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

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  • Katharine Kripke
  • Frank Chimbwandira
  • Zebedee Mwandi
  • Faustin Matchere
  • Melissa Schnure
  • Jason Reed
  • Delivette Castor
  • Sema Sgaier
  • Emmanuel Njeuhmeli

Abstract

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.

Suggested Citation

  • Katharine Kripke & Frank Chimbwandira & Zebedee Mwandi & Faustin Matchere & Melissa Schnure & Jason Reed & Delivette Castor & Sema Sgaier & Emmanuel Njeuhmeli, 2016. "Voluntary Medical Male Circumcision for HIV Prevention in Malawi: Modeling the Impact and Cost of Focusing the Program by Client Age and Geography," PLOS ONE, Public Library of Science, vol. 11(7), pages 1-11, July.
  • Handle: RePEc:plo:pone00:0156521
    DOI: 10.1371/journal.pone.0156521
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    1. Susanne F Awad & Sema K Sgaier & Gertrude Ncube & Sinokuthemba Xaba & Owen M Mugurungi & Mutsa M Mhangara & Fiona K Lau & Yousra A Mohamoud & Laith J Abu-Raddad, 2015. "A Reevaluation of the Voluntary Medical Male Circumcision Scale-Up Plan in Zimbabwe," PLOS ONE, Public Library of Science, vol. 10(11), pages 1-16, November.
    2. Markus Haacker & Nicole Fraser-Hurt & Marelize Gorgens, 2016. "Effectiveness of and Financial Returns to Voluntary Medical Male Circumcision for HIV Prevention in South Africa: An Incremental Cost-Effectiveness Analysis," PLOS Medicine, Public Library of Science, vol. 13(5), pages 1-19, May.
    3. Susanne F Awad & Sema K Sgaier & Bushimbwa C Tambatamba & Yousra A Mohamoud & Fiona K Lau & Jason B Reed & Emmanuel Njeuhmeli & Laith J Abu-Raddad, 2015. "Investigating Voluntary Medical Male Circumcision Program Efficiency Gains through Subpopulation Prioritization: Insights from Application to Zambia," PLOS ONE, Public Library of Science, vol. 10(12), pages 1-25, December.
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    Cited by:

    1. Katharine Kripke & Marjorie Opuni & Melissa Schnure & Sema Sgaier & Delivette Castor & Jason Reed & Emmanuel Njeuhmeli & John Stover, 2016. "Age Targeting of Voluntary Medical Male Circumcision Programs Using the Decision Makers’ Program Planning Toolkit (DMPPT) 2.0," PLOS ONE, Public Library of Science, vol. 11(7), pages 1-17, July.
    2. Emmanuel Njeuhmeli & Melissa Schnure & Andrea Vazzano & Elizabeth Gold & Peter Stegman & Katharine Kripke & Michel Tchuenche & Lori Bollinger & Steven Forsythe & Catherine Hankins, 2019. "Using mathematical modeling to inform health policy: A case study from voluntary medical male circumcision scale-up in eastern and southern Africa and proposed framework for success," PLOS ONE, Public Library of Science, vol. 14(3), pages 1-15, March.
    3. Katharine Kripke & Karin Hatzold & Owen Mugurungi & Gertrude Ncube & Sinokuthemba Xaba & Elizabeth Gold & Kim Seifert Ahanda & Natalie Kruse-Levy & Emmanuel Njeuhmeli, 2016. "Modeling Impact and Cost-Effectiveness of Increased Efforts to Attract Voluntary Medical Male Circumcision Clients Ages 20–29 in Zimbabwe," PLOS ONE, Public Library of Science, vol. 11(10), pages 1-16, October.
    4. Juan Dent & Nuno Gaspar & Emmanuel Njeuhmeli & Katharine Kripke, 2019. "Age targeting and scale-up of voluntary medical male circumcision in Mozambique," PLOS ONE, Public Library of Science, vol. 14(2), pages 1-14, February.

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