DEMOGRAPHIC

AND

HEALTH

SURVEYS

DHS WORKING PAPERS

2017 No. 134

Rukhsana Khan

Arshia Bilal

Shakira Huma Siddiqui

July 2017

This document was produced for review by the United States Agency for 

International Development.

Knowledge about HIV and Discriminatory Attitudes 

toward People Living with HIV in Pakistan

Knowledge about HIV and Discriminatory Attitudes toward 

People Living with HIV in Pakistan 

Dr. Rukhsana Khan1

Dr. Arshia Bilal1

Dr. Shakira Huma Siddiqui2

ICF 

Rockville, Maryland, USA 

July 2017 

1

Fazaia Medical College, Air University 

2

Faculty of Social Sciences, Air University 

Corresponding author: Dr. Rukhsana Khan, Fazaia Medical College, Air University, email: 

drrukhsanakhan@hotmail.com 
Acknowledgments 

This research is supported by USAID through ICF. We would like to express our deepest 

appreciation to USAID and ICF for providing us the opportunity to complete this research. Special 

gratitude goes to our facilitators Wenjuan Wang and Shireen Assaf, whose stimulating suggestions 

and encouragement helped us to complete this research paper. We would also like to thank cofacilitators Bupe B. Bwalya and Mulenga C. Mulenga for their thoughtful support. We are grateful 

to the reviewers Joy Fishel and Bryant Robey for their guidance, reviews, and comments 

throughout the process. 

Editor: Bryant Robey 

Document Production: Joan Wardell 

The DHS Working Papers series is a prepublication series of papers reporting on research in 

progress that is based on Demographic and Health Surveys (DHS) data. This research is carried 

out with support provided by the United States Agency for International Development (USAID) 

through The DHS Program (#AID-OAA-C-13-00095). The views expressed are those of the 

authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and 

evaluate population, health, and nutrition programs. For additional information about The DHS 

Program, contact DHS Program, ICF, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA. 

Phone: +1 301-407-6500; Fax: +1 301-407-6501; Email: reports@dhsprogram.com; Internet: 

www.dhsprogram.com. 

Recommended citation: 

Khan, Rukhsana, Arshia Bilal, and, Shakira Huma Siddiqui. 2017. Knowledge about HIV and 

Discriminatory Attitudes toward People Living with HIV in Pakistan. DHS Working Paper 

No. 134. Rockville, Maryland, USA: ICF.
iii 

Abstract 

Background: The current study explored the association between knowledge about HIV and 

discriminatory attitudes toward people living with HIV in Pakistan. The incidence of HIV among 

high-risk groups in Pakistan has reached 5% or higher, indicating a concentrated epidemic. 

However, little evidence is available about the attitudes of the general population toward people 

living with HIV. People living with HIV fear being stigmatized and anticipate discriminatory 

behavior from health care providers and the general community. Having incorrect knowledge 

about HIV leads to more discriminatory attitudes. 

Methods: This study is based on secondary analysis of data from the Pakistan Demographic and 

Health Survey (PDHS) conducted in 2012-13. Ever-married women and men age 15-49 who had 

heard about AIDS were included in the study. Variables measuring composite knowledge about 

HIV and discriminatory attitudes were developed and categorized into three groups for the purpose 

of statistical analysis: no knowledge, some knowledge, and more knowledge. A chi-square test 

and multinomial regression analysis were performed to see the association between HIV/AIDS 

knowledge and discriminatory attitudes by background characteristics of the study group. 

Results: The study found a statistically significant inverse relationship between knowledge about 

HIV and discriminatory attitudes toward people living with HIV. That is, having more knowledge 

about HIV was associated with a lower likelihood of exhibiting a more discriminatory attitude. 

The likelihood of having a more discriminatory attitude toward people living with HIV decreased 

as the level of knowledge about HIV increased. Regression analysis showed that the effects of 

wealth, education, and region were also statistically significant. Respondents with secondary and 

higher education and those in the middle, rich, and highest wealth quintiles were less likely to hold 

a discriminatory attitude. Men, despite having more knowledge than women about HIV, held a 

more discriminatory attitude toward people living with HIV. 

Conclusions: The results suggest that there is a need for Pakistani society to become better 

informed about HIV and AIDS to reduce the stigma associated with HIV, which will in turn reduce 

discriminatory attitudes toward people living with HIV. Positive attitudes towards HIV will 

encourage them to seek medical care for their disease, which will control further spread of this 

epidemic. 

Keywords: HIV and AIDS, people living with HIV (PLHIV), knowledge about HIV, 

discriminatory attitude, Pakistan

1 

1. Introduction 

There are 37 million people living with HIV (PLHIV) globally, with annual incidence of more 

than 2 million in 2015. AIDS remains a major global public health issues, resulting in more than 

1 million deaths worldwide (WHO 2016). In Asia and the Pacific, the number of people living 

with HIV has increased by 10% since 2001 (UNICEF 2003). With the fastest growing HIV and 

AIDS epidemics, the Eastern Mediterranean region (EMRO 2017) is one of the top two regions of 

the world in the number of PLHIV. At the same time, HIV/AIDS-related mortalities are also on 

the rise in this region. Pakistan is among the five countries of EMRO, contributing about 80% of 

total cases (EMRO 2017). 

The HIV epidemic in Pakistan is comparable to that in other Asian countries, having moved from 

low prevalence, high risk to concentrated epidemic in the early to mid-2000s (Pakistan Global 

2015; WHO 2016). Concentrated epidemic means 5% or higher incidence of HIV among highrisk groups. The most vulnerable high-risk groups in Pakistan are injecting drug users and 

commercial sex workers (Bokhari et al. 2007; Farid-ul-Hasnain, Johansson, and Krantz 2009). 

