title: Cost-effectiveness of newborn circumcision in reducing lifetime HIV risk among U.S. males.
abstract: BACKGROUND
  HIV incidence was substantially lower among circumcised versus uncircumcised heterosexual African men in three clinical trials. Based on those findings, we modeled the potential effect of newborn male circumcision on a U.S. male's lifetime risk of HIV, including associated costs and quality-adjusted life-years saved.
  
  
  RESULTS
  Given published estimates of U.S. males' lifetime HIV risk, we calculated the fraction of lifetime risk attributable to heterosexual behavior from 2005-2006 HIV surveillance data. We assumed 60% efficacy of circumcision in reducing heterosexually-acquired HIV over a lifetime, and varied efficacy in sensitivity analyses. We calculated differences in lifetime HIV risk, expected HIV treatment costs and quality-adjusted life years (QALYs) among circumcised versus uncircumcised males. The main outcome measure was cost per HIV-related QALY saved. Circumcision reduced the lifetime HIV risk among all males by 15.7% in the base case analysis, ranging from 7.9% for white males to 20.9% for black males. Newborn circumcision was a cost-saving HIV prevention intervention for all, black and Hispanic males. The net cost of newborn circumcision per QALY saved was $87,792 for white males. Results were most sensitive to the discount rate, and circumcision efficacy and cost.
  
  
  CONCLUSIONS
  Newborn circumcision resulted in lower expected HIV-related treatment costs and a slight increase in QALYs. It reduced the 1.87% lifetime risk of HIV among all males by about 16%. The effect varied substantially by race and ethnicity. Racial and ethnic groups who could benefit the most from circumcision may have least access to it due to insurance coverage and state Medicaid policies, and these financial barriers should be addressed. More data on the long-term protective effect of circumcision on heterosexual males as well as on its efficacy in preventing HIV among MSM would be useful.
authors.affiliation: Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Sansom
authors.forename: Vimalanand S
authors.initials: VS
authors.lastname: Prabhu
authors.forename: Angela B
authors.initials: AB
authors.lastname: Hutchinson
authors.forename: Qian
authors.initials: Q
authors.lastname: An
authors.forename: H Irene
authors.initials: HI
authors.lastname: Hall
authors.forename: Ram K
authors.initials: RK
authors.lastname: Shrestha
authors.forename: Arielle
authors.initials: A
authors.lastname: Lasry
authors.forename: Allan W
authors.initials: AW
authors.lastname: Taylor
mesh_terms: D002944:Circumcision, Male / Q000191:economics*; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D007231:Infant, Newborn; D008297:Male; D011159:Population Surveillance; D019057:Quality-Adjusted Life Years; D012307:Risk Factors; D014481:United States / Q000453:epidemiology