Awareness on Prevention and Control of HIV/AIDS Among the Adults

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“Awareness on Prevention and Control of HIV/AIDS

Among the Adults.”

Chapter- 1

Background and Rationale

1.1 Introduction:

AIDS, the acquired immuno-deficiency syndrome is a fatal illness caused by a retrovirus known as the Human Immuno-deficiency Virus (HIV) which breaks down the body’s immune system, living the victim vulnerable to a host of life threatening opportunistic infections, neurological disorders or unusual malignancies. The HIV/AIDS pandemic has become a permanent challenge to health, development and humanity. It is one of the leading causes of death in the world. World young’s people have been identified to be at special risks of HIV infection, with majority of infection due to unprotected sex1.

Usually, adolescent age is the time when they begin to take interest in sexual relationship. They may want to experiment with sex without giving much consideration to take implication of their present behavior. It is also at this stage that many of them develop lifelong habits, which could easily be influenced through proper guidance. Several studies can be carried out to evaluate the knowledge of adult, to identify gaps in awareness and perception about HIV/AIDS. A national baseline HIV/AIDS survey among young people aged 15-24 years established that the STI disease burden was high among them. Approximately 25 percent of males and 21 percent of females in the surveyed population reported symptoms of sexually transmitted infections (STIs). Young men and women do not perceive themselves to be at risk of acquiring STI/HIV due to lack of awareness and rampant misconception regarding the transmission and prevention of STIs. Lack of knowledge on STI symptoms and consequent delays in care-seeking behavior increases their risk towards HIV2.

Misperceptions and stigmas surrounding HIV/AIDS are a huge barrier to successful prevention and treatment of the disease in our country. Our society has an extremely conservative attitude toward sexual relations and therefore, issues relating to sexuality such as HIV/AIDS are not openly discussed. Because of the lack of education and awareness, misperceptions and stigmas at the virus are common. For example, it is generally believed that those infected with HIV at some way `law_article`morally corrupt.’’ The discrimination faced by infected people is so bad, that (PLWHAs) people living with HIV/AIDS attempt to keep their status a secret and do not seek help or support. The traditional and conservative social values about sexuality, combined with a lack of education and awareness about the disease, help to explain why the disease may expand quickly. This situation is particular serious for women. Women and girls face heavier risks of HIV infection than men because their diminished economic, social and cultural status compromises their ability to choose safer and healthier life strategy. Educational initiatives are needed to make people aware of how to protect themselves against the virus3.

High levels of illiteracy, religious and cultural modes, gender inequality and political instability contribute to low risk perception and high levels of stigma and discrimination related to HIV. Increasing premarital sex, sex between men and substance is abuse point to the potential for increasing HIV vulnerability and prevalence rates. Recurrent major disasters, such as annual floods and river erosions displace thousands of vulnerable people every year and make them poorer. Many young girls from these families are forced into sex work4.There is little awareness about prevention of vertical transmission interventions among the general population, including health care workers. This is largely due to limited availability of information about vertical transmission and low levels of education among women in rural areas5.

Although Bangladesh is a low prevalence country for HIV/AIDS, all the factors that may allow rapid spread of infection leading to an epidemic are present here. These factors include high-risk behavior, lack of awareness, very mobile populations and being surrounded by countries that have a higher prevalence of HIV. More recently, the risk of an impending concentrated HIV epidemic among IDU has been documented in a city of central Bangladesh where HIV prevalence has dramatically risen to 7 percent from 1.7 percent in six years. Sharing of injection equipment is common in most IDUs surveyed and the IDUs are also mobile traveling from one city to another and sharing injection equipment in different cities. Mobility is another major factor that increases the risk of acquiring and spreading HIV infection. Passive case reporting suggests that another population group vulnerable to HIV may be migrants returning from jobs overseas or through cross-border traffic to regions of high prevalence. The major challenge faced by Bangladesh at present is to keep the prevalence of HIV low.

Young people aged between 10 and 24 years account for one third of the total population of Bangladesh or approximately 38 million. Although Bangladesh is a conservative society, studies have revealed that young people irrespective of marital status engage in unprotected sexual encounters that are high risk for exposure to HIV. They are not always aware of the risks and dangers posed by unsafe sexual activity and other risk behaviors like injecting drugs and are ill informed and unprepared to protect themselves. With this as background, young people have been identified as one of the more vulnerable groups in Bangladesh with regard to HIV/AIDS. There are several factors that make Bangladesh vulnerable to an HIV epidemic. The country is geographically situated in close proximity to India and Myanmar, which have a high HIV prevalence, and Nepal which has a concentrated HIV epidemic among IDUs. Open borders, sex industry, links between high risk groups and bridging populations, labour migration, gender inequities, poverty, low literacy levels, gaps in healthcare delivery and low levels of HIV/AIDS awareness have also been identified as important factors in the spread of HIV infection7.

Girls and young women are more susceptible to STI/ HIV infection than men due to biological and other factors such as the need to receive blood transfusion more often on account of anemia or complications at child birth. Low social status of women in Bangladesh and other contextual features including widespread poverty, low literacy and educational levels and limited skill training and employment opportunities place girls and young women in particular at a high risk of infection. Women are also more at risk from violence, trafficking and coercive sex or from the economic vulnerability that forces them into sex work. Their economic situation also compromises their ability to negotiate protection or leave risky relationships. Early marriage further deprives women of a chance of acquiring more autonomy, access to information and negotiating power in matters of sexuality. The mean age of marriage of girls in Bangladesh is 16.9 years. While 48% of 15-19 year-old girls are married, about 60 percent of them become mothers before the age of 19 years. Married women are also at a growing risk of HIV and STIs due to the risky behavior of their spouses who may visit sex workers or engage in IDU practice. In fact, a higher prevalence of STI was observed in married women in comparison with unmarried women. To tackle AIDS, prevention is the most effective and cheapest way out that must be given worldwide public health priority. Prevention of HIV/AIDS is possible through awareness and behavioral changes8.

