To response HIV infections among the college students, the National Health Commission of China keeps continuously strengthening the publicity and health education to reduce HIV infection risks of the students, and improve their self-protection capabilities[8, 14].Due to the factors such as acceptance of a natural opening to sex, and being in the sexually active period, the implementation of nPEP among college students is one of the measures and strategies to prevent HIV infection after high-risk behaviors[15, 16]. It is necessary for the college students to understand and be aware of the nPEP knowledge and the access to nPEP services in order to timely receive nPEP after their exposure to high-risk sexual behaviors and reduce the risks of HIV infection.
21.7% of the surveyed students had sexual behavior in this study and among them 28.7% was homosexual, 66.1%heterosexual, and 5.2%bisexual. The rate of sexual behavior was much less than the rate(50%) of the 15-24 teenagers who had sex with temporary partners, but more than the rate of self-reported sexual behavior among college students in a cross sectional study nationwide during 2010-2015, which was from 8.3%to 10%, and the result of the study in Zhejiang province of China (6.5%).
This study found that the average awareness rate of AIDS knowledge among the college students in the three cities (85.6%) was higher than that of the students in Tanjin (75.8%) and Harbin (72.7%), which was similar to the results of the students in the survey of surveillance sentinel in Haikou (81.1% -88.5%) in recent years. In the three cities, the awareness rate of the college students in Beijing was significantly lower than that in the other two cities. The reason may be related to the sample size, in which the students in Beijing was larger and younger with less relevant AIDS knowledge, than those of other two cities. So the rate of 85.6%is lower than the rate required by the national health authority on the awareness rate of AIDS prevention knowledge among college students 95%. It suggests we need to further strengthen the AIDS knowledge education especially for the freshmen when they were enrolled in the colleges.
The rates of once hearing of nPEP services, awareness of nPEP knowledge, and acceptance of nPEP services among the college students were 48.6%, 16.5%, and 2.4% respectively. There was a trend of gradual downward among these three indexes. This trend showed the logical relation of KABP (knowledge, attitude, belief, practice) pattern of behavior change. The results also showed 48.6% of the college students in this survey heard of nPEP, which was higher than that of MSM with24.2% in other study in Guangxi of China. 42.2% of students who heard of nPEP knew the role of nPEP as preventing HIV correctly. 57.2% of them thought nPEP should be initiated as soon as possible, within no later than 72 hours after the potential exposure. This finding reflects the awareness of comprehensive knowledge of nPEP related the role and the timing of nPEP, which were the basic criteria of clinical management of nPEP, was weak and poor among college students.
During nPEP medications, it is necessary to maintain HIV preventive approaches such as using condom.97.2% of students who heard of nPEP knew using a condom while taking nPEP. It will help college students to avoid behavioral disinhibition occurs during nPEP medications. The behavioral disinhibition of nPEP receivers will decrease condom use or increase other HIV infection risk behaviors, because they think they are protected from HIV infection by nPEP.
Although the correct awareness rates of any single question about nPEP was high (42.2%, 57.2%, 97.2%), the level of comprehensive rate (16.5%) was still low. This finding might related to health education for AIDS and nPEP knowledge in college campus was not enough or not effective, and suggests that comprehensive PEP knowledge publicity and education should be given to college students to help them to recognize the risk of HIV-related behaviors, and acquire the knowledge and skills of nPEP, while health education of the knowledge of AIDS prevention and control combined with publicity campaigns delivered by the colleges, student club or union, etc.
According to the survey, the rate of awareness of nPEP knowledge among college students who know the knowledge of AIDS was higher than that of those who do not know the knowledge of AIDS. The reason may be the correlation of knowledge of AIDS and nPEP knowledge, and awareness of knowledge of AIDS will promote acquisition of knowledge of AIDS. The result suggests that the content of health education in college should adapt to the new situation which the number of newly reported HIV/AIDS cases among college students has been increasing year by year, and the transmission route is mainly by male homosexual transmission, the prevention and control facing with more challenges in college.
