Introduction

Following detection of the first case of acquired immunodeficiency syndrome (AIDS) in 1981, human immunodeficiency virus (HIV) continues to affect people all over the world. Eastern Europe has had experienced comparatively recent and rapid growth of HIV infection (1). In Armenia, one of the former republics of the Soviet Union, there are a total of 153 officially registered HIV cases, and most of them have contracted the virus through sexual intercourse (43.8%) and intravenous drug use (43.7%). The virus has developed into AIDS among 28 patients, 16 of whom have already died. However, it is believed that the real number of people infected with HIV may be estimated to be about 1,800 (2).

Despite the fact that HIV/AIDS statistics in Armenia may pale compared to the extent of the epidemic in other countries in the region and elsewhere in the world, conditions are present in Armenia that contribute to vulnerability of the population to HIV infection. Following the collapse of the Soviet Union, the social and economic changes in Armenia have resulted in declined standard of living, growing deprivation, poverty, unemployment, and migration. In these circumstances factors increasing the likelihood of a rapid spread of HIV include lack of knowledge about HIV/STI and their modes of transmission, liberalization of sexual behavior, high rate of sexually transmitted infections (STIs), prostitution, substance abuse, especially intravenous drug use, and labor migration to Russia and other nearby countries where HIV is spreading at a catastrophic rate.

Because HIV is transmitted primarily by behavior that can be modified (unprotected sexual intercourse and intravenous drug use) educational programs designed to influence appropriate behavior can be effective in controlling the epidemic in Armenia. Young people deserve primarily attention in these educational efforts. In Armenia, the overwhelming majority of people registered with HIV/AIDS are young males aged between 20 and 39 years (2).

A variety of factors place young people at increased risk for HIV infection and, therefore, call for early intervention. Puberty is a time of discovery, rousing feelings and investigation of new behaviors including engagement in unprotected sex, sex with multiple partners, and experimentation with substance use (alcohol, illicit drugs and other substances). In addition, it is usually easier to modify risky behaviors of young people through behavior change interventions before they reach their adulthood with already established patterns of behaviors (3). Furthermore, if HIV prevention in youth population fails, human and economic costs of adult AIDS cases will have devastating effect on economic, social, and even political stability of any developing country and Armenia in particularly. Thus, HIV/STI/sex educational programs targeting at young people are of paramount importance. Many young people can be easily reached through schools, since no other institution can contend in terms of youth population enrolled (3). It is therefore essential to integrate HIV/STI prevention and health promotion programs in the school settings.

This project is aimed to analyze the political feasibility and the institutional readiness and potential for integration of AIDS educational program in the school curricula in Armenia.

Background and current situation

Health education including education about HIV and other STIs, modes of their transmission and means of prevention as well as information on the harm of intravenous drug use is not included in the school education programs in Armenia. There is a persistent belief shared by many government officials and society members as well that sex education itself will entice our adolescents into sexual activity. It follows that schools and other educational and health facilities would better remain dormant about this topic or introduce sexuality in a context of fear and danger.

Historically, sexual abstinence, virginity, taboos on premarital sex and sex outside of marriage have been widely encouraged and promoted as a traditional cultural norms of Armenian society. This approach in its pure context is of necessity and should be integrated in the programs aimed at adolescents’ education. At the same time, nowadays young Armenians are getting confusing messages and are faced with double standards calling for virginity in females but allowing early sexual activity in males, exposed to sex, smoking and drinking media advertisements and movies. This massive flow of “information” coming through our liberalized television and other mass media is readily absorbed by our adolescents since it fills the gaps in and satisfy their demands for information about sex, peer-acceptable behavior standards, and gender relations. Whether there is a demand for such information is no longer a question.

Resistance to promote in schools anything but sexual abstinence is also based on the argument supported mostly by parents and other adults that “when the time comes, our children will learn everything about this issue by themselves”. This ambivalent and meager approach to sex education in schools, however, has not discouraged Armenian youth from engagement in sexual behavior. Indeed, in a sample of University students (17-21 years) of Yerevan, Armenia, both males and females reported being sexually active, and the average age of the first sexual intercourse for them was 15/16 years (4). Quite high number of sexual partners in this sample was found to be an important risk factor for HIV infection. Another indicator of high-risk behavior among Armenian youth is an increase in the rates of STIs, which is highly correlated with the increase in the number of young females involved in commercial sex work (CSW) (5).

