Predictors of HIV/AIDS Knowledge and Attitude among Young Women of Nigeria and Democratic Republic of Congo: Cross-Sectional Study

Background: Adequate HIV/AIDS knowledge and positive attitude towards People Living with HIV/AIDS (PLWHA) are very important and vanguards in averting and ending the epidemics. This study was aimed at assessing predictors of HIV/AIDS knowledge and acceptance attitude towards PLWHA among young women aged 15-24 of Nigeria and Democratic Republic of Congo (DRC). Methods: This was a cross-sectional study which used 2013 Nigeria and 2013-2014 DRC demographic health survey data, with a sample size of 14,619 in Nigeria and 7661 for DRC. SPSS Version 22 was employed to analyze chi-square tests and multivariate logistic regression. P-values of 0.05 were set up to show the statistical significance. Results: Awareness of the young women of Nigeria (91.1%) and DRC (90.6%) was universal. HIV/AIDS knowledge (33.6% Vs 9.8% respectively) and acceptance attitude towards PLWHA (28.4% vs. 3.2%, respectively) was low. Multivariate logistic regression model showed that age, residence, education, religion, marital status and wealth index were significant associates with HIV/AIDS knowledge. Similarly, age, education, religion, marital status, wealth index and HIV/AIDS knowledge showed significant associations with acceptance attitude towards PLWHA. After controlling the confounding variables, higher HIV/AIDS knowledge (OR 1.09, 95% C.I 1.01-1.17) and acceptance attitude towards PLWHA women (OR2.54, 95% C.I 2.17-2.98) was observed among young women in Nigeria than in DRC. Conclusion: Increased HIV/AIDS awareness was observed. However the level knowledge on HIV/AIDS and positive attitude towards PLWHA was very low. Hence educational intervention programs to increase the knowledge of the young women on the epidemic are highly needed. Citation: Gebremedhin SA, Youjie W, Tesfamariam EH (2017) Predictors of HIV/AIDS Knowledge and Attitude among Young Women of Nigeria and Democratic Republic of Congo: Cross-Sectional Study. J AIDS Clin Res 8: 677. doi: 10.4172/2155-6113.1000677


Introduction
HIV/AIDS has become one of the world's most serious public health and development challenges, particularly in low-and middleincome countries [1]. Young women (aged [15][16][17][18][19][20][21][22][23][24] are particularly most vulnerable to HIV with infection rates twice as high as in young men, and accounting for 22% of all new HIV infections and 31% of new infections in Sub-Saharan Africa [2]. In this region, women acquire HIV infection at least 5-7 years earlier than men, often associated with sexual debut [3,4]. According to UNAIDS, the HIV prevalence for young women in Nigeria and DRC in 2013 were estimated 1.3% and 0.5% as compared to 0.7% and 0.3% of young men, respectively [4]. Young women are more susceptible to HIV, as a result of lack of correct health information, inadequate access to reproductive health services, engagement in risky behaviors, financial insecurity, regional and national conflicts, age-disparity, intergenerational sexual relationships, early, forced, and child marriage, gender violence and discrimination [5][6][7][8].
Despite the fact that young women are highly exposed to HIV infection, they were also less likely to have adequate HIV/AIDS about knowledge compared to young men [9]. Adequate knowledge on HIV/AIDS is crucial for averting the HIV infection and ending the negative acceptance attitude and discrimination towards the infected and affected person [10]. Improving HIV/AIDS knowledge has been suggested as an effective HIV preventive behavioral intervention and has been associated with increased safe sex practices, HIV testing and treatment uptake [11]. Several studies of young people from Nigeria [12][13][14][15][16] and elsewhere [17][18][19][20][21] have sought to understand the gaps in their knowledge of HIV/AIDS, with a view towards creating an appropriately targeted educational interventions in improving their HIV/AIDS knowledge and decreasing their risky behaviors. Knowledge about HIV among young people in the western and central Africa continued to be alarmingly low. According to the most recent household surveys, only 24% of young women aged 15-24 years compared to 31% of young men of the same age had comprehensive and correct knowledge of how to prevent HIV [16]. On the other hand, negative attitudes towards HIV/AIDS and PLWHA have been shown to be hindrances for HIV prevention, voluntary counseling and testing, HIV status disclosure and treatment compliance [22,23]. Other studies showed the association between negative attitudes of people towards PLWHA and individual's wrong information about prevention and transmission of the disease [24,25].
Young women are at the center of the global HIV/AIDS epidemic, not only in terms of new infections but also an opportunities for halting the transmission of HIV [26]. United nations made a political declaration in 2016 with a specific target which showed that by 2020 the new HIV infections among young women aged 15 to 24 years should reduce to fewer than 100, 000. Nigeria and DRC were identified as Fast-Track countries in western and central region of SSA [27]. Moreover they are two of those six countries that face the triple threat of a high HIV burden, low treatment coverage and little or no decrease in HIV infections [28]. Adequate Comprehensive HIV/AIDS knowledge and Positive acceptance attitude towards people living with HIVAIDS are vital aspects and vanguard in preventing and reversing the HIV infection [29,30]. No evidence has been shown on associates and comparison of knowledge on HIV/AIDS and acceptance attitude towards PLWHA among young women between Nigeria and DRC, using nationally representative sample data. Therefore the main aim of this study was to assess the main correlates of HIV/AIDS knowledge and acceptance attitude towards PLWHA and to compare the variables between young women aged 15-24 of Nigeria and DRC. It mainly focused on young women aged 15-24 years because they are most vulnerable and highly exposed to HIV/AIDS in both countries and they also have inadequate knowledge about HIV/AIDS and negative attitude towards people living with HIV/AIDS. Hence this study will provide evidence based information which will help program managers for both countries in designing HIV/AIDS programs, proper implementation and evaluation for their contribution regarding HIV/AIDS prevention, hence moving towards achieving the global targets of ending the epidemic.

