Our study proved that although there are disparities in knowledge levels amongst islands in Indonesia, the distribution of the knowledge follows a remarkably similar pattern. The uniformity in the proportion of accurate responses across all islands is most likely due to Indonesia’s HIV/AIDS preventive policy being structured and coordinated from the national to local government levels [13]. According to the findings of sociodemographic studies based on multiple linear regression analysis, the following variables influence Indonesians’ knowledge of HIV/AIDS: (i) region/island; (ii) education level; (iii) monthly expenses; (iv) occupation; (v) background in health education; and (vi) participation in seminars or workshops on the topic. Furthermore, this study found that most participants know that HIV can be caused by having sex with more than one partner. The findings corroborate a previous study conducted in Yogyakarta, Indonesia [14]. Although addressing sexuality is widely considered taboo in Indonesia [15, 16], it has been stated that education regarding free sex and HIV began around two decades ago in the country, even at the elementary school level [17].
Remarkably, less than a quarter of participants were familiar with the use and varieties of condoms. This indicates a dearth of condom knowledge in the general population of Indonesia. It is common knowledge that HIV/AIDS prevention and promotion programs are standardized, i.e., based on a plan approved by government ministries [18, 19]. In the Asia-Pacific region, including Indonesia, the HIV epidemic is concentrated among the significant populations of men who have sex with men (MSM), female sex workers, people who inject drugs (PWID), and transgender women (waria), making HIV education and treatment a national priority for these populations [20, 21]. Several HIV-related studies undertaken in Indonesia's key populations have established an association between condom awareness and usage frequency. Greater understanding of condoms is associated with increased prevalence of their use [22–26]. According to the findings of this study, there is an urgent need to educate not only targeted populations but also the general community about condoms, despite the fact that explaining or socializing people about how to use condoms properly remains a challenge.
In addition, we also discovered that only around a third of all participants were able to accurately respond to questions about the HIV virus's incubation period (window period) and transmission from pregnant woman to the fetus. Notably, Indonesia is not the only nation dealing with this problem, while the lack of public awareness regarding HIV symptoms and mother-to-child transmission routes has been noted in various Asian and African countries, particularly among non-HIV/AIDS populations [27–32]. These findings should be considered when developing HIV/AIDS instructional materials. In summary, we recommend that HIV/AIDS education materials focus on: (i) mother-to-child HIV/AIDS transmission; (ii) condom usage to prevent HIV/AIDS transmission; and (iii) understanding of the incubation period of HIV. Finally, we advise that HIV/AIDS education be targeted at the undergraduate I for those whose highest level of education is Senior High School, including those with backgrounds in disciplines other than health education. Additionally, Eastern Indonesia needs to be included in the geographic area covered by HIV/AIDS education (more specifically, remote and rural areas). Regarding teaching materials, we seriously encourage strengthening awareness on condom use, which not only works to prevent pregnancy but also HIV, particularly among adolescents.
The regression analyses demonstrated that regions, education level, monthly expense, occupation, background in health science, and workshops on HIV/AIDS were determinant factors for HIV knowledge. As shown in Table 2, Javanese and 'Bali and Nusa Tenggara' participants have a significantly higher average level of knowledge (12%) than participants from Sumatra, Kalimantan, Sulawesi, Papua, and Maluku. Over half of those infected with HIV in Indonesia are found in Java and Bali [33]. Furthermore, the majority of urban concentration areas are located in both regions [34]. It is generally recognized that living in larger cities and having a higher prevalence of HIV provide greater availability and access to sources of HIV/AIDS information, resulting in a better understanding of the disease [35–38].
In line with previous investigations performed on various populations [28, 35, 36, 39–44], the present study found that for overall participants, the higher their degree, the higher their monthly expenses, having permanent jobs, having a health educational background, and having attended HIV/AIDS seminars/ workshop, then the more knowledgeable they are. However, the results of the one-way ANOVA analysis for participants’ monthly expenses and experience in HIV/AIDS workshop per island have shown a difference in the trends of participants from Bali and Nusa. It is essential to recognize that, the R2 value of this study is relatively low. Several studies in countries with a high incidence of HIV highlight additional knowledge-related characteristics that have not been investigated in this study, including HIV awareness and behavior, stigma, social media use, and HIV testing history [28, 31, 45–47]. Thus, it is challenging to develop a complete picture of the factors impacting the HIV knowledge of the general population of Indonesia.
