Teaching AIDS

By Jessica Portner — March 01, 1997 13 min read
Studies reveal that students need strategies—not just information —to protect themselves from the deadly disease.

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, employed both in and outside the classroom, can change sexual behaviors that put young people at risk for the deadly disease.

But the research also highlights the fact that few schools follow those strategies. The importance of safer practices for those who are sexually active is not a lesson students will absorb from a lecture or a pamphlet. Unless schools are willing to commit the time and effort to teach about AIDS properly--and in the graphic detail that pays off in altered student behavior--they might as well not teach about it at all.

According to the federal Centers for Disease Control and Prevention, more than 200,000 people under age 20 in the United States are infected with HIV, the virus that causes AIDS. And the CDC expects that one of every four new infections will be in people ages 13 to 20. Although some young people may get the virus through intravenous drug use, the majority will become infected as a result of unprotected sex.

Many researchers believe most courses taught in schools do little or nothing to deter adolescents from risky sexual behavior.

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 educating young people about the disease. A majority of states require that the subject be taught in schools. In fact, more than 86 percent of high school students say they receive some sort of AIDS education during their school years. But in a 1995 poll by the Sexuality Education and Information Council of the United States, a New York City-based research and advocacy group, only 5 percent of high school students nationally said the instruction was comprehensive.

Many researchers believe most courses 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 curricula, institutional resistance, public and political opposition, and a lack of financial resources to train teachers often block effective AIDS education efforts.

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

Sex education has had a long and often tumultuous history in U.S. schools. At the turn of the century, teachers hoping to calm hormonal urges delivered stern lectures about the ravages of venereal disease. It wasn’t until the 1960s that teachers began to do more, accenting 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.

Teachers must try to dispel the common myth among adolescents that all their peers are having sex.

Building knowledge is an important foundation of AIDS education, but young people also need to learn specific strategies to shield themselves from infection, says Douglas Kirby, director of research at ETR Associates, a nonprofit education, training, and research group in Santa Cruz, California. In 1995, Kirby, one of the country’s leading experts on adolescent health, sifted through 49 studies of existing school-based sex curricula conducted by researchers at the CDC, dozens of universities, and other research institutions. He identified nine classroom strategies that can help reduce risky sexual behaviors among young people. (“What Works,” from this issue.)

To be effective, he found, 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. Teachers must try to dispel the common myth among adolescents that all their peers are having sex. Indeed, research shows that a crucial element of effective AIDS education is instruction that abstinence is the surest way to avoid the disease.

To do that, Kirby says, courses need to reinforce students’ “refusal skills.” One popular lesson directs students to set goals and limits. If a young person’s objective is to lose 10 pounds, 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.

AIDS education encourages role-playing. “If you can’t even talk to your partner, you can’t tell them no.”

John Santelli, CDC

Another way to strengthen refusal skills is through role-playing. A student might rehearse in class a conversation with a boyfriend or girlfriend about the dangers of unprotected sex. “If you can’t even talk to your partner, you can’t tell them no,” explains John Santelli, an epidemiologist at the CDC’s division of adolescent and school health, which evaluates AIDS education.

Successful programs, Kirby says, employ a wide range of instructional methods and settings. One curriculum encourages students to initiate the dreaded “facts of life” talk with their parents, while another dispatches high school students to a family planning clinic to quiz professionals about contraceptives. Mixing experiences like these with different classroom activities, Kirby’s research found, seems to works best with kids.

It’s a winter afternoon in Denver, and four 9th graders at John F. Kennedy High School are on a “condom hunt” at a local supermarket. Their assignment: collect information about condom prices and brands and any literature the store carries on sexually transmitted diseases. Once their mission is accomplished, they are to report back to their social studies class.

Standing near the vitamins, feminine-hygiene products, and cold remedies, Oscar Campos and three of his classmates study the condom display. They are 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, he’ll feel less intimidated about 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.”

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 educator 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 district, those in 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 says. “So we have to make sure they’re safe.”

Both the condom hunt and demonstration 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 Kirby’s study, is one of only a handful of AIDS education curricula endorsed by the CDC.

Although there has been little opposition to the curriculum in Denver, some religious organizations and parents’ groups across the country have condemned approaches like these, saying that teaching kids safe-sex strategies actually encourages sexual activity. Such arguments have derailed efforts to adopt courses in dozens of school districts in recent years.

“If you go through explicit demonstrations, you undermine your own message of abstaining until marriage,” explains Gracie Hsu, a policy analyst for the Family Research Council, a Washington, D.C.-based research and advocacy group.

