AIDS Education: Gaps in Coverage Still Exist

Published by the Government Accountability Office on 1990-05-03.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                   United   States General   Accounting    Office                       -.-
GAO                Testimony

For Release          AIDS EDUCATION:
on Delivery          Gaps in Coverage         Still
Expected    at       Exist
9:30 a.m. EDT
May 3, 1990

                     Statement    of
                     Mark V. Nadel,    Associate           Director
                     for National    and Public           Health    Issues
                     Human Resources    Division

                     Before    the
                     Senate    Committee      on Governmental

                                                                             GAO Form 160 (12/67)

Most American     teenagers   have received      essential    information                                             on the
causes of AIDS and how to minimize          the risks      of becoming                                           infected
with    HIV.   However,   GAO found that    there    still   were gaps                                           in the
provision    of AIDS education.
In reviewing   the         school-based                  HIV      education             program           nationwide,
GAO found that
  --   Two-thirds        of     the        nation's           school        districts             offer       HIV

  --   smaller      districts          were           less      likely       to     provide          HIV      education;
  --   HIV education   is             not provided   at all                       levels,   particularly                     in
       the upper grades,               where the likelihood                          of sexual     activity                  is
  --   essential       planning             and monitoring                  data on students'
       knowledge,        beliefs,            and behaviors                  are inadequate:                   and
  --   teacher      training          is      often          insufficient            or     lacking.
In reviewing        education  programs                       targeted         at    high-risk,               out-of-
school   youth,      GAO found that
  --   CDC's Division            of Adolescent     and School                            Health       has      been       slow
       to address    HIV         education    needs:
  --   the Division     has primarily      funded                           education agencies                      and    the
       resulting    out-of-school     activities                             have been limited;

  --   the Division         plans a new initiative                            to fund health
       departments        to reach out-of-school                             youth  that potentially
       duplicates        another  CDC Center's                           approach.
Mr.      Chairman              and Members               of       the        Committee:

I am pleased                   to    be here            today           to       discuss           our        review                of     education
programs              for      youth        designed              to     limit            the      spread                of    the         human
immunodeficiency                       virus          (HIV),           which            causes           acquired

immunodeficiency                       syndrome               (AIDS).               We focused                     our        work        on the            lead
federal          effort--            the     HIV       education                   program              run     by the               Division               of
Adolescent                  and     School       Health                (DASH),            within          the         Centers               for        Disease
Control              (CDC).          Without           a human vaccine                           or      cure         available,
education              is     the      primary           weapon              against             the      profound                   medical             and

social          costs         of     the     HIV      epidemic.

Most      American                teenagers           have         received                essential                  information                      on the
causes          of     AIDS         and how to            minimize                  the        risks          of      becoming                  infected
with      HIV.              However,         there        still              are        gaps       in     the         provision                   of    AIDS
education.                   For     example,           AIDS           education                drops           off           sharply             in    the
11th      and        12th         grades,        just         as sexual                  activity               tends           to        increase.
In     addition,              students           in      smaller                 school         districts                     are        less      likely
to     receive              any AIDS         education.                      Furthermore,                     AIDS            education                efforts
are      most        clearly           deficient              where              they      are        most          clearly               needed--in
the      high-risk                out-of-school                 population,                     which           includes                  runaway            and
homeless             youth.


Many young               people         are        engaging             in           sexual         behaviors              and      drug        use

that      place          them     at      risk        of     HIV        infection.                      Although             few        teenagers
have      AIDS,          about         20 percent                of     people              with        AIDS        are      in    their             20s.
Because           HIV's         median         incubation                    period            is      estimated             at    nearly             10

years,          many of          these        people             were           infected               with        HIV     while         they         were


CDC has           the     lead         responsibility                        for        federal            HIV      education              efforts.
Its      Center          for     Chronic             Disease            Prevention                   and Health                Promotion,
responsible               for     HIV      education                  for          school-age                 youth,         initiated                a
nationwide               HIV     education             program                  in      late        1986.           DASH, which                 is
within          this      Center,          provides               technical                    and      financial             assistance
through          cooperative               agreements                   to         state        and        selected            local
education              agencies           and national                      organizations.                          These         cooperative
agreements               are     designed             to    help            schools             and agencies                  serving            both

in-      and     out-of-school                   youth         develop                  HIV     education                programs.               The
education              agencies          and       national                 organizations                      then       design          and

operate          their          own programs.

CDC allocated                   $136     million            of        its          fiscal           year       1987       budget          for        all
AIDS      programs.               Funding             increased                    to    about          $438       million          in      fiscal
year      1990.           As shown            in      figure            1,         about        half          of   these          funds         were
used      for      prevention              activities,                      such         as counseling                    and      testing,
health          education           and       risk         reduction,                    and minority                    initiatives,

which     are     administered             by another              CDC component,           the      Center        for
Prevention            Services.           About        10   percent        of      CDC's   overall         AIDS

funding       was targeted            specifically                 for    youth      education        activities
in   DASH.

