Panos AIDS Briefing No. 4 / July 1996
Paul Chinnock and James Deane. Edited by Panos.

Key Facts

1.AIDS HITS YOUNG PEOPLE

A lost generation?

Why young people are at risk

Are people having sex earlier?

Girls are more at risk than boys

2. SEX, SOCIETY AND PREVENTION

Societies' responses to AIDS

Can sex education deliver?

Initiating sex education... and cultural constraints

Outside the classroom

Youth on the margins

Friend to friend

Building for life

Access to condoms

Using the mass media

3. TAKING CONTROL

Tackling AIDS in the future

Young people demand a say

Hope for the next generation

References

Contacts

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1 December - World AIDS Day

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Introduction

Young people around the world stand vulnerable to AIDS as never before. Some 60% of new infections of HIV - the virus that causes AIDS - are among those between the ages of 15 and 24, a figure that is steadily rising.

And young women from developing countries are at severe risk. In Uganda, for example, it is estimated that HIV infection among women is 20 times higher than men in the 13 to 19 age group. Such high risk levels are largely due to the unequal status of men and women in sexual relationships. Scientific studies also show that a young woman faces a greater physiological risk of HIV infection.

From the onset of the pandemic in the Eighties, it was inevitable that young, sexually active people would be hit hardest. For one, the global population is a young one. But being young has its own dangers. Many are unaware of risks linked to sex such as HIV and other sexually transmitted diseases. And in some communities, contracting diseases like gonorrhoea is all part of growing up for young men.

Such rites of passage are being countered by other messages to tackle the AIDS crisis. Schools and health centres play a vital role in alerting young people to the dangers of HIV. However, in some countries, authorities argue that sex education and condom distribution will only lead to earlier sexual initiation and may actually spread HIV.

For many practitioners, sex education has to go beyond the classroom. Millions vulnerable to AIDS live their lives on the streets of the world's biggest and meanest cities, or in isolated villages where sheer survival is the name of the game.

Yet new initiatives are gathering pace. TV, radio, street theatre and pop groups are beginning to get more effective messages across. And young people themselves are getting involved. But many AIDS workers argue that until authorities seriously address issues of youth sex and sexuality, and involve young people in protecting their lives, tomorrow's generation remains at grave risk.

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Key Facts

60% of all new infections of HIV, the virus which causes AIDS, are among people aged between 15 and 24 years.

Two-thirds of those who get HIV will become infected before they reach the age of 25.

One-fifth of the global population is between the ages of 10 and 19.

Worldwide, up to 60% of all HIV infections in females occur by the age of 20.

Each year, one in 20 adolescents worldwide contract a sexually transmitted disease.

Worldwide, 42% of people living with the HIV virus are women.

A study in South Africa found that AIDS was mentioned in only one in 48 visits to a family planning clinic.

One study in Russia found that 25% of young girls had been subject to sexual abuse.

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1 AIDS HITS YOUNG PEOPLE

"My friends tell me to drink and have sex if I want to be cool. I know life is not all about being cool, but what can I do?" Simon, aged 17, from Uganda.

A lost generation?

According to the Joint United Nations Programme on AIDS (UNAIDS), up to 60% of all new infections of HIV are among those between 15 and 24 years old, a figure which is steadily rising. And many people over 24 who now have HIV, or have developed AIDS, contracted the virus when they were within this age group.

"AIDS is foremost a disease of the young," says the United Nations Children's Fund, Unicef. "Two-thirds of those who get [HIV] will become infected before they turn 25." [1]

Young women, particularly in developing countries, are at great risk. The Global AIDS Policy Coalition, a Harvard-based think-tank, estimates that HIV infection among women in Uganda is 20 times higher than men in the 13 to 19 age group [2]. In Zimbabwe 30% of pregnant 15 to19-year-olds attending an antenatal clinic were found to be HIV positive [3].

From the beginning of the AIDS pandemic in the Eighties, it was inevitable that it would hit young, sexually active people hardest. Yet fundamental debates continue on the risks confronting young people and the most effective way to tackle the crisis. Should schools teach sex education? Should young teenagers, or even pre-teens, have access to condoms? Is AIDS in youth a reflection of a decline in moral values? Indeed, is it that adults and authorities are endangering young lives by refusing them information and the means to protect themselves?

And on it goes. But for many practitioners, education is critical. "We have a window of hope between the ages of 5 and 18 years", says Dr Sam Okware, Uganda's Commissioner for Health. "If that group can be educated, if their behaviour change can be modulated to ensure they do not have risk behaviour, I think we have a future."

Of course many young people exposed to HIV and AIDS never enter the classroom and new ways of reaching street children and those in villages are greatly needed. Meanwhile, it is increasingly argued that the future course of the AIDS pandemic is likely to be determined by the success, or otherwise, that societies have in protecting their young people, and the extent to which young people are able to protect themselves.

Why young people are at risk

AIDS afflicts the young partly because the world's population is a young one. One-fifth of the global population is between the ages of 10 and 19 [4], and in developing countries young people constitute at least 50% of the population [5]. Young people are at risk, partly through their own behaviour and partly through the attitudes, expectations and limitations of the societies in which they grow up.

