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R E S E A R C H A R T I C L E Open Access
HIV comprehensive knowledge and
prevalence among young adolescents in
Nigeria: evidence from Akwa Ibom AIDS
indicator survey, 2017
Titilope Badru
1
, Jefferson Mwaisaka
2
, Hadiza Khamofu
1
, Chinedu Agbakwuru
1
, Oluwasanmi Adedokun
1
,
Satish Raj Pandey
1
, Patrick Essiet
3
, Ezekiel James
4
, Annie Chen-Carrington
4
, Timothy D. Mastro
5
, Sani H. Aliyu
6
and
Kwasi Torpey
2*
Abstract
Background: Despite the recent increase in HIV infections among adolescents, little is known about their HIV
knowledge and perceptions. This study, therefore, sought to examine the factors associated with comprehensive
HIV knowledge, stigma, and HIV risk perceptions among young adolescents aged 10–14 years in Akwa Ibom State,
Nigeria. Additionally, consenting parents and assenting young adolescents were tested for HIV.
Methods: We used cross-sectional data from the 2017 Akwa Ibom AIDS Indicator Survey to analyze comprehensive
HIV knowledge, stigma, and HIV risk perceptions among young adolescents. Demographic characteristics of young
adolescents were summarized using descriptive statistics. Chi-square test (or Fisher’s exact test in cases of small
subgroup sample sizes) was used to elicit associations between demographics and study outcomes. Separate
multivariable logistic regression models were then conducted to determine associations with the study outcomes.
Sampling weights were calculated in order to adjust for the sample design. P-values less than 0.05 were considered
to be significant.
Results: A total of 1818 young adolescents were interviewed. The survey highlighted significant low levels of
comprehensive HIV knowledge (9.4%) among young adolescents. Adolescent-parent discussions [AOR = 2.19, 95%
C.I (1.10–4.38), p= 0.03], schools as sources of HIV information [AOR = 8.06, 95% C.I (1.70–38.33), p< 0.001], and
sexual activeness [AOR = 2.55, 95% C.I (1.16–5.60), p= 0.02] were associated with comprehensive HIV knowledge.
Majority (93%) of young adolescents perceived themselves not to be at risk of HIV. Overall, 81.5% of young
adolescents reported stigmatizing tendencies towards people living with HIV. HIV prevalence among young
adolescents was 0.6%.
Conclusions: Results indicate low comprehensive HIV knowledge among young adolescents. Our findings suggest
that there is a need for increased attention towards young adolescents particularly in the provision of
comprehensive, functional sexuality education, including HIV at the family- and school-levels. Consequently, age
appropriate interventions are needed to address the epidemiological risks of young adolescents that are influenced
by a myriad of social issues.
Keywords: Comprehensive HIV knowledge, Stigma, Risk perceptions, Young adolescents, Nigeria
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribut ion 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
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the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: ktorpey@hotmail.com
2
University of Ghana College of Health Sciences, Accra, Ghana
Full list of author information is available at the end of the article
Badru et al. BMC Public Health (2020) 20:45
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Background
Young people today have more sources of information
for improving their HIV knowledge such as family mem-
bers, friends, teachers, and the Internet. Adequate HIV
knowledge is critical for protecting young adolescents
from HIV as evidence has shown that they are among
the most vulnerable groups [1]. In spite of these many
sources, HIV prevalence among young adolescents re-
mains a public health concern. In 2015, it was estimated
that globally 29 adolescents acquired HIV every hour
and that approximately 1.8 million adolescents aged 10–
19 years were living with HIV, majority of whom were
girls [2]. HIV deaths among adolescents in Africa con-
tinue to rise at an alarming rate [3]. AIDS is currently
the number one cause of death among adolescents in
Africa, and second leading cause of adolescent deaths
worldwide, with sub-Saharan Africa having the highest
number of deaths [4]. The number of adolescents dying
from HIV related illnesses is estimated to have tripled
over the last two decades [4]. An estimated 1.9 million
people are living with HIV in Nigeria accounting for a
prevalence of 1.4%. Among children aged 0–14 years,
HIV prevalence is estimated to be 0.2% [5]. The HIV
prevalence of adolescents in Nigeria is estimated to be
3.5%, the highest among countries in West and Central
Africa [6]. UNICEF in 2017 estimated in Nigeria 230,000
adolescents aged 10–19 live with HIV and 5400 have
succumbed to AIDS-related deaths [3]. As adolescents
and young people continue to be disproportionately af-
fected by HIV, global and national efforts should focus
on shifting the age disaggregation to accommodate
young adolescents aged 10–14, as they tend to be over-
looked by interventions due to programs prioritizing
15–19-year-old adolescents and young people aged 20–
24. The 2014 Nigeria Demographic and Health Survey
(NDHS) reported that 89.3% of boys and 89.5% of girls
aged 15–19 had heard of AIDS. On HIV prevention
methods, 63% of boys compared to 51.6% of girls knew
that consistency in condom use could reduce the risk of
HIV infection [7]. Young adolescents aged 10–14 were
not included in the NDHS, except for when adults 18–
49 responded on whether children aged 12–14 should
be provided knowledge on condom use for HIV preven-
tion. Lack of data for young adolescents aged 10–14
makes it difficult for them to be included in the national
strategic plans, thereby limiting the available evidence to
inform age-specific programming that targets young ad-
olescents [8].
