Prevalence,Associated Risk Factors,Knowledge,Attitude,and Practice of HIV/AIDS among Patients Visiting Metema Yohanness Primary Hospital,Northwest Ethiopia

Abstract

Introduction

HIV/AIDS remains a major global public health challenge and continues to be a significant cause of morbidity and mortality, particularly in sub-Saharan Africa. In Ethiopia, HIV infection remains a major public health concern, yet evidence on its prevalence and associated factors is limited in some areas. This study aimed to assess the prevalence of HIV infection, associated risk factors, and the knowledge, attitude, and practice related to HIV/AIDS among patients visiting Metema Yohanness Primary Hospital, Northwest Ethiopia.

Methods

A hospital-based cross-sectional study was conducted to assess HIV prevalence and associated factors. Given the binary nature of the outcome variable (HIV status: positive/negative), associations with independent variables were analyzed using logistic regression. Bivariable logistic regression analysis was performed to assess the association between HIV seropositivity and each independent variable, including socio-demographic, behavioral, biological, and practice related factors. Due to the small number of HIV-positive cases, multivariable logistic regression was not conducted to avoid model overfitting and unstable estimates. Crude odds ratios (CORs) with corresponding 95% confidence intervals were calculated to estimate the strength of associations, and a two-tailed P-value ≤ 0.05 was considered statistically significant.

Results

The overall prevalence of HIV infection was (3.7%). The prevalence of HIV was marginally higher in women (3.94%) than in men (3.15%) and in urban dwellers (3.8%) than in rural ones (3.1%). Participants who were divorced or widowed had significantly higher odds of HIV infection than those who were single after controlling for potential confounders (COR = 4.62% and COR = 4.43%, respectively). The odds of being HIV-positive were 10.57 times higher for participants who reported having three or more lifetime sexual partners than for those who reported having no lifetime sexual partners (COR = 10.57%). The majority of respondents (94.5%) showed a good understanding of HIV/AIDS, and 63.3% had positive attitudes. Nonetheless, poor HIV preventive practices were reported by more than half of the participants (56.5%).

Conclusion

This study demonstrated a notable prevalence of HIV infection in the study area, with significant associations observed with socio-demographic and behavioral factors. Although knowledge and attitudes toward HIV/AIDS were generally high, unsafe practices remained common. These findings highlight the need for strengthened, community-based HIV prevention, care, and support programs that focus on translating knowledge into safer practices, particularly among high-risk and vulnerable populations.

Plain Language Summary Title

Understanding HIV/AIDS in Metema Yohanness: How Common It Is, What Factors Increase Risk, and What People Know, Believe, and Do

Plain Language Summary

HIV/AIDS is a serious health problem that affects many people in Ethiopia and around the world. This study looked at how common HIV is among patients visiting Metema Yohanness Primary Hospital and explored factors that may increase the risk of infection. We also assessed what people know about HIV, how they feel about people living with HIV, and their behaviors that could affect the spread of the disease. We collected information from 381 patients who came to the hospital for testing. Blood tests were used to determine HIV infection, and questionnaires were used to understand people's knowledge, attitudes, and practices related to HIV. We also looked at 5 years of hospital records to see how HIV cases changed over time. Our study found that 3.7% of patients were HIV-positive. Women, older adults, urban residents, people who were divorced or widowed, illiterate individuals, and certain occupational groups were more likely to be infected. Behaviors such as having multiple sexual partners, high-risk sex, not using condoms, exchanging sex for money or gifts, and having a sexually transmitted infection were also linked to higher risk. Most participants (94.5%) had good knowledge about HIV, including how it spreads and how it can be prevented. About 63% had positive attitudes toward people living with HIV, but risky practices were common, showing that knowledge does not always translate into safe behavior. These findings suggest that health programs should focus on high-risk groups, promote safer sexual behaviors, and provide education and support to prevent HIV spread. Community-based care and effective condom promotion programs are important to reduce new infections and support people living with HIV in Metema Yohanness.

Keywords

HIV/AIDS prevalence risk factors Ethiopia

Introduction

Background

The acquired immuno-deficiency syndrome (AIDS) was first recognized in men who had sex with men in the United States.¹ While initially limited, infection with the human immuno-deficiency virus (HIV) has literally exploded over the past four decades to become the worst epidemic of the twentieth century.^2–4 With more than 50 million fatalities, the AIDS epidemic now ranks alongside the influenza pandemic of the early 1900s and the bubonic plague of the fourteenth century in terms of fatalities.^5–8 Despite the huge progress achieved in the past 20 years in reducing HIV/AIDs,^9–11 In 2020, HIV caused an estimated 1.5 million new infections and 680,000 AIDS-related deaths globally, underscoring its continued public health impact.^12,13 In addition, there were 37.7 million people living with HIV (PLHIV) in 2020, including 10.2 million who were not on HIV treatment.^14–16 Among those not on treatment, about 4.1 million did not know their HIV-positive status, and 6.1 million knew their HIV status but could not access treatment.^17,18 Poor health-seeking behaviors, a lack of diagnostic services, and inadequate or nonexistent treatment of reproductive tract infections (RTIs) contribute to these high magnitudes in developing countries.¹⁹ The epidemiological synergy between RTIs and HIV infection is well established, and the heavy burden of RTIs continues to put sub-Saharan Africa at high risk of an escalating HIV-1 epidemic. Studies of the role of male circumcision in HIV prevention have shown that male circumcision may prevent up to 60% of HIV infections.^20,21 Alcohol and illicit drugs are also important factors in the spread of HIV in Africa today.²² The influence of alcohol and experimentation with drugs promotes an increase in the incidence of high-risk behaviors in particular sexes.^23,24 Sexual offenses such as rape are usually committed under the influence of alcohol or drugs,^25,26 in spite of emerging reports of an increasing role of injecting drug users in HIV transmission, particularly in Tanzania, Kenya, and Nigeria.^27,28 Transmission of HIV infection in sub-Saharan Africa remains largely heterosexual.^29,30 The rate of HIV infection has also remained persistently high among young people aged 15-24.^31,32 This rate has been explained by the higher risk and greater vulnerability to HIV infection among young people. However, the South ^31,33–35 Encouraging trends in young people's sexual behavior are associated with declining HIV prevalence among this group in urban and rural Kenya, urban Botswana, Rwanda, rural Tanzania, and Zimbabwe. These positive behavioral changes include increased age at sexual debut, decreased number of sexual partners, and increased condom use with non-regular partners.^36,37

