Oral Presentation of Abstract Title “Association Between Risky Sexual Behaviors and HIV Risk Perception among In-School Adolescents in a Municipality in Ghana” BY James Afriyie Maame Ewurama Essilfie [Department of Biomedical Sciences, School of Allied Health Sciences University of Cape Coast, Cape Coast, Ghana]

Outline of Presentation Background to the Study Aim of the Study Research Methodology Results and Discussion Conclusion Implications for Interventions References

Background to the Study AIDS/HIV) a serious global health issue. AIDS-related illnesses - the 2nd leading cause of death for women (15 – 49 years) in Africa1 The national median HIV prevalence in Ghana has been increasing for 2015 and 2016 2 . (from 1.6 in 2014; to 1.8% for 2015 and 2.4 for 2016) Lowest HIV prevalence of 0.6% was recorded for people of 15 – 19 years Extra efforts needed to bring down HIV prevalence among adolescents .

Background to the Study (cont’d) Adolescents (people between 10 and 19 years) 3 Have high natural tendency for risk-taking behaviors , Vulnerable to STDs More understanding of issues associated with HIV infection among adolescents needed - perception on risk of HIV infection - How risk perception influences sexual risk behaviors Necessary for appropriate interventions to fight AIDS.

Background to the Study (cont’d) According to the Heath Belief Model, Likelihood for a preventive health action is influenced by perceived susceptibility to the disease.4 Perceiving one’s self to be at risk of getting HIV infection should influence the adolescent not to engage in risky sexual behaviors Some studies have found different results

Background to the Study (cont’d) On condom use -From an earlier study in Ghana - perceived susceptibility to HIV infection was a predictor of condom use (condom ever used), but this did not directly influence condom use at last sexual intercourse.5 - In a recent study in South Africa- perceived risk for HIV infection had no impact on consistency in using condoms.6 On multiple sexual partners: - In a study in Cameroun, low HIV/AIDS risk perception was associated with having multiple sexual partners.7 - In a study in Ethiopia, good (high) HIV risk perception was associated with having multiple sexual partnerships.8

Aim of the study Scarcity of studies that consider the association between adolescents’ risky sexual behaviors and their HIV risk perception (how they perceive themselves to be at risk of getting HIV infection). The aim of this study was to assess the association between HIV risk perception and risky sexual behaviors among in-school adolescents in a municipality in Ghana. The sexual behaviors considered were: - being sexually active (defined as “ever had sex within 1 year to the survey”), - age at first sexual intercourse, - condom use, - number of sexual partners.

Methodology Study design, population and Sampling A cross-sectional study design Questionnaire for data collection 718 JHS students participated; Data 707 aged 11 – 19 years used JH Schools in the Komenda-Edina-Egyafo-Abirem (KEEA) Municipal of Central Region, Ghana from March to May, 2017 Two schools randomly selected from the list of schools in Elmina educational circuit; one school randomly selected from each of the other 7 circuits. In selected schools, one class of JHS1, JHS 2, and JHS 3 selected. All students in selected classes were invited to voluntarily participate in the study (consent forms) by answering the questionnaire.

Methodology (cont’d) Variables and Measures Socio-demographics - Age, School Class , Residential Location , Tribe, and Religion HIV risk perception assessed by the: Question - “How will you rate your risk or chances of getting the AIDS virus someday?” Responses - “no risk at all”, “low risk”, “medium risk”, and “high risk”. “No risk at all” was scored as “0” - having no HIV risk perception. “low risk”, “medium risk”, or “high risk” were scored “1”, - having HIV risk perception.

Methodology (cont’d) Variables and Measures Risky sexual behaviors: - Being sexually active = “ever had sex within 1 year to survey” (yes or no) - Age at first sexual intercourse (before 14 years or at 14 years and after), - Condom Used at least sexual intercourse (no or yes) - Number of sexual partners (1 or 2 or more),

Methodology Analyses and Ethical Considerations SPSS version 22 used for analyses. Descriptive statistics for frequencies and percentages Bivariate and multivariate logistic regression analyses for assessment of association between HIV risk perception and risky sexual behaviors, at significant level of 0.05 The study was approved by the Institutional Review Board (IRB) of UCC. Written permission was given by the Municipal Educational Office of KEEA, Parents or wards gave consent for their children to participate in the study.

