RESEARCH
Who is utilizing anti-retrov
e
3,4
y (
c
ati
efforts by other public and private organizations have to geographical and gender-based health inequities
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62
http://www.equityhealthj.com/content/11/1/62and treatment, as well as general health care utilization
[13,14]. Theoretical work on why males and females
Ghana
Full list of author information is available at the end of the articleensured the scale-up of ART in resource-constrained
settings over the last 8 years [5-8]. In 2010 it was esti-
mated that approximately 6.6 million people in low- and
middle-income countries were receiving HIV treatment,
related to HIV treatment, not all patients in need of
ART in resource-limited settings utilize the service.
Inherent challenges such as limited institutional, finan-
cial, and human resources can cause geographic dispar-
ities in utilization of ART within resource-limited
contexts [11,12]. Additionally, gender-based inequities
have been increasingly identified with HIV-related care
* Correspondence: gyekenay@yahoo.com
1Department of Social and Behavioral Sciences, School of Public Health,
College of Health Sciences, University of Ghana, P. O. Box LG 13, Accra,to address the gender-based and geographic inequities related to the utilization of ART services in Ghana.
Methods: We reviewed National AIDS/STIs Control Program’s ART service provision records from January 2003
through December 2010, extracting data on adults aged 15+ who initiated ART in Ghana over a period of eight
years. Data on the number of patients on treatment, year of enrollment, sex, and region were obtained and
compared.
Results: The number of HIV patients receiving ART in Ghana increased more than 200-fold from 197 in 2003, to
over 45,000 in 2010. However, for each of six continuous years (2005-2010) males comprised approximately
one-third of adults newly enrolled on ART. As ART coverage has expanded in Ghana, the proportion of males
receiving ART declined from 41.7% in 2004 to 30.1% in 2008 and to 27.6% in 2010. Also, there is disproportionate
regional ART utilization across the country. Some regions report ART enrollment lower than their percent share of
number of HIV infected persons in the country.
Conclusions: Attention to the comparatively fewer males initiating ART, as well as disproportionate regional ART
utilization is urgently needed. All forms of gender-based inequities in relation to HIV care must be addressed in
order for Ghana to realize successful outcomes at the population level. Policy makers in Ghana and elsewhere need
to understand how gender-based health inequities in relation to HIV care affect both men and women and begin
to design appropriate interventions.
Keywords: Inequities, ART, Utilization, Sex, Regional, Ghana, HIV and AIDS
Introduction
The global expansion of antiretroviral therapy (ART) for
HIV patients has raised concerns regarding inequities in
utilization of ART services within countries [1-4]. The
Global Fund, PEPFAR, WHOs “3 by 5” initiative, and
representing approximately 47% of people who needed
treatment [9]. In Ghana, a total of 33,745 people were
receiving ART by the end of 2009 [10]. The availability
of ART has transformed what was once a deadly disease
into a manageable chronic condition [1]. However dueAn analysis of ART servic
Phyllis Dako-Gyeke1*, Rachel Snow2 and Alfred E Yawson
Abstract
Introduction: The global scale-up of antiretroviral therap
inequities in utilization of ART services in resource-limited
differentials in the distribution of ART among adult HIV p© 2012 Dako-Gyeke et al.; licensee BioMed Ce
Creative Commons Attribution License (http:/
distribution, and reproduction in any mediumOpen Access
iral therapy in Ghana:
utilization
ART) for HIV patients has led to concerns regarding
ontexts. In this paper, we describe regional and sex
ents in Ghana. We highlight the need for interventionsntral Ltd. This is an Open Access article distributed under the terms of the
/creativecommons.org/licenses/by/2.0), which permits unrestricted use,
, provided the original work is properly cited.
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62 Page 2 of 8
http://www.equityhealthj.com/content/11/1/62differ in health seeking behavior has seen extensive, if
not decisive, treatment in the global health and socio-
logical literature [15-18]. This literature suggests that
gender inequities, norms and attitudes may work differ-
ently in different contexts to hinder either men or
women from accessing HIV treatment [13,14,19-22].
Even though women are often more susceptible to HIV
infection than men [23], their access to HIV treatment
can be constrained by limits on their mobility, limited
control over household resources, poverty, lack of health
insurance, social support, or fear of stigma [13,21-25].
