Journal of Adolescence 1992, 15,335-343
Editorial HIV and Adolescents: An International Perspective RICHARD WILLIAMS
AND LYNN PONTON
As we enter the second decade of the HIV (Human Immunodeficiency Virus) epidemic, much has been learned in a relatively short period of time. There have been rapid advances in epidemiology, immunology, diagnostics and clinical therapeutics. Adolescents as a group have only recently been identified as being at high risk for HIV infection. (DiClemente, 1990; Hein, 1989). A number of factors have contributed to adolescents’ this, including high rates of sexual experimentation, increased physiological susceptibility related to their anatomy, a reluctance to use condoms, experimentation with intravenous drug use, and an unwillingness to believe that they could contract this illness. In 1987, the US House of Representatives used the title phrase, “A Generation in Jeopardy”, to describe the impact of HIV on adolescents and in 1989 a U.K. newspaper, The Daily Telegraph, carried a headline, “Devastating Spread of AIDS Among US Teenagers”. The accompanying text reported the, “alarming figures on the spread of the AIDS virus among heterosexual American teenagers”. Apparently a U.S. Government agency had concluded that 21 year olds, from New York and Miami, who probably would have contracted the disease in their teens, had an infection rate triple the national figures. It is the very importance of this subject matter and the contribution of the rapidly developing psychosocial research in this arena which motivates this special issue of the Journal of Adolescence. A cure for HIV related illness is not on the immediate horizon and so the best approach lies in prevention. this demands health education and For adolescents, in particular, modification of sexual behaviour at a sensitive period in development when the relevant knowledge, attitudes and behaviours are themselves the issues through which psychosocial development is worked out. Hence this issue Reprint requests should be addressed to Dr Richard Williams, Bristol Royal Hospital for Sick Children, Bristol BS2 8BJ 0140-1971/92/040335+09
$08.00/O
8 1992 The Association for Professionals in Services for Adolescents
336
R. WILLIAMS
AND L. PONTON
focuses on health education and preventative matters. It contains articles summarizing a very large body of research conducted in the U.K. Germany, the United States and Australia. The papers selected examine HIV-related knowledge, attitudes and risk-taking behaviours in adolescents; the problems adolescents show in changing their sexual behaviours and the difficulties experienced by adults in incorporating information about attitudes, behaviours and specific HIV related matters into general sex education programmes for adolescents. They discuss the barriers to HIV prevention for adolescents and examine specific ways in which the HIV epidemic has affected the lives of adolescents. This special edition begins with a contribution from the USA (Bowler et al.) which highlights the danger posed by HIV infection and AIDS to adolescents and young adults in that country. It presents a contemporary account of epidemiological data on HIV seroprevalence and of teenagers’ knowledge, beliefs and behaviours related to HIV and AIDS. The authors review the barriers to prevention and propose ways of combating them. Whilst it remains true that the viral pool is at a relatively low level in the general population in many western countries, this is not universally the case throughout the world. Specific risk factors identified in this paper indicate why the HIV risk should be taken as a serious matter by, and for, all adolescents. Important, on an international level, are a number of other factors affecting the spread of HIV to the world’s youth. These factors include poverty, which might require an adolescent to engage in professional sex work for economic reasons; economic and political factors, which limit the availability of condoms; traditional, cultural and social values, which also discourage the use of condoms; inadequate or non-existent health services for adolescents; policy barriers at national levels when Governments have failed to implement necessary prevention programmes; and the nature of the adolescent process of development itself. Physicians, parents and adolescents are selected as the targets for education by Bowler et al. Our second article compares and contrasts HIV knowledge, attitudes, and behaviours in adolescents in East and West Berlin. It focuses on the sexual behaviours and attitudes towards sexual relationships reported from two substantial samples of mid-adolescent school attenders, one drawn from West and the other from East Berlin. Although the authors report differences in the attitudes and behaviours of these two groups it is their similarities which are more striking. So too, is the discontinuity between apparent knowledge of HIV and mechanisms for preventing its transmission and the practice of “safer sex”. This article considers adolescent contraceptive behaviour and the criteria employed by young people in their choice of contraceptive method. Despite relatively early age
HIV AND ADOLESCENTS
337
