Mitigating Risk

1. 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]

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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2. Sex and HIV education with certain characteristics (see introduction) prior to the onset of sexual activity may be effective in 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 comprising 33 studies from low- and middle-income countries between 1990 and 2010 found that school-based sex education had a significant effect in reducing HIV-related risk, with significantly greater knowledge, self-efficacy related to refusing sex or using condoms, fewer sexual partners and delayed sexual debut following school-based sex education. Most studies included both male and female participants; three studies evaluated school-based sex education for girls only. No school-based sex education found detrimental effects of school based sex education on increased risky sexual behavior.

A meta-review of successful HIV prevention interventions (both in school and out of school) that included training, skills negotiation and communication techniques, found that interventions increased HIV-related knowledge, increased beliefs enabling safer sex, such as favorable attitudes, increased age of sexual debut, increased condom use and decreased the number of sexual partners. Eleven qualitative reviews and meta-analysis from studies from 1985 until 2011 included studies of adolescents ages 10 to 19 from Sub-Saharan Africa, but mostly from the USA. Some of the five meta analyses and 6 qualitative reviews included randomized controlled trials. Positive outcomes were in terms of knowledge, favorable intentions, delay of sexual intercourse or abstinence, decreased number of sexual partners and actual condom use. 

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 pre/post 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 that evaluated 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 cross-sectional, longitudinal study in the Bahamas in 2011 found that grade six students attending schools where the Focus on Youth in the Caribbean (FOYC) intervention had been implemented in 2004 and 2005 had a higher level of HIV knowledge and reproductive health skills, a greater intention to use protection during sex, and increased self-efficacy regarding their ability to prevent HIV infection, compared to grade six students from schools where a control program had been implemented. Male students from the FOYC schools had significantly higher levels of intention to use protection when having sex, compared to male students from the control schools. Male students from the FOYC schools were also found to have higher knowledge of preventive reproductive health skills, higher self-efficacy and a greater intention to engage in risky behaviors compared to female students from these schools. In addition, this study also compared data from 1,724 students attending the FOYC schools in 2011 to data from a randomized, control trial in 2004/2005 of 1,360 students that participated in the FOYC intervention when it was first implemented in these schools. The cohort of students from 2011 was found to have a higher level of HIV/AIDS knowledge, reproductive health skills, self-efficacy, and intention to use protection compared to the cohort of students from 2004/2005, indicating that “new cohorts of students benefited from the extensive training and/or experience in teaching the FOYC curriculum received by teachers, guidance counselors and administrators in schools which had delivered the FOYC intervention… several years earlier.” However, these positive effects were only found among male students, as data from female students did not vary between 2004/2005 and 2011.

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 to 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). However, an analysis done about the impact in 2012 found that without addressing transactional sex, gender norms and other structural interventions the project could not have a long lasting durable effect.

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 teacher- led school HIV prevention program in 2010 that targeted students in two South African sites (Capetown and Mankweng) and one Tanzanian site (Dar es Salaam) found that students in the intervention program in Dar es Salaam were less likely to have their sexual debut during the intervention, however the intervention had no effect in South Africa. The study included 5,352students in Capetown (53.2% females in the intervention group and 53.4% females in the control group) 2,590 in Mankweng (53.9% females in the intervention group and 56.7% females in the control groups) and 4,197 in Dar es Salaam (52% females in the intervention group and 53.7% females in the control group).  Schools were paired based on demographics, and were randomly assigned to the intervention group or the control group.  The study measured knowledge and attitudes towards HIV, perceived social norms, and self-efficacy. The intervention involved 11 to 17 hours of teacher-led classroom sessions, presentations, group discussions and role-playing, as well as homework assignments that required parental help.  Condom demonstrations were only included in the Capetown schools and drama exercises were only included at the Dar es Salaam site. In Capetown and Mankweng, the intervention sessions were led by life orientation teachers, while in Tanzania the sessions were led by science teachers.  The topics discussed in these sessions included sexuality and reproduction, substance use, condom use, gender roles, intimate partner violence, self- image, emotional and physical development, sexual risk assessment, misconceptions, healthy life style, sexual decision making, contraception, reproductive health rights, HIV/AIDS and other STIs. At baseline, 13% of students in Capetown had experienced sexual debut and, of these students, 44% had used a condom during their last sexual experience.  In Dar es Salaam, 17% of the students had experienced their sexual debut and 37% of these students had used condoms during their last sexual experience.  In Mankweng, 5% of the students had had their sexual debut and only 20% of them had used condoms during their last sexual experience. Follow up occurred 12 to 15 months after baseline.  In Dar es Salaam, students in the intervention group were less likely to have their sexual debut during the study, and males were less likely than females to report having had sexual debut during the study.  In Capetown and Makweng, there were no changes regarding sexual debut. Over all knowledge scores improved in Mankweng and Dar es Salaam, but in Capetown they did not change. This is most likely because Capetown already has a variety of HIV/AIDS educational programs, thus students in both the control and study group had already been exposed to HIV prevention programs before the intervention.  In comparison, the Tanzanian students had not had previous exposure to HIV prevention in an educational setting.

