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  • Published: 24 November 2021

A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data

  • Shobhit Srivastava   ORCID: 1 ,
  • Shekhar Chauhan   ORCID: 2 ,
  • Ratna Patel   ORCID: 3 &
  • Pradeep Kumar   ORCID: 1  

Scientific Reports volume  11 , Article number:  22841 ( 2021 ) Cite this article

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Acquired Immunodeficiency Syndrome caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. This study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with the change in awareness level on HIV-related information among adolescents over the period. Data used for this study were drawn from Understanding the lives of adolescents and young adults, a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh. The present study utilized a sample of 4421 and 7587 unmarried adolescent boys and girls, respectively aged 10–19 years in wave-1 and wave-2. Descriptive analysis and t-test and proportion test were done to observe changes in certain selected variables from wave-1 (2015–2016) to wave-2 (2018–2019). Moreover, random effect regression analysis was used to estimate the association of change in HIV awareness among unmarried adolescents with household and individual factors. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2 to 39.1% between wave-1 & wave-2. With the increase in age and years of schooling, the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV. Adolescent boys' paid work status was inversely associated with HIV awareness [Coef: − 0.01; p  < 0.10]. Use of internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness with reference to their counterparts. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups, as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents.


Acquired Immunodeficiency Syndrome (AIDS) caused by Human Immunodeficiency Virus (HIV) poses a severe challenge to healthcare and is a significant public health issue worldwide. So far, HIV has claimed almost 33 million lives; however, off lately, increasing access to HIV prevention, diagnosis, treatment, and care has enabled people living with HIV to lead a long and healthy life 1 . By the end of 2019, an estimated 38 million people were living with HIV 1 . More so, new infections fell by 39 percent, and HIV-related deaths fell by almost 51 percent between 2000 and 2019 1 . Despite all the positive news related to HIV, the success story is not the same everywhere; HIV varies between region, country, and population, where not everyone is able to access HIV testing and treatment and care 1 . HIV/AIDS holds back economic growth by destroying human capital by predominantly affecting adolescents and young adults 2 .

There are nearly 1.2 billion adolescents (10–19 years) worldwide, which constitute 18 percent of the world’s population, and in some countries, adolescents make up as much as one-fourth of the population 3 . In India, adolescents comprise more than one-fifth (21.8%) of the total population 4 . Despite a decline projection for the adolescent population in India 5 , there is a critical need to hold adolescents as adolescence is characterized as a period when peer victimization/pressure on psychosocial development is noteworthy 6 . Peer victimization/pressure is further linked to risky sexual behaviours among adolescents 7 , 8 . A higher proportion of low literacy in the Indian population leads to a low level of awareness of HIV/AIDS 9 . Furthermore, the awareness of HIV among adolescents is quite alarming 10 , 11 , 12 .

Unfortunately, there is a shortage of evidence on what predicts awareness of HIV among adolescents. Almost all the research in India is based on beliefs, attitudes, and awareness of HIV among adolescents 2 , 12 . However, few other studies worldwide have examined mass media as a strong predictor of HIV awareness among adolescents 13 . Mass media is an effective channel to increase an individuals’ knowledge about sexual health and improve understanding of facilities related to HIV prevention 14 , 15 . Various studies have outlined other factors associated with the increasing awareness of HIV among adolescents, including; age 16 , 17 , 18 , occupation 18 , education 16 , 17 , 18 , 19 , sex 16 , place of residence 16 , marital status 16 , and household wealth index 16 .

Several community-based studies have examined awareness of HIV among Indian adolescents 2 , 10 , 12 , 20 , 21 , 22 . However, studies investigating awareness of HIV among adolescents in a larger sample size remained elusive to date, courtesy of the unavailability of relevant data. Furthermore, no study in India had ever examined awareness of HIV among adolescents utilizing information on longitudinal data. To the author’s best knowledge, this is the first study in the Indian context with a large sample size that examines awareness of HIV among adolescents and combines information from a longitudinal survey. Therefore, this study intends to examine the change in the awareness level of HIV among adolescents. Furthermore, this study examined the factors associated with a change in awareness level on HIV-related information among adolescents over the period.

Data and methods

Data used for this study were drawn from Understanding the lives of adolescents and young adults (UDAYA), a longitudinal survey on adolescents aged 10–19 in Bihar and Uttar Pradesh 23 . The first wave was conducted in 2015–2016, and the follow-up survey was conducted after three years in 2018–2019 23 . The survey provides the estimates for state and the sample of unmarried boys and girls aged 10–19 and married girls aged 15–19. The study adopted a systematic, multi-stage stratified sampling design to draw sample areas independently for rural and urban areas. 150 primary sampling units (PSUs)—villages in rural areas and census wards in urban areas—were selected in each state, using the 2011 census list of villages and wards as the sampling frame. In each primary sampling unit (PSU), households to be interviewed were selected by systematic sampling. More details about the study design and sampling procedure have been published elsewhere 23 . Written consent was obtained from the respondents in both waves. In wave 1 (2015–2016), 20,594 adolescents were interviewed using the structured questionnaire with a response rate of 92%.

Moreover, in wave 2 (2018–2019), the study interviewed the participants who were successfully interviewed in 2015–2016 and who consented to be re-interviewed 23 . Of the 20,594 eligible for the re-interview, the survey re-interviewed 4567 boys and 12,251 girls (married and unmarried). After excluding the respondents who gave an inconsistent response to age and education at the follow-up survey (3%), the final follow-up sample covered 4428 boys and 11,864 girls with the follow-up rate of 74% for boys and 81% for girls. The effective sample size for the present study was 4421 unmarried adolescent boys aged 10–19 years in wave-1 and wave-2. Additionally, 7587 unmarried adolescent girls aged 10–19 years were interviewed in wave-1 and wave-2 23 . The cases whose follow-up was lost were excluded from the sample to strongly balance the dataset and set it for longitudinal analysis using xtset command in STATA 15. The survey questionnaire is available at & .

Outcome variable

HIV awareness was the outcome variable for this study, which is dichotomous. The question was asked to the adolescents ‘Have you heard of HIV/AIDS?’ The response was recorded as yes and no.

Exposure variables

The predictors for this study were selected based on previous literature. These were age (10–19 years at wave 1, continuous variable), schooling (continuous), any mass media exposure (no and yes), paid work in the last 12 months (no and yes), internet use (no and yes), wealth index (poorest, poorer, middle, richer, and richest), religion (Hindu and Non-Hindu), caste (Scheduled Caste/Scheduled Tribe, Other Backward Class, and others), place of residence (urban and rural), and states (Uttar Pradesh and Bihar).

Exposure to mass media (how often they read newspapers, listened to the radio, and watched television; responses on the frequencies were: almost every day, at least once a week, at least once a month, rarely or not at all; adolescents were considered to have any exposure to mass media if they had exposure to any of these sources and as having no exposure if they responded with ‘not at all’ for all three sources of media) 24 . Household wealth index based on ownership of selected durable goods and amenities with possible scores ranging from 0 to 57; households were then divided into quintiles, with the first quintile representing households of the poorest wealth status and the fifth quintile representing households with the wealthiest status 25 .

Statistical analysis

Descriptive analysis was done to observe the characteristics of unmarried adolescent boys and girls at wave-1 (2015–2016). In addition, the changes in certain selected variables were observed from wave-1 (2015–2016) to wave-2 (2018–2019), and the significance was tested using t-test and proportion test 26 , 27 . Moreover, random effect regression analysis 28 , 29 was used to estimate the association of change in HIV awareness among unmarried adolescents with household factors and individual factors. The random effect model has a specific benefit for the present paper's analysis: its ability to estimate the effect of any variable that does not vary within clusters, which holds for household variables, e.g., wealth status, which is assumed to be constant for wave-1 and wave-2 30 .

Table 1 represents the socio-economic profile of adolescent boys and girls. The estimates are from the baseline dataset, and it was assumed that none of the household characteristics changed over time among adolescent boys and girls.

Figure  1 represents the change in HIV awareness among adolescent boys and girls. The percentage of adolescent boys who had awareness regarding HIV increased from 38.6% in wave-1 to 59.9% in wave-2. Among adolescent girls, the percentage increased from 30.2% in wave-1 to 39.1% in wave-2.

figure 1

The percenate of HIV awareness among adolescent boys and girls, wave-1 (2015–2016) and wave-2 (2018–2019).

Table 2 represents the summary statistics for explanatory variables used in the analysis of UDAYA wave-1 and wave-2. The exposure to mass media is almost universal for adolescent boys, while for adolescent girls, it increases to 93% in wave-2 from 89.8% in wave-1. About 35.3% of adolescent boys were engaged in paid work during wave-1, whereas in wave-II, the share dropped to 33.5%, while in the case of adolescent girls, the estimates are almost unchanged. In wave-1, about 27.8% of adolescent boys were using the internet, while in wave-2, there is a steep increase of nearly 46.2%. Similarly, in adolescent girls, the use of the internet increased from 7.6% in wave-1 to 39.3% in wave-2.

Table 3 represents the estimates from random effects for awareness of HIV among adolescent boys and girls. It was found that with the increases in age and years of schooling the HIV awareness increased among adolescent boys ([Coef: 0.05; p  < 0.01] and [Coef: 0.04; p  < 0.01]) and girls ([Coef: 0.03; p  < 0.01] and [Coef: 0.04; p  < 0.01]), respectively. The adolescent boys [Coef: 0.06; p  < 0.05] and girls [Coef: 0.03; p  < 0.05] who had any mass media exposure were more likely to have an awareness of HIV in comparison to those who had no exposure to mass media. Adolescent boys' paid work status was inversely associated with HIV awareness about adolescent boys who did not do paid work [Coef: − 0.01; p  < 0.10]. Use of the internet among adolescent boys [Coef: 0.18; p  < 0.01] and girls [Coef: 0.14; p  < 0.01] was positively associated with HIV awareness in reference to their counterparts.

The awareness regarding HIV increases with the increase in household wealth index among both adolescent boys and girls. The adolescent girls from the non-Hindu household had a lower likelihood to be aware of HIV in reference to adolescent girls from Hindu households [Coef: − 0.09; p  < 0.01]. Adolescent girls from non-SC/ST households had a higher likelihood of being aware of HIV in reference to adolescent girls from other caste households [Coef: 0.04; p  < 0.01]. Adolescent boys [Coef: − 0.03; p  < 0.01] and girls [Coef: − 0.09; p  < 0.01] from a rural place of residence had a lower likelihood to be aware about HIV in reference to those from the urban place of residence. Adolescent boys [Coef: 0.04; p  < 0.01] and girls [Coef: 0.02; p  < 0.01] from Bihar had a higher likelihood to be aware about HIV in reference to those from Uttar Pradesh.