The first documented case of HIV infection in Ethiopia was reported in 1984. Although the prevalence of HIV/AIDS remained low throughout the late 1980s, it increased rapidly from the early 1990s onward.³⁸ By the end of the year 2000 G.C, an estimated 2.6 million Ethiopians were living with HIV/AIDS, including approximately 250,000 children under 9 years of age.^39,40 In 2017, an estimated 613,000 people in the Amhara region were living with HIV, with 60% being female and 30% being male.^41,42 The lowest prevalence, on the other hand, was reported in Somalia (0.1%) and the Southern Nations, Nationalities, and Peoples (SNNP, 0.4%) regional states. The adult^15–59 HIV prevalence in Ethiopia is 0.9%, with varying burdens by sex, age, and other demographic characteristics, across sub-regions and population groups. The urban HIV prevalence (2.9%) is seven times higher than the prevalence in rural settings (0.4%), with women (1.2%) having a twice higher HIV prevalence than men (0.6%). The Ethiopian population-based HIV impact assessment showed that the prevalence of HIV is 3.0% in urban settings (EPHI, 2018).^43–45 Therefore, this study aims to assess the prevalence rate and trend of HIV in the Metema area of the Amhara region.⁴⁶

The spread of HIV in any community is in part determined by the knowledge and attitude towards sexuality of its members and by their actual sexual practices.^47,48 Before formulating public health policies for the prevention of HIV, it is critical to obtain information about the prevalent knowledge, attitude and practice (KAP) regarding HIV/AIDS, other STDs and sexuality in the target community.⁴⁹ Therefore, assessing current KAP about HIV/AIDS is critical in order to know KAPS about HIV/AIDs currently. In addition, the study assessed the current prevalence and associated risk factors of HIV/AIDS in Metema town.⁵⁰

Among women and men combined, HIV prevalence is seven times higher in urban areas than in rural areas (2.9% vs 0.4%). HIV prevalence is 3.1% among women in urban areas compared with 0.6% among women in rural areas.⁵¹

Unprotected sex, multiple partnerships, no or inconsistent condom use, drug abuse, having multiple sexual partners, casual sex, sex while under the influence of alcohol, and paying or receiving goods or money for sexual intercourses are all risk factors for HIV infection.^52,53 Further analysis of the 2005 Ethiopian Demographic and Health Survey showed that women and men aged 35-49 were more likely to have HIV than those aged 15-24. Compared with never-married women and men, formerly married (widowed, divorced, or separated) women were at higher risk for being HIV-positive. Household wealth status was positively related to HIV risk among women. Women living in the wealthiest conditions were 7 times more likely to have HIV infection than those living in the poorest conditions. Having three or more lifetime sexual partners was also found to be significantly related to HIV infection in women. Circumcised men were significantly less likely to be HIV-positive than uncircumcised men. HIV infection is also strongly associated with reported sexually transmitted infections (STIs) or STI symptoms among men.^54,55 However, contrary to expectations, knowledge of HIV prevention methods, accepting attitudes toward PLHIV, regular exposure to mass media, and condom use were positively associated with HIV infection.^56,57

These are common factors that have been thoroughly addressed and are widely known. However, more importantly, there are underlying factors that must be explored in depth and addressed, which may be very specific to local contexts and embedded within the culture of the local community. In this regard, no previous studies have been conducted in Metema Yohannes Town. So the purpose of this study was to investigate such a distantly underlying local context-wise factor and HIV infection in the Metema Area. In addition, this research work was conducted to look into the prevalence of HIV and associated risk factors in Metema Primary Hospital.

Statement of the Problem

HIV remains a major global public health challenge and a leading cause of death worldwide, despite decades of interventions aimed at controlling its spread. In 2019, an estimated 38 million people were living with HIV globally, with 1.7 million new infections and 690,000 HIV-related deaths reported.^12,58 Among the 46 countries with the highest HIV prevalence (>0.7%), 35 are in Africa, including Ethiopia.⁴³

Although global HIV prevalence has shown a declining trend, sub-Saharan Africa continues to bear the highest burden, with a prevalence of 3.6% in 2019.^58,59 In this region, approximately 25.7 million people were living with HIV, and 440,000 deaths occurred due to HIV-related illnesses in the same year. Notably, 4500 new infections occur daily worldwide, with 59% of these cases concentrated in sub-Saharan Africa.⁶⁰

In Ethiopia, the estimated HIV prevalence is 0.9%, but the epidemic is unevenly distributed by sex, geography, and population group. HIV prevalence among women and men combined is seven times higher in urban areas compared to rural areas (2.9% vs 0.4%). Among women specifically, prevalence is 3.1% in urban areas versus 0.6% in rural areas.⁶¹

Despite ongoing prevention and control efforts, the persistence of regional, sex-specific, and population-level disparities highlights the continuing public health challenge posed by HIV in Ethiopia.

To determine the Prevalence, Associated Risk Factors, KAP of HIV/AIDS among patients visiting the Metema Yohannis primary Hospital in Metema Yohannis town.

To determine the trends of 5 years (2017/18 to 2021/22) HIV infection by using retrospective data from Metema Yohannis Hospital.

To determine prevalence of HIV infection in Metema Yohannis area

To identify the risk factors that contributes the rate of HIV/AIDS in Metema Yohannis town To assess the KAPs of study participants about HIV/ AIDs and their association with HIV prevalence

The significance of the study is to give current information and understanding of the prevalence and associated risk factors of HIV infection in Metema Yohannis Town administration and serve as a guide for other researchers who want to conduct exhaustive research on the topic under investigation. In addition, the study collects data on the current KAP of study participants, which helps health sector practitioners and policymakers in the development of effective control measures to reduce the transmission of the infection.

