Knowledge and Attitude of Nursing Students about HIV/AIDS in Sohag, Egypt

Background: Egypt is reported to have the fastest growing epidemic of HIV in the Middle East and North Africa Region. Nurses who play a crucial role in delivering health care to persons with HIV/AIDS should be equipped with adequate knowledge about HIV/AIDS, in order to have sense of comfort to enable positive attitude towards such patients. Objective(s): The aim of this study was to assess knowledge and attitude regarding HIV/AIDS among nursing students in Sohag University. Methods: Across-sectional study was conducted among 324 randomly selected students of Faculty of Nursing, Sohag University, Egypt during the academic year 2019/2020. A self-administered questionnaire was used for collecting data about socio-demographic characteristics, HIV/AIDS knowledge and attitude of the study participants. Results: Most of the participants (78.4%)had a good overall knowledge about HIV/AIDS. However, some misconceptions were found as only 12.7% of them knew that HIV/AIDS cannot be prevented by vaccine. About 19% of the respondents mentioned that HIV cannot be transmitted by using toothbrushes. Less than one third were aware that HIV cannot be transmitted by either mosquito bites or by using swimming pools or toilets with infected persons and that persons may be symptoms free for more than 10 years. Concerning attitude, more than half of the students (52.6%) had negative attitude towards HIV/AIDS patients. On conducting logistic regression analysis, male sex and residing in urban areas were significant predictors of good knowledge and positive attitude towards HIV/AIDS, respectively. Information about HIV/AIDs was gained from TV (60.6%) followed by internet (45%), university curriculum (27%), friends (22%) and family (18%) Conclusion: The studied nursing students had moderately good general knowledge about HIV, but several misconceptions were prevalent among them. However, more than half of them exhibited negative attitude towards HIV/AIDS indicating urgent need for training programs to improve their knowledge and change their attitude towards persons with HIV/AIDS.


INTRODUCTION
ince the beginning of its epidemic in 1981, more than 70 million people had been infected with HIV. It was estimated that about 37.9 million people were living with HIV till the end of 2018. (1) Egypt is classified as having low epidemic level of HIV with a prevalence rate less than 0.1%. (2) The estimated number of people living with HIV in Egypt till the end of 2016, is considered relatively low (11,000). However, Egypt is reported to have the fastest growing epidemic in the Middle East and North Africa Region (MENA) by a 76% increase in number of cases between 2010 and 2016. (2,3) More than 62% of HIV infected persons receive antiretroviral therapy. (4) This means that HIV/AIDS is becoming a chronic disease, so, more health care providers especially nurses will encounter HIV-infected individuals throughout their work. In addition, weakness in adherence to infection control protocols in most developing countries pose great risk of HIV infection of the nurses during their daily work. (5) Nurses play a significant role in the prevention, care, and support of HIV infected patients. Higher levels of knowledge about HIV/AIDS positively influence the nurses' level of self-protection, their level of comfort and are conducive to more positive attitudes towards persons with HIV/AIDS. (6) Several studies identified discriminating attitude of nurses towards HIV/ AIDS patients. (7)(8)(9) Stigmatizing attitudes from healthcare workers against such patients had been reported to be responsible for decreased medication adherence, decreased retention in care, and increased the number of new HIV infections. (10,11) The current study aimed at assessing the knowledge and attitude regarding HIV/AIDS among students of the Faculty of Nursing, Sohag University, Egypt.

METHODS
A cross-sectional study was conducted in the Faculty of Nursing, Sohag University during the academic year 2019/2020.The sample size was calculated by Epi-Info program based on the following assumptions: Expected percentage of poor knowledge regarding HIV= 30 ± 5%% (12) , and 95% confidence level. It was found that the minimum required sample size was 323.
The studied students were selected by a stratified random sampling technique. Students were divided into four strata representing the four grades. From each grade, one or two classes were selected randomly from a list that contained all classes in each grade, based on proportion of the number of students in this grade to the total number of students in the faculty.
A self-administered structured questionnaire that was prepared by the researcher was used for data collection. The questionnaire consisted of three parts. The first part included questions about the socio-demographic characteristics of the students, such as age, sex, type of preuniversity education (whether secondary school or nursing institute), residence, maternal and paternal education.
The second part was the HIV/AIDS knowledge questionnaire, which included 35 questions. The first section included 14 questions that tested general knowledge about HIV/ AIDS, while the second section contained 14 questions which tested different routes of transmission of HIV and the third section consisted of 7 questions that tested methods of control and prevention of HIV infection. For each question of the questionnaire participants were instructed to choose one of three answers (yes, no and I do not know). Regarding scoring of the knowledge part, 1 point was given for each correct answer and 0 points for wrong answer or I do not know answer. Scores of each response were then added to obtain a final score ranging between 0-35. Participants whose overall knowledge score was 17 or below were considered as having poor knowledge, while score of 18 or more was considered as good knowledge.
The third part was for assessment of attitude. The AIDS Attitude Scale (AAS) developed by Froman and Owen (1997) (13) was used. It consisted of 10 items designed to assess students' personal attitudes and beliefs towards persons with HIV/ AIDS. Nursing students were asked to identify the degree to which they agreed with each item on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Scores of all responses were added and the mean score was calculated, it ranged between 1-5 and a mean score of 3 or above was considered a positive attitude.