of first experience of penetrative sex, it is clear that the majority of adolescents are not sexually promiscuous. This paper introduces the concept of serial monogamy as an important standard in current adolescent sexual morality. Many of the concepts used in describing the moral and sexual attitudes and the behaviours of young people in the U.K. have a very great deal in common with their German counterparts. The third paper reports a series of substantial and comprehensive studies of randomly selected cohorts of young people between 16 and 24 years of age in the UK. It looks at their knowledge of HIV and AIDS and of its transmission characteristics and also at the sexual behaviours and attitudes and contraceptive practices of these young people. The significant proportion of adolescents reporting first experience of penetrative sex before the age of 16 and the decreasing use of condoms with age and with duration of sexual relationships with partners are striking features. Again discontinuity between knowledge, awareness of risk and behaviour appears and this is an important finding which motivates the author, Ford, to call for a move of educational targeting from that of solely transmitting information to that of including endeavours to influence attitudes, lifestyles and sexual behaviours in adolescents. Indeed, he identifies a group of adolescents who face health risks in a number of domains simultaneously arising from their lifestyle of heavy drinking, multiple sexual partners and unprotected intercourse. This feature is also reported from the USA by our fifth set of contributors, Hernandex et al. A positive feature of Ford’s article, reiterated in others, is the use of the research results to suggest more effective ways of educating young people. Moore and Rosenthal’s paper again addresses this topic of adolescent HIV-related knowledge, attitudes and behaviours, this time in Australia. The authors used both qualitative and quantitive measures to obtain detailed descriptions of adolescent sexuality and then relate this information to the topic of HIV-related risk factors. They found that pathways to risk differ between genders and that unsafe sex occurs across a range of sexual ideologies and contexts. Their findings serve to inform us about the development of interventions once more. The contribution from Hernandez et al., investigates the role of very specific personality factors with unprotected sex in a group of college age males in the United States. The authors underscore the point that condom use by adolescents is the outcome of multifactorial decision making processes affected by biological, social, developmental, and psychological influences. Their study highlights the importance of the psychological and development factors, specifically the level of self-control and ego identity measures, and also suggests ways to develop more specific inter-
338
R. WILLIAMS
AND L. PONTON
vention strategies for HIV prevention with adolescents that take these factors into account. A number of broadly. similar themes emerge in all these articles which provide strong messages for all interested in adolescents and the phenomena which adolescent development demonstrate. These matters are of interest to a wide range of professional disciplines and it is fascinating to witness investigators, drawn from a wide range of educational, medical, psychological and epidemiological disciplines, grappling with the issues which educating young people about sex, HIV and AIDS raise. In particular, two questions are provoked by all this evidence. Firstly - given a reasonable awareness of the risk, why don’t adolescents change their sexual behaviours? Secondly - can we use this theoretical research knowledge to generate strategies to improve the education of young people so that their attitudes and behaviours can be influenced in the direction of safer sexual activity and, hopefully, containment of the AIDS epidemic? There seems to be something about the process of growing up in adolescence which is, itself, a complicating factor and which makes the educational messages hard to receive and to adopt into one’s behavioural repertoire. Hurrelmann, in an article entitled, “Health Promotion for Adolescents: Prevention and Corrective Strategies Against Problem Behaviour”, in a previous addition of this Journal, considers evidence as to how risk-taking in adolescence may result from difficulties in handling the tasks of growing up. The article argues that risk-taking may have a value in dealing with developmental tasks such that progression to further risky behaviour is reinforced. His article looks at the implications of this thesis for the health education of the young. It suggests positive initiatives which include moving from a narrow focus of education directed at specific areas of risk-taking towards helping adolescents with developing individual competence, promoting the construction of networks, in which peer group membership is built on positive characteristics rather than on mutual support coming from sharing risky behaviour, and suggests that the quality of educational materials and student-teacher relationships need to be high if intervention is to be effective. It is interesting that, within the narrower frame of educating young people about HIV and AIDS, many of these lessons are reflected in the advice offered by the authors of the papers in this special edition. Readers will learn that supporting the development of high self-esteem and positive skills on a broad basis is recommended above further stressing the scary messages, which many Western adolescents already seem to have absorbed reasonably well. In the penultimate article Mellenby et al., consider the topic of sex education from a wide perspective. They take up the gauntlet thrown down
HIV AND ADOLESCENTS
339
