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

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          Abstract

          Background

          Zimbabwe aims to increase circumcision coverage to 80% among 13- to 29-year-olds. However, implementation data suggest that high coverage among men ages 20 and older may not be achievable without efforts specifically targeted to these men, incurring additional costs per circumcision. Scale-up scenarios were created based on trends in implementation data in Zimbabwe, and the cost-effectiveness of increasing efforts to recruit clients ages 20–29 was examined.

          Methods

          Zimbabwe voluntary medical male circumcision (VMMC) program data were used to project trends in male circumcision coverage by age into the future. The projection informed a base scenario in which, by 2018, the country achieves 80% circumcision coverage among males ages 10–19 and lower levels of coverage among men above age 20. The Zimbabwe DMPPT 2.0 model was used to project costs and impacts, assuming a US$109 VMMC unit cost in the base scenario and a 3% discount rate. Two other scenarios assumed that the program could increase coverage among clients ages 20–29 with a corresponding increase in unit cost for these age groups.

          Results

          When circumcision coverage among men ages 20–29 is increased compared with a base scenario reflecting current implementation trends, fewer VMMCs are required to avert one infection. If more than 50% additional effort (reflected as multiplying the unit cost by >1.5) is required to double the increase in coverage among this age group compared with the base scenario, the cost per HIV infection averted is higher than in the base scenario.

          Conclusions

          Although increased investment in recruiting VMMC clients ages 20–29 may lead to greater overall impact if recruitment efforts are successful, it may also lead to lower cost-effectiveness, depending on the cost of increasing recruitment. Programs should measure the relationship between increased effort and increased ability to attract this age group.

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          Most cited references12

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          Acceptability of Male Circumcision for Prevention of HIV/AIDS in Sub-Saharan Africa: A Review

          Based on epidemiological, clinical and experimental evidence, male circumcision (MC) could have a significant impact on the HIV epidemic in selected areas. We reviewed studies of the acceptability of MC in sub-Saharan Africa to assess factors that will influence uptake of circumcision in traditionally non-circumcising populations. Thirteen studies from nine countries were identified. Across studies, the median proportion of uncircumcised men willing to become circumcised was 65% (range 29–87%). Sixty nine percent (47–79%) of women favored circumcision for their partners, and 71% (50–90%) of men and 81% (70–90%) of women were willing to circumcise their sons. Because the level of acceptability across the nine countries was quite consistent, additional acceptability studies that pose hypothetical questions to participants are unnecessary. We recommend pilot interventions making safe circumcision services available in conjunction with current HIV prevention strategies and evaluating the safety and acceptability of circumcision.
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            Understanding the Impact of Male Circumcision Interventions on the Spread of HIV in Southern Africa

            Background Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes – either alone or in combination with other established approaches – is not known and no further field trials are planned. We have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level. Findings Our results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25–35%, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision , i.e. ‘risk compensation’, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall. Conclusions Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches.
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              Lessons learned from scale-up of voluntary medical male circumcision focusing on adolescents: benefits, challenges, and potential opportunities for linkages with adolescent HIV, sexual, and reproductive health services.

              By December 2013, it was estimated that close to 6 million men had been circumcised in the 14 priority countries for scaling up voluntary medical male circumcision (VMMC), the majority being adolescents (10-19 years). This article discusses why efforts to scale up VMMC should prioritize adolescent men, drawing from new evidence and experiences at the international, country, and service delivery levels. Furthermore, we review the extent to which VMMC programs have reached adolescents, addressed their specific needs, and can be linked to their sexual and reproductive health and other key services.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                26 October 2016
                2016
                : 11
                : 10
                : e0164144
                Affiliations
                [1 ]Health Policy Project, Avenir Health, Washington, District of Columbia, United States of America
                [2 ]Population Services International, Harare, Zimbabwe
                [3 ]Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe
                [4 ]Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
                [5 ]The United States Agency for International Development (USAID), Washington, District of Columbia, United States of America
                [6 ]USAID, Harare, Zimbabwe
                Cardiff University, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                • Conceptualization: KK.

                • Data curation: KH.

                • Formal analysis: KK.

                • Funding acquisition: NKL EN.

                • Investigation: KK.

                • Methodology: KK.

                • Project administration: KK EN.

                • Resources: KH OM GN SX NKL.

                • Software: KK.

                • Supervision: KH EN.

                • Validation: KH OM GN SX EG KSA NKL EN.

                • Visualization: KK.

                • Writing – original draft: KK.

                • Writing – review & editing: KK KH OM GN SX EG KSA NKL EN.

                Author information
                http://orcid.org/0000-0001-5370-4827
                Article
                PONE-D-16-12802
                10.1371/journal.pone.0164144
                5082672
                27783637
                05dbc1cf-e072-4ae4-a1f4-ed41441250fb

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 30 March 2016
                : 20 September 2016
                Page count
                Figures: 6, Tables: 3, Pages: 16
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000200, United States Agency for International Development;
                Award ID: AID-OAA-A-10-00067
                Funded by: funder-id http://dx.doi.org/10.13039/100000200, United States Agency for International Development;
                Award ID: AID-OAA-14-00026
                This manuscript is made possible by the generous support of the American people through the United States President’s Emergency Plan for AIDS Relief (PEPFAR) with the United States Agency for International Development (USAID) under the Cooperative Agreement Health Policy Project, Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010, and Cooperative Agreement Project SOAR (Supporting Operational AIDS Research), number AID-OAA-14-00026. The Health Policy Project is implemented by Futures Group, in collaboration with Plan International United States of America, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The funder was involved in study design, decision to publish, and preparation of the manuscript. The findings and conclusions in this paper do not necessarily represent the views or positions of PEPFAR, USAID, or the United States Government.
                Categories
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