Corresponding author: Samuel Malogae Badiekang, Ghana Health Service, Ghana
Received: 09 Dec 2023 - Accepted: 09 Dec 2024 - Published: 18 Dec 2024
Domain: Epidemiology,Public Health informatics,Public health
Keywords: HIV, Youth, Awareness, Barriers, Status, Testing, Strategies, Access, Stigma, Ghana
©Dawuda Jawarah Adamu et al Journal of Interventional Epidemiology and Public Health (ISSN: 2664-2824). This is an Open Access article distributed under the terms of the Creative Commons Attribution International 4.0 License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Cite this article: Dawuda Jawarah Adamu et al . Awareness of HIV Status and Barriers to Accessing Testing Services among the Youth in Asutifi North District, Ghana, 2020. Journal of Interventional Epidemiology and Public Health. 2024;7:56.
Available online at: https://www.afenet-journal.net/content/article/7/56/full
Awareness of HIV status and barriers to accessing testing services among the Youth in Asutifi North District, Ghana, 2020
Dawuda Jawarah Adamu1, Atsu Dodor2, Samuel Malogae Badiekang2, Bernard Aanoume Ziem2, Abdul Gafaru Mohammed3, Samuel Bortier Borlabi2, Blaise Kuubabongnaa Bagyilko4, Samuel Dapaa3, Kofi Agyabeng5, Gyesi Razak Issahaku6, Joshua Billy2, Samuel Boakye-Boateng7
1Goakro Effah Senior High School, Ghana Education Service, Offuman, Ghana, 2Ahafo Regional Health Directorate, Ghana Health Service, Hwidiem, Ghana, 3Ghana Field Epidemiology and Laboratory Training Programme, Accra, Ghana, 4Wa East District Health Directorate, Ghana Health Service, Funsi, Ghana, 5Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana, 6Tamale Teaching Hospital, Ministry of Health, Tamale, Ghana, 7Upper East Regional Health Directorate, Ghana Health Service, Bolgatanga, Ghana
&Corresponding author
Samuel Malogae Badiekang, Ghana Health Service, Ghana.
Introduction: The burden of HIV/AIDS among the youth has remained high at 12% in 2020. The levels of awareness of HIV status and barriers to testing services uptake among the youth are not fully determined. We studied HIV status awareness and barriers to HIV testing among the youth in Asutifi North district, Ghana.
Methods: A cross-sectional study was conducted among 396 youths aged 15-24 years selected through a multistage sampling technique from Jan-Feb 2020. We used a structured questionnaire to gather data on HIV status awareness, testing services, and barriers to testing services uptake. The level of awareness of HIV status was estimated, and factors associated with the uptake of testing services were examined using multiple logistic regression at a 95% confidence interval.
Results: The mean age of youth was 19.9±2.5 years. Awareness of HIV status among the youth was 25.5% (101/396), HIV testing uptake was found to be 25.7% (46/179) among females. Health workers' attitude was 100.0% (93/93); fear, stigma, and discrimination, 70.5% (279/396) were the main barriers to HIV testing services uptake. Having intentions for an HIV test (AOR= 1.80; 95% CI= 1.06 -3.05) was associated with higher odds of knowing one's HIV status.
Conclusion: We found low HIV status awareness among the youth which could be attributed to stigma and discrimination and poor healthcare worker attitude. Ghana Health Service and partners should adopt innovative strategies to improve the youth's HIV status awareness and testing uptake.
Human Immuno-deficiency Virus (HIV) prevention, diagnosis, and treatment are still challenging despite several interventions. Globally, 39 million people were living with HIV and 630,000 died from HIV-related causes in 2022 [1]. Sub-Saharan Africa remained the most affected region, with 25.6 million people living with HIV (PLHIV), accounting for almost 60% of the global new HIV infections [2]. It is estimated that 5/100,000 HIV-related deaths are associated with youth (15-24 years) in Africa which outnumbers the global burden by five times. In Ghana, the estimated adult national HIV prevalence in 2021 was 1.7% however, this was higher (2.5%) among the youth [3]. In 2022, there were an estimated 354,927 PLHIV with 40,497 new infections in Ghana. Of these, 16,629 were young people (15-24 years), representing 5% of the PLHIV. The number of new HIV infections shows that the youth are more affected with about 14% (5,613) of the total new infections [4]. From the 2020 HIV Sentinel Survey (HSS), Ahafo recorded a higher HIV prevalence (3.5%), compared to the national average (2.0%). HIV prevalence in the Asutifi North District was 1.84% in 2019 [5].