Although men’s utilization of ART can be inhibited for
similar reasons, [26-28] compelling arguments have been
made that hegemonic masculinities across many cultures
include demands that men under-attend to potential
physical weaknesses [16,17,29]. Consequently, men are
keen to identify as ‘not feminine’, which includes avoid-
ing frequent and trivial use of health services [18]. We
would argue that such anxieties may be augmented for
the diagnosis and treatment of HIV or other potential
sexual infections, in which the patient-provider inter-
action must inevitability focus on issues of sexual ill-
health, and potential fears of sexual disempowerment.
Several sex disaggregated analyses conducted in vari-
ous parts of Africa show either high proportions of
females receiving ART in some countries (South Africa,
Botswana, Ethiopia, Ivory Coast, Malawi, and Zim-
babwe) [13,14,30-32] or high male utilization of ART in
others (Swaziland, and Zambia) [14]. Advancing equity
in health means addressing gender-based and geograph-
ical disparities associated with the utilization of ART ser-
vices across Africa.
In Ghana, the HIV population is estimated at ap-
proximately 221,941 [33], and the HIV virus has spread
to all ten administrative regions in the country. ART
services have been available to HIV patients since June
2003; guidelines from the National AIDS/STIs Control
Program (NACP) recommend patients to initiate treat-
ment when their CD4 count is less than 350 cells/ml
and/or they become symptomatic with HIV infection
in WHO stage III or IV [34]. Although there has been
an increase in the number of patients receiving ART,
approximately 70% of the HIV- infected population in
Ghana is not on treatment [35,36]. UNAIDS identified
Ghana as one of 11 countries with less than 40% ART
coverage in 2009 [36]. To help address this problem,
the Ghanaian government is currently making efforts
to increase coverage to 60% of those eligible for treat-
ment by 2013 [10]. To inform the further scale up of
ART services, we undertook a review of patients re-
ceiving ART in the country. Both the regional and sex
distribution of patients receiving ART, especially when
cost of ART no longer seems to be a constraint, are
highlighted.Rigorous examination of current ART programs in
resource-limited settings is critical to identify implemen-
tation gaps and to suggest context-specific interventions
that can improve accessibility for all eligible HIV patients
[1,37]. It is imperative to address inequities regarding ac-
cess and utilization of ART, ensuring wide spread and
timely access, as well as prolonged healthy living among
HIV patients [6]. Prolonged healthy living helps HIV re-
sponse efforts at the population level by reducing stigma,
promoting prevention-oriented behavior and thereby re-
ducing the further spread of the virus [9]. To document
the regional and sex disparities, this study reviews NACP
dataset [10,38].
Methods
The data source for this review is NACP sex and region
disaggregated records on adults aged 15+ who initiated
ART from 2003 to 2010. The NACP is responsible
for coordination and implementation of HIV and AIDS-
related aspects of the Ghana Health Strategic Frame-
work. Implementation is managed by the Disease
Control and Prevention Department of the Public Health
Directorate of the Ghana Health Service. NACP sources
and collates computerized HIV and AIDS- related ser-
vice provision data from community health centers, dis-
trict hospitals, regional hospitals and teaching hospitals
throughout the country, every quarter. From these
records, NACP generates a comprehensive national
dataset that covers service provision across all ten ad-
ministrative regions in Ghana. These data were the
source for the 2010 Ghana’s Progress Report on the Uni-
ted Nations General Assembly Special Session [10].
National and regional HIV prevalence for adults aged
15-49 years are estimated by NACP from antenatal and
STI surveillance data, using recommended United
Nations’ algorithms [39]. Regional adult population fig-
ures provided in Table 1 were generated using the Uni-
ted States Census Bureau’s 2010 estimation that 52% of
the Ghanaian population is aged between 15-49 years
[40]; this was applied to the 2010 Ghana population and
housing census data for each region [41]. In order to de-
termine who is utilizing ART, the sex of adult HIV
patients receiving ART in each year (2003-2010) are dis-
played. Also, trends are examined by comparing new
ART enrollments (sex and total) over time. In addition,
a detailed analysis of the geographic (regional) location
of patients receiving treatment in the year 2010 is pro-
vided by contrasting the proportion of the total Ghan-
aian population residing in each region with the
proportion of the total HIV+ population, and the ART-
using population in that region; discrepancies are noted.
