The vast majority of HIV cases occur in sub-Saharan Africa, where nearly 2 million people become infected with HIV/AIDS every year. One quarter of these new HIV infections are among people under 25, and almost all are due to unprotected sex. AIDS is incurable and no successful AIDS vaccine has been developed. Ensuring the adoption of safer sexual behavior among youth is critical to preventing the transmission of this disease. However, there is surprisingly little evidence concerning the relative effectiveness of different programs to reduce risky sexual behavior.
Kenya has the 10th largest HIV infected population in the world – nearly 7% of Kenyans are infected.[i] Children are seen as a “window of hope” in the fight against AIDS, because their sexual patterns are not firmly established. In an effort to prevent HIV infections in new generations, in the late 1990s UNICEF and the Kenya Institute of Education jointly developed an AIDS education curriculum, including student and teacher handbooks. However, by 2003, this curriculum had not been fully implemented, likely due to teacher inexperience and discomfort with talking about this sensitive material.
This evaluation tested two interventions to reduce risky sexual behavior: training teachers on the existing HIV curriculum, and reducing the costs of schooling by providing free uniforms. The 328 study schools were randomly assigned to one of four groups of about 82 schools. Each of the four groups of schools received a different set of programs:
In groups 1 and 3, three teachers were trained on HIV/AIDS and on how to teach the HIV curriculum. The curriculum covers facts about the disease, and encourages abstinence until marriage and faithfulness afterwards. It also teaches life skills, such as how to say “no” to unwanted or unsafe sexual relations.
In groups 2 and 3, children already enrolled in sixth grade classes were given a free uniform. Implementers also announced that students still enrolled in school the following year would be eligible for a second uniform, and distributed uniforms again the following year.
All in all, group 1 schools received the teacher training program only, group 2 schools received the uniforms program only, group 3 schools received both programs, group 4 received no program at all and thus served as a comparison group.
To evaluate the impact of the two programs on sexual behavior and sexual health, survey data was collected on youths’ sexual behavior. Such survey data can be subject to reporting biases, however. It was therefore important to complement this data with an objective measure of the incidence of unprotected sex, which is the main mode of HIV transmission in Kenya. Two such measures were considered: (1) childbearing rates and (2) STI infection rates. Childbearing rates were monitored regularly between 2003 and 2010. STI infection rates (specifically, Herpes and HIV infection rates) were measured during a long-term follow-up in 2009-2010.
Impact of Teacher Training only: Training teachers on how to implement the national HIV/AIDS curriculum greatly increased the likelihood that teachers teach about HIV in the classroom. Two years after the training students whose teachers had been trained had greater knowledge about the disease and also reported more tolerant attitudes toward those with AIDS. However, the intervention did not reduce childbearing rates among girls, suggesting that it did not decrease the likelihood that girls engage in unprotected sex. It also did not reduce the risk of STI as measured after 6-7 years.
Impact of Free Uniforms only: Free school uniforms led students to stay enrolled for significantly longer, and reduced the incidence of teen marriage and teen pregnancy. Girls who benefitted from free uniforms were not less likely to have an STI after 6-7 years, however, suggesting that some of the adolescent girls in the free uniforms program, while less likely to engage in committed relationships that lead to pregnancy and marriage, might have engaged in casual relationships.
Combined Impact: In schools that received both free uniforms and teacher training on the HIV/AIDS curriculum, the reduction in drop-outs and teenage pregnancy among girls was lower than that observed in schools that received free uniforms only. This suggests that the curriculum’s emphasis on abstinence until marriage may have persuaded some girls who would have delayed marriage thanks to the free uniforms to instead privilege committed relationships, where pregnancies are more likely. On the other hand, the two programs combined led to a significant reduction in the risk of STI. This suggests that among girls who chose to delay marriage in order to stay in school with the free uniform, the HIV curriculum convinced some to abstain altogether in order to avoid the STI risk associated with casual relationships.