Guest blog: Secondary Schooling Reduces Risk of HIV Infection in Botswana

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Jan-Walter De Neve
19 August 2016

It has long been suggested that formal education acts as a ‘social vaccine’ to reduce the spread of HIV. But it has proved difficult to isolate the effect of education on HIV risk from the complex web of other causal factors like personal motivation, psychological traits, socioeconomic status, and family background. In a previous study, published in The Lancet Global Health, we presented what we believe is the first causal evidence that formal schooling is an important structural determinant of HIV infection and that this relationship is causal.

The study, conducted by a research team based at the Harvard T.H. Chan School of Public Health, Boston University and the Botswana Harvard Partnership, found that an extra year of secondary schooling reduces the risk of acquiring HIV – especially for girls.

While the study provides strong evidence of a protective effect of secondary schooling, and its cost-effectiveness as an HIV prevention intervention, many questions remain unanswered. In particular, the role of causal pathways between secondary schooling and HIV risk remains unclear, and how these may play out differentially by gender in Botswana. In a new study, presented at Adolescence, Youth and Gender: Building Knowledge for Change, we extend our previous work by assessing how secondary schooling may have affected HIV risk in Botswana.

Botswana’s HIV landscape

HIV remains a major issue in global health. More than two million people are newly infected each year. In Botswana in 2015 about 22% of people aged between 15 and 49 were HIV positive, which means the country has one of the highest infection rates in the world. Where there is no randomized trial data, social scientists sometimes use a statistical technique that exploits ‘natural experiments’ to evaluate causal links.

Our research used this technique, examining a 1996 education policy reform that made it a requirement for pupils in Botswana to complete Grade 10 in order to obtain a junior secondary certificate. The policy resulted in almost one year of additional schooling among teenagers. Using data from about 7,000 people who participated in Botswana’s AIDS Impact Surveys, we compared those who were young enough to have benefited from the education policy reform with those who were not. We looked at their HIV status outcomes about a decade after finishing school. From this, it emerged that spending the additional year in secondary school lowered the risk of HIV infection among students by about a third a decade later. The effects were particularly strong for women.

But how does it work?

The question in our study is how formal education lowers HIV risk. Botswana did not have a national HIV education curriculum in 1996, so what we see is not the effect of HIV-specific education, but education more generally.

So what do people gain or develop when they spend more time in school? Our results indicate that secondary education led to fundamental changes in labor market outcomes for women, in particular, which may have empowered women to reduce exposure to HIV due to increased bargaining power or financial independence. The reform caused over half of those women who would have otherwise been out of the labor force to seek employment. These changes in economic opportunity may have enabled women to make explicit choices to reduce HIV risk.

We also find evidence that education changed norms for both women and men about the acceptability of women carrying condoms, and led to increases in condom use and HIV testing.  Additionally, secondary schooling may have led women to think differently about their future, changing expectations about whether they would have their own career or be a homemaker, and changing fertility preferences. Indeed, women delayed their sexual debut and saw a large reduction in the probability of having ever given birth.

These results are consistent with evidence from other countries on the effects of schooling on women’s labor market outcomes and fertility.

 

This blog has been written by Jan-Walter De Neve from the Harvard T.H. Chan School of Public Health, who will be presenting his work at the conference on Adolescence, Youth and Gender in Oxford on 8 and 9 September 2016.