Knowledge and attitude of secondary school students in Nakaseke, Uganda towards HIV transmission and treatment

Background: One of the major health concerns in Nakaseke district, Uganda is the high prevalence of HIV/AIDS. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), as of March 2014, the prevalence rate of the disease in the district was estimated at about 8%, compared to the national average of 6.5%, making Nakaseke district have the sixth-highest prevalence rate of HIV/AIDS in the entire country. We set out to explore the knowledge and attitude of secondary school students in Nakaseke, Uganda on HIV transmission and treatment. Methods: This was a cross sectional survey-based study with data collected during the month of February 2020. Data were analyzed using R programming language version 3.6.2. Results: A total of 163 participants volunteered for the study, 53.37% males and 46.63% females with ages ranging from 12 – 20 years. Participants came from 5 senior classes (S1, S2, S3, S4 and S6). In total, 87.73% participants were aware of HIV/AIDS while 12.27% were not. The major source of information was through teachers/schools. 96.50% knew the mode of transmission of HIV/AIDS and 95.11% were conversant with HIV/AIDS prevention. 63.6% were aware of the terms DNA and genes whereas 36.36% were not. Discussion: Generally, the students in Nakaseke district, Uganda had a high level of awareness of HIV/AIDS based on Bloom’s cut-off point. However, with regards to aspects such as the cause and modern prevention methods like taking prep and prevention of mother to child transmission were less known to them. Efforts to find a cure for HIV/AIDS are still in vain. Therefore, strong emphasis on up to date control and prevention methods should be implemented to fight the HIV/AIDS scourge .


Introduction
The vast majority of people living with human immunodeficiency virus (HIV) are located in low-and middle-income countries, with an estimated 68% living in sub-Saharan Africa 1 . Among this group, 20.6 million are living in East and Southern Africa which saw 800,000 new HIV infections in 2018 1 . HIV and acquired immunodeficiency syndrome (HIV/AIDS) has remained a challenge in Uganda among adolescents despite the ABC (Abstinence, Be faithful, use a Condom) strategy 2 . Globally, the most vulnerable group of individuals to HIV infection are reported to be the youth in the reproductive age group of 15 -24 years with adolescents contributing to a large percentage 3-5 . Previous research found that only 45.5% of women and men between 15-24 years old correctly identified ways of preventing the transmission of HIV through sex. In 2018, Uganda had 53,000 people newly infected with HIV 6 . There are many political and cultural barriers which have hindered effective HIV prevention programming in Uganda. Consequently, new HIV infections are expected to rise in coming years 7 .
Community-based interventions (CBIs) for the prevention and control of HIV allow increased access and ease availability of medical care to populations at risk, or already infected with HIV by reaching individuals in schools, homes or community centers. School-based delivery of HIV prevention education has also been advocated as potential strategies to target high-risk youth groups 8,9 . Community engagement activities with Persons Living with HIV in Nakaseke have been utilised to reduce the number of new infections. This is led by local leaders, the sub county chief, religious leaders, Village health team members, health workers, community decision makers and the community development officers 10 . But this is largely targeting adults while students at schools may get HIV/AIDS prevention messages either through their parents, teachers, fellow students and the Presidential Initiative on AIDS Strategy to Youth (PIASCY). Creating awareness among the youth on HIV/AIDS is the key to reducing its spread.
The aim of this study was to evaluate the knowledge and attitude of secondary school students towards HIV transmission and treatment in a rural secondary school in Nakaseke, Uganda.

Study design and setting
This was a cross-sectional study conducted in a secondary school in a church of Uganda founded school in Nakaseke district of Uganda. This school is both day and boarding and students are supported through a number of mechanisms such as the government of Uganda's universal secondary education quota system, while others are sponsored privately or by nongovernmental organisations like World Vision Uganda. Nakaseke district was conveniently chosen to represent a rural setting. It was purposely selected because it had the sixth-highest prevalence rate of HIV/AIDS in 2014 in Uganda. Nakaseke district is bordered by Nakasongola district to the north ( Figure 1). The location of the district headquarters lies approximately 66 kilometers (41 mi) by road, north of Kampala, the capital of Uganda and the largest city in the country. It is estimated that 59.2% of the Nakaseke district community is literate, which is largely limited to the local Luganda language. This district has seven health units including a 100-bed public hospital, Nakaseke Hospital, administered by the Uganda Ministry of Health. Nakaseke Hospital is connected to other health units by a radio 11 . One of the major health concerns is the high prevalence of HIV/AIDS. The prevalence rate of the disease in the district was estimated at about 8%, compared to the national average of 6.5%. Nakaseke district has the sixth-highest prevalence rate of HIV/AIDS in Uganda 10 .

