HIV/AIDS knowledge and attitudes towards HIV and condom use among internally displaced Libyan males. Is there a need to implement sex education?

Abstract

Background

Displacement has been associated with an increased risk of HIV transmission. In light of the lack of data from Libya on sexual behavior and HIV/AIDS knowledge, the effort was undertaken to assess HIV/AIDS knowledge and attitudes towards HIV and condom use in Libyan internally displaced males (IDPs) in Tripoli.

Methods

Cross-sectional study design using purposive sampling to identify internally displaced Libyan males from five camps in Tripoli. HIV/AIDS knowledge, attitudes towards HIV and condom use, and prevention practices were evaluated through a self-administered, close/ended anonymous questionnaire in Arabic.

Results

The study population consisted of 390 participants, all Muslims, with a mean age of 32.81 years (SD = 8.93). Overall, the average HIV and prevention knowledge score was 6.34 (SD = 1.98). The majority of the respondents thereby had an insufficient or low knowledge’ level of HIV and prevention knowledge (58.70%). The mean attitude score indicated overall a negative attitude towards condom use (Mean = 32.60, SD = 7.97).

Conclusions

This is the first biobehavioral survey among IDPs in Libya demonstrating a low level of HIV and prevention knowledge as well as a prevailing negative attitude level of HIV/AIDS and condom use.

Keywords:

• Internally displaced persons
• HIV
• knowledge
• attitude
• condom use
• Libya

Introduction

Forced displacement has been an enduring reality of Libyan statehood for more than one decade now. In 2019–2023, spikes in conflict and insecurity have become the central drivers of the surge in internal displacement and the deterioration in the humanitarian situation in Libya [1]. The conflict forced about a million people from their homes, mostly to cities such as the capital, Tripoli. Most internally displaced persons (IDPs) were hosted by relatives and friends, while others stayed in collective shelters. As a result of the ceasefire in October 2020 there has been a marked decrease in IDP numbers, but while thousands of people have returned home, others are unable to do so, due to destroyed properties, insufficient basic services and continued armed conflicts.

Indeed, armed conflicts and forced displacement have been associated with increases in HIV transmission [2]. People may no longer have access to information about HIV prevention, condoms or more general knowledge on sexually transmitted diseases.

Of note, the Middle East and North Africa (MENA) region has the lowest prevalence of HIV in the world, less than 0.1% [2]. Main reason for the low HIV prevalence is because the MENA region is being predominately made up by countries that are religiously and culturally conservative. Nevertheless, an increase of HIV prevalence from 0.13% in 2004 to 0.2% in 2019 and 2022 has been reported for Libya [3–5] with. recent national data suggesting that there may be an increasing trend towards sexual transmission [6].

Currently no community-based prevention services or distribution of condoms through the Ministry of health are in place. In light of the lack of data from Libya on sexual behavior and HIV/AIDS knowledge, the effort was undertaken to survey 1) the knowledge level of IDPs regarding to HIV/AIDS, 2) their attitudes towards HIV/AIDS and condom use.

Methods

This cross-sectional study was designed to assess HIV/AIDS knowledge, attitudes, and prevention practices (KAP), employing a questionnaire with closed-ended answers. The study was conducted in Tripoli, where around 53,000 IDPs are living [7]. The target population was exclusively male IDPs aged between 18–49. This particular age range was chosen because of anticipated higher probability of sexual activity. With the permission of the local government of Tripoli, we asked for recruitment assistance from each camp. 390 participants were purposively recruited via social workers referral in the selected categories from five camps, respectively.

Data collection

All participants accessed the questionnaires as a hard copy between April-May 2023. They were encouraged to complete the self-administered questionnaire by receiving a bonus of internet coupons upon the completion of the survey. The 66-item questionnaire was adapted from previous studies [6,7] and adjusted for some questions to be suitable within an Arabian context. The questionnaire was translated into Arabic by one of the authors (FE) who speaks Arabic. In order to ensure that the translation was correct, a professional translator was engaged to check the translation and re-translate the questionnaire. Both versions were pilot-tested in 30 participants which were not included into the main study. All data was collected with the help of three assistants. The questionnaire was divided into six main themes as listed below:

