Knowledge, attitudes and practices on HIV/AIDS and prevalence of HIV in the general population of Sucre, Bolivia

ww w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Knowledge,

attitudes

and

practices

on

HIV/AIDS

and

prevalence

of

HIV

in

the

general

population

of

Sucre,

Bolivia

Carolina

Terán

Calderón

_,

_Dorian

_Gorena

_Urizar

_,

_Cristina

_González

_Blázquez

_,

Belén

Alejos

Ferreras

_,

_Oriana

_Ramírez

_Rubio

_,

_Francisco

_Bolumar

_Montrull

_,

Marta

Ortiz

Rivera

_,

_Julia

_del

_Amo

_Valero

a_{SchoolofMedicine,SanFranciscoXavierofChuquisacaUniversity,Sucre,Bolivia}

b_{HealthArea,SimonBolivarAndeanUniversity,Sucre,Bolivia}

c_{NationalCentreforEpidemiology,CarlosIIIInstituteofHealth,Madrid,Spain}

d_{DepartmentofPublicHealthSciences,UniversityofAlcalá,AlcaládeHenares,Madrid,Spain}

e_{NationalCentreforMicrobiology,CarlosIIIInstituteofHealth,Madrid,Spain}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received14January2015 Accepted5April2015 Availableonline19May2015

Keywords:

HIVprevalence KnowledgeonHIV/AIDS AttitudetowardsPLWHA SexualpracticesonHIV

a

b

s

t

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Background:Toanalyseknowledge,attitudesandsexualpracticesonHIV/AIDS,andestimate

HIVprevalenceamongresidentsofSucre(Bolivia).

Methodology:Population-based survey of residents aged 15–49 randomly selected

dur-ing 2008/2009. Bloodsampleswerecollected onWhatman-filterpaperand testedwith enzyme-linkedimmunosorbentassay.KnowledgeonHIV/AIDS,sexualriskpracticesand discriminatoryattitudesagainstpeoplelivingwithHIV/AIDS(PLWHA)weremodelledwith multiplelogisticregression.

Results:Of1499 subjects,59%werewomen.All subjectswereHIV-negative.Inadequate

knowledgeofHIV/AIDStransmissionandpreventionwasobservedin67%andrisk fac-torsvariedbygender(interactionp-value<0.05).Discriminatoryattitudesweredisplayed by85%subjects;associatedfactorswere:ruralresidence,loweducationallevel andlow income.Unsafesexwasreportedby10%;riskfactorsvariedbyresidencearea

(interac-tionp-value<0.05).Inurbanareas,riskfactorsweremalesex,youngerageandbeingin

common-lawunion.

Conclusions: PrevalenceofHIVinfectionisverylowandunsafesexisrelatively

uncom-mon.InadequateknowledgeonHIV/AIDSanddiscriminatoryattitudestowardsPLWHAare extremelyhighandareassociatedtogender,ethnicandeconomicinequalities.

©2015ElsevierEditoraLtda.Allrightsreserved.

∗ _{Correspondingauthorat:SchoolofMedicine,SanFranciscoXavierofChuquisacaUniversity,ColonStreet(BetweenRenéMorenoand}

PastorSainz),Sucre,Bolivia.

E-mailaddress:carolina.teran@gmx.net(C.T.Calderón). http://dx.doi.org/10.1016/j.bjid.2015.04.002

Introduction

Inspiteoflargeregionaldifferences,theHIVepidemicin Cen-tralandSouthAmericahasshownastablepatternoverthe lastdecade.Inthemajorityofcountriesintheregion,the epi-demicisconcentratedandremainsatalowlevel.1,2 _Among

menwho have sexwith men(MSM), prevalencestands at around10%inmostcountries,thoughheterosexual transmis-sionofHIVhasincreased,particularlyinSouthAmerica.3

ThereislittleinformationontheepidemiologyofHIVin Boliviaisavailable.Surveillancedataindicatethat4889HIV caseswere reportedfrom1984to2009;89%ofwhichcame fromLaPaz, SantaCruz andCochabamba.4_{In 2009,itwas}

estimatedtherewere12,000[range9000–16,000]personsliving withHIV/AIDS(PLWHA)andtheestimatedprevalenceinthe populationaged15–49yearswas0.2%[95%CI:0.1–0.3%].5_The

HIVepidemicinBoliviaisconcentratedintheMSMgroup.5–7

InthedepartmentofChuquisacaaccordingwiththe Depart-mentalHealthService(SEDES-Chuquisaca)datareportof2010 (unpublished result),only27 new HIVcaseswere reported in2010;78%wereresidentsofSucre,butnoHIVprevalence estimatesinthegeneralpopulationareavailable.