Descriptive statistics include simple frequencies, propor-
tions, percentages and ratios. These are presented by
year of enrollment, sex and region. All analyses were
Results
Table 1 Regional Distribution of HIV Patients on ART
Regional Distribution of HIV Patients Enrolled on ART, By Population Distribution & HIV Prevalence (2010)
Region Adult Population
Sharea
Adult HIV
Prevalence,
2010b
Number of Adults
Infectedc
Regional Share
of Ghana’s
Infected Adults
Number Started
on ART, 2010
Regional Share of Adults
who Initiated ART
in Ghana, in 2010
Ashanti 19.5% (2457024) 3.0% 73711 25.4% 2395 20.2%
Eastern 10.7% (1349927) 3.2% 43198 14.9% 2116 17.8%
Greater Accra 16.1% (2033077) 2.6% 52860 18.2% 1952 16.5%
Brong Ahafo 9.4% (1186707) 2.0% 23734 8.2% 1432 12.1%
Volta 8.7% (1091936) 1.8% 19655 6.8% 1118 9.4%
Western 9.6% (1209310) 2.5% 30233 10.4% 1,048 8.8%
Central 8.7% (1095749) 1.7% 18628 6.4% 609 5.1%
Northern 10.2% (1283650) 0.7% 8986 3.1% 464 3.9%
Upper West 2.8% (352437) 1.7% 5991 2.1% 347 2.9%
Upper East 4.3% (536369) 2.4% 12873 4.4% 385** 3.2%
ach
sha
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62 Page 3 of 8
http://www.equityhealthj.com/content/11/1/62ART utilization trends in Ghana
The data (Figure 1) show- high increases in the number
of adults enrolled on ART from 2003 to 2004, and againperformed using the statistical software package SPSS
version 19.
Total 100% (12596184) 289868
** 2009 data for Upper East was used due to missing data for 2010.
aAdult population (15-49 years) share estimated as 52% of total population for e
bRegional adult HIV prevalence.32
cNumber infected is estimated using adult HIV prevalence and adult populationfrom 2006 to 2007. When ART was initially rolled-out
in 2003, 197 adults enrolled for the service. In the sec-
ond year (2004) new enrollees increased to almost 2,000
adults, representing a 900% increase in one year. In 2007
a record 6,091 adults enrolled, an approximately two-
Adults Enrolled on A
0
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
2003 2004 2005 2006
N
um
be
r
Number Newly
Enrolled
Cumulative
Total
Figure 1 Adults Enrolled on ART in Ghana (2003-2010). Number of adu
Figure shows total number of adult HIV patients in Ghana who newly enro
Figure also demonstrates the cumulative total of adult HIV patients who en
to 2010.Regional distribution of HIV patients on ART in Ghana
Regional HIV prevalence rate in 2010 range from 3.2%
in the Eastern region to 0.7% in the Northern regionfold increase in enrollments the previous year (Figure 1).
By the end of 2010 the cumulative number of adults en-
rolled on ART in Ghana was approximately 45,000.
100.0% 11866 100.0%
region.33,34
re.(Table 1). With a 3.0% HIV prevalence rate, Ashanti region
contributed approximately 25.4% of the total number of
HIV infected persons in Ghana, in the year 2010. Ashanti,
Eastern and Greater Accra regions each accounted for a
greater share in total HIV-positive cases in Ghana than
ntiretroviral Therapy in Ghana 
2007 2008 2009 2010
Year
lts enrolled on antiretroviral therapy in Ghana from 2003 to 2010.
lled on antiretroviral therapy each year starting from 2003 to 2010.
rolled on antiretroviral therapy across the country starting from 2003
their share of the overall adult population in the country.
This discrepancy was greatest in the Eastern region, which
represents 10.7% of the adult Ghanaian population, but
14.9% (i.e. 39% more) of the adult HIV-positive cases in
Ghana. The remaining seven regions of Ghana had pro-
portions of HIV-positive cases that were either compar-
able or less than their share of the adult population.
