A Vulnerability Interpretation of the Geography of HIV/AIDS in

Ghana, 19861995*

Joseph R. Oppong
University of North Texas

Ten years after the human immuno-deficiency virus (HIV) was first reported in Ghana, it continues to spread throughout
the country following patterns that are rare in other African countries. HIV is seen in twice as many females as males,
more frequently in rural than urban regions, and regions with high rates of polygamy have significantly lower rates.
The evidence presented in this paper shows that HIV diffusion patterns probably reflect the spatial distribution and
social networks of vulnerable social groups. While information-based campaigns are still necessary in the fight against
HIV/AIDS, they fail to enable or empower vulnerable people to protect themselves against infection. Key Words:
HIV/AIDS, Ghana, vulnerability, empowerment, polygamy, Islam, rural-urban.

Introduction are observed in other West African countries,

ore than twenty million persons were liv-
M ing with HIV/AIDS in Sub-Saharan Af-
rica in December 1997, about two-thirds of the
worlds total, and an estimated 7.4% of all per-
sons aged between 15 to 49 were infected with
HIV (UNAIDS and WHO 1997). While the
devastating impact of AIDS, the disease associ-
ated with the late clinical stage of HIV infection,
has generally been felt throughout the African
continent, particularly in southern Africa, con-
siderable variations exist among and within
countries. In the so-called main AIDS
belt,Uganda, Rwanda, Burundi, Western
Kenya, Western Tanzania, parts of Eastern
Zaire, Malawi, Zambia, Zimbabwe, and Bot-
swanaHIV-seropositivity rates of 20% to 30%
are common in the general adult population of
large urban areas and 5% to 20% is observed in
rural areas (Caldwell 1995). By early 1997, the
Government of South Africa estimated that 2.4
million South Africans were living with HIV
(UNAIDS and WHO 1997). In West Africa, the
epidemic has traditionally been most severe in
Cte dIvoire where pregnant women report a
rate of 14.8% (Health Studies Branch 1995).
However, Nigeria, where the National AIDS
Program estimates that 2.2 million people were
living with HIV by December 1997 (UNAIDS
and WHO 1997), is quickly emerging as a
trouble spot. Much smaller seropositivity rates
and, usually, among high risk groups such as sex
workers, their long-term partners and custom-
ers. The highest rates are observed in major
urban areas, typically the largest cities. This is
the case in Burkina Faso, Mali, Nigeria, and
Sierra Leone, but not Ghana. Ghana has a com-
parably low HIV/AIDS rate, and the major areas
of infection are rural, not urban.
In the early stages of the epidemic in Sub-
Saharan Africa, the populations most rapidly
and most heavily affected in most countries were
in urban areas, and seroprevalence levels fell
with declining urban size (Caldwell 1995). To-
day, urban areas and trading centers generally
continue to show much higher prevalence rates
than rural areas, but in some places rural infec-
tion rates are approaching those in urban popu-
lations. This is particularly true in rural areas
that have strong links (expressed in major popu-
lation flows) with major urban centers (Kalipeni
1997). Thus, the spread of HIV/AIDS in Sub-
Saharan Africa usually follows a hierarchical dif-
fusion pattern, spreading from the most urban
to more rural areas (Gould 1993). In contrast,
Ghanas pattern is quite unusual. Rural regions
have higher rates than the most urban region,
and diffusion appears to follow a contagious,
rather than a hierarchical, diffusion pattern.
Africas AIDS pandemic has been dubbed Pat-
tern Two to distinguish it from Pattern One, the
epidemiological pattern prevailing in Europe

*This research was funded by a Research Initiation Grant from the University of North Texas. The author acknowledges the comments of David
Williamson, Ezekiel Kalipeni, and anonymous reviewers of the Professional Geographer on earlier drafts of this paper.

