GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

United States General Accounting Office

Washington, DC 20548

Health, Education, and

Human Services Division

B-286071

September 20, 2000

The Honorable Ernest J. Istook, Jr.

Chairman, Subcommittee on the District of Columbia

Committee on Appropriations

House of Representatives

Subject: District of Columbia: Adolescent AIDS Prevention Program

Dear Mr. Chairman:

In response to your request, we have reviewed the District of Columbia’s Adolescent

AIDS Prevention Program, which makes condoms available to students in the D.C.

Public Schools. Specifically, you asked us to obtain (1) statistics on the specific

schools that are participating in this program; (2) information about how the schools

were selected to participate in the program; (3) the source and amount of funding

identified in the D.C. government budget; (4) statistics on sexually transmitted

diseases, human immunodeficiency virus/acquired immunodeficiency syndrome

(HIV/AIDS), and pregnancies among D.C. public school students;1(5) the policies that

govern the distribution of all forms of contraception devices to students in the D.C.

Public Schools; and (6) information on policies governing sex education in the D.C.

Public Schools.

In summary, the Adolescent AIDS Prevention Program is administered by school

nurses in all 17 of the District’s currently operating public senior high schools, at the

discretion of the Mayor, the D.C. Public Schools Superintendent, and the D.C. Health

and Hospitals Public Benefit Corporation. Although the program is not a separate

item in the D.C. budget, a D.C. Department of Health (DOH) official reported that the

condoms distributed by school nurses in the 1999-2000 school year cost $2,625 and

were purchased through a grant from the Centers for Disease Control and Prevention

(CDC). Information on the incidence of sexually transmitted diseases and HIV/AIDS

among D.C. public high school students is not available. However, there were 1,862

reported cases of sexually transmitted diseases (about 55 per 1,000 teenagers) and

fewer than 5 newly reported AIDS cases among all D.C. teenagers in 1999. For the

1998-99 school year, school nurses were aware of and monitoring 249 student

1

HIV/AIDS can be contracted through means other than sexual contact and is counted separately from

other sexually transmitted diseases. In addition to sexual transmission, HIV may be contracted in a

number of ways, including contaminated needles, mother-to-child transmission through birth or

breastfeeding, or transfusions of infected blood.
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2 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

pregnancies among all D.C. public school students. The D.C. Health and Hospitals

Public Benefit Corporation sets the policies governing the program, which allows

condoms to be distributed only through school nurses and only after a student has

specifically requested them. No other forms of contraception may be distributed in

the D.C. Public Schools. The D.C. City Council established regulations that require

the D.C. Public Schools to teach age-appropriate sex education as part of the regular

curriculum; submit a list of all textbooks to be used for sex education to the D.C.

Board of Education annually for approval; notify parents or guardians in writing

before sex education is taught; and make all instructional materials available for

inspection by parents or guardians of students receiving sex education.

To address your request, we collected data and policy documents from DOH, the D.C.

Health and Hospitals Public Benefit Corporation, the D.C. State Center for Health

Statistics, and the D.C. Public Schools. We also interviewed officials from each of

these agencies, and reviewed the D.C. budget for fiscal year 2000 and the proposed

budget for 2001. Although some data are available by school, we are presenting

aggregated data to protect the confidentiality of students. We did not independently

verify health statistics or statistics on the number of condoms distributed to public

school students. In every other respect, our work was performed in accordance with

generally accepted government auditing standards.

BACKGROUND

The Adolescent AIDS Prevention Program was implemented in all of D.C.’s public

senior high schools and in four junior high schools in September 1992 under former

Mayor Sharon Pratt Kelly.2 The program was part of Mayor Kelly’s response to the

rising incidence of HIV infection in the District. The program’s objective is to prevent

the spread of HIV infection among high school students in the D.C. Public Schools

through a combination of (1) prevention education, (2) individual counseling, and (3)

condom access.