Some of the challenges for effective control and response to the HIV epidemic in Pakistan include 

lack of reliable data regarding the trend of the epidemic, low national commitment, the stigma 

attached to HIV (Alonzo and Reynolds 1995; Pitpitan et al. 2012), risk behaviors associated with 

HIV transmission, and discrimination toward PLHIV (EMRO 2017). Research suggests that 

individuals who express greater agreement with stigmatizing statements about PLHIV are those 

who have incorrect knowledge about HIV transmission (Ekstrand et al. 2012). Stigmatizing is not 

only restricted to discriminatory statements; it also extends to discriminatory behavior toward 

PLHIV. Studies have shown that HIV-related stigma and discrimination inhibit HIV prevention 

and mitigation (MacQuarrie, Eckhaus, and Nyblade 2009; Pitpitan et al. 2012) and ultimately lead 

to avoidance of HIV testing by people living with AIDS (Pitpitan et al. 2012) and unwillingness 

of the general community to provide social support to PLHIV (Steward et al. 2008). 

People living with HIV fear being stigmatized (Heckman, Kochman, and Sikkema 2004; Vanable 

et al. 2006), and they anticipate discriminatory behavior not only from the community (Major and 

O’Brien 2005) but also from medical care providers (Kelly et al. 1987). PLHIV experience 

rejection from others when they disclose their disease status (Rutledge 2007; Wong et al. 2009). 

Disclosing HIV status can have some positive effects; for example the risk of disease transmission 

can be reduced (Pinkerton and Galletly 2007), and PLHIV can start medication earlier, may 

regularly take medication, and receive its beneficial effects (Mellins et al. 2002; Serovich et al. 

2001; Winstead et al. 2002). Nevertheless, to avoid social rejection, PLHIV do not usually disclose 

their disease status and instead keep it secret (Chandra, Deepthivarma, and Manjula 2003). 

Though studies have been conducted on HIV- and AIDS-related knowledge and attitudes 

concerning high-risk groups (Khan et al. 2009, 2011; Zafar et al. 2014), little evidence is available 
2 

about the attitude of the general population toward PLHIV in Pakistan, and it cannot be generalized 

to the entire population. Currently, the data available in the 2012-13 Pakistan DHS survey are 

likely to fill the gap by providing information about the attitudes of individuals toward PLHIV in 

their communities. The DHS findings can be easily generalized due to their representativeness and 

adequate sample size. 

From the existing data, we intend to measure the relationship between the knowledge men and 

women of reproductive age have regarding HIV and AIDS and their attitudes toward PLHIV. Our 

research also aims to investigate the association of demographic and socioeconomic indictors with 

knowledge of individuals about HIV and their attitudes toward PLHIV. The study’s findings will 

possibly guide policymakers in addressing the causes of discriminatory attitudes toward PLHIV 

and focus resources on changing discriminatory community attitudes through promoting 

awareness and health education. This change in attitudes is likely to improve social responses of 

the communities toward PLHIV, and also to reduce the stigma attached to HIV testing/screening. 

In addition, it will motivate HIV patients to not hide their disease status and to regularly visit the 

health centers to seek care. We hope that present research will have greater social impact on the 

society by making the prevention and mitigation program a success. 

1.1 Research questions 

Our research questions were the following: 

1. Does knowledge about HIV predict discriminatory attitude toward PLHIV? 

2. Is there any association of socioeconomic and demographic variables with knowledge 

about HIV and discriminatory attitudes toward PLHIV? 

1.2 Conceptual framework 

Figure 1 shows the conceptual framework of the study. We investigated the relationship of 

knowledge about transmission and prevention of HIV and discriminatory attitudes of individuals 

toward PLHIV. We also assessed the effect of socioeconomic and demographic factors on this 

relationship. 

 
3 

Figure 1. Conceptual framework 

Socioeconomic and demographic 

variables

• Age 

• Gender 

• Education 

• Residence 

• Region 

• Wealth quintile 

Knowledge about transmission and 

prevention of HIV 

• Knows HIV can be prevented by using 

condoms and limiting sexual intercourse 

to one uninfected partner 

• Knows a healthy-looking person can 

have HIV 

• Rejects the two most common local 

misconceptions about HIV transmission: i.e., HIV can be transmitted by 

mosquito bites and by sharing food with 

PLHIV

Discriminatory attitudes toward 

PLHIV 

• Would not buy fresh vegetables 

from a person if they knew that this 

person had the AIDS virus 

• Would keep positive HIV status of 

a family member secret 

• Would not be willing to care for a 

family member sick with AIDS 

• Believes a female teacher with 

HIV should not be allowed to 

continue teaching 

5 

2. Data and Methods 

2.1 Data 

This study is based on secondary analysis of data provided by the 2012-13 Pakistan Demographic 

and Health Survey (Pakistan Demographic & Health Survey 2012-13). The sampling frame for 

urban areas included 26,543 enumeration blocks updated through the economic census conducted 

in 2003 and identified by the Pakistan Bureau of Statistics (PBS), whereas the sampling frame for 

rural areas included a list of 46,307 villages/Mouzas/Dehs, which was developed through the 1998 

population census. The PDHS used a two-stage stratified cluster sampling method. Enumeration 

blocks from urban areas and villages/Mouzas/Dehs from rural areas were included as the primary 

sampling units (PSUs). In the first stage, 500 PSUs comprising 248 urban areas and 252 rural areas 

were selected using a probability proportional to size. The PBS staff compiled a list of households 

in the selected PSUs. In the second stage, a total of 14,000 households, 28 from each PSU, were 

selected using a systematic sampling technique with a random start. 

