Assessing Progress, Impact, and Next Steps in Rolling Out Voluntary Medical Male Circumcision for HIV Prevention in 14 Priority Countries in Eastern and Southern Africa through 2014

Abstract

Background: In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries across eastern and southern Africa for scaling up voluntary medical male circumcision (VMMC) services. Several years into this effort, we reflect on progress.

Methods: Using the Decision Makers' Program Planning Tool (DMPPT) 2.1, we assessed age-specific impact, cost-effectiveness, and coverage attributable to circumcisions performed through 2014. We also compared impact of actual progress to that of achieving 80% coverage among men ages 15-49 in 12 VMMC priority countries and Nyanza Province, Kenya. We populated the models with age-disaggregated VMMC service statistics and with population, mortality, and HIV incidence and prevalence projections exported from country-specific Spectrum/Goals files. We assumed each country achieved UNAIDS' 90-90-90 treatment targets.

Results: More than 9 million VMMCs were conducted through 2014: 43% of the estimated 20.9 million VMMCs required to reach 80% coverage by the end of 2015. The model assumed each country reaches the UNAIDS targets, and projected that VMMCs conducted through 2014 will avert 240,000 infections by the end of 2025, compared to 1.1 million if each country had reached 80% coverage by the end of 2015. The median estimated cost per HIV infection averted was $4,400. Nyanza Province in Kenya, the 11 priority regions in Tanzania, and Uganda have reached or are approaching MC coverage targets among males ages 15-24, while coverage in other age groups is lower. Across all countries modeled, more than half of the projected HIV infections averted were attributable to circumcising 10- to 19-year-olds.

Conclusions: The priority countries have made considerable progress in VMMC scale-up, and VMMC remains a cost-effective strategy for epidemic impact, even assuming near-universal HIV diagnosis, treatment coverage, and viral suppression. Examining circumcision coverage by five-year age groups will inform countries' decisions about next steps.

Fig 1. Annual numbers of VMMCs conducted in eastern and southern Africa by country, 2008–2014.

Reprinted with permission from [9]: WHO progress brief, voluntary medical male circumcision for HIV prevention in 14 priority countries in East and southern Africa. Available from: http://www.who.int/hiv/topics/malecircumcision/male-circumcision-info-2014/en/.

Fig 2. Progress toward 80% MC coverage among males ages 15–49 as of 2014, by country.

This figure shows the number of VMMCs conducted through 2014 in each of the 14 priority countries in comparison with the estimated VMMC target number required to reach 80% male circumcision coverage among males ages 15–49.

Fig 3. Projected HIV infections averted by 2025.

(a) VMMCs performed through end 2014; (b) Scenario assuming scale-up to 80% MC coverage among males ages 15–49 by 2015 and maintained at 80% coverage through 2025. HIV infections averted are not discounted.

Fig 4. Cost per HIV infection averted, 2009–2025, for VMMC priority countries.

Error bars represent 95% uncertainty bounds.

Fig 5. Proportion of HIV infections averted and VMMCs by age group.

The left column shows the proportion of HIV infections averted attributable to VMMCs performed in each age group; the right column shows the proportion of VMMCs performed in each age group.