by other authors to review, in depth, the need for, and possible impacts and limitations of, school-based approaches to educating young people about sex. In offering a rich review of the field they raise fundamental questions as to what the objectives of sex education should be and they document both lack of adult clarity and differences of view about policy and aims. Their title, “Sex Education: More is Not Enough”, clearly indicates that a general clamour for increasing the quantity of input in schools fails to address the need to define its context and aims. In so doing they generalize the challenge posed by HIV and AIDS to society’s attitudes towards education, curriculum development and sex generally. Our last paper focuses on adolescents’ hypothetical attitudes towards a friend infected with HIV. As the number of infected adolescents in the world climbs, this situation will occur more frequently. In contrasting potential responses to a friend who is suicidal and potential responses to a friend who is infected with HIV, the authors emphasise the coping strategies that would be employed by adolescents in both situations. Potential coping strategies appear to be affected by both gender and the overall level of distress. Although all the articles submitted for review for this special issue were from Europe, North America and Australia, we believe that it is important to acknowledge the magnitude of the problem of HIV infection for adolescents in Africa, Asia, and South America. Six and a half million individuals in Africa were reported to be infected with HIV at the 1992 World Conference (World Health Organisation, 1992). An infection rate in some African cities that is greater than 100 times that of Western countries, coupled with a lack of technological and economic resources, makes the problem formidable (Kerr, 1989). Investigators (Moore, et al. 1990, and Musagara et al., 1990) have examined the nature, course, and distribution of risk factors among late adolescents and young adults in Zaire and Uganda respectively. Factors that increase the possibility of transmission in high-risk parts of Africa include migration of large populations, movement of soldiers and traders who may be infected, economic privation, overcrowding, the breakdown of traditional family structure, prolonged unrest, overcrowding, cultural ceremonies such as blood bonding, and the lack of adequate medical services (Brown, 1992). The studies being conducted on Africa’s youth are important components of the international struggle against AIDS. In South America, there are reported to be over one million people infected with HIV (World Health Organisation, 1992). Economic privation, overcrowding in urban centres, and the lack of adequate medical services are longstanding factors associated with the spread of HIV. Caceres et al. (1992) found serious deficiencies of HIV-related knowledge among
340
R. WILLIAMS
AND L. PONTON
Peruvian high school students and teachers. Combating inadequate knowledge does not alter the serious economic problems of the world but such studies suggest interventions that can help stop the spread of AIDS. The World Health Organisation (1992) reports that there are one million infected individuals in Asia and fifty thousand in the Western Pacific Region. High rates of heterosexual transmission from intravenous drug use and infected adolescent sex workers are serious health problems for youth in many Asian countries. (Jayaraman, 1990; Nail et al., 1990). Programs to reduce HIV infections among Asia’s youth are complex and have to address many cultural factors. (Directorate General of Health Services, 1990). These observations emphasise the critical importance of research and of the development of social, education and health policies. The articles in this special issue also stress these very same points, directly and indirectly. Adult responsibilities for offering young people education and an optimistic view of a positive world and, specifically, interventions to combat the threat of HIV/AIDS overlap in a crucial, yet intriguing, way. It is our contention that the development of effective risk reducing and prevention strategies depends on taking into account all sources of knowledge. Equally it is important to understand how it is that knowledge alone is not enough. There is a need for policy makers, researchers and a broad range of professionals who are concerned with adolescents to work together. Such a conclusion could be drawn in many areas relating to young people but the threat of HIV/AIDS adds a new dimension and a new urgency to this collaboration. In the U.K. the Government has, recently, published a White Paper, “The Health of the Nation”. This has launched a strategic policy initiative in England which raises the profile of health promotion to sit alongside health care. It selects five Key Areas for action and one is that of, “HIV/AIDS and Sexual Health”. The Health of the Nation sets national objectives and targets in each key area, outlines initiatives to begin implementation of the strategy and sets a framework for monitoring, development and review. Its objectives for sexual health include - reduction of the incidence of HIV infection; reduction of the incidence of other sexually transmitted diseases (STDs); the provision of effective services for monitoring, diagnosis and treatment of HIV and other STDs; reduction of the number of unwanted pregnancies; and ensuring that effective family planning services are available for those who want them. An awareness of the particularly important position of young people is evident in this document. At this point it is, clearly, too early to say if this initiative will have the desired effects. However, the U.K. Government has committed
HIV AND ADOLESCENTS
341
itself to further action and its White Paper recognises the need for a combined, multifocal approach involving public policy development, improvements in the environment and changes in personal lifestyles as well as developments in the health services. This is, at very least, hopeful. It also offers a model for integrating policy and practice. Our opinion is that effective HIV/AIDS risk reduction strategies in all countries must be based on multidimensional knowledge of how adolescents develop and an awareness of their needs for information and for positive support in developing personal and social skills and relationships. Those who work with adolescents have much to offer in the field of prevention. They know much about the development of autonomy in the young and how adolescents experience and begin to use, for instance, oppositionality, ambivalence and their crucial, yet potentially complicated, networks of evolving relationships with parents, other adults and peers