Ghana has made great progress in meeting most Millennium Development Goals; 1 however, the country's reproductive health indicators continue to lag. Among married women, use of modern contraceptives is low (23%) and unmet need for family planning remains high (26%). 2 Similarly, the total fertility rate decreased only slightly between 1998 and 2008, from 4.4 to 4.0. 3 As a result, the Ghanaian government has identified increasing contraceptive prevalence as a priority. 4Among the reasons for low use of contraceptives in Ghana are barriers to access, stock-outs and a shortage of trained health staff.5 These problems are more acute in rural areas of the country, where health facilities tend to be few and the distribution chain is often weaker-conditions that contribute to an urban-rural disparity in contraceptive use and unmet need. 3 In addition, access to communitybased family planning services is limited outside of select hard-to-reach areas where nurses have been mandated to provide family planning as part of the Community-Based Health Planning and Services (CHPS) model. CHPS zones are currently being scaled up, but as of 2011, only 22% of the population was being served under CHPS. 6In many countries, private-sector drug shops are the first place people seek health care, especially in areas with few health facilities or pharmacies. [7][8][9][10] In Ghana, such shops are called licensed chemical sellers and are independent businesses operated by nonpharmacists who have a minimum of a secondary education and are licensed by the Pharmacy Council to sell some over-the-counter medicines. Shop operators sometimes receive training from the Licensed Chemical Seller Association and Pharmacy Council, but it is not required to obtain a license. As privately owned enterprises, licensed chemical seller shops are positioned to provide socially marketed family planning methods using their existing infrastructure, which is sustained by the sale of other health products. Most pill and condom users in Ghana (75% and 54%, respectively) receive their contraceptives from such shops; however, the country's most popular method-the threemonth injectable contraceptive, depot medroxyprogesterone acetate or DMPA-is a prescription drug and is available only from a qualified medical provider or for purchase, but not injection, from a pharmacy.3 Most injectable users (87%) rely on public-sector health facilities to receive their injections, even though these facilities often experience stock-outs of the method.

Background: HIV self-testing (HIVST) has the potential to greatly increase HIV testing uptake, particularly among key populations (KPs) at higher risk for HIV. Studies have shown high acceptability and feasibility of HIVST among various target populations globally. However, less is known about the perspectives of policymakers, who are critical to the success of HIVST implementation. Their views on barriers to the introduction and scale-up of self-testing are critical to understand in order for HIVST to become part of the national HIV guidelines. We sought to understand policymakers' perspectives of challenges and facilitators to the introduction of HIVST at the client and structural levels.Method: Key informant interviews (KIIs) were conducted with national and regional level policymakers involved in the HIV response. Twenty policymakers were purposively selected from Greater Accra (capital) and Brong-Ahafo (outlying) regions. Qualitative content analysis was used to arrive at the results after the verbatim transcripts were coded.Results: Client-level challenges included lack of pre-test counseling, the need for confirmatory testing if reactive, potential for poor linkage to care and treatment, and client-level facilitator from policy makers' perspectives included increase testing modality that would increase testing uptake. Structural-level challenges mentioned by policymakers were lack of a national policy and implementation guidelines on HIVST, cost of HIVST kits, supply chain management of HIVST commodities, data monitoring and reporting of positive cases. The structural-level appeal of HIVST to policymakers were the reduced burden on health system and HIVST's contribution to achieving testing targets. Despite the challenges mentioned, policymakers unanimously favored and called for the introduction of HIVST in Ghana.Conclusions: Findings indicate that a non-conventional HIV testing strategy such as HIVST is highly acceptable to policymakers. However, successful introduction of HIVST hinges on having national guidelines in place and stakeholder consultations to address various individual and structural -level implementation issues.

Background Key populations (KPs) such as female sex workers (FSWs), men who have sex with men (MSM), people who inject drugs (PWID), and their partners contribute more than a quarter (27.5%) of new HIV infection in Ghana. Oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV acquisition among this group. While the available research indicates KPs willingness to take PrEP in Ghana, little is known about the position of policymakers and healthcare providers on the introduction of PrEP for KPs. Methods Qualitative data were collected from September to October 2017 in the Greater Accra (GA) and Brong-Ahafo (BA) regions of Ghana. Key informant interviews were conducted with 20 regional and national policymakers and supplemented with In-depth Interviews with 23 healthcare providers to explore their level of support for PrEP and their perspectives on challenges and issues to consider for oral PrEP implementation in Ghana. Thematic content analysis was used to unearth the issues emerging from the interviews. Results Policymakers and healthcare providers in both regions expressed strong support for introducing PrEP for KPs. Key concerns regarding oral PrEP introduction included potential for behavioral disinhibition, non-adherence and side effects of medication, cost and long-term financial implications, and stigma related to HIV and key populations. Participants stressed the need to integrate PrEP into existing services and the provision of PrEP should start with high risk groups like sero-discordant couples, FSWs and MSM. Conclusions Policymakers and providers recognize the value of PrEP in cubing new HIV infections but have concerns about disinhibition, non-adherence, and cost. Therefore, the Ghana health service should roll-out a range of strategies to address their concerns including: sensitization with providers to mitigate underlying stigma towards KPs, particularly MSM, integration of PrEP into existing services, and innovative strategies to improve continued use of PrEP.

BackgroundKey populations (KPs) such as female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and their partners contribute more than a quarter (27.5%) of new HIV infection in Ghana. Oral pre-exposure prophylaxis (PrEP) can substantially reduce HIV acquisition among this group. While the available research indicates KPs willingness to take PrEP in Ghana, little is known about the position of policymakers and healthcare providers on the introduction of PrEP for KPs. MethodsQualitative and quantitative data were collected through a cross-sectional study from September to October 2017 in the Greater Accra (GA) and Brong-Ahafo (BA) regions of Ghana. In-depth interviews (IDIs) were conducted with 20 regional and national policymakers and 23 healthcare providers to explore their level of support for PrEP and their perspectives on challenges and issues to consider for oral PrEP implementation. The quantitative survey involved interviews with 409 healthcare providers to examine willingness to provide PrEP, challenges to PrEP roll-out and how it should be implemented. Thematic content analysis was used for the qualitative interviews descriptive analysis was conducted using frequencies of variables of interest for the quantitative analysis. ResultsPolicymakers and providers (95%) in both regions expressed strong support for introducing PrEP for KPs. Key concerns regarding oral PrEP introduction included potential for behavioral disinhibition, non-adherence and side effects of medication, cost and long-term financial implications, and stigma related to HIV and key populations. Participants stressed the need to integrate PrEP into existing services. While over three-fourths of providers indicated they would personally provide PrEP to HIV negative partners of HIV positive clients (87%), people who have multiple sex partners (83%), and FSWs (78%), a smaller percentage indicated they would provide PrEP to MSM (66%) and PWID (58%). ConclusionsPolicymakers and providers recognize the value of PrEP but have concerns about disinhibition, non-adherence, and cost. Therefore, a range of strategies are needed to address their concerns including: sensitization with providers to mitigate underlying stigma towards KPs, particularly MSM, integration of PrEP into existing services, and innovative strategies to improve continued use of PrEP.