Evaluating knowledge, practice, and attitude of Syrian population on sexually transmitted infections and human immunodeficiency virus

Abstract

Background

Human immunodeficiency virus (HIV) and sexually transmitted infections (STIs) can cause severe and fatal complications; knowledge about these diseases is essential for promoting safe sex practices and modifying behaviours that are harmful to one’s health. This study investigates Syrian people’s understanding, attitudes, and behaviors towards HIV/AIDS and STIs, aiming to identify factors promoting safe sex practices and modifying harmful behaviors.

Methods

This online cross-sectional study was conducted in Syria between 3 September and 23 November 2022, involving all 18+ individuals. The questionnaire was adapted from a previous study containing 74 questions from five sections: socio-demographic information, knowledge and practice regarding STIs, knowledge and practice regarding HIV/AIDS, attitude towards HIV/AIDS, and attitude regarding STIs and analyzed using descriptive and multivariate logistic regression.

Results

The study involved 1073 participants mostly aged between 18–30, with 55.3% females. Over half had good awareness of STIs and HIV/AIDS, with 55% and 63% respectively. Specifically, the overall knowledge level of STI type, signs/symptoms, risks of transmission, preventive methods, and complications for untreated STIs were (45.7%), (52.9%), (58.1%), (66.1%), and (59.6%), respectively. Medical field respondents had higher knowledge of HIV (P-value < 0.05, OR = 2).

Conclusion

Our results show that Syrian people have a knowledge level of STIs and HIV was moderate. However, the attitude toward STIs was negative, as less than half of the participants had a good attitude. It is essential to solve these knowledge gaps, especially in low-income countries such as Syria.

Keywords:

• Knowledge
• HIV
• Syrial population
• attitude

1. Introduction

Sexually transmitted infections (STIs) refer to certain types of infectious diseases that are acquired mainly through sexual contact [1]. Certain viruses and bacteria mostly cause STIs. However, other microorganisms, such as parasites, fungi, protozoa, and arthropods, can also be responsible. Among more than 30 types of STIs, human immunodeficiency virus (HIV) infection, gonorrhoea, trichomoniasis, chlamydia, syphilis, chancroid, genital herpetic infection, genital HPV infection, and HBV infection are the most common types [1]. Globally, WHO documented that more than 1 million people acquire new STIs every day, the majority of which are asymptomatic [2]. Different types of STIs may coexist or be acquired simultaneously, and the presence of one type can raise the possibility of acquiring another type. STIs also have a direct effect on sexual and reproductive health because they can lead to infertility, several cancers, complications during pregnancy, social stigma, and a higher risk of getting HIV [2].

HIV primarily targets the immune system and, over time, makes it ineffective in fighting many infectious diseases and some cancers [3]. HIV infection and its resulting acquired immune deficiency syndrome (AIDS) remain a global health issue despite intensive measures locally and internationally to control this disease [4]. According to recent data from the WHO Programme on HIV/AIDS in 2022 globally, it is estimated that 39 million people were living with HIV infection, with 29.8 million people receiving antiretroviral therapy (ART).

Among the infected people, 1.5 million were children aged between 0 and 14 years, and more than half of the infected people were females (53%). Approximately 1.3 million new cases of AIDS were reported in 2022, and 630,000 individuals died from AIDS-related illnesses [5].

In the Eastern Mediterranean region, the year 2022 witnessed the documentation of 490,000 extant instances of AIDS, with an additional 56,000 newly identified cases. Notably, the same year recorded 20,000 fatalities attributed to HIV-related factors, reflecting a substantial 72.3% surge compared to statistics from 2010 [6]. In 2022, Syria recorded an HIV prevalence of fewer than 1000 cases among individuals aged 15 and above, with less than 200 of them being females. However, the reported fatalities attributed to AIDS in this demographic were fewer than 100 cases. Within the subset of adults aged 15 and above undergoing ART, the utilization of ART was documented in only 332 cases [7].

Worldwide, heterosexual contact between men and women remains the main route for HIV transmission, as well as homosexual contact between men and men remains one of the most common mode of HIV transmission, and it was estimated to be responsible for 17% of new infections in 2018, followed by drug injections, which accounted for 12% of new infections. However, drug injections were the most common mode of HIV transmission in the Middle East and North Africa, as they were estimated to be responsible for 37% of new HIV infections in 2018 [8].

The risk of HIV transmission is very high in the early months of infection; however, most HIV-infected people are unaware of their condition during this crucial period. Thus, early diagnosis and treatment of newly infected individuals are important to reduce the possibility of infection transmission [9]. Adolescent girls, sex workers, gay men, transgender people, people who inject drugs, prison populations, and migrants are key demographic groups in many countries that have considerably higher rates of HIV incidence and AIDS-related death than the overall population [10].

