Introduction

An estimated 38.4 million people are living with human immunodeficiency virus (HIV) globally, including 1.7 million children in 2021 (UNAIDS, 2021). Early diagnosis and therapy for HIV- positive individuals is crucial for survival and wellbeing (Poorolajal et al., 2016). HIV rates vary across geographical regions, and even though the global rates of HIV are declining, reports show that the rates are rising in the Middle East and North Africa (MENA) region (UNAIDS, 2021). Evidence suggests that the incidence of HIV in the MENA has doubled from 1990 to 2017 (Shakiba et al., 2021). The MENA region continues to be the only region with limited knowledge and prevention efforts (Abu-Raddad et al., 2010; Alomair et al., 2020a).

HIV/AIDS is the most recognized sexually transmitted infection amongst Arabs and Muslims, yet knowledge about HIV’s nature, mode of transmission, and prevention remains lacking (Aldhaleei & Bhagavathula, 2020; Alomair et al., 2020a). Socio-cultural and religious factors are well-documented barriers to HIV awareness and discussions in the MENA region (Abu-Raddad et al., 2013; Alomair et al., 2020a). Religious and cultural sensitivities towards sexual health topics act as deterrent to public health interventions from tackling the HIV epidemic in the MENA region (Abu-Raddad et al., 2013; Alomair et al., 2020a, 2021a). Socio-cultural and religious views influence Muslims’ perceptions for the need for HIV and other sexually transmitted infection prevention efforts (Alomair et al., 2020a, b). Many Muslims believe that religious practises provide sufficient protection against HIV and that it is non-existent in Muslim communities (Abu-Raddad et al., 2013). Several studies reported negative attitudes toward HIV/AIDS because of social-culture taboos, including viewing HIV/AIDS as a deserved punishment from God (Aldhaleei & Bhagavathula, 2020; Alomair et al., 2020a). Stigma and discrimination of people living with HIV have been reported across different settings and religions. The stigma stems from religious beliefs condemning behaviours that could lead to HIV (Reyes-Estrada et al., 2015). Evidence also suggests that religion has a dominant effect on healthcare professionals’ stigmatisation of people living with HIV (Reyes-Estrada et al., 2018; Zarei et al., 2019). This does not only act as a barrier to HIV prevention efforts, it also makes it challenging for people to seek diagnosis and treatment when needed (Chollier et al., 2016; Darlington & Hutson, 2017).

Digital media (e.g., the internet and social media) is considered one of the best tools for disseminating health messages, particularly sexual health messages (Bailey et al., 2015; Byron et al., 2013). The use of digital media for communicating sexual health information has great potential due to its popularity and reach (Bailey et al., 2015). Evidence suggests that digital media interventions of sex education have the potential to improve sexually transmitted infection awareness, increase intention, and behaviour of condom use and safe sex practises (Wadham et al., 2019). Social media provide people with discreet representation and profiles, which can affect how people acquire and react to sexual health-related content (Byron et al., 2013). Evidence suggests that Muslims prefer using the Internet to acquire sexual health information as it is easily accessible and offers privacy and anonymity (Alomair et al., 2021b; El-Tholoth et al., 2018).

Salamatak is an educational health programme produced by the Gulf Health Council (GHC) to promote health literacy and improve the wellbeing of the Gulf Cooperation Council (GCC) countries citizens. The GCC region is part of the MENA region and comprises Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates, with Islam as the predominant religion in the region. Countries in the GCC region share similar language and culture.

