MILITARY MEDICINE, 169, 3:221, 2004 Humn Immunodeficiency Virus / Acquired Immunodeficiency Syndrome Knowledge nd Risk Fctors in Ethiopin Militry Personnel Gurntor: Ludmil N. Bkhirev, MD MPH Contributors: Ludmil N. Bkhirev, MD MPH*; Yegeremu Abebe, MD ; CAPT Stephnie K. Brodine, MC USN (Ret.)*; LCDR Heidi S. Krft, MSC USNR*; CDR Richrd A. Shffer, MSC USN*; Cherrie B. Boyer, PhD Humn immunodeficiency virus / cquired immunodeficiency syndrome (HIV/AIDS)-relted knowledge nd behviors were ssessed in fce-to-fce structured interviews with 314 Ethiopin militry personnel. A significnt finding of this reserch ws the ssocition between HIV/AIDS knowledge nd risky sexul behvior. Tht is, militry personnel who hd inccurte knowledge bout HIV/AIDS trnsmission nd prevention were 3.4 times s likely to engge in combined sexul risk behviors compred with personnel with ccurte knowledge, fter controlling for ge, militry rnk, nd mritl sttus (odds rtio, 3.4; 95% confidence intervl, 1.86 6.22). This finding highlights the potentil vlue of eductionl progrms in slowing the spred of HIV/AIDS in sub-shrn Afric. Introduction he humn immunodeficiency virus/cquired immunodeficiency syndrome (HIV/AIDS) pndemic hs become the T most urgent of ll globl public helth problems. This is prticulrly true in sub-shrn Afric, which ws home to 28.5 million of the 40 million people living with HIV/AIDS by the end of 2001. 1 HIV/AIDS is now the leding cuse of deth in sub- Shrn ntions, ccounting for 17.2 million ftlities in this region since the beginning of the epidemic. Although mny fctors contribute to high HIV/AIDS rtes in sub-shrn Afric, highly mobile popultions re of specil concern in the spred of the epidemic. Popultion migrtions in generl, resulting from vrious socioeconomic nd politicl disruptions of Africn societies, hve creted significnt public helth problems nd hve contributed to the rpid increse of HIV/AIDS. 2 In ddition to problems ssocited with popultion migrtions, however, there re dditionl public helth issues nd concerns ssocited with individul workers, including long-distnce truck drivers, migrnt workers, refugees, nd militry forces, whose jobs crry them cross regionl nd ntionl boundries. The lifestyles of these mobile workers often involve extended fmily seprtion, csul nd multiple sexul prtners, nd sexul contcts with commercil sex workers, ll of which contribute to incresed risk of contrcting HIV nd other sexully trnsmitted diseses (STDs). 3 Militry forces re mobile popultion of prticulr concern becuse of their importnt role in ntionl security s well s *Deprtment of Epidemiology nd Biosttistics, Sn Diego Stte University, Sn Diego, CA 92182-4162. Helth Services, Ministry of Defense. Addis Abb, Ethiopi. Deprtment of Peditrics, Division of Adolescent Medicine, University of Cliforni Sn Frncisco, Sn Frncisco, CA 94143-0503. This mnuscript ws received for review in Jnury 2003. The revised mnuscript ws ccepted for publiction in June 2003. Reprint & Copyright by Assocition of Militry Surgeons of U.S., 2004. public helth. Militry personnel re t incresed risk becuse they re predominntly mle, young, sexully ctive, often deployed for prolonged time wy from their fmilies, nd exposed to frequent opportunities for csul sex, often with commercil sex workers who themselves re t high risk for HIV cquisition nd trnsmission. 4 For exmple, 1998 study conducted mong commercil sex workers in Addis Abb, Ethiopi documented HIV prevlence rte of 73.7%. 