Male circumcision at different ages in Rwanda: a cost-effectiveness study.

BACKGROUND: There is strong evidence showing that male circumcision (MC) reduces HIV infection and other sexually transmitted infections (STIs). In Rwanda, where adult HIV prevalence is 3%, MC is not a traditional practice. The Rwanda National AIDS Commission modelled cost and effects of MC at different ages to inform policy and programmatic decisions in relation to introducing MC. This study was necessary because the MC debate in Southern Africa has focused primarily on MC for adults. Further, this is the first time, to our knowledge, that a cost-effectiveness study on MC has been carried out in a country where HIV prevalence is below 5%. METHODS AND FINDINGS: A cost-effectiveness model was developed and applied to three hypothetical cohorts in Rwanda: newborns, adolescents, and adult men. Effectiveness was defined as the number of HIV infections averted, and was calculated as the product of the number of people susceptible to HIV infection in the cohort, the HIV incidence rate at different ages, and the protective effect of MC; discounted back to the year of circumcision and summed over the life expectancy of the circumcised person. Direct costs were based on interviews with experienced health care providers to determine inputs involved in the procedure (from consumables to staff time) and related prices. Other costs included training, patient counselling, treatment of adverse events, and promotion campaigns, and they were adjusted for the averted lifetime cost of health care (antiretroviral therapy [ART], opportunistic infection [OI], laboratory tests). One-way sensitivity analysis was performed by varying the main inputs of the model, and thresholds were calculated at which each intervention is no longer cost-saving and at which an intervention costs more than one gross domestic product (GDP) per capita per life-year gained. RESULTS: Neonatal MC is less expensive than adolescent and adult MC (US$15 instead of US$59 per procedure) and is cost-saving (the cost-effectiveness ratio is negative), even though savings from infant circumcision will be realized later in time. The cost per infection averted is US$3,932 for adolescent MC and US$4,949 for adult MC. Results for infant MC appear robust. Infant MC remains highly cost-effective across a reasonable range of variation in the base case scenario. Adolescent MC is highly cost-effective for the base case scenario but this high cost-effectiveness is not robust to small changes in the input variables. Adult MC is neither cost-saving nor highly cost-effective when considering only the direct benefit for the circumcised man. CONCLUSIONS: The study suggests that Rwanda should be simultaneously scaling up circumcision across a broad range of age groups, with high priority to the very young. Infant MC can be integrated into existing health services (i.e., neonatal visits and vaccination sessions) and over time has better potential than adolescent and adult circumcision to achieve the very high coverage of the population required for maximal reduction of HIV incidence. In the presence of infant MC, adolescent and adult MC would evolve into a "catch-up" campaign that would be needed at the start of the program but would eventually become superfluous. Please see later in the article for the Editors' Summary.

Under-two child mortality according to maternal HIV status in Rwanda: assessing outcomes within the National PMTCT Program.

INTRODUCTION: We sought to compare risk of death among children aged under-2 years born to HIV positive mother (HIV-exposed) and to HIV negative mother (HIV non-exposed), and identify determinants of under-2 mortality among the two groups in Rwanda. METHODS: In a stratified, two-stage cluster sampling design, we selected mother-child pairs using national Antenatal Care (ANC) registers. Household interview with each mother was conducted to capture socio-demographic data and information related to pregnancy, delivery and post-partum. Data were censored at the date of child death. Using Cox proportional hazard model, we compared the hazard of death among HIV-exposed children and HIV non-exposed children. RESULTS: Of 1,455 HIV-exposed children, 29 (2.0%; 95% CI: 1.3%-2.7%) died by 6 months compared to 18 children of the 1,565 HIV non-exposed children (1.2%; 95% CI: 0.6%-1.7%). By 9 months, cumulative risks of death were 3.0% (95%; CI: 2.2%-3.9%) and 1.3% (96%; CI: 0.7%-1.8%) among HIV-exposed and HIV non-exposed children, respectively. By 2 years, the hazard of death among HIV-exposed children was more than 3 times higher (aHR:3.5; 95% CI: 1.8-6.9) among HIV-exposed versus non-exposed children. Risk of death by 9-24 months of age was 50% lower among mothers who attended 4 or more antenatal care (ANC) visits (aHR: 0.5, 95% CI: 0.3-0.9), and 26% lower among families who had more assets (aHR: 0.7, 95% CI: 0.5-1.0). CONCLUSION: Infant mortality was independent of perinatal HIV exposure among children by 6 months of age. However, HIV-exposed children were 3.5 times more likely to die by 2 years. Fewer antenatal visits, lower household assets and maternal HIV seropositive status were associated with increased mortality by 9-24 months.

Prevention of mother-to-child transmission: program changes and the effect on uptake of the HIVNET 012 regimen in Malawi.

OBJECTIVE(S): To evaluate uptake of HIV testing in a prevention of mother-to-child transmission program (PMTCT) in Lilongwe, Malawi from April 2002 until December 2006. DESIGN: Retrospective analysis of monthly reports from the beginning of the program. SETTING: Four antenatal clinics in Lilongwe, Malawi. METHODS: Pregnant women attending urban antenatal clinics in Lilongwe were invited to participate in a PMTCT program. Women were given information and education on antenatal care and PMTCT in groups of 8 to 12. Written informed consent for HIV testing was obtained privately. Women returned for the test result 1-2 weeks later. Mothers and infants were given the HIVNET 012 regimen. Rapid HIV testing and 'opt-out' testing were instituted in July 2003 and April 2005, respectively. Infants were tested using HIV DNA PCR and, if HIV positive, a CD4 cell percentage was obtained and the infants were referred for further medical evaluation and treatment. RESULTS: The program reached 20 000 pregnant women in the first 12 months. Acceptance of HIV testing increased from 45% to 73% (P < 0.001) when rapid, same day testing was instituted. When opt-out testing was instituted, 99% of the mothers agreed to testing. Of the infants tested, 15.5% were HIV positive. CONCLUSION: Rapid HIV testing using the opt-out method increased acceptance of HIV testing in the PMTCT program to 99% in urban Lilongwe, Malawi.