title: Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when?
abstract: OBJECTIVE
  Male circumcision (circumcision) reduces HIV incidence in men by 50-60%. The United Nations Joint Programme on HIV/AIDS (UNAIDS) recommends the provision of safe circumcision services in countries with high HIV and low circumcision prevalence, prioritizing 12-30 years old HIV-uninfected men. We explore how the population-level impact of circumcision varies by target age group, coverage, time-to-scale-up, level of risk compensation and circumcision of HIV infected men.
  
  
  METHODS
  An individual-based model was fitted to the characteristics of a typical high-HIV-prevalence population in sub-Saharan Africa and three scenarios of individual-level impact corresponding to the central and the 95% confidence level estimates from the Kenyan circumcision trial. The simulated intervention increased the prevalence of circumcision from 25 to 75% over 5 years in targeted age groups. The impact and cost-effectiveness of the intervention were calculated over 2-50 years. Future costs and effects were discounted and compared with the present value of lifetime HIV treatment costs (US$ 4043).
  
  
  RESULTS
  Initially, targeting men older than the United Nations Joint Programme on HIV/AIDS recommended age group may be the most cost-effective strategy, but targeting any adult age group will be cost-saving. Substantial risk compensation could negate impact, particularly if already circumcised men compensate. If circumcision prevalence in HIV uninfected men increases less because HIV-infected men are also circumcised, this will reduce impact in men but would have little effect on population-level impact in women.
  
  
  CONCLUSIONS
  Circumcision is a cost-saving intervention in a wide range of scenarios of HIV and initial circumcision prevalence but the United Nations Joint Programme on HIV/AIDS/WHO recommended target age group should be widened to include older HIV-uninfected men and counselling should be targeted at both newly and already circumcised men to minimize risk compensation. To maximize infections-averted, circumcision must be scaled up rapidly while maintaining quality.
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK. richard.white@lshtm.ac.uk
authors.forename: Richard G
authors.initials: RG
authors.lastname: White
authors.forename: Judith R
authors.initials: JR
authors.lastname: Glynn
authors.forename: Kate K
authors.initials: KK
authors.lastname: Orroth
authors.forename: Esther E
authors.initials: EE
authors.lastname: Freeman
authors.forename: Roel
authors.initials: R
authors.lastname: Bakker
authors.forename: Helen A
authors.initials: HA
authors.lastname: Weiss
authors.forename: Lilani
authors.initials: L
authors.lastname: Kumaranayake
authors.forename: J Dik F
authors.initials: JD
authors.lastname: Habbema
authors.forename: Anne
authors.initials: A
authors.lastname: Buvé
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Hayes