SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA LEGON UTILIZATION OF HIV TESTING AND COUNSELLING SERVICES BY MEN IN THE BOLGATANGA MUNICIPALITY BY EZEKIEL APASERA A DISSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY, 2013 University of Ghana http://ugspace.ug.edu.gh i DECLARATION By submitting this dissertation entitled “UTILIZATION OF HIV TESTING AND COUNSELING SERVICES BY MEN IN THE BOLGATANGA MUNICIPALITY”, I hereby declare that the entirety of the work contained therein is my own, original work which was supervised in accordance with the procedures laid down by the University; that I am the sole author thereof; that the sources I have used or quoted have been indicated and duly acknowledged by means of references, and that, this study has never been presented either in its entirety or in part for the award of any degree or certificate. _______________________________ _______/_________/__________ Ezekiel Apasera Date (10233155) _________________________ _________/_________/_________ Amos Laar, PhD Date (SUPERVISOR) University of Ghana http://ugspace.ug.edu.gh ii DEDICATION To all my siblings: Mercy, Rachel, Ernest, and Prosper. University of Ghana http://ugspace.ug.edu.gh iii ACKNOWLEDGEMENT My first thanks go my academic supervisor, Dr. Amos Laar, for his guidance, time and constructive criticism despite his busy work schedule. But for him this research would not have been a success. Sir! I will always remember your favorite quote: “Knowledge shared is not knowledge halved”. I hope to continue to learn from you. My profound gratitude also goes to the Dean, Prof. Richard Adanu and the entire staff of School of Public Health of University of Ghana, Legon, for the knowledge they imparted in us and for their moral support and encouragement. I would also like to acknowledge my course mates, especially Mariam Bogobire and Bismark Akasoe for their encouragement and support throughout the study period. Mention must also be made of Thomas, George, Darius, Pius and David for their invaluable assistance in data collection. I wish to express my sincere gratitude to all my friends, especially Peter Adatara and Shirley Adombire-Naba for their moral support and pieces of advice throughout the entire period of the programme. Finally, I wish to say thank you to all those who contributed in diverse ways to the successful completion of this study. God bless! University of Ghana http://ugspace.ug.edu.gh iv ABSTRACT Background: In the absence of an effective vaccine and cure for HIV, testing and counseling for HIV remains an important intervention in the control of the infection. However, utilization of this service in Ghana is very low especially among men. This study sought to determine the extent of utilization of HIV testing and counseling services among men in the Bolgatanga Municipality, and to document the reasons for their use or non-use of the service. Methods: The study was a population-based cross-sectional survey. A total of 610 men, aged 18 – 59 years residing in Bolgatanga Municipality were randomly selected using multi-stage sampling technique. Data was collected through structured interviews during home visits by the use of a questionnaire over a period of two weeks. Results: Majority of the respondents (99.3%) knew of a test that could identify HIV in an individual; however, 63.6% felt they were at no risk/low risk of being infected with HIV. About 89.8% of those who had heard of HIV test could locate at least one testing centre. Radio/television was the most frequent (68.4%) source of information while the hospital was the most preferred place for testing. Only 27.7% of the respondents had ever tested for HIV of which 99.4% of them had received their test results; 7.7% of men tested within the last 12 months prior to the study. Reasons given by respondents for use or non- use of testing and counseling services included socio-cultural and health service-related reasons, and personal beliefs. Educational and employment statuses of respondents were found to associated with the uptake of HIV testing and counseling services (p<0.001) and the likelihood of testing within the next 12 months (p<0.05). University of Ghana http://ugspace.ug.edu.gh v Conclusion: Utilization of HIV testing and counseling services by Men in Bolgatanga Municipality was low. Low perception of HIV risk and fear of stigma and false positive results were the key reasons for not being tested. There is urgent need for formulation of pragmatic policies and strategies that can help improve uptake of testing and counseling. University of Ghana http://ugspace.ug.edu.gh vi Table of Contents Page DECLARATION…………………………………………………………………..…….. I DEDICATION…………………………………………………………………… ……..II ACKNOWLEDGEMENT…………………………………………………………........III ABSTRACT……………………………………………………………………………..IV TABLE OF CONTENTS………………………………………………………………..VI LIST OF TABLES……………………………………………………………………….X LIST OF FIGURES……………………………………………………………………...XI LIST OF ACRONYMS…………………………………………………………………XII DEFINITION OF TERMS……………………………………………………………..XIII CHAPTER ONE 1.1 Introduction……………………………………………………………………………1 1.2 Background to the Study………………………………………………………………1 1.3 Statement of the Problem……………………………………………………………...4 1.4 Conceptual Framework………………………………………………………………..6 1.5 Justification for the Study……………………………………………………………..8 1.6 Objectives of the Study………………………………………………………………..9 1.6.1 General Objective………………………………………………………………...9 1.6.2 Specific Objectives……………………………………………………………….9 CHAPTER TWO LITERATURE REVIEW………………………………………………………….......10 2.1 Introduction………………………………………………………………………......10 2.2 General Overview of the HIV Epidemic in Ghana……...……………………….......11 University of Ghana http://ugspace.ug.edu.gh vii Table of Contents Page 2.3 HIV Testing and Counseling……………………………………..…………….........12 2.4 Uptake of HIV Testing and Counseling………………………………………….......15 2.5 Awareness and Perception of HIV Testing and Counseling…………..…………......18 2.6 Factors influencing utilization of HIV Testing and Counselling Services..................22 2.6.1 Socio-demographic Factors.................................................................................22 2.6.2 Socio-Cultural Factors..........................................................................................24 2.6.3 Health Service – Related Reasons........................................................................29 CHAPTER THREE MATERIALS AND METHODS....................................................................................32 3.1 Research Design...........................................................................................................32 3.2 Research Setting...........................................................................................................32 3.3 Variables for the Study................................................................................................35 3.3.1 Outcome Variable.................................................................................................35 3.3.2 Explanatory Variables...........................................................................................36 3.4 Study Population.........................................................................................................38 3.4.1 Eligibility Criteria.................................................................................................39 3.5 Sampling......................................................................................................................39 3.5.1 Sample Size Determination...................................................................................39 3.5.2 Sampling Technique.............................................................................................40 3.6 Data Collection Techniques………………………………………………………….42 3.7 Data Collection Instrument………………………………….……………………….42 3.8 Training of Interviewers……………………………………………………………..43 University of Ghana http://ugspace.ug.edu.gh viii Table of Contents Page 3.9 Pretest of Questionnaire……………………………………………………………..43 3.10 Actual Data Collection……………………………………………………………..44 3.11 Quality Control…………………………………..…………………………………45 3.12 Data Processing and Analysis……………………………….....…………………..45 3.13 Limitations of the Study...........................................................................................46 3.14 Ethical Consideration.................................................................................................47 CHAPTER FOUR RESULTS……………………………………………………………………….............49 4.1 Introduction ……………………………………………………………………........49 4.2 Socio-Demographic Characteristics of Respondents………………………………...49 4.3 Awareness and Perception of Men Regarding Testing and Counseling……………..51 4.3.1 Awareness of Testing and Counseling ………………………………………….51 4.3.2 Source of Information, Testing Centers and Benefits of Testing..………...........52 4.4.3 Risk perception and Perceived Importance of Testing and Counseling…..........53 4.4 Use of Testing and counselling Services/ Likelihood to Use Testing Services...........54 4.5 Reasons for use or non-use of Testing and Counselling Services...............................56 4.5.1 Reasons for Testing..............................................................................................56 4.5.2 Socio-Cultural Reasons/Personal Beliefs for Not Testing....................................57 4.5.3 Health Service-Related Reasons for Not Testing.................................................58 CHAPTER FIVE DISCUSSION OF FINDINGS.......................................................................................64 5.1 Introduction.................................................................................................................64 University of Ghana http://ugspace.ug.edu.gh ix Table of Contents Page 5.2 Awareness and Perception of Men in Bolgatanga Municipality Regarding HIV Testing...........................................................................................................................64 5.3 Proportion of Men who have ever used Testing and counselling Services.................67 5.4 Reasons for use or non-use of HIV Testing and Counselling Services.......................69 5.4.1 Reasons for undergoing HIV Testing and Counselling........................................69 5.4.2 Reasons for non-use of Testing and Counselling Services...................................70 5.4.2.1 Socio-Cultural Reasons/Personal Beliefs......................................................70 5.4.2.2 Health Service-Related Reasons....................................................................71 5.5. Socio-demographic Characteristics and Testing.........................................................72 CHAPTER SIX CONCLUSIONS AND RECOMMENDATIONS........................................................74 6.1 Conclusions..................................................................................................................74 6.2 Recommendations........................................................................................................75 6.2.1 Policy makers........................................................................................................75 6.2.2 Future research.....................................................................................................76 REFERENCES.................................................................................................................77 APPENDICES..................................................................................................................87 Appendix 1: Questionnaire ……………………………………………….…87 Appendix 2: Informed Consent Form………………………………….