AIDS

In South Africa, HIV is spread mainly through sexual contact between men and women (Department of Education, 1999). An estimated 7 million South Africans are HIV-positive with the highest prevalence rates among young people, especially teenage girls (Department of Education, 1999, 2001; Coombe, 2002). Findings of a HIV/AIDS survey by the South African Department of Health among pregnant women attending public antenatal clinics show that the prevalence of HIV/ AIDS among pregnant women under the age of 20 years has risen 65.4% from 1997 to 1998 (Department of Education, 1999).

The scale of the AIDS epidemic among youth in South Africa is enormous and HIV/AIDS continues its deadly course. Throughout South Africa, the AIDS epidemic is affecting large number of adolescents, leading to serious psychological, social, economic, and educational problems (Department of Education, 2001; Coombe, 2002).

When it is considered that 40% of the South African population is less than 15 years of age and that 15.64% of the South African youth between the ages of 15-24 is infected with HIV, one recognizes that HIV/AIDS represents a devastating pandemic among the youth of South Africa (Coombe, 2002; Department of Education, 2001). This points to the need for research on the sexual behavior of this group. Information on existing knowledge about the sexual behavior among adolescents can provide an important base for educational interventions aimed at reducing further transmission. What is being written could be crucial in informing the course and impact of the disease, and how its effects can be systematically addressed. This is especially the case with respect to educational research and publications. It is therefore important to have a clear sense of what is being researched and published (however limited) on this subject (sexual behavior of adolescents) in South Africa today.

Accordingly the main aim of this paper is to provide a comprehensive analytical review of available research concerning the sexual behavior of adolescents in South Africa. Second, it is to determine from the research findings why HIV infections among adolescents in South Africa are high. Third, it aims to determine the impact of AIDS education programs on the sexual behavior of adolescents. Fourth, it is to make recommendations for future preventative interventions.

Research Strategy

The following sources were identified in order to collect data on available research on the sexual behavior of adolescents: interviews with leading individual researchers working in the area of HIV/MDS and education; summation of research on HIV/AIDS and education by the major research organizations; review of (hard copy) journal-published research on this subject; synthesis of on-line journal research publications; summaries of theses and dissertations conducted on this topic; studies of research proposals representing research in progress which has not yet been completed for publication; and review of AIDS Conference abstracts. In reviewing the various data sources, the analytic strategy was to ask: Who is writing what, about whom, from where, for whom, in what forums, with what results, using what methods and in which communities?

FINDINGS

Sexual Behavior of Adolescents in South Africa

An important finding of the 1998 South African Demographic and Health Survey was that although awareness and knowledge about HIV and AIDS are high among adolescents in South Africa, this has not translated into substantial behavior change (Galloway, 1999). Results of an extensive research show a high awareness about HIV and AIDS (97% of respondents). However, detailed knowledge that would enable behavior change, was not as high. For example, 10% said that staying with one faithful partner and using a condom will not protect them from HIV/AIDS. Further, the majority felt that they are not susceptible to HIV infection.

A survey by Harvey (1997) found that the knowledge, attitudes, and behavior related to AIDS among Standard 8 (Grade 10) Zulu-speaking students (N = 1,511) in KwaZulu-Natal were on the whole inadequate to provide a foundation for developing safer sexual behaviors. Although most students acknowledge the severity of the disease, few reported feeling personally susceptible--denying the immediacy of the threat. Adolescents' lack of knowledge is also highlighted by Visser (1995) in an extensive research among 314 secondary school students from 10 schools in different parts of the country. Findings in this study showed that, although adolescents are sexually active and have basic knowledge about AIDS, they do not know how the virus is transmitted, nor do they know how to protect themselves from the disease. Thus adolescents in South Africa must be regarded as a high-risk group for HIV infection.

A group-administered, multiple-choice, paper-and-pencil questionnaire was used by Carelse (1994) in his research to determine the level of knowledge of AIDS and reported sexual behavior of the students at Ottery School of Industries in Cape Town. Findings that over 80% admitted to being sexually active and that knowledge of HIV/AIDS issues and the use of preventative measures among students were poor. Carelse (1994) concluded that these factors pointed toward an urgent need for AIDS intervention efforts in the institutional (school) environment.

A study (UNICEF, 1995) was made of adolescents' knowledge and experience of sexuality through focus groups in five provinces. It was found that adolescents receive conflicting messages about sex and sexuality and that they lack the knowledge, confidence, and skills to discuss sexual issues, including contraception and prevention of infection. Furthermore, this study found that widely believed myths reinforce negative attitudes about safer sex and contraceptive use, and that most adolescents make decisions about sex in the absence of accurate information and access to support services. Students' feedback indicated that their need for accurate information could be satisfied through AIDS education in schools.

