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

Abstract

BackgroundZimbabwe aims to increase circumcision coverage to 80% among 13- to 29-year-olds. However, implementation data suggest that high coverage among men ages 20 and older may not be achievable without efforts specifically targeted to these men, incurring additional costs per circumcision. Scale-up scenarios were created based on trends in implementation data in Zimbabwe, and the cost-effectiveness of increasing efforts to recruit clients ages 20–29 was examined.MethodsZimbabwe voluntary medical male circumcision (VMMC) program data were used to project trends in male circumcision coverage by age into the future. The projection informed a base scenario in which, by 2018, the country achieves 80% circumcision coverage among males ages 10–19 and lower levels of coverage among men above age 20. The Zimbabwe DMPPT 2.0 model was used to project costs and impacts, assuming a US$109 VMMC unit cost in the base scenario and a 3% discount rate. Two other scenarios assumed that the program could increase coverage among clients ages 20–29 with a corresponding increase in unit cost for these age groups.ResultsWhen circumcision coverage among men ages 20–29 is increased compared with a base scenario reflecting current implementation trends, fewer VMMCs are required to avert one infection. If more than 50% additional effort (reflected as multiplying the unit cost by >1.5) is required to double the increase in coverage among this age group compared with the base scenario, the cost per HIV infection averted is higher than in the base scenario.ConclusionsAlthough increased investment in recruiting VMMC clients ages 20–29 may lead to greater overall impact if recruitment efforts are successful, it may also lead to lower cost-effectiveness, depending on the cost of increasing recruitment. Programs should measure the relationship between increased effort and increased ability to attract this age group.

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

“…The VMMC modeling collection also includes four papers that explore the impact of scale-up progress thus far [4], the potential cost-effectiveness of increasing demand among 20- to 29-year-olds in Zimbabwe [31] the projected contribution of VMMC scale-up to the Fast Track goals in light of the 90-90-90 and 95-95-95 treatment cascade targets [32], and the cost and impact of introducing early infant male circumcision (EIMC) for long-term sustainability of VMMC programs [33]. …”

Effectiveness of Demand creation promotions and demand creation personnel in creating demand for Voluntary Medical Male Circumcision in Chitungwiza district, Zimbabwe in 2016

“…In our evaluation of the effectiveness of personnel used in demand creation and demand creation promotions, we found out that demand creation officers and community mobilisers were the most effective cadres in creating demand for VMMC in the target age group of 16-29 years in Chitungwiza district. The target age group is the sexuallygroup active and has the highest incidence of new HIV infections and is the age that MOHCC is emphasising on to have an immediate impact on HIV reduction (1,16). We also found out that intensifying campaigns during school holidays and the use of tent-based/caravan campaigns were the most effective strategies that created demand for VMMC under sales promotions.…”

The emerging health impact of voluntary medical male circumcision in Zimbabwe: An evaluation using three epidemiological models

“…Our current analysis—and past cost-effectiveness analyses [ 22 , 25 , 40 , 41 ]—have mostly focused on the direct benefits of VMMC for protecting HIV-negative men against acquisition from HIV-positive female partners, amplified by indirect effects on women through the reduced HIV prevalence among their male partners. However, the impact and cost-effectiveness become even more favorable if additional benefits are considered, such as direct protection of HIV-negative women against HIV acquisition from circumcised HIV-positive male partners (see our sensitivity analysis), the concurrent protection afforded by VMMC against sexually transmitted bacterial infections, and a side benefit of pre-VMMC HIV testing as a way to bring HIV-positive men into care.…”

“…A modeling study indicated that the program was reaching an efficient and impactful age bracket (13–29 year-olds) via school-based campaigns but boosting uptake among already sexually active young men would increase short-term impact and cost-effectiveness [ 21 ]. However, another study [ 22 ] cautioned that prioritizing older men (age 20 and over) might incur greater demand creation costs. 'Hotspots' of HIV risk identified in Zimbabwe informed the targeting of VMMC and other prevention efforts [ 23 ].…”