1. Assessing Costs and Impact on the Epidemic of Male Circumcision Catherine Hankins UNAIDS (hankinsc@unaids.org) 5th IAS Conference on HIV Pathogenesis, Treatment & Prevention Cape town, South Africa, July 2009 Session: Circumcision – Moving from Research to Implementation

2. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation UNAIDS global resource needs estimates for male circumcision - 2007 Overall target was 80% of 15-24 year old males circumcised in sub-Saharan Africa Three scenarios considered: 1. Historical growth in coverage of VCT and PMTCT applied to prevention and to care & treatment 2. Universal access by 2015 3. Universal access to prevention by 2010 and to care and treatment by 2015. Target for each country: reduce the gap between current male circumcision prevalence and the 80% target by half by 2015 (scenario 2) or by half by 2010 (scenario 3) With these assumptions, resources needed for male circumcision: –$60-160 million in 2010 (i.e. 950,000 - 2.5 million circumcisions in the year 2010) –$50-60 million in 2015

3. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Illustrative Results - 2007 Targets reached in 2010

4. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation 2005 JulyRCT South Africa (PLoS Med Nov 2005) 2006 JulyModelling Williams (PLoS Med) 1 st modelling meeting (Geneva, Switzerland)Nov 1 st modelling meeting (Geneva, Switzerland) DecRCTs Uganda and Kenya (Lancet Feb 2007) 2007 MarchWHO/UNAIDS recommendations Modelling Nagelkerke (BMC Inf Dis) Modelling Gray (AIDS) 2 nd modelling meeting (Stellenbosch, South Africa)Nov 2 nd modelling meeting (Stellenbosch, South Africa) Modelling Podder (Bull Math Biol) 2008 3 rd modelling meeting (London, UK)March 3 rd modelling meeting (London, UK) Modelling Londish (Int J Epidemiol) Modelling Hallett (PLoS ONE) Modelling White (AIDS) Modelling Alsallaq (Mexico abstract # MOPE0254) Modelling Fieno, (AIDS Care) 2009Expert Group (Hankins et al in press PLoS Medicine) Timeline 3 meetings convened by UNAIDS/WHO/SACEMA

5. Expert Review Group Consensus In high HIV prevalence/low male circumcision settings, models predict that: One HIV infection averted for every 5-15 male circumcisions performed. Costs to avert one HIV infection range from $150-900 using a 10- year time horizon. Premature postoperative resumption of sexual intercourse has only small population-level effect because the time frame is short Any behavioural risk compensation confined to newly or already circumcised men and their partners has only a small population- level effect on the anticipated impact of MC service scale-up on HIV incidence MC scale-up acts synergistically with other HIV prevention strategies MOPDC106. Hankins et al. Informing Decision-making on Male Circumcision for HIV Prevention in High HIV Prevalence Settings: Insights from Modelling

6. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Decision-makers’ programme planning tool Developed by Futures Institute under the Health Policy Initiative in collaboration with UNAIDS Supports decision makers to understand the cost and impact of scaling-up male circumcision services by service delivery approach, priority populations, pace of scale-up Populations: All adult males, 15-24 or 15-29 year old males, adolescents prior to starting sexual activity, newborns, high risk males, others

7. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Steps in using the Decision-makers’ programme planning tool Approach: Select technical team (technical support can be accessed through UNAIDS & technical support facility) Collect epidemiological and behavioural data Set up impact model Populate the tool with demographic, epi and behavioural data Collect cost information at central and facility level Determine cost per male circumcision performed Analyze cost and impact of alternate strategies Conduct dialogue with stakeholders and decision makers

8. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Coverage Specify target coverage and year for each population Select scale-up rate –Slow –Linear –Fast –S-shaped

9. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Data required Type of DataSource DemographyUN Pop Div, Census Sexual behaviourDemographic and health surveys HIV prevalenceAntenatal surveillance, Demographic & health surveys CostMOH, clinic visits

10. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation

11. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation

12. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation

13. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation

14. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation

15. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Botswana: Linear scale-up starting 2009 80% coverage by 2015 Bollinger LA, Stover J, Musuka G, Fidzani B, Moeti T, Busang L. The cost & impact of male circumcision on HIV/AIDS in Botswana. J Int AIDS Soc. 2009; 27;12(1):7

16. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Botswana sensitivity analysis

17. Namibia: Number of yearly MC performed with target of 80% by 2015 and beyond ( Gaillard & Godlove) 661,082 MC performed for period 2008-2025

18. Namibia: Number of yearly MC performed on all three Populations with target of 80% by 2015 & beyond ( Gaillard & Godlove) 1,268,066 MC performed for period 2008-2025

19. Estimated Number of Yearly HIV Infections Averted – Namibia (Gaillard & Godlove) 77,025 infections averted for period 2008-2025

20. Total savings in Billions of Namibian Dollars 77,000 infections averted at a net saving of $66,010 per infection averted for the period 2009-2025 means $5.0 billion Namibian dollars in total savings (after costs of $823 million from 2008-2025) Discounted Value expressed in Constant 2007 Namibian dollars

21. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Acknowledgements John Stover, Futures Institute Lori Bollinger, Futures Institute Nicolai Lohse, UNAIDS Brian Houle, UNAIDS Tim Hallett, Imperial College Brian Williams, WHO, SACEMA John Hargrove, SACEMA UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV prevention Model and manual available at www.FuturesInstitute.org

22. Cape town IAS July 2009 Hankins UNAIDS Assessing costs and impact on the epidemic of male circumcision Circumcision – Moving from research to implementation Developed by the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the AIDS Vaccine Advocacy Coalition (AVAC), and Family Health International (FHI)World Health Organization Joint United Nations Programme on HIV/AIDSAIDS Vaccine Advocacy CoalitionFamily Health International