Operational Definitions

Knowledge

In this study, respondents who correctly answered five or fewer knowledge-related questions (<50%) were categorized as having poor knowledge, whereas those who correctly answered six or more questions (≥60%) were categorized as having good knowledge about HIV/AIDS.

Attitude

Attitude refers to the respondents’ tendency or relatively stable feelings toward HIV prevention methods. Participants who responded positively to more than half of the attitude-related questions were considered to have a positive attitude toward HIV prevention.

Practice

Practice is defined as the health-related behaviors an individual engages in that may promote health or prevent disease. In this study, it refers to what respondents have been doing in relation to HIV prevention practices.

Materials and Methods

Study Area

This study was conducted in Metema Yohanness, a town located in the West Gondar Zone of the Amhara National Regional State, Northwest Ethiopia. Metema Yohanness is situated approximately 900 km northwest of Addis Ababa, the capital city of Ethiopia. According to the Metema Town Administrative Office, the town has a total population of 54,652, of whom 28,568 are women and 26,084 are men, and it covers an area of 1111.6 hectares. Administratively, the town is divided into three kebeles, the smallest administrative units in Ethiopia.

Geographically, Metema Yohanness lies at 12°58′ N latitude and 36°12′ E longitude, with an elevation of 685 meters above sea level. The town shares an international border with the Sudanese town of Gallabat, and strong economic ties based on trade and agriculture enable daily cross-border movement of local residents.

Metema Yohanness is one of the three major overland migration routes out of Ethiopia, alongside Djibouti and Moyale, and serves as a key entry and exit point for migrant populations traveling to and from Sudan. In addition, internal migrants—predominantly men—are attracted to the area for employment on large-scale agricultural plantations within the woreda. The continuous flow and movement of people into and out of the town is believed to contribute to an increased risk and prevalence of HIV/AIDS in the area.⁶² The hospital serves a total population of 320,000 and migrant workers who works in investment activities.⁶³ In addition, the hospital provides preventive, curative, and rehabilitative services. It has 54 beds and a total of 215 staff, including 12 general practitioners, 14 midwives, 81 nurses of various specialties, 3 emergency surgery and obstetric officers, 3 radiographers, 11 laboratory technicians, 1 biomedical technician, and 3 health information technicians, along with other supportive and health professionals.

Study Design, Setting, and Period

A health institution-based cross-sectional study was conducted in Metema Yohanness Town from February to May 2022 to assess the prevalence of HIV infection, associated risk factors, and KAP related to HIV/AIDS. In addition, a 5-year retrospective review of HIV data, covering the period from July 2017/18 to May 2021/22, was conducted to examine trends in HIV prevalence in Metema Yohanness.

Primary data were collected from individuals who presented to Metema Yohanness Primary Hospital and underwent HIV testing. Structured questionnaires were administered to participants selected for HIV testing to collect information on socio-demographic characteristics, risk factors, and KAP related to HIV/AIDS. Secondary data were obtained from Metema Yohanness Primary Hospital records, including patient registration logbooks. Additional information was supplemented through a review of relevant books, journal articles, annual reports, and research publications. This secondary data was extracted from the 5-year retrospective review was based on routine HIV testing records maintained at Metema Yohannis Primary Hospital. These data were obtained from the hospital's HIV testing and counseling registration books and laboratory logbooks, which record all clients tested for HIV as part of routine clinical services during the study period.

The denominator across all years was consistent and comprised the total number of individuals tested for HIV in the hospital during each respective year, rather than only suspected cases. This ensured comparability of annual prevalence estimates across the 5-year period.

Data extraction was conducted using a standardized data abstraction checklist. Variables extracted included year of testing, age, sex, test result (reactive/non-reactive), and testing site. Records with incomplete test results, unclear identifiers, or duplicate entries were excluded from analysis. To avoid double counting, unique identifiers (registration numbers and dates of testing) were cross-checked, and repeat tests for the same individual within the same year were counted only once, using the most recent definitive result. Only records with a final HIV test result determined according to the national HIV rapid testing algorithm were included. Indeterminate or inconclusive results without documented follow-up were excluded.

Participants

We acknowledge that “random selection” and “consecutive recruitment” represent different sampling techniques and should not be used interchangeably. In this study, participants were not recruited consecutively. Instead, a systematic random sampling technique was employed to select study participants.

Eligible participants attending the selected health facilities were listed in their order of attendance, and every kth individual was selected after a randomly determined starting point.

In addition, the health facilities were selected using simple random sampling through the lottery method from the list of eligible facilities. We have revised the Methods section to consistently and accurately describe these sampling procedures and have removed any reference to consecutive sampling.

Inclusion and Exclusion Criteria

The study included individuals aged 10 years and above who provided informed consent to participate. Participants who declined to give consent and those aged below 10 years were excluded from the study.

Sample Size Determination and Sampling Technique

The sample size was initially calculated using a single population proportion formula with an assumed prevalence of 50% (P = 0.5), a 95% confidence level, and a 5% margin of error, yielding a minimum required sample size of 381. To account for an anticipated 5% non-response rate, the final planned sample size was increased to 404.

Systematic random sampling was employed to select study participants. The sampling frame included all patients expected to attend the selected health facilities during the data collection period (N = 1200).

The sampling interval (k) was calculated by dividing the total expected number of patients by the required sample size (1200/404 ≈ 3). A random starting point between 1 and 3 was selected, and subsequently every third eligible patient was approached for interview until the planned sample size was reached.

A total of 404 patients were approached. Of these, 23 were excluded due to refusal to participate, ineligibility, or incomplete responses. Finally, 381 participants were included in the analysis, yielding a response rate of 94.3%.