Secondary students in Kenya who received HIV 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 HIV/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 HIV education in primary school and 6,287 students who did not have HIV education in primary school. Among students who had had HIV education in primary school, 20.2% had ever tested for HIV, compared to 10.3% for students who had not had HIV education in primary school, a significant difference. For students that had had HIV education in primary school, there was a delay in sexual initiation, reduced numbers of partners and higher condom use among female students.

A study conducted with adolescents aged 15 to 24 years old in Thailand to examine intention of using HIV counseling and testing services found that teaching young people about HIV counseling and testing services and where to access these services can increase intention to test for HIV.  A majority of the adolescents who participated in this study were high school students between the ages of 15 and 19 years old.  Of the 2,536 adolescents who participated in the study, 738 reported having had sexual intercourse at least once before and 159 reported having had their sexual debut before the age of 15 years old. Additionally, students who identified as gay, lesbian, bisexual, or transgender, students between the ages of 20 and 24 years old, and those who were living with their significant other had a higher rate of sexual experience. Of the 81.77% sexually active adolescents who had never utilized HIV counseling and treatment services, 74.06% reported an intention to use HIV counseling and treatment services and 25.94% reported no intention of utilizing HIV counseling and treatment services.  Adolescents with multiple sex partners and consistent condom use were more likely to utilize HIV counseling and testing services.  Similarly, having a higher score of expectation of youth friendly HIV testing and counseling services, a higher score on attitude toward HIV testing, a higher perceived risk of HIV, willingness to pay for services, and access to HIV counseling information were all significantly associated with an increase in intention to use HIV counseling and treatment services.

A cross- sectional study of 8,183 adolescents (4,146 males and 4,037 females) aged 11 to 17 in Kenya found that adolescents that attended schools where the Primary School Action for Better Health program had been implemented were less likely to report sexual debut than the youth that were not involved in the program. The program trained teachers to provide an HIV educational program in the schools that focused on preventing HIV infection and negotiating safe sex. Sexual debut was delayed among students of both sexes that attended schools where the intervention was implemented and where teachers had been trained to deliver HIV education.

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 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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3. Training for teachers to conduct age-appropriate participatory sexuality and HIV 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 to 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.

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 to 17 found that HIV 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 to 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 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 $2,700 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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4. Mass media and social marketing campaigns provide young people with HIV information and 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 (eight), perceived risk of contracting HIV (six), interpersonal communication about AIDS or condom use (six), self-efficacy to negotiate condom use (four) and abstaining from sexual relations (three). 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.

JSI 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 to 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 to 24) in Harare, Zimbabwe found that students who had participated in SHAPE (Sustainability, Hope, Action, Prevention, Education), a comprehensive HIV 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 HIV 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."

A cross-sectional study of 1,225 university students (518 males and 707 females) in Nigeria from 2013 to 2014 found that the students’ main source of HIV-related knowledge was the mass media and that 73.4% of students with high knowledge scores of HIV and AIDS were willing to test for HIV, compared to 34.3% of the students with poor knowledge scores.  The participants were from 15 to 32 years of age and 99.5% of them were single.  97.1% of the students had high knowledge of HIV and AIDS.  Male participants had higher knowledge scores than females. 82% understood that a person living with HIV cannot be readily identified based on their appearance, while 60.5% knew that there is no cure for HIV. 95% of students knew where they could get an HIV test, but only 30.4% of them had been tested for HIV in the 6 months before the study. 72.2% of the students (66.4% of males and 76.5% of females) were willing to test for HIV.  The highest willingness to test for HIV/AIDS was among those from ages 21 to 25 (78.8%) and lowest for those age 15 or less (58.8%).

Of 330 university students in Ethiopia, 67.9% used the media as the source of information on where to obtain an HIV test. A cross sectional survey was conducted in 2010.