Professional Geographer, 50(4) 1998, pages 437448 Copyright 1998 by Association of American Geographers.
Initial submission June 1996; revised submissions August 1997, March 1998; final acceptance April 1998.
Published by Blackwell Publishers, 350 Main Street, Malden, MA 02148, and 108 Cowley Road, Oxford, OX4 1JF, UK.
438 Volume 50, Number 4, November 1998
and the United States (Chin 1990; Mann et al.
1992). In Pattern One, the sex ratio of AIDS
cases is much higher for men with transmission
occurring predominantly among homosexual
and bisexual men. For example, in the early and
mid-1980s the sex ratio of US AIDS cases was
16:1 male to female, but in 1992 it was closer to
8:1 (Mann et al. 1992; Hunt 1996). In Pattern
Two, where transmission is primarily heterosex-
ual, 50% of cases are usually found in women
resulting in a 1:1 male-female ratio or slightly
higher rates in men (Chin 1991; Hunt 1996).
This pattern emerges because HIV transmission
to men with multiple sexual partners predomi-
nates initially, and the infection increasingly
spreads to women as the epidemic matures
(Health Studies Branch 1995). Ghanas pattern
is highly unusual; it resembles a Reversed Pat-
tern One. Since the beginning of the epidemic,
the number of infected females has always been
multiple times the number of males. By the end
of 1996, twice as many women as men had AIDS.
Polypartner sexual activity is implicated in the
spread of HIV/AIDS throughout the world. In
Africa, polygamy is identified as an important
factor in the spread of the virus. According to
Rushing (1995), it is the only relevant factor.
Similarly, on Malawi, Kalipeni states that the
first and foremost practice that is implicated in
the proliferation of the disease is polygamy in all
its forms (Kalipeni 1997, 26). Appropriately,
AIDS awareness and prevention programs have
emphasized lasting, monogamous sexual unions
to prevent HIV infection. Thus, areas with high
rates of polygamy are expected to have high
HIV/AIDS rates. Surprisingly, in Ghana, re-
gions with very high polygamy rates have unusu-
ally low HIV/AIDS rates, in fact, much lower
than regions with low polygamy rates.
Understanding these unusual patterns of
Ghanas HIV/AIDS epidemic is important if
programs designed to curb further spread are to
be effective. Research presented in this paper
uses a vulnerability framework to examine the
changing geography of HIV/AIDS infection in
Ghana from 1986 through 1995. Data from the
Ghana AIDS Control Program (GACP) and
seroprevalence data from the United States Bu-
reau of the Census are used in an attempt to
explain these distinct patterns of Ghanas
HIV/AIDS problem, namely: 1. HIV/AIDS
spread in Ghana appears to follow a contagious,
rather than a hierarchical, diffusion pattern;
2. Commercial sex may be a major factor that
helps to explain the unusually high female-male
ratio; and 3. Polygamy alone may not be a very
important factor in explaining the geography of
HIV/AIDS in Ghana. The paper begins with a
brief outline of the vulnerability conceptual
framework after which the geographic and tem-
poral variations of HIV/AIDS in Ghana are
presented and explained.
Vulnerability Theory and AIDS
Vulnerability theory posits that adverse life cir-
cumstances such as hunger and disease do not
affect social groups uniformly. For example,
while all human beings are biologically suscep-
tible to HIV infection, certain social and eco-
nomic factors place some individuals and social
groups in situations of increased vulnerability
(Parker 1996). Economic need may drive vul-
nerable groups of people to risky survival activi-
ties such as commercial sex work that makes
them a population at risk (Watts and Bohle
1993). In fact, behavioral interventions based
solely on information and reasoned persuasion
are insufficient to produce risk-reducing behav-
ior change among vulnerable social groups (Ag-
gleton 1996; Parker 1996). The geographical
distribution of such vulnerable populations and
their social interaction patterns may suggest the
geography of HIV/AIDS infection. AIDS as a
global problem has unique local expressions that
reflect the spatial distribution and social net-
works of vulnerable social groups. Conse-
quently, unraveling the factors responsible for
vulnerability to HIV/AIDS for different social
groups is crucial if prevention and control pro-
grams are to be effective.
HIV/AIDS Data Sources and
Problems
Determining the exact magnitude of the
HIV/AIDS pandemic in Sub-Saharan Africa is
extremely difficult (Barnett and Blaikie 1992). A
dearth of accurate diagnostic equipment and the
fact that many rural residents do not use the
primarily urban-based biomedical health care
facilities, where diagnostic equipment is based,
are major problems. Two important sources of
