HIV-related knowledge level among Indonesian women between 15 years and 49 years of age

Background Women are a highly vulnerable population for HIV-infection, influenced by biological, cultural, social and economic factors. Inadequate knowledge about the risk for exposure to HIV will impact the prevention and treatment of HIV. Objectives The aim of this study was to examine HIV-related knowledge among women in Indonesia and the associated demographic determinants that influence their access to accurate HIV-related information. Methods This was a secondary analysis of the Indonesia Demographic and Health Survey in 2012. Level of HIV-related knowledge was determined by analyzing nine items on the 2012 IDHS instrument. Results The percentage of women in Indonesia between the ages of 15 and 49 years of age, more than half (53.6%) had high score of HIV-related knowledge. The results from logistic regression showed that women aged 30–34 years old had 2.2 times higher knowledge level about HIV compared to older women. Married women, living in rural area, with a lower level of education, reported to have limited or no access to HIV related information; thus, had a correspondingly lower knowledge level of HIV. Conclusion Study findings underscore the lack of knowledge-level among Indonesian women about HIV, especially the prevention, transmission, and prevention mother to child transmission (PMCT).


Introduction
Human immunodeficiency virus (HIV) in Indonesia is a serious public health concern, and the associated social problems remain a priority for action. Indonesia is ranked second highest number of people (males and women) living with HIV (PLWH) in the South-East Asia Region (SEAR), and the rate increased significantly annually ranging from 5,846 in 2004 to 242.699 in 2017 1 . The HIV prevalence among Women also continues to increase every year, accounting for 32% of total PLWH in 2017 2, 3 .
Although the number of new HIV infection decreased by 19% from 2014 to 2017, the risk of HIV transmission remains high 3 . Associated with lack of knowledge and the serious stigma in HIV, individuals in the highest risk groups tend to have limited access to relevant HIV education and social services. In turn, this probably results in the underreporting of HIV in those medically underserved and more remote regions of the nation 1,4,5 . Therefore, the knowledge level of HIV is a critical factor in HIV prevention 6 .
Women are a highly vulnerable population for HIV-infection, influenced by biological, cultural, social and economic factors 1,5 . The risk of HIV in women is estimated to be from 2 to 4 times greater than for male due to their reproductive and genital anaomic structures which facilitates HIV transmission with sexual intercourse 7 . Culturally, gender inequality, male dominance, and stigma exacerbate the Women vulnerability further increasing their vulnerability for HIV exposure 8

. A previous study
African Health Sciences Vol 20 Issue 1, March, 2020 83 in Indonesia reported that most Indonesia women have been involved in deciding their health care but are relegated less power in social and economic decision making 2,9 . Furthermore, for a married woman who is pregnant with HIV, there are long-term consequences for her children such as her child has the potential to be infected by HIV if did not do prevention in advance. Inadequate knowledge about the risk of exposure to HIV will also impact the prevention and treatment for PLWH, perpetuated by the stigma and the discrimination of being HIV positive 10  on Indonesian demographic data classification) and marital status was defined based on the Indonesian law (unmarried, married). Education was determined by formal years of education (not at all, primary, secondary, higher education) and economic status by measure monthly income (lowest, lower middle, middle, upper middle, higher); access to information such as newspaper, radio and television (no. yes -at least once each week).
All data were analyzed using IBM SPSS version 22.0 for Windows 10. Univariate analysis and Chi-square test were used to determine the relationship among demographic variables, place of residence (geographic area), socio-economic factors and access to information with knowledge-level of HIV. Further analysis was undertaken to determine significant factors associated with knowledge-level of HIV using a logistic regression model. Table 1 summarizes demographic characteristics of all Indonesian women ranging in age from 15 years to 49 years of age. Of these, the majority were married (76.5%); more than half had completed secondary education (52%) and were lower-mid socioeconomic status (20.1%). More than half had access to a newspaper and or radio at least once weekly, but almost all had access to televisions (95.2%).

Results
HIV-related knowledge level among Indonesian women is highlighted in  The logistic regression analysis found that age, marital status, place of residence, education level, socioeconomic status, and access to information was significantly associated with knowledge-level of HIV (Table 4). Indonesian women between 30 to 34 years of age (OR=2.13, 95% CI=1.88-2.40), were not married (OR=1.12, 95% CI=1.01-1.26), and living in the urban area (OR=1.62, 95%CI= 1.52-1.74) contributed more notably to the modest knowledge level about HIV. Furthermore, women between 30 to 34 years of age (OR=2.21, 95% CI=1.98-2.45) and living in the urban area (OR=1.84, 95% CI=1.73-1.95) were found to be stronger factors associated with higher level of HIV-related knowledge.

