Scaling-up voluntary medical male circumcision – what have we learned?

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Abstract

In 2007, the World Health Organization (WHO) and the joint United Nations agency program on HIV/AIDS (UNAIDS) recommended voluntary medical male circumcision (VMMC) as an add-on strategy for HIV prevention. Fourteen priority countries were tasked with scaling-up VMMC services to 80% of HIV-negative men aged 15–49 years by 2016, representing a combined target of 20 million circumcisions. By December 2012, approximately 3 million procedures had been conducted. Within the following year, there was marked improvement in the pace of the scale-up. During 2013, the total number of circumcisions performed nearly doubled, with approximately 6 million total circumcisions conducted by the end of the year, reaching 30% of the initial target. The purpose of this review article was to apply a systems thinking approach, using the WHO health systems building blocks as a framework to examine the factors influencing the scale-up of the VMMC programs from 2008–2013. Facilitators that accelerated the VMMC program scale-up included: country ownership; sustained political will; service delivery efficiencies, such as task shifting and task sharing; use of outreach and mobile services; disposable, prepackaged VMMC kits; external funding; and a standardized set of indicators for VMMC. A low demand for the procedure has been a major barrier to achieving circumcision targets, while weak supply chain management systems and the lack of adequate financial resources with a heavy reliance on donor support have also adversely affected scale-up. Health systems strengthening initiatives and innovations have progressively improved VMMC service delivery, but an understanding of the contextual barriers and the facilitators of demand for the procedure is critical in reaching targets. There is a need for countries implementing VMMC programs to share their experiences more frequently to identify and to enhance best practices by other programs.

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Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa

Emmanuel Njeuhmeli, Steven Forsythe, Jason Reed … (2011)