HIV/AIDS data are national data reported to
the World Health Organization (WHO) and
seroprevalence data provided by the Health
 Geography of HIV/AIDS in Ghana, 19861995
Studies Branch of the Center for International
Research in the United States Census Bureau
(from now on Health Studies Branch)
HIV/AIDS Surveillance Data.
With rare exception, surveys of HIV sero-
prevalence are not based on national samples
(Health Studies Branch 1995). Consequently,
due to sample size, nonrepresentative samples,
and geographic and testing bias, every seropreva-
lence estimate is defective if generalized beyond
its sample population. Furthermore, testing it-
self is problematic. The ELISA test, which was
the predominant test to determine seropositivity
during the early years of the epidemic, produces
some false positives, and test results must be
confirmed by a second test, usually the Western
Blot (Health Studies Branch 1995). Where both
HIV-1 and HIV-2 are present, reporting only
one results in undercounting, while reporting
both may produce double counting in those with
joint infection. Since people can carry the virus
for a long time without knowing it while inad-
vertently infecting others, reported cases are
mere estimates of the total number of real cases
and underreporting is inevitable.
National data reported to WHO is also prob-
lematic. Differences between countries in ade-
quacy of testing facilities and reporting
practices, varying definitions of what constitutes
a case of AIDS, and political distortions of data,
make national data reported by WHO incom-
plete (Mann et al. 1992). For example, some
African governments may conceal the real di-
mensions of the AIDS problem out of a sense of
shame and concern that the real figures would
drive investors and tourists away. Many doctors
with experience across the continent estimate
that actual HIV/AIDS cases are 80% to 90%
underreported (Gould 1993). Nevertheless,
while national data do not reflect the current
status of the epidemic, they portray general
trends such as intra-country variations.
This study is based on national AIDS data
reported by the Ghana AIDS Control Program
(GACP), also published by WHO (1995), and
HIV/AIDS Surveillance Data provided by the
Health Studies Branch. GACP reports a sum-
mary figure of AIDS patients without distin-
guishing between HIV-1 and HIV-2.
Cumulative incidence rates for AIDS were cal-
culated for each region using the annual total
AIDS figure from the GACP and WHO. While
imperfect, this data is the most complete record
439
of AIDS available for Ghana. GACP has an
ongoing surveillance program providing volun-
tary testing and screening of blood donors and
pregnant women. HIV testing facilities are avail-
able in most district hospitals throughout the
country, all regional centers and large cities. Due
to this, seroprevalence data presumably under-
estimate HIV rates in rural areas. Pregnancy-
based HIV/AIDS screening services, for
example, probably underestimate rural
HIV/AIDS prevalence. In a sample of 2,168
babies delivered in 1993, 46% of urban mothers
received prenatal care from doctors compared
with 14% for rural women (Ghana Demo-
graphic and Health Survey 1993). Given this
disparity in access to prenatal care services,
fewer rural women are likely to be screened. It
is precisely for this reason that the higher sero-
prevalence rates observed in rural areas should
not be discounted. It would seem that construct-
ing a plausible, even if scaled-down, picture of
the dimensions of the epidemic from national
reports, and the HIV/AIDS Surveillance Data
Base is feasible. Consequently, data presented
here suggest current patterns and trends and
should not be assumed to describe the current
situation.
Sociodemographic data on urbanization and
polygamy rates used in this study are from the
GDHS of 1993. The 1993 GDHS is a nationally
representative survey of 4,562 women aged
1549 and 1,302 men aged 1559. The GDHS
was conducted by the Ghana Statistical Service
with technical assistance provided by Macro In-
ternational Inc., through a contract with the
United States Agency for International Devel-
opment. The express purpose of the GDHS is
to furnish reliable and up-to-date information
on key variables and indicators of social devel-
opment for the country. Other data were ob-
tained from the Ghana Living Standards Survey
(GLSS 3) (Ghana Statistical Service 1995).
General Characteristics of HIV/AIDS
in Ghana
Ghana is bounded on the west by Cte
dIvoire, on the north by Burkina Faso, on the
east by Togo, and on the south by the Atlantic
Ocean. Administratively, the country is di-
vided into ten regions. The southern parts of
the country, including Greater Accra Region,
Eastern, Central, Western, Ashanti and Volta
440 Volume 50, Number 4, November 1998

