Multi-Dimensional Predictors of HIV PrEP

Knowledge, Acceptability and HIV Testing Among

Adolescents and Young Adult Men in Ghana:
Evidence from the 2022 Ghana Demographic and
Health Survey
Ikenna Obasi Odii

University of Alabama at Birmingham

Edson Chipalo
Lewis University

Research Article

Keywords: HIV, HIV prevention, HIV PrEP Knowledge, HIV Testing, Adolescents and Young Adults, Men,
Ghana

Posted Date: April 17th, 2024

DOI: https://doi.org/10.21203/rs.3.rs-4243856/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.
Read Full License

Additional Declarations: No competing interests reported.

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Abstract
Background
Adolescents and young adults (AYAs) face structural, social, biological, behavioral, and psychological
barriers, making them susceptible to new HIV infections due to high-risk behaviors. Research on sexuality
and HIV prevention among AYAs in Ghana is severely lacking despite recent progress in HIV prevention
efforts and low generalized HIV levels, highlighting significant empirical knowledge gaps, particularly
regarding HIV PrEP knowledge and testing among AYA males aged 15–24 years.

Methods
The men’s dataset of the 2022 Ghana Demographic and Health Survey (n = 2,453) were utilized for this
study. Descriptive characteristics were summarized using frequencies and proportions. Three sets of
multivariate logistic regression models examined the relationship between independent and dependent
variables.

Results
Findings reveal that among young men aged 15–24 years in Ghana, only 15.3% had knowledge of PrEP,
with a low acceptability rate of 32.1%, while merely 8.5% had undergone HIV testing, despite a 49% rate of
sexual activity. Significant associations existed between socio-demographic factors such as region (Volta,
Eastern, Western North, Bono East), being widowed/separated/divorced, and having a higher education,
and HIV PrEP knowledge; while being from Central region, ages 20–24 years, having secondary or higher
education and being sexually active were also significantly associated with HIV testing. No statistical
significance was found between HIV PrEP acceptability, and socio-demographic factors. The logistic
regression results suggests that there were higher odds of HIV PrEP knowledge, HIV PrEP acceptability,
and HIV testing among the AYA male population from the Volta, Eastern, Western, Bono, and North East
regions, coupled with the widowed/separated/divorced, and the participants with a higher education.

Conclusion
Region, marital status, employment status, religion, and recent sexual activity are universal predictors of
HIV PrEP knowledge, HIV PrEP acceptability, and HIV testing among the AYA population in Ghana; whereas
having a higher education is a sole strongly significant predictor of both HIV PrEP knowledge and HIV
testing respectively. AYA men remain a key population of focus in achieving the global targets of reducing
new HIV infections in Ghana, therefore existing HIV prevention efforts should be intensified using these
empirically significant multi-dimensional predictors as a useful guide.

Introduction
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Globally, there were 1.3 million new HIV infections worldwide, along with 630,000 AIDS-related deaths in
2022 (1). These figures suggest that we are falling short of the global target to have less than 370,000
new HIV infections annually by 2025 (1). Moreover, an estimated 9.2 million people living with HIV did not
receive antiretroviral treatment in 2022 (1).The situation is even more dire for adolescents and young
adults (AYA) who account for 37% of the daily new HIV infections worldwide (2).

Compelling evidence suggests that AYAs reach sexual maturity before they develop mental and emotional
maturity coupled with the social skills to cope with the consequences of their sexual behaviors (3, 4).
Unfortunately, AYAs typically engage in risky sexual behaviors before they are exposed to comprehensive
HIV prevention information, making them one of the key populations with significant behavioral
vulnerability to new HIV infection (5). In spite of the Centers for Disease Control and Prevention
recommendation that all persons 13–64 years avail themselves of HIV testing at least once during routine
healthcare, and more frequently if engaged in activities that heighten the risk of HIV transmission (6), AYAs
remain a key vulnerable population to HIV infection. The prevalence data from recent nationally
representative studies in Cameroon reveals that 55% of men aged 15 to 24 have never undergone HIV
testing, while only a mere 23.7% had undergone HIV testing in another study involving men in Cote d’Ivoire
(7, 8). Some sexual and behavioral choices made by AYAs increases their vulnerability to HIV transmission
risk behaviors such as inconsistent use of condom, patronage of transactional sex to meet basic needs,
older sexual partners who may not afford them condom negotiation opportunity due to unequal power
dynamics (5, 7). Current evidence corroborates the existence of high rate of HIV infection as a result of
high prevalence and vulnerability to risky sexual behaviors among AYAs such as unsafe sexual practices
and multiple sexual partnerships coupled with an early sexual debut which in turn pre-disposes them to
HIV acquisition (5, 9). AYAs may also be encumbered by fear of parental consent or simply fear of being
judged as being promiscuous if they access PrEP services (10). Given the higher fluctuations in the
structural, behavioral, emotional and biological realities of AYAs, concern abounds regarding the
relationship between these factors and their knowledge of HIV pre-exposure prophylaxis (PrEP) and their
engagement in HIV testing. HIV PrEP is a bio-medical intervention medication that provides up to 99%
protection from HIV infection for those who test HIV negative (11). Despite its effectiveness with
adherence, other concerns persist about PrEP potentially leading to higher levels of risky sexual behavior
and reduced use of alternative HIV prevention methods due to the perception of lowered susceptibility to
HIV.

