Published Online: February 5, 1997

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Teaching About AIDS

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Denver

Anyone who has ever tried to quit smoking, lose weight, or forgo sweets knows how difficult it can be to kick a habit. Research has shown that altering basic human activities--from eating to sleeping to having sex--can be a very tricky task.

It's particularly challenging to persuade adolescents--more than half of whom say they have had sex by the time they turn 18--to practice safer sex. The same belief in their immunity from harm that makes teenagers vulnerable to drinking and driving has proved especially difficult to overcome when trying to educate them about the dangers of AIDS.

In the past several years, however, research on AIDS education has shown that certain strategies can be employed, both in and outside the classroom, to change sexual behaviors that put young people at risk for the deadly disease.

But the research also highlights the fact that few of the schools now using some sort of AIDS education program follow those strategies. The importance of safer practices for those who are sexually active is not a lesson students will absorb during a lecture at an assembly or from pamphlets handed out by the school nurse.

Unless schools are willing to commit the time and effort to teach about AIDS properly--and in the sometimes graphic detail that pays off in altered student behavior--some researchers conclude that they might as well not teach about it at all.

Lack of Sound Instruction

More than 200,000 people under age 20 in the United States are infected with HIV, the virus that causes AIDS, the federal Centers for Disease Control and Prevention in Atlanta estimates.

And one in four new HIV infections is expected to occur in young people between the ages of 13 and 20, according to the CDC. While some young people may get the virus through intravenous drug use, the majority of adolescents will acquire it as a result of unprotected sex.

Since 1986, when then-U.S. Surgeon General C. Everett Koop released an unusually frank report outlining precautions people should take to prevent the spread of AIDS, states and school districts have spent millions of dollars in attempts to educate young people about the disease. A majority of states require that the subject be taught in schools.

More than 86 percent of high school students say they have received some sort of AIDS education during their school years, a 1995 CDC study found. But in a national poll conducted the same year, only 5 percent of high school students said their instruction was comprehensive, according to the Sexuality Information Council of the United States.

Many experts believe most of the courses currently taught in schools do little or nothing to deter adolescents from the risky sexual behavior that can place them in the path of the disease.

Besides teenagers' resistance to behavioral changes, external factors such as poor curriculum, institutional resistance, public and political opposition, and a lack of financial resources to train teachers often block effective AIDS education efforts, researchers say.

"Although most American students will tell you they've had AIDS education, the vast majority of that is learning and regurgitating the facts," said Jerald Newberry, the executive director of the Health Information Network, a Washington-based advocacy group that is supported by the National Education Association. "It's better than nothing, but it isn't good enough," he said.

Knowledge and Skills

Sex education has had a long and often tumultuous tenure in U.S. schools. At the turn of the century, teachers delivered stern lectures about the ravages of venereal disease in an attempt to calm hormonal urges. By the 1960s, teachers began to accent traditional lectures on anatomy and personal hygiene with information about healthy sexual behavior.

But only in the past decade or so, since AIDS became widely recognized as a major public-health crisis, have sex education curricula begun to emphasize the skills students need to protect themselves.

Building knowledge is an important foundation of AIDS education, but young people also need to learn specific strategies to shield themselves from infection, said Douglas B. Kirby, the director of research at ETR Associates, a nonprofit education, training, and research group in Santa Cruz, Calif., who is one of the country's leading experts on adolescent health.

In a 1995 review of existing school-based sex and AIDS curricula, Mr. Kirby sifted through 49 studies conducted over several years by researchers at the CDC, dozens of universities, and other research institutions to glean which AIDS education techniques work and which fail to work in the classroom.

Mr. Kirby's analysis identified nine classroom strategies that can help to reduce risky sexual behaviors among young people. (See chart, this page.)

To be effective, courses should last at least 14 hours, focus narrowly on AIDS and unintended pregnancy, and include accurate, detailed information about the risks of unprotected sex, the researchers found. Teachers must also try to dispel the commonly held myth among adolescents that all their peers are having sex.