In December 2020, the programme aired an educational video about HIV/AIDS awareness in response to World AIDS day (GHC, 2020). The video showed methods of HIV prevention (i.e., condom use) and modes of transmission (i.e., extramarital relationships) in an open and transparent manner. The video was filmed in Kuwait, showing actors speaking Arabic with a Kuwaiti accent. The video shows a man receiving a phone call from the blood bank following his recent visit for blood donation, asking him to visit the bank to speak to him face to face. The man was visibly distressed following the phone call, as he assumed that they called him to inform him about an HIV diagnosis. The phone call was followed by a conversation with several of his friends, where he was asked whether he was “wearing anything” during his recent encounter with a female acquaintance. The “wearing anything” in the video is an implicit reference to condom use. Intercourse was not explicitly mentioned but was suggested in the actor’s conversation with his friends. The ambiguity and indirectness in discussing sex-related topics is common and customary in Arab/Muslim communities (Alomair et al., 2021b; Horanieh et al., 2020). The end of the video shows the man receiving acknowledgement for being a blood donor and the video concluded with the message “do not push your luck” in Arabic. Information on HIV/AIDS modes of transmission, HIV treatment, and that a person who is HIV positive can live a normal life were presented after the video. The media portrayal of condom use as a measure of HIV prevention is unprecedented in a conservative Muslim society such as the Gulf and Arab regions. The video received substantial attention and reactions from people from the GCC and beyond. Examining the public’s response in the Muslim and Arab world to sexual health content and messages is critical for addressing sexual health challenges in the region and developing future public health interventions.

Methods

This study was aimed at examine people’s perceptions and views of the HIV/AIDS awareness video. We performed a qualitative thematic analysis of comments posted on Salamatak video on three social media platforms (YouTube, Instagram, and Twitter). People from all over the GCC and beyond follow the GHC social media accounts. According to GHC reports in 2021 (Council, 2021), Twitter account followers were mostly males from different countries in the GCC including, Kuwait, Oman, and Saudi Arabia and aged between 18 and 44 years old. Followers of their Instagram account were from Bahrain, Kuwait, Oman, and Saudi Arabia and were mainly females with ages ranging from 25 to 44 years old. The diversity and number of followers of the GHC accounts reflect the population density of each GCC country and the nature of social media accounts.

Data Collection

We extracted all comments on the video on three social media platforms (YouTube, Instagram, and Twitter) from December 31st, 2020, to January 6th, 2021. We extracted the comments a week after publishing the video to allow changes in the views over time to be explored and captured. The lifespan of social media posts on most platforms does not exceed two days (Symonds, 2021). Nonetheless, we extracted one week’s worth of data to ensure capturing as much of the data as possible. We identified a total of 502 comments and extracted the data into an Excel file for data cleaning. We excluded duplicate comments or unrelated comments to the research aim from the analysis. The exclusion of unrelated tweets was conducted with discussions between the authors (SA and NA). After data cleaning, 486 comments were included in the analysis.

Data Analysis

We used thematic analysis of social media comments (Braun & Clarke, 2019). We exported comments into ATLAS.ti, a qualitative data management software program. The lead author (SA) independently coded all comments, and the second author (NA) double-coded a random sample of the comments. Discussions and amendments of the codes between researchers were done in an iterative and collaborative process where the initial coding frames were developed following an inductive approach. The researchers moved continuously between data familiarization, interpretation, and reporting to ensure a comprehensive interpretation and representation of the public’s responses. Some comments had multiple codes and contributed to several themes. After coding all data, we grouped and categorised codes based on thematic content, creating initial themes and developing the conceptual framework.

During all phases of the analysis, it was clear that the role of religion and culture overlap in GCC communities. As Beyers explained, religion may surpass as a cultural identity affecting how people view themselves and view others (Beyers, 2017). Beyers also suggests that in religious communities there is a need to conform to both religious ruling and cultural expectations to be accepted and valued (Beyers, 2017). Therefore, any deviation from religious and cultural norms are viewed as a threat, even if these divergences exist, acknowledging it is considered a moral hazard. The quotes presented in the findings were independently translated from Arabic to English by the authors (SA and NA) then jointly agreed on the final translation.

Ethical Considerations

There is a major concern when dealing with social media data as to whether the data is considered private or public data (Townsend & Wallace, 2016). Social media users share their comments in a public platform; therefore, it could be considered “public data” (Townsend & Wallace, 2016). Nonetheless, for ethical reasons, any identifiable information about people commenting on the video (e.g., usernames) was not published. Quotes used in this paper were translated from Arabic to English, making it difficult to retrieve their source. Direct messages or comments from private accounts were not included in this study. This study was reviewed and approved by King Saud University Human Research Ethics Committee (approval number: KSU-HE-21–151).

