adult sexual practices. To be accepted as an adult and a member of society in many African cultures, one must prove one's fertility—often in the context of marriage. Many cultures have strong expectations for early marriage and child-bearing soon after puberty, especially for girls. HIV-prevention messages must be developed with a recognition that postponement of sexual debut may be in potential conflict with local mores. Further, even where delay in sexual debut is considered possible or desirable, there is a paucity of information available to adolescents about responsible, safe expressions of sexuality once sexual relations have been initiated.

African adolescents, like adolescents elsewhere in the world, are often unable to discuss openly with their parents their questions, fears, and concerns about sex, marriage, and other adult topics. They also have poor negotiation skills when approached for sex by adults. With the exception of cultures that have adult female initiators, 9 youth have little opportunity for frank discussions with adults about sex. Youth therefore rely heavily on their peers for information. Unfortunately, peer information is often inaccurate. In addition, some youth may feel pressure from their peers to experiment with sex. Elders, who have traditionally been respected and whose guidance has been valued by youth, are now seeing their role and influence being eroded slowly by modern influences. the impact of these significant social changes remains unknown.

The escalating number of children and adolescents orphaned by parents who have died of AIDS is also a critical issue (see Chapter 6). The World Health Organization predicts that by the year 2000, more than 10 million HIV-negative children under age 10—90 percent of them in sub-Saharan Africa—will have lost their mothers to AIDS (World Health Organization, 1992b). Traditionally, orphaned children are absorbed by the extended family. But in many areas, such as the Rakai district in Uganda and the Kagera region of Tanzania, many heads of households have died of AIDS, leaving elderly grandparents to care for multiple sets of children. Inevitably, some children also slip through the cracks in the extended family network and find themselves living on the streets, where modifying high-risk behavior becomes secondary to satisfying basic needs, including food, shelter, and clothing.

Other issues relate to the subgroup of youth that attends school. On the one hand, schools are ideal vehicles for HIV education because they exist everywhere, even in rural areas, and provide easy access to youth. Moreover, schools can reach students daily, making critical reinforcement of prevention messages more practical. But schools as vehicles for HIV-prevention programs have their limitations. Many schools are overcrowded, and in some countries, such as Zambia, schools run double and sometimes even triple shifts per day. Consequently,


 Initiators are female elders who teach pubescent young girls about sex, marriage, childbearing, child rearing, and other adult responsibilities.

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