HIV/AIDS prevention and sexuality education must change to meet their promise

All over the world, education is identified as having a critical role to play in teaching people about sex, sexuality, and the prevention of HIV/AIDS. Yet all too often, the radical potential of education to promote safer and more pleasurable kinds of sex and to effect change remains unfulfilled.

In study after study, for example, young people state that what education they have received about HIV/AIDS was "too little, too late," and substantial numbers of adults continue to have serious misconceptions about the epidemic.

These range from the view expressed in a recent Australian study of young heterosexual men that HIV/AIDS is a disease of "dirty women and gay men" to the continued belief among large numbers of adults in developing countries that condoms have holes through which HIV can pass. Clearly, in many ways, education is failing to live up to its potential-and we as educators must bear some of the responsibility for this.

I want to address some of the issues upon which education must focus if it is to fulfill its promise in HIV/AIDS prevention and care. There has never been a better moment for this. A new strategic framework for such education to which the United Nations Education, Scientific, and Cultural Organization (UNESCO) and all other cosponsors from the Joint United Nations Programme on HIV/AIDS (UNAIDS) have signed, is currently being finalized. This offers an excellent starting point for more explicit and coordinated efforts.1

FOCUS OF EDUCATION

It should go without saying that much HIV/AIDS education has focused heavily upon knowledge, attitudes, and behaviors. Both adults and young people have been taught the "facts" in the belief that they will then act on the basis of what they know.

Alternatively, they have been given the chance to reflect on existing attitudes they may hold or others around them may hold-attitudes toward sexual practices, for example.

Beyond this, there has been an emphasis on skills acquisition-so-called "life skills" related to decision making as well as skills of sexual "communication" and "negotiation."

But too often, the focus is on the isolated individual who must be "taught," who must learn the "right attitudes," and who must become "skilled." Rarely, if ever, has there been concern about the affective and emotional-what people feel about the issues as well as what they know and do.

All of us probably know that our judgement about sexual and drug-related matters can be swayed by circumstance. And if this is true for us, then it must be true for others.

But why is this true? At least part of the answer is found in the different meanings that operate within a given context. What sex or drug use signifies, for example, can influence whether or not someone engages in it. And meanings shift and change depending on circumstances.

Notions of honor, for example, are central to sexual selfunderstanding. For many young men and some young women, it is "honorable" to show that they are sexually experienced. For many young people involved in sex work in countries such as Thailand, it is "honorable" to send earned money to parents in the village. For many of us, it is "honorable" to remain faithful to our sexual partners. But these "honors" differ according to context and circumstance.

It is also important to recognize irrationality as a powerful force structuring sexual life. Rarely are the kinds of interaction that lead to sex best understood in terms of the negotiation and communication taught in "Just Say No" programs.

Rarely does one weigh all the pros and cons of having sex in the ways suggested by rational decision-making models of risk-related behavior and behavior change. While actions can be re-constructed in this way after the event, at the time they are more often than not responses to opportunity and chance.

The power of transgression-or the excitement that comes from doing something unusual or naughty, that is forbidden-is, I believe, also underestimated. True, there has been talk about such issues within the context of some gay men's apparent abandonment of condoms and the adoption of new and more complex forms of negotiated safety But there has been relatively little attention given to transgression within heterosexual "safer sex" education or drug-use education.

Finally, there is the thorny issue of love, a concept conspicuous by its absence on the agendas of many conferences dealing with sexuality-related issues. While concepts of love vary considerably around the world, they are real enough for many people (at least some of the time).

As Francios Delor's recent work on sero-discordant couples in France shows, love legitimizes a range of sexual practices where the likelihood of HIV transmission is very real-unsafe sex between long-established sero-discordant partners, for example, who believe that the passions of first encounters will last.2

We are left, therefore, with a series of important absences in the focus of much education relating to HIV/AIDS.

RANGE OF MATTERS ADDRESSED

The absence of certain subjects in education is compounded by what might be called a series of approaches to such education that have solidified over the years. I will say something about five.

