Inadequacies of Male Condom Promotion as a Means of HIV/AIDS Prevention Among Commercial Sex Workers in Madagascar – Alison Mickiewicz

Introduction

Madagascar, an island nation located off the south east coast of Africa, is a country faced with numerous health issues, one of the direst being rising rates of sexually transmitted infections (STIs) and HIV/AIDS. With a population of approximately 21.3 million, the number of persons 15-49 years of age living with HIV/AIDS is estimated at 0.1%, a number that has risen steadily over the past 20 years (1).

Figure 1. Source: Epidemiological Fact Sheet on HIV and AIDS, UNAIDS, 2008.

Although this is a relatively low figure compared to many countries in sub-Saharan Africa, the rates of STIs including syphilis, gonorrhea, and trichomoniasis remain high (2). According to the U.S. Agency for International Development (USAID), rates of STIs in Madagascar are among the highest in the world (1). The presence of an STI has been linked to heightened susceptibility to HIV infection (3). In addition to the prevalence of STIs in Madagascar, low literacy, limited access to healthcare services, pervasive poverty, and the acceptance of multiple sexual partners, has created the potential for epidemic-level HIV infections among the general population (4).

Three groups have been identified by USAID as most at risk of HIV infection: commercial sex workers (CSWs), men who have sex with men (MSM) and injecting drug users (1). This paper will focus on the effectiveness of condom promotion interventions as a method of HIV/AIDS prevention among CSWs. In Madagascar, CSWs have their own set of challenges for HIV prevention in addition to those of the general population. Fifty percent of the Malagasy population lives at or below the poverty line (5), when combined with low literacy rates and poor infrastructure, sex work is a quick and easy option for women to support their families (6). The work of a CSW is not without risk, in 2001, a study found the prevalence of chlamydia, gonorrhea, syphilis, and trichomoniasis among CSWs to be: 16.35%, 23.2%, 29.5%, and 53.05% respectively (7). In 2005, , the rate of HIV/AIDS among CSWs ranged from 0.6% for ‘major urban areas to 1.3% for ‘outside major urban areas’ (8), rates higher than the general population.

Focusing specialized interventions on CSWs is imperative, as this population has been described as the ‘nucleus of HIV transmission” (9). Condom promotion as a means of prevention against HIV transmission and other STIs is important to the general population, and critical to high risk groups such as CSWs. Current condom promotion interventions are centered around social marketing techniques which are based on the Theory of Reasoned Action (TRA). By employing mass media campaigns, the majority of the population is exposed to radio ads, billboards, and store signs promoting the use of condoms, an effective way to reach large numbers of people. However, my argument lies in the lack of support and education aimed directly at CSWs, given that they are such a high risk group with potential to act as a catalyst to the transmission of HIV and other STIs.

Developed in 1975 by Martin Fishbein and Icek Ajzen, The Theory of Reasoned Action lies on the premise that an individual’s actions are determined by said individual’s intentions (10). According to Fishbein, “at the simplest level, a reasoned action approach to the explanation and prediction of social behavior assumes that people’s behavior follows reasonably from their beliefs about performing that behavior” (11). Employing behavioral intentions as a basis for a health intervention appears reasonable, however, emotions and innate human irrationality is not taken into account. It is fair to say that what an individual intends to do is quite often not what that individual actually does; this is even more evident with behaviors related to health.

Figure 2. Theory of reasoned action. Adapted from Glanz, Rimer, & Lewis, 2002.

Sheppard, et al. point out that the original intention of TRA is to manage behaviors, not consequences that result from behaviors; more specifically, the behaviors outlined in the model are completely under the control of the individual (12). These limitations make TRA an unsuitable model for interventions that aim to modify behaviors with any strong outside influence, such as that from family, friends, media, and in the case of a CSW, a client.

Condom promotion in Madagascar is based heavily in brand recognition using mass media outlets. In 1998, Population Services International assumed management responsibility for the marketing of Protector brand condoms (13). In addition to administrative infrastructure changes and a product line expansion, PSI began an aggressive social marketing campaign to encourage use of Protector condoms as a means of HIV and STI prevention. PSI has succeeded in increasing sales, and presumably the use of, Protector brand condoms for the general population (see Figure 3). However, many studies conducted in recent years have demonstrated that condom use among CSWs is extremely low (14-16). Data suggests that such high risk groups present a need for dedicated condom promotion efforts that exceed current social marketing strategies through the TRA model. Current strategies do not address a number of limitations that CSWs are faced with in regard to condom use.

Figure 3. Source: Madagascar: Revitalizing a Social Marketing Program. PSI/Madagascar, 2003.

CSWs Have Limited Control Over a Male Partner’s Use of Condoms

Although male condoms do not eliminate the risk of infection, they are one of the most effective and economical options for prevention of HIV and other STIs (17,18). The drawback of male condom use is female reliance on her male partner to agree with use, therefore reducing female control over HIV and other STI prevention. In a study investigating perceived control over condom use among CSWs, it was found that almost 44% of the women interviewed answered “sometimes” when asked how frequently they used condoms with a client, approximately 41% answered “almost always,” and less that 7% answered “always” (16). Additionally, 40% of participants responded that they had “none/little” perceived control over male condom use with their client (16). CSWs face resistance to male condom use from their clients for a variety of reasons, some attributed to lack of knowledge, while other reasons stem from perceived loss of pleasure. Thomsen et. al. identified 50 reasons for not using a condom, gathered from interviews with male clients of CSWs in Mombasa, Kenya, an area that is similar to Madagascar in terms of CSW activity, as well as similar condom promotion techniques (19).

Clearly, current strategies are effective in condom promotion to the general population, but CSWs are faced with a set of challenges unique to their situation. When engaging in intercourse in exchange for money, CSWs are in a position in which they are often unable to negotiate the use of a male condom. Refusing to have sex with a client who will not use a male condom would mean loss of income for a CSW. More often than not, the decision is made to engage in unprotected sex; declining money is not an option for these women, many of whom support a family (6).Whether the CSW understands the dangers of unprotected sex and has knowledge of her risk for HIV/AIDS is inconsequential when her livelihood is dependent on satisfying her clients to obtain payment.

Variations in Definition of Relationship

Many CSWs polled in a study by Stoebenau, et. al. had a nonpaying “main partner” whom they identified as a boyfriend, husband, regular partner, or intimate partner (20). The majority of condom promotion mass media campaigns in Madagascar depict either a man and a woman together or a woman alone (21). The downside to this approach is that it does not clearly define what a partner is. Brochures and efforts targeting CSWs focus on condom use with a client, thus oversimplifying the range of relationships that a CSW may have. Often, the distinction between a nonpaying partner and a client can become unclear, as is the case when a tourist may began a relationship with a CSW as a paying client, but over the course of a two week vacation may enter into a relationship with the CSW. In this case, the tourist may pay for meals, clothes, and other gifts rather than exchange money for sexual intercourse exclusively; the definition of a “paying client” becomes uncertain.

Pettifor et al. found that of the CSWs participating in the study, approximately 42% had a nonpaying main partner; of those with a main partner, “the vast majority (70.8%) of women reported that their main partner probably or definitely had sex with other women in the past month” (16). Over 40% of CSWs surveyed reported never using a condom with their main partner; only 0.5% of CSWs in this same group reported that they never use a male condom with a client. Given that condom use with main partners is low, and sexual relationships with multiple partners is a common practice, relationships between CSWs and nonpaying or main partners are at a tremendous risk for HIV/AIDS and other STIs.

