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The Open AIDS Journal

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RESEARCH ARTICLE

Public Awareness and Stigmatizing Attitudes toward People Living with Human
Immunodeficiency Virus Acquired Immune Deficiency Syndrome in Saudi
Arabia
Marwan J. Alwazzeh1,* , Abdullah H. Kabbani1, Muhannad A. Alghamdi1, Khalid I. Alharbi1, Abdullah A. Qoqandi1,
Abdulrazaq I. Alsomali1 and Jose Ramon Fiore1,2
1
Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
2
Department of Clinical and Experimental Medicine, Clinic of Infectious Diseases, University of Foggia, Foggia, Italy

Abstract:
Background:
Recently, there have been efforts to increase HIV/AIDS education and awareness programs to reduce the stigmatization and discrimination of
people living with human immunodeficiency virus/acquired immune deficiency syndrome (PLWHA). However, it is essential to understand that
these efforts must be ongoing and sustained to be effective.

Objective:
This study aimed to assess the Saudi population’s awareness and stigmatizing attitudes toward PLWHA.

Methods:
This is a cross-sectional study on individuals (patients or families of patients) who attended “King Fahad Hospital of The University (KFHU)”. The
study was conducted between September 1st and December 31st, 2018. Each participant provided informed consent, and data were collected through
an informative, validated, anonymous, self-administrated questionnaire. The questionnaire was designed by experts and included all the data
regarding demographic information, assessment of knowledge of HIV transmission, general awareness of HIV, assessment of attitudes toward
PLWHA, etc. The collected data were analyzed using the SPSS version 22.

Results:
The majority of the participants were aware that HIV might be spread by receiving blood from an infected person, sharing a needle or syringe, and
receiving organs from an infected person. There is a strong correlation between HIV transmission knowledge with age (p = 0.001), marital status (p
= 0.001), an education level (p = 0.001), and economic status (p = 0.049). The study indicated negative stigmatizing attitudes toward PLWHA.

Conclusion:
This study highlights significant public awareness gaps about HIV/AIDS and stigmatizing attitudes of the public toward HIV/AIDS.

Keywords: HIV, AIDS, Awareness, Attitude, Transmission, Stigmatization.

Article History Received: September 22, 2022 Revised: February 18, 2023 Accepted: February 23, 2023

1. INTRODUCTION [1]. In 2018, the estimated number of PLWHA reached 37.9

million [2]. Furthermore, the eastern Mediterranean region has
HIV was first identified in the early 1980s and has since
one of the fastest-growing HIV infection rates despite having a
spread around the globe. The most common routes of HIV
low HIV/AIDS prevalence [1, 3].
transmission are via sexual contact or vertically from mother to
child. There is still a long way to go before achieving the Joint In the Kingdom of Saudi Arabia, young people between
United Nations Programme on HIV/AIDS (UNAIDS) goal of the ages of 14 and 24 years represent 20% of the population
decreasing new HIV infections each year to less than 500,000 [3]. In 2020, the projected HIV prevalence was less than 0.1%,
the incidence was 7/10000 among adults aged 15 to 49, and
* Address correspondence to this author at the Imam Abdulrahman Bin Faisal
University, Dammam, Saudi Arabia; Tel: +966 554358861; 79.1% of those living with HIV were men [4]. The frequency is
Fax: +966 13 8966741; E-mail: [email protected] greatest in the western province, followed by the central

