Uptake of HIV testing and counseling among tertiary institution students in...

[Full title: Uptake of HIV testing and counseling among tertiary institution students in the Hohoe Municipality, Ghana]

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[Journal of Public Health in Africa 2019; 10:1044] [page 95] Uptake of HIV testing and counseling among tertiary institution students in the Hohoe Municipality, Ghana Evans Agamlor, 1 Lilian Pencille, 2 Prosper Lutala, 3 Derick Akompab Akoku, 4 Elvis Tarkang 1,2 1 Department of Population and Behavioral Sciences, School of Public, Health, University of Health and Allied Sciences, Ho, Ghana; 2 HIV/AIDS Prevention Research Network Cameroon, Kumba, Cameroon; 3 School of Public Health & Family Medicine College of Medicine University of Malawi, Malawi; 4 Community Research and Training Institute, Yaounde´, Cameroon Abstract HIV Testing and Counselling (HTC) is a critical strategy to reduce the rate of new HIV infections and the key entry point to HIV treatment, care and support services This study aimed to determine the uptake of HTC among students of tertiary institutions in the Hohoe Municipality of Ghana. This was a quantitative cross-sectional study. A structured questionnaire was used to collect data among a proportionate stratified sample of students from tertiary institutions Chi-square and Logistic regression analyses were performed using Stata version 12.0 at the 0.05 level of significance. Only 30.6% of the total respondents had ever tested for HIV/AIDS of which, only 22.9% tested less than 6 months before the current study Students above twenty-four years of age were 3 times more likely to go for HTC than those below 20 years [OR=2.56 (95% CI: 1.07-6.11; p=0.034)]; those in the fourth year of study were 3 times more likely get HTC than those in the first year [OR=3.05 (95%CI: 1.10-8.49; p=0.033)]; and those attending THERESCO, the Midwifery training college and UHAS were more than 2 times more likely to get tested for HIV than those attending FRANCO [OR =2.67 (95% CI: 1.14-6.15; p=0.024)], [OR=2.40 (95% CI: 1.04-5.54; p=0.040)] and [OR=2.63 (95% CI: 1.13-6.13; p=0.026)] respectively. The uptake of HTC among tertiary institution students in Hohoe municipality was considerably low. Policymakers should design programs and interventions that would increase uptake of HTC among tertiary students, with focus on those aged less than 20 years, those at the lower level of study and those in the non-health related institutions. Introduction To increase the uptake of HIV Testing, several models suiting individual and provider’s needs such as HIV testing and counseling (HTC), provider-initiated testing and counseling (PITC), home-based HIV counseling and testing (HBCT) and HIV self-testing, have been adopted overtime 1 HIV testing and counseling is the most common mode globally 1 and plays a link between prevention and mitigating activities. For those who are still HIV negative, HTC can be an incentive to change highrisk sexual behavior; while for those who are already positive, it can serve as a link to care, support and treatment options 2 Over fifty percent of all HIV cases globally are among young people aged 10– 24 years 2 It was noted that the high likelihood of acquiring HIV among youths is in contrast with their low intake of HIV testing 3 According to a sub-Saharan Africa (SSA) survey, only 10% male and 15% female aged 15–24 years know their HIV status, implying that majority of young people in this age group are undiagnosed of HIV, thus exposing them to a high risk of either acquiring or transmitting the disease 3 There are increasing efforts to increase adolescents’ utilization of HTC services; however, its utilization in Ghana in the general population remains low 4 In 2008 in Ghana, the percentage of people who had ever been tested in the age range of 15-49 was 21% for female and 14% for males 5 Reasons for this low uptake of HTC services include emotional impact experienced by those tested positive 6 ; fear of positive results and HIV-related stigma; 6,7 lack of confidentiality, cost of testing and individual’s baseline socioeconomic conditions; 8,9 coercion from healthcare providers, lowquality counseling components and low effectiveness in facilitating linkages of HTC to care 10 This low HTC uptake implies that a vast majority of youths, including those already infected with HIV, ignore their HIV status 11 The