Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries

Clinical Infectious Diseases, Apr 2018

The new World Health Organization and Joint United Nations Programme on HIV/AIDS strategic framework for voluntary medical male circumcision (VMMC) aims to increase VMMC coverage among males aged 10–29 years in priority settings to 90% by 2021. We use mathematical modeling to assess the likelihood that selected countries will achieve this objective, given their historical VMMC progress and current implementation options.

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Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries

CID Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries 0 Palladium Group 1 Independent Consultant , Geneva , Switzerland 2 Office of HIV/AIDS, Global Health Bureau, United States Agency for International Development , Washington, District of Columbia , USA 3 Emmanuel Njeuhmeli 4 Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland , USA 5 Johns Hopkins Center for Communication Programs 6 Avenir Health , Washington, District of Columbia , USA Background. The new World Health Organization and Joint United Nations Programme on HIV/AIDS strategic framework for voluntary medical male circumcision (VMMC) aims to increase VMMC coverage among males aged 10-29 years in priority settings to 90% by 2021. We use mathematical modeling to assess the likelihood that selected countries will achieve this objective, given their historical VMMC progress and current implementation options. Methods. We use the Decision Makers' Program Planning Toolkit, version 2, to examine 4 ambitious but feasible scenarios for scaling up VMMC coverage from 2017 through 2021, inclusive in Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, and Zimbabwe. Results. Tanzania is the only country that would reach the goal of 90% VMMC coverage in 10- to 29-year-olds by the end of 2021 in the scenarios assessed, and this was true in 3 of the scenarios studied. Mozambique, South Africa, and Lesotho would come close to reaching the objective only in the most ambitious scenario examined. Conclusions. Major changes in VMMC implementation in most countries will be required to increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021. Scaling up VMMC coverage in males aged 10-29 years will require significantly increasing the number of circumcisions provided to 10- to 14-year-olds and 15- to 29-year-olds. - Voluntary medical male circumcision (VMMC) is a highly effective [ 1–3 ] and cost-effective [ 4–6 ] intervention to reduce femaleto-male human immunodeficiency virus (HIV) transmission. It is recommended in countries with high HIV prevalence and low levels of male circumcision [ 7, 8 ]. Fourteen countries in sub-Saharan Africa are scaling up service delivery of adult VMMC for HIV prevention [9]. In 2011, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) released a strategic framework outlining VMMC implementation objectives in priority countries [ 9 ]. The strategy set a target of reaching VMMC coverage of at least 80% among males aged 15–49  years by 2015. Modeling conducted in 2011 to inform this strategy indicated that >20 million males aged 15–49  years would need to be circumcised between 2011 and 2015 to increase the proportion of circumcised men in this age group to 80% [ 6 ]. By the end of 2015, almost 12 million men and adolescent boys had been circumcised [ 10 ]. More recently, in the context of plateauing global resources for HIV services [ 11 ] and international commitment to respond more effectively to the epidemic [ 7, 12–15 ], additional modeling was conducted to inform country prioritization of VMMC scale-up [ 16–24 ]. Two main insights emerged from these analyses. First, to focus limited resources, countries are transitioning from national scale-up of VMMC service provision to focused scale-up in a subset of priority subnational locations. Second, in addition to this geographical prioritization, countries are framing their scale-up targets around reaching high coverage among younger men and adolescent boys. Increasing the proportion of circumcised 15- to 29-year-olds will produce the most immediate impact on HIV incidence [ 16–24 ] compared to circumcising other age groups. Increasing VMMC coverage in younger adolescent boys aged 10–14 years contributes to increasing the proportion of circumcised 15- to 29-year-olds in the near term and it takes advantage of existing demand for VMMC among 10to 14-year-olds. Whereas the roll-out of VMMC programs has not specifically focused on attracting this age group, more than a third of clients accessing VMMC services to date have been younger adolescents aged 10–14 years, among whom