Misunderstood: The Educational System’s Failure to Prevent Human Immunodeficiency Virus (HIV) in At-Risk Adolescents – Veena Thomas

Introducing AIDS in Adolescents

"If you love yourself, you can protect yourself," says Marvelyn Brown, a 24-year old woman who states that, as a teenager, she did not care enough about herself to require that her boyfriend consistently use condoms when she contracted HIV (1). She shares her story and experiences in her autobiography, The Naked Truth: Young, Beautiful, and (HIV) Positive. Might her story help to convey the message of safe sex more effectively across to adolescents at risk for HIV? Although there has been a great focus on men who have sex with men (MSM), as this group had the largest increase in HIV diagnoses in recent years, diagnoses of AIDS in adolescents of both sexes has been on the rise (2). Sexual risk factors in the 13 to 19 year olds contribute to adolescents’ HIV risk, including heterosexual transmission, MSM, and early age of sexual initiation (3). Young women are at risk for sexually transmitted HIV for several reasons, including “biologic vulnerability” and greater efficiency for the virus to be transmitted from males to females, lack of recognition of their partners’ risk factors, inequality in relationships, and having sex with older men who are more likely to be infected with HIV” (3). These women may contract HIV from infected MSM as well, who may be stigmatized by their sexual orientation. A study on college-age African-American MSM with sexual risk factors for HIV infection showed that 20% had a female sex partner during the preceding year (4). Approximately 47% of high school students report ever having had sexual intercourse, and 7.4% of these students report having had sex before age 13, according to Center for Disease Control’s (CDC) Youth Risk Behavior Surveillance in 2003 (5). Even among the 25 to 44 year old age group, given the long incubation period, a large number of these adults may have acquired the virus as teenagers (6,7). This data translates to the need for HIV/AIDS education before young people engage in sexual behaviors that put them at risk for HIV infection.

CDC’s Guidelines for AIDS Education
Schools are the key collaborative public health partners for reaching adolescents before high-risk behaviors are established (3). Therefore, the role that the educational system plays in HIV prevention must be scrutinized, because many infected adults could have been reached as adolescents through schools. The CDC, in consultation with the American Public Health Association among other national and academic organizations, developed the “Guidelines for Effective School Health Education to Prevent the Spread of AIDS” (8). While the CDC’s guidelines can be found in its entirety online, this section delineates the key areas which will be later focused on in the critique of this public health intervention.
The guidelines, updated in 2004, incorporate AIDS education principles that were developed by the President's Domestic Policy Council and approved by the President in 1987, which among other statements, include the following: “Any health information developed by the Federal Government that will be used for education should encourage responsible sexual behavior–based on fidelity, commitment, and maturity, placing sexuality within the context of marriage” and “Any health information provided by the Federal Government that might be used in schools should teach that children should not engage in sex and should be used with the consent and involvement of parents” (8).
According to the CDC’s guidelines, the content of the AIDS education programs should be developed “with the active involvement of parents” and in secondary grades, the secondary school health education teacher should provide the students with AIDS education (8). The school system’s message should be two-fold: one, “abstain from sexual intercourse until they are ready to establish a mutually monogamous relationship within the context of marriage,” and two, “refrain from using or injecting illicit drugs”; if young people are already engaging in sexual intercourse or using illicit drugs, they should stop (8). The late elementary/middle school model includes other details: the definition of viruses, what AIDS stands for, occurrence of AIDS-associated conditions like pneumonia and Kaposi’s sarcoma, and the 240 million Americans with AIDS who are capable of infecting others (8). The junior and senior high school model focuses on the sexual and intravenous drug routes of transmission, who is at increased risk - MSM, IV drug users, people with numerous sexual partners, including male or female prostitutes, those who received blood transfusions, infants born to infected mothers, what to do if infected, and so on (8). So, what’s wrong with these guidelines? Why is HIV in adolescents still increasing despite such educational measures being in place?

