Memoire Online - Knowledge and perception on HIV premarital counseling and testing among unmarried young people of Kintampo town in the republic of Ghana,

KNOWLEDGE AND PERCEPTION TOWARDS PREMARITAL COUNSELING AND TESTING ON HUMAN IMMUNODEFICIENCY VIRUS INFECTION AMONG UNMARRIED YOUNG ADULTS IN KINTAMPO DISTRICT OF GHANA

To my wife Lucie Tshongo Kavira Makelele, that I missed too much and who reciprocally suffered patiently my long absence, for your motherly cordial care you provided to our children during my study leave, for your caring love and mutual understanding,

To my children Amos Makelele M'Yisa, Dieu-Exauce Makelele Vutokii, Miriam Makelele Mukiranya, Esther Kavuo Makelele and to you all my dependants for the suffering you faced from the lack of fatherly care due to my studies, and for your prayerful supports , your encouragement , your good wishes and warm regards to your father,

To my whole family members, especially my Mother Kahindo Mukiranya who kept praying for me throughout this hard course,

To every body who has ever supported me somehow; either morally, materially or financially towards the attainment of the current educational level and the successful end of this course,

I acknowledge a grant from my Sponsor Word Council of Churches (COE-WCC)/Switzerland which made it possible to achieve my study dream and the Union Evangelical Mission (UEM-VEM)/Germany for the additional financial support which solved my life hardship in Ghana, thereby enabling me to produce this work.

I thank the Director Prof. Isabella A. Quakyi and the entire staff of School of Public Health of University of Ghana, Legon, for the entire knowledge they insistently and consistently imparted in us and for their moral support and encouragement.

I thank Dr Seth Owusu- Agyei and Mr. Alfred.A.D. OBUOBI, my Academic Supervisors, who, despite their busy work schedule, diligently and profoundly assisted me in planning, conducting, correcting and enriching this work; and to Dr E.T.ADJASE, my field Supervisor, for approving the study topic, for his unlimited constructive advice as well as fatherly support which made my stay in Kintampo very enjoyable and comfortable, and finally for the training care which we received while on the field. This has successfully provided me enough field knowledge, skills and experiences.

I thank the entire staffs of Kintampo District Health Directorate, of Kintampo Rural Health Training School (KRHTS) and of Kintampo Health Research Centre (KHRC) for all their fruitful, caring, supervisory, and skilled expertise and support during this study,

Finally I thank my course mates, my key informants and all respondents for their generous contribution towards the achievement of this work.

			Pages
DECLARATION...........................................................................			ii
DEDICATION..............................................................................			iii
AKNOWLEDGEMENT...................................................................			iv
TABLE OF CONTENTS..................................................................			v
ABBREVIATIONS...........................................................................			ix
ABSTRACT..................................................................................			x
LIST OF DIAGRAM, MAP, FIGURES AND TABLES			Xii

Chapter One INTRODUCTION.......................................			1

I.1. BACKGROUND INFORMATION..............................................			1
I.1.1. Marriage and its reproductive health implication.......................			1
I.1.2. Scope and objectives of premarital Screening............................			2
I.1.3. Study Area...................................................................			4
I.2. STATEMENT OF THE PROBLEM.............................................			7
I.3. CONCEPTUAL FRAMEWORK: PROBLEM ANALYSIS DIAGRAM...			10
I.4. RATIONALE OF THE STUDY.................................................			11
I.5. GOAL AND OBJECTIVES OF THE STUDY................................			12

Chapter Two LITTERATURE REVIEW.......................................			14

2.0. Definition of concepts			14
2.1. Premarital examination in Ghana and in Kintampo District..........			14
2.2. HIV-AIDS situation in west Africa and Ghana.........................			16
2.2.1. In West Africa..................................................			16
2.2.2. In Ghana.........................................................			17
2.3. HIV VCT and premarital HIV counseling and testing			20
2.4. Procurement of Materials for VCT			23
2.5. Factors influencing willingness to undergo HIV PCT			23
2.6. Reasons for undergoing HIV VCT			24
2.7. Barriers to HIV VCT/PCT			24
2.8. Marriage between HIV discordant or HIV seropositive couples			24

Chapter Three METHODOLOGY..........................................			25

3.1. STUDY DESIGN AND STUDY POPULATION ...........................			25
3.2. VARIABLES UNDER STUDY.................................................			25
3.3. DATA COLLECTION TECHNIQUES AND TOOLS ......................			28
3.3.1. Data Collection Techniques...........................................			28
3.3.2. Data Collection Tools..................................................			28
3.4. SAMPLING........................................................................			28
3.4.1. Sample size calculation ..............................................			28
3.4.2. Sampling method ......................................................			29
3.5. DATA COLLECTION............................................................			32
3.6. DATA PROCESSING AND ANALYSIS.....................................			34
3.6.1. Qualitative data ...........................................................			34
3.6.2. Quantitative data .........................................................			34
3.6.2.1. Data quality control .........................................			34
3.6.2.2. Data presentation and statistical analysis .................			34
3.6.2.3. Score allocation for level of knowledge and perception towards HIV PCT.......................................		35
3.7. SOME ETHICAL CONSIDERATIONS.......................................		35
3.8. LIMITATION OF THE STUDY................................................		36
3.9. RETRO INFORMATION AND DISSEMINATION OF FINDINGS...........................................................................		37

Chapter Four FINDINGS.......................................................		38

4. 1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS..................................................................		38
4.1.1. Distribution of respondents by age and sex.............................		38
4.1.2. Educational background of respondents ...............................		39
4.1.3. Religion, ethnic group and occupation background of respondents................................................................		40
4.2. PREMARITAL SEX HISTORY AND HIV-AIDS RISK FACTORS AMONG SURVEYED RESPONDENTS.....................................		41
4.3. GENERAL AWARENESS AND KNOWLEDGE OF RESPONDENTS ON HIV/AIDS, VCT AND HIV PCT..........................................		44
4.4. SCORE OBTAINED ON AWARENESS AND KNOWLEDGE OF RESPONDENTS ON HIV PCT................................................		49
4.5. GENERAL PERCEPTION OF RESPONDENTS TOWARDS HIV PCT.		52
4.6. SCORE OBTAINED ON PERCEPTIONS OF RESPONDENTS TOWARDS HIV PCT............................................................		55
4.7. RELATIONSHIP BETWEEN SCORE OF KNOWLEDGE AND SCORE OF PERCEPTION AMONG RESPONDENTS....................		57
4.8. FACTORS INFLUENCING PERCEPTION OF THE NEED OF HIV PCT SERVICES..................................................................		58
4.9. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT..................................................................................		59
4.10. DEDUCTION OF PROBABILITY FOR RESPONDENTS TO PERCEIVE THE NEED OF HIV PCT SERVICE AND TO INTE ND UNDERGOING HIV PCT................................................		60
4.11. PREFERENCE TO UNDERGO HIV VCT FOR MARITAL REASON OR NOT........................................................................		61
4.12. BARRIERS TO HIV PCT ACCEPTANCE AND IMPLEMENTATION IN KINTAMPO DISTRICT...................................................		61
4.13. KEY ISSUES TOWARDS HIV PCT HEALTH PRACTICE IN KINTAMPO DISTRICT................................................		64
4.13.1. Views on frequency of HIV test before marriage among would-be couples...................................................		64
4.13.2. Views of respondents on who should send would-be couples at the hospital for HIV PCT....................................................		66
4.13.3. Views on to who the HIV test result should communicated after a PCT session.......................................................		66
4.13.4. Ways to promote HIV PCT in K'po district.........		67
4.13.5. Ways to create easier accessibility to HIV PCT in K'po district........................................................		68
4.13.6. Ways to make HIV PCT more effective, acceptable and attractive for young people in K'po district........................		69
4.13.7. Health facilities where HIV PCT centre should be established in K'po district............................................................		70
4.14. POSSIBLE DECISIONS THAT WOULD-BE COUPLES ARE MORE LIKELY TO MAKE GIVEN DIFFERENT SCENARIOS OF HIV TEST RESULTS.....................................................................		71
4.15. POINTS OF VIEW OF RESPONDENTS ABOUT MARRIAGE BETWEEN DISCORDANTS COUPLES AND HIV INFECTED COUPLES............................................................................		72

Chapter Five DISCUSSION.....................................................		74

5.1. PREMARITAL SEX HISTORY AND HIV-AIDS RISK FACTORS AMONG SURVEYED RESPONDENTS....................................		74
5.2. KNOWLEDGE AND PERCEPTION OF RESPONDENTS TOWARDS HIV PCT...........................................................................		75
5.2.1. Indicators on awareness and knowledge on HIV PCT...............		75
5.2.2. Level of knowledge on HIV PCT.......................................		79
5.2.3. Indicators of perception of respondents towards HIV PCT.........		81
5.2.4. Relationship between level of knowledge and level of perception of respondents towards HIV PCT.......................................		88
5.3. FACTORS INFLUENCING PERCEPTION OF THE NEED OF HIV PCT S ERVICES..................................................................		89
5.4. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT		92
5.5. PREFERENCE TO UNDERGO HIV VCT FOR MARITAL REASON OR NOT.........................................................................		97
5.6. BARRIERS TO HIV PCT ACCEPTANCE AND IMPLEMENTATION IN KINTAMPO DISTRICT...................................................		98
5.7. KEY ISSUES TOWARDS HIV PCT HEALTH PRACTICE IN KINTAMPO DISTRICT.......................................................		102
5.7.1. Views on frequency of HIV test before marriage among would-be couples......................................................		102
5.7.2. Views on who should send would-be couples at the hospital for HIV PCT.............................................		103
5.7.3. Views of respondents on to who the HIV test result should communicated after a PCT session....................................		104
5.7.4. Ways to promote HIV PCT in K'po district............................		105
5.7.5. Ways to create easier accessibility to HIV PCT in K'po district..		108
5.7.6. Ways to make HIV PCT more effective, acceptable and attractive for young people in K'po district........................		109
5.7.7. Health facilities where HIV PCT centre should be established in K'po district............................................................		111
5.8. POSSIBLE DECISIONS THAT WOULD-BE COUPLES ARE MORE LIKELY TO MAKE GIVEN DIFFERENT SCENARIOS OF HIV TEST RESULTS AND POINT OF VIEW OF RESPONDENTS ABOUT MARRIAGE BETWEEN DISCORDANTS COUPLES AND HIV INFECTED COUPLES................................................	112

Chapter Six CONCLUSION AND RECOMMENDATIONS ................	114

REFERENCES...........................................................................	123

ANNEX 1. QUESTIONNAIRE FOR THE SURVEY.................................	A
ANNEX 2a: INTERVIEW GUIDE FOR HEALTH CARE PROVIDERS.........	H
ANNEX 2b: IN-DEPHT INTERVIEW GUIDE FOR RELIGION LEADERS.....	J
ANNEX 3: FOCUS GROUP DISCUSSION GUIDE (FGDG)........................	L
ANNEX 4. DESCRIPTION OF VARIABLES UNDER STUDY AND SCORING SCALE....................................................................	N

ABSTRACT

HIV PCT, as part of VCT, is recognized worldwide as a core strategy of limiting the spread of HIV in new couples and their offspring. The study on «Knowledge and perception towards PCT on HIV infection among unmarried young adults in Kintampo District» was one of the preliminary studies needed for the implementation of VCT services in the District.

AIM: The general objective of the study was to generate useful information on current level of knowledge and perception of unmarried young adults towards HIV premarital counseling and testing (HIV PCT) in order to predict their acceptance and behaviours towards utilization of such service and to deduce appropriate program/policy for intervention in the relevant area.

METHODS: We analyzed data from a cross sectional survey among 150 unmarried young adults between 15 and 30 years old and from FGDs and IDIs. The survey was carried out in 3 of the 8 sub-districts in the district. Compounds where to find respondents were randomly selected and an interviewer-administered questionnaire was used. We allocated scores of knowledge on HIV PCT and of perception towards HIV PCT to given answers. We also applied 2 Logit models to determine predictors of willingness to undergo HIV PCT and of perceived need towards HIV PCT service.

FINDINGS: Out of 150 respondents, 71% lived in urban and 29% in rural areas. Respondents were of a mean age of 21.0 years (SD 4.48), the majority of them (76%) being aged between 15-24 years. The sex ratio was 104 [little predominance of males (51%)]. In general 97% of respondents had Good Knowledge on HIV PCT, with 41.3% showing Adequate good Knowledge, versus 55.7% showing Average good knowledge on HIV PCT. Only 3% of respondents showed Poor knowledge on HIV PCT. The entire totality (100%) of respondents in both sexes had Adequate positive perception towards HIV PCT. There was a significant weak positive linear relationship between level of knowledge and level of perception (p-value 0.007). Willingness to undergo HIV PCT was strongly positively associated with readiness of a respondent to know and accept his/her HIV result (p<0.001). Willingness to undergo HIV PCT was negatively associated with age, post-primary educational level, being student, having ever had premarital sex, perceiving the need of HIV PCT services and suggestion that HIV PCT should be provided free of charge, with no significant associations. Willingness to undergo HIV PCT was slightly positively associated with Akan & Mo Ethnic groups, urban residence, being Christian and female, level of knowledge and level of perception towards HIV PCT and suggestion of confidentiality in PCT services, with no significant associations.

CONCLUSION: In view of the study findings showing good knowledge and adequate positive perception towards HIV PCT among unmarried young adults, HIV PCT service for would-be couples is needed and feasible at present in Kintampo District. Majority of unmarried young adults showed positive acceptance towards utilization of such service.

Not all populations of unmarried young groups have an equal likelihood of accepting to undergo HIV PCT. Therefore Public health intervention (BCC/IEC) in the district on HIV PCT should be adapted specifically for each population segment and address perceived barriers to HIV PCT. A policy document is needed to specify the scope and procedures of premarital examinations in light of the findings in this study.

KEY WORDS: HIV/AIDS; Kintampo District; marriage, premarital counseling and testing (PCT), unmarried young adults, would-be couples.

LIST OF DIAGRAM, MAP, FIGURES AND TABLES	Page

DIAGRAMS

Diagram 1: Conceptual framework: problem analysis diagram .................................................................	10
Diagram 2: Relationship between variables: assumptions of logit models....................................	27

FIGURES

Figure 0: Map of Kintampo District showing Centroids of study (villages/Towns) and roads network...	32
Figure 1: Distribution of surveyed respondents by age and sex..................................................	39
Figure 2: Distribution of surveyed respondents by educational level and sex.................................	40
Figure 3: Distribution of Respondents by Religion, Ethnic group and Occupation...........................	41
Figure 4: Distribution of respondents by sex and age at first sexual intercourse..............................	42
Figure 5: Distribution of respondents according to their scores of knowledge on HIV PCT................	51
Figure 6: Distribution of Respondents by location and score of knowledge on HIV PCT...................	52
Figure 7: Distribution of respondents by sex and their score of perception towards HIV PCT..............	56
Figure 8: Distribution of respondents by sex and suggestion on the required number of HIV tests to undergo before marriage....................................................................................	65
Figure 9: Distribution of respondents according to their choices on the person who should send would- be couples for HIV PCT...................................................................................	66
Figure 10: Suggestion of respondents about to whom the HIV test result should be communicated after a PCT session..............................................................................................	66
Figure 11: Frequency of ways suggested by respondents to make easier accessibility to HIV PCT in the District......................................................................................................	68
Figure 12: Trend of possible decisions on marriage that respondents are more likely to make given different scenarios of HIV test results after a HIV PCT session....................................	71
Figure 13: Points of view of respondents about marriage between HIV discordant would-be couples and both infected would-be couples....................................................................	73
Figure 14. Steps and actions needed in order to promote HIV PCT in the K'po District, based on Suggestions of beneficiary respondents...............................................................	107
Figure 15: Steps and actions needed to make HIV PCT practice more acceptable and attractive for young adults in K'po district, based on suggestions of beneficiary respondents .........	110

TABLES

Table 1: Sub- districts of Kintampo District and their respective populations.................................	5
Table 2: Sampling characteristics of selected towns and villages per sub-district...........................	31
Table 3: Distribution of respondents according to premarital sex history and sex............................	41
Table 4: Trend of general awareness and knowledge on HIV/AIDS, VCT and HIV PCT...................	44
Table 5: Level of knowledge on HIV PCT..........................................................................	50
Table 6: Trend of general perception of respondents towards HIV PCT.......................................	53
Table 7: Level of perceptions towards HIV PCT..................................................................	56
Table 8: Linear Regression: Regress score of perception =score of knowledge, CL 95%.........................	57
Table 9. Factors (predictors) influencing Perceived need of HIV PCT service (p₁) among unmarried young adults in Kintampo District.........................................................................	58
Table 10. Factors (predictors) influencing willingness to undergo HIV PCT service (p₂) among unmarried young adults in Kintampo District..........................................................	59
Table 11: Distribution of respondents according to their probability of perceiving the need of HIV PCT and of willingness to undergo HIV PCT................................................................	60
Table 12. Distribution of respondents by sex and HIV testing choices.........................................	61
Table 13: Respondents' perception of barriers to HIV PCT acceptance and implementation...............	61
Table 14: Distribution of respondents by religion and perception of Islam as a barrier to HIV PCT Implementation.............................................................................................	64
Table 15: Suggestions from respondents on ways to promote HIV PCT in Kintampo District..............	67
Table 16 : Suggestions for the HIV PCT practice to be more effective, acceptable and attractive to unmarried young people in Kintampo district.........................................................	69
Table 17: Health facilities where respondents suggest HIV PCT services to be established................	70

Chapter One

INTRODUCTION

1.1.1. MARRIAGE AND ITS REPRODUCTIVE HEALTH IMPLICATION

Legal relationship between a husband and a wife ^{1, 2,
3}, marriage can maintain good sexual reproductive health if it is safe or rather create ill-sexual reproductive health in couples, if it is unsafe.⁴ In fact a marriage may be legal-and miserable; religious-and diseased. This is partly due to the colossal ignorance of the public in regard to sex and health implication of marriage, and partly due to the fact that marriage is mainly controlled by lawyers and priests or pastors- most of who take no regard for the health status of would-be couples and their offspring- than by would-be couples themselves and medical doctors.⁴ Health aspects related to marriage union require enlightened interventions from health policy-makers and practitioners to ensure that marriage is safe for both partners and their offspring, that it is not leading them to some diseases.⁴ In fact marriage union can expose to several diseases such as STI including HIV-AIDS, genetic diseases (such as sickle cell anemia or thalassemia in children), rhesus incompatibility, among others ^4,5,6,7,8. According to WHO, «safe sex is a consensual sexual contact with a partner who is not infected with any sexually transmitted pathogens and involving the use of appropriate contraceptive measures to prevent pregnancy unless the couple is intentionally attempting to have a child» ^7,9.

In her book in early 1922, Ettie A. Rout⁴ recognized venereal diseases as the chief obstacle to safe (healthy) marriage, fact that is still true and even far true nowadays with the incurable HIV-AIDS which has come to endanger further the humanity. Therefore one of the main means recommended by WHO to promote sexual reproductive health and safe marriage in new couples is prior medical control of marriage in paying close attention and care about the health status of would-be couples as a prerequisite to pass through before the official celebration of marriage. ^{3, 4, 5, 6} Indeed most STIs/HIV-AIDS transmission in new couples and their offspring could be avoided by strict adherence to safe marriage practices through prenuptial medical counseling and testing of would-be couples¹⁰. That is why, according to WHO, a number of countries require individuals who are about to enter into marriage to undergo an examination designed to confirm or infirm the absence of specific diseases, including those transmitted sexually such as HIV-AIDS and that if evidence of an infectious disease is found, the marriage cannot be contracted until the affected would-be couple has undergone treatment and is no longer infective ¹¹.

One of the countries where premarital examination and counseling is regular is China where law on premarital examination legally requires every Chinese man and woman planning to get married to undergo a medical check -up before they tie the knot. ^12,13

1.1.2. SCOPE AND OBJECTIVES OF PREMARITAL SCREENING

Pre-marital screening is a comprehensive group of tests specially designed for those who are planning to get married ¹⁴. Generally, premarital check-up is broadly designed to detect many types of diseases or health-related problems in would-be couples and when possible to take preventive or therapeutic intervention and/or provide appropriate counseling to help them decide. The main specific objectives of premarital examination commonly recommended and that medical practitioners are called to carry out in would-be couples, not exhaustively nor exclusively, are as follows:

2) To assess the fertility or fecundability ability of would-be couples ^5,14,15,16

3) To detect Sexually Transmitted Infections (STIs), including HIV/AIDS among would-be couples ^{2,3,5,11,14,15,17,18}.

4) To detect the possibility of blood incompatibility reactions between would-be couples, mainly negative rhesus factor in women when the would-be husband is rhesus positive ^{3,6,14,15,19,20,21,22}.

5) To detect genetic diseases in would-be couples susceptible to be hereditarily transmitted to children, e.g. sickle cell anemia, Thalassemia... ^{3,5,7,14,15,21,23,24}.

6) To detect diseases or factors in would-be couples susceptible to cause congenital abnormalities or serious pathologies to children, e.g. Toxoplasmosis,

7) To detect chronic diseases in would-be couples that can destabilize life in family, such as diabetes mellitus, cardiac diseases, mental deficiency etc ^5,6,14,15,21.

8) To establish a pre gestational health status baseline as part of the engaged woman (would-be mother)'s health profile, determining in advance her obstetrical prognosis and assess her readiness for child bearing ^{6,13,14,15,18,20,22,25}.

9) To verify whether or not there is an ongoing unknown/hidden and illegitimate premarital pregnancy in engaged woman ²⁶.

10) To give counseling and health education on safe sexuality and family planning ²⁷.

11) To exceptionally conduct vaccination for some Preventable Disease, such as Hepatitis B and Rubella vaccine ^15,27. This is rarely done.

12) Finally, most controversially, premarital examination in some part of the world , particularly in China, also routinely aims to verify whether or not a woman's hymen is still intact, even though doctors say that it is not a reliable guide to virginity ¹².

These objectives demonstrate how complex and vast the scope of premarital examination is and how it can vary from a country to another depending on the prevailing burden of diseases or health-related problems generated from marriage and on the national strategies chosen to address them.

For academic purpose and due to time and financial constraints this study will deal only with premarital check-up on HIV-AIDS. This is because a VCT service is planned to be implemented in Kintampo District in the near future²⁸. Thus this preliminary study aims to unveil the knowledge and perceptions of unmarried young adults on Premarital HIV VCT and to provide useful information to policy-makers and health authorities for appropriate methods and strategies to promote premarital HIV counseling and testing in Kintampo.

1.1.3. STUDY AREA

Kintampo district is located in Brong Ahafo Region in Ghana. It is one of the 13 Districts in the Brong Ahafo Region. The District has a surface area of 7162 square kilometers and is bound to the North by the Black Volta, Wenchi District to the West, and in the East by the Atebubu District and the Techiman and Nkoranza to the South and South East respectively.

The District has a population of 162008 inhabitants as of end 2004 (This is based on the year 2000 national population census), of whom 27541 (17%) are adolescents and 21060 (13%) are adults aged more than 50 years. The main indigenous ethnic groups are the Bono`s (most found in Jema Health sub-district), and the Mos (most found in New Longoro sub-district). Settlements are mainly concentrated in the Southern part and a long the main truck road linking the District capital to the Northern Region.^28,30

For administrative convenience of health service delivery, Kintampo District has been demarcated into 8 sub-districts with respective populations below:

As a whole there are 13 health facilities of which 9 (69%) are governmental and 4 (31%) are private. ²⁸

The 3 sub-districts under study are partly urban and rural. While Kintampo sub-district is mainly urban, of heterogeneous ethnic groups and even of multinational residents, New Longoro and Jema are mainly rural area of homogenous ethnic group, respectively constituted mainly by the Mos and the Bonos.

The main religion groups in the District and the sub-districts under study are Christian and Moslem.

Malaria is the leading cause of morbidity and mortality in Kintampo District. Sexually transmitted infections, including HIV/AIDS are also among the major public health problems in the District and the 3 sub-districts.²⁸

The STI/HIV-AIDS situation in Kintampo District is favored by the fact that Kintampo is a major transit centre for all kind of travelers among them drivers and traders from foreign countries (Burkina Faso, Mali, Niger....). A part from this fact, it is observed that, due to trading taking place over 24 hours and girls/young women selling the whole night their foodstuffs, drivers and other travelers are more likely to solicit those girls for sex at early age , putting them at high risk of HIV infection. With the high HIV-AIDS prevalence in adults aged 15-49 years which is the interval age where most young people get married in the area, also given the trend of HIV-AIDS prevalence among blood donors in 2004 and of reported AIDS cases in Kintampo District Hospital and Annor Asare Memorial Clinic (18 cases in 1998, 24 in 1999, 45 in 2000, 52 in 2001, 108 in 2002, 142 in 2003 and 133 in 2004)³⁰, the HIV menace is considerable in the area. Furthermore sex workers in Kintampo welcome multiple partners, national and foreigner clients. According to a reliable key informant source quoted in a previous study, they require different price for unprotected sex which is expensive and protected sex which is cheaper.³²

Because nowadays premarital unprotected sex with multiple partners seems common among young adults in the area, unmarried young adults are at high risk of contracting HIV-AIDS before marriage.

