Advancing Education

A systematic review of published peer-reviewed articles explored the time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa and found that HIV infections appear to be shifting towards higher prevalence among the least educated in sub-Saharan Africa, reversing previous patterns. Articles were identified that reported original data comparing individually measured educational attainment and HIV status among at least 300 individuals representative of the general population of countries or regions of sub-Saharan Africa. Statistical analyses were required to adjust for potential confounders but not over-adjust for variables on the causal pathway. Approximately 4000 abstracts and 1200 full papers were reviewed. Thirty-six articles were included in the study, containing data on 72 discrete populations from 11 countries between 1987 and 2003, representing over 200,000 individuals. Studies on data collected prior to 1996 generally found either no association or the highest risk of HIV infection among the most educated. Studies conducted from 1996 onwards were more likely to find a lower risk of HIV infection among the most educated. Where data over time were available, HIV prevalence fell more consistently among highly educated groups than among less educated groups, in whom HIV prevalence sometimes rose while overall population prevalence was falling. In several populations, associations suggesting greater HIV risk in the more educated at earlier time points were replaced by weaker associations later.

A 2001 cluster-randomized study evaluated the impact of school attendance on the sexual risk behaviors and HIV prevalence of 916 males and 1,003 females between the ages of 14 and 25 in rural Limpopo Province, South Africa, where HIV prevalence in antenatal clinics was 13.2 percent. The study found that school attendance correlates with lower HIV prevalence among males, fewer sexual partners for both sexes, and among females, a lower likelihood of having partners who are more than three years older, more frequent condom use, and less frequent sex within relationships. Because students did not have greater access to HIV prevention materials than non-students, the study suggests that school attendance may have a protective effect on HIV risk by affecting the sexual network structure of young people. “School attendance might affect communication within sexual networks, in turn helping to improve confidence, self-efficacy and the adoption of safer sexual behaviors. It might also increase group negotiation of positive attitudes toward positive behaviors, by putting young people in regular contact with each other in a structural environment” (Hargreaves et al., 2008b: 118). Women from very poor households were less likely to be students. Among study participants, HIV prevalence rates were 3.4% for men and 9.8% for women, increasing over the age range.

A study in Ethiopia of 35,512 VCT clients of Family Guidance Association of Ethiopia found that male and female VCT clients with more than secondary level education are 58% and 66% (respectively) less likely to be HIV-positive than those with no education.

Evidence from population-based surveys in Zambia (1995-2003) shows a marked decline in HIV prevalence among higher educated young people. Data are from serial population-based HIV surveys conducted in selected urban and rural communities in 1995 (n = 2989), 1999 (n = 3506) and 2003 (n = 4442). Analyses were stratified by residence, sex and age group. Logistic regression was used to estimate age-adjusted odds ratio of HIV between low (< or = 4 school years) and higher education (> or = 8 years) for the rural population and between low (< or = 7 school years) and higher education (> or = 11 years) for the urban population. Results show there was a universal shift towards reduced risk of HIV infection in groups with higher than lower education in both sexes among urban young people in men and in women. A similar pattern was observed in rural young men but was less prominent and not statistically significant in rural women. In age 25-49 years, higher educated urban men had reduced risk in 2003 but this was less prominent in women. The findings suggested a shift in the association between educational attainment and HIV infection between 1995 and 2003. The most convincing sign was the risk reduction among more educated younger groups where most infections can be assumed to be recent. The changes in older groups are probably largely influenced by differential mortality rates. The stable risk among groups with lower education might also indicate limitations in past preventive efforts.

A survey of 1,087 Malawian youth, of whom 722 were young women, with 133 in-depth interviews found that being enrolled in school was strongly negatively associated with having had sex for young women.

A survey of 669 boys and 699 girls ages 14 to 19 in Lao PDR found that “having some education and attending school are protective factors for both sexes…” (Sychareun et al., 2011: 8) for age at first sex before 15 years of age; two or more partners during the last six months and not using condoms during the last sexual intercourse. By contrast, out of school adolescents of both sexes were more likely to have these risk factors.

Data from a longitudinal HIV surveillance and a linked demographic surveillance in a poor rural community in KwaZulu-Natal, South Africa, showed that in multivariable survival analysis, one additional year of education reduced the hazard of acquiring HIV by 7% net of sex, age, wealth, household expenditure, rural vs. urban/periurban residence, migration status and partnership status. The purpose of the study was to investigate the effect of three measures of socioeconomic status on HIV incidence: educational attainment, household wealth categories (based on a ranking of households on an assets index scale) and per capita household expenditure, the sample comprised of 3325 individuals who tested HIV-negative at baseline and either HIV-negative or -positive on a second test (on average 1.3 years later). Holding other factors equal, members of households that fell into the middle 40% of relative wealth had a 72% higher hazard of HIV acquisition than members of the 40% poorest households. Per capita household expenditure did not significantly affect HIV incidence. The results suggest that increasing educational attainment in the general population may lower HIV incidence.

A 2003 household survey of 1,708 15-24 year-old women in South Africa who were sexually experienced but only had one lifetime partner (typically considered “low risk” for HIV) found that women who had not completed high school were more likely to be HIV-positive by odds of 3.75 than those who had completed high school. Fifteen percent of the women surveyed were HIV-positive, and 77.5 percent had not completed high school.

