Introduction
A pathogenic organism transmitted through contact with bodily fluids causes Human Immunodeficiency Virus (HIV). Acquired Immune Deficiency Syndrome (AIDS) is advanced HIV disease characterized by severe immune depression leading to the presence of other infections.
In 1981, the first case of HIV was documented. By 1985, the virus had spread across the United States and invaded over 50 countries.[1] Twenty years later, HIV, the virus that causes AIDS, is still a widespread problem in the United States. Within the nation, Maryland ranks fourth highest in the AIDS incidence rate, behind only the District of Columbia, New York, and Florida.[2] With no cure and few effective long-term treatments for HIV/AIDS, prevention through education has become key in the fight against the disease.
Maryland's adolescents and young adults (13-29) account for 23.4 percent of the states HIV/AIDS cases.[3] Nationwide, 50 percent of new cases are people under 25 years of age.[4] The majority of these people are infected through sexual behavior.[5] It is during childhood and adolescence that people learn healthy sexual behavior.[6] Therefore, education targeted towards the youth population is necessary to instill healthy behavior and enable them to make responsible, informative decisions.
Because of the risk presented by the disease and the social problems associated with HIV/AIDS, we recommend reform in the public schools HIV/AIDS Curricula requirements. The reform in the current HIV/AIDS curriculum requirements would include establishing a uniform HIV/AIDS curricula, an increased number of grade levels responsible to teach HIV/AIDS curricula, and assessments at the end of each unit in order to promote effective learning. In addition, mandatory teacher training would ensure that each student receives high quality information concerning HIV/AIDS.
Maryland's Predicament
The rapid transmission of HIV is one of Maryland's largest health risks.� Maryland has recorded over of 32,000 HIV/AIDS cases in the state since 1992.[7] Currently, more than 21,000 Maryland residents are living with HIV/AIDS.[8] From 1994 to 1999 the number of people living with the disease more than doubled.[9]
Much like other sexually transmitted diseases (STDs), anyone who is sexually active, especially one who practices sexual activities without a condom or with multiple partners, is at risk for HIV. Those who share needles and drug injection paraphernalia are also at risk.
Populations highly impacted by the HIV/AIDS epidemic suffer disproportionate rates of other illnesses.[10] Surrogate markers and co-morbidities of HIV infection include other STDs.[11] Baltimore, Maryland's most populated city, has the nation's highest rate of the STDs gonorrhea and syphilis.[12] The prevalence of STDs is relevant to the transmission of HIV for two reasons. First, the spread of STDs indicates a high level of unprotected sexual activity.[13] This behavior facilitates the transmission of HIV.� Secondly, certain STDs that produce lesions on the skin accommodate HIV transmission.[14]
"With the inception of community planning in 1994, [by the Center for Disease Control and Prevention,] the Maryland AIDS Administration decided to have an officially-constituted statewide community planning group who is responsible for developing the HIV Prevention Plan. A few years into the community planning process, the AIDS Administration and the Community Planning Group, determined that a Regional Work Group in each of the five regions of the state was needed [to gather information and conduct needs assessment] at the community level."[15]� Regional Work Groups are separated into 5 regions; Central, Eastern, Southern, Suburban and Western. Each of the Regional Work Groups has completed a needs assessment, which included a review of the epidemiological data, the results of Structured Public Input, Regional Work Group member experience, and a review of relevant Behavioral Science research.[16]� Using this information, each Regional Work Group ranked specific populations to target prevention efforts.� The Central Regional Work Group and Western Regional Work Group ranked the youth population as its first priority.[17] The Suburban Regional Work Group ranked youth as its second highest priority.[18]� The Eastern Regional Work Group ranked youth/Department of Juvenile Justice as its fourth priority, while the Southern Regional Work Group ranked youth as its seventh highest priority.[19]
This illustrates that these Regional Work Groups from the state view a need to prevent the transmission of HIV among our targeted population. As the Western Regional Group recognizes, "adolescence represents the era in which sexual habits are being formed, and prevention providers have the best opportunity to affect behavioral change during this phase."[20]� The Southern Regional Work Group and Suburban Regional Work Group agree with these sentiments as well.[21] In addition, each of the Regional Work Groups identified the need for more and better education in schools, in order to address the youth population.[22]�
An overview of Maryland's HIV/AIDS Curricula
Prevention through education is the most valuable and cost-effective method in the fight against HIV/AIDS.� Despite the benefits of HIV/AIDS education, Maryland's public schools continue to present curricula that does not adequately prepare them to understand the health risks and social problems associated with HIV/AIDS.
