Knowledge , Attitude and Practice Regarding HIV / AIDS among Students in China

HIV/AIDS remains one of the world’s most significant public health challenges, particularly in low and middle-income region. China has witnessed a moderate effect of global HIV/AIDS endemic for which HIV/AIDS awareness and prevention program have been developed and conducted. In China the university students are among the affected target population because of the recent development of casual attitude towards sex, the rapid economic revolution and degradation of traditional value. The purpose of this paper is to describe HIV/AIDS knowledge, attitudes, and practice and identify personal risk behaviors among students in China. Selection of the articles suitable for the review was done from 2007 to 2016 on the basis of their study regarding HIV/AIDS in accordance with different students of schools, undergraduate and postgraduate study. Knowledge of the students is accordance with their education level while attitude have no relation with the knowledge and still there is unsafe sexual practice present among students. Although students have good knowledge regarding HIV/AIDS, they have still negative attitude towards HIV/AIDS patients. There are still misconceptions especially concerning mosquitos and kissing as routes of transmission of HIV. There is difficulty in separating HIV from AIDS by many students. Due to insufficient knowledge regarding HIV/AIDS among school students many of them believe that there is a medicine that can cure HIV/AIDS. Comparatively Students are more focused on knowledge regarding HIV/AIDS rather than developing and maintaining safe sexual behavior among the students. We believe that the review will help to focus further into the more effective attitude based implementation of knowledge and practice among Chinese students.


Introduction
Human immune virus infects cells of the immune system which result in the progressive deterioration of the immune system, breaking down the body's ability to fend off some infections and other diseases [1].AIDS (Acquired immune deficiency syndrome) refers to the most advanced stages of HIV infection, defined by the occurrence of any of more than 20 opportunistic infections or related cancers [1] [2] [3].The first case of Human immune Virus (HIV) was recognized in United States in 1981 [4].HIV/AIDS remains one of the world's most significant public health challenges, particularly in low and middle-income region [5].The statisticians from joint United Nations Program on HIV/AIDS (UNAIDS) and WHO estimated that there are approximately 36.7 million people living with HIV at the end of 2016.34.5 million are adults, 17.8 million women, 16.7 million men, and 2.1 million children below 15 years.People newly infected with HIV in 2016 are 1.8 million of which 1.7 million are adults.Total AIDS death in 2016 was 1.0 million of which 890,000 were adults [6].Recently due to non-achievement of millennium goals on HIV/AIDS in different countries in the world especially in developing countries, the joint UN program on HIV/AIDS has fixed new objectives to overcome HIV infections by 2030 [7] [8].

Overview of HIV/AIDS in China
The first case of HIV was reported in 1985 [9].In 2011, more than 50% of people living with HIV did not know their HIV status.55% were infected by heterosexual activities.Among them 68.7% contracted the disease through casual or commercial sexual interactions.The United States Nations, WHO and Ministry of Health of China Joint panel on HIV and AIDS presented the data that there were 780,000 estimated numbers of people living with HIV in China in 2011 [10].The national HIV prevalence was 0.058%.3.5 million people are living with HIV in Southeast Asia in 2016 [6].Treatment aimed at improving prognosis and delaying morbidity is costly not only in China but in the whole world.Although government and international organizations made effort to stop new HIV infection by 2015 in China, but evidence showed that communicable infections continue to occur while decimating the lives [11].The HIV/AIDS epidemic in China presents four major characteristics: first, the national HIV/AIDS epidemic maintains a low-prevalence trend, with higher-prevalence in some areas and among some groups; second, the number of people living with HIV/AIDS continues to increase, with HIV/AIDS showing high differentiation in prevalence among different groups; third, the number of AIDS patients rises markedly, with the number of all-cause deaths becoming stable; and fourth, sexual transmission is the primary mode of transmission with sexual transmission between men increasing markedly [12].In 2014, according to the requirements of "the Regulations on HIV/AIDS Prevention and Control" and "China's 12th Five-Year" Action Plan for Containment and Prevention of HIV/AIDS", China continued to implement the major response measures of "Five Expands and Six Strengthens", World Journal of AIDS thus achieving marked progress in multiple areas.In the area of prevention and intervention, the percentage of female sex workers who are living with HIV has been comparatively low in recent years and in 2014 it was 0.22%.The percentage of people who inject drugs who are living with HIV has been stable with a slight decline, dropping from 6.33% in 2013 to 6.00% in 2014 [1] [7] [12].During 2010-2014, reported cases of people living with HIV/AIDS continued to increase from 307,000 in 2010 to 352,000, 386,000, 437,000 and 501,000 in 2011, 2012, 2013 and 2014 respectively (Figure 1) [12].
The main reasons for the increase include: the number of people receiving testing has been growing year by year and therefore, more cases of HIV/AIDS have been found accordingly; the number of patients receiving ART treatment has been steadily increasing by a large margin each year, prolonging the lives of people living with HIV/AIDS [7] [12].Many studies have shown that HIV infection is shifting from men who sex with men to heterosexuals particularly among youth at reproductive age [13].Particularly the Vulnerable groups to the HIV are young people [14].

