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Acquired Immune Deficiency Syndrome (AIDS) is caused by a human immunodeficiency virus (HIV) that weakens the immune system and makes the body susceptible to and unable to recover from diseases. HIV/AIDS is one of the most complex health problems of the 21st century and has become a pandemic disease that threatens the world population.¹ Since there is no treatment or cure in sight, the disease continues to spread at an alarming rate.^1,2 Recent epidemiological data indicate that an estimated 40 million individuals are living with HIV/AIDS.³ Over 30 million people have already died from AIDS, with the year 2006 alone seeing 3 million deaths.⁴ The disease has reached all age groups and it is estimated that one-third of infected individuals are in the age bracket 15 to 24 years old.^5,6 This health problem has virtually affected all countries around the world and Saudi Arabia is no exception.

In Saudi Arabia the first few cases of HIV infection were reported in 1984. By the end of 2003, the cumulative reported number of HIV patients among Saudi and non-Saudi residents was 1,743 and 6,064 respectively.⁶ Of the infected Saudi patients, 237 (14%) of individuals were aged between 15 and 24 years. The government of Saudi Arabia took serious note of the problem and initiated a series of important measures to tackle the epidemic.⁷ Generally, the status of the HIV/AIDS epidemic in the Kingdom, as well as in other Islamic countries, is not yet clearly defined and the reported figures may not reflect the actual number of cases.

In the literature, there are several studies, which assess knowledge and attitudes of the high (secondary) school students towards HIV/AIDS. These studies were conducted in countries with different cultures and values.^8,9,10 One area that has not received a great deal of attention in Saudi Arabia is HIV/AIDS awareness among students in general education. Previous studies on HIV/AIDS in Saudi Arabia were limited and restricted to specific target groups such as physicians,¹¹ university students,¹² drivers,¹³ drug users,¹⁴ children¹⁵ and adult patients.¹⁶ Only one study on high school students' knowledge about HIV/AIDS was conducted in Saudi Arabia. Although valuable, it was conducted a decade ago and was set to evaluate the impact of an educational program on the students' knowledge about the infection.¹⁷

Since the Saudi population is a very young society, as evidenced by the official statistics,^18,19 it is believed that an important starting point for designing proper prevention strategy among the population is to know how much the young people, such as students, know about HIV/AIDS and what are their attitudes towards this infectious disease. This was the particular aim of this study. Therefore, the present study sought to address the Saudi high school students' knowledge and attitudes about HIV/AIDS and to explore their sources of information about the disease. Such knowledge assumes significance, not only in developing effective strategies for HIV/AIDS prevention in the future, but also in evaluating the impact of HIV/AIDS awareness measures taken so far by authorities in Saudi Arabia.

To serve the purpose of this study, a stratified random sampling technique was used to represent both male and female high school students in different parts of Riyadh city. The sample size equation n=(p)(1-p)(Z)²/e² yields that a sample size of 384 is required to represent large populations with 95% confidence level (Z=1.96), an error rate (e) of 5% and a proportion of the target population (p) equals 50%. To ensure a satisfied sample size and to allow for the possibility of non-responses such as refusal or incomplete answers, trained research assistants targeted 600 students in four high schools (two for boys and two for girls) using self-administered questionnaire during May and June 2008. Out of the distributed 600 questionnaires, 567 questionnaires were returned and valid for analysis (94.5% response rate).

The questionnaire was divided into five sections with a total of 40 items. Section I included questions on general knowledge about HIV/AIDS (9 items). Section II included questions about HIV/AIDS mode of transmission (11 items). Section III consisted of statements regarding students' attitude towards HIV/AIDS (7 items). In section IV, students were asked about their source of information about the disease (8 items). Finally, section V included questions about the degree to which respondents had discussed HIV/AIDS with friends, classmates, teachers, health staff and parents or relatives (5 items). The responses for items on the general knowledge and mode of transmission were in "true", "false" and "don't know" form and for items on attitudes a 5-point Likert scale ranging from "strongly disagree" to "strongly agree" were used. Items on respondents' source of information were scored on a 5-point Likert scale ranging from "none" to "very much". The responses for items on discussions of HIV/AIDS were dichotomized into "yes" and "no" responses.

