Girmay Haile, UNAIDS Country Director, Ghana
“Lily is newly married to the love of her life, Eli, and expecting a baby with her husband, so she is having unprotected sex.
Eli, however, has another woman in his life, Yawa, whom he is also having an affair with, they also have unprotected sex because, according to Eli, Yawa is a decent lady and he loves ‘skin to skin’ during sex.
Besides, Yawa is the only person, other than his wife Lily, whom he is having unprotected sex with and so assures himself that they are the only two women and he trusts them both.
Decent Yawa, on the other hand, has her other man, Nii Osa, who means the world to her and so agrees to have unprotected sex with him to show her commitment to the relationship because that is the man she intends to marry.
She also believes having unprotected sex is safe because she is sexually involved with only two men; Eli, the married man and Nii Osa, her future husband.
But Nii Osa has an outside woman named Precious, a young ‘good’ undergraduate student he is also considering to marry and is having unprotected sex with her.
Nii Osa thinks Precious is faithful, so he tells himself that they are the only two women he is having sex with so he cannot be at risk of being infected with STIs.
Unknown to Nii Osa, Precious has other friends and lectures who assists her when she has urges in the absence of Nii Osa. She also has unprotected sex with them.”
The scenario presented above gives a vivid picture of the new trend of high HIV infection among urban communities across Ghana where sexually-active people think that they are safe although they engage in unprotected sex with more than one partner, says the United Nations Programme on HV & AIDS (UNAIDS).
The increasing dearth of safe sex among unhappy couples, with many of them having multiple sex partners outside their marital home, the UN agency indicates, compounds the already dire situation shooting up more than thrice the risk of getting infected with HIV/AIDS or other STIs in urban settlements.
This is evident in the latest National Demographic and Health Survey (GDHS) which saw the tables turn in high infection rate from key populations such as sex workers, truck drivers and men who have sex with men to the educated, professionals, students and married couples in urban communities across the country.
Previous GDHS have found out that HIV transmission among sex workers was very high as about 70 percent and over 50 percent between men who have sex with men (MSM).
But the 2014 survey report shows the infection rate among this key population has come down dramatically, with the sex workers infection rate now below 10 percent and the MSM below 15 percent following increased advocacy, testing and condom use.
However, the survey conducted in 2014 among respondents aged between 19 to 49 years shows a stabilised or higher infection rate among urban communities.
One percent of female respondents reported that they had had two or more partners in the past 12 months.
Among the women who had two or more partners in the past 12 months, 11 percent reported using a condom during their last sexual intercourse.
Fourteen percent of the men aged between 15 and 49, the report shows, also had two or more partners in the past 12 months, with only 19 percent revealing that they used a condom during their last sexual intercourse.
About 1,700 cohabiting couples were tested for HIV in the survey and in 0.8 percent of the couples tested, both partners were HIV positive. In 2.4 percent of couples tested, one partner was HIV positive and the other was HIV negative. In 96.7 percent of couples, both partners were HIV negative.
The UNAIDS Country Director for Ghana, Girmay Haile, says the revelations are not surprising, considering factors such as the change in demography and complexities associated with urban communities.
Urban Epidemic
According to 2014 GDHS, there has been a shift in population settlements from rural to urban areas.
Fifty four percent of the country’s population now lives in urban areas.
This change in demography has had a rippling effect on the HIV status in these rapidly changing population settlements.
A closer look at the survey findings further shows that the infection rate of HIV epidemic through sex in the urban centre is higher than rural centres.
“Because over 54 percent of the population lives in urban centres, the epidemic has gradually started to also shift towards the urban centres, and now we can actually begin to classify the epidemic as an urban epidemic. So with this data, you know that something is going on in this other group in the urban centres where you see stabilised or slightly going up of new infections,” Mr Haile says.
The UNAIDS country director says the reason we focus more on sexual contact when we look at new infections in HIV is because over 98 percent of new infections “are through sexual contact that is why we look at it as a primary contact driver or mode of transmission.”
Low Condom Usage
The lifestyle of people, especially in the urban centres, is such that because they have access to quite a number of opportunities, there is a growing trend of multiple sexual partnerships where people have more than one sex partner.
But for HIV prevention to achieve an impact, usage of condom which should be freely available to almost everybody, should not be any less than 80 to 85 percent, the UNAIDS director says.
However, the percentage of people who use condoms to protect themselves in urban communities is below 20 percent.
Mr Haile says among the urbanite, not using a condom is a social trend.
“It’s a cool way to go ‘raw’ and also celebrity influence on having unprotected sex has fueled this trend. If you don’t use a condom and you don’t know your status and then you have more than on sex partner then you have more than tripled or quadrupled your risk,” he explains.
Ironically, the country has an overstock of both male and female condoms which are not made available to end users because of a crack in the supply chain.
Stigma/Testing
Most urban dwellers live in a façade where they are celebrities and known publicly for one reason or the other and, therefore, do not want to be associated with this health condition or even get tested for it.
He said most of the HIV testing that goes on is repeat testing where people who know their status go for tests and no that new people are getting tested to know their HIV status.
The HIV stigma is also shifting from what people feel others will say about them if they know they have HIV to about protecting themselves during sex.
A typical scenario is asking a woman if she carries condoms in her bag. She will ask you if you are out of your mind and she will tell you that if I do that people will thing I am promiscuous.
But Mr Haile says, “So if the women don’t have condoms and the men who have more power in negotiating sex also do not have condoms as well and when those instances avail themselves for contact there is a higher risk of infection.”
The stigma index at the health centres have shown little improvement with a lot of training so health workers will come to terms with the fact that their role is to provide service regardless of what or who sexual orientation or situation.
“Providing health service is an unquestionable human right of the person who is in need of the service but many people take that sigma from society, culture and religious bodies and bring it in to an area of professional studies,” Mr Haile puts it.
Way Forward
Ghana has achieved a high level of success in terms of reducing new HIV infections, in mother to child transmission, key population transmission, and medical based transmission.
The country has more than quadrupled the number of people on treatment and is are poised to double that in its new policy which projects that by 2020, over 90 percent of people who need treatment will be on HIV treatment.
Ghana has also cut by more than half deaths due to AIDS, so less people are dying of AIDS, with more people having a normal livelihood because they are on treatment.
Mr Haile says for this success to be recorded among the urban population, the country must take prevention of new infections seriously.
“Prevention is very central in this and prevention comes with awareness, and awareness comes with advocacy which is very important because the population in the urban centres is the population that has access to information so this information that is being made available to this group should be information that is empowering and leading people to take measures.
Generally speaking, if you are consistently practising safe sex where you are protecting yourself, that means that you are preventing possibilities of infections both of HIV and other STIs,” he says.
By Jamila Akweley Okertchiri