Preplanned Studies: HIV-Related Knowledge, Attitude, and Practices Research Among College Students — Six Chinese Cities, 2021

Globally, around 4,000 new human immunodeficiency virus (HIV) infections occur daily including among 1,100 youth aged 15–24 years (1). In China, newly diagnosed HIV cases among 15–24-year-olds — including young students — increased from 9,373 in 2010 to 15,790 in 2019 (2). To reduce new infections among students, a combination of prevention education and behavioral as well as biomedical interventions was implemented. This implementation calls for a geographically larger-scale study to assess and identify gaps in students’ HIV-related knowledge, attitudes, and practices (KAP). A survey of college students in 6 large cities was thus conducted in 2021, with a total of 54,052 respondents. In addition to finding knowledge gaps on HIV, especially on treatment, HIV self-testing (HIVST) and post-exposure prophylaxis (PEP), significant knowledge and behavior gaps in practicing safe sex were identified. These gaps, coupled with early sexual initiation, suggest that comprehensive prevention education should start early.

The survey was conducted from September to December 2021 at 30 colleges and universities in 6 large cities (Tianjin Municipality, Changchun City, Hangzhou City, Changsha City, Guangzhou City, and Chengdu City) that rank high in newly identified student infections. Convenience sampling along with a minimum number of classes per grade and a minimum of 600 samples per school was used. A WeChat-based anonymous questionnaire was distributed and accessed by respondents via a quick response (QR) code scan. Each internet protocol (IP) address was set for one enrollment. This structured online questionnaire included both sociodemographic and KAP questions related to HIV. The KAP questions focus on basic HIV information, PEP, HIVST, and sexual experiences. Results were presented with descriptive statistics, including proportions and their 95% confidence intervals (CIs). R software (Version 4.1.3, R Foundation for Statistical Computing, Vienna, Austria) was used for data cleaning and analysis.

A total of 54,052 valid questionnaires were collected, of which 59.5% (32,178/54,052) were female and 55.9% (30,211/54,052) were freshmen. Regarding sexual orientation, 86.9% (46,985/54,052) reported being heterosexual, whereas 1.7% (930/54,052) and 5.7% (3,058/54,052) reported being homosexual or bisexual, respectively. In addition, 10.0% (5,384/54,052) of respondents reported having had sexual experience, and 0.05% (26/54,052) reported testing positive for HIV in the latest test (Table 1).

The survey consisted of 9 questions on basic HIV knowledge. Knowledge of condom use (Q7, Q8, Q9) was relatively high with an over 90% passing rate. Nearly everyone (94.2%; 50,896/54,052) knew that intentional HIV transmission was illegal (Q3). However, as many as 29.0% (15,694/54,052) of respondents did not know that HIV cannot be cured (Q1). Furthermore, 34.9% (18,865/54,052) were unaware that being infected with sexually transmitted diseases (STDs) increases the risk of HIV infection (Q5), and 33.2% (17,940/54,052) were unaware that male homosexual behavior is the main route of HIV transmission among young Chinese students (Q4). Only 64.7% of respondents reported having heard of PEP, but nearly all respondents (91.7%, 49,549/54,052) expressed willingness to take the drug after possible HIV exposure to prevent seroconversion. When asked the multiple-choice question on where to find PEP drugs, the answers were Centers for Disease Control and Prevention (82.3%, 28,773/34,958), hospitals (83.1%, 29,067/34,958), community-based organizations (20.5%, 7,176/34,958), and online purchases (13.6%, 4,746/34,958). Nearly all respondents knew that an HIV test should be taken after risky behaviors (97.5%, 52,697/54,052) to know their status, start treatment, and suppress HIV replication (97.8%, 52,859/54,052). Furthermore, 98.2% (53,082/54,052) indicated that HIV testing could give them peace of mind. However, 37.4% (20,204/54,052) of respondents worry about others’ attitudes, and 19.7% (10,669/54,052) worry about a positive result. Still 57.9% (31,321/54,052) have not heard of HIV self-testing (HIVST) (Table 2).

Among those who reported sexual experience, 33.2% (1,790/5,384) first had sex at the age of 18, followed by 22.3% (1,203/5,384) at 17 or below, and 17.4% (937/5,384) at 20. Among the first sexual experiences, 2.2% (116/5,384) were forced sex, 9.1% (489/5,384) were sex between males, and 72.4% (3,896/5,384) were with correct condom use. Among them, 84.9% (4,573/5,384) had sex in the past 12 months, of which 94.2% (4,307/4,573) reported having a fixed partner. Of those with fixed partners, 71.4% (3,076/4,307) reported consistent condom use. However, 29.7% (1,359/4,573) reported casual sex, with 65.5% (890/1,359) reporting consistent condom use. In addition, 15.5% (708/4,573) reported sex with a commercial partner, during which 64.3% (455/708) reported consistent condom use. Furthermore, 2.4% (109/4,573) reported drug use before/during sex. Approximately 6.4% (292/4,573) reported male homosexual intercourse in the past 12 months, of whom 36.0% had a role of either exclusively receptive anal sex (36.0%, 105/292) or mixed receptive and insertive anal sex (34.2%, 100/292). Among them, 42.1% (123/292) reported having more than one homosexual partner in the past 12 months. Overall, only 47.6% (139/292) reported consistent condom use during sex with another male (Table 3).

Among all respondents, 1,106 (2.0%, 1,106/54,052) reported ever having had an HIV test, with 67.5% (746/1,106) of them testing only once. Nearly half (48.0%, 531/1,106) had an HIV test in the past 6 months, and 32.6% (361/1,106) have had an HIVST. As for the major reasons for not using HIVST, 25.0% (186/745) did not know where to obtain HIVST kits and 18.3% (136/745) did not know how to conduct an HIVST.