RESPONDING TO RISK: CIRCUMCISION, INFORMATION, AND HIV PREVENTION Susan Godlonton, Alister Munthali, and Rebecca Thornton* Abstract—Understanding behavioral responses to changes in actual or per- In this paper, we study asymmetric responses to informa- ceived risk is important because risk-reduction goals can be undermined by risk-compensating behavior. This paper examines the response to new tion about personal risk in which new information informs information about the risk of HIV infection. Approximately 1,200 circum- individuals of their type, either high or low risk. Individuals cised and uncircumcised men in rural Malawi are randomly informed that learning their type should revise their beliefs about personal male circumcision reduces the HIV transmission rate, predicting asym- metric behavioral responses. We find no evidence that the information risk either upward or downward, predicting opposite beha- induces circumcised men to engage in riskier sex while uncircumcised vioral responses. While the new information may be used men practice safer sex in response to the information. There were no sig- beneficially by one risk type, the same information may nificant effects of the information on child circumcisions after one year. cause the other type to engage in potentially harmful risk- compensating behavior. The theoretical predictions of the behavioral responses to information about risk are straight- I. Introduction forward, yet testing these predictions empirically is more difficult. Access to information about risk is typically corre- EGINNING with the seminal work of Peltzman lated with unobserved characteristics that introduce bias to (1975), economists have sought to understand beha- B causal inference. Moreover, it is difficult to identify a set- vioral responses to changes in actual or perceived risk. ting in which information is likely to induce an asymmetric Much of the empirical literature has focused on measuring response. The most common strategy within the economics behavioral responses to the introduction of risk-reducing re- literature is to measure how information about risk interacts gulations such as mandatory seat belt laws or risk-reducing with ex ante beliefs (Gong, 2014; Boozer & Philipson, technologies including protective sports gear, sunscreen, 2000; Wilson, Xiong, & Mattson, 2014).2 treatment for high cholesterol, or vaccines.1 Although these The specific context of risk examined in this paper is the innovations strictly decrease personal risk, the net impact of risk of HIV infection. We estimate the response to learning their introduction is ambiguous because risk-compensating new information—that male circumcision is partially pro- behavior may offset their positive technological effects. In tective against HIV infection—among two types of men: contrast to the introduction of risk-reducing technologies men who are circumcised (low risk) and men who are uncir- where the effects of risk compensation may be offset by cumcised (high risk). We expect both low- and high-risk safety benefits, the net behavioral effect of the introduction men to change behavior in response to learning their type of information about risk relies exclusively on the direction by practicing either safer or riskier sex. This context is and extent to which individuals change their behavior. uniquely suitable to analyze asymmetric responses to infor- mation about risk in that the information is newly available, Received for publication February 6, 2012. Revision accepted for publi- cation August 20, 2014. Editor: Philippe Aghion. highly relevant, and provides clear theoretical predictions * Godlonton: Williams College and IFPRI; Munthali: University of of behavior change. Ultimately, the net impact of the disse- Malawi; Thornton: University of Illinois at Urbana-Champaign. mination of this information is an empirical question. Funding for this study was provided by Michigan Center for Demogra- phy of Aging (MiCDA), OVPR, and Rackham at the University of Michi- As background, recent randomized control trials in South gan, as well as the Institute for Research on Women and Gender. We Africa, Kenya, and Uganda find that male circumcision is acknowledge the extensive contributions of the field team, including up to 60% effective in reducing HIV transmission risk James Amani, Sheena Kayira, Collins Kwizombe, Denise Matthijsse, Ern- 3 est Mlenga, and Christopher Nyirenda. We also thank the assistance of (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). Kondwani Chidziwisano, Jessica Kraft, Erica Marks, Julie Moran, Jason Shortly after the release of the results of these trials, organi- Stanley, and Kondwani Tomoko. For helpful comments, we thank seminar zations such as WHO and UNAIDS set an ambitious goal