Knowledge, attitudes and behaviours towards people with HIV and AIDS among private higher education students in Johannesburg, South Africa

Background Human immunodeficiency virus and acquired immunodeficiency syndrome (HIV and AIDS) is a global health and social problem, with South Africa having an estimated overall prevalence rate of 13.5%. Compared to young male participants, young female participants have been reported to have less knowledge about HIV and AIDS, including prevention strategies, and this is associated with risky sexual behaviours and negative attitudes towards condom use. Objectives The study investigated gender differences in knowledge, attitudes and behaviours towards HIV and AIDS among 542 private higher education students in Johannesburg, South Africa. Method Participants completed an online structured questionnaire measuring knowledge, attitudes and behaviours as well as demographics (including age, gender and relationship status). Results The results indicate that overall there were no significant differences between male and female students in terms of HIV and AIDS knowledge. However, female students had significantly less knowledge with regard to unprotected anal sex as a risk factor for HIV and AIDS. In addition, young female students reported condom use at last sex less frequently than male students. Nonetheless, both genders reported a positive attitude towards condom use and towards people living with HIV and AIDS. Conclusion It is recommended that the relevant authorities at the state and the higher education level seriously consider implementing specific strategies for preventing HIV and AIDS through improved knowledge, attitudes and behaviours among young females.


Introduction
Since the beginning of the epidemic, human immunodeficiency virus and acquired immunodeficiency syndrome (HIV and AIDS) has affected more than 70 million people globally, accounting for 35 million deaths. 1 As of 2018, over 30% of the global HIV and AIDS prevalence has been among the youth aged 15-25 years, with 5 million young people currently living with HIV and AIDS. 1 The youth between the ages of 15 and 24 years account for 45% of new infections. 2 The burden of HIV and AIDS is concentrated in sub-Saharan Africa, where 71% of people living with HIV reside and where 65% of new infections reported in 2017 occurred. 3 The female population is disproportionately affected by HIV, with three in four new infections reported among girls aged 15-19 years, while the young female population aged 15-24 years is twice as likely to be living with HIV and AIDS than their male counterparts. 4 among the youth by improving their ability to practice safe sex. This is likely to improve the uptake of HIV prevention strategies to address the increase in the prevalence of HIV and AIDS in vulnerable populations. 6,7 Young female participants are twice as likely to be infected with HIV and AIDS, compared to young male participants, with the most common means of transmission being unprotected sex, and the key barriers to prevention being lack of knowledge, negative attitudes and risky sexual behaviour. 3,6,8 Knowledge facilitates familiarity with and awareness of HIV and AIDS, which influences attitudes (resulting in support and motivation for prevention) as well as behaviour (safer sex practices), thereby reducing the risk of infection. 9 A high prevalence of HIV and AIDS is associated with lower levels of knowledge about the modes of transmission and condom use, negative attitudes towards condom use and risky sexual behaviours such as unsafe sex and multiple sex partners. 10,11 The young female population has been shown to possess significantly lower levels of knowledge as well as misconceptions and erroneous beliefs about HIV and AIDS, compared to the male population. 6,12 This is often associated with negative attitudes to prevention strategies, which have been shown to affect behaviours such as condom use. 13 Studies have also confirmed that HIV and AIDS testing attitudes and the intention to use condoms are influenced by knowledge. 14,15 Charles et al. 16 reveal that although the young female population is more concerned about HIV and AIDS infection, they agree less than the young male population on condom use as a safe sex strategy. The attitudinal gender differences of the young female population with regard to transactional sex are thought to result in risky behaviours such as unprotected sex with older men. 17 Although it is known that the young female population is more susceptible to HIV and AIDS infection, there is a paucity of research on gender differences in knowledge, attitudes and behaviours among young people in higher education settings, thereby inhibiting an in-depth understanding of factors contributing to HIV and AIDS infection among this population in South Africa. Such a gap in the literature negatively influences policy and practice aimed at reducing HIV and AIDS rates among vulnerable youth within this context. This study was aimed at identifying gender differences in knowledge, attitudes and behaviours among the youth at a private higher education institution in Johannesburg, South Africa. It is envisaged that this will allow for the development of specific strategies for preventing HIV and AIDS infection among the youth at private higher education institutions in South Africa. The research question seeks to determine differences between the male and female populations on knowledge, attitudes and behaviours towards HIV and AIDS. It is hypothesised that knowledge, attitudes and behaviours will differ between the male and the female populations.

