Education and Vulnerability: the role of schools in protecting young women and girls from HIV in Southern Africa

Abstract

Education has a potentially important role to play in tackling the spread of HIV, but is there evidence that this potential is realized? This analysis combines the results of previous literature reviews and updates them with the findings of recent randomized controlled trials and a discussion of possible mechanisms for the effect of schooling on vulnerability to HIV infection. There is a growing body of evidence that keeping girls in school reduces their risk of contracting HIV. The relationship between educational attainment and HIV has changed over time, with educational attainment now more likely to be associated with a lower risk of HIV infection than earlier in the epidemic. Educational attainment cannot, however, be isolated from other socioeconomic factors as the cause of HIV risk reduction. The findings of this analysis suggest that the equitable expansion of primary and secondary schooling for girls in southern Africa will help reduce their vulnerability to HIV. Evidence of ineffective HIV prevention education in schools underlines the need for careful evidence-based programme design. Despite the challenges, recent provisional evidence suggests that highly targeted programmes promoting realistic options for young adults may lead to safer sexual behaviour. Targeted education programmes have also been successful in changing students' attitudes to people living with HIV and AIDS, which is associated with testing and treatment decisions. This reduction in stigma may be crucial in encouraging the uptake of voluntary counselling and testing, a central strategy in the control of the epidemic. Expansions of carefully designed and evaluated school-based HIV prevention programmes can help to reduce stigma and have the potential to promote safe sexual behaviour.

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Education and vulnerability: the role of schools in
protecting young women and girls from HIV in
southern Africa
Matthew Jukes
a,b
, Stephanie Simmons
a
and Donald Bundy
c
Education has a potentially important role to play in tackling the spread of HIV, but is
there evidence that this potential is realized? This analysis combines the results of
previous literature reviews and updates them with the findings of recent randomized
controlled trials and a discussion of possible mechanisms for the effect of schooling on
vulnerability to HIV infection. There is a growing body of evidence that keeping girls in
school reduces their risk of contracting HIV. The relationship between educational
attainment and HIV has changed over time, with educational attainment now more
likely to be associated with a lower risk of HIV infection than earlier in the epidemic.
Educational attainment cannot, however, be isolated from other socioeconomic factors
as the cause of HIV risk reduction. The findings of this analysis suggest that the equitable
expansion of primary and secondary schooling for girls in southern Africa will help
reduce their vulnerability to HIV. Evidence of ineffective HIV prevention education in
schools underlines the need for careful evidence-based programme design. Despite the
challenges, recent provisional evidence suggests that highly targeted programmes
promoting realistic options for young adults may lead to safer sexual behaviour.
Targeted education programmes have also been successful in changing students’
attitudes to people living with HIV and AIDS, which is associated with testing and
treatment decisions. This reduction in stigma may be crucial in encouraging the uptake
of voluntary counselling and testing, a central strategy in the control of the epidemic.
Expansions of carefully designed and evaluated school-based HIV prevention pro-
grammes can help to reduce stigma and have the potential to promote safe sexual
behaviour. ß2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
AIDS 2008, 22 (suppl 4):S41–S56
Keywords: education, prevention of HIV transmission, sexual behaviour,
southern Africa, women
Introduction
Education has been suggested as a ‘social vaccine’ to
prevent the spread of HIV. In sub-Saharan Africa,
infection rates are lowest among children in primary
school. These children represent a ‘window of hope’
for the future [1]. If they can gain the skills and
knowledge necessary to make healthy choices about their
sexual behaviour, the potentially devastating effects of
the pandemic on the next generation could be
attenuated.
A focus on girls
There is a strong rationale for making girls a particular
focus of such HIV prevention efforts. Biologically,
socially, and culturally, girls are particularly vulnerable
to HIV infection. For physiological reasons women are
more likely to be infected with HIV from an infected
male partner than are men who have sex with an infected
female partner [2]. In many of the hyperendemic
countries social and cultural influences on girls’ behaviour
prevent them from making choices that could be
protective: staying in school, buying condoms, or
a
Graduate School of Education, Harvard University, Cambridge, Massachusetts, USA,
b
Partnership for Child Development,
Department for Infectious Disease Epidemiology, Imperial College London, UK, and
c
Human Development Network, World
Bank, Washington, DC, USA.
Correspondence to Matthew Jukes, Harvard Graduate School of Education, 6, Appian Way, Cambridge MA 02138, USA.
Tel: +1 617 495 8142; e-mail: matthew_jukes@gse.harvard.edu
ISSN 0269-9370 Q2008 Wolters Kluwer Health | Lippincott Williams & Wilkins S41

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
discussing safer sex measures with parents, teachers, or
partners, for example. Girls are also more likely than boys
to be sexually abused, and their first sexual encounters
are often forced or violent [3]. Even in schools, girls are
targets of sexual harassment and abuse [4]. Given the
social and economic insecurity that many adolescent girls
face, risky behaviour such as sex with an older partner
may be a rational decision. In one study, girls who became
pregnant by a man more than 10 years older were more
likely to marry than if the father was less than 5 years older
(79% versus 42%) [5]. HIV cannot be tackled effectively
unless boys’ and men’s behaviour changes along with
girls’. Girls’ vulnerabilities to infection, however, make it
critical to focus on general or HIV/AIDS-specific
educational programmes that may reduce their risk.
We examine the evidence on this issue in two sections.
First, we look at the impact of increased schooling on
HIV infection. Does reaching a higher level of education
lead to a reduced risk of infection? Does attending school
lead to a reduced risk of infection? We review studies
addressing these two questions including a recent
systematic review of evidence for a relationship between
educational attainment and HIV [6]. Second, we report
findings from our own systematic review of studies of the
effectiveness of school-based HIV prevention pro-
grammes. Third, we make a series of educational policy
recommendations as well as suggestions for HIV/AIDS-
specific curriculum development. This analysis furthers
the discussion of HIV and education by combining the
results of previous literature reviews and updating them
with the results of recent randomized controlled trials and
a discussion of possible mechanisms for the impact of
schooling on vulnerability to HIV infection.
Section 1: the relationship between
educational attainment and HIV infection
In this first section we examine the relationship between
schooling and HIV infection. Here we are concerned
with two distinct effects of formal schooling. The first
involves the consequences of merely attending school,
regardless of what is learned there. The second involves
the consequences of higher levels of educational
attainment. This latter effect concerns the general
education resulting from formal schooling rather than
specific HIV-prevention education programmes.
Throughout the following discussion we aim to keep
these two pathways, of school attendance and educational
attainment, distinct because they are supported by
different bodies of evidence and involve different causal
mechanisms. A number of limitations are faced when
investigating the connection between general education
levels in a population and HIV infection. Studies that aim
to answer this question are generally associational rather
than causal as a result of the logistical and ethical concerns
that would accompany a randomized controlled trial of
education provision. We believe, however, that sufficient
evidence exists to suggest patterns. We examine the
evidence in three sections, moving up the chain of
causality from education to HIV infection. First we look
at education’s influence on the determinants of sexual
behaviour, then on sexual behaviour itself, and finally we
assess whether education influences the risk of HIV
infection.
Schooling and the determinants of sexual
behaviour: a theoretical framework
Attending formal schools can lead to behaviour change in
many ways. Here we identify three routes by which
increased educational attainment may affect sexual
behaviour: by changing the sociocognitive determinants
of behaviour (knowledge, attitudes and perceived
control), by influencing social networks, and by leading
to a change in socioeconomic status. These mechanisms
are illustrated in Fig. 1. We later discuss separately the
ways in which school attendance alone can affect
sexual behaviour.
Educational attainment and sociocognitive
determinants of behaviour
In a direct wayeducation may affect the thought processes
of individuals, which subsequently affect their behaviour.
Social cognition models point to several such key
determinants of sexual behaviour. In most theories,
knowledge and understanding of a behaviour and its
consequences is a necessary but not sufficient condition
for performing the behaviour and underpins the
perception of [7] and attitudes towards [8] that behaviour.
In the context of HIV, understanding transmission routes
and methods of blocking them are essential for the
adoption of safer sexual behaviour.
More educated people are more likely to be exposed to
prevention information as part of formal schooling and
also through the media [9]. Greater levels of education
may also provide a framework of biological knowledge
and an understanding of causality into which HIV
prevention messages can be assimilated. Education thus
helps individuals understand the connection between a
behaviour (e.g. unprotected sex) and its outcome (HIV
infection). Social cognition models [10] also suggest that
the evaluation of this outcome is important. Individuals
must be sufficiently motivated to avoid HIV infection and
pregnancy in order to avoid unprotected sex. Evidence
suggests that attending school influences the evaluation of
this outcome [11] (discussed below).
Another key theoretical determinant of behaviour is the
perceived control one has over the behaviour. This
includes self-efficacy, one’s belief in one’s capabilities to
perform a specific action required to attain a desired
outcome [12], the perceived personal power one has over
the behaviour [8] and the actual personal power one has
S42 AIDS 2008, Vol 22 (suppl 4)

