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There is increasing knowledge of the population's sexual behaviour and attitudes, including young people's, emerging from local and externally-funded programmes. This is leading to greater government interest and response. Previous government reluctance towards sexual health education programmes for young people is changing. Ministry of Education and Science 2003 invitation to Moscow-based Project HOPE staff to produce HIV/AIDS materials for vocational school students has been funded and is being implemented. The invitation illustrates the political and professional success and acceptance of earlier drug education materials; and the adoption by the Ministry of a 'catalyst' role. Research from the materials shows the variance of attitudes between students and their teachers and parents to those who are HIV +. A further invitation was issued by the Ministry of Education and Science to produce sex education materials for main-stream school pupils aged 16 to 17, now in place. Ministerial confidence is needed to present and argue the case for school sex education to the Russian population. Introduction: statistics and behaviour The latest epidemiological evidence shows that rates of sexually transmitted infections, including HIV, and unprotected sexual intercourse in Russia continue to maintain the high levels that emerged during the 1990s. This indicates high levels of sexual activity and a low level of condom use and other safer sex practices amongst young people - and adults. In contrast to statistics produced in the 1990s, which indicated that the principal - and in the view of some official sources, sole - HIV transmission route was though injecting drug use, current figures indicate that 25% of newly recorded cases of HIV have been contracted through heterosexual sex. At a July 5. 2004 seminar organised by Moscow Education Committee and UNESCO, the Head of the City of Moscow AIDS Centre, A Mazus, claimed that 53% of new cases of HIV transmission could be traced to sexual intercourse. Figures presented at this seminar suggest that in the Moscow region the ratio of those who are HIV + is 15: 9 male: female amongt younger age groups. It needs to be emphasized that reliable epidemiology is not yet fully established and that many in the public health field see the published figures as under-estimates or under-recordings. Shapiro (2001) has described in this journal the sense of loyalty - and distrust? - which inhibits the naming of contacts to sexual health clinics. A similar sense of loyalty or solidarity pertains amongst injecting drug users, with shared use of injecting equipment required to maintain the ethos and friendship of the group of injecting peers. Government statistics state that there were 87,000 registered cases of HIV in 2000 and 264,000 on January 1. 2004. The July Moscow seminar gave the number of registered cases of HIV and AIDS as 282,000, of which approximately 10,000 are under 20. Of these, about 2,000 are receiving anti-retroviral drug treatment from the state health system. UNAIDS estimates that there are presently 700,000 cases of HIV. The Director of the Centre for AIDS Prevention and Treatment, Vadim Pokrovsky, estimates the present (2004) figure of HIV cases at 1.5 million. (This figure represents 1% of the population of the Russian Federation.) Pokrovsky’s figures further suggest that 43% of those testing HIV + did not know how they contracted the virus. Whatever the actual figures, official attitudes and responses still do not seem to fully acknowledge the extent and urgency of the situation these statistics represent. There remains a need to clarify knowledge of sexual and other risk-taking behaviours amongst the population in general, including the adolescent population; and amongst high-risk populations in particular - e.g. school drop outs, the homeless. A clearer knowledge of who is doing what will enable prevention work to be conducted more effectively and where it is most needed, tailored to the needs of specific groups. This assumes an official willingness to engage in or support preventive work. Epidemiology regarding HIV and AIDS and sexual health and behaviour in the Russian Federation is included in government statistical collection, which includes recording the incidence of contagious diseases, for example HIV. Each administrative region (oblast) has an AIDS Centre which collects statistical information about HIV and AIDS. It is generally accepted that the figures collected by these official sources under-record totals. This is seen as the combined result of a lack of trust in public services and providers; that not every HIV + person attends medical treatment; that there is a significant 'untested' HIV + population; and that high risks groups, including commercial sex workers and homosexual men, are, in the main, marginalised to the extent that they avoid contact with public services. Additional survey results are available are often the products of individuals' work (cf Cheryakov & Kon, 1998; 2000); or are part of the monitoring procedures externally funded programmes (cf. Vannappagari & Ryder). These may represent differing populations because of the different programmes; and are not