HIV knowledge and associated factors among young Ethiopians: application of multilevel order logistic regression using the 2016 EDHS

HIV continues to be a major global health issue. Since the beginning of the epidemic, 75 million people have been infected with HIV and about 32 million people have died of it [1‐3]. The Joint United Nations Program on HIV (UNAIDS) and other partners had launched an ambitious plan of diagnosing 90% of all HIV-positive persons, providing ART for 90% of those diagnosed, and achieving viral suppression for 90% of those treated by 2020 which was believed to enable the world to end the AIDS epidemic by 2030 [4]. Even though aggressive responses were made to HIV/AIDS by different stakeholders, the 2019 reports from USAID and WHO showed that 37.9 million people were still living with HIV/AIDs at the end of 2018. The same reports had witnessed that 1.7 million people were newly infected with the disease and 770,000 people died from the disease-related causes in the same year [2, 3]. The global annual number of HIV new infections had declined from 2.1 million in 2010 to 1.7 million in 2018, which left the world far off the 2020 target to have fewer than 500,000 new infections. The globally annual number of deaths from HIV/AIDS-related illnesses among People living with HIV (PLWH) had also fallen from a peak of 1.7 million in 2004 to 770,000 in 2018. However, reaching the 2020 milestone of fewer than 500,000 deaths will still require further declines of 135,000 deaths per year [3, 5]. Sub-Saharan Africa (SSA) disproportionately carries a higher burden of HIV accounting for more than 70% of the global burden of infection. Of the estimated 6000 new infections that occur globally each day, about two-thirds are in SSA [6]. East and Southern Africa are especially the home to the largest number of PLWH where 20.6 million were PLWH and 800,000 were newly infected in 2018 [7]. A geospatial analysis of national survey data collected from SSA showed that national-level HIV prevalence for young adults ranged from 2.2% in Tanzania to 7.7% in Mozambique [8]. According to a 2016 WHO report, an estimated number of 710,000 PLWH in Ethiopia where the estimated adult HIV prevalence was 1.1% [9]. However, the number of PLWH was decreased to 690,000 in 2018 when an estimated number of 23,000 people were newly infected [5].

Youths are people between the ages of 15 and 24 years [10]. Globally, 3.9 million youths were living with HIV and there were 590,000 new infections among global youths in 2017. Approximately 1600 youth acquire HIV every day, and one young person dies of AIDS-related illness every 10 min worldwide [11]. According to 2020 WHO estimates, over 30% of all new HIV infections globally are estimated to occur among youths aged 15 to 25 years [12]. Globally, new HIV infections among young women were reduced by 25% between 2010 and 2018, but 6000 adolescent girls and young women become infected with HIV every week [5]. Adolescent girls and young women have up to eightfold higher rates of HIV infection compared to their male peers [6]. Of the 37,832 new HIV diagnoses in the US in 2018, 21% were among youth [13]. In sub-Saharan Africa, adolescent girls and young women aged 15–24 years are particularly vulnerable to HIV infection. Even though they accounted for only one-tenth of the total population residing in the region, adolescent girls and young women in SSA accounted for 25% of all new HIV infections globally in 2017. Eighty percent of all HIV infections occurring among adolescents in SSA occur among youth girls aged 15–19 years [14]. There was 290,000 new HIV infection among youths in Eastern and Southern Africa in 2017 which was the highest of all HIV incidences that occurred among youths across the globe in the same year [11]. In Ethiopia, 690, 000 people were living with HIV in 2018, whereas, 23, 000 people were newly infected and 11,000 people died from an AIDS-related illness in the same year. Women are disproportionally affected by HIV in Ethiopia: of the 650, 000 adults living with HIV, 410, 000 (63.08%) were women. At the end of 2018, new HIV infections among young women aged 15–24 years were more than double of those among young men: 5800 young women were newly infected compared to 2000 new infection among young men. In Ethiopia, in 2018, only 79% of people living with HIV knew their HIV status and only 65% of people living with HIV were on treatment [15].

