HIV-Related Knowledge among PLWHA Attending a Tertiary Care Hospital at Coastal South India

Abstract

Background:

Adequate knowledge about HIV/AIDS among people living with HIV (PLHIV) is essential for the prevention of HIV transmission.

Methods:

A cross-sectional study consisting of 409 PLHIV aged ≥18 years were interviewed regarding their HIV-related knowledge, from April 2014 to April 2015. HIV-related knowledge was assessed using the HIV knowledge questionnaire 18 . Univariate and multivariate analyses were done to determine the factors associated with high HIV-related knowledge. Odds ratios with its corresponding 95% confidence intervals were reported. A value of P < .05 was considered to be statistically significant.

Results:

Among 409 PLHIV, 46.2% had high HIV-related knowledge. Univariate analysis yields factors like upper socioeconomic status, those who are literates, unemployed, and adherent to antiretroviral therapy (ART) were associated with higher HIV-related knowledge. On multivariate analysis, upper socioeconomic status and adherence to ART were the factors that remained significantly associated with higher HIV-related knowledge.

Conclusion:

HIV-related knowledge among PLHIV can be improved through HIV educational programs.

Keywords

HIV/AIDS PLHIV HIV-related knowledge HIV-KQ-18 South India

Introduction

Despite HIV/AIDS being a major public health problem and both international and national health agencies making information pertaining to HIV prevention available to all, there is still a rise in the number of new HIV cases globally. Also, some people living with HIV (PLHIV) still indulge in high-risk behavior,^1
–3 which is a setback for ongoing preventive programs on HIV/AIDS.

Knowledge regarding HIV and its transmission is essential to reduce the risk of superinfection and also prevention of HIV transmission. Studies have shown that, PLHIV with sound knowledge of HIV had improved adherence to antiretroviral therapy (ART).^4,5

In the recently published National Integrated Biological and Behavioural Surveillance survey findings, it was reported that comprehensive knowledge among the high-risk groups such as female sex workers, men who have sex with men, and injecting drug users were 43%, 46%, and 43%, respectively.⁶

Heterosexual route of HIV transmission is most common in India and this transmission usually occurs from someone who is unaware of their HIV status. If the same person is aware of their serostatus, they are more likely to use protective measures like condoms to reduce the risk of transmission.^7
–9 Increasing awareness and early initiation of ART among PLHIV have shown to reduce the HIV burden.¹⁰ These are essential component of comprehensive preventive strategies of HIV.^11,12

Most of the studies assessing knowledge regarding HIV have been conducted on people who are not infected with HIV; there is a lack of literature focusing on knowledge regarding HIV among PLHIV. Also, as perception and attitude of PLHIV regarding HIV is directly related with the social, cultural, and regional setting of PLHIV, the present study was conducted to assess the level of HIV-related knowledge and factors associated with HIV-related knowledge among PLHIV in coastal South India.

Methodology

In this facility-based cross-sectional study, PLHIV were interviewed to assess their HIV-related knowledge during the period of April 2014 to April 2015 at the Infectious Disease Department of the tertiary care hospitals, in Mangalore, Karnataka.

The protocol of the study was approved by the Institutional Ethics Committee of Kasturba Medical College (Manipal University), Mangalore, India, prior to the commencement of the study.

The sample size of 409 PLHIV was calculated considering the proportion of HIV-related knowledge among PLHIV from a previous study as 80%,¹³ with 95% confidence interval (CI) and a relative precision of 5%.

All PLHIV aged 18 years and above and those receiving ART were included in the study. Study participants were clearly explained about the study objectives in their vernacular language. A written informed consent was obtained from those who were willing to participate in the study.

People living with HIV were interviewed in a separate consultation room to maintain confidentiality. A pretested semi-structured questionnaire was used to collect data regarding PLHIV characteristics (sociodemographic and clinical characteristics). Modified Kuppuswamy scale¹⁴ was used to assess the socioeconomic status of PLHIV.

HIV-related knowledge among PLHIV was assessed using the “HIV Knowledge Questionnaire 18” (HIV-KQ-18).¹⁵ HIV-KQ-18 is a validated self-administered questionnaire, which has been shown to be reliable and internally consistent, used to assess HIV knowledge mainly regarding transmission, diagnosis, and prevention of HIV. It consisted of 18 items and PLHIV responded for each item as “true,” “false,” or “don’t know.” People living with HIV responded as don’t know to an item were considered as false. Each correct answer was scored as 1 and incorrect answer as 0. A single summary score was yielded by summing the number of items correctly answered. The possible HIV knowledge scores ranged from 0 to 18. The responses were dichotomized into high and low HIV-related knowledge by taking a cutoff point as 9. Participants who had scored above 9 were considered as having high HIV-related knowledge and those scored 9 and below were considered as having low HIV-related knowledge among PLHIV.

