Blood-borne viruses (BBVs) and sexually transmissible infections (STIs) constitute a global public health threats as they account for annual 2.3 million deaths and 1.2 million cases of cancer1. Sexual transmission of BBVs/STIs occurs through unprotected anal, oral and/or vaginal sexual contact between at least two people, one of whom, is infected. Though there are over 30 bacteria, viruses and parasites that could be transmitted through unprotected sexual contact, eight of these pathogens are associated with the greatest incidence of BBVs/STIs2. Of these eight pathogens, four (chlamydia, gonorrhoea, syphilis and trichomoniasis) are curable, while the other four (hepatitis B Virus HBV, herpes simplex virus HSV, human immunodeficiency virus HIV and human papilloma virus HPV) are not. Globally, BBVs/STIs are public health threats that affect quality of life, increase morbidity and mortality and impact individual and national economies3–6.
For instance, HIV poses a significant public health concern with a record 79.3 million infections and 36.3 million AIDS-related deaths since the start of the HIV epidemic7. Unless far-reaching actions are taken, HIV is projected to claim an additional 7.7 million lives over the next ten years8. This projection raises further concern because it predates the emergence of an even more virulent strain of HIV, which in comparison with other strains, spreads faster, doubles the rate of immune system decline and triples the risk of AIDS9–11. Though tremendous progress has been made in reducing AIDS-related deaths due to antiretroviral therapy (ART) the number of new HIV infections keeps driving the HIV epidemic5,12,13. With 1.5 million new infections in 2020, there are now 37.7 million people living with HIV globally1.
Of note, the global response to the threats of BBVs/STIs has seen more resources and efforts directed to treatment than primary prevention, hence the relatively high number of new HIV infections. Of note, of the $526 billion US Dollars spent globally on HIV/AIDS control between 2000–2015, only 19% was committed to primary prevention, with management disproportionately accounting for 81% of this fund14. Consequently, greater success has been recorded in reducing AIDS-related deaths, than in reducing new HIV infections5. This response strategy, which largely focuses attention on managing and treating BBVs/STIs, while paying less attention to primary prevention, weakens control efforts15. In addition, it may also derail the set target of eliminating HIV, viral hepatitis and STIs as public health threats by 203016.
The purpose of the present study is to understand how to promote primary prevention among international students in Australia, who come from more conservative sexual cultures. Using a mixed-methods design, the present study explores BBVs/STIs protective practices among international university students in Sydney, Australia, who come from East Asian and sub-Saharan African countries and territories. While quantitative data explored predictors of BBVs/STIs protective practices (abstinence, condom use and partner fidelity), qualitative data examined, in greater detail, how sexually active participants understand, practice and rationalise condom use in protective sex.
Understanding BBVs/STIs protective practices among international students is important because a large body of evidence links international migration to the global spread of BBVs/STIs17–19. Though international university students, with temporary visa status, are not settled migrants; they are considered a migrant population by the United Nations20. Importantly, emerging evidence indicates that high proportions of migrants in Western countries who contract HIV, do so postmigration21–24. This postmigration HIV acquisition might be attributable to ineffective interventions for migrant populations in high-income countries. To be effective, BBVs/STIs interventions for migrants moving from low or middle-income to high-income countries, must consider the complex interplay between migration experience, health system, and sociocultural factors that influence risk and prevention practices25.
While Australia has recorded significant progress in HIV prevention and control26–29, there are concerns around rising notifications of STIs in the general population30,31. There are also concerns around HIV notifications among migrant populations26,27,29. Specifically, in 2018, 46% of new HIV notifications in Australia occurred among migrants28. In addition, while there was a decline in new HIV notification among Australian born residents between 2017 and 2018; there was an increase among migrants, within the same period28. The disproportionately higher HIV notification among migrant population in Australia may be linked with high BBVs/STIs related stigma, especially among migrant and international student communities from more conservative cultures. This high stigma may impact prevention, screening and treatment uptake among this population26,32.
Importantly, international students from backgrounds where BBVs/STIs are stigmatised may experience double vulnerabilities to BBVs/STIs. First, international students from more conservative cultures are members of the general migrant population in Australia that are more vulnerable to BBVs/STIs26–29. Second, international students are part of the general population of young people who are known to be at higher risk of the sexual transmission of BBVs/STIs13,33,34, especially if enrolled in the university35–38. The social settings of universities can drive risky sexual practices and increase young people’s vulnerabilities to sexual transmission and acquisition of BBVs/STIs35–38. Some students perceive their time at the university as a period for intensified sexual exploration36. Thus, movement of students across international borders may have implications for acquisition and transmission of BBVs/STIs, since transnational mobility is a major driver of the global spread of BBVs/STIs17–19. Students who move from sexually conservative backgrounds to a more permissive sexual society, such as Australia, may use their migration experience as an opportunity to explore sexual freedoms, thereby initiating or becoming more sexually active39–41.
