Journal of Infection and Public Health 11 (2018) 80–84

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Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Knowledge and attitudes toward HIV/AIDS among the general

population of Jeddah, Saudi Arabia
Heba A. Alwafi a , Alaa M.T. Meer b , Alaa Shabkah c , Fahtima S. Mehdawi d,∗ ,
Hadeel El-haddad d , Nezar Bahabri d , Hani Almoallim d,e
a
King Abdulaziz Univeristy, Abdullah Sulayman, Jeddah 21589, Saudi Arabia
b
Ministry of National Guard Hospital, King Abdulaziz Meidcal City, Department of Medicine, Jeddah 21423, Saudi Arabia
c
International Medical Center, Department of Surgery, Hail Street Al-Ruwais, Jeddah 23214, Saudi Arabia
d
Dr. Soliman Fakeeh Hospital, Department of Medicine, Falastin Street Al-Hamra’a, Jeddah 23323, Saudi Arabia
e
Umm Alqura University an Alzaidi Chair of Research, Saudi Arabia

a r t i c l e i n f o a b s t r a c t

Article history: Background: In contrast to most regions of the world where a decline of the HIV epidemic can be seen,
Received 26 November 2016 data from the Middle East and North Africa (MENA) region suggests increasing incidence among key
Received in revised form 18 March 2017 populations in the region. Accurate data collection has long been limited by social, cultural, and religious
Accepted 28 April 2017
taboos. Understanding knowledge levels and attitudes toward HIV/AIDS is an important component to
design adequate and culturally appropriate awareness and prevention programs.
Keywords:
Methods: A survey was conducted including 3841 participants during a series of public HIV/AIDS aware-
HIV/AIDS
ness campaigns from 2013 to 2015 in Jeddah, Saudi Arabia. Participants completed a questionnaire
Saudi Arabia
Knowledge and attitudes
including socio-demographic data, and questions around knowledge and attitudes toward HIV/AIDS.
Survey A knowledge score was created. Frequencies were calculated for all variables, mean knowledge scores
General population were compared using non-parametric tests. Categorical variables were compared using Chi-squared test.
The mean knowledge score was 5.2 out of 9 possible points. Respondents in the age class 19–25, respon-
dents with university degrees, and those who know people living with HIV/AIDS had higher scores. Overall
the attitude toward people living with HIV/AIDS was negative, more than 40% suggested that HIV posi-
tive people should be isolated and less than 20% would support a marriage with an HIV positive person.
Negative attitudes were more common among people in older age groups, with a lower educational
background, and respondents that did not know anyone living with HIV/AIDS.
Conclusion: Knowledge gaps and negative attitudes of the general public toward people living with
HIV/AIDS have been identified and can be used to tailor educational campaigns in Saudi Arabia.
© 2017 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction (MENA) region suggests a growing epidemic among key popula-

Human immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS) represents one of the leading global health
problems [1]. Despite progress in diagnosis, treatment, and pre-
vention, HIV/AIDS is still a serious public health challenge [1]. In
contrast to most regions of the world, where a decline of the epi-
demic can be seen, data from the Middle East and North Africa
∗ Corresponding author.
E-mail addresses: Hebal.alwafi@gmail.com (H.A. Alwafi),
Dr.alaameer@gmail.com (A.M.T. Meer), Dr.3la2@msn.com
(A. Shabkah), fmehdawi@drfakeehhospital.com, fahtimamehdawi1989@gmail.com
(F.S. Mehdawi), Hadeel haddad@hotmail.com (H. El-haddad),
nbahabri@drfakeehhospital.com (N. Bahabri), hanialmoallim@gmail.com
(H. Almoallim).
tions in the region [2]. However, data are limited in some countries
and there is considerable heterogeneity within the region. Accu-
rate data collection on the prevalence and incidence of HIV/AIDS in
many Middle Eastern countries has been slow compared to other
regions because of social, cultural, and religious taboos [3]. HIV
remains a controversial topic in the MENA region, thus information
about HIV prevalence and trends in the region is insufficient, under-
reporting is likely, and it is not possible to obtain exact statistics or
to ascertain the specific determinants of levels and trends of HIV.
According to the latest Saudi Ministry of Health report there has
been a 0.5–2.5% increase in the incidence of HIV infection between
1984 and 2009 [4]. Interestingly, HIV infections are more preva-
lent in Jeddah than in any other city within the Kingdom, which
might at least partially be attributed to the fact that Jeddah is the
main sea- and airport of the country and population movement is

https://doi.org/10.1016/j.jiph.2017.04.005
1876-0341/© 2017 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 H.A. Alwafi et al. / Journal of Infection and Public Health 11 (2018) 80–84 81

