HIV Prevention Education and HIV-Related Policies in Secondary Schools --- Selected Sites, United States, 2006

Persons who engage in sexual risk behaviors are at increased risk for human immunodeficiency virus (HIV) infection. School health education can help reduce the prevalence of sexual risk behaviors among students ( 1). In addition, school health policies can help protect the rights and health of HIV-infected students and staff members and reduce the likelihood of transmitting HIV infection to others ( 2). To determine the prevalence and extent of HIV prevention education and the prevalence of HIV infection policies among public secondary schools,* CDC analyzed data from the 2006 School Health Profiles for schools in 36 states and 13 large urban school districts. The results of that analysis indicated that, in 2006, the majority of secondary schools included HIV prevention in a required health education course (state median: 84.2%; district median: 57.2%); however, few secondary schools (state median: 21.1%; district median: 28.5%) taught all 11 topics listed in the questionnaire related to HIV prevention. Approximately half of schools (state median: 51.6%; district median: 48.3%) had a policy regarding students or staff members with HIV infection or acquired immunodeficiency syndrome (AIDS). To help reduce HIV-related risk behavior and protect the rights and health of HIV-infected students and staff members, schools should increase efforts to teach all HIV prevention topics and implement policies regarding students or staff members with HIV infection.

School Health Profiles surveys have been conducted biennially since 1994 to assess school health programs ( 3). States and large school districts participate in the surveys, selecting either all public secondary schools within their jurisdictions or systematic, equal-probability, representative samples of schools.^† At each school, the principal and lead health education teacher are sent questionnaires to be self-administered and returned to the state or local agency conducting the survey. Participation in School Health Profiles is confidential and voluntary. In 2006, lead health education teachers were asked questions regarding the content of required health education courses and staff development on health education topics. Principals were asked questions regarding policies on students or staff members with HIV infection or AIDS. Follow-up telephone calls and written reminders were used to encourage participation. Data from each questionnaire were cleaned and edited by CDC. Those surveys that used a representative sample of schools, had appropriate documentation, and achieved a response rate of 70% or higher were weighted to reflect the likelihood of schools being selected and to adjust for differing patterns of nonresponse. For the 2006 School Health Profiles survey, lead health education teachers were asked the following questions: 1) "During this school year, have teachers in this school tried to increase student knowledge on each of the following topics in a required health education course in any of grades 6 through 12?" Respondents were asked to indicate yes or no on a list of topics that included "HIV prevention." 2) "During this school year, did teachers in this school teach each of the following pregnancy, HIV, or sexually transmitted disease (STD) prevention topics in a required health education course for students in any of grades 6 through 12?" The following 11 topics were listed: abstinence as the most effective method to avoid pregnancy, HIV, and STDs; how to correctly use a condom; condom efficacy; risks associated with having multiple sexual partners; social or cultural influences on sexual behavior; how to prevent HIV infection; how HIV is transmitted; how HIV affects the human body; influence of alcohol and other drugs on HIV-related risk behaviors; how to find valid information or services related to HIV or HIV testing; and compassion for persons living with HIV or AIDS. 3) "During the past 2 years, did you receive staff development (such as workshops, conferences, continuing education, or any other kind of in-service) on each of the following health education topics?" Respondents were asked to indicate yes or no on a list of topics that included "HIV prevention." Principals were asked the following question: "Has this school adopted a policy on students and/or staff who have HIV infection or AIDS?"

In 2006, 34 states and 13 large urban school districts^§ met the criteria for both their principal and lead health education teacher surveys to be weighted and two states^¶ met the criteria for the principal survey only. Among states, the number of lead health education teachers who participated ranged from 68 to 659 (median: 250), and response rates ranged from 70% to 91% (median: 77%); among school districts, the number of lead health education teachers ranged from 32 to 212 (median: 56), and response rates ranged from 70% to 100% (median: 79%). Among states, the number of principals who participated ranged from 68 to 661 (median: 262), and response rates ranged from 70% to 91% (median: 78%); among school districts, the number of principals ranged from 31 to 234 (median: 55), and response rates ranged from 71% to 98% (median: 79%). Only 21 states and eight large urban school districts that obtained weighted data in both 1996 and 2006 were included in comparisons of data for those 2 years. The Wilcoxon rank-sum test, a nonparametric analogue to a two-sample t-test, was used to test for differences across states and school districts. Differences were considered statistically significant at p<0.05.