……….93 Appendix 3: Ethical Approval Letter Appendix 4: Letter of Introduction University of Ghana http://ugspace.ug.edu.gh x List of Tables Page Table 1: Socio-demographic characteristics of respondents........................................51 Table 2 : Respondents‟ Awareness of HIV Testing and Counselling...........................52 Table 3: Risk Perception and Perceived Importance of HIV Testing / Counselling ...54 Table 4: Proportion of Respondents Ever Tested and Likelihood to Test....................56 Table 5: Reasons for Use or Non-use of HIV Testing and Counselling Services ……59 Table 6: Associations between Socio-Demographic Characteristics and Testing……61 Table 7: Associations between Background Characteristics & Likelihood to Test….62 University of Ghana http://ugspace.ug.edu.gh xi List of Figures Page Figure 1: Conceptual Framework……………………………………………………7 Figure 2: Map of Upper East Region showing the location of Bolga Municipality…35 University of Ghana http://ugspace.ug.edu.gh xii List of Acronyms/Abbreviations AID Acquired Immune Deficiency Syndrome ART Anti-Retroviral Therapy CDC Centers for Disease Control and Prevention DHS Demographic Health Survey GAC Ghana AIDS Commision GDHS Ghana Demographic and Health Survey GHS Ghana Health Service GSS Ghana Statistical Service HIV Human Immunodeficiency Virus JHS Junior High School MHMT Municipal Health Management Team MOH Ministry of Health MPH Master of Public Health NACP National AIDS Control Programme PLWHA People Living with HIV/AIDS PMTCT Prevention of Mother to Child Transmission SHS Senior High School STDs Sexually Transmitted Diseases STI Sexual Transmitted Infection UNAIDS Joint United Nations Programme on HIV/AIDS UNICEF United Nations Children‟s Fund University of Ghana http://ugspace.ug.edu.gh xiii Definitions of Terms and Concepts Used in the Study Acquired Immunodeficiency Syndrome (AIDS): This refers to the late and most advanced stage of HIV infection. Confidentiality: Confidentiality is a situation in which you trust someone not to tell secret or private information to anyone else. Counseling: A confidential dialogue between a client and a counselor aimed at giving the client advice and support on personal or psychological matters, usually in a professional context. Generalized epidemic: This refers to HIV prevalence rate of 1% or greater in the general population (WHO). HIV testing: Obtaining bodily sample for the specific purpose of performing a medical test or a number of medical tests to determine the HIV status of a person. HIV testing and counseling: The process by which an individual is tested for HIV and then giving some counseling to prepare him or her emotionally for the results of the test. Household: Household is defined as a person or a group of persons, related or unrelated, who live together in the same house or compound, share the same housekeeping arrangements, and eat together as a unit (GSS et al., 2009) Human Immunodeficiency Virus (HIV): This is the virus that causes AIDS. Mother - to - child transmission: The transmission of HIV from infected mothers to unborn babies which may occur during pregnancy, delivery or after delivery during breastfeeding. University of Ghana http://ugspace.ug.edu.gh xiv Post-test counseling: Counseling provided to a client before disclosing his or her HIV test result to him as well as the moral support given immediately after the client has received the result. Serostatus: Refers to “seroconvert” which is defined as the production of specific antibodies in response to the presence of an antigen (HIV). Seronegative: Uninfected: after a blood test, showing no immunological evidence of infection with HIV. Seropositive: Infected: after a blood test, showing immunological evidence of infection with HIV. University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE 1.1 Introduction This chapter provides the introduction of the study. The chapter presents the background to the study, statement of the problem, conceptual framework, justification for the study, and objectives of the study. 1.2 Background to the Study Despite the increase in access to antiretroviral therapy (ART) HIV transmission continues to spread worldwide (Corbett, Makamure, Cheung, Dauya, Matambo, et al., 2007). In 2010 about 34 million people were living with HIV worldwide, an increase of 17% from 2001. About 68% of them were residing in sub-Saharan Africa (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2011). An estimated 225,478 people were living with HIV in Ghana as at 2011 with about 12,077 new infections occurring in the same year. There was a rise of antenatal care (ANC) prevalence from 2.0% in 2010 to 2.1% in 2011 (Ghana AIDS Commission [GAC], 2012). Testing and counseling has been identified as an effective intervention in the fight against HIV transmission (Sebudde and Nangendo, 2009; Ghana Health Service [GHS], 2010). Studies have shown that there is low level of knowledge on HIV especially regarding the modes of transmission despite the high level (over 95%) of awareness of the existence of HIV (NACP/GHS, 2010). Thus, HIV testing and counseling intervention provides an opportunity for health information and promotion (Yahaya, Jimoh, and Balogun, 2010; Kakimoto, Sasaki, Kuroiwa, Vong, and Kanal, 2007). It provides an avenue for University of Ghana http://ugspace.ug.edu.gh 2 preventing HIV-negative people from being infected and controlling the progression of the HIV in infected people by providing early health care and psychosocial support (Aho, Nguyen, Diakite, Sow, Koushik, et al., 2012; Kalichman and Simbayi, 2012). Similarly, available research indicates that HIV testing and counseling facilitates access to prevention services for seronegative people such as prevention of mother-to-child transmission of HIV (PMTCT) services and medical and supportive services for seropositive individuals that can help prevent opportunistic infections and promote longer and healthier lives Joint United Nations Programme on HIV/AIDS [UNAIDS], 2002; Kakimoto et al., 2007). Research has indicated that HIV testing and counseling decreases high-risk sexual behavior and reduces the spread of sexual infections including HIV (Bollinger, Cooper- Arnold, and Stover, 2004; Bassett, 2002). Results from an exploratory study in Nairobi, Kenya, and Kampala and Masaka, Uganda, involving youth showed that among young people who had tested for HIV, most of them said they would adopt safer behaviors such as abstaining from sexual intercourse, practicing monogamy, using condoms or reducing the number of sexual partners (Horizons Program, Kenya Project Partners and Uganda Project Partners, 2001). According to European Centre for Disease Prevention and Control [ECDC] (2010), there is strong evidence that early diagnosis of HIV infection and early initiation of treatment can result in significant improved prognosis for the individual and consequently, low morbidity, a good quality of life and a near normal life expectancy. There is evidence that University of Ghana http://ugspace.ug.edu.gh 3 late diagnosis of HIV (CD4B/200) significantly increases the risk of death within one year of diagnosis compared to those not diagnosed late (Chadborn, Baster, Delpech, Sabin, Sinka, et al., 2005; Chadborn, Delpech, Sabin, Sinka, and Evans, 2006) and higher direct healthcare costs (Krentz and Gill, 2012). Testing and counseling is also important in the fight against HIV-related stigma and discrimination. A Ghanaian study conducted on HIV stigma and discrimination revealed that women who had ever being tested for HIV had significantly lower levels of stigmatizing and discriminating attitudes compared with those who had not tested for HIV (Tenkorang and Owusu, 2013). According to Walker (2003) HIV testing and counseling is found to be cost-effective intervention in the prevention of HIV as compared to most treatment strategies. However, the utilization of HIV testing and counseling services in Ghana is low (Ghana Statistical Service [GSS], Ghana Health Service [GHS], ICF Macro, 2009). The 2008 Demographic and Health Survey (DHS) indicates that only 16.9% of women and 12.7% of men had ever tested and received the results, and only 6.8% of women and 4.1% of men had tested and received the results in the last 12 months (GSS et al., 2009). According to Donkor (2012), though the awareness of testing and counseling is high (81%), only 23% of the respondents had tested for HIV. Fourteen percent (14%) tested voluntarily while 9% tested as a requirement for visa, blood donation, or employment. University of Ghana http://ugspace.ug.edu.gh 4 Men‟s utilization of HIV testing and counseling is very crucial especially in the Ghanaian society where men are decision makers with regard to health seeking practices by household members by virtue of their status as household heads. This study therefore sought to determine the proportion of men in Bolgatanga municipality who have ever been tested for HIV and the reasons for use or non-use of HIV testing and counseling services. 1.3 Statement of the Problem The increase in the number of people living with HIV (PLHIV) partly reflects the continued large number of new HIV infections. Sub-Saharan Africa accounted for 70% of new HIV infections in 2010 (UNAIDS, 2011). According to the 2010 Sentinel Survey Report, the HIV prevalence rate for Bolgatanga increased sharply from 2.6% in 2009 to 3.8% in 2010 resulting in Bolgatanga Municipality moving from 24th position on the National Chart in 2009 to 4th position in 2010, and from 17th to 3rd position on the National Urban Sites Chart (GAC, 2012).Though the situation has improved over the last two years, the HIV prevalence rate in Bolgatanga municipality for 2011 according to the 2011 HIV Sentinel Survey Report is 2.2% which is still higher than the median prevalence rate in the region (1.5%) as well as the national median HIV prevalence rate of 2.1%(Ghana Health Service [GHS], 2012). Ghana Demographic and Health Survey (GDHS) 2008 data indicates that a higher proportion of men tend to have multiple sexual partners compared to women (11.4% and 1.1% respectively) (GSS et al., 2009). This behavior tends to expose them as well as their University of Ghana http://ugspace.ug.edu.gh 5 partners to HIV infection (Bingenheimer, 2010; GSS et al., 2009). Meanwhile, majority of men still express their unwillingness to test for HIV (Bwambale, Ssali, Byaruhanga, Kalyango, and Karamagi, 2008). As at 2008, only 12.7% of men in Ghana had ever tested for HIV and received the results of the test (GSS et al., 2009). Since an effective vaccine against HIV has not yet been developed, HIV testing and counseling remains an integral component of prevention and care strategies (Denison, O‟Reilly, Schmid, Kennedy, and Sweat, 2008) because knowledge of positive serostatusfacilitates early referral for care and support and may promote behavioural changes that reduce HIV transmission (Sebudde and Nangendo, 2009). Though a couple of studies have been carried out in Ghana on HIV and Acquired Immune Deficiency Syndrome (AIDS) many of those studies have focused on awareness and practices towards HIV. Not much has been done on HIV testing and counselling use (especially among men) as a strategy for HIV prevention. To the best of my knowledge no study has been conducted in the Bolgatanga municipal regarding the proportion of men who have tested for HIV. This motivated the conduct of this survey to determine the proportion of men in the municipality who have tested for HIV and the circumstances that influence their willingness or otherwise to use the testing and counselling services. University of Ghana http://ugspace.ug.edu.gh 6 1.4 Conceptual Framework The conceptual framework for this study is adapted from Andersen and