Background

Human Immunodeficiency Virus (HIV) remains a significant global health issue, with approximately 40 million people living with the virus and an estimated 630,000 deaths reported globally [1]. Sub-Saharan Africa (SSA) continues to bear the brunt of the epidemic, accounting for 65% of global Acquired Immune Deficiency Syndrome (AIDS)-related deaths [1]. In SSA, adolescent girls and young women aged 15–24 years are disproportionately affected, facing infection rates up to eight times higher than their male counterparts [1]. Globally, women account for nearly half of all HIV cases (around 21 million) [2]. Recent estimates show that the African region remains the most severely affected, with one in every thirty adults living with HIV and accounting for more than two-thirds of all persons living with HIV worldwide [2].

Despite significant progress in HIV prevention and treatment, the epidemic in SSA persists, driven by structural inequities, stigma, and unequal access to healthcare [3]. The UNAIDS 95-95-95 targets aim to end the AIDS epidemic as a public health threat by 2030, yet progress remains uneven, particularly in resource-limited settings [4]. While some sub-Saharan African countries, including Ghana, have achieved reductions in new HIV infections and AIDS-related deaths, many remain off track to meet global goals due to ongoing social and health system barriers [5,6].

Women’s increased vulnerability to HIV is influenced by a combination of biological, behavioural, and structural factors, including limited access to sexual health services, socioeconomic inequality, and cultural norms [7]. Biological factors such as mucosal susceptibility increase their risk, while social challenges like gender-based violence and economic dependence further exacerbate their exposure [7]. These factors also worsen women’s vulnerability to HIV-related complications, including the risk of mother-to-child transmission during pregnancy, childbirth, and breastfeeding [8]. Additionally, women face a higher likelihood of gynaecological complications such as cervical disorders linked to HPV infection [9] and pelvic inflammatory diseases, including chlamydia and gonorrhoea, which can damage the fallopian tubes [10].

In Ghana, HIV remains a significant public health concern despite relatively low national prevalence compared to other sub-Saharan African countries [11]. However, key populations such as female sex workers (FSWs), men who have sex with men (MSM), and transgender individuals continue to be disproportionately affected, accounting for 28% of all new HIV cases [12]. To address these challenges, the government has implemented a comprehensive national response in collaboration with the President’s Emergency Plan for AIDS Relief (PEPFAR) to provide technical support, ensure a consistent supply of antiretroviral drugs, and deliver targeted prevention services for high-risk groups [12].

Over the years, various HIV prevention strategies have been implemented with varying degrees of success. These strategies include HIV testing, counselling, and educational programmes aimed at raising awareness, encouraging safe practices, and lowering the risk of transmission [13]. Among the most promising and relatively new biomedical interventions is pre-exposure prophylaxis (PrEP), which involves HIV-negative individuals using antiretroviral medications to prevent HIV infection [14]. Several clinical trials have shown the effectiveness of daily tenofovir/emtricitabine as an oral PrEP regimen, leading to its approval by the Food and Drug Administration and endorsement by the Centre for Disease Control and Prevention and the World Health Organization (WHO) for individuals at high risk of contracting HIV [14,15]. Consistent use of PrEP reduces the risk of HIV transmission by more than 90% [16]. Maximising the benefits of PrEP depends on adherence, highlighting the importance of understanding and supporting factors that promote consistent use [14].

Despite its proven efficacy, awareness of PrEP and negative attitudes towards it remain significant barriers to its adoption and acceptance, especially among women in resource-limited settings, such as Ghana, who are particularly vulnerable to HIV [3]. PrEP implementation encounters challenges such as stigma, adherence difficulties, and integration with existing healthcare services, as well as economic and personal factors, including affordability, awareness, perceived HIV risk, and willingness to use it [17,18]. Contextual factors, such as the quality of healthcare infrastructure, healthcare providers’ knowledge and attitudes, cultural beliefs, and policy support, also significantly influence PrEP uptake and accessibility. These issues are further worsened by community stigma against PrEP users and logistical obstacles [19,20].

