1. COST, IMPACT and CHALLENGES of ACCELERATED SCALE-UP
Voluntary Medical Male Circumcision for HIV Prevention in Eastern and Southern Africa
COST, IMPACT and CHALLENGES
of ACCELERATED SCALE-UP
Emmanuel Njeuhmeli, MD, MPH, MBA
Senior Biomedical Prevention Advisor
Co-Chair PEPFAR Male Circumcision Technical Working Group
USAID / Global Health Bureau / Office of HIV/AIDS

2. WHO-UNAIDS Recommendations Male Circumcision Priority Countries

3. Biological plausibility
Scientific Evidence
Biological plausibility
Inner surface of the foreskin highly vulnerable to HIV infection
Up to nine times more vulnerable than cervical tissue
Over 50 ecological and observational studies: lack of male circumcision associated with higher HIV in men
Three RCTs in Kenya, Uganda, and South Africa: 60% protection
Longer-term (4-5 yrs) follow up of the Kenya and Uganda RCT participants: protective effect sustained/increased
Community level impact evaluation in South Africa (Orange Farm) demonstrate 76% incidence reduction
There is strong evidence showing that voluntary medical male circumcision (MMC) reduces HIV incidence in men and there is international agreement that MMC should be incorporated into HIV prevention strategies in settings with high HIV prevalence and low MMC coverage.

4. Minimum Package of Services
Male circumcision is always part of a package of prevention services:
Provider-initiated HIV counseling and testing, incl couples HTC
Screening (and treatment) of STIs
Age-appropriate counseling on risk reduction, including reduced number and concurrency of sexual partners, delaying/abstaining from sex
Provision and promotion of correct and consistent use of condoms (male and female)
Active referral and linkage to HIV care/treatment/support services, including other HIV prevention services
Post-operative clinical care and reinforced education/counseling
Interventions for male circumcision should include a minimum package of prevention services which include:
Pre-operative provider-initiated HIV testing and counseling routinely provided on-site for all men and, where possible, their female partners;
Active exclusion of symptomatic STIs and syndromic treatment when indicated;
Provision and promotion of correct and consistent use of condoms;
Post-operative wound care and abstinence instructions;
Age-appropriate counseling on risk reduction, including reducing number and concurrency of sexual partners, delaying/abstaining from sex, and provision and promotion of correct and consistent use of condoms and;
Active linkage to other HIV prevention, treatment, care and support services as needed.

5. DMPPT Estimate of Number of Adult 15-49 years VMMC needed per countries to reach 80% coverage

6. 13 Countries: MC Required Early Infant Male Circumcision

7. 13 Countries: Adolescents and Adults MC Required

8. 13 Countries: EIMC, Adolescents and Adults MC Required

9. Cumulative Number and Percentage of HIV Infections Averted between 2011 to 2025 by scaling up VMMC
The impact of such a scale-up would result in averting 3.36 million new HIV infections and 386,000 AIDS deaths through 2025.
We find a strong impact of scaling up MMC to achieve 80% coverage by 2015 on the number of adult HIV infections averted. A total of 430,000 HIV infections are averted in the 13 countries between while a total of almost 3.36 million HIV infections are averted by South Africa is the country with the largest number of HIV infections averted with over 1 million averted between More than 20% of new HIV infections are averted between in Botswana, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Uganda, Zambia, and Zimbabwe. Zimbabwe is the country with the highest percentage of new HIV infections averted with 42% of new infections averted between 2011 and 2025; in the single year 2025, over 90% of the anticipated annual new HIV infections are projected to be averted (results not shown).
Table 4 shows the impact of MMC scale-up to achieve 80% coverage by 2015 on AIDS deaths averted. While relatively few deaths (<400) are averted in the 13 countries in the initial five years during which MMC scale-up occurs, 386,000 deaths are averted between with deaths averted in South Africa comprising over a third of the total deaths averted in the 13 countries.

10. Total – New HIV Infections Averted

11. HIV Infections Averted in Men and Women
Although circumcision of HIV infected men has not been found to reduce HIV transmission to their female partners, and the primary impact of increasing MMC coverage is to reduce the number of new HIV infections in men, the number of new infections in women is also reduced. This occurs by reducing the exposure of women to HIV-infected men (as HIV incidence decreases in men following MMC scale-up, the probability of women encountering infected male partners decreases, with a consequent reduction in women’s HIV incidence). The HIV infections averted and AIDS deaths averted presented in the previous slide thus represent infections and deaths in both men and women. This slide illustrates the male and female HIV infections averted over time by country for In all countries, the cumulative number of male HIV infections averted between 2011 and 2025 is higher than the cumulative number of female HIV infections averted. In the early years, the HIV infections averted occur mostly among men but over time the proportion of HIV infections averted in women steadily increases with HIV infections averted in women representing almost half of the total HIV infections averted by 2025.
In Lesotho, Rwanda, Swaziland and Zimbabwe, in the final year 2025, there are actually more HIV infections averted in women than in men.

12. Net savings by scaling up VMMC – US$16
Net savings by scaling up VMMC – US$16.5 Billion (2011 to 2025 in Millions US$)

13. No. VMMCs Needed to Prevent 1 Infection
The number of MMCs required to avert one HIV infection is calculated by dividing the additional number of MMCs required by the number of HIV infections averted over the relevant time period. For the period , the number of MMCs per HIV infection averted ranges from 25 in Swaziland to 239 in Rwanda while for the full study period ( ), the number of MMCs per HIV infection averted ranges from 4 in Zimbabwe to 44 in Rwanda. For the period , the number of MMCs per HIV infection averted is less than 10 in Botswana, Lesotho, Mozambique, Nyanza, Kenya, South Africa, Swaziland, Zambia, and Zimbabwe.

14. WHO-UNAIDS Joint Strategic framework for Acceleration of the VMMC Scale-Up 2012-2016
Almost 5 years after WHO-UNAIDS recommendations,
Neither the elegance of the science nor the strength of the effect predict the ease of implementation
PEPFAR-UNAIDS Recent Publications in PLoS Medicine: Signpost the way forward to accelerate the scaling up of VMMC service delivery safely and efficiently to reap individual-and population-level benefits
PEPFAR-WHO-UNAIDS-BMGF-World Bank collaboration to launch the WHO-UNAIDS Joint Strategy Action Framework for Acceleration of the Scale-Up of VMMC

15. Number of VMMC done from 2008 to 2011 in eastern and southern Africa

16. Number of VMMC done per countries as off October 2011

17. Strategy for Achieving Pace and Scale
Political will and country ownership
Strong leadership and coordination from MOH
Effective demand creation strategy with strong community level buy-in
Enough financial resources for service delivery including some level of dedication of staff time, facilities space and commodities
Excellent technical support from partners to allow a good match of demand and supply for efficient use of limited available to reach maximum number of men

18. High Volume, High Quality Service Delivery
Efficient VMMC Program
Effective Demand Creation
Dedicated Commodities
Dedicated Human Resources
Dedicated Space

19. Thank You