1.1 Background :

The human immunodeficiency virus (HIV) epidemic has emerged as a formidable challenge to public health development and human rights. At the end of 2006, there were an estimated 39.5 million people living with HIV (PLHIV) globally. More than 95 percent of the new infections in 2006 were in low and middle income countries. Among the WHO regions, Sub-Saharan Africa is the most affected followed by South –East Asia. Although the overall adult HIV prevalence in South-East Asia is still low (0.7 percent) the total number of people affected is huge- an estimated 7.2 million PLHIV by the end of 20069.

Ever since the first report of acquired immunodeficiency syndrome (AIDS) in 1981 in the United States, human immunodeficiency virus (HIV) infection has reached pandemic proportions, resulting in more than 65 million infections and 25 million deaths worldwide. The global HIV epidemic has emerged as a formidable challenge to public health, development and human rights. In countries most severely affected by HIV, it has eroded improvements in life expectancy. One in every hundred sexually active adults worldwide is infected with HIV. Every day more than 6800 people become infected with HIV and more than 5700 people die from AIDS, mostly because of inadequate HIV prevention and treatment services. If current rates of transmission continue, more than 40 million people would live with HIV in 2010. In spite of advances in the areas of prevention and treatment, the virus continues to spread at an estimated rate of 16,000 new infections a day. Of these, half are women and 40 percent are young people (15-24 years old). Of the estimated 37 million adults living with HIV worldwide, nearly 18 million are women. Sub-Saharan Africa continues to bear the burnt of the global epidemic. Two-thirds (63 percent) of all adults and children with HIV globally live in sub-Saharan Africa. In southern Africa, HIV epidemics in Swaziland, South Africa and Mozambique continue to grow. In Swaziland, an estimated one in three (33 percent) adults was living with HIV in 2005- the most intense epidemic in the world. South –East Asia with an estimated 7.2 million PLHIV has the second highest of HIV in the world following sub-Saharan Africa. In the Middle East and North Africa Region, Sudan has the largest epidemic. In the Caribbean Region, HIV prevalence has either remained stable or is decreasing with two-thirds of the affected people living in Dominican Republic and Haiti9.

At the end of 2006, an estimated 7.2 million (4.7 million -11 million) people were living with HIV in South –East Asia Region which included 0.77 million (0.47 million -2.1 million) new infections in 2006. Approximately, 550000 people died of AIDS during 2006. The majority of the HIV burden in the Region is concentrated in five countries, namely India, Indonesia, Myanmar, Nepal and Thailand. India, the world’s second-most populous country, has multiple and diverse HIV epidemics. In five of the 35 states/ union territories of the country, the median adult HIV prevalence is >1 percent .Thailand is among the few countries in the world to have turned around a rapidly escalating generalized HIV epidemic. The number of estimated new HIV infections decreased from 1, 40,000 per year in 1991 to 17,000 in 2005. Myanmar has the third highest HIV burden in the region with 3, 39,000 adults living with HIV in 2005, i.e. 1.3 percent of the adult population is HIV-infected. As in other Asian countries, HIV is highest among groups practicing high risk behaviors; these include sex workers, IDUs and MSM. Indonesia has the fastest growing epidemics in the Region, although the aggregate national HIV prevalence is still very low, with 48 percent of drug users in Jakarta and up to 23 percent of sex workers in Papua being infected10.

Nepal reported its first cases of AIDS in 1988. It is considered to have a concentrated epidemic in populations with high-risk behaviors with IDUs having the highest rates of HIV infection. HIV prevalence among male IDUs in Kathmandu valley increased from 2 percent in 1991 to 68 percent in 2002 and remained high at 51 percent in 2005. In Sri Lanka, the main risk groups are sex workers and their clients and MSM. Maldives already has a massive epidemic of drug users among the youth and could have an explosive HIV epidemic among IDUs in the future if adequate measures are not taken urgently. In Bhutan, STIs are high among certain population groups and early indications of the spread of HIV among IDUs10.

Bangladesh with a population of about 158 million is one of the most densely populated countries in the world11. In Bangladesh the first case of HIV was detected in 1989. The total number of HIV infected person was 1745 up to the year of 2009. The number of patients suffering from AIDS was 619. The newly AIDS patients were 143 in number and newly infected were 250 in the year 2009. The death from AIDS was 204 in number till 2009 and 39 died in this year.HIV prevalence in general population is still < 0.1 percent.

Concentrated epidemic among the IDUs at certain areas of Dhaka city is 7.0 percent. Total number of IDUs and prostitutes are 40,000 and 90,000 at present. It reveals Bangladesh at a crossroad. 12.

1.3 Justification:

The first case of HIV/AIDS in Bangladesh was detected in 1989, and since 1994, prevalence has steadily risen with approximately 11,000 people living with HIV/AIDS by 2005 13-14.The most at-risk populations include IDUs, CSWs, babus (the regular boyfriends of CSWs), men who have sex with men (MSM), and migrant workers. Prevalence in this vulnerable population has tripled over the last six years. National survey data reveals an increase in HIV infection in IDUs from 1.8 percent in 2001 to more than 4.9 percent in 200515. This remains just short of the 5 percent rate necessary to define a “concentrated epidemic”16. In one hotspot of Dhaka, prevalence has jumped as high as 9 percent17. This data reveals Bangladesh at a crossroad. If epidemic control measures in at-risk populations are not rapidly addressed, it could easily endanger the rest of the country as it becomes a generalized epidemic.

