Knowledge and Awareness about HIV and AIDS among Iraqi College Students

Molecular Virology Laboratory, Department of Molecular and Medical Biotechnology, College of Biotechnology, Al-Nahrain University, Baghdad, Aljadriya POBox 64030, Iraq Department of Microbiology, College of Medicine, Diyala University, Diyala, Iraq Department of Biology, College of Science, Diyala University, Diyala, Iraq Department of Biology, College of Education for Pure Science, Diyala University, Diyala, Iraq


BACKGROUND
Human Immunodeficiency Virus (HIV) is the etiologic agent of Acquired Immunodeficiency Syndrome (AIDS).It was first described as a new disease in 1981 and since then it has been considered as a major global health problem worldwide [1].AIDS represents the final stage manifestation of HIV infection and the earlier stages of the infection are asymptomatic [2].Transmission of HIV occurs in multiple ways namely: through infected blood and blood derivatives, by sexual contact, and vertically through transmission of the virus from infected mother to baby either across the placenta (in utero), during the birth process or via breast feeding [3,4].In addition, it is distinguished by different clinical features and further complications in the long term that lack effective and durable vaccine.The total estimated global HIV-infected population in 2030 is exceeding to 36•9 million people, with about 1.2 million AIDS-related deaths having occurred in 2016 [5].
In the Middle East and North Africa (MENA) region, the HIV epidemic has been on the rise since 2001.Although the overall HIV prevalence in the region is still low, the increase in new infections has put MENA among the top two regions in the world with the fastest growing HIV epidemic, nearly 222,000 people are living with HIV in the MENA region mainly in Pakistan and Sudan [6 -10] and around 20,000 were newly infected cases with an increase of 12% of those reported in 2010 (UNAIDS, 2017).At the end of 2003, the number of HIV patients among Saudi and non-Saudi residents was 1,743 and 6,064, respectively [11].In Yemen, the number of people who are living with HIV or AIDS has also increased between 2002 and 2008 from 1122 to 2075 [12].In Iraq, the number of HIV cases did not exceed more than 124 cases in 2001, with a cumulative number of 247 cases for the period between 1986 and 2005 [13].Eighty four per cent of these cases were attributed to infection via imported blood products, 11.3% by sexual route and 5% from the mother to child.A non-official data was provided for 2017 -2019 which indicated that an estimated 200 people are living with HIV/AIDS in Iraq (CDC, Baghdad 2019).Interestingly, no cases clearly indicated that transmission was due to needle injections or unprotected sexual contact among homosexuals [14].This latter may be due to social stigma associated with AIDS in Muslim cultural and moral values.However, there was almost no formal education about HIV/AIDS, and thus a high degree of ignorance and fear surrounds the disease pandemic.
Until now, there is no cure or effective vaccine for HIV infection, however, antiretroviral therapy is offering an important relief for those living with the disease.HIV is a behavior related disease in which knowledge and awareness could influence the course of its spread particularly among young vulnerable university students [10,15].Therefore, this study was planned to assess the knowledge and awareness levels about HIV/AIDS among Diyala's and Al-Nahrain Iraqi University students.

Subjects And Ethical Clearance
Using the simple random sampling technique, this study included 506 university students, as estimated by epi-info version 7.2 (CDC, USA), who were in their third and fourth year of study from different colleges of Diyala and Al-Nahrain Universities.This cross sectional study comprised of 334 students from Diyala's University in Diyala governorate of Iraq, conducted in two rounds in 2010 and 2017 to assess the consistency of knowledge and awareness level between the two surveys.The second period 2017 survey was concurrently carried out at Al-Nahrain University in Baghdad with a sample size of 172 students.Ethical clearance was obtained from the scientific committees of Diyala and Al-Nahrain Universities.The study participants were informed about the purpose of the study in Arabic and only those who signed the informed consent were included.

Survey Measures
A structured questionnaire was designed to assess the knowledge and awareness about HIV and AIDS, which was based on previous published studies [16 -18].Data was collected from the first section of the questionnaire which included the demographic information related to age, gender and the year of the education.The second section was about the risk factors of modes of transmission, sexual and vertical transmission, vaccine availability and prevention.The assessment was based on closed-ended questions: "yes/ no/ don't know".The questionnaire was written in Arabic and English when it was presented to the students.The questionnaire was handed to students and collected in the same meeting room.For each of the ten HIV-related questions, a score of one was assigned for each "yes" answer for positive knowledge and awareness and zero for both "no" or "don't know" answers.

