RG644. A25 H68 bite C.l G370425 University of Ghana http://ugspace.ug.edu.gh THE SPREAD OF HIV/AIDS IN SEKONDI-TAKORADI GIDEON SELORM HOSU-PORBLEY THESIS SUBMITTED TO THE DEPARTMENT OF GEOGRAPHY AND RESOURCE DEVELOPMENT, UNIVERSITY OF GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF THE MASTER OF PHILOSOPHY [M.PHIL] DEGREE. DEPARTMENT OF GEOGRAPHY AND RESOURCE DEVELOPMENT UNIVERSITY OF GHANA LEGON-ACCRA AUGUST 2002 University of Ghana http://ugspace.ug.edu.gh DEDICATION I gratefully dedicate this work to the Almighty God, my family, my deceased sister and friend (Juliet Enyonam Ama Hosu-Porbley) and all loved ones. University of Ghana http://ugspace.ug.edu.gh DECLARATION I declare that I single handedly undertook this study and all information in this document are results of my own studies under supervision. All secondary works used have been duly acknowledged. I am however solely liable for any criticism and correction to be made to this work University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I thank the Almighty God for His loving-kindness extended to me throughout my efforts towards this work. Indeed He guides me with His eyes and truly upholds me with His precious right hand. Glory and honour be unto Him forever and ever more. I owe a multitude, a great deal of appreciation. I take my hat for all and sundry who helped in one way or the other to bring this work to a successful completion. I wish to express my sincere gratitude to my supervisors, Dr. Samuel Agyei-Mensah and Mr. S.K. Kufogbe for their efforts at getting this work done well. I also wish to sincerely say thank you to Mr. Charles Afare, Regional Director of NFED Western Region and his team for their enormous contribution during data collection for this for this study. In the same way my appreciation goes to Dr. Sowah [Senior Medical Officer and the Head of HIV/STI] and the staff of HIV/STI unit of the Effia Nkwanta Regional Hospital, Takoradi who contributed to this study. To the Director and all staff of the Disease control unit, Takoradi, I say thank you. To my family, my parents [Stephen and Fidelia Hosu- Porbley], Uncles and Aunts, God richly bless you for your invaluable contributions and support towards my studies and the production of this work. Mawuena [Frankie] Ian and Evans, I earnestly salute your love and support. I also recognize the enormous efforts and love of my sisters [Esime, Emefa, Sitsofe, Dzigbordi and Mawufemor], may God bless you. I wish to specially recognize the concern and inspiration from my grandfather [Mr. G. Hosu-Porbley, Former Chairman for Public Services Commission]. I also want to appreciate the efforts of all friends especially Linda Opoku and the Baye family. The Amen Dzomeku family and other loved ones, may God bless you for your encouragement, support and prayers. Francis Gbedemah and Augustina, I say thank you. Mr. Felix Asante and Patrick Kley, thank you for the roles you played. I wish I could really mention all, but I do believe that God who knows all will reward the rest of you accordingly. Thank you all. University of Ghana http://ugspace.ug.edu.gh iv TABLE OF CONTENTS DEDICATION.......................................................................... » DECLARATION...................................................................... u ACKNOWLEDGEMENT....................................................... iii TABLE OF CONTENTS.......................................................... iv ABSTRACT.............................................................................. v CHAPTER ONE 1.0 TH E PROBLEM AND RESEARCH METHODOLOGY- - 1 1.1 Introduction - - - 1 1.2 Problem Statement - - - 16 1.3 Objectives - - - 18 1.4 Research Propositions - - - 18 1.5 Methodology - - - 19 1.5.1 Sources of Data - - - 19 1.5.2 Levels of the study - - - 20 1.5.3 Research instruments - - - 20 1.5.4 Sampling Design - - - 21 1.5.5 Methods of data analysis - - - 23 1.5.6 Problems of the study - - - 23 CHAPTER TWO 2.0 LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK 25 2.1 General factors in the spread of HIV - - 25 2.1.1 Sexual behaviour and practices as factors influencing the spread of HI V 25 2.1.2 Mobility, Prostitution and livelihood - - 27 2.1.3 Poverty and Lower socio-economic status - - 31 University of Ghana http://ugspace.ug.edu.gh V2.1.4 Socio-cultural issues and gender inequality - - 32 2.1.5 Influence of Sexually Transmitted Diseases on HIV/AIDS * 35 2.1.6 Stigma on the disease - - - 36 2.1.7 Polygamy - - - 38 2.1.8 Knowledge of the disease. - - - 39 2.1.9 Influence of Multiple co-factors - - - 39 2.1.10 The influence of Wars and Conflicts - - - 41 2.2 Conceptual Model - - - 42 CHAPTER THREE 3.0 THE STUDY AREA - - - 47 3.1 Location - - - 48 3.2 Physical Characteristics - - - 51 3.3 Population - - - 51 3.4 Settlements, Housing and Spatial development patterns - - 52 3.5 Education - - - - 55 3.6 Economic Activities - - - 57 3.7 Recreation, Culture and Social Activities - - 58 3.8 Health - - 59 3.8.1 History of the development of STDs in Sekondi-Takoradi - 63 CHAPTER FOUR 4.0 PATTERNS AND TRENDS OF HIV/AIDS IN SEKONDI -TAKORADI 65 4.1 Prevalence rates of HIV/AIDS in Sekondi-Takoradi from 1992-2000 - 66 4.2 Age distribution - - - 68 4.3 Sex distribution of HIV/AIDS patients interviewed - - 70 4.4 Marital status - - - 7 1 University of Ghana http://ugspace.ug.edu.gh vi 4.5 Occupational differentials ■ - - 74 4.6 Levels of education of patients - - 75 4.7 Places of residence of patients - - - 77 4.8 Ethnic Differentials ■ - - 79 4.9 Religious affiliations - - - 80 4.10 Symptoms and opportunistic diseases - - - 81 CHAPTER FIVE 5.0 ANALYSIS OF THE FACILITATING FACTORS IN THE SPREAD OF HIV/AIDS IN SEKONDI-TAKORADI - - - 82 5.1 Mamage and infidelity - - - 82 5.2 The use of condom - - - 83 5.3 The culture of ‘ divorce and re-marriage’ - - - 84 5.4 Sexual Behaviour - - - 85 5.5 Polygamy - - - 86 5.6 Mobility - - - 88 5.7 Inadequate knowledge of the disease - - - 90 5.8 Socio-economic status - - - 92 5.9 Mother to child transmission - - - 93 5.10 Occupational hazard - - - 94 5.11 Narratives of some people living with the HIV/AIDS - - 94 5.11.1 Case one - - - 95 5.11.2 Case two - - - 95 5.11.3 Case three - . _ 96 CHAPTER SIX 6.0 ANALYSIS OF THE RISK ELEMENTS - 97 University of Ghana http://ugspace.ug.edu.gh 6.1 Background of community respondents - - - 97 6 .1.1 Age distribution of respondents - - - 97 6.1.2 Sex composition of respondents - - - 99 6.1.3 Occupation of respondents - - - 99 6.1.4 Marital status of respondents - - - 101 6.1.5 Education levels - - - - 102 6.1.6 Religious background of respondents - - - 103 6.2 Mobility - - - - - 103 6.3 Sexual behaviour and practices - - - 105 6.4 Condom usage among community respondents - - 107 6.5 Knowledge of HI V/AIDS - - - - 111 6.5 Stigma on the disease - - - - 114 6.7 Health seeking habit - - - - 116 6.8 Socio-economic hardships - - - - 117 CHAPTER SEVEN 7.0 IMPLICATIONS AND CONTROL MEASURES OF THE DISEASE IN THE METROPOLIS - - - 119 7.1 The implication of the disease in the metropolis- - - 119 7.2 Controlling the spread of HIV/AIDS in Sekondi-Takoradi - - 121 CHAPTER EIGHT 8.0 SUMMARY, CONCLUSION AND RECOMMENDATION 124 8.1 Summary . . . . . 124 8.2 Conclusion - - - - - 127 8.3 Recommendations - - - - - 128 University of Ghana http://ugspace.ug.edu.gh viii LIST OF FIGURES 1-1 HIV/AIDS estimates global and sub Saharan Africa - - 11 2-1 A framework showing component of facilitating factors in the spread offflV/AIDS - - - - 46 3-1 Map of the study area. - - - - SO 4-1 Reported cumulative AIDS cases by region-march 1986 to December 2000 68 4-2 Age distribution of patients - - - - 69 4-3 Sex differentials of HIV/AIDS cases in Sekondi-Takoradi - - 71 4-4 Marital status of patients - - - - 72 4-5 Marital status of reviewed cases, 1996-June 2000 - - 73 4-6 Level of education of HI V/AIDS patients - - - 76 4-7 Ethnic origins - - - - 80 4-8 Religious affiliation of patients - - - 81 5-1 Condom usage among patients - - - 84 5-2 Extra-marital relations - - - 86 5-3 Number of partners - - - - 87 5-4 Knowledge of disease - - - - 91 6-1 Age distributions of community respondents - - 98 6-2 Pie graph showing sex composition of community respondents - 99 LIST OF TABLES 1.1 Regional HIV/AIDS statistics and features, December 1998 - - 10 1.2 HIV prevalence in pregnant women in Ghana, 1992-1999 - - 14 3.1 Shama Ahanta East Metropolitan Assembly’s (SAEMA) landuse - 53 3.2 Number of schools and management units in Sekondi-Takoradi - 55 3.3 Top Ten causes of OPD attendance: Effia-Nkwanta regional hospital - 60 3.3b Top ten admission cases 1997-1999: Effia-Nkwanta regional Hospital - 61 3.4 Diseases treated at the general government hospital in 1947 - 62 University of Ghana http://ugspace.ug.edu.gh ix 4.1 HIV prevalence in pregnant women in Sekondi-Takoradi 67 4.2 ShamaAhanta East Metro (Sekondi-Takoradi) HIV test: 1992-1999 68 4.3 Age distribution of HIV AIDS patients interviewed - 69 4.4 Sex distribution of HIV/AIDS patients interviewed - 70 4.5 Marital status of HIV/AIDS patients interviewed in 2001 - - 72 4.6 Occupation of the forty-one HIV/AIDS patients - - 75 4.7 Residential areas of people living with the disease in Sekondi-Takoradi 78 5.1 Travel history of respondents - - 88 5.2 Travel destination of patients 89 5.3 Responses on the reality of HIV/AIDS by patients 90 6.1a Age distribution of community respondents - - 98 6.1b Occupation of community respondents - 100 6.2 Levels of education among community respondents - 102 6.3 External mobility among respondents 104 6.4 Condom usage among respondents 108 6.5 Regularity of condom usage - - 108 6.6 Females’ appreciation of condom use 119 6.7 Cross-tabulation of condom usage by class 110 6.8 Is HTV/AIDS sexually transmitted? - 112 6.9 Knowledge of symptoms 113 6.91 Can HTV/AIDS be cured - - 114 6.10 Health care preference 116 6.11 Engaging other partners apart from wife/husband/regular partner 118 8.1 Summary of facilitating factors 124 8.2 Risk element/factors at the community level 126 9.0 REFERENCES- - - - - 132 APPENDIX I (Interview guide for HIV/AIDS patients) APPENDIX II (Questionnaire for community respondents) 137 140 University of Ghana http://ugspace.ug.edu.gh XABSTRACT Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic has killed over 14 million people worldwide. Over 36.1 million people are also living with the disease the world over. Sub Saharan Africa has been the hardest hit region in the whole world, with high incidence on women and children. The disease has affected every nation in the world such that, it has drawn international attention. As a result, ideas are being sought and measures being planned to curb its spread. The disease is seen as wiping the gains of development and halting the future development of individuals and nations as a whole. In Ghana, over 430 000 people are living with HIV/AIDS. It has claimed over thousands of lives since its recognition in 1986. Efforts are therefore being made to reduce the spread of the disease in order to reduce its impact. It is in this vein that this study was conducted to find out dimensions of the disease in Sekondi-Takoradi, a vibrant port city in the Western region of Ghana. This study has found that the disease is spreading increasingly among young married couples, followed by divorcees and those who have re-married, and singles with sexual partners. The disease has higher incidence on women and people of lower socio-economic status. The research has also found that the disease is driven in Sekondi-Takoradi by infidelity in marriage, sexual behaviour in terms of pre-marital relations and extra-marital relations as well as multiple sexual partnerships. Also low level and inappropriate application of condom, inadequate knowledge of the disease, stigma, lower socio­ economic status, and mobility both internal and external were found as driving the spread of the disease in the metropolis. These findings would help to initiate appropriate measures like community education to fight the spread of the disease. University of Ghana http://ugspace.ug.edu.gh 1CHAPTER ONE 1.0 THE PROBLEM AND RESEARCH METHODOLOGY This very first chapter comprises of an introduction to HIV/AIDS, problem statement, objectives, research propositions, methodology and sources of data, research instruments sampling design and methods of data analysis. 1.1 Introduction HTV and AIDS, (a pandemic in the world, ‘the dreadful killer’, ‘and the hidden epidemic’) are the acronyms, which stand for Human Immuno-deficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) respectively. AIDS is the end stage manifestation of the disease caused by HIV*. HIV destroys the biological ability of the human body to fight off opportunistic infections such as tuberculosis. AIDS is defined in terms of how much deterioration of the immune system has taken place as seen by the presence of opportunistic infections (MOH, 1999). AIDS is not inherited but acquired. All infected persons virtually die from the AIDS disease. AIDS was initially recognised as a disease in 1981 by the Centre for Disease Control (CDC) in the United States, but might have started in the late 70s in some areas as recorded by UNAIDS (1999). The disease has a controversy over its origin, but it is most often believed to have an African origin, with its hardest hit countries in sub Saharan Africa, hence Africa is referred to as the global epicentre by UNAIDS (1999). * There is a debate on this. Thabo Mbeki (President of South Africa) claims HIV is not the cause o f AIDS. University of Ghana http://ugspace.ug.edu.gh 2HIV infection is first and foremost a biomedical condition. HIV is a family of retroviruses that enters the bloodstream and attacks the body’s immune system, compromising its ability to fight infections. Although one HIV is spoken about, two basic strains of HIV have been discovered, each with its associated subtypes. HIV-1, with its nine subtypes is the most common virus strain and is found principally in the First World, Asia, Latin America, and in most African countries. HIV-2 is geographically linked to West Africa, although HIV-2 cases have been reported in Mozambique, suggesting that it is now spreading to other regions. HIV-1 is a more virulent strain than its counterpart and has a shorter incubation period. A cause for concern amongst virologists is that both virus strains mutate and it is possible for one type to transform itself into another within the infected person. Thus, to date, attempts to find a vaccine or a cure have eluded the scientific community. There is also the Simian Immunodeficiency Virus (SIV), which is antigenically related and found in primates in Africa. When HIV enters the body, it attaches itself to the wall of the CD4 cell. This cell is a white blood cell, or lymphocyte, belonging to a class of lymphocytes called T cells. T cells are a critical part of the body’s immune system for they organize the overall immune response to a variety of infectious diseases. Having attached itself to the CD4 cell, the virus enters the cell and, through a process that is not entirely understood, kills the cell. This results in fewer CD4 cells to organize the immune response, further resulting in increased vulnerability to infections. As the immune system weakens, a clinical point is reached where the condition is diagnosed as AIDS. From that point forward, numerous opportunistic infections can invade the body with little resistance, ultimately resulting in death. The HIV infections to AIDS could be in stages. Once infected with HIV, a person is labeled ‘HIV