Knowledge,Attitudes,and Practices Toward HIV/AIDS Among Health Faculty Students at a University in East Java,Indonesia: A Path Analysis Approach

Abstract

Introduction

East Java ranked second among Indonesian provinces for HIV/AIDS cases in June 2022. Barriers to prevention include limited knowledge, negative attitudes, and risky practices. This study assessed knowledge, attitudes, and practices (KAP) toward HIV/AIDS and examined their relationships with sexual activity status and preventive sexual behaviors among health faculty students at a University in East Java, Indonesia.

Methods

A cross-sectional study was conducted from May to June 2024 using a validated questionnaire. Descriptive statistics summarized participant characteristics and KAP levels. Path analysis using a partial least square examined relationships among variables, with sexual activity status in the full sample and preventive sexual behaviors in the sexually active sub-sample as outcomes.

Results

A total of 441 students were included. Most participants demonstrated high HIV/AIDS knowledge (75.3%), positive attitudes toward people living with HIV/AIDS (PLWHA) (61%), and safe practices (91.6%). In model 1, knowledge had a significant positive relationship with attitudes (β = 0.165; p = 0.000) and sexual activity status (β = 0.038; p = 0.048), while attitudes showed a significant negative relationship with sexual activity status (β = -0.065; p = 0.019). In model 2, knowledge had a significant positive relationship with attitudes (β = 0.615; p = 0.000). However, both knowledge and attitudes showed a non-significant relationship with preventive sexual behaviors.

Conclusions

Health faculty students exhibited high KAP levels. Knowledge consistently was related to attitudes across models, emphasizing the importance of strengthening information-based curricula to improve HIV/AIDS knowledge, including transmission, prevention, and treatment.

Keywords

attitude HIV/AIDS knowledge KAP practice path analysis

Introduction

The human immunodeficiency virus (HIV) works by infecting human white blood cells, which leads to decreased immunity in the body.¹ HIV infection decreases the body’s immunity, leading to a collection of symptoms known as acquired immune deficiency syndrome (AIDS).² Globally, an estimated 40.8 million people are living with HIV (PLHIV), and approximately 630,000 die annually from AIDS-related causes.³ Moreover, the number of HIV cases reported in Indonesia from 2005 to June 2022 cumulatively amounted to 478,784 people, while the number of AIDS cases reported from 1987 to June 2022 was as high as 139,500 people.⁴ East Java Province has the second-highest number of reported HIV infections and AIDS cases in Indonesia, with 73,096 and 21,952, respectively.⁴

The highest percentage of HIV infections was reported in the 25 to 49 years age group (70.4%), followed by the 20 to 24 years age group (15.9%). On the other hand, the age group with the highest percentage of AIDS cases was the 20 to 29 years group (31.9%), followed by the 30 to 39 years group (31.4%).⁴ Given that most HIV and AIDS cases are concentrated in individuals within the productive age group, particularly those aged 20 to 29 years, university students constitute a high-risk population group. Therefore, it is crucial to assess their knowledge, attitudes, and practices (KAP) toward HIV/AIDS to support the development of evidence-based and targeted educational interventions to improve prevention efforts in this vulnerable group.

The study of KAP, which is based on Ajzen’s Theory of Planned Behavior (1991), suggests that practice is positively influenced by favorable attitudes and the accuracy of information from knowledge.⁵ Consistent with this theory, increasing public knowledge is essential for reducing the incidence of HIV infection; the more educated the community is regarding the virus and its transmission, the lower the likelihood of risky practices and unfavorable attitudes toward people living with HIV/AIDS (PLWHA).^6,7 The KAP survey is a commonly used instrument for collecting important information in health program planning because of its relative cost-effectiveness in planning, conducting, processing, and interpreting the data.⁸ Given its advantages, KAP information related to HIV/AIDS involving students has been reported by several researchers in various countries.^6,9-11 Previous studies conducted on adolescent Islamiyya girls in Nigeria and students in Ethiopia revealed a relationship between KAP and HIV/AIDS.^10,11 Research conducted at Bahir Dar University revealed a lack of knowledge, positive attitudes, and risky practices related to HIV/AIDS.¹² The topic of KAP toward HIV/AIDS has not been widely investigated among health faculty students.

Therefore, this study aims to assess the level of KAP and to examine the direct and indirect relationships using a path analysis approach among health faculty students, involving students across diploma, undergraduate, and professional programs, including nursing, pharmacy, and physiotherapy at a university in East Java, Indonesia. The findings are expected to inform the development of evidence-based educational interventions aimed at improving HIV/AIDS prevention strategies within health education settings.

Methods

We followed Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) to promote the transparency of this study and reported in accordance with the STROBE guidelines.¹³ [see supplementary file 1].

Study Design and Setting

This study is an observational study with a cross-sectional design. We conducted this study on health faculty students at a university in East Java, Indonesia, from May to June 2024. This research received ethical approval from the Ethics Committee of the Universitas Padjadjaran (411/UN6. KEP/EC/2024, 18 April 2024).

Participants and Study Size

The population of this study included health faculty students at a university in East Java, Indonesia, who met the inclusion criteria, including diploma, undergraduate, and professional program students from the health faculty who were Indonesian citizens, aged 18 to 26 years, and able to understand Bahasa Indonesia. Students who were foreign nationals and those who were married were excluded from the study. Participants were recruited using cluster sampling on the basis of study programs and class groups. This method allows for heterogeneous clusters that reflect variation,^14,15 across study programs and class level.

The total population consisted of 3,394 students enrolled during the 2022 to 2023 academic year on the basis of official records provided by the faculty’s academic division. The minimum required sample size was calculated using Slovin’s formula with a 0.05 margin of error.^2,16 To account for potential unusable responses, an additional 10% was added to the calculated sample size.^17,18 The minimum sample size in this study was 398 participants. Furthermore, we conducted proportionate sampling to determine the minimum number of samples from each department. This is important for generalization and mitigates the risk of the sample being skewed. The distribution of the study programs and sample sizes can be found in the supplementary materials 2 (Table S1).

