Research Article: Neonatal Circumcision for HIV Prevention: Cost, Culture, and Behavioral Considerations

Date Published: January 19, 2010

Publisher: Public Library of Science

Author(s): Seth C. Kalichman

Abstract: Seth Kalichman discusses a new study that finds neonatal circumcision in Rwanda to be a cost-saving HIV prevention strategy.

Partial Text: Decades of epidemiological studies and three carefully controlled randomized clinical trials have definitively shown that male circumcision (MC) reduces risks for HIV transmission from women to men by as much as 55% [1]. Male circumcision is therefore more protective against HIV transmission than even the most promising vaccines and topical microbicides. The protective biological mechanisms of MC are most likely a combination of removing HIV vulnerable cells that are present at high densities in the foreskin, particularly Langerhans cells, keratinization of mucous membranes, and reduction of penile trauma during intercourse. There is also evidence that MC offers protection against other sexually transmitted infections, further reducing the risk of HIV acquisition and transmission [2]. Although MC offers little, if any, direct protective benefits to women who engage in vaginal or anal intercourse with HIV infected men, or to male receptive anal intercourse partners of HIV-positive men, population-level reductions in HIV prevalence among men will ultimately lead to fewer infections in their sex partners.

In a study published in this issue of PLoS Medicine, Agnes Binagwaho and colleagues conducted a comparative cost-effectiveness analysis of neonatal, adolescent, and adult MC scale-up in Rwanda, a country with a moderate adult HIV prevalence of about 3% [8],[9]. The study used the perspective of the Rwandan government as the health care payer and used standard costs associated with the procedure as well as costs associated with HIV testing, treatment, and care. The model was based on current estimates of HIV incidence in Rwanda and an estimated 55% protective effect of MC. Analyses once again showed that MC is a cost-saving HIV prevention intervention, with both neonatal and adult MC saving Rwanda resources for each HIV infection averted. Furthermore, neonatal MC is less expensive than adult and adolescent MC, rendering greater dividends despite the time lag between the procedure and averted infections.

The case for MC, including neonatal MC, for HIV prevention is biologically and medically compelling. However, as with any other public health intervention, the effectiveness of MC will be determined by access and uptake. Cost-effectiveness analyses such as those reported by Binagwaho et al. illustrate the public health utility of increased access to neonatal MC. However, uptake may turn out to be a far greater challenge than can be estimated in cost-effectiveness analyses.

Cultural and religious beliefs are not the only nonbiological factors to consider in scaling-up neonatal MC. Anticircumcision groups have long existed and are increasingly vocal as MC programs for HIV prevention are promoted [12]. Anticircumcision groups resemble other antiscience and antimedicine extremists including AIDS denialists who refute public health realities to maintain entrenched belief systems [13].

MC offers one of the few available effective HIV prevention interventions. Scaling up MC in southern Africa has the potential to stem entire HIV epidemics, saving countless lives. Lifetime protection against HIV, and therefore reductions in population levels of HIV/AIDS, can be realized when circumcision occurs prior to sexual debut. The cost-savings of neonatal MC are compelling and suggest that implementation is economically feasible in developing countries hit hardest by HIV/AIDS. Neonatal MC should therefore be considered a priority in comprehensive HIV prevention plans for southern Africa.



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