Introduction Three randomized controlled trials have shown that voluntary medical male circumcision (VMMC) reduces heterosexual HIV acquisition in men by up to 60% [1]–[3]. On the basis of these trial results, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) now recommend that VMMC be offered to heterosexual men in combination with other effective HIV risk reduction interventions in settings with generalized HIV epidemics and where a substantial proportion of men are not circumcised [4]. The long-term population-level impact of implementing and scaling up VMMC services is expected to be considerable in terms of HIV infections averted, as well as net savings associated with the reduced need for treatment, care, and support of infected individuals. Previous model-based studies estimated that VMMC scale-up in countries with generalized HIV epidemics could result in substantial reductions in HIV transmission and prevalence over time among both men and women [3],[5]–[9]. A recent review of these studies concluded that one HIV infection could be averted for every five to 15 VMMCs performed [10]. Modeling studies also have found that expansion of VMMC services produces net savings when compared to lifetime HIV treatment costs [8],[9],[11]. In addition, studies have shown VMMC to be protective against some other sexually transmitted infections (STIs) in both men and women. VMMC has been found to reduce the risk of herpes simplex virus-2 in men [12] and human papillomavirus in men [12]–[15] and their female partners [16], and is associated with a reduction in the risk of genital ulcer disease [3],[17] and genital cancers [18]–[20] in both men and women. In light of this evidence, in early 2007, WHO and UNAIDS identified the following priority countries for VMMC scale-up: Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya (Figure 1). Four years later, most of these 13 countries have developed plans for VMMC scale-up and are at various stages of program implementation. However, with a few exceptions (e.g., Nyanza Province in Kenya and the Iringa Region in Tanzania), progress in expanding VMMC services remains slow [21]. 10.1371/journal.pmed.1001132.g001 Figure 1 Geographic distribution of HIV and male circumcision prevalence. For the 13 countries included in the study, the map on the left indicates the prevalence of HIV in adults ages 15 to 49 y. The map on the right indicates the percentage of men who are circumcised. There is consensus that VMMC scale-up will require substantial funding and massive efforts to adequately train personnel, equip facilities, and ensure the regular distribution of necessary commodities—mostly in settings with weak health systems and resource constraints. As background for the scale-up of safe VMMC, WHO, UNAIDS, and collaborating partners have developed a number of guidelines and toolkits, including a recommended minimum package of VMMC services [22] and clinical guidelines for the provision of these services [23]. In addition, to facilitate a more rapid scale-up of safe VMMC, WHO has outlined considerations for models to optimize the volume and efficiency (MOVE) of VMMC services [24]. Central to these considerations is the efficient use of facility space through the dedication of multiple surgical beds to one surgical team and the coordination of client flow; the efficient use of staff time through task shifting and task sharing, including deployment of non-physicians to complete all or specific steps in VMMC surgery; and the bundling of commodities and supplies required to perform VMMC, including consumable materials and surgical instruments [24]. To support decision making and planning for VMMC scale-up, the United States Agency for International Development (USAID) Health Policy Initiative collaborated with UNAIDS to develop the Decision Makers' Program Planning Tool (DMPPT) [25]. This modeling tool, which has been reviewed by an expert panel [10], allows analysts and decision makers to estimate the epidemiologic impact and cost of alternative programmatic options for scaling up VMMC. The objective of this study is to estimate the country-specific epidemiologic impact and the cost and net savings associated with scaling up VMMC services based on MOVE considerations in the 13 priority countries in eastern and southern Africa. The perspective that is taken is that of governments and their international partners in their roles as health program funders. To do this, we run country-specific DMPPT models and explore how the results for each country vary by VMMC effectiveness, VMMC coverage level, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and antiretroviral therapy (ART) cost. This study expands on previous related work [8],[9],[11] in several ways. All of our analyses are country-specific and based on the most recent data on HIV and male circumcision prevalence available. Our calculations provide more comprehensive estimates of VMMC-related costs than was the case in previous studies since they include costs for supply chain management and waste management, as per WHO's recent recommendations for efficient VMMC scale-up [24]. In addition, we provide country-specific results on impact (VMMC per HIV infection averted), cost-effectiveness (cost per HIV infection averted) and cost savings (cost of VMMC relative to the averted cost of lifetime provision of ART). Methods The Model The DMPPT is a Microsoft-Excel-based modeling tool that estimates the epidemiologic impact (HIV infections averted) and the cost and net savings associated with different programming scenarios for VMMC scale-up. A list of all the equations used in the model can be found in Table S1. Additional details, including a copy of the workbook and the model manual [25], can be found at http://www.malecircumcision.org/programs/DMPPT.html. The DMPPT is a compartmental deterministic model in which the population is disaggregated into four sex/age groups (females ages 15–24 y, males ages 15–24 y, females ages 25–49 y, and males ages 25–49 y). For each population group, a susceptible and infected population is described [26],[27]. The susceptible population is increased by people aging into it (15-y-olds entering the younger age group and 25-y-olds leaving the younger age group and entering the older age group) and decreased by non-AIDS deaths and new infections. The infected population is increased by new infections and decreased by non-AIDS deaths, AIDS deaths, and aging out. In the model, HIV incidence (the proportion of the susceptible population becoming infected each year) is the product of HIV prevalence in the population and the force of infection. The force of infection is determined by the base rate of infection (which is a fitting parameter specific to each population group), changes in behavior, and changes due to male circumcision. Changes in behavior are assumed to occur as the epidemic progresses because of two key influences. Individuals with the riskiest behaviors are assumed to become infected first and die sooner than the rest of the population. Also, as AIDS deaths accumulate, a powerful effect on individual behavior is assumed, as those who know someone who has died from AIDS are motivated to adopt safer behaviors. Thus, the force of infection can drop over time as the cumulative number of AIDS deaths increases. The amount of the effect is determined by a fitting parameter that produces the best fit to the historical HIV prevalence trend. The impact of other prevention interventions is incorporated through exogenous reductions in the force of infection. The effect of male circumcision on the force of infection is simply the increase in the prevalence of male circumcision multiplied by the reduction in susceptibility due to circumcision. For each scenario of interest, the DMPPT model generates two projections: a baseline projection, in which male circumcision coverage is held constant at the pre-scale-up level, and a scale-up projection where VMMC coverage is scaled up to the desired coverage level. In the baseline projection, new infections increase over time in response to the initial force of infection. This causes HIV prevalence to rise rapidly in early years. The force of infection then declines somewhat as AIDS deaths accumulate and prevalence stabilizes. Implementation of a male circumcision program can cause a further reduction in the force of infection (depending on the increase in male circumcision coverage), leading to a decline in new infections and HIV prevalence. There is some concern that men who undergo circumcision may develop a false sense of protection against HIV and thereafter decrease or even stop previously implemented protective behaviors [28],[29]. Post-circumcision behavior change is modeled in the DMPPT as a proportional change in the force of infection, with a VMMC scale-up scenario in which circumcision does not lead to any behavior change being modeled as having a 0% post-circumcision behavior change effect. The DMPPT model calculates the yearly cost of the additional circumcisions (the number of VMMCs required above and beyond those occurring at pre-scale-up coverage levels) as the sum of the additional circumcisions performed per annum times the VMMC unit cost. The model also calculates the net savings associated with HIV infections averted and the subsequent treatment costs averted. Demographic, Epidemiologic, and Sexual Behavior Data The demographic and epidemiologic inputs required to estimate the epidemiologic impact of VMMC scale-up include the following: Demographic data—size of adult population by sex and age group, adult population growth rate, crude birth rate, crude death rate, proportion of population surviving to age 15 y, pre-scale-up male circumcision prevalence. Epidemiologic data—HIV prevalence among adults by sex and age group; effectiveness of male circumcision in preventing HIV infection; underlying HIV transmission factors based on scientific evidence, including probability of transmission from mother to child; fertility reduction due to HIV. Sexual behavior data—sexual mixing patterns by sex and age group, post-circumcision behavior change (change in condom use and/or change in number of sexual partners following VMMC resulting from lowered perceived risk). We obtained the required demographic, epidemiologic, and sexual behavior data for each country from recent household surveys [30]–[42] and Spectrum, a modeling software package, which includes a demographic platform populated with UN population data [27],[43],[44]. Country-specific pre-scale-up population characteristics, including size of the adult population, adult population growth rate, male circumcision and adult HIV prevalence, and HIV incidence, are shown in Table 1. A complete listing of the data used for each country is available from the authors upon request. 