Data Collection

Data collection was conducted through classroom visits to each department within the faculty after regular teaching sessions had ended. During these visits, the researcher explained the study objectives and procedures, obtained informed consent from the participants, and distributed the questionnaire via a Google Forms link. In the first section of the form, participants were asked to enter their initials and student identification numbers for verification purposes and subsequently anonymized prior to analysis ensure that responses were submitted exclusively by health faculty students and to prevent duplicate entries. Participation was voluntary, and participants were given the option to consent by selecting “Yes, I agree” or decline by selecting “No, I do not agree” on the initial page of the form, which provided detailed information about the study. All the responses were treated confidentially.

Variables and Measurement

KAP toward HIV/AIDS among health faculty students was assessed using modified instruments adapted from previous studies.^6,19,20 The questionnaire was translated from English into Bahasa Indonesia by the East Java Provincial Language Centre, a government institution. Three expert panels (academics, medical doctors, and pharmacists) validated the content and cultural appropriateness of the Bahasa Indonesia questionnaire to ensure it fit the local context. In the second round of validation, all the items achieved a Lawshe content validity ratio (CVR) of 1.00.^21,22 Validity and reliability were assessed through a pilot study involving 30 participants. All the items showed acceptable validity, with a Pearson correlation > 0.361 and reliability, with a Cronbach’s alpha > 0.600.^23,24

The final questionnaire consists of 37 questions divided into four sections. The first demographics section consists of five questions, which include age, gender, department, cumulative grade point average, and year of academic entry. The following sections address each KAP variable: HIV/AIDS knowledge (20 questions), attitudes toward PLWHA (5 questions), and HIV-related practices (6 questions). An additional questionnaire file shows this in more detail [see supplementary file 3].

Statistical Analysis

Descriptive analyses, including frequencies and percentages, were conducted to summarize demographic characteristics, response distributions, and levels of KAP toward HIV/AIDS among students using IBM SPSS version 25.²⁵ The knowledge and practice variables consisted of yes and no options with a score of 1 if correct and 0 if incorrect.⁶ Attitude consisted of yes and no options, with a score of 1 for positive and 0 for negative responses.⁶ To minimize response bias, the questionnaire included several reverse-coded items in the knowledge variable (K5; K6; K7; K8; K9; K14; and K18). The distribution of the data was assessed using the Kolmogorov-Smirnov test to evaluate normality. We used the median to classify attitudes as either negative or positive and practice variables as either safe or risky.⁶ Furthermore, knowledge levels were classified as low (<50%), intermediate (51-74%), or high (≥75%).⁶

A path analysis approach using observed composite variables was employed in this study. Partial least square structural equation modeling (PLS-SEM) was used with SmartPLS version 4.²⁶ PLS-SEM was used as an estimation tool to model path relationships and accommodate non-normal data distributions²⁷; however, no latent variable measurement model was specified. Significance testing for all path coefficients was conducted using a bootstrapping procedure with 5,000 sub-samples.²⁷ The explanatory power of the models was assessed using the coefficient of determination (R²), which ranges from 0 to 1.^27,28 The f² effect size is used to assess the relative impact of predictor variables on endogenous variables in the context of their explanatory power using the thresholds of 0.02 (small), 0.15 (medium), and 0.35 (large).²⁷ The model’s predictive power was assessed using Q²_predict with a value > 0 means that the observation data in the model already have predictive power.²⁹ Ultimately, the model fit was assessed using the standardized root mean square residual (SRMR).²⁷

The development of the KAP model in this study refers to previous research models.^10,11,30 According to the Theory of Planned Behavior, good attitudes positively influence practice, whereas the accuracy of knowledge-based information influences attitudes.⁵ Figure 1 displays the conceptual framework of the KAP toward HIV/AIDS.

Figure 1.

Conceptual framework of the KAP toward HIV/AIDS

In this context, the item assessing lifetime sexual activity (P1) was not conceptualized as a safe practice but rather as a behavioral status indicator. Consistent with established KAP frameworks, preventive practices were operationalized exclusively using risk-reduction behaviors (e.g., condom use), and abstinence was not treated as a protective behavioral outcome within the practice construct. Accordingly, to address conceptual concerns regarding the operationalization of practice, two analytically distinct outcomes were specified: (1) sexual activity status (P1), treated as a behavioral descriptor rather than a preventive practice, and (2) preventive sexual behaviors (P2–P6), assessed exclusively among sexually active participants. This separation avoids conflating abstinence with safe sexual practices and aligns with standard behavioral epidemiology definitions of HIV prevention behaviors.

Results

Students’ Characteristics

Table 1 shows the students’ characteristics. This study enrolled 441 students, with no missing data, and all the data could be analyzed. The mean age of the students was 20.95 years (SD=1.85). Most of the participants were female (368, 83.4%), enrolled in the undergraduate pharmacy program (176, 39.9%), 269 (61%) had a cumulative grade point average (GPA) of 2.76-3.50, and 178 (40.4%) had an academic entry year in 2022.

Table 1.

