Background
An estimated 2·1 million individuals are newly infected with HIV every year.
Cross-sectional and longitudinal studies have reported conflicting evidence for
the association between education and HIV risk, and no randomised trial has
identified a causal effect for education on HIV incidence. We aimed to use a
policy reform in secondary schooling in Botswana to identify the causal effect
of length of schooling on new HIV infection.
Methods
Data for HIV biomarkers and demographics were obtained from the nationally
representative household 2004 and 2008 Botswana AIDS Impact Surveys (N=7018). In
1996, Botswana reformed the grade structure of secondary school, expanding
access to grade ten and increasing educational attainment for affected cohorts.
Using exposure to the policy reform as an instrumental variable, we used
two-stage least squares to estimate the causal effect of years of schooling on
the cumulative probability that an individual contracted HIV up to their age at
the time of the survey. We also assessed the cost-effectiveness of secondary
schooling as an HIV prevention intervention in comparison to other established
interventions.
Findings
Each additional year of secondary schooling caused by the policy change led
to an absolute reduction in the cumulative risk of HIV infection of 8·1
percentage points (p=0·008), relative to a baseline prevalence of 25·5% in the
pre-reform 1980 birth cohort. Effects were particularly large in women (11·6
percentage points, p=0·046). Results were robust to a wide array of sensitivity
analyses. Secondary school was cost effective as an HIV prevention intervention
by standard metrics (cost per HIV infection averted was US$27 753).
Interpretation
Additional years of secondary schooling had a large protective effect against
HIV risk in Botswana, particularly for women. Increasing progression through
secondary school could be a cost-effective HIV prevention measure in HIV-endemic
settings, in addition to yielding other societal benefits.
Read the full article: http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)00087-X/fulltext
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