There has also been a decline in formal sex education
given to young adolescents, specifically on topics dis-
cussing abstinence, birth control, and prevention of
HIV/AIDS and other STDs [9]. This has mainly been
reported in the Western countries, whereas Nigeria re-
mains in limbo as to whether such topics should be
discussed in the open or not. As a result, young people
in Nigeria, especially young adolescents aged 10–14, face
substantial challenges in accessing timely and appropri-
ate health education, including comprehensive sexuality
education [10]. This may be attributed to societal atti-
tudes and misperceptions about sexuality education,
therefore exposing young adolescents to other unreliable
sources of information. Parent-child sexual communica-
tion plays a protective role in adolescent safer sex behav-
iors, including condom use [11]. In Nigeria, age, religion,
and socioeconomic status have been found to be positive
influencers for parent-child communication [12]. In
addition, most parents tend to communicate sexual mat-
ters to their children after they have already engaged in
sexual acts [12].
Inadequate HIV knowledge among young adolescents
coupled with socio-cultural factors may contribute to
stigmatizing tendencies towards those infected and af-
fected by HIV. If not addressed, increased stigma and
discrimination, especially against young adolescents will
continue to hinder them from testing and adhering to
treatment. Among the general population in Nigeria, the
HIV stigma level has declined [13], however this is yet to
be determined among young adolescents aged 10–14.
Similarly on risk perceptions, some studies in Africa
[14–16] have found perceived low and inaccurate report-
ing of HIV risks among adolescents. It is therefore bene-
ficial to accurately understand why young adolescents
perceive themselves to be at low risk in order to address
misconceptions associated with their beliefs. Under-
standing and addressing HIV knowledge gaps among
young adolescents is therefore critical for programs and
policy makers when designing behavior change interven-
tions. This paper, therefore, sought to determine the fac-
tors associated with comprehensive HIV knowledge,
HIV perceptions, stigma, and sexual behaviors among
young adolescents in Akwa Ibom State Nigeria.
Methods
Survey methodology
The Akwa Ibom AIDS Indicator Survey (AKAIS) was
conducted between April and June 2017 among children
aged 0 months to 14 years and adults 15 years and older.
AKAIS was a population-based survey of household resi-
dents designed to produce unbiased estimates of HIV
prevalence and incidence, and to identify the risk factors
associated with HIV infection in Akwa Ibom state. It
was estimated that a sample of 4653 households within
226 Enumeration Areas (EAs) would provide a represen-
tative sample of adults aged 15 years and older and chil-
dren aged 0 months to 14 years.
A two-stage probability sampling technique was employed
in selecting participants from a frame of eligible household
residents of Akwa Ibom State. The primary sampling unit
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was EAs as defined by the National Population Commission
(NPC) during the 2006 Nigeria Census. At the first stage,
226 clusters (EAs) were selected with probability propor-
tional to size and stratified by geographic location. At the
second stage, a fixed number of households within the se-
lected EAs were selected using systematic sampling. A
complete listing of all households in selected EAs was con-
ducted. All adults 15 years and older and young adolescents
10–14 years in the sampled households, who were either
permanent residents or visitors in the household on the
night preceding the survey, were eligible for the interview
and/or HIV testing. Similarly, all children less than 10 years
were eligible for HIV testing.