This is the first study of its kind to address awareness of HIV among adolescents utilizing longitudinal data in two indian states. Our study demonstrated that the awareness of HIV has increased over the period; however, it was more prominent among adolescent boys than in adolescent girls. Overall, the knowledge on HIV was relatively low, even during wave-II. Almost three-fifths (59.9%) of the boys and two-fifths (39.1%) of the girls were aware of HIV. The prevalence of awareness on HIV among adolescents in this study was lower than almost all of the community-based studies conducted in India 10 , 11 , 22 . A study conducted in slums in Delhi has found almost similar prevalence (40% compared to 39.1% during wave-II in this study) of awareness of HIV among adolescent girls 31 . The difference in prevalence could be attributed to the difference in methodology, study population, and study area.

The study found that the awareness of HIV among adolescent boys has increased from 38.6 percent in wave-I to 59.9 percent in wave-II; similarly, only 30.2 percent of the girls had an awareness of HIV during wave-I, which had increased to 39.1 percent. Several previous studies corroborated the finding and noticed a higher prevalence of awareness on HIV among adolescent boys than in adolescent girls 16 , 32 , 33 , 34 . However, a study conducted in a different setting noticed a higher awareness among girls than in boys 35 . Also, a study in the Indian context failed to notice any statistical differences in HIV knowledge between boys and girls 18 . Gender seems to be one of the significant determinants of comprehensive knowledge of HIV among adolescents. There is a wide gap in educational attainment among male and female adolescents, which could be attributed to lower awareness of HIV among girls in this study. Higher peer victimization among adolescent boys could be another reason for higher awareness of HIV among them 36 . Also, cultural double standards placed on males and females that encourage males to discuss HIV/AIDS and related sexual matters more openly and discourage or even restrict females from discussing sexual-related issues could be another pertinent factor of higher awareness among male adolescents 33 . Behavioural interventions among girls could be an effective way to improving knowledge HIV related information, as seen in previous study 37 . Furthermore, strengthening school-community accountability for girls' education would augment school retention among girls and deliver HIV awareness to girls 38 .

Similar to other studies 2 , 10 , 17 , 18 , 39 , 40 , 41 , age was another significant determinant observed in this study. Increasing age could be attributed to higher education which could explain better awareness with increasing age. As in other studies 18 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , education was noted as a significant driver of awareness of HIV among adolescents in this study. Higher education might be associated with increased probability of mass media and internet exposure leading to higher awareness of HIV among adolescents. A study noted that school is one of the important factors in raising the awareness of HIV among adolescents, which could be linked to higher awareness among those with higher education 47 , 48 . Also, schooling provides adolescents an opportunity to improve their social capital, leading to increased awareness of HIV.

Following previous studies 18 , 40 , 46 , the current study also outlines a higher awareness among urban adolescents than their rural counterparts. One plausible reason for lower awareness among adolescents in rural areas could be limited access to HIV prevention information 16 . Moreover, rural–urban differences in awareness of HIV could also be due to differences in schooling, exposure to mass media, and wealth 44 , 45 . The household's wealth status was also noted as a significant predictor of awareness of HIV among adolescents. Corroborating with previous findings 16 , 33 , 42 , 49 , this study reported a higher awareness among adolescents from richer households than their counterparts from poor households. This could be because wealthier families can afford mass-media items like televisions and radios for their children, which, in turn, improves awareness of HIV among adolescents 33 .

Exposure to mass media and internet access were also significant predictors of higher awareness of HIV among adolescents. This finding agrees with several previous research, and almost all the research found a positive relationship between mass-media exposure and awareness of HIV among adolescents 10 . Mass media addresses such topics more openly and in a way that could attract adolescents’ attention is the plausible reason for higher awareness of HIV among those having access to mass media and the internet 33 . Improving mass media and internet usage, specifically among rural and uneducated masses, would bring required changes. Integrating sexual education into school curricula would be an important means of imparting awareness on HIV among adolescents; however, this is debatable as to which standard to include the required sexual education in the Indian schooling system. Glick (2009) thinks that the syllabus on sexual education might be included during secondary schooling 44 . Another study in the Indian context confirms the need for sex education for adolescents 50 , 51 .

Limitations and strengths of the study

The study has several limitations. At first, the awareness of HIV was measured with one question only. Given that no study has examined awareness of HIV among adolescents using longitudinal data, this limitation is not a concern. Second, the study findings cannot be generalized to the whole Indian population as the study was conducted in only two states of India. However, the two states selected in this study (Uttar Pradesh and Bihar) constitute almost one-fourth of India’s total population. Thirdly, the estimates were provided separately for boys and girls and could not be presented combined. However, the data is designed to provide estimates separately for girls and boys. The data had information on unmarried boys and girls and married girls; however, data did not collect information on married boys. Fourthly, the study estimates might have been affected by the recall bias. Since HIV is a sensitive topic, the possibility of respondents modifying their responses could not be ruled out. Hawthorne effect, respondents, modifying aspect of their behaviour in response, has a role to play in HIV related study 52 . Despite several limitations, the study has specific strengths too. This is the first study examining awareness of HIV among adolescent boys and girls utilizing longitudinal data. The study was conducted with a large sample size as several previous studies were conducted in a community setting with a minimal sample size 10 , 12 , 18 , 20 , 53 .

The study noted a higher awareness among adolescent boys than in adolescent girls. Specific predictors of high awareness were also noted in the study, including; higher age, higher education, exposure to mass media, internet use, household wealth, and urban residence. Based on the study findings, this study has specific suggestions to improve awareness of HIV among adolescents. There is a need to intensify efforts in ensuring that information regarding HIV should reach vulnerable sub-groups as outlined in this study. It is important to mobilize the available resources to target the less educated and poor adolescents, focusing on rural adolescents. Investment in education will help, but it would be a long-term solution; therefore, public information campaigns could be more useful in the short term.

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This paper was written using data collected as part of Population Council’s UDAYA study, which is funded by the Bill and Melinda Gates Foundation and the David and Lucile Packard Foundation. No additional funds were received for the preparation of the paper.

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Conception and design of the study: S.S. and P.K.; analysis and/or interpretation of data: P.K. and S.S.; drafting the manuscript: S.C., and R.P.; reading and approving the manuscript: S.S., P.K., S.C. and R.P.

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Srivastava, S., Chauhan, S., Patel, R. et al. A study of awareness on HIV/AIDS among adolescents: A Longitudinal Study on UDAYA data. Sci Rep 11 , 22841 (2021).

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HIV/AIDS epidemiology, pathogenesis, prevention, and treatment

The HIV-1 pandemic is a complex mix of diverse epidemics within and between countries and regions of the world, and is undoubtedly the defining public-health crisis of our time. Research has deepened our understanding of how the virus replicates, manipulates, and hides in an infected person. Although our understanding of pathogenesis and transmission dynamics has become more nuanced and prevention options have expanded, a cure or protective vaccine remains elusive. Antiretroviral treatment has transformed AIDS from an inevitably fatal condition to a chronic, manageable disease in some settings. This transformation has yet to be realised in those parts of the world that continue to bear a disproportionate burden of new HIV-1 infections and are most a% ected by increasing morbidity and mortality. This Seminar provides an update on epidemiology, pathogenesis, treatment, and prevention interventions pertinent to HIV-1.

HIV pandemic

An estimated 38·6 (33·4–46·0) million people live with HIV-1 worldwide, while about 25 million have died already. 1 In 2005 alone, there were 4·1 million new HIV-1 infections and 2·8 million AIDS deaths. 1 These estimates mask the dynamic nature of this evolving epidemic in relation to temporal changes, geographic distribution, magnitude, viral diversity, and mode of transmission. Today, there is no region of the world untouched by this pandemic ( figure 1 ). 2

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HSex=heterosexual. MSM=Men who have sex with men. IDU=injection drug users. Based on Joint UNAIDS and WHO AIDS epidemic update December, 2005.

Heterosexual transmission remains the dominant mode of transmission and accounts for about 85% of all HIV-1 infections. Southern Africa remains the epicentre of the pandemic and continues to have high rates of new HIV-1 infections. 3 Although overall HIV-1 prevalence remains low in the emerging epidemics in China and India, the absolute numbers, which are fast approaching those seen in southern Africa, are of concern. 1 Outside of sub-Saharan Africa, a third of all HIV-1 infections are acquired through injecting drug use, most (an estimated 8·8 million) of which are in eastern Europe and central and southeast Asia. 1 The rapid spread of HIV-1 in these regions through injecting drug use is of importance, since it is a bridge for rapid establishment of more generalised epidemics.

A defining feature of the pandemic in the current decade is the increasing burden of HIV-1 infections in women, 4 which has additional implications for mother-to-child transmission. Women now make up about 42% of those infected worldwide; over 70% of whom live in sub-Saharan Africa. 1 Overall, a quarter of all new HIV-1 infections are in adults aged younger than 25 years. 1 HIV-1 infection rates are three to six times higher in female adolescents than in their male counterparts, 1 , 5 – 7 and this difference is attributed to sexual coupling patterns of young women with older men. Population prevalence of HIV-1 infection, concurrent sexual relationships, partner change, sexual practices, the presence of other sexually transmitted diseases, 8 – 11 and population mobility patterns 12 – 14 for economic and other reasons (eg, natural disasters and wars) further increase the probability of HIV-1 acquisition. 3 , 15 Emerging data accord with strong links between risk of sexual HIV-1 acquisition and episodic recreational drug or alcohol use. 16

Although sub-Saharan Africa continues to bear a disproportionate burden of HIV-1 infections, there is now an increasing number of countries reporting stabilisation or declines in prevalence (eg, Zambia, Tanzania, Kenya, Ghana, Rwanda, Burkina Faso, and Zimbabwe). 1 There is some evidence to attribute these reductions to effective changes in sexual behaviour, such as postponement of sexual debut, reduction in casual relationships, and more consistent condom use in casual relationships. 17 , 18 However, increasing morbidity and mortality rates associated with a maturing HIV-1 epidemic need to be considered when interpreting these data. 19 For example, the death of a few high-risk individuals who are key to transmission chains could exert a major effect on sexual networks and result in major reductions in infection rates. 20 Additionally, since most HIV-1 estimates are based on surveys in antenatal populations, increasing morbidity and mortality could cause the numbers of women in this group to decrease, and thus lead to underestimates of the true prevalence in these countries. 19