Seventy-seven percent of IDUs in Bangladesh generally share needles freely. In addition, the IDU population is growing. Each year for the past five years, 10-20 percent of previously non-injecting drug users began injecting18. The rapid increase in infection rates in this vulnerable and growing population of individuals has important implications for the spread of the epidemic in the general population. IDUs act as an important bridge population. Not only do they move frequently between regions of Bangladesh, but also frequently interact with other populations in society including male and female sex workers, MSM, and transport and industry workers. Ninety one percent of IDUs in non-intervention sites reported having sex with female sex workers, with 53 percent admitting to never using condoms, and 64 percent having unprotected sex with regular partners.

Furthermore, many participate in the illegal sale of blood, thus increasing the risk for the tainting of the national blood supply. With knowledge of HIV transmission lacking, where 34 percent of IDUs do not know that HIV could be spread through needle sharing, and unaware of their own status, the potential for spread to the general population is significant.

Further compounding factors of the epidemic include geographic location and open borders. Due to its close proximity and porous borders to parts of India and Myanmar with a generalized epidemic, and Nepal with a concentrated epidemic among IDUs, where both legitimate and informal traffic crosses regularly, Bangladesh remains in a vulnerable situation. Behavioral surveillance in Bangladesh revealed that most people who engage in high-risk behaviors do not know how the virus is transmitted, and are unaware of how their behaviors put them at risk. Furthermore, in the male-dominated society of Bangladesh, the low status of women puts them at greater risk of contracting HIV. Married women who are faithful to their husbands are at a growing risk of HIV and STIs due to the behavior of men in engaging in acts with sex workers and practicing injection drug use. Even equipped with the knowledge of risk involved with their husband’s behavior, they do not have the power to negotiate safer sex with their partners. An increasing number of women and girls are being driven into sex work due to poverty, and are putting them at risk for HIV acquisition. Additionally, in societies where girls and women are not empowered to think critically, make decisions, and solve problems, they lack the self-efficacy needed to protect them against HIV.

A set of Millennium Development Goals (MDGS) is an UN declaration on 2000 in New York, represented by 189 countries. MDGs place health at the heart of development. Three of eight goals are directly related with health, of which sixth one is to combat HIV/AIDS, malaria and other diseases. Goals have to be achieved by 2015 or earlier outlining progress from 1990. To tackle HIV/AIDS, prevention is the most effective and cheapest way. Prevention of HIV/AIDS is possible through awareness and behavioral changes. The present study is therefore conducted to check the level of HIV/AIDS awareness among the adults attending at the outpatient department of Dhaka Mohanagar General Hospital, Naya bazar, Dhaka.

1.4 Research question

Does the awareness on Prevention and control of HIV/ AIDS among the adults vary with the socio-demographic or other factors?

1.5 Objectives:

1.5.1 General objective:

To assess the level of awareness on prevention and control of HIV/AIDS and to identify the factors influencing awareness among the adults attended at out patient department of Dhaka Mohanagar General Hospital, Naya Bazar, and Dhaka.

1.5.2 Specific objectives: To assess the level of awareness on prevention and control of HIV/AIDS among the adults attended at out patient department of Dhaka Mohanagar General Hospital, Naya Bazar, and Dhaka. To identify factors influencing awareness on HIV/AIDS among the adults attended at outpatient department of Dhaka Mohanagar General Hospital, Naya Bazar, and Dhaka. To relate socio-demographic characteristics of the adults with the level of awareness on prevention and control of HIV/AIDS.

1.6 Operational definition:

1.6.1 HIV/ AIDS

HIV stands for Human Immunodeficiency Virus.

AIDS means Acquired Immune Deficiency Syndrome.

HIV causes AIDS. AIDS is a disease that slowly destroys the body’s immune system. HIV is spread by

(a) Having sex without a condom. Vaginal and anal sex carry a high risk,

(b) Sharing needles or syringes to inject drugs or steroids.

c) a mother to her infant during pregnancy, delivery or breastfeeding.

d) Getting a tattoo or piercing from a dirty needle

e) Transfusions of blood or blood products and organ transplants.

The average time between HIV infection and the appearance of signs that could lead to an AIDS diagnosis is 8-11 years. This time varies greatly from person to person and can depend on many factors including a person’s health status and behaviors. The only way to determine whether you are infected is to be tested for HIV. Many people who are infected with HIV don’t have any symptoms at all for many years. Many AIDS deaths result from pneumonia, tuberculosis or diarrhea: Death is not caused by HIV itself but by one or more of these infections 22.

1.6.2 Adult

The term adult has at least three distinct meanings. It can indicate a biologically grown or mature person. In modern developed countries, puberty and therefore biological adulthood generally begins around 10 years of age for girls and 12 years of age for boys, though this will vary from person to person. Those who have graduated from high school (18 or over) are often recognized as social adults in addition to being biological adults. The legal definition of entering adulthood usually varies between ages 15-21, depending on the region. In most of the world, the legal adult age is 18 for most purposes 23.

1.6.3 Outpatient

An outpatient is a patient who is not hospitalized overnight but who visits a hospital, clinic, or associated facility for diagnosis or treatment. Treatment provided in this fashion is called ambulatory care. Outpatient surgery eliminates impatient hospital admission, reduces the amount of medication prescribed, and uses a doctor’s time more efficiently. More procedures are now being performed in a surgeon’s office, termed office-based surgery, rather than in an operating room. Outpatient surgery is suited best for healthy people undergoing minor or intermediate procedures (limited urologic, ophthalmologic, or ear, nose, and throat procedures and procedures involving the extremities).

1.6.4 Awareness

Synonyms are aware, cognizant, conscious, sensible, awake, alert, watchful and vigilant. These adjectives mean mindful or heedful. Aware implies knowledge gained through one’s own perceptions or by means of information. It emphasizes the recognition of something sensed or felt. It also implies knowledge gained through intuition or intellectual perception. To be a awake is to have full consciousness of something i.e., as much as awake to the novelty of attention. It is meant by stresses of quickness to recognize and respond. Finally it can be implied as looking out for what is dangerous or potentially so.

