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