Voluntary Medical Male Circumcision Coverage Research Articles

Applying mathematical modelling to estimate the impact of COVID-19-related VMMC service disruptions on new HIV infections in Zimbabwe

BackgroundThe COVID-19 pandemic has overwhelmed health systems with knock on effects on diagnosis, treatment, and care. To mitigate the impact, the government of Zimbabwe enforced a strict lockdown beginning 30 March 2020 which ran intermittently until early 2021. In this period, the Ministry of Health and Childcare strategically prioritized delivery of services leading to partial and full suspension of services considered non-essential, including HIV prevention. As a result, Voluntary Medical Male Circumcision (VMMC) services were disrupted leading to an 80% decline in circumcisions conducted in 2020. Given the efficacy of VMMC, we quantified the potential effects of VMMC service disruption on new HIV infections in Zimbabwe.MethodsWe applied the GOALS model to evaluate the impact of COVID-19-related disruptions on reducing new HIV infections over 30-years. GOALS is an HIV simulation model that estimates number of new HIV infections based on sexual behaviours of population groups. The model is parameterized based on national surveys and HIV program data. We hypothesized three coverage scenarios by 2030: scenario I - pre-COVID trajectory: 80% VMMC coverage; Scenario II - marginal COVID-19 impact: 60% VMMC coverage, and scenario III - severe COVID-19 impact: 45% VMMC coverage. VMMC coverage between 2020 and 2030 was linearly interpolated to attain the estimated coverage and then held constant from 2030 to 2050, and discounted outcomes at 3%.ResultsCompared to the baseline scenario I, in scenario II, we estimated that the disruption of VMMC services would generate an average of 200 (176–224) additional new infections per year and 7,200 new HIV infections over the next 30 years. For scenario III, we estimated an average of 413 (389–437) additional new HIV infections per year and 15,000 new HIV infections over the next 30 years. The disruption of VMMC services could generate additional future HIV treatment costs ranging from $27 million to $55 million dollars across scenarios II and III, respectively.ConclusionCOVID-19 disruptions destabilized delivery of VMMC services which could contribute to an additional 7,200 new infections over the next 30 years. Unless mitigated, these disruptions could derail the national goals of reducing new infections by 2030.

Ethical implications of economic compensation for voluntary medical male circumcision for HIV prevention and epidemic control.

Despite tremendous efforts in fighting HIV over the last decades, the estimated annual number of new infections is still a staggering 1.5 million. There is evidence that voluntary medical male circumcision (VMMC) provides protection against men's heterosexual acquisition of HIV-1 infection. Despite good progress, most countries implementing VMMC for HIV prevention programmes are challenged to reach VMMC coverage rates of 90%. Particularly for men older than 25 years, a low uptake has been reported. Consequently, there is a need to identify, study and implement interventions that could increase the uptake of VMMC. Loss of income and incurred transportation costs have been reported as major barriers to uptake of VMMC. In response, it has been suggested to use economic compensation in order to increase VMMC uptake. In this discussion paper, we present and review relevant arguments and concerns to inform decision-makers about the ethical implications of using economic compensation, and to provide a comprehensive basis for policy and project-related discussions and decisions.

Voluntary Medical Male Circumcision for HIV Prevention: a Global Overview.

With the promise of HIV prevention, there has been a scale-up of voluntary medical male circumcision (VMMC) in high HIV incidence/low circumcision prevalence nations worldwide. Nonetheless, debates over the implementation and the effectiveness and safety of the VMMC in real-world settings persist. We revisit the role of VMMC in HIV prevention to inform health professionals, policymakers, and advocates or opponents in this new era. There has been substantial progress on VMMC scale-up to date, but this has varied considerably by region. The evidence of solid and direct protection of VMMC is available for heterosexual men and older adolescent boys in sub-Saharan Africa. The protective effect in men who have sex with men is suggested by systematic reviews but is not confirmed by clinical trials. Sexual partners, including women, likely benefit indirectly from the increased VMMC coverage through a decreased risk of exposure to infected male partners. Fortunately, the preponderance of studies does not suggest higher sexual risk behaviors among circumcised men, so-called risk compensation. VMMC requires health systems strengthening and continued promulgation of other evidence-based HIV prevention strategies to be successful. Health authorities in high HIV incidence areas that have low circumcision coverage should implement VMMC within a context of complementary biomedical and behavioral prevention strategies.