To remove the influence of confounding variables, the logistic regression analysis included predictors such as social demographic information, knowledge of AIDS and nPEP, and sexual behavior characteristic. We found the received nPEP services among college students age 18 and below， and 19-year-old age group were higher compared with the students with age group of 22-24 years old. The reason for this result likely to be that college students age 18 and below，and 19-year-old age group were freshman and sophomore of college; when students enter college, they are relieved from highly intensive study pressure and entrance tests in high school, escaping their parents’ supervision and school’s management. And they had less academic burden and more social time when college beginning. Students have ready access to information via the Internet and can connect to social networks, e.g., the gay community, casual sex partner.Therefore, it is important to develop health education lessons and materials targeting the freshman and sophomore of college.
Through analysis, it was found that the proportion of male college students was higher in nPEP medication than female students. It is suggested that male students may have high-risk behaviors or factors that lead to high-risk behaviors when they are newly enrolled. Students have certain demands for nPEP medication. The part of students at this stage should be the critical point and target of AIDS prevention and control in colleges.
The proportion of college student’s male homosexual and heterosexual behavior received nPEP services was higher than asexuality student group. The high proportion of receiving nPEP services indirectly reflects the high incidence of high-risk behaviors among this group. It is suggested that the group of men who have sex with men is the main high-risk group among college students. After realizing the risk of HIV exposure or high-risk sexual behavior, they have a strong sense of seeking counseling and assistance, and a willingness to further accept nPEP services. It also reminded that men who have sex with men among college students are the key people in the comprehensive intervention of AIDS prevention and control in colleges and universities[28,29], and the target population of nPEP knowledge promotion. With the development of economy and the frequent international cultural exchanges in recent 20 years, the Chinese have become more tolerant toward various sexual practices, sexual freedom, and openness, like homosexuality, casual sex and pre-marital sex, especially among youths. The results of previous studies showed that the phenomenon of high level of knowledge related to AIDS[30,31], but more sexual partners and low condom utilization rate also exists widely among MSM college students. It was necessary and urgency of carrying out effective knowledge publicity of AIDS prevention and control, and nPEP knowledge in colleges and providing the classes of health education. While promoting nPEP knowledge, colleges and universities should still emphasize the importance of healthy sex, safe sex and condom use, so as to prevent over-reliance on nPEP and "disinhibition" of high-risk behaviors.
MSM college students are characterized by the high-risk HIV-related sexual behaviors, such as young age of first intercourse, multi-sex partners, low rate of condom use, group sex, commercial behavior and drug abuse. Particularly, they usually had high rate of AIDS knowledge, but low rate of safe sexual behavior like condom use, and more sexual partners. AIDS prevention and treatment for this group needs to be paid more attention, and effective measures are urgently needed to intervene high-risk sexual behaviors.
The result of the study showed the awareness of AIDS and nPEP knowledge among the college students were factors for acceptance of nPEP services. The group without the knowledge had the higher rate of the acceptance of nPEP services than that with AIDS and nPEP knowledge because the group without AIDS and nPEP knowledge would have more high-risk behavior, which was more likely to lead them to access to the nPEP services. It is recommended that public education be promoted to increase nPEP knowledge and services for the college students, to let them know what is the nPEP, what is the time for nPEP, and how to assess the risk of exposure to the infection, HIV counseling and testing, management, and follow-up.
There were some limitations in this study. First, the definition of nPEP knowledge awareness only covers three questions, related to the use of nPEP by the potential users, timing of nPEP and condom use during nPEP. It is not related to counseling and testing, treatment, and follow-up. The questions need to be developed further and standardized in the future. Second, the distribution of the college students in the study were unevenly in grades, with fewer freshmen and seniors about to graduate, and the group may have relatively high-risk behavior. Third, the nPEP services should include counseling, testing and antiretroviral drug treatment (ART). This might be because parts of the college students may only access to counseling and testing services without taking nPEP for 28 days, and they had not experienced in the whole process of nPEP. This may be because the surveys were conducted online and some participants just received counseling without taking nPEP, so the number of the students receiving nPEP services may be overestimated. Forth, because the snowball sampling was used instead of common statistical sampling methods in this study, the sample was not fully representative of college students.
We will further refine high-risk sexual behavior factors, such as condom use, number of sex partners, and explore the impact of behavioral factors other than sexual behavior factors on nPEP knowledge and application among college students.