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HIV knowledge, sexual attitudes, and PrEP-Eligible behaviors among college students in Southwest China: a cross-sectional study

BMC Infectious Diseases volume 24, Article number: 827 (2024) Cite this article

Abstract

Background

There is an increasing number of human immunodeficiency virus (HIV) reported cases among students in Southwest China. However, the data on HIV/sex-related knowledge, attitude toward sex, sexual behaviors, and correlates of pre-exposure prophylaxis (PrEP)-eligible behaviors among college students in this area is still limited. This study aimed to assess the prevalence of HIV/sex-related knowledge, sexual attitudes, sexual behaviors, and factors associated with PrEP-eligible behaviors among college students.

Method

An online survey from 2020 to 2021 based on a multistage stratified and cluster sampling method was conducted among college students in Southwest China, and a well-designed questionnaire collected data. Propensity score matching (PSM), logistic, and log-binomial regression were used to identify the determinants of PrEP-eligible behaviors.

Result

A total of 108,987 students participated in the survey, and 92,946 provided valid responses. 91.6% (85,145/92,946) had good HIV-related knowledge, while only 26.0% (24,137/92,946) reported awareness of sex-related knowledge. Furthermore, more than half of the participants (64.5%) held negative stances towards engaging in “one-night stand”, and 58.9% (617/1,047) reported PrEP-eligible behaviors. Log-binomial regression analysis indicated that unaware of HIV-related knowledge (aPR = 1.66, 95% CI:1.22–2.26, P = 0.001), not discussing about sex with their parent(s) (aPR = 1.16, 95% CI:1.01–1.33, P = 0.021), not receiving sex-related education in school(aPR = 1.24, 95% CI: 1.07–1.45, P = 0.005), not participating in HIV/AIDS prevention activities in the past year (aPR = 1.32, 95%CI:1.09–1.60, P = 0.004), experiencing forced sex (aPR = 2.08, 95% CI: 1.19–3.63, P = 0.010), and having the drug abuse (aPR = 22.21, 95% CI:5.59–88.31, P < 0.001) were significantly associated with increased odds of PrEP-eligible behaviors.

Conclusion

College students in Southwest China exhibited suboptimal HIV/sex-related knowledge, received limited sex education, reported conservative attitudes towards casual sex, and significant PrEP-eligible behaviors. These findings suggest that sexually experienced college students who were unaware of HIV-related knowledge, lacked sex education, experienced forced sex, and reported drug abuse were the key individuals for evaluating eligibility for PrEP initiation, and interventions aimed at increasing awareness of HIV/sex-related knowledge, promoting participation in sex education, addressing issues related to forced sex and tackling drug abuse could contribute to reducing the incidence of PrEP-eligible behaviors among college students.

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Introduction

Acquired immunodeficiency syndrome (AIDS) continues to pose a huge challenge for youth populations worldwide. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), there was an average of 3,200 new Human Immunodeficiency Virus (HIV) infections each day among adults aged 15 and older, with approximately 30% of these infections occurring in individuals aged 15–24 in 2022 [1]. Worryingly, the number of new HIV infections among college students in China has been growing sharply in recent years, increasing at an annual rate of 30–50% [2]. Furthermore, the proportion of students among reported HIV cases has increased from 8.5% in 2010 to 21.7% in 2019, with 98.2% of these cases resulting from sexual transmission [3]. Therefore, college students in China have become a high-risk group for HIV infection.

US Public Health Service published the “Prevention of HIV Infection in the United States: 2021 Update Clinical Providers’ Supplement”, which proposed that PrEP should be considered for sexually active individuals engaging in unprotected sex, those with sexual partners who are HIV-positive, and individuals who have been diagnosed with Sexually transmitted infections (STIs) [4]. In China, the Chinese Center for Disease Control and Prevention (CCDC) issued “Chinese AIDS diagnosis and treatment guidelines” in 2021, which recommended that individuals engaging in unprotected sexual activities, men who have sex with men (MSM), sex workers, individuals with multiple sexual partners and needle sharers should initiate PrEP [5]. In 2023, the eligibility criteria for PrEP use in China as proposed are as follows: (1) Individuals who are sexually active, HIV-negative, or medically eligible to take PrEP medications; (2) Individuals who have engaged in unprotected sex, shared needles or reported recent STIs; (3) Individuals whose sexual partners are HIV-positive; and (4) Individuals who have frequently utilized Post-exposure Prophylaxis (PEP) to prevent HIV infection through sexual or intravenous transmission [6]. Therefore, PrEP-eligible behaviors were defined as activities that qualify individuals for the initiation of PrEP, such as unprotected sex, sharing needles, and sex with HIV-positive partners.