Tablet-based questionnaires used for this study
was adapted from the AIDS Indicator Survey tool
(Additional file 1, Akwa Ibom AIDS Indicator Survey
Adolescent Individual Questionnaire [10–14 yrs.])
were administered through face-to-face interviews.
Three types of questionnaires were used: (1) a
household questionnaire, (2) an individual adolescent
questionnaire for individuals aged 10–14 years, and
(3) an individual adult questionnaire for women and
men aged 15 years or older. The individual adoles-
cent and adult questionnaires collected information
from eligible adolescents aged 10–14 years and adults
aged 15 years and older on basic demographic char-
acteristics, marriage, sexual activity, HIV and STI
knowledge, attitudes and behaviors, and previous
HIV testing. In addition to the interview, blood was
drawn from consenting participants for HIV antibody
testing. Informed consent was sought for participa-
tion in the interview and blood draw. Parental con-
sent was sought from the parent or guardian of
children less than 17 years. In addition, assent was
sought from children aged 10–17 years whose parent
or guardian had consented to their participation.
Consenting participants were tested for HIV accord-
ing to national algorithm and confirmed with Bio-
Rad Geenius HIV 1/2 Confirmatory Assay. Personal
identifiers were excluded from the data set before
analyses were performed.
Study measures
The adolescent questionnaire elicited information on
demographic characteristics, comprehensive knowledge of
HIV, attitudes, HIV risk perception, HIV testing, and alco-
hol and drug use. Adolescents aged 12–14 years were add-
itionally asked questions about sexual activity, social
norms, abstinence, self-efficacy, and assertiveness.
In this study, we analyzed the following outcomes re-
ported by adolescents aged 10–14 years: comprehensive
HIV knowledge, stigma, and HIV risk perceptions. HIV/
AIDS awareness was assessed by asking adolescents if
they had ever heard of HIV/AIDS. Comprehensive
knowledge of HIV was assessed, and this was defined as:
i) knowing that someone can protect himself/herself
from HIV by using condom during sexual intercourse,
ii) knowing that a healthy-looking person can have HIV,
iii) knowing that HIV can be transmitted by having un-
protected sex with an HIV-infected person, iv) knowing
that there are medicines that people with HIV can take
to help them live longer, and v) knowing that HIV can
be transmitted by sharing of sharp objects. A binary out-
come of “1”was designated if all questions were an-
swered correctly and “0”if any of the questions were
answered incorrectly.
Stigma was assessed by asking the following questions:
i) would you be willing to share food with an HIV-
infected person? and ii) would you play with someone
who has HIV? For the stigma-related outcome, these
questions were combined. HIV risk perception was
assessed by asking adolescents the following question:
“How likely do you think is it that you can get HIV: Very
Likely, Somewhat Likely, or Not Likely? A binary outcome
of “1”was designated if adolescents reported very likely or
somewhat likely and “0″if adolescents reported not likely.
Independent variables included: sex, educational status, lo-
cation/residence, ever had sex, having discussed HIV with
parents/guardians, and ever tested for HIV.
Data analysis
Adolescent characteristics including age, gender, and
level of education were summarized using descriptive
statistics. Ever heard of HIV, ever had sex, condom use,
and having HIV discussions with parents/guardians were
reported using weighted proportions and 95% confi-
dence intervals. Chi-square test (or Fisher’s exact test in
cases of small subgroup sample sizes) was used to elicit
associations between demographics and HIV/AIDS
awareness and ever had sex. Separate multivariable logis-
tic regression models were conducted to determine asso-
ciations with comprehensive HIV knowledge, HIV risk
perception, and stigma. Sampling weights were calcu-
lated in order to adjust for the sample design. P-values
less than 0.05 were considered to be significant. Statis-
tical analyses were performed using Stata 12.0 (Stata-
Corp, 2012, Stata Statistical Software: Release 12.0,
College Station, TX: StataCorp LP).
Results
Characteristics of the respondents
A total of 2076 adolescents (10–14 years) were eligible
for the survey, 1818 participated in the interviews. Inter-
view response rate amongst adolescents was 87.6%. Of
the 1818 adolescents interviewed, 70% (1281) resided in
rural areas and 53% (972) were males. The mean age
was 11.9 ± 1.4 years. Majority (97%, or 1770) were cur-
rently in school, 96% (1765) had at least a primary
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education. Almost two-thirds (64%) were aged 10–12
years and none of the adolescents reported ever being
married. Among the adolescents surveyed, 732 (40.4%)
reported ever drinking alcohol and 25 (1.4%) reported
ever taking mood-enhancing drugs/substances.