Although the relative contribution of cell-free virus compared with cell-associated virus in HIV-1 transmission remains unclear, there is growing evidence that viral load is predictive of transmission risk. 21 , 22 The highest levels of viraemia are seen during acute infection and advanced HIV-1 disease. 22 Further, co-infections with other sexually transmitted diseases in asymptomatic HIV-1 infected people can increase viral shedding to levels similar to those seen during acute infection. 23 Thus, sexually transmitted diseases could enhance HIV-1 transmission to rates similar to those seen during primary infection. 24 This observation could help to explain why the efficiency of HIV-1 transmission exceeds, in some settings, the earlier mathematical projections. 25 Thus, identification and treatment of recently infected people is an important means to reduce transmission. However, most people are unaware of their HIV-1 status during these crucial first months of infection. Several screening strategies based on laboratory testing and clinical algorithms are being developed and tested 26 for efficient identification of early infection before antibody development. 27 Additionally, a more aggressive management of sexually transmitted infections in settings with generalised epidemics has the potential to affect current epidemic trajectories. 24

Based on their genetic make-up, HIV-1 viruses are divided into three groups (eg, M [main], N, and O group, figure 2 ). These HIV-1 groups and HIV-2 probably result from distinct cross-species transmission events. 28 Pandemic HIV-1 has diversified into at least nine subtypes ( figures 1 and ​ and2) 2 ) and many circulating recombinant forms, 29 , 30 which encode genetic structures from two or more subtypes (eg, A/E=CRF01; A/G=CRF02). The continuously evolving HIV-1 viral diversity poses an immense challenge to the development of any preventive or therapeutic intervention. 29

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The HIV-1 pandemic is largely due to viral isolates belonging to the HIV-1 M-group, with HIV-1 subtype C being the most prevalent (red). Recombinant circulating forms cluster with the M-group but have been omitted for clarity. HIV-1 M group and the contemporary SIV strains identified in wild chimpanzees in Cameroon (SIVcpzLB7/EK5 28 ) are highlighted. HIV-1 sequences cluster closely with SIV from chimpanzees (SIVcpz), whereas HIV-2 resembles SIV from macaques and sooty mangabeys (SIVmac/SIVsm).

In terms of viral diversity, subtype C viruses continue to dominate and account for 55–60% of all HIV-1 infections worldwide ( figure 1 ). 30 Non-subtype B isolates might differ in their virological characteristics from the subtype B isolates (eg, viral load, chemokine co-receptor usage, transcriptional activation in specific biological compartments). 31 – 33 However, the clinical consequences of subtype variations remain unclear.

Infection with two or more genetically distinct viruses could lead to new recombinant viruses. Recombination takes place at a higher rate than initially predicted, 30 and circulating recombinant forms account for as much as 20% of infections in some regions (eg, southeast Asia). 31 These findings are in agreement with the occurrence of co-infections with multiple distinct isolates in a close temporal context. 34 – 36 Further, superinfections in which time points of virus acquisition are months to years apart have been described, although at a much lower frequency than co-infections. 34 , 37 – 39 Collectively, these observations challenge the assumption that HIV-1 acquisition happens only once with a singular viral strain and that, thereafter, the infected individual is protected from subsequent infections. 40 This lack of immunisation has substantial implications for vaccine development. Emerging evidence suggests that clinical progression to AIDS might be more rapid in individuals with dual infections, 35 and encouraging safer sex practices in viraemic HIV-1-infected people might be appropriate to keep recurrent exposure to new viral strains to a minimum.

Pathogenesis of HIV-1

The worldwide spread of HIV-1 indicates that the virus effectively counteracts innate, adapted, and intrinsic immunity. 41 , 42 Despite its modest genome size (less than 10 kb) and its few genes ( figure 3 ), HIV-1 excels in taking advantage of cellular pathways while neutralising and hiding from the different components of the immune system. 43 – 45 Notably, our understanding of pathogenesis is often derived from studies of subtype B viruses and non-human primate studies.

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(A) Envelope glycoproteins gp120/41 form the spikes on the virion’s surface. During maturation the gag protein is cleaved and Gag p24 forms the core. The viral genome, viral reverse transcriptase (RT), integrase as well as a number of host proteins are encapsidated. (B) Dir erent steps of the viral life cycle on a cellular level and the potential targets for treatment interventions. (C) HIV-1 has evolved strategies to counteract the restriction factors TRIM5α and APOBEC3G/3F. If left unchecked by HIV-1 Vif, APOBEC3G/3F is encapsidated into the egressing virion, and on infection of a target cell leads to G-to-A hypermutations in the viral genome. Rhesus TRIM5α inhibits HIV-1 replication early after infection of the target cell before the step of reverse transcription.

The HIV-1 life cycle is complex ( figure 3 ) and its duration and outcome is dependent on target cell type and cell activation. 46 In the early steps, HIV-1 gains access to cells without causing immediate lethal damages but the entry process can stimulate intracellular signal cascades, which in turn might facilitate viral replication. 47 , 48 The two molecules on the HIV-1 envelope, the external glycoprotein (gp120) and the transmembrane protein (gp41), form the spikes on the virion’s surface. 49 During the entry process, gp120 attaches to the cell membrane by first binding to the CD4+ receptor. Subsequent interactions between virus and chemokine co-receptors (eg, CCR5, CXCR4) trigger irreversible conformational changes. 49 , 50 The actual fusion event takes place within minutes by pore formation, 50 , 51 and releases the viral core into the cell cytoplasm. After the core disassembles, the viral genome is reverse transcribed into DNA by the virus’ own reverse transcriptase enzyme. 46 Related yet distinct viral variants can be generated during this process since reverse transcriptase is error prone and has no proofreading activity. 46 At the midpoint of infection, the viral protein integrase in conjunction with host DNA repair enzymes inserts the viral genome into gene-rich, transcriptionally active domains of the host’s chromosomal DNA. 52 – 54 An integrase binding host factor, LEDGF/p75 (lens epithelium-derived growth factor), facilitates integration, 55 , 56 which marks the turning point by irreversibly transforming the cell into a potential virus producer. In the late steps, production of viral particles needs host driven as well as virus driven transcription. 46 Viral proteins are transported to and assemble in proximity to the cell membrane. Virus egress from the cell is not lytic and takes advantage of the vesicular sorting pathway (ESCRT-I, II, III), which normally mediates the budding of endosomes into multivesicular bodies. 57 , 58 HIV-1 accesses this protein-sorting pathway by binding TSG101 via its late domain, a short sequence motif in p6 of Gag. 59 , 60 Cleavage of the Gag-Pol poly-protein by the viral protease produces mature infectious virions. 46 , 61

Since cytoplasmic molecules of the producer cell and components from its cell surface lipid bilayer are incorporated into the new viral particle, virions bear characteristics of the cells in which they were produced. 62 Incorporated host molecules can determine the virus’ phenotype in diverse ways (eg, shape the replicative features in the next cycle of infection or mediate immune activation of bystander cells 62 ).

Studies of the early events that happen after HIV-1 breaches the mucosal barrier suggest the existence of a window period in which viral propagation is not yet established and host defences could potentially control viral expansion. 63 The important co-receptors for HIV-1 infection are two chemokine receptors—CCR5 and CXCR4. Independently of the transmission route, most new infections are established by viral variants that rely on CCR5 usage. 64 CXCR4-tropic viruses generally appear in late stages of infection and have been associated with increased pathogenicity and disease progression. 65

Compelling evidence from non-human primate models (eg, simian immunodeficiency virus [SIV] infection of rhesus macaques) suggest that vaginal transmission results in infection of a small number of CD4+ T lymphocytes, macrophages, and dendritic cells located in the lamina propria. 63 Potential pathways for virus transmission involve endocytosis, transcytosis, and virus attachment to mannose C-type lectin receptors (eg, DC-SIGN) located on dendritic cells and macrophages. 66 The initial replication takes place in the regional lymph organs (eg, draining lymph nodes) and is composed of few viral variants, and leads to modest primary amplification. With migration of infected T lymphocytes or virions into the bloodstream, secondary amplification in the gastrointestinal tract, spleen, and bone marrow results in massive infection of susceptible cells. In close temporal relation with the resulting peak of viraemia (eg, 10 6 to 10 7 copies per mL plasma), clinical symptoms can be manifest during primary HIV-1 infection ( figure 4 ). The level of viraemia characteristic for the chronic phase of infection in an individual (viral set point) differs from the peak viraemia by one or two orders of magnitude. This reduction is largely attributed to HIV-1 specific CD8+ responses but target cell limitation could also play a part. The viral population is most homogeneous early after transmission, but as viral quasi-species diversify in distinct biological compartments, mutant viruses that are resistant to antibody neutralisation, cytotoxic T cells, or antiretroviral drugs are generated and archived in long-lived cells (ie, viral reservoirs).

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Plasma viraemia (top), and dynamic changes of the CD4+ T-lymphocyte compartments (bottom). Primary infection characterised by high plasma viraemia (red line, top), low CD4 cells (green line, bottom), and absence of HIV-1 specific antibodies (orange line, bottom). Viraemia drops as cytotoxic CD8+ T-lymphocytes (CTL) develop (blue line, bottom) and an individual viral-load set point is reached during chronic infection. Viral set points dir er greatly among individuals (eg, red dotted line, top) and predict disease progression. Viral diversity increases through out the disease (closed circles, top). The risk of transmission is highest in the first weeks when viraemia peaks (closed circles, top). GALT=gut-associated lymphoid tissues.

A pronounced depletion of activated as well as memory CD4+ T cells located in the gut-associated lymphoid tissues has been seen in individuals identified early after infection. 67 The preferential depletion of the CD4+ cells in the mucosal lymphoid tissues remains despite years of antiretroviral treatment, a striking observation that contrasts with the fact that the number of CD4+ T lymphocytes in the peripheral blood can return to normal under antiretroviral treatment.

A gradual destruction of the naive and memory CD4+ T-lymphocyte populations is the hallmark of HIV-1 infection, with AIDS being the last disease stage ( figure 4 ). 68 Despite the frequent absence of symptoms during early and chronic phase, HIV-1 replication is dynamic throughout the disease. The half-life of a single virion is so short that half the entire plasma virus population is replaced in less than 30 minutes, 69 and the total number of virions produced in a chronically infected person can reach more than 10¹P particles per day. 69 , 70 The turnover rates of lymphocyte populations are upregulated many fold during HIV-1 infection, whereas cell proliferation decreases once viral replication is reduced by antiretroviral treatment. 71 , 72 Different depletion mechanisms have been proposed, with an emerging consensus favouring generalised immune activation as cause for constant depletion of the CD4+ cell reservoir. 73

Immune activation predicts disease progression 74 and, thus, seems to be a central feature of pathogenic HIV-1 infections. Recently, Nef proteins from SIV lineages that are non-pathogenic in their natural hosts (eg, African green monkeys) have proved to down-regulate CD3-T-cell receptors, resulting in reduced cell activation and apoptosis. 75 HIV-1 Nef fails to quench T-cell activation, possibly leading to the high degree of immune activation seen in infected people.