So far one of the main activities carried out in 2004 in Kintampo District was the intensification of Behavior Change Communication in addressing the HIV/AIDS menace.^{30, 31}

As yet Brong Ahafo Region runs only one VCT centre in Sunyani⁴³. To extend VCT coverage in the Region, one more VCT center is planned to be implemented in Kintampo in the future.

I.2. STATEMENT OF PROBLEM

Although recommended by UNAIDS/WHO ^10,11,44 , HIV Premarital counseling and testing (PCT) is not yet implemented in Kintampo, leading to uncontrolled marriages with risk of spreading HIV infection in new couples and their offspring. This stands true since in Brong Ahafo Region, including Kintampo District, the HIV/AIDS prevalence is reported to be of 3.6% in 2003 and of 4.5% in 2004, the most affected group being females and adults aged 15-49 years, with the peak ages of 25-39 years.^29,38 Therefore given the high HIV prevalence among young people, the probability for a unmarried young adult to come across a HIV infected fiancé(e) is considerable.

Furthermore, estimations and projections of HIV-AIDS prevalence and mortality suggest that marriages between HIV-AIDS discordant couples and HIV-AIDS seropositive couples in a society could result, within decades, in decimation of generations by early deaths of HIV infected parents and children if adequate HIV preventive and precautionary measures are not taken appropriately ^8,10. This means that policy makers and all bodies who are involved in marriage celebration and legalization, such as political and health authorities, lawyers, registrars, traditional chiefs and religious leaders; have a big responsibility in managing marriage matters and defining regulations and procedures related to the quality control of marriage. In fact like birth control is needed in all developed society, quality control of marriage is also necessary in order to ensure that marriage is safe to both partners, their offspring and the whole nation. In this purpose WHO/UNAIDS recommend HIV premarital counseling and testing in order to prevent the spread of the disease in new couples and their children ^10,11,42. That is why some churches in Ghana and in Kintampo are currently conducting sometimes HIV premarital testing in would-be couples.

Therefore policy makers should make sure that there are clear policies that include not only all requirements needed before marriage but also and especially restricting and limiting rules against unsafe marriages. In Ghana as yet there is no specific law that regulates premarital examinations. Yet Ghanaian people still need this service and some churches are currently allowing would-be couples to undergo HIV premarital examination on either compulsory or voluntary basis. In this context, HIV premarital counseling and testing is offered without any detailed regulatory law/policy. Meanwhile many are those marriages that continue to occur without any HIV premarital check-ups, putting at HIV risk partners and their offspring. That is why VCT, including HIV premarital counseling and testing, is recognized nationwide among current strategies in the national framework to limit the spread of the disease in Ghana ³⁵. For this purpose a VCT service is planned to be implemented in Kintampo.

Since the HIV premarital testing will be incorporated in VCT service in Kintampo, the research questions we ask ourselves are the following:

· Do unmarried young adults in Kintampo really perceive and express the need of HIV premarital counseling and testing program in Kintampo and what are factors associated with the perception of this need?

· How far do young people in Kintampo know about HIV premarital examinations and what are their perceptions towards premarital counseling and testing?

· What are the factors that influence the willingness of young people towards HIV premarital counseling and testing?

· Is HIV premarital examination really a core way to catch young adults to VCT in Kintampo District as it can be inferred from the findings in the previous study?³²

· What are some barriers against the acceptability and the institutionalization of HIV premarital examination in VCT services in Kintampo?

· What key suggestions would unmarried young adults make towards a very effective, operational, attractive, acceptable and accessible HIV PCT program in Kintampo?

· What are the points of view of unmarried young adults on marriage between HIV discordant or HIV seropositive couples and what possible decisions on marriage are they likely to make in regard to HIV positive test results?

· What kind of programmes should be carried out in order to promote HIV premarital counseling and testing in Kintampo district?

I.4. RATIONALE OF THE STUDY

VCT service is planned to be implemented in the District in the future. That is why exploratory studies are being conducted to gather useful information in this pre-VCT implementation period. This second pre-VCT implementation study focusing on HIV PCT among unmarried young adults aged between 15-30 years is conducted as an evidence-based research. In fact being a follow-up and a complementary research to the previous preliminary study on «Formative research for the implementation of VCT service in Kintampo»³², the present study actually looks at the health need of HIV PCT expressed indirectly by majority of respondents in that survey which targeted all the community members both married and unmarried ones aged between 15-49 years. In fact in this previous study 92.1% of respondents said not every body should go for HIV VCT, 15.7% mentioned that the main reason to go for VCT is when one wants to get married while 93% said VCT benefit is to help decide whether to marry or have children. All these findings clearly and relevantly support the need of HIV premarital health care services and strongly demonstrate how VCT implementation in Kintampo District should go together with the implementation of HIV PCT as it is recommended by WHO/UNAIDS ^10,11,42.

Now since most people who get married in Kintampo are in the age range between 15-40 years (Source: marriage registration in Kintampo Magistrate court and data from some churches) while the most affected by HIV/AIDS in Ghana and in the District are in the age group of 15-49 years²⁹, also because it is reported worldwide that more than half of people living with HIV/AIDS (PLWHA) were infected before they were 25 years of age with young people aged 15-24 accounting for more than 50 percent of all HIV infections worldwide⁴⁴ and in Ghana ²⁹, implementing HIV premarital examinations in the area will help to detect those young adults unknown carriers of the HIV/AIDS; so that appropriate measures can be taken early to reduce the HIV spread and further new infections in new couples/families and their offspring.

Given the fact that authors and WHO recognize that operational researches on human sexuality perception and counseling are strongly needed in order to improve reproductive sexual health^{7,9,11,54,55,56}, and considering that a nation's collective attitude and perception towards human sexuality is culturally determined and can profoundly influence several aspects of reproductive health and related policy-making ³⁹, including HIV premarital examinations, we hope that the study results on knowledge and perceptions towards HIV premarital medical examination will constitute a data base on which policy makers can refer to in examining the matter on the horizon.

Knowing fewer researches have been undertaken on the ground on HIV PCT, we think the study will generate practical suggestions from primary beneficiaries, that District Health Authorities in Kintampo could take into account in order to implement a highly locally owned and compatible HIV PCT program which meets the real expectations of the beneficiary population and consequently culminates in success, like it has been proved in many other parts of the world. ^10,57

I.5. GOAL AND OBJECTIVES OF THE STUDY

The community youth-based research aim is to generate useful information on current level of knowledge and perceptions of unmarried young adults towards HIV premarital counseling and testing (PCT) in order to predict their acceptance and behaviours towards utilization of such service and to deduce appropriate program/policy for intervention in the relevant area.

1. To identify factors (predictors) that influence the willingness of young unmarried adults to undergo HIV premarital counseling and testing.

2. To determine factors (predictors) influencing perception of health need towards HIV premarital medical counseling and testing among unmarried young adults.

3. To determine whether unmarried young adults will prefer to undergo HIV VCT for marital reason or not.

4. To identify any barriers to the acceptance and the implementation of HIV PCT in Kintampo and collect evident suggestions from respondents for an effective HIV PCT service.

5. To determine the point of view of unmarried young adults on marriage between HIV discordant or HIV seropositive couples and identify possible decisions on marriage that they are likely to make in regard to HIV positive test results after PCT.

Chapter Two

LITTERATURE REVIEW

- Youth: the time of life when a person is young, especially before a child becomes an adult¹

Note that in this study we are dealing with unmarried young adults aged between 15 (mid adolescents) and 30 years.

- Knowledge: the state of knowing about a particular fact or situation¹. The study deals with the state of knowing about HIV PCT.

- Perception: the way you notice things, the ability to understand the true nature of something¹. The study deals with the way respondents notice HIV PCT and understand its true nature.

2.1. PREMARITAL EXAMINATION IN GHANA AND IN KINTAMPO

«Laws on Premarital examination» is classified by WHO among core specific legislations for the prevention of Sexually Transmitted Infections (STIs) and other diseases in new couples in a country ¹¹. Yet so far in Ghana there is no specific law about premarital counseling and testing that describes its objectives, practical procedures and formal legal processes. However current existing policies (National Population Policy 1994, Adolescent reproductive Health Policy 2000 and National Reproductive Health Service Policy and Standards 2003, National HIV/AIDS and STI Policy) clearly mention the importance of «Information and counseling'' for young people, including premarital counseling and testing ^9,33,34,61. For instance the section 4.3.7 of the objectives of the above revised National Population Policy strongly shows the government's responsibilities towards young people, and I quote «To educate the youth on population matters which directly affect them such as sexual relationships, fertility regulation, adolescent health, marriage and childbearing, in order to guide them towards responsible parenthood and small family sizes»³⁴. The right for young people to have access to all information and counseling regarding reproductive health is also reemphasized in the adolescent reproductive health policy in section 3.2 which states: « ... Available evidence suggest that adolescents behave responsibly when they are well informed, especially on issues such as career development, relationships and reproductive health. Therefore at this stage individuals need adequate and reliable information to enable them make the right decisions and choices...»³³. In addition in the national strategic framework for HIV-AIDS, access to HIV VCT (including HIV premarital exam) is considered nation wide as a crucial service in the national response to combat HIV/AIDS ^35,36. All these literatures, just to mention a few, demonstrate that Ghanaian young people have the right to access HIV premarital counseling and testing services in order to make informed and right decisions and choices towards marriage.

In Ghana, like in most countries in sub-Saharan Africa, pre-marital HIV VCT is being widely promoted, particularly by churches and religious groups. Meanwhile in practice due to the expressed need of such service by young adults, HIV premarital examination is being carried out, not commonly, in certain towns, including Kintampo town. In fact report from the laboratory of Kintampo District Hospital (KDH) indicates that since January 2004 till July 2005, 14 would-be couples aged between 24 - 34 years old were received for HIV PCT, of whom 12 (86%) were sent by their churches while 2 (14%) came voluntarily. None of them tested HIV positive. These data showing a timid starting of the service in an embryonic stage constitute an undeniable and strong opportunity which will enable the smooth official implementation of HIV PCT in the District.

In general premarital examination is done on voluntary demand and consent of some would-be couples or in most cases by some churches that impose it instead. Furthermore, the examination has a selective meaning since in most cases it targets only HIV-AIDS testing and forgets about all other required premarital tests, thus resulting in an incomplete premarital check-up.

2.2. HIV-AIDS SITUATION IN WEST AFRICA AND GHANA

Since HIV-AIDS is nowadays the common most well known scourge that frightens humanity and that justify for many people the necessity of premarital check-up which is one of the preventive measures to reduce the spread of the infection, most young adults are likely to opt for HIV premarital check-up only because of fear of being married to an HIV seropositive fiancé(e). Therefore it is fair to elucidate in this paper the particular magnitude of this scourge in the region.

4.1.2. 2.2.1. In West Africa

Although varying in scale and intensity, the epidemic in West Africa appears to have stabilized in most countries. Median HIV prevalence measured among women in 112 antenatal clinics in the sub region remained at an average 3% to 4% between 1997 and 2002.³⁷ Overall, HIV prevalence is lowest in the Sahel countries and highest in Burkina Faso, Côte d'Ivoire and Nigeria--the latter having the third-largest number of people living with HIV in the world (after South Africa and India). In the two countries flanking it--Ghana and Benin--HIV prevalence is in the 2% to 4% range with little change noted over time ³⁷.

A variety of factors (economic changes and cooperation, transportation links, periods of instability and war...) experienced across the West African sub region have all contributed to increased mobility and, subsequently, the cross-border spread of HIV in Ghana. ²⁹

4.1.3. 2.2.2. In Ghana

In Ghana HIV prevalence was in the 2% to 4% range (median prevalence of 3.6%) in 2003 ²⁹ versus 0.4% to 7.4% range (median prevalence of 3.1%) in 2004 ³⁸ with little change noted over time ³⁷. By the end of 2003, close to 4 percent (3.6%) of the country's adult population was estimated to be HIV infected. This corresponds to about 395,000 Ghanaians aged 15-49 years, most of who do not even know they carry the virus. HIV prevalence differs from Region to Region, the least being in the Upper West (1.8% in 2003 versus 1.7% in 2004) and the highest in the Eastern Region (6.6% in 2003 versus 6.5% in 2004).

Being among regions with high HIV prevalence, Brong Ahafo Region including Kintampo District recorded a prevalence of 3.6% in 2003 ²⁹ versus 4.5% in 2004 ³⁸, suggesting an increasing trend of the epidemic in the region.

In Ghana, as in the rest of Africa, two main transmission mechanisms account for most new HIV infections: Heterosexual contact (80%) and mother-to-child transmission `MTCT`(15%). Other mode of contamination through contaminated blood (transfusions, sharing of needles or blades...) account for 5% ²⁹.

Although the probability of transmitting HIV during intercourse can be quite low ³⁹, a number of factors increase the risk of infection dramatically. One is the presence in either partner during unprotected sex of a sexually transmitted infection (STI), such as syphilis or gonorrhea. These diseases cause genital ulcers and sores that facilitate the penetration of the virus during the coitus. The 2003 sentinel surveillance results showed that a significant number of Ghanaian young adults suffer from STIs, and many have multiple sexual partners but don't use condoms to protect themselves ²⁹. It is estimated that most new HIV infections in Ghana are due to heterosexual contact ²⁹. Programmes designed to reduce the spread of HIV should focus on reducing transmission through unsafe sexual contact. HIV Premarital screening meets this strategy.

HIV Premarital examinations will also impact on HIV Mother-To-Child Transmission.

HIV has spread more slowly in Ghana than in many other African countries. For example, in several southern African countries, HIV prevalence among people 15-49 years old is now estimated at more than 15%. No one is quite sure why the epidemic has spread more slowly in Ghana and in some other West African countries. What should be kept in mind is that many eastern and southern African countries had prevalence rates in the late 1980s similar to those currently found in Ghana and that the situation worsened very rapidly ²⁹. All this demonstrates how an unchecked HIV-AIDS epidemic including uncontrolled marriages could still result in much higher increased HIV prevalence levels in Ghana, hence the necessity of preventive measures among which is HIV premarital examination in order to reduce particularly HIV prevalence in new couples and their future offspring. Ghana should not wait until it reaches much higher HIV prevalence to now formalize HIV premarital counseling and testing like it was in Ethiopia ⁴⁰.

The threat of HIV/AIDS and the concern for Africa's future generation were earlier reflected in the 1992 Organization of African Union (OAU) Declaration on AIDS in Africa. It is pertinent to extensively quote a part of this Declaration as quoted by UNDP ⁴¹., thus:

«... The hope of Africa is its younger generation who still has a chance to escape infection, we must seize this opportunity and ensure that today's girls and boys, who will be the mothers and fathers of tomorrow's children, are safe from HIV...»

This declaration strongly implies the necessity of preventive interventions to protect younger African people from the threatening HIV-AIDS infection. In fact more than 7,000 young people are newly infected with HIV each day throughout the world⁴². In Africa alone, an estimated 1.7 million young people are infected annually.^43,44

Some countries including Ghana are now acknowledging the importance of targeting youth in their HIV prevention and care strategies and include VCT and premarital HIV testing for youth in their agenda. Preventing HIV among young people through VCT and HIV PCT is particularly urgent in sub-Saharan Africa, where in many countries young people comprise more than 30 percent of the population and general HIV prevalence rates is often high.⁴⁴ National guidelines for the Republic of Ghana state that it shall «seek to ensure the expansion of the access of young people to youth-friendly facilities and services including HIV and STI (sexually transmitted infection) prevention, management and testing, counseling and the provision of care and support services.»³⁵

In Ghana there is near universal awareness of HIV-AIDS, 98 % among females and 99 % among males in the whole country, the level of awareness of HIV-AIDS in Brong Ahafo Region (Kintampo District included) being 99.5% and 100% respectively in women and men. However, risk perception is still low: about one-third of the population believes they are not personally vulnerable to HIV infection. ^29,53 This high HIV awareness rate is a strong opportunity upon which prevention programs could be based.

2.3. HIV PREMARITAL COUNSELING AND TESTING (PCT)

4.1.4. 2.3.1. DEFINITION

HIV premarital counseling and testing is a specific form of HIV VCT by which an individual who is about to enter into marriage undergoes counseling enabling him/her to make an informed choice about being tested for HIV in order to be able to make informed, right and responsible decision about marriage and production of offspring. However, some countries classify HIV PCT as a mandatory HIV testing rather than voluntary.^10,35,42,45

4.1.5. 2.3.2. JUSTIFICATION OF PREMARITAL EXAMINATION

Why is pre-marital examination important?
Many people are not aware of their state of health. An individual might look healthy but he may be a silent carrier to potentially contagious infections or serious hereditary disorders. A routine medical test will reveal such conditions so that necessary precautions or course of treatment could be initiated to avoid affecting the partner or passing on the disease to the next generation. Therefore premarital screening is important since it allows would-be couples to assess their own general health status, maintain good physical health for a 'happily ever after' marriage and strengthens the marriage relationship.^14,15,27,46

With advancements in medicine engineering opening up new possibilities of medical screening - and with the fear of the spread of diseases like STIs including HIV-AIDS - there is considerable pressure to require prospective spouses to undergo pre-marital medical exams. Thus some countries, like France, China, Syria, Tunisia, Egypt, Morocco, Saudi Arabia, the United Arab Emirates (UAE), among others, have encouraged their citizens to go for such pre-medical exams. Some have even made doing so a legal mandatory requirement for marriage that allows not only informed, right and responsible decision about marriage but also the control of targeted diseases and health related problems in new couples.^10,14,15

Furthermore, the marriage contract is a serious commitment that is supposed to be permanent and stable. If it surfaces after marriage that one of the spouses has a serious disease, this could lead to a premature termination of the marriage (divorce) if the other party refuses to stay with the person on account of the illness.^14,15

Finally research has shown that there is higher level of marital satisfaction and stability among couples who attended a satisfactory premarital counseling and testing than those who did not.⁴⁶

4.1.6. 2.3.3. HIV PCT PACKAGE 10

Like in all VCT service, counseling plays a significant role in HIV premarital examinations. Therefore classic HIV PCT service package ensures that:

In certain part of the world, doctor can even recommend against marriage and let the couple decide on the recommendation.^10,13

The essential thing is that if a fiancé(e) is found HIV seropositive, he will be informed by a medical counselor on the dangers facing the couple and the expected offspring so that (s)he makes responsible and informed decision about marriage. The physician/counselor shall also inform both parties to the intended marriage of the nature of the disease, the possibilities of transmitting such infection to his or her marital partner or to their children and the possible available preventive actions (e.g. protected sex by condom, mutual faithfulness, PMTCT...) to be applied for life if they still wish to marry. The couple, or each fiancé at least, then decides freely and knowingly whether they go ahead with the marriage, regardless of the results or break the marriage project. ^48,49

g. Deliverance of prenuptial medical certificate (marriage license) to the client after post test counseling, document that is required for the publication and the celebration of marriage.^3,5

2.4. PROCUREMENT OF MATERIALS FOR VCT

The important step in procurement of VCT materials is deciding how much of each commodity to buy. Commodities needed for youth friendly VCT services may include-- HIV test kits, -Automated analyzers, such as enzyme-linked immunoassay (ELISA) readers, -Centrifuges, -Refrigerators, TV/video equipment and health education videos, - Information leaflets, - Contraceptives, - Drugs for palliative and supportive care, such as pain management, - Antiretroviral (ARV) drugs for treatment and prevention of mother-to-child transmission, - Drugs to prevent and/or treat Opportunists Infections (OI), such as tuberculosis (TB) prophylaxis, - etc All these should be provided in a VCT /PCT site¹⁰.

2.5. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT

Studies have shown that willingness to have premarital HIV counselling and testing is positively associated with increased age, urban residence, and wish to keep one's own HIV testing result confidential. However, knowledge of a person with HIV/AIDS, HIV testing location, and other sexually transmitted infections/diseases, as well as belief that abstinence protects against HIV are inversely related to desire to take an HIV test.⁴⁵

The main reasons clients seek VCT include unprotected sexual intercourse, wanting to get intimate, premarital,

believing that they are already infected, STI infections, pre-university or employment.¹⁰

2.7. BARRIERS TO HIV VCT/PCT

Some barriers to HIV VCT/PCT have been recognized worldwide¹⁰. These are:- Availability and acceptability of VCT services, including legal issues ,- Waiting time ,- Costs and pressure by health staff to notify partners, - Worries about confidentiality and fear that results would be shared with parent(s) or partner(s) without their consent , - Lack of perceived risk and lack of perceived benefits in knowing HIV status, - Lack of information about VCT services/shortage of VCT centres. -Fear of being labelled and stigmatized by their families, friends and communities

- Perceptions of the consequences of living with HIV, - Inadequate responses from health care providers, including counsellors, to effectively meet the HIV prevention, care and support needs of youth - etc

2.8. MARRIAGE BETWEEN HIV DISCORDANT OR HIV SEROPOSITIVE

COUPLES

The third International Consultation on HIV/AIDS and Human Rights recognized rights of PLWA, including marriage.^70,71,72However because of stigmatisation and discrimination, people tend to exclude PLWA to their right to marry. Some groups (including evangelical church groups) demand to cite test results as grounds to deny a marriage ceremony (where results are discordant or positive). Test result certification is not provided by most VCT sites because of the potential misuse or negative consequences, including stigma, discrimination and false hopes of «safety»¹⁰. Also, despite the proved `Assisted Reproduction in HIV infected individuals` many people are reluctant to marriage between discordant and HIV seropositive couples.⁷³

Chapter Three

METHODOLOGY

3.1. STUDY DESIGN AND STUDY POPULATION

The study was a descriptive cross-sectional community based study using both qualitative and quantitative tools. The study population was all unmarried young adults of 15-30 years old living in the district. This target group of unmarried young adults has been chosen because they are the premarital age population and primary beneficiary and stakeholder of HIV PCT.

3.2. VARIABLES UNDER STUDY

The study variables were as follows (see Diagram 2 on page A and annex 4 on page N):

A-Socio-demographic background variables: Age, sex, place of residence, level of education, occupation, religion and ethnic group.

H-Perceived need of confidentiality and privacy regarding HIV PCT exam and results

J- Suggestions of clients towards a very effective and acceptable HIV PCT program

K-Point of view on marriage between HIV discordant couples and HIV seropositive couples and possible decisions on marriage that unmarried young adults are likely to make in regard to HIV positive test results.

We assumed that there was some relationships between these variables as it is described in Diagram 2. In fact we thought that the likelihood for a young unmarried adult to perceive the need of HIV PCT services was function of background personal specifications (age, sex, educational level, religion, residence area, tribe), the premarital sex history, the general knowledge on STI, HIV/AIDS, VCT/PCT and the general perceptions towards HIV PCT.

We also assumed that the willingness of a respondent to undergo HIV PCT was function of all the variables above plus the perceived need of HIV PCT services, the readiness to know and accept HIV test results, the suggestion that the provision of HIV PCT services should be at affordable or free cost and the perceived need of confidentiality and privacy regarding HIV PCT results. We also thought that application of key suggestions given by respondents may stimulate their willingness and their attendance towards HIV PCT, thus culminating to a very attractive, effective and successful HIV PCT program.

From these two first assumptions we derived two logit models which we attempted to verify in our data analysis.

Finally we assumed that once an unmarried young adult has the willingness to undergo HIV PCT, (s)he might then take the HIV test and attend counseling sessions. Counseling would then help him/her to know and accept his/her HIV test results. Counseling sessions might also help him/her take informed decision about marriage and develop a clear point of view on marriages between HIV infected people.

3.3. DATA COLLECTION TECHNIQUES AND TOOLS

4.1.7. 3.3.1. Data collection techniques

The study was performed into two phases and employed five main data collection techniques, namely the Review of available records and literature (Desk Research), the Focus group discussion (FGD), the In-depth Interviews (IDI) and the survey.

The first phase of the study -through desk research, in depth interviews and focus group discussion-was fully exploratory and qualitative in order to generate primary information while the second-one was the survey which generated quantitative data.

4.1.8. 3.3.2. Data Collection Tools

The tools used in the study were as follows: Problem analysis diagram (Diagram 1), Assumption of relationship between variables (Diagram 2), survey structured questionnaire (Annex 1), In-depth Interview guide (Annex 2a & 2b), FGD guide (Annex 3), existing reports, Table of variables (Annex 4), list of selected compounds, notebook, cameras, tape recorder, papers , pens and computers.

The structured questionnaire was mostly made of closed-ended questions offering either a choice among "yes", "no", or "I don't know" or a choice among several options.

3.4. SAMPLING

4.1.9. 3.4.1. SAMPLE SIZE CALCULATION

We calculated the sample size using EPI_INFO version 3.3 based on the following:

1. Population size of unmarried young adults in the age group 15-30 years old in the 3 sub-districts under study: 16.944 (data source: KDSS, see Table 2 ).

2. Expected frequency on level of perceived need towards HIV premarital examination and of willingness to undergo HIV PCT: 16%. This expected frequency was drawn from the previous study on VCT establishment where findings showed that 15.7% of respondents mentioned when one wants to get married as the main raison for going for VCT ³².

