Association for Public Policy Analysis & Management

We show evidence of risk compensation that diminishes the protective effect against HIV and HSV-2 infection of male circumcision through a long-term follow-up of a field trial that randomly provided male circumcision to 2,663 adolescent students in Malawi.

2. Extended Abstract

-Background: Medical male circumcision has been discussed as one of the most cost-effective HIV/AIDS prevention strategies. However, preventive effects of male circumcision against HIV and HSV-2 infection may diminish if circumcised men are more likely to engage in risky sexual behaviors. Aim of the study is to assess the short- and long-term impacts of medical male circumcision on risky sexual behaviors as well as HIV and HSV-2 infection.

-Method: We randomized the intensity and timing of the male circumcision to 2,663 adolescent students at secondary schools (9th and 10th graders) in Malawi, and measured risky sexually behaviors, HIV and HSV-2 infection two and four years after the offer.

-Results: We provide new striking findings which are quite contrary to what previous studies suggested. We find that those who received a more intensive male circumcision offer (and thus high take-up rate), were 34 percent more likely to be infected with HSV-2 than those with less intensive male circumcision offer (and thus low take-up rate). In addition, we do not find significant change in HIV infection.

We also find evidence of risk compensation in the long run, which supports our biomarker results: those with the intensive offer are more likely to engage in inconsistent condom use, and are less likely to use a condom in the last sexual intercourse.

-Implication: Our results can remind policymakers of the importance of carefully designed policy: the introduction of risk-reducing technology can lead to unintended consequences, especially when risk compensation is a concern.