Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa

Background

There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data.

Methods and Findings

We use the Decision Makers'' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization''s considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion.

Conclusions

This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region''s HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs. Please see later in the article for the Editors'' Summary.     

Voluntary medical male circumcision: a qualitative study exploring the challenges of costing demand creation in eastern and southern Africa

Background

This paper proposes an approach to estimating the costs of demand creation for voluntary medical male circumcision (VMMC) scale-up in 13 countries of eastern and southern Africa. It addresses two key questions: (1) what are the elements of a standardized package for demand creation? And (2) what challenges exist and must be taken into account in estimating the costs of demand creation?

Methods and Findings

We conducted a key informant study on VMMC demand creation using purposive sampling to recruit seven people who provide technical assistance to government programs and manage budgets for VMMC demand creation. Key informants provided their views on the important elements of VMMC demand creation and the most effective funding allocations across different types of communication approaches (e.g., mass media, small media, outreach/mobilization). The key finding was the wide range of views, suggesting that a standard package of core demand creation elements would not be universally applicable. This underscored the importance of tailoring demand creation strategies and estimates to specific country contexts before estimating costs. The key informant interviews, supplemented by the researchers'' field experience, identified these issues to be addressed in future costing exercises: variations in the cost of VMMC demand creation activities by country and program, decisions about the quality and comprehensiveness of programming, and lack of data on critical elements needed to “trigger the decision” among eligible men.

Conclusions

Based on this study''s findings, we propose a seven-step methodological approach to estimate the cost of VMMC scale-up in a priority country, based on our key assumptions. However, further work is needed to better understand core components of a demand creation package and how to cost them. Notwithstanding the methodological challenges, estimating the cost of demand creation remains an essential element in deriving estimates of the total costs for VMMC scale-up in eastern and southern Africa.     

Voluntary medical male circumcision: strategies for meeting the human resource needs of scale-up in southern and eastern Africa

Voluntary medical male circumcision (VMMC) reduces female-to-male HIV transmission by approximately 60%; modeling suggests that scaling up VMMC to 80% of men 15- to 49-years-old within five years would avert over 3.3 million new HIV infections in 14 high priority countries/regions in southern and eastern Africa by 2025 and would require 20.33 million circumcisions. However, the shortage of health professionals in these countries must be addressed to reach these proposed coverage levels. To identify human resource approaches that are being used to improve VMMC volume and efficiency, we looked at previous literature and conducted a program review. We identified surgical efficiencies, non-surgical efficiencies, task shifting, task sharing, temporary redeployment of public sector staff during VMMC campaign periods, expansion of the health workforce through recruitment of unemployed, recently retired, newly graduating, or on-leave health care workers, and the use of volunteer medical staff from other countries as approaches that address human resource constraints. Case studies from Kenya, Tanzania, and Swaziland illustrate several innovative responses to human resource challenges. Although the shortage of skilled personnel remains a major challenge to the rapid scale-up of VMMC in the 14 African priority countries/regions, health programs throughout the region may be able to replicate or adapt these approaches to scale up VMMC for public health impact.     

Voluntary medical male circumcision: a cross-sectional study comparing circumcision self-report and physical examination findings in Lesotho

Background

Overwhelming evidence, including three clinical trials, shows that male circumcision (MC) reduces the risk of HIV infection among men. However, data from recent Lesotho Demographic and Health Surveys do not demonstrate MC to be protective against HIV. These contradictory findings could partially be due to inaccurate self-reported MC status used to estimate MC prevalence. This study describes MC characteristics among men applying for Lesotho Defence Force recruitment and seeks to assess MC self-reported accuracy through comparison with physical-examination-based data.

