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1b r a z j i n f e c t d i s . 2 0 1 5;1  9(4):369–375
w ww.elsev ier .com/ locate /b j id
The Brazilian Journal of
INFECTIOUS  DISEASES
riginal article
nowledge,  attitudes  and  practices  on HIV/AIDS
nd prevalence  of  HIV  in  the  general  population  of
ucre, Bolivia
arolina Terán Calderóna,b,∗, Dorian Gorena Urizarb, Cristina González Blázquezc,
elén  Alejos Ferrerasc, Oriana Ramírez Rubioc, Francisco Bolumar Montrull d,
arta  Ortiz Riverae, Julia del Amo Valeroc
School of Medicine, San Francisco Xavier of Chuquisaca University, Sucre, Bolivia
Health Area, Simon Bolivar Andean University, Sucre, Bolivia
National Centre for Epidemiology, Carlos III Institute of Health, Madrid, Spain
Department of Public Health Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain
National Centre for Microbiology, Carlos III Institute of Health, Madrid, Spain
 r  t  i  c  l  e  i  n  f  o
rticle history:
eceived 14 January 2015
ccepted 5 April 2015
vailable online 19 May 2015
eywords:
IV prevalence
nowledge on HIV/AIDS
ttitude towards PLWHA
exual practices on HIV
a  b  s  t  r  a  c  t
Background: To analyse knowledge, attitudes and sexual practices on HIV/AIDS, and estimate
HIV  prevalence among residents of Sucre (Bolivia).
Methodology: Population-based survey of residents aged 15–49 randomly selected dur-
ing  2008/2009. Blood samples were collected on Whatman-filter paper and tested with
enzyme-linked immunosorbent assay. Knowledge on HIV/AIDS, sexual risk practices and
discriminatory attitudes against people living with HIV/AIDS (PLWHA) were modelled with
multiple logistic regression.
Results: Of 1499 subjects, 59% were women. All subjects were HIV-negative. Inadequate
knowledge of HIV/AIDS transmission and prevention was observed in 67% and risk fac-
tors varied by gender (interaction p-value < 0.05). Discriminatory attitudes were displayed
by  85% subjects; associated factors were: rural residence, low educational level and low
income. Unsafe sex was reported by 10%; risk factors varied by residence area (interac-
tion p-value < 0.05). In urban areas, risk factors were male sex, younger age and being in
common-law union.
Conclusions: Prevalence of HIV infection is very low and unsafe sex is relatively uncom-mon.  Inadequate knowledge on HIV/AIDS and discriminatory attitudes towards PLWHA are
extremely high and are associated to gender, ethnic and economic inequalities.©  2015 Elsevier Editora Ltda. All rights reserved.
∗ Corresponding author at: School of Medicine, San Francisco Xavier of Chuquisaca University, Colon Street (Between René Moreno and
astor  Sainz), Sucre, Bolivia.
E-mail address: carolina.teran@gmx.net (C. T. Calderón).
ttp://dx.doi.org/10.1016/j.bjid.2015.04.002
413-8670/© 2015 Elsevier Editora Ltda. All rights reserved.
i s . 2 0
the question: “if some relative had the infection, would you
prefer that no-one knew?”.370  b r a z j i n f e c t d 
Introduction
In spite of large regional differences, the HIV epidemic in Cen-
tral and South America has shown a stable pattern over the
last decade. In the majority of countries in the region, the epi-
demic is concentrated and remains at a low level.1,2 Among
men  who have sex with men  (MSM), prevalence stands at
around 10% in most countries, though heterosexual transmis-
sion of HIV has increased, particularly in South America.3
There is little information on the epidemiology of HIV in
Bolivia is available. Surveillance data indicate that 4889 HIV
cases were reported from 1984 to 2009; 89% of which came
from La Paz, Santa Cruz and Cochabamba.4 In 2009, it was
estimated there were 12,000 [range 9000–16,000] persons living
with HIV/AIDS (PLWHA) and the estimated prevalence in the
population aged 15–49 years was 0.2% [95% CI: 0.1–0.3%].5 The
HIV epidemic in Bolivia is concentrated in the MSM group.5–7
In the department of Chuquisaca according with the Depart-
mental Health Service (SEDES-Chuquisaca) data report of 2010
(unpublished result), only 27 new HIV cases were reported
in 2010; 78% were residents of Sucre, but no HIV prevalence
estimates in the general population are available.
