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
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
Human immunodeficiency virus (HIV) risk stratification according to the pre-specified reported characteristics and behaviours of the survey participants and their partners.
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 participants 2 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
Reported characteristics, sexual, social and risk behaviours of the participants, stratified by gender.
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
Pre-exposure prophylaxis (PrEP) interest and its impact on safe sex behaviours of the participants, stratified by gender.
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
Comparison of characteristics between participants with false perception of low HIV risk and those with correct risk perception.
Note: Data are in number (%) unless otherwise indicated.
Total of nine questions.
Factors associated with false perception of low HIV risk and no interest in pre-exposure prophylaxis (PrEP) among the study participants.
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.)