Drawing on Berry’s acculturation model42,43, international students from conservative cultures may experience any of the following four types of sexual acculturations: assimilation (identifying more with host country than home country sexual cultures), integration (maintaining both Australian and home sexual cultures), separation (rejecting Australian but upholding home sexual cultures) and marginalization (rejecting both Australian and home sexual cultures). On one hand, international students who become more acculturated into liberal sexual cultures may change their sexual practices. This change in sexual practice may occur within the context of inadequate knowledge and other structural factors that impact safer sex practices such as consistent condom use44–46.
On the other hand, international students who are less acculturated may largely network with communities from their home country. Since social isolation is linked to sexual risk practices among international students in Australia47,48, gaining social support from communities that share home country norms may reduce BBVs/STIs risks. However, reducing BBVs/STIs risks may not translate to strengthening protective practices. Moreover, lower sexual acculturation has also been associated with higher protective sexual behaviours among migrant adults49, and young 50–52 populations. Choosing to remain part of a migrant community and keeping strong ties to this community may provide social support, and may enhance maintenance of more traditional sexual norms and practices.
There is a paucity of evidence around whether and how acculturation influences BBVs/STIs protective practices among international students who migrate from conservative settings to Australia. Similarly, the role of social support, which has been linked to protective and safer sexual health outcomes among young people53–55, has not been explored among international students in Sydney.
Further, while sexual health knowledge remains vital in promoting safer sexual practice, it does not always translate into protective practices56. Efficacy belief could be a factor in translating sexual health knowledge to protective practices57. Thus, while young people may know that BBVs/STIs can be prevented through abstinence, partner fidelity or condom use58–60, self-perceived ability to adopt any of these behaviours is also important. Moreover, though efficacy belief is positively associated with sexual communication61, talking about sex as a young person may be seen as a taboo in many conservative cultures39,40,62. This may partly explain the reason why international students who come from conservative cultures have limited sexual health knowledge, efficacy beliefs, and confidence to discuss sexual health concerns or access sexual health services in Australia47,48,62–65.
In the Australian context, previous studies have investigated sexual health knowledge, values, norms and risk behaviours among international students, who come from more conservative cultures39,40,44,45,47,48,62–65. However, there is still a research gap around strengthening BBVs/STIs protective practices, beyond risk reduction, among this population. Strengthening protective practices is important because a risk-reduction approach, alone, may not be effective in achieving required positive sexual health and well-being. Thus, in contributing to filling this research gap, quantitative data is used to address the hypothesis that that international students would be more likely to practice BBVs/STIs protective behaviours if they are: less acculturated to Australian sexual culture, possess greater BBVs/STIs prevention knowledge, have access to sexual health information in Australia, possess greater efficacy belief and have access to emotional social support.
Previous studies among samples of international students in Sydney, Australia, have suggested that this population may change their more traditional sexual views and practices to more liberal ones, as a result of their contact with sexual norms in Australia40,62. Thus, it is important to understand whether and how any of such changes from traditional sexual views about BBVs/STIs, impact protective sex among sexually active participants. Therefore it is useful to explore how sexually active international students understand, practice and rationalise protective sex, and whether acculturation shape their protective practices.
Evidence from Australia66–68 and elsewhere69,70 indicates that consistent or occasional condom use is a commonly cited protection strategy among sexually active young people. However, considering that condoms provide dual protection against both pregnancy and BBVs/STIs, it is important to understand the motives that drive condom use among young people. Understanding condom use motives is important because of the likelihood of two potentially conflicting messages that either stress the prevention of pregnancy over BBVs/STIs or BBVs/STIs over pregnancy67.
Research evidence among young people in Australia indicates that contraception is critical in condom use decisions66–68. A large scale national survey that examined Australian secondary school students’ choices for contraception and STIs prevention showed that condom was the choice contraception method among participants67.
This finding is supported by a more recent study among a sample of predominatly young women in Australia68 and by another study among a general Australian sample66. Watson et al reported the use of dual contraceptive methods; which involve condoms and other contraceptives such as pills68. Notably, 1 in 5 of the study participants, who used condoms solely for the purpose of contraception, also reported condomless sex68. Thus, when condoms are primarily used for contraception, sex may become condomless, if the chances of pregnancy is low or non-existent. Such instances may include the use of other forms of contraceptives, withdrawal, billings ovulation method, and anal/oral sex.
Beyond understanding predictors of BBVs/STIs protective practices, it is equally important to understand how sexually active international students perceive and practice protective sex. This way, we would be able to provide more comprehensive and tailored sexual health services that may be effective in meeting the sexual health needs of this population. Against this backdrop, this study also used qualitative data to explore protective sexual practices among sexually active participants, and the implications such practices may have for BBVs/STIs risk and prevention.