Over the years, several laudable efforts have been made in Ghana towards HIV prevention and control as
demonstrated by policy directives in the Ghana AIDS commission national HIV and AIDS policy, the
consolidated guidelines for HIV care in Ghana, the ABC of HIV PrEP implementation guidelines (second
edition 2022) and the 2020–2024 national strategic plan to reduce human rights-related barriers to HIV
and TB services (12). With an estimated HIV prevalence rate of 1.7%, females of reproductive age 15–49
years account for 68% of the 345,599 people living with HIV in Ghana (12). This higher prevalence of HIV
among AYA women is consistent with empirical evidence across Sub-Saharan Africa (13, 14). However,
unlike women who have a good chance of their HIV status being identified during antenatal care, AYA
males may be a key demographic with undiagnosed HIV infection. Overall, it is estimated that only 72% of
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people living with HIV actually know their HIV status, leaving 28% who are unaware of their HIV status who
might fall in this AYA age group in Ghana (12). The possibility of the existence of AYA men who are
unaware of their HIV status may be supported by pertinent findings that men account for the greatest gap
in HIV prevention and control services throughout Sub-Saharan Africa (15). Among men in Sub-Saharan
Africa, key barriers against male HIV testing have been closely associated with a lack of HIV knowledge,
HIV clinic location or practices, confidentiality issues, fear of doing a HIV test and discovering a positive
status (16). Overall, previous research in Ghana indicates that AYA possessing secondary or higher
education, or emanating from the richest wealth status had greater odds of engaging in multiple sexual
partnerships than those who were poor with primary or no education (17). Similarly, age and marital status
were significantly associated with HIV testing among Ghanian AYA involved in another study (18). Within
the few recent studies that have examined the knowledge of PrEP in Ghana, a low knowledge of PrEP and
morbid fears of harm from PrEP uptake has been reported among sexual and gender minority groups (19,
20). This is unsurprising given that a recent U.S based study also found higher PrEP willingness among
sexual minority youth in college in spite of concerns over the (21). Beyond Ghana, findings from east and
southern Africa determined that the initiation of PrEP among AYA may lead to unprotected sex, reduced
condom usage, having multiple partners, early sexual debut, neglect of alternative prevention methods,
relying solely on PrEP or uncertainty about the HIV status of sexual partners (22).

Research Gaps/Purpose of the Study

Previous studies focusing on HIV PrEP in Ghana have focused on sexual and gender minority men (19, 20,
23), female sex workers (24), and sexually-active adults 18 years and above (25). There are several gaps in
the literature regarding HIV PrEP and HIV testing in Ghana. First, there is a lack of recent HIV PrEP research
using recent nationally representative data in order to reflect newer investments in PrEP services and the
HIV prevention trends showing the emerging low level of generalized HIV in Ghana which have impacted
the science in this field. Second, previous HIV PrEP studies in Ghana have used mainly qualitative
methods in their studies which curtails the recruitment of very large sample size that facilitate greater
generalization of the findings from the accessible population to the general population. Third, the best
available evidence has not focused their PrEP research solely on AYA or examined PrEP and HIV testing
concurrently in the same study in Ghana. Therefore, this study will be the first to utilize the 2022 Ghana
Demographic and Health Survey, a nationally representative sample, in examining the predictors of HIV
PrEP knowledge and HIV testing among AYA men aged 15–24 years in Ghana. The following research
questions will be addressed: 1) What is the prevalence of HIV PrEP knowledge and HIV testing
engagement among male AYA aged 15–24 years in Ghana? and, 2) what are the significant predictors of
HIV PrEP knowledge and HIV testing among AYA men in Ghana aged 15–24 years?

