Scaling up Voluntary Medical Male Circumcision (VMMC) in Southern and Eastern Africa: Successes Achieved and Challenges Overcome

Transcription

1 Scaling up Voluntary Medical Male Circumcision (VMMC) in Southern and Eastern Africa: Successes Achieved and Challenges Overcome Kelly Curran Director, HIV and Infectious Diseases, Jhpiego 7 March 2014

2 Voluntary Medical Male Circumcision Reduces female to male HIV transmission by approximately 60% Reduces acquisition and transmission of other sexual and reproductive tract infections including HSV-2, HPV, syphilis and bacterial vaginosis: Female partners of circumcised men have lower rates of cervical cancer Aggressive scale-up of VMMC has the potential to avert 3.4 million new HIV infections by

3 Minimum Package of VMMC Services 3

4 Number of VMMCs Needed: 20.3 M years, HIV-negative males for 80% VMMC coverage in 5 years 5,000,000 4,500,000 4,000,000 3,500,000 4,333,134 4,245,184 3,000,000 2,500,000 2,000,000 1,500,000 1,000, , ,244 40, , ,788 2,101,566 1,059, ,218 1,746, ,450 1,373,271 1,949,292 1,912,595

5 # infections averted % infections averted Cumulative Number and Percentage of HIV Infections Averted between 2011 to 2025 by Scaling Up VMMC 1,200, % 1,000, , , % 36.6% 28.3% 25.2% 28.7% 19.8% 33.9% 41.7% 24.5% 29.9% 40.0% 35.0% 30.0% 25.0% 20.0% 400, , % 15.7% 9.2% 15.0% 10.0% 5.0% - 0.0%

6 Challenge: Insufficient Number of Doctors Solution: Empower nurses to provide VMMC surgery: Ethiopia, Kenya, Malawi, Mozambique, Namibia, Zambia and most recently Zimbabwe allow nurses to provide VMMC; other countries allow task sharing 6

7 Adult Men Do Not Want to Queue for Services with Adolescent Boys Adult-only hours or even adult-only clinics The Apex Clinic in Maseru, Lesotho, serves only men age 25 and older 7

8 Clients Live Far from Health Facilities? Take Services to the People Carrying instruments to a rural site near Lake Nyasa in Tanzania 8

9 Clients Live far from Health Facilities? Take Services to the People! Tents and Mobile Clinics in Mozambique 9

10 Seasonality of Demand (Strong Preference for VMMC in Winter) Solution: Increase service delivery capacity in winter through campaigns and efficiency approaches like MOVE 10

11 Some Men Are Afraid of Injections, Scalpels, Blood and Sutures PrePex does not require injectable anesthesia or cutting of live tissue, but PP clients have to wear the device for one week, they often experience an unpleasant odor, and healing time is generally longer than with regular surgery. 11

12 PEPFAR-Supported VMMCs through December 31, TOTAL PEPFAR-SUPPORTED VMMCS 1,997,800 4,700, , ,000 73, ,000 10,000 <10,000 Represents results from October 1, 2012 to December 31, 2013 (September 30 December 31 estimated) Coverage not to scale

13 Focusing Demand Creation Strategies for the Voluntary Medical Male Circumcision for HIV Prevention Program in Malawi New Modeling Exercise Approach and Preliminary Results Sharing PEPFAR through USAID Health Policy Project & BMGF August 24, 2015 Version

14 Current Challenges and Questions Challenges Previous model didn t reflect the programmatic reality in terms of age disaggregation in the field; didn t allow us to understand the relative contribution of each age group. Previous model didn t include year olds. Questions Can we prioritize sub-populations to decrease the level of effort needed and preserve the potential epi/econ impact? How important are older men? Of all infections averted, how many come from the men age 35+? What would be the benefit of circumcising males ages 10 14?* Would it be advisable to prioritize certain regions of a country? *substantial % of the VMMC currently done are below age 15

15 Use exogenous estimates of: Population by age and sex (World Population Prospects 2012) Non-AIDS mortality by age and sex (Spectrum) Incidence by age and sex (Spectrum AIM or Goals) Estimate Approach: DMPPT 2.0 Incidence among circumcised and non-circumcised men Project effects of changing rates of male circumcision by age Pros: Model is easy to set-up for a new country and uses official national HIV estimate Cons: Model does not simulate full details of sexual transmission and age and sex mixing