HIV/AIDS awareness
Approximately 72% (1286) of young adolescents re-
ported to have heard of HIV. Awareness of HIV or AIDS
was higher among adolescents who resided in urban
areas (79.7%) than rural areas (68.1%) (p< 0.001). HIV
awareness did not differ by sex (females 73.1% vs males
70.6%; p= 0.32) (Table 1).
Major sources of HIV information were schools
(79.7%), media (31.9%), and friends (20.9%). Other
sources of information included religious leaders (7.0%),
hospitals (3.6%), and the Internet (1.5%). Slightly over a
quarter (26.2%) of adolescents ever discussed HIV or
AIDS with their parents or guardians (males 26.1% vs fe-
males 25.3%, p= 0.64). Almost three out of ten adoles-
cents who resided in the rural areas (28.5%) and 21.6%
who resided in urban areas had ever discussed HIV or
AIDS with their parents or guardians (p= 0.02).
HIV/AIDS knowledge
Out of the 1286 adolescents who had ever heard of HIV,
almost half (45.7%) of the adolescents answered correctly
that HIV can be transmitted by having unprotected sex
with an HIV-infected person and by sharing sharp ob-
jects (72.6%). Sixty percent of the adolescents knew that
a healthy-looking person can have HIV and 62.7% knew
that there are medicines that people with HIV can take
to help them live longer. Only 12% knew that the use of
a condom can prevent HIV transmission (Fig. 1).
Almost one out of ten (9.4%) adolescents had compre-
hensive knowledge of HIV. A multivariable logistic re-
gression of factors associated with HIV comprehensive
knowledge indicated that adolescents who had ever had
a discussion on HIV or AIDS with their parents/
guardians [AOR = 2.19, 95% C.I (1.10–4.38), p= 0.03]
were more likely to have comprehensive knowledge of
HIV than those who had never had a discussion on HIV
or AIDS with their parents/guardians. Adolescents who
had ever had sex were more likely [AOR = 2.55, 95% C.I
(1.16–5.60), p= 0.02] to have comprehensive knowledge
of HIV than adolescents who had never had sex. Adoles-
cents whose source of HIV information was from
schools [AOR = 8.06, 95% C.I (1.70–38.33), p< 0.001]
were more likely to have comprehensive knowledge of
HIV than those who did not receive HIV information
from schools (Table 2).
Sexual behaviors
Data on sexual behaviors were collected among respon-
dents aged 12–14 years (1029). Forty-two percent (392)
reported to have ever heard of sex while 22.1% (86) re-
ported to have ever had sex. Of the 86 who reported to
have ever had sex, 40% reported their sexual debut be-
fore the age of 12 years and 9.3% reported using con-
doms at first sex. Twelve percent of the sexually active
respondents reported to have had sex for material sup-
port. Adolescents aged 12–14 years who had ever had
sex did not differ between females (23.4%) and males
(20.6%) (p= 0.64). Exposure to sexual intercourse did
not differ by location of residence (rural 24.3% vs. urban
17.4%; p= 0.12) (Table 3).
HIV risk perception
Only 7% of the adolescents aged 12–14 years who had
heard of HIV perceived themselves to be at risk of HIV.