Statistical analysis
The statistical analysis was carried out using SPSS software for Windows (version 22.0). Descriptive statistics was presented as frequencies, percentages, mean and standard deviation. Predictors of HIV/AIDS knowledge and attitude were determined by logistic regression analysis. Statistical difference was considered when pvalue was less than 0.05.

Ethical considerations
The current study complied with the International Guidelines for Research Ethics and the principles of Helsinki declaration. The approval for conducting this study was obtained from the Scientific Research Ethics Committee of the Faculty of Medicine, Sohag University. In addition, a written informed consent was obtained from each participant after explaining the purpose of the study to all the participants ensuring confidentiality and anonymity of all the collected data. Table 1 illustrates the socio-demographic data of the study participants. The age of the studied nursing students ranged between 17 and 26 years (Ẍ ± SD= 20.3 ± 1.3 years).The students were nearly equally distributed between the four grades of the Faculty of Nursing. About two thirds of the study participants were females (64.5%), 78.4% of the students had secondary school pre-university education compared to 21.6% of them who studied in nursing institutes. There was a larger proportion of rural students (65.4%), and 36.4% of the students' father had university education compared to 32.1% of the students' mothers.  Figure 1 shows the distribution of nursing students according to their knowledge and attitude regarding HIV/AIDS. Most (78.4%) of the studied subjects had good overall knowledge about HIV/ AIDS, while 52.6% had a negative attitude towards HIV/AIDS. As regards knowledge about HIV/AIDS, the overall mean knowledge score was 20.5 ± 5.3 points with a minimum of 5 and a maximum of 30 points. The mean score for knowledge regarding modes of transmission was 8.1 ± 2.73 out of 14 points with a minimum of 1 and a maximum of 13 points (data not shown).

Figure 1: Distribution of the studied nursing students according to their HIV/AIDS knowledge and attitude scores
Frequency and percentage distribution of the correct answers of the nursing students concerning questions on HIV/AIDS are displayed in table 2. Most of the respondents (83.3%) knew that AIDS is an infectious disease, that it is caused by a virus that attacks the immune system(82.4%) and that HIV/AIDS increases body susceptibility to other infections (81.8%). As regards routes of transmission, the vast majority of the respondents were aware that HIV can be transmitted by receiving contaminated blood, by having unprotected sex with an infected person and by sharing needles with infected persons (83.3%, 80.2% and 81.4%, respectively). However, some misconceptions were found as only 10.5% of the studied subjects were aware that persons with HIV/AIDS do not always look ill or tired and 12.7% of them knew that HIV/AIDS cannot be prevented by vaccine. Less than one fifth of the respondents (18.8%) mentioned that HIV cannot be transmitted by using toothbrushes. Only less than one third of respondents were aware that HIV cannot be transmitted by either mosquito bites or by sharing swimming pools or toilets with infected persons and that persons may be symptoms free for more than 10 years (28.7%, 27.8% and 29%, respectively). Data about the response of participants on the different questions of AIDS attitude scale are displayed in table 3. The responses of the studied nursing students reflected negative attitude towards people with HIV/AIDS, as many of the respondents strongly agreed (36.4%) or just agreed (22.7%) that people with HIV/AIDS only have themselves to blame. Most of them strongly agreed (46.3%) or just agreed (35.8%) that persons with HIV/AIDS should be kept in separate rooms on hospital admission. Most of them either strongly agreed (37.7%) or just agreed (39.8%) that they should worry about putting their family and friends at risk of contracting the disease when caring for a person with HIV/AIDS. Also the majority of the respondents strongly agreed (32.7%) or just agreed (42.6%) that healthcare workers are worried about getting the infection from caring for a person with HIV/AIDS in their work environment. Mean knowledge score ± SD 20.5 ± 0.3 SD, standard deviation

Figure 2: Sources of knowledge for HIV/AIDS among the studied nursing students in Sohag University, Egypt
On the other hand, most participants strongly agreed or just agreed that patients with HIV/AIDS have the right to the same quality of care as any other patients (47.2% and 28.1%, respectively), the importance of working with them in a caring manner (62.3% and 25.6%, respectively) and that patients with HIV/AIDS should be treated with the same respect as any other patient (59.6% and 28.7%, respectively). The majority of the respondents strongly agreed (34.3%) or just agreed (49.1%) on having sympathy with HIV misery. However, nearly equal percentage generally agreed (41.6%) and disagreed (40.5%) regarding keeping confidentiality, even if it puts other people at risk of contracting the disease. Male sex was a significant predictor of good knowledge about HIV/AIDS and urban residence was a significant predictor of positive attitude towards HIV/AIDS. No significant association was found between knowledge and attitude of the studied students towards HIV/AIDS. Sources of knowledge for HIV/AIDS among nursing students are displayed in figure 2. Information about HIV/AIDs was gained from TV (60.6%), followed by the internet (45%), university curricula (27%) and friends (22%). Family represented the least frequent source of knowledge among the studied participants (18%) ( Table 4).

