.1007/s10461-017-2011-3

Awareness and Willingness to use Condoms and Preexposure Prophylaxis among Gay,Bisexual,and Other Cisgendered Men who Have sex with men in Slum Communities in Ghana. BSGH-004

Abstract

Keywords

Introduction

Methods

Research Design

Sampling and Recruitment Procedure

Inclusion Criteria

Data Collection

Procedure

Nature of Questions

Analytical Strategy

Ethical Approval and Informed Consent

Results

Description of Participants

Description of Categories and Subcategories

Condom Use Determinants

PrEP use Determinants

Discussion

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References