10.1371/journal.pmed.1001132.t001 Table 1 Pre-scale-up population characteristics, by country. Country Population Aged 15–49 y (Millions) Adult Population Growth Rate (Percentage) Male Circumcision Prevalence (Percentage) Adult HIV Prevalence (Percentage) Adult HIV Incidence (Percentage) Botswana 1.08 2.42 10.2 22.9 2.0 Lesotho 1.06 1.34 0.0 23.6 2.9 Malawi 6.84 3.02 20.7 12.5 1.0 Mozambique 10.32 2.45 59.5 12.9 1.4 Namibia 1.09 2.22 21.0 14.1 0.8 Nyanza Province, Kenya 1.51 2.80 44.8 13.1 1.6 Rwanda 4.49 3.29 10.0 3.1 0.3 South Africa 26.84 0.89 44.7 16.9 2.1 Swaziland 0.59 1.51 8.2 26.4 3.2 Tanzania 19.63 2.89 66.8 6.7 0.8 Uganda 14.16 3.87 24.8 6.5 0.7 Zambia 6.85 2.61 10.8 14.9 1.6 Zimbabwe 6.19 1.50 10.3 17.9 2.2 Table 1 provides the size of the 2008 population aged 15–49 y, adult population growth rate, and adult HIV incidence from Spectrum, which is populated with UN population data [27],[43],[44]. The years for the pre-scale-up male circumcision and adult HIV prevalence data are as follows: Botswana (2004) [30], Lesotho (2004) [9],[39], Malawi (2004) [40], Mozambique (2003) [35], Namibia (2007) [38], Nyanza Province, Kenya (2008/2009) [36], Rwanda (2005) [9],[34], South Africa (2008), Swaziland (2006/2007) [32], Tanzania (2007/2008) [42], Uganda (2004) [37], Zambia (2007) [31], and Zimbabwe (2005/2006) [33]. Cost Data A breakdown of the VMMC unit cost used in the model is provided in Table 2. With the exception of the waste management and supply chain costs, the unit cost components are derived from a VMMC costing study conducted in Zimbabwe in 2010 as part of a multi-country study that also included Kenya, Namibia, South Africa, Uganda, and Zambia [45]–[50]. Zimbabwe was chosen because it is one of the first countries to scale up VMMC services following WHO's MOVE considerations for more efficient use of facility space and staff time and for the bundling of the commodities required to perform VMMC [24]. Information on required inputs and costs was collected from sites providing VMMC in Zimbabwe. This includes data on both direct costs (consumables, staff costs, and training costs) and indirect costs (capital costs, maintenance and utility costs, support overhead, and management overhead). Because significant variations in labor costs were noted across countries, we vary the staff costs by country, adjusting them by after tax median monthly disposable salary. We also adjust the costing information collected in the Zimbabwe study for underreporting on waste management and other supply chain costs [51]. We base the waste management costs on a costing analysis conducted in Swaziland, a detailed description of which is provided elsewhere [52]. The VMMC unit cost used for each country is shown in Table 3. 10.1371/journal.pmed.1001132.t002 Table 2 VMMC unit cost components. Category Cost Component Cost (US$) Direct costs Consumables 28.67 Waste management 9.39 Other supply chain 10.91 Staff costs Variablea Training costs 1.70 Indirect costs Capital costs 0.45 Maintenance and utility costs 3.24 Support overhead 4.42 Management overhead 2.32 Table 2 presents the components of the VMMC unit cost used in this study. The VMMC unit cost was derived based on a VMMC costing study conducted in Zimbabwe in 2010 [50] and supplemented with analysis of data from Swaziland. a We vary staff costs by country, adjusting them by after tax median monthly disposable salary. 10.1371/journal.pmed.1001132.t003 Table 3 VMMC unit cost by country. Country VMMC Unit Cost—Base Case (US$) VMMC Unit Cost Range (US$) Botswana 78.07 62.45–93.68 Lesotho 83.78 67.03–100.54 Malawi 83.78 67.03–100.54 Mozambique 86.29 69.03–103.55 Namibia 86.60 69.28–103.92 Nyanza Province, Kenya 74.89 59.92–89.87 Rwanda 80.13 64.10–96.16 South Africa 95.15 76.12–114.18 Swaziland 74.83 59.86–89.79 Tanzania 82.56 66.04–99.07 Uganda 65.85 52.68–79.02 Zambia 89.65 71.72–107.58 Zimbabwe 78.23 62.58–93.87 Table 3 shows the country-specific VMMC unit costs used in the study. To obtain the VMMC unit cost for each country, we vary staff costs in each country, adjusting them by after tax median monthly disposable salary [51]. The range used in the sensitivity analysis is country base case unit cost ±20%. For lifetime HIV treatment costs, we use the default discounted value in the DMPPT model (US$7,400) [25]; we use the same value for all countries. This value includes costs of AIDS treatment and care, including ART, treatment of major opportunistic infections, laboratory tests, and home-based care. The lifetime HIV treatment cost is based on a unit cost of US$155 for first-line antiretroviral drugs and US$1,678 for second-line antiretroviral drugs [53]. We also assume that need for treatment begins after 8 y of infection and that the annual continuation rate on ART is 97.5% [27]. Following common practice in economic evaluation, we apply an annual discount rate of 3% on future expenditures and savings [54] as well as on infections averted [55]. Base Case and Sensitivity Analysis Our analyses are limited to the scale-up of VMMC services among males ages 15 to 49 y who are HIV-negative. For all models, we assume that the scale-up begins in 2011 and that the pace of scale-up is slower at first, followed by a more rapid scale-up, and then another slow period of scale-up, to allow for training and other logistic developments likely to occur in the early stages of implementation. The model observation period for all models is 2011 to 2025. This allows us to evaluate the 15-y impact of VMMC more comprehensively. For the base case, we assume the following: VMMC effectiveness—we use 60% for the protective effect of VMMC and assume that the effect is constant over the model simulation period [1],[56]. Target VMMC coverage level—male circumcision coverage is increased from pre-scale-up levels to 80% of HIV-negative males ages 15 to 49 y. Time to 80% scale-up—male circumcision coverage is increased from pre-scale-up levels to 80% of HIV-negative males ages 15 to 49 in 5 y, with the coverage target reached by 2015 and maintained at 80% thereafter. Post-circumcision behavior change—no post-circumcision behavior change is associated with VMMC scale-up. VMMC unit cost—the VMMC unit cost used for each country is shown in Table 3. Given uncertainty in model inputs, we also conduct sensitivity analyses, exploring various alternative scenarios. We vary VMMC effectiveness, VMMC coverage level, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and lifetime HIV treatment cost as follows: VMMC effectiveness—34% and 77% (versus 60%) [1]. Target VMMC coverage levels—50% and 100% (versus. 80%). Time to 80% scale-up—1, 10, and 15 y (versus 5 y). Post-circumcision behavior change—a 30% post-circumcision behavior change effect is associated with MMC scale-up (versus no post-circumcision behavior change, or 0%). VMMC unit cost—country base case unit cost ±20% as shown in Table 3. Lifetime ART cost—ART cost is assumed to decline over time, leading to a lifetime cost of US$3,400 (versus US$7,400) [53]. Results Base Case—80% VMMC Coverage by 2015 The number of additional VMMCs required to achieve 80% male circumcision coverage by 2015 is presented in Table 4. A total of 20.34 million VMMCs are required to scale up male circumcision coverage to 80% by 2015 in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. When taking the longer-term view (to 2025), an additional 8.42 million VMMCs are required between 2016 and 2025, for a total of almost 29 million VMMCs in the model's full study period (2011–2025). The number of VMMCs needed to achieve 80% male circumcision by 2015 varies by country, with the largest number of VMMCs required in South Africa (the country with the largest population and a high adult HIV prevalence) followed by Uganda (the country with a large and fast-growing population and low baseline VMMC prevalence), Malawi, Zambia, and Zimbabwe (also countries low baseline VMMC prevalence). 10.1371/journal.pmed.1001132.t004 Table 4 Impact of VMMC on HIV infections averted in base case, by country, 2011–2015 and 2011–2025. Country Time Period Additional VMMCs (Millions) HIV Infections Averted (Millions) HIV Infections Averted (Percentage) VMMC per HIV Infection Averted Botswana 2011–2015 0.35 0.01 12 36 2011–2025 0.49 0.06 28 8 Lesotho 2011–2015 0.38 0.01 12 28 2011–2025 0.54 0.11 37 5 Malawi 2011–2015 2.10 0.03 11 66 2011–2025 3.04 0.24 28 13 Mozambique 2011–2015 1.06 0.03 5 38 2011–2025 1.53 0.22 13 7 Namibia 2011–2015 0.33 0.00 9 109 2011–2025 0.48 0.02 25 26 Nyanza Province, Kenya 2011–2015 0.38 0.01 6 36 2011–2025 0.57 0.07 16 8 Rwanda 2011–2015 1.75 0.01 10 239 2011–2025 2.53 0.06 29 44 South Africa 2011–2015 4.33 0.14 7 30 2011–2025 5.94 1.08 20 5 Swaziland 2011–2015 0.18 0.01 12 25 2011–2025 0.27 0.06 34 5 Tanzania 2011–2015 1.38 0.02 3 56 2011–2025 1.98 0.20 9 10 Uganda 2011–2015 4.25 0.05 10 91 2011–2025 6.35 0.34 25 19 Zambia 2011–2015 1.95 0.04 12 43 2011–2025 2.87 0.34 30 8 Zimbabwe 2011–2015 1.91 0.06 13 31 2011–2025 2.17 0.57 42 4 Total 2011–2015 20.34 0.43 8 47 2011–2025 28.76 3.36 22 9 Table 4 presents the additional VMMCs and the impact of VMMC on HIV infections averted for 2011–2015 and 2011–2025 for the base case scenario. HIV infections averted are not discounted. We find a strong impact of scaling up VMMC to achieve 80% coverage by 2015 on the number of adult HIV infections averted. A total of 430,000 HIV infections are averted in the 13 countries between 2011 and 2015, while almost 3.36 million HIV infections are averted by 2025 (Table 4). South Africa is the country with the largest number of HIV infections averted (with more than 1 million infections averted between 2011 and 2025) followed by Zimbabwe, Zambia, and Uganda. More than 20% of new HIV infections are averted between 2011 and 2025 in all countries except Mozambique, Nyanza Province (Kenya), South Africa, and Tanzania (the countries with the highest baseline VMMC prevalence). Zimbabwe is the country with the highest percentage of new HIV infections averted, with 42% of new infections averted between 2011 and 2025. The large benefit of VMMC in Zimbabwe is largely driven by the currently low prevalence of VMMC (10.3%) and high HIV prevalence (17.9%) and incidence (2.2%). The number of VMMCs required to avert one HIV infection is calculated by dividing the additional number of VMMCs required by the number of HIV infections averted over the relevant time period. For the period 2011–2015, the number of VMMCs per HIV infection averted ranges from 25 in Swaziland to 239 in Rwanda, while for the full study period (2011–2025), the number of VMMCs per HIV infection averted ranges from four in Zimbabwe to 44 in Rwanda (Table 4). For the period 2011–2025, the number of VMMCs per HIV infection averted is ten or less in all countries except Malawi, Namibia, Rwanda, and Uganda, each of which has a relatively low incidence of HIV. Although circumcision of HIV-infected men has not been found to directly reduce HIV transmission to their female partners [57], and the primary impact of increasing VMMC coverage is to reduce the number of new HIV infections in men, the number of new infections in women is also reduced. This occurs by reducing the exposure of women to HIV-infected men. That is, as HIV incidence decreases in men following VMMC scale-up, the probability of women encountering infected male partners decreases, with a consequent reduction in HIV incidence among women. The HIV infections averted (presented in Table 4) thus represent infections averted in both men and women. Figure 2 illustrates the male and female HIV infections averted over time, by country, for 2011–2025. In all countries, the cumulative number of male HIV infections averted between 2011 and 2025 is higher than the cumulative number of female HIV infections averted. In the early years, the HIV infections averted occur mostly among men, but over time, the proportion of HIV infections averted in women steadily increases, with new HIV infections averted in women representing almost half of the total HIV infections averted in 2025. 