DOI: 10.2174/18746136-v17-230420-2022-15, 2023, 17, e187461362303080

2 The Open AIDS Journal, 2023, Volume 17 Alwazzeh et al.

province and the eastern province [5]. It is important to note security was ensured. The autonomous questionnaire was
that these figures may not fully reflect the true extent of HIV in designed to collect the data from September 1st, 2018, to
the population, as there are definitely undiagnosed cases. The December 31st, 2018. The questionnaire was reviewed by a
reasons for the high percentage of HIV-infected men in Saudi team of experts consisting of biotechnicians and physicians
Arabia are not well investigated. Suggested explanations with a particular interest in treating PLWHA, having no
include knowledge gaps among young men with risky participation in authorship.
behaviors and increased risk of exposure through travel to
This questionnaire was divided into five sections: (a)
HIV-endemic countries [4, 6].
Demographic data: age and gender, (b) Assessment of
The Saudi National AIDS Program started various knowledge of HIV transmission, (c) General awareness, (d)
programs and provided treatment and assistance to PLWHA to Assessment of attitudes toward PLWHA, (e) Inquire how to
lower the incidence rate and treat individuals infected with collect HIV/AIDS information. A pilot study was conducted
HIV [7]. However, the conservative nature of Saudi society, with 42 participants; certain items were rephrased to enhance
the rising number of injecting drug users, and the non- the questionnaire's reliability and content validity. The sample
disclosure of risky practices that may transmit the virus are the from the pilot study was not included later in the statistical
greatest obstacles to HIV/AIDS awareness, along with the analysis of the study. 5- point Likert scale was used to measure
limited number of studies assessing public awareness and the respondents' attitudes towards PLWHA.
stigmatizing attitudes toward PLWHA [8]. These alarming
statistics demonstrate the need to investigate the public 2.4. Ethical Approval
knowledge gaps that play a significant role in HIV The study proposal was validated and approved by the
transmission in Saudi Arabia, as well as stigmatizing attitudes Research Ethics Committee of “KFHU”.
toward the rising number of PLWHA. This research aims to
analyze the general Saudi population's knowledge of 2.5. Statistical Analysis
HIV/AIDS and their awareness and attitudes toward PLWHA.
The statistical analysis was performed using SPSS 22.0.
Descriptive statistics were adopted as a simple percentage
2. MATERIALS AND METHODS
technique to describe the patients' demographic characteristics.
Categorical variables are summarized and presented in tables.
2.1. Study Design and Participants
Numerical variables are presented as means and standard
This cross-sectional study was conducted among healthy or deviations and were assessed with unpaired Student’s t-test,
sick individuals visiting “KFHU”. All participants who were linear correlation coefficients, analysis of variance (ANOVA),
16 years old or older and could read the Arabic questionnaire chi-square test, and logistic regression. The results were
were included in the research, but those who had major considered significant if the calculated P-values were less than
communication and language barriers were excluded. This was 0.05.
done in consideration of Saudi culture and social norms.
3. RESULTS
2.2. Sample and Recruitment
A total of 691 out of 700 participants filled out the
Out of 700 distributed questionnaires, 691 (98.6%) were questionnaire, and 325 of the respondents (47%) were between
completed and analyzed. Nine questionnaires were excluded as 31 and 50 years of age. Most of them were married (n = 462,
they were incomplete or did not fulfill the study's inclusion 66.9%) and graduates (n = 416, 60.2%) with good economic
criteria. status (Table 1).
The majority of the participants were aware that HIV
2.3. Procedure
might be spread by receiving blood from an infected person (n
After demonstrating the study's goals, participants gave = 640, 92.6%, p = 0.000), sharing a needle or syringe (n = 594,
their written or oral informed consent. No personal 86%, p = 0.000), followed by receiving organs from an
identification was collected during this study. Basic data infected person (n = 426, 61.6%, p = 0.000) (Table 2).

Table 1. Demographic profile of the respondents.

- - N %
Male 395 57.2
Gender
Female 296 42.8
16 - 20. 52 7.5
21 - 30. 190 27.5
31 - 40. 209 30.2
Age (years)
41 - 50. 116 16.8
60 - 51. 95 13.7
More than 60 29 4.2
Stigmatization of People Living with HIV Infection The Open AIDS Journal, 2023, Volume 17 3

(Table 1) contd.....
- - N %
Saudi 606 87.7
Nationality
Non-Saudi 85 12.3
Single 195 28.2
Married 462 66.9
Marital status
Widowed 14 2.0
Divorcee 20 2.9
Illiterate 7 1.0
Reads and writes 10 1.4
Primary 18 2.6
Education level
Intermediate 35 5.1
High school 205 29.7
University 416 60.2
Weak 52 7.5
Average 217 31.4
Economic status
Good 296 42.8
High 126 18.2

Table 2. Awareness of respondents about HIV/AIDS transmission.