Methods and Findings

During Lesotho Defence Force applicant screening in 2009, 241 (77%) of 312 men, aged 18–25 y, consented to a self-administered demographic and MC characteristic survey and physician-performed genital examination. The extent of foreskin removal was graded on a scale of 1 (no evidence of MC) to 4 (complete MC). MC was self-reported by 27% (n = 64/239) of participants. Of the 64 men self-reporting being circumcised, physical exam showed that 23% had no evidence of circumcision, 27% had partial circumcision, and 50% had complete circumcision. Of the MCs reportedly performed by a medical provider, 3% were Grade 1 and 73% were Grade 4. Of the MCs reportedly performed by traditional circumcisers, 41% were Grade 1, while 28% were Grade 4. Among participants self-reporting being circumcised, the odds of MC status misclassification were seven times higher among those reportedly circumcised by initiation school personnel (odds ratio = 7.22; 95% CI = 2.29–22.75).

Conclusions

Approximately 27% of participants self-reported being circumcised. However, only 50% of these men had complete MC as determined by a physical exam. Given this low MC self-report accuracy, countries scaling up voluntary medical MC (VMMC) should obtain physical-exam-based MC data to guide service delivery and cost estimates. HIV prevention messages promoting VMMC should provide comprehensive education regarding the definition of VMMC.     

Voluntary medical male circumcision: logistics, commodities, and waste management requirements for scale-up of services

Background

The global HIV prevention community is implementing voluntary medical male circumcision (VMMC) programs across eastern and southern Africa, with a goal of reaching 80% coverage in adult males by 2015. Successful implementation will depend on the accessibility of commodities essential for VMMC programming and the appropriate allocation of resources to support the VMMC supply chain. For this, the United States President’s Emergency Plan for AIDS Relief, in collaboration with the World Health Organization and the Joint United Nations Programme on HIV/AIDS, has developed a standard list of commodities for VMMC programs.

Methods and Findings

This list of commodities was used to inform program planning for a 1-y program to circumcise 152,000 adult men in Swaziland. During this process, additional key commodities were identified, expanding the standard list to include commodities for waste management, HIV counseling and testing, and the treatment of sexually transmitted infections.The approximate costs for the procurement of commodities, management of a supply chain, and waste disposal, were determined for the VMMC program in Swaziland using current market prices of goods and services.Previous costing studies of VMMC programs did not capture supply chain costs, nor the full range of commodities needed for VMMC program implementation or waste management. Our calculations indicate that depending upon the volume of services provided, supply chain and waste management, including commodities and associated labor, contribute between US$58.92 and US$73.57 to the cost of performing one adult male circumcision in Swaziland.

Conclusions

Experience with the VMMC program in Swaziland indicates that supply chain and waste management add approximately US$60 per circumcision, nearly doubling the total per procedure cost estimated previously; these additional costs are used to inform the estimate of per procedure costs modeled by Njeuhmeli et al. in “Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa.” Program planners and policy makers should consider the significant contribution of supply chain and waste management to VMMC program costs as they determine future resource needs for VMMC programs. Please see later in the article for the Editors'' Summary     

Understanding the impact of male circumcision interventions on the spread of HIV in southern Africa

Background

Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes – either alone or in combination with other established approaches – is not known and no further field trials are planned. We have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level.

Findings

Our results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25–35%, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision , i.e. ‘risk compensation’, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall.

Conclusions

Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches.     

Voluntary medical male circumcision: matching demand and supply with quality and efficiency in a high-volume campaign in Iringa Region, Tanzania

The government of Tanzania has adopted voluntary medical male circumcision (VMMC) as an important component of its national HIV prevention strategy and is scaling up VMMC in eight regions nationwide, with the goal of reaching 2.8 million uncircumcised men by 2015. In a 2010 campaign lasting six weeks, five health facilities in Tanzania's Iringa Region performed 10,352 VMMCs, which exceeded the campaign's target by 72%, with an adverse event (AE) rate of 1%. HIV testing was almost universal during the campaign. Through the adoption of approaches designed to improve clinical efficiency-including the use of the forceps-guided surgical method, the use of multiple beds in an assembly line by surgical teams, and task shifting and task sharing-the campaign matched the supply of VMMC services with demand. Community mobilization and bringing client preparation tasks (such as counseling, testing, and client scheduling) out of the facility and into the community helped to generate demand. This case study suggests that a campaign approach can be used to provide high-volume quality VMMC services without compromising client safety, and provides a model for matching supply and demand for VMMC services in other settings.     