10.1371/journal.pmed.1001132.g002 Figure 2 HIV infections averted in base case, by male and female, by country, 2011–2025. Figure 2 provides data for males and females for 2011–2025 for the base case scenario in which 80% coverage of VMMC is reached in 2015 and maintained thereafter, and there is no post-circumcision risk behavior change. Figure 3 shows the discounted cost of scaling up VMMC to achieve 80% coverage by 2015 for each of the 13 priority countries for the period 2011–2015. The cost ranges from US$12.53 million in Swaziland (the country with the smallest number of additional VMMCs required) to US$376.55 million in South Africa (the country with the highest number of additional VMMCs required), with a total of US$1,520,000,000 needed to scale up VMMC coverage to 80% in the 13 countries by 2015. The cost for the period 2011–2025 is shown in the first column of Table 5. A total of over US$2,000,000,000 is needed to scale up VMMC coverage to 80% by 2015 and maintain this level of coverage in the 13 countries until 2025. 10.1371/journal.pmed.1001132.g003 Figure 3 Cost for scaling up VMMC coverage in base case, by country, 2011–2015. Figure 3 provides the discounted cost of scaling up VMMC coverage for 2011–2015 for the base case scenario in which 80% coverage of VMMC is reached in 2015 and maintained thereafter, and there is no post-circumcision risk behavior change. 10.1371/journal.pmed.1001132.t005 Table 5 Total cost and net savings per HIV infection averted for base case scenario, by country, 2011–2025. Country Cost of VMMC Scale-Up, 2011–2025 (US$ Millions) Cost per HIV Infection Averted, 2011–2025 (US$) Net Savings, 2011–2025 (US$ Millions) Net Savings per HIV Infection Averted, 2011–2025 (US$) Botswana 32.79 693 317.14 6,707 Lesotho 34.97 442 550.57 6,958 Malawi 218.46 1,216 1,110.98 6,184 Mozambique 113.32 704 1,077.25 6,696 Namibia 35.52 2,558 67.21 4,842 Nyanza Province, Kenya 36.38 660 371.23 6,740 Rwanda 173.78 4,096 140.21 3,304 South Africa 489.47 605 5,498.55 6,795 Swaziland 17.18 406 295.88 6,994 Tanzania 140.40 950 953.74 6,450 Uganda 357.29 1,408 1,520.36 5,992 Zambia 220.42 869 1,679.41 6,623 Zimbabwe 153.84 369 2,930.64 7,031 Total 2,023.80 809 16,513.15 6,608 Table 5 provides the discounted cost of scaling up VMMC coverage, cost per HIV infection averted, and net savings per HIV infection averted for 2011–2025 for the base case scenario. HIV infections averted are discounted. Combining the cost data with the number of HIV infections averted, we obtain the discounted cost per HIV infection averted. The cost per HIV infection averted for the period 2011–2025 ranges from US$369 in Zimbabwe, where adult HIV prevalence is 17.9%, to US$4,096 in Rwanda, where adult HIV prevalence is lower than in any of the other 13 countries studied (3.1%). The overall cost per HIV infection averted for 2011–2025 for all 13 countries is US$809. Finally, we calculate the net savings associated with VMMC scale-up. The savings due to future ART costs avoided (with the discounted value of lifetime HIV treatment costs estimated at US$7,400 per infection) minus the discounted VMMC costs amount to US$16,510,000,000 for the 13 countries from 2011 to 2025 (Table 5). The net savings can also be combined with the number of HIV infections averted to obtain the net savings per HIV infection averted. For 2011–2025, this value ranges from US$3,304 in Rwanda to US$7,031 in Zimbabwe. The overall net savings per HIV infection averted for 2011–2025 for all 13 countries is US$6,608. Sensitivity Analysis Table 6 presents the results of the sensitivity analysis. The table provides the values for the HIV infections averted, the number of VMMCs per HIV infection averted, the cost per HIV infection averted, and the net savings per HIV infection averted for 2011–2025 for each parameter examined. The values for the base scenario (80% male circumcision coverage within 5 y) are shown in the third column of Table 6. 10.1371/journal.pmed.1001132.t006 Table 6 Sensitivity analysis of key parameters (2011–2025). Country Results from DMPPT Base Case Scenario VMMC Effectiveness VMMC Coverage Time to Scale-Up BC 30%a Cost per VMMC ART Cost = US$3,400 34% 77% 50% 100% 1 y 10 y 15 y −20% Base Case Cost +20% Base Case Cost Botswana IA 62,773 34,504 82,029 35,620 80,877 75,952 45,226 30,171 62,773 62,773 62,773 62,773 VMMC per IA 8 14 6 8 8 7 10 14 8 8 8 8 Cost per IA (US$) 693 1,253 533 694 694 605 881 1,197 836 555 832 693 Net savings per IA (US$) 6,707 6,147 6,867 6,706 6,706 6,795 6,519 6,203 6,564 6,845 6,568 2,707 Lesotho IA 106,427 60,123 132,245 66,385 129,578 130,568 73,664 46,994 100,848 106,427 106,427 106,427 VMMC per IA 5 9 4 5 5 4 7 10 5 5 5 5 Cost per IA (US$) 442 777 356 440 454 382 579 816 466 354 530 442 Net savings per IA (US$) 6,958 6,623 7,044 6,960 6,946 7,018 6,821 6,584 6,934 7,046 6,870 2,958 Malawi IA 240,685 131,912 315,299 121,012 317,639 292,121 172,169 113,722 172,576 240,685 240,685 240,685 VMMC per IA 13 23 10 12 13 11 16 23 18 13 13 13 Cost per IA (US$) 1,216 2,210 930 1,194 1,233 1,064 1,543 2,100 1,696 973 1,459 1,216 Net savings per IA (US$) 6,184 5,190 6,470 6,206 6,167 6,336 5,857 5,300 5,704 6,427 5,941 2,184 Mozambique b IA 215,861 103,714 314,141 421,592 262,897 153,291 100,400 159,030 215,861 215,861 215,861 VMMC per IA 7 14 5 7 6 9 13 10 7 7 7 Cost per IA (US$) 704 1,440 491 714 615 900 1,235 954 563 845 704 Net savings per IA (US$) 6,696 5,960 6,909 6,686 6,785 6,500 6,165 6,446 6,837 6,555 2,696 Namibia IA 18,373 9,936 24,335 9,243 24,174 23,160 12,520 7,924 12,947 18,373 18,373 18,373 VMMC per IA 26 48 20 25 26 21 36 53 37 26 26 26 Cost per IA (US$) 2,558 4,741 1,929 2,502 2,601 2,134 3,453 4,955 3,629 2,047 3,070 2,558 Net savings per IA (US$) 4,842 2,659 5,471 4,898 4,799 5,266 3,947 2,445 3,771 5,353 4,330 842 Nyanza Province, Kenya IA 73,420 35,776 105,322 2,382 72,961 53,834 32,309 21,649 31,567 44,636 44,636 73,420 VMMC per IA 8 16 5 8 8 7 10 13 11 8 8 8 Cost per IA (US$) 660 1,337 465 661 661 585 820 1,089 933 528 793 660 Net savings per IA (US$) 6,740 6,063 6,935 6,739 6,739 6,815 6,580 6,311 6,467 6,872 6,607 2,740 Rwanda c IA 56,840 32,138 72,988 33,163 72,039 68,999 40,514 26,480 (1,183) 56,840 56,840 56,840 VMMC per IA 44 79 35 43 45 38 58 81 (2,132) 44 44 44 Cost per IA (US$) 4,096 7,248 3,188 4,015 4,152 3,594 5,195 7,118 (192,148) 3,276 4,915 4,096 Net savings per IA (US$) 3,304 152 4,212 3,385 3,248 3,806 2,205 282 N.A. 4,124 2,485 (696) South Africa IA 1,083,869 553,267 1,496,933 164,840 1,677,803 1,340,315 750,846 478,788 954,426 1,083,869 1,083,869 1,083,869 VMMC per IA 5 11 4 5 6 5 7 11 6 5 5 5 Cost per IA (US$) 605 1,161 444 595 614 518 798 1,135 685 484 726 605 Net savings per IA (US$) 6,795 6,239 6,956 6,805 6,786 6,882 6,602 6,265 6,715 6,916 6,674 2,795 Swaziland IA 56,810 31,886 71,520 33,356 70,597 69,466 39,535 25,032 53,234 56,810 56,810 56,810 VMMC per IA 5 8 4 5 5 4 6 9 5 5 5 5 Cost per IA (US$) 406 717 323 401 418 366 534 755 436 325 487 406 Net savings per IA (US$) 6,994 6,683 7,077 6,999 6,982 7,034 6,866 6,645 6,964 7,075 6,913 2,994 Tanzania b IA 199,249 92,261 300,691 492,563 241,090 143,379 95,386 173,793 199,249 199,249 199,249 VMMC per IA 10 21 7 10 9 13 18 11 10 10 10 Cost per IA (US$) 950 2,035 633 967 838 1,190 1,600 1,090 760 1,139 950 Net savings per IA (US$) 6,450 5,365 6,767 6,433 6,562 6,210 5,800 6,310 6,640 6,261 2,450 Uganda IA 339,524 182,516 451,568 157,211 458,128 408,009 245,533 1,654,578 104,102 339,524 339,524 339,524 VMMC per IA 19 35 14 18 19 16 24 32 61 19 19 19 Cost per IA (US$) 1,408 2,615 1,060 1,387 1,422 1,250 1,755 2,322 4,589 1,126 1,690 1,408 Net savings per IA (US$) 5,992 4,785 6,340 6,013 5,978 6,150 5,645 5,078 2,811 6,274 5,710 1,992 Zambia IA 339,632 188,110 441,327 252,260 570,773 536,129 321,756 215,692 407,557 444,352 444,352 339,632 VMMC per IA 8 15 7 8 8 7 10 14 9 8 8 8 Cost per IA (US$) 869 1,560 671 865 874 769 1,082 1,440 948 695 1,043 869 Net savings per IA (US$) 6,531 5,840 6,729 6,535 6,526 6,631 6,318 5,960 6,452 6,705 6,357 2,531 Zimbabwe IA 565,749 311,075 691,348 320,894 686,019 699,894 375,010 231,007 520,864 565,751 565,751 565,749 VMMC per IA 4 7 3 4 4 3 6 9 4 4 4 4 Cost per IA (US$) 369 669 300 370 390 309 523 795 401 292 437 369 Net savings per IA (US$) 7,031 6,731 7,100 7,030 7,010 7,091 6,877 6,605 6,999 7,108 6,963 3,031 Table 6 presents sensitivity analysis for the following key parameters: VMMC effectiveness, VMMC coverage, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and lifetime HIV treatment cost. a BC is post-circumcision risk behavior change. b No models were run for the scale-up to 50% VMMC coverage scenario for Mozambique and Tanzania, since national pre-scale-up VMMC coverage in these two countries was greater than 50%. c Scaling up VMMC in the presence of 30% post-circumcision risk behavior change in Rwanda resulted in an increase in HIV infections. IA, infection(s) averted. The results help to confirm the internal consistency of the DMPPT model and show that, in large measure, the VMMC impact, cost, and savings results that we observe in the base case are robust to changes in VMMC effectiveness, VMMC coverage, time to scale-up, level of post-circumcision behavior change, VMMC unit cost, and lifetime HIV treatment cost. Our analysis varying VMMC effectiveness shows that even if we assume much reduced effectiveness (34% instead of 60%), high numbers of infections are averted and net savings per infection averted are obtained. The same is true if the VMMC coverage target is reduced from 80% to 50% or if the time to achieve 80% VMMC coverage is increased to 10 or 15 y. To assess the potential impact of post-circumcision risk behavior change, the model calculates the impact of risky sexual behaviors reverting to patterns that existed earlier in the epidemic, prior to the scale-up of VMMC services. It should be noted that this impact is different from the early resumption of sexual activity