Male Circumcision at Different Ages in Rwanda: A Cost-Effectiveness Study
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{"title"=>"Male circumcision at different ages in Rwanda: A cost-effectiveness study", "type"=>"journal", "authors"=>[{"first_name"=>"Agnes", "last_name"=>"Binagwaho", "scopus_author_id"=>"8314417100"}, {"first_name"=>"Elisabetta", "last_name"=>"Pegurri", "scopus_author_id"=>"6507090442"}, {"first_name"=>"Jane", "last_name"=>"Muita", "scopus_author_id"=>"57195302702"}, {"first_name"=>"Stefano", "last_name"=>"Bertozzi", "scopus_author_id"=>"7003362740"}], "year"=>2010, "source"=>"PLoS Medicine", "identifiers"=>{"sgr"=>"75749124617", "pmid"=>"20098721", "isbn"=>"1549-1676", "pui"=>"358224426", "issn"=>"15491277", "scopus"=>"2-s2.0-75749124617", "doi"=>"10.1371/journal.pmed.1000211"}, "id"=>"8141f8ff-7ecb-3a36-8573-77af324abfff", "abstract"=>"BACKGROUND There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%. METHODS AND FINDINGS A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. RESULTS Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man. CONCLUSIONS The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services (i.e., neonatal visits and vaccination sessions) and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence. In the presence of infant MC, adolescent and adult MC would evolve into a \"catch-up\" campaign that would be needed at the start of the program but would eventually become superfluous. Please see later in the article for the Editors' Summary.", "link"=>"http://www.mendeley.com/research/male-circumcision-different-ages-rwanda-costeffectiveness-study", "reader_count"=>103, "reader_count_by_academic_status"=>{"Unspecified"=>1, "Professor > Associate Professor"=>3, "Researcher"=>23, "Student > Doctoral Student"=>3, "Student > Ph. D. Student"=>22, "Student > Postgraduate"=>5, "Student > Master"=>28, "Other"=>3, "Student > Bachelor"=>9, "Lecturer"=>3, "Lecturer > Senior Lecturer"=>3}, "reader_count_by_user_role"=>{"Unspecified"=>1, "Professor > Associate Professor"=>3, "Researcher"=>23, "Student > Doctoral Student"=>3, "Student > Ph. D. Student"=>22, "Student > Postgraduate"=>5, "Student > Master"=>28, "Other"=>3, "Student > Bachelor"=>9, "Lecturer"=>3, "Lecturer > Senior Lecturer"=>3}, "reader_count_by_subject_area"=>{"Unspecified"=>7, "Agricultural and Biological Sciences"=>2, "Arts and Humanities"=>1, "Business, Management and Accounting"=>1, "Economics, Econometrics and Finance"=>10, "Environmental Science"=>2, "Nursing and Health Professions"=>9, "Mathematics"=>1, "Medicine and Dentistry"=>35, "Design"=>1, "Pharmacology, Toxicology and Pharmaceutical Science"=>1, "Sports and Recreations"=>1, "Psychology"=>7, "Social Sciences"=>25}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>35}, "Social Sciences"=>{"Social Sciences"=>25}, "Sports and Recreations"=>{"Sports and Recreations"=>1}, "Psychology"=>{"Psychology"=>7}, "Mathematics"=>{"Mathematics"=>1}, "Unspecified"=>{"Unspecified"=>7}, "Environmental Science"=>{"Environmental Science"=>2}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>1}, "Arts and Humanities"=>{"Arts and Humanities"=>1}, "Design"=>{"Design"=>1}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>10}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>2}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>9}}, "reader_count_by_country"=>{"Malawi"=>1, "United States"=>1, "Tanzania"=>1, "Rwanda"=>1, "South Africa"=>1, "Australia"=>1, "Peru"=>1}, "group_count"=>6}

