Spread Information, Not HIV: An Analysis of AIDS Education in the United States

Experiences in United States health classes vary widely. One student might remember getting D.A.R.E.-style warnings about alcohol and substance abuse. Another may cringe at the memory of an awkward sex-ed class.

No one remembers learning about AIDS.

There’s an explanation for this, and it stems from two causes: the inept response to the AIDS crisis from the United States government, and the nature of the American secondary education system as it is today. The two have paired to create an educational environment in which HIV — which, in 2010, saw 26% of new cases occur among 13–24 year-olds (1) — is not talked about nearly enough. The potential for comprehensive, impactful education on this subject has long been discussed; it has never been put into practice.

ACT UP New York: “Lying to Teenagers About AIDS Is Not Christian” (https://www.icp.org/browse/archive/objects/the-truth-shall-set-you-free-teach-aids-education-lying-to-teenagers-about)

Following the outbreak of AIDS throughout the United States in 1981 (2), the Institute of Medicine (IOM) released a report in 1986 calling for a dramatic increase in funding and planning for HIV/AIDS education:

“The committee recommended that it [the education campaign] be targeted at high-risk groups, including homosexual men, intravenous drug users, sexually active heterosexuals, and teenagers. It was a time for plain speaking. The messages should be as direct and as explicit as possible, using whatever language people could understand and reflecting the basic reality that anal or vaginal intercourse with an infected person without using a condom was risky behavior.” (3)

At face value, this decree sounds entirely unproblematic. Education programs and curricula directed at those who need the information the most? Heck yes. Explicit, easy-to-understand instruction? Sign me up. However, as straightforward and insistent the IOM’s report may have seemed, it accomplished very little actual change. The loudest comments about educational reform were coming from the sitting Surgeon General, C. Everett Koop, not from the classroom. In 1988, the IOM released another report in which they criticized the continued slow response. This too, was less than effective, mostly because 1988 was a never-ending cycle of reports offering opinions and criticism of AIDS public policy (4).

The initial campaign for better HIV and AIDS education fizzled, but the epidemic itself managed to have a positive impact on sex education across the country.

I know, I know — this is better sex education? The hetero-normative, gendered, only-okay-when-you’re-married sex education? This system, one that focuses more on abstinence than common sense or healthy communication, is a step in the right direction? (5)

Actually, considering how things stood in the 1980s, it is.

One can argue that today’s standards for sex education are lacking — and someone should, frankly — but the status of these programs prior to the AIDS epidemic was near nonexistent. Any progress that has been made since is almost entirely a result of the pressure HIV and AIDS placed on the government. Surgeon General Koop, previously known for his conservatism and support of President Reagan, insisted that the education cover both hetero- and homo- normative sexual practices in an effort to reign in the death and destruction caused by HIV and AIDS. Like the IOM report, he believed that straightforward, common sense curriculum would be most effective: “Because of the ‘deadly health hazard’…we have to be as explicit as necessary to get the message across. You can’t talk of the dangers of snake poisoning and not mention snakes” (6).

This upward trend in comprehensive sex education has not continued. When treatment for AIDS became more accessible and the prospect of living with the disease became a reality, the threat of teenage deaths decreased (7). As a result, the number of states requiring compulsory sexual education in public schools has dropped significantly — as of April 2018, only 24 states and the District of Columbia mandate sex education, with only 22 states requiring both sex and HIV education (8).

Currently, there is no national standard for HIV/AIDS-based education in health classes (9). To understand this, basic information about the U.S. educational system is necessary. Most importantly, the difference between standards and curriculum.

This is a distinction that stirs up a whole lot of emotion at the moment, especially when the dirty phrase common core entires the conversation. But the difference is important, and it’s not awfully complicated. Standards are enforced at the national level — they provide a guideline for student learning outcomes and indicate benchmarks students should reach at a given grade level. Ideally, they are loose enough for teachers to adapt as they see fit to their courses, communities, and classrooms, while still maintaining a level of desired proficiency for schools across the country (10).

States can create and enforce standards, too. New York, for instance, implemented the Next Generation Learning Standards in the fall of 2017 (11). In New York’s case, the state standards are simply a revision of the national ones, adapted to be more streamlined, effective, and easier to implement in the classroom.

