Determinants of HIV/AIDS Knowledge, Attitudes, and Practices Among High School Students in Burayu Town, Ethiopia

Abstract

Background: HIV is one of the deadliest viruses in the world and the leading cause of mortality and morbidity in the Sub-Saharan African countries, including Ethiopia. Millions of new HIV infections are reported every year among the population in the 15–24 age group. Particularly, adolescents are vulnerable to HIV infection due to a lack of adequate information and engagement in risky sexual practices. Thus, the assessment of knowledge, attitudes, and practices (KAPs) is one of the cornerstones in the fight against HIV/AIDS for designing appropriate prevention strategies. This study aimed to assess the KAPs regarding HIV/AIDS among high school students in Burayu town, Ethiopia. Methods: A cross-sectional study design was conducted on students from three higher secondary schools in Burayu town from February to June 2022. A total of 394 students were selected using a stratified proportional sampling technique. Data were collected using pre-tested and self-administered questionnaires and analyzed by SPSS version 26. Descriptive statistics were conducted, and logistic regression was used to determine the associations between variables. A p-value ≤ 0.05 was considered significant in all cases. Results: Out of the 394 students, the majority of respondents (70%) had sufficient knowledge about HIV/AIDS transmission and prevention, while only 61% demonstrated a positive attitude towards people living with HIV/AIDS (PLWHA). In bivariate analysis, a higher level of knowledge was significantly associated with a positive attitude towards PLWHA at OR 23.4, 95% CI, 2.9–185.5, p = 0.003, and not having had sexual practice at OR 4.1, 95% CI, 1.2–13.9, p = 0.025. In multivariate analysis, sexual practice was significantly (p ≤ 0.05) associated with the level of knowledge, age, gender, and places of residence at AORs values of 5.5, 9.7, 3.4, and 5.5, respectively. Conclusions: This study suggests that students with high levels of knowledge had a positive attitude towards PLWHA and less sexual practice compared to students with low levels of knowledge. Furthermore, students’ sexual practice was significantly associated with knowledge level, age, gender, and place of residence. This underscores the urgent need for targeted education to empower vulnerable groups, foster positive attitudes and practive, and curb HIV/AIDS transmission for improved health outcomes.

1. Background

HIV/AIDS continues to be a major public health issue. Globally, 39 million people were living with HIV/AIDS (PLWHA), and 630,000 people died due to HIV/AIDS-related illnesses at the end of 2022 [1,2]. Almost 860,000 out of the global 1.5 million new HIV infections were reported from the WHO African Region [3]. The WHO African Region is the most affected region, with 25.6 million PLWHA in 2022 [2]. Furthermore, an estimated 420,000 people died in the African Region from HIV-related causes in 2021, which accounted for 64.6% of the global burden [3]. The 15–24-year-old age group was at a higher risk of acquiring HIV infection due to a lack of knowledge about HIV testing [4,5,6].

In Sub-Saharan Africa (SSA), about six out of seven new HIV infection cases occur among adolescents aged 15–19 years, and young women aged 15–24 years [7]. For example, in 2019, about 82% of new HIV infections among young women globally were from SSA [5]. Adolescence refers to a transitional phase between childhood and adulthood characterized by physiological, cognitive, and emotional changes. These changes include the development of sexual characteristics, abstract thought, fantasizing about roles in different situations, increased sexual interests, and highlighted peer influences [8]. According to the current estimate from UNAIDS, globally about 3.5 million young people between the ages of 15–24 years are living with HIV/AIDS, with a prevalence of 0.3%. However, only one-third of young people have deep insight into the disease in SSA [9].

Heterosexual contact is considered the primary mode of transmission of HIV/AIDS in the world, including in developing countries. Blood transfusion from infected blood and blood products, occupational transmission, and prenatal transmission are other routes of transmission of HIV/AIDS [10,11,12]. The spread of HIV/AIDS among the community is determined by the knowledge and attitude toward the sexuality of its members and by their actual sexual behavior [13]. So, community-based HIV/AIDS prevention programs should emphasize changes in knowledge, attitudes, and practices. Such efforts would contribute to the commitment to end the AIDS epidemic as a public health threat by 2030 as part of the Sustainable Development Goals (SDGs). The WHO has designed a global health sector strategy for HIV/AIDS with a particular emphasis on the innovative combination of prevention packages for adolescent girls and young women, particularly in SSA [14].

