HIV knowledge,risk perception and pre-exposure prophylaxis interest among Thai university students

Abstract

To assess HIV risk perception and pre-exposure prophylaxis (PrEP) interest among university students, an anonymous survey was conducted among students from a large public university in Thailand. There were 641 participants; 118 (18%) were categorised into moderate or high-risk group. Of these 118 participants, 111 (94%) perceived themselves as no or low risk. Despite high levels of knowledge about HIV transmission risks, rates of consistent condom use with vaginal, oral and anal sex were all low (43%, 18% and 33%, respectively). The low rates of consistent condom use were significantly associated with false perception of low HIV risk (P < 0.05). Independent factors associated with the false perception were male gender (P < 0.001), living with a domestic partner (P = 0.004), being homosexual or bisexual (P = 0.02) and being students from a non-medicine faculty (P = 0.04). Of the 641 participants, 211 (33%) were not interested in PrEP. Consistent condom use with oral sex (P = 0.004), consistent condom use with vaginal sex (P = 0.04) and being heterosexual (P = 0.02) were independently associated with no PrEP interest. Our study suggests the need for enhanced interventions to improve HIV risk perception and safe sex practices among the university students.

Keywords

Human immunodeficiency virus HIV AIDS PrEP risk perception pre-exposure prophylaxis interest university students Thailand

Introduction

The incidences of HIV infection have remained stable at about 10,000–12,000 cases per year despite several campaigns and efforts to reduce HIV transmission in Thailand.¹ One of the possible causes of the ongoing transmission is false perception of low HIV risk despite high-risk behaviours among the population. This false perception may lead to no interest in preventive strategies and persistent high-risk behaviours.^2,3 However, data on HIV risk perception among Thai population are currently limited.⁴

Condom use has been the most widely available preventive strategy. Nonetheless, the rates of consistent condom use were reported to be only 4–60% among Thai men and 45% among persons aged 17–20 in northern Thailand.^5,6 In addition, the association between HIV risk perception and consistent condom use has not been previously investigated. Pre-exposure prophylaxis (PrEP) is the newer strategy that uses antiretroviral agents to prevent HIV infection in HIV-negative persons. The protective effects of PrEP have been demonstrated to be 39–75% in previous studies.^7–11 The efficacy of PrEP has been reported to be higher among persons with higher rates of PrEP adherence.^7–9 This benefit suggests that PrEP may be another effective preventive strategy in HIV-prevalence settings. However, PrEP is considered new and is not widely recommended in Thailand. Assessment of PrEP interest is required before widespread implementation in the country.

A report from the Bureau of Epidemiology, Ministry of Public Health of Thailand indicates that the age groups of the Thai population with the highest prevalence of AIDS were 30–34 years (24.97%) followed by 25–29 years (21.73%) in 2011.¹² Given that the diagnosis of HIV infection may occur 5–15 years after the time of HIV acquisition, the population groups with the highest rates of HIV acquisition would be persons in late adolescence and early adulthood age. University students are amongst populations in late adolescence and early adulthood age which should be the targets for assessing risk perception and use of HIV preventive strategies. The aims of this study were to (1) assess HIV risk perception, (2) identify risk factors associated with false perception of low HIV risk and PrEP interest, and (3) assess PrEP interest and the potential impact of PrEP use on risk behaviours among Thai university students.

Methods

Study population and setting

The study was conducted among Thai students from six different faculties including Science, Engineering, Medicine, Medical Technology, Journalism and Mass Communication, and Laws from a large public university during the period from 1 January to 30 September 2013. The reason for selection of these six faculties was to have a sample representative of all university students from major faculties in medical science, science and social science fields. This study was approved by the Faculty of Medicine, Thammasat University Ethics Committee.

