Background
Methods
Study design
Recruitment and consent
Data collection
Topic domain | Question | Sample prompts |
---|---|---|
Community Norms and Stigma | How would you describe the community in which you live? | • What have been some of the obstacles or challenges that you’ve experienced in your community as MSM? |
Network Mental Resources – Health Seeking Attitudes (STI/HIV) | What are your thoughts about getting tested for STIs? | • Have you ever been tested [for HIV]? • What prompts you to get tested [for HIV]? |
Network Mental Resources – Condom Use Attitudes | Tell us about how often you use condoms now during sex? | • How do you feel about using condoms during sex? o With men? o With women? |
Network Mental Resources – Gender Equitable Norms | What are your thoughts about women who carry condoms? | How would you feel if your female partner asked you to use a condom? |
Network Mental Resources – Competence Support | What are the HIV/STI prevention needs of guys like you and your friends? | • What are the needs you think you have within your social network? |
Network Tangible Resources | What are other needs you have in your life? | • How do you earn money? |
Health Care Climate Experiences – Autonomy Support | Who do you go see when you have a sexual health related issue? | • What do you like/not like about the provider that you visit? • Do you feel like you have a say in what happens to you there? • How would you like the experience to be different? |
Health Care Climate Experiences – Relatedness Support | Do you think that the health care provider cares about what happens to you? | • Why do you think so? • Why don’t you think so? • Do you want to do what they advise? Why? Why not? |
Health Care Climate Experiences – Competence Support | When you leave the health office how capable do you feel to follow provider’s instructions? | • Do you want to do what they advise? Why? Why not? |
Data analysis
Addressing positionality
Findings
Accra | Kumasi | Manya Krobo | ||||||||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Group No. | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Total (Accra) | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | Total (Kumasi) | 1 | 2 | 3 | 4 | 5 | 6 | Total (Manya Krobo) | Total (all sites) |
Sample Size (n=) | 8 | 6 | 6 | 7 | 6 | 6 | 6 | 8 | 53 | 6 | 8 | 5 | 6 | 6 | 6 | 8 | 6 | 51 | 4 | 6 | 6 | 7 | 6 | 4 | 33 | 137 |
Age (years) | ||||||||||||||||||||||||||
25 or less |
88
|
67
|
17
|
71
|
33
|
50
|
33
|
100
|
60
|
17
|
100
|
80
|
100
|
100
|
83
|
100
|
100
|
86
|
25
|
83
|
83
|
86
|
17
|
–
|
55
|
69
|
26–35 |
13
|
17
|
50
|
14
|
67
|
50
|
67
|
–
|
32
|
83
|
–
|
20
|
–
|
–
|
17
|
–
|
–
|
14
|
75
|
17
|
17
|
14
|
83
|
100
|
45
|
28
|
> 35 |
–
|
17
|
33
|
14
|
–
|
–
|
–
|
–
|
8
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
3
|
Education Level | ||||||||||||||||||||||||||
< Primary 10th |
13
|
–
|
–
|
–
|
50
|
17
|
67
|
13
|
19
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
75
|
83
|
33
|
43
|
67
|
25
|
55
|
20
|
Primary 10th |
38
|
17
|
33
|
29
|
33
|
50
|
17
|
25
|
30
|
–
|
–
|
–
|
17
|
–
|
–
|
–
|
–
|
2
|
–
|
–
|
–
|
14
|
–
|
–
|
3
|
13
|
Diploma |
50
|
83
|
50
|
71
|
17
|
33
|
17
|
63
|
49
|
33
|
75
|
–
|
83
|
–
|
33
|
25
|
67
|
41
|
–
|
–
|
67
|
43
|
–
|
–
|
21
|
39
|
College |
–
|
–
|
17
|
–
|
–
|
–
|
–
|
–
|
2
|
67
|
25
|
100
|
–
|
100
|
67
|
75
|
33
|
57
|
25
|
17
|
–
|
–
|
33
|
75
|
21
|
27
|
HIV Serostatus | ||||||||||||||||||||||||||
HIV negative |
63
|
67
|
100
|
86
|
100
|
100
|
100
|
100
|
89
|
33
|
25
|
40
|
83
|
33
|
33
|
75
|
67
|
49
|
75
|
83
|
100
|
100
|
83
|
100
|
91
|
74
|
HIV positive |
–
|
17
|
–
|
–
|
–
|
–
|
–
|
–
|
2
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
1
|
Status unknown |
25
|
–
|
–
|
14
|
–
|
–
|
–
|
–
|
6
|
50
|
75
|
60
|
17
|
67
|
67
|
25
|
33
|
49
|
25
|
17
|
–
|
–
|
17
|
–
|
9
|
23
|
Decline to answer |
13
|
17
|
–
|
–
|
–
|
–
|
–
|
–
|
4
|
17
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
2
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
2
|
HIV Testing History | ||||||||||||||||||||||||||
Never Tested |
38
|
–
|
–
|
14
|
–
|
–
|
17
|
–
|
9
|
67
|
75
|
80
|
83
|
50
|
83
|
50
|
50
|
67
|
–
|
17
|
–
|
–
|
33
|
25
|
12
|
31
|
Tested ≥1 time |
63
|
83
|
100
|
86
|
100
|
100
|
83
|
100
|
89
|
33
|
25
|
20
|
17
|
50
|
17
|
50
|
50
|
33
|
100
|
83
|
100
|
100
|
67
|
75
|
88
|
68
|
Sexual Attraction | ||||||||||||||||||||||||||
Men only |
25
|
33
|
17
|
43
|
67
|
50
|
100
|
100
|
55
|
83
|
75
|
100
|
67
|
67
|
67
|
88
|
100
|
80
|
25
|
–
|
17
|
71
|
17
|
–
|
24
|
57
|
Men and Women |
75
|
67
|
67
|
57
|
33
|
50
|