The most fundamental risk facing young people stems from simple ignorance of the dangers of sex caused by lack of information about HIV. Compared with adults, young people in many societies still remain unaware of sex's health risks. They are more likely to know about the possibility of unwanted pregnancy than they are to know about sexually transmitted diseases (STDs). Even those who visit family planning clinics are often not given information about STDs.

Each year one in 20 adolescents worldwide contract a sexually transmitted disease [6]. Untreated STDs, such as gonorrhoea and chancroid, are known to increase substantially the risk of HIV transmission. Young people are even more reluctant than adults to seek treatment. Many are embarrassed and fearful that their parents will find out that they are sexually active. The concentration of AIDS among young people reflects the pattern of more familiar, but less deadly, STDs. In the United States, the incidence of gonorrhoea - one of the most common treatable STDs - is highest among 15 to 19-year-olds [7].

In some cultures, STDs are so widespread that contracting one is an accepted part of growing up. Indeed for boys, it can be seen as a test of manhood. And even if treatment for STDs is sought, young people, particularly in developing countries, are less likely to be able to pay for their treatment, an important factor in the Nineties when much free health provision has been abandoned as part of structural adjustment programmes. And many STDs do not show any symptoms, particularly among young women, which means that sufferers therefore do not seek treatment.

Information on AIDS can also be in short supply. A study in South Africa found that AIDS was mentioned in only one in 48 visits to a family planning clinic [8]. Ignorance is accentuated by the difficulty or embarrassment young people face in obtaining condoms. And many of those who do manage to get a packet often use them inconsistently or incorrectly. One study of Russian adolescents found that three-quarters of females and two-thirds of males believed erroneously that condoms could be used safely more than once [9].

Young people may also be influenced by the messages put out by the multi-media which in Southern countries can carry a heavy Western cultural bias. As countries increase their wealth and consumerism expands, advertising focuses heavily on sexual messages to target young audiences. At a recent meeting in Zimbabwe, a country where it is estimated that 17% of the adult population is HIV positive [10], radio disk jockeys discussed the morality of their playing records with titles such as I wanna sex you up, for fear of encouraging unprotected sex.

Are people having sex earlier?

Young people who become sexually active at a very early age (15 or younger) are at a heightened risk of HIV. Those who start having sex early are likely to have more partners - and of course, the more partners the bigger the risk.

Yet whether the first age of sexual intercourse is dropping is open to debate. The evidence is unclear and the situation varies between countries. In Britain the average age of first intercourse has fallen by three years for boys and four years for girls since the Fifties[11]. But in the United States, a study found that the number of high school students who reported having sex had fallen from 54% in 1990 to 36% in 1995.

According to a survey carried out by the Johns Hopkins School of Public Health, data from several developing countries indicates that there has been no significant change in most countries [12]. The survey found that in many countries, the age at first sexual intercourse had actually increased among women in many countries, particularly in Asia and Latin America.

Sex before marriage does, however, seem to be increasing. "Over the last 15 years, studies in Africa and Latin America have reported increasing percentages of unmarried young adults who are sexually active," claims the Johns Hopkins study. "At least one researcher points out, however, that casual sexual activity is also more common now among adults, both married and unmarried, as well as among youth" [12].

And sexual behaviour varies enormously from country to country. A survey carried out in Burundi found that 10% of unmarried 15 to 19-year-old males said they had had intercourse in the previous year; the figure for Guinea Bissau is over 50%. Such variation may simply reflect what people are prepared to say to investigators and indeed different perceptions as to what counts as intercourse, but if the variations are real they should have an impact on the way education programmes are run in each country [14]. And it is clear that youth in some countries are especially in danger of HIV infection because of early sex. For example, a study in Jamaica found that 47% of boys were sexually active by age 14, and 47% of girls had been pregnant by age 19; over 80% of these pregnancies were unwanted [15].

Girls are more at risk than boys

Worldwide, 42% of people living with the HIV virus are women [16]. But although in global terms more men are infected than women, this masks the fact that the proportion of women who are HIV positive is growing. And the risk of HIV infection for young women and girls in particular can be dramatically greater, especially in those societies most heavily affected by HIV. One Zairean study showed women aged between 15 and 30 to be four times more likely to have HIV than men in the same age group [17]. Worldwide, up to 60% of all HIV infections in females occur by the age of 20, according to the World Health Organisation [18].

"While men's behaviour tends to put them at greater risk of HIV infection - they are more likely to pay for sex, use injecting drugs, for example - it is women who are more vulnerable to HIV infection", says Dr Tony Burton of UNAIDS. One of the main, unalterable reasons women are exposed to greater risk of HIV infection than men is a physiological one. There is now scientific evidence that the reproductive tract of the younger woman is a poor barrier to the virus. This further increases the vulnerability of girls compared either with that of boys or of older women. Compounding this risk is the fact that in most cultures, sexual expectation and socially acceptable behaviours vary greatly for girls and boys. Frequently, girls have less control over what happens to their bodies than boys.