The participants with the highest level of HIV knowledge were the ones who spend between 2–3 million rupiahs per month in Bali and Nusa. Bali's population is more than 90% economically active and almost evenly distributed across all educational levels [48]. Bali is a target area for national tourism. It was interesting to note that tourism is linked to a rise in knowledge on reproductive health issues including HIV/AIDS and sexually transmitted illnesses [49–51]. Recognizing the serious threat, the Bali community and government have developed a comprehensive HIV/AIDS promotion and prevention program that involves community empowerment at all levels [52–54].
To date, we have yet to locate a comparable study in Indonesia, particularly with the number of participants representing nearly all regions of Indonesia (West, Central, and East). We compared our results in the 17–25 age range (n = 3,104) with a study of university students in Malaysia (n = 405) [55]. The mean score of HIV-AIDS knowledge among Indonesian students was 10.8, with Java (n = 1,209) having the highest score (11.2/18) and Sulawesi (n = 1,735) having the lowest (9.8/18). One study in Jakarta, Indonesia, conducted in 2019 used the HIV-KQ-18 instrument to assess participants' knowledge of HIV/AIDS. There were 81 participants in total, with an equal number of men and women. According to the study's findings, 56% of participants had low test scores, with a mean of 8.20 out of 18. There were 19 participants in the 18–25 age range, and 10 of them scored in the low range [56]. Comparing these results to a study with a student population in Malaysia revealed that their mean HIV/AIDS knowledge score was 7/18 [55]. In addition, we did not detect a significant difference between males and females, although the Malaysian study found that male students had greater knowledge than female students [55]. In addition, an analysis of the level of HIV/AIDS awareness among university students in South-eastern Ethiopia (n = 442.67% male) revealed that more than half of the students showed a low level of HIV/AIDS knowledge. Field of study, year of study (duration of study), and monthly income were three significant factors. In that study, it is advised that HIV/AIDS teaching at universities should involve several years of study and that risk reduction measures should prioritize behavior modifications [57].
Another finding that is also interesting to discuss is the item that is most easily answered correctly by the participants. Our study found that almost 100% of Indonesian participants agreed that 'Having sex with more than one partner can increase a person's chance of becoming infected with HIV (item number 14).' Comparing this finding to a research on HIV Knowledge and Associated Factors among Internet-Using Men Who Have Sex with Men (MSM) in South Africa and the United States revealed that nearly 100 percent of participants answered questions 16 (a person can get HIV by sitting in a hot tub or a swimming pool with a person who has HIV) and 17 (A person can get HIV from oral sex) correctly [56]. In addition to continuing with the 'faithful to 1 married couple' campaign, the HIV/AIDS education topics that have been implemented in Indonesia should also emphasize the possibility of other transmission routes, such as oral and anal sex, as strongly suggested by this study.
One of the research's strengths is the location of the data collection in all main Indonesian islands, where each island is represented by at least one urban region (provincial capital) and one rural area (city/ district). Furthermore, we found that Indonesian people continue to hold the belief that only "having several sex partners (free sex) causes and transmits HIV/AIDS." In fact, HIV transmission can actually happen due to a variety of causes, such as from a pregnant woman to the fetus. Also, negative stigma against those who are living with HIV/AIDS is very likely to emerge due to a lack of understanding of this disease. The fact that young adult people and adolescents are more habituated to using condoms as a method of contraception is more known than condoms' effectiveness in preventing the transmission of HIV. In fact, this age demographic is the most vulnerable compared to others. Beyond that group, the Indonesian authorities still have significant work to do in the area of condom education. A qualitative study in Indonesia on condom use with 42 male participants who had sexual relations with female commercial sex workers (FCSW) confirmed that some of the reasons they eventually decided not to use condoms despite knowing that doing so could increase their risk of contracting HIV/AIDS are as follows: (i) limited sexual pleasure obtained during biological intercourse; (ii) difficulty in accessing and relatively expensive condom prices; (iii) condoms are perceived as having no benefit; (iv) low self-awareness to avoid the negative effects of not using condoms; and (v) feeling embarrassed to purchase condoms [25]. In addition, an analysis of condom use trends among female commercial sex workers in Bali, Indonesia found that FCSWs with higher rates of sexual transactions are more knowledgeable of condom use during risky activities than those with lower/middle rates. Moreover, the role of 'a pimp' in the transaction also plays an important role [25]. Hence, our results can be used as a scientific resource to inform and generate more pertinent HIV/AIDS condom education.