1.6.5 Prevention

Prevention means act of preventing. In other wards that it can be explained as `law_article`there was no bar against leaving’’. To prevent literally means to keep something from happenings The term of prevention is reserved for those interventions that occur before the initial onset of disorder. Universal preventive intervention is targeted to the general public or a whole population group that has not been identified on the basis of individual risk. Selective preventive intervention is targeted to individuals or a subgroup of the population whose risk is significantly higher than average. Indicated preventive intervention is targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms but who do not meet diagnostic levels at the present time.

1.6.6 Control:

It means power to direct or determine. It is a physiological regulation or maintenance of a function or action or reflex. Control condition is a standard against which other conditions can be compared in a scientific experiment. It can also be defined as restraint, discipline in personal and social activities. It is a relation of constraint of one entity (thing or person or group) by another Dominic. The state of dominance that exists when one person or group has power over another can also be marked as control.

1.7 Key variables

a. Variable related to socio demographic characteristics

1. Sex of the patient

2. Age

3. Education

4. Religion

5. Marital status

6. Monthly family income

7. Number of children

8. Type of family

9. Occupation

10. Educational qualification of spouse

b. Variables related with HIV/AIDS awareness

1. Knowledge regarding HIV/AIDS

2. Source of information about AIDS

3. Prevalence

4. Clinical features

5. Methods of transmission of HIV

6. Transmission of HIV between mother and child

7. Diagnosis of AIDS

8. Opportunistic infections associated with AIDS

9. Treatment of AIDS

10. Consequences

11. Vulnerable groups of HIV/AIDS

12. Prevention of HIV/AIDS

13. Protection from HIV/AIDS

14. Role of family planning on prevention and control of HIV/AIDS

15. Situation of HIV/AIDS in Bangladesh

16. Role of media on prevention and control of HIV/AIDS

17. Bangladesh government strategy on prevention and control of HIV/AIDS

18. Role of NGO on prevention and control of HIV/AIDS

19. HIV/AIDS epidemic in other countries

20. Relationship between addiction and HIV/AIDS

c. Variables regarding the factors related with HIV/AIDS awareness

1. Factors leading to HIV/AIDS

2. Form of protection for safe sex

3. Risk groups of HIV/AIDS

4. Vaccine of AIDS

5. Free distribution of condom

6. Sex education

7. Level of education system for incorporation of sex education

8. Place for HIV screening

9. Free distribution of disposable syringes

10. Behavior towards a man suffering from AIDS

11. Barriers for HIV/AIDS prevention

Chapter- 2

Literature review

The battle against the disease AIDS is undoubtedly getting more and more serious all over the world. Unless the population has an adequate understanding of AIDS and the ability to practice low risk behaviors, the increasing rates of development of HIV/AIDS would be considerable public health threat. This is why; several studies had been carried out in different groups and classes among the communities throughout the world to evaluate the knowledge about the awareness of HIV/AIDS. This will help to identify gaps in awareness about HIV/AIDS, thus recommending the various programmers in the HIV/AIDS awareness campaigns.

In a study 185 male drug users who attended a drug addict treatment centre in Dhaka city were investigated and it was found that 99 percent of them had some awareness of AIDS28.In a study from (BDHS) Bangladesh Demographic Health Survey it is found that, the knowledge on AIDS varied significantly in different parts of the country. Nearly a quarter of adolescents in Dhaka and Chittagong division had heard of AIDS, while only 8 percent of Rajshahi division had heard of AIDS. Education had a linear and positive relationship with having knowledge on AIDS. About 43 percent of the adolescents with secondary or above education had heard of AIDS compared to 12 percent with primary education and 7 percent with no formal education29. Findings in a study done in Rajshahi district of Bangladesh revealed that about 87 percent male were aware about HIV/AIDS and comparatively women were found same aware of AIDS30.

A cross sectional study was carried out in 2007 in South Delhi, India to investigate the perception, knowledge and attitude of adolescent urban schoolgirls. In this study 77 percent of the respondents had knowledge that multiple sex partners increase the risk of HIV infection, indicating good awareness about HIV transmission among the adolescent girls31. To find out the level of awareness a study was done among the students of 13-18 years. It was observed that 82.2 percent of the students knew the virus as the causative agent and 63.2 percent students stated that the virus could transmit both prenatally as well as postnatally. Only 34 percent students were aware of all the precautions to be taken to avoid AIDS8.

A study was conducted to know the present knowledge regarding occupational exposure to HIV amongst doctors in non-governmental hospitals and clinics across Delhi. Majority of them had suffered needle stick injuries. Many had also experienced splash over face and eyes. Some participants were still recapping needles most of times. 85.7 percent of participants were fully vaccinated for hepatitis B .Awareness was low (36 percent). The study highlighted the low awareness of post exposure prophylaxis measures amongst health care workers 32.