As detailed in figure 1, the first component—prevention education—is taught to all

high school students and is administered by the school nurse in cooperation with

other relevant agencies and outside resources. The second component—individual

counseling—is given only at the request of a student. School nurses and student peer

educators3

are available to assist students who have concerns or questions about

HIV/AIDS that they would like addressed privately.

2

In the 1992-93 school year, there were 22 senior high schools in the District of Columbia. Since then,

several of these high schools have closed, leaving a total of 17 public high schools, all of which

continue to participate in the Adolescent AIDS Prevention Program. One of the participating junior

high schools dropped out of the program in the 1993-94 school year and the remaining three dropped

out in the 1996-97 school year.

3

Student peer educators, also known as Peer AIDS Prevention Educators, are students who are trained

to help their peers identify pressures that may lead to sexual involvement, to provide skill building

workshops that encourage abstinence and safer sex, to network with other schools to promote AIDS

prevention education activities, and to conduct AIDS prevention education activities within their

schools.
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3 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Figure 1: Adolescent AIDS Prevention Program Components
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4 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Students do not automatically receive condoms through the Adolescent AIDS

Prevention Program. Students must request condoms from a school nurse, who

provides information about abstinence as an alternative to engaging in sexual activity

in addition to providing instruction in how to use condoms to reduce the risk of HIV

infection.

STATISTICS AND POLICIES

The Adolescent AIDS Prevention Program is administered in all 17 of the District’s

currently operating public senior high schools at the discretion of the Mayor, the D.C.

Public Schools Superintendent, and the D.C. Health and Hospitals Public Benefit

Corporation. Table 1 provides basic information about each of the participating

schools, and figure 2 shows where these schools are located.

Table 1: D.C. Public High Schools Participating in the Adolescent AIDS Prevention

Program

Senior high school Ward

Number

of

studentsa

Black

(%)a

White

(%)a

Hispanic

(%)a

Asian/

Pacific

Islander

(%)a

Eligible

for free/

reduced price

lunch

(%)b

Promotion

rate

(%)a

Attendance

rate

(%)c

Anacostia 6 778 99.9 0.1 0.0 0.0 98.0 70.0 85.2

Ballou 8 1,033 99.5 0.5 0.0 0.0 68.0 77.5 80.9

Banneker 1 432 92.8 0.7 3.2 3.2 27.0 98.1 96.4

Bell Multicultural 1 662 23.7 0.5 64.4 11.5 96.0 91.2 Unavailable

Cardozo 1 825 75.5 0.4 20.7 3.3 79.0 80.1 90.1

Coolidge 4 1,064 96.5 0.2 2.8 0.5 22.0 94.9 85.3

Dunbar 5 697 99.0 0.0 0.9 0.1 77.0 86.9 84.2

Eastern 6 1,543 99.5 0.1 0.4 0.1 77.0 85.4 88.6

Ellington

School of the Arts 2 489 86.9 8.8 3.9 0.4 36.0 87.7 87.4

Luke C. Moore Academy 5 196 96.4 0.0 3.6 0.0 34.0 53.2 45.0

Phelps Career Senior High

School 5 435 99.8 0.2 0.0 0.0 88.0 74.2 94.3

Roosevelt 4 703 78.9 0.0 20.1 0.7 49.0 86.7 81.8

School Without Walls 2 339 64.9 19.5 8.0 7.4 11.0 95.4 Unavailable

Joel Elias Spingarn 5 580 99.0 0.2 0.7 0.2 62.0 79.0 78.7

M. M. Washington Career

Senior High School 5 383 97.4 0.0 2.3 0.3 42.0 94.1 86.4

Woodrow Wilson 3 1,510 56.3 18.1 17.2 8.4 31.0 89.0 94.4

H. D. Woodson 7 778 99.6 0.0 0.4 0.0 87.0 70.1 79.8

All senior high schools 12,447 85.4 3.2 9.0 2.3 57.9d

83.1d83.9d

a

As of October 7, 1999.

b

For school year 1999-2000.

c

For school year 1998-99.

d

Column average.