It is more common for a sexually active girl to have a sexual partner who is older than it is for a boy. Several studies have found that most teenage girls who become pregnant do so as the result of sex with an older man and not with a teenage boy. A US study found that in 70% of teenage pregnancies the father was over 20; when the mother was under 15 an even higher proportion of fathers were over 20. Studies in Ghana and Tanzania have produced similar findings. In Thailand, men tend to have sex from the ages of 15 or 16, often with commercial sex workers, but do not get married until they are well into their twenties when they are economically self-sufficient. Women, however, tend to start sexual relations later and much closer to marriage.

In some societies it is quite normal for a girl to be married soon after puberty, or even younger, whereas boys will not marry before their late teens. Within marriage, therefore, a girl becomes sexually active at an early age with an older man who is probably sexually experienced and is more likely to be HIV positive.

And in many societies, a woman's first duty is still seen as a helpmate to her husband. This is the case regardless of how the man is behaving. A young woman may be aware that her sexual partner has been unfaithful or has had sex previous to the marriage and could thus be HIV positive, but it may be considered her duty as wife or girlfriend to continue to have sex with him.

Sex is sometimes the only way in which a young woman can earn money. In some societies many girls are forced into prostitution at an early age or simply taken advantage of by older men. The growing number of street children in many cities must resort to desperate measures in order to survive and it is no surprise that so many girls on the street become prostitutes. However, it would be wrong to think that only girls living on the street earn money this way. At the University of Calabar, Nigeria, nearly 15% of women students said they engaged in commercial sex to pay for their education [19]. Such part-time sex work may well be more common in many societies than is generally recognised.

Aware of the risks of HIV infection, many men are now actively seeking out younger women and girls in the belief that they are less likely to be HIV positive. Some will already be infected themselves. This can be compounded by the high rates of sexual abuse that exist in many societies worldwide. In Kenya, one study found that 24% of women reported rape as their first sexual experience [20].

The Ugandan Government amended its law on rape in 1990 to make it a capital offence following a sharp increase in the reported cases of sexual abuse of young schoolgirls. Young girls are targeted because their attackers often perceive them as being "safe" and uninfected with HIV. So far, it appears the new law is making little difference. In the year following its enactment, women's rights groups estimated that reported cases of rape increased by 9% [21].

And sexual abuse tends to affect young girls more than boys. One questionnaire survey of adolescents in Russia found that 25% of females and 12% of males reported being sexually abused [22].

Condom use, the most commonly used barrier to infection with HIV, presents particular problems for young women. The condom is basically a male method of contraception and STD prevention. Condoms are often unknown to women or difficult to obtain. Female condoms are not widely available and are more expensive. A young man who carries condoms runs only the risk of embarrassment, but in many societies a young woman found with a condom, will be accused of immorality and could well be punished severely. And it can be difficult for a young woman to insist on the use of a condom, even when they are available.

Some observers argue that female genital mutilation could also increase the risk of HIV transmission. Between 85 and 114 million girls and women are affected by this practice [23], and it is usually performed on girls between the ages of four and eight. Female circumcision may in later life lead to more efficient sexual transmission of HIV and other STDs if the man is infected. "Because scar tissue is inelastic, the vaginal orifice doesn't stretch," says Dr Irene Thomas who heads the Nigerian branch of the Inter-African Committee on Traditional Practices (IAC). "If penetration occurs forcibly, something has to give. There can be a lot of blood if tearing occurs," she says.

There are additional potential risks if girls are circumcised in groups and in unsterile conditions. The practice of mass circumcision - which also applies to male circumcision in some cases - has been highlighted by some health workers as a possible route for HIV transmission. However, some experts point out that those areas of high HIV prevalence do not coincide with those areas where female genital mutilation is most common, suggesting that the increased risk from circumcision is low.

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2 SEX, SOCIETY AND PREVENTION

"In my country, Botswana, there is a serious problem of communication between parents and their children. This a cry from our hearts. Parents - talk to us. Without your communication, guidance, dialogue, we are a lost generation, come to our aid." A 14-year-old girl, addressing AIDS conference in Kampala, Uganda, 1995.

Societies' responses to AIDS

Societies' responses to the threat of HIV among their youth vary enormously. One response is to urge all young people to remain chaste and stay a virgin until they are married. Another is to provide young people with frank information on sex and sexuality, and access to protection like condoms on the assumption that no amount of moral teaching will ultimately prevent adolescents from exploring their own sexuality. Many prevention programmes include elements of both.

The argument that the most effective way to control HIV among young people is to urge them not to have sex at all is often promoted by religious authorities and many governments. Some programmes based around this thinking have had some success. In Zambia, Malawi and several other African countries, a series of "Anti-AIDS Clubs" have been started in schools. These involve young people pledging themselves to be faithful to their partners and refrain from sex until marriage. Members are also urged to show solidarity with people who are infected or affected by HIV. One of the most successful aspects of these clubs is that many are started spontaneously by pupils themselves, and although their success in achieving behaviour change has been limited [24], over 1,700 school and community-based clubs have now been started in Zambia alone.