According to the most recent WHO statistics, 0.02% of all deaths were due to HIV/AIDS in Syria in 2020 [11]. With an age-adjusted death rate of 0.09 per 100,000, Syria comes in at the 159th position in the world [11]. Several studies have shown that knowledge about HIV/AIDS is crucial for encouraging safe sex practices and altering behaviours that harm one’s health [12,13]. In developing countries, STI treatment and follow-up measures are hampered due to many factors, including a pervasive stigma regarding STIs, especially HIV, a lack of good public knowledge, insufficiently educated healthcare professionals, and the high cost of STIs diagnostic tests [2].

In Syria, data on knowledge, attitude, and practice regarding STIs are limited; furthermore, there is little information on the Syrians’ issues regarding sexual and reproductive health. Thus, this study aimed to identify which individual variables best predict knowledge, attitudes, and behaviours regarding HIV/AIDS and other STIs among a Syrian sample.

2. Methods

2.1. Study design and setting

A descriptive community-based cross-sectional study was conducted in Syrian governorates from the 3 September to the 23 November 2022 to identify which individual variables best predicted knowledge, attitudes, and behaviours regarding HIV/AIDS and other STIs. The inclusion criteria for the study were Syrian nationality, male or female, aged at least 18 years, a citizen of any Syrian governorate, and being willing to participate. We excluded non-Syrian nationals, Syrians under 18, and respondents who could not complete the poll. Sample size calculation was performed using the Calculator.net website [14]. Taking into consideration a total Syrian population of 18,410,965 million [15], with a 5% margin of error at a 95% confidence level, the expected proportion = 50% (assumption of a 50% knowledge level, since there is no founded data on HIV/AIDS and other STIs knowledge in Syria), the minimal required sample size was estimated to be 385. The final sample size was 1076.

2.2. Data collection and measures

Data were collected using a modified online semi-structured questionnaire created on Google Forms based on an earlier similar study [16]. Questionnaires were not modified majorly to ensure their integrity as it has already been validated and accepted for use in cross-sectional studies to assess knowledge and attitudes. Two public health experts translated the questionnaire into Arabic (native language) so that the participant could comprehend it, and it was then retranslated into English to ensure correctness. Seven medical students (Data Collection Group) were responsible for the data collection process. Participants were invited to participate via an invitation link through social media platforms such as Facebook, WhatsApp, and Telegram. In addition, the data collection group utilized a face-to-face interview to collect the data from participants.

A professional healthcare investigator monitored the data collection process and guided the data collection group to prevent biased data and repeated or illogical responses.

The questionnaire was divided into five main sections: socio-demographic information, knowledge and practice relating to STIs, knowledge and practice relating to HIV/AIDS, attitude towards HIV/AIDS, and attitude towards STIs.

2.2.1. Socio-demographic variables

Participants’ socio-demographic characteristics were inquired through eight questions: age, sex, marital status, religion, education level, occupation, residence, and economic status.

2.2.2. Knowledge and practices relating to STIs

Respondents’ knowledge of STIs was evaluated by six groups of questions, which were about the ‘meaning of STIs,’ ‘its types,’ ‘its risk factors,’ ‘its main clinical manifestations,’ ‘its prevention methods,’ and ‘its complications if not treated.’ The given answers to the included questions were ‘yes’, ’no," and ‘I do not know.’ Each correct answer was scored one (1) point, while each incorrect answer was scored zero (0) point. From the total given points for all questions, the mean score was calculated to differentiate the respondents into two categories: knowledgeable and non-knowledgeable. Respondents with a score equal to the mean or more were considered knowledgeable, whereas those who got a score less than the mean were considered non-knowledgeable [3]. Regarding respondents’ practice about STIs, it was measured by calculating the percentage of respondents who had themselves screened for STIs at least once.

2.2.3. Knowledge and practices relating to HIV/AIDS

Respondents’ knowledge of HIV/AIDS was evaluated by two groups of questions, which were: ‘routes of HIV transmission’ and ‘prevention methods of HIV.’ The given answer options for each particular question were ‘yes,’ ‘no,’ and ‘I do not know.’ As previously, the mean score was used to differentiate between respondents who were considered knowledgeable or not [3].

Regarding respondents’ practice of HIV, it was measured by calculating the percentage of respondents who had been tested for HIV infection at least once [3].

2.2.4. Attitude towards HIV

Respondents’ attitude towards HIV-related facts was inquired using attitude-based 11 questions; 3-point Likert-scale items (‘agree,’ disagree and do not know) were used as answer options for these questions. Each correct answer scored one (1) point, while each incorrect answer scored zero (0). From the total given points for all questions, the mean score was calculated to differentiate the respondents into two categories: positive attitude and negative attitude. Respondents with a score equal to or more than the mean were considered to have a positive attitude towards HIV-related facts. In contrast, those who scored less than the mean were considered to have a negative attitude towards HIV-related facts [3].

2.2.5. Attitude towards STIs

Respondents’ attitude towards STIs was examined using attitude-based eight questions; similarly, a 3-point Likert-scale item (‘agree,’ disagree and do not know) was used to collect the overall attitude score. Each correct answer scored one (1) point, while each incorrect answer scored zero (0). From the total given points for all questions, the mean score was calculated to differentiate the respondents into two categories: positive attitude and negative attitude. Respondents who scored equal to the mean or more were considered to have a positive attitude towards STIs-related facts, whereas those who scored less than the mean had a poor attitude towards them [3].