1. Socio-demographics information

2. Knowledge on HIV/AIDS, modes of transmission and condoms use

3. Attitudes regarding HIV/AIDS and condom use

4. Availability, accessibility, affordability and acceptability of condom use

5. Alcohol consumption and drug use

6. Sexual activities as a risk behavior information

Demographic data collected included religion, education level, occupation, monthly average income, marital status, duration of stay in the IDP camp, and reasons for leaving home. HIV-related knowledge was assessed with a 11-item questionnaire [8,9]. Each item was measured via a yes/no/I don’t know, and only the correct response scored 1 point. Mastering 80% or more of the knowledge in the questionnaire was considered as having high or sufficient knowledge and was equal to a total score of 10 points or higher; moderate knowledge was defined as a score between 7–8 corresponding to 60–80% correct answers and a low knowledge as a score from 0–6 with 60% or less correct answers. Scoring was used in vise versa for the negative statements. The internal reliability (KR-20) for this questionnaire was 0.67. The Attitude Scale was used to measure the Libyan male IDPs’ condom use attitudes. The 8-item scale assessed the attitudes towards consistent and correct use of condoms reducing the risk of STD and HIV transmission, condoms availability, accessibility, affordability, and acceptability. Participants rated items on a Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). For each item, scores lower than 3 were recoded as ‘disagree, and scores of 3 and higher were recoded as ‘agree. A composite score was obtained by summing up the scores of each item, with higher scores indicating more conservative condom use attitudes. A score of 6–20; < 59% was considered a negative attitude, a score of 21–25; 60–80% as a neutral attitude and a score of 26–30; 81–100% as a positive attitude. Additional risk behaviors such as alcohol drinking, marijuana smoking and drug use in the context of sexual activities were also assessed. Sexual behavior wase assessed by asking IDPs about their sexual experiences, sexual orientation, current sexual partner, number of sex partner(s), and condom use during sexual intercourse. Those participants who had regular sexual intercourse were asked to rate the frequency of condom use during the last three intercourses based on three response options (1 = three times, 2 = two or less, 3 = don’t remember).

Data analysis

Descriptive statistic: categorical variables were analyzed by frequency, and percentage. Continuous variables were analyzed by mean, standard deviation to describe demographic characteristic. Inferential statistic: Logistic regression was used to explore unadjusted association between independents variables. Multiple logistic regression was used to analyzed adjusted association and fitting of the model by Pearson Chi-square statistic, and Hosmer and Lemeshow test. All data were performed by IBM SPSS version 26 and reported by adjusted odds ratios (aORs) and 95% confidence intervals at p < 0.05.

Ethical consideration

The study received clearance and approval to conduct the research through the Review Committee for Research Involving Human Research Subjects, Health Science Group Chulalongkorn University. Bangkok, Thailand under COA No.083/66, and from the Ethical Regulatory Authority of the Department of Health, Libya. Potential participants were informed about the nature and purpose of the study when they were invited to participate. We obtained consents from all participants. Appropriate measures were taken to ensure confidentiality and anonymity of participants. No names or any other individual identifiers were recorded in any part of the study.

Results

Demographic characteristics

The study population consisted of 390 participants, all Muslims (100%), majority (63.1%) aged between 18–34 years with a mean age of 32.81 years (SD = 8.93). The main baseline characteristics are shown in Table 1.

Table 1. Demographic characteristics.

Characteristics	n	Percentage (%)
Age (years)
18–34	246	63.1
35–44	95	24.3
>45	49	12.6
Mean ± SD = 32.81 ± 8.93
Religion Muslim	390	100
Marital status
Single	249	63.8
Married	141	36.2
Education
High School or lower	235	60.3
College or Postgraduate	155	39.7
Occupation
Student	56	14.4
Government Employee	88	22.6
Company employee	41	10.5
Self-owned business	142	36.4
Unemployed	50	12.8
Others	13	3.3
Monthly income
No income	116	29.7
200–500 USD	243	62.3
more than 500 USD	31	7.9
Duration of living in the IDP camps
4 years or less	286	73.3
more than 4 years	104	26.7
Reasons of leaving their home
My/my family Home was destroyed	279	71.5
Forced to leave home due to the war	81	20.8
Other reasons	30	7.7

Nearly two-third of participants had obtained a high school education or lower school form with an average monthly income between 200–500 USD in 62.3%. Around 63% were single. The majority 73.3% of IDPs had been residing in a camp for ≤4 years. The primary reasons for leaving their homes were the destruction of their own or their family’s home (71.5%) and being forced to flee due to war (20.8%).

