Cost-Effectiveness of Adult Circumcision in a Resource-Rich Setting for HIV Prevention among Men Who Have Sex with Men

Background. We examined the effects and cost-effectiveness of 4 strategies of circumcision in a resource-rich setting (Australia) in a population of men who have sex with men (MSM). Method. We created a dynamic mathematical transmission model and performed an economic analysis to estimate the costs, outcomes, and cost-effectiveness of different strategies, compared with those of the status quo. Strategies included circumcision of all MSM at age 18 years, circumcision of all MSM aged 35-44 years, circumcision of all insertive MSM aged >= 18 years, and circumcision of all MSM aged >= 18 years. All costs are reported in US dollars, with a cost-effectiveness threshold of $42,000 per quality-adjusted life-year. Results. We find that 2%-5% of human immunodeficiency virus (HIV) infections would be averted per year, with initial costs ranging from $3.6 million to $95.1 million, depending on the strategy. The number of circumcisions needed to prevent 1 HIV infection would range from 118 through 338. Circumcision of predominately insertive MSM would save $21.7 million over 25 years with a $62.2 million investment. Strategies to circumcise 100% of all MSM and to circumcise MSM aged 35-44 years would be cost-effective; the latter would require a smaller investment. The least cost-effective approach is circumcision of young MSM close to their sexual debut. Results are very sensitive to assumptions about the cost of circumcision, the efficacy of circumcision, sexual preferences, and behavioral disinhibition. Conclusions. Circumcision of adult MSM may be cost-effective in this resource-rich setting. However, the intervention costs are high relative to the costs spent on other HIV prevention programs.