available in a consistent, longitudinal pattern. The absence of long-term, national, state-commissioned statistical evidence has resulted in differing interpretations of the evidence which is available; and provided a basis for some official denial or reassurance that the statistics which are available are atypical or carried out amongst high-risk groups who should not be seen as representative of the population as a whole. Nevertheless, one international project reports that over 70% of the HIV infections officially recorded in central and eastern European and central Asian countries are in Russia (Rhodes, Platt et. al., 2002.) Key findings from University of North Carolina research in 2002 (Vannappagari & Ryder, 2004) with a survey sample of 6115 showed that: one third of all 14-20 year old respondents reported being sexually active, more young women than young men the average age of first intercourse has fallen: 41-49 year olds reported the average age of first sex as 19.7; 31-40 year olds 18.9; 21-30 year olds 17.4; 14-20 year olds 15.9 62.5% of sexually active 14-20 year olds did not use a condom the last time they had sex condom use in casual sex was lower than the figure reported above, including amongst adults some respondents reported having sex in exchange for money or gifts A report published by the Ministry of Health of the Russian Federation on the health of children included figures showing that the average age of first intercourse was 15.5; (Ministry of Health, 2003.) The State Report showed that syphilis incidence rates amongst 15 - 17 year olds was 126.7 per 100,000; gonorrhea 130.1 per 100,000; and that there were 35 abortions per 1000 amongst 15 - 19 year olds (Ministry of Labour and Social development, 2002.) Research in 1993 and 1995 (Chervyakov & Kon, 2000) demonstrated an increase in the previous decade of the numbers of young people who were sexually active; and the associated fall in the age of first intercourse. Findings from Kon's research (Kon, 2001)are summarised in the following table. The combined sample sizes were 4,500 young people aged between 12 and 19. The surveys were conducted in European Russia. "These findings suggest that changes over the last three decades in the sexual behaviour of Russian people show similar trends to those observed in the west. … because of political and ideological restrictions [these changes] have taken place largely 'under cover'." (Chervyakov & Kon, 2000: P. 120.) SexSurvey YearType of schoolMainstreamVocational16 year olds17 year olds16 year olds17 year oldsMale199335.7%42.9%41.2%55.9%199544.1%44.1%62.7%71.9%Female199316.4%29.0%39.3%58.5%199523.9%40.3%46.0%60.8% Shapiro (2001) gave a thorough and clear context for this situation in his article in the first issue of Sex Education. While the cultural and behavioural settings he described remain largely true, some changes in political responses and public attitudes are discernible and these represent, albeit at an early stage, some indication of further future shifts in response. Some Russian voices point out that his comments tend to be universal rather than nuanced. The Russian Orthodox Church, for example, is opposed to birth control and to abortion but is not opposed to condom-use to prevent the spread of STIs. In Tver, north-west of Moscow, the Church works alongside local health staff in providing treatment and care for those with AIDS; and in running public education campaigns which include safer sex messages (Project HOPE Moscow, 2004). Practice and official stance often differ, although the picture Shapiro paints at the official and organizational level remains largely accurate. Changing responses International organizations and institutions continue to express both concern at the Russian situation; and eagerness to initiate change, now usually in partnership with other international agencies and Russian governmental institutions. There is sufficient learning and experience from elsewhere in the world for models relevant to Russia to be available and adapted. At an official level, it appears that the Russian government would prefer to see Russia as a country - and culture - unlike others and therefore requiring unique provision. Changes in the functions and responsibilities of Federal Ministries have sometimes concealed a lack of official response, sometimes assisted in the prevarication resulting from the lack of a clear lead to HIV/AIDS at high levels of government. Some official voices continue to refer to 'sex education' as contradicting the cultural norms of Russia as a 'northern country' - a view which contrasts interestingly with the description of sex education programmes and attitudes in neighbouring Finland, Sweden, Norway and Denmark as representing a 'Nordic' model (Cf. UNICEF 2001); and local research into sexual behaviour (see for example Chervyakov & Kon, 2000.) A 1997 Ministry of Education-UNESCO project to develop a programme of sex education for use in the Russian school system was ended before its planned completion as a result of populist opposition, mainly based on a campaign of mis-information embracing the media, the communist-dominated state Duma (parliament) and the Russian Orthodox Church. The campaign appealed to nationalist feeling; and