Evaluation of two school-based HIV prevention interventions in the Border City of Tijuana, Mexico

Journal of Sex Research, August, 2004 by Ana P. Martinez-Donate, Melbourne F. Hovell, Jennifer Zellner, Carol L. Sipan, Elaine J. Blumberg, Claudia Carrizosa

In Mexico, over 86% of all known cases of HIV/AIDS can be attributed to sexual transmission (Secretaria de Salud de Mexico, 2000). Because adolescence is a time when many young people first engage in sexual activities, this period presents a significant risk for HIV infection if no precautions are taken. Estimates of the percentage of Mexican adolescents who have ever engaged in sexual intercourse range from 17% to 31% (Caballero Hoyos & Villasenor Sierra, 2001; Fleiz-Bautista et al., 1999; Huerta-Franco & Malacara, 1999; Stewart et al., 2001), with most studies lacking a specific definition of the sexual practices included in these estimates. While many sexually active adolescents report having at some time used a method of contraception, condom use is inconsistent. For example, of the sexually active adolescents in Caballero Hoyos and Villasenor Sierra's (2001) sample, only 30.7% reported always using a condom, while 41.4% reported inconsistent use and 27.9% reported never having used a condom. Among the sexually active 15- to 25-year-olds surveyed by Garcia-Baltazar and Figueroa-Perea (1992), only 12.4% of males and 1.4% of females reported having used condoms as a method of contraception.

Adolescents in Mexico, and elsewhere, often begin sexual activities without taking precautions. Efforts must therefore be aimed at educating adolescents about HIV prevention and encouraging preventive measures such as condom use.

CHARACTERISTICS OF THE TIJUANA, MEXICO REGION

San Diego and Tijuana are twin cities located on opposing sides of the U.S.-Mexico border. With about two million residents each, they share one of the busiest international borders in the world: In 2002, over 56 million people crossed the Tijuana-San Diego border (U.S. Department of Transportation, n.d.). In general, the Mexican states that border the U.S. report higher rates of infectious diseases, including HIV/AIDS (4.6 vs. 4.1 cases per 100,000 persons), than Mexico as a whole (Rangel, 2002). Baja California has the highest AIDS mortality rate in all of Mexico. Within this state, the area surrounding the border city of Tijuana ranks highest: An estimated 11.4 to 21.7 of every 100,000 Tijuana deaths are AIDS-related (Instituto Nacional de Salud Publica, 1998) compared to a national mortality rate of 4.2 per 100,000 deaths (Secretaria de Salud, 2000). The mixing of Mexican and American cultures may influence risk practices for HIV infection among all age groups, including youth, in this border region. Thus, cross-cultural exposure and increased regional rates of risk practices may significantly impact both the risk and preventive behaviors of adolescents living in border regions. However, to our knowledge, no epidemiological data regarding HIV infection and risk practices among Tijuana youth are available. In addition, to date no HIV prevention interventions for adolescents in this Mexican border region have been formally tested.

SCHOOL-BASED HIV PREVENTION PROGRAMS

Due to their accessibility to a large number of youth, schools offer a potentially efficient method for delivering HIV prevention programs (Centers for Disease Control and Prevention [CDC], 1996; Main et al., 1994). In the United States, several studies have examined the effectiveness of these programs in altering behavioral and/or psychosocial variables that may impact HIV risk behaviors (e.g., Basen-Engquist et al., 2001; Coyle et al., 2001, 1999; Fisher, Fisher, Bryan, & Misovich, 2002; Jemmott & Jemmott, 2000; Kim, Stanton, Li, Dickerson, & Galbraith, 1997; Kirby, 2002b; Main et al., 1994). Kirby's (2002b) review of such studies consistently found that these programs do not increase sexual activity but may significantly increase condom use. In addition, many of these programs significantly impact HIV-related knowledge and attitudes (e.g., Basen-Engquist et al., 2001; Fisher et al., 2002).

While the majority of the programs reviewed by Kirby (2002b) involved multiple sessions, brief interventions have been reported to change risk behavior as well (Kalichman et al., 2001). For example, Jemmott, Jemmott, and Fong (1992) reported that their single-session workshop with African American adolescents significantly increased HIV knowledge and resulted in lower frequencies of high-risk sexual behaviors at 3-month follow-up. Single group session interventions are less expensive, may be cost-effective, and reduce problems associated with participant attrition that arise during multiple-session formats.

In Mexico, efforts to implement and evaluate school-based sex education and HIV prevention programs have been hindered by sociocultural norms that disapprove of sexual activity among adolescents (Pick, Givaudan, & Brown, 2000). However, recent efforts have led to the implementation and evaluation of a school-based HIV prevention program. McCauley et al. (2002), conducted a study of an HIV education program in four public secondary schools in urban areas of central Mexico. They found that postintervention, students exposed to the intervention reported significantly increased confidence in using a condom correctly, especially among females (from 23% at baseline to 80% at 4-month follow-up), when compared to a control group. Condom use also significantly increased in the intervention group from baseline to follow-up; however, this increase was not significantly different by group. Reporting on the same sample, Walker, Givaudan, Leenen, and Pick (2002) found that students who obtained HIV education showed significantly increased knowledge of HIV transmission and biomedical facts about HIV, as well as increased understanding of the consequences of HIV infection. To our knowledge, no such studies have been reported for students in Tijuana or other Mexican border regions.