Introduction

The Human Immunodeficiency Virus (HIV) continues to be a significant global public health challenge. In 2023, it was reported that approximately 630,000 people died from HIV-related illness worldwide [1]. This disease has a significant economic effect which includes direct medical costs, lost productivity, and public health expenditures. In fact, according to the joint United Nations Program on HIV/AIDS (UNAIDS), the annual global cost of HIV/AIDS is estimated to be over $30 billion [2]. Despite major advancements in treatment and prevention, HIV continues to be a major health challenge especially in low and middle-income countries (LMIC). A study published in 2023 revealed an increasing rate in HIV incidence, mortality, and disability-adjusted life years across the Middle East and North Africa (MENA) region [3]. In Tunisia, the adult HIV prevalence is estimated at 0.1%, with approximately 8,000 people living with the virus in 2022 [4].

Several factors are associated with challenges in HIV care, including limited health education, socioeconomic disparities, inadequate health literacy and persistent knowledge gap [5,6]. Stigma and discrimination against people living with HIV (PLHIV) particularly from healthcare providers continues to be a significant barrier discouraging individuals from seeking necessary care [7,8]. According to a qualitative study conducted in Tunisia [9], healthcare provider misconceptions about this disease are one of the major leading causes to stigmatization and thus hinder combatting the HIV epidemic. In fact, HIV discrimination manifests as reluctance to provide care to PLHIV and use of extra precautionary measures resulting in delayed diagnosis and poor treatment adherence [10]. Sexual education remains a taboo and HIV infection is wrongly seen as a divine punishment and a consequence of immoral behavior especially in MENA countries [11]. This knowledge gap fuels stigma both among the general population and healthcare professionals [12,13]. However, HIV stigma is still underexplored in developing countries compared to developed ones, particularly among healthcare workers. For instance, a 2021 study in Sana’a, Yemen revealed discriminatory attitudes among healthcare workers stemming from a lack of institutional policies against HIV stigma [14,15].

Hence, educating healthcare providers is crucial in assessing their knowledge gap and reducing stigmatizing practices. Several studies have shown that the impact of training healthcare professionals on HIV transmission, prevention and treatment can improve their attitudes and reduce stigma [16]. According to a recent study conducted among healthcare workers in Vietnam [17], focused education programs raised engagement in HIV care and decreased stigma. It highlights the importance of educational trainings in improving healthcare worker knowledge and attitudes toward PLHIV. Addressing this issue among medical students in the medical curriculum is fundamental for establishing a generation of future healthcare professionals who can provide equitable and compassionate care to PLHIV. Indeed, medical student attitudes and knowledge about HIV are shaped during their training, making this population a key target for interventions aimed at reducing stigma [18]. However, most research on HIV-related stigma was among practicing clinicians, with limited focus on medical students, particularly in LMICs. A recent study in Saudi Arabia assessed this gap, reporting misconceptions and poor HIV knowledge among medical students. Thus, it is important to establish educational interventions among pre-clinical medical students.

Furthermore, while educational interventions have shown significant effects in reducing stigma, the effectiveness of active learning methods remains underexplored in the context of HIV [19]. For instance, a thematic review revealed that the student-centered learning (SCL) method has the ability to foster deeper engagement, empathy and understanding by placing learners at the center of the educational process preparing them for professional challenges [20].

Given these data, the current study aimed to assess the impact of active training (workshops) on reducing stigma against PLHIV among fifth medical students in the Faculty of Medicine of Monastir (Tunisia) and to explore its related factors.

Method

Results

Sociodemographic characteristics and sexual practices of participants

A total of 216 medical students answered the questionnaire completely with a response rate of 43.2%. The mean age of participants was 23 years±0.84 with a majority of female (63%). Participant background demographics and practices are outlined in Table 1.

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Table 1. Sociodemographic characteristics and sexual practices among medical students.

https://doi.org/10.1371/journal.pone.0350810.t001

Pre-intervention HIV stigma among medical students and its related factors

The majority of participants presented good knowledge levels (88.4%). Table 2 presents the results of univariate analysis on variables influencing the total stigma score among medical students. In fact, individuals having good HIV knowledge, high parental educational level and those who were involved in associative activities, HIV units or screening campaigns exhibited lower stigma scores (Table 2).

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Table 2. Factors influencing the total stigma score among medical students: Univariate analysis.

https://doi.org/10.1371/journal.pone.0350810.t002

Prejudice related factors

Table 3 highlights variables influencing prejudice among dimension among medical students through univariate analysis. Having a high educational level of parents and being involved in associative activities, HIV units or screening campaigns were associated with lower prejudice scores (Table 3).

