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PrEP Awareness, Willingness, and Likelihood to Use Future HIV Prevention Methods among Undergraduate College Students in an Ending the HIV Epidemic Jurisdiction

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Title: PrEP Awareness, Willingness, and Likelihood to Use Future HIV Prevention Methods among Undergraduate College Students in an Ending the HIV Epidemic Jurisdiction
Language: English
Authors: Meagan Zarwell (ORCID 0000-0002-3562-7415), Alexandra Patton, Laura H. Gunn, Alyssa Benziger, Brian Witt, Patrick A. Robinson, Debra F. Terrell
Source: Journal of American College Health. 2025 73(2):700-709.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 10
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Acquired Immunodeficiency Syndrome (AIDS), Equal Education, Sex Education, Health Education, Intervention, Undergraduate Students, Student Attitudes, Prevention, Private Colleges, Black Colleges, Student Surveys, LGBTQ People, Sexual Orientation, Gender Identity, Health Behavior, Contraception, Futures (of Society), Student Characteristics
Geographic Terms: North Carolina
DOI: 10.1080/07448481.2023.2232885
ISSN: 0744-8481
1940-3208
Abstract: Objective: Identify factors associated with PrEP awareness, willingness, and future prevention modalities among undergraduate college students. Participants: Undergraduates (N=701) were recruited from a private university, a public research university, and a private historically Black college and university for an online survey. Methods: Upon multiple imputations, a multivariate logistic model, a multivariate multinomial model, and independent multivariate ordinal logistic models were used to calculate Rubin's rules-pooled adjusted odds ratios for PrEP awareness, willingness, and future HIV prevention methods. Results: Only 33.4% of students had heard of and 32.4% were willing to take PrEP. PrEP willingness was higher among sexual minority students compared to heterosexual/straight students (OR = 1.65; 95% CI: 1.03-2.63); p=0.036). The likelihood to take a future vaccine or antibody prophylaxis treatment was higher than the likelihood to take injectable PrEP or implants. Conclusions: Interventions to increase PrEP uptake and willingness among undergraduates should emphasize equity in HIV education and include future prevention modalities.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1472510
Database: ERIC
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  Value: <anid>AN0182848221;acl01feb.25;2025Feb10.04:08;v2.2.500</anid> <title id="AN0182848221-1">PrEP awareness, willingness, and likelihood to use future HIV prevention methods among undergraduate college students in an ending the HIV epidemic jurisdiction </title> <p>Objective: Identify factors associated with PrEP awareness, willingness, and future prevention modalities among undergraduate college students. Participants: Undergraduates (N = 701) were recruited from a private university, a public research university, and a private historically Black college and university for an online survey. Methods: Upon multiple imputations, a multivariate logistic model, a multivariate multinomial model, and independent multivariate ordinal logistic models were used to calculate Rubin's rules-pooled adjusted odds ratios for PrEP awareness, willingness, and future HIV prevention methods. Results: Only 33.4% of students had heard of and 32.4% were willing to take PrEP. PrEP willingness was higher among sexual minority students compared to heterosexual/straight students (OR = 1.65; 95% CI: 1.03–2.63); p =.036). The likelihood to take a future vaccine or antibody prophylaxis treatment was higher than the likelihood to take injectable PrEP or implants. Conclusions: Interventions to increase PrEP uptake and willingness among undergraduates should emphasize equity in HIV education and include future prevention modalities.</p> <p>Keywords: HIV prevention; PrEP; sexual health; undergraduate college students</p> <hd id="AN0182848221-2">Introduction</hd> <p>New HIV diagnoses persist among people ages 13–24 in the United States, with 20.8% of new HIV diagnoses occurring among this group in 2019.[<reflink idref="bib1" id="ref1">1</reflink>] The highest number of new diagnoses occurred among people ages 25 to 34 (35.7%). Mecklenburg County, North Carolina, a large urban-suburban county with a population of over 1.1 million, experiences the highest number of new HIV diagnoses in the state per year. One in six new HIV diagnoses between 2015 and 2019 occurred among young people ages 13–24 years.[<reflink idref="bib2" id="ref2">2</reflink>] Ongoing transmission among young persons may be attributed to lower awareness of HIV status, low rates of testing, higher rates of STIs, condomless sex, and lower uptake of pre-exposure prophylaxis (PrEP) to prevent sexual transmission.[[<reflink idref="bib3" id="ref3">3</reflink>], [<reflink idref="bib5" id="ref4">5</reflink>]]</p> <p>HIV incidence also varies by sexual minority status, race, and gender. Sexual minoritized men (SMM; including those who are gay, bisexual, or another sexual orientation) accounted for 69% of newly diagnosed HIV cases in 2019.[<reflink idref="bib1" id="ref5">1</reflink>] African American and Hispanic SMM comprised 70% of all new diagnoses among SMM. Moreover, 81% of diagnoses among SMM were among adolescents and young adults ages 13–24. In 2019, women accounted for only 19% of all HIV diagnoses. However, 55% of those diagnoses were among African American women and 27% of new diagnoses were among women ages 25 to 34.[<reflink idref="bib6" id="ref6">6</reflink>] Better outreach and education among young people to reduce HIV transmission are needed.</p> <p>Prior studies indicate low awareness of and engagement in HIV prevention among college students. A national survey among 23,600 undergraduate students found that only 8.5% had been tested for HIV in the previous 12 months.[<reflink idref="bib7" id="ref7">7</reflink>] Stutts et al. (2022)[<reflink idref="bib8" id="ref8">8</reflink>] surveyed 1,516 undergraduate students in North Carolina and found that 73% did not use condoms consistently, 41% had never tested for HIV, and 54.8% had never heard of PrEP. Nkwonta and Harrison (2023)[<reflink idref="bib9" id="ref9">9</reflink>] reported that although 84.8% of the 256 students surveyed in South Carolina were sexually active, only 18.7% considered themselves at risk for HIV and 8% had previously been tested for HIV. Moreover, HIV knowledge was suboptimal: on average students answered approximately 66% of questions correctly. Low rates of testing among college students are concerning because studies suggest that HIV testing can both improve knowledge and ameliorate HIV-related stigma among college students. For example, a 2016 study among a random sample of 2,343 students found that more frequent testing was associated with higher HIV-related knowledge.[<reflink idref="bib10" id="ref10">10</reflink>] Higher knowledge scores were also associated with lower perceived HIV-related stigma. Another study from the 2012 American College Health Association (ACHA) National College Health Assessment II found that the odds of previously testing for HIV were higher among older students.[<reflink idref="bib7" id="ref11">7</reflink>] Low testing rates among college students may be attributed to multiple factors. A Northeastern U.S. study found college students may have low perceived susceptibility of acquiring HIV, despite engaging in behaviors that increase HIV risk, such as having multiple sex partners, inconsistent condom use, and alcohol use.[<reflink idref="bib11" id="ref12">11</reflink>] HIV testing is also the gateway to accessing PrEP, a critical prevention tool to reduce HIV transmission.</p> <p>Despite its efficacy to prevent sexual transmission of HIV, PrEP awareness and uptake remain low among young persons.[<reflink idref="bib4" id="ref13">4</reflink>]<sups>,</sups>[[<reflink idref="bib12" id="ref14">12</reflink>], [<reflink idref="bib14" id="ref15">14</reflink>]] For example, in 2020 the Centers for Disease Control and Prevention (CDC) estimated that PrEP coverage was only 15.6% among individuals with PrEP Indications between the ages of 16 and 24 years.[<reflink idref="bib14" id="ref16">14</reflink>] PrEP coverage was higher among men with PrEP indications (28.0%) compared to women (10.4%). By race and ethnicity, PrEP coverage among Black (9%) and Hispanic (15.6%) individuals with indications was substantially lower than coverage among white individuals (65.7%). A 2018 study that analyzed a national prescription database also found that PrEP uptake and awareness remained low among women, individuals younger than age 25, and people who live in the South.[<reflink idref="bib12" id="ref17">12</reflink>] Thus, younger individuals, women, and people with racial and ethnic minority idenities may experience the largest gap between PrEP eligibility and prescription. Research is needed that explores differences in PrEP awareness, willingness, and likelihood to use future HIV prevention methods among college students, including perceptions of next generation PrEP technologies (i.e. injectable PrEP), which was approved by the U.S. Food and Drug Administration in December of 2021.[<reflink idref="bib15" id="ref18">15</reflink>]</p> <p>U.S. Department of Health and Human Services' <emph>Ending the HIV Epidemic</emph> (EHE) initiative goals to increase PrEP coverage by 2030[<reflink idref="bib16" id="ref19">16</reflink>] will require innovative strategies to engage young persons, including college students. Suboptimal PrEP uptake among members of populations most affected by HIV highlights the need for more education among all young persons, including college students who comprise an important subgroup of the 13–24 age range. Reducing HIV among young people will require monitoring HIV education (including understanding HIV risk behaviors), access to resources, and willingness to use tools such as PrEP and confidential HIV testing.