Evaluating the Impact of the Voluntary Medical Male Circumcision Program in Kenya Francis Ndwiga Benson 1, Mathews Onyango 2, John Stover 3 1 National AIDS and STD Control Programme, Nairobi, Kenya 2 Consultant, Nairobi, Kenya 3 Avenir Health, Glastonbury, CT, USA MOAC0205: Monday, November 30, 2015, 12:45-14:15

Purpose Evaluate the cost, impact and cost-effectiveness of the VMMC program in Kenya from inception to date. Key indicators: infections averted, cost per infection averted and reduction in future treatment costs Use results to advocate for support for VMMC programs in Kenya and in sub-Saharan Africa Main research questions: How many HIV infections have been averted by the program? What has been the net cost and cost per infection averted? What is the contribution of VMMC to reducing future treatment costs?

Approach Use simulation modeling to evaluate the impact by comparing the actual outcomes with the situation if the VMMC program did not exist Perform the analysis with multiple models and compare the results Approach previously used to investigate the impact of VMMC (Hankins et al., PLoS Med 2009), ART in South Africa (Eaton et al. PLoS Med, 2012), WHO Treatment Guidelines (Eaton et al. Lancet Global Health, 2013 Avenir Health Goals model DMPPT 2.0 Imperial College London Institute for Disease Modeling Weill Cornell Medical College in Qatar

Locations Activities now underway in Kenya Zambia Zimbabwe

Levels of Traditional Male Circumcision and HIV Prevalence in Kenya

Implementation in Kenya Steering Committee: VMMC Technical Working Group, the M&E, Quality and Research subcommittee Steering Committee reviewed and approved the research protocol Data collection conducted by NASCOP and data consultant Steering Committee review and approved data for the modeling Modeling workshop in February 2016

VMMC Program in Kenya Source: VMMC End Term Report 2014, MOH (NASCOP) From 2008 to 2013 the program provided 793,000 medical male circumcisions. The initial targets were exceeded in Nyanza province. Focus for new strategy EIMC, adolescents, men Reach 95% of men circumcised by 2019 including 80% in traditionally non- circumcising communities 40% uptake of EIMC in selected facilities

VMMC Strategy Focus counties Nyanza: Homa Bay, Kisumu, Migori, Siaya Western: Busia Rift Valley: Kericho, Nakuru, Nandi, Turkana, West Pokot Nairobi: Nairobi

VMMC Strategy Focus counties Nyanza: Homa Bay, Kisumu, Migori, Siaya Western: Busia Rift Valley: Kericho, Nakuru, Nandi, Turkana, West Pokot Nairobi: Nairobi

Data Collection Visits to facilities in each of 10 priority counties Data collected Number of circumcisions performed Client characteristics: age, marital status, location Cost per procedure Research studies Risk compensation Sexual activity

Model Fit to Surveillance and Survey Data

Preliminary Results Treatment Savings ($7,000 lifetime cost of ART) Program Costs ($500 per infection averted)

Preliminary Conclusions VMMC program to date has demonstrated that VMMC can be scaled- up quickly to high levels Impact of VMMCs conducted from 2008 to date has been significant and will grow many times in the coming years The VMMC program is very cost-effective; it will result in significant cost saving in the long term Focus on priority counties with remaining need will support the ‘Prevention Revolution’ in Kenya