In the early 1990's, the Center for Disease Control and the Maryland Board of Education implemented Health education units into every grade, and in 1995, established HIV/AIDS curricula.� A distinction exists between the Maryland Department of Education and the Maryland Government curriculum requirements as to when, where, and how HIV/AIDS education is taught.� The Maryland Government requires that HIV/AIDS curricula be taught in Maryland's public school system at least three times: once in elementary school, once in middle school or junior high, and once in high school.� However, the Maryland Department of Education's position is that HIV/AIDS education should begin as early as kindergarten when children are taught to be aware of their hygiene and told to wash their hands and never touch blood.� They also maintain that HIV/AIDS education should overlap into many areas besides disease and sex education, citing the importance of talking about HIV/AIDS in the context of social skills, personal hygiene, abstinence, as well as family life and health units.
Maryland annotated code 13A.04.18.04 states, "AIDS education is critical in preventing the spread of the human immunodeficiency virus (HIV) that causes AIDS."[23]� The provision requires that local school systems provide annual instruction in AIDS education that includes the following: the definition and description of HIV/AIDS, symptoms and complications associated with HIV/AIDS and related disorders, means by which HIV is transmitted, diagnosis and treatment of AIDS, methods for prevention of the spread of HIV/AIDS, and information on the available research concerning HIV/AIDS.[24]� Each county board of education determines what information is appropriate for varying age groups.
To study the current conditions of HIV/AIDS education in Maryland, our group contacted the board of education in each county, collecting copies of curriculum for any class in which HIV/AIDS was addressed.� It is important to note that, although curricula for public schools is public information and schools are required to provide copies to parents, our requests were met with resistance.� Despite repeated attempts to collect curricula over a 45-day period, six of the 23 counties did not supply the information.[25]� In addition, some counties informed us that they have no countywide written curricula for HIV/AIDS education.[26]
The majority of the counties in Maryland have established curricula designed to implement HIV/AIDS education three times during thirteen years of school (K-12).� The law allows school systems in each county to teach HIV/AIDS curricula according to what the local board of education determines is important for the children in their area. For example, if in Prince George's county, the majority of new HIV cases are due to injection drug use, a teacher may chose to present information on the dangers and risks associated with injection drug use. Many counties have used this provision as way to avoid lengthy discussions on HIV/AIDS because they may not see the disease as a problem in their area.
The five main problems with the current HIV/AIDS curricula in Maryland's public schools are as follows: the lack of repeated exposures, the use of inaccurate and/or misleading information, a lack of uniformity, an absence of assessment to gauge the students knowledge about HIV/AIDS, and insufficient teacher ability to instruct HIV/AIDS education.�
The first problem with current curriculum requirements is a lack of repeated exposure.� Schools are required to teach HIV/AIDS education only three times during thirteen years.� It has been proven that repeated exposure improves retention of information.[27] Schools require basic knowledge in subjects including math, English, science, and history.� However, there is no requirement for a student to learn basic information about HIV/AIDS, which could potentially save their life.��
While studies have shown beneficial effects of HIV education programs, the current guidelines allow for a parent to excuse his or her child from the HIV/AIDS unit.� The child is then given his/her own project dealing with a topic other than HIV/AIDS.� Although the issue of AIDS is sometimes uncomfortable to discuss, by allowing a student to miss out on the vital information presented in classes, he/she remains ignorant to the health risks and social problems associated with HIV/AIDS. This ignorance contributes to the crisis.