Young people also are at risk of becoming infected with HIV through substance use, especially intravenous drug use. National Rapid Assessment survey conducted in 2000 revealed that there were between 19,000 to 23,000 current drug users in Armenia, 10% of whom were injecting drug users, and the majority (56%) of drug users were young men in the 19 to 30 age group. HIV incidence rate in this population was found to be 5.8% (6).

Although Armenian youth are at risk of becoming infected with and transmitting HIV as they become sexually active, several studies have shown that they do not believe they are likely to become infected (4,6,7). This denial of the risk combined with the engagement in casual sexual contacts and inconsistent use of condoms was found to be quite common in Armenian youth (4). At the same time, the findings from several studies suggest that although young people demonstrated a reasonable understanding of the risk factors associated with HIV acquisition, their knowledge about transmission modes of HIV and other STIs as well as a general concept of sexual and reproductive health were still poor (4,6,7,8). Furthermore, when asked about source of information about HIV/AIDS/sex, an overwhelming majority mentioned TV/radio being the main source. School as a source of information about these topics was cited only by 37% of the young people surveyed in 2000 (4).

Issue

Thus, Armenian youth are practicing behaviors that increase their chance of becoming infected with and transmitting STI/HIV. However, due to cultural and ideological beliefs supported by policy environment, our children are left uninformed and untaught in how to make responsible decisions about their intimate relationships and how to develop safe practices.

Currently, the government policies on AIDS education in schools are infrequent and insufficient. In 1998, the Ministry of Science and Education of Armenia recognizing the necessity for schoolchildren to have basic information on HIV/AIDS, adopted school health education program on “Basic Knowledge about HIV/AIDS ” and included it in the curriculum of the 8th grade school children. However, the Ministry has not undertaken concrete policies and actions to support the realization of this program. Lack of institutional readiness and trained teachers willing and able to provide HIV/AIDS education presented additional obstacles to implementation of this program.

The Ministry of Health (MOH) of Armenia is currently in the process (1998-2003) of a comprehensive National Strategic Planning for a national response to HIV/AIDS in Armenia. These activities are mainly focused on the identification of priorities for and design of effective HIV prevention programs for youth.

Scientific Association of Medical Students of Armenia was largely involved in sex/AIDS education through series of lectures conducted in secondary schools of Yerevan and the regions. Peer education programs organized by international private agency and designed in a way that trained through this program schoolchildren further teach their peers have also contributed to education of schoolchildren about the health risks and tools for protection.

Although there are government institutions as well as local and international non-governmental organizations involved in the implementation of school AIDS education programs, their efforts are solitary and short-term, and are lacking coordinated approach. A comprehensive government policy on school AIDS education should be developed in close collaboration between the Ministries of Science and Education, Health, Youth and other government sector, policy makers, school principles, teachers, parents’ associations, and other interested parties.

Purpose

The aim of this project is to investigate the possibilities of integrating HIV/AIDS/STIs prevention education program in the school curriculum in Armenia. Important institutional, policy, cultural, and societal barriers to its implementation will be analyzed and policy recommendations for effective integration of HIV/STI education into school curricula and extra-curricular activities will be communicated.

Objectives and strategies for fulfillment

1. Review and analyze the experience of other countries that have been proven to have effective governmentally approved sexual health education programs in schools. Specific government regulations, policies and school practices of those countries will be studied. Selected programs will be examined in terms of their impact on sexual behavior of adolescents, their benefits and possible limitations. Possibilities of incorporating proven frameworks for designing sex/AIDS education program appropriate for Armenian schools will be considered. The sources of information will include information pages and articles in the Internet, scientific and legislative journals, as well as extensive library resources and personal communication with professionals from the selected country(ies) while attending conferences, seminars or other professional development activities under the terms of this project.

