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.
Principles of Effective HIV Prevention
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.
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.
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.
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.
". . . 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).
How CBOs Can Help School HIV Prevention Programs
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.
Societal HIV prevention interventions try to change social and environmental factors that contribute to individuals' HIV risk. AIDS Action (1997) articulated three kinds of interventions that Thomas Coates identified at this level:
Societal-Level HIV Prevention
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.
Prevention Strategies and Approaches that Are Working for Young People
Sources: Office of National AIDS Policy; CAPS, University of California, San Francisco; Funders Concerned About AIDS.