The results of this study suggest that undergraduates in mainland China tended to systematically overestimate their risk relative to their self-reported exposure to unsafe sex, because approximately half of the participants perceived themselves to be at risk of HIV infection, yet only 8.9% reported they had in fact engaged in risky sexual behaviors such as having multiple sexual partners in the past six months, having sex with non-regular partners, or failing to use condoms correctly and consistently. Monde inferred that a large-scale public health campaign, which has recently been conducted to distribute the information about the severity of HIV infection, contributed to the overestimation of risk of being infected by HIV [21]. However, Fagbamigbe and colleagues [26] thought overestimation of self-perceived risk could serve as a cautionary message to even HIV-uninfected individuals to have safer sex.
Consistent with previous studies [27,28], no significant relationship was found between perceived and actual risks. This apparent discordance can be explained by the following three factors. One possible explanation is that only sex-related risky behaviors [28] were assessed in this study, given the fact that the predominant mode of HIV transmission among Chinese young students is through sexual intercourse, accounting for up to 81.6% of new HIV infections in 2014. The second possible explanation is that self-perception of HIV risk question, despite being widely applied, has a low positive predictive value (i.e. only a minority of the individuals who perceived themselves to be at risk were actually HIV infected [26]), especially in the low-prevalence population [29]. Therefore, self-perception of risk may not truly indicate the presence of an HIV infection, but reflect a worry about being infected with HIV. The third possible explanation is that undergraduates have a tendency to under-report their risky sexual behaviors due to the sensitivity of these questions.
Based on the health belief model, eight variables (i.e., gender, sexual orientation, residential areas, grade, awareness of the national AIDS policy, willingness to utilize HCT service, HIV-related stigma and self-efficacy of condom use) were found to be significantly associated with self-perceived risk of HIV acquisition. Some of these findings were consistent with previous research.
Contrary to findings of a previous study [11], female undergraduates were more likely to perceive themselves to be at risk of contracting HIV, due to their lower awareness [20] and also because they remain in vulnerable positions during sexual intercourse and have less power to refuse sex or negotiate for safe sex [16]. On the other hand, females' perception was higher possibly because they were more likely to shoulder the burden of caring for a chronically ill family member including an AIDS victim and the intimate contact with patients aroused their sense of being at risk of HIV infection. Non-heterosexual individuals, who have long been identified as target audience for many prevention programs, made relatively accurate evaluation of their risks and thus exhibited higher levels of self-perceived risk of HIV infection.
Similar to the findings from a previous study conducted by Admasu, Kifle, Tefera, Nega, Meseret and Rai, 83.4% of undergraduates expressed their willingness to use VCT service, and those who had the intention of utilizing VCT service were more likely to perceive themselves at risk of acquiring HIV [23]. This result has important implication for the government to launch a large-scale testing campaign to achieve the ambitious "90–90–90" targets by 2020 and the final goal of zero AIDS.
Our findings also indicated that non-freshmen, urban undergraduates, and those who knew about the national AIDS policy were less likely to perceive themselves at risk, compared to their respective counterparts. These finding support the idea that exposure to accurate levels of HIV and AIDS information through the media, health education and access to VCT services may improve knowledge about risks for HIV infection and dispel worries about being infected with the virus, which can help to a certain extent reduce overestimation bias and contribute to accurate risk perception.
Our findings indicated that stigma is highly prevalent among undergraduates and stems from the fact that HIV infection is linked to immoral behaviors such as homosexuality, drug addiction and prostitution. Therefore, undergraduates with higher stigma would be less likely to perceive themselves to be at risk of contracting HIV, because they adopted cognitive coping strategies such as denial, distancing, and downward comparison to minimize their HIV risk perception [16,21,23,30].
Consistent with the health belief model, undergraduates with higher self-efficacy of condom use are indeed more likely to use condoms during sexual intercourse to prevent HIV transmission and are consequently less likely to perceive themselves to be at risk of contracting HIV.
