Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a systematic review

Modelling Methods of Economic Evaluations of HIV Testing Strategies in Sub-Saharan Africa: A Systematic Review

BACKGROUND AND OBJECTIVE

Economic evaluations, a decision-support tool for policy makers, will be crucial in planning and tailoring HIV prevention and treatment strategies especially in the wake of stalled and decreasing funding for the global HIV response. As HIV testing and treatment coverage increase, case identification becomes increasingly difficult and costly. Determining which subset of the population these strategies should be targeted to becomes of vital importance as well. Generating quality economic evidence begins with the validity of the modelling approach and the model structure employed. This study synthesises and critiques the reporting around modelling methodology of economic models in the evaluation of HIV testing strategies in sub-Saharan Africa.

METHODS

The following databases were searched from January 2000 to September 2020: MEDLINE, Embase, Scopus, EconLit and Global Health. Any model-based economic evaluation of a unique HIV testing strategy conducted in sub-Saharan Africa presenting a cost-effectiveness measure published from 2013 onwards was eligible. Data were extracted around three components: general study characteristics; economic evaluation design; and quality of model reporting using a novel tool developed for the purposes of this study.

RESULTS

A total of 21 studies were included; 10 cost-effectiveness analyses, 11 cost-utility analyses. All but one study was conducted in Eastern and Southern Africa. Modelling approaches for HIV testing strategies can be broadly characterised as static aggregate models (3/21), static individual models (6/21), dynamic aggregate models (5/21) and dynamic individual models (7/21). Adequate reporting around data handling was the highest of the three categories assessed (74%), and model validation, the lowest (45%). Limitations to model structure, justification of chosen time horizon and cycle length, and description of external model validation process were all adequately reported in less than 40% of studies. The predominant limitation of this review relates to the potential implications of the narrow inclusion criteria.

CONCLUSIONS

This review is the first to synthesise economic evaluations of HIV testing strategies in sub-Saharan Africa. The majority of models exhibited dynamic, stochastic and individual properties. Model reporting against the 13 criteria in our novel tool was mixed. Future model-based economic evaluations of HIV testing strategies would benefit from transparency around the choice of modelling approach, model structure, data handling procedures and model validation techniques.

Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent models

BACKGROUND

Voluntary medical male circumcision (VMMC) has been a recommended HIV prevention strategy in sub-Saharan Africa since 2007, particularly in countries with high HIV prevalence. However, given the scale-up of antiretroviral therapy programmes, it is not clear whether VMMC still represents a cost-effective use of scarce HIV programme resources.

METHODS

Using five existing well described HIV mathematical models, we compared continuation of VMMC for 5 years in men aged 15 years and older to no further VMMC in South Africa, Malawi, and Zimbabwe and across a range of setting scenarios in sub-Saharan Africa. Outputs were based on a 50-year time horizon, VMMC cost was assumed to be US$90, and a cost-effectiveness threshold of US$500 was used.

FINDINGS

In South Africa and Malawi, the continuation of VMMC for 5 years resulted in cost savings and health benefits (infections and disability-adjusted life-years averted) according to all models. Of the two models modelling Zimbabwe, the continuation of VMMC for 5 years resulted in cost savings and health benefits by one model but was not as cost-effective according to the other model. Continuation of VMMC was cost-effective in 68% of setting scenarios across sub-Saharan Africa. VMMC was more likely to be cost-effective in modelled settings with higher HIV incidence; VMMC was cost-effective in 62% of settings with HIV incidence of less than 0·1 per 100 person-years in men aged 15-49 years, increasing to 95% with HIV incidence greater than 1·0 per 100 person-years.

INTERPRETATION

VMMC remains a cost-effective, often cost-saving, prevention intervention in sub-Saharan Africa for at least the next 5 years.

FUNDING

Bill & Melinda Gates Foundation for the HIV Modelling Consortium.

An economic evaluation of an intervention to increase demand for medical male circumcision among men aged 25-49 years in South Africa

BACKGROUND

Studies estimate that circumcising men between the ages of 20-30 years who have exhibited previous risky sexual behaviour could reduce overall HIV prevalence. Demand creation strategies for medical male circumcision (MMC) targeting men in this age group may significantly impact these prevalence rates.

OBJECTIVES

The objective of this study is to evaluate the cost-effectiveness and cost-benefit of an implementation science, pre-post study designed to increase the uptake of male circumcision for ages 25-49 at a fixed MMC clinic located in Gauteng Province, South Africa.

METHODS

A health care provider perspective was utilised to collect all costs. Costs were compared between the standard care scenario of routine outreach strategies and a full intervention strategy. Cost-effectiveness was measured as cost per mature man enrolled and cost per mature man circumcised. A cost-benefit analysis was employed by using the Bernoulli model to estimate the cases of HIV averted due to medical male circumcision (MMC), and subsequently translated to averted medical costs.

RESULTS

In the 2015 intervention, the cost of the intervention was $9445 for 722 men. The total HIV treatment costs averted due to the intervention were $542,491 from a public care model and $378,073 from a private care model. The benefit-cost ratio was 57.44 for the public care model and 40.03 for the private care model. The net savings of the intervention were $533,046 or $368,628 - depending on treatment in a public or private setting.