The Ashanti region had the highest share of ART
enrollees (20.2%) in the year 2010 (Table 1), notably less
than their 25% share of HIV-positive adults. Greater
Accra also had proportionately more HIV-positive cases
than they had enrollees on ART (Table 1). At the same
time, the Eastern, Brong Ahafo and Volta regions had
proportionately more adults using ART than their share
been available in Ghana, more females than males have
In the most recent year of data (2010), the F:M ratio in
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62 Page 4 of 8
http://www.equityhealthj.com/content/11/1/62all ten regions was above 2.0 (Table 3). The Central re-
gion recorded the highest F:M ratio (3.4), followed by
three regions (Brong Ahafo, Volta, and Upper East) each
recording 2.9 F:M ratio in 2010 (Table 3). The lowest F:
Table 2 Proportion of Females and Males on ART
Proportion of Females and Males Enrolled on ART From
2003 - 2010
Year Total Number
of Patients
Enrolled
FEMALES MALES
Number
Enrolled
Proportion Number
Enrolled
Proportion
2003 197 112 0.569 85 0.431
2004 1831 1067 0.583 764 0.417
2005 2032 1270 0.625 762 0.375
2006 3278 2060 0.628 1218 0.372
2007 6091 3911 0.642 2180 0.358
2008 10185 7119 0.699 3066 0.301been enrolling (Table 2). In 2003 43.1% of adults en-
rolled on ART were males, and this proportion declined
precipitously in the following years, progressing to 41.3%
in 2004, to 30.1% in 2008 and 27.6% in 2010 (Table 2).
The F:M ratio was 1.3 in 2003, but steadily increased
over the years (Figure 2).
Sex distribution of HIV patients on ART in the ten regions
of Ghanaof HIV-positive persons. Other regions where the per-
cent share of overall ART enrollments was lower than
the region’s percent share of HIV infections included
Western, Central and Upper East) regions (Table 1).
Sex differentials in the distribution of patients on ART
For the 8 year period within which ART services have2009 10131 7027 0.694 3104 0.306
2010 11481 8315 0.724 3166 0.276M ratio of 2.4 was reported by Ashanti, Eastern and
Upper West Regions (Table 3).
Discussion
Despite profound increases in ART utilization, lower
proportions of males are obtaining ART services in
Ghana. For each of the six recent years (2005-2010),
males consisted of less than one third of adults who
newly enrolled on ART each year. The proportion of
males who newly enrolled declined from 41.7% in 2004
to 27.6% in 2010. Our finding is consistent with Family
Health International’s report on pilot projects that
initiated ART in Ghana, Kenya and Rwanda [42]. The
FHI report indicates women comprised a majority (62%)
of ART patients in all three countries [42]. Also, several
studies conducted in other parts of Africa (South Africa,
Botswana, Ethiopia, Ivory Coast, Malawi, and Zim-
babwe) indicate similar over-representation of women in
persons receiving ART [13,14,30-32]. After conducting a
systematic review, Muula and his colleagues found a F:
M ratio of patients receiving ART to be equal to, or
greater than 1, in all but 2 of 21 published studies in
seven Southern African countries [14].
The over-representation of women receiving ART may
partially reflect the sex proportions of the adult popula-
tion infected with HIV in African countries [43]. For in-
stance, the 2003 Ghana Demographic and Health Survey
reports nearly 3% national HIV prevalence for women
aged 15-49 years, but less than 2% for men aged 15-
59 years [44], suggesting an F:M ratio of 1.8 to 1. Also,
the Ghana NACP 2010 [33] HIV estimates suggest that
the F: M ratio of the HIV-positive population in Ghana is
1.3:1. Irrespective of the comparatively high HIV preva-
lence among females, the Ghana AIDS Commission
claims that in 2009, 50% of females who needed ART
were accessing the service while only 39% of males who
needed ART had access [10], suggesting a 1.2:1 F:M ratio.