Studiesonknowledge,attitudesandpractices(KAP)have been widely used to design public health policies and for planninghealthinterventionstakingintoaccounttheneeds ofthe community.8,9 _{There islimited information on KAP}

on HIV/AIDS among the general population of Bolivia, a multiculturalnationwithgreatethnicdiversityandmarked socio-economicinequalities.Therefore,theaimsofthisstudy weretoanalyseknowledgeonHIV/AIDS,aswellasattitudes andpracticeswithrespecttoHIV/AIDSandtoestimatethe prevalenceof HIVinfection amonginhabitants aged 15–49 yearsresidinginthetownofSucre(departmentofChuquisaca, Bolivia)in2008–2009.

Materials

and

methods

We conducted a cross-sectional population-based study consisting of a KAP survey linked to a sero-survey using WhatmanpapertoestimateHIVprevalence.Inclusion crite-riaweresubjectsaged15–49yearswhohadresidedinSucre duringthepreceding12monthsandconsentedtoparticipate, excludingthosewhohadsomementaldisabilityorrefusedto participateinthestudy.Samplesizecalculationswerebased onanexpectedprevalenceofHIV-relatedknowledgeof12%, basedon aprevious study developedbytheSimon Bolivar AndeanUniversity(UASB)withUNAIDSon2006(unpublished result),witha95%confidencelevel, and aprecisionof2%. Separatesamplesizecalculationsweremadeforthe estima-tionoftheHIVprevalenceinSucreastheprevalenceofHIV wasexpectedtobelow.ForanexpectedHIVprevalenceof 1%,witha95%confidencelevel, and anabsoluteprecision of0.5%,thenecessarysamplesizewas1500subjects.Dueto budgetaryconstrictions,theHIVdeterminationscouldonly bedonein1000personswiththeinevitablelossofprecision. Subjects were randomlyselected withineach ofthe urban and rural districtsof Sucre,with a proportional allocation to the respective district populations. Since there are no

population-based registries in Sucre, we used the address records keptbyHealthCentres,selectedhomesatrandom, andtheninterviewedthefirstpersoninthehouseholdwho fulfilledtheinclusion/exclusioncriteria,withamaximumof onepersonbeinginterviewedperdwelling.

Datawerecollectedbypersonalinterviewsconductedby trained interviewers, followed bythe extraction ofa blood specimen. Interviewers (fourth-yearstudents attendingthe Faculty ofMedicineat SanFrancisco Xavier ofChuquisaca University,andphysiciansandnursesathealthcentres com-ing under the aegis of the Ministry of Health) underwent onemonth’strainingandwereadditionallyrequiredtospeak Quechua,thenativelanguage.Thesurveywasadministered personally,lastedapproximately25min,andwasconducted fromSeptember2008toMarch2009.Nosurveyresponserate wasformallyrecorded,thoughacceptancewasgoodandnone ofthepersonswhowereofferedthebloodtestrefusedto par-ticipate. Itwasonlyforbudgetary reasons thatblood tests wereconductedinonly998persons,67%ofthetotalnumber ofinterviewees.

The questionnaire was made up of five sections: (a) sociodemographiccharacteristics;(b)knowledgeaboutmodes of HIV/AIDS transmission; (c) attitudes and practices with respecttoHIV/AIDS;(d)clinicalhistoryofsexually transmit-tedinfections(STI)and/orHIV/AIDS;and(e)otherriskfactors relatedtoHIV/AIDS.Datacollectedinthequestionnairewere used toconstructthe KAPindicators, basedon the recom-mendationsoftheBasicIndicatorsoftheJointUnitedNations Programmeon HIVand AIDS,(UNAIDS)and appliedtothe epidemicsituationinBolivia.10,11

Indicatordefinitions

Indicatorofknowledgeaboutpreventionandtransmission ofHIVinthepopulation

“Adequate knowledge”: In response to the question as to whetherthesubjectknowshowtopreventthesexual trans-missionofHIV,he/sheanswers,“byusingcondom”and“by havingasinglesexualpartner”.Inresponsetothequestion astowhetherahealthylookingpersonmayhaveHIV/AIDS, thesubjectanswers,“yes”;andinresponsetothequestion astowhetherhe/sheknowsthewaysinwhichthediseaseis transmitted,rejectstheoptions,“bymosquitobite”and“by cohabitingwithaPLWHA”.