Students’ Characteristics

No.	Characteristics	Frequency (N)	Percentage (%)
1.	Age in years (Mean ± SD)	20.95 years (SD=1.85)
2.	Gender
	Male	73	16.6
	Female	368	83.4
3.	Department
	Diploma nursing study	18	4.1
	Undergraduate pharmacy	176	39.9
	Undergraduate nursing	101	22.9
	Undergraduate physiotherapy	62	14.1
	Nurses’ professions program	27	6.1
	Pharmacist professions program	28	6.3
	Physiotherapy professions program	29	6.6
4.	Grade point average (GPA)
	2.00-2.75	20	4.5
	2.76-3.50	269	61.0
	3.51-4.00	152	34.5
5.	Year of academic entry
	First year (2023)	122	27.7
	Second year (2022)	178	40.4
	Third year (2021)	75	17.0
	≥ Fourth year (≥2020)	66	15.0

Knowledge of HIV/AIDS Transmission, Prevention, and Treatment

The frequency distributions and percentages of students correct answers to questions regarding knowledge of HIV/AIDS transmission, prevention, and treatment can be found in the supplementary materials 2 (Table S2). The majority of the students were able to answer questions correctly on the basis of their knowledge of HIV/AIDS transmission, prevention, and treatment. However, 75 (17%) students correctly identified the use of pre-exposure prophylaxis (PrEP) in an HIV-positive person with an undetectable viral load. Furthermore, only 149 (33.8%) of the participants correctly identified the role of ARV therapy in curing HIV/AIDS.

Attitude Toward PLWHA

The responses of students’ attitudes toward PLWHA can be found in the supplementary materials 2 (Table S3). On average, the majority of the students reported a positive attitude toward PLWHA. However, a less favorable response (42%) was shown in the students’ willingness to shop with shopkeepers or food vendors with HIV-positive.

HIV/AIDS-Related Practices

The health student practices related to HIV/AIDS, with “yes” answers can be found in the supplementary materials 2 (Table S4). The majority of the 404 (91.6%) health faculty students reported safe practices related to HIV/AIDS. However, 36 (8.2%) health faculty students reported that they had ever had sexual intercourse. Among them, 16.66% (n=6/36) had ever had same-sex sexual intercourse, 77.78% (n=28/36) of the participants had ever used condoms during sexual intercourse, and 75% (n=21/28) of the participants used condoms regularly during sexual intercourse with casual partners.

The Level of KAP Toward HIV/AIDS

Table 2 presents the level of KAP toward HIV/AIDS. The normality test run using Kolmogorov-Smirnov revealed that the data were not normally distributed. Therefore, attitudes were categorized as positive (median = 4), and practices were categorized as safe (median = 6) if the sum of the scores was greater than or equal to the median and vice versa. A total of 332 (75.3%) students had a high level of knowledge of HIV/AIDS transmission, prevention, and treatment; 269 (61%) had positive attitudes toward PLWHA; and 404 (91.6%) had safe HIV/AIDS-related practices.

Table 2.

The Level of KAP Toward HIV/AIDS

Variables	Frequency (N)	Percentage (%)
Knowledge of HIV/AIDS transmission, prevention, and treatment
Low	10	2.3
Intermediate	99	22.4
High	332	75.3
Attitude toward PLWHA
Positive	269	61
Negative	172	39
HIV/AIDS-related practices
Risky	37	8.4
Safe	404	91.6

SEM

Theory testing using PLS-SEM follows a two-step process, in which the measurement model is tested to confirm reliability and validity, while the structural model is subsequently assessed to evaluate the proposed relationship among variables.³¹ Prior to structural analysis, measurement model testing was conducted for the attitude variable in model 1, as it was not operationalized as a composite score. Subsequently, path analysis was conducted to examine the relationship among variables using PLS-SEM approach. However, no full latent variable measurement model was specified, as the analysis primarily relied on observed composite variables.

Measurement Model Testing

The measurement model testing of the outer loading value, Cronbach’s Alpha, and convergent validity using the average variance extracted (AVE) for both model 1 and model 2 can be found in the supplementary materials 2 (Table S5). Knowledge and practice variables were operationalized as single-item composite (summated score). Consequently, traditional internal consistency metrics such as Cronbach’s Alpha and AVE were reported as not applicable (N/A) for these specific variables, as they were treated as observed scores with a fixed reliability of 1.000. Attitude variables met the Cronbach’s Alpha and AVE, furthermore, which remained reflective in model 1, three items (A3, A4, and A5) exhibited strong outer loadings exceeding 0.70, and two items (A1 and A2) showed loadings ≥ 0.40. Based on the established criteria, indicators with outer loadings ≥ 0.70 are considered ideal, while those with ≥ 0.40 are retained.²⁷ In model 2, the analysis is explanatory in nature, and the findings should be interpreted with considerable caution due the limited statistical power and potential instability of estimates.

The measurement model analysis of discriminant validity, assessed using the Heterotrait-Monotrait (HTMT) ratio can be found in the supplementary materials 2 (Table S6). The HTMT value between knowledge, attitude, and sexual activity practice in model 1 were < 0.90, indicating that the variables are completely different.²⁷ In the model 2, HTMT values were reported as N/A because the use of single-item composite precludes the calculation of the HTMT ratio of correlations.

Structural Model Testing

Table 3 presents the results of structural model testing. Structural model testing in PLS-SEM includes an assessment of inner collinearity, structural model relationship, significance, model’s explanatory power, model’s predictive power, and model fit indices (SRMR).²⁷ The inner collinearity was assessed using the variance inflation factor (VIF).^27,32 This study demonstrated all VIF values in both models were below the ideal threshold of 3, indicating that there were no concerns of multicollinearity among the predictor variables. A VIF value of less than 3 is considered ideal; VIF values between 3 and 5 indicate potential collinearity issues, whereas values of 5 or greater suggest critical collinearity problems.^27,32

Table 3.

