Sunday, October 30, 2011

Executive Summary

Executive Summary
There is an urgent need to address the emerging and re-emerging epidemics of HIV and other sexually transmitted
infections (STIs) among men who have sex with men (MSM) and transgender people. Strengthening strategic
information systems and implementing interventions for the prevention and treatment of HIV and other STIs among
MSM and transgender people should be considered a priority for all countries and regions as part of a comprehensive
effort to ensure universal access to HIV prevention, care and treatment.
Reports from a diverse range of countries and regions have highlighted that prevalence of HIV and other STIs
among MSM and transgender people is high when compared with men in the general population. Unprotected
anal sex is common and surveys show that some MSM have female partners, many are married, some are engaged
in sex work and some use drugs. Existing second-generation HIV surveillance systems, research, and efforts of
national HIV/AIDS and STI programmes have not adequately captured biological and behavioural data on these
populations, nor implemented prevention interventions on a sufficient scale. Resources to address HIV and STIs
among MSM, transgender people and their partners do not match the burden of disease.
The risk of and vulnerability to infection are reinforced by societal attitudes, which deny human rights to MSM and
transgender people, as well as their right to health.

Plug the supply and resource gaps.

Plug the supply and resource gaps. It is critical that a regular supply of condoms be
guaranteed by national programmes and supported by the donor and non-governmental
organization communities. Male and female condoms should be available to everyone who
needs them, whenever and wherever they want them. Condom education and promotion
must be accompanied by a stable and affordable supply of condoms. Coordinated and
collective actions at global and national levels (between donors, national governments
and the private sector) are required to improve commodity purchasing and distribution.
Improve impact measurement. Condom-promotion programmes need to have
programme effectiveness measured, regardless of the group being targeted. Other than
Senegal, Thailand, Uganda and, possibly, Cambodia, there are still too few examples
of low- and middle-income countries that have successfully halted and begun reversing
their epidemics. Trends in the parameters of condom use in countries (e.g., distribution
numbers, consistent condom use with casual and regular partners) should be vigilantly
monitored and the effects on HIV transmission assessed. For example, there are
encouraging findings from a study among 18–24-year-old young men in a South African
township that showed significant impact at the general population level of consistent
condom use on HIV, herpes simplex-2, and genital ulceration. Young men who used
condoms consistently were two to three times less likely to be infected with HIV and to
have genital ulceration 46.
Behavioural information on the proportion of people in different populations in a country
who consistently use condoms with various types of partners is a key to tracking the
effects of condom programming on HIV incidence, although methodological challenges
remain. Condom promotion aimed at the general population should ideally include
measurement of trends in the numbers of sexual partners (especially casual partners and
among the young). Research should focus on establishing the level of condom use that
is required to make a difference in incidence and prevalence rates in different epidemic
situations.
Whatever the challenges to ensuring condom access, availability and correct and
consistent use, the promotion of condoms is a strategy that must be used to the best
advantage. There are so few effective tools to prevent HIV transmission that there is
no leeway to forego any of them—least of all the one that, arguably, provides the best
chance of success.

Draw on the synergistic interaction

Draw on the synergistic interaction of interventions. With the continued rise in
the spread of the epidemic across all regions, HIV prevention programmes must include
a wide range and mix of interventions that are tailored to the country’s epidemiological
and cultural situation. This should include, but not be limited to, education on the
‘ABCs’ of prevention, treatment and care of STIs, voluntary counselling and testing
services, harm reduction, and addressing discrimination and stigmatization.
Promoting sexual abstinence or reduction in the number of sexual partners does not
preclude the promotion of condoms. All prevention programmes have the responsibility
to provide people with complete and accurate information so that they are able to make
informed choices. Providing accurate information includes avoiding overstating the
effectiveness of condoms, such as saying that sex with a condom is “safe sex” (instead
of “safer sex”), and telling the truth about condoms (i.e., that they are highly effective
when used correctly and consistently).
Successful programmes that encourage delayed sexual onset and partner reduction can
also help people to be aware of the importance of condom use whenever they do not
meet these objectives. Monitoring the outcomes of these programmes can provide useful
insights for optimal calibration of the mix of prevention interventions.

Saturday, October 29, 2011

Address critical misperceptions

Address critical misperceptions. The correct and consistent use of condoms in
stable relationships continues to be a challenge. This issue, as well as the continued
promotion of condom use with casual partners, must be directly addressed. In addition
to promoting the use of condoms with regular partners through traditional mass media
and small media channels, it is important to reinforce it through voluntary counselling
and testing networks. Couples and others who may assume it is already too late to
adopt safer sexual practices must be encouraged and supported to use condoms through
post-test and ongoing counselling. Consistent condom use is essential for HIV-positive
persons who choose to remain sexually active.
HIV prevention programmes need to regularly draw from the findings of operational
research on how consistent condom use for key groups in different settings can be
achieved.

Despite the experience of the

Despite the experience of the past two decades, many questions remain unanswered
regarding the promotion, use and effectiveness of condoms. Objective and unbiased
research is needed and should, ideally, make it easier for condom programmes to ensure
an appropriate mix of prevention approaches that include condom promotion for key
populations at higher risk, promoting consistent condom use in stable relations, and
securing a regular supply of condoms to all who need them.
1. Build on the condom’s advantage. Condom promotion is an essential part of HIV
prevention programmes, both for key populations with high risk of HIV exposure and
for the general population. The use of condoms by those living with HIV enables them
to continue having a healthy and safer sex life. For sex workers in every country in the
world, condoms represent the only real option for reducing the risk of contracting and
transmitting HIV. Other groups whose risk of exposure is high include injecting drug
users and their sexual partners, and heterosexuals with many sexual partners or with a
high turnover of partners. Targeted condom promotion addresses the need for condom
availability at critical delivery points.
2. Condom promotion for the general population can encourage people to think and
talk about HIV prevention; it also helps to make safer sex the norm. Condom promotion
programmes have had the greatest impact on prevalence rates when introduced early in
a country’s epidemic and when they are accessed and used consistently by populations
at higher risk of HIV exposure. Condom promotion also yields other benefits, such as
preventing unintended pregnancy and reducing the transmission of other STIs.
Operational research is needed to determine both how condom promotion can best
be integrated into combination approaches to reduce sexual transmission of HIV and
to better understand the interactions that take place between different programme
components. It is essential that condom promotion programmes, while using successful
condom social marketing techniques to reduce common fears and misperceptions in the
general population, also target priority populations. In addition, such programmes must
incorporate approaches that create a more supportive sociocultural climate by providing
balanced arguments on the benefits of condom use versus its risks.

Getting condoms to those who need them most

Getting condoms to those who need them most
The rise in the need for condoms is fuelled by increasing HIV
prevalence in many developing countries, by large numbers of people
beginning sexual activity, and by a growing interest in contraceptive
use. However, sexually active young people (especially young women)
are regularly and repeatedly denied information about, and access to,
condoms. This means that misconceptions (such as the belief that
condoms do not protect against HIV infection) are not corrected.
If condoms are to be used at all, and especially if they are to be used
consistently, then it is clearly important that people have access to them
and that they be able to afford them. A reliable supply and distribution
system for those who need condoms is essential. Numerous surveys
cite non-availability of condoms at the time of sexual interactions as a
main reason for non-use 44.
Experience has shown that, when condoms are available and affordable,
people use them. Decreasing condom prices in Brazil in the early 1990s
resulted in a massive increase in the numbers of condoms purchased.
The increase in condom accessibility and availability promoted by
the Ford Foundation in South Africa (through mass distribution and
vending machines in workplace toilets) increased uptake 25-fold 45.
The gender aspects of condom use are undoubtedly the most difficult
hurdles to overcome. Until men and women share equal decisionmaking
power in their interpersonal relationships, the female
condom will provide women with greater opportunities for protecting
themselves from HIV and STIs than the male condom. Research studies
in South Africa, Thailand, the United States and Zambia indicate that
a greater number of sexual acts are protected when female condoms
Increasing
access to
condoms by
overcoming
supply
shortages,
reinforcing
promotion
strategies
and improving
distribution
systems is
absolutely vital
to success
against the
spread of HIV.
Making condoms work for HIV prevention:
Cutting-edge perspectives
25
are available as a supplement to male condoms, although more investigation is needed
to confirm these findings.

Resources to meet demand for

Resources to meet demand for condoms come from domestic government sources
and out-of-pocket expenditures; multilateral agencies, including the United Nations
Population Fund (UNFPA) and the World Bank Multi-Country AIDS Programme
(MAP); the Global Fund to fight AIDS, TB, and Malaria; the private sector (foundations,
employers, international nongovernmental organisations) and bilateral donors. Donors
provided 3.574 billion condoms in 2002, at a cost of US$ 94.9 million. Condom funding
peaked in 1996 when international funding of condoms was at US$ 68 million, but it
subsequently declined to US$ 40 million annually in 1999 and 2000.
Condoms needed for STI/HIV Prevention, 2000–2015 (in millions)
12 000
10 000
8 000
6 000
4 000
2 000
2000 2005 2010 2015
Asia and Pacific
LatinAmerica
and Caribbean
Arab States
Sub-SaharanAfrica
Source: UNFPA (personal communication), 2001.
These figures include condoms needed for protection from STI and HIV infection only, and exclude those needed for
family planning.
Figure 2. Regional estimates of condom need: Condoms needed for
STI/HIV prevention, 2000–2015 (in millions)
UNAIDS
24
Part of this decline may be attributed to policy changes in the United
States, which substantially cut donations from 800 million condoms in
1992 to 300 million a year in 2000. While many developing countries
now provide and promote condoms as part of their HIV prevention
strategies, many of the poorest countries still depend on assistance
provided through bilateral and multilateral funding. Such cutbacks are
sorely felt in the places where condoms are most needed.

