Voluntary Male Medical Circumcision Case for Accelerated Scale Up for HIV Prevention Case for Accelerated Scale Up 4th Botswana International HIV Conference 2012 Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor, USAID Washington Co-Chair PEPFAR Male Circumcision Technical Working group

WHO-UNAIDS Recommendations Voluntary Medical Male Circumcision Priority Countries

Scientific Evidence Biological plausibility Inner surface of the foreskin highly vulnerable to HIV infection Up to nine times more vulnerable than cervical tissue Over 50 ecological and observational studies: lack of male circumcision associated with higher HIV in men Three RCTs in Kenya, Uganda, and South Africa: 60% protection Longer-term (4-5 yrs) follow up of the Kenya and Uganda RCT participants: protective effect sustained/increased Community level impact evaluation in South Africa (Orange Farm) demonstrate 76% incidence reduction There is strong evidence showing that voluntary medical male circumcision (MMC) reduces HIV incidence in men and there is international agreement that MMC should be incorporated into HIV prevention strategies in settings with high HIV prevalence and low MMC coverage.

Cumulative Number and Percentage of HIV Infections Averted between 2011 to 2025 by scaling up VMMC The impact of such a scale-up would result in averting 3.36 million new HIV infections and 386,000 AIDS deaths through 2025. We find a strong impact of scaling up MMC to achieve 80% coverage by 2015 on the number of adult HIV infections averted. A total of 430,000 HIV infections are averted in the 13 countries between 2011-2015 while a total of almost 3.36 million HIV infections are averted by 2025 . South Africa is the country with the largest number of HIV infections averted with over 1 million averted between 2011-2025. More than 20% of new HIV infections are averted between 2011-2025 in Botswana, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Uganda, Zambia, and Zimbabwe. Zimbabwe is the country with the highest percentage of new HIV infections averted with 42% of new infections averted between 2011 and 2025; in the single year 2025, over 90% of the anticipated annual new HIV infections are projected to be averted (results not shown). Table 4 shows the impact of MMC scale-up to achieve 80% coverage by 2015 on AIDS deaths averted. While relatively few deaths (<400) are averted in the 13 countries in the initial five years during which MMC scale-up occurs, 386,000 deaths are averted between 2011-2025 with deaths averted in South Africa comprising over a third of the total deaths averted in the 13 countries.

Total – New HIV Infections Averted

HIV Infections Averted in Men and Women Although circumcision of HIV infected men has not been found to reduce HIV transmission to their female partners, and the primary impact of increasing MMC coverage is to reduce the number of new HIV infections in men, the number of new infections in women is also reduced. This occurs by reducing the exposure of women to HIV-infected men (as HIV incidence decreases in men following MMC scale-up, the probability of women encountering infected male partners decreases, with a consequent reduction in women’s HIV incidence). The HIV infections averted and AIDS deaths averted presented in the previous slide thus represent infections and deaths in both men and women. This slide illustrates the male and female HIV infections averted over time by country for 2011-2025. In all countries, the cumulative number of male HIV infections averted between 2011 and 2025 is higher than the cumulative number of female HIV infections averted. In the early years, the HIV infections averted occur mostly among men but over time the proportion of HIV infections averted in women steadily increases with HIV infections averted in women representing almost half of the total HIV infections averted by 2025. In Lesotho, Rwanda, Swaziland and Zimbabwe, in the final year 2025, there are actually more HIV infections averted in women than in men.

Male circumcision is always part of a package of prevention services: Minimum Package of Services Male circumcision is always part of a package of prevention services: Provider-initiated HIV counseling and testing, incl couples HTC Screening (and treatment) of STIs Age-appropriate counseling on risk reduction, including reduced number and concurrency of sexual partners, delaying/abstaining from sex Provision and promotion of correct and consistent use of condoms (male and female) Active referral and linkage to HIV care/treatment/support services, including other HIV prevention services Post-operative clinical care and reinforced education/counseling Interventions for male circumcision should include a minimum package of prevention services which include: Pre-operative provider-initiated HIV testing and counseling routinely provided on-site for all men and, where possible, their female partners; Active exclusion of symptomatic STIs and syndromic treatment when indicated; Provision and promotion of correct and consistent use of condoms; Post-operative wound care and abstinence instructions; Age-appropriate counseling on risk reduction, including reducing number and concurrency of sexual partners, delaying/abstaining from sex, and provision and promotion of correct and consistent use of condoms and; Active linkage to other HIV prevention, treatment, care and support services as needed.

Tanzania National VMMC Program Outputs as off July 2012 Male Circumcision Is Safe and High Quality… Tanzania National VMMC Program Outputs as off July 2012 VMMCs since October 2009: 114,962 HTC acceptance: 99.7% AE rate < 1% Follow-up rate: 70-80%

Zimbabwe National VMMC Program Outputs as off August 2012 Male Circumcision Is Safe and High Quality… Zimbabwe National VMMC Program Outputs as off August 2012 Cumulative VMMCs: 75,200 HTC uptake: 100 % AE rate: <1% Post-op follow-up rates: 98% Day 2 90% Day 7 43% Day 42

…. Acceptable, and …..

….in Demand

DMPPT Estimate of Number of Adult 15-49 years VMMC needed per countries to reach 80% coverage

13 Countries: EIMC, Adolescents and Adults MC Required

Net savings by scaling up VMMC US$16 Net savings by scaling up VMMC US$16.5 Billion (2011 to 2025 in Millions US$)

No. VMMCs Needed to Prevent 1 Infection The number of MMCs required to avert one HIV infection is calculated by dividing the additional number of MMCs required by the number of HIV infections averted over the relevant time period. For the period 2011-2015, the number of MMCs per HIV infection averted ranges from 25 in Swaziland to 239 in Rwanda while for the full study period (2011-2025), the number of MMCs per HIV infection averted ranges from 4 in Zimbabwe to 44 in Rwanda. For the period 2011-2025, the number of MMCs per HIV infection averted is less than 10 in Botswana, Lesotho, Mozambique, Nyanza, Kenya, South Africa, Swaziland, Zambia, and Zimbabwe.

Number VMMC from March 2007 to March 2012

Number of VMMC done as off March 2012

NOW, IT’S TIME TO ACT Acceleration of the VMMC Scale-Up More than 5 years after WHO-UNAIDS recommendations, Neither the elegance of the science nor the strength of the effect predict the ease of implementation PEPFAR-UNAIDS Recent Publications in PLoS Medicine: Signpost the way forward to accelerate the scaling up of VMMC service delivery safely and efficiently to reap individual-and population-level benefits www.ploscollections.org/VMMC2011 PEPFAR-WHO-UNAIDS-BMGF-World Bank collaboration to launch the WHO-UNAIDS Joint Strategy Action Framework for Acceleration of the Scale-Up of VMMC 14 Countries and PEPFAR-WHO-UNAIDS-BMGF-GF will come together next week in Johannesburg to put the framework into action Johannesburg September 25th to 28th, 2012

Strategy for Achieving Pace and Scale Political will and country ownership Strong leadership and coordination from MOH Effective demand creation strategy with strong community level buy-in Enough financial resources for service delivery including some level of dedication of staff time, facilities space and commodities Excellent technical support from partners to allow a good match of demand and supply for efficient use of limited available to reach maximum number of men

High Volume, High Quality Service Delivery Efficient VMMC Program Effective Demand Creation Dedicated Commodities Dedicated Human Resources Dedicated Space

Thank You