A study of key findings from nationally representative surveys conducted in 2004 of 5,950 young people ages 12 to 19 in Burkina Faso; 4,252 in Ghana; 4,012 in Malawi and 5,065 in Uganda found that formal education was positively associated with protective behaviors such as delaying first sex, abstaining from sex and using condoms. Surveys were supplemented with 16 focus groups each in Burkina Faso and Ghana, 11 focus groups in Malawi and 12 focus groups in Uganda. The research team also conducted 406 in-depth interviews with adolescents and 240 in-depth interviews with key adults in the lives of the adolescents.

Cross sectional data from a population-based survey with 9,843 adults (80% of those eligible) including 2,268 young women large-scale, conducted between 1998 and 2000 in rural Zimbabwe found that young women’s chances of having avoided HIV were strongly associated with experience of secondary education. “Young women with higher levels of school education... had better knowledge about HIV...(and) young women with greater knowledge about HIV” were more likely not to have started sex and to have avoided HIV (Gregson et al., 2004: 2126). Greater education was positively associated with self-efficacy in both married and unmarried young women.

A review of demographic data and HIV prevalence found that in India, women with less than five years of education had the highest HIV prevalence. In Cambodia, the highest HIV prevalence was among uneducated women; however, conversely, men with higher levels of education had higher HIV prevalence than men with lower levels of education.

DHS surveys from 11 countries found that women with some schooling were nearly five times as likely as uneducated women to have used a condom the last time they had sexual intercourse (Global Campaign for Education, 2004). Literate women are three times more likely than illiterate women to know that a healthy-looking person can be HIV-positive and four times more likely to know preventive behaviors (Vanandemoortele and Delamonica, 2000 cited in Global Campaign for Education, 2004). While universal primary education is not a substitute for HIV/AIDS treatment and prevention, young people with little or no education may 2.2 times more likely to become HIV-positive as those who have completed primary education (De Walque, 2004 cited in Global Campaign for Education, 2004). Even controlling for income, education’s impact on HIV/AIDS is robust. In the five years before the publication, better-educated young people have increased condom use and reduced the number of casual partners at a much steeper rate than those with little or no education (Hargreaves and Glynn, 2002; World Bank, 2002 cited in Global Campaign for Education, 2004).

A 2009 World Bank and UNICEF study evaluated the impact of primary school fee abolition in five African countries. Ethiopia abolished primary school fees in 1994, Ghana in 1995, Kenya in 2003, Malawi in 1994, and Mozambique began implementation in 2004. Fees were abolished in all countries for grades 1 through 7, with several countries extending the fee abolition to higher grades. Fee abolition resulted in a 23% increase in total enrollment from 1994/95 to 1995/1996 in Ethiopia, a 14% increase in total enrolment from 2004/2005 in Ghana, an 18% increase from 2002/03 to 2003/04 in Kenya, a 51% increase from 1993/94 to 1994/95 in Malawi, and a 12% increase from 2003/04 to 2004/2005 in Mozambique. The ratio of girls to boys enrolled in primary school increased in Ethiopia from 0.61 girls to 1 boy in 1994/95 to a ratio of 0.79 girls to 1 boy in 2004/2005. The increase in the ratio of girls to boys was insignificant in the other countries.

A successful strategy for increasing access to education has been the elimination of school fees, which otherwise put education out of reach for many families. Because staying in school is linked with better HIV outcomes, abolishing school fees, particularly for girls, should lower HIV vulnerability. In Tanzania, the removal of school fees more than doubled primary school enrollment. Kenya saw enrollment jump by 22% in the first week alone with their abolition. In Uganda, girls’ school enrollment leapt by over 30% when school fees were dropped, including a near doubling for the poorest economic fifth of girls (Bruns et al., 2003; UNICEF, 2005; Deininger, 2003; Bundy and Kattan, 2005, cited in Global Coalition on Women and AIDS, year not specified). 

A randomized control trial during two school years of a conditional cash transfer program for girls to remain in school in Malawi resulted in higher percentages of school attendance for girls who received the cash (95%, compared to 89% of girls in the control group). School girls who received monthly cash payments of various amounts were significantly less likely than girls who did not receive payments to be HIV positive (1.2% or seven of 490 young women) as compared to 3% or 17 of 799 young women). Self-reported behavior change was correlated with lower rates of HIV in those who received cash transfers. Girls and their parents were given up to $10 per month conditional on satisfactory school attendance, that is, if the girl attended school for at least 75% of the days her school was in session. School fees for the girls were also paid through the intervention. The analysis was conducted on a panel sample consisting of 396 treatment and 408 control girls who had dropped out of school as of baseline, and 480 treatment and 1,408 control girls in school, for a total sample size of 2,692 girls. The percentage of initial dropouts who returned to school (and were in school at the end of the 2008 school year) was 17.2% among the control group compared with 61.4% among the treatment group. Program beneficiaries were 3-4 times more likely to be in school at the end of the 2008 school year than the control group. The program led to significant declines in early marriage, teenage pregnancy, and self-reported sexual activity among program beneficiaries after one year of program implementation. For program beneficiaries who were out of school at baseline, the probability of getting married and becoming pregnant declined by more than 40% and 30%, respectively. In addition, the incidence of the onset of sexual activity was 38 percent lower among all program beneficiaries than the control group (Baird et al., 2010). Subsequent analysis of biomarker data 18 months after the program was initiated showed an HIV infection rate of 1.2% among the girls who received the CCT, compared to 3% among the control group. However, HIV incidence was not measured nor was HIV testing conducted until after the program was initiated, rather than at baseline. Costs for a scaled up cash transfer program was estimated at $5,000 per HIV infection averted.