HIV-related knowledge, attitude and practices of healthy adults in Cross River State Nigeria: a population based-survey

Introduction Human Immunodeficiency Virus (HIV) remains a global health problem disproportionately distributed across Nigeria. Cross river state (CRS), a tourist state, located in the Niger delta, has one of the highest prevalence rates. There is evidence that poor knowledge and stigmatization are obstacles to achieving universal access to HIV prevention programs. The objective of this study was to determine the Knowledge, Attitude and Practice (KAP) of HIV among adults resident in CRS, Nigeria. Methods A cross sectional descriptive survey design was employed. A total of 1,620 healthy adults were recruited. KAP towards HIV was assessed using a structured pre-tested questionnaire. Categorical variables were described as frequencies and continuous variables as median and interquartile range. Kruskal-Wallis test was used to determine relationship between variables and median KAP scores. P value < 0.05 was considered significant. All analyses were performed using Stata 12 statistical package. Results A total of 1,465 respondents completed the questionnaire correctly giving a response rate of 91%. The M: F ratio was 1:1.8. The median age was 38 years. Majority was married and had formal education. Knowledge of HIV and common routes of transmission was high (>80%). However, misconception that HIV can be transmitted through hugging, hand shake, mosquito bites and witch craft was also common (> 60%). The overall attitude and practice towards persons living with HIV infection was poor. Conclusion This study showed misconceptions in the knowledge and consequences of HIV infection which is associated with negative attitude towards persons living with HIV.


Introduction
Human Immunodeficiency Virus (HIV) is a global epidemic currently affecting approximately 37 million persons [1]. Since the beginning of the epidemic in the 80s, more than 70million people have been affected and 35million of them have died [2]. Although tremendous progress has been made in combating the pandemic globally with a 43% reduction in the annual Acquired immunodeficiency syndrome (AIDS) related mortality, huge challenges still lie ahead [1]. The showed that uptake of HIV testing is low with just 23% of males and 29% of females knowing their status [4]. In addition; only 24% of adults who were HIV positive were receiving anti-retroviral drugs.
Thus, over 70% of infected persons remain untreated and serve as sources of new infection. Cross River State (CRS) located in the south-south geographical region of Nigeria is known for it's many international festivals of which the most notable is the annual carnival float which attracts tourists from all over the world. CRS had one of the highest prevalence rates of HIV in the country at the outset of the epidemic. However, with concerted efforts by the government and its agencies, the prevalence of HIV had dropped from 12% in 2003 to 6.9% in 2014 [5]. Nonetheless, this is still higher than the national average of 3.1%. Some of the drivers of this epidemic in the State include high risk sexual behavior and low risk perception of HIV and its consequences [6]. The Cross River State Agency for the Control of AIDS (CRSACA) reported that 75% of the population in the State do not perceive themselves as being personally at risk of HIV infection [7]. Unprotected heterosexual sex is the predominant mode of HIV transmission in Nigeria accounting for about 80% of new HIV infections [8]. Majority of the rest occurs among minority groups such as sex workers, men who have sex with men and intravenous drug users. Although these groups make up less than 2% of the Nigerian population, they account for around 23% of new HIV infections [9,10]. Unsafe injection practices and mother-to-child transmission are other significant modes of transmission [11,12]. Transfusion of unscreened blood or blood products was reported not to be a major source of new infection [13]. Studies in Nigeria among segments of the general population have shown that while knowledge of the nature of HIV is high, practice of unsafe sexual behavior is common and is associated with low knowledge of modes of transmission and risk perception [14][15][16]. The Nigerian Ministry of Health in 2013, reported that only 24% of young people could correctly identify ways to prevent sexual transmission of HIV, and reject common myths [4]. Moreover, the attitude towards PLWHAs is generally negative even among healthcare workers [16,[17][18][19]. The United Nations as part of its Sustainable Development Goals, committed to ending the HIV epidemic by 2030 [20]. For Nigeria to achieve this mandate, KAP studies are necessary to develop suitable health promotion interventions to facilitate health behavior change. It is hoped that this study will add to available knowledge and help promote already LGAs, three wards were randomly selected except in one LGA where 5 wards were selected for ease of access. A total of 29 wards in 9 LGAs in 3 senatorial districts were sampled. whereas categorical variables were presented in frequencies (n) and relative frequencies (%). For knowledge and practice questions, a score of 1 was given to "yes" correct responses while a score of 0 was given to "no" incorrect responses. On the other hand, a score of 1 was assigned to "No" correct responses, whereas a score of 0 was assigned to "yes" incorrect responses (e.g. can HIV be transmitted through witchcraft?). For attitude questions, a score of 1 was assigned to "disagree" responses while a score of 0 was given to "agree" responses (e.g. non-infected persons should not work in the same office as HIV patients). The range of scores for knowledge, attitude and practice were 0-27, 0-5 and 0-3, respectively. The KAP scores were categorized as follows; for knowledge, score of 0-10 = knowledge is minimum, 11-20 = knowledge is adequate, >20 =knowledge is very good. Attitude score of 0-2 = attitude is negative, 3-4 = attitude is fairly positive, >4 = attitude is very positive. Practice score of 0-2 = practice is poor, >2 = practice is good. Spearman correlation was used to assess the relationship between knowledge, attitude and practice HIV scores. All statistical tests were undertaken at 5% significance level.

Results
A total of 1,465 respondents completed the questionnaire correctly giving a response rate of 91%. There were 928 females (63.3%) and 517 males (35.3%). Twenty persons (1.36%) did not indicate their gender. The median age of the study participants was 38years.
Sixty percent were married and 78% had formal education mostly tertiary education. There were 520 (35.4%), 517 (35.2%) and 428 (29.2%) respondents from the southern, northern and central senatorial districts respectively. The majority of the respondents (92%) had heard of HIV but only 52% were aware that it causes chronic infection. The knowledge of the modes of transmission of HIV was also high at 90% for sexual route, 88%, 87%, and 81% for blood transfusion, sharps and mother-to-child transmission respectively. Nonetheless, 78%, 67% and 62.5% responded erroneously that HIV could be transmitted through hugging, handshake, mosquito bites and witchcraft. Concerning knowledge of HIV prevention and control, majority believed that prevention of mother-to-child transmission by treating positive mothers was effective while only 13% agreed that screening family members of openly seek information about HIV against societal expectations [26]. Although education on HIV and related sexually transmitted diseases was recently incorporated in the Nigerian curriculum for primary and secondary schools, lack of adequately qualified teachers and counselors is a major challenge [27].
A negative attitude towards PLWHA was evident in the younger age group, persons with none or moderate education and those from the southern senatorial districts. The finding of a negative attitude towards PLWHA among the younger age group and people with low levels of education is not peculiar to our study. Similar results were reported in studies amongst youths in Nigeria and Tanzania [28,29].