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AIDS in America - Education and Prevention
Why does America need AIDS education?
AIDS education up until now
AIDS education in American schools
AIDS education and adults
AIDS education and HIV+ people
Mother to child transmission (MTCT)
What else is needed to prevent HIV
transmission?
Condoms
Needles
There are two main reasons that AIDS education is
needed, and both of them are apparent in the USA. The first is to
reduce stigma and discrimination experienced by HIV+ people. The
second is to prevent new infections from occurring.
The ongoing discrimination that occurs across
America and the regular number of new infections each year suggest
that AIDS education in the USA is either insufficient, or that it is
not getting through to, and having the desired impact on, the groups
who need it. There is clearly more that needs to be done. Surveys
indicate that the American people lack knowledge about HIV - a 2004
survey found that whilst 99% of Americans knew that having
unprotected intercourse and sharing an IV needle might transmit HIV,
38% thought that it could be transmitted by kissing, 25% by sharing
a drinking glass, and 18% thought that they could be infected by
touching a toilet seat.
Adequate AIDS education can help to prevent new
infections from occurring - and at the moment in America, as we have
seen, new infections continue to occur. Teaching people who are not
infected with HIV what activities are risky will empower them to
protect themselves. Education can also prevent new infections by
teaching HIV+ people how they can lead their sex life without
passing the virus on to anyone else. The same survey quoted above
also found that 21% of Americans were unaware that there was not an
AIDS vaccine available - an ignorance which may have alarming
influences on their sexual behaviour.
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Although AIDS education is vitally important in
saving lives, religious and moral values have greatly influenced the
content of what is taught. In 1981 Congress passed the Family Life
Act which funded educational programs to promote 'self-discipline',
emphasizing sexual abstinence until marriage as the best form of
protection from unwanted pregnancy and sexually transmitted disease.
This, whilst undoubtedly true, is not the only way of remaining
safe, and is not always a realistic prospect when addressing
hormonally-charged young people.
In 1987, President Reagan advocated a modest federal
role in AIDS education, "as long as they teach that one of the
answers to it is abstinence - if you say it's not how you do it, but
that you don't do it ". Ever since, the classroom was opened up to
the religious right who used sexual health education to spread an
ideological message - that of sexual abstinence until marriage.
Federal government involvement has come, in part,
via the CDC, which has included in its budget specific funding for
HIV education ever since 1988. The CDC, however, has not been immune
from 'family values' biasing of 'facts' - in October 2002, a fact
sheet on the CDC website that included information on proper condom
use, the effectiveness of different types of condoms, and studies
showing that condom education does not promote sexual activity was
replaced with a document that emphasizes condom failure rates and
the effectiveness of abstinence. In 1996, Congress made federal
funding available for a five-year period to teach abstinence-only
education in schools. By 2002, some $500 million had already been
spent to fund abstinence-only sex education - about $100 million a
year since 1996. The federal government will spend approximately
$170 million on abstinence-only education programs in FY2005, more
than twice the amount spent in FY2001.
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AIDS education in American schools today falls into
one of two categories - either Abstinence-only or Abstinence plus
(or Comprehensive). These are really types of sex education, rather
than AIDS education specifically - AIDS education in American
schools usually comes as a part of a sex education program, if it
occurs at all. Sex education has for some time been led by the
'family values' movement, which dictates what can and what can't be
taught. AIDS education, by association, has fallen victim to
faith-based fact-filtering.
Abstinence-only education teaches students that they
must say no to sexual activity until they are married. This approach
does not teach students anything about how to protect themselves
from STDs or HIV, how pregnancy occurs or how to prevent it, and
teaches about homosexuality and masturbation only as far as to say
that they are wrong. Those who favour this method of education claim
that teaching young people about sex will make them want to try it -
thus increasing their risk of contracting HIV, amongst other things.
Abstinence plus or Comprehensive sex education
teaches about sexual abstinence until marriage, and teaches that it
is one way of protecting yourself from HIV transmission, STDs and
unwanted pregnancy. It also teaches that there are other ways of
preventing these things, such as condom use. People who favour this
approach take the perspective that young people should be taught to
remain sexually abstinent until marriage, but that there will always
be some who won't - and that they must be provided with the
information to enable them to protect themselves.
