Secondary education and HIV infection in Botswana
Authors: Jan-Walter De Neve, Günther Fink, S V Subramanian, Sikhulile Moyo, Jacob Bor
Journal: The Lancet Global Health (2015)

In a reanalysis of our results,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 (85) Google Scholar Michelle Remme and colleagues (October, 2015)2Remme M Watts C Heise L Vassall A Secondary schooling might be as good an HIV investment as male circumcision.Lancet Glob Health. 2015; 3: e591Summary Full Text Full Text PDF Scopus (5) Google Scholar found that "secondary schooling might [even] be as good an HIV investment as male circumcision", not to mention more expensive biomedical options.2Remme M Watts C Heise L Vassall A Secondary schooling might be as good an HIV investment as male circumcision.Lancet Glob Health. 2015; 3: e591Summary Full Text Full Text PDF Scopus (5) Google Scholar As Remme and colleagues rightly point out, we had excluded from our cost-effectiveness calculations the myriad other benefits to secondary schooling beyond HIV. If the HIV community paid the costs of schooling net of those other benefits, secondary schooling would be extremely cost-effective. A crucial question is how to operationalise this insight. Remme and colleagues suggest a "cofinancing" approach based on willingness to pay in the HIV sector: HIV budgets would contribute to educational funding up to the value of their next best investment (ie, male circumcision).3Remme M Vassall A Lutz B Luna J Watts C Financing structural interventions.AIDS. 2014; 28: 425-434Crossref PubMed Scopus (39) Google Scholar Of course, the impact of cofinancing will depend not just on the size of the subsidy, but also on the elasticity of supply in the education sector. There is urgent need for case studies to determine whether cofinancing can be successfully implemented. In a Comment,4Grépin KA Bharadwaj P Secondary education and HIV infection in Botswana.Lancet Glob Health. 2015; 3: e428-e429Summary Full Text Full Text PDF Scopus (4) Google Scholar Karen Ann Grépin and Prashant Bharadwaj wrote: "increasing access to education in low-income countries should be an important priority." But at what level of schooling should such investments be made? Investments at different school levels may have vastly different health effects due to several factors such as stages of cognitive development,5Baker DP Leon J Collins JM Facts, attitudes, and health reasoning about HIV and AIDS: explaining the education effect on condom use among adults in sub-Saharan Africa.AIDS Behav. 2010; 15: 1319-1327Crossref Scopus (30) Google Scholar risk exposures, and long-run habit formation. We found a large causal effect of upper secondary schooling on HIV infection, but no association with primary schooling. In a natural experiment in Zimbabwe, secondary schooling led to delayed sexual debut, delayed fertility, and reduced child mortality.6Grépin KA Bharadwaj P Maternal education and child mortality in Zimbabwe.J Health Econ. 2015; 44: 97-117Crossref PubMed Scopus (102) Google Scholar There is mounting evidence of health returns at the secondary level. Whether these results can be integrated into policy (eg, through cofinancing) will have real implications for global health. We declare no competing interests. Secondary education and HIV infection in BotswanaThere 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. However, there are a couple of important exceptions, including the link between education and HIV. In 2002, a systematic review of studies found that education was either not associated or was positively associated with HIV status, suggesting that more education might actually increase exposure to the virus. Full-Text PDF Open Access