Catherine Hankins MD MSc FRCPC Chief Scientific Adviser to UNAIDS Office of the Deputy Executive Director Scaling up male circumcision programmes in Eastern and Southern Africa: Country Update- lessons, opportunities, challenges Arusha, Tanzania, June 8-10, 2010 Assessing Costs and Impact on the Epidemic of Male Circumcision using the Decision-Makers Programme Planning Tool: Overview and methodology
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Catherine Hankins MD MSc FRCPC Chief Scientific Adviser to UNAIDS Office of the Deputy Executive Director Scaling up male circumcision programmes in Eastern.
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Catherine Hankins MD MSc FRCPCChief Scientific Adviser to UNAIDS
Office of the Deputy Executive Director
Scaling up male circumcision programmes in Eastern and Southern Africa: Country Update-
lessons, opportunities, challenges
Arusha, Tanzania, June 8-10, 2010
Assessing Costs and Impact on the Epidemic of Male Circumcision using
the Decision-Makers Programme Planning Tool: Overview and
methodology
2005• July RCT South Africa (PLoS Med Nov 2005) • Nov 11stst modelling meeting (Geneva, Switzerland) modelling meeting (Geneva, Switzerland)
2006• July Modelling Williams (PLoS Med)• Dec RCTs Uganda and Kenya (Lancet Feb 2007)2007• March WHO/UNAIDS recommendations
• Nov 22ndnd modelling meeting (Stellenbosch, South Africa) modelling meeting (Stellenbosch, South Africa)Modelling Podder (Bull Math Biol); DMPPT presentedDMPPT presented
2009 Expert Group Results (PLoS MedicinePLoS Medicine)
Trial Results and Modelling Timeline
3 meetings convened by UNAIDS/WHO/SACEMA
Expert Review Group ConsensusExpert Review Group ConsensusIn 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 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 anticipated impact of MC service scale-up on HIV incidence
• MC scale-up acts synergistically with other HIV prevention strategies[Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009;6, September 8]
Population-level Impacts by Coverage
Hankins et al. Male circumcision for HIV prevention in high
HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009;6, September 8
Decision-makers’ programme planning tool• Developed by Futures Institute under the
USAID/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, males at higher risk, others
Steps in using the Decision-makers’ Programme Planning Tool (DMPPT)
• 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
Coverage
• Specify target coverage and year for each population
High Risk Males Other population 1Other population 2 Other population 3Other Prevention
Data required
Type of Data Source
Demography UN Pop Div, Census
Sexual behaviour Demographic and health surveys
HIV prevalence Antenatal surveillance, Demographic & health surveys
Cost MOH, clinic visits
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
Botswana sensitivity analysis
Use of the Decision Makers’ Programme Planning Tool (DMPPT)
• Botswana and Namibia: results presented at the Dakar DMPPT meeting December 2008
• USAID desk review
• Nairobi training workshop April 18-20, 2010
• Uganda: costing and impact completed
• Kenya, Zambia, Zimbabwe, South Africa: costing completed or underway
• Rwanda, Tanzania, and Namibia (update): planning stage
0
50,000
100,000
150,000
200,000
250,000
Year
Num
ber o
f MC
Baseline (21%) Adolescents All adult males New Born Males
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
Acknowledgements
• John Stover, Lori Bollinger, Stephen Forsythe, Futures Institute
• Nicolai Lohse and Brian Houle, UNAIDS
• Tim Hallett, Imperial College
• Brian Williams and John Hargrove, SACEMA
• Eric Gaillard and Albena Godlove, consultants
• UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV prevention
• Emmanuel Njeuhmeli, USAIDModel and manual available at www.malecircumcision.org