The Threat
We will begin this critique by evaluating the basic content and source of the message. There are two problems with the CDC guidelines for AIDS education: the threatening content of the message and the dissimilarity of the source to the target audience. The guidelines, as recommended by the President’s Domestic Policy Council and the CDC, explicitly state that schools should instruct children not to engage in sex, practice abstinence until marriage, and refrain from using drugs.
Psychological reactance theory can be applied to understand adolescent reactions to the imposition of abstinence. According to this theory, when people perceive that a behavioral freedom is threatened, they experience a motivationally-aroused state called reactance, aimed at restoring that threatened freedom (9,10,11). In response, the opposite of the desired behavior, the “boomerang effect,” occurs in an effort to exercise and cling to their freedom (11).
There are four key elements of psychological reactance theory, specifically: perceived freedom, threat to freedom, reactance, and restoration of freedom (9). The greater the perceived freedom and threat to freedom are, the greater the level of reactance and restoration of freedom in response. Adolescents have the perceived freedom to choose to have sex; the threat imposed by the guidelines is that adolescents should not have sex, which in turn creates a motivationally aroused state where the adolescent fears losing that freedom. The adolescent instead may react by having sex, and unsafe sex at that, to restore that freedom. If we measured reactance by the five-point scale developed by Dillard and Shen (12) to see how adolescents felt about the CDC guidelines, we may have found that that adolescents found the message threatened their freedom to choose, pressured them not to have sex, tried to make a decision for them, and evoked any or all of the following emotions: anger, irritation, aggravation, or annoyance. Therefore, these guidelines would actually be a recipe for creating the opposite of prevention – unintentionally increasing the incidence of HIV in adolescents, in concordance with the current statistics (2), not to mention the US teenage pregnancy rate which is higher than any other high-income country (13).
Next, these guidelines for HIV prevention education are to be developed via the active involvement of parents, as recommended by the President’s Domestic Policy Council and CDC. Since when were parents considered the most effective communicators to adolescents? “Don’t do this, don’t do that...” say the parents, while the adolescent responds, “Everybody else is doing it. Why can’t I?” and the parent retorts, “Because I said so.” This so-called discussion between parents and adolescents is rarely fruitful or effective in preventing a behavior, based on anecdotal evidence. Social and behavioral theories support this anecdotal experience, however. In a study on deflecting reactance, researchers investigated the role of similarity between the source conveying a message and the audience and found that interpersonal similarity can reduce reactance, by increasing compliance and reducing resistance (11). Even if the message were threatening in nature, the audience still agreed with the communicator if they were similar, as much as they agreed with the similar source if the message were non-threatening (11).
Could a parent be more dissimilar to an adolescent? Threats by a parental figure may tend to cause boomerang effects, because the source similarity to the adolescent is low (11). Adolescents often view parents as the enemy, one who is from a different generation who does not understand what it is like to be a teenager today and fit in, therefore if a parent, a dissimilar source, is delivering a threatening message, we are likely to have the least compliance and most resistance by an adolescent audience.