“Inadequateknowledge”:Numberofmenandwomenwho answeranyofthesequestionsdifferently.

Indicatorofattitudesofdiscriminationandstigmatisation “Attitudeofdiscrimination”:thesubjectrespondsnegatively tothequestions,“wouldyoubewillingtogiveaccommodation toarelativeifyouknewthathe/shehadHIV/AIDS?”,“would youallowateacherwhohasHIV/AIDStocontinueteachingat theschool?”,and“wouldyoubuyfromafruitvendor,ifyou knewhe/shehadHIV/AIDS?”;andrespondsaffirmativelyto thequestion:“ifsomerelativehadtheinfection,wouldyou preferthatno-oneknew?”.

“Attitudeofacceptance”:subjectshowsattitudesof accep-tancetowardsanyofthefourquestionsposedaboutPLWHA.

Indicatorofsexualriskpractices

“Unsafesex”:adolescents,youngadultsandsingletonswho reporthavinghadsexinthepreceding12monthswithmore thanonepartner;andpersonswhoareeithermarried,ina common-lawunion,widowedanddivorcedwhoreporthaving hadunprotectedsex(withoutacondom)outsidethecouple.

“Safesex”:adolescents,youngadultsandsingletonswho reportnothavinghadsexinthepreceding12monthswith morethanonepartner;andpersonswhoareeithermarried, inacommon-lawunion,widowedanddivorcedwho report nothavinghadunsafesexoutsidethecouple.

Laboratoryanalysis

BloodsampleswerecollectedonWhatmanN◦ 5filterpaper withmeasurestoensureasepsia;thepadofthefingertip(ring finger ofthe left hand forright-handed persons and right handforleft-handedpersons)waspuncturedwithasterile lancet;specimenswerelefttoairdryandstoredat4◦Cwith desiccants,untilbeingdispatched,inlinewithinternational regulationsfortransportofbiological samplesfor diagnos-ticpurposes,totheRetrovirusandPapillomavirusUnitatthe NationalCentreforMicrobiologyoftheCarlosIIIInstituteof HealthinSpain,foranalyses.AcommercialassayGenscreen HIV-1/2(BioRad,France)wasusedforHIVantibodies detec-tion.A5mmdiameterdiscswerepunchedfromdriedblood spots (DBS) using Delfia Wallac Plate Punch (PerkinElmer, USA)andplacedintoa96-wellplateforelutionin125␮Lof phosphate-bufferedsaline-Tween80(pH7.2;0.05%Tween80 and0.005%sodiumazide).Theplatewasincubatedovernight at4◦Cundershaking.HIVantibodydetectionassaywas per-formedusing80␮LofDBSeluate.

Statisticalanalysis

Descriptiveanalysesofpatients’socio-demographic charac-teristicswere stratifiedbysexandcomparedusingtheChi Squaredtest(2_{test)fortrend.Thethreeindicatorsusedas}

responsevariableswereinadequateknowledgeonHIV/AIDS, unsafe sex, and discriminatory attitudes towards PLWHA. CrudeOddsRatios(ORs)and95%confidenceintervals(95% CI)werecalculatedtoquantifytheassociationbetweeneach potentialriskfactorandtheresponsevariablesandmodelled using multivariatelogistic regression.The final modelwas selectedusinga“backwards”procedure.Possibleinteractions between risk factors and outcome variables were investi-gated.Assexwasfoundtobeaneffectmodifierfortherisk factorsassociatedwithinadequateknowledgeonHIV/AIDS, (p-valueforinteraction<0.05),analyseswerestratifiedbysex. Also,asareaofresidence wasfoundtobeaneffect modi-fierfortheriskfactorsassociatedwithunsafesex(p-valuefor interaction<0.05),analyseswerestratifiedbyresidentialarea. AnalyseswereperformedwithSPSSforWindowsv.12.0and Stataversion10.

