EMMANUEL NJEUHMELI, MD, MPH, MBA OFFICE OF HIV/AIDS, GLOBAL HEALTH BUREAU USAID WASHINGTON AIDS 2016 CONFERENCE, DURBAN, SOUTH AFRICA 7/21/2016 AIDS 2016

OBJECTIVES MODEL PARAMETERS ASSUMPTIONS How have countries progressed toward their targets of reaching 80% coverage of males ages 15–49? What is the projected impact of the VMMCs conducted to date (through 2015)? What is the projected cost per HIV infection averted of the VMMCs conducted to date? How does progress toward the 80% coverage target vary by five-year age group? What is the impact attributable to VMMCs conducted in each age group? MODEL DMPPT 2.11 PARAMETERS Numbers of VMMCs collected from country reporting to WHO Age distribution of VMMCs from country data and PEPFAR reporting Baseline MC prevalence by age group derived from DHS or other survey data prior to start of VMMC program ASSUMPTIONS HIV incidence projections are based on the assumptions that countries reach the 90-90-90 targets for scale-up of ART (both adult and pediatric, including 2020 and 2030 targets) Assumed no scale-up of other HIV interventions over base levels VMMC unit costs were derived from SA VMMC costing study2, with labor costs adjusted for each country 1Kripke K, Opuni M, Schnure M, Sgaier S, Castor D, Reed J, et al. 2016. Age targeting of voluntary medical male circumcision programs using the Decision Makers' Program Planning Toolkit (DMPPT) 2.0. PLoS ONE. DOI: 10.1371/journal.pone.0156909. 2Tchuenche M, Palmer E, Haté V, Thambinayagam A, Loykissoonlal D, Njeuhmeli E, et al. 2016. The cost of providing medical male circumcision in South Africa. PLoS ONE. In press. 7/21/2016 AIDS 2016

ANNUAL NUMBERS OF VMMCS CONDUCTED IN EASTERN AND SOUTHERN AFRICA BY COUNTRY, 2008–2015 3.24 2.66 2.62 1.71 0.88 As Julie Samuleson from WHO presented on [day of Julie’s presentation on the WHO progress numbers], countries have scaled up VMMC dramatically since 2008, with the most circumcisions (over 3 million) done in 2014. By the end of 2015, the 14 priority countries had performed nearly 12 million circumcisions, more than half (56%) of the target set out by the Joint Strategic Action Framework in 2011. 0.42 0.12 0.02 Total cumulative VMMCS: 11.7M 7/21/2016 AIDS 2016

NUMBER OF VMMCS CONDUCTED THROUGH 2015 IN EACH COUNTRY AND ESTIMATED TARGET NUMBER REQUIRED TO REACH 80% MALE CIRCUMCISION COVERAGE AMONG MALES AGES 15–49 The greatest cumulative numbers of VMMCs were performed in Uganda (2.7 million), South Africa (2.3 million), and Tanzania (1.7 million). Kenya, Tanzania, and Ethiopia have exceeded their numerical targets. Mozambique, Uganda, Zambia, and South Africa are more than 50% toward their estimated numerical targets. Malawi and Namibia have yet to achieve 15% of the projected numbers. 7/21/2016 AIDS 2016