Wagner and his colleagues argue that most people do
not seek HIV testing and care until they are experien-
cing severe symptoms and thus have a more advanced
disease stage [7]. This situation is more likely the case
for males in Africa as studies indicate that men start
treatment with more advanced stages of illness which
negatively impacts their prognosis [13,45]. In investigat-
ing the relationship between patient’s clinical stage and
CD4 count in Ghana, Torpey and his colleagues
observed that seeking testing and care at a later HIV
stage, and with very low CD4 count jeopardizes treat-
ment outcomes [46].
The underrepresentation of males in ART enrollment
may be attributed to lower HIV testing among males
compared to females. Several studies in sub-Saharan
Africa suggest women test for HIV more than men
[44,47,48] and also start treatment at an earlier clinical
Female:Male Ratio of Adults Tha
1.3 1.4
1.7 1.7
0.0
0.5
1.0
1.5
2.0
2.5
3.0
2003 2004 2005 2006
Fe
m
al
e 
to
 M
al
e 
R
at
io
Figure 2 Female to Male Ratio of Adults Enrolled on ART in Ghana. Fi
therapy in Ghana for each year, starting from 2003 to 2010. Figure shows t
who newly enrolled on antiretroviral therapy each year starting from 2003
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62 Page 5 of 8
http://www.equityhealthj.com/content/11/1/62stage of HIV than men [13]. Since HIV testing serves
as the funnel into HIV care and eventual ART initi-
ation the underrepresentation of males in ART
utilization in Ghana may simply be a direct conse-
quence of the documented low HIV testing among
men [7,44,47-49]. A recent four-year review (2007-
2010) of HIV Testing and Counseling data from the
NACP in Ghana found that F:M ratio of HIV testing
ranged from 7.6 in 2007 to 4.2 in 2010 [49]. This find-
ing was also confirmed by the 2008 Ghana Demo-
graphic and Health Survey which reported that women
(17%) were slightly more likely to have been tested for
HIV and received their results than men (12%) [48].
More structural and pragmatic explanations for male
under-utilization of both HIV testing and ART enroll-
ments are plausible, including the fact that women are
generally more acculturated to the routine use of health
services through child-bearing and responsibility for
children’s health. This may be particularly salient in
Table 3 Enrollment of Patients on ART
Enrollment of Patients on ART in All Regions in 2010 by Sex;
Showing F: M Ratio
Region Total Number
Started on ART
in 2010
Number of Males
Started on ART
in 2010
F:M Ratio
Ashanti 2395 702 2.4
Eastern 2116 624 2.4
Greater Accra 1952 536 2.6
Brong Ahafo 1432 364 2.9
Volta 1118 285 2.9
Western 1048 286 2.7
Central 609 138 3.4
Northern 464 130 2.6
Upper West 347 101 2.4
Upper East 385** 100 2.9
Total 11866 3266 2.6
** 2009 data for Upper East was used due to missing data for 2010.African contexts where annual physical check-ups or
health screening services are not yet routine for adult
men or women. In this context, improvements in access
to HIV testing among women attending antenatal care
has been noted as a key entry point for women into
HIV- related care [14]. In Ghana, HIV testing among
pregnant women is encouraged as part of efforts to pre-
vent mother to child transmissions.
Furthermore, researchers on masculinity and health
generally attribute low male utilization of health care
services to traditional concepts of masculinity that disas-
sociate male identity from disease and project males as
invulnerable and not needing health care [16,17,29].
We would argue that such anxieties may be augmen-
ted for the diagnosis and treatment of HIV or other po-
tential sexual infections, in which the patient-provider
interaction must inevitability focus on issues of sexual
ill-health, and potential fears of sexual disempowerment.
That said, one should adopt western theories to the
Ghanaian context with some degree of caution, given
t Enrolled on ART in Ghana Each Year
1.8
2.3 2.3
2.6
2007 2008 2009 2010
Year
gure shows female to male ratio of adults enrolled on antiretroviral
he female to male ratio of total number of adult HIV patients in Ghana
to 2010.evidence of wide-ranging strategies for affirming domin-
ant masculinity across social class, profession, or cultural
location even within the USA or UK [50,51]. Instead,
further investigation is warranted in the Ghanaian
setting.