According to the 2016 Ethiopian Demographic and Health Survey (EDHS) report, only 20% of women and 38% of men aged 15–49 have comprehensive knowledge of HIV/AIDS. Only 30% of women and 49% of men knew that a healthy-looking person could have HIV/AIDS. In addition, 48% of women and 35% of men have a positive attitude towards PLWHA to attend schooling without discrimination. Furthermore, 20% of women and 51% of men had used condoms during their last sexual intercourse [15]. A study conducted in 2013 among 240 high school students in the Northern part of Ethiopia, Mekelle City, revealed that 86% had good knowledge and 66% had regularly used condoms during sexual intercourse; however, a very low level of attitude towards the disease was reported [16]. Another study in Ethiopia indicated that 68% and 55% had comprehensive knowledge of HIV/AIDS transmission and prevention, respectively [17].

Generally, boosting knowledge on HIV/AIDS can be a powerful means of promoting positive attitudes and building safe practices among the population [18]. Therefore, the assessment of adolescents’ KAPs towards HIV/AIDS transmission and prevention is helpful to understand the gaps and devise appropriate HIV/AIDS control programs to reduce the incidence and burden of HIV/AIDS in the general population. Higher secondary school students are a vulnerable age group of society, and studying this active segment of the population is important to achieve the national HIV/AIDS prevention strategy [19,20]. Thus, this study aimed to assess the knowledge, attitude, and practices of higher secondary school students on HIV/AIDS in Burayu town, Oromia region, Ethiopia.

2. Methods

2.1. Study Area and Design

A cross-sectional study was conducted from February to June 2022 on Burayu Higher Secondary School students in Burayu town. Burayu has an estimated population size of 400,000 inhabitants with three government-run higher secondary schools. The town is located 15 Km away from the capital city, Addis Ababa [21]. Administratively, Burayu town is under Sheger City Administration, Oromia regional state, Ethiopia, located from 9°02′ to 9°02′30″ N latitudes and 38°03′30″ to 38°41′30″ E longitudes (Figure 1). It is bounded by Addis Ababa City to the east, Sululta District to the north, Walmera District to the west, and Sabata Hawas District to the south and northwest. Burayu town administration consists of six administrative units (Kebeles). This location was selected due to rapid population growth and high levels of informal settlements, driven by migration from rural areas and former residents of Addis Ababa seeking cheaper housing. Due to the huge influx of migrants and rapid population growth rate, which suggests a mix of economic backgrounds, and with many adolescents seeking employment opportunities, these factors might be indirectly influencing the youth to participate in unprotected sexual practices.

Figure 1. Description of the study area.

2.2. Study Population and Sampling

The study population included all active students from grades 9 to 12 in the three government schools in Burayu town, namely, Burka Nono, Dire, and Burayu Higher Secondary Schools, during the academic year of 2021–2022. The sample size was determined by a single population proportion formula, with an estimated HIV/AIDS prevalence rate of 50% (p = 0.5) by considering that 50% of the study participants are knowledgeable, at a 95% confidence interval (Zα/2 = 1.96) and 5% marginal error (d = 0.05) [22]. A total of 394 study participants were selected from 5190 students enrolled in the three schools employing a stratified proportional sampling technique.

The number of samples from each high school was determined by applying a sampling ratio n/N (394/5190) = 0.0759 multiplied by the number of students in each high school. The sample was stratified first by grade, then by section [23]. Finally, the student population from each grade was selected proportional to the size using a simple random sampling technique to obtain the total sample size from the list of student names found in the class attendance. The total students for each high school was 1542 for Burka Nono, 2218 for Burayu, and 1430 for Dire Higher Secondary School. From the total sample size (394), 117 (30%) were from Burka Nono, 168 (42.6%) from Burayu, and 109 (27.66%) from Dire Higher Secondary School. The schematic presentation of the stepwise study participants’ selection procedure is illustrated in Figure 2.

