Research Article: Cost-Effectiveness of Newborn Circumcision in Reducing Lifetime HIV Risk among U.S. Males

Date Published: January 18, 2010

Publisher: Public Library of Science

Author(s): Stephanie L. Sansom, Vimalanand S. Prabhu, Angela B. Hutchinson, Qian An, H. Irene Hall, Ram K. Shrestha, Arielle Lasry, Allan W. Taylor, Patricia Kissinger.

Abstract: HIV incidence was substantially lower among circumcised versus uncircumcised heterosexual African men in three clinical trials. Based on those findings, we modeled the potential effect of newborn male circumcision on a U.S. male’s lifetime risk of HIV, including associated costs and quality-adjusted life-years saved.

Partial Text: Three randomized, controlled clinical trials conducted in South Africa, Kenya, and Uganda found that medical circumcision in men reduced participants’ risk of HIV infection [1]–[3]. In these studies, men who had been randomly assigned to the circumcision group had a lower (60% in South Africa, 53% in Kenya, and 51% in Uganda) incidence of HIV infection compared with men assigned to the wait list group to be circumcised at the end of the study. In a per protocol analysis, men who had been circumcised had a 76% (South Africa), 60% (Kenya), and 55% (Uganda) reduction in risk of HIV infection compared to those who were not circumcised. In Kenya, efficacy increased to 64% when the follow-up period was extended from 24 to 42 months (Bailey RC, Moses S, Parker CB, Agot K, Maclean I, et al. The protective effect of male circumcision is sustained for at least 42 months: results from the Kisumu, Kenya trial. XVII International AIDS Conference. Aug. 3–8, 2008. Mexico City, Mexico.).

Institutional review board consideration was not required for this work because it did not involve the collection or analysis of primary data. We developed a static Excel-based (Version 2003, Microsoft Corporation, WA) decision model to compare the HIV-related costs and quality-adjusted life-years among U.S. males who are circumcised at birth with those who are not. We based our analysis on previously published estimates of lifetime HIV risk for U.S. males[16]. We calculated the expected difference in lifetime HIV risk among circumcised and uncircumcised males given the portion of lifetime HIV risk attributed to heterosexual contact, the prevalence of circumcision in the United States and the observed efficacy of circumcision on HIV prevention in Africa. Our work is consistent with reference-case recommendations of the Panel on Cost-Effectiveness in Health and Medicine for conducting and reporting cost-effectiveness analyses, including the use of a societal perspective [17].

We estimated that at 60% lifetime efficacy, circumcision would reduce the lifetime risk of HIV diagnosis for all males by 15.7% in the base case analysis, and the reduction ranged from 7.9% among white males to 20.9% for black males (Table 3). The number of circumcisions needed to prevent one HIV infection was 298 for all males, and ranged from 65 for black males to 1,231 for white males. For all males, circumcision increased undiscounted HIV-related quality-adjusted life expectancy by 19.6 days, and discounted (at 3%) quality-adjusted life expectancy by 2.6 days. For all males, circumcision resulted in undiscounted lifetime HIV-related healthcare savings of $2,070 per male and discounted lifetime HIV-related healthcare savings of $427. Newborn circumcision resulted in savings in costs and in quality-adjusted life-years for all males and for black and Hispanic males. For white males, newborn circumcision cost $87,792 for each QALY saved, under base case assumptions.

A U.S. male has a 1.87% chance of becoming infected with HIV over his lifetime, and the risk varies substantially by race and ethnicity, from 0.94% among white males to 6.22% among black males. Using randomized clinical trial results from Africa, our analysis shows that newborn circumcision can reduce the lifetime risk of HIV, and that the protective effect also varies by race/ethnicity. The reduction is 16% for all males, nearly 21% for black males, and 8% for white males, given the base case assumption that the protective effect of circumcision applies only to heterosexually acquired HIV.



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