5 In light of these concerns, number of studies hve now focused on HIV/AIDS issues in sub-shrn Africn militry personnel. A survey conducted mong South Africn militry recruits reveled serious gps in their knowledge bout HIV trnsmission. For exmple, 41.8% indicted tht HIV cn be trnsmitted through blood-sucking insects nd 17.5% were uncertin bout it; 11.7% thought tht HIV cn be cured nd 27.6% were uncertin; nd more thn one-hlf of recruits reported either tht HIV cnnot be trnsmitted through heterosexul intercourse (13.6%) or were uncertin bout it (41.8%). 6 Results of n nonymous HIV-1 serosurvey of 19- to 22-yer-old high-risk Ugndn mle militry recruits sttioned ner metropolitn Kmpl demonstrted high prevlence of HIV infection (16%). 7 The current study exmines issues surrounding HIV/AIDS in Ethiopin militry personnel. This work is of immedite importnce, in prt, becuse the mssive demobiliztion under wy fter the Ethiopi/Eritre wr cretes potentilly dngerous conditions for the spred of disese by returning troops. In Ethiopi, the prevlence of HIV infection ws reltively low in the 1980s but drmticlly incresed during the lst two decdes even before the present demobiliztion. 8 By the end of 2001, 2.1 million dults nd children were estimted to be living with HIV/AIDS in Ethiopi, which is ntion of 64.5 million. 1 Ethiopi hs hd to confront extreme poverty, high unemployment rte, socil disintegrtion, nd mssive demobiliztion. 9 In such conditions, excerbtion of the HIV/AIDS epidemic by returning soldiers poses potentilly devstting economic burden to the country. Dt from sentinel surveillnce indicted tht in 1991, 3% of Ethiopin militry recruits tested were HIV positive. 10 A high prevlence of HIV infection (9.6%) ws lso observed mong Ethiopin silors whose lifestyle chrcteristics re similr in mny wys to those of militry recruits. 11 More recent unpublished dt from the Ethiopin Ministry of Defense Ntionl Behvior Surveillnce Survey suggest tht the HIV prevlence mong Ethiopin recruits is pproximtely 6%. This number is consistent with the prevlence found mong demobilized veterns undergoing voluntry counseling nd testing s prt of joint World Bnk/Ethiopin government demobiliztion project. 221
222 HIV/AIDS Knowledge nd Risk Fctors This pilot study ws conducted to ssess knowledge, ttitudes, nd sexul behvior relted to HIV/AIDS mong Ethiopin militry personnel. The purpose ws to provide preliminry informtion bout HIV-relted knowledge, ttitudes, nd mjor risk fctors in the Ethiopin militry nd to identify the subgroups most susceptible to contrcting HIV infection, in prt to help pln future prevention progrms. Methods Study Design Ethiopin militry personnel who were deployed in nd round Addis Abb, Ethiopi were selected for prticiption in this pilot study. Prticipnts were recruited from Debrezit Air Force Bse (27.3%), Armed Forces Ttek Militry Hospitl nd AIDS Rehbilittion Center (21.4%), Defense Helth Sciences College (13.1%), Armed Forces Generl Hospitl (11.1%), Ethiopin Army Hedqurters (6.6%), nd vrious other ground forces trining sites (20.4%). Prticipnts were rndomly selected from roster of ctive duty militry personnel t ech site in proportion to the totl number of militry personnel nd were representtive of the Ethiopin militry sttioned in the urbn sites. Development of questions ws guided by constructs of the informtion-motivtion-behviorl skills model 12 with n emphsis plced on known risk fctors for HIV in militry settings. Becuse of the low litercy level mong militry personnel, 18-item, fce-to-fce structured interviews were conducted by senior militry personnel who hd bckground in HIV/AIDS. After explining the purpose of the study nd confidentility, the interview ws conducted