HIV-/AIDS-Related Knowledge and Attitudes among Saudi Health Professionals and Students: A Review Article

Keywords

attitudes - behavior - health students - health workers - HIV/AIDS - knowledge - review - Saudi Arabia

Introduction

Human immunodeficiency virus (HIV) is an infection that attacks the immune system of the body, while acquired immunodeficiency syndrome (AIDS) is the most advances stage of the disease. HIV remains a major concern in global public health, with around 40.4 million deaths, 39 million individuals living with HIV at the end of 2022, and an ongoing transmission globally.[1]

The first confirmed case in Saudi Arabia was in 1984.[2] In 2020, there were 12,000 adults and children living with HIV, among them 1,000 new infections, with less than 200 deaths.[3] Saudi Arabia has a low prevalence of HIV/AIDS, but there is a high influx of foreign nationals with high risk of transmission of HIV.[2]

It has been reported that 9 out of every 10 cases in Saudi Arabia remain undiagnosed, and this contradicts with article 31 of the basic law of Saudi Arabia, as these rights for all its citizens are affirmed. The right to health care declares, “The state takes care of health issues and provides health care for every citizen.”[4]

All health care staff are at risk of HIV infection, with an increasing number of surviving HIV-positive patients.[5] Fear of HIV infection or AIDS phobia among health care providers is a major barrier to successful delivery of care to people living with HIV/AIDS (PLWHA). The risk of infection by blood-borne pathogens such as HIV, hepatitis C virus, and hepatitis B virus represents a significant threat to health care providers.[6] The occupational exposure to HIV with needle-stick injury has risk linked ranging from 0.2 to 0.5%.[7]

The minimal infection prevention and control measures are the standard precautions that should be applied to all patients by health care deliveries at all times, regardless of the patient's suspected infection or not.[8] To ensure provision of a safe health service, infection prevention programs should play their role in the reduction of the risk of hospital-acquired infection through their established policies and strategies.[9] In addition, adequate knowledge and effective antitransmission measures, such as taking universal precautions in the handling of blood and other body fluids, are important factors in minimizing the risk of HIV transmission in the health care settings. These might lead to the prevention of its transmission and help in delivering successful care.[5] [10]

Therefore, all health care workers should have adequate knowledge of HIV/AIDS and its implications, maintain positive attitudes, and should meet professional expectations. This review aimed at reviewing the literature regarding HIV- and AIDS-related knowledge and attitudes among Saudi health professionals and students.

Methods

A literature search was performed using combined keywords in three scientific databases of peer-reviewed publications in the last 10 years (2014 to 2024). The search included Google Scholar using the following search wording: (HIV AIDS knowledge OR attitudes OR belief “Saudi Arabia”); PubMed (Ovid Medline) using the following search wording: (((HIV/AIDS) AND (knowledge)) AND (attitudes)) AND (Saudi Arabia); and Web of Science using the following search wording: (((ALL= (HIV AIDS)) AND ALL= (Knowledge and Attitude)) AND ALL= (Saudi)) NOT ALL= (population). The inclusion criteria were the following: open access, published in the English language, and Saudi health professionals or students as study population. The author excluded duplicates and studies that were not available as open access for full article.

Search Findings

The initial search for articles identified 78 studies ([Fig. 1]). This included results from the listed databases searched. The abstracts of all 78 results were reviewed manually to determine whether they met the inclusion criteria. Among all these, 39 (50%) studies did not qualify because they did not concern the population of interest. Among the qualified studies, duplicated studies (18) were identified and excluded, and one study was excluded, as it was not an open access. Ultimately, 19 studies were finally included in the review. [Table 1] depicts the characteristics of the 19 included studies in the chronological order of publication that met the inclusion criteria.

Fig. 1 Flowchart of the search process.

