Health beliefs and barriers related to HIV prevention and screening among students of the University of Vlora: a cross-sectional study

There are many minor and major factors that help the HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) epidemic in national, regional, continental and global level. Even though the epidemics follow various courses in different countries, there are some common features as for the transmission and distribution method, which help us estimate the fast spreading of the virus globally [1]. The factors that raise the vulnerability to HIV include some cultural practices, the inappropriate control of health and resources, especially on health care, education and wellbeing, religious beliefs, poor governing, migration, conflicts, urbanizing, and stigma of the marginalized groups [2].

A significant diminuition in new cases of HIV infections has occured internationally, in specific 16% during these last 10 years, along with a reduction in number of deaths due to AIDS, 48% since 2005 [3]. Nonetheless, there are some countries around the world that have shown a different trend. In 2016, the majority of the European countries reported 160,453 new HIV cases in the World Health Organisation. This continued trend corresponds to a rate of 18,2 per 100,000 people [4]. While Albania remains a low HIV prevalence country, the rise of new HIV diagnoses in Albania is concerning. The European Centre for Disease Prevention and Control (ECDC) listed Albania third in the region in terms of affected individuals. According to ECDC, 94 albanian people had been affected by the HIV virus during 2017. Most of the cases are undergoing the developing phase of a disease, and the sum total of diagnosed people has gone to 1400. In Albania, as in the wider region, young people seem to be particularly vulnerable to HIV. The number of reported HIV- positive cases for youth aged 15–29 was about 22% of the total number of cases [4, 5].

A positive answer to the spread of HIV/AIDS starts with prevention [6]. Our country, Albania has followed the same line with the objectives of World Health Organization (WHO) and other scientific international institutions on HIV/AIDS prevention [7]. A lot of awareness campaigns are conducted in order to increase the youth awareness, so that they may be oriented toward a healthier life style, adopt positive behavior and increase the request for reproductive sexual services [8].

Various studies have reported that university students, who are mostly young people, rarely use existing HIV/AIDS preventive methods [9]. In Albania some studies report that the prevalence of not using condoms during the first sexual act is high in this age group [10] and the main reason is the pregnancy avoidance. Only a small percentage of the young people use the condom to avoid sexually transmitted diseases (STD) and HIV/AIDS [8]. In order to understand the behavior of young people who do not use condoms, it is essential to determine the beliefs and the perceived barriers that predispose condom use and non-use [11‐13].

Another element which should be taken into consideration during the studies is the utilization of health services among the youth. Voluntary counseling and testing (VCT) is an effective approach for facilitating behavioral change, reducing unprotected sex around both preventing HIV as well as getting early access to care and suppor [14]. In Albania, VCT are services offered to all people who want to know their HIV status and a redesign of them is needed to better target and outreach to vulnerable populations. The data show that the use of health services from the youth is very low. Seeking an HIV test may be more difficult for young people because many lack experience and some barriers in accessing VCT services [15, 16]. The aim of the present study is therefore to evaluate health beliefs and barriers related to HIV prevention and screening with an emphasis on the association between VCT uptake and explanatory factors among students of the University of Vlora. To this end, this article addresses the following question: Will students’ beliefs influence health services uptake?

In the present study, the perception of health beliefs and barriers shows a satisfactory result and comparable to other studies [17, 23]. Only 24% of the students have incorrect perceptions. It is very interesting the fact that the higher percentage of the incorrect answers of the participants was found to be related to the feeling of being insulted of one partner when the other suggested the use of condom during the sexual act. This feeling is considered in literature as a component of the perceived barriers based on Health Beliefs Model related to HIV/AIDS and is considered to be one of the factors that affect the condom use [12, 24, 25]. In order to better analyze this factor in our study, we assessed the association between students knowledge about condom use as a preventive method and the barriers that may interfere on its use. There is a significant statistical association between the two above variables (p < 0.000) that is consistent with other studies [13, 26] which found that the perception of barriers was statistically related to the reduction of the condom use among university students.

