Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting

Abstract

BackgroundConsistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa.Methods and FindingsCost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year.For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189–428) infections over 20 years. The cost is $181 (80% CI $117–$306) per HIA, and net savings are $2.4 million (80% CI $1.3 million to $3.6 million). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is $551 (80% CI $344–$1,071) and net savings are $753,000 (80% CI $0.3 million to $1.2 million). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage.ConclusionsIn settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.

The cost effectiveness of home-based provision of antiretroviral therapy in rural Uganda

“…These include standard childhood immunization costs ($1-$5 per DALY); INH prophylaxis ($25 per DALY; cost saving if counting secondary transmission); peer HIV prevention education for sex workers ($4 -$7 per DALY); adult male circumcision ($12 per DALY and cost-saving if averted HIV treatment costs are included). 11,30,[51][52][53][54] HAART provision is also less costeffective than cotrimoxazole delivered in the same setting, which may be cost-saving. 39 Therefore, from an economic point of view expenditures on HAART are questionable while there remains a large unmet need for these more cost-effective alternatives.…”

Risk compensation in HIV prevention: Implications for vaccines, microbicides, and other biomedical HIV prevention technologies

“…Williams et al [39] suggested that increased coverage of male circumcision among men in southern Africa could avert as many as 2 million HIV infections and 300,000 deaths over a 10-year period. Kahn et al [40] also suggested that the protective value of circumcision will be cost saving. The evidence for potential HIV protective benefits of male circumcision is therefore compelling.…”

Why circumcision is a biomedical imperative for the 21stcentury

“…(25) Cost-effectiveness estimates are, moreover, substantial. (25,26) Although condoms reduce risk by 80-90% when always used, (27) they are not infallible, nor used universally, and do not protect during foreplay when the inner prepuce may come into contact with infected fluids. Circumcision in contrast is once only, so does not need to be applied each time sex is contemplated, is permanent, and when coupled with condom use should virtually guarantee complete protection from infection by HIV.…”