Study design
This cross-sectional survey was conducted at a private higher education institution in Johannesburg, South Africa. Participants were invited via an online learning platform where they completed and submitted a structured questionnaire assessing sexual risk and sexual prevention behaviours.

Setting
Johannesburg is the capital of Gauteng province and is considered the largest and the wealthiest city in South Africa. With a population estimated at 5.6 million, it is the most populous city in the country, with 66% growth rate in population expected over the next 30 years. Racial profiles indicate that 76.4% of the population is black African, 5.6% is mixed race, 12.3% is white or of European descent and 4.9% is of Indian or Asian descent. Approximately, 7% of the population is illiterate, 3.4% have only a primary education, 41% have completed secondary education and 6% have a tertiary qualification. 18

Study population and sampling
Random sampling was used to recruit 845 students enrolled at a private higher education institution in Johannesburg, South Africa. Random numbers were generated using a computer program to select participants from the sampling frame -enrolment records. A global email was sent to all potential participants inviting them to participate in the study. Of those invited to participate in the study, 542 responded -a response rate of 64%. Participants completed an online questionnaire via their online learning platform, which contained study information and instructions for accessing and completing the questionnaire.

Data collection and analysis
An online structured questionnaire measuring knowledge, attitudes and behaviours as well as demographics (including age, gender and relationship status) was completed by the participants. The questionnaire was developed as part of a larger study using existing literature and consisted of 93 questions of which 51 questions were on knowledge about HIV and AIDS transmission and prevention, attitudes towards HIV and AIDS, including treatment and prevention methods (six questions), and sexual behaviours (36 questions).
Data were cleaned and checked for errors before coding and analysing using STATA 14.0 (StataCorp, College Station, TX, USA). To evaluate knowledge and behaviours, respondents were required to provide mostly 'yes' or 'no' responses. For the knowledge score, a score of 1 was assigned for a correct answer and 0 for a wrong answer. For the attitude questions, a rank was assigned using the Relative Importance Index to obtain an overall rank for each attitude item. For knowledge, attitudes and practice questions (knowledge and awareness of HIV & AIDS, prevention and control of HIV, students' attitudes towards condom use and people living with HIV, risky sexual behaviours), the frequency of responses in each category was determined. A chi-square test was used to evaluate the variation in knowledge, attitude and behaviour between male and female students. For all tests, p < 0.05 was considered statistically significant.

Ethical considerations
Ethical approval to conduct the study was obtained from Monash University Human Research Ethics Committee (MUHREC) (approval number CF15/1095 -2015000518). No identifying information was obtained from students when they completed the questionnaire. A unique identifier was generated when the questionnaire was submitted. All the data were deidentified for analysis. Data were stored in password-protected files and will be retained for up to 5 years after the study.
There were high levels of awareness and knowledge about biomedical methods of HIV prevention amongst the sample group. More female (77.1%) than male students (64.1%, p = 0.003) said that they had heard about medication that HIV-positive pregnant women could take to reduce the risk of infecting the baby with HIV, and more female (59.9%) than male students (47.6%, p = 0.015) had heard about medication that could help to reduce the risk of HIV infection if a woman had been raped. A higher proportion of male (95.8%) versus female students (85.7%, p = 0.001) said that they were able to obtain a condom. There was no significant difference between the proportion of male (97.0%) and female students (94.1%) about where to get condoms ( Table 2).
Knowledge about HIV transmission was high, with 98.1% of female students and 96.4% of male students knowing that the virus could be passed on through unprotected sex. A high proportion of male students (92.9%) and female students (90.9%) knew that a person can have HIV and pass it on to others without showing symptoms. Also, most female students (77.4%) and male students (76.8%) knew that STIs put people at greater risk of HIV infection. However, only 33.6% of female students and 39.3% of male students admitted that they knew that anal sex increased the risk of HIV infection. A low proportion of female students (16.9%) and male students (21.4%) knew that people can reduce their chance of getting HIV by using a condom every time they have sex. More female (96.2%) than male students (91.7%) were aware that AIDS could not be cured. Most of the female students (n = 307, 82.5%) and male students (n = 119, 70.8%) indicated that partners could not have sexual intercourse if both partners were HIV-positive (p = 0.002) ( Table 3).
As illustrated in Table 4, a substantial number of students expressed positive attitudes towards condom use. Across age and gender groups, a significant majority of students       (3) 7.6% of students felt that people who get infected with HIV are promiscuous. Forty-one (7.6%) students also said they do not want to be associated with HIV-positive people, and 6.4% of students felt that HIV-negative people should not be allowed to socialise with HIV-positive people. Students had positive attitudes towards treatment for HIV and AIDS. Around two-thirds (63.1%) of the students agreed that HIV treatment would keep an HIV-positive person alive (ranked the most important attitude). Two hundred and seventy-four (50.8%) students agreed that HIV medication really works (with a relative importance score of 2). Most of the respondents (69% students) rejected the notion that antiretroviral (ARV) medication is poisonous (Table 5).
Condom use at last sex was higher when with a regular partner: female students (n = 147) and male students (n = 93). The difference is statistically significant (p < 0.001). Fewer female students (n = 53) and male students (n = 57) reported using condoms consistently with a non-regular partner (p = 0.049). More female students (n = 83) reported consistent condom usage (every time) with regular sex partners than male students (n = 54); however, the difference was not significant (p = 0.240) ( Table 6).