2.3. Pilot study

In order to prove the questionnaire’s validity and clarity, we first administered it to 20 random people (who were then excluded from the final sample). We used this sample to ensure it was internally consistent (Cronbach’s alpha ranged from 0.712 to 0.861).

2.4. Ethical consideration

The ethical approval was granted by the Syrian Ethical Society for Scientific Research (IRB: AP-067/13). In addition, Aleppo University granted ethical clearance. All respondents were informed about the purpose of the survey, the researchers’ identities, and their ability to reject participation. The respondents’ consent was inquired on the first page of the survey: ‘yes’ or ‘no.’ Furthermore, the respondents were informed about data protection, their privacy rights, and the reality that only fully entered data would be examined. Each answer was stored in a secure online database.

2.5. Statistical analysis

The statistical data analysis was performed using the IBM SPSS version 28.0 package program (IBM Corporation, Armonk, NY). A p value less than 0.05 was considered for statistical significance. Categorical variables based on the sociodemographic characteristics of the parents were expressed using descriptive statistics and frequencies. For the statistical analysis, we categorized the levels of knowledge into ‘good’ and ‘poor’ based on two modified Bloom’s cutoff criteria: 70% and 80% of the total score (i.e. if a participant answered 24 and 27 of the total 34 questions correctly, respectively). A univariate analysis using the Mann–Whitney U-test (for non-normal continuous variables), t-test (for normal distribution of continuous variables), and chi-square test (for categorical variables) was performed to determine factors influencing the knowledge level of participants. Then, a multivariate logistic regression analysis was conducted for the variables with significance (p < 0.05) in the univariate analysis to evaluate the odds ratios of the factors determining the knowledge level of participants.

3. Results

3.1. Sociodemographic characteristics

A total of 1073 participants were included in this study. The majority were (n = 929, 85.7%) (aged 18–30 years old, and more than half (n = 599; 55.3%) were females. Eighty-one percent of participants were single, and (89.7%) had a college education degree. Regarding the living sites and conditions (60.5%) of participants were living in cities, and 70.3% lived with their families (Table 1).

Table 1. The characteristics of the participants.

	Frequency	Percentage
Age
18–30	929	85.7
31–40	109	10.1
41–50	30	2.8
>50	16	1.5
Gender
Female	599	55.3
Male	485	44.7
Social status
Single	882	81.4
Married	187	17.3
Divorced/widowed	15	1.4
Educational level
No education	10	0.9
Primary School	7	0.6
Middle School	19	1.8
Secondary School	76	7.0
College Education	972	89.7
Working status
Had no job	130	12.0
Employed	207	19.1
Student	658	60.7
Others	89	8.2
Belonging to the medical field
No	443	40.9
Yes	641	59.1
Living place
Rural area	428	39.5
City	656	60.5
Living condition
Alone	94	8.7
With family	762	70.3
With friends	66	6.1
With wife/husband	150	13.8
With relatives	12	1.1
Having chronic disease
No	989	91.2
Yes	95	8.8

3.2. Knowledge and attitude of participant towards AIDS/HIV

A high proportion of participants had heard about AIDS/HIV, 98%. In contrast, 737 (68.7%) respondents had heard about voluntary counselling and testing (VCT). Fifty-one percent of participants had knowledge regarding how HIV transmits among people. Unsafe sexual intercourse and blood transfusion were the most commonly reported ways of HIV transmission (both at 98%). Moreover, 34.6% of respondents knew how to protect themselves from HIV infection; the most known protective methods were avoiding unsafe injections and avoiding contaminated sharp objects (96.6%) (97.3%). Generally, 55% of participants were knowledgeable in terms of AIDS/HIV (Table 2). Regarding the attitude towards HIV, we concluded that 47.1% had a good attitude. The most reported fact related to AIDS/HIV was that people with multiple sex partners have a high risk of acquiring HIV (92.4%) (Table 3).

Table 2. The knowledge of participants about AIDS/HIV.