positive’ and carries the virus for the rest of his or University of Ghana http://ugspace.ug.edu.gh 3her life. At the point of infection, a battle begins between the virus and the body’s immune system. This battle proceeds through various stages before the person dies. Four stages have been identified (Addler, 2000). The first stage is known as ‘primary (or acute) HIV infection’ and lasts until the body’s initial immune response develops a small measure of control over the virus. This stage lasts for up to three weeks during which time up to 90 percent of people will develop non-specific symptoms common to many viral infections. These can include amongst others, night-sweats, fever, malaise, headaches, and enlarged lymph glands. According to Addler (2000), recent studies suggest that ‘infectivity can vary dramatically according to the stage of HTV’. ‘Two peaks of infectivity have been linked to the periods of highest viral load. The first and highest is during the first few months of infection (before the body develops sufficient antibodies to the virus), and the second peak (although not as high as the first) is at the end of the third stage, as the person progresses to AIDS. The initial peak during early infection, coupled with the type of virus strain (HIV-1 is more easily transmitted than HIV-2), is considered to be one reason why many Third World countries have experienced such a rapid spread of HIV’. The second stage is called ‘seroconversion’ - a period during which the body develops antibodies to ward off HIV. Even though HIV ultimately wins the battle, the body’s immune system is able to keep the virus in check for a number of years. Acute infection precedes this stage because the body takes a while to detect foreign substances before it develops antibodies to fight them. The seroconversion stage lasts from six to twelve weeks during which time antibodies are not detectable and a blood test during this time will return a negative result. This period is often referred to as the ‘window period’, a dangerous time during which a person can inadvertently infect others. However, once antibodies are detected, the blood test result is positive and University of Ghana http://ugspace.ug.edu.gh 4seroconversion is said to have taken place. While the antibodies reduce the concentration of HIV, they do not eliminate it entirely and the person remains infected and capable of transmitting the virus for life. Subsequent to seroconversion, an HIV positive person enters a third stage called ‘asymptomatic stage’ during which time he or she will generally remain clinically healthy. This stage occupies about 80 percent of the time from infection to death. The asymptomatic stage is a marker of the 'silent epidemic’ where the virus slowly but surely spreads throughout the body. Although not perfect, a useful method of tracking the spread of HIV in the body is to count the CD4 cells in the blood. A healthy, HIV negative person has a CD4 count of between 700 and 1,300 per millilitre of blood. As the virus spreads and CD4 cells are destroyed, the loss of these cells reaches a point where the CD4 count drops to between 200 and 300 and the body begins to battle to fight infections. This marks the final leg of the asymptomatic stage. Thrush, shingles and tuberculosis, coupled with weight loss, diarrhoea, fever and fatigue are all common symptoms of the late asymptomatic stage, and act as a marker for the onset of AIDS. While these associated infections are common in HIV negative persons, the critical difference is that those who are HIV positive experience these complaints as chronic infections, and they can persist for several weeks or months. In most Third World countries, people live with HIV infection throughout the asymptomatic stage without knowing it. If a diagnosis is made, it is invariably at the late stage when the person goes to a clinic or hospital. Undiagnosed HIV infection increases the susceptibility of a society to the epidemic. When the CD4 blood count drops below 200, a person becomes vulnerable to serious opportunistic infections such as drug resistant pneumonia, Karposi’s Sarcoma (KS), tuberculosis, meningitis, and other bacterial infections. It is at this University of Ghana http://ugspace.ug.edu.gh 5stage that the person moves from being merely HIV positive to having full-blown AIDS; marking the beginning of the final stage. It is during this stage that medical costs escalate and jobs are lost, placing enormous strain on the finances of the individual and the state. The vulnerability of an individual or a country to the impact of the epidemic is dependent upon income levels and the ease of access to medications, health and social services. Where the HIV epidemic is low and health and social services are accessible, such as in First World countries, the burden on the individual might still be relatively high, but it will not seriously be on the country. In Third World countries, the impact of the epidemic, both on the individual and on the country is most keenly felt at this final stage of infection due to insufficient resources to provide for the care of the infected individual. Addler (2000) is however of the view that, “Although, technically, AIDS is not strictly a disease, it is often referred to as such. Rather, AIDS is a catchall for the many medical conditions that arise from a weakened immune system that can no longer fight infections. A person, therefore, does not die o f AIDS, but rather succumbs to an infection, or collection o f infections Studies (Bosenge and Ryder 1988, UNAIDS, 1999; MOH-Ghana, 1996, 1999; Allen et al, 1991; Sanders and Sambo, 1991) have consistently shown that the virus is transmitted mainly by three modes: through sexual intercourse, blood-to-blood contact, and mother-to-child transmission. The way in which HIV is transmitted is closely associated with the biomedical nature of the virus. In order for a person to become infected with HIV, it is necessary for the virus to enter the bloodstream. The greatest concentration of the virus is found in the blood, and sexual secretions, including semen of infected persons. According to UNAIDS (1999), sexual intercourse is the principal mode of transmission, accounting for an estimated 75 percent of infections globally, of which 75 percent involve heterosexual intercourse and 25 percent sexual University of Ghana http://ugspace.ug.edu.gh 6relations between men and the other modes of transmission. In Third World countries, sexual transmission accounts for even higher proportions of infections. In Africa, Asia, and the Caribbean, infections are overwhelmingly heterosexual, with an estimated less than one percent through homosexual sex. The story is different in Latin America and Eastern Europe, where homosexual sex still accounts for the majority of infections through sex (UNAIDS, 1999). This pattern appears to be changing as more women are becoming infected, suggesting that HTV is spreading to the general population through heterosexual intercourse as a proximate with its background issues. Blood-to-blood transmission occurs when HIV-contaminated blood comes into direct contact with that of an uninfected person. The main transmissions occur through the sharing of intravenous drug-injecting equipment and through contaminated blood products used in transfusions. HIV transmission through blood transfusion services have all but been eliminated in First World countries (Addler 2000), where sophisticated screening mechanisms have been introduced to ensure that blood products are HIV-free. However in the Third World, numerous countries have yet to implement such mechanisms leaving the risk of transmission through contaminated blood an issue to contend with. In spite of the risks, HIV transmissions through transfusions have never exceeded 10% of total HIV infections, even in Third World countries. More serious than transmission through blood transfusions, is the sharing of contaminated needles among injecting drug users. In some countries, drug injecting accounts for more cases of HIV infection than sex. Malaysia, Vietnam, Southwest China, Northeast India and Myanmar, all report that three quarters of recorded cases are due to injecting drug use. In Eastern Europe, the problem is even more troubling. For example, in Belarus, some 87 percent of infections are among injecting drug users. The principal problem with injecting drug use is that, the sharing of University of Ghana http://ugspace.ug.edu.gh 7infected needles is able to introduce HIV directly into the bloodstream of an uninfected person, a highly efficient means of transmitting HIV. As a result, HIV has grown more rapidly in drug- injecting populations. Mother-to-child transmission of HIV, the third recognized mode, occurs in either two ways. The first is at birth when the infant comes into contact with the blood of an infected mother in the uterus. The second is through infant breastfeeding. It is estimated that about 50 to 65 percent of infections occur at birth. Since mother-to-child transmission is a result of the heterosexual epidemic, infants in the Third World are at greatest risk, particularly in sub-Saharan Africa. Globally, mother-to-child transmission accounts for about 5 to 10 percent of infections, and possibly 15 to 20 percent in Africa. Those infants that escape infection at birth, nevertheless, run the risk of infection through breastfeeding (UNAIDS, 1999). Generally, after infection, an average of 8 to 9 years may pass before AIDS fully develops, but this incubation period varies; in children it lasts for a maximum of 2 years. According to Mann et. al. (1988), the interval between diagnoses of AIDS to death varies greatly in between the developed and the developing countries. Survival periods in Africa and other developing regions seem to be shorter than the developed world. This may be attributed to early diagnosis and medical facilities availability and it may also be due also the type of virus at work. HTV/AIDS has different dimensions ranging from global, regional to specific areas or countries. On the global scale and according to UNAIDS (1999), the total number of people living with HIV/AIDS was over 33.4 million, including 32.2 million adults of which 13.8 million were women and 1.2 million, children under 15 years. The statistics also shows that since the beginning of the epidemic, to 1998, a total number of 13.9 million people have died of AIDS, out University of Ghana http://ugspace.ug.edu.gh 8of which 10.7 million were adults, and 4.7 million were women and 3.2 million were children under 15 years. Since the beginning of the epidemic two decades ago, AIDS deaths in 1998 alone amounted to 2.5 million of the cumulative 13.9 million death cases. This indicates that the disease is increasing at a very fast rate the world over. Out of the over 33.4 million cases of HIV/AIDS reported in the world as of end 1998, people newly infected in 1998 totalled 5.8 million revealing 10% more than previous years. Virtually every country in the world had seen new infections in 1998 and the epidemic is frankly out of control in many places. The UNAIDS (1999) record, also shows that more than 95% of all HIV infected people now live in the developing world, which has likewise experienced 95% of all deaths to date from AIDS, and largely among young adults who would normally be in their peak productive and reproductive years. The repercussions of these deaths due to AIDS are so great, ranging from falling child survival rates, crumbling life expectancy, overburdened health care systems, increasing orphanhood and likely deteriorating businesses. The disease revealed men bias trend, but women have now closed up the gap forming 43% of the figure as at the end of 1998. According to UNAIDS (2000), in most badly affected countries, women outnumber the men. In sub Saharan Africa, 55% of HIV-positive adults are women (UNAIDS 2000). As at the end of 1998, a total of over 47 million people (both the living and the dead) had been infected with HIV since its beginning. The disease has claimed the lives of nearly 14 million adults and children out of which 2.5 million deaths occurred only in 1998, more than ever before in a single successive year. HIV/AIDS on regional levels showed interesting features since its discovery up to the year 1998. In sub-Saharan Africa, the disease, which started between the late 70s and the early 80s, had 22.5 million adults and children living with HIV/AIDS. In 1998 only, 4.0 million University of Ghana http://ugspace.ug.edu.gh 9newly infected HIV cases were recorded from adults and children, with an adult (15-49 years of age) prevalence rate, of 8.0% using 1997 UN population numbers. The region also recorded 50% of HIV positive adults being women. Sub-Saharan Africa tops every aspect of HIV/AIDS among the ten (10) regions delineated by UNAIDS, as shown in Table 1.1 (Regional HIV/AIDS statistics and features, December 1998) .The Global and sub-Saharan African HTV/AIDS estimates for 1998 as shown in figure 1, also reveal the escalating issues in the sub region as against the global cases. University of Ghana http://ugspace.ug.edu.gh Table 1.1 Regional HIV/AIDS statistics and features Region Epidemic started Adults & children living with HIV/AIDS Adults & children newly infected with HIV/AIDS Adult prevalence rate (15-49) age group Percentage of HIV positive adults who are women Main modi transmissk For adults with HIV/, ub-Saharan Africa Late 70s - early 80s 22.5 million 4.0 million 8.0% 50% Hetero North Africa &middle East Late 80s 210 000 19 000 0.13% 20% IDU, Herei South & Southeast Asia Late 80s 6.7 million 1.2 million 0.69% 25% Hetero East Asia &Pacific Late 80s 560 000 200 000 0.068% 15% IDU,Heter MSM Latm America Late70s to Early 80s 1.4 million 160 000 0.57% 20% MSM,IDU Hetero Caribbean Late 70s - early80s 330 000 45 000 .96% 35% Hetero, MS Eastern Europe &Central Asia Early 90s 270 000 80 000 0.14% 20% IDU,MSM Western Europe Late 70s - Early 80s 500 000 30 000 0.25% 20% MSM,IDU Northern America Late 70- Early80s 890 000 44 000 0.56% 20% MSM,IDU Hetero Australia &New Zealand Late 70s- Early 80s 120 000 600 0.1% 5% MSM,IDU Total 33.4 million 5.8 million 1.1% 43% Source: UNAIDS, 1998. Hetero: Heterosexual transmission. MSM: Sexual transmission among men who have sex men.