Since the first case of acquired immunodeficiency syndrome (AIDS) was announced in the US in the early 1980s, it has spread rapidly around the world, and it continues to be a major global public health problem [1]. According to the World Health Organization (WHO), at the end of 2015, approximately 36.7 million people were living with human immunodeficiency virus (HIV), and 1.1 million people died from HIV-related causes globally in 2015 [2].

In Iran, the first case of AIDS was reported in 1986. Although, the prevalence of HIV/AIDS in Iran is lower than the average of the world and Eastern Mediterranean countries, it has been estimated in recent years that Iran is facing a dramatic rise in HIV infections. According to the estimations of the WHO/Joint United Nations Programme on HIV/AIDS (UNAIDS), the number of people in Iran currently living with HIV has tripled since 2000, increasing from 24,000 cases to 73,000 (95% confidence interval [CI], 50,000 to 130,000) cases in 2015, of which 26,000 were women aged 15 and above [3,4]. While the total number of registered cases of HIV in Iran has gradually decreased since 2004, the number of women cases has steadily increased; the proportion of women among those infected with HIV has increased from only 6% in 2004 to almost 30% in 2013 [3].

Women play a key role in socioeconomic development in the family-oriented context of Iran, as well as in the welfare and health of their family members and in public health; therefore, they should be focused on as part of HIV/AIDS-related interventions in Iran.

Prevention is the main strategy to deal with the AIDS pandemic. Individuals can reduce their risk of HIV infection by limiting their exposure to known risk factors. Inaccurate knowledge and misperceptions are the main barrier to preventing the spread of HIV/AIDS [1,5-7]. However, knowledge alone is not adequate for preventing and limiting HIV infection among women of reproductive age; instead, knowledge must be accompanied by a sufficiently accepting attitude toward engaging in healthy behaviors [8,9]. Characterizing the population’s knowledge of and attitudes toward people with HIV/AIDS is an essential prerequisite to developing effective educational and preventive interventions [1,10]. Previous studies in Iran have reported inconsistent results. Moreover, most of the available studies had a small sample size, were conducted in small settings such as schools or universities, and focused on the population of a particular city or province [11], or were not based on responses to a survey about AIDS. Therefore, their results have limited external validity and are not generalizable to the overall women population of Iran.

In this study, we aimed to fill this gap by investigating the knowledge and attitudes of Iranian women aged 15-49 years regarding HIV/AIDS, based on data from Iran’s Multiple Indicator Demographic and Health Survey (IrMIDHS), a naturally representative survey conducted in 2015. Additionally, socio-demographic correlates of women’s knowledge of and attitudes toward HIV were identified. We hope that this study provides required information for Iranian policy-makers to develop interventions or to improve preventive strategies for combatting HIV/AIDS in Iran.

A total of 44,921 women were approached, of whom 42,630 participated (response rate, 94.9%). The mean± standard deviation age was 32.8± 5.6 years, and the proportions of participants in different age groups were as follows: 25.8% (n= 11,307) were 15-24 years old, 33.5% (n= 14,658) were 25-34 years old, 28.5% (n= 12,471) were 35-44 years old, and 12.8% (n= 5,359) were 45-49 years old. Furthermore, 64.7% of participants lived in in urban areas, 71.0% were married, and 58.0% had university educations; however, only a minority (7.3%) were wealthy, according to the wealth index.

This study aimed to assess the knowledge and attitudes of women aged 15-49 years in Iran about HIV/AIDS. The results showed that the majority of women (78.5%) had heard about HIV/AIDS, which is consistent with the results of the IrMIDHS-2010 (79.8%) [13]. Only 19.1% of women had comprehensive knowledge of HIV/AIDS, which is comparable to the results of a similar study conducted in Ethiopia (19.3%) [8]. Comprehensive knowledge of HIV/AIDS is an indicator often used to measure awareness of important facts about HIV transmission and prevention. Correct and comprehensive knowledge of HIV transmission and prevention is important to avoid infection [8]. Lack of access to sexual health information could be a reason underlying the low levels of comprehensive knowledge of women about HIV [11]. Gender inequalities and taboos regarding issues of sexuality and sexual health may also contribute to women’s relatively low levels of knowledge [8].

We found a relatively large knowledge gap and extensive misconceptions about HIV/AIDS transmission and prevention in this survey, which is consistent with the results of the IrMIDHS-2010 [13] and a study in India [14]. Most women knew that a healthy-looking person can be HIV-positive, similar to the result of the IrMIDHS-2010 (70%) and a study among young people in Iran [11, 13]. However, misconceptions about transmission were observed among a large proportion of women; such as the belief that HIV can be transmitted by mosquito bites, sharing a meal with an infected person, and shaking hands. Similar misconceptions have been reported in other studies [6,11,15,16]. These findings suggest the need to strengthen educational interventions, especially by health workers for women. Comprehensive knowledge about HIV will support women to make informed choices about practices that may protect them from HIV/AIDS [1].