Condom promotion and distribution

Condom promotion and distribution programmes have grown
significantly since the beginning of the AIDS epidemic. Despite
this, it is estimated from a survey of 70 countries that only 18% of risky
sex acts in low and middle income countries in 2003 were protected
by condom use 42. In this survey, a risky sex act is defined as one with
a casual partner or with spouse, if at least one partner has contacts
with outside partners. UNFPA estimates that 8 billion condoms were
needed in 2000 for HIV/STI prevention alone, and that, by 2015, at
least 18.6 billion condoms will be needed (Figure 2) 43. These figures
exclude condoms needed for family planning purposes, and assume
People can
be persuaded
to use
condoms,
validating
the argument
that condoms
represent an
acceptable
and viable
strategy for
reducing HIV
transmission.
Making condoms work for HIV prevention:
Cutting-edge perspectives
23
that the condoms would, in any case, not be used consistently. Excluding the costs of
delivery, distribution, promotion or other services, it would have cost US$ 239 million
to procure the minimum number of condoms (8 billion) needed in 2000. This cost is
estimated to increase to US$ 557 million by 2015.
There are two important questions regarding condom supply:
• Are there sufficient resources to meet the demand?
• Are the available supplies of condoms reaching the people who need them most?

The examples of Senegal and Thailand

The examples of Senegal and Thailand indicate that the introduction
of condom-promotion programmes early in the epidemic strengthens
HIV prevention. High rates of condom use among populations
at higher risk of HIV acquisition, before an epidemic spreads to
the general population, may account for successful control of the
epidemic. In countries where the HIV epidemic has spread to the
general population, high rates of consistent condom use among the
general population will be needed over an extended period of many
years before an effect on prevalence rates can be detected.
The available evidence clearly shows that a dramatic increase in
condom use can make, and over the past two decades has made, a
difference. This has occurred in a variety of geographic regions
and cultures and has far exceeded what many sceptics would have
believed possible even a few years ago. People can be and have been
convinced of the need to use condoms, supporting the argument that
for many people condoms represent an acceptable, viable strategy for
HIV control.

High rates of condom use have

High rates of condom use have been achieved, at least for casual sexual partnerships,
in some of the countries hardest hit by AIDS. This has not invariably led to a
demonstrable fall in the rate of HIV infection because of the timing of their introduction,
the target population and the level of coverage. For example, it is estimated that overall
provision of condoms in Africa in 1999 amounted to only 4.6 per man per year 42.
It is quite possible that HIV prevalence would have risen even faster in some countries
if condom use had not increased. But the current situation raises many questions, such
as the following:
• What level of condom use is necessary to control and roll back a generalized
heterosexual epidemic?
• In settings reporting high rates of condom use, are condoms being used
consistently and correctly enough to have the desired impact?
• At what point is condom use only with casual sexual partners no longer good
enough?
• How can high rates of condom use in steady sexual partnerships be achieved
when HIV prevalence in the general population is high?
These questions remind us that the number of condoms distributed is not the sole
indicator of success of an HIV prevention programme. In addition to measuring condom
uptake and condom use, we need to ask ourselves what exactly should be measured.
From an epidemiological point of view, rates of condom use are essential indicators in
UNAIDS
22
situations where exposure to HIV is more likely, such as sex between
new, nonsteady or casual partners. Most condom use studies tend to
focus on this indicator. However, condom use with regular partners is
also an important indicator of successful condom promotion and must
be included in monitoring and evaluation efforts.

These studies demonstrate

These studies demonstrate that lower age seems to be one of the strongest predictors
of condom use. At the same time, there remain a number of obstacles to ensuring that
young people use condoms. Myths, fears and misperceptions about condoms among
young people, combined with inaccessibility to supplies, severely weaken prevention
practices among 15–24-year-olds, yet this is the age group hit hardest by the epidemic
in many settings. Structural barriers such as gender norms and roles, social stigma,
and lack of access to youth friendly health services constitute additional major factors
undermining the capacity of young people to protect themselves from HIV infection.
Top-level commitment is needed to put in place policy and programmatic interventions
aimed at young people, which back up prevention education with access to prevention
tools.

Among young people

Among young people
Condom use among young people is especially important because the young are often
UNAIDS
20
at greatest risk for HIV infection and have the least access to condoms. Moreover,
young people are establishing patterns of sexual behaviour that may last a lifetime. One
indicator often used to examine condom use among the youngest sexually active persons
is to ask whether a condom was used during their first ever sexual encounter. Rates as
high as 77% are reported in France and 68% in England. But developing countries such
as Brazil (48%) and Mexico (43%) also have a high proportion of young people who say
they used a condom the first time they had sex39.
Demographic and health surveys (DHS) show that young age is a strong predictor of
condom use, except apparently among young MSM, for whom condom use may be
lower in some settings. DHS data from 27 countries in Africa and Latin America showed
higher rates of condom use at last high risk sex for 15–24 year olds compared to 25–29
year olds in every country40. High risk sex was defined as sex with a non-marital, noncohabiting
partner. Figure 1 shows the results from selected African countries in studies
conducted between 1994 to 2001 among 15–24 year old young men and women.

Friday, October 28, 2011

In the sex industry

In the sex industry
Experience throughout the developing world confirms that the greatest changes in
sexual behaviour have taken place among sex workers and their clients. Thailand’s
100% Condom Use Programme achieved nearly universal use of condoms in its large
sex industry. After an intensive campaign of condom promotion and distribution in
brothels, a survey found that the proportion of female sex workers who said that they
always use condoms during commercial sex rose from 14% in 1989 to over 90% in
1994 32,33. Another study found that consistent condom use among brothel-based sex
workers went up from 87% in 1993 to 97% in 1996 34.
Evaluations of HIV programmes and randomized trials in various parts of the world
reveal that some of the most effective prevention programmes have taken place in
sex-worker settings. Post-intervention in a randomized trial in Mumbai, India, 70%
of women reported using condoms at least sometimes and 28% said they used them
always. These proportions compared to 53% and 0% respectively for women in control
brothels who did not receive the intervention. HIV incidence was 5% per year in the
intervention group, versus 16% per year in the control group, with similar differences
in the incidence of other STIs 35. In the Democratic Republic of the Congo in 1994, an
HIV-prevention programme for sex workers increased consistent condom use from
11% to 68% and decreased HIV incidence from 11.7% per year to 4.4% per year, with
parallel decreases in other STIs 36. In Senegal in 1999, 94% of sex workers reported
using a condom the last time they had sex with a regular client and 98% with a new
client 37. In Kampala, Uganda, in 2001, 99% of female sex workers reported using a
condom when they last had intercourse 38. Unfortunately, these success stories are by
no means typical of all parts of the developing world. Nevertheless, they demonstrate
that very high rates of condom use in commercial sex are achievable.

Clear evidence that people

Clear evidence that people can be convinced to use condoms, and that condoms can be
a successful public health strategy for HIV prevention, has been documented among
MSM and sex workers. In San Francisco, condoms were heavily promoted from the
beginning of the epidemic by public health officials and by leaders of the local gay
community 28. Incidence rates for all STIs fell substantially, and annual HIV incidence
rates fell from double digits in the early 1980s to less than 1% after 1985 29.
There have been similar increases in condom use among MSM in many places in
industrialized countries. However, this has not necessarily been true in developing
countries. Where condom use among MSM remains low, this has more often been
due to lack of effort than to failure of condom promotion campaigns. HIV prevention
programmes in many countries have not given MSM the prevention and care services
that they warrant. This may be because of outright discrimination and stigmatization or
because of a belief that MSM are hard to reach. Yet, concerted efforts targeted at MSM
have usually been successful in increasing condom use. In Salvador, Brazil, for example,
consistent condom use during anal sex increased from 81% to 97% in MSM following
Making condoms work for HIV prevention:
Cutting-edge perspectives
19
participation in safer-sex workshops30. Recent epidemiological and behavioural data
show a rise in unprotected sex among a small but significant proportion of MSM in
developed countries coinciding with widespread access to accessible antiretroviral
(ARV) treatment regimens 31. Findings in many industrialized countries that show lower
condom use among young MSM, combined with growing complacency among those
on ARV treatment, demonstrate the need to revitalize and sustain primary prevention
messages aimed at promoting protected sex for MSM in high-income countries.

Persons in steady sexual relationships

Persons in steady sexual relationships
A high proportion of HIV transmission takes place between steady partners. Therefore,
not using condoms or using them inconsistently can be a problem. This is particularly
true in settings with high HIV prevalence, where the likelihood that a partner may be
infected is raised.
UNAIDS
18
There are barriers, of course, to using condoms with steady partners or in stable
relationships. Trust, power inequalities, and the desire for children are common issues
among married couples which can discourage condom use 21. Studies in Kenya and
Zambia show that, while marriage increases the frequency of sex, it decreases condom
use and can severely restrict women’s ability to protect themselves from infection. The
association of condom use with casual or commercial sex persists as a barrier because
it reinforces the misperception that protection against STIs or HIV is not needed with
regular sexual partners. However, there is growing evidence in many countries of the
risk of HIV infection within marriage. In a recent study in India, 90% of women being
treated for STIs had only one lifetime partner, and 14% were HIV-positive. In Kisumu,
Kenya and Ndola, Zambia, adolescent married girls age 15–19 years were found to
have higher levels of HIV infection than non-married sexually active girls the same age,
demonstrating that not only is marriage not protective in some settings, but it actually
can increase risk22.