Studies on knowledge, attitudes and practices (KAP) have
been widely used to design public health policies and for
planning health interventions taking into account the needs
of the community.8,9 There is limited information on KAP
on HIV/AIDS among the general population of Bolivia, a
multicultural nation with great ethnic diversity and marked
socio-economic inequalities. Therefore, the aims of this study
were to analyse knowledge on HIV/AIDS, as well as attitudes
and practices with respect to HIV/AIDS and to estimate the
prevalence of HIV infection among inhabitants aged 15–49
years residing in the town of Sucre (department of Chuquisaca,
Bolivia) in 2008–2009.
Materials  and  methods
We  conducted a cross-sectional population-based study
consisting of a KAP survey linked to a sero-survey using
Whatman paper to estimate HIV prevalence. Inclusion crite-
ria were subjects aged 15–49 years who had resided in Sucre
during the preceding 12 months and consented to participate,
excluding those who  had some mental disability or refused to
participate in the study. Sample size calculations were based
on an expected prevalence of HIV-related knowledge of 12%,
based on a previous study developed by the Simon Bolivar
Andean University (UASB) with UNAIDS on 2006 (unpublished
result), with a 95% confidence level, and a precision of 2%.
Separate sample size calculations were made for the estima-
tion of the HIV prevalence in Sucre as the prevalence of HIV
was expected to be low. For an expected HIV prevalence of
1%, with a 95% confidence level, and an absolute precision
of 0.5%, the necessary sample size was 1500 subjects. Due to
budgetary constrictions, the HIV determinations could only
be done in 1000 persons with the inevitable loss of precision.
Subjects were randomly selected within each of the urban
and rural districts of Sucre, with a proportional allocation
to the respective district populations. Since there are no 1 5;1  9(4):369–375
population-based registries in Sucre, we used the address
records kept by Health Centres, selected homes at random,
and then interviewed the first person in the household who
fulfilled the inclusion/exclusion criteria, with a maximum of
one person being interviewed per dwelling.
Data were collected by personal interviews conducted by
trained interviewers, followed by the extraction of a blood
specimen. Interviewers (fourth-year students attending the
Faculty of Medicine at San Francisco Xavier of Chuquisaca
University, and physicians and nurses at health centres com-
ing under the aegis of the Ministry of Health) underwent
one month’s training and were additionally required to speak
Quechua, the native language. The survey was administered
personally, lasted approximately 25 min, and was conducted
from September 2008 to March 2009. No survey response rate
was formally recorded, though acceptance was good and none
of the persons who were offered the blood test refused to par-
ticipate. It was only for budgetary reasons that blood tests
were conducted in only 998 persons, 67% of the total number
of interviewees.
The questionnaire was made up of five sections: (a)
sociodemographic characteristics; (b) knowledge about modes
of HIV/AIDS transmission; (c) attitudes and practices with
respect to HIV/AIDS; (d) clinical history of sexually transmit-
ted infections (STI) and/or HIV/AIDS; and (e) other risk factors
related to HIV/AIDS. Data collected in the questionnaire were
used to construct the KAP indicators, based on the recom-
mendations of the Basic Indicators of the Joint United Nations
Programme on HIV and AIDS, (UNAIDS) and applied to the
epidemic situation in Bolivia.10,11
Indicator  definitions
Indicator  of  knowledge  about  prevention  and  transmission
of HIV  in  the  population
“Adequate knowledge”: In response to the question as to
whether the subject knows how to prevent the sexual trans-
mission of HIV, he/she answers, “by using condom” and “by
having a single sexual partner”. In response to the question
as to whether a healthy looking person may have HIV/AIDS,
the subject answers, “yes”; and in response to the question
as to whether he/she knows the ways in which the disease is
transmitted, rejects the options, “by mosquito bite” and “by
cohabiting with a PLWHA”.