With increasing liberal sexual attitude [7] and inadequate sex education [8], college students are more likely to report PrEP-eligible behaviors in sex, exposing them to disproportionately high risk of unplanned pregnancies and STIs, including HIV, Hepatitis C Virus (HCV) and syphilis. Indeed, previous studies have revealed that 17.5% of sexually active female students experienced unplanned pregnancies, 31.7-54.2% of sexually active college students had multiple sexual partners in their lives and 79.5% reported unprotected sex, which were significantly associated with an increased risk of STIs [9, 10]. PrEP-eligible behaviors among college students have become an obstacle on the way to combating the spread of HIV, as well as causing a considerable burden on their mental and physical health [11]. Previous studies indicate that their awareness of HIV/sex-related knowledge remains suboptimal [12,13,14]. The rate of correct response to HIV-related knowledge was 87.4% among freshmen in Jiangsu Province and 67.3% among male college students in Guangxi [12, 13], while the rate of correct response to sex-related knowledge was even as low as 0.5% across China [14]. Lack of HIV/sex-related knowledge also contributes to increased rates of HIV infection and other reproductive health problems [15, 16], such as STIs and unplanned pregnancies, which can be mitigated by increased sex education and decreased Risky sexual behavior (RSB) [17]. Hence, it is urgent to examine the awareness of HIV/sex-related knowledge and the prevalence of PrEP-eligible behaviors, as well as its correlates among college students.

Previous studies have determined numerous factors associated with PrEP-eligible behaviors among college students. For example, sociodemographic factors such as sex, age, education, and marital status have been reported to be associated with it [18,19,20]. Students with liberal sexual attitudes and low sex-related knowledge are found to be more likely to report PrEP-eligible behaviors in sex [7, 21]. In addition, family and school factors also play a key role in safe sex for college students. Students who refrained from discussing sex issues with their parents in the past year showed a higher likelihood of reporting PrEP-eligible behaviors in sexual activities, while those who felt they were under parental supervision were less likely to report PreEP-eligible behaviors in sex [22]. Students who received counseling from teachers equipped with comprehensive sexuality education were intended to use contraceptive protection and postpone their sexual debut [23]. Other behaviors such as smoking, alcohol and drug use, and finding sexual partners online also promote PrEP-eligible behaviors among college students [24,25,26]. However, previous studies have not comprehensively analyzed the impact of HIV/sex-related knowledge, sexual attitudes, sexual behavior, school sex education, and family sex education on PrEP-eligible behaviors among college students. Understanding the prevalence of reporting PrEP-eligible behaviors in sexual intercourse and its correlates among university students will provide crucial information for the development of effective HIV prevention strategies and measures.

The HIV epidemic in Guangxi is the third highest province in China, and the HIV reported cases among college students are also increasing year by year [12]. To curb the spread of HIV, 10 departments, including the National Health Commission made the target of over 95% awareness of AIDS prevention and treatment among young students [27]. Alarmingly, sex education is not yet fully available in Chinese families and schools [28], and students receive incompletely correct HIV/sex-related knowledge online [29]. In the era of information technology, students have more channels to obtain sexual health knowledge, and their sexual concepts have also changed accordingly. However, the latest research on the prevalence of HIV/sex-related knowledge, sexual attitudes and behaviors, and factors associated with PrEP-eligible behaviors among college students are suboptimally elucidated. Previous studies mostly are based on a small sample scale, which limited the generalizability of the findings. Therefore, this study based on a large-scale sample aiming to assess the HIV/sex-related knowledge, sexual attitudes and behaviors, and factors associated with PrEP-eligible behaviors among college students.