Evidence from SSA indicates that awareness of and positive attitudes toward PrEP among women remain comparatively low. For instance, a multilevel analysis across five countries revealed that only 5.61% of women in Tanzania, 6.43% in Burkina Faso, and 9.56% in Côte d’Ivoire were aware of PrEP and held positive attitudes toward it, though the proportion was higher in Kenya (34.29%) [21]. Likewise, a population-based study in Malawi showed that, although some individuals were aware of PrEP, overall awareness and willingness to use it were limited among sexually active adults [22]. In Ghana, recent studies suggest that, despite relatively high awareness and acceptability of PrEP among key populations (such as MSM and FSWs), actual uptake remains low [23–26]. Among FSWs, only 53.59% expressed willingness to use PrEP, and just 6.39% had ever used it [23]. For MSM living in slum communities, barriers such as limited access to healthcare services and distance to facilities hinder uptake [26]. Evidence from Ghana further indicates a gap between awareness, willingness, and actual uptake of PrEP among MSM [27]. Even when awareness exists, misinformation and fear of side effects remain widespread [28].

Although previous studies have focused on MSM, transgender individuals, and FSWs [23–28], little is known about awareness of and positive attitudes toward PrEP among women of reproductive age in Ghana. This study aims to address this gap by utilising nationally representative data from the 2022 Ghana Demographic and Health Survey (GDHS) to explore the socio-demographic and structural factors associated with awareness of and positive attitudes toward PrEP among women of reproductive age in Ghana.

Methods

Results

Background characteristics of the respondents

A total of 13,980 women aged 15–49 years were included in the analysis. Table 1 presents the background characteristics of the respondents. Nearly one-fifth of the women in the study were aged 20–24 (18.1%), with over half having secondary education (62.0%). Regarding marital status, around 40% were married (38.9%). The majority identified as Christians (78.6%) and were employed (74.8%). In terms of media exposure, most women were exposed to television (63.6%), and nearly half listened to the radio (43.6%). Most of the women (76.3%) reported having no additional partners besides their spouse, while 78.2% had heard of other STIs, and more than half (52.4%) visited a health facility in the past 12 months. Wealth was evenly distributed, with nearly a quarter of the women falling within the richer and richest groups, at 23.4% and 23.4%, respectively. More than half of the women lived in urban areas (58.7%), and about one-fifth of respondents were from the Ashanti region (20.2%) (Table 1).

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Table 1. Background characteristics of the respondents.

https://doi.org/10.1371/journal.pone.0347111.t001

Awareness of and positive attitudes toward PrEP among women in Ghana

Table 2 and Fig 1 present the results on awareness of and positive attitudes toward PrEP across the background characteristics of the respondents. The overall proportion of women who were aware of and held positive attitudes toward PrEP was 12.1%. Awareness of and positive attitudes toward PrEP were highest among women aged 25–29 (15.8%) and lowest among those aged 15–19 (7.3%). Women with higher levels of education showed greater awareness of and positive attitudes toward PrEP (23.0%). Married women showed higher levels of awareness of and positive attitudes toward PrEP (13.9%). Media exposure also contributed; women who listened to the radio (13.5%) or used the internet (13.8%) showed greater awareness of and positive attitudes toward PrEP. Women living in urban areas had higher awareness of and positive attitudes toward PrEP (12.9%). Awareness of and positive attitudes toward PrEP were also higher among women who had heard about other STIs (13.3%) and those who visited a health facility in the last 12 months (14.0%). Regarding wealth, women in the richer (13.1%) and richest (13.4%) quintiles had higher awareness of and positive attitudes toward PrEP. Regional disparities were evident, with women from the Ahafo (21.1%), Volta (18.8%), and Northern (18.8%) regions having the highest levels of awareness of and positive attitudes toward PrEP.

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Table 2. Distribution of awareness of and positive attitudes toward PrEP across exposure variables.

https://doi.org/10.1371/journal.pone.0347111.t002

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Fig 1. Prevalence of awareness of and positive attitudes towards PrEP by region, Ghana, 2022.