“Inadequate knowledge”: Number of men  and women who
answer any of these questions differently.
Indicator  of  attitudes  of  discrimination  and  stigmatisation
“Attitude of discrimination”: the subject responds negatively
to the questions, “would you be willing to give accommodation
to a relative if you knew that he/she had HIV/AIDS?”, “would
you allow a teacher who has HIV/AIDS to continue teaching at
the school?”, and “would you buy from a fruit vendor, if you
knew he/she had HIV/AIDS?”; and responds affirmatively to“Attitude of acceptance”: subject shows attitudes of accep-
tance towards any of the four questions posed about PLWHA.
 2 0 1 
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ab r a z j i n f e c t d i s .
ndicator  of  sexual  risk  practices
Unsafe sex”: adolescents, young adults and singletons who
eport having had sex in the preceding 12 months with more
han one partner; and persons who  are either married, in a
ommon-law union, widowed and divorced who report having
ad unprotected sex (without a condom) outside the couple.
“Safe sex”: adolescents, young adults and singletons who
eport not having had sex in the preceding 12 months with
ore  than one partner; and persons who  are either married,
n a common-law union, widowed and divorced who report
ot having had unsafe sex outside the couple.
aboratory  analysis
lood samples were collected on Whatman N◦ 5 filter paper
ith measures to ensure asepsia; the pad of the fingertip (ring
nger of the left hand for right-handed persons and right
and for left-handed persons) was punctured with a sterile
ancet; specimens were left to air dry and stored at 4 ◦C with
esiccants, until being dispatched, in line with international
egulations for transport of biological samples for diagnos-
ic purposes, to the Retrovirus and Papillomavirus Unit at the
ational Centre for Microbiology of the Carlos III Institute of
ealth in Spain, for analyses. A commercial assay Genscreen
IV-1/2 (BioRad, France) was used for HIV antibodies detec-
ion. A 5 mm diameter discs were punched from dried blood
pots (DBS) using Delfia Wallac Plate Punch (Perkin Elmer,
SA) and placed into a 96-well plate for elution in 125 L of
hosphate-buffered saline-Tween 80 (pH 7.2; 0.05% Tween 80
nd 0.005% sodium azide). The plate was incubated overnight
t 4 ◦C under shaking. HIV antibody detection assay was per-
ormed using 80 L of DBS eluate.
tatistical  analysis
escriptive analyses of patients’ socio-demographic charac-
eristics were stratified by sex and compared using the Chi
quared test (2 test) for trend. The three indicators used as
esponse variables were inadequate knowledge on HIV/AIDS,
nsafe sex, and discriminatory attitudes towards PLWHA.
rude Odds Ratios (ORs) and 95% confidence intervals (95%
I) were calculated to quantify the association between each
otential risk factor and the response variables and modelled
sing multivariate logistic regression. The final model was
elected using a “backwards” procedure. Possible interactions
etween risk factors and outcome variables were investi-
ated. As sex was found to be an effect modifier for the risk
actors associated with inadequate knowledge on HIV/AIDS,
p-value for interaction < 0.05), analyses were stratified by sex.
lso, as area of residence was found to be an effect modi-
er for the risk factors associated with unsafe sex (p-value for
nteraction < 0.05), analyses were stratified by residential area.
nalyses were performed with SPSS for Windows v. 12.0 and
tata version 10.
thical  considerationshe study obtained Departmental STI/HIV/AIDS Programme
pproval from the Ministry of Health in Chuquisaca, which
cted as the ethics committee in 2008. Prior to undertaking5;1 9(4):369–375 371
the survey, the interviewers explained the aims of the study,
the voluntary nature of participation and blood-extraction
procedure to all participants. In addition, participants were
informed they would only be contacted if they tested positive.