Structural Model Testing

Hypothesis path	VIF	Path coefficient	Path coefficient CI (2.5%; 97.5%)	P-value	Decision
Model 1: Sexual activity status (N=441)
H1: Knowledge → Attitude	1.000	0.165	0.132; 0.202	0.000	Supported
H2: Knowledge → Sexual activity status	1.181	0.038	0.002; 0.077	0.048	Supported
H3: Attitude → Sexual activity status	1.181	-0.065	-0.121; -0.013	0.019	Supported
H4: Knowledge → Attitude → Sexual activity status	-	-0.011	-0.021; -0.002	0.028	Supported
Model 2: Preventive sexual behaviors (n=36)
H5: Knowledge → Attitude	1.000	0.615	0.343; 0.784	0.000	Supported
H6: Knowledge → Preventive sexual behaviors	1.608	-0.059	-0.440; 0.343	0.768	Rejected
H7: Attitude → Preventive sexual behaviors	1.608	-0.334	-0.727; 0.048	0.085	Rejected
H8: Knowledge → Attitude → Preventive sexual behaviors	-	-0.205	-0.506; 0.027	0.127	Rejected

Structural model testing was used to assess the relationship and significance between the variables. In model 1 (full sample, N=441), which predicts the lifetime sexual activity status. Knowledge demonstrated a significant positive relationship with attitude (β = 0.165; p = 0.000) and a significant positive relationship with sexual activity status (β = 0.038; p = 0.048). Furthermore, attitude showed a significant negative relationship with sexual activity status (β = -0.065; p = 0.019). A similar pattern was observed for the indirect relationship between knowledge, attitude, and sexual activity status (β = -0.011; p = 0.028). However, the observed negative relationship should be interpreted with caution, as this outcome reflects behavioral status rather than preventive practice. Therefore, this relationship does not indicate a protective behavioral effect but may instead reflect differences in underlying behavioral exposure or reporting patterns.

Conversely, in model 2 (sexually active sub-sample, N=36), knowledge maintained a significant positive relationship with attitude (β = 0.615; p = 0.000). On the other hand, knowledge demonstrated a non-significant negative relationship with preventive sexual behaviors (β = -0.059; p = 0.768), and attitude similarly showed a non-significantly negative relationship with preventive sexual behaviors (β = -0.334; p = 0.085). Furthermore, the indirect relationship knowledge to preventive sexual behaviors through the mediation of attitude was found to be negative and non-significant (β = -0.205; p = 0.127). Given the small sample size and limited statistical power of the sexually active sub-sample, these findings should be interpreted with caution, and the results are considered exploratory in nature.

The final model of KAP is presented in Figure 2. The value connecting the two blue circles shows the path coefficients and p-value between the two constructs. Moreover, the values inside the blue circles represent R² values.

Figure 2.

Final model of KAP towards HIV/AIDS

The explanatory power, predictive power, and effect size can be found in the supplementary materials 2 (Table S7). The explanatory power of the models was used the coefficient of determination (R²) range from 0 to 1, with higher values indicating greater explanatory power.^27,28 In model 1, the R² for sexual activity status was low (R² = 0.018), indicating that the model explains only a small proportion of variance in this outcome. This suggests that knowledge and attitude, as specified in the model, have limited relevance in explaining sexual activity status, which may be influenced by a broader set of factors beyond the scope of the present variables. In model 2, the R² for preventive sexual behavior among sexually active participants was higher (R² = 0.140). This may indicate a potential relationship, although findings remain explanatory and should be interpreted with caution.

Furthermore, for attitude, the R² for model 1 showed 0.154, while in model 2 it was higher at 0.378, indicating the knowledge explains 37.8% of the variance in students’ attitude within sexually active sub-group. Overall, while several relationships in the model were statistically significant, the R² values suggest that the explanatory scope of the models is limited. Therefore, these findings should be considered in light of the model specification and the nature of the outcomes examined.

The f² effect size is used to assess the relative impact of predictor variables on endogenous variables in the context of their explanatory power using the thresholds of 0.02 (small), 0.15 (medium), and 0.35 large.²⁷ In model 1, knowledge demonstrated a medium effect on attitude (f² = 0.181), a small effect on sexual activity status (f² = 0.017), and attitude demonstrated a small effect on sexual activity status (f² = 0.009). In model 2, knowledge demonstrated a large effect on attitude (f² = 0.608), whereas the effect of knowledge on preventive sexual behaviors was small (f² = 0.003), and the effect of attitude on preventive sexual behaviors was small (f² = 0.081).

The model’s predictive power was assessed using Q²_predict with a value > 0 means that the observation data in the model already have predictive power.²⁹ The result showed that values for attitude in both model 1 (0.023) and model 2 (0.355). While, the values of model 1 remained low, the overall findings may indicate that the model maintains sufficient predictive relevance within the context of behavioral research.

The model fit was assessed using the standardized root mean square residual (SRMR). Model 1 yielded an SRMR of 0.092, which was close to the threshold of 0.08, while model 2 demonstrated an ideal fit of 0.000 due to its saturated nature in a smaller sample. Goodness-of-Fit Index can be found in the supplementary materials 2 (Table S8).

Discussion

This study highlights that health faculty students possess high levels of HIV/AIDS knowledge and generally positive attitudes, and safe practices related to HIV/AIDS. The path analysis revealed that knowledge is a robust driver for positive attitudes in both models. In model 1, attitude showed a statistically significant negative relationship with sexual activity status; however, this finding should be interpreted with caution, as the outcome reflects a behavior descriptor rather than a preventive practice. Conversely, among the sexually active sub-group in model 2, neither knowledge nor attitude demonstrated significant relationship with preventive sexual behaviors, and these findings should be interpreted as exploratory given the small sample size.

