Kacker Seema, Frick Kevin D, Quinn Thomas C, Gray Ronald H, Tobian Aaron A R
Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA.
Sex Transm Dis. 2013 Jul;40(7):559-68. doi: 10.1097/OLQ.0b013e3182945e56.
The financial implications of male circumcision (MC) scale-up in sub-Saharan Africa associated with reduced HIV have been evaluated. However, no analysis has incorporated the expected reduction of a comprehensive set of other sexually transmitted infections including human papillomavirus, herpes simplex virus type 2, genital ulcer disease, bacterial vaginosis, and trichomoniasis.
A Markov model tracked a dynamic population undergoing potential MC scale-up, as individuals experienced MC procedures, procedure-related adverse events, and MC-reduced sexually transmitted infections and accrued any associated costs. Rakai, Uganda, was used as a prototypical rural sub-Saharan African community. Monte Carlo microsimulations evaluated outcomes under 4 alternative scale-up strategies to reach 80% MC coverage among men aged 15 to 49 years, in addition to a baseline strategy defined by current MC rates in central Uganda. Financial outcomes included direct medical expenses only and were evaluated over 5 and 25 years. Costs were discounted to the beginning of each period, coinciding with the start of MC scale-up, and expressed in US $2012.
Cost savings from infections averted by MC vary from US $197,531 after 5 years of a scale-up program focusing on adolescent/adult procedures to more than US $13 million after 25 years, under a strategy incorporating increased infant MCs. Over a 5-year period, reduction in HIV contributes to 50% of cost savings, and for 25 years, this contribution rises to nearly 90%.
Sexually transmitted infections other than HIV contribute to cost savings associated with MC scale-up. Previous analyses, focusing exclusively on the financial impact through averted HIV, may have underestimated true cost savings by 10% to 50%.
在撒哈拉以南非洲地区扩大男性包皮环切术（MC）规模与降低艾滋病病毒感染率之间的经济影响已得到评估。然而，尚无分析纳入了一系列其他性传播感染预期减少的情况，这些感染包括人乳头瘤病毒、2型单纯疱疹病毒、生殖器溃疡疾病、细菌性阴道病和滴虫病。
一个马尔可夫模型追踪了一个动态人群，该人群可能会扩大MC规模，因为个体经历了MC手术、与手术相关的不良事件、MC降低的性传播感染，并产生了任何相关成本。乌干达的拉凯被用作撒哈拉以南非洲农村社区的典型代表。蒙特卡洛微观模拟评估了4种替代扩大规模策略下的结果，以在15至49岁男性中实现80%的MC覆盖率，此外还评估了以乌干达中部当前MC率定义的基线策略。财务结果仅包括直接医疗费用，并在5年和25年内进行评估。成本按每个时期开始时进行贴现，与MC扩大规模开始时一致，并以2012年美元表示。
通过MC避免感染带来的成本节省在侧重于青少年/成人手术的扩大规模计划实施5年后为197,531美元，而在纳入增加婴儿MC的策略下，25年后超过1300万美元。在5年期间，艾滋病病毒感染率的降低占成本节省的50%，而在25年期间，这一贡献上升至近90%。
除艾滋病病毒外的性传播感染有助于与MC扩大规模相关的成本节省。以往仅关注通过避免艾滋病病毒感染产生的财务影响的分析，可能低估了实际成本节省的10%至50%。