before complete wound healing that can also be an issue of concern in the context of expanding VMMC services. The impact is the result of behavior change due to a false perception that VMMC has eliminated the risk of HIV transmission. As compared to no post-circumcision risk behavior change, assuming 30% post-circumcision risk behavior change results in a decrease in the HIV infections averted, an increase in the numbers of VMMCs per HIV infection averted, an increase in the cost per HIV infection averted, and a decrease in net savings. In all of the countries studied except Rwanda, VMMC scale-up remains cost saving, even with 30% post-circumcision risk behavior change. In Rwanda, the country with the lowest HIV prevalence, scaling up VMMC in the presence of this level of post-circumcision risk behavior leads to an increase in the number of new HIV infections. Predictably, decreasing (increasing) the base case VMMC unit cost by 20% results in a decrease (increase) in the cost per HIV infection averted and an increase (decrease) in the net savings per HIV infection averted in countries. Assuming the lower VMMC unit cost for each country, the cost and net savings associated with scaling up VMMC coverage to 80% by 2015 and maintaining this level of coverage in the 13 countries until 2025 are US$1,620,000,000 and US$16,900,000,000 instead of US$2,020,000,000 and US$16,510,000,000 in the base case. Assuming the higher VMMC unit cost, the cost of scaling up VMMC services in the 13 countries is US$2,430,000,000, resulting in net savings of US$16,090,000,000. Reducing lifetime ART cost from US$7,400 to US$3,400 does significantly reduce the net savings per infection averted in all countries, although it remains well above US$2,000 in almost all countries. Rwanda is the only country where such a reduction in lifetime ART cost would lead to net losses per infection averted. Net savings associated with scaling up VMMC coverage is reduced to US$6,480,000,000 in the 13 countries if lifetime ART cost is US$3,400. Discussion To support decision making and planning for VMMC scale-up in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya, we estimate the country-specific impact and cost of scaling up VMMC services using the DMPPT model developed by the USAID and UNAIDS. Our study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and the resultant cost savings. Model results also show that, although the primary impact of scaling up VMMC coverage is to reduce the number of new HIV infections in men, the intervention also prevents HIV infections in women. While the cumulative number of male HIV infections averted between 2011 and 2025 is higher than the cumulative number of female HIV infections averted, the proportion of HIV infections averted in women steadily increases until HIV infections averted in women represent almost half of the new HIV infections averted in 2025. Our results show that the costs per infection averted are comparable to the estimated cost per infection averted of a number of key HIV prevention interventions implemented in the region. The cost per HIV infection averted, which ranges from US$369 in Zimbabwe to US$4,096 in Rwanda, is below US$1,000 in all countries except Malawi, Namibia, Rwanda, and Uganda. These costs per infection averted are comparable to those of prevention of vertical transmission (US$663 per HIV-positive birth averted), voluntary counseling and testing (US$1,315 per HIV infection averted), and prevention of STIs (US$321–US$1,665) [58]. Our results are somewhat sensitive to changes in VMMC effectiveness, VMMC coverage targets, time to scale-up, and VMMC cost. Nonetheless, all of the values tested for these parameters resulted in lives saved and cost savings for all countries. It is especially important to note that even if VMMC coverage is scaled up to 50% in 5 y instead of to 80%, high numbers of infections will be averted and net savings per infection averted will be obtained in all countries except Mozambique and Tanzania—the two countries where pre-scale-up coverage is higher than 50%. This is critical because even though there is no evidence available yet on the feasibility of scaling up VMMC coverage to 80%, there is evidence that VMMC coverage rates of above 50% can be reached through VMMC scale-up efforts [56]. Similar to the results reported by other authors, our results suggest that post-circumcision risk behavior change is unlikely to completely reverse the benefits of male circumcision, with the possible exception of Rwanda. In the case of Rwanda, the low incidence of HIV (0.3%) means that risk compensation associated with male circumcision could actually make the epidemic worse. In the remaining countries, the negative consequences from a 30% risk compensation would be insufficient to fully reverse the benefits of VMMC. In all countries, it is critical that VMMC programs emphasize that male circumcision is not 100% protective and that condom use and other behavioral risk reductions remain essential [8],[59]. Effective messaging in this regard is critical to ensure that men and their sexual partners do not increase their sexual risk behaviors following VMMC scale-up. This study has a number of limitations. Because this model was designed primarily for advocacy purposes, certain elements are not modeled, including treatment, a more fully articulated age structure, and force of infection, which probably leads to an overestimate of the impact of male circumcision. Another limitation is that we use pre-scale-up male circumcision coverage estimates based on men's self-reported circumcision status in household surveys. There is some evidence that uncircumcised and partially circumcised men may report being circumcised in some populations [60]. Unfortunately, there is no information available on the prevalence of this phenomenon in the countries studied. In the one country where partial circumcision is known to be widely practiced (Lesotho), we assume baseline VMMC prevalence to be at 0% rather than using the self-reported data. Additional limitations relate to our cost assumptions. Ideally, we would have obtained country-specific VMMC unit cost estimates based on the MOVE model instead of only adjusting the staff costs by country based on after-tax median monthly disposable salary. However, this model for delivering VMMC was available in only a limited number of sites. Our VMMC unit cost, which is higher than that used in previous studies [8],[11],[59],[61],[62], reflects a better understanding of the service delivery components required for such a program, including waste management and logistics associated with the scaling up of VMMC services [52]. It should also be noted that countries are procuring the same circumcision kits and are adopting the same service delivery model that was costed in this study. If possible, we would also have adjusted VMMC unit cost over time and scale [63],[64]. However, no information is currently available on how VMMC unit cost might vary over time and with scale. Another limitation is that we do not include costs associated with demand creation in our study [65]. Finally, it would have been preferable for us to obtain country-specific ART costs; however, country-specific data for the 13 countries studied were not available. HIV prevalence and incidence estimates used in the model and how they compare to the actual present and projected prevalence and incidence in each of the selected countries is another factor that affects the accuracy of our findings. A steeper decline in baseline incidence, for example, will result in fewer infections averted as a result of VMMC. Conversely, if these incidence trends are overly optimistic, then the number of infections available to be averted by VMMC may in turn be larger than estimated here. We also recognize that our modeling assumes that males seeking out VMMC services are typical of the general male population in the selected age range. If, for example, those seeking out VMMC services are in fact those who are at least risk of becoming infected (perhaps VMMC clients already disproportionately use condoms), then the benefits of VMMC are likely to be overestimated. Conversely, if those who are at most risk of infection (those with a large number of partners and/or low condom use) are disproportionately attracted to VMMC services, then the modeling presented in this paper may underestimate the value of VMMC scale-up. Given that VMMC client sexual behavior, relative to the behavior of the general male population, remains unknown, it is not possible to determine whether our projections are underestimated or overestimated. There are also a number of prevention benefits that are indirectly associated with seeking out VMMC services. These include the benefits of counseling and testing, STI treatment, and early antiretroviral treatment. For example, for those males who seek out VMMC services but find that they are already HIV-infected, there could be societal prevention benefits if these men subsequently are able to access early treatment and reduce their infectivity. Since we focus only on the direct benefits received by those receiving VMMC and do not quantify any additional benefits of counseling and testing, STI treatment, and early antiretroviral treatment as a result of seeking VMMC services, it is possible that the prevention benefits of VMMC could be underestimated. The past year has been marked by important advances in HIV prevention, including the finding that early treatment initiation reduces sexual transmission by as much as 96% in stable serodiscordant couples [66]. However, the population-level impact of treatment is not currently well known. And coverage of those eligible for antiretroviral treatment under WHO guidelines remains low, with less than half of people needing treatment having access to it in eastern and southern Africa in 2010 [67]. VMMC is a one-time surgical procedure with the promise of substantial impact on population-level HIV incidence. Its effects accrue to both men and women, and it compares favorably with other HIV prevention programs in terms of cost-effectiveness. Countries are adopting WHO/UNAIDS recommendations to incorporate VMMC within their HIV prevention portfolios. Best practices from Kenya [68], Tanzania [69], and South Africa [56] show that with government leadership, community involvement, and collaboration among partners, it is possible to scale up rapidly by implementing service delivery models that take into consideration available resources, efficiency, and quality to achieve the maximum public health impact. To ensure that high coverage rates are achievable, countries and their international partners should allocate enough resources to take advantage of the returns on investment predicted for this biomedical HIV prevention modality. Supporting Information Table S1 Model details and equations. (DOCX) Click here for additional data file.

