Previous studies have demonstrated that MC reduces HIV transmission. The present analysis demonstrates that MC can lower health system costs. This is due to moderate implementation costs, high and durable protective effects, and the resulting averted HIV care costs. This finding is robust across a wide range of plausible parameter input values for South Africa, including lower effectiveness, higher costs, and lower HIV incidence.
This analysis also suggests that MC, at $181 in program cost per HIV infection prevented and cost saving when adjusted for averted medical costs, is amongst the most economically efficient of HIV prevention strategies in sub-Saharan Africa. The cost per HIA has been estimated at $68–$79 for peer education for sex workers, $58 for mass media, $10–$2,188 for condom distribution, $393–$482 for voluntary counseling and testing, $20–$2,198 for antiretroviral drugs to prevent mother-to-child transmission, $271–$514 for treatment of other sexually transmitted infection, and $7,288–$13,326 for school-based education. As noted below, the latter three interventions have mixed data on effectiveness, making the cost-effectiveness estimates less certain. MC is as economically favorable as inexpensive medical interventions for HIV, such as INH prophylaxis at $703 per fatal case averted or cost saving if averted secondary TB cases are included [19
] and cotrimoxazole prophylaxis, which is also likely to be cost saving [49
Other infectious disease interventions that are considered economically attractive in sub-Saharan Africa according to the World Bank's Disease Control Priorities in Developing Countries
] have costs per averted DALY ranging from $2–$400. Standard childhood immunization costs $1–$5 per DALY. Malaria interventions including insecticide treated bed nets and residual household spraying cost $2–$24 per DALY. Improved quality and coverage of maternal and neonatal care are less cost-effective, $82–$409 per DALY [52
]. We assume that these cost-effectiveness estimates were adjusted for medical care costs, suggesting net costs rather than net savings as with MC.
The evidence of the effectiveness of MC is consistent but not yet definitive. Results from the OF trial, consistent with a meta-analysis of observational studies, show a 60% protective effect. However, a limitation of this study is relying on only one clinical trial; two further trials are pending. Some other prevention interventions, though having an attractive cost per HIA in favorable circumstances, have often been found to lack evidence of effectiveness. This is true of mass media programs, school programs, and may also pertain to STI treatment [6
Acceptability of MC remains a significant concern, due to strong cultural values regarding circumcision status and practices. Coercion should not be employed to overcome reluctance to obtain MC. Yet, high levels of acceptability of MC have been demonstrated in various African settings including Botswana, Kenya, Zimbabwe, and South Africa, where acceptability rates of 60%–70% were reported [53
]. A community cross-sectional survey conducted in South Africa suggests that over 70% of noncircumcised men would elect circumcision if it protected against STIs. Two-thirds of the African population is already circumcised, including many African countries where all are circumcised, and where there is only a minority of Muslims (Benin, Cameroon, Democratic Republic of the Congo). Historical data suggest that MC can be increased (South Korea from 0% in 1900 to about 60% today) or decreased (Zulu were circumcised 200 years ago but not today) [57
In some settings, low acceptability will reduce uptake. However, even if due to limited acceptability MC occupies a smaller HIV prevention niche, its high cost-effectiveness still argues for implementation of appropriately scaled programs. This may be especially true if acceptability evolves over time: “early adopters” pave the way for others later [59
In the South African survey, 29% of circumcised and 22% of noncircumcised men believed that circumcision protects against HIV and other STIs [53
]. A less encouraging result from this survey is that 30% and 18%, of circumcised and uncircumcised men respectively, believed that circumcision would permit them safely to have sex with multiple partners. Furthermore, circumcised men were more likely to report many lifetime partners than were their uncircumcised peers. These data underline the importance of further research regarding the educational campaigns and specific messages that would encourage participation while minimizing risk compensation.
These concerns also argue for capitalizing on the complementarities between MC and behaviorally based HIV prevention modalities such as condom promotion and counseling for partner reduction and other risk reduction. MC can serve as a portal for other male reproductive health services, including HIV prevention, which clients might otherwise not access. Even if not fully integrated with broader prevention services, MC facilities could routinely refer patients to programs that provide these services. For HIV-infected MC candidates this could also include referral for ART.