The potential risks for young people for becoming newly infected with HIV are closely linked with the age of sexual initiation. Therefore, abstinence from sexual intercourse and delayed initiation of sexual behavior are among the central aims of HIV prevention efforts for young people [12]. Studies done in Iran and Ethiopia showed that only a few proportions of young people do have comprehensive HIV-knowledge [16‐18]. Exposure to mass media, being from a rich family, ever HIV VCT uptake, receiving education on HIV, being male, socioeconomic status, and employment status were significantly associated with HIV-knowledge among youths [17‐20].

The 2016 Ethiopian demographic and health survey (EDHS) report depicted that only 39% of youth males and 24% of youth females had comprehensive HIV-knowledge [21]. Even though 61% of youth males and nearly three-fourth of youth females did not have comprehensive HIV-knowledge, to the knowledge of the authors, proximate determinants of comprehensive HIV-knowledge among youths in the country are not well studied. Therefore, the current study is aimed to study the determinants of HIV-knowledge among Ethiopian youths using the 2016 EDHS data.

Results show that 20.92% of youths aged 15–24 have low knowledge of HIV, whereas, 48.76 and 30.31% of them had a moderate and comprehensive level of knowledge on HIV respectively. In the EDHS report, the percentage of females and males having a comprehensive knowledge of HIV was 24 and 39% respectively [22].

Rural dwellers are less likely to have a comprehensive knowledge of HIV, instead of low to moderate knowledge of HIV. This is consistent with the findings from Nigeria and Bangladesh where rural residents were less likely to have HIV-knowledge compared to the urban residents [28, 29]. This could be due to differences in access to mass media between urban and rural youths which play a very vital role in disseminating HIV-related educations and awareness creations. This study and other studies [18, 29‐39] depicted that exposure to mass media is associated with acquiring comprehensive HIV-knowledge.

Unambiguously education is expected to increase knowledge in almost all dimensions. The result of this study was not against this statement. The odds of having comprehensive HIV-knowledge among youths who completed primary school compared to those with no education were more than two-fold. Youths who completed secondary and above were more likely to have a comprehensive knowledge of HIV than low to a moderate HIV-knowledge compared to those with no education. This finding is also consistent with the findings from Nigeria and Bangladesh which were done using DHS data where youths with better educational attainment had better knowledge of HIV [28, 29]. This could be due to the integration of HIV-related education in academic curricula and the information grasping and analytical capacity of educated people.

For mobile owners compared to non-owners, the odds of having a comprehensive knowledge of HIV instead of low to moderate knowledge of HIV was higher by more than 27%. This finding is similar to the study done on adolescents from the United States and Botswana, where adolescents who discussed peer pressure and connectedness with mobile phones and social media had a general knowledge of Sexually Transmitted Infections (STIs) and HIV [38]. On the other hand, studies from Ghana, Uganda, and the United States elucidated that mobile phone usage among youths is useful for delivering HIV related information and HIV prevention [36, 37, 39]. This puts mobile phones at the heart of other strategies used to disseminate HIV/AIDS-related educations and awareness creations.

Generally, it is unquestionable that differences in getting information can result in differences in the level of knowledge that one has and this study affirms this fact. Not only access but also the frequency of accessing information matters and this is reflected in the current study. The odds of having comprehensive HIV-knowledge instead of having low to moderate for those watching TV less than once a week and at least once a week was higher by 20 and 42% than those not watching at all respectively. Similarly, the odds of having comprehensive HIV-knowledge instead of low to moderate among those listening to the radio for less than once a week and at least once a week was higher by 24 and 27% than those not listening at all respectively. This result is concordant with the findings from 27 SSA countries and India where people who frequently watch television and frequently listen to the radio had more comprehensive HIV-knowledge than people who do not [34, 35]. Several studies [18, 29‐33] had also witnessed that exposure to mass media had an impact on acquiring comprehensive HIV-knowledge, due to the HIV-related educations and information conveyed through mass media. This might be explained by differences in exposure to HIV related information between those who do have frequent access to mass media and those who do not have as mass media are potential sources of information.

Despite the infancy of the implementation during the data collection period, the coverage of health insurance has a significant association with HIV-knowledge. Results show that the odds of having comprehensive HIV-knowledge instead of having a low to moderate among the insured youths were 45% higher than those with no health insurance coverage. This could be due to the reason that youths who do have health insurance might have more access to health facilities than youths who are not covered under health insurance. Youths who have more access to health facilities, in turn, might have more health-related knowledge than those who do not have access.