CDC Funding     of AIDS Programs
(FY 1990)                                         60   Pacontot*IDs~

My testimony             today     will      cover          DASH's       efforts      targeted        to    both         in-
school        youth      and out-of-school                   youth,       which      includes        runaways,            the

homeless,          migrants,         and     incarcerated                youth.

YOUTH IN PUBLIC                    SCHOOLS

First,         I will         discuss            efforts               to     provide           HIV           education                to    students
in    public        schools            nationwide.                      HIV         education                 in     the      school           setting
attempts          to     give        students                the       knowledge              and        skills            they         need            to
avoid       HIV     infection.                   DASH focused                       on public             school              students
because         most      youth           are         in     rather           than      out         of    school.                 Also,            it
reasoned          that        HIV      education                  provided             in     the        school            system            could
influence           behavior              before             youth          dropped           out        of         school.             Our
information              is     based           largely            on a telephone                        survey            of     a nationally
representative                  sample           of         school          district            officials.

HIV      Education            Is     Not      Provided
at    All      Grade      Levels

CDC recommended                    that       students                 at     every         grade         level            receive            age-

appropriate              HIV       education                 to    expand            and     reinforce                  knowledge.

However,          only        5 percent                of     school           districts                 required               that         HIV
education           be provided                  at        every        grade          level.             Coverage                is        most
extensive           in    the       middle             grades           and      less        so in             the      upper           grades.
As figure           2 shows,              only         15 percent                of     school            districts                provided
HIV      education            in    the       11th           and       12th      grades.                 This         is      troublesome
because         sexual          activity               is     likely           to      increase                at     these        grade

levels.           School           district                officials             told        us that                 already            crowded
curricula           restricted                their           ability            to     provide                HIV      education               at
every       grade        level.
 Figure      2
llmlng    of HIV Education
                                                   rm      Pwuntd!kflooIDlmrkis


                                                    60                             \



                                                           7th            8th           Sth      10th     11th      12th

Two-thirds           of      public      school          districts                     nationwide          required           that   HIV
education           be provided           at      some point                      in    grades          7 through          12 during

the       1988-89      school         year.        Of the              districts               that       did    not       require     HIV

education,           most       were     small,          enrolling                     fewer      than     450 students.

Essential              Plannins                and Monitorinq

Data       Are      Inadequate

For      programs            to        set         priorities,                evaluate                 success,              and          improve
operations,                 they        must          collect           data          on students'                     HIV          knowledge,
beliefs,           and       sexual                and drug         use           behaviors.

However,           over           80 percent                of    recipients                      of    CDC funds                   did        not
collect           this       essential                  information.                       Only         11 percent                   of        recipients
met     CDC standards                        for      generalizable                       surveys            dealing                with        students

sexual           and drug              behaviors.                 CDC officials                         stated              that          essential
information                 was not                collected            because              this        was the               first            program
year       for     many states,                       and      some lacked                   staff           to    conduct                 surveys.             In
some cases,                 recipients                  could       not           obtain           state          or        local
authorization                     to    ask         questions             about            students'               sexual                 or    drug      use


Teacher          Trainina               Is         Often

Insufficient                 or        Lackinq

Training           for       some HIV                 teachers           was absent                     or    often            insufficient.
CDC has          not        set        any         standards            for         the     amount            of       training                 required
to     effectively                 teach            about        HIV,         but         educational                  authorities                     with
whom we consulted                        recommended                    at        least           12 hours             of     HIV          training.

One-fifth              of    HIV        teachers               received              no specialized                          training.                  The
remainder              received               some training,                        but      it        was often               less            than     12

hours.             That          is,      teachers                 in        two-thirds               of     the        districts                     received
training             of        10 hours               or    less,             with         a median            of       7 hours.                      Most
school            district              officials                 we talked                   to     wanted         to        provide             more

training             to        their       HIV         teachers.

OUT-OF-SCHOOL                     YOUTH

Now I would                    like       to     turn         to        the         status           of    HIV      education                    for         out-
of-school              youth.              These            youth             are       especially                vulnerable                     to     HIV
infection              because             of        the     extraordinary                           stresses                in     their         lives,

their       psychological                        problems,                    and the              resulting             high-risk                     sexual
and      drug        behaviors                  they        are         more           likely         to    engage                in    than           other

youth.             Providing               HIV         education                   to     these           youth         is        difficult
because            they         often           are        hard         to     locate              and     resistant                   to     prevention
messages.                 HIV          education             programs                   targeting              out-of-school                           youth
should          provide                information                  on HIV              transmission                    and prevention                         and
the      skills           to      change             high-risk                 behaviors.                   These             programs                 are     most
effective              when            linked          to    others                that         provide           for         basic           needs,            such

as food            and       shelter.