Study protocol

An anonymous survey was conducted among convenient samples of students in each faculty. The research team approached the students and obtained their consent for participation. The survey instrument was reviewed for its validity by experts in HIV medicine and social and behavioural sciences prior to administration. The HIV risk categorisation tool used in this study has been validated in previous studies (Table 1).^2,13 Risk characteristics of survey participants and their sexual partners assessed in the survey included number of different or new sexual partners in the previous 30 days; history of sexual intercourse including vaginal sex, oral sex and anal sex in the lifetime; condom use practices for vaginal, oral and anal sex in the lifetime; use of drugs or alcohol with sex within 30 days; history of injection drug use in the lifetime; exchanging sex for drugs or money in the lifetime; having STIs within the past year, and history of being incarcerated in the lifetime.^2,13 Participants completed the survey form on their own in a private room and returned it in the blinded collecting box.

Table 1.

Human immunodeficiency virus (HIV) risk stratification according to the pre-specified reported characteristics and behaviours of the survey participants and their partners.

Characteristics and behaviours	HIV risk
Characteristics and behaviours	Low	Moderate	High
Number of different sexual partners in the previous 30 days
0–1	√
2–3		√
>3			√
Number of new sexual partners in the previous 30 days
0–1	√
2–3		√
>3			√
Using condom with vaginal sex^a
Always	√
Most of the time	√
About a half of time		√
Sometimes			√
Never			√
Using condom with oral sex^a
Always	√
Most of the time	√
About a half of time		√
Sometimes		√
Never		√
Using condom with anal sex^a
Always	√
Most of the time	√
About a half of time		√
Sometimes			√
Never			√
Exchanging sex for money or drugs^a
No	√
Yes			√
Drinking alcohol with sex within 30 days
Never	√
Sometimes		√
About a half of time			√
Most of the time			√
Always			√
Using drug with sex within 30 days
Never	√
Sometimes		√
About a half of time			√
Most of the time			√
Always			√
Ever injected drug with needles
No	√
Yes			√
Ever shared needle to inject drugs
Never	√
Sometimes			√
About a half of time			√
Most of the time			√
Always			√
Ever been in a jail or a prison
No	√
Yes			√
History of STIs within the past year
No	√
Yes			√
Sexual partner had STIs within the past year
No	√
Yes			√
Sexual partner had exchanged sex for money or drugs within 30 days
No	√
Yes			√
Sexual partner had used drug within 30 days
No	√
Yes			√

Sexual partner had ever been in a jail or a prison
No	√
Yes			√

STIs: sexually transmitted infections.

In the lifetime.

Study definitions

Participants self-identified their HIV risk perception within the survey. To identify their own HIV risks, the participants chose ‘No risk at all’, ‘A little risk (low risk)’, ‘More than a little (moderate risk)’ and ‘A lot of risk (high risk)’. The investigators subsequently evaluated the participants’ risk as ‘low risk’, ‘moderate risk’ and ‘high risk’ based on the pre-specified risk characteristics reported in the survey (Table 1). Only one characteristic or behaviour that met the certain risk level was required to classify the participants into that risk level. The participants were categorised into the highest risk level if their characteristics met several risk levels. The moderate or high-risk participants were classified to have false perception of low HIV risk if they perceived their risks as no or low risk. Pre-exposure prophylaxis was described in the survey as an oral antiretroviral pill taken regularly to prevent HIV infection in HIV-negative persons. The participants who stated in the survey form that they would not take PrEP were classified into ‘no PrEP interest’ group.

Statistical analyses

To detect a 15% difference in rates of false perception of low HIV risk between heterosexual participants and homosexual/bisexual participants² with 80% power and an alpha of .05, a sample size of 500 participants was needed. Since we anticipated that 15% of the returned survey forms were incomplete and would be excluded, the required total sample size would be 600 or 100 from each of the six faculties. All statistical analyses were performed using SPSS version 15.0 (SPSS, Chicago, IL, USA). Categorical variables were compared using Pearson’s χ² or Fisher’s exact test as appropriate. Continuous variables were compared using Mann–Whitney U test. All p-values were two-tailed; p < .05 was considered statistically significant. Variables that were present at a significance level of p < .20 in univariate analysis or had prior significance for false perception of low HIV risk (age, sex and sexual orientation)^3,14,15 and no PrEP interest (low risk perception)¹⁶ were entered into logistic regression models. These variables were subsequently removed from the models in backward stepwise fashion if their p-values were > 0.05 until the final model had reached. Adjusted odd ratios (aORs) and 95% confidence intervals (CIs) were determined for factors associated with false perception of low HIV risk and no PrEP interest.