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Table 3. Factors influencing prejudice dimension among medical students: Univariate analysis.

https://doi.org/10.1371/journal.pone.0350810.t003

Multivariate linear regression showed that lower parental educational level and experiences of stigma or discrimination were independently associated with higher HIV prejudice scores (for more details, see Table 4).

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Table 4. Factors influencing prejudice among medical students: Multivariate linear regression analysis.

https://doi.org/10.1371/journal.pone.0350810.t004

Stereotype related factors

Table 5 shows variables influencing stereotype among medical students through univariate analysis.

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Table 5. Factors influencing stereotype among medical students: Univariate analysis.

https://doi.org/10.1371/journal.pone.0350810.t005

Impact of SCL method on HIV knowledge and stigma against PLHIV

Table 6 shows the score trends before and after the active workshops (knowledge, stigma, prejudice, stereotype and discrimination scores).

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Table 6. Impact of SCL method on HIV knowledge and stigma dimensions (N = 216).

https://doi.org/10.1371/journal.pone.0350810.t006

Regarding HIV knowledge, the overall score increased significantly from 15.57 ± 1.61 to 16.3 ± 1.5. A notable reduction was observed in the stigma score following the SCL method. In fact, the mean score significantly decreased from 60.56 ± 21.94 to 52.64 ± 22. Similar results were found for all stigma dimensions (Table 6).

Discussion

To our knowledge, our study is among the first in North Africa to focus on stigma among medical students against PLHIV and to assess the impact of the SCL method on both knowledge and stigma. In fact, we found that of all stigma dimensions, prejudice showed significant associations in multivariate analysis. Interestingly, poor parental educational level and being stigmatized were independently associated with higher prejudice scores. In addition, we found that the SCL method was effective in significantly improving HIV-related knowledge as well as in reducing stigma scores among medical students.

We found that the majority of participants were not involved in HIV related activities or screening campaigns (76.9%). This result is in contrast to findings in Hong Kong showing that 72.1% of final-year medical students were exposed to HIV patients during attachment to an HIV clinic in the late 2000s, compared with 39.3% in the mid-2010s [26]. The significantly lower exposure in Tunisia (23.1%) compared to Hong Kong likely stems from structural and institutional differences. Tunisian HIV care remains highly centralized in a few specialized units. Furthermore, pervasive socio-cultural stigma in Tunisia often necessitates a higher degree of patient anonymity, which, combined with strict confidentiality protocols, limits the integration of HIV-positive patients into general undergraduate clinical training. More broadly, in MENA countries, stigma, cultural taboos and lack of structured programs may contribute to the low involvement rates [11]. In our study, most medical students reported having an unreliable source of sexual knowledge (85.5%). However, studies in Iran and Greece reported greater use of reliable source [27]. This may be influenced by cultural and societal differences. In fact, in Tunisia, sexual health topics are still taboos leading younger individuals to seek false information elsewhere.

Among students who were sexually active in our sample, only 57.1% use condoms for protection. This contrasts with results among Mexican medical students in 2024, where a higher proportion of students reported condom use during vaginal intercourse (83.6% in men and 67.7% in women) [28]. However, condom use cannot be attributed only to the level of sexual health education. Indeed, other influencing factors such as partner preference, access to condoms, personal and cultural attitudes affect the use of this protective measure [29]. We found that only 2.3% of participants underwent STI screening. Similarly, in a 2023 study conducted in Warsaw, Poland, Only 21.43% of participants had ever been tested for HIV [30]. Several explanations could be cited such as low sexual encounters, fear of being stigmatized for testing and lack of HIV related knowledge [30]. In our cultural context, sexual health remains a sensitive topic, which may explain the very low STI screening rates and reliance on unreliable sources of information. These findings highlight the urgent need for broader, culturally appropriate sexual health education among medical students.