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Figshare

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  • {"files"=>["https://ndownloader.figshare.com/files/867311"], "description"=>"<p>Threshold analysis.</p>", "links"=>[], "tags"=>["evidence-based healthcare", "evidence-based healthcare/health services research and economics", "evidence-based healthcare/statistical methodologies and health informatics", "infectious diseases/epidemiology and control of infectious diseases", "infectious diseases/hiv infection and aids", "infectious diseases/sexually transmitted diseases", "infectious diseases/viral infections", "surgery/pediatric surgery"], "article_id"=>537761, "categories"=>["Medicine", "Infectious Diseases"], "users"=>["Agnes Binagwaho", "Elisabetta Pegurri", "Jane Muita", "Stefano Bertozzi"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000211.t005"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Threshold_analysis_/537761", "title"=>"Threshold analysis.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-21 03:03:31"}
  • {"files"=>["https://ndownloader.figshare.com/files/867342"], "description"=>"<p>Savings for neonatal, adolescent, and adult MC in Rwanda, 2008.</p>", "links"=>[], "tags"=>["mc"], "article_id"=>537795, "categories"=>["Medicine", "Infectious Diseases"], "users"=>["Agnes Binagwaho", "Elisabetta Pegurri", "Jane Muita", "Stefano Bertozzi"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000211.t004"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Savings_for_neonatal_adolescent_and_adult_MC_in_Rwanda_2008_/537795", "title"=>"Savings for neonatal, adolescent, and adult MC in Rwanda, 2008.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-21 03:03:45"}
  • {"files"=>["https://ndownloader.figshare.com/files/867373"], "description"=>"a<p>The incidence rates are multiplied by cohorts of 150,000, minus the number of infections that occurred previously.</p>", "links"=>[], "tags"=>["mc"], "article_id"=>537837, "categories"=>["Medicine", "Infectious Diseases"], "users"=>["Agnes Binagwaho", "Elisabetta Pegurri", "Jane Muita", "Stefano Bertozzi"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000211.t001"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Effectiveness_of_neonatal_adolescent_and_adult_MC_in_Rwanda_2008_/537837", "title"=>"Effectiveness of neonatal, adolescent, and adult MC in Rwanda, 2008.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-21 03:03:56"}
  • {"files"=>["https://ndownloader.figshare.com/files/867410"], "description"=>"a<p>Coverage assumptions come from published literature (WHO) and routine data/consensus discussions among HIV service providers in Rwanda.</p><p>PLHIV, people living with HIV/AIDS; TB, tuberculosis.</p>", "links"=>[], "tags"=>["savings", "hiv"], "article_id"=>537867, "categories"=>["Medicine", "Infectious Diseases"], "users"=>["Agnes Binagwaho", "Elisabetta Pegurri", "Jane Muita", "Stefano Bertozzi"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000211.t003"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Life_time_savings_per_each_HIV_infection_averted_/537867", "title"=>"Life-time savings per each HIV infection averted.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-21 03:04:06"}
  • {"files"=>["https://ndownloader.figshare.com/files/867448"], "description"=>"<p>Base case year, 2008.</p>a<p>The costs of a promotion campaign for a circumcision program that targeted infants, adolescent, and adults would be less than the sum of the individual campaigns, which would increase the cost-effectiveness of each if implemented jointly.</p>b<p>Dorsal slit method (reflecting current practice in Kigali) in hospital.</p>", "links"=>[], "tags"=>["standardised", "mc", "cohort", "adults", "newborns"], "article_id"=>537905, "categories"=>["Medicine", "Infectious Diseases"], "users"=>["Agnes Binagwaho", "Elisabetta Pegurri", "Jane Muita", "Stefano Bertozzi"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000211.t002"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Costs_standardised_to_one_MC_procedure_for_a_cohort_of_150_000_adults_and_150_000_newborns_in_Rwanda_2008_/537905", "title"=>"Costs standardised to one MC procedure for a cohort of 150,000 adults and 150,000 newborns in Rwanda, 2008.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2013-02-21 03:04:17"}

PMC Usage Stats | Further Information

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  • {"unique-ip"=>"23", "full-text"=>"34", "pdf"=>"7", "abstract"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2013", "month"=>"4"}
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Relative Metric

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