in privte room. Nmes were not included in the questionnires. Informtion ws collected on sociodemogrphic chrcteristics of militry personnel (ge, sex, current militry rnk, mritl sttus), their knowledge bout HIV trnsition nd prevention, ttitudes towrd condom use nd HIV testing, nd different spects of sexul behvior. Mesures HIV/AIDS-relted knowledge ws scored s ccurte (ll four knowledge questions correct), or inccurte (if prticipnts mde one or more errors of four knowledge questions). Prticipnts involvement in sexul risk behviors ws ssessed using five different mesures of sexul behviors, including csul sex, multiple prtners, lcohol/drug use before or during sexul intercourse, sexul intercourse with HIV-positive person, nd nonuse of condoms. In ddition to ssessing ech sexul risk behvior seprtely, we ssessed prticipnts involvement in combintion of risk behviors. All five risk behvior vribles listed bove were incorported into single combined risk behvior vrible. If prticipnts indicted involvement in ny sexul risk behviors, they were ctegorized s t risk, nd if they were not involved in ny risk behviors, they were ctegorized s not t risk. Sttisticl Anlysis A totl of 321 Ethiopin militry personnel prticipted in the study. The nlyses presented in this study were bsed on 289 men. Twenty-seven (8.4%) women prticipted in the study nd only 18 of them hd complete dt. Therefore, becuse of this smll smple size nd the need for strtifiction on rnk nd ge ctegories, women were excluded from the nlysis. Additionlly, it ws not deemed pproprite to group both sexes becuse their risk fctors nd sexul behviors re different. We lso excluded five prticipnts becuse of lck of gender informtion. Missing vlues were ccounted for in the nlysis by pirwise deletion; therefore, the effective smple size vries slightly with regrd to ny prticulr vrible due to missing dt. Anlyses included descriptive sttistics for ll vribles nd univrite comprison of HIV/AIDS risk fctors nd gps in knowledge mong different ge groups nd between officers nd enlisted personnel. As test of significnce, 2 ws used. Age ws ctegorized into three groups, under 25 yers old, 25 34 yers old, nd 35 yers old nd over. Univrite ssocitions of knowledge (ccurte vs. inccurte) with ech of the five sexul risk behviors nd combined risk behvior ( risk vs. no risk ) were nlyzed using odds rtios (ORs) with 95% confidence intervls (CIs). Reltionships between prticipnts ttitudes bout using condoms nd HIV/ AIDS risk (combined risk behvior, self-reported STD sttus) were lso exmined. A multiple logistic regression model ws developed to ssess the effect of knowledge on combined risk behvior fter controlling for ge, mritl sttus, nd militry rnk. Results Chrcteristics of Study Prticipnts A totl of 289 mle militry personnel, 41.1% officers nd 58.9% enlisted, prticipted in the study. The prticipnts ges rnged from 18 to 55 yers, with men of 31.4 7.6 yers. Approximtely one-hlf of the respondents were presently mrried (52%). Knowledge bout HIV/AIDS The questionnire results regrding respondents knowledge, ttitudes, risk perception, nd prctices re presented in Tble I. Prticipnts demonstrted reltively ccurte knowledge bout HIV/AIDS, becuse the mjority of respondents (69.5%) nswered ll four knowledge questions of the survey correctly. However, 16% of the respondents indicted tht condoms with lubricnt do not protect ginst HIV, 11.8% indicted tht HIV cn be trnsmitted by mouth-to-mouth kissing, nd 10.4% indicted tht person who hs HIV lwys looks sick. Anlyses of knowledge s function of demogrphic chrcteristics were lso conducted, nd