3. Worst acceptable frequency on level of perceived need towards HIV premarital examination and of willingness to undergo HIV PCT: 10% (meaning an acceptable margin error of 6%)

Thus a sample size of 142 individuals was targeted. This was rounded up to 150 unmarried young adult respondents. However in prevision of eventual drop out from interviews or questionnaire disqualification due to incompleteness or inconsistency, an extra 20 more interviews was conducted so that the sample size is fully met.

4.1.10. 3.4.2. SAMPLING METHOD

Non-probability sampling was used. In order to obtain complete and balanced insight in how knowledge and perceptions towards HIV premarital examination were distributed in different cultures in males and females, in rural and urban areas, in educated and illiterate ones, in different religious and ethnic groups and in different professional categories, all these different background groups were included in the sample as much as possible in order to capture a holistic picture.

· Purposeful choice of 3 study sub-districts (Kintampo, Jema Health and New Longoro) and proportionate attribution of quota sample based on population density of each sub-district.

· Purposive selection of Twelve settlements (towns and villages) from the 3 sub-districts ( 4 in Kintampo, 4 in Jema Health and 4 in New Longoro) based on population density, geographic location (urban /rural) and mix of high HIV/AIDS risk (proximity to the highway and prevalence of stop-over) so that the sample is as much heterogeneous as possible.

· Random selection of 210 compounds out of 3973 (from the whole total of 19167 in the 3 sub-districts) compounds identified with eligible respondents from selected settlements, using the computer based data of Kintampo Demographic Surveillance Survey (KDSS) used in KHRC with STATA command «draw random sample». Note that the computer ballot system was done by the KHRC agent, head of field workers in charge of KDSS.

Any unmarried young adult between 15-30 years old found in any selected compound was interviewed. In case two or more eligible respondents were found in the same compound, priority was made on one volunteer who consented to participate in the interview; otherwise a drawing lot was carried out to choose only one of respondents who all consented to participate. In case no respondent was found in a compound, the next selected compounds were targeted until the full quota sample required was covered.

In order to purposefully equilibrate the sex distribution of respondents or get a less skewed sex distribution, systematic random selection of compounds was made from two sex (female and male) sub-sampling computer based frames drawn from the KDSS which contains data on all the characteristic of people per registered compound. Thus to each selected compound was assigned automatically the sex of the respondent to be interviewed.

Table 2 describes the selected settlements and their assigned quota samples. The district map below also describes the geographical situation of the selected settlements.

Table 2: Sampling characteristics of selected towns and villages per sub-district
Selected Towns and villages per Sub-District	Town & Village Code	Pop. Density	Category of settlement	HIV Risk Level	Number of RA	Population of 15 - 30 years	Sample Size*	Number of Cpd**
I. KINTAMPO SUB DISTRICT
1.Kintampo Town	X	High	Urban	High	5	11066	70 (80)	100
2. Agyegye- makunu	AG	Low	Rural	Low	1	178	1 (1)	2
3. Babator City	BB	High	Urban	High	2	1386	9 (10)	12
4. Punpuatifi	PF	Low	Rural	Low	-	109	1 (1)	2
TOTAL					8	12739	81 (92)	116
II. JEMA SUB DISTRICT
5. Jema Town	JM	High	Urban	High	2	1542	19 (22)	26
6. Nante	NN	High	Rural	High	1	791	11 (12)	14
7. Kokuma	KK	Low	Rural	Low	1	312	4 (5)	6
8. Ampoma	NP	Low	Rural	Low	1	517	7 (8)	9
TOTAL					5	3162	41 (46)	53
III. NEW LONGORO SUB DISTRICT
9. New Longoro Town	LL	High	Urban	High	1	402	10 (12)	14
10. Asantekwa	AS	Low	Rural	Low	1	283	8 (9)	11
11. Busuama	BS	Low	Rural	Low	1	315	9 (10)	12
12. Sogliboi	SL	Low	Rural	Low	-	43	1 (1)	2
TOTAL					3	1043	28 (32)	39

OVERALL TOTAL					16	16944	150 (170)	210
Source : Kintampo Health Research Centre (KHRC) demographic surveillance survey sampling frame and our Field survey, Kintampo (June 2005).
RA= Research assistants (Interviewers)
* The number in bracket corresponds to the total sample size including extra sample units needed for replacement of eventual opt out or questionnaire disqualification so that an overall sample units of 150 with consistent and complete questionnaires is met.
** Number of Compounds selected per town/village in each sub-District.

3.5. DATA COLLECTION

- In-depth interviews with 17 key informants and 8 Focus group discussions of 6 members each (2 FGD for unmarried young adults and 6 for parents) were conducted at appointed and agreed times between 13^th June and 15^th July 2005 in Kintampo Town and Ampoma village.

- To minimize information bias, 20 research assistants who speak both English and Twi were selected and trained on 14^th June (for the 3 assistants involved in qualitative study) and on 25^th June 2005 (for the 17 field workers involved in the survey) in order to enable them do their work appropriately. These were made of 1 field supervisor, 16 interviewers to administer the structured questionnaire, 1 language translator for translating the questionnaire, the IDI and FGD-guides and qualitative data from English into «Twi» (a local dialect), 1 moderator for moderation of FGDs, and 1 note-taker for note-taking and reporting. All the research assistants were from KHRC staffs who were assigned to help us in part-term while still doing their KHRC routine work.

- The pre final questionnaire was pre-tested on 25^th June 2005 in Kintampo Sub-District among 20 respondents from compounds not selected in the study. Six questions were reframed and adjusted based on the results from feed-back of the pretesting session.

- The survey involved 16 experienced and well trained KHRC field research assistants. It included at large 170 respondents (150 for study purpose and 20 for eventual back-up in case of questionnaire disqualification for incompleteness or inconsistency) and was carried out during 7-10 days from 28^th June to 7^th July 2005, with average rates of 17-24 questionnaires per day (that is 1-2 questionnaires per day per interviewer) and 30-40 minutes per questionnaire.

- Illustrative photographs on the course of the study were taken among participants.

3.6. DATA PROCESSING AND ANALYSIS

4.1.11. 3.6.1. QUALITATIVE DATA

Qualitative data from IDI and FGD were recorded and translated into English and summarized in Matrix by the researcher. The transcribed information was reviewed and the main issues summarized.

4.1.12. 3.6.2. QUANTITATIVE DATA

For better quality of data we carefully checked the completeness and the internal consistency of each questionnaire. Thus out of the 170 administered questionnaires, twenty found incomplete and with inconsistent data were simply canceled and replaced by complete ones.

For easier analysis, pre-coded data from survey questionnaires were entered into FOXPRO view and then converted into EPIINFO 3.3, STATA and EXCEL formats that we used in analysis.

For analytical interpretation, we carried out calculation of frequencies and relative frequencies. Statistical tests included X²(chi square), P-values and Odd ratio with 95% confidence intervals. The level of statistical significance was set at p<0.05.

Two Logit models were used to determine the factors that affect the probability for a respondent to perceive the need of HIV PCT service and the probability of willingness to perform premarital HIV counseling and testing (from Diagram 2). As the data were mostly categorical and the response binary (Yes/No answers), Logit models were found appropriate to be used.⁵⁸

3.6.2.3. Score allocation for level of knowledge and perception towards HIV PCT

In order to evaluate level of knowledge and level of perception towards HIV PCT with a more measurable scale, we assigned scores to answers to specific defined questions. Thus all respondents were given each a total score of level of knowledge and of level of perception towards HIV PCT (see ANNEX 4 for details on score attribution per specified question). Then the following tri-polar marking scale was drawn in order to assess the level of knowledge and of perception of respondents towards HIV PCT:

3.7. SOME ETHICAL CONSIDERATIONS

The study topic was conceptualized with the District Director of Ghana health service of Kintampo District. Nevertheless the study subject was thereafter actually put in mind of the District Assembly, all local Traditional, Religious and other opinion leaders in order to co-opt their ideas to ensure their consent, ownership and permission on the study.

All key informants and interviewees received explanations that the study would be beneficial to the District in the sense that findings would really help Kintampo District Health Authorities to implement a very effective VCT/HIV PCT service in the near future.

Autonomy of all key informants, interviewees and even interviewers was respected. Respect of confidentiality was assured regarding all information given by participants. The questionnaire was anonymous for confidentiality purposes.

The research team members were kindly soliciting free self-acceptance (voluntary participation) and informed consent of all participants involved after explaining them the relevance of the study and the role expected from them.

Freedom of refusing or abstaining from answering some questions or of even withdrawing from an ongoing interview or discussion was guaranteed for people who consented to participate. Consent from participants was also sought regarding recording their voices and or taking their pictures and using them in the study report. Thus pictures in this work received prior verbal permission of concerned participants to be published as live testimonies.

For some sensitive and intimate questions, like having ever had sex, interviewers used polite introductive word like «Sebi» to kindly beg respondents to freely consent not only to answer but to just give right answers although the question directly touched their intimacy.

3.8. LIMITATION OF THE STUDY

1. The exercise was originally conceived to have full district coverage but because of resource constraints the study was limited only in 3 of the 8 sub-districts of Kintampo District.

2. Focusing the study only among unmarried young adults between 15-30 years might have been source of bias about perceptions towards HIV PCT since it may generate a partial and selective picture rather than a holistic one. This is of true value since unmarried young adult aged more than 30 years may perceive HIV PCT differently. Also married people, based on their experiences and testimonies on marriage, whether or not they got married after undergoing a HIV PCT session, also have a lot of information and strong perception towards HIV PCT and that should have been normally taken into account to give a wider picture on the matter. This last limitation was partially solved in involving parents and old couples in FGD and IDI.

3. In order to reduce interviewer bias, most questions were close-ended. This might have created loss of some important information which may-be open-ended questions could have captured.

Nevertheless despite all these limitations, we hope results, conclusions and recommendations from this study stand true and will help Kintampo District Health Authorities as reference to plan for health policy/programmes or further researches related to VCT and premarital examination implementation.

3.9. RETROINFORMATION AND DISSEMINATION OF THE FINDINGS

As soon as the study results were released, retro information was done successively to the DDHS, the DHMT, and the District HIV/AIDS Response Initiative coordinator and to KHRC team. Copies of the final report were sent to the DHMT and the KHRC.

Chapter Four

FINDINGS

4.1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

INVOLVED IN THE SURVEY

One hundred fifty (150) respondents were interviewed in the survey, of who 81 (54%) were from Kintampo Sub-District, 41(27%) from Jema Health Sub-District and 28 (19%) from New Longoro Sub-District. Majority (71%) were from urbanized settlements.

In total 65 individuals of different socio-demographic background, 29 (45%) females and 36 (55%) males were part of key informant participants in the qualitative study, with ages ranging from 20 to 64 years and a mean age of 30.6 years (SD 11.78). Seventeen of them (26%) ,made up of the District HIV-AIDS response initiative coordinator, the District Public Health Nurse in Charge of Family Health Clinic, the different religious leaders, one traditional herbalist, one laboratory technician, one medical doctor, 3 newly married couples (old couples), one prospective would-be couple, one single influential young boy and one counselor, were key informants contacted for In-Depth Interview (IDI) whereas the majority (74%), made up of unmarried young adults and parents, took part in Focus Group Discussions.

4.1.13. DISTRIBUTION OF RESPONDENTS BY AGE AND SEX

The 150 surveyed respondents were unmarried young adults aged between 15 and 30 years with a mean age of 21.0 years (SD 4.48), the majority of them (76%) being aged between 15-24 years (age distribution left skewed). The sex distribution of respondents was slightly skewed with a little but insignificant predominance of males (51%) [p-value=0.29]. Figure 1 below describes these features.

4.1.2. EDUCATIONAL BACKGROUND OF RESPONDENTS

The educational features of respondents in the survey (Figure 2) ranged from those with no formal education to post secondary school level, majority of them (36%) being in Middle continuation and Junior Secondary Schools (JSS), constituting a quasi-normal distribution. In both sexes the trend showed an increased number from primary school level to Middle/JSS level followed by a progressive sharp decrease of respondents in the subsequent higher levels up to Post Secondary School, with no respondent at University level at all. The trend also showed many surveyed males predominated over females in Middle/JSS and Senior Secondary Schools (SSS) whereas surveyed females were predominant in Primary and Post secondary schools (Figure 2). The average number of years successfully completed at the highest level reached by respondents was 3.

4.1.3. RELIGION, ETHNIC GROUP AND OCCUPATION BACKGROUND

Majority of responds were mostly Christians (65%), followed by Moslem (28%), the minority (7%) being without any defined religion.

Almost half part of respondents belonged to Akan (34%) and Mo (27%) ethnic groups.

A higher proportion of respondents were students (36%), followed by farmers (16%), with a minority of government or salaried workers (3%).

Out of 150 respondents, 99(66%) have had premarital sex already (78% of females and 55% of males), majority involved being females (58%). Results in Table 3 show that female respondents were 2.97 times more engaged in premarital sex than males (p-value =0.004116).

Respondents in FGD mentioned the following as being the major contributory factors to premarital sex in Kintampo District:

The age at first sex ranged from a minimum of 10 years up to a maximum of 25 years and for the whole sample the mean age at first sex was 18 years (SD:2.98). However the mean age at first sex was 18.125 years (SD:2.6) for females and 18.075 years (SD:3.34) for males, meaning both male and female respondents engaged in premarital sex at about same age of 18 years . The earliest age at first sex was 10 years in males and 12 years in females, the latest age at first sex being 25 years in both sexes. Also the trend showed a gradual increase of first sex rate as the age increases, the peak age of first sex being 20 years in males and 18 years in females. Figure 4 describes these features.

In addition, the number of sexual partners among those who have had sex ranged from 1 to 15, with a mean of 2.7 (SD:2.38) partners per respondents.

These findings reinforce trends from qualitative study where participants attested to the fact that premarital sex was normal in Kintampo society. This notion is captured in the responses below during IDIs and FGDs.

Table 4: Trend of general awareness and knowledge on HIV/AIDS, VCT and HIV PCT [Chi-Square, Note: X²(Y)=Yates corrected chi-square, p<0.05, CI:95%]
*Indicators on awareness and knowledge on HIV/AIDS,* *VCT and HIV PCT*	*Yes (%)* *Male* *(N=77)*	*Yes (%)* *Female* *(N=73)*	*Yes (%)* *Total* *(N=150)*	*p-value* X^2* OR
1.Knows or have known a young adult who suffers/suffered from HIV AIDS	32(41.6)	31(42.5)	63(42.0)	OR=0.96 p=0.95
2. Know that unprotected pre-marital sex with casual/multiple partners is a risky behaviour that could expose to STI-HIV/AIDS	74(96.1)	71(97.1)	145(96.7)	X²=1.95 p=0.375
3. Know that a child could be born HIV positive from sexual union of his/her parents/mother	70(90.9)	66(90.4)	136(90.7)	X²=5.6 p=0.0604
4. Know that HIV/AIDS does not have any effective cure yet	71(92.2)	71(97.3)	142(94.7)	OR=0.33, p=0.31
5. Know that not all sexual unions and marriages are safe and good for health of both partners and offspring:	47(61.0)	45(61.6)	92(61.3)	X²=3.39 p=0.1833
5.1.Know that HIV/AIDS makes unsafe sexual unions and marriages	33(42.9)	26(35.6)	59(39.3)	X²=1.15 p=0.7664
5.2. Know that others diseases a part from HIV/AIDS makes unsafe some sexual unions and marriages	7(9.1)	7(9.6)	14(9.3)
5.3. Know that both HIV/AIDS and others diseases make unsafe sexual unions and marriage	9(11.7)	12(16.4)	21(14)
6. Recognize that they will consider health status as core criteria when they choose their marriage partners	74(96.1)	68(93.2)	142(94.7)	OR=1.8 X²(Y)=0.19
7. Way to assess «Good Health Status» of marriage partner before marriage: 7.1.By observing his/her appearance	3(3.9)	4(5.5)	7(4.7)	-
7.2.By asking close family member /friends	5(6.5)	5(6.8)	10(6.7)
7.3.Through premarital medical examination	66(85.7)	58(79.5)	124(82.7)
8. Have ever heard about HIV voluntary counseling and testing (VCT)	53(68.8)	55(75.3)	108(72)	OR=0.7, p=0.48
9. Have ever heard about HIV premarital counseling and testing	62(80.5)	65(89)	127(84.7)	OR=0.5, p=0.22
10. Sources of information about HIV PCT : 10.1.Radio/TV/Cinema/Video	61(83.5)	52(73.2)	113(78.5)	-
10.2. Churches or mosques	22(30.1)	30(42.2)	52(36.1)
10.3.Friends/third person	15(20.5)	32(45)	47(33)
10.4. Health workers	26(35.6)	20(28.2)	46(31.9)
10.5.Schools/University	23(31.5)	18(25.3)	42(29.2)
10.6.News papers or books or posters	16(22)	11(15.5)	27(19.75)
10.7 .Parents	10(17)	10(14)	20(14)
10.8.Conference/youth camp	5(6.8)	2(2.8)	7(4.9)
10.9. Internet	2(2.7)	3(4.2)	5(3.5)
10.10. Others sources	1(1.36)	1(1.4)	2(1,38)
11. Know that HIV PCT is one of the main measures to limit the spread of HIV/AIDS in new couples	70(91)	68(93)	138(92)	X²=1.01 p=0.6
12. Know of someone or a couple who underwent HIV PCT before marriage	26(34)	29(40)	55(37)	X²(Y)= .35 p=0.55, OR=0.7
13. Knowledge of who is required to undergo Premarital Counseling and Testing (PCT): 13.1.The male partner	11(14.3)	2(2.7)	13(8.7)	-
13.2.The female partner	1(1.3)	8(11)	9(6)
13.3.Both partners	65(84.4)	63(86.3)	128(85.3)
14. Know major advantages of HIV PCT:				-
14.1.To know about their health and HIV status so that they decide responsibly about marriage	67(87)	61(83.5)	128(85.3)
14.2.Stability and safety in marriage	36(47)	32(44)	68(45)
14.3.It strengthens marital relationship and enhance marriage satisfaction	23(30)	20(27.4)	43(29)
14.4.To ensure fertility in couples	17(22)	14(19)	21(14)
Source: Field survey, Kintampo, June 2005

In general, the main trend of awareness and knowledge of respondents on HIV/AIDS, VCT and HIV PCT summarized in Table 4 are the following:

Less than half of respondents of both sexes knew of any young adult who suffer/suffered from or died of HIV/AIDS, male respondents knowing less than females, but with no statistical significant difference between both sexes.

More than 96% of both males and females respondents knew unprotected premarital sex with casual and multiple partners expose to HIV/AIDS, no statistical significant difference between them.

Also more than 90% of both males and females knew that HIV could be transmitted from mother to child through sexual union of parents, again the trend shows no statistical significant difference between the two categories.

94.7% of respondents were aware that HIV/AIDS does not have any cure yet (no statistical difference between both sexes). This finding is obvious since in Kintampo society even some traditional healers are aware of this fact. They are currently taking advantage of the inexistence of any effective cure against HIV/AIDS to attract the community members to their services, pretending they have traditional drug to cure HIV/AIDS (See illustrative pictures below):

Pictures 4 and 5: Poster of an herbalist on the main road just at Apaaso, Kintampo Police barrier

Majority (>60%) of both male and female respondents were similarly aware that not all sexual unions and marriages are safe and good for health of both partners, and their offspring ( no statistical significant difference). However, surprisingly fewer (42.9% of males and 35.6% of females) knew that HIV/AIDS makes unsafe sexual union and marriage.

A higher number of both males (96.1%) and females (93.2%) were similarly aware that they will consider health status as core criteria when they will choose their marriage partners.

In all FGD and IDI, all participants also strongly considered health status is the major criteria in choosing spouses.

Although the neat majority of males (85.7%) and of females (79.5%) recognized premarital medical examination as the right way to assess «Good health status» of their marriage partners, a few part of them thought they would assess it simply by observation of external appearance (4.7%) or by asking close family members (6.7%). There was no significant statistical difference between the trends in both sexes.

In all FGDs and IDIs all participants said premarital medical examination was not included in the marriage procedures in Kintampo and showed a great disagreement to this sort of managing marriage, saying PCT was very important.

Surprisingly, although HIV PCT is a specific type of VCT, majority of respondents (84.7%) had heard more about HIV PCT than VCT itself (72%). No significant statistical difference in males and females trends.

The top source of information on HIV PCT among respondents was through Radio, TV, Cinema or Video (78.5%), the second source being churches and mosques (36.1%), followed by friends or third person (33%). Worst still parents were at the seventh position (14%).

In both sexes, HIV PCT was well known as one of the major measures to limit the spread of HIV/AIDS in new couples. No statistical difference between the trends in the 2 groups.

Less than half (37%) of respondents knew of someone or couple who underwent a HIV PCT before marriage.

Large majority of both males (84.4%) and females (86.3%) recognized that both partners are required to undergo PCT.

Also majority of respondents in both sexes (85.3%) knew the first main advantage of HIV PCT (To know about their health and HIV status so that they decide responsibly about marriage), less than half of them knew the 2^nd advantage (To ensure stability and safety in marriage) [45%] and the 3^rdone (It strengthens marital relationship and enhances marriage satisfaction) [29%], with few of them (14%) considering HIV PCT advantage is to ensure fertility in couples.

Using a scale of measurement described in point 3.6.2.3 , Findings in Table 5 suggest that as a whole, all different groups of respondents in different categories (age group, residence, sub-districts, sex, occupation, religious group, ethnic group, educational level..) had Good knowledge on HIV PCT since none of the categories ranked below the cut-off mean score of 11 below which we would consider there is poor knowledge. Majority of different groups described in Table 5 fell in Average Good Knowledge, except 3 groups which fell into Adequate Good knowledge (AKAN, SSS and Post-middle college respondents). The mean score of knowledge for the whole sample was 15.72 [SD2.8], falling in average level. Most mean scores in different categories studied in table 5 varied between 14.4 and 17.5 (over the total score 22 ) and did not show big significant differences between them, meaning the adequacy of knowledge on HIV PCT seems similar in all these different groups. . Only one category had a mean score corresponding to the cut-off point (Respondents of post-secondary school level with a mean score of 11).

Also when one considers the individual scores as it is shown in Figure 5 below, large proportion of respondents (97 % beyond the cut-off line from average score 11 and over) proved «Good Knowledge» (GK) on HIV PCT, with 41.3% scoring «Adequate Good Knowledge» versus 55.7% scoring «Average Good Knowledge». On the other hand a minority of respondents proved «Poor Knowledge» (3 % below average score 11). The trend shows a right skewed distribution with a peak at score 15 (17.3%), then the number of respondents gradually decreases as the score increases, with few people scoring the maximum (1.3%).

Table 5: Level of knowledge on HIV PCT among respondents
Background characteristic	Total score computed in the whole(n)	Range score obtained	Mean score obtained (u) [SD]	Conclusion on level of knowledge*
Age : 15-19	942 (n=61)	7-22	15.4[SD=2.87]	Average GK
21-24	843 (n=53)	10-22	15.9[SD=2.54]	Average GK
25-30	574 (n=36)	4-21	15.9[SD=3.94]	Average GK

Residence: Urban	1673(n=107)	4-22	15.6[SD=2.9]	Average GK
Rural	686 (n=43)	11-22	15.9[SD=2.8]	Average GK

Sub districts: K'po	1259(n=81)	4-22	15.5[SD=2.7]	Average GK
JH	672(n=41)	7-22	16.4[SD=3.3]	Average GK
NL	428(n=28)	11-19	15.3[SD=2.3]	Average GK

Sex M	1208(n=77)	4-22	15.68[SD=2.6]	Average GK
F	1151(n=73)	7-22	15.76[SD=3.1]	Average GK

Educ. level: None	489(n=32)	11-20	15.2[SD=2.26]	Average GK
Primary	393(n=27)	8-20	14.5[SD=2.75]	Average GK
Middle/JSS	844(n=54)	7-22	15.6[SD=2.83]	Average GK
Tech/SSS/sec sch	544(n=31)	14-22	17.5[SD=2.15]	Adequate GK
Post.mid college	69 (n=4)	15-20	17.2[SD=2.06]	Adequate GK
Post secondary S.	22 (n=2)	4-18	11[SD=9.89]	Average GK
Occupation: Farmer	365(n=24)	11-22	15.2[SD=2.8]	Average GK
Gov.Workers	58(n=4)	4-22	14.5[SD=7.59]	Average GK
Trader	334(n=20)	12-21	16.7[SD=2.6]	Adequate GK
Student	854(n=54)	10-21	15.8[SD=2.3]	Average GK
Others	748(n=48)	7-20	15.5[SD=2.94]	Average GK
Religion Christian	1558(n=98)	4-22	15.9[SD=2.9]	Average GK
Moslem	649 (n=42)	8-21	15.4[SD=2.57]	Average GK
None	151(n=10)	12-22	15.1[SD=2.96]	Average GK
Tribe: Akan	867(n=50)	4-22	17.3[SD=3.3]	Adequate GK
Mo	640(n=41)	11-19	15.6[SD=1.8]	Average GK
Others	852(n=59)	8-20	14.4[SD=2.8]	Average GK
Total sample	2359 n=150)	4-22	15.72 [SD2.8]	Average GK
*Note: Scale of measurement of level of knowledge on HIV PCT=
If u < 11: POOR knowledge (PK) If u = 11: GOOD Knowledge (GK),
11-16.5: Average GK and >16.5: Adequate GK.
Source: Field survey, Kintampo, June 2005.

