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.
Improving Condom Use Among Young People is Essential
Promisingly, an analysis of survey data in countries worldwide shows that condom use at last sex among young people is increasing (Wellings et al., 2006). However, 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). Improving condom use among young people is critical—data 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). 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). At the same time, condom use within established relationships, and particularly marriage, remains low (Ali and Cleland, 2005). [See also Chapter 3. Prevention for Women]
Young people need information to know how to protect themselves. Key findings from nationally representative surveys of nearly 20,000 young people ages 12–19 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). Young people, as well as adults, also need to have a realistic understanding of the risks of differing sexual practices, for example, 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 may increase the risk of HIV transmission to one transmission for every three episodes of heterosexual anal sex (Powers et al., 2008a). “Yet anal sex continues not to be targeted – nor even specifically mentioned – in most prevention campaigns….” (Halperin et al., 2009: S57). On the other hand, transmission via oral–genital 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).
Comprehensive Sex Education Programs Can Be Effective
School 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 (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 recent review from UNESCO of studies of sex education in 29 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, 2009). However, 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., 2007) and again for a longer period of time between 1999 and 2008 (MEMA Kwa Vijana, 2008a and b). 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., 2007).
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, only 40% of young men and 35% of young women had accurate knowledge of HIV/AIDS; 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).
Until recently, “programs promoting abstinence were found to be ineffective at increasing abstinent behavior and were possibly harmful,” according to the 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) (Gray I). Cochrane reviews are the “gold standard” of study syntheses. Further, a review of 86 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 (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).
Some countries have scaled up sexuality education. 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. Brazil’s goal is to reach more than 40 million children and adolescents in public schools (Donini et al., 2008) and 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).
Clearly, young people need access to correct information on sex and its consequences and means of protection so that they can make responsible decisions when they do start having sex.
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, 2009). 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, 2009; Peacock, 2009).
If school-based sexuality education is to have maximum impact, however, it must be taught by trained teachers (UNESCO, 2009). 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 (ages 7 to 19 years) 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. Some young people prefer to get information about sexuality from “younger people and those who discuss sexuality in a positive, non-judgmental way… They found the sexuality education provided in schools and communities to be too technical, negative and moralistic” (Thompson and Nordfjell, 2008).
Effective Sex and HIV Education Programs Should Be Scaled Up
Young people who do not have access to accurate sexuality information and education are at increased risk of HIV acquisition (Toole et al., 2008). Gender norms dictate that boys are expected to be sexually aware. In many settings, girls equate sex with love and lack of condom use a sign of love and trust in a relationship (Machel, 2001; Vuttanont et al., 2006). Youth need to be reached with sex and HIV education in a variety of venues—in school, out of school, at work—in 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. Cell phone text messaging, computer programs, and the internet may be a useful way to provide sexuality education and HIV/AIDS information to young people (Kasi, 2008). In addition, programs are needed which address the structural factors that affect young people’s vulnerability and risks, such as gender norms and violence against women. [See also Chapter 11. Strengthening the Enabling Environment]
Peer education by youth living with HIV can reinforce messages about protective behavior and can be part of a larger intervention. There are no studies, however, demonstrating that presentations by HIV-positive speakers alone can change sexual risk behavior (Paxton, 2002). 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 (Givudian et al., 1996 cited in Weiss et al., 1996; Abdool Karim et al., 1991 cited in Wojcicki and Malala, 2001; Damalie, 2001).
Traditional Gender Norms, Early Marriage Put Young Women at Risk
A recent 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). “Even if sexuality education programmes improve knowledge, skills and intentions to avoid sexual risk or to use clinical services, reducing their risk may be challenging to young people if social norms do not support risk reduction and/or clinical services are not available” (UNESCO, 2009: 10). Programs are needed to challenge gender norms as well as harmful practices, sexual relationships including early and forced marriage between young girls and older men, and sexual coercion, which increase HIV risk for adolescent girls and women. [See Chapter 11A. Strengthening the Enabling Environment: Transforming Gender Norms]
Early marriage is still common and each year 82 million girls marry before the age of 18 (WHO, 2002a, cited in UNAIDS et al., 2004b). Research in 16 countries in sub-Saharan Africa (year(s) not specified) showed that on average, husbands of young girls ages 15 to 19 were, at a minimum, 10 years older than their young wives (UNICEF, 2001 cited in Mathur et al., 2003). Girls in child marriages are financially dependant on their husbands and cannot leave because they cannot repay their dowry, thus they have extremely limited power to refuse sex, negotiate condom use or access HIV testing and services (Nour, 2006). Increased sexual experience is often associated with increased age and therefore young girls married to older men are at an increased risk of HIV transmission. Data collected in Zambia and Kenya (year(s) not specified) showed that “young married girls are more likely to be HIV-positive than their unmarried peers because they have sex more often, use condoms less often, are unable to refuse sex, and have partners who are more likely to be HIV-positive” (Clark, 2003; Luke and Kurz, 2002 cited in Mathur et al., 2003: 9). Girls and their families and communities need to know that early marriage does not necessarily offer protection against HIV transmission. A recent study in Ethiopia demonstrated that facilitated community conversations and mentors can reduce the number of child marriages that put girls at risk for HIV (Erulkar and Muthengi, 2009). Further efforts to reduce child marriage are needed.
Interventions that encourage adolescents to adopt protective behavior and those that address the power disparities between young girls and older male partners are of the utmost importance in further efforts to protect adolescents from acquiring HIV. The tendency for unmarried sexually active adolescent girls to have much older sexual partners puts them at risk of HIV (Luke and Kurz, 2002). Anecdotal evidence suggests that men who are aware of AIDS are targeting younger girls and, assuming they are ‘risk free,’ are less likely to use condoms with young partners. Studies in South Africa and Zimbabwe have found high levels of rape and sexual abuse. [See also Chapter 11B: Strengthening the Enabling Environment: Addressing Violence Against Women] In many countries, few men who have sex with young girls, with or without coercion, are prosecuted.
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 adolescents—particularly adolescents who are not in school—is also important and youth-friendly technologies such as text messaging should be further explored.