Cost effectiveness of option B plus for prevention of mother-to-child transmission of HIV in resource-limited countries: evidence from Kumasi, Ghana.

BackgroundAchieving the goal of eliminating mother-to-child HIV transmission (MTCT) necessitates increased access to antiretroviral therapy (ART) for HIV-infected pregnant women. Option B provides ART through pregnancy and breastfeeding, whereas Option B+ recommends continuous ART regardless of CD4 count, thus potentially reducing MTCT during future pregnancies. Our objective was to compare maternal and pediatric health outcomes and cost-effectiveness of Option B+ versus Option B in Ghana.MethodsA decision-analytic model was developed to simulate HIV progression in mothers and transmission (in utero, during birth, or through breastfeeding) to current and all future children. Clinical parameters, including antenatal care access and fertility rates, were estimated from a retrospective review of 817 medical records at two hospitals in Ghana. Additional parameters were obtained from published literature. Modeled outcomes include HIV infections averted among newborn children, quality-adjusted life-years (QALYs), and cost-effectiveness ratios.ResultsHIV-infected women in Ghana have a lifetime average of 2.3 children (SD 1.3). Projected maternal life expectancy under Option B+ is 16.1 years, versus 16.0 years with Option B, yielding a gain of 0.1 maternal QALYs and 3.2 additional QALYs per child. Despite higher initial ART costs, Option B+ costs $785/QALY gained, a value considered very cost-effective by World Health Organization benchmarks. Widespread implementation of Option B+ in Ghana could theoretically prevent up to 668 HIV infections among children annually. Cost-effectiveness estimates remained favorable over robust sensitivity analyses.ConclusionsAlthough more expensive than Option B, Option B+ substantially reduces MTCT in future pregnancies, increases both maternal and pediatric QALYs, and is a cost-effective use of limited resources in Ghana

HIV vulnerability of men and women who inject drugs in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.Reducing vulnerability to HIV infection among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. While a number of studies have explored HIV risk behaviours among several key vulnerable populations in Ghana including female sex workers, men who have sex with men, and prisoners, little is known about the drug use and sexual vulnerability of people who inject drugs (PWID). In addition, no programs have been implemented to reduce the vulnerability among this population. This report provides the findings from a qualitative study that aimed to understand the social, economic and behavioral vulnerability to HIV of PWID in Kumasi and to inform the development and implementation of HIV prevention programs for this population. The research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) School of Medical Sciences. It is one of nine studies under the Operations Research on Key Populations project funded by the United States Agency for International Development (USAID). The study was designed and carried out in collaboration with the Ghana AIDS Commission (GAC).Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Research report: "It’s all about making a life": young female sex workers vulnerability to HIV and prevention needs in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents findings from a qualitative study examining the vulnerability to HIV of young female sex workers (FSW) in Kumasi, Ghana and their prevention needs. The study was conducted by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) as part of the Project SEARCH Program funded by PEPFAR and the United States Agency for International Development Ghana. The objectives of this study were to: 1) Investigate knowledge about and perceptions of HIV in young FSW in the Kumasi Metropolitan area, 2) Explore their risk behaviors, and 3) Identify their most urgent prevention needs. A secondary objective was to provide foundational knowledge to inform the design of future studies of girls and young women engaging in sex work in Ghana.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Program brief: HIV vulnerability and prevention needs of young female sex workers in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.Adult HIV prevalence in Ghana in 2013 has been estimated at 1.31%.1 Among female sex workers (FSW), prevalence is, however, much higher at 12.9%, compared to 2.2% in the general female population. HIV prevalence among FSW in the Ashanti region is 13%, the second highest FSW prevalence after the Greater Accra Region (16.3%).2 Sex work plays a significant role in HIV transmission, with 2.4% of sex workers, 13.2% of male clients, and 22.2% of clients’ partners contributing to new HIV infections.2 While recent national and regional prevalence and behavior data on FSWs are available, little qualitative research has been published on sex workers in Kumasi, and specifically on younger sex workers. This qualitative study was conducted by Boston University’s Center for Global Health and Development and the Kwame Nkrumah University of Science and Technology with funding from the United States Agency for International Development (USAID)/Ghana. The study objectives were to: (1) investigate knowledge about and perceptions of HIV among young FSW in Kumasi, capital of the Ashanti region and second largest city in Ghana; (2) explore their HIV risk behaviors; and (3) identify their HIV prevention needs. Focus group discussions and in-depth interviews were done with 48 FSW Ten key informant interviews were held with health care providers at local clinics.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Program brief: "Using what you have to get what you want: HIV vulnerability and prevention needs of female post‐secondary students engaged in transactional sex in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.HIV prevalence among young Ghanaian men and women aged 15–24 years old is estimated at 1.7%.1 HIV prevalence in the specific population of female post-secondary students is unknown. The Ghana AIDS Commission (GAC) recognizes the need for further research in communities participating in less well-defined risky sex practices. This study was conducted by Boston University’s Center for Global Health and Development and the Kwame Nkrumah University of Science and Technology with funding from the United States Agency for International Development/Ghana. The objective was to provide academic institutions, the GAC, the National AIDS Control Program, donors, and other stakeholders with data to inform research and programmatic efforts in Kumasi, specifically, as well as academic institutions, in general. Study participants were recruited from five post-secondary institutions in the greater Kumasi area. Data were collected on students’ perceptions of transactional sex (TS) on campus, individual and structural HIV vulnerabilities, and prevention needs through in-depth interviews with seven female post-secondary students involved in TS and focus groups with twenty-nine female and male students. Key informant interviews were also conducted with faculty, residence hall matrons, and hotel staff. Non-commercial transactional sex is defined here as engaging in sex for the purposeof obtaining material goods, financial support, or grades.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