[<reflink idref="bib5" id="ref20">5</reflink>] The purpose of this study is to examine factors associated with PrEP awareness and willingness among undergraduate students in an urban area with elevated HIV incidence. The primary aim of this study is to explore whether demographic characteristics, HIV risk perceptions, testing history, HIV-related knowledge, and self-reported HIV risk behaviors are associated with: (<reflink idref="bib1" id="ref21">1</reflink>) PrEP awareness; (<reflink idref="bib2" id="ref22">2</reflink>) PrEP willingness; and (<reflink idref="bib3" id="ref23">3</reflink>) likelihood to use four different future HIV prevention methods.</p> <hd id="AN0182848221-3">Materials and methods</hd> <p></p> <hd id="AN0182848221-4">Procedures</hd> <p>Undergraduate college students were recruited to participate in an online survey in April and May of 2021 from three four-year institutions in Mecklenburg County: a private urban university, a public state university, and a private historically Black college or university (HBCU). Eligibility included undergraduate students, ages ≥18 years, currently enrolled at one of the universities, who could complete the online survey in English. An email describing the study and requesting participation was distributed through university listservs and within individual undergraduate courses. The survey included two screening questions to verify participant age and university enrollment prior to providing informed consent.</p> <p>Consenting participants were notified that the survey link would expire after approximately three weeks, coinciding with the end of the semester. Respondents completing the survey were invited to enter a raffle for a chance to win one of 10 $50 e-gift cards. The survey was conducted using an online Qualtrics (Provo UT, USA) survey platform. Average time for survey completion was approximately 15 min. This study was approved at the Institutional Review Boards at University of North Carolina at Charlotte and Johnson C. Smith University.</p> <hd id="AN0182848221-5">Measurements</hd> <p></p> <hd id="AN0182848221-6">HIV prevention methods</hd> <p>Data consists of six response variables and 11 covariates. Response variables include: (<reflink idref="bib1" id="ref24">1</reflink>) PrEP Awareness: "Before today, have you ever heard of Pre-Exposure Prophylaxis (PrEP), (e.g. Truvada or Descovy)," coded as binary ("No"/"Don't Know" and "Yes"); (<reflink idref="bib2" id="ref25">2</reflink>) PrEP Willingness: "Would you be willing to take a pill every day (i.e. PrEP) to prevent HIV infection?" coded as unordered categorical ("No," "Don't Know," and "Yes"); and (<reflink idref="bib3" id="ref26">3</reflink>)–(<reflink idref="bib6" id="ref27">6</reflink>) Likelihood to use four different HIV prevention methods in the future: "Researchers are developing medications and technologies to prevent HIV that may be available in the future. How likely would you be to consider using each of the following, if they were found to be effective at preventing HIV?" Items included: Long-acting injectable PrEP (LAIP), PrEP implant, antibody prophylaxis treatment, and vaccine. Each of these four measures were coded using a 5-point Likert scale ordered categorical variable, ranging from "Very Unlikely" to "Very Likely." Respondents who indicated "Don't Know" (DK) to any of the ordered categorical response variables were grouped with those who responded "Neutral."[<reflink idref="bib17" id="ref28">17</reflink>]</p> <hd id="AN0182848221-7">Demographic characteristics</hd> <p>Sexual minority status, a binary variable, was recoded from original categories "Straight/Heterosexual," "Gay," "Lesbian," "Bisexual," or "Another identity" (with a write-in option), with students not identifying as straight recoded as a sexual minority status. Age was recoded as binary ("18–22" vs "23+") from a continuous variable. Race/ethnicity included Hispanic, Asian, Black, white, and another race (inclusive of more than one race). Gender was recoded based on student responses from six original categories into three categories: cisgender men, cisgender women, and transgender (i.e. including nonbinary or another gender identity). Class year combined "first-year students and sophomores" versus "juniors and seniors." Insurance status responses were grouped as: "None," "Other," "Parent," and "School." Institution response options include: "Private University," "Public Research University," and "a private HBCU."</p> <hd id="AN0182848221-8">HIV perceived risk, testing history, knowledge score, and risk score</hd> <p>HIV perceived risk ("In the next 12 months, how likely are you to get HIV") categories included "Very unlikely," "Somewhat unlikely" or "Not likely," "Somewhat likely" or "Very likely," and "Don't know." This measure was recoded based on responses into four categories: (a) "Somewhat unlikely"/"Not likely"; (b) "Somewhat likely"/"Very likely"; (c) "Very Unlikely"; and (d) "Don't know." Ever tested for HIV, a binary variable, was derived from responses to the question "Have you ever been diagnosed with HIV?" and included (a) never tested for HIV and (b) tested for HIV (with either negative or DK regarding test results). Participants with positive HIV test results were excluded because the study focuses on HIV prevention among people who are not living with HIV. HIV knowledge score was adapted from 11 true/false items from the HIV-KQ-18 scale.[<reflink idref="bib18" id="ref29">18</reflink>] This variable was constructed first as a composite score from 11 binary HIV knowledge questions, and then categorized according to overall knowledge based on the number of correct responses: (<reflink idref="bib1" id="ref30">1</reflink>) 0–6="Low knowledge"; (<reflink idref="bib2" id="ref31">2</reflink>) 7–8="Medium knowledge"; and (<reflink idref="bib3" id="ref32">3</reflink>) 9–11="High knowledge." The HIV risk score was constructed as a composite score-based categorical variable comprising self-reported measures within the past 3 months: (<reflink idref="bib1" id="ref33">1</reflink>) Number of sexual partners (0 = none; 1 = 1; 2 = 2 or more); (<reflink idref="bib2" id="ref34">2</reflink>) Condom usage during sex (0="Always"; 1="Less than half the time," "Half the time," or "More than half the time"; 2="Never"); and (<reflink idref="bib3" id="ref35">3</reflink>) sexually transmitted infection (STI) diagnosis (0="No"; 1="Don't know"; 2="Yes"). The composite HIV risk score was categorized as 0="Low risk," 1="Medium risk," and 2 or more="High risk." Those who responded with no sexual partners were not asked subsequent sexual risk questions and were categorized as low risk.</p> <hd id="AN0182848221-9">Statistical analysis</hd> <p>Descriptive statistics were conducted for all covariates and responses. Multiple imputations was performed on all missing values across responses and covariates except for the covariate HIV knowledge score. Item-level missingness was low across covariates and outcome measures (see Tables 1 and 2). For participants providing responses to at least eight of the items comprising this score, the remaining one to three questions were imputed. For those not responding to any of the questions, a "missing" category was created and kept throughout the analyses, as complete missingness may not occur at random and could be reflective of lack of interest/care or stigma about lack of knowledge, which could be informative of variability in the response variables for this population. Multiple imputations by chained equations was used for imputation[<reflink idref="bib19" id="ref36">19</reflink>] and combined for each model using Rubin's rules[<reflink idref="bib20" id="ref37">20</reflink>] with a common set of <emph>m</emph> = 5 imputations to facilitate retention of data in multivariable models.</p> <p>Table 1. Demographic characteristics, and perceptions of HIV risk, HIV knowledge, and HIV risk behaviors of undergraduate college students.</p> <p> <ephtml> <table><thead><tr><td>Measure</td><td>Response</td><td><italic>N</italic></td><td>%</td></tr></thead><tbody valign="top"><tr><td>Sexual minority status</td><td>No</td><td char=".">503</td><td char=".">71.8</td></tr><tr><td /><td>Yes</td><td char=".">198</td><td char=".">28.3</td></tr><tr><td>Age group</td><td>18–22</td><td char=".">570</td><td char=".">81.3</td></tr><tr><td /><td>23+</td><td char=".">131</td><td char=".">18.7</td></tr><tr><td>Race / Ethnicity</td><td>Asian</td><td char=".">49</td><td char=".">7.0</td></tr><tr><td /><td>Black</td><td char=".">111</td><td char=".">15.8</td></tr><tr><td /><td>Hispanic</td><td char=".">80</td><td char=".">11.4</td></tr><tr><td /><td>Another Race</td><td char=".">48</td><td char=".">6.9</td></tr><tr><td /><td>White</td><td char=".">413</td><td char=".">58.9</td></tr><tr><td>Gender identity</td><td>Cisgender man</td><td char=".">183</td><td char=".">26.1</td></tr><tr><td /><td>Cisgender woman</td><td char=".">485</td><td char=".">69.2</td></tr><tr><td /><td>Transgender<sup>d</sup></td><td char=".">33</td><td char=".">4.7</td></tr><tr><td>Class</td><td>First-year / Sophomore</td><td char=".">285</td><td char=".">40.7</td></tr><tr><td /><td>Junior / Senior</td><td char=".">416</td><td char=".">59.3</td></tr><tr><td>Insurance status</td><td>None</td><td char=".">15</td><td char=".">2.1</td></tr><tr><td /><td>Other</td><td char=".">104</td><td char=".">14.8</td></tr><tr><td /><td>Parent</td><td char=".">504</td><td char=".">71.9</td></tr><tr><td /><td>School</td><td char=".">78</td><td char=".">11.1</td></tr><tr><td>Institution</td><td>HBCU</td><td char=".">50</td><td char=".">7.1</td></tr><tr><td /><td>Private</td><td char=".">162</td><td char=".">23.1</td></tr><tr><td /><td>Public</td><td char=".">489</td><td char=".">69.8</td></tr><tr><td>HIV perceived risk</td><td>Very unlikely</td><td char=".">458</td><td char=".">65.3</td></tr><tr><td /><td>Somewhat unlikely / Not likely</td><td char=".">148</td><td char=".">21.1</td></tr><tr><td /><td>Somewhat likely / Very likely</td><td char=".">15</td><td char=".">2.1</td></tr><tr><td /><td>DK</td><td char=".">40</td><td char=".">5.7</td></tr><tr><td /><td>Missing<sup>b</sup></td><td char=".">40</td><td char=".">5.7</td></tr><tr><td>Ever tested for HIV<sup>a</sup></td><td>Never tested for HIV</td><td char=".">129</td><td char=".">18.4</td></tr><tr><td /><td>Tested but no HIV positive or DK</td><td char=".">539</td><td char=".">76.9</td></tr><tr><td /><td>Missing<sup>b</sup></td><td char=".">33</td><td char=".">4.7</td></tr><tr><td>HIV knowledge score</td><td>Low (0–6)</td><td char=".">264</td><td char=".">37.7</td></tr><tr><td /><td>Medium (7–8)</td><td char=".">241</td><td char=".">34.4</td></tr><tr><td /><td>High (9–11)</td><td char=".">161</td><td char=".">23.0</td></tr><tr><td /><td>Missing<sup>c</sup></td><td char=".">35</td><td char=".">5.0</td></tr><tr><td>HIV risk score</td><td>Low</td><td char=".">287</td><td char=".">40.9</td></tr><tr><td /><td>Medium</td><td char=".">85</td><td char=".">12.1</td></tr><tr><td /><td>High</td><td char=".">326</td><td char=".">46.5</td></tr><tr><td /><td>Missing<sup>b</sup></td><td char=".">3</td><td char=".">0.4</td></tr></tbody></table> </ephtml> </p> <p>1 DK: Don't know.