Encouraging Behavior Change

1. Sex and HIV education with certain characteristics (see overview) prior to the onset of sexual activity may be effective in reducing stigma and preventing transmission of HIV by increasing age at first sex and, for those who are sexually active, increasing condom use, testing, and reducing the number of sexual partners.

A meta-analysis of educational and behavioral interventions advocating sexual risk reduction and using interpersonal contact, with a review of 98 interventions with 51,240 participants aged 11 to 19, found that relative to controls, interventions increased condom use and increased acquisition of condoms. Interventions also reduced or delayed penetrative sex. Studies until Jan. 1, 2009 were included if they were RCTs or used a quasi-experimental design with rigorous controls, with 78% of the studies conducted in the United States but also in Africa. Interventions were conducted in groups for a median of 13 sessions of 75 minutes each with one facilitator. Interventions included condoms skills training and interpersonal skills training. Differences by sex did not reach statistical significance. Benefits were durable for as long as three years post intervention, with particular success among adolescents who were institutionalized, such as detainees; the intervention had fourteen sessions of at least 45 minutes to one hour; and the intervention did not emphasize abstinence. Motivational training had a larger effect on condom use in studies with higher judged methodological quality.

A review of 28 HIV prevention studies among youth from 1990 to 2008 in sub-Saharan Africa found that for those participants who were virgins at the time of exposure to the intervention, participants reported higher rates of abstinence after the intervention, less sexual intercourse in the past months and higher intentions to use a condom, which is a “validated predictor of actual condom use” (Albarracin et al., 2005 cited in Michelsen et al., 2010: 1194). Interventions included intensive sexual health education; combining teacher led activities with peer led activities; use of media to relay messages; and provision of youth friendly health services. Of the 28 studies, 11 were randomized trials, five had a prepost design controlling for exposure level and 12 used a parallel group design, comparing interventions groups with control groups (Michielsen et al., 2010). However, only two studies of 28 studies reported biological outcomes of the interventions and many of the studies had suboptimal study designs.

A review by UNESCO of 87 sex and HIV education programs in developing and developed countries found that 23 studies showed a delayed initiation of sex (40 had no significant impact); 16 decreased the number of sexual partners (20 had no significant impact); 23 increased condom use (35 had no significant impact) and 16 studies reduced sexual risk taking, one increased sexual risk taking and 13 had no significant impact. Evaluated programs were curriculum and group-based; focused on sexual behavior; focused on young people; had a experimental or quasi-experimental design; a sample size of at least 100; measured impact on sexual behaviors for at least three to six months and were published after 1990.

A review evaluating 83 sex and HIV education programs in developing and developed countries that were based on a written curriculum and were implemented among groups of youth in schools, clinics or other community settings found that two-thirds of the studies found a significant positive impact on one or more sexual behaviors or outcomes, while only seven percent found a significant negative impact. One-third of the programs had a positive impact on two or more behaviors or outcomes. The 83 studies generally reported on one or more of six aspects of sexual behavior: initiation of sex, frequency of sex, number of sexual partners, condom use, contraceptive use in general, and composite measures of sexual risk-taking (e.g., frequency of sex without condoms). A few studies reported on pregnancy and STI rates. Initiation of Sex. Of the 52 studies that measured impact on this behavior, 22 (42 percent) found that the programs significantly delayed the initiation of sex among one or more groups for at least six months, 29 (55 percent) found no significant impact, and one (in the United States) found the program hastened the initiation of sex. Frequency of Sex. Of the 31 studies that measured impact on frequency, nine (29 percent) reduced the frequency, 19 (61 percent) found no significant change in frequency, and three (all in developed countries) found increased frequency among any major groups at any point in time. Number of Sexual Partners. Of 34 studies measuring this factor, 12 (35 percent) found a decrease in the number of sexual partners, while 21 (62 percent) found no significant impact. Condom Use. Of the 54 studies measuring program impact on condom use, almost half (48 percent) showed increased condom use; none found decreased condom use. Contraceptive Use in General. Of the 15 studies measuring impact, six showed increased contraceptive use, eight showed no impact, and one (in the United States) showed decreased contraceptive use. Sexual Risk Taking. Some studies (28) developed composite measures of sexual activity and condom use (e.g., frequency of sex without condoms). Half of them found significantly reduced sexual risk-taking. None of them found increased sexual risk-taking. Pregnancy Rates. Of the 13 studies that measured pregnancy rates, three found significant positive effects, nine found insignificant effects, and one (in the United States) found significant negative effects. STI Rates. Of the 10 studies that measured impact on STI rates, two found a positive impact, six found no significant impact, and two found a negative impact. For example, in Tanzania, a sexuality education intervention reduced the number of sexual partners among boys and increased condom use among both boys and girls. This evaluation used an experimental design and found positive behavioral impacts over a three-year period (Ross et al., 2003 cited in Kirby et al., 2007a). Skills based programs were more effective at changing behavior than were the knowledge-based programs. In the programs reviewed, female adolescents constituted between 44% and 100% of participants (Kirby et al., 2007a; Kirby et al., 2007b; Kirby et al., 2006; Kirby, 2009).