Research report: "Using what you have to get what you want": Vulnerability to HIV and prevention needs of female post‐secondary students engaged in transactional sex in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents findings from a qualitative study examining vulnerability to HIV of female post‐secondary students engaged in transactional sex in Kumasi, Ghana and their prevention needs. The study was conducted by Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) as part of Project SEARCH funded by the United States Agency for International Development Ghana. Participants were recruited from five post‐secondary institutions in the greater Kumasi area. Our objective is to provide academic institutions, the Ghana AIDS Commission (GAC), the National AIDS Control Program, donors, and other stakeholders with rich data to inform research and programmatic efforts in Kumasi specifically, as well as academic institutions in general. We set out to document what forms of transactional sex female students are engaging in, who their partners are, and what motivates them to participate. We asked students about the individual and structural vulnerabilities for HIV reported by female post‐secondary students involved in transactional sex and what their prevention needs are. We also interviewed a small sample of faculty, residence hall matrons, and hotel staff to get their perspective on the behavior of female students practicing transactional sex that might put them at risk for HIV. The findings of this study can be used as well to inform the design of future studies of young women engaging in transactional sex in Ghana. With such limited understanding of HIV transmission among young female post‐secondary students engaged in transactional sex, research is needed to determine how this group contributes to the overall HIV epidemic. The Ghana AIDS Commission has recognized the need for further research among communities engaged in less well‐defined risky sex practices in the National Strategic Plan for Most‐at – Risk Populations (MARP) 2011‐2015.4 This study attempts to fill in gaps in the research regarding transactional sex, taking into account the complexities and nuances of the practice, in addition to examining the needs of female students for targeted HIV prevention programs.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

HIV destigmatization: perspectives of people living with HIV in the Kumasi Metropolis in Ghana