Newman framework of health services utilization. According to the framework, an individual's access to and use of health services (in this case HIV testing and counseling service) is considered to be a function of three characteristics: 1. Predisposing Factors: Social Structure: Education, occupation, ethnicity, social networks, social interactions, and culture. Health Beliefs: Attitudes, values, and knowledge that people have concerning and towards the health care system Demographic: Age and gender 2. Enabling Factors: Personal/Family: The means and know how to access health services, income, health insurance, extent and quality of social relationships, etc. Community: Available health personnel and facilities, quality of service, distance to facilities, and waiting time 3. Need Factors: Perceived need: "How people view their own general health and functional state, as well as how they experience symptoms of illness, pain, and worries about their health and whether or not they judge their problems to be of sufficient importance and magnitude to seek professional help." (Andersen, 1995) Evaluated need: "Represents professional judgment about people's health status and their need for medical care" (Andersen, 1995) University of Ghana http://ugspace.ug.edu.gh 7 Figure 1: Conceptual framework for the study of utilization of HIV testing and counseling services (source: Modified from Andersen 1995) Socio-cultural factors • Stigma • Fear of being tested positive • Fear of rejection by sexual partner • Disclosure of test results • Fear of illness/dying early • Social beliefs • Fear of loss of job/ housing • Busy work schedule • Socio-cultural beliefs • Requirement for job/ marriage/new relationship/ blood donation • Influence of social relations Health service factors • Distance to testing centres • Waiting time • Privacy and confidentiality • Cost • Quality of test results • Stigma/negative response of healthcare providers Knowledge/ perception testing  Awareness of testing/counselling  Source of information  Awareness of testing centres  Benefits of testing,  Importance of testing  Couple testing  Discordance of HIV results  HIV risk perception Socio-demographic characteristics • Age • Marital status • Employment status • Education • Religion Use of HIV testing and counselling service Non-use of HIV testing and counselling service University of Ghana http://ugspace.ug.edu.gh 8 1.5 Justification for the Study The study is very critical to health at this point in the country‟s drive for the better Ghana agenda. The unwillingness of men to test for HIV has dire consequences for the public health effort to control the HIV epidemic in Ghana. HIV seropositive men who are unaware of their HIV serostatus but continue to engage in high risk sexual behaviors with multiple sexual partners are at increased risk of spreading the virus to others. Increased rate of morbidity and mortality among the populace as a result of HIV has a direct negative effect on the socio-economic development of the country. In order to tackle the problem of underutilization of HIV testing and counseling services by men, improving understanding of the factors that militate against the use of the service is very crucial. The study will therefore provide evidence for stakeholders including the government, donor agencies, health managers, and public health practitioners regarding the possible barriers to the use of HIV testing and counselling services. Thus, it will inform policy formulation and measures aimed at address those challenges. Notwithstanding the importance of HIV testing and counselling in the prevention of HIV infection, there is dearth of empirical data on the utilization of HIV testing and counseling service by men in the Bolgatanga municipality and the reasons for use or non- use of the service. Understanding factors that impede or encourage men to test for HIV is important in developing effective intervention programmes aimed at scaling-up and promoting HIV testing and counseling among men. Findings from this survey will therefore help the Municipal Health Management Team (MHMT) to develop University of Ghana http://ugspace.ug.edu.gh 9 interventions to improve utilization of HIV testing and counselling. Furthermore, the study will provide empirical information for future reference. 1.6 Objectives of the Study 1.6.1 General To determine the uptake of HIV testing and counselling and the associated reasons for use or non-use of the service among men in the Bolgatanga Municipality 1.6.2 Specific (1) To determine the awareness and perceptions of men regarding HIV testing and counselling (2) To determine the proportion of men in the Bolgatanga municipality who have ever used HIV testing and counselling services (3) To document reasons for use or non-use of HIV testing and counselling services by men (4) To assess the associations between socio-demographic attributes and use of HIV testing and counselling services University of Ghana http://ugspace.ug.edu.gh 10 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter presents the literature review related to this study. Relevant studies in both developed and developing countries were reviewed with particular emphasis on the findings in developing countries. The review of literature was conducted with the use of peer reviewed articles, journals, annual reports, data sheets, theoretical research findings, edited textbooks and dissertation reports that are relevant to the research topic. Relevant studies were identified through computer searches of Medline and HINARI data bases using the combination of key terms such as HIV, AIDS, prevalence, men, test, utilization, factors and barriers. The reference lists of relevant articles retrieved were also inspected for relevant articles and explored for the review of literature. The research literature is organized in five sections. The first section of the chapter presents a general overview of the HIV epidemic situation in Ghana. The second section discusses HIV testing and counselling including its importance while the third section reviews literature on the uptake of HIV testing and counselling services. Knowledge and perception of HIV testing and counselling is discussed in the fourth section while the fifth section discusses the factors that influence the utilization of HIV testing and counselling services with emphasis on socio-demographic, socio-cultural and health service factors. University of Ghana http://ugspace.ug.edu.gh 11 2.2 General Overview of the HIV Epidemic in Ghana HIV was first recognized internationally in 1981(UNAIDS, 2002). It has since been a major global health problem especially in countries in sub-Saharan Africa because of its negative impact on the social and economic gains in many countries. In Ghana HIV was first identified in March 1986 (Ghana Statistical Service [GSS], Ghana Health Service [GHS], and ICF Macro, 2003; Ghana AIDS Commission [GAC], 2012). By 1987, the National AIDS Control Programme (NACP) was established under the MOH to implement and coordinate the country‟s HIV/AIDS programme. In addition, a National HIV/AIDS and STI Policy was developed to guide the national response. A number of strategies were subsequently implemented to control the infection. These include maintaining a safe blood supply, ensuring safe use of needles, and disseminating information through public campaigns to change social attitudes and behavior. In 2000, Ghana AIDS Commission (GAC) was established by the government for effective resource mobilization, management, and co-ordination of HIV and AIDS activities and targeted prevention measures expected to raise awareness and promote behavioral change among the populace. The national HIV/AIDS Strategic Framework was subsequently developed in 2001 to provide goals and objectives for a national response to the disease. The framework has since been revised (Ghana Statistical Service [GSS], Ghana Health Service [GHS], and ICF Macro, 2004; Ghana AIDS Commission [GAC], 2005). Controlling the spread of HIV is one of the major objectives in the fight against HIV infection. In Ghana, as in the rest of Africa, sexual (especially heterosexual) contact and mother-to-child transmission (MTCT) are the two most common ways HIV/AIDS University of Ghana http://ugspace.ug.edu.gh 12 infections are spread. The focus is to significantly reduce new HIV infections among the sexually active population through the promotion of safer sexual behavior. Testing and counseling is also done for pregnant mothers at the antenatal clinic to identify those infected in order to put them on ART early enough to prevent their unborn babies from being infected (GSS et al., 2004; GSS et al., 2009). The HIV epidemic status in Ghana is described as a generalized epidemic. According to the 2011 HIV Sentinel survey report, the Median HIV prevalence rate for 2011 was 2.1 per cent, which was a marginal rise of 2.0 per cent for 2010. Central Region of Ghana recorded the highest prevalence rate of 4.7% while the Northern Region recorded the least prevalence rate of 0.3%. However, the prevalence rate in 2011 ranged from 0.0% in Adibo, a rural site in the Northern Region, to 9.6% in Cape Coast (urban) in the Central Region (GHS, 2012). In 2011, approximately 225,478 adults and children were living with HIV ((30,401 children) while there were 12,077 new infections. Of the 225,478 people who were living with HIV, 100,336 were males and 125,141 were females. The estimated annual AIDS deaths for 2011 were 15,263 (GAC, 2012). 2.3 HIV Testing and Counselling HIV testing and counselling has been shown to be an effective strategy to facilitate behaviour change for HIV prevention. It provides an opportunity for health promotion thereby preventing HIV negatives individuals from contracting the infection and controlling the progression of the infection in those already infected by providing early health care and psychosocial support (Aho et al., 2012). Knowledge of HIV serostatus University of Ghana http://ugspace.ug.edu.gh 13 can motivate people to practise safer sexual behaviour so as to protect themselves and other sexual partners from being infected (Denison et al., 2008; Joint United Nations Programme on HIV/AIDS [UNAIDS], 2000). Related studies have indicated that HIV testing and counseling is effective in reducing spread of HIV by reducing unprotected sexual intercourse among individuals who have received testing and counseling. A randomized trial to determine the efficacy of HIV testing and counseling in reducing unprotected sexual intercourse among individuals and sex partners in three countries (Kenya, Tanzania and Trinidad) by the Voluntary HIV-1 Counseling and Testing Efficacy Study Group (2000) revealed a significant reduction in the proportion of individuals reporting unprotected sex with non-primary partners more for participants receiving testing and counseling than those receiving health information (that is, 35% reduction with testing/counseling as against 13% reduction with health information among men, and 39% reduction with testing/counseling as against 175 reduction with health information among women). Couple HIV testing and counseling is an effective behavioral intervention in the prevention of HIV transmission among couples (Painter, 2001). Research has shown that providing testing and counseling to a couple together is an effective intervention for reducing the spread of HIV as compared to counseling the female partner alone (Allen, Meinzen-Derr, Kautzman, Zulu, Trask, et al., 2003) because most new HIV infections in Africa are acquired from cohabiting heterosexual partners (Allen et al., 2003; Painter, 2001; Trask, Derdeyn, Fideli, Chen, Meleth, et al., 2002). University