Results

Of the 872 students approached, 698 (80%) agreed to participate in this survey study. Fifty-seven participants (8%) were excluded due to incompleteness of the survey data. Reported characteristics of the remaining 641 study participants are shown in Table 2. There were 523 low-risk participants (82%) and 118 participants (18%) with moderate or high HIV risk. There were 377 women (58%), 218 heterosexual men (34%) and 46 homo/bisexual men (7%). Inconsistent condom use for vaginal sex, oral sex and anal sex were reported in 57%, 82% and 67% of the students, respectively. Thirty-three students (6%) reported history of alcohol use while 2 (0.3%) reported using drugs with sex. Four students (1%) reported history of exchanging sex for money and one each (0.2%) reported history of STIs within the past year and history of incarceration in the lifetime.

Table 2.

Reported characteristics, sexual, social and risk behaviours of the participants, stratified by gender.

Characteristics	All (N = 641)	Men (N = 264)	Women (N = 377)	P ^a
Demographics
Age (years, median, IQR)	20 (19–21)	20 (19–21)	20 (20–21)	0.42
Marital status				0.74
Single	622 (97)	251 (95)	371 (98)
Living with a domestic partner	19 (3)	13 (5)	6 (2)
Monthly household income (baht)				0.95
0–15,000	65 (10)	27 (10)	38 (10)
15,001–60,000	271 (42)	108 (41)	163 (43)
60,001–150,000	200 (31)	85 (32)	115 (31)
More than 150,000	105 (16)	44 (17)	61 (16)
Education
Faculty name
Science	119 (19)	23 (9)	96 (26)	<0.001
Engineering	104 (16)	64 (24)	40 (11)	<0.001
Medicine	102 (16)	52 (20)	50 (13)	0.03
Medical Technology	100 (16)	33 (13)	67 (18)	0.07
Journalism and Mass Communication	114 (18)	42 (16)	72 (19)	0.3
Laws	102 (16)	50 (19)	52 (14)	0.08
Study year				0.30
1	76 (12)	32 (12)	44 (12)
2	185 (29)	88 (33)	97 (26)
3	195 (30)	77 (29)	118 (31)
4	180 (28)	65 (25)	115 (31)
5	1 (0.2)	0 (0)	1 (0.3)
6	4 (1)	2 (1)	2 (0.5)

