AIDS

Skip Navigation LinksHome > September 12, 2008 - Volume 22 - Issue 14 > Male circumcision for HIV prevention in sub-Saharan Africa:...
AIDS:
doi: 10.1097/QAD.0b013e32830e0137
Epidemiology and Social

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

White, Richard Ga; Glynn, Judith Ra; Orroth, Kate Ka; Freeman, Esther Ea; Bakker, Roelb; Weiss, Helen Aa; Kumaranayake, Lilania; Habbema, J Dik Fb; Buvé, Annec; Hayes, Richard Ja

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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 HIV-uninfected 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.

© 2008 Lippincott Williams & Wilkins, Inc.

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