Co-Developing a Women-Centered HIV Prevention Intervention to Reduce Stigma, Increase HIV Self-Testing, and Improve Pre-Exposure Prophylaxis (PrEP) Uptake in Ghana (WISE WOMAN): A Study Protocol

This study protocol outlines a pilot implementation of a co-developed, WhatsApp-based intervention designed to reduce stigma and increase HIV self-testing and PrEP uptake among young women in Ghana by leveraging community-based participatory research and human-centered design approaches.

The Gist

🌍 The Big Picture: A Gap in the Road

Imagine the fight against HIV in Ghana is like a massive highway. The government has built excellent exits and rest stops (new tools like HIV Self-Testing kits and PrEP medication) to help young women stay safe.

However, there's a problem: Too many young women (ages 18–35) are stuck in traffic. They aren't using these life-saving tools. Why?

• Fear of Judgment: It's like being afraid to walk into a pharmacy because everyone might stare and whisper.
• Confusion: They don't know how the tools work or where to find them.
• Power Dynamics: Sometimes, they can't make health decisions without their partners' permission.

The WISE WOMAN study is a new plan to build a private, friendly shuttle bus to get these women from "stuck in traffic" to "safe and healthy."

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🚌 The Solution: The "WhatsApp Shuttle"

Instead of forcing women to go to a crowded clinic, this study uses WhatsApp, an app almost everyone in Ghana already has on their phone.

Think of the intervention as a 4-week digital support group that lives inside a private WhatsApp chat. It's not just a teacher lecturing from a podium; it's a group of friends chatting, sharing memes, and learning together.

How the Shuttle Works (The 4-Week Journey)

The trip is broken down into four stops, each with a specific goal:

1. Week 1: The "Welcome Aboard" (Foundations)
   • The Vibe: "Hey, let's talk about HIV without the scary stuff."
   • The Activity: Short videos and fun polls. They ask questions like, "What comes to mind when you hear 'self-testing'?" to break the ice and clear up myths.
2. Week 2: The "Real Talk" (Stigma & Relationships)
   • The Vibe: "Let's be honest about the hard stuff."
   • The Activity: Discussing the fear of being judged by partners or neighbors. They practice how to have safe conversations about testing without getting into a fight.
3. Week 3: The "Driver's Ed" (Skills & Action)
   • The Vibe: "Okay, let's actually do it."
   • The Activity: Showing exactly how to use a self-test kit (like a video tutorial) and helping them figure out how to get PrEP medication. They might even practice asking a pharmacist a question.
4. Week 4: The "Graduation" (Empowerment)
   • The Vibe: "You've got this!"
   • The Activity: Celebrating their new knowledge and making a personal plan to stay safe in the future.

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🛠️ How They Built the Bus: "Co-Design"

This is the most important part. The researchers didn't just sit in an office and guess what women needed. They used a method called Co-Design.

• The Analogy: Imagine a chef trying to cook a meal for a group of people. Instead of guessing what they like, the chef invites the guests into the kitchen to taste the ingredients and say, "Add more spice," or "I don't like that texture."
• In the Study: Before building the WhatsApp group, the researchers held workshops with young Ghanaian women. The women said, "We need privacy," "We need to talk about our relationships," and "We want to use our phones." The researchers then built the program exactly based on those requests.

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📝 What Are They Measuring? (The Report Card)

Since this is a pilot study (a "test run"), they aren't trying to prove the bus saves lives yet. They are checking if the bus works at all.

They are looking for three things:

1. Feasibility (Does the engine start?): Can women actually log in, watch the videos, and stay in the group for 4 weeks?
2. Acceptability (Do they like the ride?): Do the women feel comfortable? Is the tone right? Do they feel safe?
3. Appropriateness (Is it the right vehicle?): Does this actually fit their culture and daily lives?

They will also check if the women learned more about HIV, felt less scared of stigma, and were more willing to try self-testing or PrEP after the 4 weeks.

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🛡️ Safety First: The "Privacy Helmet"

Because talking about sex and HIV can be dangerous if secrets get out, safety is the top priority.

• The "Secret Club" Rule: The WhatsApp group is closed. No screenshots allowed. Participants can use nicknames.
• The "Safe Word" System: If a woman feels unsafe or scared, she can message a facilitator privately. The team has a plan to help her immediately.
• Data Protection: All names are removed from the data. It's like turning a real person into a character in a story so no one can trace it back to them.

🏁 The Goal

The WISE WOMAN study is like a prototype. If this 4-week WhatsApp test run is successful, the researchers will have proof that this "digital shuttle" works.

The ultimate dream? To turn this pilot into a nationwide program where thousands of young women in Ghana can hop on their phones, get the info they need, and take control of their health—all from the privacy of their own homes.

Technical Summary

Based on the provided study protocol, here is a detailed technical summary of the WISE WOMAN study.