BackgroundHuman immunodeficiency virus (HIV)-related stigma has been identified as one of the principal factors that undermines HIV prevention efforts and the quality of life of people living with HIV (PLWH) in many developing countries including Ghana. While studies have been conducted on HIV-related stigma reduction, very few have sought the views of PLWH on how this might be done. The purpose of the study was to (i) identify factors that cause HIV-related stigma in Ghana from the perspective of PLWH, (ii) identify challenges that HIV-related stigma poses to the treatment and care of PLWH, and (iii) to obtain recommendations from PLWH on what they think various groups (community members, health care providers, and adolescents) including themselves should do to help reduce HIV-related stigma in Ghana.MethodsA mixed methods cross-sectional study design was used to collect data from 404 PLWH at the Suntreso Government Hospital in the Kumasi Metropolis of Ghana across six domains using Qualtrics from November 1–30, 2022. Quantitative data was analyzed using the Statistical Package for Social Sciences (SPSS) version 26 and the Statistical Analysis System (SAS) version 9.4. Qualitative data was analyzed using a thematic approach.ResultsMost of the study participants (70.5%) said HIV-related stigma in Ghana is due to ignorance. Of this population, 90.6% indicated that they had experienced stigma because they have HIV, causing them to feel depressed (2.5%), ashamed (2.2%), and hurt (3.0%). Study participants (92.8%) indicated that the challenges associated with HIV-related stigma has affected their treatment and care-seeking behaviors. Recommendations provided by study participants for HIV destigmatization include the need for PLWH not to disclose their status (cited 94 times), community members to educate themselves about HIV (96.5%), health care providers to identify their stigmatizing behaviors (95.3%), health care providers to avoid discriminating against PLWH (96.0%), and the need for adolescents to be educated on HIV and how it is transmitted (97.0%).ConclusionIt is important for the government and HIV prevention agencies in Ghana to target and address co-occurring HIV-related stigma sources at various levels of intersection simultaneously This will help to shift harmful attitudes and behaviors that compromise the health and wellbeing of PLWH effectively

Understanding the relationship dynamics between female sex workers and their intimate partners in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents findings from a qualitative study examining vulnerability to HIV and the prevention needs of men involved in intimate relationships with female sex workers (FSW) in Kumasi, Ghana. The study was conducted by a collaborative team of researchers from Boston University’s Center for Global and Health and Development (CGHD), Kwame Nkrumah University of Science and Technology (KNUST), and FHI 360. It is the last of nine small qualitative studies conducted under the Operations Research among Key Populations in Ghana project designed to gather in-depth, personal information from members of key populations about their vulnerability to HIV and other threats to their health and well-being. This project was funded by the United States Agency for International Development Ghana in collaboration with the Ghana AIDS Commission (GAC). The findings will be used to strengthen harm reduction interventions for sex workers and their intimate partners. Intimate partners of FSW are a population of growing interest in Ghana, where interventions focused on sex workers and both their paying and non-paying partners are being implemented by FHI 360 and other local organizations with support from the GAC and USAID. In 2012 Boston University and KNUST conducted a qualitative study looking at the backgrounds, living conditions, vulnerabilities, and HIV prevention needs of young female sex workers in Kumasi. Most (22/24) of the young women participating in in-depth interviews reported having a boyfriend or intimate partner, and half reported either never or only sometimes using condoms with these partners (1). In addition, quantitative data from two previous integrated bio-behavioral surveillance studies (IBBSS) conducted in 2009 and 2011 provide critical data showing the degree to which these men and their female partners (both those involved in sex work and others) are highly vulnerable to HIV and other sexually transmitted infections. The specific objectives were to: explore the emotional, financial and other power dynamics within these relationships; describe the sexual behaviors and HIV knowledge and vulnerabilities of both partners; and document the perceived availability and accessibility of social support and health services.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

"I can decide to use the property I have to make money": HIV vulnerability of bar workers and bar patrons in Kumasi, Ghana

