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More for less: Study addresses cost-saving of male circumcision programs

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Reports in the past several years have shown that male circumcision can reduce HIV transmission risk by up to 60 percent, so some African governments have since been trying to promote the procedure among young adults. But could governments working to establish circumcision programs actually save money—and possibly be more effective—by shifting their focus to newborn and adolescent boys?

In a study published January 19 in PLoS Medicine, researchers address this question for the Rwandan government. In this small country in Central Africa, about 30 percent of men are circumcised and the incidence of new HIV infections in 2008 was 1.56 percent. The authors determine that, unlike circumcision programs aimed at adults, the government would actually save money in the long run by circumcising newborns. Because Rwanda’s circumcision costs and HIV incidence are similar to those of Uganda and South Africa, these results could suggest potential cost savings for other African governments.

Based on the cost savings, the authors "deduce that infant circumcision has a better potential to achieve the very high coverage over time of the population required to achieve maximal reduction on HIV incidence than adolescent and adult circumcision." The research team, which included members of the Rwandan Ministry of Health, UNAIDS and UNICEF, adds that circumcision is less painful, disruptive and carries less stigma among newborns than among older males.

To assess the potential cost-saving for the Rwandan government, the researchers examined two expenses: male circumcision and treating new HIV infections. Based on the cost of supplies and health care staff time, the researchers estimated that it would cost a little more than $200,000 to circumcise 150,000 newborns but nearly $900,000 dollars to perform the procedure on the same number of adolescents or adults.

On the other side of the equation was the cost of treating an HIV-infected male for 14 years, which the authors estimated is his expected lifetime in Rwanda. The authors calculated that the Rwandan government would save $600,000 for every 150,000 adolescents or adults circumcised based on the country’s lowered rate of new HIV infections and the reduced rate of transmission (up to 60 percent) among circumcised men. The authors assumed that circumcision would prevent the same number of HIV infections in newborns once they became sexually active teens, which they estimated to be 15 years from their circumcision. Because the researchers also assumed that HIV treatment would be less expensive by the time this group became infected, circumcising 150,000 newbors would only save the government  $400,000 in eventual HIV treatment.

Although, the researchers determined that circumcising newborns males is a cost-saving ($200,000 for circumcision compared to $400,000 saved in HIV treatment), while the procedure on adolescents and adults is not ($900,000 for circumcision versus $600,000 saved in HIV treatment), they point out that circumcision is still cost-effective in these groups. The economic contribution made by an individual in these age groups is still greater than the additional cost to circumcise an adult or adolescent.

"The next step for Rwanda is to explore how best to introduce male circumcision at different ages, including the appropriate mass media campaigns," the authors wrote. These types of strategies, they add, should be part of a growing shift from treating HIV as a national emergency to developing a sustainable plan.

Rwanda in particular "may represent a best case scenario for neonatal scale-up in Africa," wrote Seth Kalichman, a psychologist at University of Connecticut in Storrs, in an accompanying editorial published in the same issue of PLoS Medicine. He reasons that, because more than 90 percent of the country is Christian, and thus not necessarily adverse to circumcision for religious reasons, the potential to expand newborn circumcisions is promising.

Image courtesy of iStockPhoto/countour99

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  1. 1. P D Hoath 6:53 pm 01/19/2010

    The study that produced the ’60%’ figure was deeply flawed ( and didn’t agree with real world observations which put HIV infections in circumcised men higher in some African countries than non-circumcised.

    I would like to know how the agencies thought they could provide the safe clean circumcisions in a continent where over half the population don’t even have safe drinking water.

    I would like to know how the agencies plan to deal with the epidemic of unsafe circumcisions that must surely follow as the news that "circumcision prevents AIDS" permeates the continent.

    I would like to know why the agencies are wasting money on an infective prevention method when a proven, cheaper alternative is available; condoms.

    People are dying now from infections from unsafe circumcisions ( and many more will die from the inevitable spike in HIV infection this will cause.

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  2. 2. Eldersage 6:57 pm 01/19/2010

    The issue here is health, not money.

    When you treat personal health as a business, you injure uncountable lives to squeeze out some hypothetical dollars. The harm inflicted is never worth the price.

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  3. 3. Semiahmoo 10:17 pm 01/19/2010

    Perhaps east asian children should have their eyelids altered to help them see better? (my apologies)
    Any form of mutilation should require the informed consent of the person being mutilated.
    Circumcision had been required in many (canadian) hospitals 60 years ago without any consent given. I’m glad those days are over. Let’s not bring them back. Circumcision has not been proven definitively to prevent HIV spread but condoms have.