participants at the Development Day Conference at University of Michigan, NEUDC, Population Association of America, University of Illinois, Chi- to circumcise 80% of men ages 15 to 49 in fourteen priority cago, Princeton University, Yale University, University of Georgia, Georgia State University, DePaul, University of California Berkeley, University of Illinois Urbana–Champaign, the CSWEP CeMENT Workshop, and the 2 Other examples of studies that examine behavioral responses to infor- anonymous referees. mation about risk are Dupas (2011) and Bennear et al. (2013). Dupas A supplemental appendix is available online at http://www.mitpress (2011) finds that after an information session on the relative risk of HIV journals.org/doi/suppl/10.1162/REST_a_00516. infection by partner’s age, teenagers substitute away from older partners 1 Blomquist (1988) provides an extensive review of the literature on toward same-age partners. In the context of water source choices, Bennear safety belt regulations and car safety technologies (other recent examples et al. (2013) examine how learning the level of arsenic in one’s well include Evans & Graham 1991, and Cohen & Einav, 2003). Other papers affects the decision to change water sources. examine the use of protective gear in risky sports (Walker, 2007; Braun 3 Across the three trials, there were 11,054 HIV negative men who were & Fouts, 1998; Williams-Avery, & MacKinnon, 1996), increased sun willing to be circumcised. Approximately half of these were randomly exposure with the availability of sunscreen (Autier et al., 1998; Dickie & assigned to be offered circumcision surgery, while the others remained Gerking, 1997), poor eating habits and increased BMI with the introduc- uncircumcised. All participants were extensively counseled in HIV pre- tion of high cholesterol treatment (Kaplan, 2012), and risky sexual beha- vention. The studies found 61% reduction in risk in the South African vior in response to receiving the HPV vaccination (Lo, 2006; Kapoor, trial, a 53% reduction in the Kenyan study, and a 48% reduction in the 2008). Ugandan study. The Review of Economics and Statistics, May 2016, 98(2): 333–349 Ó 2016 by the President and Fellows of Harvard College and the Massachusetts Institute of Technology doi:10.1162/REST_a_00516 Downloaded from http://www.mitpressjournals.org/doi/pdf/10.1162/REST_a_00516 by guest on 28 September 2021 334 THE REVIEW OF ECONOMICS AND STATISTICS countries by 2015, making voluntary medical male circum- Our sample consists of approximately 900 circumcised and cision one of the key components of HIV prevention strate- 300 uncircumcised men who are unlikely to have had prior gies. While the medical evidence points to male circumci- exposure to the information. We randomize information sion as a viable HIV prevention strategy, one concern that about male circumcision and HIV transmission risk to has prevented the rapid scale-up of male circumcision pro- causally estimate behavioral responses. Information was vision in several African countries is the potential beha- randomized across villages to limit information spillovers vioral responses to learning that male circumcision is par- within villages. Approximately one year after the informa- tially protective against HIV infection. Some policymakers tion intervention, the project revisited respondents to mea- have noted the need to ‘‘proceed with caution’’ (Namangale, sure sexual behavior and whether the uncircumcised men or 2007) and researchers have noted that risk compensation any young male dependents had been circumcised in the may reduce the overall estimated benefit of male circumci- previous year. sion (Kalichman, Eaton, & Pinkerton, 2007; Cassel et al., We find that uncircumcised men who receive the infor- 2006). More recently, a panel of Nobel Prize economists mation about circumcision and HIV transmission risk prac- ranked ‘‘scaling up male circumcision’’ as priority 7 out of tice safer sex with approximately two fewer sexual acts in eighteen other HIV prevention strategies, ranked low the past month (a 26% reduction) and one additional con- mainly due to concerns of disinhibition behaviors. The dom used in the past month (an increase of 65%). These panel noted ‘‘Circumcision is protective, but only to a cer- results are consistent across marital status of the respondent, tain extent. It is possible that, as a consequence of large- albeit stronger for nonmarital sexual encounters. We docu- scale male circumcision with an accompanying information ment an asymmetric response to the information by circum- campaign about its protective effect, males and their part- cision status; however, we find no evidence of risk compen- ners opt for less safe sexual practices and for example sation on average among