A multivariable logistic regression of factors associated
with HIV risk perception showed that sex, location of
the respondents, ever discussed HIV with parents/guard-
ians, ever tested for HIV, and having comprehensive
knowledge of HIV were not significantly associated with
HIV risk perception. Adolescents aged 12–14 years who
had ever had sex were more likely to perceive themselves
to be at risk of HIV [AOR = 4.18, 95% C.I (1.63–10.69),
Table 1 HIV/AIDS Awareness amongst young adolescents by select characteristics
Select Characteristics Awareness of HIV/AIDS among adolescents
Unweighted Weighted % p-value
Sex
Male 972 70.6 0.32
Female 846 73.1
Location
Urban 537 79.7 < 0.001
Rural 1281 68.1
Education
No education 53 61.0 0.09
At least primary education 1765 72.0
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Fig. 1 Percentage of adolescents who answered the HIV knowledge questions correctly. Method and results: Proportion of young adolescents
who had ever heard of HIV and gave correct responses on HIV knowledge questions including mode of HIV transmission, HIV misperceptions, HIV
treatment and HIV prevention. Data is shown as a percentage of 1286 adolescents who had ever heard of HIV
Table 2 Factors associated with HIV comprehensive knowledge among adolescents
Crude OR (95% C.I) P-value Adjusted Crude OR (95% C.I) P-value
Location
Urban 1 1
Rural 0.91 (0.61–1.37) 0.66 0.91 (0.44–1.89) 0.80
Sex
Male 1 1
Female 1.06 (0.72–1.54) 0.78 0.75 (0.37–1.49) 0.41
Age (years) 1.41 (1.22–1.65) < 0.001 1.45 (0.96–2.20) 0.08
Education
No form of education 1 1
At least primary education 1.02 (0.35–2.93) 0.98 0.35 (0.09–1.44) 0.15
Ever discussed HIV with parents/guardians
No 1 1
Yes 1.89 (1.26–2.82) < 0.001 2.19 (1.10–4.38) 0.03
Ever had sex
No 1 1
Yes 2.18 (1.09–4.39) 0.03 2.55 (1.16–5.60) 0.02
Ever tested for HIV
Yes 1 1
No 0.59 (0.32–1.09) 0.09 0.56 (0.24–1.30) 0.17
Source of HIV information: internet
No 1 1
Yes 5.27 (1.82–15.28) < 0.001 0.58 (0.08–3.95) 0.58
Source of HIV information: media
No 1 1
Yes 2.02 (1.35–3.01) < 0.001 1.45 (0.69–3.07) 0.33
Source of HIV information: school
No 1 1
Yes 11.51 (5.45–24.29) < 0.001 8.06 (1.70–38.33) < 0.001
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p< 0.001) than those who had never had sex. HIV risk
perception increased with an increase in age [AOR =
1.80, 95% C.I (1.02–3.50), p= 0.04] (Table 4).
HIV stigma
Seventy-seven percent of young adolescents reported
that they will be unwilling to play with someone who
has HIV and 84% indicated that they will be unwilling to
share food with someone who has HIV. Overall, 81.5%
of adolescents reported stigmatizing attitudes towards
people living with HIV. Multivariable logistic regression
results revealed that adolescents without comprehensive
HIV knowledge [AOR = 3.39, 95% C.I (1.57–7.31), p <
0.001] were more likely to have stigmatizing attitudes to-
wards PLHIV than those with HIV comprehensive
knowledge. Adolescents who perceive themselves not at
risk for HIV [AOR = 3.07, 95% C.I (1.14–8.23), p= 0.03]
were more likely to have stigmatizing attitudes towards
PLHIV than those who perceived themselves to be at
risk. Also, adolescents who reported to have never tested
for HIV [AOR = 2.23, 95% C.I (1.15–4.32), p= 0.02] were
more likely to have stigmatizing attitudes towards
PLHIV than those who had ever tested for HIV. Adoles-
cents without any form of education [AOR = 5.02, 95%
C.I (1.34–18.76), p = 0.02] were more likely to have stig-
matizing attitudes than those who had at least primary
education (Table 5).
HIV prevalence
Majority (97%, or 1765) of the adolescents tested for HIV
during the survey. Of these, 11 (0.6%) adolescents tested
HIV positive. HIV prevalence was higher among adoles-
cents who resided in rural areas than urban areas (0.9% vs.
0.0%, p= 0.04). HIV prevalence did not differ between male
(0.8%) and female (0.4%) adolescents (p=0.49)(Table6).
