Persistent infection with oncogenic human papillomavirus (HPV) is the major cause of almost all cervical cancers and contributes to other anogenital and oropharyngeal malignancies [1]. The carcinogenic role of oncogenic viruses, including HPV, reflects persistent viral infection and molecular alterations that can support malignant transformation and may also provide targets for biomarker-based surveillance [2]. Cervical cancer is highly preventable through vaccination, screening, and treatment of precancerous lesions. The World Health Organization (WHO) elimination strategy established the 90-70-90 targets: 90% of girls fully vaccinated against HPV by age 15, 70% of women screened with a high-performance test by ages 35 and 45, and 90% of women with cervical disease received appropriate treatment by 2030 [1]. Therefore, effective prevention requires accurate HPV knowledge and accessible preventive services. Assessing knowledge gaps, preventive practices, and barriers among university students can inform targeted interventions that support these elimination goals.

HPV prevention is especially important in sub-Saharan Africa, where HPV infection coexists with a high burden of HIV [3]. Furthermore, HIV-related immunosuppression is associated with greater HPV persistence and progression, while women living with HIV experience a markedly higher cervical cancer risk than women without HIV [3]. In a global analysis, women living with HIV had approximately six times the risk of cervical cancer, with the largest HIV-attributable cervical cancer burden occurring in sub-Saharan Africa [3]. Maintaining accessible HIV prevention, testing, and treatment services is therefore important not only for HIV control but also for broader sexual and reproductive health.

Some studies in Nigeria evaluating cervical cancer screening have identified cost, limited service availability, and poor knowledge as barriers to uptake. These findings highlight the need to address both information gaps and access to preventive care [4]. HPV and HIV share sexual transmission routes, while HIV-related immune dysfunction increases susceptibility to persistent HPV infection. Nigerian research has also documented a higher prevalence of high-risk HPV among women living with HIV [5]. However, findings from women attending screening or HIV clinics may not explain how university students understand and access prevention services. Assessing HPV/HIV knowledge, preventive practices, and perceived access barriers together can help identify priorities for university-based interventions.

Evidence from university populations suggests that awareness does not necessarily translate into prevention [6]-[9]. A 2025 systematic review and meta-analysis of 56 studies involving 184,351 university students estimated HPV awareness at 68.3% and vaccine awareness at 53.5%, yet only 10.4% had received at least one vaccine dose [6]. Also, studies conducted among tertiary students in Plateau State found that only 5% met the study definition of good HPV knowledge [7]. Other institution-based studies have reported low vaccine uptake despite varying levels of HPV knowledge and awareness [8]-[10]. Systematic reviews identify cost, inadequate information, stigma, and limited access to services as barriers to HPV vaccination. Provider recommendations, targeted communication, school-based delivery, and community engagement can improve uptake [11]-[13].

Cervical screening studies among female undergraduates have similarly shown that awareness of cervical cancer does not necessarily translate into knowledge of where, when, or why to screen [14]. Because these studies were conducted in specific institutions and populations, their findings cannot necessarily be assumed to reflect students in other university settings, including those in Anambra State. Institution-specific evidence is therefore important for understanding local patterns of knowledge, preventive practices, service accessibility, and barriers.

Against this background, there is a need to understand these relationships within the specific context of Nnamdi Azikiwe University in Anambra State, Nigeria. This study assessed HPV and HIV-HPV knowledge, preventive practices, information sources, and perceived barriers to service access among students at Nnamdi Azikiwe University. The findings can guide university-based interventions to improve HPV vaccination uptake and engagement with preventive services. We further examined whether consistent knowledge across four core HPV/HIV items was associated with previous HIV testing.

This study identified a gap between HPV awareness, prevention knowledge, and service engagement among students at Nnamdi Azikiwe University. Although the majority (84.7%) of study participants had heard of HPV, only 60.3% knew that HPV can cause cancer, 51.3% were aware of HPV vaccination, and 42.0% met the study definition of complete core HPV/HIV knowledge. Preventive engagement was lower, with 37.7% having ever tested for HIV, no respondents reporting HPV vaccination, and two-thirds did not know whether cervical-screening services were accessible. The findings therefore suggest that exposure to health information alone is insufficient when knowledge lacks depth or when service pathways remain unclear, costly or stigmatised.

The high level of general HPV awareness in this study exceeds the pooled estimate of 68.3% reported in a 2025 meta-analysis of 56 studies involving more than 184,000 university students [6]. It also contrasts with recent Nigerian evidence from the University of Ilorin, where only 5.6% and 6.6% of undergraduates met study-specific definitions of good knowledge of HPV infection and HPV vaccination, respectively [15]. Direct numerical comparison might not be impactful because instruments and scoring thresholds differ, but the broader pattern is consistent; however, recognising HPV does not necessarily imply detailed knowledge of transmission, oncogenic risk, vaccination or prevention pathways. A similar awareness-practice gap was observed in our previous study of 548 Nigerian university students on breast-cancer prevention, where awareness was nearly universal but detailed knowledge and use of early-detection practices remained substantially lower [16]. Together, these findings suggest that high headline awareness can coexist with important deficits in actionable cancer-prevention literacy.

