Assessing Progress, Impact, and Next Steps in Rolling Out Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa through 2014

Abstract

BackgroundIn 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries across eastern and southern Africa for scaling up voluntary medical male circumcision (VMMC) services. Several years into this effort, we reflect on progress.MethodsUsing the Decision Makers’ Program Planning Tool (DMPPT) 2.1, we assessed age-specific impact, cost-effectiveness, and coverage attributable to circumcisions performed through 2014. We also compared impact of actual progress to that of achieving 80% coverage among men ages 15–49 in 12 VMMC priority countries and Nyanza Province, Kenya. We populated the models with age-disaggregated VMMC service statistics and with population, mortality, and HIV incidence and prevalence projections exported from country-specific Spectrum/Goals files. We assumed each country achieved UNAIDS’ 90-90-90 treatment targets.ResultsMore than 9 million VMMCs were conducted through 2014: 43% of the estimated 20.9 million VMMCs required to reach 80% coverage by the end of 2015. The model assumed each country reaches the UNAIDS targets, and projected that VMMCs conducted through 2014 will avert 240,000 infections by the end of 2025, compared to 1.1 million if each country had reached 80% coverage by the end of 2015. The median estimated cost per HIV infection averted was $4,400. Nyanza Province in Kenya, the 11 priority regions in Tanzania, and Uganda have reached or are approaching MC coverage targets among males ages 15–24, while coverage in other age groups is lower. Across all countries modeled, more than half of the projected HIV infections averted were attributable to circumcising 10- to 19-year-olds.ConclusionsThe priority countries have made considerable progress in VMMC scale-up, and VMMC remains a cost-effective strategy for epidemic impact, even assuming near-universal HIV diagnosis, treatment coverage, and viral suppression. Examining circumcision coverage by five-year age groups will inform countries’ decisions about next steps.

Modeling Impact and Cost-Effectiveness of Increased Efforts to Attract Voluntary Medical Male Circumcision Clients Ages 20–29 in Zimbabwe

“…As of the end of 2014, Zimbabwe had reached an estimated 21% MC coverage (including both traditional circumcisions and VMMCs) among 10- to 14-year-olds, 22% coverage among 15- to 19-year-olds, 16% coverage among 20- to 24-year-olds, and 14% coverage among 25- to 29-year-olds. These coverage levels represented increases of 17%, 17%, 8%, and 4% in coverage over baseline levels for these four respective age groups [6]. If these trends continue, the VMMC program will reach 80% coverage among adolescents ages 10–19 long before reaching this level of coverage among adults ages 20–29.…”

“…The circumcisions conducted by the end of 2014 in Zimbabwe were projected to avert 6,300 HIV infections by 2025, with coverage estimated at 19% among 10- to 29-year-olds and 18% among 15- to 29-year-olds [6]. …”

Voluntary Medical Male Circumcision for HIV Prevention: New Mathematical Models for Strategic Demand Creation Prioritizing Subpopulations by Age and Geography

“…The VMMC modeling collection also includes four papers that explore the impact of scale-up progress thus far [4], the potential cost-effectiveness of increasing demand among 20- to 29-year-olds in Zimbabwe [31] the projected contribution of VMMC scale-up to the Fast Track goals in light of the 90-90-90 and 95-95-95 treatment cascade targets [32], and the cost and impact of introducing early infant male circumcision (EIMC) for long-term sustainability of VMMC programs [33]. …”

“…The age-specific impact, cost-effectiveness, and coverage attributable to male circumcisions conducted through the end of 2014 were modeled to assess actual progress in comparison with the scenario of achieving 80% coverage among men ages 15–49 years by 2015 in the original 12 priority countries and in Nyanza Province, Kenya [4]. This work used DMPPT 2.1, which is an updated version of DMPPT 2.0 that begins with the onset of each country’s VMMC program and can vary start and end dates for model outputs.…”

“…Undoubtedly, this is substantial progress, but will staying the course with current strategies maximize HIV prevention benefits? Demand for VMMC services has been lower than expected among men 30 years of age and older, while circumcision of young males ages 10–14 years—an age group outside the original target of 15- to 49-year-olds—accounts for nearly 35% of procedures performed to date [4]. Thus, it is timely for decision makers to examine the implications of what has been achieved thus far and to consider prioritization strategies informed by the results of mathematical modeling.…”