Young people and HIV. Knowledge and risk behaviours in a group of residents in Spain

Human immunodeficiency virus (HIV) infection, like other sexually transmitted infections (STIs), is highly prevalent among young adults. According to the results of the report published in November 2017 by the Sistema de Información sobre Nuevos Diagnósticos del VIH y Registro Nacional de Casos de SIDA [Spanish Information System on New HIV Diagnoses and National Register of AIDS Cases], an increase in the rate of new diagnoses was seen in the 30–34 age group from 2009 to 2014, followed by a stabilisation thereafter. No statistically significant changes were observed in other age groups. The median age at diagnosis of HIV infection was 36 years, with it being significantly lower in men (36 years) than women (39 years). Most new diagnoses are detected in the 30–39 age group (33.6%). The percentage of individuals under 30 years of age at the time of HIV diagnosis was 25.9%. The percentage of individuals aged 15–24 years old was 11.1%, and 16.4% were aged 50 or older.¹

In Spain, there is a paucity of information among young people on knowledge relating to the routes of transmission of HIV and protective measures to prevent infection, hence our interest in the article published by Velo-Higueras et al., in which the authors describe some incredibly useful results and conclusions for designing prevention strategies targeted primarily at young people. The objective of said article, entitled “Young people and HIV. Knowledge and risk behaviours in a group of residents in Spain”, is to assess knowledge on the transmission mechanisms and protection methods against HIV, as well as to understand risk behaviours for contracting HIV/STIs in a sample of young people in Spain.² The study was conducted on 241 HIV-negative individuals with ages ranging from 16 to 36 and a median age of 26. Out of these individuals, 83% had received further education. The respondents filled out an online or paper questionnaire in the hospital setting, which collected information about their health and sexual habits in relation to HIV. They were then divided into two risk profiles for HIV transmission: high and low risk. The authors considered subjects with a high risk of HIV transmission (48.1%) to be those who did not always use a condom and who had had three or more sexual partners in their lifetime. Low risk subjects (47.3%) were deemed to be those who always used a condom and who had had fewer than three sexual partners in their lives.

Despite the fact that the questionnaire focuses on assessing HIV-related knowledge, collecting further information on other STIs such as chlamydia, gonorrhoea and syphilis, which are most prevalent among young people, might improve the study's quality.³ These STIs often go unnoticed since they are mostly asymptomatic, potentially leading to severe complications, especially among women and in cases of extra-genital infection.^4,5 In order to assess the risk of HIV infection or other STIs, there are guidelines that recommend gathering information about the patient's sociodemographic, clinical and behavioural characteristics.⁶ Among these, the following are considered particularly relevant: the number of sexual partners; sexual orientation; condom use during all sexual activities; a history of STIs; the number of HIV tests performed; recreational drug use associated with sexual activities or not; and the use of pre- and post-exposure prophylaxis against HIV.⁷

As in other publications, Velo-Higueras et al. highlight that knowledge about HIV prevention mechanisms is often not associated with the adoption of safer practices. Thus, 81% of the subjects deemed high risk by the authors indicated that they perceived themselves to be at no or little risk of HIV infection. Moreover, having a high degree of knowledge on any effective HIV prevention measure, such as condom use, does not guarantee an understanding of other preventative measures like suppressive antiretroviral therapy, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) and the diagnosis and treatment of other STIs.^8,9

The results obtained in this article show that there is inadequate knowledge among young people regarding HIV transmission mechanisms. Thus, 17.8% think HIV can be contracted through mosquito bites and 4.6% by sharing toilets, while 15.8% believe spermicide use to be an effective protection method. In spite of the vast information available online, young people have no clear or concise messages about HIV and its routes of transmission. To reduce high-risk sexual behaviours and the related health problems among young people, health education in schools must be broadened, particularly in the sphere of sexuality, with a view to providing information and encouraging the adoption of attitudes and behaviours that support their health and well-being, including behaviours that reduce the risk of contracting HIV, other STIs and unwanted pregnancies.¹⁰

In the USA, the National HIV/AIDS Strategy requires all citizens to be educated on HIV. This includes understanding how HIV is transmitted and prevented, and knowing which behaviours place people at a greater risk of infection. HIV awareness and education should be included in all education systems worldwide.¹¹

Velo-Higueras et al. report that most of the respondents knew that HIV was sexually transmitted and that male condoms are an adequate protection measure. They therefore conclude that the problem not only lies in the lack of information, but also in applying these health messages to real life. This may be one of the points on which the most emphasis should be placed. Why don’t young people use prevention measures despite knowing about them? Various studies have found that some causes could perhaps be: a loss of fear regarding AIDS, stemming from the security generated by the great clinical and preventative efficacy shown by suppressive antiretroviral therapy; recreational drug use associated with sex; and the use of apps to search for risky sexual relations, all of which impede safe sex.^12,13

There is a documented high risk of contracting HIV or other STIs under the influence of recreational drugs associated with unprotected sex.¹⁴ This phenomenon is increasingly common among young people and adolescents. As indicated by the authors, recreational drug use was associated with the group who had high risk factors. Therefore, for young people suffering from alcohol and drug abuse, it is important to: promote the reduction of risk and harm; make referrals to the relevant mental health services according to each individual's needs; carry out regular STI/HIV screening; and carry out contact tracing. Analysing people's toxic habits, particularly among young people, is vital in order to design tailored prevention strategies.

Preventative actions designed specifically for young people must be devised. Mobile applications, the use of which is widespread among individuals in this age group, could be a used as a tool to facilitate the dissemination of clear and concise information on the routes of transmission and different prevention measures against HIV infection, with a view to achieving a significant change in risk behaviours and other factors associated with the transmission of HIV and other STIs. Several apps are currently available which offer recommendations for promoting adherence to the trans-activation response (TAR) element and PrEP.¹⁵

Moreover, it is of the utmost importance that we provide young people and adolescents with easy access to HIV and other STI tests across different points of care, such as STI clinics, primary care, NGOs, drug rehabilitation clinics and young people's sexual and reproductive health centres, in which advice tailored to adolescents on safe sex and risk reduction should also be offered, and condom use promoted.^16–18

In conclusion, information on the routes of transmission of HIV and the associated factors is incomplete among the majority of young people, who often underestimate the risk. Although there are some scales for measuring HIV-related knowledge and risk behaviours, a standardised questionnaire is needed in order to assess and identify the risk of contracting HIV and other STIs, with a view to establishing personalised preventative advice.

Conflicts of interest

The authors declare that they have no conflicts of interest.