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  4. 4. SciChick 12:08 am 01/20/2010

    Probably the same way they guarantee the safety and necessity of female clitoral mutilation (I mean circumcision) which happens on a daily basis with absolutely no scientic reasoning or necessity. At least science has a correlation between lowered STD’s and circumcised males. The only thing female mutilation has accomplished is generations of women that have no interest in sex because of the pain or lack of sensation involved.

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  5. 5. JamesDavis 7:54 am 01/20/2010

    Do not let any of those researchers or doctors come back into the United States…they are idiotic terrorist. "Assumeing" always makes an ass-of-u-an-me. Don’t these witchdoctors think there has been enough of this kind of butchering in Africa and the rest of the world? These idiots are trying to spread this circumcism plague around the world again. Since when did "assuming" become a science that has ever bettered a society?

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  6. 6. Hugh77 3:12 pm 01/20/2010

    Bizarre! According to the National Health and Demographic Survey for Rwanda for 2005 ( p10/17), 3.8% of circumcised men have HIV while only 2.1% of non-circumcised men (N=3,909) do. So circumcising men or boys in Rwanda could have a disastrous effect. Certainly there is no mandate for applying trials on men in three other countries to boy babies in Rwanda – or the US.

    And "it would cost a little more than $200,000 to circumcise 150,000 newborns" WHAT? That’s $1.33 each! Talk about cut-rate! Something is seriously wrong here.

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  7. 7. georgeg23 3:52 pm 01/20/2010

    "circumcision is less painful, disruptive and carries less stigma among newborns than among older males", have you ever seen a picture of a shrieking baby being circumcised? Wait ’till he grows up for the stigma. Disruptive for whom? I have lost various body parts, but that is one I am happy to have kept. I guess they can use the two stone method for a rite of passage used in some tribes. ‘Nuff said.

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  8. 8. jgrosay 9:10 am 01/21/2010

    OK: circumcision decreases the rates of some STD such as AIDS, HPV and so on, but, has anybody adressed the possible influence of circumcision on such things as sexual response and personality traits? If the zion behaviour on palestinians is a reflect of such personality changes, I will think twice before advising circumcision to anybody

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  9. 9. richw 12:27 am 01/22/2010

    Widespread human rights violations (amputation of penile tissue without consent of the amputee) are being justified by a badly flawed study. Now that study is being touted as a reason to cut and slash helpless newborns in the US. Prevention through education, condom use and personal hygiene is the least expensive method of prevention. Who are these people that are advocating widespread genital mutilation?

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  10. 10. Jenny1919 10:34 pm 01/23/2010

    Gosh, circumcision has worked so well here in the United States in preventing HIV, especially when you realize that over 80% of the men in the U.S. were already circumcised as infants when the AIDS epidemic first appeared on the scene back in the 80s … Bet those dumb Scandanavians with their intact penises and extremely low rates of HIV infection really wish they’d mutilated themselves so they could be protected like us. And if circumcision is such a good preventative, why do you still need a to use a condom to prevent transmission of the virus? By the way, a condom is not so bad to wear if you’re not circumcised….

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  11. 11. gewisn 1:15 am 01/25/2010

    Say it with me:
    To the Women. Don’t leave it up to the men.

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  12. 12. buztid 6:29 pm 01/30/2010

    OMG! I cannot believe they are wanting to circumcise more people, now that the tide is turning to where it should be, in the hands of the person to make their own decisions about permanent damage to neves, muscles and skin tissues that they will have to live with for the rest of their lives!
    If some one said to you, "Oh I got my little girl circumcised" most would react with horror, but what about the little boys?
    to amputate the prepuce would be removing a healthy, vital, fully functioning organ from a non-consenting person. We forever change the sexuality of this future adult man and his partner. All human beings – male and female – have the basic human right of genital integrity. They have a right to ALL their functioning, healthy body parts. A man (even as a newborn) has a right to his whole, intact penis, to do with as he pleases.

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  13. 13. AamirFiroz 2:12 am 02/13/2010

    I agree circumcision reduce the chance of affected by HIV an other STD’s, no pain is bigger then life threating disease, we should now complete focus on implementing this.

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  14. 14. mggordon 9:49 pm 02/15/2010

    "The issue here is health, not money.

