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Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among US males |
Sansom SL, Prabhu VS, Hutchinson AB, An Q, Hall HI, Shrestha RK, Lasry A, Taylor AW |
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Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of circumcision of newborn males, considering its impact on the lifetime risk of human immunodeficiency virus (HIV). Newborn circumcision was a cost-effective intervention, especially in racial and ethnic groups who were at a higher lifetime risk of HIV, such as Hispanic and Black males. There was limited information on the derivation of the clinical and economic inputs, but the methods appear to have been valid and the authors’ conclusions appear to be robust. Type of economic evaluation Study objective The study examined the cost-effectiveness of circumcision of newborn males, considering its impact on the lifetime risk of human immunodeficiency virus (HIV). Interventions Circumcision for all newborn males was compared against no circumcision. Methods Analytical approach:The analysis was based on a decision-tree model, with a lifetime horizon. The authors stated that a societal perspective was adopted.
Effectiveness data:The clinical data came from a selection of relevant studies. Most of the epidemiological inputs came from US sources, including US statistics and published studies. The key clinical input was the lifetime efficacy of circumcision and these data were from three randomised controlled trials, carried out in South Africa, Kenya, and Uganda. These trials found that medical circumcision, in heterosexual men, reduced their risk of contracting HIV infection, compared with no circumcision. Some assumptions were needed.
Monetary benefit and utility valuations:The utility values were from a published study.
Measure of benefit:Quality-adjusted life-years (QALYs) were the summary benefit measure and they were discounted at an annual rate of 3%.
Cost data:The economic analysis included the cost of medical circumcision of newborn males (physician time to perform the procedure and facility services) and the lifetime cost of HIV. The circumcision cost was from four published cost estimates plus a review of newborn circumcision costs in the MarketScan Medicaid database. The HIV costs were from a published study. All costs were in US dollars ($) and a 3% annual discount rate was applied. The price year was 2007.
Analysis of uncertainty:One- and multi-way sensitivity analyses were carried out for each parameter. Most of the alternative clinical estimates were based on published confidence intervals. A first-order probabilistic analysis, simulating 10,000 iterations, for all males and for subgroups of Black, Hispanic, and White males, was also undertaken. Results In the base case, for all males, with a 60% lifetime efficacy of circumcision, circumcision saved $170 and produced a gain of 0.007 QALYs, compared with no circumcision. Circumcision was dominant, as it was less costly and more effective. This dominance was found in the subgroups of Black and Hispanic males, but in White males, who have a low risk of contracting HIV, there was an additional cost of $154 and a gain of 0.002 QALYs, giving an incremental cost per QALY gained of $87,792.
The discount rate and circumcision efficacy and cost were the most influential inputs. A two-way sensitivity analysis showed that the highest incremental cost-utility ratio for all males was $102,789, with a low efficacy and a high cost of circumcision.
The probabilistic analysis indicated that circumcision was dominant in 78.3% of simulations for all males, 100% for Black males, 88.3% for Hispanic males, and 0.3% for White males, assuming that it was ineffective in preventing HIV among men who have sex with men. Assuming a 5% efficacy in men who have sex with men, the probabilities rose to 91.0% for all males, 100% for Black males, 97.1% for Hispanic males, and 3.3% for White males. Authors' conclusions The authors concluded that newborn circumcision was cost-effective, especially for racial and ethnic groups who were at a higher lifetime risk of HIV, such as Hispanic and Black males, who generally have less access to the procedure due to insurance coverage. CRD commentary Interventions:The selection of the comparators was appropriate and they appear to have been relevant for other health care settings.
Effectiveness/benefits:No literature review, to identify the relevant sources of data, was reported. Three newly available trials that were carried out in Africa were chosen to capture the most up-to-date data on the efficacy of circumcision. The details of the methods and characteristics of the patient populations of these trials would have been useful to judge the internal and external validity of these data. The epidemiological data were appropriately from US sources, where available. Little information on the other sources of evidence, including the valuation of the health-related utilities, was provided. QALYs were a valid benefit measure given the impact of the disease on both quality of life and survival.
Costs:The economic analysis was not clearly presented as the most influential cost category (the lifetime cost of HIV) was from a previous study and its methods were not reported. This cost was presented as a total and was not broken down into individual items, limiting the transparency of the analysis. A societal perspective was chosen, but it was not clear whether productivity losses were included. The unit cost of circumcision was given together with its source. The price year was reported, allowing reflation exercises for other time periods. The impact of variations in the cost estimates was considered in the sensitivity analyses.
Analysis and results:The results were clearly reported and the projected costs and benefits were synthesised, using an incremental approach, where appropriate. The presentation of the results by ethnic or racial group was valid and useful for applying the findings to multi-ethnic populations. Various sensitivity analyses were carried out to satisfactorily assess the uncertainty, but only a first-order probabilistic sensitivity analysis was conducted. The authors stated that some assumptions were made against or in favour of circumcision. For example, the benefits of a reduction in HIV risk for partners of circumcised men were not included, while the adverse events associated with circumcision (e.g. bleeding) were also not considered.
Concluding remarks:There was limited information on the derivation of the clinical and economic inputs, but the methods appear to have been valid and the authors’ conclusions appear to be robust. Bibliographic details Sansom SL, Prabhu VS, Hutchinson AB, An Q, Hall HI, Shrestha RK, Lasry A, Taylor AW. Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among US males. PLOS ONE 2010; 5(1):e8723 Indexing Status Subject indexing assigned by NLM MeSH Circumcision, Male /economics; Cost-Benefit Analysis; HIV Infections /epidemiology /prevention & Humans; Infant, Newborn; Male; Population Surveillance; Quality-Adjusted Life Years; Risk Factors; United States /epidemiology; control AccessionNumber 22010000843 Date bibliographic record published 21/07/2010 Date abstract record published 02/02/2011 |
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