The sex of the respondents has a significant association with the level of HIV-knowledge among youths. The odds of having comprehensive HIV-knowledge instead of low to moderate level among males were 85% higher than females. This finding contradicts the result described by studies conducted in Nigeria, where females are more likely to have HIV-knowledge than that of the males [40]. Additionally, the study in Sub Saharan Africa (SSA) uncovered that females have a positive association with having better knowledge than males [41]. Contrary to this, sex did not affect having HIV knowledge in the study done among university students in the United Arab Emirates (UAE) [42]. The current study is similar to the assessment of comprehensive HIV/AIDS knowledge levels among in-school adolescents in eastern Ethiopia and the study done in Nigeria using DHS data, where females were less likely to have comprehensive HIV/AIDS knowledge compared to males [18, 28]. Different studies have shown that there are gender disparities in academic achievement in different countries. In more civilized and industrialized countries females have more academic achievement than males [43‐46]. But in developing countries like Ethiopia, females have less access and less academic achievement than males [47]. So, one of the possible reasons for discrepancies in HIV-knowledge among males and females in studies done in different areas and the current study may be due to differences in access to education and academic achievement. On the other hand, it is evidenced in the current study and other studies, that access to media increases HIV-related knowledge. Studies have shown that females are more economically disadvantaged and have less access to media than males in many countries [48, 49]. Therefore, gender disparities in HIV-related knowledge between males and females may also be due to differences in accessing media.

It is expected that religion affects many things, it can make differences in knowing HIV knowledge and this expectation is supported by this study. The odds of having comprehensive HIV knowledge among Orthodox Christians instead of having low to moderate was by 29, 25, and 33% higher than Protestant Christians, Muslims, and other belief followers respectively. The current study reaffirms the study conducted in China in that following different religions has contributed to making a variation of HIV knowledge [50]. The possible reason for this could be differences in conveying HIV-related information between different religious organizations. Consistent condom use was one of the domains for measuring HIV knowledge but the ministers of any religion confidently speak about this prevention method and it is clear that the followers were likely to not consider the method as means of prevention and hence the disparity can be linked to the effect of views reflected while preaching in Churches and Mosques.

The result of this study uncovered that the marital status of the youths has a significant association with the level of HIV-knowledge. The odds of having comprehensive HIV-knowledge instead of having low to moderate for married youths compared to never-married were lower by about 21%, controlling for the effect of the other predictors in the model. In a study conducted among university students in UAE, marital status didn’t make a difference on level HIV-knowledge [42] but the current finding agrees with the study conducted in Vietnam in that those who live with their spouses were more likely to have knowledge of HIV than singles [51]. This probably is because of the different age groups included in either of the studies and also it could be due to cultural and norm differences across the countries in which the studies were conducted.

Results from multilevel regression show that there was significant variability due to residing in different regions of Ethiopia. The variation on HIV-knowledge due to regions accounted for 12% of the variability and this could be attributed to the difference in the quality of health systems across the regions of the country. As depicted in Fig. 1, the distribution of the prevalence of moderate knowledge on HIV among youths in Ethiopia is more or less similar across regions. On the other hand, there were differences across regions on both low and comprehensive knowledge of HIV.

Regardless of all efforts put in place to prevent HIV/AIDS in Ethiopia since its first footstep in the country, still less than one-third (30.31%) of Ethiopian youths have deep insight on the disease, whereas, nearly one-fifth of the youths have a lower level of knowledge on the disease. This study has also evidenced that there are significant disparities in HIV-related knowledge among Ethiopian youths living in different regions of the country. Rural residents, less educated, female, and married youths have less knowledge of HIV as compared to their counterparts. On the other hand, youths who do not have a mobile phone, who have no health insurance coverage, and who have limited access to media have less knowledge of HIV. Ethiopia is committed to ending AIDS as a public health threat by 2030. But achieving this goal without scaling up the current lower level of HIV-knowledge among the youths of the country is super absurd and futile efforts. Therefore, any stakeholder working on HIV prevention and control should give due focus to promoting education among the country’s youths by integrating and mainstreaming HIV-related education in the academic curricula, promoting HIV-related awareness creation through community-based education and religious organizations, encouraging and empowering female and rural resident youths, promoting health insurance, and expanding media coverages to best realize their mission.