Problems also exist with counties presenting inaccurate information, especially concerning HIV/AIDS risk factors.� In the county curricula, there is a great deal of inaccurate and/or misleading information, which contributes to misconceptions about HIV/AIDS.� Carroll County's curriculum touches on all the requirements made in Maryland annotated code 13A.04.18.04; however, listed risk factors are presented in a misleading fashion.� When outlining risk factors for HIV, the curriculum states, "men who have sex with other men." A more accurate statement would assert that� "anyone who has unprotected sex with an infected person" is at risk. The curriculum in Carroll County makes many statements saying HIV "targets homosexuals and bisexuals." Statements like this one promote false ideas about HIV/AIDS and lead to misinformation.
Many curricula from around the state do not clearly present that a person infected with HIV will eventually develop AIDS and die.� Because HIV/AIDS is often taught within units on STDs, young people may make the mistake of thinking HIV/AIDS is treatable like other STDs.� The distinction between other diseases and HIV/AIDS must be clearly shown.�
The third problem develops from the lack of uniformity in the curricula.� Some counties have no countywide curriculum and HIV/AIDS education is given in health/physical education class, while other counties, like Montgomery County, are characterized by a wide array of age appropriate information and lists of outside sources for further information.�
The law does not specify where this information will be presented; it could be health class, sex education, or biology class studying viruses.� In addition, current curriculum guidelines make no mention of the tremendous social and economic impact HIV/AIDS has in the world, the nation, and their communities.� With the number of HIV infections growing every day, it is important to understand the physical consequences of the deadly disease, to discuss how people with HIV/AIDS are treated and how this virus has brought about social change.
Our concern is that, because the information presented varies, teachers and students may miss important information outlined above and in the State Board of Education Guidelines.� With no standard, mandatory curricula established, a teacher may overlook the importance of HIV/AIDS curricula, or the lessons could be pushed aside to the end of the semester and perhaps overlooked.�
The fourth problem is that the state does not require an assessment process for students to ensure that the information is mastered and retained. Without adequate assessment procedures in place, there are no methods to evaluate the effectiveness of HIV/AIDS education.
The fifth and final problem is that no adequate teacher training exists. Although the state requires teachers to undergo training, there are no specifications on what this training entails. A major problem with a student's ability to learn about HIV/AIDS involves the teacher's ability to teach topics that are sometimes uncomfortable to discuss. The teacher's discomfort with the topic may explain why lessons about HIV/AIDS are pushed aside until the end of the semester, where they may go untaught because of time constraints.
After twenty years of tracking the HIV/AIDS epidemic, the information available to the general public is plentiful and accurate.� We urge that the HIV/AIDS curricula in Maryland be revised. We suggest implementing a strong, mandatory core curricula that would include up-to-date information regarding origin, transmission and treatment of HIV/AIDS, cognizance of physical, social, and emotional consequences of the disease, increased exposures to the information, accountability of information by students, and mandatory teacher training.�
Recommendations
Our recommendation is to implement a mandatory, core HIV/AIDS curriculum in Maryland's public school system. By implementing this program in the schools, the state will reach a large percentage of the targeted population and will remedy the deficiencies found in current curricula.
The proposed core curriculum will target public school students who are from all racial and socioeconomic backgrounds. Primarily, the core curriculum will involve a comprehensive HIV prevention strategy that will address multiple levels surrounding the HIV/AIDS epidemic including individual, dyadic, community, medical, and legal issues. Addressing all issues concerning HIV/AIDS will make students more aware of the physical, social, and emotional consequences of HIV/AIDS.
The curriculum will be delivered to Maryland's public school students for a minimum of three lessons in grades three through five, a minimum of five lessons in grades six through eight, and a minimum of five lessons in grades nine through twelve.