Knowledge, Attitude and Practice Regarding HIV/AIDS
In China the university students are among the effected target population because of the recent development of casual attitude towards sex, the rapid economic revolution and degradation of traditional value [15].In these groups there is lack of adequate information regarding HIV knowledge and behavior that might be hit hard by the HIV pandemic.So it is essential to access Knowledge, Attitude and Practice of individuals before planning preventions.The purpose of this review is to summarize the latest publications about HIV/AIDS-related Figure 1.Geographic Distribution of People Living in China with HIV/AIDS in 2014 [12].World Journal of AIDS knowledge, beliefs and sexual behavior among students in China.This summarized study will provide knowledge and understanding of issues and lead to effective suggestions for further research and implementation.There are several articles regarding the HIV/AIDS-related knowledge, beliefs and sexual behavior among students in China.
We went through the search engine as GOOGLE SCHOLAR, PUBMED, BAIDU and SCOPUS.79 articles related to the topic regarding HIV/AIDS were selected of which 25 articles related to HIV/AIDS in China were separated.Of the 25 articles 8 articles related to our study regarding Chinese students Knowledge; attitude and practice were finalized for the review (Figure 2).
All the 8 articles were published between 2007 to 2016 and selected on their validity, reliability, number of samples, relation to the AIDS/HIV, Chinese students' knowledge, their attitude and Practice towards the disease (Table 1).

Lönn, E., Sahlholm K., Maimati R., et al., AIDS Patient Care and STDS, 2007 [16]
The study was based on questionnaire and personal interviews of medicine  The validity test was 0.7 and reliability was 0.78.Self-administered questionnaire was used to investigate KAP regarding HIV/AIDS.The questionnaires were modified in accordance to WHO recommendation and Chinese culture.Total range for score was 0 to 57 with students of HIV knowledge have higher score, more accepting attitude about and engaged in fewer HIV risky behaviors.In the survey 259 students participated of which 125 male and 132 female.The mass media (newspapers and magazines, 64% television and radio 48.8%) was the major sources for getting information about HIV and AIDS.The analysis of research showed that although some has high knowledge (17.8% Today's students live in an era of mass communication, in which they have easier access to HIV information compared with decades ago.It is essential to focus not only on knowledge but also on developing and maintaining safe sexual behavior.
It is important that all the students from schools and colleges should have

Figure 2 .
Figure 2. Flow diagram showing selection process of articles included in the review.
knowledge regarding HIV transmission and prevention as well as they should develop positive attitude towards the HIV patients.To ameliorate the deficiencies, China desperately needs higher quality evidence-based knowledge dissemination and attitude improvement programs for students.It can be concluded from the review that Chinese students have high level of knowledge while there are several misconceptions, confusion, and fear existed among them.Students' background and sexual activity has strong impact on their attitude and behaviors towards people infected with HIV/AIDS.All these analyses lead to the conclusions about the fight against AIDS.It is important to focus research and interventions on young people especially students.This review paper will promote our knowledge and understanding of these issues and lead to effective suggestions regarding directions for further research and implementation in the field of HIV/AIDS in China.

