AIDS Experts Fear Education Programs Are Insufficient

As a result of new evidence from behavior studies of teen-agers in San Francisco and gay men in Massachusetts, AIDS experts now fear that educational programs to prevent the spread of the deadly disease may be falling far short of their goal.

In fact, one Harvard Medical School expert warns bluntly, in a special AIDS issue of a major medical journal published today, that “education will not control the AIDS epidemic.”

The new concern about the possible inability of educational campaigns to fulfill public and official expectations was illustrated by two new studies.

In the San Francisco survey, resulting in what was termed “disquieting” news, researchers found that though teen-agers intellectually understood the dangers of getting acquired immune deficiency syndrome through sex, only a fraction of them acted on the information and adopted safe-sex practices--most notably condom use.

Progress Ebbs After 6 Months

The researchers in Massachusetts reported that although safe-sex programs in a group of affluent, college-educated gay men produced dramatic decreases in such high-risk behaviors as anal sex, the period of progress lasted only about six months and was far from uniformly or universally effective.

The finding led the Massachusetts experts to conclude that, while AIDS education programs in a well-motivated, wealthy group were generally successful, results showing that large numbers of that group continued to engage in high-risk sex raised troublesome questions.

The two conclusions coincide with the increasing concern among AIDS experts over the design and success of a plethora of education programs, widely touted as the most useful short-term tactic in the struggle to control spread of the disease.

It is not that many AIDS-education programs don’t work or shouldn’t be attempted, said Dr. Allan Brandt, an associate professor of the history of medicine and science at Harvard Medical School, but the near panic over AIDS may be prompting Americans to expect too much of such efforts.

In a historical review essay on lessons relevant to the AIDS fight in the history of sexually transmitted diseases, it was Brandt who warned that there was ample reason to believe that education had failed.

Difficult, Complex Changes

“I think that some of the calls for education have been naive (although) I’m hopeful that education could have a major impact on the epidemic,” Brandt said, “but it is clear just how difficult and complex changes in behavior are.

“The traditional liberal approach to an epidemic, i.e. education, has severe limits. The traditional reactionary or conservative approach, i.e. coercive public health measures, is severely limited. The traditional technocratic approach, i.e. drugs and vaccines, while promising, is not an immediate solution.

“So what I am calling for is something that doesn’t fall easily into the traditional ways of thinking about disease and public health. Most of my friends and colleagues will say education is where we should be spending our money, but I don’t think we’ve thought clearly enough about what that means in the long term. I think there’s considerable evidence these measures will fail.”

Brandt and other researchers suggested that what has come to be called the nation’s AIDS education program may have been started in almost knee-jerk fashion without enough attention to basic research on what is likely to work and what is not.

Brandt was particularly critical of programs predicated on the belief that the “just say no” approach championed by First Lady Nancy Reagan as a means of reducing drug abuse can be expanded to AIDS.

“ ‘Just say no’ is an unsophisticated and naive approach to the complex of behaviors and risks that lead to the transmission of (AIDS),” Brandt said. “And just as we wouldn’t expect ‘just say no’ to really solve our problem of intravenous drug use in the United States, ‘just say no’ will not end the AIDS epidemic.”

Not Getting the Message

James Watkins, a retired U.S. Navy admiral who heads the special White House AIDS commission appointed by President Reagan, said that new questions about the effectiveness of AIDS education are far from surprising. While young people in particular may comprehend AIDS educational messages, Watkins said, they often “just don’t believe” the disease will strike them.

“We may kid ourselves that education in a classroom is going to make a difference, but we are kidding ourselves,” Watkins said. “When you talk about AIDS education,” he said, often what such programs amount to “is dictating down from above.

“We need different programs from just telling kids about condoms. We need more wide-ranging health and biology issues. We’re inundated by a lot of piecemeal Band-Aiding in this society. We need to get kids to say no (to high-risk behavior) in a substantive way, not just because someone told them to say no.”

