Special Article
Prevalence of the Human Immunodeficiency Virus among University Students
N Engl J Med 1990; 323:1538-1541November 29, 1990
- Abstract
- Abstract
Background and Methods.
To estimate the magnitude of the human immunodeficiency virus (HIV) epidemic among university students, we conducted a blinded HIV-seroprevalence survey at 19 universities throughout the United States. HIV-antibody testing was performed on blood collected for routine medical purposes at the student health centers of the participating institutions. At each campus, from 250 to 1000 blood specimens were collected consecutively and tested for HIV antibodies by enzyme-linked immunosorbent assay and Western blot analysis. Nonidentifying demographic data were linked with the test results.
Results.
Of 16,863 specimens in the sample, 30 (0.2 percent) were positive for antibodies to HIV. Positive specimens were found at 9 of the 19 schools. All were from students over 18 years old; 19 (63 percent) were from students over 24. All but 2 of the 30 infected students were men. The seroprevalence rate for men was 0.5 percent (95 percent confidence interval, 0.3 to 0.7), and for women it was 0.02 percent (95 percent confidence interval, 0.002 to 0.066). Seroprevalence increased with age — from 0.08 percent (95 percent confidence interval, 0.04 to 0.15) for students 18 to 24 years old to 1.0 percent (95 percent confidence interval, 0.2 to 2.9) for those 40 or older.
Conclusions.
HIV infection is present on U.S. university campuses, although the rate appears to be far lower than that of populations known to be at high risk. The potential clearly exists, however, for the further spread of HIV infection in this population, and preventive measures are needed. (N Engl J Med 1990; 323:1538–41.)
Media in This Article
Table 1
Demographic Characteristics of Students in the Survey of Seroprevalence, at the Participating Institutions and at All U.S. Universities, 1988–1989.Table 2
Seroprevalence of HIV Infection at 19 U.S. Universities, 1988–1989.Article Activity
- Article
APPROXIMATELY 13 million people are enrolled in institutions of higher education in the United States. Most are adolescents and young adults, a group often characterized by a new-found sense of independence, experimentation with sex and sometimes drugs, and a feeling of invincibility. Risk factors associated with human immunodeficiency virus (HIV) infection, such as sex with a number of partners, clearly exist among adolescents and young adults, including those on university campuses.1 2 3 Sexually transmitted diseases are an important cause of morbidity on many campuses,4 5 6 7 8 and unwanted pregnancies continue to occur despite the availability of reliable contraceptive methods.3 Information from university health centers suggests that intravenous drug use is not prevalent among students, but the use of alcohol and other drugs that can impair decision making about sexual choices and behavior is frequent. There are few data about HIV infection on university campuses, however.
This report describes the initial survey conducted by the Centers for Disease Control (CDC), in collaboration with the American College Health Association, among university students to estimate and monitor HIV seroprevalence on campuses.
Methods
Between April 1, 1988, and February 28, 1989, blood specimens from students attending 19 U.S. universities were collected to test for the presence of antibodies to HIV type 1 (HIV-1) in a blinded, unlinked manner. The schools that were recruited were members of the American College Health Association and represented geographically diverse areas. In addition, their student health centers served as the primary source of medical care for most of the enrolled students and drew enough blood specimens as part of routine clinical care to provide the designated sample size. Most of the schools chosen were public, since their student bodies were more likely to be representative of the geographic area in which they were located. A sample of 1000 specimens per school was determined on the basis of the national seroprevalence among military recruits, a group of similar age.9 Consecutive serum samples from all students who had blood drawn in the health center were included in the sample regardless of the student's status (i.e., part-time or full-time, undergraduate or graduate, and resident or nonresident). Samples from faculty members attending the health facility were excluded.
Duplicate specimens were eliminated without compromising the blinded, unlinked nature of the survey. Generally, this was done by excluding specimens from students whose blood had been drawn previously during the study period, as indicated by medical records or coded computerized lists. Nonidentifying demographic data (age, race or ethnic group, and sex) were abstracted from the medical records, transferred to a standard data-collection form, and assigned a unique study number. Data from the National Center for Education Statistics on the distribution according to age, race, and sex for all students attending institutions of higher education throughout the country were compared with similar data from the participating institutions.