However, many of the arguments in favour of young people delaying sex have been accompanied by warnings of punishment, prohibition and sin. "People with AIDS are sinners", said a Christian minister at a journalists' meeting in Malawi. "One of the great sources of relief against the growing threat of AIDS stems from Islam, which, like other divine religions, prohibits drug abuse and unbridled sexual activity," said Prince Sattam bin Abdel Aziz of Saudi Arabia when opening an HIV/AIDS conference [25].

These views, and those similar to them, have had a major impact on AIDS prevention. In Kenya, where over 10% of the urban adult population is HIV positive, both Christian and Muslim religious organisations have opposed initiatives by government and non-government agencies to make information on sexual issues more widely available.

In the USA, many politicians, usually citing Christian principles, have also called for a moral approach to fighting AIDS. The US Red Cross Society recently responded to campaigns from Christian groups which considered its health education publications on AIDS to be too explicit and revised its materials.

And in many societies, there are strict limitations on the kinds of language and issues that can be dealt with publicly. In Egypt, it is forbidden to use the word "condom" on radio or television except in a strictly technical sense.

Although for most AIDS organisations promoting abstinence from sex and advocating fidelity to one partner are important options, simple moral appeals to refrain from sex are, they argue, unlikely to work. If they did, they argue, there would not be an AIDS epidemic in the first place. The moral position urging young people not to have sex before marriage has long been made but it has not so far prevented widespread occurrence of other sexually transmitted diseases, and unmarried mothers. Alternatively, it is argued that providing information to young people on sex, along with protection, saves lives rather than undermining morals.

Many religious people working in communities affected by AIDS take substantially different views to issues such as condom use from those in religious hierarchies. Pope John Paul II, when visiting Uganda in 1993, stated that chastity was "the only sure and virtuous way" of avoiding AIDS. But in a break in policy, Catholic bishops in France recently responded to pressure from French Catholic doctors by condoning condom use "where it is necessary to avoid serious risk and where sexual activity is already integrated into a person's behaviour."

Can sex education deliver?

"Here in Uganda, sex education is gaining momentum. But unless it is formalised and made accessible to the rural and out of school youth, how do you expect us to cope with this pandemic?"

Lillian Matengo, 21 years old from Uganda, addressing AIDS conference in Kampala, December 1995

Long before the AIDS epidemic appeared, sex education was a moral, religious and political minefield. Nevertheless, in most countries in the North formal sex education has become routine and many studies have been conducted with a view to establishing the most effective ways of running sex education programmes.

In the South, however, formal sex education is still a relatively new idea and there have been very few studies to investigate how it is being done and what it is achieving. There is also a poor understanding and knowledge of the many traditional forms of sex education, and limited research as to whether these can be more effectively drawn upon in relation to AIDS prevention programmes.

The most common objection to sex education surrounds fears that it encourages early sex. There is very little research which either proves or disproves this argument in developing countries. Where research has been done, mostly in the USA and Europe, research has consistently shown that sex education either delays the age of first intercourse, or makes no difference.

A World Health Organisation summary [26] of 19 research studies found that in no study was there evidence of sex education leading to earlier or increased sexual activity. Six of the studies found that sex education led either to a delay in the onset of sexual activity or to a decrease in overall sexual activity. In 10 studies, sex education increased the adoption of safer practices by those who were already sexually active. And two studies showed that access to counselling and contraceptive services did not encourage earlier or increased sexual activity.

A separate study in the Philippines among high school students tried to find out the impact that an AIDS prevention programme developed by teachers and AIDS experts had on students' sexual behaviour [27]. The study found that, although there had been little impact in terms of students using condoms during sex, the age at which they were first having sex was delayed and their understanding of HIV and AIDS was increased.

The anecdotal evidence that sex education in developing countries is effective in reducing sex is increasingly strong. "When I first came to this school in 1994, we had several drop-outs from girls who fell pregnant," says Patience Ruyeko-Mi-engamero, a teacher at a rural school an hour's drive from the Zimbabwe capital, Harare. "But last year [following sex education programmes] in 1995 we never experienced that and for this year as yet there are no reports of pregnancies."

Zimbabwe is one of the many countries where the debate over sex education has been intense. "We feel that sex education is presented entirely in a negative context," says Fr. Anthony Berridge, secretary general of the Zimbabwe Catholic Bishop's Conference which urges young people to abstain from sex before marriage. "In other words it wasn't being presented as about the formation of relationships and particularly the formation of life-long relationships, but it was simply being presented in the context of avoiding infection. Related to that was the whole question of safe sex which again was simply being presented as though promiscuity was a factor that simply had to be accepted by everybody and the only response was simply to make it safe. We felt that was inadequate."

Martha Tromp, project coordinator with Adolescence and AIDS Prevention in Zimbabwe disagrees with the views of Zimbabwe's Catholic Church. "When you consider the very rapid spread of HIV in the teenage population it is really not enough to say that people should abstain from sex. Obviously people are not abstaining, and whether an individual wants to abstain or not does not always figure in the situation, particularly in the case of girls."