Table 1
Knowledge and attitude questions and answers.

Questions provided on the survey Answer options Correct answer

1-Do you know someone living with HIV? Yes, friend

Yes, relative
No
2-Does HIV transmit through infected person cough/sneeze? Yes No
No
3-Does HIV transmit through sharing food utensils with an infected person? Yes No
No
4-Does HIV transmit through mosquito’s bites? Yes No
No
5-Does HIV transmit through touching the blood of an infected person? Yes No
No
6-Does HIV transmit through pets bites? Yes No
No
7-Does HIV transmit from infected mother to her unborn/newborn baby? 50%, 70%, 90%, if the mother is if the mother is on treatment
on treatment less than 1% less than <1%
8-Does HIV transmit through sexual relations with infected person more than 90% of the time? Yes No
No
9-Is there available medication for HIV patients so they can live an ordinary life? Yes Yes
No
10-Does HIV patient require total isolation or legally jailed in Saudi Arabia? No they are not isolated nor No they are not isolated, nor
put in prison put in prison
No they are not but I would
prefer isolation, Yes they are
and I agree Yes they are and I
don’t agree
11-Do you accept that a relative would marry an HIV patient? Yes
No
12-Do you accept to live with an HIV patient? Yes
No
13-Do you think HIV patients should be isolated from the community? Yes
No

therefore higher [5]. Whilst a large percentage of the overall HIV
cases in Saudi Arabia is among the immigrant population, there
was a significant increase in the proportion of cases among the
Saudi population [6].
With modern antiretroviral therapy HIV related mortality has
been reduced significantly [7,8] and quality of life of affected
patients has dramatically improved. Highly active antiretroviral
therapy (HAART) contributes to reduced risk of perinatal transmis-
sion, in addition it also reduces the general risk of transmission
[9,10]. The advances in patient management of HIV/AIDS over the
last decades have resulted in a paradigm shift and HIV/AIDS is no
longer seen as a fatal disease but rather a chronic illness.
Despite these positive developments, primary preventive
measures remain crucial to control and reduce incidence. Under-
standing knowledge levels and attitudes toward HIV/AIDS is an
important component to design adequate and culturally appropri-
ate awareness and prevention programs. We therefore conducted a
survey to explore knowledge and attitudes toward HIV/AIDS among
the general population in Jeddah, Saudi Arabia.
Methods
Participants and setting
The study was approved by the Institutional Review Board (IRB)
of King Abdul Aziz University Hospital (KAUH), Jeddah. All partic-
ipants provided oral informed consent after receiving the study
information. No financial or other incentives were offered to par-
ticipants for completion of the survey before their inclusion in the
study.
Data collection
A questionnaire was developed including 17 questions listed
in Table 1. The research team reviewed the survey multiple times
before release and piloted the survey in a small sample of respon-
dents. Data was entered from the paper questionnaires into a
custom made excel database.
The survey contained 9 knowledge questions and 3 questions
about the attitudes of respondents toward people living with HIV.
Participant’s responses were categorized as follows:
Demographic (6 items)
Participants were asked to provide information on gender, age
group, educational background, whether they work in the medical
field, and whether they know someone living with HIV.