university students’ population in Ghana falls in the 15-24 age group peculiar among the youth concerning HIV transmission and HTC uptake for several reasons The students’ lifestyle exposes them to high vulnerability to HIV. The university environment 12 combined with peer pressure on students to get involved in transactional sex relations in exchange for money, 13,14 promote sexual activity among the student population. Furthermore, students as any other youth between the ages of 15 and 24 years represent the highest risk group to get infected with HIV 15 Although the increasing number of testing sites that followed the rollout of antiretroviral (ARV) program across Africa, increased HTC uptake as an entry point to HIV care, HTC uptake remains low in several African countries. The percentage of youth who went for HIV testing was 21.6% in Metropolitan Kumasi, Ghana, 16 same level in Kenya, 17 26% in Ethiopia 18 and 18% in South Africa 19 A recent review of demographic and health surveys of 4 countries in Africa (Congo Brazzaville, Central Africa Republic, Mozambique and Nigeria) among 23,367 male and female respondents aged 15-24 years showed that only 36.5% of youth has ever been tested for HIV 20 Furthermore, studies aimed at increasing awareness to get tested among participants led to a high willingness to get tested among participants 21 Paradoxically, the high willingness to get tested for HIV does not automatically translate to actual testing 21-23 Journal of Public Health in Africa 2019; volume 10:1044 Correspondence: Elvis Tarkang, School of Public Health, University of Health and Allied Sciences, PMB 31 Ho, Volta region Ghana Tel.: +233.0505754478 E-mail: ebeyang 1@yahoo.com Key words: HTC uptake, knowledge, students, tertiary institutions, Hohoe, Ghana Acknowledgements: The authors wish to thank the research participants who accepted to be part of this research endeavor Contributions: EA and ET conceived the research idea, wrote the protocol and carried out the data collection. EA, LP, PL, DAA and ET wrote and critically reviewed versions of the manuscripts. All authors read and agreed on the final version of this manuscript Conflict of interest: The authors declare no potential conflict of interest Funding: None Received for publication: 5 February 2019 Revision received: 2 August 2019 Accepted for publication: 17 August 2019 This work is licensed under a Creative Commons Attribution NonCommercial 4.0 License (CC BY-NC 4.0) ©Copyright: the Author(s), 2019 Licensee PAGEPress, ItalyJournal of Public Health in Africa 2019; 10:1044 doi:10.4081/jphia.2019.1044 Non-commercial use only

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[page 96] [Journal of Public Health in Africa 2019; 10:1044] Others studies conducted in public, as well as private universities in Accra and Kumasi (Ghana), reached the same conclusion regarding the low HTC uptake in Ghana 15,24 Knowing routes of HIV transmission 15 , age, gender, place of residence, perceived susceptibility to HIV, 25 having multiple sexual partners, practising unprotected sex and being aware of HTC services 26 are associated with a high HTC uptake Inversely fear, being uninformed about HTC, and low HIV risk perception are associated with not getting tested 1 There is no information about HTC among the general population in Hohoe municipality regarding either the HTC uptake or factors that are driving the testing; more so, among university youth studying in the municipality. We doubt if the information found on HTC services use among university students in Accra 15 and Kumasi 24 could be valid for students in Hohoe municipality. Moreover, this municipality has an HIV prevalence of 3.4%, which is higher than the Ghana national HIV prevalence of 1.7%, 27 and no study has been conducted on the subject matter in this site. Such information can help in tailoring Hohoe-specific message that could increase the uptake of HTC in this Municipality. Therefore, we conducted this study aimed at determining the level of HTC uptake and to explore factors associated with HTC uptake among university students in Hohoe Municipality, Ghana Materials and Methods Study site description The study was conducted in the Hohoe Municipality of Ghana, specifically the tertiary institutions in the municipality. The municipality is one of the twenty-five municipalities and districts of the Volta Region of Ghana. It has its administrative capital