This population-based nationally-representative study was designed to identify factors predicting the knowledge and acceptability of PrEP coupled with HIV testing engagement among adolescents and young adult (AYA) males aged 15–24 years in Ghana. To fill the gap in existing research, the most recent GDHS data to inform current health seeking behaviors of the AYA male population has been utilized. Existing studies on PrEP did not specifically focus on this demographic, making our findings quite interesting. A number of key findings emerged from the study regarding knowledge of PrEP, acceptability of PrEP, and HIV testing.
Majority of the AYA originated from Savannah, Ashanti, Oti, Central, Northern, Upper East, drawn from rural areas, aged 15–19 years, overwhelmingly never married, primary/Middle/JSS educated, employed, and Christian. Moreover, the rate of sexual activity in this population was high, yet knowledge of PrEP, acceptability of PrEP among participants with knowledge of the existence of PrEP, and HIV testing were very low. These findings align well with existing studies among men and AYA with similar nationally representative sample in Sub-Saharan African countries of Ghana, Cote d’Ivoire, Cameroon, and South Africa which found lower levels of HIV PrEP knowledge, acceptability and low testing for HIV (7, 27, 28). Similarly, a South African study found that low PrEP knowledge was the most consequential barrier to PrEP willingness among young people (28). Other key populations at risk for HIV infection that were recently studied within Sub-Saharan Africa such as female sex workers, sexual and gender minority groups also share a similar trend regarding low HIV PrEP knowledge but high acceptability following PrEP awareness (20, 29). Given the high rate of sexual activity in these group of male populations amidst poor HIV PrEP knowledge and HIV testing, there is urgent need to launch multifarious HIV prevention manifesto for young men across Ghana and beyond. At present, the African women HIV prevention community accountability board has launched a HIV prevention choice manifesto for women and girls in Africa which focuses on tackling inequalities for girls and women, expanding access to newer PrEP options such as long-acting HIV PrEP and flexible silicone vaginal ring, and enhancing women leadership in HIV prevention (30). This should be replicated across Africa for AYA men starting with Ghana in order to stem the tide on new HIV infection and transmission in this demographic all through Africa. Carrying AYA men along in specialized new HIV preventive interventions will be a useful transformational step in the overall reduction in HIV prevalence, and AIDS mortality for Sub-Saharan Africa. Given that men account for the greatest gap in HIV prevention and control services throughout Sub-Saharan Africa (15), more specialized interventions for AYA men would be quite strategic. Providing PrEP alongside other prevention strategies within existing adolescent sexual and reproductive health initiatives, coupled with information and support, can mitigate potential health risks associated with PrEP initiation, thereby fostering healthy sexual behavior changes (22, 31).
Aside the prevalence findings, for knowledge of HIV PrEP, this study found statistically significant relationships for participants originating from Volta, Eastern, Western North, Bono East, being widowed/separated/divorced, and having a higher than secondary school education. Similarly, for HIV testing, originating from the Central region, being within ages 20–24 years, having a secondary or higher education and being sexually active, showed statistical significance in the study. These findings are congruent with a previous study in Ghana which found statistical significance between HIV testing, and age and marital status among AYA (18). Beyond Ghana, existing studies in Cameroon, Congo, Nigeria, Uganda, and Mozambique, also found age and higher education as significant predictors of HIV testing (7, 32, 33). However, this current study found a noteworthy lack of any statistically significant relationship between the sociodemographic factors, and HIV PrEP acceptability, which appears to be a consequence of the low PrEP knowledge finding among this AYA male population in Ghana. This is slightly different for other key populations such as female sex workers and sexual/gender minority groups where PrEP acceptability is demonstrably higher (20, 29, 34) and stands out as a key difference between this current study and previous recent studies in Ghana. In this current study, the findings regarding low HIV PrEP knowledge, acceptability, and HIV testing highlight the need to be innovative in rolling out PrEP in such a way that it reverses the existing trend and coincides with AYA readiness for sex or important milestones. Guilamo-Ramos, Thimm-Kaiser (35) opines that sexual reproductive health outcomes among youths are improved when parental support is harnessed for AYA, particularly as they navigate important milestones and socio-cognitive emotional maturity. It is a call for the return of family values where parents take a special interest in guiding AYA males through their readiness for sex and condom use behavior in order to ensure a safe sexual reproductive health outcome. Consequently, parents can play a critical role in teaching their AYA about PrEP as a protective mechanism should they become sexually active.