The sample size was calculated using the formula:

N = \frac{Z 2 P (1 - P)}{D 2}

Where:

N = required sample size

Z = standard normal value at 95% confidence level (1.96)

P = assumed prevalence of HIV infection (0.5)

D = margin of error (0.05)

Accordingly, the initial sample size was calculated as follows:

N = \frac{(1.96) 2 (1 - 0.5)}{(0.05) 2} = 384

After adding 5% to account for possible non-response, the final sample size was 404 participants. Study participants were recruited consecutively from eligible volunteers attending the selected health facility until the required sample size was achieved.

HIV Testing Algorithm and Laboratory Methods

HIV testing in Ethiopia is performed using the national HIV rapid testing algorithm, which is a serial testing strategy employing three rapid diagnostic tests to determine an individual's HIV status. In this algorithm, testing is done in a stepwise fashion such that only reactive results proceed to the next assay, in order to ensure high diagnostic accuracy.⁶⁴

Under the Current National Algorithm

First test (T1) is used as the initial screening assay. If the result is non-reactive, the person is reported as HIV negative and no further testing is required.

Second test (T2) is used to confirm reactivity. If T2 is reactive, a third test is performed.

If T2 is non-reactive, the first and second tests are repeated. If the repeated tests are both non-reactive, the result is reported as HIV negative. If the repeated tests have discordant results (reactive T1 and non-reactive T2), the result is reported as HIV inconclusive and repeat testing after 14 days is recommended.

Third test (T3) is used when both T1 and T2 are reactive. If T3 is reactive, the final result is reported as HIV positive. If T3 is non-reactive, the result is considered HIV inconclusive, and the person is advised to return for retesting after 14 days.⁶⁵

Study Variables

Dependent Variables

HIV serostatus (seropositive or seronegative), Knowledge of HIV infection, Attitude toward HIV infection and Practice of HIV prevention methods.

Independent Variables

Socio-demographic factors: age, sex, marital status, occupation, educational level, and place of residence, Behavioral factors: number of lifetime sexual partners, condom use during the most recent sexual intercourse, engagement in high-risk sexual behavior (sexual intercourse with non-spouse or non-cohabiting partners), history of HIV testing, and knowledge of HIV/AIDS, Biological factors: history of STI treatment in the previous 12 months and male circumcision status.

Data Quality Assurance

To ensure the quality and reliability of the data, multiple procedures were implemented:

Questionnaire review and translation: The questionnaire was thoroughly reviewed by the research team prior to data collection. It was prepared in English, translated into Amharic, and then back-translated into English to ensure consistency and accuracy.

Pretesting: A pretest was conducted on 10% of participants who were not included in the final analysis. The pretest assessed clarity, understandability, logical flow of questions, and the time required for completion. Necessary modifications were made based on the pretest findings.

Validity and reliability: The questionnaire's content validity was evaluated by the research team, and internal consistency (reliability) was assessed using Cronbach's alpha coefficient.

Training of data collectors: Data collectors and blood sample collectors received a one-hour orientation to ensure uniform understanding of the study objectives, tools, and procedures.

Registry data quality assurance :For the 5-year retrospective dataset, duplicates and repeat tests were identified and managed using unique patient identifiers, including medical record numbers and demographic information (name, date of birth, and sex). Only the first positive test per individual was included in prevalence calculations, and repeat tests were excluded to avoid overcounting. Data completeness checks were performed to ensure that all records contained key variables (test result, date, patient identifier), and records with missing or inconsistent information were excluded.

These quality assurance procedures ensured that both the questionnaire-based cross-sectional data and the registry-based retrospective data were accurate, complete, and reliable, thereby strengthening the validity and interpretability of the study findings.

Data Analysis

Data were manually checked for completeness, cleaned, coded, and entered into SPSS version 24 for analysis. Descriptive statistics were used to summarize socio-demographic, behavioral, and clinical characteristics of the participants and to estimate the seroprevalence of HIV infection.

Bivariable logistic regression analysis was performed to assess the association between HIV seropositivity and each independent variable. Due to the small number of HIV-positive cases, multivariable logistic regression analysis was not conducted to avoid model overfitting and unstable estimates.

Crude odds ratios (CORs) with corresponding 95% confidence intervals (CIs) were calculated to estimate the strength of associations. A two-tailed P-value ≤ 0.05 was considered statistically significant.

Ethical Consideration

The study protocol was reviewed and approved by an appropriate Institutional Review Board (IRB), with institutional identifiers withheld to ensure anonymization during peer review. Ethical approval for this study was obtained from the University of Gondar College of Natural and Computational Sciences Ethical Review Committee with approval number IRB-2496. In addition, permission to conduct the research was secured from Metema Yohannis Primary Hospital, with official approval granted by the head of the hospital. The IRB approval number is 2496 with the Declaration of Helsinki, and written informed consent was obtained from all participants. For any further clarification, the co-author can be contacted via the institutional email: jember.ayelgne@thsc.edu.et

Results

Socio-Demographic Characteristics

A total of 381 (94.3%) suspected patients participated in the study; 23 (5.7%) were excluded due to incomplete data or consent issues. Of the participants, 127 (33.3%) were male and 254 (66.7%) were female. Most respondents (367, 96.3%) were over 15 years old, 317 (83.2%) lived in urban areas, 329 (86.4%) were literate, 133 (34.9%) were married, and 77 (20.2%) were farmers.

Trends of HIV Infection

The difference between the 5-year retrospective prevalence (0.71%) and the cross-sectional survey prevalence (3.7%) likely reflects differences in denominators, testing context, and potential selection or referral biases. The retrospective dataset captured all individuals tested over a long period, representing a broader, largely low-risk population. In contrast, the cross-sectional survey involved systematically selected facility attendees during a short period, who may have had higher risk factors or clinical indications for testing, leading to a higher observed point prevalence.

Prevalence and Distribution of HIV

In the current study, the overall prevalence of HIV was 3.7% (n = 14). HIV prevalence was slightly higher in females (3.9%) than males (3.1%), though this was not statistically significant (χ²=0.150, P = 0.70). Prevalence differed by age group (χ²=10.18, P = 0.006), with those over 30 years (5.8%) most affected, followed by ages 15-30 years (3.2%). Urban residents had a slightly higher prevalence (3.8%) than rural residents (3.1%), but the difference was not significant (χ²=0.066, P = 0.798).