(Fig. 1), are more developed compared with the
northern parts of the country. With 88% urban
population, the Greater Accra Region, contain-
ing Accra, the primate city and national capital
whose 1997 population was estimated to be 1.9
million (de Blij and Muller 1997) and Tema, a
major seaport, is the most urban of the ten
regions. Ashanti Region, with Kumasi, the sec-
ond largest city of Ghana as its capital, is the next
most urbanized region.
At the end of 1996, Ghana reported a total of
20,859 AIDS cases (Hotard et al. 1998). When
HIV was first detected in Ghana in 1986, 63
of the initial 72 cases were found in women, a
7:1 female-male ratio (Perdigao et al. 1996).
Almost 98% of the cases were found in people
with a history of recent residence or an ex-
tended visit outside the country, particularly

Upper East
Rate per 100,000
Upper West

0.0 to 0.1

Northern

0.1 to 1.0

Volta
Brong Ahafo

Ashanti

Eastern

Greater
Western Accra
Central

Miles

0 50 100

Figure 1: Cumulative incidence of reported AIDS cases 1986.

 Geography of HIV/AIDS in Ghana, 19861995
former residents of Cte dIvoire. Seropreva-
lence of the general population is low compared
with Cte dIvoire. Out of a total of 14,362 blood
donors tested in 1990, seroprevalence of HIV-1
was 2.2%, while HIV-2 was 0.6% (Health Stud-
ies Branch 1993). Reported infection levels
among commercial sex workers increased from
25.2% in 1987 to 37.5% in 1991 (Health Studies
Branch 1996a). Prevalence of infection in males
attending a sexually transmitted disease clinic in
Accra in 1988 was 2.1, but in 1991 it had quad-
rupled to 8.6%. HIV prevalence among preg-
nant women ranged from 1.6% to 2.8% in
1995. Studies of pregnant women in the East-
ern and Ashanti regional capitals in 1992 re-
ported infection levels of 3.2% and 4.2%
respectively. However in Agomanya, a rural
district of the Eastern Region, prevalence
among pregnant women was 18% (Table 1)
(Health Studies Branch 1996b).
The peak age for male AIDS cases is 30 to 34,
while for females, it is 25 to 29 (Fig. 2). More
than 90% of all AIDS cases occur in adults aged
between 20 to 54, but less than 2% occur in
children aged 0 to 14. Finally, while in 1986,
97.6% of new cases were found in people with a
history of a residence or extended visit outside
5000
4500
4000
3500
Number of Cases
3000
2500
2000
1500
1000
500
0
0-4 5-9 10-14 15-19
Figure 2: Age-sex breakdown of reported AIDS cases 19861995.
441
the country, in 1992, the figure was 40.2%
(Ghana Ministry of Health Epidemiology Divi-
sion 1992). This trend suggests a maturing of
Ghanas AIDS epidemic and a spread from the
original core of high risk, migrant, commercial
sex workers into the general adult population as
an endemic problem.
Sex-Ratio of AIDS Patients
Based on GACP data, from the initial female-
male ratio of 5:1 in 1986, the sex ratio of AIDS
patients may be gradually converging toward a
1:1 female-male ratio (Fig. 3). Currently, unlike
other parts of Africa, AIDS in Ghana strikes
twice as many females as it does males (Fig. 4).
For the whole country, 16,690 AIDS cases were
reported by December 19955,383 male and
11,307 female (WHO 1995). While this is prob-
ably an underestimate, the 2:1 ratio is not a mere
artifact of the data collection process. Ghanas
Reverse Pattern One HIV/AIDS epidemic is
now noted by many researchers who attribute it
to returning female commercial sex workers.
For example, Hotard et al. (1998) attribute the
spread of HIV to and within Ghana to return-
ing Ghanaian female commercial sex workers in
neighboring Cte dIvoire. Caldwell (1995, 300)
MALE
FEMALE
20-29 30-39 40-49 50-59 60+ Not Stated
Age
442 Volume 50, Number 4, November 1998
observed that due to the large number of sex
workers returning infected from Abidjan, an
AIDS epidemic in Ghana seemed inevitable.
Decosas et al. (1995) note that more than half of
all professional commercial sex workers in Abid-
jan are Ghanaian, many from the Krobo tribe in
the Eastern Region of Ghana. Moreover, 80%
of those who are still working as commercial sex
workers in Abidjan are infected with HIV
(Decosas et al. 1995, 827). A review of
epidemiologic data collected from 1987 to
1993 by Project RETRO-CI in Cte dIvoire
concluded that due to the initial concentration
of HIV in a core group of female commercial
sex workers, many of whom originate from
neighboring countries, migration of sex work-
ers is likely to have contributed to the spread
of HIV infection in West Africa (Djomand et
al. 1995). In fact, seroprevalence among sex
workers in Abidjan was 86% in 1995. Thus,
Ghanas initially high rate of HIV/AIDS
among females may be directly linked to com-
mercial sex work in Abidjan, Cte dIvoire. As
Decosas (1996, 276) puts it, almost all the
Ghanaian prostitutes in Cte dIvoire are in-
fected with HIV and many are returning home
sick and destitute.
5 Female
Number of Cases
0
1986 1987 1988
Figure 3: Sex ratio of reported AIDS cases 19861992.
Regional variations in Ghanas female-male
ratio are also revealing (Fig. 4). In the Eastern
Region, the female-male ratio is 5:1 and most
regions have higher female ratios except Upper
East and Upper West with 0.7:1 and 0.8:1 re-
spectively. The persistently high female-male
ratio, particularly in the Eastern Region, seems
to lend credence to the migrant sex worker
thesis. It appears that migration ties between
Cte dIvoire and Ghana, specifically Abidjan
and the Eastern Region of Ghana, funnels the
high rates among sex workers in Cte dIvoire
into Ghana (Decosas 1996; Hotard et al., 1998).
Polygamy and HIV/AIDS in Ghana
Polygamous behavior is considered a major fac-
tor in the spread of HIV/AIDS in Africa. Con-
sequently, areas with high rates of formal
polygamy are expected to have high rates of
HIV/AIDS. Using data from the 1993 GDHS,
the relationship between polygamy and
HIV/AIDS was examined. GDHS measured
polygamy by asking married women whether
their husbands had other wives and, if so, their
number. Overall about 28% of married women
in Ghana were in polygamous unions (Table 2).
However, contrary to expectation, the regions
Male
1989 1990 1991 1992
 Geography of HIV/AIDS in Ghana, 19861995 443
Table 1 Seroprevalence of HIV in Pregnant Women in Selected Regions (1992).
Region Urban/Rural Number Number Prevalence
Tested Positive %