the results re shown in Tble II. These were mong the key findings: misconceptions bout condoms with lubricnt were significntly higher mong enlisted militry personnel compred with officers (19.5% vs. 10.2%, respectively; p 0.042), nd misconceptions bout HIV trnsmission by kissing were significntly higher in those under 25 yers old compred with prticipnts between ges 25 nd 34 yers nd 35 yers or older (21.1% vs. 8.3% vs. 9.6%, respectively; p 0.020). Condom Attitudes nd HIV/STD Sttus Militry personnel ttitudes regrding condom use, HIV testing, nd certinty bout being HIV negtive were ssessed. Only 37% of the overll smple reported being tested for HIV, wheres
HIV/AIDS Knowledge nd Risk Fctors 223 TABLE I KNOWLEDGE, ATTITUDES, AND HEALTH BEHAVIORS OF ETHIOPIAN MILITARY PERSONNEL A Sttement Agreed, n (%) HIV/AIDS knowledge HIV, the virus tht cuses AIDS, cn be cured with medicine. 15 (5.2) HIV cn be pssed from one person to nother by kissing. 34 (11.8) Condoms with lubricnt do not protect ginst HIV. 46 (16.0) A person who hs HIV lwys looks sick. 30 (10.4) Condom ttitudes nd use Using condoms is too much of problem. 37 (13.0) I cn lwys get condoms when I need them. 221 (77.3) The lst time I hd sexul intercourse, I did not use condom. 82 (28.6) HIV/STD sttus I hve been tested for HIV. 104 (37.0) I know for certin tht I m HIV negtive. 125 (44.2) In the previous 12 months, I ws told by doctor tht I hd sexully trnsmitted infection. 33 (11.5) Sexul behvior In the previous 12 months, I hd more thn one sexul prtner. 69 (24.0) In the previous 12 months, I engged in sexul intercourse with someone I hd known for only 81 (28.3) short period of time. In the previous 12 months, I drnk lcohol or used drugs before or during sexul intercourse. 58 (20.1) In the previous 12 months, I hd sexul intercourse with someone who ws infected with HIV. 16 (5.7) Smple size rnged from 281 to 288 due to pirwise deletion of missing dt. 44.2% of ll prticipnts indicted certinty of their HIV-negtive sttus. Tht certinty ws significntly higher in people under 25 yers old nd 35 yers or older compred with those in the 25- to 34-yer ge group (50.7% vs. 52.7% vs. 32.2%, respectively; p 0.005). Overll, ttitudes regrding condom use were positive; only 13% of respondents indicted tht using condoms is too problemtic (Tble I). However, s indicted in Tble II, significntly higher proportion of enlisted militry personnel thn officers indicted tht condom use is too much of problem (17% vs. 8.5%, respectively; p 0.049), s well s reltively higher proportion of people under 25 yers old compred with those between the ges 25 nd 34 yers nd 35 yers or older (22.5% vs. 6.7% vs. 13.0%, respectively; p 0.007). Reported ccessibility of condoms ws high, with 77.3% of the overll smple reporting tht they could lwys get condoms when needed. Accessibility to condoms ws slightly higher mong officers (80.4%) thn enlisted men (73.9%), but this difference ws not sttisticlly significnt (p 0.222). Exmintion of reltionships between condom use ttitudes nd HIV/STD risk indicted tht prticipnts who endorsed the sttement using condoms is too much of problem hd higher prevlence of self-reported STD sttus (OR, 3.75; 95% CI, 1.61 8.76). However, there ws no ssocition between condom use ttitudes nd combined sexul risk behviors (OR, 1.95; 95% CI, 0.88 4.35). Sexul Risk Behviors Sexul prctices, use of potentil HIV preventive methods, nd drugs nd lcohol use were ssessed by questionnire. Almost one-third of ll respondents (28.3%) indicted tht during the previous 12 months they engged in sexul intercourse with