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Twenty-five
years into the AIDS epidemic, teens have become silent victims of sexually
transmitted diseases (STDs) and HIV. Uninformed, misinformed, and not
knowing whom to talk to, they stumble through adolescence, with consequences
that can last a lifetime.
The statistics paint a grim picture. Though
young people ages 15 to 24 constitute only a quarter of the sexually active
U.S. population, they account for nearly half of all new STD cases, as
well as half of new HIV infections. By age 25, one of two sexually active
youths will acquire an STD. The lifetime medical costs of STDs acquired
by American youth ages 15 to 24 in the year 2000 was at least $6.5 billion.
REVERSING
THE DIRECTION
African
American female adolescents are especially vulnerable to HIV and STDs,
thus making tailored interventions a public health priority. The challenge
is to get teens to recognize that they are at risk.
"I want to make sure that our young
women are empowered to know the effects of HIV and that it's preventable,"
says Tiffaney Renfro, a lead health educator for AFIYA, an HIV prevention
program for adolescent African American females run through the Rollins
School of Public Health (RSPH).
"AFIYA is about enabling young women
to emerge into strength and good health, to feel pride as black women,
and to identify role models. We talk about their future plans and get
them to explore ways to make better decisions regarding their sexual health.
It's all about choices," Renfro adds.
"I learned a lot," says Gimel Rogers,
a Spelman College sophomore who went through Horizons, a program similar
to AFIYA, when she was 17. As for sex, she learned "to be safe through
abstinence and through sex, to be safe with it. Now, when they show commercials
on TV about HPV [human papillomavirus], I talk to my friends and educate
them about it."
Thanks to Horizons, Rogers began to set
goals to empower herself and chart a positive course for her life. That
skill led her to apply to Spelman, the first step toward earning a doctorate
in child psychology. She still has her list of goals from when she went
through the program. "It holds even more value now," Rogers
says.
Girls ages 14 to 20 in the AFIYA treatment
group are involved in similar activities. They participate in a face-to-face
intervention, followed by one-on-one telephone counseling nine times in
18 months and access to a website where they can learn various coping
skills: how to talk to their partner about STDs, how to use a condom,
resources for HIV testing, approved websites tailored for teens, and current
events and outings that help promote safer sex options.
The two researchers who designed the AFIYA
intervention and its predecessor programs are Ralph DiClemente and Gina
Wingood. They met in San Francisco at the Bayview-Hunter Point Foundation
Multicultural Research Institute in the early 1990s, and with a common
interest in HIV prevention, have been working together ever since.
"In AFIYA, with both the face-to-face
intervention and one-on-one phone counseling, we're seeing 50% reductions
in STDs," says DiClemente. "If you could expand that, you would
reduce the number of STDs by more than 6 million nationally."
DiClemente has come a long way since his
1986 article in the American Journal of Public Health alerted
AIDS researchers to the risk of HIV for adolescents. He is the Charles
Howard Candler Professor of Public Health in the Department of Behavioral
Sciences and Health Education, where Wingood is associate professor and
recipient of the Agnes Moore Research in AIDS Endowment. Additionally,
Wingood is director and DiClemente is associate director of prevention
science in the Social and Behavioral Sciences Core of the Emory Center
for AIDS Research.
EARLIER
SUCCESS
In
San Francisco, the two conducted a study called SISTA (Sisters Informing
Sisters about Topics on AIDS), designed to address the growing number
of African American females at risk for HIV and STDs. The study applied
social cognitive theory and the theory of gender and power to a culturally
tailored, gender-tailored intervention for African American women ages
18 to 29. A 1995 article in the Journal of the American Medical Association
(JAMA) reported that after the SISTA intervention, women used condoms
more consistently, displayed stronger interpersonal skills, and exhibited
better cognitive coping skills. Adopted and disseminated by the CDC, SISTA
is requested by more people than any other CDC program, DiClemente says.
Wingood adds that over 700 U.S. community agency educators have been trained
to implement SISTA, at least one in every state.
In the early 1990s at the University of
Alabama's Center for AIDS Research in Birmingham, DiClemente and Wingood
built upon the SISTA program with an intervention called SiHLE, a Zulu
word that means beauty and stands for Sistas Informing, Healing, Living,
and Empowering. This program aimed to reduce sexual risk for African American
females ages 14 to 18.
The four-hour SiHLE sessions were held on
four consecutive Saturdays and involved African American females as health
educators and as peer educators. The theme, "Stay Safe for Yourself,
Your Family, and Your Community," helped the young women who received
the intervention learn to value themselves and realize their value to
both family and community. SiHLE focused on teaching them to communicate
with their often older male partners, since successful sexual risk avoidance
requires that the female negotiate with the male to use condoms or to
practice abstinence. Peer educators modeled desired behaviors, and participants
role-played to enhance adoption of the behaviors.
Close bonds are struck among SiHLE participants.
"We hope this forms a peer social network of like-minded women who
are supportive of safer sex activities," Wingood says. When moms
see the program's benefits, they often ask if their younger daughters
can participate. "They want their daughters' lives to be better than
theirs," DiClemente says.
A July 2004 issue of JAMA reported
that during and at the end of the 12-month SiHLE study, participants were
more likely to report using a condom consistently, and they reported fewer
chlamydia infections and fewer pregnancies. SiHLE is the first HIV/STD
intervention to reduce risk behaviors and increase HIV preventive behaviors
and also decrease STDs and unintended pregnancy. These results were confirmed
again at an 18-month follow-up.