The data for this study were taken from interviews with ever-married women and men age 15–49 

who have ever heard about AIDS. Our sample size after correction for sampling weight was 7,821, 

including 5,675 women and 2,146 men. 

2.2 Variables 

2.2.1 Dependent variables 

In the PDHS, an affirmative response to some survey questions indicated an accepting attitude 

towards PLHIV, e.g., “Would you buy fresh vegetables from a shopkeeper or vender if you knew 

that this person had the AIDS virus?” In other questions, an affirmative response indicated a 

discriminatory attitude; e.g., “If a member of your family got infected with the AIDS virus, would 

you want it to remain a secret?” In our study, each variable was re-coded so that the same value 

indicated a discriminatory attitude for all questions, and a composite variable of discriminatory 

attitude was constructed. These modified indicators included: 

1. Not willing to buy fresh vegetables from an HIV-infected person, 

2. Want to keep the positive HIV status of a family member secret,

3. Not willing to care for family member sick with AIDS, and 

4. Not willing to let an HIV-infected female teacher continue teaching in the school. 

The Cronbach alpha for these four variables was 0.7. On the basis of responses to the four 

variables, discriminatory attitude was categorized into “no discriminatory attitude” (if no on all 

variables), “some discriminatory attitude” (if yes on one or two variables), and “more 

discriminatory attitude” (if yes on three or four variables).
6 

2.2.2 Independent variables 

Knowledge about HIV 

For the present study, a composite variable regarding knowledge about HIV and AIDS was 

developed on the basis of five questions, including knowing that: 

1. A healthy-looking person can have HIV. 

2. HIV can be prevented by using a condom every time a person has sex. 

3. HIV can be prevented by limiting sex to one uninfected partner who has no other partners. 

4. HIV cannot be transmitted by mosquuito bites. 

5. HIV cannot be transmitted by sharing food with someone who has HIV. 

The Cronbach alpha for these five variables was 0.86. The composite knowledge variable 

constructed from the five variables was categorized into “no knowledge” if the respondent gave 

no correct response, “some knowledge” if one or two responses were correct, and “more 

knowledge” if three to five responses were correct. 

Socioeconomic and demographic variables 

Variables related to background characteristics of study participants included age, sex, education, 

region, residence, and wealth. As mentioned, the study included ever-married persons age 15-49 

who had heard about AIDS. While the PDHS dataset variables for age are in 5-year groups, this 

made it difficult for us to use because it included seven age categories, some with a very small 

sample size for men. Instead, for our analysis this variable was divided into three categories: age 

15-26, 27-37, and 38-49. The education variable has four categories: none, primary, secondary, 

and higher education. Residence was divided into urban or rural. As in the PDHS, region is 

subcategorized into six broad areas: the five provinces of Pakistan, namely, Punjab, Sindh, Khyber 

Pakhtonkhwa (KPK), Balochistan, Gilgit and Baltistan (GB), and the capital, Islamabad Capital 

Territory (ICT). Household wealth status is an index divided into quintiles: lowest, second, middle, 

fourth, and highest. 

2.3 Statistical analysis 

Descriptive analysis was performed for each of the component variables and composite variables 

of knowledge and discriminatory attitudes as well as socioeconomic and demographic variables. 

A chi-square test was applied to see the association of knowledge about HIV and AIDS and 

anticipated discriminatory attitudes toward PLHIV. Two models were developed to determine the 

association by using multinomial regression between knowledge of HIV and discriminatory 

attitudes. The first model was unadjusted, and the second model was adjusted for socioeconomic 

and demographic variables. Relative risk ratios with 95% confidence interval were calculated. The 

effect of the complex multistage sampling design was taken into consideration and sample weights 

were applied for all the analysis performed using STATA version 14.0 software.
7 

3. Results 

3.1 Background characteristics of study sample 

 A total of 7,821 individuals were included in the study, of whom about three-fourths were female. 

Table 1 shows the background characteristics of the sample population included in the study. The 

highest proportion of respondents (46%) were age 27-37. Thirty-seven percent of respondents had 

a secondary education, while 22% had no education. Nearly two-thirds (62%) were residents of 

Punjab province, and just over half (52%) of respondents were rural. 

Table 1. Ever-married women and men age 15-49 who heard about AIDS by background 

characteristics 

Women Men Total 

Variables Frequency % Frequency % Frequency % 

Age 

Young 1,437 25.3 272 12.7 1,709 21.9 

Middle age 2,641 46.6 950 44.3 3,592 45.9 

Old age 1,596 28.1 924 43.0 2520 32.2 

Education 

No education 1,424 25.1 324 15.1 1,748 22.4 

Primary 1,083 19.1 443 20.7 1,526 19.5 

Secondary 1,958 34.5 902 42.0 2,860 36.6 

Higher 1,210 21.3 477 22.2 1,687 21.5 

Region 

ICT 53 0.9 16 0.7 69 0.9 

Punjab 3,562 62.8 1,318 61.4 4,879 62.4 

Sindh 1,365 24.1 471 22.0 1,836 23.5 

KPK 560 9.8 246 11.5 806 10.3 

Balochistan 124 2.2 87 4.1 212 2.7 

Gilgit Baltistan 11 0.2 8 0.3 19 0.2 

Residence 

Urban 2,540 44.8 1,217 56.7 3,757 48.0 

Rural 3,135 55.2 929 43.3 4,064 52.0 

Wealth 

Lowest 167 3.0 197 9.2 365 4.7 

Second 482 8.5 335 15.6 817 10.5 

Middle 1,017 17.9 401 18.7 1,418 18.1 

Fourth 1,646 29.0 592 27.6 2,239 28.6 

Highest 2,361 41.6 621 28.9 2,982 38.1 

Total 5,675 100 2,146 100 7,821 100 

3.2 Distribution of knowledge about HIV 

Knowledge about HIV is almost equally distributed among men and women, as Figure 2 shows. 