–
|
–
|
43
|
17
|
25
|
–
|
33
|
33
|
33
|
13
|
–
|
20
|
75
|
100
|
83
|
29
|
83
|
100
|
76
|
42
|
Women only |
–
|
–
|
17
|
–
|
–
|
–
|
–
|
–
|
2
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
1
|
Housing | ||||||||||||||||||||||||||
Renting |
50
|
17
|
33
|
14
|
67
|
17
|
67
|
–
|
32
|
50
|
13
|
60
|
–
|
–
|
17
|
–
|
–
|
16
|
75
|
50
|
50
|
29
|
33
|
25
|
42
|
28
|
Live with parents |
38
|
67
|
67
|
71
|
33
|
50
|
33
|
100
|
58
|
50
|
63
|
40
|
100
|
17
|
33
|
25
|
–
|
41
|
25
|
50
|
50
|
43
|
33
|
25
|
39
|
47
|
Boarding House |
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
25
|
–
|
–
|
83
|
50
|
75
|
100
|
43
|
–
|
–
|
–
|
29
|
–
|
–
|
6
|
18
|
Squatting |
–
|
–
|
–
|
–
|
–
|
17
|
–
|
–
|
2
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
1
|
Home Owner |
13
|
17
|
–
|
14
|
–
|
17
|
–
|
–
|
8
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
33
|
50
|
12
|
6
|
Marital Status | ||||||||||||||||||||||||||
Not Married |
100
|
100
|
83
|
100
|
100
|
100
|
100
|
100
|
98
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
100
|
50
|
75
|
88
|
96
|
Married |
–
|
–
|
17
|
–
|
–
|
–
|
–
|
–
|
2
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
–
|
50
|
25
|
12
|
4
|
Characteristics | Occupation | ||||||||
---|---|---|---|---|---|---|---|---|---|
A | B | Ca
| D | Eb
| F | G | H | I | |
Gender | |||||||||
Man | • | •• | •• | • | • | • | ••••• | ||
Woman | • | •• | • | •••••• | •• | ||||
Community | |||||||||
Accra | • | • | ••••••• | • | |||||
Kumasi | • | ••• | • | • | • | ••• | |||
Manya Krobo | • | •••• |
MSM experiences using HIV prevention resources
Findings and Supporting Data | Accra (n = 8)a
| Kumasi (n = 8)a
| Manya Krobo (n = 6)a
|
---|---|---|---|
1. MSM Experiences Using HIV Prevention Resources | |||
Condom Quality is Low, Condom Access is Poor and Condom Use is Disruptive | ••••••• | ••••••• | •••• |
Stigma and Inaccurate Information Undermine HIV Testing | • | ••••••• | •• |
Positive Attitudes Towards HIV Prevention Exist Among MSM | ••••••• | ••• | •••• |
2. Health Care Climate Factors that Influence Use of HIV Prevention | |||
MSM Are Not Free to Be Themselves | ••• | ••••• | • |
MSM Are Not Understood By Health Care Providers | •• | •••••• | • |
MSM Do Not Feel that Health Care Providers Care About Them | •• | ••••••• | • |
3. Strategies for Improving HIV/STI Prevention among MSM | |||
HIV Prevention Education Tailored to MSM Enables Self-advocacy | •• | • | • |
Education and Awareness to Protect Human Rights of LGBT Ghanaians | ••••• | ••••• |
Condom quality is low, condom access is poor and condom use is intermittent
MSM Respondent: [Condoms are] necessary to prevent STDs [sexually transmitted diseases] but I don’t think I’ve used it before… It’s a question of convenience and comfort. It’s not comfortable.Facilitator: Would you use it if you were sleeping with a woman?MSM Respondent: If I were sleeping with a woman? I don’t think I will still feel comfortable… As I said, there should be a direct contact. Nothing should be an intermediate. That is the only way you can make full satisfaction.-Kumasi, Focus Group 5
Health Care Provider (HCP) (Senior Nursing Officer): Some time back, when we were on a project, they gave us the lubes and the condoms, which we [gave] to them, free of charge. When that project ended, now the condoms that we are getting, it’s not for free. Then we sell them. Some of them cannot afford. [Also], we don't have the lubes and therefore we talk about the use of condoms and the lubes but you cannot provide to the clients because of limitations. We don't have many. What we have, we sell and some of those folks don't have money.-Accra, Health Care Provider Interview 9
Inaccurate information undermines HIV testing
MSM Respondent: Well, I strongly agree with what [Participant 2 and 4] have said. As he said, if you are not aware, you can’t be hurt by [HIV] so knowing I may have HIV will put me under a lot of stress and that will probably kill me earlier than it should. So I would not go for the test.- Kumasi, Focus Group 7
Stigma undermines HIV testing
Facilitator: … do you have plans of testing [for HIV]?MSM Respondent: Not really, I’m a timid person so if I should find out that I am positive, maybe it will affect me very much and maybe it will affect my career even as a whole. So, I really don’t have any plans. And I don’t intend to.- Kumasi, Focus Group 1
MSM Respondent: From the beginning, when you go to the hospital, [when] the doctors find out that you have contracted this virus, [and] after leaving the office, people around will be looking at you even though you may not be infected by the virus. So because of this not all of us have been able to make it [for testing].- Manya Krobo, Focus Group 1