Social Marketing Campaigns Do Not Utilize CSW Support Systems

Although CSWs are stigmatized in Malagasy society, associations do exist to act as a support system. With the help of associations such as Fikambanana Miaro ny Zon’ny Rehetra (FIMIZORE), CSWs are able to seek out support in a safe environment. According to the International HIV/AIDS Alliance in Madagascar (the Alliance), a group that has provided financial and technical support to FIMIZORE, the group “promotes respect for [C]SWs through advocacy, information dissemination and training for relevant stakeholders, and contributes to the fight against infection” (9). Due to the shame many CSWs feel in response to societal marginalization, many are hesitant to join an association such as FIMIZORE. The association points out that CSWs are more inclined to prioritize their health when they are not forced to do so and when they have a strong support system (9).

Current condom promotion campaigns in Madagascar largely ignore the tremendous potential of groups like FIZIMORE as a resource. Creating a supporting environment for CSWs has been touted as an HIV/AIDS prevention best practice from the United Nations Programme on HIV/AIDS (22). A support system comprised of other CSWs promotes a sense of solidarity; by incorporating such groups into condom promotion interventions, the efficacy of such interventions will increase. Providing recognition to groups like FIZIMORE empowers CSWs and encourages positive health behavior change.

Proposed Intervention

Current efforts to increase awareness of and reduce rates of HIV/AIDS in Madagascar are commendable, given that such efforts have increased tremendously from virtually nothing in 15 years. Utilizing condom promotion as a primary means of HIV/AIDS prevention has proven an effective and financially prudent method. I would like to suggest that a proposed intervention would not replace current social marketing techniques, but rather build upon and expand the scope of the intervention.

Creating a plan that involves a multi-faceted approach to HIV/AIDS prevention aimed at CSWs will draw upon existing resources such as CSW associations and health clinics. The current situation in Madagascar is akin to a ticking time bomb, if preventative action is not taken immediately, rates of HIV/AIDS cases will skyrocket to rates currently occurring in other sub-Saharan countries.

Changing perception of CSWs is difficult and will require time, but it is possible to change efforts now to provide CSWs with HIV/AIDS education that goes beyond male condom social marketing promotion. It is imperative that Malagasy CSWs are equipped with the correct tools to protect themselves against HIV transmission, as they are in a position to potentially transmit HIV and other STIs to a large percentage of the population in a short amount of time.

Health clinics are located throughout the country and provide a framework upon which increased interventions can be built. As part of the Malagasy national health care system, Centre de Santé de Base (CSB) are local health clinics located throughout the country, providing healthcare access (albeit often rudimentary) to the Malagasy people. The CSB provides a location for expanded HIV/AIDS prevention efforts to reach a larger audience of CSWs while remaining accessible. As the CSB is a primary source of healthcare for the vast majority of Malagasy citizens, it services a wide range of healthcare issues and will not stigmatize CSWs as a healthcare center branded for CSWs only would. To address the three flaws identified with current HIV/AIDS prevention methods, I recommend three solutions that can be achieved with the proposed multi-faceted intervention.

Increase Awareness and Accessibility of Female Condoms

The most difficult barrier to overcome in regard to condom use cited among CSWs is convincing a client to use a male condom. Often, a higher rate can be negotiated to engage in sexual intercourse without a condom or a client may become violent at the suggestion of condom use (16). In the instance that a CSWs client refuses to use a male condom, a female condom can be used often without the client’s knowledge. Hoke et. al. states “a woman’s capacity to propose use of an alternative prevention method has reportedly heightened her bargaining power to insist on male condom use, furthering contributing to increases in protection” (15).

With respect to the proposed intervention, ensuring that female condoms are as readily available in shops as male condoms are will provide CSWs with a method to prevent the transmission of HIV that has proven as effective as the male condom (23). Many CSWs are aware of the benefits of condoms, but often are in a position in which they have limited influence over the decision to use or not use a condom when negotiating with a client. Promotion of the female condom puts the control in the hands of the CSW. Current social marketing campaigns promoting male condoms can easily be adapted in the context of female condoms, thereby building upon existing techniques, while also utilizing new interventions by involving the CSB.

Defining Sexual Relationships

In Malagasy culture, having multiple sexual partners is a practice which is quietly accepted. Based on the evidence, it is quite clear that many CSWs that have reported having a boyfriend or intimate partner are less likely to use a condom with that main partner than they are with a client. It is feasible that the main partner maintains a sexual relationship with one or more women in addition to the CSW; the interconnected nature of this situation allows for potential transmission of HIV or other STIs to an enormous number of people.

It is also important to recognize the various “levels” of sex work, low, middle, and high. Low sex work takes place during the day, often taking place in shacks or locations rented out in half hour increments for the purpose of sex. Middle work typically takes place at night on the street and is often prefaced by a verbal agreement between the CSW and client regarding financial compensation. Taking place in bars and nightclub, the high level of sex work is often the most undefined. Financial compensation is rarely discussed before the sexual exchange takes place, as many CSWs hope to find a potential husband. Regardless of the level of sex work, CSWs are at risk at every level, whether the sexual encounter took place in 30 minutes or over the course of a one year relationship.

The proposed intervention would rework current condom promotion strategies to explain the health implications of multiple partners and clearly emphasize the importance of condom use with all sexual partners. Providing a visual aid to show the connections that can potentially exist between multiple sexual partners will educate everyone to their possible risk of HIV/AIDS. It is important to highlight that a nonpaying partner is still at risk by not using a condom.

Collaborating With Existing CSW Support Systems

Faced with a great many hardships, CSWs often have limited or no access to healthcare. Social and environmental factors are highly influential to the behaviors of CSWs (33). Specifically, Peer-influence and social network norms have been found to increase condom use among CSWs (24). A strong social support system has been shown to help in reducing rates of HIV/AIDS among CSWs by promoting the use of condoms in a trustworthy environment. A recent study of CSWs in China found that a well-structured CSW social network prompted condom use in several ways: promoting wholesale purchasing of condoms, mediating condom use with clients, and providing options for clients who refuse to use a male condom (24).

Existing CSW groups in Madagascar, such as FIZIMORE, could benefit from collaboration with the local CBS to increase influence over decisions such as condom distribution and the availability of HIV testing opportunities. By establishing a presence in the community and making condom use and HIV/AIDS prevention a topic of conversation, CSB doctors and nurses can provide backing to the work of the CSW groups. Additionally, demographic information and health statistics can be gathered at the CSB, allowing for quantitative analyses to aid in the overarching campaign goals.

Conclusion

Poverty, stigma, violence, and lack of education are just a few adversities facing CSWs in Madagascar. The threat of HIV/AIDS may not appear as a threat to many CSWs, as symptoms are not immediately visible. Given the reach CSWs have among sexual relationships with clients and nonpaying partners, adoption of an effective HIV prevention method such as condom use is critical to preventing new cases. Existing condom promotion campaigns have laid the foundation for expanded techniques, and have brought to light the importance of HIV/AIDS prevention among CSWs as factor in HIV/AIDS prevention for the entire population.