A survey was conducted during a public HIV/AIDS awareness Knowledge (9 items)

campaign between December 2012 and September 2015 in Jed-
dah. Participants attending those campaigns in a range of different
settings were actively approached to fill out the questionnaire. The
questionnaires were distributed during several HIV/AIDS aware-
ness campaigns, in shopping malls, exhibitions, and universities.
The questionnaire was self-administered and returned to the inves-
tigators upon completion.
Individuals below the age of 10 years, and individuals who never
had formal education or were illiterate were excluded from partic-
ipating in the survey.
There were a total of 9 knowledge questions, 7 of them had only
yes/no options and 2 questions had 4 possible answer options. One
of those questions was a combined question for knowledge and
attitude, and this variable was later divided into 2 variables for
analyses.
Attitude (3 items)
Attitude questions were also closed-ended questions with
yes/no answer options.
82 H.A. Alwafi et al. / Journal of Infection and Public Health 11 (2018) 80–84

Table 2 individuals having a satisfactory score between 7 and 9 points, 2054

Baseline data of respondents.
(53.48%) individuals having a fair score between 4 and 6 points, and
N % 728 (18.95%) respondents having a poor score of 0–3 points. Table 3
Male gender (n = 3777) 1835 48.58 summarizes the results for the individual knowledge questions.
Age group (n = 3805) There were a total of 128 (3.33%) respondents having answered all
10–18 years 300 7.88 9 questions correctly and 34 (0.89%) respondents answered every
19–25 years 1700 44.68 question wrong.
26–35 years 1121 29.46
There was a small but significant difference in the mean knowl-
36–45 years 413 10.85
>45 years 271 7.12 edge score between genders with a mean score of 5.15 among
Marital status (n = 3793) female respondents and a score of 5.33 among male respondents
Single 2301 60.66 (p = 0.0007). The highest mean score was in the age group of
Married 1376 36.28
the 19–25 year olds with 5.33, and lowest in the under 18 year
Divorced 116 3.06
Level of education (n = 3789) olds with 4.73 (p = 0.0001). Knowledge scores were highest among
Elementary school 40 1.06 participants with university degrees and postgraduate education
High school 784 20.69 and lowest among those with elementary, middle, or high school
Middle school 129 3.40 degrees only (5.32 and 5.78 versus 4.27, 4.75, and 4.88 respectively,
Post graduate 305 8.05
p = 0.001). There was also a small but significant difference in scores
University 2531 66.80
Working in the medical field (n = 3795) 990 26.09 among respondents working in the medical field and those work-
ing elsewhere (5.77 versus 5.06, p < 0.0001). The knowledge score
Data analysis among respondents who have a friend or family member living
with HIV was 5.49 compared to those who do not know anyone
Data was analyzed using STATA 12 (US). A knowledge score was with HIV with a score of 5.22 (p = 0.01).
calculated for each respondent whereby one point was assigned to
each correct answer and no points were given for an incorrect or
missing answer. The highest possible score was therefore 9 points. Attitude
Frequencies were calculated for all variables and mean knowledge
scores were compared using non-parametric tests (Mann–Whitney Less than half of the respondents (1579/3779, 41.78%) said that
U, and Kruskal–Wallis test) as appropriate. Categorical variables they would live with a friend or relative who has HIV, and 642 par-
were compared using Chi-squared test. ticipants (17.26%) said that they would accept a relative to marry
someone with HIV. A total of 1509 (40.73%) respondents indicated
Results that they think HIV patients should be isolated from the commu-
nity.
Baseline data More people between 19 and 25 years of age (44.74%) would
agree to live with someone with HIV compared to the other age
A total of 3841 subjects participated in the survey. Baseline char- groups (41.22% for the under 18 year olds, 38.76% for the 26–35 year
acteristics such as gender, age group, and educational background olds, 40.00% for the 36–45 year olds, and 38.64% for those >45 years,
of the respondents are listed in Table 2. p = 0.019). More respondents with higher education (43.25%) would
Most respondents stated that they do not know anyone liv- agree to live with an HIV positive person compared to those with-
ing with HIV/AIDS (3611/3798; 95.08%) and only 3.19% and 1.74% out a university degree (37.53%, p = 0.002). A similar difference was
stated that they have a friend or relative living with HIV respec- found for those working in the medical field compared to those
tively. working elsewhere (49.64% versus 39.26%, p < 0.001) and for those
who know someone with HIV (65.45% versus 40.32%, p < 0.001).
Knowledge Female respondents were more likely to accept a relative marry-
ing someone with HIV than their male counterparts (19.83% versus
The mean knowledge score of the respondents in this study was 14.37%, p < 0.001). Older participants were less likely to accept a
5.23 (95% confidence interval [CI]: 5.17–5.29) with 1059 (27.57%) relative marrying someone with HIV than their male counterparts

Table 3
Results of knowledge and attitude questions.

