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

<h4>Background</h4>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 eff...

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Autores principales:	Agnes Binagwaho, Elisabetta Pegurri, Jane Muita, Stefano Bertozzi
Formato:	article
Lenguaje:	EN
Publicado:	Public Library of Science (PLoS) 2010
Materias:	Medicine R
Acceso en línea:	https://doaj.org/article/01397b7b20ca4137992d9419a6bbbedb
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spelling	oai:doaj.org-article:01397b7b20ca4137992d9419a6bbbedb2021-12-02T19:55:52ZMale circumcision at different ages in Rwanda: a cost-effectiveness study.1549-12771549-167610.1371/journal.pmed.1000211https://doaj.org/article/01397b7b20ca4137992d9419a6bbbedb2010-01-01T00:00:00Zhttps://www.ncbi.nlm.nih.gov/pmc/articles/pmid/20098721/pdf/?tool=EBIhttps://doaj.org/toc/1549-1277https://doaj.org/toc/1549-1676<h4>Background</h4>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%.<h4>Methods and findings</h4>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.<h4>Results</h4>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.<h4>Conclusions</h4>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.Agnes BinagwahoElisabetta PegurriJane MuitaStefano BertozziPublic Library of Science (PLoS)articleMedicineRENPLoS Medicine, Vol 7, Iss 1, p e1000211 (2010)
institution	DOAJ
collection	DOAJ
language	EN
topic	Medicine R
spellingShingle	Medicine R Agnes Binagwaho Elisabetta Pegurri Jane Muita Stefano Bertozzi Male circumcision at different ages in Rwanda: a cost-effectiveness study.
description	<h4>Background</h4>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%.<h4>Methods and findings</h4>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.<h4>Results</h4>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.<h4>Conclusions</h4>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.
format	article
author	Agnes Binagwaho Elisabetta Pegurri Jane Muita Stefano Bertozzi
author_facet	Agnes Binagwaho Elisabetta Pegurri Jane Muita Stefano Bertozzi
author_sort	Agnes Binagwaho
title	Male circumcision at different ages in Rwanda: a cost-effectiveness study.
title_short	Male circumcision at different ages in Rwanda: a cost-effectiveness study.
title_full	Male circumcision at different ages in Rwanda: a cost-effectiveness study.
title_fullStr	Male circumcision at different ages in Rwanda: a cost-effectiveness study.
title_full_unstemmed	Male circumcision at different ages in Rwanda: a cost-effectiveness study.
title_sort	male circumcision at different ages in rwanda: a cost-effectiveness study.
publisher	Public Library of Science (PLoS)
publishDate	2010
url	https://doaj.org/article/01397b7b20ca4137992d9419a6bbbedb
work_keys_str_mv	AT agnesbinagwaho malecircumcisionatdifferentagesinrwandaacosteffectivenessstudy AT elisabettapegurri malecircumcisionatdifferentagesinrwandaacosteffectivenessstudy AT janemuita malecircumcisionatdifferentagesinrwandaacosteffectivenessstudy AT stefanobertozzi malecircumcisionatdifferentagesinrwandaacosteffectivenessstudy
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Male circumcision at different ages in Rwanda: a cost-effectiveness study.

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