Estimating male circumcision coverage in 15 priority countries in sub-Saharan Africa.

IntroductionGiven the importance of voluntary medical male circumcision (VMMC) in reducing HIV incidence, access to and use of quality data for programme planning and management are essential. Unfortunately, such data are currently not standardized for reliable and consistent programme use in priority countries. To redress this, the UNAIDS Reference Group (RG) on Estimates, Modelling, and Projection worked with partner Avenir Health to use the Decision Makers Program Planning Toolkit (DMPPT) 2 Online to provide estimates of VMMC coverage and to support countries to set age‐ and geographic‐specific targets. This article describes the methods and tools used for assembling, reviewing and validating VMMC programme data as part of the 2021 Estimates process.DiscussionThe approach outlined for integrating VMMC data using the DMPPT2 Online required significant country engagement as well as upgrades to the DMPPT2 Online. The process brought together local‐level VMMC stakeholders, for example Ministries of Health, the Joint United Nations Programme on HIV/AIDS (UNAIDS), the US President's Emergency Plan for AIDS Relief, the World Health Organization (WHO), VMMC implementers and so on, to review, amend and agree on historical and more recent VMMC data. The DMPPT2 Online was upgraded to align with the Spectrum and Naomi models used in the Annual HIV Estimates process. In addition, new and revised inputs were incorporated to enhance accuracy of modelled outputs. The process was successful in mobilizing stakeholders behind efforts to integrate VMMC into the annual HIV Estimates process and generating comprehensive, country‐owned and validated VMMC data that will enhance programme monitoring and planning.ConclusionsVMMC programme data from most of the priority countries were successfully reviewed, updated, validated and incorporated into the annual HIV Estimates process in 2020. It is important to ensure that these data continue to be used for programme planning and management. Current and future data issues will need to be addressed, and countries will need ongoing support to do so. The integration of the DMPPT2 Online into the annual HIV Estimates process is a positive step forward in terms of streamlining country‐owned planning and analytical practices for the HIV response.

Towards a context-specific understanding of masculinities in Eswatini within voluntary medical male circumcision programming

Compelling evidence from three randomised controlled trials, which showed that voluntary medical male circumcision (VMMC) reduces HIV acquisition from women to men by up to 60%, led to WHO recommending that VMMC be implemented in 14 priority countries. As one of the priority countries, Eswatini aimed to reach 80% VMMC coverage among boys and men aged 10–49 years since programme inception in 2009. By the end of 2019, however, the country had reached a modest 40%. VMMC is intrinsically tied to perceptions of masculinity and male gender identity. Comprehending the role of context-specific masculinity as it relates to VMMC may contribute to our understanding of community attitudes towards VMMC and men’s decision-making. Drawing on focus group discussion data, this study aimed to explore the linkage between sexuality, masculinity and health interventions within Eswatini. Using critical discourse analysis, the study identified two discourses: sexuality, masculinity and circumcision, and income, masculinity, and circumcision. In the first discourse, participants constructed discursive linkages between circumcision as an adult and loss of penile sensitivity, decreased libido and sexual performance, and adverse events. The second discourse, income, masculinity, and circumcision located circumcision within the social and material realities faced by Swazi men, gender norms and provision within family structures.

Adapting “MOVE” to Accelerate VMMC Coverage for HIV Prevention in Priority Populations: Implementation Experiences from Uganda’s Military Settings

This paper describes the WHO’s Model of Optimizing Volumes and Efficiencies (MOVE), adapted by the University Research Council (URC) - Department of Defense HIV/AIDS Prevention Program (DHAPP) to rapidly scale up Voluntary Medical Male Circumcision (VMMC) within Uganda’s military health facilities. First, we examine the MOVE model and then present the URC-DHAPP adapted intervention package comprising of: a) a Command-driven approach, b) Mobile theatres c) Quality assurance d) Data strengthening and reflection. To expand VMMC, URC-DHAPP worked with army commanders to create awareness, mobilize their troops and surgeons were assigned daily targets. The mobile theatre involved regular visits to hard-to-reach outposts and placing several mobile camps at health facilities close to deployment sites. All stakeholders were briefed on performance trends of previous medical camps and the program was monitored through VMMC camp reports. URC-DHAPP registered an exponential increase in VMMC coverage from 13% performance at Q2 to over 140% in Q4. The integrated approach led to circumcision of over 22,000 men (15-49 years) in a record four months. Our approach also contributed to health system strengthening and national HIV preventiontargets. We conclude that the MOVE is cost-effective and can be successfully scaled up in resource-limited settings with a high HIV burden when implemented with cognizance of contextual specificities.