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Everybody's business -- strengthening health systems to improve health outcomes : WHO's framework for action

(2007)

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Achieving the HIV Prevention Impact of Voluntary Medical Male Circumcision: Lessons and Challenges for Managing Programs

Sema Sgaier, Jason Reed, Anne Thomas … (2014)

Summary Points Large-scale implementation of voluntary medical male circumcision (VMMC) in 14 priority countries of Eastern and Southern Africa has the potential to significantly reduce heterosexual transmission of HIV to males, saving lives, averting suffering, and avoiding health care costs. Resource and capacity constraints pose a serious challenge to the ability of the priority countries to reach their goals for VMMC scale-up. The 13 papers in this collection examine issues of service quality, demand creation, cost, and efficiency faced by governments, donors, and programs. Systematic, evidence-based management of programs and a dynamic culture of learning are proposed to help meet the challenges of VMMC scale-up. Recommendations include greater prioritization and funding of VMMC, strategic targeting and demand creation, a focus on programmatic efficiencies, and exploration of new technologies. Further recommendations are for strengthened data use, improving governments' program management capacity, strategizing for sustainability, and maintaining a flexible scale-up strategy. Introduction Voluntary medical male circumcision (VMMC) has been shown to be effective in reducing the sexual transmission of HIV from women to men (Figure 1) [1]–[4]. Fourteen countries in Eastern and Southern Africa with high HIV prevalence and low levels of male circumcision (MC) are following the recommendations of the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) to expand VMMC services as an HIV prevention strategy [5],[6]. These countries are Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Uganda, the United Republic of Tanzania, Zambia, and Zimbabwe. Modeling studies done in 2009–2011 showed that in these 14 priority countries, achieving 80% circumcision prevalence among males aged 15–49 within five years (“catch-up”), and maintaining this coverage rate in subsequent years (“sustainability”), could avert 3.4 million new HIV infections within 15 years and generate treatment and care savings of US$16.5 billion [7],[8]. VMMC is a highly cost-effective HIV prevention strategy for both generalized and high-prevalence HIV epidemics [7]. It differs from most other prevention methods (e.g., pre-exposure prophylaxis, sexual behavior change, or condom use) in that it only requires a one-time action in order to provide continuous benefits. VMMC has political support at both the global and national levels. Most of the 14 priority countries have developed strategic plans and established infrastructure to implement the plans and scale up VMMC interventions. (These efforts are referred to collectively in this paper as “the VMMC program” or “the program.”) 10.1371/journal.pmed.1001641.g001 Figure 1 Timeline and key milestones of the voluntary medical male circumcision program in 14 priority countries. 6 million circumcisions listed in 2013 is an estimate by PEPFAR and the Bill & Melinda Gates Foundation. RCTs, randomized controlled trials; TWG, technical working group; TAG, technical advisory group; MOVE, Models for Optimizing the Volume and Efficiency of MC services. Nevertheless, the VMMC strategy faces challenges at multiple levels. The goals set out in the Joint Strategic Action Framework (JSAF) are highly ambitious: to circumcise 20.2 million men in five years (2012–2016) across 14 African countries [6]. Furthermore, the choice to be circumcised involves deep-seated values, beliefs, and motivational factors that vary with ethnic, religious, and cultural identities, and must be addressed effectively to generate demand for circumcision. While at a broad level the program is increasing its outputs each year (Figures 2 and 3), the current growth rate of the program is not sufficient to reach the JSAF's goal of 80% coverage by 2016 (Figure 4). 10.1371/journal.pmed.1001641.g002 Figure 2 Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, aggregate, 2008–2013. Number of circumcisions completed each year in millions. Source of 2008–2012 data is the WHO 2012 VMMC report [38]. 2013 numbers have been estimated using data from PEPFAR and the Bill & Melinda Gates Foundation. *CAGR, compound annual growth rate, calculated based on the average proportional growth each year. CAGR (t0,tn) = (V(tn)/V(t0))1/(tn − to) −1, where V(t0) is the start value and V(tn) is the finish value and tn − t0 is the number of years. 10.1371/journal.pmed.1001641.g003 Figure 3 Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, 2008–2012. Totals reflect progress through 2012. Percentage figures represent the achieved proportion of the target of 80% coverage among males ages 15–49, but totals include circumcisions done for all age groups, regardless of the age-range target. Data obtained from WHO 2012 VMMC report [38]. 10.1371/journal.pmed.1001641.g004 Figure 4 Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries: growth scenarios, 2008−2016. Source of 2008–2012 data is the WHO 2012 VMMC report [38]; 2013 figures are estimates, and 2014–2016 figures are projections. In the “no growth” scenario, the program continues to perform the same numbers of circumcisions each year as in 2013. In the “current growth” scenario, the program continues the trend of historical growth rate. This collection of research and review articles, “Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up,” presents new research that underscores both the challenges and the opportunities for the accelerated scale-up of VMMC (Box 1). This review article synthesizes and briefly describes the findings, which focus on four key areas of the VMMC program: (1) quality of services, (2) demand creation, (3) cost, and (4) efficiencies for service delivery. Building on these findings, we propose a set of priority focus areas for the global VMMC program and for the governments of the priority countries, and we highlight new areas of opportunity to accelerate scale-up. Box 1. Scope of the Collection The PLOS Collection “Voluntary Medical Male Circumcision for HIV Prevention: Improving Quality, Efficiency, Cost Effectiveness, and Demand for Services during an Accelerated Scale-up” includes 13 research papers and an overview that highlight key findings from several countries that have moved to high-volume VMMC services, explore challenges faced, and offer recommendations for programs as they scale up VMMC services. It focuses on the following: Quality and efficiency of VMMC services – results of the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale Up (SYMMACS) facility-based survey conducted in Kenya, South Africa, Tanzania, and Zimbabwe Costing and Impact – findings from three studies by PEPFAR through the USAID funded Health Policy Project of interest to decision-makers determining allocation of HIV prevention resources Demand Creation – studies from Kenya, Zimbabwe, and Tanzania highlight importance of tailoring demand-creation interventions and service delivery models to specific age group of clients Quality of VMMC Services Ensuring safe and efficient execution of the VMMC procedure and high-quality pre- and post-procedure services, even as programs expand rapidly, is essential in order to realize the full impact of VMMC, reduce program costs, and increase and sustain demand for the service. While most previous quality assessments focused on adverse events in clients [9], two papers in this collection examine facility preparedness for providing quality surgical services using data across two years of program scale-up. Jennings and colleagues undertook a comparative assessment of facility preparedness and surgery in Kenya, South Africa, Tanzania, and Zimbabwe through direct observation [10]. Results for facility preparedness were mixed: in some settings, improvements were seen over time, while in others, early problems that went uncorrected prior to expansion were amplified system-wide at scale. Rech and colleagues explored in further detail the implications of scale-up in South Africa [11]. They assessed readiness to provide quality services and quality of surgical care in 2011 and 2012. Rapid scale-up in South Africa led to human resources being stretched too thinly, with negative effects on quality overall. These studies, and a further study of surgical efficiencies and quality of surgical technique in VMMC in Kenya, South Africa, Tanzania, and Zimbabwe [12], remind us that while it is possible to maintain high standards of surgical care during rapid scale-up (Zimbabwe is a good example), there is always a need to manage adverse events by proactively following up with clients and facilitating postoperative services. As programs expand, it is also necessary to improve initial and refresher training for providers on all aspects of the VMMC service package, strengthen ongoing quality and performance assessments, reinforce supervision and mentoring, and create functional systems to continuously assess and improve service quality. Demand Creation There is general agreement among the authors about the need to foster greater demand among men for VMMC in order to achieve the desired reduction in HIV incidence [6]. Although most programs aim to reach men aged 15–49, those over 25 are underrepresented thus far in the scale-up [13]. Two studies have explored barriers to and facilitators of demand [14], and three papers in this collection specifically address men aged 25 and above, a group for whom the reasons for low demand are not well understood, and whose contribution to HIV prevalence is currently being evaluated by new modeling work. Macintyre and colleagues examined barriers to and facilitators of demand in Turkana County, Kenya, a traditionally non-circumcising community [15]. Older married men did not consider themselves at risk of acquiring HIV, and they echoed the findings of other literature on acceptability in viewing circumcision as more appropriate for younger men, whom they perceived as being at higher risk of HIV [16]–[20]. The authors argue that promoting circumcision as a modern, biomedical procedure rather than as a cultural practice (which may be associated with other tribal groups or young men's rites of passage) will be an important demand-creation message in this particular setting. In Zimbabwe, Hatzold and colleagues conducted quantitative and qualitative studies to explore barriers to and motivating factors for VMMC and to assess the use of existing VMMC communication channels to promote VMMC [21]. A large majority of the respondents had heard about VMMC, mainly through radio. Prevention of HIV was the most cited motivator for circumcision, but men were also motivated by prospects for improved hygiene. Non-HIV-related benefits could be part of the messaging for demand-creation activities. Only 11% of all the men surveyed had been circumcised, and among male respondents expressing an unwillingness to become circumcised, fear of pain was the most frequently cited reason. The paper does not directly identify the reasons why men who expressed a willingness to undergo