Catherine Hankins MD MSc FRCPCChief Scientific Adviser to UNAIDS

Office of the Deputy Executive Director

Scaling up male circumcision programmes in Eastern and Southern Africa: Country Update-

lessons, opportunities, challenges

Arusha, Tanzania, June 8-10, 2010

Assessing Costs and Impact on the Epidemic of Male Circumcision using

the Decision-Makers Programme Planning Tool: Overview and

methodology

2005• July RCT South Africa (PLoS Med Nov 2005) • Nov 11stst modelling meeting (Geneva, Switzerland) modelling meeting (Geneva, Switzerland)

2006• July Modelling Williams (PLoS Med)• Dec RCTs Uganda and Kenya (Lancet Feb 2007)2007• March WHO/UNAIDS recommendations

Modelling Nagelkerke (BMC Inf Dis)Modelling Gray (AIDS)

• Nov 22ndnd modelling meeting (Stellenbosch, South Africa) modelling meeting (Stellenbosch, South Africa)Modelling Podder (Bull Math Biol); DMPPT presentedDMPPT presented

2008• March 33rdrd modelling meeting (London, UK) modelling meeting (London, UK)

Modelling Londish (Int J Epidemiol)Modelling Hallett (PLoS ONE)Modelling White (AIDS)Modelling Alsallaq (Mexico abstract # MOPE0254)Modelling Fieno, (AIDS Care); DMPPT refinedDMPPT refined

2009 Expert Group Results (PLoS MedicinePLoS Medicine)

Trial Results and Modelling Timeline

3 meetings convened by UNAIDS/WHO/SACEMA

Expert Review Group ConsensusExpert Review Group ConsensusIn high HIV prevalence/low male circumcision

settings, models predict that:

• One HIV infection averted for every 5-15 male circumcisions performed.

• Costs to avert one HIV infection range from $150-900 using a 10-year time horizon.

• Premature postoperative resumption of sexual intercourse has only small population-level effect because time frame is short

• Any behavioural risk compensation confined to newly or already circumcised men and their partners has only a small population-level effect on anticipated impact of MC service scale-up on HIV incidence

• MC scale-up acts synergistically with other HIV prevention strategies[Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009;6, September 8]

Population-level Impacts by Coverage

Hankins et al. Male circumcision for HIV prevention in high

HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009;6, September 8

Decision-makers’ programme planning tool• Developed by Futures Institute under the

USAID/Health Policy Initiative in collaboration with UNAIDS

• Supports decision makers to understand the cost and impact of scaling-up male circumcision services by service delivery approach, priority populations, pace of scale-up

• Populations: All adult males, 15-24 or 15-29 year old males, adolescents prior to starting sexual activity, newborns, males at higher risk, others

Steps in using the Decision-makers’ Programme Planning Tool (DMPPT)

• Select technical team (technical support can be accessed through UNAIDS & technical support facility)

• Collect epidemiological and behavioural data• Set up impact model• Populate the tool with demographic, epi, and

behavioural data• Collect cost information at central and facility level• Determine cost per male circumcision performed• Analyze cost and impact of alternate strategies• Conduct dialogue with stakeholders and decision

makers

Coverage

• Specify target coverage and year for each population

• Select scale-up rate– Slow– Linear– Fast– S-shaped

Percent Circumcised

0

10

20

30

40

50

60

70

80

90

2008 2009 2010 2011 2012 2013 2014 2015

All Adults 15-24Adolescent Males New Born Males

High Risk Males Other population 1Other population 2 Other population 3Other Prevention

Data required

Type of Data Source

Demography UN Pop Div, Census

Sexual behaviour Demographic and health surveys

HIV prevalence Antenatal surveillance, Demographic & health surveys

Cost MOH, clinic visits

Botswana: Linear scale-up starting 2009 80% coverage by 2015

Bollinger LA, Stover J, Musuka G, Fidzani B, Moeti T, Busang L. The cost & impact of male circumcision on HIV/AIDS in Botswana. J Int AIDS Soc. 2009; 27;12(1):7

Botswana sensitivity analysis

Use of the Decision Makers’ Programme Planning Tool (DMPPT)

• Botswana and Namibia: results presented at the Dakar DMPPT meeting December 2008

• USAID desk review

• Nairobi training workshop April 18-20, 2010

• Uganda: costing and impact completed

• Kenya, Zambia, Zimbabwe, South Africa: costing completed or underway

• Rwanda, Tanzania, and Namibia (update): planning stage

0

50,000

100,000

150,000

200,000

250,000

Year

Num

ber o

f MC

Baseline (21%) Adolescents All adult males New Born Males

Namibia: Number of yearly MC performed on all three Populations with target of 80% by 2015 & beyond (Gaillard

& Godlove)

1,268,066 MC performed for period 2008-2025

Acknowledgements

• John Stover, Lori Bollinger, Stephen Forsythe, Futures Institute

• Nicolai Lohse and Brian Houle, UNAIDS

• Tim Hallett, Imperial College

• Brian Williams and John Hargrove, SACEMA

• Eric Gaillard and Albena Godlove, consultants

• UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV prevention

• Emmanuel Njeuhmeli, USAIDModel and manual available at www.malecircumcision.org

hivthisweek.unaids.org