An analysis of the cost-effectiveness of male circumcision for HIV prevention in Rwanda has concluded that circumcising newborn babies would be cheaper and prevent more infections than providing the operation to adolescents or adults.
The authors, writing in the open-access journal PLoS Medicine, call on policy makers to stop treating HIV solely as an emergency issue. Although the benefit of infant circumcision will not be seen for another two decades, “action cannot be deferred simply because gains will be in the distant future.”
Circumcision policies have focused on provision to adolescents and young adults. UNAIDS and WHO argue that circumcision of males aged 12 to 30 has the potential to reach a group in which HIV prevalence is currently low, but who may be at significant risk of acquiring HIV in the next few years. Such an approach would have a public health impact more quickly than a policy of circumcising newborn babies, whose impact would not be seen for at least 20 years.
Whereas the cost-effectiveness of adult circumcision has been demonstrated in southern African countries with an HIV prevalence above 15%, HIV prevalence is much lower in Rwanda (3%). On the other hand, only 15% of Rwandan men are circumcised and the operation does not have cultural connotations that would discourage uptake, suggesting that a circumcision programme could have an impact on HIV transmission.
Agnes Binagwaho and colleagues developed a simple cost-effectiveness model and applied it to three hypothetical groups of Rwandans: newborn boys, 15-year-old boys, and 30-year-old men. For their model, the researchers calculated the effectiveness of male circumcision (the number of HIV infections averted) by estimating the reduction in the annual number of new HIV infections over time. They obtained estimates of the costs of circumcision (including the costs of surgical supplies, staff time and treatment of complications) and adjusted these costs for the money saved through not needing to treat HIV in so many men.
In contrast to other studies, the cost-savings were considered over the lifetime of the circumcised males, rather than the next ten or twenty years.
The cost-per-circumcision was estimated to be much lower for babies (US$15) than for adolescents or adults (US$59), because the adult operation is more complex, requires anaesthetic and other more expensive materials, involves HIV testing and counselling, as well as more staff time and greater infrastructure.
The researchers estimated that if 150,000 men aged 30 were circumcised in 2008, then 859 infections would be avoided in their lifetimes. The impact would be seen in the years immediately following the operation, with most infections avoided between 2008 and 2022.
An alternative policy of circumcising the same number of 15-year-old boys would prevent 1,283 HIV infections. The greatest reduction in infections would take place between 2018 and 2037 (i.e. when the boys are aged 25 to 44).
If babies were circumcised within a month of birth, a similar number of infections would be avoided, 1,288. The greatest benefit would be seen between 2033 and 2052.
Providing the operation to babies would cost $2.25 million and would save $3.80 million in future costs, and would therefore be cost-saving. However, as the operation for adolescents or adults is considerably more expensive ($8.85 million for each group), the costs are higher than the savings.
The authors make a cost-effectiveness analysis based on the cost per life year gained. If this cost is below Rwanda’s per-capita GDP (gross domestic product), the intervention is thought to be cost-effective.
On this basis, circumcision of both babies and adolescents was highly cost-effective, whereas adult circumcision was not.
The researchers conducted a sensitivity analysis in which they modified their assumptions concerning the cost and effectiveness of circumcision. Infant circumcision remained cost-effective in a number of different scenarios, whereas adolescent circumcision did not.
The authors comment that neonatal circumcision is faster, less complicated and has fewer adverse effects than adolescent or adult circumcision. It can also be integrated into existing health services such as neonatal visits and vaccination sessions.
They believe it has other advantages: a compensatory increase in risky sexual behaviour is less likely; there is no possibility of sexual activity during healing; and it is associated with less stigma, discomfort and days out of work or school.
The researchers recommend that countries with moderate HIV epidemics should offer routine circumcision to newborn babies, integrated into existing health services. In addition, adolescents and higher-risk adults should be offered circumcision until the ageing of boys circumcised at birth makes such a policy obsolete.
“African leaders and development partners should stop managing the HIV response as only an emergency issue and release themselves from a 1-y or even a 5-y planning perspective to focus on sustainable long-term choices for countries,” they write.