VMMC had not yet done so, and further research on this would be useful. However, three primary predictors of VMMC uptake were identified: self-efficacy (the belief that one can make the decision oneself to be circumcised), social support from friends, and availability of VMMC services. The study of the modality and intensity of service delivery in Tanzania and Zimbabwe by Adamu and colleagues [22] shows that campaigns conducted during school holidays lead to higher attendance by younger clients, an effect enhanced in Tanzania by the cultural preference for circumcision at a younger age [23]. This underscores the importance of considering cultural preferences and service delivery timing when designing demand-creation approaches. Costs While modeling showed that scaling up VMMC to 80% coverage among men aged 15–49 in the 14 priority countries could result in savings of US$16.5 billion in treatment costs, the resources required to achieve this are substantial—an estimated US$2 billion [7],[8],[24]. Three papers in this collection undertake unit cost analyses to identify the cost drivers and explore where efficiency gains are possible. Bollinger and colleagues (data from Kenya, Namibia, South Africa, Tanzania, Uganda, and Zambia) and Menon and colleagues (data from three regions of Tanzania) use programmatic and financial data (including direct and indirect costs) from VMMC facilities to determine the unit cost of a surgical VMMC [24],[25]. Both studies illustrate that the two largest cost drivers are personnel (36% of costs) and commodities (28%), with ranges varying by country and model of service delivery. An economies-of-scale analysis suggests that further cost reductions will be seen as the supply side of the program plateaus [24]. These studies highlight the possibility of further efficiency gains in the personnel and consumables components of the program by maximizing efficiencies in human and material resources and technology. Three independent modeling studies, including one in this issue, using different starting assumptions, have forecast little if any cost savings with the initial use of circumcision devices such as PrePex and Shang Ring [26]–[28]. Njeuhmeli and colleagues note that the single greatest determinant of unit cost was site utilization, with underutilization doubling the per-procedure price, regardless of whether circumcision was device-based or surgical [28]. Device-based circumcision has yet to be provided as a routine procedure under efficiency conditions, as surgical circumcision is currently provided. If device-based service models function closer to maximum capacity, decreased unit costs could be realized. However, there will always be a need for national programs to provide surgical circumcision for men who are not eligible for devices or who prefer surgery. A major limitation of the cost studies in this collection is that they do not include the costs of demand creation nor analyze how increased spending on demand creation might affect the actual demand for services. This is partly because of limitations in the available data. In future studies, it will be important to address this knowledge gap. Efficiencies Several papers in this collection explore improvements in the efficiency of service delivery, with specific emphasis on efficiencies around the surgical procedure, using data from Kenya, South Africa, Tanzania, and Zimbabwe [9]. None of the four countries surveyed had adopted all six elements of surgical efficiency tracked by the data, which were (1) use of multiple surgical beds, (2) use of pre-bundled surgical supply kits, (3) task-shifting, (4) task-sharing, (5) use of forceps-guided surgical method, and (6) use of electrocautery. The use of the forceps-guided surgical method was the only element adopted by all countries. Rech and colleagues found that innovative human resource models such as the sharing of tasks among a coordinated team of clinicians, as well as electrocautery and the use of multiple beds, reduced the overall procedure time and increased the number of clients served by the primary surgeon in a given period of time [12]. An encouraging finding was that the quality of surgical technique was not compromised by reducing the amount of time the primary provider spent with each client, meaning that quality was maintained in high-service-volume settings. In fact, in South Africa, reduced operating time was associated with higher surgical quality, which the authors suggest might be the result of experienced providers being more skilled and working more efficiently. While these papers focus on efficiencies that could be gained at the site level, an assessment of efficiency gains at the macro level of overall program delivery is also needed, as discussed below. Mavhu and colleagues found that providers held positive attitudes toward the six recommended elements of surgical efficiency in countries where national policies were supportive [29]. This study highlights the value of consulting with those who will implement policies at the service-delivery level. The finding that national policy bodies in South Africa and Zimbabwe did not adopt task-shifting—even though providers supported it—is significant, because task-shifting could alleviate the human resources constraint that is a major challenge to the scale-up of VMMC in these countries. Perry and colleagues identified factors associated with provider burnout (physical or emotional exhaustion as a result of prolonged stress or frustration) and explored a possible relationship between burnout and job satisfaction [30]. In 2012, more than three-fourths of providers surveyed in Kenya, South Africa, Tanzania, and Zimbabwe reported that providing VMMC was personally fulfilling. Providers' median work span in VMMC was longest in Kenya (31 months), but the proportion of providers who reported that they were starting to experience burnout was much higher there (67%) than in the other three countries. However, the study failed to identify any correlates associated with burnout in Kenya. Discussion The VMMC program is an ambitious public health intervention. While it is estimated that close to 6 million circumcisions had been completed by the end of 2013, against a goal of 20.2 million by 2016, this progress should be viewed within the context of the recent and rapidly developing understanding of the importance of VMMC as an HIV prevention intervention (Figure 1). Less than three years after a consensus was reached to recommend VMMC as an additional HIV prevention intervention in countries with high HIV prevalence and low MC rates [6], 11 of the 14 priority countries had approved national VMMC strategies and operational plans. The program has been scaling up in many countries since then, with the result that the number of circumcisions performed each year, which in 2008 had been only 0.02 million, grew to an estimate of at least 2.8 million in 2013, representing a compound annual growth rate of 166% (Figure 2). Despite the rapid implementation and scale-up of VMMC programs and the doubling of the cumulative total VMMC procedures in the past year (from 3.2 million by the end of 2012 to an estimated 5.8–6 million by the end of 2013), progress at the country level has varied widely (Figure 3) and the year-on-year rate of growth in the number of VMMCs performed is declining (Figures 2 and 4). This is due to a combination of factors: the JSAF goal of reaching 80% of uncircumcised men by 2016 did not fully take into account country-specific constraints that have tempered the pace of scale-up, lack of sufficient demand, and insufficient funding from a broad base of international donors (the United States President's Emergency Plan for AIDS Relief [PEPFAR] has funded more than 80% of circumcisions to date). Modeling suggests that even if the current growth rate is maintained and adequate funds are forthcoming, the number of VMMCs completed by 2016 would fall about 3 million short of the JSAF goal of 20.2 million (Figure 4). This collection provides an opportunity to reflect on ways to maximize the potential of the VMMC program during the remainder of the accelerated scale-up period (until 2016) (Box 2). This means prioritizing strategies that can improve programmatic impact and efficiency in order to avert the greatest possible number of HIV infections through VMMC within realistic cost and capacity constraints, as well as taking into account funds available for VMMC. Box 2. Key Points from the Collection Quality of services: It is possible to maintain and even improve service quality, especially surgical performance, as VMMC is scaled up, but improved provider training is needed to strengthen quality of pre- and postoperative care and infection control. Costs: Personnel and consumables are the largest cost drivers, but costs may be reduced as programs scale up and economies of scale are achieved, as well as by improving service efficiency. Underutilization of service capacity increases unit costs more than any other variable, highlighting the importance of predictable demand and nimble service platforms so that sites are consistently performing as close to capacity as possible. Responsible public-sector pricing strategies for devices have the potential to reduce overall unit costs, and further discounts should be negotiated as procurement volumes increase. Demand creation: Messaging must be tailored to different age groups and to the cultural norms of different communities. Men aged 25 and above are less motivated to undergo VMMC. Studies suggest that we need to go beyond simple HIV messaging and present VMMC in terms of hygiene, appearance, attractiveness to partners, peer group norms, and modernity. Efficiencies: Adoption of various elements of surgical efficiency is variable between countries studied. Task-sharing, sharing, bundling of surgical instruments, and electrocautery are associated with surgical efficiency outcomes, and surgical quality need not be compromised by measures to reduce operating time. We believe it is essential to take a systematic approach to improving the design, implementation, and evaluation of the program. Several enabling factors and levers may accelerate and maximize the impact of scale-up (Figure 5). These enabling factors—leadership, policy, and to a certain extent funding—are largely in place both globally and in VMMC priority countries. Increased funding for VMMC is needed to meet the growing targets and outputs of the program. Given that PEPFAR is the predominant donor, getting other donors and governments to contribute is essential. In addition, the levers for scale identified in Figure 5 (government program management capacity, use of data for decision-making, and technologies) require further strengthening in order to match supply and demand. This challenge may be met by incorporating principles of managing large-scale enterprises such as standardization of service delivery and training, market segmentation, and data-driven management [31]. Building on the findings presented in this collection, we propose below a set of actions for the VMMC community. 