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Cost of the roll-out of male circumcision in sub-Saharan Africa
Presented by Bertran Auvert, France.
Auvert B.1, Kahn J.2, Korenromp E.3, Lloyd-Smith J.4, Helleringer S.5, Taljaard D.6, Sitta R.7, Hargrove J.8, Williams B.9, Marseille E.2
1INSERM U687, Saint-Maurive, France, 2UCSF, San Francisco, United States, 3The Global Fund, Geneva, Switzerland, 4Pennsylvania State University, Pennsylvania, United States, 5University of Pennsylvania, Pennsylvania, United States, 6Progressus, Johannesburg, South Africa, 7INSERM U687, Saint-Maurice, France, 8SACEMA, Stellenbosch, South Africa, 9WHO, Geneva, Switzerland
Introduction: Three randomized control trials tested the effect of medicalized adult male circumcision (MAMC) on HIV acquisition in sub-Saharan Africa and demonstrated a reduction of 50-60%. An economic analysis showed that MAMC is cost effective in South Africa, and an epidemic modeling study suggested that African countries where most males are uncircumcised will benefit from the roll-out of MAMC. This paper provides the first estimates of the economic and human resources required for this roll-out.
Method: We developed a costing tool reflecting MAMC implementation by either the private or public health sector. This tool was integrated with demographic and HIV transmission models, and applied to the 14 sub-Saharan countries where the prevalence of male circumcision is <80% and HIV prevalence among adults is >5% in 2007, assuming 85% of uncircumcised men accept MAMC. We calculated the cost and personnel required for a rapid roll-out of MAMC, and the net cost adjusting for averted HIV treatments. Costs were discounted and given in millions of US$. Ranges were estimated via Monte Carlo simulation.
Results: The private/public cost of a roll-out in an initial 5-year period was $922(707–1 249) / $397(315–532). The number of required circumcisers was 1 912(1 632–2 510), corresponding to 0.23(0.19–0.31) per 10 000 adults. In years 6-10, the number of required circumcisers fell to 504(433–719) and the cost to $208(148–287) / $84(66–116). The cumulative net cost over the first 10 years was $538 (296–846)/-$111(-282–90).
Conclusion: A rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first years. These investments are justified by MAMC’s favorable cost-effectiveness and large projected health benefits. Because of the lower cost after the initial period and savings on averted HIV treatment, the roll-out of MAMC should be sustainable.
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