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over a behaviour [13]. Evidence suggests that education is
associated with increased self-efficacy in general [12] and
in the context of the HIVepidemic in sub-Saharan Africa
in particular [14]. In addition, more educated people are
more likely to believe they have control over their own
behaviour, rather than another individual or fate, and
they are more likely to have actual control over their own
behaviour. For example, educated women are more able
and likely to negotiate safer sex [15–17], discuss family
planning with their partner [18], and feel a sense of
control in their sexual relationships [19].
Educational attainment and social/sexual networks
Increased education levels can also influence the kind of
people one meets and the way they behave. The enhanced
social status or wealth associated with increased education
may lead to someone having different sexual networks. It
may also influence the behaviour of other individuals in
this network, perhaps increasing their willingness to
become sexual partners or influencing their effectiveness
in negotiation about sexual behaviour. The suggestion
that more educated individuals have different sexual
networks than poorly educated individuals has an implied
impact on an individual’s risk, which depends on the
particular epidemiology of HIV in the individual’s
country and region. Assortative sexual mixing by
education level is likely to reinforce the relationship
between education and HIV, increasing the risk or
bolstering the protection. It is difficult to discern whether
education influences HIV risk in this way. The nature of
this impact is likely to be long term and linked to social
mobility. To our knowledge, little research has been done
linking educational levels to sexual networks in sub-
Saharan Africa; the hypothesis that education may act as
an HIV prevention mechanism by sorting educated
people into safer sexual networks deserves further
enquiry.
Social networks are also important because of the power
of the normative beliefs that are held by groups of people.
These norms influence individuals’ behaviour, especially
for young people [20]. In South Africa, social norms
surrounding men’s dominance over women in sexual
relationships are prevalent, and these norms are proble-
matic in terms of HIV prevention efforts [21]. Social
norms can influence protective behaviours as well as risk-
taking behaviours. According to a study in Kenya ‘the
probability that women will favor sexual faithfulness
depends significantly on the number of network partners
who also favor this method of protective behaviour’ [22].
Social norms were a strong predictor of intention to use a
condom in a South African study [23].
Social norms and education are interrelated in several
ways. First, people of different educational levels may
have different sets of social norms. Case studies in South
Africa found separate social group identities for
adolescents who had different types and levels of
education, those who went to school outside of the
community, those who went to local schools, and those
who had dropped out of school [24]. Second, in a reversal
of the relationship, social norms may determine how
interested an individual is in HIV/AIDS education. For
university students in Ethiopia, the perception of social
norms regarding HIV/AIDS was a significant predictor of
the desire to learn about HIV/AIDS [25]. Admittedly,
Education and vulnerability Jukes et al.S43
Educational attainment
Epidemic
maturity
Social
network
Exposure
to HIV
messages
Understanding
HIV messages
Sociocognitive factors
Knowledge
Attitudes
Self-esteem
Self-efficacy
Socio-
economic
status
Behavioural
norms Behavioural
intentions
Control over
behaviour
Sexual
contacts Transmission
probability
Sexual behaviour
Sexual
network
HIV infection
Fig. 1. Pathways for the effect of educational attainment on HIV infection and how these mechanisms are influenced by
epidemic maturity. In the absence of HIV prevention messages, greater control over behaviour puts educated individuals at greater
risk. When HIV prevention messages become more common, educated individuals are better placed to act on them. (See text for
full explanation.)