Results

A total of 486 comments were included in the analysis. The majority of comments were from Twitter (n = 305 comments), followed by Instagram (n = 122 comments) and YouTube (n = 59 comments). Overall, about half of the comments were positive and supported raising awareness about HIV/AIDS in the GCC region.

Initially, the majority of comments were against the video, with people demanding removing the video from all social media platforms. However, following the initial backlash to the video, positive comments started emerging, defending the video, and emphasising the need for it.

Several themes emerged from the data including the need for HIV/AIDS awareness, where is the moral message, the target audience for HIV/AIDS prevention, strategies for raising HIV/AIDS awareness, and views on people living with HIV/AIDS. Throughout the comments, it was observed that people referred to HIV as AIDS and HIV was rarely acknowledged as a term.

Throughout the results, Zina or Zinah is referred to an Islamic legal term referring to unlawful sexual intercourse. According to traditional jurisprudence, Zina can include adultery (of married parties) or fornication (of unmarried parties).

The Need for HIV/AIDS Awareness

The commenters’ views on raising the public’s awareness were divided into two opposing approaches. The first group accepts and promotes a harm reduction approach (e.g., safe sex and condom use) irrespective of personal religious views and social norms.

“The video is extremely informative and shows strong messages. I suggest the next video you show ‘how to be a realistic person away from idealism’ so that people in the comments can realise the idea behind the video.” (Twitter, Unknown)

“To be honest, the concept of the video is excellent; however, the terminology used, and some of the dialogues are extremely inappropriate, but it could be helpful for the sake of raising awareness. Hopefully, it won’t backfire.” (Twitter, Kuwait)

The second group believed that awareness in GCC communities should be respectful of Islamic values and social norms, focusing on promoting abstinence only and using religious messages. HIV/AIDS was perceived as uncommon in GCC countries, and therefore, education was deemed unnecessary.

“The priority of the video should be focused on advising against Zina!! And since when is this normal in the Kuwaiti society? You neglected the most important and prevalent topics, such as diabetes and hypertension, and focused on this thing [HIV/AIDS] that is not common in our society at all!! A blatant insult to the country of Kuwait and its people, please remove it [the video]!” (Twitter, Kuwait)

“There are a million ways to raise awareness… This is not boldness, its “filth”.. This is not funny at all... Zina is a major sin and a huge deal that should not be taken lightly. If you do not know how to raise awareness, do not make a campaign in the first place.” (Instagram, Kuwait)

The rejection of promoting a harm reduction approach stems from the belief that it is accepting the existence of extramarital sex. Acknowledging the existence of extramarital sex in GCC communities was viewed as disrespecting the Islamic ruling forbidding extramarital sex and distorting society’s image.

“What you portrayed about our society is that we live in a rotten swamp, we [Muslim society] are above those ideals and portrayal.” (Instagram, Kuwait)

“A damaging video that is an insult to the Gulf and the fact that the person is talking in a Kuwaiti accent gives a very bad image about Kuwait, like it is full of moral corruption.” (Twitter, Kuwait)

Treatment of HIV (i.e., antiretroviral therapy) is not commonly known, and therefore, it is not known that people living with HIV could live a normal healthy life, have sexual partners, and have children. Some of the comments were against raising awareness of the availability of treatment as it would normalise HIV and simplify the infection, and it was perceived as making people less fearful of the consequences of extramarital sex.

“Oh wow. So, you are basically saying it’s all normal and simple, even if you get the infection, there is a solution. So do whatever you want, whether it was Halal [permissible] or Haram [forbidden], it’s just one pill a day!!!!!!” (Instagram, Kuwait)

Where Is the Moral Message?