Brandt and other AIDS experts cautioned that expectations that education programs will have quick, decisive results ignore many public health realities. Brandt and many other researchers said the tactical comparison most relevant to AIDS education may be the 30-year-old drive to reduce cigarette smoking, which has shown dramatic--but gradual--reduction in tobacco use.

The at-times pessimistic impressions about AIDS education are contained in an issue of the American Journal of Public Health to be distributed to subscribers starting today. Copies were released in advance to news organizations.

The study of San Francisco youths, ages 14 to 19, was conducted by a research team at UC San Francisco. The project involved 151 girls and 53 boys in the city’s public school system who were exposed to educational programs about sexually transmitted diseases.

Between February, 1984, and September, 1985--a period of intensive AIDS education in the Bay Area--the proportion of teen-age girls who said their sex partners used condoms declined from 27% to 23%, and the proportion of boys who said they used prophylactics remained at less than half, rising from 41% to 49%.

The results confounded observations that the same teen-agers developed a sophisticated awareness of the dangers of AIDS and the risks of sex in general, and unprotected sex in particular. While boys reported a greater commitment to follow through on what they had learned with condom use, girls were surprisingly reluctant.

Continued Risk

“These results are disquieting,” the research team concluded. “Sexually active adolescents continued to have multiple sex partners and did not substantially increase their use of condoms, thus continuing to place themselves and their partners at risk for (sexually transmitted diseases) and HIV (human immunodeficiency virus, the precursor of AIDS) infection.”

Nancy Adler, one of the UC San Francisco researchers, said the findings underscore one of the troubling realities of fighting AIDS--that human sexual response, as a practical matter, often confounds intellectual instincts and reduces rational programs to meaningless failures.

“Is this finding surprising? Unfortunately not,” she said. “I think psychologists are well aware that it’s a slippery slope between attitudes, attention and behavior. It’s not just your beliefs about about (the condom’s) protective qualities, but for a teen-ager, what it would mean to raise (the issue) with your partner. It’s such a complicated behavior.

“There is this kind of abstract belief that it might protect you against a disease that seems so distant.

“I think in the traditional health education mold, you alert people to the danger. (You tell them:) ‘There’s this dread disease out there.’ I think that’s not likely to succeed. Neither has the traditional sex education model for avoiding pregnancy. Neither have worked very well (against AIDS) because the behavior is driven by other variables.

“I think the health issues about AIDS at the moment that you’re about to have intercourse are just not predominantly in your mind. In the long run, it means changing the kinds of things we talk to kids about.”

Dr. Charles Irwin, another San Francisco researcher, said the crisis caused by tampon-related toxic-shock syndrome several years ago established that it was possible to change health behavior through education fairly quickly. In that case, women were warned to stop using high-absorbency tampons and a specific brand, in particular.

‘Frightening’ Findings

Nevertheless, said Irwin, “I guess what still remains frightening to me is that, given information regarding sexually transmitted diseases (STDs) and that these kids are in an environment in which they’re beaten over the head with STD information, that they don’t intend to use condoms.

“That’s frightening and it really raises questions about how we are dealing with kids who are not really comfortable with the area of sexuality. Are we really giving people an option? I think we have to go backward and deal with basic human biology first before we talk about using condoms.”

Dr. Kenneth Mayer of Memorial Hospital in Pawtucket, R.I., and a researcher in the University of Massachusetts study of gay men, said that his research had focused on 270 homosexual men. While the men showed some change in sexual behavior in terms of a reduction in anal sex, the behavioral changes tended to disappear after six months. There even was a sharp increase in anal sex in which one partner was HIV-positive but the other partner was unaware of his status.

“I think (the absence of a long-term reduction in high-risk sex) is cause for concern,” Mayer said. “We’re seeing a subgroup of men slipping. Most people seem to make some effort for condom use or withdrawal, but it clearly hasn’t been a perfect transition.

“We haven’t reduced risk to zero, which is frustrating. If you can’t reduce (risk) to zero in a group that clearly perceives itself as high risk and has all the accouterments to make (its members) able to modify (their behavior), then you do worry about other groups of people.”