REFERENCES

1. USAID. HIV/AIDS Health Profile. Antananarivo, Madagascar: USAID/Madagascar, 2010.
2. World Bank. Results-Oriented Monitoring: A Successful Transition in Madagascar. World Bank Global HIV/AIDS Program, 2008.
3. World Health Organization Media Center. Treatment for Sexually Transmitted Infections Has a Role in HIV Prevention. Geneva, Switzerland: World Health Organization, 2006.
4. UNAIDS Regional Support Team for Eastern and Southern Africa. Madagascar Country Profile. Antananarivo: UNAIDS Country Office.
5. The World Factbook. Madagascar Country Profile. Washington, DC: U.S. Centeal Intelligence Agency, 2011.
6. Academic Presentation, Rachel Pryzby. Helping Women Help Themselves: Sex Work, Health, and Development in Mahajanga, Madagascar. Madagascar: Culture and Society, Fall 2007.
7. UNAIDS. Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections. Antananarivo: USAIDS Country Office, 2004.
8. UNAIDS. Epidemiological Fact Sheet on HIV and AIDS: Core Data on Epidemiology and Response. Geneva, Switzerland: UNAIDS/WHO Working Group on Global HIV/AIDS and STI Surveillance, 2008.
9. International HIV/AIDS Alliance in Madagascar. Giving a Voice to Sex Workers in Madagascar: The Alliance’s Work with FIZIMORE. Madagascar.
10. Fishbein, M and Ajzen, I. Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley, 1975.
11. Fishbein, M. A Reasoned Action Approach to Health Promotion. Medical Decision Making 2008; 28:834-844.
12. Sheppard, B.; Hartwick, J.; Warshaw, P. The Theory of Reasoned Action: A Meta-Analysis of Past Research with Recommendations for Modifications and Future Research. The Journal of Consumer Research 1988; 15:325-343.
13. Profile: Social Marketing and Communications for Health. Madagascar: Revitalizing a Social Marketing Program. Antananarivo, Madagascar: PSI/Madagascar, 2003.
14. Feldblum, PJ; Hatzell, T; Van Damme, K; Nasution, M; Rasamindrakotroka, A; Grey, TW. Results of a randomised trial of male condom promotion among Madagascar sex workers. Sexually Transmitted Infections 2005; 81:166-172.
15. Hoke, et. al. Randomised controlled trial of alternative male and female condom promotion strategies targeting sex workers in Madagascar. Sexually Transmitted Infections 2007; 83(6):448-453.
16. Pettifor, A. Perceived control over condom use among sex workers in Madagascar: a cohort study. BMC Women’s Health 2010; 10:4.
17. Weller, S; Davis-Beaty, K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database of Systematic Reviews 2002, 1:4.
18. Warner, L et.al. Condom use and risk of gonorrhea and Chlamydia: a systematic review of design and measurement factors assessed in epidemiological studies. Sexually Transmitted Diseases 2006; 33(1):36-51.
19. Thomsen, S; Stalker, M; Toroitich-Ruto, C. Fifty ways to leave your rubber: how men in Mombasa rationalise unsafe sex. Sexually Transmitted Infections 2004; 80:430-434.
20. Stoebenau, K. “…But Then He Became My Sipa”: The Implications of Relationship Fluidity for Condom Use Among Women Sex Workers in Antananarivo, Madagascar. American Journal of Public Health 2009; 99(5):811-819.
21. Population Services International: HIV Department. Madagascar Condom Use BCC Catalogue. PSI/Madagascar. http://misaccess.psi.org/bcc_catalog/web/Content117.html
22. UNAIDS Best Practices Collection. Sex work and HIV/AIDS: Technical Update. Geneva, Switzerland: UNAIDS, 2002.
23. French, P.P. MD,MPH, et al. Use-Effectiveness of the Female Versus Male Condom in Preventing Sexually Transmitted Diseases in Women. Sexually Transmitted Diseases 2003; 30(5):433-439.
24. Tucker, J. et. al. Female Sex Worker Social Networks and STI/HIV Prevention in South China. PLoS One 2011; 6(9). http://www.ncbi.nlm.nih.gov.ezproxy.bu.edu/pmc/articles/PMC3172283/?tool=pubmed

NYC Department of Health’s “It’s Never Just HIV” Campaign: An Impractical Public Health Approach - Leilani Hernandez

Introduction

The population most severely impacted by HIV in the United States is men who have sex with men (MSM). The Centers for Disease Control estimates that men who have sex with men are 44 to 86 times more likely to be diagnosed with HIV compared to other men (3). The high prevalence of HIV infections coupled with unawareness of having an infectious disease increases the risk of men transmitting HIV to other men. A study conducted by the CDC revealed that in 2008, 19% of men who have sex with men in 21 U.S. cities were infected with HIV and 44% of these men were unaware that they were infected (3). New York City recognized that MSM in their city are particularly vulnerable to HIV since men with male partners account for 55% of annual new diagnoses in their city (5). They decided to address this problem by convincing men who have sex with men to adapt to the behavior of using condoms and their means of persuasion to doing this was creating a poorly designed educational campaign that appealed to men’s fear for their health.

New York City’s Response to the HIV Problem

In December 2010, New York City’s Department of Health and Mental Hygiene debuted their new educational campaign for combating HIV in the MSM community which revolved around the saying “It’s Never Just HIV (5).” The outright, threatening message of their campaign’s catch phrase meant that becoming infected with HIV will ultimately ruin your life. The sad video associated with this campaign has a deep-voiced, disembodied narrator bluntly stating that having HIV puts you at higher risk for ‘dozens of diseases even if you take medications,’ and in addition to having many sad-faced male models, the commercial showcases three types of medical conditions (bone loss, dementia, and anal cancer) which it deems are follow-up diseases to getting HIV and then finally ends by telling the viewer to stay HIV free by always using a condom (18). This video ran on television for two weeks in December 2010, two weeks in January 2011, and can still be viewed on YouTube today (5). This campaign also included a subway advertisement component which started in February 2011 (6). The poster component used in the city’s subways displayed identical images and written scripts that were from the video.

Why this campaign was ineffective

NYC’s public health department had had previous success in using a fear appeal message for an anti-smoking campaign so they decided to apply this same fear tactic into convincing MSM into wearing condoms. However this just demonstrated that there are not one-size fits all solutions for public health problems since this campaign was met with much criticism from the media. The practice of not using a condom during anal sex with someone is a high risk behavior for HIV infection; however, this is not the only behavior that needs to be addressed in order to reducing HIV transmission among men who have sex with men. Other behaviors that impede our goal of reducing transmission in the MSM population is being unaware that you have HIV (which is more prevalent amongst young black men), having multiple sexual partners, and using drugs during sex (3). Also homophobia and the stigma are social factors associated with HIV which create significant barriers to reducing the prevalence of HIV within the MSM population. Homophobia can affect these men’s ability to make health choices for themselves while stigma can affect these men’s disposition for seeking methods of prevention or care for HIV (3).

The New York City campaign, which only had the goal of convincing men who have sex with men to wear a condom, mainly took the appeal to fear route but also included other social behavior models such as the Health Belief model and Theory of Reasoned Action. These theories and New York City’s inappropriate application of them will now be dissected in order to prove why the “It’s Never Just HIV” Campaign was an impractical approach to reducing HIV transmission among MSM living in NYC.

Fear Appeal: Extended Parallel Process Model

The most obvious theory that officials at the department of health tried to apply when designing this campaign was appealing to people’s fear of contracting a serious medical disease on top of HIV. Fear appeal models posit that “an emotional response and a desire to eliminate the danger are triggered upon exposure to a fear appeal.” (2). The most modern fear appeal model is called the Extended Parallel Process Model (EPPM). This model simply states that a “perceived threat contributes to the extent of a response to a fear appeal whereas perceived efficacy contributes to the response of the nature and if no information on the efficacy is provided then individuals will rely on past experiences and beliefs to determine perceived efficacy (17).” And while fear appeals have been highly criticized in class and in the literature for use in public health interventions they have proved to be effective for certain issues used with certain populations. A campaign in Uganda was extremely effective in changing Ugandans attitudes towards sexual behavior thus significantly reducing HIV prevalence in this country. The campaign’s simple ‘ABC message’ was that you can choose either choices A, B, C or you can choose D with D standing for Death and used imagery of skulls, coffins, and grim reapers to get this message across to Ugandans (9). Ugandans surveyed were asked why their sexual behavior was changed and their two most common responses were first ‘Fear of AIDS’ and second ‘so many people are dying from AIDS (9).’