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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5. Promoting gender equitable norms among adolescents can reduce HIV risk behavior.

A review of studies from 1990 to 2012 that used rigorous designs, such as randomized controlled trials or quasi-experimental studies that adjusted for baseline differences and measured the effect of the intervention on STIs, HIV, pregnancy or childbearing found that programs that addressed gender or power were five times as likely to be effective as those that did not address gender or power. Studies were included that were group- and curriculum-based and assessed effects on adolescents aged 19 or younger, including pregnancy, childbearing and acquisition of STIs including HIV. Of the 22 studies included, 14 were in the United States, 6 in lower- and middle-income countries and two in other high-income countries. Of the studies, 15 were randomized controlled trials. Curricula that included gender or power had to have one explicit lesson, topic or activity covering gender or power in sexual relationships, such as how harmful notions of femininity and masculinity affect behaviors and can be transformed; fostering young women’s empowerment; gender and power dynamics of condom use; and fostered personal reflection.

A cross-sectional study of 983 youth (551 girls and 432 boys) aged 14 to 17 in South Africa in 2003 examined gender beliefs and HIV risk factors and found that discussing condom use with a partner was the strongest predictor of condom use at last sexual experience, resulting in a seven-fold increase in condom use among males and a five-fold increase in condom use among females.  Of the youth, 87.9% believed that condoms protect against STDs, HIV and pregnancy and 74.6% believe that abstinence from sex could prevent HIV, STDs and pregnancy.  However, 57.4% of youth believed that a girl could not become pregnant from the first time she had sex and 63.3% believed that oral contraceptive pills could prevent both HIV and pregnancy. Among males, perceptions of male peer behavior were strongly associated with condom use at last sex and ever having participated in sexual activity.  Males were more likely to agree that it was acceptable for a female to “propose love” or initiate a relationship, which was a strong indicator of male condom use.  Males were also more concerned that a partner would stop the relationship if they refused sex and they were more likely to report that it was acceptable for a male to pressure a female into sex.  Both males and females believed that condom use demonstrates love and respect for their partner, which was a strong predictor of condom use among males. Males were more likely to believe that if a female suggested condom use she had multiple partners. In addition, females who associated condom use with having multiple partners were more likely to use condoms during their last sexual experience.  Another significant predictor of condom use among males was believing that it is acceptable for a girl to refuse sex if her partner refuses to use condoms. Among girls, a perception of higher risk for pregnancy was a significant predictor of condom use. Girls were also found to have a strong sense of self-efficacy regarding refusing sex if their partner refused to use condoms. HIV prevention interventions can strengthen and promoting gender equitable beliefs that already exist in this population.

A cross-sectional study among 5,913 sexually active and non-sexually active adolescents ages 14 to 18 in Bolivia and Ecuador found that gender equality was correlated with easier communication with their partner about sex and they considered it less necessary to have sexual intercourse in order to maintain a relationship.

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6. Community or school-based HIV education can reduce stigmatizing attitudes towards those living with HIV

An intervention study conducted between 2010 and 2011 among youth migrant female workers in China found that free access to information about HIV increased knowledge about HIV. The intervention package consisted of no cost access to educational materials and no cost monthly lectures on HIV prevention. The study had 1,425 young women in the intervention arm and 2,139 young women in the control arm and received injury prevention information. All participants were female single manual workers, with ages ranging from 15 to 29 years of age with an average age of 20. Of the participants, 95% were younger than 25. At baseline, over 85% did not know that HIV could not be transmitted by mosquito bit, over 71% did not know that HIV could not be transmitted through shaking hands and under 37% knew that condoms could prevent HIV transmission during sexual intercourse.  After six months, those in the intervention arm were significantly more likely to know that it is possible to acquire HIV from sex without a condom and sharing a meal cannot transmit that HIV. The proportion of correct answers to questions about HIV was significantly higher in the intervention as compared to the control group.

A 2010 cross sectional study of 300 unmarried male students aged between 16 and 19 years of age in Lao PDR found that students with medium and high levels of knowledge were 4.3 times more likely to display positive attitudes towards people living with HIV. Safer sex was also observed among students with medium (2.8 times more likely) and high levels  (1.9 times more likely) of knowledge of HIV.