Positive attitudes towards HIV prevention exist among MSM
MSM Respondent: I think it’s easy for me [to use condoms] because I don’t want to get any disease from the person with whom I’m having sex with. Because, as I said earlier, I don’t want to get any disease so I wouldn’t have any difficulty in my contract to play football in any country in my career. We footballers do [medical examinations] and through having these condoms, I will be able to reach the place I want to go.- Kumasi, Focus Group 2
Health care climate factors that influence HIV prevention
MSM are not free to be themselves
Facilitator: Who do you see when you have a sexual health related issue?MSM Participant: I think mostly I [Google] to find a solution and if there is no solution, I contact the pharmacy.Facilitator: Why do you choose this option?MSM Participant: I think it is the safest to avoid stigmatization.Facilitator: Why don’t you go to the hospital?MSM Participant: The hospitals in this community have this stigmatization against [MSM] so if they get to know what we do or who we are, it becomes a problem living in the community. So normally to avoid this, we avoid the hospital as much as we can.-Kumasi, Focus Group 7
HCP (Public Health Nurse): … most of them don't come to the health facility when they have problems because they have stigmatization and don't like to come. So most of them would like to be in their houses when they have problems... we've swore that whatever patients do, we do not discuss with others. But they themselves thought that maybe when [they] come for treatment or services, the nurses will disclose. They have fear of disclosure so they don't come.Interviewer: So, again, any other [barriers]?HCP: Yes, and stigma. Maybe this person going is such and such and such, so they don’t come. When [MSM] come, they don’t want to keep long. Maybe thinking that people will come to know. So they don't like to come at all. They will be at their house doing their own thing instead of coming to the clinic for early detection and treatment.- Accra, Health Care Provider Interview 2
Health care providers do not understand the health needs of MSM
MSM Respondent: … we already have hospitals where the workers are friendly but when you go there, the nurses will take the Bible and start preaching to you, and say a whole lot of things to you. I think there should be trained providers who are MSM so that, we will take care of ourselves-Accra, Focus Group 5
MSM Respondent: I went to the hospital… for a check-up and [my friend] was there with me. But the moment I got there and wanted to talk to the doctor, the way the woman watched me and watched my friend, the way the doctor talked about "partner reduction”, “usage of condoms” and “you still don't get it". He's helping me, but the way and the manner that he's talking, he’s got a problem with it.-Accra, Focus Group 2
HCP (Nurse): I believe [MSM] are people that really need much attention and care, I don’t know why some of them are into that situation, but I believe the society can help them by sort of education.Interviewer: Why do you think that they need help?HCP: To be honest with you, it is clear that they need help. I understand that is not how it supposed to be, that it’s not natural, and that is not what we are accustomed to. Even the Bible tells us a particular way but they choose to go a particular way so I think they need help. That is what I believe.-Accra, Health Care Provider Interview 6
MSM do not feel that health care providers care about them
MSM Respondent: I had a fight with someone and the person cut me with a blade. I went to the hospital and the nurse was insulting me, saying ‘Gay, your boyfriend has beat you and you don’t want to tell the truth’. Look at the disgrace.-Accra, Focus Group 2
MSM Respondent 1: I think here in Ghana, we [MSM] are not accepted. So if you should go to doctor and tell him or her your problem and what is happening to you… some of them will not talk to you. They'll tell you to go away.MSM Respondent 2: [Agreeing] [It is] their expression, and their attitude.-Accra, Focus Group 2
HCP: I would propose MSM should be treated fairly and kindly. It’s an issue that is worrying me personally. It’s true we may not endorse their practice, but they should be treated kindly so that they may come for treatment.-Manya Krobo, Health Care Provider Interview 5