Data source
The data was sourced from current publicly available Demographic and Health Surveys (DHS) of two countries: 2013 Nigeria and 2013-14 Democratic Republic of Congo (DRC) [31]. In this study only women aged 15-24 years were considered. Variables of HIV-related knowledge and attitudes were selected and categorized based on HIV/AIDS Survey Indicators from DHS [32].

Measures
Dependent variables: The two dependent binary variables were used in this study were two binary variables, HIV/AIDS knowledge and acceptance attitude towards PLWHA. These variables were selected and categorized based on the MEASURE DHS online tools for HIV/ AIDS Survey Indicators Database. The indicators used in this database were drawn from guides from UNAIDS, the United Nation General Assembly Special Session on HIV/AIDS, the Millennium Development Goals, the President's Emergency Plan for AIDS Relief, and the Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis [32].
Comprehensive HIV/AIDS knowledge means an individual is capable of identifying the two major methods of HIV prevention (condom use and having one faithful uninfected sexual partner), Knows that anyone can be diagnosed with HIV despite the health status and reject at least the two most common misconceptions of HIV transmission (can get infected through mosquito bite, sharing food with person who has AIDS and witchcraft and supernatural means). Knowledge was coded 1 if respondents reported five correct responses and 0 was coded if not. On the other hand, acceptance attitudes towards people living with HIV/AIDS means a respondents who had heard of AIDS were asked if willingly they can take care of HIV positive family member, being able to buy vegetables from a person who had HIV, Allow HIV positive female teacher who is not sick to teach and would not hide the status of the family Member's sero-status. Acceptance attitude was coded 1 if the respondents answered all four questions correctly and was coded 0 if not.

Independent variables:
The demographic and socioeconomic characteristics of the survey respondents included were age, level of education, place of residence, marital status, religion, wealth index and occupation. This study focused only on young women aged 15-19 and 20-24 out of seven groups created in DHS data. Type of place of residence was categorized into two groups, 'Urban' and 'Rural' areas in the DHS and were taken without any change. The level of education was also taken as the originally classified four groups: 'No Education' , 'Primary Education' , 'Secondary Education' and 'Higher Education' . Marital status was grouped into three categories: 'Never in union' , 'Currently in Union/living with a man' and 'Formerly in Union/living with a man' . The respondents were asked about their religion, and the responses were grouped into many categories which varied among the two countries. However, this study recoded them into four groups: 'Christian' -(Catholic, Protestant, Arme de Salut, Kimbanguiste and Other Christians), 'Muslim' , 'Other religion' -(Bundu dia Kongo, Animist, Traditionalist and other religions) and 'No religion' . DHS grouped wealth quintiles, including 'Poorest' , 'Poorer' , 'Middle' , 'Richer' , and 'Richest' , were taken to compare the influence of wealth on the dependent variables. The various categories of occupation in the two countries were re-grouped to ' Agricultural' -(self-employed and employee) and 'Non Agricultural' -(professional/technical/managerial, clerical, sales, household and domestic, services, skilled/unskilled manpower, army and others) and 'Not working' .