Methods
Study Design and Setting

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This study is both a population-based nationally representative study and a secondary cross-sectional
study based on the 2022 Ghana Demographic and Health Survey (GDHS) which originally adopted a
cross-sectional study design, across communities in Ghana (26). The 2022 GDHS furnishes national
statistics on demographic and health metrics, maintaining comparability with data from Ghana's six
previous DHS surveys and analogous surveys in other developing nations. The data compiled in the 2022
GDHS contribute to the expansive and burgeoning global repository of population-based metrics for
Ghana. Conducted with a nationally representative sample, the survey covered around 18,540 households
selected in 618 clusters spanning all 16 regions. Out of the 18,540 households chosen for the GDHS
sample, 18,065 were determined to be occupied. Among these occupied households, 17,933 were
successfully interviewed, resulting in an impressive response rate of 99%. In the subset of households
selected for the male survey, 7,263 men aged 15–59 were identified as suitable for individual interviews,
with 7,044 of them successfully interviewed, yielding a response rate of 97%.

Data Source and Study Population

The Ghana Statistical Service (GSS) executed the 2022 Ghana Demographic and Health Survey (GDHS)
from October 17, 2022, to January 14, 2023 (26). Hence, datasets for this study were derived from the
man’s questionnaire of the GDHS which covered topics such as knowledge of HIV, modes of transmission,
information sources, behavior to avoid STIs and HIV, stigma, and HIV testing history. Technical assistance
for the survey was provided by Inner City Fund (ICF) through The Demographic and Health Survey
Program (DHS), which receives funding from the United States Agency for International Development
(USAID) and the U.S. President’s Malaria Initiative (PMI). Additionally, various other agencies and
organizations contributed to the successful implementation of the survey, including the Government of
Ghana, the United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF), the World
Bank, the Global Fund, the Korean International Cooperation Agency (KOICA), the World Health
Organization (WHO), and the Foreign, Commonwealth and Development Office, UK AID, by offering either
technical expertise or financial support. The 2022 GDHS utilized a survey designed for males to collect
data from eligible participants aged 15 to 59 from 17,933 households. Only adolescents and young adults
aged 15 to 24 years in this population were included in the study.

Sample Size and Sampling Procedures

The sampling frame utilized for the 2022 GDHS is the revised framework developed by GSS, relying on
data from the 2021 Population and Housing Census (26). Originally, interviews were conducted with
17,933 households among 7,044 men aged 15 to 59 in the GDHS (26). In the current study, 2,453
adolescents and young adults aged 15–24 years in Ghana were selected and included in the analysis.

The 2022 GDHS adopted a stratified two-stage cluster sampling method aimed at generating nationally
representative data across urban and rural areas, as well as within each of the 16 regions, covering various
DHS indicators. Initially, 618 target clusters were chosen in the first stage using probability proportional to
size (PPS) for both urban and rural areas within each region. Subsequently, an equal number of clusters
were selected with systematic random sampling from the clusters identified in the first phase, maintaining
representation across urban and rural locales in each region. Following cluster selection, a comprehensive
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household listing and mapping operation was conducted in all selected clusters to compile a complete
roster of households, serving as the sampling frame for household selection. To ensure the accuracy of
this process, the Ghana Statistical Service (GSS) conducted a 5-day training course on listing procedures
for the appointed listers and mappers, with assistance from ICF. These personnel were organized into 25
teams, each comprising one lister and one mapper, tasked with completing the listing operation over a
two-month period. In addition to listing households, listers also recorded the geographical coordinates of
each household using GPS dongles provided by ICF, adhering to the guidelines outlined in the DHS Listing
Manual. Tablet computers equipped with software from The DHS Program facilitated the household
listing process. Finally, 30 households were randomly selected from each cluster for interview, ensuring a
standardized approach to data collection.
Data Quality Control
A pretest was administered by the DHS prior to data collection, followed by a debriefing session with the
pretest field workers. The GSS verified that data protocols were accurately collected and documented.
Subsequently, adjustments to the questionnaires were made as needed. The English versions of the
questionnaires were definitively translated into three local languages: Twi, Ga, and Ewe. To ensure
accuracy, back translations into English were conducted by individuals independent of the initial
translators. Any issues encountered during translation were addressed prior to the scheduled training of
trainers and the pretest. Following the finalization of the questionnaires, ICF staff collaborated with GSS
staff to develop Interviewer and Supervisor/Editor’s Manuals, along with fieldwork control forms for
monitoring survey progress. These manuals offer guidance to interviewers and supervisors/editors,
explaining the purpose of various questions and sections of the questionnaires, and aiding trainers in
conducting pretest and main survey training sessions. Further information on the data-collection
procedure can be found on www.dhsprogram.com.