CONCLUSIONS

The intervention was cost-effective compared to similar MMC demand interventions and led to statistically significant cost savings per individual enrolled.

Prevalence and correlates of voluntary medical male circumcision adverse events among adult males in the Copperbelt Province of Zambia: A cross-sectional study

BACKGROUND

Voluntary Medical Male Circumcision (VMMC) is a key intervention in HIV/AIDS. Improving VMMC program uptake in Zambia requires careful monitoring of adverse events (AE) to inform program quality and safety. We investigate the prevalence of VMMC AE and their associated factors among adult males in Ndola, Copperbelt Province, Zambia.

METHODS

We performed a cross-sectional study using secondary clinical data collected in 2015 using two validated World Health Organisation/Ministry of Health reporting forms. We reviewed demographics and VMMC surgical details from 391 randomly sampled adult males aged ≥18 years at Ndola Teaching Hospital, a specialised VMMC fixed site in Zambia. Non-parametric tests (Fisher's exact test or Chi-square depending on assumptions being met) and logistic regression were conducted to determine the relationships between associated factors and VMMC AE.

RESULTS

The overall VMMC AE prevalence was 3.1% (95% CI 1.60%- 5.30%) and most AEs occurred postoperatively. In decreasing order, the commonly reported VMMC AE included; bleeding (47.1%), swelling (29.4%), haematoma (17.6%), and delayed wound healing (5.9%). There was an inversely proportional relationship between VMMC volume (as measured by the number of surgeries conducted per VMMC provider) and AEs. Compared to the highest VMMC volume of 63.2% (247/391) as reference, as VMMC volume reduced to 35.0% (137/391) and then 1.8% (7/391), the likelihood of AEs increased by five times (aOR 5.08; 95% CI 1.33-19.49; p = 0.018) and then sixteen times (aOR 16.13; 95% CI 1.42-183.30; p = 0.025) respectively.

CONCLUSIONS

Our study found a low prevalence of VMMC AEs in Ndola city, Copperbelt Province of Zambia guaranteeing the safety of the VMMC program. We recommend more surgically proficient staff to continue rendering this service. There is a need to explore other high priority national/regional areas of VMMC program safety/quality, such as adherence to follow-up visits.

Moving away from the "unit cost". Predicting country-specific average cost curves of VMMC services accounting for variations in service delivery platforms in sub-Saharan Africa

BACKGROUND

One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called "unit costs") vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists.

METHODS

We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset.

RESULTS

The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings.

CONCLUSION

While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.

Cost-effectiveness analysis of two-way texting for post-operative follow-up in Zimbabwe's voluntary medical male circumcision program

Objective

Although adverse events (AEs) following voluntary medical male circumcision (VMMC) are rare, their prompt ascertainment and management is a marker of quality care. The use of two-way text messaging (2wT) for client follow-up after VMMC reduces the need for clinic visits (standard of care (SoC)) without compromising safety. We compared the cost-effectiveness of 2wT to SoC for post-VMMC follow-up in two, high-volume, public VMMC sites in Zimbabwe.

Materials and methods

We developed a decision-analytic (decision tree) model of post-VMMC client follow-up at two high-volume sites. We parameterized the model using data from both a randomized controlled study of 2wT vs. SoC and from the routine VMMC program. The perspective of analysis was the Zimbabwe government (payer). The time horizon covered the time from VMMC to wound healing. Costs included text messaging; both in-person and outreach follow-up; and AE management. Costs were estimated in 2018 U.S. dollars. The outcome of analysis was AE yield relative to the globally accepted safety standard of a 2% AE rate. We estimated the incremental cost per percentage increase in AE ascertainment and the incremental cost per additional AE identified. We conducted univariate and probabilistic sensitivity analyses.

Results

2wT increased the costs due to text messaging by $4.42 but reduced clinic visit costs by $2.92 and outreach costs by $3.61 –a net savings of $2.10. 2wT also increased AE ascertainment by 50% (92% AE yield in 2wT compared to 42% AE yield in SoC). Therefore, 2wT dominated SoC in the incremental analysis: 2wT was less costly and more effective. Results were generally robust to univariate and probabilistic sensitivity analysis.

Conclusions

2wT is cost-effective for post-VMMC follow-up in Zimbabwe. Countries in which VMMC is a high-priority HIV prevention intervention should consider this mHealth intervention to reduce overall cost per VMMC, increasing the likelihood of current and future VMMC program sustainability.

Impact of Educational Interventions on Acceptance and Uptake of Male Circumcision in the General Population of Western China: A Multicenter Cohort Study

To compare different intervention models for promoting male circumcision (MC) to prevent HIV transmission in Western China. A total of 1690 male participants from multiple study sites were cluster randomly allocated to three-stage (Model A), two-stage (Model B), and one-stage (Model C) educational interventions. In all three interventions models, knowledge about MC significantly increased and the reported willingness to accept MC increased to 52.6% (255/485), 67.0% (353/527), and 45.5% (219/481) after intervention, respectively (P < 0.05). Rate of MC surgery uptake was highest (23.7%; 115/485) among those who received Model A intervention, compared to those who received Model B (17.1%; 90/527) or Model C (9.4%; 45/481) interventions (P < 0.05). Multivariable Cox regression analysis identified that Model A or Model B had twice the effect of Model C on MC uptake, with relative risks of 2.4 (95%CI, 1.5-3.8) and 2.2 (95%CI, 1.3-3.6), respectively. Model B was the most effective model for improving participants' willingness to accept MC, while Model A was most successful at increasing uptake of MC surgery. Self-reported attitude towards MC uptake was not strongly correlated with actual behavior in this study focusing on the general male population in Western China.