(men sex men) IDU: Transmission through injecting and drug use. University of Ghana http://ugspace.ug.edu.gh 11 Figure 1: HIV/AIDS estimates, global and Sub-Saharan Africa (Infections and Deaths in Millions) 16 14 12 10 z z y / I Z . -Sub Saharan Africa -Global new AIDS deaths,1998 Child infection,1998 Child AIDS to date AIDS death to date Source: UNAIDS, 1998. As shown figure 1, child infections, which stood at 0.59% in the world, as of end 1998, had 0.53% for the Sub-Saharan African (SSA). The region also had 4.0 million out of the 5.8 million new HTV infections in 1998. SSA also scored 22.5 million out of the global case of 33.4 million people living with HIV by the end of 1998. On child AIDS death to 1998, SSA scored 3 million out of a global case of 3.2 million. On AIDS death to 1998, the region had 11.5 million out of the world’s total of 13.9. However on general HIV infections which stood at 47.3 million worldwide (by the end 1998), 34 million came from the Sub-Saharan Africa region. It is recognized that HIV infection in Sub-Saharan Africa is primarily acquired through heterosexual activities, which is also the fastest mode of transmission among the three notable ones. However, among the 34 most affected HIV/AIDS countries in the world as revealed by UN Population Division (1998), 29 are in the sub-Saharan Africa. They are Benin, Botswana, Burundi, Burkina Faso, Cameroun, Central Africa Republic, Chad, Congo, Cote d ’Ivoire, Democratic Republic o f the Congo, Eritrea, Ethiopia, Gabon, Guinea Bissau, Kenya, Lesotho, Liberia, Malawi, Mozambique, Namibia, Nigeria, Rwanda, Sierra Leone, South Africa, Togo, University of Ghana http://ugspace.ug.edu.gh 12 Uganda, United Republic o f Tanzania, Zambia and Zimbabwe. The remaining 3 are in Asia; Cambodia, India and Thailand, Latin America; Brazil and Caribbean, Haiti. Moreover, of the 30 million persons estimated in 1997 by UNAIDS with HIV/AIDS, 26 million (88%) were residing in these 34 countries. It was also found that 91% of all AIDS deaths occurred in these 34 countries, with higher records from the Sub-Saharan countries (UNAIDS, 1998). All these show that the epidemic, although a pandemic, is more of a developing world disease than associated with the developed world, as illustrated in table 1, with reference to the positions occupied by Western Europe, North America, Australia and New Zealand. Nonetheless, the southern part of the African continent holds the majority of the world’s hard-hit countries. In Botswana, Namibia, Swaziland and Zimbabwe, current estimates show that between 20% and 26% of people aged 15-49 are living with HIV/AIDS. By the end of 1998, Zimbabwe was especially hardest-hit. The record also shows that South Africa, which lagged behind some of its neighbors in HTV infection at the start of the 1990s, caught up fast contributing one in seven new infections in sub Sahara Africa in 1988. As of end 2000, South Africa with a total of 4.2 million infected people had the largest number of people living with HIV/AIDS in the world (UNAIDS, 2000). The story differs on the other side of the continent. One in ten adults or more were infected in Central African Republic, Cote d’Ivoire, Djibouti and Kenya by the end of 1998. HTV affects West Africa on a smaller scale than it does in southern and east Africa, but Sierra Leone and Cote d’Ivoire have current escalating rates of HIV in the West African Region. The general lower rates of HIV in West Africa could be attributed to the virus type and also the early- sustained prevention efforts adopted by some countries, such as Senegal. University of Ghana http://ugspace.ug.edu.gh 13 In Ghana, a total of 43,587 people had AIDS by the end of 2000 (MOH/DCU, 2001). The MOH (1999) report shows a projection of 200 people being infected daily with HIV, which resulted in a prevalence rate of 4.0% in 1998 and 4.6% in 2000. A survey carried out by MOH in 1998 also shows that 380 000 people were living with HIV, out which 24,000 were estimated AIDS cases forming 7% and 356,000 representing 93% were people living with HIV. In 1999, the number of people infected were about 430,000 (MOH/NACP, 1999). It is estimated that the number would rise steadily reaching more than a million in 2009 and about 1.4 million in 2014. The implication is that large numbers of Ghanaians will die over this period of time or the number of infected people would be higher. Already over 114,000 people have died of the disease since thel980s; and it is estimated that the number of annual new AIDS cases would rise from about 31,000 in 1999 to 51,000 in 2004 and 117,000 further in 2014, as against the initial cases of 42 in 1986 and 29,546 in 1998. It is also estimated that by the year 2009 about 200 Ghanaians in the age group, 15-49, will die from AIDS everyday (MOH / NACP 1999). All these projections have been made on the basis that 200 people are being infected daily in Ghana. Even at the prevalence rate of 4.6% and 200 infections per day, Ghana’s rate is relatively lower than most West African (like its neighbouring) countries and Southern African countries such as Botswana, Namibia Swaziland, and Zimbabwe, which have prevalence rates of between 6-10% and 20-26% respectively. Ghana is however likely to exceed the 5% threshold seen by experts as marking the beginning of an AIDS explosion, considering its diffusion pattern (of south, middle, and the north modes) facilitating the spread of HIV to the three major sections in the country (Agyei-menash, 2001). These modes enable HIV to spread simultaneously at the three major different belts of the country, though at different rates. The table 1.2 shows HIV prevalence in University of Ghana http://ugspace.ug.edu.gh 14 pregnant women between 1992-1999 for different sentinel sites in Ghana indicating, that some sentinel sites have already exceeded the 5% threshold. Table 1.2. HIV Prevalence (%) in pregnant women in Ghana. 1992-1999 SITE 1992 1994 1995 1996 1997 1998 1999 KORLE-BU - 2.0 ” 2.2 2.2 ADABRAKA 0.7 - 1.3 2.2 2.1 3.4 2.0 ASSIN FOSU 2.5 1.2 1.6 1.2 3.6 2.0 CAPE COAST 3.5 2.4 2.6 0.8 3.4 3.2 KUMASI 4.6 2.4 3.2 3.8 5.5 6.8 4.9 MAMPONG 2.0 3.6 2.0 5.2 5.0 3.4 SUNYANI 4.0 3.0 2.2 2.0 3.4 2.8 WENCHI 4.0 - 3.2 2.6 2.4 2.0 2.2 TAKORADI 1.8 4.2 3.8 3.0 4.0 EIKWE 3.0 5.7 5.8 5.8 4.8 KOFORIDUA 3.2 2.4 3.8 2.6 4.2 2.4 1.0 AGOMANYA 18.0 9.4 10.5 12.8 13.4 13.2 8.2 TAMALE 1.0 1.0 1.6 1.0 - 0.8 NALERIGU 1.0 1.0 0.4 0.2 - 0.6 BOLGATANGA - 2.0 1.6 1.0 2.8 3.0 1.6 BAWKU 2.4 2.4 - 1.6 1.8 1.6 WA 1.8 3.0 0.8 1.8 1.6 2.3 2.2 JIRAPA 0.4 2.5 0.3 3.0 1.4 - 0.6 NANDOM - 2.0 2.9 - - HAMILE - 4.3 4.2 - - HO 2.4 2.4 2.8 3.8 4.0 5.2 HOHOE 2.3 3.2 2.1 4.2 4.0 4.4 AMASAMAN 2.6 TEMA 2.6 Source: National AIDS Control Programme /Ministry of Health [2000] University of Ghana http://ugspace.ug.edu.gh 15 In table 1.2, Agomanya consistently recorded higher prevalence rates far above the 5% rate implying HIV/AIDS has exploded in this area and if not checked would influence Ghana’s rapid entry in to the explosion zone. The majority of the infected adults in Ghana develop AIDS from 2 to 12 years after infection (MOH 1999). Thus some develop AIDS more quickly while others more slowly. On an average, most adults die fairly quickly in a year’s time after developing AIDS. HIV is predominantly transmitted in Ghana by sexual intercourse. It is estimated that 85% of the infections in Ghana are results of heterosexual relationships, while 10% and 5% have been due to mother to child and intravenous means respectively. Data on HIV in Ghana is based on sentinel surveillance, carried out by persons in various regions through anonymous testing of blood samples collected from people especially pregnant women. The geographical pattern of the disease in Ghana shows a concentration in the southern sector. Out of the 115 cases of HIV/AIDS reported in 1986, more than 50% came from the Eastern Region (Nee Quaye et al, 1987), and there were no cases reported from the North and the Upper East Regions. A decade after, the pattern revealed Ashanti Region (which was second to Eastern Region in the first reported cases) as having the highest number of reported cases of AIDS. A pattern to note is the increasing number of cases in the Northern and the Upper East Regions which by 1986, reported no cases, but have been ranked sixth in 1997 and fourth in 1998 respectively with respective percentages of 14.4% and 12.5%. The epidemic in Ghana could be said to be more of rural than an urban phenomenon (Oppong, 1998). It also shows a trend of female dominance even though current statistics indicate that there is a gradual convergence to a 1:1 female male ratio (Agyei-Mensah, 2001). Sixty three percent (63%) of the cumulative reported AIDS cases between 1986 1998 have occurred in women (Agyei-Mensah, 2001). Analysis of the age-sex distributions of the reported University of Ghana http://ugspace.ug.edu.gh 16 cases shows 90% of the AIDS cases found in persons between the ages of 15 and 49. The peak ages for reported AIDS cases so far fall between 25 - 34 for females and 30 - 39 for males (Agyei-Mensah, 2001). 1.2 Problem Statement Since the disease was first reported in the country, it was believed to be among commercial sex workers, people with travel abroad history and homosexuals. Nonetheless, people believe the disease has ethnic differential as a result of ethno-cultural, as well as religious practices, (e.g. forced widowhood inheritance and polygamy). Moreover, the disease is currently following location and functional attributes of places. For example ‘entry points’ (port cities and boarder towns) are developing more cases as well as places of vibrant economic activities that promote massive human interactions. The disease also has rural - urban differentials. On another note, some socio economic groups such as commercial sex workers, drivers, artisans, ‘peace officers’ among others are being identified by laymen as carriers of the disease. Studies on HTV/AIDS in Ghana also have mainly been biomedical. This study however is a geographical one among others conducted by Oppong (1998) and Agyei-Mensah (2001). The latter studies were largely based on analyses of national data. This study extends beyond these ones by interviewing HTV/AIDS patients in a locality (Sekondi-Takoradi) to have a better understanding of their background characteristics, including their travel history and other attributes. It is therefore relevant to note that this study at the community level is different in approach since it involves interviewing of HIV/AIDS patients for a first hand information, making it an original work. This will enhance an in-depth understanding of the spread of the infection. Sekondi-Takoradi has been chosen for some specific reasons. It is a geographic unit that has University of Ghana http://ugspace.ug.edu.gh 17 basic facilities promoting human interaction commercially, administratively and socio­ politically. Sekondi-Takoradi is a port city, with a characteristic feature of the concentration and development of commercial sex activity, which has been noted by scholars as a risk element in the spread of HIV/AIDS. Nonetheless, Sekondi-Takoradi has a history of prevalence of commercial sex activity in pre-colonial and postcolonial periods, which predisposed residents to sexually transmitted infections (STIs). National records (NACP/MOH 2000) have also shown that HIV/AIDS is developing increasingly in Sekondi-Takoradi. Geographically, the area is a nodal town linking series of settlements, and a growth point for all these settlements. Is it the regional capital of the Western Region, and serves as the biggest commercial centre for all economic activities in the Western Region. The area is close to Abidjan, the capital city of La Cote d’Ivoire, and a country leading in the concentration of people living with HIV/AIDS in West Africa. With regard to all these notions and concerns, the research focuses to study the distribution, frequency and the determining factors in the spread of HIV / AIDS in Sekondi-Takoradi, in the Western Region of Ghana. Findings from this research would help formulate effective and more efficient control measures to curb the escalating rates of HIV/AIDS’ spread especially in Sekondi - Takoradi as a geographic unit and the country as a whole. The study would address some questions like: • Which socio-economic group is more prone to the infection • What has behaviour got to do in the spread of the disease? • What has urban or rural settings got to do in the spread of HIV/AIDS? • Has functions of places or towns influence the spread of HIV / AIDS? • What is the magnitude of HIV /AIDS in the study area? University of Ghana http://ugspace.ug.edu.gh 18 • What factors really facilitate the spread of the disease and at certain geographical settings • What policy recommendations are in place to curb the spread of the disease? • What is the disease implication for the youth, and the country as a whole? • What are the effective ways of controlling highly behaviour-influenced diseases such as HIV/AIDS? • Has the disease any spatial and temporal dynamics 1.3 Objectives The main objective of this study is to investigate the patterns and the determinants of the spread of the HTV/AIDS in Sekondi-Takoradi. The specific objectives for the study are as follows: 1. To investigate and discuss the magnitude of the HTV /AIDS in Sekondi -Takoradi 2. To find out and analyse the factors that influence the spread of the disease in the study area. 3. To analyse the socio-economic implications of HTV / AIDS on the population 4. To discuss policies concerning HTV/AIDS and suggest appropriate recommendations to reduce the spread of the disease. 1.4 Research Propositions • The frequency of HTV infection is directly proportional to increase in heterosexual relationships • The spread of HIV/AIDS is directly related to ‘occupational interactions’ induced by increase in mobility. University of Ghana http://ugspace.ug.edu.gh 19 • Lower socio-economic status has implications for HIV/AIDS predisposition. • Location and functions of places have direct influence on the spread of HIV/AIDS. 1.5 Methodology This section on methodology discusses sources of data, research instruments, sampling design and methods of data analysis. Although this is a social research, the methodology could also be described as descriptive and analytic epidemiological approach. 1.5.1 Sources of data Primary and Secondary sources of data were used in this research. Primary data were collected from selected communities in the study area and HIV/AIDS patients at the Effia- Nkwanta Hospital. Narratives from HIV/AIDS patients also form part of the primary data. Health officers, some religious leaders and other functionaries were informally interviewed and this has immensely gone into qualitative analysis. Secondary data were also gathered from several sources. The libraries were very useful in this aspect. The Balme library, ISSER library, RIPS library, Noguchi Memorial Institute library, Department of Geography and Resource Development Library (all in the University of Ghana, Legon) among others were used. At these libraries Books, Journals, Newsletters and other forms of publications were reviewed. The Internet was also very useful for this study. It enabled the study to have access to quick information from all other comers of the globe concerning the spread of the disease. Data from the disease control unit (DCU) of the Ministry of Health was also used. HIV/AIDS cases from 1992 to June 2000 in Sekondi-Takoradi were reviewed from this unit. The HIV sentinel surveillance data 1992 -1999 was also used and duly acknowledged. University of Ghana http://ugspace.ug.edu.gh 20 Information from Hospital reports, the records department and the STD/HIV units of the Effia- Nkwanta Hospital were valuable as secondary data. 1.5.2 Levels of the study The study was conducted at the following levels: 1. Case histories. This was a review, based on documented HIV/AIDS cases at the Effia- Nkwanta hospital and the Public Health Unit (PHU). 2. Interview of AIDS patients at the Counselling Unit of the Effia Nkwanta Hospital 3. Community study of the knowledge and attitudes on HIV/AIDS 4. Other reviews. These include secondary data, published and unpublished. These blended in the analyses of patterns of the disease, facilitating factors and risk elements as presented in this report. 1.5.3 Research Instruments The main instruments used to gather information for this study include case review, interview, questionnaire and observation. ■ Case histories were based on data at the hospital from the onset of reported HTV/AIDS cases. ■ There was personal interview of HIV/AIDS patients. (See appendix I for patients’ interview guide). ■ There was a community study, based on the administration of questionnaire. (See appendix II for questionnaire). ■ Review of census data and other published and unpublished works. University of Ghana http://ugspace.ug.edu.gh 21 ■ Observation. This was useful at all stages of the study. It was very useful at the hospital where HIV/AIDS patients were interviewed. It helped in the identification of some of the symptoms of AIDS on patients at the Hospital as well as in the Sekondi-Takoradi township. 