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social norms are difficult to alter through interventions;
however, ‘once altered the new norms tend to be
perpetuated’ [26].
In addition to the above mechanisms, education may also
enhance the effectiveness of social support networks. One
study in Manicaland, Zimbabwe, showed that more
educated women are able to benefit more from other
protective measures. This study looked at membership in
social groups related to churches or political parties,
among other organizations. Women who were members
of a well-functioning social group were 1.3 times more
likely to avoid HIV infection than those who were not in
such groups or who were in groups with which they were
dissatisfied. Women with secondary education were more
likely to belong to such groups and among women with
secondary education, those who were members of well-
functioning groups were 1.5 times less likely to be
infected with HIV, whereas women with no education
received no such benefits from group membership [27].
Membership of a social group may provide support to
individuals in making protective decisions that are
contrary to local social norms [26]. Social networks
may also be informal conduits of protective resources. For
example, almost 50% of individuals obtaining condoms at
12 health clinics in South Africa had given condoms to or
received them from others in the previous month. This
percentage rose with education level [28].
Educational attainment and socioeconomic factors
Sexual behaviour is influenced directly by the higher
socioeconomic status that can result from increased
educational attainment. There are a number of mediating
pathways involved in this relationship. We discussed two
of these above: the increased psychological sense of
control over sexual behaviour and the different sexual
networks associated with people of higher socioeconomic
status. In addition, sexual behaviour, particularly of men,
is influenced by higher levels of disposable income,
increased leisure time, and increased ability to travel and
to use commercial sex partners [29–31]. Psychological
factors, mobility and income all contribute to individuals
having more choice and greater control over their sexual
behaviour [32].
For women, one consequence of higher levels of
education is that they start having sex later but delay
marriage to an even greater extent. This leads to them
being single and sexually active for a longer period of time
and thus to having a greater number of sexual partners
[33].
School attendance
In this section we discuss mechanisms for changes in
sexual behaviour that result merely from attending
school. These mechanisms are distinct from the con-
sequences of increased educational attainment discussed
above. Here, we are interested in how school enrollment
can affect behaviour, regardless of what is learnt in the
classroom. There are a number of ways in which this can
happen. One mechanism that increases the risk of HIV
infection are the widely reported [4,34] but rarely
documented cases of male teachers using their position of
power to engage in sex with female pupils. In one
qualitative study conducted in Tanzania, sexual relation-
ships between female students and male teachers were
reported in eight of nine villages in which interviews
were conducted [35].
Many other mechanisms lead to safer sexual behaviour
among school pupils. Hargreaves and colleagues [36]
suggested that school pupils have smaller sexual networks
than their out-of-school peers. This suggestion was based
on the finding that students have less risky sexual
behaviour and fewer sexual partners than non-students,
even though there was no difference in HIV knowledge
or access to HIV prevention materials between the two
groups because school-based HIV prevention pro-
grammes were poorly developed in the study area at
the time.
The preliminary finding (discussed below) that inter-
ventions to keep girls in school lead to a reduction in
pregnancy rates [37] suggests other mechanisms for the
effect of school attendance on sexual behaviour. School
policies insisting that pregnancy should result in exclusion
may act as an incentive for girls to avoid unprotected sex.
Alternatively, girls may be more optimistic about their
future as a result of their continuing education and thus
see greater opportunity costs in getting pregnant. This
interpretation is supported by a number of findings. As
discussed above, school girls are more likely to evaluate
negatively the consequences of unprotected sex [11]. In
addition, a study in Kenya [38] found that girls’ dropout
from school was more sensitive to the quality of schooling
than boys’ dropout. In schools in which academic
achievement was lowest, girls were more likely to drop
out from school than in higher-quality schools and were
more likely to be married or pregnant. This suggests that
education competes with another life course for girls, and
when education is of poor quality girls choose to marry
and start families. Other aspects of school quality are also
important. Studies in Kenya and Egypt found that ‘gender
neutral’ schools are more likely to encourage girls to
persist with their education [39–41].
To conclude, we have identified four classes of
mechanisms by which schooling may affect sexual
behaviour. Three of these mechanisms relate to
educational attainment: sociocognitive determinants,
social networks and socioeconomic/demographic factors.
One final mechanism relates to changes in sexual
behaviour resulting from school attendance. We now
turn to the evidence of whether sexual behaviour is
indeed influenced by educational attainment and school
attendance.
S44 AIDS 2008, Vol 22 (suppl 4)

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Schooling and sexual behaviour
Educational attainment and sexual behaviour
To our knowledge, no evidence exists identifying
increased educational attainment as the causal factor in
an individual’s sexual behaviour. Much evidence,
however, suggests that sexual behaviour is associated
with education level. For some behaviours, education is a
risk factor for HIV infection. For other behaviours
education is protective. We deal first with the risk factors.
There are a number of aspects of the sexual behaviour of
more educated individuals that initially puts them at
greater risk of infection, largely related to the socio-
economic and demographic mechanisms discussed above.
More educated individuals change partners more rapidly
[32] and have a greater number of sexual partners [33]. A
study in South Africa found that more educated
individuals were more likely to have multiple concurrent
sexual partners (Cockroft, personal communication).
Educated women who delay marriage also have more
sexual partners [33]. The choice of contraceptives also
differs by level of education. Although educated people
may be more likely to use contraception overall, they
are also more likely to choose methods, such as the
contraceptive pill, which do not protect against sexually
transmitted infections such as HIV. Taken together, and in
the absence of any educational response to an epidemic,
these factors increase the vulnerability of more educated
individuals to HIV infection in the early stages of an
epidemic.
There are also ways in which education leads to a greater
adoption of safer sexual behaviour in response to the HIV
epidemic. Data from demographic and health surveys in
11 countries [16] showed that women with primary
school education were more likely than those with no
education to report using a condom at last sex. In nine of
these countries, secondary education was associated with
a further increase in the likelihood of using a condom at
last sex. Another study in Zimbabwe [42] found that
women with secondary education were less likely to
report having had unprotected casual sex and were more
likely to delay sexual debut. Of these factors, the delay of
sexual debut was a better predictor of HIV status. A study
in the four African cities of Cotonou in Benin, Ndola in
Zambia, Yaounde
´in Cameroon, and Kisumu in Kenya
found that education was associated with less risky sexual
behaviour. Condom use was more common among more
educated individuals in all four cities [43]. The exchange
of money for sex was less likely among educated women
in all four cities and among more educated men in
Yaounde
´. Non-marital sex without a condom was less
prevalent among more educated women in all four cities
and among more educated men in Cotonou and Kisumu.
In Yaounde
´, more educated men and women were less
likely to have sex with a casual partner on the day of
meeting, and in Ndola, for both men and women, not
knowing a partner’s age was much more common among
those with little schooling [44]. Among Zambians aged
15–24 years, increases in condom usage between 1995
and 2003 were greatest for those with higher educational
levels. In addition, they were less likely to have had more
than one sexual partner in the previous year than those
with lower educational levels [45].
Other behaviours that reduce HIV infection are also more
common among the educated. For example, more
educated people are more likely to seek treatment for
other sexually transmitted diseases, which would decrease
their vulnerability to becoming infected with HIV [32].
School attendance and sexual behaviour
Evidence for a causal relationship between general
education and sexual behaviour comes from a recent
study in Kenya [37], which aimed to lower the cost of
education by providing school uniforms and thus reduce
school dropout. Girls in schools in which uniforms were
distributed were 2.5 percentage points less likely to drop
out, a 15% reduction in the dropout rate. The dropout
rate for boys also decreased by approximately 15%. Girls
in schools in which uniforms were distributed were
1.5 percentage points less likely to have had a child, which
amounts to nearly a 10% decrease in the childbearing rate
for teenagers. Self-efficacy may also have been improved;
girls in the uniform schools were significantly more likely
to be confident that they could say no to a partner who
wanted to have sex. The authors suggest that the reason
for the change in behaviour is not related to what pupils
learn at school but that girls typically plan to delay child-
bearing and marriage until after they complete schooling.
This may reduce the likelihood of their engaging in
unprotected sex while they are at school, and indicates
that they believe that they have a future through
education. This study is currently under peer review
but if the results are confirmed they will provide the first
experimental evidence to our knowledge demonstrating
that attending school for a longer period of time leads to
safer sexual behaviour.
One study in South Africa [36] compared the sexual
behaviour of students with those out of school. They
found that the lifetime number of partners was lower for
students of both sexes. Among young women, fewer
students reported having partners more than 3 years older
than themselves, having sex more than five times with a
partner, and having had unprotected sex during the
past year.
Schooling and sexual behaviour: conclusions
To summarize the preceding sections, there is much
evidence showing an association between sexual beha-
viour and both attendance and attainment. Experimental
evidence that school attendance leads to safer sexual
behaviour is currently under review. Studies suggest
several pathways through which sexual behaviour, and the
risk of HIV infection, may be influenced by schooling.
Students attending school have a smaller sexual network
Education and vulnerability Jukes et al.S45

