Abstract

BackgroundEmpirical studies and population-level policy simulations show the importance of voluntary medical male circumcision (VMMC) in generalized epidemics. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach—analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year. This approach yields more precise estimates of VMMC’s cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period.Methods/FindingsThe model has three components. We adapted the ASSA2008 model, a demographic and epidemiological model of the HIV epidemic in South Africa, to analyze the impact of one VMMC on HIV incidence over time and across the population. A costing module tracked the costs of VMMC and the resulting financial savings owing to reduced HIV incidence over time. Then, we used several financial indicators to assess the cost-effectiveness of and financial return on investments in VMMC. One circumcision of a young man up to age 20 prevents on average over 0.2 HIV infections, but this effect declines steeply with age, e.g., to 0.08 by age 30. Net financial savings from one VMMC at age 20 are estimated at US$617 at a discount rate of 5% and are lower for circumcisions both at younger ages (because the savings occur later and are discounted more) and at older ages (because male circumcision becomes less effective). Investments in male circumcision carry a financial rate of return of up to 14.5% (for circumcisions at age 20). The cost of a male circumcision is refinanced fastest, after 13 y, for circumcisions at ages 20 to 25. Principal limitations of the analysis arise from the long time (decades) over which the effects of VMMC unfold—the results are therefore sensitive to the discount rate applied, and more generally to the future course of the epidemic and of HIV/AIDS-related policies pursued by the government.ConclusionsVMMC in South Africa is highly effective in reducing both HIV incidence and the financial costs of the HIV response. The return on investment is highest if males are circumcised between ages 20 and 25, but this return on investment declines steeply with age.

Highlights

  • The effectiveness of male circumcision in reducing sexual transmission of HIV from HIV-positive women to HIV-negative men has been generally accepted at least since 2007 [1], after the results of three randomized control trials from Kenya [2], South Africa [3], and Uganda [4] became known

  • The model used in this analysis consists of three elements: a demographic and epidemiological model used to estimate the projected impacts of one voluntary medical male circumcision (VMMC) on HIV incidence, a costing module used to project the costs caused by a new HIV infection, and a financial analysis describing the costeffectiveness of and the financial returns to investments in VMMC

  • We determined the impact of VMMC on HIV incidence for the individual circumcised and among men and women across the population, identified financial savings accruing from VMMC by age, and incorporated these savings in the analysis of the cost-effectiveness of VMMC, by age of the individual circumcised

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Summary

Introduction

The effectiveness of male circumcision in reducing sexual transmission of HIV from HIV-positive women to HIV-negative men has been generally accepted at least since 2007 [1], after the results of three randomized control trials from Kenya [2], South Africa [3], and Uganda [4] became known. This paper complements available scenario-based studies (projecting costs and outcomes over some policy period, typically spanning decades) by adopting an incremental approach—analyzing the expected consequences of circumcising one male individual with specific characteristics in a specific year This approach yields more precise estimates of VMMC’s cost-effectiveness and identifies the outcomes of current investments in VMMC (e.g., within a fiscal budget period) rather than of investments spread over the entire policy period. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that individuals living in countries with generalized HIV epidemics (countries where more than 1% of the general population is HIV positive) should be offered voluntary medical male circumcision (VMMC) to help prevent HIV transmission

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