Encouraging Behavior Change
Ideally, young women should be able to decide when they are ready to have sex and have the information they need to make informed decisions about protecting themselves when they do decide to become sexually active. A number of interventions have been successful in encouraging young people to do just that, but many interventions have not changed behavior and many challenges and gaps remain.
Young People Need Information
"Adolescents' high risk for HIV infection [is] due to high frequency of sex and rate of partner change, short duration of sexual relationships, risk-taking behavior, low perceptions of HIV/STI risk and limited access to contraception..." (Mantell et al., 2005: 324).A review of the global literature on adolescents found that "there is a significant unmet need for information, education, and services for sexual and reproductive health for married and unmarried young people" (Shaw, 2009: 135). In order to change behavior, young people need to know what the risks are and how to protect themselves. And they need this information early enough to make a difference in outcomes. "Young women, who bear an increasing share of HIV infection, must be reached early ideally before their first sexual experience (which is coerced for many girls in high risk settings) and in time to address other factors, for example, school dropout, need to generate income without skills... which put them at risk for acquiring HIV" (Bruce et al., 2011: 8). Young women who can stay in school have increased knowledge about HIV: Women with post-primary education are five times more likely than illiterate women to be educated on the topic of HIV and AIDS (UNESCO, 2010). Equitable expansion of primary and secondary schooling for girls may contribute to the reduction of girls vulnerability to HIV infection (Jukes et al., 2008). [See also Advancing Education]
Where young people get their sexual and reproductive health information is also important. Key findings from nationally representative surveys of nearly 20,000 young people ages 1219 conducted in 2004 (5,950 in Burkina Faso; 4,252 in Ghana; 4,012 in Malawi and 5,065 in Uganda) showed that young people want information especially from trusted sources such as health care providers or teachers (Biddlecom et al., 2007).
Misinformation is dangerous and must be corrected. For example, young people (and adults) need to have a realistic understanding of the risks of differing sexual practices so they may avoid those behaviors that perhaps put them at increased risk for HIV. A study of girls in Senegal found that they engaged in anal, oral and manual sex to remain technically virgins for their wedding night, yet provide pleasure both for themselves and their boyfriends (van Eerdewijk, 2009). Anal sex can increase the risk of HIV transmission (Powers et al., 2008), "yet anal sex continues not to be targeted nor even specifically mentioned in most prevention campaigns..." (Halperin et al., 2009b: S57). On the other hand, transmission via oralgenital contact is extremely low, with a study of 135 HIV-negative people (110 women and 25 men in Spain) whose only risk to exposure was unprotected orogenital sex with their infected partner, with 210 person-years of follow-up and 19,000 unprotected orogenital exposures with the infected partner and no single HIV seroconversion (del Romero et al., 2002). Sexual health information also needs to clear up misperceptions by youth such as that those with HIV and/or TB will be thin (Puoane et al., 2010) and other misinformation that may lead to stigma or discrimination.
Improving Condom Use Among Young People is Essential
Condom use remains low in most countries with a high HIV burden (UNICEF, 2010b). Young women in developing countries are less likely than young men to use condoms during higher risk sex. Among young men aged 1524, only 43% reported condom use at last higher risk sex in developing countries (excluding China); among young women, 28%. Condom use is also much less common among young people in poorer households and in rural areas (WHO et al., 2011b).
However, some countries have been shown remarkable improvements in condom use by young people during first sexual intercourse: in Brazil, in 1986, condom use at first sexual intercourse was 9%; by 2008, it had reached 60% (UNAIDS, 2011a). An analysis of survey data in countries worldwide shows that condom use at last sex among young people is also increasing (Wellings et al., 2006). But young people's use of condoms is generally inconsistent (Minkin and Wright, 2005), and the proportion of sexually active adolescents who report condom use remains too low to control the transmission of STIs (Dehne and Riedner, 2005).