Risk Factors for HIV Infection

Bivariate analysis identified marital status, number of lifetime sexual partners, and exchange of money/gifts for sex as significant predictors of HIV infection. Key findings include:

Being Females were 1.26 times more likely to be HIV-positive than males (COR=1.25), Age: Individuals aged 15-30 years (COR=1.10) and >30 years (COR=1.97) had higher risks than those <15 years, Residence: Urban residents had a 1.21 times higher risk than rural residents, Religion: Muslims had 4.06 times higher risk than Orthodox Christians, Education: Illiterate participants had 1.95 times higher risk than those with primary education, Marital status: Divorced and widowed individuals had 4.62 and 4.43 times higher risk, respectively, compared to single individuals, Occupation: Farmers, employees, and other occupational groups had 1.48, 1.45, and 2.43 times higher risk, respectively, than merchants.

Behavioral Factors

Sexual activity: Participants with sexual intercourse had 1.07 times higher risk, Lifetime sexual partners: Prevalence increased with number of partners: three or more (COR=10.57), two (COR=4.63), one (COR=1.25) compared to none, High-risk sexual activity in the past 12 months: OR = 2.94, Condom use during last casual sex: COR=1.38 (95% CI: 0.30-6.29), Exchange of money/gifts for sex: COR=6.43,No prior HIV testing: OR = 1.83.

Biological Factors

STI symptoms in the past 12 months: COR=1.13 and Male circumcision: COR=1.29 (95% CI: 0.13-12.82).

These results indicate that socio-demographic, behavioral, and biological factors significantly influence the risk of HIV infection in the study population (Table 1).

Table 1.

Prevalence of HIV Infection and Associated Socio-demographic, Clinical, and Behavioral Factors among Participants Attending Metema Yohannis Primary Hospital, February-May 2021/22 (n = 381).

Variable	Category	Total N (%)	HIV– N (%)	HIV + n (%)	COR (95% CI)	P-Value
A. Socio-demographic factors
Sex	Male	127 (33.3)	123 (32.3)	4 (3.1)	1.00	–
	Female	254 (66.7)	244 (64.0)	10 (3.9)	1.26 (0.39-4.10)	.701
Age group (years)	<15	34 (8.9)	33 (8.7)	1 (2.9)	1.00	–
	15–30	278 (73.0)	269 (70.6)	9 (3.2)	2.03 (0.22-18.91)	.534
	>30	69 (18.1)	65 (17.1)	4 (5.8)	1.84 (0.55-6.16)	.323
Residence	Rural	64 (16.8)	62 (16.3)	2 (3.1)	1.00	–
Residence	Urban	317 (83.2)	305 (80.1)	12 (3.8)	1.22 (0.27-5.59)	.798
Marital status	Single	156 (40.9)	153 (40.2)	3 (1.9)	1.00	–
	Married	133 (34.9)	130 (34.1)	3 (2.3)	1.18 (1.07-23.12)	.041*
	Widowed	47 (12.3)	43 (11.3)	4 (8.5)	4.74 (0.91-19.67)	.066
Religion	Orthodox	317(83.2)	309(81.1)	8(2.5)	1.0
	Muslim	39(10.2)	35(9.2)	4(10.3)	4.41(0.13-4.49)	.763
	Other	25(6.6)	23(6.0)	2(8.0)	3.36(0.67-16.74)	.139
Occupation	Farmer	77(20.2)	74(19.4)	3(3.9)	1.50(0.33-8.69)	.535
	Merchant	152(39.9)	148(38.8)	4(2.6)	1.0
	Employed	105(27.6)	101(26.5)	4(3.8)	1.47(0.37-8.02)	.489
	Other	47(12.3)	44(11.5)	3(6.4)	2.52(0.54-11.70)	.237
B. Clinical factors
History of STI symptoms (past 12 months)	No	110 (31.3)	106 (27.8)	4 (3.6)	1.00	–
History of STI symptoms (past 12 months)	Yes	242 (68.8)	232 (6.1)	10 (4.1)	1.14 (0.35-3.73)	.825
Circumcision status (males only)	No	38 (29.9)	37 (9.7)	1 (2.6)	1.00	–
Circumcision status (males only)	Yes	89 (23.4)	86 (22.6)	3 (3.4)	1.29 (0.13-12.82)	.829
C. Behavioral factors
Lifetime number of sexual partners	0	148 (38.8)	146 (38.3)	2 (1.4)	1.00	–
	1	118 (31.0)	116 (30.4)	2 (1.7)	1.26 (0.18-9.07)	.819
	2	80 (21.0)	75 (19.7)	5 (6.3)	4.87 (0.92-25.68)	.062
	≥3	35 (9.2)	30 (7.9)	5 (14.3)	12.17 (2.25-65.69)	.004*
Transactional sex (ever)	No	275 (78.1)	270 (70.9)	5 (1.8)	1.00	–
Transactional sex (ever)	Yes	77 (21.9)	68 (17.8)	9 (11.7)	7.15 (2.32-22.02)	.001*
Condom use during last casual sex (past 12 months)	Yes	65 (18.5)	63 (16.5)	2 (3.1)	1.00	–
Condom use during last casual sex (past 12 months)	No	287 (75.3)	275 (72.2)	12 (4.2)	1.38 (0.30-6.29)	.682
Ever received or gave money, gifts, or goods in exchange of sex	Yes	77(21.9)	68(17.8)	9(11.7)	7.15(2.32-22.02)	.001*
	No	275(72.2)	270(70.9)	5(1.8)	1.0
Undergone a HIV test	Yes	117(30.7)	114(29.9)	3(2.6)	1.0
Undergone a HIV test	No	235(66.8)	224(58.8)	11(4.7)	1.87(0.51-6.82)	.346
Had STI symptoms in past 12 months	Yes	242(68.8)	232(60.9)	10(4.1)	1.14(0.35-3.73)	.825
Had STI symptoms in past 12 months	No	110(31.3)	106(27.8)	4(3.6)	1.0
Circumcised	Yes	89(70.1)	86(22.6)	3(3.4)	1.29(0.13-12.82)	.829
Circumcised	No	38(29.9)	37(9.7)	1(2.6)	1.0

Footnote

COR = Crude Odds Ratio.