in the pursuit of emotional separation from family of origin. All these matters have an important bearing on effective sex education for the young. Several papers in this volume reiterate a striking international finding from research which is that of the apparent discontinuity between adolescents’ knowledge of the risks on one hand, and their sexual attitudes and behaviours on the other. It is essential that this be taken into account by all those responsible for health promotion strategies. However, as Mellanby et al., show, adults have other responsibilities too. Policy makers, advised by young people, their families and professionals, must first decide what the objectives for this education are to be. In this regard, whether all concerned approve of the direction and specific targets of its White Paper or not, the U.K. Government has taken an initial, positive, multisectoral stance which could promote real collaboration. In order to achieve a worldwide reduction in HIV seroprevalence, AIDS and other HIV related illnesses, researchers from different nations must work together sharing knowledge, educational programmes, treatment advances and policy formation. HIV does not stop at national borders. High infection rates in one part of the world have a serious impact on other areas. So we cannot ignore HIV and related illness in other countries or continents. Some countries have made advances that would significantly benefit others. This special issue represents such a worldwide collaboration. The overwhelming statistics and the appalling reality of working in the arena of HIV/AIDS affecting adolescents make the situation extremely difficult and severe. Yet the papers published here show that professional investigators have a vital role in extending knowledge and testing practical interventions through health promotion, prevention and treatment. A partnership between them, practitioners, educators, policy makers and young people themselves is going to be extremely
342
R. WILLIAMS
AND L. PONTON
important as nations try to work together in combating this worldwide epidemic. Exchange among researchers must continue in order to promote this collaboration among nations - a process that will benefit adolescents throughout the world. We conclude by emphasising the role that young people themselves can play. The positive value of asking them about themselves is shown in the research we publish here. Empowering young people with both knowledge, appropriately and sensitively delivered, and high quality positive experiences on a broad basis, aimed at fostering confidence and good selfesteem, are likely to be important longer term factors in reducing the extremes of risk-taking behaviours. They are, therefore, also likely to be important matters in health education generally and helping young people to help themselves in managing the HIV threat, in particular. The value of the peer group in preventative sex education is referred to by a number of our contributors and those who work with adolescents will know of the positive impact of involving older peers in influencing those younger than themselves. It seems that this is one potential way of diluting the oppositional responses that some young people feel they must make to information and advice proffered by adults, in their struggle to develop a sense of automony whilst under pressure. It has been our privilege to edit this special issue. We are grateful to the editor, John Coleman, for his vision and inspiration, to all those who submitted papers but, particularly, to the adolescents who participated in so much of the research. Richard Williams
and Lynn Ponton,
Guest Editors,
December
1992.
REFERENCES Brown, L. (1992). Personal communication. Caceres, F. C., Rocasco, A. M., Munoz, S., Gotuzzo, E., Mandel, J. & Hearst, T. (1992). Necesidades Educativas En Relation Con La Sexualidad Humana Y El Sida Entre Estudiantes Y Profesores De Escuela Secundaria En Lima. Rewista Latin0 Americana De Psicologia, 24, 109-122. DiClemente, R. J. (1990). The emergence of adolescents as a risk factor for human immunodeficiency virus infection. Journal of Adolescent Research, 5, 7-71. Directorate General of Health Services, Ministry of Health and Family Welfare. (1990). Medium Term Plan for the Prevention and Control of AIDS in India, 1990-I 992. New Delhi. Hein, K, (1989). AIDS in adolescence, Journal of Adolescent Health Care, 10, 105-35s. Hurrelmann, K. (1990). Health Promotion for Adolescents: Preventative and Corrective Strategies Against Problem Behaviour. Journal of Adolescence, 13, 231-50.
HIV AND ADOLESCENTS
343
Jayaraman, K. S. (1990). India prostitutes and the spread of AIDS. Lancet, 335, (8701): 1332. Kerr, D. L. (1989). HIV infection and AIDS in Africa and the Third World. Journal of School Health, 59, 369-370. Moore, M., Bomboko, B., Bertrand, W., Adjou, M. & Kashala, T. (1990). Distribution and determinant for risk behaviours of HIV infection among young adults in Zaire. Sixth International Conference on AIDS, June 21, 1990. Musagara, S., Konde-Lule, J., Musgrave, S., Serwadda, D., Wawer, M. & Sewankambo, N. (1990). Recent changes in behaviour and practices in relation to the HIV epidemic in rural Rakai District, Uganda. Sixth International Conference on AIDS, June 21, 1990. Naik, T. S., Sarkar, H. L., Singh, S. C., Bhunia, Y. J., Singh, P. K. & Singh, S. C. PAL: Intravenous drug users: A high risk group for HIV infection. (1990). AIDS, 5, 117-118. Secretary of State for Health. (1992). The Health of the Nation - A Strategy for Health in England. London. HMSO. 1992. U.S. House of Representatives, a generation in Jeopardy: Children and AIDS, a report of the Select Committee on Children, Youth, and Families (1987) U.S. Government Printing Office, Washington 1988. World Health Organisation (1992). World Health Organisation Global Program on AIDS. Presented at the Eighth International AIDS Conference in Amsterdam, 1992.