However Americans have a more ‘sex-positive’ culture than Ugandans do which could be the reason why the NYC campaign’s use of the instilling fear was not very effective for changing sexual behavior over here (9). A meta-analysis conducted on fear appeal research highlighted certain implications for using this model. These implications are that fear appeals are effective only if they show a significant and relevant threat and when they increase perceptions of self-efficacy by outlining a response that is easy to accomplish(17). The imagery and messages sent out by the NYC campaign failed to take into account both of these implications. First off, while HIV is associated with anal cancer, osteoporosis, and dementia the way that the video depicted these medical conditions was not done in a manner that would incite fear in the viewer especially in a an age where most people are extremely de-sensitized to the most shocking images. Showing x-rays of bones, brains, and other body parts is not very frightening to most people nowadays. Also these diseases that HIV can lead up to are too far into the future for a person to consider as significant threat or even possibly relevant to them. As a public health student interested in HIV, I was not even aware that these diseases are associated with HIV so I’m not sure how the common lay person would know this thus believing that they could actually affect him if he gets HIV. This video and its images are not enough to elicit a strong response to perform the video’s recommendation which is to start using condoms. The very best possible scenario that these scare tactics would accomplish is have the individual use condoms for a short time period. Secondly, while wearing a condom seems like a simple thing to do it is not easy to do if a person does not have a condom on them at the time of sex or if alcohol and/or drugs are clouding a person’s judgment. A report by the CDC states that men who have sex with men continue to engage in sexual and drug-use which increases the risk for HIV infection (8).

Health Belief Model

The New York City campaign also applied the Health Belief model (HBM) since they sought to educate men who have sex with men about the dangers of not wearing a condom. HBM is an individual level model which identifies factors associated with influencing a person’s behavior. Decisions that a person makes are based on the susceptibility or the subjective risks of contracting a condition, perceived seriousness or perceived difficulties that person believes a given health condition will create, and the perceived benefits and barriers of performing the recommended action which will be determined by that subject’s beliefs and availability and effectiveness of taking this action (13). The primary focus of the Health Belief Model is on health education which the video does do. New York City thought that simply educating people on the risks associated with HIV and telling them that a condom would offer them enough protection from these risks was convincing enough evidence for MSM. Dialogue from the “It’s Never Just HIV” Video states, “HIV puts you at higher risk for dozens of diseases even if you take medications, like osteoporosis a disease that can dissolve your bones, dementia a condition which causes permanent memory loss, and you’re over 28x more likely to get anal cancer.”

In this video, new information regarding the severity of AIDS was clearly communicated in this video. However, men who have sex with men are most likely already aware that they are highly susceptible to getting HIV and the message of the severity of HIV/AIDS is also probably already well known to them as well. So the HBM was an inappropriate use of this theory in attempting to get people to change their behavior since most MSM are already aware of this information and yet still continue to engage in risky behavior. The message and the images shown were not persuasive enough to change a person’s perception of how HIV can change his life. But most importantly, this theory assumes that people are rational thinkers so educating them about the dangers of HIV will convince them into using condoms. But in reality most people, not just men who have sex with men, are not rational thinkers in the moments leading up to or during sex.

Theory of Reasoned Action

Lastly, the campaign also included elements from the theory of reasoned action since the models in the video acted their best to make the viewer feel guilty for not having worn condoms in the past. This theory assumes that people are rational beings and so they consider their actions before they decide to perform or not perform a behavior; thus intention is a function of two basic determinants: the person’s attitudes towards the behavior on whether it is good or bad and the person’s perceptions of social pressures to do the behavior or not (14,15). The recommended behavior of the “It’s Never Just HIV” Campaign for men who have sex with men is to use condoms. For their HIV campaign, New York City employed attractive men in their video and subway posters. The men used in the video would be considered a social group that a man who viewed the video might be concerned about their perception of him for not using a condom. In the video, these men are seen looking glumly into the camera. A few of them even give accusing glares into the camera as the video talks about the consequences of HIV. You as the viewer feel as if you’re the one that had unprotected sex with them and accidently transmitted the disease and now it’s your fault that they are being diagnosed with anal cancer. The intention of doing this is to make men who do not wear condoms feel guilty and shame for this behavior. Unfortunately, another side effect of this video places a higher burden of shame and guilt on those men who already have the HIV infection. This video is blaming them for other men getting osteoporosis, dementia, or anal cancer since they are the ones who can spread the HIV to others. And like the HMB, the theory of reasoned action also assumes that people are rational thinkers and again it’s ridiculous to use this theory for promoting condom use since most people don’t think rationally during sex.

Proposed, alternative intervention

When used consistently and correctly, condoms are an effective way to reduce HIV transmission so I agree with this campaign’s message to promote condom use. However condoms are not the only preventative measure against HIV transmission. The “It’s Never Just HIV” campaign did not address the underlying causes of HIV transmission amongst men who have sex with men and further did not mention other preventative measures. We also need to discourage multiple sexual partners and use of drugs during sex since they increase the risk of becoming infected. HIV stigmatization compounded with homophobia is an underlying root cause of why this is such a problem in this population. Also none of NYC’s advertisements mentioned the importance HIV testing especially since symptoms of having the disease do not begin to appear until later stages of the disease. Knowing one’s HIV status is important because obviously you would make more conscious choices in regards to sex and you will also be referred to the health care and treatments you need to properly manage the disease. Furthermore, I also feel as if the way that HIV is spread is also important information that not many people know. If people understand the methods by which HIV is transmitted then they would be able to recognize situations in which they could possibly be at risk for infection.

My proposed alternative to is a multi-fold intervention that includes not only encouraging condoms during sex but also promoting HIV testing, reducing HIV stigmatization in the MSM community, reducing homophobia, promoting safe sexual practices, and educating men who have sex with men on how HIV is spread. Gary Marks from the Division of HIV/AIDS Prevention at the CDC wrote an editorial review about the need for collective responsibility in order to reduce HIV transmission. He wrote that “Collective responsibility emphasizes that all of us, infected or now, low right or high, bear a responsibility to change our attitudes and behaviors that promote HIV infection (11).” He suggests strategies to reducing HIV transmission at the population level would be promoting use of condom usage and HIV testing, promoting norms of responsibility and protection during sex, and fostering the perception that HIV is still a life-threatening disease (11). Due to this idea of collective responsibility not all components of my campaign will be targeted to the MSM community especially the components aimed at reducing HIV stigma and homophobia.

My campaign will have a positive, hopeful video that depicts gay men in a positive light and will also include a message that encourages sex safe practices and getting tested for HIV. Secondly, it will also have an educational component toward it geared towards educating these men about the different methods of HIV transmission, recognizing high risk situations, and again encouraging safe sex practices. Lastly, my intervention will include a program aimed at creating awareness of sexual diversity and HIV in the community by encouraging MSM to be more active thus increasing their visibility within the community.

Framing the message in a Positive Light

One of the reasons why the NYC campaign was such a failure amongst the MSM community was because of the video’s negative tone and the dreadful information they decided to include for supporting their message. For framing, it is important to incorporate emotional processes to influence a person’s decision-making between choices (12). While this campaign obviously had an emotional component to it, the tone and images used to bring about emotions were not persuasive enough to spur someone into using condoms.

For my intervention, I plan to frame my recommended action of using condoms and getting tested in a positive way. Like NYC, I will also create a short video that uses men to deliver message. Having gay men deliver the message to other gay men is a way to reduce resistance to the message. Similarity between the message deliverer and its recipient has been shown to increase persuasion by increasing the liking of the message heard and making the message less threatening (16). My video will involve men talking directly into the camera rather than having a creepy disembodied voice narrate it. I will recruit two gay men who are in a serious long term relationship to talk about their experience of one discovering the other has HIV, how they cope, and how one supports the other one. Most importantly they will say that having this discussion demonstrated mutual respect and trust in their relationship. The reason why their relationship has such a strong foundation is because they were courageous enough to talk to one another about it. This will shed light on the importance of using condoms, practicing other safe sexual practices and disclosure of the other’s HIV status. The video will show how in love they are with each other as a result of them sharing this information with each other. Framing the message positively is a more effective way of promoting condom use and testing rather than scaring people into doing it.