"SiHLE received the highest rating
of any HIV prevention intervention for adolescents in this country ever,"
DiClemente says, referring to independent panel ratings at CDC and the
research firm Sociometrics. Wingood says that SISTA, SiHLE, and WILLOW,
a program for HIV-positive women, will be disseminated nationally to community-based
organizations and health departments as a triad through the CDC's Diffusion
of Effective Behavioral Interventions project. The team's current programs
are designed to be included with these in a larger suite of sexual risk-reduction
programs. Using common theories, the programs focus on enhancing gender
and ethnic pride, self-worth, and altruism, imparting knowledge and skills,
and changing attitudes, perceptions, and values.
In the June 2006 American Journal of
Public Health, Wingood reported that the SiHLE intervention was as
effective for girls who reported a history of gender-based violence as
for those who did not. SiHLE was also successful for girls who reported
depression, a finding that DiClemente presented at the 2006 International
AIDS Conference in August. "The SiHLE program is robust, more so
than we would have imagined. We can't work fast enough to disseminate
it," he says.
TEENS,
WOMEN, AND COUPLES
DiClemente
and Wingood have a number of other intervention studies under way, designed
for teens, women, and couples. T3, Tracking Teen Trends: Adolescents,
Sex, and the Web, looks at adolescents' exposure to the Internet. Every
year, about 60% of 15- to 17-year-olds wind up at a sexually explicit
website. This national study hopes to determine the impact of these sites
on the beliefs, values, attitudes, and behavior of this group of teens.
Results should be available by spring of 2007.
STYLE, an STD/HIV prevention program for
young people who have an emotional disorder, tests whether involving parents
is more effective than just kids. "We train parents and adolescents
to raise sensitive issues and problem-solve without becoming frustrated
and angry," DiClemente says.
For many community agencies, an interactive
DVD is a more cost-effective choice than face-to-face programs. Wingood's
program, SAHARA (Sistas Accessing HIV/AIDS Resources At a click), uses
a DVD to reach more women with the hope of reducing their risk behaviors
while using fewer resources.
She also spearheads an HIV prevention program
for female Kaiser HMO patients, ages 18 to 29, called STARS. "It's
a myth to think that if you're working and you have a college education
you're not at risk for HIV," Wingood says. After an eight-hour HIV
education session, participants may be randomized to receive a booster
session at six and again at nine months. The question Wingood seeks to
answer is, do women have safer sex, get HIV tested, and have fewer sexually
transmitted infections if they have boosters than if they do not?
A multisite study called EBAN addresses
the risks African American couples face when one partner is HIV-positive
and the other is not. For some serodiscordant couples, using a condom
erodes trust; some aren't afraid to get HIV. The importance of this study
becomes clear when Wingood points out that a positive partner could acquire
a different strain of HIV and make their health much worse.
AROUND
THE WORLD
Wingood
also adapted SISTA for Xhosa women in rural Cape Town, South Africa. "There
are very few interventions for women in sub-Saharan South Africa, who
are at great, great risk of HIV. We have a program in Durban as well,
for adolescents ages 16 to 21," she says. UNAIDS statistics support
the need: sub-Saharan Africa carries the largest burden of the AIDS epidemic.
Here, on average, three young women ages 15 to 24 are HIV-infected for
every one young man. In the same age group, high levels of HIV infection
found in a 2003 national survey remained high two years later.
The Caribbean is the second-most HIV-affected
world region. SiHLE was adapted for young women ages 14 to 18 on St. Maarten,
a multicultural island, where the program's name was changed to Girl Power.
The island's governor decided to adopt the program in schools and to request
a program for boys. "That's the power of taking research and putting
it into action," DiClemente says.
WHAT'S
NEXT
The
Structural HIV Prevention Intervention looks at the power of media in
the lives of African American teens ages 14 to 18. "Many people think
that media is harmful to adolescents. We think that we can use media to
promote health among them," DiClemente says. Four cities are paired
according to like demographics, and one in each pair will receive media
messages in addition to an intervention like SiHLE. Messages will be divided
half and half on radio and TV, including prime time shows like American
Idol and Girlfriends. "What do adolescents love more than TV and
radio? If we can reach them this way, we'll reach thousands upon thousands
of adolescents," DiClemente says.
Wingood and DiClemente plan an interactive
computer delivery intervention, a national survey of African American
and white women that will uncover risk factors, and more work with social
groups. "Faith-based organizations are one of the largest social
organizations in Georgia. Working with churches is our next direction
and goal," Wingood says.
This team's recipe for success: determine what makes women and teens vulnerable
to STDs and HIV, and then inspire motivation and teach healthy behaviors.
When the intervention works, get it out into the community, and follow
up by tailoring effective programs to other vulnerable populations.
"The challenge is always to increase
awareness among adults, including politicians and policymakers, that young
people are engaging in risk behaviors and we can't deny them the knowledge,
tools, and skills they need to minimize their risk," DiClemente says.
The possibilities for turning lives around
seem endless. As long as the need exists, DiClemente, Wingood, and their
staff will continue to stir up the Girl Power and spread it around.
Susan
Hodges is a freelance writer in Atlanta.
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