HIV Risk and Intention to Use HIV Pre-exposure Prophylaxis Among Sexually Active Female University Students in Zambia: A Cross-Sectional Survey to Understand Influential Factors

Limited research exists on HIV pre-exposure prophylaxis (PrEP) interest among female university students in high-HIV-prevalence African settings. This study sought to establish the relationship between epidemiological and perceived HIV risk and PrEP intention among young women in higher education in Zambia. We recruited female students at an urban university to complete an online survey on intention to use PrEP in the next year (primary outcome); PrEP knowledge, attitudes, and behaviors; demographics; epidemiological HIV risk; and risk perception. Descriptive statistics, regression, and mediation analyses were used. Of the 454 sexually active participants, 118 (26%) reported PrEP intention. Actual PrEP use was rare (<5%). The odds of PrEP intention increased for those with perceived high HIV risk [adjusted odds ratio (aOR) = 3.08; 95% confidence interval (CI): 1.71-5.55] and with each year at university (aOR = 1.47; 95% CI: 1.21-1.80) but decreased with higher PrEP stigma (aOR = 0.91; 95% CI: 0.86-0.96) and more negative PrEP perceptions (aOR = 0.91; 95% CI: 0.85-0.97). More epidemiological risk factors were originally associated with PrEP intention (aOR = 1.24; 95% CI: 1.01-1.53 for each risk factor), though this relationship weakened after adjustment for perceived HIV risk, which mediated 69% of the relationship between epidemiological HIV risk and PrEP intention. Only 23% of high-risk participants recognized their high epidemiological HIV risk (3+ risk factors). Along with PrEP education and stigma reduction, there is a need for approaches that help female university students in Zambia accurately identify their HIV risk to make informed decisions about PrEP use.