VATTACHARYYA: May 4, 2007

INTRODUCTION

Why is AIDS Education Important for Young People?

The HIV epidemic has been spreading steadily for the past two decades, and now affects every country in the world. Each year, more people die and the number of people living with HIV continues to rise – in spite of the fact that we have developed many proven HIV prevention methods. We now know much more about how HIV is transmitted that we did in the early days of the epidemic, and we know much more about how we can prevent it being transmitted. One of the key means of HIV prevention is education – teaching people about HIV : what it is, what it does, and how people can protect themselves. Over half of the world’s population is now under 25 years old. This age group is more threatened by AIDS than any other; equally it is the group that has more power to fight the epidemic than any other. Education can help to fight HIV, and it must focus on young people.

There are two main reasons that AIDS education for young people is important:
To prevent them from becoming infected.

Young people are often particularly vulnerable to sexually-transmitted HIV, and to HIV infection as a result of drug-use. Young people (14-21 years old) account for half of all new HIV infections worldwide - more than 6,000 become infected with HIV every day . More than a third of all people living with HIV or AIDS are under the age of 25, and almost two-thirds of them are women. In many parts of the world, young people in this age-group are at particularly high risk of HIV infection from unprotected sex, sex between men and IV drug-use because of the very high prevalence rates often found amongst people who engage in these behaviours. Young people are also often especially vulnerable to exploitation that may increase their susceptibility to infection. Even if they are not currently engaging in risk behaviours, as they become older, young people may soon be exposed to situations that put them at risk. Indeed, globally, most young people become sexually active in their teens. The fact that they are – or soon will be – at risk of HIV infection makes young people a crucial target for AIDS education.

To reduce stigma and discrimination.

People who are infected with HIV around the world often suffer terribly from stigma, in that people who are HIV+ are somehow thought to be ‘dirty’, or to have ‘brought it on themselves’ by ‘immoral practices’. They often experience discrimination in terms of housing, medical care, and employment. These experiences, aside from being extremely distressing for HIV+ people, can also have the effect of making people reluctant to be tested for HIV, in case they are found to be HIV+. Stigma and discrimination often starts early – as name-calling amongst children. AIDS education can help to prevent this, halting stigma and discrimination before they have an opportunity to grow.

Why is AIDS education for young people an issue?

The problem seems to stem from the fact that HIV is often sexually transmitted, or is transmitted via drug use. Any subject that concerns sex between young people or drug use tends to be seen from a moralistic perspective. Many adults – particularly those of the religious right – believe that teens need to be prevented from indulging in these high-risk activities. They believe that young people shouldn’t – and don’t need to be – provided with any education about these subjects, other than to be told that they are ‘wrong’, and not to do such things. Unfortunately, however, adults have been trying to stop young people from having sex and taking drugs for many, many years with little success, so this method alone seems unlikely to offer any real relief in terms of the global AIDS epidemic.

There are other difficulties in taking an exclusively moral approach to HIV education. Firstly, this is what tends to perpetuate stigmatisation of HIV+ people. By teaching young people that indulging in ‘immoral’ sex and drugs will lead to HIV infection, educators imply that anyone who is HIV+ is therefore involved in these ‘immoral’ activities. This stigmatisation tends to make people reluctant to be tested for HIV, and therefore more inclined to remain ignorant of their status – and perhaps go on to infect others. AIDS education shouldn’t ever include a moral judgement – it is one thing to teach young people that promiscuous sex and intravenous drug use are unsafe, another thing to teach them that these things are morally wrong.

AIDS education shouldn’t ever include a moral judgement – it is one thing to teach young people that promiscuous sex and intravenous drug use are unsafe, another thing to teach them that these things are morally wrong.

Many AIDS educators around the world are disturbed at this growing trend of providing AIDS education from a moralistic perspective, and argue that AIDS education ought to be non-judgemental, making young people aware of how HIV can be transmitted and how they can avoid becoming infected - without passing moral judgement on those who engage in infection-related behaviours, whether they do so safely or not.

The opposing, more conservative viewpoint, however, argues that young people shouldn’t be taught about sexual health and drug-related dangers at all. They feel that teaching them about these things, even teaching about their dangers, may encourage young people to indulge in these risk behaviours. Research suggests that this is not the case at all, and certainly young people themselves tend to be very enthusiastic about the fact that they need sex and sexual health education. Unfortunately, curriculum planners tend not to listen to the young people who will be their students. This viewpoint can result in no AIDS education at all being offered.
“I did not go to school and learn about the civil war and decide to start a civil war, nor would I have had sex because of a class in school.”by a student.

However, many young people become sexually active long before adults would prefer them to do so, or expect them to do, and teens are not all ‘innocent ‘. Quite simply, if teens are having sex, they need sexual health information. Fortunately, many curriculum planners and legislators have recognised this, and provide young people in many countries with abstinence-plus or comprehensive sex & HIV education. A more detailed look at the results of such curriculum in the classroom can be found in our Teaching AIDS in schools page.

Different approaches to AIDS education for young people

Most countries in the world offer teens some sort of sexual health and HIV education in their schools at some stage. AIDS education can also be targeted at young people in non-school environments – through their peers, through the media, and through doctors or their parents. In some countries, individual schools are allowed to determine what AIDS education they will offer. In other countries, this is determined by legislation passed by central government. And in other countries – especially poor ones that are severely affected by HIV – AIDS education is imported by foreign governments, charities and NGOs, that come in to the country and deliver AIDS education as part of a larger package of HIV prevention work.

AIDS education for young people today falls generally into one of two categories: either 'abstinence-only', or 'comprehensive'. These are actually types of sex education, rather than AIDS education specifically - AIDS education in many schools comes as a part of a sex education program, if it occurs at all. The type of AIDS education program that is offered usually depends on the attitudes of those who determine the syllabus content. Right-wing organisations, some religious organisations, and the family-values lobby tend to prefer abstinence-only education, while those who feel that preventing young people from becoming infected with HIV is more important than keeping them ignorant about sexual behaviour prefer comprehensive AIDS education.

A report found that over 80% of abstinence-only curricula contained false or misleading information

Abstinence-only education teaches students that they must say no to sexual activity until they are married. This approach does not teach students anything about how to protect themselves from STDs or HIV, how pregnancy occurs or how to prevent it, and teaches about homosexuality and masturbation only as far as to say that they are wrong. Those who favour this method of education claim that teaching young people about sex will make them want to try it, thus increasing their risk of contracting HIV, amongst other things.

Abstinence-only education is popular in America, especially so now that it has a Republican President. A House of Representatives report at the end of 2004 found that over 80% of abstinence-only curricula contained false or misleading information. 2 This is not only a concern for those living in America, but increasingly for the rest of the world, as America exports its HIV-prevention and education attitudes to countries with much higher levels of HIV infection. This is particularly worrying in that abstinence-only programmes have been shown not only to fail to reduce the numbers of sexually transmitted infections and unplanned pregnancies seen in pupils, but recent studies indicate that they might actually be related to an increase in these problems.

Comprehensive AIDS education teaches about sexual abstinence until marriage, and teaches that it is one way of protecting yourself from HIV transmission, STIs and unwanted pregnancy. It also teaches that there are other ways of preventing these things, such as condom use. People who favour this approach take the perspective that, while abstaining from sex until marriage is a good idea and should possibly be encouraged, there will always be some young people that do not choose to abstain – and these people must be provided with information that enables them to protect themselves. This type of education also teaches not only about the dangers of drug use, but also about methods of HIV-prevention that drug users can employ – the use of clean needles, for example.

Abstinence-only and comprehensive AIDS education have been combined to produce abstinence-plus education. This type of education focuses on sexual abstinence until marriage as the preferred method of protection, but also provides information about contraception, sexuality and disease prevention. Many abstinence-only campaigners complain that abstinence-plus and comprehensive education are the same thing, although abstinence-plus educators claim that this type of course contains more focus on sexual abstinence until marriage.

There has been debate for many years over which form of sex education is most effective in terms of preventing underage sex, unwanted pregnancy and STD and HIV transmission, although most studies seem to show that comprehensive sex and AIDS education is at least as effective as abstinence-only – and probably more so. However, currently the trend in America – and which is being exported to much of the developing world – is towards abstinence-only education. If it is as unsuccessful as studies indicate it to be, then we can expect this morality-induced type of education to become responsible for an increase in HIV figures amongst the young, especially in high-prevalence parts of the world to which America has taken its methods.

Fifteen percent of Americans believe that schools should teach only about abstinence from sexual intercourse and should provide information on how to obtain and use condoms and other contraception. Forty-six percent believe that the most appropriate approach is abstinence-plus 3. Almost half of those surveyed felt that the word ‘abstinence’ included not only sexual intercourse, but ‘passionate kissing’ and ‘masturbation’, too.

What types of AIDS education can be offered outside schools?