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report provides the findings from a qualitative study exploring the social, economic and behavioral vulnerability to HIV of women working in bars and restaurants in Kumasi, Ghana’s second largest city. This research was conducted by a collaborative team comprised of researchers from Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology (KNUST) School of Medical Sciences. It is one of nine studies under the Operations Research on Key Populations project funded by the United States Agency for International Development (USAID). The study was designed and carried out in collaboration with the Ghana AIDS Commission (GAC). Reducing vulnerability to HIV infection among key populations in Ghana is a major goal for the National AIDS Control Program (NACP) and the GAC. While a number of studies have explored HIV risk behaviours among self-identified female sex workers and their partners in Ghana, little is known about the vulnerability of women working in small bars and restaurants who may be involved in transactional sex. Further, we have little information about how best to reach this population with services that will enable them and their clientele to protect themselves from HIV and reduce other vulnerabilities related to their health and well-being. To address this gap, this study aimed to explore behavioural, social, and economic factors that contribute to HIV vulnerability; types and extent of transactional sex; the relationship between alcohol/drug use, unsafe sex and transactional sex; and the health and social service needs of this population. The study findings are meant to inform the development and implementation of HIV prevention programs for bar workers and bar patrons.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201

The Ghana retention on ART study (ROARS): keeping HIV-positive patients on antiretroviral therapy

This study was implemented by Boston University in collaboration with the Kwame Nkrumah University of Science and Technology with support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 2010. The content and views expressed here are the authors’ and do not necessarily reflect the opinion or policy of USAID or the U.S. Government.This report presents the findings of a study that employed qualitative research methods to explore the beliefs, attitudes, and behaviors of people living with HIV (PLHIV) in Ghana who are either in care and on antiretroviral therapy (ART), or are no longer in care and have been lost to follow-up. The study was designed to deepen our understanding of the challenges ART patients face in continuing on ART in Ghana and to contribute information with the potential to improve retention in care and outcomes for PLHIV in Ghana.This study was carried out by a collaborative team of researchers based at Boston University’s Center for Global and Health and Development (CGHD) and the Kwame Nkrumah University of Science and Technology’s (KNUST) School of Medical Sciences. The team conducted this research in Kumasi, Ghana’s second largest urban center. It is a component of the ‘Operations Research among Key Populations in Ghana’ project funded by the United States Agency for International Development (USAID). We designed and conducted the research in collaboration with the Ghana AIDS Commission (GAC).Expanding access to ART among HIV-positive individuals has been a major goal of the Ghana AIDS Commission and Ghana Health Service. Since 2005, Ghana has scaled up ART rapidly; by 2011, 150 health facilities were providing ART to over 60,000 people, an increase from fewer than 5,000 just six years earlier. At the same time, like in most countries in sub-Saharan Africa, ensuring that those who begin ART remain on treatment has proven a major challenge. Previous studies suggest that retention in care for 12 months or longer is approximately 70-80% in Ghana, similar to the rate in many other low-resource settings. While research elsewhere in sub-Saharan Africa indicates that a number of barriers affect retention in care, little research on this topic has been conducted in Ghana. Given that ART is currently the only known way to prolong life for PLHIV, it is critical to identify barriers that affect different groups of patients and to find ways to support them in remaining on treatment.This study was motivated by a desire to increase understanding of the challenges of and facilitators to retention in care among individuals on ART in Kumasi, Ghana. We conducted it in collaboration with the Suntreso Government Hospital, one of Kumasi’s largest medical facilities, and specifically with the hospital’s STI (sexually transmitted infection)/HIV clinic, which has experienced high levels of patient dropout from care and treatment. Together with staff at the clinic, we designed this research with the aim of contributing to understanding of the range of barriers PLHIV in Ghana experience trying to stay on treatment, the reasons they default, and the types of supports they believe would help themselves and other patients remain on or return to treatment if they do default. Our hope is that the study’s findings will add in a meaningful way to the evidence base on strategies and approaches for improving retention in treatment, thereby maximizing the potential benefits of ART, for PLHIV in Ghana.Support from the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under Project SEARCH Task Order No. GHH‐I‐00‐07‐00023‐00, beginning August 27, 201