Background: In Ethiopia the first case of HIV infection was identified in 1984. Since then HIV/AIDS has created an enormous challenge to several communities, affecting the social and economic well-being of the entire nation. Realizing the enormous consequences of the epidemic, the Ethiopian government deployed tremendous efforts to create HIV awareness in order to bring changes in HIV-related behaviors to reduce the risk of HIV infection. Therefore, it is necessary to assess the role of HIV-related knowledge, attitude and behavior in HIV/AID prevention in Ethiopia. AIM: The aim of the study was to assess the changes in HIV-related knowledge, attitude, and behavior between 2005 and 2011 and its impact on HIV status among Ethiopians. METHODS: The study used a nationally representative sample from the cross sectional years of 2005 and 2011 Ethiopian Demographic and Health Survey (EDHS). Sample sizes of study population were 12,845 in 2005 and 28,532 in 2011. SAS-callable SUDAAN was used provide descriptive characteristics of socio-demographic characteristics and independent variable of HIV-related knowledge, attitude, and behavior. The binary and multivariable logistic regression analysis was conducted to assess changes in HIV-related knowledge, attitude, and behavior and, association between these factors and HIV status. For all results, statistical significant were determined if there were no overlap in the 95% CI of the percentages being compared. RESULTS: There was no difference in correct comprehensive knowledge of HIV between 2005 and 2011. However, there was significant change in knowledge of Mother to Child transmission (MTCT) of HIV, accepting attitude towards people living with HIV (PLWH) and sexual behavior between 2005 and 2011. Respondents who had high level of knowledge of MTCT increased from 40.2% in 2005 to 71.0% in 2011. Likewise, respondents with high level of accepting attitude towards PLWH also increased from 3.9% to 10.8%. Besides, in 2011 fewer people had started sex before the age of 15 years old, and more people knew sources of condoms in comparison to 2005 However the percentage of people who had multiple sexual partners increased from 1.2% to 1.8% between 2005 and 2011 respectively. The study also found significantly protective association between HIV positive status and having low or medium level of knowledge of MTCT of HIV (OR 0.08 or 0.78) and accepting attitude towards people living with HIV (OR 0.12 or 0.48). In contrast, HIV infection was significantly associated with having multiple sexual partners (OR 4.49). Conclusion: Efforts deployed by Ethiopian government and other international organizations in response to HIV/AIDS epidemics have had success in terms of improving MTCT knowledge of HIV, accepting attitude towards PLWH, knowledge of sources of condom and sexual debut between 2005 and 2011. Surprisingly, we did not find an evidence of high level of HIV knowledge to be protective against HIV infection in the current study. Therefore continuous intervention is recommended to seal the gap between knowledge and sexual practices that may influence safer sexual behavioral changes.

Background: As high HIV transmission rates persist in Sub-Saharan Africa, the effect of wealth inequality rather than solely absolute wealth as a potential driver of the HIV epidemic has been given increased attention in recent research, but has not yet been investigated in the Nigerian setting. As, particularly in contexts of socioeconomic inequality, individuals may face barriers to both obtaining health-related knowledge and translating this knowledge into actual engagement in preventive measures, it is relevant to assess the level of HIV-related knowledge in the Nigerian population. Furthermore, it is of interest to investigate its socioeconomic predictors, and to identify risk-groups for low HIV-related knowledge, which consequentially are also potential risk groups for high HIV transmission. This will ultimately facilitate the targeting and implementation of more appropriate and effective preventive interventions among these groups. Due to the country’s high HIV prevalence and its ethnic and socioeconomic heterogeneity, it is both an interesting and highly relevant setting in which to analyse the socioeconomic determinants of HIV-related knowledge. Methods: Utilizing data from the Nigerian Demographic and Health Survey, Paper 1 of this thesis investigates wealth inequality as a predictor of low HIV-related knowledge in the Nigerian population through logistic regression modeling. The effects of other sociodemographic factors such as sex, literacy and rural or urban residence on HIV-related knowledge are also explored. In paper 2, a trend analysis is conducted of HIV-related knowledge in the country