Not all young people are fortunate enough to attend school. This might be for one of a variety of reasons. In some countries, it is necessary to pay for schooling, and poor families may be unable to afford to send a child to school, or may be unable to send all their children to school. Sometimes children will be required to work, making them unavailable for school. In other areas, young people may live in areas where a local school is not accessible. In some situations, young people may have been excluded from school for reasons that might be due to the young person’s behaviour, academic or intellectual abilities, or due to discrimination. Some young people play truant, and will have only very limited attendance. The proportion of young people who attend school differs markedly in various parts of the world.

Clearly, although AIDS education offered through the school might reach many young people, it will not reach all, and other forms of education are required.

One of these is the media. Most young people will, at some time, be exposed to the media. This can include newspapers, television, books, radio, and also traditional media such as street performances or murals. One advantage of media-based AIDS education is that it can target specific groups amongst the population. If the message is to be targeted at young people, then it will be placed in media that are favoured by this audience.

Many countries have tried some form of AIDS education advertisements, films, or announcements. A good example of this is the LoveLife campaign in South Africa, an education program ‘by young people, for young people’. LoveLife used eye-catching posters and billboards to tell young people that sex was fun, but that it could be dangerous, too. The campaign also inserted its message into TV soaps that were popular with young people, and used rap and kwaito music to get its message across.

There are, however, problems with media-based campaigns. It is hard to know to what extent the AIDS information has reached young people, and it is difficult to gain continued funding for initiatives whose success is so hard to measure.

Another way in which young people receive information about sex and HIV is through their peers. This is something that happens anyway to a great extent – many young people receive their first information about sexuality from their friends, although this information is often distorted and inaccurate. This type of peer education can be harnessed, though, and used to convey accurate, targeted information. Peer education is, quite simply, the process by which a group is given information by one of their peers who has received training and accurate information. This is a method often used with groups which have been marginalised. Such groups might have cause to distrust information given to them by an authority figure; if the same information comes from a member of their own group, however, they may well listen. This method of information-provision is often used with such groups as sex workers, the homeless, or drug-users. There is no reason that this method shouldn’t be used with young people, however, and in many parts of the world, it is used. Indeed, it is particularly appropriate for young people who do not attend schools and will not have an opportunity to benefit from an AIDS education curriculum.

AIDS education for the future

Although the debate continues about how much – if any – AIDS education young people should receive, studies continue to show that being informed about the facts and the dangers of HIV and AIDS enables young people to protect themselves and is a crucial tool in the battle against HIV. There is no cure or vaccine for HIV, so prevention is the only way in which we can place any limits on the epidemic. One of the most economical and effective means of HIV prevention is education – involving young people themselves in the HIV prevention effort.

On a global level, America’s disposition towards the promotion of abstinence-only education is cause for concern. America’s spending on HIV prevention around the world exceeds that of any other country, and is to be welcomed – as long as it doesn’t use this money to promote its pro-abstinence-only views of AIDS education. These views – which have been shown to be less successful than comprehensive AIDS education techniques which include an abstinence element – may prove to be damaging to America’s domestic AIDS prevention work 4. When exported to high-prevalence countries in Africa, they could prove disastrous.

Whenever educators and planners ask, and listen to young people, they are told time and time again that young people overwhelmingly ask for adequate AIDS education. In most parts of the world, this means more AIDS education than they are presently getting. Young people know that they have the right to the information that enables them to safeguard their lives and those of their sexual partners – they must be listened to, and provided with that information clearly, openly and honestly.
Sex education in India:

In India, there is a discrepancy between the large amount of effort invested in HIV/AIDS curriculums and training packages on a national level and the lack of actual education being carried out in many schools. In the states of the country where there is a relatively low prevalence of HIV, officials have been reluctant to encourage AIDS education, claiming that the problem is not significant enough in these areas to warrant a widespread educational response. In reality, it is crucially important that young people learn about AIDS in areas with a low prevalence so that the prevalence stays low.

Where AIDS education is carried out in India it is incorporated into science lessons, with students being taught purely about the biological aspects of the subject. This approach has advantages, in that it is more adaptable to teachers who have not received any training to teach about AIDS and avoids the cultural and religious barriers that make it difficult for teachers to talk about sex in the classroom. At the same time, most experts agree that programmes that address the social side of HIV and AIDS are more effective than purely scientific approaches, which can make it difficult for students to appreciate the ‘human’ side of the topic.

In many districts of India, the topics of HIV and AIDS have been integrated into existing adolescence education curriculums, rather than being treated as stand-alone subjects. This approach has generally been successful; as one government official stated, even when school curriculums are overburdened it is always possible to adapt existing subjects to include information about AIDS:
“ If you have a glass of water, you cannot add any more water to it. But you can add more salt, sugar and colour to the glass. In the same way, no more extra curriculum should be added to school education, but existing subjects can be modified to add in HIV/AIDS.”

In 2007, India's examination board is planning to introduce HIV/AIDS education in nurseries and schools. Children as young as five will be taught about HIV and AIDS, as well as drugs and hygiene and nutrition, in an appropriate manner. This is a major step forward, and could make a huge difference to the situation.

LESSONS & ACTIVITY PLANS:

This group of pages describes a number of activities that can be used to educate young people about HIV infection and AIDS. The activities are designed for use with groups of young people and aim to be effective by involving young people. The activities are suitable for use with a wide range of young people. They may be adapted slightly for younger and older age groups.

There are four basic types of activity

HIV and AIDS - the facts

HIV and AIDS - transmission

Attitudes to HIV and AIDS

Focusing on sex and HIV

The greatest benefit will be obtained by combining activities in a short programme over a number of lessons. How you combine activities will depend on your experience and your group, as well as on the time available.
A basic programme with only limited time might consist of:

The AIDS Quiz (Facts)

Trans. Runaround (Transmission)

Ten Differences (Attitudes)

A slightly more comprehensive programme might consist of:

Lesson 1 Three Statements about AIDS (Facts)

Lesson 2 Ten Differences (Attitudes)

Lesson 3 Talking About Sex (Sex)

Lesson 4 Trans. Runaround (Transmission)

Finally, a very comprehensive programme might consist of:

Lesson 1 The AIDS Quiz (Facts)

Lesson 2 Talking About Prejudice (Attitudes)

Lesson 3 Trans. Runaround (Transmission)

Lesson 4 Condom Leaflet (Facts)

Lesson 5 Negotiating Sex (Sex)

Getting started:

In order to get the most out of these activities you might need to think about the context in which you will be working on HIV/AIDS, and also about working with groups, and some further information to help you with this is provided

Before you start work on HIV/AIDS

HIV/AIDS is a potentially sensitive subject and discussion about it can provoke strong views as well as highlighting the need for additional information. People working with young people need to be aware of the legal and cultural context in which they operate and how it might support their plans and affect young people.
Check out your own attitudes and values;
Check out your knowledge;
Check out what institutional, local or national policies and laws offer guidance and affect teaching around

HIV/AIDS

Check out what support or expertise there is within your institution or locality
Reflect on the local culture and community attitudes towards HIV/AIDS and how that will affect what you aim to achieve and do.

HIV/AIDS.

Starting HIV/AIDS work with groups

Effective teaching and learning involves open discussion, interaction between teachers and learners, and critical evaluation of points of view as well as the acquisition of new knowledge. In order to engage with groups in this kind of learning and on a potentially sensitive subject like HIV/AIDS, you need to think about how to make the group a safe place for you and young people to talk and interact together. You can think about the following:
Advantages and disadvantages of working in single-sex and mixed sex groups;
Agreeing ground rules with a group on confidentiality, behaviour, challenging and disagreeing with others, asking personal questions and so on;
Check out what institutional, local or national policies and laws offer guidance and affect teaching around

HIV/AIDS
Deciding if young people will be able to opt-out of activities if they want to

Looking Back On The Programme

However a session or programme went it can be helpful to reflect on it to see what you can learn for future work and about your own skills.

It can be helpful to get feedback from the group. One way of doing this is to provide some sheets of paper on which young people can write one of the following before they leave the room:
Something that I've learnt
Something that I've enjoyed
Something that could have been better.
You can also reflect on your own experience, and it can be helpful to use the following questions
Did everyone seem to understand what was going on and the information that was made available?
Did anyone find the exercise upsetting or offensive? What can be done to avoid this?
Which group members seemed most at ease, and why?
Did anyone ask a question you had difficulty answering?

Notes:
Legislation regarding which types of sexual health education should be given to young people differs around the world. You should ensure that this material is used appropriately with regard to the age of the learners and both legal and curriculum requirements. We have taken all possible care in preparing these resources and we cannot be held responsible for any inaccuracies or errors of fact contained within them, or for their use with learners for whom their content is inappropriate

WHY IS IT NECESSARY

This page describes two activities, Three Statements about AIDS, and the AIDS Quiz. Both of these focus on the facts about HIV and AIDS.
Three Statements about AIDS

Aims

To distinguish between facts and misinformation about HIV and AIDS.