of Ghana http://ugspace.ug.edu.gh 14 Testing and counseling does not only provide an avenue for health education and behavior change but also allows people who are tested seropositive to seek care and support (Higgins, Galavotti, O'Reilly, Schnell, Moore et al., 1991) including access to ART (Kawichai, Celentano, Chariyalertsak, Visrutaratna, Short, et al., 2007). According to UNAIDS Voluntary Counseling and Testing Technical update (2000), people who test HIV seropositive can benefit from timely medical care and interventions to treat and/or prevent HIV associated illnesses. There is evidence that treatment has improved survival rates dramatically, especially since the introduction of highly active antiretroviral therapy (HAART) in 1995 (Palella, Deloria-Knoll, Chmiel, Moorman, Wood, et al., 2003). In a systematic review and meta-analysis of 11 studies on the effect of ART on tuberculosis (TB) incidence among HIV - infected patients, ART was found to reduce TB incidence by 65% (Suthar, 2012). Several countries in sub-Saharan Africa have experienced a remarkable expansion of HIV testing and counselling services and the emergence of new strategies. In the 1990s, HIV testing was conducted mainly in client-initiated centres. In recent times, however, provider-initiated testing strategies and outreach programmes have been implemented in many countries including Malawi and Boswana (Creek, Ntumy, Seipone, Smith, Mogodi, et al., 2007). Similarly, national testing and counselling campaigns have been implemented in Burkina Faso, South Africa and Uganda while Rwanda and Zimbabwe have initiated innovative approaches in which tests are offered at workplaces (Feeley, Collier, Richards, Van der Borght, and Rinke de Wit, 2007; Corbett et al., 2007) through mobile units or at people‟s homes (Negin, Wariero, Mutuo, Jan, and Pronyk, 2009). This University of Ghana http://ugspace.ug.edu.gh 15 is particularly important because in many African settings health services are accessed only when there is a specific need, and only when it is perceived to be serious (Burns, Imrie, Nazroo, Johnson, and Fenton, 2007). The Centers for Disease control and Prevention (CDC), in 2003, reported that persons tested late in the course of their infection were more likely to be black or Hispanic and to have been exposed through heterosexual contact. According to the report, 87% received their first positive HIV test result at an acute or referral medical care setting, and 65% were tested for HIV antibody because of illness. In 2006, CDC issued recommendations for routine HIV testing in all health-care settings with HIV prevalence of 0.1% or greater for all persons aged 13 to 64 years, regardless of risk (Centers for Disease Control and Prevention [CDC], 2006). The government of Ghana, supported by the WHO, UNAIDS, UNICEF and other organizations, has committed itself to the fight against HIV by issuing a strategic framework and supporting HIV prevention activities including the promotion of testing and counselling (Centers for Disease Control and Prevention [CDC], 1995; GAC 2003; GAC, 2005). All these efforts are intended to reach individuals earlier in the process of infection so as to provide the needed counselling, prevention and treatment services. 2.4 Uptake of HIV Testing and Counselling The use of HIV testing and counselling globally is very low in spite of increased accessibility of testing and counselling services and the fact that the test is conducted free of charge in government-own health facilities in many developing countries (Obermeyer University of Ghana http://ugspace.ug.edu.gh 16 and Osborn, 2007; Angotti, Bula, Gaydosh , Kimchi , Thornton, et al., 2009). As a result, many people living with HIV tend to be diagnosed late, after their immunity is compromised (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2009). In comparison of data from population-based surveys conducted in 2005 and 2006 from 22 countries including 16 countries in sub-Saharan Africa, a median of 10% of women and men in the general population reported having ever tested for HIV and received the results, and a median of 4% and 5% of women and men respectively reported having tested and received the results 12 months preceding the survey (UNAIDS, 2009). It is estimated that 20%- 30% of HIV infected individuals in developed countries are unaware of their HIV serostatus while approximately 80% of people living with HIV in low and middle income countries are unaware of their HIV serostatus (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2007). A study by Bateganya, Abdulwadud, and Kiene (2007) has shown that only 10% of HIV infected persons know their HIV serostatus. However, in a Ugandan study, the prevalence of HIV testing among men was found to be 23.3% (Bwambale et al., 2008). A number of similar studies also reported low uptake of HIV testing and counselling services especially among men. For instance, a study in Eastern Cape Province in South Africa on testing and counselling use indicated that only 17% of men had HIV test (Hutchinson and Mahlalela, 2006) while 11% of men were reported to have tested for HIV in a study in Malawi (de Graft et al., 2005). Furthermore, a Nigerian study found that majority of the participants (98.6%) has never been tested for HIV (Illiyasu, Abubakar, Kabir, and Aliyu, 2006). An Ethiopian study which utilized data from Ethiopian Demographic Health Survey (EDHS) 2005, revealed University of Ghana http://ugspace.ug.edu.gh 17 that 21.9% of urban and 2.6% of rural men had tested for HIV through testing and counseling with most of them having received their HIV test results (Leta, Syndøy, and Fylkesnes, 2012). According to He, Zhang, Yao, Tian, Zhao, et al. (2009) out of 2,690 participants in a study aimed at determining the knowledge, attitudes and practices of testing and counseling, only 62 (2.3%) had tested for HIV; 19 of them underwent the testing at a testing and counseling centre . In a related study only a few (35%) of the respondents had tested for HIV although the respondents were aware of the benefits of HIV testing and counseling (Charles, Kweka, Mahande, Barongo, and Shekalaghe, 2009). A study conducted in Bushenyi District of Uganda by Nuwaha, Kabatesi, Muganwa, and Whalen (2002) reported that 38(17.4%) of the 219 people interviewed had ever undergone an HIV test of which 36 of them had received their test results. Similarly, in a study conducted in Cape Town, South Africa, Kalichman and Simbayi (2003) reports that 44% of the participants had been tested for HIV of which more than 1 in 3 of those tested were not aware of their test results even though at the time rapid testing with same day results was in place. The picture is not different in Ghana. According to the 2008 GDHS, 70% of women and 75% of men aged 15 – 49 years knew where to locate a testing centre, however, only 16.9% and 12.7% of women and men respectively had ever tested and received the results of the test and 6.8% of women and 4.1% of men had tested and received the results in the last 12 months (GSS et al., 2009). A study to determine HIV testing and University of Ghana http://ugspace.ug.edu.gh 18 counselling use among men in the University of Ghana revealed that only 19% of the respondents had tested for HIV (Fiaveh, Okyerefo, and Fayorsey, 2011). Denison, McCauley, Dunnett-Dagg, Lungu, and Sweat (2009) in their study on HIV testing among youth reported that 28% reported that they plan to test for HIV within the next 12 months and most of the youth answered that they wanted to know their status or to free their mind when they were asked why they wanted to undergo testing and counseling. However, according to Alemayehu (2010), people will not accept HIV testing unless they are planning for marriage or to travel abroad. A study on acceptability and challenges of implementing testing and counseling in rural Zimbabwe revealed that people felt the clinic was an appropriate testing and counseling centre because the clinic is centrally located within the community thereby making it accessible to most community members (Chirawu, Langhaug, Mavhu, Pascoe, Dirawo et al., 2010). A related study by Kassler, Dillon, Haley, Jones, and Goldman (1997) revealed that rapid, on-site HIV testing with same day results and counseling was feasible, preferred by clients and resulted in significant increase in the number of persons learning their HIV status (4% increase for uninfected and 16% increase for infected clients) without decreasing the effectiveness of or increasing the cost of testing and counseling. 2.5 Awareness and Perception of HIV Testing and Counselling The utilization of HIV testing and counselling is partly influenced by one‟s knowledge and perception regarding testing and counselling for HIV. According to Sherr, Lopman, Kakowa, Dube, Chawira, et al. (2007), knowledge positively influences the uptake of University of Ghana http://ugspace.ug.edu.gh 19 HIV testing and counselling services. Though HIV testing and counselling is well established in the health care system, many people have misconceptions and inadequate knowledge regarding the service. According to Illiyasu et al. (2006) more than half (55%) of the respondents knew of a test that identifies individuals with HIV, however, only 26% knew where they could have the test. Lack of information about where to obtain the test and what the results might turn out to be are cited by Deblonde, De Koker, Hamers, Fontaine, Luchters, et al. (2010) as barriers to uptake of HIV testing and counseling services. A Ghanaian study on knowledge, attitudes and practices of voluntary counseling and testing for HIV among university students showed that majority (81%) of the respondents had heard about testing and counseling for HIV (Donkor, 2012). Among those who had heard of about testing and counseling, 48% of them had the information through the mass media, 18% through health personnel, and 11% through their friends/peers. Regarding the importance of testing and counseling, majority (70%) of the respondents indicated that testing and counseling helps one to know one‟s HIV status, 29% mentioned that testing will help individuals who test positive for HIV to seek medical care, 6% indicated it will protect one from HIV infection, and 3% mentioned it help prevent transmission of HIV if one was tested HIV positive (Donkor, 2012). A related study in Tanzanian on evaluation of uptake and attitudes to voluntary counseling and testing among health care professional students reported that the respondents indicated sources of information on testing and counseling to include radio and television, friends, schools, church seminars, and through visiting testing and counseling centers (Charles et al., 2009). University of Ghana http://ugspace.ug.edu.gh 20 Studies have shown that persons willing to test for HIV are more likely to perceive themselves to be at high risk (Fylkesnes and Siziya, 2004; Wolff, Nyanzi, Katongole, Ssesanga, Ruberantwari, et al., 2005). However, HIV awareness does not always translate into perception of individual risk (Burns et al., 2007). A study of knowledge, attitudes and practices of voluntary counseling and testing among rural migrants in Shanghai, China, revealed that out of 2,690 participants, 80% knew HIV infection was diagnosed through a blood test and 46.5% had ever heard of voluntary counseling and testing, however, only 3.5% felt they were likely to be infected with HIV now or in the future (He el al., 2009). A related study by Bwambale et al. (2008) revealed that majority (80.1%) of men is aware about HIV testing and counselling programme in their area. The study also showed that most of them knew of at least a testing centre and felt HIV