Ethical Considerations
Permission to utilize the GDHS datasets was gotten from the Department of Health and Human Services
(DHS) Inner City Fund International (ICF), receiving approval on November 27th, 2023. The study was
carried out with ethical considerations and in adherence to established protocols. A summary report of the
2022 Ghana DHS data by the GSS can be accessed through www.dhsprogram.com. Originally, GSS
presented the survey protocol to the Ethical Review Committee (ERC) of the Ghana Health Service to
ensure compliance with Ghana’s ethical research standards. The ERC granted ethical clearance for the
survey. Similarly, ICF submitted the GDHS survey protocol to the ICF Institutional Review Board (IRB) to
obtain ethical clearance, ensuring alignment with US and international ethical research standards. The IRB
approved ethical clearance for the survey. Data confidentiality was strictly maintained throughout the
study. Ethical considerations, including informed consent, confidentiality, and privacy, were addressed by
the DHS office; no manipulation of the microdata occurred beyond the scope of this study, and there was
no patient or public involvement, thereby adhering to the principles of the declaration of Helsinki.

Data Analysis

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In the present study, we conducted descriptive statistics by computing and tabulating frequencies and
proportions of the socio-demographic variables due to the categorical nature of the variables. Three sets
of multivariate logistic regression analysis were performed to ascertain the association across various
dependent variables (HIV PrEP awareness, PrEP acceptability, and HIV testing), and independent variables
(socio-demographic factors) among adolescents and young adults in Ghana. The odds ratios (OR) and
95% confidence interval was used to determine the probability or likelihood. The data analysis utilized the
IBM Statistical Package for the Social Sciences (IBM SPSS version 29), and the statistical significance
was set at p < 0.05.

Measures
Dependent Variables
There are three sets of dependent variables that were assessed in this study: knowledge of HIV PrEP,
acceptability of HIV PrEP, and HIV testing status. Given the importance of a HIV negative status as a
condition for PrEP initiation and continued use; 1) knowledge of HIV PrEP was assessed by asking
participants the following questions: “Have you heard about PrEP used to prevent someone from getting
infected with HIV? 2) Acceptability of HIV PrEP was assessed by asking the participants, “Do you approve
of the use of PrEP?” and, HIV testing status was assessed by asking the participants: "I don't want to know
the results, but have you ever been tested for HIV?" All the three variables were coded dichotomously as
"yes" or “no”.
Independent Variables
Sociodemographic characteristics cross-cutting biographic (age), structural (region and resident),
social/behavioral (marital status, employment, and recent sexual activity), educational (level of
education), and religious (religion) dimensions were chosen because of their dominance in the literature
and their availability in the DHS dataset. Sociodemographic characteristics examined were region, resident
type, age, marital status, education, employment, religion, and recent sexual activity in the current study.
Region was assessed by asking the participants: “Before you moved here, which province did you live in?”
This was categorized as Western, Central, Greater Accra, Volta, Eastern, Ashanti, Western North, Ahafo,
Bono, Bono East, Oti, Northern, Savannah, North East, Upper East, and Upper West regions. Resident type
was assessed by asking the participants: Before you moved here, did you live in another city, in a town, or
in a village? This was binary coded as 1 = urban, and 2 = rural. Age was assessed by asking participants:
“How old were you on your last birthday? In the original survey, this was coded as 1 = 15–19 years old, 2 =
20–24 years old, 3 = 25–29 years old, 4 = 30–34 years old, 5 = 35–39 years old, 6 = 40–44 years old, 7 =
45–49, 8 = 50–54 years old, 9 = 55–59 years old.” In the current study, age groups were recoded into two
categories only as 1 = 15–19 years old, and 2 = 20–24 years old to reflect the study population
(adolescents and young adults).

