Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study
Background:
There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%.
Methods and Findings:
A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. Results: Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man.
Conclusions:
The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services (i.e., neonatal visits and vaccination sessions) and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence. In the presence of infant MC, adolescent and adult MC would evolve into a “catch-up” campaign that would be needed at the start of the program but would eventually become superfluous.
: Please see later in the article for the Editors' Summary
Vyšlo v časopise:
Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study. PLoS Med 7(1): e32767. doi:10.1371/journal.pmed.1000211
Kategorie:
Research Article
prolekare.web.journal.doi_sk:
https://doi.org/10.1371/journal.pmed.1000211
Souhrn
Background:
There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%.
Methods and Findings:
A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. Results: Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man.
Conclusions:
The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services (i.e., neonatal visits and vaccination sessions) and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence. In the presence of infant MC, adolescent and adult MC would evolve into a “catch-up” campaign that would be needed at the start of the program but would eventually become superfluous.
: Please see later in the article for the Editors' Summary
Zdroje
1. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO) 2007 Male circumcision: global trends and determinants of prevalence, safety and acceptability Geneva UNAIDS/WHO
2. Department of Statistics, in the Ministry of Economics (MINECOFIN) and MEASURE DHS Interim Rwanda Demographic and Health Survey (2007–2008) Kigali, Rwanda Ministry of Finance and Economic Planning
3. GrayRH
KigoziG
SerwaddaD
MakumbiF
WatyaS
2007 Male circumcision for HIV prevention in men in Rakai, Uganda: a randomized controlled trial. Lancet 369 657 666
4. BaileyRC
MosesS
ParkerCB
AgotK
MacleanI
2007 Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomized controlled trial. Lancet 369 643 656
5. AuvertB
TaljaardD
LagardeE
Sobngwi-TambekouJ
SittaR
2005 Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial. PLoS Med 2 e298 doi:10.1371/journal.pmed.0020298
6. WeissHA
ThomasSL
MunabiSK
HayesRJ
2006 Male circumcision and risk of syphilis, chancroid and genital herpes: a systematic review and meta-analysis. Sex Transm Inf 82 101 110
7. TobiasAR
SerwaddaD
QuinnTC
KigoziG
CravittPE
2009 Male circumcision for the prevention of HSV-2 and HPV infections and syphilis. N Engl J Med 360 1298 1309
8. Singh-GrewalD
MacdessiJ
CraigJ
2005 Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child 90 853 858
9. WHO, UNAIDS, UNFPA, UNICEF, The World Bank 2007 Information package on male circumcision and HIV prevention. Insert 3 Geneva WHO/UNAIDS
10. WHO, UNAIDS, JHPIEGO 2007 Manual for male circumcision under local anaesthesia. Version 2.5B Geneva WHO
11. Department of Statistics, in the Ministry of Economics (MINECOFIN) and MEASURE DHS 2005 Rwanda demographic and health survey III Kigali, Rwanda Ministry of Finance and Economic Planning
12. USAID I Health Policy Initiative 2007 Costing male circumcision in Lesotho and implications for the cost-effectiveness of circumcision as an HIV intervention Washington (D.C.) USAID
13. USAID I Health Policy Initiative 2007 Costing male circumcision in Swaziland and implications for the cost-effectiveness of circumcision as an HIV intervention Washington (D.C.) USAID
14. GrayRH
2005 Reducing HIV transmission: lessons from Rakai and other African studies. International AIDS Society. Rio de Janeiro, Brazil. Reported in UNAIDS and WHO (2007) Male circumcision: global trends and determinants of prevalence, safety and acceptability Geneva UNAIDS/WHO
15. KahnJG
MarseilleE
AuvertB
2006 Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med 3 e517 doi:10.1371/journal.pmed.0030517
16. WhiteRG
GlynnJR
OrrothKK
2008 Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when? AIDS 22 1841 1850
17. WHO 2006 Life tables. Available: http://www.who.int/whosis. Accessed 25 September 2008
18. UNAIDS 2007 Safe, voluntary, informed male circumcision and comprehensive HIV Prevention: programming guidance for decision-makers on human rights, ethical and legal considerations. Available: http://data.unaids.org/pub/Manual/2007/070613_humanrightsethicallegalguidance_en.pdf. Accessed 25 September 2008
19. CNLS, TRAC Plus, NIS, MOH, UNAIDS, WHO, USAID/Health Policy Initiative 2008 HIV-AIDS in Rwanda. 2008 Epidemic update. Available: http://www.cnls.gov.rw. Accessed 9 February 2009
20. World Health Organization 2002 The world health report, 2002 - Reducing risks, promoting healthy life. Technical considerations for cost-effectiveness analysis. Chapter 5 Geneva World Health Organization
21. UNAIDS 2009 Available: http://www.unaids.org/en/KnowledgeCentre/HIVData/Epidemiology/. Accessed 12 June 2009
22. WalenskyRP
PaltielAD
LosinaE
MercincavageLM
SchackmanBR
2006 The survival benefits of AIDS treatment in the United States. J Infect Dis 194 11 19
23. NACC/CNLS 2007 Dataset to estimate the amount of financial resources needed to implement the National Strategic Plan on HIV (2005–2009). An application of the Goal and Resource Needs Model, Rwanda Kigali, Rwanda USAID/Health Policy Initiative
24. CNLS Plan National de Prevention 2005–2009, VCT unit cost (Annex 4) Kigali, Rwanda CNLS
25. WHO/INSP global costing exercise for Sub-Saharan African and Agence Européenne pour le Développement et la Santé (AEDS), 2005. Etude sur le coût de la prise en charge des PVVIH - Projet INT/107 Initiative ESTHER - LUX Development - December 2004 - Mars 2005. AEDS
26. TRAC 2007 Report on the evaluation of clinical and immunologic outcomes from the national antiretroviral treatment program in Rwanda, 2004–2005.
27. International Monetary Fund 2008 World Economic Outlook Database Washington (D.C.) International Monetary Fund
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