accused the project of promoting abortion and de-population (Chervyakov & Kon, 2000.) Nevertheless, recent activities indicate strongly that the most acceptable model for the introduction of new initiatives, in particular in areas seen by some as being sensitive, such as substance use and sexual health, is a ‘home grown’ approach, with local professionals and institutions producing materials and packages for use within Russia. That these programmes and inputs are financed externally is variously seen as a benefit, an unfortunate reality, an expectation or a requirement. This model can be compared with the strategy being adopted by the European Regional Office of the World Health Organisation since 1999. WHO resources will now be devolved to individual governments and country programming rather than to finance regional and inter-country programmes. The priorities remain HIV/AIDS - sloganised as '3 by 5' - and TB; and the 12 to 25 age group. ('3 by 5' refers to the target of 3 million HIV + people receiving anti-retroviral treatment in developing and middle-income countries by 2005.) Such structural changes notwithstanding, international and European concern at the high Russian rates of HIV transmission remains (Peterson, 2004; Galvin & Feshbach, 2004.) This concern can be seen as having two foci, not always openly expressed. The first is the increasing risk of the spread of HIV through sexual transmission across Russia’s borders with European nations as HIV becomes increasingly established in the main-steam Russian population. The second is the failure, or reluctance, of the Russian government to acknowledge the public health situation and put in place national responses, foremost amongst these being public education campaigns (there is a high level of discrimination in Russia against those who are HIV + mainly, it would seem, based on fear and ignorance) and programmes of sex education in schools. School sex education is underdeveloped and, as a result, systematic HIV prevention at state level and with state approval does not yet exist. Governmental action Government agencies are now beginning to take the initiative in responding to HIV, no longer waiting for or relying on international agencies or NGOs to set up local responses and campaigns. Ministry of Education and Science funded rehabilitation centres for young drug misusers have been established(Project HOPE Moscow 2004.) Success rates have, so far, been disappointing, with high levels of relapse by young people once they have left the residential setting and returned to their previous environments and drug-using peers. However, it is a significant step that such centres are being set up, as many practitioner and official voices five years ago took the view that illegal drug users and those who were HIV + should not be regarded as entitled to any treatment by or concern from the state and were marginalised. Opinions and practices are changing and it is now likely that the 'failure' rates of these centres will be learnt from, rather than used as a reason to end such provision. (Following the 2004 reorganisation of Ministries resulting from the election of a new government, the former Ministry of Education is now known as the Ministry of Education and Science.) Although the legal framework can be described as humane, public attitudes towards the virus and those living with it remain, on the whole, uninformed, unsympathetic and hostile, to the extent that some mothers, on learning that their new-born child might be HIV +, don’t take them home after birth in maternity wards or clinics but relinquish their legal rights as that child’s mother, as they are able to do under present Russian law. All Russian mothers, including those who are substance dependent and who decline their maternal rights, are informed of their HIV status. HIV testing is now a condition of treatment in public-sector maternity services, and in other services where surgery is required. Where a patient tests positive they are transferred to a dedicated HIV hospital or clinic for further treatment - that is, isolated. Professional attitudes are not always better informed: health workers do not always respect the legally-established confidentiality of patients’ HIV status and doctors have been known to refuse treatment to patients who declare their HIV + status. There is a legal right for HIV status to be kept confidential by health service professionals, not always practised or absorbed into day-to-day professional roles. This adds to the reluctance of those who are HIV + to disclose their status to others, in particular in the health service, and, as mentioned above, in tracing sexual contacts by sexual health clinics. This also contributes to statistical under-recording. Individual schools and local governments continue, as Shapiro (2001) pointed out, to be aware of the situations in which young people find themselves, with early ages of sexual initiation and increasing rates of STIs, and are increasingly making provision for lessons in schools intended to have a prevention outcome. The most widely used is probably the Changes programme, which concentrates on puberty. This programme was developed by the Russian Family Planning Association, funded by Procter