at Hohoe. The population of the municipality according to 2010 population and housing census stands at 167,016 with 79,967 males and 87,049 females 28 It has 4 tertiary institutions: 1 university (the University of Health and Allied Sciences [UHAS]), and 3 colleges (Midwifery Training College, St. Theresa’s College of Education [THERESCO] and St, Francis College of Education [FRANCO]). The university is owned by the Ghana government, and Hohoe municipality houses the school of public health, while the two colleges of education are owned by the Roman Catholic Church and the Midwifery school is owned by the government of Ghana Study population The study population comprised students who were studying in the tertiary institutions in the Municipality Inclusion and exclusion criteria We included in this study all regular students who were eighteen years and above. Students attending on the non-regular basis (sandwich or top-up) or those above first-degree levels were excluded from this study Study design A quantitative, descriptive, cross-sectional design was used for the current study This design is relatively inexpensive and can be used in a short period Sample size determination The sample size for the current study was 403. This was determined using the formula below: 29 n = (Z α/2 )2 P (1-P) / е 2 , where: n= Sample size to be determined, Z α/2 = Z score (reliability coefficient) of 1.96 at 95% Confidence Interval (C.I), P = Proportion (50%) of uptake of HTC among university students in case the prevalence is not known (p=0.5) and е = represents margin of error of 5% = 0.05. Substituting the figures to the formula, gave a sample size of 384. Adding a non-response rate of 5% to this sample size, gave a minimum sample size of 403 respondents for the current study Sampling method A proportionate stratified sampling method was used to select the required number of students from each of the 4 tertiary institutions. This method was used to achieve a greater degree of representativeness. The students were stratified into four strata as year I, year II, year III and year IV The number of study participants for each stratum was allocated proportionally and samples were selected by simple random sampling technique using the list of students as the sample frame. All students recruited into the study signed an informed consent after the purpose of the study and what their participation entailed had been explained to them Data collection procedure Data collection was done from 12 th to 19 th of October, 2017 using structured selfadministered questionnaires. Three trained data collection personnel of similar age and gender as the respondents assisted in the process of the data collection. The data collection instrument was pre-tested among 20 regular tertiary students in Hohoe municipality, who were not part of the actual study to test the feasibility of the instrument for data collection. After the pretesting, the completion time of the questionnaire was increased in the actual study, to give the respondents enough time to complete the questionnaire. Data analysis The data collected were entered into Epi Data 3.1 and exported into STATA 12.0 for analysis. To ensure the quality of the data entered, double-entry was done to address discrepancies and the data were cleaned before the analysis. All data were analyzed using descriptive statistics such as frequencies, means and standard deviation. Chisquare and multiple logistic regressions were performed and p-value of less than 0.05 was considered as statistically significant at a 95% confidence interval Ethical issues The research was conducted after approval was granted by the Ethics Review Committee of the Ghana Health Service, Research and Development Division, Accra (Reference number: GHSERC 105/05/17) Permission to gain entry to the study site was obtained from the Hohoe Municipal Education Service and the Administrative Authorities of each institution before the commencement of the study. Participants were assured of confidentiality and anonymity, that under no circumstance would their names and other details be linked to the data analysis and dissemination of the findings of the study. Data management, storage, analysis and reporting were done in formats that would not expose the details of participants. This was done using codes. There were no direct risks associated with the study and no incentive was made to any respondent for participation. None of the participants opted out of the study Results Demographic characteristics The study was conducted in four tertiary institutions in the Hohoe municipality All the 403 students that were approached, participated in the study; however, 386 questionnaires were fully completed, giving a response rate of 95.8%. Majority of the respondents, 32.6% (n=126) were from school Z, were females 61.4% (n=237) and aged 20-24 years 64.7% Article Non-commercial use only