HCP (Physician): They do come for health care all right. They don’t normally come and disclose but one on one they will tell you that this is what has happened - because they need help and before they come, the case would have [become] severe. That is my worry. And I think that because the community or society [does] not accept them, they feel shy coming forward. But when they meet me one on one, they tell me all that has happened. But at the end of the day, you can feel that, they are not comfortable as somebody might come with malaria and expressing it here and there.-Kumasi, Health Care Provider Interview 10
Strategies for improving HIV prevention among MSM
HIV prevention education tailored to MSM enables self-advocacy
MSM Respondent 1: ... We also need more study on this HIV issue because day in and day out there are more research study findings coming…MSM Respondent 2: We are supposed to know much about antibiotic so that when we are in STI trouble, you know that this antibiotic will help me from year to year. So that you can show other friends that, oh, when I'm in need I use this antibiotic. So if you go to the pharmacy or the drug place you can get this antibiotic for your needs.-Accra, Focus Group 3
MSM Respondent: …one of our needs is we want to go out and talk to people. Because we know there's a lot of stuff happening. I can just stay in my house and feel good, but I know my friend is suffering outside, so we go outside and talk to people… About condom usage, STIs.Facilitator: So you want more resources to educate people about STIs?MSM Respondent: Yes, exactly [agreement from group]-Accra, Focus Group 2
MSM Respondent: … I tested about 6 months ago. I heard all gay people have HIV and it made me wonder a lot so I decided to go for the test and it came out negative. So, when I hear someone saying something like that, I can defend it by saying not all gay men have HIV. We can’t challenge them on those assumptions because we haven’t gotten that opportunity…-Kumasi, Focus Group 5
Education for the public and health care providers to protect MSM human rights
HCP (Physician assistant): … our culture does not accept homosexuality and lesbianism. … education [should go] around that we are now in a free society and people are free to do whatever they want, so long as it does not go against the law. Because culture prohibits it – but the law in Ghana does not prohibit it. I don't know if there's anything there in the law books that prohibits lesbianism or homosexuality, you see? But the culture overrides the law, in our eyes, you see? So until the law enforcement or the government comes out in the open to make it clear that all people are free, the MSM will continue to be discriminated against.-Accra, Health Care Provider Interview 3
MSM Respondent 1: I think in Ghana, or in Africa this is frowned upon so if we could dress as normal people, it will help. Because I know people who put on eye shadows, mascara, dress up with acrylic paint, handbags and they walk around with everything about them but voices like men.MSM Respondent 2: To add to that, I have been telling people that, to get others to sleep with you isn’t about your physical touch ups… So I guess that's one point of education. Sometimes we bring violence unto ourselves. This stuff is frowned upon so people are ready to get into vigilante justice as practiced in some other countries. And so when they see you in such ornaments, they just pounce at you. They are not justified though, but you are calling it on yourself.-Accra, Focus Group 5
MSM Respondent: …we are also human beings and we will also like to have freedom like others, but those [other people] who think so are very few. And so, if we go by them, we will just feel isolated in the midst of so many [MSM] in the society. I think those who know we are in this community should let [us] be like this.-Kumasi, Focus Group 5
HCP: … the politicians have to come in. Our traditional leaders also have to come in. If we institute very formidable rules, it can help us to curb or mitigate that particular act from this society. But because there are no proper measures against that particular act, they are doing it. And it will go on and on and on till it becomes something that cannot be controlled anymore because our leaders have left such issues aside.-Kumasi, Health Care Provider Interview 3
MSM Respondent: [Improving our lives] is about educating us on our social grounds. There are most of us who don’t even know where to go for help when they need one. So if there is sometime like bars and clubs where normally hangout, if people can be educated there, it’s the only simple way they can get the message through.-Accra, Focus Group 5