Among both women and men, 67% were aware that a healthy-looking person can have HIV. 

Regarding transmission of HIV, 50% had correct knowledge that HIV cannot be transmitted by 

sharing food with someone who has HIV. When asked about the transmission of HIV by mosquito 

bites, 49% of women and 59% of men gave a correct answer. When asked about prevention, overall 

78% of individuals (76% of women and 84% of men) knew that limiting sex to one uninfected 
8 

partner can reduce the risk of getting HIV, and 54% of respondents (52% of women and 57% of 

men) said that condom use can reduce the risk of HIV. 

Figure 2. Distribution of knowledge about HIV prevention and transmission among 

men and women 

Figure 3 shows that 17% of respondents correctly answered all five questions regarding 

transmission and prevention of HIV, while 23% gave four correct answers, and 26% gave three 

correct answers. Overall, by the composite three-category knowledge variable, two-thirds (66%) 

had more knowledge (three to five correct responses), 29% had some knowledge (one or two 

correct responses), and only 5% had no knowledge (no correct responses) about HIV. 

Figure 3. Percentages of correct responses regarding knowledge about HIV 

67.1

49.1 49.3 52.4

75.7

67.1

58.5

50.2

56.8

83.8

0

10

20

30

40

50

60

70

80

90

100

Healthy person

has HIV

Virus cannot be

transmitted by

mosquito

Cannot get HIV

by sharing food

Condoms reduce

HIV risk

One uninfected

partner reduces

HIV risk

Women Men

5.1

10.4

18.8

25.7

23.0

17.0

0

5

10

15

20

25

30

None One Two Three Four Five
9 

3.2 Distribution of discriminatory attitudes among women and men 

As Figure 4 shows, only a small percentage of respondents said they would be unwilling to care 

for HIV-infected family members (8% of women and 10% of men), while 58% of women and 

62% of men said they would keep the positive HIV status of a family member secret. About half 

of the respondents (54% of women and 53% of men) said they would not buy vegetables from an 

HIV-infected vendor, and 35% of women and 48% of men would not be willing to allow an HIVinfected teacher to continue teaching in a school. 

Figure 4. Distribution of discriminatory attitudes 

The “discriminatory attitudes” variable in our study is measured by the four questions shown in 

Figure 4. Figure 5 shows the distribution of responses to these questions. One-third (33%) of 

respondents showed a discriminatory attitude on only one variable, while about a fifth (21%) 

showed a discriminatory attitude on three variables. Only 16% of the respondents showed no 

discriminatory attitude toward PLHIV. 

7.9

53.5

57.8

35.4

10

52.7

62.4

38.9

0

10

20

30

40

50

60

70

80

90

100

Not willing to care

relative with HIV

Not buy vegetables

from vendor with HIV

Keep HIV in family

secret

HIV infected teacher

not allowed

Women Men
10 

Figure 5. Percentages of response to the variables assessing discriminatory

attitudes 

3.4 Association of knowledge about HIV by discriminatory attitude 

Figure 6 shows the results concerning knowledge about HIV by discriminatory attitude toward 

PLHIV. Respondents with no knowledge about HIV had the highest proportion of responses with 

a more discriminatory attitude (41%) compared with those with some or more knowledge (30% 

and 18% respectively). A chi-square test was used to see the association of knowledge with 

discriminatory attitude and was found highly significant, with p-value <0.001. 

Figure 6. Discriminatory attitude toward PLHIV and knowledge about HIV 

16.1

33.0

28.1

20.6

2.2

0

5

10

15

20

25

30

35

None One Two Three Four

7.9 9.2

19.9

51.3

60.6

62.1

40.9

30.2

18.0

0

10

20

30

40

50

60

70

80

90

100

No knowledge Some knowledge More knowledge

No Discrimination Some Discrimination More Discrimination
11 

3.5 Association of knowledge about HIV with socioeconomic and demographic factors 

This analysis explored the association of the composite variable of knowledge about HIV with 

selected socioeconomic and demographic factors, using a chi-square test. Table 2 shows that sex, 

education, region, residence, wealth (all p<0.001), and age (p<0.001) were significantly associated 

with HIV knowledge. Knowledge about HIV was greater in ICT, the capital city of Pakistan. A 

higher proportion of men than women had more knowledge about HIV, and individuals age 27-37 

had higher proportions of more knowledge compared with other age groups. The level of the more 

knowledge variable was also high in the highest wealth quintile and in urban areas. 

