Transcending taboos and illegality: Pioneering inclusivity in Ghana's HIV solutions

354,927 people are living with HIV in Ghana but over 100,000 Ghanaians are unaware of their status due to a lack of testing according to the last National HIV Prevalence, Estimates, and Projections report. Among them, 60,049 are female sex workers who face the heavy burden of stigma, taboo, legal constraints, and lack of access to treatment.

Female sex workers are confronted with various significant challenges. In the domains of prevention, testing, and treatment, this challenge demands collective attention.

Amidst a prevalent HIV rate of 4.6%, among female sex workers spotlight swings to "Maame Akua: A Story of Resilience and Transformation."

Maame Akua's warm and infectious smile was quite unexpected. She extended her hand with genuine enthusiasm and shook mine as if we were long-lost friends reuniting after years apart.

It was a gesture that instantly made me feel welcome. Interestingly, I approached her with a grim face, a response influenced by my previous encounters with other sex workers. Despite that, Maame Akua responded with a broad smile, completely catching me off guard.

Before I could ponder further, she returned with a chair for me to sit on in front of the house. She even offered me water, a gesture that spoke volumes about her hospitality in what some people refer to as a brothel.

My journey led me to various places in Kumasi – Tafo, Asafo, Dichemso, and Bantama. Most of these encounters were marked by aggression, avoidance, or harsh words from the sex workers. Some were not willing to open up at all except a few.

At Tafo in Kumasi, the leader, known as Princess, a fluent Twi-speaking Nigerian, was particularly hostile towards me. She firmly told me and my fellow reporter that she had no time for interviews or journalism business.

She expressed her frustration about how journalists came and collected their stories, but little changed in their lives. Her message was clear: leave.

Maame Akua, now 30, is from a small town in Fomena, Adansi Asokwa, in the Ashanti region. Before settling in Manso Atwere, a mining community known for the Mansoman Secondary School, in the Amansie West District of the Ashanti region, in 2019, Maame Akua's journey took her to various mining areas across the country.

She offered her services to men, often targeting foreigners: Chinese, Nigerians, Ivoirians, Senegalese, and even men from Burkina Faso involved in mining. She explained that foreigners paid more for their services compared to their Ghanaian counterparts, some of whom were miners themselves.

I asked if she was aware that the HIV epidemic is still real in the country, infecting numerous individuals daily. She responded with a smile and said, "I'm well aware and I take it seriously. Even though HIV isn't frequently discussed in the news these days, some of us stay informed."

Akua mentioned that she received training from NGOs about eight years ago to become an HIV peer educator. "I felt compelled to undergo the training after losing my mother to AIDS in 2008." Her tone shifted as she mentioned her mother, and I noticed tears in her eyes and a quiver in her voice. She paused to collect herself, wiped her tears, and continued sharing, though her emotions occasionally broke through in her words.

"We learn to accept our circumstances and NGOs provide resourceful individuals who help us cope."

Through these groups, Akua and others receive counseling, meeting both in person and over the phone. "NGOs ensure our mental well-being. They guide us on how to navigate our situation," she emphasized. Beyond counseling and treatment, some NGOs offer practical skills like soap and bead making, alongside connections to health services.

However, this isn't the case everywhere in the country. In many areas, female sex workers with HIV face isolation due to stigma and legal constraints. Without the necessary support, they grapple with depression on their own. This is where the importance of decriminalizing sex work becomes evident in the country. The Path Forward:

Ghana's journey through the HIV epidemic reflects a complex interplay of challenges, successes, and ongoing efforts. Through collaborative partnerships, innovative strategies, and the collective will of the Ghanaian people, the path toward a future free of the burden of HIV remains within reach.

According to a report from UNAIDS, in 2022, a huge 39 million people around the world were living with HIV. 86% of them knew they had HIV. 76% of those, which is about 29.8 million people, were getting antiretroviral treatment (ART) to help them.

Unfortunately, in 2022, 1.3 million people still got HIV. Countries need a lot of money to fight HIV properly - about $29.3 billion by 2030.

UNAIDS also talks about a big problem that stops many people from getting the help they need for HIV - it's when their actions are treated as crimes. It's worrying that in many countries, sex work is still considered a crime. 143 countries have laws that can punish people for not telling someone they have HIV.

The head of UNAIDS, Winnie Byanyima, wants world leaders to take strong actions to end AIDS.

"If we don't find a way to fill this big money gap, we might lose the progress we've worked so hard for."

The HIV epidemic has brought significant changes to Ghana's society and economy, and it's still affecting the country's growth.