One of the main messages in the video focused on promoting safe sex and condom use, particularly in the context of extramarital sex. This goes against the Islamic religious belief forbidding any sexual practises outside of marriage. Many comments highlighted the importance of religious morals for HIV/AIDS prevention. Following the Islamic ruling of abstinence until marriage was viewed as the only acceptable way to protect against HIV/AIDS. Social norms and beliefs were also viewed as protective against HIV/AIDS. Fear of God and God’s punishment were emphasised as important messages in Muslim communities.

“Where is the moral message and fear of God and God’s punishment for people who do such horrible acts without shame, it is like you are saying commit Haram [forbidden] actions but be careful. Our youth are better than this… Focus on fear of God.” (Twitter, Saudi Arabia)

“Awareness should be focusing on the fact that this is forbidden and goes against our Sharia [Islamic] law, and the fact that the punishment in the afterlife is going to be worse. Promoting condom use is like teaching them the satanic ways.” (Twitter, Saudi Arabia)

Commenters explained that the video is not suitable for Muslim communities as it implicitly normalises and acknowledges the existence of extramarital sex. Although many commenters confirmed that some people engage in extramarital sex in Muslim communities, they explained that they are a minority and outliers that do not represent their community.

“This person [the man in the video] should be stoned to death. Don’t make light of this [extramarital sex]. It might be happening, but it is not common among us.” (YouTube, Unknown)

“Unfortunately, the video might benefit non-Muslims but since we are Muslims and the video is presented to the Arab Islamic regions this goes against our religious values and not beneficial to us at all.” (YouTube, Unknown)

Other commenters praised the content of the video and defended its messages. They believed that extramarital sex exists in GCC communities and advocated for the need for HIV/AIDS awareness. Commenters mentioned that “we need” to accept that sex outside of marriage exists, as denying it is naïve and dangerous. They emphasised that the denial could lead to severe consequences to the community (i.e., the spread of sexually transmitted infections).

“Dear all, let’s not kid ourselves, extramarital sex exists since prophet Mohammad’s time, if someone wants to commit wrongdoings, they will do it. Public health has nothing to do with religion, let’s leave this [religious advice] to religious scholars.” (Twitter, Unknown)

“Ughhh The reactions to the video are frustrating … We are a community who like to bury their heads in the sand. Do you genuinely believe that they don’t know it’s [extramarital sex] forbidden? They either don’t care or can’t control themselves. We’ve been raised with religious messages since we were six years old, it doesn’t work. Harm reduction is achieved by raising health awareness.” (Twitter, Kuwait)

Commenters in support of the video discussed the role of health organisations in promoting protective behaviours, emphasising that health awareness should be separated from religion. Using religious and moral advice in sex education was believed to be insufficient.

“To those who say where is the religious aspect of the video, why are you attacking a medical account about not involving religion. It is a medical account; it’s only natural for them to focus on medical advice. Not religious advice. We have been fed scary messages about AIDS forever now. It doesn’t work.” (Twitter, Unknown)

“You [people who are against the video] are living in different planet or what? Most guys who travel to Bahrain and Emirates will commit Zina they don’t think with their brains. So since they will do it anyways just tell them to wear condom because if you tell them it’s Haram [forbidden] it will not affect them. You just give them the advice [condom use] and hope that God will lead them to the right path eventually.” (YouTube, Unknown)

Nonetheless, some supporters of the video commented that adding a religious element is necessary. Using a verse from the Quran or Hadith was believed to strengthen the message and increase its acceptability.

“I wish they just briefly mentioned the religious aspect when dealing with such issues [Sexually transmitted infections prevention], because it is the foundation and salvation on this earth and the thereafter.” (YouTube)

“Excellent video... but they neglected the religious part.” (Twitter, Kuwait)

The Target Audience for HIV/AIDS Prevention

The content of education depended on how commenters perceived the target group’s religiosity. Religious views forbidding extramarital sex were viewed to be irrelevant to the target audience. Commenters believed that people more likely to engage in extramarital sex are less likely to be religious and therefore would not be influenced by religious messages.

“Not everyone is deterred by religion, and the message in video is focused on providing medical advice. Because people who engage in such actions [extramarital sex] would not care about religion.” (Instagram, Unknown)

Some commenters viewed the target group as “sinners” and a minority undeserving of health advice or awareness. They explained that the target group are uninfluenced by religious values or social norms. Some commenters believed that those who engage in extramarital sex do not deserve health messages tailored to their lifestyle and needs.