Achieving the 95-95-95 targets is one of the key strategies to end the AIDS epidemic by 2030, which means that 95% of people living with HIV know their status, 95% of those diagnosed receive antiretroviral therapy, and 95% of those on treatment have viral suppression [6,7]. There are still significant gaps and challenges in reaching these targets [7], especially among young people [8], who are at higher risk of acquiring HIV and face multiple barriers to accessing HIV testing and treatment services [9]. In Ghana, only 28.3% of young people aged 15-24 years had ever tested for HIV, and only 16.7% knew their current HIV status in 2019 [10].
Stigma and discrimination continue to play a significant role in deterring youth from seeking HIV testing services [11]. Negative attitudes and behaviors towards individuals living with HIV can create an environment of fear and shame, discouraging youth from getting tested and knowing their HIV status [12]. The influence of healthcare worker behavior cannot be overlooked either, as it can either foster a supportive environment or contribute to reluctance in seeking testing [13,14]. An improved HIV test utilization by the youth requires enhancing the caliber and availability of health services designed for adolescents, which provide all-encompassing, personalized care, and intersectionality. This involves educating healthcare providers about the unique requirements of young individuals, guaranteeing sufficient resources and facilities, and creating systems for referrals and continued support [14,15].
Many young people are at risk of getting infected with HIV, without timely testing and treatment, the number of adolescents living with HIV will increase dramatically in the future[16] and they will lose their chance to live longer and healthier lives [16]. HIV testing plays a vital role as an initial step for both prevention and treatment [17]. However, numerous young individuals are unaware of their status or encounter obstacles in obtaining healthcare services. Enhancing the adolescent-friendliness of public health facilities is an approach employed to promote testing, alongside helping survivors of sexual violence who have an increased susceptibility to HIV infection [14]. Nearly, 30% of new HIV infections were among the youth in 2020[18], this shows the urgent need to scale up HIV testing and treatment among adolescents and young adults, as well as to educate them about how to prevent HIV transmission [12]. Understanding HIV status awareness and barriers to testing amongst the youth is vital to adopting effective strategies alongside the facility-based strategies to improve testing rates for the achievement of the 95-95-95 targets by the year 2030.
This study assessed awareness of the youth on their HIV status, HIV testing uptake, and barriers to HIV testing uptake.
Study Setting
Asutifi North District is one of the six administrative districts in the Ahafo Region with an annual and youth population of 16,670 and 76,678 respectively for the year 2023. The district shares boundaries with Sunyani Municipality to the north, Tano North District to the northeast, Dormaa Municipality and Dormaa East to the northwest, and Asutifi South District to the south and East.
The district has four (4) sub-districts with 14 health facilities including one government hospital, two health Centres, five Community-Based Health Planning and Services (CHPS) compounds, one private maternity home, three private clinics, and two private hospitals. The district has two adolescents´ health corners and two facilities with built Prevention of Mother to Child Transmission (PMTCT) centres. There are two Antiretroviral Therapy Centres in the district. Agriculture and related work is the major occupation in the district. The district is also rich in gold deposit. This is attested by gold mining activities in two sub-districts namely Kenyasi and Gyedu subdistricts.
Study design
We used a cross-sectional design to assess HIV awareness and barriers to testing among the youth (15-24 years) in Kenyasi sub-district of Asutifi North District. Data for this study was collected from January to February, 2020. Study sites and respondents were selected through a multi-stage sampling technique. A structured questionnaire was used to gather data on HIV status awareness, testing uptake, and barriers to HIV testing uptake. Chi-squares and binary logistic regression were conducted in STATA 18.5 to measure association between HIV testing uptake, HIV status awareness, and the other study variables. Findings were reported in frequencies, percentages, crude and adjusted odds ratios at 95% confidence intervals, and p-values of less than 0.05 were reported as significant.
Study Population and Eligibility Criteria
The study included individuals who were within the age range of 15 to 24 years and residing in Kenyasi sub-district of Asutifi North from January to February 2020. Eligible respondents who were extremely ill and those absent at the time of interview were excluded from the study.