Although there are few guarantees that sex education will lead to behaviour change, there is an increasing consensus that messages that rely on fear and simple appeals to morality have not worked. A number of Christian organisations acknowledge this. The UK Catholic aid agency, CAFOD, argues that although advocating celibacy before marriage runs throughout its work, the Church needs to acknowledge that young people are having sex, and that sex education "based on human values and responsible relationships" [28] needs to take place before secondary school.

Initiating sex education... and cultural constraints

The age at which sex education should begin is subject to strong arguments, and this is confused further by what sex education actually is. Many teachers start educating young children about their body at an early age and teach them, for example, that if someone touches them inappropriately that they should tell their parents or teacher. "We start at age eight or even below, " says Ruth Gumbie of the National AIDS Co-ordination Programme in Zimbabwe. "But when we start at that age, we don't just start by talking about sex, talking about HIV, AIDS and things like that. We start talking about the information that helps this child to know who they are and how they can best protect themselves."

In many Northern countries some basic education about sex is given at primary school. However, most development agencies Panos contacted told us that the programmes they support in the South generally start at age 13, mainly because they considered that starting any earlier would be seen as being unacceptable in individual countries.

The Joint United Nations Programme on AIDS (UNAIDS) policy on the age to start AIDS education is that it should be as early as possible. For many AIDS workers, starting sex education at 13 is too late. Some teenagers will already be sexually active before they receive any education about the risks involved. And more pragmatically, by 13 many have already left school. Primary school enrolment rates are now approaching 100% in many countries in the South, but secondary school enrolment, particularly for girls, is a lot lower. And for many in the South, secondary education does not start until 15 or older.

In some countries, North and South, teachers are often expected to teach formal lessons to classes with over 40 students. Clearly, there is a limit to what can be achieved in this kind of setting. And many teachers in most parts of the world are uncomfortable and embarrassed discussing issues of sex and sexuality. It is partly because of this that in many countries, if information on sexual issues is provided at all, it is included in subjects such as biological sciences and human physiology.

Nevertheless, new initiatives are happening all the time, many of which have been highly successful. In Senegal, for example, a project aimed at 13 to18-year-olds in schools in the district of Ziguinchor ensured that 100% of secondary school teachers understood HIV/STD prevention and were capable of organising a discussion with students; 80% of Ziguinchor students and 50% of their parents received information through such discussions.

Other constraints on sex education stem from laws, which apply in most countries, prohibiting young people from having sex before a certain age. Although these laws probably play a limited role in influencing young people's behaviour, they can cause difficulties for teachers and others involved in sex education and AIDS prevention who seek to provide information on sex to young people.

Yet the biggest single constraint on formal sex education is that most adolescents in many developing countries have left school by the age of 15. Reaching these groups, many of whom are poor, unable to read and write and among the most vulnerable to HIV infection, is arguably the highest AIDS prevention priority.

Outside the classroom

Although some of the most intense arguments around AIDS education have centred around sex education in schools, organisations such as Unicef argue that education needs to be targeted as a high priority at those young people who are not in school. In some countries, up to 80% of students do not continue beyond the primary level. And it is among these groups - described by UNAIDS as "especially vulnerable young people" - who are often at much higher risk of HIV infection than those in school. Among these children are those living in rural areas, refugees, migrants and sex workers.

Among those at greatest risk are street children. Some estimates suggest that there are as many as 100 million children and adolescents in the world who are working or living on the street, often in violent and dangerous conditions [29]. In Brazil alone, there are an estimated seven million children and adolescents from very poor families who live on the streets. These groups are some of the most vulnerable to HIV infection and, of course, to many other dangers. For many, sex may be a means of securing money, affection, comfort, shelter or protection. And increasingly, street children are the victims of abuse by adults and those in authority.

Many initiatives have been started to try to educate out of school youth about HIV/AIDS issues. Kabalikat, a non-government organisation (NGO) in the Philippines, operates a drop-in centre for street children in Manila. Meanwhile, the Canadian NGO Street Kids International has produced one of the most widely publicised education initiatives for street children, Karate Kids, a video which uses explicit, street-wise language in a cartoon format to educate and entertain. The video is shown to street children, and afterwards they talk over situations in their lives which are similar to those shown in the video: one film shows Karate Kid chasing a way a man who is trying to have sex with Mario, another character.

When the Zimbabwean Government tried to reduce the number of children living on its streets by putting them in probation centres, most of the children simply ran away. In response to this a new organisation of young people called Youth In Touch was formed, believing that the most effective way to reach young people was through other young people. In 1994, it started a street children programme targeted at 4 to12-year-olds. "This age group are still open and adaptable to life, unlike the street adolescents who are often victims of the street subculture," says a member. Visits are made by youth volunteers to selected points in the city centre twice a week. "Kids are taught about life and growing up while having games and fun," says a volunteer.

In many developing countries, young people are often more concerned about their education and economic and social development than they are about AIDS. In Zambia, the Copperbelt Health Education Project has been working with young people since the earliest days of the AIDS epidemic in the country. Its work focuses not only on providing education to young people about AIDS, but also on much wider issues such as job hunting and staying out of jail.