Odds ratios were used because the study design was cross-sectional.

Due to the small number of HIV-positive cases (n = 14).

Statistically significant at P < 0.05.

CI=confidence interval; HIV=human immuno-deficiency virus.

Knowledge, Attitude, and Practice of Study Participants on HIV Infection

All respondents (381; 100%) had heard of HIV/AIDS. The majority correctly identified major modes of transmission, including sexual intercourse (89%), blood transfusion (85%), mother-to-child transmission (75.1%), and sharing needles or syringes (78%). Most respondents also correctly recognized that HIV/AIDS is not transmitted through witchcraft, mosquito bites (90%), sharing toilets (97.6%), handshakes (89%), sharing eating utensils (90%), or having sexual intercourse with a virgin (95.8%). In addition, most participants knew that there is no vaccine or cure for HIV/AIDS, and that antiretroviral therapy does not cure the disease (over 95%). A large proportion (91.9%) were aware that circumcised individuals can still acquire HIV. Overall, 94.5% of respondents demonstrated good knowledge of HIV/AIDS.

Regarding attitudes, 71.9% of participants were willing to care for a relative living with HIV/AIDS, 51.7% were willing to remain friends with an HIV-positive person, and 53% would continue buying goods from an HIV-positive individual. Concerning prevention attitudes, 66.9% expressed willingness to use condoms, 61.9% were willing to advise others on condom use, 67.7% supported abstinence until marriage, and 69.8% agreed on being faithful to one partner. Overall, 63.3% of respondents exhibited positive attitudes toward PLHIV/AIDS.

Discussion

This study assessed the prevalence of HIV infection and its associated factors at Metema Yohanness Primary Hospital. The observed HIV prevalence (3.7%) was higher than reports from Dire Dawa (2.2%), Addis Ababa (3.4%), and most other regions of Ethiopia.^66,67 The relatively higher prevalence of HIV observed in Metema may be attributed to its role as a major overland migration route out of Ethiopia and a primary crossing point for migrants entering Sudan. In addition, internal migrants—predominantly men—are attracted to the area for employment on large-scale agricultural plantations within the woreda. Such population mobility may contribute to increased HIV transmission in the study area. Nevertheless, the prevalence reported in this study remains lower than findings from Lesotho (22.7%), Botswana (22.2%), and South Africa (19.2%).^68–71 These variations may be attributed to differences in study coverage (regional vs national), data sources (secondary records vs survey data), population behaviors, the effectiveness of HIV prevention and control programs, and levels of community awareness regarding HIV screening and unsafe sexual practices. In this study, HIV seropositivity was higher among females (3.9%) than males (3.1%).^72,73 The higher vulnerability of women to HIV in this study may reflect the influence of biological and socio-cultural factors that increase women's risk compared to men in Ethiopia. Possible explanations include biological susceptibility, reproductive health-related exposures such as childbirth and abortion, sexual violence, and differences in immune response. The findings also indicated that HIV prevalence increased with age, with the highest prevalence observed among individuals older than 30 years (5.8%), followed by those aged 15-30 years (3.2%), and those younger than 15 years (2.9%). This age-related increase may be associated with cumulative exposure and unsafe sexual practices among older age groups. However, this finding is inconsistent with reports from rural Malawi.⁷⁴ The majority of participants (83.2%) were urban residents, among whom HIV prevalence was slightly higher (3.8%) than among rural residents (3.1%); however, this difference was not statistically significant. This finding is consistent with a study conducted in sub-Saharan Africa by Magadi.^75–77

Previous research has found that HIV infection varies by location^51,78–80 and that towns have higher HIV infection rates.^43,81,82 This pattern may be related to differences in access to and quality of HIV prevention and control services, population density, the burden of TB-HIV co-infection, poverty, and individual behaviors such as alcohol and substance use, unsafe sexual practices, and the effects of urbanization on risk behavior. A retrospective analysis was also conducted to assess trends in HIV prevalence over time.

Gender was significantly associated with HIV infection, with females having higher odds of infection than males (COR = 1.26). This finding is consistent with previous studies reporting a substantially higher burden of HIV among women compared with men.^51,83,84 The observed sex differences in HIV prevalence may be explained by biological and reproductive health-related factors, including increased biological susceptibility, exposure during childbirth and abortion, sexual violence, and differences in immune response. In addition, women tend to utilize health facilities more frequently for family planning, antenatal care, and delivery services, which may increase opportunities for HIV testing. As a result, a higher proportion of women may know their HIV status and access antiretroviral therapy compared to men.

The risk of HIV infection was higher among individuals aged 15-30 years and above 30 years, with relative risks of 1.10 and 1.97, respectively, compared with those younger than 15 years. This finding is consistent with studies conducted in Ethiopia,^85,86 Previous studies have shown that the odds of HIV infection are 1.33 times higher among individuals older than 35 years compared with those younger than 18 years. This may be attributed to cumulative exposure and unsafe sexual practices among older age groups. In this study, the risk of HIV infection among Muslim participants was 4.06 times higher than among Orthodox Christians. This difference may be related to the study area's proximity to the Sudan border, where increased population mobility and cross-border interactions may elevate HIV risk. The observed variation in HIV prevalence by religion is consistent with findings from other studies,⁸⁷ Previous studies have reported a higher prevalence of HIV among Muslim communities (4.7%), which has been attributed to socio-cultural practices such as wife inheritance and polygamy.