Results and Discussions Socio-demographic Characteristics of respondents Of the 707 adolescents whose data were included for the analyses: 43.3% were males and 56.7% were females. The mean age of the respondents was 14.8 ± 1.44 years. Most of the respondents were of the Fanti tribe (91.5%) Most were Christians (91.6%). They were JHS 1, JSH 2 and JHS 3 Students; from Urban and Rural areas

Results and Discussions (cont’d) Risky Sexual Behaviors Table 1. Risky Sexual Behaviors among adolescent respondents Factors N % Being Sexually Active (Had Sex within 1 year) (N=683)   No 494 72.3 Yes 189 27.7 Age at first sexual intercourse (N = 139) Below 14 years 72 51.8 At 14 years or after 67 48.2 Used Condom at last Sexual Intercourse (N = 179) 117 65.4 62 34.6 Number of Sexual Partners (N= 145) 2 or more 54 37.2 1 91 62.8

Results and Discussions (cont’d) Risky Sexual Behaviors 27.7 % have had sex within a year to the study; Among the sexually active: - 51.8% had sexual intercourse below 14 years, - 65.4 % did not use condoms at their last sexual intercourse, and - 37.2 % had multiple sexual partners (Table 1). The finding of this study agrees with a previous study among in-school young people in Accra, Ghana, which reported that 9 (Doku, 2012). - 25% young people were sexually active; 31% had multiple sexual partners A good number of the adolescents were involved in risky sexual behaviors. The adolescents might be undertaking these sexual risk behaviors to learn more about themselves and to explore the world of sexuality.

Results and Discussions (cont’d) HIV Risk Perception Table 2. Self-Assessed HIV Risk perception among subgroups of respondents HIV Risk perception N % Among all respondents (N=706)   No HIV risk perception 561 79.5 HIV risk perception 145 20.5 Among Sexually Active respondents (N=189) 140 74.1 49 25.9 Among Sexually Inactive respondents (N= 494 ) 402 81.4 92 18.6

Results and Discussions (cont’d) HIV Risk Perception Only a small proportion (20.5%) had HIV risk perception An earlier study in Ghana reported a generally low risk perception [ only 15% of females and 16% of males perceiving themselves to be at risk of HIV infection].10 (Darteh et al., 2016) Possible Reasons for low HIV risk perception: Difficulties in correctly assessing their risk of getting the disease11. - Youth in general think that they are not vulnerable to diseases12. - The high stigma attached to HIV infection in Ghana

Having HIV Risk Perception Results and Discussions (cont’d) Association between Risky Sexual Behaviors and HIV Risk Perception Table 3. Bivariate and multivariate analyses of relationship between risky sexual behaviors and HIV risk perception among adolescent respondents.   Factor Having HIV Risk Perception Crude Odds Ratio p-value Adjusted Odds Ratio ¥ NO YES N (%) OR (95% CI) AOR (95% CI) Being Sexually Active (Had sex in the last 1 year) (N=542) Yes 140 (74.1) 49 (25.9) 1.539 (1.029-2.273) 0.035 1.333 (0.869-2.045) 0.188 No 402 (81.4) 92 (18.6) Age at First Sexual Intercourse (N=106) Below 14 years 54 (75.0) 18 (25.0) 0.865 (0.395-1.895) 0.718 ≥ 14 years 52 (77.6) 15 (22.4) Used Condom at last sexual intercourse (N=134) 90 (76.9) 27 (23.1) 0.733 (0.365-1.472) 0.382 44 (71.0) 18 (29.0) Number of Sexual Partners (105) 2 or More 33 (61.1) 21 (38.9) 2.411 (1.145-5.079) 0.019 2.393 (1.101-5.199) 0.028 1 72 (79.1) 19 (20.9) Abbreviation: CI, confidence interval; OR, odds ratio; AOR, adjusted odds ratio. ¥Adjusted for residential location, ethnicity, religion, and age

Results and Discussions (cont’d) Association between Risky Sexual Behavior and HIV Risk Perception Being sexually active was independently associated with HIV risk perception In a study in Uganda - ever had sex was a significant factor associated with perceived risk of contracting HIV.13 (Osingada et al., 2016) Adolescents who were sexually active could more easily than those who were not sexually active to admit their susceptibility to HIV infection as most the adolescents reported that they did not use condom during their last sexual intercourse

Results and Discussions (cont’d) Association between Risky Sexual Behavior and HIV Risk Perception Number of sexual partners was associated with HIV risk perception 38.9% among those with multiple sexual partners versus 20.9% among those with 1 sexual partner, p = 0.019. Association persisted even after considering the effects of age, religion, ethnicity, and residential location.

Results and Discussions (cont’d) Association between Risky Sexual Behavior and HIV Risk Perception Sexually active adolescents with multiple sexual partners were 2.39 times more likely than those with single sexual partner to assess themselves to be at risk for HIV infection. The study established a strong association between multiple sexual partnership and HIV risk perception among adolescents It agrees with a study in Ethiopia which found that youth having two or more sexual partners perceived themselves to be at high risk of getting HIV infection than their counterparts with one sexual partner.14 (Negeri, 2014) The acceptance of their risk of HIV infection by adolescents with multiple sexual partners could be attributed to their knowledge and information about how HIV is transmitted.

