Abstract
BackgroundTrials in Africa indicate that medical adult male circumcision (MAMC) reduces the risk of HIV by 60%. MAMC may avert 2 to 8 million HIV infections over 20 years in sub-Saharan Africa and cost less than treating those who would have been infected. This paper estimates the financial and human resources required to roll out MAMC and the net savings due to reduced infections.MethodsWe developed a model which included costing, demography and HIV epidemiology. We used it to investigate 14 countries in sub-Saharan Africa where the prevalence of male circumcision was lower than 80% and HIV prevalence among adults was higher than 5%, in addition to Uganda and the Nyanza province in Kenya. We assumed that the roll-out would take 5 years and lead to an MC prevalence among adult males of 85%. We also assumed that surgery would be done as it was in the trials. We calculated public program cost, number of full-time circumcisers and net costs or savings when adjusting for averted HIV treatments. Costs were in USD, discounted to 2007. 95% percentile intervals (95% PI) were estimated by Monte Carlo simulations.ResultsIn the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to 2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10 000 adults. In years 6–10, the number of circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of rolling out MAMC in the public sector was $919 million (95% PI: 726 to 1 245). The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to 1 021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4).ConclusionA rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by MAMC's substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability.
Highlights
Observational studies have repeatedly shown that male circumcision (MC) offers substantial protection against HIV infection [1]
We focused on 14 countries with existing male circumcision prevalence lower than 80% and HIV prevalence among adults higher than 5%, since these settings have been shown to be best for MAMC to produce a large reduction in HIV with favourable economic outcomes
In the aggregate analysis across all 16 settings, the number of full-time circumcisers needed for MAMC roll-out over the initial, intensive 5-year phase was 2 282 (95% PI: 2 018 to 2 959)
Summary
Observational studies have repeatedly shown that male circumcision (MC) offers substantial protection against HIV infection [1]. In 2005, the first RCT of medical adult MC (MAMC), conducted in Orange Farm, South Africa, found a risk reduction between study arms of 60% (95% CI: 32 to 76) [2]. The encouraging results of the Orange Farm trial prompted wide interest in Africa towards MC as an HIV prevention strategy. About a third of the African male population is circumcised but the practice is less common in southern and East Africa, where the HIV epidemic is especially severe. The circumcision of adult males was shown to be more effective and cost-effective than other general population HIV prevention strategies [6]. Trials in Africa indicate that medical adult male circumcision (MAMC) reduces the risk of HIV by 60%. This paper estimates the financial and human resources required to roll out MAMC and the net savings due to reduced infections
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