Statistical analysis
Data analysis was performed using SPSS version 22. Descriptive and chi-square test results were displayed using a table. Multivariate analysis was run using binary logistic regression to analyze the associations between the selected variables of HIV/AIDS knowledge and acceptance attitude towards PLWHA and between these selected variables and countries. Odds ratios and 95% CI were estimated to examine the associations. For all types of analyses, the study used 0.05 of significance level. Table 1 describes the socio-demographic characteristics of young women aged 15-24 years between Nigeria (2013) and DRC (2013/2014). The two countries had majority of respondents from rural areas than urban areas. Considerable number of young women in Nigeria (27.5%) had never attended school. The dominant religious denomination of the young women in DRC was Christians (96.7%) whereas in Nigeria both Christians (51.2%) and Islam (47.8%) share the proportion. Moreover, highest proportion of young women from DRC (52.2%) and Nigeria (56.0%) were single who had never been in union. Majority of the young women were not working. As shown in Figure 1, before the survey most of the Congolese (90.6%) and Nigerian (91.1%) young women had already heard about HIV/AIDS. The knowledge of HIV/ AIDS (28.4% vs. 33.6%, respectively) and acceptance attitude towards PLWHA (3.2% vs. 9.8%, respectively) was low.

Predictors of acceptance attitude towards PLWHA
The data as shown in Table 3  *P-value<0.05, †Religion and † †Occupation were re-categorized

Comparison among the countries
After controlling for confounding factors, HIV/AIDS and acceptance attitude was compared between countries. Likewise, Nigerian young women had 1.09 times more HIV/AIDS knowledge than their counterpart Congolese young women (AOR 1.09, 95% CI 1.01-1.17). The impact was also reflected in acceptance attitude, where Nigerian young women had two and half times more acceptance attitude towards PLWHA than the Congolese young women (AOR 2.54, 95% CI 2.17-2.98).

Awareness and HIV/AIDS knowledge
Awareness is a prerequisite in prevention of HIV/AIDS. In this study the understanding of the young women about HIV/AIDS in Nigeria and DRC was found to be stable. Similar results were also reported in sub-Sahara Africa [33][34][35] and elsewhere [36]. However, despite the high level of awareness of HIV/AIDS, the Nigerian and Congolese young women had low level of knowledge. It is far below the target set in 2001 by the United Nations General Assembly Special Session (UNGASS) to ensure 95% of young people aged 15-24 worldwide have access to correct information, services necessary to boost the life skills needed to reduce their risk to HIV infection [37]. Even it is below the average HIV/AIDS knowledge of western and central region of SSA. Studies done in Sub-Saharan countries and eastern India showed that knowledge of HIV/AIDS ranged from 9% to 42% [9,20,[38][39][40].  However, other studies in Europe revealed an increased degree of HIV/ AIDS and related issues awareness [41]. Age of the respondent was associated with knowledge of HIV/AIDS. Women of aged 20-24 years were more likely to have knowledge than women of aged 15-19 years in both countries. The present findings were similar to previous studies conducted elsewhere [42,43]. Urban based young women were more likely to have knowledge of HIV/AIDS compared to rural based young women. This finding is similar with other studies done in Sub-Saharan African countries [34,44] and elsewhere [40,45,46]. This probably could be due to limited availability of higher educational institutions, modern health services and less coverage of mass media and hence less exposure to information related to sexual and reproductive health information in rural than in urban areas [34,44]. Educational level has strong positive association with HIV/AIDS knowledge among young Nigerian and DRC women. Similar results were also found in other study [34,43,47]. This might be associated with gaining more information and experience from media, academics, students' gender club, the anti HIV/AIDS club and other extra curricula activity in the school that could contribute to raise their understanding and knowledge about HIV/AIDS [48]. Nigerian Christian young women had significantly higher HIV/AIDS knowledge than young women with other religion. Related study from Ghana showed that Christian women had increased knowledge on modes of HIV transmission than women who belonged to African traditional religions or were not religiously affiliated [49]. Other similar finding was also reported elsewhere [43,48]. Both Congolese (AOR=1.16, p<0.023) and Nigerian (AOR=1.48, p<0.008) women who were currently in union/living with a man had increased knowledge about HIV/AIDS than young women who have never been in union. In contract to the present findings, a study conducted in Kenya revealed that ever married young women had less knowledge of HIV/AIDS than never in union women [10]. Wealth index of the young women was found to be a strong associated of HIV/AIDS knowledge in both Nigeria and DRC. This is consistent with other study in Ghana [34]. In another similar study conducted in Ethiopia, wealth index was a strong predictor of knowledge of HIV/ AIDS among adolescents [9]. Socioeconomic deprivation was also associated with reduced media exposure or reduced educational level achievement which turn out to have a negative impact on HIV/AIDS knowledge [20,44]. Knowledge about HIV/AIDS was observed among young Nigerian women belonged to non-agriculture work than those not working.