testing was important, however, only 9.1% of them perceived themselves to be at high risk of HIV. Besides, Fiaveh et al. (2011) indicated that 2 of 5 men did not believe that they were at risk of contracting HIV. According to Kalichman and Simbayi (2003), individuals who had not been tested for HIV and those tested but who did not know their results held significantly more negative testing attitudes than individuals who were tested, particularly people who knew their test results. A study by Lamessa (2005) on utilization of HIV testing and counseling services, perceived barriers and preferences of adolescents in Harar town in Ethiopia revealed that majority of adolescents (92.2%) had heard about HIV testing and counseling, with most frequent source of information being radio/television (59.2%); however, majority of the University of Ghana http://ugspace.ug.edu.gh 21 respondents (83.3%) felt they were at either no risk or low risk of being infected with HIV. Similarly, findings from a study by Nuwaha et al. (2002) indicate that most of the respondents felt they were at no risk or low risk of being infected with HIV. Their intention to test for HIV in the next one year was positively associated with perceived risk of HIV infection. The study also found that only 21.9% of the respondents had ever been tested for HIV. Low risk perception and fear of stigma and discrimination if tested seropositive were found to be common perceived barriers to testing and counseling. A couple of studies have shown that people have positive perception towards testing and counselling as majority of the respondents indicated their readiness to test for HIV (Irungu, Varkey, Cha, and Peterson, 2008; Illiyasu et al., 2006). The majority of the respondents felt HIV testing and counselling was important (Irungu et al, 2008). However, on the issue of discordance of HIV test results among partners, over half of respondents in a study by Bwambale et al., 2008, did not believe that there could be discordant HIV test results. Perceived positive outcomes of testing and counseling are found to encourage people to accept HIV testing. In a study conducted on factors influencing acceptability of voluntary counseling and testing for HIV in Bushenyi District of Uganda, Nuwaha et al., 2002, indicated that respondents in focus group discussions mentioned that positive consequences of testing and counseling would encourage testing. They mentioned that testing will encourage positive living like stopping smoking and drinking, generally caring about one‟s health, planning for one‟s future regarding marriage and having children, planning treatment, and practicing safer sex or abstinence among others if tested University of Ghana http://ugspace.ug.edu.gh 22 negative. In the contrary, some anticipated negative consequences of testing that would discourage HIV testing as mentioned by the respondents included loss of hope leading to destructive behavior; early death through worries, and sometimes suicide; stigma from society and rejection from friends, relatives, and sexual partners. According to Burns et al. (2007) people feel one would face social isolation, and even violence, if their HIV status were disclosed. 2.6 Factors influencing the utilization of HIV Testing and Counselling Services Studies have shown that a variety of factors influence the use of HIV testing and counselling services. These factors include socio-demographic, socio-cultural and health service factors. 2.6.1 Socio-demographic factors A study in Zimbabwe revealed that knowledge and education influence positively HIV testing and counselling use (Sherr et al., 2007). A related study on women reported that people who have obtained more years of education are more likely to use HIV testing and counselling services (de Walque, 2006), because such people may have more understanding of the benefits of such services. Similarly, Gage and Ali, 2005, indicated that secondary or higher education is associated with an increased likelihood of HIV testing. A South African study revealed that individuals who had undergone HIV testing had more years of education than people who had not tested, although the difference between means was less than one year of education. No other significant differences in demographic characteristics were found between people who had tested and people who had not tested (Kalichman and Simbayi, 2003). However, a study on acceptance of University of Ghana http://ugspace.ug.edu.gh 23 testing and counseling and treatment for HIV among pregnant women in Kumasi, Ghana, reports that women with secondary education were 88% less likely to accept HIV testing as compared to those with no/primary education. The study showed that women who have ever tested for HIV were 95% less likely to accept testing (Holmes, Preko, Bolds, Baidoo, and Jolly, 2008.). A number of studies have indicated that age influences the use of testing and counselling services. According to Hutchinson et al., 2006, older men (≥ 30 years) are more likely to use testing and counselling services than younger men. However, a similar study by Fiaveh et al. (2011), reported that younger persons (20-29 years) are more likely to use the service. The study also indicated that level of education, religion, marital status and social status have no significant influence on the use of HIV testing and counselling by men. A cross-sectional survey on factors affecting voluntary HIV counseling and testing among men in Ethiopia revealed that HIV test rates in rural areas were higher among younger men (≤ 47years) and those of higher socio-economic status while Muslim was inversely associated with use of testing and counseling service (Leta et al., 2012). A Ugandan study on HIV testing and counselling also showed that men aged 35 years and below were more likely to use HIV testing and counselling services than older men. The study also revealed that occupation is associated with HIV testing use among men (Bwambale et al., 2008). Similarly, a study conducted in Uganda on factors associated with self-reported HIV testing among men indicated that older men were less likely to test, and if not tested, were less willing to test for HIV (Gage and Ali, 2005). University of Ghana http://ugspace.ug.edu.gh 24 A study on HIV testing among youth in Zambia found age as the only socio-demographic variables that is strongly associated with HIV testing and counseling use with younger respondents less likely to have plans to test than older respondents (Denison et al., 2009). Also, Nyblade, Menken, Wawer, Sewankambo, Serwadda et al. (2001) reported that younger age is associated with lower use of HIV testing and counseling services. Research has shown that gender, working venue, having multiple sexual partners, and knowledge of testing and counseling are independently associated with uptake of testing and counseling (He el al., 2009). According to Stein and Nyamathi (2000), men are more likely to underestimate their risk for HIV infection as compared to women notwithstanding the fact that men report more high-risk sexual behavior. In a study on factors affecting HIV testing and counseling among men, it was revealed that being Muslim is inversely associated with use of testing and counseling service (Leta et al., 2012). 2.6.2 Socio-cultural factors The behaviour and practices of people is largely influenced by the socio-cultural setting they live. Over the years HIV-related stigma and discrimination has been a major obstacle to HIV testing and counselling use, treatment, care and support. Findings from studies have indicated that more than half of HIV positive respondents have experienced stigma (Odindo and Mwanthi, 2008; Li, Wang, Williams and He, 2009). HIV related stigma is found to be associated with delays in testing and treatment throughout the developing world (Ford, Wirawan, Sumantera, Sawitri, and Stahre, 2004; Rankin, University of Ghana http://ugspace.ug.edu.gh 25 Brennan, Schell, Laviwa, and Rankin, 2005. The perception of HIV as predominantly a sexually transmitted disease and a deadly disease is the main cause of fear and stigma which impacts negatively on accessing testing and counseling services. Presenting for an HIV test itself carries an implication of blame that one only undergoes testing if they consider themselves susceptible because of their behavior (Burns et al., 2007). A study in South Africa showed that perceived stigma was the reason for low utilization of HIV testing and counselling services among men and women (Hutchinson and Mahlalela, 2006). Other studies have cited HIV-related stigmas as the most important barrier to seeking HIV testing and counselling (Wolfe, Weiser, Bangsberg, Thior, Makhema, et al., 2006; Babalola, 2007; Bwambale et al., 2008; Khumalo-Sakutukwa, Morin, Fritz, Charlebois, van Rooyen, et al., 2008). Moreover, stigma was reported to be the primary barrier to HIV testing and counselling by men (Wolff et al., 2005; Morin, Khumalo-Sakutukwa, Charlebois, Routh, Fritz, et al. 2006; Sherr et al., 2007; Irungu et al., 2008). An Indian study on HIV testing revealed that 20.2% of the males and 18.1% of the females seeking testing and counseling reported discrimination in more than one area including family relations, work place and treatment availability while 2.3% and 1.0% of the males and females respectively did not perceive any discrimination as a result of their HIV status. Most of the respondents did not answer questions related to that aspect (Madhu, Kamalika, Meenakshi, Sharad, and Vibhuti, 2009). According to Bwambale et al. (2008), men prefer to go to distant clinics for HIV testing for fear of meeting familiar people in HIV testing centres within their locality. A study conducted in the US reported that 38% of a US national sample of adults indicated that they would be very concerned University of Ghana http://ugspace.ug.edu.gh 26 about stigma if they tested positive for HIV, and 44% of these people said that stigma influences their testing decisions (Herek and Capitanio, 1999). In a related study more than one third of all respondents reported that concerns about AIDS stigma would affect their decision to be tested for HIV in the future (Herek, Capitanio and Widaman, 2003). Stigma does not only influence the use of HIV testing and counselling but also the adherence to ART among HIV-infected persons. A study in the United States of America reported that patients with high stigma concerns were more likely not to stick to their treatment regimen (Dlamini, Wantland, Makoae, Chirwa, Kohi, et al., 2009). Ostermann, Reddy, Shorter, Muiruri, Mtalo, et al. (2011), reports that stigma and fears of testing and test disclosure are major barriers to testing and counselling. According to de Wit and Adam (2008), fear of the consequences of testing seropositive (discrimination and rejection) hinders the uptake of HIV testing and counseling service while persons who perceive more benefits from testing appear more likely to test for HIV. Similarly, a qualitative research on perceived barriers to HIV testing among sun-Saharan African migrants in Belgium reports that factors such as fear of positive test results and its associated personal and social consequences, lack of information, and denial of HIV risks are barriers to HIV testing (Manirankunda, Loos, Alou, Colebunders, and Nöstlinger, 2009). However, a Kenyan study reported fear of partner‟s reactions as the most important barrier to utilization of testing and counselling services by women (Maman, Mbwambo, Hogan, Kilonzo, and Sweat, 2001). University of Ghana http://ugspace.ug.edu.gh 27 Grinstead, Gregorich, Choi, Coates; Voluntary HIV-1 Counselling and Testing Efficacy Study Group (2001) explored the social