A review of 23 studies of evaluations of interventions in sub-Saharan African schools, health services or communities from 2005 to 2008 found that curriculum-based, adult led interventions that included the characteristics recommended by Kirby, 2009 reduced sexual risk behaviors. 

A randomized life-skills education program in Swaziland with 135 students, including 64 girls, successfully increased HIV testing among in-school youth.  The program ran for 13 weeks and used role-playing for topics such as assertive behavior; HIV testing; living with HIV; and stigma. Among the 53 students who received life-skills education, 11 or 19% had had an HIV test prior to the sex education program; following the sex education program, 42 or 65% had had an HIV test. Among the control group, only 5 or 7.6% had had an HIV test and 13 weeks later only 9 or 13.6% had had an HIV test. 

A community-randomized trial with a cohort of 9,645 adolescents in 20 communities in Mwanza Region, Tanzania that included multiple components to improve the sexual health of adolescents, resulted in statistically significant improvements in knowledge, reported attitudes, reported STI symptoms, and some behavior change but no change in HIV seroconversion rates. The intervention included comprehensive sex education, youth-friendly services, community-based condom promotion and distribution by youth, and a range of community-wide, youth-focused activities. All students age 14 or older in grades 4-6 in 1998 were eligible for enrollment and the final follow-up took place three years after recruitment, in 2001-2002. There were statistically significant differences among young men – but not young women – in the intervention group compared to the control group in sexual debut and having more than one sex partner in the past year.  Initiation of condom use was higher for both young men and women in the intervention groups although condom use at last sex remained low, at below 30%. “Reported behavioral effects were stronger in male than female participants, possibly because young women were exposed to older male participants who had not benefited from the programme” (Ross et al., 2007a: 1951). Furthermore, “the interventions that were tested within the trial were all directly targeted to adolescents themselves. Cultural norms, however, such as gendered and age-related power relationships and marriage and fertility norms within marriage and fertility norms within the wider community, compromise the ability of adolescents to change their sexual behavior.  Community-wide interventions aimed at changing societal norms may be particularly important” (Ross et al., 2007a: 1952).

A cluster randomized controlled trial with 1,360 sixth grade youth in the Bahamas found that a program on sex education for students and parents resulted in 1.49 higher condom use rates 36 months following the intervention. The intervention consisted of 10 primary sessions, delivered weekly and two annual boosters. A video on parent child communication about sex was followed by role-playing and condom demonstrations. The control group received education on environmental issues, such as wetlands. 

A quasi-experimental research study in South Africa in 2001 found that of the 646 students included, exposure to HIV/AIDS curriculum increased levels of knowledge related to HIV transmission, knowledge of risky behaviors, levels of approval of abstinence, intention to abstain or use a condom, and reported partner reduction among males.  The intervention did not increase rates of sexual activity. Of the 22 schools included in the study, Life Orientation HIV/AIDS curriculum was taught in 11 schools, while the remaining 11 did not receive the class and served as controls. Two classrooms from each of the 11 intervention schools were selected to receive Life Orientation classes, a total of 16 hours, and measurements were taken from both students and teachers at baseline, immediately upon completion of the course, and four months post-intervention. Eleven teachers were also selected from the intervention schools to undergo five days of training. Although baseline measurements showed that students in both groups had a high level of prior existing knowledge related to HIV transmission and risk behaviors, post-intervention assessments showed that students in the intervention group had a significantly increased knowledge when compared to students in the control group. Approval of abstinence increased among males in the intervention group, from 54% at baseline, to 81% at the end of the intervention, and finally 73%, at four months post-intervention. Furthermore, for both males and females a significant increase was observed in the number of students who reported to believe that abstinence was a good idea/choice for teenagers. No similar trends were observed in the control group. Intention to abstain, however, was similar in both groups and was maintained throughout the study period. Intention to use a condom increased in the intervention group from 25% at baseline, to 33%, and finally to 30% post-intervention, while rates for students in the control group declined from 25% to a final 23%. In addition, both intervention students and control students consistently agreed that forced or coerced sex was not acceptable. Finally, intervention students expressed the wish that the course would better address practical communication skills and peer pressure, while many teachers reported a preference of focusing on the more factual aspects of the curriculum rather than on life skills that included decision-making, communication, and assertiveness. 