Acceptance attitude of young women towards PLWHA
Negative attitude and discrimination against PLWHA remains the major obstacles in the fight against HIV/AIDS. It creates barriers to HIV testing and treatment, care and support networks for people infected and affected by HIV/AIDS [50,51]. Acceptance attitude of young women in DRC and Nigeria towards PLWHA was very low. Young Nigerian women aged 20-24 years had more likely to have acceptance attitude towards PLWHA than those young women aged 15-19 years. This finding were similar with findings of a study done in Kenya [52]. However young women from DRC do not show any statistical significance and similar result was reported in Ethiopia and Malaysia [53,54]. Place of residence did not show a significant association with attitudes of young women towards PLWHA in both countries. In contrast to the present finding, study in Bolivia, Botswana and Ethiopia showed different result [35,40,43]. The probability of acceptance attitude towards PLWHA increases with increasing level of education. Young women with secondary and higher education in Nigeria have more likely to have acceptance attitude towards PLWHA than young women with no education. Similar finding was reported from a study conducted elsewhere [35,40,43,48,53]. Young Christian Nigerian women had higher positive attitude towards PLWHA than the young women with other religion. This result is in agreement with a study conducted in Botswana [43]. Young women formerly in union/ living with a man from Nigeria had higher positive attitude than young women never in union. However other study in Malaysia indicated that attitude towards PLWHA was not affected by difference in marital status [54]. Even though the pattern is not uniform, young women in highest socio-economic status both in Nigeria and DRC had more likely to have highest acceptance attitudes towards PLWHA compared to young women in lower socio-economic status. Similar results have also been reported from Bolivia, Tanzania and Nigeria [40,55,56]. Young women from DRC working in agricultural sector had less likely to have positive acceptance attitude towards PLWHA than young women not working. This probably could be due to the fact that young women working in agricultural activities had more likely to live in rural areas and have limited access to education and health services. Hence limited access to accurate information about HIV/AIDS-related knowledge may yield to negative attitudes. Furthermore, young women, from Nigeria and DRC, who have adequate knowledge about HIV/AIDS have more likely to have positive acceptance attitude towards PLWHA compared to those who have inadequate knowledge about HIV/AIDS. Similar results were found in other studies [35,43,53,57]. Thus, whatever intervention made on HIV/AIDS knowledge will positively affect the attitude of the respondents as well [58] .

Comparison among the countries
Generally the HIV/AIDS knowledge and acceptance attitude of the young women in both countries were very low. Comparatively after controlling all the variables, the knowledge of HIV/AIDS and attitude towards PLWHA of young women in Nigeria was found to be 1.1 and 2.5 times more than the Congolese young women, respectively. This mainly could be due to the fact that, Democratic Republic of Congo (DRC) is still struggling to emerge from two decades of armed conflict, which ravaged the country's economic and social welfare systems. According to Human Development Index report of 2014, despite the political and economic progress achieved in recent years, DRC is still one of the least developed countries, ranking 186 out of 187 with an estimated 74% of its population living in poverty.

Conclusion
The study identified, universal awareness, substantial gap in HIV/ AIDS knowledge and negative attitude towards PLWHA among young women in Nigeria and DRC. Age, place of residence, education and wealth index were significantly associated with HIV/AIDS knowledge and acceptance attitude towards PLWHA. Moreover Nigerian young women had more likely to have increased knowledge on HIV/AIDS and positive attitude towards PLWHA than the Congolese women. Realizing, the specific target of 2016 Political declaration on ending AIDS, to reduce new HIV infections among young women aged 15-24 years to fewer than 100, 00 by 2020 and 95% of 2010 UNGASS agreement, we are far from the thresholds. Hence young women, particularly those with lower age, living in rural, with lower educational level and low wealth index should be targeted urgently with dramatic acceleration of action and expanding of education on HIV/AIDS. Future research involving nationally representative samples for male and female, related to sexual behaviors could contribute also significantly to HIV/AIDS prevention and transmission.

Strength and Limitations Strength
The data used in this study were nationally representative with large sample sizes from both Nigeria and DRC. Thus, the results have capacity to estimate the parameter of the whole population in both countries. Moreover the dependent variables were defined based an internationally-accepted and consistent standard method of MEASURE DHS tool.

Limitations
The present study has some limitations that need to be considered; first the study was cross-sectional in nature, which means it is difficult to establish the cause-effect relationship between the independent variable with the outcome variable. Secondly some of the independent variables were documented on self-reported basis, which may have led to recall bias among respondents. Lastly despite that the sample size of the data was large but it also had missing variables which might affect the results.