Variables	Frequency	Percentage
Have you ever heard about AIDS/HIV?
No	21	2.0
Yes	1052	98.0
What are the ways of HIV transmission? (n = 1076)
Unsafe sexual intercourse
No	19	1.8
Yes	1054	98.2
Sharing needles and syringes
No	25	2.3
Yes	1048	97.7
Blood transfusion
No	17	1.6
Yes	1056	98.4
During pregnancy
No	191	17.8
Yes	882	82.2
During childbirth
No	374	34.9
Yes	699	65.1
Through breast milk
No	693	64.6
Yes	380	35.4
Through mosquito and another insect bite
No	794	74.0
Yes	279	26.0
Casual contact with a person (handshaking.)
No	978	91.1
Yes	95	8.9
Average knowledge of HIV transmissions
Mean\SD	6.42	1.10
Not knowledgeable	524	48.8%
Knowledgeable	549	51.2%
What are the ways of HIV prevention? (n = 1076)
Abstain from sexual intercourse
No	575	53.6%
Yes	498	46.4%
Use a condom during sexual intercourse
No	255	23.8%
Yes	818	76.2%
Remain faithful to a partner
No	48	4.5%
Yes	1025	95.5%
Avoid contaminated sharp objects
No	36	3.4%
Yes	1037	96.6%
Avoid unsafe injections
No	29	2.7%
Yes	1044	97.3%
Avoid sex with sex workers
No	73	6.8%
Yes	1000	93.2%
Average knowledge of HIV preventions
Mean\SD	5.05	0.90
Not Knowledgeable	700	65.4%
Knowledgeable	370	34.6%
Have you ever heard about VCT?
No	336	31.3%
Yes	737	68.7%
Have you ever tested for HIV?
No	971	90.5%
Yes	102	9.5%
Overall HIV knowledge level
Mean\SD	11.48	1.55
Not knowledgeable	483	45.0%
Knowledgeable	590	55.0%

Table 3. The attitude of the participants towards HIV/AIDS.

	Frequency	Percentage
Do you think a person can get HIV for the first time he or she has sex?
Disagree	169	15.8%
Do not know	219	20.4%
Agree	685	63.8%
Do you think, by looking carefully, one can know if someone has HIV
Disagree	613	57.1%
Do not know	211	19.7%
Agree	249	23.2%
Do you think HIV/AIDS is severed and more affects youth?
Disagree	118	11.0%
Do not know	127	11.8%
Agree	828	77.2%
Do you think premarital sex for youths is not supported?
Disagree	134	12.5%
Do not know	111	10.3%
Agree	828	77.2%
Do you think AIDS patients should be isolated for the safety of others?
Disagree	316	29.5%
Do not know	79	7.4%
Agree	678	63.2%
Do you think discussing condoms or contraceptives with young people promote promiscuity?
Disagree	443	41.3%
Do not know	204	19.0%
Agree	426	39.7%
Do you think that using a condom is a sign of not trusting a partner?
Disagree	686	63.9%
Do not know	189	17.6%
Agree	198	18.5%
Wife has a right to refuse unprotected sex with her husband if she wants to use a condom and if a husband not?
Disagree	225	21.0%
Do not know	266	24.8%
Agree	582	54.2%
Do you think a person having multiple sex partners has a high risk of acquiring HIV?
Disagree	31	2.9%
Do not know	51	4.8%
Agree	991	92.4%
Do you think HIV infected person can live longer if she or he is taking antiretroviral treatment?
Disagree	183	17.1%
Do not know	332	30.9%
Agree	558	52.0%
Do you think eating healthy foods can keep a person from getting HIV?
Disagree	750	69.9%
Do not know	195	18.2%
Agree	128	11.9%
Attitude of HIV/AIDS
Mean\SD	6.1379	2.08888
Poor attitude	561	52.9%
Good attitude	499	47.1%

3.3. Knowledge and attitude of participant towards STIs

As reported in (Table 4), the percentage of participants who had ever heard about STIs was 93.6%, while those who knew the definition of STIs were 89.7|%. (52.9%) Moreover (45.7%) of respondents, respectively, had knowledge about the signs and symptoms of STIs and their types. Furthermore, knowledge of STI prevention methods and STI transmission ways was 66.1% and 58.1%, respectively. Overall, 56% of participants were considered knowledgeable regarding STIs, and only 38.4% had a favourable attitude (Table 5).

Table 4. The knowledge of participants about STIs.