There has been debate for many years over which form
of sex education is most effective in terms of preventing underage
sex, unwanted pregnancy and STD and HIV transmission. A recent
study30 in President Bush's home state of Texas found that students
who have abstinence-only education are just as likely to have sex as
their comprehensively-educated peers.
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Of the 40,000 approximate new HIV infections in
America, it has been estimated that at least half occur in people
aged under-25 years old31. Of the 43,171 AIDS diagnoses in the same
year, the CDC estimated that 41% were amongst the 35 - 44 age group.
This shows clearly that, whilst young people might be more
accessible for AIDS education, they are not the only age-group
adversely affected by the epidemic. Federal AIDS education in
America, however, focuses almost exclusively on young people, where
it exists at all. Adults are assumed by the government to already
know about HIV transmission risks, and how to prevent them. Some
federal money is spent on providing abstinence-only AIDS education
to young unmarried adults. In recent years, there has been very
little national adult HIV education strategy, despite of the obvious
evidence that adults continue to become infected. What has been done
has occurred at a state level, and adults receive their information
primarily from either the media or from the church, which tends to
emphasise ideology over scientific fact.
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HIV+ people are a group who are sometimes overlooked
by AIDS education planners, but they can benefit greatly from
effective education strategies. AIDS education with HIV+ people aims
to
• Help them to cope with the knowledge that they are
HIV+.
• To inform HIV positive people about the nature of
HIV and AIDS.
• To enable them to have a safe and active sex life,
if they wish to.
• To ensure that the infection isn't passed on by
any other means.
• To enable them to lead full and healthy lives.
• To empower them to confront discrimination where
it occurs.
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This is one area in which the US has responded very
well to the HIV epidemic. The CDC reports that through 2003 there
have been a cumulative 8749 cases of AIDS in children under 13
years, which occurred via MTCT, but annual numbers have been
continuing to fall in recent years, and in 2003 only 58 children
were infected via MTCT. The chance that HIV infection is transmitted
from a mother who is HIV+ to her child during pregnancy can be
reduced to 2 percent or less if the correct antiretroviral
medication is administered. This, of course, means that the mother
needs to know that she is HIV+.
The CDC recommends that an 'opt-out' approach to the
testing of pregnant women is used, in which a woman is told that a
HIV test is to be one of a number of pre-natal tests, but that she
may choose to opt out, and refuse to be tested. If she does refuse,
however, she might be considered to be putting the health of her
unborn baby at risk, and her competence as a mother might be called
into question. Essentially, then, a woman is forced to have a HIV
test if she does not want to risk losing her child or children. This
amounts to compulsory testing, and raises significant ethical
issues, but MTCT of HIV in America has almost been eliminated.
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Education is a major component of AIDS prevention,
but there are other things which must be done if HIV transmission is
to be prevented. The first step in enabling people to protect
themselves from HIV infection is giving them the information they
need to be aware of the risks, and to know how to prevent
transmission from occurring. This is only the first step, however -
they then need the resources to put this information to practical
use. In the same way that there is no point in teaching a person to
drive a car and then banning them from setting foot in one, there is
no point in teaching people how to prevent HIV transmission if they
are not given the tools they need to make use of this knowledge.
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Studies are beginning to indicate that planning on
sexual abstinence until marriage doesn't help to reduce the
likelihood of a person's experiencing STD infection or pregnancy. It
seems that actually, a person planning on abstaining until marriage
will often be unequipped with the knowledge the person would need to
protect him/herself, if an unexpected sexual encounter did take
place.
The United States has experienced criticism that it
has substituted 'abstinence until marriage' programs for
science-based HIV prevention strategies that included correct and
consistent condom use. The U.S. Global AIDS Coordinator Randall
Tobias responded by saying that the US HIV prevention message could
be characterised as being "ABC", which stands for "Abstain, Be
faithful, use Condoms", in that order. In recent months, however, he
has been commenting that "statistics show that condoms really have
not been very effective". There has been growing concern that the
United States' policies have been swayed more by faith than by fact
- many religious groups, such as the Catholic Church, are
anti-condoms, despite the millions of lives these cheap, easily
distributed things save. CDC and USASID information giving
instructions on how to use a condom properly, on condom
effectiveness, and evidence that condom education does not encourage
sex in young people has been quietly removed from their websites.
