Effectiveness of and Financial Returns to Voluntary Medical Male Circumcision for HIV Prevention in South Africa: An Incremental Cost-Effectiveness Analysis

Evidence Gaps in Economic Evaluations of HIV Interventions Targeting Young People: A Systematic Review

PURPOSE

Young people living with HIV (YPLWH) face the burden of navigating the unique physical, psychological, and social challenges of adolescence while coping with a stigmatized infectious disease that requires lifelong care. Consequently, YPLWH experience worse HIV outcomes compared to children and adults. This systematic review seeks to collate evidence on the health and economic impact of HIV interventions targeting YPLWH and to identify gaps in the available evidence that may inform future economic evaluations of interventions for YPLWH.

METHODS

We searched the MEDLINE, Embase, Scopus, and Global Index Medicus databases for peer-reviewed articles published through April 24, 2022 (PROSPERO ID: CRD42022356244). Our inclusion criteria encompassed economic evaluations of HIV interventions that report health and economic outcomes among individuals ages 10-24 years. Three investigators screened articles at the title, abstract, and full-text levels. The data were extracted in accordance with the Consolidated Health Economic Evaluation Reporting Standards 2022.

RESULTS

Of the 3,735 unique articles retrieved through our search, 32 met our inclusion criteria. Of these 32 articles, 8 (25%) evaluated a behavioral, educational, or financial intervention, 6 (19%) voluntary medical male circumcision, 5 (16%) HIV screening or testing, 4 (13%) pre-exposure prophylaxis, 3 (9%) a hypothetical HIV vaccine, 2 (6%) antiretroviral therapy, 1 (3%) condom distribution, and 3 (9%) a combination of interventions. Twenty-two studies (69%) focused on Africa, 9 (28%) on North America, and 1 (3%) on Europe. Thirty studies (94%) were cost-effectiveness analyses and 2 (6%) were cost-utility analyses. Of the intervention types captured by this review, most were deemed cost-saving or cost-effective. Only two studies-one evaluating a financial intervention and one evaluating HIV testing-concluded that the intervention was not cost-effective.

DISCUSSION

Evidence presented by this review suggests that investments in HIV prevention and treatment for young people can be a cost-effective, and sometimes cost-saving, solution to combating the global HIV epidemic. However, additional evaluations of HIV interventions targeting young people, which adhere to standardized reporting practices, are needed to permit comparability of cost-effectiveness outcomes between interventions and settings.

Voluntary medical male circumcision in selected provinces in South Africa: Outcomes from a programmatic setting

Introduction

Voluntary medical male circumcision (VMMC) remains an effective biomedical intervention for HIV prevention in high HIV prevalence countries. In South Africa, United States Agency for International Development VMMC partners provide technical assistance to the Department of Health, at national and provincial levels in support of the establishment of VMMC sites as well as in providing direct VMMC services at site level since April 2012. We describe the outcomes of the Right to Care (RTC) VMMC program implemented in South Africa from 2012 to 2017.

Methods

This retrospective study was undertaken at RTC supported facilities across six provinces. Young males aged ≥10 years who presented at these facilities from 1 July 2012 to 31 September 2017 were included. Outcomes were VMMC uptake, HIV testing uptake and rate of adverse events (AEs). Using a de-identified observational database of these clients, summary statistics of the demographic characteristics and outcomes were calculated.

Results

There were a total 1,001,226 attendees of which 998,213 (99.7%) were offered VMMC and had a median age of 15 years (IQR = 12–23 years). Of those offered VMMC, 99.6% (994,293) consented, 96.7% (965,370) were circumcised and the majority (46.3%) were from Gauteng province. HIV testing uptake was 71% with a refusal rate of 15%. Of the newly diagnosed HIV positives, 64% (6,371 / 9,972) referrals were made. The rate of AEs, defined as bleeding, infection, and insufficient skin removal) declined from 3.26% in 2012 to 1.17% in 2017. There was a reduction in infection-related AEs from 2,448 of the 2,602 adverse events (94.08%) in 2012 to 129 of the 2,069 adverse events (6.23%) in 2017.

Conclusion

There was a high VMMC uptake with a decline in AEs over time. Adolescent men contributed the most to the circumcised population, an indication that the young population accesses medical circumcision more. VMMC programs need to implement innovative demand creation strategies to encourage older males (20–34 years) at higher risk of HIV acquisition to get circumcised for immediate impact in reduction of HIV incidence. HIV prevalence in the total population increased with increasing age, notably in clients above 25 years.