1.5.4 Sampling Design The study sampled two groups of respondents for primary data. They are HIV/AIDS patients and ordinary respondents from the community. The AIDS patients’ study (clinical survey) was conducted to specifically find out trends and factors facilitating the spread of the disease. The study at the community level was carried to find out the knowledge and attitude of the residents about the disease and risk elements predisposing the residents to HIV/AIDS infection. Both studies therefore played complimentary roles to validate findings to further the design of measures to curb the spread of the disease. This study operated within the sample frame of 359 298 people (2000 population census provisional report), being the total population of the study area (334.43 km2) as at the time of the research. Out of this total, a sample population of two hundred (200) people was interviewed from the community. The target group for the community respondents was male-female adolescents and adults, in the age groups of 15-24, 25-49. The sample population for the study is heterogeneous, hence the stratified method of sampling was used to enable categorization in to two groups, based on major residential patterns and rural urban settings for the community respondents. Low class and High-class residential settings were identified as two major categories of people in the metropolis. The metropolitan assembly has demarcated three settings of residences: High, Middle and Low Classes. A reconnaissance survey revealed that both the middle and the low classes have basic and similar characteristics, which are very irreconcilable to that of the high University of Ghana http://ugspace.ug.edu.gh 22 class. In behavioural terms also, the low class is just like the identified middle class. More so, this is a behavioural study, which envisages characteristics of two categories. For the sake of clearer analysis therefore, the study finds it suitable using two settings of High and Low classes categorisation, based on the two major residential settings, depicting income level and to an extent levels of education. Simple random method was used to select eight (8) communities. Four (4) communities each was selected from the high class and low class categories respectively. They as follows: Selected Low Class communities 1. Affia - 25 male respondents from 25 households in 22 houses. 2. Kwesimintsim - 25 male respondents from 25 households in 21 houses. 3. Tanokrom - 25 female respondents from 25 households in 20 houses. 4. Effiakuma - 25 female respondents from 25 households in 20 houses. Selected High Class communities 1. Sekondi Ridge - 25 female respondents from 25 households in 25 houses. 2. Top Ridge (West line, West Tanokrom) - 25 male respondents from 25 households in 25 Houses. 3. Newsite - 25 female respondents from 25 households in 25 houses. 4. Windy Ridge - 25 male respondents from 25 households in 24 houses. In each class 100 people were interviewed consisting of 50 males and 50 females. Since communities in each category were considered homogeneous, two each of the communities in a class provided 25 male respondents whiles the other two provided 25 female respondents each. That is to say, in a community, 25-males or 25-females were interviewed. University of Ghana http://ugspace.ug.edu.gh 23 In all, 182 houses were visited. Households formed the basic units of interview in the selected communities. The Households were selected at random. One person at least was interviewed from each household, but a maximum of two households was selected in a housing unit where there was more than one household. Due to sensitive issues in the questionnaire, two female field assistants were chosen to interview female respondents. Akan, Ewe and English languages were used for all the interviews. In the Clinical Survey, forty-one (41) HIV/AIDS patients were interviewed. An average of ten (10) patients per week (on HIV/AIDS counselling day), at the Effia-Nkwanta Hospital. Five health officers and other functionaries were also informally interviewed. All the interviews for the community and HIV/AIDS patients lasted for two months. (March - April 2001). 1.5.5 Methods of Data Analysis Data has been analysed quantitatively and qualitatively in this study. SPSS was used for data transformation, interpretation and analysis. Simple correlations and cross-tabulations were used to establish relationships (like level of condom usage between the two residential classes). Other relevant statistical tools such as percentages, ratios, charts, tables and graphs have been employed where and when necessary in this report. 1.5.6 Problems of the study/ Reliability and validity of the data Financial and time constraints did not permit a continuous and large sample of cases to be interviewed. HIV/AIDS patients were interviewed only on their counselling day. It could be argued against the study that, some of the patients who could offer other views as presented in this report were not present at the time of the study, but the counselling unit revealed that University of Ghana http://ugspace.ug.edu.gh 24 patients on counselling are very consistent in attendance and therefore none missed out. More so the clinical survey adopted the simple random strategy. Many of the 41 cases in the clinical survey were married. It is possible this could be due to wrong reporting from patients. The identification of one’s status as single with HIV/AIDS presupposes promiscuity. As a result, many people were likely to have said they were married. This needs a further clarification with another data. The data presented in this study could be true, as it complements the data on marital status from recorded cases from the hospital. University of Ghana http://ugspace.ug.edu.gh 25 CHAPTER TWO 2.0 LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK This chapter discusses general factors that have contributed to the spread of HIV/AIDS in various settings. These factors are presented and discussed in relation to their roles. The chapter ends with the discussion of a model, comprising of all the factors and how they influence the transmission of HIV. 2.1 General factors in the spread of HIV These include: Sexual behaviour and practices; Mobility, Prostitution and livelihood; Poverty and lower socio-economic status; Socio-cultural issues and gender inequality; Influence of sexually transmitted diseases on HIV/AIDS; Stigma on the disease; Polygamy; Inadequate knowledge of the disease; Multiple co-factors and the influence of conflicts and wars. 2.1.1 Sexual behaviour and practices as factors influencing the spread of HIV Peter Piot (1998), in a paper titled ‘Changing the way people behave’, said in spite of the increasing rates, some countries still do not recognize HIV as a major threat to public health. He emphasized that change in behavior is helping some countries to control the high rates of HIV while this same element of behavior is worsening the spread of HIV in some other countries. Uganda, Thailand, and Senegal have been cited as countries, which have used sustained programs of controlled behavior to reduce the spread of HIV. In Uganda, delayed first sexual intercourse, increased condom use and University of Ghana http://ugspace.ug.edu.gh fewer sexual partners have been responsible for 40% drop in HIV prevalence among pregnant women. In Thailand also, young men cut their visits to sex workers by almost half between 1991 and 1995; and the number using condoms increased from 60% to nearly 95%. In Senegal, safer behaviour prevention efforts appear to have reduced the rates of STDs and stabilized HIV rates at low levels of less than 2% among sexually active adults. Talking about facilitators of rapid proliferation of the pandemic, Gould (1993), discussed a simple model, that; “HIV needs people to exist, and it needs connections between people to move from one person to another”. In his discussion he said, ‘if we had simply an unconnected and unstructured sets of people, a person infected with HIV would eventually convert to AIDS and die and her virus would also disappear. But people axe seldom-unstructured sets; they are connected by relations’ - all sorts of relations in both the common and mathematically rigorous sense of the word. Relations connect sets of elements and thereby form structures and it is these connected up and structured sets of people that he calls 'backcloths It is on a human backcloth that a virus exists as traffic and it needs the backcloth of connective tissue to move from person to person as ‘traffic transmission’. Gould (1993) in this model is of the view that HTV is transmitted by heterosexual activities. He continued with his expositions that, ‘the major connective yam that forms the basic material to weave the human backcloth is obviously humans and their insatiable appetite for sex and sexual relations in a general sense’. Quiggin et.al. (1989) in a paper titled ‘Social context of AIDS in sub-Saharan Africa’; mentioned behavioral-change as responsible for the high rate of STDs’ spread. 26University of Ghana http://ugspace.ug.edu.gh 27 Pat Quiggin wrote, “life style played a dominant role in determining individuals’ chances of being infected”. 2.1.2 Mobility, Prostitution and livelihood Anarfi (1995) shows that migration renders societies vulnerable to diseases, including HTV/AIDS. This fact was confirmed by Decosas (1995) when he wrote that 80% of Ghanaian prostitutes in Abidjan are infected with HIV, many of whom are returning home to seek cure. Pappoe (1996) also demonstrates that currently 8 out of every 10 women working in the prostitution industry in the largest cities in the West African sub region are infected with HTV. This establishes a relation between prostitution and HIV infection. UNESCO (1991) in a study on sexual behavior and networking in the transmission of HIV in Zambia in 1989, revealed that fish traders, businessmen, truck drivers and soldiers were in the risky category for STDs infection. Mushingeh (1990) also confirms this. A conclusion drawn from this is that, occupations involving mobility influence frequency of sexual partner change, which has implications for being infected with HIV. Writing on sexual networking in selected communities in Ghana and the behavior of Ghanaian female migrants in Abidjan, Anarfi (1991) further expressed that, occupation is considered to exert some influence on the degree of sexual networking. The study shows that apart from prostitutes, wives of policemen, soldiers, sailors, miners, long distance drivers were found to be at higher risk of contracting STDs. It was also found University of Ghana http://ugspace.ug.edu.gh out that 75% of the women he reviewed were in prostitution of all kinds and car drivers and white sailors were identified as their clientele. In Arhin’s (1981) report on prostitution among Ghanaian women in Ivory Coast, as far back as 1971, half a million Ghanaians living there and 70% of them women, were in the prostitution industry. This shows that 350,000 were in prostitution. Comparing this with Decosas (1995) report, which revealed that 80% of Ghanaian prostitutes in Abidjan were infected with HIV means that 280,000 Ghanaian prostitutes in Abidjan had been living with HTV since 1995. This research establishes the implications of this for Ghana, especially in the case of Sekondi - Takoradi. UNDP’s (1997) project document on HIV and Development in the sub Sahara Africa shows that the HIV/AIDS epidemic on the African continent has been exacerbated by cross national currents and other dynamics. These include: mass movements of people across borders, as refugees seeking asylum. The document illustrates migration of the unemployed and under employed to other countries to seek work as an example. South Africa, for example, is a focal point of such migration (especially from southern African countries, which have high prevalence of HIV) as much as Cote d’Ivoire, which attracts many people in West Africa. There is also the movement of sex workers as well as pastorals in search of pasture. This document has established migration as a major contributor to the spread of HTV, detailing source regions as areas of high HIV prevalence. Sekondi - Takoradi has also been a central point of in-migration in Ghana. This study however discusses mobility in this context in relation to HIV infections. University of Ghana http://ugspace.ug.edu.gh Igbinovia (1986) discussing prostitution said that in order to make ends meet in a hostile urban environment, women have no choice but to resort to prostitution, which naturally, is a major facilitator of HIV/AIDS. In Igbinovia’s analysis, prostitution has contributed so much to the HIV/AIDS surge in the Southern African region. In the Malawian case, all kinds and levels of prostitution were identified to the extent that laymen could think that prostitution is a sort of legalized profession. In this context, prostitutes move about in hotels, bars, migrate from city to city and to rural areas to transact their business. Bus and truck drivers are particularly notorious for frequently visiting prostitutes in Malawi. Gould (1994) reports that 75% truck drivers in Eastern and Central Africa were infected with HIV. This shows that some socio-economic groups are more prone to the infections, hence the socio - economic differentials in the spread of the disease. Anarfi et. al. (1997) expressed that itinerant trading is the second major economic activity for women who constitute an important chain in the distribution of goods in West Africa. Historically they have played important roles in the political economy of Ghana. With the out-break of AIDS, these women, some of whom move far away from home sometimes for days or even weeks, stand the risk of being infected with HIV through their activities. Using a combination of methods including a survey and focus group discussion, these writers found that itinerant women traders appear highly vulnerable. This state of affairs occasioned by the extremely difficult condition in which the women work, is exploited for the sexual gratification of the men with whom they come into contact. Evident to this was the personal testimonies given by some of the traders (Anarfi et. al., 1997). Four (4) cases discussed in the document showed that itinerant women 29University of Ghana http://ugspace.ug.edu.gh traders practice indiscriminate sex with fanners and their male counterparts to get favor to purchase their commodities. This greatly exposes them to HIV infection. The record therefore indicates that people who move about a lot for one reason or the other are at the greatest risk of contracting HIV/AIDS in Ghana. In their work on Itinerant Gold Mines: Mobility Sexuality And The Spread Gonorrhoea and Syphilis In Twentieth Century Ghana, Acheampong and Agyei-Mensah (2001) have demonstrated that prostitution is an issue of old, which has contributed vehemently to the spread of STDs (in present times including HTV) in pre-colonial, colonial and present Ghana. They also established that commercial sex activities and STD-transmissions have been associated with mobile women (as made explicit in the works of Little, 1973; Naanen, 1991; Weiss, 1993). Mobile men in the categories of sailors, porters, soldiers, migrant laborers and traders have also equally been responsible for the transmission of STDs including HTV, as in the case of truck drivers in present sub Saharan Africa. It is clear in their work that entry points and port cities (like Bole and Hamile, Tema and Sekondi-Takoradi respectively) have increasing rates of HIV as well as some urbanized towns as against other rural areas. UNAIDS (1999) in ‘AIDS epidemic update’ reveals that HTV is driven by ‘Loneliness’ among migrant workers in South Africa. The update shows that more than a decade ago, 2.5 million South Africans were registered as migrant workers, and that number is likely to have increased. The document shows that ‘Carltonvile is at the heart of South Africa’s gold mining industry and was home to 88, 000 mine workers in 1998, of which 60% of them were migrants from other parts of Southern Africa or nearby countries like Lesotho, Malawi and Mozambique’. According to the update, the University of Ghana http://ugspace.ug.edu.gh mineworkers are well paid and therefore deal in drugs and casual sex. The update shows that some 400 to 500-sex workers service the Carltonvile mine. As a result HIV has been so much identified with Carltonvile. The city has become the hot spot of Gauteng Province. About 22% of adults in Carltonvile were infected in 1999 with HIV. The facilitating element over here is that, most migrant men live lonely lives in single-sex dormitories, often hundreds of miles away from their families. Therefore the freedom, loneliness and the presence of numerous sex workers facilitate the spread of HTV in Carltonvile. These migrant workers often visit home to see their wives, and as a result spread the disease among their wives. 