someone they hd known for only short period of time. Tht proportion ws significntly higher mong enlisted militry personnel compred with officers (34.4% vs. 12.3%; p 0.001) nd mong people under 25 yers old nd those between ges 25 nd 34 yers compred with people 35 yers or older (42.3% vs. 35.0% vs. 9.7%, respectively; p 0.001). Moreover, 24% of the overll smple reported hving multiple sexul prtners in the previous 12 months nd 11.5% indicted tht they were dignosed with STD. Approximtely one-third of prticipnts (28.6%) did not use condom during their lst sexul intercourse. This proportion ws much higher mong the oldest ge group (41.3%). Of specil concern is the question of whether individuls who hve multiple prtners or hve csul sex (pproximtely 25% of the smple) use condoms. Becuse this subgroup is t reltively higher risk of cquiring nd trnsmitting HIV/AIDS, higher rtes of condom use in the subgroup re desirble from public helth perspective. However, there ws no ssocition between condom use nd hving multiple prtners (OR, 0.96; 95% CI, 0.54 1.73) or between condom use nd hving csul sex (OR, 0.99; 95% CI, 0.58 1.72). There were borderline significnt differences mong ge groups on enggement in multiple sexul reltionships with the highest proportion mong those under 25 yers old (under 25 yers, 29.0%; 25 34 yers old, 27.3%; 35 yers or older, 14.9%; p 0.051) long with significnt differences between officers nd enlisted personnel on self-reported STD dignosis (officers, 6.5%; enlisted, 15.7%; p 0.024). A high proportion (20.1%) of prticipnts reported tht in the previous 12 months they drnk lcohol or used drugs before or during sexul intercourse. Influence of Accurte HIV/AIDS Knowledge on Risky Sexul Behvior Associtions between prticipnts knowledge nd sexul behviors re presented in Tble III. Positive sttisticlly significnt ssocitions emerged between prticipnts inccurte knowledge bout HIV/AIDS nd history of hving more thn one prtner in the previous 12 months (OR, 2.50; 95% CI, 1.42
224 HIV/AIDS Knowledge nd Risk Fctors TABLE II DIFFERENCE IN KNOWLEDGE, ATTITUDES, AND HEALTH BEHAVIORS BETWEEN ETHIOPIAN OFFICERS VS. ENLISTED AND AMONG AGE GROUPS A Sttement Officers (n 108) Militry Rnk Enlisted (n 155) Agreed (%) Age Groups (Yers) 25 (n 71) 25 34 (n 121) 35 (n 94) HIV/AIDS knowledge HIV, the virus tht cuses AIDS, cn be cured with medicine. 2.8 5.2 5.6 5.0 3.2 HIV cn be pssed from one person to nother by kissing. 10.2 12.3 21.1 8.3 9.6 b Condoms with lubricnt do not protect ginst HIV. 10.2 19.5 b 17.1 14.9 17.0 A person who hs HIV lwys looks sick. 7.4 12.3 12.7 10.0 9.6 Condom ttitudes nd use Using condoms is too much of problem. 8.5 17.0 b 22.5 6.7 13.0 b I cn lwys get condoms when I need them. 80.4 73.9 76.1 78.2 78.5 The lst time I hd sexul intercourse, I did not use condom. 31.8 28.6 25.4 21.5 41.3 b HIV/STD sttus I hve been tested for HIV. 40.7 33.1 42.9 34.2 36.2 I know for certin tht I m HIV negtive. 41.1 45.7 50.7 32.2 52.7 In the previous 12 months, I ws told by doctor tht I hd 6.5 15.7 b 15.7 12.6 6.4 sexully trnsmitted infection. Sexul behvior In the previous 12 months, I hd more thn one sexul prtner. 16.7 25.5 29.0 27.3 14.9 In the previous 12 months, I engged in sexul intercourse with 12.3 34.4 c 42.3 35.0 9.7 c someone I hd known for only short period of time. In the previous 12 months, I drnk lcohol or used drugs before 13.9 22.7 25.4 20.7 16.0 or during sexul intercourse. In the previous 12 months, I hd sexul intercourse with 2.8 6.6 10.1 4.3 3.2 someone who ws infected with HIV. The lst time I hd sexul intercourse, I did not use condom. 