Wednesday, March 16, 2011

Male circumcision at different ages in Rwanda. A cost-effectiveness study.

Friday, March 11, 2011

There is strong evidence in favour of MC to reduce HIV infection and other STI. In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. To inform policy and programmatic decisions in relation to introducing MC, the Rwanda National AIDS Commission modelled cost and effects of MC at different ages. This study was needed given that the MC debate in Southern Africa had focused primarily on MC for adults.

A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents and adult men. Effectiveness is defined as the number of HIV infections averted, and is 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 were adjusted for the averted lifetime cost of health care (ART, OI, laboratory tests). One-way sensitivity analysis was performed for different values of the main inputs of the model and the thresholds at which each intervention is (a) no longer cost-saving and (b) at which it costs more than one GDP/capita/life year gained were calculated.

Neonatal male circumcision is less expensive than adolescents and adult male circumcision (15 USD instead of 59 USD per procedure) and is cost-saving (the cost effectiveness ration is negative); even though savings from infant circumcision will be realized later in time. The cost per infection averted is 3,932 USD for adolescent MC and 4,949 USD for adult MC. Results for infant MC appear robust. Infants MC remains highly C-E for a reasonable amount of changes in the base case scenario. Adolescent male circumcision is highly cost-effective for the base case scenario but no longer so for very small changes in the input variables. Adults MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man. Additionally, infant MC can be easily integrated into existing health services (i.e. neonatal visits and vaccination sessions) and has a better potential to achieve the very high coverage over time of the population required for maximal reduction on HIV incidence, than adolescent and adult circumcision.

African leaders and development partners should stop managing the HIV response as an emergency issue and release themselves from a one-year or even a five-year planning perspective to focus on sustainable long-term choices for countries. The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with highest priority to the very young. In the presence of infant MC, adolescent and adult MC should become a sort of “catch up” campaign that would be needed at the start of the program but would then become superfluous over time.