“A person living in a Muslim country like Kuwait, and is not deterred by religion or morals, or social responsibility... This person does not deserve dedicating a message particularly for his needs because this might lead others to take these actions [extramarital sex] lightly and commit it. Who do you think is more deserving of your advice and efforts? Those who are drowning in sins or others who have not done anything yet.” (Instagram, Kuwait)

Some comments were more tolerant of people that do not follow religious advice and explained that if God forgives sinners, we should do the same and accept them and provide them with the tools to protect themselves.

“Muslims make mistakes, even Adam and Eve were seduced by Satan, God is merciful and forgives all those who repent for their sins, even Zina. Who are we to judge?” (YouTube, Unknown)

The gender discrimination and the social expectations in relation to virginity until marriage (i.e., premarital sex) were observed in the comments. It is more acceptable for men to have extramarital sex compared to women.

“Just imagine if it was a woman in the video. Would her actions be justified like if it was a man? For men this is normal and realistic. However, if it was a woman there will be outrage and the video will be removed, and its possession will be illegal.” (Twitter, Kuwait)

Promoting Condom Use

Promoting the use of condoms for HIV/AIDS prevention was perceived as encouraging extramarital sex, which was viewed as inappropriate for a Muslim community, and official organisations should not advocate such messages.

“The suggestion to wear condoms while committing Zina??!!! I can’t wrap my head around it. So, you are basically saying do this [extramarital sex] but don’t forget to wear condoms, instead of saying you should avoid forbidden relations, which is not just any sin, but a major sin.” (Twitter, Saudi Arabia)

“​​I was okay with the video up until you said use condoms. We are Muslims and this message should not come from any official organisation. I am not okay with you conveying it’s okay to have extramarital sex just remember to wear a condom.” (Instagram, Kuwait)

Although commenters stated that condom use promotes safe sexual practises and reduces sexually transmitted infections. Some commenters who held the same beliefs still viewed these messages as inappropriate and unacceptable.

“Sadly, I felt like the video is making light of major sins by suggesting prevention strategies to help individuals who want to do this [extramarital sex].” (YouTube, Saudi Arabia)

There was a debate in the comments on whether promoting condom use for sexually transmitted infection prevention is necessary. One commenter believed that education on safe sex provides people with the tools and gives them the green light to engage in extramarital sex.

“Commenter 1: An unfortunate video that does not go with our values and morals in the Gulf and Arab communities and carries a lot of wrong messages. Protection is achieved through following God's path, avoiding sins, and staying away from the company of corrupt people, and nothing else. (Bahrain)

Commenter 2: But this does not mean that this segment of the population does not exist… the least we can do if we can’t influence them with religion is protect their health. Even if he commits sins, he is still a Muslim in need of medical advice. The video is good because it gives prevention strategies. Policing people’s morals and sins is not the responsibility of the ministry of health. (Kuwait)

Commenter 1: With all due respect, this is a twisted logic. Based on your logic, you think they should also educate drug addicts on how to inject heroin safely??!(Bahrain)” (Twitter)

Strategies for Raising HIV/AIDS Awareness

Views on raising public’s awareness and content of education were discussed in the comments. Some people suggested that HIV/AIDS awareness is the responsibility of healthcare professionals, with emphasis on private, one-to-one education/counselling based on individual risk.

“No waaaaay, wear condoms?? The doctor should explain this to him individually. There is no need for the public to be involved.” (Instagram, Kuwait)

“As other comments have mentioned, these topics are inappropriate to be displayed so publicly. That’s just my opinion.” (YouTube, Saudi Arabia)

The public’s outrage towards using social media to promote condom use was due to children and adolescents’ access to it. Subjecting “minors” to such content was believed to be opening their eyes and harming their innocence. Nonetheless, some argued that younger generations are in need of this form of awareness, especially since there is no formal sex education in GCC communities.

