Cost-effectiveness of male circumcision for HIV prevention in a south African setting

• Published in: PLoS medicine 2006-12, Vol.3 (12), p.2349-2358
• Main Authors: KAHN, J.G, MARSEILLE, E, AUVERT, B
• Format: Article
• Language: English
• Subjects: Acquired immune deficiency syndrome; Adolescent; Adult; AIDS; Biological and medical sciences; Circumcision; Circumcision, Male; Circumcision, Male - economics; Cost analysis; Cost control; Cost Savings; Cost-Benefit Analysis; Disease prevention; Economic aspects; Factor Analysis, Statistical; Health aspects; Health care expenditures; Health Economics; Health Policy; HIV; HIV infection; HIV Infection/AIDS; HIV Infections; HIV Infections - economics; HIV Infections - prevention & control; Human health and pathology; Human immunodeficiency virus; Humans; Infections; Infectious Diseases; Life Sciences; Male; Medical sciences; Medicine in Developing Countries; Miscellaneous; Models, Econometric; Non-Clinical Medicine; Prevention; Prevention and actions; Proportional Hazards Models; Public Health; Public Health and Epidemiology; Public health. Hygiene; Public health. Hygiene-occupational medicine; Randomized Controlled Trials as Topic; Sexually transmitted diseases; South Africa; STD
• ISSN: 1549-1277; 1549-1676; 1549-1676
• DOI: 10.1371/journal.pmed.0030517

Consistent 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. Cost-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 dollars (80% CI 117-306 dollars) per HIA, and net savings are 2.4 million dollars (80% CI 1.3 million to 3.6 million dollars). 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 dollars (80% CI 344-1,071 dollars) and net savings are 753,000 (80% CI 0.3 million to 1.2 million dollars). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage. 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, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.