General population

General population
Promoting widespread condom use in the general population is a greater challenge than
promoting it in specific populations, such as sex workers and their clients. Furthermore,
it is not easy to measure the success of condom promotion efforts directed at the general
population. Statistics on the number of condoms distributed give some idea of the scope
of the effort but do not indicate what proportion of the population, particularly those at
highest risk, is consistently using condoms. Most surveys do not identify key populations
at highest risk and do not ask about high-risk settings where condom use could make
a difference to transmission. For instance, in epidemics concentrated among specific
segments of the population (e.g. MSM and sex workers), high condom use would make
a substantial difference, regardless of the rate of condom use in the general population.
Numerous studies show high rates of condom use in the general population of various
developing countries. Data collected by the Brazilian Ministry of Health showed that 63%
of men and 69% of women reported using a condom during their last sexual encounter
with a casual partner 18. In a 1999 study in Zimbabwe, over 70% of men reported using a
condom the last time they had high-risk sex 19. However optimistic the trends in condom
use are, the rise in condom use generally applies only to a tiny fraction of all sexual
encounters in these countries. Condom use is much lower in rural areas, and condom
promotion has had little impact in the context of steady sexual relationships. Across
all regions of the world, the poor results of promotion efforts to encourage consistent
condom use within regular partnerships highlight this as one of the major challenges in
condom promotion20.

No matter how effective

No matter how effective condoms may be, they can have little impact
in preventing HIV if people do not use them. There is growing
evidence that in key populations at higher risk of HIV exposure, such as
men who have sex with men (MSM) and sex workers and their clients,
people can be persuaded to use condoms. In these groups, both increases
Condoms are
about 90%
effective when
used correctly
and consistently.
If the risk of
transmission
is one in
500 without
a condom,
it would be
reduced to one
in 5000 when a
condom is used.
Making condoms work for HIV prevention:
Cutting-edge perspectives
17
in condom use and high rates of condom use have been documented. Global experience
shows that the use of condoms is often not consistent, whether in the general population,
among persons in steady relationships, or in key populations at risk of HIV infection.

Thursday, October 27, 2011

Consistent condom use

Consistent condom use
A population may use large numbers of condoms but the impact will
be limited if the persons who use them most do not do so consistently.
There is little evidence that using condoms sometimes (but not always)
provides any greater protection than not using condoms at all. In fact,
one study from Uganda found that individuals who sometimes used
condoms were at higher risk of infection than those who never used
them, perhaps because they were more risky in other aspects of their
sexual behaviour, such as the number of partners they had 17.
In analysing overall data on condom use, it is critical to determine who
is using condoms. In a situation where overall condom use in general
is high, but condom use is low in those few encounters where it could
make a measurable difference, condom promotion must become more
focused. This could occur, for example, if those at highest risk of HIV
infection have lower rates of condom use, while people at low risk
have higher rates of condom use.

Reproductive health programmes

Reproductive health programmes for young people vary in their
approach. Some are fairly explicit (e.g., by demonstrating the correct
use of condoms). Most, however, are basically conservative in their
approach and encourage delay in sexual initiation and limiting the
number of one’s partners. Some studies indicate that more explicit
approaches that include skills training—i.e., how to use condoms
correctly and how to negotiate their use with partners—may produce
greater reductions in sexual risk than programmes that provide only
information11,12. However, even the more explicit condom promotion
programmes for adolescents seldom emphasize ‘eroticizing safer sex’.
This approach is more commonly taken in prevention programmes
aimed at key populations at risk, such as men who have sex with men
or sex workers and their clients.
If protected or safer sex is promoted as part of an array of means, which
also include abstinence, and partner reduction, aimed at preventing
sexual transmission of HIV, there is greater likelihood that strategies will
complement and mutually reinforce each other. In different situations,
the emphasis placed on each strategy will differ in accordance with
epidemiological, contextual and behavioural evidence.

The ABCs of HIV Prevention

The ABCs of HIV Prevention
(A) Abstinence refers to not engaging in sexual intercourse
Sexual expression is a natural and healthy part of life, however, for certain
periods during one’s life, one may choose to abstain from all sexual expression
or from higher-risk activities such as penetrative sexual intercourse. Prevention
strategies encouraging delay of sexual initiation or debut help young people
to postpone sexual intercourse until they have developed the personal and
social skills that will enable them to practise protected intercourse. The goal of
delay-oriented programmes is to facilitate the development of young people’s
capacities for informed decision-making regarding their sexual health, including
the prevention of pregnancy and sexually transmitted infections (STIs), including
HIV. Whether abstinence occurs as a delay of sexual debut or as adoption of
a period of abstinence at a later stage, access to information and education
about alternative safer sexual practices is critical to avoid HIV infection on sexual
initiation or resumption of sexual activity.
(B) Being safer by being faithful to one’s partner or reducing the number of
sexual partners
The lifetime number of sexual partners is a very important predictor of HIV
infection. Thus, having fewer sexual partners reduces the risk of HIV exposure.
However, strategies to promote faithfulness among couples do not necessarily
lead to lower incidence of HIV unless neither partner has HIV infection and both
are consistently faithful.
(C) Condom use refers to consistent and correct use of condoms, both
male and female
Effective condom promotion within a combination prevention strategy must
involve the equally important and interrelated components of informed choice,
empowerment, supportive environment, demand and supply. To meet the
needs and socioeconomic conditions of all population groups, greater access
to, and availability of, condoms should be ensured through diverse channels,
including free distribution, commercial sale and social marketing programmes.
Condoms need to be actively promoted among sexually active young people
and other populations at higher risk of HIV exposure such as sex workers and
their clients, men who have sex with men (MSM), and people with HIV and their
partners. Studies conducted by the US National Institutes of Health and the US
Centers for Disease Control and Prevention (CDC) have found that, without
access to condoms, other prevention strategies lose much of their potential
effectiveness. In addition, for young people, condom education and promotion
are most effective within the context of life-skills education to help them make
responsible decisions related to sexual behaviour and reproductive health.

The continuing debate on the place

The continuing debate on the place and role of condom promotion in HIV prevention
programmes particularly for young people has generated mixed messages. These tend
to confuse young people and constrain consensus as to what works for youth. This
controversy illustrates concern about the interactions between condom promotion,
on the one hand, and other behavioural change approaches (particularly those aimed
at sexual abstinence) on the other. At the root of this concern is a fear that condom
promotion may increase sexual activity and may encourage people to have more sexual
partners9.
Reproductive health programmes for young people, including sexual health education,
have been investigated extensively to determine whether condom education and
promotion have, in fact, resulted in young people switching from abstinence to
sexual activity with condoms. A review in 2002 identified 41 studies that examined
programmes with condom education components. These programmes were based in
schools or in the community, or were carried out through the mass media, workplaces
or health facilities10. Almost all resulted in improved knowledge and attitudes, and
many produced an increase in contraceptive use. Seven of the programmes showed a
significant impact in the direction of reduced sexual risk (in terms of delayed sexual
initiation or reduced number of sexual partners). It may be noted that most of these
studies did not specifically focus on condom promotion interventions.
This conclusion reinforces the need for a range of prevention options for young people,
covering the full spectrum of sexual behaviour. It is important to offer adolescents
choices for HIV prevention. This combination behavioural change approach has been
labelled as ABC—i.e., Abstinence, including delay of sexual initiation or debut, Being
safer by being faithful to one’s partner or reducing the number of sexual partners, and
correct and consistent Condom use (see box). Providing information and education on
a range of safer sexual behaviours is consistent with current empirical evidence of the
diversity of young people’s sexual behaviours.

While the two programmes

UNAIDS

While the two programmes differed in their emphasis on particular preventive measures,
there were some noteworthy parallels underlying each programme’s success.
Thailand Uganda
Programme emphasis on condom use,
especially in sex work venues such as
brothels:
Did not discourage reducing number
of sexual partners
Thais reduced their number of sexual
partners, particularly those involving
commercial sex transactions
Public promotion of condom use led
to an increase in condom use and
a decrease in the number of sexual
partners, which was additive to the
increased condom use
Programme emphasis on partner
reduction:
Did not discourage condom use
Ugandans reduced their number
of casual sexual partners
Public debate about condom use
led to an increase in condom
use in the general population,
particularly among young people
and in sex work, which was
additive to the decline in the
number of sexual partners
The difference in programme emphasis between use of condoms and reduction in the
number of sexual partners appears more related to differences in local epidemiology—
namely differences in the prominence of commercial sex in HIV transmission—than to
differences in philosophy.
These two countries’ responses to the HIV epidemic were based on correct assessment
of the main factors driving their epidemics and an understanding of local sociocultural
characteristics. Thailand’s emphasis on condom use in sex work venues would not have
worked in Uganda as this factor was not driving the Ugandan epidemic. A Ugandanstyle
programme emphasizing partner reduction for the general population probably
would not have worked well in Thailand. In both cases, what did work was a determined,
multisectoral effort that enlisted broad public support and responded to local realities.

Wednesday, October 26, 2011

Common elements for success

Common elements for success
There are common elements to these success stories. In general, both Thailand and
Uganda:
• responded to the AIDS epidemic quickly and decisively;
• had leadership commitment from the highest levels for active
involvement in their respective HIV-prevention programmes;
• used a multisectoral approach and achieved broad public consensus
for support;
• avoided stigmatization and included important aspects of care for
HIV-infected persons;
• developed local responses to a locally-perceived threat;
• benefited from international public health and scientific collaboration; and
• had international donors playing essential roles in programme financing.

