HIV prevention education and infection rates among youth in sub-Saharan Africa

HIV Risk Prevention: Educating Minority Adolescents

Fighting HIV / AIDS involves no less than changing our whole sexual culture." Peter Piot, Executive Director of UNAIDS, feels that what is most vital is that preventive education be stressed into young people's behavior. (UNESCO Courier, October 1999). Around half of all new cases of HIV infection in the whole world involve young people between 15 and 24, and in more and more cases, below age 15. Why is this so? Because everybody knows that it is the age when you begin experimenting with sex and change partners most often which compounds the problem because it multiplies the risk of infection. Studies in Kenya and Zambia show that 23% of the girls between 15 and 19 are HIV-positive compared with only three to four percent of boys. Girls are more vulnerable because of two reasons: the female genitals are more susceptible to infection than those of males (because they have not yet developed) as well as socio-cultural ones (they are most often won by gifts or are the victims of force). They often have as partners adult men who because of their age are more likely to be HIV-positive than boys.

The roots of the problem are most often poverty and male chauvinism. Hence, it is important to educate boys who have to learn that their worth doesn't depend on the number of women they have seduced.

It's been statistically proven that preventive education makes people much more sexually responsible. Youth are more receptive to prevention messages and go on to adopt a more responsible attitude to sexuality than adults.

In countries where there's been a good response to prevention campaign we've seen a very marked drop in the rate of infection among the 15 to 24-year-olds. The rate in Uganda urban areas has dropped 40%. In Zambia it has dropped most markedly among school children.

All this shows that education has an important role to play. While it's true that many children in developing countries don't go to school, the majority pass through school. The opportunity must be grabbed to give them an education about AIDS adapted to their age group, right from the start of primary school. While people feel that this will still encourage children to have sexual relationships, individuals really don't wait for lessons before starting their sexual life.

It has been statistically proven that preventive education makes people much more sexually responsible, namely by having sexual relationships later and using protection. (UNESCO Courier, 1999).

CONCEPTUAL FRAMEWORK

While the highly industrialized world has successfully stemmed the tide of new HIV / AIDS infection and has sharply reduced the number of AIDS deaths through the use of new and more potent anti-HIV drugs, everywhere else in the world the pandemic is still spreading uncontrolled with the sick being treated poorly or left untreated. This is noticeable in South and East Asia and most specially in sub-Sahara, Africa (UNESCO Courier, 1999).

In the United States, HIV/STD infections are prevalent among the African-Americans, and the Latinas in urban and rural areas specially in districts where the unemployment rate is high and impoverished families cannot send their children to school. Out-of-school youth ages 12-19 are most stricken and while efforts are being heightened and the federal government and other funding organizations are helping out, HIV/STD cases still exist and programs don't seem to work out at all. The following glaring statistics stand out in surveys conducted throughout the United States:

as of June 2000, the Centers for Disease Control and Prevention reported that 431,924 individuals are living with HIV infection and AIDS in the United States

There are an estimated 250,000 Americans who are unaware that they are HIV-infected and many of them are young people.

Half of all new HIV infections are thought to occur in young people under 25 years of age.

More than 123,000 young adults in the United States have developed AIDS in their twenties. The delay between HIV-infection and the onset of AIDS means that most of these young people were infected with HIV as teenagers.

Although the total number of youth in the United States who have been infected with HIV is unknown, public health officials believe that 20,000 people between 13 and 24 years of age are infected with HIV every year at the rate of about 2 every hour.

In the United States, more females than males are now being diagnosed with HIV in the 13- to 19-year-old age group.

By 12th grade, 65% of American youth are sexually active and one in five has had four or more sexual partners.

In the United States, 25% of high school students who have had sex said they were under the influence of alcohol and other drugs the last time they had sex.

HIV infections are usually contracted sexually among American young people.

The percentage of high school students who say they have had sexual intercourse decreased from 54% in 1991 to 50% in 1999. The percentage of sexually active high school students who say they used a condom the last time they had sex increased from 45% to 58% during the same period. Their accounts were confirmed when in 1999, births to teenagers fell to their lowest rate in 60 years. (Office of National Aids Policy, Youth and HIV / AIDS 2000: A New American Agenda).

A research system with an objective of applying science, technology, communication should be used to provide alternatives to meeting specific needs of adolescents. Each member included in the team plays a specific and essential role. An active exchange of resources must take place to enable each one to perform his particular task. As each one influences the other, there ensues dynamic interdependence. Interaction is fostered by which the program is able to survive, adapt, maintain itself and grow. The effectiveness of the program is entirely dependent on the communications established within it and between it and others. The successful conduct of the program requires that those responsible for its planning and implementation interact with the other factors in its environment. (Valdecanas, 1983).

