An institution-based cross-sectional study was conducted among regular students at Injibara University from January 20 to 30, 2020 G.C.

The study was conducted at Injibara University located in the Awi zone of the Amhara region, 114 km from Bahir-Dar and 447 km from Addis Ababa, the nation's capital. According to the data from the registrar and alumni directorate, there were 2,269 regular undergraduate students (1,282 males and 1,024 females) in the university at the beginning of the 2019/20 academic year. Of the total regular students, 1,245 were in their second year, and 1,024 were in their third year. First-year students for the 2019/20 academic year were not registered at the time of data collection.

All Injibara University undergraduate regular students during the study period were included in this study.

Inclusion criteria:

All Injibara University undergraduate regular students during the study period were included in this study regardless of having or not having their first sexual intercourse. Exclusion criteria:

Students with vision disability were excluded from the study as they can't fill self-administered questionnaire.

The sample size was determined using a single population proportion formula using the following assumptions: the probability of an event from the previous study was 35%, the proportion of students who had experienced risky sexual behaviors in a study conducted at Mizan Aman College of Health Sciences (14), the probability of type 1 error or alpha was 0.05, and the 95% confidence level. The sample size was also calculated using the double population proportion formula for the second objective by considering different odds ratios (ORs) of significant factors from previous studies, including alcohol consumption, peer pressure and khat chewing. However, the largest sample size, which was found in the following formula, was considered as the final sample size.n=[(Za/2)2p(1−p)]/d2=350,Adding a 10% nonresponse rate and design effect 2, we use a final sample size of 770.

A multistage sampling technique was employed to select students from four colleges of Injibara University (Social Sciences and Humanities College, Business and Economics College, Agriculture, Food and Climate College, and Natural and Computational Sciences College). Samples were proportionally allocated to each college and then further allotted based on the year of study and the number of males and females proportionally. Finally, participants were selected randomly using the lottery method from the selected class.

Dependent Variables: Risky sexual behavior (Yes/No).

Sociodemographic variables: Age, sex, religion, parental education level, pocket money, marital status, and year of study.

Knowledge and psychosocial factors: HIV risk perception, use of VCT, peer pressure, knowledge of contraceptive methods, and basic HIV knowledge.

Behavioral factors: Substance use, alcohol, khat, cigarette and social media use pornography videos, Facebook.

Risky sexual behaviors: a student who practiced at least one of the following: early initiation of sexual intercourse, unprotected sex, having sex with sex workers, having sexual intercourse with multiple sexual partners and practicing sexual intercourse while under the influence of substances in the last 12 months (14–18).

Early initiation of sex: a student who experienced sexual intercourse before 18 years old (14, 19).

Unprotected sex: a student who did not use a condom at every act of sexual intercourse (sex without a condom or inconsistent use of a condom) was considered to have unprotected sex.

Multiple Sexual Partners: a student who had more than one sexual partner in the last 12 months prior to the study (14).

Sexually active: a student who reported that she/he has had sexual intercourse, irrespective of their marital status at least once prior to the study (20).

Basic HIV knowledge: A participant was considered to have basic knowledge of HIV transmission and prevention methods if he/she responded “YES” to the following two questions: (1) People can reduce their chance of getting HIV by having just one uninfected and faithful sexual partner, and (2) People can reduce their chance of getting HIV by using a condom every time they have sex (6).

HIV Risk Perception: Students were asked “What are the chances that you might get HIV?” Responses include no chance, low chance, moderate chance, high chance, and do not know. Then, the data were dichotomized into “Yes” and “No” (21).

Knowledge of contraceptive methods: a student who could list at least one modern contraceptive method was considered knowledgeable (22).

Substance use: a student who has consumed at least one of the substances (khat, cigarettes, and illicit drugs) in any amount in the last 12 months is considered a substance user (23, 24).

A pretested and semi structured Amharic-version self-administered questionnaire was used to collect the data. The questionnaire was first prepared in English and then translated to Amharic and back to English by language experts to check consistency and conceptual similarity. Two MSc instructor supervisors and four BSc data collectors were recruited to collect the data. The data collectors and supervisors were trained for 1 day to make them familiar with the questionnaires and the way how to orient the study participants in filling the questionnaire. A pretest was conducted on 5% of the sample size at the University of Gondar before the actual data collection period, and the necessary revisions of questions were made.

