assessing costs and impact on the epidemic of male circumcision catherine hankins unaids...

Assessing Costs and Impact on the Epidemic of Male Circumcision

Catherine Hankins

UNAIDS ([email protected])

5th IAS Conference on HIV Pathogenesis, Treatment & Prevention

Cape town, South Africa, July 2009

Session: Circumcision – Moving from Research to Implementation

Cape town IASJuly 2009

HankinsUNAIDS

Assessing costs and impact on the epidemic of male circumcision

Circumcision – Moving from research to implementation

UNAIDS global resource needs estimates for male circumcision - 2007

• Overall target was 80% of 15-24 year old males circumcised in sub-Saharan Africa

• Three scenarios considered: 1. Historical growth in coverage of VCT and PMTCT applied

to prevention and to care & treatment 2. Universal access by 2015 3. 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


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Illustrative Results - 2007

Resources Needed for Prevention

02,0004,0006,0008,000

10,00012,00014,00016,000

2006 2010 2015

Millions

of U

S$

Univ Precautions

Male circumcision

Safe injections

PEP

Blood safety

PMTCT

STI treatment

Condoms

Social marketing

Other vuln. pops.

Prevention for PLHA

Workplace

IDU

MSM

CSW

Youth out of school

Youth in school

VCT

Comm. Mobilization

Mass media

Targets reached in 2010


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2005• July RCT South Africa (PLoS Med Nov 2005)2006• July Modelling Williams (PLoS Med)• Nov 11stst modelling meeting (Geneva, Switzerland) 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 22ndnd modelling meeting (Stellenbosch, South modelling meeting (Stellenbosch, South Africa)Africa)

Modelling Podder (Bull Math Biol)2008• March 33rdrd modelling meeting (London, UK) 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

Expert Review Group Consensus

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

MOPDC106. Hankins et al. Informing Decision-making on

Male Circumcision for HIV Prevention in High HIV Prevalence Settings: Insights from Modelling


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Decision-makers’ programme planning tool• 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


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Steps in using the Decision-makers’ programme planning tool

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


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Coverage

• Specify target coverage and year for each population

• Select scale-up rate– Slow– Linear– Fast– S-shaped

Percent Circumcised

0

10

20

30

40

50

60

70

80

90

2008 2009 2010 2011 2012 2013 2014 2015

All Adults 15-24Adolescent Males New Born Males

High Risk Males Other population 1Other population 2 Other population 3Other Prevention


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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


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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


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Botswana sensitivity analysis

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

Year

Num

ber o

f MC

Baseline (21%) Adolescents All adult males

Namibia: Number of yearly MC performedwith target of 80% by 2015 and beyond (Gaillard & Godlove)

661,082 MC performed for period 2008-2025

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

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

HIV

infe

cti

on

s a

ve

rte

d

Adolescent Males Adolescent + all adult males

Estimated Number of Yearly HIV Infections Averted – Namibia (Gaillard & Godlove)

77,025 infections averted for period 2008-2025

Total savings in Billions of Namibian Dollars

77,000 infections avertedat a net saving of $66,010 per infection averted

for the period 2009-2025means

$5.0 billion Namibian dollars in total savings

(after costs of $823 million from 2008-2025)

Discounted Value expressed in Constant 2007 Namibian dollars


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Acknowledgements

• 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


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Developed by the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), the AIDS Vaccine Advocacy Coalition

(AVAC), and Family Health International (FHI)

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