consequences of HIV testing and counseling by examining the incidence of positive and negative life events at the first follow-up (≈7.3 months) after recruitment of respondents. The authors compared the incidence of positive and negative life events between those who were randomly assigned to HIV testing and counseling versus health information (HI); those who tested seronegative and those who tested seropositive; and those who disclosed their serostatus and those who did not. It was revealed that the occurrence of most negative life events was rare (0 - 4%) while positive life events were more common (17- 39%).Those assigned to HIV testing and counseling were no more likely to experience negative life events than those who were assigned to HI. For individuals, positive serostatus was associated with increased support from health professionals, the break-up of a marriage and being neglected or disowned by their family while disclosure was associated with strengthening of a sexual relationship except for HIV-seropositive women. They concluded that these findings, in combination with findings supporting the efficacy and cost-effectiveness of HIV testing and counseling, support the dissemination of testing and counseling with appropriate support services in developing countries A study conducted by Spielberg, Kurth, Gorbach, and Goldbaum (2001), indicated that individuals who do not consider themselves to be at risk or who fear testing positive or the consequence of testing positive are less likely to test for HIV. The study also revealed routine testing to be most important reason indicated by the respondents for testing for HIV followed by having been at risk. Findings from a qualitative research conducted in University of Ghana http://ugspace.ug.edu.gh 28 two cities (Sikasso and Bamako) in Mali, showed that a large number of the respondents did not believe in the existence of HIV. Some people lacked confidence in the competence of the testing personnel and expressed fear of stigma in the community if tested positive for HIV (Castle, 2003). A Ugandan study revealed that planned marriage/new relationship, distrust of sexual partner, and illness/death of a partner are some of the reasons associated with HIV testing (Muller, Barugahare, Schwartlander, Byaruhanga, Kataaha, et al., 1992). A related study found that the most common reason for testing for HIV among the youth of Jijiga town was to know their HIV status (61.6%) while fear to get the results was the most reported reason for not testing for those who had not tested (Zenebu, 2005). According to Downing et al. (2001), peer encouragement and support is an important behavioral factor associated with HIV testing while fear of infection and stigma of HIV or positive diagnosis are important barriers to HIV testing and counseling use. Similar studies have indicated that relational and individual factors are strongly correlated with HIV testing and counseling use. A research on HIV testing among adolescents in Ndola, Zambia, revealed that discussing HIV testing with family members, sex partners or friends is each associated with plans to test for HIV (Denison et al., 2009). In a related study by Nuwaha et al., 2002, about two-thirds of the respondents said their decision to test for HIV is likely to be by themselves. However, some people mentioned that their decision to test is likely to be influenced by social relations and other people such as spouses, sexual partners, prospective marriage partners, relatives, friends, health workers/counselors, University of Ghana http://ugspace.ug.edu.gh 29 religious leaders, political leaders and those that have undergone testing and counseling in the past According to Nuwaha et al., 2002, some reasons mentioned by respondents for undergoing VCT included showing symptoms of AIDS; loss of sexual partner; for marriage; mandatory requirements like joining the army, when one is to get a scholarship, when demanded by a sexual partner, and after undergoing various risk behaviors such as unprotected sex with somebody you do not trust, undergoing blood transfusion, and after being involved in a road traffic accident. 2.6.3 Health-service factors People have cited the issue of cost and transportation as some of the reasons why they have not tested for HIV (Obermeyer and Osborn, 2007). A study in Kigali and Lusaka, has shown that one-quarter of the respondents cited lack of money as a factor that hinder them from accessing testing and counselling services, though at the time of the survey testing in government health facilities was free (Kelley, Karita, Sullivan, Katangulia, Chomba, et al., 2011). Also, lack of access to testing centres and poor quality of testing and counselling services in developing countries act as barriers to HIV testing and counselling (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2001; Bwambale et al., 2008). Another important health service factor that acts as an obstacle to testing and counselling is lack of privacy and confidentiality. A number of studies indicate that confidentiality is often compromised in established practices in health service. In a study on AIDS – related discrimination, 34% of the respondents reported University of Ghana http://ugspace.ug.edu.gh 30 breaches of confidentiality by health care professionals (Paxton, S., Gonzales, G., Uppakaew, K., Abraham K.K., Okta S., et al. 2005). Related studies have shown that perception of how confidentiality is handled during the testing and counselling process influences the willingness of clients to be tested (Bwambale et al., 2008; Fylkesnes and Siziya, 2004; Burns et al., 2007). According to Chirawu et al., 2010, people prefer testing personnel to come from outside their community due to the perception that local clinic staffs do not often respect confidentiality. People however appreciated having access to testing close to home. Both men and young people found the clinic a less acceptable testing and counseling centre as compares to women. A study by van Dyk and van Dyk (2003) cited shortages of counselors, long lines, lack of privacy, no trust in the health care system or fearing a breach of confidentiality, and fear of rejection as factors hindering the use of HIV testing and counseling services. There are also reports of discrimination against HIV patients in health care settings. Studies in India reported health services as the predominant setting in which discrimination occur (Mulye, Raja, Menon, Pereire and Barnes, 2005; Marfatia, Sharma, and Modi, 2007). According to Nuwaha et al. (2002), some barriers to testing and counseling mentioned by respondents in their study on influencing acceptability of voluntary counseling and testing for HIV include long distance to testing centers, high cost of services, poor perceived quality of care, long waiting time before testing, confidentiality and secrecy in handing of the results, and the danger of labeling one HIV positive whereas he/she is not HIV positive. Manirankunda et al. (2009) also reported fear of stigma and negative response from healthcare providers are barriers to HIV testing. University of Ghana http://ugspace.ug.edu.gh 31 Evidence from part of a longitudinal study in rural Malawi where a door-to-door rapid blood testing for HIV was offered to the respondents indicates that the vast majority of those offered the HIV test in their homes agreed to be tested and to receive their results immediately. Respondents found door-to-door HIV testing convenient and confidential, and the rapid blood test, credible. The researchers concluded that cost, accessibility and threats to confidentiality and privacy in local health facilities may be more important barriers to VCT than fear (Angotti et al., 2008). In a study conducted in Cambodia to assess whether a difference exists in provider trust levels, it was revealed through focus group discussions and household surveys that people trusted public providers for their skills and abilities, and for an effective referral system, and believed that public providers were honest, sincere and explained the status of the disease to clients. However, the respondents trusted private providers for being very friendly and approachable, extremely thorough and careful, easy to contact, and gives room for deferment of payment in a situation where a client does not readily have money (Ozawa and Walker, 2011). In a study on the influence of antiretroviral therapy on uptake of HIV testing, Warwick, 2006, reported that high cost of existing retroviral medication is a barrier to HIV testing and counseling utilization. University of Ghana http://ugspace.ug.edu.gh 32 CHAPTER THREE MATERIALS AND METHODS This chapter describes the materials and methods that were employed for this study. According to Burns and Grove, 2001, research methods refer to “the strategy of the study, from identification to final data collection”. A description of the research design, research setting, variables, study population, sampling, and data collection techniques and instrument are given. Training of research assistants, pre-test of questionnaire, quality control, data processing and analysis, and ethical consideration relating to the study are also given. 3.1 Research design A descriptive population-based cross-sectional survey design employing quantitative method for data collection was used for this study. This research design was chosen taking into consideration the limited period of time available for the study. It is a design that can measure multiple variables at a particular short period of time. 3.2 Research Setting The study was conducted in Bolgatanga Municipality. Information on sub-section 4.2.1 through sub-section 4.2.91 was taken from www.ghanadistricts.com and the Composite Budget of the Bolgatanga Municipal Assembly for the 2012 Fiscal year. 3.2.1. Establishment The Bolgatanga Municipal Assembly with its capital- Bolgatanga was established by (LI) 1797 of 2004. Bolgatanga is also the capital town of the Upper East Region. University of Ghana http://ugspace.ug.edu.gh http://www.ghanadistricts.com/ 33 3.2.2 Location & Size The Assembly is located at the center of the Upper East Region (Fig. 2) and is bordered to the north by the Bongo District, to the south and east by Talensi-Nabdam District and to the west by the Kassena-Nankana East District. It occupies a land area of 729sq km with a tropical climate of two distinct seasons, namely wet season (May - October) and a dry season (October – April). 3.2.3 Structure of the Assembly It is divided into three (3) administrative zones which are; Bolgatanga, Zuarugu and Sumbrungu-Sherigu zonal councils. 3.2.4 Communities in this municipality The main communities in addition to Bolgatanga include Tindonsobulugu, Yarigabisi, ZuarunguDachio, Gambibigo-Azuabisi, and Kumbosigo. Others include SheriguDorungu-Agobgabisi, Zaree, and Zonno. No map is readily available indicating these communities. 3.2.5 Demographics The indigenous ethnic group in the Municipality is Grunis with migrant settlers like the Dagombas, Akans, Ewes, Yoruba, and Gas among others. The population of the Municipality was recorded as 131,550(Source: 2010 Population and Housing Census, GSS). 3.2.6 Climate and Vegetation The climate is tropical with a rainy season from May to October and a long dry season with virtually no rainfall from October to April. Mean annual rainfall is 950mm. The most common economic trees are the shea nut, dawadawa, baobab and acacia. University of Ghana http://ugspace.ug.edu.gh 34 3.2.7 Topology & Drainage The municipality has gentle slopes ranging from 1% to 5% with some isolated rock outcrops and some uplands which have slopes over 10%. It falls within the Birimian, Tarkwaian and Voltarian rocks of Ghana. There is ample evidence of the presence of minerals especially gold. 3.2.8 Economy The economy of the Bolgatanga Municipality can be classified into primary, secondary and tertiary sectors. The primary sector activities are predominantly agriculture in nature. The secondary sector is dominated by Small – Scale Industrial Enterprise activities, whilst the tertiary sector has to do with the provision of services. All these sectors contribute towards the Gross Domestic Product and labor employment of the district. 