Abstract

Introduction: Adolescents living with HIV/AIDS (ALHIV) treated in pediatrics at the Bouaké Teaching Hospital, face numerous physical, psychological and social challenges exposing them to risky behaviours. The aim of the study was to analyze their knowledge, attitudes and practices (KAP) related to HIV/AIDS. Methods: The study, conducted between April 1 to 30, 2024, included adolescents followed up in the pediatrics department of Bouaké Teaching Hospital, with the consent of their parents or legal parents or legal guardians. The variables studied included knowledge about HIV, attitudes to the disease and the practices. Variables were compared at the significance level p ≤ 0.05. Results: A total of 61 of the 71 adolescents in the active file participated in the study (85.9%). Full disclosure was made in 16.4% of cases. School was the place of information for 76.4%. In 18% of cases, they knew that HIV was transmissible. In 52.5%, they knew the means of prevention. They were non-compliant with treatment in 22.9% of cases. In 11.5% of cases, they stated that they had sexual relations but had not informed their partner of their serological status. Factors significantly associated with good knowledge, attitude and practice were age ≥ 15 years (p < 0.01), high level of education (p = 0.031) and full disclosure (p < 0.01). Conclusion: It thus becomes imperative to reinforce therapeutic adherence, the total announcement process and communication relating to sexual and reproductive health for the attention of AVVIH.

Keywords

Adolescent, HIV/AIDS, Knowledge, Attitudes, Practices, Côte d’Ivoire

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1. Introduction

HIV infection in adolescents remains a major public health problem worldwide. Of the 690,000 deaths linked to HIV/AIDS, 34,000 were adolescents, i.e. around 5% [1] [2]. It is the second leading cause of death among adolescents worldwide, and the leading cause in sub-Saharan Africa [3]. In Côte d’Ivoire, out of 48,349 children living with HIV in 2019, 16,686 were adolescents, i.e. 34.5% [4]. The period of adolescence, according to the World Health Organization (WHO), is a time of great vulnerabilitý [5]. In addition to the many physical and psycho-behavioral changes usually associated with adolescence, these HIV-infected adolescents, must also learn to live with this infection that has become a chronic disease and to manage their treatments in socio-cultural contexts where HIV-related stigma still remains major [6]. This period of vulnerability can lead to interruptions in antiretroviral treatment and medical follow-up, difficulties in adherence to treatment, mental health problems, treatment failures and the risk of HIV transmission to uninfected sexual partners. Improving the level of knowledge about HIV infection among adolescents living with HIV, and their attitudes towards this scourge, is essential for better support in their care, and to limit the spread of this pandemic to the rest of the population [7]. In the pediatrics department of Bouaké Teaching Hospital, a study reported that 60.6% of children treated for HIV infection were adolescents [8]. The same study also showed that 65% of these adolescents were non-compliant with antiretroviral treatment. This non-compliance could be at the root of serious complications that could jeopardize their prognosis. What are their attitudes and practices regarding HIV/AIDS infection? Answering these questions would help to improve the prognosis of adolescents living with HIV and clinical practice. Hence the interest of this research project, whose aim was to assess the knowledge, attitudes and practices of HIV-positive adolescents regarding HIV infection at Bouaké Teaching Hospital.

2. Methods

• Types and periods of study

This was a cross-sectional analytical study of the knowledge, attitude and practice (KAP) type. It took place over a 1-month period from April 1 to April 30, 2024.

• Study location

The study took place in the pediatrics department at Bouaké Teaching Hospital, specifically in the outpatient care unit for children living with HIV and prevention of mother-to-child transmission (PMTCT). The HIV care unit occupies an office within the pediatrics department. It is headed by a Professor and staffed by six agents. The unit carries out several activities, including care, training and research.

• Study population, inclusion and non-inclusion criteria

This research study involved all adolescents aged between 10 and 19 years followed up in the HIV care unit of the pediatric ward of the Bouaké Teaching Hospital. The study included HIV/AIDS-positive adolescents who had given their consent, as well as that of their parents and/or legal guardians. Not included in the study were HIV/AIDS-positive adolescents who did not attend their appointments or whose parents objected.