Source: D.C. Public Schools.
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5 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Figure 2: Locations of D.C. Public High Schools, by Ward

Ward 3

!	Woodrow Wilson

Ward 4

	!	Coolidge

	!	Roosevelt

Ward 8

	 !	Ballou

Ward 6

	!	Anacostia

	!	Eastern

Ward 1

	!	Banneker

	!	Bell Multicultural

	!	Cardozo

Ward 2

	!	Ellington School

of the Arts

	!	School Without Walls

Ward 5

	!	Dunbar

	!	Luke C. Moore 

 Academy

	!	Phelps

	!	Spingarn

	!	M.M. Washington

Ward 7

	!	H.D. Woodson 

Sources: Map obtained from the D.C. Board of Elections and Ethics. School information obtained

from the D.C. Public Schools.

The Adolescent AIDS Prevention Program is funded through the D.C. Health and

Hospitals Public Benefit Corporation, which pays the salaries of the public school

nurses who administer the program, and through DOH, which purchases the

condoms that nurses distribute to students. In fiscal year 1999, the Public Benefit

Corporation’s budget for school nursing services was $4,797,000, but this total

includes the services of school nurses who did not administer the Adolescent AIDS

Prevention Program, and it covers all the services that school nurses perform. In the

1999-2000 school year, nurses at 17 high schools distributed 23,483 condoms to high

school students, at a cost of about 10 cents per condom. DOH purchases the

condoms that are made available to students with grant moneys received from CDC.

The total cost of the condoms purchased by DOH for the 1999-2000 school year was

$2,625.
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6 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Available statistics show that the number of condoms distributed to D.C. public high

school students through the Adolescent AIDS Prevention Program has fluctuated

since the program began, although there has been an overall increase in the number

of condoms distributed. (See figs. 3 and 4.) The drop in the number of condoms

distributed between the 1993-94 and 1994-95 school years is due, in part, to the

phasing out of the program in junior high schools and the closure of a senior high

school. Also, according to one Public Benefit Corporation official, a number of

school nurses retired during this time period and were replaced with contract nurses,

who were not permitted to distribute condoms. This official also attributed the

sudden decline to waning interest in the program after its initial start-up.

Figure 3: Total Condoms Distributed in D.C. Public Schools, School Years 1992-93

Through 1999-2000

0

5,000

10,000

15,000

20,000

25,000

1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-2000

Number of Condoms

School Years

22,408

13,674

22,418

15,198

17,351

13,495

19,865

23,483

a

a

Through May 2000.

Source: D.C. Health and Hospitals Public Benefit Corporation, Community and School Health

Program.
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7 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Figure 4: Average Number of Condoms Distributed per Student, School Years

1992-93 Through 1999-2000

0.0

0.4

0.8

1.2

1.6

2.0

1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-2000

Average per Student

School Years

1.24

0.77

1.25

0.91

1.20

0.88

1.57

1.75

a

a

Through May 2000.

Source: D.C. Health and Hospitals Public Benefit Corporation, Community and School Health Program.

According to DOH, the total number of reported cases of sexually transmitted

diseases among D.C. teenagers rose between 1996 and 1998. Much of the overall

increase appears to be attributable to an increase in diagnosed cases of chlamydia.

Cases of gonorrhea have declined since 1995, and syphilis cases have declined since

1996. However, it is not known how many public high school students in D.C. have

been infected, because the D.C. Public Schools do not monitor the incidence of

sexually transmitted diseases among students. The numbers reported by DOH

include diagnosed cases of sexually transmitted diseases among all D.C. teenagers,

including those who do not attend D.C. Public Schools and who do not participate in

the Adolescent AIDS Prevention Program. The total number of cases decreased from

1998 to 1999. (See fig. 5.)
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8 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Figure 5: Reported Cases of Sexually Transmitted Diseases Among D.C. Teenagers

Aged 13 Through 19, 1995-2000

0

500

1000

1500

2000

2500

1995 1996 1997 1998 1999 2000

Diagnosed Cases

Calendar Years

1,771

2,317

1,668

2,324

1,862

698

Other

Chlamydia

Syphilis

Gonorrhea

a

Note: Data for 1992 through 1994 are not consistent with those for 1995 through 2000 because of DOH

reporting changes and are therefore excluded.

a

Through June 2000.

