Abstract
Background: South Africa began offering medical male circumcision (MMC) in 2010. We evaluated the current and future impact of this program to see if it is effective in preventing new HIV infections. Methods: The Thembisa, Goals and Epidemiological Modeling Software (EMOD) HIV transmission models were calibrated to South Africa's HIV epidemic, fitting to household survey data on HIV prevalence, risk behaviors, and proportions of men circumcised, and to programmatic data on intervention roll-out including program-reported MMCs over 2009-2017. We compared the actual program accomplishments through 2017 and program targets through 2021 with a counterfactual scenario of no MMC program. Results: The MMC program averted 71,000-83,000 new HIV infections from 2010 to 2017. The future benefit of the circumcision already conducted will grow to 496,000-518,000 infections (6-7% of all new infections) by 2030. If program targets are met by 2021 the benefits will increase to 723,000-760,000 infections averted by 2030. The cost would be $1,070-1,220 per infection averted relative to no MMC. The savings from averted treatment needs would become larger than the costs of the MMC program around 2034-2039. In the Thembisa model, when modelling South Africa's 9 provinces individually, the 9-provinces-aggregate results were similar to those of the single national model. Across provinces, projected long-term impacts were largest in Free State, KwaZulu-Natal and Mpumalanga (23-27% reduction over 2017-2030), reflecting these provinces' greater MMC scale-up. Conclusions: MMC has already had a modest impact on HIV incidence in South Africa and can substantially impact South Africa's HIV epidemic in the coming years.
Highlights
South Africa continues to face one of the highest burdens of HIV globally, despite extensive roll-out of prevention programs since the 1990s and treatment programs since 20041,2
Avenir Health applied the deterministic Spectrum Goals model, previously applied in South Africa[24,25,26] and other southern African countries. This compartmental, risk-structured model sits in the Spectrum platform, building on a demographic module that projects populations over time and models HIV epidemic spread between compartments of adults 15–49 years: low-risk adults who have one heterosexual partner; medium-risk adults with two or more partners in a year, high-risk adults who are female sex workers (FSW) and their clients, and men who have sex with men (MSM)
Adult HIV incidence and prevalence from Goals are fed into the linked Spectrum module AIM, which translates these into outputs such as numbers of people living with HIV, new infections, AIDS deaths, the need for antiretroviral therapy (ART), and prevention of mother-to-child transmission, by age group including those below 15 and above 49 years
Summary
South Africa continues to face one of the highest burdens of HIV globally, despite extensive roll-out of prevention programs since the 1990s and treatment programs since 20041,2. Medical male circumcision (MMC) has been shown by three randomized control trials to reduce the transmission of HIV from females to males by about 60%11–13. It is a one-time intervention that provides life-long protection.[14]. The World Health Organization (WHO) and Joint United Nations Program on HIV/AIDS (UNAIDS) suggested a target of 80% MMC coverage by 2015 among adult men (ages 15–49 years) in 14 priority countries including South Africa[17].
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