Does partner selection mediate the relationship between school attendance and HIV/Herpes simplex virus-2 among adolescent girls and young women in South Africa: An analysis of HIV prevention trials network 068 data

Objective: School attendance prevents HIV and herpes simplex virus-2 (HSV-2) in adolescent girls and young women, but the mechanisms to explain this relationship remain unclear. Our study assesses the extent to which characteristics of sex partners, partner age, and number mediate the relationship between attendance and risk of infection in adolescent girls and young women in South Africa. Design: We use longitudinal data from the HIV Prevention Trials Network 068 randomized controlled trial in rural South Africa, where girls were enrolled in early adolescence and followed in the main trial for more than 3 years. We examined older partners and the number of partners as possible mediators. Methods: We used the parametric g-formula to estimate 4-year risk differences for the effect of school attendance on the cumulative incidence of HIV/HSV-2 overall and the controlled direct effect (CDE) for mediation. We examined mediation separately and jointly for the mediators of interest. Results: We found that young women with high attendance in school had a lower cumulative incidence of HIV compared with those with low attendance (risk difference =-1.6%). Partner age difference (CDE =-1.2%) and the number of partners (CDE =-0.4%) mediated a large portion of this effect. In fact, when we accounted for the mediators jointly, the effect of schooling on HIV was almost removed, showing full mediation (CDE =-0.3%). The same patterns were observed for the relationship between school attendance and cumulative incidence of HSV-2 infection. Conclusion: Increasing school attendance reduces the risk of acquiring HIV and HSV-2. Our results indicate the importance of school attendance in reducing partner number and partner age difference in this relationship.