• Data sources and collection

Data were collected using a standardized, computerized, structured and anonymous questionnaire containing the following study variables: adolescents’ socio-demographic characteristics, HIV follow-up and knowledge, attitudes and practices.

• Operational definitions

• Disclosure of HIV-positive status to a child or adolescent is defined as a process in which the status is revealed to the child or adolescent by the provider and/or parent. It takes place in three essential stages: pre-announcement or partial announcement, full announcement and post-announcement. The pre-announcement corresponds to the stage of preparation and sensitization of the parents and the child by the caregiver (starting from age 7, when the child is capable of understanding the information given). Full disclosure is the stage during which the child is informed of his or her HIV-positive status (by age 14 at the latest). The post-announcement phase is a follow-up to the announcement.

• Knowledge corresponds to information about HIV infection and its chronic evolution, modes of transmission, prevention methods and sources of information about the disease. Evaluate the level of knowledge. This objective is expressed in 4 levels (poor, insufficient, average and good). Poor (<25% correct answers), Insufficient (<50% correct answers), Fair (<70% correct answers) and Good (>70% correct answers).

• Data entry and analysis

Data were entered and analyzed using Epi Info 7.2 software. The data collected were grouped and presented in the form of frequency tables and figures using Microsoft Excel 2019. Quantitative variables were expressed as median, mean and extremes. Qualitative variables were expressed as proportions. Categorical variables were compared using the Chi-square test and Fisher’s exact test, depending on the validity conditions. The significance threshold was set at p ≤ 0.05.

• Ethical considerations

This study was carried out after obtaining authorization from the Medical and Scientific Director of the Bouaké Teaching Hospital. The free and informed consent of the parents and the adolescent was obtained before the start of the study. Anonymity and confidentiality were respected by assigning an anonymity number to each survey form.

3. Results

• Frequency

Seventy-one children in the active file were adolescents, of whom 61 participated in the study, i.e. a participation rate of 85.9%.

• Socio-demographic characteristics of adolescents

The average age of participants was 14.43 ± 2.73 years, with extremes ranging from 10 to 19 years. They were male in 55.7% of cases, with a sex ratio (M/F) of 1.26. Participants living with HIV lived in urban areas in 75.4% of cases, and attended primary and secondary school in 44.3% and 47.6% of cases respectively. 64% of participants were orphans. Only 16.4% of adolescents living with HIV had been diagnosed (Table 1).

Table 1. Distribution by socio-demographic characteristics of adolescents.

• Participants’ knowledge

Participants claimed to have information on HIV/AIDS in 86.9% of cases, the main source of information being school in 76.4% of cases, followed by family sources in 27.86%, hospital in 24.59%, media 9.84%, others in 6.57%. Adolescents were aware that HIV infection is a transmissible disease in 18% of cases. The routes of contamination cited were soiled objects 72.1%, sexual transmission 46%, blood transmission 44.3%, mother-to-child transmission 21.3%. Adolescents stated that they knew HIV infection was an incurable disease in 47.5% of cases, and that the means of prevention were abstinence in 36.1% and condoms in 16.4% (Table 2).

Table 2. Distribution of participants according to their knowledge.

• Attitudes and practices

Participants had sexual partners in 14.8% of cases and sexual intercourse in 11.5%. All participants did not inform their partners of their HIV status, and stigmatization was the reason reported in 100% of cases (Table 3).

Table 3. Distribution of adolescents according to attitudes and practices.

• Analytical study

Factors statistically associated with good knowledge were: Child age ≥ 15 years (p < 0.01) as well as high level of education (p = 0.026) and Participants informed of their status (p < 0.01) (Table 4).

Table 4. Factors associated with good knowledge.

