Introduction
Human Immunodeficiency Virus (HIV) continues to be a major global public health problem with an estimated 38.0 million people living with HIV (PLWH) with the greatest impact in Africa (25.7 million) [
1]. In 2019, the estimated adult HIV prevalence for Ghana was 1.7% with an estimated HIV population of 316, 352 and 25, 955 adults and children respectively [
2]. In the same year, Ghana’s Eastern Region recorded an HIV prevalence of 2.7% according to the annual HIV Sentinel Survey conducted by the National AIDS/STIs Control Programme [
3].
Early detection, coupled with rapid linkage to care is particularly essential in mitigating the HIV/AIDS epidemic. However, the proportion of people living with HIV (PLWH) who know their status remains inadequate in Western and Central Africa populations [
4]. As of 2017, only 48% of people living with HIV in Western and Central African knew their status [
4]. Scaling-up antiretroviral therapy (ART) is crucial to the control of the HIV/AIDS pandemic [
5]. Initiation of early ART does not only reduce morbidity and mortality but also reduces incidence rates of HIV, resulting in the concept of “Treatment as Prevention (TasP)” [
6,
7]. To maximize the benefits of TasP, PLWH must be diagnosed early in the course of their HIV infection, link to care and remain adherent to ART to attain full virologic suppression [
8]. However, due to poor health-seeking behaviour coupled with socio-cultural dynamics, most PLWH in Africa do not access health facility-based voluntary counselling and testing services resulting in delayed diagnosis.
In response to the 95-95-95 global strategy, by the Joint United Nations Programme on HIV/AIDS to accelerate efforts toward ending the AIDS epidemic by 2030 [
9], the Ghana National AIDS/STI Control Programme (NACP) developed a 5-year road map to Locate, Test, Treat and Retain (L2TR) [
10]. The road map focussed on lower-level health workers, volunteers, and other stakeholders but also included expanding community health screening, also known as HIV “know your status” (KYS) campaigns to scale up HIV testing in communities and timely ART initiation. The KYS campaign is an outreach program that was introduced in Ghana in 2007 following its success in other resource-limited settings to encourage the general population to know their HIV status [
11]. This innovative approach to HIV testing which has been demonstrated to improve testing uptake [
12,
13] is an important step in realizing the goal of diagnosing at least 95% of PLWH in the UNAIDS strategy to end the HIV epidemic [
9].
Most large-scale community-based health screening campaigns are usually designed to create awareness of pertinent health issues. A few like the KYS goes a step further by linking participants to treatment and care services.
Here, we describe how we implemented a community based multi-disease health screening to recruit healthy controls in seven communities in an ongoing HIV Microbiome study [
14] and in the process identified PLWH and linked them to care. Data on the HIV-Microbiome study has been published elsewhere [
14]. The HIV-Microbiome study is under the project for Science and Technology Research Partnership for Sustainable Development Program (SATREPS). It is a collaborative project between the Noguchi Memorial Institute for Medical Research (NMIMR), Eastern Regional Hospital, Koforidua, Ghana Health Service (GHS), and Japanese partner institutions (National Institute of Infectious Diseases- NIID, Institute of Medical Sciences, the University of Tokyo).
Results
A total of 738 persons from the 7 communities participated in the health screening exercise with females constituting the highest number 68% (500/738). Over 70% had formal education, 48% were traders and over 50% were not married. Some participants (48%) have ever participated in a health screening exercise but only 30% and 12% have ever tested for HIV and HBV respectively (Table
1). A clear majority of the participants (71%) just wanted to know their health status.
The health screening exercise varied significantly between males and females across the communities (p < 0.001). Half (50%) of the participants had a normal BMI. There was a significant association between BMI and the communities; with the highest number of people with normal BMI coming from Koforidua township. Similarly, the reason for the health screening, educational status (p < 0.001), occupation (p < 0.001), and marital status (p < 0.001) also varied significantly across the 7 communities. However, there was no significant association between testing positive for syphilis and gender. Furthermore, there was no significant association between the various indicators (Syphilis, HIV, and HBV) and age groups.
