Since the first reported case of HIV/AIDS in 1981, the disease has had a devastating effect on all components of our society and has become the most deadly infectious disease epidemic in recent times. The disease is seen as a threat to the stability of entire nations and regions affecting the most productive members of the society. HIV/AIDS has become a global phenomenon, however the disease is most pronounced in developing countries particularly Sub-Saharan Africa. The spread of the disease has reached pandemic proportions in most parts of the African continent (WHO 2007).

The numbers of people infected with HIV keeps on increasing particularly among the young people. The estimated number of persons living with HIV worldwide in

2009 is 33 million. African continent alone had 22.5 million of the world’s estimated 33 million people living with HIV/AIDS (UNAIDS/WHO 2007).

UNAIDS estimates showed that young people under 25 accounted for about 45% of all new HIV cases (over 6800 people become infected with HIV everyday) in adults in 2007. The disease continues to ravage Sub-Saharan Africa and it remains the most serious of infectious disease that challenges Africa. The leading cause of death in Sub-Saharan Africa is HIV/AIDS (Tanaka, Kunii, Hatano & Wakai 2007).

It is true HIV/AIDS continues to spread among the population of urban communities in Rwanda, with its heavy toll on the 15 – 49 year age groups, who constitute the economically productive sector of the country’s economy. Kanombe and Muhima Districts are urban communities in Kigali City Province, which has seen increase in the spread of HIV/AIDS. Urban districts are part of the worst HIV/AIDS prevalence in Rwanda. As at 2006 it had prevalence rate of 5.1% far higher than the rural average of 2.1 the same year. Rwanda is among the ten countries in Africa most severely affected by HIV/AIDS. The country is facing a generalized epidemic. National estimates indicate that in 2006, the adult prevalence rate is in the range of 3.1% among the general population (WHO 2007).

Behavioral data serve as an early warning system and provide information to guide program design and evaluate interventions. In addition, the data provide information that can explain HIV prevalence trends.

Prevention supports of donor agencies and the government have been working assiduously to curb the HIV/AIDS epidemic but there has not been any considerable decrease in the prevalent rate within Kigali City Province. A critical question here is; what could have accounted for this? Prevalence in 15-24 years group shows an increase trend though efforts have been made to slow down the spread. Young female adolescents are vulnerable and may be influenced into high-risk behaviors. The gab between male-female percentage regarding condom use in Rwanda is 40.9 and 19.7 respectively (WHO 2007).

The aim of this study was to investigate the knowledge, perceptions, and attitudes of adolescents towards HIV/AIDS in order to institute meaningful preventive measures for the control of HIV/AIDS in Kigali City urban community. The findings of this study can be added to the existing body of knowledge on HIV/AIDS in Kigali City Province and in Rwanda as a whole. The findings of this study will help policymakers and healthcare professionals to develop adolescent centered, all-round and intensive programs that will curtail the spread of HIV in the province.

2. LITERATURE REVIEW

2.1 HIV/AIDS – Definition

HIV is the short form of Human Immunodeficiency Virus, the virus that causes AIDS. (Levy. 1993). AIDS is an abbreviation for Acquired Immunodeficiency Syndrome. Simply put Acquired Immunodeficiency Syndrome (AIDS) is caused by the human immunodeficiency virus (HIV), which destroys the cells in the human body that combat infections. Dr. Samuel Border, formerly at the National Cancer Institute in the United States of America, reminds us the history of HIV/AIDS. He said “In June of 1981 we saw a young gay man with the most devastating immune deficiency we had ever seen. We said, we don’t know what this is, but we hope we don’t ever see another case like it again” (WHO 1994).On 5th June, 1981, AIDS was first reported in Los Angeles, California. (Centers for Disease Control 1981). According to Broder S 1984 cited by Katrak 2006, the Human Immunodeficiency Virus type 1 (HIV – 1) was discovered in 1983 as the root cause of Acquired Immunodeficiency Syndrome (Katrak 2006).