2.1.3 Poverty and Lower socio-economic status Adomako-Ampofo (1993) explained that women’s disadvantaged positions have a direct influence on the kind of sexual relationships they enter and their clout to negotiate within these relationships. She furthered her discussion that poor and disadvantaged young women service the sexual needs of relatively better older males. She also emphasized that it is proven through research in sexual behavior (Adomako-Ampofo, 1991b; Asimeng, 1981; Konotey Ahulu, 1989) that most women who enter into relationships with sex being the medium of transaction, do so because of their disadvantaged or marginalized positions, which also predispose them to disease infection. This shows that marginalized groups are prone to ‘sexual transactions’, which expose them to diseases including HIV/AIDS. This study investigates the relationship between marginalized groups and HIV infection through sexual relationships. University of Ghana http://ugspace.ug.edu.gh It is clear in the work of Anarfi (1995) and Adomako-Ampofo (1991, 1993) on prostitution in Ghana, Cote d’Ivoire and the Netherlands that, harsh socio-economic conditions which twigs out of poverty highly influence commercial sex work, among most ‘practitioners’, to enable them cope with the hardships. Anarfi et. al. (1997) pointed out that HIV infections in parts of the sub-Saharan Africa show the possibility of multiple infections under conditions of poor nutrition due to poverty. Banda (1988) also identified level of socio-economic status as a major factor influencing STD transmission in Zambia. His study reveals that people of lower socio­ economic status are infected with more STDs than people with high socio-economic status. 2.1.4 Socio-cultural issues and gender inequality Helitzer-Allen (1994) has studied girls’ initiation rites among the Lomwe of Southern Malawi in which the art of sex making is emphasized. It is evident in his study that those prepared for the initiation have to definitely experiment with sex. This however exposes them to HIV infections. Awusabo-Asare (2000) also emphasized that research and intervention strategies on HTV/AIDS in sub-Saharan Africa are increasingly recognizing the socio-cultural, economic, environmental and political dimensions of the epidemic. These factors, he said, constitute a range of issues referred to as background factors, such as gender inequality, the general social organization of space and political issues. He again emphasized that the gender inequality manifests itself in areas such as the double sexual University of Ghana http://ugspace.ug.edu.gh standards for males and females and higher vulnerability of women than men. Carael et. al, (1997) and Mason (1994), also share this view. According to Awusabo-Asare (2000), other factors such as poverty, types of residence, mobility, displacement as a result of wars and social as well as political unrest have also been associated with the spread of HTV among certain categories of people. The UNFPA (2000) discussed the vulnerability of females and their risk levels in contracting HIV, in the article, ‘Preventing HIV infection’. UNFPA explained that, women are more physically and socially vulnerable than males in the issues of HIV. It also stated that: • In sub-Saharan Africa, 55 per cent of HIV-positive adults are women. • Worldwide, at least half of all new infections are among women. • Men are eight times more likely to transmit HIV to a female partner through unprotected sexual intercourse than women are to transmit the vims to men. • More than 70 per cent of HIV infections worldwide occur through heterosexual sex, between men and women. The document also shows that lower status has more positive implications for being infected. In the text it said ‘lower status means higher risk’. It explains it ass follows: ‘Women often have less control over when, where and whether sex takes place’. Although many women can and do control their sexual lives, many more fear disapproval, violence or abandonment if they ask a husband or boyfriend to use a condom. When poverty impels a woman to seek income from sex, her risks of disease 33University of Ghana http://ugspace.ug.edu.gh and social sanction are even greater. It therefore emphasized that the underlying causes of HIV transmission are often linked to women’s lower status (Poverty; Lack of information; Inability to negotiate safer sex; Early age of first intercourse; Polygamy; Men having multiple partners; Coercion by males who are older, stronger or richer; Harmful traditional practices; Less access to education; Fewer opportunities to earn income; Sexual abuse and exploitation and Violence against women). The document also pointed out that biological, cultural and economic factors make girls vulnerable to HIV infection. It said: • ‘Girls are more likely than boys to be uninformed about HTV, including their own biological vulnerability to infection if they start having sex very young’ • ‘Girls are more likely than boys to be coerced or raped, or to be enticed into sex by someone older, stronger or richer’. • ‘Girls have sex with older men, who are more likely to be infected than younger males and tend to have other high-risk partners’ According to Banda (1994), many studies are of the view that in a population where marriages are universal and maintain a stable state, STD transmission is not as high as in a population with high marital instability where divorce, separation and re-marriage are common. His study shows higher percentage records of STDs among his married respondents than the single respondents (never married, divorced, separated and widowed). He argued that, several explanations could be given this trend, one being the stigma associated with STDs which could make it difficult for singles to openly come out University of Ghana http://ugspace.ug.edu.gh and admit responsibility for being infected with STD; and the other way round for the married. PIP/GHANA (2000), analyzed ‘youth, HIV/AIDS and STDs in Ghana’. The document confirms that adolescent females are biologically and economically more vulnerable as compared to their male counterparts in Ghana. On the account of their vulnerability many adolescent females are unable to avoid sexual activity or negotiate for safer sex such as the use of condoms. Many sexually adolescents are therefore exposed to the risk of STDs and hence have higher chances of being infected with HIV. 2.1.5 Influence of Sexually Transmitted Diseases on HIV/AIDS Caldwell and Caldwell (1996) discuss circumcision, chancroid and ADDS. Their study considered the likelihood of the role of ‘foreskin’ in the spread of HIV/AIDS. Their research shows that certain STDs particularly chancroid, which causes large soft sore on the genitals, tend to occur more frequently among uncircumcised men in poor areas where maintaining personal cleanliness is difficult. Their study proves that chancroid disappeared in the West around the beginning of the 20th century, apparently as societies became more affluent, making hygiene easier to maintain. Caldwell and Caldwell show that a recent research in Kenya finds that uncircumcised men with chancroid are at greater risk of being infected with HIV. The Kenyan study reveals, 2.5% circumcised men had HTV but without chancroid as against 13% circumcised men who had HTV and also had chancroid. Comparing this with uncircumcised men shows that 29% of the uncircumcised men had chancroid but who did not have AIDS, however 53% of the uncircumcised men who had AIDS also had chancroid. The crust of their argument is University of Ghana http://ugspace.ug.edu.gh that, chancroid increases the risk of contracting HIV because, the presence of genital sores make ‘transmissions’ during sexual intercourse more likely and more effective. UNFPA (2000) shows that STDs generally increase vulnerability to HIV infection. The document demonstrates that the presence of one or more STD greatly increases the risk of becoming infected with HIV. Since characteristic symptoms are often absent in women, nearly half of women with an STD are unaware of the infection. Consequently, they do not seek or receive treatment. UNFPA has on record that new cases of STDs number 333 million each year and six out of ten women in many countries have sexually transmitted disease, although many are unaware and do not seek treatment. Addler (2000) expresses that, ‘the spread of the epidemic in societies where heterosexual intercourse is the main mode of transmission is largely dependent upon two main factors: the presence of other untreated sexually transmitted diseases (STDs), and sexual behaviour. Therefore, any attempts to reduce the spread of HTV must address these two factors’. 2.1.6 Stigma on the disease According to Bullough and Bullough (1987), the evaluation and legal determination applied by society gives prostitution a special status of stigma. This was recounted by Anarfi (1995), that prostitution is highly stigmatized in Ghana, and as a result, prostitutes prefer practicing in cities of anonymity. This behaviour has developed into a culture of silence over STDs infection which is an element spreading HIV. This study considers prostitution having a link to the spread of HIV and therefore correlates the level of stigmatization and how it affects the spread of the disease in the study area. University of Ghana http://ugspace.ug.edu.gh PIP/GHANA (2000) gave an evidence that data on STDs, like abortion are not readily available in Ghana. This has been ascribed to the stigma society attaches to the disease and its victims. Persons who consequently get infected with an STD may either resort to self-medication or delay seeking treatment from a modem health facility until their situation deteriorates to unbearable limits. The Daily Graphic (Ghana) of ‘Tuesday, January 11 2000 edition’ carries the story ‘AIDS major killer in Berekum District’, reported by Rosemary Ardayfio. In this report, over the last two years HIV/ AIDS has been identified as the leading cause of death in the Berekum district of Brong Ahafo region. Prevalence rates have been on the increase, with 2.8% in 1998 to 3.2% in (January) 2000. According to Anthony Ofosu (Dr.), the district medical officer, patients prefer to stay in prayer camps than reporting to clinics and hospitals. He emphasized the impact of stigma, making it difficult for people living with the disease and their relations to declare HIV status or report to the available health facilities. The Holy Family hospital and the District Health Administration has started a home-based program to take care of patients. Saturday 15 January 2000 edition of the Daily Graphic (Ghana) shows Zimbabwe, one of the worst HIV-affected countries, where one in four Zimbabwean is HIV positive, introducing an AIDS levy. The paper reports that from January 2000, every Zimbabwean will pay 3% more of income tax to help fight the disease and also take care of about the one million orphans caused by AIDS. The criticism that arose demonstrates the high stigma on the disease. These are the words of a critic, “ why should I pay more tax to look after the promiscuous?” The document shows that 40% of pregnant women have the virus and 200 people die every day from AIDS related complications. 37University of Ghana http://ugspace.ug.edu.gh UNAIDS’ (1999) ‘AIDS epidemic update December 1998’ reveals HIV is driven by stigma, silence, shame and denial. The document established that most people do not talk about HIV, when they realize they are at risk, or have been infected, because of the stigma associated with the disease. Most people who contract the disease do not also say it until their condition comes to very critical states that demands clinical test. The document confirms that this kind of silence, shame and stigma spreads the disease so fast in indigenous areas mostly, where the culture of silence and stigma are so high. 2.1.7 Polygamy Talking about marital unions and sexual networking, Berkeley (1989) said polygamy most especially in Africa, has also been identified as one of the risk factors associated with STDs. In his study among patients in a hospital (in Uganda) population with an overall HIV prevalence rate of 42%, those in polygamous union were found to be infected more than those in the monogamous marriages. In the works of Tempo and Phiri (1993), it is clear that marriage systems and patterns facilitate the spread of HIV. Practices such as sororate and levirate, polygamy cannot be ruled out as factors facilitating the spread of HIV in Malawi. 2.1.8 Knowledge of the disease. Awusabo-Asare and Anarfi (1997) examined the health seeking behavior of persons with HIV/AIDS in Ghana and in their historical analysis found that, diseases whose aetiology could not be really explained have been given supernatural explanations among the various ethnic groups in Ghana. HIV/AIDS has been put in this category. Such University of Ghana http://ugspace.ug.edu.gh an explanation of disease causation influences peoples’ attitude to the disease and influences health seeking behavior of infected persons; and also in a way facilitates the spread. Their study indicates that some infected persons in Ghana felt they were be­ witched and therefore used multiple care outlets, either serially or in chorus hoping one of them would provide a cure or relief as well as explain the source of their infection, which in a way exacerbates the spread if not well handled. Because of the supernatural explanation given to HIV infection in some settings, traditional healers have become noted as health care outlets. In Ghana, a number of traditional healers claim to have found a cure for AIDS. A well known one was Nana Drobo, who claimed he had a cure for AIDS. His issue became a national and international case between 1989 and 1993. He was invited to Japan to proof his cure, where he claimed he had healed an infected person from France. He died on his return in 1993 after accusing his hosts of forcing him to reveal the secrets of his cure. Musara (1991), Lindan et al (1991) and Irwin et al (1991), have also reported of cure for AIDS in East and Central Africa. This however influences to some extent casual sexual behavior, knowing that traditional healers could cure the disease. 