Limitation
Our study has several limitations. First, because this study used a cross-sectional design, it is impossible to draw firm causal conclusions due to the uncertainty and ambiguity associated with temporal orderings among the observational variables. Second, all data were self-reported and anonymous, so there was no mechanism to verify survey responses. Third, dichotomizing self-perception of possibly having an HIV infection might oversimplified or magnified differences of the measured relationships. However, when performing Logistic regression models with any of the interval, we found that all these independent variables were consistently significant predictors of self-perception of HIV infection. Therefore, the use of dichotomized risk perception was an appropriate strategy given the purposes of the current investigation. Fourth, due to the sensitivity of sexual behaviors, respondents might be reluctant to admit their sexual experiences or that they are sexually active, thus introducing misclassification bias into the assessment of the association between self-perceived risk and past sexual behaviours. Finally, after answering the questions regarding HIV-related risky behaviors, undergraduates were then required to assess their risks of being infected with HIV, which might affect participant responses and the observed relationships, according to Alexovitz and colleagues [31].
Implications of the study
In spite of the above-mentioned limitations, the findings from our study have several implications for the design and implementation of HIV risk reduction programs on college campuses. To the best of our knowledge, ours is the first to employ the health belief model as theoretical framework, combined with the more rigorous statistical techniques, to determine the level of self-perceived risk of HIV infection and the factors associated with HIV risk perception among a large undergraduate sample selected from 30 provinces throughout the whole country (except for Tibet). Our findings suggested that females, undergraduates residing in urban areas, having higher levels of condom use self-efficacy and being knowledgeable of the national AIDS policy were less likely to perceive themselves to be at risk of acquiring HIV, while freshmen, non-heterosexuals and those who had expressed less stigma towards PLHIV and more willingness to utilize VCT service perceived themselves to be at increased risk for HIV infection. Consequently, five main types of intervention aimed at helping undergraduates accurately assess their risk of being infected with HIV and effectively avoid risk are recommended.
(1) Target undergraduates with higher risk perception: Undergraduates in this study have a tendency to overestimate their own risk of acquiring HIV infection and no significant relationship was found between perceived and actual risks. In order to help undergraduates accurately assess their risk of being infected with HIV and effectively protect themselves from negative outcomes, the first and foremost intervention is to target undergraduates with higher risk perception such as females, non-heterosexuals, freshmen and those residing in rural areas so as to better understand the relationship between their actual behavioral risk and perceptions of risk, given the fact that the ability to accurately judge one's risk to HIV is an essential element in developing and implementing successful strategies for prevention [16, 21].
(2) Enhance condom-use self-efficacy: due to its simplicity, cheapness, safety and effectiveness, consistent condom use is still highly recommended for college students to prevent HIV and other sexually transmitted diseases. In order to promote consistent use of condoms, it is of program and policy relevance to improve their skills for negotiation of condom use. Also, the intervention should focus on the individuals' perceived barriers to negotiating with sexual partners about condom use and develop strategies appropriate to make these individuals feel at ease with the negotiating process and thus enhance condom-use self-efficacy [32].
(3) Conduct a large-scale education campaign: a large-scale education campaign should be launched to inform the undergraduates of HIV-related knowledge and the national AIDS policy (i.e., "Four Frees and One care" policy), so as to relieve stigma against PLHIV and dispel worries about being infected with the virus, and consequently reduce overestimation bias and contribute to accurate risk perception, and finally to adopt safety measures and to achieve the ultimate goal of zero-AIDS.
(4) Provide free VCT services in college campus: According to a study conducted by Addis and colleagues [33], the main reason cited by university students for not utilizing VCT was fear of a positive result and fear of being stigmatized. Furthermore, given the fact that the majority of undergraduates expressed their willingness to use VCT service, continued effort should be made to recruit and train student volunteers to provide free VCT services in college campus [25], and meanwhile more effort should be made to provide positive individuals with the information about the treatability and controllability of HIV infection [33].