Kahende (2001), in his thesis viewed HIV/AIDS as a cause as well as a symptom

of underdevelopment. Its long incubation period makes it hard to predict the social and economic effects it may have on households and national development as a whole. The disease mostly affects individuals in their prime between the ages of 15 to 49 years and sizable number of those in this category will have major social and economic effects in the long run (World Bank 2007, International Development Committee (IDC) 2001). The United Nations International Labor Organization’s (ILO) report in Akukwe (2006), suggest that “a minimum of 26 million people worldwide living with HIV/AIDS are in the workforce with at least two-thirds of them living in Africa”. The consequence of this is that the labor force in Africa will be in jeopardy in the near future. The disease has an incubation period of about 8 years and someone infected with the virus could infect many other people (Kahende, 2001). This means that a person infected with HIV may not show any noticeable symptoms until between 8years to 10 years when the body’s immune system can no longer withstand the HIV virus. During this time many more persons will have become infected [around 6800 new infections per day at present) USAIDS (2007)]. This creates continuing rolling burden and a vicious cycle of illness and deaths which effects could be perilous to the affected countries. This makes AIDS much more dangerous than other diseases since diseases without incubation periods can be easily identified and treated (Kahende, 2001). Cure for HIV/AIDS has not been found yet, however, anti-retroviral therapy can prolong the lives of individuals living with HIV/AIDS (Akukwe 2006). This therapy is however currently expensive and not available to majority of infected people in sub-Sahara Africa (Fry 2007).

2.2 Rwanda Country Profile

2.2.1 Rwanda History

Rwanda is a small, landlocked country in Central Africa with 9.7 million and a high population density (368 people per sq. km). Rwanda became independent in 1962 after colonization by Germany (1899) and Belgium (1919). In 1961 its monarchical government was formally abolished by a referendum and the first parliamentary elections were held.

Political turmoil over the sharing of power and access to opportunities resulted in explosions of ethnic violence which have marked much of the recent history of the country. A civil conflict pitting the Hutu-led government against the Rwanda Patriotic Front (RPF), a Tutsi-led rebel movement, culminated in genocide, between April and June 1994. About 800,000 people were massacred by the army and the extremist Interahamwe militia. The RPF overthrew the regime in June 1994.

While the country is currently at peace, Rwandans continue to struggle with the legacy of genocide. National reconciliation is a long-term endeavor that has the full commitment of the Government and the support of the international community. The Rwandan Government has undertaken significant measures to consolidate reconciliation including the continuation of the demobilization and reintegration project for ex-combatants and a model of democratization focused on a decentralized administration (World Bank 2009).

2.2.2 Economic and Social Progress

Rwanda has made remarkable progress since the 1994 genocide and civil war. Peace and political stability have been re-established, reconciliation efforts are continuing, and democratic institutions and processes are being strengthened. Poverty and social indicators have also improved. Rwanda has been able to maintain overall macroeconomic stability and implement extensive reforms which have contributed to a strong growth performance.

Rwanda is on track to achieve several of the Millennium Development Goals (MDGs): MDG 2 on universal primary education; MDG 3 on gender equality; and MDG 6 on HIV/AIDS and malaria. Net primary enrollment is currently 95 percent, with 97 percent enrollment of girls. However, low completion rates and poor quality of basic education show that there are still major challenges to meeting MDG 2. HIV prevalence is estimated at about 3 percent with female infection rates (3.6 percent) substantially higher than those of males (2.3 percent). Rwanda is also on track to achieve the targeted reduction in malaria incidence (World Bank 2009).

2.3 Adolescents and HIV/AIDS

Adolescence is one of the most captivating and complex transitions in the life span. It is a period of tremendous adjustment for children and parents. As children transition from childhood to adulthood, they undergo many physical, emotional and behavioral changes. These changes include; very fast physical growth, the rise of reproductive sexuality, new social roles, growth in thinking, feelings and morals. The sequence of pubertal changes is relatively predictable and consistent; however, their timing is extremely variable (National Academies Press 1999, 1-2.).