As for HIV knowledge, findings in our study showed a good knowledge level among 88.4% of medical students. In fact, in the Tunisian medical curriculum, students start learning about HIV and its impact early in their education. This is in accordance with results reported in Iran and in countries from both sub-Saharan Africa and North Africa [31,32]. Nevertheless, it remains essential to sustain efforts aimed at further enhancing HIV knowledge by screening the related factors and by developing targeted interventions in educational medical trainings. To the best of our knowledge, our study is the first to focus on stigmatizing attitudes towards PLHIV among medical students in Tunisia. As medical students play a key role in future care delivery, it is crucial to assess stigma and its related factors. Students with higher scores on HIV-related knowledge exhibit lower stigma rates. These results align with studies conducted in Yemen and Indonesia among healthcare professionals, where poor knowledge of HIV was linked to higher rates of stigma [14,33]. However, an Indonesian study suggested that physicians exhibited both the highest HIV knowledge and the highest levels of stigma [34]. Thus, combatting stigma requires interventions that transcend knowledge and highlight cultural beliefs and other factors influencing healthcare professionals’ attitudes. We found that female participants exhibit a higher stigma score compared to males. These results align with findings from an Iranian study [35] and contradicts with another study from the USA [36]. However, the gender difference observed in our study was not statistically significant and should therefore be interpreted with caution. In certain sociocultural contexts where discussions surrounding sexuality and HIV may be more socially constrained for women, gender-related norms could potentially influence attitudes. This hypothesis warrants further investigation in larger and more diverse samples. In our survey, students who were involved in associative activities, HIV units and screening campaigns exhibited a lower stigma score. Likewise, a study conducted in Jordan among medical students stated that pre-clinical students had a significantly more negative attitude towards PLHIV compared to their clinical counterparts [37]. Likewise, from a study carried out among students from Hong Kong, it was found that pupils who were not willing to provide care for PLHIV had less clinical experience with HIV patients [26]. We found that individuals untested for HIV tend to have a higher stigma score. These findings align with results from Indonesia [33]. One possible explanation is that during HIV testing and counseling, individuals might gain great HIV knowledge and undergo the emotional experience of diagnosis. Our study found no significant association between the reliability of the source and stigma rates. However, although the effect is weak, the media was found to be an enhancing factor for HIV knowledge and a reducing factor of HIV stigma in Iran [38]. The media is a powerful tool for combatting stigma against PLHIV when it is guided by accurate information about the disease. However, in many conservative societies, PLHIV continue to face negative representations in the media, reinforcing panic and misconceptions. Thus, it is urgent to implement media-based awareness and evidence-based education [39].

HIV prejudice refers to negative feelings, judgments, and attitudes towards PLHIV rooted in negative beliefs and often reinforced by fear of the disease [24]. We found that students with better HIV-related knowledge showed lower levels of prejudice. Similarly, dental healthcare providers in Pakistan with limited HIV-related knowledge tended to hold more negative attitudes towards HIV [40]. Participation in HIV-related workshops or screening campaigns was linked to a lower prejudice score in our sample. Likewise, trainings on HIV stigma and/or discrimination was associated with less negative attitudes in healthcare providers in Germany [41]. This highlights the importance of structured educational interventions for reducing prejudice among healthcare professionals. Beyond the univariate analysis, multivariate analysis of stigma dimensions revealed specific predictors of prejudice. Notably, previous personal experience of being stigmatized and poor parental educational level were independently associated with higher prejudice scores. Limited research has explored how an individual's own history of being stigmatized shapes their attitudes toward PLHIV. However, based on results reported in Zambia, healthcare professionals who did not stigmatize but witnessed stigmatizing attitudes among their coworkers, were more likely to hold critical and stigmatizing attitudes [42]. We did not find evidence of an association between the parental educational level of students and their attitude towards PLHIV. On the other hand, in Indonesia, belonging to the richest or rich economic group was associated with higher levels of stigma against PLHIV [43]. In contrast, a Ugandan study reported that wealthier individuals were less likely to endorse social distance and stigma against PLHIV [44]. These findings suggest that neither wealth nor parental education level predicts young people's attitudes. To the best of our knowledge, this is the first study to report associated factors with prejudice scores. Nonetheless, factors such as relationship dynamics, personal convictions, and social barriers must also be taken into account when evaluating attitudes toward HIV. Assessing related factors to HIV stigma into medical curriculum is needed to prepare future professionals into delivering compassionate and equitable care to PLHIV and to combat HIV disease [45].

Reducing stigma is essential to improving healthcare outcomes and care delivery especially among healthcare professionals [17,46]. Through the years, Depersonalization of patient cases and lack of diverse learning methods have limited student engagement and empathy. Traditional learning approaches often fail to nurture humanistic and relational skills. As a result, various learning methods have been used in different curricula and medical education such as problem-based learning, Case-based discussions, and flipped-classroom methods. Another innovative approaches involve Game-based learning, Team-based learning, Simulation-based learning, and peer teaching. They all embody the concept of SCL placing the learner at the core of the educational process [47]. It involves active participation where students engage in role-playing scenarios, open discussions and lectures. Students take on the roles of actors in various role-playing scenarios and are often placed in patient and doctor shoes [48]. Further, a range of educational interventions has been employed for HIV-stigma reduction [16]. Thus, we aimed to assess the impact and effectiveness of this method in enhancing HIV-related knowledge and reducing stigma among medical students. In our study, after the SCL approach, the overall HIV knowledge score significantly improved. A significant decline in HIV stigma scores was also noted and similar improvements were observed across all stigma dimensions. For instance, similar Tunisian data showed that both active participants and observers achieved significant gains in knowledge scores after a role-play simulation [49]. Similarly, a Tunisian study assessed the impact of the SCL among medical students in the faculty of medicine of Monastir. Significant improvement in hand hygiene and biomedical waste management after the SCL intervention [50].