Promoting Self-Efficacy

Know your status and get tested! Have either you or your partner wear a condom so that you can protect yourselves from HIV! The NYC campaign did nothing to promote self-efficacy in their campaign. They just hoped that the information they provided would be enough to convince people to do what they want them to do. My intervention will support self-efficacy for doing the following actions: getting tested and using condoms. Whereas the NYC campaign utilized concepts from the Theory of Reasoned Action (TRA) into the design of their video, mine will use the most recent theory for this, Theory of Planned Behavior (TPB). This theory extends upon TRA by adding in an additional component called behavior intention which is the “degree to which a person believes they have control over whether they can do that action and the strength of the belief they can do it.” (7).

To promote self-efficacy, the men in my video will stress to MSM viewers that they have the control and the power to safeguard their health and their partners and make a difference in the fight against AIDS/HIV. They can do this if they speak up to their partners about condom use and knowing one’s HIV status. I am hoping that the video made for use in my intervention will be an empowering one, which is difficult to achieve. It will highlight how one man’s decision to talk with his partner about the sensitive issue of sex and HIV brought about a sense of admiration and respect from his partner. Hopefully this video will increase the viewer’s perception of how easy and most importantly rewarding it is to have this serious discussion before engaging in sex.

Increasing the general Community’s awareness of MSM and HIV

The third component of my intervention is not at all directed at men who have sex with men but includes everyone in the community since two of my intervention’s aims of this component are reducing HIV stigmatization and homophobia. This component involves a program that would increase the general community’s awareness of HIV and stigmatization. The program encourage men who have sex with men to increase their visibility in the community by engaging in activities in an effort to counter people’s perceptions of the homosexual lifestyle and those living with HIV (1).

In his article on preventing HIV in a context of HIV stigma, discrimination, and homophobia, Ronald Brooks suggests activities for gay men to do in the community would be ‘participating in HIV prevention programs at local health fairs, participating in gay and lesbian group festivals, and/or establishing a gay/straight alliance.” He also recommends venues for HIV prevention activities to take place in to be “churches, barber shops, beauty salons, jails and prisons, social service agencies, health clubs, schools, neighborhood center, needle exchange programs, and non-gay setting and non-HIV community events.” One community level HIV intervention program targeted towards young gay men recognized the importance of creating new setting and events to attract their target population. Setting for events to promote safer sex included dance parties, picnics, hikes, and bicycle rides (13). In my intervention, I would suggest that participants go to any of the places listed above as a starting point for spreading the word on HIV prevention and getting involved in the community.

Also gay role models from the community will be recruited and trained. These role models will educate everyone on the methods of HIV prevention and on how HIV is transmitted so that people can recognize situations in which they could possibly be at high risk for HIV infection. They will also dispel rumors on how HIV spread (which is not by casual contact, kissing, or sharing air or water with someone with HIV) in order to try to reduce HIV stigmatization. These role models will also be trained to act counselors for any MSM who experience homophobia and need the social support so that they won’t engage in self-destructive behavior in reaction to it.

Conclusion

Even though HIV transmission is preventable, sadly, the CDC estimates that 1.2 million people in the United States are living with HIV infection and 20% of those people are unaware of their infection (4). It is important that people, especially vulnerable populations such as MSM, know their status and understand ways to protect themselves and others from HIV because even though treatment is available, HIV is still a life-threatening disease. Prevention campaigns such as the “It’s Never Just HIV” campaign do not effectively showcase all of the prevention methods available or address underlying social factors of why MSM are the ones most severely impacted by HIV. Interventions to combat HIV need to be multi-fold in its approach since the root causes of this problem for the MSM population are multi-fold. Not only should they be aimed at promoting safer sexual practices but they also need to tackle the daunting task of reducing the social factors which are barriers for MSM to receiving the care they need. If these multi-fold interventions are implemented then we will be able to see a significant reduction in HIV prevalence for this group.

References

1. Brooks, Ronald and Mark Etzel, Ernesto Hinojos, Charles Henry, ad Mario Perez. “Preventing HIV among Latino and African American Gay and Bisexual Men in a Context of HIV-related Stigma, Discrimination and Homophobia: Perspectives of Providers.” AIDS Patient Card STDS. 2005 November; 19 (11): 737-744.

2. Camerson, Kenzie. “A Practitioners Guide to Persuasion: An Overview of 15 Selected Persuasion Theories, Models, and Frameworks.’ Patient Education and Counseling 74, 2009. Pp 309-317.

3. CDC. “HIV among Gay, Bisexual and Other Men Who Have Sex with Men (MSM).” http://www.cdc.gov/hiv/topics/msm/index.htm. December 7, 2011.
4. CDC. “HIV in the United States.”

http://www.cdc.gov/hiv/resources/factsheets/us.htm. December 7, 2011.

5. Craig, Susan and Celina de Leon. “New Health Department Media Campaign Shows How HIV can Compromise Health and Well Being, even when Treatment Controls the Infection.”

http://www.nyc.gov/html/doh/html/pr2010/pr059-10.shtml. December 7, 2011.

6. Craig, Susan and Zoe Tobin. “Health Department Takes Its Latest HIV Awareness Campaign to the Subway- Agency’s new subway posters show how HIV can lead to other serious diseases.”

http://home2.nyc.gov/html/doh/html/pr2011/pr002-11.shtml. December 7, 2011.

7. Edberg, Mark. ‘Chapter 4: Individual Health Behavior Theories.” Essentials of Health Behavior: Social and Behavioral Theory in Public Health, Sudbury, MA: Jones and Bartlett Publishers, 2007. Pp 35-49.

8. Finlayson, Teresa and Binh Le, Amanda Smith, Kristina Bowles, Melissa Cribbin, Isa Miles, Alexandra M Oster, Tricia Martin, Alicia Edwards, Elizabeth DiNenno. “HIV Risk, Prevention, and Testing Behaviors Among Men Who Have Sex With Men --- National HIV Behavioral Surveillance System, 21 U.S. Cities, United States, 2008.” MMWR Surveillance Summaries October 28, 2011 / 60(SS14);1-34.

9. Green, Edward and Kim Witte (2006). “Can Fear Arousal in Public Health Campaigns Contribute to the Decline of HIV Prevalence?” Journal of Health Communication, 11:3, 245-259.

10. Kegeles, Susan M and Robert Hays, Thomas Coats. “The Mpowerment project: A Community-Level HIV Prevention Intervention for Gay Men.” American Journal of Public Health. 1996 :86 :1129-1136.

11. Marks, Gary and Scott Burris, Thomas Peterman. “Reducing Sexual Transmission of HIV from those who know they are infected: the need for personal and collective responsibility.” AIDS 1999, 13: 297-306.

12. Martino, Benedetto and Dharshan Kumaran, Ben Seymour, Raymond Dolan. “Frames, Biases, and Rational Decision-making in the Human Brain.” Science, 313 August 4, 2006. Pp. 684-687.

13. Rosenstock, Irwin. “Historical Origins of the Health Belief Model.” Health Education Monographs, 2(4) Winter 1974. Pp. 328-335.
14. Salazar, Mary Kathryn. “Comparison of Four Behavioral Theories.” AAOHN journal, 39 (3) March 1991. Pp. 128-135.
15. Sheppard, B.H.; Hartwick, J. & Warshaw, P.R (1988). The theory of reasoned action: A meta-analysis of past research with recommendations for modifications and future research. Journal of Consumer Research, 15, 325–343.

16. Silvia, Paul. “Deflecting Reactance: The Role of Similarity in Increasing Compliance and Reducing Resistanc.” Basic and Applied Social Psychology. 27 (3) 2005. Pp 227-284.

17. Witte, Kim and Mike Allen. “A Meta-Analysis of Fear Appeals: Implications for Effective Public Health Campaigns.” Health Education Behavior 2000 27:591.
18. YouTube video by NYC Health- “It’s Never Just HIV.” Available at:

http://www.youtube.com/watch?v=d0ANiu3YdJg. December 7, 2011.

