A cross-sectional study using self-administered questionnaire and structured interviews was carried out between October and November 2014, among secondary school adolescent students in both urban and rural schools of central Uganda. The essential features of the study included: 1) sampling of the secondary schools located in the district 2) Sampling of the adolescents that participated in the study 3) Data collection using a self-administered questionnaire and structured interview and 4) Conducting analysis of the collected data.

Study was conducted in eight secondary schools in Kampala and Buikwe district in Uganda. An equal number of schools (4 schools in each) were randomly selected from Kampala city, the capital and largest city in Uganda that represented urban district and Buikwe district to represent rural areas. Kampala district was chosen purposively and for convenience while Buikwe district was chosen purposively and for logistical reasons. Buikwe district is located in central Uganda and is bordered by Kayunga District to the north, Jinja district to the east, Buvuma district to the southeast, the Republic of Tanzania to the south and Mukono district to the east. It was created by Act of Parliament and commenced operations on 1 July 2009.

The target population was the adolescents, both male and female students in rural and urban areas of central Uganda. The accessible population was the sample size of students in the selected secondary schools. Sampling was done using multistage cluster sampling procedure. The schools were stratified in each selected district. A total of eight secondary schools were considered, with each selected district having 4 schools. A total of 245 participants were recruited into the study with 120 from urban schools of Kampala city and 125 participants from rural schools of Buikwe district. The sample size was adequate with an assumption of 80% power and an estimated error margin of 0.05. Using the Uganda Ministry of Education and Sports list of schools in Kampala and Buikwe district, the secondary schools were randomly selected. Four schools represented each district and of these, half were government sponsored and the rest were private schools. The sample size for each school was determined by proportionate sampling. In each school, a students’ list was obtained from which participants were randomly selected. The schools consisted of a total population of 4392 students with 2126 males and 2266 females. Within the selected schools, the participants in all classes aged between 10 to 19 years were recruited, consented/assented before the questionnaire with structured interviews were administered to them.

The participants were both male and female students in the secondary schools within the age bracket of 10 - 19 years. Participants with the age group of 10 - 17 years had to give informed consent and assent and those between 18 - 19 years gave consent.

Primary data were collected using a pre-tested self-administered questionnaire with structured interviews. The questionnaire was designed after considering recommendations from previous researchers on Theory of Planned Behaviour (TPB) and the ecological perspectives [28] . The questionnaire had both closed and open ended questions which assessed knowledge of the students about HIV/AIDS and their attitudes towards HIV transmission, prevention and condom use. The questionnaire was pre-tested on third year medical students at Makerere University College of Health Sciences. The questionnaire collected information related to socio-demographic variables, knowledge, attitude and practices on HIV transmission and prevention. The questions were presented in three format: yes or no, Likert scale questions with responses ranging from three categories (agree, uncertain, disagree) or five categories (totally agree, agree, uncertain, disagree, and totally disagree) responses [29] [30] . The questionnaire was administered within the classroom by a trained research assistant. Research assistants were introduced to students by a teacher who later on was asked to leave the classroom to give students more freedom and privacy in their responses. Participation was voluntary and the questionnaire was anonymously filled. Participants had an opportunity to withdraw at any point without being asked any questions. The questionnaire was in English since it the language of communication in the schools and any question raised by the participants was taken care of by the research assistant.

Knowledge on HIV/AIDS was measured using the participants’ views on HIV/AIDS transmission and prevention. Correct responses to these questions were analyzed and an average percentage was computed. A percentage greater than 60% represented good knowledge about HIV/AIDS. Attitudes on HIV transmission, prevention and condom use were assessed. The background and demographic characteristics included age, residence and gender, which was a dichotomous measure such as female = 0 and male = 1. Dummy variables for religion were created based on the following categories; catholic, protestant, Pentecostal, Muslim and other religions. Also residence was a dichotomous measure (urban student = 0, rural student = 1).