Nearly 50% of the world’s population is under 25 (UNFPA 2003). The threat of

HIV pandemic to young people cannot be over emphasized as UNAIDS estimates showed that young people under 25 accounted for about half of all new

HIV cases in adults in 2007 and more than half of them still lack accurate and comprehensive information about how to avoid exposure to the virus (USAID

2008).The indication that less than 40% of young people globally have accurate and comprehensive knowledge about HIV (UNGASS indicator 13) is unacceptably low and consequently worrisome. Previous studies done in USA (DiClemente, Zorn, Temoshok, 1986; Bhattacharya, Cleland, Holland, 2000),Nepal (Mahat G & Scoloveno 2006) and Turkey ( Savaser 2003) where adolescents in those studies knew of only sexual route of transmission. There is the need to step up HIV/AIDS education among the youth particularly in Sub-Sahara Africa where various cultures frown at sex education among adolescents.

Young People between the ages of 15 to 24 accounts for 30% of all people living with HIV/AIDS (UNSAIDS 2001). The disease keeps on spreading especially among young people making it even harder to control. The HIV/AIDS epidemic remain invisible to both young people and the society, people usually carry the disease for years without their knowledge. As a result, the epidemic is spreading among young people at an alarming rate.

In sub-Sahara Africa, the situation looks gloomier. More than half of sub-Saharan

Africa have generalized HIV/AIDS epidemic, this means 5% or more of the young

people are infected (UNAIDS 2000). The youth constitute one-fifth of the world’s population and nearly two-fifths in the developing countries’ populations (Population Reference Bureau (PRB) 2000). All hands must be on deck to reverse the trend in order to salvage our youth from the scourge of HIV pandemic, the future looks bleak if current situation must be allowed to continue.

Young people have been designated as a group at high risk of acquiring HIV/AIDS due to their involvement in sexual experimentation and the use of recreational drugs. Vulnerability of young people to HIV/AIDS can be attributed to physical, social, economical and psychological features of adolescents (Offer, Ostrov, Howard, & Atkinson, 1988, 270 & Senderowitz, 1995). Socially and economically, most adolescents are dependent and inexperienced therefore, they are unable to protect themselves from infections, and have less access to health care than adults. Again, young people’s vulnerability to HIV/AIDS increases as result of cultural practices that shape their behaviors. Adolescence is a stage where young people establish their sexual identities, in doing so they are faced with pressures from society as well as their peers.

2.4 Adolescents’ knowledge, attitudes, perceptions and prevention of HIV/AIDS

HIV/AIDS has caused indescribable suffering to millions of people world wide.

The fight against the scourge and epidemic of HIV/AIDS is and continue to be one of the biggest challenges facing the world today. The impact of the disease touches on the lives of the global community in different predictable and unpredictable ways. Though the severity of the crisis is obvious, biochemical and pharmaceutical development of vaccines continue to have limited success; current drugs available can suppress the virus but they do not cure HIV infections or AIDS (The National Institute of Allergy and Infectious Diseases (NIAID), 2009).Therefore, promotion of prevention strategies needs to be intensified in order to halt the spread of HIV.

It is now a common knowledge as reported in many studies that Transmission of human immunodeficiency virus (HIV) via sexual contact is the most common(UNAIDS 2002) and accounts for 75 to 85 percent of all infections(Royce, Seña, Cates, & Cohen, 1997). Over the past two decades, rates of infection with sexually transmitted diseases have continued to increase among teenagers. Roscoe and Kruger (1990) in their article titled ‘Late adolescents’ knowledge and its influence’ concluded that although adolescents’ knowledge of HIV transmission might have improved over the past few years, their risk-related behaviors remain unchanged. This, no doubt can be linked to Adolescents’ sexual behavior and knowledge, attitudes, perceptions towards HIV/AIDS.

Numerous studies have been done on adolescents’ sexuality, knowledge, attitudes, and/or behaviors relevant to AIDS in order to improve the over all sexual behavior of adolescents. It is important at this point to consider such surveys of adolescents. A random-sample surveyed by Strunin and Hingson (1987) of 860 adolescents, 16 to 19 years of age, concerning their knowledge, beliefs, attitudes, and behaviors regarding AIDS indicated 70% were sexually active (having sexual intercourse or other sexual contact) but only 15% of them reported changing their sexual behavior because of concern about contracting AIDS, and only 20% of those who changed their behavior used effective methods.