Data Analysis
Data were checked for completeness and analysed using SAS version -9.1.(Inst.Inc, Cary, NC, USA).For descriptive statistics, frequency, percentage, mean and standard deviation were used.While for categorical analysis, Chi-square test was used to compare between different variables according to the reported answers by students to each question.P value of <0.05 was considered significant for comparison.The overall knowledge and awareness of the study participants were assessed using the sum score of each outcome based on Bloom's cut-off point (60-80%).Having a score above the cutoff point was scaled into three levels, where high level scored 80-100%, moderate level ranged between 60-79%, and poor or inadequate level was <60%.

RESULTS
A total of 506 participants were enrolled from Diyala and Al-Nahrain Universities.Among them, there were 341 females and 165 males with a very similar age range of 19-30 years with a mean age of 22.58±1.53years.The quantitative baseline data of the gender and age of participants are shown in Table 1.

Diyala University Students' Survey
The result of Diyala students' answers of the questionnaire carried out in 2010 and 2017 is presented in Tables 2 and 3. Results of the two survey periods were almost comparable whereas the majority of students, regardless of gender, knew that HIV or AIDS is a viral disease (88.3%), and can be transmitted through unprotected sexual intercourse (92.5%) (Table 2).For the rest of the studied parameters, the level of knowledge and awareness differed but systematically it can be  In 2017 survey, there was a general decline in respondents' knowledge and awareness levels in all studied factors compared to the outcomes of the first survey conducted in 2010 Table 2.This decline was significant for HIV transmission through blood and blood products (92.2% vs 70.7%, P=0.006), in utero (79.0%vs 59.9%, P=0.007), during birth (55.1% vs 37.7%, P=0.006), sharing needles (88.6% vs 73.6%, P=0.008), drug abuse (65.9% vs 44.9%, P=0.006), and in vaccine availability (62.3% vs 34.7%, P=0.004).Moreover, the decline in respondents' knowledge and awareness levels was insignificant for breast feeding (38.3% vs 39.5%, P=0.285), tooth brushing and razor use (68.9% vs 61.7%, P=0.064).

Al-Nahrain University Students' Survey
The levels of knowledge and awareness were compared between Diyala and Al-Nahrain students in a survey conducted at the same time in 2017 on similar age range and education grade.The cohort of Al-Nahrain students involved a larger number of females (79%) than males (21%).There was an elevation of knowledge and awareness levels among Al-Nahrain students on HIV transmission routes through blood/products (30%, P=0.009), in utero (32%, P=0.008), and sharing needle injection by 24% (P=0.009).On the other hand, there was a significant decline in knowledge and awareness level among Al-Nahrain students of the viral spread via drug abuse by 21.6% (P=0.008) and vaccine availability by 23% (P=0.008).Otherwise, there were no noticeable changes in other studied parameters (Table 4).Extrapolating from the 2010 Diyala students' survey (Table 2) there were no significant differences between the two sets of data, except a significant decline in knowledge and awareness level among Al-Nahrain students about the risk from drug abuse (42.6%) and lack of vaccine availability (50.7%).These latter findings were well understood, however, the majority of students reside in Baghdad, the capital city of Iraq.