Ethicalconsiderations

ThestudyobtainedDepartmentalSTI/HIV/AIDSProgramme approvalfromthe MinistryofHealthinChuquisaca,which actedastheethicscommitteein2008.Priortoundertaking

thesurvey,theinterviewersexplainedtheaimsofthestudy, the voluntary nature ofparticipation and blood-extraction procedure toall participants.Inaddition, participantswere informedtheywouldonlybecontactediftheytestedpositive. Subjectswererequestedtogivetheiroralconsent,andforthe bloodtest,theyhadtosignorplacingtheirfingerprintonthe informedconsentform.

Results

Atotalof1499persons,614menand885women,were inter-viewed.Table1showstheirsociodemographiccharacteristics bygender showingsignificantdifferences;with moremale residentsinurbanareasandmorefemaleresidentsinrural areas.Brokendownbymaritalstatus,60%weresingle(mainly men).Noage-related differenceswere foundbetweenmen andwomen.Whilemostofthepopulationhadamedium/high educationallevel(secondary/university),thepercentagethat hadscarcelycompletedtheirprimaryeducationwashigher amongwomen than amongmen(15% vs.7%). Therewere gender-related differences by language and income; more womenspoke“SpanishandQuechua”oronlyQuechuaand morewomenreportedlowermonthlyfamilyincomes.

PrevalenceofHIVinfection

Ofthe1499personssurveyed,only998(67%)hadblood sam-plestakenduetobudget limitations.Nonerefusedtohave bloodtaken.Noseropositivecaseswerefoundthusprevalence ofHIVinfectionwas0.0%(95%CI:0.0–0.4%).Therewerenot statisticallysignificantdifferences betweenthe characteris-ticsofthepeoplewhohadandhadnotbloodtestsdone(data notshown).

KnowledgeofpreventionandtransmissionofHIV

Overall, prevalenceofinadequate knowledgeofthecorrect formsofpreventionandtransmissionofHIV/AIDSwas67% (95% CI: 64.6–69.4%);broken downby gender69% (95%CI: 65.4–71.5%)inwomenand65%(95%CI:61.2–68.8%)inmen. The risk factors associated with this indicator varied by gender(interaction p-value<0.05)and multivariateanalysis were stratified bygender (Table 2). In women, inadequate knowledge was associated with rural vs. urban residence [OR=3.9(95%CI:1.9–8.29)],speakingQuechuavs.only Span-ish,[OR=1.4(95%CI:1.0–1.9)],loweducationallevel[OR=7.8 (95%CI:3.1–19.7)]and earningamonthlyfamily incomeof “Bs<1000”, [OR=2.0 (95% CI: 1.4–2.7)]; in men, associated factors were rural residence [OR7.3(95% CI:2.6–21.0)] and speakingQuechua[(OR1.695%CI:1.1–2.6)]).

Discriminationandstigmatisation

Prevalenceofattitudesofdiscriminationandstigmatisation towardsPLWHAwas85%(95%CI:83.3–86.9)andwerealmost threetimeshigheramongsubjectsinthe“ruralarea”thanin theurbanarea[OR2.9(95%CI:1.4–5.0)],inpersonswithalow educationallevelandfamilyincome,[OR2.1(95%CI:1.1–4.2)] and[OR2.0(95%CI:2.0–0.5)],respectively(Table3).

Table1–Socio-demographicvariablesstratifiedbygender.

