Education 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 bivariate or multivariable associations 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.

Introduction

Education—specifically formal schooling— has long been imagined as a powerful tool to address the HIV epidemic in sub-Saharan Africa. Existing evidence is almost entirely focused on the role of schooling in reducing sexual risk behaviors, particularly among those who are uninfected [1,2]. Yet, in the current era of ‘treatment as prevention’, we know remarkably little about how formal education can support HIV treatment adherence among people living with HIV (PLWH) [3–5]. When HIV treatment (aka, antiretroviral therapy (ART or ARVs)) is taken regularly, leading to viral suppression, PLWH can lead long and healthy lives and there is nearly zero risk of sexual transmission of the virus [6]. Thus, increasing viral load suppression (VLS)—a common biomarker for HIV treatment adherence—among PLWH is a key public health objective for addressing HIV as both a communicable and chronic condition. Despite dramatic improvements in HIV treatment access under Universal Treatment policies in southern and eastern Africa since 2010, improvements in HIV outcomes have been unevenly distributed [4,7,8]. By examining educational disparities in viral load suppression, this study is responsive to calls to better understand and address inequities in HIV care and treatment in southern and eastern Africa [7,9], the region of the world with the highest HIV prevalence [1].

As one of the most widely diagnosed and treated chronic conditions in sub-Saharan Africa, the case of HIV also provides a unique opportunity to study educational associations with chronic care more broadly at the population level. In a context where the prevalence of chronic health conditions is rapidly increasing, many in the global health community are now looking to the successful expansion of HIV treatment in the sub-Saharan African region as an example for expanding chronic care for other health issues [10]. Indeed, chronic HIV treatment mirrors numerous other conditions that require daily or routine medication and medical visits over the course of one’s life to avoid negative consequences. For most chronic conditions, care and treatment is only recently and slowly expanding in sub-Saharan Africa [11], which has historically hampered our ability to study associations between education and chronic care management [12]. By leveraging insights from the case of HIV, this study can inform more equitable chronic care interventions in the region.