“An extremely inappropriate video coercing viewers and minors into being subjected to a multitude of disgusting and corrupt ideas. Lawyers in Kuwait please do your job and sue them!” (YouTube, Unknown)

“An informative and lovely video. We need something like this from time to time to educate people especially younger generations, because they are ignorant in these topics.” (Twitter, Kuwait)

“People against this informative Ad rather keep their kids in a strict bubble than to be aware and careful in case they do f*** around.” (Twitter, United Arab Emirates)

Many emphasised that HIV/AIDS awareness content should be tailored to meet Muslim culture standards. Adopting HIV/AIDS awareness programmes implemented in the west was viewed as problematic and not reflective of Muslim cultures, thus unrelatable. The need for a culturally sensitive “tailored” HIV/AIDS awareness programmes was highlighted.

“It’s a huge problem when we copy the west in our videos.” (Twitter, Saudi Arabia)

“And then people will say that such content goes against our values and traditions, even though these issues exist in our Arab communities. Denying the problem and hiding it under the pretence of your outdated ideologies does not solve the problem, instead it will exacerbate it.” (Twitter, Kuwait)

Creating bold messages was viewed as a definite way to get people’s attention, whether it be positive or negative attention. Even if met with initial resistance, it was believed that people still needed to see/hear it. Comments highlighted that raising awareness of sensitive topics, although uncomfortable, is needed to promote protective health behaviour.

“I appreciate your boldness and transparency. A realistic content far from hypocrisy and blind denial, like we are living in a perfect society without any issues or diseases. Thank you!! We hope you create more of these bold messages. Well done.” (Twitter, Kuwait)

“What is wrong is withholding information and not this video. So, its okay for kids to learn from the streets but not a credible source?” (Twitter, Saudi Arabia)

HIV/AIDS awareness messages need to be clear, smart, transparent, and reflecting reality as focusing on promoting abstinence was viewed as idealistic and unrealistic.

“One of the best videos I’ve seen recently. Very realistic. The dialog and the scenes were very smart and well thought of…. Viewing the issues from a contemporary angle instead of saying that does not represent us, I say thank you for this unapologetically transparent accomplishment.” (Twitter, Kuwait)

“An excellent video that will deliver the message to the youth who are not aware of consequences. Claiming perfectionism will not protect anyone.” (Twitter, Kuwait)

Views on People Living with HIV

HIV/AIDS was linked with “immoral” and forbidden behaviours. Many comments showed negative views towards people living with HIV. It was believed that people living with HIV deserved having it for their “sinful behaviours.” Some commenters viewed HIV diagnosis as a punishment for straying from “God’s path.”

“AIDS is the least possible punishment they deserve for committing Zina, may God protect us all.” (Twitter, Saudi Arabia)

“A video dedicated to the lowest of the low humans, don’t inform them, let them all get the disease and go extinct.” (Twitter, Unknown)

There was an apparent stigma towards people living with HIV/AIDS. It was stated that people living with HIV/AIDS should not live a normal life, be allowed to get married and procreate, and be isolated from the community.

“And who thinks that he could get married when he has AIDS??! No one will accept marrying him except someone with even worse morals.” (Twitter, Kuwait)

Stigma towards people living with HIV was frightening and isolating for people living with it. One commenter who is living with HIV explained concealing their diagnosis out of fear of being ostracised from the community.

“The most difficult feeling is that you are living in secret, no one knows that you have the disease, not even your family.” (Twitter, Kuwait)

One of the suggestions for reducing stigma and discrimination against people living with HIV/AIDS is through raising awareness. Misconceptions regarding HIV nature and modes of transmission contribute to the fear of people living with HIV/AIDS and stigma attached to it. It is a common perception that HIV/AIDS is a fatal incurable illness, which is one of the reasons for fearing people living with HIV/AIDS.