A school health education program in primary school in Uganda sponsored by the Ugandan AIDS Commission emphasized improved access to information for health, sexual behavior decision-making and improved peer interaction regarding decision-making related to HIV/AIDS and sexuality. Students with an average age of 14 years were surveyed with a cross-sectional sample and after two years of interventions. The percentage of students who stated they had been sexually active fell from 42.9% (123 out of 287) to 11.1% (30 out of 280) in the intervention group, while no significant change was recorded in a control group.

Secondary students in Kenya who received AIDS education as primary school students in the 18,500 primary schools had greater positive attitudes for HIV testing and used safer sex practices than those who did not get AIDS education. From Dec. 2005 to Jan. 2006, all students in forms 1 through 3 (equivalent to US grades 9 to 11) in 154 randomly selected secondary schools in five of Kenya’s eight provinces were invited to complete questionnaires. Questionnaires were given to 6,874 students for whom it could be established that they received AIDS education in primary school and 6,287 students who did not have AIDS education in primary school. Among students who had had AIDS education in primary school, 20.2% had ever tested for HIV, compared to 10.3% for students who had not had AIDS education in primary school, a significant difference. For students that had had AIDS education in primary school, there was a delay in sexual initiation, reduced numbers of partners and higher condom use among female students. 

A study with 513 children, 274 boys and 239 girls ages eight to 14 in primary school in Thailand found that HIV prevention education, which included information on HIV transmission results led to more supportive attitudes towards HIV-positive children and reduced stigma. Girls were more likely than boys to be more accepting of those children who are HIV-positive or affected by HIV. When parents told them not to play with children affected by HIV, children had more negative attitudes towards those with HIV. Although there was no significant difference in the knowledge score between schools at the time of the pre-intervention questionnaire, the knowledge score of the children in the program schools was higher than that of the non-program schools after they had received the information on how HIV is transmitted. The attitude score towards children with HIV was significantly improved in the program schools.

A quasi-experimental study using 4,795 questionnaires from adolescents who participated in a school-based sex education program in public schools in four municipalities in the state of Minas Gerais, Brazil found that the program succeeded in more than doubling consistent condom use with casual partners from 58.3% prior to the program to more than 71% following the program, with no effect on age at first intercourse or on adolescents engagement in sexual activities.

A review of comprehensive sex education programs for females 10–20 years of age in Kenya found four of five well-designed programs according to the criteria by UNESCO, 2009b, with delay of sexual debut, increased condom use, decrease in number of partners, decrease in adolescent pregnancy and use of health clinics by youth. The programs reached 18,500 primary schools in one program; 6,160 schools for another program, along with out-of-school youth; another program reached one district in Western Kenya, the reach of the fourth program was unknown. 

A survey in 2001 by the Ministry of Health in Brazil found that 70% of schools carried out prevention activities with students; 97% of students had correct information on how AIDS was transmitted; and 90% of students who were sexually active changed their behaviors regarding AIDS after exposure to school prevention activities. Brazil has a low HIV prevalence, with HIV infections well under a third of expected cumulative totals due to early prevention efforts, early universal treatment and nondiscrimination.

A study of 1,581 low-income fourth-graders in Mexico’s marginalized Hidalgo and Campeche States found that a communications-centered life skills program taught by comprehensively trained teachers in elementary schools improved communication attitudes, self-efficacy, intentions, and perceived socio-cultural norms about communications. The 30-hour “I Want to, I Can… Prevent HIV/AIDS” program used gender-sensitive, participatory methods to teach fourth-graders a range of life skills. The program introduced games to teach children about human physiology, anatomy, sexuality, and HIV/AIDS. The program had a significant impact on communication about sexuality, and it changed the perception in the community that parents should not talk to their children about sex.

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2. Training for teachers to conduct age-appropriate participatory sexuality education can improve students’ knowledge and skills.

A review by UNESCO of 87 sex and HIV education programs in developing and developed countries found that to have maximum impact, school-based sexuality education must be taught by trained teachers.

A project in Uganda with students ages 13-14 that included teacher training found that students whose teachers who had received training reported a significant decline both in having sexual intercourse in the past month and in the average number of sexual partners. Among students in the sample from the intervention schools, those who had been sexually active fell from 43% in 1994 (123 of 287) to 11% in 1996 (31 of 280). Teachers were the main source of information for adolescents (Shuey et al., 1999 cited in James-Traore et al., 2004).

