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Mendeley | Further Information

{"title"=>"Cost-effectiveness of male circumcision for HIV prevention in a South African setting", "type"=>"journal", "authors"=>[{"first_name"=>"James G.", "last_name"=>"Kahn", "scopus_author_id"=>"35404032000"}, {"first_name"=>"Elliot", "last_name"=>"Marseille", "scopus_author_id"=>"6603138445"}, {"first_name"=>"Bertran", "last_name"=>"Auvert", "scopus_author_id"=>"7004943317"}], "year"=>2006, "source"=>"PLoS Medicine", "identifiers"=>{"issn"=>"15491277", "scopus"=>"2-s2.0-33845875438", "sgr"=>"33845875438", "pui"=>"46026452", "isbn"=>"1549-1676 (Electronic)", "pmid"=>"17194197", "doi"=>"10.1371/journal.pmed.0030517"}, "id"=>"b5f06b48-db97-3f99-92e4-98470d1bf85a", "abstract"=>"BACKGROUND: Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa. METHODS AND FINDINGS: Cost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year. For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189-428) infections over 20 years. The cost is 181 dollars (80% CI 117-306 dollars) per HIA, and net savings are 2.4 million dollars (80% CI 1.3 million to 3.6 million dollars). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is 551 dollars (80% CI 344-1,071 dollars) and net savings are 753,000 (80% CI 0.3 million to 1.2 million dollars). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage. CONCLUSIONS: In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.", "link"=>"http://www.mendeley.com/research/costeffectiveness-male-circumcision-hiv-prevention-south-african-setting", "reader_count"=>79, "reader_count_by_academic_status"=>{"Professor > Associate Professor"=>1, "Librarian"=>1, "Student > Doctoral Student"=>1, "Researcher"=>18, "Student > Ph. D. Student"=>13, "Student > Postgraduate"=>2, "Student > Master"=>31, "Other"=>3, "Student > Bachelor"=>5, "Lecturer"=>2, "Lecturer > Senior Lecturer"=>2}, "reader_count_by_user_role"=>{"Professor > Associate Professor"=>1, "Librarian"=>1, "Student > Doctoral Student"=>1, "Researcher"=>18, "Student > Ph. D. Student"=>13, "Student > Postgraduate"=>2, "Student > Master"=>31, "Other"=>3, "Student > Bachelor"=>5, "Lecturer"=>2, "Lecturer > Senior Lecturer"=>2}, "reader_count_by_subject_area"=>{"Unspecified"=>2, "Agricultural and Biological Sciences"=>4, "Philosophy"=>1, "Business, Management and Accounting"=>4, "Computer Science"=>1, "Decision Sciences"=>1, "Economics, Econometrics and Finance"=>13, "Engineering"=>2, "Nursing and Health Professions"=>2, "Biochemistry, Genetics and Molecular Biology"=>1, "Mathematics"=>1, "Medicine and Dentistry"=>34, "Sports and Recreations"=>1, "Psychology"=>4, "Social Sciences"=>8}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>34}, "Social Sciences"=>{"Social Sciences"=>8}, "Decision Sciences"=>{"Decision Sciences"=>1}, "Sports and Recreations"=>{"Sports and Recreations"=>1}, "Psychology"=>{"Psychology"=>4}, "Mathematics"=>{"Mathematics"=>1}, "Unspecified"=>{"Unspecified"=>2}, "Engineering"=>{"Engineering"=>2}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>13}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>4}, "Computer Science"=>{"Computer Science"=>1}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>4}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>2}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>1}, "Philosophy"=>{"Philosophy"=>1}}, "reader_count_by_country"=>{"Canada"=>1, "United States"=>5, "Tanzania"=>1, "Uganda"=>1, "South Africa"=>1, "Spain"=>1}, "group_count"=>3}

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• {"type"=>"COMMENT", "annotationUri"=>"info:doi/10.1371/annotation/74d49530-3dc0-4c09-aa54-034c4d8f66f5", "title"=>"Failure to Fully Account for Behavioral Risk Compensation Likely Overestimates the Prevention Benefits of Male Circumcision", "body"=>"Author: Seth Kalcihman\nPosition: Professor\nInstitution: University of Connecticut\nE-mail: seth.k@uconn.edu\nAdditional Authors: Lisa Eaton, Steven D. Pinkerton\nSubmitted Date: January 29, 2007\nPublished Date: January 31, 2007\nThis comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.