“An excellent video! We need this kind of awareness in our community. The rejection of people with HIV must end and the myths on modes of transmission only contributes to the discrimination and harm patients [people living with HIV] go through in our community.” (Twitter, Kuwait)

Raising the public’s awareness was believed to be one of the tools to advocate for the rights of people living with HIV in GCC countries. Although many people were against raising awareness on HIV treatment, some commentors viewed it as a way of helping people living with HIV cope with their diagnosis and improve “their outlook on life.”

In response to a negative comment: “Please dear educate yourself and read about treatment before writing such hurtful comments. How can you say who is going to marry someone with HIV except someone with even worse morals??! You say that like they are nobodies and undeserving humans!! The least you can do is grace us with your silence if you have nothing nice to say.” (Twitter, Kuwait)

“Just because you want to warn people from having extramarital sex doesn’t mean you have to plant fear and depression for people with the infection, making them feel like their diagnosis is life ending.” (Instagram, Unknown)

Another important determinant of people’s perceptions towards people living with HIV is the mode of transmission. There was an emphasis on raising awareness of other routes of transmission (i.e., blood transmission and mother-to-child). This reflects a belief that HIV stigma is dependent and justified based on the actions that led to the infection (i.e., injecting drug use and extramarital sex).

“Please people know that it is not just transmitted from Zina, I got it from unlicensed Hijama [cupping].” (Twitter, Kuwait)

“Excellent and realistic video. Let’s not kid ourselves, however AIDS is not necessarily transmitted through sexual contact, but the person who got it from other sources could unknowingly transmit it to his wife [through sexual contact].” (Twitter, Unknown)

Discussion

In this study, we explored people’s perceptions and views of the HIV/AIDS awareness video. Public responses to HIV/AIDS awareness content varied depending on perceived commonality of HIV and religiosity in the GCC community. Some comments were against the video and public outrage towards the content of the video was prevailing. The absence of the moral message and lack of cultural sensitivity were the main reason for this response. However, some comments were supporting of a harm reduction approach, emphasising that the promotion of abstinence only is unrealistic and ineffective for HIV prevention. It was also apparent from the public’s response to the video that stigma and discrimination against people living with HIV/AIDS are common in the community.

HIV/AIDS is strongly linked with forbidden, illegal, and socially unacceptable practises in the MENA region (McFarland et al., 2010). In many Muslim countries, any form of extramarital sex and homosexuality is a prohibited sin that is punishable by law (McFarland et al., 2010). This is the main reason for the stigma against HIV and people living with HIV/AIDS (Alomair et al., 2020a). Some Muslims believe that people with HIV/AIDS should be punished, isolated from the community, with some reports of people advocating for the killing of people with HIV (Alomair et al., 2020a). Many countries in the MENA region do not consider HIV/AIDS epidemic as a threat due to the belief of religious practises providing “moral prophylaxis” (Abu-Raddad et al., 2013; Kamarulzaman & Saifuddeen, 2010). This denial may act as a deterrent to any public health efforts tackling the spread of HIV in the MENA region. The assumption that Muslims are not at risk of HIV is unrealistic as many Muslims are engaging in extramarital sex (Alsubaie, 2019; Raheel et al., 2013). This denial means that Muslims are lacking essential knowledge on safe sex practises and sexually transmitted infections’ prevention and mode of transmission (Alomair et al., 2020a). This lack of knowledge and misinformation also contribute to the stigma and discrimination towards HIV/AIDS and people living with HIV (Alomair et al., 2020a). Public health efforts are needed to improve the public’s sexual health knowledge and practises.

Public responses to HIV/AIDS content highlight the need for public health interventions sensitive to religious beliefs and social norms. To gain community’s acceptance, public health efforts should not copy educational content adopted in Western countries. Muslims believe modernity experienced in the MENA region should not be viewed as synonymous with Westernisation (Horanieh et al., 2020). There is a need to provide programmes drawn from scientific evidence as well as religious doctrine (Horanieh et al., 2020). Although the co-existence of sexual health content and religion can be challenging (Horanieh et al., 2020), many Islamic jurisprudences support knowledge of any form, prevention, and the preservation of human life. All of which could be used to justify and facilitate the provision of sex education in the MENA and Muslim communities.

