/ 12 August 2008

Discovery won’t pay for the snip

South Africa’s biggest medical aid, Discovery Health, refuses to pay for voluntary male circumcision, even though last week’s International Aids Conference in Mexico affirmed that it is the most effective intervention against HIV infection in adult men.

The next biggest schemes, Bonitas and the Government Employees Medical Scheme (Gems), both fund the procedure. Bonitas explicitly recognises the prophylactic effect of male circumcision.

Three years ago researchers in South Africa showed that circumcision reduced the risk of HIV in men by about 60%. The findings were backed by later studies and confirmed observations that communities where male circumcision was widespread tended to have lower infection levels.

Bonitas pays for male circumcision on an outpatient basis. Shama Padayachey, senior clinical manager for Bonitas’s administration company, Medscheme, said the medical aid pays for circumcision because of ”the evidence with regards to HIV”.

Eugene Watson, principal officer of Gems, said the scheme ”does pay for voluntary circumcisions according to managed care rules”.

Pre-authorisation is needed to ”manage the hospital, supplies and other costs by ensuring the rational utilisation of benefits”, he said.

Medical schemes can decide whether benefits are paid from the risk pool — the accumulated funding shared by all members — or from individual medical savings accounts. Paying from the risk pool makes a procedure more affordable for members who do not have to worry about exhausting their personal benefits on one operation.

Gems pays for circumcisions from the risk pool as does Bonitas in all cases except its Boncap option.

Elaine McKay, head of HIV strategy at Discovery Health, said that the scheme will pay only for circumcisions that are medically indicated, including such conditions as narrowing of the foreskin. This did not include HIV prophylaxis.

McKay said the scheme ”is encouraged at the emerging scientific evidence of the role that circumcision could potentially play in preventing future HIV infection in men, as well as growing evidence relating to prevention of penile cancers”.

”We believe in evidence-based decision-making in terms of our healthcare funding decisions and will therefore continue to monitor research in this regard.”

Circumcision does not seem to protect men’s female sexual partners from HIV, but does reduce the risk for women by cutting the number of men carrying the virus.

Further evidence supporting circumcision as an HIV prevention measure was presented this week at the 17th International Aids Conference in Mexico.

Mathematical models suggest that the risk of HIV infection for women would drop by 20% if 50% of men were circumcised — and would fall by 38% if 95% of men underwent the procedure.

At the conference, Richard White of the London School of Hygiene and Tropical Medicine presented data on a mathematical model of the impact of circumcision on a country with 18% HIV prevalence in men and 25% in women.

White forecasts that increasing circumcision levels from 25% to 75% of men would cut the number of new HIV infections by almost a quarter within 10 years — even if the impacts of other prevention strategies and treatment are ignored.

Research in Kenya among more than 2 700 men found that there was no difference between the sexual performance of men who had been circumcised and those who had not.