Trends in the Marginal Cost of Male Circumcision in Rural Rakai Uganda

INTRODUCTION

Male circumcision (MC) is an effective intervention to reduce HIV acquisition in men in Africa. We conducted a cost analysis using longitudinal data on expenditures on services and community mobilization to estimate the marginal cost of MC over time and understand cost drivers during scale-up.

METHODS

We used a time series with monthly records from 2008 to 2013, for a total of 72 monthly observations, from the Rakai MC Program in Uganda. Generalized linear models were used to estimate the marginal cost of an MC procedure.

RESULTS

The marginal cost per MC in a mobile camp was $23 (P < 0.01) and in static facilities was $35 (P < 0.1). Major cost drivers included supplies in mobile camps with increasing numbers of surgeries, savings due to task shifting from physicians to clinical officers, and increased efficiency as personnel became more experienced.

CONCLUSIONS

As scale-up continues, marginal costs may increase because of mobilization needed for less motivated late adopters, but improved efficiency could contain costs.

Modeling and Cost-Effectiveness in HIV Prevention

With HIV funding plateauing and the number of people living with HIV increasing due to the rollout of life-saving antiretroviral therapy, policy makers are faced with increasingly tighter budgets to manage the ongoing HIV epidemic. Cost-effectiveness and modeling analyses can help determine which HIV interventions may be of best value. Incidence remains remarkably high in certain populations and countries, making prevention key to controlling the spread of HIV. This paper briefly reviews concepts in modeling and cost-effectiveness methodology and then examines results of recently published cost-effectiveness analyses on the following HIV prevention strategies: condoms and circumcision, behavioral- or community-based interventions, prevention of mother-to-child transmission, HIV testing, pre-exposure prophylaxis, and treatment as prevention. We find that the majority of published studies demonstrate cost-effectiveness; however, not all interventions are affordable. We urge continued research on combination strategies and methodologies that take into account willingness to pay and budgetary impact.

The Price of Prevention: Cost Effectiveness of Biomedical HIV Prevention Strategies in South Africa

BACKGROUND

South Africa has the highest global burden of human immunodefciency virus [HIV]. The study compared the cost-effectiveness of individual and combination HIV preventive strategies against the current rollout of ART and possible ART scale-up.

METHODS

Adolescents attending South African schools in 2012 were included in the semi-Markov running annual cycles. The ART and HIV counseling and testing program [comparator] was weighed against the interventions [viz. HIV vaccine, a dual vaccine strategy [HIV and HPV vaccines], oral pre-exposure prophylaxis [PrEP] and voluntary medical male circumcision [VMMC]; and various combinations thereof. Quality-adjusted life years [QALY] determined changes in HIV associated mortality and infections averted. One-way and probabilistic sensitivity analysis determined parameter uncertainty. Discount rates of 3% with a lifetime horizon [70 years] were applied.

RESULTS

Dual vaccination was highly cost-effective strategy [US$ 7 per QALY gained] and averted 29% of new HIV infections. VMMC [US$ 30 per QALY gained] proved more cost-effective than HIV vaccination alone [US$ 93 per QALY gained], though VMMC averted 6% more new infections than the HIV vaccine when considered among male participants. PrEP interventions were the least cost-effective with pharmaceutical and human resource spending driving the costs. Combined dual vaccination and VMMC strategies were a dominant intervention. Strategies involving PrEP were the least cost-effective.

CONCLUSION

VMMC, HIV vaccination and dual vaccination strategies were more cost-effective than any PrEP strategies. A multi-intervention biomedical approach could avert considerable new HIV infections and present a cost-effective use of resources; particularly where large scale multi-interventional randomized controlled trials are absent.

The Cost of Voluntary Medical Male Circumcision in South Africa

Given compelling evidence associating voluntary medical male circumcision (VMMC) with men's reduced HIV acquisition through heterosexual intercourse, South Africa in 2010 began scaling up VMMC. To project the resources needed to complete 4.3 million circumcisions between 2010 and 2016, we (1) estimated the unit cost to provide VMMC; (2) assessed cost drivers and cost variances across eight provinces and VMMC service delivery modes; and (3) evaluated the costs associated with mobilize and motivate men and boys to access VMMC services. Cost data were systematically collected and analyzed using a provider's perspective from 33 Government and PEPFAR-supported (U.S. President's Emergency Plan for AIDS Relief) urban, rural, and peri-urban VMMC facilities. The cost per circumcision performed in 2014 was US$132 (R1,431): higher in public hospitals (US$158 [R1,710]) than in health centers and clinics (US$121 [R1,309]). There was no substantial difference between the cost at fixed circumcision sites and fixed sites that also offer outreach services. Direct labor costs could be reduced by 17% with task shifting from doctors to professional nurses; this could have saved as much as $15 million (R163.20 million) in 2015, when the goal was 1.6 million circumcisions. About $14.2 million (R154 million) was spent on medical male circumcision demand creation in South Africa in 2014-primarily on personnel, including community mobilizers (36%), and on small and mass media promotions (35%). Calculating the unit cost of VMMC demand creation was daunting, because data on the denominator (number of people reached with demand creation messages or number of people seeking VMMC as a result of demand creation) were not available. Because there are no "dose-response" data on demand creation ($X in demand creation will result in an additional Z% increase in VMMC clients), research is needed to determine the appropriate amount and allocation of demand creation resources.

