What Works for Women and Girls

Improving Condom Use Among Young People Is EssentialPromisingly, an analysis of survey data in countries worldwide shows that condom use at lastsex among young people is increasing (Wellings et al., 2006). However, young people’s use ofcondoms is generally inconsistent (Minkin and Wright, 2005), and the proportion of sexuallyactive adolescents who report condom use remains too low to control the transmission of STIs(Dehne and Riedner, 2005). Improving condom use among young people is critical—datashow that if condom use is established during adolescence, it is more likely to be sustainedin the long-term (Schutt-Aine and Maddaleno, 2003). A study of 802 sexually active youthin Ethiopia, of whom more than 74% were women, found that once youth had started to usecondoms, they were more likely to continue to use condoms in the future (Molla et al., 2007).At the same time, condom use within established relationships, and particularly marriage,remains low (Ali and Cleland, 2005). [See also Chapter 3. Prevention for Women]Young people need information to know how to protect themselves. Key findings fromnationally representative surveys of nearly 20,000 young people ages 12–19 conducted in 2004(5,950 in Burkina Faso; 4,252 in Ghana; 4,012 in Malawi and 5,065 in Uganda) showed thatyoung people want information especially from trusted sources such as health care providersor teachers (Biddlecom et al., 2007). Young people, as well as adults, also need to have a realisticunderstanding of the risks of differing sexual practices, for example, so they may avoidthose behaviors that perhaps put them at increased risk for HIV. A study of girls in Senegalfound that they engaged in anal, oral and manual sex to remain technically virgins for theirwedding night, yet provide pleasure both for themselves and their boyfriends (van Eerdewijk,2009). Anal sex may increase the risk of HIV transmission to one transmission for everythree episodes of heterosexual anal sex (Powers et al., 2008a). “Yet anal sex continues not tobe targeted—nor even specifically mentioned—in most prevention campaigns….” (Halperinet al., 2009: S57). On the other hand, transmission via oral–genital contact is extremely low,with a study of 135 HIV-negative people (110 women and 25 men in Spain) whose only riskto exposure was unprotected orogenital sex with their infected partner, with 210 person-yearsof follow-up and 19,000 unprotected orogenital exposures with the infected partner and nosingle HIV seroconversion (del Romero et al., 2002).Comprehensive Sex Education Programs Can Be EffectiveSchool sex education programs are effective ways to reach a large number of (but not all)young people. Despite the fears of some community leaders and parents that sex educationwill encourage young people to engage in sex, available evidence indicates that sex educationcan delay sexual debut, and can increase condom or contraceptive use by sexually active adolescents(Kirby, 2001; Coyle et al., 1999; Hubbard et al., 1998, cited in Satcher, 2001; Grunseit,1997). Achieving behavior change is difficult and many interventions achieve only moderate, ifstatistically significant, results that include behavior change. In reviewing evidence related tosex education and HIV education, it is important to remember that most studies do not havesufficient information on the details of the intervention, the strength with which the interventionwas implemented or even more importantly, how awareness of gender norms, condomWHAT WORKS FOR WOMEN AND GIRLS115