THEORETICAL FRAMEWORK

The Theory of Reasoned Action (TRA) will be used as a framework for this proposal. First introduced by Fishbein in 1967, it suggests that a person's attitude toward any object is a function of his or her belief about the object and the evaluative aspects of those beliefs (Terry, 1993). The theory is based on the assumption that human are rational and behaviors are under voluntary control. It provides a framework that connects individual beliefs, attitudes, intentions and behaviors as shown in the model below Theory variables are defined by Fishbein and described by Demson (1996).

They are:

Behavior: A specific behavior defined by a combination of four components: action, target, context, and time

Intention: The intent to perform a behavior is the best predictor that a desired behavior will actually occur. To be able to measure it accurately and effectively, it should be defined using the same components used to define behavior, action, target, context and time.

Attitude: The individual's positive or negative feelings toward performing the defined behavior.

Behavioral beliefs: A combination of a person's belief regarding the outcomes of a defined behavior and the person's evaluation of potential outcomes. These beliefs differ from population to population.

Norms: A person's perception of the other people's opinion regarding the defined behavior

Normative beliefs: A combination of a person's beliefs regarding other people's views of a behavior and the person's willingness to conform to those views. These beliefs vary from population to population.

The theoretical framework supports a linear process in which the changes in an individual's behavioral and normative beliefs eventually affect the person's actual behavior. The theory forms a causal chain that links belief to behavior. According to the theory, cognitive structures, behavioral and normative beliefs, influence individual attitudes and subjective norms (Fishbein,1994). Consequently attitudes and norms shape a person's intention and remain the best indicator of the desired behavior.

The TRA has been used to successfully influence behaviors involved in the control and spread of STDs and AIDS. Other studies have used the TRA successfully. Ross and McLaus (1992) found that subjective norms were good predictors of intention to use condoms but attitudes were poor predictors of intention. However, research conducted by Fisher, Fisher and Rye (1995) with gay men, and heterosexual college and high school students, suggests that AIDS preventive behavior were predicted by behavioral intention and the behavioral intentions were a functions of attitudes and norms.

In a survey on 12- to 19-year-olds, attitude toward condom use, subjective social norms and self-sufficiency expectations are important determinants of condom use.

The theory has been used successfully as a framework in several AIDS studies. The theory suggests that by providing appropriate knowledge or information, the performance of a given behavior will be influenced. Also, the more one knows about the factors influencing decisions to perform or not to perform a given behavior, the greater the possibility one can develop successful intervention to change that behavior (Fishbein, 1994).

In conclusion, it would be advantageous to use the TRA for this project since studies have shown successful outcomes with this theory in past HIV / AIDS prevention programs. By providing appropriate knowledge or information, eventually the performance of a given behavior will be influenced. This HIV / AIDS prevention program will be education for seventh to eighth grade students in HIV / AIDS with the intent to change belief leading to a change in behavior. The TRA can provide a workable theoretical framework that has been used successfully in the past with HIV / AIDS education.

RESEARCH QUESTION/HYPOTHESIS

This study will attempt to answer the following questions:

Can an interactive school-based HIV / AIDS prevention/education program for multiethnic urban seventh and eighth graders increase their knowledge about HIV / AIDS, promote positive attitudes towards people with AIDS and encourage the desire for changes in the high risk behavior.

METHODOLOGY

RESEARCH DESIGN

An HIV educational program intervention will be used. The design consists of a pre-test and post-test evaluation of an educational intervention on HIV / AIDS prevention to seventh and eighth grade students. The pre and post test is a modified version of the Healthy Oakland Teens Survey developed by the University of California which can be completed in twenty minutes. The survey is intended to be used for a multiethnic, urban population of seventh and eighth graders. The same survey has been chosen for this study because it was designed for a similar population of students: multiethnic, urban, seventh and eighth graders, belonging to families not economically well-off, some barely managing to survive.

The school has a total of seventh and eighth grade students in the total population of the school. All of these students will be enlisted in the HIV educational program based on the curriculum for the Healthy Oakland Teens Project.

The investigation will perform the intervention which will consist of an interactive two and one half hour HIV / AIDS educational program adapted from the curriculum for the Healthy Oakland Teens Project.