A 1998 study on HIV/AIDS awareness levels among adolescents at St. Xavier’s College in Mumbai (Bombay) found that female students were significantly better informed about the disease and its manifestations than their male counterparts. The study also found that students in the Arts stream and those in the younger age group (15 to 20 years) were more knowledgeable about AIDS than those studying science or commerce who were over 20 years.33

The internet is currently used as a tool to obtain information, make conversation, and find sexual partners. A study included 898 participants. Internet users were in visited to participate from December 2003 to march 2004 through a link on the homepage of the internet health website ( Two e-mail messages were sent to all internet subscribers, the first one on the first day of the program and the second after a week period, inviting them to participate in the survey. A total of 898 persons participated in the survey with regard to general information about AIDS. Half of the respondents said that it was a viral disease and was transmitted only sexually and 11.4% of them stated that AIDS was curable. This showed that Turkish society did not have adequate awareness of the treatment of HIV/AIDS. 34

A qualitative study using focus group discussions was conducted in both rural and urban areas among the disabled and non-disabled participants. Participants with disability were less well informed about HIV/AIDS than their non-disabled peers35. A study was conducted in 7 private co-educational English medium schools for classes IX and XI in Cochin, Kerala, India. More than 70 percent of adolescents were aware about AIDS. But adequate knowledge about its spread and prevention was lacking 36. To create awareness/ sensitization campaigns on HIV/AIDS in dangers of the HIV/AIDS pandemic in Nigeria, a study was done, from last week of March, 2007 to last week of April, 2007. The senior and junior staffs of Keffi Local Government Area of Nasarawa state of Nigeria took part in this study. Majority (50.7 percent) demonstrated clear knowledge of risky-behavior while 49.3 percent claimed poor knowledge of the same concept.

Long distance truck drivers in Pakistan had serious gaps in their knowledge about HIV/AIDS, especially its modes of transmission, signs/ symptoms and prevention. In a study, 75 truck drivers at Badami Bagh Truck Stand, Lahore, Pakistan, were interviewed on non-random basis. Forty to fifty percent of respondents had the misconception that AIDS could be contracted by casual contract and by being in the same room with a person with AIDS. Two third of the truck drivers did think that monogamy and condom use was an effective method for AIDS prevention. They also had a negative attitude towards persons with AIDS 38. A study about awareness of HIV/AIDS and its oral manifestations among people living with HIV in Dares Salaam, Tanzania was performed. A total of 13.4 percent of the participants were completely unaware of the oral manifestations of HIV/AIDS whereas all participants were fully aware of general symptoms of AIDS. There were no significant associations between awareness of oral manifestations and general awareness of HIV/AIDS on level of education .

Impact of Educational intervention on knowledge regarding HIV/AIDS among adults of Kathmandu, Nepal was examined. Finding of the study revealed that most of the respondents had misconception about transmission of HIV/AIDS. Before intervention, mean knowledge for ways to prevent transmission of HIV/AIDS was 2.05 which were increased to 5.65 after intervention 40. A nationwide survey, HIV/AIDS knowledge among Malaysian youths shows that knowledge among the respondents was knowledge score of 20.1 out of 32 points 41.

A study was performed at an urban antenatal hospital clinic in Maharastra, India, from April to September 2001. Structured interviews were conducted on 707 randomly selected antenatal clinic patients related to HIV/AIDS knowledge. Nearly 70 percent of women demonstrated knowledge of maternal to child transmission; however, only 8% knew of any methods of prevention. Education of the women was strongly related to HIV/AIDS. In addition, if the husband was reported to have a higher status employment the women were 50 percent more likely to have adequate knowledge of AIDS42.

The US Embassy celebrated World AIDS Day with the US Agency for International Development (USAID) and its partners in the fight against HIV/AIDS in Nepal through a program of informative games and interesting events designed to raise awareness and highlight key issues. The World AIDS Day program represented an important educational initiative in support of USAID/ Nepal. USAID/ Nepal was hopeful that the opportunity that World AIDS Day represented would be used to place the issues of those affected by HIV/AIDS at the forefront and to act as a catalyst for improving efforts to mitigate the impact of HIV/AIDS in Nepal. 43

A recent survey by Assumption University revealed that a third of Thai girls who responded to the poll thought it neat to lose virginity on Valentine’s Day. The World Bank Thailand Youth Club had been focusing on promoting awareness among young people. In February- the Month of love for many youths around the youth Club organized two events to encourage youth dialogue on HIV/AIDS. The `law_article`Co Park” on February 10 aimed to raise funds for the HIV/AIDS center at a temple in central. The `law_article`Safe sex or no sex’’ campaign on February 13 aimed to encourage youth to choose and protect themselves from HIV/AIDS 44.

A study was carried out in January and February, 2005 among secondary school teachers in Abeokuta, the capital city of Ogun State, and jebu Ode, the second largest town in Ogun State, Nigeria. Twelve schools were randomly selected out of 35 public schools in the towns. The study found that the teachers who participated in the survey had good knowledge of HIV/AIDS. However efforts are still needed on the parts of those concerned to increase the knowledge of these teachers as they had few misperceptions about facts, modes of transmission and the right attitudes towards people with HIV/AIDS. There is need to train teachers for them to be able to deliver information of sufficient quality and intensity that could have positive behavioral impact on the students4. HIV/AIDS awareness program was conducted in health care workers working in out-patient Health Care facilities in the city of Bangalore in India. The health care workers were doctors, pharmacists, nurses/ nursing assistants, laboratory staffs, health assistants and cleaning staffs. In results, doctors showed 16 percent increase in the correct responses whereas 82 percent of the other participants improved their correct responses by 15 to 70 percent and 14 percent did not show any change. Surprisingly, 4 percent deteriorated by 10 to 15 percent. Conclusion was drawn by stating that HIV/AIDS awareness programs are quite effective in informing & educating health care workers who form the backbone of AIDS control programmes45.

In Kante, situated about 400 miles north of Lome, several hundred young people gathered to view a video entitled `law_article`Sahel Scenario”. After the film, the ARS nouveaux horizons book, `law_article`Sida- Ce Que Les Jeunes Doivent Savoir” (`law_article`AIDS- What young people must know”), was presented by the local physician and staff of an AIDS NGO. The focus of the program was `law_article` Girls confronted with AIDS.” The film shown at the HIV/AIDS program in Kante was more effective than speeches to convey to young people the causes and effects to HIV/AIDS 46.