Non-therapeutic infant male circumcision. Evidence, ethics, and international law perspectives

OBJECTIVES

To review the evidence of the benefits and harms of infant male circumcision, and the legal and ethical perspectives of infant male circumcision.

METHODS

We conducted a systematic search of the literature using PubMed, EMBASE, and the Cochrane library up to June 2015. We searched the medical law literature using the Westlaw and Lexis Library law literature resources up to June 2015.

RESULTS

Male circumcision significantly reduced the risk of urinary tract infections by 87%. It also significantly reduced transmission of human immunodeficiency virus among circumcised men by 70%. Childhood and adolescent circumcision is associated with a 66% reduction in the risk of penile cancer. Circumcision was associated with 43% reduction of human papilloma virus infection, and 58% reduction in the risk of cervical cancer among women with circumcised partners compared with women with uncircumcised partners. Male infant circumcision reduced the risk of foreskin inflammation by 68%. 

CONCLUSION

Infant male circumcision should continue to be allowed all over the world, as long as it is approved by both parents, and performed in facilities that can provide appropriate sterilization, wound care, and anesthesia. Under these conditions, the benefits of infant male circumcision outweigh the rare and generally minor potential harms of the procedure.

The Spear and Shield intervention to increase the availability and acceptability of voluntary medical male circumcision in Zambia: a cluster randomised controlled trial

Background

Widespread voluntary medical male circumcision (VMMC) in Africa could avert an estimated 3·436 million HIV infections and 300,000 deaths over the next 10 years. Most Zambian men, however, have expressed little interest in undergoing VMMC. This study tested the effect of an intervention designed to increase demand for VMMC among these “hard to reach” men.

Methods

This cluster randomized controlled trial was conducted from 2012 to 2014 in Lusaka, Zambia (HIV prevalence = 20·8%). 13 Community Health Centers (CHCs) were stratified by HIV voluntary counseling and testing (VCT) rates and patient census and randomly assigned (5:5:3) to Experimental, Control or Observation Only conditions. CHC health care providers at all 13 sites received VMMC training. Trial statisticians did not participate in randomization. 800 uncircumcised HIV-, post-VCT men, 400 per condition, were recruited; female partners were invited to participate. The primary outcome was the likelihood of VMMC by 12 months post-intervention. The trial registration is NCT 01688167.

Findings

161 participants in the Experimental condition underwent VMMC as compared to 96 Control participants [adjusted odds ratio = 2·45, 95% CI = (1·24, 4·90) p = ·0166]. Post-VMMC condom use among Experimental condition participants increased compared to baseline, with no change among Control participants. No adverse events related to study participation were reported.

Interpretation

The Spear and Shield intervention combined with VMMC training was associated with a significant increase in the number of VMMCs performed as well as in condom use among “hard to reach” Zambian men. Results support the importance of comprehensive HIV prevention programs that increase supply of and demand for VMMC services.

Funding

NIH/NIMH R01MH095539.

Voluntary medical male circumcision in resource-constrained settings

Throughout East and Southern Africa, the WHO recommends voluntary medical male circumcision (VMMC) to reduce heterosexual HIV acquisition. Evidence has informed policy and the implementation of VMMC programmes in these countries. VMMC has been incorporated into the HIV prevention portfolio and more than 9 million VMMCs have been performed. Conventional surgical procedures consist of forceps-guided, dorsal slit or sleeve resection techniques. Devices are also becoming available that might help to accelerate the scale-up of adult VMMC. The ideal device should make VMMC easier, safer, faster, sutureless, inexpensive, less painful, require less infrastructure, be more acceptable to patients and should not require follow-up visits. Elastic collar compression devices cause vascular obstruction and necrosis of foreskin tissue and do not require sutures or injectable anaesthesia. Collar clamp devices compress the proximal part of the foreskin to reach haemostasis; the distal foreskin is removed, but the device remains and therefore no sutures are required. Newer techniques and designs, such as tissue adhesives and a circular cutter with stapled anastomosis, are improvements, but none of these methods have achieved all desirable characteristics. Further research, design and development are needed to address this gap to enable the expansion of the already successful VMMC programmes for HIV prevention.

Does Routine Pathology Analysis of Adult Circumcision Tissue Identify Penile Cancer?

OBJECTIVE

To assess the utility of foreskin pathology analysis, we evaluated the outcomes and the costs of this practice in patients for whom penile cancer was not suspected. Adult circumcision specimens are routinely sent for pathologic analysis even when penile cancer is not suspected, increasing costs with little benefit.

MATERIALS AND METHODS

All adult patients who underwent circumcision between January 2000 and August 2013 at a single institution were evaluated by retrospective chart review. Cases of suspected penile cancer (n = 6) were excluded. We identified cases where foreskin specimens were sent for pathologic analysis and reviewed pathology reports. Our Department of Pathology estimated the cost for evaluation of specimens at $311 per case.