Students will be given a pre-test and a post-test at the beginning of the program. Each pre and post-test handed to the student will have the same number on the left-hand corner so that pre and post-tests could later be matched. Students will be told not to place their names on either test. All pre-tests are pink and all post tests are blue. Students are handed both tests in a blank manilla envelope at the same time. Students will be instructed to take the pink pre-test prior to the HIV program and to place the test back in the envelope when finished. After the programs students will be instructed by the investigator to take the blue post test out of the envelope and when finished taking the survey place the test back in the envelope. All the blank manilla envelopes will be collected after the post tests are completed. No names or identifiers will be used. The tests are randomly handed to the students in the blank manilla envelopes. No name is used and there is no way to link students' names with the data. All the results are recorded as group data.

Setting: The study will take place during the students' science class at the charter school.

Research Sample

The sample will consist of 37 seventh and eighth grade students. This include students in seventh and eighth grade at the school who had permission by their parents to attend a program on HIV. This program is part of the school's customary educational practices and philosophies. The students whose parents do not want the child to participate in educational learning on controversial topics such as HIV are to be identified by the co-directors of the school and are removed from the program and given an alternative assignment by their teachers.

INDEPENDENT VARIABLE

The independent variable in this study is an HIV / AIDS interactive educational program to seventh and eighth grade students. The educational program is a modified version of the Healthy Oakland. Teens Project 1995-1996 curriculum which includes a system and HIV, transmission, protection, and myths and facts about HIV / AIDS, a 20 minute video, "In Our Own Words: Teens and AIDS" by Jean Blake, will be shown as part of the program. A question and answer session by the investigator follows the video and students are encouraged to express their thoughts. Also an interaction HIV transmission will be implemented during the program

RESEARCH RESULTS

The first problem this study will address is whether educational intervention could change a student's attitudes towards HIV / AIDS. Several aspects of the student's attitudes will be assessed: student's comfort level in discussing HIV / AIDS related topics with their parents/guardian.

This study focuses on the educational content towards only students. To efficiently facilitate communication between students and parents the educational program should focus on educating both parents and children.

The study will also assess the students' comfort level associating with someone with HIV / AIDS. As part of the educational program, the students will be shown the video "In Our Own Words: Teens and AIDS. This video will present "Give your love to individuals infected with HIV" and talking candidly to peers about HIV / AIDS issues. The purpose of the video's format is to encourage a more comfortable rapport with individuals infected with HIV.

The second problem to be addressed by this study is whether an educational intervention could change a student's intent toward risk-taking behavior. One manifestation of the student's risk-taking behavior is his attitudes toward condoms. Therefore, there will always exist a group of students that must be made to understand the importance of condom use in the practice of safe sex.

The California study produced interesting results as to how educational intervention affects the fears and concerns students have towards sexually transmitted disease. Two questions focused on the students' concerns about contracting HIV / AIDS or sexually transmitted diseases. Both questions showed that educational intervention caused a shift from students who were "very worried" to students who were "somewhat worried." These results are encouraging because they suggest that the educational interventions effectively addressed the concerns of students and positively influenced their attitudes.

The strongest data that the previous study produced shows a significant increase in the knowledge of students concerning HIV / AIDS. The questions showed an increase in knowledge is a result of the educational intervention concerning the transmission of the HIV virus. Several questions addressed some of the false myths about HIV transmission like "you can get AIDS from a swimming pool or toilet seat (questions 14 & 15. Table 3). Both of the questions showed a statistically significant (p-value

In conclusion, the data collected from the California study indicate that a 2-hour educational intervention can have statistically significant effects on student's knowledge. Student's intent for behavioral change was not statistically significant although results indicated a trend toward. HIV / AIDS infected individuals indicated improvement after undergoing the educational program.

IMPLICATIONS FOR FAMILY/

COMMUNITY HEALTH NURSE PRACTITIONERS

These encouraging results show that educational intervention can increase knowledge of HIV / AIDS. This study focused on pre-high school students and shows that these students can be effectively educated. The implication for nurse practitioners is that they should begin the education of their younger patients before they enter high school. Knowledge can hopefully give students the resources to make wiser decisions in the future regarding their health. Education is an important prevention technique for nurse practitioners.

This study used a variety of strategies to educate students. Lecture, video presentation and role-playing were all used to present and reinforce critical information about HIV and virus transmission. The multimedia and interactive forum maintained the interest of the students and promoted discussion in the class. Interactive education needs to be utilized in practice to actively involve the individual in the learning process.

Results from this study justify the use of education to help reduce the risk of HIV transmission among adolescents. Given the high evidence of HIV infection among younger adults the evidence supports the use of education as a desirable intervention for risk reduction by nurse practitioners. Measures should be taken to provide education to students during early adolescence continuing throughout adolescence and young adulthood. Educational interventions should be implemented both in schools and in clinical settings by nurse practitioners.

