Research Article: Education and HIV incidence among young women in KwaZulu-Natal: An association but no evidence of a causal protective effect

Date Published: March 4, 2019

Publisher: Public Library of Science

Author(s): Dick Durevall, Annika Lindskog, Gavin George, Bruno Masquelier.


We examine the relationship between school attendance and HIV incidence among young women in South Africa. Our aim is to distinguish a causal effect from correlation. Towards this end, we apply three methods to population-based longitudinal data for 2005–2012 in KwaZulu-Natal. After establishing a negative association, we first use a method that assesses the influence of omitted variables. We then estimate models with exclusion restrictions to remove endogeneity bias, and finally we estimate models that control for unobserved factors that remain constant over time. All the three methods have strengths and weaknesses, but none of them suggests a causal effect. Thus, interventions that increase school attendance in KwaZulu-Natal would probably not mechanically reduce HIV risk for young women. Although the impact of school attendance could vary depending on context, unobserved variables are likely to be an important reason for the common finding of a negative association between school attendance and HIV incidence in the literature.

Partial Text

Although HIV infections are decreasing in most countries, about 800 000 individuals in Eastern and Southern Africa became infected in 2016. In South Africa, there were 270 000 new HIV infections, increasing the number of infected to 7.1 million people [1]. Since providing antiretroviral treatment to a rapidly growing number of HIV-positive citizens is a major challenge, the international effort to deal with HIV needs to focus much more strongly on prevention. Currently, keeping girls in school is considered one of the most powerful prevention methods for reducing HIV among adolescent girls across Africa [2, 3, 4]. And large investments have been devoted towards this end. For example, it is a key component of the DREAMS program, a USD 385 million partnership that aims to reduce HIV infections among adolescent girls and young women in South Africa and nine other sub-Saharan African countries during the next few years [5].

In this section we review the empirical evidence on the relationship between education and HIV. S1 Appendix describes about the potential links between education and HIV, and the differences between attendance and attainment.

The data are from a population-based longitudinal surveillance of 85,000 people who are members of approximately 11,000 households [34]. It is conducted by the Africa Health Research Institute in a predominantly rural community in KwaZulu-Natal. It is one of the poorest communities in South Africa. HIV is very common, as can be seen in Fig 1, which shows female HIV prevalence and incidence rates in 2005 by age. The HIV prevalence peaks at over 50%, for women aged 29–30, and the HIV incidence approaches 10% at age 23.

We estimate the probability of leaving a state, HIV negative in this instance, at time t conditional on not having done so before, Pr[t≤T0)(1)yit=1(xitπ+sitβ+εit>0)(2)[uε]∼N([00],[1ρρ1]).(3)

In spite of recent achievements in providing antiretroviral treatment to an increasing number of people, HIV/AIDS remains a serious challenge in heavily affected sub-Saharan African countries. With a growing number of infected on life-long treatment, the costs are escalating, threatening the achievements in South Africa and several other African countries. Consequently, there is an urgent need to increase investments in prevention. According to UNAIDS, among others, keeping girls in school is one of the most powerful structural interventions for HIV risk reduction among young women across Africa [2, 3, 4].




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