Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when?

Authored by Roel Bakker, Esther E Freeman, Richard G White, Kate K Orroth, Helen A Weiss, Anne Buve, Richard J Hayes, Judith R Glynn, Lilani Kumaranayake, J Dik F Habbema

Date Published: 2008

DOI: 10.1097/qad.0b013e32830e0137

Sponsors: Wellcome Trust

Platforms: No platforms listed

Model Documentation: Other Narrative

Model Code URLs: Model code not found

Abstract

Background and objective: Male circumcision (circumcision) reduces HIV incidence in men by 50-60\%. The United Nations Joint Programme on HIV/AIDS (UNAIDS) recommends the provision of safe circumcision services in countries with high HIV and low circumcision prevalence, prioritizing 12-30 years old HIV-uninfected men. We explore how the population-level impact of circumcision varies by target age group, coverage, time-to-scale-up, level of risk compensation and circumcision of HIV-infected men. Design and methods: An individual-based model was fitted to the characteristics of a typical high-HIV-prevalence population in sub-Saharan Africa and three scenarios of individual-level impact corresponding to the central and the 95\% confidence level estimates from the Kenyan circumcision trial. The simulated intervention increased the prevalence of circumcision from 25 to 75\%. over 5 years in targeted age groups. The impact and cost-effectiveness of the intervention were calculated over 2-50 years. Future costs and effects were discounted and compared with the present value of lifetime HIV treatment costs (US\$ 4043). Results: Initially, targeting men older than the United Nations Joint Programme on HIV/AIDS recommended age group may be the most cost-effective strategy, but targeting any adult age group will be cost-saving. Substantial risk compensation Could negate impact, particularly if already circumcised men compensate. If circumcision prevalence in HIVuninfected men increases less because HIV-infected men are also circumcised, this will reduce impact in men but would have little effect on population-level impact in women. Conclusion: Circumcision is a cost-saving intervention in a wide range of scenarios of HIV and initial circumcision prevalence but the United Nations Joint Programme on HIV/AIDS/WHO recommended target age group should be widened to include older HIV-uninfected men and counselling should be targeted at both newly and already circumcised men to minimize risk compensation. To maximize infections-averted, circumcision Must be scaled up rapidly while maintaining quality. (C) 2008 Wolters Kluwer Health vertical bar Lippincott Williams \& Wilkins.

Tags

Infection Uganda Prevalence Simulation-model Impact Middle-income countries Sexually-transmitted-diseases Intervention trials Rakai Hiv/aids