</p> <ulist> <item>2 <sups>a</sups>Variable defined as "Have you ever been diagnosed with HIV?" – Diagnosed but status negative or unknown were combined into a common category; diagnosed and positive were excluded.</item> <item>3 <sups>b</sups>Missing values imputed using multiple imputations by chained equations.</item> <item>4 <sups>c</sups>Missing values kept as a separate category in the analysis.</item> <item>5 <sups>d</sups>Transgender or another gender identity such as nonbinary or agender.</item> </ulist> <p>Table 2. Descriptive statistics (counts and percentages) of outcome variables.</p> <p> <ephtml> <table><thead><tr><td>Outcome</td><td>Response</td><td><italic>N</italic></td><td>%</td></tr></thead><tbody valign="top"><tr><td>Before today, have you ever heard of Pre-Exposure Prophylaxis (PrEP), a daily pill</td><td>No/DK</td><td char=".">429</td><td char=".">61.2</td></tr><tr><td>Yes</td><td char=".">234</td><td char=".">33.4</td></tr><tr><td>Missing<sup>a</sup></td><td char=".">38</td><td char=".">5.4</td></tr><tr><td>Would you be willing to take a pill everyday (i.e. PrEP) to prevent HIV infection?</td><td>No</td><td char=".">236</td><td char=".">33.7</td></tr><tr><td>DK</td><td char=".">191</td><td char=".">27.3</td></tr><tr><td>Yes</td><td char=".">227</td><td char=".">32.4</td></tr><tr><td>Missing<sup>a</sup></td><td char=".">47</td><td char=".">6.7</td></tr><tr><td char=".">Long-acting injectable PrEP (Receive a shot every 1–2 months)</td><td>Very Unlikely</td><td char=".">154</td><td char=".">22.0</td></tr><tr><td>Unlikely</td><td char=".">143</td><td char=".">20.4</td></tr><tr><td>Neutral / DK</td><td char=".">169</td><td char=".">24.1</td></tr><tr><td>Likely</td><td char=".">110</td><td char=".">15.7</td></tr><tr><td>Very Likely</td><td char=".">73</td><td char=".">10.4</td></tr><tr><td>Missing<sup>a</sup></td><td char=".">52</td><td char=".">7.4</td></tr><tr><td>PrEP Implant (Device under the skin, similar to birth control)</td><td>Very Unlikely</td><td char=".">244</td><td char=".">34.8</td></tr><tr><td>Unlikely</td><td char=".">140</td><td char=".">20.0</td></tr><tr><td>Neutral / DK</td><td char=".">125</td><td char=".">17.8</td></tr><tr><td>Likely</td><td char=".">80</td><td char=".">11.4</td></tr><tr><td>Very Likely</td><td char=".">59</td><td char=".">8.4</td></tr><tr><td>Missing<sup>a</sup></td><td char=".">53</td><td char=".">7.6</td></tr><tr><td>Antibody Treatment (Receive a shot of anti-HIV antibodies)</td><td>Very Unlikely</td><td char=".">117</td><td char=".">16.7</td></tr><tr><td>Unlikely</td><td char=".">57</td><td char=".">8.1</td></tr><tr><td>Neutral / DK</td><td char=".">164</td><td char=".">23.4</td></tr><tr><td>Likely</td><td char=".">171</td><td char=".">24.4</td></tr><tr><td>Very Likely</td><td char=".">139</td><td char=".">19.8</td></tr><tr><td>Missing<sup>a</sup></td><td char=".">53</td><td char=".">7.6</td></tr><tr><td>Vaccine to prevent HIV Infection</td><td>Very Unlikely</td><td char=".">67</td><td char=".">9.6</td></tr><tr><td>Unlikely</td><td char=".">26</td><td char=".">3.7</td></tr><tr><td>Neutral / DK</td><td char=".">129</td><td char=".">18.4</td></tr><tr><td>Likely</td><td char=".">145</td><td char=".">20.7</td></tr><tr><td>Very Likely</td><td char=".">280</td><td char=".">39.9</td></tr><tr><td>Missing<sup>a</sup></td><td char=".">54</td><td char=".">7.7</td></tr></tbody></table> </ephtml> </p> <ulist> <item>6 DK: Don't know.</item> <item>7 <sups>a</sups>Missing values imputed using multiple imputations by chained equations.</item> </ulist> <p>A multivariate logistic model was used for PrEP awareness, while a multivariate multinomial model was used for PrEP willingness. Future HIV prevention tools were modeled using independent multivariate ordinal logistic models. All adjusted (multivariate) odds ratio (OR) estimates and corresponding standard errors, confidence intervals (CIs), and <emph>p</emph>-values are provided after five imputations and upon pooling results across the common imputed datasets.</p> <p>A graphical representation of tetrachoric and polychoric correlations among outcomes for the complete cases was produced using a graphical lasso representation,[<reflink idref="bib21" id="ref38">21</reflink>] and visualizations of adjusted ORs and corresponding 95% CIs are provided for each category and covariate across models. For the latter visualization, results for the multinomial model are only depicted for the comparison between "Yes" and "No" (reference), so that coefficient interpretations are more equivalent across models. All analyses were performed using R version 4.0.3.[<reflink idref="bib22" id="ref39">22</reflink>]</p> <hd id="AN0182848221-10">Results</hd> <p>The majority of participants were straight (71.8%), ages 18–22 (81.3%), white (58.9%), cisgender women (69.2%), and insured through their parents (71.9%) (See Table 1). In total, 69.8% of students attended the public research university, followed by the private university (23.1%), and the private HCBU (7.1%). A large number of students answered six or fewer knowledge questions correctly (37.7%). Correct answers for item-level responses were low for questions about PrEP efficacy (30.8%), STI diagnosis as a risk for HIV infection (45.9%), high rates of new diagnoses locally (31.38%) (See Supporting Information Table S1). The majority of students perceived their likelihood to acquire HIV to be very unlikely (65.3%). In contrast, HIV risk scores were relatively high among the sample: 46.5% had high risk scores and 12.1% had medium risk scores.</p> <p>While 76.9% of students previously tested for HIV, only 33.4% of students surveyed had heard of PrEP and only 32.4% were willing to take oral PrEP daily. The percentages of students who reported they were likely or very likely be willing to take a future vaccine (60.6%) or antibody prophylaxis treatments (44.2%) were higher than the percentages of those who said they would be likely or very likely to use injectable PrEP (26.1%) or PrEP implants (19.8%).</p> <p>Tables 3–6 display the results from all multivariable analyses. Sexual minority status was associated with higher odds of positive responses than those identifying as heterosexual across all outcomes, with all 95% CIs for odds ratios above 1, except for the comparison between those who responded DK versus No for <emph>Willingness to use PrEP</emph>.</p> <p>Table 3. Multivariable logistic regression model for PrEP awareness among college students, adjusted odds ratio estimates, standard errors, 95% confidence intervals, and <emph>p</emph>-values after imputation (<emph>m</emph> = 5) and pooling.</p> <p> <ephtml> <table><thead><tr><td>Variable</td><td>Response</td><td>OR estimate</td><td><italic>SE</italic></td><td>95% CI</td><td><italic>p</italic>-value</td></tr></thead><tbody valign="top"><tr><td>Intercept</td><td /><td char=".">1.02</td><td char=".">0.08</td><td char=".">0.88 − 1.20</td><td char=".">.775</td></tr><tr><td>Sexual minority</td><td>Yes</td><td char=".">1.19</td><td char=".">0.04</td><td char="."><bold>1.10</bold>−<bold>1.29</bold></td><td char="."><bold><.001</bold></td></tr><tr><td>Age</td><td>23+</td><td char=".">1.17</td><td char=".">0.05</td><td char="."><bold>1.06</bold>−<bold>1.29</bold></td><td char="."><bold>.002</bold></td></tr><tr><td>Race / Ethnicity</td><td>Asian</td><td char=".">0.86</td><td char=".">0.07</td><td char="."><bold>0.75</bold>−<bold>0.99</bold></td><td char="."><bold>.033</bold></td></tr><tr><td>Black</td><td char=".">1.15</td><td char=".">0.06</td><td char="."><bold>1.01</bold>−<bold>1.29</bold></td><td char="."><bold>.029</bold></td></tr><tr><td>Hispanic</td><td char=".">1.03</td><td char=".">0.06</td><td char=".">0.92 − 1.15</td><td char=".">.658</td></tr><tr><td>Another Race</td><td char=".">1.02</td><td char=".">0.07</td><td char=".">0.88 − 1.18</td><td char=".">.758</td></tr><tr><td>Gender</td><td>Cisgender woman</td><td char=".">1.01</td><td char=".">0.04</td><td char=".">0.93 − 1.10</td><td char=".">.797</td></tr><tr><td>Transgender</td><td char=".">1.03</td><td char=".">0.10</td><td char=".">0.85 − 1.24</td><td char=".">.791</td></tr><tr><td>Class</td><td>Junior / Senior</td><td char=".">1.03</td><td char=".">0.04</td><td char=".">0.96 − 1.11</td><td char=".">.448</td></tr><tr><td>Insurance</td><td>None</td><td char=".">0.84</td><td char=".">0.13</td><td char=".">0.65 − 1.08</td><td char=".">.178</td></tr><tr><td>Other</td><td char=".">1.01</td><td char=".">0.07</td><td char=".">0.87 − 1.16</td><td char=".">.898</td></tr><tr><td>Parent</td><td char=".">1.03</td><td char=".">0.06</td><td char=".">0.92 − 1.16</td><td char=".">.561</td></tr><tr><td>Institution</td><td>HBCU</td><td char=".">0.87</td><td char=".">0.09</td><td char=".">0.73 − 1.03</td><td char=".">.104</td></tr><tr><td>Private</td><td char=".">0.99</td><td char=".">0.04</td><td char=".">0.91 − 1.07</td><td char=".">.741</td></tr><tr><td>HIV perceived risk</td><td>Somewhat unlikely / Not likely</td><td char=".">0.95</td><td char=".">0.04</td><td char=".">0.87 − 1.03</td><td char=".">.229</td></tr><tr><td>Somewhat likely / Very likely</td><td char=".">0.84</td><td char=".">0.12</td><td char=".">0.67 − 1.06</td><td char=".">.146</td></tr><tr><td>Don't know</td><td char=".">1.00</td><td char=".">0.07</td><td char=".">0.86 − 1.15</td><td char=".">.974</td></tr><tr><td>Ever tested for HIV</td><td>Test result negative or don't know result</td><td char=".">1.06</td><td char=".">0.05</td><td char=".">0.97 − 1.16</td><td char=".">.220</td></tr><tr><td>HIV knowledge score</td><td>Medium (7–8)</td><td char=".">1.13</td><td char=".">0.04</td><td char="."><bold>1.04</bold>−<bold>1.22</bold></td><td char="."><bold>.003</bold></td></tr><tr><td>High (9–11)</td><td char=".">1.41</td><td char=".">0.05</td><td char="."