South Africa has the largest HIV epidemic in the world. An estimated 7.2 million people are living with HIV and 4.4 million are on antiretroviral therapy. Despite the progress made, AIDS remains the leading cause of death among adolescents. There were an estimated 270 000 new HIV infections in 2017. The rate is particularly high in young women between the ages of 15 and 24.
Risky sexual behaviour, such as failing to use a condom, or having sex while drunk or on drugs, increases the risk of HIV infection.
In our study, we wanted to examine why adolescent girls are engaging in risky sexual behaviour. Is this behaviour driven by childhood adversity, such as poverty, coming from a family where someone is ill with HIV/AIDS, or exposure to violence and experiencing psychological distress? We also wanted to find out if a government policy such as free schooling has the potential to mitigate some, or all, of these drivers.
We interviewed 1 498 teenage girls between the ages of 10 and 17 in rural and urban areas in South Africa using a standardised questionnaire in 2011. We interviewed the same teenage girls again in 2012.
During both interviews we asked them about child abuse experience, exposure to domestic violence, numbers of days per week in which they did not have enough food in the home, and if a caregiver was ill with AIDS. We screened them for depression, anxiety and suicidal thoughts, measured their drug use, conduct, and peer relationships. We asked how often they did not use a condom during sex, or had sex with multiple partners or while they were drunk or using drugs.
We also measured if they received a free school meal or free text books and attended a no-fees school.
This is what we found
Our study showed that rates of childhood adversity were high in this study. We found that 34.3% of girls had a family member ill with HIV/AIDS. They reported an average of two days without sufficient food in the home and an average of three abusive events in their life.
The study also found that 12% did not always use condoms, 2% had sex while drunk or on drugs and 8% had multiple sexual partners in the past year. Of those interviewed, 71% received free schooling.
Our research showed that the association between childhood adversity and HIV risk behaviour is not direct. Instead, we found that increased vulnerability led to certain negative outcomes. These included internalised psychological distress in the form of suicidal thoughts, depression and anxiety, and externalised psychological distress in the form of drug and alcohol use, problems with behaviour and poor peer relationships. These pathways, in turn, heightened the probability that girls would engage in risky sexual behaviour.
These findings are important because they help us understand why girls have risky sex, and help us consider interventions that might help prevent this behaviour. They support and complement existing evidence that suggest vulnerability is an important driver of risky sexual behaviour.
And this is where free schooling may help.
South Africa introduced non-fee schools in 2007 and the National School Nutrition Programme for primary schools in 2004. This was extended to secondary schools in 2009. Learners in the poorest three-fifths of schools (so called three lowest quintiles) pay no school fees and receive a hot, nutritious meal.
To date, school feeding reaches 77% of learners in public schools, while 66% benefit from not paying tuition fees.
Tentative evaluations of these two policies have shown a reduction in stunting, heightened levels of school enrolment in primary and secondary schools, and improved attendance and educational outcomes.
Our findings show additionally that receipt of free schooling directly reduces externalising psychological distress and mitigates the association between childhood adversity and internalising mental health distress; and thereby lessens HIV risk behaviour.
Further research may help us understand why this is the case. One possibility is that free schooling reduces hunger and worries about the ability to pay school fees, thereby reducing psychological distress. Free schooling could also increase attendance, giving teenage girls the opportunity to make friends with peers and build support networks .
Whatever the mechanisms, our findings suggest that free education in the forms of no-fees, free meals and text books appear important in promoting mental health among teenage girls in South Africa - and, in turn, reducing risky sexual behaviour.
Author: Franziska Meinck - Postdoctoral research fellow, University of Oxford