Aliquots of 0.5 to 1.0 ml of serum were labeled with a unique study number that linked the demographic data with the serologic results. All testing of specimens was performed under contract by one laboratory. A result was considered positive if two enzyme-linked immunosorbent assays (ELISA) and one Western blot assay were positive for antibodies to HIV-1. The results of Western blot analysis were determined with previously published criteria.10
Data analysis was performed at the CDC with SAS statistical software.11 We calculated the seroprevalence for the total sample population and according to each demographic variable. We determined statistically significant differences in rates of seroprevalence according to age, sex, and race or ethnic group and calculated rate ratios for different strata of these variables. Ninety-five percent confidence intervals for seroprevalence rates were calculated on the basis of binomial distribution.12
Results
A total of 16,863 specimens were collected and tested from the following 19 universities (17 public and 2 private): Central Missouri State University; Emory University; Mississippi State University; Northwestern University; Rutgers University; San Diego State University; Southern Illinois University; University of California, Berkeley; University of Colorado; University of Connecticut, Storrs; University of Georgia; University of Kansas; University of Maryland, Baltimore County; University of Maryland, College Park; University of Massachusetts, Amherst; University of New Hampshire; University of Southern California; University of Texas, Austin; and University of Washington.
Demographic data for this sample are shown in Table 1Table 1
Demographic Characteristics of Students in the Survey of Seroprevalence, at the Participating Institutions and at All U.S. Universities, 1988–1989.. The median age of the students in the sample was 21 years (range, 13 to 73). Female students predominated, composing 64.5 percent of the sample. All but one of the schools provided information on race and ethnicity. Most students in the sample (78 percent) were white.Thirty specimens were positive for HIV antibodies, giving a seroprevalence of 0.2 percent (range for institutions, 0.0 to 0.9) (Table 2Table 2
Seroprevalence of HIV Infection at 19 U.S. Universities, 1988–1989.). Ten schools had no positive specimens, and only one school had a rate of seroprevalence of more than 0.6 percent. Seroprevalence increased with age, from 0.08 percent among students from 18 to 24 years old to 1.0 percent among those 40 or older (Table 3Table 3
HIV Seroprevalence According to Age, Sex, and Race or Ethnic Group at 19 U.S. Universities, 1988–1989.*). Seroprevalence was markedly higher for men (0.5 percent) than for women (0.02 percent). Results for white, black, and Hispanic students did not differ significantly, but the numbers for black and Hispanic students were too small to provide meaningful estimates of seroprevalence according to race and ethnic group. Students who were over the age of 24 and male were, respectively, 6.5 and 25 times more likely to be seropositive than those who were 24 or younger and female (Table 4Table 4
Rate Ratios for HIV Infection According to Age, Sex, and Race or Ethnic Group at 19 U.S. Universities, 1988–1989.).The demographic characteristics of the students in our survey, all the students at the survey schools, and students at all U.S. universities are shown in Table 1. Seventy-six percent of students on the survey campuses were undergraduates, and 75 percent were state residents. The age and racial or ethnic distribution of the overall student body and the samples from the health centers were similar. However, since young women use the health services more frequently than young men, the proportion of women in the sample was larger than the proportion in the schools overall (64.5 vs. 49 percent, P<0.0001). The chief differences between the student population at the 19 schools in our sample and the national post-secondary-school population were a larger average size and younger age distribution at our schools.
Using the age, sex, and racial or ethnic distribution of the students at the 19 schools in our sample and at all U.S. universities, we calculated seroprevalence rates that were standardized to those populations. On the basis of the results in our sample population, the rate of seroprevalence would increase to 0.25 percent (2.5 per 1000) if the proportion of male students were the same as in the 19 schools altogether or in all U.S. universities. Standardization according to age or sex did not change the rate of seroprevalence.