To determine the marital status, the participants were asked the following question, "What is your marital
status?" Initially, responses were coded as follows: 0 = never in union, 1 = married, 2 = living with partner, 3
= widowed, 4 = divorced, 5 = no longer living together/separated. In the current study, marital status was re-
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coded thus, “0 = single, 1 = married, 2 = cohabitation, 3 = widowed, divorced, and separated. Education level
was gauged by asking participants, "What is the highest level of school you attended?" The original
categories included 0 = no education, 1 = pre-primary, 2 = primary, 3 = middle, 4 = JSS/JHS, 5 = secondary, 6
= SSS/SHS, 7 = Higher, and 8 = Don’t know. Educational level was re-coded thus, “0 = no education/don’t
know/pre-primary, 1 = primary/middle/JSS, 2 = secondary/SSS/SHS and 3 = higher education.
Employment status was determined by asking, "Are you currently working?" This was dichotomously
coded as 0 = no, and 1 = yes in the present study and was the same in the original code. Religion was
assessed through the question, "What is your religion?" Initially, the survey coded responses as 1 =
Catholic, 2 = Anglican, 3 = Methodist, 4 = Presbyterian, 5 = Pentecostal/Charismatic, 6 = Other Christian, 7 =
Islam, 8 = Traditionalist/Spiritualist, and 95 = No Religion. In this study, religion was re-coded thus,
“Traditionalist/Spiritualist/No religion = 1, Christian = 2, Islam = 3. Recent sexual activity was assessed by
asking the participants: “I would like to ask you about your recent sexual activity. When was the last time
you had sexual intercourse?” This was coded as 0 = No (Never had sex) and 1 = Yes (Active in last four
weeks and not active in last four weeks).

Results
Sociodemographic Characteristics of the Study Participant
Table I shows that the AYA population (N = 2,453) were mostly composed of participants from Savannah
(8%), Ashanti (7.8%), Oti (7.3%), Central (7.3%), Northern (7.2%), and Upper East (7%). Most participants
were mainly drawn from the rural areas (54.5%), aged 15–19 years (58.3%), overwhelmingly never married
(92.1%), primary/Middle/JSS educated (57.3%), employed (64.1%), and Christian (64.9%). Nearly an equal
number of participants were sexually active (49%), while 51% reported they never had sex. Furthermore, a
mere 15.3% had knowledge of the existence of HIV PrEP, out of which only 32.1% approved of PrEP
(acceptability). Overall, only 8.5% had tested for HIV among this sample in Ghana, whereas an
overwhelming number of participants never tested for HIV (see Table I).

The Relationship Between Sociodemographic Predictors, HIV PrEP knowledge, HIV PrEP Acceptability
(Approval) and Ever Tested for HIV

The Results of the logistic regression with three models outlines the relationship between the
sociodemographic factors (region, resident type, age group, marital status, educational level, employment
status, religion, and recent sexual activity), and HIV PrEP knowledge, HIV PrEP acceptability, and HIV
testing among AYA males aged 15–24 years old in Ghana (see Table II). Firstly, there was a statistically
significant relationship between knowledge of HIV PrEP, and originating from Volta (p = .002), Eastern (p
= .001), Western North (p < .001), Bono East (p = .003), being widowed/separated/divorced (p = 014),
having a higher than secondary school education (p = .008). Likewise, originating from the Central region
(p = 016), being within ages 20–24 years (p < .001), having a secondary or higher education (p = 013),
being sexually active (p < .001), showed statistical significance with HIV testing. Conversely, no statistically

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significant relationship was found between any of the sociodemographic factors and HIV PrEP
acceptability.

Regarding the regression analysis for HIV PrEP knowledge (see table II), Model 1 shows that participants
from Central (AOR = 1.31, 95% CI = 0.74–2.30), Northern (AOR = 1.13, 95% CI = 0.59–2.15), Savannah (AOR
= 1.28, 95% CI = 0.68–2.41), North East (AOR = 1.41, 95% CI = 0.73–2.70), Upper East (AOR = 1.47, 95% CI =
0.82–2.62), and Upper West (AOR = 1.13, 95% CI = 0.59–2.15) had higher odds of having PrEP knowledge
than residing in the Western region. Similarly, residing in rural areas (AOR = 1.19, 95% CI = 0.92–1.55), aged
between 20–24 (AOR = 1.13, 95% CI = 0.83–1.53), married (AOR = 1.02, 95% CI = 0.58–1.8), cohabitation
(AOR = 1.06, 95% CI = 0.53–2.1), widowed/separated/divorced (AOR = 3.57, 95% CI = 1.30–9.85),
secondary education (AOR = 1.31, 95% CI = 0.73–2.35), higher education (AOR = 2.60, 95% CI = 1.29–5.26),
employed (AOR = 1.26, 95% CI = 0.96–1.67), Christian (AOR = 1.07, 95% CI = 0.66–1.72), and sexually
active (AOR = 1.26, 95% CI = 0.95–1.66) were all associated with higher odds of having knowledge about
HIV PrEP.