Study population and sampling procedures
The sampling procedure was voluntary response participation. It was inexpensive since we needed to utilize students' breakfast and lunch hours as requested by the school administration. Students from classes Senior 1, Senior 2, Senior 3, Senior 4, and Senior 6 were interviewed. Senior 5 students were excluded because they had not yet reported to school. The study was expected to interview a total of 200 students but only 163 of them turned up on the day of the study.

Data collection
The students were interviewed using structured questionnaires 12,13 , with the help of trained research assistants in the students' language of preference (English or Luganda). The questionnaire had closed-ended questions, presented in two formats: yes or no, and multiple choice or objective responses with an aim of accessing the knowledge of students about HIV/AIDS and their attitudes towards HIV transmission, prevention and stigma.

Amendments from Version 1
Within the abstract, we have included the criteria (Bloom's cut-off point) that we assessed one to have knowledge and awareness about HIV/AIDS In the Introduction, more information about community based Interventions has been added Under study design and setting, more information about the school where the study was conducted has been included Tables have been merged as; Tables 3, 4 and 6 into Table 1; Table 5, 7 merged into Table 2; Table 8, 9, merged into Table 3;  Table 10, 11 merged into Table 4; Table 12 to Table 5; Table 13 to Table 6 In the Discussion section, the "Knowledge and attitude about HIV/AIDS diagnosis, symptoms, transmission, prevention, treatment, and cure by participants in a rural school" subheading has been divided into 3 sub-headings The reference named "Salam RA, Haroon S, Ahmed HH, et al.: Impact of community-based interventions on HIV knowledge, attitudes, and transmission" and its corresponding citations have been deleted from the article Study variables Treatment, transmission, prevention, cure, and diagnosis were the variables used to evaluate the degree of knowledge about HIV. This was done through computing percentages for every correct response and the KAP was categorised using Bloom's cut-off point where Bloom's cut-off of (≥80%) was used to determine sufficient knowledge. The demographic characteristics: age, gender and class were also considered.

Data quality control
Trained research assistants interviewed the participants in their preferred language of communication (English or Luganda) to ensure comprehension and better expression while responding to the questions. Questions were simple and easy to understand. The data was entered using an excel spreadsheet, triple checked for errors, saved as a comma-separated values file (CSV) and later imported into R.

Data analysis plan
All questions in the questionnaires were entered into the excel spreadsheet and the data was imported and analyzed using R version 3.6.2. All questionnaires with missing data were regarded as invalid and excluded from the analysis. The frequencies and percentage responses for each question was computed and the data was transformed into tables.

Ethical considerations
Ethical clearance and approval for project was obtained from the School of Medicine Research and Ethics Committee (SOMREC) at Makerere University College of Health Sciences with approval number, #REC REF 2019-028. Administrative permission was obtained from both the Ugandan Ministry of Education and Sports (assigned reference number, ADM. 217/323/01) as well as the school. For participants in the age group 12 to 17 years, consent was sought from the school administrator and then assent was obtained from individual students. For mature and emancipated minors (between ages of 16 to 17), written informed consent was independently sought from them. For the age group of 18 years and above, consent was sought from the students themselves. Confidentiality of information was ensured by the principal investigator during and after the study by blinding the participants' names and replacing them with arbitrarily chosen IDs.