Data Analysis

Data were analyzed using Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS Inc, Chicago, Illinois). The results were expressed as proportions. Univariate logistic regression was done to assess various factors favoring high HIV-related knowledge. Multivariate logistic regression was done to rule out the effect of potential confounding factors. A value of P < .05 was considered to be statistically significant. Odds ratios and corresponding 95% CIs were also reported.

Results

Out of 409 PLHIV, 46.2% had high HIV-related knowledge. The mean age of the participants was 43 ± 8.7 years, with higher proportion of the participants (42.1%, n = 172) in the age group of 41 to 50 years. Majority (62.6%, n = 256) were male and 64.8% (n = 265) were married. About half of the participants belonged to middle socioeconomic status (49.6%; n = 203). Baseline characteristics of the study participants are shown in Table 1.

Table 1.

Baseline Characteristics of the Study Participants.^a

Characteristics	n (%)
Age, years
18-30	024 (05.9)
31-40	140 (34.2)
41-50	172 (42.1)
>50	073 (17.8)
Gender
Male	256 (62.6)
Female	153 (37.4)
Socioeconomic status
Upper middle	042 (10.3)
Middle/lower middle	203 (49.6)
Lower/upper lower	159 (38.9)
Lower	005 (01.2)
Mode of transmission
Sexual	394 (96.3)
Blood	002 (0.5)
Other	013 (3.2)
Marital status
Married	265 (64.8)
Unmarried	054 (13.2)
Widowed	090 (22.0)
Cohabitation status
Living alone	016 (03.9)
Companion	393 (96.1)
CD4, cells/mm³
<200	028 (06.8)
201-600	244 (59.7)
>601	137 (33.5)
Opportunistic infections
Present	028 (06.8)
Absent	381 (93.2)
Duration of ART, in months
<12	092 (22.5)
13-36	142 (34.7)
>37	175 (42.8)
Adherence to ART
Present	288 (70.4)
Absent	121 (29.6)

Abbreviation: ART, antiretroviral therapy.

^aN = 409.

Factors Influencing HIV-Related Knowledge among PLHIV

On univariate analysis, participants who were literate, those belonging to upper socioeconomic status, who were unemployed, and who were adherent to ART were found to have higher HIV-related knowledge (P < .05). However, on multivariate analysis, higher socioeconomic status (OR = 2.0, 95% CI = 1.3-3.1; P = .002) and adherence to ART (OR = 3.4, 95% CI = 2.1-5.5; P < .001) were found to be independently associated with high HIV-related knowledge (Table 2).

Table 2.

Factors Influencing HIV-Related Knowledge among the Study Participants.^a

Variables	Total (n)	High HIV-Related Knowledge, n (%), 189 (46.2)	Unadjusted OR (95% CI)	P Value	Adjusted OR (95% CI)	P Value
Age group, years
≤40	164	071 (52.6)	0.7 (0.4-1.0)	.069
>40	245	118 (43.1)	1.00
Gender
Male	256	124 (48.4)	0.8 (0.5-1.2)	.243
Female	153	065 (42.5)	1.00
Marital status
Married	265	131 (49.4)	0.7 (0.4-1.0)	.076
Single	144	058 (40.3)	1.00
Socioeconomic status
Upper	245	130 (53.1)	0.5 (0.3-0.7)	<.001^b	2.0 (1.3-3.1)	.002^b
Lower	164	059 (36.0)	1.00
Education
Literate	291	145 (49.8)	1.7 (1.1-2.6)	.021^b	1.4 (0.8-2.2)	.192
Illiterate	118	044 (37.8)	1.00
Adherence to ART
Adherent	288	158 (54.9)	0.3 (0.2-0.4)	<.001^b	3.4 (2.1-5.5)	<.001^b
Nonadherent	121	031 (25.6)	1.00
Duration on ART, months
<1	092	037 (40.2)	1.00
≥1	317	152 (47.9)	1.4 (0.8-2.2)	.190

Abbreviations: ART, antiretroviral therapy; CI, confidence interval; OR, odds ratio.

^aN = 409.

^b P value significance at .05 level.

Discussion

The present study was conducted to assess the level of HIV-related knowledge among PLHIV and to study the various factors influencing it. Only 46.2% of the PLHIV had a high HIV-related knowledge in our study despite the regular counseling regarding HIV given before ART initiation and also during the course of treatment. Also considering majority of the study participants belong to our study district, which has a literacy rate of 83%, higher than the national average of 59.5%, the finding of low-level HIV-related knowledge among PLHIV in coastal South India was surprising.