Methods

Study design and procedure

From October 1, 2021, to December 20, 2021, a cross-sectional survey was conducted by the Nanning Centre for Disease Control among students from 16 colleges in Nanning City. Based on the National HIV Sentinel Surveillance Questionnaire issued by the National Center for HIV Control and Prevention [30], we designed an anonymous online questionnaire Wenjuanxing (https://www.wjx.cn/) by combining expert guidance and literature review. A unique link or QR code for the questionnaire was sent to uniformly trained class teachers, who then sent it to students for survey. Before the formal survey, we determined the sample size for a pre-survey based on the total sample size, using the principle that the number of pre-survey respondents would be 10–20% of the total sample size. After the pre-survey, the Cronbach’s alpha and the Measure Sampling Adequacy (Kaiser-Meyer-Olkin, KMO) of the questionnaire were respectively 0.751 and 0.820, the HIV-related knowledge scale were respectively 0.770 and 0.867, the sex-related knowledge scale were respectively 0.741 and 0.790, and sexual attitude scale are respectively 0.758 and 0.786. The online questionnaire was used to collect respondents’ sociodemographic characteristics, HIV/sex-related knowledge, sexual attitudes, sex education, sexual behavioral characteristics, use of drugs, and HIV/AIDS education/prevention services.

The inclusion criteria for participants were (1) students who were studying in the colleges located in Nanning (2) aged 18–25 years old, and (3) consent to participate in this survey. The exclusion criteria were (1) foreign students; (2) students with serious mental health; and (3) college students with postgraduate degree.

The prevalence of sexual behaviors among Chinese college students ranged from 10.40 to 11.9% [8, 31]. It is assumed that the prevalence of sexual behaviors among college students in Guangxi was 11.0% and the sample size in this study was calculated as follows.

$$n = {\left( {\frac{{{Z_{1 - {\raise0.7ex\hbox{$\alpha $} \!\mathord{\left/{\vphantom {\alpha 2}}\right.\kern-\nulldelimiterspace}\!\lower0.7ex\hbox{$2$}}}}}}{\delta }} \right)^2} \times P \times (1 - P)$$

The ɑ was set to 0.05, Z1−ɑ/2 represents the standard normal distribution bound at an alpha of 0.05 and δ represents the permissible error taken as 0.011. A sample size of n = 3,198 was calculated by using the Power Analysis and Sample Size Software version 21.0.3, taking into account a 15% drop-out rate, a minimum of 3,763 participants were required.

This study used a multistage stratified and cluster sampling method. Firstly, 16 colleges were randomly selected from the 35 colleges in Nanning, Guangxi, based on a random number table (simple random sampling). Secondly, four college departments were randomly selected from each selected college. Third, students in each department were divided into six strata by grade: grades 1 to 5 and graduate students. Subsequently, five classes were selected from selected departments at each level of grades one to three and two classes at each level of grades four to five.

Ethical consideration

This study was reviewed and approved by the Medical Ethics Committee of Guangxi Medical University (no. 2019-SB-088). The data collected was stored in the online platform we managed and it wasn’t compromised.

Measure

Sociodemographic and behavioral characteristics

Sociodemographic characteristics included sex (male or female), age (18–20 or ≥ 20), registered residence (Guangxi or outside of Guangxi), Ethnic minority (yes or no), degree in study progress (undergraduate or junior college), sexual orientation (heterosexual or non-heterosexual), social relationship (single or not) and sexual experience (yes or no). Other behavioral characteristics included having drug abuse, receiving HIV/AIDS knowledge education, HIV/AIDS prevention activities, or HIV testing in the past year.

HIV/sex-related knowledge, sexual attitudes of individuals, and sex education

HIV/sex-related knowledge consisted of 15 questions, of which the first eight were HIV-related knowledge and the last seven were sex-related knowledge with “yes”, “no” and “I don’t know” response options for each question. HIV-related knowledge questions answered six or more correctly were considered aware of HIV-related knowledge according to the National Center for HIV Control and Prevention. There was no gold standard cut-off method to access sex-related knowledge levels, so the highest quartile of the distribution of sex-related knowledge correct responses as aware of sex-related knowledge (i.e., correct responses of 5 and above). The HIV/sex-related knowledge questions are shown in Table S1. Sexual attitudes of individuals were measured by the following questions: attitudes toward premarital sex, premarital cohabitation, and “one-night stands”, with response options of “Opposed,” “Neutral,” or “Acceptable.” Sex education included school sex education and family sex education. School education items included “Have you ever received sex education in school?“, “Stage of participating sexual courses in school”, and “Satisfaction of school sex courses”. Family sex education included “Have you ever got solution about sex questions from your parent(s)?“, “The frequency of discussion sex with your parents” and “The evaluation of your family’s attitudes about sex”.