In the present study, the risk of HIV infection was 1.95 times higher among illiterate participants compared with those who had primary-level education. This finding is consistent with results from other studies,⁸⁷ which states that educationally illiterate participants were highly vulnerable (4.6%) for HIV infection, which is also in line with a study done in the same economic class Sub- Saharan country, Tanzania,^88,89 which may be due to low consciousness about means of HIV transmission and its prevention mechanisms.⁹⁰ This study result is inconsistent with a study was done,⁹¹ which states that HIV prevalence is higher in educated individuals than in those who have no education or preschool-level education. They also stated that the odds of HIV infection among individuals with primary-level education are 1.695 times greater than the odds of HIV infection among individuals with no education or preschool-level education. This could be because those with the highest levels of education were found to be more likely to be infected with HIV than those at the lower end of the education spectrum, for reasons such as wealth, mobility, and a larger network of sexual partners.

The risks of HIV infection for those whose marital status was divorced or widowed were approximately 4.62 and 4.43 (COR = 4.62 and COR = 4.43), respectively, twice as high as for those who were single. This study supports the finding who found that unmarried study participants were less likely to have HIV infection than married study participants [COR = 0.409; 95% CI: 0.252, 0.666].⁹² The risks of HIV infection for those whose occupational status was farmer, employee, or other than listed were about 1.48, 1.45, and 2.43 (COR = 1.48, COR = 1.45, and COR = 2.43) as high as the risk of HIV infection, respectively, compared to those with merchant occupational status. The result of this variable was not shown in other studies. The risk of HIV suspicion in patients who had sexual intercourse was 1.07 times as high as the risk of HIV infection compared to suspected patients who had no sexual intercourse. When compared to those who had no lifelong partner, the risk of HIV suspected infection was 10.57, 4.63, and 1.25 times higher for those who had three or more, two, or one lifelong partner, respectively. This study result is in line with the study by Mbaga (intercourse was 1.07 times as high as the risk of HIV infection compared to suspected patients who had no sexual intercourse. The risk of HIV suspected infection for patients who had three or more, two, or one lifelong partner was 10.57, 4.63, and 1.25 times as high as the risk of HIV infection, respectively, compared to those who had no lifelong partner. This study result is in line with the study by Mbaga (2013), which states that having fewer lifetime sexual partners is associated with a lower likelihood of HIV infection compared with reporting 10 or more lifetime partners.

When compared to those who had no sexual activity in the previous 12 months, the risk of HIV infection was 2.94 (COR = 2.94) times higher in HIV suspected patients who had high-risk sexual activity in the previous 12 months. This finding was similar to studies in Tanzania by Mmbaga (activity in the past 12 months was 2.94 (COR = 2.94) times as high as the risk of HIV infection compared to those who had no sexual activity in the past 12 months. This finding was similar to studies in Tanzania,⁹³ which state that not having sex during the past 12 months preceding the survey was associated with an almost 99% lower likelihood of infection compared with reporting high-risk sex (sex with a non-spousal, non-cohabiting partner). The odds of HIV infection for those who did not use condoms during their last casual sex in the previous 12 months are estimated to be 1.38 times higher (95% CI: 0.30-6.29) than for those who did use condoms during

their last casual sex in the previous 12 months. The result of this variable was not shown in other studies. The risk of HIV infection for those who had ever received or given money, gifts, or goods in exchange for sex was 6.43 times as high as the risk of HIV infection compared to those who did not receive or give money, gifts, or goods in exchange for sex. The result of this variable was not shown in other studies. The risk of HIV infection for those who had not undergone an HIV test was 1.83 times as high compared to the risk of HIV infection for those who had undergone an HIV test. The result of this variable was not shown in other studies. The risk of HIV infection for those who had STI symptoms in the past 12 months was 1.13 times as high as the risk of HIV infection compared to those who had no STI symptoms in the past 12 months. The odds of HIV infection among circumcised people are estimated to be 1.29 times higher (95% CI: 0.13-12.82) than among non-circumcised people. The result of these variables was not shown in other studies.

This study's results revealed that almost all respondents (360, or 94.5%) had good knowledge, a slight majority of the respondents (241, or 63.3%) had positive attitudes, and the majority of the respondents (215, or 56.5%) were engaging in bad practices regarding HIV. Although our study showed high knowledge regarding HIV and AIDS transmission modes and methods, misconceptions were observed among some of the respondents. A small portion of the respondents believed that HIV spread could not be controlled by remaining faithful to a single partner (115, 30.2%); HIV could not be spread through birth from mother to child (95, 24.9%); HIV could not be spread through sharing needles or syringes (84, 22%); HIV could not be spread through blood transfusion (57, 15%); HIV and AIDS could be transmitted through witchcraft (54, 14.2%); HIV spread could be controlled by abstaining (47, 12.3%); HIV could be transmitted by handshakes (42%); HIV could be transmitted by eating off the Conflicting findings were revealed in several studies that were conducted to assess HIV and AIDS KAPs among learners. HIV and AIDS knowledge was below average; there were misconceptions, risky practices were discovered, and there were negative attitudes toward HIV and AIDS patients.^94–97 Other studies revealed good HIV and AIDS

knowledge, safe sexual practices, and positive attitudes towards PLHIV and AIDS.^98–100 HIV risk is associated with distorted knowledge or perceptions of reality in HIV and AIDS prevention.

The observed difference between the 5-year retrospective prevalence (0.71%) and the cross-sectional prevalence (3.7%) may be explained by differences in denominators, testing context, and potential selection or referral biases. The retrospective dataset captured all individuals tested over a prolonged period, representing a broad population, including low-risk individuals. In contrast, the cross-sectional survey was conducted over a short period among systematically selected facility attendees, who may have had higher risk profiles or clinical indications for testing. Consequently, the higher point prevalence observed in the cross-sectional survey likely reflects selection and referral biases rather than a true increase in population prevalence. These differences highlight the importance of interpreting prevalence estimates within the context of sampling and testing strategies.

Strengths and Limitations of the Study

One of the key strengths of this study is its comprehensive assessment of the prevalence of HIV infection alongside associated risk factors and KAP related to HIV/AIDS among patients attending Metema Yohanness Primary Hospital. The use of a structured questionnaire and the national HIV rapid testing algorithm enhanced the reliability and consistency of data collection. In addition, random selection of participants and the inclusion of multiple socio-demographic, behavioral, and biological variables strengthened the internal validity of the findings.