In our study, 85.3% of the participants incorrectly believed that HIV spreads by sharing a glass of water with HIV-infected person and 82.9% thought that a person can get HIV by sharing a swimming pool or sitting in a hot tub with PLHIV. This shows that there is still a lot of misconception about the mode of HIV transmission and this needs to be improved upon. However, 88% of them knew that HIV will not spread through coughing and sneezing and 91.9% were aware of the facts that having multiple sex partners increased the chance of getting HIV.

People living with HIV belonging to upper socioeconomic status were found to be having a higher knowledge about HIV and this association was found to be statistically significant (P < .05). Similar findings were observed in Malawi,¹⁶ United States,¹⁷ Mozambique,¹⁸ and Kenya.¹⁹ Our findings may be due to the fact that PLHIV from upper strata of society would have better access to healthcare facilities to seek treatment and information regarding their status compared to participants with lower socioeconomic status. Though the availability of ART is free of cost from National AIDS Control Organization and with regular counseling about HIV/AIDS available in our center, indirect costing like loss of daily wages, travelling expenses to reach the health care center, and so on might deter the participants from lower socioeconomic status to avail the ART services.

Literate participants were found to have a higher HIV-related knowledge than participants who are illiterate and this association was found to be statistically significant (P < .05). Studies conducted in Malawi,¹⁶ Kenya,¹⁹ Fiji,²⁰ Ghana,²¹ Guinea-Bissau,²² and Nigeria²³ also had similar associations between literacy and HIV-related knowledge.

Our study also found that participants who were adherent to ART were more likely to have a higher HIV-related knowledge than those who were nonadherent to ART (P < .05). These findings are in congruence with studies conducted in Kenya,¹⁹ Nigeria,²⁴ and South Africa.²⁵ Higher HIV-related knowledge among adherent PLHIV could be due to their frequent contact with healthcare providers and counselors at integrated counseling and testing center at our facility, which might have enabled them to know more about their disease.

When we compare the role of gender in HIV-related knowledge, we found that males tend to have a higher HIV-related knowledge compared to females. Studies conducted in Mumbai, India,²⁶ Malaysia,²⁷ Fiji,²⁰ and rural South India²⁸ also found the similar findings. This could be due to fact that, in our setting males are considered to be the sole breadwinner for the family and females tend to stay at home to take care of the household work. As a result, men are more exposed to knowledge, awareness programs, and are ready to seek information regarding their status. Since females are mostly confined to their houses, their source of information is predominantly from mass media, family members, and friends. Also, in our study males were more literate (64.3%) compared to females (35.7%), which could be another reason for lower HIV-related knowledge among females.

Limitation of our study was we didn’t assess temporality between adherence to ART and HIV-related knowledge. In conclusion, HIV-related knowledge was high among those belonging to higher socioeconomic status and who are adherent to ART. Identifying the factors that influences HIV-related knowledge can guide the policy makers in addressing these factors and incorporating them into HIV awareness and prevention programs. Illiterates and PLHIV from lower strata of the society usually have less awareness regarding HIV and its transmission, along with limited access to treatment which makes them more vulnerable. Our study emphasizes that HIV-related knowledge is a modifiable factor that can reduce further HIV transmission. Hence, HIV educational programs should target PLHIV with lower socioeconomic status, illiterates, and those who are nonadherent to ART as this vulnerable group might become a potent source of infection and would fuel the already overwhelming burden of HIV.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Avants

Warburton

Hawkins

Margolin

. Continuation of high-risk behavior by HIV-positive drug users. Treatment implications. J Subst Abuse Treat. 2000;19(1):15–22.

O’Mahony

Barry

. HIV risk of transmission behaviour amongst HIV-infected prisoners and its correlates. Br J Addict. 1992;87(11):1555–1560.

Wingood

DiClemente

Mikhail

. A randomized controlled trial to reduce HIV transmission risk behaviors and sexually transmitted diseases among women living with HIV: The WiLLOW Program. J Acquir Immune Defic Syndr. 2004;37(suppl 2):58–67.

Pradier

Bentz

Spire

. Efficacy of an educational and counseling intervention on adherence to highly active antiretroviral therapy: French prospective controlled study. HIV Clin Trials. 2003;4(2):121–131.

Goujard

Bernard

Sohier

. Impact of a patient education program on adherence to HIV medication: a randomized clinical trial. J Acquir Immune Defic Syndr. 2003;34(2):191–194.

National AIDS Control Organization. National Integrated Biological and Behavioural Surveillance (IBBS), India 2014-15. New Delhi, India: NACO, Ministry of Health and Family Welfare, Government of India; 2015.