"If we use condoms, we do not get pregnant; so, we can go to school and prepare our future" -Adolescent girl in Liberia (Atwood et al., 2011)Improving condom use among young people is criticaldata show that if condom use is established during adolescence, it is more likely to be sustained in the long-term (Schutt-Aine and Maddaleno, 2003). For example, a study of 802 sexually active youth in Ethiopia, of whom more than 74% were women, found that once youth had started to use condoms, they were more likely to continue to use condoms in the future (Molla et al., 2007). Condom use within established relationships, and particularly marriage, remains low, however (Ali and Cleland, 2005). [See also Prevention for Women]
A strong review of 28 HIV prevention studies among youth from 1990 to 2008 in sub-Saharan Africa assessed condom use and found the interventions' effects on condom use at last sex were larger in males than in females in all studies except one, suggesting that "women still experience marked difficulties in negotiating condom use or assuming full control over their sexual activity" (Michielsen et al., 2010: 1201). Given the risks faced by young women, "adolescent girls and young women deserve a larger share of resources and policy attention than they have been receiving" (Bruce et al., 2011: 2).
Comprehensive Sex Education Programs Can Be Effective
School-based comprehensive sex education programs are effective ways to reach a large number of (but not all) young people. Despite the fears of some community leaders and parents that sex education will encourage young people to engage in sex, available evidence indicates that sex education can delay sexual debut, and can increase condom or contraceptive use by sexually active adolescents (UNESCO, 2009a; Mavedzenge et al., 2010a; Kirby, 2001; Coyle et al., 1999; Hubbard et al., 1998, cited in Satcher, 2001; Grunseit, 1997). Achieving behavior change is difficult and many interventions achieve only moderate, if statistically significant, results that include behavior change. In reviewing evidence related to sex education and HIV education, it is important to remember that most studies do not have sufficient information on the details of the intervention, the strength with which the intervention was implemented or even more importantly, how awareness of gender norms, condom negotiation skills and other critical elements were included. The evidence on sex education seems to suggest, however, that such education, given to young people before they initiate sex, and that focuses on a number of key elements, can have positive outcomes.
A review from UNESCO of studies of 87 sex education studies, including 29 in developing countries, found a number of positive outcomes: delayed initiation of sexual intercourse, decreased number of sexual partners, increased use of condoms and decreased sexual risk taking. Not every intervention resulted in a decreased risk of HIV acquisition. However, no studies showed hastened initiation of sex, no studies showed an increased number of sexual partners, and no studies showed decreased use of condoms. Only one study of the 29 showed increased sexual risk taking, with the remainder of studies showing no harmful effects of sex education (UNESCO, 2009a).
One community randomized trial in rural Tanzania found a significant impact on knowledge and reported attitudes and behavioral outcomes but had no consistent biological outcome as measured by seroconversion to HIV-positive over the three year period (Ross et al., 2007a) and again for a longer period of time between 1999 and 2008 and again during follow-up nine years after program initiation (Doyle et al., 2010a; Mema Kwa Vijana, 2008a; Mema Kwa Vijana, 2008b). Some have argued that this means "we do not know yet about how to deliver effective HIV prevention through schools" (Jewkes, 2010b: 2; Harrison et al., 2010). Yet a review of studies that included comprehensive sex and HIV education programs in developing and developed countries found that two-thirds of the studies reported that adolescents who received sex education were significantly more likely than those who did not receive the intervention to have better knowledge and to engage in protective behaviors (Kirby et al., 2007a).
Views on appropriate programs for adolescents vary. However, strong evidence supports comprehensive sex education that includes promotion of delayed sexual initiation, and also information on contraception including condoms so that when they do start having sex, young people will be protected from unwanted outcomes. Yet according to the 2007 UNGASS reports less than 70% of countries with generalized epidemics have implemented school-based HIV/AIDS education and 61% have put in place HIV prevention for out of school youth (Bertozzi et al., 2008), even though UNICEF estimates that just 31% of boys in developing countries and 19% of girls have accurate information about HIV/AIDS (UNICEF, 2010c). In Latin America and the Caribbean [as in many other parts of the world], numerous countries have no system in place for evaluating the impact of their sex education programs on reducing HIV acquisition and transmission by young people. However, in 2008, 33 countries from Latin America and the Caribbean signed a declaration agreed to incorporate sex education within schools, a large advance (DeMaria et al., 2009).