Editorial HIV and Adolescents: An International Perspective RICHARD WILLIAMS
AND LYNN PONTON
As we enter the second decade of the HIV (Human Immunodeficiency Virus) epidemic, much has been learned in a relatively short period of time. There have been rapid advances in epidemiology, immunology, diagnostics and clinical therapeutics. Adolescents as a group have only recently been identified as being at high risk for HIV infection. (DiClemente, 1990; Hein, 1989). A number of factors have contributed to adolescents’ this, including high rates of sexual experimentation, increased physiological susceptibility related to their anatomy, a reluctance to use condoms, experimentation with intravenous drug use, and an unwillingness to believe that they could contract this illness. In 1987, the US House of Representatives used the title phrase, “A Generation in Jeopardy”, to describe the impact of HIV on adolescents and in 1989 a U.K. newspaper, The Daily Telegraph, carried a headline, “Devastating Spread of AIDS Among US Teenagers”. The accompanying text reported the, “alarming figures on the spread of the AIDS virus among heterosexual American teenagers”. Apparently a U.S. Government agency had concluded that 21 year olds, from New York and Miami, who probably would have contracted the disease in their teens, had an infection rate triple the national figures. It is the very importance of this subject matter and the contribution of the rapidly developing psychosocial research in this arena which motivates this special issue of the Journal of Adolescence. A cure for HIV related illness is not on the immediate horizon and so the best approach lies in prevention. this demands health education and For adolescents, in particular, modification of sexual behaviour at a sensitive period in development when the relevant knowledge, attitudes and behaviours are themselves the issues through which psychosocial development is worked out. Hence this issue Reprint requests should be addressed to Dr Richard Williams, Bristol Royal Hospital for Sick Children, Bristol BS2 8BJ 0140-1971/92/040335+09
$08.00/O
8 1992 The Association for Professionals in Services for Adolescents
336
R. WILLIAMS
AND L. PONTON
focuses on health education and preventative matters. It contains articles summarizing a very large body of research conducted in the U.K. Germany, the United States and Australia. The papers selected examine HIV-related knowledge, attitudes and risk-taking behaviours in adolescents; the problems adolescents show in changing their sexual behaviours and the difficulties experienced by adults in incorporating information about attitudes, behaviours and specific HIV related matters into general sex education programmes for adolescents. They discuss the barriers to HIV prevention for adolescents and examine specific ways in which the HIV epidemic has affected the lives of adolescents. This special edition begins with a contribution from the USA (Bowler et al.) which highlights the danger posed by HIV infection and AIDS to adolescents and young adults in that country. It presents a contemporary account of epidemiological data on HIV seroprevalence and of teenagers’ knowledge, beliefs and behaviours related to HIV and AIDS. The authors review the barriers to prevention and propose ways of combating them. Whilst it remains true that the viral pool is at a relatively low level in the general population in many western countries, this is not universally the case throughout the world. Specific risk factors identified in this paper indicate why the HIV risk should be taken as a serious matter by, and for, all adolescents. Important, on an international level, are a number of other factors affecting the spread of HIV to the world’s youth. These factors include poverty, which might require an adolescent to engage in professional sex work for economic reasons; economic and political factors, which limit the availability of condoms; traditional, cultural and social values, which also discourage the use of condoms; inadequate or non-existent health services for adolescents; policy barriers at national levels when Governments have failed to implement necessary prevention programmes; and the nature of the adolescent process of development itself. Physicians, parents and adolescents are selected as the targets for education by Bowler et al. Our second article compares and contrasts HIV knowledge, attitudes, and behaviours in adolescents in East and West Berlin. It focuses on the sexual behaviours and attitudes towards sexual relationships reported from two substantial samples of mid-adolescent school attenders, one drawn from West and the other from East Berlin. Although the authors report differences in the attitudes and behaviours of these two groups it is their similarities which are more striking. So too, is the discontinuity between apparent knowledge of HIV and mechanisms for preventing its transmission and the practice of “safer sex”. This article considers adolescent contraceptive behaviour and the criteria employed by young people in their choice of contraceptive method. Despite relatively early age
HIV AND ADOLESCENTS
337