Figure 2. Schematic stepwise sampling procedure of study participants. Students from all three government Higher Secondary Schools were enrolled proportionally across grades to ensure the desired sample size was achieved.

2.3. Inclusion and Exclusion Criteria

The study included students aged 14–25 who were enrolled in grades 9 through 12 at the three government-run Higher Secondary Schools and consented to participate. Students were excluded if they refused to give consent, interrupted or discontinued their education, were penalized by the school administration, or fell outside the 14–25 age range.

2.4. Data Collection

Data were collected using pre-tested and self-administered questionnaires prepared in three languages: Amharic, Afan Oromo, and English. The questionnaire was adapted from previous studies associated with KAPs on HIV/AIDS, with some modifications [16,24]. The questionnaire was first developed in English, then translated into both Amharic and Afan Oromo (local spoken languages) and checked for correctness of the translation by fluent speakers of both languages. To ensure the quality of data collection, the questionnaire was pre-tested on a similar group of 20 (5%) students at Holeta Higher Secondary School, and the content, completeness, and suitability of the target study were validated. Furthermore, we followed a manual double-entry when transferring the paper data to an electronic format and performed post-data entry verification.

2.5. Study Variables and Measurement

The main outcome variables (dependent variables) in this study were knowledge of HIV/AIDS (transmission, prevention, and control), attitude towards PLWHA, and sexual practices. There were 19 knowledge-related questions, and “1” was coded for the right answer, while “0” was coded for the wrong answer. From the overall 19 knowledge-related questions, the total knowledge score was calculated and then categorized into three groups: low knowledge (score ≤ 50%), medium knowledge (scores between 51 and 74%), and high knowledge (score ≥ 75%), which were used in the descriptive statistics. Attitude-related questions were five in number; “1” was coded for a positive attitude and “0” for a negative attitude, and the total score was categorized into two groups: respondents with at least one negative response were considered to have a negative attitude towards PLWHA, and respondents with all positive responses were considered to have a positive attitude towards PLWHA. Sexual experiences were categorized into two groups: respondents engaging in sexual practices and those with no sexual practice. The independent variables were the socio-demographic characteristics (age, gender, place of residence, level of education, marital status, and others).

2.6. Data Analysis

Completeness and consistency of the data were checked and double-entered into SPSS version 26 software and analyzed. The data were processed and analyzed by descriptive statistics, percentage, and frequency. The association between variables was measured and tested using the chi-square test and odds ratio. Binary and multivariate logistic regression analyses were performed to determine the independent variables that had an association with the dependent variable, students’ sexual practices. A p-value ≤ 0.05 was considered significant in all cases.

2.7. Ethics Approval and Consent to Participate

The ethical clearance letter was obtained from the Institutional Review Board (IRB) of the College of Natural and Computational Sciences, Addis Ababa University (Ref. No. CNCSDO/295/13/2021). The study was conducted in accordance with the Declaration of Helsinki. Oral and written informed consent were obtained from all study participants after explaining the nature and purpose of the study. For participants between 15 and 18 years of age, approval to participate in the survey was obtained from the school administration (many of whom were parents/guardians of students in those schools), following a review of the questionnaire to be administered to the students, while students gave assent to participate. Furthermore, information provided by the participants was kept anonymous and confidential.

3. Results

3.1. Socio-Demographic Characteristics

A total of 394 students (197 males and 197 females) participated in the study. The average age of participants was 19.5 years. Participants were recruited from grades 9 to 12 in relatively equal proportions. In total, 369 (94%) of respondents were urban dwellers, 382 (97%) of the participants were living with their parents, and 383 (97%) of participants were single or not married. Regarding parents’ education status, 377 (96%) of the participants’ fathers and 114 (29%) of participants’ mothers were illiterate. In total, 140 (36%) of the students’ fathers were working in private businesses, and 21 (5%) were daily laborers. Similarly, 121 (31%) of the mothers were working in private business, 107 (27%) were housewives, and 11 (3%) were daily laborers. The detailed sociodemographic data is presented in Table 1.

Table 1. Socio-demographic characteristics of study population.