An HIV education school-based intervention program in 2011 that targeted 1,468 secondary-school students (702 boys and 766 girls) in Wuhan, China found a significant increase in accepting attitudes towards those living with HIV and AIDS. The program was implemented for 877 middle school students and 591 high school students, and consisted of a promotional video and a 30-minute lecture by Chinese medical graduates. The mean age of the students was 14.71 years and the majority of their parents were either factory workers or self-employed. Before the intervention 61.2% of middle school students and 68.7% of high school students said that they would like to help those living with HIV/AIDS, while after the intervention this increased to 75.3% of middle school students and 83.9% of high school students.  In addition, 72.1% of middle school students and 81.7% of high school students initially wanted to take care of family members or classmates living with HIV, compared to 81% of middle school students and 87.5% of high school students after the intervention.  At the start of the intervention 44.7% of middle school students and 82.8% of high school students understood that a person cannot be identified as living with HIV based on their appearance.  This rate increased to 68.9% of middle school students and 85.7% of high school students after the education program.  Regarding non-transmission modes of HIV/AIDS, only 37.1% of middle school students and 81.4% of high school students initially understood that they could not contract HIV from hugging, kissing or shaking hands with individual living with HIV.  After the intervention, this rate increased to 76.1% of middle-school students and 93.7% of high-school students.  Similarly, before the intervention only 29 % of middle school students and 66.7% of high school students knew that they could not get HIV from sharing a toilet seat or swimming pool with a person living with HIV, compared to 74.1% of middle school students and 91.7% of high school students. At the start of the education program 47.3% of middle school students and 82.9% of high school students knew that they could not get HIV from sharing a classroom with a student living with HIV.  After the program, this rate increased to 80.5% and 91.5% (Gao et al., 2013). 

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 children living with HIV and reduced stigma. Girls were more likely than boys to be more accepting of those children who are living with 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.

Discussions led by physician facilitators with 46 female and 54 male secondary school and college students in Uganda found that young people changed their attitude during the course of the one day workshop from viewing HIV as a death sentence to viewing HIV as an opportunity for early treatment (Gaffy et al., 2012). 

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”.

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

A randomized controlled trial of a combined intervention, named SHAZ! in Zimbabwe with life skills, health education, vocational training, micro-grants and social support resulted in a statistically significant change in the risk of transactional sex and a higher likelihood of using a condom with a current partner. Of the out of school adolescent and young women, ages 16 to 22, 158 received the full intervention and the 157 control received just life skills education. Based on a pilot, which showed increased risk of HIV acquisition for those who participated (Dunbar et al., 2010), the project was redesigned with input from young women. Participants received condoms upon request and those who tested positive were referred to local clinics, where they were assisted with payment for CD4 tests required to enroll. Life skills consisted drew upon Stepping Stones and the livelihoods intervention consisted of financial literary education and a choice of vocation training of six months. Social support consisted of counseling by trained staff and adult mentors. However, HIV incidence was the same between the two groups.

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

An analytical cross-sectional study of 397 (202 women and 195 men) university students in Cali, Colombia in 2011 found that 33% of the students regularly used condoms and that those with a regular sexual partner were 19 times more likely to engage in regular condom use. The students ranged from 15 to 25 years old, and 96% of them were single. Of the students, 72% had a regular sexual partner and 31% had irregular sexual partners in the last year. Young men were more likely to have irregular sexual partners than young women. Among the students, 61% thought that it was all right for young women to suggest condom use.  In addition, 46% had a general knowledge of condoms and 73% had an understanding of how to use condoms. In addition, 27% of them always used condoms as their means of contraception, while 57.1% always or occasionally used different forms of contraception instead of condoms.  Young women liked condom use more than young men.  However, the majority of those that used different forms of contraceptives were young women.  Risk factors for non-regular condom use involved not having the intention to use condoms with a regular partner, participating in anal sexual practices, and using a different form of contraception. Choosing another form of contraception reduced the probability of regular condom use by 60%.  Predictive factors associated with regular condom use involved having the intention to use a condom, high self-efficacy regarding condom use, having irregular sexual partners, and liking the use of condoms. Students that liked using condoms had a 53% likelihood of regular condom use, and a high self-efficacy was associated with a 66% likelihood of regular condom use.  Reinforcing factors associated with regular condom use included believing that condoms intensify pleasure because one feels protected, and a knowledge that condom use is accepted among friends.  Not using condoms or stopping condom use with a partner was associated with feelings of security, confidence, emotional stability, and a strong commitment to the relationship (Valencia, 2012). 

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 students 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. 

