1. The U.S. President’s Emergency Plan for AIDS Relief Title Cost and Impacts of expanding male circumcision services in Eastern and Southern Africa Emmanuel Njeuhmeli 1, Jason Reed 2, Lori Bollinger 3, Steven Forsythe 3, Delivette Castor 1, John Stover 3, Timothy Farley 4, and Catherine Hankins 5 1. USAID Washington 2. CDC Atlanta 3. Future Institutes 4. WHO Geneva 5. UNAIDS Geneva XVIII International AIDS Conference Vienna July 2010

2. Background Randomized controlled trials have shown consistently that male circumcision (MC) is 60% effective in reducing HIV incidence Current WHO/UNAIDS guidelines recommend MC for HIV prevention in generalized epidemic settings where HIV prevalence is high and MC prevalence is low Cost and population level impact has not been determined for successful implementation of MC in these settings

3. Objectives Estimate the cost of implementing MC in 14 countries in Eastern and Southern Africa Determine the impact of increased MC coverage on HIV incidence Evaluate the cost effectiveness of MC for HIV prevention

4. Methodology – DMPPT Mathematical modeling developed by USAID Health Policy Initiative | UNAIDS - Decision Makers Program Planning tool – DMPPT –Calculates the cost of MC services –Estimates the impact on the epidemic –Conduct sensitivity analysis for key inputs HIV and MC Prevalence –From most recent DHS and other Surveys Model Input parameters: –Age – newborn, adolescent / adult –Risk group – STD clinic attendees, seronegative men in discordant partnerships –Service delivery model – fixed, outreach, mobile –Provider – physician, clinical officer, nurse –Ancillary services – HIV testing and counseling, program promoting gender sensitivity –Potential risk compensation – increase number of sexual partner, decreased condom use –Scale up rate –Coverage goals

5. Methods - Assumptions Desk review - using readily available data –no individual item cost data collection was done Main scenario –Implementation coverage of 80% MC prevalence within 5 years for both adults and neonates Alternate scenarios –Implementation coverage 50% and 100 % within 5 years –Implementation pace 80% coverage within 1 year vs 10 years vs 20 years –Adult only vs Neonate only

6. Number of MC needed 29.1 M men to be circumcised across all 14 countries

7. Adult Vs Neonate MC

8. Incremental Additional Cost US$1 B is needed across all 14 countries for the 5 years catch up period

9. Discounted Cost Savings and Cumulative Discounted Cost Savings

10. Number and Percent of Infections Averted

11. New HIV Infection Averted in Men, Women and general population (Cumulative 2009 to 2025)

12. Implementation Pace - Infection Averted (%)

13. Implementation coverage within 5 years - infection averted (%)

14. Number of MC per Infection Averted and Cost per Infection Averted

15. Limitations Inadequate understanding of MC program cost: –Facility based data collection Direct costs (Personnel, Drugs and supplies, Equipment, Transport / Vehicles) Indirect Costs (Personnel, Overhead - building, land, utilities) –Monitoring of program expenditures : Demand creation, Community mobilization, Training, Management Issues related to data –Self reported MC from DHS Mis-report of MC (e.g. Lesotho, Malawi) Simplifying assumptions made –Lack of age-specific sexual mixing matrix –Use of HIV prevalence to fit the epidemic model rather than HIV incidence

16. Conclusions Scaling up MC to reach 80% coverage within 5 years can potentially avert up to 4 Million or 20% new HIV infections in ESA and will cost US$1B Spending US$1B to achieve this impact will also save US$20.3B The greatest cost effectiveness can be achieve with a two pronged implementation approach combining accelerated saturation for adult and adolescents and sustain program for neonate The impact is directly proportional to the implementation pace and scale

17. Acknowledgements The DMPPT was designed by John Stover and Lori Bollinger under USAID Health Policy Initiative Catherine Hankins has lead the validation and adoption of the DMPPT by UNAIDS Emmanuel Njeuhmeli designed the desk review study The DMPPT was populated by Lori Bollinger The data was reviewed by Catherine Hankins, Timothy Farley, John Stover, Steve Forsythe, Jason Reed, Delivette Castor, and Emmanuel Njeuhmeli The initial 15 issues brief that was published by USAID HPI was written by Lori Bollinger and review by all including the PEPFAR country team This paper was written by Emmanuel Njeuhmeli, Jason Reed, Delivette Castor and Lori Bollinger and review by all authors All this was possible with PEPFAR (Through USAID Health Policy Initiative) and UNAIDS funding (Through TSF) The current costing exercise is a joint USAID HPI and UNAIDS activity