Table 1 The main characteristics of the included studies in the chronological order

Study	Design, population, sample size, and sampling technique	Data validity and reliability and statistical analyses	Conclusion
Bamashmous et al[6]	Cross-sectional questionnaire survey-based study Dental hygienists and assistants practicing in Jeddah (160) Convenience	Response rate: 80% Questionnaire: structured Validity: pilot tested for construct validity Pearson's correlation Reliability, Cronbach's α: 92% Descriptive statistics, Pearson's correlation, independent t-test S. size equation: Yes	Good general knowledge Importance of treating and supporting AIDS patients   Recommendations: Future research might explore the significant effects of continuous, targeted HIV education programs
Ahmed[11]	A quantitative cross-sectional survey Senior-level dentistry and dental hygiene students, currently enrolled in 12 dental and 4 dental hygiene institutes (468) Nonprobability voluntary response sampling	Response rate: NOT Questionnaire: structured Content validity: peer review Construct validity: tested via a pilot study Descriptive statistics, chi-squared test, Fisher's exact test, ANOVA S. size equation: Yes	Incomprehensive, unfamiliar, and lacking in expertise Inadequate level of comprehension   Recommendations: HIV/AIDS ought not to persist as an unspoken taboo or disregarded subject within the dental field
Alotaibi et al[5]	Cross-sectional Dental students and interns (502) Not mentioned	Response rate: NOT Questionnaire: adopted Reliability validity: NOT Descriptive statistics, unpaired t-test, ANOVA S. size equation: Not	Good knowledge Attitude was not good   Recommendations: it is extremely important to conduct HIV-related courses before the clinical training to build sufficient knowledge and attitudes.
Malli et al[12]	Cross-sectional study Medical interns graduates of five medical colleges practicing in Jeddah (346) Nonprobability random sampling	Response rate: NOT Questionnaire: adopted from a previous study Validity: pilot tested for content validity Internal consistency, Cronbach's alpha: 68% Descriptive statistics, chi-squared, Kruskal–Wallis test S. size equation: Yes	Insufficient knowledge and stigmatizing behavior Recommendation: HIV education and training programs should be added, which might have a significant positive impact on their attitude
Alali et al[16]	Cross-sectional Undergraduate dental students and internship dental students at government and private universities in Saudi Arabia (405) Convenience	Response rate: 67% Questionnaire: adopted from a previous study Validity: described (experts: piloted) Descriptive statistics, chi-squared statistic S. size equation: yes	Negative attitude Inadequate knowledge and unprofessional attitude Recommendation: Dental educators and health care planners in Saudi Arabia should plan to promote knowledge and attitudes toward the treatment of HIV patients
Alenezi[15]	Cross-sectional Mental health nurses, including nurse interns in Riyadh 323/(241) Convenience	Response rate: 74.4% Questionnaire: adopted from a previous study The internal consistency, Cronbach's α: 97% Descriptive statistics, Student's t-test S. size equation: yes	Gaps in knowledge Higher stigmatizing attitudes Committed acts of discrimination Recommendation: HIV/AIDS should receive prominence in dental schools and professional development programs
Abiadh et al[10]	Cross-sectional Dental students and interns, Umm Al-Qura (216) Not mentioned	Response rate: 65% Questionnaire: adopted previous study Validity mentioned: not explained Descriptive statistics, independent t-test S. size equation: not	Acceptable knowledge and favorable attitude Recommendation: More efforts are required to improve the attitudes of future dentists
Alharbi et al[14]	Cross-sectional Health care workers, Medina (doctors, nurses, pharmacists, and laboratory technicians) (182) Not mentioned	Response rate: NOT Questionnaire: adopted previous study Validity described (experts) Descriptive statistics, Student's t-test, ANOVA, multiple linear regression S. size equation: Yes	Stigmatization and discrimination were less prevalent in health care workers who had good HIV-related knowledge and had received in-service training Recommendation: There is an urgent need to implement a training program
Mostafa et al[17]	Cross-sectional Dental students and dentists (Jeddah, Riyadh, Almadina, Hail, Dammam, Jazan, and Sakaka) (461) Not mentioned	Response rate: NOT Questionnaire: NOT Validity: NOT Descriptive statistics, Student's t-test ANOVA S. size equation: Not	Lack of knowledge and attitude Recommendation: More education on AIDS patients is needed
