|Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa
|Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, Heard N, Castor D, Stover J, Farley T, Menon V, Hankins C
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.
This study examined the cost-effectiveness of encouraging adult voluntary male medical circumcision, to reduce the incidence of HIV, in several priority countries in eastern and southern Africa. The authors concluded that the rapid scale-up of voluntary circumcision led to a substantial reduction in HIV infections, which reduced the health care costs and produced net savings. The methods were valid and transparent, and the authors’ conclusions appear to be robust.
Type of economic evaluation
This study examined the cost-effectiveness of encouraging adult voluntary male medical circumcision, to reduce the incidence of HIV, in several priority countries in eastern and southern Africa.
Increasing the rate of male circumcision to a target of 80% coverage, was compared with usual care, in which coverage remained at the usual level, which varied by country, ranging from zero in Lesotho to 66.8% in Tanzania.
Thirteen eastern and southern African countries/primary and secondary care.
The analysis used the Decision Makers’ Program Planning Tool (a behavioural simulation) to model the clinical and economic impact of adult male circumcision, in a hypothetical population of men aged 15 to 49 years, who were HIV negative. A 15-year time horizon was considered. The authors stated that the perspective was that of each country's government and their international partners, who funded the health programme.
The demographic and epidemiologic data for each country were from up-to-date household surveys and a modelling software package (Spectrum) that included United Nations population data. The efficacy of voluntary circumcision was based on three clinical trials. Other data were from published studies, conducted in the 13 countries. The change in coverage rate before and after the intervention was the key input for the analysis and was based on authors’ assumptions.
Monetary benefit and utility valuations:
Measure of benefit:
The rate of HIV infections averted was the summary benefit measure and was discounted at an annual rate of 3%.
The economic analysis included the costs of the programme implementation and the lifetime cost savings from reduced HIV treatment. Implementation included consumables, waste management, supply chain, staff, training, capital purchases, maintenance and utility services, support overheads, and management overheads. These costs were from a study of voluntary male medical circumcision carried out in Zimbabwe in 2010, as part of a study that included Kenya, Namibia, South Africa, Uganda, and Zambia. This study was carried out in accordance with World Health Organization (WHO) criteria. Some waste management costs were from a cost analysis conducted in Swaziland. HIV treatment covered AIDS treatment and care, including antiretroviral therapy, treatment of major opportunistic infections, laboratory tests, and home-based care. These costs came from a published study. All costs were expressed in US $ and a 3% annual discount rate was applied.
Analysis of uncertainty:
One-way sensitivity analyses were carried out by varying the assumptions for the following inputs: circumcision effectiveness, target circumcision coverage, time to target coverage, change in behaviour after circumcision, circumcision unit cost, and lifetime HIV treatment cost. Alternative assumptions were either from the literature or were arbitrary.
The rate of HIV infections averted, over the period of programme (2011 to 2025), ranged from 9% in Tanzania to 42% in Zimbabwe. High rates were observed in Swaziland, Zambia and Lesotho.
The cost of the programme, over 15 years, ranged from $17.18 million in Swaziland (the country with the highest coverage before implementation) to $489.47 million in South Africa (the country with the lowest coverage). Considering only the programme costs, on average, the cost per HIV infection avoided was $809. The net savings with the programme were far greater than the intervention costs and ranged from $67.21 million in Namibia to $5,498.55 million in South Africa.
The programme was more effective and less expensive than the usual circumcision coverage in every country analysed. In all 13 countries together, the programme cost approximately $2 billion, over 15 years, but saved more than $16.51 billion and avoided 3.36 million new HIV infections.
The sensitivity analysis confirmed that these findings were robust and were not altered in any of the alternative scenarios.
The authors concluded that the rapid scale-up of voluntary male circumcision led to a substantial reduction in HIV infections, in eastern and southern Africa, which reduced the health care costs and produced net savings.
The selection of the comparators was appropriate as the proposed intervention to increase the rate of male circumcision was compared with the usual rate before the intervention.
The clinical and epidemiological data appear to have been from valid sources, but no systematic review to identify all potential sources was reported. The epidemiological data came from local databases and the treatment effect was from clinical trials. All the sources appear to have been appropriate and extensive sensitivity analysis was conducted on the clinical parameters. The benefit measure was relevant to HIV, but will not allow comparisons with other diseases.
The categories of costs were relevant to the perspective stated. Most of the economic data were from a study published in one of the countries analysed and they are likely to have been representative of the settings considered. The long-term HIV costs were from a published study, which was not fully described. Most of the cost items and some of the unit costs were provided. The price year was not explicitly reported, but the main cost study was conducted in 2010. The costs were treated deterministically.
Analysis and results:
The study results (additional benefits and costs) were clearly reported for all countries. An incremental analysis was used to combine the costs and benefits of the two interventions. The uncertainty was investigated in a deterministic analysis, varying individual inputs. A validated model was used to assess the long-term economic and clinical impact of the programme. The authors acknowledged some limitations to their analysis, mainly due to the need for assumptions and the lack of good quality data, which could have under- or over-estimated the impact of the programme. The results were stable to wide variations in the parameters and when assuming a coverage of 50%. The findings might be transferable to settings with similar epidemiology.
The methods were valid and transparent, and the authors’ conclusions appear to be robust.
Funded by the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Joint United Nations Programme on HIV/AIDS (UNAIDS).
Njeuhmeli E, Forsythe S, Reed J, Opuni M, Bollinger L, Heard N, Castor D, Stover J, Farley T, Menon V, Hankins C. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLOS Medicine 2011; 8(11):e1001132
Subject indexing assigned by NLM
Adolescent; Adult; Africa, Eastern /epidemiology; Circumcision, Male /economics /statistics & Cost-Benefit Analysis; Decision Making, Organizational; Female; HIV Infections /economics /epidemiology /prevention & Health Policy; Humans; Male; Middle Aged; Models, Economic; National Health Programs /economics /organization & Sexual Behavior /psychology; South Africa /epidemiology; Young Adult; administration; control /transmission; numerical data
Date bibliographic record published
Date abstract record published