4. Discussion

This is a descriptive and analytical cross-sectional study carried out in the HIV care unit of the pediatrics department at Bouaké University Hospital. The general objective of the study was to assess the knowledge, attitudes and practices of adolescents treated for HIV infection at Bouaké University Hospital. The results must be qualified, as the study is monocentric, and the information was collected during an interview with the adolescent in the presence of the parent or legal guardian. For adolescents who did not understand French, we used an interpreter. The use of an interpreter, while necessary to include all adolescents, may have introduced errors of interpretation likely to influence the validity of responses in the assessment of knowledge, attitudes and practices (KAP). This methodological limitation must be taken into account when analyzing the results, as it may have contributed to the over-representation of erroneous information. Despite the methodological limitations, the study raises the following points for discussion in terms of participation rates, socio-demographic characteristics, and the knowledge, attitudes and practices of the adolescents surveyed.

The participation rate observed in this study was 85.9%, higher than that reported by Azagoh et al. in Abidjan in 2020 [9]. This high level of participation could be explained by the fact that the interviews with adolescents were carried out on the same day as their medical appointments, which facilitated their availability. In addition, the fact that the adolescents and their parents understood the importance of the study probably encouraged them to take part. In terms of age distribution, 40.5% of participants were aged between 10 and 13, with an average age of 14 (extremes: 10 - 19). These results are similar to those reported by Aba et al. (2018) in Abidjan [10]. The high proportion of adolescents under the age of 15 may be attributed to the mode of transition of care: in our practice, the transition from paediatric to adult care takes place from the age of 16, unless the adolescent expresses the wish to remain under paediatric care until he or she comes of age. The majority of adolescents included were male (55.7%), with a sex ratio of 1.26. This result is comparable to that reported by Ya et al. (2018) in Mali, who found a sex ratio of 1.2 [11]. However, other studies, notably those by Diarra et al. (2018, Bamako) and Brentano et al. [12], reported a predominance of females (58.9% and 67% respectively). This is a descriptive and analytical cross-sectional study carried out in the HIV care unit of the pediatric ward at the Bouaké University Hospital. The general objective of the study was to assess the knowledge, attitudes and practices of adolescents treated for HIV infection at Bouaké University Hospital. The results must be qualified, as the study is monocentric, and the information was collected during an interview with the adolescent in the presence of the parent or legal guardian. For adolescents who did not understand French, we used an interpreter. Transcription bias cannot be ruled out. Despite methodological limitations, the study raises the following points for discussion in terms of participation rates, socio-demographic characteristics, and the knowledge, attitudes and practices of the adolescents interviewed.

The male predominance observed in our study is nevertheless consistent with national data on HIV/AIDS in Côte d’Ivoire. Indeed, in 2019, among the 31,663 children living with HIV aged 0 - 14 years, the number of boys (16,087) was slightly higher than that of girls (15,576). The increased vulnerability of young women generally appears from adolescence onwards (≥15 years) and becomes more pronounced in the 20 - 24 age group [13]. Socially, 64.0% of adolescents were orphans, and 60.7% lived with legal guardians. This situation reflects data from UNAIDS (2008), which estimated that 15 million children had been orphaned by HIV, 80% of them in sub-Saharan Africa [14]. In Côte d’Ivoire, some 320,000 children aged 0 - 17 have lost at least one parent to HIV/AIDS [14]. Finally, full announcement of the diagnosis was achieved in only 16.4% of adolescents living with HIV, a significantly lower rate than that reported by Diarra (2018, Bamako), which was 55% [15]. This low proportion could be linked to parental refusal, often motivated by the fear of being rejected by their children or held responsible for their infection. In this study, 86.9% of adolescents had already heard about HIV/AIDS, mainly through school (76.4%), which is in line with the results reported by Azagoh et al. in Abidjan [9]. However, despite this exposure to information, the level of knowledge remains insufficient. Indeed, a very high proportion of participants (72.1%) thought that HIV could be transmitted by “soiled objects”, while only 45.9% cited sexual transmission, 44.2% blood transmission and 21.3% mother-to-child transmission. These results contrast with those of Kanon [16], where sexual transmission and mother-to-child transmission were identified as the main modes of transmission (48.7%). The high prevalence of this misconception about soiled objects deserves particular attention. It reveals not only a gap in health education, but also a major risk to public health. Such a belief can divert attention from the true modes of transmission, and compromise the effectiveness of prevention strategies. In practice, it can lead to unjustified stigmatization of people living with HIV, while allowing risky behavior linked to sexual or blood transmission to persist. The study shows that only 47.5% of adolescents knew that HIV/AIDS is an incurable disease, and that an equivalent proportion (47.5%) had no information on means of prevention. This lack of knowledge may be linked to the fact that the full announcement of the diagnosis was only made in 16.4% of adolescents living with HIV, a much lower rate than that reported by Diarra (2018, Bamako: 55%) [15]. Parental refusal, motivated by fear of being rejected or held responsible for the disease, is probably an explanatory factor. This persistent ignorance of preventive measures highlights the need to strengthen health education programs, taking into account socio-cultural and linguistic determinants. Taking these factors into account is essential to improving the acceptability of prevention messages and, ultimately, to stepping up the fight against HIV/AIDS.