Sexual behaviors

The following information was collected from participants in this section: sex-related behaviors (whether they had sex in the past year, age at first sex, sexual partner at first sex (steady sexual partner or other), whether they experienced forced sex, condom use at first sex, unintended pregnancy at first sex). The steady sexual partner in this study refers to a boy/girl friend, husband/wife.

PrEP-eligible behaviors

In this region, the main route of transmission of HIV among college students is sexual behaviors [32], and the non-use of condoms during sex could increase the risk of HIV transmission [33]. Additionally, according to the Experts’ consensus issued by China, individuals with consistent condoms use during casual, commercial, and anal sex are not eligible for PrEP, which shows that condom use as a criterion for defining PrEP-eligible behavior is reasonable [6]. Therefore, we exclusively consider the use of condoms during casual, commercial, or anal intercourse as the criteria for defining PrEP-eligible behaviors. PrEP-eligible behaviors in this study were defined as behaviors that would qualify participants to initiate PrEP, considering known behavioral predictors of HIV acquisition. Participants had to meet two following criteria: (1) Reporting engaging in sexual behavior(s)in the recent one year; (2) Acknowledge involvement in any of the following sexual activities—casual, commercial, or anal sexual intercourse(s)—without consistent condom use during these activities.

Data analysis

Data were processed with the Excel program. The response of participants to each variable was analyzed using descriptive statistics (SPSS.26) with frequency and percentage (95% CI). GraphPad Prism 9.5 software was used to graph the prevalence of casual, commercial, or anal sex behavior and the proportion of PrEP-eligible behaviors in these sexual activities. We employed PSM to mitigate differences in sociodemographic characteristics between the PrEP-eligible behaviors group and PrEP-ineligible behaviors group and enhance the efficiency of the study. PSM by MatchIt package in R version 4.3.3 was performed on socio-demographic characteristic, including gender, age, registered residence, Ethnic minority, degree in progress, sexual orientation, and social relationship. Secondly, 8 independent variables of sexual attitudes, awareness of HIV/sex-related knowledge, sex education, sexual behaviors, and other behaviors (including drug abuse, HIV/AIDS knowledge education, HIV/AIDS prevention services or HIV testing) screened by stepwise logistic regression, AIC = 900.83, and PrEP-eligible behaviors as dependent variable both were included in log-binomial regression to identify the determinants of PrEP-eligible behaviors by R version 4.3.3. The PSM ratio was set to 1:1 and the caliper to 0.20. Finally, we got 850 respondents included in the model. The data used for analysis are shown in Figure S1.

Results

Sociodemographic and behavioral characteristics

A total of 108,987 students participated in the survey, and 92,946 valid questionnaires were obtained, giving a validity rate of 85.3%. Table 1 showed the socio-demographic and behavioral characteristics of the participants. Among the 92,946 participants, the median age (interquartile range) of the participants was 19 (19–20) years, 61.3% were female, and 72.3% were identified as single. 51.7% of the individuals were undergraduate and 90.1% self-identified as heterosexual orientation. Moreover, 12.5% of the respondents reported having sexual experience and only 0.5% reported drug abuse. Notably, a substantial portion of participants reported involvement in HIV/AIDS education (84.2%) and AIDS/HIV prevention activities (74.8%), while a minority, 8.7%, indicated having received HIV testing in the past year.

Table 1 Sociodemographic and behavioral characteristics of college students in Guangxi, 2021(N=92,946)
Full size table

HIV/sex-related knowledge, attitudes toward and sex education

Table 2 described the response of HIV/sex-related knowledge among participants. An overwhelming 91.6% of respondents demonstrated awareness of HIV-related knowledge, while, only 13% were aware of sex-related knowledge. The HIV-related knowledge questions, “Consistent and correct use of condoms can reduce the risk of HIV infection”, and “After engaging in high-risk behaviors, such as needle sharing, drug use, or unsafe sex, people should actively seek HIV testing and counseling”, had a correct response rate above 95.0%. The sex-related knowledge questions with the highest correct response rate, “Having sex before menstruation (14 days) is likely to get pregnant”, and “Genital herpes is a sexually transmitted disease”, had a percentage of correct responses of more than 60.0%. Figure S2 presented the awareness of HIV/sex-related knowledge on sex, age, and degree in progress. More than 90.0% of participants exhibited being aware of HIV-related knowledge on sex, age, and degree in progress, while approximately 25.0% exhibited being aware of sex-related knowledge on sex, age, and degree in progress. There were statistical differences of awareness of HIV/sex-related knowledge on sex, age, and degree in progress.

