Cost-effectiveness of Adult Male Circumcision in AIDS prevention
25 Jan, 2007 10:28 am
Adult male circumcision is an effective HIV prevention strategy, and in Sub-Saharan Africa saves money.
Most HIV prevention strategies focus on reducing key HIV risk behaviors. Yet risk behaviors are hard to keep low over time, and the most effective interventions, such as sex worker programs, apply only to limited groups. Effective vaccines remain elusive and are unlikely to be ready for many years. Thus, new biologically-based interventions that provide durable protection could make a significant contribution.
Observational studies have long suggested that male circumcision (MC) offers substantial protection. In 2005, a randomized clinical trial of MC, conducted in Orange Farm (OF), South Africa, provided the first experimental evidence. This trial found a risk reduction of 60%, with very few side effects. Two additional trials, in Kenya and Uganda, were stopped in December 2006 due to early evidence of effectiveness in reducing HIV (by 50%).
While funds for prevention have greatly increased in recent years, they still fall far short of what is needed. It is thus appropriate to consider how MC compares with other prevention and treatment strategies in developing countries in terms of economic criteria. Cost-effectiveness estimates the cost per health outcome, e.g., the cost per HIV infection averted. Recent reviews of HIV prevention cost-effectiveness suggest a range of $10 to more than $10,000 per HIV infection averted, depending on the intervention and the setting.
The purpose of this analysis was to assess the cost-effectiveness of MC for Gauteng Province, South Africa and for other sub-Saharan African settings with different HIV epidemiology or costs.
We estimated cost-effectiveness for a hypothetical group of 1,000 newly circumcised South African adult men (current HIV prevalence 25.6%). Data for the analysis derived from the trial in South Africa and from other studies. Costs considered included performing the circumcisions, providing community publicity, and treating side effects. Effectiveness, defined as number of HIV infections averted among adults, was calculated by projecting the reduction in HIV cases observed in the trial over 20 years, using a simple HIV epidemic model. Cost-effectiveness was calculated with and without adjustment for the averted lifetime costs of HIV treatment. We assessed results for different HIV epidemiology and costs.
The study found that 1,000 circumcisions would avert an estimated 308 HIV infections over 20 years. The cost is $181 per HIV infection averted. When accounting for averted costs of HIV treatment, the net savings are $2.4 million.
In settings with lower HIV prevalence (8.4%), the cost per infection averted would be $551, and net savings would be $753,000. In settings with sharp reductions in HIV risk behaviors (due to the success of behavioral prevention strategies), the program averts 48 infections, at net savings of $264,246
We found that the MC remains cost-saving for a wide range of assumptions relevant to Sub-Saharan Africa -- HIV epidemiology, program costs, HIV treatment costs, MC effectiveness in reducing HIV transmission, and potential compensatory increases in risk behaviors.
This study suggests that in 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. Aside from saving lives, it is likely to save substantial money for the health system.
Studies suggest high acceptance rates for male circumcision. It is expected that in many settings 50% or more of uncircumcised men will choose to be circumcised. It is, of course, critical that male circumcision be offered non-coercively, and to the extent possible in a manner consistent with existing cultural norms.
Based on the three clinical trials, economic analysis, and recognition of the potential gains with MC, there are now international discussions underway to plan programs that are acceptable and effective at a large scale.
Kahn JG, Marseille E, Auvert B (2006) Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med 3(12): e517. doi:10.1371/journal.pmed.0030517