Male Female Total p-valuea

N(%) N(%) N(%) 614(41.0) 885(59.0) 1499(100.0) Placeofbirth 0.042 Beni 5(0.8) 6(0.7) 11(0.7) Chuquisaca 440(71.7) 686(77.5) 1126(75.1) Cochabamba 7(1.1) 11(1.2) 18(1.2) LaPaz 17(2.8) 21(2.4) 38(2.5) Oruro 11(1.8) 5(0.6) 16(1.1) Pando 2(0.3) 2(0.2) 4(0.3) Potosí 107(17.4) 114(12.9) 221(14.7) SantaCruz 15(2.4) 28(3.2) 43(2.9) Tarija 7(1.1) 12(1.4) 19(1.3) Argentina 3(0.5) 0(0.0) 3(0.2) Residentialsetting 0.012 Urban(centre/outskirts) 548(89.3) 750(84.7) 1298(86.6) Rural 66(10.7) 135(15.3) 201(13.4) Age 0.424 15–24 323(52.6) 447(50.5) 770(51.4) 25–49 291(47.4) 438(49.5) 729(48.6) Maritalstatus <0.001 Married 156(25.4) 270(30.5) 426(28.4) Divorced/widowed 10(1.7) 20(3.2) 38(2.5) Single 408(66.4) 489(55.3) 897(59.8)

Common-law(stable)union 40(6.5) 98(11.1) 138(9.2)

Language <0.001

SpanishorSpanishandanothernon-nativelanguage 339(55.2) 357(40.3) 696(46.4) Spanishandnativelanguageoronlynativelanguage 275(44.8) 528(59.7) 803(53.6)

Religion 0.001 Catholic 513(83.6) 788(89.0) 1301(86.8) Other 61(9.9) 72(8.1) 133(8.9) None 40(6.5) 25(2.8) 65(4.3) Educationallevel <0.001 Low 40(6.5) 129(14.6) 169(11.3) Medium/high 574(93.5) 756(85.4) 1330(88.7)

Monthlyfamilyincome(inBolivianos) 0.005

<1000 236(38.4) 408(46.1) 644(43.0)

≥1000 374(60.9) 466(52.7) 840(56.0)

Noreply 4(0.7) 11(1.2) 15(1.0)

No.offamilymembers 0.258

<1to5 392(63.8) 590(66.7) 982(65.5)

≥6 222(36.2) 295(33.4) 517(34.5)

a _2_test.

Sexualriskpractices

Prevalenceofunsafesexamongpersonswhohadalready ini-tiatedtheirsexuallifewas10.7%(95%CI:8.6–12.1%),andwas higherinurban,11%(95%CI:8.9–12.5%),thaninruralareas,8% (95%CI:3.5–11.9%).Riskfactorsforthisindicatorwere differ-entintheruralandurbanarea(p-valueforinteraction<0.05) andmultivariateanalysiswerestratifiedbyresidentialarea (Table4).Increasedprevalenceofunsafesexintheurbanarea wasreportedbymen,the“youngest”segmentandsubjects livingina“stableunion”whileintheruralarea,novariable wasfoundtohaveastatisticallysignificantassociationwith unsafesex.

Discussion

InadequateknowledgeonHIV/AIDStransmissionand preven-tion mechanisms and thediscriminatory attitudes towards personswithHIVareveryfrequentinSucreinspiteof rel-ativelylowprevalenceofunsafesexbehaviourandaverylow prevalenceofHIVinfection.Moreover,indicatorsof knowl-edge,attitudesandpracticesonHIV/AIDSdisplayimportant differences accordingtogender, ethnicandsocio-economic origin,andurbanversusruralresidence.

TheprevalenceofHIVinthegeneralpopulationaged15–49 in Sucrewas 0.0%(95%CI:0.0–0.37)and is lower than the

Table2–PrevalenceofinadequateknowledgeonHIVpreventionandtransmissionmechanismsandadjustedOR estimatedbymultivariatelogisticregression.

Prevalence AdjustedOR p-valuea

n(%) (95%CI) Women 606(68.5) Residentialsetting Urban 480(64.0) 1.0 Rural 126(93.3) 3.9(1.9–8.2) <0.001 Language

SpanishorSpanishandanothernon-nativelanguage 201(56.3) 1.0

Spanishand/orQuechua 405(68.5) 1.4(1.0–1.9) 0.031

Educationallevel

Medium/high 482(63.8) 1.0

Low 124(96.1) 7.8(3.1–19.7) <0.001

Familyincome(inBolivianos)

≥1000 271(58.2) 1.0 <1000 324(79.4 2.0(1.4–2.7) <0.001 Men 399(65.0) Residentialsetting Urban 337(61.5) 1.0 <0.001 Rural 62(93.9) 7.3(2.6–21.0) Language