DISCUSSION
Undergraduate nursing students should be equipped with sufficient knowledge about HIV/AIDS in order to develop well trained nursing staff strictly adherent to the infection control measures and at the same time compassionate towards these patients. Many previous studies assessed nursing students' knowledge and attitude towards HIV/AIDS in many developing and developed countries. (7)(8)(9)(10) In Egypt, as far as we know, only one study was conducted by Taher et al., assessed knowledge and attitude of the nursing satff of Kasr El Aini Teaching Hospital and of the first grade Nursing Institute students regarding HIV. (14) The current results demonstrated that the nursing students exhibited good overall knowledge about HIV/AIDS. The overall mean knowledge score was 20.5 ± 5.3 points, and most of the respondent (78.4%) had good level of knowledge. These results were comparable to results found by Taher et al., (14) Akin et al., in Turkey (15) and Souminen et al., in three Baltic Sea countries. (16) In respect to general knowledge of the nature of HIV/AIDS, only 10% of the participants were aware that persons with HIV/AIDS do not always look ill or tired. This finding was lower than what reported by Wong et al., in Malaysia and Ayranci in Turkey, who reported that 28.7% and 39.2% of the studied nursing students thought that persons with HIV/AIDS could be recognized by appearance. (17,18) This fact necessitates the development of educational interventions that correct such misconception before graduation and patients contact. Otherwise, students will be at high risk of getting the infection form apparently healthy patients.
Previous literature (15,19,20) supported our findings that the majority of the participants (more than 80%) were aware that HIV/AIDS can be transmitted by using infected syringes, blood transfusion and sexual intercourse. On the other hand, these results were lower that what was reported by Suominen et al., (21) and Mahesh and Vaishali (22) , as more than 90% of the participants knew the correct modes of HIV transmission.
In contrast to previous studies, (19,21,22) the present study participants had many misconceptions regarding the modes of HIV/AIDS transmission. Such misconceptions were also found among Assiut University students, (12) among Turkish nursing students (15) and among students at Yemen health institutes. (23) Our results were better than those of the study conducted by Goel at al., (24) who reported that only 1.1 % and 2.1% of the nursing students were aware of the fact that HIV could not spread by urine and mosquito bites, respectively. The above observation needs attention from Faculty of Nursing authorities regarding the necessity of providing full knowledge to the nursing students.
We found that 52.6% of the nursing students had negative attitude towards persons with HIV/AIDS. Negative attitude of nurses towards HIV/AIDS had been reported in many studies. Hassan and Wahsheh, found that the Jordanian nurses expressed overwhelming fear of patients who tested positive for HIV/AIDS, and the majority refused to provide care to them. (25) Moreover, Taher et al., (14) and Ayranci (18) reported the presence of negative attitude among nurses towards HIV/AIDS patients despite having good knowledge about the disease. Furthermore, Al-Rabeei et al., reported that students at Yemen health institutes stated that HIV-infected persons needed to be punished (65.5%) and isolated (41.0%). However, 86.8% were willing to care for an HIV-infected person. (23) This confusion between having negative attitude towards persons with HIV/AIDS and admitting their rights of receiving good quality of care was also observed in the current results.
The present study showed that male sex was a predictor of good knowledge about HIV/AID, which was in agreement with Akin et al. (15) In line with Akin et al., (15) HIV/AIDS attitude scores were not significantly associated with age, sex, grade, paternal and maternal education although those living in urban areas were found to have more positive attitude towards HIV/AIDS than those living in rural areas.
No significant association was found between knowledge and attitude of the studied students regarding HIV/AIDS. These results were in accordance with those reported by Akin et al., (15) and Maharashtra and Vaishali. (22) This means that the knowledge and attitude of nursing students are built independently and emphasizes focusing attention of the Faculty authorities on building better nurse to patients relationships that is based on developing confident skillful nurse that can deal and cope with HIV patients. Today variant sources for knowledge about HIV/AIDS are available, so every person can easily access such knowledge. Observations of the present study were supported by results of many studies in Egypt and other countries. (12,14,18,25) These studies revealed that television and the internet were the main sources of knowledge about HIV/AIDS. On the other hand, Akin et al., (15) found that Turkish nursing students listed school courses, magazines and the internet as the most common sources of information about HIV/AIDS. TV has always played prominent effect in raising awareness of various health issues, including HIV, hence these findings are not surprising but indicate the urgent need to incorporate more HIV related information in nursing students curricula to reduce misconceptions

CONCLUSION AND RECOMMENDATIONS
The current study revealed that nursing students had moderately good level of knowledge about HIV/AIDS, but they still had many misconceptions, especially regarding the modes of transmission of the disease. Moreover, more than half of them had negative attitude towards persons with HIV/ AIDS. TV was the source of information for about 60% of the studied nursing students, internet for 45%, while university curriculum was only for 27% of them. That necessitates presence of an educational curriculum focusing on routes of transmission and how to reduce the risk of infection and capable to achieve behavioral and attitudinal change towards HIV/AIDS patients.