A study in Yemen with 2,510 students who received school-based HIV prevention found that they were significantly more likely to provide care and support for people with HIV compared to a cohort control sample of 2,274 students. Those who had not participated in the intervention suggested either killing or punishing people living with HIV. For the intervention group, school coordinators were trained in a nine day workshop of eight hours per day; peer educators were recruited on a volunteer basis and trained in a 10 day of eight hours per day; and school management was trained during a five day, 7 hours per day workshop.

A 2006-2007 study in the Cameroon with 2,279 adolescents ages 15-17 found that HIV/AIDS teacher training resulted in students being significantly more likely to have used a condom during their last sexual intercourse. Respondents were also significantly more likely to have had an HIV test. Girls aged 15-17 years old were between 7 and 10 percentage points less likely to have started childbearing. Within the five Cameroonian provinces of Adamaoua, Nord, Extrème Nord, Sud, and Centre, roughly 2000 teachers of varied disciplines participated in HIV/AIDS teacher training sessions. Disciplines within which the module was taught were languages, civic education, history and geography, physical education, and life sciences, with nine teachers selected from each to participate in the training program. The teachers were granted a per diem of $100, costing $2700 per school. Trained teachers were taught to explain HIV/AIDS, explain prevention, transmission, and treatment, promote voluntary counseling, debunk various folk myths concerning transmission and curing of HIV/AIDS, explain opportunistic infections and other STDs, and most importantly, how to use condoms.

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3. Mass media and social marketing campaigns are modestly effective in persuading both female and male adolescents to change risky behaviors.

A systematic review of the effectiveness of 24 mass media interventions on HIV-related knowledge, attitudes and behaviors was undertaken in 2006. The intervention studies were published from 1990 through 2004 and reported data from developing countries comparing outcomes using (i) pre- and post-intervention data, (ii) treatment versus control (comparison) groups or (iii) post-intervention data across levels of exposure. The most frequently reported outcomes were condom use (17 studies) and knowledge of modes of HIV transmission (15), followed by reduction in high-risk sexual behavior (8), perceived risk of contracting HIV/AIDS (6), interpersonal communication about AIDS or condom use (6), self-efficacy to negotiate condom use (4) and abstaining from sexual relations (3). The review yielded mixed results, and where statistically significant, the effect size was small to moderate (in some cases as low as 1-2% point increase). On two of the seven outcomes, at least half of the studies did show a positive impact of the mass media: knowledge of HIV transmission and reduction in high-risk sexual behavior. Further rigorous evaluation on comprehensive programs is required to provide a more definitive answer to the question of media effects on HIV/AIDS-related behavior in developing countries.

A case control survey study conducted in Rwanda between 2000 and 2002 evaluated the effectiveness of a social marketing campaign targeting nearly 150,000 youth with messages promoting the use of a multipurpose, youth-friendly center that provides VCT, STI diagnosis, and reproductive health services. The study found that youth exposed to the program were more likely to use VCT services, and more likely to have had an HIV test in the past year, increasing from 2% in both sexes to 7% in males and 9% in females. Peer educators, radio shows, print materials, and mobile video-unit shows were used to motivate youth to practice safe behaviors and visit the youth-friendly health center, as young people in this area had little access to television. Results of such approaches showed a significant change among youth who were highly exposed to the program regarding their attitudes and behavior toward VCT and condom use. The percentage of young men who reported believing that condoms are effective for preventing HIV/AIDS was 92%, as compared to 73% in the low-exposure group; confidence in correct condom use was 30%, as compared to 17%; 29% of young men reported having discussed STIs/AIDS with someone in the past year, as compared to 9% of the low-exposed young men; and the percentage of those men with high exposure who had an HIV test in the past year was 9%, as compared to 2%. Among females in particular, exposure to the program was associated with decreased shyness when buying condoms, with 21% reporting not being shy, versus 44% in the unexposed group, and an increased perception of personal reproductive health risks, 61% compared to 32%. Eighty-one percent of young females in the exposed group reported believing condoms are effective for HIV/AIDS prevention, as compared to 64% of the low-exposed group; 27% of the exposed group reported discussing STIs/AIDS with someone in the past year, as compared to 10%; and 7% had an HIV test in the past year, as compared to 2% of the unexposed group.