Sexual social and risk behaviours
HIV risk				<0.001
Low	523 (82)	184 (70)	339 (90)
Moderate	55 (9)	39 (15)	16 (4)
High	63 (10)	41 (16)	22 (6)
Ever had sexual intercourse	152 (24)	102 (39)	50 (13)	<0.001
Sexual orientation				<0.001
Heterosexual	569 (89)	218 (83)	351 (93)
Homosexual	43 (7)	30 (11)	13 (3)
Bisexual	29 (5)	16 (6)	13 (3)
Number of different sexual partners within the previous 30 days (median, IQR)^b	1 (0–1)	1 (0–1)	1 (0–1)	0.3
Number of new sexual partners within the previous 30 days (median, IQR)^b	0 (0–0)	0 (0–0)	0 (0–0)	0.92
Having vaginal sex^c	127 (20)	82 (31)	45 (12)	0.13
Use condom with vaginal sex^c				0.88
Never	13/127 (10)	7/82 (9)	6/45 (13)
Sometimes	20/127 (16)	12/82 (15)	8/45 (18)
About a half of time	14/127 (11)	9/82 (11)	5/45 (11)
Most of the time	26/127 (21)	18/82 (22)	8/45 (18)
Always	54/127 (43)	36/82 (44)	18/45 (40)
Having oral sex^c	113 (18)	78 (30)	35 (9)	0.39
Use condom with oral sex^c				0.46
Never	35/113 (31)	22/78 (28)	13/35 (37)
Sometimes	27/113 (24)	19/78 (24)	8/35 (23)
About a half of time	16/113 (14)	11/78 (14)	5/35 (14)
Most of the time	15/113 (13)	9/78 (12)	6/35 (17)
Always	20/113 (18)	17/78 (22)	3/35 (9)
Having anal sex^c	38 (6)	32 (12)	6 (2)	0.01
Use condom with anal sex^c				0.02
Never	3/38 (8)	1/32 (3)	2/6 (33)
Sometimes	9/38 (23)	6/32 (18)	3/6 (50)
About a half of time	5/38 (13)	5/32 (15)	0/6 (0)
Most of the time	9/38 (23)	8/32 (24)	1/6 (17)
Always	13/38 (33)	13/32 (39)	0/6 (0)
Exchanged sex for money or drugs^c	4 (1)	4 (2)	0 (0)	0.03
Drank alcohol within 30 days	211 (33)	112 (42)	99 (26)	<0.001
Number of alcohol drinking days within 30 days (median, IQR)	2 (1–5)	2 (2–8)	2 (1–4)	0.02
Number of drinks per day within 30 days (median, IQR)	5 (2–10)	5 (2–12)	3 (2–10)	0.01
Drinks alcohol with sex^c				0.73
Never	63 (10)	41 (16)	23 (6)
Sometimes	24 (4)	14 (5)	10 (3)
About a half of time	3 (0.5)	2 (1)	1 (0.3)
Most of the time	3 (0.5)	2 (1)	1 (0.3)
Always	3 (0.5)	3 (1)	0 (0)
Drug use within 30 days^d
Marijuana	5 (1)	4 (2)	1 (0.3)	0.17
Uses drug with sex^c
Never	3/5 (60)	3/4 (75)	0 (0)
Sometimes	1/5 (20)	1/4 (25)	0 (0)
About a half of time	1/5 (20)	0/4 (0)	1 (0.3)
Ever been in jail or prison	1 (0.2)	1 (0.4)	0 (0)	0.41
STIs within the past year	1 (0.2)	0 (0)	1 (0.3)	1.00
Type of STIs
HSV	1/1 (100)	0 (0)	1/1 (100)	–
STIs in sexual partner within the past year	1 (0.2)	0 (0)	1 (0.3)	1.00
Type of STIs in the partner
HSV	1/1 (100)	0 (0)	1/1 (100)	–
Sexual partner exchanged sex for money or drugs within 30 days	3 (0.5)	3 (1)	0 (0)	1.00
Sexual partner ever been in jail or prison	1 (0.2)	0 (0)	1 (0.3)	1.00

Note: Data are in number (%) unless otherwise indicated. HSV: herpes simplex virus; IQR: interquartile range; STIs: sexually transmitted infections.

Compare between men and women groups.

Data for participants who have ever had sexual intercourse only.

In their lifetime.

The drugs the participants were asked in the survey about their use included cocaine, heroin, LSD, amphetamine and ecstasy.

HIV risk perception and knowledge about HIV transmission risks

Of the 118 moderate or high-risk participants, 111 (94%) perceived themselves as no or low risk. When asking nine questions about HIV transmission risk in the survey, most of the 641 study participants correctly stated that ‘you can get HIV from vaginal sex (95%), anal sex (86%), tattoo needles (93%) and sharing needles’ (98%), ‘having multiple sexual partners increases risk of HIV’ (98%), ‘condom use decreases risk of HIV’ (96%) and ‘exchanging sex for money or drugs increases risk of HIV’ (98%). A lower proportion of the participants correctly stated that ‘you can get HIV from oral sex’ (70%), and ‘getting high increases risk of HIV’ (65%).

PrEP interest and its impact on risk behaviours

There were 430 participants (67%) who stated in the survey that they would take PrEP (Table 3). Taking PrEP once a week was the most acceptable option (75%), while taking PrEP once a day was the least accepted option (43%). Most of the participants reported that PrEP had to have 100% efficacy (62%) or at least 80% efficacy (28%) before they would take PrEP. When asked if they thought taking PrEP would change their behaviours, 13% of the participants would use condoms less, while 6% do not normally use and would not use condoms if taking PrEP. Thirty-eight (6%) participants would have more sexual partners if taking PrEP. Men were more likely than women to have more sexual partners if taking PrEP (9% vs. 4%; P = 0.005).