Discussion
These results demonstrate that HIV infection and the potential for its transmission are present on many college campuses. The overall seroprevalence of 0.2 percent, or one positive result per 500 students tested, is lower than the rates found among groups known to be at increased risk of HIV infection, but seroprevalence varied among the schools. The results of this study are within the range of those found in other national surveys.9 , 13 14 15 16 For example, the overall seroprevalence among civilian applicants for military service since 1985 was 0.14 percent, slightly lower than the rate found in our university sample. The armed forces exclude people who use intravenous drugs and discourage homosexual men from applying, which may account for some of the difference. Also, the military data do not include people who were seeking health services. For patients at selected sentinel hospitals across the country who did not have HIV-related conditions, the median seroprevalence since 1986 was 0.24 percent (range, 0.12 to 0.81), very similar to the college results. Preliminary statewide, population-based surveys of women who have recently given birth revealed seroprevalence rates from 0.02 to 0.7 percent. Between 1985 and 1988, seroprevalence among all first-time voluntary donors to Red Cross blood programs (a population in which people at increased risk of HIV infection were asked to exclude themselves from donation) was 0.04 percent. Seroprevalence among residential Job Corps entrants (a group comprising primarily inner-city, economically disadvantaged youths) since 1987 was 0.41 percent.13 On the basis of available data, it is estimated that approximately 1 million people in the United States are infected with HIV, equivalent to a rate of seroprevalence of 0.4 percent.14
By contrast, published seroprevalence rates in groups at recognized risk, such as men who have sex with men, intravenous drug users, and people attending clinics for sexually transmitted diseases, have been substantially higher. The results of recent studies of homosexual and bisexual men in clinics treating sexually transmitted diseases have varied with geographic location, with rates ranging from 14 percent in Albuquerque, New Mexico, to 50 percent among male prostitutes in New York. Across the country, rates among intravenous drug users ranged from 1 to 57 percent.13
Many students engage in behavior that could place them at risk of HIV infection, according to studies of adolescents and young adults as well as of college and university students.1 2 3 4 5 6 7 8 , 17 18 19 20 Two recent studies conducted in college health centers found the prevalence of chlamydia among asymptomatic women to be 6.9 and 8.2 percent.6 , 7 Intravenous drug use is unlikely to be a major problem on most campuses, but the use of alcohol and other drugs impairs judgment and may lead to unsafe sexual behavior. Messages designed to prevent the use of drugs should include information on the effect that any drug, including alcohol, may have on the ability to make informed judgments about safe sexual behavior. Needle sharing that is not related to intravenous drug use — for injecting anabolic steroids among athletes, for example — should also be considered potentially dangerous.
Our data suggest that older students and men are at greatest risk of HIV infection in this population. The pattern of HIV seroprevalence increasing with age is consistent with the results of most surveys. On the basis of surveillance data, more than 50 percent of all cases of the acquired immunodeficiency syndrome (AIDS) are diagnosed in people between the ages of 25 and 39; HIV prevalence peaks in most U.S. populations in the young-adult and middle-aged years. The higher prevalence among male students is not unexpected. In the United States, approximately 90 percent of the cases of AIDS have occurred among men, and over 60 percent of the cases have been reported among homosexual and bisexual men.21
Certain limitations of our data should be noted. First, the survey was not a random sample of all colleges and universities or of all the students at the survey institutions. Students who attend health centers and have blood drawn may not be representative of all students. Students with HIV infection or at risk for such infection may differ from other students in their use of the health center or may present with illnesses that make it more likely that they will have blood drawn. Since the survey was blinded and unlinked, self-selection by students should not have biased the sample of blood specimens. We attempted to assess the demographic representativeness of our sample by comparing demographic data on our students with data on all students at the participating schools and data on all students attending U.S. institutions of higher learning. In addition, we did not include schools from geographic areas, such as New York and Florida, that might have provided greater variability in HIV seroprevalence.
Studies indicate that students still have misconceptions about HIV infection and its modes of transmission.22 23 24 25 Moreover, students with a reasonable knowledge of HIV infection may not perceive themselves to be at risk and may continue to engage in high-risk behavior.25 Educational methods and materials must address the diversity of students on U.S. campuses by providing effective learning opportunities for those of different ages, sexes, racial and ethnic groups, and sexual orientations.26 27 28 29 30 Students are greatly influenced by peer opinions, and their involvement in the planning and implementation of HIV-prevention activities is critical. Preventing HIV infection through education and working to develop and maintain safe forms of behavior that will reduce the risk of HIV transmission should be priorities of all institutions of higher education.
The use of trade names is for identification only and does not imply endorsement by the Public Health Service or the Department of Health and Human Services.
*Deceased.
Miguel Garcia-Tunon died shortly after this study was completed. We at the American College Health Association and the CDC acknowledge with the greatest respect and affection his outstanding work in implementing and managing the project and his leadership in promoting programs for HIV and AIDS prevention.
Source Information
From the Division of HIV/AIDS, Center for Infectious Diseases, Centers for Disease Control, Atlanta (H.D.G., B.W.K., J.P.N., F.R.I., M.F.R., J.W.C.); the American College Health Association, Rockville, Md. (R.P.K., M.G.-T.); and the Departments of Student Health and Internal Medicine, School of Medicine, University of Virginia, Charlottesville (R.P.K.). Address reprint requests to Dr. Gayle at the Division of HIV/AIDS (MS E50), Centers for Disease Control, Atlanta, GA 30333.
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