Source: Author-generated, 2025.

https://doi.org/10.1371/journal.pone.0347111.g001

Factors associated with awareness of and positive attitudes toward PrEP among women in Ghana

Table 3 shows the factors associated with awareness of and positive attitudes toward PrEP among women in Ghana. In Model IV, age was a significant factor, with women aged 25–29 (aOR = 1.75, 95% CI: 1.28–2.39), 30–34 (aOR = 1.61, 95% CI: 1.14–2.27), 35–39 (aOR = 1.69, 95% CI: 1.22–2.32), and 40–44 (aOR = 1.48, 95% CI: 1.03–2.12) having higher odds of awareness of and positive attitudes toward PrEP than those aged 15–19. Women with higher educational levels had higher odds of awareness of and positive attitudes toward PrEP (aOR = 3.27, 95% CI: 2.35–4.55) than those with no education. Women who listened to the radio also had higher odds of being aware of and having positive attitudes toward PrEP (aOR = 1.20, 95% CI: 1.01–1.43). Having two or more partners was associated with lower odds (aOR = 0.51, 95% CI: 0.28–0.96) of having awareness of and positive attitudes toward PrEP than those with no partners. Women who had heard about other STIs had higher odds of awareness of and positive attitudes toward PrEP (aOR = 1.79, 95% CI: 1.40–2.28). Regional variations were also observed, with women from Central (aOR = 3.28, 95% CI: 1.76–6.12), Volta (aOR = 3.28, 95% CI: 1.63–6.62), Western North (aOR = 2.59, 95% CI: 1.26–5.29), Ahafo (aOR = 5.02, 95% CI: 2.54–9.91), Bono (aOR = 2.87, 95% CI: 1.37–6.02), Bono East (aOR = 2.87, 95% CI: 1.56–5.26), Oti (aOR = 5.64, 95% CI: 3.06–10.39), Northern (aOR = 2.47, 95% CI: 1.10–5.51), Upper East (aOR = 4.17, 95% CI: 2.05–8.50), and Upper West (aOR = 3.62, 95% CI: 1.85–7.08) regions having significantly higher odds of awareness of and positive attitudes toward PrEP than those in the Western region.

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Table 3. Factors associated with awareness of and positive attitudes toward PrEP among women in Ghana.

https://doi.org/10.1371/journal.pone.0347111.t003

Discussion

This study examined awareness of and positive attitudes toward PrEP for HIV prevention among women of reproductive age in Ghana. Only 12.1% of women were aware of and held positive attitudes toward PrEP, indicating low overall awareness and positive attitudes. This is consistent with earlier research among sexually active adults in Ghana [31]. However, the percentage reported in this study is higher than in Tanzania (5.61%), Burkina Faso (6.43%), and Côte d’Ivoire (9.56%), but lower than in Kenya (34.29%) [21,32]. These differences may be due to country-specific variations in PrEP awareness campaigns and their implementation. Kenya, a leader in the national rollout of PrEP since 2017, has focused its efforts on high-risk groups such as MSM, sex workers, and adolescent girls [33].

In Ghana, low awareness of and negative attitudes toward PrEP are concerning, particularly with increasing HIV infections [34]. Although PrEP acceptability has been reported as relatively high among MSM and healthcare providers in Ghana, actual use remains limited in both the general and key populations. Barriers include stigma, cost, and misinformation [20,35,36]. Our study identified several factors associated with awareness of and positive attitudes toward PrEP, including women’s age, educational level, radio exposure, number of sexual partners, knowledge of other STIs, and region of residence.

Older women had higher odds of being aware of and holding positive attitudes toward PrEP than adolescents, consistent with findings by Terefe et al. [21] across five sub-Saharan countries. Older women are more likely to attend antenatal clinics where HIV education is provided, increasing their exposure to prevention methods like PrEP [37]. Conversely, adolescent girls face numerous social and structural barriers, such as stigma surrounding adolescent sexuality and disapproving attitudes from healthcare providers. In Ghana, conversations about sex are often taboo, and young girls seeking information or services for HIV prevention may be perceived as promiscuous [38–40]. Given the high vulnerability of adolescent girls and young women to HIV [41], interventions should prioritise them through targeted education and the integration of comprehensive sexuality education into programmes like the School Health Education Programme (SHEP), to empower young girls with the knowledge and confidence needed to protect themselves.

Women with secondary or higher education had higher odds of being aware of and having positive attitudes toward PrEP. This finding aligns with previous studies [21,42]. Bailey et al. reported no significant association between education and PrEP knowledge among nurses in South Africa [43]. Higher education improves women’s access to healthcare and health information, including comprehensive knowledge of HIV/AIDS [21,36,44,45], potentially influenced by internet access, community groups, and health promotion initiatives. However, these mixed results may stem from differences in study populations and contexts. In the general population, higher educational levels often lead to better access to health information and more proactive health-seeking behaviour [21,44,46], whereas among healthcare professionals such as nurses, standardised clinical training and workplace exposure may be more influential. These contrasting findings highlight the need for context-specific strategies to enhance PrEP awareness and foster positive attitudes toward its use.

