Reviewing a middle-school book in health

AIDS Education
1993. 45 pages. ISBN of the student's edition: 0-02-652466-X.
Glencoe Division, Macmillan/McGraw-Hill School Publishing
Company, 936 Eastwind Drive, Westerville, Ohio 43081.
(This company is a division of McGraw-Hill, Inc.)

A Poorly Conceived Book
That Neglects Vital Issues

Mardge Cohen

Why do these books have AIDS in their titles? The paramount issue for teenagers is exposure to HIV during their experimentation with drugs and sex, not the challenge of living with AIDS. The difference between HIV and AIDS is never made clear in AIDS Education, though this would be a good starting point; most teenagers have already heard the terms "HIV" and "AIDS," even if they aren't sure about what the terms mean.

The first chapter of AIDS Education attempts to familiarize students with the immune system and with the concept of a virus, and it presents various facts and myths about how people become infected with "the AIDS virus." I think that middle-school students are ready to call HIV by its right name. I also think that it would be useful to describe some of the studies which have shown that HIV is not spread by casual contact in homes or restaurants where there are people infected with HIV, so students can understand how scientific knowledge is gathered and how it can be used to overcome fears and prejudices; students are more likely to absorb and remember scientific information if they know how it has been acquired. I think, too, that more attention should be paid to the fact that an HIV infection usually involves a long asymptomatic period.

All the chapters in AIDS Education have pictures, but the pictures generally are too dark and are not really useful. In the pictures that show teenaged couples in romantic settings, the couples are heterosexual, even though we know how important it is to provide information about HIV to the many teenagers who are pursuing homosexual relationships. AIDS Education does not address this matter in any way. The word "homosexual" is used only in the first chapter, to describe "the first group of people in the United States to be infected in large numbers." In the second chapter, the box titled "Ways HIV Is Spread" has a paragraph about "sexual contact," but it deals only with intercourse between a male and a female. It doesn't mention male-to-male sex at all.

Chapter 3 tells about tests for HIV antibodies, lists the more common diseases associated with AIDS, and then presents a section called "AIDS Research and Treatment." This section includes a discussion of the costs of hospitalization and of home care, though these topics are probably not interesting to most teenagers.

Chapter 4, the last chapter in the book, discusses the prevention of HIV infection. This topic should have been considered much earlier; as I have said, the big issue for teenagers is exposure to HIV, not the pathology of AIDS. The discussion of condoms is explicit and well written, though again the perspective is strictly heterosexual. Anal intercourse is mentioned as a form of "high-risk sex" that should be avoided, but the writers have failed to emphasize that anal intercourse occurs not only between men and women but also between men and men.

There are several other important points that are not mentioned, or are not sufficiently emphasized, in AIDS Education. First, the incidence of HIV infection in teenagers is increasing, especially among blacks, Latinos and residents of rural areas in the South. Although schools have been using books like AIDS Education for some years, the numbers of infected teenagers are going up. Second, the social issues involved in the spread of HIV infection are the same issues that are involved in teenage pregnancies, abusive relationships, and sexual abuse. Separating these issues from the HIV epidemic has not been a winning strategy. Educational efforts in schools have to connect these factors, let students talk about them, and make more use of peer educators. Providing appropriate time and an appropriate atmosphere for discussing the real issues will do a lot more good than having students perform the written exercises in AIDS Education.

Largely Valid Information,
Disquieting Social Aspects

David F. Busch

This book is not simply about AIDS, however. It presents passages about "high-risk behaviors" linked to the spread of HIV, and it vigorously advises teenagers to avoid them. "Safer" sex is described, including the use of condoms, but the writers' bias toward abstinence from all sexual activity is obvious.

AIDS Education was first copyrighted in 1990; the version that I am reviewing here is dated in 1993. The information that it presents remains valid, in general, though a few statements don't measure up. One error is the equating of "the wasting syndrome" with Mycobacterium avium intracellulare infection (page 24). Wasting may be attributable to other kinds of opportunistic infection as well, or it may occur even if no recognized opportunistic infection is present. Another inaccuracy is the statement that "All HIV test results remain confidential" (page 25). California and some other jurisdictions have laws that impose confidentiality, but such laws are not universal, and there are grave concerns about the possible misuse of information regarding the HIV status of individuals.

The years since 1990 have seen a number of advances in our understanding of HIV and AIDS, but these advances are not consistently reflected in AIDS Education. For example, we now know that HIV infects not only lymphocytes but also brain cells and other cells as well. We have evidence that genital herpes and other ulcerative diseases may facilitate the sexual transmission of HIV. We know that the initial manifestation of exposure to HIV may be a relatively brief illness characterized by fever and rash, or it may include such serious diseases as meningitis or encephalitis. We have new tests that measure the quantity of active HIV that an individual is carrying, and these tests of viral load may supplement or even supplant the ELISA and Western-blot antibody tests mentioned in AIDS Education. On the therapeutic side, AZT remains useful but several other medications (e.g., DDI, DDC, D4T, 3TC) seem to have some ability to control HIV; these agents may prove to be valuable as alternatives to AZT, or they may be used in conjunction with it. There is increasing use of medication in efforts to prevent opportunistic infections in patients whose immune systems have been severely compromised. And finally, researchers are studying individuals whose state of health seems stable even though have been infected with HIV for many years.

Because of the rapid expansion of our knowledge about HIV infection and AIDS, curriculum materials rapidly become outdated unless they are revised regularly. Some of the new developments that I have cited may be useful to teenagers who are trying to understand AIDS, and such developments should be incorporated into any future editions of AIDS Education.

Issues of scientific accuracy and currency aside, I find AIDS Education disquieting in its social aspects. There is a limited acknowledgment of homosexuality early in the book, but all of the later discussion of sexual behavior and of ways to prevent HIV infection is directed solely toward heterosexuals. Furthermore, the writers' preachy emphasis on abstinence may alienate some teenagers and may negate both the educational value and the message of this book.

Mardge Cohen is a physician and a specialist in internal medicine. Since 1988 she has directed the Women and Children HIV Program at Cook County Hospital, in Chicago.

David F. Busch is a physician, a specialist in internal medicine, and a professor of medicine at the University of California at San Francisco. He has been providing medical care to AIDS patients since 1981.

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