Results
163 participants volunteered for the study with more males (87, 53.37%) than females (76, 46.63%) 14 . The participants were aged between 12 -20 years, with a modal age group of 15 -17 years and an average age of 15.45 ± 1.82.
In total, 143 (87.73%) participants were aware of HIV/AIDS while 20 (12.27%) were not. The mean age of those who were aware of the disease was 15.37 ± 1.77 years whereas those who were not had a mean age of 16.05 ± 2.06 years. The downstream analysis after the question regarding awareness of HIV/AIDS was exclusive of participants that were not aware of the disease. Most of the participants (109, 76.22%) were aware of HIV treatment (antiretroviral drugs; ARVs) while 34 (23.78%) were not aware. In total, 65 (60.75%) knew that HIV can be transmitted through sexual intercourse with an HIV infected person without using a condom, 5 (4.67%) mentioned sharing injecting equipment, and 68 had multiple responses (contaminated blood transfusion or organs/tissues, sexual intercourse with an HIV infected person without using a condom, sharing injecting equipment and mother to child transmission during childbirth and breastfeeding). Only 5 (4.67%) participants didn't know of any mode of transmission (Table 1). Blood (65, 53.72%) was the most known bodily fluid in which HIV is transmitted. Others mentioned breastmilk (1, 0.83%), vaginal fluids (4, 3.31%) and 33 (27.27%) participants did not know ( Table 2).
In regards to the cause of HIV/AIDS, most of the participants (88, 61.54%) knew that it was caused by a virus, 9 (6.29%) said that it was caused by bacteria and the rest 46 (32.17%) didn't know the cause (Table 1). For the signs and symptoms of HIV/AIDS, 105 (73.43%) individuals pointed out frequent illnesses and 38 (26.57%) did not know the signs and symptoms one could identify a person infected with HIV/AIDS. 85 (59.44%) participants had ever seen someone with HIV/AIDS whereas the rest 58 (40.56%) had never. Among those that had ever seen someone infected with the disease, 52 (61.18%) had guessed, 26 (30.59%) were told by the patient, 3 (3.53%) got to know through their families, 3 (3.53%) knew through the hospitals and 1 (1.18%) got to know through their teachers/schools (Table 2).
When participants were asked whether there was a cure for HIV, 116 (81.12%) knew that there was no cure for HIV whereas 27 (18.88%) thought that there was a cure for HIV. Those that said there is a cure for HIV claimed to have heard from different sources of information. 5 (18.52%) from health professionals, 5 (18.52%) from friends/family, 8 (29.63%) from TV/Radio, 6 (22.22%) from Teachers/school, 2 (7.41%) from church/mosque and 1 (3.71%) from both health professionals and TV/ Radio. None got to know from the internet and newspapers (Table 3). HIV prevention methods were generally known. Most responses (52, 46.02%) were for appropriate and consistent condom use, 48 (42.48%) were for abstinence, 2 (1.77%) for avoiding sharing sharp objects and the rest (1, 0.88%) were for taking prep consistently, checkups and avoiding blood contact with an infected person ( Table 3). Most of the participants (126, 88.11%) knew that HIV/AIDS was diagnosed using a blood test, 1 (0.70%) said that it was diagnosed through the urine test and 16 (11.19%) did not know how the disease is diagnosed (Table 4).
With regards to knowledge on HIV transmission from parent to child, most of the students were not sure whether the children would get infected in case at least one of the parents was HIV positive (Table 4). Over two thirds (99, 69.23%) of students said they would not marry a person infected with HIV and 92 (69.70%) would discontinue the relationship if they discovered that the person they were dating was infected with HIV. Though 44 (30.77%) respondents were willing to marry a person infected with HIV, 9 (6.82%) would continue the relationship and 28 (21.21%) would seek counselling and treatment (Table 5).
Concerning knowledge on Host Genetics in HIV infection, 91 (63.64%) students had heard about the terms "DNA" or "Genes" and 52 (36.36%) hadn't. For those who had heard about the terms, their major sources of information included; TV or radio (33, 38.37%), health professionals (29, 33.72%), family/friends (11, 12.79%), teachers/schools (11, 12.79%), church/mosque (1, 1.16%) and movies (1, 1.16%). Those who knew about DNA or genes were further asked whether their DNA or genes would determine if they would get infected with HIV or not; 56 (61.54%) said no, 31 (34.07%) said yes and 4 (4.40%) did not know. In addition, they were also asked whether their DNA or Genes would affect the outcome of their HIV treatment; 60 (65.93%) responded no to the question, 26 (28.57%) knew that DNA would affect HIV treatment whereas 5 (5.50%) were undecided (Table 6).