2.1.9 Influence of Multiple co-factors There is a school of thought that HIV/AIDS is influenced by multiple co-factors congruently. N’Galy and Ryder (1988) demonstrated this in their paper, when they analyzed the epidemiology of HIV infection in Africa. They discussed series of co­ factors as responsible for the spread of the infection on the continent. Behavior, prostitute patronage, high prevalence of STDs, the presence of genital ulcers, and blood University of Ghana http://ugspace.ug.edu.gh transfusions caused by high prevalence of malaria and during child-birth were identified. They drew substantive examples from Zaire (now Democratic Republic of Congo), Kenya, Senegal, Uganda and Rwanda in support of their claims. The AIDS Foundation of South Africa (1999) also points out the factors exacerbating the epidemic in South Africa, as follows: • Social and family disruption as a consequence of apartheid and migrant labor • High mobility and a good transport infrastructure • High poverty and low education levels, resulting in more risk taking behavior and commercial sex work. • A burdened and transforming health system • An overwhelmed welfare system • High level of sexually transmitted diseases • Low status of women in society and in relationships, making is difficult for them to protect themselves in sexual relationships • Shifting social norms which permit high numbers of sexual partners • A resistance to change high and risky behaviors, often centered around notions of cultural resistance to condom usage • A lack of clear and non-judgmental information and services for young people and denial about teenage sexual activity • Significant denial of homosexuality in the black community and a history of poor governmental interventions for the gay community. University of Ghana http://ugspace.ug.edu.gh 2.1.10 The influence of Wars and Conflicts UNAIDS (1999) reveals that HIV is driven by conflicts and danger among survivors in Rwanda and soldiers in Cambodia. Before the political turmoil of the mid- 1990s in Rwanda, studies had been done to understand the HIV epidemic in the country more than any other country (the update stated). The pre-war pattern was that, there were high rates of infections in the urban areas (more than 10% of pregnant women infected) than rural areas, which was the bulk of the population. The update has it that the war changed the shape of the epidemic. That a survey conducted in 1997 revealed a bridged gap between the urban and the rural areas, all scoring little over 11%, but with the urban having some few digits higher. In a broader spectrum, the disease became higher in the rural area than in the cities; and was mostly among the teenagers in the ages of 12, 13 and 14. These changes have been attributed to the mass movements during and after the ethnic conflict. HIV prevalence among people who spent the conflict years outside Rwanda in neighboring countries was lower than among people who survived the conflict in the country and at refugee camps. During the conflict, sex was being ‘sold or given away’ to survive. Rape was also on the increase. HIV rate was however high among camp dwellers. The post war survey concluded that wars and armed conflicts generated fertile conditions for the spread of HTV. Rape was also found to be responsible for the spread of HTV in Rwanda during the war. The AIDS epidemic update (1998) again shows that, most of Cambodia’s soldiers are teenagers with no education and do not really think about the future but live day by day. A long-term risk to them however is nothing, but see sex as a source of comfort in their kind of troubles. A survey shows that one in five soldiers visits a prostitute and also University of Ghana http://ugspace.ug.edu.gh 42 has girlfriends. This practice o f indiscriminate sex among soldiers has also contributed to the spread of the disease. 2.2 Conceptual Model The study has adapted the framework of Hagerstrand’s (1953) diffusion model. In his model, Hagerstrand examined the spread of a number of innovations among the population of a part of Sweden. Some of these innovations concerned agricultural practices, and other general issues like telephone service. Hagerstrand’s model was built on the following six assumptions: 1. Only one person has the information at the beginning. 2. The method is accepted once when heard of. 3. Only the ‘telling at pair-wise meeting’ spreads the information. 4. The ‘telling’ takes place only at certain times with constant intervals. 5. At each of these times every knower tells one other person who may be knower or non-knower. 6. The probability of being paired with a knower depends on the geographical distance between knower and teller in a way determined by an empirical estimate derived from distance function fitted to migration movements and telephone contacts over space. The model was applied successfully but he realized it has some limitations therefore in later analysis; he adjusted his simple method by introducing a ‘resistance’ to acceptance of the information and by introducing ‘barriers’. This model has been adapted because of some similarities it has with this study. University of Ghana http://ugspace.ug.edu.gh Conceptualizing the spread of HIV, this study considers the existence of initial case(s), which enter(s) a population just as information is disseminated and later on spreads through those who have the information willing or unwilling. In this study’s framework, some factors and co-factors, which are classified as background and behavioral, institutional, proximate and interventional (some of which Awusabo-Asare, 2000, also described), have been considered determining the rate of spread of HIV. Hagerstrand’s model is quite different in the sense that, he talks about: only one person having the information at the beginning, whiles this study emphasizes simply, the initial presence of the disease, which could be one or multiple. He also talked about the dissemination of information through ‘only pair-wise meetings’, which would necessarily involve two or more people, but in this model it could just be one person using infected equipment. The model for this study does not have any specific or ‘certain times’ as conceived by Hagerstrand, as periods of spread. This study looks at conflict, war, unrests, mobility, stigma, poverty, housing, awareness and education, type of profession, genetic conditions, religion, culture, promiscuity and presence of STDs as background and behavioral factors influencing the spread of HTV. These factors do not have direct link with the transmission but work through another factor called proximate, which denotes ‘sexual patterns and behavior’ in this study. Proximate factors are the direct elements involved in the spread of HIV in Africa. Proximate factor could be outlined as: extra-marital relationships, pre-marital sexual relationships, the practice of casual sex, regularity and timely usage of condom in sexual unions and the patronage of commercial sex workers. The proximate factors relate to all other factors in the sense that, they influence one’s sexuality or are the reasons for University of Ghana http://ugspace.ug.edu.gh one being in the type of sexual unions he/she finds him/herself. Institutional factors in this model are units where blood transfusion is administered, as well as handling of cutting and piercing instruments. Units like health facilities, ‘ the beauty industry’ that has barbering, saloon and other categories in the institutional aspect; one could be directly infected with HIV through the use of infected instruments or through the administration of infected blood. When this happens, the infected person is likely to spread the disease, but only through the proximate factors, influenced by the background factors. The link therefore between the institutional factors and the proximate factors is stronger than the link between the institutional factors and the background factors since in sub-Saharan Africa, HIV is mainly spread through heterosexual means. The model also considers the transmission of HIV from mother to child essential. This medium of transmission is quite direct but experience and practical example (as demonstrated in chapter 5) has proved that not every infected mother transmits the infection to the child at birth, which there have been some cases where mothers were positive but the babies were not infected. This kind of infection could either be the result of influence of proximate or institutional factors. The factor of intervention is very important since, interventions influence the immune system after infection and in a way have effects on the years between HIV and AIDS and death. Interventions could be in the form of regular counseling for patients, available drugs to fight opportunistic infections, prayers, miraculous healing and any other issues that either slows the spread, changes the positive status of the infected person, or delays the period from being positive to the full blown AIDS and death. It is worthy to recount here that at the stage of AIDS the infected person definitely dies within 44University of Ghana http://ugspace.ug.edu.gh some period, since no cure has yet been authentically found to combat the disease to restore health. This also implies that once an infected person gets to the period where AIDS is fully discovered, the person dies shortly if no interventions are made to keep the person in HIV status. This model of facilitating factors in the spread of HTV is shown in figure 2. 45University of Ghana http://ugspace.ug.edu.gh 46 Fig 2. A Frame Work Showing Component of Facilitating Factors in the Spread of HIV/AIDS (Background/behavioral) 1 (Institutional factors) Source: Author’s construct University of Ghana http://ugspace.ug.edu.gh 47 CHAPTER THREE 3.0 THE STUDY AREA This chapter discusses various characteristics of the study area. Issues of concern here include location and physical characteristics, population, settlements, housing and spatial development patterns, education, economic activities, recreation, culture and social activities, health and history of the development of STDs in Sekondi-Takoradi. Since this is a regional study, it is relevant that the characteristics of the area are understood to facilitate analysis of the problem. It is important also to know that a regional study like this offers the opportunity where primary information is sought from the people concerned, hence HIV/AIDS patients in this study. This chapter therefore helps us understand the interrelationships that exist among phenomena in the study area. The study area for this research is the Sekondi - Takoradi metropolis. The area is known administratively as the ‘Shama Ahanta East Metropolitan Assembly’ (SAEMA) of the Western Region of Ghana. It was selected for this study for several reasons. In the first place, it is the capital city of one of the ‘hardest hit’ HIV/AIDS regions in Ghana, with the prevalence rate of over 4.0% since 1999 (with Sekondi-Takoradi contributing largely to this figure). Secondly, all the other regions highly affected by the disease have had this kind of study, leaving the western region behind hence the need to study at least one major city (Sekondi-Takoradi) in the region. Also, the study area has good combination of rural and urban settings needed for a geographic study of this nature, which makes use of spatial as well as temporal dimensions. University of Ghana http://ugspace.ug.edu.gh Moreover, the functions of the city among other things being administrative, commercial and social would pre-dispose its dwellers to certain behaviour, which could facilitate the spread of diseases such as HIV/AIDS. Sekondi Takoradi has very good road and rail networks helping to link people in Accra and Kumasi, areas with high HIV prevalence in Ghana. The presence of air and sea ports make the area a very dynamic and vibrant one where interaction of people of diverse kind is facilitated. One other factor prompting the selection of the area is the city’s closeness to La Cote d’Ivoire, the leading country in West Africa with high HIV/AIDS cases. The people of Sekondi - Takoradi have easy access to the Abidjan city where they transact businesses of varied kinds. The Vanef STC has bus services to Abidjan every day from the study area. Sekondi - Takoradi has a remarkable history of commercial, social and security activities, during which time prostitution flourished in the area. To be able to understand a sexually transmitted disease of this kind and in Sekondi-Takoradi, it is important to have a coherent picture of some of the more important aspects of social life of the metropolis. These include housing, occupation, marital life, education, group associations and other indices of social maladjustment, which will be discussed. 3.1 Location The location of the area points to issues that would help understand vividly the dynamics of the spread of HIV epidemic in the metropolis. The study area, which is the SAEMA, started as the Sekondi town council in 1903, extended to include Takoradi in 1946 and on the 25th of June 1962 was elevated to a city status. The area lies within latitude 4.51N-5.09N and longitude 1.35W-1.50W. It is the smallest of the eleven (11) 48 University of Ghana http://ugspace.ug.edu.gh districts in the Western region. It covers an area of 334.43 sqkm. It shares boundaries with Ahanta West, Mpohor Wassa East and Komenda-Edina Equafo-Abrem Districts. The study area is shown in figure 3-1. The area is 280km west of Accra and 130km east of La Cote d’Ivoire by road. University of Ghana http://ugspace.ug.edu.gh University of Ghana http://ugspace.ug.edu.gh 51 3.2 Physical characteristics The topography is very varied, which serves as an attraction for tourists. The coastline has capes and bays, which have been eroded, especially around Shama, Essamang, Nkotompo and New-Takoradi. The central area of Takoradi is low lying with an altitude of 6 meters below sea level allowing several lagoons to intersperse with ridges and hills between 30 to 60m high. The relief of Sekondi is a unique undulating one. There are two main rivers .The Whin and the Ayire, which are perennial in nature. The equatorial type of climate characterizes the area. Temperatures are high with an average of 22 degree Celsius. The mean annual rainfall is about 1,380mm and covers an average of 122 rainy days mainly from the month of March to July. The second season, which is quite minor, starts from September to November. During the second season, the intensity of the rains is quite high but with a short duration, associated with line-squalls and thunderstorms. There are short but intense dry seasons which occur mostly in the months of August to September and December to February. The main vegetation was the equatorial rain forest type, which have been degraded by slash and bum farming practice and the development of the wood industry coupled with the activities of chain -saw operators. The area is now mainly woodland 3.3 Population The current population of the metropolis stands at 359,398 (2000 pop. census provisional results) with a male population of 183,416. The female population constitutes 51.0%, with a sex ratio of 95.9. The population grew rapidly from 152,607 to 249,371 University of Ghana http://ugspace.ug.edu.gh between 1960 and 1984 respectively with a growth rate of 3.5% per annum. Based on this growth rate the population was expected to be over 400,000 people as of end 2000. Currently, the youth (15-40) constitutes 45% (162,000) of the population in the metropolis. The population density of the area stands at 1197 persons per square kilometer. This ratio is expected to increase, holding present conditions constant. The growth points in the area (in terms of increasing population) are basically Sekondi, Takoradi, Affia- Kwesimintsim. Facilities in these areas have been over stretched to the extent that farmlands are being converted for housing development. 