Secondary education and HIV infection in Botswana.

Karen Ann Grépin,Prashant Bharadwaj

doi:10.1016/s2214-109x(15)00050-9

Abstract

In The Lancet Global Health Jan-Walter De Neve and colleagues present exciting results from an important study of the effect of a policy change that increased access to education among junior high school students in Botswana in 1996. The policy change led to an average increase of 0.8 years of schooling among teenagers who were just young enough to benefit from this policy. Using age-specific exposure to the policy as an instrumental variable De Neve and colleagues identified increases in education that were unlikely to be correlated with other factors that also affect HIV status and then showed that individuals who gained an additional year of schooling due to the policy were 8.1 percentage points (p=0.008) less likely to test positive for HIV about a decade later when most of those exposed to the policy were then in their mid-20s. Hence De Neve and colleagues provide strong and convincing evidence that increased education in Botswana was protective against HIV infection among young adults and is even cost effective by most standards. Their results were strongest among women (11.6 percentage points per extra year p=0.046) which is especially important given the worldwide inequities in access to secondary schooling for girls especially in Africa. Although this study provides important new insights into this important global health issue it has a few limitations. First the results are generalisable only to individuals who were surveyed and provided a blood sample which could be undermined if there were important rates of mortality or migration or if education was associated with completing the survey or consenting to an HIV test. Second the study was also not able to identify effect of education on risk of HIV infection for the entire lifetime. Irrespective of these considerations increasing access to education in low-income countries should be an important priority because of the proven economic returns to such investments. The health returns from education such as its potential role in HIV and child mortality should also make it a top priority for the global health community. (Excerpts)

Highlights

There is a strong relationship between socioeconomic factors and health outcomes
The next-best option is to look for natural experiments that have led to changes in education that are unrelated to other factors likely to affect HIV status, which can be evaluated using rigorous econometric methods, such as instrumental variables or regression discontinuity
The policy change led to an average increase of 0·8 years of schooling among teenagers who were just young enough to benefit from this policy

Summary

Introduction

There is a strong relationship between socioeconomic factors and health outcomes. These links are so well established that there is very little debate among researchers about their existence. The next-best option is to look for natural experiments that have led to changes in education that are unrelated to other factors likely to affect HIV status, which can be evaluated using rigorous econometric methods, such as instrumental variables or regression discontinuity.

Results

Conclusion