摘要：SummaryBackground 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. Methods 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. Findings 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). Interpretation 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. Funding 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.
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