The percentage of secondary schools that taught HIV prevention in a required health education course ranged from 35.6% to 99.3% (median: 84.2%) among states, and from 0.0% to 100.0% (median: 57.2%) among school districts (Table 1). The percentage of schools that taught all 11 HIV prevention topics ranged from 1.0% to 53.1% (median: 21.1%) among states and from 0.0% to 66.5% (median: 28.5%) among school districts. The percentage of secondary schools that taught how to correctly use a condom ranged from 1.0% to 59.1% (median: 24.3%) among states and from 0.0% to 74.8% (median: 33.7%) among school districts. The percentage that taught about condom efficacy ranged from 11.7% to 90.0% (median: 56.0%) among states and from 0.0% to 91.1% (median: 56.0%) among school districts. For the other nine HIV prevention topics the median percentage of secondary schools that taught each in a required health education course ranged from 64.1% (how to find valid information or services related to HIV or HIV testing) to 78.7% (how HIV is transmitted) among states and from 50.0% (social or cultural influences on sexual behavior) to 57.2% (six different topics) among school districts.

The percentage of secondary schools in which the lead health education teacher received staff development on HIV prevention during the 2 years preceding the survey ranged from 21.3% to 63.9% (median: 43.7%) among states and from 42.9% to 100.0% (median: 65.6%) among school districts (Table 1). The percentage of secondary schools with a policy regarding students or staff members with HIV infection or AIDS ranged from 27.0% to 89.5% (median: 51.6%) among states and from 28.1% to 100.0% (median: 48.3%) among school districts (Table 2). The median percentage of schools with such a policy decreased from 71.9% in 1996 to 52.9% in 2006 among states and from 86.2% to 49.2% among school districts, when analysis was limited to comparing results from the same 21 states and eight school districts in each year.

Reported by: A Balaji, PhD, N Brener, PhD, L Kann, PhD, L Romero, DrPH, H Wechsler, EdD, Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

The findings in this report indicate that, in 2006, the majority of secondary schools in 34 states and 13 school districts provided some education on HIV prevention topics in required health education courses. However, more than half the states that conducted surveys reported that less than one fourth of their schools taught all 11 HIV prevention topics listed in the questionnaire; more than half the school districts that conducted surveys reported that less than one third of their schools taught all 11 topics. Health education can increase knowledge and skills regarding how to avoid HIV infection ( 4). This analysis also indicated that a median of less than 50% of lead health education teachers among states and a median of approximately two thirds among school districts had received staff development on HIV prevention. Staff development on health topics is critical for effective teaching ( 5).

The finding that in approximately half of the states and school districts conducting surveys, less than 50% of secondary schools had a policy on students or staff members with HIV infection or AIDS is consistent with previously reported national data ( 6). In addition, the median percentage of schools with such a policy has decreased since 1996. Reasons for these decreases warrant further investigation. Policies for addressing HIV infection in the school setting can provide guidance, support, and protection to those who are infected and to other students and staff members, families, and community members. These groups, along with public health and legal professionals, should work together to develop and implement HIV-related policies and continually assess them, based on new legislation, scientific data, and real-world experience ( 2).

The findings in this report are subject to at least three limitations. First, these data apply only to public secondary schools and, therefore, do not reflect practices at private schools or elementary schools. Second, these data were self-reported by principals and lead health education teachers and were not verified by other sources. Finally, these data were collected during spring and fall 2006 and do not reflect any state, district, or school policies enacted, modified, or discontinued since then.

Despite limitations, School Health Profiles remains an important tool for states and school districts to monitor the current status of HIV prevention education and HIV-related policies. These data can be used by public health and education agencies to assist schools in improving their HIV prevention curricula and HIV-related policies.

Acknowledgments

The findings in this report are based on data collected by state and local School Health Profiles coordinators.