A number of steps were taken to increase the content validity of the questionnaire. Firstly, a review of the relevant literature was carried out. Secondly, two epidemiologists and two school teachers reviewed the questionnaire. Finally, a pilot survey of 50 students (25 boys and 25 girls) was conducted. On the basis of the outcome of the pilot survey, a few questions were reformed and others were excluded. The covering letter of the questionnaire outlined the title and the purpose of the study and the identity of the researcher. Students were informed about the importance of the study and were encouraged to participate. All participants were informed on the issue of anonymity and no identifying information was included on the questionnaire. The data was analyzed in a descriptive fashion using the Statistical Package for Social Sciences (SPSS).

Respondents' profile
The findings revealed that the majority of students were Saudis 559 (98.6%) and unmarried 557 (98.2%). They were between 15 and 19 years old with a mean age of 17.1 years and 1.04 years of standard deviation. The majority 484 (85.4%) were aged 16 to 18 years. 291 (51.3%) were boys and 276 (48.7%) were girls. 199 (35.1%) of the students were in their 2nd grade of the high school and the remainder were split between first and third grades.

Respondents' general knowledge
Table 1 shows that three-quarters of respondents answered correctly that "there is no vaccine for HIV/AIDS that protects a person from getting HIV/AIDS" and more than two-thirds of respondents reported correctly that there is no active treatment for HIV/AIDS. Similarly, about two-thirds of respondents knew that AIDS is an infectious disease and a similar percentage of students reported that it is difficult to tell that a person has HIV/AIDS through appearance. The majority of students answered correctly that HIV/AIDS attacks the immune system. Over one-half of respondents reported that a person can have HIV for several years without knowing it. Only 40.7% of respondents knew that HIV and AIDS are not the same. Approximately one-third of respondents answered correctly that AIDS stands for the acquired immune deficiency syndrome. Just below 20% of the students answered correctly the statement that "all people who have HIV have AIDS".

Female students responded more correctly in this regard than males. For instance, girls were more likely to respond correctly to such questions as AIDS stand for acquired immune deficiency syndrome (p<0.001), that there is an active treatment for HIV/AIDS (p<0.01) and that a person cannot be known to have HIV/AIDS by his or her appearance (p<0.05). On the contrary, boys were more likely to respond correctly to the statement that HIV and AIDS are the same than girls (p<0.001).

Table 2 shows that the vast majority of students knew that HIV/AIDS could be transmitted through sexual relations (94%), receiving blood transfusions (85.4%) and sharp blades or needles (77.8%). Three-quarters of respondents knew that touching or shaking the hand of infected persons does not transmit the infection and a similar percentage of respondents identified correctly that a person can get HIV infection through "contaminated dentistry tools". The majority of students were able to report correctly that insect bites (71.8%), coughing or sneezing of an infected person (69.5%) and the use of public toilets (63.5%) do not transmit the disease. Similarly, just above half of the respondents knew that food utensils of infected persons do not transmit the disease. On the contrary, about one-third of students reported mistakenly that the infection can be transmitted from pregnant mothers to her unborn baby and more than half of students reported that "tears or mucus of infected person" can transmit the infection.

Male students were more likely to respond correctly to the statements that HIV/AIDS can be transmitted through sexual relations (p<0.01) and that HIV/AIDS can be transmitted by contaminated dentistry tools (p<0.05). Female students showed significantly more knowledge about what cannot transmit HIV/AIDS than male students. They were more knowledgeable about statements that HIV/AIDS cannot be transmitted through touching or shaking hands (p<0.05), exposure to coughing or sneezing (p<0.05) and through tears or mucus of infected persons (p<0.001).

Respondents' attitudes
Table 3 shows that over 95% of students agreed that the HIV/AIDS-infected students should be supported to cope with their disease and more than 85% of students indicated that HIV/AIDS-related topics should be added to schooling curricula. About 80% of students indicated that HIV/AIDS-infected students should inform others about their disease and a similar percentage reported that they would not sit close to HIV/AIDS-infected students. Over half of the students indicated that they would end their friendship with HIV/AIDS-infected classmates. Only 27% of the students agreed with the statement that students with HIV/AIDS should be isolated in special schools. There were no significant differences between male and female students in all statements about attitudes towards HIV/AIDS disease.

