Original research article
HIV knowledge, risk perception and pre-exposure prophylaxis interest among Thai university students
International Journal of STD & AIDS 2015, Vol. 26(14) 1007–1016 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414564607 std.sagepub.com
Thana Khawcharoenporn1,2, Krongtip Chunloy2 and Anucha Apisarnthanarak1,2
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 ¼ 0.004), being homosexual or bisexual (P ¼ 0.02) and being students from a non-medicine faculty (P ¼ 0.04). Of the 641 participants, 211 (33%) were not interested in PrEP. Consistent condom use with oral sex (P ¼ 0.004), consistent condom use with vaginal sex (P ¼ 0.04) and being heterosexual (P ¼ 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 Date received: 22 September 2014; accepted: 24 November 2014
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 HIVnegative 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 1 Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathumthani, Thailand 2 HIV/AIDS Care Unit of Thammasat Univesity Hospital, Pathumthani, Thailand
Corresponding author: Thana Khawcharoenporn, Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Klong Luang, Pathumthani 12120, Thailand. Email: [email protected]
Downloaded from std.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
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International Journal of STD & AIDS 26(14)
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
Table 1. Human immunodeficiency virus (HIV) risk stratification according to the pre-specified reported characteristics and behaviours of the survey participants and their partners. HIV risk Characteristics and behaviours 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 sexa Always Most of the time About a half of time Sometimes Never Using condom with oral sexa Always Most of the time About a half of time Sometimes Never Using condom with anal sexa Always Most of the time About a half of time Sometimes Never Exchanging sex for money or drugsa 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
Downloaded from std.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
Low Moderate High
ˇ ˇ ˇ
ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ (continued)
Khawcharoenporn et al.
1009
Table 1. Continued. HIV risk Characteristics and behaviours
Low Moderate High
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
ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ
‘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.
ˇ
Statistical analyses ˇ ˇ
ˇ ˇ
ˇ ˇ
ˇ
Sexual partner had ever been in a jail or a prison No ˇ Yes
ˇ
ˇ
STIs: sexually transmitted infections. a In the lifetime.
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.
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
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 2 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
Downloaded from std.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
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International Journal of STD & AIDS 26(14)
Table 2. Reported characteristics, sexual, social and risk behaviours of the participants, stratified by gender. All (N ¼ 641)
Characteristics Demographics Age (years, median, IQR) Marital status Single Living with a domestic partner Monthly household income (baht) 0–15,000 15,001–60,000 60,001–150,000 More than 150,000 Education Faculty name Science Engineering Medicine Medical Technology Journalism and Mass Communication Laws Study year 1 2 3 4 5 6 Sexual social and risk behaviours HIV risk Low Moderate High Ever had sexual intercourse Sexual orientation Heterosexual Homosexual Bisexual Number of different sexual partners within the previous 30 days (median, IQR)b Number of new sexual partners within the previous 30 days (median, IQR)b Having vaginal sexc Use condom with vaginal sexc Never Sometimes About a half of time Most of the time Always
20 (19–21)
Men (N ¼ 264)
20 (19–21)
Women (N ¼ 377)
20 (20–21)
622 (97) 19 (3)
251 (95) 13 (5)
371 (98) 6 (2)
65 271 200 105
(10) (42) (31) (16)
27 108 85 44
(10) (41) (32) (17)
38 163 115 61
(10) (43) (31) (16)
119 104 102 100 114 102
(19) (16) (16) (16) (18) (16)
23 64 52 33 42 50
(9) (24) (20) (13) (16) (19)
96 40 50 67 72 52
(26) (11) (13) (18) (19) (14)
76 185 195 180 1 4
(12) (29) (30) (28) (0.2) (1)
32 88 77 65 0 2
(12) (33) (29) (25) (0) (1)