References

1. Kirby D, Laris BA, Rolleri L. Sex and HIV education programs for youth: their impact and important characteristics. Scotts Valley, CA: ETR Associates; 2006. Available at http://www.etr.org/recapp/programs/SexHIVedProgs.pdf.
2. National Association of State Boards of Education. Someone at school has AIDS: a complete guide to education policies concerning HIV infection, 2001. Alexandria, VA: National Association of State Boards of Education. Available at http://www.nasbe.org/index.php/component/content/article/78-model-policies/120-policies-concerning-students-and-staff-with-hiv-infection.
3. Balaji AB, Brener ND, McManus T, Hawkins J, Kann L, Speicher N. School Health Profiles: characteristics of health programs among secondary schools 2006. Atlanta, GA: US Department of Health and Human Services, CDC; 2008. http://www.cdc.gov/healthyyouth/profiles/pdf/profiles_2006.pdf.
4. Johnson BT, Carey MP, Marsh KL, Levin KD, Scott-Sheldon LA. Interventions to reduce sexual risk for the human immunodeficiency virus in adolescents, 1985--2000: a research synthesis. Arch Pediatr Adolesc Med 2003;157:381--8.
5. Jones SE, Brener ND, McManus T. The relationship between staff development and health instruction in schools in the United States. Am J Health Educ 2004;35:2--10.
6. Brener ND, Wheeler L, Wolfe LC, Vernon-Smiley M, Caldart-Olson L. Health services: results from the School Health Policies and Programs Study 2006. J Sch Health 2007;77:464--85.

* Middle, junior high, and senior high schools with one or more of grades 6--12.

^† In the 2006 survey, statewide samples were representative of all public secondary schools in the state with two exceptions: no schools from the New York City Department of Education were included in the New York state sample, and no schools from the Chicago Public Schools were included in the Illinois sample.

^§ States: Alabama, Alaska, Arizona, Arkansas, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maine, Massachusetts, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New York, North Carolina, North Dakota, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, and West Virginia. School districts: Charlotte-Mecklenburg County, North Carolina; Chicago, Illinois; Dallas, Texas; District of Columbia; Hillsborough County, Florida; Los Angeles, California; Memphis, Tennessee; Miami-Dade County, Florida; Orange County, Florida; Palm Beach County, Florida; Philadelphia, Pennsylvania; San Diego, California; and San Francisco, California.

^¶ Illinois and Washington.

Table 1


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Table 2

Trends in HIV- and STD-Related Risk Behaviors Among High School Students --- United States, 1991--2007

Persons who engage in unprotected sexual intercourse or use injection drugs are at increased risk for human immunodeficiency virus (HIV) infection and sexually transmitted diseases (STDs). Changes in HIV- and STD-related risk behaviors among high school students in the United States during 1991--2005 were reported previously ( 1). To update these analyses through 2007, CDC analyzed data from nine biennial national Youth Risk Behavior Surveys (YRBS). This report summarizes the results of that analysis, which indicated that, during 1991--2007, the percentage of U.S. high school students who ever had sexual intercourse decreased 12%, the percentage who had sexual intercourse with four or more persons during their lifetime decreased 20%, and the percentage who were currently sexually active decreased 7%. Among students who were currently sexually active, the prevalence of condom use increased 33%. However, these changes in risk behaviors were not observed in some subgroups. In addition, no changes were detected in the prevalence of sexual risk behaviors from 2005 to 2007, and many students still engaged in behaviors that place them at risk for HIV infection and STDs. Additional efforts to reduce sexual risk behaviors, particularly among black, Hispanic, and male students, must be implemented to meet the Healthy People 2010 national health objective for adolescent sexual behaviors (objective no. 25-11) ( 2) and to decrease rates of HIV infection and STDs.

The biennial national YRBS, a component of CDC's Youth Risk Behavior Surveillance System, used independent, three-stage cluster samples for the 1991--2007 surveys to obtain cross-sectional data representative of public and private school students in grades 9--12 in all 50 states and the District of Columbia ( 3). Sample sizes ranged from 10,904 to 16,296. School response rates ranged from 70% to 81%, and student response rates ranged from 83% to 90%; therefore, overall response rates for the surveys ranged from 60% to 70%.

For each cross-sectional national survey, students completed anonymous, self-administered questionnaires that included identically worded questions about sexual intercourse, number of sex partners, condom use, and injection-drug use.* Sexual experience was defined as ever having had sexual intercourse. Multiple sex partners was defined as having four or more sex partners during one's lifetime. Current sexual activity was defined as having sexual intercourse during the 3 months before the survey. Condom use was defined as use of a condom during last sexual intercourse among currently sexually active students. Injection-drug use was defined as ever having used a needle to inject any illegal drug into one's body. Race/ethnicity data are presented only for non-Hispanic black, non-Hispanic white, and Hispanic students (who might be of any race); the numbers of students from other racial/ethnic groups were too small for meaningful analysis.

Data were weighted to provide national estimates ( 3), and the statistical software used for all data analyses accounted for the complex sample design. Temporal changes were analyzed using logistic regression analyses, which controlled for sex, race/ethnicity, and grade and simultaneously assessed significant (p<0.05) linear and quadratic time effects.^† T-test analyses were used to test for significant (p<0.05) differences between results from 2005 and 2007.