The major decline in HIV incidence

The major decline in HIV incidence clearly happened before large-scale condom
promotion was incorporated into HIV prevention efforts. Condom promotion was not
given greater emphasis in Uganda until the early 1990s. However, widespread debates
about condom promotion among political and religious leaders played a constructive
role early on in Uganda’s response to the epidemic because they encouraged people to
think and talk about AIDS. As controversy over condoms faded, the promotion and use
of condoms became generally accepted as a necessary component of HIV prevention
efforts. Social marketing of condoms got off the ground on a large scale in the mid-
1990s. The Ugandan Demographic and Health Survey (DHS) conducted in 2000–2001
showed that, among the 15–24-year-olds in Uganda who had non-cohabitating partners,
44% of the women and 62% of the men used condoms during their most recent sexual
interaction.
Overall rates of condom use were comparatively low at the time that incidence rates
began declining. However, even low levels of condom use in the overall population can
still make a difference as long as condom use is higher among those subgroups of the
population that are at highest risk. This may apply in Uganda, where condom use in
commercial sex was high8. Also, rates of condom use among young people, compared
to older adults in general, possibly contributed to the decreased HIV incidence observed
in that age group.

Two major behavioural changes

Two major behavioural changes took place: condom use increased in sex work settings,
as was intended, and the frequency of visits to sex workers by men fell dramatically,
an unanticipated outcome. The proportion of 21-year-old men who indicated visiting a
sex worker in the past year fell from nearly 60% in 1991 to 8% in 1998 while condom
use during commercial sex transactions rose to more than 95% of all acts in 19985.
These changes were the result of greater awareness of risk generated by the 100%
Condom Use Programme. The programme’s effectiveness was evident in the rapid drop
in sexually transmitted infections (STIs) among men reporting at government clinics
UNAIDS

and, in particular, among male military conscripts (a fairly representative sample of
men in their late teens since conscription in Thailand is primarily by lottery). Although
the programme did not explicitly aim to discourage commercial sex, increased risk
awareness apparently caused large numbers of men to avoid visits to sex workers.

Other success stories indicate positive

Other success stories indicate positive interactions between different approaches, with
some interventions leading to outcomes beyond those intended. Programmes in several
countries have shown that positive interactions among prevention interventions can
stabilize or reduce HIV prevalence. A condom promotion campaign directed at male port
workers in Brazil had the unexpected result of not only increasing condom use among
these men but also decreasing the proportion of men who reported having sex with casual
partners4. Senegal’s prevention efforts, which began in the mid-1980s, led to high levels
of knowledge about HIV prevention in the general population and to unexpectedly high
rates of condom use with non-regular partners, particularly by sex workers and their
clients. Prevention programmes in Thailand and Uganda are outstanding examples of
the effectiveness of comprehensive programmes including condom promotion leading
to reductions in HIV transmission. Condom promotion played a different role in each of
these two countries’ successes.
Learning from successes
The Thai lesson: targeting condom promotion
Condoms clearly played a key role in HIV prevention efforts in Thailand. Promoting the
use of condoms in sex work venues such as brothels was the core strategy of the Thai
100% Condom Use Programme, but other interventions—such as substantial health
education, sexually transmitted infection (STI) control, HIV testing, and clinical care
for persons with HIV-related disease—played supporting roles. The success of the 100%
Condom Use Programme’s implementation was rooted in strong political commitment
and support at all levels, including that of government officials, local health workers,
nongovernmental organizations (NGOs), the media, brothel owners, and the public in
general. The pattern of the epidemic in Thailand in the late 1980s mandated the need
for a prevention strategy targeting sex work venues, at a time when unprotected sexual
activity was the driving force of the Thai epidemic.

Tuesday, October 25, 2011

Other success stories

Other success stories indicate positive interactions between different approaches, with
some interventions leading to outcomes beyond those intended. Programmes in several
countries have shown that positive interactions among prevention interventions can
stabilize or reduce HIV prevalence. A condom promotion campaign directed at male port
workers in Brazil had the unexpected result of not only increasing condom use among
these men but also decreasing the proportion of men who reported having sex with casual
partners4. Senegal’s prevention efforts, which began in the mid-1980s, led to high levels
of knowledge about HIV prevention in the general population and to unexpectedly high
rates of condom use with non-regular partners, particularly by sex workers and their
clients. Prevention programmes in Thailand and Uganda are outstanding examples of
the effectiveness of comprehensive programmes including condom promotion leading
to reductions in HIV transmission. Condom promotion played a different role in each of
these two countries’ successes.

An important area that has received

An important area that has received surprisingly little scientific attention is the
interaction between condom promotion and other strategies in reducing the
transmission of HIV. Examining condom promotion in isolation from other strategies
gives, at best, a narrow view of HIV prevention. The optimum role of condom promotion
in a comprehensive AIDS prevention programme depends on several factors including
local epidemiology, the populations being targeted and the sociocultural context.
Condom promotion and other prevention interventions have to be balanced so that they
work in synergy to achieve the greatest overall impact.
Synergies between multiple interventions
The use of combination approaches in HIV prevention is recognized as sound strategy.
Multiple interventions complement each other and compound the impact for curbing
the epidemic. For instance, reducing the average number of sexual partners that persons
have in a given population could cut the rate of transmission of HIV just as much as an
increase in the numbers of people consistently using condoms. If both these changes
were achieved simultaneously, the reduction in the rate of transmission would likely
be more than the additive effects of the two interventions on their own. The greater
the number of effective strategies employed, the greater the potential for achieving
maximum overall impact.
In settings where resources are constrained, decisions on the best possible mix of
interventions are usually made on the basis of cost-effectiveness. Interventions that
score highly are more likely to pull in financial support. Systematic monitoring and
evaluation of the effectiveness of interventions can provide useful information on
whether combined interventions are working in harmony toward desired prevention
objectives.
Programmes that promote use of the female condom have demonstrated that different
risk-reduction strategies can reinforce one another. The female condom provides women
with an additional option to protect themselves from both pregnancy and infection.
Female condom acceptability studies in Tanzania, Zimbabwe, Senegal, Costa Rica,
Indonesia, and Mexico show that women find the female condom empowering, as it
provides an opportunity for improving dialogue within couples on the issues that put
them at risk, such as sexual partners external to the relationship 3.

Introduction: making condoms

Introduction: making condoms work for HIV prevention
Condoms play an important role in HIV prevention. The question is not whether
condom promotion is a successful public health strategy for HIV prevention but
how to effectively position the use of condoms within a comprehensive HIV prevention
strategy. Condom programming1 is an integral component in a range of prevention
strategies which include informed, responsible and safer sexual behaviour exemplified
by delayed age of onset of sexual activity, abstinence, condom use and reduction in the
number of sexual partners.
Analysis of the scientific literature on condoms and HIV prevention2 and study of the
experiences of various prevention programmes show that, to achieve the full prevention
potential that condoms offer, four critical elements must be addressed.
These are:
• realizing that there are interactions between condom promotion, including
condom social marketing and peer-based condom education, and other
prevention strategies;
• understanding and correctly communicating information on the effectiveness
of condoms;
• convincing people to use condoms when they are needed and to do so
consistently and correctly; and
• ensuring a sufficient and regular supply of condoms for those who require them.
This document draws attention to insights in these areas gained from both studies and
programme experiences. The policy and programme implications of these insights can
assist AIDS programme providers, decision-makers with particular responsibilities
in condom programming, and key community leaders who influence decisions on
reproductive health in their constituencies to position condom use optimally within
overall prevention programming.

With HIV continuing to spread

With HIV continuing to spread across all regions of the world, effective HIV
prevention programmes must be rapidly scaled up to match the scope of the
AIDS epidemic. The range and mix of interventions needed vary by country depending
on local epidemiology and sociocultural context. They should include, but not be
limited to, education on the ‘ABCs’ of prevention (abstinence/delayed sexual initiation,
being safer by being faithful to one’s partner/reducing the number of sexual partners,
and correct and consistent condom use), treatment and care of sexually transmitted
infections, voluntary counselling and testing services, prevention of mother-to-child
transmission, harm reduction, safe blood supplies and medical injections, and addressing
discrimination and stigmatization.
Condom promotion plays an important role in HIV prevention. The question is how to
position this successful public health strategy within a comprehensive HIV prevention
strategy which includes the promotion of informed, responsible and safer sexual
behaviour.
This ‘cutting-edge perspective’ publication draws attention to policy and programme
implications of insights on the role of condoms gained from scientific studies and
programme experiences. Its goal is to assist AIDS programme providers and decisionmakers
with particular responsibilities in condom programming, and key community
leaders who influence decisions on reproductive health in their constituencies to position
condom use optimally within overall prevention programming in their communities and
countries.

UNESCO and EI-EFAIDS.

UNESCO and EI-EFAIDS. 2007. Supporting HIV-Positive Teachers in East and Southern Africa: Technical Consultation
Report, 30 November - 1 December 2006, Nairobi, Kenya. Paris, UNESCO.
UNFPA. 2004. Education is Empowerment: Promoting Goals in Population, Reproductive Health and Gender. Report
of a Technical Consultation on UNFPA’s Role in Education. 8-10 December 2003, New York.
Wang, L.Y., Davis, M. et al. 2000. Economic evaluation of Safer Choices: a school-based human immunodefi -
ciency virus, other sexually transmitted diseases, and pregnancy prevention programme. Archives of Paediatric and
Adolescent Medicine. Vol. 154, No. 10, pp. 1017–24.
Warwick, I., Aggleton, P., Rivers, K. 2005. Accrediting success: evaluation of a pilot professional development
scheme for teachers of sex and relationship education. Sex Education. Vol. 5, No. 3, pp. 235–252.
Wegbreit, J., Bertozzi, S. et al. 2006. Effectiveness of HIV prevention strategies in resource-poor countries: tailoring
the intervention to the context. AIDS. Vol. 20, No. 9, pp. 1217-35.