circumcision is socially and culturally most acceptable [ 25, 26 ]. Indeed the new WHO/UNAIDS strategic framework for VMMC aims to increase VMMC coverage among males aged 10–29 years in priority settings to 90% by 2021 [10]. In this article, we use mathematical modeling to examine the impact of 4 hypothetical scenarios for VMMC program implementation from 2017 through 2021. We explore the ways in which annual uptake of circumcision in various age groups between 2017 and 2021, inclusive, could affect the proportion of circumcised males aged 10–29 years by the end of 2021. Our analyses focus on 9 of the 14 priority countries scaling up VMMC for HIV prevention: Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, and Zimbabwe. The purpose of this analysis is to assess the likelihood that these countries will increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021, given their historical VMMC progress and current implementation options. METHODS We used the Decision Makers’ Program Planning Toolkit (DMPPT), version 2, to examine 4 scenarios for scaling up VMMC coverage from 2017 through 2021. Our analyses are limited to those countries for which age-disaggregated program data were available for all years of the VMMC program, which excluded 5 of the 14 priority countries scaling up VMMC for HIV prevention (Botswana, Ethiopia, Kenya, Rwanda, and Zambia) from this study. Decision Makers’ Program Planning Toolkit 2 Model The DMPPT 2 model, described in depth elsewhere [ 22, 26 ], has been used extensively to assess the epidemiological impact and cost-effectiveness of circumcising different age groups of VMMC clients. In brief, the DMPPT 2 model is a simple compartmental model implemented in Microsoft Excel 2010. The model tracks the number of males circumcised as newborns and in each 5-year age group over time, taking into account age progression and mortality. The model also calculates discounted VMMC program costs and HIV infections averted in the population in each year of user-specified VMMC scale-up strategies. These are compared to a baseline scenario in which male circumcision prevalence is held constant at the level found prior to the initiation of VMMC services for HIV prevention. Data Sources Key model inputs for Lesotho, Malawi, Mozambique, Namibia, Swaziland, South Africa, Tanzania, Uganda, and Zimbabwe can be found in the Supplementary Appendix 1. The DMPPT 2 model is populated with population, mortality, and HIV incidence and prevalence projections from an external source. Population by age and year, mortality by age and year, annual number of male births, and HIV prevalence by age and year were exported from Spectrum/Goals or Spectrum/AIDS Impact Model (AIM) files for all countries [27]. The HIV incidence was also obtained from Spectrum/Goals or Spectrum/ AIM files for all countries except Swaziland. For Swaziland, the age-specific HIV incidence was derived from the Swaziland Incidence Measurement Survey [ 28 ]. The male circumcision prevalence by age group in the model’s base years for each country was derived from Demographic and Health Surveys or AIDS Indicator Surveys from the most recent years before the start of the VMMC program. Information on the annual number of male circumcisions performed since the beginning of the program was obtained from WHO and the age disaggregation of the annual number of VMMCs performed was estimated using the US President’s Emergency Plan for AIDS Relief (PEPFAR) annual reporting [ 26 ]. Scenarios Analyzed We explored 4 hypothetical scale-up scenarios representing ambitious but feasible VMMC program implementation objectives, given historical trends in scaling up male circumcision in countries. We defined “aggressive” scale-up as multiplying the numbers of circumcisions performed in 2016 by 1.5 and performing that number of circumcisions annually between 2017 and 2021, inclusive. We defined “very aggressive” scale-up as doubling the numbers of circumcisions performed in 2016 and performing that number of circumcisions annually from 2017 through 2021. In scenario 1, no circumcisions were performed in young adolescent boys aged 10–14  years, and the annual number of circumcisions performed in men aged 15–29 years from 2017 through 2021 was equal to the number of VMMCs performed in 2016. In scenario 2, the annual number of circumcisions performed in boys and men aged 10–29 years from 2017 through 2021 was equal to the number of VMMCs performed in 2016. In scenario 3, the annual number of circumcisions performed in boys aged 10–14 years from 2017 through 2021 was equal to the number of VMMCs performed in 2016 and the number of VMMCs in men aged 15–29 years was scaled up aggressively. In