Subjects were requested to give their oral consent, and for the
blood test, they had to sign or placing their fingerprint on the
informed consent form.
Results
A total of 1499 persons, 614 men  and 885 women, were inter-
viewed. Table 1 shows their sociodemographic characteristics
by gender showing significant differences; with more  male
residents in urban areas and more  female residents in rural
areas. Broken down by marital status, 60% were single (mainly
men). No age-related differences were found between men
and women. While most of the population had a medium/high
educational level (secondary/university), the percentage that
had scarcely completed their primary education was higher
among women than among men  (15% vs. 7%). There were
gender-related differences by language and income; more
women spoke “Spanish and Quechua” or only Quechua and
more  women reported lower monthly family incomes.
Prevalence  of  HIV  infection
Of the 1499 persons surveyed, only 998 (67%) had blood sam-
ples taken due to budget limitations. None refused to have
blood taken. No seropositive cases were found thus prevalence
of HIV infection was 0.0% (95% CI: 0.0–0.4%). There were not
statistically significant differences between the characteris-
tics of the people who had and had not blood tests done (data
not shown).
Knowledge  of  prevention  and  transmission  of  HIV
Overall, prevalence of inadequate knowledge of the correct
forms of prevention and transmission of HIV/AIDS was 67%
(95% CI: 64.6–69.4%); broken down by gender 69% (95% CI:
65.4–71.5%) in women and 65% (95% CI: 61.2–68.8%) in men.
The risk factors associated with this indicator varied by
gender (interaction p-value < 0.05) and multivariate analysis
were stratified by gender (Table 2). In women, inadequate
knowledge was associated with rural vs. urban residence
[OR = 3.9 (95% CI: 1.9–8.29)], speaking Quechua vs. only Span-
ish, [OR = 1.4 (95% CI: 1.0–1.9)], low educational level [OR  = 7.8
(95% CI: 3.1–19.7)] and earning a monthly family income of
“Bs < 1000”, [OR = 2.0 (95% CI: 1.4–2.7)]; in men, associated
factors were rural residence [OR 7.3 (95% CI: 2.6–21.0)] and
speaking Quechua [(OR 1.6 95% CI: 1.1–2.6)]).
Discrimination  and  stigmatisation
Prevalence of attitudes of discrimination and stigmatisation
towards PLWHA was 85% (95% CI: 83.3–86.9) and were almost
three times higher among subjects in the “rural area” than in
the urban area [OR 2.9 (95% CI: 1.4–5.0)], in persons with a low
educational level and family income, [OR 2.1 (95% CI: 1.1–4.2)]
and [OR 2.0 (95% CI: 2.0–0.5)], respectively (Table 3).
372  b r a z j i n f e c t d i s . 2 0 1 5;1  9(4):369–375
Table 1 – Socio-demographic variables stratified by gender.