Brief Report: Modeling the Impact of Voluntary Medical Male Circumcision on Cervical Cancer in Uganda.

In addition to providing millions of men with lifelong lower risk for HIV infection, voluntary medical male circumcision (VMMC) also provides female partners with health benefits including decreased risk for human papillomavirus (HPV) and resultant cervical cancer (CC). We modeled potential impacts of VMMC on CC incidence and mortality in Uganda as an additional benefit beyond HIV prevention. HPV and CC outcomes were modeled using the CC model from the Spectrum policy tool suite, calibrated for Uganda, to estimate HPV infection incidence and progression to CC, using a 50-year (2018-2067) time horizon. 2016 Demographic Health Survey data provided baseline VMMC coverage. The baseline (no VMMC scale-up beyond current coverage, minimal HPV vaccination coverage) was compared with multiple scenarios to assess the varying impact of VMMC according to different implementations of HPV vaccination and HPV screening programs. Without further intervention, annual CC incidence was projected to rise from 16.9 to 31.2 per 100,000 women in 2067. VMMC scale-up alone decreased 2067 annual CC incidence to 25.3, averting 13,000 deaths between 2018 and 2067. With rapidly-achieved 90% HPV9 vaccination coverage for adolescent girls and young women, 2067 incidence dropped below 10 per 100,000 with or without a VMMC program. With 45% vaccine coverage, the addition of VMMC scaleup decreased incidence by 2.9 per 100,000 and averted 8000 additional deaths. Similarly, with HPV screen-and-treat without vaccination, the addition of VMMC scaleup decreased incidence by 5.1 per 100,000 and averted 10,000 additional deaths. Planned VMMC scale-up to 90% coverage from current levels could prevent a substantial number of CC cases and deaths in the absence of rapid scale-up of HPV vaccination to 90% coverage.

Economic compensation interventions to increase uptake of voluntary medical male circumcision for HIV prevention: A systematic review and meta-analysis.

BackgroundEconomic compensation interventions may help support higher voluntary medical male circumcision (VMMC) coverage in priority sub-Saharan African countries. To inform World Health Organization guidelines, we conducted a systematic review of economic compensation interventions to increase VMMC uptake.MethodsEconomic compensation interventions were defined as providing money or in-kind compensation, reimbursement for associated costs (e.g. travel, lost wages), or lottery entry. We searched five electronic databases and four scientific conferences for studies examining the impact of such interventions on VMMC uptake, HIV testing and safer-sex/risk-reduction counseling uptake within VMMC, community expectations about compensation, and potential coercion. We screened citations, extracted data, and assessed risk of bias in duplicate. We conducted random-effects meta-analysis. We also reviewed studies examining acceptability, values/preferences, costs, and feasibility.ResultsOf 2484 citations identified, five randomized controlled trials (RCTs) and three non-randomized controlled trials met our eligibility criteria. Studies took place in Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. Meta-analysis of four RCTs showed significant impact of any economic compensation on VMMC uptake (relative risk: 5.23, 95% CI: 3.13 to 8.76). RCTs of food/transport vouchers and conditional cash transfers generally showed increases in VMMC uptake, but lotteries, subsidized VMMC, and receiving a gift appeared somewhat less effective. Three non-randomized trials showed mixed impact. Six additional studies suggested economic compensation interventions were generally acceptable, valued for addressing key barriers, and motivating to men. However, some participants felt they were insufficiently motivating or necessary; one study suggested they might raise community suspicions. One study from South Africa found a program cost of US$91 per additional circumcision and US$450-$1350 per HIV infection averted.ConclusionsEconomic compensation interventions, particularly transport/food vouchers, positively impacted VMMC uptake among adult men and were generally acceptable to potential clients. Carefully selected economic interventions may be a useful targeted strategy to enhance VMMC coverage.

