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Article Excerpt
Objective. This article updates our 1997 review that examined the literature on HIV risk behavior among college students. Methods. The current review focuses on college student sex-risk behaviors related to HIV-related knowledge, communication with sex partners, self efficacy, and behavioral skills. Results. As reported in our original review, the majority of students continue to have multiple sex partners, use condoms inconsistently during intercourse, and have a tendency to combine alcohol and/or other drugs with their sexual experiences. They remain very knowledgeable about the virus and routes of basic transmission, but that does not impact condom use. Communication among partners about safer sex continues to be limited. Conclusions. Enhancing self efficacy should be an important focus for intervention strategies among students, given consistent evidence for its impact on lowering risk for HIV transmission. Additional evidence-based recommendations for strategies to prevent the spread of HIV within the college population are provided.
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Fifty percent of all new HIV infections occur among people under 25 years of age (Centers for Disease Control and Prevention, 2004) and the majority of sexually transmitted infections (STI) is contracted in people between the ages of 19 and 24 (DiClemente & Crosby, 2003). Studies of STI prevalence on college campuses are limited, but those infected are thought to range from 12% (Patrick, Covin, Fulop, Calfas, & Lovato, 1997) to 25% (Reinisch, Hill, Sanders, & Ziemba-Davis, 1995) of students. About 75% to 90% of all students are sexually active (Dalton, Donald, & Ratliff-Crain, 1999; LaBrie, Earleywine, Schiffman, Pedersen, & Marriot, 2005) and on average they report more than 2 partners per year (DiLorio, Dudley, & Soet, 1998; LaBrie et al., 2005) and over 6 lifetime partners (Civic, 2000). The actual number of HIV-infected college students is estimated to be low relative to other populations (Karon, Fleming, Steketee, & De Cock, 2001). To date only one national study has been conducted (Gayle et al., 1990), and college students still have not been labeled at high-risk as the epidemic has spread (Sepkowitz, 2001). Two recent studies found that HIV infection in college men in the Southeastern United States was significant and their sexual networks were expansive (Hightow et al., 2005; Hightow et al., 2006). Given the extended time between contracting HIV and exhibiting clinical symptoms and since many college students engage in conduct that places them at risk for serious health problems (Centers for Disease Control and Prevention, 1997) such as inconsistent condom use, alcohol drinking, and other drug use, the number of infected college students may be underestimated.
In assessing articles for this review, we utilized an exhaustive electronic search of the published literature with PsychINFO, ERIC, EMBASE, and OVID Medline databases. To ensure that we only selected appropriate papers, keywords included "college students," "condom use," and "HIV risk behavior." In addition, articles were taken from the third author's weekly HIV Lserv. In order for studies to be selected for this review article, the work had to be: (1) only among US college students; (2) peer-reviewed publications: (3) published between 1997 and 2007; and (4) in the context of utilizing psychosocial mediators of HIV risk based on popular theoretical models, including the Health Belief Model (HBM) (Janz & Becker, 1984), Self Efficacy Theory (Bandura, 1990), the Theory of Reasoned Action (TRA) (Ajzen & Fishbein, 1980), the AIDS Risk Reduction Model (ARRM) (Catania, Kegeles, & Coates, 1990), and the Information-Motivation-Behavioral Skills Model (IMB) (Fisher & Fisher, 1992). Studies were excluded from this analysis if the article: (1) was conducted on students outside the US (2) focused on non-heterosexual college students, since the dynamics of HIV risk behavior are likely to be significantly different from heterosexual students.
Psychosocial variables theorized as important contextual factors used to frame this review were: (a) HIV knowledge and information, (b) normative beliefs (c) perceived susceptibility of HIV and attitudes toward safer sex (d) self efficacy (e) sex communication (f) behavioral skills Condom use, sex behaviors, alcohol and other drug use prior to and during sex, gender, and ethnicity were the other variables used to structure the findings. Salient points will also be presented in comparison to our previous review paper on college students (Lewis, Malow, & Ireland, 1997).
Condom Use and Sex Partners
Even with the risk of the transmission of HIV and STI, college students typically inconsistently use condoms and have multiple lifetime sex partners. Without an effective vaccine for HIV, short of abstinence, the best way to reduce the risk of HIV is still through the use of condoms. Thus, increasing the use of condoms is the primary outcome measure to determine the level of sex-risk behavior. In addition, measuring the number of lifetime partners and partner type, e.g., casual or committed, is also an important indicator of sex-risk behavior.
Perhaps the largest self-report survey of college student sex behavior is a 2006 national survey of 34 colleges and universities including almost 24,000 students. This study revealed in the prior 30 days that over 43% had engaged in oral sex, over 46% had vaginal intercourse, and a little over 4% had anal sex (American College Health Association, 2007). Of those who had oral sex, fewer than 4% used a condom during the last episode, for vaginal intercourse 54% used a condom during the last act, and for anal sex over 26% used a condom during the last incident. Students who are experienced in anal sex are more likely to engage in risky vaginal sex and not use condoms during the last act (Baldwin & Baldwin, 2000). About 35% of sexually-active students always use condoms and only half of those who report being concerned about HIV always used condoms (Opt & Loffredo, 2004). About half of students report that they never use condoms and only 10% use condoms 100% of the time (Prince & Bernard, 1998). Condom use and HIV knowledge have been shown to increase following a brief, computerized IMB model intervention (Kiene & Barta, 2006).
Gender differences continue to be found for sex-risk behavior, as college males report greater condom use than females (Rhodes et al., 2007), but males engage in more unsafe sex practices (Lance, 2001). Males also typically report more lifetime partners (McCormack, 1997; Siegel, Klein, & Roghmann, 1999). For college women, higher levels of condom use are related to the ability to be assertive, intentions to use condoms, and avoidance of substance use (Roberts & Kennedy, 2006). Students also feel that using condoms is not necessary with a primary partner, but they are more inclined to use a condom with a casual partner, especially among women (Weinberg, Lottes, & Aveline, 1998).
African-American college students report inconsistent condom use during prior sexual encounters and many of them had at least two sex partners over the previous year (Bazargan, Kelly, Stein, Husaini, & Bazargan, 2000; Lewis, Melton, Succop, & Rosenthal, 2000; Whaley & Winfield,...
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