As said by Felix Asante, the main expert of a study, the total money spent on HIV and AIDS activities in Ghana was about US$92,573,993 in 2017 and US$67,413,057 in 2018. Most of this money came from foreign funds (63%) and government funds (51%), which were the biggest parts of the spending in 2017 and 2018.

As the Ghana AIDS Commission (GAC) reported in 2022, around 9,357 people died because of illnesses linked to HIV/AIDS.HIV among Female Sex Workers in Ghana In 2022, the West Africa Program to Combat AIDS and STI (WAPCAS) indicates that even though the general HIV rate in Ghana is 1.66%, it's much higher among Female Sex Workers - about 4.6%.

The differences in HIV rates between regions and high rates among key groups show that the virus could spread faster to the entire population. The Ashanti regional Technical Coordinator of the Ghana AIDS Commission (GAC)Mrs Olivia Graham, has this to say about new infections among female sex workers when i spoke to her in her office in Kumasi :

"When we take a closer look at the number of new infections among female sex workers in the past year, we can see a slight increase. If we compare the numbers from last year to this year, we'll notice that the cases of new infections among sex workers have gone up a bit. In terms of new infections, the numbers are nearly the same. Last year, it was around 3450, and this year it's approximately 3487. If we look back a bit further, we see that in previous years, the numbers used to be higher. For example, in 2019, we recorded around 4500 cases, and in 2020, it was about 3500. While there's a slow decrease in new infections, it's not happening as quickly as we'd like it to be ."

To really gain control over the epidemic across the country, we need to significantly bring down the number of new infections. Ideally, we'd want it to be around 3000. Currently, with the figure at 16,500, it's still quite high. If this trend continues, it's going to be tough for us to reach our goal.", she stresses.

Hindrances Imposed by Taboos and Illegality on Traditional HIV Solutions in Ghana

Taboos and illegality have created big obstacles for Ghana in fighting HIV. These problems are rooted in culture and laws, making it tough to prevent HIV, do tests, give treatment, and make people aware.

In its 2022 National HIV Prevalence, Estimates, and Projections report, the Ghana AIDS Commission stated that there are more than 100,000 people in Ghana who are HIV positive but are unaware of their status due to not testing.

This problem is made worse by the barriers that are part of the stigmatization and taboos. These barriers especially affect groups like female sex workers. Even though selling sex is against the law in Ghana, it's a part of their history and shows up differently in different places.

Selling sex is seen as breaking the law and could lead to fines. The Criminal Code of 1960 (Act 29) says selling sex is when someone offers their body for sexual acts for money, even if it's not regular sex.

According to the Ghana Statistical Service (GSS), there are 60,049 female sex workers (FSW) in Ghana. They're divided into two main groups. 93% of these FSWs are roamers, while only 7% are sitters.

Roamers account for over 55.6 thousand FSWs. When we look at different parts of the country, Greater Accra has the highest number of roamers with 19,081, followed by the Western Region with 11,535, Ashanti with 5,561, Eastern with 4,753, and Central with 4,061.

In total, the estimated number of stationary FSWs is 4,363. When we add it all up, there are around 60,049 FSWs in Ghana. These FSWs are quite young, mostly around 26 years old. More than 90% of them are younger than 35.

According to the Ghana AIDS Commission (GAC) in 2022, around 4.6% of FSWs in Ghana tested positive for HIV. This is a decrease from 7.0% in 2015 and 11.0% in 2011. The areas with the highest HIV rates are Upper East (7.8%) and Upper West (7.7%), followed by Bono East (6.6%), Western (6.4%), and Western North (6.0%).

Although the overall HIV rates have decreased since 2015, some regions like Upper East, Upper West, and Western have seen a significant increase.

The recent 2022 report from the Ghana AIDS Commission shows that there are about 354,927 individuals living with HIV in Ghana, making up around 1.66% in terms of its prevalence rate. However, the rate among FSWs is much higher, at 4.6%, more than twice the rate of the general HIV population in the Country. It's important to understand these numbers to help create better strategies for dealing with HIV in Ghana.

In this connection, some notable figures are urging Ghana to rethink its stance on criminalizing sex work. They're advocating for a different approach, one that includes sex workers in the country's efforts to fight HIV. Among these voices are Dr. Emmanuel Tinkorang, the Ashanti Regional Director of Ghana Health Services, and Human Rights Lawyer Mr. Maurice Ampaw.

Dr. Emmanuel Tinkorang at his office in Kumasi highlighted the need for a comprehensive solution.