scenario 4, the annual number of VMMCs in boys aged 10–14 years was scaled up aggressively and the number of circumcisions in men aged 15–29 years was scaled up very aggressively. In all 4 scenarios, the annual number of circumcisions performed in men aged 30–39 years was kept constant at 2016 levels. The numbers of male circumcisions projected in each of the 4 scenarios are shown in Supplementary Table 1. RESULTS The numbers of male circumcisions that would be performed from 2017 through 2021 in the 4 scenarios described above are shown in Figure 1 for each country and age group. Figure 1 also compares these to the numbers of circumcisions performed Scaling Up VMMC for Boys and Young Men • CID 2018:66 (Suppl 3) • S167 since the beginning of the VMMC programs in each country and the age distribution of the VMMCs performed to date. Supplementary Figure 1 shows the annual numbers of male circumcisions performed in scenario 4 and compares these to the annual numbers of circumcisions performed since the beginning of the VMMC programs in each country. These figures highlight that there are notable differences across countries in the age distributions of VMMCs provided to date and that not performing circumcisions in the 10- to 14-year age group would affect countries differently. Whereas circumcisions of boys aged 10–14  years have made up just 5% of all circumcisions performed to date in Namibia, the proportion of VMMCs performed in this age group has been between 30% and 50% in Lesotho, Malawi, Mozambique, Tanzania, Uganda, and Zimbabwe. These figures also underline that the vast majority of VMMCs performed to date have been circumcisions of adolescent boys aged 10–19  years. Seventy percent or more of all VMMCs performed in Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, and Zimbabwe have been of adolescent boys aged 10–19 years. Figure  2 shows the proportion of circumcised males aged 15–29 and 10–29  years in the population by the end of 2021 S168 • CID 2018:66 (Suppl 3) • Njeuhmeli et al for each of the 4 scenarios. Figure 2 also compares these to the male circumcision coverage in these age groups at baseline and by the end of 2016. Figure 2 illustrates that providing circumcisions to boys aged 10–14 years would lead to increased VMMC coverage in the 15- to 29-year age group. In addition, focusing on the 10- to 29-year age group, not conducting any VMMCs in boys aged 10–14 years and holding constant the annual number of VMMCs in men aged 15–29  years at 2016 levels (scenario 1) would lead to proportions of circumcised males aged 10–29  years in the population by the end of 2021 that range from 14% in Malawi to 73% in Tanzania. Holding constant the annual number of VMMCs in boys and men aged 10–29 years at 2016 levels (scenario 2)  would lead to proportions of circumcised males aged 10–29 years in the population by the end of 2021 that range from 18% in Malawi to 93% in Tanzania. Aggressively increasing the annual number of circumcisions of 15- to 29-year-olds and holding constant the annual number of VMMCs of boys aged 10–14  years at 2016 levels (scenario 3) would lead to proportions of circumcised males aged 10–29  years in the population by the end of 2021 of ≥60% in Lesotho, Mozambique, South Africa, and Tanzania. Very aggressively increasing the annual number of circumcisions of 15- to 29-year-olds and aggressively increasing the number of circumcisions of 10- to 14-year-olds (scenario 4) would lead to proportions of circumcised males aged 10–29 years in the population by the end of 2021 of ≥60% in Lesotho, Mozambique, South Africa, Tanzania, Uganda, and Zimbabwe. This proportion would be ≥80% by the end of 2021 in Mozambique, South Africa, and Tanzania and ≥90% only in Tanzania. Figure  3 shows historical male circumcision coverage by age group at the end of each year from the beginning of the VMMC program through 2016 and the projected annual year-end coverage through the end of 2021 for scenario 4, underlining the contribution of historical coverage in each age group to the current and future coverage of male circumcision. Baseline VMMC coverage in most age groups was higher in those countries projected to reach the highest coverage levels by the end of 2021, including Lesotho, Mozambique, South Africa, Tanzania, and Uganda. Table 1 shows the number of HIV infections averted from 2008 through 2025 for each of the 4 scenarios. Whereas scenario 1 led to the smallest number of HIV infections averted in each country, scenario 4 produced the largest number. Providing circumcisions to adolescent boys aged 10–14 years increases both male circumcision coverage and VMMC’s impact on HIV infections averted. DISCUSSION The analyses