WHAT YOU DO:

Hand out 3 small pieces of paper to each group member and ask them to write on each one some statement they have heard about HIV or AIDS (this need not be something they agree with).
Collect in the small pieces of paper and deal them out at random.
Divide the group members into two roughly equal groups.
Distribute a large sheet of paper to each group with headings 'AGREE', 'DISAGREE' and 'DON'T KNOW' on it. Ask group members to sort their small pieces of paper into each of these columns, reaching agreement on where each statement should be placed.
When they have done this (about 20 minutes probably), both groups should be asked to justify their decisions to the main group as a whole. So group members must be prepared to say why they made the choices they did.
Facilitate a discussion of the scientific, medical and social issues raised by the statements and where they are placed.

Likely outcomes

By having to defend the decisions made, the group will have a chance to begin to distinguish facts from prejudice and misinformation. Your own interventions will help consolidate understanding.

The AIDS Quiz

1. Does HIV only affect gay people?

Yes
No
Only gay men
Only gay women

2. Approx. how many people are infected with HIV world wide?

3.5 million
25 million
40 million

3. How can you tell if somebody has HIV or AIDS?
Because of the way they act
They look tired and ill
You cannot tell

4. Can you get AIDS from sharing the cup of an infected person?
No
Yes
Only if you don't wash the cup.

5. Which protects you most against HIV infection?
Contraceptive Pills
Condoms
Spermicide Jelly

6. What are the specific symptoms of AIDS?
A rash from head to toe
You look tired and ill.
There are no specific symptoms of AIDS

7. HIV is a…
Virus
Bacteria
Fungus

8. Can insects transmit HIV?
Yes
No
Only mosquitoes

9. Is there a cure for AIDS?
Yes
Only available on prescription
No

10. When is World AIDS Day held?
1st January
1st June
1st December

11. Is there a difference between HIV and AIDS?
Yes
No
Not very much

12. Approximately what percentage of those infected with HIV are women?
19%
50%
74%

13. Worldwide, what is the age range most infected with HIV?
0-13 years old
14-24 years old
25-34 years old

14. Is it possible to prevent a women infected with HIV from having an infected baby?
Yes
No
Only is she takes a special drug

15. Are extra large condoms....
Wider
Longer
Both

Quiz Questions Answer Sheet
1 No
2 40 million
3 You cannot tell
4 No
5 Condoms
6 There are no specific symptons of AIDS
7 Virus
8 No
9 No
10 1st December
11 Yes
12 50%
13 14-24 years old
14 Only if she takes a special drug
15 Both

This page describes two activities, Transmission Runaround, and Condom Leaflet, which help group members to learn about the transmission of HIV

Transmission Runaround

You can get HIV from toilet seats.
If you are fit and healthy you won't become infected with HIV.

Married people don't become infected with HIV.
If you stick with one partner you won't become infected with HIV.

Women are safe from HIV as long as they use a contraceptive.

You can become infected with HIV from sharing toothbrushes.

If you have sex with people who look healthy, you won't become infected with HIV.

If you only have sex with people you know, you won't become infected with HIV.

Anal sex between two men is more risky than anal sex between a man and a woman.

You can become infected with HIV from kissing.

A man can become infected with HIV if he has oral sex with a woman.

A woman can become infected with HIV if she has oral sex with a man.

Condoms can stop you becoming infected with HIV.

True/False Answer Sheet
Sleeping around is not in itself risky, but having unprotected sex with an infected person is.

By using condoms properly and by avoiding sex with penetration, you can substantially reduce the risk of infection.

Only if the needle or syringe previously has been contaminated with HIV.

There are no known cases of HIV infection via toilet seats.

It does not matter how healthy or unhealthy you are, if you engage in risky activities you stand a chance of being infected.

This depends on the partners involved, what they did before they met, whether either has unprotected sex outside of the marriage or injects drugs using contaminated equipment. Marriage by itself offers no guarantees of safety.

Only condoms offer women protection against HIV, and even condoms cannot offer complete safety. Other forms of contraception do not offer protection from HIV.

There is no evidence of transmission via this route, but it is sensible not to share toothbrushes for general health reasons.

Most people with HIV will look perfectly healthy. Looks are therefore a useless way of assessing risk.

Knowing someone well offers no reliable guide to whether or not they have HIV infection.

Anal sex is equally risky regardless of whether it takes place between two men or a man and a woman.

There is no evidence of transmission in this way, although kissing when there are sores or cuts in the mouth may pose some risk.

HIV is present in cervical and vaginal secretions as well as in (menstrual) blood, so there is the possibility of transmission this way.

HIV is present in semen so there is a possibility of transmission in this way.

Condoms used properly will help to prevent transmission of HIV from an infected partner to an uninfected partner. Condoms are not 100% safe though. Use a lubricant which is water based, as oil based lubricants can weaken the condom. When buying condoms check the 'sell by' date.

HIV / AIDS AND SCHOOL

Across the world, schools play a major role in shaping the attitudes, opinions and (perhaps most importantly) the behaviour of young people. Today’s generation of school children have been born into a world where AIDS is a harsh, unavoidable reality - a situation that their time at school can help them to prepare for. As well as providing an environment in which people can be educated about AIDS, schools often act as a centre-point for community discussion and activity; as such, they can be a vital tool in monitoring the epidemic and co-ordinating a response to it. With a capacity to reach large numbers of young people with information that can save their lives, basic school education can have such a powerful preventive effect that it has been described as a ‘social vaccine’.

At the same time, efforts to educate young people in developing countries are being hampered by the epidemic itself. Pupils and teachers are falling ill, taking time off to care for family members and, in many cases, dying as a result of AIDS. This page explores these problems and the other effects that AIDS is having on schools, as well as the ways in which schools can be used to reduce the impact of the epidemic.

The effect of AIDS on schools:

AIDS is one of the most serious challenges currently facing the education systems of poorer countries. As the diagram below shows, the damaging effect that AIDS is having on schools is, in turn, aggravating the epidemic itself in a vicious cycle:

“ Without education, AIDS will continue its rampant spread. With AIDS out of control, education will be out of reach. ”

The most obvious way in which AIDS can affect a pupil is where the individual concerned is living with HIV, but a child’s education is also likely to be seriously disrupted if one or more of their family members are infected. In many of the areas that have been hit hardest by AIDS, the majority of children are likely to be ‘affected’ by the epidemic, in that they probably have close friends or relatives who are living with HIV or have died from AIDS. In such areas, it is likely that some children will take time off school to care for others living with HIV, or to take care of household duties that those people would otherwise have done.

AIDS orphans:

Worldwide, 15.2 million children had been orphaned as a result of AIDS by the end of 2005. Upon the death of their parents, a child may be forced to move house and/or be affected by emotional stress and poverty, which can disrupt their education and lead them to drop out of school. If they have younger siblings, they may also be forced to leave school to look after them and act as the head of the household. Studies have shown that orphans in sub-Saharan Africa are 13% less likely to attend school than non-orphans.

The prospects of children who have been orphaned by AIDS are often further dampened by compulsory school fees, which must still be paid in the majority of poor countries. These fees are simply not affordable for most AIDS orphans or those who care for them, and often extended families that care for orphans see school fees as a major factor in deciding not to take on additional children orphaned by AIDS.

It is not only pupils that are affected by the epidemic. Teachers, many of whom are part of an older generation that did not receive AIDS education in their younger years, are also highly susceptible to HIV infection in many countries. For example, in Zimbabwe one study found that 19% of male teachers and close to 29% of female teachers were HIV positive. As in many other countries, teachers are in short supply in Zimbabwe. In rural areas of the country in particular, schools often depend upon a small number of teachers; if one is ill, or taking time off to care for family members or attend to funerals as a result of AIDS, it can seriously disrupt classes.

Other adult members of staff can be affected too. Schools depend on a variety of individuals, from pupils and teachers to cleaners and support staff; if anyone involved with the school is affected by AIDS then this is likely to have repercussions for the ability of that school to function.
The role of schools in the fight against AIDS

The devastating effect that AIDS is having on schools should be one of the biggest concerns to those involved in fighting the epidemic, not least because schools provide one of the most cost-effective and efficient ways of reaching young people. While the education sector is seriously threatened by AIDS, it is also an invaluable tool in the fight to establish an environment where people living with HIV are well-supported and new infections are prevented.

Providing education to young people and others:

A mural painted by school children near Lesotho, South Africa
Young people are more likely to be affected by HIV and AIDS than any other age group, but they are also more likely to change their behaviour as a result of education than any other group. At a time when, globally, more children are in school than ever before, it is therefore vitally important that countries invest in schools as a means of informing young people about how they can avoid HIV and AIDS before it is too late. Studies have shown that the HIV prevalence of an area is likely to decrease as education increases, that primary education can half the risk of infection amongst young people and that reduced vulnerability to HIV is observed in people with secondary or higher education. Schooling increases earning power, self-confidence and social status, allowing young people to take greater control over their sexual choices.

