Despite the rallying cry to tackle the high transmission rate of HIV (human immunodeficiency virus) to young women, particularly in sub-Saharan Africa, scientists have not reached a consensus on how to best prevent HIV infection among young people. Writing in the journal Public Library of Science (PLoS), an international team of researchers makes a unique attempt to provide concrete evidence on the effectiveness of sex education by carefully analysing what works and what does not in existing intervention programmes. The statistics of the AIDS (acquired immune deficiency syndrome) epidemic can be overwhelming, sometimes perhaps even obscuring the fact that each case is a personal tragedy. In Malawi and Zimbabwe, one person in four is HIV positive. However, in some areas of Zimbabwe infection rates are as high as 70%. Life expectancy is just 48 years, and the number of children aged below 15 years that have been orphaned as a result of AIDS is increasing alarmingly. In the absence of affordable or effective treatment for HIV, a group of researchers from the London School of Hygiene & Tropical Medicine (LSHTM) in the UK collaborated with the Kenyan-based African Medical Research Foundation (AMREF) and the Tanzanian National Institute for Medical Research (NIMR) to put an educational 'firebreak' around the virus. LSHTM's Professor Aiofe Doyle and her colleagues focused on the MEMA kwa Vijana intervention trial in Tanzania, where the HIV epidemic is severe but has not yet risen to the levels recorded in Zimbabwe. The MEMA kwa Vijana programme is being tested in primary schools in a community-randomised trial partially funded by the European Commission for the last 14 years. This highly-structured, three-year health programme is based on sound educational principles. Pupils aged between 10 and 15 years are trained to act in a series of dramas, which are used to stimulate discussion and help set parameters for their behaviour. Using role play in this way to build interpersonal skills is a key part of the programme. At the time of its design, a major concern for the researchers was the poor level of services provided by clinics as well as worryingly large numbers of untreated sexually transmitted diseases. These would undermine the effectiveness of any sex education at school if young people arrived at a clinic only to be told by health workers that contraception is for married couples and they ought to behave themselves. This again is an issue facing many countries, and not just those in Africa. It now seems that the biggest threat to this intervention trial comes from the school environment itself. Reporting the impact of the MEMA kwa Vijana intervention, the researchers argue that this intervention - like many other school-based interventions in sub-Saharan Africa - has been ineffective in changing sexually risky behaviour. More specifically, the impact of the intervention was evaluated in 2007-2008, approximately 9 years after recruitment, in a cohort of 13,814 young people aged between 15 and 30 years. Although the MEMA kwa Vijana intervention led to an improvement in knowledge, attitudes and intentions, the researchers did not find evidence of lasting behavioural changes. Some young men who attended the school trials delayed their sexual debut, others reduced the number of their sexual partners, and still others may even have used a condom in casual sexual encounters. However, many denied that they are at risk for HIV infection and insisted that you can never fully protect yourself against the dangers of life, including the spread of HIV. How do the findings from this follow-up survey answer the question 'what works' to prevent HIV infection in young people in sub-Saharan Africa? Interventions in African schools face numerous challenges due to high levels of student absenteeism, frequent violence, as well as the lack of appropriate training for those delivering the intervention. Still, despite these difficulties, schools offer several advantages for intervention delivery including the ability to reach a large number of youngsters. Adults in the community meanwhile recognise what a huge problem HIV is, as no family has been left untouched by this illness. In fact, the constant cry is 'Why have you waited so long to do this?' rather than 'What are you doing this for?' These findings led the researchers to suggest that 'youth interventions may be more effective if they were integrated within intensive, community-wide risk reduction programmes'. At the same time, recognition of the considerable variation in young people's needs is of crucial importance, and interventions in community or other venues designed to reach out-of-school youth should also be research priorities. While we wait for a safe, inexpensive and effective means of controlling HIV, there can be no doubt that prevention is better than no cure.
Kenya, Malawi, Tanzania, United Kingdom, Zimbabwe