Variable	Category	Frequency	Percent
Gender	Male	197	50
	Female	197	50
Age	Less than 18 years	151	38
	18 years and above	243	62
Grade level	Grade 9	98	25
	Grade 10	107	27
	Grade 11	95	24
	Grade 12	94	24
Residence	Urban	369	94
	Rural	25	6
Living condition	With both parents	382	97
	Other	12	3
Marital status	Single	383	97
	Married	11	3
Religion	Orthodox	154	39
	Muslim	32	8
	Protestant	188	48
	Other	20	5
Mother’s education	Illiterate	114	29
	Primary	152	39
	Secondary and above	128	33
Father’s education	Illiterate	377	96
	Primary and above	17	4
Father’s occupation	Merchant	69	18
	Government	89	23
	Private	140	36
	Farmer	75	19
	Daily labor	21	5
Mother’s occupation	Merchant	67	17
	Government	48	12
	Private	121	31
	Farmer	40	10
	Daily labor	11	3
	Housewife	107	27

3.2. Information on HIV/AIDS

Students had various sources of information about HIV/AIDS. The primary source of information for the students was family (47%), followed by television (16%) and radio (14%). Internet and newspapers were the least common sources, at 1% and 4%, respectively (Figure 3).

Figure 3. Main sources of information for HIV/AIDS.

3.3. Knowledge of HIV/AIDS Transmission, Prevention, and Control

About 97% of the study participants knew that HIV/AIDS is transmitted through sexual intercourse, 85% through blood transfusion, 74% from mother to child during birth, and 93% through the use of contaminated sharp materials. Only half of the participants knew all modes of HIV/AIDS transmission, while 14%, 10%, and 9% of the respondents wrongly perceived the mode of transmission of HIV/AIDS, such as a shared toilet, eating, and coughing, respectively. Some of the participants did not know the mode of HIV/AIDS transmission at all.

The majority of participants had a high knowledge of the different HIV/AIDS prevention methods; 96%, 85%, and 67% of the respondents knew that avoiding sharp materials, the use of condoms, and abstinence prevented HIV/AIDS, respectively. Furthermore, 67% of the respondents considered avoiding tattoos as an HIV/AIDS preventive measure. However, only 36% of the respondents correctly knew all the possible HIV/AIDS prevention methods.

A significant proportion of the participants had good knowledge about the different control methods for HIV/AIDS; 72% knew testing, 73% knew faithfulness, and 87% knew abstinence could control the spread of HIV/AIDS. However, only 20% of the respondents knew all the HIV/AIDS control methods, and 59% of the respondents either were wrongly informed or did not know HIV/AIDS control methods. The knowledge status of study participants about HIV/AIDS transmission is depicted in Table 2.

Table 2. Participants’ knowledge about HIV/AIDS transmission, prevention, and control.

Knowledge Component	Variable	Category	Frequency	Percent
Knowledge of HIV/AIDS transmission	Sexual intercourse	Yes	383	97
		No	11	3
	Blood transfusion	Yes	334	85
		No	60	15
	During birth	Yes	293	74
		No	101	26
	Sharp materials	Yes	368	93
		No	26	7
	Toilet	Yes	53	14
		No	341	87
	Eating	Yes	36	10
		No	358	91
	Coughing	Yes	35	9
		No	359	91
Knowledge of HIV/AIDS prevention	By avoiding tattoos	Yes	264	67
		No	130	33
	Condom use	Yes	335	85
		No	59	15
	Avoiding alcohol and drug use	Yes	197	50
		No	197	50
	Abstinence	Yes	334	85
		No	60	15
	Not sharing sharp materials	Yes	377	96
		No	17	5
Knowledge of HIV/AIDS control	Testing	Yes	285	72
		No	109	28
	Faithfulness	Yes	286	73
		No	105	28
	Abstinence	Yes	341	87
		No	53	14
	Hand shaking	Yes	34	9
		No	360	91
	Hugging and kissing	Yes	59	15
		No	335	85
	Sharing clothes	Yes	50	13
		No	344	87
	Mosquito bite	Yes	197	50
		No	197	50

3.4. Attitude Towards People Living with HIV/AIDS

About 91% of the respondents were willing to give care to PLWHA, 85% allowed HIV-positive teachers to teach them, 82% were willing to maintain their friendship with HIV-positive students, 85% thought that HIV-positive students could continue to study in the school, and 80% were willing to buy from HIV-positive shopkeepers. A significant number of respondents had a positive attitude towards PLWHA, as indicated in Figure 4.