Before the study was conducted in the selected schools, questionnaires were pre-tested. Each participant responded to the questionnaire using a structured interview with the assistance of a research assistant. Adequate spacing was ensured to promote confidentiality. Questionnaires were screened, on each day for incomplete information and consistency. The principal investigator collected all the questionnaires, stored them under lock and key and personally supervised the entry of the data into a computer which was pass-worded. Data entry was done using Epi-data entry sheets created using logic checks. Double data entry was done using two separate data entrants. The two entry sheets were compared for consistency and analyzed using SPSS and any discrepancies was resolved by referring to source document.

Each response to question in the questionnaire was coded and then entered into the epidata tool, version 3.1. The data was exported and analyzed using Statistical Package for Social Scientists (SPSS version 11). The frequencies and percentage response for each question was computed and the data was transformed into a 2 × 2 table.

Ethical clearance and approval for study was obtained from the School of Medicine Research and Ethics Committee (SOMREC) at Makerere University College of Health Sciences and from the Uganda National Council of Science and Technology (UNCST). For participants in the age group 10 to 17 years, assent was sought from the parents/guardians and then consent was obtained from the student. For mature and emancipated minors, informed consent was independently sought from them. For the age group of 18 to 19 years, consent was sought from the students themselves. Confidentiality of information was ensured by the principal investigator during and after the study.

The study assessed the knowledge, attitudes and perceptions of secondary school teenagers towards HIV transmission and prevention in rural and urban areas of central Uganda. In this study, 51.0% (n = 125/245) of the participants were from rural schools and of the total participants, 55.5% (n = 136/245) were females. There was no difference in the gender distribution of male and female participants in the study groups. Most of the participants were residing in rural areas (51.0%) in comparison to urban areas (49.0%). The results show that all religious affiliations were represented in the study groups, with majority being Anglicans (31.5%) followed by Catholics (28.6%) and then Muslims (21.3%). The age distribution of the participants varied from 12 years to above 18 years with the majority in the range of 16 years (17.5%) and ≥18 years (17.1%) (Table 1). The mean age of the participants was 15.9 ± 2.5 years and for the rural and urban participants, it was 15.4 ± 2.1 and 15.7 ± 1.8 years respectively. Previous reports show that this age group is more vulnerable to HIV infection and that HIV prevalence is reported to be higher among the youth including the adolescents with the young women most affected as compared to the men except for the age group of 15 - 17 years where there was no gender difference [1] [8] [10] [12] .

The findings of the study showed that, generally there was an excellent awareness of the HIV/AIDS among the

participants (95.1%, n = 233/245) as compared to the 4.9% (n = 12/245) participants who were not knowledgeable. Majority of the participants who were knowledgeable about HIV/AIDS were from rural schools (49.0%; n = 120/125) as compared to the 46.1% (n = 113/120) in urban schools. The lack of knowledge about HIV/AIDS from the study were mainly from urban schools 2.9% (n = 7/120) as compared to the rural schools (2.0%, n = 5/125) (Table 2). The excellent awareness of the HIV/AIDS among the participants could be due to the instituted national and international programmes that preach the abstinence, be faithful and condoms use (ABC strategy) message and the outcome of the study is comparable to previous studies elsewhere [31] - [35] . The ABC strategy has tremendously reduced the HIV prevalence globally and in Uganda, the strategy reduced prevalence from 30% in early 1990s to nearly 6.4% by 2004/2005 [20] - [22] , but by 2011, the HIV prevalence rate has slightly increased to 7.3% possibly because of the behavioral change, knowledge gap on HIV and the socio- economic hardship among the population thus causing a national concern in the health sector [20] - [22] . Various studies globally have reported that comprehensive school and community-based HIV prevention programs, involving provision of information on abstinence, condoms, monogamy/partner reduction, help reduce HIV prevalence rates and improve risk behaviors among young people [5] [20] [24] [25] [27] [31] [33] and this seems to have contributed to the excellent awareness of HIV/AIDS among the study participants. The finding indicated that majority of the participants were knowledgeable about the HIV/AIDs existence, though however, there were still a small group in the general population who are not aware of the HIV/AIDS existence and this group could be at a risk of acquiring the infection and possibly transmitting it to others. And therefore the message of the ABC strategy need to be further strengthened to all schools and most especially to the most vulnerable youth in the adolescent age group to which, the study findings found to be unaware of HIV/AIDS.