SpanishorSpanishandanothernon-nativelanguage 195(57.5) 1.0 0.013 Spanishandnativelanguageoronlynativelanguage 204(74.2) 1.6(1.1–2.3)

a _2_test.

prevalenceestimatedbyUNAIDSin2010forthegeneral pop-ulation of the same age in Bolivia, namely, 0.2% (95% CI: 0.1–0.34).ThesedatarankSucreasoneofthe regionswith thelowestestimatedprevalenceinSouthAmerica.3

Prevalenceofinadequate knowledgeon HIV/AIDS trans-mission and preventionmechanismsin Sucreishigh;65% inmenand69%inwomen.Furthermore,riskfactorsdiffer bygender.Althoughinadequateknowledgeismorefrequent in rural areas and among Quechua-speakers of both gen-ders, among women it is additionally associated with a loweducationalandsocio-economiclevel,highlightingtheir

Table3–Prevalenceofdiscriminatoryattitudesto

PLWHAa_{andadjustedORestimatedbymultivariate}

logisticregression. Prevalence n(%) 1276(85.1) AdjustedOR (95%CI) p-valueb Residentialsetting Urban 7(7.4) 1.0 0.004 Rural 8(7.7) 2.9(1.4–5.0) Educationallevel Medium/high 6(7.1) 1.0 0.030 Low 6(8.3) 2.1(1.1–4.2) Familyincome ≥1000 271(58.2) 1.0 <1000 324(79.4 2.0(1.4–2.7) 0.027

a _{PLWHA:peoplelivingwithHIV/AIDS.} b _2_test.

vulnerability. The prevalence of inadequate knowledge observed byour study is lower than that reportedby pre-vious studies conducted in Bolivia. The study developed in Chuquisacabythe UASB withUNAIDS on 2006 (unpub-lishedresult)alsousedtheUNAIDSindicatorsandestimated the prevalence of inadequate knowledge as being 88% in ruralareas,mostlyQuechua-speaking,inthedepartmentof Chuquisaca, and datafurnished bythe most recent (2008) BolivianNationalDemographic&HealthSurvey12_estimated

inadequateknowledgeofmodesofHIVtransmissionamong

Table4–Prevalenceofunsafesexpracticesand adjustedORestimatedbymultivariatelogistic regressionintheurbansetting.

Prevalence n(%) 114(10.7) AdjustedOR (95%CI) p-valuea Sex Male 83(17.4) 1.0 Female 31(5.3) 0.3(0.2–0.4) <0.001 Age 15–24years 75(16.7) 1.0 25–49years 39(6.4) 0.4(0.2–0.6) <0.001 Maritalstatus Married 19(5.2) 1.0 Divorced-widowed 3(9.1) 2.3(0.6–8.2) 0.221 Single 75(13.4) 1.30(0.7–2.4) 0.457 Common-law (stable)union 17(15.0) 2.9(1.4–6.1) 0.004 a _2_test.

personsaged15–49asbeing76%inmenand78%inwomen. Apartfrommethodologicaldifferencesintheinstrumentsfor measuringandselectingthesample,thesediscrepanciesmay beduetothehighermeaneducationallevelofpersonswho answeredoursurveygiventhatSucreisauniversitycitywith alargenumberofresidentialstudents.Ourstudy’sfindings arecomparabletothoseofthe2008ElSalvadorNational Fam-ilyHealth Survey,13 _{whichdescribesinadequate knowledge}

ofHIVas 66% amongpersons aged15–49and 63% among aged15–24butsuggestshigherlevelsofinadequate knowl-edgethanothercountries.InBrazil,inadequateknowledgeof HIVwasestimatedat39%and43%in2005.14,15_Itis

notewor-thythat,asinElSalvador,inadequateknowledgewashigherin ruralwomenwithloweducationalandsocio-economiclevels, andthat,asinBrazil,16_{inpersonswithlowereducationlevel.}

Finally,whilethereareotherstudiesonknowledgeand prac-ticeswithrespecttoHIV/AIDSinLatinAmerica,theirresults arenotcomparabletoours,sincetheywerenotconductedon thegeneralpopulation.16,17