Male Female Total p-valuea
N (%) N (%) N (%)
614 (41.0) 885 (59.0) 1499 (100.0)
Place of birth 0.042
Beni 5 (0.8) 6 (0.7) 11 (0.7)
Chuquisaca 440 (71.7) 686 (77.5) 1126 (75.1)
Cochabamba 7 (1.1) 11 (1.2) 18 (1.2)
La Paz 17 (2.8) 21 (2.4) 38 (2.5)
Oruro 11 (1.8) 5 (0.6) 16 (1.1)
Pando 2 (0.3) 2 (0.2) 4 (0.3)
Potosí 107 (17.4) 114 (12.9) 221 (14.7)
Santa Cruz 15  (2.4) 28 (3.2) 43 (2.9)
Tarija 7 (1.1) 12 (1.4) 19 (1.3)
Argentina 3 (0 .5) 0 (0.0) 3 (0.2)
Residential setting 0.012
Urban (centre/outskirts) 548 (89.3) 750 (84.7) 1298 (86.6)
Rural 66 (10.7) 135 (15.3) 201 (13.4)
Age 0.424
15–24 323 (52.6) 447 (50.5) 770 (51.4)
25–49 291 (47.4) 438 (49.5) 729 (48.6)
Marital status <0.001
Married 156 (25.4) 270 (30.5) 426 (28.4)
Divorced/widowed 10 (1.7) 20 (3.2) 38 (2.5)
Single 408 (66.4) 489 (55.3) 897 (59.8)
Common-law (stable) union 40 (6.5) 98 (11.1) 138 (9.2)
Language <0.001
Spanish or Spanish and another non-native language 339 (55.2) 357 (40.3) 696 (46.4)
Spanish and native language or only native language 275 (44.8) 528 (59.7) 803 (53.6)
Religion 0.001
Catholic 513 (83.6) 788 (89.0) 1301 (86.8)
Other 61 (9.9) 72 (8.1) 133 (8.9)
None 40 (6.5) 25 (2.8) 65 (4.3)
Educational level <0.001
Low 40 (6.5) 129 (14.6) 169 (11.3)
Medium/high 574 (93.5) 756 (85.4) 1330 (88.7)
Monthly family income (in Bolivianos) 0.005
<1000 236 (38.4) 408 (46.1) 644 (43.0)
≥1000 374 (60.9) 466 (52.7) 840 (56.0)
No reply 4 (0.7) 11 (1.2) 15 (1.0)
No. of family members 0.258
<1 to 5 392 (63.8) 590 (66.7) 982 (65.5)
≥6 222 (36.2) 295 (33.4) 517 (34.5)
a 2 test.
Sexual  risk  practices
Prevalence of unsafe sex among persons who had already ini-
tiated their sexual life was 10.7% (95% CI: 8.6–12.1%), and was
higher in urban, 11% (95% CI: 8.9–12.5%), than in rural areas, 8%
(95% CI: 3.5–11.9%). Risk factors for this indicator were differ-
ent in the rural and urban area (p-value for interaction < 0.05)
and multivariate analysis were stratified by residential area
(Table 4). Increased prevalence of unsafe sex in the urban area
was reported by men, the “youngest” segment and subjects
living in a “stable union” while in the rural area, no variable
was found to have a statistically significant association with
unsafe sex.Discussion
Inadequate knowledge on HIV/AIDS transmission and preven-
tion mechanisms and the discriminatory attitudes towards
persons with HIV are very frequent in Sucre in spite of rel-
atively low prevalence of unsafe sex behaviour and a very low
prevalence of HIV infection. Moreover, indicators of knowl-
edge, attitudes and practices on HIV/AIDS display important
differences according to gender, ethnic and socio-economic
origin, and urban versus rural residence.
The prevalence of HIV in the general population aged 15–49
in Sucre was 0.0% (95% CI: 0.0–0.37) and is lower than the
b r a z j i n f e c t d i s . 2 0 1 5;1 9(4):369–375 373
Table 2 – Prevalence of inadequate knowledge on HIV prevention and transmission mechanisms and adjusted OR
estimated by multivariate logistic regression.
Prevalence Adjusted OR p-valuea
n (%) (95% CI)
Women 606 (68.5)
Residential setting
Urban 480 (64.0) 1.0
Rural 126 (93.3) 3.9 (1.9–8.2) <0.001
Language
Spanish or Spanish and another non-native language 201 (56.3) 1.0
Spanish and/or Quechua 405 (68.5) 1.4 (1.0–1.9) 0.031
Educational level
Medium/high 482 (63.8) 1.0
Low 124 (96.1) 7.8 (3.1–19.7) <0.001
Family income (in Bolivianos)
≥1000 271 (58.2) 1.0
<1000 324 (79.4 2.0  (1.4–2.7) <0.001
Men 399 (65.0)
Residential setting
Urban 337 (61.5) 1.0 <0.001
Rural 62 (93.9) 7.3 (2.6–21.0)
Language
Spanish or Spanish and another non-native language 195 (57.5) 1.0 0.013
Spanish and native language or only native language 204 (74.2) 1.6 (1.1–2.3)
p
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Chuquisaca, and data furnished by the most recent (2008)
12a 2 test.