Demographic characteristics
The study assessed the knowledge, attitudes and perception of secondary school students in Nakaseke, Uganda. Of the 163 participants, 143 (87.73%) were aware of HIV/AIDS and 20 (12.27%) were not. The mean age of those who were aware of the disease was 15.37 ± 1.77 years while those who were not aware of the disease had a mean age of 16.05 ± 2.06. Similar results were seen in other studies 15,16 Knowledge and attitude about HIV/AIDS treatment by participants in a rural school Since awareness hinges on the knowledge about HIV/AIDS, what our participants knew about HIV was very key. The source of information about HIV was also important as it conveyed the basic information about HIV/AIDS and in this study. Teachers or schools (29.81%), and health professionals (27.88%) were the most used avenues to convey the message to the participants 17 . The Presidential Initiative on AIDS Strategy to Youth (PIASCY) started in 2001, and was introduced in all primary and post primary schools' education curriculum 18 . This program was designed to prevent the spread of HIV/ AIDS and to mitigate its impact on primary and post-primary education institutions in Uganda. It is no surprise that the participants received most information about HIV/AIDS through their teachers 18 . None of the participants got information through the internet and newspapers. This is typical of rural secondary schools as such services do not reach rural areas 19 . A substantial  Knowledge and attitude about the role of an individual's genetics on HIV/AIDS in acquisition and effect on treatment Despite more than half (63.64%) of the total number of participants being familiar with the terms DNA and genes, 34.07% knew these terms in accordance with HIV transmission

Conclusion
This study provides preliminary data from a country and region where current information on the knowledge of young adults about HIV/AIDS and their attitude toward infected persons are sparse. This study highlights the basic knowledge of HIV/AIDS among young students, modes of transmission, treatment and management; it also indicates that stigma about the disease and discrimination of affected individuals in society is common among students. The basic approach for control and prevention of HIV/AIDS remains prevention through better knowledge and awareness since an effective cure or vaccine is not yet available.
Generally, the secondary school students had a high level of awareness of HIV/AIDS. However, with regards to aspects such as the cause and modern prevention methods like taking prep and prevention of mother to child transmission were less known to them. Efforts to find a cure for HIV/AIDS are still in vain. Therefore, strong emphasis on up to date control and prevention methods should be implemented to fight the HIV/AIDS scourge. 1.

Data availability
The title of the questionnaire suggests that the study was on students' awareness of host genomics and anti-retrovirals. This is an important and topical issue and one that has been less studied. However, in reporting the results of the study, less emphasis is given on this aspect of the study, including why it was important to survey students' knowledge on host genomics and anti-retrovirals and if students had previously been exposed to such information, either as part of public health awareness programs, research, or educational programs in school. This should ideally be covered in the introduction and results section.

2.
Currently the main information is that the low awareness on HIV-host genomics and antiretroviral therapy is not alarming as genomics is not thought in secondary schools. If that is the case, and that information was known, why did this section form part of the study?

Methods:
It is mentioned that the Nakaseke district was purposely selected because it has the sixthhighest prevalence rate of HIV/AIDS in Uganda. What is not clear is why the 1 st five districts with the highest prevalence were not selected or if similar studies have been carried out in this region. This information needs to come out clearly in the methods section, otherwise the justification for the study site is not convincing.

1.
It is stated that sampling was voluntary. Kindly include a sentence, or two, and references, on what this sampling strategy involves and why it was used.

2.
For readers who may not be familiar with the Ugandan school system, it is important to provide basic information on what S1 S2 is, in terms level of education (e.g. 5 years post primary, the age group etc) and possible HIV educational activities they may have been exposed to either in school, in their communities to suppose that this class is expected to have such knowledge etc. 3.
The sentence "The prevalence rate of the disease in the district was estimated at about 8%, compared to the national aver-age of 6.5%"-needs a reference.

4.
Kindly include more information on how the sample size of 200 students was reached, as well as what is meant by 163 students turn up for the study? Is this the number that consented, while the remaining 37 students did not? Or what were the reasons the other 37 did not complete the questionnaire? Information on how parental consent was obtained will be useful for including measures put in place to ensure that participation in the study was voluntary and that the students did not feel compelled to complete the study especially if it was administered in school.

5.
Provide details on the administration of the questionnaire; was it done in school, or selfadministered in some cases?

6.
It is stated that the students were interviewed using structured questionnaires adopted from... (a reference is provided). For improved readability it is better to state what the questionnaire is and why that questionnaire was chosen over those that have been used in similar studies around the world. If any changes were made to the questionnaire, what were these changes and why was there a need to make these changes?