Table 2. Relationship of knowledge with socioeconomic and demographic factors 

No knowledge Some knowledge More knowledge 

N p-value 

Socioeconomic and 

demographic factors % CI % CI % CI 

Region

ICT 1.8 [1.1, 2.8] 15.0 [12.5, 17.7] 83.3 [80.2, 85.9] 69 

<0.001 

Punjab 5.6 [4.6, 6.9] 30.3 [27.8, 32.9] 64.1 [61.3, 66.8] 4,879 

Sindh 4.5 [3.5, 5.7] 24.9 [22.3, 27.8] 70.6 [67.3, 73.6] 1,836 

KPK 7.4 [5.8, 9.3] 33.1 [29.5, 36.8] 59.6 [55.5, 63.5] 806 

Balochistan 6.2 [4.0, 9.6] 31.9 [26.5, 37.8] 61.9 [55.5, 67.9] 211 

Gilgit Baltistan 4.1 [2.3, 7.2] 23.5 [18.2, 29.8] 72.4 [65.3, 78.4] 19 

 

Sex 

Women 5.7 [4.9, 6.7] 31.4 [29.4, 33.4] 62.9 [60.6, 65.1] 5,675 

<0.001 

Men 4.9 [3.6, 6.7] 23.4 [20.9, 26.2] 71.6 [68.6, 74.5] 2,146 

 

Age

Young 7.3 [5.7, 9.2] 32.0 [29.4, 34.7] 60.7 [57.9, 63.5] 1,709 

<0.001 

Middle age 4.9 [4.0, 6.0] 27.4 [25.1, 29.9] 67.7 [65.0, 70.2] 3,592 

Old age 5.2 [4.0, 6.7] 29.8 [27.1, 32.6] 65.0 [62.1, 67.8] 2,521 

 

Education 

No education 10.2 [8.1, 12.6] 42.4 [38.9, 46.0] 47.4 [43.7, 51.2] 1,748 

<0.001 

Primary 8.0 [6.3, 10.0] 34.4 [30.7, 38.2] 57.7 [53.4, 61.9] 1,526 

Secondary 3.8 [2.9, 4.8] 27.8 [25.3, 30.4] 68.5 [65.9, 70.9] 2,860 

Higher 1.4 [0.9, 2.3] 13.2 [11.3, 15.4] 85.3 [83.1, 87.3] 1,687

 

Residence

Rural 7.0 [5.9, 8.4] 34.2 [31.9, 36.7] 58.7 [56.1, 61.3] 3,757 

<0.001 

Urban 4.1 [3.3, 5.2] 24.5 [22.1, 27.1] 71.4 [68.5, 74.0] 4,064 

 

Wealth 

Lowest 12.0 [8.6, 16.5] 32.6 [26.9, 38.9] 55.4 [48.7, 62.0] 365

<0.001 

Second 9.1 [6.7, 12.3] 36.4 [31.6, 41.6] 54.4 [49.0, 59.7] 817 

Middle 7.8 [5.8, 10.4] 37.0 [33.7, 40.4] 55.2 [51.6, 58.8] 1,418 

Fourth 5.4 [4.3, 6.6] 32.6 [29.7, 35.7] 62.0 [58.8, 65.2] 2,239

Highest 2.8 [2.0, 3.8] 20.5 [18.2, 23.1] 76.7 [74.0, 79.2] 2,982 

 

Total 5.5 [4.8, 6.4] 29.2 [27.5, 31.0] 65.3 [63.3, 67.2] 7,822 
12 

3.6 Association of discriminatory attitude with socioeconomic and demographic factors 

The study also assessed the association of discriminatory attitudes with socioeconomic and 

demographic factors. Table 3 shows that discriminatory attitude was significantly associated with 

sex, education, wealth, and region (p<0.001). Discriminatory attitude was also significantly 

associated with age (p<0.05), while the association with residence was of borderline significance 

(p=0.05). A higher proportion of men than women had a more discriminatory attitude toward 

PLHIV, and as respondents’ level of education increased, the proportion with a more 

discriminatory attitude decreased. 

Table 3. Relationship of socioeconomic and demographic factors with discriminatory attitude 

