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)– $50-60 million in 2015
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
Illustrative Results - 2007
Resources Needed for Prevention
02,0004,0006,0008,000
10,00012,00014,00016,000
2006 2010 2015
Millions
of U
S$
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
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
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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
Cape town IASJuly 2009
HankinsUNAIDS
Assessing costs and impact on the epidemic of male circumcision
Circumcision – Moving from research to implementation
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)