RESULTS

A total of 147 circumcisions were performed in patients with no suspicious findings. Pathologic analysis was obtained in 69% (101 of 147) of the cases. Inflammation (58%) was the most common finding. One unsuspected instance of squamous cell carcinoma (Tis) was identified in a patient with human immunodeficiency virus (1 of 147 = 0.7%). The overall cost of pathologic analysis in this study was $31,411.

CONCLUSION

In individuals without predisposing immunodeficiency and where cancer was not suspected, we found that pathologic analysis of circumcision specimens identified no additional malignancies. Our data suggest that in this normal risk population, pathologic analysis may not be required. Additionally, forgoing pathology on foreskin specimens in lower risk cases may reduce costs to the health care system.

Circumcision as a primary HIV preventive: extrapolating from the available data

Billions of dollars to circumcise millions of African males as an HIV infection prevention have been sought, yet the effectiveness of circumcision has not been demonstrated. Data from 109 populations comparing HIV prevalence and incidence in men based on circumcision status were evaluated using meta-regression. The impact on the association between circumcision and HIV incidence/prevalence of the HIV risk profile of the population, the circumcision rates within the population and whether the population was in Africa were assessed. No significant difference in the risk of HIV infection based on the circumcision status was seen in general populations. Studies of high-risk populations and populations with a higher prevalence of male circumcision reported significantly greater odds ratios (odds of intact man having HIV) (p < .0001). When adjusted for the impact of a high-risk population and the circumcision rate of the population, the baseline odds ratio was 0.78 (95% CI = 0.56-1.09). No consistent association between presence of HIV infection and circumcision status of adult males in general populations was found. When adjusted for other factors, having a foreskin was not a significant risk factor. This undermines the justification for using circumcision as a primary preventive for HIV infection.

How do you circumcise a nation? The Rwandan case study

Voluntary medical male circumcision has been conclusively demonstrated to reduce the lifetime risk of male acquisition of HIV. The strategy has been adopted as a component of a comprehensive strategy towards achieving an AIDS-free generation. A number of countries in which prevalence of HIV is high and circumcision is low have been identified as a priority, where innovative approaches to scale-up are currently being explored. Rwanda, as one of the priority countries, has faced a number of challenges to successful scale-up. We discuss here how simplifications in the procedure, addressing a lack of healthcare infrastructure and mobilizing resources, and engaging communities of both men and women have permitted Rwanda to move forward with more optimism in its scale-up tactics. Examples from Rwanda are used to highlight how these barriers can and should be addressed.

[Actual controversies about circumcision]

INTRODUCTION

Circumcision, the oldest and most frequently performed surgery in the world, is the subject of controversies. The aim of this study was to conduct a general review of circumcision in the light of the ten questions most frequently raised in the medical community.

METHODS

Automated search of scientific articles published has been used by interviewing computer databases Medline and Embase from 1990 to 2013.

RESULTS

The results of three randomized controlled trials have provided information on preventive contributory role of this medical male circumcision. This intervention reduces the risk of acquiring HIV infection, HSV2 infection and the carrier prevalence of HPV. Male circumcision has proven to be effective in reducing the risks of penile cancer and cervical cancer in female partners of circumcised men, urinary tract infections in infants and children. Complications are rare.

CONCLUSION

The health benefits of circumcision balance the procedure's risks. Circumcision could be considered as a kind of "surgical vaccine", especially in developing countries to prevent the transmission of HIV infection.

Differential compartmentalization of HIV-targeting immune cells in inner and outer foreskin tissue

Ex vivo foreskin models have demonstrated that inner foreskin is more susceptible to HIV-1 infection than outer foreskin. In the present study we characterized the compartition of HIV-1 target cells and quantified these cells in the epidermis and dermis of inner and outer foreskins using immunohistochemistry and flow cytometry. Our data showed that the epidermis of the inner foreskin was more enriched with CD4⁺ T cells and Langerhans cells (LCs), with the co-expression of CCR5 and α4β7 receptors, than the outer foreskin. Interestingly, the vast majority of CD4⁺ T cells and LCs expressed CCR5, but not CXCR4, indicating that the inner foreskin might capture and transmit R5-tropic HIV strains more efficiently. In addition, lymphoid aggregates, composed of T cells, macrophages and dendritic cells (DCs) in the dermis, were closer to the epithelial surface in the inner foreskin than in the outer foreskin. As dendritic cells are able to capture and pass HIV particles to susceptible target cells, HIV may be able to more efficiently infect the inner foreskin by hijacking the augmented immune communication pathways in this tissue. After the inoculation of HIV-1 particles in a foreskin explant culture model, the level of p24 antigen in the supernatant from the inner foreskin was slightly higher than that from the outer foreskin, although this difference was not significant. The present study is the first to employ both CCR5 and α4β7 to identify HIV target cells in the foreskin. Our data demonstrated that the inner foreskin was more enriched with HIV target immune cells than the outer foreskin, and this tissue was structured for efficient communication among immune cells that may promote HIV transmission and replication. In addition, our data suggests the R5-tropism of HIV sexual transmission is likely shaped through the inherent receptor composition on HIV target cells in the mucosa.