Indeed, research shows that a crucial element of effective AIDS education is for teachers to emphasize that the surest way to avoid the disease is to abstain from sex. At the same time, refuting many critics of sex education, research has also shown that learning about such specifics as condom use does not result in increased sexual activity among students.

In a 1994 study of high school students in six Colorado districts, researchers at the University of Colorado at Denver found that a CDC-endorsed curriculum titled Reducing the Risk that includes units on contraceptive use actually helped postpone the onset of sexual activity.

But courses should also enhance students' "refusal skills," the ETR study said. One popular lesson directs students to set goals and limits for a day. If a young person's objective is to lose 10 pounds, for example, the student might practice abstaining from fried foods and cakes for a week.

The idea is that by doing something as simple as renouncing a snack, students may develop the confidence to assert themselves in more challenging situations. Successful programs also encourage students to rehearse with their classmates how to talk to their boyfriends or girlfriends about the dangers of unprotected sex.

"If you can't even talk to your partner, you can't tell them no," said Dr. John Santelli, an epidemiologist at the CDC's division of adolescent and school health, which evaluates AIDS education.

Exploration of the ways in which popular culture and peer pressures can influence a student's decisions is another vital component of any curriculum, according to researchers.

Teachers, for example, might demonstrate how a particular television show or music video sends out the erroneous message that casual sexual encounters are devoid of health consequences.

Successful AIDS-prevention courses often employ a variety of teaching methods. One curriculum even encouraged students to initiate the dreaded "facts of life" talk with their parents. Another dispatched high school students on a field trip to a family planning clinic to quiz professionals about contraceptives.

Field Research

For a school project this winter, four 9th graders at Denver's John F. Kennedy High School spent part of an afternoon on a "condom hunt" at a local supermarket. Their assignment: collect information about condom prices, brands, and any literature the store carried on sexually transmitted diseases and report back to their social studies class.

Inside the store, near the vitamins, feminine-hygiene products, and cold remedies, Oscar Campos and his three classmates seem surprised by the variety of colorful contraceptives.

As he plucks a shiny Gold Coin condom package off the shelf to check the price, the 14-year-old admits he hasn't yet had occasion to use one. He says that when he does, however, he'll feel less intimidated about the making the purchase.

Erika Mendez, a petite 14-year-old, nods in agreement. "When I'm older," she says, "I'll know how to protect myself."

'If you want to be abstinent, I applaud you. But if you're having sex, you need to protect yourself from something that will kill you.'

Paul Carreras,
Teacher, John F. Kennedy High School, Denver

When the four students return to class, teacher Paul Carreras is standing next to a collage of multicolored prophylactics. He rips open a foil package and rolls a condom onto two fingers, seeming quite at ease discussing such intimate topics with his students.

"If you want to be abstinent, I applaud you," the 53-year-old teacher tells the two dozen freshmen. "But if you're having sex, you need to protect yourself from something that will kill you."

Long after the final bell, students fire questions at him: Are condoms reusable? How many sperm does it take to get pregnant?

Like most 9th graders in the 63,000-student Denver district, those in Mr. Carreras' class are not sexually experienced. But he believes it is vital that they be prepared for eventual sexual activity.

"We know that 100 percent of these students are not going to be celibate," he said. "So we have to make sure they're safe."

Both the condom demonstration and the information-gathering exercise are part of a curriculum called Skills for Life, which was first tested in Denver in 1993 by the CDC.

The Denver schools require AIDS education, but the district doesn't dictate a particular curriculum. Skills for Life, which uses the nine strategies detailed in Mr. Kirby's study, is one of only a handful of AIDS education curricula endorsed by the CDC.

Does Teaching Promote Sex?

Although there has been little opposition to the curriculum here, some religious organizations and parents' groups across the country have condemned approaches like these.

