Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
Lancet Glob Health. 2015 Aug;3(8):e470-e477. doi: 10.1016/S2214-109X(15)00087-X. Epub 2015 Jun 28.
An estimated 2·1 million individuals are newly infected with HIV every year. Cross-sectional and longitudinal studies have reported conflicting evidence for the association between education and HIV risk, and no randomised trial has identified a causal effect for education on HIV incidence. We aimed to use a policy reform in secondary schooling in Botswana to identify the causal effect of length of schooling on new HIV infection.
Data for HIV biomarkers and demographics were obtained from the nationally representative household 2004 and 2008 Botswana AIDS Impact Surveys (N=7018). In 1996, Botswana reformed the grade structure of secondary school, expanding access to grade ten and increasing educational attainment for affected cohorts. Using exposure to the policy reform as an instrumental variable, we used two-stage least squares to estimate the causal effect of years of schooling on the cumulative probability that an individual contracted HIV up to their age at the time of the survey. We also assessed the cost-effectiveness of secondary schooling as an HIV prevention intervention in comparison to other established interventions.
Each additional year of secondary schooling caused by the policy change led to an absolute reduction in the cumulative risk of HIV infection of 8·1 percentage points (p=0·008), relative to a baseline prevalence of 25·5% in the pre-reform 1980 birth cohort. Effects were particularly large in women (11·6 percentage points, p=0·046). Results were robust to a wide array of sensitivity analyses. Secondary school was cost effective as an HIV prevention intervention by standard metrics (cost per HIV infection averted was US$27 753).
Additional 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.
Takemi Program in International Health at the Harvard T.H.Chan School of Public Health, Belgian American Educational Foundation, Fernand Lazard Foundation, Boston University, National Institutes of Health.
每年约有 210 万人新感染艾滋病毒。横断面和纵向研究报告了教育与艾滋病毒风险之间的关联存在相互矛盾的证据，没有随机试验确定教育对艾滋病毒发病率的因果效应。我们旨在利用博茨瓦纳中学教育政策改革来确定受教育年限对新艾滋病毒感染的因果效应。
从全国代表性的家庭 2004 年和 2008 年博茨瓦纳艾滋病影响调查中获得了艾滋病毒生物标志物和人口统计学数据（N=7018）。1996 年，博茨瓦纳改革了中学的年级结构，扩大了十年级的入学机会，提高了受影响队列的教育程度。利用接触政策改革作为工具变量，我们使用两阶段最小二乘法估计了受教育年限对个体在调查时年龄之前感染艾滋病毒的累积概率的因果效应。我们还评估了中学教育作为艾滋病毒预防干预措施与其他既定干预措施相比的成本效益。
政策变化导致的每增加一年中学教育，导致艾滋病毒感染的累积风险绝对降低 8.1 个百分点（p=0.008），与改革前 1980 年出生队列的基线患病率 25.5%相比。在女性中，效果尤其显著（11.6 个百分点，p=0.046）。结果在广泛的敏感性分析中仍然稳健。按照标准指标，中学教育作为艾滋病毒预防干预措施具有成本效益（每避免一次艾滋病毒感染的成本为 27753 美元）。
在博茨瓦纳，受教育年限的增加对艾滋病毒风险有很大的保护作用，尤其是对女性而言。除了带来其他社会效益外，增加中学教育的完成率可能是艾滋病毒流行地区的一种具有成本效益的艾滋病毒预防措施。
哈佛陈曾熙公共卫生学院 Takemi 国际卫生计划、比利时美国教育基金会、Fernand Lazard 基金会、波士顿大学、美国国立卫生研究院。