of first experience of penetrative sex, it is clear that the majority of adolescents are not sexually promiscuous. This paper introduces the concept of serial monogamy as an important standard in current adolescent sexual morality. Many of the concepts used in describing the moral and sexual attitudes and the behaviours of young people in the U.K. have a very great deal in common with their German counterparts. The third paper reports a series of substantial and comprehensive studies of randomly selected cohorts of young people between 16 and 24 years of age in the UK. It looks at their knowledge of HIV and AIDS and of its transmission characteristics and also at the sexual behaviours and attitudes and contraceptive practices of these young people. The significant proportion of adolescents reporting first experience of penetrative sex before the age of 16 and the decreasing use of condoms with age and with duration of sexual relationships with partners are striking features. Again discontinuity between knowledge, awareness of risk and behaviour appears and this is an important finding which motivates the author, Ford, to call for a move of educational targeting from that of solely transmitting information to that of including endeavours to influence attitudes, lifestyles and sexual behaviours in adolescents. Indeed, he identifies a group of adolescents who face health risks in a number of domains simultaneously arising from their lifestyle of heavy drinking, multiple sexual partners and unprotected intercourse. This feature is also reported from the USA by our fifth set of contributors, Hernandex et al. A positive feature of Ford’s article, reiterated in others, is the use of the research results to suggest more effective ways of educating young people. Moore and Rosenthal’s paper again addresses this topic of adolescent HIV-related knowledge, attitudes and behaviours, this time in Australia. The authors used both qualitative and quantitive measures to obtain detailed descriptions of adolescent sexuality and then relate this information to the topic of HIV-related risk factors. They found that pathways to risk differ between genders and that unsafe sex occurs across a range of sexual ideologies and contexts. Their findings serve to inform us about the development of interventions once more. The contribution from Hernandez et al., investigates the role of very specific personality factors with unprotected sex in a group of college age males in the United States. The authors underscore the point that condom use by adolescents is the outcome of multifactorial decision making processes affected by biological, social, developmental, and psychological influences. Their study highlights the importance of the psychological and development factors, specifically the level of self-control and ego identity measures, and also suggests ways to develop more specific inter-
338
R. WILLIAMS
AND L. PONTON
vention strategies for HIV prevention with adolescents that take these factors into account. A number of broadly. similar themes emerge in all these articles which provide strong messages for all interested in adolescents and the phenomena which adolescent development demonstrate. These matters are of interest to a wide range of professional disciplines and it is fascinating to witness investigators, drawn from a wide range of educational, medical, psychological and epidemiological disciplines, grappling with the issues which educating young people about sex, HIV and AIDS raise. In particular, two questions are provoked by all this evidence. Firstly - given a reasonable awareness of the risk, why don’t adolescents change their sexual behaviours? Secondly - can we use this theoretical research knowledge to generate strategies to improve the education of young people so that their attitudes and behaviours can be influenced in the direction of safer sexual activity and, hopefully, containment of the AIDS epidemic? There seems to be something about the process of growing up in adolescence which is, itself, a complicating factor and which makes the educational messages hard to receive and to adopt into one’s behavioural repertoire. Hurrelmann, in an article entitled, “Health Promotion for Adolescents: Prevention and Corrective Strategies Against Problem Behaviour”, in a previous addition of this Journal, considers evidence as to how risk-taking in adolescence may result from difficulties in handling the tasks of growing up. The article argues that risk-taking may have a value in dealing with developmental tasks such that progression to further risky behaviour is reinforced. His article looks at the implications of this thesis for the health education of the young. It suggests positive initiatives which include moving from a narrow focus of education directed at specific areas of risk-taking towards helping adolescents with developing individual competence, promoting the construction of networks, in which peer group membership is built on positive characteristics rather than on mutual support coming from sharing risky behaviour, and suggests that the quality of educational materials and student-teacher relationships need to be high if intervention is to be effective. It is interesting that, within the narrower frame of educating young people about HIV and AIDS, many of these lessons are reflected in the advice offered by the authors of the papers in this special edition. Readers will learn that supporting the development of high self-esteem and positive skills on a broad basis is recommended above further stressing the scary messages, which many Western adolescents already seem to have absorbed reasonably well. In the penultimate article Mellenby et al., consider the topic of sex education from a wide perspective. They take up the gauntlet thrown down
HIV AND ADOLESCENTS
339