2. Review the current status of the national school health education policies and programs. Existing school policies and regulations will be analyzed in a context of health education goals, basis for health education standards and guidelines, how health education is delivered, topics included in health education (particularly, HIV prevention), number of hours devoted to health topics etc. Data will be collected in a close collaboration with the Ministry of Science and Education.

3. Explore views and attitudes of the key policy-makers regarding the necessity of and obstacles to introduction of AIDS education in schools, assess the extent of their support in and the possibilities of adopting legislative changes in the existing school policies, and identify collaboration areas among representatives of different government bodies and non-governmental groups. In-depth interviews with the government officials, representatives of the related ministries and regional departments, and school principles will be conducted on both national and selected regional levels.

4. Examine professional and theoretical background of teachers engaged in school-health program delivery, as well as assess their knowledge and perceptions about HIV/AIDS, and explore their opinion on the necessity of AIDS education and obstacles to its implementation in the school setting. Both qualitative and quantitative research methods will be applied.

5. Investigate parents’ attitudes and beliefs regarding sex education in schools. Qualitative research techniques such as focus group discussions and pile sorting will be used to collect information on the role of a family in determining the content of sex/health education in schools and to ensure that AIDS education efforts are consistent with parental values.

Significance and dissemination of the results

The societal norms and policy environments influence the risky and safe behaviors of people (9). In turn, policy interventions also can effectively change societal norms and behaviors to promote HIV prevention at the aggregate level. Hence, there should be an aggressive government effort in sex/HIV/AIDS education in Armenia.

The development of school policies on AIDS education is an important first step in planning and designing AIDS education program. This project will provide in-depth understanding of political, institutional, societal, and cultural environment to be considered while outlining school policy interventions. Based on the results of this research the recommendations for development of culturally and institutionally acceptable policies and regulations on AIDS education in schools will be made and presented to the key policy makers and representatives of the related ministries, and other officials.

The research is also consistent with the MOH ongoing youth-related activities and will provide background information for design of effective HIV prevention program for youth.

This project constitutes a built-in part of a bigger intervention plan initiated through collaborative efforts between Emory University, Andrews University, and Loma Linda University.  This new team of specialists is involved in prevention research targeting at youth in Armenia. Similar studies with adolescents in other high-risk countries including Ukraine, Romania, Caribbean, Philippines, South Africa, and Mexico are also in the process.

The results of this research will also be available to a general public in a form of scientific publications in journals, public health lecture series at the American University of Armenia, articles in newspapers, and other mass media activities.
 
 

References

1. CDC. The Global HIV and AIDS Epidemic, 2001. Morbidity and Mortality Weekly Report 2001; 50(21): 434-439
2. National Center for AIDS Prevention, Yerevan, Armenia (July 2001)
3. UNAIDS. Statement for the World Conference of Ministers Responsible for Youth (8-12 August, 1998). (internet source)
4. Babikian T. AIDS and Youth in the Republic of Armenia: An Application of a Risk Behavior Model. Master Thesis submitted to Loma Linda University
5. Melikyan G.L. HIV infection among Commercial Sex Workers in Yerevan: Findings and Policy Recommendations. Armenian Forum: A Journal of Contemporary Affairs, 1999; 2(1), 1-16
6. UNAIDS, Ministry of Health/ National Center for AIDS Prevention, Yerevan, Armenia. Support to the National Strategic Planning process for a National response to HIV/AIDS in Armenia: Summary of Situational Analysis, 2000
7. A Report of the Knowledge and Attitudes of STDs, AIDS, and Condom Use: A Study of University Students in Yerevan, 1996. American University of Armenia Center for health Services Research, 1996
8. Zohrabyan LS, Sargsyan NA, Ghukasyan GG, Nahapetyan KL, Ter-Hovakimyan AA. Sexual Behavior and Knowledge about AIDS/STD in Yerevan Higher School Students. Abstracts of the 2nd European Conference of the Methods & Results of Social and Behavioral Research on AIDS, Paris, January 12-15, 1998, p.153
9. Auerbach J.D., Coates T.J. HIV Prevention Research: Accomplishments and Challenges for the Third Decade of AIDS. American Journal of Public Health, July 2000; 7(90): 1029-1032