Variables	Frequency	Percentage
Have you ever heard about STIs?
No	69	6.4%
Yes	1004	93.6%
What is STIs (n = 1076)
Illnesses transmitted by sexual intercourse	110	10.3%
Do not know	963	89.7%
Which type of STIs did you know? (n = 1076)
Gonorrhea
No	228	21.2%
Yes	845	78.8%
Syphilis
No	252	23.5%
Yes	821	76.5%
Chancroid
No	604	56.3%
Yes	469	43.7%
Lymphogranuloma venerum
No	700	65.2%
Yes	373	34.8%
HIV/AIDS
No	24	2.2%
Yes	1049	97.8%
Do not know
No	649	60.5%
Yes	424	39.5%
Average knowledge of the type of STIs
Mean\SD	3.3150	1.27238
Not knowledgeable	583	54.3%
Knowledgeable	490	45.7%
Which signs/symptoms of STIs did you know? (n = 1076)
Genital ulcer
No	201	18.7%
Yes	872	81.3%
Genital discharge
No	180	16.8%
Yes	893	83.2%
Pain during urination
No	303	28.2%
Yes	770	71.8%
Genital swelling
No	264	24.6%
Yes	809	75.4%
Do not know
No	636	59.3%
Yes	437	40.7%
Average knowledge of signs/symptoms of STIs
Mean\SD	3.1165	1.19406
Not knowledgeable	505	47.1%
Knowledgeable	568	52.9%
Which risks of STIs transmission did you know? (n = 1076)
Unprotected sex
No	47	4.4%
Yes	1026	95.6%
Inconsistent condom use
No	227	21.2%
Yes	846	78.8%
Having multiple partners
No	33	3.1%
Yes	1040	96.9%
Sex work
No	26	2.4%
Yes	1047	97.6%
Pregnancy
No	656	61.1%
Yes	417	38.9%
Sharing cloths
No	788	73.4%
Yes	285	26.6%
Do not know
No	737	68.7%
Yes	336	31.3%
Average knowledge of risks of STIs transmissions
Mean\SD	4.5666	0.87964
Not knowledgeable	450	41.9%
Knowledgeable	623	58.1%
Which prevention methods of STIs did you know? (n = 1076)
Screening and diagnosis of risky individuals
No	32	3.0%
Yes	1041	97.0%
Treatment of patients & their sexual partners
No	63	5.9%
Yes	1010	94.1%
Use of condom prevent STIs
No	333	31.0%
Yes	740	69.0%
Do not know
No	703	65.5%
Yes	370	34.5%
Average knowledge of prevention methods of STIs
Mean\SD	2.6011	0.61940
Not knowledgeable	364	33.9%
Knowledgeable	709	66.1%
What are the complications of untreated STIs? (n = 1076)
Upper genital tract infections
No	134	12.5%
Yes	939	87.5%
Infertility
No	272	25.3%
Yes	801	74.7%
Cervical cancer
No	212	19.8%
Yes	861	80.2%
Enhanced transmission and acquisition of HIV
No	102	9.5%
Yes	971	90.5%
Others (bleeding)
No	232	21.6%
Yes	841	78.4%
Average knowledge of complication of untreated STIs
Mean\SD	3.3290	0.98063
Not knowledgeable	434	40.4%
Knowledgeable	639	59.6%
Overall knowledge of STIs
Mean\SD	17.8257	3.47545
Not knowledgeable	397	37.0%
Knowledgeable	676	63.0%

Table 5. The attitude of the participants towards STIs.

	Frequency	Percentage
Do you think STIDs are not as dangerous as they can be cured?
Disagree	715	66.6%
Do not know	120	11.2%
Agree	238	22.2%
Do you think screening for STIDs is good?
Disagree	35	3.3%
Do not know	77	7.2%
Agree	961	89.6%
Do you think a person who is infected with STID must be treated?
Disagree	30	2.8%
Do not know	40	3.7%
Agree	1003	93.5%
Do you think isolating a person who is infected with STID can help prevent the spread of the disease?
Disagree	244	22.7%
Do not know	84	7.8%
Agree	745	69.4%
Do you think STIDs affect the marital relationship?
Disagree	38	3.5%
Do not know	51	4.8%
Agree	984	91.7%
Do you think a person who is infected with STIDs can be cured?
Disagree	105	9.8%
Do not know	178	16.6%
Agree	790	73.6%
I do not mind if others know that I am with STIDs
Disagree	541	50.4%
Do not know	205	19.1%
Agree	327	30.5%
Do you think STIDs patients pay the price for their immoral life?
Disagree	191	17.8%
Do not know	147	13.7%
Agree	735	68.5%
The overall attitude towards STIs
Mean\SD	5.0596	1.38495
Poor attitude	661	61.6%
Good attitude	412	38.4%

Table 6. Determinants of knowledge about HIV/AIDS and other STIs among participants.