A cross-sectional study of the factors associated with male circumcision status among college youth in Ndola, Zambia, 2016

Background: New cases of HIV are increasing among young adults in Zambia; yet voluntary medical male circumcision (VMMC) coverage as an HIV prevention measure remains low. Despite having the highest HIV burden in the province, Ndola district had a VMMC coverage of 23% in 2015 compared to the national target of 80% among high-risk groups. Objectives: To determine predictive factors associated with circumcision status among male students in Ndola district. Methods: We conducted a cross-sectional study in May 2016 among students aged 18–35 years enrolled in five conveniently sampled colleges. We administered a structured questionnaire to assess the knowledge, attitudes and perceptions about VMMC. We used multivariable logistic regression to determine factors associated with male circumcision (MC) status. Results: Of 136 students interviewed, 63% were circumcised, and of those, 96% were medically circumcised. Half of all students were aged 21–24 years. Those who perceived the circumcision procedure to be ‘safe’ (adjusted odds ratio [aOR] = 5.13; 95% CI: 2.09–14.82), and knew that it reduced female to male HIV transmission risk (aOR = 3.65; 95% CI: 3.12–11.67), were more likely to be circumcised. The perception that MC promotes ‘promiscuous behaviour’ (aOR = 0.20; 95% CI: 0.07–0.61), and that sexual sensitivity is the ‘same’ regardless of circumcision status, were associated with not being circumcised (aOR = 0.13; 95% CI: 0.02–0.80). Conclusion: Students had adequate knowledge about the safety of medical circumcision, and the subsequent risk reduction of HIV infection. Interventions aimed at addressing negative sexual perceptions about circumcision may increase VMMC coverage among college students.

Voluntary Medical Male Circumcision to Prevent HIV: Modelling Age Prioritization in Namibia

Voluntary Medical Male circumcision (VMMC) has been part of prevention in Namibia since 2009. Yet, as of 2013, VMMC coverage among 15- to 24-year-olds was estimated at less than 22%. Program data suggests uptake of VMMC below age 15 is lower than expected, given the age distribution of the eligible population. Nearly 85% of VMMCs were for males between ages 15 and 29, while boys 10–14 years were referred outside the program. This analysis uses the Decision Makers Program Planning Tool to understand the impact of age prioritization on circumcision in Namibia. Results indicate that circumcising males aged 20–29 reduced HIV incidence most rapidly, while focusing on ages 15–24 was more cost effective and produced greater magnitude of impact. Providing services to those under 15 could increase VMMC volume 67% while introducing Early Infant Medical Circumcision could expand coverage. This exercise supported a review of VMMC strategies and implementation, with Namibia increasing coverage among 10- to 14-year-olds nearly 20 times from 2016 to 2017.

Modeling economic and epidemiological impact of voluntary medical male circumcision among men who have sex with men in Beijing, China.

Voluntary medical male circumcision (VMMC) among men who have sex with men (MSM) may protect against HIV acquisition. We conducted a series of analyses to assess if expanded VMMC might reduce HIV incidence among MSM effectively and economically. We used a deterministic compartmental model to project new HIV cases (2016-2026) under annual VMMC coverage rates (λ) ranging from 0.0001 to 0.15. The 'number needed to avert' (NNA) is defined as the cumulative number of VMMCs conducted up to that year divided by the cumulative number of HIV cases averted in that specific year. Compared with the baseline circumcision coverage rate, we projected that new HIV cases would be reduced with increasing coverage. By 2026 (last year simulated), the model generated the lowest ratio (11.10) when the annual circumcision rate was the most optimistic (λ = 0.15). The breakeven point was observed at the year of 2019 with the annual VMMC coverage rate of 0.001. The total cost saved by averting HIV cases would range from 2.5 to 811 million US dollars by the end of 2026 with different hypothetical coverage rates. Our model suggests that acceleration in VMMC implementation among MSM could help stem the HIV/AIDS epidemic.

Using mathematical modeling to inform health policy: A case study from voluntary medical male circumcision scale-up in eastern and southern Africa and proposed framework for success.