Yes No Do not know

- Correct answer p-value
N (%) N (%) N (%)
Well-established Mode of Transmission
Receiving blood from an infected person Yes 640 (92.6) 25 (3.6) 26 (3.8) 0.000
Receiving organs from an infected person Yes 426 (61.6) 85 (12.3) 180 (26.0) 0.000
Sharing needle or syringe Yes 594 (86.0) 48 (6.9) 49 (7.1) 0.000
During pregnancy Yes 417 (60.3) 131 (19.0) 143 (20.7) 0.030
During delivery Yes 356 (51.5) 139 (20.1) 196 (28.4) 0.040
Breastfeeding Yes 248 (35.9) 218 (31.5) 225 (32.6) 0.062
Tattoos Yes (rare) 349 (50.5) 142 (20.5) 200 (28.9) 0.050
Wrongly Perceived Mode of Transmission
Coughing and sneezing No 235 (34.0) 348 (50.4) 108 (15.6) 0.050
Bites of insects/mosquitoes No 230 (33.3) 306 (44.3) 155 (22.4) 0.042
Sharing food or drinks No 147 (21.3) 402 (58.2) 142 (20.5) 0.050
Sharing toothbrushes No (not established) 541 (78.3) 65 (9.4) 85 (12.3) 0.070

Table 3. Respondents' attitudes toward HIV/AIDS people.

Strongly Disagree Do Not Know N Agree Strongly Agree

Attitudes Disagree N (%)
N (%) (%) N (%) N (%)
PLWHA should be isolated from public places 103 (14.9) 205 (29.7) 99 (14.3) 175 (25.3) 109 (15.8)
PLWHA should inform others about their disease 56 (8.1) 120 (17.4) 86 (12.4) 250 (36.2) 179 (25.9)
I will end my relationship with my friend if he/she gets
201 (29.1) 234 (33.9) 132 (19.1) 75 (10.9) 49 (7.1)
infected with HIV
I do not mind sharing a meal with PLWHA 127 (18.4) 145 (21.0) 156 (22.6) 203 (29.4) 60 (8.7)
I do not mind buying from PLWHA 146 (21.1) 148 (21.4) 122 (17.7) 206 (29.8) 69 (10.0)
I do not mind hosting PLWHA in my house 131 (19.0) 141 (20.4) 141 (20.4) 209 (30.2) 69 (10.0)
I do not mind being treated by a doctor with HIV/AIDS 224 (32.4) 180 (26.0) 107 (15.5) 134 (19.4) 46 (6.7)
I do not mind a surgeon with HIV/AIDS doing my surgery 337 (48.8) 173 (25.0) 109 (15.8) 48 (6.9) 24 (3.5)
I do not mind marrying a person with HIV/AIDS 490 (70.9) 113 (16.4) 45 (6.5) 18 (2.6) 25 (3.6)
I do not mind living with PLWHA 279 (40.4) 190 (27.5) 104 (15.1) 89 (12.9) 29 (4.2)
PLWHA are careless regarding the dangers of spreading their
92 (13.3) 117 (16.9) 323 (46.7) 122 (17.7) 37 (5.4)
illness
PLWHA should be ashamed of their illness 215 (31.1) 240 (34.7) 113 (16.4) 72 (10.4) 51 (7.4)
4 The Open AIDS Journal, 2023, Volume 17 Alwazzeh et al.

(Table 3) contd.....
Strongly Disagree Do Not Know N Agree Strongly Agree
Attitudes Disagree N (%)
N (%) (%) N (%) N (%)
All people with HIV/AIDS have multiple illegal sexual
208 (30.1) 194 (28.1) 172 (24.9) 65 (9.4) 52 (7.5)
relations
PLWHA gets it as a consequence of wrong behaviors 91 (13.2) 138 (20.0) 161 (23.3) 213 (30.8) 88 (12.7)
Women with HIV/AIDS have the right to get pregnant 192 (27.8) 139 (20.1) 234 (33.9) 91 (13.2) 35 (5.1)
PLWHA has the capability and right to work in the society 54 (7.8) 86 (12.4) 145 (21.0) 294 (42.5) 112 (16.2)
PLWHA must disclose its status to the public 109 (15.8) 202 (29.2) 137 (19.8) 164 (23.7) 79 (11.4)
I will not allow my children to play with PLWHA 76 (11.0) 116 (16.8) 150 (21.7) 200 (28.9) 149 (21.6)
PLWHA causes danger for those around them 67 (9.7) 175 (25.3) 143 (20.7) 184 (26.6) 122 (17.7)

Table 4. Level of knowledge about transmission of HIV based on demographic characteristics.

