to offer instruction on HIV and/or STD prevention, and most health education teachers reported teaching STD prevention. However, studies indicate that instruction, when it exists, is not consistently implemented at an early enough age. In addition, teaching materials for STDs need to be developed. Current instruction is of inconsistent quality and effectiveness, and variable content and time is devoted to it. Besides providing information, school-based education programs need to provide students with the skills to implement healthy sexual behaviors. The committee believes that it is possible to increase knowledge, change attitudes, and influence behavior of adolescents by expanding the use of school-based health education curricula and by providing the training and support necessary to improve existing programs.

Given the high rates of sexual intercourse among adolescents and the significant barriers that hinder the ability of adolescents to purchase and use condoms (as cited in Chapter 4), the committee believes that the current evidence is sufficiently strong to recommend expansion of condom availability in schools. Definitive data regarding the effectiveness of condom availability programs in schools are limited, because such programs are relatively new and few have been designed for measurements of effectiveness. However, available data regarding school- and community-based condom availability programs cited in Chapter 4 suggest that such programs are effective. Data also show that both parents and students are highly supportive of such programs and believe that they have a positive effect on prevention of HIV infection and other STDs among adolescents. None of the studies reviewed by the committee suggests that access to condoms in schools results in increased sexual activity among students. Legal challenges to these programs based on constitutionality arguments have been found to be largely without merit. Because of the sensitive nature of this issue, it is clear that schools, school boards, public health officials, health plans, parents, and students will have to work closely together in establishing condom availability programs.

As discussed in Chapters 3 and 5, students in universities and colleges also are at high risk for STDs. The scope and quality of STD-related services in these institutions, however, are unclear. Because many adolescents and young adults do not have private health insurance, school and student health clinics should ensure that confidential and comprehensive STD-related services are available.

Hepatitis B vaccine is highly effective and recently has been recommended for all infants and adolescents (11- and 12-year-olds), as well as for other adolescents and adults at high risk for hepatitis B virus infection. Many adolescents and adults at high risk for this infection, however, have not been vaccinated. Immunizing adolescents is difficult because of their relatively infrequent encounters with health care professionals and inadequate access to health care. Until childhood hepatitis B immunization ensures that all adolescents are protected, all clinical opportunities to immunize adolescents against hepatitis B virus infection need to be utilized. This includes school-based and school-linked clinics and



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