Understanding the mechanisms that lead to protection or long-lasting control of infection will guide vaccine development by providing correlates of protection. Natural resistance to HIV-1 infection is rare and varies greatly between individuals. Two groups—long-term non-progressors and highly exposed persistently seronegative individuals—have been studied widely to identify innate and acquired protective determinants ( table 1 ). 76 Host resistance factors consist of human leucocyte antigen (HLA) haplotypes, autoantibodies, mutations in the promoter regions, and coding regions of the co-receptors CCR5 and CCR2, as well as the up-regulation of chemokine production ( table 1 ). 76 , 77 Indeed, individuals encoding a truncated CCR5 version (CCR5Δ32) have slower disease progression (heterozygote) or are resistant to CCR5-using viruses (homozygote). 78 The CCL3L1 gene encodes MIP1α, a CCR5 co-receptor ligand and chemokine with antiviral activity. Recent findings show that CCL3L1 gene copies vary individually and higher numbers of gene duplications result in reduced susceptibility to infection, 77 , 79 possibly by competitive saturation of CCR5 co-receptor. Cytotoxic T-lymphocyte responses, helper T-cell functions, and humoral responses are some of the acquired factors that modulate the risk of transmission in highly exposed persistently seronegative individuals, 76 and could also contribute to spontaneous control of replication in long-term non-progressors. The putative protective role of cytotoxic T-lymphocyte activity has been suggested in seronegative sex workers and in some long-term non-progressors. 76 , 80

Some of the host factors affecting susceptibility to HIV-1 infection

HLA=human leucocyte antigen. CCR5=chemokine receptor 5. CCR2=chemokine receptor 2. CCL3L1=CC chemokine ligand like-1, APOBEC3G/3F=apolipoprotein B mRNA editing complex 3.

Mammalian cells are not welcoming micro-environments, but rather deploy a defensive web to curb endogenous and exogenous viruses. HIV-1’s ability to circumvent these defences is as impressive as its efficiency to exploit the cellular machinery. APOBEC3G/3F and TRIM5α are recently described intrinsic restriction factors that are constitutively expressed in many cells. 81 , 82 Both gene loci have been under strong selective pressure throughout primate evolution, 83 indicating an ancient need to neutralise foreign DNA and maintain genome stability that precedes the current HIV-1 pandemic.

APOBEC3 enzymes (A3) belong to the superfamily of cytidine deaminases, 84 a group of intracellular proteins with DNA/RNA editing activity. 84 , 85 Most representatives of the APOBEC3 group have some mutagenic potential and restrict endogenous retroviruses and mobile genetic elements. The deaminases A3G, A3F, and A3B have potent antiviral activity, with the first two being expressed in cells that are susceptible to HIV-1 infection (T-lymphocytes, macrophages). HIV-1 evades APOBEC3 mutagenesis by expressing Vif, which leads to APOBEC3G/3F but not A3B degradation. 42 , 86 – 90

We still need to establish how the mechanisms of DNA editing and antiviral activity are interwoven, since some antiviral activity can be maintained despite defective DNA editing. 91 The early replication block in non-stimulated CD4+ T cells has been attributed to low molecular mass complexes of APOBEC3G. 92 Hypermutated genomes in HIV-1 infected patients 93 and mutations in Vif resulting in abrogated or differential APOBEC3 neutralisation capacity have been described. 94 , 95 The degree to which APOBEC3G/3F mRNA expression predicts clinical progression remains an area of intensive investigation. 96 , 97

Several representatives of the heterogeneous family of tripartite motif proteins (TRIM) inhibit retroviruses in a species-specific manner. 81 , 98 TRIM5α from rhesus macaques and African green monkeys inhibit HIV-1 replication, whereas the human homologue is inactive against SIV and HIV-1, leading to the recorded susceptibility of human cells to both viruses. 81 Rhesus TRIM5α recognises the capsid domain of HIV-1 Gag and manipulates the kinetics of HIV-1 core disassembly within minutes after cell entry. 99 , 100 Thus, experimental approaches to render HIV-1 resistant to rhesus TRIM5α could lead to immunodeficiency viruses capable of replicating in rhesus macaques. Such a non-primate model would allow testing of antiviral treatment and vaccine interventions with HIV-1 viruses instead of SIV or SIV/HIV chimeric viruses.

Clinical management

The diagnosis of HIV-1 infection is based on the detection of specific antibodies, antigens, or both, and many commercial kits are available. Serological tests are generally used for screening. A major advance has been the availability of rapid HIV-1 antibody tests. These assays are easy to do and provide results in as little as 20 minutes, 101 enabling specimen collection and proper diagnosis at the same visit. Rapid tests are important tools for surveillance, screening, and diagnosis, and can be reliably done on plasma, serum, whole blood, or saliva by health-care providers with little laboratory expertise. The two limitations of these serological tests are detection of infection during primary infection when antibodies are absent, and in infants younger than 18 months who might bear maternal HIV-1 antibodies. In these instances direct virus detection is the only option (eg, quantification of viral RNA [standard] or p24 antigen in heat denatured serum [less expensive]).

For staging purposes, measurement of CD4+ cells and viraemia is required. Plasma viral load is widely used to monitor therapeutic success on antiretroviral treatment. Several commercially available tests provide sensitive quantification of plasma HIV-1 RNA copies. The newer versions of the Amplicor and Quantiplex (Roche, Indianapolis, IN, USA, and Bayer Diagnostics, Walpole, MA, USA, respectively) assays have overcome initial suboptimum performance for non-B subtypes. 102 While the viral load determines the rate of destruction of the immune system, the number of CD4+ cells reveals the degree of immunodeficiency and is, therefore, used to assess the stage of infection. CD4+ cell counts together with clinical manifestations (eg, occurrence of opportunistic infections) are key criteria for HIV-1 disease classification. Flow cytometry analysis is the standard method for CD4+ cells quantification.

Standard methods for quantifying viral load and CD4+ cell counts need advanced laboratory infrastructures, and assays require a specimen to be tested within a short time of collection. These requirements pose challenges for resource-constrained settings. The use of dried blood spot specimen has resolved some of the difficulties associated with transportation of samples needed for virological assessments. 103 Measurement of reverse transcriptase activity in plasma samples, simplification of gene amplification methods (eg, Taqman technology), and paper-strip quantification (dipstick assays) might provide cost-effective alternatives for the future. 104 – 106 Similarly microcapilliary flow-based systems, CD4+ chips, or total white counts (panleucocyte gating) provide alternatives for establishment of the level of immunodeficiency in resource-limited settings. 107 – 110

Drug treatment

Antiretroviral compounds.

Antiretroviral treatment is the best option for longlasting viral suppression and, subsequently, for reduction of morbidity and mortality. However, current drugs do not eradicate HIV-1 infection and lifelong treatment might be needed.

20 of the 21 antiretroviral drugs currently approved by the US Food and Drug Administration target the viral reverse transcriptase or protease ( table 2 ). Eight nucleoside/nucleotide analogues and three non-nucleoside reverse transcriptase inhibitors inhibit viral replication after cell entry but before integration. Fixed-dose combination tablets simplify treatment regimens by reducing the daily pill burden, and drugs with long half-lives allow once or twice daily dosing. Eight protease inhibitors prevent the maturation of virions resulting in production of non-infectious particles. The recently approved darunavir (June, 2006) is the first of its class that retains activity against viruses with reduced susceptibility to protease inhibitors. Enfuvirtide targets a gp41 region of the viral envelope and stops the fusion process before the cell is infected. This drug needs to be injected twice daily and its use is reserved for treatment of heavily drug-experienced patients since it can help overcome existing drug resistance. 111 , 112 Development of new antiretrovirals focuses on molecules that target entry, reverse transcription, integration, or maturation. Compounds that have been designed to inhibit resistant viruses are urgently needed since many patients treated during the past decades harbour viral strains with reduced susceptibilities to many if not all available drugs ( table 3 ).

Antiretroviral drugs currently approved by US Food and Drug Administration

Drugs belong to five drug classes and target three dir erent viral steps (entry, reverse transcription, or protease). Availability of these drugs in resource-limited countries is subject to country specific licensing agreements.

Antiretrovirals currently in phase II/III of clinical development

The goal of antiretroviral treatment is to decrease the morbidity and mortality that is generally associated with HIV-1 infection. A combination of three or more active drugs is needed to achieve this aim in most patients. Effective treatment returns to near normal the turnover rates of both CD4+ and CD8+ T-cell populations. 72 Potent but well tolerated drugs with long half-lives and simplified regimens improve the options for first-line and second-line chemotherapeutic interventions.

Combination antiretroviral treatment

High rate of viral replication, low fidelity of reverse transcription, and the ability to recombine are the viral characteristics that lead to the diversity of HIV-1 species (quasi-species) in chronically infected individuals. This high genetic variability provided the rationale for highly active antiretroviral treatments (HAART). By combination of several potent antiretroviral agents, viral replication is suppressed to such low levels that emergence of drug resistant HIV-1 variants was, if not prevented, at least delayed. By doing so, CD4+ T-lymphocyte numbers increase, leading to a degree of immune reconstitution that is sufficient to reverse clinically apparent immunodeficiency. Widespread introduction of HAART in industrialised countries resulted in a striking decrease in morbidity and mortality, putting forward the hope that HIV-1 infection can be transformed into a treatable chronic disease. 113 – 115

A set of criteria composed of plasma viraemia concentration, absolute or relative CD4+ cell counts, and clinical manifestations, is used to recommend initiation of HAART. The benefits of treatment clearly outweigh the potential side-effects in patients with clinical signs of immunodeficiency (eg, AIDS defining illnesses) or with CD4+ numbers less than 200 per μL (recommendation of US Department of Health and Human Services, October, 2005). However, the best time point to begin treatment remains controversial in asymptomatic patients with modest depletion of CD4+ T cells (eg, more than 350 per μL) and modest levels of viraemia (eg, less than 100 000 copies per mL). 116 Studies with clinical endpoints supporting the validity of early versus late interventions in asymptomatic patients are difficult to do and insufficient clinical data are currently available. Early depletion of gut CD4+ T lymphocytes, 117 increasing viral diversity, and the poor regenerative abilities of key populations of the immune system provide arguments for beginning treatment as early as possible. The wide application of this principle is restricted by long-term drug toxicities that lead to reduction of quality of life, and by treatment costs. Toxicities (eg, renal, hepato, mitochondrial), metabolic changes (eg, lipodystrophy, diabetes mellitus), and immune reconstitution disease are some of the long-term problems that complicate decade-long HAART. 118 – 121

One strategy addressing life-long daily compliance to HAART has been structured treatment interruptions. The rationale for this approach was based on the premise that the body’s own immune system could keep the virus in check if exposed to a very modest level of viral replication. If successful, this strategy could limit drug toxicity and reduce treatment costs. 122 Although preliminary findings for this strategy were mixed in terms of benefits, 123 – 125 the recent early closure of the SMART trial was based on increased morbidity and mortality in the treatment interruption arm. 126 Thus, in the absence of clinical benefits, most investigators strongly discourage treatment interruptions except as needed to address treatment intolerance.