and Gamble, and approved by the Federal Council of Experts of the Ministry of Education for national use in 1999. In the main, however, school work is a series of local initiatives which do not need Federal approval or authority, so that there is currently little collation of in-puts or evaluation of materials or outcomes. This means that learning and experience are not being appreciated or disseminated. It also means that comparison between regions - of teaching programmes, outcomes and related data - is not taking place in any organized way. Resourcing difficulties in the Russian public sector have not been resolved and statistical and other data collection is not high on the priority list of cash-weak local and regional governments. This is one aspect of work where external funding would be valuable and welcomed. (See too the discussion of the Tables included in this article.) While sex education in schools remains a topic for which there is no national consensus or framework, it is important to remember that there are three administrative influences on what is taught in schools. These are: national: where the Federal Ministry of Education and Science recommends or requires that certain subjects are taught and approves the materials to be used local: where local government has the power and autonomy to recommend, approve or require that certain topics are taught or materials used school: where an individual school or school managers can introduce topics and lessons to that school’s provision Teachers’ professional training encourages them to personally identify with the views they express in their lessons, making it difficult for many to represent a range of views or opinions - and even facts - about social issues, including sexual health. Without high-quality training and support, it is unrealistic to expect teachers to present clear, accurate, comprehensive and non-judgemental sex education programmes in the class-room. Education and prevention: work in progress While local initiatives and approaches can be seen as protecting the Ministry of Education and Science from confrontation or criticism from agencies and organisations hostile to sex education, some change of attitude is becoming evident at official levels. In 2003, the then Ministry of Education invited the Moscow office of Project HOPE to produce a package for use in technical schools in Moscow as a pilot for materials to be distributed nationally. This package - Useful Practice: Real Alternatives - comprises HIV/AIDS education and prevention resources: a student work-book; a classroom poster and student buttons; teaching materials; and a leaflet for parents. Technical schools have been chosen because of the higher risk sexual behaviours of students attending those schools. (See Table 4.) The programme is the first to produce materials for HIV/AIDS work in technical schools which has been approved by the Federal Council of Experts of the Ministry of Education and Science of the Russian Federation for national use. The materials are being requested by schools and education authorities across Russia even before they are completed; and before they have been submitted to the Federal Council of Experts for final - as distinct from 'in principle' - approval and, therefore, permission/authority to use them nationally. The programme has been introduced and trialled in Moscow City and the suburban Moscow municipality of Khimky. Funding is being sought for a second printing to extend distribution to other administrative Russian regions. It is the Ministry's intention to make the final materials and teacher training programme available nationally. This programme is also of interest because it seems to presage the shift in approach indicated by the WHO reform. It has been customary for international agencies and national governments to develop programmes of work; to agree external finance; and to seek consortia to undertake the work programme. Here, a government ministry has identified a preferred contractor; an invitation been issued; a work programme developed; and, finally, funding sought - the ‘home grown’ approach. Funding for this programme has been obtained from the Elton John AIDS Foundation and the EXEL Foundation by Project HOPE UK on behalf of Project HOPE Moscow - another established collaborative relationship which has contributed to earlier work with young people. While this runs counter to current practice of announcing tenders for undertaking programmes, in itself designed to ensure effectiveness and reduce local favouritism or nepotism, it can be seen, in this case, as reflecting a professional and political confidence in the capability of Project HOPE Moscow (PHM) on the part of the Ministry of Education and Science. It can also be seen as a first step by the Ministry towards introducing sex education programmes into the wider school curriculum without attracting wide-spread opposition or hostility: the expected quiet success of the technical schools work, it is hoped, will enable further programmes to be introduced. The Ministry has since commissioned a separate sex education programme - 'Useful Innoculation' - of class-room materials and a teacher training package for 16 and 17 year olds, again using PHM as the