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(n=250) (Table 1). The mean age of the respondents was 21.9 years with a standard deviation of 2.81. Most 46.4% (n=179) were first year students, 92.7% (n=358) were single, 93.5% (n=361) were Christians and 52.0% (n=201) were from the Ewe ethnic group (Table 1) Utilization of HIV Testing and Counseling services Only 30.6% (n=118) of the total respondents had ever tested for HIV/AIDS, of whom only 22.9% (n=27) tested less than 6 months before the current study. Majority 68.6% (n=81) of the ever-tested respondents were counseled before testing, 89.1% (n=344) would recommend HTC to others and 88.3% (n=341) were interested in taking HTC irrespective of whether they had done it before or not (Table 2) Barriers to HIV Testing and Counseling Of the respondents, 21.8% reported never had sexual intercourse, 20.0% reported fear of stigma and discrimination, 22.0% reported fear of positive test results, 17.6% reported lack of trust in HTC service providers and 25.4% reported unavailability of HTC services as barriers to HTC uptake (Figure 1) Perception regarding the provision of HTC services in schools Figure 2 shows that majority of the respondents (91.0%) believed that HTC centers should be provided in schools Logistic regression analysis showing the factors that affect HTC service utilization Students from Midwifery training college, THERESCO AND UHAS were more than two times more likely to have utilized HTC services than those from FRANCO [OR=2.67 (95% CI: 1.14-6.15); p=0.024], [OR=2.40 (95% CI: 1.04-5.54); p=0.040] and [OR=2.63 (95% CI: 1.13-6.13); p=0.026] respectively. Furthermore, students above 24 years of age were 3 times more likely to have utilized HTC services than those below 20 years of age [OR=2.56 (95% CI:1.07- 6.11); p=0.034] and fourthyear students were 3 times more likely to have utilized HTC services than first-year students [OR=3.05 (95% CI: 1.10-8.49); p=0.033] (Table 3) Article Table 1. Demographic characteristics of respondents. Variable Frequency (n=386) % Name of school FRANCO 97 25.2 MIDWIFERY SCHOOL 80 20.7 THERESCO 83 21.5 UHAS 126 32.6 Sex Male 149 38.6 Female 237 61.4 The age group Below 20 years 74 19.2 20-24 years 250 64.7 a Above 24 years 62 16.1 Year of study First-year 179 46.4 Second-year 133 34.4 Third-year 49 12.7 Fourth-year 25 6.5 Marital status Married 27 7.0 Not married 358 92.7 Divorced 1 0.3 Religion Christianity 361 93.5 Islam 25 6.5 Ethnicity Ewe 201 52.1 Akan 102 26.4 Hausa 15 3.9 Guan 26 6.7 Ga-Adangme 17 4.4 Northerners 25 6.5 Table 2. Utilization of HIV Testing and Counseling services. Variable Frequency % Ever had HTC in the past (n=386) Yes 118 30.6 No 268 69.4 Time of last test (n=118) Less than 6 months 27 22.9 6 months 22 18.6 7-12 months 53 44.9 Above 1 year 16 13.6 Where the HTC service was provided (n=118) Hospital 59 50.0 Health Center 31 26.3 NGO Clinic 10 8.5 Private Clinic 7 5.9 Church 1 0.8 Home 1 0.8 School 9 7.7 Received counselling before the test was done (n=118) Yes 81 68.6 No 37 31.4 Would recommend HTC to others (n=386) Yes 344 89.1 No 42 10.9 Interested in having HTC whether I have had it before or not (n=386) Yes 341 88.3 No 45 11.7 Figure 1. Barriers to HIV Testing and Counseling. Figure 2. Provision of HTC centers in schools. [Journal of Public Health in Africa 2019; 10:1044] [page 97] Non-commercial use only