All 738 persons recruited consented to syphilis and HBV testing. However, 38 of them did not consent to be tested for HIV. Of the 700 participants that tested for HIV, 23 (3%) were positive while 2% (17/738) were positive for syphilis and 4% (33/738) for HBV infection (Table
2). Co-infection of HIV and HBV was detected in 4 participants. However, there was no co-infection of syphilis with either HIV or HBV. Tafo and Suhum communities recorded the highest proportion (6.8% and 6.0% respectively) of HIV-infected individuals (Table
2). A higher proportion of males were infected with HBV (Males = 13/238, 6%; Females = 20/500, 4%) and syphilis (Male = 9/238, 4%; Females = 8/500, 2%). In contrast, the proportion of males infected with HIV (6/226, 3%) was lower compared to females (17/474, 4%). The majority of the participants were older than 40 years (441/738) (Table
3). However, the proportion of participants infected with syphilis, HBV, and HIV was higher among individuals in the age group less than 40 years. The highest proportion of syphilis (4%) was detected in the 31–35 year age group. The highest proportion (7%) of HBV was detected in the 36–40 year age group. Likewise, the highest proportion (7%) of HIV was detected in the 36–40 year age group.
Table 1
Demographics of participants in the community health screening
Total Recruited | Male | 100 | 20 | 72 | 32 | 8 | 3 | 3 | 238 | 32% | < 0.001 |
Female | 141 | 67 | 99 | 178 | 5 | 6 | 4 | 500 | 68% |
Total | 241 | 87 | 171 | 210 | 13 | 9 | 7 | 738 | |
% | 33% | 12% | 23% | 28% | 2% | 1% | 1% | | |
BMI | Normal | 128 | 33 | 86 | 111 | 2 | 3 | 3 | 366 | 50% | < 0.001 |
Underweight | 31 | 12 | 18 | 16 | 2 | 1 | 2 | 82 | 11% |
Overweight | 55 | 2 | 59 | 54 | 4 | 3 | 1 | 178 | 24% |
Obese | 27 | 40 | 8 | 29 | 5 | 2 | 1 | 112 | 15% |
Educational Status | Educated | 201 | 81 | 111 | 157 | 7 | 5 | 3 | 565 | 77% | < 0.001 |
Not Educated | 40 | 6 | 60 | 53 | 6 | 4 | 4 | 173 | 23% |
Occupation | Trader | 90 | 40 | 94 | 126 | 4 | 2 | 1 | 357 | 48% | < 0.001 |
Student | 46 | 13 | 36 | 21 | 3 | 3 | 2 | 124 | 17% |
Teacher | 45 | 18 | 18 | 22 | 1 | 0 | 2 | 106 | 14% |
Farmer | 35 | 9 | 5 | 24 | 4 | 3 | 4 | 84 | 11% |
Others | 23 | 7 | 18 | 17 | 1 | 1 | 0 | 67 | 9% |
Marital Status | Married | 117 | 33 | 50 | 104 | 6 | 3 | 4 | 317 | 43% | 0.001 |
Not Married | 124 | 54 | 121 | 106 | 7 | 6 | 3 | 421 | 57% |
Ever participated in a community health screening | Yes | 110 | 38 | 129 | 68 | 2 | 3 | 1 | 351 | 48% | < 0.001 |
No | 131 | 49 | 42 | 142 | 11 | 6 | 6 | 387 | 52% |
Reason for the health screening | To know my health status | 135 | 52 | 132 | 185 | 10 | 5 | 4 | 523 | 71% | < 0.001 |
To test for HIV | 70 | 23 | 25 | 15 | 3 | 3 | 2 | 141 | 19% |
To test for HepBsAg | 36 | 12 | 14 | 10 | 0 | 1 | 1 | 74 | 10% |
Ever Tested for HIV | Yes | 129 | 32 | 22 | 31 | 1 | 2 | 1 | 218 | 30% | < 0.001 |
No | 112 | 55 | 149 | 179 | 12 | 7 | 6 | 520 | 70% |
Ever Tested for HepBsAg | Yes | 45 | 10 | 20 | 15 | 0 | 1 | 0 | 91 | 12% | 0.009 |
No | 196 | 77 | 151 | 195 | 13 | 8 | 7 | 647 | 88% |
Table 2
Summary of STI test results
Total Screened (N = 738) | Male | 100 | 20 | 72 | 32 | 8 | 3 | 3 | 238 | (32%) | < 0.001 |