In model 2, residing in Western North (AOR = 1.30, 95% CI = 0.21–8.11), Ahafo (AOR = 2.65, 95% CI = 0.76–
9.22), Bono (AOR = 1.63, 95% CI = 0.46–5.70), and Upper West (AOR = 2.49, 95% CI = 0.74–8.3) were
associated with higher odds of PrEP acceptability or approval. Furthermore, residing in rural areas (AOR =
1.00, 95% CI = 0.57–1.74), married (AOR = 1.24, 95% CI = 0.40–3.90), cohabitation (AOR = 1.73, 95% CI =
0.38–7.90), widowed/separated/divorced (AOR = 1.36, 95% CI = 0.20–9.14), employed (AOR = 1.03, 95% CI
= 0.58–1.82), Christian (AOR = 3.07, 95% CI = 0.92–10.29), Islam (AOR = 2.89, 95% CI = 0.80-10.43) and
recent sexual activity (AOR = 1.04, 95% CI = 0.59–1.85) were associated with higher odds of HIV PrEP
approval or acceptability.

Model 3 indicates that there were higher odds of testing for HIV among participants from North East (AOR
= 1.03, 95% CI = 0.45–2.38), and Upper East (AOR = 1.17, 95% CI = 0.57–2.41) compared to participants
from Western region. Moreover, AYA between ages 20–24 years (AOR = 2.11, 95% CI = 1.41–3.17), married
(AOR = 1.26, 95% CI = 0.65–2.44), cohabitation (AOR = 1.24, 95% CI = 0.55–2.77),
widowed/separated/divorced (AOR = 2.19, 95% CI = 0.73–6.56), secondary education (AOR = 2.68, 95% CI
= 1.23–5.85), higher education (AOR = 7.07, 95% CI = 2.94–16.99), employed (AOR = 1.18, 95% CI = 0.82–
1.70), Christian (AOR = 1.20, 95% CI = 0.60–2.40) and were recently sexually active (AOR = 1.99, 95% CI =
1.37–2.90) had higher odds of testing for HIV (see Table II).

Discussion
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.
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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
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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
Page 11/22
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.

Page 12/22
Conclusion
In social contexts such as Ghana where consistent condom use is considered inconvenient or hindering
sexual pleasure, the uptake of PrEP remains the best tool towards maintaining control over sexual health
outcomes for AYA men. This study found a low knowledge of PrEP, low PrEP acceptability, and low HIV
testing. Significant associations between HIV PrEP knowledge (the outcome) and socio-demographic
factors such as region (Volta, Eastern, Western North, Bono East), being widowed/separated/divorced, and
having a higher education were found. Likewise, significant associations were found between HIV testing
(the outcome), and being from Central region, ages 20–24 years, having secondary or higher education
and being sexually active. Notably, no statistically significant associations were found between HIV PrEP
acceptability (the outcome), and socio-demographic factors. Having a higher education stood out as the
common statistically significant factor associated with both HIV PrEP knowledge and HIV testing, and
therefore a significant predictor of both. Furthermore, based on the logistic regression findings; region,
marital status, employment status, religion, and recent sexual activity were universal predictors of HIV
PrEP knowledge, HIV PrEP acceptability, and HIV testing among the AYA population in Ghana.
Commensurably, only AYA males ages 20–24 years, marital status, educational status, religion and recent
sexual activity were universal predictors of both HIV PrEP knowledge, and HIV testing respectively. Overall,
our findings are consistent with the few existing studies that focus on key populations that mostly benefit
from PrEP, but has added unique findings and implications for reducing negative health outcomes for AYA
males in Ghana that is different from prior studies. Consequently, formal and informal HIV prevention
interventions should focus on these multi-dimensional predictors as the best available evidence to drive
the science in this population, and sustain the progress made in reducing negative AYA sexual
reproductive health outcomes in Ghana.