Youth on the margins

There is a growing recognition that whole communities of young people have been marginalised or ignored. This is particularly true of young men who have sex with men. They are often ignored or bypassed in broader youth programmes in developing countries. Many of these programmes assume that all sex occurs heterosexually, despite increasing evidence that sex between men of all ages occurs in every society, even those with the strictest taboos against it. Poor knowledge and insufficient understanding of this issue is compounded by stigma and discrimination. The result has often been that essential education messages have not been targeted at this group who are frequently at high risk because of their sexual practices.

Friend to friend

Most people across the world, if asked where they got most of their information about sex when they were growing up, will say it was from their peers [31]. AIDS educators have concentrated heavily on using young people to inform each other about sex and HIV/AIDS. "Peer education", as this approach is called, involves small groups of young people being given intensive training on how to carry out sex education; they then go out to work directly with people of their own age. Young people receiving information from their peers are, it is argued, less inhibited about participating in the process of their own education.

Building for life

Many agencies are concentrating their efforts on young age groups. UNAIDS argues that one of the most important age groups is the 10 to14-year-old group. The approach adopted by most agencies, including international organisations such as Unicef, focuses on building "life-skills". The approach recognises that AIDS is just one of a number of threats to children and young people, and that preparing children to face those threats means preparing them for life in general. So protection requires not just information but also a series of skills, such as how to talk about sex, how to negotiate safer sex, how to obtain condoms, how to delay the age of first sex, and how to recognise and deal with potentially violent situations.

In Mexico, a major television series for children called Plaza Sesamo - based on the US-originated Sesame Street - uses highly entertaining programming to communicate basic life skills to children as young as three. The programme uses lively animation, documentary footage and puppetry to convey both direct health messages, such as encouraging children to wash their hands after using the bathroom, to presenting strong and positive role models of girls and women. Although the programme was not started in response to HIV/AIDS, acknowledging the strong role of "machismo" in Latin American society and the implications of this for girls and women has prompted the programme to challenge gender stereotypes. One of the cast, for example, is an independent mother with her own career and sharing household chores is often illustrated. The programme is produced by the US organisation, the Children's Television Workshop, through a partnership with Televisa Mexico and Unicef.

Access to condoms

"No programme, no amount of money, no support will make a difference if it does not provide youth and women with the means to control their lives", argues Unicef. Perhaps the most controversial of these "means" is the issue of access to condoms. Many organisations who are prepared to sanction sex education are not prepared to sanction or promote condom use. For others, information about condoms would be acceptable but providing them would be a step too far.

Many different ethical stances have been adopted by agencies operating in this area. Some are opposed to all use of condoms. Others would restrict their use to within marriage. Some agencies will provide condoms to young people over a certain age, say 15. Some will give them to younger people but only if they are already sexually active. For many development agencies, the main focus should be on the provision of information. Few would disagree that condoms on their own are not enough.

Most agencies are convinced of a huge unmet demand for condoms among young unmarried people. Agencies are providing these as part of comprehensive reproductive health programmes designed to address not only AIDS but a whole range of issues ranging from other STDs, reproductive tract infections and unwanted pregnancies. In a recent case in the UK [32], a family planning clinic which distributes condoms to clients of 13 or older, but does not ask for proof of age, came in for widespread criticism for giving condoms to children even younger than this. Politicians said the clinic was both encouraging and facilitating under-age sex. The clinic said it was not its policy to supply condoms to such young children but pointed out that many 11-year-olds in the area were known to be having sex.

Using the mass media

Young people can be reached effectively - perhaps more so than adults - by the cultural media. Puppets, popular music, comics, films, radio, TV and soap operas are all used in AIDS education. Popular entertainment can also attract commercial support, which makes this a cost-effective approach.

Soul City In South Africa, health and media organisations have joined forces to produce a highly successful "multi-media" soap opera, Soul City. The soap opera is set in a South African township and is broadcast on prime-time television and on radio, and additional information and story lines are emphasised through newspaper booklets and through publicity and advertising campaigns. The programmes, which reach up to 11 million people, use dramatic story lines on issues such as HIV/AIDS, immunisation, breastfeeding and child abuse. "Through drama, you can show the real issues that happen in people's lives," says Garph Japhet, the originator of the project.

Straight Talk In Uganda, a newspaper targeted at young people has been highly successful in reaching young people. With a circulation of around 100,000 per month, Straight Talk has broken new boundaries in its explicit discussion of sex and has won a large and involved audience. The paper is targeted at 14 to 19-year-olds and is sent to all Ugandan high schools as well as being distributed with one of the main Ugandan newspapers, New Vision. Much of the paper is taken up with comments and questions from its readers and the advice provided is forthright. In reply to one question from a male reader, the paper wrote, "if you are afraid of having sex with your girlfriend then it means you are not ready yet. Sexual feeling at your age is normal but you don't have to have sex. Masturbation could help you relieve tense feelings." Editor Cathy Watson says, "These are not normal days. We have to deal with reality and ensure a spade is called a spade in order to unravel the myths and problems related to youth sexuality." Despite the conservative nature of Ugandan society, the paper is flourishing.