Figure 4. Participants’ attitude towards people living with HIV/AIDS.

3.5. Sexual Practice Towards HIV/AIDS Prevention

In total, 320 (81%) of the respondents never had a sexual experience. Of the 19% of students who had a sexual experience, 35% of them did not use condoms during sex, and only 45% used condoms in the last encounter. Furthermore, 42% of the respondents who have had a sexual experience were not willing to stop sex when a condom broke during sex, and 18% had sex under the influence of alcohol and drug use. The detailed data on the sexual practices of students is presented in Figure 5.

Figure 5. The overall KAPs of study participants.

Sexual practices of the students showed a statistically significant relationship with students’ knowledge, age, gender, grade level, and their parents’ living status at p ≤ 0.05 (Table 3). The percentage of students who had never started sex was higher among students who had a high knowledge level (83%), were female (89%), were of a younger age (96%), were of a lower grade level (93%), and were living together with both parents (82%).

Table 3. Participants’ sexual practices and sociodemographic characteristics (n = 394).

Variable	Category	Sexual Practice		p-Value
		Have No Sex (n, %)	Have Sex (n, %)
Overall knowledge	Low knowledge	6 (55)	5 (45)	0.050 *
	Medium knowledge	84 (79)	22 (21)
	High knowledge	230 (83)	47 (17)
Overall attitude	Negative attitude	200 (83)	42 (17)	0.360
	Positive attitude	120 (79)	32 (21)
Age	Less than 18 years	145 (96)	6 (4)	<0.001 *
	18 years and above	175 (72)	68 (28)
Gender	Male	144 (73)	53 (27)	<0.001 *
	Female	176 (89)	21 (11)
Religion	Orthodox Christian	122 (79)	32 (21)	0.529
	Muslim	24 (75)	8 (25)
	Protestant	158 (84)	30 (16)
	Other	16 (80)	4 (20)
Residence	Urban	297 (80)	72 (20)	0.154
	Rural	23 (92)	2 (8)
Living status	Both parents	314 (82)	68 (18)	0.013 *
	Other	6 (50)	6 (50)
Grade	Grade 9	91 (93)	7 (7)	<0.001 *
	Grade 10	91 (85)	16 (15)
	Grade 11	70 (74)	25 (26)
	Grade 12	68 (72)	26 (28)
Father’s education	Illiterate	308 (82)	69 (18)	0.335
	Primary and above	12 (71)	5 (29)
Mother’s education	Illiterate	94 (82)	20 (18)	0.850
	Primary	124 (82)	28 (18)
	Secondary and above	102 (80)	26 (20)
Father’s occupation	Merchant	50 (72)	19 (28)	0.200
	Government	75 (84)	14 (16)
	Private	114 (81)	26 (19)
	Farmer and daily laborer	81 (84)	15 (16)
Mother’s occupation	Merchant	49 (73)	18 (27)	0.454
	Government	39 (81)	9 (19)
	Private	100 (83)	21 (17)
	Farmer and daily laborer	42 (82)	9 (18)
	Housewife	90 (84)	17 (16)
Source of information	Family	153 (82)	33 (18)	0.319
	Friend	27 (68)	13 (33)
	Internet and newspaper	15 (79)	4 (21)
	Radio	44 (83)	9 (17)
	Television	54 (84)	10 (16)
	Education at school	27 (84)	5 (16)

* Statistically significant at p ≤ 0.05.

3.6. Overall KAPs on HIV/AIDS

The average knowledge score recorded was 15.5 ± 2.5 out of 19, where 5 and 19 were recorded as the minimum and maximum correct responses. In total, 277 (70%) of the study participants had a high level of overall knowledge with a score above 75% and only 3% of them had a low level of overall knowledge, with a score below 50%. The average attitude towards PLWHA was 4.2 ± 0.8, with a minimum positive score of 0 and a maximum score of 5. Furthermore, 61% of the participants had a positive attitude towards PLWHA. The study participants’ overall KAPs are presented in Figure 4.

