Using EpiData 3.1 and SPSS 21.0 for statistical analysis, and employing logistic regression to analyze influencing factors, ten critical issues related to high-risk HIV behaviors were identified among university students in City S, requiring urgent attention.

Among respondents, 277 (8.49%) had sexual experience: 153 males (20.24% of males) and 124 females (4.95% of females). Excluding freshmen, 16.65% of respondents reported sexual experience. Only 54.51% (151 individuals) reported using condoms during their first sexual encounter. In heterosexual encounters, consistent condom use was low—27 individuals (9.74%) had never used condoms. For casual male-to-male sexual encounters, consistent condom use was even lower at 35.14%. Overall, consistent condom use in high-risk sexual behavior was alarmingly low.

The age of first sexual experience among respondents was low, especially among men who have sex with men (MSM). Nearly 10% of respondents had their first sexual experience with a non-romantic partner, and casual sexual encounters were prevalent. Among 137 males who had sexual experiences within the past six months, 125 (91.27%) did not have a girlfriend, indicating a high rate of sexual activity outside of committed relationships and significant detachment of sex from romantic connections.

Among the respondents, 33 reported exclusively same-sex orientations (1.01%), 168 indicated attraction to multiple genders (5.15%), and 145 expressed uncertainty regarding their orientation (4.45%). Many MSM participants exhibited low self-acceptance, with some feeling depressed about their sexual orientation and fearing social alienation if their identity was exposed.

The majority of respondents did not perceive themselves as at risk for HIV infection, even after engaging in unprotected sexual activities. More than half believed they would not contract HIV, regardless of their behaviors.

Regarding negotiation skills, only slightly over half could ensure proper condom use during sexual encounters. Nearly 10% reported being unable to persuade their partners to use condoms, indicating a need to enhance students’ abilities to negotiate safer sexual practices.

Only 6.74% (220/3262) of respondents had undergone HIV testing, highlighting a lack of awareness that testing is a preventive measure. Among those tested, some students admitted to being HIV-positive.

Awareness of the guidelines was only 45.05% (1468/3262), showing a significant gap between the student population’s knowledge and the national expectations. Specifically, many students remained unaware of the heightened risk of HIV infection through male-to-male sexual activity.

Many respondents misunderstood condoms, associating them solely with contraception and overlooking their role in disease prevention. There was widespread skepticism about condoms’ effectiveness in preventing HIV and other sexually transmitted infections (STIs). Among students who had experienced unintended pregnancies, abortions, or STI/HIV infections, condom use was even lower.

Most respondents supported premarital sex and were open to cohabitation with their partners. They also showed high tolerance for multiple sexual partners, commercial sex, and casual sexual encounters, yet underestimated the risks of contracting HIV through such behaviors.

Only 1.75% (57/3262) of respondents expressed intent to undergo HIV testing within the next six months, while 14.44% (471/3262) indicated a possibility of getting tested. The majority were unwilling to engage in self-testing, doubting the accuracy of self-administered tests and their results.

While the coverage of sex education at universities in City S exceeded national and provincial levels, the modes of HIV education remained limited, mainly relying on lectures and pamphlets, resulting in a relatively monotonous approach to awareness campaigns.

High-risk sexual behaviors among university students in City S are influenced by multiple social, cultural, and personal factors:

University life is highly communal, making students susceptible to peer influence. Young people today often seek individuality, embrace trends, and enjoy trying new things, which includes a more open attitude toward sex compared to previous generations. Young people like to express their emotions on the Internet. The research results of heterosexual dating software also show that there is widespread false personal information on dating software, and the phenomenon of “one-night stand” is prominent [2] . The prevalence of premarital sex among peers sets a norm that influences others. Additionally, casual relationships and frequent breakups further increase the likelihood of students engaging in sexual activity with multiple partners during their time in university, making them more vulnerable to HIV infection.

The majority of students in this survey come from rural areas (71.61%), and about 80% of their parents have an education level of junior high or below. Traditional values, combined with limited parental education, mean that topics around sex are often avoided or not discussed openly in families. Furthermore, 40% of students were raised without close parental supervision, leading to a lack of proper guidance on safe sexual practices. Once in university, away from parental control, students are more likely to engage in risky behaviors, increasing their vulnerability to HIV.

The survey reveals that over 70% of students have a monthly allowance below 1000 yuan, with 10.33% receiving less than 500 yuan. The economic situation of college students makes them have many typical problems at the emotional and behavioral levels, such as low self-esteem, excessive negative emotions, excessive stress, etc. [3] . Financial hardships can push students toward risky behaviors. The pressure of materialism, along with societal influences, drives some students to seek financial rewards through sexual services. Commercial sex or transactional sexual relationships for financial gain increase their risk of HIV infection. Some students may even engage in sex work for higher compensation, significantly raising the potential for HIV transmission.

