AIDS and Auntie Stella

HIV and sex education programmes in Zimbabwe

The statistics of the AIDS epidemic can be almost overwhelming, sometimes perhaps even obscuring the fact that each case is a personal tragedy. In Zimbabwe and Botswana, one person in four is HIV positive. In areas of Zimbabwe infection rates are as high as 70 per cent. Life expectancy in Zimbabwe has dropped from 61 to 49 years in the past decade, and some 900 000 children under the age of 15 have been orphaned as a result of AIDS.

In the absence of affordable or effective treatment for HIV, a collaborative group of researchers from the University of Zimbabwe, University College London, and the London School of Hygiene and Tropical Medicine are attempting to put an educational ‘firebreak’ around the virus. "We have to find some way of preventing 30 per cent of 20-year-old women being positive for HIV," says Professor Richard Hayes of the London School.

There are two strands to the Trust-funded work of this collaborative group, which is being coordinated in Zimbabwe by Frances Cowan of UCL. One is aimed at testing the effectiveness of targeting HIV prevention strategies at sex workers, for example by maximising condom use and minimising the prevalence of sexually transmitted diseases. However, due to the current political unrest in Zimbabwe, this study has temporarily been put on hold.

The second strand focuses on community-randomised trials in rural schools, to test the effectiveness of sex education programmes in reducing the incidence of HIV infection among young people. For the past ten years Professor Hayes and colleagues have been using similar methods to evaluate preventive measures against HIV in Mwanza, Tanzania, where the HIV epidemic is severe but has not yet risen to the levels seen in Zimbabwe. The Tanzanian research showed that improving STD treatment at primary health units reduced the incidence of HIV almost by half.

In Zimbabwe, Professor Hayes, Dr Cowan and colleagues are running a feasibility study, funded by the Trust, assessing three approaches to sex education: the Zimbabwean Ministry of Education’s AIDS Action Programme, a four-year teacher-led AIDS prevention programme; ‘Auntie Stella’, a one-year teacher-administered programme concentrating on small group discussion; and a programme designed by Angela Obasi and the MEMA kwa Vijana project team in Mwanza. This latter programme is being tested in primary schools in a community-randomised trial in Tanzania funded by the European Commission. In Zimbabwe, the three programmes are currently being piloted in four rural schools as a prelude to a much larger trial. Feedback from teachers and pupils will be used to shape the full study.

The AIDS Action Programme is delivered over four years and only moves specifically towards AIDS prevention in years 3 and 4. This may be a drawback, as up to 40 per cent of children drop out of rural schools between Form 1 and Form 4. Moreover, points out Dr Cowan, the programme was originally designed as an HIV prevention programme rather than a reproductive health programme, and doesn’t explicitly discuss sexual intercourse, contraception or menstruation: "It is possible to undertake the entire programme and not know how one gets pregnant!"

In the MEMA kwa Vijana programme, by contrast, there is explicit discussion of reproductive biology. It is a highly structured three-year health programme based on sound educational principles. Six pupils within each class are trained to act in a series of dramas, which are used to stimulate discussion and help frame pupils’ attitudes. Using role play in this way to build skills is a key part of the programme. The programme is concentrated on the first year, during which all the material is delivered, and revisited in the following two years. The materials have been adapted for use in Zimbabwean schools and are currently being tested in the pilot.

‘Auntie Stella’ is a one-year programme based on a problem-page format that involves pupils working on their own in small groups. Information and advice comes from ‘Auntie Stella’ rather than the teacher. The programme was devised in Zimbabwe and is highly regarded by both teachers and students.

One aim of the pilot study has been to test the possibility that intervention might prove counterproductive. Critics of sex education argue that it encourages children to experiment with sex sooner than they might. The age at which to intervene is also a key concern. Intervention at age 13 to 14 is something of a compromise. Ideally it might be done sooner, before patterns of sexual behaviour are established, but this raises issues of acceptability. Many Zimbabweans feel that the only way forward is to return to ‘traditional values’, which means advocating abstinence and not promoting contraception. These arguments are ones often heard in the UK too. "It is precisely in this situation, where there is genuine disagreement about benefits and risks, that well-designed trials are urgently needed to obtain reliable evidence that can be used by policy makers," notes Professor Hayes.

A further objective of the project is to work towards making health services more ‘youth friendly’ and less dismissive of the concerns of young people. It 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 people and they ought to behave themselves! This again is an issue facing many countries, not just in Africa.

There is an awareness of the need for change, says Dr Cowan, but nurses are already overworked and do not have time to spend counselling people at length. "What they could realistically focus on is improving confidentiality, privacy and reducing judgmental attitudes. These changes would benefit everyone, not just youth." Moreover, HIV is transmitted more readily in people with sexually transmitted diseases. This makes it vital that young people feel confident about turning up at a clinic for treatment.

With scientists at the Central Public Health Laboratory, Colindale, the team is also aiming to develop a urinary assay to detect antibodies to herpes simplex virus type 2 (HSV-2). In the 1990s, Dr Cowan discovered that, in the UK, HSV-2 antibody was strongly linked to lifetime sexual behaviour, a finding later confirmed by Professor Hayes and colleagues in Tanzania. HSV-2 is almost always sexually transmitted and high levels of HSV-2 antibody in groups of adolescents are strongly suggestive of potentially risky sexual activity. Given the difficulty in obtaining reliable information about sexual behaviour through questionnaires, such an assay would be particularly useful as a surrogate measure of adolescent behaviour, and one that could be used to measure response to an intervention.

As well as the social factors to take into account, there are also practical problems with carrying out a study like this in Zimbabwe. Due to the political unrest, it is currently difficult to work in rural communities without causing suspicion, and work in schools has had to be cut back until after the election. "We are all hoping that calm will return and we can continue as before," says Dr Cowan. "This is what we are assuming will happen and hope not to be proved wrong."

However, she is also keen to stress the overwhelmingly positive reaction to the study: "We have had fantastic support locally, both officially through the Ministries of Health and Education, and on the ground. Headmasters and teachers, almost without exception, have been very interested and committed to the programme." The response of the Zimbabwean populace has also been encouraging. "Adults in the community recognise what a huge problem HIV is - no family has been untouched. Communities wanted something done straight away. In fact, the constant cry was ‘why have you waited so long to do this?’ rather than ‘what are you doing this for?’."

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. "Our main focus throughout has been on prevention," says Professor Hayes, "and that should remain a very high priority."

Acknowledgements: The Auntie Stella programme referred to in the title and within the text of the article was devised by Barbara Kaim (Training and Research Support Centre in Zimbabwe) and her colleagues.

AIDS and Auntie Stella

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