Several prominent studies showed high engagement in unsafe sexual behaviors such as sex with multiple partners, sex with unknown persons, as well as negative views about condom use, and a low rate of behavior change even after learning about HIV/AIDS (Buysse, 1996, Gray & Saracino, 1989). This corroborates the suggestion that a moderate to high knowledge level of AIDS may not be a predictor of safe sexual behavior practices (Gray & Saracino, 1989). However, a study conducted by Roscoe & Kruger, (1990) of 300 late adolescents suggests that one-third had altered their sexual behavior as a result of fear of the disease. Available Research on the effects of beliefs of susceptibility to AIDS indicates that adolescents and adults who report high perceived risk for AIDS practice safer sexual behaviors, whereas those who perceive low risk for contracting AIDS report practicing unsafe sexual behaviors (Gray & Saracino, 1989 Villarruel, A.M., Jemmolt, Howard, Taylor, & Bush, 1998).

Youth Education and prevention programs have been used as the primary means of decreasing rate of HIV infections among adolescents, it can be summed up in three letters ABC(A=Abstinence, B=Be Faithful, C=Condoms). Barnett and Parkhurst (2005) have described abstinence as the best followed by faithfulness to one partner and condom use as last. Anytime ABC is mentioned Ugandan situation comes to mind, in 1991, the government, opinion leaders and the people of Uganda had the courage to change the attitudes and behaviors that were spreading the HIV. A Harvard study in Uganda finds HIV rates drop 50% within eight years. The study credits abstinence education in reducing HIV/AIDS in Uganda (Trafford 2002). Again, it has been argued that condoms have about 10-13% failure rate in preventing pregnancy and 10-20% failure rate in preventing HIV for several reasons. Museveni (2004) in his commentary on HIV titled ‘Behavioral Change Is the Only Way To Fight AIDS’ cited Uganda as being excellent in this direction; it has successfully managed to bring the seroprevalence rate from 18.6% to 6.1% using just social vaccine (behavior change), approximately 70% reduction. Molomo 2008, National coordinator of NACA(National Action Committee on AIDS) said “behavioral change is the responsibility of the individual and not the community”. He explained the latter could provide enabling environment within which the former can effect behavioral change. Attitudes, beliefs, and/or intentions have been described by many theories as proximal determinants of behavior. Consequently, changes in attitudes toward abstinence and condoms, and Perceptions of personal risk or susceptibility to HIV should be the main goals in any HIV/AIDS prevention program.

3. AIMS AND OBJECTIVES OF THE STUDY

The aim of this study is to investigate the knowledge, perceptions, and attitudes of adolescents (15-24) towards HIV/AIDS in order to institute meaningful preventive measures for the control of HIV/AIDS.

Ultimately, the study will provide information on appropriate intervention methods necessary for preventing HIV/AIDS among adolescents in the community.

3.1 Research Questions

With respect to the theme of our research, the following research questions shall be addressed:

1. What knowledge do adolescents in Kigali City Province have about HIV/AIDS?

2. What are the perceptions and attitudes by adolescents towards HIV/AIDS preventions?

3. Which preventive method(s) do they use?

4. Do they perceive any risk of contracting/getting HIV/AIDS?

4. RESEARCH METHODS AND DATA SOURCES

Qualitative research approach will be used to address HIV/AIDS prevention among adolescents. Qualitative methodology or deductive approach according to

Pope and Mays (1995) is used to explore, interpret or illustrate the actions and/or subjective experiences of research participants. In other words qualitative research tends to give a comprehensive data about human observations, thoughts and feelings; it tries to establish meaning from human life experiences.

As the focus of our study is to investigate the knowledge, perceptions, and attitudes of adolescents and young adults towards HIV/AIDS and its prevention, a qualitative approach will allow the participants to express their feelings and experiences genuinely (Punch 1998).