Abstinence-Only Education Has Been Largely Ineffective in Changing Behavior
According to a Cochrane review, "programs promoting abstinence were found to be ineffective at increasing abstinent behavior and were possibly harmful" (Cochrane Collaborative Review Group on HIV Infection and AIDS,2004: 4). These conclusions were based on systematic reviews and a meta-analysis of high methodological quality, which met pre-determined criteria of methodological rigor. Sixty reviews met the criteria (Cochrane Collaborative Review Group on HIV Infection and AIDS, 2004). Cochrane reviews are the "gold standard" of study syntheses. Further, a review of 87 sexuality education programs found no strong evidence that abstinence-only programs delay sexual initiation, hasten a return to abstinence, or reduce the number of sexual partners among adolescents (UNESCO, 2009b; Kirby, 2007). However, a study conducted from 2001 to 2004 in the U.S. found that an abstinence-only curriculum (as opposed to an abstinence-only until marriage curriculum) which did not portray sex in a negative light, did not use a moralistic tone and did not disparage the efficacy of condoms did result in a significant delay of sexual debut among adolescents between the ages 12 and 14. Among the group that received abstinence-only education, 20.6% of the participants reported coitus in the previous three months, compared to 29% in the control group. The abstinence-only intervention did not affect condom use (Jemmott III et al., 2010).
Peer Education Can Be Useful As Part of a Larger Effort
Peer education by youth living with HIV can reinforce messages about protective behavior and can be part of a larger intervention. But there is little evidence demonstrating the effectiveness of peer education in preventing HIV among young people. A synthesis of studies from 24 peer-evaluated programs 1997 to 2008 for youth in low- and middle-income countries found that peer education did increase condom use, but had no impact on STI rates (Maticka-Tyndale and Barnett, 2010). Peer education to promote HIV prevention in one study in Zimbabwe with 4,684 students did not result in decrease in HIV prevalence (Cowan et al., 2010). Others have also noted that peer education among youth has not had an impact (Harrison et al., 2010). As previously noted, many young people prefer to get information from trusted sources such as health care providers or teachers (Biddlecom et al., 2007). It is possible that peers may not always be seen as a "trusted" source. As for evaluating youth programs, it is helpful to evaluate the effectiveness of youth programs by using biomarkers, such as HIV or STI incidence and/or prevalence and pregnancy whenever possible and "not just indicators for knowledge or self-reported behavior" (DeMaria et al., 2009: 485 translated from the original Spanish by Jill Gay).
Programs also need to help parents talk to children about sex. There is some evidence that good communication with parents is associated with delayed sexual debut. Studies in Mexico, South Africa, and Uganda found that parents can be an important source of information about sex and that parents themselves want these skills to talk with their children (Remes et al., 2010; Givudian et al., 1996 cited in Weiss et al., 1996; Abdool Karim et al., 1991 cited in Wojcicki and Malala, 2001; Damalie, 2001). However, a study in Kenya with 403 parents of 1012-year-old children found that HIV/AIDS communication was more likely to have occurred if parents had received information to educate their child about sex (Poulsen et al., 2010).
Effective Sex and HIV Education Programs Have Key Characteristics
The evidence shows that key characteristics of effective sex education programs involve experts in research on human sexuality; assess the reproductive health needs and behaviors of those young people who get the education programs; specify health goals, types of behavior affecting these goals, the risk and protective factors affecting the types of behavior, and activities that change the risk and protective factors; design activities that are sensitive to community values and consistent with available resources; pilot test the program and obtain on-going feedback; focus on clear goals of prevention HIV; address situations that might lead to unwanted or unprotected intercourse and how to avoid these and how to get out of them; focus on knowledge, values, norms, attitudes and skills; employ participatory teaching methods; provide scientifically accurate information about the risk of unprotected sexual intercourse and the effectiveness of different methods of protection; address perceptions of risk; address personal values and norms; address peer norms; and address skills and self-efficacy (UNESCO, 2009b). In addition, discussion of gender norms that can put both male and female adolescents at risk is also critical to successful efforts (Pulerwitz et al., 2006; Barker et al., 2010b; Peacock, 2009).
