When the lesson can mean life or death AIDS education failing to change teens' behavior

THE BALTIMORE SUN

In Howard County, an eighth-grade class explores the ABCs of whether condoms always prevent the spread of AIDS.

At a student workshop in Baltimore, middle-school girls practice ways of saying "no" that won't cost them their boyfriends.

Elsewhere in the city, children act out scenarios that illustrate the connection between intravenous drug use, sex and HIV infection.

As of March 31, 3,710 people in Maryland have died from AIDS, including 2,302 in the Baltimore metropolitan area. And with the onset of this sexually transmitted epidemic, sexual relations, once talked about only among family or friends, have become a matter of public health.

Obeying a state mandate, Baltimore-area school systems sprinkle units about AIDS prevention into health, science and other courses, beginning in the elementary grades and continuing into high school.

But teaching children about the transmission of a fatal disease is different from teaching anything else.

Unlike history or spelling, AIDS prevention is one of the few subjects in which grades simply do not matter. What matters is whether children take what they learn and use it to change how they behave.

"That is the crux of this issue," says Dr. John Santelli, an epidemiologist for the city Health Department. "Somehow education and knowledge aren't getting translated into behavior changes.

"A lot of kids know about HIV and know how it's transmitted," he says. "But we still see a lot of kids engaging in high-risk behavior."

Even teen-agers, when asked, echo his words. Many would agree that knowing is one thing, doing is another.

"Kids are listening to the information and in the back of their minds, they might be hearing it," says Jason Hines, a senior at Baltimore's Douglass High School. "But at that last, given second when some might say, 'Wait for the condom,' they're not. There's still some with the attitude that, 'It won't happen to me.' "

Indeed, teen-age boys who boast they "got burned" by their girlfriends don't mean they were dumped -- they're talking about the pain of gonorrhea, says Andy Hannon, a social work administrator who coordinates Three for Free, a statewide condom giveaway program. "Things like gonorrhea and chlamydia are almost rites of passage to some kids."

The test of the curricula's success will be given, then, not in class but in private, when these students say "no" to drugs or when they make love -- or don't.

"There's a lot of concern that a lot of adolescents are going to be dying 10 years from now," says Dr. Santelli.

ABCs of AIDS

It's review time in an eighth-grade health class at Mayfield Middle School in Howard County. In a brightly colored room, students sit at tables, forming teams with names like "The Jamals," "The Four People" and "The Guys, Girls and Squires."

A wholesome-looking girl with long, dark hair gazes, smiling, at the class from a poster. The words under her say, "She shows all the signs of having HIV."

Pat Johnston, director of the county AIDS curriculum, is refereeing a game designed to make students go over what they've learned about the disease.

A cheerful, no-nonsense woman, dressed today in a denim jumper decorated with a tiny red ribbon, the symbol of AIDS awareness, Ms. Johnston asks the students to rate behaviors that deter HIV.

Abstaining from drugs gets a 100 rating.

Abstaining from sex gets a 100 rating.

Using condoms does not.

Still, Ms. Johnston drills the students by asking questions about the effectiveness of condoms: To provide any protection, what material should they be made of? What if they're too old? What if they have holes? What if they're not used throughout the entire sexual act? What if there's no space at the tip?

The students seem to know the answers. They pay close attention, and there is no snickering during the 15-minute discussion.

According to the federal Centers for Disease Control and Prevention in Atlanta, 40 percent of U.S. teen-agers are sexually active by the ninth grade. And that rises by 10 percentage points each year -- with 70 percent of high school seniors reporting they have had sexual intercourse.

But in many schools, mandatory AIDS instruction tapers off just as students are most likely to be sexually active, says Dr. Lloyd Kolbe, director of adolescent and school health for the CDC.

Paradoxically, 82 percent of schools nationwide require some AIDS material in middle school, but only 38 percent require it in 11th and 12th grades, the CDC has found.

In Maryland, a 1987 bylaw mandates one lesson during each of these intervals: grades three to six, six to nine and nine to 12.

In the metropolitan area, only the city and Baltimore County require 11th- and 12th-graders to take AIDS-prevention lessons.

However, state school officials point out that students get information not only from AIDS instruction but also from required and elective courses that deal with related health issues.

Learning to say 'no'

In the city, at a daylong workshop on the Morgan State University campus, high school students teach younger students how to deal with social situations in which risky behavior is a temptation.

"What if you were on a date and your partner wanted to have sex?" asks one of the "teachers," a girl in jeans and a bright green shirt. "What if your partner said, 'If we don't have sex it makes me feel you don't care about me?' "

"I'd tell him, 'No, we can still have a relationship without sex,' " answers a younger girl sitting at a front-row desk.

These students are participating in what's called skill-based learning, at a conference for selected Baltimore middle-school children.

Called "Harambee" -- Swahili for "to pull together" -- the workshop has been held each spring for the last four years, and is run by senior high students trained in HIV prevention. Each middle school in the city is invited to send six students, a teacher and a parent to the conference, which includes classes titled "The Love Bug Bites," and "Male Responsibility."