presented in this paper reveal that significant changes in VMMC implementation in most countries will be required to increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021. We explored hypothetical scale-up scenarios representing ambitious but feasible VMMC implementation objectives, given historical trends in scaling up annual uptake of male circumcision. Tanzania is the only country studied that would reach the goal of 90% VMMC coverage in 10- to 29-year-olds by the end of 2021. It could achieve this goal by maintaining constant the annual number of VMMCs in boys and men aged 10–29  years at 2016 levels (scenario 2). The second country that would come close to reaching the WHO/UNAIDS objective is Mozambique, where very aggressively increasing the annual number of circumcisions of 15- to 29-year-olds and aggressively increasing the annual number of VMMCs in boys aged 10–14 years (scenario 4)  would lead to 86% VMMC coverage in 10- to 29-year-olds by the end of 2021. South Africa would reach 80% coverage among 10- to 29-year-olds by the end of 2021 in scenario 4 and Lesotho would get close to reaching 80% coverage among 10- to 29-year-olds in this scenario. Our work highlights the importance of historical numbers of circumcisions conducted and coverage levels in each age group to current and future male circumcision coverage. Baseline VMMC coverage in most age groups was highest in the countries projected to reach or come close to reaching the WHO/UNAIDS target coverage levels by 2021—Tanzania, Mozambique, Lesotho, and South Africa. It is also noteworthy that Tanzania, the only country studied that would reach the WHO/UNAIDS target coverage by 2021, is unique in that it has had a focused approach to scaling up VMMC since the beginning of its program [ 23 ]. The Tanzania National VMMC Program has been focusing on scaling up VMMC service delivery to males aged 10–34 years since it was launched in 2010 even though the international guidance at the time recommended Scaling Up VMMC for Boys and Young Men • CID 2018:66 (Suppl 3) • S169 scaling up services to males aged 15–49 years [ 9 ]. Conversely, VMMC coverage levels in certain countries, including Malawi, Namibia, and Swaziland, have been and continue to be so low that attaining WHO/UNAIDS target coverage levels is unlikely without significant strategic changes in both demand creation and service delivery. The figure shows total human immunodeficiency virus infections averted from 2008 through 2025 for the 4 scenarios. In scenario 1, no voluntary medical male circumcisions (VMMCs) of boys aged 10–14 years are performed and the annual number of VMMCs of men aged 15–29 years is held constant at 2016 levels. In scenario 2, the annual number of VMMCs of 10- to 29-year-olds is held constant at 2016 levels. In scenario 3, the annual number of VMMCs of boys aged 10–14 years is held constant at 2016 levels, we increase by 50% the number of VMMCs of men aged 15–29 years in 2016, and those numbers are maintained each year thereafter. In scenario 4, we increase by 50% the number of VMMCs of boys aged 10–14 years in 2016 and double the number of VMMCs of men aged 15–29 years in 2016, and those numbers are held constant from 2017 to 2021, inclusive. S170 • CID 2018:66 (Suppl 3) • Njeuhmeli et al Looking forward, these analyses also show the importance of scaling up VMMC services to adolescent boys aged 10–19 years and especially of ensuring that circumcision programs include young adolescent boys aged 10–14 years. Most of the VMMCs performed to date have been circumcisions of adolescent boys aged 10–19  years and more than a third of clients accessing VMMC services have been young adolescent boys aged 10–14 years even though roll-out of VMMC programs has not focused on appealing to this age group in most countries. Given the high demand for services in the 10- to 14-year age group in most countries and the limited demand for VMMC in men aged ≥20 years [ 29 ], increasing VMMC coverage in younger adolescent boys aged 10–14 years takes advantage of cultural preferences and existing demand for VMMC in this age group. Changing demand creation and service delivery strategies to explicitly focus on boys aged 10–14 years could lead to further increases in demand for VMMC in young adolescent boys. Notably, providing circumcisions to adolescent boys aged 10–14  years increases male circumcision coverage in the 10- to 29-year age group and in the 15- to 29-year age group as well as increasing VMMC’s impact on HIV infections averted. Scaling up VMMC coverage in men aged 10–29 years to 90% will require significantly increasing the number of circumcisions provided to both 15- to 29-year-olds and 10- to 