Socioeconomic 

and demographic 

(SED) Indicators 

No discriminatory attitude

Some discriminatory 

attitude 

More discriminatory 

attitude 

% CI % CI % CI N p-value 

Region 

ICT 19.9 [16.3, 24.1] 64.2 [60.5, 67.8] 15.9 [13.4, 18.7] 69 

Punjab 17.3 [15.4, 19.4] 60.4 [57.4, 63.3] 22.3 [20.0, 24.8] 4,879 

Sindh 13.4 [11.5, 15.4] 63.3 [60.4, 66.1] 23.3 [20.7, 26.2] 1,836 

KPK 16.9 [13.4, 21.0] 63.1 [59.3, 66.8] 20.0 [17.3, 23.1] 806 

Balochistan 9.3 [6.1, 13.9] 48.7 [41.9, 55.5] 42.0 [36.0, 48.4] 211 

Gilgit Baltistan 11.2 [7.9, 15.8] 63.8 [53.5, 72.9] 25.0 [17.1, 34.9] 19 

 <0.001 

Sex 

Women 16.5 [15.1, 18.1] 63.5 [61.5, 65.5] 20.0 [18.5, 21.5] 5,675 

Men 15.1 [12.5, 18.2] 54.5 [50.8, 58.2] 30.4 [26.8, 34.2] 2,146 

 <0.001 

Age 

Young 16.3 [14.1, 18.7] 63.1 [59.7, 66.3] 20.7 [18.2, 23.4] 1,709 

Middle age 16.4 [14.7, 18.3] 62.1 [59.3, 64.8] 21.5 [19.2, 24.0] 3,592 

Old age 15.6 [13.7, 17.7] 58.3 [55.1, 61.4] 26.1 [23.3, 29.2] 2,521 

 0.022 

Education 

No education 10.5 [8.7, 12.5] 59.9 [56.5, 63.3] 29.6 [26.6, 32.7] 1,748 

Primary 13.7 [11.0, 16.9] 60.9 [56.5, 65.2] 25.4 [21.9, 29.3] 1,526 

Secondary 17.6 [15.1, 20.4] 61.4 [58.1, 64.5] 21.0 [18.9, 23.4] 2,860 

Higher 21.8 [19.4, 24.4] 61.8 [58.6, 64.9] 16.4 [14.0, 19.2] 1,687 

 <0.001 

Wealth 

Lowest 9.4 [6.5, 13.3] 46.4 [36.9, 56.1] 44.2 [36.0, 52.8] 365 

Second 11.2 [8.3, 15.0] 61.4 [56.3, 66.3] 27.4 [23.0, 32.3] 817 

Middle 16.8 [14.3, 19.7] 59.4 [55.7, 63.1] 23.7 [20.9, 26.8] 1,418 

Fourth 17.1 [14.7, 19.8] 59.5 [56.7, 62.4] 23.4 [20.8, 26.1] 2,239 

Highest 17.2 [15.3, 19.4] 64.7 [61.3, 67.9] 18.1 [15.8, 20.7] 2,982 

 <0.001 

 Residence 

Rural 15.1 [13.3, 17.2] 60.0 [57.4, 62.7] 24.8 [22.3, 27.5] 3,757 

Urban 17.1 [15.2, 19.1] 62.0 [59.0, 64.9] 20.9 [18.9, 23.2] 4,064 

Total 16.1 [14.8, 17.6] 61.1 [59.0, 63.0] 22.8 [21.2, 24.5] 7,822 0.050 
13 

3.7 Regression results for discriminatory attitude by knowledge about HIV 

Table 4 shows the unadjusted results of the multinomial regression model using knowledge about 

HIV to predict discriminatory attitudes toward PLHIV, with “no knowledge” and “no 

discriminatory attitude” as reference. Respondents with more knowledge about HIV exhibited half 

the risk of expressing some discriminatory attitude (versus no discriminatory attitude) compared 

with those with no knowledge (p<0.05). When comparing “more discriminatory attitude” with “no 

discriminatory attitude,” respondents with more knowledge about HIV exhibited about one-fifth 

the risk of discriminatory attitude as those with no knowledge (p<0.001). 

The likelihood of people in the “some knowledge” category exhibiting discriminatory attitude 

toward PLHIV was not significantly different compared with the “no knowledge” group. 

Table 4. Multinomial regression of discriminatory attitude and knowledge 

Some discriminatory 

attitude More discriminatory attitude 

Variables RR CI RR CI 

No knowledge 1.0 1.0 

Some knowledge 1.0 [0.5, 1.9] 0.6 [0.3, 1.2] 

More knowledge 0.5* [0.3, 0.9] 0.2*** [0.1, 0.3] 

*** p<0.001, ** p<0.01, * p<0.05 

3.8 Regression results for discriminatory attitude toward PLHIV by knowledge about 

HIV adjusted for socioeconomic and demographic factors 

Table 5 shows that the risk of having “more discriminatory attitude” toward PLHIV (versus “no 

discriminatory attitude”) is lower among respondents in the “more knowledge” category 

compared with the “no knowledge” group, and this relationship was significant (p<0.001) even 

after adjusting for socioeconomic and demographic factors. However, after including these factors 

in the model, the association between knowledge of HIV and “some discriminatory attitude” 

toward PLHIV found in the unadjusted model was no longer significant.

Table 5 also shows the results of a model predicting discriminatory attitude toward PLHIV by 

knowledge about HIV adjusted for socioeconomic and demographic factors. “Some discriminatory 

attitude” (versus “no discriminatory attitude”) was significantly associated with the level of 

education. Risk of exhibiting some discriminatory attitude was lower among individuals with 

secondary and higher education compared with no education. The risk of having a more 

discriminatory attitude (versus no discriminatory attitude) was lower among those with secondary 

and higher levels of education compared with no education. 

Risk of “some discriminatory attitude” was 1.4 and 1.9 times higher among respondents in the 

provinces of Sindh and Gilgit Baltistan, respectively, compared with ICT. Residents of Balochistan 
14 

province had three times the risk of exhibiting more discriminatory attitude (versus no 

discriminatory attitude) as residents of ICT. 

Men were almost twice as likely as women to have a more discriminatory attitude (versus no 

discriminatory attitude), and the relative risk ratio was extremely significant (p<0.001). 

Individuals in the top three wealth quintiles had lower risk for more discriminatory attitude 

(versus no discriminatory attitude) compared with the lowest quintile. However, there was no 

difference between some discriminatory attitude versus no discriminatory attitude when 

comparing the top four wealth quintiles with the lowest quintile. 

Table 5. Multinomial regression of knowledge and discriminatory attitude adjusted for 

socioeconomic and demographic factors 

Variables Categories 

Some discriminatory 

attitude 

More discriminatory 

attitude 

RR CI RR CI 

Knowledge No knowledge 1.0 1.0 

Some knowledge 1.1 [0.5, 2.1] 0.7 [0.3, 1.4] 

More knowledge 0.5 [0.3, 1.0] 0.2*** [0.1, 0.4] 

Age Young age 1.0 1.0 

Middle age 1.0 [0.8, 1.2] 1.0 [0.8, 1.3] 

Old age 0.9 [0.7, 1.1] 1.1 [0.8, 1.5] 

Education No education 1.0 1.0 

Primary 0.8 [0.6, 1.1] 0.8 [0.5, 1.1] 

Secondary 0.6** [0.5, 0.9] 0.5*** [0.4, 0.8] 

Higher 0.5*** [0.4, 0.7] 0.4*** [0.3, 0.6] 

Region ICT 1.0 1.0 

Punjab 0.9 [0.7, 1.2] 1.0 [0.7, 1.5] 

Sindh 1.4* [1.0, 1.8] 1.6* [1.1, 2.3] 

KPK 0.9 [0.6, 1.4] 0.8 [0.5, 1.3] 