The stigma towards people living with HIV reported in this study is not unique to Muslim societies. Stigma towards people living with HIV stems from religiously prohibited behaviours that could lead to the infection which are common in many religions, such as extramarital sex, same sex relationships, drug use, and sex work (Idler, 2014). It is important to note that although religiosity may act as a factor contributing to stigma and discrimination, evidence suggests that many people living with HIV use religion and spirituality as a means to cope with the diagnosis and improve mental health outcomes (Himelhoch & Njie-Carr, 2016; Pinho et al., 2017). This points towards the value of religion in promoting preventive measures and access to diagnostic and treatment services and long-term positive management of HIV. To achieve this, stigma reduction intervention could reframe the role of religion in public health. It has been suggested that involving religious leaders in stigma reduction intervention and providing such interventions in faith-based settings (e.g., churches and mosques) may facilitate the success of these interventions in improving sympathy and reducing stigma towards people living with HIV (Bradley et al., 2018; Payne-Foster et al., 2018).

The rejection of harm reduction approaches, such as the promotion of condom use, has been reported across different cultures and religions. For example, Christian leaders condemned the promotion of condom use as a measure of sexually transmitted infections prevention as it was believed to be encouraging sin, marital infidelity, and undermining the religious messages of abstinence until marriage (Rankin et al., 2008). The negative connotation of condom use is a global issue and has been linked with promiscuity in many different cultures and religions, regardless of its existence and legality (Alomair, 2022; D’Souza et al., 2022).

In most religions, human life and health are a priority and must be protected at all costs (Kamarulzaman & Saifuddeen, 2010). The provision of harm reduction policies and interventions in religious communities are ethically imperative and are proven to be globally cost-effective (Wilson et al., 2015). Although similarities in accepting harm reduction exist across different religions, combining policies with religious standpoints is more prominent in GCC countries, as well as many Muslim countries. Religious rulings and beliefs influence not only health policies and interventions but also the process in which these policies are implemented (Barmania & Aljunid, 2016).

Our results show that HIV prevention programmes in the MENA region require adopting a comprehensive approach. There is a need to improve political commitments to the de-stigmatisation of HIV/AIDS through establishing regulations that advocate for the rights of people living with HIV. It is critical to offer funding for public health research and interventions as well as improve the surveillance and reporting of HIV/AIDS in the region (Bashir et al., 2019). Research efforts need to be directed towards understanding the unique needs of Muslims and perceptions towards establishing sex education in the MENA region.

This study offers unique findings due to the chosen sample and methodology. This is the first study, to our knowledge, to explore the public’s responses to HIV/AIDS awareness content in the GCC in a neutral environment. Analysing comments posted online is believed to reduce social desirability bias, as these comments represent the honest views of the commenters. We have included all comments posted in response to the video in three different social media platforms, therefore capturing the views of people from different countries in the GCC and beyond.

Due to the nature of social media platforms, we do not have detailed demographic information about the commenters. The anonymous nature of social media makes it more likely for people to find adverse or negative comments, which may lead to over representation of negative views that may not be reflective of the views of Muslims. Additionally, comments on social media are by nature brief and may lack the depth, nuance, or complexity of other narrative forms. The lack of context can make it difficult for in-depth exploration of the meaning behind the comments. Additionally, the written nature of the data could lead to misinterpretation (Cavazos-Rehg et al., 2016). However, continuous meetings and discussions were conducted amongst researchers to explore and resolve uncertainties in the data. To maximise validity, we have included as many quotes as possible from the extracted data to improve trustworthiness and enhance the reader’s interpretation (Green & Thorogood, 2018).

Conclusions

It is suggested from our results that stigma and discrimination against people living with HIV are common in the GCC countries. Special care should be taken in planning and developing future interventions and awareness campaigns focusing on sexual health in GCC and Muslim communities. Religiously and culturally sensitive content is lacking in the region, and the need for tailored intervention was highlighted in our findings. Collaborative efforts between policymakers, public health practitioners, opinion makers, and researchers are needed to tackle the HIV epidemic and destigmatize people living with HIV in the region.