Cost Effectiveness of Male Circumcision for the Prevention of HIV at High Prevalence STD Clinics in Andhra Pradesh, India

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 Africa. We adapt Kahn's model (2006) to analyze the potential effectiveness of MC in a high prevalence population in Andhra Pradesh, India. Methods: In Monte Carlo simulations, we evaluated cost effectiveness of 1000 MC procedures for men attending STD clinics in Andhra Pradesh. Data was derived from 2008 HIV prevalence estimates in India; effectiveness estimates were based on mean results from published trials in sub-Saharan Africa. Effectiveness was evaluated in discounted HIV infections averted (HIA) over 20 years at differing cost, prevalence, incentives and epidemic multiplier. Threshold analysis was used to determine cost benefits of MC compared to the lifetime medical cost of HIV. Results: For those attending an STD clinic in Andhra Pradesh, assuming effectiveness of 60% for MC, an STD clinic prevalence of 24.4%, procedural costs in government clinics, 1,000 circumcisions would avert an estimated 202 (discounted) HIV infections over 20 years. For the base case, cost per discounted HIA was estimated as $145 with a net saving of approximately $160,000. Conclusions: While MC 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 lower middle income country such as India.