HIV knowledge

A high level of awareness about HIV/AIDS in general was observed with 99.0% (386) of participants having heard of it. The responses to the HIV/AIDS knowledge questions (Table 2) provide insights into the participants’ comprehension of HIV/AIDS. Notably, the question with the highest correct answer rate was ‘One can get HIV through sharing piercing and cutting instruments like needles’, with a correct ratio of 89.38%. Clearly, the majority have a strong awareness of the risks associated with sharing contaminated instruments. However, it is worth noting that two other questions ‘Is there a medication that a person can use as prophylaxis to protect against HIV transmission?’ and ‘Do male and female condoms provide the same protection against HIV’? were only answered correctly by 24.09% and 37.05%, respectively. Overall, the average HIV and prevention knowledge score was 6.34 (SD ± 1.98). Most respondents had an insufficient or low knowledge’ level of HIV and prevention knowledge (58.70%).

Table 2. Results from the HIV/AIDS knowledge questions.

Question	Correct answers
	n	%
HIV can be transmitted by shaking hands/touching a person living with with HIV.^a	283	73.32
One can get HIV through unprotected sexual intercourse with an infected person	341	88.34
One can get HIV through sharing piercing and cutting instruments like needles.	345	89.38
One can get HIV through kissing on the cheek.^a	201	52.07
Do you think that people living with HIV look sick?^a	151	39.12
HIV patients can be treated? by treatment I mean availability of drugs that if taken regularly will make the person with HIV live normally	230	59.59
Can a person get a vaccine to prevent HIV infection?	214	55.44
Does using condoms reduce risk of HIV infection?	260	67.36
Do male and female condoms provide the same protection against HIV?	143	37.05
Does douching after sex reduce the risk of HIV infection?^a	170	44.04
Is there a medication can a person use it as prophylactic to protect against HIV transmission?	93	24.09

^a Negative question.

HIV/AIDS attitude

In term of attitudes towards HIV/AIDS, the average score was 15.47 (SD = 6.06) representing a negative attitude. Based on the criteria, 76.2% of participants held a negative attitude (6–20; < 59%), 18.7% had a neutral attitude (21–25; 60–80%), and 4.1% showed a positive attitude (26–30; 81–100%). Approximately 51.0% agreed that persons with a history of an AIDS-defining illness should be kept separately from their families and community. Furthermore, a significant majority of 65.3% agreed that HIV/AIDS is a form of divine punishment. Approximately 51.6% answered that HIV/AIDS diagnosis should be kept confidential, suggesting the existence of a potential stigma associated with disclosure. Only 39.4% agreed that, having sex without a condom a few times will not infect a person with HIV, indicating a relatively low level of awareness about the risks of unprotected sex and HIV transmission. Lastly, a significant proportion of 57.3% expressed trust in their partners’ inability to transmit HIV, suggesting a potential misconception about the role of trust in preventing transmission.

Attitudes towards condom use

The mean attitude score indicated overall a negative attitude towards condom use (M = 32.60, SD = 7.97). Approximately 84.4% agreed that condoms are effective in preventing pregnancy. However, 59.7% expressed concerns that condom use implies a lack of trust in their sexual partner. Additionally, 54.6% believed that insisting on condom use could potentially lead to relationship issues. Cost was a concern for 31.3% of participants. Furthermore, around 66.9% reported feeling uncomfortable purchasing condoms or asking for them. Communication challenges were evident, as approximately 55.4% of participants felt unable to discuss condom use with their sexual partner.

Condom use availability, accessibility, affordability, and acceptability

Most participants (97.2%) demonstrated awareness of what a condom is. However, 44.1% stated that they have never utilized one. In terms of accessibility, 75.9% respondents indicated easy access. The primary source for obtaining condoms was pharmacies (85.1%). Safety and trust (27.7%) and comfort (27.4%) emerged as the primary factors influencing condom purchase, followed by cost (13.6%). In terms of the supply of condoms, 38.7% of respondents reported providing condoms themselves. Finally, among the barriers to condom use, discomfort (28.5%) emerged as a significant concern.

Alcohol consumption and drug use risk behaviors

Overall, only few respondents stated to drink alcohol during their stay in the IDPs camp (16.4%). Furthermore, only few took Tramadol tablets (21.3%). However, Hashish (Marijuana) consumption was surprisingly high (42.1%). Most respondents denied injections (96.90%) as well as sharing of needles/syringes (98.20%).