First, until recently, the majority of general population or school-based HIV/AIDS education initiatives have proceeded from the erroneous belief that all of those whom educators are trying to reach are HIV negative. This is dangerous not only because the majority of individuals simply do not know their sero status but also because, in an increasing number of circumstances (and most certainly within schools throughout Africa), a substantial proportion of both teachers and pupils may be (and may know themselves to be) HIV positive. The barriers between primary prevention and other forms of prevention are breaking down.

Second, and not unrelated to the above, is the erroneous belief that people with HIV/AIDS are some kind of a problem and not part of the solution to the epidemic. Frightening imagery of the physical effects of HIV/AIDS, together with warnings to young people to avoid those who might pose a "risk" do little to build the kinds of social solidarity central to an effective response. In contexts where relatively few people know their sero status, this assumption reinforces denial, making the educated "take sides" in a divisive and unnecessary battle against the epidemic.

Third, AIDS education programs are among the relatively few educational programs to date where stigma, discrimination, and human rights are central to prevention work. It is a sad fact that it has taken nearly 20 years for the first World AIDS Campaign to focus on what arguably is the greatest social ill associated with the epidemic: namely, the willingness of people to ostracize, vilify, and reject their brothers and sisters, sons and daughters, friends and lovers. HIV/AIDS education needs to get real in addressing these elements of social abuse.

Fourth, until recently our understanding of gender has been relatively superficial in our educational work. True, it cannot be denied that women, and young women in particular, are systematically disadvantaged in the majority of the world's societies. And true, for many young women, education represents a route out of poverty and away from sexual health risk. Having said this, and as Dr. Geeta Rao Gupta of the International Center for Research on Women in Washington, DC, has pointed out in the last two international HIV/AIDS conferences,3 we have failed to engage adequately with the manner in which gender systems work to ensure that both women and men are rendered vulnerable to the epidemic men, through ideologies that encourage them to appear knowledgeable when they are not (for fear of threatening their manhood); women, through ideologies that encourage them to be "innocent" about sex when they need to know.

Fifth, there has been the belief that the messages and approaches that worked early on in the AIDS epidemic will continue to do so. Nothing could be further from the truth. It is now abundantly clear from research with some of the first groups known to be infected (gay men, sex workers, and injecting drugs users) that messages and approaches have to be changed over time. Not only are new generations of especially vulnerable people always in the making, but they enter into this world in circumstances very different from those that prevailed early in the epidemic, when any talk of effective treatment was nothing short of a fantasy.

THE ISSUE OF PEDAGOGY

Too often, HIV/AIDS education has proceeded from what Professor Richard Parker of Columbia University and I have called a model of "liberal enlightenment."4 Here, those who know best intervene to correct the "bad" thoughts and actions of others.

This "banking" theory of pedagogy, as the educator Paulo Freire once described it, sees the minds of those who are being educated as empty vessels waiting to be filled with the good ideas of intervention specialists and communications experts.5

A parallel set of assumptions leads us to understand sex as a behavior to be controlled, not a passion to be played with safely. Needless to say, people are rarely taken in by such formal pedagogic approaches. More often than not, they end up paying lip service. They may appear to listen carefully but change little behind the scenes.

More successful by far are efforts to unleash the power of critical and systematic thought based on people's own positions in life. Such approaches usually have their starting point in the everyday concerns of individuals, not in those of intervention experts and specialists.

It is this kind of pedagogy that has characterized, at various times and in disparate ways, the prevention work of programs and projects as diverse as the Sonagachi project working with female sex workers in India, TASO (The AIDS Service Organization) working with a wide range of individuals in Uganda, the Gay Men's Health Crisis (GMHC) in New York City, the various AIDS Councils in Australia, and Grupo Pela Vidda in Brazil.

In each case, the principal aim of the pedagogy was not to tell people what to do but to unleash the power of community to take charge and fight back. The importance of such approaches-which seek to consolidate and build social capital-is well documented, especially in contexts where "popular education" was used to help develop not only understanding but also to combat the social inequality and exclusion that disempowers those most vulnerable to HIV.

THE ISSUE OF CONTEXT

Perhaps the most important thing to take into account in planning future work relating to AIDS education is the notion of context. Far from being peripheral to the effectiveness of education, context-the "background noise"is vitally important to understanding how people respond to learning opportunities.