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. Unconditional cash transfers to parents’ households or to adolescent girls may lead to increased age of sexual debut and/or reduce transactional sex

A study conducted in Kenya from 2007 until 2009 on the impact of the Government of Kenya’s Cash Transfer for Orphans and Vulnerable Children on the risk of HIV by postponing sexual debut among adolescents ages 15 to 25 years old found that the program reduced the odds of sexual debut by 23-31%. The Government of Kenya’s Cash Transfer for Orphans and Vulnerable Children program provided unconditional cash transfers of $20USD per month to poor households that had at least one orphan or vulnerable child under the age of 18 years old.  Unconditional cash transfer programs may be less costly to implement than conditional cash transfers, as they do not require monitoring school attendance.  A majority of the adolescents who participated in the study were living in extreme poverty (living on less than 60 cents per day), and did not have access to a protected water source.  Of the 1,442 adolescents who participated, 61% were male. Locations in seven districts were randomly assigned to either the control or treatment arm, and information on sexual debut, number of partners, vaginal intercourse, and unprotected sex acts were recorded in both 2009 and 2011. Although attrition was 17% between baseline and the first follow up due to election-related instability in two locations in which the study was taking place, the difference in attrition between the treatment and control arms was negligible.  The Government of Kenya’s Cash Transfer for Orphans and Vulnerable Children Program had a larger impact on females than males, and was found to reduce the odds of sexual debut among females by 42% and among males by 26%.

A prospective, observational study of 3,401 (1,926 girls and 1,475 boys) ages 10 to 18 in two South African provinces from 2009 to 2012 found that government provided child-focused cash transfers were associated with a reduction in the incidence and prevalence of age-disparate and transactional sex among females. The study assessed the incidence and prevalence of a variety of risky sexual behaviors, including unprotected sex, multiple sexual partners, sex while drunk or after taking drugs, age-disparate sex and transactional sex among a group of 1,986 adolescents whose households received cash-transfers and a control group of 1,415 adolescents whose households did not receive cash transfers. Risky sexual behaviors were recorded at baseline and at a follow-up one year later. The likelihood of engaging in risky sexual behaviors increased with age in both genders.  However, the receipt of a cash transfer did not show significant effects in sexual risky behaviors among boys.  In adolescent girls, receipt of cash transfers was associated with a 2.5% incidence and 2.7% prevalence of transactional sex, while not having a cash-transfer was associated with a 5.5% incidence and 6.2% prevalence.  In addition, receipt of cash transfers in adolescent girls’ households was associated with 1.2% incidence and 1.7% prevalence of age-disparate sex in the past year, while not having a cash-transfer was associated with a 4.3% incidence and 4.8% prevalence (Cluver, 2013).

A prospective observational study of 2,668 adolescents aged 10 to 18 in South Africa, 56.7% girls, found that integration of provision of cash plus involved parenting (not defined) and supportive teachers reduced HIV risk behaviors. Cash alone was associated with reduced HIV risk for girls but not for boys. Integrated cash plus care was associated with halved HIV-risk behavior incidence for both boys and girls compared with no support and controlling for confounders. Girls in AIDS-affected families had higher HIV risk behavior but were less likely to access integrated social protection. Adolescents were randomly selected and interviewed for one hour between 2009 and 2010 and then again one year later. Providing skills to parents and teachers may be important to reduce HIV risk among adolescents. HIV risk was assessed by questions on transactional sex, multiple partners, sexual debut, age-disparate sex, all of which are associated with increased risk of HIV acquisition.

A pilot cash transfer intervention conditional on school attendance paid to young women and their families in South Africa found that cash transfers to adolescents improved their relationships with caregivers, as they no longer had to depend on caregivers to meet all their needs. However, young men objected and stated that now that girls knew their HIV-negative status, they would “refuse to make relationships with us”.

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10. Voluntary medical male circumcision (VMMC) may be effectively integrated into school programs. [See also Voluntary Medical Male Circumcision]

