Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent models

Bansi‐Matharu, Loveleen; Mudimu, Edinah; Martin-Hughes, Rowan; Hamilton, Matt; Johnson, Leigh F.; Brink, Debra ten; Stover, John; Meyer‐Rath, Gesine; Kelly, Sherrie L; Jamieson, Lise; Cambiano, Valentina; Jahn, Andreas; Cowan, Frances M; Mangenah, Collin; Mavhu, Webster; Chidarikire, Thato; Toledo, Carlos; Revill, Paul; Sundaram, Maaya; Hatzold, Karin; Yansaneh, Aisha; Apollo, Tsitsi; Kalua, Thoko; Mugurungi, Owen; Kiggundu, Valerian; Zhang, Shufang; Nyirenda, Rose; Phillips, Andrew; Kripke, Katharine; Bershteyn, Anna

doi:10.1016/s2214-109x(22)00515-0

Cited by 12 publications

(13 citation statements)

References 33 publications

(38 reference statements)

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“…As VMMC costs are largely provided by the global donor community, including the US President's Emergency Plan for AIDS Relief (PEPFAR), and to mirror the approach taken to assess costs benefits of 2wT for VMMC in Zimbabwe, we assessed costs from the payer perspective. This approach is also in line with recent evidence suggesting continuing donor support for VMMC costs for at least 5 additional years given the costeffectiveness of the overall VMMC intervention for HIV prevention [31].…”

Section: Introductionsupporting

confidence: 79%

Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa

Mukora

Ndebele

et al. 2023

Preprint

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Introduction Voluntary medical male circumcision (VMMC) clients are required to attend multiple post-operative follow-up visits in South Africa (SA). However, up to 98% of VMMC clients heal without adverse events (AEs). With demonstrated VMMC safety across global programs, stretched clinic staff in SA may conduct more than 400,000 unnecessary reviews for males without complications per year. As part of a randomized controlled trial (RCT) to test two-way texting (2wT) follow-up as compared to routine, in-person visits for adult VMMC clients, the objective of this study was to compare costs of 2wT-based telehealth to routine post-VMMC care in both rural and urban SA settings. Methods We used an activity-based costing (ABC) approach to estimate the costs in post-VMMC care, including counselling, follow-ups, and tracing activities. All costs were estimated in $US dollars for both 2wT and routine care to test the hypotheses that 2wT follow-up would result in per-client cost savings. Data were collected from routine National Department of Health VMMC forms, the RCT database, and time-and-motion surveys. Sensitivity analysis presents different scale-up scenarios. Results We included 1,084 clients: 537 in routine care and 547 in 2wT. Average client follow-up cost is $6.48 for routine care and $4.25 for 2wT. 2wT saved costs in both rural and urban locations. Average savings of $2.23 was greater in rural ($1.61) than urban areas ($0.62). 2wT would save $0.88, $2.23, and $4.93, respectively, if: men attended one visit; men attended visits in similar proportions to that observed in the RCT; and men attended both visits. Conclusion 2wT reduces post-VMMC care costs by supporting most men to heal at home while using telehealth to triage clients with potential AEs to timely, in-person care. 2wT savings are higher in rural areas. Scale-up of 2wT-based follow-up could significantly reduce overall VMMC costs while maintaining service quality.

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Section: Introductionsupporting

confidence: 79%

Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa

Mukora

Ndebele

et al. 2023

Preprint

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Section: Discussionmentioning

confidence: 99%

“…However, studies by the HIV Modeling Consortium have shown that while these models differ in some aspects, in general, they produce very similar results for incidence and mortality trends, especially during the historical period. [14][15] There are many other prospective scenarios that we might have examined such as a gradual reduction in PEPFAR funding or the elimination of some but not all PEPFAR-supported interventions. Thus, our results may represent maximum impact.…”

Section: Discussionmentioning

confidence: 99%

The Impact of the President’s Emergency Program for AIDS Relief (PEPFAR) on Children

Stover,

Flanagan,

Teng

2023

Preprint

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Background: The AIDS epidemic has had severe impacts on children causing 7.7 million child deaths and orphaning 15 million children. The impact would have been even greater if the PEPFAR program had not provided drugs and services to avert millions of new infections and AIDS-related deaths. This paper estimates the historical impact of PEPFAR support on children and projects the impact through 2030 if the PEPFAR program were to stop in 2024. Methods: We used the Goals RSM HIV simulation model to project counterfactual scenarios of no PEPFAR support during both the historical period (2000-2022) and the future period (2024-2030). We applied the model to 53 countries receiving PEPFAR support. Results: From 2004-2022 the PEPFAR program averted 2.8 million new child HIV infections, 1.5 million child HIV-related deaths and prevented 8.2 million children from becoming AIDS orphans. A continuation of PEPFAR at its current level through 2030 would avert one million new child HIV infections, 460,000 child HIV-related deaths and 2.8 million AIDS orphans. Discussion: The PEPFAR program has been crucial to the success that has been achieved to date in the global fight against AIDS. That success has created an obligation. Continuation of PEPFAR is critical to the effort to achieve the end of AIDS in the coming years.

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“…Although sustainability was initially conceived as a distinct phase of program transition, sustainability of VMMC will require a more gradual evolution including measured integration of VMMC services into national health systems. The sustainability of VMMC is particularly important with economic modeling predicting the program will continue to be a cost-effective prevention strategy and, in fact, cost-saving in most countries over a 50-year horizon [57]. In 2020, as part of the updated recommendations for VMMC, WHO published a framework for sustaining VMMC services [17 ••].…”

Section: Sustainabilitymentioning

confidence: 99%

Defining the Global Research and Programmatic Agenda and Priority Actions for Voluntary Medical Male Circumcision for HIV Prevention

et al. 2022

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Purpose of Review Since 2007, voluntary medical male circumcision (VMMC) programs have been associated with substantially reduced HIV incidence across 15 prioritized countries in Eastern and Southern Africa. Drawing on the programmatic experience of global VMMC leaders, this report reviews progress made in the first 15 years of the program, describes programmatic and research gaps, and presents considerations to maximize the impact of VMMC. Recent Findings Overall, key programmatic and research gaps include a lack of robust male circumcision coverage estimates due to limitations to the data and a lack of standardized approaches across programs; challenges enhancing VMMC uptake include difficulties reaching populations at higher risk for HIV infection and men 30 years and older; limitations to program and procedural quality and safety including variations in approaches used by programs; and lastly, sustainability with limited evidence-based practices. Considerations to address these gaps include the need for global guidance on estimating coverage, conducting additional research on specific sub-populations to improve VMMC uptake, implementation of responsive and comprehensive approaches to adverse event surveillance, and diversifying financing streams to progress towards sustainability. Summary This report’s findings may help establish a global VMMC research and programmatic agenda to inform policy, research, and capacity-building activities at the national and global levels.

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Cost-effectiveness of voluntary medical male circumcision for HIV prevention across sub-Saharan Africa: results from five independent models

Cited by 12 publications

References 33 publications

Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa

Cost savings in male circumcision post-operative care using two-way text-based follow-up in rural and urban South Africa

The Impact of the President’s Emergency Program for AIDS Relief (PEPFAR) on Children

Defining the Global Research and Programmatic Agenda and Priority Actions for Voluntary Medical Male Circumcision for HIV Prevention

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