HIV Education and How Not To Do It
June 28, 2018
by Andrè Van Mol, MD
My home state of California requires HIV education as part of junior high and high school sex education curricula. School board members from various counties asked me to review elements of some available courses that they suspected were flawed. The ones presented to me were inaccurate and likely misleading and harmful to students, putting at particular risk the very group most in harm’s way: males having sex with other males (MSM).
A few land mines are lurking in the field of our state’s educational laws. California Education Code 51931 “definitions” section details that only “medically accurate” information can be taught. Seemingly fair enough. Also, Code 51933 states: “(4) Instruction and materials shall not reflect or promote bias against any person on the basis of any category protected by Section 220. (5) Instruction and materials shall affirmatively recognize that people have different sexual orientations and, when discussing or providing examples of relationships and couples, shall be inclusive of same-sex relationships.” Translation: All must affirm. There cannot be a discouraging word about sexual orientations. As you shall see, that gets tricky.
One curriculum explained that among behaviors considered “low risk” for HIV transmission was “vaginal or anal intercourse with a condom.” The same curriculum also lumped “vaginal, anal or oral sex” to imply equal protection through condom use. And with that, we say goodbye to medical accuracy. Condoms are not FDA approved for anal intercourse. Next, pooling oral, vaginal and anal intercourse together is inherently misleading. A rectum is not a vagina. Viruses have far easier access to blood through rectal vascular beds than through thick vaginal walls.
Furthermore, a 2013 U.S. Centers for Disease Control (CDC) report found that even a 100 percent use of condoms for anal intercourse failed an estimated 30 percent of the time. That is not low risk. The CDC’s “HIV Among Gay and Bisexual Men” webpage says: “Anal sex is the riskiest type of sex for getting or transmitting HIV. Receptive anal sex is 13 times as risky for getting HIV as insertive anal sex.” This seems an important detail for students to know, but it seems they don’t get this information. It would be one thing to state a degree of protection is afforded for various sexual practices though regular condom use, but quite another to broadly and vaguely generalize results as “low risk.”
California Education Code 51934(7) states: “This instruction shall emphasize that successfully treated HIV-positive individuals have a normal life expectancy, all people are at some risk of contracting HIV, and the only way to know if one is HIV-positive is to get tested.” Obfuscation is a poor substitute for clear warning, and equivalency arguments are misleading since things are rarely equivalent. This requirement of the code is easily misinterpreted by adolescents to mean all intercourse and abstinence are of nearly equal risk—“all people are at some risk”—leading to a sense of futility in prevention efforts. That is the wrong message to send. And there is more.
“Normal life expectancy” is a bit of a half story about HIV positivity. As one HIV-positive person asked of this program’s statements, “Who tells the students about the fist full of medications I have to take every single day and what happens if I miss a few days?” (Statement paraphrased by me). Who indeed. I am thrilled for people with HIV that the treatments have improved along with the life expectancy, but flippancy toward infection and its transmission—and a panacea view of treatment—can ruin it all for someone or many. A 2009 report from the Netherlands found that the benefits of “highly active antiretroviral therapy and early diagnosis” have “been entirely offset by increases in the [sexual] risk behavior rate.”
As one astute school board member pointed out during our review process, the California Education Code also says in 51934(2) that instruction is to include: “Information on the manner in which HIV and other sexually transmitted infections are and are not transmitted, including information on the relative risk of infection according to specific behaviors, including sexual activities and injection drug use.” She immediately recognized the code’s requirements are in flagrant contradiction of each other.
Medically accurate information on the relative risk of HIV infection from sexual behaviors looks much like this. The CDC reports that gay (men having sex with men, MSM) and bisexual men (MSM&W) account for the majority of new HIV cases in the U.S. “Gay and bisexual men” were estimated to be 2 percent of the U.S. population. Yet MSM represent 70 percent of new HIV infections in the U.S., and “Gay and bisexual men accounted for 82 percent (26,376) of new HIV diagnoses among all males aged 13 and older and 67 percent of the total new diagnoses in the United States.” “Gay and bisexual men aged 13 to 24 accounted for 92 percent of new HIV diagnoses among all men in their age group.” The CDC reported in 2016 that, at current rates, one in six MSM will be diagnosed with HIV in their lifetimes. MSM have 83 times the lifetime HIV diagnosis rate of heterosexual men (MSW) and six times the lifetime HIV diagnosis rate of men who inject drugs. To be forewarned is to be forearmed.
We are not in the dark as to why the HIV statistics are so poor in men having sex with men. According to a team led by Professor C. Beyrer at Johns Hopkins, MSM are more likely to have HIV, to have HIV variants and to spread HIV. There is more risk for transmission for each sex act with each person having anal-receptive sex. Only MSM can be inserters and receivers (pitchers and catchers). MSM have far higher rates of anal-receptive sex than women.
Students are poorly served by HIV awareness curricula that make generalizations and inaccuracies regarding the relative safety of sexual practices, exaggerate and blur the efficacy of condom use in them as though equivalent, and functionally tell students HIV infection is nothing because with medications you’ll live as long as anyone else. Reducing stigma associated with HIV is a goal of these programs, but in the name of that they seem to be clearing the way for more students to contract it. HIV awareness programs like the ones I’ve seen make students less aware, more naïve and more at risk.