In figure 6, we see that respondents from rural parts knew slightly more about HIV PCT than those coming from urban area, with the minimum score of 11 and a mean score of 16.5 for rural respondents versus a minimum score of 4 and a mean score of 13 among urban respondents. However the difference in the trends of scores of knowledge between the two groups was not statistically significant (p-value=0.25). The peak score was 15 among rural respondents (20.9%) versus 2 peak scores of 15 (15.9%) and 17 (15.9%) among urban respondents. Higher proportion of respondents who got maximum score of 22 were from rural parts (2.3%) as compared to those from urban ones (0.9%).

Findings in Table 6 below summarize the trend of how respondents perceived HIV/AIDS and HIV PCT when the survey was carried out. The following observations can be highlighted:

Large majority of Male (92.2%) as well as female (94.5%) respondents perceived that although healthy they or their fiancé(e)s could be unknown carrier of HIV AIDS. Females presented a slight higher risk perception than males although there is no significant statistical difference (p=0.81). This perception was expressed as well in FGDs carried out:

«Because of money, a woman forced her daughter to marry a man who came from London. This man was apparently healthy. But who knew he was having it? Just 2 years and six months later he started showing the symptoms and later died. The poor lady is also dying».(A 27-year-old boy: FGD Christian young adults)
Table 6: Trend of general perception of respondents towards HIV PCT
*Indicators on perception towards HIV PCT*	*Yes (%)* *Male* *(N=77)*	*Yes (%)* *Female* *(N=73)*	*Yes (%)* *Total* *(N=150)*	*p-value* X^2* OR
1.Perceive that one or one's partner [fiancé (e)] though apparently healthy can be an unknown carrier of HIV/AIDS that could be detected during PCT (Risk perception)	71 (92.2)	69 (94.5)	140 (93.3)	OR=0.7 p=0.81
2.Perceive that HIV-AIDS is a very dangerous/fatal disease (Perceived severity of HIV/AIDS)	77 (100.0)	73 (100)	150 100.0	-
3.Perceive that there is a high risk of getting married unknowingly to an HIV infected person and of becoming HIV infected when two fiancés do not attend any premarital medical examination on HIV test (Perceived threat of contracting HIV in case one marries without attending HIV PCT)	74 (96.1)	73 (100)	147 98.0	-
4.Believe that HIV Premarital Counseling and Testing (PCT) is important (Perceived benefit of HIV PCT)	77 (100.0)	73 (100.0)	150 (100.0)	-
5.Believe they are self-confident and able to decide themselves to undergo HIV PCT (Perceived self efficacy towards HIV PCT)	76 (98.7)	71 (97.3)	147 (98.0)	-
6.Believe that their family will support them or encourage them to perform HIV PCT before getting married (perceived HIV PCT as a subjective -family norm a)	75 (97.4)	69 (94.5)	144 (96.0)	-
7. Believe that their family will support them or encourage them to perform HIV PCT before getting married (perceived HIV PCT as a subjective-peer norm b)	71 (92.2)	60 (82.2)	131 (87.3)	OR=2.5 p=0.11
8. Perceive that HIV PCT should be institutionalized in the district (Perceived HIV PCT as a social norm)	76 (98.7)	72 (98.6)	148 (98.7)	OR=1.0 p=0.5
8.1.Perceive that HIV PCT should be made compulsory	48 (63)	42(58)	90(61)	OR=1.2 p=0.66
8.2.Perceive that HIV PCT should be made optional	28(37)	30(42)	58(39)	OR=1.2 p=0.66
9. Perceive there are some barriers to HIV PCT acceptance and implementation in Kintampo (perceived barrier to HIV PCT)	61 (79.2)	60 (82.2)	121 (80.7)	OR=0.8 p=0.79
10. Perceive there is the need of implementing HIV PCT services in Kintampo district in the fight against HIV/AIDS in new couples (Perceived need of HIV PCT services)	76 (98.7)	73 (100.0)	149 (99.3)	-
11. Have the willingness to undergo HIV PCT with their fiancé (e) before Marriage.	75 (97.4)	72 (98.6)	147 (98.0)	-
12. Perceive they are ready to know and accept their HIV test result after HIV PCT	75 (97.4)	70 (95.9)	145 (96.7)	-
[Chi-Square, Note: X²(Y)=Yates corrected chi-square, p<0.05, CI:95%]
Source: Field survey, Kintampo, 2005.

The totality of respondents (100%) in both sexes perceived the severity of HIV/AIDS and subsequently also perceived perfectly the importance of HIV PCT. Also most of them perceived the threat of contracting HIV/AIDS in case they marry without performing the HIV test. This trend also emerged from qualitative discussions:

Large majority of respondents in both sexes (98%) believed they were able personally to perform HIV PCT.

Large majority of respondents perceived that the family members and peers could support and encourage them towards HIV PCT.

Large majority of respondents (98.7%) in the survey perceived HIV PCT should be institutionalized in Kintampo District, with the majority (61%) perceiving it should be compulsory versus the minority (39%) saying it should be optional rather.

This is supported by findings from qualitative study where almost majority of participants opted HIV PCT should be compulsory with a few of them opting it should be optional.

Respondents of both sexes almost universally perceived the need of implementing HIV PCT services in Kintampo District (99.3%) although they also recognized there were some barriers to its implementation and acceptance (80.7%).

Finally Table 6 shows that almost all the respondents in both sexes had the willingness to undergo HIV PCT before their marriage (98.0%) and said they were ready to know and accept their HIV test results after PCT (96.7%).

The general trend showed no significant difference of views in males and females, meaning they similarly perceived HIV PCT.

Using a scale of measurement described in point 3.6.2.3 (see Methodology), Table 7 and Figure 7 show that the entire totality (100%) of respondents in both sexes had «adequate positive perception» towards HIV PCT irrespective of their different socio-demographic backgrounds , the minimum score obtained being 18, with a mean score of 21.81 (SD=1.16 ). The curve is right skewed with no great difference between males (mean score= 21.7[SD=1.2]) and females (mean score= 21.8[SD=1.13]). 20-28% of respondents scored the maximum of 23 marks.

Table 7: Level of perception towards HIV PCT among respondents
Background characteristic	Total score computed in the whole(n)	Range score obtained	Mean score obtained (u) [SD]	Conclusion on level of perception*
Age : 15-19	1333 (n=61)	19-23	21.8[SD=1.04]	AP
21-24	1160 (n=53)	18-23	21.8[SD=1.12]	AP
25-30	779 (n=36)	18-23	21.6[SD=1.4]	AP
Residence: Urban	2334(n=107)	18-23	21.8[SD=1.3]	AP
Rural	938 (n=43)	18-23	21.8[SD=1.07]	AP
Sub Districts: K'po	1751(n=81)	18-23	21.6[SD=1.09]	AP
JH	913(n=41)	19-23	22.2[SD=0.9]	AP
NL	608(n=28)	18-23	21.7[SD=1.4]	AP
Sex: M	1678(n=77)	18-23	21.7[SD=1.2]	AP
F	1594(n=73)	18-23	21.8[SD=1.13]	AP
Educational level: None	720(n=32)	18-23	21.8 [SD=1.18]	AP
Primary	591(n=27)	19-23	21.8[SD=1.12]	AP
Middle/JSS	1151(n=54)	18-23	21.7[SD=1.3]	AP
Tech/SSS/sec sch	679(n=31)	19-23	21.9[SD=0.87]	AP
Post.mid college	89 (n=4)	21-23	22.5[SD=0.9]	AP
Post secondary S.	42 (n=2)	19-23	21[SD=2.8]	AP
Occupation: Farmer	524(n=24)	19-23	21.8[SD=1.27]	AP
Gov.Workers	86(n=4)	19-23	21.5[SD=1.7]	AP
Trader	432(n=20)	18-23	21.6[SD=1.3]	AP
Student	1175(n=54)	19-23	21.7[SD=1.1]	AP
Others	1055(n=48)	18-23	21.9[SD=1.08]	AP
Religion: Christian	2158(n=98)	18-23	21.7[SD=1.16]	AP
Moslem	893 (n=42)	18-23	21.7[SD=1.19]	AP
Others	221(n=10)	20-23	22.1[SD=1.19]	AP
Tribe: Akan	1096(n=50)	18-23	21.9[SD=1.04]	AP
Mo	908(n=41)	18-23	21.6[SD=1.3]	AP
Others	1268(n=59)	18-23	21.8[SD=1.16]	AP
Total sample	3272 n=150)	18-23	21.8[SD=1.16]	AP
Note: Scale of measurement of level of perception on HIV PCT= If u < 11.5: Negative or bad perception* If u = 11.5: Positive (high, good)perception: 11.5-17.5: Average Positive perception and >17.5=Adequate Positive perception (AP)
Source: Field Survey, Kintampo, June 2005.

As it can be implied in Table 8 below, there was a weak positive linear relationship between the two variables which was statistically significant (p-value 0.007). The score of perception slightly increases as the score of knowledge increases. But even respondents with poor score of knowledge also had higher score of perception.

From Table 8, we derived the model of the form: Y= á + ßX, where Y is the score of perception and X the score of knowledge towards HIV PCT.

Using this modal we could predict the score of perception of any unmarried young adults based on his/her score of knowledge in answering to the defined questions in the questionnaire. Thus for instance a respondent with a score of knowledge of 10 would have a score of perception of 21.302.

Although there is no significant association between dependant variable and explanatory variables under study, Table 9 above demonstrates the following:

1. Perception of the need of HIV PCT was inversely (negatively) associated with Urban residence, with the fact of having had premarital sex and with score (level) of knowledge.

2. Perception of the need of HIV PCT service was positively associated with increased level of perception towards HIV PCT, age, being female, Christian, being of Akan and Mo ethnic group, being of post-primary educational level and being student.

Table 10 below shows that there was only one reliable positive predictor of willingness to undergo HIV PCT. This predictor was the readiness of a respondent to know and accept his/her HIV result. In fact willingness to undergo HIV PCT was strongly associated with readiness of a respondent to know and accept his/her HIV result (p<0.001), with Odds ration far exceeding the constant (1 x constant E¹²= 162754.79).

Table 10. Factors (predictors) influencing willingness to undergo HIV PCT service (p₂) among unmarried young adults in Kintampo District
*Variables*	*Coefficient*	SE	Z-test*	*p-value* >Z	*Odds ratio* *(95%CI Odds ratio)*
Intercept (constant á₂)	-39.715	15.934	-2.5	0.0127	*
Socio-Demographic Background: (X'₁) Age	-0.0296	0.1839	-0.2	0.8722	0.9 (0.7,1.4)
(X'₂)Sex (Female)	1.2901	1.252	1.03	0.3028	3.6 (0.3,42.3)
(X'₃)Place of residence (Urban)	1.1279	1.3789	0.8	0.4134	3.1(0.2, 46.1)
(X'₄) Religious group (Christian)	1.2919	1.5037	0.86	0.3903	3.6 (0.2, 69.3)
(X'₅) Ethnic group (Akan & Mo)	0.9243	1.4945	0.62	0.5363	2.5 (0.1, 47.1)
(X'₆) Level of education (Post Primary)	-1.2049	1.434	-0.84	0.4008	0.3 (0.01, 5.0)
(X'₇) Profession (Student)	-0.3604	1.7713	-0.2	0.8387	0.7 (0.02,22.4)
(X'₈) Premarital sex history : Have had premarital sex (Yes)	-1.5237	1.6286	-0.9	0.3495	0.2 (0.01,5.3)
(X'₉) SCORE (LEVEL) OF KNOWLEDGE ON HIV/ PCT**	0.1913	0.2191	0.9	0.3826	1.2 (0.8, 1.9)
(X'₁₀) SCORE (LEVEL) OF PERCEPTION TOWARDS HIV/PCT**	0.7263	0.5674	1.3	0.2006	2.1(0.7, 6.3)
(X'₁₁) Perceived need of HIV PCT service (Yes)	-3.1371	7.3989	-0.4	0.6716	0.04 (0.0, 86196)
(X'₁₂) Perceived need of confidentiality and privacy in HIV/PCT service.	0.9644	7.5131	0.13	0.8979	2.6(0,6516187)
(X'₁₃) Readiness to know and accept HIV PCT Results (Yes)	28.3658	3.605	7.9	<0.001	>162755 (14423,>162755)
(X'₁₄) Suggestion that HIV PCT service should be provided free of charge (yes)	-0.8604	4.2528	-0.2	0.8397	0.4(0.0001,1763.26)
Z-test, p-value<0.05, * See ANNEX 5 to view variables used in scoring scales.
Logit Model: Ln[p₂/(1- p₂)]= -39.715-0.0296X'₁+ 1.2901X'₂-1.1279X'₃ + 1.2919X'₄ +0.9243X'₅ -1.2049X'₆ -0.3604X'₇-1.5237X'₈ + 0.1913X'₉ +0.7263X'₁₀-3.1371X'₁₁+0.9644X'₁₂+28.3658X'₁₃ -0.8604X₁₄
Source: Field survey, Kintampo, June 2005.

1. Willingness to undergo HIV PCT was negatively associated with age, post-primary educational level, being student, having ever had premarital sex, perceiving the need of HIV PCT services and suggestion that HIV PCT should be provided free of charge.

2. Willingness to undergo HIV PCT was slightly positively associated with Akan & Mo Ethnic groups, urban residence, Christian religion, female sex, score (level) of knowledge, and score (level) of perception towards HIV PCT and suggestion of confidentiality in PCT services.

4.10. DEDUCTION OF PROBABILITY FOR RESPONDENTS TO PERCEIVE THE NEED OF HIV PCT SERVICE AND TO INTEND UNDERGOING HIV PCT

Using the two logit models described in Tables 9 and 10, we deduced the probability for each respondent to perceive the need of HIV PCT service and the probability of willingness to undergo HIV PCT. Table 11 above shows that 86% of respondents had a higher probability (>0.75%) of perceiving the need of HIV PCT service (Mean probability: 0.923786) and of willingness to undergo HIV PCT (mean probability: 0.946193992).

Table 12 illustrates that majority of respondents (77%) preferred undergoing HIV PCT while minority of them (23%) preferred voluntary HIV testing outside marriage context. Table 12 does not show any significant difference of preference choices given the sex of respondents (p-value 0.55), the Odd ratio of preference of HIV PCT in females being 1.36 times the odd in males.

Respondents were asked about what they think were the barriers to HIV PCT acceptance and implementation in Kintampo District. A long list of barriers was generated as shown in Table 13 below.

Table 13: Respondents' perception of barriers to HIV PCT acceptance and implementation
No	Perceived Barriers to HIV PCT	Yes (%)	No (%)	NK (%)
1	Inexistence of regulatory procedures and Law/Policy on PCT in Ghana	90 (60.00)	59 (39.30)	1 (0.7)
2	Mandatory imposition of PCT that infringes the Human Right of individuals	86 (57.3)	63 (42.00)	1 (0.7)
3	High cost (price) of premarital examinations	110 (73.3)	40 (26.7)	-
4	The location of the centre/hospital at long distances	94 (62.7)	56 (37.3)	-
5	The attitude of the service provider	116 (77.3)	34 (22.7)	-
6	Premarital sex and fear to know one's HIV status	110 (73.3)	40 (26.7)	-
No	*Perceived Barriers to HIV PCT (Continued)*	*Yes* *(%)*	No *(%)*	NK (%)
7	Fear of stigma and discrimination in marriage (denial of marriage for HIV+)	116 (77.3)	33 (22.0)	1 (0.7)
8	Ignorance of the importance of PCT (illiteracy...)	111 (74.0)	39 (26.0)	-
9	Reluctance of fiancés	98 (65.3)	50 (33.3)	2 (1.3)
10	Preference of young people to get married without PCT	88 (58.7)	61 (40.7)	1 (0.7)
11	Opposition of some churches	71 (47.7)	78 (52.3)	-
12	Opposition of some parents	72 (48.0)	77 (51.3)	1 (0.7)
13	Polygyny (Polygynous/polygamous marriages) & Islamic religion	78 (52%)	72 (48.0)	-
14	Marriage by convenience (outside churches & civil registrar officer our court or without customary ritual)	94 (62.7)	55 (36.7)	1 (0.7)
15	Forced marriage (e.g. traditional early marriage)	93 (62.4)	56 (37.6)	-
16	Unregistered marriage	81 (54.0)	60 (46.0)	-
17	Inadequate VCT/PCT facilities	109 (72.7)	41 (27.3)	-
18	Lack or inadequate trained personnel & counselors	107 (71.3)	43 (28.7)	-
19	Fiancés are in a hurry to get married very quickly for any reason	91 (60.7)	58 (38.7)	1 (0.7)
20	Lack of confidentiality and privacy among health care providers in PCT services.	109 (72.7)	41 (27.3)	-
21	Medical premarital certificate provided to fiancé(e) by doctors without performing any medical check-ups (fraud)	97 (64.7)	53 (35.3)	-
22	Re-marriage ( for divorced or widowed)	84 (56.0)	66(44.0)	-
23	Inability for girls to negotiate for HIV PCT when boys don't like it	100 (67.1)	49 (32.9)	-
24	Little solution for those who test HIV (+) ( no effective drugs to treat AIDS)	106 (70.7)	44 (29.3)	-
25	Blind love among young people	85 (56.7)	64 (42.7)	1 (0.7)
26	Others (not providing gifts to couples, ...)	26 (17.4)	111 (74.5)	12 (8.1)
NK=Not known (Don't know) Source: Field survey, Kintampo, June 2005.

For easier interpretation perceived barriers described in Table 13 could be grouped under 4 categories:

2. Moderate barriers: the proportion of respondents who said yes is between 50-69%.

These are barriers number 1, 2, 4, 9, 10, 13, 14, 15, 16, 19, 21, 22, 23 and 25.

3. Minor barriers: the proportion of respondents who said yes is between 30-49 %. These are barriers number 11and 12

Some of these barriers were also recognized in qualitative study as it can be related in the following quotes.

Since during FGD of Moslem girls participants also recognized their religion as a barrier to HIV PCT implementation we found better to stratify frequencies of this barrier over religion background.

Table 14 below shows that 43.9 % of Moslem respondents also mentioned Islam as a barrier to HIV PCT. Though statistically insignificant, there is some level of association between religion and perception of Islam as a barrier to HIV PCT (p-value = 0.08), meaning Moslem and non Moslem respondents perceive in the same way that Islam is a barrier to HIV PCT.

4.3.2. 4.13.1. VIEWS ON FREQUENCY OF HIV TEST BEFORE MARRIAGE

Figure 8 below shows that a third of respondents in both sexes suggested the HIV test should be done at least twice before marriage, with 3-6 months interval between two tests. Almost one fifth of respondents in both sexes suggested HIV test should be done just once 2-3 months before marriage. Another fifth suggested it should be done at least once, without specifying the maximum number of tests. Few respondents also thought the frequency of HIV tests should vary depending on the length of the engagement/marriage period.

We have to also note that almost one fifth of respondents did not know (NK) any answer at all, possibly because of lack of knowledge.

4.3.3. 4.13.3. VIEWS OF RESPONDENTS ON WHO THE HIV TEST RESULT SHOULD

From Table 15 below the totality of respondents (100%) recommended that other required premarital tests should be added to HIV test in order to reduce stigma associated to HIV/AIDS, especially when HIV test is done solely.

Table 15: Suggestions from respondents on ways to promote HIV PCT in Kintampo District
N⁰	Ways and means suggested by respondents	Yes (%)	No (%)	NK (%)
1	There should be a specific law (decree-law) on premarital examinations in Ghana	135 (90.6)	14 (9.4)	-
2	PCT should be clearly mentioned in the health reproductive policies of Ghana	145 (96.7)	5 (3.3)	-
3	Mass sensitization campaigns about PCT through durbars, Radio/TV, news papers, churches/mosques, NGO, asso- ciations, clubs, schools & university, Hotels, hospitals etc	149 (99.3)	1 (0.7)	-
4	Open discussions on Youth sexual education about HIV-AIDS and PCT in youth durbars such as sports...	149 (99.3)	1 (0.7)	-
5	PCT should be taught in the health education & reproduction matters in school	146 (97.3)	4 (2.7)	-
6	Churches and mosques should teach PCT to young couple before marriage	149 (99.3)	1 (0.7)	-
7	Strictly prohibit all marriage (be it civil, religious or traditional) before PCT, through a decree law	118 (79.2)	31 (20.8)	-
8	Strictly recommend a prenuptial medical certificate from the doctor for each fiancé before celebration of marriage	140 (93.3)	9 (6.0)	1 (0.7)
9	Providing care and support services for people living with HIV/AIDS	144 (96.0)	6 (4.0)	-
10	Reducing stigma and discrimination against people living with HIV/AIDS	136 (90.7)	14 (9.3)	-
11	Creating youth HIV associations/clubs like Virgin club etc	139 (92.7)	11 (7.3)	-
12	Add other premarital required tests to reduce stigma associated to HIV	*150* *(100)*	-	-
13	Encouragement by providing free treatment for any other diseases detected among those would-be couples who come for HIV PCT.	145 (97.3)	4 (2.7)	-
14	Others (PCT before pride price is paid, quoting that couple did PCT during marriage ceremony, PCT film/posters....)	49 (32.9)	90 (60.4)	10 (6.7)
Source: Field survey, Kintampo, June 2005.

Findings in Figure 11 shows that majority of respondents (59.88%) suggested that HIV PCT services should be free or set at affordable cost or paid by the government or any charity NGO in order to make HIV PCT services accessible to young people. One fifth of respondents also suggested that the number of health facilities providing HIV PCT services should be increased, one tenth saying VCT/PCT centres should be put within the community not at long distances.

Some of the participants even linked the accessibility to HIV PCT to the District Mutual Health Insurance Scheme (DMHIS):

Table 16 below regroups all measures that respondents suggested for the HIV PCT to be more acceptable and attractive to them. Some of these measures were suggested by the large majority of respondents (e.g. Guarantee complete confidentiality and privacy ) etc. The suggestions implied certain interventions to be put in place so that people are attracted by the service (see Discussion, point 4.7.6 and Figure 15).

Table 16 : Suggestions for the HIV PCT practice to be more effective, acceptable and attractive to unmarried young people in Kintampo district
N°	Ways to make HIV PCT more effective	Yes (%)	No (%)	NK (%)
1	Provide for unbiased, clear and non-judgmental advices to would-be couples	139 (92.7)	10 (6.7)	1 (0.7)
2	Guarantee complete confidentiality and privacy	149 (99.9)	1 (0.7)	-
3	Secure permission of patients before passing on information to anybody (parents, pastors/bishop, Imam and other care providers..)	142 (94.7)	8 (5.3)	-
4	Provide permanent caring and support services	147 (98.0)	3 (2.00)	-
5	Examiner/counselor of the same sex as the client	127 (84.7)	22 (14.7)	1 (0.7)
6	To be counseled by knowledgeable, well trained, kind, wise and good communicator examiner/counselors	145 (96.7)	5 (3.3)	-
7	To be counseled by counselors not known in the area and change continuously the old counselors by new ones after a certain period.	135 (90)	14 (9.3)	1 (0.7)
8	Follow up of fiancés / newly married is done after HIV PCT	132 (88.6)	15 (10.1)	2 (1.3)
N°	Ways to make HIV PCT more effective (Continued)	Yes (%)	No (%)	NK (%)
9	Provide for the presentation of test results as soon as possible, to reduce the anxiety of waiting to long (same day result)	141 (94.0)	7 (4.7)	2 (1.3)
10	Affordable cost or free HIV PCT examinations	147 (98)	3 (2.0)	-
11	To be counseled by young adults counselors	99 (66.0)	51 (34.0)	-
12	More than one counseling session is provided to the fiancés	126 (84.0)	23 (15.3)	1 (0.7)
13	When there will be a treatment or effective cure for HIV/AIDS	140 (94.0)	9 (6.0)	-
14	Provide entertainment in VCT/PCT centres	136 (90.7)	14 (9.3)	-
15	Others (give marriage gifts to would-be couples who come for HIV PCT, quote it in marriage ceremony...)	42 (28.0)	108 (72.0)	-
Source: Field survey, Kintampo, June 2005.

Table 17 shows that majority (72%) of respondents suggested HIV PCT services should be established in Kintampo District Hospital (KDH). Also it is noted that majority of respondents from Jema Sub-district (75.6%) chose Jema health centre for the HIV/PCT service to be implemented. Majority of respondents from New Longoro Sub-District quoted KDH rather than their health centre as the site for the HIV PCT centre.

Respondents were asked to give their likely decisions on marriage given assumptions of possible HIV tests results in different scenarios.