Kirby says this simply isn’t the case. “The overwhelming weight of the evidence,” Kirby writes in his 1995 report, “demonstrates that sex and AIDS education programs do not cause harm as some people fear.” In fact, he says, research shows that courses employing a combination of the nine strategies help delay the start of sexual activity. And for those already active, they help reduce the frequency of sex and increase the use of condoms and other contraceptives.

Some religious organizations and parents’ groups across the country have condemned AIDS education, saying that teaching kids safe-sex strategies actually encourages sexual activity.

Many researchers believe that distributing condoms on school grounds--some 50 districts have such programs--increases their use among sexually active students, although they admit that confirming evidence remains sketchy. A three-year study by the Academy for Educational Development, a national research and policy organization, promises to shed some light on the issue. Set to be published later this year, the study compares 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. “The weight of the evidence,” Kirby writes, “indicates that these abstinence-only programs do not delay the onset of intercourse.”

Hsu argues that such an assessment is premature. A study last year of a sex education program in the District of Columbia showed that abstinence-only teaching can yield positive results, she says. The evaluation of the program run by Best Friends, a Washington, D.C.-based organization that promotes abstinence education, 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,” Hsu says, “found that participants were far less likely to have engaged in sex than were nonparticipants.”

The public debate over the content and tone of AIDS curricula tends to overshadow some of the practical challenges of putting an effective program in place. The costs of curricular materials and teacher training alone can be prohibitive. “Many districts face inadequate resources,” says Brenda Greene, manager of school health programs for the National School Boards Association, “and so they’re going to focus on the core subjects.” Even in schools with both the funding and enthusiasm for effective AIDS education, she adds, there may not be enough time in the school day to teach it.

“The most effective AIDS education is peer-to-peer talk, in clubs and social settings, not necessarily in schools.”

Chris Yu, Funders Concerned About AIDS

At Kennedy High, 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,” says Bernadette Seick, a district administrator. What’s more, several Denver teachers who were trained in the Skills for Life curriculum have transferred or retired, and the district has found it hard to find replacements. Says Seick, “Not every teacher wants to get into the classroom and show kids how to use a condom.” Similarly, many parents balk at the detail considered vital to making such teaching effective, even though national surveys show substantial parental support for teaching about AIDS in schools.

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,” says Chris Yu, program coordinator for Funders Concerned about AIDS, a New York City-based association of grantmakers.

A study published in The Journal of the American Medical Association in 1991 found that small-group counseling sessions with runaways ages 11-18 were effective in promoting abstinence and reducing instances of unprotected sex. After undergoing three months of counseling, the percentage of youths living in runaway shelters who reported using condoms nearly doubled, from 33 percent to 63 percent, according to Mary Jane Rotheram-Borus, a professor at Columbia University and lead author of the study. And researchers at the University of California at San Francisco found in a 1996 study that educating young gay men about AIDS at social events like picnics and volleyball games influence them to practice safer sex.

While these kinds of community-based approaches have succeeded in reaching gay youngsters, a group particularly at risk for AIDS, 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 curricula tailored to gay students and by students’ lack of candor or understanding about their sexual identities. Some young students, researchers say, simply do not know their sexual orientation.

One thing AIDS education advocates and researchers agree on is that school-based initiatives should not be abandoned. “For people who say this is an experiment that has failed, we say it has never been tried,” says Carolyn Patierno, director of program services for the Sexuality Education and Information Council of the United States.

“For people who say this is an experiment that has failed, we say it has never been tried.”

Carolyn Patierno, Sexuality Education and Information Council of the United States

Santelli of the CDC says it’s important for AIDS educators to take the long view. He points to the sluggish progress of several other national health campaigns: It took years for people to start wearing seat belts, for example. And while the surgeon general issued a report linking cigarettes to cancer in 1964, our culture has only recently begun to shift away from smoking. “It’s been a large effort by a lot of people over many years,” Santelli says. “What really changes behavior is hearing things over and over again; your wife nagging you to stop smoking cigarettes actually works.”

Tim Dunn, director of school health at the Education Development Center in Newton, Massachusetts, says he has already begun to see a change in the way schools approach AIDS education. “Most programs,” he says, “are moving toward these proven, effective methods.”

Still, much more needs to be done. Kristin Moore, director of the Washington-based Child Trends Inc. and an expert on teenage pregnancy, points out that 85 percent of young women ages 15-19 who have children out of wedlock are from low-income families. Only programs that address poverty, attempt to prevent school failure, and provide job training will have a sustainable impact, Moore argues.

“Kids think it doesn’t matter if they have sex or have a child,” she says, “because they are going to be working at a fast-food restaurant anyway.”

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The “Research” section is being underwritten by a grant from the Spencer Foundation.
A version of this article appeared in the March 01, 1997 edition of Teacher as Teaching AIDS


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