3.4 Settlements, Housing and Spatial development patterns The metro has forty - five (45) pockets of settlements and close to fourteen of these have population each exceeding over seven thousand (7000) people. The rural- urban dimensions are pronounced in the metropolis. The size of the total population dwelling in the urban area is currently 69.0% as against 31.0% rural. The urban portion of the metropolis constitutes about 32% of the land area while the rural composition is 68%. Although the rural area takes relatively large land size, it spatially accommodates little over 30% of the population while the urban takes nearly over 70% of the population. The landuse pattern is shown in Table 3.1 Using a different classification based on facility availability, three types of residential patterns could be identified. The first, second and third classes of residences. Residential areas cover 21% of the land in the metropolis, while farmlands cover the highest portion of 40.1 %. As a result of growing population and the need for the construction of more houses, farmlands are being converted for residential uses. 52University of Ghana http://ugspace.ug.edu.gh 53 Table 3.1 Shama Ahanta East Metropolitan Assembly’s (SAEMA) Landuse LANDUSE ACRE CAGE (in km) PERCENT (%) Residential 70.2 21 Commercial 20.7 6.2 Educational 25.8 7.7 Industrial 40.1 12.0 Agricultural 134.8 40.3 Civic / Cultural 31.8 9.5 Open Spaces 11.0 3.3 Source: SAEMA Physical Planning Department (2000) The first class residences are mostly state owned. Examples are the Windy Ridge, Beach Road, Chapel Hill among others. These areas have good roads, adequate power supply and good water services. Plot sizes are large and population densities are generally low. Good landscape design and clean environment characterize the area. Some of the second-class areas are the Anaji estate, Assakae, Effiakuma Estate and Tanokrom. These second class areas of residence have fairly good facilities and services just as described in the first class. The second class is not well developed and too different from the third class. In the third class however, the areas are poorly serviced in terms of water, power and telecommunication facilities. Large areas of this class are not accessible to vehicular traffic. Plot sizes are very small. In sharp contrast to the second and first class areas, population densities are very high and the environments are very dirty. Some of the residential areas that fall within this category are: Kwesimintstim, Effiakuma, Adeambra and Fijai. The increase in population in the metropolis has placed tremendous pressure on housing. Generally demand for housing is very high, projected close to four thousand University of Ghana http://ugspace.ug.edu.gh (4000) units per year out of which about 20% is met. As a result, there is an overcrowding situation in the metropolis to the extent that most of the houses have high occupancy levels of eight (8) persons per room. Coupled with this, the SAEMA issues an average of 974 housing permits per year as against a rising demand as demonstrated above. These have however given way to increase in construction of houses with an estimated 40% of the houses being constructed illegally and are mostly unaccounted for. (SAEMA, 2000). Individuals provide the bulk of the housing units, with a sizeable number constructed for rental purposes. According to the GLSS 4 (1998), just a little over 24% of the households in the urban areas are owned by those who live in them. The government provides 4% of accommodation on rental basis while private employers provide 2%. Real estate developers such as Regimauel Gray, State Housing Company (SHC) and the Social Security and National Insurance Trust (SSNIT) in the Metropolis have been providing housing schemes. Ghanaians living abroad have largely patronized these housing units as well as staff of some organizations. Individuals have really found it very difficult to acquire these housing units because of affordability. More over, the prices of rental units are also expensive as a result of expensive infrastructure cost in the light of high utility rates. These problems would explain the high room occupancy ratio and the presence of some social vices linked to inadequate housing. In the 1930s, 1940s and the 1950s, Sekondi - Takoradi was noted for three types of overcrowding, (Busia, 1950). His study revealed that, there were too many houses built in a given area, too many persons living in a house and too many persons living in a room. This went on to the extent that in certain houses in Takoradi, landlords had to 54University of Ghana http://ugspace.ug.edu.gh convert latrines and kitchens into rooms so as to take more tenants. This situation prevailed because population kept on growing as against inadequate housing. It also made it difficult for parents to control their children, which resulted in high delinquency of the youth. Large numbers of people regularly slept on the streets at night and under open verandas. 3.5 Education Institutions within the metropolis range from nursery, kindergarten, Primary, Junior Secondary, Senior Secondary, Teacher Training, Technical and Vocational Institutes to Polytechnic The schools are being managed by the SAEMA, Religious bodies and other units as indicated in table 3.2. Table 3.2 Number of Schools and Management Units in Sekondi-Takoradi MANAGEMENT UNIT NUMBER OF SCHOOL TOTAL African Methodist Episcopal Kinderg arten 3 Primary 4 Junior Secondary School 2 9 Anglican 9 10 6 25 Catholic 17 19 8 44 Garrison 7 7 7 21 Islamic 8 10 2 20 Methodist 21 27 16 64 Metropolitan Assembly 37 47 49 133 Presbyterian 3 2 2 7 Seventh Day Adventist T.I. Ahmadiya 1 2 1 3 TOTAL 106 130 93 329 Source: SAEMA, 2000. The Metropolitan Assembly controls the majority of the schools in the metropolis as shown in the table. There are also 12 senior secondary schools, 1 Teacher Training, 1 Technical College and 1 Polytechnic. The kindergartens take care of children from 4 to 6 University of Ghana http://ugspace.ug.edu.gh years. Out of the 106 kindergartens indicated in the table above, forty (40) are found in Sekondi, twenty-six (26) in Shama and forty-one in Takoradi. A kindergarten is made up of two classes with maximum intake of 30 children. The total number of enrolled children by the end of 2000 stood at 11, 716. There are 702 teachers at the Kindergarten out of which 274 (39%) are trained and 428 (61%) are not trained’. According to available statistics on enrollment, more males are enrolled in Primary and Junior Secondary schools than females. In pure analytical terms, this means that literacy levels will be higher among males than females, hence any issue that relates to level of literacy would mean that females will fall more victims. In the primary schools in the metropolis, were 4628 males and 4319 females enrolled as of end 2000. Also, in the twenty - two (22) Junior Secondary Schools, there were 1513 and 1487 males - females respectively by the end of 2000. Though statistics for senior secondary and other institutions were not available as at the time of this research, the trend is that, more males enroll in schools than females and a good proportion of the youth (162000) are students*. The major Senior Secondary Schools and Polytechnic in the study area are: The Community Day Secondary, Shama Secondary, Diabene Secondary, Archbishop Porter Girls’ Secondary, Ahantaman Secondary, Sekondi College, GSTS, St Johns fijai and Takoradi Polytechnic. Most Secondary schools in the metropolis do not have boarding facilities, especially for girls. There is however a great demand for girl-child education in the metropolis. The enrollment level for females as discussed earlier, is a figure which has shown an improvement on previous records, which are not available for this report, 56 * Data available at the physical planning department of the SAEMA University of Ghana http://ugspace.ug.edu.gh but revealed by the metropolitan office. In brief, among other problems affecting education is the likelihood of pre-disposition of students to vices of urban culture. 3.6 Economic Activities All kinds of economic activities or businesses could be found in Sekondi-Takoradi. The main commercial activities range from buying and selling on small and large scales, manufacturing activities, transport services, ‘galamsey’ and other illegal as well as ‘immoral’ economic activities such as commercial sex activities prevail in the metropolis. The commercial zones in the metropolis cover a total of 6.2% of the urban landuse. The hub of commercial activities is located in the central business district of Takoradi. This place covers an area of about 350 acres and includes all sections bounded by the Accra, Cape Coast and Axim roads in the Sekondi-Takoradi metropolis. The Takoradi central market is the core of trading activities and spans an area of 9 acres. It has been observed that about 3 out of every 8 vehicular trip in Takoradi are to and from the Market circle. The Market circle area continues to experience congestion with an in - traffic waiting time of about 4 minutes. This situation is accounted for by booming commercial activities and the central location of the market. The core of the market is choked with wooden stalls and has made it difficult for easy movements. These stalls are also used for all kinds of nocturnal immoral and illegal activities. The SAEMA has detailed a number of measures to decongest the area. These include the establishment of satellite markets at Apremdu, Kokompe and Bogoso.The Kokompe light industrial area has been established to absorb industrial and hardware sellers from the central area. University of Ghana http://ugspace.ug.edu.gh According to available data, a total of 12.05% of the metropolis’ land is under industrial activities. The study area is indeed the third largest industrial center in the country after Accra-Tema and Kumasi. Some of the major industries include WAMCO, Ghana Household Utilities Manufacturing Company (GHUMCO), as well as bulk petroleum installations. There is also the export-processing zone, demarcated into 100 plots of an average size of 2.5 acres. 2000 acres of farmland has also been converted into an industrial estate at Sofokrom to support the zone. 3.7 Recreation, Culture and Social Activities The Essei Lagoon Beach Resort at Sekondi, the Tokoradi Sports Club and the Sekondi Gyandu Park are the main recreational centers in the metropolis. Most of the potential sites such as the Essikadu Railway Park, remain abandoned and undeveloped. Most of the communities are without children’s playing ground and the existing open spaces are also encroached upon. In spite of these, there are so many drinking bars, restaurants and hotels in the area that offer recreational services to the public and tourists to the area. There are football clubs as well as cultural groups. However, cultural activities have not featured as major sources of entertainment. A 25-acre land has been acquired at Fijai near Sekondi for the construction of a Cultural Center. The development of the complex is ongoing, and it includes a 3000-seater theatre, a craft village, a durbar ground, artiste hostels and an administrative block. The SAEMA revealed that an entertainment program code-named western carnival is yet to be institutionalized. 58University of Ghana http://ugspace.ug.edu.gh Religious activities are one of the major socio-cultural activities in the area. There are different kinds of faiths of Christianity. There are also indigenous traditional sets, as well as recognized Moslems groups. The heterogeneous population has brought about cultural diversities, whereby almost all cultural practices representing various ethnic groups in Ghana could be found. The major native indigenous ethnic group is the Ahantas. The main language spoken is Fante. 3.8 Health The Effia-Nkwanta Hospital is the main health facility in the study area. It is also the regional hospital in the Western Region. It is also the regional reference hospital and accounts for all HIV/AIDS cases in the Western region. Sekondi - Takoradi is a sentinel surveillance site known as ‘Takoradi’. This site is situated at the Effia-Nkwanta Regional Hospital. Other health facilities in the area include the European hospital, Polyclinics and Pharmacies. There are traditional and spiritual healing centers. Malaria has been the number one of reported cases of diseases just as any other tropical area. Accidents, fractures and bums have also remained high over the years. Reproductive health cases also feature prominently as causes of hospital attendance. The Table 3.3 (a and b) show the statistics from 1997 to 1999 of top ten reported diseases at the OPD and Admissions. Unfortunately, HIV/AIDS is mainly not reported in the area of study, but mostly detected during blood tests and when its symptoms are reported. This again clearly points to the fact that, HIV/AIDS is not a disease that can only be singled out of others but a combination of series of diseases as a result of weak immune system. This is why it did not appear as a reported case in the statistics presented in Table 3.3. One should not look at the data and conclude that, HIV/AIDS has not been an OPD case. It could also be 59University of Ghana http://ugspace.ug.edu.gh strongly argued out that, the principal symptoms of HIV/AIDS in Sekondi-Takoradi (Diarrhoeal Diseases and skin disorder) have prominently featured in the reported cases shown in the Table 3.3 hence AIDS has been fully covered. This is not also to say that all the diarrhoeal diseases and skin disorder cases shown in the table, are HIV/AIDS related Table 3.3a Top Ten Causes of OPD Attendance: Effia-Nkwanta Regional Hospital SERIAL NO. DISEASE 1997 NO. SERIAL OB J % NO. msam m DISEASE OF 1998 CASES % | S E R IA L DISEASE NO. % NO. 1999 OF CASES 1 Malaria 13186 *5 33.7 Malaria ^ 36.0 1 J | Malaria 18014 36. 