The Maryland AIDS Administration, in collaboration with the Maryland State Department of Education, will develop the HIV/AIDS curriculum. These agencies will work together to produce a thorough HIV/AIDS curriculum that is age specific and appropriate. However, each county can supplement the state-developed core curriculum according to the individual school and/or community needs.�
Teachers who have undergone HIV/AIDS teacher training and education will deliver the proposed curricula in the standard classroom setting. This training will generate familiarity with information about HIV/AIDS, making it easier to answer questions from students. The training will enable teachers of the curriculum to feel more comfortable with the topic of HIV/AIDS and the issues that surround the disease, including sexual and drug behavior.� The designated teachers will undergo the HIV/AIDS education and training before initiating instruction with students and annually thereafter. The Maryland AIDS Administration and the Maryland State Department of Education will develop the HIV/AIDS teacher-training and education program.
Assessment shall be implemented to monitor students' knowledge of the information.� Only through assessment will the state accurately gauge the effectiveness of the core curriculum and determine whether education efforts are reaching the students to the full potential or whether it requires further development.� Currently, Lynne Weise, HIV/AIDS Prevention Coordinator for the Student Services Alternative Programs Branch of the Maryland State Department of Education, is responsible for ensuring that the county's curriculum adhere to requirements set forth in Maryland annotated code 13A.04.18.04. Therefore, the duties of the HIV/AIDS Prevention Coordinator will be amended to assess the students' knowledge of the curricula. The State Department of Education will determine methods of assessment.
Given the looming issue of treating the population of HIV/AIDS patients, Maryland must consider the costs that it faces in the coming years.�
Counting the Costs
Preventative measures are characteristically more cost effective than treatment methods.� Because 85% of adolescents in Maryland attend public schools, preventative training in the school system is a thorough and cost effective method to disperse valuable prevention information while saving valuable state resources.
The Costs of HIV/AIDS
The estimated costs for lifetime treatment of a person infected with HIV now averages$155,000.[28]�� This cumulative cost of lifetime treatment "doubles yearly if the number of infections stays steady, as it has over the last decade."[29]� This cost does not reflect the increased financial losses due to inflation or future treatment options.
In addition to the social costs, the loss of income due to the illness is a serious dilemma: "For the first 10,000 AIDS cases in the US, the average cost of years of work lost equaled about $480,000 per death, or $4.6 billion total.� As the epidemic affects a younger population, these costs will undoubtedly rise."[30]� People with HIV/AIDS require costly treatments that drain government resources.�
Benefits are hard to measure, as no one can know the exact number of HIV cases prevented by HIV/AIDS education. Nonetheless, Maryland faces a serious financial burden because of the number of HIV/AIDS patients already residing in the state.� In Maryland, 21,582 people are living with HIV/AIDS.[31] Each of these patients requires treatment at the cost of at least $155,000.� The simple calculations of the minimum costs facing Maryland indicate a $3.4 billion price tag.� Given that the cost of treatment as well as other additional costs will rise each year, this number is an extremely conservative estimate.�
Education -> Prevention�����
One way to assess the number of HIV infections prevented, is to compare the number of HIV infections likely to be prevented over 5 years, in a program that reduces risk behaviors by a modest 10 percent.[32] In populations with an HIV prevalence of about 0.4%, such as Maryland, $1 million will prevent eight infections.[33] As previously stated, treatment cost for lifetime care for an HIV infected person is estimated at $155,000. For every 8 people prevented from becoming infected, $1,240,000 would be saved in treatment costs. After subtracting the $1,000,000 spent towards prevention, the state would save $240,000 annually.
The cost of implementing the core curriculum is minimal, as HIV/AIDS education is already a mandated element of public school training; material costs and teacher training are built into budgets.� The new core curriculum would also require little maintenance throughout the years, necessitating only updates to keep the information current.� Individual counties would not have to invest time and money in creating the curriculum, thereby saving valuable resources.���
In summary, the cost-benefit analysis indicates that preventative measures are a financial investment that Maryland cannot delay.� The costs are overwhelming and the benefits are very attractive.� Benefits include the avoidance of enormous medical and curative costs as well as the maintenance of a healthy population and work force, an asset that is not quantifiable.� Unfortunately, this investigation finds that Maryland's curricula do not adequately equip students to avoid contracting the disease, as evidenced in the previous summaries.
