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.
Highlights
Despite hopeful signs of abatement in a few countries, the HIV epidemic continues to spread [1]
The objective of this study is to present the first cost-effectiveness analysis of the use of male circumcision (MC) as an intervention to reduce the spread of HIV in sub-Saharan Africa
We estimate that over 20 years, the 1,000 circumcisions would avert 427 adult HIV infections (308 discounted to the present at 3%). This represents the combined effect of protection from the MC, 25% behavioral risk compensation, and a 1.5 epidemic multiplier reflecting secondary effects
Summary
Despite hopeful signs of abatement in a few countries, the HIV epidemic continues to spread [1]. In the face of this challenge, substantial new resources have been committed to expand access to both prevention and treatment These include the United States’ Emergency Plan for AIDS Relief, the World Bank’s Multi Country AIDS Projects, the World Health Organization’s 3 by 5 Initiative, and the Global Fund to Fight AIDS, Tuberculosis and Malaria [2,3,4]. The geographical area with the highest numbers of infected persons is sub-Saharan Africa [5] Success in this setting remains critical to stemming the global epidemic. The results of a trial carried out in South Africa, the ANRS 1265 trial (published in PLoS Medicine in October 2005) seem to support this theory, and additional trials are being carried out in Kenya and Uganda The results from these further trials will help determine whether, and to what extent, the effect of circumcision seen in the South African trial is true more generally
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