If school-based sexuality education is to have maximum impact, however, it must be taught by trained teachers (UNESCO, 2009a). In Brazil, more than 60% of schools provide HIV/AIDS prevention activities, with 43% of these schools having trained teachers and 18% of the high schools with HIV/AIDS prevention activities also distributing condoms. While not necessarily directly attributable to teachers alone, Brazil has had success in increasing condom use, with a 2008 study showing 81% of adolescents in some schools using condoms during sexual intercourse (Bretas et al., 2008).
Young people also want sexuality education programs to address issues of importance to them. A review of research conducted in 13 African countries presenting child and adolescent (719 years old) perspectives on HIV prevention, together with programmatic work by Save the Children Sweden and the Swedish Association for Sexuality Education, found that sexuality education as taught in schools fails to address issues of concern, such as love, relationships, and how to negotiate safe sex, as well as the need for easier access to confidential health services (Thomsen, 2007). Education can be eye opening for young people. A study in Kenya found that providing adolescent girls with information on the relative risk of HIV infection with older partners led to a 28% reduction in unprotected sex. Only 29% of girls and 25% of boys knew that older men were more likely to be HIV-positive than adolescent boys (Dupas, 2011).
Effective Sex and HIV Education Programs Are Cost-Effective and Should Be Scaled Up
"None of the girls could ask questions because they said only boys were at risk. This was our sexual education. I was refused by the clinic when I went for HIV testing. They said it was because I was too young and not married. But I know that I am also too young to die of AIDS." Rachel Judhistari, founder of Indonesian Independent Youth Alliance (UNAIDS, 2011a: 115)
Sex and HIV education can be cost saving as well as cost-effective. A review of government-implemented sexuality education programs in Nigeria, India and Estonia found that sexuality education programs were a relatively inexpensive way to avert the higher costs of HIV treatment. The cost per student reached in 2009 for the duration of the entire curriculum in US dollars was $6.90 per student in Lagos State in Nigeria; $13.50 per student in the State of Orissa in India; and $32.90 per student in Estonia with national coverage. However, if only budgetary outlays are considered, i.e. the costs in addition to regular expenses on teacher salaries, costs per student reached were only US$0.60 in Nigeria, US$2.50 in India and US$8 in Estonia. The result of the cost-effectiveness study conducted in Estonia estimate that sexuality education averted 1,970 HIV infections between 2000 and 2009, as well as 4,280 unintended pregnancies and 7.240 STIs. The costs of the sexuality education program (US$5.6 million) were compared with the averted treatment costs of HIV infections averted (estimated lifetime treatment cost per person, US$67,825). It was estimated that the sexuality education program could be considered not only cost-effective but cost saving if it had prevented 83 or more HIV infections, a mere 4% of the HIV infections averted (UNESCO, 2011).
Youth need to be reached with sex and HIV education in a variety of venuesin school, out of school, at workin both rural and urban areas. Continued efforts are needed to improve quality of the content, teaching and facilitation methods of sex and HIV/AIDS education and information, along with policies that support access to effective sex and HIV/AIDS education programs for young people. Some countries have scaled up sexuality education. But more countries need policies concerning adolescents, with increased clarity for different age groups within adolescence (Bruce et al., 2011). In addition, programs are needed which address the structural factors that affect young peoples vulnerability and risks, such as gender norms and violence against women. [See also Strengthening the Enabling Environment]
Ultimately, enabling young people to delay their first sexual experience, to negotiate condom use when they do have sex, to be able to say no when sex is unwanted, and to reduce the number of concurrent sexual partners are critically important in protecting young women from acquiring HIV. Finding new and promising ways to get accurate information to more adolescentsparticularly adolescents who are not in schoolis also important and youth-friendly technologies such as text messaging and other communication strategies should be further explored.