Often, critics have argued that explicit talk about AIDS and contraceptives encourages young people to become sexually active. Conservative groups have successfully used this argument to derail efforts to adopt courses on sex and AIDS in dozens of school districts in recent years.

Such courses are "a 'how to' to have sex," said Gracie Hsu, a policy analyst for the Family Research Council, a Washington-based research and advocacy group. "If you go through explicit demonstrations, you undermine your own message of abstaining until marriage," she said.

Much recent research on AIDS education, however, contradicts that argument.

"The overwhelming weight of the evidence demonstrates that sex and AIDS education programs do not cause harm, as some people fear," Mr. Kirby writes in his 1995 review.

In fact, the research found that courses that employed a combination of the nine strategies helped delay the start of sexual involvement, he said. The courses also helped reduce the frequency of sexual involvement among students who were already sexually active and increased the use of condoms and other contraceptives among sexually active young people, Mr. Kirby said.

Other Approaches

Programs that make condoms available to students on school grounds are also promising, many researchers believe, although the evidence to confirm that opinion remains sketchy.

AIDS-education courses are "a 'how to' to have sex."

Gracie Hsu,
policy analyst,
Family Research Council

Many experts suspect that the addition of free condoms in student health centers and administrative offices can increase condom use among sexually active students.

More than 430 public schools and 50 districts have adopted condom-availability programs, according to a study published by the Alan Guttmacher Institute, a nonprofit research group based in New York City.

A three-year study by the Academy for Educational Development, a national education research and policy organization, promises to shed some light on the issue. Set to be published later this year, the study compared condom-distribution programs in two big-city districts and is expected to provide the best documentation so far of the theory that making condoms available in schools can reduce risky sexual conduct among students.

The bulk of the research on "abstinence only" curricula--which promote sexual abstinence until marriage and eschew discussion of contraceptives except to detail their failure rates--has been less convincing, researchers say. "The weight of the evidence indicates that these abstinence-only programs do not delay the onset of intercourse," Mr. Kirby writes.

However, Ms. Hsu argues that such an assessment is premature. A study last year of a sex education program in the District of Columbia schools showed that abstinence-only teaching can yield positive results, she said.

The evaluation of the program run by Best Friends, a Washington-based organization that promotes abstinence education in schools, found that 1.1 percent of the girls in grades 5-12 enrolled in the course became pregnant, compared with a 25 percent pregnancy rate among girls of the same age in the city's population as a whole. "This study found that participants were far less likely to have engaged in sex than were non-participants," Ms. Hsu said.

Funding, Time Constraints

Often, the public debate over the content and tone of AIDS curricula overshadows some of the practical dilemmas faced by educators in the classroom, said Brenda Z. Greene, the manager of school health programs for the National School Boards Association.

Curriculum and teacher training costs can be prohibitive, especially in schools that are struggling to improve academic achievement.

"Many districts face inadequate resources," Ms. Greene said, "and so they're going to focus on the core subjects." Even in schools with both the funding and the enthusiasm for effective AIDS education, she added, there still may not be enough time in the school day to teach it.

In Denver, Mr. Carreras sandwiches his three-week Skills for Life course in between lessons on Mesopotamia and the evolution of human culture.

"We always have to ask what we can displace to make room for this," said Bernadette Seick, an assistant superintendent of the Denver schools. Teacher attrition can also be a barrier to a consistent approach, she added.

Several Denver teachers who were trained in the Skills for Life curriculum have transferred or retired, and district leaders have found it hard to find replacements. "Not every teacher wants to get into the classroom and show kids how to use a condom," Ms. Seick said.

A lack of parental involvement can also stand in the way of successful AIDS-prevention programs, researchers say. While a number of national surveys show substantial parental support for teaching about AIDS in schools, many parents balk at the level of detail considered so vital to making such teaching effective, researchers and advocates say.

Reaching Gay Students

Because of these barriers, some experts argue that community efforts, not school programs, should be the central focus of AIDS education campaigns.