31.8 28.6 25.4 21.5 41.3 b Becuse of pirwise deletion of missing dt, smple size rnged from 258 to 263 for comprisons between officers nd enlisted personnel nd from 278 to 286 for comprisons mong ge groups. b p vlue for Person s 2 test 0.05. c p vlue for Person s 2 test 0.001. 4.39), enggement in csul sex (OR, 1.75; 95% CI, 1.02 3.00), nd nonuse of condoms during the lst sexul intercourse (OR, 1.99; 95% CI, 1.12 3.33). Knowledge ws found to be strongly ssocited with risk behvior in both univrite nd multivrite nlysis. After controlling for ge, mritl sttus, nd militry rnk in multivrite nlysis, people who reported involvement in ny of the five risk behviors were still found to be 3.4 times more likely to hve inccurte knowledge bout HIV/AIDS compred with people who were not involved in such behviors (OR, 3.43; 95% CI, 1.79 6.59). As shown in Tble IV, militry rnk ws significntly ssocited with combined risk behviors in univrite nlysis (OR, 1.74; 95% CI, 1.04 2.92). However, this ssocition disppered fter djusting for other independent vribles in the model. Discussion This pilot study ws designed to obtin bsic informtion bout HIV-relted knowledge, ttitudes, nd sexul prctices in Ethiopin militry personnel. Overll, the mjority of prticipnts demonstrted firly good knowledge bout HIV/AIDS. The most common misconception ws tht condoms with lubricnt do not protect ginst HIV. Despite the generlly positive findings, prticipnts younger thn 25 yers old nd enlisted militry personnel emerged s reltively high-risk groups. These two groups responded less ccurtely to questions bout HIV/AIDS nd lso reported higher prevlence of risk behviors. In contrst, nonuse of condoms ws the one risk behvior tht ws higher mong prticipnts 35 yers or older versus the younger prticipnts. However, older prticipnts were more likely to be mrried nd less likely to be involved in csul sex, which my prtly explin their low use of condoms. Overll, self-reported condom use during the lst sexul intercourse ws reltively high (71.4%) in our study compred with the 14.2% vlue reported by Demissie et l. 11 in study mong Ethiopin silors nd the 18% vlue reported by Shlu et l. 13 in study mong fctory workers in suburbn re of Addis Abb. A higher rte of reported condom use in our study compred with the previous ones could be result of HIV/AIDS eduction progrms in Ethiopi, progressive increse in the sle nd distribution of condoms during the lst decde, 14 nd prticipnts positive ttitude towrd condoms, especilly mong officers nd those between ges 25 nd 34 yers. However, nerly 30% of prticipnts did not report condom use during the lst sexul intercourse. This fct, coupled with reltively high self-reported prevlence of STDs (11.5%) in our smple, indictes the need for further interventions. It should lso be noted
HIV/AIDS Knowledge nd Risk Fctors 225 TABLE III UNIVARIATE ASSOCIATION OF HIV/AIDS KNOWLEDGE (ACCURATE VS. INACCURATE) WITH SELF-REPORTED RISK BEHAVIORS Self-Reported Risk Behviors OR 95% CI (Lower Upper) Hd more thn one prtner in the previous 12 months Inccurte knowledge 2.50 1.42 4.39 Engged in csul sex in the previous 12 months Inccurte knowledge 1.75 1.02 3.00 Drnk lcohol/used drugs before/during sex in the lst 12 months Inccurte knowledge 1.26 0.68 2.32 Hd sexul intercourse with HIV-positive person in the previous 12 months Inccurte knowledge 1.56 0.54 4.53 Did not use condom during the lst sexul intercourse Inccurte knowledge 1.99 1.12 3.33 Smple size rnged from 278 to 283 due to pirwise deletion of missing dt. b Reference ctegory. TABLE IV RELATIONSHIP OF HIV/AIDS