HIV This Week

Auvert B, Marseille E, Korenro§mp EL, Lloyd-Smith J, Sitta R, Taljaard D, Pretorius C, Williams B, Kahn JG. Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in Sub-Saharan Africa. PLoS ONE. 2008;3(8):e2679.

Trials in Africa indicate that medical adult male circumcision reduces the risk of HIV by 60%. Medical adult male circumcision 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 medical adult male circumcision and the net savings due to reduced infections. Auvert and colleagues developed a model which included costing, demography, and HIV epidemiology and 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. The authors assumed that the roll-out would take 5 years and lead to a male circumcision prevalence among adult males of 85%. They also assumed that surgery would be done as it was in the trials. They 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. In 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 medical adult male circumcision 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). The authors conclude that a rapid roll-out of medical adult male circumcision in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by medical adult male circumcision’s substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability.

Editors’ note: This modelling optimistically assumes that the proportion of men circumcised in these 15 countries plus Nyanza Province, Kenya will rise from a range of 0 to 70% (in 2007 the number of uncircumcised males aged 15 to 49 was 30.5 million) to 85% in five years. This would require very high demand for services as well as unprecedented capacity for well-trained, adequately equipped, health care personnel to meet that demand safely. Although relevant costs were contained in the modelling, the cost of HIV testing and counselling was not, with the authors stating that it ‘may not be required by many male circumcision programmes’. WHO/UNAIDS advise health professionals to recommend voluntary HIV testing to all individuals seeking male circumcision services. Asymptomatic HIV-positive men and healthy men of unknown serostatus who do not wish to be tested should not be refused circumcision unless there are medical contraindications. However, consistent with provider-initiated testing policies, men requesting circumcision should be given the opportunity to learn their HIV status.