Overview of the current evidence on male circumcision and HIV

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					 UNAIDS/WHO/SACEMA Consultation
Stellenbosch, November 15 and 16, 2007
Making Decisions on Male Circumcision for HIV
Risk Reduction: Modelling the Impact and Costs

  Introduction and Objectives of the Meeting




                           Catherine Hankins
      Chief Scientific Adviser to UNAIDS and Associate Director,
             Department of Evidence, Monitoring and Policy
                 Timeline to date 2005- 2007
 •    June 2005 (Johannesburg): closed UNAIDS-convened meeting of researchers
      from the 3 RCT trials, country reps (govt and NGO) and UN agencies (regional and
      headquarters)
 •    July (Rio): Orange Farm Results announced; UNAIDS position statement released;
      meeting with donors on work plan
 •    August: UN Work Plan developed
 •    September to December: plan approved, resource mobilisation successful,
      oversight committees established (Steering Group, Interagency Task Team &
      UNAIDS/WHO Working Group)
 •    November (Geneva): UNAIDS/WHO/SACEMA Modelling meeting
 •    December (Athens): presentation on modelling meeting results to UNAIDS
      Reference Group on Modelling, Estimates & Projections
 •    January to December 2006: Planning assessments, country stakeholder
      consultations; preparation of surgical manual, human rights/legal ethical
      guidance/background document on MC trends and determinants (prevalence, safety
      and acceptability), situational analysis toolkit, regional meeting
 •    December 2006 trial results from Kenya and Uganda announced
 •    March 2007 (Montreux): WHO/UNAIDS technical consultation on programme and
      policy implications: March 28th conclusions and recommendations
 •    September 2007: second UN Work Plan funded
Stellenbosch       Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                  Modelling the Impact and Costs                   UNAIDS
    UNAIDS/WHO/SACEMA Modelling
     meeting: Geneva November 2005

   Broad Issues Discussed
   • Key questions: What are the key questions that
     modelling can help us to answer?
   • Policy: How can modelling the impact of male
     circumcision assist in decision making about policy and
     programme planning for HIV prevention services?
   • Data: What data are currently available and what new
     data are needed?
   • Methodological approaches: What kinds of models
     can we use to answer what kind of questions?

Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS
    UNAIDS/WHO/SACEMA Modelling
     meeting: Geneva November 2005
   Actions and Next Steps
   •    Ensure that available DHS data are fully analysed and interpreted.
   •    Investigate more fully the extent of problems concerning self-
        reported MC status and explore the accuracy of female partner
        reports of male partner circumcision status.
   •    Formulate modelling questions that can be answered now using
        available data.
   •    Ensure that current modelling work is informed by these discussions.
   •    Share approaches and ideas; take steps to provide rapid access to
        new data as they emerge.
   •    Begin to develop more specific models to be applied either nationally
        or to particular communities where relevant data may already be
        available.
   •    Present findings from the meeting to the UNAIDS Reference Group
        on Estimates, Modelling and Projections in December 2005.
   •    Present modelling results to relevant meetings convened in 2006
        under the framework of the UN Male Circumcision Work Plan.

Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS
Modelling the impact of male circumcision on HIV
prevalence/incidence/cost per infection averted
   Williams et al., 2006
   • 100% uptake could avert 2.0 million new infections and 0.3
     million deaths over ten years in sub-Saharan Africa (5.7 million
     new infections over 20 years)
   Mesesan et al., 2006
   • 50% uptake could avert 32,000 – 53,000 new infections in
     Soweto, SA over 20 yrs. Prevalence declines from 23% to 14%
   Nagelkerke et al., 2007
   • Prevalence in Nyanza Province, Kenya would decline from 18% to
     8% over 30 years with 50% uptake over 10 years
   Hallett et al, 2007 (Kigali)
   • Impact determined by rate of delivery, targeting, real life risk
     on acquisition & transmission, patterns of partnership formation
   Martin et al, 2007 (Kigali)
   • Unit costs from Lesotho, Swaziland and Zambia; cost-
     effectiveness per HIV infection averted ($417 to 618 for 2008-
     2015); pace of scale-up critical
Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS
    Prevention Research Landscape