Respondents' source of information
Table 4 shows that more than 90% of the respondents indicated that television (TV) had contributed much to their knowledge about HIV/AIDS while about 73% and 63% of the respondents indicated that radio and newspapers respectively had contributed a little to their knowledge about the disease. About two-thirds of students indicated that none of the brochures or schools had contributed to their knowledge about the disease. The vast majority of students indicated that no health staff and parents (83.2% and 93.1% respectively) had contributed to their knowledge about HIV/AIDS. More than 60% of the students indicated that school has 'no' contribution to their knowledge about the disease. Moreover, Table 5 shows that more than 90% of the students had not discussed HIV/AIDS with their teachers, health staff or parents. The students reported that the major sources of their discussion about HIV/AIDS were friends and classmates (28% and 15.5% respectively).

Male students had a significantly higher mean score than female students in receiving information from newspapers (p<0.001), friends (p<0.01), schools (p<0.01) and health staff (p<0.05). On the contrary, female students had a significantly higher mean score (4.71) than males (4.47) in receiving information from TV (p<0.001). Findings about discussions on HIV/AIDS revealed that there were no significant differences between male and female students in all statements about sources of discussions.

The results of the study provide evidence that a considerable percentage of high school students were not knowledgeable enough on basic facts of HIV/AIDS, like the cause, mode of transmission, nature of the disease and its prevention. This yawning gap in knowledge most likely led to a defective attitude and some misconceptions towards HIV/AIDS and the infected people. These findings are in agreement with those reported earlier both from developing countries^20,21,22 and developed countries.^8,23

In this study, the negative attitudes toward infected persons might not be surprising since some individuals in Islamic communities link HIV/AIDS infection with the stigma of adultery, homosexuality and intravenous drug use.²⁴ Similar results of negative attitudes were reported in other studies. For example, some studies identified that a considerable percentages of students expressed that they would terminate their friendship with infected persons.²⁵ Similarly, a study conducted in Iran2 found that approximately half of the respondents expressed that an infected person should not be allowed to enter schools.

Consistent with findings in previous research,²⁶ the principle students' source of information about HIV/AIDS was TV. In this study, students claimed that the contribution of other sources of information was either "none" or "little". Generally, studies showed the importance of visual media in increasing people's knowledge about HIV/AIDS. Surprisingly, the contribution of sources, which should play a major role in acquiring students with necessary information about the disease, such as school and health staff, were minimal. A suggestion that would be of benefit is that teachers and health care providers should enhance students' knowledge and diminish the misconceptions about HIV/AIDS infection.

The results showed that more than 90% of the students did not discuss HIV/AIDS infection with their teachers, health staff and parents. This finding might not be surprising since discussions on sexual matters and related topics in Islamic countries, as well as in other countries, are taboo and diseases such as HIV/AIDS are stigmatizing. A study reviewed knowledge and attitudes of students about HIV/AIDS reported that sexual intercourse is perceived to be one of the most intimate and spontaneous behaviours about which verbal communication is often unacceptable in most societies.²⁷

The results of this study revealed significant difference in knowledge, attitudes and source of information about HIV/AIDS according to students' gender. It has been reported that there should be no difference between individuals in knowledge about a disease that is transmitted to all, not respecting race, color or gender.²⁸ Therefore, efforts should be given to remove inequalities in knowledge about this infectious disease among male and female students.

The findings of this study have several implications in terms of health education and HIV/AIDS prevention among students. Firstly, educational efforts and prevention programs targeting adolescents and high school students are needed in Saudi Arabia. Secondly, there should be an active involvement of teachers and health care providers in acquiring students with appropriate knowledge about the disease. Thirdly, information on HIV/AIDS, its mode of transmission and prevention should be integrated in the high schools curricula. In the absence of an effective treatment or vaccine for HIV/AIDS at present, health education remains the best format to prevent infection among the young generation.

Although the findings reported here may be influenced by the inevitable limitations of the study design and the available data, it is believed that the results provide a valuable insight into student's knowledge and attitudes towards HIV/AIDS in Saudi Arabia. One major limitation with this study is that the researcher was restricted in asking questions concerning students' behaviors and beliefs on matters such as sex and drug use. Secondly, this study took place in Riyadh city only.

Accordingly, the results may have limited applicability to other cities in Saudi Arabia. Thirdly, the results reported here are based on information collected by questionnaires and are subject to the usual problems of bias in reporting health care events. However, the questionnaire was anonymous, which should have encouraged accurate and honest self-disclosure. Future research should attempt to address some of the concerns indicated in the limitations.

This research was financially supported by the Research Center, College of Business Administration, King Saud University.

The author of this research would like to thank the Research Center in the College of Business Administration, King Saud University for financing this research.

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