While most students in City S reportedly received some form of sex and HIV education starting in middle school, nearly 300 said they had never received any education on these topics. Furthermore, the HIV knowledge rate was only 45.05%, indicating that current sex education programs in universities are not as effective as they should be. It may be because the dissemination of new media information has the characteristics of wide coverage, small amount of information and relatively shallow, so that young students lack an in-depth understanding of the relevance of the knowledge and their own behavior while acquiring some knowledge [4] . Students’ increasingly liberal attitudes toward sex, combined with insufficient education on safe practices, contribute to higher HIV risks. Many male students, driven by curiosity, experiment with male-to-male sexual encounters, often without protection. These “individuals” are troubled by various mental health problems to varying degrees, such as depression, anxiety, etc. [5] , and the psychological problems of high-risk groups are related to the occurrence of their high-risk sexual behavior and the risk of HIV infection [6] . Additionally, some of these individuals have relationships with both men and women, creating a potentially risky transmission chain for HIV. This chain could lead to the infection of female partners, who may unknowingly transmit the virus to future partners, posing a serious health risk.

These factors collectively increase the likelihood of HIV infection among university students in City S, highlighting the urgent need for improved sex education, better awareness of safe sexual practices, and support systems for at-risk students.

HIV prevention is a government responsibility, and strengthening HIV prevention in universities is essential. A leadership and coordination mechanism should be established, led by the government and supported by universities, health departments, education departments, public security, and cyber-monitoring agencies. The government should continue implementing the “AIDS Prevention and Control Regulations” and relevant measures, actively supporting HIV prevention in universities through financial and policy means. Health authorities should prioritize HIV prevention efforts among men who have sex with men (MSM), Network intervention models can improve the awareness of AIDS knowledge to a certain extent, thus promoting the formation of a more positive attitude towards safety behavior [7] , while educational authorities should enhance oversight to ensure HIV education is effectively integrated into university curricula. Carry out AIDS prevention performance and propaganda competitions and AIDS prevention galas, and use administrative force and popular recreational activities of students to jointly promote the continuous development of school AIDS prevention and control work [8] . Law enforcement agencies should strengthen efforts to combat prostitution, drug use, and other illegal activities near campuses and online.

Early sex education at home is crucial in preventing risky behaviors like early sexual initiation. Parents should overcome taboos around discussing sex and integrate sex education into daily life. This education should include topics like proper hygiene, sexual health, safe sex practices, and awareness of HIV and sexually transmitted diseases (STDs). A proactive approach to sex education in the family can prepare students to enter university with a healthy understanding of sexuality, reducing risky behaviors.

Universities must take responsibility for comprehensive HIV prevention education. It is necessary to establish a sense of social responsibility and correct sexual morality, cultivate a civilized and healthy lifestyle, promote the healthy development of college students, and effectively put the AIDS prevention publicity and education activities for college students into practice [9] . The current awareness of HIV knowledge among students is below 50%, which is far from the national target of 90%. To bridge this gap, universities should expand the scope and frequency of HIV education. In addition to traditional media such as posters, broadcasts, and lectures, schools should leverage modern technology, including social media and online platforms, to reach more students effectively. In AIDS education, colleges and universities should focus on lower-grade and non-medical students, carry out diversified health education methods, and strengthen classroom education [10] . Medical departments at all levels should carry out differentiated health education for HIV susceptible groups according to the actual situation of MSM groups with different characteristics, strengthen the attention and intervention of this group, carry out AIDS prevention and education for them, regularly carry out HIV testing, and timely grasp the status of HIV infection [11] . Special focus should be placed on raising awareness about the importance of condoms and HIV testing. Universities should also provide free access to condoms in dormitories and health centers. Promote and implement the application of positive psychological group counseling in AIDS prevention and control, and strengthen the mental health of this group through active psychological group counseling and other ways [12] .

HIV prevention is a societal issue that requires comprehensive societal engagement. Social control of AIDS is not only the control of HIV, but also the control of fear [13] . Adhere to the dual policies of disease prevention and control and social governance, and adopt a three pronged approach of identifying and managing infectious sources, blocking transmission routes, and protecting susceptible populations. Starting from comprehensive governance, we should do a good job in group prevention and control, providing a clean and healthy environment for the growth of young people. Social institutions should focus on creating a healthy information environment by regulating and monitoring the dissemination of explicit and harmful content. On the one hand, through community work methods, that is, through structured and macro-intervention strategies, community mobilization, community education and community care for AIDS patients are carried out [14] . They should also use books, newspapers, television, and internet platforms to strengthen HIV awareness, especially targeting high-risk groups with specific guidance.

Ultimately, students themselves must take responsibility for preventing HIV infection. The individual is the first person responsible for their own health. College students should be aware of risk and deeply realize that AIDS is not far away from us. As long as there is a high-risk behavior that is prone to AIDS infection, they may be infected. They should self-love themselves, maintain a healthy lifestyle, avoid unprotected sex with people whose infection status is unknown, avoid sex under drunkenness and unconsciousness, refuse drugs, and avoid abuse of psychoactive substances. Universities should encourage students to take an active role in learning about HIV prevention and make responsible personal choices. This includes avoiding risky behaviors such as unprotected sex, using drugs, or engaging with sex toys, and consistently using condoms during sexual activities. Students should also be educated on the importance of regular HIV testing and how to seek medical help if they test positive. The AIDS self-service testing package is an anonymous testing method that can not only protect personal privacy but also understand their infection status, which is of great significance to the early detection and early treatment of AIDS [15] .

By implementing these recommendations, it is possible to create a comprehensive, multi-faceted approach to HIV prevention in university settings that involves government, family, school, and societal efforts.