Entertainment can also involve participation. Touring health education theatre groups are now in operation in many developing countries. Drama is particularly popular when performed in local languages. Some productions start as school projects but are then taken out into the community. In the Dominican Republic, a provocative theatre group created by the Centro de Orientaci-n e Investiagi-n Integral draws crowds in streets and bars into debates over condom use.

The Talking Drum In C-te d'Ivoire one project uses a travelling radio road show as one component of a mass media project to promote condoms and provide information and education about HIV/AIDS and other health issues. The recording of the programme takes place in the main marketplace of a small town in front of an audience of 1,000 to 2,000 people. The centrepiece of the programme is a competition in which participants are tested on their knowledge of health and HIV/AIDS issues. The programme, called Attoungnblan or The Talking Drum is aired at peak listening time on Sunday mornings on Radio C-te d'Ivoire.

Ads Advertising has also been found to be highly effective, particularly when used in conjunction with other mass communication initiatives and when promoting condoms. This "social marketing" of condoms seeks to use commercial marketing techniques to make affordable, quality condoms available to people when and where they need them. Condoms are sold in street markets, gasoline stations, motels, bars and night clubs. In Brazil, condoms are sold by a cosmetic company's door-to-door salesforce. Social marketing programmes are accompanied by innovative and dynamic advertising campaigns which seek to address negative stereotypes about condoms. In Ethiopia, social marketing campaigns have lead to a fivefold increase in condom sales in four years to a total of over 17 million condoms sold in 1994. In Haiti, one US government-sponsored programme boosted condom sales from less than a million to over 7 million in four years.

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3 TAKING CONTROL

Tackling AIDS in the future

Millions of dollars have now been spent on HIV/AIDS prevention worldwide, a significant proportion of which has been allocated to trying to alter the sexual behaviour of young people. There are signs in some countries, such as Uganda and Zaire, that the prevalence of HIV, although still very high, is beginning to stabilise or to fall [33]. However, whether this is because the epidemic has reached a natural plateau or because education and prevention initiatives have worked is difficult to assess. The evidence of what works, in terms of influencing behaviour, and what does not, is scanty. Limited research on behaviour change has so far been completed and much of what has been done has been carried out in the United States.

A consensus view is beginning to emerge within many AIDS organisations around the direction in which prevention activities for young people should now be heading. Among the key issues is the need to provide young people with information which they can relate to and understand, whilst at the same time persuading decision makers and the public that doing so does not encourage promiscuity.

Other key issues include the need:

- to highlight the dangers faced by girls and young women and to lobby for an improvement on

- their position in society;

- to set AIDS in its social and reproductive health context;

- to develop the "life skills" of the young;

- to use techniques such as role-play, peer education and entertainment;

- and to have open-minded debate on the age and circumstances in which the provision of condoms is desirable.

It is also recognised in all health education work that the more highly targeted a programme is the more effective it will be. Some experts are now focusing on the need to move away from stereotypes and textbook accounts of adolescent sexuality and to get closer to the 'sexual cultures' of the young [34]. And one of the biggest challenges facing AIDS educators is how to take the lessons of successful small-scale AIDS projects and "scale" them up so that they can be applied to much larger groups of people.

Young people demand a say

Young people have begun to organise protecting themselves from HIV/AIDS, and when given the right kind of support, are increasingly do so. Those who have done so have argued consistently that reaching young people requires the involvement of young people.

At an international conference on AIDS in Africa in 1995, a "delegation" of young Africans from 11 countries ranging in age from 14 to 24 issued a declaration of their needs and priorities: "We strongly believe that our energy, idealism and commitment can be used to stop the further spread of the AIDS epidemic that is devastating the social and economic fabric of our own countries."

The declaration puts forward a series of principles which are seen as essential if effective AIDS education is to work. In their words:

Youth participation: involve us in programme planning, implementation and evaluation and policy development in community decision making processes.

Youth friendly services: support the provision of services, including centres where we can access information, support and referral.

Parental involvement: strengthen the capacity of parents and other significant persons in our lives to better communicate with us and provide guidance and support to us, our brothers and sisters.

Education about HIV/AIDS and sexuality: promote skills-based education on physical development, reproductive health and sexuality for both in and out of school youth.

Protection of girls and young women: prevent the sexual abuse and exploitation of girls in vulnerable situations; emphasise the sensitisation of boys, young men and elder men.

Partnership with people with HIV and AIDS (PWAs): build networks between young PWAs and other youth to promote prevention of HIV/AIDS, protection of human rights and acceptance of PWAs in society.

Young people's commitments: commit ourselves to responsible decision making about our own sexual behaviour and positively influence our peers.

Hope for the next generation

The AIDS pandemic itself is less than two decades old. Although great strides have been made during that time in understanding HIV, societies' understandings of the motivations and opinions of their young people have progressed much more slowly. No cure or vaccine for AIDS has yet been developed, and any that is developed is likely to be too expensive for widespread application in developing countries. Knowledge and information remain at the heart of humankind's response to AIDS. But it is difficult to see how HIV is likely to be contained in any society unless young people themselves have a greater influence over the programmes and messages that are designed to protect them, and unless the status of young people is improved.