HAART in resource-constrained settings

The transformation of AIDS into a chronic disease in industrialised countries has yet to be realised in resource-constrained settings. Access to HAART is an absolute humanitarian necessity to avert mortality in people who are central to the future survival of their countries. 127 Despite restricted health infrastructures and diverse co-morbidities in these regions, remarkable therapeutic success rates have been shown, with adherence rates at least comparable with those reported in industrialised countries. 128 – 131 WHO and UNAIDS treatment guidelines focusing on resource-limited settings suggest use of standard first-line regimen followed by a set of more expensive second-line options 132 and proposes the use of standardised decision-making steps (eg, when to start, to substitute for side-effects, to switch for virological failure). 132 , 133 In many countries, treatment options are limited not only by the costs of HAART but also by restrictive licensing policies, and current estimates suggest that 80% of people infected with HIV-1 with a clinical need for treatment do not yet have access to antiretroviral drugs. 1 Thus, efforts and strategies to further scale up treatment access are crucial, 134 – 137 since antiretroviral treatment is also an effective intervention for prevention. 138

Drug resistance

Emergence of drug resistance is the most common reason for treatment failure. Insufficient compliance, drug side-effects, or drug-drug interactions can lead to suboptimum drug concentrations, resulting in viral rebound. Viral resistance has been described to every antiretroviral drug and therefore poses a serious clinical as well as public-health problem. 139 HIV-1 subtypes differ in the sequence of mutations leading to drug resistance, and some naturally occurring polymorphisms might actually modulate resistance. 140 , 141 Drug-resistant HIV-1 is transmissible and can be detected in up to 20% of newly infected individuals in countries with broad access to antiretrovirals. 34 The prevalence of drug resistance in the untreated population remains low in regions with poor access to treatment. 142

Short-term antiretroviral-based interventions are effective in prevention of mother-to-child transmission. However, these interventions could result in drug resistant viral variants in the mother, baby, or both. 143 Around half the women who received one dose of nevirapine to prevent mother-to-child transmission harbour viruses resistant to non-nucleoside reverse transcriptase inhibitors (NNRTI). 144 , 145 These resistant viruses replicate efficiently and can be transmitted by breast milk, 146 and minor resistant populations present long after the intervention can possibly decrease the effectiveness of subsequent NNRTI-based treatment regimens. 147 The combination of short-course zidovudine, lamivudine, and nevirapine prevents peripartum transmission while reducing the risk of nevirapine resistant viruses. 148

Viral reservoirs

Viral reservoirs consist of anatomical sanctuaries and a small pool of infected long-lived memory T lymphocytes. HIV-1 latency in long-lived cell populations (eg, memory T lymphocytes, macrophages) poses an obstacle to eradication because current antiviral combination treatments fail to eliminate integrated proviruses from resting cells. Different strategies, including immune-modulatory molecules (interleukin 2, anti-CD3 mAb, interleukin 7), have been used to reactivate resting cells in the setting of HAART. Histone deacetylase-1 inhibitors, like valproic acid, release an inherent transcriptional block and by doing so facilitate viral long terminal repeat-driven expression. 149 Augmenting standard antiretroviral treatment with enfuviridine and valproic acid reduced the number of latently infected CD4+ T cells (29–84%), but to establish the relative contribution of each drug with respect to the final outcome is difficult. 150

Mother-to-child transmission

Prevention of mother-to-child transmission has seen advances in both industrialised and resource-constrained settings. 151 – 153 Intrapartum transmission has been reduced by increasing access to interventions such as one dose of nevirapine to mother and newborn baby. 154 Concerns about drug-resistant viral strains have led to several trials with combination treatments to reduce transmission during the intrapartum period. 148 , 152 , 155 In some settings, elective delivery by caesarean section can further reduce HIV-1 transmission during the intrapartum period, but the benefits of the intervention could be countered by post-partum sepsis and increasing maternal mortality. 156

Because HIV-1 can be transmitted by breastfeeding, replacement feeding is recommended in many settings. Poor access to clean running water precludes, however, the use of formula feeding under these circumstances, 157 and exclusive breastfeeding with abrupt weaning is one option for reducing transmission. 158 A potential novel intervention still being tested is the daily use of antiretrovirals during breastfeeding. More attention is starting to focus on the pregnant mother, especially initiation of antiretroviral therapy in mothers with low CD4+ counts during pregnancy and thereafter. 159 , 160 Only limited data are available regarding the health of uninfected children born to HIV-1-positive mothers. 161 In a European cohort of exposed-uninfected children, no serious clinical manifestations were apparent, at least in the short term to medium term (median follow-up 2 years). 162

Sexual transmission

Reduction of heterosexual transmission is crucial for control of the epidemic in many parts of the world. 1 , 163 Prevention is achieved through reduction in the number of discordant sexual acts or reduction of the probability of HIV-1 transmission in discordant sexual acts. The first can be achieved through abstinence and sex between concordantly seronegative individuals. Abstinence and lifelong monogamous relationships might not be adequate solutions for many people and therefore several interventions aimed at lowering the risk of transmission per discordant sexual act are in the process of clinical testing. Male and female condoms provide a proven and affordable prevention option. 164 , 165 In combination, these options are also more commonly referred to as the ABC (abstinence, be faithful, condom use) approach.

Other biomedical prevention interventions include male circumcision, antiretrovirals for prevention (eg, pre-exposure or post-exposure), chemoprophylactic treatment of herpes simplex virus-2 (HSV-2), microbicides, and vaccines. Results from one of three independent phase III male circumcision trials underway in South Africa, Kenya, and Uganda has helped to allay some of the ambivalence around the protective effect of male circumcision. 8 , 166 The findings from the South African trial show a 60% protective effect of male circumcision. 167 The possible mechanism relates to the fact that the foreskin has apocrine glands that secrete lysozymes but also Langerhans cells expressing CD4 and other receptors. 168 , 169 These skin-specific dendritic cells can uptake virus and are believed to play a part in transport of the virus to susceptible T cells. Immunofluorescence studies of foreskin mucosa suggest that these tissues might be more susceptible to HIV-1 infection than cervical mucosa. 170 Findings from this proof-of-concept trial need to be compared with evidence from the two trials still underway in Kenya and Uganda, and to acceptability data, behaviour change after circumcision, surgical complication rates, and logistics of undertaking the procedures before policy formulation and wide-scale access as a prevention strategy. 171 – 173

Since high plasma viraemia increases the risk of transmission by as much as an order of magnitude, 21 does reducing viral load in the infected partner through, for example, antiretroviral treatment reduce the risk of HIV-1 transmission in the uninfected sexual partner? A trial to explore this question is currently being run jointly by the HIV Prevention Trials Network ( ) and the Adult Clinical Trials Group. Mathematical projections estimate up to 80% HIV-1 reduction, 174 , 175 but scarce observational data currently exist. 176 Post-exposure prophylaxis is recommended after occupational (eg, needle stick) 177 and non-occupational (eg, rape, sexual abuse) 178 exposure, although data for efficacy and optimum drug combinations are few. 179 Some clinical trials assessing the benefits of once daily pre-exposure chemoprophylaxis with antiretroviral compounds with long biological half-life (eg, tenofovir) have been put on hold or stopped. 175 , 180 Neither the overall idea of pre-exposure prophylaxis nor the drug itself, which is well tolerated, was at the root of the protests. Concerns were centred on clinical trials in resource-poor settings and the perceived scarcity of adequate interventions protecting these vulnerable populations.

HSV-2 might increase both the risk of transmitting and acquiring HIV-1. 181 , 182 Antivirals (eg, aciclovir, valaciclovir) are effective in reducing viral shedding 183 – 185 and HSV-2 transmission in discordant heterosexual couples. 182 The future of HSV-2 prevention might reside in the vaccine that is currently under development. 186 Whether prophylactic use of aciclovir in populations with high HSV-2 prevalence and incidence rates results in reduced HIV-1 incidence rates remains unresolved but several trials addressing this issue are underway, including HPTN039.

Gender disparities lie at the centre of women’s vulnerability. Prevention options need to be provided that can be used by women independently of their male sexual partner’s knowledge or consent. 187 Notwithstanding that redressing these disparities is a long-term challenge, several preventive interventions can be implemented in the interim on the basis of our incomplete understanding at a biological level of HIV-1 risk for women. For example, there seems to be a correlation between levels of sexual hormones (eg, progesterone) and transmission risk. 188 Observational studies also highlight the relation between abnormal vaginal flora and increased risk of HIV-1 infection. 189 , 190 The high prevalence of vaginal infections such as bacterial vaginosis (30–50%), vulvovaginal candidosis (10–13%), and trichomonas vaginalis (7–23%) in African women is associated with a substantial risk of HIV-1 acquisition. 189 In addition to increasing access to female condoms and treatment of other sexually transmitted infections, trials are underway to assess the use of other barrier methods such as cervical caps, invisible condoms, diaphragms, and diaphragms combined with micro bicides. 190 The control of vaginal infections is a potentially important method for decreasing HIV-1 acquisition that has yet to be tested. Periodic presumptive treatment for vaginal infections is being explored as an HIV-1 prevention strategy. 191


Microbicides are an additional important biomedical intervention technology that is covert and under women’s control. 192 These topical products potentially could be used to prevent rectal and vaginal transmission of HIV-1, but proof of concept has been elusive. Although the three phase III trial results of the first microbicidal product (nonoxynol-9) done in the mid-1980s and 1990s did not show protective effects, 193 , 194 they have informed the medical knowledge in terms of product selection, clinical testing, and safety assessments. The past 5 years have seen major advances in investment and product development. 66 , 195 , 197 Early clinical testing of multiple products including the launch of advanced clinical trials for five different products is continuing ( table 4 ). The development of antiretroviral gels increased the specificity of these third generation microbicides in relation to surfactants, vaginal enhancers, or entry inhibitors that have dominated the product pipeline so far ( figure 5 ). The first antiretroviral gel to undergo early testing is tenofovir gel, and the findings in terms of safety profile, tolerance, low systemic absorption, and slight adverse events are promising. 192 As with vaccines, a major obstacle is the absence of a surrogate marker of protection. Additional challenges are adherence to product use and the high rates of pregnancy in trial participants.

