Written by: Rachel Berman

Introduction

Human Immunodeficiency Virus (HIV) is a sexually transmitted infection (STI) that attacks the CD4 cells in a person’s body. HIV weakens the immune system and makes a person susceptible to other infections or infection related cancers. If HIV is not treated, a person can develop Acquired Immunodeficiency Syndrome (AIDS) which can increase the likelihood of opportunistic illnesses as well as death. There are 2.5 million cases of HIV/AIDS worldwide in children less than 15 years old. 1.9 million of these cases are in Sub-Saharan Africa alone. What is the cause of this alarmingly high prevalence rate specifically in Sub-Saharan Africa? 

Research reveals an indirect relationship between the implementation of school-based sex education programs and the rates of HIV/AIDS infection. While sex education programs can take many different forms, abstinence only education and comprehensive sex education programs are considered to be the two most prominent programs in the world. These programs are used in the United States as well, but when used in Sub-Saharan Africa, they are designed to meet different environmental and cultural needs. 

Abstinence only education programs advocate for the importance of refraining from sex until marriage. These programs typically “denigrate the effectiveness of contraceptives and safer-sex behaviors.” Comprehensive sex education programs, however, promote the opposite philosophy; these programs acknowledge that sex among adolescents is inevitable and society must “concentrate on helping adolescents avoid the negative consequences of sex.” Comprehensive sex education methods cover a wide range of topics “from fertility and reproduction to STIs, from relationships and communication to gender norms, culture and society.” They work to prepare youth for the social realities that lie ahead of them. Based on previous studies, comprehensive sex education programs show lower prevalence of adolescent HIV/AIDS whereas abstinence only education programs have not made similar influential improvements. The implementation of comprehensive sex education programs in Sub-Saharan African schools leads to a decrease in HIV/AIDS prevalence as well as a change in risky sexual behaviors.  

This article describes abstinence only education and comprehensive sex education programs in greater detail. It characterizes the structure of these two programs and describes how comprehensive sex education programs make crucial improvements to combat the HIV/AIDS crisis in Sub-Saharan African among adolescents. These programs can also have direct implications, whether it be harmful or beneficial, on ideologies such as uneven development and marginalization, global interdependence, and identity.

Abstinence Only Education: Why Doesn’t It Work?

            Abstinence only education programs in Sub-Saharan Africa have been a source of ongoing controversy. While many believe that abstinence, not engaging in sex until marriage, should be taught in schools, others point out the possible consequences of this education later in life. For example, if a person waits until marriage to engage in sex, they remain at high risk of developing an STI without the prevention knowledge they could have gained through a comprehensive sex education program. 

One of the largest funders of abstinence only programming in Sub-Saharan Africa is The President’s Emergency Plan for AIDS Relief (PEPFAR), a U.S. supported health program. Since 2004, PEPFAR has contributed over $1.4 billion to countries in Sub-Saharan Africa to implement abstinence only programs in schools for the purpose of reducing the risk of HIV transmission. A study compared the results among twenty-two Sub-Saharan countries, some of which received funding from PEPFAR and others which did not. The study shows that there was no evidence that PEPFAR funding “led to a reduction in HIV transmission risk behaviors.” Additionally, the study finds that in countries with PEPFAR funding, there is no “relative change over time in the number of sexual partners in the past twelve months, age at first intercourse, or proportion of teenage pregnancy” within the study cohort. All of these elements can be contributing factors to HIV transmission and abstinence only programs show no reduction effect on any of these components.  

Thanks to the presence of U.S. funding, this example supports the idea of global interdependencies. The U.S. contributes funds with the intent of creating better solutions in Sub-Saharan Africa, however, they are only making matters worse. The use of western resources to support abstinence-only education made no improvements and instead contributed to uneven development. Not every country in Sub-Saharan Africa received funding from PEPFAR, leaving some areas more financially well off than others. The lack of funding in certain countries limited the global connectivity of some countries as opposed to others, further contributing to uneven development. 