44 97 118 115 1 2
(12) (26) (31) (31) (0.3) (0.5)
Pa
0.42 0.74
0.95
HIV knowledge, risk perception and pre-exposure prophylaxis interest among Thai university students
International Journal of STD & AIDS 2015, Vol. 26(14) 1007–1016 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414564607 std.sagepub.com
Thana Khawcharoenporn1,2, Krongtip Chunloy2 and Anucha Apisarnthanarak1,2
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 ¼ 0.004), being homosexual or bisexual (P ¼ 0.02) and being students from a non-medicine faculty (P ¼ 0.04). Of the 641 participants, 211 (33%) were not interested in PrEP. Consistent condom use with oral sex (P ¼ 0.004), consistent condom use with vaginal sex (P ¼ 0.04) and being heterosexual (P ¼ 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 Date received: 22 September 2014; accepted: 24 November 2014
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 HIVnegative 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 1 Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Pathumthani, Thailand 2 HIV/AIDS Care Unit of Thammasat Univesity Hospital, Pathumthani, Thailand
Corresponding author: Thana Khawcharoenporn, Division of Infectious Diseases, Faculty of Medicine, Thammasat University, Klong Luang, Pathumthani 12120, Thailand. Email: [email protected]
Downloaded from std.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
1008
International Journal of STD & AIDS 26(14)
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
Table 1. Human immunodeficiency virus (HIV) risk stratification according to the pre-specified reported characteristics and behaviours of the survey participants and their partners. HIV risk Characteristics and behaviours 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 sexa Always Most of the time About a half of time Sometimes Never Using condom with oral sexa Always Most of the time About a half of time Sometimes Never Using condom with anal sexa Always Most of the time About a half of time Sometimes Never Exchanging sex for money or drugsa 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
Downloaded from std.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
Low Moderate High
ˇ ˇ ˇ
ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ (continued)
Khawcharoenporn et al.
1009
Table 1. Continued. HIV risk Characteristics and behaviours
Low Moderate High
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
ˇ ˇ ˇ ˇ ˇ ˇ ˇ ˇ
‘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.
ˇ
Statistical analyses ˇ ˇ
ˇ ˇ
ˇ ˇ
ˇ
Sexual partner had ever been in a jail or a prison No ˇ Yes
ˇ
ˇ
STIs: sexually transmitted infections. a In the lifetime.
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.
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
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 2 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
Downloaded from std.sagepub.com at CHINESE UNIV HONG KONG LIB on November 16, 2015
1010
International Journal of STD & AIDS 26(14)
Table 2. Reported characteristics, sexual, social and risk behaviours of the participants, stratified by gender. All (N ¼ 641)
Characteristics Demographics Age (years, median, IQR) Marital status Single Living with a domestic partner Monthly household income (baht) 0–15,000 15,001–60,000 60,001–150,000 More than 150,000 Education Faculty name Science Engineering Medicine Medical Technology Journalism and Mass Communication Laws Study year 1 2 3 4 5 6 Sexual social and risk behaviours HIV risk Low Moderate High Ever had sexual intercourse Sexual orientation Heterosexual Homosexual Bisexual Number of different sexual partners within the previous 30 days (median, IQR)b Number of new sexual partners within the previous 30 days (median, IQR)b Having vaginal sexc Use condom with vaginal sexc Never Sometimes About a half of time Most of the time Always
20 (19–21)
Men (N ¼ 264)
20 (19–21)
Women (N ¼ 377)
20 (20–21)
622 (97) 19 (3)
251 (95) 13 (5)
371 (98) 6 (2)
65 271 200 105
(10) (42) (31) (16)
27 108 85 44
(10) (41) (32) (17)
38 163 115 61
(10) (43) (31) (16)
119 104 102 100 114 102
(19) (16) (16) (16) (18) (16)
23 64 52 33 42 50
(9) (24) (20) (13) (16) (19)
96 40 50 67 72 52
(26) (11) (13) (18) (19) (14)
76 185 195 180 1 4
(12) (29) (30) (28) (0.2) (1)
32 88 77 65 0 2
(12) (33) (29) (25) (0) (1)
44 97 118 115 1 2
(12) (26) (31) (31) (0.3) (0.5)
Pa
0.42 0.74
0.95