During 1991--2007, the prevalence of sexual experience decreased 12% overall, from 54.1% to 47.8%. Logistic regression analyses indicated a significant linear decrease overall and among female, male, 9th-grade, 10th-grade, 11th-grade, 12th-grade, black, and white students (Table). Among Hispanic students, no significant change was detected. Among male students, 11th-grade students, and black students, a significant quadratic trend also was detected. Among male students and 11th-grade students, the prevalence of sexual experience declined during 1991--1997 and then leveled off during 1997--2007. Among black students, the prevalence of sexual experience declined during 1991--2001 and then leveled off during 2001--2007. From 2005 to 2007, no significant change was detected in the prevalence of sexual experience overall or among any sex, grade, or racial/ethnic subgroup of students.

During 1991--2007, the prevalence of multiple sex partners decreased 20%, from 18.7% to 14.9%. A significant linear decrease was detected overall and among female, male, 9th-grade, 10th-grade, 11th-grade, 12th-grade, black, and white students (Table). Among Hispanic students, no significant change was detected. A significant quadratic trend also was detected among male students, 11th-grade students, and 12th-grade students. For each group, the prevalence of multiple sex partners declined during 1991--1997 and then leveled off during 1997--2007. From 2005 to 2007, no significant change was detected in the prevalence of multiple sex partners overall or among any sex, grade, or racial/ethnic subgroup of students. During 1991--2007, the prevalence of current sexual activity decreased 7%, from 37.5% to 35.0%. A significant linear decrease was detected overall and among 9th-grade students and black students (Table). Among 9th-grade and 11th-grade students, a significant quadratic trend was detected. For 9th-grade students, the prevalence of current sexual activity remained stable during 1991--1999 and then declined during 1999--2007. For 11th-grade students, the prevalence of current sexual activity declined during 1991--1999 and then remained stable during 1999--2007. From 2005 to 2007, no significant change was detected in the prevalence of current sexual activity overall or among any sex, grade, or racial/ethnic subgroup of students.

During 1991--2007, among students who were currently sexually active, the prevalence of condom use increased 33%, from 46.2% to 61.5%. A significant linear increase in condom use was detected among currently sexually active students overall and among all sex, grade, and racial/ethnic subgroups of students who were currently sexually active. A significant quadratic trend also was detected among currently sexually active students overall and among female students, 10th-grade students, and black students who were currently sexually active. Among currently sexually active students overall, female students, and 10th-grade students, the prevalence of condom use increased during 1991--2003 and then leveled off during 2003--2007. The prevalence of condom use among currently sexually active black students increased during 1991--1999 and then leveled off during 1999--2007. From 2005 to 2007, no significant change was detected in the prevalence of condom use overall or among any sex, grade, or racial/ethnic subgroup of currently sexually active students.

During 1995--2007, the prevalence of injection-drug use remained below 4%. However, a significant linear increase in injection-drug use was detected among black and Hispanic students. From 2005 to 2007, no change was detected in the prevalence of injection-drug use overall or among any subgroup, except for 10th-grade students, whose prevalence decreased from 2.3% to 1.4%.

Reported by: A Balaji, PhD, R Lowry, MD, N Brener, PhD, L Kann, PhD, L Romero, DrPH, H Wechsler, EdD, Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

A Healthy People 2010 national health objective (no. 25-11) is to increase to 95% the proportion of adolescents in grades 9--12 who abstain from sexual intercourse or use condoms if currently sexually active ( 2). CDC reported previously that, in 2007, 87% of high school students reported abstaining from sexual intercourse or using condoms if currently sexually active ( 4), compared with 80% in 1991. Despite this progress, the analyses in this report indicate that no changes were detected in the prevalence of sexual risk behaviors from 2005 to 2007, and some subgroups did not experience the overall changes observed during 1991--2007. For example, among black students, the prevalence of sexual experience, multiple sex partners, and current sexual activity remained higher than among any other subgroup of high school students, the prevalence of sexual experience did not decrease during 2001--2007, and the prevalence of condom use did not increase during 1999--2007. Among Hispanic students, the prevalence of sexual experience, multiple sex partners, and current sexual activity did not change during 1991--2007. Among male students, the prevalence of sexual experience and multiple sex partners did not decrease after 1997, and current sexual activity did not change during 1991--2007. Therefore, renewed efforts to delay onset of sexual activity and increase condom use among students who are sexually active are warranted, especially among black, Hispanic, and male students.