    When you treat personal health as a business, you injure uncountable lives to squeeze out some hypothetical dollars. The harm inflicted is never worth the price."

    The issue here IS money. Money is a proxy for labor. "Treat personal health" is not a magical process; human people do the treating and they will not do it for free. A few will, maybe even you and I commend you for it. But not many. It takes labor and medicine and that does not come free.

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  15. 15. tefish 11:12 pm 11/13/2012

    Here is why I question the 3 randomized clinical trials (RCTs) on which these male circumcision campaigns are based, and large-scale plans to implement them:

    1) The researchers who conducted these studies are not infectious disease experts; they are known circumcision proponents. Auvert had been a circumcision proponent since at least 2003; Moses since at least 1994; Bailey since at least 1998. The researcher bias was overwhelming.

    2) The research did not control for malaria, which greatly increases HIV viral load in the bloodstream. It did not control for female sex workers per county, one of the biggest factors for female-to-male transmission. It did not control for the method of transmission, even though other studies point to contaminated medical supplies as a significant vector. Boyle & Hill’s analysis finds a number of methodological flaws, including expectation bias, experimental mortality, safe sex counseling exclusively for the circumcised group, inadequate double blinding, and lead-time bias. The latter is to say that the circumcised group had 2 months extra HIV protection, as they could not have sex while they healed from the surgery. The researchers did not control for this difference. What’s more, the RCTs were terminated early, before the circumcised group had time to catch up with the control group. It gets even worse: the researchers circumcised the control group so no follow-up studies could be done. The quality of the research would be totally unacceptable to any professional, if not for an American cultural bias toward male circumcision.

    3) There is conflicting evidence regarding the foreskin’s role in HIV transmission. In addition to its other immunological components (lymphatic vessels, plasma cells, Langerhans cells which combat microbial antigens), the foreskin’s subpreputial wetness contains the enzyme lysozyme, a known agent for killing HIV. Circumcised men are stripped of this protection. Additionally, Fleiss et al report that the subpreputial wetness (lubrication) provided by the foreskin reduces friction during sexual intercourse, preventing vaginal tears and microfissures through which HIV can enter the partner’s bloodstream. It is plausible that mass male circumcision puts women at greater risk for contracting HIV, unless they habitually use artificial lubrication with circumcised partners.

    4) Even if the RCTs’ findings were accurate, they are countered by larger demographic trends. By the WHO’s records, only 1 of 18 countries in Africa has a lower HIV prevalence among circumcised men; the remaining countries show either a significantly higher HIV prevalence among circumcised men or no difference at all.

    5) The Oxford University blog put out a must-read article titled “When Bad Science Kills, or How to Spread AIDS.” The gist of it is that African men who fall victim to circumcision campaigns believe they are protected against HIV, and therefore are less likely to use condoms and more likely to spread HIV. A handful of African prime ministers have rejected the campaigns on the basis that circumcision has greatly increased the prevalence of HIV/AIDS in their countries by misleading the public.

    6) Circumcision is particularly risky in unsterile Third World medical scenarios, and would likely kill more people than it would save.

    7) Circumcision is an excruciatingly painful surgery that men rarely consent to in own own society. The foreskin also has documented sexual functions, so there are ethical considerations to be made when encouraging the procedure among uneducated populations who lack the resources to make an informed choice. The RCTs bear an uncomfortable resemblance to the Tuskegee study, an unethical syphilis study conducted on a different poor black population. Here’s an article you won’t see published in Western media:

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  16. 16. brinxster 3:30 pm 03/21/2013

    Most recent non-biased studies show that circumcised men are actually more prone to HIV and other STD infections, this correlates with the US having higher HIV infections than Europe where genital cutting of boys is rare. The old studies that claimed there is a HIV prevention were likely biased and only show that in Southern Africa where water is scarce, likely being dirty may increase risk of disease. Which is totally irrelevant to most of the world.

    Having a scientific mind means you have the ability of critical thinking, you simply should not accept a study’s findings if the people involved have monetary reasons for a specific outcome, that is a conflict of interest. The people who tout these pro-circumcision studies often profit of it, there is over $1,000,000,000 that has come from the US and much of it is spent promoting circumcision in Africa… Why not promote Condoms? That is the logical, scientifically supported method to prevent HIV… not amputation of a perfectly healthy body part that likely has no if not a negative impact on the HIV epidemic.

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