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Assessing Costs and Impact on the Epidemic of Male Circumcision

5th IAS Conference on HIV Pathogenesis, Treatment & Prevention Cape town, South Africa, July 2009 Session: Circumcision – Moving from Research to Implementation. Assessing Costs and Impact on the Epidemic of Male Circumcision. Catherine Hankins UNAIDS (hankinsc@unaids.org).

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Assessing Costs and Impact on the Epidemic of Male Circumcision

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  1. 5th IAS Conference on HIV Pathogenesis, Treatment & Prevention Cape town, South Africa, July 2009 Session: Circumcision – Moving from Research to Implementation Assessing Costs and Impact on the Epidemic of Male Circumcision Catherine Hankins UNAIDS (hankinsc@unaids.org)

  2. Overall target was 80% of 15-24 year old males circumcised in sub-Saharan Africa Three scenarios considered: Historical growth in coverage of VCT and PMTCT applied to prevention and to care & treatment Universal access by 2015 Universal access to prevention by 2010 and to care and treatment by 2015. Target for each country: reduce the gap between current male circumcision prevalence and the 80% target by half by 2015 (scenario 2) or by half by 2010 (scenario 3) With these assumptions, resources needed for male circumcision: $60-160 million in 2010 (i.e. 950,000 - 2.5 million circumcisions in the year 2010) $50-60 million in 2015 UNAIDS global resource needs estimates for male circumcision - 2007 Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  3. Illustrative Results - 2007 Targets reached in 2010 Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  4. 2005 July RCT South Africa (PLoS Med Nov 2005) 2006 July Modelling Williams (PLoS Med) Nov 1st modelling meeting (Geneva, Switzerland) Dec RCTs Uganda and Kenya (Lancet Feb 2007) 2007 March WHO/UNAIDS recommendations Modelling Nagelkerke (BMC Inf Dis) Modelling Gray (AIDS) Nov 2nd modelling meeting (Stellenbosch, South Africa) Modelling Podder (Bull Math Biol) 2008 March 3rd modelling meeting (London, UK) Modelling Londish (Int J Epidemiol) Modelling Hallett (PLoS ONE) Modelling White (AIDS) Modelling Alsallaq (Mexico abstract # MOPE0254) Modelling Fieno, (AIDS Care) 2009 Expert Group (Hankins et al in press PLoS Medicine) Timeline 3 meetings convened by UNAIDS/WHO/SACEMA Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  5. In high HIV prevalence/low male circumcision settings, models predict that: One HIV infection averted for every 5-15 male circumcisions performed. Costs to avert one HIV infection range from $150-900 using a 10-year time horizon. Premature postoperative resumption of sexual intercourse has only small population-level effect because the time frame is short Any behavioural risk compensation confined to newly or already circumcised men and their partners has only a small population-level effect on the anticipated impact of MC service scale-up on HIV incidence MC scale-up acts synergistically with other HIV prevention strategies Expert Review Group Consensus MOPDC106. Hankins et al.Informing Decision-making on Male Circumcision for HIV Prevention in High HIV Prevalence Settings: Insights from Modelling

  6. Decision-makers’ programme planning tool Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation Developed by Futures Institute under the Health Policy Initiative in collaboration with UNAIDS Supports decision makers to understand the cost and impact of scaling-up male circumcision services by service delivery approach, priority populations, pace of scale-up Populations: All adult males, 15-24 or 15-29 year old males, adolescents prior to starting sexual activity, newborns, high risk males, others

  7. Approach: Select technical team (technical support can be accessed through UNAIDS & technical support facility) Collect epidemiological and behavioural data Set up impact model Populate the tool with demographic, epi and behavioural data Collect cost information at central and facility level Determine cost per male circumcision performed Analyze cost and impact of alternate strategies Conduct dialogue with stakeholders and decision makers Steps in using the Decision-makers’ programme planning tool Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  8. Coverage Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation • Specify target coverage and year for each population • Select scale-up rate • Slow • Linear • Fast • S-shaped

  9. Data required Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  10. Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  11. Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  12. Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  13. Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  14. Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  15. Botswana: Linear scale-up starting 2009 80% coverage by 2015 Bollinger LA, Stover J, Musuka G, Fidzani B, Moeti T, Busang L. The cost & impact of male circumcision on HIV/AIDS in Botswana. J Int AIDS Soc. 2009; 27;12(1):7 Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  16. Botswana sensitivity analysis Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  17. Namibia: Number of yearly MC performedwith target of 80% by 2015 and beyond (Gaillard & Godlove) 661,082 MC performed for period 2008-2025

  18. Namibia: Number of yearly MC performed on all three Populations with target of 80% by 2015 & beyond (Gaillard & Godlove) 1,268,066 MC performed for period 2008-2025

  19. Estimated Number of Yearly HIV Infections Averted – Namibia (Gaillard & Godlove) 77,025 infections averted for period 2008-2025

  20. Total savings in Billions of Namibian Dollars 77,000 infections averted at a net saving of $66,010 per infection averted for the period 2009-2025 means $5.0 billion Namibian dollars in total savings (after costs of $823 million from 2008-2025) Discounted Value expressed in Constant 2007 Namibian dollars

  21. John Stover, Futures Institute Lori Bollinger, Futures Institute Nicolai Lohse, UNAIDS Brian Houle, UNAIDS Tim Hallett, Imperial College Brian Williams, WHO, SACEMA John Hargrove, SACEMA UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV prevention Model and manual available at www.FuturesInstitute.org Acknowledgements Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

  22. Developed by the World Health Organization (WHO), theJoint United Nations Programme on HIV/AIDS (UNAIDS), theAIDS Vaccine Advocacy Coalition (AVAC), and Family Health International (FHI) Assessing costs and impact on the epidemic of male circumcisionCircumcision – Moving from research to implementation

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