Scaling up voluntary medical male circumcision

Catherine Hankins MD MSc FRCPCChief Scientific Adviser to UNAIDS

Office of the Deputy Executive Director, Programme

THE CUTTING EDGE: What's New in Voluntary Medical Male Circumcision

Rome, 19th International AIDS Society, July 2011

WHO/UNAIDS Technical Consultation Male Circumcision and HIV Prevention: Research Implications for Policy and Programming Montreux, Switzerland 6- 8 March 2007

Courtesy C Hankins

Male Circumcision Priority Countries

Facilitating Factors in VMMC scale-up• Community buy-in and

engagement of traditional leaders

• Political will and country ownership

• Strategic communication • Strong leadership and

coordination from the Ministry of Health with the National and Provincial MC Task Forces

• Enough resources for service delivery

• Technical support from partners

• Capacity to change strategy as new information becomes available

• Task shifting to clinical officers and nurses

• Mobility of service delivery: taking services to people

• Dedication of sites with campaign style

• Mixed staffing models (public and private/NGO)

• Practicality: temporary services, continuous services

• Innovation

Communicating about partial protection

Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009: e1000109

UNAIDS/WHO/SACEMA

Women will benefit indirectly, although the effect will be smaller than the direct effect for men and will take longer to develop.

The benefits are likely to be large, with one HIV infection averted for every 5 to 15 male circumcisions performed, using a 10 year horizon.

Circumcised men Women Uncircumcised men Whole population0

20

40

60

80

100

Red

uctio

n in

HIV

inci

denc

e (%

) 5% circumcised20% circumcised35% circumcised50% circumcised70% circumcised90% circumcised

6 modelling teams addressed 8 questions of key concern to policy makers

Population-level Impacts by Coverage

Medical male circumcision is highly cost-effective with costs to avert one HIV infection from US$150-$900 using a 10 year time horizon.

Number of MC needed per Infection Averted from 2011 to 2025

Botswan

a

Ethiop

iaKen

ya

Leso

tho

Malawi

Mozam

bique

Namibi

a

Rwanda

South

Africa

Swazila

nd

Tanza

nia

Ugand

a

Zambia

Zimba

bwe

0

10

20

30

40

50

60

70

8

59

8 5 137

26

44

5 510

198

4

Courtesy Emmanuel Njeuhmeli, PEPFAR

Decision-makers’ programme planning tool• Developed by Futures Institute in collaboration with

UNAIDS under the USAID/Health Policy Initiative • 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– Men at higher risk of HIV exposure– others

AIDS at 30 Nations at the crossroads

Annual male circumcisions for HIV prevention in eight countries* in Eastern and Southern Africa, 2008–2010

* Kenya, Malawi, Namibia, Rwanda, South Africa, Swaziland, Zambia and Zimbabwe

Thousands

100

200

300

400

2008 2009 20100

Achievement toward target of 80% coverage

Botswan

a

Ethiop

iaKen

ya

Leso

tho

Malawi

Mozam

bique

Namibi

a

Rwanda

South

Africa

Swazila

nd

Tanza

nia

Ugand

a

Zambia

Zimba

bwe

0%

10%

20%

30%

40%

50%

60%

70%

4%

12%

66%

0% 0% 1% 1% 0%3%

14%

3% 0%4%

1%

Courtesy Emmanuel Njeuhmeli, PEPFAR

Supply & Demand - Ideal

VMMC Supply VMMC Demand

Courtesy Jason Reed PEPFAR

Supply & Demand Equation Calculus

Courtesy Jason Reed PEPFAR

Developed by WHO, UNAIDS, AVAC, and FHI

Zero new HIV infections Zero discrimination Zero HIV-related deaths