Investigating Voluntary Medical Male Circumcision Program Efficiency Gains through Subpopulation Prioritization: Insights from Application to Zambia

Abstract

BackgroundCountries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia.Methods and FindingsA population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs (age-structured mathematical (ASM) model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15–49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20–24 age-group) to 36 (45–49 age-group); cost-effectiveness ranged from $888 (20–24 age-group) to $3,300 (45–49 age-group). Circumcising 10–14, 15–19, or 20–24 year old achieved the largest incidence rate reduction; prioritizing 15–24, 15–29, or 15–34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9–12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs.ConclusionEpidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.

Optimum resource allocation to reduce HIV incidence across sub-Saharan Africa: a mathematical modelling study

“…10 However, it is not always clear what priority these concerns receive in programmes over other considerations such as achieving scale or rolling out new interventions. Finally, new interventions or additions to health programmes have typically been evaluated in isolation [11][12][13] and held in comparison to an estimate of the cost-effectiveness of interventions already funded, an approach that ignores the relative costs and impacts of alternative options. Exceptions in Africa include a national-level cost-effectiveness analysis of prevention portfolios 14 and an exploration of combination prevention in a hyperendemic setting.…”

Modeling Impact and Cost-Effectiveness of Increased Efforts to Attract Voluntary Medical Male Circumcision Clients Ages 20–29 in Zimbabwe

“…To date, seven countries (Malawi, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe) have completed detailed country DMPPT 2 model applications to reexamine their age-targeting strategies for VMMC [13–17,21,22]. In most cases, these modeling exercises have led to revised age-specific targets in the countries’ VMMC operational plans.…”

Voluntary Medical Male Circumcision for HIV Prevention: New Mathematical Models for Strategic Demand Creation Prioritizing Subpopulations by Age and Geography

“…Based on the modeling undertaken for this journal supplement, priority age groups can vary by country and by indicator of interest, as Table 1 shows. Although many countries had initially aimed to achieve 80% male-circumcision prevalence in the age group 15–49 years [3], several countries that participated in the modeling exercises—including Malawi [18], Swaziland [19], Uganda [20], and Zambia [21]—have revised their strategies and/or operational plans to focus on achieving targets among younger age ranges (most frequently 10–34 years) to maximize a combination of impact, cost-effectiveness, and feasibility.…”

“…It revealed that epidemic impact and program efficiency would be improved by prioritizing young males who are sexually active or just before sexual debut, high HIV-prevalence geographic areas, and men who are at highest risk of HIV acquisition [21]. Likewise, the ASM model applied to Zimbabwe projected that program efficiency would improve by prioritizing young sexually active males and those whose sexual behaviour puts them at higher risk for acquiring HIV [24].…”