My first HIV patient that I cared for was in Korle-bu Teaching Hospital, Accra, Ghana in the late 1990s. I can still remember the woman in her mid-thirties who we had admitted with symptoms suggestive of meningo-encephalitis; I do not really remember whether I was a house-officer or a final year medical student. I had suggested getting a HIV test on her because I thought it was unusual for a patient with meningitis in her 30s to have delirium early in the disease process. On hindsight this lady most likely had meningo-encephlaitis secondary to CMV (Cytomegalovirus), HSV (Herpes Simplex Virus) or possible VZV (Varicella Zoster Virus). I do not remember requesting for viral serology on this patient but she was transferred her to the HIV Unit after she was diagnosed. We never figured out for sure how she got infected with HIV however our theory was that her husband whose work involved a lot of travel could have infected her. In the mid-1990s in Ghana foreign travel was a risk factor for HIV diagnosis in Ghana. Nucleoside Analogue drugs had been discovered but were still not available in Ghana. ARVs (Anti-Retroviral Therapy) became available in Ghana due mainly to the leadership of Kofi Annan, the then-UN Secretary General, in setting up the Global Fund for Tuberculosis (TB), AIDS and Malaria. All these occurred after several protest by many human rights and social justice groups instrumental among these being Health GAP (Health Global Access Project). The past two weeks I have been in Mfantsipim School my high school alma mater a school I share with Kofi Annan and Korle-bu Teaching Hospital where, I trained as physician and saw my first HIV patient, it is therefore appropriate that I talk about HIV in Ghana today.
Today, Ghana has its own established HIV epidemic with prevalence rate among 15 – 49 yrs of about 1.6% the current prevalence by sex is 2.1% in women and 1.1 % in men based on UNAIDS data. Whilst current data suggests a steady decrease in HIV infection rates among Commercial Sex Workers, the rates in Men Who have Sex with Men (MSM) has not shown similar steady declines. The Ghana AIDS Control Program has several initiatives including AIDS Ambassadors that was used to target control of the epidemic among commercial sex workers since it is well recognized that the flames of the epidemic within the general population were being fanned by connecting individuals such as clients of sex workers and non-paying sexual partners of sex workers. Even though officials of the Ghana AIDS Control Program are aware that MSMs contribute significantly to HIV transmission in the country this has not been addressed openly on account of what I would like to report as “societal norms”. Maybe these norms are contributing to the deaths of our young brothers and sisters.
From discussions with many Ghanaian doctors it is quite evident to me that progress in HIV prevention among MSMs has always been a challenge and political will is mostly barely available or just completely non-existent. Rampant homophobia and denialism of gay behavior has always plagued my country of birth. This makes it very unpopular for anyone to even consider championing the rights of gays. In such an environment any business person even considering offering targeted services towards gays may be putting their business at risk since they would not be favored by the general population and gays and lesbians may still not patronize such a provider because that may advertise their sexuality. This highly homophobic environment would continue to hamper any efforts to address HIV risks among gay men in Ghana today.
High rates of untreated sexually transmitted infections increases risk of HIV infection, in the United States today most physicians involved in the care of patients with sexuality transmitted infections are aware of the need to screen based on site of potential exposure. The current clinical environment in most general care settings in Ghana would not be conducive to most patients reporting any form of sex between men and as such opportunities to screen MSMs in the mouth and rectally is totally non-existent in general care. Recent studies suggest that more than 80% of both rectal Chlamydia and Gonorrhea are not symptomatic and adequate treatment of sexually transmitted infections can reduce overall HIV transmission by about 40%. Under these conditions one can understand why control of HIV among MSMs in Ghana is stagnating.
This is a very sad situation because stigma and provider lack of comfort in discussing alternate sexuality with patients is likely reducing the ability of providers to effectively address the sexual health needs of gay and transgender men. In a situation such as exists in Ghana and in other African countries today I ask myself what can be done to address this most important need. At this time all I can say is that I do not have a good solution. Initial HIV treatment availability followed the human rights approach however attempts by donors to address rights of lesbians, gay and transgender individuals using this approach was met by outright resistance by civil society in Ghana. My experience in Ghana is that most religious people would consider the advice of their pastors. At this time, though this may sound far-fetched I am inclined to believe that assistance of good influential pastors would play a big role in addressing the spread of HIV among MSMs in Ghana.
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Dr. Leonard Sowah is an Internal Medicine Physician in Baltimore, Maryland