Female | 141 | 67 | 99 | 178 | 5 | 6 | 4 | 500 | (68%) |
Total | 241 | 87 | 171 | 210 | 13 | 9 | 7 | 738 | |
% | 33% | 12% | 23% | 28% | 2% | 1% | 1% | | |
Syphilis (VDRL) Positive (N = 738) | Male | 7 | 1 | 1 | 0 | 0 | 0 | 0 | 9 | 17 (2%) | 0.52 |
Female | 2 | 0 | 3 | 3 | 0 | 0 | 0 | 8 |
Total | 9 | 1 | 4 | 3 | 0 | 0 | 0 | 17 |
% | 3.7% | 1.1% | 2.3% | 1.4% | 0.0% | 0.0% | 0.0% | |
HBsAg (N = 738) | Male | 8 | 2 | 1 | 0 | 2 | 0 | 0 | 13 | 33 (4%) | 0.190 |
Female | 8 | 2 | 3 | 6 | 1 | 0 | 0 | 20 |
Total | 16 | 4 | 4 | 6 | 3 | 0 | 0 | 33 |
% | 6.6% | 4.6% | 2.3% | 2.9% | 23.1% | 0.0% | 0.0% | |
HIV | Total tested (N = 700) | Male | 95 | 19 | 68 | 30 | 8 | 3 | 3 | 226 | (32%) | < 0.001 |
Female | 134 | 64 | 94 | 169 | 5 | 5 | 3 | 474 | (68%) |
Total | 229 | 83 | 162 | 199 | 13 | 8 | 6 | 700 | |
% | 32.7% | 11.9% | 23.1% | 28.4% | 1.9% | 1.1% | 0.9% | | |
Positive | Male | 1 | 1 | 4 | 0 | 0 | 0 | 0 | 6 | 23 (3%) | 0.624 |
Female | 3 | 4 | 7 | 3 | 0 | 0 | 0 | 17 |
Total | 4 | 5 | 11 | 3 | 0 | 0 | 0 | 23 |
% | 1.7% | 6.0% | 6.8% | 1.5% | 0.0% | 0.0% | 0.0% | |
Table 3
Age group of persons who participated in the community health screening
HIV | Tested | 10 | 59 | 68 | 69 | 77 | 66 | 83 | 268 | 700 | |
Positive | 0 | 3 | 2 | 2 | 5 | 2 | 2 | 7 | 23 | 0.769 |
% | 0.0% | 5.1% | 2.9% | 2.9% | 6.5% | 3.0% | 2.4% | 2.6% | 3% | |
Syphilis | Tested | 11 | 60 | 72 | 73 | 81 | 70 | 88 | 283 | 738 | |
Positive | 0 | 1 | 1 | 3 | 1 | 1 | 1 | 9 | 17 | 0.798 |
% | 0.0% | 1.7% | 1.4% | 4.1% | 1.2% | 1.4% | 1.1% | 3.2% | 2% | |
HBV | Tested | 11 | 60 | 72 | 73 | 81 | 70 | 88 | 283 | 738 | |
Positive | 0 | 4 | 5 | 1 | 6 | 2 | 3 | 12 | 33 | 0.517 |
% | 0.0% | 6.7% | 6.9% | 1.4% | 7.4% | 2.9% | 3.4% | 4.2% | 4% | |
Discussion
Community-based multi-disease screening, such as the one undertaken in our study could be critical for identifying HIV infected persons from the community and linking them to care. This study will greatly contribute to achieving the first two 95s towards ending the AIDS pandemic by 2030. Using this approach, we were able to recruit HIV seronegative persons as a control cohort for an ongoing study on HIV and Gut Microbiota [
14]. Participants identified to be infected with HIV were referred for counselling and linked to care at the community health facilities. Of the total number of individuals recruited, 52% were participating in a community health screening such as KYS for the first time. We observed that HIV/STI testing uptake was very low in our study population; 30% and 12% of participants had ever tested for HIV and HBV respectively. The lower patronage could be attributed to stigma and discrimination. It was shown that a major barrier to voluntary testing and counselling in sub-Saharan Africa is the stigma and discrimination associated with HIV/AIDS [
15‐