Through education, schools can also help to reduce stigma and discrimination – a major problem for people around the world who are living with HIV, which, as well as being distressing for those people themselves, has created a situation where others who may be infected are sometimes reluctant to be tested or access treatment for fear of prejudice. Education in general is likely to encourage a more respectful, open-minded attitude towards other people; in the case of HIV/AIDS education, giving pupils a greater understanding of the epidemic can help them to realise that AIDS can affect anyone, and that no-one has the right to judge an individual on the basis of their HIV status.

It is not just pupils that are educated through schools, though - members of the wider community, including teachers, cleaners, other members of staff and parents, can also increase their knowledge about HIV and AIDS by means of the school environment. Teachers who expand their understanding of the subject while researching for a lesson can pass this information on to adults as well as pupils, and the same can be said for the children themselves; once informed about AIDS, they can go home and tell their parents or their friends what they have learnt. If there are HIV positive children at the school, the adults connected to that school are also likely to learn more about HIV and AIDS through the school’s efforts to support those children.

Schools and the wider community
As a place where friendships are formed and bonds are established between teachers, pupils and parents, schools have always been more than just places where education takes place. They are often the focal-point of local community activity, especially in rural areas. This gives them enormous potential to act as the base from which local responses to the AIDS epidemic can be co-ordinated and strengthened. Unfortunately, in many developing countries schools do not have the staff, resources, or finances to effectively harness this potential.

One school that AVERT has worked with in rural South Africa is as an example of how schools can serve as more than just educational outlets. Here, an after school club has been set up where pupils who are severely affected by HIV are kept behind after normal classroom hours to do their homework, but in addition are offered food and support that they do not receive at home. At this particular school, around a quarter of the pupils are directly affected by HIV – that is, they are either living with HIV themselves, have lost parents to AIDS or have a family member who is affected. Still, when asked what she thought was the biggest problem facing the school the headmistress pointed to the leaking roofs, cracks in the walls of classrooms and a lack of books – evidence that schools in developing countries are suffering from numerous problems besides AIDS.

Supporting children who are living with HIV:

Schools can give children who are living with HIV a better understanding of their situation. As well as supporting those children themselves, schools can also provide assistance to the families that are caring for them. This is particularly important in countries where large numbers of children are living with HIV. Through education, HIV positive children can learn to stand up for their rights and challenge discrimination. They can also be encouraged to access treatment where available.

Reducing the vulnerability of girls:
More than 113 million school-age children in developing countries do not attend school, two thirds of whom are girls. In many countries, traditional gender roles grant men greater economic and social power than women, and for some parents the education of their daughters is not seen as a priority. This poses a huge problem, because female subordination allows a situation where young women cannot encourage the use of condoms and may be coerced into sex with older men, which can lead them into situations where HIV is more likely to be transmitted.

Schools can help to reduce the vulnerability of girls to HIV and AIDS by empowering them with knowledge. Education can contribute to female economic independence, delayed marriage, and family planning. Several studies have demonstrated the fact that education can protect women from HIV; for example, a study in Zambia showed that young women with a secondary education were less likely to be HIV-positive than those who had not received a secondary education. Another study carried out in Uganda showed that, while infection rates had fallen among all young women, the decline was greatest for women with a secondary education.

Unfortunately, gender inequalities thrive in some schools. Sexual abuse carried out by male pupils and teachers is common in poorer countries, with some teachers taking advantage of their position to coerce schoolgirls into sex, often in exchange for food or good exam results. By acting in this way, those teachers not only create a situation where HIV transmission can occur but also undermine the very messages that they are supposed to be teaching to pupils about safe sex and a woman’s right to enforce condom use. Sexual abuse of this kind is also likely to discourage girls from attending school, which will damage their education and possibly prevent them from learning how to protect themselves against HIV infection.

AIDS education in schools worldwide: some case studies:

There is no single model of school-based HIV/AIDS education that is appropriate to every country. Different situations call for different responses; a typical developed country programme that emphasises the importance of individual responsibility may be thoroughly inappropriate in a developing country where social interdependence is key to survival and personal choice is limited by poverty. What is universally clear, though, is that schools are in a position to change young people’s attitudes and behaviour, and that where this potential is harnessed successfully the impact of the AIDS epidemic can be significantly reduced. The following are some interesting examples of different national responses to HIV and AIDS education and the concerns that have surrounded the subject in different countries.

Kenya:

Kenya has witnessed a declining HIV prevalence in recent years, partly helped by increased efforts to provide AIDS education in schools. A weekly compulsory HIV/AIDS lesson has been inserted into all primary and secondary state curriculums, and on top of this AIDS education has been integrated into all subjects at school – a strategy that has been widely commended. At the same time, AIDS education in Kenya still faces numerous problems. A recent survey carried out by the Kenya National Union of Teachers (KNUT) showed that Kenyan teachers are not generally well prepared for lessons and that many are not well informed about the subject. Only 45% of the teachers surveyed understood that HIV had no cure, whereas 24.4% and 12.4% respectively thought that herbs and traditional medicines as well as witchdoctors could cure infection. More positively, the study found that Kenyan pupils were generally happy to learn about HIV and AIDS: at least 55.7% of students had a positive attitude towards the topic, with only 14.4% displaying a negative response.

AIDS education in Kenya is based around a ‘life skills’ approach – that is, an approach that focuses on relationship issues and the social side of HIV, as well as simply the scientific facts about infection. But since Kenyan teachers are more used to teaching subjects in a factual, academic fashion, many find it difficult to address the topic in a way that is relevant to the social realities of student’s lives. With school education in Kenya very much focused on examinations, teachers are used to inundating students with facts and figures, whereas AIDS education requires that they engage pupils in active learning sessions.

HIV positive teachers in Kenya have also reported that school administrators and other members of staff have failed to support them, and that they have often faced discrimination. HIV positive teachers are less likely to get promoted than those who are not infected, and many claim that they do not feel secure in their job

Uganda:

As with Kenya, the Ugandan government has put a lot of effort into AIDS education and this seems to have paid off in the form of a falling national HIV prevalence. In 2001, The Presidential Initiative on AIDS Strategy for Communicating to Young People (PIASCY) was launched – the country’s first national AIDS curriculum for primary schools. Under this programme, primary schools are required to hold weekly assemblies about HIV and AIDS and a set of teachers manuals have been distributed to give guidance on teaching the subject. Similar initiatives have been carried out in colleges and universities, although it has been reported that AIDS education in secondary schools is virtually non-existent. A lack of knowledge among teachers is also a problem, as teacher training initiatives have not been included in the government’s strategy. Difas Munywa, a member of the Uganda National Teachers’ Union, argues that even in primary schools, AIDS education is still not visible enough:
“ PIASCY requires only that we hold a weekly assembly to pass on information about HIV/AIDS to pupils. That is what we do… we now need a more comprehensive strategy. We would feel more comfortable if we had more HIV/AIDS training. Except in large assemblies, teachers fear to talk about HIV/AIDS because pupils may ask difficult questions. ”

AROUND THE WORLD

When AIDS first emerged, no-one could have predicted how the epidemic would spread across the world and how many millions of lives it would change. There was no real idea what caused it and consequently no real idea how to protect against it.

Now we know from bitter experience that AIDS is caused by the virus HIV, and that it can devastate families, communities and whole continents. We have seen the epidemic knock decades off countries' national development, widen the gulf between rich and poor nations and push already-stigmatized groups closer to the margins of society. We are living in an 'international' society, and HIV has become the first truly 'international' epidemic, easily crossing oceans and borders.

Just as clearly, experience shows that the right approaches, applied quickly enough with courage and resolve, can and do result in lower national HIV infection rates and less suffering for those affected by the epidemic.

Globally, we have learned that if a country acts early enough, a national HIV crisis can be averted.

It has also been noted that a country with a very high HIV prevalence rate will often see this rate eventually stabilise, and even decline. In some cases this indicates, among other things, that people are beginning to change risky behaviour patterns, because they have seen and known people who have been killed by AIDS. Fear is the worst and last way of changing people's behaviour and by the time this happens it is usually too late to save a huge number of that country's population.

Already, more than twenty-five million people around the world have died of AIDS-related diseases. In 2006, around 2.9 million men, women and children lost their lives. Many more than have died so far - 39.5 million - are now living with HIV, and most of these are likely to die over the next decade or so. The most recent UNAIDS / WHO estimates show that, in 2006 alone, 4.3 million people were newly infected with HIV.

It is disappointing that the global numbers of people infected with HIV continue to rise, despite the fact that effective prevention strategies already exist.