AlQumayzi et al[19]	Cross-sectional Medical and nonmedical students in Riyadh (602) Convenience	Response rate: NOT Questionnaire: developed Validity: pretest pilot tested for content validity Internal consistency, Cronbach's alpha: 48% Descriptive statistics, ANOVA, correlation coefficient S. size equation: Yes	Medical and health sciences students scored higher than nonmedical students in terms of knowledge, and lower in the stigma score Recommendation: Reduce or eliminate stigmatization and a negative attitude by raising awareness about HIV
Ansari et al[18]	Cross-sectional Dental students in all dental universities in Saudi Arabia (521) Census	Response rate: 97% Questionnaire: adopted from a previous study Validity: internal consistency, Cronbach's alpha: 86% Descriptive statistics, chi-squared test S. size equation: Not	The level of ethical awareness is much better The behavior was not satisfactory   Recommendations: N/A
Alzahrani et al[20]	Cross-sectional Health care workers (physicians, nurses, laboratory technicians and dentists) (372) Census	Response rate: NOT Questionnaire: adopted from a previous study Validity: mentioned; not explained Descriptive statistics S. size equation: Not	Insufficient level of knowledge, inappropriate attitudes and inadequate behavior Recommendation: Health education programs should be adopted
Al-Qahtani et al[23]	Cross-sectional Dental students and interns three dental institutes at southern and central region of Saudi Arabia (722) Not mentioned	Response rate: 91.6% Questionnaire: designed Validity: pilot tested for content validity, face and content validity by professionals Descriptive statistics, chi-squared test S. size equation: Yes	Lack in the knowledge and average level of attitude Recommendation: Extensive courses and training program should be implemented in the curriculum
Alawad et al[22]	Cross-sectional Saudi male medical students of Qassim University (204) Convenience	Response rate: 46.68% Questionnaire: adopted from a previous study Validity: pilot tested for content validity Descriptive statistics, ANOVA, chi-squared and Fisher's exact tests, independent sample t-test, Spearman's correlation S. size equation: Not	Major misconceptions Negative attitudes Recommendation: Educational institutions should tailor their educational approach based on the identified gaps
Alshouibi and Alaqil[21]	Cross-sectional Senior dental students from four dental schools in Jeddah (400) Not mentioned	Response rate: 68.5% Questionnaire: adopted and modified from previous studies Validity: NOT Descriptive statistics, binary logistic regression S. size equation: Not	Reluctant to treat Negative tendency Stigmatizing Recommendation: University educators must take greater responsibility to promote more positive attitudes
Kumar et al[24]	Cross-sectional Dental students of Jazan University (208) Census	Response rate: 88.1% Questionnaire: adopted from a previous study Validity: pilot tested for content validity Descriptive statistics, unpaired “t”-test, ANOVA S. size equation: Not	Knowledge and attitudes are poor Recommendation: Incorporate information related to the management of HIV/AIDS in dental practice
Alshouibi and AlAlyani[25]	Cross-sectional General dentists practicing in Jeddah (430) Not mentioned	Response rate: 71.7% Questionnaire: adopted from a previous study Validity: NOT Descriptive statistics, chi-squared, binary logistic regression S. size equation: Not	Discrimination was influenced by dentists' gender, type of practice, and self-protective attitudes Recommendation: Future research could be directed to prevent factors contributing to developing HIV-related discrimination
Alhamoud et al[26]	Cross-sectional Saudi surgery trainees (500) Convenience	Response rate: NOT Questionnaire: pretested (no reference) Reliability and validity: by professionals Descriptive statistics, chi-squared test S. size equation: Yes	Knowledge gaps Negative attitudes Recommendation: Medical training and social media awareness campaigns
Memish et al[27]	Cross-sectional Saudi doctors, Jeddah, Riyadh, Dammam, Jizan (1,483) Proportionally systematic random sample	Response rate: 97% Questionnaire: adopted from a previous study Validity: internal consistency, Cronbach's alpha: 82% Descriptive statistics, Student's t-test (ANOVA), a binary logistic regression model S. size equation: Yes	Poor knowledge Stigmatizing attitudes Recommendation: Further training of health workers on HIV transmission mode