The city schools sponsor a half-dozen other programs that also teach negotiating skills. One effort is called Students Making Statements on HIV (SMASH).

This summer, the city's HIV/AIDS curriculum, written five years ago, is being revamped to include even more skill-based lessons, says Dr. Patricia Brownlee, curriculum director.

"When I say 'skill-based,' I'm not saying teach them to have sex," she says. "We are now looking at providing practice and skills for students to say 'no' to risk behaviors."

Though Baltimore-area school systems push abstinence as the only sure way to avoid AIDS, educators also recognize that adolescents often act on impulse.

That's why "knowledge by itself is not enough to change behaviors," says Michele Prumo, health curriculum specialist for the Maryland Department of Education. "One thing that has to be in place is parental guidance," she says.

Though many parents are squeamish about discussing sex and AIDS with their children, few mothers and fathers raise formal objections to AIDS instruction as practiced in the city and in Anne Arundel, Baltimore and Howard counties.

"Parents in general see the need to teach about the HIV virus and AIDS," says Carolyn Roeding, president of the PTA council for Anne Arundel. "We all want to believe that our child is not sexually active but, quite frankly, . . . if your child is active he needs to be informed of the dangers."

Under the 1987 bylaw, a parent can request that a child receive alternative instruction, rather than attend an AIDS-prevention class.

Two metropolitan counties, though, go a step further and put the choice directly on the parent: In Carroll County, parental permission is a prerequisite for any classes dealing with sex or AIDS; in Harford, permission is necessary after ninth grade.

But even in those counties, the refusal rate is low. In Harford, about 1 percent of the parents say no, and in Carroll, from 1 percent to 5 percent do.

However, parents can be vociferous about presentations that do not seem to emphasize abstinence.

Last summer, for example, the Carroll school board voted not to show ninth-graders a film, "Teen AIDS in Focus," because about 200 parents threatened to pull their children out of class. The parents said the film promoted condom use.

Now the AIDS-education curriculum is being reviewed and revamped. The new one will be ready in the fall of 1994.

Education for adults

Some Baltimore-area parents believe that AIDS-prevention instruction doesn't go far enough.

In Harford County, for example, Susan Rosseau, president of the Jarrettsville Elementary School PTA, and Sandy Sosinowski, a member, are preparing an HIV information presentation aimed at parents.

A mother of a third- and a sixth-grader, Ms. Rosseau says that instruction about the virus should begin before third grade -- in conjunction with workbooks and lesson plans that would be sent home for family discussion.

"My emphasis is to . . . take away fear of HIV and the fear of what can be taught," says Ms. Rosseau, who hopes to present a video and information packet to other parents in the fall.

"We cannot put our heads in the sand and say, 'These children don't know about sex or relationships,' because they do," she contends.

"And I want them to have the right information, not what they pick up on the bus or on TV or at lunch."

In the metropolitan area, Baltimore City leads in the number of AIDS cases reported since 1981, with 2,942. Baltimore County is next with 381, followed by Anne Arundel, 203; Howard, 78; Harford, 72; and Carroll, 28.

Statewide, 1,370 people under 30 have been diagnosed with AIDS since 1981, according to the Maryland AIDS Administration. Because a decade can pass before someone infected with HIV shows symptoms of AIDS, many of the 1,370 were infected in their teens.

Drugs and sex

At Baltimore's Southeast Middle School, eighth-grader Emmanuel Frangakis stands in the middle of his classroom trying to convince a "drug dealer" to stop having sex with women addicts who buy the merchandise.

"If those girls use needles, they can infect you during sex," Emmanuel tells the other boy.

But the dealer, played by classmate Damon McCalla, is unconvinced. "I thought only junkies who shot drugs got AIDS," he says.

This kind of role playing helps students understand that shared syringes can spread HIV -- and so can unprotected sex with an infected person.

Though the scenario may seem far-fetched, children "need to practice the how-to-say-no techniques" that could help in many kinds of real-life situations, says Sara Mullin, the petite, precise woman who teaches health and science at Southeast Middle.

Now her class switches to another game. Each student writes 15 things of great personal importance on strips of paper. One child lists a grandmother; another, a cat. A third student scribbles the words "hair dryer" and "a chance to go to college."

To illustrate how AIDS can ravage a life, Ms. Mullin pretends she is HIV. As she walks by students' desks, she snatches away the things they love.

Amid their squeals of dismay, she asks, "How does this make you feel when something you have no control over takes everything you love away?"

"Angry." "Mad." "I want to kill someone," say the students.

"But you do have control over it," the teacher says.

"There are certain things you have to be doing to get the virus. Things that put you at risk. Like what?"

The eighth graders, their attention caught and held by this exercise, respond nearly in unison: "By not having sex. By not doing drugs."

Later, though, Ms. Mullin reflects on the uncertainty of whether students will apply those lessons in real life.

"All you can do is teach them to think before they act . . . to look at what they want out of their lives," says Ms. Mullin.

"But it's hard. I don't know where these kids will be in 10 years."

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