In terms of health beliefs related to HIV infection, our study found that participating students were more likely to have sexual intercourse with more than one partner, without being afraid of HIV infection, pretending that they should be worried only when they have serious clinical signs. This finding indicates that a proportion of students are engaged in risky sexual behaviours that may expose them to risk of contracting STD including HIV infection. Interestingly, a significant proportion of students believe the misconception regarding HIV diagnosis, including that having an HIV test within 1 week of risk behaviour will tell if a person has HIV. These findings are reflected in similar other studies [27] that also show limited knowledge on this issue, which raises the need to have informing and preventing ongoing activities. About a third of the students believed that those who contracted HIV through illegal behaviour should not be treated in hospital and clinics. This may indicate that negative beliefs can contribute to continued stigma towards key at-risk populations and may be a barrier to HIV prevention efforts.

In relation to socio-demographic factors, we observed a significant correlation between health beliefs & barriers and academic year, which is similar to international studies. These findings showed that the students of second and third year were more likely to have correct perceptions that is probably because the university curriculum structure teaches HIV topic in the 2nd year and beyond [20, 27]. While it is encouraging to note that health science students and those with sexual experiences have more correct beliefs and attitudes related to HIV, which is consistent with previous studies [20, 27, 28].

In addition, the incorrect perception found to have the single students followed by married ones. These results are consistent with those of Sarcar, which found out that the socio-cultural aspects and the beliefs regarding the sexual act serve as barriers or influence on the condom use in marriage relations or the married students in India, while in other countries as Brazil, Africa, Mexico etc. the fear of condom use shows the absence of faith within the couple, and acts as a barrier of not using the condom from these couples [26] .

Counseling and testing for HIV/AIDS is another valued literature method which plays an important role in screening and keeping this infection under control. Our study analyzed this role and found out a low prevalence of voluntary testing for HIV among the students with sexual experience compared to other similar studies [18, 29]. In relation to demographic factors we notice that there is a slight change in males who have the tendency to use VCT services more than females, which can be explained by the fact that albanian females hesitate to get tested for HIV due to the prejudice [30]. Contrary, other studies revealed a higher incidence of VCT uptake in females compared to males [31‐34], probably because HIV effects last much longer on females and they are aware of this fact.

Indeed, HIV infection is equally dangerous for males and females, which means that the VCT uptake has the same level of importance for both genders. Meanwhile our study shows a statistically significant correlation between VCT practice and the residence of the participants with sexual experience. The students who live in the city have a higher probability to use VCT services than the ones who live in the rural areas. Referring the data from Universal Periodic Review of Albania 2018, the people who live in rural areas and the ones with lower income do not refer to the primary health care, because going to health care institutions of a higher level asks for more money and time [35]. This is why the students who show a higher percentage of using VCT services are the ones that live in urban areas. The association between VCT practices and sexual behaviours shows that there is no statistical association, which means that the number of sexual partners and the age of first sexual intercourse do not have an impact on the fact that the students use VCT services or not. These results are in contrary to another study which showed that participants engaging in higher-risk sexual behaviours were more likely to be tested for HIV [36]. The results show that regardless the students’ exposure to risky behaviours, there is a low number of voluntary testing for HIV even within the risky groups, similar to other studies previously carried out in Albania [35, 37]. Additionally, Albania is a traditional and patriarchal society in which stigma and discrimination play a significant role in preventing sexually active young people like tertiary level students accessing HIV testing for earlier diagnosis and treatment of HIV infection [30]. Regarding the fact that the barriers may have a negative impact on VCT practice, our study found that the fear of stigmatization may be one of them, which is similar to other studies [9, 17, 30, 32, 38]. As a whole, our results demonstrate that the students’beliefs may be barriers to universal access to use VCT services.

The results of this study showed that the perceptions of barriers are good predictors of the preventive behaviours toward HIV infection. Nevertheless, this study discovered that “the feeling of insult” related to condom use and “the fear of personal consequence” related to HIV testing such as “fear of losing partner”, were the main barriers that influence health services uptake, answering the research question of the study. In addition, the prevalence of VCT services resulted low and the fear of stigmatization was considered another potential barrier to non-use of them by students. The present study provides evidence to suggest that creating awareness about prevention and screening methods for HIV among student community, especially those from non-health sciences, could contribute to increased uptake of the VCT services, the condom use and to reduce the identified stigmatizing barriers. Identifying the barriers related to preventive and screening methods for HIV would help the health practitioners to implement better professional education, promote healthy sexual behaviors and increase access to quality services. This paper highlights the need to integrate stigma reduction with HIV prevention activities and the importance of investigating the impacts of the healthcare utilization among young people especially students with high-risk behaviors and those from rural areas which will constitute formidable challenges to the international community.