Results and Discussion

Two studies were published in 2024,[6] [11] and two were published in 2023.[12] [13] Four studies were published in 2022,[10] [14] [15] [16] one study in 20201,[17] and two studies in 2020.[18] [19] Four studies were published in 2019,[20] [21] [22] [23] three in 2018,[24] [25] [26] and only one in 2015.[27]

Objective, Study Design, and Study Population

Almost all studies aimed to assess knowledge of their participants including general knowledge regarding HIV/AIDS, safety-related issues such as body fluids and their ability of transmission, modes and routes of transmission, coinfections, the management of needle-stick injury, beside prevention of transmission of HIV infection. Three studies (15.7%) evaluated the participants' knowledge regarding oral manifestations of HIV, oral and periodontal lesions, periodontal manifestations, and periodontal management of patients with HIV.[6] [11] [16] All studies also assessed their participants' HIV-/AIDS-related attitude practice toward PLWHA, which included stigmatizing and discriminating behaviors, and willingness to provide care to HIV patients. Only one study (5%) compared medical with nonmedical groups.[19]

All studies used the cross-sectional design. The selection of the appropriate method to study the research question is the first step in the research process. It is known that cross-sectional designs help determine the proportion of people in a population with a condition or an attribute in a specific period or point of time, regardless of the development of the condition. This shows the suitability of the selected cross-sectional designs concerning the reported aims and objectives.[28]

Eleven studies (58%) focused on dental professionals, including dentists, dental hygienists, interns, and students.[5] [6] [10] [11] [16] [17] [18] [21] [23] [24] [25] Eight studies (42%) were among medical professionals, including doctors, nurses, interns, and students.[12] [14] [15] [20] [22] [26] [27] [29]

Sampling Techniques and Sample Size

Sampling technique is a crucial component of research methodology that guarantees making significant inferences. The most common sampling approach used was convenience sampling by six studies (31.6%).[6] [15] [16] [19] [22] [26] Three studies (15.7%) used census,[18] [20] [24] with exception of two studies (10.5%) that used nonprobability random sampling[11] [12] and one that used proportionally systematic random sampling.[27] Seven studies (36.8%) did not report their sampling techniques.[5] [10] [14] [17] [21] [23] [25] The sampling technique is used to ensure the representativeness of the study population. Two main approaches in sampling used are probability or nonprobability. Convenience sampling is a nonprobabilistic sampling technique commonly employed when obtaining representative samples from the target population is challenging, and it has several limitations mainly in the level of the representativeness. It is more suitable in exploratory studies or pilot projects.[30] The sample size for any epidemiological study is an important component of the process and it is estimated based on some assumptions before the conduction of the study, and it must be an adequate size. A smaller sample size leads to insufficient statistical power to answer the primary research question; a larger sample size provides better representativeness and results that are more accurate. However, beyond a certain point, the increase in accuracy will be small and not worth the effort and expense.[31] Regarding sample size calculation, only 10 studies (52.6%) either explicitly reported (the formula or equation used) or referred to the calculation of the sample size to a previously published study. The sample size ranged between 182 and 1,483. Eight studies (42.1%) did not report their response rates.[5] [11] [12] [14] [17] [19] [20] [26] Studies that reported response rates ranged from 46 to 97%. The response rates to a questionnaire-based research is highly important. The sufficient response rate enables generalizing the results to the target population; hence, low response rates compromise the representativeness of the study population.[32]

Data Collection

All studies reported using a questionnaire for data collection. Thirteen studies (68.4%) used adopted questionnaires from previously published studies.[5] [10] [12] [14] [15] [16] [18] [20] [21] [22] [24] [25] [27] Four studies (21%) used structured questionnaires,[6] [11] [19] [23] while two studies (10.5%) reported using validated questionnaires without a clear explanation or reference to previous studies.[17] [26]

Ensuring the reliability and validity is the most important and fundamental domain in the assessment of any tool used for data collection. Validity is about whether an instrument measures what it intends to measure, whereas reliability is about the repeatability, truthfulness, and degree to which the measuring tool controls random error. An assessment of the data collection methodology is through meticulous assessment of validity and reliability.[33] Four studies (21%) did not mention the descriptions of reliability and validity,[5] [17] [21] [25] while one (5.2%) study reported the use of a validated questionnaire without any clarification of the method used.[10] Eight studies (42.1%) tested for construct validity through piloting their questionnaires.[6] [11] [12] [16] [19] [22] [23] [24] Five studies (26.3%) used field experts' opinion for content validity testing,[11] [14] [16] [23] [26] and only one study (5.2%) used Pearson's correlation for construct validity.[6] Only six studies (31.6%) tested the internal consistency reliability by using Cronbach's alpha, and their reported scores ranged from 48 to 97%.[6] [12] [15] [18] [19] [27]