A social marketing campaign conducted in 2000 in Cameroon targeting nearly 600,000 youth with messages promoting the consistent use of condoms among sexually-active youth found that both young men and women exposed to the campaign were more likely to know how to use condoms correctly and were less shy about purchasing condoms. After an 18-month campaign involving television and radio advertisements, radio shows, radio dramas, a youth newspaper, youth-friendly condom sellers, and a peer education program, 69% of young men with high levels of exposure to the program reported having used a condom the last time they had sex, as compared to just 56% of those with low exposure. Confidence in knowing how to use condoms correctly was reported by 79% of young men and 64% of young women exposed to the campaign, as compared to 68% and 38% of those with low exposure, respectively. Both young men and young women exposed to the marketing campaign reported being less shy when purchasing condoms than those with low exposure to the campaign. Among sexually active young women, program exposure was associated with an increase in condom purchasing, a significant increased perception of personal risk, and greater perceived support from peers for using condoms.

A six-month multimedia campaign in Zimbabwe encouraged abstinence for young people with no sexual experience together with condom use and reduction in partners for those already sexually active by promoting self-respect and self-control. In the campaign areas, 97% reported being exposed to the campaign. Youth in the campaign areas reported that they had said no to sex 2.5 times more than youth in the comparison areas. Youth in campaign sites were 4.7 times more likely to have visited a health center and 14 times more likely to have visited a youth center than youth in the comparison areas. Significantly, youth in the campaign area were over 26 times more likely to report one sexual partner and over 5 times more likely to use condoms than youth in the comparison area. The project used 10,000 posters, 19,000 leaflets, 100,000 copies of a newsletter, 26 one hour radio shows, launch events with popular musicians, 60 community theater presentations with discussions, trained 24 peer educators, and established a hotline, with youth participating in every aspect of designing and implementing campaign materials and activities. The project intervention also designated 26 clinics as youth friendly and conducted a one-week training with a provider from each clinic in counseling youth. A baseline survey was conducted with 1,426 randomly sampled adolescents with a follow-up survey one year later with 1,400 respondents.

A national television and radio HIV prevention campaign in Zambia for young people ages 13 to 19 found that viewers were 1.68 times more likely to report primary or secondary abstinence. Viewers were 1.91 times more likely to have ever used a condom and 1.63 times more likely to report condom use during last sex when contrasted with nonviewers, holding sex, age, residence and education constant. Among adolescent females who were sexually experienced, 82% of viewers reported that they felt confident that they had “the ability to say no to unwanted sex,” in contrast with 69% at baseline and 64% of nonviewers. Nearly 86% of viewers recognized that a person who looks healthy could be HIV-positive, compared to 72% of nonviewers. The campaign design team included youth, including an HIV-positive youth, message concepts were tested, and comprehension was assessed through focus group discussions, interviews, and post-broadcast surveys. A total of 533 male adolescents and 656 female adolescents were included in the survey.

In 2002 MTV launched a global multicomponent HIV prevention campaign, "Staying Alive," reaching over 166 countries worldwide. An evaluation of this campaign focused on three diverse sites: Kathmandu, Nepal; São Paulo, Brazil; and Dakar, Senegal. Data were collected before and after campaign implementation through population-based household surveys. Using linear regression techniques, the evaluation examined the effects of campaign exposure on interpersonal communication about HIV and the effects of campaign exposure and interpersonal communication on beliefs about HIV prevention. Researchers found a consistent positive effect of exposure on interpersonal communication across all sites, though there were differences among sites with regard to whom the respondent talked about HIV. The analysis also found a consistent positive effect of exposure on HIV prevention beliefs across sites when interpersonal communication was simultaneously entered into the model. In two sites, researchers found a relationship between interpersonal communication and HIV prevention beliefs, controlling for exposure, though again, the effects differed by the type of person the communication was with. These similar findings in three diverse sites provide ecological validity of the findings that "Staying Alive" promoted interpersonal communication and influenced young people's beliefs about HIV prevention in a positive way, evidence for the potential of a global media campaign to have an impact on social norms.

Straight Talk (ST) mass media communication programs, which have been implemented in Uganda since 1993, comprise three main materials: multilingual Straight Talk Radio Shows, multilingual Straight Talk newspapers, and an English language Young Talk newspaper. Straight Talk also implemented a wide array of school-based activities to engender a youth-friendly school environment. The evaluation concludes that many Ugandan adolescents have benefited from ST activities, and that greater exposure was associated with greater benefits. Among both males and females, exposure to ST activities is associated with greater knowledge about sexual and reproductive health, more balanced attitudes toward condoms, and more communication with parents about sexual and reproductive health issues. The results also show that for girls, exposure to ST materials is further associated with greater self-assuredness, greater sense of gender equity, and the likelihood of having a boyfriend but not having a sexual relationship. Among males, ST exposure is associated with lower likelihood of sexual activity, greater likelihood of resuming abstinence, and a greater likelihood of taking relationships with girls seriously. Adolescents exposed to ST were more likely to have been tested for HIV than those never exposed.

