What Works for Women and Girls

Africa and found that HIV infections appear to be shifting towards higher prevalenceamong the least educated in sub-Saharan Africa, reversing previous patterns. Articleswere identified that reported original data comparing individually measured educationalattainment and HIV status among at least 300 individuals representative of thegeneral population of countries or regions of sub-Saharan Africa. Statistical analyseswere required to adjust for potential confounders but not over-adjust for variables onthe causal pathway. Approximately 4000 abstracts and 1200 full papers were reviewed.Thirty-six articles were included in the study, containing data on 72 discrete populationsfrom 11 countries between 1987 and 2003, representing over 200,000 individuals.Studies on data collected prior to 1996 generally found either no association orthe highest risk of HIV infection among the most educated. Studies conducted from1996 onwards were more likely to find a lower risk of HIV infection among the mosteducated. Where data over time were available, HIV prevalence fell more consistentlyamong highly educated groups than among less educated groups, in whom HIV prevalencesometimes rose while overall population prevalence was falling. In several populations,associations suggesting greater HIV risk in the more educated at earlier timepoints were replaced by weaker associations later (Hargreaves et al., 2008a). (Gray I)(education, sub-Saharan Africa)A 2001 cluster-randomized study evaluated the impact of school attendance on thesexual risk behaviors and HIV prevalence of 916 males and 1,003 females between theages of 14 and 25 in rural Limpopo Province, South Africa, where HIV prevalence inantenatal clinics was 13.2 percent. The study found that school attendance correlateswith lower HIV prevalence among males, fewer sexual partners for both sexes, andamong females, a lower likelihood of having partners who are more than three yearsolder, more frequent condom use, and less frequent sex within relationships. Becausestudents did not have greater access to HIV prevention materials than non-students,the study suggests that school attendance may have a protective effect on HIV riskby affecting the sexual network structure of young people. “School attendance mightaffect communication within sexual networks, in turn helping to improve confidence,self-efficacy and the adoption of safer sexual behaviors. It might also increase groupnegotiation of positive attitudes toward positive behaviors, by putting young people inregular contact with each other in a structural environment,” (Hargreaves et al., 2008b:118). Women from very poor households were less likely to be students. Among studyparticipants, HIV prevalence rates were 3.4% for men and 9.8% for women, increasingover the age range (Hargreaves et al., 2008b). (Gray II) (youth, education, sex behavior,risk behavior, South Africa)A 2003 household survey of 1,708 15–24 year-old women in South Africa who weresexually experienced but only had one lifetime partner (typically considered “low risk”for HIV) found that women who had not completed high school were more likely to beHIV-positive by odds of 3.75 than those who had completed high school. Fifteen percent324 CHAPTER 11 STRENGTHENING THE ENABLING ENVIRONMENT