		No		Yes		P-Value	AIR	CI 95%		P-Value	COR	CI 95%
		Frequency	Percentage	Frequency	Percentage			Lower	Upper			Lower	Upper
Variables associated with knowledge of HIV/AIDs
Age	18–30	395	36.8%	524	48.8%	.196				0.005
	31–40	66	6.2%	42	3.9%	.065	.640	.399	1.027	0.000	0.480	0.319	0.722
	41–50	15	1.4%	15	1.4%	.732	1.149	.519	2.541	0.446	0.754	0.364	1.560
	>50	7	0.7%	9	0.8%	.469	1.470	.517	4.178	0.951	0.969	0.358	2.625
Working status	Had no job	56	5.2%	70	6.5%	.043				0.003
	Employed	105	9.8%	101	9.4%	.051	.619	.383	1.002	0.249	0.770	0.493	1.201
	Student	269	25.1%	383	35.7%	.101	.693	.448	1.074	0.507	1.139	0.775	1.673
	Others	53	4.9%	36	3.4%	.005	.435	.242	.783	0.030	0.543	0.313	0.942
Belonging to the medical field	No	250	23.3%	188	17.5%
	Yes	233	21.7%	402	37.5%	.000	2.004	1.513	2.655	0.000	2.294	1.789	2.942
Have you ever heard about AIDS/HIV?	No	18	1.7%	3	0.3%
	Yes	465	43.3%	587	54.7%	.003	7.239	1.979	26.486	0.001	7.574	2.218	25.869
Have you ever heard about VCT?	No	182	17.0%	154	14.4%
	Yes	301	28.1%	436	40.6%	.031	1.356	1.027	1.790	0.000	1.712	1.320	2.220
Have you ever tested for HIV?	No	446	41.6%	525	48.9%
	Yes	37	3.4%	65	6.1%	.009	1.872	1.170	2.996	0.064	0.670	0.439	1.023
Have you ever heard about STIDs?	No	49	4.6%	20	1.9%
	Yes	434	40.4%	570	53.1%	.040	1.839	1.027	3.293	0.000	3.218	1.885	5.493
Variables associated with attitude towards HIV/AIDs
Educational level	No education	7	0.7%	1	0.1%	0.333				0.000
	Primary School	6	0.6%	1	0.1%	0.731	1.724	0.077	38.585	0.919	1.167	0.059	22.937
	Middle school	16	1.5%	2	0.2%	0.730	1.594	0.113	22.532	0.919	0.875	0.068	11.313
	Secondary school	48	4.5%	23	2.2%	0.169	4.784	0.513	44.620	0.271	3.354	0.389	28.894
	College education	484	45.7%	472	44.5%	0.163	4.744	0.533	42.249	0.073	6.826	0.837	55.697
Working status	Had no job	76	7.2%	47	4.4%	0.005				0.020
	Employed	97	9.2%	107	10.1%	0.296	1.317	0.785	2.209	0.013	1.784	1.131	2.814
	Student	333	31.4%	312	29.4%	0.133	0.697	0.435	1.116	0.039	1.515	1.021	2.249
	Others	55	5.2%	33	3.1%	0.399	0.763	0.407	1.430	0.916	0.970	0.552	1.706
Belonging to the medical field	No	288	27.2%	139	13.1%
	Yes	273	25.8%	360	34.0%	0.000	2.648	1.963	3.573	0.000	2.732	2.114	3.531
Living place	Rural area	258	24.3%	159	15.0%
	City	303	28.6%	340	32.1%	0.000	1.725	1.324	2.247	0.000	1.821	1.417	2.340
Have you ever heard about AIDS/HIV?	No	17	1.6%	1	0.1%
	Yes	544	51.3%	498	47.0%	0.026	10.823	1.338	87.522	0.008	15.562	2.064	117.367
Have you ever heard about VCT?	No	200	18.9%	130	12.3%
	Yes	361	34.1%	369	34.8%	0.129	1.247	.938	1.658	0.001	1.573	1.207	2.048
Have you ever heard about STIDs?	No	57	5.4%	8	0.8%
	Yes	504	47.5%	491	46.3%	0.001	3.988	1.806	8.807	0.000	6.941	3.278	14.700
Variables associated with knowledge of STIs
Age	18–30	321	29.9%	598	55.7%	0.480				0.005
	31–40	50	4.7%	58	5.4%	0.256	1.379	0.792	2.400	0.021	0.623	0.417	0.931
	41–50	16	1.5%	14	1.3%	0.377	1.567	0.579	4.241	0.042	0.470	0.226	0.975
	>50	10	0.9%	6	0.6%	0.575	0.690	0.188	2.530	0.030	0.322	0.116	0.894
Social status	Single	296	27.6%	579	54.0%	0.469				0.000
	Married	96	8.9%	87	8.1%	0.853	1.083	0.467	2.512	0.000	0.463	0.336	0.639
	Divorced/widowed	5	0.5%	10	0.9%	0.218	2.378	0.599	9.446	0.968	1.022	0.346	3.019
Educational level	No education	3	0.3%	7	0.7%	0.169				0.000
	Primary school	5	0.5%	2	0.2%	0.253	0.230	0.019	2.851	0.104	0.171	0.020	1.436
	Middle school	14	1.3%	5	0.5%	0.109	0.188	0.024	1.451	0.030	0.153	0.028	0.833
	Secondaryschool	52	4.8%	24	2.2%	0.067	0.187	0.031	1.123	0.027	0.198	0.047	0.832