Kuhn, Steinberg, and Matthews (1994) and Harvey (1997), in their research on knowledge, attitudes, and sexual behavior related to AIDS, found that, while knowledge of HIV/AIDS among adolescents is generally good, many engage in high-risk sexual behavior. Harvey (1997) showed that, among Zulu-speaking Standard 8 (Grade 10) students (N = 519), more than a third (34.9%) reported being sexually active, with some having more than one sexual partner. Less than half of all students (42%) acknowledged that having one uninfected sexual partner was an effective preventive measure. Almost a quarter of the students (23.8%) reported having been treated for a sexually transmitted disease in the past. The study further revealed that more than 50% of the sexually active students never used a condom. No more than 10% have used a condom regularly during sexual intercourse; a variety of misconceptions about condoms resulted in rejection of their use.

An earlier study (Kuhn, Steinberg, & Matthews, 1994) among Xhosa-speaking secondary school students in the Western Cape, indicated that 42.4% of sexually active students believed that having one uninfected sexual partner helps to prevent getting HIV/AIDS. However, relatively few students believed that AIDS could affect them, and their attitudes toward condoms were largely negative. In an extensive survey and follow-up among urban black youths aged 16 to 20 years in Soweto, Khayelitsha, and Umlazi, Richter (1996) found that 40% of young women and 60% of young men had had more than one sexual partner in the previous six months, and that condom use was relatively low.

Naidoo (1994) found, in a study of students (N = 290) at two high schools in Motherwell and Magxaki (Port Elizabeth), that nearly 55% were sexually active, with 10% having had four or more sexual partners over the last year. The majority of the sexually active students indicated that they were not using condoms. Goliath's (1995) research among students (N = 782) from 19 secondary schools in the Eastern Province, showed that most of the sexually active respondents never used a condom. Results also showed that 40.1% of the boys and 27.7% of the girls already had four or more sexual partners. A study by Carelse (1994) of the sexual behavior of students at the Ottery School of Industries in Cape Town indicated that over 80% admitted to being sexually active, and at least 15% reported incidents of institutional sodomy.

The Bambisanani project (Kelly, 2001) found that 98% of male youths and 66% of females reported having had sex; 40% reported having had more than one partner during the previous six months.

Various studies (Craig & Richter-Strydom, 1983; Flisher et al., 1993; Goliath, 1995; Buga, 1996; Kuhn, Steinberg, & Matthews, 1993; Richter, 1996; Harvey, 1997) show that adolescents do not practice safe sex in general. The reasons are related to pressure to engage in early and unprotected intercourse, coercion, pressure to have a child, lack of access to user-friendly reproductive health services, negative perceptions about condoms, low perceptions about personal risk, and low perceived self-efficacy in preventive behavior.

Sexual activity among adolescents commences at an early age (Goliath, 1995; Buga, 1996; Harvey, 1997; Matthews, Kuhn, Metcalf, Joubert, & Cameron, 1990). Harvey (1996) revealed that more than a third (34.9%0 of Zulu-speaking Standard 8 (Grade 10) students in KwaZulu-Natal are sexually active. The average age of onset for sexual activity was 15.97 years. These findings are supported by the Health Systems Development Unit (1997) in their large study which indicated that many adolescents are sexually active by the age of 15 years, with some reporting up to seven partners, yet few take steps to prevent sexually transmitted diseases.

With regard to gender differences, Goliath (1995) found in his study among 782 students from the Eastern Province that boys started sexual intercourse earlier than did girls. Of the boys, 18.3% reported having had sexual intercourse at the age of 12 years, compared to only 3.1% of the girls. Most of the boys and girls were sexually active from the age of 15 years. A study by Buga (1996) in a rural area of Transkei, in which the mean ages of the girls and boys were 15 and 16 years, found that 76% of the girls and 90.1% of the boys were already sexually experienced. Boys started sexual intercourse earlier than girls (13.43 years versus 14.86 years), had more partners, and nearly twice as many had a history of sexually transmitted diseases.

A survey (Matthews, Kuhn, Metcalf, Joubert, & Cameron, 1990) of students (N = 377) from four Cape Town high schools revealed that three-quarters of the students reported having had sexual intercourse. Furter et al. (1998) found that a high proportion of students in the Free-State are sexually active at the age of 12 years. In another survey of knowledge, attitudes, and behavior among adolescents in six villages in Xhalanga, the District Health Care Trust (1997) found that about 50% approved of sex before marriage and believed that sexual involvement should start between 10 and 17 years of age; 67% of the respondents reported having had sexual experience. Adolescents who accepted the practice of using contraceptives and condoms were unable to access them.