Beyond its implication in general medical subjects, the SCL method has also been explored in our primary focus, enhancing HIV-related knowledge and reducing stigma against PLHIV. Given the HPASS scoring range, the observed 7.9-point decrease reflects a tangible reduction in stigmatizing attitudes, indicating that the intervention may have practical educational relevance in shaping future healthcare professionals’ perspectives toward PLHIV. For instance, a peer-led education intervention among secondary school students in Sudan showed a significant improvement in participant knowledge, attitudes and practices regarding HIV. This study highlights the effectiveness of SCL and peer-based approaches in promoting HIV awareness and reducing HIV stigma among medical students [51]. Similarly, a pilot study in the United States assessed the Facilitated Resilience and Equity through Stigma-reduction and Health workshop, a reduction of HIV-related stigma intervention among healthcare workers. During the workshop, participants interacted through discussions and role-playing. Findings showed a significant reduction in stigma and a significant HIV-related knowledge increase [52]. In addition, in China, a web-based game was developed to reduce HIV-related stigma. The game used participatory gamification and storytelling to immerse university students in the lives of PLHIV. This approach enhanced empathy-building, active learning through problem solving and reflection [53]. In addition, our study results align with a previous Indian study conducted among healthcare professionals [21]. The HIV-related stigma reduction workshops in Central India significantly impacted the knowledge and attitudes of healthcare providers and students. These results were assessed through a pre and post-test similar to our intervention.

To our knowledge, our study is the first globally and in the MENA region to simultaneously integrate the HIV-KQ-18 and the HPASS in a single research framework among medical students. HIV knowledge and stigma are critical issues in the MENA region, where persistent misconceptions, cultural taboos, and deeply rooted stigma continue to hinder efforts in HIV prevention and patient care. Addressing these challenges among medical students as future healthcare providers is an essential urgent step toward a long-term stigma-free environment and improved quality of life for PLHIV. It is essential to form medical graduates with a solid foundation in professional ethics, empathy, and a clear understanding of patient rights and confidentiality, ensuring they are prepared to deliver respectful and stigma-free care for patients. Uniquely, our study also incorporates a before-and-after intervention design, embedding active training and SCL modules within the medical education curriculum.

These results should be considered in light of the study limitations. First, it was a single-center study with a limited sample size. Since the study was conducted among medical students from one institute, findings cannot be generalized to broader populations of medical or healthcare students. Similar constraints were observed in a Vietnamese study among medical students who assessed HIV knowledge and stigma among a limited group of 200 medical students [54]. In addition, the Faculty of Medicine of Monastir operates within a specific educational, institutional, and sociocultural context that may influence students’ attitudes toward PLHIV. Tunisia is part of the MENA region, where HIV-related stigma is often shaped by religious norms, cultural perceptions surrounding sexuality, and societal attitudes toward key populations. These contextual factors may influence baseline stigma levels as well as responsiveness to educational interventions. Furthermore, variations in curriculum content, clinical exposure to PLHIV, and institutional culture across medical faculties may affect the transferability of our findings to other settings, both nationally and internationally. To enhance the generalizability and reliability of the findings, it is recommended to generalize our intervention to all healthcare institutes on a national scale for reliable results. Secondly, one important limitation of this study was the lack of future follow-up of the impact of the intervention. While the training aimed to reduce HIV stigmatizing attitudes among medical students, changes in practices among healthcare professionals were not evaluated. The current research did not conduct long-term follow-up surveys to verify the sustainability of the training, making it impossible to determine whether the training truly had a positive impact on the participant behavior against PLHIV. This gap between theoretical training and healthcare practices is highlighted in an Indian study, which emphasized the absence of stage-based follow-up to assess the effectiveness of the reduction workshops [21]. Future studies should integrate multiple follow-up stages for a deeper understanding of how knowledge and attitudes evolve and potentially translate into lasting behavioral change. Furthermore, because stigma was measured immediately after the intervention, we cannot determine whether the observed reduction reflects a sustained change in attitudes or a short-term response. Future research is planned to include longitudinal follow-up assessments at multiple time points to evaluate the durability of attitude change over time. Thirdly, in our study, the relatively low response rate (43.2%) may reflect potential bias, as some students may have chosen not to participate due to the sensitive nature of certain questions related to sexuality and religious or cultural norms.

Conclusion

Our findings underscore the urgent need to integrate continuous anti-stigma education into medical curricula through active learning approaches. Interventions must be introduced early in the medical curriculum and backed by strong institutional commitment. Moreover, such efforts must be sustained and extend beyond healthcare settings to target the general population fostering an informed and nondiscriminatory society. Within the healthcare environment and the general population, a graduated accountability system should be introduced to address stigma early on.

Supporting information

Acknowledgments

We would like to thank all the participants of the study.