MC PREVALENCE BEFORE START OF VMMC PROGRAM (“BASE”) AND MODELED ESTIMATES OF COVERAGE BY THE END OF 2015 Source: Base from DHS and AIS surveys; coverage from DMPPT 2.1 modeling, Project SOAR Country 10–14 15–19 20–24 25–29 30–34 35–49 10–34 15–49 15–29 Base % 2016 Botswana 4 61 6 48 10 30 13 23 16 22 15 38 11 28 34 Kenya [Nyanza only] 37 82 47 100 44 97 77 66 62 89 45 46 98 Lesotho 1 27 41 31 43 42 19 40 26 25 Malawi 7 20 17 9 14 18 Mozambique 33 36 52 54 53 59 55 63 58 Namibia 24 32 21 Rwanda 3 51 35 12 South Africa 50 64 60 57 Swaziland 8 Tanzania [11 priority regions] 86 49 79 65 56 71 69 78 Uganda 68 39 29 Zambia Zimbabwe 5 Using the DMPPT model version 2.1, we can assess male circumcision coverage by five-year age group. This table shows the baseline male circumcision prevalence prior to initiation of the VMMC programs in the white columns, along with the estimated level of coverage in each age group by the end of 2015 in the blue columns. I won’t go into detail on this slide, but this table shows that, as we know from looking at the program data, progress has been uneven across age groups, leading to higher levels of coverage among ages 15 to 24 than the other age groups Kenya and Tanzania have already reached or exceeded 80% coverage among ages 15 to 24, and Uganda has reached around 70% coverage in that age group. These countries need to be planning to maintain achieved levels of coverage, as the scale-up phase closes down. 7/21/2016 AIDS 2016

MC PREVALENCE BEFORE START OF VMMC PROGRAM (“BASE”) AND MODELED ESTIMATES OF COVERAGE BY THE END OF 2015, SELECT AGE GROUPS In this figure, the lower bars show the baseline level of male circumcision coverage before the program started, and the level of coverage achieved among 15- to 29-year olds (lighter two bars), and 15-to-49-year-olds (darker two bars) as of the end of 2015 The analysis by five-year age group shows a few things: Most countries have higher levels of coverage by the end of 2015 among ages 15 to 29 (lighter two bars) than among ages 15 to 49 (darker two bars), since the younger males have been more responsive to VMMC roll-out Countries vary not only in the level of coverage they have achieved, but also in the amount of progress they have made in increasing coverage from baseline levels. For example, Mozambique and South Africa have relatively high baseline levels of circumcision, but several countries that started with lower baseline have made more progress, such as Rwanda, Uganda, and Zambia. 7/21/2016 AIDS 2016

PROJECTED NUMBER OF HIV INFECTIONS AVERTED BY 2030 Here we’re looking at the projected number of HIV infections averted due to scaling up circumcision. The panel on the right is the same as the left, just zoomed in because South Africa is dominating the graph on the left panel. The darker bars at the bottom show the impact of the VMMCs that have been performed through the end of 2015. Across the 13 countries (Ethiopia not included in modeling), the VMMCs conducted through 2015 are projected to avert over 450,000 HIV infections by 2030, even if the programs stopped circumcising today. The largest impact, not surprisingly, is from South Africa, contributing 218,000 HIV infections averted, nearly half of the total across all 13 countries. The lighter bars on top show what the additional impact would be if each country scaled up to 80% circumcision coverage among 10- to 29-year-olds by 2020 and maintained it at 80%. If VMMC continues to scale up to 80% by 2020 and is maintained at this level, these VMMCs will avert an additional 470,000 HIV infections by 2030, bringing the total HIV infections averted up to 922,000. In South Africa, scaling up to 80% by 2020 will avert an additional 168,000 HIV infections, bringing the total up to 386,000 by 2030. Total, from program VMMCs: 452,000 Total, from 80% scale-up: 922,000 Source: DMPPT 2.1 modeling, Project SOAR 7/21/2016 AIDS 2016

PROPORTION OF HIV INFECTIONS AVERTED (2009-2030) ATTRIBUTABLE TO VMMCS PERFORMED IN EACH AGE GROUP AND PROPORTION OF VMMCS PERFORMED IN EACH AGE GROUP Source: DMPPT 2.1 modeling, Project SOAR The left bar shows the number of HIV infections averted attributed to circumcisions through 2015 performed in each age group. The right bar shows how many VMMCs were performed in each age group. You can see that while 32% of the VMMC clients were 10 to 14 years old (blue at bottom), 16% of the HIV infections averted came from circumcisions performed in this age group. For the 15- to 19-year-olds (orange), they comprised 33% of the clients and also contributed 34% of the impact. For the 20- to 24-year-olds (pink), they were 18% of the clients and contributed 28% of the impact. In total, 50% of the impact came from circumcising 10- to 19-year-olds, and 78% of the impact came from circumcising 10- to 24-year-olds. Only 22% of the impact came from circumcising men ages 25 and above. 7/21/2016 AIDS 2016