IMPLICATIONS FOR TARGET POPULATION/COMMUNITY

The target population of this study focused on minority adolescents in seventh and eighth grades at one charter school. Past research has indicated that minority adolescents are at an increased risk for HIV / AIDS. HIV presently continues to be the leading cause of death among Americans 24 to 44 years of age. Results of this study show that the students' knowledge increase on HIV / AIDS was statistically significant. Therefore, educational program in this school and other schools throughout the city promote healthy behavior of the students.

Education on HIV / AIDS plans an important role in prevention for adolescents. Implementation of an educational HIV / AIDS program can help promote healthy behavior. This will help improve the safety and healthy behavior of the students in high-risk communities. Through knowledge, minority adolescents will hopefully be able to empower themselves and be able to make informed choices, thus decreasing the HIV transmission rate.

SUMMARY

HIV / AIDS, an extremely serious health issue affects young people in America. Teenagers most especially in the minorities in multiethnic communities are showing escalating trends in risk-taking behavior and subsequent increase in HIV infection rate. This study attempted to address the problem of HIV / AIDS in minority adolescents by developing and presenting an effective educational program to increase student's knowledge of HIV / AIDS. The design of the educational program also encouraged positive attitudes towards individuals infected by HIV.

Education can make a positive impact on behavior. The Theory of Reasoned Action used in this paper provided a framework for this study that led to positive knowledge outcomes. The results of the study show that the educational intervention significantly increased the student's knowledge of HIV / AIDS and promoted positive attitudes towards individuals infected with HIV. The majority of students completing self- reported surveys felt that this program was beneficial and contributed to their greater understanding of HIV / AIDS.

Everybody - Preventing HIV and Other Sexually Transmitted Diseases

Among Young Teens, Revised Edition

Everybody" is within Coordinated School Health Programming

It is a fact that good health and academic success go hand in hand. Students enrolled in schools with coordinated school health programs are most likely to be well-prepared for middle level HIV / AIDS education. They are also likely to receive reinforcement of prevention messages.

Everybody," the curriculum, has a role to play in school health programming. The model for coordinated school health programs has eight components. Of these eight, Everybody is directly connected to health education; health services; counseling; psychological and social service; as well as parent/community involvement. The other components of coordinated school health programming also pertain to HIV/STD related issues.

Everybody and Diversity Issues: Educators and community numbers are encouraged to tailor activities to meet local norms and needs. There are common themes throughout the curriculum as personal rights, public or community responsibilities, safety, health, respect and compassion. These themes are considered universal for a United States audience although application and interpretations may vary according to the specific ethnic, cultural, racial, etc.

Assessment (Evaluation)

The success of Everybody's curriculum is the students' behavior outside of the classroom. Several formal and informal activities can help teachers find out the extent to which students are learning and internalizing the curricular content.

The following topics form the core elements of HIV/STD education at every grade level:

The life science of HIV, AIDS and other STDs

HIV/STD transmission

HIV/STD prevention

HIV antibody testing

Psychosocial issues related to HIV/STDs

Every activity begins with guiding questions. They indicate what the students should be able to answer by the end of the activity. Extensions of lessons and evaluation activities measure the student's ability to answer the guiding questions. The teacher can also observe students "in action" during those activities with students assigned to small working groups.

In each activity there is a section on Lesson Extension and assessment. Assessment activities should develop creativity skills, personalization of HIV/STD prevention messages, and development of communication skills. The performance of the students should be linked to the overall quality of their work, the thoughtfulness of their responses and the depth of their analysis.

In 1996, the Elizabeth Glaser Pediatric Aids Foundation funded a 21-month national demonstration project. The idea was to find out if the teachers could use the RAD model in varied middle schools from four states. Charles Deutsch of the Harvard School of Public Health and John Brett, Ph.D. from the University of Colorado at Denver were principal investigators for one independent evaluation that accompanied this project. The quantitative and qualitative data derived from the investigation showed significant positive impacts on students' knowledge, perceptions and attitudes about HIV / AIDS prevention and personal risk-taking. The students manifested significant positive impacts on their knowledge, perceptions, and attitudes about HIV, AIDS prevention, and personal risk-taking. Students demonstrated significant gains in comfort with talking to peers and teachers about HIV prevention. Also, at a time when young teens often increase risky behaviors, students in this study maintained low levels of actual and intended risky behaviors from baseline through three-month post test. In addition, students, teachers, administrators, parents, and other community members strongly supported the curriculum. This really means to say, the research showed that Everybody works: it is memorable, durable and portable.