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N9=nonoxonol-9. CS=cellulose sulphate.

Summary of microbicides currently undergoing advanced clinical testing

A safe, protective, and inexpensive vaccine would be the most efficient and possibly the only way to curb the HIV pandemic. 198 Despite intensive research, development of such a candidate vaccine remains elusive. Safety concerns prohibit the use of live-attenuated virus as immunogen. 199 Many different approaches with recombinant technologies have been pursued over the past two decades. Initially, efforts were focused on generating neutralising antibodies with recombinant monomeric envelope gp120 (AIDSVAX) as immunogen. 200 , 201 This vaccine did not induce neutralising antibodies and, not unexpectedly, the phase III trials failed to show protection. 202 , 203 Antibody mediated HIV-1 neutralisation is complicated by the high genetic diversity of the variable Env regions, epitopes masked by a carbohydrate shield (glycosylation), and conformational or energetic constraints. 204 Since CD8 T-cell responses control to some extent viral replication in vivo, recent vaccine development has focused on eliciting cellular immune responses. Overcoming pre-existing immunity against replication incompetent immunogenic vectors (eg, recombinant adenovirus type 5) is one of the challenges. 205 Safety and immunogenicity studies using replication defective vaccine vectors are continuing after preliminary studies in non-human primates showed some protection. 204 The immune system generally fails to spontaneously clear HIV-1 and the true correlates of protection continue to be ill defined. 198 , 206 However, the general belief is that approaches aimed at eliciting both humoral and cell mediated immunity are most promising to prevent or at least control retroviral infection. 198


An important gateway to both prevention and care is knowledge of HIV-1 status. 207 Fear of knowledge of status, including stigma and discrimination, has discouraged many from seeking voluntary counselling and testing services. 208 As access to antiretroviral interventions (prevention of mother-to-child transmission, antiretroviral treatment) increases, the opportunities for HIV-1 testing will grow and create opportunities for a prevention-care continuum, with the voluntary counselling and testing services as a point of entry. These changes will result in a shift in prevention efforts from a focus on individuals not infected with HIV-1 to a more effective continuum of prevention that includes uninfected, recently infected, infected, and asymptomatic people, as well as those with advancing HIV disease and on antiretroviral therapy.

HIV/AIDS is an exceptional epidemic that demands an exceptional response. Much progress has been made in a short space of time, despite many scientific and programmatic challenges ( figure 6 ). In the absence of a protective vaccine or a cure, prevention and access to antiretroviral treatments are the best options to slow down the HIV-1 pandemic. Broad implementation of these principles needs improved infrastructures in resource-constrained regions, which have been and will continue to be most affected. The fact that HIV-1 is predominantly sexually transmitted and disproportionately affects populations that are already socially or economically marginalised, or both, poses many ethical, social, economic, and political challenges.

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Estimates place the cross species transmission events leading to the worldwide spread of HIV-1 to the early decades of the 20th century. Numbers circled by a hexagon identify the specific year of an event. PEPFAR=President’s Emergency Plan for AIDS Relief.

In view of the immediacy of the problem, and the fact that both research and programmes are mainly funded by the public sector, there is a greater demand from civil society for co-ownership of research and accountability for use of public funds. On the one hand, this co-ownership defines a changing role and responsibility of science in society, and on the other hand, shows a necessary synergy between activism and science. This partnership has been invaluable for antiretroviral drug development, treatment access in resource-constrained settings, and the scale-up of interventions to reduce mother-to-child transmission.

The increasing number of infected women and the disproportionate burden of infection in resource-constrained settings creates a scientific imperative to ensure research is done for people and in settings who stand to benefit most. The most affected countries face many other economic, political, and development challenges, which have raised issues in undertaking multicentre and multicountry research. Research addressing women-specific topics (such as effect of sexual hormones on transmission and disease progression, viral diversity, and antiretroviral potency) and women-specific prevention interventions including microbicides is crucial. We are probably at one of the most hopeful and optimistic points in our response to the pandemic. There is definitely more attention being directed to HIV-1, more resources ( panel ), more civil society mobilisation, more governments speaking up, more possibilities for treatment, and more evidence about what prevention and treatment strategies will work than in previous years. The unrelenting growth of the pandemic tells us that current strategies are not enough. Clearly, we need to do some things differently, while also increasing the scale and magnitude of current strategies in keeping with the pandemic.

PanelOnline resources


Treatment recommendations

Centers for Disease Control and Prevention

HIV-1 drug resistance

Stanford University HIV Drug Resistance Database

International AIDS Society–USA


Alliance for Microbicide Development

HIV Prevention Trials Network

International AIDS Vaccine Initiative

Search strategy and selection criteria

A comprehensive literature review was undertaken by searching the PubMed database online, for English language publications between January, 2000, and June, 2006. The database search terms included keywords such as “HIV/AIDS”, “epidemiology”, “prevention”, “pathogenesis”, “HSV-2”, “male circumcision”, “PMTCT”, “scaling up treatment”, “resource constrained settings”, “antiretroviral pre-exposure prophylaxis”, “HAART”, “restriction”, “host factor”, “HIV pathogenesis”, “resistance”, “latency”. Various combinations of these words were entered. All duplicate articles were removed. A subset of relevant articles was chosen and full-text manuscripts were summarised.


We thank P D Bieniasz, W Cates, L Chakrabarti, C Cheng-Mayer, J Coovadia, H Gayle, P A Fryd, R Gray, S Abdool Karim, L Kuhn, K Mayer, P Mane, L C F Mulder, L Myer, and M Wawer for helpful discussions. M Boettiger and C Baxter assisted with literature searches. This work was supported by NIH grant RO1AI064001 (VS), by grant 1 U19AI51794 (QAK) from CAPRISA that forms part of the Comprehensive International Program of Research on AIDS (CIPRA) funded by the National Institute of Allergy and infectious Disease (NIAID), National Institutes of Health (NIH) and the US Department of Health and Human Services (DHHS) and grant D43 TW00231 (QAK) from the Columbia University-Southern African Fogarty AIDS International Training and Research Program.

Conflict of interest statement

D D Ho sits on the scientific advisory boards for Monogram, Osel, Achillion, Valiant, Oyagen, Lavipharm, and XTL. Products or work from these companies are not discussed in the review. He holds patents on vaccine candidates. The other authors declare no conflict of interest.

  • Research article
  • Open access
  • Published: 17 August 2020

Knowledge, attitudes and practices of young adults towards HIV prevention: an analysis of baseline data from a community-based HIV prevention intervention study in two high HIV burden districts, South Africa

  • Simukai Shamu   ORCID: 1 , 2 ,
  • Sikhulile Khupakonke 1 ,
  • Thato Farirai 1 ,
  • Jean Slabbert 1 ,
  • Thato Chidarikire 3 ,
  • Geoffrey Guloba 1 &
  • Nkhensani Nkhwashu 1  

BMC Public Health volume  20 , Article number:  1249 ( 2020 ) Cite this article

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With an HIV incidence of 1.00 skewed against women (1.51), adolescents in South Africa are at high HIV risk. This paper assesses young adults’ (18–24 years) knowledge, attitudes and practices regarding HIV prevention in Nkangala and OR Tambo districts.

A cross-sectional household survey was conducted in two districts in 2017/8. Participants completed computer-assisted self-interviews on HIV knowledge, attitudes, behaviour practices, use of social media and condom use at last sex (proxy for high-risk sex). HIV knowledge was assessed using the South African-adapted UNAIDS scale. Descriptive analyses were conducted and logistic regression models were built to assess factors associated with being knowledgeable of HIV and condom use at last sex.

One thousand nine hundred fifty-five participants were interviewed (90% response rate). Less than half (44.7%) had correct knowledge of HIV prevention and 73% used a condom at last sex. Social media use predicted high HIV knowledge as higher odds were observed among participants using the print media (aOR1.87; 1.34–2.60), WhatsApp (aOR1.55; 1.26–1.90), radio/television (aOR2.75; 1.15–6.55) although social networking sites’ use protected against knowledge acquisition (aOR0.53; 0.34–0.82). Females (aOR0.75; 0.58–0.97) and participants reporting sexual risk were less likely to have HIV knowledge as negative associations were found for having multiple sexual partners in the last 3 months (aOR0.63;0.48–0.82) and ever having sex (aOR0.37;0.23–0.61). Participants who abused drugs (aOR1.40; 1.05–1.88) and had attitudes accepting people living with HIV (aOR2.05; 1.14–3.69) had higher odds of having HIV knowledge. Females (aOR0.70; 0.54–0.91), students (aOR0.52; 0.40–0.66) and participants who abused drugs (aOR0.58; 0.43–0.77) were less likely to report condom use at last sex.


There is a correlation between media use and HIV knowledge, non-condom use and HIV knowledge, and high-risk sexual behaviours and less HIV knowledge. An aggressive community media campaign utilising locally available, preferred and accessible media platforms among young adults is required for behaviour change.

Peer Review reports

South Africa has one of the largest HIV burdens in the world with an estimated 7.9 million people living with HIV (PLHIV) making a prevalence rate of about 13% in the entire population, or 20.6% among those aged 15 to 49 years [ 1 ]. South Africa contributes one third (33%) of all new infections in East and Southern Africa (UNAIDS 2018) followed by a distant Mozambique with 16% [ 2 ]. Nearly 200,000 people in South Africa contracted an HIV infection in 2017. Young women (aged between 15 and 24 years) have the highest HIV incidence of any age or sex cohort, at 2.01% in 2015 and 1.51% in 2016 compared to their male counterparts with 0.49% in 2016 [ 1 , 3 , 4 ]. Young women in their early 20s have a four-fold burden compared to their male peers, with approximately 2000 new HIV infections occurring every week [ 5 ]. Despite young women having the highest incidence, it is the young men who do not test for HIV which contributes to challenges to reaching the first 90 (HIV testing) of the UNAIDS’ 90–90-90 goals for South Africa. It is therefore important to develop interventions that target communities with young adults to increase HIV prevention, testing and treatment.

