Unburying the Ostrich's Head and Opening Pandora's Box: A Paradigm Shift to Address HIV Among Men Who Have Sex With Men in Ghana's National AIDS Response

For the first twenty-five years of Ghana’s national response to HIV/AIDS, the government, like most nations in Africa, did not include gay and bisexual—locally known as sasoi—and other men who have sex with men (MSM) as a high-risk group for HIV in its policies. In 2011, Ghana finally addressed this policy blind spot by acknowledging sasoi and other MSM as a key population at-risk for HIV and in need of policy and programmatic interventions—a shift that is occurring in many parts of Africa. Using Ghana as a case study of this policy shift on the continent, my dissertation examined: why sasoi and other MSM were not initially acknowledged in Ghana’s national AIDS policies; why and how the government decided to include MSM as a key population in its national AIDS policies and programs; what cultural, social, and political factors have affected the development, implementation, and reception of these policies and programs; how sasoi and other MSM perceive and experience these policy and programmatic efforts; and how sasoi and other MSM experience life in a country that criminalizes and stigmatizes same-sex sexual activities. Using ethnographic methods, I conducted a 12-month qualitative study in Ghana. I conducted: interviews with 43 state and non-state policymakers and stakeholders, HIV frontline workers, and sasoi and other MSM; focus group interviews with 18 peer educators; participant observations of policy and HIV prevention work, and meetings and other events related to the research scope; and archival research of media coverage of homosexuality. My findings indicate that Ghana’s MSM policy blind spot was due to: 1) the criminalization and stigmatization of same-sex sexualities in the country, 2) a construction of the Ghanaian epidemic as driven by migrant female sex workers, and 3) international AIDS researchers’ categorization of HIV in Africa as heterosexual, which informed donor policies and stipulations. However, in 2011, the government shifted to include MSM as a KP at risk for HIV in light of mounting epidemiological data on MSM HIV prevalence and risk, NGO advocacy efforts, and international donor policy changes that now recognize MSM as a KP in Africa. I conceptualize this change as a paradigm shift in Ghana’s national AIDS policies from a general population paradigm to a key populations paradigm that includes MSM as biomedical citizens at higher risk for HIV. The country’s progress in addressing HIV among sasoi and other MSM using evidence-based policies has earned it status as a model country in Africa in MSM HIV efforts. Stakeholders, however, face significant challenges rooted in the country’s sociocultural context, namely institutionalized homophobia and heterosexism, a dated and underfunded healthcare system, and inadequate HIV funding. Implementation of MSM HIV policies has come into conflict with the country’s legal and sociocultural realities in Ghana, where male same-sex sexual activities are criminalized and socially stigmatized. Moreover, stakeholders are strategically discreet in how they implement MSM HIV policies and programs and are hesitant to publicly push any advocacy efforts that might come across as supporting or promoting homosexuality, in fear of social and political retribution. Despite this strategy, I argue that MSM HIV efforts have attracted public attention and criticism and have constituted, in part, the politicization of homosexuality in Ghana, reshaping public representations and perceptions of homosexuality and presenting challenges to the ongoing efforts to address HIV among MSM. Stakeholders must evaluate these unintended consequences alongside the intended policy objectives and outcomes to strengthen efforts to reduce the burden of HIV among sasoi and other MSM in Ghana.