Total knowledge ANOVA or t-test

Demographics N F or T
Mean ± SD Test value P-value
16 – 20 52 11.096 ± 4.131
21 – 30 190 13.195 ± 4.003
31 – 40 209 13.751 ± 3.844
Age F 8.069 <0.001*
41 – 50 116 15.095 ± 3.863
51 – 60 95 13.368 ± 4.024
More than 60 29 13.586 ± 3.822
Male 395 13.643 ± 4.112
Gender T 0.591 0.555
Female 296 13.459 ± 3.939
Single 195 12.651 ± 4.048
Married 462 14.004 ± 3.984
Marital status F 5.882 <0.001*
Widowed 14 13.500 ± 3.006
Divorced 20 12.350 ± 4.283
Illiterate 7 11.857 ± 2.795
Read and write 10 11.500 ± 4.743
Primary 18 10.333 ± 4.498
Education level F 11.904 <0.001*
Intermediate 35 11.286 ± 4.004
High school 205 12.668 ± 3.757
University 416 14.416 ± 3.905
Weak 52 12.231 ± 4.282
Average 217 13.562 ± 3.873
Economic status F 2.636 0.049*
Good 296 13.885 ± 3.910
High 126 13.365 ± 4.410
Note: T: test value for T-test, F: Test values for ANOVA
* indicates P-value =0.05 is significant.

The 5-Point Likert Scale was used to measure the HIV.

respondents' attitudes toward PLWHA. Table 3 illustrates the
Specifically, Table 4 shows a strong correlation between
study participants’ responses to 19 items. It indicates negative
HIV transmission knowledge with age (p = 0.001), marital
stigmatizing attitudes toward PLWHA; people with HIV
status (p =0.001), an education level (p = 0.001), and economic
should inform others about their disease, and knowledge about
status (p = 0.049). In contrast, gender showed no significant
PLWHA must be disclosed to the public so that people can
correlation with knowledge about HIV transmission (p =
avoid them. In addition, 42.5% (n = 294) of the respondents
0.555).
expressed that they would not buy from PLWHA, and 39.4%
(n = 272) responded that they would not let PLWHA into their
4. DISCUSSION
homes. The majority (n = 510, 73.8%) opposed having HIV-
positive surgeons perform surgery, and a majority (n=404, This study provides descriptive information about
58.4%) will not seek medical care and advice from HIV- awareness of HIV/AIDS and attitudes towards PLWHA in
positive specialists. On the contrary, the majority expressed selective participants of Saudi Arabia. All respondents were of
positive attitudes toward specific items; 65.8% (n=455) reproductive age; the majority were married and were men. In
believed that PLWHA should not be ashamed of themselves contrast to the majority of previous studies conducted in Saudi
because they contracted the virus, and 63% (n=435) responded Arabia, this study was carried out to investigate the gaps in
that they would maintain a friendship if they were infected with broad, general public awareness about HIV/AIDS compared to
Stigmatization of People Living with HIV Infection The Open AIDS Journal, 2023, Volume 17 5