Conclusion
Maryland faces a looming epidemic as HIV/AIDS poses a serious risk to the state.� Prevention through education is a feasible and inexpensive method to stifle the rapid spread of the disease in this state.� Implementation of a standard, core curriculum is a beneficial and cost-effective step that must be taken, given the extent of the HIV/AIDS crisis in Maryland.
[1] "The History of AIDS: 1981-1986"; 17 April 2001, www.avert.org/his81_86.htm (9 August 2001).
[2] Maryland AIDS Administration, The Maryland 2000 HIV/AIDS Annual Report (Baltimore, Maryland), 85.
[3]Maryland 2000 HIV/AIDS Annual Report, 47.
[4] Center for Disease Control and Prevention, HIV Prevention Strategic Plan Through 2005 (Atlanta, Georgia: Sept. 2000), 19.
[5] Center for Disease Control and Prevention, 19.
[6] Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence, "Sexuality Education for Children," American Academy of Pediatrics 108 (2001): 498
[7] Maryland 2000 HIV/AIDS Annual Report , 1.
[8] Maryland 2000 HIV/AIDS Annual Report , 1.
[9] Maryland 2000 HIV/AIDS Annual Report, 9.
[10] Maryland 2000 HIV/AIDS Annual Report, 109.
[11] Maryland 2000 HIV/AIDS Annual Report, 109.
[12] Maryland 2000 HIV/AIDS Annual Report, 109.
[13] Maryland 2000 HIV/AIDS Annual Report, 109.
[14] Maryland 2000 HIV/AIDS Annual Report, 109.
[15] Maryland AIDS Administration, 2001 HIV Prevention Application (Baltimore, Maryland), 10-11.
[16] Maryland AIDS Administration, 2001 HIV Prevention Application, 12.
[17] Maryland AIDS Administration, Maryland HIV Prevention Priorities 2001-2003 (Baltimore, Maryland) Western Regional Work Group, 1, Central Regional Work Group, 1.
[18]Maryland HIV Prevention for 2001-2003, Suburban Regional Work Group, 4.
[19]MarylandHIV Prevention for 2001-2003, Eastern Regional Work Group, 5, Southern Regional Work Group, 9.
[20]Maryland HIV Prevention for 2001-2003 , Western Regional Work Group, 1.
[21]Maryland HIV Prevention for 2001-2003, Southern Regional Work Group, 9, Suburban Regional Work Group, 4.
[22]HIV Prevention for 2001-2003.
[23] Title 13A State Board of Education: Subtitle 04 Specific Subjects, Chapter 18: Program in Comprehensive Health Education, .04 HIV/AIDS Prevention Education, (Maryland: 1995), 120-43.
[24] Maryland annotated code 13A.04.18.04 is shown in Appendix A.
[25] Allegany, Caroline, Dorchester, Kent, Queen Annes, and  Wicomico County have not sent their HIV/AIDS curriculum.
[26] Somerset and Talbot County have no written HIv/AIDS curricula established.
[27] Robert Bauserman, Ph.D., interview by Richelle Baker, 8 August� 2001.
[28] Center for Disease Control and Prevention,� 22.
[29] Center for Disease Control and Prevention,� 22.
[30] Center for AIDS Prevention Studies, "Prevention: Is HIV Prevention a Good Investment?," Journal of the American Medical Association, (University of California, San Francisco 1995),� 1.
[31] Maryland 2000 HIV/AIDS Annual Report, 1.
[32] Center for AIDS Prevention Studies, 2.
[33] Center for AIDS Prevention Studies, 2.
To view Appendix A:
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