Ministry’s preferred partner; and again using HIV/AIDS prevention as the cue. The materials were approved by the Ministry's Council of Experts and the package was piloted in four Russian regions - Ivanovo, Saratov, Orenburg and Irtkutsk - as part of the Healthy Russia 2020 project managed by Johns Hopkins University and funded by USAID (Healthy Russia.) Based on previous collaboration between the Ministry and PHM (see Text Box), the technical schools programme currently operating includes class-room materials; a handbook for teachers; training events for teachers; and materials for parents. Student questionnaires and surveys are built in to PHM work programmes, as is frequent contact and consultation with students, teachers and educational administrators to ensure that all the materials used are clear, relevant to students lives, usable and attractive. Lessons and learning opportunities use a variety of approaches and activities, with the overall approach best described as an interactive, life-skills approach. This emphasis on interactive methodologies and the provision of discussion opportunities differs significantly from the traditional class-room approach in Russian schools. In the past the emphasis has been on a formal, teacher-led, didactic style. Implementation of the current programme is confirming previous experience from PHM projects: teachers and students respond positively and enthusiastically to the life-skills approach, and gains in knowledge and changes in attitude have been consistently recorded in questionnaires and evaluations. There is considerable Russian optimism, and some international evidence (UNICEF 2001), that these gains and changes will correspond to some changes in behaviour - including increased adoption of safer sex practices - on the part of students. It is a tribute to Russian teachers and initial teacher training that practitioners understand the theoretical basis of the life-skills approach even if it has not been previously used by them in their class-room practice. Technical schools in Russia are attended by students aged between 14 and 18 and provide vocational education. Technical school students are more likely to come from low-income families than their age peers in the parallel high schools, which prepare students for university entrance; and not to have completed their high school education. Schooling in Russia is compulsory from ages 6 to 15, with an increasing proportion of students staying on to 17 for two high-school years. At 15, the completion of middle-schooling, students go on to attend further (high) schooling on the basis of aptitude, with those opting or being selected for vocational schooling training for such roles as keyboard operators, plasterers, carpenters, cooks, fork-lift truck drivers, maintenance technicians. The Useful Practices: Real Alternatives programme, to be completed by the end of 2004, is being implemented in 5 pilot schools in Moscow City and the Khimky District in the Moscow Region, working with 420 students aged 14 to 19, 16 teachers and 5 technical specialist - i.e. teachers whose subject is the vocational specialism of the students, not the teachers of the academic curriculum such as Russian, maths and history - from the 5 schools. The work is being assisted by the involvement of Deputy Head of Education in the Khimky Administration (i.e. local authority or municipality.) Project HOPE administered pre-programme questionnaires to establish students’ attitudes to and knowledge of HIV and other STIs; and their health-related behaviours. Such surveys form an integral part of PHM practice. Designed to indicate knowledge gains and attitude changes attributable to curriculum programmes, they also demonstrate local needs to local politicians and administrators as young people's needs for preventive work in schools may not be localised or accepted from national statistics. Such statistics have been shown to carry considerable influence if locally conducted and specific, and are helping to establish a reliable, albeit small-scale, local research data-base. (See Tables 2 and 4.) Of particular interest in these samples are: lower levels of discriminatory attitudes held by students in comparison to their parents and teachers high levels of sexual initiation of 14 – 18 year olds (linked to reported high levels of monogamous sexual activity) high levels of regular alcohol use a link between alcohol use and sexual intercourse higher levels of sexual activity amongst vocational school students in comparison to their high school peers The tables. The three tables included in this article are based on recent statistics compiled by Russian practitioners. The compilers acknowledge the small sample-sizes involved. The tables published here do represent current research but the small sample sizes mean that they are best described at present as of interest rather than of statistical value. As mentioned above, a clearer picture of young people's sexual behaviour, attitudes and knowledge may become established as the PHM materials and surveys are extended to more schools; and if the cumulative statistics are collated and published. Table 1 show higher levels of awareness of sexually transmitted infections amongst high school