	College education	323	30.1%	638	59.5%	0.230	0.345	0.061	1.959	0.810	0.847	0.217	3.295
Working status	Had no job	66	6.2%	60	5.6%	0.978				0.000
	Employed	88	8.2%	118	11.0%	0.824	0.940	0.546	1.619	0.087	1.475	0.945	2.303
	Student	201	18.7%	451	42.0%	0.965	1.011	0.615	1.664	0.000	2.468	1.676	3.635
	Others	42	3.9%	47	4.4%	0.794	0.917	0.478	1.759	0.454	1.231	0.715	2.120
Belonging to the medical field	No	260	24.2%	178	16.6%
	Yes	137	12.8%	498	46.4%	0.000	4.442	3.248	6.076	0.000	5.310	4.059	6.945
Living place	Rural area	184	17.1%	239	22.3%
	City	213	19.9%	437	40.7%	0.008	1.482	1.108	1.983	0.000	1.580	1.227	2.033
Living condition	Alone	35	3.3%	58	5.4%	0.443				0.001
	With family	255	23.8%	500	46.6%	0.233	1.366	.818	2.280	0.459	1.183	0.758	1.848
	With friends	26	2.4%	39	3.6%	0.801	0.909	0.432	1.912	0.764	0.905	0.473	1.734
	With wife/husband	77	7.2%	71	6.6%	0.865	0.919	0.348	2.430	0.030	0.556	0.328	0.945
	With relatives	4	0.4%	8	0.7%	0.913	0.923	0.219	3.887	0.772	1.207	0.338	4.304
Have you ever heard about AIDS/HIV?	No	18	1.7%	3	0.3%
	Yes	379	35.3%	673	62.7%	0.008	6.757	1.636	27.915	0.000	10.654	3.118	36.404
Have you ever heard about VCT?	No	170	15.8%	166	15.5%
	Yes	227	21.2%	510	47.5%	0.003	1.591	1.175	2.156	0.000	2.301	1.765	2.999
Have you ever tested for HIV?	No	371	34.6%	600	55.9%
	Yes	26	2.4%	76	7.1%	0.003	2.332	1.326	4.098	0.012	1.807	1.137	2.874
Have you ever heard about STIDs?	No	54	5.0%	15	1.4%
	Yes	343	32.0%	661	61.6%	0.001	3.011	1.550	5.849	0.000	6.938	3.858	12.474
Variables associated with attitude towards STIs
Social status	Single	513	47.8%	362	33.7%	0.771				0.000
	Married	140	13.0%	43	4.0%	0.703	0.852	0.374	1.941	0.000	0.435	0.301	0.628
	Divorced/widowed	8	0.7%	7	0.7%	0.559	1.402	0.451	4.357	0.680	1.240	0.446	3.450
Educational level	No education	9	0.8%	1	0.1%	0.662				0.035
	Primary school	5	0.5%	2	0.2%	0.150	7.610	0.481	120.410	0.341	3.600	0.257	50.330
	Middle school	16	1.5%	3	0.3%	0.376	3.118	0.252	38.615	0.670	1.687	0.152	18.714
	Secondary school	54	5.0%	22	2.1%	0.211	4.147	0.446	38.596	0.231	3.667	0.438	30.689
	College education	577	53.8%	384	35.8%	0.256	3.561	0.398	31.905	0.090	5.990	0.756	47.467
Working status	Had no job	87	8.1%	39	3.6%	0.158				0.000
	Employed	138	12.9%	68	6.3%	0.550	0.853	0.506	1.437	0.697	1.099	0.683	1.770
	Student	368	34.3%	284	26.5%	0.981	1.006	0.625	1.618	0.009	1.722	1.145	2.589
	Others	68	6.3%	21	2.0%	0.065	0.534	0.274	1.040	0.237	0.689	0.371	1.278
Belonging to the medical field	No	321	29.9%	117	10.9%
	Yes	340	31.7%	295	27.5%	0.000	1.860	1.374	2.517	0.000	2.380	1.830	3.096
Living place	Rural area	292	27.2%	131	12.2%
	City	369	34.4%	281	26.2%	0.002	1.530	1.165	2.009	0.000	1.697	1.311	2.197
Living condition	Alone	47	4.4%	46	4.3%	0.301				0.000
	With family	459	42.8%	296	27.6%	0.071	0.653	0.411	1.037	0.058	0.659	0.428	1.015
	With friends	37	3.4%	28	2.6%	0.445	0.767	0.388	1.515	0.429	0.773	0.409	1.463
	With wife/husband	113	10.5%	35	3.3%	0.221	0.548	0.209	1.437	0.000	0.316	0.182	0.552
	With relatives	5	0.5%	7	0.7%	0.606	1.411	0.382	5.214	0.564	1.430	0.423	4.833
Having chronic disease	No	612	57.0%	368	34.3%
	Yes	49	4.6%	44	4.1%	0.042	1.615	1.017	2.563	0.066	1.493	0.974	2.289
Have you ever heard about AIDS/HIV?	No	19	1.8%	2	0.2%
	Yes	642	59.8%	410	38.2%	0.066	4.490	0.904	22.297	0.016	6.067	1.406	26.184
Have you ever heard about VCT?	No	228	21.2%	108	10.1%
	Yes	433	40.4%	304	28.3%	0.244	1.189	0.889	1.591	0.005	1.482	1.129	1.945
Have you ever heard about STIDs?	No	61	5.7%	8	0.7%
	Yes	600	55.9%	404	37.7%	0.005	3.148	1.416	6.999	0.000	5.134	2.431	10.844