Self-Perceptions Undermining Education
88% of high school students in the United States reported having been taught about AIDS or HIV infection in school (3). However, the contradiction lies in the same CDC report that states “Research has shown that a large proportion of young people are not concerned about becoming infected with HIV”(3). Clearly, there is a problem in the education itself, if despite being taught it, students do not feel it affects them and lack awareness of the problem. If we review the junior and senior high school AIDS education curriculum, one of the focuses is who is at increased risk, referring to prostitutes, IV drug users, infants through perinatal transmission, as well as MSM, people with numerous sexual partners (8). A young heterosexual woman may not consider the number of sexual partners she have to be numerous, and does not feel she falls into any of the other categories; therefore, she believes she is safe. This is optimistic bias at play. Many of the adolescents who are receiving this education may be “comparing themselves to an unrealistic stereotype of a person who… engages in counterproductive activity,” thereby concluding that their own prospects were well above average (14), contributing to the lack of awareness of their own risk. By focusing on the risks to specific groups, this curriculum encourages the view that AIDS is “somebody else’s problem” – if the student does not fit criteria for the at-risk group, he or she does not need to worry about acquiring the disease (15).
The Law of Small Numbers, a behavioral economics theory, may also be applied to understanding the inefficacy of the CDC guidelines for AIDS education. This theory states that people tend to exaggerate the degree to which a small sample resembles the population from which they are drawn (16). Adolescents’ perceptions of the probability of acquiring HIV/AIDS may be underestimated, because while they might know people who have sex with multiple partners, they do not know of anyone with HIV/AIDS.
These two theories work together to undermine the AIDS education in junior and senior high schools, because knowledge of the risks is irrelevant to the prevention of HIV, if the adolescent does not perceive themselves to be susceptible to those risks.
Rationalization of Sex
Over the years, the HIV prevention literature has demonstrated that knowledge of HIV transmission alone is not sufficient for teens to practice HIV preventive behaviors (7). The CDC guidelines educate adolescents about the definition of a virus when teaching them about HIV, and abstaining from sex until marriage as the solution (8). This is a form of intellectualizing and rationalizing a situation that, in the heat of the moment, may not be rational. They treat sexual urge and desire as a shameful switch that should be turned off robotically, at a time when adolescents are undergoing a physiological surge in hormones and becoming comfortable with their new bodies during puberty.
Sexual desire is a visceral factor, among other drive states such as hunger, thirst, physical pain, drug cravings which may cause us to behave irrationally (17). The “hot” state during which such personal decisions are made is ignored by this set of guidelines and in sex education in general. People can have the full knowledge regarding HIV and sex, but they often act against their self-interest feeling “out of control” (17). This may seem like a dead end then, as one may question how an intervention can address irrational sexual decision-making. The truth is that there are other factors that can actually influence this seemingly irrational behavior, such as sexual self-efficacy and self-esteem of the individual, that are neglected by the CDC guidelines. Taking a real case scenario, Marvelyn Brown and many other young women who have contracted HIV believe that low self-esteem played a role in their decisions not to use protection during sexual intercourse (1).
The Alternative
The following alternative intervention is aimed at addressing the inadequacies of the CDC’s guidelines for more effective HIV prevention education for adolescents. Because 47% of high schools students report having had sexual intercourse (5), this intervention should target middle school students. We must first divide male and female adolescents into separate focus groups, mostly led by a same-sex young adult opinion leader. These groups will meet once a week for eight weeks to discuss several topics. There will be sessions used to convey scientific knowledge about HIV and disease transmission, which may be led by trained high school peer educators, as the National Teen Action Research Institute's AIDS prevention research program does (19). One session must be a presentation by a young individual of the same sex diagnosed with HIV, who is willing to discuss his or her experiences to make this disease a real story. A key topic of the discussion groups would be sexual self-efficacy, or “the confidence in one’s ability to initiate, negotiate, and engage in safe-sex practices,” which has been shown to increase the likelihood that adolescents will practice safer sex and delay initiation of sex (7,19,20). Other sessions would include demonstrations of how to use a condom, as well as sessions focused on HIV education in the context of sexual health as defined by Robinson’s Sexual Health Model (21). This would involve discussion of the ten components essential to human sexuality, including talking about sex, culture and sexual identity, sexual anatomy and functioning, sexual healthcare and safer sex, challenges to sexual health, body image, masturbation and fantasy, positive sexuality, intimacy and relationships, and spirituality (21).
One randomized controlled trial evaluated the efficacy of a community-based social skills HIV risk-reduction intervention, involving weekly small group interventions for African-American women during which they discussed consistent condom use (22). Compared to those in a control group who received a single two-hour HIV risk-reduction information session, women in this group were significantly more likely to report better skills in negotiating condom use, deciding against having sex when there was no condom available, and using condoms more consistently with their partners (22). Therefore, the results of this study support the probable effectiveness of our alternative approach to HIV education.