Declarations
Ethics Approval and Consent to Participate

Permission to utilize the GDHS datasets was gotten from the Department of Health and Human Services
(DHS) Inner City Fund International (ICF), receiving approval on November 27th, 2023. The study was
carried out with ethical considerations and in adherence to established protocols. A summary report of the
2022 Ghana DHS data by the GSS can be accessed through www.dhsprogram.com. Originally, GSS
presented the survey protocol to the Ethical Review Committee (ERC) of the Ghana Health Service to
ensure compliance with Ghana’s ethical research standards. The ERC granted ethical clearance for the
survey. Similarly, ICF submitted the GDHS survey protocol to the ICF Institutional Review Board (IRB) to
obtain ethical clearance, ensuring alignment with US and international ethical research standards. The IRB
approved ethical clearance for the survey. Data confidentiality was strictly maintained throughout the
study. Ethical considerations, including informed consent, confidentiality, and privacy, were addressed by
the DHS office; no manipulation of the microdata occurred beyond the scope of this study, and there was
no patient or public involvement, thereby adhering to the principles of the declaration of Helsinki.

Consent for Publication

Page 13/22
All authors participated in the final revision and were consented prior to final manuscript submission

Availability of Data and Materials

All data for this study are provided in this document, and the comprehensive dataset is freely available
through the www.dhsprogram.com website.

Competing Interests

The author(s) declare that they have no competing interests.

Funding

No specific funding was provided for this study.

Authors' Contributions

I.O.O conceptualized the article. I.O.O and E.C wrote the initial draft of the article. I.O.O and E.C reviewed the
article and I.O.O submitted on behalf of the team.

Acknowledgements

The authors would like to acknowledge Inner City Fund International (IFC) for granting us permission to
use DHS dataset.

Authors' information

Ikenna Obasi Odii, MSN, BSN, is a PhD Candidate, Colvin Endowed Nursing Scholar & Blazer Graduate
Research Fellow at the School of Nursing, University of Alabama at Birmingham, Alabama, U.S.A.

Edson Chipalo PhD, MSc, is an Assistant Professor at the Department of Social Work, College of Education
and Social Sciences, Lewis University, Romeoville, USA

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Tables
Table I Sociodemographic Characteristics of the Participants (N=2,453)

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Variables N %

Region

Western 144 5.9

Central 180 7.3

Greater Accra 129 5.3

Volta 110 4.5

Eastern 131 5.3

Ashanti 192 7.8

Western North 136 5.5

Ahafo 125 5.1

Bono 122 5.0

Bono East 161 6.6

Oti 179 7.3

Northern 177 7.2

Savannah 197 8.0

North East 153 6.2

Upper East 172 7.0

Upper West 145 5.9

Resident Type

Urban 1115 45.5

Rural 1338 54.5

Age Group (Years)

15-19 1430 58.3

20-24 1023 41.7

Marital Status

Never Married 2258 92.1

Married 111 4.5

Cohabitation 62 2.5

Widowed/Separated/Divorced 22 0.9

Page 18/22
 Education

No Education/Don’t Know/Pre-primary 176 7.2

Primary/Middle/JSS 1406 57.3

Secondary/SSS/SHS 735 30

Higher 136 5.5

Employment

Not Employed 881 35.9

Employed 1572 64.1

Religion

Traditionalist/Spiritualist/No religion 186 7.6

Christian 1591 64.9

Islam 676 27.6

Recent Sexual Activity

Never had sex 1250 51

Sexually Active 1203 49

Knowledge of HIV PrEP

No Knowledge (haven’t heard) 1934 84.7

Yes, had knowledge (heard) 349 15.3

Acceptability of PrEP

No (Don’t Approve) 237 67.9

Yes (Approve) 112 32.1

HIV Testing

No (Never tested) 2245 91.5

Yes (Tested) 208 8.5

Table II Logistic Regression Results Showing the Relationship Between Sociodemographic Predictors, HIV
PrEP knowledge, HIV PrEP Acceptability (Approval) and Ever Tested for HIV

Page 19/22
Variable PrEP Knowledge, PrEP Acceptability, and HIV Testing

Model 1 Model 2 Model 3

HIV PrEP HIV PrEP Acceptability HIV Testing AOR

Knowledge AOR (95% C.I) (95% C.I)