><bold>1.28</bold>−<bold>1.54</bold></td><td char="."><bold><.001</bold></td></tr><tr><td>Missing</td><td char=".">1.61</td><td char=".">0.15</td><td char="."><bold>1.12</bold>−<bold>2.30</bold></td><td char="."><bold>.016</bold></td></tr><tr><td>HIV risk score</td><td>Medium</td><td char=".">1.03</td><td char=".">0.06</td><td char=".">0.92 − 1.15</td><td char=".">.655</td></tr><tr><td>High</td><td char=".">1.09</td><td char=".">0.04</td><td char="."><bold>1.01</bold>−<bold>1.17</bold></td><td char="."><bold>.027</bold></td></tr></tbody></table> </ephtml> </p> <p>8 Reference responses: Heard of PrEP="No"; Sexual Minority = "No"; Age = "18–22"; Race/Ethnicity = "White"; Gender = "cisgender man"; Class = "First-year/Sophomore"; Insurance = "School"; Institution = "Public Research"; HIV perceived risk = "Very unlikely"; Ever tested for HIV = "Never tested for HIV"; HIV Knowledge Score = "Low (0–6)"; HIV Risk Score= "Low"; an OR >1.0 indicates an increased odds of responding "Yes" to the question "Have you ever heard of PrEP," as compared to "No." Bolded values represent statistical significance at the 5% level.</p> <p>Table 4. Multivariate multinomial logistic model for <emph>Willingness to use PrEP</emph> among college students, adjusted odds ratio estimates, standard errors, 95% confidence intervals, and <emph>p</emph>-values after imputation (<emph>m</emph> = 5) and pooling.</p> <p> <ephtml> <table><thead><tr><td /><td /><td>Willingness = "Don't know"</td><td>Willingness = "Yes"</td></tr><tr><td>Variable</td><td>Response</td><td>OR estimate</td><td><italic>SE</italic></td><td>95% CI</td><td><italic>p</italic>-value</td><td>OR estimate</td><td><italic>SE</italic></td><td>95% CI</td><td><italic>p</italic>-value</td></tr></thead><tbody valign="top"><tr><td>Intercept</td><td /><td char=".">0.66</td><td>0.46</td><td char=".">0.27 − 1.63</td><td char=".">.372</td><td char=".">0.67</td><td char=".">0.44</td><td char=".">0.28 − 1.60</td><td char=".">.366</td></tr><tr><td>Sexual minority</td><td>Yes</td><td char=".">1.21</td><td>0.27</td><td char=".">0.71 − 2.08</td><td char=".">.478</td><td char=".">1.65</td><td char=".">0.24</td><td char="."><bold>1.03</bold>−<bold>2.63</bold></td><td char="."><bold>.036</bold></td></tr><tr><td>Age</td><td>23+</td><td char=".">1.15</td><td>0.30</td><td char=".">0.64 − 2.08</td><td char=".">.637</td><td char=".">0.72</td><td char=".">0.29</td><td char=".">0.41 − 1.27</td><td char=".">.254</td></tr><tr><td>Race / Ethnicity</td><td>Asian</td><td char=".">1.03</td><td>0.42</td><td char=".">0.46 − 2.34</td><td char=".">.936</td><td char=".">1.35</td><td char=".">0.39</td><td char=".">0.63 − 2.92</td><td char=".">.439</td></tr><tr><td>Black</td><td char=".">1.07</td><td>0.38</td><td char=".">0.51 − 2.24</td><td char=".">.859</td><td char=".">0.96</td><td char=".">0.34</td><td char=".">0.49 − 1.88</td><td char=".">.901</td></tr><tr><td>Hispanic</td><td char=".">1.12</td><td>0.33</td><td char=".">0.59 − 2.14</td><td char=".">.734</td><td char=".">1.11</td><td char=".">0.31</td><td char=".">0.60 − 2.05</td><td char=".">.749</td></tr><tr><td>Another Race</td><td char=".">2.51</td><td>0.43</td><td char="."><bold>1.07</bold>−<bold>5.87</bold></td><td char="."><bold>.035</bold></td><td char=".">1.50</td><td char=".">0.45</td><td char=".">0.61 − 3.68</td><td char=".">.370</td></tr><tr><td>Gender</td><td>Cisgender woman</td><td char=".">1.46</td><td>0.24</td><td char=".">0.91 − 2.35</td><td char=".">.117</td><td char=".">1.56</td><td char=".">0.23</td><td char=".">0.99 − 2.45</td><td char=".">.054</td></tr><tr><td>Transgender</td><td char=".">2.18</td><td>0.59</td><td char=".">0.68 − 6.98</td><td char=".">.190</td><td char=".">2.45</td><td char=".">0.54</td><td char=".">0.84 − 7.14</td><td char=".">.101</td></tr><tr><td>Class</td><td>Junior / Senior</td><td char=".">0.56</td><td>0.23</td><td char="."><bold>0.36</bold>−<bold>0.87</bold></td><td char="."><bold>.010</bold></td><td char=".">0.59</td><td char=".">0.22</td><td char="."><bold>0.39</bold>−<bold>0.91</bold></td><td char="."><bold>.016</bold></td></tr><tr><td>Insurance</td><td>None</td><td char=".">0.74</td><td>0.73</td><td char=".">0.18 − 3.11</td><td char=".">.681</td><td char=".">0.60</td><td char=".">0.77</td><td char=".">0.13 − 2.72</td><td char=".">.509</td></tr><tr><td>Other</td><td char=".">1.25</td><td>0.42</td><td char=".">0.55 − 2.87</td><td char=".">.594</td><td char=".">2.48</td><td char=".">0.39</td><td char="."><bold>1.16</bold>−<bold>5.30</bold></td><td char="."><bold>.019</bold></td></tr><tr><td>Parent</td><td char=".">1.30</td><td>0.34</td><td char=".">0.67 − 2.53</td><td char=".">.438</td><td char=".">1.11</td><td char=".">0.32</td><td char=".">0.59 − 2.09</td><td char=".">.742</td></tr><tr><td>Institution</td><td>HBCU</td><td char=".">1.81</td><td>0.49</td><td char=".">0.68 − 4.80</td><td char=".">.234</td><td char=".">0.86</td><td char=".">0.54</td><td char=".">0.30 − 2.50</td><td char=".">.787</td></tr><tr><td>Private</td><td char=".">1.32</td><td>0.24</td><td char=".">0.82 − 2.13</td><td char=".">.256</td><td char=".">0.98</td><td char=".">0.25</td><td char=".">0.61 − 1.60</td><td char=".">.947</td></tr><tr><td>HIV perceived risk</td><td>Somewhat unlikely / Not likely</td><td char=".">2.05</td><td>0.27</td><td char="."><bold>1.21</bold>−<bold>3.48</bold></td><td char="."><bold>.008</bold></td><td char=".">2.35</td><td char=".">0.26</td><td char="."><bold>1.41</bold>−<bold>3.92</bold></td><td char="."><bold>.001</bold></td></tr><tr><td>Somewhat likely / Very likely</td><td char=".">1.01</td><td>1.22</td><td char=".">0.09 − 11.13</td><td char=".">.994</td><td char=".">8.58</td><td char=".">0.79</td><td char="."><bold>1.80</bold>−<bold>40.86</bold></td><td char="."><bold>.007</bold></td></tr><tr><td>Don't know</td><td char=".">1.69</td><td>0.46</td><td char=".">0.68 − 4.18</td><td char=".">.258</td><td char=".">2.38</td><td char=".">0.43</td><td char="."><bold>1.03</bold>−<bold>5.49</bold></td><td char="."><bold>.043</bold></td></tr><tr><td>Ever tested for HIV</td><td>Test result negative or don't know result</td><td char=".">0.77</td><td>0.27</td><td char=".">0.45 − 1.32</td><td char=".">.348</td><td char=".">0.77</td><td char=".">0.26</td><td char=".">0.46 − 1.28</td><td char=".">.308</td></tr><tr><td>HIV knowledge score</td><td>Medium (7–8)</td><td char=".">0.95</td><td>0.23</td><td char=".">0.60 − 1.51</td><td char=".">.835</td><td char=".">1.03</td><td char=".">0.23</td><td char=".">0.65 − 1.62</td><td char=".">.916</td></tr><tr><td>High (9–11)</td><td char=".">0.66</td><td>0.28</td><td char=".">0.38 − 1.15</td><td char=".">.143</td><td char=".">1.13</td><td char=".">0.25</td><td char=".">0.69 − 1.86</td><td char=".">.630</td></tr><tr><td>Missing</td><td char=".">0.92</td><td>0.69</td><td char=".">0.21 − 4.08</td><td char=".">.908</td><td char=".">0.85</td><td char=".">1.04</td><td char=".">0.07 − 10.32</td><td char=".">.881</td></tr><tr><td>HIV risk score</td><td>Medium</td><td char=".">1.32</td><td>0.33</td><td char=".">0.70 − 2.50</td><td char=".">.391</td><td char=".">1.07</td><td char=".">0.33</td><td char=".">0.56–2.04</td><td char=".">.845</td></tr><tr><td>High</td><td char=".">0.79</td><td>0.23</td><td char=".">0.50 − 1.25</td><td char=".">.314</td><td char=".">0.82</td><td char=".">0.22</td><td char=".">0.53 − 1.27</td><td char=".">.370</td></tr></tbody></table> </ephtml> </p> <ulist> <item>9 Reference categories: Willingness to use PrEP="No"; Sexual Minority = "No"; Age = "18–22"; Race/Ethnicity = "White"; Gender = "cisgender man"; Class = "First-year/Sophomore"; Insurance = "School"; Institution = "Public Research"; HIV perceived risk = "Very unlikely"; Ever tested for HIV = "Never tested for HIV"; HIV Knowledge Score = "Low (0–6)"; HIV Risk Score= "Low."</item> <item>10 An OR > 1.0 indicates increased odds of responding "Don't Know" or "Yes" to the question "Would you be willing to use PrEP," as compared to "No." Bolded values represent statistical significance at the 5% level.</item> </ulist> <p>Table 5. Multivariate ordered logistic models for <emph>Willing to use long-acting injectable PrEP</emph> and <emph>Willing to use PrEP implant</emph>, adjusted odds ratio estimates, standard errors, 95% confidence intervals, and <emph>p</emph>-values after imputation (<emph>m</emph> = 5) and pooling.</p> <p> <ephtml> <table><thead><tr><td /><td /><td>Willing to use long-acting injectable PrEP</td><td>Willing to use PrEP implant</td></tr><tr><td>Variable</td><td>Response</td><td>OR estimate</td><td><italic>SE</italic></td><td char=".">95% CI</td><td><italic>p</italic>-value</td><td>OR estimate</td><td><italic>SE</italic></td><td char=".">95% CI</td><td><italic>p</italic>-value</td></tr></thead><tbody valign="top"><tr><td>Sexual minority</td><td>Yes</td><td char=".">1.74</td><td char=".">0.18</td><td char="."><bold>1.22</bold>−<bold>2.49</bold></td><td char="."><bold>.003</bold></td><td char=".">1.78</td><td char=".">0.18</td><td char="."><bold>1.25</bold>−<bold>2.52</bold></td><td char="."><bold>.001</bold></td></tr><tr><td>Age</td><td>23+</td><td char=".">0.89</td><td char=".">0.20</td><td char=".">0.60 − 1.33</td><td char=".">.569</td><td char=".">1.02</td><td char=".">0.21</td><td char=".">0.67 − 1.53</td><td char=".">.943</td></tr><tr><td>Race / Ethnicity</td><td>Asian</td><td char=".">1.87</td><td char=".">0.28</td><td char="."><bold>1.07</bold>−<bold>3.25</bold></td><td char="."><bold>.027</bold></td><td char=".">1.61</td><td char=".">0.27</td><td char=".">0.94 − 2.74</td><td char=".">.081</td></tr><tr><td>Black</td><td char=".">1.06</td><td char=".">0.25</td><td char=".">0.65 − 1.72</td><td char=".">.819</td><td char=".">1.00</td><td char=".">0.26</td><td char=".">0.60 − 1.67</td><td char=".">.995</td></tr><tr><td>Hispanic</td><td char=".">1.30</td><td char=".">0.23</td><td char=".">0.83 − 2.05</td><td char=".">.250</td><td char=".">1.33</td><td char=".">0.23</td><td char=".">0.85 − 2.09</td><td char=".">.210</td></tr><tr><td>Another Race</td><td char=".">0.98</td><td char=".">0.29</td><td char=".">0.56 − 1.72</td><td char=".">.940</td><td char=".">1.06</td><td char=".">0.29</td><td char=".">0.59 − 1.88</td><td char=".">.850</td></tr><tr><td>Gender</td><td>Cisgender woman</td><td char=".">1.25</td><td char=".">0.17</td><td char=".">0.89 − 1.75</td><td char=".">.191</td><td char=".">1.68</td><td char=".">0.18</td><td char="."