Radio exposure was also positively associated with awareness of and positive attitudes toward PrEP, supporting findings by Terefe et al. [21]. Asamoah et al. [47] further reported that exposure to mass media enhances HIV knowledge and lessens stigmatising attitudes in Ghana. Radio remains one of the most accessible media in Ghana, particularly in rural areas, with content often delivered in local languages [48,49]. It plays a crucial role in spreading health information, including HIV prevention education [49]. However, challenges persist, such as language barriers and limited access to modern communication tools [48]. By using culturally sensitive and empowering messaging, radio can demystify PrEP and dispel misconceptions. Nonetheless, caution is necessary to ensure these campaigns do not unintentionally reinforce harmful gender norms or stigmatise already marginalised women. This underscores the importance of collaboration between public health actors and media professionals [50].

Women who had heard about other STIs had higher odds of awareness of and positive attitudes toward PrEP. This agrees with existing literature showing that prior exposure to STI-related information increases PrEP awareness and acceptance [21]. Such information often comes from health campaigns or media, indicating that wider sexual health messaging can positively influence PrEP-related outcomes.

Women with two or more sexual partners had lower odds of PrEP awareness and positive attitudes toward it, despite being at higher risk for HIV [51]. This aligns with findings from Malawi by Kabaghe et al. [22]. While it might be expected that high-risk individuals would be more informed, this counterintuitive result may reflect the stigma, fear, and social judgment surrounding PrEP use. Studies show that women worry about being perceived as promiscuous or HIV-positive if they take PrEP [52], and they may anticipate disapproval from partners, family, or healthcare providers [53]. Furthermore, healthcare systems may not effectively reach women with complex sexual networks due to insufficiently tailored outreach. These findings emphasise the need for inclusive, stigma-free sexual health education that provides high-risk women with accurate and nonjudgmental information about PrEP.

We also found notable regional disparities in awareness of and positive attitudes toward PrEP. Women in the Ahafo, Oti, and Upper East regions had significantly higher odds of being aware of and holding positive attitudes toward PrEP than those in the Western region. This reflects earlier findings by Apreku et al. [27] on regional differences in PrEP awareness among Ghanaian MSM. Bono (formerly part of Brong Ahafo), Oti (formerly part of Volta), and Upper East regions have also been recognised for having fewer barriers to healthcare access [54]. Variations in healthcare infrastructure, cultural norms, geographical access, and socioeconomic factors may account for these disparities. Furthermore, the presence of active Non-governmental Organizations (NGOs) and local campaigns could also play a role. For example, MIHOSO International Foundation and partners have conducted HIV prevention campaigns in Ahafo [55]. These findings imply that strengthening health systems, investing in region-specific community outreach, and collaborating with local NGOs could enhance PrEP outcomes across the country.

Conclusions

Approximately 1 in 10 women aged 15–49 years in Ghana were aware of PrEP and had positive attitudes toward it. Factors such as women's age, educational level, number of sexual partners, listening to the radio, prior awareness of other STIs, and geographical region are significantly associated with women’s awareness of and positive attitudes toward PrEP. This reveals a gap in awareness of and positive attitudes toward PrEP among women in Ghana, highlighting the need for targeted educational campaigns and equitable access to HIV prevention services. Policymakers and healthcare providers should focus on addressing regional disparities and barriers to PrEP awareness and uptake to enhance HIV prevention efforts across the country. In the planning and implementation of HIV and PrEP programmes, it is essential to consider both age and educational level to ensure that interventions are appropriately tailored, accessible, and effective for the targeted populations. Mass media campaigns should be utilised to raise awareness of PrEP. Furthermore, increasing awareness among the general population in Ghana, beyond key populations, is crucial to reducing new infections and meeting the Sustainable Development Goal 3, target 3.3. Future research should examine awareness and approval of PrEP as separate outcomes. Awareness is mainly influenced by exposure to information and access to healthcare, while approval is shaped by risk perception, attitudes, and cultural norms. Distinguishing these factors in future studies will enable more targeted and effective interventions to boost PrEP uptake.