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Discussion In the current study, only 30.6% of the respondents had ever tested for HIV/AIDS This is similar to other results obtained in Ethiopia (21.3%), 18 in South Africa (18.0%) 1 and in Metropolitan Kumasi, Ghana (6.0%) 16 Moreover, very few of the respondents had tested within six months before the current study as recommended by WHO 30 This can be likewise interpreted that the majority of the few who had ever tested did not follow the routine as required Inability to adhere to routine HTC might lead to vulnerability to HIV/AIDS. Besides, the findings from the current study showed that majority of the ever-tested respondents had their tests from the hospital (50.0%) followed by the health centre (26.3%), NGO clinic (8.5%) and private clinics 7(5.9%). This implies that very few had HTC services outside the healthcare domain. This might be because, these services are made available mostly at the healthcare settings and therefore, easily accessible in the township, which provides the young people with easy access to the HTC services. This might also be explained by the fact that people often go to a health facility when they already have a health problem, providing them with more chances of getting to know their HIV status through the health care providers. More students might utilize HTC services if they are extended to schools and even run as outreaches in communities, as 91% of the students in the current study were of the opinion that HTC services should be provided in schools Majority of the respondents (89.1%) would recommend HTC to others. This is similar to a study conducted in Cameroon, which reported that 78.9% recommended HTC to a family member 31 Concerning barriers to HTC uptake, 21.8% of the respondents reported never had sexual intercourse and 12.2% also said they trusted their partners and therefore did not take up HTC, implying low-risk perception to HIV transmission. This is similar to a study conducted in Tanzania by Sanga etal., 3 which states that a significant number of the study participants considered themselves at low risk of contracting HIV infection and therefore did not bother to take up HTC. Nevertheless, there are different ways apart from sexual intercourse, that one can acquire HIV such as through sharp and pointed-infected objects. Ghana is experiencing a generalized epidemic which an HIV prevalence of above 1%, which implies that everybody is at risk of contracting HIV whether one is sexually active or not. Therefore, all the routes of transmission of HIV are important 27 Also, 20.0% reported fear of stigma and discrimination as a barrier to utilizing HTC services. This finding is similar to a study conducted in Tanzania, where a significant number of the study participants said that they did not like to go for HTC as they are afraid of being stigmatized particularly as they are likely to be labelled as HIV victims 3 The current study again revealed that 22.0% of the respondents reported fear of a positive test result as a barrier to HTC uptake. A similar study among Bahirdar University Students at Ethiopia, 32 and two others in Ghana 6,7, identified fear of positive results as a barrier to HTC uptake Furthermore, 17.6% of the students in the current study reported lack of trust in HTC service providers as a barrier to HTC uptake, which is comparatively similar to a study conducted by Bwambale et al ., (2008) in Uganda, 8 which also identified confidentiality of services as the barriers to poor utilization of HTC services among men. More importantly, 25.4% of the students in the current study reported unavailability of HTC services as a barrier to HTC uptake This is almost similar to finding in Uganda 8 Few of the students (10.1%) also complained that HTC centers are too open Because of these perceived barriers, young people may lack the confidence to go for HTC services. There is need for health promotion interventions to increase the selfefficacy of the students and to minimize these barriers so that they will be able to use HTC services Majority of the respondents in the current study (91%) showed a great desire for HTC centers in their various schools. This is in agreement with a formative evaluation of the acceptability of HTC at schools in Gauteng and North West provinces in South Africa conducted among high school students, 1 which shows that the acceptability of HTC at school was high (76.9%) and 71.8% were willing to be tested at school According to the authors, students perceived it as appropriate, convenient, and has the potential to offer the confidentiality of HIV test results and private testing Therefore, taking HTC services to the school settings may enable students to have increased access to the services After controlling for the effects of other variables through logistic regressions, it was discovered that students in the fourthyear of study and those above 24 years of age were more likely to have undergone HTC. This may be due to the