Cost Effectiveness and Costing Studies on Male Circumcision

Research indicates that circumcision is likely to be a relatively cost-effective way to prevent HIV infection in areas with high HIV prevalence. A review conducted by experts convened by the Joint United Nations Programme on HIV/AID (UNAIDS), the World Health Organization, and the South African Centre for Epidemiological Modelling, found that male circumcision was not only cost-effective, but also cost-saving. After reviewing six simulation models estimating the impact of male circumcision on HIV, this expert panel concluded that one HIV infection could be prevented for every five to 15 men circumcised in settings with high levels of HIV and low rates of male circumcision, at a cost of US $150 to $900 per HIV infection averted over 10 years. By comparison, estimates of discounted lifetime treatment costs per HIV infection typically exceed US $7,000. (1).

A modelling study estimated that for every 1,000 circumcisions performed among men in South Africa's Gauteng Province, 308 new cases of HIV would be prevented, at a cost of US $181 per HIV infection averted. Assuming a lifetime cost of about $8,000 to treat each of those infections with antiretroviral drugs, the potential savings would be $2.4 million over 20 years (2).

Modelling shows that the cost-effectiveness of male circumcision for HIV prevention depends, in part, on the prevalence of HIV in an area. A study in Uganda's Rakai District, which has a lower HIV prevalence than Gauteng Province, yielded higher estimates of the cost of averting an HIV infection. However, it still showed that male circumcision would be a cost-effective intervention compared to AIDS treatment. This study estimated that about 40 surgeries would be needed to prevent one case of HIV, costing approximately US $2,500 per infection averted (3).

Analyses of the cost of providing male circumcision in Lesotho, Swaziland, and Zambia also found that this would be a cost-effective intervention for HIV prevention. An estimated one HIV infection would be averted for every six circumcisions in Lesotho, four circumcisions in Swaziland, and eight circumcisions in Zambia. These studies addressed the potential for risk compensation, showing that moderate changes in condom use among men after they became circumcised would have little effect on the estimated impact. A 25-percent decrease in condom use among circumcised men, however, could reduce the impact of male circumcision on HIV rates by 7 percent in Lesotho, 17 percent in Swaziland, and 20 percent in Zambia (4).

Estimates of the cost and impact of expanding access to medical male circumcision in 14 countries in sub-Saharan Africa, summarised in a series of policy briefs, indicate that the result would be a net cost savings because reduced expenses for antiretroviral treatment would outweigh the costs of scale-up (5).

Another modelling study identified the most cost-effective ways of targeting circumcision services given limited resources. Its findings suggest that the most cost-effective approach to reducing HIV prevalence through male circumcision in countries in sub-Saharan Africa would be to target circumcision services to men ages 20 to 30 years who are at high risk of HIV infection because they have many sex partners (6).

References

1. UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV Prevention. Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Med 6(9): e1000109.
2. Kahn JG, Marseille E, Auvert B. Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PloS Med 2006;3(12): e517.
3. Gray RH, Xianbin L, Kigozi G, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda. AIDS 2007;21(7):845-50.
4. Martin G, Bollinger L, Pandit-Rajani T, et al. Costing Male Circumcision in Lesotho, Swaziland, and Zambia: Implications for the Cost-effectiveness of Circumcision as an HIV Prevention Intervention (2007, PDF, 586 KB). Washington, DC: The Health Policy Initiative, 2007.
   
5. Bollinger L, and Stover J. The Potential Cost and Impact of Expanding Male Circumcision in 14 African Countries (2009, PDF, 662 KB) USAID Health Policy Initiative, 2009.
6. Londish GJ, Murray JM. Significant reduction in HIV prevalence according to male circumcision intervention in sub-Saharan Africa. International Journal of Epidemiology 2008;37(6):1246-1253.