1 De Neve J-W

Fink G

Subramanian SV

Moyo S

Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. 1 De Neve J-W

Fink G

Subramanian SV

Moyo S

Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. Jan-Walter De Neve and colleaguesprovide compelling evidence of a causal relation between secondary education and HIV incidence, showing that a policy change in Botswana led to 0·792 additional years of secondary schooling, with each added year reducing HIV risk by 8 percentage points. The estimated cost per HIV infection averted was US$27 753. De Neve and colleaguesthus conclude that secondary schooling is similarly cost effective for HIV prevention as pre-exposure prophylaxis, but is more expensive than male circumcision.

2 Remme M

Vassall A

Lutz B

Luna J

Watts C Financing structural interventions: going beyond HIV-only value for money assessments. 3 Psacharopoulos G Returns to investment in education: a global update. 4 UNESCO 5 Barnighausen T

Bloom DE

Humair S Economics of antiretroviral treatment vs circumcision for HIV prevention. Table Cofinancing adjusted cost-effectiveness Cost (US$) Option 1: secondary schooling paid entirely from HIV budget * * 1 De Neve J-W

Fink G

Subramanian SV

Moyo S

Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. Data are as from De Neve and colleagues; 450 HIV infections were averted. 1 De Neve J-W

Fink G

Subramanian SV

Moyo S

Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. Cost per year of secondary school per pupil $2248 Total cost of education for study sample in Botswana $12 494 959 Cost per HIV infection averted (% total cost) $27 753 (100%) Option 2: secondary schooling cofinanced with maximum willingness to pay of HIV sector HIV sector's maximum willingness to pay for an infection averted (cost per infection averted of medical male circumcision) 1 De Neve J-W

Fink G

Subramanian SV

Moyo S

Bor J Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. , 5 Barnighausen T

Bloom DE

Humair S Economics of antiretroviral treatment vs circumcision for HIV prevention. $1096 Total HIV contribution for study sample in Botswana $493 440 Cost per HIV infection averted (% total cost) $1096 (4%) However, they also highlight that this estimate excludes other benefits of schooling. Furthermore, it is unlikely that HIV budgets would be asked to bear the full cost of increased schooling. If, instead, secondary education is regarded as an investment of value across health and other development sectors, the relevant question is what level of co-investment in education from HIV budgets could be justified, in view of the benefits against HIV?Secondary education is a sound economic investment in its own right,but remains resource-constrained in many low-income and middle-income countries.If the parties interested in HIV prevention contributed to educational funding up to the value of their next best investment (in this case, male circumcision), further schooling expansion could be achieved. With the threshold of $1096 per infection averted, we show that HIV budgets could contribute up to 4% of total costs for an additional year of secondary schooling ( table ).

If applied at scale, this cofinancing approach could change the lives of many young people, providing both education and an HIV-free future. Implementation of complementary investments across sectors could be key to tackling the HIV epidemic, and would place the HIV response at the heart of the post-2015 development agenda.

All authors are members of the STRIVE (Tackling the Structural Drivers of the HIV Epidemic) Research Programme Consortium and report grants from the UK Department for International Development (UKaid), during the conduct of the study. MR, CW, and AV are also members of the RethinkHIV consortium and report grants from the RUSH Foundation, during the conduct of the study. The opinions expressed are those of the authors and do not represent the views of the organisations or consortia to which they are affiliated.