Table 3 Ever had sex by select characteristics among
adolescents aged 12–14 years
Unweighted Weighted % p-value
Overall 392 22.1
Sex
Male 191 20.6 0.64
Female 201 23.4
Location
Urban 123 17.4 0.12
Rural 269 24.3
Education
No education 21 41.9
At least primary education 371 21.0 0.09
Age group (years)
12 114 17.8 0.17
13 121 20.2
14 157 26.6
Table 4 Factors associated with HIV risk perception among adolescents
Crude OR (95% C.I) P-value Adjusted Crude OR (95% C.I) P-value
Location
Urban 1 1
Rural 0.94 (0.51–1.73) 0.84 0.65 (0.22–1.89) 0.43
Sex
Male 1 1
Female 0.91 (0.51–1.62) 0.75 0.46 (0.16–1.33) 0.15
Age (years) 1.04 (0.75–1.46) 0.80 1.80 (1.02–3.50) 0.04
Ever discussed HIV with parents/guardians
No 1 1
Yes 1.79 (0.99–3.24) 0.05 0.91 (0.31–2.72) 0.87
Ever had sex
No 1 1
Yes 3.95 (1.55–10.07) < 0.001 4.18 (1.63–10.69) < 0.001
Comprehensive HIV knowledge
No 1 1
Yes 1.45 (0.65–3.23) 0.37 0.92 (0.26–3.22) 0.89
Ever tested for HIV
Yes 1 1
No 1.07 (0.44–2.60) 0.89 0.81 (0.23–2.93) 0.75
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Discussions
Findings from this survey established that comprehen-
sive HIV knowledge among young adolescents is abys-
mally low. Education was shown to be a factor
associated with HIV awareness as adolescents with at
least a primary education reported high levels of HIV
awareness compared to those without any formal
schooling. Although this survey didn’t confirm the type
of information young adolescents received from the
listed sources of information, including teachers; survey
findings disclosed that young adolescents who reported
schools as their source of HIV information had a bigger
Table 5 Factors associated with HIV stigmatizing attitude among adolescents
Crude OR (95% C.I) P-value Adjusted Crude OR (95% C.I) P-value
Location
Urban 1 1
Rural 1.58 (1.23–2.03) < 0.001 1.28 (0.77–2.11) 0.34
Sex
Male 1 1
Female 0.69 (0.54–0.88) < 0.001 0.82 (0.51–1.33) 0.43
Age (years) 0.74 (0.68–0.81) < 0.001 0.93 (0.69–1.24) 0.61
Education
At least primary education 1 1
No form of education 1.46 (0.65–3.32) 0.36 5.02 (1.34–18.76) 0.02
Ever discussed HIV with parents/guardians
No 1 1
Yes 0.86 (0.65–1.15) 0.31 0.93 (0.69–1.24) 0.61
Ever had sex
No 1 1
Yes 1.47 (0.85–2.57) 0.17 1.83 (0.94–3.55) 0.08
Comprehensive HIV knowledge
Yes 1 1
No 5.09 (3.45–7.52) < 0.001 3.39 (1.57–7.31) < 0.001
Ever tested for HIV
Yes 1 1
No 2.53 (1.62–3.94) < 0.001 2.23 (1.15–4.32) 0.02
Perceived risk of HIV
Yes 1 1
No 2.20 (1.24–3.91) < 0.001 3.07 (1.14–8.23) 0.03
Table 6 HIV Prevalence among adolescents by select characteristics
Select Characteristics HIV prevalence among adolescents tested for HIV
Unweighted Weighted % p-value
Sex
Male 940 0.8 0.49
Female 825 0.4
Location
Urban 524 0.0 0.04
Rural 1241 0.9
Education
No education 51 0.0 0.72
At least primary education 1714 0.6
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likelihood of having comprehensive HIV knowledge
compared to those who reported other sources. Similar
findings were observed in young adolescents in South
Africa and El Salvador where schools were the main
source of sexual and reproductive health information, in-
cluding HIV [17,18]. Moreover, a viewpoint on Family
Life and HIV Education (FLHE) education curriculum in
Nigerian secondary schools reported higher knowledge
scores on health issues related to adolescents sexuality
and reproduction including HIV [19]. These findings
reinforce the need for school curriculum changes that
will make FLHE a compulsory subject for all students in
primary and secondary schools. It has been argued that
schools provide better avenues for structured and age
appropriate HIV information compared to other sources
[20], however, parents and caregivers are equally influen-
tial in the health and social well-being of their children.
This survey found a significant association between the
comprehensive HIV knowledge of respondents and parent-
child HIV discussions; young adolescents who reported to
have had discussions on HIV with their parents were more
likely to have comprehensive HIV knowledge compared to
their peers who did not have such discussions. These re-
sults relate to a study on the HIV comprehensive know-
ledge of young people in Western Ethiopia, which
established that respondents who discussed sexual matters
with their parents were 2.36 times more likely to have com-
prehensive HIV knowledge compared to their peers [21].