KNOWLEDGE AND SOME SOCIODEMOGRAPHIC CHARACTERISTICS WITH COMBINED RISK BEHAVIOR A Risk Fctors Undjusted OR (95% CI) b Adjusted OR (95% CI) c Knowledge Inccurte 3.40 (1.86 6.22) 3.43 (1.79 6.59) Accurte 1.00 d 1.00 d Age ctegories 25 yers old 1.43 (0.74 2.77) 1.24 (0.60 2.56) 25 34 yers old 1.01 (0.58 1.76) 0.76 (0.32 1.81) 35 yers old 1.00 d 1.00 d Mritl sttus Unmrried 1.39 (0.85 2.27) 1.38 (0.78 2.47) Mrried 1.00 d 1.00 d Militry rnk Enlisted 1.74 (1.04 2.92) 1.58 (0.85 2.96) Officer 1.00 d 1.00 d Involvement in ny risk behviors: csul sex, multiple prtners, lcohol/drug use before or during sexul intercourse, sexul intercourse with HIV-positive person, nd nonuse of condoms. b Smple size rnged from 252 to 275 due to pirwise deletion of missing dt. c Adjusted ORs were clculted on 245 people with complete nswers, djusting for ll other vribles listed in the tble. d Reference ctegory. tht reported STD rtes in our smple exceed rtes from 1993 Ethiopin generl popultion survey (i.e., 4.6% mong men). 15 The overll proportion of militry personnel who reported hving sex with csul prtner in the previous 12 months ws 28.3%, which is higher thn the previously reported proportions of 18.2% mong sexully ctive men in the generl popultion of Ethiopi 15 nd 16% mong mle employees of the Fiber Products Fctory ner Addis Abb. 13 When combined with the findings of higher STD rtes in militry personnel versus civilins, these findings regrding csul sex justify the focus on militry forces s popultion of specil concern regrding the spred of HIV/AIDS nd other STDs. Our study showed tht lmost one-qurter (24%) of prticipnts hd more thn one sexul prtner in the previous 12 months. This figure is comprble to tht from survey conducted mong South Africn militry recruits in which 28.4% reported tht they hd hd multiple sexul prtners during the previous 6 months. 6 According to the informtion-motivtion-behviorl model, ccurte informtion bout HIV/AIDS trnsmission nd prevention is prerequisite of AIDS-preventive behvior. 12 The findings of this study suggest strong correltion between HIVrelted knowledge nd involvement in risk behvior mong Ethiopin militry personnel. Even fter djustment for ge, mrrige sttus, nd militry rnk, level of HIV-relted knowledge remined strong predictor of risk behvior, finding consistent with other studies. 16,17 For exmple, recent study conducted mong sex workers of Addis Abb demonstrted the protective effect of HIV/AIDS knowledge on HIV prevlence. 5 Together, these findings suggest tht eduction cn ply criticl role in slowing the spred of HIV/AIDS in sub-shrn Afric. Another importnt finding of this survey ws tht only 37% of ll respondents reported tht they were tested for HIV. The proportion ws even smller mong enlisted militry personnel (33.1%) who re t high risk of contrcting HIV/AIDS. These findings suggest tht current HIV testing progrms re indequte to meet the needs of brod-bsed HIV/AIDS prevention nd surveillnce progrms. Therefore, voluntry counseling nd testing progrms should be n importnt prt of comprehensive STD/HIV prevention interventions in militry settings. In summry, the results of our study demonstrte positive influence of knowledge on risk behvior, which is encourging in terms of the potentil benefits of prevention progrms tht ddress the gps in knowledge nd provide skills for reducing risky sexul behviors. Such progrms should prticulrly focus on enlisted militry personnel nd young recruits who re t