Table 3.

Pre-exposure prophylaxis (PrEP) interest and its impact on safe sex behaviours of the participants, stratified by gender.

Characteristics	All (N = 641)	Men (N = 264)	Women (N = 377)	p ^a
Would take a pill for PrEP				0.08
Yes	430 (67)	177 (67)	253 (67)
No	90 (14)	45 (17)	45 (12)
Do not know	121 (19)	42 (16)	79 (21)
Would take it once a week				0.02
Yes	482 (75)	186 (71)	296 (79)
No	159 (25)	78 (30)	81 (22)
Would take it once a day				0.07
Yes	274 (43)	124 (47)	150 (40)
No	367 (57)	140 (53)	227 (60)
Would take it one day before sex				0.05
Yes	409 (64)	157 (60)	252 (67)
No	232 (36)	107 (41)	125 (33)
Would take it one hour before sex				0.66
Yes	448 (70)	187 (71)	261 (69)
No	193 (30)	77 (29)	116 (31)
Percentage of efficacy of PrEP drug required for participants to take the drug				0.49
At least 40%	28 (4)	12 (5)	16 (4)
At least 60%	39 (6)	20 (8)	19 (5)
At least 80%	179 (28)	68 (26)	111 (29)
100%	395 (62)	164 (62)	231 (61)
Reasons for not taking a pill^b
I have no risk	472 (74)	178 (67)	294 (78)	0.003
Pill makes me sick	325 (51)	118 (45)	207 (55)	0.01
I practice safe sex already	173 (27)	79 (29)	97 (26)	0.39
I forget easily	123 (19)	49 (19)	74 (20)	0.74
I do not like taking pills	79 (12)	31 (12)	48 (13)	0.71
Others^c	11 (2)	3 (1)	8 (2)	0.34
Unspecified reasons	2 (0.3)	1 (0.3)	1 (0.3)	1.00
If taking the pill, I will use condoms				0.12
Less	81 (13)	38 (14)	43 (11)
More	94 (15)	38 (14)	56 (15)
The same	427 (67)	166 (63)	261 (69)
I do not normally use and will not use condoms	39 (6)	22 (8)	17 (5)
If taking the pill, the number of my sexual partners will be				0.008
Less	113 (18)	39 (15)	74 (20)
More	38 (6)	24 (9)	14 (4)
The same	490 (76)	201 (76)	286 (77)

Note: Data are in number (%).

Compare between men and women groups.

All participants can choose to answer this question regardless of PrEP interest and can choose for more than 1 reason.

Includes “The drug is costly” (N = 3), “Do not think of having sexual intercourse at all” (N = 2), “Uncertainty about risk and benefit of the drug” (N = 2), “The drug could make HIV infection worse if becoming infected” (N = 1), “Do not think that the drug is effective” (N = 1), “Do not know the exact time of having sexual intercourse” (N = 1), and “Afraid of having acnes from the drug” (N = 1).

Factors associated with false perception of low HIV risk and no PrEP interest

Characteristics associated with false perception of low HIV risk in univariate analysis are shown in Tables 4 and 5. Participants with false perception of low HIV risk were less likely to use condoms consistently with vaginal sex and oral sex compared to those with correct risk perception (36% vs. 61%; P = 0.02 and 13% vs. 35%; P = 0.02, respectively). However, the rates of PrEP interest and the median numbers of correct answers about HIV transmission risk were not significantly different between the participants with false perception of low HIV risk and those with correct risk perception (69% vs. 67% and 8 vs. 8, respectively). Independent factors associated with false perception of low HIV risk in the multivariate analysis were male gender, living with a domestic partner, being homosexual or bisexual and being students from non-medicine faculty (Table 5). Consistent condom use with vaginal and oral sex and being heterosexual were independently associated with no PrEP interest in the multivariate analysis (Table 5). The median number of correct answer about HIV transmission risk was not significantly different between the participants with and without PrEP interest (8 vs. 8, respectively).

Table 4.