The findings of this study show that 332 (75.3%) health faculty students demonstrated high levels of knowledge, regarding HIV/AIDS transmission, prevention, and treatment. Previous studies in various countries and populations have shown similar results.^20,30,33,34 Students at universities are individuals who have pursued higher education; as a result of their prior education and factual information, they may possess a high level of HIV/AIDS knowledge.³⁴ However, the participants in this study needed to understand more about the use of PrEP; a limited proportion of 75 (17%) participants correctly identified the use of PrEP in HIV-positive people with undetectable viral loads. This limitation is understandable, as PrEP was introduced as a new HIV prevention intervention for at-risk groups in Indonesia during its 2021 trial.³⁵ A systematic review identified that knowledge regarding PrEP needs to be improved among population with healthcare-related backgrounds.³⁶ Regardless of their academic background as health students, the limited understanding of new HIV prevention strategies through PrEP underscores the critical role of integrating the most up-to-date HIV prevention knowledge into the health education curriculum to ensure that future healthcare workers are informed and adequately equipped to provide comprehensive HIV education.

In terms of attitudes, 269 (61%) health faculty students reported positive attitudes toward PLWHA. Positive attitudes toward PLWHA are supported by studies conducted on trainee nurses in Ghana and medical students in Jordan.^30,37 However, 185 (42%) health faculty students in this study were willing to shop with shopkeepers or food vendors who were HIV positive. This result is similar to that of another study using data from the 2017 Indonesian Demographic and Health Survey (IDHS), which revealed that 64% of women and 54% of men would not buy fresh vegetables from a shopkeeper with HIV.³⁸ Misconceptions about the transmission of HIV/AIDS have led to discrimination or unfavorable attitudes toward PLWHA.³⁹ Increasing accurate knowledge may help reduce stigma and foster more inclusive attitudes toward PLWHA.⁴⁰ These findings underscore the need to strengthen educational interventions, particularly those addressing modes of HIV transmission. Encouraging positive attitudes among health faculty students is essential to prepare them for engaging with PLWHA without perpetuating negative stigma.

In terms of practices, 404 (91.6%) health faculty students reported safe practices related to HIV/AIDS. However, 36 (8.2%) of the participants reported behaviors that may put them at risk of contracting HIV/AIDS by having sexual intercourse. Among them, 77.78% (n=28/36) of the participants had ever used condoms during sexual intercourse, and 75% (n=21/28) of the participants used condoms regularly during sexual intercourse with casual partners. The high rates of risky sexual behavior, even among educated adolescents and young adults, suggest that social and cultural barriers other than HIV/AIDS knowledge, such as stigma and gender disparities in sexual decision-making, can play a significant role in the spread of HIV.⁴¹ Sexual education programs, campaigns, advocacy, and policy interventions can be intensified to increase safe practices and are useful in preventing new HIV infections.⁷

The path analysis demonstrated that knowledge maintains a significant positive relationship with attitudes in both models, suggesting that an increase in students HIV/AIDS knowledge is likely to improve their attitudes towards PLWHA. This finding aligns with a previous study among Islamiyya adolescent girls in Nigeria.¹¹ KAP theory states that health knowledge is the basis for forming positive attitudes.⁴² Students who have received knowledge are expected to show better attitudes toward PLWHA.³⁰ These findings are important in the fight against the spread of infection; to achieve favorable attitudes, there is a need to increase access to HIV/AIDS knowledge.³⁰ Negative attitudes may be a major barrier to effective prevention, care, treatment, and support of HIV/AIDS control programs.⁴³ Improved skills, including reducing negative attitudes due to fear of infection, can be applied to increase support for PLWHA.³⁷

In model 1, HIV/AIDS knowledge had a significant positive relationship with sexual activity status, whereas in model 2 among sexually active students, this relationship was negative non-significant. Our findings in the general student population indicate that higher levels of HIV/AIDS knowledge are associated with differences in reported sexual activity status, although this should not be interpreted as a protective behavioral effect. Previous studies in Nigeria and Ethiopia support these results.^10,11 This suggests that education increases an individual’s knowledge of control or prevention techniques that can be applied.⁴⁴ Therefore, education is among the determining factors that influence healthy behavior.^45,46 However, the non-significant relationship in model 2 suggests that among those who are already sexually active, knowledge alone may not be sufficient to influence engagement in preventive sexual behaviors.

Similarly, attitude showed a significant negative relationship with sexual activity status in model 1, while its relationship with preventive sexual behavior in model 2 was not statistically significant. However, this finding in model 1 should also be interpreted with caution, as it does not necessarily reflect a protective behavioral effect. Among the sexually active students, attitude did not significantly translate into preventive sexual behavior. These findings imply that attitudes alone may not necessarily translate into concrete preventive behaviors, as other mediating factors could be at play.⁴⁷ Thanavanh (2013), whose questionnaire was adapted in this study, reviewed health surveys for countries in South Asia and developing countries and highlighted that successful HIV prevention relies heavily on behavior change rather than knowledge or attitudes alone.^6,48 Notably, sexual behavior is among the most difficult behaviors to change, even in the presence of adequate knowledge.⁴⁸ This may indicate that attitudes toward PLWHA may transcend cultural and religious values.⁴⁹

This study further identified an indirect negative relationship between knowledge and both outcomes through the mediation of attitude, which was significant in model 1 (sexual activity status), while non-significant in model 2 (preventive sexual behaviors). Given the nature of the outcome in model 1, this indirect relationship should not be interpreted as reflecting a preventive behavioral effect. However, researchers in other fields confirm that knowledge indirectly influences behavior through attitudes.^42,50,51 Furthermore, the Theory of Planned Behavior, based on Ajzen’s (1991), shows that behavior is positively influenced by good attitudes and that attitudes are influenced by the accuracy of information from knowledge.⁵ Improving one of these factors will positively impact the other two.⁵² However, the varying result between model 1 and model 2 may be due to differences in the population characteristic, sample size, and the complexities of behavioral change in sexually active individuals.³⁰