16 Adolescents Represent a Disproportionate % of the Population Reached (Malawi National) 40% 35% 30% 25% 20% 15% 10% 5% 0% percent in age group among uncircumcised men ages percent of clients in age group among those reached in 2012

17 Malawi Age-specific HIV incidence, 2013, from Spectrum 0.9% 0.8% 0.7% 0.6% 0.5% 0.4% Male 0.3% 0.2% 0.1% 0.0%

18 Age distribution of VMMC based on target strategy in Malawi, targeting ages Baseline MC Prevalence Target Coverage in 2018 EIMC 1% 1% % 80% % 80% % 80% % 80% % 80% % 80% % 80% % 80% % 11% % 11% Total MCs during scale-up : 4.8 million Total MCs during maintenance : 3.2 million

19 Logic-tree applied to address the value of subpopulation specific targeting Effectiveness of VMMC Number of VMMCs per HIV infection averted Immediacy of impact How fast incidence rate is reduced Magnitude of impact Number of HIV infections averted Program cost Cost of VMMC program Programming efficiency Focus of modeling work Programmatic feasibility Depends whether the program has viable models to reach the subgroup

20 Effectiveness of VMMC: age-specific targeting VMMC per infection averted Malawi Age at circumcision VMMC per IA

21 Malawi: fastest incidence rate reductions (IRR) are achieved by circumcising age group; highest magnitude reductions by circumcising age group

22 Logic-tree applied to address the value of subpopulation specific targeting Effectiveness of VMMC year age group Immediacy of impact year age group Magnitude of impact year age group Program cost year age group Programming efficiency Programmatic feasibility Focus of modeling work Depends whether the program has viable models to reach the subgroup

23 Acknowledgments - Malawi GoM team Dr. Frank Chimbwandira Health Policy Project Malawi Olive Mtema Dr. Andreas Jahn Amon Nkhata PEPFAR team Malawi Wezi Msungama Faustin Matchere Martin Mtika Zebedee Mwandi

24 Acknowledgments Collaboration between PEPFAR through USAID and BMGF, this activity is implemented by Weill Medical College (WMC) in Qatar under funding from the Gates Foundation The PEPFAR USAID-funded Health Policy Project (HPP) The DMPPT 2.0 model was developed by John Stover, HPP, Futures Institute The ASM model was developed by Laith Abu Raddad and Susanne Awad, WMC The DMPPT 2.0 model was used to generate country data by Katharine Kripke, Xan Paxton, and Bernice Kuang, HPP The activity is under the technical leadership of Sema Sgaier of BMGF, Emmanuel Njeuhmeli of USAID, and Jason Reed of OGAC Special thank you for key contributions from: Naomi Bock and Stephanie Davis of CDC Anne Thomas of DoD Delivette Castor of USAID Julie Samuelson of WHO Tin Tin and Susan Kasedde of UNICEF Karl-Lorenz Dehne of UNAIDS

25 This presentation is based on research funded by PEPFAR and the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of PEPFAR or the Bill & Melinda Gates Foundation. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A , beginning September 30, The project s HIV activities are supported by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). HPP is implemented by Futures Group, in collaboration with CEDPA (part of Plan International USA), Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).

26 Additional Slides

27 Reflections of PEPFAR s HQ MC TWG Modeled projections of impact are highly sensitive to estimates of HIV incidence Inherent uncertainties must be acknowledged; limitations should be discussed Not all analyses requested by countries are possible, e.g., regional impact may be difficult to model if validated HIV incidence estimates for the geographic area in question are not available. Urban vs. rural impact estimates may be more precise than regional (province or district-level) analyses High incidence hot spots and/or high risk population groups (e.g., male clients of female sex workers) may not be apparent in sub-national HIV incidence point estimates