Figure 12 below shows that majority of respondents (94.7%) would definitely decide to break the marriage relationship and choose another healthy partner in case their fiancé(e)s test HIV positive after a PCT session. The break up of marriage relationship would also be decided by the majority of respondents (90.0%) who themselves test HIV positive while their would-be partners are HIV negative.

However in the third scenarios of both fiancé(s) being HIV positive, opinions diverged greatly: one third (34.7%) chose decision 1, followed by one fourth choosing decision 5 (23.3%), and one fifth (16%) choosing decision 3. This trend meets views of participants in both IDI and FGD.

Figure 13 below shows that majority of respondent (64%) opted that marriage between discordant couples should not be permitted versus a fifth (19.3%) saying such marriage should be permitted only under certain protective precautionary measures such as permanent condom use, limitation of childbearing, PMTCT etc.Their views greatly diverged about marriage between both infected partners, majority of less than half (44.7%) saying it should be permitted under certain protective measures and another considerable proportion (41.3%) saying such marriage could be permitted provided would-be couples and or their parents/families agree with it.

In either case it should be noted that only few respondents (0-2.7%) put consideration on the agreement by the religion bodies for such marriage to be conducted.

The entire trend here above meets the opinions observed among participants in FGDs and IDI.

Chapter Five

DISCUSSIONS

Since demographic characteristics of respondents show a very heterogeneous and representative picture of the main social groups living in the District, we believe findings in this study are quite representative of the district. We can therefore surely discuss them.

Results from Table 3 showed that 66% of respondents have had premarital sex, with the mean age at first sex of 18 years (18.125 for females and 18.075 for males). Female were significantly 2.97 times more engaged in premarital sex than males (p=0.004116). These findings show a higher level of premarital sex as compared to those found in the 2003 GDHS where it was found that by age 18, almost half of women (48%) and one-fourth of men (25%) have had sexual intercourse⁵³. Findings from this study showing that men slightly engage early in sexual intercourse are in contradiction with the same 2003 GDHS where it was seen that it was rather women who early engage in sex (median age at 18.2 years) than men (median age at 20.2 years)⁵³. The vulnerability of women to premarital sex may be likely due to gender differences which are culturally favored. These cultural deviations which include coercive sex, rape, defilement etc, promote the transmission of HIV/AIDS and endanger the lives of women through involvement in unprotected sex with multiples partners⁵⁹.

Our findings are similar to those found in China where most newly weds in China have had sex before they marry.⁵⁹

Given the fact that premarital sex was also mentioned as a core barrier to HIV PCT from participants in IDI and FGDs, since those who have had sex tend to fear to go for test because they fear they might have been HIV infected, we think reduction of premarital sex among young unmarried adults would help to promote HIV PCT in the area. A certain number of measures, such as sex education, school-based educational programs, adolescent counseling, creation of virgin clubs, parents implication in sex education, reduction of poverty and illiteracy, interdiction of projections of pornographic film...among others, could help, as it has proved success Worldwide^{9,39,59,60,61}.

Findings in Tables 4 ,5, 6 and 7 and in Figures 5,6 and 7 support that 97% of respondents had good knowledge with 100% scoring positive perception towards HIV PCT, with little variation of knowledge and perception among both men and women. This is an encouraging picture on which District Health Authorities can rely to quickly implement a HIV PCT service in order to respond to their need. Since score of knowledge showed lower scores among 3% of respondents, education on HIV PCT should still be scaled-up continuously so that all unmarried young adults and growing adolescents in the District all acquire adequate knowledge on HIV PCT.

Although majority of respondents scored higher marks showing adequate knowledge on HIV PCT and confirming near universal awareness on HIV/AIDS revealed in the 2003 GDHS ^29,53, lack of knowledge emerged from each of the indicators in Table 4 in both sexes. In fact none of the indicators performed 100% of respondents giving right answers. For example it is noticeable that 10.3% did not know that children could be born HIV infected from their mothers, figure which is quite similar to data from the 2003 GDHS⁵³. Worse still, 38.7 % did not know that not all sexual unions and marriages are safe and good for health of both partners and offspring. And as a divergence, although showing big lack of knowledge in knowing diseases making unsafe sexual unions and marriages, almost 95% of respondents recognized they would consider health status as a core criteria when they will choose their marriage partners. All these show there is a deplorable big gap since such basic knowledge is actually the one which would help them perceive well the importance of HIV PCT.

Beside that, 82.7% said they would assess health status of their marriage partner through premarital examinations. This specific observation of high level of knowledge concerning the necessity of assessing good health status of their marriage partners and the ways to assess it, explains very well the near universal positive perception they showed towards HIV PCT (Table 6, 7 and figure 7).

It should be noted that majority of respondents (58%) showed big lack of knowledge about knowing a young adult who suffers or suffered from or died of HIV/AIDS, trend which is similar to figures from the 2003 GDHS⁵³. Also majority (63%) did not know anyone or any couple who underwent HIV PCT before marriage. The first observation does not imply young adults are not having HIV/AIDS or dying from it, when we know that in Ghana more than 90% of AIDS cases are found among adults aged 15-49%, the peak ages being 25-34 for females and 30-39 for males.²⁹This fact rather shows that education and awareness creation on HIV/AIDS is still lacking in some social groups. In fact many are those dying of HIV/AIDS and yet people around them don't just know it is AIDS or they think it is just something else. Promotion of peer education, including persons living with AIDS is crucial to break up this kind of gap of knowledge on HIV/AIDS ravages.

For the second observation we agree it is possible a respondent has not known yet someone or a couple who underwent HIV PCT before marriage. This may be true since HIV PCT is not yet formally implemented in Kintampo District. The service is still at an embryonic stage where only few would-be couples go and test. And even then because the HIV PCT is surrounded by a strict rule of secrecy, it may be even possible a person or couple the respondent knows did the test before marriage, but that he/she could not just inform others for confidentiality purposes. But since we know it is by observing other person doing good things that respondent could also consider that behavior as being good and finally adopt it him/herself⁶², we think at this stage not performing HIV PCT would remain a barrier to promote the HIV PCT behavior. Also people should not confuse confidentiality on HIV test results with confidentiality on practicing or attending HIV PCT. The first can be kept confidential while the second information can be made available to relatives and to peers. There is still much to do to first implement officially the HIV PCT centres where would-be couples can go for test and let people around know that the HIV PCT health practice (behavior) is being undertaken by others.

Surprisingly, although HIV PCT is a specific type of VCT, majority of respondents (84.7%) had heard more about HIV PCT than VCT itself (72%). This shows how education and awareness creation is still low or inconsistent on VCT and that even when respondents get the information they only get it partially, inadequately and incompletely. This could be confirmed by their sources of information about VCT and HIV PCT. Although majority of respondents heard about HIV PCT through audiovisual media channels (Radio, TV, Cinema or Video...) [78.5%], churches/Mosques [36.1%] and friends/third person [33%], it is surprisingly deplorable that only 31.9% heard about it through health workers who yet should have been the very top source of information if we only want the right information on HIV PCT to reach young people. Only few respondents (14%) heard about HIV PCT from their parents, meaning young adults rely on outside sources as their parents are more likely not to inform and educate them about HIV PCT and other sexual matters. Also likely it is possible these young adults get more information on HIV PCT compared with parents. This opposes and questions the workability of one of the strategies for the implementation of BCC and IEC programmes of addressing HIV/AIDS in Ghana, where parents are supposed to be educated to be positive role models for their children and also to play an active role in educating them about sexuality and other reproductive health related matters^9,61. Mass media seemed to be playing its role in the implementation of BCC and support towards an effective HIV PCT awareness, behavioral change, care and coping strategies as it is recommended in the National HIV/AIDS and STI Policy⁶¹. However the involvement of schools in informing young people about HIV PCT seemed still very low (29.2%).

It is worthy to note that the inexistence of effective drug to cure HIV/AIDS was known by majority of respondents (94.7%). This is a good point since from this we hope they could then deduce that the only available effective way to fight HIV/AIDS is its prevention which is considered central to the National effort to reduce the spread of HIV/AIDS in Ghana.⁶¹As a result, knowing HIV/AIDS does not have any effective drug to kill the HIV would definitely help them understand the importance of HIV premarital counseling and testing, one of usual preventive measures in the national framework to fight HIV/AIDS.

With reference to pictures 4 and 5 showing the routine reality that traditional herbalists in Kintampo District are having people living with AIDS (PLWAs) who come to them for treatment, it is important to attract your attention that such false claims of cure for HIV/AIDS negatively affects BCC in Kintampo. During one FGD one woman said the following quote:

It is true such claims of cure for HIV/AIDS may affect negatively compliance and patronization of preventive services such as HIV PCT in Kintampo. Therefore we suggest that the DHMT assist and orient those traditional herbalists as it is recommended in the National HIV/AIDS policy.⁶¹

Using the tri-polar scoring scale described earlier on, we found out that majority (97%) of respondents proved Good knowledge, with 41.3% scoring «Adequate Good Knowledge» versus 55.7% scoring «Average Good Knowledge», versus a minority (3%) proving Poor knowledge on HIV PCT. These results clarify one of the factors (poor public knowledge on HIV PCT) that we mentioned in our conceptual frame work (see Introduction) and wanted to verify in this study. The findings are sufficiently encouraging in the sense that, with this higher level of knowledge revealed contrarily to what we thought initially, they suggest there is a hopeful starting point from which the District can take off in implementing such service.

However it should be noted that when analyzing level of knowledge in different professional groups (Table 5), only traders scored adequate good knowledge while students and others scored average good knowledge. This is a surprise since we would normally expect students to know more than traders and other professional groups. But all the same, wherever you are or whatever you do, you may get or may not get access to the right information needed. Just to say that awareness creation on HIV/AIDS prevention should be scaled-up at all levels to ensure equitable accessibility of people to information.⁶¹

Also although the level of knowledge showed average good knowledge in all religious groups, Christian respondents scored the highest mean score ( 15.9[SD=2.9]) than Moslem and respondents with no religion. This confirms the observation we got in the field through IDI and FGD where it was shown that Christian religious institutions have started doing some educational activities on HIV PCT among their churchgoers and even some had started sending would-be couples for HIV PCT at the KDH, whereas it was not yet the case in Islam communities. Although not significant, this disparity of level of knowledge among respondents of different religious groups demonstrates that not all religion bodies have responded to the government advocacy for an effective national response to the problem of HIV/AIDS⁶¹.

It should also be noted that respondents of Akan ethnic group were more knowledgeable (adequate good knowledge) than their counterparts from other ethnic groups who scored average good knowledge. We think this may suggest that the Akan respondents have high access to HIV PCT information than others, without being sure from which kind of sources of information. A further study is needed to deeply research into this to determine the why of this discrepancy.

In figure 6, we also surprisingly noted that respondents from rural parts actually knew slightly more about HIV PCT than those coming from urban area although there was no significant difference. This discrepancy is difficult to explain although we may just relate it to differences in accessibility to or in response of attendance to opportunities of information between the 2 groups. This unexpected finding also tells how seriously people who live in rural areas take in IEC/BCC messages compared to those in urban areas.

The higher level of knowledge on HIV PCT among respondents from Kintampo District may prove somehow how active and effective has been the comprehensive BCC strategy addressing HIV/AIDS in Ghana and in Kintampo District to provide information guided by individual needs and perceptions.^30,31,61.

Indicators of perception of respondents towards HIV PCT showed encouraging results ranking from 80.7% to 100% (Table 6).

In fact results showed high risk perception to HIV (93.3%) [far higher than figures reporting low risk perception in Ghana²⁹], higher perceived severity of HIV/AIDS (100%), higher perceived threat of contracting HIV in case one marries without attending HIV PCT (98%), higher perceived benefit of HIV PCT (100%), high perceived self efficacy towards HIV PCT action (98%), high perception of HIV PCT as a subjective-family norm (96%), high perception of HIV PCT as a subjective-peer norm (96%), high perception of HIV PCT as a social norm (98.7%), high perceived barriers to HIV PCT practice (80.7%) and high perceived need of HIV PCT services (99.3%) among respondents. These are all conducive factors which may have led most respondents to be more attracted by HIV PCT practice, looking both at the high rate of willingness (98%) they manifested to undergo HIV PCT and at the high readiness rate (96.7%) to know and accept their HIV test results after a PCT session, contrary to what we initially presumed in the conceptual framework. In fact it is believed that people will take action to prevent, to screen for, or to control ill-health conditions 1) if they regard themselves as susceptible to the condition, 2) if they believe it would have potentially serious consequences on their health/life, 3) if they believe that a course of action available to them would be beneficial in reducing either susceptibility to or the severity of the condition, 4) if they are convinced that most people (family members, peers..) approve of the action (behavior), and 5) if they believe that anticipated barriers to (or costs of) taking the action are outweighed by its benefits⁶². Therefore the district authorities should orient the BCC strategies in specifically addressing those indicators so that HIV PCT is widely promoted in Kintampo district. Thus for behavior change communication strategies to succeed in fighting HIV/AIDS in new couples in the district, unmarried young adults must feel threatened by their current behavioral patterns (perceived susceptibility and severity) and believe that change of a specific kind of behavior (getting married after attending any PCT) will result in a valuated outcome (of protecting him/her and his offspring against HIV risk infection in attending HIV premarital screening) at acceptable cost. They also must feel themselves competent (self-efficacious) to overcome perceived barriers to adopt HIV PCT practice (behavior).

As you may have seen it in Table 5, majority of respondents (61%), recommended HIV PCT should be compulsory as opposed to minority (39%), saying it should rather be optional. Views of participants in qualitative study were even much divergent, constituting itself a discussion flow in view of the following quotes, just to mention a few.

«If we truly want to save lives, I think HIV PCT should be made compulsory, so that transmission of HIV will be reduced. Optional testing will still favor HIV spread in new couples since not all would-be couples will opt to go for it.»(IDI: District HIV/AIDS Response Initiative Coordinator /DA /GES/Kintampo, Picture No 12).

«No! In church matters, we don't make things compulsory, so HIV PCT should be made optional. The would-be couples have to decide what they want to do regarding their own life and health. We haven't reached the level where we ask for a medical certificate that indicates that you are HIV/AIDS free before celebrating your marriage. Our advice is that we talk to the would-be couples and each person him/her self has to accept the advice. If he/she decides to do the HIV test, fine. If not, well, we let them know that they will have to suffer the consequences.»(IDI: Rev.Pastor Methodist church/Kintampo)

«In church we leave to people their freedom to self acceptance and decision like God does for us. So HIV testing is not compulsory in our church before marriage. We only counsel would-be couples to do it. The last decision to test is for them»

(IDI: President of S^t Joseph Catholic church, /Kintampo, Picture No 13)

«Since most of young adults may not comply voluntarily, HIV PCT should be made compulsory. I believe in my Mosque as people like marriage it can still work very well like that»

(IDI: Imam/Central Mosque/Kintampo, Picture No 14)

«I think, the simplest better way is to make it compulsory. We were doing it in our church and it worked. But sometimes ago we received a letter from an NGO saying we should not continue to do it like that. But it has become a social normal behavior among my churchgoers. If I were to make a law, frankly it should be made compulsory»

(IDI: Rev Pastor, Pentecost's church/Kintampo)

«Yes. It should be compulsory in order to reduce the spread of HIV in new couples and families. This will bring happiness in the country»

(IDI: Traditional Herbalist/Ampoma )

«I am just not comfortable for HIV PCT to be compulsory. It should be optional rather. Eeeh!, I can't really explain why. Just make it optional. It is a stressful deal.»

(IDI: Private Medical Doctor/Kintampo)

«HIV PCT should be made compulsory. Because the rate at which HIV/AIDS is going high and higher in this place is terrible. Very soon within decades each family in Kintampo will have a HIV infected person or a HIV orphans/widows. So since couples don't come voluntarily, just scarce cases, it has to be compulsory.

(IDI: Matron Counselor/KDH, Picture No 15)

«Neither compulsory nor optional. Both are not good. If you make it compulsory, fine, but people will feel infringed in their right. If you make it optional, also fine. But some people will not do the test and the disease will still spread and decimate people. We should rather educate and encourage people so that HIV PCT becomes an individual, ,familial , social and routine norm of life so that we do It just spontaneously like we eat or put our dresses»

(IDI: Laboratory Technician/KDH)

«It should be compulsory. Parents should make sure that PCT is done before they give their children for marriage»

(A 34- year- old mother: FGD Traditionalist mothers/Ampoma)

«It should be compulsory because nobody likes the illness»

(A 45-year- old father: FGD Moslem fathers)

«Yes! It has to be compulsory. In our church it is organized by the marriage committee»

(A 64- year- old father: FGD Christian parents).

«It should be made compulsory. If not many people will not test. If you can accept to marry an HIV infected partner, fine, then it can be optional. But if you know you could regret it later, the best solution is to make it compulsory, what else? »

(A 23-year- old single girl: FGD Moslem girls, Picture No 16)

«It should be compulsory. But even so, people will still don't go for test, unless the government sets a strong conducive law on premarital tests, which will first force people to do It before realizing later it has become part of personal and social spontaneity.»

(A 24-year- old single boy: FGD young adults, Picture No 17).

Can we still discuss this issue after this discussion flow? If you look at it critically, what is obvious is that although views diverged, majority if not all respondents and participants are saying it should be compulsory. But what would the policy maker choose? If you are still free of HIV/AIDS, what is the option which secures you the best? If you are a PLWA, which option fits the best? And if you are PLWA children innocent victims from mother-to-child transmission of HIV, what would have been the option to protect you? And if you are a lawyer or a medical doctor or a religion leader, what is the best solution? If you are demographer planning for a future bright generation what is the best solution? We could still lengthen the list of similar questions, just to show that the view of each person depends on his/her own interest. The legislator should put all views together in order to make a holistic representative and acceptable policy that protect each individual and the community.

This issue on compulsoriness of HIV PCT always creates polemic among people. This is the case even among WHO/UNAIDS staffs ⁶³. But from public health point of view, disease screening is one of the most basic tools of modern public health and preventive medicine.⁶⁴

Although screening programs are commonly thought of as either voluntary (optional) or mandatory, there is in fact a continuum of approaches that can be taken. Faden and colleagues (1991) characterize five types of screening programs under which HIV PCT could fall: (1) completely mandatory, (2) conditionally mandatory, (3) routine without notification, (4) routine with notification, and (5) non-directive patient choice.⁶⁴

In a completely mandatory program, a government agency requires citizens to undergo a screening test and sanctions those who do not comply. So for instance in our case study, individuals who would marry without performing the test or pastors, bishops or Imam who would celebrate a marriage when a couple did not perform any test would be sanctioned. ⁶⁴

In a conditionally mandatory program, either government or a private institution makes access to a designated service or opportunity contingent upon participation in the screening program⁶⁴. For instance, medical authorities-legislators-lawyers and religion leaders could require would-be couples to undergo HIV PCT as a condition of receiving prenuptial certificate that would allow them to marry. And this is actually what we meant in asking the question whether HIV PCT should be compulsory or not and we believe majority of respondents who opted for the compulsoriness understood this.

In a non-directive patient choice program (voluntary testing) individuals are provided information about the test, and the choice about whether to be tested is left to them. Patients actively must choose to be tested, and if they do not opt to be tested, the default is that no testing will occur. This type of program is the model typically employed in the context of genetic counseling where it is labeled "non-directive counseling." This also is the model used by HIV anonymous test sites, including HIV PCT⁶⁴.

As the epidemic continues to affect people living in poverty and people who have historically been disenfranchised, there is an increased risk that testing can and will be used to discriminate against people infected with, or even thought to be infected with, HIV and will further isolate people with AIDS⁶⁴. Some of quotes got from some participants in FGDs went even far beyond all type of acceptable discrimination. Just reread this horrible quote:

If respondents understood compulsory HIV PCT like this, then it could not work. Thus, policy decisions must incorporate strong protections for those who are already suffering from discrimination⁶⁴.

It is true VCT and HIV PCT have helped to control HIV/AIDS and to target treatment for infected persons in a number of countries, such as Uganda¹⁰. This illustrates the tangible public health benefits of such screening efforts and explains why some countries have made HIV PCT mandatory rather than optional^10,42. Thus, if HIV PCT programs are poorly conceived, organized, or implemented, they may lead to interventions of questionable merit and enhance the vulnerability of groups and individuals⁶⁴.

There is the need of still studying further as to whether compulsory HIV PCT would work or not in the Kintampo District context. Despite the view of majority of respondents suggesting HIV PCT should be compulsory, District Health authorities should study the feasibility of this approach, knowing that optional (voluntary) approach has also failed in some VCT centres still not or feebly patronized in the country³⁶. Either it starts under the Voluntary (Optional) or mandatory approach, district authorities should put in place long term education and sensitization campaign to make sure HIV PCT later becomes a spontaneous «routine screening» with the full and straight commitment and understanding of communities and the target groups.

District authorities should also be aware that it has been found that when shifting from a type of approach to another, patronization of HIV PCT is always affected in the way that the number of clients patronizing premarital service tends to decrease when the examination become optional than when it was compulsory and to increase when PCT examination is free. The same study has shown a low rate of voluntary compliance to premarital examination because of fear of the results.¹³They should also examine the cost-effectiveness of a HIV mandatory premarital screening program based on current studies ⁶⁵.

If the approach of compulsory HIV PCT is chosen in Kintampo District, a cost-effectiveness study should also be planned in order to compare the cost with the effectiveness of such program. Also if optional HIV PCT program is to be implemented in accordance with the current National HIV/AIDS and STI Policy⁶¹, then Kintampo district authorities should realize they are putting in place a system against the views of the majority of the target group interviewed in this study.

Finally, experience of Uganda with a higher HIV prevalence rate showed that lack of non-committal in HIV PCT leaves room for being optional. And this led some religious groups and parents to make testing for HIV before marriage mandatory, although the Uganda policy supports it should be rather optional⁶⁶.

Findings from Table 7 and Figures 5 and 7 showed that the entire totality (100%) of respondents in both sexes had «adequate positive perception» towards HIV PCT irrespective of their different socio-demographic background. This clarifies with disagreement one of the factors (bad perception towards HIV PCT) in our initial problem analysis diagram. Despite Table 8 showed there was a significant weak positive linear relationship between level of knowledge and perception towards HIV PCT (p-value 0.007), meaning the score of perception slightly increases as the score of knowledge increases, it was observed however that even respondents with poor score of knowledge also had higher score of perception. This means little or average knowledge on HIV PCT is enough to still create a very strong positive perception towards HIV PCT among unmarried young adults. This is a proof that little or average knowledge could still result in generating positive perception towards a given behavior⁶².The similarities in score of perception among respondents of low and high score of knowledge underpins the fact that if we want to raise perception of people towards HIV PCT practice, we only need to simply create awareness on few important issues on don'ts and not necessarily bringing sophisticated scientific matters to them. Therefore the development of BCC and IEC materials and messages aimed at promoting HIV PCT should be based on participatory methods and research evidence-based data, leading to the production of appropriate messages and materials for different target groups according to their need of knowledge to fill appropriate identified gaps⁶¹.

As a comparison, our results showing adequate positive perception of unmarried young adults towards HIV PCT are quite similar to findings in Egypt where ESHRA and Colleagues found that most respondents from Menofia Governorate, except unmarried males, had a favorable perception towards HIV PCT⁵⁰.

Perception of the need of HIV PCT service was inversely (negatively) associated with Urban residence, to the fact of having had premarital sex and score of knowledge (Table 9).

In fact respondents from urban area were 5 times less likely to perceive the need of the PCT service than respondents from rural settlements. This is contrary to what have been reported in a similar study among Malawians⁴⁵.This may be due to the fact that young people from Urban areas may take all things for granted to the point of thinking all their health need will be automatically satisfied in life irrespective of their own expression.

Also respondents who have ever had sex were 16 times less likely to perceive the need of the service than still virgin respondents. This may be explained by the fact that for those who know they have engaged in risky premarital sex, fear to know their HIV serologic status may be higher and worrisome to the extent of leading them not even to perceive the need of such service¹⁰. It even joins the view of some participants in one of the FGDS.

Therefore promotion of sexual abstinence and of virginity through appropriate sex education and establishment of virgin clubs could help ensure that target groups express and understand the need of such services as it has been proved in Uganda and Zambia¹⁰. Also education and comprehensive counseling of those who happen to have had premarital sex should be carried out in order to dissipate the fear those respondents feel.

It was also found that increased score of knowledge on HIV/PCT was associated with decreased likelihood of the respondent to express the need of such service. So the higher the score of knowledge (the more knowledgeable a respondent), the lower the likelihood to perceive the need of HIV PCT service. This is contrary to our expectations but somehow compares with results from Malawi where it was found that respondents who had knowledge of sexually transmitted diseases (STDs), knowledge of HIV testing place were less likely to desire testing prior to marriage.⁴⁵We can't truly explain why it happens this way but we could say that it is possible that more knowledgeable people may take their health for granted because of their pride. Also it could be because it has been shown that although young people have a high level of knowledge about HIV/AIDS, the internalization or conceptualization of their own potential risk is very low¹⁰. Also according to our findings, it seems that knowledge would lead to fear of HIV-testing or a sense of non-vulnerability, such that the need for HIV testing may not be appreciated by the knowledgeable respondent.