A Critique of Non-comprehensive Sexual Education in Public Schools in states lacking mandates. Doreen Gidali

Introduction

It is often speculated that the two things that separate humanity from most other animals, is our ability to think and to experience sexual pleasure. And though sexual expression and behavior is often considered one of adulthood, it is just as present in adolescents across the world. With puberty, comes the onset of sexual desire. But in recent decades, puberty is being reached at even younger ages; and in an era where sex has been freed from the constraints of procreation and marriage, and more so associated with its benefit of pleasure, we have seen an increase in sexual activity among the very young. Unfortunately, this promotion of sexual freedom preceded the effort to inform the youth on healthy sexual behavior. This has proven problematic in a time where sexually transmitted infections (STI) are rampant and carry significant morbidity, unstable economies with a greater percent of impoverished individuals: poorly informed sexual activity is becoming a significant concern for public health.

In 2009, data collected by the Center for Disease Control and Prevention (CDC) found that 46% of high school students reported having had sexual intercourse. 34% of them had it within 3months, of which 39% had unprotected sex (1-3). While it is assuring that more than half of those having sex used protection, the health consequences of having unprotected sex are unfortunate, both for the individual and for the overall state of public health. Nearly half of the 19 million new cases of STIs each year are among people aged 15-24 years, and about 8,300 new cases of HIV infection are in people aged 13-24years. In 2009 alone, 400,000 new mothers were between the ages of 15-19 (1-3). STIs are one of the main causes of morbidity in young people, and while HIV is now considered a chronic disease, acquiring it at such a young age is medically, and psychologically detrimental, not to mention financially draining. The weight of teen pregnancies is one that needs no further explanation.

Though these numbers may be alarming, it is important to note that since the 1990s, there has been a considerable decline in sexual activity, pregnancies, and births among teens, owing to “dramatic improvements in contraceptive use” through sexual education (4). But this very concept of sexual education is divisive to say the least. There are two methods of preventing the undesired outcomes of sexual activity: abstain, or engage with caution. These two divergent principles are the basis of the controversy surrounding how to implement sexual education, especially in public schools. “Abstinence only” proponents, emphasize abstaining from sex outside marriage, and suggest that education supporting the use of contraception promotes sexual activity, and should be discussed only in the context of “their failure rates” (5, 6). On the other hand, supporters of comprehensive sexual education (CHE henceforth), support an emphasis on abstinence as the only guaranteed method of protection, but in addition, strongly support scientific and medically accurate education around contraception, including social and psychological factors that influence sexual behavior. With a common goal in mind, both arguments are sound: but it is no surprise, that “targeting behaviors that are both reasonable and feasible” is often more successful in bringing about change in human behavior (7). It is therefore sensible to expect that, the comprehensive method would be preferable. In fact in 2001, the Surgeon General, Dr. David Satcher supported this in his “call to action” stating that sexual health education should “stress the value of abstinence…but assure awareness of optimal protection from sexually transmitted diseases and unintended pregnancy, for those who are sexually active” (8). Additionally, recent reviews of several interventions, demonstrate higher success rates in programs based on the comprehensive method. In fact, “research shows that abstinence-only strategies may deter contraceptive use among sexually active teens, increasing their risk of unintended pregnancy and STIs” (4, 7). So why then does this controversy still exist, and how does it affect the actual problem?

The answer lies in jurisdiction. While Washington can give its suggestions and recommendations, legislature on sexual education and the extent and manner of its enforcement is a matter of state and local governance. Though the Sexuality Information and Education Council of the United States published Guidelines for Comprehensive Sexuality Education (SIECUS), states are not required to follow these guidelines, or to mandate CHE. Current laws and policies ensure that at least some degree of sexual education is incorporated in public schools (4), but it is the degree of which it is incorporated that differs. This creates significant variability in the type of sexual education that adolescents are getting in schools across states, cities and even counties, and more so opens an opportunity for external pressures from special interest groups that have potential to influence policy. This is where our sexual education proponents come into play. Despite the data supporting the success of the comprehensive approach, proponents of “abstinence only” education remain avid. They are often financially endowed, aligned to the right, and have been known to use the political front to push their agenda (9). This does not suggest that state sexual education policy is dictated by special interest groups, but only attempts to demonstrate how lack of a national mandates on states to mandate CHE, allows for influence on state policy that results in implementation of, discredited and less-effective programs. The results is a deficit of quality programs needed to address a public health issue as considerable as this, especially in areas that are disproportionately affected, further contributing to disparities. New York City is an excellent example of this unfortunate predicament.

In 2005, New York City (NYC) was considered the “epicenter of the U.S HIV/AIDS epidemic, with almost 200,000 cases. We know that young people represent a considerable fraction of new HIV-cases; this places most of them in NYC (10-12). This is a heavy burden for any state to carry; but surprisingly, New York “has no law that mandates sex education or regulates its content if taught – it has not taken the necessary action to guarantee complete, comprehensive sex education for its students. However [it] does require that students be taught about HIV as part of health classes”(13). The state provides guidelines for HIV/AIDs curriculum that is “science-based, skills-driven, and standard-based”, but yet remains relatively vague, at most offering information about abstinence, HIV transmission and consequences, and prevention (10, 14). No wonder that even with this program in place, the STI rates among those of aged 15-24, have continued to rise, especially in New York City, disproportionately affecting African Americans and Latino young women (7,10,13). One would expect that this grim reality, would serve as impudence for the state of New York to adopt a comprehensive sexual education mandate; but in fact it hasn’t. New York is one of many states that limit sexual education to HIV only, within the greater scope of health education, and often offer limited, informatively scarce guidelines. As an outcome of the no state mandate, this limited approach and its poor guidelines, secondary are the subject of this critique using NYC as an example.

Critique Argument 1: Focus on individual level decision making

Most HIV/STI campaigns are based on models that focus on individualism and rational decision making, and the New York education curriculum for HIV/AIDS is no different. As a matter of fact the national standard for a sexual health education curriculum, of which most states attempt to emulate, is mostly based on traditional public health social theory; namely the Health Belief Model (HBM), and Theory of planned action (TPA). These are both models of behavior change that have indeed have been successful in health promotion, but unfortunately have limitations that render them less efficacious in the context of complex health problems, such as risky sexual behavior.

The HBM was developed in the late 1950s, generally to predict how individuals would respond to and use health services. It presumes that an individual will make a choice to carry out a health behavior, based on their perception of: the severity and susceptibility of disease, benefits of services and possible barriers to accessing such services. The theory assumes individuals are rational decision makers, and whilst equipped with the appropriate information (knowledge), will engage in ‘healthy’ behavior, given they value the associated outcome (15). Applying this to adolescents is inevitably futile, since most do not seem to approach the ‘AIDS [STI] issue from such a logical perspective, but seem quite capable of discounting risks and optimistically perceiving themselves as invulnerable to harm (16). Also the decisions of a teenager are highly influenced by disparities, and socio- environmental factors, of which HBM does not take into account (15, 16)

The theory of planned behavior (action) much like the HBM, posits behavior as planned and reasoned, but differs in that it does take social norms into consideration. However its limitation in this case is its assumption that behavior stems from a linear progression of attitude to action of which is determined by an individual’s intention. This process of linearity, and rationality while applicable to certain health issues, is certainly misplaced in the context of sexuality. The state of sexual excitement in itself is one of irrationality; when confounded with external factors such as non-sexual desires, power dynamic in society, structure of relationships, and most of all emotions, expecting rational behavior – simply from having knowledge of risks and benefits holds little promise. A critique of communication models for HIV/AIDs prevention seamlessly illustrates this:

“Two people who are about to begin sexual relationship typically avoid discussing their sexual past until they are more comfortable with each other at which point sexual intercourse commonly has occurred (Piskin, 1997). In this case, sexual behavior precedes sexual knowledge at least in the context of relationship, which is often the basis for most interventions on preventing HIV/AIDs. This reality of ‘behavior first’ renders the linear model of knowledge leading to attitude and behavior counterintuitive in the context of relationships and culture” (16)

This is no way insinuates that HBM and TPA are useless, as the information disseminated through the current program in high essential. This only suggests that, information only no matter how all encompassing it is, is not effective if delivered in the context of logic. Instead intervention development should be based on theory that embodies dynamic flow between thoughts, behavior and action, and explain behavior from an individual perspective and through the context of external/social factors that affect human behavior.

