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PREVENTING RISKY BEHAVIOR IN ADOLESCENTS
There is no preventive vaccine or cure for AIDS, so eliminating risky behavior that might lead to HIV infection is the only way to stop the spread of the virus.? Effective HIV prevention programs for adolescents must dispel myths, impart knowledge about HIV transmission and self-protection, reinforce or instill health promoting attitudes and behaviors, and, ultimately lead to sustained avoidance of high-risk behavior.2
Few HIV prevention programs for adolescents have been rigorously evaluated. Some interventions have increased knowledge about AIDS or even induced reported changes in relevant attitudes. Unfortunately, responses on paper in a classroom do not guarantee reductions in high-risk behavior or increases in health-promoting behavior.
HIV prevention programs have adopted promising strategies from efforts to reduce smoking and other risky behaviors common among teenagers. Additional HIV prevention program guidance has emerged from the front-line experience of educators, public health officials and youth service providers."
Even if a cure for HIV infection is found, prevention will continue to be necessary. New treatments will bring with them complex issues of experimentation with human subjects and problems with resource allocation. As the rise in the rate of syphilis infection has shown, no single intervention, even effective treatment, is likely to totally eradicate this major public health problem.
A. COMPREHENSIVE HIV PREVENTION PROGRAMS
During the past several years, many efforts to reduce or eliminate the risk of HIV infection have been undertaken. Prevention campaigns targeting teenagers are underway in classrooms, school-based and community-based health clinics, other community settings, and the media.
Program elements range from individualized counseling to comic books. Some programs employ a single type of intervention, while others utilize various combinations of strategies.?
The Select Committee on Children, Youth, and Families held hearings in June 1991, The Risky Business of Adolescence: How to Help Teens Stay Safe, to identify effective strategies for preventing risky behavior in adolescents. Several witnesses at the hearings pointed out that "AIDS 101" is insufficient to elicit behavior change in teenagers.
William Gardner of the University of Pittsburgh School of Medicine listed some of the necessary components of effective programs in his testimony to the Committee:
Preventive education should begin early, before risk-
The intervention must be persistent, with messages
The intervention should be comprehensive, addressing all
The intervention should include social skills training to
When adolescents are already participating in high-risk
Further direction for prevention programs comes from a report issued by the Committee on AIDS Research and the Behavioral, Social, and Statistical Sciences of the Institute of Medicine (IOM). The Committee found that HIV prevention programs should disseminate clear, specific information to all adolescents about the dangers of drug use and unprotected sex, and about the protective value of abstinence, condoms and spermicides. Adolescents at highest risk should be (1) provided special outreach and information, (2) aided in altering the
behaviors that put them at risk, and (3) offered assistance in escaping the social or economic conditions that foster risk-taking. This guidance was recently reiterated by the Office of Technology Assessment (OTA).10
Several sets of guidelines for HIV prevention programs for adolescents are available. References for guidelines are listed in Appendix C of this report, and include those developed by the Centers for Disease Control (CDC) and others tailored to address special needs such as those of young people in rural schools. Chapter III provides descriptions of model programs targeting specific populations.
B. LESSONS FROM TEEN PREGNANCY PREVENTION
Because few evaluations of HIV prevention programs for teens have been conducted to date," existing information about preventing other problems associated with high-risk behaviors must guide HIV prevention programmers."
Certain program components have been shown to be necessary to prevent any type of undesirable outcome of high-risk sexual behavior in this age group, and program design must take into account the psychological realities of adolescence.13
No Single Solution: Education, Communication With Adults, Skills Training and Health Care Access All Needed to Reduce Pregnancy
The Office of Adolescent Pregnancy (OAP) has funded abstinence promotion over the last ten years.24 Studies of the impact of a single "Just Say No" approach to teen pregnancy prevention show that it does not actually change behavior, and may ignore important adolescent characteristics.15
Kathleen Sullivan, Director of Project Respect in Illinois, reported statistically significant differences in teens' reported beliefs and attitudes about sex after participation in her abstinence promotion program. For example, "When asked, 'Are sexual urges controllable?' 28% said 'Always' on the pre-test in this past year and that went up to 48% on the post test.
However, formal evaluations of the program show no evidence of behavior change in Project Respect participants."7
By contrast, abstinence programs that add social skills training (including topics such as assertiveness, refusal skills, interpersonal problem solving, and decision making) which are taught by high status individuals (e.g., respected peers) have resulted in as much as one year's postponement of sexual initiation in young teens (8th and 9th graders).18 However, even the most successful abstinence programs have had little effect on the behavior of older teens who were already sexually active and therefore at higher risk of both pregnancy and HIV.19
Similarly, traditional school-based sex education alone, while necessary, appears insufficient to reduce the prevalence of unprotected sex. At the "Risky Business" hearing, Bradley P. Hayton cited evidence in his written testimony that sex education (in the absence of skills training, mentoring and health care access) has not been shown to delay sexual activity or to increase use of contraception.20
However, broader approaches that supplement education with certain additional services have proved effective with many older teenagers. A level of funding characteristic of multi-mode programs is required to "...provide ample dosage to offset this major socio-cultural problem."
Demonstration programs such as The School/Community Program for Sexual Risk Reduction Among Teens, designed by Professor Murray Vincent of the School of Public Health of the University of South Carolina,22 and Preventing Adolescent Pregnancy, by Girls' Inc. have shown that teen pregnancy rates can be cut by more than one-third when several key program elements are combined. Effective demonstration programs comprised health care services (including contraceptive access or distribution), individual counseling, career planning, social skills training, parent/child communication workshops, and sexuality or family life education.24
It should be noted that, even when comprehensive programs have demonstrated effectiveness at one point in time, continual