Cutting Risk of HIV Infection in Botswana

Extra school years spent past grade nine in Botswana substantially cut the risk of HIV infection—especially in girls—a Boston University School of Public Health (SPH) study shows.

A team headed by Jacob Bor, an SPH assistant professor of global health, examined country-wide educational changes that reformed secondary school grade structure to expand access to grade 10 and beyond. In a country with one of the world’s highest HIV infection rates (about 25.5 percent), researchers found that each additional year of secondary school led to a reduction in the risk of HIV infection of 8.1 percentage points. Among females, researchers found a drop of 11.6 percentage points.

The study was published online in the The Lancet Global Health.

“Our study is among the first to link secondary schooling causally not just to risk behaviors but to HIV infection itself,” says Bor. “The fact that our findings are consistent with the literature on behaviors in many other settings suggests that investments in secondary schooling might be a good strategy to reduce HIV risk in many countries with large, generalized HIV epidemics.”

In 1996, Botswana decided to move grade 10 from senior secondary schools to the more numerous junior secondary schools. There are many more junior secondary schools than senior secondary schools, says Bor, just as in the US there are more junior high schools and middle schools than high schools. The simple change in grade structure triggered a cascade of follow-on effects, he says.

“By shifting grade 10 from senior secondary to junior secondary, the policy increased the benefit of grade 10 education because now grade 10 was required to attain a junior secondary certificate, where previously it was only grade nine,” he says. “It also reduced the cost of attending grade 10 because it brought grade 10 closer to people, so they did not have to travel as far to get to school.”

The change also reduced the number of people ending their formal education after grade nine by improving continuity with the previous grade, says Bor. Instead of the previous natural exit point after grade nine, now that natural exit point was in grade 10.

“There was a huge jump in grade 10 completion, and one of the other impacts of that policy is that students who stayed on to grade 10 likely discovered that they liked school and wanted to stay on until grades 11 and 12. So this led to a very sharp increase in educational attainment,” he says.

The authors concluded that increasing progression through secondary school could be a cost-effective HIV prevention measure across different HIV-endemic settings, as well as yielding the expected societal benefits from better education.

“What we are saying is that from the perspective of HIV prevention, schooling has to be part of the conversation because it is at least as cost-effective as some of the other things already being considered,” says Bor. “What this suggests is that it might not be some fancy new program to help us fight prevalence of HIV. It might just be expanding access to something that we already know how to do, which is secondary education.”