BackgroundModeling contributes to health program planning by allowing users to estimate future outcomes that are otherwise difficult to evaluate. However, modeling results are often not easily translated into practical policies. This paper examines the barriers and enabling factors that can allow models to better inform health decision-making.DescriptionThe Decision Makers’ Program Planning Tool (DMPPT) and its successor, DMPPT 2, are illustrative examples of modeling tools that have been used to inform health policy. Their use underpinned Voluntary Medical Male Circumcision (VMMC) scale-up for HIV prevention in southern and eastern Africa. Both examine the impact and cost-effectiveness of VMMC scale-up, with DMPPT used initially in global advocacy and DMPPT 2 then providing VMMC coverage estimates by client age and subnational region for use in country-specific program planning. Their application involved three essential steps: identifying and engaging a wide array of stakeholders from the outset, reaching consensus on key assumptions and analysis plans, and convening data validation meetings with critical stakeholders. The subsequent DMPPT 2 Online is a user-friendly tool for in-country modeling analyses and continuous program planning and monitoring.Lessons learnedThrough three iterations of the DMPPT applied to VMMC, a comprehensive framework with six steps was identified: (1) identify a champion, (2) engage stakeholders early and often, (3) encourage consensus, (4) customize analyses, (5), build capacity, and (6) establish a plan for sustainability. This framework could be successfully adapted to other HIV prevention programs to translate modeling results to policy and programming.ConclusionsModels can be used to mobilize support, strategically plan, and monitor key programmatic elements, but they can also help inform policy environments in which programs are conceptualized and implemented to achieve results. The ways in which modeling has informed VMMC programs and policy may be applicable to an array of other health interventions.

Application of an HIV Prevention Cascade to Identify Gaps in Increasing Coverage of Voluntary Medical Male Circumcision Services in 42 Rural Zambian Communities

Increased coverage of voluntary medical male circumcision (VMMC) is needed in countries with high HIV prevalence. We applied an HIV-prevention cascade to identify gaps in male circumcision coverage in Zambia. We used survey data collected in 2013 and 2014/15 to describe circumcision coverage at each time-point, and prevalence of variables related to demandfor and supplyof VMMC. We explored whether circumcision coverage in 2014/15 was associated with demand and supply among uncircumcised men in 2013. Results show that circumcision coverage was 11.5% in 2013 and 18.0% in 2014/15. Levels of having heard of circumcision and agreeing with prevention benefits was similar at both time-points (79.8% vs 83.2%, and 49.7% vs 50.7%, respectively). In 2013, 39.3% of men perceived services to be available compared to 54.7% in 2014/15. Levels ofhaving heard of circumcision in 2013 was correlated with and higher perceived service availability associated with coverage in 2014/15. VMMC coverage was low in these study sites. Knowledge of prevention tools and of service availability are necessary to increase coverage but alone are insufficient.

High HIV incidence and low uptake of HIV prevention services: The context of risk for young male adults prior to DREAMS in rural KwaZulu-Natal, South Africa.

BackgroundYoung men are less likely than young women to engage with HIV prevention and care, and their HIV-related mortality is higher. We describe HIV incidence and uptake of HIV services in men 20–29 years(y) in rural KwaZulu-Natal, South Africa, before the roll-out of DREAMS.MethodsWe used data from a population-based demographic and HIV surveillance cohort. HIV incidence was estimated from anonymised testing in an annual serosurvey. Service uptake was assessed in 2011 and 2015, through two self-reported outcomes: 1) HIV testing in the past 12 months(m); 2) voluntary medical male circumcision(VMMC). Logistic regression was used to estimate odds ratios(OR) and 95% confidence intervals(CI) for factors associated with each outcome.ResultsHIV incidence in 2011–2015 was 2.6/100 person-years (95%CI = 2.0–3.4) and 4.2 (95%CI = 3.1–5.6) among men 20-24y and 25-29y, respectively, with no significant change from 2006–2010. N = 1311 and N = 1221 young men participated in the 2011 and 2015 surveys, respectively. In both years, <50% reported testing for HIV in the past 12m. In 2011, only 5% reported VMMC, but coverage in 2015 increased to 40% and 20% in men 20-24y and 25-29y, respectively. HIV testing was positively associated with higher education and mobility. Testing uptake was higher in men reporting >1 partner in the past 12m, or condom use at last sex, but lower in those reporting a casual partner (adjusted (a)OR = 0.53, 95%CI = 0.37–0.75). VMMC uptake was associated with survey year and higher education. Men aged 25-29y and those who were employed (aOR = 0.66; 95%CI = 0.49–0.89) were less likely to report VMMC.ConclusionsHIV incidence in men 20-29y was very high, and pre-exposure prophylaxis (PrEP) should be considered in this population. Uptake of services was low. VMMC coverage increased dramatically from 2011 to 2015, especially among younger men, suggesting a demand for this service. Interventions designed with and for young men are urgently needed.