Male circumcision: a globally relevant but under-utilized method for the prevention of HIV and other sexually transmitted infections

Randomized trials have demonstrated that male circumcision (MC) reduces heterosexual acquisition of HIV, herpes simplex virus type 2, human papillomavirus (HPV), and genital ulcer disease among men, and it reduces HPV, genital ulcer disease, bacterial vaginosis, and trichomoniasis among female partners. The pathophysiology behind these effects is multifactorial, relying on anatomic and cellular changes. MC is cost effective and potentially cost saving in both the United States and Africa. The World Health Organization and Joint United Nations Program on HIV/AIDS proposed reaching 80% MC coverage in HIV endemic countries, but current rates fall far behind targets. Barriers to scale-up include supply-side and demand-side challenges. In the United States, neonatal MC rates are decreasing, but the American Academy of Pediatrics now recognizes the medical benefits of MC and supports insurance coverage. Although MC is a globally valuable tool to prevent HIV and other sexually transmitted infections, it is underutilized. Further research is needed to address barriers to MC uptake.

Potential cost-effectiveness of schistosomiasis treatment for reducing HIV transmission in Africa--the case of Zimbabwean women

Background

Epidemiological data from Zimbabwe suggests that genital infection with Schistosoma haematobium may increase the risk of HIV infection in young women. Therefore, the treatment of Schistosoma haematobium with praziquantel could be a potential strategy for reducing HIV infection. Here we assess the potential cost-effectiveness of praziquantel as a novel intervention strategy against HIV infection.

Methods

We developed a mathematical model of female genital schistosomiasis (FGS) and HIV infections in Zimbabwe that we fitted to cross-sectional data of FGS and HIV prevalence of 1999. We validated our epidemic projections using antenatal clinic data on HIV prevalence. We simulated annual praziquantel administration to school-age children. We then used these model predictions to perform a cost-effectiveness analysis of annual administration of praziquantel as a potential measure to reduce the burden of HIV in sub-Saharan Africa.

Findings

We showed that for a variation of efficacy between 30–70% of mass praziquantel administration for reducing the enhanced risk of HIV transmission per sexual act due to FGS, annual administration of praziquantel to school-age children in Zimbabwe could result in net savings of US$16–101 million compared with no mass treatment of schistosomiasis over a ten-year period. For a variation in efficacy between 30–70% of mass praziquantel administration for reducing the acquisition of FGS, annual administration of praziquantel to school-age children could result in net savings of US$36−92 million over a ten-year period.

Conclusions

In addition to reducing schistosomiasis burden, mass praziquantel administration may be a highly cost-effective way of reducing HIV infections in sub-Saharan Africa. Program costs per case of HIV averted are similar to, and under some conditions much better than, other interventions that are currently implemented in Africa to reduce HIV transmission. As a cost-saving strategy, mass praziquantel administration should be prioritized over other less cost-effective public health interventions.

Evidence from epidemiological and clinical studies supports the hypothesis that genital infection with Schistosoma haematobium increases the risk of becoming infected with HIV among women in sub-Saharan Africa. Praziquantel is an oral, nontoxic, inexpensive medication recommended for treatment of schistosomiasis, which might be able to prevent the development of genital schistosomiasis. We constructed a mathematical model of female genital schistosomiasis and HIV infections, which we calibrated using epidemiological data from Zimbabwe. We used this model to investigate the potential cost-effectiveness of mass drug administration with praziquantel as an intervention strategy for reducing HIV transmission in sub-Saharan Africa. We showed that mass drug administration with praziquantel may be a timely, innovative, and cost-saving intervention strategy for HIV prevention in sub-Saharan Africa. As a cost-saving strategy, mass drug administration with praziquantel should be prioritized over other less cost-effective public health interventions. Our findings indicate the possible benefit of scaling up schistosomiasis control efforts in sub-Saharan Africa, and especially in areas were Schistosoma haematobium and HIV are highly prevalent.

Review: a critical evaluation of arguments opposing male circumcision for HIV prevention in developed countries

A potential impediment to evidence-based policy development on medical male circumcision (MC) for HIV prevention in all countries worldwide is the uncritical acceptance by some of arguments used by opponents of this procedure. Here we evaluate recent opinion-pieces of 13 individuals opposed to MC. We find that these statements misrepresent good studies, selectively cite references, some containing fallacious information, and draw erroneous conclusions. In marked contrast, the scientific evidence shows MC to be a simple, low-risk procedure with very little or no adverse long-term effect on sexual function, sensitivity, sensation during arousal or overall satisfaction. Unscientific arguments have been recently used to drive ballot measures aimed at banning MC of minors in the USA, eliminate insurance coverage for medical MC for low-income families, and threaten large fines and incarceration for health care providers. Medical MC is a preventative health measure akin to immunisation, given its protective effect against HIV infection, genital cancers and various other conditions. Protection afforded by neonatal MC against a diversity of common medical conditions starts in infancy with urinary tract infections and extends throughout life. Besides protection in adulthood against acquiring HIV, MC also reduces morbidity and mortality from multiple other sexually transmitted infections (STIs) and genital cancers in men and their female sexual partners. It is estimated that over their lifetime one-third of uncircumcised males will suffer at least one foreskin-related medical condition. The scientific evidence indicates that medical MC is safe and effective. Its favourable risk/benefit ratio and cost/benefit support the advantages of medical MC.

