The shadow of AIDS is spreading throughout our national consciousness. Everywhere we look we see more evidence of the human toll the disease exacts. If we do not personally know someone who is infected with the human immunodeficiency virus (HIV), we certainly have seen the tragedy of celebrities we have admired having to face down this disease.
Even the most doubtful observers admit that AIDS will not soon go away. Even if addressed immediately, the problem will continue to grow worse in the years to come. The World Health Organization (WHO) estimates that HIV will have infected 30 million people worldwide by the turn of the century, and “it is very unlikely that the global prevalence of HIV infection will stabilize or level off for at least several decades.” That makes AIDS a problem for our youth, and no one is in a better position to assist youth in preparing to confront the issue of AIDS than the nation's educators.
Some AIDS Basics
The acronym AIDS stands for acquired immunodeficiency syndrome. Most scientists believe the disease is caused by HIV, which can exist in a person's bloodstream for more than 10 years before AIDS symptoms appear.
Individuals infected with HIV can appear to be healthy, but they are contagious and can unintentionally transmit the virus to others. The diagnosis changes from HIV positive to AIDS when a person exhibits symptoms of the disease. Patients diagnosed with AIDS have only a 25 percent likelihood of living longer than a year.
In the 10 years before AIDS symptoms appear, there is no way to know if you are HIV positive without taking an AIDS test. Unless there is reason to believe otherwise, most people assume they are not infected and do not get tested. Therefore, an entire population of sexually active teenagers who do not fully understand the issues associated with AIDS may become infected with HIV and, in time, develop the disease.
Educators' Commitment
Certainly, a number of schools have already instituted AIDS-education programs, but too many of these consist of only an hour or two of instruction. Such insignificant programs cannot provide students with the skills and self-confidence they need to face the dangers of high-risk behaviors.
Educators must dedicate the time, energy, and resources necessary to provide all students with a substantial HIV-education program, or we will be forced to live with the knowledge that we could have prevented many of the next decade's AIDS-related deaths. Once students become infected with HIV, we will not have the opportunity to fall back and play catch up.
Educators should remember two important facts when developing curriculums and programs for HIV prevention. First, many students become sexually active or initiate drug use at a very young age, often around 12. Actual sexual intercourse may come later, but the experimentation leading up to that experience begins exceedingly early. School-based HIV programs should first be offered in elementary school and continue through high school graduation.
Second, educators should consider that some students at every grade level and in every class are already at risk of infection, while others have not yet engaged in HIV-risk behaviors. HIV-prevention programs, therefore, must be flexible to meet the needs of both simultaneously.
Six Important Goals
Many educators seem satisfied with their attempts to influence students' knowledge and attitudes about HIV and AIDS. But education cannot end there because this provides students with very little actual protection. Students' behavior is what puts them at risk for infection, and any successful HIV-education program must focus on that behavior. Students must learn how to eliminate or, at the very least, reduce any behaviors that put them at risk for infection. Toward that end, HIV-education programs must set some specific goals.
The first goal is to increase the percentage of students who remain sexually abstinent. Research indicates that if students can be influenced to delay their first experience of sexual intercourse even by only one or two years, they will effectively cut down on the number of sexual partners they will have throughout their lives. The National Survey of Family Growth found that 75 percent of women who were sexually active before their 18th birthday had more than one partner; 45 percent had four or more. In contrast, the number of partners among those women who waited at least until they were 19 to become sexually active was considerably lower. Only 20 percent of these women had more than one partner, and no more than 1 percent had four or more. The single factor of postponing sexual involvement will significantly reduce students' risk of becoming infected with HIV.
A successful HIV-education program should also attempt to increase the percentage of sexually active students who become sexually abstinent. This task is much more difficult, because people are reluctant to move backwards in their behavior. In fact, no school-based research program has yet succeeded in meeting this goal. But because abstinence is the only way to be completely protected from the sexual transmission of HIV, it is a goal that cannot be set aside as too difficult to achieve.
A third important goal is to increase the percentage of condom and spermicide use among the students who continue to practice high-risk sexual activities. If we cannot lead students to become abstinent, it is critical for those students who remain sexually active to practice their activities with the greatest amount of protection and safety possible.
Further, HIV-education programs should help to decrease the number of partners with whom sexually active students engage in HIV-risk behaviors. As we have seen, the greater the number of sexual partners an individual has, the greater the chance that individual has of encountering and becoming infected with HIV.