students than amongst vocational school students. There are similar - and high - levels of awareness amongst both teachers and parents. The levels of awareness are lowest for chlamydia and trichomoniasis. Table 1 also shows higher levels of knowledge amongst high school students than amongst vocational school students about HIV transmission routes and risks. Again, teachers and parents have similar levels of knowledge. There are high levels of knowledge of the risk of HIV transmission through needles and other injecting equipment amongst all three groups - students, teachers, parents. High school students are more aware than their teachers and parents that it is possible to prevent HIV transmission from sexual intercourse. There are equivalent levels of awareness in vocational school students, teachers and parents, with students slightly more aware. Amongst those who are aware of HIV prevention, there are high levels of awareness of condom use in all groups - lowest (at 97.4%) amongst vocational school students. This section of Table 1 does reveal some misunderstandings or misinformation: 6.9% of vocational school students and 9.7% of high school students thought that the use of 'disinfectant solutions used after intercourse' would prevent HIV transmission. 9.7% of high school students and 7.4% of vocational school students thought that use of the contraceptive pill would prevent HIV transmission. The results of Table 2 indicate that students are more tolerant towards those who are HIV + than both their teachers and their parents. Table 1 indicates that teachers and parents are marginally better informed than students; Table 2 suggests that this better information has not influenced attitudes. The Table 2 findings serve to reinforce the need for work for teachers on attitudes as well as knowledge as part of school and college programmes; and the desirability of parallel work with parents in the schools and colleges where the materials are being used. The small sample size for Table 2 does need to be emphasised, making the above comments tentative - but the lessons for programme design are clear. The attitudes towards those who are HIV+ amongst the students in this sample are more tolerant than those shown in the Russia Longitudinal Monitoring Survey. The figures in Table 4 illustrate higher levels of risk behaviours amongst vocational school students than their high school counterparts, particularly in the ways in which vocational school students use alcohol. Vocational school students also show higher levels of use of other drugs than high school students. Vocational school students show higher levels of sexual experience than their high school counterparts, although behaviours of those in both categories who are already sexually experienced are similar. Vocational school students use condoms less often than their high school counterparts. The attitudinal results have shown the need for the programme writers to include significant in-puts in their planning for teacher training; and for parental meetings and events. The constant challenge for the curriculum programme is to link the positive attitudes to people living with HIV and AIDS which young people are demonstrating in questionnaire responses to their own individual sexual health and behaviour. Although aimed at young people, such linkage relies heavily on the understanding and commitment of adults where linked surveys have revealed the extent of unsafe sexual behaviour amongst the 30 plus population Conclusion. The Ministry of Education and Science is playing an important catalyst role in commissioning Useful Practices: Real Alternatives and in discussing with PHM the future design and distribution of a 6 to 15 school sex education programme. The adoption of this role suggests both a confidence and a pragmatism in responding to HIV and AIDS through the willingness of the Ministry to collaborate with a tried and trusted partner as a way of spear-heading attitudinal mainstream work once professional foundations have been laid and public awareness addressed. It would be encouraging to believe that this also represents a new-found political confidence and preparedness to act; and that Russian social scientists and researchers will be able to follow-up both the implementation (process evaluation) and impact (outcome evaluation) of the programme in order to assess - and reinforce? - the 'home grown' principle and practice. Should all of this happen, it will be an important contribution to the establishment of planned programmes of officially initiated and recognised education and prevention programmes based on relevant international experience; and which have been designed to introduce Russian practitioners and administrators to well-researched, evidence-based good-practice adopted to Russian contexts and, most importantly, presented positively and confidently to the Russian public. Tables: Table 1. Comparative knowledge of students and adults about HIV/AIDS & STIs Vocational schoolHigh school Do you know the following diseases?Students N=421Teachers N=39Parents N=30Students N=67Teachers N=20Parents N=28syphilis 87.987.593.198.5100.096.0Chlamydia12.353.144.829.955.676.0gonorrhea43.581.369.059.783.384.0trichomoniasis11.162.551.728.472.264.0HIV/AIDS98.193.889.797.088.996.0hepatitis