Population size estimation of key populations at risk of HIV is essential to every national response. We implemented population size estimation of men who have sex with men (MSM) in Ghana using a three-stage approach within the 2011 Ghana Men's Study: during the study's formative assessment, the larger integrated bio-behavioral surveillance (IBBS) survey; and during the stakeholder meeting. We used six methods in combination within the three-stage approach (literature review, mapping with census, unique object multiplier, service multiplier, wisdom of the crowd, and modified Delphi) to generate size estimates from 16 locations (4 IBBS survey sites and 12 other locations) and used the estimates from the 16 sites to extrapolate the total MSM population size of Ghana. We estimated the number of MSM in Ghana to be 30,579 with a plausible range of 21,645-34,470. The overall estimate suggests that the prevalence of MSM in Ghana is 0.48 % of the adult male population. Lessons learned are shared to inform and improve applications of the methods in future studies.

Introduction: Stigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma-reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma-reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a "total facility" stigma-reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana. Methods: We evaluated the impact of a total facility stigma-reduction intervention by comparing five intervention to five comparable non-intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self-reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences-in-differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW). Results: We observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination (difference-in-differences = 20.4%; 95% CI 12.7 to 28.0); belief that discrimination would be punished (11.2%; 95% CI 0.2 to 22.3); and knowledge of and belief in the adequacy of infection control policies (17.6%; 95% CI 8.3 to 26.9). Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW-adjusted model (p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities. Conclusions: These results provide a foundation for scaling up health facility stigma-reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long-term impact.

Objectives: To describe development and implementation of a three-stage ‘total facility’ approach to reducing health facility HIV stigma in Ghana and Tanzania, to facilitate replication. Design: HIV stigma in healthcare settings hinders the HIV response and can occur during any interaction between client and staff, between staff, and within institutional processes and structures. Therefore, the design focuses on multiple socioecological levels within a health facility and targets all levels of staff (clinical and nonclinical). Methods: The approach is grounded in social cognitive theory principles and interpersonal or intergroup contact theory that works to combat stigma by creating space for interpersonal interactions, fostering empathy, and building efficacy for stigma reduction through awareness, skills, and knowledge building as well as through joint action planning for changes needed in the facility environment. The approach targets actionable drivers of stigma among health facility staff: fear of HIV transmission, awareness of stigma, attitudes, and health facility environment. Results: The results are the three-stage process of formative research, capacity building, and integration into facility structures and processes. Key implementation lessons learned included the importance of formative data to catalyze action and shape intervention activities, using participatory training methodologies, involving facility management throughout, having staff, and clients living with HIV facilitate trainings, involving a substantial proportion of staff, mixing staff cadres and departments in training groups, and integrating stigma-reduction into existing structures and processes. Conclusion: Addressing stigma in health facilities is critical and this approach offers a feasible, well accepted method of doing so.

No abstract

BackgroundHIV and negative coping mechanisms have a cyclical relationship. HIV infections may lead to the adoption of coping strategies, which may have undesired, negative consequences. We present data on the various coping mechanisms that HIV-affected households in Ghana resort to.MethodsWe collected data on coping strategies, livelihood activities, food consumption, and asset wealth from a nationally representative sample of 1,745 Ghanaian HIV-affected households. We computed coping strategies index (CSI), effective dependency rate, and asset wealth using previously validated methodologies.ResultsVarious dehumanizing coping strategies instituted by the HIV-affected households included skipping an entire day’s meal (13%), reducing portion sizes (61.3%), harvesting immature crops (7.6%), and begging (5.6%). Two-thirds of the households were asset poor. Asset-poor households had higher CSI than asset-rich households (p <0.001). CSI were also higher among female-headed households and lower where the education level of the household head is higher. Households caring for chronically ill members recorded higher CSI in comparison with their counterparts without the chronically ill (p < 0.05).ConclusionsInstitution of degrading measures by HIV-affected households in reaction to threat of food insecurity was prevalent. The three most important coping strategies used by households were limiting portion size (61.3%), reducing number of meals per day (59.5%) and relying on less expensive foods (56.2%). The least employed strategies included household member going begging (5.6%), eating elsewhere (8.7%) and harvesting immature crop (7.6%).Given that household assets, and caring for the chronically ill were associated with high CSI, a policy focusing on helping HIV-affected households gradually build up their asset base, or targeting households caring for chronically ill member(s) with conditional household-level support may be reasonable.