Bunnell

Ekwaru

Solberg

. Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. AIDS. 2006;20(1):85–92.

Bunnell

Opio

Musinguzi

. HIV transmission risk behavior among HIV-infected adults in Uganda: results of a nationally representative survey. AIDS. 2008;22(5):617–624.

Rosenberg

Pettifor

De Bruyn

. HIV testing and counseling leads to immediate consistent condom use among South African stable HIV discordant couples. J Acquir Immune Defic Syndr. 2013;62(2):226–233.

10.

Marks

Crepaz

Janssen

. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS. 2006;20(10):1447–1450.

11.

Cohen

Chen

McCauley

HPTN 052 Study Team. Prevention of HIV1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.

12.

Tanser

Bärnighausen

Grapsa

Zaidi

Newell

. High coverage of ART associated with decline in risk of HIV acquisition in rural KwaZulu-Natal, South Africa. Science. 2013;339(6122):966–971.

13.

Smith Fawzi

Jagannathan

Cabral

. Limitations in knowledge of HIV transmission among HIV-positive patients accessing case management services in a resource-poor setting. AIDS Care. 2006;18(7):764–771.

14.

Dudala

. Updated Kuppuswamy’s socioeconomic scale for 2012. J NTR Univ Health Sci. 2013;2(3):201–202.

15.

Carey

Schroder

KEE

. Development and psychometric evaluation of the brief HIV knowledge questionnaire (HIV-KQ-18). AIDS Educ Prev. 2002;14(2):174–184.

16.

Sano

Antabe

Atuoye

. Persistent misconceptions about HIV transmission among males and females in Malawi. BMC Int Health Hum Rights. 2016;16(1):16.

17.

Wejnert

Rose

Oster

Smith

Zhu

; Gabriela Paz-Bailey for the NHBS Study Group. HIV infection and awareness among men who have sex withmen-20 cities, United States, 2008 and 2011. PLoS One. 2013;8(10):e76878.

18.

Dokubo

Shiraishi

Young

. Awareness of HIV status, prevention knowledge and condom use among people living with HIV in Mozambique. PLoS One. 2014;9(9):e106760.

19.

Hong

Thompson

Wanke

. Knowledge of HIV transmission and associated factors among HIV-positive and HIV-negative patients in rural Kenya. J AIDS Clin Res. 2012;3(7):1–6.

20.

PSC

Sarangapan

Begle

Coot

Kishor

. Medical and nursing students perceived knowledge, attitudes, and practices concerning human immunodeficiency virus. ISRN Public Health. 2014: 1–9. Retrieved from: https://www.hindawi.com/journals/isrn/2014/975875/.

21.

Asante

Boafo

Nyamekye

. Identifying gender differences in Ghanaian University Students’ sexual practices, attitudes and knowledge regarding HIV. J Psychology. 2014;5(1):9–18.

22.

Dyrehave

Rasmussen

Hønge

; Bissau HIV Cohort Study Group. Nonadherence is associated with lack of HIV-related knowledge: a cross-sectional study among HIV-infected individuals in Guinea-Bissau. J Int Assoc Provid AIDS Care. 2016;15(4):350–358.

23.

Olowookere

Fatiregun

Adewole

. Knowledge and attitudes regarding HIV/AIDS and antiretroviral therapy among patients at a Nigerian treatment clinic. J Infect Dev Ctries. 2012;6(11):809–816.

24.

Kasumu

Balogun

. Knowledge and attitude towards antiretroviral therapy and adherence pattern of HIV patients in southwest Nigeria. Int J Infect Control. 2014;10(3):1–8.

25.

Chimoyi

Tshuma

Muloongo

Setswe

Sarfo

Nyasulu

. HIV-related knowledge, perceptions, attitudes, and utilisation of HIV counselling and testing: a venue-based intercept commuter population survey in the inner city of Johannesburg, South Africa. Glob Health Action . 2015;8(1):26950.

26.

Mehta

. Assessment of HIV knowledge and awareness in adults of a slum area of Mumbai, India: a cross-sectional study. Int J Community Med Public Health. 2016;3(1):314–318.

27.

Talwar

Rahman

. Assessment of HIV knowledge among university students using the HIV-KQ-18 scale: a cross-sectional study. South East Asia J Public Health. 2015;5(1):33–38.

28.

Vigneshwaran

Padmanabha Reddy

Devanna

. Assessment of knowledge about HIV/AIDS among public—a rural prospective of South India. Asian J Pharm Health Sci. 2011;1(4):154–157.

HIV-Related Knowledge among PLWHA Attending a Tertiary Care Hospital at Coastal South India—A Facility-Based Study