Table 2 Responses of HIV/sex-related knowledge among college students in Guangxi, 2021 (N = 92,946)
Full size table

Table 3 described the sexual attitudes and sex education among participants. In terms of sexual attitudes, approximately a quarter of participants exhibited opposition to premarital sexual activities (25.4%) and premarital cohabitation (24.0%). However, more than half of the participants held a negative stance towards engaging in “one-night stand” (64.5%). For sexual education, 54.4% of the respondents reported never engaging in conversations about sex with their parent(s), 40.6% seeking resolutions for sexual issues from the parent(s), and 48.4% perceiving their family’s sexual perceptions as conservative. In addition, 78.4% had received sex education in school, yet only 54.7% were satisfied with it. 67.6% began attending sex education courses at middle school.

Table 3 Sex attitudes and sex education among college students in Guangxi, 2021 (N = 92,946)
Full size table

Sexual behaviors

Figure 1 displayed the sexual behaviors at the first intercourse among sexually experienced college students. Among the 11,652 participants who reported having sexual experience, 70.3% engaged in sexual intercourse in the past year. 92.6% initiated sex with steady sexual partners, 84.1% reported not ever experiencing forced sex, and 71.8% initiated their inaugural sexual encounter between the ages of 18 and 20. Furthermore, approximately three-quarters (76.3%) reported using a condom at the first sexual intercourse, with only 9.6% having unplanned pregnancies at first sexual intercourse.

Fig. 1
figure 1

Age, sexual partners and sexual behaviors at sex debut among sexually experienced college students in Guangxi, 2021 (N = 11,652)

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Casual, commercial, and anal sexual behaviors, and PrEP-eligible behaviors

Figure 2 elucidated the prevalence of casual, commercial, and anal sexual behaviors, and PrEP-eligible behaviors in the past year. 12.8% (1,047/8,192) of sexually experienced respondents in the past year had engaged in casual, commercial, or anal sexual behavior, of which 10.4% (851/8,192) reported engaging in casual sexual behaviors, 4.8% (400/8,192) in commercial sexual activities, and 8.8% (408/4,587) in anal sexual behaviors. Overall, 58.9% (617/1,047) reported PrEP-eligible behaviors. It is pertinent to highlight that 57.3% (487/851) reported PrEP-eligible behaviors in casual sex, 77.5% (310/400) in commercial sex, and 70.3% (287/408) in anal sex.

Fig. 2
figure 2

(A) The prevalence of casual, commercial, and anal sex in the past year among participants; (B) The prevalence of PrEP-eligible behaviors in casual, commercial and anal sex in the past year

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Correlates of PrEP-eligible behaviors

A total of 8 variables screened by stepwise logistic regression were included in logistic and log-binomial regression. As Table 4 presented, log-binomial regression indicated that unaware of HIV/AIDS knowledge (aPR = 1.66, 95% CI:1.22–2.26, P = 0.001), not discussing about sex with their parent(s) (aPR = 1.16, 95% CI:1.01–1.33, P = 0.021), not ever receiving sex-related education in school (aPR = 1.24, 95% CI: 1.07–1.45, P = 0.005), not participating in HIV/AIDS prevention activities in the past year (aPR = 1.32, 95%CI:1.09–1.60, P = 0.004), experiencing forced sex (aPR = 2.08, 95% CI: 1.19–3.63, P = 0.010), and having the drug abuse (aPR = 22.21, 95% CI:5.59–88.31, P < 0.001) were significantly associated with increased odds of PrEP-eligible behaviors. The results of logistic regression were consistent with log-binomial regression’s, as showed in Table S2.

Table 4 Logistic and log-binomial regression after PSM of factors associated with PrEP-eligible behaviors among college students in Guangxi, 2021(N = 850)
Full size table

Discussion

This study employed a substantial sample size, representing 10% of college students in Guangxi Province, providing a comprehensive examination of HIV/sex-related knowledge, sex education, attitudes towards sex, and sexual behavior among college students. Importantly, the findings of the study indicated that PrEP-eligible behaviors were associated with several factors, including poor knowledge of HIV, lack of sex education, non-participation in HIV/AIDS prevention activities, experiencing forced sex, and involvement in drug abuse. These insights underscore the importance of targeted interventions and educational initiatives to address these risk factors and decrease PrEP-eligible behaviors among college students in the region.