As the name implies, Everybody is for everybody: teachers, families, health professionals, others who work with youth, and most importantly young teens, themselves. Above all, "Everybody" is about helping adolescents develop the habits of being informed regarding their own health and being responsible for preventing HIV and other STDs. Everybody is developmentally appropriate and the research shows that it matches the needs of today's youths. Everybody targets young teens, many of whom have not initiated risky behaviors with the objective of providing a prevention paradigm to help students shape their future activities. Everybody also provides potentially life-saving contents for those youth already at risk for HIV and other STD.

Everybody has a very specific mission: to facilitate communication about HIV/STD prevention and to promote safe behavior among young teens. Everybody does not seek or claim to do everything that comprehensive health education can and must do. In the context of HIV/STD education. "Everybody" does touch on alcohol and drug prevention and the impact of the media. But the curriculum does not focus on these areas. Furthermore, "Everybody" assumes that students, teachers and other adults have some familiarity with basic communication skills. If needed, the reader is urged to seek out additional resources to supplement "Everybody."

With the publication of this book, attention can now be focused on supporting teachers, families, health professionals and others as they use Everybody to promote HIV/STD prevention among youth. RAD continues to offer professional development training in "Everybody." In addition, interactive website www.preventaids.netprovides an online opportunity for dialogue about HIV/STD education and the process of implementing "Everybody."

Everybody" is not a static curriculum. It should be used, adapted and enhanced. It is a bit like the bones that stabilize our bodies. "Everybody" provides a solid structure that can support a unique and valuable individual with particular experiences and needs. "Everybody" is a way to prevent HIV/STD infections and also endorses risk reduction as an important component of HIV/STD prevention strategies. Lessons and activities promote the development, internalization, and actual use of prevention related skills and knowledge; commitment to lifelong health; self-efficacy; hope for the future, and courage.

Everybody" aims to prevent interconnected high-risk behaviors and encourage interconnected protective strategies. Young adolescents are understood as more than the sum of their risk and resiliency factors. The curriculum focuses on the importance of healthy self-esteem as it presents prevention strategies for the youth, for individual, the community and society.

Everybody" realizes the complex behavioral implications for HIV/STD prevention: individuals must understand, internalize and remain committed to safe (safer) behaviors. Young adolescents know that the world is complicated. "Everybody," the curriculum affirms the experience of reality and provides practical, acceptable prevention strategies for youths.

Everybody" focuses on relevant psychosocial issues as the feeling of fear and anger in the context of HIV/STD prevention. Healthy fear can be a motivator for safer behaviors. However, unhealthy fear can be destructive. The curriculum reduces fears related to ignorance and misunderstanding. This method of approach helps the youth to identify, acknowledge, and transform the energy of fear into productive action or understanding.

Aside from this, the curriculum "Everybody" with its activities examines anger as an uncomfortable emotion and guides the students to see that such emotions do not call for (self) destructive risk-taking. Young adolescents can understand that people can feel anger about HIV and still be able to protect themselves.

Prevention Strategies

The curriculum (Everybody) addresses high-risk behavior as opposed to high-risk groups. The program communicates that it's not who you are, but what you do that can place you at high risk for HIV. Everybody outlines the mechanism of risk for HIV/STD infection beyond listing specific risky behaviors. The possibility of HIV/STD infection is described through an equation in which the riskiness of personal behaviors interacts with other variables a such as the frequency of risky behaviors, the prevalence of HIV/STD in the community, underlying health status access to care, and chance.

Everybody" addresses sexuality as a normal part of human experience. Sexual behaviors are discussed in clinical terms that are non-threatening and non-sensational. Activities include mention of the three highest risk-sexual behaviors: vaginal, anal, and oral intercourse. The curriculum does not suggest limiting this description as students may mistakenly assume that any behaviors not termed risky are safe.

Everybody" presents two major prevention strategies: risk elimination and risk reduction. From a public health perspective, risk elimination is the measure of true safety. Yet many individuals, especially the youth do not opt for this safe measures or do not have the capacity to exercise their right to such a choice (as in cases of rape or trauma). Therefore, developmentally appropriate discussion of risk reduction, including the subject of safe sex, is critical.

Risk Elimination

Maintaining a lifestyle for an indeterminate period of time does not include any behaviors that put one at risk of HIV/STD infection, including sexual intercourse (vaginal, oral and/or anal); use of alcohol or other illegal drugs, and any needle-sharing activities.

Risk elimination" - is used by "Everybody" instead of "abstinence" because of the common association between abstinence and religious or moral beliefs. Risk elimination is a more precise or to the point description of the desired behavioral outcome.

Safe Sex - sex within a mutually monogamous, trusting relationship between people who have tested negative for HIV and other STDs, don't share needles, and have no other risky behavior. Typically such relationship has a high level of mutual respect and communication.

Safer Sex - sex involving use of risk reduction techniques. This type of sexual activity is safer than unprotected sex, but still contains some risk of disease transmission.