Male circumcision: hope for HIV infection decrease in southern Africa

Given the magnitude of the HIV pandemic, development of new prevention means is necessary. Male circumcision reduces HIV transmission from female to male by 57 % [95 % Confident Interval (CI): 42-68 %]. Its generalization in sub-Saharan Africa could avert, among men and women, from 1 to 4 millions new HIV infections over the next ten years. Acceptability of this new prevention mean is high in countries which could benefit the most from male circumcision, that means located in southern Africa, a region where in majority men are uncircumcised and where HIV prevalence is high. Male circumcision is a cost-effective prevention strategy. Actual prevention means (condoms, sexual abstinence and fidelity) are not used enough to curb the HIV epidemic. Research is ongoing on other prevention means (vaccine, pre- and post-exposition prophylaxis, microbicides, diaphragm) but their efficiency has not been demonstrated yet. Nevertheless, generalization of circumcision in southern Africa is responsible for contestations in part due to the fact that this prevention mean protects only partially from HIV infection. Moreover, for now, only a few countries integrated circumcision in their HIV prevention program in spite of WHO (World Health Organization) recommendations supporting male circumcision acknowledgement as an additional, important strategy for the prevention of heterosexually acquired HIV infection in men. Significant available funding should allow the situation to evolve quickly. At the same time, research goes on in order to know more about the effects and to facilitate the generalization of this prevention mean which is a great hope for southern Africa.     

Voluntary medical male circumcision: translating research into the rapid expansion of services in Kenya, 2008-2011

Since the World Health Organization and the Joint United Nations Programme on HIV/AIDS recommended implementation of medical male circumcision (MC) as part of HIV prevention in areas with low MC and high HIV prevalence rates in 2007, the government of Kenya has developed a strategy to circumcise 80% of uncircumcised men within five years. To facilitate the quick translation of research to practice, a national MC task force was formed in 2007, a medical MC policy was implemented in early 2008, and Nyanza Province, the region with the highest HIV burden and low rates of circumcision, was prioritized for services under the direction of a provincial voluntary medical male circumcision (VMMC) task force. The government's early and continuous engagement with community leaders/elders, politicians, youth, and women's groups has led to the rapid endorsement and acceptance of VMMC. In addition, several innovative approaches have helped to optimize VMMC scale-up. Since October 2008, the Kenyan VMMC program has circumcised approximately 290,000 men, mainly in Nyanza Province, an accomplishment made possible through a combination of governmental leadership, a documented implementation strategy, and the adoption of appropriate and innovative approaches. Kenya's success provides a model for others planning VMMC scale-up programs.     

Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up

Scaling up voluntary medical male circumcision (VMMC) for HIV prevention is cost saving and creates fiscal space in the future that otherwise would have been encumbered by antiretroviral treatment costs. An investment of US$1,500,000,000 between 2011 and 2015 to achieve 80% coverage in 13 priority countries in southern and eastern Africa will result in net savings of US$16,500,000,000. Strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilisation, and human resource deployment, are essential. This collection of articles on determining the cost and impact of VMMC for HIV prevention signposts the way forward to scaling up VMMC service delivery safely and efficiently to reap individual- and population-level benefits.     

