Knowledge, Attitude and Willingness to Use Pre-Exposure Prophylaxis (PrEP) of HIV Among Sexually Active Female Undergraduates

Human Immunodeficiency Virus (HIV) is a grave health issue in the planet, over 40 years since the virus was discovered. Lentivirus or HIV is a virus which infects predominantly CD4+ cells/T helper cells and macrophages which are key components of the immune system. The virus disrupts the performance of the immune system, draining the CD4+ cells and after several months, it leads to what is widely known as acquired immunodeficiency syndrome (AIDS), which compromises the immune system of the body and exposes it to opportunistic infections and certain types of cancer (CDC, 2018a). Normal infection begins with the acute phase of infection which is characterised by massive viral load, long phase of no symptoms and finally AIDS in case of untreated infection. HIV is known to be transmitted by bodily fluids (blood, sperm, vaginal fluids and breast milk) and is typically caused by sexual intercourse, needle sharing, or mother-to-child during childbirth or breastfeeding (CDC, 2018a). A progressive and long-term depletion of CD4+ T cells that are essential in regulating immune responses depletes the basic immunological failure of AIDS (Stine, 2014). Some of the risk factors that may predispose an individual to HIV are unprotected sex and multiple sexual partners and the lack of access to effective prophylaxis drugs such as pre-exposure prophylaxis (PrEP). The number of people with HIV since the beginning of the epidemic is over 70 million worldwide, and it has resulted in more than 30 million diseases that are caused by AIDS (WHO, 2017; Eshun et al., 2023). Even though much has been done in terms of prevention and treatment, no known cure of HIV/AIDS has been discovered yet, hence the need to prevent it. By 2022, it was estimated that there were more than 39 million HIV positive people in the world, and 1.3 million new infections were registered that year (UNAIDS, 2023a). Sub-Saharan Africa is the region that has been most hit bearing the brunt of the disease. Nigeria is the most populated nation in Africa; this country contributes a lot to regional and international response towards HIV. Nigeria is one of the most powerful states in terms of HIV burden with about 1.9 million individuals with HIV infection and prevalence rate of 1.4 percent among adults (NACA, 2019). The big state-level variances are concealed by the national average. Even the general population is far less than some of the areas, such as Akwa Ibom State, and this increases the level of public health problems (NACA, 2021). The young women are particularly susceptible to HIV particularly those who are aged between 15 and 24 years. The World Health Organisation estimates that such a group of persons comprise about 25 percent of all new HIV diagnoses in the entire world with the majority of the infections in Sub-Saharan Africa (WHO, 2021a). This increased susceptibility is due to biological, social and structural factors. The adolescent girls and young women have higher chances of transmitting the infection to others during vaginal intercourse which is a biological process. The prevalent problem among many individuals who become the victims of transactional sex or sexual violence is gender inequality, unequal relations in sexual relations and inaccessibility to health information and services (UNAIDS, 2023b). These facts demonstrate the need to have effective and comprehensive prevention programmes. Even though antiretroviral therapy (ART) has been found to be effective in controlling HIV and extending the life span of people who are already infected, prevention of new infections is among the priorities. As a result, the health systems of most countries have embraced combination prevention that entails tactical use of the biological, behavioural and structural intervention in relation to the requirements of the various populations (UNAIDS, 2009; Federal Ministry of Health, Nigeria, 2020). Combination prevention involves combining medical prevention such as condoms, PrEP and HIV testing with medical education, community mobilisation and policy changes to reduce the underlying risk factors such as stigma and economic vulnerability. Of these methods, biological treatments, especially PrEP, have proved to be one of the most effective modes of HIV prevention. Regular oral PrEP that is usually a combination of emtricitabine and tenofovir can significantly reduce the risk of HIV infection in individuals who are at high risk when taken on a daily basis. Research has shown that it works even in diverse groups of people, such as males who are sexually involved with men, heterosexuals, and drug users (Baeten et al., 2012; McCormack et al., 2016). Consequently, the World Health Organisation and the United States Centers for Disease Control and Prevention endorse PrEP as an important part of HIV prophylaxis programmes (WHO, 2015; CDC, 2017). PrEP has the potential to reduce the likelihood of HIV transmission via sexual activity by up to 99% and by approximately 74% in people who inject drugs (CDC, 