Theprevalenceofattitudesofdiscriminationand stigmati-sationtowardspersonslivingwithHIV/AIDSinthisstudywas veryhigh,85%,beinghigherintherural area,aprevalence similartothosereportedintheSimonBolivarAndean Uni-versity(UASB)-UNAIDSstudy (2006)(unpublished result).In ourstudy,personswithalowsocio-economicleveldisplayed themostpronouncedattitudesofrejection;thisisimportant tobeconsideredwhendesigningpreventivestrategiesasit hasbeenacknowledgedthatattitudesofstigmatisationand discrimination towards PLWHA reducethe effectivenessof programmesandservices.18

Theprevalenceofunsafesexualriskpracticeswas rela-tivelylow,10%,andwashigherinmenthaninwomen.These figuresarelowerthanthosefromBrazil,15_{whereunsafesex}

inthegeneralpopulationaged15–54were41%inwomenand 33% inmen.In ourstudy, therewere no significant differ-encesintheruralareaforanyofthevariables,inlinewith thefindingsoftheUASB-UNAIDSstudyinthe ruralareaof Chuquisaca.Intheurbanarea,however,womenreporteda significantlylowerprevalenceofunsafesexthanmen,and adolescentsandyoungadultsreportedmorefrequentunsafe sexpracticesthanolderadultsaged25–49.Astudyconducted inBrazil15_{reportedthatpersonsaged40–54hadhigher}

preva-lence ofunsafesexthan adolescents and youngadults.In ourstudy,22%ofthepopulationhadinitiatedsexualrelations beforetheageof15years,thoughthiswascommonerinmen thaninwomen.Thispercentagewashigherthanthatreported bythe2008BolivianNationalDemographic&HealthSurvey.12

Comparedtoothercountriesintheregion,theageofinitiation ofsexualrelationsinBoliviaishigher.16

One of the limitations of this study is not having the response rate sinceno data were gathered to calculate it. Anotherlimitationisthelossofrelativeprecisioninthe esti-mationofHIVprevalenceduetotherestrictedsamplesize, neverthelesstheabsoluteprecisionisstilllowandourresult isconsistentwithpreviousstudiesthathavereportedlowHIV prevalenceinBolivia.Sincenooptimalsamplingframework wasavailable,randomsamplingwasnotstrictlyfulfilleddue tothedifficultiesofreachingsubjectsinthe ruralarea.An effortwasalsomadetominimiseinformationbias,by ren-deringthesurveyanonymous,ensuringinterviewerswereof

thesamegenderasinterviewees,andindicatingbeforehand thatnothingsubjectsmightsaywouldbejudged,andthatit washopedtheywouldreplyashonestlyaspossibleasresults wouldbeuseful,notonlyforthemselvesbutalsoformany otherpersons.Allthesehelpedcreateaclimateoftrustand reduceinformationbias,thoughunderreportingofsexualrisk behavioursmotivatedbytheneedtogivesociallyacceptable repliescannotberuledout.

Inconclusionthisisthefirststudytoanalyseknowledge, attitudesandsexualpracticeswithrespecttoHIV/AIDSand prevalenceofHIVinfectionamongthegeneralpopulationof Sucre,Bolivia.Theresultsofthisstudythathighlightprofound andunfairdifferencesbygender,ethnicandsocio-economic origin,andurbanversusruralresidenceshouldallowtodesign policiesthattakeintoaccountethnic,intercultural,regional and gender-related realities, aligned with current national communityandinterculturalhealthpolicyastoprovidean adequateresponsetotheHIV/AIDSepidemicinBolivia.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

Wewouldliketothankthefollowing:alltheparticipants;the field teammembers ofSan FranciscoXavierofChuquisaca University who acted as the interviewers (students of the School of Medicine San Francisco Xavier of Chuquisaca University) and to the study coordinators; the Chuquisaca RegionalHealthService(ServicioDepartamentalde

Salud/SEDES-Chuquisaca)oftheBolivianMinistryofHealthforitslogistical support; and the National Centre for Epidemiology and NationalCentreforMicrobiologyoftheCarlosIIIInstituteof Health.

Our special thanksgo to the Spanish Agency for Inter-national Development & Cooperation (Agencia Espa ˜nola de

CooperaciónInternacionalparaelDesarrollo–AECID)forits

finan-cialsupportofthePublicHealthDoctoralProgrammeofthe Simon BolivarAndeanUniversity (UASB),whichled tothis study.

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