DASH Slow              to       Address
Out-of-School                     Youth

DASH has             been         slow          to     address               the        HIV        education             needs              of    out-of-

school          youth.                 Cooperative                  agreements                     with     education                   agencies

generally              included                 funding             for        both         in-       school            and        out-of-school

youth,          but            DASH initially                       targeted              efforts              to     the        larger,          easier
to    reach,              in-school                population.                       DASH provided                      no specific
guidance                 on how recipients                             should           approach               out-of-school                    youth.
Nor      did        it         specify            what         portion           of       any       particular                 cooperative
agreement                 was to            be spent                on out-of-school                           youth.

State          and        local            education                agencies,                 the    primary               recipients                of    DASH

funding,                 are      not       geared             to      serving           out-of-school                      youth.              These
agencies                 received                awards         averaging                less        than           $300,000           to       meet       the

needs          of        both         in-school                and      out-of-school                     youth.             Most          of    the
funding             was used                for         in-school              programs.                  About            5 percent             of       the
funds          awarded                to    education                  departments                  were        used        to      fund        out-of-

school          youth            programs.                     DASH also                funded         six          national
organizations                         to    target             their          efforts           to     out-of-school                       youth.

These          organizations                       received               about          5.6        percent            of    total          DASH funds
for     youth             education.

DASH-Funded                     Education                for

Out-of-School                         Youth        Is     Limited

DASH-funded                     HIV        education                efforts             for     out-of-school                      youth         are
limited.                  Few of            the      funded             education               departments                  targeted               out-
of-school                 youth            for     any         HIV      education               services.                   Services             needed,
but     usually                 not        provided,                included             direct           contact            with          out-of-
school          youth            and design                    of      appropriate                  HIV      education               materials              or
curricula.                      Recipients                said          this         happened             in        part     because             they

lacked          experience                   with         these        youth         and the           organizations                that

serve         them.            Moreover,                  those        education              departments             that         funded
efforts          outside               the        traditional                 school          setting          primarily            targeted
teenage          parents               or     problem             in-school                youth,        rather       than      homeless
or      runaway          youth.

BY Relvina               on Health                  Denartments
DASH Plans               to     Expand              Proaram

Because          these          efforts              did       not      effectively                  serve        out-of-school

youth,          DASH plans                   to     fund       six      local         health          departments             or     other
local         agencies               to      serve         as focal               points       for       adolescent           education
activities.                    These          designated                agencies             will        coordinate           community
HIV      education              efforts              in     high-incidence                     cities.             Another          center      in
CDC, however,                   has          a similar               effort          underway            to    educate        high-risk

CDC's      Center              for        Prevention                 Services
Also      Funds        Health                Departments                to
Taraet          Hiah-Risk                 Youth

The Center               for         Prevention                Services             also       funds          prevention            programs
in     health         departments                    and community-based                             organizations             for

populations               at         risk,          including             out-of-school                   youth.            These
include:           (1)         state          and      local          health          department               prevention            programs
to     support         Health                Education               and Risk          Reduction               activities            and

special            Minority                 Initiatives,                    (2)      AIDS         Community                Demonstration
Projects            to         conduct           research              on community                       HIV     education                strategies,

and      (3)       community-based                         organizations                         developing              HIV        prevention

programs            for         minority               and high-risk                    groups.                 We believe                 these
programs            potentially                      duplicate               DASH's              initiative              to        fund     health
departments                    to    target           out-of-school                    youth.                 Considering                  the        urgent
need       to      reach            these        high-risk                 youth,           it      may be preferable                            to
concentrate                    efforts           where         the         system           is      already           in      place         to        reach

this       high          risk        population,                    rather           than         waiting          to       develop              a new


Concerning                youth          in     public              schools,           we are              recommending                   that          the
Secretary            of         Health          and Human Services                                require          the        Centers             for
Disease           Control              to      (1)      take         a leadership                     role       in      developing

approaches                to        extend           and      reinforce               HIV-related                  education                for         llth-

and      12th-grade                  students,                (2)      work        with           state         education             agencies                  to
assist          smaller              school           districts               in      overcoming                 resource             or     community
barriers            that            prevent           them          from      offering               HIV        education,                 (3)        ensure
that       state          and        local           grantees              collect           adequate              survey            data         from
students            to      evaluate                 and      improve             school-based                   programs,                and         (4)
develop           guidelines                   for      the       training             of         HIV     teachers.

Concerning                out-of-school                       youth,          we are              recommending                 that         CDC
consider           whether               the         out-of-school                    youth          component                of     DASH should

be merged        with   CDC's   existing      prevention            programs     within   the

Center     for    Prevention     Services.

                                              -     -    -   -

This     concludes      my statement,        Mr.        Chairman.      I would     be happy     to
answer     any    questions     you     may have.