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The effect of school attendance and school dropout on incident HIV and HSV-2 among young women in rural South Africa enrolled in HPTN 068

Stoner, Marie C.D.a; Pettifor, Audreya,b; Edwards, Jessie K.a; Aiello, Allison E.a; Halpern, Carolyn T.c; Julien, Aiméea,b; Selin, Amandaa; Twine, Rhianb; Hughes, James P.e,f; Wang, Jingf; Agyei, Yawg; Gomez-Olive, F. Xavierb,h; Wagner, Ryan G.b,d; MacPhail, Catherineb,i,j; Kahn, Kathleenb,d,h

doi: 10.1097/QAD.0000000000001584

Objective: To estimate the association between school attendance, school dropout, and risk of incident HIV and herpes simplex virus type 2 (HSV-2) infection among young women.

Design: We used longitudinal data from a randomized controlled trial in rural Mpumalanga province, South Africa, to assess the association between school days attended, school dropout, and incident HIV and HSV-2 in young women aged 13–23 years.

Methods: We examined inverse probability of exposure weighted survival curves and used them to calculate 1.5, 2.5, and 3.5-year risk differences and risk ratios for the effect of school attendance on incident HIV and HSV-2. A marginal structural Cox model was used to estimate hazard ratios for the effect of school attendance and school dropout on incident infection.

Results: Risk of infection increased over time as young women aged, and was higher in young women with low school attendance (<80% school days) compared with high (≥80% school days). Young women with low attendance were more likely to acquire HIV [hazard ratio (HR): 2.97; 95% confidence interval (CI): 1.62, 5.45] and HSV-2 (HR: 2.47; 95% CI: 1.46, 4.17) over the follow-up period than young women with high attendance. Similarly, young women who dropped out of school had a higher weighted hazard of both HIV (HR 3.25 95% CI: 1.67, 6.32) and HSV-2 (HR 2.70; 95% CI 1.59, 4.59).

Conclusion: Young women who attend more school days and stay in school have a lower risk of incident HIV and HSV-2 infection. Interventions to increase frequency of school attendance and prevent dropout should be promoted to reduce risk of infection.

aDepartment of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA

bMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa

cDepartment of Maternal and Child Health, University of North Carolina, Chapel Hill, North Carolina, USA

dEpidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden

eDepartment of Biostatistics, University of Washington

fFred Hutchinson Cancer Research Center, Seattle, Washington

gDepartment of Pathology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA

hINDEPTH Network, Accra, Ghana, West Africa

iSchool of Health and Society, University of Wollongong, New South Wales, Australia

jWits Reproductive Health and HIV Research Institute, University of the Witwatersrand, Johannesburg, South Africa.

Correspondence to Marie C.D. Stoner, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, Chapel Hill, NC 27599-7435, USA. E-mail:

Received 10 April, 2017

Revised 20 June, 2017

Accepted 26 June, 2017

Copyright © 2017 Wolters Kluwer Health, Inc.