                 Diaphragm                                                  Vaccines
                                 PREP        HSV2/STI
                                                                       Data in long term
                                                                             future
                                          Index Microbicides
                                          Partner
                                          Rx
          Male Circumcision
                                      Data in “near” future


          Data available




Stellenbosch      Making Decisions on Male Circumcision for HIV Risk Reduction:    Hankins
Nov 15-16 2007
                                 Modelling the Impact and Costs                    UNAIDS
            Modelling potential impact
   • Key parameters: efficacy of PrEP, adherence,
     discontinuation rate, risk compensation, time
     to achieve target coverage
   • 2.7 to 3.2 million infections could be averted
     in southern Africa over 10 years targeting
     90% effective PrEP at those at highest risk
     of HIV exposure if risk compensation
     prevented (Abbas, Anderson and Mellors, PLoS ONE September 2007)
   • PrEP targeting 25% of MSM at higher risk of
     HIV exposure in NYC could prevent between
     4 and 21% of the infections predicted to
     occur over 5 years (Desai, McGreevey, Ackers et al.)
Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS
         Potential impact on HIV-1
      transmission in resource–limited
                  settings                                            51.2
                                                                      25.6




                                                      HIV Prevalence (%)
                                                                      12.8
                                                                           6.4
                                                                           3.2
                                                                           1.6
                                                                           0.8
                                                                           0.4
                                                                           0.2
                                                                           0.1
                                                                           0     20     40      60     80
                                                                            Male circumcision prevalence (%)
                                                                           100
                                                                                   (Williams BG and Hankins CA)


Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:                         Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                                         UNAIDS
                   Illustrative Results
                                                             Univ Precautions
                           Resources Needed for Prevention   Male circumcision
                                                             Safe injections
                                                             PEP
                  16,000                                     Blood safety
                                                             PMTCT
                  14,000                                     STI treatment
Millions of US$




                  12,000                                     Condoms
                                                             Social marketing
                  10,000                                     Other vuln. pops.

                   8,000                                     Prevention for PLHA
                                                             Workplace
                   6,000                                     IDU

                   4,000                                     MSM
                                                             CSW
                   2,000                                     Youth out of school

                       0                                     Youth in school
                                                             VCT

                             2006       2010      2015       Comm. Mobilization
                                                             Mass media



         Targets reached in 2010
 Decision makers’ programming planning tool
   Inspired by:
   1. WHO workbook tool for TB country planning and
       budgeting tool developed by Katherine Floyd et al.
       based on:
          –      Stop TB strategy for TB control in 7 epidemiologically-
                 defined regions
          –      at a scale to achieve MDG and Stop TB Partnership
                 objectives and universal access to ART at global level
   2.         Cost-effectiveness tool developed by Bertran
              Auvert, Jim Kahn et al.
   3.         Costing tool and cost-effectiveness tool developed
              by John Stover, Lori Bollinger and Gayle Martin et
              al. and piloted in 3 countries (Kigali: O1 presentation 17
              July)
Stellenbosch          Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                     Modelling the Impact and Costs                   UNAIDS
Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS
    Making Decisions on Male Circumcision for HIV
    Risk Reduction: Modelling the Impact and Costs
   Objectives of this meeting:
   • Review progress in modelling the potential impact of male
     circumcision since the November 2005 meeting
   • Review approaches to costing and cost-effectiveness of male
     circumcision for HIV risk reduction.
   • Assess a programme planning spreadsheet tool for decision-
     makers designed to:
          – show the time frame for impact on country’s epidemic
          – calculate the costs of various programming choices for male
            circumcision, providing budgeting information in format for
            proposals
          – calculate cost per HIV infection averted by programming option
            (age at circumcision, provider, coverage, speed of scale up)
   • Discuss the implications of the revised UNAIDS/WHO HIV
     survival estimate parameters for male circumcision modelling
     and costing

Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS
       Male circumcision for HIV risk reduction:

        If well implemented, safe male circumcision would
        increase HIV prevention choices, create synergies
        with partner reduction, avoidance of penetration,
       correct and consistent male and female condom use
                    for increased protection….
           provide a golden opportunity to invest in male
                  sexual and reproductive health

Stellenbosch     Making Decisions on Male Circumcision for HIV Risk Reduction:   Hankins
Nov 15-16 2007
                                Modelling the Impact and Costs                   UNAIDS