Ethical considerations

Ethics approval was received from the Curtin University Human Ethics Committee and the State AIDS Control Society, Delhi to conduct this research. Permission to carry out the research was also obtained from the principals of the schools involved. (Principals have the authority to allow cross sectional surveys to be conducted without parental consent in India.) This complies with the Helsinki Declaration for research conducted with humans. All participants provided written consent prior to being involved in this study and all results were de-identified prior to reporting.

HIV/AIDS related knowledge

The findings of this study indicated good awareness about the modes of HIV transmission and prevention among adolescent girls. For example, 77% (n = 193) of girls were aware of the link between high-risk behaviour such as multiple sex partner and HIV. Conversely, in a study published conducted by the ICMR (Indian Council of Medical Research) in higher secondary schools in rural areas of 22 districts and 14 states, only 13% of adolescent knew that multiple sex partners increased the risk of HIV infection [8].

Some areas still needed special attention. Approximately half of the adolescents (46%, n = 111) in this study were not sure if a healthy looking HIV infected person could transmit the HIV infection to others. In a study among school children in the state of Hariana, 57% believed that persons with HIV/AIDS could be detected by their physical appearance [9]. This is of concern as evidence shows that people with HIV may remain asymptomatic for several months or years before developing AIDS but still transmit the infection[7]. A significant number of respondents in this study (n = 30%, n = 75) also considered AIDS could be cured. Other surveys within India show similar [9]. This is clearly an area that requires attention.

There was also a lack of knowledge about the risk of transmission of infection among MSM (men who have sex with men). In 2002, a study found that the HIV prevalence among MSM in the City of Mumbai was 20% [10]. Research shows MSM were eight times more likely to be seropositive for HIV and over twice more likely to have a history of STIs compare with non – MSM [11].

It is important to note that among the school course elements that have generated most controversy and debate in India are discussions about homosexuality and information on the options of safer sex, including condom use and masturbation.

Sexual behaviour

Research indicated that attitudes, outlooks, norms and beliefs around sexual behaviour determines the intended sexual behaviour of young people [12]. In this study 15% (n = 37) of respondents did not believe that girls should remain a virgin until they marry while 9% of girls admitted a sexual experience. However, several studies have indicated that the most common reasons cited for having engaged in unwanted sex were being drunk and pressure from a sexual partner [13].

Bridging the gap between knowledge and practice (particularly with respect to the use of condoms) has emerged as a major behavior change communication challenge to reducing adolescents' vulnerability to STIs and unwanted pregnancies [14]. The present survey showed 8% (n = 20) of students felt that no one (of their age) used condoms if they had sex while 33% (n = 82) considered that a few students used condoms during sex.

Knowledge about STIs other than HIV/AIDS

The findings of this study indicated that knowledge about STIs other than HIV/AIDS was very poor among adolescent girls. The majority (71%) had not heard about Genital Herpes and almost half had not heard about Gonorrhoea (44%) or Syphilis (43%). This is of particular concern in developing countries like India, as STIs such as Chlamydia, Trichomoniasis, Syphilis and Gonorrhea are second only to maternal morbidity and mortality as the cause of death, illness and 'years of healthy life lost' among women in their child bearing years [15].

Comparison of findings is difficult as there are no published studies in India investigating the STI knowledge (other than HIV/AIDs) of adolescent schoolgirls. More than one third of student in the present study had no accurate understanding about the signs and symptoms of STIs. The only study with some comparability was conducted by Lal et. al., (2000) in Kerala where college students had 34% awareness of the symptoms of STIs [16].

The present study found that a number of students (22%, n = 54) did not know that people who always used condoms were safe from all STIs. However, male and female condoms are the only technology available that can prevent sexual transmission of HIV and other STIs [17]. Laboratory studies have found that STIs do not pass through intact latex condoms even when devices are stretched or stressed [17]. They reduce the risk of transmission of HIV, Gonorrhea and Chlamydia [18] and Herpes simplex virus [19] in both women and men during sexual intercourse. Young sexually active people need to be aware of the risk of STIs and correct use of condoms to prevent STIs transmission. The continued promotion and widespread availability of condoms is an essential STIs control strategy [20].