Source: DOH Bureau of Sexually Transmitted Disease Control.

The incidence of HIV infection among high school students in the D.C. Public Schools

is not available for analysis because, in order to protect students’ right to privacy, the

D.C. Public Schools do not gather this information from students. DOH, however,

reported that there were fewer than 5 new cases of AIDS reported for D.C. teenagers

aged 13 through 19 in 1999 and that there have been fewer than 10 newly reported

cases for D.C. teenagers in any given year since 1992.

The number of pregnancies among D.C. public school students has declined since the

1992-93 school year, which is in keeping with the national trend.4However, these

data account for all student pregnancies, not solely those identified among high

school students. Also, these data may not reflect the total number of student

pregnancies because they include only those pregnancies identified and monitored by

the school nurses. (See fig. 6.)

4

Nationally, the birth rate for adolescents dropped by more than one-fifth between 1991 and 1998. See

Federal Interagency Forum on Child and Family Statistics, America's Children: Key National Indicators

of Well-Being, 2000 (Washington, D.C.: U.S. Government Printing Office, July 2000).
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9 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

Figure 6: Newly Reported Student Pregnancies Tracked by D.C. School Nurses,

School Years 1992-93 Through 1999-2000

0

50

100

150

200

250

300

350

400

450

500

1992-93 1993-94 1994-95 1995-96 1996-97 1997-98 1998-99 1999-2000

Pregnancies Tracked

School Years

441

260

347 320

351

247 249

147

a

a

Through May 2000.

Source: D.C. Health and Hospitals Public Benefit Corporation, Community and School Health Program.

The Adolescent AIDS Prevention Program, which is administered solely in public

high schools, supplements the D.C. Public Schools sex education curriculum, which

operates under regulations established by the D.C. City Council.5The D.C. Public

Schools Superintendent oversees the implementation of these regulations and

establishes additional guidelines for schools.6 Currently, sex education is introduced

in the 5th grade and is part of the overall health and physical education curriculum.

This curriculum includes 11 content areas ranging from human sexuality to nutrition

and first aid. Students receive age-appropriate instruction on human sexuality and

reproduction, including information on human anatomy, pregnancy and childbirth,

sexually transmitted diseases, contraception, abortion, homosexuality, awareness

and prevention of rape and other sex offenses, and discussion of the process of

making personal decisions in matters involving sexuality. At the high school level,

students are required to complete three semesters of health and physical education

before they graduate, of which about one semester may be spent on sex education.

5

Regulations that govern the teaching of human sexuality and reproduction in the D.C. Public Schools

are included in the D.C. Municipal Regulations at D.C. Mun. Regs. tit. 5, 2305.

6

The D.C. Public Schools Office of Academic Services currently is revising sex education guidelines for

the D.C. Public Schools.
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10 GAO/HEHS-00-194R D.C. Adolescent AIDS Prevention Program

AGENCY COMMENTS

Officials from the Health and Hospitals Public Benefit Corporation reviewed this

correspondence and had no comments.

-----

We are sending copies of this letter to Dr. Robin Newton, Interim Chief Executive

Officer of the D.C. Health and Hospitals Public Benefit Corporation; Dr. Paul Vance,

D.C. Public Schools’ Superintendent; and Dr. Ivan Walks, Director, D.C. Department

of Health. We will also provide copies to others on request.

Major contributors to this letter were David D. Bellis, Regina Santucci, and Sharon

Price. Please contact me at (202) 512-7215 if you or your staff have any questions.

Sincerely yours,

Marnie S. Shaul

Associate Director, Education, Workforce,

and Income Security Issues

(102005)