Discussion
The findings in the analysis of secondary data from the 2012 IDHS survey showed that more than half of all Indonesian women have inaccurate or very limited HIV-related awareness and knowledge. A previous study conducted in Nigeria reported a majority of women had a higher awareness of HIV, but only 24% had comprehensive knowledge about transmission of HIV 11 . Insufficient knowledge of HIV prevention, HIV transmission, and prevention mother to child transmission (PMTCT) increases vulnerability to HIV infection in women 18 . Vulnerable groups in general, women in particular, should have the same access to health care services and the self-determination to participate in their health care decision making. Accurate knowledge about HIV prevention reduces one's risk for HIV exposure and subsequent infection. A study conducted in Sub-Saharan Africa found that accurate and comprehensive information, increased knowledge-level about HIV prevention significantly reduce the risk of getting infected by the HIV 15 . This findings of this study found there is a serious need for Indonesian women from 15 to 49 years of age need more information about HIV transmission and prevention 10 . Designing health education program about HIV and spread out the information widely is urgently needed to reduce HIV transmission among women in Indonesia.
This study showed that Indonesia women from 30 to 34 years of age had better knowledge compared to others aged groups. This finding may be associated with cultural factors, their access to information, and lower educational levels. For example, if they have high education background and therefore can accurately read and understand written information like newspapers, magazines etc, or they have a high economic status that they can afford to buy a television set and watch any educational programme that is aired. Previous study conducted in Bangladesh suggested that as the person matures, the individual is more likely to be exposed to additional accurate health-related information, which should also increase knowledge level and awareness 13 . A similar study conducted among women in Kenya, Ethiopia, and Burundi found that women aged 30 to 34 years old had better knowledge of HIV compare to younger women aged 19. However, our study found that women 39 years of age and older had lower knowledge of HIV. This finding needs to be further investigated to determine factors that contribute to this finding.
Unmarried women had a lower HIV related knowledge level compared to married counterparts. In the pre-dominate Indonesian culture, discussed sexual health or responsible sexual activity are taboo topics, especially for single and unmarried women. Thus, they are less likely to discuss sexual issues particularly topics related to HIV transmission and prevention. Therefore, unmarried women may not have this information source. A similar with a study conducted in Kenya reported that unmarried women had a higher knowledge of HIV due to they need to secure everything by them self 20 . In contrast to the previous study, found that married women had a higher knowledge of HIV. The different results in this study might be due to different demographic characteristics such as educational background 21 and media exposure. Furthermore, researchers argue that married women may have an opportunity to gain information from their partner(s) such as responsible sexual behaviors that address risk factors for HIV exposure 22 .
These findings highlight inequality in infrastructure development to help people easily able to access information. Women with more formal education also had a higher HIV knowledge level. However, the majority of Indonesian women have completed less than a secondary level of education. Years of education significantly influenced women HIV knowledge level 13,22 . More years of formal education is essential for creating awareness, hence knowledge level with exposure to relevant information, in this case, HIV transmission and prevention.
Economic status also was found to be is significantly related to Indonesian women HIV knowledge level. Consistent with a study conducted in Bangladesh, but different from research conducted in Kenya which reported no significant relationship between economic status and knowledge about HIV 20,23 . Higher economic status is associated with better ease of access to HIV related information and a better opportunity to pursue a higher education level. Women in better economic situations tend to be more aware of their health status and better prepared to make decisions about health behaviors. This study found Indonesian women residing in urban areas had 1.62 times great knowledgeable level than rural counterparts. In Indonesia access to media sources, both electronic and written materials, often is limited or perhaps even inaccessible in many more remote and rural areas 24 . Another study in Indonesia emphasized that people who lived in the rural area more prefer to rely on cultural traditions and beliefs about health, sexual activity, and reproduction. Moreover, community leaders often view HIV as a "curse" for the individual, family and even the community 25 .
This finding is consistent with other researchers in Bangladesh and Sudan 23,26 . Urban residence generally offers greater opportunity to access media of various types; and, perhaps better exposure to HIV-related information.
Transparency regarding the pevalence of HIV in Indonesia, encouraging open discussions and improving access to information are all essential to facilitate information access for Indonesian women, rural and urban alike, to learn about HIV transmission, prevention, and resources. Some limitation of our study should be acknowledged. First, our study was based on secondary of the 2012 IDHS survey may not reflect the current HIV-related knowledge level among Women in Indonesia accurately. Second, the instrument measured HIV-related knowledge level not using validate instrument which may be biased. However, our study was a national survey with a large sample size that allowed to generalize to all women aged 15-49 years old in Indonesia. A more comprehensive assessment of HIV-related knowledge level is needed to understand the impact of socioeconomic and cultural factors.

Conclusion
This study set out to determine that Indonesian women who were aged 30 to 34 years old, unmarried, living in urban area, higher education and economic status showed better knowledge of HIV compared to older age, married and living in rural area. Our findings underscore the needs for optimizing existing facilities and infrastructure in the rural area to provide comprehensive knowledge about HIV base on the local needs. Furthermore, policy maker need to design a wide health education program targeted to women who were uneducated, poor, unmarried and lived in rural area using an innovative strategy.

Declaration of conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.