Critique Argument 2: Who is delivering the message

The rising HIV/STI rates in New York City were alarming. In 2006-2007, NYC implemented a training program to provide professional development for teachers, administrators and parent groups. But even with this effort, there has been an increase in the rates of Chlamydia, Gonorrheal and Syphillis in both young men and women. So even though NY is featured on the CDC spotlight for HIV prevention in adolescents, because of their new training efforts, the statistics paint a picture that suggests the changes ineffective. While there is no disagreement that individuals delivering sexual education should be well trained, it is compelling to inquire whether using teachers and administrators is the most effective mode of delivering this education to our audience: adolescents.

Consider a student who has a negative history with an instructor for whatever reasons, how do they take this message. Or perhaps a student that feels she/he can never identify with her instructor. We can only presume that such negative feelings or associations may deter how the message is perceived and accepted. This is suggested by the communications theory in the social sciences, which posits that the most important element in making a persuasive appeal/message is the messenger and the associations surrounding the messenger. If the messenger is seen in a positive light, his/her message is more likely to be considered. This was illustrated in a HIV/STI prevention study that found a decrease in unprotected sex and number of partners after an intervention where opinion leaders within the community endorsed safe sex practices (17). This suggests that perhaps introducing an influential person, a well known community member, or someone that students ‘get’, might be more effective in delivering this message. This is not to argue that all students view their teachers in a negative light, but rather to ruminate on the idea of changing who teaches sexual education.

Critique Argument 3: Generalized program, assuming a homogeneous group.

The disparities seen in the STI epidemics are marked, therefore making HIV/AIDs prevention simply part of the curriculum, with somewhat vague guidelines, implies that the information is generalized to the entire population. The STI epidemic is not homogeneous, suggesting what is already apparent: that the adolescent population is heterogeneous on many fronts. Generalizing the curriculum makes it impossible to target the factors responsible for the disparities seen in the STI epidemic. Indeed some aspects of the curriculum can be generalized – such as skills, reproduction concepts – others, such as sexual abuse, cultural factors, absent from this curriculum, can really only be addressed from a non-generalized approach. A review of current adolescent STI/HIV prevention interventions revealed that “interventions with the most success decreasing high risk sexual behavior were those that specifically tailored and delivered their intervention to a particular subgroup of adolescents”(research facts) A successful intervention carried out in South African adolescents took this additional step at tailoring: ‘Because girls in South Africa are vulnerable to rape and other aspects of male denomination, sex-specific module addressed sexuality, sexual maturation, appropriate sex roles and rape myth beliefs’. Its success as an intervention was in part attributed to considering the heterogeneity of its target population (7, 18).

New York City is home to an extremely global population, with historically harsh urban and inner cities. With such a diverse population, with individuals stemming from different walks of life, a tailored approach only seems fitting. Yet it is not clear that complex social and cultural factors such as, sexual abuse, substance abuse, single vs. dual parent homes are taken into consideration (14). Absence of this approach, in a population such as that of NYC public schools, only sets the stage for failure

Proposed Intervention

There are several non-school based programs in New York that are delivering effective programs to other disproportionately affected youth: such as those in detention centers, young women in health clinics, and substance users. It is up to individual schools whether they choose to adopt a curriculum on sexual education in addition to the HIV/AIDs program, or don’t. This creates a potential donut hole, of young adolescents – especially racial minorities, that may not have access to the non-school based programs, but attend a school that only enforces the HIV/AIDs curricular.

This intervention is targeted at urban schools (in this case NYC) with high proportion of racial minorities, interested in establishing a sexual-education curriculum in addition to the existing HIV/AIDs mandate The proposed intervention ‘Teens Loving Cautiously (TLC)’, is program based on the merging of multiple social science theories, taking into consideration how information is delivered, the power of norms, and multi-factorial social influence do deliver sexual education. The program would continue the information approach central to most sexual education programs, stressing abstinence, contraception use, but will additionally draw on the SIECU fundamentals of comprehensive sexuality education, exploring; biological, socio-cultural, psychological, and spiritual dimensions of sexuality, while addressing development, reproductive health, interpersonal relationships, and affection, intimacy, body image and gender roles (25). It differs by far in the approach it takes in delivering this information.

It will be a yearlong portion of the curriculum, allowing continuity of lessons across semester, and across grades. With permission from parents, the program involves voluntary trained peer-educators, who along with parents, teachers, and community members, will administer both large group and small group sessions throughout the course of the year. National celebrities and leaders, if willing, will be asked to occasionally participate in these lessons. A social media and telecommunication effort is employed to facilitate communication between students of certain groups

And most importantly, the HIV/STI epidemic is affecting young minority women at astoundingly rate. Because of this, TLC has a focus on reaching out to this subgroup population through a specially tailored approach, perhaps through after school sessions. This aspect of the curriculum mirrors an approach taken from a successful program knows as HORIZONS. “It is a group-level, gender and culturally tailored STD/HIV intervention with continued follow up. Group sessions are conducted by African American women health educators. Sessions foster a sense of cultural and gender pride and emphasize diverse factors contributing to adolescents’ STD/HIV risk, such as structural factors within relationships, socio-cultural factors, perceived peer norms supportive of condom use and skills” (19).

Defense Intervention 1: Moving past the individual

When designing an intervention, understanding the target population, beyond the individual is central to success. Adolescence is a unique stage of life, placing the teenage mind in a completely different state, compared to those of us creating interventions. As such we must consider the forces that influence their behavior and thoughts. Per the theorist Erickson, adolescence is the stage of ‘Identity versus Role Confusion’. This is a time of “radical change – the great body changes accompanying puberty, the ability of the mind to search one’s own intentions and the intentions of others, the suddenly sharpened awareness of the roles society has…” (20). Therefore teenagers are innately socially oriented individuals, with a potent awareness of what their peers are doing, and what society in general is doing, in pursuit of their own identity. They are absorbed in finding their role in society – in non Erickson’s terms, fitting in, being accepted, being ‘cool’. Their behaviors and actions, award them the feeling or status they seek and their individual behaviors, and beliefs are often and consistently a result of peer influences, as measured by perceptions of peer behaviors and attitudes” (21). Sexual behavior is no stranger to this social structure, as shown by the following study on adolescent oral sex and peer popularity:

Results indicate that sexually active adolescents enjoy higher status among peers or perhaps that popular adolescents feel more pressured or inclined to report that they are sexually active. Adolescents may believe that sexual activity best matches a prototype of popular, high-status adolescents…The desire to engage in, or simply report, sexual activity may reflect adolescent motivation to imitate the [popular] student (22).

These findings are concurrent with the presumption that “individual behavior is influenced by perceptions (often inaccurate) of what other people accept and expect, and how they behave: this is the premise of social norms theory, often employed in prevention strategies” (23). Using the basis these presumptions, we can address these group-level misperceptions and thereby foster individual behavioral change.

TLC does this by training voluntary high-status (popular) students to become co-facilitators of the small group sessions in the proposed CHE curriculum; Encouraging peer educators to voluntary open reporting of healthy sexual behaviors, including abstinence, and negotiation skills. As other students meet in these intimate group sessions that are being led by popular students, the association of sexy/risky behavior with popularity will become defunct, establishing a new social norm: that of healthy sexual habits.

