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Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: A systematic review
Global Health Sciences Literature Digest
Published September 09, 2010
Journal Article

Uthman OA, Popoola TA, Uthman MM, et al. Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: A systematic review. PLoS One. 2010 Mar 10;5(3):e9628.

In Context

Male circumcision has been demonstrated to be an effective method of reducing HIV transmission to men from HIV-infected female partners. Although the evidence for HIV prevention is strong, the cost, particularly relative to other interventions, has not been systematically evaluated.


To identify published studies of the economic evaluation of male circumcision on the prevention of HIV transmission to men and to identify areas in need of further study

Search Strategy

MEDLINE, EMBASE, the Cochrane "Central" trials register, the NHS Economic Evaluation Database (NHS EED), the Database of Abstracts of Reviews of Effectiveness (DARE), and the Health Economic Evaluations Database (HEED) were systematically searched using suitable keywords and were combined with an economic study search filter. The reference lists from all studies identified through the search were also reviewed. Eligible studies were limited to those that included adult males in sub-Saharan Africa, where the intervention was adult male circumcision, the comparator was no adult male circumcision, and the study designs included cost-effectiveness, cost-utility, or cost-benefit analyses. There were no restrictions on dates or language.

One reviewer applied the inclusion and exclusion criteria and these were confirmed by a second reviewer. Discrepancies were resolved by discussion.


Of the 264 studies identified through the database search, 15 were determined to be eligible, and of these five were included.(1, 2, 3, 4, 5) All included studies were published between 2006 and 2009 and were conducted in Uganda, South Africa, Mozambique, and Botswana. One study analyzed data from 16 countires within sub-Saharan Africa (those already included as well as Burundi, Central African Republic, Kenya, Lesotho, Liberia, Malawi, Namibia, Rwanda, Swaziland, Tanzania, Zambia, and Zimbabwe. All studies were cost-effectiveness analyses, and the primary outcomes were cost per case of HIV infection averted and compared adult male circumcision to no circumcision. The studies were epidemiologic, stochiastic, and costing models. Four studies included a 3% discount rate and one study did not report discounting. The time frames ranged from 10 to 20 years.

Outcome measures

The primary outcome measures were cost per case of HIV infection averted and the incremental cost-effectiveness ratio (cost per quality adjusted life years [QALY] and cost per disability adjusted life years [DALY] averted). The net cost savings was also considered. For all eligible studies, the country where the study was conducted, study design, population, intervention, comparator, perspective, model type, pirmary outcome, discount rate, time horizen, and price per year were extracted. Data were abstracted by one reviewer and checked by a second reviewer.


The cost per case of infection averted ranged from $174 to $2808. The cost estimates varied depending on the degree of efficacy, the cost of the surgery, the cost of averted HIV treatment, and the HIV prevalence, with the cost variation being most sensitive to the estimated efficacy. The estimated cost savings ranged depending on the costs factored in and the timeframe used. Savings were estimated to be as high as 2.4 billion over 20 years. When only medical costs are considered, the estimated savings over 20 years was as high as $234 million.


All of the studies evaluated provide evidence that adult male circumcision is cost-effective and produces cost savings within the range of what is generally considered acceptable for medical interventions.

Quality Rating

The authors of this review applied the criteria outlined by Drummond,(6) and two of the five studies were rated highly. A weakness present in all of the studies was that not all relevant costs and outcomes were identified. Most of the studies did not consider complications associated with circumcision and only one applied a sensitivity analysis.

Programmatic Implications

This paper provides important information for policy makers as they determine how to direct scarce prevention resources. The estimated cost-effectiveness of other HIV interventions range from $10 to more than $10,000. Although few studies have examined the cost-effectiveness and cost savings associated with adult male circumcision, the data do indicate that this is a cost-effective intervention that can result in substantial cost savings. An important aspect of this intervention is that it requires a one-time investment of time, money, and discomfort. In contrast, other prevention efforts are dependent on the continued practice of behaviors that reduce the risk of HIV transmission, something that is hard to ensure.


  1. Kahn JG, Marseille E, Auvert B. Cost-effectiveness of male circumcision. PLoS Med 2006;3:2349-58.
  2. Gray RH, Li X, Kigozi G, et al. The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda. AIDS 2007;1(7):845-50.
  3. Auvert B, Marseille E, Korenromp EL, et al. Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in sub-Saharan Africa. Plos One 2008; 3(8);e2679.
  4. Fieno JV. Costing adult male circumcision in high HIV prevalence, low circumcision rate countries. AIDS Care 2008;20(5):515-20.
  5. Bollinger LA, Stover J, Musuka G, et al. The cost and impact of male circumcision on HIV/AIDS in Botswana. J Int AIDS Soc 2009;12:7.
  6. Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. (2005) Methods for the economic evaluation of health care programmes. New York: Oxford University Press.