HIV sexual risk behaviors and perception of risk among college students: implications for planning interventions

Recent statistics on the human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) show a continuing racial disparity. While African Americans represent 12.3% of the U. S. population, they account for 50% of HIV/AIDS diagnoses and are more than 15 times more likely in their lifetime to be diagnosed with HIV compared to Whites [1]. The Centers for Disease Control and Prevention (CDC) in 2002 estimated that 1 in 50 African American men and 1 in 60 African American women are infected with HIV. The transmission rates among African Americans have not declined significantly in response to effective interventions compared with Whites [2]. In 2006, rates of AIDS cases were 47.6 per 100,000 for African Americans compared to 5.4 for Whites [3]. Although both African American men and women are disproportionately represented in HIV/AIDS diagnosis, the disparity is greatest for African American women who experience rates more than 20 times (40.4 per 100,000 vs. 1.9 per 100,000) that of White women [1, 4].

Estimates show that 35% of new HIV infections among males and 32% of new HIV infections among females in the U.S. occur among individuals below the age of 29 years [5]. While the overall incidence of HIV infection has seen some decline in recent years, rates of HIV infection among young adults have not seen a proportionate decline [6]. At the end of 2004, an estimated 39,100 young adults ages 13-24 in the U. S. received an AIDS diagnosis, representing 4% of the nation's total estimated cases [7]. As in the general population, African American young adults have been disproportionately affected by the HIV/AIDS epidemic.

A 2002 CDC report noted that the "epicenter of the HIV/AIDS epidemic is college students" [8]. According to the Census Bureau, in 2006, about 18 million students were enrolled in U.S. colleges [9]. While CDC statistics do not provide specific data for college students, a study by Gayle and others [10] estimated that 1 in 500 college students in the U.S. is infected with HIV. It is reasonable to speculate that the HIV/AIDS cases may be higher among African American college students due to the high prevalence of HIV infection among young African Americans in the general population [11]. In fact, a study conducted by Hightow and colleagues [12] found a trend for increasing rates of HIV infection for African American men attending colleges and universities.

African American women are most likely to be infected with HIV through high risk heterosexual contact [5]. They are often unaware of their male partners' risk factors for HIV infection, such as unprotected sex with multiple partners, bisexuality, or injection drug use [13, 14]. Sexual contact is also the main risk factor for Black men. Male-to-male sexual contact was the primary risk factor for 48% of Black men with HIV/AIDS at the end of 2005, and high-risk heterosexual contact was the primary risk factor for 22% [15]. Substance users are more likely to engage in high-risk behaviors, such as unprotected sex, when they are under the influence of drugs or alcohol [16]. Sexually transmitted diseases (STDs), considered markers for HIV infection, are also more prevalent among African Americans. In 2005, African Americans were about 18 times as likely as Whites to have gonorrhea and about 5 times as likely to have syphilis [17]. Although African American students have increased risk of being infected with HIV as compared to White students, they do not manifest risk at the level that exists within their larger racial-ethnic community [18].

The college environment offers great opportunity for HIV high-risk behaviors, including unsafe sex [19]. College students are at risk because they tend to be sexually adventurous, often with multiple partners and do not consistently use condoms [20, 21]. Jemmott and Jemmott [22] found that only 20% of sexually experienced, unmarried African American undergraduates at a commuter university always used condoms. African American women, who constitute the population with highest rate of new infections, are likely to be infected while in college [23].

Most studies on African Americans and HIV infection have focused on low-income, urban, or intravenous injection users [24‐27]. Interventions developed for the African American general population may not be appropriate for African American college students. Studies conducted among African American college students [22, 28, 29], have focused mostly on condom use. In order to develop the body of knowledge necessary needed to develop interventions targeted to different ethnic/racial groups [20], it is necessary to study the overall HIV risk profile and perception of risk of African American college students, particularly their HIV risk behaviors in a variety of institutional settings. This approach is critical because of the plausible differences in risky behaviors between on-campus and off-campus (commuter) students. A 2001 study [30] found that a higher proportion of both male and female college students who stay off-campus report inconsistent condom use and two or more sexual partners compared with their on-campus colleagues. The study found that the two demographic variables that significantly predicted condom use among male and female students were age and student residence. Off-campus and older students had lower odds of consistent condom use.

The objective of this study is to determine the prevalence of HIV high risk behaviors and perception of HIV risk among students in a minority serving urban commuter university. As a sub-objective, we also explored the prevalence of HIV risky behaviors by sexual preference. In this article, we report high risk HIV risk behaviors and perception of risk of HIV infection among students in this minority institution, and discuss the implications of our findings for the planning of HIV prevention interventions for African American college students. This exploratory study provided the basis for the design and implementation of an HIV prevention intervention for students in this institution.