><bold>1.19</bold>−<bold>2.38</bold></td><td char="."><bold>.004</bold></td></tr><tr><td>Transgender</td><td char=".">3.13</td><td char=".">0.41</td><td char="."><bold>1.41</bold>−<bold>6.98</bold></td><td char="."><bold>.005</bold></td><td char=".">3.20</td><td char=".">0.42</td><td char="."><bold>1.39</bold>−<bold>7.37</bold></td><td char="."><bold>.007</bold></td></tr><tr><td>Class</td><td>Junior / Senior</td><td char=".">0.73</td><td char=".">0.15</td><td char="."><bold>0.54</bold>−<bold>0.98</bold></td><td char="."><bold>.035</bold></td><td char=".">0.99</td><td char=".">0.15</td><td char=".">0.73 − 1.33</td><td char=".">.926</td></tr><tr><td>Insurance</td><td>None</td><td char=".">0.74</td><td char=".">0.50</td><td char=".">0.28 − 1.96</td><td char=".">.541</td><td char=".">1.07</td><td char=".">0.51</td><td char=".">0.39 − 2.90</td><td char=".">.897</td></tr><tr><td>Other</td><td char=".">1.71</td><td char=".">0.29</td><td char=".">0.97 − 3.01</td><td char=".">.062</td><td char=".">1.14</td><td char=".">0.29</td><td char=".">0.65–2.02</td><td char=".">.645</td></tr><tr><td>Parent</td><td char=".">0.79</td><td char=".">0.24</td><td char=".">0.50 − 1.25</td><td char=".">.308</td><td char=".">0.70</td><td char=".">0.24</td><td char=".">0.44 − 1.11</td><td char=".">.132</td></tr><tr><td>Institution</td><td>HBCU</td><td char=".">1.31</td><td char=".">0.35</td><td char=".">0.65 − 2.63</td><td char=".">.441</td><td char=".">0.65</td><td char=".">0.36</td><td char=".">0.32 − 1.33</td><td char=".">.238</td></tr><tr><td>Private</td><td char=".">0.74</td><td char=".">0.18</td><td char=".">0.52 − 1.05</td><td char=".">.092</td><td char=".">0.77</td><td char=".">0.18</td><td char=".">0.55 − 1.09</td><td char=".">.144</td></tr><tr><td>HIV perceived risk</td><td>Somewhat unlikely / Not likely</td><td char=".">2.09</td><td char=".">0.19</td><td char="."><bold>1.44</bold>−<bold>3.02</bold></td><td char="."><bold><.001</bold></td><td char=".">1.77</td><td char=".">0.17</td><td char="."><bold>1.26</bold>−<bold>2.49</bold></td><td char="."><bold>.001</bold></td></tr><tr><td>Somewhat likely / Very likely</td><td char=".">4.15</td><td char=".">0.48</td><td char="."><bold>1.60</bold>−<bold>10.75</bold></td><td char="."><bold>.004</bold></td><td char=".">3.39</td><td char=".">0.48</td><td char="."><bold>1.32</bold>−<bold>8.69</bold></td><td char="."><bold>.011</bold></td></tr><tr><td>Don't know</td><td char=".">2.45</td><td char=".">0.31</td><td char="."><bold>1.33</bold>−<bold>4.52</bold></td><td char="."><bold>.004</bold></td><td char=".">1.39</td><td char=".">0.31</td><td char=".">0.75 − 2.57</td><td char=".">.294</td></tr><tr><td>Ever tested for HIV</td><td>Test result negative or don't know result</td><td char=".">0.88</td><td char=".">0.19</td><td char=".">0.60 − 1.30</td><td char=".">.528</td><td char=".">1.02</td><td char=".">0.19</td><td char=".">0.69 − 1.49</td><td char=".">.929</td></tr><tr><td>HIV knowledge score</td><td>Medium (7–8)</td><td char=".">1.12</td><td char=".">0.17</td><td char=".">0.81 − 1.56</td><td char=".">.480</td><td char=".">1.06</td><td char=".">0.17</td><td char=".">0.76 − 1.47</td><td char=".">.737</td></tr><tr><td>High (9–11)</td><td char=".">1.34</td><td char=".">0.19</td><td char=".">0.92 − 1.95</td><td char=".">.129</td><td char=".">1.12</td><td char=".">0.19</td><td char=".">0.77 − 1.63</td><td char=".">.564</td></tr><tr><td>Missing</td><td char=".">1.90</td><td char=".">0.40</td><td char=".">0.85 − 4.25</td><td char=".">.116</td><td char=".">0.71</td><td char=".">0.38</td><td char=".">0.33 − 1.53</td><td char=".">.373</td></tr><tr><td>HIV risk score</td><td>Medium</td><td char=".">1.10</td><td char=".">0.24</td><td char=".">0.69 − 1.76</td><td char=".">.674</td><td char=".">0.97</td><td char=".">0.24</td><td char=".">0.60 − 1.56</td><td char=".">.899</td></tr><tr><td>High</td><td char=".">0.80</td><td char=".">0.16</td><td char=".">0.58 − 1.10</td><td char=".">.170</td><td char=".">0.88</td><td char=".">0.16</td><td char=".">0.63 − 1.21</td><td char=".">.422</td></tr><tr><td>Thresholds</td><td>1|2</td><td char=".">0.36</td><td char=".">0.35</td><td char="."><bold>0.18</bold>−<bold>0.72</bold></td><td char="."><bold>.004</bold></td><td char=".">0.91</td><td char=".">0.34</td><td char=".">0.46 − 1.77</td><td char=".">.771</td></tr><tr><td>2|3</td><td char=".">1.09</td><td char=".">0.34</td><td char=".">0.55 − 2.15</td><td char=".">.802</td><td char=".">2.50</td><td char=".">0.34</td><td char="."><bold>1.28</bold>−<bold>4.88</bold></td><td char="."><bold>.007</bold></td></tr><tr><td>3|4</td><td char=".">3.49</td><td char=".">0.35</td><td char="."><bold>1.76</bold>−<bold>6.93</bold></td><td char="."><bold><.001</bold></td><td char=".">6.66</td><td char=".">0.35</td><td char="."><bold>3.37</bold>−<bold>13.15</bold></td><td char="."><bold><.001</bold></td></tr><tr><td>4|5</td><td char=".">13.15</td><td char=".">0.36</td><td char="."><bold>6.44</bold>−<bold>26.84</bold></td><td char="."><bold><.001</bold></td><td char=".">18.68</td><td char=".">0.36</td><td char="."><bold>9.27</bold>−<bold>37.62</bold></td><td char="."><bold><.001</bold></td></tr></tbody></table> </ephtml> </p> <p>11 Reference categories: Sexual Minority = "No"; Age = "18–22"; Race/Ethnicity = "White"; Gender = "cisgender man"; Class = "First-year/Sophomore"; Insurance = "School"; Institution = "Public Research"; HIV perceived risk = "Very unlikely"; Ever tested for HIV = "Never tested for HIV"; HIV Knowledge Score = "Low (0–6)"; HIV Risk Score= "Low" Thresholds correspond to the cutoff points for the continuous latent variable in the ordered logistic model that split each pair of adjacent ordered categorical responses, so fitted values below a threshold of T|<emph>T</emph> + 1 are assigned to category T. No intercept is estimated for parameter identifiability. Bolded values represent statistical significance at the 5% level.</p> <p>Table 6. Multivariate ordered logistic models for <emph>Willing to use an antibody prophylaxis</emph> and <emph>Willing to use vaccine,</emph> adjusted odds ratio estimates, standard errors, 95% confidence intervals, and <emph>p</emph>-values after imputation (<emph>m</emph> = 5) and pooling.</p> <p> <ephtml> <table><thead><tr><td /><td /><td>Willing to use antibody prophylaxis treatment</td><td>Willing to use vaccine</td></tr><tr><td>Variable</td><td>Response</td><td>OR estimate</td><td><italic>SE</italic></td><td char=".">95% CI</td><td><italic>p</italic>-value</td><td>OR estimate</td><td><italic>SE</italic></td><td char=".">95% CI</td><td><italic>p</italic>-value</td></tr></thead><tbody valign="top"><tr><td>Sexual minority</td><td>Yes</td><td char=".">1.69</td><td char=".">0.18</td><td char="."><bold>1.17</bold>−<bold>2.43</bold></td><td char="."><bold>.006</bold></td><td char=".">1.91</td><td char=".">0.19</td><td char="."><bold>1.33</bold>−<bold>2.75</bold></td><td char="."><bold>.001</bold></td></tr><tr><td>Age</td><td>23+</td><td char=".">0.74</td><td char=".">0.20</td><td char=".">0.50 − 1.10</td><td char=".">.140</td><td char=".">0.70</td><td char=".">0.21</td><td char=".">0.46 − 1.06</td><td char=".">.092</td></tr><tr><td>Race / Ethnicity</td><td>Asian</td><td char=".">1.61</td><td char=".">0.29</td><td char=".">0.91 − 2.84</td><td char=".">.101</td><td char=".">1.59</td><td char=".">0.30</td><td char=".">0.88 − 2.85</td><td char=".">.121</td></tr><tr><td>Black</td><td char=".">0.96</td><td char=".">0.26</td><td char=".">0.57 − 1.61</td><td char=".">.863</td><td char=".">0.75</td><td char=".">0.26</td><td char=".">0.45 − 1.24</td><td char=".">.260</td></tr><tr><td>Hispanic</td><td char=".">1.36</td><td char=".">0.29</td><td char=".">0.76 − 2.42</td><td char=".">.291</td><td char=".">1.55</td><td char=".">0.25</td><td char=".">0.95 − 2.53</td><td char=".">.081</td></tr><tr><td>Another Race</td><td char=".">0.99</td><td char=".">0.29</td><td char=".">0.56 − 1.75</td><td char=".">.968</td><td char=".">0.86</td><td char=".">0.32</td><td char=".">0.46 − 1.62</td><td char=".">.642</td></tr><tr><td>Gender</td><td>Cisgender woman</td><td char=".">1.41</td><td char=".">0.17</td><td char="."><bold>1.00</bold>−<bold>1.98</bold></td><td char="."><bold>.048</bold></td><td char=".">1.31</td><td char=".">0.17</td><td char=".">0.94 − 1.83</td><td char=".">.114</td></tr><tr><td>Transgender</td><td char=".">1.87</td><td char=".">0.38</td><td char=".">0.90 − 3.92</td><td char=".">.096</td><td char=".">2.23</td><td char=".">0.43</td><td char=".">0.95 − 5.20</td><td char=".">.065</td></tr><tr><td>Class</td><td>Junior / Senior</td><td char=".">0.67</td><td char=".">0.15</td><td char="."><bold>0.50</bold>−<bold>0.90</bold></td><td char="."><bold>.008</bold></td><td char=".">0.64</td><td char=".">0.15</td><td char="."><bold>0.47</bold>−<bold>0.86</bold></td><td char="."><bold>.004</bold></td></tr><tr><td>Insurance</td><td>None</td><td char=".">0.68</td><td char=".">0.52</td><td char=".">0.24 − 1.89</td><td char=".">.458</td><td char=".">1.12</td><td char=".">0.55</td><td char=".">0.38 − 3.27</td><td char=".">.833</td></tr><tr><td>Other</td><td char=".">1.14</td><td char=".">0.28</td><td char=".">0.66 − 1.98</td><td char=".">.639</td><td char=".">1.24</td><td char=".">0.30</td><td char=".">0.70 − 2.22</td><td char=".">.463</td></tr><tr><td>Parent</td><td char=".">0.81</td><td char=".">0.23</td><td char=".">0.52 − 1.28</td><td char=".">.372</td><td char=".">0.87</td><td char=".">0.24</td><td char=".">0.54 − 1.41</td><td char=".">.579</td></tr><tr><td>Institution</td><td>HBCU</td><td char=".">0.60</td><td char=".">0.34</td><td char=".">0.31 − 1.17</td><td char=".">.133</td><td char=".">0.54</td><td char=".">0.33</td><td char=".">0.28 − 1.03</td><td char=".">.062</td></tr><tr><td>Private</td><td char=".">0.92</td><td char=".">0.18</td><td char=".">0.65 − 1.30</td><td char=".">.628</td><td char=".">0.64</td><td char=".">0.18</td><td char="."><bold>0.45</bold>−<bold>0.90</bold></td><td char="."><bold>.011</bold></td></tr><tr><td>HIV perceived risk</td><td>Somewhat unlikely / Not likely</td><td char=".">1.91</td><td char=".">0.18</td><td char="."><bold>1.34</bold>−<bold>2.72</bold></td><td char="."><bold><.001</bold></td><td char=".">1.85</td><td char=".">0.18</td><td char="."><bold>1.30</bold>−<bold>2.64</bold></td><td char="."><bold>.001</bold></td></tr><tr><td>Somewhat likely / Very likely</td><td char=".">3.60</td><td char=".">0.49</td><td char="."