Given the high HIV prevalence and incidence among young adults and the need to meet the 90–90-90 goals, South Africa, through the National Department of Health, launched a community-based HIV counselling and testing (CBCT) programme. To enable the implementation of the programme, a baseline survey to understand the knowledge, attitudes and practices of young adults towards HIV was planned and conducted in two provinces prior to implementing CBCT. The baseline study was aimed at gathering information that would help planning and implementing CBCT interventions and to be used in evaluating the success of the intervention. This paper presents the results of the baseline survey on young adults’ HIV knowledge, attitudes and practices. The paper assesses the level of and factors associated with HIV knowledge and condom use at last sex among young men and women aged 18 to 24 years.

Design and setting

We used baseline cross sectional data from a community-based HIV prevention intervention study on young adult men and women aged between 18 and 24 years. The intervention aimed at increasing HIV knowledge, reducing risky sexual practices and increasing HIV testing and treatment in low income communities in two provinces, Mpumalanga and Eastern Cape. This baseline cross sectional study which was designed to plan interventions, HIV testing and targeting HIV risk people in the community was conducted in two districts - Nkangala in Mpumalanga Province and OR Tambo in the Eastern Cape Province. Data collection took place between October 2017 and January 2018 in low income urban, peri-urban and rural communities that are mostly occupied by black South Africans (97%).

The sampling design used was multi-stage cluster sampling. The methodology for this study has been described elsewhere [ 6 ]. The only one district from Mpumalanga province (Nkangala district) was purposively selected while one district from Eastern Cape province (OR Tambo district) was randomly selected from 4 districts for inclusion in the study. The study sample size was calculated as per sample size for prevalence survey with finite population correction. A minimum sample size of 1826 participants was calculated based on a formula that included a precision of 5%, power of 80% and design effect of 1.5. A sample of 29% (22 out of 76) health facilities were selected using simple random selection in the districts. Those facilities that were selected were used as the first stage clusters for the catchment areas in which the study was conducted. The second stage clusters were the catchment areas served by the selected health facilities in the districts. Areas served by facilities were then randomly selected for inclusion in the study. Participants were then consecutively recruited on a gender ratio of 1:1 – for men and women in each district to end up with 1826 participants. Participants were then recruited while using residential maps starting from the first numbered residential house until the sample size was reached in each ward before moving to the next selected ward. Not more than one person per household was interviewed.

Questionnaire development

We developed a questionnaire with several scales and questions for measuring HIV knowledge, HIV risk and condom use. The questionnaire can be accessed here ( ). Participants’ knowledge of HIV was assessed by asking five questions adopted from the UNAIDS conceptualisation of HIV Knowledge [ 7 ] that has since been used a number of times in South Africa’s national surveys [ 8 ]. An example of an HIV prevention question read: “To prevent HIV infection, a condom must be used for every round of sex’. HIV knowledge was regarded as being able to answer all the five questions correctly. Four stigma questions were used to assess participant’s attitudes towards people living with HIV by indicating one’s level of agreement with each of the statements using a 4-point Likert scale (from 1 = “strongly disagree”, 2 = “disagree”, 3 = “agree” to 4 = “strongly agree”). An example of a statement used is: “I would stay friends with someone even if I found out that he/she has HIV”. The individual responses for each participant were added and scored. We set the level of positive or accepting attitudes towards people living with HIV (PLWH) at 7 [ 6 ]. Being guided by the notion that community attitudes more broadly influence individual attitudes and also given that the study was conducted to enable an understanding of community views ahead of a community-wide programme of HIV testing, we assessed community HIV testing attitudes. These were assessed by asking participants their views about their community perceptions on HIV testing [ 9 ] using six questions. Participants indicated their level of agreement with each statement using a 4-point Likert scale with answers ranging from 1 = “strongly disagree” to 4 = “strongly agree” [ 10 ]. A typical question read, “People in my community are scared to test for HIV because they think that if they test HIV positive, they can never have a relationship again”. A combined individual’s minimum of 12 scores out of a possible 24 scores in all the questions was interpreted as having positive or accepting attitudes. Participants’ condom use at last sex was asked in the questionnaire to understand participants’ current risk of HIV. Participants were also asked about their history of transactional sex, HIV testing and HIV risk perception. Their use of any prohibited drugs such as tik, cocaine, dagga was asked in the questionnaire.

We also asked participants’ use of the media (radio, television, magazines, newspapers, electronic media, social networking sites). Questions asking participant’s demographic characteristics were added to be able to describe their gender, age, occupation, education, socio-economic characteristics (possession of household goods, income source). The English questionnaire was translated to two local languages mostly spoken by participants in their respective districts - isiNdebele in Nkangala and isiXhosa in OR Tambo. It was then back translated by an independent expert to ascertain clarity and correctness of the translation. Participants selected the language of their choice out of the three languages offered on the tool. The questionnaire was set into a RedCap system for data collection [ 11 , 12 ].

Data collection

We trained and engaged male and female local fieldworkers in participant recruitment, enrolment and data collection. The data collection procedures, ethics and instruments were pretested in the communities resulting in only minor language corrections done onto the questionnaire. Data collectors moved door to door recruiting participants. Daily tallying of participants enrolled was done to ensure adequate number of participants were enrolled in terms of gender and cluster as outlined in our minimum required sample size per area. Data collection took place over 3 months from October 2017 until January 2018. Data collected were saved onto a study database for analysis. The ‘Knowledge, attitudes and practices data’ link for the study is presented below the references.

Data analysis

Data were analysed in Stata 13.0 [ 13 ]. We used descriptive analyses for participants’ demographic characteristics, HIV knowledge, HIV risk and condom use. We conducted two multiple regression analyses. The first model assessed factors associated with HIV knowledge and the second model assessed factors associated with condom use at last sex. We selected factors for each model based on the literature on knowledge of HIV and condom use as well as considering variables observed in bivariate analyses. Regarding the latter, Hosmer and Lemeshow’s threshold for variable selection for logistic regression [ 14 ] was used and variables with a p -value of <.250 in bivariate associations were entered into the respective multiple regression model. Age and socioeconomic status were controlled for in the models. The models were built using a stepwise regression approach and the outputs were presented as adjusted Prevalence Odd Ratios (aORs). Our analysis took into account the clustering of the sample.

The study received Ethics approval from the Foundation for Professional Development Research Ethics Committee (6/2017). All participants interviewed provided written informed consent. Participants did not receive an incentive for participation.

A total of 1955 (88.8% response rate) participants enrolled into the study of which 971 (91.7%) were enrolled in Nkangala district and 871 (88.0%) in OR Tambo district. Half (50.2%) of the participants were female. The median age of the participants was 20 (IQR 19–22) years overall and did not differ by district or gender ( p  > 0.05). More than half the participants (54.9%) were students at either tertiary institutions or secondary school. More women than men reported being unemployed in Nkangala (0.001) and OR Tambo (0.047). The most preferred media channel for communicating HIV and TB messages was the radio (56.4%) followed by the television (52.1%). The print media (magazines 12.7%; newspaper 26.9%) were the least preferred media channel for HIV and TB messages.

Level of HIV knowledge

Table  1 shows the level of HIV prevention knowledge per individual knowledge item and overall knowledge score by gender. The percentages show the proportion of participants who correctly answered the respective questions while the overall HIV knowledge score shows the proportion of participants who correctly answered all questions. Only 44.7% correctly answered all HIV knowledge questions including correctly rejecting all HIV myths. More males (47.3%) than females (42.1%) were knowledgeable of HIV overall ( p  = 0.027). The question on condom use for risk reduction was the most correctly answered by participants (at least 94%), while the questions on whether AIDS can be cured or not (73.1%) and partner reduction to prevent HIV infection (74.9%) were the least correctly answered by participants. In each case, more males answered correctly than females.

Significant differences were observed between the two districts as higher knowledge levels were observed in Nkangala than in OR Tambo district (50.5% vs. 38.8%; p  < 0.0001) overall and in three knowledge domains except for partner reduction and condom use ( p  > 0.05). See Table 2 which shows HIV knowledge levels by district.

Table 3 shows demographic, media use and sexual behaviour characteristics of participants by overall HIV knowledge. HIV knowledgeable (high knowledge) participants were less likely to be females ( p  = 0.027), living in substandard housing ( p  = 0.036), living in OR Tambo district ( p  < 0.0001), but were more likely to be living in households with at least five basic commodities ( p  < 0.0001) and married ( p  = 0.003). Regarding media use, HIV knowledgeable participants were more likely to be using the radio/television ( p  < 0.0001), print media ( p  < 0.0001), and WhatsApp ( p  < 0.0001) but less likely to be using the internet for social networking ( p  = 0.09). In terms of sexual behaviours, HIV knowledgeable participants were more likely to be those with accepting attitudes towards people living with HIV ( p  < 0.0001), but less likely to have more than three lifetime sexual partners ( p  < 0.001), engage in transactional sex ( p  = 0.019) and have had sexual intercourse ( p  < 0.0001) than their non-HIV knowledgeable counterparts.

We assessed condom use among participants during last sexual intercourse as a preventative measure against HIV infections. We found 27.4% of the participants reporting not using a condom during last sex. A total of 36.7% reported that it was not easy to get a condom if they wanted it. Among the sexually active participants 62.1% reported using a condom at first sex. More women (67.8%) than men (52.7%) reported using a condom ( p  < 0.0001). A total of 83.5% reported that they were able to buy a condom without feeling embarrassed with more males reporting so than women ( p  < 0.0001). The same number reported being confident of putting on a condom correctly with significant differences observed between men and women (87.8% vs 79.3%; p  < 0.0001) (results not shown on table). Table  4 shows demographic characteristics, media use and sexual behaviours by condom use at last sex. Participants reporting condom use at last sex were less likely to be older ( p  = 0.018), female ( p  = 0.03), students ( p  < 0.0001), but more likely to be belonging to social/community clubs (0.043). Condom users were also more likely to be those with accepting attitudes towards people with HIV but they were less likely to have used illegal drugs, ( p  < 0.0001), engaged in transactional sex ( p  = 0.032) and have multiple sexual partners ( p  = 0.008).