Sexual activities: The majority (90.3%), reported feeling sexually attracted to females only, while a small percentage expressed attraction to males only (2.8%) or both females and males (6.2%). In addition, 63.6% reported having had sexual intercourse during their stay in the IDPs camp. When asked about condom use during their last three sexual encounters, only 6.7% reported always using condoms. Regarding the types of sexual partners, participants reported engaging with a variety of individuals, including girlfriends (13.3%), sex workers (1.8%), and one-night stands (45.4%). Furthermore, a significant proportion (49.0%) reported having more than two sexual partners during their stay in the IDPs camp. Lastly, the primary meeting place for current sexual partners was through the internet (31.8%).

Factors which impact condom use of IDPs Condom use

The results from the logistic regression analysis evaluating which factors impact condom use are shown in Table 3.

Table 3. Predictors for condom use of the IDPs (n = 359).

Predictor	Condom use (n = 359)
	b (SE)	aOR (95% CI)
Age	−0.004 (0.019)	0.996 (0.96–1.035)
HIV Knowledge	0.183** (0.07)	1.201 (1.046–1.379)
HIV Attitude	−0.045 (0.024)	0.956 (0.911–1.003)
Condom Attitude	0.089*** (0.021)	1.093 (1.048–1.14)
College or Postgraduate vs High school or lower	−0.269 (0.269)	0.764 (0.451–1.295)
Income
200–500 USD	1.315*** (0.31)	3.725 (2.028–6.84)
500 USD or higher	0.565 (0.571)	1.759 (0.575–5.386)
Married vs Single	1.033** (0.332)	2.809 (1.465–5.385)
Constant	−4.198*** (0.98)
Cox & Snell R Square	0,230
Nagelkerke R Square	0,307
Chi-square	93,845
Df	11
Sig.	< .001

aOR: Adjusted odds ration; ***p < .001, **p < .01, *p < .05.

The logistic regression model demonstrated a relatively good fit (Cox & Snell R Square = 0.230, Nagelkerke R Square = 0.307, χ²(11) = 93.845, p < 0.001). The significant predictor variables showed that participants with higher HIV knowledge had increased odds of condom use (aOR = 1.201, 95% CI: 1.046–1.379, b = 0.183, p < 0.01). Similarly, Individuals with a more positive attitude towards condoms showed higher odds of condom use (aOR = 1.093, 95% CI: 1.048–1.14, b = .089, p < 0.001). In term of income, Individuals with an income between 200–500 USD had significantly higher odds of condom use compared to those with no income (aOR = 3.725, 95% CI: 2.028–6.84, b = 1.315, p < 0.001). Finally, being married was associated with increased odds of condom use compared to being single (OR = 2.809, 95% CI: 1.465–5.385, b = 1.033, p < 0.01). Age, HIV attitude, education level, duration in camp, and the reason for leaving home were nonsignificant (p > 0.05).

Discussion

This is the first biobehavioral survey among male IDPs in Libya which clearly demonstrates that the majority of the respondents have a low level of HIV and prevention knowledge. Moreover, almost three quarter of the respondents had a negative attitude level of HIV/AIDS and condom use. Moreover, almost half of respondents did not use condoms thereby further increasing HIV transmission risk. Even after intensive PUBMED search we were unable to find similar studies on HIV knowledge and condom use in IDPs from other Arabian countries, thereby limiting possible comparisons with other settings. Nevertheless, it has been clearly demonstrated that people destabilized by armed conflict are at increased risk of exposure to HIV infection and have limited knowledge on contraceptive methods, STIs and HIV/AIDS [10,11]. The characteristics of the HIV epidemic, the interactions with armed forces, the occurrence of sexual violence and the risk behaviors associated with the new situation conditions of IDPs are all important factors affecting the risk of HIV transmission [12].

Despitevery limited literature related to males IDPs, it may be useful to compare data on HIV/AIDS knowledge and attitudes from other Arab countries even if they are not IDPs because they share the same culture and religious background. Indeed, a systemic review and metanalysis exploring HIV/AIDS knowledge and attitudes towards HIV/AIDS in the general population of the Arabian Peninsula found about half (52.8%) of those interviewed displayed negative attitudes toward HIV/AIDS [13]. In a large survey exploring HIV/AIDS knowledge and attitudes towards HIV/AIDS in 3841 participants more than 40% suggested that people living with HIV should be isolated and less than 20% would support a marriage with a person living with HIV [14]. Negative attitudes towards HIV/AIDS may have a significant impact on condom use. Indeed, in our study the internally displaced Libyan males who had a neutral level of attitude regarding HIV/AIDS had an increased odds of condom use compared to those who had a negative attitude level.