Sample Size Estimation
The 2019 estimated youth population of 11,761 at 95% confidence level of 95%, margin of error is 0.05 were used to estimate the sample size using Taro Yamane Formula [19]. A 5% was added to account for non-response.
where n = sample size, N = Population Size, e = margin of error
Non-response estimates =
Study Variables
The main outcome variable was youth awareness of their HIV status measured by asking the youth if they knew their HIV status. The predictor variables were barriers to testing, access, and healthcare worker attitudes.
Sampling Process
To ensure a fair and representative sample, the following steps were taken to select respondents: Step 1: From a list of four sub-districts, one (1) sub-district (Kenyasi) was chosen at random. Step 2: From a list of grouped communities with similar characteristics, eight communities were randomly selected. Step 3: In each of the selected communities, schools, churches, mosques, and markets were alternately chosen at random until the required number of respondents for each community was reached. Step 4: With the assistance of leaders from schools, churches, and mosques, individuals aged 15-24 years were identified and randomly selected for a scheduled interview. Household listing was conducted in the selected communities, and eligible respondents were recruited and interviewed.
Data Source and Collection
Data were collected through face-to-face interviews using a structured questionnaire. The questionnaires were designed in google forms and hosted on Google Drive. Trained interviewers visited the selected households, schools, markets, mosques, and churches to explain the purpose of the study.
Quality Control and Biases
The questionnaire was pretested in Asutifi South district with similar population characteristics before the main data collection. The pretest identified potential issues in wording, flow, and clarity, which were subsequently addressed to enhance the validity of the instrument.
Data Analysis and Data Management
Data were exported from Google Drive in an Excel file, cleaned, and imported into STATA 14.1 for analysis. Frequencies and percentages were computed for socio-demographics, awareness of HIV status, and barriers to HIV testing. Binary Logistic Regression was performed to establish relationships between awareness of HIV status and the socio-demographic variables, awareness of HIV testing and counselling, knowledge of where HIV testing services are provided, and barriers to taking an HIV test. A p-value of less than 0.05 at 95% Confidence Interval (CI) was considered significant at both crude and adjusted levels.
Data Availability
The data used to perform the analysis and generate the tables are available from the corresponding author upon reasonable request.
Ethical Considerations
Ethical approval was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC Number: GHS-ERC028/11/19). Informed consent was obtained from respondents and parental assent obtained for minors. Responses were anonymized and data confidentiality was assured. Permissions were obtained from teachers, and the Ghana Education Service Directorate at the District Level. Data were stored in a google drive accessible to only the investigators.
Socio-Demographic Characteristics of the Respondents
Youth marital status was 11.6% (46/396), 67.9% (269/396) of the respondents had attained secondary level education and 0.25% had primary education. Also, 59.9% (237/396) were Christians and 2.0% were traditionalists (Table 1).
Relationship between Youth Awareness of their HIV Status and Study Variables
Table 2 displays the chi-square test of relationships between youth awareness of their HIV status and the other study variables. Among the youth, 25.5% (101/396) were aware of their HIV status; 45.6% (46/101) of youth who were aware of their HIV status were within the age categories of 21-24 years. We found 75.3% (76/101) of the youth who were single were aware of their HIV status. HIV status awareness at the bivariable level had a statistically significant relationship with these variables: marital status (p=<0.001), knowledge about HTC (p<0.001), knowing about HIV testing place (p=0.036), and having HIV test intentions (p<0.001). Among youth who aware of their HIV status 95.1% (96/101) were students, and 50.5% (50/101) did not know about the place where HIV testing took place and 98.0% (99/101) had intentions of taking an HIV test (Table 2).
Barriers to HIV Testing among the Youth
All (396/396) of the youth interviewed either agreed or strongly agreed that healthcare workers´ attitudes were barriers to getting an HIV test. Fear, stigma, and discrimination were cited by 70.5% (279/396) of the youth as a barrier to taking an HIV test. All the youth who responded agreed that healthcare worker attitudes and behaviours were barriers to taking an HIV test; 81.3% (322/396) strongly agreed and 18.7% (74/396) agreed. 80.8% (320/396) of the youth reported indicated that the place where HIV tests were conducted was convenient (Table 3).