This study showed that the rate of awareness of HIV-related knowledge was 91.6%, exceeding rates observed in other cities of China, such as Shenzhen City, Kunming City, and Beijing City by 85.6% [34]. This rate also surpassed the awareness levels found in Chongqing City of China(62.62%) [8], Lagos City of Nigeria(86.3%) [35], and among Afro-Descendant Youths in Ecuador(88.8%) [36]. Nonetheless, it is noted that these rates did not meet the standards established by the China National Health Commission [27]. These discrepancies may be associated with the local economic level, cultural proficiency, and coverage of HIV prevention education in different regions. In recent years, the Guangxi government had issued strategies to strengthen sexual health and AIDS prevention education among college students [37]. In addition, colleges in Guangxi actively offered courses on health counseling and peer education for new college students [38]. These may be the reasons why college students in this study had a high rate of awareness of HIV-related knowledge. Disturbingly, the overall correct response of sexual health knowledge was merely 26.0%, some studies showed that 66% of mean scores of sexual health knowledge scored by college students in the USA [36], 60% in the UK [39], and 65% in Turkey [40]. It is difficult to compare with other studies given the different definitions and methods to access the awareness of sexual health knowledge, while the study revealed shortcomings in the structure and comprehensiveness of HIV/sex-related knowledge among college students as a whole. Additionally, this deficiency in HIV/sex-related knowledge in the study may be positively associated with a deficiency of parents’ instruction for kids in sex and school-based sex education. As shown in this study, we found that parents’ involvement in sex education for their children was relatively poor, aligning with previous studies [41,42,43,44], and the reason for this may be that parents were reluctant to discuss sexual topics with their children due to shame and embarrassments for sex [45]. Furthermore, parents tended to limit their sex education efforts to abstinence rather than offering reasoned guidance and scientific solutions [46], which underscores a troubling dilemma in family-based sex education. It is a mixed blessing that the majority of students reported ever receiving sex education in school, surpassing 55.6% in other regions of China [28], which may be attributed to the robust efforts undertaken by the Chinese government to promote the healthy development of adolescents in recent years [2]. Yet only half of the students responded affirmatively to the effectiveness of the sex education in this study and there is a pressing need for further improving students’ participation in school-based sex education. Enhancing parent-adolescent communications and enriching the educational approaches in school both are conducive to bridging knowledge gaps on HIV/sex-related knowledge and promoting healthier behavior [28, 47, 48].

Additionally, among the participants who engaged in casual, commercial, and anal sex in the past year, 58.9% of them reported PrEP-eligible behaviors, higher than 37.6% in eastern China [49], but lower than 73.2% in Zhejiang Province, China [50], 61.4% in Nigerian [51]. It’s concerning that while college students had a higher rate of awareness about HIV-related knowledge, they also reported a high the prevalence of PrEP-eligible behaviors. This finding was inline with previous study [52]. A reasonable explanation for discrepancy is that participants who were aware of HIV-related knowledge may not change their high risk behaviors, as sexual attitude was also a crucial factor associated with this behaviors. Jiang T found that Chinese college students who exhibited enlightened attitudes towards casual sex were more likely to engaged in high-risk sex behaviors [53]. In this study, approximately 35% of participants exhibited enlightened attitudes towards casual sex, making them more likely to engage in PrEP-eligible behaviors despite being aware of HIV-related knowledge. Notably, increasing the self-perceived susceptibility to the risk of HIV infection and enhancing condom self-efficacy are both effective interventions for decreasing PrEP-eligible behaviors [51].

In the study, we observed that the absence of sexual education, either at home or at school, increases the likelihood of college students reporting PrEP-eligible behaviors during sexual activities, aligning with prior research findings [28, 54, 55]. Classroom education and parental guidance served as crucial ways for Chinese students to acquire sexual health knowledge [8], while parents were reluctant to discuss sexual topics with their children due to embarrassment or stigma of sex [45]. Moreover, inadequately trained teachers were unable to meet the needs of young students regarding sex education [29]. It was noteworthy that the absence of sex education tended to lead students to decrease condom use during sexual activities, thereby which undoubtedly increased PrEP-eligible behaviors [54]. This finding indicated that these college students lacking sex education should be evaluated for taking PrEP, and those who meet the medically-eligible conditions should take PrEP timely to reduce the possibility of HIV infection. Rasberry CN and Kirby DB found that strengthening sex education in school could increase condom use during sex, consequently diminishing PrEP-eligible behaviors [48, 56], which indicated that schools could adopt educational approaches that students were most receptive to, such as specialized sex education classes, Internet-based sex education, peer education, and AIDS public welfare activities, to mitigate PrEP-eligible behaviors [8].