3.2.9 Educational Institutions The Municipality has both public and private educational institutions with a teacher/ pupil ratio in the public school of 1:56 and 1:28 for the private school. 3.2.10 Health Facilities The Bolgatanga Municipality has one (1) Regional Hospital, six (6) Health Centers, seven (7) Clinics, eight (8) CHPS Compounds, one (1) private hospital and one (1) private clinic. The Regional Hospital also serves as a referral hospital for the whole region.The total number of health personnel in the Municipality is inadequate. TheDoctor/Patient ratio is 1:30,534 whilst the Nurse/Patient ratio is 1:734. University of Ghana http://ugspace.ug.edu.gh 35 Figure 2: Map of Upper East Region showing the location of BMA 3.3. Variables for the study 3.3.1 Outcome variable The outcome variable for this survey is HIV testing and counselling service use. HIV testing and counselling service use is referred to the process of having undergone HIV testing and counselling in HIV testing and counselling centre. It will be measured in terms of three elements – testing, post-test counselling, and receiving test results. To be considered having fully used the service one should have passed through the three steps. Data for HIV testing and counseling service use will be dichotomous, Yes (have ever undergone HIV testing and counseling) and No (never underwent HIV testing and University of Ghana http://ugspace.ug.edu.gh 36 counseling). Data on those who have ever used the service will also be dichotomous, Yes (Have tested within the last 12 months) and No (Have not tested within the last 12 months) 3.3.2 Explanatory variables The independent variables for this study were selected based on the conceptual framework and prior empirical studies. They include the following:  Awareness and perception of HIV testing and counselling (awareness of testing and counselling, source of information, awareness of testing centres, benefits of testing, perceived importance of testing, couple testing, discordance of HIV results, HIV risk perception).  Socio-demographic characteristics (age, marital status, type of marriage, religion, education, and employment status).  Socio-cultural reasons/persona beliefs (stigma/discrimination, fear of being tested HIV positive, fear of rejection by sexual partner, disclosure of test results, fear of dying early, fear of falling ill early, fear of loss of job, fear of loss of housing, busy work schedule, socio-cultural beliefs, requirement for employment, marriage/new relationship or blood donation, influence of social relations).  Health service – related reasons (distance to testing centres, waiting time, stigma and negative response by healthcare providers, privacy and confidentiality, cost of service, quality of test results) University of Ghana http://ugspace.ug.edu.gh 37 For awareness and perception of HIV testing and counselling, awareness was dichotomous , i.e., Yes (Have heard about testing and counselling) and No (Have not heard about testing and counselling), source of information was categorized into 1 if “Relatives”, 2 if “Friends”, 3 if “School teacher”, 4 if “Health worker/educator”, 5 if “Radio/ television”, 6 if “Film/video”, 7 if “ News paper/public poster”, 8 if “ Church/mosque”, 9 if “other methods”; awareness of testing and counselling centres is categorized into 1 if “Hospital”, 2 if “Clinic/Health centre”, 3 if „Private laboratory”, 4 if “Don‟t know”; importance of testing is categorized into 1 if “Not important”, 2 if „Somewhat important”, 3 if “Important”, and 4 if “Very important”; benefits of testing is categorized into 1 if “Don‟t know”, 2 if “Will facilitate early treatment/support”, 3 if “Will prevent spread of HIV to partner/partners” 4 if “Will prevent HIV associated illnesses”, 5 if “others”; discordance of HIV results will be dichotomous – Yes (aware of possible discordance of results), No (Not aware of possible discordance of results); couple testing will be categorized into1 if “Not important”, 2 if “Somewhat important”, 3 if “Important‟, 4 if “Very important”; HIV risk perception is categorized into 1 if „Not at risk”, 2 if “Have low risk”, 3 if “Have high risk”. For the socio-demographic reasons, respondent‟s age was measured at last birthday in years. Education was categorized into 1 if “No formal education”, 2 if “Primary education”, 3 if “Middle School/JHS”, 4 if “Technical School/SHS”, 5 if “College/university”; marital status is categorized into 1 if “Never married”, 2 if “Married”, 3 if “Divorced”, 4 if „Widowed/separated”, 5 if “Co-habiting”; religion will be classified into 1 if “Atheist (no religion)”, 2 if “Christianity” , 3 if “Muslim”, 4 if University of Ghana http://ugspace.ug.edu.gh 38 “Traditional” and 5 if other religions. Employment status will be categorized into 1 if “Unemployed”, 2 if „Farmer‟, 3 if “Salary worker”, 4 if “Self-employed”, and 5 if “Student”. The socio-cultural reasons / personal beliefs were categorized into 1 if “It is against my tradition”, 2 if “I‟m not likely to have HIV‟, 3 if „I can‟t be cured if tested positive”, 4 if “Fear of being positive”, 5 if “Fear of stigma /discrimination by friends/relatives”, 6 if “Fear of disclosure of test results‟, 7 if “Fear of rejection by partner”, 8 if “Fear of falling ill early”, 9 if “Fear of dying early”, 10 if “fear of loss of job”, 11 if “fear of loss of housing”, 12 if “HIV is a curse from God”; 13 if “Busy schedule”; 14 if “other”; 15 if “No special reason”. The health service – related reasons were categorized into 1 if “Cost of service is high”, 2 if “Long queues”, 3 if “Fear of stigma/negative response from healthcare providers”, 4 if “Lack of privacy/confidentiality”, 5 if “Fear of false positive results”, and 6 if “Distance to facility is very far”; 7 if “No special reason”. 3.4 Study population The population for this study consisted of men in the Bolgatanga municipality. According to the 2010 Population and Housing Census, the total number of males in the Bolgatanga municipal who are 18 years and older is 33,597(GSS 2012). Therefore the study population consisted of 33,597 men. University of Ghana http://ugspace.ug.edu.gh 39 3.4.1 Eligibility criteria For the purpose of this study one had to be male aged 18 – 59 years and a resident in the area for at least twelve (12) months. 3.5 Sampling 3.5.1 Sample Size Determination A sample size of 610 men from the target population was used for the study. Data from the 2008 GDHS indicates that 12.7% of men in Ghana have undergone HIV testing and counselling (GSS et al., 2009). That for Bolgatanga municipality is unknown. This figure was therefore used to calculate the sample size using the formula n= Z 2 P (1-P)/D 2 which yielded a sample size of 170. Giving the objective and nature of the study (population- based cross-sectional survey), a sample size of 170 will be inadequate. Fifty per cent (50%) was therefore used as the proportion of men in Bolgatanga municipality who have undergone HIV testing in order to get a larger sample size that will be representative of the population. Also, the sample size calculation was based on a desired level of confidence at 95% (standard value of 1.96) and acceptable margin of error at 5% (standard value of 0.05). Hence relying on the formula based on simple random sampling (SRS), n= Z 2 P (1-P)/D 2 , where n = minimum required sample size, Z= α-value at 95% confidence level, P= proportion of men who have undergone HIV testing and counselling (in this case 50%) and D=margin of error at 5%, then n= [(1.96) 2 0.5 × (1 - 0.5]/ (0.05) 2 = 384. Since the sampling was not going to be simple random sampling, the value of n was further University of Ghana http://ugspace.ug.edu.gh 40 multiplied by the design effect of 1.5(i.e. 384 × 1.5 = 576). This sample size was further increased by 5% to account for contingencies such as recording errors and non-response to certain questions (i.e. 0.05 × 576= 28.8) therefore giving a final sample size of 607 (i.e.576 + 29= 607). However, this figure was rounded up to 610. 3.5.2 Sampling technique Multi-stage sampling was used to select the sample for this study. This method was chosen to reduce selection bias and to ensure that the sample actually reflects the true characteristic of the entire population under study. First level: Four (4) principal communities were selected out of the nine (9) principal communities in the municipality. Bolgatanga, which is the capital, formed part of the four principal communities. Simple random sampling without replacement was used to select the additional three (Gambibigo-Azuabisi, SheriguDorungu-Agobgabisi and Yarigabisi) out of the remaining eight (8) principal communities. Second level: Houses were randomly selected within each of the four selected communities. This was done by first of all determining the boundaries of those selected communities. Names of strategic landmarks in the community such as a school, market, church, mosque and community centre were then written down by the researcher and the lottery method used to decide the start point of the sampling process. After determining the start point, the researcher then span a pen and followed the direction of the pen. All the houses along that direction formed part of the sample. Upon reaching the boundary of University of Ghana http://ugspace.ug.edu.gh 41 the community the researcher returned to the start point and repeated the process by spinning the pen and following the direction of the pen. Third level: A household each was further randomly selected from houses with two or more households with eligible participants. This was done by writing the names of the households on pieces of paper which were then folded, mixed together in a container and the researcher picked one folded paper at random. The household contained in the paper formed part of the sample. Fourth level: One respondent each was selected within households with two or more eligible respondents. The names of the eligible respondents were written on pieces of paper, folded, mixed in container and the researcher picked one folded paper at random. The person whose name was picked participated in the study. Some persons declined to participate in the study and were replaced by repeating the process and selecting a different respondent. For those persons whose names were name were picked but were not immediately present, the researcher noted the house on the questionnaire and went back to the household later to interview him. This sampling technique was repeated severally until about 152 men were obtained from each of the four communities to form the total sample size of 610 men. University of Ghana http://ugspace.ug.edu.gh 42 3.6 Data collection techniques Data for the study was solely primary data and was collected through structured interviews. The interviews were mainly conducted in the local dialect (Gurune) which is largely spoken in the area to ensure that the respondents understand the questions very well and to ensure adequate responses. A total of five (5) motivated interviewers who had ever participated in a similar exercise in the district were recruited and trained well to assist the researcher in collecting the data. Criteria for selection of the interviewers included the ability to understand and speak the local dialect of the study setting fluently as well as read and write in English language. The interviewer should hail from the area or should have stayed in the area for a period of six months or more and be conversant with the local traditional practices. 