1. 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 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% % %
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: /journal. pmed 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, p
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 (March27, 2004): 1039.
8.UNAIDS. AIDS epidemic update : December 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% % % % or no data
10-20% % %
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 $
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) $ $
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