A study conducted in South Africa from 2011 to 2013 assessed the feasibility of recruiting male high school students for voluntary medical male circumcision and found that conducting voluntary medical male circumcision in high schools is safe, feasible, and acceptable. Over the course of the 24 months of the study, 5,165 male circumcisions were performed across 42 high schools with an overall coverage of 47%.  All males above the age of 12 who had received proper parental consent and were not HIV positive were eligible for the voluntary medical male circumcision services. A majority of the study participants were between the ages of 15 and 19 years old, and there was a low rate of adverse events as a result of the procedures that were performed.  The intervention was designed in three phases. The first phase addressed community involvement, and consisted of consultations with local leaders and community information sessions conducted in local churches to assess community support of the intervention.  The second phase utilized voluntary medical male circumcision coordinators to promote awareness of voluntary medical male circumcision in the schools and make referrals to local voluntary medical male circumcision clinics.  The third phase of the intervention utilized peer recruitment and decentralized HIV counseling and testing services.  During the third phase, peer recruiters were trained to disseminate information about the benefits of voluntary medical male circumcision as well as details of the procedure to their classmates.  Throughout the intervention, transportation was provided from the schools to clinics where the voluntary medical male circumcision procedures were conducted.  The recruitment program and circumcision services were coordinated with school schedules, with the goal of optimizing voluntary medical male circumcision access and convenience.  The second phase of recruitment resulted in a four-fold increase in voluntary medical male circumcision procedures among the students, contributing to a 5.4-fold increase in voluntary medical male circumcisions performed overall and an overall increase in the monthly average from 58 procedures per month to 308 procedures per month.

A cross-sectional study conducted in South Africa in 2008 on 6,654 men and 6,796 women ages 15 to 49 years old found high rates of circumcision among men and high acceptability of male circumcision among both men and women. The study found better knowledge about the benefits of male circumcision to be positively associated with the acceptability of male circumcision. More specifically, 45.7% of men ages 15 to 24 years old indicated that they would consider being circumcised, and 34.1% reported knowledge of the protective affects of male circumcision on preventing the transmission of HIV. Among the female partners between the ages of 15 and 24 years old, 30.6% reported that their partner was circumcised and 60.6% reported that they would be supportive of their partner being circumcised.  Overall, 53.3% of the men and women between the ages of 15 and 24 years old reported that they support all men being circumcised.

A study conducted in South Africa from 2011 until 2012 found that voluntary medical male circumcisions can be completed safely in low-resource settings with traditionally low rates of male circumcision.  This study was conducted on 602 males between the ages of 12 and 55 years old with a median age of 22 years old, a majority of whom lived in poverty and in communities with poor hygienic conditions. A majority (45.2%) of the participants were between the ages of 20 and 24 years old, and most were sexually active, HIV-negative, and single.  Voluntary medical male circumcision procedures were performed out of three low-resource hospitals, and volunteers were provided with information on the surgery and post-operative wound care.  There was a lower rate of adverse events among participants aged 12 to 24 years old as compared to older participants. A majority of the study participants (91.2%) credited partial protection from HIV and other sexually transmitted infections as the main reason for seeking out voluntary medical male circumcision services, and there was a high demand for voluntary medical male circumcision services among study participants between the ages of 12 and 24 years old.

By December 2013, the majority of the estimated six million boys and men who had been circumcised in 14 countries (Botswana, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Uganda, the United Republic of Tanzania, Zambia, Zimbabwe, and Ethiopia)were adolescents aged 10 to 19. Advantages of VMMC in adolescence include: maximum impact if performed before sexual debut; fewer barriers for sexual abstinence during healing; circumcision is seen as a normal procedure for adolescents in countries where there are traditional male circumcision rites and is a time when fostering equitable gender norms is more effective. Adolescents can use school holidays for the six-week healing period. WHO 2013 guidance notes that adolescents are a key target group for VMMC.

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11. Promoting condom use at sexual debut may increase consistent condom use during adolescence and beyond

A cross sectional study conducted across 23 districts in Uganda between 2003 and 2010 of 4,518 sexually active adolescents (2,235 males and 2,258 females) between the ages of 15 and 24 years old found that using a condom at sexual debut was highly associated with condom use in later years.  Young people who used a condom at sexual debut were 9.63 times more likely to have used a condom at last intercourse, 3.48 times more likely to have used a condom at last intercourse with an irregular partner, and 11.12 times more likely to practice consistent condom use.  74.8% of the youths reported having their first sexual intercourse when they were between the ages of 15 and 19 years old, and 25.6% of the youths had no perceived risk of acquiring HIV despite 49% of the youths reporting never having used a condom. Additionally, for every one-year increase in sexual debut, the likelihood of using a condom at sexual debut increased by 10%.  Similarly, youths who were either married or living with or married to their partner showed a 91% increase in the odds of consistent condom use as compared to those who were not living with their sexual partner. Higher education levels were also associated with increased condom usage among the youths, and having a secondary school education increased the chances of consistent condom use by a factor of 8.

A study of 802 sexually active young people ages 15 to 24 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.

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12. Empowerment training for adolescent girls can increase skills to confront sexual assaults. [See Addressing Violence Against Women]

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