Shell strength and primate seed predation of nontoxic species in eastern and southern Africa

The large African primates that eat fruit destroy the seeds of a number of fruiting species. This paper addresses several questions about seed-eating: What is the nature of the dietary niche provided by the nonpoisonous seeds of eastern and southern Africa? How well are these seeds mechanically protected? What other means of reducing seed predation are employed by the plants? and is the niche ecologically stable? Measurements of seed shell strength on 37 species from 17 families reveal a range of values, from <100-kg (numerous species) to over 2000-kg (palm nuts) breaking load. Primates crack open with their teeth seed shells from species exhibiting test strengths less than 600 kg. Variation in shell strength appears to increase dramatically for average species strengths above 100 kg. Plant species are not characterized by specific shell strengths but instead, display envelopes of shell strength overlapping broadly with other species. Taking this into account, adult male baboons (Papio spp.) appear to be dentally capable of preying upon most of the seed species of eastern and southern Africa. The possibility for predation of nonpoisonous seeds exists primarily because the plants periodically produce large crops in synchrony and the hard-shelled seeds are effectively dispersed, sometimes explosively but more often by means of edible fruits. The concomitant primate seed predation is a facultative specialization, of little apparent threat to the community of plants that support it.     

Estimating the resources needed and savings anticipated from roll-out of adult male circumcision in Sub-Saharan Africa

Background

Trials in Africa indicate that medical adult male circumcision (MAMC) reduces the risk of HIV by 60%. MAMC may avert 2 to 8 million HIV infections over 20 years in sub-Saharan Africa and cost less than treating those who would have been infected. This paper estimates the financial and human resources required to roll out MAMC and the net savings due to reduced infections.

Methods

We developed a model which included costing, demography and HIV epidemiology. We used it to investigate 14 countries in sub-Saharan Africa where the prevalence of male circumcision was lower than 80% and HIV prevalence among adults was higher than 5%, in addition to Uganda and the Nyanza province in Kenya. We assumed that the roll-out would take 5 years and lead to an MC prevalence among adult males of 85%. We also assumed that surgery would be done as it was in the trials. We calculated public program cost, number of full-time circumcisers and net costs or savings when adjusting for averted HIV treatments. Costs were in USD, discounted to 2007. 95% percentile intervals (95% PI) were estimated by Monte Carlo simulations.

Results

In the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to 2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10 000 adults. In years 6–10, the number of circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of rolling out MAMC in the public sector was $919 million (95% PI: 726 to 1 245). The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to 1 021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4).

Conclusion

A rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by MAMC''s substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability.     

Defining a role for herbarium data in Red List assessments: a case study of Plectranthus from eastern and southern tropical Africa

Red Lists are widely used to indicate species at risk of extinction. Specimen sheets in herbaria provide an important source of data relevant for Red List assessments. The aims of this paper are to establish which data can be sourced from specimen information to satisfy IUCN Red Data List criteria and to identify the specific criteria that can be used. Red List parameters are measured within a Geographical Information System (GIS), as this provides an objective and repeatable methodology which is less subjective than manual methods. Data used to explore this were gathered during the course of preparing a monograph on Plectranthus (Lamiaceae). Criteria relating to distribution (extent of occurrence, area of occupancy and fragmentation) and population profile (projected continuing decline and number of subpopulations) proved most suitable for assigning categories of threat. Estimates of mature individuals, generation length, population size, population reduction, extreme fluctuation and number of locations could not be derived from herbarium material without making inconsistent subjective decisions. In addition to comprehensively databased specimen information, extensive field knowledge is required to produce better estimates for assessing extinction risk. In order to enhance the usefulness of specimen information in the future, improvements in recording additional botanical data at the time of collection would be beneficial. Overall, herbaria provide a useful starting point for conservation-related work and can help to guide future work.     

Migrant European Swallows Hirundo rustica in southern Africa: a southern perspective

Oatley, T.B. 2000. Migrant European swallows Hirundo rustica in southern Africa: a southern perspective. Ostrich 71 (1 & 2): 205–209.

