This study assessed knowledge of HIV transmission and associated factors among Sierra Leonean women aged 15–49. Our analysis found that 39.73% of the women had comprehensive knowledge of HIV transmission. This study's prevalence was almost like that seen in a study conducted on Sub-Saharan African women of reproductive age (38.56%) (12). The prevalence of comprehensive knowledge of HIV in other studies done in Uganda (23.1%) (27), Ethiopia (25.2%) (29), South Sudan (21.21%) (21), and Bolivia (31%) (22) was lower than for our study. Contrary to our findings, a study conducted in Bangladesh (52.2%) (23) and Pakistan (68%) (24) found a higher prevalence of knowledge of HIV/AIDS transmission among women. The discrepancy in the prevalence reported in this study and prior studies did elsewhere could be attributable to differences in respondents' socioeconomic and sociocultural factors between nations (12). While our study focused explicitly on assessing knowledge of HIV transmission and associated determinants, the studies mentioned above looked at HIV knowledge and a few dimensions of HIV transmission.
The fact that 22.88–31.63% of Sierra Leonean women of childbearing age are unaware that a healthy person can have HIV and transmit it (31.63%), that HIV can be transmitted during pregnancy (30.88%), delivery (27.69%) and during breastfeeding (22.88%), is a major setback in the fight against the disease. Yet evidence indicates the pandemic appears to be escalating and has the potential to become a significant public health problem in Sierra Leone (7). Given that only half of the HIV-positive people are aware of their illness (5) and 38% of women have HIV risk factors (8), this is unsurprising. HIV patients who are uninformed of their HIV status, those who are not on ART, and those who are on ART but are not virologically suppressed all have a high risk of spreading the virus to others. For example, not knowing that a healthy-looking person can be infected with HIV may lead to unprotected sexual encounters with an infected person. From that perspective, educating women about HIV is paramount. Evidence suggests that having comprehensive knowledge of HIV is critical to controlling the epidemic (30). WHO states that having a good understanding of HIV/AIDS is a necessary (but often insufficient) condition for adopting behaviors that lower the risk of HIV transmission (31). This research has important public health implications in terms of developing effective public health interventions to lower HIV/AIDS incidence in Sierra Leone.
Increasing age was significantly associated with higher odds of having comprehensive knowledge of HIV transmission in our study. This means that women above the age of 20 knew more about HIV transmission than women under the age of 20. This could be attributed to the scarcity of comprehensive sexuality education programs for adolescents (32). It could also be explained by social aversion to discussing sex and sexual issues with their peers and family members, which would further limit their ability to obtain HIV-related information (25). As a result, greater HIV/AIDS information and education for young women, particularly those aged 15 to 19 in Sierra Leone, is required. Making sure that young people know how to prevent HIV infections and where they can safely access HIV prevention, sexual and reproductive health services is a critical component of HIV responses (33), especially before sexual debut. In support of our findings, evidence shows that one in every four (23%) young women in Western Africa has comprehensive knowledge about HIV prevention (32). Similar to our result, a study which was conducted among women of reproductive age in sub-Saharan Africa revealed that older age was associated with comprehensive HIV knowledge (12). When compared to older pregnant women, Amoran, Olorunfemi E et al. discovered that teenage pregnant women who were more vulnerable to HIV/AIDS infection were less likely to have HIV knowledge and to use prevention of mother to child transmission (PMTCT) services (34). A study done in Sub-Saharan Africa found, that teenage girls aged 15–19 years account for 80% of all HIV infections among adolescents (35). Furthermore, a Nigerian study discovered that the prevalence of HIV among female teenagers was 7.4%, compared to 1.8% among older women (34). Contrary to our findings, a study done in South Sudan showed that being a young woman was protective against low knowledge of HIV (21).