The findings in this report are subject to at least two limitations. First, these data apply only to youths who attend school and therefore are not representative of all persons in this age group. In 2005, of persons aged 16--17 years in the United States, approximately 3% were not enrolled in a high school program and had not completed high school ( 5). Second, the extent of underreporting or overreporting of behaviors cannot be determined, although the survey questions demonstrated good test-retest reliability ( 6).

The lack of recent change in the prevalence of HIV- and STD-related risk behaviors among high school students might have contributed to recent increases in related health outcomes. For example, during 2003--2006, in the 33 states with confidential, name-based HIV infection reporting, the estimated annual number of HIV/acquired immunodeficiency syndrome cases diagnosed among adolescents aged 15--19 increased 34%, from 993 in 2003 to 1,332 in 2006 ( 7). Similarly, after decreasing annually since 1999, gonorrhea infection rates among adolescents aged 15--19 years increased 2% from 2004 to 2005, from 421.9 to 431.8 per 100,000, and then increased 6% from 2005 to 2006, from 431.8 to 458.8 per 100,000 ( 8). Also, birth rates among adolescents aged 15--19 years decreased annually during 1991--2005 and then increased for the first time during 2005--2006, from 40.5 live births per 1,000 females in 2005 to 41.9 in 2006 ( 9). Programs and activities aimed at addressing these health outcomes should involve parents and families, schools, youth-serving organizations, health-care providers, the media, government agencies, and youths themselves.

References

1. CDC. Trends in HIV-related risk behaviors among high school students---United States, 1991--2005. MMWR 2006;55:851--4.
2. US Department of Health and Human Services. Sexually transmitted diseases; 25-11: increase the proportion of adolescents who abstain from sexual intercourse or use condoms if currently sexually active. In: Healthy people 2010: understanding and improving health. 2nd ed. Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.healthypeople.gov/document/html/volume2/25stds.htm#_toc489706328.
3. CDC. Methodology of the Youth Risk Behavior Surveillance System. MMWR 2004;53(No. RR-12).
4. CDC. Youth risk behavior surveillance---United States, 2007. MMWR 2008;57(No. SS-4):130.
5. Laird J, DeBell M, Kienzl G, Chapman C. Dropout rates in the United States: 2005. Washington, DC: US Department of Education, National Center for Education Statistics; 2007. Available at http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2007059.
6. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolesc Health 2002;31:336--42.
7. CDC. Cases of HIV infection and AIDS in the United States and dependent areas, 2006. HIV/AIDS surveillance report, volume 18. Atlanta, GA: US Department of Health and Human Services, CDC; 2008:11. Available at http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2006report.
8. CDC. Sexually transmitted disease surveillance, 2006. Atlanta, GA: US Department of Health and Human Services, CDC; 2007. Available at http://www.cdc.gov/std/stats/toc2006.htm.
9. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2006. Natl Vital Stat Rep 2007;56(7). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_07.pdf.

Table

QuickStats: Age-Adjusted Death* Rates for Human Immunodeficiency Virus (HIV) Disease, by Race and Sex --- United States, 1987--2006^†

* Per 100,000 U.S. standard population.

^† Data for 2006 are preliminary.

^§ In 1987, a new category for HIV infection was added to the International Classification of Diseases, Ninth Revision (ICD-9). In 1999, ICD-10 took effect, resulting in additional deaths classified into the HIV/acquired immunodeficiency syndrome category; therefore, death rates for 1987--1998 are not comparable with those computed after 1998.

The age-adjusted death rate for HIV disease declined by 6.7% for black males and 5.6% for white males from 2005 to 2006. The rate did not change for black females, but the low rate for white females further declined by 12.5% to 0.7 per 100,000 in 2006. After a period of steady increase from 1987 to 1995, HIV disease mortality peaked for white males in 1994, for white females in 1995, and for black males and females in 1995. Subsequently, the death rate for HIV disease decreased an average of 30.5% per year for the white population and 26.3% for the black population through 1998, with smaller decreases noted through 2006.

SOURCE: Heron MP, Hoyert DL, Xu JQ, Scott C, Tejada-Vera B. Deaths: preliminary data for 2006. Natl Vital Stat Rep 2008;56(16). Available at http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_16.pdf and http://www.cdc.gov/nchs/data/statab/hist001r.pdf.

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Date last reviewed: 7/30/2008