Consistent with previous studies [49, 57], individuals lacking awareness of HIV/AIDS-related knowledge were more predisposed to engage in PrEP-eligible behaviors. Those who had limited knowledge of HIV and perceived themselves as less susceptible to HIV infection due to their knowledge gap were more inclined to have sex without consistent condom use [58,59,60,61]. However, it’s worth noting that there was a contrasting finding among nursing students at the University of Palermo [62]. The effectiveness of HIV-related education in reducing high-risk sexual behavior among students is evident from various studies [63]. This includes educational initiatives delivered by parents and the reinforcement of school-based programs [48, 64, 65].

Forced sex plays a significant role in determining PrEP-eligible behaviors. It’s important to note that females often face obstacles to condom use due to males’ dominance, coercion, and manipulation in heterosexual relationships [66, 67]. There is compelling evidence indicating that females are disproportionately vulnerable to experiencing coerced sexual encounters [66, 68,69,70], placing them at an elevated risk of contracting HIV due to inconsistent condom use. Therefore, this finding indicated that college students who experience forced sex should be considered as the focus individuals of eligibility for PrEP initiation. Furthermore, a viable strategy to address this issue involves providing females with relevant knowledge and enhancing their communication skills in condom use. This empowerment enables them to use condoms as a protective measure during sexual intercourse, effectively advancing STIs prevention [71].

This study indicates that drug abuse increases the odds of engagement in PrEP-eligible behaviors, consistent with previous studies [72,73,74], the reason for this may be that it profoundly compromises the individuals’ judgment and makes them use condoms inconsistently during sexual intercourse [75, 76]. Noticeably, adolescents who are in the rebellious phase may engage in sexual experimentation by taking drug abuse due to sexual curiosities during this period [75,76,77]. Furthermore, university students might actively take drugs to gain an increased sexual desire and pleasure [78], which undoubtedly increases the risk of PrEP-eligible behaviors. Therefore, these drug users should be included in the intervention targets of PrEP services to provide them with opportunities to use PrEP. Additionally, there is an urgent need to enhance college students’ awareness of the negative consequences associated with drug abuse through educational initiatives and strict implementation of legal measures is essential to reduce students’ exposure to drugs.

Strengths and limitations

This study is the first to systematically assess the prevalence of correct SRH knowledge, sexual attitudes, sexual behavior, and correlates of PrEP-eligible behaviors among college students in Southwest China. Secondly, the large sample size used in this study makes the result representative and generalizable.

However, some limitations should be considered. Firstly, participants are prone to responding to certain sensitive questions with a degree of reservations or lack of seriousness considering the sensitive nature of the topics under this investigation. We adopt the way of anonymous questionnaires online to mitigate the non-response rate associated with sensitive questions. Participants were more inclined to respond according to their true thoughts in the absence of others. Additionally, we implemented restrictive settings in the questionnaire, ensuring that it could only be submitted once all questions had been answered. Secondly, the characteristics originated from an online survey were self-reported and subjected to information bias. We collected these behaviors in recent years to mitigate recall bias. Thirdly, We did not collect all the PrEP-eligible behaviors, such as frequently using Post-exposure Prophylaxis (PEP), having a sexual partner with HIV, and reporting recent infection with STIs. This might potentially underestimate the rate of PrEP-eligible behavior. However, The prevalence of recently reported sexual partners with HIV-positive, PEP use, and STIs among college students in this region was very low [32, 34, 79], so we could neglect this underestimation. Besides, the large sample size, representing 10% of the college students in this city, rendered this underestimation negligible. Fourth, log-binomial regression performs poorly in evaluating the association between rare events and variables and is only applicable to data with a high incidence of outcomes. The residuals of this model failed to meet the normality assumption, and we employed Robust Standard Errors to compute adjusted coefficient estimates and significance test results to enhance the robustness of parameter estimation testing. Fifth, Our samples are drawn from the region in China with relatively underdeveloped economic and educational levels, findings of which are limited to providing more references for other regions. Lastly, Given the cross-sectional nature of the survey, this study does not allow inference on causality.