Results and Discussions (cont’d) Association between Risky Sexual Behavior and HIV Risk Perception The study is suggesting absence of association between HIV risk perception and: - age at first sexual intercourse - condom at last sexual intercourse. (More studies needed) Absence of association between condom use at least sexual intercourse and HIV risk perception among adolescents appears to agree with a recent study in South Africa 6 (Muchiri, et al., 2017) Probably other factors such as parental approval, social norms, and accessibility of condoms in the community overshadowed the individual adolescent’s perceived risks of HIV infection in influencing condom use at least sexual intercourse.

Conclusion Only few of the adolescents in the study perceived themselves to be at risk of HIV infection. Those who had some HIV risk perception were more likely to be sexually active than those who were not sexually active. A risky sexual behavior (multiple sexual partners) was found to be associated with HIV risk perception. Adolescents with multiple sexual partners were more likely to have HIV risk perception than adolescents with single sexual partner.

Implications for Interventions Need to sustain efforts to reduce HIV infection among young people in Ghana and focusing on behavioural change. Need for interventions that help adolescents to correctly assess their HIV risk perception. Development of HIV interventions that are built on the adolescents’ belief that having multiple sexual partners puts one at risk for HIV infection.

References 1. Joint United Nations Programme on HIV/AIDS. Data 2017. UNAIDS; 2017. Retrieved from http://www.unaids.org/sites/default/files/media_asset/20170720_Data_b ook_2017_en.pdf 2. Ghana AIDS Commission. Summary of the 2016 HIV Sentinel Survey Report. Ghana AIDS Commission; 2017. Accessed March 29, 2018, from http://www.ghanaids.gov.gh/gac1/aids_info.php 3. World Health Organization. Health Topics. Adolescent Health. World Health Organisation; 2018. Accessed April 5, 2018 from http://www.who.int/topics/adolescent_health/en/ 4. Rosenstock IM. Historical Origins of the Health Belief Model. HEB. 1974: 2(4): 328–335. http://doi.org/10.1177/109019817400200403

References (cont’d) 5. Adih WK AC. Determinant of Condom Use to Prevent HIV infection among Youth in Gana. J. Adolesc. Health. 1999: 24(1): 63–72. 6. Muchiri E, Odimegwu C, De Wet N. HIV risk perception and consistency in condom use among adolescents and young adults in urban Cape Town, South Africa: a cumulative risk analysis. South Afr J Infect Dis. 2017: 32(3): 105-110. 7. Tarkang EE. Multiple sexual partnership and perception of risk of HIV infection among out-of-school youths aged 15-24 in Cameroon: A short communication. CAJPH. 2015: 1(1): 9–13. http://doi.org/10.11648/j.cajph.20150101.12

References (Cont’d) 8. Shiferaw Y, Alemu A, Assefa A, Tesfaye B, Gibermedhin E, Amare M. Perception of risk of HIV and sexual risk behaviors among University students: Implication for planning interventions. BMC Research Notes. 2014: 7(1): 1–8. http://doi.org/10.1186/1756-0500-7-162 9. Doku D. Substance use and risky sexual behaviours among sexually experienced Ghanaian youth. BMC Public Health. 2012: 12(1): 1-7. http://doi.org/10.1186/1471-2458-12-571 10. Darteh EKM, Kumi-Kyereme A, Awusabo-Asare K. Perception of Risk of HIV among Adolescents’ Living in an Urban Slum in Ghana. Afr J Repr Health. 2016: 20(1): 62–70. 11. Prata N, Morris L, Mazive E, Vahidnia F, Stehr M.. Relationship between HIV risk perception and condom use: Evidence from a population-based survey in Mozambique. Int Fam Plan Perspect. 2006: 32(4): 192–200. http://doi.org/10.1363/ifpp.32.192.06

References (Cont’d) 12. Yawson AE, Appiah LK, Yawson AO, Bonsu G, Aluze-Ele S, Owusu Amanhyia NAK, … Flanigan T. Sex differences in perceived risk and testing experience of HIV in an urban fishing setting in Ghana. International Journal for Equity in Health. 2014; 13(1): 1–8. http://doi.org/10.1186/s12939-014-0109-z 13. Osingada CP, Nabasirye C, Groves S, Ngabirano TD. Perceived Risk of HIV Infection and Associated Factors among Secondary School Students in Wakiso District , Uganda. Advances in Public Health. 2016: 2016: 1-7 http://doi.org/10.1155/2016/9864727 14. Negeri E. Assessment of risky sexual behaviors and risk perception among youths in Western Ethiopia: The influences of family and peers: A comparative cross-sectional study. BMC Public Health. 2014: 14(1): 3-12. http://doi.org/10.1186/1471-2458-14-301

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