3.7. Logistic Regression Analysis

The bivariate regression analysis revealed that the level of knowledge was significantly associated with the students’ attitudes towards PLWHA and sexual practice. Students with a high level of knowledge were likely to have positive attitudes (COR = 23.4, 95% CI = 2.9–185.5, p ≤ 0.05) towards PLWHA (Table 4). Similarly, students with a high level of knowledge had fewer sexual practices (OR = 4.1, 95% CI = 1.2–13.9, p ≤ 0.05) compared to students with low levels of knowledge.

Table 4. Logistic regression analysis (bivariate) shows the association of overall knowledge level and students’ attitude and sexual practices.

Overall knowledge	Attitudes
	Positive (%)	Negative (%)	COR	95% CI	p-value
Low	0.4	6.6	1
Medium	19.4	38.8	7.9	0.9–64.5	0.052
High	80.2	54.6	23.4	2.9–185.5	0.003 *
Overall knowledge	Sexual practice
	Have no sex (%)	Have sex (%)	COR	95% CI	p-value
Low	1.9	6.8	1
Medium	26.3	29.7	3.2	0.8–11.4	0.075
High	71.9	63.5	4.1	1.2–13.9	0.025 *

* p ≤ 0.05; COR—crude odds ratio; CI—confidence interval; variables entered, knowledge, attitude, and practice; at p ≤ 0.05; p-value calculated based on logistic regression.

Based on the multivariate logistic regression analysis, knowledge of HIV/AIDS, age, gender, and place of residence were significantly associated with students’ sexual practices. Students with higher knowledge were more likely to refrain from sexual practice compared to students with low levels of knowledge on HIV/AIDS (AOR = 5.5, 95% CI = 1.04–29.09, p ≤ 0.05). Furthermore, students younger than 18 years of age, female students, and students who came from rural areas were less likely to have engaged in sexual practice as compared to their counterparts, as presented in Table 5.

Table 5. Logistic regression analysis (multivariate) shows the association of students’ knowledge, age, gender, and place of residence with their sexual practices.

Variable	Category	AOR	95% CI	p-Value
Overall knowledge	High	5.5	1.04–29.09	0.045 *
	Medium	3.8	0.70–20.08	0.121
	Low	1
Overall attitude	Positive	0.9	0.44–1.67	0.653
	Negative	1
Age	<18 years	9.7	3.19–29.26	<0.001 *
	18 years and above	1
Gender	Female	3.4	1.64–6.83	0.001 *
	Male	1
Religion	Orthodox Christian	1	0.25–4.05	0.992
	Muslim	0.6	0.11–3.25	0.553
	Protestant	1.7	0.42–6.52	0.469
	Other	1
Residence	Rural	5.5	1.05–28.70	0.043 *
	Urban	1
Living condition	Live with both parents	4.9	0.89–26.64	0.068
	Other	1
Grade	Grade 9	0.9	0.26–3.08	0.860
	Grade 10	0.9	0.38–2.23	0.857
	Grade 11	0.6	0.29–1.40	0.267
	Grade 12	1
Father’s education	Illiterate	2.4	0.41–13.89	0.329
	Primary and above	1
Mother’s education	Illiterate	1.3	0.56–2.96	0.555
	Primary	1.5	0.73–3.24	0.257
	Secondary and above	1
Mother’s occupation	Merchant	0.7	0.29–1.78	0.472
	Government	1.2	0.40–3.50	0.765
	Private	1.6	0.71–3.67	0.259
	Farmer and daily laborer	1.5	0.53–4.09	0.453
	Housewife	1	0.29–1.78
Source of information	Family	0.8	0.26–2.69	0.761
	Friend	0.5	0.13–2.08	0.364
	Internet and newspaper	0.6	0.12–3.29	0.588
	Radio	1.0	0.27–4.12	0.946
	Television	1.0	0.26–3.73	0.978
	Education at school	1

* p ≤ 0.05; AOR—adjusted odds ratio; CI—confidence interval; variables entered, knowledge, attitude, and practice; at p ≤ 0.05; p value calculated based on logistic regression.