The study findings showed that, there was variation in the responses to the modes of HIV transmission among the participants in both the rural and urban schools. The participants were able to at least mention one mode of HIV transmission. However, only 27.4% (n = 67/245) of the total participants knew all the established modes of HIV transmission [14] [32] [34] [36] , with 14.3% (n = 35/120) and 13.1% (n = 32/125) from urban and rural schools respectively. The sexual intercourse with an infected person as mode of HIV transmission was the most mentioned mode (32.3%, n = 79/245) among the study participants with 18.0% (n = 44/120) and 14.3% (n = 35/125) from urban and rural schools respectively. This was followed by those who mentioned all the established modes of HIV transmission including sexual intercourse with an infected person, sharing sharp objects with an infected person, oral sex or contact through wounds with an infected person and blood transfusion from infected blood [14] [32] [34] [36] . Very few participants mentioned blood transfusion from infected blood as mode of HIV transmission (6.1%, n = 15/245) with 2.5% (n = 120) and 3.7% (n = 9/125) from urban and rural schools respectively. This was followed by sharing sharp objects with an infected person (4.4%, n = 11/245) with 2.4% (n = 6/120) and 2.0% (n = 5/125) from urban and rural schools respectively. The least mode of HIV transmission mentioned by participants was oral sex or contact through wounds with an infected person (2.4%, n = 6/245) with 0.4% (n = 1/120) and 2.0% (n = 5/125) from urban and rural schools respectively (Table 3). The findings show that, there was still knowledge gap among the participants on the awareness of all the established modes of HIV transmission including sharing sharp objects with an infected person as reported in drug abusers, oral sex or contact through wounds with an infected person and blood transfusion from infected blood [22] [27] [31] [33] . The lack of knowledge could be due to the fact that the programmes that are instituted in schools to control HIV transmission, the ABC strategy [22] [27] [31] [33] were mainly emphasizing sexual intercourse with infected person without wholesomely looking at all the established modes of HIV transmission. Whereas global comprehensive school and community-based HIV prevention programs have emphasized abstinence, condom use, as well as monogamy/partner reduction as important in reducing HIV prevalence and improve risk behaviors among young people [18] [20] [24] [25] [33] [36] , they do not emphasize the delivery of all established modes of HIV transmission to the group or if provided, there is misinformation on the modes as also reported in previous studies [36] . And the lack of knowledge on these modes of HIV transmission presents a knowledge gap and could be a risk factor to the vulnerable group on HIV acquisition and prevention among the participants.

The study findings showed that, majority of the participants were knowledgeable on the ABC HIV prevention strategy (83.7%, n = 205/245) with rural schools more informed about the strategy (47.4%, n = 116/125) as compared to 36.3% (n = 89/120) for urban schools. The difference could have been due to the complexity of the socio-economic groups in urban areas where the participant reside and the exposure of these participant to sexual activities at an early age, some of whom become rebellious to their parents and thus run away from their homes to go and live on streets where they encounter different individuals with various behaviors including engaging themselves in risky sexual acts. They are also not exposed to HIV prevention programmes as compared to the rural areas. However, there was a small group of participants (16.3%, n = 40/245) with 12.7% (n = 31/120) and 3.6% (n = 9/125) from urban and rural schools respectively (Table 4), who were not knowledgeable about the ABC HIV prevention strategy and this problem was more in urban schools as compared to the rural schools. This lack of knowledge on the ABC HIV prevention strategy by the urban schools could be due to the failure of some of those schools to institute and sustain the programmes for HIV prevention that offers the continued awareness of the HIV/AIDS among the participants [5] [22] [31] [34] [36] . However, the findings showed that the participants were more knowledgeable about the ABC HIV prevention strategy as compared to all other established modes of HIV transmission [22] [27] . Therefore there is need to incorporate both the HIV prevention programmes and all the other established modes of HIV transmission wholesomely as to increase the knowledge awareness about HIV/AIDS among the participants especially the youth in the adolescent age.

