VMMC: HIV prevention in Eastern and Southern Africa
In 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.
In March 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended male circumcision (MC) as an additional method of HIV prevention, and urged countries with low MC prevalence and generalized HIV epidemics to rapidly scale up voluntary medical male circumcision (VMMC) programs in the context of combination prevention. Acting on this recommendation, several countries set up programs that offered VMMC to males requesting the procedure. These programs included promotion of condoms and safer sexual practices, treatment for sexually transmitted infections, and HIV testing and counseling with linkage to HIV care and treatment for those diagnosed with HIV.
Several mathematical models estimated the impact on the HIV epidemic of scaling up VMMC programs in diverse African regional settings (sub-Saharan Africa, southern Africa, and eastern Africa) and specific countries (Botswana, Kenya, South Africa, and rural Uganda). A consensus meeting in 2008 examined the models and generated answers to key policy questions on VMMC scale-up. This led to the development of a detailed impact and costing model called the Decision-Makers’ Program Planning Tool (DMPPT), designed to help national policy makers decide the scope and pace of their country’s VMMC scale-up.
In 2011, the DMPPT was used to model the impact and cost of VMMC scale-up in 13 high-priority countries in eastern and southern Africa with high HIV incidence and low MC coverage (Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province, in Kenya). The model estimated that 20.3 million circumcisions would be required to increase circumcision prevalence from 2011 baseline levels to 80% by the end of 2015 in men ages 15–49 years. It predicted that if 80% male circumcision prevalence was then maintained through 2025 (requiring an additional 8.4 million circumcisions over 10 years), a total of 3.36 million HIV infections would be averted over the period 2011–2025, representing 22% of expected new HIV infections. Based on limited pilot program data, the estimated median cost per circumcision was $83 USD (range $66–$95 USD), leading to an estimated median cost of $700 USD (range $370–$4,100 USD) per infection averted. (All subsequent references to currency are in U.S. dollars.) Compared with an estimated lifetime HIV treatment cost of $7,400, the model predicted excellent value for money when averted treatment costs were considered.
VMMC programs have now been implemented in the original 13 high-priority countries plus Ethiopia. In light of five years of accumulated implementation experience, a new mathematical model—the Decision Makers’ Program Planning Tool, Version 2 (DMPPT 2)—was created to address questions having to do with age and geographic prioritization. DMPPT 2 projects the impact, cost, and cost-effectiveness of VMMC scale-up disaggregated by five-year client age group and subnational region. It provides scenarios for continued expansion of VMMC programs to reach and maintain specified coverage targets by age group, and incorporates new HIV incidence estimates from country surveillance data collected since 2010. Elsewhere in this collection, we describe this model, along with five country model applications.
By the end of 2014, the 14 countries had provided VMMC to more than 9 million men, nearly half way to the original target of 20 million. Given lessons learned from implementation, new modeling studies, and changes in the HIV field, we thought it timely to reassess progress toward the targets and project the impact of the VMMCs conducted already through 2014. The future HIV incidence projections used in the model in this paper are informed by new surveillance data and assume scaling up antiretroviral therapy (ART) to reach the 90-90-90 treatment goals by 2020 proposed by UNAIDS. (These goals stipulate that, by 2020, 90% of those with HIV will be diagnosed, 90% of those diagnosed will be on ART, and 90% of those on ART will be virally suppressed.) Because these new HIV incidence projections affect the projected impact of VMMC, we used the new DMPPT 2 model to re-run the 2011 impact projections from the first version of DMPPT, allowing us to compare results between the two models. Further exploration of the impact and cost of scaling up VMMC in the context of the 90-90-90 goals is described in another paper in this collection.
This paper assesses the impact, cost-effectiveness, and age-specific coverage attributable to circumcisions performed through the end of 2014. It compares actual progress against the initial 80% coverage targets and presents new insights on coverage and impact by age group that may help countries develop future targets and operational plans.
Palladium's Melissa Schnure, Health Practice Associate, contributed to this article in Plos One. To view the full article, please click here.