Curriculum, then, is the planning of standard-based instruction: “Standards are your destination. Curriculum is your road map” (12). As far as to what degree curriculum gets big-brothered, it depends on the state. If we stick with New York as our example, the state provides curricular modules for ELA and math, and curriculum guidelines for the other subjects.

What does that mean, exactly? For English and math teachers, you’re looking at constant migranes. For the rest of us, life is better. The road map, if you will, has a highlighted route, but you can still get off the interstate if you see something really interesting.

How does this circle back to HIV and AIDS? I’m getting there, no worries. While there’s certainly something to be said for letting teachers choose the curriculum they believe is most important for their students, one of the biggest disadvantages to this is the difficulty that comes with making sure all students have equal access to information, regardless of school district or zip code.

The U.S. Health Education Standards, then, discuss communication and well-being. They don’t specify that students should know how HIV is transmitted, what treatment options are available, or what constitutes a high-risk community, largely because standards across the board are not designed to be that specific. These learning targets align with the standards, for sure, but the federal government does not mandate that they be taught.

National Health Education Standards (https://www.cdc.gov/healthyschools/sher/standards/index.htm)

It falls to the states to demand proper education about HIV and AIDS. As is the case with a number of state-run programs, there is little agreement across the board as to what fulfilling this promise means. In New York, curriculum guidelines divide HIV/AIDS content into elementary, intermediate, and commencement levels — a brief section of this table can be seen below. For each group, the state has developed a number of fact-based criteria that students should know after having completed a course (13). While New York’s health curriculum certainly has large gaps — it does not, for instance, mention the HIV/AIDS related difficulties faced by LGBT+ individuals or even the community itself — it provides basic information on HIV/AIDS and works to counteract stereotypes with scientific fact.

NYS Health Education Guidelines (http://www.p12.nysed.gov/ciai/health/GuidanceDocumentFinal1105.pdf)

For comparison, let’s look at Texas — a state that does not mandate sex or HIV education, and does not require that it be medically accurate, culturally appropriate, or unbiased (14). The state has divided its health education into middle school and high school curricula, breaking each section down further by specific classes.

In the high school section, “HIV” is mentioned just four times. Only twice when you consider it appears in each class under the same learning goal. Under the heading, “Health Behaviors”:

“ The student analyzes the relationship between unsafe behaviors and personal health and develops strategies to promote resiliency throughout the life span. The student is expected to…explain the relationship between alcohol, tobacco, and other drugs and other substances used by adolescents and the role these substances play in unsafe situations such as Human Immunodeficiency Virus (HIV)/sexually transmitted disease (STD), unplanned pregnancies, and motor vehicle accidents” (15).

Instead of requiring its students to learn about how HIV and AIDS can be transmitted, or what to do when HIV positive, Texas’ education system tosses HIV in the same box as car accidents and teenage pregnancy, then asks students to analyze how substance abuse can contribute to contracting HIV. The second learning goal asks students to understand that abstinence is the only method of preventing HIV that is 100% effective, a statement that is not only false — you can become HIV positive through a number of different avenues — but is unaligned with human nature.

IMGUR (https://imgur.com/gallery/IgHubeR)

Where do we go from here? With an educational system that is less than conducive to national curriculum mandates and a free-for-all at the state level, should we continue to rely on secondary schools to provide information on HIV and AIDS?

The answer is messy, but it’s yes.

Hear me out — secondary schools are the ideal venue for getting information to the masses. Unlike institutes of higher learning, attendance at primary and secondary schools is mandatory, particularly for one of the largest groups of at-risk individuals: teenagers. If we’re talking about prevention, we can’t allow students to wait until they stumble into a collegiate public health seminar, we have to provide them with information before they need it. The best opportunity to do this is in middle and high school settings.

This isn’t blindly-optimistic speculation, this is science. Culturally appropriate, fact-based education has seen positive outcomes. In a 2015 study, ¡Cuídate!, an HIV prevention program targeted at Latinx students, was found to increase STI and HIV knowledge, self-efficacy, and condom use among its participates. Researchers credit much of their success to ¡Cuídate!’s grounding in fact, but also to its adherence to students’ culture:

“Successful behavioral outcomes were facilitated by knowing the current resources available for reproductive health care. Recognizing that our population has a number of undocumented, uninsured teens, we planned for engaging resources…to counter these disparities” (16).

As the success of ¡Cuídate! suggests, HIV and AIDS education is not one size fits all. For the most effective implementation, it should be tailored to the community being taught without sacrificing content. This makes the knowledge personal, and allows students to interact with the material and apply it to their lives.