Balochistan 1.4 [0.8, 2.4] 3.0*** [1.7, 5.2] 

Gilgit Baltistan 1.9* [1.1, 3.1] 2.1* [1.1, 4.1] 

Sex Female 1.0 1.0 

Men 1.1 [0.8, 1.4] 1.9*** [1.4, 2.6] 

Residence Rural 1.0 1.0 

Urban 0.9 [0.7, 1.1] 1.0 [0.7, 1.3] 

Wealth Lowest 1.0 1.0 

Second 1.2 [0.7, 2.2] 0.6 [0.4, 1.1] 

Middle 0.9 [0.5, 1.4] 0.4*** [0.3, 0.7] 

Fourth 1.0 [0.6, 1.6] 0.5** [0.3, 0.8] 

Highest 1.3 [0.8, 2.2] 0.5* [0.3, 0.9] 

*** p<0.001; ** p<0.01; * p<0.05 
15 

4. Discussion 

The present study had two objectives: (1) to explore the association between knowledge about 

HIV and discriminatory attitudes toward people living with HIV and (2) to describe the association 

of socioeconomic and demographic factors with knowledge about HIV and discriminatory 

attitudes toward PLHIV. 

4.1 Knowledge about HIV/AIDS 

In our study, two-thirds (66%) of respondents had more knowledge about HIV compared with less 

knowledge (29%) and no knowledge (6%). Our finding is consistent with a study in South India, 

which found that most of the population had good knowledge about HIV and AIDS (Bhagavathula 

et al. 2015). A study in Lao Republic also found that the highest proportion of individuals had a 

high level of knowledge about HIV (46%) compared with a medium level (31%) and low level of 

knowledge (22%) (Thanavanh et al. 2013). The differences in proportion between this and our 

study can be explained on the basis of differences in classifying the levels of knowledge. 

A study in Karachi by Farid-ul-Hasnain and colleagues (Farid-ul-Hasnain, Johansson, and Krantz 

2009) found that most participants (59%) had good knowledge about HIV, which is consistent 

with our study, while the proportions with no knowledge (22%) and less knowledge (19%) were 

different from our study. This difference could be because the Karachi study included only the 

population age 17-21 while our study population was age 15-49. In contrast with our finding, a 

study in Nijeria found that 27% of participants had good knowledge about HIV, 38% had fair 

knowledge, and 34% had poor knowledge. This difference among studies is possibly due to 

diffences in education among the study populations, as three-fourths of our participants had 

primary, secondary, or higher education, while two-thirds of participants in the Nigerian study had 

no formal schooling (Iliyasu et al. 2006). 

When we assessed knowledge about whether a healthy-looking person can have AIDS, we found 

that 67% of respondents gave the correct answer, which is consistent with the findings of studies 

from India (Hazarika 2010) and Bangladesh (Yaya et al. 2016), but a much lower proportion than 

found in a study among adolescents in Korea (Sohn and Park 2012). Our result was quite high 

compared with a recent study conducted among fishermen in Karachi (Leili, Elham, and 

Farkhondeh 2008; Zafar et al. 2014). The low level of knowledge about HIV among fishermen 

could be explained on the basis of their low literacy rate. 

Our study revealed that around half of the participants rejected the common misconception of 

transmission of HIV and AIDS through mosquito bites, a finding similar to studies in Bangladesh 

(Yaya et al. 2016) and Iran (Leili, Elham, and Farkhondeh 2008), while studies in Japan 

(Maswanya et al. 2000) and South India (Bhagavathula et al. 2015) observed higher levels. The 

Japanese study, however, only included college students (Maswanya et al. 2000), and in the Indian 

study more of the participants were male and all were relatives of people living with HIV 
16 

(Bhagavathula et al. 2015). In Korea, only about a third of adolescents had correct knowledge 

about transmission of HIV through mosquito bites, but the study only interviewed high school 

students (Sohn and Park 2012). 

Our finding that half of respondents had correct knowledge, rejecting the misconception that 

sharing of food can transmit HIV is consistent with another study in Pakistan (Rehan et al. 2016) 

but much lower than the study of South India, which only covered adult family members of people 

living with HIV (Bhagavathula et al. 2015), who can be presumed to have more knowledge about 

HIV than the general population. 

In our study, knowledge regarding preventive measures against HIV and AIDS was 54% 

concerning condom use and 78% concerning limiting sex to one uninfected partner. Results from 

a study in Bangladesh (Yaya et al. 2016) and a national survey (NFHS-3) in India showed almost 

similar results (Hazarika 2010). 

Our study found the level of knowledge about HIV higher among men than women, individuals 

with more education, and residents of urban area. These findings agree with studies in Bangladesh 

and India (Bhagavathula et al. 2015; Hazarika 2010; Yaya et al. 2016). Hazarika found that level 

of knowledge about HIV was lower among women in rural India (Hazarika 2010), while Yaya 

showed a significant association of knowledge about HIV with education, sex, residence, and 

wealth status (Yaya et al. 2016). 

In our study participants age 27-37 and those in the highest wealth quintile had significantly more 

knowledge about HIV. A study in Karachi also revealed the same significant association with 

knowledge (Farid-ul-Hasnain, Johansson, and Krantz 2009). The Karachi study also found that 

poor knowledge of HIV was prevalent among younger people (age 17-18), which agrees with our 

finding that the youngest participants (age 15-26) had less knowledge about HIV compared with 

the other age groups. 

