The U.S. President’sEmergency Plan for

AIDS Relief

Title

Cost and Impacts of expanding male circumcision services

in Eastern and Southern AfricaEmmanuel Njeuhmeli1, Jason Reed2, Lori Bollinger3, Steven Forsythe3,

Delivette Castor1, John Stover3, Timothy Farley4, and Catherine Hankins5

1. USAID Washington 2. CDC Atlanta 3. Future Institutes 4. WHO Geneva 5. UNAIDS Geneva

XVIII International AIDS Conference Vienna July 2010

Background

• Randomized controlled trials have shown consistently that male circumcision (MC) is 60% effective in reducing HIV incidence

• Current WHO/UNAIDS guidelines recommend MC for HIV prevention in generalized epidemic settings where HIV prevalence is high and MC prevalence is low

• Cost and population level impact has not been determined for successful implementation of MC in these settings

Objectives

• Estimate the cost of implementing MC in 14 countries in Eastern and Southern Africa

• Determine the impact of increased MC coverage on HIV incidence

• Evaluate the cost effectiveness of MC for HIV prevention

Methodology – DMPPT

• Mathematical modeling developed by USAID Health Policy Initiative | UNAIDS - Decision Makers Program Planning tool – DMPPT– Calculates the cost of MC services – Estimates the impact on the epidemic – Conduct sensitivity analysis for key inputs

• HIV and MC Prevalence– From most recent DHS and other Surveys

• Model Input parameters: – Age – newborn, adolescent / adult– Risk group – STD clinic attendees, seronegative men in discordant partnerships– Service delivery model – fixed, outreach, mobile – Provider – physician, clinical officer, nurse– Ancillary services – HIV testing and counseling, program promoting gender sensitivity– Potential risk compensation – increase number of sexual partner, decreased condom

use– Scale up rate – Coverage goals

Methods - Assumptions

• Desk review - using readily available data – no individual item cost data collection was done

• Main scenario – Implementation coverage of 80% MC prevalence within 5 years

for both adults and neonates

• Alternate scenarios– Implementation coverage

• 50% and 100 % within 5 years – Implementation pace

• 80% coverage within 1 year vs 10 years vs 20 years– Adult only vs Neonate only

Number of MC needed

29.1 M men to be circumcised across all 14 countries

Adult Vs Neonate MC

20092010

20112012

20132014

20152016

20172018

20192020

20212022

20232024

20252026

20272028

20292030

0.0

2,000,000.0

4,000,000.0

6,000,000.0

8,000,000.0

10,000,000.0

12,000,000.0

14,000,000.0

Existing Neonatal Adults (15-49)

Incremental Additional Cost

US$1 B is needed across all 14 countries for the 5 years catch up period

Discounted Cost Savings and Cumulative Discounted Cost Savings

20092010

20112012

20132014

20152016

20172018

20192020

20212022

20232024

20250

5,000,000,000

10,000,000,000

15,000,000,000

20,000,000,000

25,000,000,000

Discounted net cost savings and cumulative net cost savings for 14 countries

Net Cost Savings

Cumulative Net Cost Savings

Number and Percent of Infections Averted

Botswana

Ethiopia (G

ambela)

Kenya (N

yanza

)

Lesotho

Malawi

Mozambique

Namibia

Rwanda

South Afri

ca

Swazila

nd

Tanzan

ia

Uganda

Zambia

Zimbabwe

Overall

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

23%

17% 18%

36%

28%

13%

22%

28%

19%

33%

9%

25%28%

42%

22%

Cumulative number and percentage of HIV infections averted between 2009-2025 by scaling up male circumcision

Num

ber o

f HIV

infe

ction

s ave

rted

Percent of Infections averted by MC

New HIV Infection Averted in Men, Women and general population (Cumulative 2009 to 2025)

Botswana

Gambela

Lesotho

Malawi

Mozambique

Namibia

Nyanza

Rwanda

South Afri

ca

Swazila

nd

Tanzan

ia

Uganda

Zambia

Zimbabwe

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

50.0%

12.1% 11.7%

29.3%

20.4%

9.6%

13.8%

4.7%

20.9%

14.1%

26.5%

6.4%

18.3%21.1%

36.5%

Women Gen Pop Men

Implementation Pace - Infection Averted (%)

Botswana

Gambela

Lesotho

Malawi

Mozambique

Namibia

Nyanza

Rwanda

South Afri

ca

Swazila

nd

Tanzan

ia

Uganda

Zambia

Zimbabwe

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Coverage within 1 year Coverage within 10 years Coverage within 20 years

Implementation coverage within 5 years - infection averted (%)

Botswana

Gambela

Lesotho

Malawi

Mozambique

Namibia

Nyanza

Rwanda

South Afri

ca

Swazila

nd

Tanzan

ia

Uganda

Zambia

Zimbabwe

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

50% coverage 80% coverage 100% coverage

Number of MC per Infection Averted and Cost per Infection Averted

Limitations

• Inadequate understanding of MC program cost:– Facility based data collection

• Direct costs (Personnel, Drugs and supplies, Equipment, Transport / Vehicles)• Indirect Costs (Personnel, Overhead - building, land, utilities)

– Monitoring of program expenditures: • Demand creation, • Community mobilization, • Training, • Management

• Issues related to data– Self reported MC from DHS

• Mis-report of MC (e.g. Lesotho, Malawi)• Simplifying assumptions made

– Lack of age-specific sexual mixing matrix – Use of HIV prevalence to fit the epidemic model rather than HIV incidence

Conclusions

• Scaling up MC to reach 80% coverage within 5 years can potentially avert up to 4 Million or 20% new HIV infections in ESA and will cost US$1B

• Spending US$1B to achieve this impact will also save US$20.3B

• The greatest cost effectiveness can be achieve with a two pronged implementation approach combining accelerated saturation for adult and adolescents and sustain program for neonate

• The impact is directly proportional to the implementation pace and scale

Acknowledgements

• The DMPPT was designed by John Stover and Lori Bollinger under USAID Health Policy Initiative

• Catherine Hankins has lead the validation and adoption of the DMPPT by UNAIDS

• Emmanuel Njeuhmeli designed the desk review study • The DMPPT was populated by Lori Bollinger• The data was reviewed by Catherine Hankins, Timothy Farley, John Stover,

Steve Forsythe, Jason Reed, Delivette Castor, and Emmanuel Njeuhmeli• The initial 15 issues brief that was published by USAID HPI was written by Lori

Bollinger and review by all including the PEPFAR country team • This paper was written by Emmanuel Njeuhmeli, Jason Reed, Delivette Castor

and Lori Bollinger and review by all authors• All this was possible with PEPFAR (Through USAID Health Policy Initiative) and

UNAIDS funding (Through TSF)• The current costing exercise is a joint USAID HPI and UNAIDS activity