Results:
The results section has way too many tables (n=12) and this could distract from the main text. Some of the tables can be merged or deleted. For example, Table 1 and 2 can be deleted as that information has already been provided in the text in a clear fashion, therefore a table is not required. Also, some of the summary statistics in the tables could be deleted. Tables should have just key information for each response option rather than separately (option one and two). That is, it is better to provide percentages of people who selected abstinence, irrespective of whether that was selected together with another option, 1.
say appropriate condom use. The tables should give the reader an idea of how many persons ticked a particular response irrespective of whether the also selected another response. The methods already make it clear that in some cases participants selected more than one response. Table 3, 4 and 6 and 6 can be one table and should only contain information for each response not X and Y combined. Table 7: The question "Have you ever seen an HIV patient" is ambiguous and could propagate stigma. The phrasing suggests that people with HIV look a specific way and can therefore be identified by merely looking at someone. That is disturbing for a study that looked at attitudes towards HIV. Was the question meant to be "Do you know of anyone living with HIV? If so, what was the purpose of the question -that information needs to be provided.

2.
The referencing style and the way it is used in the article is very confusing, taking the reader away from the main text to the references. For example, page 8, (similar to 13) and page 10 (in concordance with 16 and 17). Our suggestion is that the authors should state the precise information they are referring to and then cite the text. 3.

Discussion and Conclusion:
The discussion section could be shortened and streamlined to how the results obtained compare to similar studies in Uganda and globally and the implications that it may have for public health management of HIV/AIDS in Uganda. For example, one and two of the discussion section is a repetition of the results and that is the case for most of the paragraphs in that section. The authors repeat the results.

1.
Given the low awareness of HIV/AIDS transmission, did the team introduce any educational intervention, pre or post survey? If so, what were these interventions and how was it received by the students? If not, are there plans to do awareness campaigns in the schooland what are the details particularly so on the role of host genomics in HIV transmission and therapy especially as this was the topic of the questionnaire? It will be a missed opportunity for a research program to take advantage of to raise awareness on HIV transmission and treatment especially as the authors note that there is rise in prevalence of HIV among young people in Uganda and that the district is one of those with the highest HIV prevalence in the country.

2.
We thank the authors for sharing their results on this interesting study and look forward to reading their response to the comments that we have made.

If applicable, is the statistical analysis and its interpretation appropriate?
Yes Are all the source data underlying the results available to ensure full reproducibility? Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Two reviewers are involved and their areas of research include 1) Ethical legal and social Issues in Health research . 2) Infectious disease ( HIV and RHD)-immunology and proteomics
We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

Author Response 03 Jul 2021
Stephen Kanyerezi, The African Center of Excellence in Bioinformatics and Data-Intensive Sciences, the Infectious Disease Institute, Makerere University, Kampala, Uganda

Major comments:
The introduction needs more information to give context to readers on the current state of HIV awareness in Uganda, existing educational programs for youths and secondary school students in Uganda, generally and in schools in the Nakaseke district; and the potential of this study to inform HIV educational programs in Nakaseke and/or Uganda generally. Some of this information is in the discussion, but should have come earlier on in the introduction to provide the reader with some context on HIV awareness and education in Uganda and why it was important for the researchers to carry out this study.
We have enriched the introduction as suggested.
The title of the questionnaire suggests that the study was on students' awareness of host genomics and anti-retrovirals. This is an important and topical issue and one that has been less studied. However, in reporting the results of the study, less emphasis is given on this aspect of the study, including why it was important to survey students' knowledge on host genomics and anti-retrovirals and if students had previously been exposed to such information, either as part of public health awareness programs, research, or educational programs in school. This should ideally be covered in the introduction and results section. Currently the main information is that the low awareness on HIV-host genomics and anti-retroviral therapy is not alarming as genomics is not thought in secondary schools. If that is the case, and that information was known, why did this section form part of the study?
The students did not have prior awareness of host genomics and antiretrovirals.