One of the objectives of "Everybody" is for students to adopt risk elimination as an active choice and feel good about their choice. People have different expectations for how long they are willing to adopt risk elimination. "Everybody" suggests that it is most important to focus on prevention in the present and immediate future. Staying healthy now is of the utmost importance, and sets precedence for future behavior.

Everybody" shows risk elimination as an investment in a person's future opportunities and choices. Safe sex is possible for healthy people. However, the option for safe sex can be jeopardized if one or both partners are infected with a transmissible disease.

Everybody" tackles risk elimination from a positive perspective - focusing on the benefits of eliminating risk rather than using scare techniques, i.e. "you'll die if you don't choose risk elimination.

Everybody" teaches that correct and consistent use of condoms can prevent transmission of HIV and STDs but does not promise total safety. Condoms can fail. However, risk reduction can save lives and is a valid public health choice for sexually active people.

To some, risk reduction is an intermediate step toward risk elimination. For others, reduction is a healthy way of life. In "Everybody," the students themselves create strategies to foster risk reduction, fascinating, intense, often challenging and remarkably resilient.

Curriculum affirm - promise that informed skillful adolescents are capable of making healthy decisions about themselves.

Everybody fosters active learning - format responsive to one wide perspective: Youth cognitive and emotional maturity, life experience and resiliency.

Everybody explores the boundaries between trusting and doing, perceiving and knowing.

Interactive, experiential learning techniques engage youth and adults - education, account, structured yet spontaneous, and above all safe.

Provides accurate health information respectful of students' personal beliefs and family norms.

Provides information respectful of students' personal beliefs family norms. Activities guide teachers to separate personal belief from professor responsibilities.

Offers safe proxy for actual real life experience.

In everybody, prevention of these diseases is directly linked to human connection, personalities as well as public response.

Everybody meets students where they are - relevant, engaging and practical. Pertains to students reality.

An abstinence-based approach about attitudes, knowledge and skills.

Recommended sequence for each grade takes a minimum of several grades to complete.

Recommended sequence might not match every student's needs and/or every community's norms.

Activity formal: Overview section begins each activity and provides following information:

Content Categories (attitudes, knowledge and skills)

____ Grade Level 5-9

Correlative to National Education Standards

Science Education (A.G) and Health Education (1-7)

Estimated time excluding lesson extension and assessment ranges from 10-35 minutes per activity

Materials - when required

Set Up - when required

Summary

HIV / AIDS in an extremely serious health issue focusing on young people - American Teenagers, especially minorities, are showing increasing trends - risk taking behavior and subsequent increases in HIV infection rate.

Development and risk preventing needs an effective education program to increase knowledge.

The theory of reasoned action predicts that education can make a positive impact on rational behavior. This theory was helpful in providing a framework for this study that led to positive knowledge outcome. Results of this study show that the education intervention significantly increased the students' knowledge of HIV / AIDS and promoted positive attitudes toward individuals infected by HIV. The majority of students completing self-requested surveys felt that this program was beneficial and contributed to their understanding of HIV / AIDS.

OTHER INTERVENTION PROGRAMS FOR ETHNIC GROUPS

Some sexually active young African-American and Latina women are at especially high risk for HIV infection especially those from poorer neighborhoods. A study of disadvantaged out-of-school youth in the U.S., Job Corps found that young African-American women had the highest rate of HIV infection, and that women 16-18 years old had 50% higher rates of infection than young men. Another study of African-American and Latina adolescent females found that young women with older boyfriend (3 years older or more) are at higher risk for HIV.

What Puts Adolescents at Risk?

Adolescence is a developmental period marked by discovery and experementation that comes __ a myriad of physical and emotional changes. At this time of growth and change young people get mixed messages. Teens are urged to remain abstinent while surrounded by images on television, movies and magazines of glamorous people having sex, smoking and drinking. Double standards exist for girls who are expected to remain virgins and boys who are pressured to prove their manhood through sexual activity and aggressiveness. And in the name of culture, religion or mortality, young people are often denied access to information about their bodies and health risks that can help keep them safe.

A recent survey of teens in school showed that from 1991 to 1997, the prevalence of sexual activity decreased 15% for male students, 13% for white students and 11% for African - American students. However, sexual experience among female students and Latina students did not decrease. Condom use increased 23% among sexually active students. However, only half of sexually active students (57%) used condoms during their last sexual intercourse.