Secondary education was found to be associated with a higher likelihood of having comprehensive knowledge of HIV transmission when compared to the uneducated. Similar to our study, HIV-related knowledge was found to be relatively poor among women with low literacy levels in a study conducted in Nigeria (36). This is because women with a higher level of education have a better understanding of HIV information, better access to health care, access to information (25), and engagement in HIV/AIDS public education programs. To benefit uneducated women, HIV transmission and prevention information should be distributed verbally or in pictorial forms rather than in text. Other studies found that having primary (22)(37), secondary (31) (26, 37) or higher education (9, 22, 32)(37) was associated with a higher likelihood of having good HIV knowledge (9, 22, 31, 32)(38). In our study, primary and higher education had no statistically significant relationship with the knowledge of HIV transmission.
Being in the richer wealth quintiles was significantly linked to higher odds of having comprehensive knowledge of HIV transmission compared to the poorest in our study. A study done in Nigeria found individuals in the upper wealth quintile were less than half as likely as those in the lower wealth quintile to have low HIV-related knowledge in the general population (36). Other studies done in Malawi (37), Ghana (26), and Sub-Saharan Africa (38) found that the rich have more comprehensive HIV knowledge than the poor. Women in low wealth quantiles confront several obstacles, including limited access to HIV-related information due to economic constraints (36). Furthermore, wealth influences the distribution of socioeconomic variables like education, economic opportunities, and mass media exposure in both direct and indirect ways (37). While women in higher socioeconomic quintiles can afford to access HIV information through media and health facilities, women in lower socioeconomic quintiles may lack transport funds to health centers and to gain access to HIV-related media. Our findings suggest that future HIV awareness and education campaigns should target disadvantaged women, particularly those who are worse off due to wealth disparities and empower them economically.
Women who read newspapers or magazines and those who used the internet had higher odds of comprehensive knowledge of HIV transmission compared to those who did not. This is not surprising given that mass media has been consistently linked to comprehensive HIV/AIDS knowledge among respondents (38–40), including how the HIV spreads, and preventive behaviors (41). Evidence shows women who read newspapers or magazines, listened to the radio, and watched television had higher odds of having comprehensive knowledge of HIV/AIDS, according to a study done in Ethiopia (29). Additionally, a study conducted in Uganda revealed that exposure to mass media such as print media, radio, and television enhanced the probability of adolescents´ having HIV-related knowledge (42). Though only reading newspapers/magazines and using the internet were found to be associated with a higher likelihood of having comprehensive knowledge of HIV transmission in our study, watching television and listening to the radio had no statistical association in multivariable analysis. In contrast to our findings, an Ethiopian study indicated that HIV/AIDS-related mass media exposure had no significant impact on HIV/AIDS-related knowledge in the total population (43).
Living in Southern Sierra Leone was also associated with higher odds of having comprehensive HIV knowledge. Though the reason behind this finding is not clear to us. We recommend a study to be conducted in this region to find out why living in the Southern region is associated with a higher likelihood of having comprehensive HIV transmission knowledge compared to staying in the eastern region. The HIV transmission knowledge promoting factors that will be found in women staying in southern Sierra Leone can be copied and replicated in the eastern region.
When compared to nulliparous mothers, women with 2 or more children had a lower likelihood of having comprehensive knowledge of HIV transmission in our study. This is a surprising finding because women with two or more children are assumed to have received antenatal (ANC) and postnatal care (PNC) for each child. Evidence shows that HIV/AIDS health education sessions in health institutions during pregnancy or postnatal care are associated with good awareness of HIV/AIDS transmission (44). Our findings may be attributed to Sierra Leone's poor antenatal and delivery services (45). The findings highlight the importance of the health sector monitoring the quality of antenatal and postnatal services including HIV health education as well as HIV prevention services provided to women in Sierra Leone. Improved integration of HIV services with sexual and reproductive health services, as well as antenatal care, is required (32) to educate women on HIV transmission and prevention. Belonging to the Islam religion was also associated with lower odds of having comprehensive knowledge of HIV transmission compared to non-Islam. This may be due to lack of openness about HIV/AIDS because it is associated with negative activities such as sexual activity, which is prohibited in Islam (46). It is important to consider HIV awareness programs aimed at women of Islam denomination while involving Muslim leaders, as well as adapting HIV prevention programs to Islamic religious values in order to improve program acceptability.