Another notable finding in this study is that the social demographic predictors cross-cut HIV PrEP knowledge, HIV PrEP acceptability, and HIV testing were the region, marital status, employment status, religion and recent sexual activity. Likewise, having a higher education was a highly unique significant predictor of both HIV PrEP knowledge and HIV testing respectively. Specifically, participants who originated from the Volta, Eastern, Western North, Bono East, were widowed/separated/divorced, and had higher education than secondary education, all had higher odds of HIV PrEP knowledge than participants from the Western region of Ghana. Certain prior studies found correlation between marital status and higher knowledge of HIV prevention similar to the current study suggesting that sexual behavioral health outcomes may be improved within the confines of marital experience (36–38). Moreover, the current findings are also consistent with previous studies among young men that found higher odds of HIV testing among men with a higher education (7, 36). This suggests that comprehensive PrEP counseling should be re-enforced as a HIV prevention strategy in Ghana so as to appeal to the educated group of AYA men to engage in routine HIV testing, while health authorities continue focusing on using community level structures in reaching the less educated population. A recent study also found that a highly sexually active population of young men aged 15–24 years engaged in multiple sexual relationships without requisite knowledge of their HIV status or PrEP in Cote d’Ivoire (8), which aligns with our current finding that recent sexual activity was a significant predictor of both HIV testing and HIV PrEP knowledge. Therefore, measures should be put in place to translate the predictors of PrEP and HIV testing into building social peer networks of support groups which can champion safe sex practices, make it easier for men to initiate PrEP, drive up phone reminders for peers who are on PrEP or could benefit from them, and advocate for participation in adherence counseling for AYA men. Structural issues such as providing youth friendly PrEP clinics and staff training to increase familiarity with PrEP protocols, should be urgently addressed particularly for regions with lower PrEP knowledge and HIV testing. Shifting cultural narratives from ignorance to empowerment and supporting accurate self-assessment during important milestones of AYAs are essential for effectively addressing their sexual reproductive health outcomes. This involves investing in nationwide media campaigns for clear PrEP dissemination and formal/informal community-based initiatives, guided by targeted messaging to both heterosexual, sexual or gender minorities, and rigorous routine appraisal of these measures.
Proactively, emerging technologies and artificial intelligence such as the NASSS (Non-adoption, Abandonment, Scale-up, Spread and Sustainability) framework and the Human Behavior-Change Project (HBCP), can be adopted and utilized to speed up evidence synthesis in real-time in order to effect health behavioral change among the AYA male population in Ghana (39). NASSS comprises six domains, encompassing the illness or condition, technology, value proposition, intended adopters, organization(s), and the wider system, supplemented by a seventh domain examining their evolution over time (40). Evidence exists of their use in the past for smoking cessation (41) and physical activity interventions (42) which indicates that HIV testing behavior and PrEP acceptability can be improved with technology and artificial intelligence. The NASSS framework is being seriously considered in Zimbabwe by generating evidence from key stakeholders’ perspectives on the adoption of telehealth in HIV care (43, 44). Ghana can do the same while strengthening existing interventions such as: i) health staff training about PrEP, broad social marketing campaigns, ii) scaled-up community-based outreaches to Greater Accra, Ashanti, Ahafo, Bono, Oti, Northern, Savannah, North East, Upper East, and Upper West regions with lower odds of HIV PrEP knowledge and HIV testing, and iii) integrating PrEP into school-based curriculum and services targeted at the AYA population so as to improve their overall reproductive health outcomes.
Limitations and Strengths of the Study
This study is a secondary research based on a self-report cross-sectional primary GDHS study. Therefore, flaws associated with social desirability bias of the parent study impacts the current study potentially. There exists the possibility that participants may have either underreported information or been subject to recall bias, factors which could potentially impact the outcomes of the current study. Moreover, the study's framework suggests it lacks the capacity to conclusively establish or imply a causal connection between HIV PrEP, acceptance of HIV PrEP, HIV testing, and socio-demographic predictors because of its cross-sectional design. Given that this sample utilized for this study were derived from the larger men’s dataset (ages 15–59) that used general men’s questionnaire, the item pool in the measure may have been too broad or rigorous or not tailored specifically for the youngest group (ages 15–19) which may impact their responses. Likewise, the non-inclusion of female AYA in Ghana denies the study the gender implications and nuances that may have been crucial to comprehensively evaluate sexual reproductive health outcomes among AYAs in Ghana for both genders. Therefore, future studies should focus on studying both male and female AYAs in Ghana concurrently which will best explore how we can facilitate safe sexual interactions overall. Conversely, this study boasts of several firsts. To the best of our knowledge, it is the first study to examine HIV PrEP knowledge, HIV PrEP acceptability, and HIV testing concurrently among AYA men in Ghana using the newest GDHS, and therefore the best available evidence in the field for Ghana. Secondly, the findings enjoy the advantage of generalizability to the male AYA population in Ghana considering the large nationally representative sample size. Thirdly, the quantitative methods adopted in analyzing the findings is a distinction from existing studies on HIV PrEP which mostly utilized qualitative methods. Fourthly, the focus on the general AYA male population without partitioning the sample into behavioral, sexual and gender identities, would give a better overall insight into HIV prevention evidence in Ghana. The multi-dimensional predictors identified in this study when harnessed and allowed to guide HIV prevention interventions could play a crucial role in reducing negative sexual reproductive health outcomes in Ghanaian AYA men.