Not all adolescents are equally at risk for HIV infection. Teens are not a homogenous group and various sub-groups of teens participate in higher rates of unprotected sexual activity and substance use, making them especially vulnerable to HIV and other STDs. These include teens who are gay/exploring same sex relationships, drug users, juvenile offenders, school dropouts, runaways, homeless and migrant youths. These youths are often hard to reach for prevention and education efforts since they may not attend school on a regular basis and have limited access to health care and service-delivery system.

Can Education Help?

Yes. Schools are an important venue for educating teenagers on many kinds of health risks, AIDS, HIV, STD and unintended pregnancy. Across the U.S. And around the world, studies have shown that sexuality education for children and young people does not encourage increased sexual activity and does help young people remain abstinent longer. Effective educational programs have focused curricula, have clear messages about risks of unprotected sex and how to avoid risks, teach and practice communication skills, address social and media influences, and encourage openness in discussing sexuality. In addition, HIV prevention programs that are carefully targeted to adolescents can be highly cost effective.

Are Schools the only Answer?

No. Young people need to get prevention messages in lots of different ways and in lots of different settings. Schools alone can't do the job. In the U.S. many schools are being hampered by laws and funding that prohibit comprehensive sexuality education. The federal government earmarked $50 million per year for school-based abstinence - only programs which emphasize values, character building and refusal skills, but do not discuss contraception or safer sex. Although abstinence programs are effective at delaying the onset of sexual activity, they typically do not decrease rules of sexual risk activity among adolescents the way that safer sex interventions do.

Youth who are not in school have higher frequencies of behaviors that put them at risk for HIV/STDs and are less accessible by prevention efforts. A national survey of youth aged 12-19 found that 9% were out-of-school. Out-of-school youth were significantly more likely than in- school youth to have had sexual intercourse, had four or more sex partners and had used alcohol, marijuana and cocaine. More intensive STD/HIV and substance abuse prevention program should be aimed at out-of-school youth or youth at risk for dropping out of school.

Program targeting hard-to-reach adolescents at high risk for HIV are necessary in many different venues outside of schools. Programs based in venues such as residential child care facilities, alternative schools and youth detention centers are needed. Peer educators can use an empowerment-oriented approach targeted to youth aged 12-17 to teach about preventing HIV and STDs and to mobilize and link resources for young people through social and community networks.

Families play an important role in helping teenagers avoid risk behaviors. Frank discussions between parents and adolescent children about condoms can lead teens to adopt behaviors that will prevent them from getting HIV and other STDs. Research has shown that when mothers talked and answered questions about condom use with their adolescents prior to sexual debut, the adolescents reported after use at first intercourse and most recent intercourse, as well as after lifetime condom use.

ETHNIC GROUPS AND HIV/STD OTHER PROGRAMS

The WEHO Lounge in Los Angeles, CA is a coffee house and HIV Testing and Information Center between 2 of the busiest gay discos in town. It offers free confidential oral HIV testing, weekly community forums, peer counseling, drug adherence support group, free condom distribution and a comprehensive youth and HIV resource library. The Lounge also sells coffee drinks. By placing this resource in the community and adapting it to the needs and habits of young gay men, the program has been highly successful with clients.

Project VIDA in Chicago, Illinois, a community-based service organization, provides

HIV prevention for high-risk urban Latina females, ages 12-24. Project VIDA incorporates empowerment and self-case themes into peer-facilitated street/community outreach and group interventions. They act on the belief that it is impossible to separate HIV risks from other cultural, environment, interpersonal and intrapsychic stressors that Latina youth face, and that coping skills can help manage the perplexities of their challenges.

What Needs to be Done?

HIV prevention programs for adolescents must consider the developmental needs and abilities of this age group. Programs should focus on contextual factors that lead young people to engage in higher rates of sexual activity and lower rates of condom use, such as low self-esteem, depression, substance use, gang activity, stress of living in turbulent urban environments, or boredom/restlessness related to unemployment.

Any program for adolescents should be interesting, interactive and involve youth in the planning and implementation. This is especially true for out-of the mainstream youth and youth from diverse cultures. Programs for hard-to reach youth who are most at risk for HIV infection should be implemented in venues outside of schools, such as runaway/homeless youth shelters, shopping malls, detention facilities and recreation/community centers. Adolescents not only need correct information and practice in self-protective skills but also easy access to condoms in order to keep themselves risk-free.

What Kinds of Programs Work Best?

Reducing the Risk, a program for high school students in urban and rural areas in California, used behavior theory-based activities to reduce unprotected intercourse, either by helping teens avoid sex or use protection. Ninth and 10th graders attended 15 sessions as part of their regular health education classes and participated in role playing and experimental activities to build skills and self-efficiency. As a result, a greater proportion of students who were abstinent before the program successfully remained abstinent, and unprotected intercourse was significantly reduced for those students who became sexually active.