Relationship between Awareness of HIV Status, Socio-demographic and Other Study Variables
Table 4 is a binary logistic regression conducted at the crude and adjusted level to measure the strength of associations between the independent variables and the youth´s awareness of their HIV status. At the adjusted level only youth with intentions of taking an HIV test and those who did not have knowledge about HIV Testing and Counselling (HTC) were significantly associated with awareness of their HIV status. Youth who did not know about HIV testing and counselling had 4.68 times higher odds of being aware of their HIV status than those who were aware of HIV testing and counselling (AOR= 4.68; 95% CI= 2.47, 8.86, p= <0.001). Youth with intentions of taking an HIV test had 1.80 times higher odds of being aware of their HIV status compared to youth without intentions of taking an HIV (AOR= 1.80; 95% CI= 1.06 -3.05, p= 0.030) (Table 4).
This study revealed that only a quarter of the youth were aware of their HIV status. A recent study confirmed our findings in Ghana which reported low (26.4%) proportions of youth 15-24 years being aware of their HIV status [20]. Evidence from other studies suggests that a little over one-tenth of youth have tested and known their HIV status. The low awareness of HIV status finding is consistent with a previous study which studied youth 10-19 years [14]. Low awareness of HIV status among the youth highlights challenges in accessing testing services by the youth studied, which is a major obstacle to achieving the first 95 of the 95-95-95 global goals set to be achieved by the year 2030. Achieving 95% awareness of HIV status among the youth requires multifaceted approaches; like community-based and Home-based HIV testing approaches found to be effective for some hard-to-reach groups like men will complement the facility-based approaches [21]. Further studies to examine youth willingness to take up community-level HIV testing strategies such as self-test and peer-to-peer testing can support the existing health facility-level testing approaches to increase youth awareness of their HIV status.
Married youth reported higher proportions of HIV status awareness compared to unmarried youth, this may be partly due to the mandatory prevention of mother-to-child transmission (PMTCT) services that are provided in healthcare facilities. Our findings are consistent with a study by Asare et al. (2020) in Ghana which reported low (45.5%) HIV status awareness, [22] which can affect the 95-95-95 goals. This low HIV status awareness suggests the ineffectiveness of the facility-based approaches alone[23], which can lead to increased HIV transmission, late diagnosis and treatment, and low quality of life among HIV-positive youth. Strengthening youth-friendly health services, school health services, and targeted education for organized youth groups would improve testing uptake. Further research to understand the youth perspectives on the nature of health services that would enhance their uptake of HIV testing services will be vital to the development of policies and planning of HIV intervention programmes for the youth [24,25].
We found stigma and discrimination as important barriers to HIV testing among the youth. Suboptimal knowledge of HIV status among the youth has effects like delayed diagnosis and treatment, increased community transmission and spread, and missed opportunities for prevention. Fear, stigma, and discrimination were perceived by over 70% of the youth as barriers to testing uptake which can increase the risk of HIV transmission and progression to AIDS by reducing the uptake of preventive measures, testing, treatment adherence, and viral suppression. It can also fuel violence, marginalization, and human rights violations against people living with or at risk of HIV, especially key populations such as young people, LGBTI, and commercial sex workers [26,27]. This can be worse in a mining district like Asutifi North. These findings are consistent with a systematic review by Karver et al. (2022) on documented negative effect of stigma and discrimination on HIV testing uptake [28].
Our results also highlighted the importance of healthcare worker behavior at the health facility as a key factor in preventing HIV testing among the youth. This suggests an adolescent reproductive health corners and youth-friendly clinic services of adapting intersectionality for promoting youth uptake of HIV testing in the Asutifi North district. This was reflected in the results when all respondents indicated that healthcare worker attitude at the HIV testing centre is a barrier to taking an HIV test. Without immediate reorientation and training of the healthcare worker to provide youth-friendly HIV testing and counselling services, healthcare workers´ attitudes will continue to serve as barriers to the uptake of HIV testing. Consistent with this finding is a study that reviewed literature and summarized the main challenges that healthcare workers face when providing HIV services to young people in Sub-Saharan Africa. Challenges such as lack of youth-friendly infrastructure, legal clarity, training, and caregiver support were identified as challenges with healthcare workers providing HIV testing services for young people [29].