Defense Intervention 2: Communications Theory

One unique approach that TLC offers is changing the configuration of sex health educators. As referenced to earlier, communication theory suggests that messages are likely to be taken in a positive manner, if delivered through a means that is well liked, familiar and carries positive associations. Teachers are associated with the routine day to day lessons, the jail that the classroom might be for some students, and the typical didactic approach to school. Thus, trending away from the traditional approach that mostly uses school teachers is worth exploring. The TLC approach involves carefully selected educators based on likeability, positivity and power of influence; the teams are composed of peers, community members, celebrities, and the use of social media to change the tempo of learning(5).

Using high-status peers as educators, not only sets a new norm, but also provides a messenger that shares similar characteristics as the audience. At an urban school, a peer educator will likely be from the neighborhood, culture, similar demographics…etc. At most, student will have some of familiarity with the peer-educator. Influential community members that make up the school population, to help facilitate small groups or present cases, and examples of. Celebrities passionate about sexual health, especially in minority groups, that can not only make a showing at the schools, but also place the efforts on a national media. The final approach uses text-messages and social media (face book, twitter), to spread information about sexual health among participants.

Defense Intervention 3: Tailored approach for specific at-risk subgroups

As previously alluded to, sexual behavior is a complex entity, and should be considered within the context of the influential interplays of external factors. As such, the different characteristics of individuals making up the population should be considered in order to design a tailored approach. Young African American, and Latino women are disproportionately affected by the STI/HIV epidemic; understanding and targeting factors leading to this disparity is pivotal in tailoring a solution. One of these factors is gender. While we have made considerable headway in the fight for gender equality, women continue to be subordinate to men, often objectified and depicted by social media as sexual entities. This view is even more apparent in underserved communities, demanding its attention by any sexual risk reduction program. While TLC hopes to tailor several sessions for the different groups, the young women in urban schools are an important target. The basis of the approach is routed in ‘The Theory of Gender and Power coined by Robert Connell, based on philosophical writings of sexual inequality, gender and power balance.

“ It is a social model that seeks to understand women’s risk as a function of different structures. [It] characterizes the gendered relationship between men and women: the sexual division of labor, sexual division of power, and the structure of cathexis…addressing the affective component of relationships….Each structure constitutes different risk factors and exposures that increase women’s vulnerability for adverse health outcomes. Thus is it critical to assess the exposures and risk factors of all three structures as they interact to cause an adverse impact on women’s health (24).

Two reports reviewing HIV sexual risk reduction for at-risk women both found that the most efficacious HIV prevention programs for women (1) are guided by social psychological theories; (2) include only women; (3) emphasize gender related influences, such as gender-based power imbalances and sexual assertiveness; (4) are peer led; and (5) require multiple sessions (24). This is the basis of TLCs tailored program, which borrows its structure from a current program known as HORIZONS, also based on the Theory of Gender and Power (19, 24)

Conclusion

Establishing a curriculum that promotes maintenance of a healthy sexual lifestyle and significantly reduces the rate of STI/HIV transmission, is a desirable goal, but inarguably simple at all. However we can look to evidence of previously successful programs, both within and outside the school setting, and apply these strategies to addressing this dire concern. One step towards this involves a call to politicians and special interest groups to view the world outside the context of their perspective, and accept that sexuality is innate to humanity and controlling or completely abstaining has proven difficult for the adult let alone the adolescent. That several other factors, many uncontrollable, unrecognizable and deeply institionalized that we cannot expect teenagers to just simply say no, but rather we should equip them with the psychological, social, and efficacious tools to manage their behaviors. This begins with acknowledging the most successful approach to behavioral change, equipping schools with funds, guidelines and structure on how to implement these strategies, and most of all mandating the states to actually do this. The problem of adolescence is one of role confusion—a reluctance to commit…but given the right conditions - space and time, a psychosocial moratorium, when a person can freely experiment and explore—what may emerge is a firm sense of identity, an emotional and deep awareness of who he or she is (20).

REFERENCES:

1. Sexual Risk Behavor: HIV, STD, & Teen Pregnancy Prevention www.cdc.gov/healthyyouth/sexualbehaviors/index.htm

2. Center for Disease Control and Prevention. Diagnoses of HIV infection and AIDS in the United States and dependent areas, 2009 (http://ww.cdc.gov/hiv/surveillance/resources/reports/2009report/) HIV Surveillance Report, Volume 21

3. Weinstock H, Berman S, Cates W. Sexually transmitted disease among American youth: incidence and prevalence estimates, 2000. Perspectives on Sexual and Reproductive Health 2004; 36(1): 6-10

4. Facts on American Teen’s Sources of Information About Sex . In Brief The Guttmacher

5. Kelly, JA; St Lawrence, JS; Diaz, Y E; Stevenson, L Y, Hauth, A C; Brasfield, T L; Kalichman, S C; Smithland, J E; Andrew, ME. American Journal of Public Health, Vol. 81, Issue 2 168-171.

6. Kirby D. What does the research say about sexuality education? Educational Leadership, 72-76. 2000, October

7. Sales, J; Ralph DiClemente. Adolescents STI/HIV Prevention Programs: What Works for Teens? Act for Youth Center of Excellence, 2010

8. Satcher, D. the sugeon General’s call to action to promote sexual health and responsible sexual behavior. American Journal of Health Education 2001; 32(6): 356-368 2001

9. Dailard, C. Sex education: Politicians, parents, teachers and teens. The Guttmacher report on public policy. Ney York, NY: The Alan Guttmacher Institute, 2001

10. Centers for Disease Control and Prevention. New York City: Bringing HIV Prevention Education into the Spotlight (/healthyyouth/stories/pdf/2008/successny08_

11. Centers for Disease Control and Prevention. HIV and Other STD Prevention and United States Students

12. Centers for Disease Control and Prevention. HIV, Other STD, and Teen Pregnancy Prevention and New York Students

13. State Profile. New York. STDs, HIV/AIDS, & Teen Pregnancy Prevention Policies New York

14. "HIV/AIDS Curriculum - Standards/Curriculum - New York City Department of Education."New York City Department of Education. Web. 19 Dec. 2011.

15. Edberg, Mark. Individual Health Behavior Theories (chapter 4) In: Essentials of Health Behavior Sudbury, MA 2007

16. Airhinhenbuwa, C; Obregon, R: A critical Assessment of Theories/Models Used in Health Communication for HIV/AIDS. Journal of Health Communication, 2001:5

17. Kelly J, A et al. HIV risks Behavior reduction following intervention with key opinion leaders of population: an experimental analysis. American Journal of Public Health, Vol. 81, Issue 2 168-171.

18. Jemmott III, J et al. School Based Randomized Controlled Trial of an HIV/STD Risk-Reduction Intervention for South African Adolescents. Arch Pediaric Adolesc Med. 2010:164(10):923-929

19. "HORIZONS | Best-Evidence Interventions | Prevention Research Synthesis | Research | Topics | CDC HIV/AIDS." Centers for Disease Control and Prevention. Web. 18 Dec. 2011. .

20. Gross, F. L. Introducing Erik Erikson: An invitation to his thinking. Lanham, MD: University Press of America p. 47. 1987

21. Berkowitz, AD; Perkins, HW. Problem Drinking Among College Students: A Review of recent Research. Journal of American College Health, 1986:35:21-28.

22. Prinstein, M et al. Adolescent Oral Sex, Peer Popularity, and Perceptions of Best Friends’ Sexual Behavior. Journal of Pediatric Psychology 2003:28(4):243-249

23. Hahn-Smith S, Springer F. Social Norms Prevention Strategies. Prevention Tactics 2005 (8):9

24. Wingwood G, DiClemente R. The Theory of Gender and Power: A Social Structural Theory for Guiding Public Health Interventions (Chapter 12) In: Emerging Theories in Health Promotion Practice and Research. Strategies for Improving Public Health. San Francisco Ca, 2002

25. National Guidelines Task Force. Guidelines for comprehensive sexuality education. New York, NY SIECUS, p.6 1996