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and a stronger motivation to avoid the consequences of
unprotected sex (both pregnancy and HIV infection) than
their out-of-school peers.
Educational attainment and HIV risk have a complex
relationship (see Fig. 1). As educated individuals tend to
have more control over their sexual behaviour, the
association between education and HIV depends crucially
on behavioural intentions. In the absence of information
about HIV transmission, many individuals may intend
to have several sexual partners. It is the greater control
over the behaviour of more educated individuals that
allows them to act on these intentions and puts them at
greater risk of HIV infection. Educated individuals are,
however, more likely to be exposed to HIV prevention
messages, more likely to understand them and con-
sequently have more knowledge about prevention
methods. This may lead educated individuals to have
different behavioural intentions and different behaviours.
Given that HIV prevention messages become more
prevalent with epidemic maturity, this leads to a
hypothesis about the changing relationship between
HIV and education. In the early stages of an epidemic,
education is a risk factor for HIV infection. As an
epidemic matures and prevention messages become more
common, education is a protective factor against HIV
infection. This hypothesis is examined in the next section.
Schooling and HIV prevalence
National level associations
At the national level in sub-Saharan Africa there is a
positive relationship between literacy rates and HIV
infection rates (Fig. 2): more literate countries have
higher rates of HIV infection. More literate African
countries tend to be the most developed on the
continent, and they share a number of features that
make them vulnerable to high rates of HIV infection.
First, the most developed countries often have the largest
income disparities between men and women, a factor
associated with higher HIV infection rates [46]. Similarly,
employment in the formal sector is associated with higher
HIV infection [47,48]. Increased migration and improved
transport infrastructure can facilitate the spread of HIV
[49]. Urban residence is also associated with higher levels
of HIV infection [47,48,50,51]. Finally, as discussed
below, higher levels of education per se are associated with
higher infection rates. According to this analysis the
educational advantage of the southern African countries
became their disadvantage at the beginning of the HIV
epidemic. The high levels of education in the region may
help explain initial high levels of vulnerability to HIV
infection.
Although various demographic and socioeconomic
conditions put the educated at greater risk of HIV
infection, it has been hypothesized above that they will be
more likely to change their behaviour in response to
information about the epidemic [52,53]. One way in
which this trend may manifest itself at the national level is
in the weakening of the relationship between literacy and
HIV infection rates as the epidemic matures. We would
expect the positive relationship between HIV infection
and literacy to be weaker (or even to become negative) in
the later stages of the epidemic. This hypothesis has been
tested [52] by comparing the relationship between adult
HIV prevalence in 1999 and adult literacy in 1998 in three
different regions of sub-Saharan Africa. In two regions
(west/central Africa and east Africa) the epidemic is more
mature and the relationship between HIV prevalence and
literacy is relatively weak compared with the region with
the most recent epidemic (southern Africa). A similar
inversion may be occurring in the relationship between
income and HIV status [54].
This analysis is consistent with the hypothesis that
education better prepares individuals to mount a response
to the HIV/AIDS epidemic. There are, however,
difficulties in using population-level data to draw
inferences about individuals. For example, in countries
with high HIV prevalence and high literacy rates it is not
clear whether literate individuals are the ones with HIV
infection without conducting an individual-level analysis.
It is to this that we now turn in the following section.
Individual level associations
The majority of studies investigating this issue have found
a positive relationship between educational level and HIV
infection. That is, HIV prevalence is higher among
educated individuals [31,55–63]. Five population-based
studies have, however, found the opposite trend
[42,44,64–66], whereas several other studies found no
significant relationship between education and HIV
[42,44,67].
The overall pattern of these results is complex. This is to
be expected if the pattern represents the combination of
S46 AIDS 2008, Vol 22 (suppl 4)
y = 0.2483x − 4.7922
R2
= 0.3509
0
10
20
30
40
1009080706050403020100
Adult literacy %, 1998 (UNESCO, 2000)
Adult HIV prevalence %, 1999 (UNAIDS, 2000)
Fig. 2. HIV prevalence in adults aged 15 –49 years by level of
adult literacy for 40 countries in sub-Saharan Africa. Repro-
duced from Gregson et al. [52], with permission.

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two opposing trends: the initial increased vulnerability of
educated individuals to HIV infection followed by their
more rapid behavioural change once informed about the
epidemic. The studies reported do allow us several
opportunities to try to untangle these two trends by
analysing their evolution alongside epidemic maturity.
Changing relationship between HIV and education
with epidemic maturity
A recent systematic review [6] uses three strands of
evidence to conclude that the association between
educational attainment and HIV infection is weakening
over time. First, studies conducted from 1996 onwards
were more likely to find a lower risk of HIV infection
among the most educated. A study conducted among
urban and rural men and women in Zambia found that
the risk of HIV infection among 15–49-year-olds with
10 or more years of education fell from 1995 to 2003 [68].
The situation in Africa contrasts with that in other areas of
the world. For example, in Thailand the HIV epidemic
was monitored by existing mechanisms and was initially
confined to high-risk groups. This allowed the spread of
information about the epidemic before the spread of the
infection to the general population. This is perhaps why
the most educated individuals were protected from HIV
from the early 1990s.
The second line of evidence is that, when data were
available over time, HIV prevalence fell more consistently
among highly educated groups than among less educated
groups, in which HIV prevalence sometimes rose while
the overall population prevalence was falling. The clearest
evidence comes from a longitudinal survey in rural areas
of Masaka district, Uganda [69]. The national prevalence
of HIV in the adult population declined from its peak of
14% in the early 1990s to approximately 5%, largely as a
result of a strong prevention campaign [70]. As illustrated
in Fig. 3, the rate of decline in prevalence is greater for
those with secondary education than for those with lower
levels of education, and those with primary education
show a faster decline in prevalence than those with no
education. The chances of contracting HIV during this
period was reduced by 6.7% for each year spent in school
[69], and those with no education were 2.2 times more
likely to become infected than those who had completed
primary education.
The third line of evidence is that, in several populations,
associations suggesting greater HIV risk in the more
educated groups at earlier time points were replaced by
weaker associations later. The data from Masaka district,
Uganda, demonstrate the evolving nature of the
relationship between HIV and education. In 1990, there
was no relationship between HIV prevalence and
education. In 2000, having completed primary education
was associated with a 5.1% reduction in the risk of HIV
infection, and secondary education was associated with an
8.8% reduction in risk. This relationship between HIV
and educational attainment was found for women but not
men. Similarly, in Rakai, Uganda, HIV infection was
associated with increased levels of education in 1990 and
1992 but not by 1994 [56,71]. Similar patterns are found
in other countries. In a population-based study in
Zimbabwe, men and women aged 17– 19 years were at a
lower risk of HIV infection if they had secondary
education. The benefit of education was lower for those
aged 20–24 years, and there was little or no protective
benefit for those aged 25 years and over [42]. In Fort
Portal, HIV prevalence among women aged 15 –49 years
attending an antenatal clinic was highest for those with
secondary education in 1991–1994, but by 1995 –1997
older illiterate women had the highest prevalence [59].
Education and vulnerability Jukes et al.S47
18%
16%
14%
12%
10%
HIV prevalence
8%
6%
4%
2%
0%
12345678
Rounds
9101112
No education Primary Secondary
Fig. 3. HIV prevalence by education category for individuals aged 18 –29 years, rural Uganda, 1990 –2001. Reproduced from de
Walque and colleagues [64,69], with permission.