A total of 1 457 recoveries and controls of European Swallows Hirundo rustica in the South African Bird Ringing Unit data bank were analysed to provide an update of the apparent origins and dispersion of migrant European Swallows in southern Africa, to investigate local movements within southern Africa, and to yield an estimate of the age structure of the visiting migrants. Although birds from the former USSR and from Britain and Ireland predominate, over 200 recoveries from 20 other European countries have been recorded. More than half of the swallows migrating to southern Africa are from the central third of the species' breeding range. The dispersion of recoveries of swallows ringed in Britain and Ireland is widespread, with 55% recorded from the Eastern Cape, Free State and KwaZulu-Natal. Controls of southern African-ringed swallows at roosts and recoveries elsewhere in the subcontinent suggest that the daily range of migrant swallows is encompassed within a circle of 100 km diameter, but wide-ranging intra-seasonal movements within South Africa have also been recorded. Conservative estimates of the age of European Swallows at recovery indicate that as many as 14% of migrant swallows ringed in southern Africa may Survive to more than three years of age. It is suggested that the experience of migrants that survive to return to Africa one or more times may permit some flexibility in choice of final destination and that mixing of populations in roosts may result in birds arriving at new destinations.     

Landscapes and their relation to hominin habitats: case studies from Australopithecus sites in eastern and southern Africa

We examine the links between geomorphological processes, specific landscape features, surface water drainage, and the creation of suitable habitats for hominins. The existence of mosaic (i.e., heterogeneous) habitats within hominin site landscape reconstructions is typically explained using models of the riverine and gallery forest settings, or the pan or lake setting. We propose a different model: the Tectonic Landscape Model (TLM), where tectonic faulting and volcanism disrupts existing pan or river settings at small-scales (∼10-25 km). Our model encompasses the interpretation of the landscape features, the role of tectonics in creating these landscapes, and the implications for hominins. In particular, the model explains the underlying mechanism for the creation and maintenance of heterogeneous habitats in regions of active tectonics. We illustrate how areas with faulting and disturbed drainage patterns would have been attractive habitats for hominins, such as Australopithecus, and other fauna. Wetland areas are an important characteristic of surface water disturbance by fault activity; therefore we examine the tectonically-controlled Okavango Delta (Botswana) and the Nylsvley wetland (South Africa) as modern examples of how tectonics in a riverine setting significantly enhance the faunal and floral biodiversity. While tectonic landscapes may not have been the only type of attractive habitats to hominins, we propose a suite of landscape, faunal, and floral indicators, which when recovered together suggest that site environments may have been influenced by tectonic and/or volcanic activity while hominins were present. For the fossil sites, we interpret the faulting and landscapes around australopithecine-bearing sites of the Middle Awash (Ethiopia) and Makapansgat, Taung, and Sterkfontein (South Africa) to illustrate these relationships between landscape features and surface water bodies. Exploitation of tectonically active landscapes may explain why the paleoenvironmental signals, anatomy, diets, as well as the fauna associated with Australopithecus appear largely heterogeneous through time and space. This hypothesis is discussed in light of potential preservation and time-averaging effects which may affect patterns visible in the fossil record. The model, however, offers insight into the landscape processes of how such habitats are formed. The landscape features and range of habitat conditions, specifically the wetter, down-dropped plains and drier, uplifted flanks persist in close proximity for as long as the fault motion continues. The Tectonic Landscape Model provides an alternative explanation of why mixed habitats may be represented at certain sites over longer timescales.     

Water policy in southern Africa: A brief synopsis of some of the macro driving forces

The water sector reforms that are underway in many parts of southern Africa are a manifestation of a global phenomenon. This is rooted in the human response to the undesirable consequences of development, and seeks to introduce the notion of sustainability into the modern development discourse. This has given rise to an academic discipline that is known as political ecology, which seeks to understand the political construction of environmental knowledge. As it is currently formulated, political ecology is highly Eurocentric, meaning that African scholars should become engaged in its intellectual development. This political ecology discourse is relatively new in southern African academic circles, and can be helpful in explaining dynamics that are shaping the World Water Vision, Global Water Partnership, World Commission on Dams and the United Nations Framework Convention on Climate Change, all of which are relevant in the contemporary water sector.