1. Catherine Hankins MD MSc FRCPC Chief Scientific Adviser to UNAIDS Office of the Deputy Executive Director Scaling up male circumcision programmes in Eastern and Southern Africa: Country Update- lessons, opportunities, challenges Arusha, Tanzania, June 8-10, 2010 Assessing Costs and Impact on the Epidemic of Male Circumcision using the Decision-Makers Programme Planning Tool: Overview and methodology

2. 2005 JulyRCT South Africa (PLoS Med Nov 2005) 1 st modelling meeting (Geneva, Switzerland)Nov 1 st modelling meeting (Geneva, Switzerland) 2006 JulyModelling Williams (PLoS Med) DecRCTs Uganda and Kenya (Lancet Feb 2007) 2007 MarchWHO/UNAIDS recommendations Modelling Nagelkerke (BMC Inf Dis) Modelling Gray (AIDS) 2 nd modelling meeting (Stellenbosch, South Africa)Nov 2 nd modelling meeting (Stellenbosch, South Africa) DMPPT presented Modelling Podder (Bull Math Biol); DMPPT presented 2008 3 rd modelling meeting (London, UK)March 3 rd modelling meeting (London, UK) Modelling Londish (Int J Epidemiol) Modelling Hallett (PLoS ONE) Modelling White (AIDS) Modelling Alsallaq (Mexico abstract # MOPE0254) DMPPT refined Modelling Fieno, (AIDS Care); DMPPT refined PLoS Medicine 2009Expert Group Results (PLoS Medicine) Trial Results and Modelling Timeline 3 meetings convened by UNAIDS/WHO/SACEMA

3. 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 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 anticipated impact of MC service scale-up on HIV incidence MC scale-up acts synergistically with other HIV prevention strategies [Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009;6, September 8]

4. Population-level Impacts by Coverage Hankins et al. Male circumcision for HIV prevention in high HIV prevalence settings: What can mathematical modelling contribute to informed decision making? PLoS Medicine 2009;6, September 8

5. Decision-makers’ programme planning tool Developed by Futures Institute under the USAID/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, males at higher risk, others

6. Steps in using the Decision-makers’ Programme Planning Tool (DMPPT) 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

7. Coverage Specify target coverage and year for each population Select scale-up rate –Slow –Linear –Fast –S-shaped

8. Data required Type of DataSource DemographyUN Pop Div, Census Sexual behaviourDemographic and health surveys HIV prevalenceAntenatal surveillance, Demographic & health surveys CostMOH, clinic visits

13. 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

14. Botswana sensitivity analysis

15. Use of the Decision Makers’ Programme Planning Tool (DMPPT) Botswana and Namibia: results presented at the Dakar DMPPT meeting December 2008 USAID desk review Nairobi training workshop April 18-20, 2010 Uganda: costing and impact completed Kenya, Zambia, Zimbabwe, South Africa: costing completed or underway Rwanda, Tanzania, and Namibia (update): planning stage

16. 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

17. Acknowledgements John Stover, Lori Bollinger, Stephen Forsythe, Futures Institute Nicolai Lohse and Brian Houle, UNAIDS Tim Hallett, Imperial College Brian Williams and John Hargrove, SACEMA Eric Gaillard and Albena Godlove, consultants UNAIDS/WHO/SACEMA Expert Group on Modelling the Impact and Cost of Male Circumcision for HIV prevention Emmanuel Njeuhmeli, USAID Model and manual available at www.malecircumcision.org

18. hivthisweek.unaids.org