The study results show that the participants first got the information on HIV/AIDS as early as 4 - 8 years of age but most of them got the information about the same at the age range of 9 - 12 years (55%, 136/245) with 24.1% (n = 59/120) and 31.4% (n = 77/125) for urban and rural schools respectively (Table 5). The findings showed that participants would find comfort and prefer to talk about HIV/AIDS and sexual issues with friends and peers as compared to their parents. This was because most of the parents to the participants work and have very little time to talk to their children about the sexual matters and the HIV/AIDS while some of them are left with the maids at home who become their friends and therefore they can discuss the sexual issues and HIV/AIDS matters. Also some of their friends may have televisions as well as mobile smart phones where they can access the HIV related information on the Internet which they can pass on to their friends and hence the possible reason why friends has came out as the main source of information about HIV/AIDS to the participants.

The findings also indicate that most of the participants in both urban and rural schools got the information on HIV/AIDS and talk about it mainly from the friends (37.6%, n = 92/245) (Table 6). However, the participants also were able to get the information and talk about it from the parents, school teachers and siblings. The percentage trend on whom the participants talk to and get information on HIV/AIDS did not differ in both the urban and rural schools though it was slightly higher in rural schools as compared to urban schools except for the siblings (Table 6). This possibly could be due to the HIV/AIDS school programmes that are instituted in such schools [24] [35] that emphasizes the issues related to HIV/AIDS at all times thus making the students informed about it and its dangers.

The majority of the participants, 62.0% (n = 152/245) with 30.2% (n = 74/120) and 31.8% (n = 78/125) in urban and rural areas respectively reported that there is no cure for HIV/AIDS whereas 13.1% (n = 32/245) reported that there is cure and 24.9% (n = 61/245) reported that they were not sure if it is cured. In both the urban and rural schools, there was no difference in the participants’ responses on whether HIV/AIDS can be cured or not or not sure (Table 7). The findings show that majority of the participants were aware, that HIV is not a curable disease and the drugs used only suppresses the HIV virus and boost the immune systems thus enabling the body to control the viral infection and the prevention of the opportunistic infection. The findings also show that the HIV control programmes instituted in the schools can sufficiently deliver the message that HIV infection is incurable, though some of the participants seem to be lacking such information. It is also possible that the participants were not very conversant with the term “cure” as was used in the study coupled with the misconception and myths about the cure as reported in earlier studies [36] . For those who were not sure and those that believed that there is cure for HIV/AIDS, the findings shows that there is need to be done on information delivery to the population in relation to HIV treatment and cure. The lack of updated information may be misleading and hence causing knowledge gap in management of HIV since these people can pass on false information to others especially the friends, since study findings showed that most of the participants communicate with friends mainly. However, for those whose response was YES, that HIV has cure, 50.0% (n = 16/32) in both urban and rural schools reported that antiretroviral (ARVs) drugs can cure it which is misleading. About 28.2% (n = 9/32) with 21.9% (n = 7/32) and 6.3% (n = 2/32) of the study participants in both urban and rural schools respectively reported that it can be cured abroad. The findings also show that 15.6% (n = 5/32) of the participants with 12.5% (n = 4/32) and 3.1% (n = 1/32) in both urban and rural schools respectively reported that it can be spiritually cured. The participants in urban schools also reported that it can be cured if transmitted to other people (6.2%, n = 2/32) (Table 8). This misconception on the belief that HIV can be cured was more in the urban schools as compared to the rural schools and a similar trend has been reported in previous studies [34] [36] , and this can cause a threat in HIV management since these participants can spread such false information to other friends thus leading to HIV spread (Table 6) since many of the participant talk to their friends more than other individuals on issues related to HIV/AIDS. And this information gap in urban schools could be due to laxity or inappropriate information dissemination about HIV/AIDS amongst the youth most of whom are students.