Data Analyses

Regarding data analyses, at the univariate level, all studies used descriptive statistics as frequencies for categorical variables and mean (±standard deviation [SD]) for numerical ones. At the bivariate level of analyses, the chi-squared test was the mostly commonly used, employed by eight (42.1%) studies.[11] [16] [18] [22] [23] [25] [26] Two studies (10.5%) used Fisher's exact test due to a small sample size.[11] [22] Eight studies (42.1%) applied the analysis of variance (ANOVA).[5] [11] [14] [17] [19] [22] [24] [27] Eight studies (42.1%) reported using Student's t-test.[5] [6] [10] [14] [15] [17] [22] [24] Three studies (15.7%) used the correlation coefficient: Pearson's and Spearman's correlations.[6] [19] [22] Only one (5.2%) study used the Kruskal–Wallis test.[12] Three studies applied multilevel analyses; three studies used binary logistic regression,[21] [25] [27] while one study (5.2%) used linear logistic regression.[14] A confounder is a third independent variable that affects the relationship between variables being studied leading to results that do not reflect the actual relationship between the variables under study. When the research data have no additional strata and there are only one or two confounders, stratified analysis is the best choice for analysis. When the data contain more potential confounders or large grouping, multivariate analysis (multi- and linear regression and analyses of covariance) offers the only solution, which handles large numbers of covariates and also confounders.[34]

Essential Findings

Only three studies (15.7%) reported their participants having good knowledge.[5] [6] [10] This was reported in previous studies as Saudi health care workers showed acceptable knowledge about risks of blood-borne infections.[35] Most of the Egyptian physicians had a moderate knowledge score,[36] while the majority of Malaysian hospital pharmacists were found to be well aware of the causes of HIV/AIDS.[37] Most of the health workers in the Philippines had good knowledge regarding the disease process and its mode of transmission.[38] [39]

All other studies reported major misconceptions, poor knowledge, lack of knowledge, or unsatisfactory knowledge level. This is in accordance with previous studies as one-third of the dental students at King Khalid University had insufficient knowledge,[40] and Saudi paramedical students' misconceptions and lack of knowledge were also reported.[29] In a recent study by Hakami et al, a high proportion of Saudi medical students had misconceptions about HIV transmission and prevention.[41] Indian clinical dental students showed low knowledge.[42] [43] Low level of knowledge was also reported in the Middle East and North Africa (MENA) region.[44]

Almost all studies reported negative attitudes and behaviors such as stigmatizing attitude, reluctance to treat, negative attitude, negative tendency, and committing acts of discrimination. This goes in line with previous studies in which 90.1% of dental students in King Khalid University showed a negative attitude,[40] while a significant percentage of Saudi medical students had stigmatizing attitudes toward patients with HIV.[41] In the Arabian Peninsula countries, a lower proportion (37.6%) of Saudis showed negative attitudes toward HIV/AIDS, while 93 and 70.6% of medical students in Oman and United Arab Emirates, respectively, showed negative attitudes.[45] The majority of Malaysian pharmacists (66.6%) had negative attitudes and approximately 20% held extremely negative attitudes.[37] Among the Egyptian physicians, a degree of undesirable attitude and practice was reported.[36] Indian dental students' ethical beliefs about HIV/AIDS were not consistent with the code of ethics, showing negative attitudes that may influence future attitudes.[46]

One-third of dentists from three Arab countries indicated they would refuse to treat HIV patients.[47] In the MENA region negative attitudes were reported, with an inverse correlation between the level of knowledge and negative attitudes.[44] This negative attitude was attributed to sociocultural taboos, indicating a need for targeted intervention.[45]

In contrast, a high willingness to treat HIV patients was reported among Indian clinical dental students.[42] Most of the health workers in the Philippines had a positive attitude and acceptance toward PLWHA.[38] [39]

The results showed that there is prevailing lack of knowledge and negative attitude among Saudi health professionals and students, which will have its negative impact on the access to health services for PLWHA. A need for intervention is mandatory. Many studies provided evidence of effective methods to tackle this challenge. Regular continuous behavior-based in-service training and reinforcing of infection control prevention measures through a strict policy can ensure up-to-date knowledge and might improve the attitudes of health workers.[6] [35] [44] [45] A positive impact of health education on students' knowledge and attitudes toward HIV/AIDS,[48] especially peer education, is an effective approach.[49] In-service training together with undergraduate training associated with knowledge and practice of palliative care for PLWHA is needed.[50]

Conclusion

This review highlighted the importance of continuous evaluation of health professionals'/students' knowledge and attitudes regarding HIV/AIDS. The review also reflected the still inadequate level of knowledge and unsatisfactory attitudes among Saudi health professionals and students. An important aspect that needs more investigation is the quality of studies reviewed, which showed some weaknesses in the methodological aspects.

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