Comparison of characteristics between participants with false perception of low HIV risk and those with correct risk perception.

Characteristics	Risk perception		P
Characteristics	False perception of low risk (N = 111)	Correct (N = 530)	P
Age (years, median, interquartile range)	21 (20–21)	20 (19–21)	0.03
Male gender	74 (67)	190 (36)	<0.001
Marital status			<0.001
Single	99 (89)	523 (99)
Living with a domestic partner	12 (11)	7 (1)
Monthly household income (baht)			0.32
0–15,000	12 (11)	53 (10)
15,001–60,000	55 (50)	216 (41)
60,001–150,000	29 (26)	171 (32)
More than 150,000	15 (14)	90 (17)
Students from non-Medicine faculties	103 (93)	436 (82)	0.008
Study year			0.11
1	10 (9)	66 (13)
2	26 (23)	159 (30)
3	32 (29)	163 (31)
4	43 (39)	137 (26)
5	0 (0)	1 (0.2)
6	0 (0)	4 (1)
Sexual orientation			<0.001
Heterosexual	79 (71)	490 (93)
Homosexual	22 (20)	21 (4)
Bisexual	10 (9)	19 (4)
Ever had sexual intercourse	27 (24)	127 (24)	0.94
Ever exchanged sex for money or drugs	3 (3)	1 (0.2)	0.02
Inconsistent condom use for
Vaginal sex	60/94 (64)	13/33 (39)	0.02
Oral sex	78/90 (87)	15/23 (65)	0.02
Anal sex	23/33 (70)	3/6 (50)	0.38
Median number of correct answer about HIV transmission risk^a (interquartile range)	8 (7–9)	8 (8–9)	0.24

Note: Data are in number (%) unless otherwise indicated.

Total of nine questions.

Table 5.

Factors associated with false perception of low HIV risk and no interest in pre-exposure prophylaxis (PrEP) among the study participants.

Characteristics	Univariable analysis		Multivariable analysis
Characteristics	OR (95% CI)	P	aOR (95% CI)	P
False perception of low HIV risk
Age	1.22 (1.05–1.43)	0.01	1.07 (0.85–1.35)	0.54
Male gender	3.58 (2.32–5.52)	<0.001	3.18 (1.77–5.74)	<0.001
Living with a domestic partner	9.06 (3.48–23.57)	<0.001	6.01 (1.78–20.34)	0.004
Students from non-medicine faculties	2.78 (1.31–5.90)	0.008	2.74 (1.05–7.19)	0.04
Being homosexual or bisexual	4.96 (2.94–8.36)	<0.001	2.45 (1.17–5.15)	0.02
Ever exchanged sex for money or drugs	14.53 (1.50–141.00)	0.02	5.17 (0.46–58.13)	0.18
No interest in PrEP
Age	0.96 (0.85–1.10)	0.57	–	–
Being single	2.68 (0.73–11.70)	0.14	2.12 (0.69–13.30)	0.3
Being heterosexual	1.99 (1.10–3.61)	0.02	2.00 (1.10–3.62)	0.02
Low HIV risk	1.26 (0.80–2.01)	0.33	–	–
False perception of low HIV risk	0.88 (0.57–1.37)	0.57	–	–
Consistent condom use with vaginal sex	2.20 (1.14–5.26)	0.03	2.27 (1.00–5.20)	0.04
Consistent condom use with oral sex	4.31 (1.44–13.33)	0.003	4.19 (1.38–12.92)	0.004

Note: aOR: adjusted odds ratio; CI: confidence interval; OR: odds ratio.

Discussion

Our study is the first study that assesses risk perception based on the validated risk categorisation tool, the association between knowledge about HIV transmission, condom use and HIV risk perception, and the impact of several characteristics on risk perception and PrEP interest among university students. Despite having overall high level of knowledge about HIV transmission risks, the rates of consistent condom use among the students for any types of sex were low. Students with false perception of low HIV risk used condoms less consistently than those with correct risk perception, consistent with those reported in a population-based survey.¹⁷ In addition, other studies demonstrated that condom use was more consistent when an individual was aware that he/she was going to participate in at-risk activities, and sexual intercourse with casual partners and/or commercial sex workers.^5,18 Thus, improving risk perception may increase the rates of consistent condom use.