14-year-olds. A number of limitations should be kept in mind when interpreting our findings. The DMPPT model’s limitations have been described in detail elsewhere [ 22 ]. The model relies on available national and subnational demographic, epidemiological, and program data and estimates of varying quality and completeness. The main limitation of this work is its reliance on program data. We sought to apply scale-up scenarios representing feasible VMMC program implementation objectives given 2016 program accomplishments and historical scale-up trends. In addition, due to data availability, our analysis is limited to 9 of the 14 VMMC priority countries supported by PEPFAR. Although our analysis does not address the financial and other resource implications of each scenario, assessments of existing site capacity reveal that many sites are operating below capacity. Previous work identified substantial differences in unit costs of VMMC within and among countries, indicating that substantial efficiency gains could be made in VMMC service delivery [ 30 ]. In one study, average efficiency scores ranged from 51% in Zambia to 70% in South Africa [ 31 ]. As a result, 10- to 14-year-olds presenting for circumcision in the absence of tailored demand creation programs are readily being accommodated in most settings within the confines of current budgets, and many sites have the capacity to accommodate additional clients. Furthermore, the popularity of male circumcision among adolescents this age, along with growing evidence that adolescent girls and young women are expressing preference for circumcised sexual partners [ 32 ], may be creating new social norms that could also influence their older peers aged 15–29 years to come forward for VMMC services. In conclusion, our analysis has important implications for countries and their international partners as they consider next steps in VMMC implementation to meet the WHO/UNAIDS target. Our study highlights that most countries will not increase the proportion of circumcised 10- to 29-year-olds to 90% by 2021 without significant changes in VMMC implementation. The likelihood of countries achieving the 2021 target is influenced partly by the historical numbers of circumcisions conducted and coverage levels attained, and some countries are unlikely to reach WHO/UNAIDS target coverage levels without significant strategic changes in both demand creation and service delivery. Scaling up VMMC coverage in males aged 10–29  years will require increasing the number of circumcisions provided to 10- to 14-year-olds and 15- to 29-year-olds. Supplementary Data Supplementary materials are available at Clinical Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author. Notes Acknowledgments. The authors thank John Stover of Avenir Health, who developed the DMPPT 2 model at the request of the US Agency for International Development (USAID), under the USAID-funded Health Policy Project. The authors also thank Matt Hamilton of Avenir Health for his work in updating the model version used for this manuscript. Disclaimer. The information provided does not necessarily reflect the views of USAID, PEPFAR, or the US government, and the contents of this article are the sole responsibility of projects Supporting Operational AIDS Research (SOAR) and AIDSFree, the Population Council, and the authors. Financial support. This manuscript was made possible by the generous support of the American people through PEPFAR with USAID under the cooperative agreement project SOAR (number AID-OAA-14-00026), and cooperative agreement Strengthening High Impact Interventions for an AIDS-Free Generation (number AID-OAA-A-14-00046). Supplement sponsorship. This article appears as part of the supplement “Adolescent Voluntary Medical Male Circumcision: Vital Intervention Yet Improvements Needed,” sponsored by Johns Hopkins University. Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. 1. Auvert B , Taljaard D , Lagarde E , Sobngwi-Tambekou J , Sitta R , Puren A . Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 trial . PLoS Med 2005 ; 2 : e298 . 2. Bailey RC , Moses S , Parker CB , et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial . Lancet 2007 ; 369 : 643 - 56 . 3. Gray RH , Kigozi G , Serwadda D , et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial . 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Njeuhmeli, Emmanuel, Opuni, Marjorie, Schnure, Melissa, Tchuenche, Michel, Stegman, Peter, Gold, Elizabeth, Kiggundu, Valerian, Parks, Nida, Seifert Ahanda, Kim, Carrasco, Maria, Kripke, Katharine. Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries, Clinical Infectious Diseases, 2018, S166-S172, DOI: 10.1093/cid/cix969