Adolescent sexual activeness was also associated with
comprehensive HIV knowledge in that those who re-
ported to be sexually active (ever had sex) were more
likely to have comprehensive HIV knowledge compared
to those who reported to have never had sex. Young ad-
olescents reporting sufficient comprehensive knowledge
have been evinced to be willing to engage in risky sexual
behaviors with familiar people [22], as this survey recog-
nized troubling low condom use at first sex. A similar
finding was also reported in Kenya [23], where 12–14
year old adolescents reported nil condom use at first
sex; very young adolescents were reported to be less
likely to use a condom compared to older adolescents.
This puts adolescents at greater risk of being infected
with HIV. Young adolescents, therefore, need to be
empowered to not only abstain from sex but build their
self-efficacy to negotiate for condom use.
A sexual debut of between 12 and 14 years and the
low comprehensive HIV knowledge in young adolescents
validates the need to increase focus on all adolescents
regardless of their age when providing comprehensive
sexuality education, including HIV knowledge from as
low as age 10. Targeting young adolescents with specific
interventions aimed at addressing their HIV comprehen-
sive knowledge gaps need to be the focus of the public
health community; as this study established a very low
proportion of young adolescents, 12% who knew that
the use of a condom can prevent HIV transmission.
Additionally, less than half (45.7%) of the adolescents
answered correctly that HIV can be transmitted by hav-
ing unprotected sex with an HIV-infected person. These
findings relate to other studies in Nigeria and other
African states [20,21,24] regarding low comprehensive
HIV knowledge among adolescents. Therefore, young
adolescents need early protection through repeated ex-
posures to information and interventions, and policy
makers and educators need to consider reaching out to
preadolescent groups with HIV prevention and risk re-
duction programs as a fixed module within the educa-
tion sector [25]. In addition, the transition phase from
young adolescence to adulthood is mainly regarded as
an experimentation phase where young people may want
independence as they seek social separation from adults,
including parents and other family members. However,
as their brain matures, young adolescents are in a better
stage to grasp key messages related to their health and
social wellbeing if relevant comprehensive information is
offered to them [26].
The continuous perception of fear by adults to discuss
sex with young adolescents predisposes them to risky
behaviors caused by ignorance fueled by taboo notions.
Moreover, young adolescents consider themselves to be
a low-risk population for HIV infections. The gaps in
knowledge and low risk perceptions put young adoles-
cents in a precarious state which exposes them to HIV
through risky sexual behaviors influenced by optimism
bias. As this survey established, the HIV prevalence
among young adolescents (0.6%) was greater than that
reported (0.2%) in the recently released national HIV
survey results, more so when young adolescents were
combined with children aged 0–9 years [5], thus missing
the exact estimates. Similarly, Oginni and co-authors in
trying to establish the trends and determinants of com-
prehensive HIV knowledge among adolescents missed
out on the prevalence of young adolescents [24]. There-
fore, this survey presents the first ever HIV prevalence
of young adolescents in Nigeria that can be incorporated
in the national HIV strategy for adolescents and young
people, which reported missing estimates of HIV preva-
lence for young adolescents 10–14 years despite them
forming the largest proportion (12.3%) of adolescents
and young people in Nigeria [27].
Young adolescents with adequate HIV knowledge will
most likely know how to protect themselves and are less
likely to stigmatize those infected or affected as the sur-
vey observed that stigmatizing tendencies were low
among young adolescents with comprehensive HIV
knowledge. Comprehensive sexuality and HIV know-
ledge is therefore an important determinant of positive
health outcomes among young adolescents; hence, the
Badru et al. BMC Public Health (2020) 20:45 Page 8 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
need for provision and implementation of age appropri-
ate Comprehensive Sexuality Education (CSE) to young
adolescents cannot be overemphasized. CSE should be
integrated within school-, family-, and community-
levels, emphasis needs to be on age-appropriateness and
should begin early in life in order to empower young
adolescents to take charge of their own health [28]. Like-
wise, relevant and age-appropriate social determinants of
health need to be integrated within the health interven-
tions targeting young adolescents as most adolescent-
related factors lie outside the health system. This is yet
to happen as young adolescents have consistently been
invisible in many social and health related studies, sur-
veys, and programs, resulting in their lack of consider-
ation during policy making [29]. Appropriate and
consistent age definitions coupled with sustainable infor-
mation systems will make young adolescents visible to
policy makers, researchers, donors, and other relevant
partners while appreciating the dynamic nature of health
across this young generation [30]. Involving young ado-
lescents from designing to the actual implementation of
HIV and other health related interventions should be
considered by programs and policy makers. Young ado-
lescents are not only passive recipients of HIV informa-
tion and interventions but can be made effective
advocates to reach out to their peers with accurate
health information that would ultimately dispel inaccur-
ate HIV-related attitudes and sexuality information pro-
vided to them.