The findings of this study have important implications for public health, policymakers, and healthcare education to achieve the “three zeros”: zero new HIV infections, zero AIDS-related deaths, and zero HIV-related discrimination. The significant relationship between knowledge and attitude in both models suggest that educational interventions should not only aim to improve knowledge but also foster positive attitudes towards PLWHA. Moreover, the results highlight the need for educational institutions, particularly in students with health sciences education to develop information-based curricula that integrate skills training including safe sex negotiation,⁵³ and the application of pharmacological prevention strategies such as PrEP,³⁶ which was identified as a knowledge gap in this study. By addressing this aspect, universities may better prepare future healthcare professionals to contribute effectively to HIV prevention and provide stigma-free care.⁵³

Strengths and Limitations

To the best of our knowledge, this is the first study to assess KAP toward HIV/AIDS among health faculty students and to identify the relationship between variables with PLS-SEM using path analysis approach for two distinguished model outcomes; the sexual activity status and prevention sexual behavior. The PLS-SEM differs from traditional regression by modeling multiple interrelated dependencies simultaneously without the strict requirements of distributional normality,²⁷ which is particularly beneficial for behavioral data in these studies. Furthermore, the study focused on health faculty students as the future frontline of the HIV response, providing critical baseline data for targeted curricular improvements in medical and health science education.

Despite these strengths, several limitations should be acknowledged. The self-reported data in this study might pose recall bias and social desirability biases; to mitigate this, the survey was conducted anonymously and included participant incentives. In terms of study design, the cross-sectional design limits the ability to infer causality between the variables. The sample, consisting of students from a single university’s health faculty, limits the generalizability of our findings. Moreover, the small sample size in model 2 within the sexually active sub-group suggesting that future studies should include more diverse populations across institutions and regions to enhance external validity. Regarding the measurement of variables, this study’s use of composite scores derived from dichotomous indicators may reduce variability of the data. Furthermore, future studies could expand the sample to include non-health faculty students to enhance generalizability and enable comparison of KAP towards HIV/AIDS across disciplines. Additionally, longitudinal or experimental designs could be employed to assess changes over time and evaluate the impact of educational interventions.

Conclusion

This study highlights the high levels of HIV/AIDS knowledge, positive attitudes toward PLWHA, and generally safe practice related to HIV/AIDS among health faculty students. The path analysis demonstrated a consistent positive relationship between knowledge and attitude across both models, indicating that higher levels of HIV/AIDS knowledge are more likely to have positive attitude toward PLWHA in both general student population and sexually active sub-sample. Overall, these findings underscore the importance of strengthening information-based curricula within health science education to enhance HIV/AIDS knowledge, including aspects of HIV/AIDS transmission, prevention, and treatment. This is particularly relevant in the context of emerging pharmacological interventions, such as PrEP, which has been introduced in Indonesia since 2021. Strengthening students’ knowledge is a fundamental for preparing them as future healthcare professionals to contribute to the global three zeros target.

Supplemental Material

Supplemental material - Knowledge, Attitudes, and Practices toward HIV/AIDS among Health Faculty Students at a University in East Java, Indonesia: A Path Analysis Approach

Supplemental material for Knowledge, Attitudes, and Practices toward HIV/AIDS among Health Faculty Students at a University in East Java, Indonesia: A Path Analysis Approach by Dimas Setyadi Putra, Sofa Dewi Alfian, Ika Ratna Hidayati, Aghnia Fuadatul Inayah and Irma Melyani Puspitasari in INQUIRY: The Journal of Health Care Organization, Provision, and Financing.

Supplemental Material

Supplemental material - Knowledge, Attitudes, and Practices toward HIV/AIDS among Health Faculty Students at a University in East Java, Indonesia: A Path Analysis Approach

Supplemental Material

Supplemental material - Knowledge, Attitudes, and Practices toward HIV/AIDS among Health Faculty Students at a University in East Java, Indonesia: A Path Analysis Approach

Footnotes

ORCID iD

Dimas Setyadi Putra

Ethical Considerations

The study was approved by the Ethics Committee of the Universitas Padjadjaran (411/UN6. KEP/EC/2024, 18 April 2024).

Consent to Participate

Respondents gave consent for review and signature before involved in this study.

Author Contributions

DSP, SDA, and IMP: conceptualization, resources, and visualization. DSP, SDA, and IMP: methodology and writing—review and editing. DSP, IRH, and AFI: Investigation and data curation. DSP: software, formal analysis, and writing—original draft preparation. SDA and IMP: validation. SDA and IMP: supervision. IMP: project administration and funding acquisition. All the authors contributed to the article and approved the submitted version.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The Republic of Indonesia’s Ministry of Education, Culture, Research, and Technology funded this study, number 074/E5/PG.02.00.PL/2024. This publication charge is funded by Universitas Padjadjaran through the Indonesian Endowment Fund for Education (LPDP) on behalf of the Indonesian Ministry of Higher Education, Science and Technology and managed under the EQUITY Program (Contract No. 4303/B3/DT.03.08/2025 and 3927/UN6. RKT/HK.07.00/2025).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are not openly available for reasons of sensitivity and privacy protection and are available from the corresponding author upon reasonable request.*

Authors’ Information

Dimas Setyadi Putra and Irma Melyani Puspitasari contributed equally to this work.

Supplemental Material

Supplemental material for this article is available online.

Appendix

References

Putra

Atmadani

Hidayati

. Relationship between knowledge level of hiv/aids patient with antiretroviral adherence in primary healthcare service in Malang City. J HIV AIDS Soc Serv. 2021;20(3):228-245.

Putra

Puspitasari

Alfian

Sari

Hidayati

Atmadani

. Related Factors of Antiretroviral Adherence in HIV/AIDS Patients at one of the Community Health Centers in Malang City. Pharmaceutical Journal of Indonesia. 2023;9(1):41–47. doi: 10.21776/ub.pji.2023.009.01.7.

UNAIDS JUNP on H . Global AIDS Update — AIDS, Crisis and the Power to Transform; 2025. https://www.unaids.org/en/resources/documents/2025/2025-global-aids-update. Accessed 14 July 2025.