AFRICA
It is in Africa, in some of the poorest countries in the world, that the impact of the virus has been most severe. At the end of 2005, there were 10 countries in Africa where more than one tenth of the adult population aged 13-45 was infected with HIV. In four countries, all in the southern cone of the continent, at least one adult in five is living with the virus. In Botswana, a shocking 24.1% of adults are now infected with HIV, while in South Africa, 18.8% are infected. With a total of around 5.5 million infected, South Africa has more people living with HIV than any other country except India.

A first step in publicly admitting the AIDS crisis,

Rates of HIV infection are still increasing in many countries in sub-Saharan Africa, and an estimated 2.8 million people in this region became newly infected in 2006. This means that there are now an estimated 24.7 million people living with HIV/AIDS. In this part of the world, particularly, women are disproportionately at risk. As the rate of HIV infection in the general population rises, the same patterns of sexual risk result in more new infections simply because the chances of encountering an infected partner become higher.

Whilst West Africa is relatively less affected by HIV infection, the prevalence rates in some large countries are creeping up. Côte d'Ivoire is already among the twelve worst affected countries in the world, and in Nigeria nearly 4% of adults have HIV. In West Africa the epidemic displays a diversity not seen to such an extent in other parts of the continent. National prevalence rates can remain low, while infection rates in certain populations can be very high indeed.

Infection rates in East Africa, once the highest on the continent, hover above those in the West but have been exceeded by the rates now seen in the southern cone. In 2005, the HIV prevalence rate among adults in Kenya, Tanzania and Uganda exceeded 6%.

Increasing prevalence rates are not inevitable. In Uganda the estimated prevalence rate fell to around 5% from a peak of about 15% in the early 1990s. This trend is thought in part to have resulted from strong prevention campaigns, and there are encouraging signs of the same effect happening in parts of Zambia, Kenya and Zimbabwe. Yet the suffering generated by HIV infections acquired years ago continues to grow, and a drop in HIV prevalence is generally associated with a massive number of AIDS deaths. Barely one in four Africans in need of antiretroviral treatment were receiving it at the end of 2006.

ASIA

The diversity of the AIDS epidemic is even greater in Asia than in Africa. The epidemic here appears to be of more recent origin, and many Asian countries lack accurate systems for monitoring the spread of HIV. Half of the world's population lives in Asia, so even small differences in the infection rates can mean huge increases in the absolute number of people infected.

Around 960,000 Asians acquired HIV in 2006, bringing the number living with HIV to an estimated 8.5 million. A further 630,000 Asians are estimated to have died of AIDS in 2006.

National adult prevalence is still under 1% in the majority of this region's countries. However some of the countries in this region are very large and national averages may obscure serious epidemics in some smaller provinces and states. Although national adult HIV prevalence in India, for example, is below 1%, some states have an estimated prevalence well above this level. India has around 5.7 million people living with HIV - more than any other country in the world. Other large epidemics are present in China (650,000), Thailand (580,000) and Myanmar (360,000).

In most Asian countries the epidemic is centred among particular high-risk groups, particularly men who have sex with men, injecting drug users, sex workers and their partners. However the epidemic has already begun to spread beyond these groups into the general population. Some Asian countries, such as Thailand, have responded rapidly to the epidemic with extensive campaigns to educate the public and prevent the spread of HIV – and have succeeded in cutting prevalence. Other very populous regions, such as China, have only recently admitted that the spread of HIV threatens their populations, and as a result their prevention work is lagging behind the spread of the virus. Unless rapid and effective action is taken in this part of the world, then the size of the epidemic to come will dwarf the many deaths that have already occurred.

The epidemic in Asia has ample room for growth. The sex trade and the use of illicit drugs are extensive, and so are migration and mobility within and across borders. The fluidity in international markets and especially the lack of economic stability in Asia has erupted into non-stop movement within countries and among countries, mirrored in the growing prevalence of HIV. India, China, Thailand and Cambodia, to name only a few, have highly mobile populations within their borders, with people moving from state to state and from rural to urban areas. In China, permanent and temporary migrants may total as many as 120 million people.

Eastern Europe & Central Asia:

The AIDS epidemic in Eastern Europe & Central Asia is rapidly increasing. In 2006, some 270,000 people were newly infected with HIV, bringing the total number of people living with the virus to around 1.7 million, compared to 1.4 million in 2004. AIDS claimed an estimated 84,000 lives during 2006, which is nearly twice as many as in 2004. Eastern Europe is home to the fastest growing arm of the global HIV epidemic.

In any country where many people inject drugs and share needles, a fresh outbreak of HIV is liable to occur at any time. This is especially true of the countries in Eastern Europe where the HIV epidemics are still young and have so far spared some cities and sub-populations. The route of heroin smuggled into the West crosses through a number of Eastern European countries, and its path is marked by a high concentration of injecting drug users, and a high HIV prevalence.

Worst affected are the Russian Federation, Ukraine, and the Baltic states (Estonia, Latvia, and Lithuania), but HIV continues to spread in Belarus, Moldova and Kazakhstan, and more recent epidemics are now evident in Kyrgyzstan and Uzbekistan. It is estimated that around 940,000 people were living with HIV in the Russian Federation at the end of 2005, but reporting of HIV cases is at best patchy in many areas, so it is difficult to determine a precise figure. The epidemic in Eastern Europe is primarily driven by injecting drug use, and the criminalisation of this practise makes it difficult to gain an accurate picture of the proportion of drug users who are living with HIV.

CARIBBEAN

HIV is ravaging the populations of several Caribbean island states. Indeed some have worse epidemics than any other country in the world outside sub-Saharan Africa. In the most affected countries of the Caribbean, the spread of HIV infection is driven by unprotected sex between men and women, although infections associated with injecting drug use are common in some places, such as Puerto Rico.

Haiti, where the spread of HIV may well have been fuelled by decades of poor governance and conflict, is the worst affected nation in the region. An estimated 3.8% of Haitian adults were living with HIV at the end of 2005, though rates vary considerably between regions. HIV transmission in Haiti is overwhelmingly heterosexual, and both infection and death are concentrated in young adults. Many tens of thousands of Haitian children have lost one or both of their parents to AIDS. Among pregnant women in urban areas, HIV prevalence appears to have fallen by half between the mid-1990s and 2003-2004. Probably much of this decline is due to an increase in the AIDS death rate, though behaviour change might also have played a part. There is still an urgent need for intensified prevention efforts in Haiti.

On the Caribbean coast of South America, Suriname and Guyana had adult HIV prevalence rates of 1.9% and 2.4% respectively at the end of 2005. There are only limited data on HIV in Guyana, but it appears the country has a rapidly growing epidemic, which is becoming established within the general population.

The heterosexual epidemics of HIV infection in the Caribbean are driven by the deadly combination of early sexual activity and frequent partner exchange by young people. A study published in 2005 found that in Trinidad and Tobago, HIV infection levels are six times higher among 15-19 year old females than among males of the same age. In another survey in Barbados, one quarter of 15-29 year old women said they had been sexually active by the age of 15, and almost one in three men aged 15-29 years reported multiple sexual partnerships in the previous year.

AIDS is now high on the agendas of many governments in this region, as they are beginning to notice the significant impact of the epidemic on their medical systems and labour force. Cuba's comprehensive testing and prevention programmes have helped to keep its HIV infection rate below 0.2%, and the country provides free AIDS treatment to all those in need. In Barbados and Bermuda, wider access to antiretroviral treatment has cut AIDS deaths in half. Other countries are now seeking to emulate such successes.

LATIN AMERICA

Around 1.7 million people were living with HIV in Latin America at the end of 2006. During that year, around 65,000 people died of AIDS and an estimated 140,000 were newly infected. The HIV epidemics in Latin America are highly diverse, and are fuelled by varying combinations of unsafe sex (both between men, and between men and women) and injecting drug use. In nearly all countries, the highest rates of HIV infection are found among men who have sex with men, and the second highest rates are found among female sex workers.

The Central American nations of Honduras and Belize have well-established epidemics, with adult HIV prevalence rates above 1%. AIDS is the leading cause of death among Honduran women and is believed to be the second-biggest cause of hopitilisation and death overall in the country. In these countries the virus is mainly spread through unprotected sex, particularly commercial sex and sex between men.

Commercial sex and sex between men are the major drivers of smaller epidemics elsewhere in Central America, where national HIV prevalence rates vary between 0.2% and 0.9%. Men who become infected via these routes are likely to pass the virus on to their wives and girlfriends.

Brazil had an adult HIV prevalence rate of 0.5% at the end of 2005, but, because of its large overall population, this country accounts for nearly half of all people living with HIV in Latin America. In Brazil, heterosexual transmission, sex between men and injecting drug use account for roughly equal numbers of infections.

HIV in Argentina was inititally seen as a disease of male injecting drug users and men who have sex with men. But now the virus is spread mostly through heterosexual intercourse, and is affecting a rising number of women. The other Andean countries are currently among those least affected by HIV infection, although risky behaviour has been recorded in many groups.