On the other hand, perception of the need of HIV PCT service was positively associated with older age, females, Christian religion, Akan and Mo ethnic groups, post-primary educational level, Students and level of perception towards HIV PCT.

Increased age seemed to increase gradually the likelihood for the respondents to perceive the need of HIV PCT. This may be due to the fact that as children grow up they start thinking of the formation of their own family through marriage. Therefore while seeking for and gathering information needed on marriage they may hear about and understand the need of such service.

Females were 19.5 times more likely to perceive the need of such service than males. This may be justified by the fact that females even proved slightly higher mean scores of knowledge (15.76 versus 15.68) and of perception (21.8 versus 21.7) than males. It may also be explained by the fact that generally females are more flexible and easy to be convinced than males who are mostly naturally less flexible. Our findings are in some disagreement with findings from «The Adolescent Counseling and Recreation Centre (AcRC)» in Kenya and « the Center Dushishoze» , a youth center in Butare /Rwanda, where it was rather found that more males were expressing VCT need than female clients¹⁰.

Christian respondents were 5.57 times more likely to perceive the need of HIV/PCT service than non Christian ones. This stands true because as said earlier on, most Christian religions have started educating and sensitizing their young adults towards HIV PCT.

Respondents belonging to Akan and Mo Ethnic groups were 2.8 times more likely to perceive the need of HIV/PCT service than respondents from other Ethnic groups. This could be explained by the fact that Akan and Mo showed higher scores of knowledge than respondents from other ethnic backgrounds.

Respondents of post-primary educational level were 4.13 times more likely to perceive the need of HIV/PCT service than respondents of lower educational level. This contradicts the above findings showing that score of knowledge was negatively associated with perceived need of the service. But it confirms that somehow increased level of knowledge should be translated into behavior change so as to differentiate those still not adopting a positive behavior because of their ignorance. It also affirms that educational attainment may affect the individual's perceptions and thus indirectly influence health related behavior.⁶⁴ This explanation may also explain the fact that students were 4.097 times more likely to perceive the need of HIV/PCT service than respondents of other professional categories.

Finally increased level of perception towards HIV/PCT increases by 4.47 times the likelihood for a respondent to perceive the need of the service than a respondent with lower score of perception. So the higher the score of perception the higher the likelihood to perceive the need of HIV PCT service. This stands far true since it is the individual's perceptions towards an illness or an available treatment or behavior which will lead the individual valuing the benefit of the action so that he/she can adopt the behavior to protect him/her to the disease he/she perceived as very dangerous⁶⁴.

5.4. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT

Table 10 showed that we could strongly predict the willingness of a respondent to undergo HIV PCT from his/her readiness to know and accept his/her HIV result (p<0.001). Therefore the more the respondent says he /she will be ready to know and accept his/her HIV test result, the higher the likelihood of the willingness to attend HIV PCT. This meets findings found in Thailand in a cluster randomized trial used to assess the effect of an active group intervention in promoting utilization of voluntary HIV testing and counseling⁶⁷. In fact since it is reported that most people fear to know their HIV serologic status¹⁰, it is definitely obvious that an individual who has coped with this fear will more likely intend to do the test now as he/she feels ready to know and accept his/her HIV serologic status. Therefore if the service is to be implemented in Kintampo, many sessions of sensitization and anticipated pre-counseling among the target groups would be recommended in order to dissipate the anxiety and the fear clients manifest on the eventual HIV test results.

About other associations, not significant, it was noted that increased age were associated with low likelihood to intend undergoing HIV PCT. This finding is in agreement with findings in a study done in 1970 in Yonsei-Korea among Protestant Ministers on `Knowledge and attitude and practice about marriage...' where age was found to be the most important factor influencing the attitude of respondents towards PCT, the younger respondents showing more positive attitude than the older one. ⁵¹ However our result is inconsistent with explanations given above where increased age seemed associated with positive perception of HIV PCT service. Our finding is also inconsistent with findings from a study done in Malawi in 2004 which rather showed a significant, although weak, association between increasing age and supporting HIV-testing prior to marriage⁴⁵. It is possible that older respondents, who were probably already engaged in many unprotected sexual intercourses with multiples partners, could not support premarital HIV testing because of fear of the HIV test results. It is also possible the older groups, although more appreciative of the reality of HIV/AIDS and their support, think the test is rather for those still younger. Testimony from one old couple we interviewed seemed to support this feature.

Students and respondents of post-primary level all seemed less likely to intend undergoing HIV PCT than their counterparts of other professional categories. This is in some variance with our previous discussions concerning the positive association of the two parameters with the positive perception of the need of HIV PCT services.

Also respondents engaged in premarital sex were less likely to intend doing a HIV PCT than those still virgin. This confirms the above findings and stands true by the same explanations that those who have engaged in risky unprotected sex do not intend to perform the test because of fear of the HIV test result¹⁰. This is because most people think sexual intercourse is the only major route of transmission of the disease.

One would-be couple with premarital sex history who just benefited from premarital counseling sessions organized by their pastor in their local church in Kintampo consented to testify their experience through this work in order to teach it to others that HIV PCT is still feasible and helpful despite past sexual bad behaviors.

This live testimony strongly proves how counseling sessions should be promoted and carried out in Kintampo district in order to dissipate the fear of those unmarried young people who would fear to attend HIV PCT because of their premarital sex history.

It is not understandable that respondents who yet perceived the need for the HIV PCT services were now surprisingly less likely to intend doing the test than those who do not perceive its need at all. This is completely contradictory to our expectation and partially demonstrates how when dealing with HIV testing it is difficult to predict a respondent would concretize his/her own view in doing the HIV test because of so many parameters, especially the fear of the results¹⁰. Reason why long term pre-counseling sessions could help convince such respondents to finally intend doing the HIV test.

Individuals who perceived HIV PCT should be provided free of charge or at affordable cost were less likely to intend doing the test than others. This can easily be understood insofar as most people not willing to attend a heath service usually pretend they do not have money to do so even when they have it. On the other hand individuals who truly felt they were poor might have hesitated to manifest the willingness to undergo HIV PCT until later on, once the service will be implemented at free charge, they would may be now intend to do the test once they are sure it is free.

Individuals living in the urban areas were 3.1 times more likely than rural dwellers to accept voluntary HIV counseling and testing prior to marriage. This is similar to results found in Malawi⁴⁵but enters in contradiction with previous observations showing young people from rural parts perceived more than those from urban areas the need of the implementation of HIV PCT service. Although we cannot determine the reasons for this difference on the basis of the current study, this inequality has far-reaching public health implications because over 80% of unmarried young adults live in rural areas in the district. Further studies are needed to explore this discrepancy.

Akan and Mo respondents were 2.5 times more likely to intend undergoing HIV PCT than respondents from other Ethnic groups. As said earlier on, this may be due to the fact that they also proved high level of knowledge on HIV PCT than others. If we consider the fact that Akan and Mo are the most populous Ethnic groups in the 3 sub-Districts involved in this study and in the whole district, we could assume at this stage that there is hope that such service, if implemented, would be patronized much by Akan and Mo respondents, whether this is true or not.

Christians were 3.6 times more likely to intend undergoing HIV PCT than respondents of others religion groups. This stands true using the same explanations mentioned earlier on.

Female respondents were 3.6 times more likely to intend undergoing HIV PCT than males. This joins findings from Uganda but contradicts some findings from Kenya and Rwanda.¹⁰

Increased score (level) of knowledge and of perception were positively associated with willingness to undergo HIV PCT. This meets our expectations because we believe knowledge empowers people to act positively. However our finding contradicts findings from Malawi.⁴⁵ In fact as people perish by ignorance, it is a good thing that knowledge, once acquired, could help people to adopt positive behaviour than before they got that knowledge.⁶⁴ This could also be translated into positive perception so that those with positive perception show much interest in intending undergoing HIV PCT than those with negative or low perception of it.

Finally, respondents expressing the high need of confidentiality were 2.6 times more likely to intend doing the testing than those who do not. This finding espouses results from a similar study among Malawians, where Humphreys Misiri and Adamson S. Muula found that those who preferred maintenance of confidentiality if one is HIV positive were more likely to accept HIV testing prior to marriage⁴⁵. This feature corresponds to the views of most participants in IDI and FGDs who recognized lack of confidentiality as a major barrier and suggested consequently maintenance and guarantee of confidentiality as a core way to promote the service and make it acceptable and attractive for people (see up-coming point 5.7.4).

It should be noted through Table 11 that about 86% of respondents had paired higher probability (>0.75) of perceiving the need of HIV PCT service in Kintampo and of willingness to undergo HIV PCT. Assuming this picture stands true for the whole target population in Kintampo District, we could be self-confident based on this study that once the service is implemented, majority (at least 86%) of young people would definitely patronize it. On the other hand this suggests that not implementing or not promoting HIV PCT would definitely result in low patronization of the VCT service as initially presumed in our conceptual framework. This could serve as a motivator for district authorities to plan for such service as soon as possible.

5.5. PREFERENCE TO UNDERGO HIV VCT FOR MARITAL REASON OR NOT

Findings in Table 12 suggest that 77% of unmarried young adults exclusively preferred HIV PCT whereas only minority (23%) of them preferred HIV Voluntary testing in no marital purposes. Although the difference between the two trends is not statistically significant, the findings suggest that most unmarried young adults are less likely to voluntarily go for HIV testing unless it is for marital reasons, females being 1.36 times more likely than males to prefer undergoing HIV PCT. This supports findings from the Adolescent Counseling and Recreation Centre (AcRC) in Kenya where most unmarried young adults who come for the HIV test come for certain reasons especially premarital purpose¹⁰. Therefore as implied in findings in the previous study on `Formative research for the establishment of VCT service in Kintampo District'³², the picture in this present study support that for VCT service to be well patronized, HIV PCT must be promoted as well so that unmarried young adults could come for it when they are about to enter into marriage.

5.6. BARRIERS TO HIV PCT ACCEPTANCE AND IMPLEMENTATION

Respondents had to give their view on a long list of 25 barriers drawn from IDI and FGDs.

For easier interpretation perceived barriers described in Table 13 were grouped under 4 categories, given the frequencies derived from respondents:

These are respectively -High cost (price) of premarital examinations , -The attitude of the service provider, -Premarital sex and fear to know their HIV status, -Fear of stigma and discrimination in marriage (denial of marriage for HIV+), -Ignorance of the importance of PCT, -Inadequate VCT/PCT facilities, -Lack or inadequate trained personnel & counselors, -Lack of confidentiality and privacy among health care providers in PCT services and Little solution for those who test HIV (+) ( no effective drugs to treat AIDS).

These are -Inexistence of regulatory procedures and Law/Policy on PCT in Ghana, -Mandatory imposition of PCT that infringes the Human Right of individuals, -The location of the centre/hospital at long distances, -Reluctance of fiancés, -Preference of young people to get married without PCT, Polygyny (Polygynous/polygamous marriages) & Islamic religion, -Marriage by convenience (outside churches & civil registrar officer or court or without customary ritual) , -Forced marriage (e.g. traditional early marriage), -unregistered marriage, -Fiancés are in a hurry to get married very quickly for any reason and -Medical premarital certificate provided to fiancé(e) by doctors without performing any medical check-ups (fraud), - Re-marriage (for divorced or widowed), Inability for girls to negotiate HIV PCT when their prospective husbands don't like it and Blind love among young people.

c) Minor barriers (Yes 30-49%): These barriers regroup - Opposition of some churches and - Opposition of some parents.

Barriers grouped under `others» (not providing gifts to couples) in index number 26 fit to this category.

Most of the major and moderate barriers above have been identified worldwide in VCT implementation and practice.^10,64 Some of these barriers (fear of lack of confidentiality and privacy, fear of stigma and discrimination, ignorance) were also identified in the 2004 previous study³², and therefore merit special interventions for VCT promotion in Kintampo District.

Certain barriers like «Inexistence of specific law on premarital examinations in Ghana» emerged from official key informants who wished there should be a specific law describing the scope, the procedures of the exam. And respondents also gave their approbation on this as a barrier. This confirmed one of the factors (inexistence of conducive law/policy) in our initial conceptual framework. But at this stage where some churches have already started organizing PCT among young people despite the inexistence of any specific law on PCT, we assume it is not as such a big barrier. However although this barrier fell among the category of moderate barrier, we still strongly recommend there should be a specific law/policy on premarital examinations in Ghana in order to make it clear regarding its scope and procedures, like it is the case in many other Countries in accordance to recommendation from WHO¹¹and from many other authors¹⁰.

Mandatory imposition of HIV PCT fell under moderate barriers. This is simply because from Table 6, majority of respondents (61%) opted that HIV PCT should be compulsory although it is recognized that mandatory imposition infringes human right of individuals and therefore push them not to attend the service¹⁰. In fact observations in two states of the USA (Louisiana and Illinois) where premarital testing was made compulsory showed a large proportion of premarital couples got married elsewhere in surrounding states⁶³. This may have happened like that if the governmental bodies in these two states imposed the compulsoriness of the HIV PCT to people without consulting them in a base-line study. In our case, if the view of majority was to be respected in Kintampo based on the current study, we don't assume that reluctant unmarried young adults would run away and go to marry elsewhere in Ghana. And even if it happens it will just be a minority. And since no law can satisfy completely everybody, the service would still function normally.

Polygyny (polygamous marriages) and Islamic religion fell in moderate barriers against HIV PCT. We think it is true since qualitative study also proved similar trend where Moslem girls disapproved polygyny in Islam during a FGD and recognized it would be a barrier to HIV PCT. This corresponds partially to findings from a study of the Kaguru people of Tanzania ⁶⁸

What is paradoxical and interesting in our study is that a large part of Moslem respondents (43.9%) also recognized their Religion as a barrier to HIV PCT (Table 14). They were just frank to tell the truth. This led us to seek an additional IDI from the Imam and one Moslem elder:

Without commenting much on the explanation we got from the Imam, what we can add is that it is true plygyny (polygamous marriage) could be a barrier, but just a moderate one. This is because through the FGD of Moslem Girls, it was revealed that most Moslem men do not perform any prior medical procedure when they choose to marry other wives. However we believe the integration of HIV PCT in Muslim community would change the current reality so that people do no longer claim Islam as a barrier to HIV PCT as it has been proved in many other Islamic Countries where premarital exam is legal and commonly done^14,52. Further studies would be needed in the future to follow-up this issue if possible.

Finally we recommend in priority that major and moderate barriers to HIV PCT revealed in this study should be addressed properly in order to guarantee a smooth take off of VCT and HIV PCT service in the District.

5.7. KEY ISSUES FROM RESPONDENTS TOWARDS HIV PCT HEALTH PRACTICE

IN KINTAMPO DISTRICT

5.7.1. VIEWS ON FREQUENCY OF HIV TEST BEFORE MARRIAGE

AMONG WOULD-BE COUPLES

The points of view of respondents were divergent about the required number of HIV tests before people marry (Figure 8). It is however encouraging that a third of them recognized it should be done more than twice, a fifth saying it should be more than once, and another fifth supporting it should be just once. All these findings support different levels of knowledge among respondents regarding HIV laboratory test.

In many countries with legislation on HIV PCT, the HIV test is required at least once before marriage. But in certain countries like China ¹² and certain areas in Democratic Republic of Congo (ECC/CBCA Church North-Kivu Province), due to the need of testing before the officialization of engagement, also because of possible lengthy engagement during which change could occur in serological status of one or both fiancés, HIV PCT is done at least twice. The first one is undergone before the onset of official engagement (before payment of pride price) and the second happens just a few days before the official celebration of the marriage¹².

In this study only 2.6% of respondents opted for the test being done twice, one before bride price is paid and the second prior to official celebration of the marriage. This shows that respondents disagreed with this last option which yet is being used else where.

However it may be, due to the window period, it is normal that the HIV PCT should be done at least twice, with 3 months interval between the two tests¹⁸.

From Figure 9, we saw that majority of respondents (42.86%) suggested that the fiancés themselves should decide and go for test without any body sending them. This is the best way of doing thing as far as marriage concerns two people. But this could work well only if couples discuss in pre-test counseling the implications of discordant/positive results of HIV test¹⁰.

But if we look at the social aspect of marriage, involving both families, the religious bodies or lawyers, it is possible some times that a third person (religious leader, counselor...) comes in to play a role of facilitator. This does not destroy the fact that the test remains first of all voluntary.

The big issue is on how to manage the positive HIV test results and to whom to communicate it. Knowing many couples would not be able to cope with the positive HIV test result alone and decide on marriage project without the intervention of a third person such as counselors or religious leaders came in between, we suppose in our opinion that, even if a couple decides voluntarily to undergo the test, a third neutral body, whether religious or not, medical or not, counselor or not, is still needed to facilitate and follow-up their commitment to HIV testing, and help them cope with the anxiety and the consequences of an eventual HIV test result vis-à-vis the decision on marriage.

In most of African countries, including Ghana, Religion Institutions are officially integrated as stakeholders, activists and main partners in the fight against HIV/AIDS^10,61. Thus although only 15.61% of respondents said Religion leaders could send would-be couples for HIV PCT, this role which is unavoidable should not be neglected since Religion Institutions are involved in many counseling programs, including HIV PCT. In our case study Religion institutions are even currently the only reliable and available structures providing premarital counseling sessions in Kintampo district. Therefore a religion body who sends would-be couples to undergo HIV PCT after counseling session is still acting towards the advocacy for an effective national response to the problem of HIV/AIDS as highlighted in the National HIV/AIDS policy.⁶¹ The district health authorities should play a coordinating role to train and orient religion institutions in the directives towards a voluntary consent of would-be couples on HIV PCT.

In Figure 10, about one-third of respondents suggested HIV test results should be communicated to both would-be couples together; others suggested it should also be communicated to parents or guardians, to religion leaders etc. This big issue is about how to maintain confidentiality. Confidentiality and privacy is crucial in VCT and HIV PCT matters¹⁰. But when it comes the necessity of disclosing the test results to the fiancé(e) so that they both discuss and decide on marriage issue and if it happens that the marriage relationship breaks up, confidentiality may no longer be respected.⁴⁵ And that is where the problem resides. It is not bad for religion bodies or any other third person to be involved. But the whole issue is that they should know the HIV test result belongs to the person and the couples. And the National HIV/AIDS policy is very clear on the issue of disclosure of HIV/AIDS test results with insistence that health care providers shall not disclosure any confidential information from the client to any person without the express consent of the client.⁶¹

5.7.4. WAYS TO PROMOTE HIV PCT IN K'PO DISTRICT

For easy classification we wanted to see which measures should be put in place in decreasing order of priority, depending on what beneficiaries of the service suggested in Table 15. Thus we created the following classification scale:

7. Last line measure (negligible): when less than 30 % of respondents suggest it.

Using the above scale based on the «Yes» frequency distribution for each measure suggested by respondents, we could deduce from Table 15 that 15 interventions in 5 gradual steps (Figure 14) are actually needed in Kintampo district in order to promote HIV PCT.

Depending on the resources available, the district health authorities should address the suggested measures one by one and step by step to make sure HIV PCT is established smoothly.

Because 100% of respondents insisted that other tests should be added to HIV/AIDS in order to reduce stigma associated to HIV/AIDS, this is a crucial action which should be done in priority as the very first line intervention. In fact literature supports that premarital examinations should be global and not selective so that it integrates all required tests such as Hepatitis B, Sickle cell test, Rhesus factor, just to mention a few.^5,14,15,18 Integration of other tests in premarital screening has shown success in many parts of the World.¹⁰

Others measures such as mass sensitization campaigns, open discussions on youth sexual education, provision of care and support, reducing stigma and discrimination associated to HIV have also proved success in VCT practice wordwide.¹⁰

Figure 14 below describes the 15 interventions to be put in place in 5 steps in order to promote HIV PCT in Kintampo District.

Figure 14. Steps and actions needed in order to promote

% CI of Yes Answers

HIV PCT in the K'po District, based on suggestions

Lower Limit

Upper Limit

of beneficiary respondents.

Last line action

Step 7

29%

6^th line actions

Step 6

Others (PCT done before pride price is paid, quoting that couple did PCT during marriage ceremony, PCT films /posters...)

49%

5^th line action

Step 5

69%

4^th line actions

Step 4

Strictly prohibit all marriage (be it civil, religious or traditional) before PCT is done, through a decree law

79%

3^rd line actions

Step 3

89%

2^nd line actions

Step2

Setting a specific law (decree-law) on premarital examinations in Ghana

99%

Reducing stigma and discrimination against people living with HIV/AIDS

Creating youth HIV associations/clubs like Virgin club etc

Recommending a prenuptial medical certificate from the doctor for each fiancé before celebration of marriage

Providing care and support services for people living with HIV/AIDS

Mention PCT in the health reproductive policies

Teach PCT in the health education & reproduction matters in school

Encouragement by providing free treatment for any other diseases detected among those would-be couples who come for HIV PCT

Churches and mosques teach PCT to young couple before marriage

Open discussions on Youth sexual education about HIV-AIDS and PCT in youth durbars such as sports...

Mass sensitization campaigns about PCT through durbars, Radio/TV, news papers, churches/mosques, NGO, associations, clubs, schools & university, Hotels, hospitals etc

1^stline action

Step1

Add other premarital required tests to reduce stigma associated to HIV

100%

Source: Field Survey, Kintampo, June 2005.

5.7.5. WAYS TO CREATE EASIER ACCESSIBILITY TO HIV PCT IN THE DISTRICT

Majority of respondents (almost 60%) suggested HIV PCT services should be free or set at affordable cost or paid by the Government or by any charity NGO in order to make HIV PCT services accessible to beneficiaries (Figure 11). Another part of respondents expressed that the number of VCT/PCT centres should be increased and established not at long distances from communities. This is understandable because majority of respondents recognized high cost of HIV PCT as a major barrier (Table13). In fact it has been observed in VCT practice that because of fear of HIV results, fear of stigma and discrimination associated to HIV/AIDS and little solution to cure HIV/AIDS, most people are reluctant to do the test, worse still to pay for their money for HIV testing^10,64. Also when we consider the fact that HIV/AIDS is prevalent in developing countries in poor communities, the affordability of HIV VCT and HIV PCT becomes questionable. That is why UNAIDS has recognized scaling up of free VCT centres as the suitable strategies to fight HIV/AIDS in developing countries^8,10,37. Thus in Ghana VCT is recognized nationwide as part of the strategies for National response to combat HIV/AIDS. Specifically it is stipulated in HIV/AIDS policy that Government Agencies and Institutions will ensure increased collaboration in sourcing resources and technical assistance necessary for the implementation of programmes and interventions throughout the country^35,61. Therefore establishment of VCT centre providing free HIV tests to people and to would-be couples would be very helpful in fighting HIV/AIDS in the general population and new couples in particular in Kintampo district. The only problem associated to free cost of HIV PCT is that sustainability is very low after financing institutions withdraw from sponsoring the VCT program¹⁰. Thus at the starting point, the HIV PCT service could be free, but it should be wise to later put in place some measures to ensure that the program is sustainable and owned by the community.

5.7.6. WAYS TO MAKE HIV PCT MORE EFFECTIVE, ACCEPTABLE AND

ATTRACTIVE FOR YOUNG PEOPLE IN K'PO DISTRICT

In order to deduce interventions to be put in place in decreasing order of priority, depending on what beneficiaries of the service suggested for the HIV PCT service to be more acceptable and attractive, we used similar classification scale mentioned above (point 5.7.4).

Data from Table 16 imply 15 interventions in 4 gradual steps that are summarized in Figure 15 below.

Obviously, given the proportion of respondents suggesting confidentiality should be guaranteed, the very first crucial step in launching the HIV PCT service in Kintampo should actually be maintenance of confidentiality. The patronization of the service would definitely depend upon the confidence respondents have in health care providers, regarding how they are treated with secrecy. This has been proved in VCT practice worldwide.¹⁰

Once confidentiality is worked on, the district authorities should then tackle other suggested points one by one, and step by step, or even holistically, to put in place corresponding measures. Thus for instance the second step would consist of providing care and support services for those found HIV infected and appointment of well trained personnel, especially counselors. These are also very crucial in running a very effective and attractive VCT services as it has been proved in Zambia, Uganda, Kenya and Chili, just to mention few countries¹⁰. In fact the ultimate goal to do HIV test is to let people who are detected HIV infected have access to a comprehensive and continuum care and support. These include provision of antiretroviral drugs, drugs for treatment of opportunistic infections, psychological and social support¹⁰. If clients are being cared for in a such comprehensive way, then people will appreciate and patronize the VCT service. Conversely, when clients are not well cared for, the VCT service will be contested.

The other measures in the subsequent steps could also be progressively addressed (Figure 15).

Figure 15. Steps and actions needed to make HIV PCT practice

% CI Yes Answers

more acceptable and attractive for young adults, based on suggestions of beneficiary respondents in K'po district.

Lower Limit

Upper Limit

Seventh line actions

Step 5

Others (give marriage gifts to couples, quote that couple did PCT in marriage ceremony...)

