Prevention science has identified programs that can reduce risk behavior. . . . Some of the proven programs were designed for small group or classroom use. With an emphasis on communication, negotiation, and refusal skills, they state clearly that abstinence is important, and also provide information about condoms and other contraceptives. Other effective programs offer individualized counseling to high-risk youth, or use outreach workers to deliver prevention messages. A final group of programs mentor young people in activities that make the future seem brighter and staying safe seem worthwhile.

-- Office of National AIDS Policy, 2000

Prevention science combines behavioral and social science perspectives to evaluate the effectiveness of HIV prevention. Many questions are still unanswered -- especially with respect to youth of color, both young men who have sex with men and young black and Latina women -- but the evidence is clear and compelling: prevention works. A variety of HIV prevention interventions have been proven effective in reducing HIV risk behavior among youth (see Chapter Five references, Compendium of HIV Prevention Interventions with Evidence of Effectiveness and Replicating Effective Programs Plus). No one intervention is best for all young people, and both individual-level and community-level interventions are necessary to defeat the epidemic in America's youth (Kelly, 2000).

This chapter offers an overview of what prevention science has to say about what works for preventing HIV infection in young people.

Characteristics of Effective Prevention

Although HIV prevention interventions must be targeted to the specific needs of individuals and communities, prevention science has discovered principles and characteristics of effective prevention generally. Coates and his colleagues (1996) identify nine such principles, which can be a useful guide for CBOs considering initiating HIV prevention programs as part of their constellation of services:

Principles of Effective HIV Prevention

1. Sustained interventions are more likely to lead to sustained behavior change.

2. More intense interventions are more likely to result in greater risk reduction.

3. Accessibility to devices that are necessary for safer practices reduces risk of HIV infection.

4. Skill building and the modification of social norms appear to enhance behavior change.

5. Timing of interventions matters.

6. Individual-level interventions can change behavior, but are probably not equal to the task of risk reduction for populations with high prevalence of HIV infection.

7. HIV counseling and testing have a place in HIV risk reduction, but are not sufficient for HIV prevention.

8. Working at the level of community can sometimes lead to significant behavioral changes.

9. Media interventions can sometimes lead to significant general population behavior changes. (Coates et al., 1996, p.1146)

These principles are consistent with the findings of the CDC's HIV/AIDS Prevention Research Synthesis Project (1999) and the recent report to Congress from the Institute of Medicine (2000) on the state of HIV prevention in the United States.

Targeted Prevention

Prevention research and the experiences of CBOs both attest to the importance of targeted HIV prevention. Prevention can be targeted in a variety of ways to match multiple risk factors and circumstances. Interventions can be targeted by age, gender, sexual experience, ethnicity, behavioral risk, or neighborhood, among others. Many HIV prevention programs and interventions use a combination of factors in targeting their services.

The Asian & Pacific Islander Coalition on HIV/AIDS (APICHA) in New York City is one such program. This CBO seeks to meet the needs of New York's Asians and Pacific Islanders, richly diverse communities that vary greatly with respect to culture and ethnicity. Therefore, APICHA offers a broad range of HIV prevention programs to reach these communities, many of whose members do not use mainstream services because of language and cultural barriers. The Young People's Project's bilingual volunteers reach youth with HIV prevention interventions through school-based workshops and one-on-one street outreach at community centers, video arcades, pool halls, and other places where Asian young people gather.

Timing, Frequency, and Intensity

Early and often are good guideposts for HIV prevention interventions for youth. Early prevention education encourages young people to adopt healthy behaviors and to avoid beginning unhealthy ones. Prevention is most effective when it reaches adolescents before they initiate sexual and drug-using behaviors that put them at risk for HIV. In a study on the impact of mother-adolescent communication on HIV prevention among 372 sexually active teens, the CDC found that condom use increases only among teens whose mothers talk to them about condoms before they have intercourse for the first time (CDC, 1998c). These teens are three times more likely to use condoms than teens who either never discuss condoms with their mothers or who discuss them only after initiating sexual activity. Condom use at first intercourse dramatically predicts future use, with youth who use condoms at first intercourse 20 times more likely to use condoms subsequently.

Below a certain threshold of frequency, many youth HIV prevention interventions are not effective in changing risk behavior. The frequency differs with the intervention and the group targeted, but, in general, effective interventions for youth are sustained and intense. In a social marketing campaign aimed at getting prevention messages out to youth, more frequent exposure to the messages resulted in youth feeling more able to avoid sexual risk. Reporting on a scientific review of successful interventions, Collins (1997) called 10 to 14 sessions with homeless and runaway youth a "full dose," while 12-session interventions produced substantial change in risk behavior among gay men.

Information Combined with Skill Building

Behavioral prevention interventions attempt to prevent someone from acquiring or transmitting the virus by trying to change individual sexual and drug-using behavior. In the early days of the epidemic, most interventions were based on the assumption that knowing the facts about HIV transmission would prevent someone from becoming infected. Despite early successes, however, it soon became apparent that information is not enough; high rates of risky behavior continue in hundreds of thousands of individuals who know how HIV is transmitted. Dozens of prevention science studies have since demonstrated that behavioral interventions that combine information with skills building are more effective in producing sustained behavior change and risk reduction. For example, Lawrence and colleagues (1995) in a study with 246 African American adolescents compared a cognitive-behavioral intervention with information only and found that one year after intervention almost three times as many abstinent teens had initiated intercourse in the information-only group than had in the skills training and information group.