The study findings show that 54.7% (n = 134/245) of the study participants, with 24.5% (n = 60/120) and 30.2% (n = 74/125) in urban and rural schools respectively reported that sometimes it is possible physically to recognize if someone has HIV/AIDS. And 34.3% (n = 84/245) with 19.2% (n = 47/120) and 15.1% (n = 37/125) of the participants in urban and rural schools respectively reported that it’s impossible to physically recognize if someone has HIV/AIDS. About 11.0% (n = 27/245) with 5.3% (n = 13/120) and 5.7% (n = 14/125) in urban and rural schools respectively reported that it is always possible to physically recognize if someone has HIV/AIDS (Table 9). And for the participants who reported to physically recognize if someone has HIV/AIDS, 33.5% (n = 54/161) of the participants with 20.5% (n = 33/161) and 13.0% (n = 21/161) in urban and rural schools respectively reported that such individuals are always sickly. About 31.7% (n = 51/161) with 13.7% (n = 22/161) and 18.0% (n = 29/161) in urban and rural schools respectively reported weight loss as sign of HIV/AIDS. Also 24.8% (n = 40/161) of the participants with 8.7% (n = 14/161) and 16.1% (n = 26/161) in urban and rural schools respectively reported red lips as a sign of HIV/AIDS. About 9.4% (n = 15/161) with 1.9% (n = 3/161) and 7.5% (n = 12/161) in urban and rural areas respectively reported, the presence of skin rash as sign for HIV/AIDS and 0.6% (n = 1/161) participant in urban school reported that such individuals are very rich (Table 10). Whereas most participants reported that they can physically recognize if someone has HIV/AIDS, this may not be true especially in early cases of HIV infection or HIV window period or if someone has normal CD4+ cell count which can control the opportunistic infections that in most cases are responsible for signs and symptoms reported by the participants or if someone is on antiretroviral (ARVs) drugs where the HIV infection is suppressed. In such cases, these individuals tend to look healthy with no obvious signs reported by the participants. Usually these signs occur in late stages of HIV infection and when the opportunistic infections have set, in those individuals. And this belief can be a problem among the youth especially the adolescents since they can engage in risky sexual activities with individuals who look healthy with no signs reported but infected with HIV. This facilitates the spread of HIV to others as a result of this misconception and myths as reported in earlier studies [34] [36] . The findings shows that there is a knowledge gap and belief that always HIV-infected individuals presents with the highlighted signs and symptoms thus causing a problem in controlling the HIV infection spread since the participants believe that they can tell one who has HIV/AIDS. This misconception leads to the exposure to the HIV infection with such individuals who are infected but showing no signs and symptoms of HIV infection. It is also misleading to the participants that by being rich is a sign that such a person has HIV/AIDS though in some cases, “being rich” sometimes is a risk factor to HIV infection since such individuals usually have multiple sexual partners hence increasing the risk of getting infected and this is a myths as reported in previous study [36] . And usually such individuals also confuse the young ladies with gifts and money, with the intention of having sexual intercourse with them and hence predisposing them to HIV infections and hence the belief by the study participants in the study. And therefore there is need to repackage the appropriate information on HIV/AIDS and emphasize some of the key issues as a way to prevent and control HIV infection from being transmitted to the youth and most especially to the adolescent group.