B and C83.390.682.877.688.992.0What kind of disease is HIV/AIDS?curable9.014.73.312.3none 3.7incurable 73.870.683.376.993.885.2I don't know16.914.713.310.86.311.1How can one get HIV-infection?by handshake, embrace and kisses with infected person5.48.16.719.75.3nonethrough sweat and tears 2.0none6.7none5.3noneby unprotected sexual intercourse94.994.686.792.4100.096.4though animal and insect bites6.4none6.710.610.57.1by using needles and syringes used by some-one else for drug injection which have not been properly cleaned, tattooing and piercing83.389.296.790.989.585.7through cough and sneezing2.7none3.31.55.3noneby using dishes and linen of infected person5.12.7none1.510.5noneby using public transportation1.2nonenonenone10.5nonefrom infected mother to child before, during birth and through breast milk57.175.773.381.873.778.6by using public bath and toilet5.12.7none1.510.53.6Is it possible to prevent HIV-infection having sexual intercourse with infected person?Yes79.276.373.385.168.464.3No8.97.96.76.05.321.4I do not know12.015.820.09.026.314.3If you answered “yes”, what prevents it?contraceptive pills7.4nonenone9.78.35.0sponge, spermicide gel2.0nonenone3.2nonenonepills used after sexual intercourse3.2nonenonenonenonenonedisinfected solutions used after sexual intercourse6.9none4.09.7none5.0condom97.410010098.4100.0100.0 Source: Project HOPE Moscow, 2004, 2005 Table 2. Comparison of attitudes towards PLWHA QuestionPositive answer (YES) in %Students N=67Parents N=386TeachersN = 117N= 109 Pre testPost -testShould HIV-infected person work at grocery shop?6717.840.275.3Should HIV-infected person work at state school?7337.8948.778.9Is it possible for an HIV+ person to be treated at a public outpatient clinic29.853.080.6If a member of your family is HIV+ would you want it to be kept a secret?82.378.687.2If you find out that HIV-infected person works at a grocery shop, will you go shopping there?5613.927.452.4If you find out that HIV-infected student studies together with your adolescent, will you advice him/her to study there?-54.3--If you find out that an HIV+ teacher works in your college will you still work there?--83.895.4 If you find out that HIV-infected student studies at your group, will you continue studying there/teaching there?88-85.597.2 Source: Project HOPE Moscow, 2005 Table 3. Pre-and post-test attitudes of vocational school students to PLWHA. QuestionPositive answer (YES) in %Experimental groupControl groupPre-test N = 261Post-test N = 170Pre-test N = 159Post-test N = 126You are invited to a friend's place and you know that an HIV+ person will be there. What would you do? (Would you go and communicate with him/her as much as with others?)65.779.261.674.4Should an HIV+ person work at a grocery shop?23.556.531.844.5Should an HIV+ person work at a state school?31.359.134.248.8Is it possible for an HIV+ person to be treated at a community out-patient clinic?26.453.320.1 33.1 Is it possible for an HIV+ person to study at a vocational school or college?53.879.456.663.0If you find out that an HIV+ person works at a grocery shop would you shop there?40.256.145.345.2If you find out that an HIV+ teacher works at your college, would you study there?66.377.264.873.8If you find out that there is an HIV+ student in your class, will you continue studying in the group?80.589.982.483.3 Source: Project HOPE, 2005 Table 4. Risky behaviours among school students Vocational school juniors 14-19 years old N=421 Project HOPE, February 2004High school students 14-18 years old N=67 Project HOPE, March 2004All responses in percentagesLifetime prevalence of alcohol use97.198.5Alcohol use during past month81.967.2Heavy drinking during past month49.831.1Lifetime prevalence of marijuana use38.325.8Marijuana use during past month34.627.8Lifetime prevalence of inhalants use10.13.0Lifetime prevalence of ecstasy use8.46.1Lifetime prevalence of steroids use4.17.7Lifetime prevalence of heroin use3.1noneLifetime prevalence of IDU2.2noneLife time prevalence of sexual activity59.734.3One sexual partner during lifetime 35.330.4One sexual partner during past three months 67.660.9Alcohol and drug use before last sexual intercourse33.534.8Condom use during last intercourse78.386.3 The figures used in Table 4 extract percentages from total numbers of students who reported life-time use of alcohol and marijuana; and from those who reported having sexual intercourse at least once. Source: Project HOPE Moscow, 2004, 2005 Text Box Project HOPE Moscow: the 'home grown' approach Project HOPE Moscow is the Russian office of the US-based Project HOPE. With funding raised by Project HOPE UK's London office, Project HOPE Moscow has been instrumental in producing school drug education materials since 1997. This work has been largely funded by grants from Glaxo Smith Kline and the US Substance Abuse and Mental Health Services Administration (SAMHSA.) This work has resulted in three sets of teaching resources and extensive programmes of teacher training. The teaching resources include Useful Habits, first published in 1998, for ages 6 -11; Useful Skills (2001) for ages 11 - 15; and Useful Choices (2003) for 16 - 18 year olds (Stothard & Romanova, 1999.) Useful Skills and Useful Choices