Study projects increases in health care costs, infections with declines in male circumcision

CHICAGO – Using a computer-based simulation model, researchers project that a continued decline in male circumcision rates in the United States to levels in Europe, where the procedure is not routinely covered by insurance, may be associated with increased estimated lifetime medical costs and a higher estimated prevalence of infections including human immunodeficiency virus (HIV) and human papillomavirus (HPV), according to a report published Online First by Archives of Pediatrics & Adolescent Medicine, a JAMA Network publication.

State governments are increasingly eliminating Medicaid coverage for neonatal male circumcision (MC), with 18 states having abolished coverage. Although the prevalence of circumcision among men born in the 1970s and 1980s remained stable at about 79 percent, the MC rate decreased to 62.5 percent in 1999 and to 54.7 percent by 2010. There is growing evidence of medical benefits associated with MC, including lower risk of HIV and HPV infections in some clinical trials, according to the study background.

"Continued decreases in MC rates are associated with increased infection prevalence, thereby increasing medical expenditures for men and women," the study highlights.

Seema Kacker, B.S., and colleagues at Johns Hopkins University, Baltimore, Md., used a computer-based simulation model that included a scenario whereby MC rates would be reduced to 10 percent, which the study results indicate could increase estimated lifetime health care costs by $407 per man and $43 per woman.

Under a 10 percent MC rate among males in a birth cohort of 4 million, cases of infant male urinary tract infections were estimated to increase 211.8 percent, HIV infections were estimated to increase by 12.2 percent, HPV infections were estimated to increase by 29.1 percent and herpes simplex virus type 2 by 19.8 percent. Among women, cases of bacterial vaginosis were estimated to increase by 51.2 percent, high-risk HPV were estimated to increase by 18.3 percent and low-risk HPV by 12.9 percent, according to the study results.

"Although there are multiple factors that contribute to a nation's MC rate, it is likely that reductions in insurance coverage play a role in lowered MC rates. Thus, the financial and health implications of policies that affect MC are substantial," the authors comment.

The researchers conclude: "Furthermore, a closer examination of MC rates, STI [sexually transmitted infection] incidence and the demographic characteristics of Medicaid beneficiaries suggests that the subpopulations likely to quality for Medicaid also have the lowest rates of MC and the highest infection incidence. Therefore, decreased Medicaid coverage of MC may further exaggerate racial and socioeconomic disparities."

(Arch Pediatr Adolesc Med. Published online August 20, 2012. doi:10.1001/archpediatrics.2012.1440. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: Authors disclosed grant support from the National Institutes of Health and the Doris Duke Charitable Foundation Clinician Scientist Development Award. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an editorial, Arleen A. Leibowitz, Ph.D., and Katherine Desmond, M.S., of the University of California, Los Angeles, write: "In view of the compelling evidence from randomized controlled trials about the lifelong health benefits of MC and the projections by Kacker et al on the cost-reducing potential of MC, it is now time for the federal Medicaid program to consider reclassifying MC from an 'optional' service to one that all state Medicaid plans will cover for those parents who choose the procedure for their newborn sons."

"States currently facing severe budgetary pressures due to the recession may be tempted to reduce short-term costs by dropping 'optional' benefits, so making MC a required benefit would prevent this sacrifice of long-term gains for near-term relief," they continue.

"Such a change would address three important health system goals: improving health by reducing future incidence of HIV and other STIs, reducing disparities in adult health and lowering treatment costs for STIs in the long run," they conclude.

(Arch Pediatr Adolesc Med. Published online August 20, 2012. doi:10.1001/archpediatrics.2012.1710. Available pre-embargo to the media at http://media.jamanetwork.com.)

Editor's Note: Support for the writing of this editorial was provided by the California HIV/AIDS Research Program of the University of California and the University of California, Los Angeles, Center for HIV Identification, Prevention and Treatment Services, funded by a National Institute of Mental Health grant. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

To contact Aaron A.R. Tobian, M.D., Ph.D., call David March at 410-955-1534 or email dmarch1@jhmi.edu. To contact editorial author Arleen A. Leibowitz, Ph.D., call Alex Boekelheide at 310-206-0159 or email alex.boekelheide@publicaffairs.ucla.edu.