Understanding the Evolving Role of Voluntary Medical Male Circumcision as a Public Health Strategy in Eastern and Southern Africa: Opportunities and Challenges

PURPOSE OF REVIEW

Voluntary male medical circumcision (VMMC) has been a cornerstone of HIV prevention in Eastern and Southern Africa (ESA) and is credited in part for declines in HIV incidence seen in recent years. However, these HIV incidence declines change VMMC cost-effectiveness and how it varies across populations.

RECENT FINDINGS

Mathematical models project continued cost-effectiveness of VMMC in much of ESA despite HIV incidence declines. A key data gap is how demand generation cost differs across age groups and over time as VMMC coverage increases. Additionally, VMMC models usually neglect non-HIV effects of VMMC, such as prevention of other sexually transmitted infections and medical adverse events. While small compared to HIV effects in the short term, these could become important as HIV incidence declines. Evidence to date supports prioritizing VMMC in ESA despite falling HIV incidence. Updated modeling methodologies will become necessary if HIV incidence reaches low levels.

An economic evaluation of an intervention to increase demand for medical male circumcision among men aged 25-49 years in South Africa

BACKGROUND

Studies estimate that circumcising men between the ages of 20-30 years who have exhibited previous risky sexual behaviour could reduce overall HIV prevalence. Demand creation strategies for medical male circumcision (MMC) targeting men in this age group may significantly impact these prevalence rates.

OBJECTIVES

The objective of this study is to evaluate the cost-effectiveness and cost-benefit of an implementation science, pre-post study designed to increase the uptake of male circumcision for ages 25-49 at a fixed MMC clinic located in Gauteng Province, South Africa.

METHODS

A health care provider perspective was utilised to collect all costs. Costs were compared between the standard care scenario of routine outreach strategies and a full intervention strategy. Cost-effectiveness was measured as cost per mature man enrolled and cost per mature man circumcised. A cost-benefit analysis was employed by using the Bernoulli model to estimate the cases of HIV averted due to medical male circumcision (MMC), and subsequently translated to averted medical costs.

RESULTS

In the 2015 intervention, the cost of the intervention was $9445 for 722 men. The total HIV treatment costs averted due to the intervention were $542,491 from a public care model and $378,073 from a private care model. The benefit-cost ratio was 57.44 for the public care model and 40.03 for the private care model. The net savings of the intervention were $533,046 or $368,628 - depending on treatment in a public or private setting.

CONCLUSIONS

The intervention was cost-effective compared to similar MMC demand interventions and led to statistically significant cost savings per individual enrolled.

Description of adverse events among adult men following voluntary medical male circumcision: Findings from a circumcision programme in two provinces of South Africa

BACKGROUND

Clinical trials showed strong evidence that voluntary medical male circumcision (VMMC) reduces the acquisition of HIV among heterosexual men by up to 60%. However, VMMC uptake in East and Southern Africa remains suboptimal, with safety concerns identified as a barrier to uptake. We investigated the occurrence and severity of adverse events (AEs) in a routine VMMC programme implemented in Gauteng and North West provinces of South Africa.

METHODS

We describe the frequency and characteristics of AEs using routinely collected data from a VMMC programme implemented between 01 May 2013 and 31 December 2014. The surgical procedure was provided at fixed clinics and mobile units in three districts. Adult men undertaking the procedure were referred for follow-up appointments where AEs were monitored.

RESULTS

A total of 7,963 adult men were offered the VMMC service with 7,864 (98.8%) met the age and consent requirements for inclusion in a research follow-up after the surgical procedure and were followed-up for potential AEs. In total, 37 (0.5%) patients reported AEs post-surgery with infection [11 (29.7%)] and excessive bleeding [11 (29.7%)] commonly reported AEs. In terms of severity, 14 (37.8%) were classified as mild, 13 (35.1%) as moderate, and 10 (27.0%) as severe. Further, 32 (86.5%) of the AEs were classified as definitely related to the surgical procedure, with 36 (97.5%) of all AEs resolving without sequelae.

CONCLUSION

The VMMC programme was able to reach adult men at high risk of HIV acquisition. Reported AEs in the programme were minimal, with the observed safety profile comparable to clinical trial settings, suggesting that VMMC can be safely administered in a programmatic setting.

Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe

BACKGROUND

Supply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe.

METHODS

Interpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites.

RESULTS

Total programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were $58 and $174, respectively. Highest costs per client reached were in the HCD arm-$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised.

CONCLUSIONS

There was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs.

TRIAL REGISTRATION NUMBER

PACTR201804003064160.

