SAN DIEGO: Universal circumcision not cost-effective

Ob.Gyn.News
June 14, 2012

Mandatory Circumcision Not Cost Effective for HIV Prevention

By Sherry Boschert, Ob.Gyn. News Digital Network
SAN DIEGO – Mandating circumcision in the United States would prevent 24 more cases of HIV than does the traditional optional approach to circumcision, but would increase costs by approximately $389 million, making it far less cost effective, an analysis of published data suggests.

The investigators assumed that the overall incidence of HIV in the United States is 27 cases/100,000 people and the lifetime cost of care for someone with HIV is $119,000, based on published data from government statistics and peer-reviewed studies. Using the $392 cost of a circumcision at their institution, they developed computer-generated estimates of the cost-effectiveness of mandatory or traditional circumcision strategies for various populations, said Dr. Sarah E. Drennan, a third-year resident in ob.gyn. at Ochsner Medical Center, New Orleans. [They also assumed that the reduction of heterosexually-transmitted HIV apparently found in three studies in Africa was applicable to the USA.]
 
For the overall U.S. population, mandatory circumcision would prevent 494 cases of HIV at a cost of approximately $790 million. Traditional circumcision – in which the parents choose whether or not to circumcise a newborn – would prevent 470 cases of HIV at a cost of approximately $401 million, she reported at the annual meeting of the American College of Obstetricians and Gynecologists.
[Only a handful of fanatics have ever suggested mandatory circumcision, and it is irrelevant to the study how 100% circumcision is achieved. It would be sufficient for their purposes to refer to "universal" circumcision. It would be illuminating for them to have considered no circumcision, since the rate of "traditional" circumcision is falling.]

The idea of mandatory circumcision policies in the United States has come up because of randomized, controlled trials in Africa showing that male circumcision reduces the risk of female-to-male transmission of HIV by 50%-60%, Dr. Drennan said.

She and coinvestigator Dr. Rajiv Gala, also of the Ochsner Medical Center, conducted the current analysis to account for key differences between the two geographical regions. HIV is spread mainly through heterosexual contact in Africa and by intravenous drug use or men having sex with men in the United States. The prevalence of HIV is 5% in sub-Saharan Africa and 0.6% in North America.

The study also compared the two strategies in the United States among African American and Hispanic populations, who have lower rates of circumcision and a higher prevalence of HIV, compared with the population as a whole. Traditional circumcision was the more cost-effective strategy in those subgroups too, although not as strongly as in the population as a whole, she said.

For African Americans, mandatory circumcision would prevent 1,878 cases of HIV at a cost of approximately $816 million. Traditional circumcision would prevent 1,807 cases of HIV at a cost of approximately $613 million.

For Hispanics, mandatory circumcision would prevent 472 cases of HIV at a cost of approximately $792 million. Traditional circumcision would prevent 435 cases of HIV at a cost of approximately $342 million.

"Given the U.S. incidence of HIV, recommendations for mandatory circumcision are not supported" and require more U.S. studies on the role of circumcision in HIV prevention, Dr. Drennan said.

Circumcision would have to cost a mere $2.90 for the two strategies to be equally cost effective in tmillion/case for the two circumcision strategies to be equally cost effective in the general population.

The topic has generated controversy in recent years as the Centers for Disease Control and Prevention was said to be considering recommendations promoting routine circumcision for HIV prevention. The CDC still is considering what might be recommended, but any recommendations will be voluntary in nature, according to the CDC website.

The analysis was limited by a lack of data from randomized clinical trials and by the subjective nature of measuring behavioral risk, she said. The study also did not consider adverse events associated with circumcision or other health benefits other than prevention of HIV.