Indonesia Ministry of Health . Executive Report on the Development of HIV AIDS and Sexually Transmitted Infectious Diseases (STIs) for the Second Quarter of the Year. 2022. https://siha.kemkes.go.id/portal/files_upload/Laporan_TW_III_2021.pdf

Russell

Dowding

McDonald

, et al. Factors for compliance with infection control practices in home healthcare: findings from a survey of nurses’ knowledge and attitudes toward infection control. Am J Infect Control. 2018;46(11):1211-1217. doi:10.1016/j.ajic.2018.05.005.

Thanavanh

Harun-Or-Rashid

Kasuya

Sakamoto

. Knowledge, attitudes and practices regarding HIV/AIDS among male high school students in Lao People’s Democratic Republic. J Int AIDS Soc. 2013;16:1-7. doi:10.7448/IAS.16.1.17387.

Youssef

Hallit

Sacre

, et al. Knowledge, attitudes and practices towards people living with HIV/AIDS in Lebanon. PLoS One. 2021;16(3):1-15. doi:10.1371/journal.pone.0249025.

Andrade

Menon

Ameen

Kumar Praharaj

. Designing and Conducting Knowledge, Attitude, and Practice Surveys in Psychiatry: Practical Guidance. Indian J Psychol Med. 2020;42(5):478-481. doi:10.1177/0253717620946111.

Dinopawe

Mahmud

Sabban

. The relationship between knowledge and attitude with the prevention of HIV/AIDS in adolescent communities. Pasapua Health Journal. 2022;4(1):102-105.

10.

Gemeda

Gandile

Bikamo

. HIV/AIDS knowledge, attitude and practice among Dilla University Students, Ethiopia. Afr J Reprod Health. 2017;21(3):49-61.

11.

Muhammad Hamid

Tamam

Nizam bin Osman

. Relationships between Media Exposure and Knowledge, Attitude, and Practice on HIV/AIDS: A Cross Sectional Survey of Adolescent Islamiyya Girls in Nigeria. Health Commun. 2020;35(4):419-429. doi:10.1080/10410236.2018.1564960.

12.

Mulu

Abera

Yimer

. Knowledge, attitude and practices on HIV/AIDS among students of Bahir Dar University. Science Journal of Public Health. 2014;2(2):78-86.

13.

Von

Altman

Egger

Pocock

Gøtzsche

Vandenbroucke

. The STROBE reporting checklist. In: Harwood

Albury

Beyer

Jde

Schlüssel

Collins

, eds. The EQUATOR network reporting guideline platform. The UK EQUATOR Centre; 2025. https://resources.equator-network.org/reporting-guidelines/strobe/strobe-checklist.docx. Accessed 9 October 2025.

14.

Babbie

. The Practice of Social Research. 15th ed. Cengage AU; 2021 Vol 15. doi:10.2307/2062956.

15.

Creswell

. Mixed Methods Procedures. Sage; 2018.

16.

Elen

. Slovin’s Formula Sampling Techniques; 2022. https://www.sciencing.com/slovins-formula-sampling-techniques-5475547/. Accessed 30 January 2025.

17.

Gupta

Attri

Singh

Kaur

. Basic concepts for sample size calculation: critical step for any clinical trials. Saudi J Anaesth. 2016;10(3):328-331.

18.

Rendrayani

Alfian

Wahyudin

Puspitasari

. Knowledge, attitude, and practice of medication therapy management: a national survey among pharmacists in Indonesia. Front Public Health. 2023;11:1213520.

19.

Olowookere

Fatiregun

Adewole

. Knowledge and attitudes regarding HIV/AIDS and antiretroviral therapy among patients at a Nigerian treatment clinic. The Journal of Infection in Developing Countries. 2012;6(11):809-816.

20.

Bunting

Feinstein

Hazra

Sheth

Garber

. Knowledge of HIV and HIV pre-exposure prophylaxis among medical and pharmacy students: A national, multi-site, cross-sectional study. Prev Med Rep. 2021;24:101590. doi:10.1016/j.pmedr.2021.101590.

21.

Hiew

Chin

Chan

Mohd

. Development and validation of knowledge, attitude and practice on healthy lifestyle questionnaire (KAP-HLQ) for Malaysian adolescents. J Nutr Health Sci. 2015;2(4):1-11.

22.

Gilbert

Prion

. Making Sense of Methods and Measurement: Lawshe’s Content Validity Index. Clin Simul Nurs. 2016;12(12):530-531. doi:10.1016/j.ecns.2016.08.002.

23.

BAR

da Silva Lirani

de Francisco

. Construct validity and reliability of the work environment assessment instrument WE-10. Int J Environ Res Public Health. 2020;17(20):7364.

24.

Daud

KAM

Khidzir

Ismail

Abdullah

. Validity and reliability of instrument to measure social media skills among small and medium entrepreneurs at Pengkalan Datu River. International Journal of Development and sustainability. 2018;7(3):1026-1037.

25.

Corporation

IBM

. IBM SPSS Statistics for windows (25.0. IBM Corporation; 2019. Preprint posted online.

26.

Ringle

Wende

Becker

. SmartPLS 4. Bönningstedt: SmartPLS. 2024;4. Preprint posted online. https://www.smartpls.com. Accessed 10 September 2024.

27.

Hair

Hult

GTM

Ringle

Sarstedt

. In: Fargotstein

, ed. A Primer on Partial Least Squares Structural Equation Modeling (PLS-SEM). 3rd ed. Sage Publications; 2022.

28.

Hair

Risher

Sarstedt

Ringle

. When to use and how to report the results of PLS-SEM. European business review. 2019;31(1):2-24.

29.

Avkiran

Ringle

. Partial least squares structural equation modeling: Recent advances in banking and finance. Springer; 2018. Published online.

30.