In addition to wide sex differentials, there is dispropor-
tionate ART use across the ten administrative regions in
the country. Ashanti region, being the most populous re-
gion in the country, had the highest ART enrollments,
followed by Greater Accra and Eastern regions. Consid-
ering that Accra, the capital of Ghana is located within
the Greater Accra region, it is possible that the provision
of ART in this region has become more feasible, partly
due to the wide availability of health facilities within the
urban sites of the region. Also the Eastern region which
consistently records the highest HIV prevalence in the
country continues to receive attention. Therefore, the
high ART enrollment in the Eastern region may reflect
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62 Page 6 of 8
http://www.equityhealthj.com/content/11/1/62interventions aimed at addressing the high HIV preva-
lence in that region.
Besides these three regions, other regions report ART
enrollment that is either lower or higher than the
region’s percent share of number of HIV infected per-
sons in the country. For instance, Brong Ahafo and
Volta regions had comparatively high shares of ART en-
rollment, 12.1% and 9.4%, respectively. These are more
than their respective percent shares of number of HIV
infected persons (Brong Ahafo, 8.2%; Volta, 6.8%). The
regional utilization patterns demonstrate how scale-up
efforts occurring simultaneously within different African
settings may, or may not be necessarily responding to
specific geographical needs [7]. For Ghana, these esti-
mates highlight the regional differences in population
HIV-burdens, and reflect the different coverage of ART
for HIV-positive persons across Ghana.
Regardless of sex and regional differentials, there is an
upward trend in ART utilization across the country. Al-
though few HIV patients (197) enrolled when ART was
initially piloted in June 2003 in Ghana, this effort laid the
foundation for expansion of ART services in subsequent
years. The records show over a two-hundred-fold in-
crease in the number of HIV patients on ART across the
country by the end of 2010. Similar increasing ART
utilization trends were found in various resource-limited
settings during this period [12,52,53]. One important fac-
tor that accounts for this steady increase in ART
utilization in Ghana is the concurrent increase in the
number of sites providing ART services. According to na-
tional reports, facilities providing ART services in Ghana
increased from 3 in 2003, to 13 sites in 2005 [10]. By De-
cember 2009, this number had profoundly increased to
138. These are health facilities that provide ART for HIV
patients at the district, regional and (Tertiary) national
health facilities in both the public and private sector [10].
The enormous increase in number of adults enrolled on
ART each year is indicative of numerous ART scale-up
efforts initiated by public and private organizations
across Africa including governments, non- government,
and community-based organizations [7]. In Ghana, the
scale-up has continued in the public sector with linkages
to the private sector through the NACP [10].
Whereas the upward trend in ART utilization across
the country provides evidence of the wide scale-up
efforts, sex and regional disparities in utilization high-
light HIV-related healthcare inequities that need to be
further investigated and addressed. Although inherent
challenges such as limited institutional resources and
service capacity, may explain such gaps, the availability
of a wide spectrum of alternative services for HIV
patients in Ghana may explain why some HIV patients
do not utilize ART services. Research conducted by
Awusabo-Asare and Anarfi on the health-seekingbehavior of persons with HIV and AIDS in Ghana indi-
cate that, after being diagnosed, HIV patients in Ghana
may also visit the traditional healer or spiritualist consid-
ering the supernatural explanations given to HIV infec-
tion in some cases [54]. Also, other studies suggest the
possibility of HIV patients seeking care through the in-
formal sector [13]. Preference for the informal sector
may be due to fear of stigma and disclosure of HIV sta-
tus, perception that hospitals are unfriendly and confus-
ing, and work or family responsibilities [6,13]. Given
that these factors may unequally affect women and men,
as well as the various regions in Ghana, understanding
how and why these impact the health seeking behavior
of each gender and each region warrants more inquiry.
It will be important to investigate if indeed, with the
availability of ART, male patients, vis-à-vis female
patients, are more likely to engage the services of alter-
native health care outlets. Also, differences between the
ten administrative regions in the proportion of persons
likely to solicit HIV-related care from the informal sec-
tor warrant investigation.