\n\nThree RCTs of male circumcision (MC) have been halted when interim analyses showed significant reductions in HIV infection among men who received this intervention (1,2). Modeling suggests that increased MC coverage in southern Africa could prevent as many as 2 million HIV infections over a 10-years (3). Moreover, a cost-effectiveness analysis indicates that MC could be cost-saving (4). However, the protection of MC may be partially offset by increased HIV risk behavior, or “risk compensation”, especially reductions in condom use or increases in numbers of sex partners. Risk compensation occurs when individuals adjust their behavior in response to perceived changes in their vulnerability to a disease (5). Risk compensation may be especially important for MC because avoiding the sexual dissatisfactions of condom use and the desire to have more sex partners are likely to be significant motivations for men to seek circumcision (6). In South Africa, 73% of men between the ages of 15 and 24 report using condoms during the last time they had sex (7). It is difficult to imagine a credible public health message that encourages men to undergo circumcision and continue to use condoms.\n\nCircumcised men in the ANRS 1265 trial reported 18% more sexual contacts at follow-up than did uncircumcised men, but no other sexual behavior differences were obtained (1). However, for ethical reasons all men in MC RCTs receive ongoing risk reduction counseling and free condoms, which reduces the utility of these trials for estimating the potential behavioral impact of MC when implemented in a natural setting. One model of the potential impact of MC did not take into account risk compensation (3), but noted that, “increases in risk-taking behaviour among circumcised men could reduce the benefit of MC”. Based on the 18% difference in sexual contacts for circumcised and uncircumcised men in the ANRS 1265 trial and the assumption that “risk compensation might be higher in a nonresearch program scale-up”, Kahn et al. (4) adjusted the 60% effectiveness estimate obtained in this RCT downward to 50% to reflect a 25% increase in sexual risk behaviors among circumcised men. Although Kahn et al.’s model explicitly incorporated the increased risk of HIV acquisition associated with risk compensation, it did not consider the impact of risk compensation on the HIV transmission risk of HIV-infected circumcised men, or on circumcised men’s risk for non-HIV STIs.\n\nThere is no evidence that circumcision increases or decreases the risk of HIV transmission by HIV-infected men. However, risk compensation by HIV infected circumcised men will substantially increase the risk of transmission to their sex partners. This suggests that, in the short term at least, circumcision would reduce the incidence of HIV among men, but increase the incidence among women, translating to increased prevalence among women, which in turn translates to greater risk to men. Epidemiological models of MC should take this dynamic into account.\n\nCountless studies have shown that ulcerative and non-ulcerative STIs account for at least some of the rapid increases in HIV transmission in southern Africa (8). Non-HIV STIs are associated with a two to five-fold increase in HIV transmission risk in countries with low and high rates of MC (8). In areas with prevalent STIs the relative increase in men’s STI-associated HIV risk can be as high as 60% to 340% (9). Circumcision likely reduces the risk of acquiring a non-HIV STI and may be partially responsible for the decreased HIV risk observed in circumcision RCTs (1). Nevertheless, the failure of models to account for increased STI risk due to risk compensation likely inflates estimates of averted HIV infections. Estimates of HIV risks resulting from increased exposure to STIs that coincide with reductions in condom use have been included in previous models of the cost-effectiveness of HIV prevention interventions (10) and should be included in MC models.\n\nReferences\n\n1. Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, et al. (2005) Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: The ANRS 1265 Trial. PLoS Med 2: e298. doi:10.1371/journal.pmed.0020298\n\n2. NIH News. Adult male circumcision significantly reduces risk of acquiring HIV: Trials in Kenya and Uganda stopped early. US Department of Health and Human Services, December 13, 2006. accessed from http://www.nih.gov/news/pr/dec2006/niaid-13.htm\n\n3. Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, et al. (2006). The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med 3: e262. doi:10.1371/journal.pmed.0030262\n\n4. Kahn JG, Marseille E, Auvert B (2006) Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med 3(12): e517. doi:10.1371/journal. pmed.0030517\n\n5. Pinkerton SD. Sexual risk compensation and HIV/STD transmission: Empirical evidence and theoretical considerations. Risk Analysis 2001;21:727-736.\n\n6. Westercamp N, Bailey RC. Acceptability of male circumcision for prevention of HIV/AIDS in Sub-Saharan Africa: A Review. AIDS Beh 2006, DOI 10.1007/s10461-006-9169-4.\n\n7. Shisana O, Rehle T, Simbayi L, Parker W, Bhana A, Zuma K, Connoly C, Jooste S, Pillay V, et al. South African National HIV Prevalence, Incidence, Behaviour and Communication Survey 2005. Cape Town: Human Sciences Research Council Press, 2005.\n\n8. Fleming DT, Wasserheit, JN. From epidemiological synergy to public health policy and practice: The contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Trans Infect 1999;75:3-17.\n\n9. Royce R et al. Sexual transmission of HIV. New Eng J Med 1997:336;1072-1078.\n\n10. Chesson HW, Pinkerton SD. Sexually transmitted diseases and the increased risk for HIV transmission: Implications for cost-effectiveness analyses of sexually transmitted disease prevention interventions. JAIDS 2000;24:48-55.", "isRemoved"=>false, "created"=>"2009-03-31T00:04:51Z", "lastModified"=>"2009-03-31T00:04:51Z", "creator"=>{"userId"=>"172479"}, "highlightedText"=>"", "competingInterestStatement"=>{"creatorWasPrompted"=>true, "hasCompetingInterests"=>false}, "parentArticle"=>{"doi"=>"info:doi/10.1371/journal.pmed.0030517", "state"=>"published", "journals"=>{"PLoSMedicine"=>{"journalKey"=>"PLoSMedicine", "eIssn"=>"1549-1676", "title"=>"PLOS Medicine"}}}, "replyTreeSize"=>0, "mostRecentActivity"=>"2009-03-31T00:04:51Z", "replies"=>[]}
• {"type"=>"COMMENT", "annotationUri"=>"info:doi/10.1371/annotation/8097c287-67fa-45ac-9542-f076fdca1539", "title"=>"Authors' Reply", "body"=>"Author: Jim Khan\nPosition: Institute for Health Policy Studies\nInstitution: University of California San Francisco\nE-mail: jgkahn@ucsf.edu\nAdditional Authors: Elliot Marseille, Bertran Auvert\nSubmitted Date: February 19, 2007\nPublished Date: February 19, 2007\nThis comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.\n\nThe issues regarding risk compensation raised by Kalichman et al. are cogent for refining modeled estimates of the impact of male circumcision. Even more important is to empirically monitor risk compensation during the scale-up of male circumcision.\n\nAs Kalichmen et al. note, we included in our modeling of MC impact a risk compensation level for HIV-susceptibles above that observed in the Orange Farm trial. However we did not incorporate risk compensation among the HIV-infected, an adjustment which would have lessened the estimated benefits of male circumcision. These two biases are offsetting. Another conservative bias in our analysis is that we used the per-randomization protective effect of 0.60, rather than the per-clinical protocol protective effect of 0.70. Arguably, effectiveness in practice is better captured by the latter, and this would increase the estimated benefits of male circumcision.\n\nThe inclusion of the effects of non-HIV STIs as risk co-factors would add a useful dimension to our analysis. The net effect could be to decrease or increase MC impact. As Kalichman et al note, increased STIs associated with risk compensation in newly circumcized HIV-infected men would likely lessen MC impact. However, in a concentrated epidemic setting where STIs play a greater role in HIV transmission than in South Africa, the STI-reducing effects of MC in HIV-susceptible men could further increase the benefits of MC in preventing HIV.