49%

Sixth line action

Step 4

59 %

Firth line actions

Step 3

Appoint young adults counselors

79 %

Fourth line actions

Step 2

Organize more than one counseling session is provided to the fiancés

89%

Put in place examiner/counselor of the same sex as the client

Conduct follow up of fiancés / newly married after HIV PCT

First line action

Step1

Put in place counselors not known in the area and or change continuously the old counselors by new ones after a certain period.

100%

Provide entertainment in VCT/PCT centres

Provide for unbiased, clear and non-judgmental advices to would-be couples

Provide treatment or effective cure for HIV/AIDS

Provide for the presentation of test results as soon as possible, to reduce the anxiety of waiting to long (same day result

Secure permission of patients before passing on information to anybody (parents, pastors/bishop, Imam and other care providers..)

Appoint knowledgeable, well trained, kind, wise and good communicator examiner/counselors

Provide permanent caring and support services

Provide HIV PCT at affordable cost or free of charge.

Guarantee complete confidentiality and privacy

Source: Field survey, Kintampo, June 2005.

5.7.7. HEALTH FACILITIES WHERE HIV PCT CENTRE SHOULD

BE ESTABLISHED IN KINTAMPO DISTRICT

As shown in Table 17, 72% of respondents suggested HIV PCT services should be established in Kintampo District Hospital (KDH), while 75.6% of respondents from Jema Health (who represented 27% of the whole sample) expressed that the service should be established in Jema Health Centre. These findings suggest that respondents knew that KDH fulfills well the required criteria to run such service given the trained personnel in place (doctors, lab technicians, Matron-counselor...) and the laboratory equipment available. Those from Jema just expressed that they wanted the service to be close to them, to avoid lorry fare as it came up also in FGD where people expressed that HIV PCT centres should be placed in communities for easier accessibility.

In either case, some thing more must be done now in this pre-VCT implementation period. If the service is to be implemented in KDH, the infrastructures for VCT should be prepared now so as to secure privacy and confidentiality of respondents. The same if the service is to be implemented else where like in Jema Health centre. In fact the national policy seeks for the provision of VCT facilities and procurement of VCT commodities such as laboratory equipment and supplies including reagents for diagnosis and voluntary testing for HIV⁶¹. Since facilities for VCT are currently limited in the Region and completely inexistent in Kintampo District, special advocacy efforts should be devoted now to obtaining the support of health planners at all levels, in both Governmental and Non-Governmental sectors to allocate resources in their budgets to either rehabilitate existing laboratories in KDH or build a separate VCT unit , provide VCT materials and supporting training of qualified personnel towards the implementation of VCT/HIV PCT service in Kintampo District. Also the implementation of the VCT/HIV PCT may start at KDH where majority of respondents actually expressed it to be established, before progressively expanding it later in other places like in Jema in order to bring the service closer to target groups, depending on resources available.

In general, decision on break up of marriage relationship was strongly prevalent in case of discordant HIV results whereas decisions greatly diverged when it is about both fiancés testing HIV positive (Figure 12). This confirms that premarital screening is a major determinant in marriage choices.⁶⁹

Our findings support what prevail in Nigeria where calls for rights of PLWA to marry, although quite significant, still pose problems. In fact in an article published in April 9^th 2003, a journalist wrote against marriage of PLWA, we quote «However, you will need to understand that several groups are seriously worried about the spread of HIV/AIDS in the country. It could be appropriate if we encourage the marriage of PLWHA to PLWHA, not on the basis of discrimination but to prevent the further spread of the virus. I therefore think that we all need to observe the human right not to spread HIV to others if we are infected. Campaigning against pre-marriage HIV testing is as good as campaigning against the provision of drugs to PLWHAs.»⁷⁰

Our findings definitely show there is high popular demand for HIV PCT among would-be couples, so that young people and their families can take information on HIV carrier status into account at an earlier stage in the choice of marriage partner. They also show how denial of marriage right to PLWA will be a problem which will still enhance stigmatization and discrimination associated to HIV/AIDS in Kintampo District. Although we recognize that it is difficult for a person still HIV negative to accept to marry an HIV infected one, we also recognize that PLWA also have the same right to marriage as it is recommended by UNAIDS guidelines on the rights of individuals concerning HIV/AIDS^71,72.

What is obvious is that people haven't also understood availability of PMTCT methods to prevent transmission of the virus from the mother to the baby. This may explain how few of respondents chose decision to marry and adopt PMTCT methods in case of discordant couples or HIV infected couples.

Yet studies have shown that PMTCT (using antiretrovirals & Cesarean Section, avoiding breastfeeding) and protected sexual intercourse (permanent condom use) are very effective in limiting further HIV transmission⁷³, fact that our respondents do not understand well. So decision on marriage in discordant or HIV infected couples could consist of marrying and adopting PMTCT or abandoning/limiting childbearing, adoption of children with permanent condom use, or more sophisticated methods like artificial insemination⁷³. But our respondents seemed reluctant to those measures. In FGDs and IDI majority of participants had the conviction that in actual circumstances it is totally impossible for discordant or HIV positive couples to permanently perform PMTCT and use condom. And they suggested that marriage between discordant couples should be rather purely prohibited (Figure 13). But they seemed agreeing with marriage between both HIV infected partners, joining the above mentioned view from a Nigerian Journalist⁷⁰.

Therefore large campaign of education and sensitization of young people on Assisted Reproduction in HIV infected people and on availability of effective preventive measures (PMTCT, permanent condom use) should also be carried out so that people understand that marriage between discordant couples or HIV infected couples is still workable.

Chapter Six

CONCLUSION AND RECOMMENDATIONS

We have now come to the end of the study. The main objective of the study was to generate useful information on current level of knowledge and perceptions of unmarried young adults towards HIV PCT in order to predict their acceptance and behaviors towards utilization of such services and to deduce appropriate program/policy for intervention in the relevant area. The qualitative and quantitative methods adopted in the study contributed to respond to our research questions, to verify our conceptual framework and to achieve the main and specific objectives of the study.

Findings drawn from 150 surveyed unmarried young adults in the 3 sub-districts targeted for the study proved sufficiently the attainment of our study objectives.

The study findings show that 97% of respondents have good knowledge and 100% of them have adequate positive perception towards HIV PCT. Majority of unmarried young adults express the need of HIV PCT service (99.3%) and show positive acceptance and willingness (98%) towards utilization of such service in Kintampo District. There is positive linear relationship between score of knowledge and of perception on HIV PCT with positive perception even among people with poor knowledge. Thus little or average knowledge on HIV PCT is enough to still create a very strong positive perception towards HIV PCT among unmarried young adults.

Willingness to undergo HIV PCT is strongly positively associated with readiness of a respondent to know and accept his/her HIV result and negatively associated with age, post-primary education, being a student and premarital sex. Akan and Mo ethnic groups showed greater preference for HIV PCT.

Majority of the targeted group show greater preference towards HIV VCT for marital reason.

Respondents recognize there are some barriers to HIV PCT and suggest several activities in order to deal with those barriers and make HIV PCT more effective.

Majority of respondents show disapproval of marriage between HIV discordant and HIV seropositive couples and presume that they would break marriage relationship in case of HIV positive results during HIV PCT session.

Not all populations of unmarried young groups in Kintampo have an equal likelihood of perceiving the need of HIV PCT service and of accepting HIV PCT. Therefore Public health intervention (BCC/IEC) in the district on HIV PCT implementation and promotion should be tailored specifically for each target group. A policy document is needed to specify the scope and procedures of premarital examinations in light of the findings in this study.

Based on the study findings, for the VCT /HIV PCT service to be successfully implemented, we recommend the following:

1.Since the lack of specific law was stressed as one of barriers to HIV PCT in Ghana, a specific law and policy document on premarital examination should be elaborated in light of the findings in order to make easier the implementation of HIV PCT services.

2. Since the study showed a low rate of awareness acquired on HIV PCT through mass media and religious bodies, the use of Mass Media and Religious Institutions in awareness creation on HIV PCT should be enhanced and coordinated on a regular basis.

3. Given the fact the study showed a very high premarital sex rate among unmarried adults (66%), considering that participants in IDI and FGDs also mentioned premarital sex as a core barrier to HIV PCT promotion in the area, since those who have had sex were less likely to go for test because they fear they might have been HIV infected, we recommend that:

a) A certain number of measures, such as sex education, adolescent counseling, creation of virgin clubs, parent's implication in sex education, reduction of poverty and of illiteracy.., should be put in place nationwide in order to prevent and reduce the high rate of premarital sex among young adults.

b) Because pornographic films were recognized as factors pushing young adults to engage in premarital sex in Kintampo, all cinema centres where projections of pornographic films take place should be closed in Ghana in general and in Brong Ahafo Region in particular.

4. Considering the fact that education and awareness creation on HIV/AIDS is still lacking among some unmarried young adults, promotion of peer education, including persons/unmarried young adults living with AIDS should be carried out in order to break up gaps of knowledge on HIV/AIDS and HIV PCT revealed through this study.

5. Concerning the question whether HIV PCT should be compulsory or optional, we recommend that the national and regional health authorities and legislators should put all views together in order to make a holistic representative and acceptable policy that protect each individual and the community. Long term education and sensitization campaign and programs are crucial to make sure HIV PCT later becomes a spontaneous «routine screening» with the full and straight commitment and understanding of communities and the target groups.

6. Given similarities in adequate positive perception towards HIV PCT among respondents of low and high level of knowledge on HIV PCT, we recommend that the development of BCC and IEC materials and messages aiming at promoting HIV PCT should be based on participatory methods and research evidence-based data, leading to segmentation of the audience and to the production of appropriate messages and materials for different target groups according to their need of knowledge to appropriately fill specific identified gaps.

7. Considering the crucial need of confidentiality in VCT and HIV PCT service mentioned by respondents, we recommend that national health authorities and the national AIDS control program should ensure that the personnel (counselors, lab technicians...) are adequately well trained to maintain confidentiality so that people patronize the service without fear of lack of confidentiality.

8. Considering the finding that majority of unmarried young adults (77%) exclusively prefer HIV PCT than Voluntary testing, we recommend that for VCT service to be patronized very well, HIV PCT must be implemented and promoted as well so that unmarried young adults could come for it when they are about to enter into marriage.

1. Since it was found that only 31.9% of respondents heard about HIV PCT through health workers, we recommend that the District should incorporate HIV PCT among the top IEC/BCC messages in the fight against HIV/AIDS and multiply IEC/BCC sessions on HIV PCT by Health Workers using in-service health education of patients or through local mass media (FM stations, TV, newspapers...).

2. Because the study showed the involvement of schools in informing young people about HIV PCT seems still very low (29.2%), we recommend that special programs on HIV PCT should be introduced and intensified in schools in Kintampo District.

3. Given the high perception of HIV PCT as a social norm (98.7%), the high perceived need of HIV PCT services (99.3%), the high rate of willingness (98%) to undergo HIV PCT and the high rate of readiness (96.7%) of respondents to know and accept their HIV test results after a PCT session, considering that data from KDH show a timid starting of the service in an embryonic stage where by now few would-be couples are coming irregularly for HIV PCT, also knowing that 86% of respondents had a higher probability (>0.75) of perceiving the need of HIV PCT service in Kintampo and of willingness to undergo HIV PCT, we recommend that a VCT/HIV PCT service should be officially implemented in Kintampo District in due course in order to respond to the need expressed by the beneficiaries of such service still lacking in the area. Resources should be allocated to the preparation of infrastructures, equipment, laboratory reagents and for training activities prior to the launching of such service.

4. Considering the major role of Religious bodies in promoting HIV PCT, given the fact that majority of would-be couples who came for HIV PCT so far were counseled by their Churches, we recommend that the District health authorities should coordinate and train counselors from religious institutions since their involvement is crucial in managing marriages.

5. Given the fact that results showed we could strongly predict the willingness of a respondent to undergo HIV PCT from his/her readiness to know and accept his/her HIV Result, we recommend that if the service is to be implemented in Kintampo, many sessions of sensitization and anticipated pre-counseling among the target groups should be continuously carried out in order to dissipate, through specific and appropriate BCC messages, the anxiety and the fear clients manifest to know their HIV test results.

6. In view of many barriers to HIV PCT acceptance and implementation invoked by respondents in this study, we recommend in priority that district authorities should address major and moderate barriers one by one, step by step, or even holistically, in order to guarantee smooth implementation and take-off of VCT and HIV PCT service in the area.

7 Due to the need of promoting HIV PCT among unmarried young adults, we suggest that District authorities address properly, in order of priority, all measures mentioned by respondents and summarized in Figure 14 in order to promote HIV PCT in Kintampo District. The District should imperatively collaborate with local religious bodies in order to achieve that.

8. Because majority of respondents (almost 60%) suggested HIV PCT services should be free or set at affordable cost or paid by the Government or by any charity NGO, we suggest that district authorities should examine the possibilities of implementing a free VCT/HIV PCT service through donor intervention in order to make HIV PCT services accessible to beneficiaries.

9. In order to make HIV PCT more effective, acceptable and attractive for young people in Kintampo district , district authorities should apply, in priority order, measures that respondents suggested and summarized in Figure 15 for VCT/HIV PCT service to be successful once implemented. Here again we suggest the district health authorities should imperatively collaborate with local religious bodies in order to achieve that.

10. Since majority of respondents suggested HIV PCT services should be established in Kintampo District Hospital (KDH) whilst majority of respondents from Jema Sub-district rather chose Jema Health centre, we recommend that the service should be established first in KDH in the implantation phase. However district authorities should later on assess the possibility of extending the service in Jema Health centre or even elsewhere in order to bring the service closer to beneficiaries.

11. Since our inquiry revealed a big lack of official statistics of marriages in Kintampo District Court although marriages occur regularly in local religious Institutions, we recommend that local administrative, judiciary, religion leaders and health authorities examine the problem in order to reactivate marriage registration in the area.

12. Finally given all information generated in this study, we recommend that district health authorities make some of the findings useful in policy-making towards a successful VCT and HIV PCT service in Kintampo District.

1. Since majority of respondents suggested HIV PCT should be considered as one of current social norms, all community leaders should make HIV PCT as part of marriage norms.

2. Due to the window period, we recommend that the HIV PCT should be done at least twice in all communities, with 3 months interval between the two tests, as a large part of our respondents also suggested it. Given the lack of knowledge some respondents showed on required frequency of HIV PCT before marriage, we suggest that the District should target this issue in awareness creation campaigns. During their counseling sessions, Religious bodies should orient would-be couples on the required number of tests before marriage.

3. Knowing many couples would not be able to cope with the positive HIV test result alone and decide on marriage project without the intervention of a third person, we recommend that, even if a couple decides voluntarily to undergo the test, a third neutral body within the community, whether religious or not, medical or not, counselor or not, should facilitate and follow-up their commitment to HIV testing, and help them cope with the anxiety and the consequences of an eventual HIV test result vis-à-vis the decision on marriage.

4. Since our findings show how denial of marriage right to PLWA will be a problem which will still enhance stigmatization and discrimination associated to HIV/AIDS in Kintampo district due to lower understanding of -use of Assisted Reproduction in HIV infected Individuals/couples, -use of available protective measures (PMTCT, permanent condom use) and -adoption of children, large campaign of education and sensitization of young people and the community on these measures should intensively be carried out by the district health team, religion bodies and others NGO involved so that people understand that marriage between discordant couples or HIV infected couples is possible and workable.

1. Since the study showed a very high premarital sex rate among respondents, parents should educate their young children on sexual matters, specifically on how to abstain from sex before getting married.

2. Given that it was shown is the study that not all parents educate their children on HIV PCT, parents should educate their adolescents and young adults so that they may undergo HIV PCT as a routine examination before getting married.

1. Given the approved importance of HIV PCT, each unmarried young adult should consider the practice of HIV PCT as an integral part of marriage preparation and process.

1. Since it was found that Akan respondents were more knowledgeable on HIV PCT than respondents of the Mo ethnic group, we recommend that a further study should be carried out in order to deeply research into this to determine the why of this knowledge discrepancy between these two ethnic groups.

2. Several other studies should be planned based on the gaps the current study did not explore.

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⁴¹ UNDP, Fight against HIV/AIDS, Socio-Cultural study on HIV/AIDS prevention in Liberia, 2001, 80 p, available at www.mirror.undp.org/liberia/aidshiv, accessed on Febrary 20^th, 2005.

⁴² VCT UNAIDS Technical update.English original, May 2000. UNAIDS Geneva WC 503.6 ( www.unaids.org)

⁴³ National AIDS Control Program (NACP) Bulletin, vol 2, N0 1 July 2004, Accra

⁴⁴ UNPFA, Voluntary Counselling and Testing (VCT) for HIV Prevention, 2003, available at www.unpfa.org/hiv/prevention, accessed on 9^th January 2005.

⁴⁵ Humphreys Misiri, Adamson S.Muula, Attitudes towards premarital testing on HIV among Malawians, CMJ, 2004, available at www.cmj.hr/2004/4501/17undMISIRI.pdf, accessed on February 20^th, 2005.

⁴⁶ Schumm WR, Resnick G, Silliman B, Bell DB, Premarital counseling and marital satisfaction among civilian wives of military service members,School of Family Studies and Human Services, Kansas State University, Manhattan 66506-1403, USA, available at www.ncbi.nlm.gov, accessed on January 23^rd, 2005.

⁵⁰ Eshra D.K., Dorgham L.S, El-Sherbini A.F, Knowledge and attitudes towards premarital counseling and examination, available at www.ncbi,nlm.nih.gov accessed on November 24^th, 2004.

⁵¹ Joo Sook Kim, Seung Yu and Il-Soon Kim, Protestant Ministers`knowledge, attitude and practice about family planning, sex education and marriage, Yonsei Medical journal, Yonsei University, KOREA, 1970, 13

⁵² Jordan National Population Commission/The futures Policy project, Analysis of policy and legal barriers to improved reproductive health services in Jordan, May 2000, 51p.

⁵⁴ MYST, M. , J. PIERRIENS, I. LEBUGHE, et al., SIDA : Guide pratique destiné au corps médical, Kinshasa, B.C.C. / Projet SIDA, 1990.

⁵⁵ J.Khanna,P..F.A. Van Look, P.D.Griffin, Reproductive health: a key to a brighter future, special programme of research,development and research training in Human Reproduction, WHO ,Geneva, 1992, 167

⁵⁶ Professor John S.Nabila, Dr Clara Fayorsey and Dr Matilda Pappoe,«Youth and reproductive health in Africa, Assessment of Adolescent reproductive health needs in Ghana»,UNFPA-USAID-CEDPA-JHU/PCS, Media-Design Legon-Ghana, February 1997, 130 pages

⁵⁷ Sharifah Tahir and Dr Nanta Auamkul, THAILAND Moving towards comprehensive reproductive Health services, ICOMP, September 1998, Malaysia, p 36

⁵⁸ Marcello Pagano, Kimberlee Gauvreau, Principles of Biostatistics, 2^nd ed.,New York.

⁵⁹ BBC News / Asia-Pacific/Premarital sex «Usual in China», October 2003, available at www.bbc.co.uk, accessed on 15^th March 2005.

⁶⁰ Adetoundo O.Lucas and Herbert M.Gilles, Short Textbook of Public Health, Medicine for the Tropic, Chennai/India, 4^th Edition, 2003, 389 pages.

⁶² Glanz, Karan et al, Behaviour and Education. Theory and Practice, Josey, Bass Publishers, 1990.

⁶³ Dr. Frerichs ,Personal screening for HIV in developing countries, June 12^th 1994.

⁶⁴ Michael A. Stoto, Donna A. Almario, and Marie C., Public Health Screening Programs, Reducing the Odds Preventing Perinatal Transmission of HIV in the United States, McCormick, Editors, USA, available at www.hivdent.org, accessed on 12 April 2005.

⁶⁷ Chuleeporn Jiraphongsa et al, Acceptance of HIV Testing and Counseling Among Unmarried Young Adults in Northern Thailand, available at www.extenza-eps.com, accessed on 20^th February 2005.

⁶⁸ Sexual and Reproductive self-determination, Voluntarism and Marriage, available at www.unfpa.org, accessed on 24^th January 2005.

⁶⁹ Premarital screening and choice of marriage partner, available at www.emro.who.int /publications, accessed on 5 June 2005.

⁷⁰ Raphael Oko, Can PLWA marry under Nigerian law?, available at http://www.nigeria-aids.org, accessed on 7^th July 2005.

⁷¹ Albania: Disability and the Right to Marry, Amnesty International- November 2004, available at www.pili.org, accessed on 8^th June 2005

⁷² Human Rights and Public Health: An Overview, available at http://www.aidslaw.ca, accessed on 7^th July 2005.

73 Recommended Ethical Principles Regarding the Use of Assisted Reproduction in HIV Infected Individuals, available at http://www.27802211.com ice/program /program8. htm#appe1 , accessed on June 15th 2005

3. PREMARITAL SEX HISTORY AND STI-HIV/AIDS RISK FACTORS

4.3.4. 4.3.5. 4. GENERAL KNOWLEDGE (AWARENESS) ON STI, HIV/AIDS, VCT AND PCT

26. Do you know that you or your partner [fiancé (e)] though apparently healthy

28. Do you think that there is a high risk of getting married unknowingly to an HIV

36. Do you think the following can be a barrier which can prevent young unmarried people from going for HIV PCT

36.1. Inexistence of regulatory procedures and Law/Policy on PCT in Ghana	1. Yes	2. No	8. NK	9. NA	PBARA
36.2. Mandatory imposition of PCT which is against the Human Right of individuals	1. Yes	2. No	8. NK	9. NA	PBARB
36.3. High cost (price) of premarital examinations	1. Yes	2. No	8. NK	9. NA	PBARC
36.4. The location of the centre/hospital at long distances	1. Yes	2. No	8. NK	9. NA	PBARD
36.5. The attitude of the service provider	1. Yes	2. No	8. NK	9. NA	PBARE
36.6. Premarital sex and fear to know one's HIV status	1. Yes	2. No	8. NK	9. NA	PBARF
36.7. Fear of stigma and discrimination in marriage (denial of marriage for HIV+)	1. Yes	2. No	8. NK	9. NA	PBARG
36.8. Ignorance of the importance of PCT	1. Yes	2. No	8. NK	9. NA	PBARH
36.9. Reluctance of fiancés	1. Yes	2. No	8. NK	9. NA	PBARI
36.10. Preference of people to get married without PCT	1. Yes	2. No	8. NK	9. NA	PBARJ
36.11. Opposition of some churches	1. Yes	2. No	8. NK	9. NA	PBARK
36.12. Opposition of some parents	1. Yes	2. No	8. NK	9. NA	PBARL
36.13. Polygyny (Polygymous/polygamous marriages) & Islamic religion	1. Yes	2. No	8. NK	9. NA	PBARM
36.14. Marriage by convenience (outside churches & civil registrar officer)	1. Yes	2. No	8. NK	9. NA	PBARN
36.15. Forced marriage (e.g traditional early marriage)	1. Yes	2. No	8. NK	9. NA	PBARO
36.16. Unregistered marriage	1. Yes	2. No	8. NK	9. NA	PBARP
36.17. Inadequate VCT/PCT facilities	1. Yes	2. No	8. NK	9. NA	PBARQ
35.18. Lack or inadequate trained counsellors	1. Yes	2. No	8. NK	9. NA	PBARR
36.19. Fiancés are in a hurry to get married very quickly for any reason	1. Yes	2. No	8. NK	9. NA	PBARS
36.20. Lack of confidentiality and privacy among health workers	1. Yes	2. No	8. NK	9. NA	PBART
36.21. Medical premarital certificate provided by doctor without any medical check-ups (fraud)	1. Yes	2. No	8. NK	9. NA	PBARU
36.22. Re-marriage ( for divorced or widowed)	1. Yes	2. No	8. NK	9. NA	PBARV
36.23. Inability for girls to negotiate for HIV PCT when boys don't like it	1. Yes	2. No	8. NK	9. NA	PBARW
36.24. Little solution for those who test HIV (+) ( no effective drugs to treat AIDS)	1. Yes	2. No	8. NK	9. NA	PBARX
36.25. Blind love	1. Yes	2. No	8. NK	9. NA	PBARY
36.26. Others:....................................................	1. Yes	2. No	8. NK	9. NA	PBARZ

42. In your opinion, who should send would-be couples to the hospital for HIV PCT?

43. To whom should the HIV test results be communicated to by the doctor after PCT session?

44. What ways/means should be used in order to promote HIV PCT in Kintampo district/Ghana?

45. In your opinion what should be done so that unmarried young people have easier

46. What do you suggest for the HIV PCT practice to be more effective, acceptable and attractive

48. Assuming that after a premarital examination you are found to be HIV negative but your

fiancé (e) is detected HIV positive and the doctor/counsellor advises you so that you decide

49. Assuming that after a premarital examination you are found to be HIV positive but your

fiancé (e) is detected HIV negative and the doctor/counsellor advises you so that you

decide responsibly. Of the following decisions which one will you more likely make?

50. Assuming that after a premarital examination you and your fiancé(e) are both found to

be HIV positive and the doctor/counsellor advises you so that you decide responsibly.