17]. In this study, pre-test screening revealed that the majority (71%) of the participants wanted to know their general health status but not HIV and HBV status. Only 11% and 10% wanted to know their HIV and HBV status respectively. However, through comprehensive education, counseling, and integration of HIV testing with a general health screening in our KYS model, we were able to consent all participants for HBV testing and 95% (700/738) for HIV testing. This indicates that through appropriate education, counselling, and sensitization methods, the impact of stigmatization and discrimination on HIV testing uptake could be significantly reduced as recommended elsewhere [
16]. Also, educational level is reported as a predictor of uptake of HIV testing [
17,
18]. In this study we observed that 77% of participants have had formal education, thus contributing to the positive response of consenting to HIV-STI testing.
We observed that the majority (68%) of participants in the study were females (Table
1). This could be because females in Ghana are known to exhibit a more favorable health-seeking behavior compared to the males [
17,
18]. However, it is also worth noting that females constitute a majority (51%) of the population of the Eastern Region [
19]. Thus, the higher proportion of female participants in this study may not be entirely attributable to better health seeking behavior in women.
Though the Eastern Region has a youthful population structure [
19], we observed that more participants (59%) in this study were older than 40 years, while there was low patronage from the youth (Table
3). This is consistent with other studies that reported that stigma and fear associated with knowing one’s health status, especially HIV, discourage the youth from participating in KYS campaigns [
15‐
18,
20‐
22]. However, the proportion of participants infected with syphilis, HBV, and HIV was higher among individuals in age groups less than 40 years. Particularly, individuals in the 36–40 years age group recorded the highest proportion of HIV (7%) and HBV (7%) infections (Table
3). All 4 cases of HIV-HBV co-infection were recorded in the same age group. We did not detect co-infections with syphilis.
Women are disproportionately affected by the HIV/AIDS epidemic in sub-Saharan Africa [
23]. Consistently, we recorded a higher proportion of females (17/474, 3.6%) infected with HIV compared to males (6/226, 2.7%) (Table
2). In contrast, a higher proportion of males were infected with HBV (13/238, 5.5%) and Syphilis (9/238, 3.8%) than females. The overall HIV prevalence (3%) found in this study is higher than both the national prevalence of 1.7% [
24] and the Eastern Regional prevalence of 2.7% in 2017 [
25]. Routine community based multi disease health screening campaign models such as the one reported in this study and other studies [
26‐
28] could be a spring board to inform prevention and control strategies for HIV/AIDS and other STIs.
Community based testing and counselling is part of the HIV testing approaches used in Ghana to improve achievement of the first 95 of the UNAIDS target goals for 2030 [
10,
24]. However, uptake of HIV testing remains low. In this study we demonstrated that integrating HIV testing into a general health screening in communities improves HIV testing uptake. Adapting a model such as ours could contribute to improving the first two 95s of the UNAIDS 95 95 95 target by 2030[
9].
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