As it relates to abstinence only education, Uganda is one of the few countries in Sub-Saharan Africa that has implemented this form of education into their school curriculum. As of 2020, Uganda had the eleventh highest adult HIV prevalence rate in the world. The Uganda AIDS Commission proposed an “Abstinence and Being Faithful” policy to be taught in all schools across the country in 2004. This policy was created to promote abstinence and reduce the risk of HIV transmission, but it also undermined the use of condoms as an HIV prevention measure which ironically contributes to higher rates of HIV pervasiveness. 

An additional problem with programs like Uganda’s is that they do not acknowledge that HIV/AIDS is a disease of poverty. Many Ugandan people live off of less than $1 per day and unfortunately do not have the money to afford basic needs. In many cases, HIV transmission is perpetuated by girls trading sex for money to pay for school fees or women enduring sexual harassment during marriage because of their of economic dependence. While abstinence only education programs try to encourage the postponement of sexual behavior by adolescents, they fail to acknowledge the economic inequities of the disease or to discuss ways in which women could gain economic independence. 

The negative effects of abstinence only education are seen in a study focusing on Zambian secondary schools. An abstinence only education program was randomly implemented in three of the five schools, using the other two schools as control groups, in order to measure “whether adolescents’ normative beliefs about abstinence and condoms, their personal risk perception, and safer sex practices changed.” This program focused on promoting abstinence as well as increased condom use among male and female schoolchildren. At the first follow up, two months after the baseline assessment, it was shown that “students in the intervention group were more likely to have heard of HIV from peer educators, more likely to believe that it is possible for a healthy-looking person to have HIV, and to believe that AIDS cannot be cured.” Unfortunately, even though these initial results seemed to be positive, it was found that in the long run these beliefs were not necessarily maintained.   

Nine months after the baseline assessment, the results showed that “between baseline and second follow-up there was a significant change in the [intervention group] for having heard of HIV from peer educators.” A lack of further education on the risk factors of HIV transmission after the first follow-up could result in “the possibility of a reversal between the first and second follow-up.” This study demonstrates that without ongoing education, and only the continuation of abstinence only education, children won’t understand the severity of HIV transmission and future health risks. 

Ultimately, the use of abstinence only sex education programs in Sub-Saharan Africa does more to harm youth’s perspectives on HIV/AIDS than to encourage them to take preventative measures. These programs not only promote an unreasonable expectation of adolescents waiting to have sex until marriage, but they do not recognize the unique needs of a Sub-Saharan African society. The many shortcomings of abstinence only education programs can be overcome by implementing comprehensive sex education programs instead.

Comprehensive Sex Education Programs 

            Comprehensive sex education programs work to promote a more holistic learning experience by preparing youth for the future. Since HIV is not completely curable, it is important to be able to teach children, at a young age, just how serious the effects of HIV can be. By providing youth with a comprehensive sex education, they are able to learn about STIs, safe-sex practices, and the necessary skills used in making important and healthy sexual decisions. In general, most comprehensive sex education programs show to significantly improve many target areas: STI knowledge, STI treatment-seeking behavior, and condom use. 

A randomized study of 12 schools done in Edo State, Nigeria was conducted in order to show the implications of using a comprehensive sex education program in their curriculum. Five objectives were studied in order to evaluate the impact of the program on the school children: (1) knowledge of STI symptoms; (2) condom use; (3) treatment-seeking behavior among youths who experience symptoms of STI; (4) the proportion of youths who experienced symptoms of an STI in the 6 months prior to interview; and (5) notification of partner(s) by adolescents who had STIs. This program also implemented a reproductive health club in each of the schools, had members from that club trained as peer educators, and then had these peer educators provide counseling to others. It even went one step further and created community engagement by training health practitioners in the local area to better work with adolescent STI needs. 