higher possibility that fourth-year respondents could have easier access to HTC information since they had stayed longer in their various schools than students in the lower levels of study. The finding that age is a significant factor in HTC utilization could be explained by the fact that as age increases, students become more mature and can better assimilate HIV information. It might also be because as young people grow, they are exposed to HTC/HIV education, which Article Table 3. Logistic regression analysis showing the factors that influence HTC utilization. Factors Odds ratio p-value 95% CI Tertiary institution FRANCO 1.00 MIDWIFERY SCHOOL 2.67 0.024 1.14 – 6.15 THERESCO 2.40 0.040 1.04 – 5.54 UHAS 2.63 0.026 1.13 – 6.13 Age group Below 20 years 1.00 20-24 years 1.60 0.201 0.78 – 3.30 Above 24 years 2.56 0.034 1.07 – 6.11 Year of study First-year 1.00 Second-year 1.11 0.732 0.62 – 1.96 Third-year 1.50 0.308 0.69 – 3.26 Fourth-year 3.05 0.033 1.10 – 8.49 HTC is conducted voluntarily Yes 1.00 No 1.04 0.921 0.41 – 2.62 HTC is important for prevention control of HIV Yes 1.00 No 0.50 0.409 0.10 – 2.58 HTC provision centre is around Yes 1.00 No 0.82 0.480 0.46 – 1.43 [page 98] [Journal of Public Health in Africa 2019; 10:1044] Non-commercial use only

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[Journal of Public Health in Africa 2019; 10:1044] [page 99] makes them realize the importance of knowing their HIV status. Also, the school of attendance of the students also showed a significant association with HTC utilization such that more students from UHAS and the Midwifery training college were 3 times more likely to have utilized HTC services than those from FRANCO. This might be due to the healthrelated educational background of these students since both schools are health-based institutions. This finding is in agreement with a study conducted in Cameroon 31 Also, students from THERESCO were two times more likely to have utilized HTC services than students from FRANCO Students from THERESCO and the Midwifery training college were all females. Limitations The study was based on self-reports by students who might have provided socially desirable responses regarding the issue of HTC. However, the anonymity of the questionnaire might have encouraged students to be honest in answering the questions. The study was conducted among tertiary institution students in the Hohoe municipality of Ghana. Thus, the findings may not reflect some ideas of those who have never been to school and may also not provide a national picture of HTC acceptability. Despite all of these limitations, it is believed this study might be a reasonable source of information for researchers and policymakers Conclusions The uptake of HTC among tertiary institution students in Hohoe was low School of attendance, age and year of study were the factors influencing the uptake of HTC. The study findings also demonstrated that the acceptability of HTC at school was high, and there was a willingness to uptake the service among students. Policy-makers should consider all the above factors to design appropriate policies targeting students from tertiary institutions in Hohoe Municipality, Ghana to increase HTC uptake. References 1. Madiba S, Mokgatle M. Parents Support Implementation of HIV Testing and Counseling at School: Cross- Sectional Study with Parents of Adolescent Attending High School in Gauteng and North West Provinces, South Africa. AIDS Res Treat 2016;4842814 2. Addis Z, Yalew A, Shiferaw Y, et al Knowledge, attitude and practice towards voluntary counseling and testing among university students in North West Ethiopia: a cross-sectional study Adv Prev Med 2014;906107 3. Sanga Z, Kapanda G, Msuya S, Mwangi R. Factors influencing the uptake of Voluntary HIV Counseling and Testing among secondary school students in Arusha City, Tanzania: a cross-sectional study. BMC Public Health 2015;15:452 4. Ghana AIDS Commission. 