Cost effectiveness of male circumcision for the prevention of HIV at high prevalence STD clinics in Andhra Pradesh, India Elizabeth Glaser, MSc, ACRN Doctoral student, Global Health and Development Heller School for Social Policy and Management, Brandeis University Waltham, Massachusetts, 02254 Background: Recent clinical trials in sub-Saharan Africa have established that adult male circumcision (MC) is protective and cost-effective against male acquisition of HIV through heterosexual intercourse. Few studies have examined the cost effectiveness of MC in countries beyond the continent of Africa. We adapt Kahn's model (2006) to analyze the potential effectiveness of MC in a high prevalence population in Andhra Pradesh, India. Results We have tried to evaluate the cost-effectiveness of male circumcision in 1000 men as against lifetime cost of HIV disease in a high prevalence area. We estimated costs for 1000 men for circumcision, adverse events, and an incentive program for clients, and estimates for lifetime HIV treatment for Indian men. Although the basic model from India ($191,208.93) is less cost effective than that described in the subSaharan model ($2,411,427.00), the cost inputs are based upon actual inputs from government clinics as opposed to the costs in Kahn’s model which were derived from estimates in the Orange Farm study. Table 3. Program cost, HIV Infections Averted, and cost-effectiveness of male circumcision per 1000 procedures. Table with comparison of original inputs using Kahn’s , et al. (2006) model for subSaharan Africa vs the model for high prevalence STD clinics in Andhra Pradesh, India. Methods The methods used are largely drawn from the first controlled study on the cost effectiveness of male circumcision by Kahn et al. in 2006. While Kahn et al. established base values in accordance with the results of a randomized clinical trial of male circumcision for HIV prevention in Orange Farm, South Africa, in this study we rely on reported and adjusted figures as described below. Table 2. Model inputs, adapted from Kahn ,with original inputs from India Chart 2. Cost per discounted HIV infections averted , sensitivity analysis. Results obtained by varying input of epidemic multiplier from 1 to 2 for national, state and focused data Table 5. Results by cost and type of facility Facility site type low estimate government facility middle estimate government facility high estimate government facility low estimate private facility middle estimate private facility high estimate private facility cost per procedure $24.49 $34.25 $54.72 $122.47 $219.70 $306.19 cost of 1000 Male Circumcision $29,490.00 $39,250.00 $54,720.00 $127,470.00 $224,698.30 $311,190.00 $/DALY (exclusive of savings) $8.93 $11.87 $16.52 $38.41 $67.67 $93.69 discounted HIA 202.65 undiscounted HIA 366.00 cost per HIA (unadjusted) $80.57 $107.24 $149.51 $348.28 $613.93 $850.25 net cost, adjusted for 1000 MC (savings) ($191,208.93) ($181,448.93) ($165,978.93) ($93,228.93) $3,999.37 $181,276.17 Indian HIV Prevalence estimates by state (2007) Although the general population HIV prevalence for India is low at 0.34%, the value represents approximately 2.5 million people. Prevalence varies widely by state and by risk group with some of the highest HiV prevalence rates among those attending clinics which provide treatment for sexually transmitted diseases (STD). In India, HIV prevalence rates for STD clinics are equivalent to those of sub-Saharan Africa, with rates of > 2% in 11 states of which 5 states have prevalence rates >5%. In 2007, Andhra Pradesh, one of most populous states in India has a general population prevalence of 1.05% and an STD clinic prevalence of 24.4% . Table 1. HIV Prevalence in general population and STD clinic subgroups for all India and states, 2007 Input category Input Sources India Costs Cost per male circumcision Cost of procedure in government and private clinics. Indian Government estimates   Number of male circumcisions performed assumption cost of incentive Assume 5$US/person  Cost per 1,000 male circumcisions calculated Frequency of short-term adverse events (outpatient) OF trial, Kahn Cost per short-term mild adverse event (outpatient) OF trial, Kahn, ICP tables Frequency of short-term adverse events (inpatient) OF trial Cost per short-term mild adverse event (inpatient) Frequency of long-term adverse events Cost per long-term adverse event Lifetime medical care cost of HIV/AIDS Assume 98% no ART, 2% ART Effectiveness Proportion HIV-uninfected (STD clinic, AP, India) NACO, India HIV incidence rate I=(P/1-P))/D (assume D=10) Calculated with NACO data Protective effect OF trial, range .27-.77 Kahn Risk compensation impact on protective effect (relative) Kahn Years Assumption, Kahn Multiplier due to epidemic effects Kahn, Monte Carlo simulation Map 1. India 2007:HIV Prevalence in the general population by state. 