\n\nRegarding the magnitude of risk compensation, we are encouraged by recent data suggesting that, MC does not increase risky behavior, and may lead to a transient decrease (1). However, we, like Kalichman et al and others, are eager to see the favorable experience in clinical trials carried over to routine and widely operating programs. Thus, the current efforts to plan MC scale-up emphasize the need for an MC procedure that incorporates effective risk reduction counseling. In the context of a medicalized adult male circumcision model, and a clear public health message, risk compensation can be minimized. Thus, a great value of MC scale-up is the opportunity to directly deliver a strong behavioral prevention message. A similar risk reduction message has worked well with anti-retroviral therapy in Africa (2).\n\nThe ultimate and critical test is monitoring risk behaviors in communities where MC is scaled up. If risk compensation is higher than expected, redoubled risk reduction methods will be imperative.\n\nJames G. Kahn, Elliot Marseille, Bertran Auvert\n\n1. Agot KE, Kiarie JN, Nguyen HQ, Odhiambo JO, Onyango TM, Weiss NS. Male circumcision in Siaya and Bondo Districts, Kenya: prospective cohort study to assess behavioral disinhibition following circumcision. J Acquir Immune Defic Syndr. 2007 Jan 1;44(1):66-70.\n\n2. Bunnell R, Ekwaru JP, Solberg P, Wamai N, Bikaako-Kajura W, Were W, et al. Changes in sexual behavior and risk of HIV transmission after antiretroviral therapy and prevention interventions in rural Uganda. Aids 2006;20(1):85-92.", "isRemoved"=>false, "created"=>"2009-03-31T00:05:53Z", "lastModified"=>"2009-03-31T00:05:53Z", "creator"=>{"userId"=>"172479"}, "highlightedText"=>"", "competingInterestStatement"=>{"creatorWasPrompted"=>true, "hasCompetingInterests"=>false}, "parentArticle"=>{"doi"=>"info:doi/10.1371/journal.pmed.0030517", "state"=>"published", "journals"=>{"PLoSMedicine"=>{"journalKey"=>"PLoSMedicine", "eIssn"=>"1549-1676", "title"=>"PLOS Medicine"}}}, "replyTreeSize"=>0, "mostRecentActivity"=>"2009-03-31T00:05:53Z", "replies"=>[]}

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Figshare

• {"files"=>["https://ndownloader.figshare.com/files/953989"], "description"=>"<p>For each of the varied input values, results shown correspond to the ranges shown in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030517#pmed-0030517-t001\" target=\"_blank\">Table 1</a>. The 50th percentile corresponds with the base case. Similarly, the first and 99th percentiles approximate the low and high end of the ranges shown in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030517#pmed-0030517-t001\" target=\"_blank\">Table 1</a> respectively. Parentheses indicate savings. This figure indicates that the cost per HIA adjusted for averted HIV treatment costs is most sensitive to uncertainty in the MC protective effect, lifetime medical care cost for HIV/AIDS, and epidemic multiplier.</p>", "links"=>[], "tags"=>["circumcisions", "deducting", "averted", "hiv"], "article_id"=>624289, "categories"=>["Biotechnology", "Medicine", "Infectious Diseases"], "users"=>["James G Kahn", "Elliot Marseille", "Bertran Auvert"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0030517.g002", "stats"=>{"downloads"=>1, "page_views"=>16, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_One_Way_Sensitivity_Analyses_of_the_Cost_of_1_000_Male_Circumcisions_after_Deducting_Averted_HIV_Treatment_Costs_/624289", "title"=>"One-Way Sensitivity Analyses of the Cost of 1,000 Male Circumcisions after Deducting Averted HIV Treatment Costs", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-02-21 12:55:50"}
• {"files"=>["https://ndownloader.figshare.com/files/470038"], "description"=>"<div><h3>Background</h3><p>Consistent with observational studies, a randomized controlled intervention trial of adult male circumcision (MC) conducted in the general population in Orange Farm (OF) (Gauteng Province, South Africa) demonstrated a protective effect against HIV acquisition of 60%. The objective of this study is to present the first cost-effectiveness analysis of the use of MC as an intervention to reduce the spread of HIV in sub-Saharan Africa.