by other authors to review, in depth, the need for, and possible impacts and limitations of, school-based approaches to educating young people about sex. In offering a rich review of the field they raise fundamental questions as to what the objectives of sex education should be and they document both lack of adult clarity and differences of view about policy and aims. Their title, “Sex Education: More is Not Enough”, clearly indicates that a general clamour for increasing the quantity of input in schools fails to address the need to define its context and aims. In so doing they generalize the challenge posed by HIV and AIDS to society’s attitudes towards education, curriculum development and sex generally. Our last paper focuses on adolescents’ hypothetical attitudes towards a friend infected with HIV. As the number of infected adolescents in the world climbs, this situation will occur more frequently. In contrasting potential responses to a friend who is suicidal and potential responses to a friend who is infected with HIV, the authors emphasise the coping strategies that would be employed by adolescents in both situations. Potential coping strategies appear to be affected by both gender and the overall level of distress. Although all the articles submitted for review for this special issue were from Europe, North America and Australia, we believe that it is important to acknowledge the magnitude of the problem of HIV infection for adolescents in Africa, Asia, and South America. Six and a half million individuals in Africa were reported to be infected with HIV at the 1992 World Conference (World Health Organisation, 1992). An infection rate in some African cities that is greater than 100 times that of Western countries, coupled with a lack of technological and economic resources, makes the problem formidable (Kerr, 1989). Investigators (Moore, et al. 1990, and Musagara et al., 1990) have examined the nature, course, and distribution of risk factors among late adolescents and young adults in Zaire and Uganda respectively. Factors that increase the possibility of transmission in high-risk parts of Africa include migration of large populations, movement of soldiers and traders who may be infected, economic privation, overcrowding, the breakdown of traditional family structure, prolonged unrest, overcrowding, cultural ceremonies such as blood bonding, and the lack of adequate medical services (Brown, 1992). The studies being conducted on Africa’s youth are important components of the international struggle against AIDS. In South America, there are reported to be over one million people infected with HIV (World Health Organisation, 1992). Economic privation, overcrowding in urban centres, and the lack of adequate medical services are longstanding factors associated with the spread of HIV. Caceres et al. (1992) found serious deficiencies of HIV-related knowledge among
340
R. WILLIAMS
AND L. PONTON
Peruvian high school students and teachers. Combating inadequate knowledge does not alter the serious economic problems of the world but such studies suggest interventions that can help stop the spread of AIDS. The World Health Organisation (1992) reports that there are one million infected individuals in Asia and fifty thousand in the Western Pacific Region. High rates of heterosexual transmission from intravenous drug use and infected adolescent sex workers are serious health problems for youth in many Asian countries. (Jayaraman, 1990; Nail et al., 1990). Programs to reduce HIV infections among Asia’s youth are complex and have to address many cultural factors. (Directorate General of Health Services, 1990). These observations emphasise the critical importance of research and of the development of social, education and health policies. The articles in this special issue also stress these very same points, directly and indirectly. Adult responsibilities for offering young people education and an optimistic view of a positive world and, specifically, interventions to combat the threat of HIV/AIDS overlap in a crucial, yet intriguing, way. It is our contention that the development of effective risk reducing and prevention strategies depends on taking into account all sources of knowledge. Equally it is important to understand how it is that knowledge alone is not enough. There is a need for policy makers, researchers and a broad range of professionals who are concerned with adolescents to work together. Such a conclusion could be drawn in many areas relating to young people but the threat of HIV/AIDS adds a new dimension and a new urgency to this collaboration. In the U.K. the Government has, recently, published a White Paper, “The Health of the Nation”. This has launched a strategic policy initiative in England which raises the profile of health promotion to sit alongside health care. It selects five Key Areas for action and one is that of, “HIV/AIDS and Sexual Health”. The Health of the Nation sets national objectives and targets in each key area, outlines initiatives to begin implementation of the strategy and sets a framework for monitoring, development and review. Its objectives for sexual health include - reduction of the incidence of HIV infection; reduction of the incidence of other sexually transmitted diseases (STDs); the provision of effective services for monitoring, diagnosis and treatment of HIV and other STDs; reduction of the number of unwanted pregnancies; and ensuring that effective family planning services are available for those who want them. An awareness of the particularly important position of young people is evident in this document. At this point it is, clearly, too early to say if this initiative will have the desired effects. However, the U.K. Government has committed
HIV AND ADOLESCENTS
341
itself to further action and its White Paper recognises the need for a combined, multifocal approach involving public policy development, improvements in the environment and changes in personal lifestyles as well as developments in the health services. This is, at very least, hopeful. It also offers a model for integrating policy and practice. Our opinion is that effective HIV/AIDS risk reduction strategies in all countries must be based on multidimensional knowledge of how adolescents develop and an awareness of their needs for information and for positive support in developing personal and social skills and relationships. Those who work with adolescents have much to offer in the field of prevention. They know much about the development of autonomy in the young and how adolescents experience and begin to use, for instance, oppositionality, ambivalence and their crucial, yet potentially complicated, networks of evolving relationships with parents, other adults and peers in the