Monday, October 24, 2011

Smith, G., Kippax, S. 2003.

Smith, G., Kippax, S. 2003. HIV/AIDS School-based Education in Selected Asia-Pacifi c Countries. Sex Education.
Vol. 3, No. 1.
Smith, G., Kippax, S., Aggleton, P., 2000. HIV and Sexual Health Education in Primary and Secondary Schools:
Findings from Selected Asia-Pacifi c Countries. Sydney: The University of New South Wales.
Stone, N., Ingham, R. 2006. Young people and sex and relationships education
In Ingham, R. & Aggleton, P. (eds.) Promoting young people’s sexual health; international perspectives. London,
Routledge .
Tarr, C. M., Aggleton, P. 1999. Young people and HIV in Cambodia: meanings, contexts and sexual cultures. AIDS
Care. Vol. 11, No. 3, pp. 375-384.
Terris-Presholt, F., Kumaranayake, L. et al. 2006. From Trial Intervention to Scale-Up: Costs of an Adolescent Sexual
Health Program in Mwanza, Tanzania. Sexually Transmitted Diseases, October Supplement, 33 (10): S133–S139.
Tiendrebéogo, G., Meijer, S., Engleberg, G. 2003. Life Skills and HIV Education Curricula in Africa: Methods and
Technical Evaluations. Africa Bureau Information Center/Academy for Educational Development Paper No. 119.
Underhill, K., Montgomery, P., Operario, D. 2007. Sexual abstinence only programmes to prevent HIV infection
in high income countries: systematic review. BMJ, July 2007; doi:10.1136/bmj.39245.446586.BE. (downloaded
2.12.07).
UNAIDS. 2006. AIDS Epidemic Update. Geneva: UNAIDS.

Gordon, G. and Mwale, V. 2006

Gordon, G. and Mwale, V. 2006. Preventing HIV with Young People: A Case Study from Zambia. Reproductive
Health Matters. Vol. 14, No. 28, pp. 68-79.
Grunseit, A., Kippax, S. et al. 1997. Sexuality education and young people’s sexual behaviour: a review of studies.
Journal of Adolescent Research. Vol. 12, No. 4, pp. 421-53.
Human Rights Watch. 2005. The Less They Know, the Better Abstinence-Only HIV/AIDS Programs in Uganda.
Ingham, R. 2005. We didn’t cover that at school: education against pleasure or education for pleasure. Sex education.
Vol. 5, No. 4, pp. 375–388.
International Community of Women living with HIV/AIDS. For more information about the sexual and reproductive
health needs of HIV-positive women go to: http://www.icw.org/
International Women’s Health Coalition. 2007. Young Adolescents’ Sexual and Reproductive Health and Rights:
Sub-Saharan Africa. http://www.iwhc.org/docUploads/YoungAdolescentsSSAF.pdf
Irvin, A. 2000. Taking Steps of Courage: Teaching Adolescents about Sexuality and Gender in Nigeria and Cameroon.
New York: International Women’s Health Coalition.
James, S., Reddy, S.P. et al. 2006. Ruiter, R.A.C. and Van den Borne, B. The impact of a HIV and AIDS life skills
programme on secondary school students in KwaZulu Natal, South Africa. AIDS Education and Prevention.
Vol. 18, No. 4.
James-Traore, T.A., Finger, W. et al. 2004. Teacher Training: Essential for School-Based Reproductive Health and
HIV/AIDS Education: Focus on Sub-Saharan Africa. YouthNet Youth Issues, Paper 3.
Jejeebhoy S.J., Bott S. Non-consensual Sexual Experiences of Young People: A Review of the Evidence from
Developing Countries. New Delhi, India: Population Council, 2003.

Appendix 5 – References

Appendix 5 – References
Aarø, L.E., Flisher, A.J. et al. 2006. Promoting sexual and reproductive health in early adolescence in South Africa
and Tanzania: Development of a theory- and evidence-based intervention programme. Scandinavian Journal
of Public Health Vol. 34, pp. 150–158.
Amuyunzu-Nyamongo, M. et al. 2005. Qualitative Evidence on Adolescents’ Views on Sexualand Reproductive
Health in Sub-Saharan Africa, Occasional Report, New York: The Alan Guttmacher Institute, No. 16.
Biddlecom, A., Gregory, R., Lloyd, C.B. and Mensch, B.S. 2007. Premarital sex and schooling transitions in four sub-
Saharan African countries. Poverty, Gender, and Youth Working Paper no. 5. New York: Population Council.
Biddlecom. A. et al. 2007. Protecting the Next Generation in Sub-Saharan Africa: Learning from Adolescents to
Prevent HIV and Unintended Pregnancy, New York: The Alan Guttmacher Institute, 2007.
Boler, T. 2003. The sound of silence: diffi culties in communicating on HIV and AIDS in schools. London, ActionAid
International.
Boler, T., Ingham, R. 2007. The abstinence debate: condoms, the President’s Emergency Plan for AIDS Relief
(PEPFAR) and ideology. London, ActionAid International.
Boler, T. and Aggleton, P. 2005. Life skills education for HIV prevention: a critical analysis. London, Save the Children
and ActionAid International.
Boonstra, HD. 2007. Young People Need Help in Preventing Pregnancy and HIV; How Will the World Respond?
Guttmacher Policy Review. Vol. 10, No. 3.
Brouillard-Coyle, C. et al. 2005. The Inclusion of Condoms in a School-Based HIV Prevention Intervention in Kenya.
Abstract 17th World Congress of Sexology, July 10-15 Montreal, Canada.
Campbell, C. 2004. Creating environments that support peer education: experiences from HIV/AIDS-prevention in
South Africa. Health education, Vol. 104, No. 4, pp. 197–200.
C. Campbell and C. MacPhail. 2002. Peer education, gender and the development of critical consciousness:
Participatory HIV prevention by South African youth. Social Science and Medicine. 55 : 331–345.
Campbell, C., Mzaidume, Y. 2002. How can HIV be prevented in South Africa? A social perspective BMJ. Vol. 324,
No. 7331, pp. 229–232..
Cohen, D.A., Wu, S.Y. et al. 2004. Comparing the cost-effectiveness of HIV prevention interventions. Journal of
Acquired Immune Defi ciency Syndrome. Vol. 37. No. 3, pp. 1404-14.
Davis, G. 2005. Conference report Sex Education of the Young in the Twentieth Century. The Gazette. Society for
the Social History of Medicine. No.36.
Germain, A., Kidwell, J. 2005.The Unfi nished Agenda for Reproductive Health: Priorities for the Next 10 Years.
International Family Planning Perspectives. Vol. 31, No. 2, pp. 90-93.
Global Forum for Health Research. 2007. Research Issues in Sexual and Reproductive Health for Low- and Middle-
Income Countries.
Global HIV Prevention Working Group. 2007. Bringing HIV Prevention to Scale: An Urgent Global Priority.
September 2008 37
Gordon,

Appendix 4 – Suggestions for UNESCO

Appendix 4 – Suggestions for UNESCO from Key Informants
• Push for investigation of innovative and effective approaches e.g. linking schools and health services.
• Develope a database of curricula content – what should be taught and what is being taught.
• Promote the link between condoms and pregnancy avoidance and in general put reproductive health back on the
agenda.
• Place more emphasis on challenging harmful gender roles and stereotypes.
• Promote delaying rather than abstaining from sex.
• Provide opportunities for exchange of experience among practitioners and researchers.
• Support long-term development of local competence, avoiding as far as possible the use of external technical
support agencies.
• Emphasise skills in the context of relationships.
• Organise high-level meetings to share experiences in creating educators and gaining acceptance for sex education
at community level.
• Build capacity to do local research into problem identifi cation and generation of locally relevant solutions.
• Identify best practice.
• Invest in institutions rather than individuals.
• Promote programmes that incorporate the seventeen characteristics of effective sex education programmes.
• Explore issue of how to adapt programmes to different settings without diluting impact.
• Explore what it takes to train teachers to be able to deliver sex education properly so they are comfortable with
content and methods.
• Investigate how to get Ministries of Education and Health to support the roll-out of effective programmes.
• Clarify the division of labour among the different UN agencies.
• Support research and evaluation.
• Support professionalisation of sex education as a recognisable (and examinable) subject and support development
of a career path for teachers in this area.
• Collect evidence about what young people say they want from sex education.
• Commission work on the use and abuse of religious texts as they relate to sex education.
• Advocate for infrastructure support.
• Gather and disseminate research fi ndings.
• Arrange a policy-oriented sex education forum.
• Investigate the cost aspect of sex education.
• UNESCO has the potential to promote the implementation of effective programmes, such as life skills interventions
that clearly address sexual risk reduction.