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4. Comprehensive programs for youth can improve HIV knowledge and encourage protective behavior.

John Snow, Inc. evaluated the African Youth Alliance (AYA) Programs in Uganda (implemented 2001-2005), Tanzania (2002-2005), and Ghana (2001-2005) using post-intervention analysis between and intervention sites to determine the impact AYA’s comprehensive integrated program on SRH behavior. The AYA Program had six components, namely, (1) policy and advocacy coordination; (2) institutional capacity building; (3) coordination and dissemination; (4) BCC (behavior change communication), including life planning skills and enter-education activities such as sports, dance, and rap; (5) Youth Friendly Services; and (6) Integration of adolescent sexual and reproductive health (ASRH) with livelihood skills training. The study compared knowledge, attitudes, and behavioral outcomes between intervention and control sites of 3,416 youth (17-22 year old) in Ghana, 1,900 in Tanzania, and 3,176 in Uganda and found a significant positive impact of AYA on condom use, contraceptive use, partner reduction and several self-efficacy and knowledge antecedents to behavior. Areas with little evidence of AYA impact included delay of sexual debut and abstinence among females and males and partner reduction among males. The impact of AYA was greater on young women than on young men, although in many cases, the knowledge of unexposed men was much higher than that of unexposed women. In Ghana, AYA significantly improved the confidence of young women in obtaining condoms and in insisting that a partner use a condom. The number young women who reported having ever used a condom, used a condom at last sex, used a condom at first sex, and who claimed to have had fewer than two sex partners in the last year also significantly increased. In Tanzania, young women expressed a significant increase in positive attitudes toward condom users, confidence in putting on a condom correctly, and confidence that they can insist that a partner use a condom. Tanzanian females exposed to AYA also were significantly more likely to report fewer than two sexual partners in the last year, condom use at first sex, condom use at last sex, having ever used a condom, and consistent uses of condoms. Among males in Tanzania, consistent use of condoms, condom use at first sex, and modern contraceptive use at first sex significantly increased, although their use remained low (28, 44, and 43 percent, respectively). The study limitations included a lack of comparable baseline data (Williams et al., 2007). An evaluation of the in-school Life Planning Skills component of African Youth Alliance’s program in Botswana found that the program increased knowledge of HIV transmission, improved risk reduction behaviors among those who felt at risk (getting tested for HIV, reducing partners, using condoms, or abstaining), and increased both the intention to use and actual use of condoms. Due to the program’s success, the AYA Life Planning Skills manual was adopted for use in secondary schools nationwide in 2004.

A survey of 933 university students (mostly ages 20-24) in Harare, Zimbabwe found that students who had participated in SHAPE (Sustainability, Hope, Action, Prevention, Education), a comprehensive HIV/AIDS education program that organized workshops, topical seminars, clubs, and sports teams for university and school-aged youth, were less likely to have ever had sex and had fewer sexual partners in the past year (mean 1.4 for SHAPE members vs. 2.2 for non-SHAPE respondents). SHAPE participants were more likely to have discussed AIDS in the past month (95% to 83.4%), have been tested for HIV (85% vs. 76%), get treatment for AIDS, consider abstinence as a prevention practice for HIV, and more likely to have seen a female condom. SHAPE programs had been active at the University of Zimbabwe for two years prior to the survey. However, because the rate of consistent condom usage was only 70% for both participants and control students, it is possible that “the most vulnerable couples are those who believe they know each other well enough to forgo condoms” (Terry et al., 2006: 44). 

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5. Increased employment opportunities, microfinance, or small-scale income generating activities can reduce risky behavior – particularly among young people. [See Promoting Women’s Employment, Income and Livelihood Opportunities]

   

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6. Communication between adults and young people about reproductive health information can increase protective behaviors.

