Title: Education and health outcomes
Description: Nearly 37 million people are living with HIV and there are an estimated 2.1 million new HIV infections each year, equating to 5,700 new infections per day. Approximately half of new HIV infections occur in Eastern and Southern Africa. Young people are at particularly high risk of HIV; 35% of new infections are among young people ages 15-24 years. In sub-Saharan Africa, 25% of new infections are among young women. Throughout the course of the HIV epidemic, research has described the associations between social structural and behavioral determinants of HIV acquisition. The influences of socioeconomic status, household characteristics, gender, geographical residence, and risky sexual behaviors on HIV acquisition are well reviewed in the literature. Evidence on the impact of education on factors that influence HIV acquisition is less robust and associations have changed over time as both education and the HIV epidemic have evolved. Globally, access to education and educational attainment has increased over the past several decades.

In developing countries, the number of years enrolled in school for both men and women has significantly increased. The impact of increased educational attainment has contributed to reductions in child mortality, improvements in reproductive health, and reduced HIV transmission. In many countries, the gap in education between men and women has reversed, with women now achieving higher levels of educational attainment than men. However, in several low and middle income countries, gender disparities persist. Global public health, development, and policy communities recognize the importance of education and its influence on health outcomes. Over the past decade, education has been highlighted in the Millennium Development Goals (MDG) and now is continuing as a priority for the Sustainable Development Goals (SDG) in the post 2015-agenda. The goal of MDG 2 was to achieve universal primary education for all children; building on this goal, SDG 4 focuses on quality education, ensuring inclusive and equitable education and promoting lifelong learning opportunities for all.

The goal of this dissertation is to highlight the importance of education by summarizing the current state of literature that reviews associations between education and HIV infection for adolescents in low- and middle- income countries and illuminating the key entry points for research, policy, and programming by examining the relationship of education on determinants of HIV infection for young people. This dissertation accomplishes the stated goal by: (1) Systematically reviewing associations between education and HIV infection for youth ages 13 – 24 years living in low- and middle- income countries (Chapter 1); (2) Examining the relationship between educational attainment on HIV acquisition for young adults ages 20 – 24 years in Rakai, Uganda (Chapter 2); and (3) Commenting on the pathways to HIV acquisition and identifying key entry points and best practices in policy and research to promote improved health outcomes for adolescents (Chapter 3). This dissertation is guided by both the proximate determinants of health framework as described in Chapter 2 and the socio-ecological theory adapted from the Bronfenbrenner Model as presented in Chapter 3.

This dissertation adds to both the field of HIV and education research by synthesizing the literature that currently exists, illustrating the influence of education on known determinants of HIV acquisition, and concluding with actionable research and policy recommendations to continue progress toward educational attainment and improving health outcomes. A systematic review summarizes publications that analyze the association between education and HIV for young people living in low- and middle- income countries. Twenty-two articles include over 315,000 participants from 18 countries. While over half of the articles included in this review indicate that higher education is associated with lower rates of HIV sero-positivity, there is still significant variability in the findings. Two studies indicate that those with higher education have an increased risk of HIV; four studies show no association between education and HIV; and five studies result in mixed conclusions based on gender and age or grade level.

Key conclusions from this review echo previous systematic reviews. Dates of data collection influence the conclusion of published studies. In this review, articles that show that those with more education had a lower HIV prevalence were more likely to have data collected after the year 2000. Although articles from 2007 – 2017 are eligible to be included in this review, the most recent publications identified are from 2015 and the most recent data are from 2013. More updated data collection and publications on the association between education and HIV are needed to continue to improve this field of study. This review highlights the importance of continuing research on the association between education and HIV in low- and middle- income countries to support continued progress toward MDG 2 and SDG 4. Not only is it imperative to study the relationship and magnitude of the association in a variety of settings and populations, but also to gain a better understanding of how and why education influences HIV for young people.

This review provides sufficient evidence to show that education does have an impact on HIV and can be used to improve policies and programs to improve school enrollment, attendance, attainment, and the quality of education in low- and middle- income countries for all young people. In Uganda, school enrollment rose steadily from 1994 to 2013 among adolescents, due largely in part to changes in national policy. Increasing school enrollment in Uganda was associated with a declining risk for HIV and pregnancy among young people ages 15 – 19 years. Data from the Rakai Community Cohort Study (RCCS) were used to examine the association between educational attainment and proximate risk factors of HIV infection for young adults’ ages 20 – 24 years. Results showed that educational attainment was protective against several risk factors for HIV. Compared to those with no education, females with at least a secondary education were less likely to have their first sexual encounter before the age of 18.

Compared to those with no education, females with higher educational attainment (attending primary school, secondary school, or beyond secondary school) were more likely to use family planning methods and had fewer sexual partners. Educational attainment was also correlated with riskier behaviors. Females with higher education were more likely to report inconsistent condom use, concurrent sexual partners, and were less likely to know the HIV status of their partners. Similar results were seen in males. Compared to those with no education, males with any education were more likely to use family planning methods. Compared to those with no education, males with higher education (attending primary school, secondary school, or beyond secondary school) were more likely to report concurrent sexual partners. Educational attainment was not significantly associated with HIV incidence in males or females. The association between educational attainment and risk factors for HIV acquisition are varied.

Higher educational attainment is associated with delayed initiation of sexual activity and use of family planning methods; however, it is also associated with inconsistent condom use and more concurrent sexual partners. In an era of enhanced focus on education and educational attainment, this data helps explain how schooling can impact the risk behaviors that influence the HIV epidemic in young people. When developing sexual education in the future, researchers, program, and policy developers should utilize these findings to ensure curricula focus on consistent condom use, concurrent partners, and the importance of HIV disclosure. This study also highlights gaps in the current literature – future research questions should more closely examine the quality and content of education, as well as determining the role that education plays in exerting autonomy over behavior and behavior change. The HIV/AIDS epidemic and access to education have seen parallel improvements in recent decades. Nearly 40 years into the HIV/AIDS epidemic, there have been tremendous gains in care, treatment, and prevention of HIV.

Yet, the epidemic still impacts millions of people worldwide. Similarly, access to education has improved for many throughout the twentieth and twenty-first centuries, although major disparities and gaps remain. The importance of education for health and development is highlighted by the United Nations (UN) in the Millennium Development Goal campaign (MDG, 2000 – 2015) and in the Sustainable Development Goals effort (SDG, 2015 – 2030)21,22. The UN calls for universal primary education (MDG 2) and inclusive and quality education for all (SDG 4)21,22. In the current post-2015 agenda focusing on eliminating disparities and improving quality in education, now is a pivotal time to review what is known and what remains to be discovered about the relationship between educational attainment and the HIV/AIDS epidemic, two driving domains in policy and program planning. More updated data and research needs to be conducted in a variety of diverse settings in order to understand how education can influence the HIV epidemic in the current environment.

Moreover, researchers should ensure that they are looking at the entire context of education and desegregating educational attainment from socioeconomic status measured using alternative measures to better target key entry points for change. Policy makers can utilize this research to evaluate existing policies and implement new polices as needed. The failure to meet the MDG 2 of universal primary education indicates that much work still remains in the policy and program implementation realms of education enrollment and attainment. Beyond primary education, a renewed focus on secondary education, quality education, and gender equality will maximize the benefits of education.