Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges

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Abstract

Purpose of Review

Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations.

Recent Findings

Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines.

Summary

Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.

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Most cited references 96

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Country-Level Cost-Effectiveness Thresholds: Initial Estimates and the Need for Further Research

Beth Woods, Paul Revill, Mark Sculpher … (2016)

Background Cost-effectiveness analysis can guide policymakers in resource allocation decisions. It assesses whether the health gains offered by an intervention are large enough relative to any additional costs to warrant adoption. When there are constraints on the health care system’s budget or ability to increase expenditures, additional costs imposed by interventions have an “opportunity cost” in terms of the health foregone because other interventions cannot be provided. Cost-effectiveness thresholds (CETs) are typically used to assess whether an intervention is worthwhile and should reflect health opportunity cost. Nevertheless, CETs used by some decision makers—such as the World Health Organization that suggested CETs of 1 to 3 times the gross domestic product (GDP) per capita—do not. Objectives To estimate CETs based on opportunity cost for a wide range of countries. Methods We estimated CETs based on recent empirical estimates of opportunity cost (from the English National Health Service), estimates of the relationship between country GDP per capita and the value of a statistical life, and a series of explicit assumptions. Results CETs for Malawi (the country with the lowest income in the world), Cambodia (with borderline low/low-middle income), El Salvador (with borderline low-middle/upper-middle income), and Kazakhstan (with borderline high-middle/high income) were estimated to be $3 to $116 (1%–51% GDP per capita), $44 to $518 (4%–51%), $422 to $1967 (11%–51%), and $4485 to $8018 (32%–59%), respectively. Conclusions To date, opportunity-cost-based CETs for low-/middle-income countries have not been available. Although uncertainty exists in the underlying assumptions, these estimates can provide a useful input to inform resource allocation decisions and suggest that routinely used CETs have been too high.

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Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial.

Robert Bailey, Stephen Moses, Corette B Parker … (2007)

Male circumcision could provide substantial protection against acquisition of HIV-1 infection. Our aim was to determine whether male circumcision had a protective effect against HIV infection, and to assess safety and changes in sexual behaviour related to this intervention. We did a randomised controlled trial of 2784 men aged 18-24 years in Kisumu, Kenya. Men were randomly assigned to an intervention group (circumcision; n=1391) or a control group (delayed circumcision, 1393), and assessed by HIV testing, medical examinations, and behavioural interviews during follow-ups at 1, 3, 6, 12, 18, and 24 months. HIV seroincidence was estimated in an intention-to-treat analysis. This trial is registered with ClinicalTrials.gov, with the number NCT00059371. The trial was stopped early on December 12, 2006, after a third interim analysis reviewed by the data and safety monitoring board. The median length of follow-up was 24 months. Follow-up for HIV status was incomplete for 240 (8.6%) participants. 22 men in the intervention group and 47 in the control group had tested positive for HIV when the study was stopped. The 2-year HIV incidence was 2.1% (95% CI 1.2-3.0) in the circumcision group and 4.2% (3.0-5.4) in the control group (p=0.0065); the relative risk of HIV infection in circumcised men was 0.47 (0.28-0.78), which corresponds to a reduction in the risk of acquiring an HIV infection of 53% (22-72). Adjusting for non-adherence to treatment and excluding four men found to be seropositive at enrollment, the protective effect of circumcision was 60% (32-77). Adverse events related to the intervention (21 events in 1.5% of those circumcised) resolved quickly. No behavioural risk compensation after circumcision was observed. Male circumcision significantly reduces the risk of HIV acquisition in young men in Africa. Where appropriate, voluntary, safe, and affordable circumcision services should be integrated with other HIV preventive interventions and provided as expeditiously as possible.

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Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial.