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Prevalence reduced to the greatest extent among women
with secondary education and among young women.
Similarly, there was a positive association between
education level and HIV infection among women
attending an antenatal clinic in 1994 but not by 1998
[60,61]. Again, the largest reductions were seen among
younger, more educated women. Similar patterns were
seen in northern Malawi [72], but there was no evidence
of a changing association between HIV and education in
Blantyre, Malawi [73] or in Kagera, Tanzania [74].
Overall, causal evidence is lacking, but these observational
findings suggest that education has moved from being a r isk
factor for HIV to being a protective factor. The analysis is
consistent with the thesis that educated individuals are at a
higher risk of HIV infection initially but are better able to
mount a response to the HIV epidemic.
School attendance and HIV infection
We are aware of only one study that examined the
relationship between school attendance and HIV infec-
tion. This study in South Africa found that male students
were less likely to be infected with HIV than male non-
students [36]. No such relationship was found for young
women. The results for women were, however,
complicated because sexual activity can influence school
attendance, when pregnant girls drop out, as well as
school attendance influencing sexual activity.
Evidence of a causal relationship between educational
attainment and HIV infection
To our knowledge, only one randomized controlled trial
has been conducted to link schooling with HIV-related
behaviour [37]. The study is under review, but if findings
prove valid they will provide causal evidence that keeping
girls in school reduces the incidence of unprotected sex.
In our dichotomous classification of schooling this
supports arguments for increased school attendance of
girls but does not address the argument for increased
educational attainment of girls. Causal evidence of this
latter relationship is harder to find. Longitudinal studies
are helpful in our understanding of the relationship
between educational attainment and HIV infection.
Cross-sectional studies are unable to establish whether
HIV infection leads to poor educational attainment or
vice versa. Also, cross-sectional studies examining HIV
prevalence do not take into account the influence
educational level may have on the length of survival of
HIV-infected individuals. Longitudinal studies can help
resolve these issues. One study in a poor rural community
in KwaZulu-Natal, South Africa [75] followed individ-
uals initially uninfected with HIV for just over one year.
They found that participants were 7% less likely to
become infected with HIV for each year of education
they had completed.
A similar study in Tanzania looked at the same
longitudinal relationship using aggregated data from 20
regions over 8 years [76]. The study estimated that each
increase of 1% in female primary school enrollment was
responsible for a 0.15% reduction in HIV prevalence in
this group, corresponding to 1408 infections in the period
1994–2001. A further analysis of these data suggests that
the investment in increased school enrollment is justified
by the averted cases of HIV and the earning potential of
these individuals, with a cost–benefit ratio of between
1.3 and 2.9.
Even with such longitudinal data, however, we cannot
rule out the possibility that educational attainment is a
proxy for some other characteristic, such as socio-
economic status. We have noted that changes in the
relationship between socioeconomic status and HIV
infection over time are similar to changes in the
relationship between education and HIV – socio-
economic status is increasingly found to be protective
against HIV in associational studies [52]. Analyses from
Uganda [69] and elsewhere [77] suggest that parental and
individual income are not explanatory factors in the
relationship between HIV and educational attainment.
Several studies have attempted to determine whether
economic status, mobility or education is most important
in determining HIV vulnerability. A review of these
studies finds mixed results [34].
The ecological nature of the evidence presented implies
other limitations. It may be that participants in studies
were not representative of the overall population.
Although studies based in antenatal clinics report close
to a 100% response rate, such studies do not include men,
sexually inactive women or those who do not use clinics.
This latter group in particular may exhibit a different
relationship between education and HIV, particularly as
clinic use may be associated with education level.
Given the need for policy decisions to be based on clear
evidence, it is of concern that all evidence addressing the
relationship between HIV and educational attainment is
observational in nature. Further evidence is required
before it can be concluded that educational attainment
is a causal factor in the reduction of HIV vulnerability.
The long-term follow-up of randomized controlled trials
to improve educational access, for example through
conditional cash transfers, and analyses of the long-term
consequences of recent educational expansion policies
in Africa offer the potential to examine the causal
relationship between educational attainment and HIV. In
the final section of this paper we make suggestions about
how policy can be formulated on the basis of current
evidence.
Expanding educational access in hyperendemic
countries
The foregoing discussion of the effect of education on
HIV prevalence and risk must be placed in the context of
educational access in southern Africa. The first panel of
S48 AIDS 2008, Vol 22 (suppl 4)