1. Problem Statement

• Epidemiological Context: Adolescent girls and young women (AGYW) in Sub-Saharan Africa, particularly in Ghana, are disproportionately affected by HIV. In Ghana, women and girls account for 68.5% of people living with HIV and 67.4% of new infections.
• The Implementation Gap: Despite the availability of effective biomedical prevention tools—specifically HIV Self-Testing (HIVST) and Pre-Exposure Prophylaxis (PrEP)—uptake among young Ghanaian women remains critically low.
  • Only 18.2% of women aged 15–24 have heard of HIVST, and merely 2.4% have ever self-tested.
  • PrEP awareness and uptake are similarly low, despite evidence that women are more likely to use it when available.
• Root Causes: Low uptake is driven by intersecting structural and social barriers, including:
  • Stigma: Deeply entrenched HIV-related and sexual stigma.
  • Gender Dynamics: Unequal power relations in relationships and economic dependency.
  • Service Access: Lack of culturally relevant, youth-responsive, and women-centered prevention services.
  • Policy-Practice Disconnect: While Ghana has national guidelines and pilot programs for HIVST and PrEP, these have not translated into widespread behavioral change.

2. Methodology

The study employs a mixed-methods pilot implementation design grounded in Community-Based Participatory Research (CBPR) and Human-Centered Design (HCD).

• Study Design: A four-week, single-arm pilot intervention delivered via WhatsApp.
• Participants:
  • Target Sample: 50 young women aged 18–35.
  • Location: Greater Accra and Eastern Regions of Ghana.
  • Inclusion Criteria: Smartphone ownership with WhatsApp access, ability to provide verbal consent, and comfort discussing sexual/reproductive health.
  • Recruitment: Approximately 100 individuals will be screened to achieve the target sample (2:1 screening-to-enrollment ratio).
• Intervention Architecture:
  • Platform: A closed, moderated WhatsApp group.
  • Content: Co-designed with young women to ensure cultural relevance. It includes three integrated components:
    1. Structured Content Delivery: Three multimedia modules per week (videos, audio, visuals) covering HIVST, PrEP, stigma, and relationship dynamics.
    2. Interactive Engagement: Guided discussions, polls, and reflection prompts to foster peer-to-peer interaction.
    3. Behavioral Tasks: Voluntary weekly activities (e.g., identifying testing locations, practicing conversations, optional self-testing) to translate knowledge into action.
  • Timeline: Recruitment (May 2026) → Intervention (August 2026) → Post-interviews (October 2026).
• Data Collection:
  • Quantitative: Baseline and post-intervention surveys via REDCap. Measures include:
    • Implementation outcomes: Acceptability, Feasibility, and Appropriateness (using AIM, FIM, and IAM scales).
    • Behavioral/Psychosocial outcomes: HIV prevention knowledge, stigma levels, HIVST uptake (self-reported/verified), and PrEP willingness.
    • Engagement metrics: Completion rates and interaction levels.
  • Qualitative: Semi-structured exit interviews (voice call or in-person) with a purposive subsample (15–20 participants) to explore user experience, barriers, and facilitators.
• Analysis Plan:
  • Quantitative: Descriptive statistics and paired comparisons (pre/post) using R.
  • Qualitative: Thematic analysis (Braun & Clarke) mapped onto Proctor's implementation outcomes framework.
  • Triangulation: Integrating quantitative metrics with qualitative insights to refine the intervention.

3. Key Contributions

• Participatory Co-Creation: Unlike top-down interventions, this study utilizes CBPR and HCD to co-create the intervention with the target demographic, ensuring the content addresses specific lived experiences regarding stigma and power dynamics.
• Digital Delivery Model: It validates a scalable, low-cost delivery mechanism (WhatsApp) that leverages high mobile penetration in Ghana to provide privacy and reduce the stigma associated with visiting physical clinics.
• Implementation Science Focus: The study prioritizes implementation outcomes (feasibility, acceptability, appropriateness) over clinical efficacy, providing the necessary evidence base to justify a future fully powered effectiveness trial.
• Addressing the Policy-Practice Gap: It offers a concrete strategy to operationalize existing national HIVST and PrEP guidelines into actionable, user-friendly digital tools.

4. Results

• Status: This is a study protocol; the research has not yet commenced data collection (as of the manuscript submission date). Therefore, no empirical results or efficacy data are available.
• Expected Outcomes (Hypothesized):
  • High scores on AIM, FIM, and IAM scales (≥4.0/5).
  • ≥80% intervention completion rate.
  • Measurable improvements in HIV prevention knowledge and reduced internalized/anticipated stigma.
  • Increased willingness to use PrEP and uptake of HIVST during the pilot period.
  • Identification of specific themes regarding digital privacy, peer support, and content relevance.

5. Significance

• Public Health Impact: If successful, the WISE WOMAN study will generate critical evidence to bridge the gap between HIV prevention policy and practice for AGYW in Ghana and similar low-resource settings.
• Scalability: The WhatsApp-based model is highly scalable and adaptable, offering a blueprint for delivering sensitive health information in contexts where traditional clinic-based approaches fail due to stigma or access barriers.
• Future Research: The pilot data will inform the sample size calculations and design of a larger, fully powered randomized controlled trial (RCT) to test the intervention's effectiveness in reducing HIV incidence.
• Methodological Rigor: By combining participatory design with rigorous implementation science frameworks, the study sets a standard for developing culturally grounded digital health interventions in Sub-Saharan Africa.

Ethical Note: The study has received approval from the University at Buffalo IRB and the Ensign Global College Ethics Committee (Ghana). It emphasizes strict confidentiality, using de-identified data and secure digital consent procedures to protect participants given the sensitive nature of HIV and sexual health data.