Background: The financial implications of male circumcision (MC) scale-up in sub-Saharan Africa associated with reduced HIV have been evaluated. However, no analysis has incorporated the expected reduction of a comprehensive set of other sexually transmitted infections including human papillomavirus, herpes simplex virus type 2, genital ulcer disease, bacterial vaginosis, and trichomoniasis.
Methods: A Markov model tracked a dynamic population undergoing potential MC scale-up, as individuals experienced MC procedures, procedure-related adverse events, and MC-reduced sexually transmitted infections and accrued any associated costs. Rakai, Uganda, was used as a prototypical rural sub-Saharan African community. Monte Carlo microsimulations evaluated outcomes under 4 alternative scale-up strategies to reach 80% MC coverage among men aged 15 to 49 years, in addition to a baseline strategy defined by current MC rates in central Uganda. Financial outcomes included direct medical expenses only and were evaluated over 5 and 25 years. Costs were discounted to the beginning of each period, coinciding with the start of MC scale-up, and expressed in US$2012.
Results: Cost savings from infections averted by MC vary from US$197,531 after 5 years of a scale-up program focusing on adolescent/adult procedures to more than US$13 million after 25 years, under a strategy incorporating increased infant MCs. Over a 5-year period, reduction in HIV contributes to 50% of cost savings, and for 25 years, this contribution rises to nearly 90%.
Conclusions: Sexually transmitted infections other than HIV contribute to cost savings associated with MC scale-up. Previous analyses, focusing exclusively on the financial impact through averted HIV, may have underestimated true cost savings by 10% to 50%.
A comprehensive evaluation of the financial implications of male circumcision scale-up in sub-Saharan Africa found that previous cost analyses focusing only on HIV have underestimated impact. Supplemental digital content is available in the Article.
From the *Department of Pathology, School of Medicine; †Department of Health Policy and Management, Bloomberg School of Public Health; and ‡Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD; §Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD; and ¶Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
Funding: S.K. and A.A.R.T. were supported by the Doris Duke Charitable Foundation Clinician Scientist Development Award (No. 22006.02), and A.A.R.T was supported by the National Institutes of Health 1K23AI093152-01A1.
Conflict of interest statement: All authors declare that there is no potential conflict of interest relevant to this article.
Author contributions: All authors contributed to the study design, data collection, data analysis, writing, and reviewing the manuscript.
Correspondence: Aaron A.R. Tobian, MD, PhD, Department of Pathology, Johns Hopkins University, Carnegie 437, 600 N Wolfe St, Baltimore, MD 21287. E-mail: firstname.lastname@example.org.
Received for publication September 20, 2012, and accepted March 27, 2013.
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