Learning Outcomes

Learning Outcomes
• To what extent is sex, relationships and HIV education changing learning outcomes?
• Prompt about knowledge, skills and behaviours.
• Which behaviours is it trying to change? How successful it is in trying to: delay sexual debut, encourage abstinence
until marriage, decrease number of partners, increase condom use? Is there any evidence to support
decreased pregnancies and/or STIs and HIV incidence?
• How should these outcomes differ by age, gender, education level?
• What do you think are realistic outcomes for sex, relationships and HIV education?
Any key documents you recommend in this regard?
Basic Minimum Package
• Can you share with us any studies, initiatives, anecdotes that defi ne a basic minimum prevention package in
schools?
Any key documents you recommend in this regard?
Costs
• Could you share with us any studies or resources that address costing of quality sex, relationships and HIV education
in schools?
Promising Approaches
• What do you feel are the most promising approaches for sex, relationships and HIV education in schools?
• What do you feel are the key barriers to sex, relationships and HIV education in schools? How does one overcome
them?
• What are some of the factors that have contributed to the success of these approaches?
Any key documents you recommend in this regard?
Closing
• What are the key knowledge gaps in terms of using sex education for HIV prevention in schools?
• What would you like to see the international HIV community do with regards to sex, relationships and HIV education?
• What would you like to see UNESCO to do with regards to sex, relationships and HIV

Process and Methodology

Process and Methodology
The objective of the literature review is to address the principal and additional research questions stated above.
UNESCO will commission a global expert in sex, relationships and HIV education for a total of thirty-four days to
conduct a comprehensive review of the literature. The search strategy will be limited to the English language and
for the period from 1997 to 2007. Search strategies will include:
• Database searches of the peer-reviewed literature e.g. Medline, PsycInfo, ERIC, Social Science Abstracts.
• Hand-searching key journals e.g. Sex Education, Health Behaviour and Education, Journal of School Health,
Journal of Adolescent Health.
• Database searches of the grey literature e.g. Popline, University of Leeds database.
• Websites e.g. IBE, UNESCO, UNICEF, WHO, National Electronic Library for Health.
• Interviewing a minimum of ten key stakeholders and experts.
Publications and reports will be included if they match certain specifi ed criteria, which will be determined by the
consultant. The consultant will then conduct an analysis of the selected studies. The analysis will be complemented
with the information gathered during stakeholder interviews.
The Global Advisory Group will be sent the draft literature review to comment on a minimum of seven days before
the fi rst advisory meeting in November 2007.

Sunday, October 23, 2011

Additional research questions:

Additional research questions:
1. What is the overall history of sex education in schools? How is it linked to HIV and AIDS education? When and
why was sex education fi rst introduced in schools?
57 Smith, G., Kippax, S., Aggleton, P., 2000. HIV and Sexual Health Education in Primary and Secondary Schools: Findings from Selected
Asia-Pacifi c Countries. Sydney: The University of New South Wales. This publication distinguished three broad kinds of sex education: that
which focused on anatomy, biology and physiology; that concerned with reproduction and family; and that dealing with interpersonal sexual
relations. Throughout the following discussion, the authors attempt to keep these three aspects of ‘sex education’ separate, as the manner
in which HIV and AIDS education is positioned with respect to each is of crucial importance to their argument. In general, they used the
term ‘sexual and reproductive health’ education to refer to the fi rst two – HIV and AIDS education is more often than not framed within
sexual and reproductive health. They used the term ‘sex’ education to refer to education that focuses on interpersonal sexual relations and
sexual practice.
58 UNAIDS, 2006. Report on the Global Epidemic. Chapter six (Comprehensive HIV Prevention). Geneva: UNAIDS.
59 Boler, T., 2003. The sound of silence: diffi culties in communicating on HIV and AIDS in schools. London, ActionAid International.
30
2. What are the typologies of sex education described in HIV and AIDS curricula (pedagogical approaches, components,
content (condoms), context)? What is the known coverage of sex, relationships and HIV education in
schools to date?
3. How is sex taught in primary and secondary school? What are the specifi c learning outcomes by age, gender,
level, social class?
4. What constitutes a basic minimum package of quality sex, relationships and HIV education in school?
5. What is the cost of a basic minimum package of quality sex, relationships and HIV education in schools in lowincome,
middle-income and high-income countries?
6. What are the most promising approaches for sex, relationships and HIV education in schools in developing countries
(with a focus on sub-Saharan Africa)? What are some of the factors that have enabled their success?
Where possible, the focus will be on sex and HIV education programmes in developing countries, particularly in
sub-Saharan Africa. However, where particularly innovative approaches exist in Europe and North America, these
should also be included. This is also the case where a lack of evidence exists in developing countries.

Terms of Reference for Global Expert

Terms of Reference for Global Expert on Sex, Relationships and HIV education
Background
Within the global move towards universal access to HIV and AIDS prevention, care, treatment and support, and
the UNAIDS technical support division of labour, UNESCO’s roles are to promote comprehensive education sector
responses to HIV and AIDS, contributing to overall national HIV and AIDS responses, and to provide policy and programmatic
leadership in the area of HIV and AIDS education for young people in schools. In light of the devastating
effects of the HIV epidemic, sex, relationships and HIV education is also an important aspect in achieving Education
for All (EFA). The underlying foundation to school-based HIV and AIDS education must be sex education57 – education
about biology, education about reproduction and family life, and education about inter-personal sexual relations
– simply because over 75 per cent of all HIV infections are caused by sexual transmission58 and therefore, at some
stage, HIV and AIDS education must introduce the subject of sexual transmission of the virus and provide choices
on how to minimise risk.
Furthermore, sex education must be an important part of HIV and AIDS education because it is within the context
of sexual relationships that HIV is most often transmitted. However, many HIV and AIDS curricula for schools avoid
discussions around sex,59 alternatively focusing on wider vulnerability factors (such as poverty or gender inequality)
or through science or school health. Despite overwhelming evidence that sex education reduces chances of unintended
pregnancies and STIs (including HIV), many countries have not adequately prioritised sex, relationships and
HIV education within the formal curriculum.

Conclusions

Conclusions
Too few young people reach their adult sexual life with anything approaching adequate preparation. As a result, too
many young people experience the consequence in terms of unintended pregnancy and STIs, including HIV.
It is perhaps inevitable that a review as ambitious as this should raise questions and identify gaps rather than
provide defi nitive answers. While the volume of documentation of some programmes in sub-Saharan is to be welcomed,
a clear gap exists in relation to the lack of material from Asia and South America and the Caribbean.
Rather than repeating the content of the Executive Summary, it seems apposite at this point to fl ag some key questions
for future consideration:
• What should be the goals of sex, relationships and HIV education?
• What are the key elements of a core sex, relationships and HIV education curriculum?
• How should the impact of sex, relationships and HIV education be measured?
• What needs to exist (in a school, among teachers, in a local community) for school-based sex, relationships and
HIV education to be feasible?
• What does sex, relationships and HIV education cost?
• What can be learned from experiences in scaling up successful sex education programmes?
• What quality standards should exist in relation to school-based sex, relationships and HIV education?
This review has resulted in encouraging action led by UNESCO. A Global Advisory Group has been established that
will serve to steer UNESCO’s programme on sex, relationships and HIV education, as well as act as a leadership
forum for strategic development and increased prioritisation of the issue. UNESCO’s Global Advisory Group on sex,
relationships and HIV education is composed of eight global experts in interdisciplinary topics relating to the fi eld.
When the advisory group fi rst met in December 2007, they identifi ed the urgent need to develop guidelines for
standards in sex, relationships and HIV education and a study on the costing and cost-effectiveness of school-based
sex, relationships and HIV education.

The three-year costs of trial implementation

The three-year costs of trial implementation were $879,032, of which 70% was for the school-based component.
Initial development and start-up costs were relatively substantial at 21% of the total costs. Nonetheless, annual
costs per school child reduced from $16 in 1999 to $10 in 2001. The incremental scale-up cost is one-fi fth of ward
trial implementation running costs. The authors argue that annual costs can be reduced by almost 40% as project
implementation matures. Once the intervention is scaled up, only $1.54 more is needed per pupil per year to continue
the intervention. The authors conclude that the costs of developmental and start-up phases of any comprehensive
package of programmes are likely to be substantial and that even the recurrent costs of a more integrated
model would still be likely to require donor support.
However, few studies of sex, relationships and HIV education programmes include cost-effectiveness analyses.
Nonetheless, if programmes are effective at reducing risk, then they also have the potential to be cost-effective.
Cost elements include development of effective curricula and teacher training and classroom delivery. However,
subsequent costs can be reduced, for example, through the incorporation of the curriculum within the provision of
new teacher training. Careful selection of suitable and appropriate materials can also reduce costs.

Detailed cost-related information

Detailed cost-related information is available from a study undertaken to estimate the annual costs of the multifaceted
Mema Kwa Vijana young people’s sexual health intervention in Tanzania.56 This study is the fi rst detailed cost
analysis of a large-scale multi-component, multi-year young people’s sexual and reproductive health intervention.
Costs were assessed by input (capital and recurrent), component (in-school, community activities, youth-friendly
health services, condom distribution), and phase (development, start-up, trial implementation, scale-up). The inschool
component consisted of the development and implementation of a teacher-led and peer-assisted reproductive
health curriculum for Standard Five to Seven in all primary schools in the intervention communities. Overall,
15,000 students were reached in a total of 62 schools, 432 teachers and 1,124 peer educators were trained. The
curriculum comprised ten to fi fteen classroom sessions per year. Teachers from each school received an annual
week-long training in the delivery of a participatory curriculum, including the use of drama, games and stories. In
each school, six pupils per school year were elected to act as class peer educators. Their main role was to perform

short drama discussion starters during the classroom sessions, for which they received two days’ training each
year. Two or three slightly older young people from each community were elected by the advisory committee and
trained for three weeks to act as Trainers of Peers (TOP). They were responsible for training the class peer educators
in the fi rst two years of the programme and for supporting the class peer educator during after-school Mema
Kwa Vijana clubs. These clubs provided a more informal forum for addressing young people’s sexual and reproductive
health issues.