from 2003 to 2013, with changes in these trends represented graphically, stratified by various sociodemographic factors. ARIMA models were fit to the 2003-2013 trend data. Finally, Paper 3 presents a systematic review (using the Medline and Embase databases) and meta-analysis (conducted in R) of HIV-related knowledge interventions in Sub-Saharan Africa or among the African Diaspora, synthesising the available evidence for the efficacy of such interventions in 1) improving HIV-related knowledge, 2) resulting in increased engagement in preventive measures and safe sexual practices, and 3) reducing HIV incidence. Random-effects models were used for the meta- analyses. Results: The logistic regression model indicated that females were more than twice as likely as males to have low HIV-related knowledge in each wealth inequality category. In addition, females were more likely to have correct knowledge of mother-to-child transmission than males, but were over 1.5 times more likely to have poor knowledge of HIV risk reduction measures. Individuals with lower literacy levels were almost twice as likely as literate respondents to have low HIV-related knowledge. Ethnicity, religious affiliation, relationship status, and residing in rural areas were additional significant predictors of HIV-related knowledge. The trend analysis indicated an overall increase in HIV-related knowledge between 2003 and 2013, but a decrease in knowledge of mother-to-child-transmission. In addition, State-level disparities in knowledge regarding HIV risk reduction increased over time. The meta-analysis of HIV education interventions demonstrated significantly higher odds of correct knowledge of transmission routes as well as condom use, but insignificantly lower odds of HIV incidence. Conclusions: HIV-related knowledge in this sample is generally low among females, those with low literacy levels, the poor, the unemployed, those residing in rural areas, those with traditional religious beliefs, and those living in states with the highest wealth inequality ratios. The meta-analysis of HIV-related knowledge interventions in Paper 3 indicates that such interventions are generally effective at improving not only HIV-related knowledge but also increasing condom use, and should thus be targeted at the risk groups identified in Papers 1 and 2, in order to work towards the reduction of HIV transmission.

The overall aim of this thesis was to obtain an understanding of the dynamics of the HIV epidemic by estimating prevalence and exploring the relationship between HIV-related knowledge, attitudes, behavior, and HIV status in Nicaragua. Structured questionnaires were administered to adults from a health and demographic surveillance system in León, Nicaragua (Papers I–III). In-depth interviews and a survey were conducted among men who have sex with men (MSM, Paper IV). Blood sampling for HIV was carried out among 2,204 men and women (Paper I). Bivariate and multivariate analyses, including adjusted prevalence ratio (Papers I, II, IV), factor analysis, Cronbach’s alpha, and hierarchical regression analysis (Paper III) were performed. Thematic analysis was used with qualitative data (Paper IV). The prevalence of HIV in the general population was 0.35% (95% CI, 0.17–0.73). Those who have taken a HIV test were more likely to be females, younger, living in an urban setting, have a higher level of education, be married or cohabiting, and have no religious affiliation. HIV-related knowledge was lower among members of the general population than among MSM. Unprotected sex was reported more times with regular partners than with casual partners. Findings suggested that consistency of condom use and emotional attachment (steady relations) were inversely related. Stigma and discrimination were reported high in the general population; they appeared to be negatively associated with HIV-related knowledge, self-perception of HIV risk, HIV testing, and willingness to disclose HIV status in the event of being HIV-positive. Findings demonstrated an increasing tolerance towards same-sex attractions. MSM have a better understanding of HIV transmission than men and women of the general population. Although seven out of ten MSM and six out of ten women were concerned about becoming infected with HIV, inconsistent condom use was common. This study confirmed that Nicaragua has a low prevalence but high risk for HIV infection and transmission. Results underscore that social, behavioral, and cultural factors contribute to retard progress in achieving the Millennium Development Goals on reducing gender inequality and combating HIV/AIDS. Addressing these challenges depends not only on successful behavior change interventions, but requires a culturally gender-appropriate strategy.