Mutaru

Ibrahim

Wumpini Osuman

Atanga Agana

Sukerazu Alhassan

. Knowledge, attitude and clinical practice regarding HIV/AIDS among trainee nurses in north-eastern corridor, Ghana. Int J Afr Nurs Sci. 2023;18:100545. doi:10.1016/j.ijans.2023.100545.

31.

Hair

Black

Babin

Anderson

. Multivariate Data Analysis. London: Cengage Learning; 2019. Search in. Published online.

32.

Ghasemy

Teeroovengadum

Becker

Ringle

. This fast car can move faster: A review of PLS-SEM application in higher education research. High Educ (Dordr). 2020;80(6):1121-1152.

33.

Chugh

Sharma

Dahiya

Rai

Chopra

. Knowledge and beliefs about HIV/AIDS among physiotherapy students. Int J Community Med Public Health. 2017;4(4):1148. doi:10.18203/2394-6040.ijcmph20171340.

34.

Rachmawati

Fauzia

Rachmawati

. University of Jember Students’ Knowledge about HIV/AIDS. Jurnal Ilmiah Manuntung. 2022;8(1):106-112. doi:10.51352/jim.v8i1.502.

35.

UNAIDS . Successfully expanding the rollout of PrEP in Indonesia. 2022. https://www.unaids.org/en/resources/presscentre/featurestories/2022/september/20220901_prep-indonesia. Accessed 17 September 2024.

36.

Putra

Jannah

Saputra

. Knowledge, attitude, and practice regarding HIV pre-exposure prophylaxis (PrEP): a systematic review. J HIV AIDS Soc Serv. Published online. 2024;23:1-17. doi:10.1080/15381501.2024.2446162.

37.

Sallam

Alabbadi

Abdel-Razeq

, et al. HIV knowledge and stigmatizing attitude towards people living with HIV/AIDS among medical students in Jordan. Int J Environ Res Public Health. 2022;19(2):745.

38.

Suantari

. Misconceptions and stigma against people living with HIV/AIDS: a cross-sectional study from the 2017 Indonesia Demographic and Health Survey. Epidemiol Health. 2021;43:e2021094.

39.

Onoja

Sanni

Onoja

Adamu

Shaibu

Abiodun

. Impact of Health Interventions on the Knowledge, Perception, Attitude, and Misconception of HIV Infection in an African Rural Community. International Journal of Medicine and Health Development. 2021;26(2):91-98.

40.

Zhang

Miao

Bian

. Awareness of HIV/AIDS and its routes of transmission as well as access to health knowledge among rural residents in Western China: a cross-sectional study. BMC Public Health. 2019;19:1-11.

41.

Stephens

Bachhuber

Seloilwe

, et al. HIV-Related knowledge, attitudes, and practice among educated young adults in Botswana. J AIDS HIV Res. 2012;4(6):159-164.

42.

Chen

Jiang

Tang

, et al. Research on Knowledge, Attitudes, and Practices of Influenza Vaccination Among Healthcare Workers in Chongqing, China—Based on Structural Equation Model. Front Public Health. 2022;10:853041.

43.

Harapan

Khalilullah

Anwar

, et al. Discriminatory attitudes toward people living with HIV among health care workers in Aceh, Indonesia: A vista from a very low HIV caseload region. Clin Epidemiol Glob Health. 2015;3(1):29-36. doi:10.1016/j.cegh.2013.08.001.

44.

Brunello

Fort

Schneeweis

Winter‐Ebmer

. The causal effect of education on health: What is the role of health behaviors? Health Econ. 2016;25(3):314-336.

45.

Park

Cho

Moore

. How does education lead to healthier behaviours? Testing the mediational roles of perceived control, health literacy and social support. Psychol Health. 2018;33(11):1416-1429. doi:10.1080/08870446.2018.1510932.

46.

Braveman

Cubbin

Egerter

Williams

Pamuk

. Socioeconomic disparities in health in the United States: what the patterns tell us. Am J Public Health. 2010;100(S1):S186-S196.

47.

Rachmani

Budiyono

DNAY

. Knowledge, Attitude and Community Prevention of COVID-19 in Depok, West Java. The Indonesian Journal of Health Promotion. 2020;4(1):97-104.

48.

Policy Project. POLICY Project-USAID . HIV/AIDS in the Mekong Region Cambodia, Lao PDR. Thailand,& Vietnam: Current Situation, Future Projections, Socioeconomic Impacts, and Recommendations. (2003). Accessed June 1, 2024.https://www.policyproject.com/pubs/generalreport/ACF1B3.pdf

49.

Alawad

Alturki

Aldoghayyim

Alrobaee

Alsoghair

. Knowledge, Attitudes, and Beliefs about HIV/AIDS and People Living with HIV among Medical Students at Qassim University in Saudi Arabia. Int J Health Sci (Qassim). 2019;13(5):22-30.

50.

Peng

Yang

Sun

. Status on knowledge, attitudes, behavior regarding nutrition and food safety among 4-6 grade students from Chinas’ two poverty-stricken counties. Zhonghua Liu Xing Bing Xue Za Zhi. 2013;34(7):673-676.

51.

Huang

Chou

Wang

. Knowledge, attitudes, practice and related factors of oral cancer prevention among public health nurses in Taiwan. Eur J Cancer Care (Engl). 2020;29(5):e13262.

52.

Shah

Elgalib

Al-Wahaibi

, et al. Knowledge, attitudes and practices related to HIV stigma and discrimination among healthcare workers in Oman. Sultan Qaboos Univ Med J. 2020;20(1):e29-e36. doi:10.18295/squmj.2020.20.01.005.

53.

Ngcobo

Mchunu

. Bachelor of Nursing students’ HIV and AIDS knowledge in KwaZulu-Natal province: An evaluation study. Curationis. 2019;42(1):1-11.

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