The highest knowledge level was in the older age groups, in line with the findings of studies in India [14] and Saudi Arabia [10]. This can be attributed to more exposure to sexual health education, such as mandatory premarital trainings on sexual health and HIV, which are regularly practiced in Iran [11]. Married women showed significant differences in comparison to never-married women in terms of their knowledge about HIV/AIDS, which is expected due to their higher potential exposure to infection. This is similar to the result of a study conducted in Congo and Nigeria [17]. Our results showed that the wealth index was significantly associated with comprehensive knowledge of HIV/AIDS among Iranian women. This result is similar to those reported from other parts of the world [8,17,18]. Socioeconomic status is associated with increased exposure to media and more educational achievements, which have a positive impact on HIV/AIDS knowledge [17]. With increasing levels of education, knowledge also increases, so that women with higher levels of education had better knowledge of HIV/AIDS. This result is consistent with other studies [14,16,17] and this can be attributed to access to more information about the disease. These findings indicate the need to provide suitable education for illiterate and semi-literate women regarding HIV/AIDS transmission, which should be considered in health education programs. The difference in knowledge among rural and urban women was not significant; this finding is inconsistent with the results of the IrMIDHS-2010 (urban, 37% vs. rural, 20%; p< 0.05) [13] and other similar studies [8,16,18]. Since women living in urban areas may have greater access to education, mass media, and HIV/AIDS awareness campaigns [8,11], this finding is unexpected and should be further investigated in subsequent studies.

The Iranian media have not been effective in educating people about HIV and other sexually transmitted infections, mostly because these topics are considered socially taboo and too shameful to be discussed in mass media. A lack of access to sexual health information may lead to limited knowledge about HIV.

The results also showed that 15.4% of women had an accepting attitude toward people living with HIV, showing an improvement compared to the proportion of 9.0% in the IrMIDHS-2010 [13]. However, accepting attitudes were still uncommon, and attitudes should be a topic of particular attention in future educational interventions. Similar results have been reported in previous studies in Iran [11], Bolivia [18], Bahrain [6], and the United Arab Emirates [19]. According to UNAIDS, negative attitudes are common all over the world [8], and are one of the main obstacles in the fight against HIV/AIDS [17].

The most common item for which participants reported an accepting attitude was related to taking care of an HIV-positive family member in one’s own home, which can be attributed to the family-oriented culture of Iran Similar results have been reported in Laos [15] and Saudi Arabia [10]. The lowest rate was related to the disclosure of a family member with HIV/AIDS, which reflects the fact that the stigma of HIV/AIDS is still a major issue in our community. Negative attitudes toward buying fresh vegetables from a HIV-positive shopkeeper slightly changed, dropping from 65% in 2010 [13] to 52% in this survey.

Positive attitudes toward people with HIV were more common among women who had access to mass media and lived in urban areas, which can be attributed to greater access to information about HIV/AIDS. Exposure to mass media has been found to be related to less stigmatizing attitudes towards HIV [20,21].

The relatively negative attitudes we found toward people with HIV may have been due to inaccurate knowledge about HIV transmission and prevention [11,22,23], leading to unnecessary concerns about interacting with people with HIV and higher levels of stigma [10]. Negative attitudes toward HIV are an obstacle to the efficient implementation of educational interventions, voluntary counseling, and HIV testing [15,22], while accepting attitudes have been found to be related to willingness to receive HIV testing [11]. Negative attitudes can be modified through effective educational interventions and information about AIDS [24], which could eventually lead to healthy behaviors. Comprehensive knowledge could be a fundamental factor for building accepting attitudes towards people living with HIV.

This study has revealed important findings about women’s knowledge of and attitudes toward HIV/AIDS at the national level; however, it may have some limitations. As with other studies based on self-report data, the quality of the data may have been affected by social desirability bias, and people may not have expressed their real attitudes in face-to-face interviews.

In conclusion, our study revealed that Iranian women’s knowledge about HIV/AIDS and, in particular, their attitudes toward people with HIV were not acceptable, which should be considered as an important concern. Improving the knowledge and attitudes of the public toward HIV/AIDS has been recognized as an important factor in management of the disease. Therefore, educational programs on HIV/AIDS should be strengthened in schools and health centers in accordance with Islamic and Iranian culture to correct the misconceptions found in this study and to encourage accepting attitudes toward people with HIV, particularly among women living in rural areas, women with a low educational level, and in lower socioeconomic strata. Launching awareness campaigns for the public is another way to improve knowledge and attitudes about HIV/AIDS.