Greater Accra Urban 500 6 1.2

Eastern Rural 412 74 18.0
Ashanti Urban 455 21 4.6
Brong Ahafo Urban 500 20 4.0
Brong Ahafo Rural 500 20 4.0
Upper East Urban 505 9 1.8
Upper West Rural 315 3 1.0
Source: 1992 Annual Report of Epidemiology Division. Ghana Ministry of Health.

with the highest rates of polygamy had the low-
est rates of HIV/AIDS as reflected by the Spear-
man rank correlation coefficient of 0.927
(p < .01). Not only did the Eastern Region have
the least polygamy, but the region with the high-
est polygamy, the Northern Region with 44%,
had the lowest AIDS rate. A 1994 serosurvey of
1,264 pregnant women in the region showed a
seroprevalence of 1.6% (Health Studies Branch,
1996b) while a similar survey among pregnant
women in the Eastern Region reported a high
prevalence of 18% (Decosas 1995; Health Stud-
ies Branch 1996b). HIV infection rates among
pregnant women provide the most repre-
sentative picture of HIV infection, and fre-
quently, are considered surrogates for the gen-
eral population (Mann et al. 1992). Based on
this, the data does not provide evidence to sup-
port a direct positive link between formal polyg-
amy and HIV/AIDS rates in Ghana.
Urbanization and HIV/AIDS
Throughout Sub-Saharan Africa, HIV infection
is higher in urban areas (Berkley 1992), particu-
larly in capital cities (Bongaarts and Way 1989).
Chin (1991) estimates that HIV seroprevalence
among sexually active adults in urban areas in
some parts of Sub-Saharan Africa is about ten
times that of rural areas. However, the Greater
Accra Region, with 83% urban population and

5
Female Cases

Male cases
4
Number of Cases

0
Ashanti Brong Central Eastern Greater Northern Upper Upper Volta Western Total
Ahafo Accra East West

Figure 4: Sex ratio of reported AIDS cases by region 19861995.