><bold>1.37</bold>−<bold>9.47</bold></td><td char="."><bold>.010</bold></td><td char=".">4.24</td><td char=".">0.61</td><td char="."><bold>1.29</bold>−<bold>13.95</bold></td><td char="."><bold>.018</bold></td></tr><tr><td>Don't know</td><td char=".">1.41</td><td char=".">0.32</td><td char=".">0.76 − 2.61</td><td char=".">.281</td><td char=".">1.64</td><td char=".">0.32</td><td char=".">0.88 − 3.05</td><td char=".">.122</td></tr><tr><td>Ever tested for HIV</td><td>Test result negative or don't know result</td><td char=".">1.00</td><td char=".">0.20</td><td char=".">0.68 − 1.47</td><td char=".">.989</td><td char=".">1.38</td><td char=".">0.19</td><td char=".">0.95 − 2.01</td><td char=".">.087</td></tr><tr><td>HIV knowledge score</td><td>Medium (7–8)</td><td char=".">1.37</td><td char=".">0.17</td><td char=".">0.99 − 1.91</td><td char=".">.061</td><td char=".">1.25</td><td char=".">0.18</td><td char=".">0.88 − 1.76</td><td char=".">.209</td></tr><tr><td>High (9–11)</td><td char=".">1.22</td><td char=".">0.20</td><td char=".">0.83 − 1.80</td><td char=".">.310</td><td char=".">1.64</td><td char=".">0.21</td><td char="."><bold>1.09</bold>−<bold>2.47</bold></td><td char="."><bold>.017</bold></td></tr><tr><td>Missing</td><td char=".">0.64</td><td char=".">0.57</td><td char=".">0.18 − 2.28</td><td char=".">.455</td><td char=".">0.24</td><td char=".">0.38</td><td char="."><bold>0.11</bold>−<bold>0.52</bold></td><td char="."><bold>.001</bold></td></tr><tr><td>HIV risk score</td><td>Medium</td><td char=".">0.99</td><td char=".">0.24</td><td char=".">0.62 − 1.58</td><td char=".">.969</td><td char=".">0.75</td><td char=".">0.23</td><td char=".">0.47 − 1.19</td><td char=".">.221</td></tr><tr><td>High</td><td char=".">0.63</td><td char=".">0.17</td><td char="."><bold>0.45</bold>−<bold>0.90</bold></td><td char="."><bold>.011</bold></td><td char=".">0.70</td><td char=".">0.16</td><td char="."><bold>0.51</bold>−<bold>0.96</bold></td><td char="."><bold>.029</bold></td></tr><tr><td>Thresholds</td><td>1|2</td><td char=".">0.23</td><td char=".">0.33</td><td char="."><bold>0.12</bold>−<bold>0.43</bold></td><td char="."><bold><.001</bold></td><td char=".">0.11</td><td char=".">0.35</td><td char="."><bold>0.05</bold>−<bold>0.21</bold></td><td char="."><bold><.001</bold></td></tr><tr><td>2|3</td><td char=".">0.41</td><td char=".">0.32</td><td char="."><bold>0.22</bold>−<bold>0.78</bold></td><td char="."><bold>.007</bold></td><td char=".">0.22</td><td char=".">0.34</td><td char="."><bold>0.11</bold>−<bold>0.42</bold></td><td char="."><bold><.001</bold></td></tr><tr><td>3|4</td><td char=".">1.30</td><td char=".">0.32</td><td char=".">0.69 − 2.45</td><td char=".">.423</td><td char=".">0.69</td><td char=".">0.32</td><td char=".">0.37 − 1.30</td><td char=".">.254</td></tr><tr><td>4|5</td><td char=".">4.40</td><td char=".">0.33</td><td char="."><bold>2.31</bold>−<bold>8.41</bold></td><td char="."><bold><.001</bold></td><td char=".">1.91</td><td char=".">0.33</td><td char="."><bold>1.01</bold>−<bold>3.63</bold></td><td char="."><bold>.047</bold></td></tr></tbody></table> </ephtml> </p> <p>12 Reference categories: HIV perceived risk = "Very unlikely"; Sexual Minority = "No"; Age = "18–22"; Race/Ethnicity = "White"; Gender = "cisgender man"; Class = "First-year/Sophomore"; Insurance = "School"; Institution = "Public Research"; HIV Knowledge Score = "Low (0–6)"; Ever tested for HIV = "Never tested for HIV"; HIV Risk Score = "Low." Thresholds correspond to the cutoff points for the continuous latent variable in the ordered logistic model that split each pair of adjacent ordered categorical responses, so fitted values below a threshold of T|<emph>T</emph> + 1 are assigned to category T. No intercept is estimated for parameter identifiability. Bolded values represent statistical significance at the 5% level.</p> <p>Conversely, age was nonsignificant across outcomes except for <emph>Heard of PrEP</emph>. Students ages 23+ had 17% higher odds (OR = 1.17; 95% CI: 1.06–1.29; <emph>p</emph> =.002) of having heard of PrEP compared to students ages 18–22.</p> <p>Race/ethnicity was associated with: (<reflink idref="bib1" id="ref40">1</reflink>) <emph>Heard of PrEP</emph>, (<reflink idref="bib2" id="ref41">2</reflink>) <emph>Willingness to use PrEP, and Willingness to use LAIP.</emph> Compared to white participants, Asian students had 14% lower odds of having heard of PrEP (OR = 0.86; 95% CI: 0.75–0.99; <emph>p</emph> =.033) and Black participants had 15% higher odds of having heard of PrEP (OR = 1.15; 95% CI 1.01–1.29; <emph>p</emph> =.029). Students who identified as another race had 151% higher odds (OR = 2.51; 95% CI 1.07–5.87; <emph>p</emph> =.0345) of responding DK (vs No) than white participants about their willing to use PrEP. Asian students had 87% higher odds of reporting willingness to use LAIP compared to white students (OR = 1.87; 95% CI: 1.07–3.25; <emph>p</emph> =.027).</p> <p>Outcomes varied by gender for <emph>Willingness to use PrEP implant</emph> and <emph>Willingness to use antibody treatment</emph>. Compared to cisgender men, cisgender women experienced approximately 68% (OR = 1.68; 95% CI: 1.19–2.38; <emph>p</emph> =.004) and 41% (OR = 1.41; 95% CI: 1.00–1.98; <emph>p</emph> =.048) higher odds for both outcomes, respectively. Furthermore, transgender students had approximately 220% higher odds of <emph>Willingness to use a PrEP implant</emph> (OR = 3.20; 95% CI: 1.39–7.37; <emph>p</emph> =.007) and <emph>Willingness to use LAIP</emph> (OR = 3.13; 95% CI: 1.41–6.98; <emph>p</emph> =.005) compared to cisgender men.</p> <p>Compared to first years, Junior/senior participants had approximately 44% lower odds of responding DK versus No (OR = 0.56; 95% CI: 0.36–0.87; <emph>p</emph> =.010) and 41% lower odds of responding Yes versus No (OR = 0.59; 95% CI: 0.39–0.91; <emph>p</emph> =.016) for <emph>Willingness to use PrEP</emph>. For future prevention methods, junior/senior participants had lower odds of positive responses for <emph>willingness to use LAIP</emph>, <emph>antibody treatment</emph>, and <emph>vaccine</emph>: 27% (OR = 0.73; 95% CI: 0.54–0.981; <emph>p</emph> =.035), 33% (OR = 0.67; 95% CI: 0.50–0.90; <emph>p</emph> =.008), and 36% (OR = 0.64; 95% CI: 0.47–0.86; <emph>p</emph> =.004), respectively.</p> <p>There were no significant differences across outcomes with respect to insurance status except for <emph>Willingness to use PrEP</emph> for which students who reported another insurance (vs insurance through their respective schools) had approximately 148% higher odds of being willing to take oral PrEP daily (OR = 2.48; 95% CI: 1.16–5.30; <emph>p</emph> =.019).</p> <p>Institution was not associated with significant differences in odds for the outcome variables except <emph>Vaccine</emph>, in which participants at the private university (vs public university) had approximately 36% lower odds of willingness to use a vaccine to prevent HIV (OR = 0.64; 95% CI: 0.45–0.90; <emph>p</emph> =.011).</p> <p>Students with higher self-reported <emph>HIV perceived risk</emph> (categorized as either "Somewhat unlikely"/"Not likely" or "Somewhat likely"/"Very likely") have significantly higher odds when compared to those self-reporting as "Very Unlikely" across all outcomes, except for <emph>Heard of PrEP</emph>. However, those who responded DK to their <emph>HIV perceived risk</emph> are not statistically different from those who self-reported as "Very Unlikely" across outcomes, except for which DK respondents had 138% and 145% higher odds of willingness to use PrEP and willingness to use LAIP, respectively, than those who self-perceived HIV risk as "Very Unlikely" (OR = 2.38; 95% CI: 1.03–5.49; <emph>p</emph> =.043 and OR = 2.45; 95% CI: 1.33–4.52; <emph>p</emph> =.004, respectively).</p> <p>Students who had <emph>ever tested for HIV</emph> had no significant differences in their odds across any of the outcomes.</p> <p>Students with a high <emph>HIV risk score</emph> were associated with approximately 9% (OR = 1.09; 95% CI: 1.01–1.17; <emph>p</emph> =.027) higher odds of having <emph>Heard of PrEP</emph> than those categorized as low risk. However, these individuals had approximately 37% (OR = 0.63; 95% CI: 0.45–0.90; <emph>p</emph> =.011) and 30% (OR = 0.70; 95% CI: 0.51–0.96; <emph>p</emph> =.029) lower odds of <emph>Willingness to use antibody treatment and a vaccine</emph>, respectively, versus those categorized as low risk.</p> <p>Finally, students with a medium, high, or missing <emph>HIV knowledge score</emph> had approximately 13% (OR = 1.13; 95% CI: 1.04–1.22; <emph>p</emph> =.003), 41% (OR = 1.41; 95% CI: 1.28–1.54; <emph>p</emph> <.001), and 61% (OR = 1.61; 95% CI: 1.12–2.30; <emph>p</emph> =.016) higher odds of having <emph>Heard of PrEP</emph> than those with a low <emph>HIV knowledge score</emph>, respectively. Differences were also found for <emph>Willingness to use a vaccine</emph>, in which those with a high <emph>HIV knowledge score</emph> had approximately 64% higher odds (OR = 1.64; 95% CI: 1.09–2.47; <emph>p</emph> =.02) than those with a low <emph>HIV knowledge score</emph>. Conversely, those with all missing responses to the items forming the <emph>HIV knowledge score</emph> were found to have approximately 76% lower odds (OR = 0.24; 95% CI: 0.11–0.52; <emph>p</emph> =.001) than those with a low <emph>HIV knowledge score</emph>.</p> <p>Figure 1 represents tetrachoric and polychoric correlations among outcomes. The strongest correlation shows that students who are more likely to be willing to use a vaccine are also more likely to be willing to use antibody prophylaxis treatment. Similarly, those more willing to use a PrEP implant are more likely to use long-acting injectable PrEP (LAIP). A moderate positive association exists between LAIP use willingness and both willingness to use PrEP and antibody prophylaxis treatment. Supporting Information Figures S2–S12 provide summary visualizations of adjusted ORs and corresponding 95% CIs after imputation and pooling for each variable and outcome across all models.</p> <p>PHOTO (COLOR): Figure 1. Glasso representation of pairwise polychoric correlations between the outcome variables using complete case information. Nodes (circles) represent each of the six outcome variables, while edges (segments connecting nodes) represent polychoric correlations. Blue edges represent positive correlations and wider edges represent stronger associations.