Education and HIV/AIDS in Western Kenya: Results from a Randomized Trial Assessing the Long-Term Biological and Behavioral Impact of Two School-Based Interventions Pascaline Dupas 1, Vandana Sharma 2, Michael Kremer 3, Grace Makana 4, Carolyne Nekesa 4, Esther Duflo 2 1 University of California Los Angeles, USA 2 Massachussetts Institute of Technology, USA 3 Harvard University, USA 4 Innovations for Poverty Action, Busia, Kenya

Background Despite 2 decades of HIV prevention efforts, 2.5 million new HIV infections occur each year Young people are a key group - they are often called a “window of hope” because they are uninfected and their sexual behaviors are not yet established and may be more easily molded 45% of new infections worldwide occur in youth aged years, with 3,000 young people infected each day

Background – School Based Programs Education has been called a “social vaccine” for HIV/AIDS In sub-Saharan Africa most children now attend some primary schools School-based HIV prevention programs are inexpensive, easy to implement and replicate There is limited rigorous evidence about the effectiveness of these types of programs

Background - Study design Between , non-profit organization ICS implemented HIV prevention programs in 328 primary schools in Western Kenya Schools were randomly assigned to receive none, one or both of the following interventions: Teacher Training in Kenya’s national HIV/AIDS education curriculum National HIV curriculum focuses on abstinence until marriage and does not include condom information Program provided in-service training to 3 upper-primary teachers to enhance delivery of the curriculum Uniforms Distribution Program Provided two free uniforms for one cohort of students (girls and boys), with the aim of helping them stay in school longer (second uniform provided 18 months after first)

Background - Study design Study Location: Butere, Mumias, Bungoma South and Bungoma East districts in Western Province Study Sample : 19,300 youths (approx half females) enrolled in Grade 6 in 2003 (~13 years) Experimental Design: STUDY ARM Number of Schools Uniforms Distribution Teacher Training on HIV Curriculum Control Group 82 Group U 83Yes Group TT 80Yes Group TT+U 83Yes

Background – Initial Follow-up Follow-up data collected between suggest that: Teacher Training Program: Teachers were more likely to discuss HIV in class Had little impact on knowledge, self-reported sexual activity, or condom use. No effect on pregnancy rates 3 years and 5 years later Uniforms Distribution Program Reduced dropout rates (by 17% in boys and 14% in girls) Reduced the rate of teen childbearing  From 16% to 13% after 3 years  From 33% to 29% after 5 years

Methods A follow up study to assess the long-term biological outcomes of the two programs began in 2009 Objective: To study the impact of the teacher training, and uniforms programs on transmission of HSV-2 A cross-sectional survey to measure HSV-2 prevalence and behavioral outcomes was administered to subjects between February 2009 and March 2011 Six to eight years after interventions Note: not powered to estimate impacts on HIV

328 schools in Western Kenya Teacher Training HSV-2 Prev KAP Free Uniforms HSV-2 Prev KAP Both Programs HSV-2 Prev KAP Control HSV-2 Prev KAP Random Assignment Follow- up in Programs offered in 2003 KAP= Knowledge, Attitudes and Practices Methods

Results I Long term follow-up rate Effective Tracking Rate = RT survey rate + (1-RT survey Rate) x (IT survey Rate) = For 90% of sample, we have data on respondents herself/himself or on another “representative” student Control Uniforms Only Teacher Training Only Both Programs # obs Mean P-value Diff with Control MeanP-value Diff with Control MeanP-value Diff with Control Regular Tracking Deceased Surveyed Tested for HSV Intensive tracking Sampled for IT Surveyed Tested for HSV Effective Tracking Rate Effective HSV2 Testing rate

Uses sampling weights (those sampled during IT have higher weight) Controlled for age at baseline, randomization strata (school location, sex ratio and performance at baseline), date of survey/blood draw Results II Marriage & Childbearing 7 yrs post-intervention FemaleMale Ever MarriedEver Pregnant Ever MarriedEver Had a Child Uniforms Program0.810* CI (95%)( )( ) ( )( ) P value Teacher Training CI (95%)( )( ) ( )( ) P value Both CI (95%)( )( ) ( )( ) P value Obs Mean in Control Group

Results III HSV-2 infection 7 yrs post-intervention FemaleMale HSV-2 positive Uniforms Program CI (95%)( ) ( ) P value Teacher Training CI (95%)( ) ( ) P value Both0.802* CI (95%)( ) ( ) P value Obs Mean in Control Group

Results IV Reported Sexual Behavior 7 years post- intervention FemaleMale Ever Had Sex More than 1 sex partner Condom use at last sex Ever Had Sex More than 1 sex partner Condom use at last sex Uniforms Program ** * CI (95%)( )( )( ) ( )( )( ) P value Teacher Training CI (95%)( )( )( ) ( )( )( ) P value Both * CI (95%)( )( )( ) ( )( )( ) P value Obs Mean in Control Group

Conclusions Education subsidy (free uniforms) is effective at reducing teenage marriage and childbearing rates but not enough to reduce HSV-2 transmission National HIV curriculum focused on abstinence until marriage seems ineffective in reducing HSV-2 transmission Two programs implemented jointly appear to reduce HSV-2 transmission

Thank you Vandana Sharma, MD, MPH Abdul Latif Jameel Poverty Action Lab (J-PAL) Massachusetts Institute of Technology