Effective HIV-education programs should also address the issue of alcohol and non-intravenous drug use. Students are more likely to engage in unthinking, high-risk activity under the influence of alcohol and drugs than if they were sober. A survey of Massachusetts youth found that 64 percent of sexually active youth reported having sex after drinking alcohol. Fifteen percent reported sexual activity after drug use. In the same survey, 49 percent of sexually active youth said they were more likely to have sex after drinking, and 17 percent said they used condoms in sex less often with alcohol than without.
The final goal that a successful HIV-education program should set is to increase the percentage of students who never inject drugs. The dangers of drug use, aside from the risk of contracting HIV from infected needles, are well known, have been well documented, and need not be repeated here.
Classroom Delivery
Establishing these goals is only the first step toward a productive HIV-education program; effective classroom delivery is vital as well. Very little research has been conducted on HIV education as yet, but what we know about other health education programs can apply directly to HIV education. We have developed effective health education programs for other difficult-to-modify behaviors such as smoking and drug and alcohol use, and we must follow their lead.
One of the first lessons we can learn from other health programs is that we must focus instruction on risk behavior. The behaviors that put one at risk for HIV infection are easily identifiable and must be the core of any program. Students can't be taught merely to recognize HIV-risk behavior; they must be given the opportunity to acquire and practice refusal skills, communication skills, and other interpersonal skills that are necessary to help them deal with risk situations.
The skill that is the basis for all other skills is the ability to identify HIV-risk situations. If students cannot identify situations in which they may be at risk, they certainly will not be able to protect themselves. And when teenagers recognize that they are at risk, they must be prepared to use the skills they have learned to avoid the situation entirely, escape from it, or protect themselves if escape is otherwise impossible or undesired.
Instruction should also address students' attitudes, so they can recognize their vulnerability to HIV infection. Too many of us, educators and students alike, dismiss AIDS as a disease of gay men and drug addicts. Students assume it can't happen to them, and teens who do not feel at risk for HIV infection will have no reason to adopt careful behaviors to protect themselves (see “How Teenagers Are At Risk for HIV Infection,” p.52). Teens must understand that it is their behavior, not their peer group, that puts them at risk.
At the same time, teenagers must really understand what's going on with their peers. Many teenagers overestimate the extent to which others their age consume alcohol, use drugs, and engage in various sexual activities. Adults are often shocked by the extent of these behaviors among teenagers, but many teens assume it is even higher—and teenagers often base their own actions on their assumptions of how others act. If students learn that others actually practice fewer risky behaviors than they expected, their own risk behaviors might decrease.
Other Models
Based on a review of other health-education programs and their duration, 12 hours seems the minimum instructional time necessary for an effective, stand-alone HIV-education program. If HIV education is part of a comprehensive health curriculum emphasizing acquisition of interpersonal skills, fewer instructional hours need be committed specifically to HIV instruction.
For any HIV-education program to be successful, administrators must make a commitment to provide relevant staff development and training for teachers. Many teachers are understandably uncomfortable discussing sexually explicit topics with their students. Without specific training, a number of teachers may not be able to equip their students with the knowledge, motivation, and tactics necessary to refuse sexual intercourse or to convince a reluctant sexual partner to use a condom. Teachers need to raise their level of comfort in discussing sexuality and to develop an open attitude toward the ideas, attitudes, and behaviors their students may have. If students feel that their teacher does not understand their point of view, they won't take that teacher or that teacher's information seriously.
Program Evaluation
Because the effectiveness of HIV education can mean life or death for students, it is vital that educators accept the professional and moral responsibility to evaluate their HIV-education programs. An evaluation can concern itself with charting the effectiveness of the HIV program to improve it and smooth over any rough spots. Or, an evaluation can gather evidence to determine whether the program should continue. If incorporated into the program design at the start, evaluation can become an integral part of the program, helping to define objectives, choose curriculums, and coordinate teacher training.
The ultimate focus of any evaluation, of course, must be the vital issue of how effectively the program promotes HIV prevention. Program effectiveness can be measured by how much the HIV-risk behaviors of students have been reduced.
Blocking the spread of AIDS and HIV demands a national commitment to provide our youth with the skills they need to avoid infection with this horrible disease. If we can make that commitment, it will be possible to reduce the extent of HIV infection and AIDS among adolescents and, consequently, adults. If, however, we choose not to make a commitment for HIV education, the problem of AIDS will continue to grow to a point where any new prevention efforts will be far too little, far too late.