The patterns found in this study are also visible internationally, although the size of the gap varies by setting. Among female health-science students in Ethiopia, 72.7% had good HPV-infection knowledge, but only 52.5% had good vaccine knowledge, with major gaps in knowledge of recommended age, dose, and schedule [17]. In China, studies among university students have similarly reported relatively high HPV awareness alongside lower vaccination or preventive behaviour; one 2024 study reported 77.9% vaccine awareness but only 40.0% positive vaccination-related behaviour [18], while another found that access difficulties involving vaccination centres, vaccine type, and information were associated with both intention and uptake [19]. These cross-country findings support a layered interpretation of prevention behaviour: knowledge is important, but perceived risk, trust, affordability, service availability and ease of access can determine whether knowledge is converted into action.

Nigeria’s 2023 introduction of single-dose HPV vaccination for girls aged 9 - 14 years is an important structural advance [20]. However, the mean age of participants in this study was 23 years, meaning that many were already beyond the routine target cohort when national introduction began. Their zero reported vaccination should therefore not be interpreted as evidence of failure of the adolescent programme. Rather, it identifies a transitional population that may have missed routine adolescent delivery and now requires clear information about eligibility, availability and referral. This is especially relevant because the global university-student meta-analysis reported vaccine uptake of only 10.4% despite substantially higher awareness and willingness [6].

The cervical-screening findings also require age-sensitive interpretation. WHO population screening targets are centred on older age groups [1], and the young age distribution in this study means that zero previous screening does not imply that all female respondents were overdue. More informative is the finding that 66.3% of all respondents did not know whether screening was accessible and that 51.9% of women who provided a reason for non-screening selected “no symptoms”. This may indicate that some students conceptualise screening as a response to symptoms rather than as preventive care. Research among Nigerian female undergraduates has similarly identified not knowing where screening services are available as a barrier to uptake [14].

Complete core HPV/HIV knowledge was independently associated with previous HIV testing. Participants with complete core knowledge had higher adjusted odds of previous HIV testing (aOR 2.53, 95% CI 1.48 - 4.33). This relationship is plausible because testing encounters can expose students to counselling and prevention information, while students with stronger prevention literacy may be more willing to seek testing. However, the cross-sectional design cannot establish directionality. The result should therefore be interpreted as evidence that knowledge and service engagement cluster together, rather than as proof that improving knowledge alone will cause higher testing uptake. This distinction is important in Nigeria, where HIV prevention and testing services remain dependent on functioning health systems, sustained financing, and accessible delivery platforms [21].

The barrier profile helps explain why information exposure did not translate consistently into preventive behaviour. STI-related stigma (58.7%), lack of awareness (56.7%), cost (46.3%), and waiting time (25.3%) represent social, informational, financial, and organisational barriers operating simultaneously. This pattern is consistent with systematic reviews from sub-Saharan Africa that identify cost, inadequate information, service constraints, stigma, and access as recurrent determinants of HPV-vaccine uptake [11]-[13]. It also parallels our previous work among Nigerian university students on breast-cancer prevention, in which financial limitations and restricted access to healthcare facilities were prominent barriers despite high disease awareness [16]. The recurrence of these barriers across different preventive-health contexts suggests that awareness campaigns are unlikely to be sufficient unless they are linked to affordable and navigable services.

Universities are therefore not merely audiences for health education; they are potential implementation platforms. Social media/internet and university lectures were the two most frequently reported information channels in this study, indicating that universities already possess channels capable of reaching students. A stronger model would connect these channels directly to confidential HIV testing, clear HPV-vaccine eligibility and referral information, age-appropriate cervical-cancer prevention guidance, and low-friction referral pathways. Digital communication may extend reach, but the endpoint should be a concrete service action rather than awareness alone. This service-linked approach is also consistent with broader work on viral oncology, which emphasises that the value of prevention and surveillance technologies depends on equitable implementation and access to appropriate diagnostic pathways [2][21].

Future studies should evaluate progression across the full prevention pathway rather than measuring awareness as the principal endpoint. Useful outcomes include accurate risk knowledge, knowledge of service location, intention to use services, completed referral, HIV-testing uptake, vaccine counselling, vaccination where eligible, and measures of acceptability, confidentiality, cost and waiting time. Longitudinal or intervention studies would help clarify whether improvements in knowledge lead to subsequent service use and which implementation strategies most effectively reduce the observed drop-off between awareness and action.

Among students at this Nigerian university, the principal prevention challenge was not lack of exposure to HPV information. Rather, high awareness coexisted with incomplete prevention-relevant knowledge, uncertainty about service access, and low preventive-service engagement. Complete core HPV/HIV knowledge was independently associated with previous HIV testing, but the coexistence of stigma, cost, and service barriers indicates that education alone is unlikely to close the gap. University prevention strategies should connect accurate information to confidential, affordable, and navigable services, with explicit pathways for HIV testing, HPV-vaccine counselling, and age-appropriate cervical-cancer prevention.

We appreciate every student who took the time to participate in this study.

Conceptualization, NFE, KCA, and MCU; methodology, NFE, MA, KCA, and MCU; software, MA; investigation, NFE, CRC, KCA, and MCU; data curation, NFE, MA; writing—original draft preparation, NFE and EIO; writing—review and editing, CEU, BAM, FK, AYN, OOA, MS, KCA, and MCU; visualization, MA; supervision, CRC, KCA, and MCU; project administration, NFE, KCA, and MCU.