On time horizons in health economic evaluations

The issue of time horizons has received scant attention in discussions pertaining to health economic evaluations unlike discounting or translation of health outcomes into life-cycle measures (e.g. quality-adjusted life years or disability-adjusted life years). The available guidelines do not offer clear and consistent guidance for many problems addressed in health economic evaluations. In practice, variation of time horizons between studies for the same diseases is a matter of concern, as results on cost-effectiveness depend on the time horizon. Our paper contributes to establishing a consistent approach to setting time horizons across common types of health economic evaluations and mitigating potential bias where the choice of a time horizon may affect results of the evaluation. We find that available guidance is clear only for patient-focused interventions, but not in the presence of population-level effects owing to transmission of infections or other linkages. We distinguish between a policy period-over which an intervention is delivered or initiated-and an evaluation period over which the effects are measured. One important challenge in establishing a time horizon for evaluation is that, at least for infectious diseases, the state of the epidemic at the end of the policy period cannot be evaluated precisely and incorporated in the results of an economic evaluation. While longer policy periods partly mitigate this challenge, they are subject to greater uncertainty, and outcomes may not adequately reflect the cost-effectiveness of current policies because outcomes reflect an average over the policy period. Incremental analysis on interventions implemented in sub-periods of the policy period (especially at the beginning) potentially improves accuracy and helps to identify potential for improving cost-effectiveness by varying the path of implementation or the mix of interventions offered over time.

Access to HIV prevention services in East African cross-border areas: a 2016-2017 cross-sectional bio-behavioural study

INTRODUCTION

East African cross-border areas are visited by mobile and vulnerable populations, such as men, female sex workers, men who have sex with men, truck drivers, fisher folks and young women. These groups may not benefit from traditional HIV prevention interventions available at the health facilities where they live, but may benefit from services offered at public venues identified as places where people meet new sexual partners (e.g. bars, nightclubs, transportation hubs and guest houses). The goal of this analysis was to estimate availability, access and uptake of prevention services by populations who visit these venues.

METHODS

We collected cross-sectional data using the Priorities for Local AIDS Control Efforts sampling method at cross-border locations near or along the land and lake borders of Kenya, Rwanda, Tanzania and Uganda from June 2016-February 2017. This bio-behavioural survey captured information from a probability sample of 11,428 individuals at 833 venues across all areas. Data were weighted using survey sampling weights and analysed using methods to account for the complex sampling design.

RESULTS

Among the 85.6% of persons who had access to condoms, 60.5% did not use a condom at their last anal or vaginal sexual encounter. Venues visited by high percentages of persons living with HIV were not more likely than other venues to offer condoms. In 12 of the 22 cross-border areas, male or female condoms were available at less than 33% of the venues visited by persons having difficulty accessing condoms. In 17 of the 22 cross-border areas, education outreach visits in the preceding six months occurred at less than 50% of the venues where participants had low effective use of condoms.

CONCLUSIONS

Individuals visiting venues in cross-border areas report poor access to and low effective use of condoms and other prevention services. Availability of HIV prevention services differed by venue and population type and cross-border area, suggesting opportunities for more granular targeting of HIV prevention interventions and transnational coordination of HIV programming.

Voluntary medical male circumcision and sexual practices among sexually active circumcised men in Mzuzu, Malawi: a cross-sectional study

BACKGROUND

Voluntary Medical Male Circumcision (VMMC) is one of the strategies being promoted to prevent sexual heterosexual transmission of HIV. It has been adopted by 14 countries with high HIV prevalence and low circumcision rates. The 60.0% protective efficacy of VMMC has come with misconceptions in some societies in Malawi, hence VMMC clients may opt for risky sexual practices owing to its perceived protective effect. The study estimated proportion of circumcised men engaging in risky sexual behaviors post-VMMC, assessed knowledge on VMMC protective effect and identified socio-demographic factors associated with risky sexual practices.

METHOD

A cross sectional study was conducted at two sites of Mzuzu city. Systematic random sampling was used to select 322 participants aged 18-49 who had undergone VMMC. The independent variables included age, location, occupation, religion, marital status and education. Outcome variables were non condom use, having multiple sexual partners and engaging in transactional sex. Data from questionnaires was analyzed using Pearson's chi square test and logistic regression.

RESULTS

Out of 322 respondents, 84.8% (273) understood the partial protection offered by VMMC in HIV prevention. Ninety-six percent of the participants self-reported continued use of condoms post VMMC. Overall 23.7-38.3% participants self-reported engaging in risky sexual practices post VMMC, 23.7% (76) had more than one sexual partner; 29.2% (94) paid for sex while 39.9% (n = 187) did not use a condom. Residing in high density areas was associated with non-condom use, (p = 0.043). Being single (p < 0.001), and residing in low density areas (p = 0.004) was associated with engaging in transactional sex.