444 Volume 50, Number 4, November 1998

the national capital and primate city, Accra,
had lower AIDS rates than the Eastern and
Ashanti Regions. In 1995, the Eastern Region
with only 28% urbanization had a cumulative
incidence rate of 2.16 per 1,000 population
while the Ashanti Region, with about 33%
urbanization had 2.49 per 1,000 (Table 2).
This is confirmed by data on seroprevalence
of HIV among pregnant women in selected
regions (Table 1).
Moreover, HIV/AIDS spread in Ghana does
not appear to follow a hierarchical diffusion
pattern. The Greater Accra Region did not have
the highest rates initially as expected under a
hierarchical diffusion pattern. Instead, the East-
ern Region, with only 28% urbanization, had
the highest rates initially (Fig. 5). The largest
city in the Eastern Region had only 58,734
people during the 1984 census (Ghana Sta-
tistical Service 1992). If HIV/AIDS spread in
Ghana followed a hierarchical diffusion pat-
tern, Greater Accra Region would have the
highest rate followed by the Ashanti, Western,
and so on (Table 2). Instead, a simple conta-
gious diffusion process may be at work begin-
ning in the Eastern Region from where it
spreads to the neighboring Ashanti and
Greater Accra Regions (high urban populations
with relatively high commercial sex activity),
before expanding to the Brong Ahafo, the West-
ern and the Central Regions (Fig. 5). The
Northern, the Upper East and the Upper West
Regions (Table 2) have lower infection rates due
to much greater distance from the initial source
region and perhaps, the restraining influence of
certain practices in Islam.
Islamic Cultural Practices and
HIV/AIDS
Previous research suggests that Muslim Africa
has generally lower HIV/AIDS rates than the
rest of Africa although under reporting may be
a problem (Gould 1993; Caldwell 1995). Studies
in Senegal and Cte dIvoire show that even
where Muslims and non-Muslims live side by
side, Muslims usually have less than half the rate
of non-Muslims. Islamic cultural practices may
restrict HIV spread in two main waysstrict
sanctions against promiscuity and promotion of
circumcision (Caldwell 1995). Polygamy is the
norm in Islam, but promiscuity is taboo and
stringently punished to promote stable poly-
partner fidelity. Paradoxically, while polypartner
sexual activity is the norm, participants may not
be as vulnerable as those involved in commercial
sex work or a long series of monogamous sexual
liaisons.
Besides fidelity, another explanation for the
low rates of HIV in Islamic areas may be the
widespread practice of male circumcision, a
practice that is almost completely absent among
the ethnic groups of Africas main AIDS belt
(Caldwell and Caldwell 1993). Lack of circum-
cision either directly facilitates HIV transmis-
sion or facilitates it by rendering chancroid
genital ulcerative diseases more likely. Caldwell
(1995) attributes Southern Sudans considerably
higher seroprevalence rates to the absence of
circumcision among the predominantly non-
Muslim population. Thus, these practices of Is-
lam, circumcision and fidelity, can limit the
spread of HIV/AIDS and probably explain the

Table 2 Urbanization, Islam, Polygamy and Reported AIDS Rate.

Region % Urban % Islamic % Polygamous Cumulative
Population Household Females(3) Reported AIDS
(1) heads(2) Rate per 1000(4)

Ashanti 32.5 15.3 23.0 2.49

Brong Ahafo 26.6 12.3 29.0 1.11
Central 28.8 5.1 26.9 1.03
Eastern 27.7 4.5 17.9 2.16
Greater Accra 83.0 12.5 18.8 1.52
Northern 25.2 32.7 44.1 0.05
Upper East 12.9 3.7 32.2 0.28
Upper West 10.9 4.8 35.3 0.34
Volta 20.0 1.7 31.8 0.48
Western 22.6 7.6 24.8 1.10
Ghana 32.0 14.4 27.7 1.29
Source: 1. Ghana Statistical Service. Ghana in Figures - 1992.
2. Ghana Statistical Service, 1995. Ghana Living Standards Survey 19911992.
3. GDHS 1993.
4. Ghana AIDS Control Program, cumulative AIDS Cases 19861995, computations by author.
 Geography of HIV/AIDS in Ghana, 19861995 445

Upper East

Upper West Rate per 100,000

5 to 35

Northern
35 to 104

104 to 152

Volta
Brong Ahafo
152 to 249

Ashanti

Eastern

Greater
Western Accra
Central

Miles

0 50 100

Figure 5: Cumulative incidence of reported AIDS cases 19861995.