</p> <h3>Methods and Findings</h3><p>Cost-effectiveness was modeled for 1,000 MCs done within a general adult male population. Intervention costs included performing MC and treatment of adverse events. HIV prevalence was estimated from published estimates and incidence among susceptible subjects calculated assuming a steady-state epidemic. Effectiveness was defined as the number of HIV infections averted (HIA), which was estimated by dynamically projecting over 20 years the reduction in HIV incidence observed in the OF trial, including secondary transmission to women. Net savings were calculated with adjustment for the averted lifetime duration cost of HIV treatment. Sensitivity analyses examined the effects of input uncertainty and program coverage. All results were discounted to the present at 3% per year.</p> <p>For Gauteng Province, assuming full coverage of the MC intervention, with a 2005 adult male prevalence of 25.6%, 1,000 circumcisions would avert an estimated 308 (80% CI 189–428) infections over 20 years. The cost is $181 (80% CI $117–$306) per HIA, and net savings are $2.4 million (80% CI $1.3 million to $3.6 million). Cost-effectiveness is sensitive to the costs of MC and of averted HIV treatment, the protective effect of MC, and HIV prevalence. With an HIV prevalence of 8.4%, the cost per HIA is $551 (80% CI $344–$1,071) and net savings are $753,000 (80% CI $0.3 million to $1.2 million). Cost-effectiveness improves by less than 10% when MC intervention coverage is 50% of full coverage.</p> <h3>Conclusions</h3><p>In settings in sub-Saharan Africa with high or moderate HIV prevalence among the general population, adult MC is likely to be a cost-effective HIV prevention strategy, even when it has a low coverage. MC generates large net savings after adjustment for averted HIV medical costs.</p> </div>", "links"=>[], "tags"=>["cost-effectiveness", "circumcision", "hiv", "african"], "article_id"=>152618, "categories"=>["Cancer", "Medicine", "Biotechnology"], "users"=>["James G Kahn", "Elliot Marseille", "Bertran Auvert"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0030517", "stats"=>{"downloads"=>0, "page_views"=>6, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/Cost_Effectiveness_of_Male_Circumcision_for_HIV_Prevention_in_a_South_African_Setting_/152618", "title"=>"Cost-Effectiveness of Male Circumcision for HIV Prevention in a South African Setting", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2006-12-26 00:43:38"}
• {"files"=>["https://ndownloader.figshare.com/files/953917"], "description"=>"<p>For each of the varied input values, results correspond to the ranges shown in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030517#pmed-0030517-t001\" target=\"_blank\">Table 1</a>. The 50th percentil corresponds with the base case. Similarly, the first and 99th percentiles approximate the low and high end of the ranges shown in <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030517#pmed-0030517-t001\" target=\"_blank\">Table 1</a>, respectively. For example, the high-end cost per male circumcision is $82 (<a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0030517#pmed-0030517-t001\" target=\"_blank\">Table 1</a>), which corresponds to the 99th percentile of the range, or $250 per HIA. This figure indicates that the unadjusted cost per HIA is most sensitive to uncertainty in the MC protective effect, cost per MC, and epidemic multiplier.</p>", "links"=>[], "tags"=>["hia", "unadjusted", "anticipated", "averted", "hiv"], "article_id"=>624214, "categories"=>["Biotechnology", "Medicine", "Infectious Diseases"], "users"=>["James G Kahn", "Elliot Marseille", "Bertran Auvert"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.0030517.g001", "stats"=>{"downloads"=>2, "page_views"=>17, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_One_Way_Sensitivity_Analyses_of_the_Cost_per_HIA_Unadjusted_for_Anticipated_Averted_HIV_Treatment_Expenditures_/624214", "title"=>"One-Way Sensitivity Analyses of the Cost per HIA Unadjusted for Anticipated Averted HIV Treatment Expenditures", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2013-02-21 12:55:20"}

PMC Usage Stats | Further Information

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• {"unique-ip"=>"27", "full-text"=>"61", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2020", "month"=>"4"}
• {"unique-ip"=>"13", "full-text"=>"30", "pdf"=>"3", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"5"}
• {"unique-ip"=>"12", "full-text"=>"27", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"6"}

Relative Metric

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F1000Prime