</p> <hd id="AN0182848221-11">Discussion</hd> <p>Individuals ages 13–34 accounted for more than half of all new HIV diagnoses in 2019.[<reflink idref="bib1" id="ref42">1</reflink>] Our survey among college students from three higher education institutions in a recognized EHE jurisdiction in the Southern United States found that 76.9% of participants had previously been tested for HIV. However, a large number of students answered six or fewer knowledge questions correctly (37.7%). Although the majority (65.3%) perceived themselves as very unlikely to acquire HIV, more than half reported at least one sexual risk behavior. Previous studies have similarly found incongruent risk perception and reported behaviors among college students,[<reflink idref="bib23" id="ref43">23</reflink>] low knowledge about specific risk-related knowledge questions,[<reflink idref="bib24" id="ref44">24</reflink>]<sups>,</sups>[<reflink idref="bib25" id="ref45">25</reflink>] and misconceptions about HIV transmission routes and strategies for sexual risk reduction.[<reflink idref="bib26" id="ref46">26</reflink>]</p> <p>Increasing sexual health literacy through culturally tailored education initiatives may improve HIV risk perception among young adults.[<reflink idref="bib27" id="ref47">27</reflink>] For example, the ACHA's Best Practices in Sexual Health Promotion and Clinical Care in College Health Settings highlight the need for a holistic, inclusive, and comprehensive approach to sexual health among college students.[<reflink idref="bib28" id="ref48">28</reflink>] These guidelines suggest that in addition to raising awareness about STIs and pregnancy, students should be engaged in discussions about pleasure and intimacy. Moreover, creating a welcoming environment with cultural sensitivity to people with diverse races, ethnic, LGBTQ+ identities, religious beliefs, and physical abilities may improve engagement in health services.[<reflink idref="bib28" id="ref49">28</reflink>] Clinics should also collect sexual orientation and gender identity data to both improve services and evaluation efforts. Providers should offer gender-affirming care, address trauma, and maintain privacy and confidentiality in health clinic settings by offering sensitive exams and referrals to mental health or other services as needed. Finally, sexual health professionals should conduct community needs assessments for students on their campuses and use a socioecological lens to improve health services at individual, interpersonal, organization, community, and societal levels.[<reflink idref="bib28" id="ref50">28</reflink>] Examples may include providing low-barrier and free sexual health services and supplies, and offering products beyond external condoms. Moreover, college health centers should make available both PrEP and post-exposure prophylaxis (PEP) alongside concurrent screening for HIV and other STIs using routine, rapid, and opt-out screenings as a best practice.[<reflink idref="bib28" id="ref51">28</reflink>] To improve PrEP services, the ACHA suggests that clinics can also use online scheduling, integrate and develop diversity, equity and inclusion statements; develop appropriate sexual health history survey instruments; and train staff to be proactive in raising PrEP awareness and providing inclusive services.[<reflink idref="bib29" id="ref52">29</reflink>]</p> <p>Many institutions of higher education are not currently implementing ACHA's best practices. In the 2021 ACHA report of 145 institutions of higher education (of which 138 provided sexual health services and six did not), only 51.5% of institutions offered fourth-generation rapid HIV tests and 36.8% did not intend to implement rapid HIV tests.[<reflink idref="bib30" id="ref53">30</reflink>] Moreover, only 42.3% reported procedures to require clinicians to offer PrEP to students. Although 93.5% of institutions offered HIV/STI testing, only 65.9% offered PrEP and a remarkable 35% reported no intention to implement provider-level PrEP prescribing policies.[<reflink idref="bib30" id="ref54">30</reflink>] Although the ACHA survey may not be generalizable to all college health centers, the ACHA results suggest widespread outreach and access to PrEP services may not be uniform across college campuses. In our study, the majority of students surveyed were unaware of PrEP (61.2%) and more than half indicated uncertainty (27.3%) or unwillingness to take daily oral PrEP (33.7%). These findings align with recent literature and suggest best practices are not being followed. Another study among 210 students from two Southern HBCUs found that 48% of students were unaware of PrEP and only two individuals were taking PrEP.[<reflink idref="bib31" id="ref55">31</reflink>] Together, these results are concerning for local outreach efforts and progress toward EHE goals to reduce HIV in this prioritized jurisdiction and indicate a missed opportunity to enact best practices established by the ACHA on our local college campuses.</p> <p>In our multivariable analyses, students were more likely to be aware of PrEP if they were ages 23+ (vs 18–22), sexual minority status, Black (compared to white, had high HIV knowledge scores (vs low), and had high HIV risk scores (vs low). Willingness to use daily oral PrEP was associated with higher levels of perceived HIV risk (compared to low-risk perception), sexual minority status, first-year/sophomore class status (compared to junior/senior), and type of insurance. Efforts to increase PrEP awareness and increase willingness may be disproportionately reaching and benefiting students with particular demographic characteristics. Therefore, it is vital to provide unified PrEP messaging to improve access and uptake for all students. Students with moderate perceived risk may also benefit from more education and awareness campaigns about PrEP as a prevention option.</p> <p>First-generation PrEP (i.e. oral PrEP) may be challenging for young people to take consistently and second-generation modalities (i.e. injectable PrEP and implants) may improve adherence and provide more discretion.[<reflink idref="bib32" id="ref56">32</reflink>] Injectable PrEP willingness was associated with higher levels of perceived HIV risk, sexual minority status, Asian race (as compared to white), transgender (compared to cisgender men), and first-years/sophomores (compared to junior/senior class status). Willingness to use PrEP implants was associated with higher perceived risk, sexual minority status, and identifying as a cisgender woman or transgender (compared to cisgender men). Although we did not measure student attitudes, a recent qualitative study conducted cognitive interviews among young men who have sex with men about next-generation PrEP and found that confusion about medical language and terminology increased apprehension about taking future PrEP modalities.[<reflink idref="bib33" id="ref57">33</reflink>]</p> <p>Likelihood to use antibody prophylaxis treatment was associated with higher levels of HIV perceived risk, sexual minority status, cisgender woman gender identity (compared to cisgender men), first-years/sophomores compared to junior/senior class status, and low HIV risk scores (compared to high HIV risk scores). Likelihood to take an HIV vaccine was associated with higher levels of HIV perceived risk, sexual minority status, first-years/sophomores compared to junior/senior class status, public research university versus private university, and high HIV risk score (compared to low-risk score). More studies are needed to improve our understanding about attitudes, choices, and preferences for next-generation PrEP and future prevention tools among adolescents and young adults, including college students.</p> <p>Interestingly, students in this study with higher risk scores were not more likely to be willing to take oral PrEP or any of the four future HIV prevention methods, controlling for other factors. However, when we compared outcomes to each other, students who were likely to take a vaccine were also more likely to use antibody prophylaxis treatment. Comparatively, the likelihood to use PrEP implants was associated with the likelihood to use injectable PrEP, although a large proportion of students were very unlikely (21.0%) or unlikely (20.4%) to take injectable PrEP. This particular finding is important given that injectable PrEP was recently FDA approved in December of 2021,[<reflink idref="bib15" id="ref58">15</reflink>] after this study concluded. More studies are needed to explore specific reasons for variations in willingness to use various currently approved prevention modalities.</p> <hd id="AN0182848221-12">Limitations</hd> <p>This was an exploratory study of key sociodemographic and HIV-related risk factors that could be influential (and could be used for tailoring future interventions) for awareness of and willingness to uptake PrEP and other future prevention methods among youth. This study took place in one geographic area and results may not be generalizable to college students nationwide. However, Mecklenburg County is an EHE jurisdiction due to higher HIV transmission which may experience similar challenges to other southern jurisdictions. Because the survey occurred at the end of the semester, varying levels of interest in research participation, and concurrent COVID-19-related disruptions may have influenced participation and representativeness. Survey findings are subject to recall and self-selection biases, and the lack of random selection of participants may have resulted in higher participation among students who are more interested in HIV prevention or sexual health. Unwillingness to use PrEP may be related to other factors, such as sexual inactivity, a monogamous partnership, or an underlying illness. A single respondent indicated not knowing whether they were ever tested for HIV, however, the results were not sensitive to alternative categorizations of this individual's response. We asked about the number of sexual partners in the past three months to reduce potential recall bias and to indicate recent sexual transmission risk for HIV at the time the survey was conducted. It is possible that designating participants with no sexual partners in the prior three months may not accurately reflect their risk for HIV transmission. For example, participants may have had no sexual partners in the past three months but had multiple partners more than three months ago. Lastly, the relatively low number of participants who did not identify as cisgender resulted in the need to group together a very heterogeneous set of respondents as transgender or another gender identity who may otherwise experience largely different associations with the study outcomes. Despite these limitations, we surveyed 701 college students the Southern United States, a geographic region that experienced the highest rate of all new HIV diagnoses in 2019.