low prevalence rate in the Northern Region
where 33% of household heads profess Islam
(Table 2).
In contrast, while formal polygamy is rela-
tively low in the Eastern Region, serial polyg-
amy, a series of marriages and divorces to get a
new partner in a monogamous relationship, is
widespread. When a spouse, due to economic
reasons, migrates and is absent for a long time,
the remaining spouse gets into a new monoga-
mous, sometimes temporary, sexual relation-
ship. Thus, an infected individual, particularly
a recent emigrant, may go from one partner
to another spreading the disease. In other
words, those involved in stable polygamous
sexual relationships may not be as vulnerable
as others involved in unstable monogamous
sexual liaisons.
446 Volume 50, Number 4, November 1998
Discussion: Vulnerability Theory and
HIV/AIDS in Ghana
Ghanas recent political and economic history
and resulting vulnerability of different social
groups may provide explanations for the unusual
HIV/AIDS patterns. At independence in 1957,
Ghana had a very promising future and a solid
economy based on cocoa, timber, gold, and
other minerals. Before 1960, due to her eco-
nomic strength, Ghana received more migrants
from the West African subregion than any other
West African country (Stock 1995). Most mi-
grants came to work on cocoa farms. The steady
decline of the economy after 1960, associated
with multiple military coups and attendant po-
litical instability reduced the attractiveness of
Ghana to migrants. In the early 1970s, the deep-
ening economic crisis led to increasing numbers
of Ghanaians leaving for other countries, most
notably Nigeria with its oil boom, and Cte
dIvoire, which had a stable and steadily improv-
ing economy. Around 1983, when the economic
crisis culminated in widespread food shortages
and adoption of structural adjustment, many
young Ghanaians left the country in search of
better livelihoods in neighboring countries,
Europe, and North America. Risky sexual be-
havior, including commercial sex work, became
increasingly viable among these economic refu-
gees, frequently for economic survival. Due to
its proximity and historical migration ties, Cte
dIvoire, which has the highest HIV/AIDS
prevalence rate in West Africa, was a particularly
attractive destination for migrants from the
Eastern and Ashanti Regions.
Ghanas recent economic crisis may be, thus,
intricately linked to the current HIV/AIDS cri-
sis. The Health Studies Branch (1996b) observes
that unusually high HIV prevalence rates in
Ghanas rural areas are explained by sex worker
migrations. At the plenary session of the Van-
couver AIDS Conference, Decosas (1996) dis-
cussed the HIV/AIDS statistics of Ghana and
concluded that the high rural rates, particularly
in the Eastern Region, were attributable to com-
mercial sex workers forced by economic neces-
sity to migrate to neighboring countries
particularly, Cte dIvoire. A 1993 study con-
ducted by the Health Research Unit of the
Ghana Ministry of Health (Adjei et al. 1993),
found that unemployment, poverty and idleness
were high predisposing factors to HIV/AIDS
infection. To survive, the study concluded, un-
employed female youth resorted to promiscuity
in Ghana, and commercial sex work mostly in
Cte dIvoire. Consequently, international
prostitution, particularly in the Ivory Coast, was
identified as a major causal factor of HIV/AIDS.
Citing examples of former sex workers in Abid-
jan who were dying or had died of HIV/AIDS,
most respondents concluded that migrant pros-
titutes and their sex partners are those who get
HIV/AIDS (Adjei et al. 1993). In short, high
rates in rural regions seem directly related to the
activities of vulnerable social groupsfemale
commercial sex workers.
The same phenomenon may explain the rela-
tively low AIDS rate in the Greater Accra Re-
gion of Ghana. It should be emphasized that this
low rate is not due to data inaccuracies or poor
reporting. Unlike other regions, the Greater
Accra Region has better access to modern health
facilities including sexually transmitted disease
clinics, and HIV/AIDS screening facilities are
more readily accessible. Increased screening
and greater access to testing facilities should
produce increased detection of HIV/AIDS
cases. Nevertheless, the number of cases re-
ported in this region continues to be low com-
pared with other regions. Moreover, the
Greater Accra Region was not the initial core
of HIV/AIDS prevalence in Ghana. How,
then, is this difference interpreted?
Greater Accra Region has many more hospi-
tals and medical personnel than any other re-
gion. Improved access to biomedical health care
services provides early and effective treatment
of sexually transmitted diseases, particularly