In this study, we examined the HIV sexual risk behaviors and HIV risk perception of college students in a predominantly African American, commuter urban university located in the Midwest. The findings confirmed the prevalence of high risk sexual behaviors and low perception of risk in this cohort. Significant differences in high risk sexual behaviors found in this study support the earlier recommendation by Lewis et al. [20] of the need to conduct cross-sectional studies among diverse student populations in different settings.

Having multiple sexual partners is a recognized HIV risk [37, 38]. Therefore, reducing the number of sexual partners is a worthwhile HIV prevention strategy. Among never married respondents in our study, multiple partnerships and lack of condom use were very high. While multiple partnerships were prevalent among all "relationship types" examined, the prevalence was highest in male/female relationships with almost half of males reporting having two or more female sexual partners in the last 3 months. The rates of multiple partnership found in this study are lower than reported by Bazargan et al.[18]. This difference should be interpreted with caution as the Bazargan et al. study was conducted with a racially similar but younger population and other factors including residency and campus type may play some role. The findings of respondents 30 years and older of both genders being least likely to report multiple partnerships is consistent with report from a study by Opt and colleagues [39], which compared "traditional" (younger) and "non-traditional" (older) students in a predominantly White institution and found a lower percentage of non-traditional students reporting multiple partnerships. These findings may be attributed to the "maturing out" phenomenon. Overall, respondents who reported alcohol or illegal drug use in the last 30 days were more likely in all cases to have two or more partners. This once again suggests that individuals with one HIV risky behavior are more likely to exhibit others.

Condom use was largely low among sexually experienced respondents of all ages in our sample in our sample. The rates of consistent condom use in the last 30 days during sex are much lower than the 37% reported in studies [31‐43] with predominantly White college students. The finding that respondents age 30 years or older were significantly more likely than those below 30 years to report that they or their partners did not use a condom during last sex and are less likely to report that they or their partners always used a condom during sex in the last 30 days was unexpected. The same age group was less likely to report having more than one sexual partner. As a result of this paradox, any protective effect conferred by having single partnership is eroded by lack of condom use because their partners may also have other partners. Females were also significantly more likely than males to report that they or their partners did not use a condom during last sex and less likely to report that they or their partners always used a condom during sex in the last 30 days. Low condom use among females is quite troubling because women are more likely than men to be infected with HIV during sexual intercourse. While we did not explore who the sexual partners of the respondents in our study are, we assume they will be mostly other students. Therefore, the tandem of high rates of multiple partnerships among males and low condom use among females are of public health concern.

Alcohol and drug use are believed to increase sexual risk taking. Several studies [8, 44] including the National Youth Risk Behavior Survey [45] have documented this relationship. The use of marijuana, which is more prevalent among our sample than in national surveys of college students [46, 47], was significantly correlated with inconsistent condom use, while having at least one drink of alcohol in the previous 30 days was correlated with not using a condom last sex among females. As a group, individuals who use illegal drugs, including marijuana, were also more likely to report having multiple sexual partners and inconsistent condom use. This observation is not surprising as previous studies [48, 49] have shown that individuals engaging in HIV risk behaviors often engage in other high risk or illegal behaviors. These findings will indicate that more attention needs to be focused on the role of alcohol and drug use in the participation HIV sexual risk behaviors in the design and implementation of HIV prevention programs for college students.

Perception of risk may be a strong motivating factor for behavioral change, particularly if the individual perceives control over the risk behavior [50]. The tendency to systematically underestimate personal risk termed 'optimistic bias [51] and treating HIV infection as a distant possibility [52] have been reported among college students. Despite the high level high risk HIV sexual risk behaviors among our sample, self-perception of HIV was low. The risk here is that students might not take any HIV preventive measures as have a poor perception of their risk status. The only silver lining here was that students who reported marijuana, alcohol, or other drug use, inconsistent condom use, and multiple sexual partners were significantly more likely than those who did not to perceive themselves as having a moderate to good risk of being infected with HIV.

In an age in which the use of technology has improved communication and information delivery, college student television broadcasts, student cell phone number registration to transmit prevention messages periodically, use of blogs, students newspapers are all approaches that can be considered in designing HIV prevention interventions for college students. All these communication channels should emphasize the importance of condom use and minimizing the number of sexual partners. The use of computer based programs has been successfully implemented on some college campuses. In addition, providing free condoms in college or student residence hall bathrooms can be done. All these should occur only after an assessment of HIV prevention needs assessment on college campuses.

The students in our study had several risk factors for HIV infection and transmission and paradoxically poor risk perception for HIV infection. Their engagement in HIV sexual risk behaviors varied by age and gender. Condom use was generally poor for older students, while alcohol and drug use was important for women. The findings suggest that college students can not be considered a homogenous population for which one type of intervention will be effective. This is particularly true for colleges with older non-traditional students. These older non-traditional students, particularly those who have full-time employment like those in our study sample, might not be receiving HIV prevention interventions in their communities or place of work. The college environment therefore provides opportunities to reach them with HIV prevention interventions.