CONCLUSION

Risky sexual practices are evident among participants that have undergone VMMC. Messages on safer sexual practices and limitations of VMMC need to be emphasized to clients, especially unmarried or single and those residing in low density areas.

Service delivery interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review

BACKGROUND

Voluntary medical male circumcision (VMMC) remains an essential component of combination HIV prevention services, particularly in priority countries in sub-Saharan Africa. As VMMC programs seek to maximize impact and efficiency, and to support World Health Organization guidance, specific uptake-enhancing strategies are critical to identify.

METHODS

We systematically reviewed the literature to evaluate the impact of service delivery interventions (e.g., facility layout, service co-location, mobile outreach) on VMMC uptake among adolescent and adult men. For the main effectiveness review, we searched for publications or conference abstracts that measured VMMC uptake or uptake of HIV testing or risk reduction counselling within VMMC services. We synthesized data by coding categories and outcomes. We also reviewed studies assessing acceptability, values/preferences, costs, and feasibility.

RESULTS

Four randomized controlled trials and five observational studies were included in the effectiveness review. Studies took place in South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. They assessed a range of service delivery innovations, including community-, school-, and facility-based interventions. Overall, interventions increased VMMC uptake; some successfully improved uptake among age-specific subpopulations, but urban-rural stratification showed no clear trends. Interventions that increased adult men's uptake included mobile services (compared to static facilities), home-based testing with active referral follow-up, and facility-based HIV testing with enhanced comprehensive sexual education. Six acceptability studies suggested interventions were generally perceived to help men choose to get circumcised. Eleven cost studies suggested interventions create economies-of-scale and efficiencies. Three studies suggested such interventions were feasible, improving facility preparedness, service quality and quantity, and efficiencies.

CONCLUSIONS

Innovative changes in male-centered VMMC services can improve adult men's and adolescent boys' VMMC uptake. Limited evidence on interventions that enhance access and acceptability show promising results, but evidence gaps persist due to inconsistent intervention definition and delivery, due in part to contextual relevance and limited age disaggregation.

Cost-effectiveness of HIV Prevention Interventions in Sub-Saharan Africa: A Systematic Review

BACKGROUND

Sub-Saharan Africa carries the highest HIV burden globally. It is important to understand how interventions cost-effectively fit within guidelines and implementation plans, especially in low- and middle-income settings. We reviewed the evidence from economic evaluations of HIV prevention interventions in sub-Saharan Africa to help inform the allocation of limited resources.

METHODS

We searched PubMed, Web of Science, Econ-Lit, Embase, and African Index Medicus. We included studies published between January 2009 and December 2018 reporting cost-effectiveness estimates of HIV prevention interventions. We extracted health outcomes and cost-effectiveness ratios (CERs) and evaluated study quality using the CHEERS checklist.

FINDINGS

60 studies met the full inclusion criteria. Prevention of mother-to-child transmission interventions had the lowest median CERs ($1144/HIV infection averted and $191/DALY averted), while pre-exposure prophylaxis interventions had the highest ($13,267/HIA and $799/DALY averted). Structural interventions (partner notification, cash transfer programs) have similar CERs ($3576/HIA and $392/DALY averted) to male circumcision ($2965/HIA) and were more favourable to treatment-as-prevention interventions ($7903/HIA and $890/DALY averted). Most interventions showed increased cost-effectiveness when prioritizing specific target groups based on age and risk.

INTERPRETATION

The presented cost-effectiveness information can aid policy makers and other stakeholders as they develop guidelines and programming for HIV prevention plans in resource-constrained settings.

The effectiveness of PEPFAR's funding for women and children with HIV/AIDS

Has President's Emergency Plan for AIDS Relief's (PEPFAR) funding been effective in reducing the rate of HIV new infections and AIDS-related deaths among women and children? While previous studies have found HIV/AIDS aid to be ineffective and PEPFAR funding to produce negative externalities, there is lack of empirical examination of the impact of PEPFAR on women and children despite the emphasis on prevention of mother-to-child transmission of HIV during the Bush and Obama administrations. Using descriptive analysis and difference-in-differences (DID) regression, this study finds that PEPFAR's funding has reduced the HIV new infections and AIDS-related death rates of women and children for both focus countries and recipient countries, which are those that were added in a second phase. These findings show that PEPFAR's strategy for women and children has been effective and that it should be continued. However, while PEPFAR has contributed to the fight against HIV/AIDS, the effects of its work have been underestimated.

