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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

doi: 10.1097/QAD.0b013e32830e0137
Epidemiology and Social

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.

aLondon School of Hygiene and Tropical Medicine, London, UK

bErasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands

cInstitute of Tropical Medicine, Antwerp, Belgium.

Received 19 February, 2008

Revised 2 June, 2008

Accepted 11 June, 2008

Correspondence to Richard G. White, Infectious Disease Epidemiology Unit, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK. Tel: +44 207 299 4626; e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.