In Karachi-Sindh of Pakistan, HIV/AIDS awareness programs were initiated through quiz and poster competition among youth. Five girl’s colleges were selected and the participants were provided informative material, literature about HIV/AIDS for preparation of quiz and making posters. During quiz, questions regarding HIV/AIDS prevention, control and present data were asked. STDs and other public health problems were also covered. Cash prizes and awards were given to the all participants and trophies to the winning teams. General audiences attending the competition were also involved and encouraged by direct questions and prizes. This approach provided an opportunity of creating awareness within locally acceptable atmosphere, norms, language and cultural values. The activity attracted and evolved the youth as a active member to bring about changes in their own attitude and practices 47.

A community based cross-sectional study was conducted from August 2003 to January 2004 in 36 villages of Anand district of India. A two page structured questionnaire was prepared both in English and local language i.e., Gujarati. The questions were related to awareness of HIV/AIDS, mode of disease transmission, its prevention & assessment of health service utilization. EPI- INFO package was utilized for statistical analysis. Among all those (76.6 percent) who had heard about HIV/AIDS, 22 percent correctly knew about the sexually transmitted infections. Knowledge of prevention was very good as 76 percent of males and 52 percent of females had the opinion of having sex with single partner was a most important way of life to prevent HIV/AIDS. It was surprised to see the popularity of local so called doctors (Quacks) as 30 percent of the individuals still had the opinion to visit them to get treatment for problem related with their genitalia. Most of them (>90 percent) were uneducated. Among the educated class, 70 percent were interested to visit primary health centers and Skin & VD department of medical college hospital. About two-fifths (40 percent) of them were not interested in doing anything for the infected person 48.

The low level of awareness especially on STD, HIV and AIDS is always alarming for rapid diffusion of epidemic in population of higher size. This is because culture of a particular society can restrict partially but not forbid entirely the heterogeneous sexual relation among its inhabitants as because it is solely a spontaneous response to nature. SHAD had been working with under privileged women, children and drug users in Khulna division located at the Southern region of Bangladesh since last 8 years. From its working experience at this particular region, SHAD found that a mutiny had taken place beyond the sight and was still functioning without any mentionable indication of ending. Random practice of adolescent sex, abundance of multiple marriages for trafficking and sex trade in home and abroad made this individual population of a particular region in Bangladesh was distinguished from general culture and sexual attitude of other areas that might the reason of high vulnerability of STD, HIV/AIDS. SHAD conducted a study to explore their attitude, determine the unsafe sex along with vulnerability to STI, HIV and AIDS49.

The Asian Development Bank had funded an HIV/AIDS awareness project in remote mountains in China’s Qinghai and Gansu provinces. Religious festivals around mosques and temples provided opportunities for anti-HIV/AIDS workers to disseminate information and condoms, give lectures, and perform plays related to the fight against the epidemic. Schools were important centers for recruiting teachers and students to become long-term HIV/AIDS prevention volunteers. People between the ages of 18 to 30 were particularly receptive to visual performances as an education tool. It reported that the project was a success with HIV/AIDS prevention awareness rates of up to 90 percent among those targeted 50.

Research omnibus survey in April 2002. The survey was carried out in ten cities and ten towns throughout China with 6.777 people completing the interviews. The random sample of adults ranged from ages 18-70 years, with various levels of education (from illiterate to post graduate), and with different occupations and monthly income. Knowledge of HIV/AIDS among men and women was high: over 93 percent of city residents and almost 83 percent of town residents had heard of HIV or AIDS; Disparities in HIV/AIDS awareness existed among people with different socio-cultural backgrounds 51.

Hong Kong had a migrant worker population of almost 250, 000 of which nearly 220,000 were foreign domestic workers, 90 percent of them women. Of foreign domestic workers documented in 2004, 54.8 per cent were from the Philippines and 41.2 per cent from Indonesia. To increase awareness of the dangers of HIV/AIDS the centre had, for the last four years, organized a day-long AIDS Festival that brought together migrant workers form various countries. The event not only educated migrant workers about AIDS but promoted other health issues. A study conducted by the centre had shown that migrant workers interested to self-medicate and were teared of often reluctant to tell their employers if they’re sick because they feared losing their Jobs52.

The male participants, 190 in number from 3 plantations of Penisula, Malaysia participated in a program which was arranged to identify the level of knowledge among the plantation men as well as to initiate future HIV/AIDS programs. An exercise to gauge the level of HIV/AIDS knowledge was carried out followed by basic HIV/AIDS and STD information. In result, the plantation community men had low level of HIV knowledge. Prevention method such as condom use was not well known before this program. At the end of the program there was significant increase in the level of understanding. From the project it was noted that there was a need for more follow up programs on HIV/AIDS for the plantation community53.

A cross-sectional study design was undertaken to determine the beliefs and associated high-risk behaviors connected with the transmission of HIV among a group of adult males incarcerated in Rajaei-Shahr prison. This maximum-security prison was located in Karaj city, which was approximately 70 km North West of Tehran, the capital city of Iran. The study sample was 100 adult males, who were incarcerated in March, 2004. The majority of prisoners in this study were knowledgeable about how HIV was transmitted. Their high level of understanding might be due in large part to recent credible HIV training efforts in Iranian prisons. However the vast majority of prisoners still believed that HIV could be transmitted through kissing or hand shaking54.

The HIV/AIDS awareness program in the port city of Merauke in West Indonesia increased people’s knowledge and awareness about HIV/AIDS to help to prevent the spread of the disease. The program developed and distributed IEC (Information, Education and Communication) materials such as posters, leaflets, video films, coloured shirts as means of promoting messages on HIV/AIDS so that people in community had access to accurate information about the disease55. Evaluation of a 2-year Acquired Immunodeficiency Syndrome (AIDS) Awareness project in Sri Lanka’s West Coast confirmed the efficacy of interventions based on AIDS related drama productions and brochure distribution. Program evaluation was based on 154 pre- and 97 post-intervention tests and interviews with 30 men and women. Television and newspapers were identified as the major sources of information about AIDS56.