Strikingly, 60% of our participants expressed concerns that condom use implies a lack of trust in their sexual partner. This attitude may indicate a potential barrier to open communication and negotiation regarding condom use. Additionally, insisting on condom use could potentially lead to relationship issues or even a breakup. Cost was also a concern for a notable proportion (31%) of our participants, which may additionally affect the accessibility and consistent use of condoms. Indeed, no community program is currently in place which is distributing condoms and also no free condom distribution exists via the ministry of health. More than half of all participants felt unable to discuss condom use with their sexual partner, underscoring the importance of improving communication skills and promoting an open dialogue about sexual health and protection.

Only 2.8% of our study subjects reported same sex preferences. A recent study measuring HIV prevalence and risk factors among men who have sex with men in Libya found a higher HIV prevalence and low HIV knowledge in this particular subgroup [13]. Only 21% of the MSM included into this study reported using condoms [13]. These findings call for specific prevention programs for MSM in Libya [15].

Of note around 20% of our respondents reported alcohol use and almost half consumed at least intermittently marihuana. Clearly, alcohol and drug use has been extensively demonstrated to increase high risk sexual behavior and increase risk for transmission of HIV. Countries with Muslim majorities have the lowest alcohol use in the world [16]. However, they have a higher proportion of alcohol consumed being unrecorded. Also, IDPs may be at particular risk for substance use for reasons including coping with traumatic experiences, co-morbid mental health disorders, acculturation challenges and social and economic inequality [17].

Interestingly, a recent study on the impact of the armed conflict on the prevalence and transmission dynamics of HIV Infection in Libya demonstrated that there was no variation in the number of reported cases within the resident individuals, (16% in 2011 and 17.2% in 2020). However, those reported from the displaced individuals gradually increased from 2.9% during the beginning of the Arab spring period in 2011 to 4.7% in 2013 and 2014, and then increased further to 12.6% during the civil war, but returned to 4.8% during the cease-fire and no conflict period [18]. These results underline the enhanced HIV transmission risk in IDPs. In Summary, this is the first biobehavioral survey among IDPs in Libya demonstrating a low level of HIV and prevention knowledge as well as a prevailing negative attitude level of HIV/AIDS and condom use. Under consideration of the recent impact of the armed conflict on the epidemiological patterns of HIV infection in Libya with increasing HIV transmissions there is a clear need for educational preventive interventions with the aim to increase HIV/AIDS prevention knowledge not only to increase awareness about STDs and transmission pathways and modes of protection, but also to improve attitude levels towards HIV/AIDS in general. Only a stigma-free open discussion of HIV/AIDS eventually will have an impact on limiting the further spread of HIV in Libya

Limitations

This study only included male IDPs who were available in the respective camps; the findings therefore cannot be generalized for all IDPs in Libya. The Arab communities and families are uncomfortable with discussing their sexuality and this may have impacted individual responses. Due to the unstable political situations it was not easy to promote this kind of research within the IDPs camps. The use of a composite score which was validated in other settings may not be directly transferable into the setting of IDPs and therefore has some limitations. Finally, in our logistic regression analysis all study subjects were included. A subgroup however, reported no sex while in the IDP camp which may have impacted their answers regarding condom use accordingly.

Conclusions

In Summary, this is the first biobehavioral survey among IDPs in Libya demonstrating a low level of HIV and prevention knowledge as well as a prevailing negative attitude level of HIV/AIDS and condom use. Our findings strongly support the urgent call to develop effective strategies for prevention of HIV and promote condom use among the IDPs in Tripoli (in particular) and among young people in Libya (in general).

Acknowledgment

The authors would like give expressions their gratitude to the health care professionals at the Center for Disease Control for their generosity and invaluable assistance in collecting data and retrieving charts and to Dr. Pyae Linn Aung for supporting the data analysis.

Disclosure statement

FE, WK, YM and TP have no conflict of interest to report. JKR has received honoraria for consulting or speaking at educational events from Abbvie, Boehringer, Gilead, Merck, Janssen, and ViiV.

Additional information

Funding

Not applicable