Scaling Up Voluntary Medical Male Circumcision for Human Immunodeficiency Virus Prevention for Adolescents and Young Adult Men: A Modeling Analysis of Implementation and Impact in Selected Countries.

The new World Health Organization and Joint United Nations Programme on HIV/AIDS strategic framework for voluntary medical male circumcision (VMMC) aims to increase VMMC coverage among males aged 10-29 years in priority settings to 90% by 2021. We use mathematical modeling to assess the likelihood that selected countries will achieve this objective, given their historical VMMC progress and current implementation options. We use the Decision Makers' Program Planning Toolkit, version 2, to examine 4 ambitious but feasible scenarios for scaling up VMMC coverage from 2017 through 2021, inclusive in Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Tanzania, Uganda, and Zimbabwe. Tanzania is the only country that would reach the goal of 90% VMMC coverage in 10- to 29-year-olds by the end of 2021 in the scenarios assessed, and this was true in 3 of the scenarios studied. Mozambique, South Africa, and Lesotho would come close to reaching the objective only in the most ambitious scenario examined. Major changes in VMMC implementation in most countries will be required to increase the proportion of circumcised 10- to 29-year-olds to 90% by the end of 2021. Scaling up VMMC coverage in males aged 10-29 years will require significantly increasing the number of circumcisions provided to 10- to 14-year-olds and 15- to 29-year-olds.

Adolescent Male Circumcision for HIV Prevention in High Priority Countries: Opportunities for Improvement.

Global experts recognize the need to transform conventional models of healthcare to create adolescent responsive health systems. As countries near 80% coverage of voluntary medical male circumcision (VMMC) for those aged 15–49 years, prioritization of younger men becomes critical to VMMC sustainability. This special supplement reporting 9 studies focusing on adolescent VMMC programming and services comes at a critical time. Eight articles report how well adolescents are reached with the World Health Organization’s minimum package for comprehensive human immunodeficiency virus (HIV) prevention in South Africa, Zimbabwe, and Tanzania, analyzing motivation, counseling, wound healing, parental involvement, female peer support, quality of in-service communication, and providers’ perceptions, and one presents models for achieving high VMMC coverage by 2021. One important finding is that adolescent boys, especially the youngest, experience gaps in their comprehension of key elements in the World Health Organization’s minimum package. Although parents, counselors, and providers are involved and supportive, they are inadequately prepared to counsel youth, partly owing to discomfort with adolescent sexuality. At the country level, deliberately prioritizing young adolescents (aged 10–14 years) is likely to achieve national coverage targets more quickly and cost-effectively than continuing to focus on older, harder-to-reach men. The studies in this supplement point to areas where VMMC programs are achieving successes and they reveal areas for improvement. Given that prioritizing adolescents will be the best means of achieving sustainable VMMC for HIV prevention for the foreseeable future, applying the lessons learned here will increase the effectiveness of VMMC programs.

Age Targeting of Voluntary Medical Male Circumcision Programs Using the Decision Makers' Program Planning Toolkit (DMPPT) 2.0.

BackgroundDespite considerable efforts to scale up voluntary medical male circumcision (VMMC) for HIV prevention in priority countries over the last five years, implementation has faced important challenges. Seeking to enhance the effect of VMMC programs for greatest and most immediate impact, the U. S. President’s Plan for AIDS Relief (PEPFAR) supported the development and application of a model to inform national planning in five countries from 2013–2014.Methods and FindingsThe Decision Makers’ Program Planning Toolkit (DMPPT) 2.0 is a simple compartmental model designed to analyze the effects of client age and geography on program impact and cost. The DMPPT 2.0 model was applied in Malawi, South Africa, Swaziland, Tanzania, and Uganda to assess the impact and cost of scaling up age-targeted VMMC coverage. The lowest number of VMMCs per HIV infection averted would be produced by circumcising males ages 20–34 in Malawi, South Africa, Tanzania, and Uganda and males ages 15–34 in Swaziland. The most immediate impact on HIV incidence would be generated by circumcising males ages 20–34 in Malawi, South Africa, Tanzania, and Uganda and males ages 20–29 in Swaziland. The greatest reductions in HIV incidence over a 15-year period would be achieved by strategies focused on males ages 10–19 in Uganda, 15–24 in Malawi and South Africa, 10–24 in Tanzania, and 15–29 in Swaziland. In all countries, the lowest cost per HIV infection averted would be achieved by circumcising males ages 15–34, although in Uganda this cost is the same as that attained by circumcising 15- to 49-year-olds.ConclusionsThe efficiency, immediacy of impact, magnitude of impact, and cost-effectiveness of VMMC scale-up are not uniform; there is important variation by age group of the males circumcised and countries should plan accordingly.