4. Discussion

Knowledge, attitudes, and practices (KAPs) studies are essential tools prior to the implementation of any intervention to identify knowledge gaps, cultural beliefs, or risky behaviors [17]. Improving knowledge about HIV/AIDS among young people is a key action to reduce the risk of infection through increased condom use and to improve attitudes towards HIV-positive subjects [17].

This study aimed to assess the KAPs regarding HIV/AIDS prevention among higher secondary school students in Burayu town. In this study, 70% of the participants had high levels of knowledge of HIV/AIDS transmission, prevention, and control, with an overall knowledge score of 15.5. This study found that 50% of the participants had the correct knowledge on all the transmission methods of HIV/AIDS. A similar result was reported from a study conducted among high school students in Iraq, where 45% of the students had good overall knowledge of HIV/AIDS [25]. Other studies conducted in Ghana and South Africa revealed that 62% and 44.7% of the students had good knowledge about HIV/AIDS, respectively [26,27]. Our results were lower than those from the study conducted among high school students in Addis Ababa, where, on average, 76% of the respondents had good knowledge about HIV/AIDS [28]. However, the current study results were higher than those from a study conducted among students found in 14 high schools in Eastern Ethiopia, where about 25% of the students had comprehensive HIV/AIDS knowledge [17].

In the current study, 36% of the students demonstrated comprehensive knowledge of HIV prevention methods. This finding indicates a lower level of knowledge compared to previous studies conducted in the Mekelle, 75% [16]; Addis Ababa, 80% [29]; Bahir Dar, 57% [30]; and Bale, 47% [10] regions of Ethiopia. However, this study reported a higher level of knowledge than the EDHS 2016 report, which found that 24% of women and 39% of men aged 15–24 possessed comprehensive knowledge about HIV prevention [29].

Furthermore, 85% of the students knew that condom use and abstinence can prevent HIV transmission. A similar result was reported from Addis Ababa, where 87% of the students knew condom use can control HIV transmission [28]. The result of the current study is higher than that of a study conducted in Wombera, Ethiopia, where only 63% of the students knew that condom use controls HIV transmission [31]. The prevalence of knowledge on the prevention of HIV transmission through abstinence was higher in the current study compared to the study conducted in Addis Ababa, 46% [28], and in Bale, 67% [10], but lower than a study conducted in Bahir Dar, where 93% of the respondents knew that abstinence is used to prevent HIV [30]. The lower prevalence of the overall knowledge of HIV prevention methods (36%) is a dangerous sign, because the students may not follow the correct HIV prevention methods in their day-to-day lives.

The proportion of respondents who knew all the HIV/AIDS control methods was 20% in the current study. By comparison, 73% of the respondents knew that faithfulness could help to control HIV transmission. In addition, 91%, 85%, 87%, and 50% of the respondents believed that HIV cannot be transmitted by handshaking, hugging, sharing clothes, and mosquito bites, respectively. However, the reported knowledge of faithfulness as a prevention method was relatively lower than in a study conducted in Bale, Ethiopia, where 84% of students knew faithfulness could prevent HIV transmission [10]. Several studies reported misconceptions on the control of HIV transmission; in a study conducted in Addis Ababa, 30% responded that avoiding sharing clothes helps to control HIV transmission [28].

Generally, the higher prevalence of poor knowledge on HIV control methods is a serious sign, as this could mean a significant percentage of the students may not apply the right HIV/AIDS control method. The lower prevalence of comprehensive knowledge on HIV/AIDS might be due to the lack of attention given to HIV/AIDS, with more emphasis being given to other diseases, including COVID-19. Since family is the major source of information (Figure 1) for the students about HIV/AIDS, low-educated parents may be the source of misconceptions for students. Contrary to our study, Tanzania high school students developed awareness primarily from school-based education [32]. Therefore, the provision of proper information regarding HIV/AIDS transmission and control via education to the general community might be of importance.

