How can we tell if teenagers are responding to HIV/AIDS awareness campaigns?  Is it acceptable to conduct randomised trials in schools to find out?  University College London, together with the University Zimbabwe and the London School of Hygiene and Tropical Medicine, looked into the sensitive topic of interviewing and testing teenagers for sexually-transmitted diseases (STDs) including HIV, in a feasibility study for a large community randomised trial.  It found that communities in Zimbabwe were enthusiastic about taking part in trials in schools and recognised the importance of these. 

Teenagers in sub-Saharan Africa are one of the most important groups for HIV/AIDS awareness campaigns.  Many programmes have been aimed at this age group over the past twenty years, but are they effective?  This information is essential if the campaigns are to become more widespread. While randomised trials are the best way of measuring the effectiveness of behaviour change programmes, there are ethical considerations to involving minors in this type of research. 

In this feasibility study, conducted in rural Zimbabwe, parents gave written consent to their child's participation (children were aged between 12 and 18).  The HIV and STD testing was carried out anonymously to encourage pupils’ participation.

The study found that:

• the biological evidence did not tie in with the questionnaire responses.  Only 13 per cent of the teenagers with HIV or another STD admitted to being sexually active
• the teenagers were afraid to tell the truth about their sexual behaviour because they were afraid of reprisals: beatings, expulsion from school, and forced marriage
• it would be possible to conduct longitudinal (follow up) studies to see the effect of these programmes in later life as the researchers were able to get current contact details for 97 per cent of the pupils who had been in form 2 (the age group of the study) three years earlier
• 6.6 per cent of older teenage girls between the age of 16 to 19, and 5.1 per cent of boys of the same age, were already HIV-positive.

Some parents did not give consent. This was either because some simply did not receive the form from their child, or that, particularly those who are illiterate, felt they did not have enough information about the study.  The report recommends that in the event of a large community controlled trial being conducted:

• initial discussions should be held with community stakeholders and members parents, teachers, health workers and pupils to find out if such a project is acceptable
• information from pupils could be collected away from the school environment in order to gain the trust of the young people. In a very large study it is unlikely to be practical to conduct detailed interviews with every child in the school
• the best way of evaluating effectiveness would be to collect biological samples from all teenager participants, together with a limited amount of sexual behaviour information, then collect detailed information from a smaller sample group.

The study found it was acceptable to carry out randomised trials in schools as long as the local communities are involved. However, teenagers are unlikely to be honest about their sexual experience. A more reliable method would be biological evidence, such as urine samples.

Source(s):
‘School based HIV prevention in Zimbabwe: feasibility and acceptability of evaluation trials using biological outcomes’, AIDS 16: 1673-1678, by Frances Cowan et al, 2002
HINARI subscribers can access the full-text article here. Full document.

Funded by: The Wellcome Trust

id21 Research Highlight: 24 April 2003

Further Information:
Frances Cowan
Department of Sexually Transmitted Diseases
Royal Free and University College Medical School
University College London
Mortimer Market Centre
Capper Street
London 
WC1E 6AU
UK

Tel: +263 4 704 890
Fax: +263 4 704 897
Contact the contributor: frances@uz-ucsf.co.zw

Royal Free and University College Medical School, UK

University of Zimbabwe

London School of Hygiene and Tropical Medicine, UK

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