awareness of selected groups, such as students or health such as lack of access to accurate information, and to involve
workers, that usually do not reflect the general public the community in developing and implementing education and
awareness. Furthermore, this study describes in detail the awareness campaigns.
stigmatizing attitudes toward PLWHA.
Across the world, PLWHA is facing predicaments
The study findings on HIV/AIDS knowledge revealed that regarding their rights as a result of the lack of knowledge, bad
participants had a good level of overall understanding, with attitude, and wrong stigma [17]; however, this topic was rarely
60.34% of the knowledge questions answered correctly. Our discussed in previous studies conducted in Saudi Arabia.
results are consistent with those of previous research. For Previous studies from the Arabian Peninsula and the Middle
example, a recent meta-analysis indicated that overall HIV/ East indicated negative attitudes toward PLWHA [8, 18, 19].
AIDS awareness in the Arabian Peninsula was good (74.4%) The long list of negative attitudes in this study includes, but is
[9]. Moreover, a recent study conducted at Qassim University not limited to, isolation of PLWHA, disclosure of HIV/AIDS
showed an average HIV knowledge of 64.5% [5]. A study status to the public to avoid PLWHA, refusal to live with
conducted in Bahrain showed general awareness in 63% of PLWHA, and avoiding buying from PLWHA. These findings
participants [8]. The majority of respondents were aware that are consistent with other studies that evaluated public attitudes
HIV might be spread via sexual contact, sharing infected toward PLWHA [12, 17, 18, 20]. In the literature, the
needles, obtaining contaminated blood, and PLWHA organ stigmatization and discrimination of PLWHA were linked to
donation. Furthermore, sharing toothbrushes means sharing the lack of knowledge about HIV/AIDS [13, 20, 21]. In
oral bacteria and viruses. The transmission of HIV in such a contrast, some studies have shown no correlation between
way is rare but not totally excluded. In this study, the majority knowledge about HIV/AIDS and negative attitudes toward
had a misconception that HIV can be transmitted through PLWHA [8, 20].
sharing toothbrushes. In addition, significant information gaps When people lack accurate information about how the
were detected in terms of HIV transmission from an HIV- virus is transmitted and the realities of living with HIV, they
positive mother to her child, such as respondents being are more likely to hold stigmatizing and discriminatory
unaware or denying the potential of transmission during attitudes toward PLWHA [22]. However, it is worth noting that
pregnancy, birth, or nursing. Similar results were seen in an lack of knowledge is not the only factor that contributes to
Iraqi study [10] as well. On the other hand, important HIV-related stigma and discrimination. Other factors, such as
misconceptions were observed; a significant number of cultural attitudes, religious beliefs, and social norms, can also
respondents were unsure or gave incorrect answers regarding play a role [23]. In recent years, there have been efforts to
the transmission of HIV through coughing and sneezing, insect increase HIV/AIDS education and awareness programs to
or mosquito bites, handshakes, sharing towels or utensils, reduce the stigmatization and discrimination of PLWHA.
sharing the same toilet or sharing the same meals with However, it is important to note that these efforts need to be
PLWHA. These results are comparable to other studies ongoing and sustained in order to be effective.
conducted in Bahrain, Egypt, Iran, Yemen, and Turkey [8, 11 -
14]. Therefore, awareness campaigns were planned to reduce Freedom to conceive is vital for women. However, this
misunderstandings about HIV/AIDS. topic has seldom been addressed in past research on the
Arabian Peninsula. In the present study, the majority did not
In general knowledge questions, the majority of recognize the right of women with HIV/AIDS to become
respondents were aware that HIV\AIDS could lead to death or pregnant, which is consistent with a previous study conducted
affect any age group. In addition, 53.0% of respondents agreed in Yemen but contradicts the findings of a study conducted in
that healthy-looking individuals could be living with HIV and Nigeria, in which the majority supported the right of women
knew that there is no cure for HIV yet, while only 38.4% were with HIV/AIDS to become pregnant [3, 24]. This difference in
aware that there is no immunization against HIV. These attitudes towards the right of HIV-infected women to become
findings were consistent with other studies revealing confusion pregnant highlights the complex and varied nature of societal
regarding HIV/AIDS curability and vaccine availability [8, 11, attitudes towards HIV/AIDS, as well as the importance of
15]. The above-mentioned misconceptions and gaps can understanding and addressing the cultural, societal, and
contribute to the stigmatization and discrimination of PLWHA, economic factors that contribute to these attitudes. It is
as well as make it more difficult for public health officials to important to note that with the availability of antiretroviral
educate the public about the disease effectively. therapy (ART) and other medical advancements, it is now
It is important to raise public awareness about the role and possible for women living with HIV to have healthy
efficacy of antiretroviral therapy and pre-exposure prophylaxis pregnancies and prevent mother-to-child transmission of HIV.
as key treatments in fighting HIV/AIDS. This information Nonetheless, the lack of recognition of the right of women with
should be raised in any campaign related to HIV, which could HIV/AIDS to become pregnant can lead to discrimination and
encourage PLWHA to seek early medical advice and help stigmatization, which can further marginalize PLWHA and
make it more difficult for them to access the care and support
reduce the risk of HIV transmission [16]. Education and
they need.
awareness campaigns can be targeted to specific groups, such
as illiterates, students of middle and high schools, and An inadequate understanding of HIV transmission and the
undergraduates, to correct these misconceptions and provide availability of preventive measures may also contribute to the
accurate information about HIV transmission. Additionally, it discrepancy in the findings, coupled with demographic and
is essential to address the root causes of these misconceptions, cultural disparities. The majority of respondents in this survey
6 The Open AIDS Journal, 2023, Volume 17 Alwazzeh et al.