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Table 1 shows the primary school net enrollment ratios
for the eight hyperendemic countries and Malawi. Some
countries are far closer to achieving universal primary
education than others. National-level statistics can,
however, be misleading. Within countries there is often
large regional variation. In a number of countries,
including Zambia and Zimbabwe, internal geographical
variation in net enrollment ratios has increased since the
Dakar World Education Forum meeting in 2000 [78].
Achieving universal access is not just about meeting
national goals, but about focusing on regions within
countries that are falling behind. In addition, completion
rates for the primary cycle of education lag far behind
enrollment rates (Table 2).
Poor rates of primary completion and of secondary access
are a concern because evidence presented above suggests
that the protective benefits of education against HIV
infection continue through all levels of education. Post-
basic education has the strongest protective effect, as
discussed above for Zimbabwe and Uganda. Countries
with high HIV prevalence rates are, however, still far from
universal secondary net enrollment, as shown in the
second panel of Table 1. Another possible implication of
the proportionate relationship between sexual behaviour
and education is that the least educated individuals in a
society are vulnerable to HIV regardless of the overall
level of education in that society. This interpretation of
findings argues for the equitable expansion of schooling at
all levels. Although this is an ambitious goal, it is not an
all-or-nothing proposition; keeping girls in school a year
longer is beneficial for HIV prevention even if they do
not complete secondary school. Girls are less likely to
engage in unprotected sex while they are attending
school. Furthermore, evidence suggests that each
additional year of schooling increases one’s ability to
avoid HIV infection. Whereas national governments
should maintain high goals for the education of their girls,
it is important to recognize that even moderate steps
towards these goals help reduce vulnerability to HIV.
If these countries are to expand educational opportunities
for children, a healthy teacher corps is vital. In South
Africa, Shisana and colleagues [79] found an overall HIV
prevalence rate among teachers of 12.7%. Among
teachers aged 21–34 years, the rate was 21.4%. Many
of these teachers will see their teaching careers shortened
due to illness if they do not have access to treatment.
Antiretroviral treatment may reduce teacher absences and
mortality in sub-Saharan Africa by 90%, making it cost-
effective as a national policy option for hyperendemic
countries [80]. Considering solely education sector
benefits, Risley and Bundy [80] calculated a return of
US$2.24 per dollar invested in treatment for teachers.
Despite these benefits, many teachers do not have access
Education and vulnerability Jukes et al.S49
Table 1. Net enrollment ratios in nine southern African countries, 2005.
Country Net enrollment ratio Male net enrollment ratio Female net enrollment ratio
Primary
Botswana 85 85 84
Lesotho 87 84 89
Malawi 95 92 97
Mozambique 77 81 74
Namibia 72 69 74
South Africa (2004) 87 87 87
Swaziland (2004) 80 79 80
Zambia 89 89 89
Zimbabwe (2003) 82 81 82
Secondary
Botswana 60 57 62
Lesotho 25 19 30
Malawi 24 25 22
Mozambique 7 8 6
Namibia 39 33 34
South Africa (2002/3) 66 63 68
Swaziland (2004) 33 31 35
Zambia 26 29 23
Zimbabwe (2003) 34 35 33
Source: UNESCO [78]. Note: Net enrollment is defined as ‘enrolment of the official age group for a given level of education, expressed as a
percentage of the population in that age group’ (p. 393).
Table 2. Survival rates to last grade of primary education and
primary repetition rates in nine southern African countries.
Country
Survival rate to
last grade, 2004
Primary repetition
rate, 2005
Botswana 85 (2003) 4.8
Lesotho 61 19
Malawi 34 20
Mozambique 46 10
Namibia 76 15
South Africa 77 8 (2004)
Swaziland 61 16
Zambia – 6
Zimbabwe 62 (2002) –
Source: UNESCO [78].

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to antiretroviral treatment in the countries of southern
Africa. One exception is Zambia, where an estimated 800
teachers die from AIDS-related causes each year and
teachers now have access to free voluntary counselling
and testing and antiretroviral drugs [81]. Hyperendemic
countries must actively promote the health of their
teachers in order to staff the additional schools and
classrooms needed.
Conclusions: what does the evidence show?
Educational attainment
Cross-sectional evidence shows that educational attain-
ment is associated with a higher r iskof HIV infection in the
early stages of an epidemic and with a lower risk of HIV
infection as the epidemic matures. Longitudinal studies
show that educated individuals are less likely to acquire
HIV infections over time. The causal role of education in
these relationships cannot, however, be identified.
In some studies evidence suggests that educational
attainment is associated with an increased number of
sexual contacts. Others find that educational attainment
leads to a reduction in sexual contacts and reduced
transmission rates, as a result of increased condom use.
These findings are consistent with evidence that when
given accurate information about HIV, educated individ-
uals are more likely to engage in safer sexual behaviour.
This relationship is present at all levels of education.
School attendance
Evidence of a relationship between school attendance and
sexual behaviour comes from one experimental study,
currently under review, which demonstrates that keeping
girls in school leads to a reduction in unprotected sex.
Evidence also suggests that school attendance is associated
with a reduction in the number of partners for men and
women and a reduction in HIV vulnerability for men.
We have discussed the effects of school attendance and
increased educational attainment separately throughout
this paper to highlight the different bodies of evidence
underpinning these two effects. The implications of these
two effects are, however, the same: efforts should be made
to keep girls in school at all levels. This argument is
supported by preliminary causal evidence on the impact
of school attendance on sexual behaviour and associa-
tional evidence on the effect of educational attainment on
sexual behaviour and HIV vulnerability.
Section 2: the impact of school-based HIV
prevention education
This section focuses on education programmes con-
ducted in schools in sub-Saharan Africa that aimed to
have an impact on the sexual behaviour of participants
and to reduce the prevalence of HIV. In this category we
include both traditional knowledge-building sex edu-
cation and skills-building programmes specifically
focused on HIV prevention. Such programmes can be
challenging to design and evaluate. A long chain of events
must occur for these programmes to be successful, from
appropriate design to staff training to the precise
measurement of outcomes. Strong evidence of the
effectiveness of such programmes can only be garnered
from randomized controlled trials with biological out-
comes. Such studies are, however, rare because of their
expense and the difficulty of obtaining biomarker data
from young people. Our review of the evidence falls into
two sections. First, we look at studies that did not meet
these stringent criteria and that constitute the vast
majority of work in this area. Second, we look at more
recent trials that met the criteria required to infer
causality. To our knowledge, we have included all
randomized controlled trials with biological outcomes
that have been conducted in southern Africa. We
reviewed all programmes included in other systematic
reviews [82], evaluations found through searches con-
ducted in Web of Science, and through contacts with key
researchers in the field.
HIV prevention programmes evaluated without
biological outcomes
Several reviews have been conducted over the past several
years that condense the current knowledge on HIV and
sexual health prevention programmes. Gallant and
Maticka-Tyndale [82] focus specifically on HIV/AIDS
interventions for African youth that were conducted in
schools. They include 11 peer-reviewed studies with
quantitative evaluation data that were published between
1990 and 2002. Looking separately at knowledge,
attitudes, and behaviours, the review by Gallant and
Maticka-Tyndale [82] makes clear that a change in
knowledge or attitude does not necessarily result in the
desired change in behaviour.
All 11 programmes attempted to increase knowledge, and
10 were successful. In the remaining study, a school-based
programme in Uganda focused on HIV/AIDS and
sexually transmitted diseases, the authors found that the
programme was not fully implemented as designed [83].
The reviewed programmes were also successful in
changing student attitudes. All seven programmes that
attempted to do so were able to produce change in
students’ attitudes towards people living with HIV and
AIDS. This reduction in stigma has important implica-
tions that are discussed below.
There was, however, less consistency in programme
outcomes when condom usage and abstinence were
outcomes. Two studies found a positive change in
attitudes towards abstinence [83,84], whereas two others
found no improvement [85 –87]. According to the review
S50 AIDS 2008, Vol 22 (suppl 4)