3.7 Data collection instrument A structured questionnaire constructed by the researcher was used for data collection. The questionnaire was developed after the review of literature and questionnaires used for similar studies, and it was developed in a manner that would solicit appropriate information that would address the objectives of the study. The questionnaire consisted mainly of closed-ended questions which were formulated in simple words and a couple of open – ended questions on the testing process that respondents who have ever been tested for HIV went through. The questionnaire was divided into four sections. Section 1 contained items on socio-demographic data of the respondent including age, marital status, educational level, religion and occupation. These were included to obtain a general University of Ghana http://ugspace.ug.edu.gh 43 view of the social-demographic characteristics of the respondents.Section 2 contained items on awareness and perception of HIV testing and counselling, section 3 contained items on HIV testing and counselling history while section 4 contained items on reasons for use or non-use of HIV testing and counseling services comprising socio-cultural and health service – related reasons. The questionnaire was translated into vernacular during the training of the interviewers before it was used for the study. 3.8 Training of Interviewers Five motivated interviewers with nursing background and who have experience in conducting interviews from similar exercises were recruited and a training session organized for them to enhance their interviewing skills. Importance was attached to the training. The training covered an overview of the study including the purpose and the methodology of the study especially sampling and data collection techniques. It also covered community entry, ethics in research, interviewing and listening skills, and privacy and confidentiality. The questionnaire was well explained to them and translated into vernacular (Gurune). Emphasis was placed on the completeness of questionnaire as well as ensuring accuracy and consistency of responses from respondents. 3.9 Pretest of Questionnaire The questionnaire was pretested in Nima in the Greater Accra Region, which does not form part of the study area but has similar characteristics as those of the study area. It was pretested on 20 selected respondents. This was done to determine the appropriateness of the questionnaire to enable corrections and modifications to be made on questions that University of Ghana http://ugspace.ug.edu.gh 44 may not be well understood by the respondents before the questionnaire was used for the study proper. 3.10 Actual Data Collection Data was collected from 4 th – 17 th June, 2013.The researcher and the interviewers visited the selected households and conduced face-to-face interviews. This study was undertaken after obtaining permission from the various community and household heads. A copy of the introductory letter was shown to them. Written informed consent was obtained from participants after explaining the purpose of the study to them before they were interviewed by the researcher or research assistants. Participants were interviewed in private, away from family members and friends in Gurune or any other language spoken by both the interviewer and respondent. The questionnaires were completed by the interviewers in English. The interview solicited information regarding the participant‟s socio-demographic characteristics such as age, level of education, religious affiliation, and marital status; awareness and perception of HIV testing and counselling; HIV testing and counselling history; and reasons for seeking or avoiding HIV testing. A few of the respondents who postponed the interview or were not present but formed part of the sample were followed up later and interviewed at their own convenient time. This was made possible by noting the physical address description of such respondents on the questionnaires.An interview per respondent lasted for about 25 minutes, not including the informed consent process. University of Ghana http://ugspace.ug.edu.gh 45 3.11 Quality Control To ensure quality control of the data, interviewers were recruited and trained to enhance their data collection skills. Furthermore, the questionnaire was reviewed by my supervisor and the necessary corrections made after which it was pretested to determine its appropriateness. Questions that were found to be ambiguous during the pre-test were modified for clarity before the questionnaire was used for the actual study. Also, the researcher directly supervised the collection of data and reviewed daily completed questionnaires. 3.12 Data Processing and Analysis One major outcome variable was examined in the analysis of this study; that is, HIV testing and counselling service use by men. HIV testing and counselling service use is defined as the process of having undergone HIV testing and counselling in HIV testing and counselling centre. Data was processed and analyzed using SPSS 16.0 version. After the data collection two trained data entry clerks separately entered the survey data into SPSS16.0 version. The two files were then merged and compared for any data entry discrepancies. Frequencies and cross tabulations were performed to identify missing values and errors resulting from the data entry. All data errors were verified and corrected by checking the original questionnaires, which all had identity numbers, before the data was analyzed. All completed questionnaires were included in the analysis. An appropriate measure of centrality was computed (median age).Associations between the outcome variable and each of the explanatory variables were assessed using Chi squares test at University of Ghana http://ugspace.ug.edu.gh 46 95% confidence interval. A p-value of 0.05 or less was taken to be statistically significant. Socio-demographic data is presented in the form of frequencies and others are cross- tabulated with other key variables to better understand the associations for HIV testing and counseling use. Data on factors associated with HIV testing and counselling use is presented in the form of tables, and narrative report with the use of proportions and percentages. 3.13 Limitations of the Study Several limitations of the research design and methodology should be taken into consideration when interpreting these findings. Perhaps the most important limitation follows from the self-reported nature of the data. The study is community-based and solely relied on self-report by the respondents. This may have led to reporting bias because of the possibility of reporting behaviors that are socially desirable. In addition, recall bias may have occurred especially with regard to HIV testing history. Secondly, household size may theoretically have biased the sampling strategy towards younger men because most households usually have more young men than elderly men. Another limitation is the fact that the study did not involve the providers of the service. Obtaining a complete picture of the HIV testing and counseling utilization would require involving the providers of the service in the study to know from their perspective the factors that influence testing and counseling use and the challenges they are facing as providers of the service. University of Ghana http://ugspace.ug.edu.gh 47 3.14 Ethical Consideration The participants of this study included adult males aged 18 – 59 years. a) Approval for study Approval for the study (Appendix 3) was sought from the Ethical Review Committee of Ghana Health Service, Research and Development Division, Accra. Approval was also obtained from the Bolgatanga Municipal Assembly. Protocol was observed during entry to the communities by seeking permission from the community heads and then the household heads before the commencement of the study. An introductory letter (Appendix 4) from Population, Family and Reproductive Health Department of the School of Public Health, University of Ghana, was shown to them for confirmation. b) Voluntariness/consent The purpose of the study was explained to the respondents and a written consent obtained. They were informed that participation in the study was completely voluntary. Moreover, they were told that if they agreed to participate in the study, they may end their participation at any stage of the study or skip any questions without penalty or loss to existing benefits to which they are entitled as citizens. c) Potential risks The study had no physical risks; however, the respondents were told that a few questions may be upsetting or emotionally sensitive. Another risk may be a breach of confidentiality, something the researcher took strict precautions to guard against. University of Ghana http://ugspace.ug.edu.gh 48 d) Potential benefits/compensation The respondents were told there was no direct benefits to them except the satisfaction they would drive for participating in an important study that could help formulate health policies. Also, they were told there was no compensation for participating in the study. e) Privacy/confidentiality The interviews were conducted away from people including friends and relatives to ensure privacy and confidentiality. No personal identifiers such as names and telephone numbers of respondents were collected. f) Data storage/security and usage Data obtained from the study was stored in a password-protected computer and access was limited to only the researcher and the supervisor of the study. The results of the study will be used to design programmes regarding HIV testing and counselling as a strategy for preventing the spread of HIV. The results will also be presented at conferences and published in journals. g) Funding for study The study was self-sponsored to the tune of about GhC 3, 216.40. h) Conflict of interest The researcher had no conflict of interest in the study apart from the academic and public health relevance of the study. i) Contact persons The respondents were given functional contact numbers of the researcher and the administrator of the Ethical Review Committee of Ghana Health Service in case they wanted to enquire more information about the study (Appendix 2). University of Ghana http://ugspace.ug.edu.gh 49 CHAPTER FOUR RESULTS 4.1 Introduction In this chapter the results of the study are described and the analyses of the data are presented. The results describe information on the socio-demographic characteristics of respondents, awareness and perception of HIV testing and counseling by men, proportion of men who have used HIV testing and counseling service, the reasons for use or non-use of HIV testing and counseling services and the association between socio-demographic characteristics and testing. 4.2 Socio-Demographic Characteristics of Respondents This section presents the descriptive statistics of individual background characteristics of respondents. The background characteristics described below include the age, educational level, religion, marital status, and employment status of the respondents. Table 1 below indicates that a total of 610 men participated in the study. The mean age of the respondents was 31.6 years with a median age of 29.0 years. Almost half of the respondents 258 (42.3%) ranged between the ages of 18 and 27 followed by 199 (32.6%) of the respondents in the range of 28 and 37