One of the defining features of the Latin American epidemic is that several populous countries, including Argentina, Brazil and Mexico, are attempting to provide antiretroviral therapy to all those who need it. The governments of these countries have invested and encouraged local pharmaceutical manufacturers to produce generic copies of expensive patented medicines. This allows them to distribute drugs to a much greater proportion of their population that they would otherwise be able to help.

Treatment coverage still varies widely, but these efforts are having a definite impact. While they are improving both the length and the quality of people's lives, they are also increasing the proportion of people living with HIV, and thus HIV prevalence figures. Some concern has been voiced over the risk that HIV prevention activities may suffer if much effort and money is devoted to providing treatment.

High-income countries:
In high-income nations, HIV infections have historically been concentrated principally among injecting drug users and gay men. These groups are still at high risk, but heterosexual intercourse accounts for a growing proportion of cases. In the United States, more than a quarter of people diagnosed with HIV in 2004 were female, and more than three quarters of these women were probably infected as a result of heterosexual sex. In several countries in Western Europe, including the United Kingdom, heterosexual contact is the most frequent cause of newly diagnosed infections.

Very early in the epidemic, once information and services for prevention had been made available to most of the population, the level of unprotected sex fell in many countries and the demand rose for reproductive health services, HIV counselling and testing and other preventive services. However prevention activities are now lagging behind as the epidemics move beyond their traditional at-risk groups.

Prevention work in high-income countries has declined, and sexual-health education in schools is still not universally guaranteed, in spite of the fact that the risks of HIV are well-known to governments. Political factors have been allowed to control the HIV prevention work that is done, and politicians are commonly keen to avoid talking about any sexual issues. Furthermore, it is very hard to show that a number of people are not HIV positive who otherwise would be – and politicians like the electorate to see results.

Among gay men, the virus had spread widely before it was even identified and had established a firm grip on the population by the early 1980s. With massive early prevention campaigns targeted at gay communities, risk behaviour was substantially reduced and the rate of new infections dropped significantly during the mid- and late 1980s. Recent information suggests, however, that risky behaviour may be increasing again in some communities. People think that the danger is over because of lack of media coverage of the issues around HIV and AIDS - and many new infections continue to occur.

Some communities and countries have initiated aggressive HIV prevention efforts, particularly among high-risk groups such as injecting drug users. But in many places the political cost of implementing needle-exchange and other prevention programmes has been considered too high for such programmes to be started or maintained. As a result, there are continuing high prevalence rates among injecting drug-users in many high-income countries, particularly Italy, Spain and Portugal.

Many high-income countries suffer from the belief that HIV is something that effects other people, not their own populations. On a national level, this belief prevents policy-makers and budget-setters from seeing the epidemic on their own door-steps, looking instead to the situation in areas such as Africa. Some high-income countries fund medication provision for low-income countries whilst failing to provide medicines for their own citizens who have AIDS. Even in the US, there are people who are unable to afford to buy the drugs they need.

Where do we go from here?

Spending

Money is finally being spent on both treating the disease and on preventing new infections from occurring. This spending needs to increase both in its magnitude and its effectiveness. Many people fail to realise that actually spending money, in the very large sums the fight against HIV requires, is a difficult task, and one of which many organisations have little experience.

The Global Fund, an organisation created to channel money to where around the world it is most needed, is an already-existing way of effectively spending money. Many governments, however, wish to exert control over how their donations are spent and on what projects, so they prefer to channel their funding through other channels.

Prevention and education

Education has already been proved to be effective and necessary, both for people who are not infected with HIV, to enable them to protect themselves from HIV, and for people who are HIV+, to help them to live with the virus. There is a huge wealth of educational resources available around the world, and yet in many places people still lack the knowledge they need to protect themselves.

AIDS is a preventable disease, but to avoid HIV infection people need more than just factual information. People need empowerment to negotiate safe and responsible sexual relationships; gender inequalities must be confronted; and those who choose to have sex need access to condoms. Needle exchanges should be encouraged, as they have proven highly effective at preventing HIV transmission among injecting drug users.

MEDICATION:

Antiretroviral AIDS medication is now being distributed to low-income, high prevalence countries, but it is taking a long time to actually reach the people who need it. Access to medication must greatly improve if millions of deaths are to be avoided. When the medication finally reaches the areas where it is needed, trained nurses must be available to carry out HIV tests, administer the medicines, and teach people how to use them.

HIV has now finally been recognised as a global threat, and people are beginning to take action to prevent it killing many more millions than those who have already died. This action needs not only to continue, but to be speeded up considerably. The HIV epidemic is growing, and efforts to fight it need to grow at an even greater rate if they are to be successful.

An ever-growing AIDS epidemic is not inevitable. However, unless action against the epidemic is scaled up drastically, the damage already done will seem minor compared with what lies ahead. This may sound dramatic, but it is hard to play down the effects of a disease that stands to kill more than half of the young adults in the countries where it has its firmest hold. Entire families, communities and countries will begin to collapse if this situation is allowed to occur.

IN INDIA

HIV and AIDS affect all segments of India’s population, from children to adults, businessmen to homeless people, female sex workers to housewives, and gay men to heterosexuals. There is no single ‘group’ affected by HIV.

A GENERAL PROBLEM

In contrast to the common perception of HIV as something that only affects injecting drug users and gay men, the overwhelming majority of infections in India occur through heterosexual sex. In large numbers of cases, women in monogamous relationships are becoming infected because their husbands have had multiple sexual partners. Women currently account for 39% of HIV infections in India, and it is thought that this figure is continually rising.

Another significant trend is that most of the people becoming infected are in the sexually active and economically productive 14 to 40 age group. This means that most people living with HIV are in the prime of their working lives. Many are supporting families.

The people living with HIV in India are incredibly diverse, and many would not be considered to be members of ‘high-risk groups’. Nonetheless, it is possible to identify certain populations that face a proportionately greater risk than others. These risk groups include sex workers, injecting drug users, truck drivers, migrant workers and men who have sex with men.

SEX WORKERS--PROSTITUTES

Sex work is very widespread in India, and occurs on a much larger scale than in many other countries. Women often get involved through poverty, marital break-up, or because they are forced into it. Although sex work is not strictly illegal in India, associated activities - such as running a brothel – are. The government has plans to introduce stricter legislation in regard to sex work, a move that has been opposed by organised sex worker groups who claim that such legislation would just push the trade underground and make it harder to regulate. It would also make it more difficult to reach sex workers with information about HIV, at a time when misinformation about AIDS among this group is rife – for instance, one national study suggests that 42% of sex workers believe that they can tell whether a client has HIV on the basis of their physical appearance.

In Mumbai, which has a larger brothel-based sex industry than any other area of India, HIV prevalence among sex workers has not fallen below 44% since 2000.

Another area where sex workers are heavily affected by the epidemic is the city of Mysore, in Karnataka, southern India. Around 26% of sex workers in Mysore are living with HIV – a situation that is unsurprising, given that only 14% of sex workers in the city use condoms consistently with clients, and that 91% never use condoms during sex with their regular partners. In comparison, 80-90% of sex workers in Tamil Nadu state report condom use, which correlates with a relatively low HIV prevalence of 9%.

One way in which authorities are trying to tackle the epidemic among sex workers in Mysore is through a ‘smart card’ scheme. Sex workers are provided with cards that contain their medical details, which must be presented at a health check up at least once every three months to remain valid. On the condition that these appointments are attended, the card can be used to get discounts for food and clothes in certain shops. As well as encouraging sex workers to look after their health, this initiative raises sex worker’s self-esteem by integrating them into mainstream culture. In turn, this can help them to taker a firmer stance on condom use when negotiating with clients.

Another positive initiative – possibly the most successful of its kind in India - has been the Sonagachi project, named after the district of central Kolkata (Calcutta) where it is based. This project was started in 1992, with the aim of reaching out to sex worker communities and helping them to overcome HIV on their own terms. Its approach is based around three R’s: Respect, Reliance and Recognition – respecting sex workers, relying on them to run the program, and recognising their professional and human rights. Sex workers have been trained to act as peer-educators, and sent to brothels to teach others about HIV and AIDS, and the importance of using condoms with clients. The campaign also addresses the social and practical barriers that prevent sex workers from using a condom. Madams and pimps are educated about the economic benefits of enforcing condom use in their brothels, and police have been persuaded to stop raiding brothels, because such raids often resulted in sex workers losing income, making them less likely to insist on condom use.

By helping to put sex workers in a position where they can respond to their own needs, the Sonagachi project has achieved impressive results. Between 1992 and 1995, condom use among sex workers in rose from 27% to 82%. By 2001, it was 86%. 10 The project continues to have an impact, with HIV prevalence among sex workers in the area falling from 11% in 2001 to less than 4% by 2004. 11 The Sonagachi project has become internationally famous for its achievements, and the UN has used the project as a ‘best practice’ model for other sex worker projects around the world.