28 Reflections of PEPFAR s HQ MC TWG Models projecting impact of other interventions, e.g., treatment scale-up, vulnerable to similar uncertainties around HIV incidence assumptions The DMPPT 2.0 can include treatment scale-up scenarios as sensitivity analyses The DMPPT 2.0 model results do not reflect important programmatic considerations and experiences Feasibility of various scale-up strategies should also be based upon: available resources: staff, space, and funding challenges mobilizing demand: some groups may be easier to reach broader benefits of VMMC platform with value for all ages: HTC, risk-reduction counseling, condoms, linkages to other programs

29 Reflections of PEPFAR s HQ MC TWG Countries may wish to consider a variety of scaleup percentage targets The 80% coverage target is not based upon a particular threshold for impact Countries may test lower or higher coverage targets in the model and even choose different coverage levels for different age groups Countries may wish to consider a variety of scaleup time-frames The 5-year scale-up target is not based upon a particular threshold for impact Countries may test shorter or longer time frames in the model

30 What about older men? ASM model looks at incidence across the entire population and incorporates the effects of intergenerational sex on transmission; it still finds the highest impact in younger age groups Men already in the older age groups who are HIV-negative may have a lower risk profile; the benefit to them would be less. Older men having intergenerational sex may be more likely to be HIV positive already and thus benefit less from VMMC ASM model may overestimate impact for older age groups as it assumes no change in risk behavior for older men Highest impact on incidence in the short term is to circumcise the highest incidence age group (20 29) When these men reach the age at which they will be having intergenerational sex, if they are circumcised already they will still have the partial protection of circumcision. No benefit to female partner in circumcising an HIV+ man

31 VMMC Communication: What makes it unique? March 7, 2014 Kim Seifert-Ahanda, MPH and Liz Gold, MA

32 Session Overview 1. Creating Demand for VMMC 2. The VMMC Continuum 3. What the Modeling Means for Communication 4. The Adolescent Client 5. Some Lessons Along the Way? Nice photo here?

33 Demand Creation The Challenge A very tough sell! Structural barriers Behavioral barriers Cultural barriers Reaching older men

34 Demand Creation How Do We Create Demand? Community Mobilization Mass & Social Media M-Health/IT School Campaigns Workplace mobilization VMMC Champions Peer education & support Engaging traditional leaders

35 Zimbabwe Campaign Demand Creation

36 The VMMC Communication Continuum 1.Demand Creation 2. Pre-op education 3. Individual HIV counseling (HCT) 4. Post-op counseling 5. Follow up visit counseling 37

37 The New Modeling What Does the Modeling Mean for Communication? Emphasize demand creation for younger ages Ensure education, counseling, materials are age-appropriate Parent/Guardian involvement (pre and post) Service provider assessment & training

38 VMMC and the Adolescent Client Segment clients Tailor information to segment s specific needs Incorporate broader adolescent health issues Offer special training for providers in adolescent counseling Build on lessons learned from adolescent HCT 39

39 Some Lessons Along the Way - Importance of tailoring approaches by age segment - Community engagement is critical - Importance of peers & influencing audiences - Partial protection message is challenging - Need to include messages based on motivators beyond HIV prevention - School campaigns succeed in generating demand among youth 40

40 THANK YOU!!!! 41

41 Thank you! Next Session Room Numbers: Listen Up: What African MSM Want in the Response to HIV 301 Please fill out an evaluation by going to this session s page on your mobile app OR by filling out a paper evaluation in the back of the room. A Practical Way to Maintain Skills Wherever Providers Deliver Babies 302 Establishing an Interactive Education System for Frontline Health Workers 307 Health Finance Food Court: What's Cooking? 308 Shaken, Not Stirred: The Intersection of Alcohol, Gender, and Health 310 A Vaccine's Journey: The Many Steps to Saving Lives 311 Postpartum Family Planning: Bridging Barriers and Motivating Change 405 Combating Counterfeit and Substandard Medicines 407 How Much Will It Cost to Reach Key Populations? 413 Antenatal Corticosteroid Jeopardy!: Exploring Maternal Interventions for Preterm Birth 414 Innovations to an M&E System Improves Data Quality and Speed of Malaria Prevention Program Results Betts Theatre Continental Business Planning for the Rest of Us Ballroom Grand Bringing Together Public and Private Sectors for Health Impact Ballroom