Safety of task-shifting for male medical circumcision: a systematic review and meta-analysis

INTRODUCTION

Task-shifting for male medical circumcision is proposed as a strategy to overcome the lack of surgeons and doctors in high HIV prevalence settings. We undertook a systematic review and meta-analysis to review the safety of task-shifting for circumcision in Africa.

METHODS

We searched online databases and conference websites up to July 2011 without language restriction for studies reporting outcomes of task-shifting for circumcision in Africa. Information was extracted independently and in duplicate on study characteristics, quality, and outcome data. Case reports and case series were excluded.

RESULTS

Ten studies met our inclusion criteria, providing outcome data on 25119 circumcisions. The proportion of adverse events ranged from 0.70 [95% confidence interval (CI) 0.44-1.02%] to 37.36% (95% CI 27.54-47.72%), with an overall pooled proportion of 2.31% (95% CI 1.46-3.16%; τ  = 1.21; P < 0.001). Two studies reported outcomes separately for both doctors and non-physicians; there was no difference in the risk of adverse events by provider (pooled relative risk 1.18; 95% CI 0.78-1.78). The frequency of excessive bleeding ranged from 0.30 (0.09-0.65%) to 24.71% (16.27-34.26%) with an overall pooled prevalence of 0.55% (95% CI 0.13-0.97%). Infection occurred in 0.30 (0.14-1.47%) to 1.85% (0.07-5.96%) of cases, with an overall pooled proportion of 0.88% (95% CI 0.29-1.47%). All adverse events were reported to be non-severe.

CONCLUSION

Task-shifting of male medical circumcision to non-physician clinicians can be done safely, with reported rates of adverse events similar to doctors and specialists.

A 'snip' in time: what is the best age to circumcise?

BACKGROUND

Circumcision is a common procedure, but regional and societal attitudes differ on whether there is a need for a male to be circumcised and, if so, at what age. This is an important issue for many parents, but also pediatricians, other doctors, policy makers, public health authorities, medical bodies, and males themselves.

DISCUSSION

We show here that infancy is an optimal time for clinical circumcision because an infant's low mobility facilitates the use of local anesthesia, sutures are not required, healing is quick, cosmetic outcome is usually excellent, costs are minimal, and complications are uncommon. The benefits of infant circumcision include prevention of urinary tract infections (a cause of renal scarring), reduction in risk of inflammatory foreskin conditions such as balanoposthitis, foreskin injuries, phimosis and paraphimosis. When the boy later becomes sexually active he has substantial protection against risk of HIV and other viral sexually transmitted infections such as genital herpes and oncogenic human papillomavirus, as well as penile cancer. The risk of cervical cancer in his female partner(s) is also reduced. Circumcision in adolescence or adulthood may evoke a fear of pain, penile damage or reduced sexual pleasure, even though unfounded. Time off work or school will be needed, cost is much greater, as are risks of complications, healing is slower, and stitches or tissue glue must be used.

SUMMARY

Infant circumcision is safe, simple, convenient and cost-effective. The available evidence strongly supports infancy as the optimal time for circumcision.

Voluntary medical male circumcision: a qualitative study exploring the challenges of costing demand creation in eastern and southern Africa

Background

This paper proposes an approach to estimating the costs of demand creation for voluntary medical male circumcision (VMMC) scale-up in 13 countries of eastern and southern Africa. It addresses two key questions: (1) what are the elements of a standardized package for demand creation? And (2) what challenges exist and must be taken into account in estimating the costs of demand creation?

Methods and Findings

We conducted a key informant study on VMMC demand creation using purposive sampling to recruit seven people who provide technical assistance to government programs and manage budgets for VMMC demand creation. Key informants provided their views on the important elements of VMMC demand creation and the most effective funding allocations across different types of communication approaches (e.g., mass media, small media, outreach/mobilization). The key finding was the wide range of views, suggesting that a standard package of core demand creation elements would not be universally applicable. This underscored the importance of tailoring demand creation strategies and estimates to specific country contexts before estimating costs. The key informant interviews, supplemented by the researchers' field experience, identified these issues to be addressed in future costing exercises: variations in the cost of VMMC demand creation activities by country and program, decisions about the quality and comprehensiveness of programming, and lack of data on critical elements needed to “trigger the decision” among eligible men.

Conclusions

Based on this study's findings, we propose a seven-step methodological approach to estimate the cost of VMMC scale-up in a priority country, based on our key assumptions. However, further work is needed to better understand core components of a demand creation package and how to cost them. Notwithstanding the methodological challenges, estimating the cost of demand creation remains an essential element in deriving estimates of the total costs for VMMC scale-up in eastern and southern Africa.

