identifi ed in a study of an HIVand AIDS life skills programme

Some of the challenges associated with the implementation of life skills education are identifi ed in a study of an HIVand AIDS life skills programme with secondary school students in KwaZulu Natal, South Africa.49 Evaluation discovereda signifi cant increase only in relation to knowledge about HIV and AIDS in the intervention group. No effectswere 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, whilesome had implemented the programme in full (in terms of time spent, the number and content of lessons), othersdid so only partially. Also teachers relied upon a didactic style more and reported comfort with teaching more factbasedrather than skill-based topics. The authors argue that, in addition to knowledge, positive attitudes and beliefsabout 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.
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।
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.
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
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.
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.