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References

1 The Second Decade, A Focus on Youth and Women. Unicef, New York, 1993

2 Workshop on the Status and Trends of the HIV/AIDS epidemics in Africa: Final Report, 1995, Fran-ois-Xavier Bagnoud, Center for Health and Human Rights/AIDSCAP

3 Veruyl, D.A., Lancet 1995; 634(890): 293-6

4 Population Reports, October 1995, Series J, Number 41

5 Youth and AIDS, A Priority for Prevention Education, Global Program on AIDS, 1992

6 Quoted in youth presentation, Unicef, IX International Conference on AIDS and STDs in Africa, Kampala, 1995

7 USA Centers for Disease Control, Annual Report 1994

8 Abdul Karim Q. et al, South African Medical Journal 1992; 82(5): 360-2

9 "Adolescent sexuality in Saint Petersburg, Russia", Lunin et al, AIDS 1995, Vol 9, Supplement 1

10 World Health Organisation, Global Programme on AIDS, Provisional Working Estimates of Adult HIV Prevalence as of end 1994 by Country, 1995

11 Stuart-Smith S., British Medical Journal, 1996; 312: 17

12 Population Reports, October 1995, p4

13 ibid

14 Global AIDS News 1994, No 3, p7

15 Information supplied by Family Health International which assists national organisations in many countries, including Senegal and Thailand, to run programmes aimed at young people.

16 Figure provided verbally by UNAIDS, 24 June 1996

17 B.N. N'Galy and others, "HIV Prevalence in Zaire, 1984-1988", Abstracts of IV International Conference on AIDS, Stockholm, June 1988, 5632

18 Michael Merson, director of WHO Global Programme on AIDS, X International Conference on AIDS, 1994, quoted in AIDS: safety, sexuality and risk, ed. Peter Aggleton et al. 1995

19 Population Reports, October 1995, p13

20 Quoted in youth presentation organised by Unicef at X Conference on AIDS and STDs in Africa, Kampala, 1995

21 WorldAIDS, Panos Institute, March 1994

22 "Adolescent sexuality in Saint Petersburg, Russia", Lunin et al, AIDS Supplement, July 1995, Vol 9, Supplement 1, ppS1-S77

23 WorldAIDS, Panos Institute, May 1994

24 Effective HIV/AIDS Activities: NGO work in developing countries, UK NGO Consortium 1996

25 Quoted in WorldAIDS, Panos Institute, March 1995

26. Analysis by WHO's Global Programme on AIDS, presented at the XI International Conference on AIDS, Berlin 1993

27 HIV/AIDS education in the Philippines, Aplasca et al, AIDS 1995, Vol 9, Supplement 1

28 Panos conversation with CAFOD staff, 21 June 1996

29 Working with young people: a guide to preventing HIV and AIDS, WHO, Commonwealth Youth Programme and Unicef, Commonwealth Secretariat, 1995

30 ibid

31 Population Reports, October 1995, p24

32 Guardian newspaper UK, 29 May 1996, p6

33 Declining trends in HIV infection in urban areas in Uganda, Asimwe-Okrior, G. et al, IX International Conference on AIDS and STD in Africa

34 Discussion with Peter Aggleton, Institute of Education, London

RESOURCES

WHO/UNESCO, School Health Education to Prevent AIDS and STD. Three volumes: Student's activities; Teachers' Guide; Handbook for Curriculum Planners. Published by WHO, Geneva, 1994.

WHO/Commonwealth Youth Programme, Unicef, Working with Young People: A guide to preventing HIV/AIDS and STDs. Published by Commonwealth Youth Programme, London, 1995.

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Contacts UNAIDS

20 Avenue Appia CH-1211 Geneva 27 Switzerland Tel: (+41 22) 791 3666 Fax: (+41 22) 791 4187 e-mail: unaids@who.ch Internet site: http://158.232.20.3/ Unicef (United Nations Children's Fund)

3 United Nations Plaza New York, New York 10017, USA Tel: (+1 212) 326 7000 Fax: (+1 212) 888 7465 AIDSCAP/Family Health International

2101 Wilson Boulevard Suite 700 Arlington, VA 22201, USA Tel: (+1 703) 516 9779 Fax: (+1 703) 516 9781 e-mail: mogrady@fhi.org Population Information Program

Center for Communication Programs The Johns Hopkins School of Public Health 111 Market Place, Suite 310 Baltimore Maryland 21202-4012, USA Fax: (+1 410) 659 6266 e-mail: poprepts@welchlink.welch.jhu.edu Commonwealth Youth Programme

Commonwealth Secretariat Marlborough House Pall Mall London SW1Y 5HX Tel: (+44 171) 930 3783 Fax: (+44 171) 839 8157 Harvard School of Public Health

Fran-ois-Xavier Bagnoud Center for Health and Human Rights 8 Story Street Cambridge MA 02138, USA Tel: (+ 1 617) 496 4370 Fax: (+1 617) 496 4380

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