A study of 750 women and 870 young people in rural Limpopo Province, South Africa evaluated whether an intervention that paired a microfinance program with participatory HIV/AIDS and gender empowerment education for women in the poorest half of households could impact communication about sexuality between the women participants and adolescents in their households. During mandatory bi-weekly meetings, the Intervention with Microfinance for AIDS and Gender Equality (IMAGE) used three pathways to encourage loan holders to engage with young people in their households about sexuality issues: 1) by teaching the women participants about HIV, 2) by allowing the women to recognize their responsibility in protecting young people from HIV, and 3) by giving the women participants guidance in changing social taboos and norms. Initially, many women were “hostile to receiving what they considered to be irrelevant information.” A focus discussion group participant indicated “each time the facilitator starts the sessions we would say, “there she goes again with her condoms speech… [we] talked about AIDS and our children, we were bored.” But by the end of the training, women stated, “We saw many role-plays that showed us how to communicate with our children. These were useful skills,” (Phetla et al., 2008: 511). The study found “an overall increase in the frequency and comfort levels of participants’ efforts to convey the risk HIV poses to their community” (Phetla et al., 2008: 509). The women who participated in the intervention spoke to children about sexuality issues significantly more often, and the content of their discussions changed. While previously the women warned their children with “vague admonitions,” after the intervention, they provided concrete guidance to young people: 97.6% of the women who communicated with children about sexuality discussed condoms while 58.2% discussed HIV testing (Phetla et al., 2008: 511). Young people who lived with the women participants generally wanted to discuss sexuality with their parents.

A survey study in 1998 in three sites in Ghana with 526 youth ages 11 to 26 found that youth who talked to both adults and peers about reproductive health during the last three months were more than twice as likely to have taken actions to protect themselves from AIDS than those youth who did not talk to anyone about reproductive health during the last three months. Actions taken to protect themselves from AIDS included: abstinence or delaying sex; using condoms; one sexual partner; and avoiding risky situations.

A cross-sectional descriptive study of girls ages 12 to 18 and their mothers in Uganda in 1997 found that 75.8% of mothers reported having discussed the issues of sexuality and HIV/AIDS with their daughters and 67.9% of daughters reported having had their mothers discuss the topics with them, however, discrepancies between the two groups were noted in reported frequency and topics covered. Respondents were selected using the WHO 30 cluster, seven quota sampling method with 105 households being included from each of the sites, with a total of 186 adolescent girls and 183 of their mothers being included in the study. Five trained research assistants administered questionnaires, both open- and closed-ended, and two focus groups for mothers and four for daughters were conducted with seven to eight individuals per focus group who were randomly selected from the questionnaire group. Results from the data collected indicated that parents were the major source of information concerning sexuality and HIV/AIDS for young girls, 32.3% of the time, followed by friends 24.7% of the time, radio 21.5%, teachers 16.6%, books 4.3%, health workers 3.2%, and finally youth clubs 1.6% of the time. Seventy-five percent of mothers reported beginning sexuality dialogues at puberty, 15.9% when a daughter was leaving home for school, 13% when a daughter announced having a boyfriend, 8.7% after a relative died of HIV/AIDS, and 5.1% after the daughter became pregnant. On average, mothers reported discussing sexuality matters with their daughters 7.8 times per month. Overall, 67.9% of the adolescent girls included in the study reported having received information from their mothers, while 32.1% claimed that they had not, and 68.8% reported that their mothers assisted them in accessing information via discussions or encouragement to read material, watch television, or join a club, while 31.6% said their mothers did not. Forty percent of the daughters claimed they had some difficulty or problems discussing sexuality with their mothers for reasons such as fear, shyness, and that mothers were too busy, among others. Girls reported preferring their mothers as the source of their information. Lastly, when asked how mothers might be enabled or empowered to better communicate with their daughters on matters concerning HIV/AIDS and sexuality, 50.7% suggested providing seminars and workshops within the community to teach communication techniques and skills, 8.7% mentioned suggestions related to reading materials that would be useful, and 7.2% said they would like counselor or teacher assistance.

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7. National efforts to decrease or delay sexual activity, increase condom use and reduce the number of sexual partners may be effective in preventing HIV nationwide.

In Malawi between 2000 and 2004, there were significant reductions in the proportion of 15–19 year olds starting sex and significant increases in condom use by men with multiple partners. A downward trend in risk behavior and HIV prevalence was broadly correlated with the reach of national interventions with condom distribution and HIV testing. 

Data from the 2004 to 2005 Uganda HIV/AIDS Sero-Behavioral Survey and the 1988, 1995, and 2001 DHS surveys showed that the proportion of youth ages 15 to 24 who reported never have had sex increased significantly from 23% in 1998 to 32% in 2005, including men for whom the proportion increased from 32% in 1995 to 42% in 2005. Among women aged 15 to 19, those who reported never having had sex increased from 38% in 1995 to 54% in 2005. In addition, the proportion of sexually experienced women aged 15 to 19 who reported no sex in the 12 months preceding the survey rose from 7% in 1989 to 18% in 2005. Interventions included public health education, condom promotion, HIV counseling and testing, etc. (Opio et al., 2008). A more recent analysis of DHS data found that women in Uganda who were born after 1970 have, on average, had sex at a later age than those born earlier.