Complementarities are also present in the types of personnel required by MC programs. MC requires trained medical practitioners, but does not compete for the scarce supply of trained counselors, health educators, and field personnel who are the backbone of other HIV prevention and treatment modalities. Combined with the willingness in the OF RCT of general practitioners to perform MC at a reasonable price, these labor complementarities should enhance the feasibility of conducting an MC program without slowing other HIV activities. We are now planning research on the feasibility of scale-up.
Generalization of HIV prevention effectiveness and cost-effectiveness research is a universal concern. One issue is the effectiveness of prevention technology in other geographic settings, with different beliefs and behaviors. We believe that MC protective effect, based on biological rather than behavioral change, is more valid to generalize to other settings than are most HIV prevention strategies. For economic analyses, adjustment to local cost levels is necessary. Another issue is extrapolation from short-term trials to long-term effects. Again, we believe that the biological nature of MC fosters higher confidence in generalization. Risk compensation is an important phenomenon not reliably generalized from a short-term trial to other settings or time frames, and thus worthy of ongoing evaluation.
We believe that this analysis for South Africa applies to other sub-Saharan settings. The epidemic situation in South Africa (heterosexual spread, high HIV prevalence, low MC prevalence) is similar to most southern African countries (e.g., Lesotho, Zimbabwe, Swaziland, Botswana, Zambia). Although more men in the other sub-Saharan locations are circumcised, our economic findings are similar for large and incremental MC efforts. Our MC cost data are consistent with data from Kenya, and our sensitivity analyses confirm that MC is cost saving for a wide range of economic and epidemiologic conditions. We are therefore confident that our findings are relevant beyond South Africa.
We cannot be certain if trial-derived parameter values will differ from those found in actual practice. Some of those most subject to variability, such as risk compensation and the frequency of severe adverse events, have substantial influence on the cost-effectiveness results. High-risk compensation in the context of lower bound MC protective effect could even lead to the loss of HIV prevention benefit. However, the range of parameter values explored in the sensitivity analyses, including some that appear to be extremely pessimistic, provide substantial reassurance that MC can be effective and cost saving. Research on operating programs will permit refinement of key parameter values.
Unit costs may decline and cost-effectiveness rise following wide intervention adoption. This could arise from the usual economies attendant upon large volumes. In addition, it is possible that lower cost nonmedical doctor paramedics, nurses, and traditional circumcisers could be trained to perform MCs safely and successfully. It is also possible that benefits are greater than estimated here. This could occur, for example, if MC were found to confer protection on women in addition to the circumcised men. Our estimate did not take into account the prevention of HIV infection among newborns due to the indirect protective effect on adult women, which would also tend to lower cost-effectiveness.
By improving clinical outcomes or prevention, public health programs sometimes reduce future medical care costs. However, these medical care cost savings are often realized in a different budget. When the entity charged with funding the program does not realize the savings, it may be less motivated to implement a program of prevention than it would be if these savings accrued to its own budget. MC and HIV care are both in the medical budget rather than the public health budget. For this reason, decision makers considering implementation of an MC initiative would not only incur the costs of such a program but would also make savings in future HIV/AIDS care. On a cash-flow basis, the project should thus be attractive to the administering agency, yielding a stream of net savings starting approximately 6–8 years after implementation, when most MC clients would otherwise have started consuming medical care costs for HIV/AIDS treatment. This alignment of budgetary costs and benefits could thus raise the political and administrative acceptability of this proposal.
If adopted in the context of high-quality medical services and appropriate community and individually oriented health education programs, MC could contribute significantly to reducing HIV transmission in Southern Africa. Findings from this study suggest that MC could be highly cost-effective or could save health system funds. Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Uganda, Zambia, and Zimbabwe combine low MC prevalence with high HIV prevalence. These countries are therefore potentially high-priority candidates for implementation.