School-based HIV and AIDS education, if implemented appropriately, has the potential to improve HIV disparities in minority communities: “Adolescents and young adults continue to be disproportionately affected by HIV…within this age group, men who have sex with men (MSM), especially African American and Hispanic/Latino MSM, and youth of all ethnic minority groups are disproportionately affected” (17). While this inequality cannot be fixed through the educational system alone, it can be improved. HIV and AIDS education, implemented at a macro level, can increase positive sexual behaviors:

“Access to comprehensive sex education and access to condoms have been found to be an effective structural HIV prevention strategy…comprehensive sex education includes health promotion, disease prevention information, and contraception information” (18).

Health and sex education in the United States has a long way to go before anyone should be proud of it. Adolescents in our schools deserve comprehensive, inclusive education that provides them with fact-based information about how to promote health-positive behaviors and decrease those with a negative impact. Instruction about HIV and AIDS is unequivocally necessary as part of this improvement.

HIV and AIDS education has come a long way in the last forty years. But it hasn’t come nearly far enough.

“Ignorance = Fear”, Keith Haring (http://www.haring.com/!/art-work/253#.WudhombMzq0)

References:

1. Rothman, Lily, “Sex Education History: AIDS Changed Everything,” Time (Noveqmber 12, 2014): (n.p.). http://time.com/3578597/aids-sex-ed-history/.
2. France, David, How to Survive a Plague: The Inside Story of How Citizens and Science Tamed AIDS (New York: Vintage Books, 2016).
3. Berkowitz, Ed, “To Improve Human Health: A History of the Institute of Medicine,” National Academies Press (US) 6 (1998): (n.p.). http://www.ncbi.nlm.nih.gov/books/NBK230743/ .
4. Ibid.
5. “Sex and HIV Education,” Guttmacher Institute. April 01, 2018. https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education.
6. Leo, John, “Education: Sex and Schools: AIDS and the Surgeon General add a new urgency to an old debate,” Time (November 24, 1986): (n.p.). http://content.time.com/time/subscriber/article/0,33009,962907,00.html.
7. Rothman, Lily, “Sex Education History: AIDS Changed Everything,” Time (November 12, 2014): (n.p.). http://time.com/3578597/aids-sex-ed-history/.
8. “Sex and HIV Education,” Guttmacher Institute. April 21, 2018. https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education.
9. “National Health Education Standards,” Centers for Disease Control and Prevention. April 21, 2018. https://www.cdc.gov/healthyschools/sher/standards/index.htm.
10. Greene, Peter. “Common Core — Curriculum or Not?” Huffington Post (July 09, 2014): https://www.huffingtonpost.com/peter-greene/common-core-curriculum-standards_b_5297876.html.
11. “New York State Next Generation English Language Arts and Mathematics Learning Standards,” New York State Educational Department, April 29, 2018. http://www.nysed.gov/next-generation-learning-standards.
12. Greene, Peter. “Common Core — Curriculum or Not?” Huffington Post (July 09, 2014): https://www.huffingtonpost.com/peter-greene/common-core-curriculum-standards_b_5297876.html.
13. The University of the State of New York, “A Guidance Document for Achieving the New York State Standards in Health Education,” The State Education Department. April 29, 2018. http://www.p12.nysed.gov/ciai/health/GuidanceDocumentFinal1105.pdf.
14. “Sex and HIV Education,” Guttmacher Institute. April 21, 2018. https://www.guttmacher.org/state-policy/explore/sex-and-hiv-education.
15. “Health Education,” Texas Education Agency, April 29, 2018. https://tea.texas.gov/Academics/Subject_Areas/Health_and_Physical_Education/Health_Education/.
16. Serowoky, Mary L., George, Nancy, and Yarandi, Hossein. “Using the Program Logic Model to Evaluate ¡Cuídate!: A Sexual Health Program for Latino Adolescents in a School-Based Health Center,” Worldviews on Evidence-Based Nursing 12, 5 (2015): 297–205.
17. Prado, Guillermo, Lightfoot, Marguerita, and Brown, C. Hendricks. “Macro-Level Approaches to HIV Prevention Among Ethnic Minority Youth: State of the Sciences, Opportunities, and Challenges,” American Psychologist 68, 4 (May 2013): 286–299. DOI: 10.1037/a0032917.