A study of population-based sexual behavior surveys in one urban and one rural community of young people ages 15 to 24 in Zambia from 1995, with 1,720 youth, in 1999 with 1,946 youth and 2003, with 2,637 youth found that the proportion of both women and men who reported more than one sexual partner in the year immediately prior to the survey declined. The percent of urban young women who reported using a condom at their last sexual intercourse in 1995 was 36% but this increased to 57% by 2003. In 1999, 15% of urban females and 42% of rural males ages 15 to 19 reported sex before the age of 15; this decreased to 5% of urban females and 24% of rural males by 2003. The change in behavior may be linked to the nationwide comprehensive HIV prevention campaigns launched in the early 1990s.

A review of surveillance data between 1998 and 2003 in Manicaland, Zimbabwe among a population cohort of 9,454 adults found evidence for delay in the onset of sexual activity among adolescent men and women. At baseline, 45% of young men ages 17 to 19 reported having commenced sexual activity; 3 years later, 27% of the same age group reported having started sexual activity. During the same time period, the percentage of 15 to 17 year old women who reported sexual experience fell from 21% to 9%. HIV prevalence fell by 23% among men aged 17 to 29 and by 49% among women aged 15 to 24 years. These changes mirrored national changes of decline of HIV prevalence in the general population in Zimbabwe.

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8. Promoting condoms for pregnancy prevention may increase condom use for safe sex among young people.

An analysis of survey data from 18 African countries found that use of condoms for pregnancy prevention rose significantly in 13 of 18 countries between 1993 and 2001. Condom use among young African women increased by an average annual rate of 1.4 percent, with more than half of the users (58.5 percent) reporting that they were motivated by a desire to prevent pregnancy.

Over 75% of 3,000 male and female college students ages 18 to 24 in South Africa surveyed reported condom use at last sexual intercourse, primarily to prevent pregnancy. Almost 87% of men and 89% of women in the survey felt that condoms were part of sex. Six focus group discussions with found that condoms had become part of sex, highly acceptable and easily accessible. If a woman requested condoms, men and women agreed the man must comply. Some men were suspicious of women who agreed to unprotected sex. Students reported that they would rather use condoms than jeopardize their future. 

From 1993 to 2001 the use of condoms for pregnancy prevention rose significantly in 13 of 18 countries and the median proportion increased from 5.3% to 18.8%. In the 13 countries in Africa with available data, condom use at more recent coitus rose from a median of 19.3% to 28.4%. Of these, 58.5% of condom users were motivated by a wish to avoid pregnancy.

A study of 678 male adolescents from Brazil found that condoms were the preferred method of contraception for 95% of sexually active adolescents Avoiding pregnancy is also a primary motivation for young men in steady relationships.

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9. Providing HIV prevention education by people living with HIV (who wish to serodisclose) to youth can reinforce messages about protective behavior.

A longitudinal matched control study in Australia to evaluate the efforts on 1,280 young people of talks by people living with HIV who disclose their perspective of living with HIV found that meeting HIV-positive people decreased fear and prejudice, reinforced messages about protective behavior and increased the belief that HIV is preventable. Improved attitudes after talks by females remained significant over three months. “Female speakers, in particular, break down common stereotypes about who contracts HIV. They make students realize that anybody is vulnerable to infection” (Paxton, 2002: 288). For female students, talks by people living with HIV “reinforced messages of safe sex” (Paxton, 2002: 287). Speakers changed perceptions, broke down stereotypes, and made students realize that anybody is vulnerable to infection. Focus group discussions with 117 students were used to elucidate the impact. Six hundred and twenty-eight respondents were recruited into the intervention group and 652 into the control. The quantitative data collection tool was a highly structured Attitude Scale for Teenagers to measure attitudes, such as “I would shake hands with a person having HIV.” Short-term and long-term attitudes changed in the intervention group, with scores significantly different before the talk with after the talk, with changes sustained over three months.

Women participants in a microcredit program with a participatory HIV/AIDS and gender empowerment education aspect for the poorest half of households in rural Limpopo Province, South Africa reported that meeting a healthy-looking HIV-positive young woman during an education session was crucial to understanding their vulnerability and the vulnerability of their families to HIV.  One of the women surveyed reported that, “most people thought that HIV-positive people were skinny and sickly looking. We were scared because we found out that the virus can affect anyone indiscriminately… I will never forget her face; it reminds me about the seriousness of the virus and the need for protection” (Phetla et al., 2008: 512).

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