International Journal of Environmental Research and Public Health, 2007 [15]
Xinjiang medical university in Urumqi during spring 2004.The questionnaire consisted of 40 questions divided into four categories: general questions, Knowledge about HIV/AIDS, personal questions and questions about the work situation.Total of 400 individuals participate with age ranged from 19 DOI: 10.4236/wja.2017.74021252 World Journal of AIDS students at dents believed that there was a medicine that cures HIV/AIDS.20% of all the students answered that they would talk with fathers about HIV/AIDS.60% of undergraduate students and 52% of the postgraduate students wanted to be tested for HIV.89.8% undergraduate and 98% postgraduate students did not want to have child if they were infected with HIV/AIDS.79.3% of undergraduate students had not had any sexual contact.Over half (58%) of the postgraduates had one sexual partner.69% of undergraduate and 39.8% of the undergraduate students were afraid of being infected with HIV at work.3.2.Tan, X., Pan J., Zhou D., et al.,

et al., Applied Nursing Research, 2008 [17]
).The majority had moderate knowledge.The total correct answer rate regarding pertaining to source of HIV/AIDS was 69.4%.47.5% students answered all HIV transmission questions correctly.Moderate knowledge of prevention noted in 10.9% students.The attitudes of respondents towards people with HIV/AIDS were found accepting and Positive.153(59.8%) voiced strong willing to live in the same community with HIV/AIDS people.Rate of expression of having sexual intercourse were 6.9%.Age of onset of sexual intercourse was from 18 to 23. 35.7% mentioned condom used during sexual practice.Boys have greater acceptance in comparison to girls towards accepting people with HIV/AIDS.Knowledge difference was between medical and non-medical student while no significant attitude difference.The study was based on questionnaire that compromised 204 nursing students from 10 nursing schools at Xiangya hospital of central south university in 2004.
3.3.Li Y., C.S. Scott, Li L.,Most recognized that sharing needles can cause HIV infection (97%), an HIVpositive mother can cause HIV (87%), and HIV can be transmitted via sexual intercourse (80%).Although, 12% have only knowledge that the risk of HIV infection from needle stick injury is <1%.There were no significant difference between education level and attitudes towards PWA were noted.Most of Chinese nursing students believed that PWA has the right to the same quality of care as any other patient.Only 73% of them agreed that partners of homosexuals should receive equal respect.34% of the nursing students believed that most people with HIV/AIDS deserved what they got.48% of nursing students strongly agreed that young children should be removed from the home if one of the parents was HIV-positive.A weak positive relationship between attitude and willingness to provide care was found.3.4.Maimaiti N., Shamsuddin K., Maimaiti R.,

et al., Global Journal of Health Science, 2010 [18]
15sease.84.3% of the respondents thought their friends will avoid them if they were found to be HIV positive.54%feltpersonswithHIV/AIDSdeserve it.30%feltthatHIVinfectedstudents should be treated differently.15.8% of all respondents had risk behavior related to HIV/AIDS transmission.The questionnaires based on adolescent AIDS knowledge scale byZimet (1998)and the request of knowledge about AIDS/HIV prevention for young people by the United Nations general assembly special section.The study consisted of 38 closed-ended questions including 10 questions on socio-demography information, 18 questions on HIV/AIDS knowledge, 4 questions on HIV/AIDS attitude, 5 questions on high-risk behaviors and 1 question on source of HIV/AIDS knowledge.Response rate was 97.8% (1468/1500).It constituted 877 middle school students and 59 high schools students.The mean age was 14.71 years.691 (78.79%) of middle school students and 455 (76.99%) high school students were from middle class economy.The study showed that the middle school students had a low rate of awareness except in two questions such as "AIDS/HIV is an in-There is difficulty in separating HIV from AIDS by many students.Due to insufficient knowledge regarding HIV/AIDS among school students many of them believe that there is a medicine that can cure HIV/AIDS.This shows lack of sufficient knowledge regarding HIV/AIDS among schools students compared to university students.
[26]l transmission from mother to child and about 65% -75% thought condom could prevent HIV transmission during sexual intercourse.59.5% thought one can get HIV through mosquito bite, and 38.5% thought HIV/AIDS is homosex-ual people[23][24].Although students have good knowledge regarding HIV/AIDS, they have still negative attitude towards HIV/AIDS patients.Knowledge alone is not enough to change the negative attitude of the students towards the HIV patients but social and culture factors also play vital role for the development of the attitude.Condom use during sexual intercourse is an essential component of HIV/AIDS prevention whereas there is less rate of wearing condom during sexual intercourse.Sexually active students are still shy to buy condom due to cultural norms related especially to unmarried youths.Condom promotion should be done.HIV/AIDS education will be more successful if education is carried out using continuous and long-term realistic objectives[25][26].Health promotion program need to be focused for students.There are still misconceptions among students that mosquito bite and kissing can transmit HIV.