Knowledge questions Number of Number of Percentage of

participants who participants who participants who
answered answered correctly answered correctly

Does HIV spread through coughing or sneezing? 3782 3309 87.49

Does HIV transmit through sharing food utensils with an infected person? 3783 2736 72.32
Does HIV transmit through touching the blood of an infected person? 3788 2524 66.63
Can HIV be transmitted through a mosquito bite? 3755 2027 53.70
Can HIV be transmitted through cats and dogs? 3756 3107 82.72
If the mother has HIV what is the risk of transmission during pregnancy and breastfeeding? 3841 1287 33.51
Does HIV transmit through sexual relations with infected person more than 90% of the time? 3587 530 14.78
Is a person living with HIV in Saudi Arabia isolated or imprisoned? 3705 2397 64.70
Is there a treatment for patients with HIV, similar to treatment for other diseases? 3760 2179 57.95

Attitude questions Number of Number of Percentage of

participants who participants who participants who
answered answered yes answered yes

Do you accept that a relative would marry an HIV patient? 3601 627 17.41
Do you accept to live with an HIV patient? 3659 1521 41.57
Do you think HIV patients should be isolated from the community? 3584 1465 40.87
 H.A. Alwafi et al. / Journal of Infection and Public Health 11 (2018) 80–84
(6.8% among those >45 years and 21.47% among 19–25 year olds,
p < 0.001), participants with a university degree were more likely
to accept this (17.98% versus 14.79%, p = 0.026), and respondents in
the medical field were more likely to accept this compared to those
working elsewhere (21.06% versus 15.94%, p < 0.001).
Respondents that thought that HIV patients should be isolated
were in the older age groups compared to those stating that iso-
lation is not warranted (45.42% in those >45 years, 37.69% in the
age group 19–25 years, p = 0.005). Less respondents working in the
medical field thought isolation is appropriate compared to those
working elsewhere (33.71% versus 43.10% p < 0.001), and similarly
respondents who know someone with HIV were less likely to agree
to isolation compared to those who do not know anyone (26.07%
versus 41.61%, p < 0.001). Education did not influence this attitude
significantly (42.48% among those without a university degree sug-
gested isolation compared to 40.27%, p = 0.239).
Discussion
The current study provided insights about knowledge and atti-
tudes of the general population in Saudi Arabia in regards to
HIV/AIDS. The overall mean knowledge score among study par-
ticipants was modest with 5.2 correct answers out of 9. There is
a relatively large gap of knowledge and misconceptions regarding
modes of transmission of the infection and precautions. However,
most respondents were aware of the availability of medications for
the disease.
The modest knowledge about HIV/AIDS among the surveyed
population in the current study is comparable with earlier sur-
veys from Saudi Arabia [11] as well as other countries in the region
[12,13]. A low knowledge level in regards to HIV/AIDS was also
found among medical and non-medical students in Saudi Arabia
[14,15].
Higher knowledge scores were clearly associated with younger
age class, better education, and knowing a person who is living
with HIV/AIDS, suggesting the potential positive impact of edu-
cational campaigns. This has been shown in longitudinal surveys
in Europe were 15 years of continuous educational campaigns
have significantly improved knowledge about HIV and AIDS among
high school students in Greece [16]. Inadequate knowledge may
lead to unnecessary concerns regarding interaction with people
living with HIV/AIDS and therefore increases stigmatization [17].
When comparing gender knowledge scores, males showed a higher
knowledge score. An association can be made with males having a
higher prevalence of HIV. Males accounted for two thirds of all new
cases during the 2000–2009 decade [6].
Another important outcome of this study is the rather nega-
tive attitude toward people living with HIV/AIDS, which might be
a result of the low knowledge score. Nearly half of the respondents
indicated that people living with HIV/AIDS should be isolated, less
than 20% would want a relative to marry someone with HIV/AIDS,
and nearly 60% would not want to live with a friend who has
HIV/AIDS. Similar negative attitudes however at a lower level have
been reported in several other studies in different parts of the world