Postponing Sexual Involvement, a program for African-American 8th graders in Atlanta, GA used peers (11th and 12th Graders) to help youth understand social and peer pressures to have sex, and apply resistance skills. A unit of the program also taught about human sexuality, decision-making and contraceptives. This program successfully reduced the number of abstinent students who initiated intercourse after the program and increased contraceptive use among sexually experienced females.

Health Oakland Teens (HOT) targets all 7th graders attending a high school in Oakland, CA. Health educators teach basic sex and drug education, and 9th grade peer educators had interactive exercises on values, decision-making, communication and condom use skills. After one year, students in the program, were much less likely to initiate sexual activities such as deep kissing, genital touching and sexual intercourse.

AIDS Prevention for Adolescents in School, a program for 9th and 11th graders in schools in New York, N.Y. focused on correcting facts about AIDS, teaching, cognitive skills to appraise risks of transmission, increasing knowledge of AIDS-prevention resources, clarifying personal values, understanding external influences, and teaching skills to delay intercourse and/or consistently use condoms. All sexually experienced students reported increased condom use after the program.

A review of 21 studies found that effective sex education programs share the following characteristics:

Narrow focus on reducing sexual risk-taking behaviors that may lead to HIV/STD infection or unintended pregnancy

Social learning theories as a foundation for program development, focusing on recognizing social influences, changing individual values, and building social skills.

Experimental activities designed to personalize basic, accurate information about the risks of unprotected intercourse and methods of avoiding unprotected intercourse

Activities that address social or media influences on sexual behaviors

Reinforcing clear and appropriate values to strengthen individual values and group norms against unprotected sex

Modeling and practice in communication, negotiation and refusal skills

SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS

Shared rights, shared responsibilities" - global theme used in World AIDS Day - may well be a continuing advocacy slogan to raise awareness and stimulate proper and immediate action. Information, communication and AIDS/HIV/STD education activities have been launched by various government and non-government organizations who have concentrated on the following:

information and counseling health education and information programs media campaign research-based materials development information dissemination public and media relations

Not much emphasis is placed on laboratory services which are a basic and necessary component of the AIDS/STD prevention and control program but we mentioned them for completion and exhaustive treatment in the study.

Laboratory services include:

HIV anti-body testing, screening and confirmatory

Pre and post testing counseling

STD laboratory

Quality assurance

Diagnostic research

Case of People with HIV and AIDS:

Counseling

Clinical laboratory follow-up

Clinical management

Social support

Program Management planning and organization capability building policy development project evaluation reporting advocacy special events monitoring and supervision

Other programs, and campaign activities which may be conducted include photo exhibit documentary on AIDS/HIV

AIDS Fair - display and distribution of leaflets, posters and newsletters

AIDS commercial - advertisements produced by media agencies to be shown in cinemas aired in radio and television

Concerts - usually free featuring well-known singers, actors and actresses, TV and radio hosts

Media awards - (for radio, TV, print and entertainment format) produced in support of the AIDS program

All these activities are conducted to support the AIDS/HIV/STD Awareness campaign but this study focuses on one full-blown, completely and exhaustively developed program, the education intervention program specifically targeting multi-ethnic urban youth sector. This is the component that this researcher knows is the most effective and longest lasting as far as impact is concerned.

CONCLUSIONS

All studies investigated and researched on point to the fact that the program designed to create concrete awareness and action-producing effect is the HIV / AIDS/STDs education program

RECOMMENDATIONS

Based on the survey and other research results, the HIV / AIDS Education Program for multiethnic urban youth sector is recommended for immediate implementation. It has been proved to be most effective in enlarging the knowledge and understanding of the youth in other U.S. based sectors and has been instrumental in making the youth change their attitudes towards their sexual behavior. They now choose to defer and abstain from sexual activities until they're ready for marriage. In the extreme cases where sexual activity cannot be differed, they now use condoms for protection. They have also learned the art of skillful refusal to engage in sexual activity and are able to discuss intelligently with potential partners about delaying sexual activity and indulging only in safe sex with the use of condoms.

The youth tends to be an enlightened group and are more humane, kind and understanding to those individuals already afflicted with HIV / AIDS/STDs. Youth is a malleable sector and are easily reached through an education intervention which is protracted and easily adjusted to varied situation which can accept extension activities, which can be conducted basically in a school atmosphere and which exudes an ambience of open mindedness, democracy, freedom of expression and unconditional acceptance.

This study therefore recommends that an HIV Risk Prevention program for the minority adolescents employ the RAD (Everybody Preventing HIV) Method already experimented on in some schools across the country and proved most effective for multiethnic urban youth.