The published literature on costs

Costs
The published literature on costs and cost-effectiveness of school-based sex education and HIV prevention is
sparse, including two US-based studies, one from Tanzania and the Prevent AIDS Network for Cost-Effectiveness
Analysis study (PANCEA), a multi-country intervention in Mexico, Uganda, South Africa, India and Russia.
The cost-effectiveness of a programme will depend to a considerable extent on the HIV rate among the targeted
population. For example, the Safer Choices programme (see below) was implemented in states where HIV rates
among young people were very low. Thus, it prevented less than one case of HIV. However, if the same programme
were implemented in sub-Saharan Africa, it would prevent many cases of HIV and be dramatically more
cost-effective. Thus, cost-effectiveness depends not only on costs and on ability to change behaviour, but also on
incidence among the target group.
Published work from the US includes a study of the US-based Safer Choices programme, a school-based HIV,
STD and unintended pregnancy prevention intervention for high school students. This study55 included estimation
of intervention costs, calculation of cases of HIV, STDs and pregnancies averted, which were then translated into
medical and social costs averted. The net benefi t of the programme was then calculated. The authors concluded
that, at an intervention cost of $105,243, the programme achieved a 15% increase in condom use and an 11%
increase in contraceptive use within one year among 354 sexually active students. It is estimated that 0.12 cases of
HIV, 24.37 cases of Chlamydia, 2.77 cases of gonorrhoea, 5.86 cases of pelvic infl ammatory disease and 18.5 pregnancies
were averted. The authors calculate that, for every dollar invested, $2.65 were saved in terms of medical
and social costs and conclude that the Safer Choices programme is both cost-effective and cost-saving.

Coverage and Cost Issues

Coverage and Cost Issues
Singh et al (2005) suggest that, in some countries, such a high proportion of young people do not attend school
that school-based sex, relationships and HIV education, when it exists at all, is available to only a minority of young
people. However, 60-75% of 10-14-year-olds in sub-Saharan Africa are currently attending school. Furthermore,
school attendance appears to be a protective factor in itself in relation to young people’s sexual health. For example,
levels of contraceptive use in sub-Saharan Africa increase with years of education, and attendance in school is associated
with less sexual activity. However, many young people, particularly girls, do not progress beyond primary
school and for girls there is a rapid decline in school attendance after the age of 15.54
According to the 2007 report of the Global HIV Prevention Working Group, globally, half or more of school attendees
receive no school-based HIV education. Five of fi fteen countries reporting to UNAIDS in 2006 said HIV education
coverage in schools was below 15%. In all eighteen countries in which standardised health surveys were administered
between 2001 and 2005, fewer than 50% of young people (15-24) had accurate knowledge about HIV.

Saturday, October 22, 2011

While this review provides

While this review provides important behavioural data, other kinds of evaluation focus are suggested by others. For
example, some researchers argue for more research to increase understanding of outcomes for teachers in relation
to their own knowledge, attitudes, skills and behaviour.51
Proponents of a ‘social studies’ approach to sex education argue that they would seek to infl uence a wider range
of outcome measures than those included in standard programme evaluations. For example, changes might be
measured in relation to specifi c attitudes and behaviours related to gender equality and human rights such as
gendered leadership in school activities; girls’ participation in sports; age at marriage; attitudes regarding male and
female roles in the sexual, domestic and economic spheres; and prevalence of or attitudes toward gender-based
violence, sexual harassment, homophobic bullying and harmful practices. Similarly, measuring the effectiveness of
programmes that seek to tackle vulnerability would require different focus and methods of evaluation.
Others challenge altogether the relevance of randomised controlled trials and other experimental methods for the
evaluation of sex and relationship education programmes, arguing that what are needed are well-designed longitudinal
and cross-sectional studies that shed light upon the ways in which people actively engage with sexual health
education and that capture and describe social change.52
A different kind of challenge to evaluation is posed by those53 who argue that the domination of public health
outcomes renders invisible other aspects that also warrant attention, in particular, the role of pleasure in sexual
development and relations. Acknowledging that, in most cultures, it may be unacceptable to teach young people
how to achieve sexual pleasure, nonetheless there are indications from richer and poorer countries that public
health outcomes may benefi t from greater acceptance of positive sexual experiences. Few programmes appear to
consider or take seriously issues of sexual pleasure, intimacy and reciprocity.

Life Skills

Life Skills
A critical review of life skills education has drawn attention to the need to defi ne life skills, to identify which skills
are to be included in a curriculum and both why and how they should be taught.47 They propose that life skills
approaches need to be more educationally driven, building on educational processes that have ‘transformative
capacity’. A ‘whole-school approach’ is recommended with life skills curricula developed and reviewed as part of
wider curriculum reform. Life skills require skilled and motivated teachers and this in turn requires considerable
resources.
A review of life skills education in sub-Saharan Africa also highlights diffi culties in terms of defi ning life skills and
its introduction into the traditional, didactic and authoritarian style of teaching that is the norm in many schools in
poorer countries.48 The reviewers also point out that few life skills programmes in sub-Saharan Africa have been
rigorously evaluated. Assuming these diffi culties can be overcome, they recommend that life skills education begin
early in primary school, be taught by suitably trained teachers and become a separate topic rather than integrated
across the curriculum.
Some of the challenges associated with the implementation of life skills education are identifi ed in a study of an HIV
and AIDS life skills programme with secondary school students in KwaZulu Natal, South Africa.49 Evaluation discovered
a signifi cant increase only in relation to knowledge about HIV and AIDS in the intervention group. No effects
were reported on safe sex practices (condom use, sexual intercourse) or on measures of psychosocial determinants
of these practices, such as attitude and self-effi cacy. Process evaluation among teachers revealed that, while
some had implemented the programme in full (in terms of time spent, the number and content of lessons), others
did so only partially. Also teachers relied upon a didactic style more and reported comfort with teaching more factbased
rather than skill-based topics. The authors argue that, in addition to knowledge, positive attitudes and beliefs
about condom use, effective programmes need to include skills that address the more proximal determinants of
safe sexual behaviour, such as self-effi cacy beliefs and skills related to actual condom use, together with relevant
communication skills. In turn, this depends signifi cantly upon equipping suitably selected teachers with the ability,
skills and confi dence (and materials) to move away from information-giving to methodologies that engage students
through active student participation. The study draws attention to the need to address broader issues of school
reform such as school culture, communication between and among stakeholders, teacher effi cacy and behaviour.
46 Underhill

‘Abstinence-Only’

‘Abstinence-Only’
It is not yet possible to draw fi rm conclusions regarding the effectiveness of abstinence-only approaches because of
the diversity of programmes included under this heading, the range of cultures in which they are implemented and
the fact that only a few programmes have been evaluated. Nonetheless, available evidence indicates that some programmes
clearly do not reduce sexual risk and while there is weak evidence that a small number of programmes may
be promising, there is no strong evidence to support the argument that any particular programmes are effective.45
In theory, ‘abstinence only’ programmes should be more effective in more affl uent societies, where people have
more freedom to decide whether and how they have sex. However, researchers reviewed several such studies,
including more than 15,900 participants, and found that in comparison with control groups, there was little evidence
that risky sexual behaviour, inci-dence of STIs, or pregnancy was reduced among young people in abstinence-only
42 Wegbreit, Bertozzi et al., 2006.
43 Kirby, Obasi et al., 2006.
44 Curriculum is defi ned by the authors as: “an organized set of activities or exercises designed to convey specifi c knowledge, skills or experiences
in an ordered or incremental fashion. Such activities may be implemented either in the classroom during the school day or after
school.”
45 Doug Kirby, 2007 (personal communication).
24
programmes.46 Abstinence-only programmes did not increase primary abstinence (prevention) or secondary abstinence
(decreased incidence and frequency of recent sex).

Impact

Impact
In recent years, a number of reviews have considered the impact and effectiveness of sex, relationships and HIV
education. In view of the effectiveness of different HIV prevention strategies in resource-poor settings, researchers
argue that, while sex and relationships education can affect sexual behaviour, nonetheless their effect on biological
outcomes (such as HIV and STIs) may be relatively insignifi cant.42
Authors of the most comprehensive review so far43 argue that the choice and implementation of school-based
programmes in poorer countries is constrained by the availability of teachers together with lack of access to necessary
fi nancial, material and technical resources. In addition, the culture and norms of local communities and schools
themselves may prohibit open discussion of sexual matters and actively discourage condom use in an attempt to
promote abstinence. A total of twenty-two intervention evaluations were included in the study.44 Results indicated
that sixteen out of twenty-two programmes signifi cantly delayed sex, reduced the frequency of sex, decreased the
number of sexual partners, increased the use of condoms or contraceptives, or reduced the incidence of unprotected
sex. Several studies also measured positive impacts on personal values, peer norms, communication about
sex and condoms and decreased use of alcohol. In terms of the duration of impact, the positive effects of some
programmes lasted from a few months to a few years. Mema Kwa Vijana was the only evaluated programme to
investigate the impact of the school-based education on STI and HIV prevalence. The authors found no signifi cant
impact on HIV, genital herpes, syphilis and chlamydia and no measurable impact on either pregnancy or childbearing.
Further long-term evaluations of Mema Kwa Vijana are currently underway.
Nonetheless, these studies strongly support the argument that sex and HIV education do not increase sexual
behaviour and a substantial number of programmes actually signifi cantly decrease one or more types of sexual
activity. The review determined that programmes led by both teachers and other adults had strong evidence of
positive impact on reported behaviour. Programmes were found to be effective irrespective of their implementation
in primary, secondary or night school settings. Similar proportions of the curriculum-based programmes were
effective regardless of whether they were taught by teachers or other adults and they were effective for both male
and female students. The reviewers argue that the similarity in terms of intervention impact in both developed and
developing country settings bodes well for effective implementation regardless of the degree of economic development
and HIV prevalence.
Reviews have also been produced that refer specifi cally to different types of programmes. These are discussed
below before considering the broader reviews.