Condom use has, however, increased significantly
amongst young people over the last decade. Studies do still
indicate, however, that not all young people have access to condoms,
particularly young gay men and lesbians (who do need to be able to
access pregnancy & HIV prevention facilities). Condoms in America
are available through a number of sources, such as drug stores and
family planning clinics. Some schools do make condoms freely
available, and it has been found that this does not increase sexual
activity. However, when schools don't offer such programs, it is
still often difficult for young people to access condoms - a 1996
survey found that condoms were sold from behind the counter in 83%
of all convenience stores, and that young females asking for help in
locating / purchasing condoms encountered resistance or condemnation
from clerks 27% of the time41. It can be even more difficult for
young people to access reliable information about condoms.
Ideological viewpoints have been allowed to dictate much of the
information taught in American schools to the point that some young
people are taught untruths - for example, that HIV is small enough
to 'pass through' latex.
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HIV transmission among injecting drug users (IDUs)
has always been a serious issue in America. A study in 1988 found
that one in four persons with AIDS in the United States had used
illicit drugs intravenously42 - and, while this may not have led to
their infection, it could certainly have led to that of someone
else. More recently, 15% of adult HIV diagnoses in 2003 and 27% of
cumulative infections through 2003 were in people who had been
infected by using needles or by being the partner of an IDU43.
According to a 1996 study44, an estimated 2.4 million Americans use
heroin at some time in their lives and nearly 216,000 of them
reported using it within the month preceding the survey. Injecting
is the most commonly-favoured method of ingesting the drug, but it
is not only street users of heroin who are at risk. The drug has
spread into mainstream culture, and other drugs - such as crystal
methamphetamine, favoured by the gay community, and steroids, used
by body-builders - also carry the risks of injecting without the
stigma of heroin use. The prevalence of drug use in America shows
clearly that the potential for HIV transmission amongst American
IDUs is huge.
Injecting drug users (IDUs) have always been a
risk-group for HIV transmission due to the ease with which HIV can
be passed when injecting equipment is shared. If IDUs are provided
with information and clean injecting 'works', then they can be
empowered to take action to prevent their becoming infected with
HIV. IDU-related HIV transmission can be massively reduced by the
provision of clean needles, and the safe removal of used ones - a
needle exchange scheme.
Needle exchange schemes tend specifically to address
the risky behaviour of IDUs - sharing works - rather than the root
cause of their risky behaviour - addiction. This strategy is
therefore referred to as 'harm reduction', since it does not attempt
to prevent the non-HIV-related harm from their addiction - something
which can actually make this type of strategy very successful. An
addict is likely to be more receptive to a HIV prevention strategy
which does not attempt to curtail the addict's drug using behaviour.
IDUs are overwhelmingly aware of the risks of sharing injecting
equipment, and do not do so through choice, but through lack of an
alternative. When they are able to access clean equipment, they do
so. These schemes have been shown by a number of studies to hugely
reduce HIV transmission amongst IDUs, but they are often unpopular -
even criminalised - in much of America.
Many states have 'drug paraphernalia' laws which
make it a crime to possess or distribute needles or syringes, and
five U.S. states impose a total ban on sales of syringes in
pharmacies without a prescription. Because they are so difficult to
acquire and in order to reduce the chances of prosecution, IDUs are
forced to either share, or stop taking their drugs, something they
are unlikely even to consider. Even where over-the-counter sales of
syringes are permitted by law, pharmacists are often reluctant to
sell to IDUs.
One argument against the provision of needle-exchange facilities
comes from the discriminatory view of IDUs as 'guilty victims' -
which forgets that IDUs endanger not only themselves, but their
sexual and injecting partners and their families. Another argument -
which has been proved wrong - is that needle exchanges actually
encourage the use of illegal drugs. Needle exchange schemes in
America have opened and been closed again as the political climate
has shifted. Positive notes are being seen, however - in September
2004, Arnold Schwarzenegger, Governor of California, signed
legislation permitting the sale of sterile syringes without a
prescription - something not previously possible in California.
Hopefully, this may mark the beginning of a shift
away from prejudice towards scientific prevention methods, but this
is only one state. In many parts of America it remains illegal for
HIV prevention workers to give out clean injecting equipment, and in
spite of all the evidence to the contrary, American legislators
prefer the belief that needle exchanges cause increased drug use to
the scientific fact that they do not. Furthermore, they are using
their economic power to export this fallacy to the rest of the world
- America has recently pressured the United Nations Office on Drugs
and Crime to remove all support for harm reduction programs.
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