Study limitations
Responses were self-reported; social desirability bias
from young adolescents might have led to under or over
reporting, however, the representativeness of the survey
sample and comparability with other studies strengthen
the results. Another limitation was that, sexual behav-
iors’and risk perceptions’data for young adolescents
aged 10 and 11 years was not collected. Additionally, the
survey questionnaire did not capture questions that
would identify adolescents with perinatal HIV infection,
these specific results should therefore be interpreted
with caution.
Conclusion
The gap in comprehensive HIV knowledge, early sexual
debut, and the recent increase in HIV infections among
young adolescents necessitates the need for increased at-
tention towards this age group. Preventive measures
through increased comprehensive functional HIV know-
ledge need to be emphasized by all players in the fight
against HIV infections among young adolescents. In
addition, focus should not only be towards older adoles-
cents and young people aged 15–24 but efforts should be
pooled towards designing age appropriate, preventive,
educational and cultural programs and interventions to
reach the growing number of young adolescents in Africa
with relevant sexual health information and interventions.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s12889-019-7890-y.
Additional file 1. Akwa Ibom AIDS Indicator Survey Adolescent
Individual Questionnaire (10–14 yrs).
Abbreviations
AKAIS: Akwa Ibom AIDS Indicator Survey; CSE: Comprehensive Sexuality
Education; EA: Enumeration Area; NDHS: Nigeria Demographic and Health
Survey
Acknowledgements
We would like to thank Akwa Ibom State Ministry of Health Nigeria and FHI
360 Nigeria for the provision and permission to use raw data for this study.
Authors’contributions
KT, TB, HK, OA, CA, EJ conceptualized the study. KT, TB, HK, OA, CA, SRP, PE,
EJ, A-CC, TDM, oversaw data collection. TB, OA analyzed the data, JM, KT, TB,
OA, TDM drafted the manuscript. JM, TB, HK, CA, OA, SRJ, PE, EJ, A-CC, TDM,
SHA, KT provided critical input in the development and revision of the
manuscript. All authors read and approved the final manuscript.
Funding
This study was carried out using data from a project funded by the U.S.
President’s Emergency Plan for AIDS Relief (PEPFAR) through the United
States Agency for International Development (USAID) under the Cooperative
Agreement AID-620-A-00002, managed by an FHI 360-led consortium. The
funder had no role in the study design, data collection and analysis, and in
interpretation of the data. The views expressed in this article are those of the
authors and not the funding agency.
Availability of data and materials
The datasets used and analyzed in this study are available from the
corresponding author upon request.
Ethics approval and consent to participate
The Akwa Ibom AIDS Indicator Survey protocol was approved by the FHI 360
Protection of Human Subjects Committee, North Carolina, USA, the Akwa
Ibom State Ministry of Health Ethics Committee, the University of Uyo
Teaching Hospital Review Committee, and the University of Nigeria Nsukka
Teaching Hospital Research Ethics Review Committee. Written informed
consent was sought for participation in the interview and blood draw.
Parental consent was sought from the parent or guardian of children less
than 17 years. In addition, assent was sought from children aged 10–17 years
whose parent or guardian had consented to their participation. Consenting
participants were tested for HIV according to national algorithm and
confirmed with Bio-Rad Geenius HIV 1/2 Confirmatory Assay.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
1
FHI 360 Nigeria, Abuja, Nigeria.
2
University of Ghana College of Health
Sciences, Accra, Ghana.
3
Akwa Ibom State Ministry of Health, Uyo, Nigeria.
4
United States Agency for International Development, Abuja, Nigeria.
5
FHI
360 NC, Durham, North Carolina, USA.
6
National Agency for the Control of
HIV/AIDS, Abuja, Nigeria.
Badru et al. BMC Public Health (2020) 20:45 Page 9 of 10
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Received: 24 April 2019 Accepted: 1 November 2019
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