AOR (95% C.I)

Region

Western Ref Ref Ref

Central 1.31 (0.74- 0.47 (0.15-1.49) 0.37 (0.16-0.83)*

2.30)

Greater Accra 0.65 (0.33- 0.78 (0.21-2.94) 0.66 (0.31-1.42)

1.28)

Volta 0.21 (0.08- 0.97 (0.12-7.70) 0.63 (0.25-1.56)

0.58)**

Eastern 0.23 (0.10- 0.34 (0.03-3.36) 0.60 (0.26-1.41)

0.57)**

Ashanti 0.82 (0.46- 0.38 (0.11-1.35) 0.70 (0.34-1.40)

1.48)

Western North 0.20 (0.08- 1.30 (0.21-8.11) 0.73 (0.33-1.62)

0.49)***

Ahafo 0.90 (0.46- 2.65 (0.76-9.22) 0.38 (0.15-0.99)

1.69)

Bono 0.93 (0.48- 1.63 (0.46-5.70) 0.54 (0.22-1.30)

1.80)

Bono East 0.29 (0.13- 0.81 (0.15-4.40) 0.76 (0.35-1.68)

0.66)**

Oti 0.55 (0.29- 1.71 (0.18-2.84) 0.49 (0.22-1.12)

1.06)

Northern 1.13 (0.59- 0.70 (0.20-2.45) 0.62 (0.27-1.45)

2.15)

Savannah 1.28 (0.68- 0.70 (0.20-2.41) 0.50 (0.21-1.21)

2.41)

North East 1.41 (0.73- 0.47 (0.13-1.76) 1.03 (0.45-2.38)

2.70)

Upper East 1.47 (0.82- 0.97 (0.32-2.90) 1.17 (0.57-2.41)

2.62)

Upper West 1.13 (0.59- 2.49 (0.74-8.3) 0.42 (0.15-1.15)

2.15)

Page 20/22
Resident Type

Urban Ref Ref Ref

Rural 1.19 (0.92- 1.00 (0.57-1.74) 0.90 (0.64-1.25)

1.55)

Age Group

15-19 Ref Ref Ref

20-24 1.13 (0.83- 0.61 (0.34-1.11) 2.11 (1.41-3.17)***

1.53)

Marital Status

Never Ref Ref Ref

Married 1.02 (0.58-1.8) 1.24 (0.40-3.90) 1.26 (0.65-2.44)

Cohabitation 1.06 (0.53-2.1) 1.73 (0.38-7.90) 1.24 (0.55-2.77)

Widow/Separate/Divorced 3.57 (1.30- 1.36 (0.20-9.14) 2.19 (0.73-6.56)

9.85)*

Education

No Education/Don’t Ref Ref Ref

Know/Pre-primary

Primary/Middle/JSS 0.97 (0.56- 0.63 (0.19-2.10) 0.92 (0.42-2.01)

1.70)

Secondary/SSS/SHS 1.31 (0.73- 0.75 (0.22-2.59) 2.68 (1.23-5.85)*

2.35)

Higher 2.60 (1.29- 0.91 (0.21-3.93) 7.07 (2.94-

5.26)** 16.99)***

Employment

Not Employed Ref Ref Ref

Employed 1.26 (0.96- 1.03 (0.58-1.82) 1.18 (0.82-1.70)

1.67)

Religion

Ref Ref Ref

Traditionalist/Spiritualist/

No Religion

Christian 1.07 (0.66- 3.07 (0.92-10.29) 1.20 (0.60-2.40)

1.72)

Islam 0.74 (0.44- 2.89 (0.80-10.43) 0.99 (0.47-2.08)

1.24)

Page 21/22
 Recent Sexual Activity

Never had sex Ref Ref Ref

Sexually active 1.26 (0.95- 1.04 (0.59-1.85) 1.99 (1.37-2.90)***

1.66)
*=p<.05, **=p<.01, ***=p<.001. PrEP = Pre-Exposure Prophylaxis, AOR = Adjusted Odd Ratio, CI =
Confidence Intervals, Model 1 = HIV PrEP knowledge is analyzed as an outcome variable, Model 2= HIV
PrEP acceptability is analyzed as an outcome, and Model 3= HIV testing is analyzed as an outcome. Ref=
Reference comparison group.

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