Strangely youth who were not aware of HIV testing and counselling services were much aware of their HIV status than those who were unaware of HIV testing and counselling services. Their HIV status awareness can be attributable to Know Your Status (KYS) campaigns that sometimes take place with the support of some Non-governmental Organizations in the Asutifi North District. Increasing public sensitization about HIV, providing them with alternative testing strategies, and showing them where to get tested will improve HIV testing rates. Married youth were also found to be more aware of their HIV status than the youth who were not married. Youth who were within the age of 18-24 years were much aware of their HIV status compared to the other age groupings. Studies in both Uganda and Kenya confirm youth awareness of HIV testing services, and marital status, have significant relationship with HIV status awareness among the youth [30,31]. Since health facility-based approaches are less preferred by youth due to perceived barriers [23,24].
The major strength of this study is unravelling youth intentions of taking an HIV test as an important variable that influence youth awareness of their HIV status compared to youth who reported no intentions of taking an HIV test. Similar findings were reported by Kidman et al. 2020 [26] revealing more than 50% of youth having intentions of taking an HIV test once test is made available. Adopting multiple HIV testing strategies will health the health system take advantage of translating the high HIV test intentions among the youth into high testing and increased HIV status awareness among the youth. Blending HIV testing approaches like; peer and community-led HIV testing strategies (Self-test Approaches, partner notification services, workplace HIV testing services) and facility-based testing (PMTCT, PITC) will increase HIV testing rates and increased HIV awareness among the youth in the Asutifi North district.
It is important to interpret these findings with care since they are limited to self-reported data from the youth, which may be subject to recall and social desirability bias. Perspectives and experiences of the healthcare workers who provided HIV testing and counselling services, which may be important for understanding the quality, accessibility, and effectiveness of the HIV testing services were not assessed in this study. This study did not also measure when the youth last tested for HIV hence their recent exposure risk is unknown, the study only measured the proportion of youth who are aware of their HIV status. To address these biases, questionnaires were pretested during the design phase and reworded to avoid leading, judgmental, or ambiguous terms that might trigger social desirability bias.
Future studies using longitudinal study designs may be needed to assess changes in attitudes and behaviors related to HIV testing and to better understand the factors that influence these changes to guide interventions that will improve HIV status awareness and testing uptake among the youth.
This study found low awareness of HIV status among the youth in the Asutifi North District, intention to take an HIV test is an essential variable for the awareness of HIV status among the youth. Healthcare worker attitudes and behaviors at healthcare facilities was a major barrier to HIV testing. The findings emphasize the need to adopt both peer-community-led and facility-based HIV testing approaches to increase testing rates and awareness of HIV status among the youth. The National AIDS Commission in collaboration with the Ghana Health Service and other implementing partners should adopt more inclusive approaches such as Peer-Community-led HIV testing strategies to provide supportive environments, and intersectionality to move closer towards achieving the 95-95-95 goals and empowering a proactive youth generation in managing their sexual health.
What is known about this topic
What this study adds
The authors declare no competing interests.
Funding
This study was fully funded by the principal investigator.
ADJ and SMB conceptualized and designed the study. SKB, BAZ and SBB provided technical inputs and administrative support during the field data collection. ADJ, KA and SMB collected and analyzed the data. ADJ, KA and SMB interpreted the results. SMB, GRI, JB, SKB and BKB wrote the initial draft of the manuscript with input from all authors. MAG provided critical feedback and revisions. All authors read and approved the final manuscript.
Sincere gratitude goes to Dr. Vitalis Bawontuo for supervising this work, his guidance, feedback, and encouragement throughout the project. His expertise and insights were instrumental in shaping our research question, methodology, and analysis. We also thank the School of Public of the Catholic University of Ghana, Sunyani for their constructive comments and suggestions on our draft project. We appreciate the professional editing services provided by AFENET, which helped us improve the clarity and readability of our manuscript.
Table 1: Socio-Demographic Characteristics of the Youth (N=396)
Table 2: Bivariate Analysis between Independent Variables and Youth Awareness of their HIV Status
Table 3: Barriers to HIV Testing (N=396)
Table 4: Relationship between Youth Awareness of their HIV Status and Independent Variables
HIV
Youth
Awareness
Barriers
Status
Testing
Strategies
Access
Stigma
Ghana