Evaluating Opportunities for Achieving Cost Efficiencies Through the Introduction of PrePex Device Male Circumcision in Adult VMMC Programs in Zambia and Zimbabwe.

Results from recent costing studies have put into question potential Voluntary Medical Male Circumcision (VMMC) cost savings with the introduction of the PrePex device. We evaluated the cost drivers and the overall unit cost of VMMC for a variety of service delivery models providing either surgical VMMC or both PrePex and surgery using current program data in Zimbabwe and Zambia. In Zimbabwe, 3 hypothetical PrePex only models were also included. For all models, clients aged 18 years and older were assumed to be medically eligible for PrePex and uptake was based on current program data from sites providing both methods. Direct costs included costs for consumables, including surgical VMMC kits for the forceps-guided method, device (US $12), human resources, demand creation, supply chain, waste management, training, and transport. Results for both countries suggest limited potential for PrePex to generate cost savings when adding the device to current surgical service delivery models. However, results for the hypothetical rural Integrated PrePex model in Zimbabwe suggest the potential for material unit cost savings (US $35 per VMMC vs. US $65-69 for existing surgical models). This analysis illustrates that models designed to leverage PrePex's advantages, namely the potential for integrating services in rural clinics and less stringent infrastructure requirements, may present opportunities for improved cost efficiency and service integration. Countries seeking to scale up VMMC in rural settings might consider integrating PrePex only MC services at the primary health care level to reduce costs while also increasing VMMC access and coverage.

P3.373 Male Circumcision Prevalence, Knowledge, Perceptions, and Intent Among Men in Bulawayo, Zimbabwe: A Cross-Sectional Study

<h3>Background</h3> Zimbabwe has a target to reach 80% voluntary medical male circumcision (VMMC) coverage among HIV-negative 15–29 year-old men by 2015. This is a central strategy in the nation’s HIV response. Despite considerable recent investment, uptake has been slower than hoped. A cluster-randomised trial began in 2012 to assess the effectiveness of a sport-based VMMC demand-creation intervention. <h3>Methods</h3> At baseline, 663 men aged 18–45 years (median age 24 years) on 47 local soccer teams (both social and professional) in Bulawayo completed a self-administered questionnaire on VMMC-related knowledge, perceptions and intent using touchscreen mobile phones. Linear and logistic regressions were used to assess differences by age, educational attainment, and study group, adjusting for team-level clustering. <h3>Results</h3> 141 men (21.0%) reported being circumcised, the majority (80.6%) at a hospital or clinic and 24 (17.0%) within the last three months. Among the uncircumcised men, the majority (90.8%) knew that VMMC reduces HIV risk and thought that getting circumcised was a good idea (89.3%). About half (54.2%) correctly identified at least one local clinic providing VMMC services and 62.6% reported that they were planning to get circumcised. Among uncircumcised men, those with A-level/higher education had better VMMC knowledge (AOR = 3.15, 95% CI = 1.52–6.53), but were less likely to intend to become circumcised (AOR = 0.57, 95% CI = 0.37–0.89). Being circumcised was weakly associated with having A-Level/higher education (AOR = 1.52, 95% CI = 0.95–2.43). No differences were observed between study groups in reported circumcision status, age, education, VMMC knowledge, or VMMC intention. <h3>Conclusion</h3> This study provides evidence that VMMC-related knowledge and intentions are high amongst uncircumcised, soccer-playing men in Bulawayo, though VMMC coverage remains far below 80%. Effective demand creation interventions are needed and should ensure uncircumcised men are aware of local sites offering VMMC services. Further research should investigate barriers to VMMC uptake among men in Bulawayo.