[<reflink idref="bib1" id="ref59">1</reflink>] Our findings demonstrate the need for interventions to increase PrEP awareness, monitor HIV risk, address barriers to PrEP, and develop messaging for future prevention methods.</p> <hd id="AN0182848221-13">Conclusions</hd> <p>As the fifth decade of the HIV epidemic in the United States unfolds, the ongoing burden of HIV in the south necessitates continued research on adolescent and young adult populations at elevated risk for infection. We found low awareness about HIV infection risk and prevention methods among college students in the southeastern United States. Future studies should continue efforts to engage all students, regardless of demographic characteristics, in sexual health literacy and HIV prevention education. Engaging adolescents and young adults will require future studies to identify novel and innovative strategies to promote current and emergent HIV prevention modalities. Institutions of higher education may provide an optimal setting to reach young adults and provide relevant programming to enhance awareness and uptake of first- and next-generation PrEP among college students. Increasing awareness of prevention methods among college students may also reach other young adults connected through social, sexual, and drug use networks. Colleges and universities are optimally positioned to improve sexual health literacy among all students and should include students in the development of HIV prevention messaging at campus health services and events.</p> <hd id="AN0182848221-14">Acknowledgment</hd> <p>We thank all survey participants and members of the research team.</p> <hd id="AN0182848221-15">Conflict of interest disclosure</hd> <p>Ethics approval and consent to participate. All participants provided informed consent prior to participation. This study was approved by the Institutional Review Boards at the University of North Carolina at Charlotte and Johnson C. Smith University. The authors declare that they have no competing interests.</p> <hd id="AN0182848221-16">Authors' contributions</hd> <p>All authors reviewed and approved the final manuscript.</p> <hd id="AN0182848221-17">Availability of data and materials</hd> <p>The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request with a data use agreement.</p> <hd id="AN0182848221-18">Abbreviations</hd> <p></p> <p>• ACHA:</p> <p></p> <ulist> <item> American College Health Association</item> <p></p> </ulist> <p>• CDC:</p> <p></p> <ulist> <item> Centers for Disease Control and Prevention</item> <p></p> </ulist> <p>• CIs:</p> <p></p> <ulist> <item> confidence intervals</item> <p></p> </ulist> <p>• EHE:</p> <p></p> <ulist> <item> Ending the HIV Epidemic</item> <p></p> </ulist> <p>• HBCU:</p> <p></p> <ulist> <item> historically black college or university</item> <p></p> </ulist> <p>• HIV:</p> <p></p> <ulist> <item> human immunodeficiency virus</item> <p></p> <item> LGBT Q+:</item> <p></p> <item> lesbian, gay, bisexual, transgender, queer, questioning plus another identity or identities</item> <p></p> </ulist> <p>• LAIP:</p> <p></p> <ulist> <item> long acting injectable PrEP</item> <p></p> </ulist> <p>• OR:</p> <p></p> <ulist> <item> odds ratio</item> <p></p> </ulist> <p>• PrEP:</p> <p></p> <ulist> <item> pre-exposure prophylaxis</item> <p></p> </ulist> <p>• SMM:</p> <p></p> <ulist> <item> sexual minoritized men</item> <p></p> </ulist> <p>• STI:</p> <p></p> <ulist> <item> sexually transmitted infection</item> </ulist> <ref id="AN0182848221-19"> <title> Footnotes </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Supplemental data for this article can be accessed online at https://doi.org/10.1080/07448481.2023.2232885.</bibtext> </blist> </ref> <ref id="AN0182848221-20"> <title> References </title> <blist> <bibtext> Centers for Disease Control and Prevention. 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  Group: Audnce
  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink><br /><searchLink fieldCode="EL" term="%22Postsecondary+Education%22">Postsecondary Education</searchLink>
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Acquired+Immunodeficiency+Syndrome+%28AIDS%29%22">Acquired Immunodeficiency Syndrome (AIDS)</searchLink><br /><searchLink fieldCode="DE" term="%22Equal+Education%22">Equal Education</searchLink><br /><searchLink fieldCode="DE" term="%22Sex+Education%22">Sex Education</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Education%22">Health Education</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Undergraduate+Students%22">Undergraduate Students</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Attitudes%22">Student Attitudes</searchLink><br /><searchLink fieldCode="DE" term="%22Prevention%22">Prevention</searchLink><br /><searchLink fieldCode="DE" term="%22Private+Colleges%22">Private Colleges</searchLink><br /><searchLink fieldCode="DE" term="%22Black+Colleges%22">Black Colleges</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Surveys%22">Student Surveys</searchLink><br /><searchLink fieldCode="DE" term="%22LGBTQ+People%22">LGBTQ People</searchLink><br /><searchLink fieldCode="DE" term="%22Sexual+Orientation%22">Sexual Orientation</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Identity%22">Gender Identity</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Contraception%22">Contraception</searchLink><br /><searchLink fieldCode="DE" term="%22Futures+%28of+Society%29%22">Futures (of Society)</searchLink><br /><searchLink fieldCode="DE" term="%22Student+Characteristics%22">Student Characteristics</searchLink>
– Name: Subject
  Label: Geographic Terms
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22North+Carolina%22">North Carolina</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/07448481.2023.2232885
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0744-8481<br />1940-3208
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: Objective: Identify factors associated with PrEP awareness, willingness, and future prevention modalities among undergraduate college students. Participants: Undergraduates (N=701) were recruited from a private university, a public research university, and a private historically Black college and university for an online survey. Methods: Upon multiple imputations, a multivariate logistic model, a multivariate multinomial model, and independent multivariate ordinal logistic models were used to calculate Rubin's rules-pooled adjusted odds ratios for PrEP awareness, willingness, and future HIV prevention methods. Results: Only 33.4% of students had heard of and 32.4% were willing to take PrEP. PrEP willingness was higher among sexual minority students compared to heterosexual/straight students (OR = 1.65; 95% CI: 1.03-2.63); p=0.036). The likelihood to take a future vaccine or antibody prophylaxis treatment was higher than the likelihood to take injectable PrEP or implants. Conclusions: Interventions to increase PrEP uptake and willingness among undergraduates should emphasize equity in HIV education and include future prevention modalities.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1472510
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1472510
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/07448481.2023.2232885
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 10
        StartPage: 700
    Subjects:
      – SubjectFull: Acquired Immunodeficiency Syndrome (AIDS)
        Type: general
      – SubjectFull: Equal Education
        Type: general
      – SubjectFull: Sex Education
        Type: general
      – SubjectFull: Health Education
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Undergraduate Students
        Type: general
      – SubjectFull: Student Attitudes
        Type: general
      – SubjectFull: Prevention
        Type: general
      – SubjectFull: Private Colleges
        Type: general
      – SubjectFull: Black Colleges
        Type: general
      – SubjectFull: Student Surveys
        Type: general
      – SubjectFull: LGBTQ People
        Type: general
      – SubjectFull: Sexual Orientation
        Type: general
      – SubjectFull: Gender Identity
        Type: general
      – SubjectFull: Health Behavior
        Type: general
      – SubjectFull: Contraception
        Type: general
      – SubjectFull: Futures (of Society)
        Type: general
      – SubjectFull: Student Characteristics
        Type: general
      – SubjectFull: North Carolina
        Type: general
    Titles:
      – TitleFull: PrEP Awareness, Willingness, and Likelihood to Use Future HIV Prevention Methods among Undergraduate College Students in an Ending the HIV Epidemic Jurisdiction
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Meagan Zarwell
      – PersonEntity:
          Name:
            NameFull: Alexandra Patton
      – PersonEntity:
          Name:
            NameFull: Laura H. Gunn
      – PersonEntity:
          Name:
            NameFull: Alyssa Benziger
      – PersonEntity:
          Name:
            NameFull: Brian Witt
      – PersonEntity:
          Name:
            NameFull: Patrick A. Robinson
      – PersonEntity:
          Name:
            NameFull: Debra F. Terrell
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          Dates:
            – D: 01
              M: 01
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 0744-8481
            – Type: issn-electronic
              Value: 1940-3208
          Numbering:
            – Type: volume
              Value: 73
            – Type: issue
              Value: 2
          Titles:
            – TitleFull: Journal of American College Health
              Type: main
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