Social norm

Attitudes, norms and motivational factors are crucial elements in the decision making process of adolescents around engaging in risky behaviours [21]. Interestingly, in the present survey, almost one quarter of the adolescent respondents (22%, n = 55) had agreed that there was nothing wrong with unmarried boys and girls having a sexual relationship if they loved each other. This observation is reflected in the increasing incidence of premarital sex in India.

When asked if students should have access to condoms, surprisingly, 49% (n = 123) of respondents felt that condom should not be available to youth because it encouraged them to have sex. In a similar study conducted in both India and Kenya, there was also a strong resistance towards the availability of condoms in both countries [22].

Though contemporary literature reveals that oral contraceptives are safe for adolescents, in India, less than 10% of adolescents use any form of contraceptive [23]. In the current study 32% (n = 82) of girls thought that girls should not take the contraceptive pill as it should only be taken by married women. Adolescents' attitude towards contraceptives (including condoms) may be based on cultural and other beliefs that need specific educational efforts to change.

Sources of information

The result of the present study indicated that for adolescent students the Internet, media, friends, books and magazines were the main sources of information regarding safe sex and HIV/STIs. Often students were confused or misinformed due to erroneous information received from these sources. Therefore evidence-based sex education must be a major strategy in school-based programs, with user friendly resources ready available to students.

Currently HIV/AIDS education is only taught in science which is an optional subject in India. In the current study more than half of the adolescents (53%, n = 132) had never attended classes about STIs, HIV/AIDs or safe sex. Most of the adolescent (87% n = 215) felt that there should be classes related to HIV/AIDS, other STIs and safe sex in school. This findings is supported by a study conducted by the Kore et. al., (2002) where 71% students showed a willingness to attend awareness programs arranged related to HIV/AIDS [24].

In order to intensify the focus on STI prevention among young people, in June 2005, the Government of India announced the National Adolescent Education Program (AEP). While the main focus of the program was on HIV/AIDS prevention, it also covered sexual reproductive health issues, gender and life skills [10]. Regrettably the proposal to incorporate compulsory sex education in the school curricula as part of anti-AIDS course was rejected outright by State Governments of Madhya Pradesh [25], Maharashtra [26] and Gujarat [27, 28] even before implementation of the program. Kerala and Karnataka [27], India's progressive states, were also considering sex education bans. [29]

The opponents of sex education in schools say that the AEP is not culturally sensitive, it has ambiguous material and could encourage students to experiment with sex, defeating the very purpose of the campaign and contributing to the spread of HIV/AIDS. Reacting to the Central Government's circular for immediate implementation of the AEP in all CBSE (Central Board of Secondary Education) and state-syllabus schools, Karnataka Education Minister Basavaraj Horatti said, "In today's world, we need moral education and not sex education" [27]. He also claimed that school-going children were too young to contract the disease, therefore sex education would unnecessarily affect their tender minds [27]. Most Indian states are yet to make a decision about introducing sex education [26]. If schools do agree to implement the AEP, further training in communication skills for educators/teachers and health personnel will be required. In addition, support of state political leaders and health and education authorities is essential for STI prevention interventions to be effectively executed in Indian schools[30].

Unfortunately, many school students are exposed to sex and pornography through various television channels, cell phones and Internet cafes. Educating adults and children is essential under these non-regulated conditions. According to AIDS activists, sex education helps to make students cautious against the dangers of experimenting with sex at a young age, sensitising them and also warning them about the potential exposure to deadly diseases. Many parents are hesitant to talk about sex with their teenage children at home; even mothers hesitate to talk to daughters about something as simple as menstruation. Moreover, widespread illiteracy underlines the importance of being able to talk about sexuality comfortably in a gathering or congregation. Policymakers also believe that many people will be critical of moves to implement sex education to young people therefore may seek political advantage by promoting traditional values.