Involving Families

Prevention science has demonstrated that involving parents is an effective strategy for preventing HIV infection in youth. Frank discussions about sex between parents and young people can lead youth to adopt healthy behavior, such as condom use. One survey of 522 African American adolescent girls found that those who regularly discussed sex with their parents were significantly less likely to engage in risky sexual behavior and much more likely to bring up STD and HIV prevention with their sexual partners when compared to girls whose parents did not talk with them about sex (Crosby, et al., 2000).

The AIDS and Adolescents Network of New York (AANNY) demonstrates how involving parents can help overcome community resistance to HIV prevention education in the schools. AANNY recruits and trains lesbian and gay youth, their parents, and lesbian and gay parents to serve as advocates and educators for school-based AIDS education. Since 1987, this diverse group of youth service providers, health care providers, teachers, activists, researchers, parents, and youth have been promoting HIV/AIDS education and prevention programs for young people, as well as advocating for public policies to end the epidemic among youth. AANNY offers a series of small interactive workshops facilitated by parents and youth who have experience in peer education and advocacy around HIV. Among the workshop content are: HIV/AIDS 101, adolescent development, sexual identity issues, attitudes about sexuality, communication, and living with HIV/AIDS in the family.

Sexuality Education and HIV Prevention Education

Both the Institute of Medicine and the President's Council on HIV/AIDS recently identified a key problem in preventing HIV among America's teenagers -- the proliferation of abstinence-only sexuality education in our schools at the expense of comprehensive programs:

". . .  the nation is spending approximately $440 million in federal and state funds over five years on abstinence only sex education -- in the absence of any evidence that this approach is effective, much less cost-effective -- solely because of social forces that prevent effective comprehensive sex education courses from being offered." (IOM, 2000, p.9)

"Unlike many other nations, the U.S. government has been unwilling to implement systematic, population-wide education that teaches children and adults about sexual and drug-related risks for transmitting HIV. This barrier to explicit sexual and drug-related conversations with young people has had enormous consequences. . . . Fears that explicit sexual information would increase sexual initiation among U.S. youth have not been supported by studies that have evaluated such claims. Yet too many policy makers continue to push to censor the prevention that youth receive by mandating and funding 'abstinence only' approaches." (PACHA, 2000, p.20)

One of the most persistent challenges to HIV prevention for youth is the widely held belief that early sexuality and HIV prevention education lead to promiscuity, a myth that underpins the abstinence-only movement. In fact, the opposite is true. Several studies reviewing the scientific literature found that teens who receive HIV education are less likely to engage in sexual intercourse; those who do have sex less often and use contraceptives more when they have intercourse (IOM, 2000; Kirby, 1995). In contrast, no scientific evidence supports the effectiveness of abstinence-only programs.

Although most young people know the facts about HIV transmission (KFF, 2000b), they still want and need to know more, including how to protect themselves. Unfortunately, in schools all across the country, they are being taught less now than they were a dozen years ago. Abstinence-only programs are proliferating: in 1999, 23 percent of public school sexuality teachers reported teaching abstinence as the only way to prevent STDs, including HIV, compared with 2 percent in 1988 (Alan Guttmacher Institute, 2000).

Because policies on sexuality education and condom availability are to a large extent determined locally, community-based organizations are much better positioned than national ones to advocate for comprehensive sexuality and HIV prevention education in their local schools. Where such advocacy is not successful, CBOs can help to fill the gap by offering these kinds of programs for youth.

Even when schools do provide comprehensive programs, many youth at highest risk are out of school entirely, while others do not attend regularly. These young people will not be reached by school-based programs, and they are significantly more likely than in-school youth to be sexually active, to have had four or more sex partners, and to have used alcohol and other drugs (Harper and DeCarlo, 1999) -- all behaviors that put them at very high risk for HIV infection. Prevention programs for these young people are needed in venues accessible to them, and CBOs can play an important part in meeting this need.

Peer Education

Peer education is a highly effective prevention strategy with youth. In fact, it is more than just a strategy; it is also an "approach, a communication channel, a methodology, [and] a philosophy" (UNAIDS, 1999, p.2). Peer education uses young people as credible prevention messengers to effect change among other young people. It has been successful both at the individual level, in changing attitudes and skills, and also at the societal level in influencing group norms. Peer education is consistent with several behavior change theories, among them social learning theory, the theory of reasoned action, the diffusion of innovation theory, and the theory of participatory education.

Social Marketing

Community-level interventions have demonstrated considerable efficacy in preventing HIV infections. The social marketing of condoms in developing countries is one often-cited example of a remarkably effective community-level intervention (IOM, 2000). Social marketing uses advertising expertise -- media campaigns and other marketing strategies -- to reach large numbers of people and influence their attitudes and behavior, motivating them to healthy behavior change. Because advertising is so effective in helping to define youth culture, social marketing for HIV prevention has great potential for use with young people. Evaluations of social marketing stress that the messages must be delivered through diverse channels, be sustained over time, and respond to changes in the market (Collins, 1997).

The CDC studied the effectiveness of social marketing approaches with adolescents in a five-city project called the Prevention Marketing Initiative (PMI). Volunteer coalitions that included youth as members planned and launched youth-oriented media campaigns that reached thousands of young people with HIV prevention messages. In one city, in 15 zip codes with high STD rates, 60 percent of 15 to 18 year olds reported hearing of PMI, and the campaign was associated with significant increases in condom use (Kennedy and Mizuno, 1999).

One effective social marketing approach uses members of high-risk populations who are popular with other members to advocate behavior change at the community level. This "opinion leader" model, developed by Kelly and his colleagues at the Center for AIDS Intervention Research (CAIR), recruits popular people within a community and trains them to deliver and model prevention messages to their peers. This approach has been used successfully with gay men in bars, with inner-city women in housing developments, and with young people, among others.

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