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Abstract
Cost-effectiveness of male circumcision in sub-Saharan Africa
J.G. Kahn1, E. Marseille2, B. Auvert3
1University of California, Institute for Health Policy Studies, San Francisco, United States, 2IHPS, UCSF, Health Strategies International, Orinda, United States, 3Hopital Ambroise-Pare, Assitance Publique, Hopitaux de Paris, Boulogne, INSERM U 687, Saint-Maurice; University Versailles Saint-Quentin, IFR , Villejuif, France
Background: A randomized controlled trial of adult male circumcision (MC) conducted in Gauteng Province, South Africa, demonstrated a 60% protective effect against HIV acquisition. This study assesses the cost-effectiveness of an MC intervention to reduce the spread of HIV in sub-Saharan Africa.
Methods: Cost-effectiveness was modeled for 1000 MCs within a general adult male population. Intervention costs included the MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated for a steady-state epidemic. Effectiveness was defined as HIV infections averted, estimated by projecting over 20 years the reduction in HIV incidence observed in the trial. Net savings reflect the averted lifetime costs of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. Monte Carlo simulations indicated 80% confidence intervals (CI). Results were obtained for the trial province in South Africa and other sub-Saharan settings. Results are discounted to the present at 3% annually.
Results: For Gauteng, South Africa (2005 adult male prevalence of 25.6%), at full MC coverage, each 1000 circumcisions would avert an estimated 308 (80% CI: 189 – 428) infections over 20 years; two-thirds in men and one-third in women. The cost is $181 (80% CI $117 – 306) per HIV infection averted (HIA), and net savings are $2.4 million (80% CI: $1.3 – $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 HIV prevalence of 8.4%, the cost per HIA is $550 (80% CI $318 –$1 200) and net savings are $753 thousand (80%-range: $0.3 – $1.3 million). Cost-effectiveness is insensitive to coverage.
Conclusions: In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult male circumcision appears very cost-effective and, when adjusted for averted HIV medical costs, cost-saving.
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