Matthews et al. (1990), Visser (1995), Council for Advancement and Support of Education (CASE; 1995), and Harvey (1997) found that few adolescents perceive themselves to be at risk. Students from four Cape Town township high schools did not acknowledge that AIDS could affect them directly (Matthews et al., 1990). They attributed the problem to prostitutes, promiscuous people, and to white people. Harvey's (1997) study among Zulu-speaking adolescents in KwaZulu-Natal revealed that although most students acknowledge the severity of the disease, few reported feeling personally susceptible, playing down the immediacy of the threat. Respondents did not acknowledge the disease to be a problem in their area. Additionally, the benefits of adopting preventive behaviors were not acknowledged. Furthermore, perceived self-efficacy in preventive behavior was low.

A study by CASE (1995) concluded that the level of knowledge of HIV/AIDS among adolescents is high, but few perceive themselves to be at risk and few take the need for safer sex seriously. Similar results in a study by Visser (1995) among 314 students from 10 secondary schools showed that although students have basic knowledge of AIDS, they do not see AIDS as a personal threat.

Carelse (1994) illustrates that the environment in which high-risk behavior occurs needs to be examined because it may contribute to the incidence of high-risk behavior and may prevent the successful implementation of AIDS prevention programs. A critical analysis of the South African Juvenile System as well as a juvenile correctional institution was undertaken by Carelse (1994). It was postulated that the institutional environment contributed to the incidence of AIDS-related, high-risk behavior and made effective AIDS intervention programs difficult. It was concluded that the reasons underlying the failure of AIDS intervention efforts were identical to those contributing to the failure of institutional rehabilitation programs in general. It was also concluded that the social factors underlying juvenile delinquency were the same as those contributing to the spread of AIDS in institutionalized juvenile delinquents.

Impact of AIDS Education Programs on Sexual Behavior

Little research has been done on the evaluation and impact of AIDS education programs on the sexual behavior of adolescents. Ogunbanjo and Henbests' (1998) research on the knowledge, attitudes, and behavior of adolescents with regard to HIV/AIDS proved that an AIDS program can significantly increase awareness and knowledge and decrease high-risk sexual behavior. A study was conducted in Kwaggafontein in which 352 students from three high schools were used as study and control groups. Following the AIDS education program, the percentage of students in the study group showed a dramatic increase in awareness of AIDS as a problem in their community (from 44% to 74%) and knowledge about AIDS as a preventable (48% to 88%) and an incurable disease (41% to 87%). However, the control group that followed a general hygiene program, did not, that is (49% to 53%), (49% to 58%), and (44% to 45%), respectively. Most importantly, the study group showed a significant decrease in reported high-risk sexual behavior following the program.

A review (Harrison, Smit, & Meyer, 2000) of behavior change interventions have shown that behavior interventions including information, education, and communication programs, condom promotion, and behavior change initiatives that encourage people to reduce the number of their sexual partners can bring about a reduction in high-risk sexual behavior.

Carelse (1994) illustrates that MDS intervention programs that stress education alone do not necessarily change high-risk behavior-students must also be empowered with the skills necessary to put knowledge gained into practice. In a review of behavior change interventions, Harrison, Smit, and Meyer (2000) emphasized that interventions should develop negotiation- and decision-making skills especially among girls. An evaluation (University of Natal, 1996) of MDS education in KwaZulu-Natal schools revealed that existent programs were insufficient. The recommendations were that AIDS prevention programs should occur in the context of development of more general skills--skills in negotiating sexuality and sexual relationships and skills for the negotiation of life in the late twentieth century.

DISCUSSION

The following key findings of this research emerge as the reasons for the high HIV infections among adolescents in South Africa: more than a third of adolescents in South Africa are sexually active and that they commence sexual activity at an early age. The average age of onset for sexual activity with several partners is 15 years. Reasons may include peer pressure, curiosity, and (particularly for young girls) coercion and material gain.

Adolescents appear to have a high level of awareness about HIV/ AIDS but this has not translated into substantial behavior change. They have more than one sexual partner; between 40% and 60% of adolescents have more than one partner within a 6-month period. Few perceive themselves to be at risk, few take the need for safer sex seriously, and do not see AIDS as a personal threat, although most adolescents acknowledge the disease's severity.