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of Gallant and Maticka-Tyndale [82], student under-
standings of personal risk level may be the most difficult
attitude for a school health programme to change. Despite
this challenge, two programmes were able to improve
reported self-efficacy [84,85,88].
Behaviour change proves more difficult than changing
knowledge and attitudes. Only one of the three studies
focusing on sexual behaviour found an impact on sexual
debut and the number of partners [89]. Of four studies
aimed at condom use, only one increased the reported
rates of condom usage [84]. Although sexual behaviours
may be difficult to impact directly, related behaviours
seem to be more malleable. Several studies were able to
increase communication between students and their
parents, friends, and sexual partners about sexual issues
and HIV [87–90]. Importantly, Gallant and Maticka-
Tyndale [82] note that in no case did sexual activity rates
increase as a result of the interventions. In all reviewed
cases sexual activity decreased, although in many cases the
changes were not statistically significant.
One key study using self-reported outcomes has been
conducted since this review. A recent evaluation of the
primary school action for better health programme in
Kenya used matched pairs of 40 control schools and 40
intervention schools to identify programme effects [91].
The programme’s effects differed by gender. Boys in
programme schools who had been highly exposed to the
programme were significantly more likely to report
condom use at last sex [odds ratio (OR) 1.56 for pre-
programme virgins and 1.47 for those who were not virgins
at programme initiation], whereas there were no significant
effects of the programme on girls’ reported condom use
even at a high exposure level. Both boys and girls in
programme schools who were virgins at baseline were
significantly less likely to begin sexual activity during the
programme, but the effect was stronger for girls (OR 0.59)
than for boys (OR 0.71). That study underlines the
importance of tracking programme dose received by
different groups of students, as many of the outcome
measures differed between youth who had ‘high’ and ‘low’
programme exposure. Poor implementation fidelity and
low programme dose threaten the results of even the best-
designed programmes. This conclusion is supported by a
randomized evaluation of KwaZulu-Natal’s ninth grade
life-skills-based programme. The study found that the
programme did not change abstinence rates, condom use,
measures of confidence, or communications regarding
HIV/AIDS. The authors hypothesize that these poor
outcomes are related to incomplete programme imple-
mentation in some schools [92].
A second useful review was conducted by Kirby and
colleagues [93]. The review by Kirby et al. [93] covered 83
studies in 22 developed and developing countries. The
programmes focused on sexually transmitted infections,
HIV/AIDS, and pregnancy. Programme impacts varied
by sexual behaviour. Half of the programmes focusing on
reducing sexual risk-taking were successful, compared
with only 29% of programmes designed to reduce the
frequency of sex. Overall, however, Kirby et al. [93] found
that 65% of the studies reviewed had a positive and
significant impact on at least one sexual behaviour,
and only 7% had a significant negative impact on
participants’ behaviours. In addition to consolidating the
findings of the 83 studies, Kirby et al. [93] identified 17
common traits of the successful programmes. The list of
characteristics, covering curriculum, curriculum devel-
opment, and implementation of the curriculum, can be
used by designers of new school health programmes to
maximize chances of success. Such a study is not
unequivocal. Identifying the causal factors determining
the success of interventions is not, however, possible with
the data available and the analysis of Kirby et al. [93] is a
valuable first step in building the evidence base for HIV
prevention education.
Randomized trials of HIV prevention education
interventions with biological outcome measures
Three recent studies have assessed the impact of HIV
prevention education using a randomized trial design
with biological outcome measures, either using preg-
nancy as a proxy for sexual behaviour or directly assessing
HIV infection. Duflo and colleagues [37] compared two
HIV-related education interventions using a randomized
controlled design in western Kenya. A condom essay and
debate programme had a positive outcome on self-report
measures; those who participated were more likely to
report that they used condoms. A teacher training
programme resulted in little change. Neither intervention
had an impact on pregnancy rates.
Working in the same population in western Kenya, another
recent study showed that risk-reduction education had a
significant effect on risky HIV-related behaviour. Dupas
[5] conducted a randomized controlled trial involving
328 primary schools in Kenya to evaluate an education
campaign focusing on the risks of cross-generational sex.
The campaign involved a 40-minute talk, a 10-minute
video, and a survey. The programme was successful in
reducing cross-generational sex: there was a 65% decrease
in the number of pregnancies with adult fathers in the
experimental group. Although sexual activity with same-
age partners did increase, condom usage also rose and there
was no increase in pregnancies by same-age partners. This
study is currently undergoing peer review and its results
should be interpreted with caution. If they are validated,
the results would demonstrate that when a realistic goal is
given for behaviour change, even a 50-minute information
campaign may lead to changes in sexual behaviour. This
potential for ‘actionable knowledge’ is worthy of further
investigation.
Another large randomized trial has recently been
conducted in neighboring Tanzania [94]. In that study
Education and vulnerability Jukes et al.S51

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20 communities were randomly assigned to receive
intervention or control activities. The Mema Kwa Vijana
intervention included a teacher-led, peer-assisted sexual
health education programme as well as community
activities, training and supervision of health workers to
provide ‘youth-friendly’ sexual health services, and peer
condom social marketing. The intervention had a
significant impact on knowledge and reported attitudes,
reported sexually transmitted infection symptoms and
several behavioural outcomes. There was, however, no
evidence of a reduction in HIV incidence in the
intervention group. This was possibly because HIV
prevalence was still very low at the time of the evaluation.
HIV prevention programmes and stigma
Stigma and discrimination are major barriers to testing
and treatment in southern Africa [95]. Many individuals
would rather not know their status, as the social
consequences of a positive test result can be dire. School
children are no exception, as children in families affected
by HIV and AIDS face stigma and discrimination from
community members [96,97]. The internal or felt stigma
as well as the experienced stigma can make children feel
different from their peers and isolated from their
communities. Anecdotal evidence suggests that stigma
and discrimination in schools may result in dropout
among children affected by HIV and AIDS [98]. These
children may be explicitly barred from schools or they
may be treated so poorly by teachers, administrators, and
other students that they drop out [99].
Evidence suggests that there is an association between
stigma and the likelihood of having been tested for HIV.
In South Africa, women who had less stigmatizing views
towards people living with HIV and AIDS were more
likely to have been tested [100]. Programmes that can
reduce stigma, therefore, may increase the level of testing
and consequently treatment. In the review by Gallant and
Maticka-Tyndale [82] of school HIV prevention pro-
grammes in Africa discussed above, every programme that
measured students’ attitudes towards people living with
HIVand AIDS was successful in changing these attitudes.
A randomized study conducted in Tanzania measured
student attitudes towards people living with HIV and
AIDS before and after a 20-h prevention programme
[87]. The authors found that changes in student attitudes
remained significant at the 12-month follow-up, indi-
cating that targeted in-school programmes can have a
lasting effect on stigma.
Integrating HIV/AIDS responses into broader
school health programmes and the education
sector
Increasingly, HIV/AIDS responses are being scaffolded
onto school health and nutrition programmes in Africa
and in the rest of the world [101]. A few countries,
including Kenya and the United Republic of Tanzania,
have taken the further step of mainstreaming HIV/AIDS
throughout the education sector, from central offices to
districts to local schools [81]. Combining anti-HIV efforts
with other health campaigns should result in more
consistency in focus and funding. Stand-alone HIV
projects are more likely to be affected by political whim or
trends in support than if they are enveloped in a wider
curriculum of health promotion.
Conclusions: what does the evidence show?
Overall, there is evidence that HIV prevention education
can lead to a change in sexual behaviour. The pattern of
results does not, however, strongly support the effec-
tiveness of school-based prevention education pro-
grammes. This may be attributable to the difficulties in
using schools and teachers to deliver sensitive messages
about sexual behaviour [35] and the absence, until
recently, of good evidence to guide the design of effective
programmes [93]. It is intriguing that one behaviour
change intervention claiming success [5] was not
implemented by teachers. The possibility of external
agencies implementing HIV prevention education in
schools is worth further exploration. The provisional
results of that trial in Kenya point to another aspect of the
future potential of school-based interventions. When
adolescents are given a realistic option for their sexual
behaviour (i.e. choose sexual partners of your own age
rather than older sexual partners) rather than unattainable
ideals (i.e. abstinence) behaviour change may be more
likely to occur.
Section 3: policy recommendations
The policy recommendations below are divided into two
sections: those directed at national-level educational
policy, and those directed towards curriculum developers
and programme planners designing HIV/AIDS inter-
ventions. Whereas making changes at either level would
be beneficial, the evidence shows that both are necessary
to exploit education fully as a means of combating HIV.
Policies on access to education
We presented substantial evidence of a link between
schooling and protection against HIV. The evidence is
not, however, unequivocal. In the case of the relationship
between educational attainment and HIV, no causal
inferences can be drawn. For the relationship between
school attendance and HIV, experimental studies have
been conducted but results are not yet published. There is
an urgent need to strengthen the evidence base. In the
interim there are strong arguments for pursuing a policy
of increased educational access to reduce the vulnerability
of girls to HIV infection. Based on the studies relating to
mechanisms, sexual behaviour and HIV infection the
most likely interpretation of findings is that increased
educational attainment leads to increased protection
against HIV. Similarly, the best interpretation of findings
S52 AIDS 2008, Vol 22 (suppl 4)

