Secondary schooling might be as good an HIV investment as male circumcision
Authors: Michelle Remme, Charlotte Watts, Lori Heise, Anna Vassall
Journal: The Lancet Global Health (2015)

Jan-Walter De Neve and colleagues1De Neve J-W Fink G Subramanian SV Moyo S Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.Lancet Glob Health. 2015; 3: e470-e477Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar provide compelling evidence of a causal relation between secondary education and HIV incidence, showing that a policy change in Botswana led to 0·792 additional years of secondary schooling, with each added year reducing HIV risk by 8 percentage points. The estimated cost per HIV infection averted was US$27 753. De Neve and colleagues1De Neve J-W Fink G Subramanian SV Moyo S Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.Lancet Glob Health. 2015; 3: e470-e477Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar thus conclude that secondary schooling is similarly cost effective for HIV prevention as pre-exposure prophylaxis, but is more expensive than male circumcision. However, they also highlight that this estimate excludes other benefits of schooling. Furthermore, it is unlikely that HIV budgets would be asked to bear the full cost of increased schooling. If, instead, secondary education is regarded as an investment of value across health and other development sectors, the relevant question is what level of co-investment in education from HIV budgets could be justified, in view of the benefits against HIV?2Remme M Vassall A Lutz B Luna J Watts C Financing structural interventions: going beyond HIV-only value for money assessments.AIDS. 2014; 28: 425-434Crossref PubMed Scopus (39) Google Scholar Secondary education is a sound economic investment in its own right,3Psacharopoulos G Returns to investment in education: a global update.World Dev. 1994; 22: 1325-1343Crossref Scopus (1303) Google Scholar but remains resource-constrained in many low-income and middle-income countries.4UNESCOEducation for all 2000–2015: achievements and challenges. United Nations Educational, Scientific and Cultural Organization, Paris2015Google Scholar If the parties interested in HIV prevention contributed to educational funding up to the value of their next best investment (in this case, male circumcision), further schooling expansion could be achieved. With the threshold of $1096 per infection averted, we show that HIV budgets could contribute up to 4% of total costs for an additional year of secondary schooling (table).5Barnighausen T Bloom DE Humair S Economics of antiretroviral treatment vs circumcision for HIV prevention.Proc Natl Acad Sci USA. 2012; 109: 21271-21276Crossref PubMed Scopus (55) Google ScholarTableCofinancing adjusted cost-effectivenessCost (US$)Option 1: secondary schooling paid entirely from HIV budget*Data are as from De Neve and colleagues; 450 HIV infections were averted.11De Neve J-W Fink G Subramanian SV Moyo S Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.Lancet Glob Health. 2015; 3: e470-e477Summary Full Text Full Text PDF PubMed Scopus (90) Google ScholarCost per year of secondary school per pupil$2248Total cost of education for study sample in Botswana$12 494 959Cost per HIV infection averted (% total cost)$27 753 (100%)Option 2: secondary schooling cofinanced with maximum willingness to pay of HIV sectorHIV sector's maximum willingness to pay for an infection averted (cost per infection averted of medical male circumcision)1De Neve J-W Fink G Subramanian SV Moyo S Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.Lancet Glob Health. 2015; 3: e470-e477Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 5Barnighausen T Bloom DE Humair S Economics of antiretroviral treatment vs circumcision for HIV prevention.Proc Natl Acad Sci USA. 2012; 109: 21271-21276Crossref PubMed Scopus (55) Google Scholar$1096Total HIV contribution for study sample in Botswana$493 440Cost per HIV infection averted (% total cost)$1096 (4%)* Data are as from De Neve and colleagues; 450 HIV infections were averted.1De Neve J-W Fink G Subramanian SV Moyo S Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment.Lancet Glob Health. 2015; 3: e470-e477Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar Open table in a new tab If applied at scale, this cofinancing approach could change the lives of many young people, providing both education and an HIV-free future. Implementation of complementary investments across sectors could be key to tackling the HIV epidemic, and would place the HIV response at the heart of the post-2015 development agenda. All authors are members of the STRIVE (Tackling the Structural Drivers of the HIV Epidemic) Research Programme Consortium and report grants from the UK Department for International Development (UKaid), during the conduct of the study. MR, CW, and AV are also members of the RethinkHIV consortium and report grants from the RUSH Foundation, during the conduct of the study. The opinions expressed are those of the authors and do not represent the views of the organisations or consortia to which they are affiliated. Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experimentAdditional years of secondary schooling had a large protective effect against HIV risk in Botswana, particularly for women. Increasing progression through secondary school could be a cost-effective HIV prevention measure in HIV-endemic settings, in addition to yielding other societal benefits. Full-Text PDF Open Access