10.1371/journal.pmed.1001641.g005 Figure 5 Enabling factors and levers to achieve scale and impact for the voluntary medical male circumcision program. Strong enabling factors of leadership, policy, and financing are needed to accelerate and maximize the impact of scale-up of the VMMC program. The levers for scale—government management capacity, use of data for decision-making, and technologies—are needed to match supply and demand. Action Recommendations Continue advocating for prioritization and funding for VMMC The program faces increasing competition for declining funding for HIV prevention and treatment. The funding need for VMMC remains significant, and continued evidence-based advocacy is necessary to secure funds for accelerated scale-up from a broad base of donors. One way to do this is to evaluate the population-level impact of those VMMC programs that have already been scaled up. Another is to continue to draw comparisons between VMMC and other HIV prevention programs, highlighting specifically that if VMMC coverage reaches the JSAF goal of 80%, it will prove the most cost-effective and cost-saving HIV prevention intervention in Eastern and Southern Africa. In addition, it does not require sustained adherence, and there is evidence that referrals made from the VMMC program increase HIV-positive males' access to treatment [32]. Increase program efficiency by identifying and prioritizing those most at risk of acquiring HIV Circumcisions performed on those males most at risk of acquiring HIV will have the greatest epidemiological impact in terms of HIV infections averted [7]. There is an opportunity to strategically prioritize subpopulations (for example, by age and geography) to maximize the program's impact and efficiency within the required time period, while also ensuring that VMMC is available to all males who want it. Given what is known about the relatively low uptake of VMMC among men aged 25 and above [14],[23], we also recommend more modeling to ascertain the relative contribution of this subgroup to overall infections averted in the short and long terms. Focus on program efficiency and quality at all levels, and on matching supply with demand While a large portion of this collection focuses on surgical efficiency or quality [9]–[12], the bigger challenge is overall programmatic efficiency. The challenge of scale-up can be approached as a management challenge that requires addressing each element of the delivery value chain (the specific activities that deliver the end product to the user), using time and resources appropriately, and matching supply with demand for VMMC services while working to increase both. Human resource constraints must be addressed in some places (e.g., through the sharing of clinical tasks [33]), while mechanisms to monitor the quality and safety of the rapidly expanding programs must also be enhanced [11],[12]. Advocacy for including surgical circumcision within the scope of practice for nurses (task-shifting) should be sustained in those countries that have not yet adopted it. Supply of VMMC services must be calibrated to meet demand and located in areas where it will reach the prioritized populations. Explore the role technologies, especially devices, can play in accelerating scale-up The cost of circumcision devices and other supply chain costs must be brought down considerably if devices are to reduce overall program costs. This will require advocacy as well as negotiation with manufacturers and suppliers in tandem with demand-creation activities. We recommend further study to ascertain whether devices make circumcision more attractive to men and to understand whether devices could assist with balancing supply and demand to help achieve needed programmatic efficiencies. It is also important to tailor demand-creation activities for devices in order to reach those who may already be aware of circumcision's benefits but who have avoided conventional surgical methods. Rethink demand creation through market segmentation and insights from other disciplines More needs to be done not only to stimulate demand for VMMC [15],[21],[22], but also to normalize it, or at least to better forecast the fluctuations in demand that are apparent in many places [15]. Barriers and facilitators to uptake of services must be understood, with male populations properly segmented demographically to make best use of limited resources. To date little research has looked at the male population as a market of consumers of an intervention with multiple benefits. A market research approach, along with insights from diverse fields such as behavioral economics and anthropology, can provide new tools to inform the development of new approaches. More funding should be allocated to systematically evaluate the effectiveness of the many approaches to creating and mobilizing demand. Those that show positive results should be taken to scale. Gather and use standardized, high-quality data for program management and decision-making A broad range of data should be collected and reported on a frequent and regular basis and used by program managers at all levels to analyze program constraints and manage supply and demand [34]. Examples of such data include the performance of a site (i.e., the number of VMMCs performed) against its functional capacity and projected demand; the demand-creation channels that bring individuals to specific VMMC sites; daily outputs of community members engaged to generate demand; and information on seasonal fluctuations in demand [35]. We recommend that systems and tools be developed to empower and enable managers to use data for day-to-day decision-making and to adjust services in real time. Useful lessons may be learned from other programs (e.g., the Avahan India HIV prevention program), including the use of micro-planning [36]. There is a related need for continual analysis of cost drivers to see where efficiency gains are possible [24]. However, cost analysis should look at the overall program—not just the cost of individual procedures—and should include management, the cost of demand-creation activities, and the opportunity cost of underutilized services sites. Strengthen government capacity to manage and coordinate programs We recommend exploring ways to support the program management capacity of national and subnational governments to coordinate multiple donors and implementers [37], manage competition for limited human resources and health infrastructure, and avoid duplication of efforts. Governments must also lead in strategic planning, including target-setting, geographic prioritization, quality assurance, and monitoring and evaluation. Related to this is the need to support government capacity for streamlined data collection using tracking systems that are standardized across implementers. Strategize for the sustainability phase of the program It is important to begin strategizing for the sustainability phase that should follow the present “catch-up” activities. It will take time to determine the best approach to sustaining high MC prevalence in each country, develop global and national frameworks, secure resources, and implement long-term programs. Since the cohorts prioritized in the sustainability phase will likely be some combination of uncircumcised boys (aged 10−14 years) and infants (aged 0−60 days), it will also be important to explore how best to reach young adolescents and parents of infants, taking into account impact, cost, the feasibility of scale-up, cultural acceptability, and other factors. Keep strategy dynamic, informed by a strong monitoring, evaluation, and learning platform Our final recommendation is that ministries of health, donors, program planners, and implementers strive to maintain a dynamic strategy and evidence-based programs that are agile and able to correct their course when necessary. This is crucial because of the constantly developing understanding of the complexities and challenges of managing VMMC supply and demand, dealing with new technologies, managing costs, and improving efficiency and quality. For this reason too, investment in disseminating and incorporating lessons learned, informed by monitoring and evaluation data, should also be prioritized (Box 3). Box 3. What Needs to Be Done to Accelerate Scale-up and Impact of the VMMC Program? Continue advocating for prioritization and funding for VMMC. Increase program efficiency by identifying and prioritizing those most at risk of acquiring HIV. Focus on program efficiency and quality at all levels, and on matching supply with demand. Explore the role that technologies, especially devices, can play in accelerating scale-up. Rethink demand creation through market segmentation and insights from other disciplines. Gather and use standardized, high-quality data for program management and decision-making. Strengthen government capacity to manage and coordinate programs. Strategize for the sustainability phase of the program. Keep strategy dynamic, informed by a strong monitoring, evaluation, and learning platform. Conclusion Large-scale implementation of VMMC has the potential to significantly reduce the incidence of HIV infection among men having heterosexual sex. In the 14 priority countries of Eastern and Southern Africa, the prospective gains through lives saved, suffering averted, and health care costs avoided make VMMC programs a crucial intervention in the struggle against HIV and AIDS. This realization is reflected in the considerable progress already made in scaling up VMMC programs; but resource and capacity constraints pose a serious challenge to the ability of the priority countries to reach the goal set out in the JSAF. This challenge, readily acknowledged by the countries themselves, is also reflected in a growing body of research that examines the complexity of designing, implementing, scaling up, and evaluating VMMC programs. We believe that many of these challenges can be addressed through systematic, evidence-based management of the programs and a dynamic culture of learning. The papers in this collection add further to our understanding of issues of cost, demand creation, efficiency, and service quality. They represent a significant contribution to our knowledge and help point the way toward the achievement of the VMMC program's ambitious goals.

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Journal ID (nlm-ta): HIV AIDS (Auckl)

Journal ID (iso-abbrev): HIV AIDS (Auckl)

Journal ID (publisher-id): HIV/AIDS – Research and Palliative Care

Title: HIV/AIDS (Auckland, N.Z.)

Publisher: Dove Medical Press

ISSN (Electronic): 1179-1373

Publication date Collection: 2014

Publication date (Electronic): 08 October 2014

Volume: 6

Pages: 139-146

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[1 ]International Training and Education Center for Health, Botswana, Gaborone, Botswana

[2 ]Department of Global Health, University of Washington, Seattle, WA, USA

Author notes

Correspondence: Bazghina-werq Semo, PO Box AC46, ACH, Riverwalk, Gaborone, Botswana, Tel +267 390 0925, Fax +267 390 0952, Email bazsemo@ 123456uw.edu

*These authors are joint first authors

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Publisher ID: hiv-6-139

DOI: 10.2147/HIV.S65354

PMC ID: 4199973

PubMed ID: 25336991

SO-VID: 64e2950d-9088-4781-876d-960d30446aae

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The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

Scaling-up voluntary medical male circumcision – what have we learned?

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