Furthermore, disparities in utilization of ART can be
explained by inequities related to access to health service
benefits in Ghana. Studies have shown differentials in
the distribution of health service benefits across various
subgroups in Ghana [55]. For instance, geographical ac-
cess to health care services has been identified as a key
challenge for rural populations in Ghana [55]. Unfortu-
nately, such barriers potentially prevent some eligible
HIV patients from having equal and timely access to
treatment, thereby further widening the health inequity
gap. In this context, promoting equal access to ART
means addressing inherent inequities in access to health
service benefits in the country. Structures must be put
in place to ensure timely access to ART by all eligible
HIV patients irrespective of gender, age, location or
socio-economic status.
In this study, we reviewed a national dataset to de-
scribe the sex and regional distribution of HIV patients
receiving ART in Ghana. The limitation, however, is that
this dataset is based on routine service provision records
that may sometimes be incomplete. Also, since these
data do not include other demographic information on
patients it is difficult to determine double counting or to
identify patients who are no longer receiving the service
due to death or loss to follow-up. Another limitation is
in using the national proportion of the 15-49 year age
group to estimate the regional adult population. It is im-
portant to note, however, that the US Census Bureau
estimations, the source for these regional estimations,
uses the Ghana Demographic Health Survey, a
population-based survey which provides good coverage
of the general population [56]. The GDHS is also used
in calculating population estimations of HIV prevalence
Dako-Gyeke et al. International Journal for Equity in Health 2012, 11:62 Page 7 of 8
http://www.equityhealthj.com/content/11/1/62in Ghana [39,57]. Despite these limitations, it is remark-
able to note that our study uses data from different time
periods and different regions within the country to show
the disproportionally lower use of ART services by
males. Also, by using a national dataset we were able to
look critically at the outcome of the ART scale-up efforts
in the launching years from 2003 to 2010, offering
insight into operational realities.
Conclusions
Considering findings from this study and several others,
it is clear that men are underrepresented in the distribu-
tion of HIV patients receiving ART in Ghana, and several
other African settings. Unfortunately, this has led to
increased mortality among the male HIV- population in
Africa [13,45]. Although explanations for increased mor-
tality among men include men’s poor healthcare deci-
sions, service structures need to enhance their capacity
to attract and serve males [20]. Policy makers in Ghana
and elsewhere need to understand how gender inequality
affects both men and women and begin to design
gender-based interventions. Barriers against accessing
HIV-related care amongst men must be investigated. In
addition, HIV- related services, such as HIV testing, can
be established within male-dominated spaces, e.g. in
locales such as sports arenas or social clubs. By so doing
HIV-related care will be brought closer to males. ART
scale-up efforts across Africa should pay candid attention
to sex and regional disparities if indeed we want to en-
courage high involvement in HIV-related care by all eli-
gible subgroups.
Abbreviations
ART: antiretroviral therapy; PEPFAR: President’s Emergency Plan for AIDS
Relief; WHO: World Health Organization; NACP: National AIDS/STIs Control
Program; GHS: Ghana Health Service.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
All authors (PDG, RC and AEY) contributed to the conception, analysis and
interpretation of data. AEY assisted with acquisition of the dataset. PDG, RC
and AEY participated in the writing of the manuscript. All authors read and
approved the final manuscript.
Acknowledgements
We are grateful to Dr Nii A. Addo (Program Manager of NACP) for leading
the fight against HIV and AIDS in Ghana; Drs Dornoo and Ayisi-Addo of the
NACP, for explanations on aspects of the data. Also to Mr. Ekow Wiah
(National Data Manager of the NACP). Manuscript preparation was made
possible through funding from the Fogarty International Center at the
National Institutes of Health, Grant Number: 1R24TW008814 - 01, as part of
the Ghana-Michigan PARTNER program (Postdoctoral And Research Training
NEtwoRk).
Author details
1Department of Social and Behavioral Sciences, School of Public Health,
College of Health Sciences, University of Ghana, P. O. Box LG 13, Accra,
Ghana. 2Department of Health Behavior and Health Education, School of
Public Health, University of Michigan, 109 Observatory, 3814, Ann Arbor, MI48109-2029, USA. 3Department of Community Health, University of Ghana
Medical School, College of Health Sciences, P. O. Box 4236, Korle-Bu, Accra,
Ghana. 4National AIDS/STIs Control Program, Ghana Health Service, Korle- Bu,
Accra, Ghana.
Received: 9 November 2011 Accepted: 7 May 2012
Published: 16 October 2012
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