Factors associated with false perception of low HIV risk identified in this study were male gender, living with domestic partners, being homosexual/bisexual and students from the non-medicine faculties. While male gender and being homosexual/bisexual have been previously reported as risk factors for the false perception of risk,¹⁴ our study is the first to suggest living with a domestic partner (vs. being single) and students from non-medicine faculties as additional risk factors. These findings may represent a better perception of HIV risk through the more and constant opportunities to receive information and/or be educated about HIV/AIDS among students from the Faculty of Medicine. Although most of the students living with domestic partners reported to be in a monogamous relationship, they were still categorised as having moderate or high-risk for HIV infection based on their and their partners’ risk characteristics other than condom use practice. They might think they had a committed relationship and had false perception of low HIV risk despite their and their partners’ other high risk characteristics. Students with the characteristics associated with false perception of low HIV risk should be the targeted populations to explore in detail the reasons why they have false perception of risk and to further implement relevant interventions to correct their risk perception.

The rate of PrEP interest among the students in this study was lower than that of heterosexual attendees of an STI clinic in the USA (67% vs. 83%).² This may be due to lower motivation for preventive strategies and/or less overall knowledge about PrEP among the students. However, the rate of PrEP interest was even lower (35%) among men who have sex with men (MSM) in another study from Thailand.¹⁹ The difference in the rates of PrEP interest may be due to differences in methods of collecting data, study populations, participants’ attitude and the awareness of PrEP between the students and MSM. If the students decided to take PrEP, the majority of them stated that efficacy of at least 80% would be required and taking once a week would be the best option. Given that only an oral once-daily dosing PrEP regimen has been shown to be effective and available for use currently,^8–11 counselling and education about PrEP use is needed and PrEP that could be taken less frequently is desired and would improve the uptake. Some of the students would use condoms less and some would have more sexual partners, especially the male students if taking PrEP. These findings suggest a potential for risk compensation as previously observed in men who have sex with men (MSM).²⁰ However, the proportion of the participants who would use condom less was lower in this study compared to that of the MSM study (13% vs. 36%). Since PrEP is not currently proved to be 100% effective in HIV prevention, concurrent use of other preventive methods, risk behaviour assessment and risk reduction counselling are recommended with PrEP use.

There were some limitations in our study. First, the results of the study may have limited generalisability to Thai university students. Second, using a convenient sample of students may preclude generalisability of the results. However, due to a relatively large sample size and equally distributed numbers of students from each faculty, the findings should be able to represent other students in the university. Third, our survey asked several hypothetical questions about what participants would do if taking PrEP. Participants could only speculate as to what their behaviour would be as future actions. Fourth, given the anonymous nature and design of the study, we could not assess participants’ partners’ risk characteristics directly but they were assessed through what the participants reported in the survey. Lastly, the ability to assess HIV risk level and PrEP interest may be limited due to the small proportions (39% of men and 13% of women) of participants who have had sexual experience in this study.

In conclusion, a high proportion of university students with moderate or high risk for HIV acquisition had false perception of low HIV risk which was significantly associated with inconsistent condom use. The rates of consistent condom use were all low with vaginal, oral and anal sex despite the students’ high level of knowledge about HIV transmission risks. The dissociation between knowledge and risk perception may be due to suppression mechanism that they could not accept themselves as persons with high HIV risk and/or the inability to apply HIV knowledge for their own risk assessment. The real underlying mechanisms for this dissociation require further studies. Interventions that should be implemented to improve risk perception may include an interactive interview session with an HIV risk assessment expert or education sessions on HIV risk assessment skill while PrEP awareness and knowledge may be improved via various educational interventions including didactic sessions, HIV transmission prevention campaign and/or peer education group. These interventions could potentially facilitate HIV transmission prevention among the university student population.

Footnotes

Acknowledgements

The results of this study were partly presented at the 54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) 2014, Washington, D.C. in a poster walk session (Abstract H-1000).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by the Thammasat University funding (to T.K.)

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