Pre and post-intervention questionnaires were given out to assess changes in the five identified objectives measured. Results from these questionnaires showed there were significant increases in the knowledge of STIs, condom use, seeking treatment for an STI, and informing a partner of STI symptoms. One of the great achievements of the program was “the proportion of study subjects who reported [STI] symptoms [six months prior to the initial questionnaire] decreased from 33.1% to 22.0%.” The implementation of this comprehensive sex education program made significant impacts in this region of Nigeria and serves as a model for how other programs can make a difference. 

One of the benefits of a comprehensive sex education program is that not all programs must be structured the same way. Comprehensive sex education programs work best if they are arranged to meet the needs of that specific society. A different comprehensive sex education program was implemented in eleven secondary school in Mashonaland Central, Zimbabwe. This program included lectures, videos, and education and communication (IEC) materials in order to cover three main areas: male and female reproductive function, STIs, and sexuality; human sexuality and responsible sexual behavior; and unwanted/unplanned pregnancy and contraception. Similar to the previous study, a baseline test was administered as well as two follow-ups, five and nine months after baseline testing, which were scored on the correctness of responses. Significant improvements were seen after looking at the results from the study. From the baseline to the second follow-up, knowledge on STIs increased by 20% and the knowledge of symptoms associated with HIV infection increased by 20.7%. This study supports the idea that comprehensive sex education in schools “has an impact on knowledge and positive trends of knowledge on reproductive health, [STIs] and HIV/AIDS.” 

The results of this study also support the idea that comprehensive sex education programs can combat uneven development and aid marginalized people. In Mashonaland Central, Zimbabwe, 81.6% of households are living in poverty, with 41.2% of households living in extreme poverty. These percentages were higher than any other region in Zimbabwe in 2017. While comprehensive sex education programs cannot all together eliminate poverty, they can contribute. For example, if these programs were implemented across more schools in the region, significant change would be seen in knowledge about STIs and HIV in general. With increased knowledge, people could better protect themselves against infection and limit the money they may spend on medical treatments. Ultimately, this can lower the poverty prevalence in the area and create greater equality. 

Recently, many intergovernmental agencies decided to become involved with the matter of sex education. UNESCO recently introduced the Our Rights, Our Lives, Our Future (O³) Program. This program aims to implement comprehensive sex education 45,000 primary and secondary schools between 2018 and 2020 in Sub-Saharan Africa. The hope is that these education programs will decrease the amount of new HIV infections, reduce early and unintended pregnancy, decrease in gender-based violence rates, and decrease child marriage. These programs also support the 2030 Agenda for Sustainable Development, working to improve goals three, four, and five: good health and well-being; quality education; and gender equality. 

Efforts to establish comprehensive sex education programs in schools across Sub-Saharan Africa are growing at an increasing fast rate. From the aforementioned studies, it is clear that  these programs have a statistically significant effect on improving a number of different health crises. The changes in knowledge of HIV transmission as well as lower rates of HIV transmission were both significantly improved through comprehensive sex education programs when compared with abstinence only education programs. Comprehensive sex education programs also give adolescents a sense of identity: especially young women. These programs work to teach women at a young age that they are in control of their sexual choices and bodies. In a region where genital mutilation, sexual harassment, and HIV transmission are extremely high, teaching young women the value of their worth through these programs gives them a sense of self and confidence. 

Conclusion

            The implementation of comprehensive sex education programs in schools in Sub-Saharan Africa made considerable differences in the sexual behavior of adolescents. These education programs resulted in decreased HIV prevalence as well as increased HIV knowledge. Children are better off learning about the risk factors associated with sexual behaviors as opposed to only learning why they should not be engaging in premarital sex. 

The use of comprehensive sex education programs has additional benefits besides lowering the HIV transmission rate. These programs are able to promote equality between the genders, discuss ways to practice safe sex, and engage discussions about staying healthy and staying informed about sexual behaviors. Comprehensive sex education programs can also work to even development in impoverished areas and help marginalized people increase their economic and social status. Thus far, comprehensive sex education programs show positive outcomes and continue to improve quality of life for many in Sub-Saharan Africa. The use of comprehensive sex education to reduce or eliminate the significant health issues experienced by these residents should lead to further global development and serve as a model to other developing countries.