2014 Status Report. Available from: http://www ghanaids.gov.gh/gac 1/pubs/2014%20 S TATUS%20 REPORT.pdf 5. Ghana Statistical Service (GSS) Ghana Health Service, ICF Macro. Ghana Demographic and Health Survey 2008 Accra: GSS, GHS, and ICF Macro; 2009 6. Koku EF. Stigma, sexual risk and desire for HIV tests in Ghana. Sex Health 2011;8:110-19 7. Ulasi CI, Preko PO, Baidoo JA, et al HIV/AIDS-related stigma in Kumasi, Ghana. Health Place 2009;15:255-62 8. Bwambale MF, Ssali NS, Byaruhanga S, et al. Voluntary HIV counselling and testing among men in rural western Uganda: Implications for HIV prevention. BMC Public Health 2008;8:263 9. Wringe A, Isingo R, Urassa M, et al Uptake of HIV voluntary counselling and testing services in rural Tanzania: Implications for effective HIV prevention and equitable access to treatment Trop Med Int Health 2008;13:319-27 10. Witzel TC, Lora W, Lees S, Desmond N. Uptake contexts and perceived impacts of HIV testing and counseling among adults in East and Southern Africa: A meta-ethnographic review PLoS One 2017;12:e 0170588 11. UNICEF. Statistical Update: Children, Adolescents and AIDS, 2014. Available from: http://www.childrenandaids org/files/Stats_Update_11-27.pdf. 12. Anhomah A. condom use in sexual exchange relationship among young single adults in Ghana. AIDS Educ Prev 1998;10:303-13. 13. Longfield K, Glick A, Whaitaka M, Berman J. Cross-generational relationships in Kenya: couples’ motivations, risk perception for STI/HIV and condom use. Working paper. No. 52 PSI Research Division: Washington, DC; 2002. Available from: https://www.psi org/wp-content /uploads/drupal/ sites/default/files/...files/WP 52.pdf 14. Onah HE, Mbah AU, ChukWukwa JC, Ikema AC. HIV/AIDS awareness and sexual practices among undergraduates in Enugu, Nigeria. Niger Postgrad Med J 2004;11:121-5 15. Oppong A. HIV Knowledge and uptake of HIV counseling and testing among undergraduate private university students in Accra, Ghana. Reprod Health 2013;10:17 16. Razak MG, Kabila A. Sexual risk behavior and uptake of HIV counseling and testing among youth in Metropolitan Kumasi, Ghana. J HIVAIDS Soc Serv 2018;17:127-45 17. Mwangi R, Ngure P, Thiga M, Ngure J Factors influencing the utilization of voluntary counselling and testing services among university students in Kenya Glob J Health Sci 2014;6:84–93 18. Teklehaimanot HD, Teklehaimanot A, Yohannes M, Biratu D. Factors influencing the uptake of voluntary HIV counselling and testing in rural Ethiopia: A cross-sectional study. BMC Public Health 2016;16:239. 19. Mohlabane N, Tutshana B, Peltzer K, Mwisongo A. Barriers and facilitators associated with HIV testing uptake in South African health facilities offering HIV counseling and testing. Health SA Gesondhei 2015;21:86-95 20. Asaolu IO, Gunn JK, Center KE, et al Predictors of HIV Testing among Youth in Sub-Saharan Africa: A Cross- Sectional Study. PLoS One 2016; 11:e 0164052 21. Abokyi LV, Zandoh C, Mahama E, et al Willingness to undergo HIV testing in the Kintampo Districts of Ghana Ghana Med J 2014;48:43-6 22. Munthali AC, Mvula PM, Maluwa- Banda D. Knowledge, Attitudes and Practices about HIV Testing and Counselling Among Adolescent Girls in Some Selected Secondary Schools in Malawi. Afr J Reprod Health 2013; 17:60-8 23. Abiodun O, Sotunsa J, Ani F, Jaiyesimi E. Knowledge of HIV/AIDS and predictors of uptake of HIV counseling and testing among undergraduate students of a privately-owned university in Nigeria. BMC Res Notes 2014;7:639 24. Oppong AK, Oti-Boadi M. HIV/AIDS knowledge among undergraduate university students: implications for health education programs in Ghana. African Health Sciences 2013;13:270-7 25. Andoh-Robertson T, Ofori KN. HIV Testing and Counselling Among The Youth Of Ghana: The Case Of Tarkwa- Nsuaem and Fante-Akwa District. Adv Soc Sci Res J 2018;5:199-213. Article Non-commercial use only

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[page 100] [Journal of Public Health in Africa 2019; 10:1044] 26. Gyasi RM, Abass K. Sexual risk behavior and uptake of HIV counseling and testing among youth in Metropolitan Kumasi, Ghana. J HIV AIDS Soc Serv 2018;17: 127-45 27. National AIDS/STI Control Programme. HIV sentinel survey, Accra. Ghana, 2018 28. Ghana Statistical Service. 2010 Population and Housing Census District Analytical Report, Hohoe, 2014 29. Cochran WC. Sampling Techniques (3 rd ed) New York: Wiley & Sons 1977 30. WHO. Consolidated guidelines on HIV testing services. WHO Geneva 2015 31. Haddison EC, Nguefack-Tsague G, Noubom M, et al. Voluntary counseling and testing for HIV among high school students in the Tiko health district, Cameroon. Pan Afr Med J 2012;13:18 32. Fikadie G, Bedimo M, Alamrew Z Prevalence of Voluntary Counseling and Testing Utilization and Its Associated Factors among Bahirdar University Students. Adv Prev Med 2014;906107 Article Non-commercial use only

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