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Financial Implications of Male Circumcision Scale-Up for the Prevention of HIV and Other Sexually Transmitted Infections in a Sub-Saharan African Community

Kacker, Seema BS*; Frick, Kevin D. PhD; Quinn, Thomas C. MD‡§; Gray, Ronald H. MD; Tobian, Aaron A.R. MD, PhD*

Sexually Transmitted Diseases: July 2013 - Volume 40 - Issue 7 - p 559–568
doi: 10.1097/OLQ.0b013e3182945e56
Original Study

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:

Received for publication September 20, 2012, and accepted March 27, 2013.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text, and links to the digital files are providedin the HTML text of this article on the journal’s Web site (

© Copyright 2013 American Sexually Transmitted Diseases Association