1-1.9% 0.1-0.9% 0-.09% Conclusions: For those attending an STD clinic in Andhra Pradesh: Assuming effectiveness of 60% for male circumcision An STD clinic prevalence of 24.4% Procedural costs in government clinics Estimated 202 (discounted) HIV infections over 20 years. For 1000 procedures: Cost per discounted HIA ranged from $80.57-$850.25 Net savings ranged from $191,208-$93,228.93 Therefore Male circumcision can be cost effective in high prevalence group Cost effective if the procedure is performed in government clinics In general, MC is not cost effective in private facilities While male circumcision may not be cost effective for all populations at risk for HIV, the result of this analysis demonstrates that it may provide a relatively safe, reliable, cost-effective method for reducing acquisition of HIV in a high-prevalence population in a middle income country such as India. References 1.Chandiok N, Nabi E, Sharma A, (2008) personal correspondence. 2.Chandiok N, Gangakhedkar RR. (2007) The New Evidence on Male Circumcision: An Indian Perspective. Reproductive Health Matters 2007;15(29)53 – 55. 3.Freedberg KA; Kumarasamy, N, et al.(2007) Clinical impact and cost-effectiveness of antiretroviral therapy in India: starting criteria and second-line therapy. AIDS. 21 Suppl 4:S117-S128, July 2007. 4.Kahn JG, Marseille E, Auvert B (2006) Cost-effectiveness of male circumcision for HIV preventionin a South African setting. PLoS Med 3(12): e517. doi:10.1371/journal. pmed.0030517. pg 1 – 4. 5.Kumarasamy N. (2005) Can we reduce morbidity & mortality due to HIV & stop transmission in India? Indian J Med Res 122, December 2005, p461-463. 6.National AIDS Control Organisation (NACO), India (2008) Note on HIV Sentinel Surveillance and HIV Estimation_01 Feb 08. 7.Reynolds SJ, Shepherd SE, et al., (2004) Male circumcision and risk of HIV-1 and other sexually transmitted infections in India. The Lancet. 363.9414 (March27, 2004): 1039. 8.UNAIDS. AIDS epidemic update : December 2007. Joint United Nations Programme on HIV/AIDS(UNAIDS) and World Health Organization (WHO) 2007. Acknowledgements Many thanks to: George Eluwa for his assistance with the literature review and set up for the initial study Donald Shepard, AK Nandakumar, Laurence Simon, Joan Kaufman and Jennifer Perloff for their comments, suggestions and continued encouragement. Elizabeth Rivera and Jodi Sperber for their friendship and encouragement. Peter, Christopher and Madeline Desnoyers for their patience, love and support. Chart 3. National , regional and focused analysis by HIV prevalence. Sensitivity analysis of cost per HIV infections averted, data derived from varying input on cost per procedure by national, state and risk group HIV prevalence. State HIV Prevalence 2007 STD clinics Overall All INDIA 3.74 0.36 Andhra Pradesh 24.4 1.05 Maharashtra 10 0.74 Goa 8.6 0.73 Tamil Nadu 8 0.39 Karnataka 7.57 0.81 Manipur 4.8 1.67 Pondicherry 4.03 0.55 Gujarat 3.31 0.43 Mizoram 3.07 Orissa 2.8 0.22 Chhattisgarh 2.58 0.17 Delhi 2 0.27 HIV STD Clinic Prevalence <2 % Chandigarh 0.34 Rajasthan Kerala 0.13 Meghalaya 0.06 West Bengal 0.3 HIV STD Clinic Prevalence <1 % Haryana 0.1 Andaman & Nicobar Islands 0.37 Uttar Pradesh 0.11 Himachal Pradesh 0.03 Assam Madhya Pradesh Tripura 0.12 Arunachal Pradesh 0.05 Bihar 0.16 Jharkhand Punjab HIV STD Clinic Prevalence <0.1% Jammu & Kashmir 0.04 Lakshadweep  0 Nagaland 1.26 Sikkim 0.08 Uttaranchal HIV STD clinic no data Dadra Nagar Haveli Daman & Diu Map 2. India 2007: HIV Prevalence in STD clinics by state >20% 5-10% 1-1.9% 0% or no data 10-20% 2-4.9% 0.1-0.9% Chart 4. Cost effectiveness by lifetime cost of HIV Sensitivity analysis of cost effectiveness by lifetime cost of HIV, data derived from varying input on cost per procedure and lifetime cost of HIV treatment in India, 2007. Category Element Value Program costs Cost of male circumcision $ 54,724.00 $ 29,490.00 Cost of adverse events $ 1,030.00 $ 184.47 Total cost $ 55,754.00 $ 29,674.00 HIV infections averted (HIA) Undiscounted HIA 426.70 360.00 Discounted HIA 308.40 199.32 Cost-effectiveness Cost per HIA (unadjusted for averted medical care costs) $ 181.00 $ 80.57 Net cost, adjusted for averted medical care costs, for 1000 male circumcisions ($2,411,427.00) ($191,208.93) Chart 1. HIV prevalence in general population and STD clinics for 11 states in India, 2007