"The most effective AIDS education is peer-to-peer talk, in clubs and social settings, not necessarily in schools," said Chris Yu, the program coordinator for Funders Concerned about AIDS, a New York City-based association of grantmakers that encourages public-private partnerships to respond to the AIDS crisis.

Research indicates, however, that both school and community approaches can be effective.

The CDC recently launched a "social marketing" effort that will target AIDS education money to particular populations of high-risk youths, such as homosexuals and intravenous drug users, in several communities. Community-based approaches have been successful in educating young people who are at high risk for contracting HIV.

A study published in The Journal of the American Medical Association in 1991 found that small-group counseling sessions with 67 young runaways ages 11-18 were effective in promoting abstinence and reducing the instances of unprotected sex. After undergoing three months of counseling, the percentage of youths living in runaway shelters who reported using condoms consistently nearly doubled, from 33 percent to 63 percent, according to Mary Jane Rotheram-Borus, a professor at Columbia University and the lead author of the study.

Researchers at the University of California, San Francisco, found in a 1996 study that educating young gay men about AIDS at social events like picnics and volleyball games influenced them to practice safer sex.

While these community-based AIDS education approaches have been successful in reaching gay youths, who are disproportionately at risk for the disease, there has been little research on which classroom-based programs specifically work to protect gay teenagers from HIV infection.

Such investigations have been stymied by a lack of AIDS curricula tailored to gay students and by students' unwillingness or inability to identify themselves as gay, experts say. Some may not even know their sexual orientation at that age, researchers say.

AIDS education experts point to several other areas that warrant rigorous study. Research is already under way on which AIDS-prevention curricula work in middle schools, which are increasingly adopting such programs.

Another unanswered question is the degree to which a particular curriculum's successful implementation determines its effectiveness.

Other researchers cite a need for greater understanding of why young people engage in risky behaviors to begin with. Understanding a teenage girl's motivation to have a child, for example, could help educators devise better curricula, they say.

Slow Progress

Many AIDS education advocates and researchers say that despite the obstacles before them, school-based initiatives shouldn't be abandoned.

"For people who say this is an experiment that has failed, we say it has never been tried," said Carolyn Patierno, the director of program services for the Sexuality and Education Information Council of the United States.

SEICUS commissioned the national poll in 1995 that found that only 5 percent of high school students said they had had sex education that was "comprehensive in nature."

Dr. Santelli of the CDC suggests that AIDS educators view their efforts in light of the sluggish progress of several other national health campaigns during this century.

It took years for people to start wearing seat belts in cars, he said. And while the U.S. surgeon general issued a report in 1964 that linked smoking cigarettes with cancer, he said, only in recent years has there been widespread evidence of a cultural shift away from smoking--bans on airplane flights, in restaurants, and workplaces--and a drop in the percentage of adults who smoke.

"It's been a large effort by a lot of people over many years," Dr. Santelli said of anti-smoking efforts. "What really changes behavior is hearing things over and over again, like your wife nagging you to stop smoking cigarettes actually works.''

Tim Dunn, the director of school health at the Education Development Center in Newton, Mass., which tracks curriculum developments, said he already sees evidence of a shift in schools' approach to AIDS education.

"Most programs are moving toward these proven effective methods," said Mr. Dunn, noting that more school systems are providing AIDS education in middle schools. "Five years ago that wasn't the case."

But ultimately, some researchers say, AIDS and sex education in schools must be completely retooled in an effort to provide students with reasons to stay abstinent and delay parenthood.

Eighty-five percent of young women ages 15-19 who have children out of wedlock are poor or low-income, said Kristin Moore, the director of the Washington-based Child Trends Inc. and an expert on teenage pregnancy.

Only programs that address poverty, attempt to prevent school failure, and provide job training will have a sustainable impact, she argued. "Kids think it doesn't matter if they have sex or have a child because they are going to be working at a fast-food restaurant anyway."

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