The Role of Similarity
This intervention would be effective because it remedies the major flaws of the CDC guidelines noted above. First, by using similar aged peer educators and the same-sex young adult health educators as the source of the message, middle school students would be more likely to heed the message and comply. Feeling similar to the source increases attraction towards the person and promotes resistance-reducing perceptions (11). Rather than hand-slapping and dictating that one should abstain from sex, this focus group method reverses reactance by delivering a message about safe sex that is less paternalistic and less threatening, and fosters a supportive environment for discussion and education. It eliminates the threat to freedom and emotionally-aroused state that the CDC guidelines may evoke in an adolescent. By reducing perceptions of the threat, similarity augments a force towards compliance, and reduces a force toward resistance (11).
Peer health educators have been shown to be effective communicators of HIV prevention messages because they are perceived to be a credible source of information, communicate information in a manner that is understood easily by their peers, and serve as positive role models (22). The value of similarity between source and audience in HIV prevention interventions specifically has been demonstrated in previous studies. In one study, opinion leaders were recruited from African-American gay communities to lead focus groups among African-American men who have sex with men (23). They were trained to facilitate discussions on safer sex practices to prevent HIV. This intervention significantly increased condom use and significantly decreased the number of sexual partners over four to twelve months in this group (24), showing effective HIV risk behavior change. In the alternative intervention, the similar source and the non-threatening message will deflect reactance, leading to safer sex practices.

Defeating Optimistic Bias
This intervention uses the Law of Small Numbers in a different approach, by having a young individual with HIV tell his or her unique story to the focus group. One real person’s story is effective in changing behaviors and making the risk real, as demonstrated in a qualitative study of the impact of anti-smoking campaigns on youth (25). The most effective advertisements that deterred youth from smoking were those that featured the suffering of Marlboro Man’s brother with images of the Marlboro Man with tubes in his throat, the appearance of the young woman with emphysema who has a “fat face”, and the hole in the neck of another woman who continued to smoke through this hole (25). The women clearly explain their current plight that resulted from smoking, initiated between the ages of 10 and 13 (25).
Students will be more likely to remember and be touched by the image of this one person similar to them who has been affected by behaviors which may be similar to their own. For example, 24-year old Marvelyn Brown, who did not realize she could transmit HIV through heterosexual contact and did not consider herself high-risk, tours the country providing HIV education to young people and sharing her story (26). This method creates a more realistic picture of this disease and the risks, and becomes more applicable than just far-removed, impersonal statistics about “other” high-risk individuals. In the anti-smoking campaign study, they found that the fact these were real people who suffered helped the youth respondents to understand the serious consequences of smoking (25). Similarly, based on the true story of the individual with HIV, the students in our intervention would comprehend the consequences of unprotected sex. Optimistic bias may therefore diminish as students now have a living example before their eyes.

Embracing Sexuality
The Sexual Health Model is the final piece of this alternative intervention that is able to address the hot state in which sexual decision-making may occur, which the CDC guidelines ignore. Abraham and Sheeran stated that HIV-preventive behavior depends on the “effective management of sexual excitement which may in turn rely on self-acceptance of sexuality” (27, 21). Rather than imposing abstinence on a group that will have sex due to reactance as long as they are told not to, the Sexual Health Model affirms sexuality as a positive force that must be explored (21). It empowers individuals with a new ability to understand sexuality in the physiological context, to communicate their needs and desires, to act intentionally and responsibly by setting appropriate boundaries, and to have a sense of self-esteem and self-acceptance based on knowledge and behavior based on their individual values (21). Particularly important in this age group, they are taught dating and relationship skills that improve self-efficacy in negotiating safer sex (21). By enhancing sexual self-efficacy through this culturally and gender-specific model, sexual identity is integrated into the individual’s core values, which is more likely to influence sexual decision-making.
The CDC guidelines, like many other HIV prevention programs, regard sexual exploration in terms of disease and risk. By discussing sexuality among adolescents, sex may become a less taboo topic, creating less rebellion and less overall reactance as perceived sexual freedom is no longer threatened. Interventions that use the Sexual Health Model are currently under study, with preliminary results in men who have sex with men showing that those who received education based on this model had significantly higher rates of consistent condom use, compared to a control group (21).

Conclusion
The CDC guidelines may meet their basic objective of HIV education about the disease, as almost all students claim they have received the education in school. However, this approach is not sufficient in accomplishing the overarching public health objective: HIV prevention. This goal of HIV prevention requires a novel approach to education that empowers adolescents by promoting positive, sexually-healthy and safe behaviors in an open learning environment, ultimately reducing the numbers of those infected and dying with HIV.

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