Male circumcision for HIV prevention: current evidence and implementation in sub-Saharan Africa

Heterosexual exposure accounts for most HIV transmission in sub-Saharan Africa, and this mode, as a proportion of new infections, is escalating globally. The scientific evidence accumulated over more than 20 years shows that among the strategies advocated during this period for HIV prevention, male circumcision is one of, if not, the most efficacious epidemiologically, as well as cost-wise. Despite this, and recommendation of the procedure by global policy makers, national implementation has been slow. Additionally, some are not convinced of the protective effect of male circumcision and there are also reports, unsupported by evidence, that non-sex-related drivers play a major role in HIV transmission in sub-Saharan Africa. Here, we provide a critical evaluation of the state of the current evidence for male circumcision in reducing HIV infection in light of established transmission drivers, provide an update on programmes now in place in this region, and explain why policies based on established scientific evidence should be prioritized. We conclude that the evidence supports the need to accelerate the implementation of medical male circumcision programmes for HIV prevention in generalized heterosexual epidemics, as well as in countering the growing heterosexual transmission in countries where HIV prevalence is presently low.

The potential impact of RV144-like vaccines in rural South Africa: a study using the STDSIM microsimulation model

BACKGROUND

The only successful HIV vaccine trial to date is the RV144 trial of the ALVAC/AIDSVAX vaccine in Thailand, which showed an overall incidence reduction of 31%. Most cases were prevented in the first year, suggesting a rapidly waning efficacy. Here, we predict the population level impact and cost-effectiveness of practical implementation of such a vaccine in a setting of a generalised epidemic with high HIV prevalence and incidence.

METHODS

We used STDSIM, an established individual-based microsimulation model, tailored to a rural South African area with a well-functioning HIV treatment and care programme. We estimated the impact of a single round of mass vaccination for everybody aged 15-49, as well as 5-year and 2-year re-vaccination strategies for young adults (aged 15-29). We calculated proportion of new infections prevented, cost-effectiveness indicators, and budget impact estimates of combined ART and vaccination programmes.

RESULTS

A single round of mass vaccination with a RV144-like vaccine will have a limited impact, preventing only 9% or 5% of new infections after 10 years at 60% and 30% coverage levels, respectively. Revaccination strategies are highly cost-effective if vaccine prices can be kept below 150 US$/vaccine for 2-year revaccination strategies, and below 200 US$/vaccine for 5-year revaccination strategies. Net cost-savings through reduced need for HIV treatment and care occur when vaccine prices are kept below 75 US$/vaccine. These results are sensitive to alternative assumptions on the underlying sexual network, background prevention interventions, and individual's propensity and consistency to participate in the vaccination campaign.

DISCUSSION

A modestly effective vaccine can be a cost-effective intervention in highly endemic settings. To predict the impact of vaccination strategies in other endemic situations, sufficient knowledge of the underlying sexual network, prevention and treatment interventions, and individual propensity and consistency to participate, is key. These issues are all best addressed in an individual-based microsimulation model.

The cost-utility analysis of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a probabilistic decision model

OBJECTIVE

The aim of this study was to assess the cost-utility of adult male circumcision (AMC) versus no AMC in the prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa.

METHODS

A decision tree was constructed and parameterized using data from published sources. The economic evaluation was conducted from the perspective of government health care payer. Benefits (disability adjusted life years [DALYs]) and costs were discounted at 3%. Costs were assessed in 2008 US dollars. One-way and probabilistic sensitivity analyses were conducted to assess the stability of the base-case results. The uncertainty surrounding the estimates of cost effectiveness was illustrated through a cost-effectiveness acceptability curve and cost-effectiveness plane.

RESULTS

In the base-case analysis, AMC can be regarded as cost saving because it is associated with higher DALYs gained and lower costs than no AMC. The probability that AMC is cost effective is above 0.96 at a threshold value of $150 and remains high over a wide range of threshold values. Thus, there is very little uncertainty surrounding the decision to adopt AMC for prevention of heterosexual acquisition of HIV in men. The results were found to be sensitive to varying any of the following parameters: DALYs averted, discount, and circumcision efficacy.

CONCLUSIONS

AMC is found to be cost saving. AMC may be seen as a promising new form of strategy for prevention of heterosexual acquisition of HIV in men, but should never replace other known methods of HIV prevention and should always be considered as part of a comprehensive HIV prevention package.

Communicable Diseases: Achievements and Challenges for Public Health

The past two centuries have seen enormous achievements in control of infectious diseases, previously the leading cause of death, in large measure due to sanitation and food safety, vaccines, antibiotics and improved nutrition. This has led people to put their faith in the notion that medical science would succeed in overcoming the remaining obstacles. Vaccination has eradicated smallpox, nearly eradicated poliomyelitis and greatly reduced many other highly dangerous infections such as diphtheria, tetanus and measles. New diseases such as HIV and new forms of influenza have taken both professional and popular opinion by surprise and have renewed the challenges before the world public health community. Emergence of antibiotic-resistant strains of common organisms due to overuse of antibiotics and lack of vaccines for many dangerous microorganisms poses problems to humanity. This stresses the need for new vaccines, effective antibiotics and strengthened environmental control measures. New knowledge of the microbiological origins of cancers such as that of the cervix, stomach and liver have strengthened primary prevention and brought hope that new cures will be found for other chronic diseases of infectious origin. Tragically long delays in adopting "new" and cost effective vaccines cause hundreds of thousands of preventable deaths each year in developing and mid-level developed countries. Gains are being made in control of many tropical diseases, but malaria, tuberculosis and other infectious diseases remain enormous global problems. Research and acquisition of new knowledge, risk communication, application of currently available means and fair distribution will be great challenges to public health in the coming decades.