Conclusion

College students in Southwest China exhibited suboptimal HIV/sex-related knowledge, received limited sex education, reported conservative attitudes about casual sex, and high prevalence of PrEP-eligible behaviors. Our findings indicated that sexually experienced college students who had unawareness of HIV-related knowledge, lacked sex education, experienced forced sex, and reported drug abuse should be the key individuals for evaluating eligibility for PrEP initiation, and interventions aimed at increasing awareness of HIV/AIDS, enriching sex education styles, addressing issues related to forced sex, and tackling drug abuse could contribute to reducing the incidence of PrEP-eligible behaviors among college students.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available because of ethical and legal reasons but are available from the corresponding author on reasonable request.

Abbreviations

PSM:

Propensity score matching

AIDS:

Acquired immune deficiency syndrome

HIV:

Human immunodeficiency virus

HCV:

Hepatitis C Virus

RSB:

Risky sexual behaviors

MSM:

Men who have sex with men

STIs:

Sexually transmitted infections

PEP:

Post-exposure Prophylaxis

PrEP-eligible behaviors:

Pre-exposure prophylaxis-eligible behaviors

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Acknowledgements

We thank all researchers involved in this study and the staff of the Nanning Center for Disease Control and Prevention.

Funding

This work was supported by the Guangxi Scientific and Technological Key Project (2022AC23005 and 2022JJA141110), Guangxi Natural Science Foundation (2023GXNSFAA026287), Thousands of Young and Middle age Key Teachers Training Program in Guangxi Colleges and Universities (To Bingyu Liang), Nanning Scientific Research and Technological Development Project (20223051), National Natural Science Foundation of China (No. 82060610 and 82103899).

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  1. Shiyu Qin, Jiao Qin and Qiuqian Su contributed equally to this work.

Authors and Affiliations

  1. Guangxi Key Laboratory of AIDS Prevention and Treatment, School of Public Health, Guangxi Medical University, Nanning, 530021, Guangxi, China

    Shiyu Qin, Jiao Qin, Qiuqian Su, Ting Huang, Jinfeng He, Zhifeng Lin, Xinju Huang, Li Ye, Hao Liang, Ping Cen & Bingyu Liang

  2. Nanning Center for Disease Control and Prevention, Nanning, 530023, Guangxi, China

    Junyu Zhan, Xi Yang, Yuanhong Yang, Zhifeng Lin, Li Ye, Hao Liang, Hongyang Tang & Ping Cen

  3. Collaborative Innovation Centre of Regenerative Medicine and Medical Bioresource Development and Application Co-constructed by the Province and Ministry, Life Science Institute, Guangxi Medical University, Nanning, 530021, Guangxi, China

    Bingyu Liang

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Contributions

Li Ye, Hao Liang, Bingyu Liang, Hongyang Tang and Ping Cen conceived and designed the study. Shiyu Qin, Jiao Qin and Qiuqian Su analyzed the data and wrote the manuscript. Junyu Zhan, Xi Yang, Yuanhong Yang, Ting Huang, Jinfeng He, Zhifeng Lin, Xinju Huang assisted in data collection. Li Ye, Hao Liang, Bingyu Liang, Hongyang Tang and Ping Cen directed the data analysis. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Hongyang Tang, Ping Cen or Bingyu Liang.

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Ethics approval and consent to participate

This study has been reviewed and approved by the Ethics Committee of Guangxi Medical University (no.2019-SB-088). The study methods used in this study were by the relevant guidelines and regulations. All respondents were aware of the content and purpose of this study and agreed to provide informed consent online before this survey.

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Figure S1

. Flow chart of data exclusion and analysis

Figure S2

. Awareness of HIV/sex-related knowledge on gender, age, and degree in progress.

Supplementary Material 3

Supplementary Material 4

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Qin, S., Qin, J., Su, Q. et al. HIV knowledge, sexual attitudes, and PrEP-Eligible behaviors among college students in Southwest China: a cross-sectional study. BMC Infect Dis 24, 827 (2024). https://doi.org/10.1186/s12879-024-09657-7

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