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

Abstract

Background: 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.

Methods and findings: 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.

Conclusions: 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.

Figure 1. One-Way Sensitivity Analyses of the Cost per HIA Unadjusted for Anticipated Averted HIV Treatment Expenditures

For each of the varied input values, results correspond to the ranges shown in Table 1. The 50th percentil corresponds with the base case. Similarly, the first and 99th percentiles approximate the low and high end of the ranges shown in Table 1, respectively. For example, the high-end cost per male circumcision is $82 (Table 1), which corresponds to the 99th percentile of the range, or $250 per HIA. This figure indicates that the unadjusted cost per HIA is most sensitive to uncertainty in the MC protective effect, cost per MC, and epidemic multiplier.

Figure 2. One-Way Sensitivity Analyses of the Cost of 1,000 Male Circumcisions after Deducting Averted HIV Treatment Costs

For each of the varied input values, results shown correspond to the ranges shown in Table 1. The 50th percentile corresponds with the base case. Similarly, the first and 99th percentiles approximate the low and high end of the ranges shown in Table 1 respectively. Parentheses indicate savings. This figure indicates that the cost per HIA adjusted for averted HIV treatment costs is most sensitive to uncertainty in the MC protective effect, lifetime medical care cost for HIV/AIDS, and epidemic multiplier.