A close ended questionnaire study on knowledge, attitude and practice (KAP) about HIV/AIDS was conducted amongst first year MBBS students immediately on joining the course. One hundred and fourteen students participated in the study. Overall level of knowledge about AIDS was found to be 72 percent. Boys were better informed about possible methods of prevention of AIDS than girls. Misconceptions regarding mode of transmission, clinical presentation and prevention existed amongst large number of them. Seventeen percent of boys and 5 percent of girls approved of pre-marital sex for boys while 14.8 percent of boys approved the same for girls. Thirteen and half percent of boys admitted sexual experience. Awareness programs should be intensified amongst students to improve the overall knowledge of AIDS 57.

A study of Nigeria investigated the level of awareness of HIV/AIDS among the rural dwellers in life zone, Osun state. A total of 240 respondents from different age categories were selected through systematic random sampling. It was found that the level of education (p=0.02) and marital status (p=0.02) were significantly related to the awareness of HIV/AIDS by the respondents. A small majority (67 percent) indicated their awareness of the diseases, among which 36.3 percent indicated radio, while 14 percent indicated television, as their sources of awareness. In conclusion, there was an average level of awareness about HIV/AIDS in the studied rural areas, indicating the need for more campaigns against the disease, especially in the rural areas.

To examine the awareness of HIV/AIDS amongst students of tertiary institutions in Edo state of Nigeria, a study was performed. The analysis of data showed that the awareness of HIV/AIDS was relatively high accounting 53 percent of respondents. It was revealed that 55 percent of the respondents got their information about HIV/AIDS mostly from the media (television, radio and newspapers), 28 percent got mostly from public lectures, seminars and bills, 17 percent on the other hand got their information from other sources specially, from friends and neighbours.Based on data from 33 states of USA, it was shown that many older persons were sexually active but might not be practicing safer sex to reduce their risk for HIV infection. Some older person’s injected drugs or smoke crack cocaine, which could put them at risk for HIV infection. HIV transmission through injection drug use accounted for more than 16 percent of AIDS cases among persons aged 50 and older. Some older persons, compared with those who are younger, might be less knowledgeable about HIV/AIDS and therefore less likely to protect themselves.

In 2003, China initiated an ambitious program to raise the awareness of the disease, reduce stigma and prevent HIV epidemic in the country. China’s first major television campaign to promote condom use was not launched until 2007.The campaign targeted the young and mobile and comprised of on short public service announcements on public transport, using slogans such as “Life is too good, please protect yourself”. It was shown in the literature that people who had sex in the last six months with someone other than their spouse, 42 percent had not used a condom during their last two acts of sexual intercourse. Nearly 30 percent of all respondents did not know how to correctly use a condom61.A study was conducted to determine the awareness of AIDS control and sex behavior of youth in Assam state of India. In this study, it was interesting to note that unmarried respondents were better exposed to media than married youth. While 25 percent of the respondents of the high income were “High exposed” to media, only 16.7 and 7.1 percent of the respondents from middle and low income families respectively were “High exposed” to media. Further 40.4 percent of the low income respondents were “Less exposed” to media. Majority of the illiterate respondents were “Less exposed” to media and only one percent was “High exposed”. There was no single case of “Low exposed” among those who studied up to graduation and only 2.2 percent of secondary level educated respondents were low exposed. It was significant to note that students and unemployed youth were “High exposed” than those who are engaged in any occupation. Only “Highly exposed” respondents were “knowledge-able” about AIDS.

A study was performed to know the awareness and attitudes about HIV/AIDS among males in a rural population. It was observed that 90 percent of the rural males had knowledge about HIV/AIDS, 32 percent knew what caused AIDS and 20 percent could state the effect of HIV on the body. There was inadequate knowledge about the relationship between STD and HIV/AIDS. 75 percent of the rural males could endorse at least three methods of prevention of HIV/AIDS. The predominant source of information was TV (78 percent). Friends were a major source of information among the younger males. Majority (57 percent) felt that a person with HIV must be isolated or even put in prison (22 percent). There was attribution of the risk of acquiring disease mainly to truck drivers or commercial sex workers. There existed a lack of perception of risk that HIV could also affect rural populations. Small proportion of people still felt that there was a cure for HIV/AIDS (14 percent).

Chapter- 3

Methods and Materials

3.1 Study Design: Cross-sectional descriptive study

3.2 Study Place: Out patient Department of Dhaka Mohanagar General Hospital (DMGH) run by Dhaka city corporation (DCC) under the ministry of local Government and rural development (LGRD) which is situated at Naya bazaar area of old town under Dhaka city. This institution was established in 1988. It was a fifty bedded hospital under the management of chief health officer of Dhaka City Corporation. It is capable of providing curative, preventive, promotive and rehabilitative services to the population.

The outdoor of the hospital provides various types of medical services like medicine, surgery, dental, gynae and obstetrical, eye, otolaryngology and pediatrics. At present daily hospital out door attendance is 350-400 in number. In indoor, bad occupancy rate is over 70 percent. In surgery and gynae departments, all routine operations and laparoscopy operations are performed. In obstetric, normal/ instrumental delivery, caesarian section are done. In pathology, all investigations are done in automatic computerized machine. The childhood vaccination is provided by this hospital according to the international guidelines recommended by the World Health Organization. This institution always takes a positive role in all the NID (National Immunization Day) for immunization coverage.