Methods:
It is mentioned that the Nakaseke district was purposely selected because it has the sixth-highest prevalence rate of HIV/AIDS in Uganda. What is not clear is why the 1st five districts with the highest prevalence were not selected or if similar studies have been carried out in this region. This information needs to come out clearly in the methods section, otherwise the justification for the study site is not convincing.
We conveniently selected Nakaseke district because it was ranking poorly among in HIV/AIDS prevention It is stated that sampling was voluntary. Kindly include a sentence, or two, and references, on what this sampling strategy involves and why it was used.
We have included more details under Study population and sampling procedures.
For readers who may not be familiar with the Ugandan school system, it is important to provide basic information on what S1 S2 is, in terms level of education (e.g. 5 years post primary, the age group etc) and possible HIV educational activities they may have been exposed to either in school, in their communities to suppose that this class is expected to have such knowledge etc.
These are classes or grades for Secondary level of education.
The sentence "The prevalence rate of the disease in the district was estimated at about 8%, compared to the national aver-age of 6.5%"-needs a reference.
This was cited with citation 9.
Kindly include more information on how the sample size of 200 students was reached, as well as what is meant by 163 students turning up for the study? Is this the number that consented, while the remaining 37 students did not? Or what were the reasons the other 37 did not complete the questionnaire? Information on how parental consent was obtained will be useful for including measures put in place to ensure that participation in the study was voluntary and that the students did not feel compelled to complete the study especially if it was administered in school.
The study school had a total of 200 students but 163 reported at school on the day of data collection.
Provide details on the administration of the questionnaire; was it done in school, or self-administered in some cases?
It was administered at school within the school main hall, with help of research assistants to interpret to their local languages for those who could not comfortably read English and Luganda.
It is stated that the students were interviewed using structured questionnaires adopted from... (a reference is provided). For improved readability it is better to state what the questionnaire is and why that questionnaire was chosen over those that have been used in similar studies around the world. If any changes were made to the questionnaire, what were these changes and why was there a need to make these changes?
Thank you for this comment, The questionnaire was purposely designed to probe aspects of knowledge and attitude of secondary school students in Nakaseke, Uganda towards HIV/AIDS transmission and treatment.

Results:
The results section has way too many tables (n=12) and this could distract from the main text. Some of the tables can be merged or deleted. For example, Table 1 and 2 can be deleted as that information has already been provided in the text in a clear fashion, therefore a table is not required. Also, some of the summary statistics in the tables could be deleted. Tables should have just key information for each response option rather than separately (option one and two). That is, it is better to provide percentages of people who selected abstinence, irrespective of whether that was selected together with another option, say appropriate condom use. The tables should give the reader an idea of how many persons ticked a particular response irrespective of whether the also selected another response. The methods already make it clear that in some cases participants selected more than one response. Table 3, 4 and 6 and 6 can be one table and should only contain information for each response not X and Y combined.
We have addressed these accordingly as below; Deleted table 1 and 2  Merged tables 3, 4 and 6 into table 1  Table 5, 7 merged into table 2  Table 8, 9, merged into table 3  Table 10, 11 merged into table 4  Table 12 to table 5  Table 13 to table 6   Table 7: The question "Have you ever seen an HIV patient" is ambiguous and could propagate stigma. The phrasing suggests that people with HIV look a specific way and can therefore be identified by merely looking at someone. That is disturbing for a study that looked at attitudes towards HIV. Was the question meant to be "Do you know of anyone living with HIV? If so, what was the purpose of the question -that information needs to be provided.
We agree. We meant to ask, "Do you know of anyone living with HIV?
The referencing style and the way it is used in the article is very confusing, taking the reader away from the main text to the references. For example, page 8, (similar to 13) and page 10 (in concordance with 16 and 17). Our suggestion is that the authors should state the precise information they are referring to and then cite the text.
This has been addressed accordingly.

Discussion and Conclusion:
The discussion section could be shortened and streamlined to how the results obtained compare to similar studies in Uganda and globally and the implications that it may have for public health management of HIV/AIDS in Uganda. For example, one and two of the discussion section is a repetition of the results and that is the case for most of the paragraphs in that section. The authors repeat the results.
We have removed the repetition of the results.
Given the low awareness of HIV/AIDS transmission, did the team introduce any educational intervention, pre or post survey? If so, what were these interventions and how was it received by the students? If not, are there plans to do awareness campaigns in the school -and what are the details particularly so on the role of host genomics in HIV transmission and therapy especially as this was the topic of the questionnaire? It will be a missed opportunity for a research program to take advantage of to raise awareness on HIV transmission and treatment especially as the authors note that there is rise in prevalence of HIV among young people in Uganda and that the district is one of those with the highest HIV prevalence in the country.
The post survey was not done due to school closure as a result of COVID-19 global Pandemic. bias.

Is the work clearly and accurately presented and does it cite the current literature? Partly
Is the study design appropriate and is the work technically sound? Partly

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate? Not applicable Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Partly Thank you. This has been corrected.
B. Please provide current literature on HIV/AIDS prevalence in Uganda. The citation referring to the year 2014 is old. Citation 2 is wrongly cited to have provided information on the contribution of adolescents to HIV/AIDS prevalence globally yet that study was about knowledge, attitudes, and perceptions.