A review of the evidence on voluntary medical male circumcision (VMMC), which was conducted to help inform updated guidelines from the World Health Organization (WHO) in 2019, concluded that VMMC services are a cost-effective and cost-saving HIV prevention intervention in countries in eastern and southern Africa compared to the lifetime costs of providing antiretroviral therapy (ART).1
Cost of VMMC provision
The cost of providing VMMC varies across countries and settings. The cost per client ranged from US $23 to US $191 in 11 studies in various African countries1 and from US $66 to US $160 in three of the studies that included cost data from several countries.2–4A systematic review and meta-analysis of primary data on VMMC costs from 220 facilities in eight African countries calculated an average unit cost per client of US$59.5
Cost per client drops as the number of clients served increases. For example, the systematic review found that the cost per client was 34% lower in large-scale facilities compared to small-scale ones.5 In one study conducted in four countries in sub-Saharan Africa, supply side factors associated with lower VMMC unit costs included type of facility (with the lowest costs in primary health care facilities), provision of other services along with VMMC, delegation of some tasks to less specialised staff, and volume of VMMC clients.4 Personnel costs were the largest expense involved in VMMC provision, followed by recurrent costs such as VMMC kits and HIV testing kits.4,5
A 2019 systematic review of economic evaluations of HIV prevention interventions found that VMMC is cost-effective in almost all contexts, with a cost per HIV infection averted second only to that of prevention of perinatal transmission. The review, which analysed data from 14 studies that provided cost-effectiveness estimates for VMMC in sub-Saharan African countries, calculated a median cost per HIV infection averted of US $2,965.6
The systematic review found that VMMC was most cost-effective in interventions prioritising younger men. A 2016 WHO consultation that reviewed multiple modelling studies reached the same conclusion, finding that prioritising men ages 15–19, 20–24, and 25–29 would maximize the cost-effectiveness of VMMC.7 At these ages, fewer circumcisions are required to avert one HIV infection, resulting in lower costs and greater savings.
The modelling evidence indicates that VMMC is not only cost-effective but also cost-saving because the ART costs saved due to HIV infections averted outweigh the cost of VMMC provision. For example, a study in Zimbabwe modelled savings of US $55–198 million in ART costs avoided from 2007 through 2030 due to the preventive effects of VMMC.8
World Health Organization. Preventing HIV Through Safe Voluntary Medical Male Circumcision for Adolescent Boys and Men in Generalized HIV Epidemics: Recommendations and Key Considerations. Geneva: WHO, 2020.
Uthman OA, Popoola TA, Uthman MM, Aremu O. Economic evaluations of adult male circumcision for prevention of heterosexual acquisition of HIV in men in sub-Saharan Africa: a systematic review. PLoS One 2010;5(3):e9628. doi: 10.1371/journal.pone.0009628.
Galarraga O, Colchero MA, Wamai RG, Bertozzi SM. HIV prevention cost-effectiveness: a systematic review. BMC Public Health 2009;9(Suppl 1):S5. doi: 10.1186/1471-2458-9-S1-S5.
Bautista-Arredondo S, Sosa-Rubi SG, Opuni M, et al. Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia. PLoS One 2018;13(9):e0203121.
Pineda-Antunez C, Martinez-Silva G, Cerecero-Garcia D, et al. Meta-analysis of average costs of HIV testing and counselling and voluntary medical male circumcision across thirteen countries. Afr J AIDS Res 2019;18(4):341-49. doi: 10.2989/16085906.2019.1679850.
Sarkar S, Corso P, Ebrahim-Zadeh S, et al. Cost-effectiveness of HIV prevention interventions in Sub-Saharan Africa: a systematic review. EClinicalMedicine 2019;10:10-31. doi: 10.1016/j.eclinm.2019.04.006.
Farley T, Samuelson J. Models to Inform Fast Tracking Voluntary Medical Male Circumcision in HIV Combination Prevention. Meeting Report. Geneva: World Health Organization, 2017.
McGillen JB, Stover J, Klein DJ, et al. The emerging health impact of voluntary medical male circumcision in Zimbabwe: an evaluation using three epidemiological models. PLoS One 2018;13(7):e0199453. doi: 10.1371/journal.pone.0199453.