Use of expenditure analysis to enhance returns on investments in HIV services

PURPOSE OF REVIEW

Globally, the response to the HIV epidemic is at a crisis point. International investments in the HIV response have been essentially flat for 8 years and domestic budgets in low and middle-income countries - still recovering from the global recession - have not been able to fill the resource gap to drive a full-fledged HIV response. Still, efficiencies and prioritization of evidence-based interventions enable a significant scale-up of treatment, but millions more people remain without treatment. This review looks at recent data and research to evaluate interventions that may help close gaps in service provision that undermine testing and treatment programs.

RECENT FINDINGS

The President's Emergency Plan for AIDS Relief recently began publicly releasing vast programmatic and expenditure data. These data reveal potential efficiency gaps in testing and treatment programs, particularly in the area of linkage and retention. Interventions such as HIV self-testing have been proposed to help, but whether they can deliver better results remains unclear. Same-day initiation on treatment improves initiation, retention, and viral suppression rates.

SUMMARY

Near real-time analysis of data and active response is critical in improving efficiencies in programs. More investment in implementation research is necessary to improve linkage to care and treatment to reach 90-90-90 goals.

Consequences of a changing US strategy in the global HIV investment landscape

Supplemental Digital Content is available in the text

Objective:

The global fight against HIV/AIDS in Africa has long been a focus of US foreign policy, but this could change if the federal budget for 2018 proposed by the US Office of Management and Budget is adopted. We aim to inform public and Congressional debate around this issue by evaluating the historical and potential future impact of US investment in the African HIV response.

Design/methods:

We use a previously published mathematical model of HIV transmission to characterize the possible impact of a series of financial scenarios for the historical and future AIDS response across Sub-Saharan Africa.

Results:

We find that US funding has saved nearly five million adults in Sub-Saharan Africa from AIDS-related deaths. In the coming 15 years, if current numbers on antiretroviral treatment are maintained without further expansion of programs (the proposed US strategy), nearly 26 million new HIV infections and 4.4 million AIDS deaths may occur. A 10% increase in US funding, together with ambitious domestic spending and focused attention on optimizing resources, can avert up to 22 million HIV infections and save 2.3 million lives in Sub-Saharan Africa compared with the proposed strategy.

Conclusion:

Our synthesis of available evidence shows that the United States has played, and could continue to play, a vital role in the global HIV response. Reduced investment could allow more than two million avoidable AIDS deaths by 2032, whereas continued leadership by the United States and other countries could bring UNAIDS targets for ending the epidemic into reach.

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

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.

Voluntary Medical Male Circumcision for HIV Prevention in Malawi: Modeling the Impact and Cost of Focusing the Program by Client Age and Geography

BACKGROUND

In 2007, the World Health Organization (WHO) recommended scaling up voluntary medical male circumcision (VMMC) in priority countries with high HIV prevalence and low male circumcision (MC) prevalence. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 5.8 million males had undergone VMMC by the end of 2013. Implementation experience has raised questions about the need to refocus VMMC programs on specific subpopulations for the greatest epidemiological impact and programmatic effectiveness. As Malawi prepared its national operational plan for VMMC, it sought to examine the impacts of focusing on specific subpopulations by age and region.

METHODS

We used the Decision Makers' Program Planning Toolkit, Version 2.0, to study the impact of scaling up VMMC to different target populations of Malawi. National MC prevalence by age group from the 2010 Demographic and Health Survey was scaled according to the MC prevalence for each district and then halved, to adjust for over-reporting of circumcision. In-country stakeholders advised a VMMC unit cost of $100, based on implementation experience. We derived a cost of $451 per patient-year for antiretroviral therapy from costs collected as part of a strategic planning exercise previously conducted in- country by UNAIDS.

RESULTS

Over a fifteen-year period, circumcising males ages 10-29 would avert 75% of HIV infections, and circumcising males ages 10-34 would avert 88% of infections, compared to the current strategy of circumcising males ages 15-49. The Ministry of Health's South West and South East health zones had the lowest cost per HIV infection averted. Moreover, VMMC met WHO's definition of cost-effectiveness (that is, the cost per disability-adjusted life-year [DALY] saved was less than three times the per capita gross domestic product) in all health zones except Central East. Comparing urban versus rural areas in the country, we found that circumcising men in urban areas would be both cost-effective and cost-saving, with a VMMC cost per DALY saved of $120 USD and with 15 years of VMMC implementation resulting in lifetime HIV treatment costs savings of $331 million USD.

CONCLUSIONS

Based on the age analyses and programmatic experience, Malawi's VMMC operational plan focuses on males ages 10-34 in all districts in the South East and South West zones, as well as Lilongwe (an urban district in the Central zone). This plan covers 14 of the 28 districts in the country.