2020). Nonetheless, frequent use is still challenging especially by people who would use it most. Although PrEP is a major development in the prevention of HIV, it is not fully used in most of the high-burden areas because of several structural and psychosocial factors. PrEP was officially introduced in Nigeria in 2018, and the Federal Ministry of Health has been making efforts to make it more available. Nigeria has become one of the world leaders in PrEP implementation by 2023, and an estimated 550,000 people in the country are already taking PrEP (AVAC, 2023). But these numbers are insignificant when one considers the scale of the endangered population. Although national guidelines suggest PrEP usage in the highest-risk groups, including sex workers, men who have sex with men, and sexually active young women, the uptake remains low due to a variety of reasons, such as low awareness and stigma around the use of the medication and access to youth friendly sexual health services (NACA, 2019; Prepwatch, 2024). Universities are important, yet very often neglected in the fight against HIV. Colleges and universities are social centres that the youths and young adults spend the first time of their lives with no parental guidance, indulge in habits that may expose them to HIV infection such as casual or multiple sex, poor use of condoms and alcohol or drug use during sexual intercourse. Peer pressure, economic vulnerability, and deficiency of comprehensive sexual health education are additional factors that expose female students to greater and increased risks of HIV (Maticka-Tyndale et al., 2010; Baeten et al., 2012). The University of Uyo is situated within the Akwa Ibom State where the prevalence rate of HIV is among the highest in Nigeria. Nigeria AIDS Indicator and Impact Survey (NAIIS) of 2018 showed that the HIV rate and prevalence in Akwa Ibom State was 5.5% with a recent estimate of 4.4% (Medbury Medical Services, 2023). The given epidemiological scenario makes it clear that it is necessary to learn the extent to which female students know and understand PrEP, their perception of it, and whether or not they are willing to use it or not. Some studies show that in spite of the fact that the HIV awareness in some Nigerian students of universities is usually high, the level of PrEP knowledge remains low (Ajayi et al., 2019). Negative attitudes towards PrEP have been noted as the reasons including misinformation, fear of side effects, and stigma in the society, all of which discourage potential users. In other researches carried out, willingness to use PrEP does not match actual use due to a shortage of access, insufficient information about the advantages of PrEP, and social norms that do not allow discussing sexual health openly (Liu et al., 2014). Stigma regarding HIV and its prevention is another significant hindrance as well. Most individuals fear that taking PrEP will make others assume that they are HIV positive or promiscuous, which will prevent them to desire the intervention even when they are at risk (Gamarel et al., 2018; Shokoohi et al., 2016). The issue is aggravated by cultural taboos and gender-related expectations because young women often have no control and means to choose decisions related to their sexual health or to negotiate safe sex (Cianelli et al., 2012; Dellar et al., 2015). It is critical that these socio-behavioural processes are acknowledged to devise specific and efficient therapies. Research shows that understanding and correcting the misperceptions about PrEP can help increase its acceptability among young women. Other studies of Africans have discovered that with correct information in favorable settings, female students who are given the opportunity to use PrEP will want to do so significantly (Pintye et al., 2018). Nevertheless, the Nigerian environment is not well researched, especially when it comes to female students. The information regarding this group is vital in shaping the health programs of the people especially in the states with the highest prevalence rates like in Akwa Ibom State. It is on this background that this paper will explore knowledge, attitude and willingness to use PrEP of HIV among sexually active female undergraduate students in the University of Uyo, Uyo, Akwa Ibom State. The study will be critical in establishing the barriers and enabling factors to PrEP use in this category of demographics, and in informing policies and educational programmes to reduce HIV spread amongst young women in Nigeria.

The primary aim of this study is to assess the knowledge, attitudes, and willingness to use PrEP (Pre-exposure prophylaxis) of HIV among sexually active female undergraduates.

1. 1How many sexually active female undergraduates of the University of Uyo have a good knowledge of the PrEP of HIV?
2. 2How many sexually active female undergraduates of the University of Uyo have a positive attitude towards PrEP of HIV?
3. 3What proportion of sexually active female undergraduates of the University of Uyo are willing to use PrEP as an HIV prevention strategy?
4. 4What factors influence willingness to use PrEP of HIV?