Injecting drug users

Nationally, HIV prevalence among injecting drug users appears to have declined slightly in recent years, from 13% in 2003 to 10% in 2005. However, transmission through injecting drug use is still a major driving factor in the spread of HIV in India. This is particularly the case in the north-eastern states of India, such as Manipur, where the HIV prevalence among injecting drug users has been consistently high in recent years. Injecting drug use is also a major problem in urban areas outside the north, such as Mumbai, Kolkata and Chennai.

The alarming levels of infection occurring through needle-sharing have implications that extend beyond networks of drug users. Some of those who inject drugs are also sex workers or truck drivers, and many are sexually active, which can result in infection being passed on to their partners. Experts have argued that there needs to be more information aimed at both injecting drug users and their sexual partners.

The Indian government’s approach to drug use is based around law-enforcement and prosecution, with very little done in terms of treating drug users or helping them to stop using drugs. Harm reduction – a method of HIV prevention that has been successful in other countries, which acknowledges that drug use occurs and seeks ways to reduce HIV transmission in this context – has not been adopted in the government’s drug policies. Some states, however, such as Manipur, have adopted their own harm reduction policies and consider that:

“Harm reduction is the urgent, practicable and feasible HIV prevention method among Injecting Drug Users and their sex partners.”

In the majority of Indian states, though, tough regulations on drug users make it hard to reach this group with HIV messages, and to survey how they are being affected by the epidemic.

TRUCK DRIVERS
INDIA-2006
India has one of the largest road networks in the world, involving millions of drivers and helpers. Truck drivers spend long periods of time away from home, and it is common practice for them to have relations with sex workers while on the road. 24-34% of truck drivers in various surveys have reported engaging in sex with commercial sex workers. Sometimes, this occurs at roadside ‘dhabas’, which act as both brothels and hotels for truck drivers. In other cases, drivers stop to pick up women by the side of the road, and transport them to another area after they have had sex with them. Both truck drivers and sex workers move from area to area, often unaware that they are infected with HIV.

”There is no entertainment. It is day-in-day-out driving... When they stop, they drink, dine and have sex with women. Then they transfer HIV from urban to rural settings.“

There have been a number of major HIV/STI prevention projects aimed at truckers, many of which have aimed to promote condom use. Some of these projects include not just truckers, but also other stakeholders such as gas station owners and employees. A specific example from Mumbai is the AIDS Workplace Awareness campaign, which is mandatory and which targets the drivers at the regional transport authority, where the drivers get their licenses renewed annually.

Other campaigns have targeted the wives and partners of truck drivers, who often become infected when their partner returns home after a long absence. Yet as the testimony of one woman in Vijayavada demonstrates, these campaigns do not always manage to reach those at risk:

Truck drivers being handed leaflets on HIV & AIDS prevention in Maharashtra

“My husband is a truck driver and I got HIV through him. I had never heard of HIV or condoms before that and because I can't read, I couldn't understand any of the posters or banners.”

There are signs that some efforts to prevent HIV among truck drivers have been successful. For example, a recent survey of truck drivers in Tamil Nadu - carried out after an HIV prevention program - found that the proportion of drivers who reported engaging in commercial sex declined from 14% in 1996 to 2% in 2003. Of those who did report having commercial sex, the proportion that had not used a condom the last time they did so fell from 45% to 9%. 23

Men who have sex with men

Sex between men is highly stigmatised in India and is not openly talked about, making it easy for people to underestimate how commonly it occurs. Studies have shown that sexual activity between men is relatively common in both urban and rural areas of India, although it is illegal. 24

In India, as elsewhere, many men who have sex with men (MSM) do not consider themselves homosexual, and a large number have female partners. A large study in Andhra Pradesh found that 42% of MSM in the sample were married, that 50% had had sexual relations with a woman within the past three months and that just under half had not used a condom. As such, unprotected sex between men can also present a risk to any women that they may subsequently have sex with.

The stigma surrounding MSM, and the fact that their lifestyles are criminalised, makes it hard for both the government and NGOs to reach them with information about HIV. Outreach workers and peer educators working with MSM have frequently been harassed by police, and in some cases arrested. In 2001, four members of the Naz Foundation Trust (an Indian NGO that works with MSM and other groups affected by HIV) were jailed for 47 days after police raided their offices:
“I was arrested for promoting homosexuality. The leaflets we use for our outreach work were dubbed obscene. The police claimed that the replica of a penis used to demonstrate the proper use of condoms was actually a sex toy!”
Arif Jafar, Naz Foundation 26

Since conditions are so restrictive, there is little information available to MSM in India. Because so many MSM also have heterosexual relationships, there is a high chance that rising levels of infection among MSM in India will aggravate the epidemic among the general population. 27
Migrant workers
Large numbers of Indians have moved around within India, to neighbouring countries or overseas, in order to work. In some parts of India, three out of four households include a migrant.

Migrant workers near Sangli, India – 2005
“Being mobile in and of itself is not a risk factor for HIV infection. It is the situations encountered and the behaviours possibly engaged in during mobility or migration that increase vulnerability and risk regarding HIV/AIDS.” UNAIDS 29

In many cases, migration does not change an individual’s sexual behaviour, but leads them to take their established sexual behaviour to areas where there is a higher prevalence of HIV. For some, though, migration does change their sexual behaviour. Long working hours, isolation from their family and movement between areas may increase the likelihood that an individual will become involved in casual sexual relationships, which in turn may increase the risk of HIV transmission. Cultural and language barriers can also make it harder for workers to access health services and information about sexual health when they are away from their home communities.

INTRODUCTION

Why is AIDS Education Important for Young People?

The HIV epidemic has been spreading steadily for the past two decades, and now affects every country in the world. Each year, more people die and the number of people living with HIV continues to rise – in spite of the fact that we have developed many proven HIV prevention methods. We now know much more about how HIV is transmitted that we did in the early days of the epidemic, and we know much more about how we can prevent it being transmitted. One of the key means of HIV prevention is education – teaching people about HIV : what it is, what it does, and how people can protect themselves. Over half of the world’s population is now under 25 years old. This age group is more threatened by AIDS than any other; equally it is the group that has more power to fight the epidemic than any other. Education can help to fight HIV, and it must focus on young people.

There are two main reasons that AIDS education for young people is important:
To prevent them from becoming infected.

Young people are often particularly vulnerable to sexually-transmitted HIV, and to HIV infection as a result of drug-use. Young people (14-21 years old) account for half of all new HIV infections worldwide - more than 6,000 become infected with HIV every day . More than a third of all people living with HIV or AIDS are under the age of 25, and almost two-thirds of them are women. In many parts of the world, young people in this age-group are at particularly high risk of HIV infection from unprotected sex, sex between men and IV drug-use because of the very high prevalence rates often found amongst people who engage in these behaviours. Young people are also often especially vulnerable to exploitation that may increase their susceptibility to infection. Even if they are not currently engaging in risk behaviours, as they become older, young people may soon be exposed to situations that put them at risk. Indeed, globally, most young people become sexually active in their teens. The fact that they are – or soon will be – at risk of HIV infection makes young people a crucial target for AIDS education.

To reduce stigma and discrimination.

People who are infected with HIV around the world often suffer terribly from stigma, in that people who are HIV+ are somehow thought to be ‘dirty’, or to have ‘brought it on themselves’ by ‘immoral practices’. They often experience discrimination in terms of housing, medical care, and employment. These experiences, aside from being extremely distressing for HIV+ people, can also have the effect of making people reluctant to be tested for HIV, in case they are found to be HIV+. Stigma and discrimination often starts early – as name-calling amongst children. AIDS education can help to prevent this, halting stigma and discrimination before they have an opportunity to grow.

Why is AIDS education for young people an issue?

The problem seems to stem from the fact that HIV is often sexually transmitted, or is transmitted via drug use. Any subject that concerns sex between young people or drug use tends to be seen from a moralistic perspective. Many adults – particularly those of the religious right – believe that teens need to be prevented from indulging in these high-risk activities. They believe that young people shouldn’t – and don’t need to be – provided with any education about these subjects, other than to be told that they are ‘wrong’, and not to do such things. Unfortunately, however, adults have been trying to stop young people from having sex and taking drugs for many, many years with little success, so this method alone seems unlikely to offer any real relief in terms of the global AIDS epidemic.

There are other difficulties in taking an exclusively moral approach to HIV education. Firstly, this is what tends to perpetuate stigmatisation of HIV+ people. By teaching young people that indulging in ‘immoral’ sex and drugs will lead to HIV infection, educators imply that anyone who is HIV+ is therefore involved in these ‘immoral’ activities. This stigmatisation tends to make people reluctant to be tested for HIV, and therefore more inclined to remain ignorant of their status – and perhaps go on to infect others. AIDS education shouldn’t ever include a moral judgement – it is one thing to teach young people that promiscuous sex and intravenous drug use are unsafe, another thing to teach them that these things are morally wrong.