On the chances of getting HIV infection, 39.2% (n = 96/245) of the study participants with 20.4% (n = 50/120) and 18.8% (n = 46/125) in urban and rural schools respectively reported that it is impossible to get HIV infection. About 31.0% (n = 76/245) with 15.5% (n = 38/120) and 15.5% (n = 38/125) in urban and rural schools respectively reported that the chance of getting HIV infection is minimal especially if precaution are taken in relation to sexual activities with individuals who may be infected with the HIV. About 18.4% (n = 45/245) of the study participants with 8.6% (n = 21/120) and 9.8% (n = 24/125) in urban and rural schools respectively reported that the chance of getting HIV infection is high especially if someone engages themselves in a reckless life and having so many sexual partners. About 11.4% (n = 28/245) of the study participants with 4.5% (n = 11/120) and 6.9% (n = 17/125) in urban and rural schools respectively reported that the chance of getting HIV infection is moderate especially if precautions are taken by the individuals (Table 11). The findings clearly show mixed responses by the participants on possibility of acquiring HIV infection with some reporting that it’s impossible at all which is wrong perception and myths as reported somewhere else [34] [36] . Since it is known that HIV virus can be transmitted through various routes other than the sexual intercourse [5] [9] [21] [25] [37] , such as in cases of accident and individuals who get wounds and then contaminated with blood of infected individuals or accidental needle pricking with infected blood in hospitals especially to health workers or sharing of sharp objects with infected individuals unknowingly especially among the youth who at times also engage themselves in alcohol and substances of abuse. Whereas the standard practices in HIV prevention, is to minimize the risk factors to HIV infection [17] [33] ; however there are some inevitable circumstances like the accidents that increases one’s risk to exposure to HIV infection. This misconception and perception is a knowledge gap among the participants that need to be addressed by the relevant concerned parties’ involved in HIV control and prevention programmes.

On the views of condom use, 41.6% (n = 102/245) of the study participants with 20.4% (n = 50/120) and 21.2% (n = 52/125) in urban and rural schools respectively reported that condom use reduces sexual pleasure. About 34.3% (n = 84/245) participants with 18.0% (n = 44/120) and 16.3% (n = 40/125) in urban and rural areas respectively reported that using the condoms is a sign of mistrust. About 18.8% (n = 46/245) participants with 9.8% (n = 24/120) and 9.0% (n = 22/125) in urban and rural schools respectively reported that condoms are embarrassing to buy. And 2.9% (n = 7/245) participants with 0.8% (n = 2/120) and 2.1% (n = 5/125) in urban and rural schools respectively did not agree with all the above which their fellow participants had reported (Table 12). However in rural schools only, participants reported that condom use reduces sexual pleasure and it shows a sign of mistrust (1.2%, n = 3/245). And also 0.8% (n = 2/245) of the participants reported that condom use reduces sexual pleasure and they are embarrassing to buy and about 0.4% (n = 1/245) of the study participants reported that condom use is a sign of mistrust and they are embarrassing to buy (Table 12). The findings show a mixed attitude, perception and misconception on condoms and condom use among the participants which is a myth as reported earlier [36] . This shows that if the participants were to engage in sexual intercourse, majority of them are likely not to use condoms while others hate them because of various reasons similar to what has been reported in previous studies [36] . This predisposes them to HIV infection if they happen to have sex with an infected individual. The global standard on HIV prevention and control that emphasizes the ABC strategy (abstinence, being faithful and condom use) and instituting comprehensive school and community-based HIV prevention programs, that involves abstinence, condoms, as well as monogamy/partner reduction [3] [21] [22] [25] [27] . This standard has tremendously reduced the HIV prevalence in many countries around the world especially among adolescents who are school-going. The strategy emphasizes condom use and the findings from the study shows knowledge gap, misconception, poor attitude and practice on condom use. This predisposes to the vulnerable youth especially the adolescents to HIV infection if they engage themselves into risky sexual behaviors since they have misconception on condoms and condom use. Therefore there is need for organizations and the public involved in HIV prevention and control and the school programmes to emphasize to the students the relevance of each of the components of the ABC strategy including the condom use as reported in previous studies elsewhere [4] [24] [25] , to ensure that the participants clearly understand them properly if the world is to reduce the HIV prevalence among the vulnerable youth especially the adolescents where the HIV prevalence is currently reported to be high and on increase in that group. Generally, the findings from this study show knowledge gap on HIV prevention, transmission and control among the youth especially in the adolescent age group thus predisposing them to HIV infection as reported in previous studies [31] [32] [35] [36] .