revalence estimated by UNAIDS in 2010 for the general pop-
lation of the same age in Bolivia, namely, 0.2% (95% CI:
.1–0.34). These data rank Sucre as one of the regions with
he lowest estimated prevalence in South America.3
Prevalence of inadequate knowledge on HIV/AIDS trans-
ission and prevention mechanisms in Sucre is high; 65%
n men  and 69% in women. Furthermore, risk factors differ
y gender. Although inadequate knowledge is more  frequent
n rural areas and among Quechua-speakers of both gen-
ers, among women it is additionally associated with a
ow educational and socio-economic level, highlighting their
Table 3 – Prevalence of discriminatory attitudes to
PLWHAa and adjusted OR estimated by multivariate
logistic regression.
Prevalence
n (%)
1276 (85.1)
Adjusted OR
(95% CI)
p-valueb
Residential setting
Urban 7 (7.4) 1.0 0.004
Rural 8 (7.7) 2.9 (1.4–5.0)
Educational level
Medium/high 6 (7.1) 1.0 0.030
Low 6 (8.3) 2.1 (1.1–4.2)
Family income
≥1000 271 (58.2) 1.0
<1000 324 (79.4 2.0 (1.4–2.7) 0.027
a PLWHA: people living with HIV/AIDS.
b 2 test.vulnerability. The prevalence of inadequate knowledge
observed by our study is lower than that reported by pre-
vious studies conducted in Bolivia. The study developed
in Chuquisaca by the UASB with UNAIDS on 2006 (unpub-
lished result) also used the UNAIDS indicators and estimated
the prevalence of inadequate knowledge as being 88% in
rural areas, mostly Quechua-speaking, in the department ofBolivian National Demographic & Health Survey estimated
inadequate knowledge of modes of HIV transmission among
Table 4 – Prevalence of unsafe sex practices and
adjusted OR estimated by multivariate logistic
regression in the urban setting.
Prevalence
n (%)
114 (10.7)
Adjusted OR
(95% CI)
p-valuea
Sex
Male 83 (17.4) 1.0
Female 31 (5.3) 0.3 (0.2–0.4) <0.001
Age
15–24 years 75 (16.7) 1.0
25–49 years 39 (6.4) 0.4 (0.2–0.6) <0.001
Marital status
Married 19 (5.2) 1.0
Divorced-widowed 3 (9.1) 2.3 (0.6–8.2) 0.221
Single 75 (13.4) 1.30 (0.7–2.4) 0.457
Common-law
(stable) union
17 (15.0) 2.9 (1.4–6.1) 0.004
a 2 test.
i s . 2 0
r374  b r a z j i n f e c t d 
persons aged 15–49 as being 76% in men  and 78% in women.
Apart from methodological differences in the instruments for
measuring and selecting the sample, these discrepancies may
be due to the higher mean educational level of persons who
answered our survey given that Sucre is a university city with
a large number of residential students. Our study’s findings
are comparable to those of the 2008 El Salvador National Fam-
ily Health Survey,13 which describes inadequate knowledge
of HIV as 66% among persons aged 15–49 and 63% among
aged 15–24 but suggests higher levels of inadequate knowl-
edge than other countries. In Brazil, inadequate knowledge of
HIV was estimated at 39% and 43% in 2005.14,15 It is notewor-
thy that, as in El Salvador, inadequate knowledge was higher in
rural women with low educational and socio-economic levels,
and that, as in Brazil,16 in persons with lower education level.