Discussion
South Africa is battling an HIV and AIDS pandemic, which remains one of the primary social and health concerns in the country. Notwithstanding the outstanding effort by the Department of Health in implementing HIV and AIDS prevention strategies, South Africa is still the country worst  affected by the HIV and AIDS pandemic, with the youth between the ages of 15 and 24 years being the hardest hit. 5 Young female students are reported to have higher infection rates owing to a lack of knowledge and poor attitudes towards condom use and risky sexual behaviours, 6 making them twice as likely as male students to be infected with HIV. 3,6,8 This study was aimed at determining gender differences in knowledge, attitudes and behaviour in relation to HIV and AIDS among students at a private higher education institution in Johannesburg, South Africa.
Findings in this study indicate that there is no significant difference between male and female students in terms of their general knowledge of HIV and AIDS. However, it is noteworthy that female students had significantly less knowledge of unprotected anal sex as a risk factor for HIV and AIDS. In addition, a smaller proportion of female students reported condom use at last sex, compared to their male counterparts. This could be attributed to the female population having limited control over male condom usage. 19 The complex power imbalance in this scenario, with most females not having the power to negotiate condom use with their partners, is the likely underlying cause. 20,21 Moreover, 8.3% of male students and 3.8% of female students believed that AIDS can be cured. Although these percentages are comparatively low, they are equally as disconcerting as the results in Haroun et al., 22 who found that just over 20% of a sample of university students in the United Arab Emirates did not know whether HIV and AIDS could be cured or not. This poor knowledge of basic messages relating to HIV and AIDS is a likely reason as to why the youth engage in risky sexual behaviour and why the prevalence of HIV infection among them is high. 23 Regarding risky sexual behaviour, this study revealed notable differences between male and female students, with the latter (57.3%) and the former (37.2%) reporting not having used a condom at last sex with a non-regular partner. As the chisquare test revealed no significant variation in attitudes between male and female students, we opted to investigate the entire sample's attitudes rather than to compare male and female students. Results revealed that the majority of participants (83.4%) had a positive attitude towards people living with HIV and AIDS. This differs from previous findings where the majority indicated negative attitudes towards people living with HIV and AIDS. 22 Positive attitudes such as these have been attributed to parental and social communication aimed at promoting HIV and AIDS awareness among the youth. 24

Limitations
There were a disproportionate number of female students, compared to male students in this study. It is possible that this might have affected the robustness of the chi-square test and therefore skewed the findings. In addition, the sample came from one private higher education institution in Johannesburg, South Africa. It would have been ideal for more institutions to be included in the study to get a better picture of the knowledge levels, attitudes and behaviours towards HIV and AIDS at private higher education institutions in the Johannesburg metropolitan area. Notwithstanding these limitations, these findings could serve as a springboard for national research that would be more representative of the wider student population in both private and public higher education institutions.

Recommendations
It is recommended that future research should sample students from several private and public higher education institutions with a representative number of both male and female students. This could then inform interventions that reduce HIV infection among the youth in South Africa through improved attitudes facilitated by communication at both social and parental levels. 24 It is further recommended that sex education in secondary schools should be introduced to close the gender gap in knowledge and prevent risky sexual behaviours.

Conclusion
This study found that the level of HIV and AIDS knowledge in female students was not significantly different than in male students although risky sexual behaviour in female students was more frequent. In addition to the existing interventions aimed at reducing the prevalence of HIV and AIDS among the youth in South Africa, efforts towards implementing interventions at educational as well as social and family-based levels are imperative.