However, the study has several limitations. As a hospital-based study conducted in a single primary hospital, the findings may not be generalizable to the wider community or to other healthcare settings in Ethiopia. The cross-sectional design also limits the ability to establish causal relationships between HIV infection and the identified associated factors. Furthermore, limited information on participants’ medication history and reliance on self-reported data may have introduced recall and social desirability biases. Some participants may have been reluctant or lacked confidence to disclose sensitive information, potentially leading to underreporting. Finally, time constraints and limited financial resources restricted the scope of data collection and the depth of analysis.

Conclusion and Recommendations

HIV infection was identified among a small proportion of suspected patients attending Metema Yohanness Primary Hospital. Relatively higher prevalence was observed among females, older adults, urban residents, individuals with no formal education, divorced participants, and those engaged in farming. Differences in HIV seropositivity were also observed across several behavioral and biological characteristics, including history of sexual intercourse, having multiple lifetime sexual partners, engagement in high-risk sexual activities within the previous year, inconsistent condom use, exchanging money or gifts for sex, lack of prior HIV testing, presence of symptoms suggestive of STIs, and circumcision status. These findings reflect observed associations rather than causal relationships.

The retrospective review showed variation in HIV case detection across the reviewed years, with the highest number of cases occurring in the later years of the study period and the lowest in earlier years. Assessment of KAP revealed that most respondents had good knowledge about HIV, while just over half demonstrated positive attitudes. However, risky practices remained common, indicating persistent behavioral gaps despite relatively high levels of awareness.

Recommendations

Stakeholders should implement well-organized community-based care and support programs targeting PLHIV and vulnerable populations.

Health planners and policymakers should prioritize HIV prevention and control activities, focusing on high-risk groups identified in the study.

Comprehensive condom promotion and utilization programs should be established and strengthened for populations at increased risk of HIV infection.

What This Study Adds

This study provides updated evidence on the prevalence of HIV infection among patients visiting a primary hospital in Northwest Ethiopia, showing an overall HIV prevalence of 3.7% among suspected patients. This highlights that HIV infection remains a public health concern at the primary health care level.

The study identifies important socio-demographic and behavioral risk factors for HIV infection. Higher prevalence was observed among females, urban residents, and individuals who were divorced or widowed. In addition, having three or more lifetime sexual partners was associated with a markedly increased risk of HIV infection, underscoring the role of sexual behavior in HIV transmission.

Although the majority of respondents demonstrated good knowledge of HIV/AIDS (94.5%) and a relatively favorable attitude (63.3%), more than half of the participants (56.5%) reported poor preventive practices. This gap between KAP highlights the need for behavior-focused interventions, beyond information dissemination alone.

The findings emphasize the importance of strengthening community-based HIV prevention, care, and support programs, particularly those targeting high-risk and vulnerable groups, to improve safe practices and reduce HIV transmission in Northwest Ethiopia.

Supplemental Material

sj-docx-1-jia-10.1177_23259582261443731 - Supplemental material for Prevalence, Associated Risk Factors, Knowledge, Attitude, and Practice of HIV/AIDS among Patients Visiting Metema Yohanness Primary Hospital, Northwest Ethiopia

Supplemental material, sj-docx-1-jia-10.1177_23259582261443731 for Prevalence, Associated Risk Factors, Knowledge, Attitude, and Practice of HIV/AIDS among Patients Visiting Metema Yohanness Primary Hospital, Northwest Ethiopia by Getu Melkamu Gorfu, Solomon Tesfaye Sime and Jember Ayelgne Beyene in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Supplemental Material

sj-docx-2-jia-10.1177_23259582261443731 - Supplemental material for Prevalence, Associated Risk Factors, Knowledge, Attitude, and Practice of HIV/AIDS among Patients Visiting Metema Yohanness Primary Hospital, Northwest Ethiopia

Supplemental material, sj-docx-2-jia-10.1177_23259582261443731 for Prevalence, Associated Risk Factors, Knowledge, Attitude, and Practice of HIV/AIDS among Patients Visiting Metema Yohanness Primary Hospital, Northwest Ethiopia by Getu Melkamu Gorfu, Solomon Tesfaye Sime and Jember Ayelgne Beyene in Journal of the International Association of Providers of AIDS Care (JIAPAC)

Footnotes

Abbreviations and Acronyms

Acknowledgments

The authors would like to thank Metema Yohannes Primary Hospital administration and staff for their cooperation during data collection. We are also grateful to the study participants for their voluntary participation and valuable information provided for this research.

ORCID iD

Jember Ayelgne Beyene

Ethical Considerations

The study protocol was reviewed and approved by the Ethical Review Committee of the College of Natural and Computational Sciences, University of Gondar.

Ethical approval number: IRB-2496 (IRB approval number: 2496).

Permission to conduct the study was also obtained from Metema Yohannes Primary Hospital, with official approval granted by the hospital administration.

The study was conducted in accordance with the principles of the Declaration of Helsinki.

Written informed consent was obtained from all study participants prior to data collection. For participants aged below 18 years, written informed consent was obtained from their legally authorized representatives (parents or guardians), and assent was obtained from the minors themselves where appropriate. For participants who were mentally incapable of providing consent, written informed consent was obtained from their legally authorized representatives. No deceased participants were included in the study.

This statement is provided in compliance with the guidelines of the Committee on Publication Ethics (COPE).

Informed Consent

Informed written consent was obtained from all participants before enrollment in the study. Participation was voluntary, and confidentiality of the information was assured throughout the research process.

Author Contributions

GMG contributed to conceptualization, study design, data collection, data analysis, interpretation of results, and manuscript drafting. STS contributed to methodological support, supervision, data interpretation, and critical revision of the manuscript. JAB contributed to study design refinement, statistical analysis support, manuscript review, and final approval of the version to be published. All authors read and approved the final manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

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

Supplemental Material

Supplemental material for this article is available online.

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