Questionnaires were distributed among randomly selected students just after university lessons, and the filled questionnaires were collected on the same day. The selected students were seated at a reasonable distance when they filled out the questionnaire, and they were provided with a box with an opening at the front desk into which they placed all completed questionnaires to ensure anonymity and also to reduce social desirability bias The data collection process was closely monitored by the principal investigator and the supervisors throughout the data collection period. Filled questionnaires were checked regularly for completeness of information, and any problems were immediately discussed with the data collectors.

Data were entered using Epi Info version 7 and exported to SPSS version 25 for analysis. Frequency tables, percentages, and means were used to describe the data. Risky sexual behavior was coded as “1” = “Yes” and “0” = “No” then univariate binary logistic regression was fitted to screen factors for the multivariable binary logistic regression. The Chi-square (χ²) assumption was checked for each variable before fitting the univariate binary logistic regression analysis. Variables with P-values ≤0.2 in the bivariable analysis were entered into the multivariable analysis to identify independent factors associated with risky sexual behavior. The adjusted odds ratio (AOR) with 95% CI was calculated, and statistical significance was declared at a P-value of 0.05 in the multivariable analysis. The goodness of fitness of the model was checked using Hosmer and Lemeshow test.

A total of 770 students participated in the study, providing a response rate of 100%. The mean age of the participants was 23.02 (±2.52 SD) years, and the majority of the participants (586, 76.1%) were between the age groups of 18 and 24 years. More than half 397 (51.6%) of the participants were males, and only 30 (3.9%) were ever married. More than three-fourths 599 (77.8%) of the respondents were Orthodox Christian followers, and nearly two-thirds 482 (62.6%) of the participants were second-year students (Table 1).

More than one in ten students 93 (12.08%) were substance users. Of these, 68 (8.8%) chewed khat, 57 (7.4%) smoked cigarettes, and 40 (5.2%) smoked Hashish. Nearly two-thirds of the participants [484 (62.9)] used Facebook, and 246 (31.9%) had a habit of watching pornography (Table 2).

Of the total respondents, 470 (61%) had basic knowledge of HIV transmission and prevention. More than one-third (281, 36.5%) of the participants perceived that they were not at risk of HIV infection. More than two-thirds (542, 70.4%) of the students ever tested for HIV. Nearly half 346 (45%) of the respondents were sexually active, of whom 208 (60%) were males and 138 (40%) were females. The mean age at first sexual intercourse was 18.01 years (SD ± 2.35 years) (18.56 years (SD ± 2.1 years) for males and 17.18 years (SD ± 2.5 years) for females (Table 3).

More than one-third 294 (38.2%) of the participants had risky sexual behavior. Of these, 131 (17%) of the participants started sex before the age of 18 years, 78 (10%) had more than one sexual partner in the last year, 77 (10%) had sexual intercourse under the influence of substance, and 239 (31%) did not use condoms consistently (Figure 1).

More than half 193 (57.8) of the respondents did not use condoms during their last sexual intercourse. Among sexually active females, 4 (2.9%) had sex for money, and more than one-third of 75 (36.1%) sexually active males had sexual intercourse with female sex workers.

Of the total respondents, 274 (73.5%) females and 222 (56%) males had knowledge of contraceptive methods. Nearly two-thirds (88, 63.8%) of sexually active females had used at least one type of modern contraceptive method, and 16 (11.6%) females had a history of unwanted pregnancy or abortion.

In this study, factors such as, tested for HIV, basic HIV knowledge, HIV risk perception, peer pressure, watching pornography films, and substance use were associated with risky sexual behavior in the multivariable analysis.

Students who had never been tested for HIV were 1.62 times (AOR = 1.62, 95% CI: 1.15–2.31) more likely to have risky sexual behavior than those who had been tested for HIV. Similarly, students who lacked basic knowledge of HIV were 2.16 times (AOR = 2.16, 95% CI: 1.56–2.98) more likely to engage in RSB than those who had basic HIV knowledge.

Participants who faced peer pressure for sexual intercourse were approximately 2 times (AOR = 1.90, 95% CI: 1.37–2.64) more likely to have risky sexual behavior than those who did not face peer pressure.

Participants who use substances were 3.56 times (AOR = 3.56, 95% CI: 2.11–6.06) more likely to have risky sexual behavior than those who did not use substances. Participants who watched pornography films were 1.58 times (AOR = 1.58, CI: 1.11–2.23) more likely to be involved in risky sexual behavior than those who did not watch pornography films. Students who had no perceived HIV risk were 1.37 times (AOR = 1.37, CI: 1.02–1.19) more likely to have risky sexual behavior than those who had HIV risk perception (Table 4).