Cost-effectiveness of voluntary medical male circumcision (VMMC) for HIV prevention across sub-Saharan Africa: results from five independent models

Background

Voluntary medical male circumcision (VMMC) has been a recommended HIV prevention strategy in sub-Saharan Africa since 2007, particularly in countries with high HIV prevalence. However, given the scale-up of antiretroviral therapy (ART) programmes, it is not clear whether VMMC still represents a cost-effective use of limited HIV programme resources.

Methods

Using five existing well-described HIV mathematical models, we compared continuation of VMMC for 5 years in males aged 15 and older to no further VMMC in South Africa, Malawi, and Zimbabwe and across a range of setting scenarios in sub-Saharan Africa. Outputs were based on a 50-year time horizon, VMMC cost was assumed to be US$90, and a cost-effectiveness threshold of US$500 was used.

Findings

In South Africa and Malawi, the continuation of VMMC for 5 years resulted in cost savings and health benefits (infections and disability-adjusted life years (DALYs) averted) according to all models. Of the two models modelling Zimbabwe, the continuation of VMMC for 5 years resulted in cost savings and health benefits by one model but was not as cost-effective according to the other model. Continuation of VMMC was cost-effective in 68% of setting scenarios across sub-Saharan Africa. VMMC was more likely to be cost effective in modelled settings with higher HIV incidence; VMMC was cost effective in 62% of settings with HIV incidence <0.1/100 person-years (py) in 15-49 year olds, increasing to 95% with HIV incidence >1.0/100py.

Interpretation

VMMC remains a cost-effective, often cost-saving, prevention intervention in sub-Saharan Africa for at least the next 5 years.