Preplanned Studies: Knowledge, Attitude, and Practice Towards Mpox and Associated Factors Among HIV-Infected Individuals — Beijing Municipality, China, 2023

The global mpox outbreak, starting in May 2022, has spread rapidly across non-endemic regions (1). In this wave of the epidemic, 38% to 50% of mpox patients are also human immunodeficiency virus (HIV)-infected individuals, which face a higher risk of mpox infection, more severe clinical symptoms, and higher mortality rates due to their compromised immune system (2). The spread of mpox is particularly insidious (3), and the absence of smallpox vaccination among individuals born after 1980 has resulted in their lack of resistance to mpox (4). Furthermore, there is currently a lack of effective treatment measures for mpox, with symptomatic supportive therapy being the primary approach in clinical practice. Consequently, preventing and controlling mpox heavily relies on individuals’ self-regulation and responsible behavior. The Knowledge, Attitude, and Practice (KAP) theory, frequently used in health education for HIV-infected individuals and men who have sex with men (MSMs), addresses this need. Establishing beliefs in individuals requires both knowledge and a strong sense of responsibility. Behavior changes positively only when knowledge transforms into belief. Given these circumstances, the objective of this study is to evaluate the current level of mpox KAP among HIV-infected individuals and identify potential influencing factors.

This cross-sectional study was conducted at the Beijing Ditan Hospital of Capital Medical University from July 18 to August 9, 2023, using convenience sampling through a combination of online and field surveys. The study included participants who were 18 years or older, without any gender restrictions, while those who had previously experienced mpox infection or participated in mpox-related programs were excluded. The field survey involved on-site data verification, while the online survey utilized the Questionnaire Star platform to implement logical jumps and limit responses to one per WeChat account, thus ensuring the questionnaire’s data quality.

The questionnaire surveyed sociodemographic characteristics, HIV infection status, and mpox KAP. The 25-question knowledge section, based on the study by Jairoun AA et al. (5), scored 1 point per correct answer, with ≥16 points (≥60% accuracy) indicating mpox awareness. The attitude section included 16 questions and utilized a 5-point Likert scale. Higher scores indicated a more favorable attitude, with 5 points for strongly agree and 1 point for strongly disagree (and vice versa for negative statements). The total attitude score ranged from 16 to 80. Participants scoring ≥48 points (representing more than 60% of the total score) were considered to have a positive attitude towards mpox. To obtain the standardized attitude score, the dimension score was divided by the number of dimension entries. The practice section consisted of 7 questions. The highest score for each question was 3 points, while the lowest score was 1 point. The total practice score ranged from 7 to 21. Participants scoring ≥17 points (representing more than 80% of the total score) were considered to have a positive practice towards mpox. A collinearity test was conducted on the independent variables (Supplementary Table S1). The mpox knowledge, attitude, practice, and KAP scores were converted into binary variables for binary logistic regression analysis.

Subject duplication was prevented by cross-verifying paper and electronic questionnaires using a unique identification code referred to as the ART (antiretroviral therapy) number. Statistical analysis was performed using SPSS software (web version 26.0; IBM, New York, USA) and RStudio software (version 4.2.1; R Foundation for Statistical Computing, Vienna, Austria). A significance level of P<0.05 (two-tailed) was employed to determine statistical significance. The Ethics Committee of Ditan Hospital granted approval.

A total of 1,235 individuals with HIV infection were included, with 486 from field surveys and 749 from online surveys. Among the participants, 48.3% (597/1,235) were aged between 35 and 55, 91.5% (1,130/1,235) were male, 61.5% (760/1,235) identified as homosexual, and 61.7% (762/1,235) reported a monthly income over 5,000 Chinese Yuan (CNY). The majority of participants had not received influenza vaccination (72.5%, 895/1,235), had not experienced other sexually transmitted diseases (85.9%, 1,061/1,235), and did not have any chronic diseases (68.9%, 851/1,235). In addition, most respondents reported being infected with HIV for more than 3 years (75.7%, 935/1,235), had a latest CD4 cell count greater than 500/mm³ (55.3%, 683/1,235), and had a latest viral load test result of less than 20 copies/mL (76.2%, 941/1,235) (Table 1).

The mean knowledge score for mpox was 14 (interquartile range: 8–18, range: 0–25), with an awareness rate of 46.0%. Out of the 25 questions, two had a correct answer rate of over 80% (Q1 and Q8), while the other three questions had a correct answer rate over 70% but not exceeding 80% (Q7, Q18, and Q19). The lowest correct answer rate was observed for the two questions related to “rash” (Q12 and Q20). The dimension of epidemiologic characteristics had a relatively high correct answer rate (mean: 62.8%), while the treatment dimension had a low correct answer rate (mean: 37.4%). Three questions in the treatment dimension had a correct answer rate of less than 30.0% (Q22, Q23, and Q24) (Supplementary Table S3). The results of the binary logistic regression analysis indicated that residing in an urban area, homosexual orientation, having a master’s degree or above, and having undetectable viral copies (<20 cps/mL) were all positively associated with knowledge of mpox (Figure 1).

Figure 1. 

Binary logistic regression analysis of Knowledge, Attitude, and Practice of mpox.

Abbreviation: OR=odds ratio; CI=confidence interval; KAP=Knowledge, Attitude, and Practice.

After accounting for standardization, the total score for mpox attitude was 3.81 (interquartile range: 3.50, 4.12). The barrier dimension had the lowest score, 3.25 (interquartile range: 2.50, 4.00) points (Supplementary Table S4). The results of the binary logistic regression analysis showed that having a master’s degree or higher education and not having any other sexually transmitted diseases (STDs) were positively associated with a favorable attitude towards mpox (Figure 1).

The score for mpox practice was 20 (interquartile range: 19, 21). Among the 1,235 individuals infected with HIV, a majority of them (87.3%, 1,078/1,235) sought medical advice upon experiencing unexplained lymphadenopathy and voluntarily disclosed recent exposure to mpox. Furthermore, 78.9% (975/1,235) of individuals expressed willingness to receive the mpox vaccine. With the exception of 27 individuals who had not initiated ART, the majority (87.0% 1,075/1,235) demonstrated good adherence to their daily ART medication. In the past six months, almost 30% (325/1,235) reported having two or more sexual partners, with 107 individuals engaging in male-to-male group sex. When experiencing mpox-related symptoms, the most common actions taken were seeking medical treatment at an infectious disease hospital (96.8%, 1,195/1,235), practicing home quarantine (30.8%, 380/1,235), and notifying the local CDC in their community of residence (29.4%, 363/1,235) (Table 2). The results of the binary logistic regression analysis indicated that not suffering from other STDs was a positive factor associated with the practice of mpox (Figure 1).

The total KAP score is calculated by summing the scores of mpox KAP. The score range is from 23 to 126, with the highest score being 124 points and the lowest score being 30 points. The majority of research subjects fall within the range of 90 to 106 points. Binary logistic regression analysis revealed that individuals below the age of 35, with homosexual orientation, holding a master’s degree or higher, and having undetectable viral copies (<20 cps/mL) were all positive factors associated with higher mpox KAP scores. The relationship between suffering from chronic diseases and mpox KAP remains uncertain (Figure 1).