Finally, while there are other studies on knowledge and prac-
tices with respect to HIV/AIDS in Latin America, their results
are not comparable to ours, since they were not conducted on
the general population.16,17
The prevalence of attitudes of discrimination and stigmati-
sation towards persons living with HIV/AIDS in this study was
very  high, 85%, being higher in the rural area, a prevalence
similar to those reported in the Simon Bolivar Andean Uni-
versity (UASB)-UNAIDS study (2006) (unpublished result). In
our study, persons with a low socio-economic level displayed
the most pronounced attitudes of rejection; this is important
to be considered when designing preventive strategies as it
has been acknowledged that attitudes of stigmatisation and
discrimination towards PLWHA reduce the effectiveness of
programmes and services.18
The prevalence of unsafe sexual risk practices was rela-
tively low, 10%, and was higher in men  than in women. These
figures are lower than those from Brazil,15 where unsafe sex
in the general population aged 15–54 were 41% in women and
33% in men. In our study, there were no significant differ-
ences in the rural area for any of the variables, in line with
the findings of the UASB-UNAIDS study in the rural area of
Chuquisaca. In the urban area, however, women  reported a
significantly lower prevalence of unsafe sex than men, and
adolescents and young adults reported more  frequent unsafe
sex practices than older adults aged 25–49. A study conducted
in Brazil15 reported that persons aged 40–54 had higher preva-
lence of unsafe sex than adolescents and young adults. In
our study, 22% of the population had initiated sexual relations
before the age of 15 years, though this was commoner in men
than in women. This percentage was higher than that reported
by the 2008 Bolivian National Demographic & Health Survey.12
Compared to other countries in the region, the age of initiation
of sexual relations in Bolivia is higher.16
One of the limitations of this study is not having the
response rate since no data were gathered to calculate it.
Another limitation is the loss of relative precision in the esti-
mation of HIV prevalence due to the restricted sample size,
nevertheless the absolute precision is still low and our result
is consistent with previous studies that have reported low HIV
prevalence in Bolivia. Since no optimal sampling framework
was available, random sampling was not strictly fulfilled due
to the difficulties of reaching subjects in the rural area. An
effort was also made to minimise information bias, by ren-
dering the survey anonymous, ensuring interviewers were of 1 5;1  9(4):369–375
the same gender as interviewees, and indicating beforehand
that nothing subjects might say would be judged, and that it
was hoped they would reply as honestly as possible as results
would be useful, not only for themselves but also for many
other persons. All these helped create a climate of trust and
reduce information bias, though underreporting of sexual risk
behaviours motivated by the need to give socially acceptable
replies cannot be ruled out.
In conclusion this is the first study to analyse knowledge,
attitudes and sexual practices with respect to HIV/AIDS and
prevalence of HIV infection among the general population of
Sucre, Bolivia. The results of this study that highlight profound
and unfair differences by gender, ethnic and socio-economic
origin, and urban versus rural residence should allow to design
policies that take into account ethnic, intercultural, regional
and gender-related realities, aligned with current national
community and intercultural health policy as to provide an
adequate response to the HIV/AIDS epidemic in Bolivia.
Conflicts  of  interest
The authors declare no conflicts of interest.
Acknowledgements
We would like to thank the following: all the participants; the
field team members of San Francisco Xavier of Chuquisaca
University who acted as the interviewers (students of the
School of Medicine San Francisco Xavier of Chuquisaca
University) and to the study coordinators; the Chuquisaca
Regional Health Service (Servicio Departamental de Salud/SEDES-
Chuquisaca) of the Bolivian Ministry of Health for its logistical
support; and the National Centre for Epidemiology and
National Centre for Microbiology of the Carlos III Institute of
Health.
Our special thanks go to the Spanish Agency for Inter-
national Development & Cooperation (Agencia Espan˜ola de
Cooperación Internacional para el Desarrollo – AECID) for its finan-
cial support of the Public Health Doctoral Programme of the
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