Let me give you an example. It might matter enormously what we should do to promote safer sex in an educational setting if that sex is: (1) first sex or regular sex, (2) sex within an enduring marital relationship or sex on an occasional basis outside this relationship, (3) sex with love or sex in order to satisfy a momentary feeling of lust, (4) sex freely entered into by consenting adults or sex within the context of "ethnic cleansing," or (5) the sex that occurs between men in prisons or the sex that takes place in loving gay relationships.

Ultimately, there are no universal panaceas to discover in prevention science. The approaches we use must be context specific. Context matters when it comes to planning interventions and thinking about what education can achieve.

Context is important because of its intimate relationship with what we call vulnerability. Undertaking HIV/AIDS prevention requires focusing not only on individual risk-taking behavior but also on the environmental, political, and economic factors that influence susceptibility or vulnerability.

We need to take into account key sets of variables: factors linked to social networks and relationships, factors pertaining to the quality and coverage of services and programs, and broad-based societal factors.

OTHER FACTORS

The programmatic factors that educators need to take into account are the cultural appropriateness of HIV/AIDS and sexuality education programs, the accessibility of services due to distance, the cost of programs and services, and the capacity of health systems to respond to a growing demand for care and support.

Societal factors influencing vulnerability include cultural norms, laws, social practices, and beliefs that act as barriers or facilitators to prevention messages and approaches. Such influences may lead to the inclusion, neglect, or exclusion of individuals.

Inequalities of age, gender, sexuality, poverty, and social exclusion are among the many factors enhancing vulnerability to HIV/AIDS. They do so in enormously complex ways. In the case of poverty, for example, violations of rights, physical abuse, sexual exploitation, and the withdrawal of entitlements can deepen the gap between those who benefit from economic growth and those who suffer its ill effects.6

Somewhat paradoxically, development policies and programs themselves may have inadvertently negative effects on the spread and impact of HIV/AIDS. They may, for example, increase disproportionately the economic gap between immediate beneficiaries and others. The very poor may become vulnerable to HIV/AIDS as a result of increased marginalization on economic grounds and the need for dependence on alternative means of livelihood (for example, sex work).

If the new and more realistic forms of learning are to be an important element of future HIV/AIDS education, they must take place alongside structural or environmental interventions to change the social context in which individuals and communities live.7 These might logically seek to address the broader political, economic, and social forces that determine HIV/AIDS-related vulnerabilities and prevent people from acting on the basis of what they feel and what they know.

CONCLUSION

Some 20 years into the global HIV/AIDS epidemic, the time is ripe to re-evaluate what counts as HIV/AIDS education. New and more realistic programs and interventions are needed if we are ever to meet the goals set out in the Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS).8

Business as usual will not work. We need to radically renew and upgrade our efforts if the potential of education to change lives and to promote reductions in HIV/AIDS-- related vulnerability and risk is to be fully realized.

REFERENCES

1. See www.unesco.org/education/just_published_en/pdf/hiv_ approach_english.pdf

2. E Delor, SEROPOSITIFS: Trajectoires Identitaires et Rencontres du Risque (Paris: L'Harmattan-Logiques Sociales, 1999).

3. See, for example, www.icrw.org/docs/Durban_HIVAIDS _speech700.pdf

4. R. Parker and P Aggleton, "HIV- and AIDS-related Stigma and Discrimination: A Conceptual Framework and Implications for Action," Social Science and Medicine, 2002. (In press.)

5. P. Freire, The Pedagogy of the Oppressed (New York: Continuum, 1970).

6. See, www.icrw.org/docs/Durban_HIVAIDS-speech700.pdf

7. M. Sweat and J. Dennison, "Reducing HIV Incidence in Developing Countries with Structural and Environmental Interventions," AIDS, 1995, vol. 9, supplement A, pp. 5225-57.

8. See www. icaso.org/ungass/dclonofconmmt.pdf

Peter Agg eton, M.Ed., Ph.D.

Director, Thomas Coram Research Unit, Institute of Education, University of London

London, England

(For more information, contact Professor Aggleton at Thomas Coram Research Unit, Institute of Education, University of London, 27-28 Woburn Square, London WCIH OAA, United Kingdom. His e-mail address is P.Aggleton@ioe.ac.uk)

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