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

Abstract

Over 11 million voluntary medical male circumcisions (VMMC) have been performed of the projected 20.3 million needed to reach 80% adult male circumcision prevalence in priority sub-Saharan African countries. Striking numbers of adolescent males, outside the 15-49-year-old age target, have been accessing VMMC services. What are the implications of overall progress in scale-up to date? Can mathematical modeling provide further insights on how to efficiently reach the male circumcision coverage levels needed to create and sustain further reductions in HIV incidence to make AIDS no longer a public health threat by 2030? Considering ease of implementation and cultural acceptability, decision makers may also value the estimates that mathematical models can generate of immediacy of impact, cost-effectiveness, and magnitude of impact resulting from different policy choices. This supplement presents the results of mathematical modeling using the Decision Makers’ Program Planning Tool Version 2.0 (DMPPT 2.0), the Actuarial Society of South Africa (ASSA2008) model, and the age structured mathematical (ASM) model. These models are helping countries examine the potential effects on program impact and cost-effectiveness of prioritizing specific subpopulations for VMMC services, for example, by client age, HIV-positive status, risk group, and geographical location. The modeling also examines long-term sustainability strategies, such as adolescent and/or early infant male circumcision, to preserve VMMC coverage gains achieved during rapid scale-up. The 2016–2021 UNAIDS strategy target for VMMC is an additional 27 million VMMC in high HIV-prevalence settings by 2020, as part of access to integrated sexual and reproductive health services for men. To achieve further scale-up, a combination of evidence, analysis, and impact estimates can usefully guide strategic planning and funding of VMMC services and related demand-creation strategies in priority countries. Mid-course corrections now can improve cost-effectiveness and scale to achieve the impact needed to help turn the HIV pandemic on its head within 15 years.

Modeling the Impact of Uganda’s Safe Male Circumcision Program: Implications for Age and Regional Targeting

“…Clients ages 10–14 were not included when the national target was set, nor are they a focus of SMC outreach efforts. At the same time, a recent data quality assurance (DQA) exercise conducted by the Uganda Ministry of Health and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) revealed that the number of clients over the age of 25 receiving SMC services is far lower than would be expected based on population estimates, suggesting unique barriers to demand creation for this subpopulation [ 14 ]. Program experiences such as these have led to interest in reconsidering Uganda’s age-specific SMC targets to better account for age disparities in the use of VMMC services.…”

Attitudes, Beliefs and Predictors of Male Circumcision Promotion among Medical University Students in a Traditionally Non-Circumcising Region

“…Regarding the HIV epidemic in Europe, the males are the more affected gender [ 11 ]. Voluntary non-medical adult MC can make a contribution to combination prevention due to its unique features: it is a single event without ongoing adherence challenges that has lifetime direct benefits [ 30 , 31 ]. However, assuming that adult MC might be promoted at a national level in traditionally non-circumcising countries, several issues should be taken into consideration.…”

“…The potential impact and cost-effectiveness of voluntary MC are not uniform and vary by age of circumcised males [ 40 ]. Therefore, studies based on mathematical models should be initiated to help examine the potential effects on programme impact and the cost-effectiveness of prioritizing specific subpopulations by age [ 30 , 40 ].…”

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

“…As implementers rolled out VMMC programs in Zimbabwe and the other VMMC priority countries in eastern and southern Africa, it became evident that recruiting adolescents ages 10–19 was much easier than recruiting adult men for VMMC, and that few men over the age of 35 were accessing VMMC services [7, 8]. In some communities where traditional circumcision is practiced, circumcision during adolescence is normative [9], whereas circumcision for older men can be seen as shameful [10].…”