4.2 Discriminatory attitudes toward people living with HIV 

Overall, only 16% of individuals in our study expressed no discriminatory attitude toward PLHIV, 

while 61% had some discriminatory attitude and 23% had more discriminatory attitude. A study 

in Iran also found a high level of negative attitude toward PLHIV among the general public (Leili, 

Elham, and Farkhondeh 2008). In the Lao Republic study 44% of high school students showed a 

negative attitude toward PLHIV (Thanavanh et al. 2013), which is much lower than our finding 

but could be due to a difference in classification. A study in Bangladesh found a moderate level of 

discriminatory attitudes among health care workers (Hossain and Kippax 2010). A study in an 

anti-retroviral clinic in South India found that more than half of the respondents had an accepting 

attitude toward PLHIV (Bhagavathula et al. 2015), which may reflect the fact that the participants 

were family members of PLHIV. 
17 

In our study examining the individual components of discriminatory attitudes, 54% of respondents 

showed a discriminatory attitude toward buying vegetables from an HIV-infected vendor, 38% 

toward allowing an HIV-infected teacher to continue in a school, and 9% toward provision of care 

to their HIV-infected family members. These findings are similar to a study conducted in Botswana 

(Letamo 2003), where 11% of participants were unwilling to care for an HIV-infected family 

member, 42% would not allow an HIV-infected teacher to continue teaching, and 60% would not 

buy vegetables from an HIV-infected vendor. A study in India found less prevalence of 

discriminatory attitudes (Hazarika 2010), a difference that could be explained by the higher 

educational level of participants compared with our study. This highlights the importance of 

education in reducing the discriminatory attitudes of the general population toward PLHIV. 

Our finding that 59% of respondents would keep secret the status of an HIV-positive family 

member is much higher than in the study in India, where only about a third of participants held 

this view, with little variation among rural and urban areas (Hazarika 2010). The difference may 

be because more than half of respondents in the Indian study had at least a secondary education. 

The current study also found that men were more likely to have a more discriminatory attitude 

than women, and that individuals with no education were more likely to have a more 

discriminatory attitude than those with secondary or higher levels of education. These associations 

were statistically highly significant. Similarly, a study among youth in Botswana showed that 

male had more negative attitudes than females toward PLHIV (24% versus 18%), and less 

educated participants had more negative attitudes than more educated participants (Majelantle et 

al. 2014). The Indian clinic study also found a significant association between more education and 

lower discriminatory attitudes (Bhagavathula et al. 2015). 

4.3 Association of knowledge about HIV and discriminatory attitudes toward people 

living with HIV 

The study revealed a highly significant association (p <0.001) between knowledge about HIV and 

discriminatory attitudes toward PLHIV. There is an inverse relationship between the level of 

knowledge and the odds of having a discriminatory attitude, such that having more knowledge 

about HIV is associated with a lower likelihood of exhibiting a more discriminatory attitude toward 

PLHIV. The finding is consistent with the studies in India, Bangladesh, and Iran (Bhagavathula et 

al. 2015; Ekstrand et al. 2012; Hossain and Kippax 2010; Tavoosi et al. 2004). Bhagavathula et al. 

found a statistically significant correlation between knowledge and negative attitudes 

(Bhagavathula et al. 2015). Ekstrand et al. (2012) found that a discriminatory attitude toward 

PLHIV was reduced with more correct knowledge about transmission of HIV (Ekstrand et al. 

2012). In Iran, Tavoosi et al. found a significant correlation between more negative attitude toward 

PLHIV and less knowledge about HIV (Tavoosi et al. 2004). Another study in Iran also agrees 

with the finding of our study, as a significant negative correlation was found between awareness 
18 

about HIV and AIDS and discriminatory attitudes toward people with symptoms of HIV and AIDS 

(Masoudnia 2015). 

A study in Kuwait showed a high level of negative attitude toward PLHIV despite a high level of 

knowledge about HIV (Ellepola et al. 2011), which actually supports our result, as men in our 

study showed twice the risk of discriminatory attitude in spite of having more knowledge about 

HIV. In Bangladesh, Hossain and Kippax also found that holding a negative attitude was more 

prevalent among men (Hossain and Kippax 2010). 

We found that discriminatory attitudes toward PLHIV was more common among participants in 

the low wealth quintile and those with less education. Similarly, studies in India, Bangladesh, and 

Tanzania also found a significant association between level of education and attitudes toward 

PLHIV (Amuri et al. 2011; Bhagavathula et al. 2015; Hossain and Kippax 2010).
19 

5. Conclusion 

There is a significant association between knowledge about HIV and discriminatory attitudes 

toward PLHIV after adjusting for socioeconomic and demographic background characteristics of 

respondents. Some discrimination was found at all levels of knowledge about HIV. Having 

secondary and higher education, being in the middle, fourth, and highest wealth quintiles, and 

having more knowledge about HIV were associated with lower likelihood of a more discriminatory 

attitude toward PLHIV. Participants in Sindh, Balochistan, and Gilgit Baltistan provinces were 

associated with increased risk of more discrimination. Men, despite having more knowledge than 

women about HIV, had more discriminatory attitudes toward PLHIV. 

6. Policy Implications 

Since 1987, the government of Pakistan has maintained a sustained response to the HIV epidemic. 

Awareness about HIV among the general population is also a component of the National Aids 

Control Program (NACP). Despite having knowledge about HIV, our study population showed 

negative views reflected through their discriminatory attitudes toward people living with HIV. 

Results of this study will encourage policymakers to provide adequate resources and pay attention 

to all aspects of the HIV epidemic. Pakistani society must be better informed about HIV and AIDS. 

It is critical to reduce the stigma associated with HIV and the discriminatory attitudes that many 

people hold, which is one of the factors that may influence the further spread of HIV and AIDS in 

Pakistan.

21 

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