We conducted a logistic regression analysis to find out the association between knowledge of AIDS and participants’ variables. Belonging to the medical field, knowing STIs and AIDS, and previously undergoing HIV tests were all factors that correlate with a higher level of knowledge of AIDS (p value < 0.05). Participants belonging to the medical field were found to be more informative about AIDS compared to participants who were not (p value < 0.05, AOR = 2). A significant association was recorded between participants’ living place and their attitude regarding AIDS (p value < 0.05), as those living in cities have acquired a more positive attitude compared to residents of rural areas (p value < 0.05, AOR = 1.72). Participants who had heard about STIs were 10.8 times more likely to have a good attitude than those who had not (p value < 0.05). Also, Variables associated with higher knowledge of STIs were living place, belonging to a medical place, previous knowledge of AIDS, previous testing for AIDS, and previous knowledge of VCT (p value < 0.05).

In contrast to participants who never heard about HIV before, individuals with a prior awareness of AIDs were 6.7 times more likely to have a good knowledge of STIs (p value < 0.05). Regarding attitude towards STIs, we noticed a significant correlation between living place, prior knowledge of HIV, prior knowledge of STIs, belonging to the medical field and participants’ attitude (p value < 0.05). Participants who previously talked about STIs were 3.14 times more likely to have a positive attitude than those who did not (p value < 0.0). Details data about HIV/AIDS knowledge amongs participants are mentioned in Table 6.

4. Discussion

HIV and STIs are a growing public health concern worldwide, with increasing detection rates over the past few years [17,18]. Our research results demonstrated that almost all participants (98%) had heard about AIDS/HIV. However, this percentage decreased to (68.7%) for respondents who had heard about VCT. Those findings are consistently similar to those reported in a study conducted in Ethiopia by Mekonnen AG et al., where 98% of participants had heard about HIV and approximately three-fourths about VCT [16]. Additionally, our results reported that approximately half (51.2% of participants) knew about HIV transmission between people; these results are consistent with those found in a Bahraini study conducted by Janahi EM et al., where knowledge of the mode of transmission and high-risk groups was rated as medium [19]. Concerning HIV transit ways, unsafe sexual activities and blood donation were reported as the most chosen by 98% of the participants; however, causal contact and insect bites were the least chosen. Also, for HIV infection, wrong misconceptions and HIV transmission correlation were found since 63.8% of participants think that HIV can be transmitted after only one sexual relationship, which is also similar to misconceptions found in a study conducted in Ghana by Dzah et al. [20].

Regarding STIs in general, the percent of participants who had ever heard about STIs was 93.6%, a similar high knowledge percentage was found in a study conducted in Melaka, Malaysia by Mansor N et al. [21]. For demographic data and HIV/STI knowledge, strong correlations were found; respondents belonging to the medical field and participants living in cities showed much better knowledge than their counterparts. These findings are also similar to several other studies, such as a Nigerian study by Okonkwo U et al. [22] and an Indian study by Meundi et al. [23].

Although the knowledge and perception of HIV and STIs seem to be good in Syria, they must be improved to reduce STD transmission. This could be achieved by:

• Assuring free tests and improving strong early diagnosis efforts, especially among lower socioeconomic patients [24].

• Improving education levels and increasing sensibilization about STI-related medical events through free online webinars, in-person courses, and volunteer care. Medical organizations involvement is also of extreme importance [24–26].

• Improving socioeconomic conditions is key to decreasing contagious infection prevalence, especially STIs. This could be guaranteed by risk factor correction, essentially purchasing capacities and living and care conditions [27].

• War in Syria is a strong factor for chronic disorders and infectious diseases; hence, working on finding solutions for arming conflicts and making the situation stable and safe is itself an extremely important solution [28].

5. Strengthens and limitations of the study

Our study has some limitations that must be acknowledged. First, cross-sectional study design may not show the cause-effect relationship of variables, and the results may be less reliable. Second, this study is susceptible to a high risk of bias due to using an online questionnaire, as an online questionnaire limits the ability of people who do not have an internet connection to participate in studies like this. The sample size of our study was adequate to produce significant results; however, more studies with larger sample sizes are required to confirm our findings.

6. Conclusion

In our study, we have noticed an acceptable level of knowledge and understanding of STIs and HIV among the Syrian population. Improvement is always required, and aiming for better knowledge will impact achieving better preventable measures. Overall, 51.2% scored well in the HIV transmission and prevention section, while 47.1% had a good attitude towards HIV. On the other hand, 58.1% were knowledgeable enough about STI transmission, while 38.4% had a good attitude towards STIs.

Authors’ contributions

Sarya Swed: Conceptualization, Methodology, Formal Analysis, Writing-Original draft, review and editing.

Other co-authors: Writing-Review and editing.

Data collection group

1. Anas Alali: Faculty of Medicine, Alfurat University, Deir ezzor, Syria. ([email protected])

2. Youmna Zeiniah: Faculty of Medicine, Aleppo University, Aleppo, Syria. ([email protected])

3. Yasser Almohammad: Faculty of Medicine, Alfurat University, Deir ezzor, Syria. ([email protected])

4. Rama Reslan: Faculty of Medicine, Tishreen University, Lattakia, Syria. ([email protected])

5. Hind Homesha: Faculty of Pharmacy, Al-Andalus University, Tartous, Syria. ([email protected])

Disclosure statement

None.

Availability of data and materials

The authors have access to and have saved all of the data necessary to support this paper’s conclusion. All data are accessible upon reasonable request from the corresponding author.