Ronald Gray, Godfrey Kigozi, David Serwadda … (2007)

Ecological and observational studies suggest that male circumcision reduces the risk of HIV acquisition in men. Our aim was to investigate the effect of male circumcision on HIV incidence in men. 4996 uncircumcised, HIV-negative men aged 15-49 years who agreed to HIV testing and counselling were enrolled in this randomised trial in rural Rakai district, Uganda. Men were randomly assigned to receive immediate circumcision (n=2474) or circumcision delayed for 24 months (2522). HIV testing, physical examination, and interviews were repeated at 6, 12, and 24 month follow-up visits. The primary outcome was HIV incidence. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, with the number NCT00425984. Baseline characteristics of the men in the intervention and control groups were much the same at enrollment. Retention rates were much the same in the two groups, with 90-92% of participants retained at all time points. In the modified intention-to-treat analysis, HIV incidence over 24 months was 0.66 cases per 100 person-years in the intervention group and 1.33 cases per 100 person-years in the control group (estimated efficacy of intervention 51%, 95% CI 16-72; p=0.006). The as-treated efficacy was 55% (95% CI 22-75; p=0.002); efficacy from the Kaplan-Meier time-to-HIV-detection as-treated analysis was 60% (30-77; p=0.003). HIV incidence was lower in the intervention group than it was in the control group in all sociodemographic, behavioural, and sexually transmitted disease symptom subgroups. Moderate or severe adverse events occurred in 84 (3.6%) circumcisions; all resolved with treatment. Behaviours were much the same in both groups during follow-up. Male circumcision reduced HIV incidence in men without behavioural disinhibition. Circumcision can be recommended for HIV prevention in men.

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Author and article information

Contributors

Anna Bershteyn:

ORCID: http://orcid.org/0000-0002-6604-7093

Anna.Bershteyn@nyulangone.org

Journal

Journal ID (nlm-ta): Curr HIV/AIDS Rep

Journal ID (iso-abbrev): Curr HIV/AIDS Rep

Title: Current HIV/AIDS Reports

Publisher: Springer US (New York )

ISSN (Print): 1548-3568

ISSN (Electronic): 1548-3576

Publication date (Electronic): 2 December 2022

Publication date PMC-release: 2 December 2022

Publication date (Print): 2022

Volume: 19

Issue: 6

Pages: 526-536

Affiliations

[1 ]GRID grid.137628.9, ISNI 0000 0004 1936 8753, Department of Population Health, , New York University Grossman School of Medicine, ; 227 East 30th Street, New York, NY 10016 USA

[2 ]GRID grid.412801.e, ISNI 0000 0004 0610 3238, Department of Decision Sciences, College of Economic and Management Sciences, , University of South Africa, ; Pretoria, Gauteng South Africa

[3 ]GRID grid.442494.b, ISNI 0000 0000 9430 1509, Strathmore Institute of Mathematical Sciences, , Strathmore University, ; Nairobi, Kenya

[4 ]GRID grid.508239.5, ISNI 0000 0004 9156 7263, Zambia Field Epidemiology Training Program, Workforce Development Cluster, , Zambia National Public Health Institute, ; Lusaka, Zambia

[5 ]GRID grid.415794.a, ISNI 0000 0004 0648 4296, Directorate of Public Health and Research, , Ministry of Health, ; Lusaka, Zambia

[6 ]GRID grid.475068.8, ISNI 0000 0004 8349 9627, Avenir Health, ; Takoma Park, MD USA

Author information

Anna Bershteyn http://orcid.org/0000-0002-6604-7093

Article

Publisher ID: 639

DOI: 10.1007/s11904-022-00639-5

PMC ID: 9759505

PubMed ID: 36459306

SO-VID: d790361d-fdad-4ba3-becd-0bab7d46e25b

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

History

Date accepted : 16 August 2022

Custom metadata

ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: male circumcision,hiv prevention,sexually transmitted infections,mathematical modeling,cost-effectiveness,sub-saharan africa

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ScienceOpen disciplines: Infectious disease & Microbiology

Keywords: male circumcision, hiv prevention, sexually transmitted infections, mathematical modeling, cost-effectiveness, sub-saharan africa

Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges

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Abstract

Purpose of Review

Recent Findings

Summary

Related collections

Point-Of-Care Testing for STIs

Most cited references 96

Country-Level Cost-Effectiveness Thresholds: Initial Estimates and the Need for Further Research

Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial.

Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial.

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