Factors associated with HIV knowledge

Table 5 shows the results of the multivariate regression analyses on factors associated with HIV knowledge presented first in unadjusted Odds Ratios (uORs) and then in adjusted Odds Ratios (aORs). The impact of the media on HIV knowledge is strongly evident as people who used the media platforms had higher odds of reporting high HIV knowledge levels compared to those not using the media. Participants who listened to the radio or watched the television compared to those who did not had the highest odds (aOR 2.75 CI 1.15–6.55) of reporting high HIV knowledge levels. Those who used the print media (aOR 1.87) or used WhatsApp (aOR 1.55) also had higher odds of being knowledgeable of HIV than those who reported not using the respective media source. Being female (aOR 0.75), ever having sex (aOR 0.37) and having multiple sexual partners in the last 3 months (aOR 0.63) were associated with lower odds of having high HIV knowledge. Those who used social networking sites were less likely to have higher knowledge scores (aOR 0.53). Having accepting attitudes towards people living with HIV was strongly associated with reporting high HIV knowledge (aOR 2.05).

Factors associated with condom use at last sex

Table  6 shows the results of the multivariate regression analyses on factors associated with condom use at last sex. Participants who were female (aOR 0.70), students (aOR 0.52) or used drugs (aOR 0.58) were less likely to report condom use at last sex. Participants with a high HIV testing knowledge score had 58% chances of using a condom during last sexual intercourse.

The study made four key findings. Firstly and unexpectedly, less than half of the participants were knowledgeable about HIV. Secondly, a high proportion of participants (72%) reported condom use at last sex. Thirdly, media use (television/radio, WhatsApp, print media) factors were found to be key influences of HIV knowledge. Lastly, sexual risk factors including multiple sexual partners and attitudes towards HIV-infected people were associated with HIV knowledge while being knowledgeable of HIV was also associated with condom use at last sex. The following paragraphs discuss these key findings and their implications for community-based counselling and testing for which this study aimed to gather baseline information.

The study unexpectedly found low HIV prevention knowledge (44.7%) among participants. Knowledge levels differed by district and gender. Women had lower levels of knowledge compared to men in both districts and much lower in OR Tambo district. The predominantly rural nature and high poverty levels of participants in the surveyed districts may explain the low levels of HIV knowledge. Several studies have linked HIV knowledge and also infection with poverty and low levels of development [ 8 , 15 , 16 , 17 , 18 ]. The lower knowledge levels in OR Tambo was possibly due to the predominantly rural setting of many clusters surveyed in OR Tambo compared to Nkangala whose greater population is more exposed to urban life in the Capital City, Tshwane. Several communities that we surveyed in Nkangala acted as dormitory towns for Tshwane. More information is needed to assess these geographical differences considering the Ndebele and Xhosa cultures that make up the two communities, Nkangala and OR Tambo respectively. Although we found low knowledge levels among the participants (44.7%), these are higher than found in other studies (27% in Shisana et al. [ 8 ] study). While Shisana et al. [ 8 ] found that there were significant decreases in knowledge as reflected in their series of surveys since the 2009 survey [ 19 ], our finding shows an increase instead of a decline if we consider the 2009 Shisana survey as a baseline. By any standards, these knowledge levels are unacceptably low considering that participants were asked basic HIV questions which ordinarily are expected to be known, three decades since the first HIV case was discovered, also given the sexual and HIV education in schools and in the media. This calls for an aggressive strategy for community-based HIV prevention marketing and testing [ 4 ] to address the persisting knowledge gaps.

Another unexpected finding, in a positive direction though, was the high rate of condom use at last sex (72.6%) when compared to what other studies found. Our figure is double the one found in a South African 2012 national survey [ 8 ] which found only 36.2% of the participants reporting condom use at last sex [ 20 ]. The difference most probably signals behaviour change towards increased condom use in the population. We cannot speculate that there was interviewer bias since our interviews were self-administered on a tablet which gave the participant freedom and a good environment to answer the questions, free from interviewer bias. We understand that our survey enrolled a specific population, 18 to 24 year olds who were mostly single and not living with their partners, while Shisana eta al [ 8 ] enrolled 15–49 year olds who are mostly married and living together, factors that predispose people to not use condoms. Studies have shown that married or cohabiting people do not use condoms at most recent sexual intercourse than those neither married nor not cohabiting [ 21 , 22 ]

We found positive associations between participants who use the mass media and being knowledgeable of HIV. This association may be a testimony to the power of the media in educating young adults about HIV. Exposure to the media has been effectively found to help positively educate people and change negative HIV behaviours [ 23 , 24 , 25 , 26 , 27 ]. Although some studies found the television only as the most significant medium for TB and HIV prevention messages [ 8 ], we found the radio, WhatsApp and print media as equally important in HIV education. While we found the print media to be the least preferred media channel in disseminating HIV/TB messages, it had the strongest association with HIV knowledge after the radio/TV among all the media types. This may be because the print media is linked to high levels of user literacy which may mediate for the relationship between print media and HIV knowledge. Further research is required to understand this relationship. The significant effect of the WhatsApp platform could be because of the accessibility and affordability of internet facilities while the negative association with the internet facility could be that exposure to the internet was mainly for purposes such as entertainment other than educational purposes.

Gender differences in HIV knowledge and condom use were observed in this study. First, contrary to what was found in the national survey that there were no differences between knowledge levels by gender [ 8 ], we found gender differences as fewer women were knowledgeable of HIV than men. Secondly, women, compared to men, had less odds of reporting condom use at last sex. This echoes a finding by Peltzer et al. [ 28 ]. This may be related to gender inequities and inequalities which are prevalent in South Africa [ 29 , 30 ]. Very high rates of rape and sexual violence in South Africa which are also explained by gender inequalities have been explained before as major underlying causes of and factors associated with HIV infection [ 31 ]. Empowering women and work with boys and men may be a good intervention [ 32 , 33 ] to increase negotiation of condom use and empowering relations on the part of women for HIV prevention.

The association between mass media and HIV knowledge highlights the importance of mass media in HIV knowledge acquisition. Seventeen studies reviewed in a systematic review on mass media’s effectiveness on HIV outcomes illustrate that mass media positively influences and results in condom use [ 34 ]. Johnson et al. attempts a critical explanation of the relationship by arguing that social and behavioural communication programmes including mass media do not directly impact on HIV incidence and prevalence but through the availability of sociocultural norms and commodities such as condoms [ 9 ]. We however, did not find an association between mass media and condom use which some have found [ 21 ]. Instead, our results show that mass media was associated with HIV knowledge and that HIV knowledge was associated with condom use. Although we did not conduct a causal pathway analysis, we speculate that condom use at last sex could have been influenced by having high HIV knowledge which could have been an effect of exposure to the mass media in the communities. A causal pathway analysis or an intervention study is required to understand the relationship further. The relationship between knowledge of HIV testing and condom use at last sex is encouraging in this era of high HIV prevalence and incidence in South Africa as it informs us to find ways to intervene. We believe that strengthening HIV and AIDS prevention campaigns such as LoveLife, Soul City and Soul Buddyz [ 28 ] in the surveyed communities may fast track closing the HIV knowledge, testing and condom use gaps.

The study found that those who were sexually active or engaged in high risk sexual activities (ie people who abused drugs, were sexually active or had multiple sexual partners in the last 3 months) had lower odds of having high HIV knowledge. Our finding reiterates the findings from the Shisana et al. national behaviour survey [ 8 ] that key populations at high risk such as high risk drinkers had low levels of HIV knowledge. Such high risk people need to be targeted with HIV prevention messages and HIV testing programmes using specially designed and targeted programmes. We found that high HIV knowledge scores were associated with condom use at last sex and that those who held positive attitudes towards people with HIV were more likely to report being knowledgeable of HIV. This may suggest the power of knowledge in influencing young adults’ behaviours. However, since this was a cross sectional study we cannot conclude on the direction of these relationships which maybe be temporal [ 8 ] e.g. being knowledgeable made them to engage in less risky sexual behaviours or vice versa. Longitudinal studies are needed to understand causal relationships of the various associations that we found in the study.

The study has its strengths which include a large sample size overall. That the study was a household survey and that we visited households at least three times to locate the identified eligible participant helped to ensure that we adequately covered the study area giving potential participants adequate opportunity to participate in the study. The study clusters also covered urban, semi urban and rural settings enabling us to recruit participants with characteristics representative of communities and districts where the study was conducted. This helps to make comparisons with data from other household surveys conducted in South Africa. Although some have argued that questions asking one to self-declare intimate behaviours or socially stigmatised behaviours have challenges eliciting accurate data due to reporting bias the key variables used in the study relied on internationally and nationally tested scales and questions such as HIV knowledge and myths [ 7 , 8 , 35 ]. These questions have over the years been used in South Africa and our data is comparable to a greater extent to a series of studies conducted in South Africa. Methodological strengths of the study include a large sample size for adequate power in data analysis. The study also had a very high response rate of 89%, we enrolled equal numbers of men and women of the same age groups. We acknowledge the limitation that weighting was not done in the analysis.

We found low HIV prevention knowledge levels which were much lower among women, coupled by inadequate but relatively high levels of condom use at last sex. We learnt from this study that young adults who are at high risk of HIV infection also have lower knowledge levels, a relationship that could be bi-directional and needs further analysis in controlled longitudinal studies. We also found that utilising the various media channels to disseminate HIV prevention messages could be a significant contribution towards HIV prevention. Providing community-based HIV testing and counselling services that incorporate behaviour change and HIV prevention communication could be a game changer to doubly meet HIV prevention and treatment goals. Based on our results – low HIV knowledge, high HIV risk and non-condom use at last sex could be simultaneously targeted by providing HIV prevention knowledge and HIV prevention commodities such as condoms and pre-exposure prophylaxis (PrEP). This may empower young adults both with HIV prevention knowledge and power over themselves.

Availability of data and materials

The dataset supporting the conclusions of this article is included with the article.


Adjusted Prevalence Odds ratio

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People living with HIV

Pre-exposure Prophylaxis

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We acknowledge our research assistants who collected data for this study, the Centre for Communication Impact for their initial views on the study and Humana People to People in South Africa for providing office space to our research team in OR Tambo district.

The study was funded through the KFW programme. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The authors have declared that no competing interests exist.

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SS conceived and designed the study and led the data collection, analysis and interpretation of data, drafted the article, led the revisions and approved the version to be published. NN, SK, TF, TC, JS and GG substantially contributed towards study design, data analysis, and interpretation of data, revision of the manuscript. All authors have read and approved the manuscript.

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Shamu, S., Khupakonke, S., Farirai, T. et al. Knowledge, attitudes and practices of young adults towards HIV prevention: an analysis of baseline data from a community-based HIV prevention intervention study in two high HIV burden districts, South Africa. BMC Public Health 20 , 1249 (2020).

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  • HIV prevention
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