COST PER HIV INFECTION AVERTED, 2009–2030, VMMC PRIORITY COUNTRIES Min $1,200 Max $18,600 Median $3,800 There is a wide range of costs per HIV infection averted, from $1,200 in Swaziland to $18,200 in Rwanda, with a median of $3,800. For 11 of the 13 countries, the cost per HIV infection averted is less than $7,000. The countries with the highest cost per HIV infection averted have the lowest projected HIV incidence over the period assessed. 7/21/2016 AIDS 2016

TREATMENT COSTS AVERTED 2009–2030 BY PROGRAM CIRCUMCISIONS CONDUCTED THROUGH 2015 For every HIV infection that is averted by VMMC, thousands of dollars in HIV treatment are saved. Across the 13 countries, the HIV infections averted translate into $1.7 Billion in treatment costs averted. Not surprisingly, South Africa contributes nearly half of this, with almost $800 Million in treatment cost savings. Total treatment costs averted: $1.7 billion, 2009-2030 7/21/2016 AIDS 2016

SUMMARY Over 11 million VMMCs had been conducted through 2015: 56% of the estimated 20.9 million VMMCs required to reach 80% coverage by end 2015. Assuming each country reaches the 90-90-90 HIV treatment targets, the modeling analysis projected that VMMCs conducted through 2015 will avert a total of 452,000 infections by 2030. If male circumcision is scaled up to 80% coverage among 10-29 year- olds by 2020 and maintained at that level of coverage, an additional 470,000 HIV infections will be averted by 2030. The median estimated cost per HIV infection averted was $3,800. Countries should monitor MC coverage by five-year age group to better plan their programs. Across all countries modeled, 50% of the projected HIV infections averted were attributable to circumcising the 10-19 year-olds. 7/21/2016 AIDS 2016

ACKNOWLEDGEMENTS The figures in this presentation are from a journal article entitled “Assessing Progress, Impact, and Next Steps in Rolling Out Voluntary Medical Male Circumcision for HIV Prevention in Fourteen Priority Countries in Eastern and Southern Africa as of 2015.” The manuscript is being published today (21 July 2016) in PLoS One as part of a collection on VMMC modeling and costing, entitled, “Voluntary Medical Male Circumcision: New modelling exercises looking at impact and cost-effectiveness of age and geographic prioritization of the program.” Co-authors of this manuscript are: Katharine Kripke and Peter Stegman, Project SOAR (Supporting Operational AIDS Research), Avenir Health Melissa Schnure, Project SOAR, Palladium Emmanuel Njeuhmeli, U.S. Agency for International Development Julia Samuelson and Shona Dalal, World Health Organization Timothy Farley, Sigma3 Services Catherine Hankins, Amsterdam Institute for Global Health and Development Ann G. Thomas, Naval Health Research Center, US Department of Defense Jason Reed, Jhpiego Naomi Bock, U.S. Centers for Disease Control and Prevention This work was supported by PEPFAR through USAID under Project SOAR. Katharine Kripke and Emmanuel Njeuhmeli designed this analysis; Katharine Kripke and Melissa Schnure conducted the analysis The DMPPT 2.0 model was developed by John Stover, Avenir Health, with the support of PEPFAR through USAID under the Health Policy Project Revisions to produce the DMPPT 2.1 model were conducted by Matthew Hamilton, Avenir Health, with the support of PEPFAR through USAID under Project SOAR 7/21/2016 AIDS 2016

SENIOR BIOMEDICAL PREVENTION ADVISOR enjeuhmeli@usaid.gov PHOTO BY CHARLES WANGA, JHPIEGO EMMANUEL NJEUHMELI SENIOR BIOMEDICAL PREVENTION ADVISOR enjeuhmeli@usaid.gov 7/21/2016