DOTS was introduced in March, 2008 at this hospital under the national TB control program. CARE (Co-operation for American Relief Everywhere), Bangladesh started VCT (Voluntary Counseling and Testing) program in this hospital from 17th July 2008 for the IDUs (Injecting Drug Users) to detect HIV/AIDS. Rehabilitation program is conducted by Women’s Voluntary Organization in this hospital via physiotherapy department among the children and adults. There was a social welfare center in this hospital for providing help to the poor who were unable to purchase outdoor tickets/ necessary drugs or operation materials not available in the hospital and also to arrange blood/ blood products and for burial of the dead body.

3.3 Study period: From June 2009 – May 2010

3.4 Study Population : All the adult patients at the age of 18 to 35 years, attended at the Out Patient Department of Dhaka Mohanagar General Hospital under Dhaka City Corporation, situated at Naya Bazar area of old town of Dhaka city.

3.5 Study sample: Purposive sampling technique was followed until the desired number of sample met.

3.6 Sample size: Sample size was calculated by applying the following formula with accuracy level at 5%

n= z2 pq/d2here z = 1.96,

p= 0.77 (Awareness about HIV/AIDS among the adults about 77 percent)12

q= 1 – p = 1 – 0.77 = 0.23

d= .05


n= Sample size

So, the eventual sample size n= 272,

But my feasible sample size was 155.

3.7 Eligibility criteria:

3.7.1 Inclusion criteria:

· Adult patients

· Age between 18 – 35 years

· Only out door attended patients

· Who were willing to participate

3.7.2 Exclusion criteria:

  • Emergency patients
  • Pregnant patients
  • Severely ill patients
  • Addicted patients
  • Who were not able to understand the nature and purpose of the study.

3.8 Development of research instrument:

A semi- structured interview questionnaire was developed according to the variables of the study. Variables were determined depending upon the specific objectives of the present study. In general, all questions would meet the following standards- a) easily understood by the respondent, 2) be simple i.e., would convey only one thought at a time, c) Would be concrete and d) Would conform as much as possible to the respondent’s way of thinking. Size of the questionnaire was tried to keep minimum. Questions usually followed general to the more specific and proceeded in logical sequence moving from easy to more difficult. Personal and intimate questions were kept at the first part of the questionnaire. Technical terms and vague expressions capable of different interpretations were avoided. Concerning the form of questions, two principal forms were used- the open-ended questions and closed-ended questions. In the former the respondent had to supply the answer in his own words, whereas in the latter the respondent selected one of the alternative possible answers put to him. In open-ended questions, answers were specified by the researcher and comments in the respondent’s own words were held to the minimum. The questions were presented with exactly the same wording and in the same order to all respondents. Report was taken to this sort of standardization to ensure that all respondents reply to the same set of questions. Therefore, the questionnaire prepared for this study could be called as a semi-structured questionnaire. Questionnaire was developed in both English and Bengali language (Annexure- 1 and 2).

3.9 Pre testing of questionnaire: the questionnaire was pre tested among the adult population (fifteen percent of the sample size) in out patient department of Mitford hospital, Dhaka with due permission from the administration. Some changes like inclusion and exclusion of some variables and correction in the pattern of questions were made to finalize the interview questionnaire.

3.10 Data Collection:

Information was collected by researcher him-self from the study population by face to face interview with the help of pre-tested semi-structured interview questionnaire. The researcher explained the aims and objects of the study and also tried to remove the difficulties which any respondent might feel free in understanding the meaning of a particular question or the concept of difficult terms. Data collection was done in every working days from Saturday to Wednesday except government holidays. Everyday data collection was started from 8-00 am to 01-00 pm during the period of out patient department. The duration was average 45 to 50 minutes for each interview. Each day 3/4 respondents were interviewed. Data was collected until the desired number of sample met.

3.11 Data analysis:

Data analysis was done by SPSS software program. Using suitable test statistics, the significance of the findings were tested.

Following measuring scale and test statistics were used for data analysis.

Name of the variable Measuring scale Statistical test used




Monthly family income

Family typeContinuousOrdinal




QualitativeMean, SD, percentage, frequencies, ranges.Percentage, frequencies

Percentage, frequencies

Percentage, frequencies

Percentage, frequenciesRelationship between dependent and independent variablesDichotomousChi-square

To assess the level of patient’s awareness about HIV/ AIDS, 20 factual information were collected. Then information’s were categorized in a five point scale, as very good -5, good – 4, neither good nor bad =3, average-2, Poor= 1. Each of the respondent’s answer was marked as graded in the questionnaire. The total marks of each individual from twenty factual information i.e.,, awareness related variables regarding HIV/AIDS was divided by twenty and the average mark was calculated for each individual regarding his knowledge.

Afterwards, recoding was made about the value of five point scale measuring the awareness related variables regarding HIV/AIDS to indicate knowledge of HIV/AIDS for each individual in the following manner:-

1-1.9 indicates poor knowledge

2-5 indicates good knowledge.

Again, recoding was done in regarding each of the socio-demographic variables. The adult against each of the variables was divided into two groups.

Sex Age Education Religion Marital status
Male Higher age group28-35 years Literate Muslims Married
Female Lower age group18-27 years Illiterate Non Muslims Unmarried
Monthly family income Number of children Type of family Occupation Education of spouse
High income group>10,000 taka Group having no children Nuclear group Employed group Literate group
Low income group<10,000 taka Group having children Joint/ Extended group Unemployed group Illiterate group


Name of the variable objectives Question no.



Marital status

Monthly family income

Number of children

Type of family


Educational qualification of spouseTo assess the socio-demographic characteristics with the level of awareness on prevention and control of HIV/AIDS.1 to 9Awareness related variablesTo assess the level of awareness on prevention and control of HIV/AIDS.10-29Factors related with HIV/AIDS awareness.To identify factors influencing HIV/AIDS awareness.30-40

3.13 Presentation of findings<