DISCUSSION
This study was designed to recruit university undergraduate students from two Iraqi public universities to assess their general knowledge and awareness about HIV and AIDS.This sample choice was used as university students represent an average intelligent young community, most have outreached extended family and they are considered the future responsible leaders of the society.HIV and AIDS are considered a sensitive global community health issue, so an understanding is must in our young community that they are not immune to HIV and furthermore that there is no reason for this community to become sensational or panicked about its severe consequences.Therefore, the main message to the young generations is to realistically understand the disease transmission and to avoid infection.In accordance with the original Bloom's cut-off points [19,20], university student participants were comprised of 32.6% males and 67.4% females with high levels of knowledge and awareness about the etiology of HIV and AIDS, modes of sexual transmission, risks from transfusion of blood or blood products and sharing of needles.Nevertheless, moderate levels of knowledge and awareness were observed for the risks form vertical transmission and shared use of a toothbrush or a razor with the rest of parameters having a low or inadequate level of knowledge (Table 2) contd..... and awareness, such as spread via breast feeding, during birth, needle sharing and availability of a vaccine.
Results of high knowledge and awareness levels about these parameters were consistent irrespective of the period of survey, a university campus, or a gender difference.These findings were consistent with a similar study conducted in Sudan [10], but varied considerably with those conducted on Taif University students in Saudi Arabia [21], as well as poor knowledge and awareness among medical and non-medical undergraduate students in Oman [22].Khan et al. [8], in a study conducted on colleges in Peshawar, Pakistan found that only a small numbers of students could positively answer that HIV or ADIS can be transmitted by a contaminated blood transfusion (28%) and unsterilized syringes (10%).Moreover, students from Qatar University and the University of Saskatchewan in Canada had higher levels of knowledge and awareness about the route of transmission of HIV through sexual contact (100% for both), and blood transfusion (92.0%The moderate levels of knowledge and awareness about sharing tooth brushes and the risk of vertical transmission, were similar to those reported in another study conducted in Saudi Arabia [16].On the other hand, the low levels of knowledge and awareness of parameters in this study about viral spread by breast feeding, during birth, drug abuse and vaccine availability were compatible with those reported by others who found that poor levels of knowledge about breast feeding as a route of transmission [26,27,16,28].Although, others observed higher knowledge and awareness ratios in Saudi Arabia (82.4%) and China (96%) [16,25].Moreover, a lack of knowledge about drug abuse has been observed, of only 38.8% [26] and 58% in another study [29] in India.These differences in knowledge could be attributed to lack of awareness or availability of education programs by health authorities, insufficient public information about the disease, societal ignorance because of the social stigma associated with homosexuality, absence of sex education in schools, and social attitude toward sex outside marriage in Muslim countries, leaving young students to think that they are immune to HIV infection.
Regarding the gender effect, females had higher levels (90.73%) of awareness than males (84.49%) of the Diyala and Al-Nahrain (data not shown) students surveyed.These results were similar to previous reports from Sudan [10] and China [25] and other Asian studies [30,31].This variability was statistically evident with the HIV and AIDS awareness markers such as blood transfusion, vertical transmission, sharing needles, razor use, and tooth brushes.The concordance in results was only a report from Saudi Arabia [16] where they observed strongly negative attitudes about discussing AIDS topics publically.It could also be due to gender segregation in university education.Moreover, different results may reflect the social equity for both genders in different societies, freedom of expression, or family religious values and social cultures.However, in this study both genders had almost the same poor levels of knowledge about the infection routes of breast feeding, during child birth, and vaccine availability.However, knowledge and awareness of these markers were shown to be higher in females than in males in Taiwan [30].
In this study, it was observed that there was a decline in the levels of knowledge and awareness about HIV and AIDS in the second survey period in 2017 conducted in Diyala University where a significant drop was observed only in two factors in the Al-Nahrain survey in 2017.This may be explained by the lack of knowledge about sexually transmitted diseases in the education curricula.Additionally, during the 2017 survey period, Diyala governorate was markedly affected by civil unrest and fear attack by ISIS jihadis and militias which had put much stressful pressure on students and their parents.As far as Al-Nahrain data is concerned, due to the lack of familiarity with a vaccine availability and drug abuse, students might misinterpret the phrase as an effective protective vaccine rather than just availability, while a misconception between drugs as medicine may contribute to the confusion of proper responses, therefore, both parameters would be considered of less grounded outcomes.

CONCLUSION
In general, the knowledge and awareness of Diyala and Al-Nahrain university students about HIV and AIDS common markers in Iraq were fair in many aspects of surveyed risk factors, however, strong attention needs to be given to protected sex and health education programs as well as strengthening public awareness about HIV and AIDS and other sexually transmitted diseases by a systematic way of educating people through brochures, posters and social media.These data will be forwarded to the AIDS Center, Ministry of Health to be included in their strategy for HIV and AIDS education and control policy.

Table 1 . Gender and age characteristics of participants from Diyala and Al-Nahrain University students.
No., number of students in surveys conducted in 2010 and 2017.NA= not applicable.

Table 2 . Knowledge and awareness levels students about HIV/AIDS among Diyala University students over two surveys conducted in 2010 and 2017.
Chi-square 0.418 P-value =0.566[NS]Is HIV/AIDS transmitted by blood transfusion, blood products such as plasma?Chi-square 7.82** P-value =0.0063[S]Is HIV/AIDS transmitted during pregnancy from mother to fetus inside the uterus?Chi-square 7.24** P-value =0.0074[S]Is HIV/AIDS transmitted from mother to child through breast feeding?