included a section on HIV and AIDS, introduced at the request of the Ministry of Education. The materials have been printed in several editions and are available both in bound (paper) formats; and electronically, enabling local authorities to re-print the materials when needed. Useful Habits was originally intended for schools in the Moscow City and Region authorities. The opportunity arose early in the programme's life (originally planned and funded on a realistic four-year basis) to work with the Ministry of Education, leading to national recognition and approval of the materials and subsequent extensions to older age-groups. This work also involved support in kind from the Ministry in the organisation of teacher training programmes and the national distribution of printed materials, a considerable logistical task in a country the size of the Russian Federation. All three resources have been approved by the Ministry of Education's Federal Council of Experts for use throughout the Russian Federation. The materials have been introduced into 68 of the 89 local government administrations in Russia. Project HOPE staff have conducted training events for teachers in most of these regions and the Ministry of Education has accredited this training in its national programme of continuing professional development. Correspondence: Blaine Stothard, Independent Consultant in Health Education, 42 Dalyell Road, London SW9 9QR, UK; email: blaine@healthed.demon.co.uk Olga Romanova, Project HOPE Moscow, Russia; email: projhope@online.ru Larissa Ivanova, Project HOPE Moscow, Russia; email: projhope@online.ru REFERENCES: CHERYAKOV, V & KON, I S.(2000) Sexual revolution in Russia and the tasks of sex education, in: MOATTI et.al. (Eds) AIDS in Europe: new challenges for social sciences (London, Routledge) pp. 119 - 134. CHERYAKOV, V & KON, I S. (1998) Sex education and HIV prevention in the context of Russian politics, in: ROSENBROCK, R. (Ed) Politics behind AIDS policies: case studies from India, Russia and South Africa (Berlin, SWZ) GALVIN, C. & FESHBACH, M. (2004) Russia in denial over its AIDS epidemic, The Irish Times, August 23. 2004 www.ireland/com HEALTHY RUSSIA: For further details see the Healthy Russia 2020 web-site:  HYPERLINK http://www.jhuccp.org/pressroom/2004/05-25.shtml www.jhuccp.org/pressroom/2004/05-25.shtml KON, I S. (2001) Adolescent sexuality on the eve of the 21st century (Fenix, Dubna, Russia): Text in Russian only: Podroskovaya seksualnost' na poroge XX1 veka. The surveys referred to are those undertaken by V Chervyakov. Further background to Kon's work can be found at: http://sexology.narod.ru/info.html which has English pages. MINISTRY OF HEALTH, (2003) The state of children's health in the Russian Federation (total Russian follow-up): Moscow, Russia. Text in Russian only. MINISTRY OF LABOUR AND SOCIAL DEVELOPMENT, (2002) The state of children in the Russian Federation: Moscow, Russia. Text in Russian only. PETERSON, S. (2004) Reluctantly, Russia confronts AIDS, Christian Science Monitor, August 16. 2004 www.csmonitor.com/ PROJECT HOPE MOSCOW, (2004) Visit and interviews by first author. PROJECT HOPE MOSCOW, (2005) Vocational schools based life-skills approach to HIV/AIDS prevention in Moscow to prevent the spread and suffering caused by HIV/ AIDS project: final report to funders, February 2005 RHODES, T., PLATT, L. et. al. (2002) Behavioural factors in HIV transmission in eastern Europe and central Asia, Unpublished paper, UNAIDS, Geneva. SHAPIRO, B. Y. (2001) School-based sex education in Russia: the current reality and prospects Sex Education, 1, 1 pp. 87 - 96 STOTHARD, B. & ROMANOVA, O. (1999) Moscow materials: useful habits, Drugs: education, prevention and policy, 6 3. Pp 309 - 319 UNICEF (2001) A league table of teenage births in rich nations Innocenti Report Card Issue No 3, (Florence) VANNAPPAGARI, V. & RYDER, R. (2004) Monitoring sexual behaviour in the Russian Federation: The Russia Longitudinal Monitoring Survey 1992 - 2003, Report submitted to US Agency for International development by Carolina Population Centre, University of North Carolina at Chapel Hill, North Carolina, April 2004. 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”¢p£‹£ģ¤8„ŗ„½„¾„żųżųżųżųżųżųżųżųżųżųżųżųżųżųżņķņķņķņķņķēķķņąŲąŲąŲąĶąæĶ¶Ķąķ°ķąŲąŲąŲą H*OJQJ0JCJOJQJjCJOJQJUjCJOJQJU6CJOJQJ CJOJQJ 6OJQJOJQJ 5OJQJCJmH mH E‘‘‘@‘E‘J‘K‘p‘u‘z‘{‘›‘ ‘„‘¦‘ˑБԑՑų‘ü‘’’%’)’-’śß°ÜśśßĄÜśśß¬Üśśß¼Üśśß°Üśśß“Üśś$$$–lÖÖ ”’Ø čĄ!$$-’.’P’T’Y’Z’u’y’~’’§’¬’±’²’Ö’Ū’ą’į’““““M“R“W“X“ä°įÜÜä”įÜÜäĢįÜÜä¼įÜÜäąįÜÜäüįÜÜäø$$$$$–lÖÖ ”’Ø čĄ!X“{“€“…“†“‡“Q”R”z”}”~””€””‚”ƒ”„”…”Ž””¾”æ”4–5–”˜¢˜ü÷÷ÜŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁŁ$$$–lÖÖ ”’Ø čĄ!$$$„”…”Ž””¾”æ”4–5–”˜¢˜ųšłš»œ¼œ½œ¾œæœĄœŃœWåęēōõ¾ž™Ÿ Ķ ¢Æ¢8£²£ō£Ē¤[„Ś„Z¦Ę¦ż§‘ؒؓ؞ةػؼØĒØĻØŃØÓØęØēØčØéØžüüśüüüśśśśśśśųõõśņššķķšššššķššš     7¢˜ųšłš»œ¼œ½œ¾œæœĄœŃœWåęēōõ¾ž™Ÿ Ķ ¢Æ¢8£²£ō£Ē¤[„Ś„üüüüüüüüüüüüüüśśųśśśöųųųųųųų$ĶDŠÉźyłŗĪŒ‚ŖK© www.thelancet.comąÉźyłŗĪŒ‚ŖK© 4http://www.thelancet.com/ĶDŠÉźyłŗĪŒ‚ŖK© www.thelancet.comąÉźyłŗĪŒ‚ŖK© 4http://www.thelancet.com/DŠÉźyłŗĪŒ‚ŖK© #httŚ„Z¦Ę¦ż§‘ؒؓ؜؝؞ةػؼØÅØĘØĒØÓØęØēØčØéØz(|(Ž((Ž(ą(“+üśśśųüļķėļķėļķėļķėėüüėėėėüü&`#$„ü’„$3 0&P 1h°…. °ĀA!°"°# $ %°°Ā°Ā Ä0&P 1h°…. °ĀA!°"°# $ %°°Ā°Ā ÄTable 1. 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