[12,13,16,18]. Nearly 30% of the respondents are working in the
medical field and they showed more positive attitudes than those
working elsewhere; however, stigmatization of people living with
HIV/AIDS also occurred in this group. Social stigma has been shown
to be a barrier to initiating treatment [19].
Occurrence of social stigma associated with HIV/AIDS and its
negative impact on AIDS prevention activities has been analyzed
in depth and strategies for alleviating the stigma have been dis-
cussed by Mahajan et al. [17]. South Africa has set an interesting
example in implementing HIV/AIDS prevention programs including
community-based HIV awareness programs and education cam-
83
paigns, research on HIV prevention together with the introduction
of anti-retroviral therapy (ART). This comprehensive approach has
led to increased knowledge within the community which reduced
the social stigma and led again to better uptake of voluntary coun-
seling and HIV testing [20]. Recently awareness toward HIV has
increased, in the form of campaigns, advertisements, and social
media. A next step in improving routine health care would be pro-
moting an awareness campaign such as the “Get Tested” concept
introduced by the CDC that recommends all individuals between
the ages of 13 and 64 be tested for HIV [21]. The need to decrease
social stigma toward HIV/AIDS, providing social protection and
improving the knowledge and attitudes of the general public
toward people living with HIV/AIDS have been identified as critical
factors in the management of this epidemic [17,22,23].
Overcoming those negative attitudes requires a comprehen-
sive approach including increased support for people living with
HIV/AIDS and strengthening of the respective sectors of the health
care system. Confidentially for patients needs to be assured since
many patients in Saudi Arabia still feel uncomfortable to seek
appropriate care, which leads to inadequate treatment and delayed
care. Patients are often unaware of the electronic systems used in
hospitals to guarantee anonymity and awareness for this needs to
be increased. In response to the epidemic, a national AIDS program
was established within the Saudi Ministry of Health to oversee and
coordinate country-wide efforts to prevent, diagnose and treat HIV.
By law, every Saudi citizen who is infected with HIV or has AIDS is
entitled to free medical care and has protection of their privacy as
to how they got infected. Support groups would be another helpful
tool to address discrimination and stigmatization.
There are several limitations to this study. Firstly, though the
sample is of reasonable size, some selection bias in people agree-
ing to participate cannot be excluded. Respondents might have
been generally more interested and knowledgeable than those who
refused and this might have led to better knowledge scores and
an underestimation of negative attitudes. Secondly, in order to
ensure high participation rates the questionnaire was deliberately
made relatively short. Therefore, questions around blood transfu-
sion, drug usage, and risk behavior in relation to HIV/AIDS were not
included. Adding those topics would have allowed a more compre-
hensive picture. Thirdly, no qualitative questions were included.
A qualitative component might have helped to better understand
negative attitudes toward people living with HIV/AIDS and provide
a richer picture of the reasons behind those attitudes.
In conclusion there is fairly modest knowledge about HIV/AIDS
among the general population in Jeddah, Saudi Arabia and a general
rather negative attitude toward people living with HIV/AIDS. Bet-
ter knowledge and more positive attitudes however are linked to
higher educational background, suggesting that educational cam-
paigns might be helpful to increase knowledge and awareness and
reduce stigma. Educational campaigns may use different outlets
from schools, medical training, and social media to reach the tar-
geted audience. There is an urgent need to address those gaps and
attitudes in the Saudi general population, and more specifically also
among medical professionals.
Conflict of interest
We have no conflict of interest to declare.
Acknowledgement
We would like to thank Research-Medics for their editorial assis-
tance in the preparation of this manuscript.
84 H.A. Alwafi et al. / Journal of Infection and Public Health 11 (2018) 80–84
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