genital ulcerating diseases, which are known to
facilitate the spread of HIV (Caldwell 1995). It
also means relatively safe health care. Besides,
better economic opportunitiesgovernment
jobs, private industry and commercemake
fewer Greater Accra residents vulnerable
enough to join the exodus to neighboring coun-
tries in search of economic survival. In effect,
residents of Greater Accra are not as vulnerable
as residents of less economically strong and
medically underserved rural regions.
Endemicity of malaria makes lack of access to
modern health care facilities a particularly wor-
risome problem. Monekosso, WHO Regional
Director for Africa, estimates that each person
less than 15 years of age experiences four to nine
clinical attacks per year while older people expe-
rience about half that number (Monekosso
 Geography of HIV/AIDS in Ghana, 19861995
1993). In rural areas, many of these malaria
victims usually patronize inexpensive itinerant
drug vendors (IDVs) who bring their services
right to their doorsteps, instead of traveling to
more costly, urban-based facilities. Since many
of these IDVs do not sterilize the injection nee-
dles they use between patients, the potential for
HIV spread is high. Again, the risk of HIV
infection reflects the differential vulnerability of
social groups. Those who are unable to afford
the urban-based, biomedical facilities, but are
compelled to rely on IDVs, face a higher risk.
The high rate in Ashanti Region may be at-
tributed to commercial sexual activity and
greater mobility of the population, particularly
in leading cities such as Kumasi and Obuasi.
Agadzi (1989) identifies returning migrants to
American and European cities or other African
countries, many of who have multiple sexual
partners, as a contributory factor. Besides,
Ashanti Region has 23% polygamy among fe-
males (Table 2), and serial polygamy is common.
Moreover, a large portion of the region is made
up of rural farming villages. Due to the dearth
of modern biomedical health facilities in rural
villages, genital ulcerative diseases may not be
treated quickly. Many people also patronize
IDVs.
In summary, Ghanas difficult economic crises
created a substantial exodus of economic refu-
gees who migrated temporarily into high
HIV/AIDS prevalence regions and indulged in
high risk activities. The high HIV/AIDS rates
in rural, not urban, regions reflect dissemination
through relocation diffusionreturn migration
of people who left Ghana in the late 1970s and
early 1980s due to difficult economic circum-
stances, got infected, and subsequent contagious
diffusion. The high rate among females is due to
higher vulnerability among females, particu-
larly those involved in commercial sex work.
Heterosexual activity has spread the virus
throughout the country primarily through poly-
partner sexual activity and possibly the activities
of IDVs. Circumcision and fidelity limit vulner-
ability to HIV/AIDS and probably explain the
low rates observed in the Northern region, an
area with a high concentration of Muslims
(Tastemain and Coles 1993). Poor rural access
to biomedical health facilities makes rural resi-
dents vulnerable to HIV since it exposes them
to risky health practices by unscrupulous health
providers.
447
Conclusion
The evidence presented here suggests that pat-
terns of diffusion of HIV probably reflect the
spatial distribution and social networks of vul-
nerable social groups. Understanding the subtle
differences in HIV/AIDS patterns between re-
gions, perhaps through identification of vulner-
able social groups in spatial settings, is critical
for the formulation and implementation of ef-
fective HIV/AIDS intervention policies and
strategies. While information-based campaigns
are still necessary in the fight against
HIV/AIDS, it is time to supplement them with
intervention programs aimed at enablement and
empowerment of vulnerable people. For poor
women forced by hardship into commercial sex
work and rural residents forced to rely on dan-
gerous health providers, behavior change does
not come simply through education and dis-
semination of information. It comes through
empowermentproviding opportunities to en-
able the poor secure respectable livelihoods, and
safe health services for those beyond the reach
of costly, urban-based health care. Unfortu-
nately, disseminating information about
HIV/AIDS is much easier to accomplish than
empowering those who are vulnerable to this
disease.
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JOSEPH OPPONG is an Associate Professor of
Geography at the University of North Texas, Den-
ton, TX 76203. Email: oppong@unt.edu. His re-
search focuses on the geography of disease and
health services in sub-Saharan Africa and Texas.