51. What do you think about marriage between couples where one is HIV positive and the

52. What do you think about marriage between two HIV positive fiancés after a PCT?

53. What is your last word about HIV Premarital Counselling and Testing (PCT) implementation in Kintampo?

_________________________________________________________________________________________

KNOWLEDGE AND PERCEPTIONS TOWARDS PREMARITAL COUNSELLING AND TESTING (PCT) ON HIV INFECTION AMONG UNMARRIED YOUNG ADULTS IN KINTAMPO DISTRICT

1.Do you some times receive would-be couples for Premarital Medical Counselling and Testing (PCT) in your hospital? Y/N

2. If yes to Q1 what is the approximate average frequency?.............couples/individuals per Month/Trimester/year (Tick the correct measure)

................................................................................................................................................

6.Do you think HIV PCT should be institutionalized in Kintampo as a core strategy to limit the spread of HIV/AIDS in new couples and their children? Yes/No. Why?

11. If yes to Q1 what is the current cost of (HIV) PCT in your hospital? Per individual or per couple?

................................................................................................................................................

12.Do you think this amount is affordable to Ghanaian in Kintampo? Y/N. If No why?

14.What do you take as position when you face a discordant couple or a HIV/AIDS seropositive couple after a HIV PCT?

15.In case of a STI is found through PCT to one or both fiancés what do you decide about the marriage process?

16.Do you deliver a prenuptial medical certificate (marriage licence) to the fiancés after (HIV) PCT? Y/N and why?

................................................................................................................................................

18.In your opinion what barriers can prevent young unmarried people from undergoing HIV PCT in Kintampo?

19. What existing opportunities (enabling factors) in the society today can make easier the implementation of HIV PCT in Kintampo district?

20. Given barriers to HIV PCT (Q 18) and enabling factors to HIV PCT (Q 19), is HIV PCT implementation workable and feasible in Kintampo district? Why?

22. In your opinion what should be done so that unmarried young Ghanaian people have easier access to attend HIV PCT in Kintampo?

23. What do you suggest for the HIV PCT practice to be more effective, acceptable and attractive for unmarried young Ghanaian people in Kintampo?

24. What do you think about marriage between HIV discordant couple (one partner is seropositive, the other still seronegative) or HIV seropositive fiancés after a PCT?

25. In case of marriage between discordant couples or HIV infected couples, those couples should be given certain precautionary measures such as permanent condom use, limitation of childbearing or prevention of mother-to-child transmission (PMTCT) measures (e.g. Nevirapine, breastfeeding....) so that they protect themselves and children.

a) Do you think those couples can permanently be able to practice them all their life long? Yes /No and why?

......................................................................................................................................................

b) Can one rely on the ability of couples to practices those measures all their life long? Yes/No why?

......................................................................................................................................................

c) Is the application of these permanent measures truly workable and feasible? Yes/No and why?

......................................................................................................................................................

26. What difficulties or challenges do you often encounter in your hospital during PCT in general and HIV PCT in particular?

27.What do you suggest to the following bodies in order to solve these difficulties/challenges?

1. Do you think the church or mosque has a major role to play towards the control of the spread of HIV-AIDS in the general population and would-be couples particularly? Yes/No

2.What actions does your church and mosque carry out in the fight against HIV-AIDS?

3. According to you, do those actions have a positive impact towards the reduction of the spread of HIV-AIDS in the area?

4.What of the following preventive measures does your church or mosque support in the fight against HIV-AIDS? And why?

5.Do you think people respect all the preaching the church or mosque support towards the reduction of the spread of HIV-AIDS in the area? Yes/No Why?

6.How many marriage do you celebrate on average in your church or mosque during a month/year?................/month/year.(statistics needed )

7.What activities does your church or mosque conduct when preparing young adults who are about to enter into marriage? Do you tell them about HIV PCT? Yes No

8.Are you already trained in medical marriage guidance counselling and testing? Y/N

9.Does your church or mosque require HIV Premarital Medical Counselling and Testing (PCT) for all your church/mosque members who are about to enter into marriage? Yes/No , Why?

10. If yes to Q 9, is HIV PCT compulsory/optional in your church/mosque? Yes No and why?

11.If yes to Q 9,what is the average frequency?.............Month/Trimester/year (statistics needed if possible)

12.If yes to Q 9, for what purpose do you send would-be couples for PCT to the hospital?

15.What do you take as position when you face a discordant couple or a HIV/AIDS seropositive couple after a HIV PCT?

16.Do you require would-be couples to present a prenuptial medical certificate (marriage licence) before the church/mosque can publicize and celebrate their weddings? Y/N and why?

18.In your opinion what barriers can prevent young unmarried people from undergoing HIV PCT at the Hospital?

19. What existing opportunities (enabling factors) in the society today can make easier the implementation of HIV PCT in Kintampo district.

20. Given barriers to HIV PCT (Q 18) and enabling factors to HIV PCT (Q 19), is HIV PCT implementation workable and feasible in Kintampo district? Why?

21. What ways/means should be used in order to promote HIV PCT in your church/Mosque and in Kintampo society?

22. In your opinion what should be done so that unmarried young people have easier access to attend HIV PCT in Kintampo?

23. What do you suggest for the HIV PCT practice to be more effective, acceptable and attractive for young adults in Kintampo society? :

24. What do you think about marriage between HIV discordant couple (one partner is seropositive, the other still seronegative) or HIV seropositive fiancés after a PCT?

a) Do you think those couples can permanently be able to practice them all their life long? Yes /No and why?

b) Can one rely on the ability of couples to practices those measures all their life long? Yes/No why?

c) Is the application of these permanent measures truly workable and feasible? Yes/No and why?

26. What difficulties or challenges do you often encounter in your church/mosque concerning PCT in general and HIV PCT in particular?

27.What do you suggest to the following bodies in order to solve these difficulties/challenges?

KNOWLEDGE AND PERCEPTIONS TOWARDS PREMARITAL COUNSELLING AND TESTING (PCT) ON HIV INFECTION AMONG UNMARRIED YOUNG ADULTS

1. What are some of the factors pushing younger children to have sex before marriage in Kintampo district? Can this be prevented? If yes how? If no why?

2. a) Is HIV/AIDS a real disease killing young people in Kintampo district? Y/N How, give examples if possible?

b) What do you think is the effect of HIV/AIDS on the right and freedom of people towards marriage today ??

c) What should be done to limit the spread of HIV/AIDS among would-be couples who are about to enter into marriage?

3. Must young people consider «Health status» as a core criteria when they choose their marriage partner? why?

4. a) How is marriage organized in K'po district and what is the place of PCT in the marriage process in K'po?

d) If yes is HIV PCT being currently conducted systematically and in a very effective way?

5. Do you believe HIV Premarital Counselling and Testing (PCT) is important (beneficial)? Why?

7. Do you believe that families, parents and peers should support or encourage their younger children to perform HIV PCT before getting married? Why?

8. In your opinion, who should send would-be couples to the hospital for HIV PCT?

9. In your opinion, how often would you like the HIV PCT to be set before marriage and why?

10. What are some barriers which can prevent young unmarried people from going for HIV PCT services in Kintampo district?

11. What existing opportunities (enabling factors) in the society today can make easier the implementation of HIV PCT in Kintampo district.

12. Given barriers to HIV PCT (Q 10) and enabling factors to HIV PCT (Q 11), do you think HIV PCT implementation is workable and feasible in Kintampo district? Why?

13. What ways/means should be used in order to promote HIV PCT in Kintampo district?

14. What should be done so that unmarried Ghanaian young people have easier access to HIV PCT services in Kintampo district?

15. What do you suggest for the HIV PCT practice to be more effective, acceptable and attractive for young adults in Kintampo district?

16. What do you think about marriage between discordant couples (one would-be couple is HIV infected) and HIV infected couples (both are HIV infected) in Ghana and Kintampo? Should such marriage be allowed or forbidden? And why?

17. In case of marriage between discordant couples or HIV infected couples, those couples should be given certain precautionary measures such as permanent condom use, limitation of childbearing or prevention of mother-to-child transmission (PMTCT) measures (e.g. Nevirapine, breastfeeding....) so that they protect themselves and children.

a) Do you think those couples can permanently be able to practice them all their life long? Yes /No and why?

b) Can one rely on the ability of couples to practices those measures all their life long? Yes / No why?

c) Is the application of these permanent measures truly workable and feasible? Yes/No and why?

ANNEX 4. DESCRIPTION OF VARIABLES UNDER STUDY (Source: The researcher).

N° of the

Question^*(*)

Variables

Definitions

Scale of measurement

& Scoring scale

BACKGROUND VARIABLES

Sex

The biological state of being male or female

-Female:2

-and male:1

Educational level

Nature and level of studies done by the respondent

None, Primary, JSS,SSS,Tertiary

Religion

systems of faith that are based on the belief in the existence of a particular god or gods that the respond belongs to

Christian, Moslem, Traditionalist and others

Tribe (Ethnic group)

Ethnic group or class of people to which the respondent belongs to

1.Akan 2.Mo3.Gonja/Dagomba

4.Konkomba/Basare 5.Frafra, 6.etc.

Age

Number of birth days the respondent will have had by the time the survey is conducted

Age in years

-Age group:15-19 years,20-24,25-30

Profession

Category of profession that the respondent belongs to.

1.Farmer,2. Gvnmt workers

3.Trader,4.Students/Pupils,5.Others

Place of Residence

Place where the respondent lives

Urban: 2

Rural:1

PREMARITAL SEX HISTORY

-Rate of premarital sex

Those who will have had premarital sex the day of interview

Yes/No

Age at first sex

Age when respondent had first sex (sexarche)

Age at first sex,Normal: >=18 year

Abnormal:<18 year

Sexual partners before marriage

Any sexual partners with who respondent had had sex before marriage

N0 of partners

Normal: 0-1, Abnormal: >1

GENERAL KNOWLEDGE ON STI, HIV/AIDS, VCT AND HIV PCT

11-25

Level of general knowledge on HIV PCT

Knowledge revealed in answering on questions 11-25 assessing knowledge on HIV PCT

-Yes/No, -Yes: score 1-2, -No: score o

-Expected score: 22

-Good Knowledge: Mean score =11 (11-16.5: Average, >16.5=Adequate)

Poor Knowledge: Mean score < 11

Knowledge of any young adults HIV/AIDS sick person.

The respondent knows of any HIV/AIDS sick person

Know: Yes = score 1

Don't know: No or NK= score 0

Knowledge of unprotected premarital sex as risk factor to STI/HIV/AIDS

The respondents knows that unprotected premarital sex is a risk factor to STI/HIV/AIDS

Know: Yes = score 1

Don't know: No or NK= score 0

Knowledge on mother-to-child transmission of HIV

The respondent knows that the HIV could be transmitted from the mother to her child

Know: Yes = score 1

Don't know: No or NK= score 0

Knowledge on the Cure of HIV/AIDS

The respondent knows that there is not yet any effective Cure of HIV/AIDS .

Know: Yes = score 1

Don't know: No or NK= score 0

N°

Question*

Variables

Definitions

Scale of measurement

& Scoring scale

Knowledge on safety of sexual unions and marriages

The respondent knows that not all marriages are safe

Know: No = score 2

Don't know: Yes or NK= score 0

16.

Knowledge of factors/diseases making some sexual unions and marriages unsafe.

The respondent knows factors/diseases making some sexual unions and marriages unsafe.

Know: score 1 or 2, 1.HIV/AIDS: score 1

2.Other diseases: score 1, 3.Both 1 & 2: score 2, Don't know: score 0

Consideration of good health status is a core criteria in the choice of a fiancé(e)

The respondent knows that good health status is a core criteria in the choice of a fiancé(e)

Know: Yes = score 2

Don't know: No or NK= score 0

Knowledge that PCT is the right mean to assess health status of oneself and one's fiancé(e)

The respondent knows that PCT is the right mean to assess health status of oneself and one's fiancé(e)

Options 1-4, Know: choose option 3 (PCT): score 2, Don't know: choose any other option: score 0

Awareness on VCT.

The respondent is aware of VCT .

Have heard: yes, score 1

Have not heard: No, score 0

Awareness on HIV PCT

The respondent is aware of HIV PCT

Have heard: yes, score 1

Have not heard: No, score 0

Source of information on HIV PCT

The respondent know the source of information by which he heard about HIV PCT.

1-9 different possible sources of information.

Knowledge that HIV PCT is a core measure to limit the spread of HIV/AIDS in new couples

The respondent knows that HIV PCT is a core measure to limit the spread of HIV/AIDS in new couples

Know: Yes = score 2

Don't know: No or NK= score 0

Knowledge of any person/couple who underwent HIV PCT

The respondent knows of a person/couple who underwent HIV PCT

Know: Yes = score 1

Don't know: No or NK= score 0

Knowledge on who are the beneficiaries of HIV PCT

The respondent knows who are the beneficiaries of HIV PCT

Right answer: both fiancés, score 1

Wrong: any other answer, score 0

Knowledge of the major advantage of HIV PCT

The respondent knows of the major advantage of HIV PCT

-Know: adv1= score 2, adv 2= Score 1

adv 4= Score 1, Total score=4

-Don't know: No or NK or 3=score 0

PERCEPTION TOWARDS HIV PCT

26-40

Perception of respondents towards HIV PCT.

The way respondents understand and consider HIV PCT.

-Yes /No questions;-Yes: score 1-2

-No: score 0, -Expected score:23

-Positive perception: Score =11.5 (11.5-17.5=average, >17.5=Adequate)

-Negative perception: score < 11.5

Risk perception of oneself/one's fiancé(e) to HIV infection

The respondent perceives that he/she and or his/her fiancé(e) are at risk to be HIV infected

-Perceive (yes): score 2

-Don't perceive (no): score 0

Perception of severity of HIV/AIDS

The respondent perceives the severity of HIV/AIDS which is a fatal disease that does not have any effective drug yet.

-Perceive (yes): score 1

-Don't perceive (no): score 0

Perceived threat of contracting HIV/AIDS in case one get married to a infected HIV person when HIV PCT is not done.

The respondent perceives the threat of contracting HIV/AIDS in case one gets married to a infected HIV person when HIV PCT is not done.

-Perceive (yes): score 2

-Don't perceive (no): score 0

Perception of benefit of HIV PCT

The respondent perceives the benefit of HIV PCT which is reducing the risk of contracting HIV/AIDS in new couples

-Perceive (yes): score 2

-Don't perceive (no): score 0

N°

Question*

Variables

Definitions

Scale of measurement

& Scoring scale

Perceived self control over HIV PCT action

The respondent perceives self control over HIV PCT action. (S)He feels competent to decide her/him self to undergo HIV PCT)

-Perceive (yes): score 2

-Don't perceive (no): score 0

Perception that family members could approve HIV PCT action

The respondent perceives that his/her family members support HIV PCT action.

-Perceive (yes): score 1

-Don't perceive (no): score 0

Perception that peers could approve HIV PCT action

The respondent perceives that his/her peers support HIV PCT action.

-Perceive (yes): score 1

-Don't perceive (no): score 0

Perception that HIV PCT should be institutionalized

The respondent perceives that HIV PCT should be made and become part of an organized system, society or culture, so that it is considered as a social normal.

-Perceive (yes): score 2

-Don't perceive (no): score 0

Perception of respondents whether HIV PCT should be compulsory or optional

The respondent perceives that HIV PCT should be compulsory or optional

-option 1 :compulsory: score 1

-Option 2: optional: score1

-NK or NA: score 0

Perception of barriers to HIV PCT

The respondent perceives barriers to HIV PCT and find that HIV PCT benefits outweigh these barriers

Yes or no: score 1

Don't know : score 0

Types of eventual barriers to HIV PCT.

The respondent gives some types of eventual barriers to HIV PCT

Yes/No per type of barrier

Preference of respondents to undergo HIV VCT for marital reason or not

The respondent gives his/her preference to undergo HIV VCT for marital reason or not

-Preference to do VCT outside marriage: score 1;

-Preference to do HIV PCT: score 1

-preference of both HIV VCT and HIV PCT: score 2

- NK or None of them: score 0

PERCEPTION OF THE NEED OF HIV PCT SERVICES

Perception of the need of HIV PCT services

The respondent perceives the need of HIV PCT services

Perceive (yes): score 2

Don't perceive (no): score 0.

WILLINGNESS TO UNDERGO HIV PCT

Willingness for respondents to undergo HIV PCT

The respondent says S(he) will undergo HIV PCT with his/her fiancé(e) when he/she will be about to marry

Willingness (yes):score 2

Unwillingness (no): score 0

READINESS TO KNOW AND ACCEPT HIV PCT RESULTS

Readiness to know and accept HIV PCT results.

The respondent is ready to know and accept HIV test result after a PCT session.

Ready (yes):score 2

Not ready (no): score 0

KEY SUGGESTIONS FROM CLIENTS TOWARDS A VERY EFFECTIVE AND ACCEPTABLE HIV PCT PROGRAM/POLICY

41-47

Key Suggestions from clients towards a very effective, accessible and acceptable HIV PCT program/Policy

Respondents suggest certain recommendations for HIV PCT services to be more effective, accessible, attractive and acceptable to them.

-Yes / No

-Suggestion to be considered: suggested by = 50% of respondents.

-Suggestion may not be considered: suggested by = 50% of respondents

Suggestion on the number of HIV PCT needed before marriage.

The respondent gives the number of HIV PCT sessions he/she think is needed.

6 different options:

- once, -Twice, -At least once

-Dependence to length of marriage period

-More than 2 sessions, -Others - NK

N°

Question*

Variables

Definitions

Scale of measurement

& Scoring scale

Suggestion of the person who should send would-be couples for HIV PCT.

The respondent suggests the person who should send would-be couples for HIV PCT

9 options: 11-18, 88 (see questionnaire)

Suggestion of the person to whom clients think the HIV test results should be communicated to after HIV PCT

The respondent suggests the person to whom the HIV test results should be communicated to after HIV PCT

9 options 11-18, 88

(see questionnaire)

Suggestion of different ways/means to be used in order to promote HIV PCT in the district.

The respondent suggests different ways/means to be used in order to promote HIV PCT in the district

14 options

(see questionnaire)

Suggestion of different ways/means to be used in order to have easier access to HIV PCT in the district

The respondent suggests different ways/means to be used in order to have easier access to HIV PCT in the district

7 options

(see questionnaire)

Suggestion of different ways/means to be used in order to make HIV PCT more effective, acceptable and attractive to youth in the district

The respondent suggests of different ways/means to be used in order to make HIV PCT more effective, acceptable and attractive to youth in the district

25 options with Yes/No

(see questionnaire)

COST OF HIV PCT SERVICES

45.1

and

46.20

Recommendation that HIV PCT services should be provided at affordable or free costs.

The respondent says HIV PCT services should be provided at affordable or free costs.

Recommend (yes)

Don't recommend (no)

PERCEIVED NEED OF CONFIDENTIALITY AND PRIVACY REGARDING HIV PCT RESULTS

46.18

Perceived need of confidentiality and privacy regarding HIV PCT results

The respondent perceives the need of confidentiality and privacy regarding HIV PCT results

Perceive (yes)

Don't perceive (no)

Facility(ties) clients think HIV PCT service should be established

The respondent suggests facility(ties) in which he/she thinks HIV PCT service should be established

18 options

(see questionnaire)

POSSIBLE DECISIONS RESPONDENTS COULD MAKE ABOUT MARRIAGE GIVEN HIV PCT RESULTS

48-50

Possible decisions respondents could make about marriage given HIV PCT results

The respondent gives possible decisions he/she is more likely to make about marriage given HIV PCT results in 3 different scenarios

-7 options

-Decision to be considered: predicted by = 50% of respondents.

-Decision may not be considered: predicted by = 50% of respondents

51-52

Point of view of would-be couples about marriage between HIV discordant couple/HIV positive couple

Respondent gives his/her position about marriage between HIV discordant couple and between HIV positive couple

7 options

Last word about HIV PCT implementation in K'po district.

The respondent gives his/her last word about HIV PCT implementation in K'po district

Open-ended

* ^Code : The last right columns contain field names (codes) that will be used in data entry and analysis.

* ^* For every uneducated respondent who does not remember his/her age, the interviewer can look at him/her and estimate his/her age group.

* ^* N^o of the question refers to the corresponding question in the questionnaire (Annex 1).

Knowledge and perception on HIV premarital counseling and testing among unmarried young people of Kintampo town in the republic of Ghana,

ABSTRACT

Chapter One

INTRODUCTION

1.1.1. MARRIAGE AND ITS REPRODUCTIVE HEALTH IMPLICATION

1.1.2. SCOPE AND OBJECTIVES OF PREMARITAL SCREENING

1.1.3. STUDY AREA

I.2. STATEMENT OF PROBLEM

I.4. RATIONALE OF THE STUDY

I.5. GOAL AND OBJECTIVES OF THE STUDY

Chapter Two

LITTERATURE REVIEW

2.1. PREMARITAL EXAMINATION IN GHANA AND IN KINTAMPO

2.2. HIV-AIDS SITUATION IN WEST AFRICA AND GHANA

4.1.2. 2.2.1. In West Africa

4.1.3. 2.2.2. In Ghana

2.3. HIV PREMARITAL COUNSELING AND TESTING (PCT)

4.1.4. 2.3.1. DEFINITION

4.1.5. 2.3.2. JUSTIFICATION OF PREMARITAL EXAMINATION

4.1.6. 2.3.3. HIV PCT PACKAGE 10

2.4. PROCUREMENT OF MATERIALS FOR VCT

2.5. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT

2.7. BARRIERS TO HIV VCT/PCT

2.8. MARRIAGE BETWEEN HIV DISCORDANT OR HIV SEROPOSITIVE

COUPLES

Chapter Three

METHODOLOGY

3.1. STUDY DESIGN AND STUDY POPULATION

3.2. VARIABLES UNDER STUDY

3.3. DATA COLLECTION TECHNIQUES AND TOOLS

4.1.7. 3.3.1. Data collection techniques

4.1.8. 3.3.2. Data Collection Tools

3.4. SAMPLING

4.1.9. 3.4.1. SAMPLE SIZE CALCULATION

4.1.10. 3.4.2. SAMPLING METHOD

3.5. DATA COLLECTION

3.6. DATA PROCESSING AND ANALYSIS

4.1.11. 3.6.1. QUALITATIVE DATA

4.1.12. 3.6.2. QUANTITATIVE DATA

3.7. SOME ETHICAL CONSIDERATIONS

3.8. LIMITATION OF THE STUDY

3.9. RETROINFORMATION AND DISSEMINATION OF THE FINDINGS

Chapter Four

FINDINGS

4.1. SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

INVOLVED IN THE SURVEY

4.1.13. DISTRIBUTION OF RESPONDENTS BY AGE AND SEX

4.1.2. EDUCATIONAL BACKGROUND OF RESPONDENTS

4.1.3. RELIGION, ETHNIC GROUP AND OCCUPATION BACKGROUND

4.3.2. 4.13.1. VIEWS ON FREQUENCY OF HIV TEST BEFORE MARRIAGE

4.3.3. 4.13.3. VIEWS OF RESPONDENTS ON WHO THE HIV TEST RESULT SHOULD

Chapter Five

DISCUSSIONS

5.4. FACTORS INFLUENCING WILLINGNESS TO UNDERGO HIV PCT

5.5. PREFERENCE TO UNDERGO HIV VCT FOR MARITAL REASON OR NOT

5.6. BARRIERS TO HIV PCT ACCEPTANCE AND IMPLEMENTATION

5.7. KEY ISSUES FROM RESPONDENTS TOWARDS HIV PCT HEALTH PRACTICE

IN KINTAMPO DISTRICT

5.7.1. VIEWS ON FREQUENCY OF HIV TEST BEFORE MARRIAGE

AMONG WOULD-BE COUPLES

5.7.4. WAYS TO PROMOTE HIV PCT IN K'PO DISTRICT

5.7.5. WAYS TO CREATE EASIER ACCESSIBILITY TO HIV PCT IN THE DISTRICT

5.7.6. WAYS TO MAKE HIV PCT MORE EFFECTIVE, ACCEPTABLE AND

ATTRACTIVE FOR YOUNG PEOPLE IN K'PO DISTRICT

5.7.7. HEALTH FACILITIES WHERE HIV PCT CENTRE SHOULD

BE ESTABLISHED IN KINTAMPO DISTRICT

Chapter Six

CONCLUSION AND RECOMMENDATIONS

Contact address: drjpkmakelele_m_amos@yahoo.frREFERENCES

73 Recommended Ethical Principles Regarding the Use of Assisted Reproduction in HIV Infected Individuals, available at http://www.27802211.com ice/program /program8. htm#appe1 , accessed on June 15th 2005

ANNEX 1. QUESTIONNAIRE FOR THE SURVEY

3. PREMARITAL SEX HISTORY AND STI-HIV/AIDS RISK FACTORS

4.3.4. 4.3.5. 4. GENERAL KNOWLEDGE (AWARENESS) ON STI, HIV/AIDS, VCT AND PCT

ANNEX 2b: IN-DEPHT INTERVIEW GUIDE FOR RELIGION LEADERS

ANNEX 4. DESCRIPTION OF VARIABLES UNDER STUDY (Source: The researcher).