Formal educational attainment and HIV treatment adherence in southern and eastern Africa

Abstract Social policy makers frequently leverage formal schooling as a tool for curbing the HIV epidemic in sub-Saharan Africa. Yet, in the era of ‘Treatment as Prevention’, evidence about the association between formal education and chronic HIV care and treatment in the region remains limited. In this study, I use population-level data from the first round of the Population HIV Impact Assessment to examine the association between years of formal education and HIV treatment adherence (measured via viral load suppression) across seven southern and eastern African countries. Given persistent gender and age disparities in both education and HIV care in the region, I further test for moderation of these associations by gender and age. I find no association between education and viral load suppression in the pooled regional sample (N=12,198), in country-specific analyses, and no modification of these findings by gender or age. Further, results were robust in sensitivity analyses using different measures of educational attainment. These somewhat surprising findings challenge our common understanding about education as a catalyst for improved health, and provide theoretical insights into what may drive the relationship (or lack thereof) between education and chronic health in different contexts. More research is needed into the contextual factors and countervailing mechanisms that may explain such results. Competing Interest Statement The authors have declared no competing interest. Funding Statement Funding sources: This research was supported by the National Institutes of Health under Ruth L. Kirschstein National Research Service Award (T32HD049302) from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development or the National Institutes of Health. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics Statement: To conduct this study I used secondary, publicly available Population HIV Impact Assessment (PHIA) data, and I carefully reviewed and followed all documentation and guidelines for appropriately managing and analyzing PHIA data. All PHIA survey protocols, consent forms, screening forms, refusal forms, referral forms, recruitment materials and questionnaires were reviewed and approved by in-country ethics and regulatory bodies and the institutional review boards of Columbia University Medical Center, Westat, and the U.S. Centers for Disease Control and Prevention. All publicly available data is free of identifiers and numerous measures are in place to protect respondent confidentiality. PHIA ethical protocols, including procedures to ensure privacy and confidentiality, are outlined in detail in country Final Reports that can be found here: https://phia.icap.columbia.edu/resources/ I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data Availability Data and code availability: All data is publicly available upon request from the PHIA study at https://phia-data.icap.columbia.edu/. All statistical code is available upon request from the author.