226 HIV/AIDS Knowledge nd Risk Fctors higher risk for HIV cquisition. Given the immedite need to implement HIV prevention progrms, the Ethiopin militry my do well to provide the younger enlisted personnel with informtion nd skills to prevent cquisition of HIV nd other STDs, prticulrly emphsizing the benefits of condom use nd sexul monogmy. Similr surveys should be repeted in other militries of sub- Shrn Afric becuse of the lrge vribility of findings bout knowledge, ttitudes, beliefs, behviors, nd skills in different studies. There is need for more detiled surveys in this popultion to better understnd the interreltionship mong knowledge, ttitudes, beliefs, behviors, nd skills. Acknowledgments The uthors re grteful to Dr. Gerld Lrson for vluble criticism in the preprtion of this mnuscript, Sbrin Seib for dt mngement, nd Dr. Mry-Ann Shfer for ssistnce with study design. The uthors lso thnk Dr. Germchew Mmo, Dr. Tesfye Tetmke, nd Dr. Sisye Kebede whose support contributed to the success of the study. References 1. UNAIDS: The Report on the Globl HIV/AIDS Epidemic. Tble of Country-Specific HIV/AIDS Estimtes nd Dt, End 2001. Brcelon, XIV Interntionl Conference on AIDS, 2002. 2. Decoss J, Kne F, Anrfi J, Sodji K, Wgner H: Migrtion nd AIDS. Lncet 1995; 346: 826 8. 3. Gysels M, Pool R, Bwnik K: Truck drivers, middlemen nd commercil sex workers: AIDS nd the medition of sex in south west Ugnd. AIDS Cre 2001; 13: 373 85. 4. Yeger R, Hendrix C, Kingm S: Interntionl militry humn immunodeficiency virus/cquired immunodeficiency syndrome policies nd progrms: strengths nd limittions in current prctice. Milit Med 2000; 165: 87 92. 5. Aklilu M, Messele T, Tsegye A, et l: Fctors ssocited with HIV-1 infection mong sex workers of Addis Abb, Ethiopi. AIDS 2001; 15: 87 96. 6. vn der Ryst E, Joubert G, Steyn F, Heunis C, le Roux J, Willimson C: HIV/ AIDS-relted knowledge, ttitudes nd prctices mong South Africn militry recruits. S Afr Med J 2001; 91: 587 91. 7. Hom D, Johnson J, Mugyenyi P, et l: HIV-1 risk nd vccine cceptbility in the Ugndn militry. J Acquir Immune Defic Syndr 1997; 15: 375 80. 8. Abdurehmn A, Enquoselssie F: Demogrphic impct of HIV/AIDS in Addis Abb. Ethiop Med J 2001; 39: 9 22. 9. Mils S, Abdel LJ: The politicl economy of complex emergency nd recovery in Northern Ethiopi. Dissters 2000; 24: 363 79. 10. UNAIDS/WHO/UNICEF: Epidemiologicl Fct Sheet on HIV/AIDS nd Sexully Trnsmitted Infections, Vol 2001. Ethiopi, 2000. Avilble t http://www. who.int/emc-hiv/fct_sheets/pdfs/ethiopi_en.pdf. 11. Demissie K, Amre D, Tseg E: HIV-1 infection in reltion to eductionl sttus, use of hypodermic injections nd other risk behviours in Ethiopin silors. Est Afr Med J 1996; 73: 819 22. 12. Fisher J, Fisher W, Willims S, Mlloy T: Empiricl tests of n informtionmotivtion-behviorl skills model of AIDS-preventive behvior with gy men nd heterosexul university students. Helth Psychol 1994; 13: 238 50. 13. Shlu T, Kss E, Agonfer T, et l: Sexul behviors, perception of risk of HIV infection, nd fctors ssocited with ttending HIV post-test counseling in Ethiopi. AIDS 1999; 13: 1263 72. 14. Kebede D, Aklilu M, Snders E: The HIV epidemic nd the stte of its surveillnce in Ethiopi. Ethiop Med J 2000; 38: 283 302. 15. Mehret M, Mertens T, Crel M, et l: Bseline for the evlution of n AIDS progrmme using prevention indictors: cse study in Ethiopi. Bull World Helth Orgn 1996; 74: 509 16. 16. Orr R, Lngefeld C: Fctors ssocited with condom use by sexully ctive mle dolescents t risk for sexully trnsmitted disese. Peditrics 1993; 91: 873 9. 17. Ismil S, Giorgis F, Legesse D, et l: Knowledge, ttitude nd prctice on high risk fctors pertining to HIV/AIDS in rurl community. Ethiop Med J 1995; 33: 1 6.