AIDS education shouldn’t ever include a moral judgement – it is one thing to teach young people that promiscuous sex and intravenous drug use are unsafe, another thing to teach them that these things are morally wrong.

Many AIDS educators around the world are disturbed at this growing trend of providing AIDS education from a moralistic perspective, and argue that AIDS education ought to be non-judgemental, making young people aware of how HIV can be transmitted and how they can avoid becoming infected - without passing moral judgement on those who engage in infection-related behaviours, whether they do so safely or not.

The opposing, more conservative viewpoint, however, argues that young people shouldn’t be taught about sexual health and drug-related dangers at all. They feel that teaching them about these things, even teaching about their dangers, may encourage young people to indulge in these risk behaviours. Research suggests that this is not the case at all, and certainly young people themselves tend to be very enthusiastic about the fact that they need sex and sexual health education. Unfortunately, curriculum planners tend not to listen to the young people who will be their students. This viewpoint can result in no AIDS education at all being offered.
“I did not go to school and learn about the civil war and decide to start a civil war, nor would I have had sex because of a class in school.”by a student.

However, many young people become sexually active long before adults would prefer them to do so, or expect them to do, and teens are not all ‘innocent ‘. Quite simply, if teens are having sex, they need sexual health information. Fortunately, many curriculum planners and legislators have recognised this, and provide young people in many countries with abstinence-plus or comprehensive sex & HIV education. A more detailed look at the results of such curriculum in the classroom can be found in our Teaching AIDS in schools page.

Different approaches to AIDS education for young people

Most countries in the world offer teens some sort of sexual health and HIV education in their schools at some stage. AIDS education can also be targeted at young people in non-school environments – through their peers, through the media, and through doctors or their parents. In some countries, individual schools are allowed to determine what AIDS education they will offer. In other countries, this is determined by legislation passed by central government. And in other countries – especially poor ones that are severely affected by HIV – AIDS education is imported by foreign governments, charities and NGOs, that come in to the country and deliver AIDS education as part of a larger package of HIV prevention work.

AIDS education for young people today falls generally into one of two categories: either 'abstinence-only', or 'comprehensive'. These are actually types of sex education, rather than AIDS education specifically - AIDS education in many schools comes as a part of a sex education program, if it occurs at all. The type of AIDS education program that is offered usually depends on the attitudes of those who determine the syllabus content. Right-wing organisations, some religious organisations, and the family-values lobby tend to prefer abstinence-only education, while those who feel that preventing young people from becoming infected with HIV is more important than keeping them ignorant about sexual behaviour prefer comprehensive AIDS education.

A report found that over 80% of abstinence-only curricula contained false or misleading information

Abstinence-only education teaches students that they must say no to sexual activity until they are married. This approach does not teach students anything about how to protect themselves from STDs or HIV, how pregnancy occurs or how to prevent it, and teaches about homosexuality and masturbation only as far as to say that they are wrong. Those who favour this method of education claim that teaching young people about sex will make them want to try it, thus increasing their risk of contracting HIV, amongst other things.

Abstinence-only education is popular in America, especially so now that it has a Republican President. A House of Representatives report at the end of 2004 found that over 80% of abstinence-only curricula contained false or misleading information. 2 This is not only a concern for those living in America, but increasingly for the rest of the world, as America exports its HIV-prevention and education attitudes to countries with much higher levels of HIV infection. This is particularly worrying in that abstinence-only programmes have been shown not only to fail to reduce the numbers of sexually transmitted infections and unplanned pregnancies seen in pupils, but recent studies indicate that they might actually be related to an increase in these problems.

Comprehensive AIDS education teaches about sexual abstinence until marriage, and teaches that it is one way of protecting yourself from HIV transmission, STIs and unwanted pregnancy. It also teaches that there are other ways of preventing these things, such as condom use. People who favour this approach take the perspective that, while abstaining from sex until marriage is a good idea and should possibly be encouraged, there will always be some young people that do not choose to abstain – and these people must be provided with information that enables them to protect themselves. This type of education also teaches not only about the dangers of drug use, but also about methods of HIV-prevention that drug users can employ – the use of clean needles, for example.

Abstinence-only and comprehensive AIDS education have been combined to produce abstinence-plus education. This type of education focuses on sexual abstinence until marriage as the preferred method of protection, but also provides information about contraception, sexuality and disease prevention. Many abstinence-only campaigners complain that abstinence-plus and comprehensive education are the same thing, although abstinence-plus educators claim that this type of course contains more focus on sexual abstinence until marriage.

There has been debate for many years over which form of sex education is most effective in terms of preventing underage sex, unwanted pregnancy and STD and HIV transmission, although most studies seem to show that comprehensive sex and AIDS education is at least as effective as abstinence-only – and probably more so. However, currently the trend in America – and which is being exported to much of the developing world – is towards abstinence-only education. If it is as unsuccessful as studies indicate it to be, then we can expect this morality-induced type of education to become responsible for an increase in HIV figures amongst the young, especially in high-prevalence parts of the world to which America has taken its methods.

Fifteen percent of Americans believe that schools should teach only about abstinence from sexual intercourse and should provide information on how to obtain and use condoms and other contraception. Forty-six percent believe that the most appropriate approach is abstinence-plus 3. Almost half of those surveyed felt that the word ‘abstinence’ included not only sexual intercourse, but ‘passionate kissing’ and ‘masturbation’, too.

What types of AIDS education can be offered outside schools?

Not all young people are fortunate enough to attend school. This might be for one of a variety of reasons. In some countries, it is necessary to pay for schooling, and poor families may be unable to afford to send a child to school, or may be unable to send all their children to school. Sometimes children will be required to work, making them unavailable for school. In other areas, young people may live in areas where a local school is not accessible. In some situations, young people may have been excluded from school for reasons that might be due to the young person’s behaviour, academic or intellectual abilities, or due to discrimination. Some young people play truant, and will have only very limited attendance. The proportion of young people who attend school differs markedly in various parts of the world.

Clearly, although AIDS education offered through the school might reach many young people, it will not reach all, and other forms of education are required.

One of these is the media. Most young people will, at some time, be exposed to the media. This can include newspapers, television, books, radio, and also traditional media such as street performances or murals. One advantage of media-based AIDS education is that it can target specific groups amongst the population. If the message is to be targeted at young people, then it will be placed in media that are favoured by this audience.

Many countries have tried some form of AIDS education advertisements, films, or announcements. A good example of this is the LoveLife campaign in South Africa, an education program ‘by young people, for young people’. LoveLife used eye-catching posters and billboards to tell young people that sex was fun, but that it could be dangerous, too. The campaign also inserted its message into TV soaps that were popular with young people, and used rap and kwaito music to get its message across.

There are, however, problems with media-based campaigns. It is hard to know to what extent the AIDS information has reached young people, and it is difficult to gain continued funding for initiatives whose success is so hard to measure.

Another way in which young people receive information about sex and HIV is through their peers. This is something that happens anyway to a great extent – many young people receive their first information about sexuality from their friends, although this information is often distorted and inaccurate. This type of peer education can be harnessed, though, and used to convey accurate, targeted information. Peer education is, quite simply, the process by which a group is given information by one of their peers who has received training and accurate information. This is a method often used with groups which have been marginalised. Such groups might have cause to distrust information given to them by an authority figure; if the same information comes from a member of their own group, however, they may well listen. This method of information-provision is often used with such groups as sex workers, the homeless, or drug-users. There is no reason that this method shouldn’t be used with young people, however, and in many parts of the world, it is used. Indeed, it is particularly appropriate for young people who do not attend schools and will not have an opportunity to benefit from an AIDS education curriculum.

AIDS education for the future

Although the debate continues about how much – if any – AIDS education young people should receive, studies continue to show that being informed about the facts and the dangers of HIV and AIDS enables young people to protect themselves and is a crucial tool in the battle against HIV. There is no cure or vaccine for HIV, so prevention is the only way in which we can place any limits on the epidemic. One of the most economical and effective means of HIV prevention is education – involving young people themselves in the HIV prevention effort.

On a global level, America’s disposition towards the promotion of abstinence-only education is cause for concern. America’s spending on HIV prevention around the world exceeds that of any other country, and is to be welcomed – as long as it doesn’t use this money to promote its pro-abstinence-only views of AIDS education. These views – which have been shown to be less successful than comprehensive AIDS education techniques which include an abstinence element – may prove to be damaging to America’s domestic AIDS prevention work 4. When exported to high-prevalence countries in Africa, they could prove disastrous.

Whenever educators and planners ask, and listen to young people, they are told time and time again that young people overwhelmingly ask for adequate AIDS education. In most parts of the world, this means more AIDS education than they are presently getting. Young people know that they have the right to the information that enables them to safeguard their lives and those of their sexual partners – they must be listened to, and provided with that information clearly, openly and honestly.

VATTACHARYYA

Friday, May 4, 2007

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