2 Accidents, 3588 * 11.7 Accidents “ 6.5 2 if Accidents, Fractures ' ;i Fractures and 1 Hi Fractures and 3130 6.6 and Burns Bums 1 BUmS >3 Upper 2740 4 7.0 i Pregnancy and ’ 1414 , 4.3 8 8 Pregnancy and 2017 4.1 Respiratory related k2 Related infection ;v | complications EjS complications 4 Diarrhoeal ^ 9 8 9 5.1 Gynaecological 1 1408 4.2 k ffe Diseases of 1928 3.9 Disease Disorders Oral Cavity 5 Skin H I 3,4 Upper 3.3 S a Upper 1857 3.8 Diseases i Respiratory ■ I Respiratory and ulcer i ! Tract infections B ",,'m Infection s Rheumatism 1220 * n 3.1 mm Diarrhoeal 2.5 6 If Gynaecological 1275 2.6 I & Joint pains I Diseases I Disorders 7 Pneumonia 1125 * 2.9 Tuberculosis 552 1.7 Diarrhoeal 1046 2 1 I Diseases 8 m Hypertension m 12.1 Skin Diseases 541 1.6 8 R Hypertension 777 ; ';' ' l I Ulcers Bj 9 jj Tuberculosis m ' 1.8 Diseases of 533 1.8 1 Diseases of 858 1.2 w 1 Oral cavity 1 jl Skin & Ulcers10 Anaemia 635 § 1.6 10 Hypertension 519 1.6 1 10 1 Tuberculosis 449 1.0 Source: Records Department-Effia Nkwanta Hospital University of Ghana http://ugspace.ug.edu.gh 61 Table 3.3b Top Ten-Admission Cases- 1997-1999: Effia Nkwanta Regional HosDital SERIAL NO. DISEASE 1997 NO. OF CASES % SERIAL NO. DISEASE 1998 NO. OF CASES % SERIAL NO. DISEASE 1999 NO. OF CASES 1 Malaria 702 16.5 1 Malaria 725 117 1 Malaria 606 2 Pneumonia 269 6.3 2 Severe Anaemia 329 5.3 2 Malaria with Anaemia 418 3 Tuberculosis 230 5.4 3 Pneumonia 285 4.6 3 Pneumonia 293 4 Anaemia 212 5.0 4 Tuberculosis 225 3.6 4 Tuberculosis 207 5 Febrile Convulsion 150 3.5 5 Hypertension 133 2.1 5 Abortions 200 6 Hypertension 97 2.3 6 Appendicitis 101 1.6 6 Severe Anaemia 154 7 HIV 91 2.1 7 Diarrhoeal Diseases 98 1.5 7 Hernia 144 8 C.V.A. 84 2.0 8 Sickle Cell Diseases 78 1.3 8 Hypertension 142 9 Fracture Femur 62 1.5 9 C.V.A. with Hemiplegia 67 1.1 9 Appendicitis 106 10 Meningitis 56 1.3 10 H.I.V. 64 1.0 10 Sickle Cell 90 Disease Source: kecoras Department-Effia Nkwanta Hospital Delving into the past shows that the density and overcrowding in the town increased the danger of contagious and infectious diseases. Sickness was general and frequent. Among the most common diseases were yaws, malaria, tuberculosis, pneumonia, dysentery and gonorrhoea (Busia, 1950). Health facilities available then were the welfare clinic (owned by the then government and Red Cross) and the Government General Hospital. However hospital health seeking was not good. Most people preferred to buy medicines from shops, drug stores or the market. Others also consulted University of Ghana http://ugspace.ug.edu.gh Mohammedans, native doctors and traditional priest. Some of the most common diseases treated at the General Hospital in 1947 are shown in the table 3.4. 62 Table 3.4 Diseases Treated At The General Government Hospital In 1947 Disease In-patients Death Out-patients Disease of the eye 38 - 1,465 Malaria 189 2 871 Gonorrhoea 240 - 475 Other Veneral Diseases 5 1 Yaws 1 - 685 Helminthes Diseases 115 181 Broncho-Pneumonia 7 6 3 Cober Pneumonia 92 18 10 T B of the respiratory system 56 26 9 Other T B 6 - 21 Nutritional Diseases 17 5 74 Source: Computed from tiusia (1950) In addition to the figures in table 3.4 there was a total of 3,012 attendances at the Veneral Disease Center (The Seamen’s Clinic) at Takoradi. In Table 3.4, it could also be seen that, malaria has been an old time ‘top and characteristic’ disease of the study area. However for the purpose of this study one would again see that diseases related to sex have also been a hallmark of Sekondi-Takoradi. It is however relevant to briefly look at the development of this kind of diseases. University of Ghana http://ugspace.ug.edu.gh 3.8.1 History of the development of STDs in Sekondi-Takoradi This is discussed in the context of Busia’s (1950) study where he looked at the collapse of sexual morality as an index of social failure. The high incidence of STDs in the area could strongly be attributed to the high level of prostitution that started in the past. In his study, Busia (1950) discovered that the collapse of sexual morality was among the indices of maladjustment to urban life. His data supports the general explanation of economic pressure and social isolations as important factors predisposing ‘to the fraction of law and custom’. Evident to this problem was the frequency of pre­ marital sexual relationships as well as the frequency of divorces due to adulteries, which is still a problem in present day Sekondi-Takoradi. The most obvious index to this problem was the growing practice of prostitution, favored by the presence of large un-married males, who were Africans, Europeans, Indians and Syrians and the regular visits of seamen. In the course of his survey (Busia, 1950), 127 prostitutes residing in Sekondi-Takoradi were interviewed, but only 9 of them were indigenous Ahantas. Fifty-two of them came from other parts of the country principally Cape Coast and Axim; 55 from Nigeria and 11 from Liberia. The study shows that there were many prostitutes in the study area when business was really thriving. Many of them had no ties with home and had changed their identities. To make up for this loss of touch with home, their union provided security of befitting funeral celebration and burial. Fifty (50) of the 127 interviewed had been to school, 10 had completed primary and the remaining 40 had discontinued schooling at various levels between standards four and seven, because of the following reasons. Some had babies while in school. Their parents could not pay their school fees, provide food and clothing. Some 63University of Ghana http://ugspace.ug.edu.gh were driven to prostitution through sheer poverty and had to leave home and fend for themselves. Some prostitutes made their living by remaining mistresses to Europeans, sleeping at their quarters. Many of them rented room in Takoradi where ‘pilot’ boys assisted them to get customers especially among seamen. Prostitution was a very lucrative trade during the ‘wars’, (when troops were quartered in Takoradi) such that prostitutes earned from £8-£l5 a month or more. A ‘pilot’ boy usually received eight shillings out of every £1 he enabled a prostitute to earn. However, public opinion regarded sexual immorality as a very serious evil. Disappointing comments were passed upon pre-marital relations, adultery, frequent divorce and prostitution. This is however a background to the strong stigma attached to sexually transmitted diseases especially HIV/AIDS, spreading so fast in the area but victims find very difficult to talk about. The more serious prevalence of prostitution was the one among schoolgirls and pre-marital adventures among schoolboys as well as other youngsters (Busia, 1950). The level of prostitution would however justify the huge number of sexually transmitted diseases reported as treated in the General Hospital in 1947, as shown in Table 3.4. However, most of the factors that contributed to the development of the prostitution business are still prevalent, and again promoting commercial sex activities in the Sekondi-Takoradi metropolis. As can be seen in Table 3.3a and 3.3b, HIV/AIDS and its manifestations have become the number one dominant and current STDs in Sekondi -Takoradi. Sekondi Takoradi scores the highest number of HIV/AIDS cases in the Western region. The area’s function as administrative, commercial, nodal centre and also as tourist destination 64University of Ghana http://ugspace.ug.edu.gh among others, have contributed a lot in the spread of HIV in the area. These functions encourage different levels of interaction between and among people of different socio­ economic status hence in a way, spreading the disease. According to available data, between 1994 and 2000, the region recorded over 1192 cases of AIDS, with the study area leading in these diagnosed cases. It is however clear that, most of the cases that come to the hospital are fully blown AIDS cases, since the patients report to the hospital only when they are very sick and most often when they are beleaguered by the opportunistic diseases. HIV cases are only arrived at during screening of blood and other clinical tests. University of Ghana http://ugspace.ug.edu.gh 66 CHAPTER FOUR 4.0 PATTERNS AND TRENDS OF HIV/AIDS IN SEKONDI -TAKORADI In this chapter, trends and patterns in HIV/AIDS are discussed. Data on cases treated at the Effia-Nkwanta Hospital since 1992 to 2000 and patterns revealed by the data gathered on HIV patients in 2001 are all discussed. Focus is on the distribution of cases in years, ages, sexes, marital statuses, occupations, places of residence, symptoms and other socio-economic indices. The data in this fourth chapter also serve as a background to the facilitating factors analyzed in chapter five. To fully appreciate the trends and patterns of the disease in Sekondi Takoradi, regional and national trends are presented alongside that of the study area where necessary. It is however important to appreciate the two types of data presented in this chapter on reviewed HIV/AIDS cases within the period 1992 to 2000 and data on HIV/AIDS patients. The essence is for the two to complement each other to really establish the patterns. 4.1 Prevalence rates of HIV/AIDS in Sekondi-Takoradi from 1992 - 2000 The prevalence rate of HIV in Sekondi-Takoradi, which is currently over 4.0%, shows a fluctuating trend over the years (1992-2000). This fluctuation cannot solely be attributed to any specific issue, but involves late reporting to hospital with the symptoms, stigma and data handling, which be-deviled this elementary years of prevalence calculation. Prevalence rates have been between 1.8 to 4.0 within the period 1992 to 1999 as presented in Table 4.1 At these prevalence rates, HIV in Western Region has contributed 9.1% to the cumulative (AIDS) national total of 43587 by the end of 2000. University of Ghana http://ugspace.ug.edu.gh 67 Table 4.1. HIV prevalence in pregnant women in Sekondi-Takoradi: 1992-1999 Year 1992 1994 1995 1996 1997 1998 1999 Prevalence Rates (%) 1.8 4.2 3.8 3.0 4.0 Source: NACP Sentinel Surveillance, 2000. (No data was computed fo r 1993 and no records were made for 1992 and 1995) HIV in Western region cumulatively contributed 9.1% of the national value, which seems small a percentage to the total value, but making the region the fourth highest with HTV/AIDS currently in the country. The cases in the Western region are mainly reported from Sekondi-Takoradi. Ashanti region has the highest cases in the country representing 29.9%, followed by Eastern region with cases forming 15.9% and Greater Accra with cases representing 14.7 before Western region, where Sekondi-Takoradi metropolis contributes nearly half of all screened cases. This is also shown in figure 4-1, on reported cumulative AIDS cases in Ghana by regions. The actual figures provided by the STD/HIV unit at the Effia-Nkwanta Hospital also show fluctuating trends but depicting relative increase in cases. As shown in Table 4.2 from 1992 to 1995 the total positive cases fluctuated, but started increasing from 1996 to 1999. This indicates that the number of people being infected currently with HIV is increasing. University of Ghana http://ugspace.ug.edu.gh 68 Fig. 4-1 Reported cumulative AIDS cases by Region- March 1986 to Dec. 2000 s-' vO ^ ^ ^ ^v s yysy/ V Source: DCU/MOH 2000. (Figures have been rounded up to the nearest degrees in the chart) Table 4.2 Shama Ahanta East Metro (Sekondi-Takoradi) HIV Tests, 1992 - 1999 YEAR TOTAL SCREENED TOTAL POSITB E \ 1992 1899 178 1993 2583 367 1994 2916 341 1995 2433 290 1996 2365 191 1997 2731 292 1998 2866 465 1999 3257 472 Source: STD/HIV Unit, Effia-Nkwanta Hospital. 4.2 Age distribution The age distribution of patients interviewed is shown in Table 4.3. The data portrays only the categories of the reproductive and productive age group, which is actually the target age group for the study. The patients interviewed, show high frequencies in the 25-29 and 35-39 age groups. The national average age group of high incidence (30-34) has recorded a lower percentage among the other groups shown in University of Ghana http://ugspace.ug.edu.gh Table 4.3. This could generate a lot of debate, but the fact here is, the peak group of the patients interviewed is the 35-39 age group, which is also shown in figure 4-2. The age distribution computed for cases in Sekondi-Takoradi from 1996 to June 2000 reveals a presence of HIV/AIDS in the 15 to 49 age group. This pattern of prevalence with high incidence in the productive and reproductive age group is revealed everywhere in the country. The national cumulative reported ADDS cases from 1986 to 2000 and AIDS cases reported from January to December 2000 also show similar trends, with the peak cases in the age groups of 30-34 (9295) and 30-34(1270) respectively. Table 4.3 Age distributions of HIV/AIDS patients interviewed 69 ■ Frequency H Percentage 1 Age Group Frequency Percent (%) 20-24 6 14 25-29 10 24.4 30-34 5 12.2 35-39 11 26.8 40-44 4 9.8 45-49 5 12.2 Totals 41 100 Source: Field survey, 2001. Fig. 4-2 Age distribution of Patients 45-49 40-44 8. = 35-39 o 3 ° - 3 4 o> < 25-29 20-24 0 5 10 15 20 25 30 Values Source: Field survey, 2001. ...............— , ™ , . . ' W L W Q i8 00i L „ L --------------- - .......,• "-'--JIM i________________ * ... University of Ghana http://ugspace.ug.edu.gh 70 4.3 Sex Distributions of HIV/AIDS patients interviewed The general trend as discussed in the introduction shows high percentage of females (63%) with the disease as against their male counterparts (Agyei-Mensah, 2001). This trend is similar to what has been found in the case of Sekondi-Takoradi as shown in Table 4.4. Females formed 68.3% while the males constituted 31.7% of the patients interviewed. The female dominance in the spread of the HIV has been attributed to series of issues. Among these are their inability to negotiate for safer sex and their ‘second person identification’ imbued in the African culture, causing them to be at the receiving end of any thing. Coupled with their lower economic status, most African women are easily lured to submit themselves to sex at the peril of their lives. Table 4.4 Sex Distributions of HIV/AIDS patients interviewed Sex Frequency Percent (%) Male 13 31.7 Female 28 68.3 Totals 41 100 Source: Field survey, 2001. The impression from the above table is that, there are more females living with HIV/AIDS than men in the study area. Females dominated each category of age groups shown in Table 4.3 with a ratio of little over 2:1. This pattern is also not different from the cases reviewed prior to the live interviews shown in figure 4-3. University of Ghana http://ugspace.ug.edu.gh 71 Source: Disease Control Unit, MOH Takoradi 4.4 Marital status In Ghana and most other countries, HIV prevalence is high among single people (separated, divorced, widowed and unmarried). On the contrary however, this study has found high cases of HIV/AIDS rather among married couples. This is quite different from documented prevailing trends, but the reasons for this pattern will be discussed in chapter five. The pattern as shown in Table 4.5 and figure 4-4, reveals as much as 48.8 percent of the patients in the married category, with the immediate following categories being the divorced and the re-married constituting 19.5% respectively. This pattern showing fewer ‘singles’ category as against the married confirms the fact that HIV is mainly an issue of heterosexuality in sub Saharan Africa. Case histories reviewed from 1996 to June 2000, shown in figure 4-5 also reveal high cases of HIV/AIDS among married couples, yielding 46%, followed by singles with 30%, then the divorced with 11%, un-married with 8% and the widowed, 5% respectively. This however points to the fact that, HIV/AIDS in Sekondi-Takoradi is an issue of high concern among married couples than other sorts of people. ■ Sexes Fig 4-3 Sex Differentials of HIV/AIDS Cases In Sekondi Takoradi 1996-June 2000 MALE FEMALE University of Ghana http://ugspace.ug.edu.gh Va lu es 72 Table 4.5 Marital status of HIV/AIDS patients interviewed in 2001 Status Frequency Percent (%) Married 20 48.8 Single 1 2.4 Divorced 8 19.5 Widowed 2 4.9 Re-Married 8 19.5 Un-married 2 4.9 Totals 41 100 Source: Field survey, 2001. m Frequencies ■ Percentages Fig. 4.4 Marital Status of Patients jjP - W K l,