pursuit of emotional separation from family of origin. All these matters have an important bearing on effective sex education for the young. Several papers in this volume reiterate a striking international finding from research which is that of the apparent discontinuity between adolescents’ knowledge of the risks on one hand, and their sexual attitudes and behaviours on the other. It is essential that this be taken into account by all those responsible for health promotion strategies. However, as Mellanby et al., show, adults have other responsibilities too. Policy makers, advised by young people, their families and professionals, must first decide what the objectives for this education are to be. In this regard, whether all concerned approve of the direction and specific targets of its White Paper or not, the U.K. Government has taken an initial, positive, multisectoral stance which could promote real collaboration. In order to achieve a worldwide reduction in HIV seroprevalence, AIDS and other HIV related illnesses, researchers from different nations must work together sharing knowledge, educational programmes, treatment advances and policy formation. HIV does not stop at national borders. High infection rates in one part of the world have a serious impact on other areas. So we cannot ignore HIV and related illness in other countries or continents. Some countries have made advances that would significantly benefit others. This special issue represents such a worldwide collaboration. The overwhelming statistics and the appalling reality of working in the arena of HIV/AIDS affecting adolescents make the situation extremely difficult and severe. Yet the papers published here show that professional investigators have a vital role in extending knowledge and testing practical interventions through health promotion, prevention and treatment. A partnership between them, practitioners, educators, policy makers and young people themselves is going to be extremely
342
R. WILLIAMS
AND L. PONTON
important as nations try to work together in combating this worldwide epidemic. Exchange among researchers must continue in order to promote this collaboration among nations - a process that will benefit adolescents throughout the world. We conclude by emphasising the role that young people themselves can play. The positive value of asking them about themselves is shown in the research we publish here. Empowering young people with both knowledge, appropriately and sensitively delivered, and high quality positive experiences on a broad basis, aimed at fostering confidence and good selfesteem, are likely to be important longer term factors in reducing the extremes of risk-taking behaviours. They are, therefore, also likely to be important matters in health education generally and helping young people to help themselves in managing the HIV threat, in particular. The value of the peer group in preventative sex education is referred to by a number of our contributors and those who work with adolescents will know of the positive impact of involving older peers in influencing those younger than themselves. It seems that this is one potential way of diluting the oppositional responses that some young people feel they must make to information and advice proffered by adults, in their struggle to develop a sense of automony whilst under pressure. It has been our privilege to edit this special issue. We are grateful to the editor, John Coleman, for his vision and inspiration, to all those who submitted papers but, particularly, to the adolescents who participated in so much of the research. Richard Williams
and Lynn Ponton,
Guest Editors,
December
1992.
REFERENCES Brown, L. (1992). Personal communication. Caceres, F. C., Rocasco, A. M., Munoz, S., Gotuzzo, E., Mandel, J. & Hearst, T. (1992). Necesidades Educativas En Relation Con La Sexualidad Humana Y El Sida Entre Estudiantes Y Profesores De Escuela Secundaria En Lima. Rewista Latin0 Americana De Psicologia, 24, 109-122. DiClemente, R. J. (1990). The emergence of adolescents as a risk factor for human immunodeficiency virus infection. Journal of Adolescent Research, 5, 7-71. Directorate General of Health Services, Ministry of Health and Family Welfare. (1990). Medium Term Plan for the Prevention and Control of AIDS in India, 1990-I 992. New Delhi. Hein, K, (1989). AIDS in adolescence, Journal of Adolescent Health Care, 10, 105-35s. Hurrelmann, K. (1990). Health Promotion for Adolescents: Preventative and Corrective Strategies Against Problem Behaviour. Journal of Adolescence, 13, 231-50.
HIV AND ADOLESCENTS
343
Jayaraman, K. S. (1990). India prostitutes and the spread of AIDS. Lancet, 335, (8701): 1332. Kerr, D. L. (1989). HIV infection and AIDS in Africa and the Third World. Journal of School Health, 59, 369-370. Moore, M., Bomboko, B., Bertrand, W., Adjou, M. & Kashala, T. (1990). Distribution and determinant for risk behaviours of HIV infection among young adults in Zaire. Sixth International Conference on AIDS, June 21, 1990. Musagara, S., Konde-Lule, J., Musgrave, S., Serwadda, D., Wawer, M. & Sewankambo, N. (1990). Recent changes in behaviour and practices in relation to the HIV epidemic in rural Rakai District, Uganda. Sixth International Conference on AIDS, June 21, 1990. Naik, T. S., Sarkar, H. L., Singh, S. C., Bhunia, Y. J., Singh, P. K. & Singh, S. C. PAL: Intravenous drug users: A high risk group for HIV infection. (1990). AIDS, 5, 117-118. Secretary of State for Health. (1992). The Health of the Nation - A Strategy for Health in England. London. HMSO. 1992. U.S. House of Representatives, a generation in Jeopardy: Children and AIDS, a report of the Select Committee on Children, Youth, and Families (1987) U.S. Government Printing Office, Washington 1988. World Health Organisation (1992). World Health Organisation Global Program on AIDS. Presented at the Eighth International AIDS Conference in Amsterdam, 1992.