Furthermore, this study revealed that students with higher levels of knowledge are more likely to have a positive attitude towards PLWHA. In total, 61% of the respondents had a positive attitude towards PLWHA; 91% would care for an HIV-positive person, 85% would allow an HIV-positive teacher to teach them, 82% were willing to make friendship with HIV-positive students, 82% believed that HIV-positive students could continue their education with HIV-negative students, and 80% of them were willing to buy items from HIV-positive shopkeepers.

These results were higher than those in the EDHS report, which found that 48% of women and 35% of men thought that children living with HIV/AIDS should not attend school, and 55% of women and 47% of men would not buy from HIV-positive shopkeepers [15]. The study in Addis Ababa reported that the average positive attitude of respondents towards the prevention and control of HIV/AIDS was 79% [28]. A study from Ghana reported that 79% of the respondents were willing to care for PLWHA, 75% willing to make friends with HIV-positive individuals, and 78% of students and 76% of teachers believed that HIV-positive students should continue their education. On the contrary, 68% of the respondents did not want to buy from an HIV-positive shopkeeper [26].

Another study conducted among Bahir Dar University students in Ethiopia reported that students with good knowledge and positive attitudes demonstrated safer sexual practices compared to students with low levels of knowledge [30]. Based on this finding, 92% of the students had a positive attitude toward HIV-positive friends [30]. Generally, this study found that students had better attitudes towards PLWHA (61%). This might be due to the visible presence of PLWHA accessing anti-HIV/AIDS resources within the community.

In this study, the prevalence of sexual activity was 19%. Among these participants 66% reported frequent condom use; however, 45% did not use a condom during their last encounter, a finding consistent with a study conducted in Gondar city [33]. Furthermore, 42% of males noted that they would cease intercourse if a condom broke. In comparison, a higher prevalence of sexual activity (26%) was reported among high school students in Mekelle, though a larger proportion of those participants (75%) demonstrated better condom utilization practices [16].

A study in Addis Ababa showed a lower prevalence of condom use, with 16% of the students reporting regular use [28]. Another study from Ghana reported that, while 26% of the students had a sexual experience, 52% did not use condoms during sexual intercourse [26]. According to an EDHS report, the prevalence of condom use among men aged 15–49 was 51% [15]. The Federal HIV/AIDS Prevention and Control Office (HAPCO) also emphasizes the comprehensive use of condoms among adolescent groups as one of its six strategic pillars [34]. Other studies in Laos (Asia) and Jiangsu Province in China showed that male high school and college students with medium-to-high knowledge of HIV/AIDS were significantly more likely to engage in safe sexual practices [18,35].

Similar findings were reported among high school students in South Africa and Somalia; students with a high level of knowledge had a more positive attitude toward PLWHA and safer HIV/AIDS preventive practices compared to students with low knowledge levels (CORs of 12.6 and 2.7, respectively) [24,36]. In the current study, students with high levels of knowledge were 23.4 times more likely to demonstrate positive attitudes towards PLWHA. Additionally, students with high knowledge levels were 4.1 times less likely to be sexually active compared to those with low knowledge levels.

Generally, this study identified a significant number of students who were at high risk of HIV/AIDS infection due to unsafe sexual practices, as they lacked knowledge of HIV/AIDS control, transmission, and prevention methods. Although the curriculum had certainly incorporated sexual and reproductive health, several barriers remained, including cultural taboos, low literacy and education, lack of school involvement, and parental communication gaps [37]. Therefore, first, we strongly suggest that the government/policy makers ensure the proper integration of HIV/AIDS education into school curricula, and strong follow-up should be in place to confirm sexual and reproductive health communication. Second, we urge non-governmental organizations (NGOs) and other stakeholders to develop community outreach programs tailored to adolescents and to foster effective collaboration for the development of comprehensive, culturally appropriate, and sustainable prevention and care programs in the study area.

5. Conclusions

This study highlights that students’ attitudes and sexual practices appear to be associated with their level of knowledge, age, gender, and place of residence. Furthermore, the study population exhibited misconceptions regarding HIV/AIDS transmission, prevention, and control, as well as discriminatory attitudes toward people living with HIV (PLWHA), and risky sexual behaviors. This finding underscores an urgent need to develop and implement extensive HIV/AIDS health education programs targeting vulnerable populations.