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related to school attendance is that girls attending school
are less vulnerable to HIV infection. Given the urgency of
the situation, there is reason to act on the best available
evidence.
On the basis of these arguments, achieving education for
all (EFA) would be an important contribution to HIV
prevention. Current global efforts as part of the EFA
fast track initiative already recognize the importance
of addressing HIV within the education sector and
specifically encourage the inclusion of an HIV response
with education sector plans [102]. Focusing EFA efforts
on the poor, who are the least likely to attend school, may
be disproportionately advantageous in fighting HIV.
Poverty and HIV, the two most critical issues for the
countries of southern Africa, are now firmly intertwined.
When faced with financial constraints, it may be
impossible for HIV and AIDS-affected families to pay
school fees and the indirect costs of education such as
uniforms and books. Programmes need to address this
factor explicitly and make schooling affordable for the
poorest segment of the population.
Action points
(1) Strengthen country actions to achieve universal access to
basic education, addressing equity and equality in
gender and geography.
(2) Develop a new focus on promoting participation in
secondary education, especially for girls.
Policies on curriculum responses to HIV/AIDS
Whereas increasing levels of general education can be
effective, a tailored HIV prevention curriculum also has a
role to play. There are at least three successive levels at
which a curriculum response can be effective. At the most
basic level, even relatively simple interventions in
resource-poor environments can usefully address stigma
and discrimination, as discussed above. At a slightly higher
level of complexity, provisional evidence suggests that
strategic information or actionable knowledge can have
an important impact while requiring relatively manage-
able interventions by the education sector. Provision of
information that is useful, targeted, and relevant to
students is one factor that influences parent and student
perceptions of school quality. At the highest level of
complexity, there is a clear and sound theoretical
argument for providing an educational package that aims
to develop knowledge, attitudes and skills specifically
aimed at HIV prevention, promoting behaviours such as
condom use and partner reduction [103]. It is not easy to
implement these programmes well, especially at a large
scale, and poorly implemented programmes are unlikely
to show an effect. Guidance on how to develop skill-
building programmes is vague and there is a great deal of
confusion, resulting in enormous variation in programme
content and quality. Although the recommendations by
Kirby et al. [93] are an invaluable contribution towards
consolidating knowledge about HIV prevention pro-
gramme design, they are not based exclusively on
evidence from rigorous trials and further evidence is
needed.
Action points
(1) Ensure immediately that curricula at all levels address
stigma and discrimination.
(2) Explore the potential for approaches involving action-
able knowledge, starting with implementing approaches
of known effectiveness, while simultaneously identify-
ing and testing new approaches.
(3) Launch a systematic, subregional approach to imple-
menting high-quality HIV prevention programmes,
which incorporate impact evaluation as an intrinsic
component of programme design.
(4) Promote sustainability of the HIV response by packa-
ging within existing frameworks, especially school
health and nutrition programmes.
Building a community of practice and sharing
knowledge
The challenges that HIV presents to the education sectors
of southern Africa are unique to the region. In the
education sector, however, there is a lack of a systematic
mechanism for sharing knowledge and experiences of
HIV, and in particular experiences that involve both the
health and education sectors. Under guidance from
UNAIDS the UN system has helped create mechanisms
for information sharing among agencies, development
partners and countries. The education sector has,
however, not played a strong role in these mechanisms.
It is apparent from the discussion above that there are
actions that need to be taken, including developing new
tools and approaches that are largely region-specific, but
applicable to all the hyperendemic countries. Networks
involving HIV focal points from Ministries of Education
as well as representatives of national AIDS authorities
have proved very effective mechanisms for facilitating the
sharing of information in the western and eastern regions
of Africa. Establishing such a mechanism among the
countries of southern Africa might provide an important
platform for sharing information and optimizing the
investment in evaluations while avoiding duplication, and
should be a specific area for donor focus.
Action point
(1) Create an enabling network for the region, promoting
information sharing and joint action by the education
sector.
Many of these recommendations are not new but they are
justified by emerging evidence that strengthening current
efforts will have a big impact on the HIV epidemic. We
have argued that keeping girls in school promotes safe
sexual behaviour, that education can reduce HIV-related
stigma, and that there is potential for girls to change their
sexual behaviour when given effective HIV prevention
Education and vulnerability Jukes et al.S53

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
education, and that subregional information sharing and
leadership is crucial in these efforts. In all these ways,
education can help protect young women and girls in
southern Africa from HIV.
Acknowledgements
The authors would like to thank Tania Boler, Amaya
Gillespie, James Hargreaves, Gillian Holmes, Michael
Kelly, Changu Mannathoko, Rick Olson and Danny
Wight for their valuable comments on an earlier version
of this paper. Publication of this article was funded by
UNAIDS.
Conflicts of interest: None.
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