disagreed with undergoing surgery done by HIV-positive be done by implementing further outreach campaigns, creating
surgeons or receiving medical care and advice from HIV- creative media content, and publishing it to the community.
positive specialists. In general, the probability of HIV Additionally, incorporating awareness programs into schooling
transmission from an infected health professional to a patient is will improve public knowledge about HIV/AIDS, reduce the
very low [25, 26]. Nevertheless, this attitude cannot be incidence of the disease, and improve attitudes toward
attributed only to stigmatization; other variables may also play PLWHA. Finally, the reasons behind the stigmatizing attitudes
a role, such as the fear of being infected or the perspective on should also be investigated to resolve related misconceptions.
safety problems. Regarding marrying a person with HIV/AIDS,
the majority of participants refused and disagreed with living LIST OF ABBREVIATIONS
with PLWHA. These findings are in agreement with those of
HIV = Human Immunodeficiency Virus
the findings reported in a study conducted by Alwafi et al. [6],
which found that fewer than 20% support marrying an PLWHA = People Living with HIV/AIDS
HIV/AIDS patient. AIDS = Acquired immune deficiency syndrome

On the other hand, our study revealed that the majority of ETHICALS APPROVAL AND CONSENT TO
respondents had positive attitudes regarding the continuation of PARTICIPATE
their relationships with friends if they were infected with HIV,
acknowledged the right of PLWHA to work within society, The study proposal was validated and approved by the
denied that all PLWHA engage in multiple illegal sexual Research Ethics Committee at Imam Abdulrahman bin Faisal
relations, agreed that PLWHA should not be ashamed of their University (Ethical Approval # IRB-UGS-2018-01-173).
illness, and reported that PLWHA is not careless regarding the
HUMAN AND ANIMAL RIGHTS
risks of spreading the infection. These findings are positive, as
they indicate that the majority of respondents understand and No animals were used in the studies that are the basis of
support the rights and dignity of PLWHA. This positivity in this research. This research was conducted on humans and in
attitudes is a good indication that there is a shift in societal accordance with the Helsinki Declaration of 1975, as revised in
attitudes towards PLWHA, and it can be seen as a sign of a 2013.
more inclusive and equitable society. The findings are
consistent with prior research addressing the employment CONSENT FOR PUBLICATION
rights of PLWHA [27]. Informed consent was obtained from all the participants.
The Internet began to detach conventional mass media
(television, radio, and newspapers) as the primary public AVAILABILITY OF DATA AND MATERIALS
information source about HIV/AIDS. Successful HIV/AIDS The datasets used and analyzed during the current study
campaigns and eradication initiatives will rely heavily on are available from the corresponding author [M.A] upon
interactive national websites that provide HIV/AIDS health reasonable request.
education materials and direct counseling in addition to
medical care. STANDARDS OF REPORTING
One of the limitations of this study is that it is based on a STROBE guidelines were followed in this study.
questionnaire, which may be subjected to response bias.
Respondents may be reluctant to report stigmatizing attitudes FUNDING
or lack of knowledge about HIV/AIDS, leading to an None.
underestimation of these issues. Additionally, the questionnaire
has not captured all aspects of knowledge and attitudes toward CONFLICT OF INTEREST
PLWHA; more comprehensive measures may be needed to
fully understand these issues. Another limitation is that this The author declares no conflict of interest, financial or
study focuses on HIV/AIDS knowledge and attitudes toward otherwise.
PLWHA in the Eastern Province of the Kingdom of Saudi
ACKNOWLEDGEMENTS
Arabia. Therefore, these findings may not be generalizable to
other regions or populations. To design HIV/AIDS education The author would like to thank all the associated personnel
programs based on evidence and to have a better understanding for any reference contributing to this research.
of negative stigmatizing attitudes towards PLWHA, it is
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