In this study, 14.8% of participants reported having at least one sexual partner, a significantly lower figure than that reported by Azagoh et al. (2020, Abidjan: 62%) [9] and Elkington et al. (USA: 88.9%) [17]. This difference can be explained by the demographic structure of our sample, where 40.5% of adolescents were between 10 and 13 years of age, an age group generally less exposed to sexual behavior. Furthermore, 11.5% of participants reported having had sexual intercourse, and 23.0% were non-compliant with antiretroviral (ARV) treatment. These risky behaviours have major consequences: increased viral load, onset of opportunistic infections, development of resistance to ARVs, risk of reinfection by other strains of HIV, transmission of HIV to a partner, contracting sexually transmitted infections (STIs), unwanted pregnancies. Of particular concern was the fact that 11.5% of sexually active adolescents had not informed any partner of their HIV status. This lack of disclosure may be attributed to a lack of knowledge of their serostatus, or to fear of stigmatization [18]. This situation illustrates a critical public health issue: silence about HIV status increases the risk of transmission and reinforces the dynamics of marginalization. In this study, the factors significantly associated with adolescents’ level of knowledge about HIV/AIDS, as well as with their attitudes and practices, were: age over 15, high level of education, and the fact that the diagnosis had been announced. With regard to educational level, our results concur with those of Ouedraogo et al. (Burkina Faso) [19], who, in a multivariate analysis, identified educational level as the only factor significantly associated with level of knowledge about HIV/AIDS. This association may be explained by better access to sources of information among school-educated adolescents, notably via school and educational programs. On the other hand, the role of parents in the acquisition of knowledge about sexuality remains limited [20], underlining the need to strengthen their involvement in health education. Rabi Adamou et al. (Côte d’Ivoire) have highlighted the importance of diagnosis in improving know-ledge of HIV and its modes of transmission [21]. Their study showed that disclosure of serological status enabled the adolescent to develop a clear understanding of transmission methods and protective measures. In our context, the announcement process is carried out taking into account the child’s psychological development and the prior consent of the parent or legal guardian. The announcement includes the explicit designation of the disease, which facilitates understanding. In the absence of an announcement, adolescents’ knowledge remains inadequate, limiting their ability to adopt appropriate preventive behaviors. It should also be remembered that data collection sometimes necessitated the use of an interpreter, which may have introduced misinterpretation into responses relating to knowledge, attitudes and practices. For example, technical terms relating to HIV or sexuality could have been mistranslated or simplified, influencing the validity of the results. This methodological limitation needs to be taken into account, as it may have contributed to an underestimation of actual knowledge or a misclassification of attitudes and practices.

5. Conclusion

The study shows that adolescents’ level of knowledge about HIV/AIDS is inadequate. In fact, the majority of teenagers are unaware of the modes of transmission and the means of prevention, which could be due to the low rate of disclosure of serological status to participants. This level of knowledge may have repercussions on the attitudes and practices of the adolescents: the participants had sexual partners, had sexual relations, and some were non-compliant with treatment. Hence the need to reinforce the HIV/AIDS therapeutic education program to encourage compliance, reduction in the number of sexual partners and abstinence. Follow-up must necessarily be accompanied by substantial psychosocial support.

Conflicts of Interest

The authors declare that they have no conflict of interest

References