Thursday, July 26, 2007

Economic Analysis Supports Adult Male Circumcision for HIV Prevention in Sub-Saharan Africa

Emma Hitt, PhD

July 25, 2007 (Sydney) — Male circumcision has been shown to reduce HIV acquisition in studies conducted in countries in sub-Saharan Africa; the cost of the approach appears to be justified given the savings that will result from the expected health benefits, according to new research.

Three randomized controlled trials demonstrated recently that adult male circumcision could reduce the acquisition of HIV in sub-Saharan Africa by 50% or more. The current analysis, by Bertran Auvert, MD, from the INSERM U687, Saint-Maurive, France, and colleagues sought to evaluate the cost effectiveness of this approach.

The researchers presented their findings here today in an oral presentation at the 4th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention.

Using a "costing tool" to reflect the economic effect of adult male circumcision in this setting, the researchers found that the cost of a roll-out over an initial 5-year period would be $1036 million ($748 – $1319 million) and $965 million ($763 – $1301 million) for private and public health sectors, respectively. The cumulative net cost over the first 10 years was estimated at $1271 million and $173 million for the private and public sectors, respectively.

After adjustment for averted HIV medical costs, the researchers determined that the program would result in a net savings of about $2 per adult per year over the first 20 years of the program.

Demographic and HIV transmission models were integrated into the analyses and applied to 16 countries in which HIV prevalence was more than 5% and in which fewer than 80% of the men had undergone circumcision. The analysis also assumed that 85% of uncircumcised men would agree to undergo the procedure.

"Our findings suggest that this approach is economically feasible and worth the expense," Dr. Auvert told Medscape. "At this point, it would be unethical not to offer free and safe male circumcision to all males and newborn in Africa," he added.

According to Dr. Auvert, some of the hurdles to overcome "include political issues, issues of communication, and the need to train healthcare workers in the procedure."

Another study presented at the same session indicated that postcoital penile cleansing, a strategy that has been promoted as an alternative to male circumcision in rural populations in Africa, may in fact increase the risk of HIV transmission.

"This finding was contrary to what we would have expected," said study author Fred E. Makumbi, PhD, a researcher from Makerere University, Institute of Public Health, Kampala, Uganda. "Circumcision has been proven to be protective against male HIV acquisition and is recommended by the World Health Organization for HIV prevention," he told Medscape. "This should be our priority."

Session moderator David Serwadda, MMed, also from Makerere University, told Medscape that a potential issue that needs to be surmounted is that circumcision may generate "a false confidence that may undo some of the gains that have been attained with health education, condom use, abstinence, and other preventive measures." He added that "circumcision should be viewed as just another measure on top of other forms of prevention."

The researchers and moderator report no relevant financial relationships. The study by Dr. Makumbi and colleagues was funded by the National Institutes of Health.

4th International AIDS Society Conference on HIV Pathogenesis, Treatment, and Prevention: Abstracts WEAC1LB and WEAC105. Presented July 25, 2007.