Peer Education

Peer Education
While many students may relate more easily to their peers, peer educators are less likely to be equipped with the
depth of knowledge and skills required to deliver effective sex and HIV education independently of any adult-led
intervention.40 Regular turnover of peer educators, together with the sustainability and cost implications for training
and supervision, may make peer education less suitable as the principal mode of delivery of a sex education
curriculum.
Critical refl ection on an unsuccessful HIV and AIDS peer education project in South Africa highlights a number of
important issues in relation to the delivery of peer education in school settings.41 Through the project, 120 young
people aged between 13 and 25 were interviewed on their perceptions of health, sexuality and HIV. Twenty young
volunteers were recruited from the community and received training and information on HIV and other STIs, as
well as participatory learning techniques. They were also provided with condoms for distribution among their peers.
However, when the educators began to implement the programme, they encountered authoritarian rules, didactic
teaching methods, and a negative attitude toward autonomy or critical thinking on the part of students. Firm control
over the peer education programme was held by the guidance teacher and principal. This included scrutiny of activities,
schedules, message content, and access to resources. Furthermore, male pupils dominated the activity and
decisions that were made within the programme, and marginalised and bullied their female counterparts. After a
few months, the guidance teacher summarily dissolved the peer education team. The authors highlight the need to
develop supportive school environments as well as a unifi ed governmental position on HIV and AIDS; to raise community
and parental awareness of the importance of open communication about sex; better understanding of peer
educators’ need to think critically about the issues and messages they are conveying; and the need for materials
that are explicit, focused and promote discussion of the ways in which gender impacts upon sexual health.
There is more evidence to support the effectiveness of adult-led over peer-led programmes. There is some evidence
to support the value of suitably trained peer educators complementing the work of teachers, but there are
serious constraints vis-à-vis scaling-up and sustainability.
In addition to the methods outlined above some schools subcontract specialist groups, such as local NGOs and
networks of people living with HIV, to deliver sex, relationships and HIV education.

Effective delivery of sex, relationships and HIV

Effective delivery of sex, relationships and HIV education is also hampered in some settings by sexual harassment
or abuse of schoolgirls,36, 37 a phenomenon that has been reported in a number of sub-Saharan African countries.38
This is a signifi cant problem that seriously undermines the potential credibility of sex, relationships and HIV education
in schools. In addition, mandatory pregnancy examinations and the punishments imposed on those who fail
them can undermine the success of such programmes.
Despite these barriers, school-based programmes have potential if they can be adapted to the realities of the local
educational system by such means as simplifi cation of subject matter, pre- and in-service training on teaching
methods, improvement of teacher-pupil and teacher-community relationships, and close supervision and appropriate
responses to abusive or exploitative practices.
Implementation of sex, relationships and HIV education can be promoted through provision of teacher training;
appropriate screening and selection of teachers charged with delivery of the programme; supporting schools in the
development of an HIV and AIDS policy, and developing school-based health programmes that go beyond HIV or
sexual health and are embedded in broader school development programmes that improve school functioning. The

organizational characteristics of schools and a supportive community are important determinants of the success of
HIV prevention programmes.38
As well as having to compete in a crowded curriculum, sex, relationships and HIV education does not have the
same status as other subjects, either for students or teachers. In part this is because it is usually non-examinable,
but also because of the sensitive nature of the content, despite its potential importance to students’ well-being. For
teachers of sex, relationships and HIV education there is rarely, if ever, a tradition of advanced training. Teachers are
sometimes instructed to teach sex, relationships and HIV education despite lack of training, experience or interest.
Taken together, these issues raise a question as to whether or not sex, relationships and HIV education is in need
of professionalisation.39

Given their number and proximity

Given their number and proximity to students, teachers are best placed to deliver sex, relationships and HIV education.
Pre-service training provides an opportunity to familiarise all teachers with the basic concepts and elements
of a sex, relationships and HIV education curriculum and to ‘mainstream’ its delivery across the curricula. In addition,
targeting trainee teachers (in pre-service teacher training) is likely to be more successful, not only in terms
of scaling-up, but also because young teachers are probably more likely to be open to teaching sex, relationships
and HIV education, with older more experienced teachers being more resistant. The same applies for introducing
some of the participatory teaching methodologies that are expected of many sex education programmes. However,
teachers will not be equally interested or adept at teaching the subject. Their interest and aptitude may only emerge
after some time spent in the classroom, making the provision of in-service training a likely necessity.
Teacher training should be supported by national ministries, local school management and communities.34 Curricula
should include content on sexual and reproductive health and HIV, teaching methodologies and teacher skills, personal
attitudes, and teachers’ own HIV-risk behaviours. Attention should also be paid in such curricula to policies,
administrative practices and cultural norms that can affect teaching. Those involved in teaching sex, relationships
and HIV curricula should include both men and women who are motivated and willing and perceived as trustworthy
by students. Finally, they argue that there should be a policy of zero tolerance of exploitation of students.
Experience in Tanzania35 suggests that problematic teacher–pupil relationships create one of the most signifi cant
barriers to potential programme success. In many settings in sub-Saharan Africa, established teaching culture and
practice are authoritarian and didactic and hardly conducive to the trusting relations and participatory approach
required by many sex and HIV education programmes.

Friday, October 21, 2011

The successful development of these

The successful development of these kinds of approaches to tackling vulnerability is likely to require long-term planning
and investment in human and material resources together with innovative evaluation methodologies.
Recognising that knowledge alone is usually insuffi cient to bring about behaviour change, the concept of life skills
has gained popularity and is another approach aimed at reducing underlying vulnerability. Rooted in North American
and European psychology, the notion of life skills is based upon the assumption that unproductive (or completely
absent) behaviours can be replaced with specifi c behavioural skills such as decision-making, communication, or
condom use and that these can be acquired through structured learning.
With a broad generic (i.e. non-sexual) orientation, the adoption of life skills curricula proved popular in settings
where opposition to sex education was likely. So much so that it was incorporated into Article 53 of the United
Nations General Assembly Special Session on HIV and AIDS (UNGASS) Declaration, which requires that young
people have access to information and education necessary: ‘to develop the life skills required to reduce their vulnerability
to HIV infection’. Relevant skills include critical thinking and decision-making, for example, about initiating
or delaying sexual intercourse or negotiating safer sex, including condom use.
While the title ‘life skills’, without reference to either sex or HIV, may make it uncontroversial and politically acceptable,
lack of clarity in terms of defi nition and the absence of an explicit theoretical and evidence base, may leave life
skills open to the broadest interpretation, with the possible result that mention of both sex and HIV prevention are
removed. Also, too narrow a focus upon the level of the individual without consideration of broader contexts and
power relations within these will affect the extent to which young people will be able to utilise various life skills.

Other approaches to addressing

Other approaches to addressing vulnerability in school settings include ‘Stepping Stones’,31 a programme for HIV
prevention that aims to improve sexual health through building stronger, more gender-equitable relationships with
better communication between partners. It uses participatory learning approaches to build knowledge of sexual
health, awareness of risks and the consequences of risk-taking and communication skills, and provides opportunities
for facilitated self-refl ection on sexual behaviour. Stepping Stones was developed in Uganda and has since
been used in more than 40 countries and translated into 13 languages. Key features of Stepping Stones include
its community action orientation and time-limited delivery (thirteen three-hour sessions), use of highly participatory
learning approaches including critical refl ection, role play, drama and its facilitation by skilled leaders of the same
sex and slightly older age than participants.
In Zambia,32 the International HIV/AIDS Alliance, Planned Parenthood Association of Zambia (PPAZ) and the Ministry
of Education are working with teachers and pupils in Grades Four to Nine33 in twenty basic schools to analyse why
schools are high-risk places for HIV transmission and unintended pregnancy and to identify what can be done about
it. Teachers have been engaged in a participatory process to explore their own experience and concerns regarding
HIV, reproduction, gender, sexuality, pleasure and harm and their role in the creation of sexual risk and its prevention
in the school. Teachers have received two specifi c training inputs. The fi rst helped them to explore their own
attitudes and values while the second focused on the development of skills and materials. Teachers acknowledged
the problem of sexual abuse and made plans to address it. They then facilitated a participatory assessment with
pupils, using many of the same tools to analyse the situation with them and elicit their ideas on how to respond.
This produced a wealth of material that revealed high levels of sexual activity and sexual abuse and fed into the
development of an initial set of lessons aimed at the creation of a safe environment for teaching about sex and
relationships. Working in partnership with the Curriculum Development Centre and Ministry of Education, a set of
materials was developed. This included a curriculum, two manuals for teacher training and three books for pupils.

Approaches that Address Vulnerability

Approaches that Address Vulnerability
In the context of sex, relationships and HIV education, addressing vulnerability means going beyond the development
of a curriculum to address the sexual and social realities that exist beyond the classroom. It means, for
example, giving consideration to contextual issues such as the school institution itself, including power relations
that exist among pupils and between teachers and pupils. Sexual vulnerability is also linked to other forms of risk
and vulnerability, such as racism and homophobia, drug and alcohol use and gender inequality in the household as
refl ected in decision-making, use of household expenditure and violence.
In recognition of the social nature of sexual relations, there have been calls for a paradigm shift in relation to sex,
relationships and HIV education.30 Proponents of this approach argue that the content of sex, relationships and HIV
education curricula has tended to neglect consideration of issues of gender, equity and rights, together with the
underlying power inequities that these refl ect. To this end, the Population Council’s Rethinking Sexuality Education
initiative has been working towards a ‘social studies’ approach to sex, relationships and HIV education. This kind of
approach promotes the development of critical thinking skills and learning and refl ection about the ways in which
gender, rights and other aspects of social context (e.g. race, ethnicity and class) affect sexual experience. In so
doing, it may also promote the active, informed participation of young people in civil society.