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

Abstract

BackgroundZimbabwe adopted voluntary medical male circumcision (VMMC) as a priority HIV prevention strategy in 2007 and began implementation in 2009. We evaluated the costs and impact of this VMMC program to date and in future.MethodsThree mathematical models describing Zimbabwe’s HIV epidemic and program evolution were calibrated to household survey data on prevalence and risk behaviors, with circumcision coverage calibrated to program-reported VMMCs. We compared trends in new infections and costs to a counterfactual without VMMC. Input assumptions were agreed in workshops with national stakeholders in 2015 and 2017.ResultsThe VMMC program averted 2,600–12,200 infections (among men and women combined) by the end of 2016. This impact will grow as circumcised men are protected lifelong, and onward dynamic transmission effects, which protect women via reduced incidence and prevalence in their male partners, increase over time. If other prevention interventions remain at 2016 coverages, the VMMCs already performed will avert 24,400–69,800 infections (2.3–5% of all new infections) through 2030. If coverage targets are achieved by 2021 and maintained, the program will avert 108,000–171,000 infections (10–13% of all new infections) by 2030, costing $2,100–3,250 per infection averted relative to no VMMC. Annual savings from averted treatment needs will outweigh VMMC maintenance costs once coverage targets are reached. If Zimbabwe also achieves ambitious UNAIDS targets for scaling up treatment and prevention efforts, VMMC will reduce the HIV incidence remaining at 2030 by one-third, critically contributing to the UNAIDS goal of 90% incidence reduction.ConclusionsVMMC can substantially impact Zimbabwe’s HIV epidemic in the coming years; this investment will save costs in the longer term.

HIV prevention cascades: a unifying framework to replicate the successes of treatment cascades

“…This may be particularly important for VMMC, where the link between effective use and infections averted is less clear given the incomplete efficacy of VMMC. 17 Our proposed cascade with three core steps is generic in that it is not developed for a particular method or setting. Rather, it is designed to be used with any prevention method or combination of methods (such as PrEP or condoms) which makes it possible to compare the state of progress with use of different HIV prevention methods at a particular point in time (although the expected population-level impacts from effective use of different methods may not be directly comparable given different levels of efficacy) and also to compare HIV prevention use across populations and over time.…”

Usability and acceptability of a two-way texting intervention for post-operative follow-up for voluntary medical male circumcision in Zimbabwe

“…Over 22 million MCs were performed across 14 sub-Saharan African (SSA) countries between 2008-2018 [9]. MC is cost-effective for HIV prevention [10][11][12][13] making investment in MC a priority across SSA [12,[14][15][16][17]. However, severe health system constraints threaten the quality and pace of MC scaleup [18][19][20], reducing the likelihood of meeting the ambitious global target of 5 million annual MCs in SSA [21].…”

Critical evaluation of arguments opposing male circumcision: A systematic review

“…201 VMMC has been very effective in lowering HIV infections in epidemic settings in sub-Saharan Africa. [202][203][204][205][206] In a recent Kenyan study the reduction was 50%. 206 Criticisms of the RCT findings by MC opponents [176][177][178][179][188][189][190][191][192] were shown by scientists and public health authorities to contain fundamental flaws.…”

“…Roll‐out of VMMC programs has resulted in 18.6 million MC procedures in high‐priority countries . VMMC has been very effective in lowering HIV infections in epidemic settings in sub‐Saharan Africa . In a recent Kenyan study the reduction was 50% .…”