"We need a specialized prevention and treatment program for female sex workers. If we compare their HIV rates with the general population, it's clear that sex workers consistently have higher numbers. This calls for a program tailored to their unique situation." But he pointed out a hurdle: "Commercial sex isn't recognized by law here. It's illegal, but we know it's happening in large numbers."

I asked if legalizing sex work would be a good idea, and he shared, "I think we should consider legalizing it. That way, they can organize themselves and work on prevention. It's sometimes hard to even identify them. So, legalizing could help categorize them, leading to better strategies for their well-being. It could work."

He also added, "Currently, NGOs are helping female sex workers through the Global Fund. They offer services and teach about preventing infections, including HIV. But people are hesitant to admit they're involved in sex work. Forming associations could help them challenge the existing laws."

Dr. Tinkorang stressed, "In other countries, strong associations have educated people about safe sex through peer groups. We need that here, especially for female sex workers. These approaches bring them together, giving them strategies. Stigma surrounds sex work, and we need to tackle that. Also, it's not just females; male partners are involved too, hidden most of the time. So, identifying and supporting them is crucial."

He concluded, "We need a comprehensive program focused on sex workers' needs. They're a unique group that requires special attention."

Another courageous voice speaking up on this issue is Human Rights Lawyer Mr. Maurice Ampaw. His view is slightly different.

"We need to be cautious about legalizing sex work all at once. If we go down that route, we might lose control of its effects, potentially harming young girls' lives. But there's another way. We can think about a controlled system where a limited number of sex workers are identified and legalized. They could be given licenses for regulated sex tourism. This could prevent many young girls from getting into prostitution or illegal sex work," he suggested.

Our focus should shift towards treating sex workers as professionals who are well-screened, including tests for HIV and other diseases. Legalizing it for a specific group within an age range would allow us to provide specialized healthcare, stopping the spread of HIV/AIDS.

While the law still applies, we should create provisions that emphasize rehabilitation over punishment. When caught, individuals should be engaged seriously. Counseling sessions could help them leave the trade, find better work, or get education and healthcare tailored to their needs. This is vital, especially to protect them from HIV," he emphasized.

Breaking the Silence: Battling Taboos to Overcome Stigma

HIV has been shrouded in secrecy due to cultural taboos, which have bred stigma and discrimination.

This fear has deterred people from getting tested, treated, or even discussing their condition openly.

There is no specialized health services tailored to the need of female sex Workers in Ghana.

I reached out to Dr. Emmanuel Tinkorang, the Ashanti Regional Director of Ghana Health Services, to explore the healthcare landscape for female sex workers. He shared that while his directorate doesn't offer specialized services exclusively for sex workers, their comprehensive healthcare programs extend to all Ghanaians, regardless of their background.

"We don't have a specific program for sex workers, but our services cover everyone, including female sex workers. It's important to note that these workers often find it challenging to reveal their occupations openly. Yet, our wide-ranging programs encompass testing and counseling for everyone in the country.

Anyone can walk in, get an HIV test, and know their next steps. This is at the core of our healthcare approach," he explained.

Another perspective came from Dr. Ruth Owusu Ofori, Head of the Public Health Department at Kumasi's Komfo Anokye Teaching Hospital:

"Most healthcare facilities, including ours, lack designated spaces for female sex workers. Unfortunately, many health facilities are overcrowded, even consultation rooms are often filled with doctors seeing numerous patients. Given the stigma around this disease, it's essential to provide privacy for these workers."

So, the question of whether Ghana should reconsider its stance on decriminalizing sex work lingers. Regardless, the pressing need is to forge comprehensive solutions that shield citizens from HIV.

“ This urgency calls for prevention strategies such as condom usage, Anti Retroviral Therapy (ART), PreExposure Prophylaxis (PReP), and Post-Exposure Prophylaxis (PEP), particularly for vulnerable groups like female sex workers.”, Mr Isaac Nsiah Foster,the Operations Director in charge of Human Rights at African Liberators Economic Institute stresses Time to Act:

Sex work, a topic typically shrouded in taboo and illegality, has lingered in silence for far too long in Ghana. Recently, a disconcerting trend has emerged: young girls flaunting carefully crafted personal profiles on social media, showcasing explicit images of themselves.

Behind these polished online personas, complete with nude pictures and solicitations for paid encounters, lies a troubling truth. These young girls often grapple with feelings of depression, lacking a supportive outlet for their emotions.

The numbers of these female sex workers, encompassing both sitters and roamers, continue to swell by the day. One might even argue that their population, coupled with those living with HIV, surpasses what Ghana Statistical Services and the Ghana AIDS Commission have revealed to us.

This story was supported by the Internews Health Journalism Network