Adolescents do not practice safe sex in general; use of preventative measures are poor. More than 50% of the sexually active adolescents never used a condom. Less than 10% use a condom regularly during sexual intercourse. Failure to practice safe sex is related to pressure to engage in early and unprotected intercourse, pressure to have a child, lack of access to user-friendly reproductive health services, negative perceptions about condoms, low perceptions of personal risk, and low perceived self-efficacy in preventative behavior.

General knowledge of adolescents about transmission of disease were found on the whole to be inadequate to provide a foundation for developing positive attitudes and safer sexual behavior. It was found that many young people receive conflicting messages about sex and sexuality: nonpenetrative sex is not considered to be proper sex; widely believed myths reinforce negative attitudes about safer sex and contraceptive use; most adolescents make decisions about engaging in sex without having accurate information and access to support and services; they lack knowledge and negotiation skills in sexual relationships; and many do not acknowledge the disease to be a problem in their area or in their race group.

Recommendations for Preventive Strategies

In spite of the attempts to develop ways to manage the spread of HIV in South Africa, the rapid increase in the prevalence of infection indicates that these efforts have not had a significant impact. Thus, new behavioral interventions are needed that can have a lasting public and personal health impact.

Promotion of appropriate and culturally relevant programs. Health educators should invite young people to help plan, implement, and evaluate sex and HIV/AIDS programs. In South Africa, with its diverse cultures, programs should be developed within the context of the specific cultural beliefs and values of the target group. Such culturally relevant programs will help eliminate myths and misconceptions regarding HIV/MDS.

Early commencement of programs and parental involvement. Because adolescents commence sexual activity at an early age, sex and HIV/AIDS education programs should start in primary school and be developmentally appropriate. In order to obtain support of parents and other relevant role players, researchers, educators, and policy makers should take local cultural traditions into account. All those involved should be invited to voice their concerns and suggestions regarding the program.

HIV/AIDS education programs should encompass both knowledge and skills. This research showed that adolescents lack specific knowledge about HIV/AIDS. Factual information (e.g., the means of transfer, how it affects the body, the lack of a cure, preventive measures) should constitute the core of the program.

HIV/AIDS education programs should emphasize social norms and skills needed for healthy human relationships, effective communication, and responsible decision making that offer protection from HIV infection. Programs should incorporate responsible decision-making strategies, communication, and problem-solving skills, particularly in combatting the social pressures for having sex.

It is increasingly clear from the research that young women in South Africa are at particularly high risk of infection. Although there is now a better understanding of the determinants of risk for young women--gender inequality, a lack of power in decision making, and social coercion--how to address these issues is still not clear. Behavioral interventions for young women should include empowerment and the development of negotiation skills. For young men, respect and support for women and for gender equality, need to taught.

Condoms should be more readily available. Although research shows that adolescents express a negative attitude toward the use of condoms, they are still seen as important in the prevention of HIV infection. For young adolescents who are sexually active, schools, universities, and community organizations should provide contraceptives.

Adolescence often seek contraceptives without parents' knowledge and hence must cope with such problems as finding transportation to clinics and harassment or refusal to be served at pharmacies. Since the way condoms are provided on campuses influences adolescents' acceptance and use, making them more easily accessible will help solve the problem.

Abstinence should be made "valuable" to adolescents. Messages that encourage them to abstain or delay sexual activity may help them adopt this attitude.

Educators and peers should be trained to provide an effective HIV / AIDS education program. Effective programs offer accurate information in a way that shows sensitivity to the issues of adolescents. An effective peer education program transfers control of knowledge from the hands of experts to lay members of the community, making the educational process more accessible and less intimidating. Furthermore, peer education allows for debate and negotiation of messages and behaviors, leading to the development of new collective norms of behavior rather than merely seeking to convince individuals to change their own behavior.

CONCLUSION

Much research still needs to be done on the effectiveness (or lack thereof) of educational programs on adolescents' sexual behavior. What seems certain, however, is that the little research that has been done proves that AIDS education programs can significantly decrease high-risk sexual behavior among adolescents. An important conclusion is that a general strategy would not be feasible, since the norms, values, cultures, and traditions of the various communities in South Africa are too different. Thus the focus of a prevention program for students would have to be based on the particular needs and beliefs of each community.

The most important conclusion of this study is that, despite the efforts of researchers, there has been no significant change in the rate of infection among adolescents in South Africa. This study recommends a new generation of behavioral interventions which provide both factual knowledge and life skills which promote behavioral risk reduction.

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Requests for reprints should be sent to Cycil George Hartell, Faculty of Education, University of Pretoria, Groenkloof Campus, Leydsstreet, Pretoria 0002, South Africa. E-mail: chartell@hakuna.up.ac.za

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