Introducing Early Infant Male Circumcision (EIMC): DMPPT 2.0 Modeling January 28, 2015 Photo by Sterling Riber/MFDI for Jhpiego/Tanzania Emmanuel Njeuhmeli Katharine Kripke John Stover
Hypothetical Historical Impact of EIMC What if South Africa had 80% MC prevalence from the beginning of the HIV epidemic?
What if South Africa had 80% MC prevalence from the beginning of the HIV epidemic? Millions 6 5 4 3 2 1 0 1990 1992 Number of People Living with HIV 1994 1996 1998 2000 2002 2004 2006 2008 2010 baseline MC prevalence 80% 2012! Analyze the HIV epidemic using the South Africa Goals model! Baseline scenario:! MC prevalence as recorded in National Communication Surveys 2009 and 2012! 80% scenario! MC prevalence 80% for all years
EIMC Impact on HIV Incidence
South Africa: Incidence Reductions in the Population by Age of Client 1 HIV incidence relative to no MC scale-up 0.9 0.8 0.7 0.6 EIMC 10 14 15 19 20 24 25 29 30 34 35 39 0.5 2013 2018 2023 2028 2033 2038 2043 2048 Year
How does adding EIMC affect the program? What will be the cost and impact of introducing EIMC into an existing adult and adolescent VMMC program?
Three Scenarios: South Africa Scale up to 80% coverage among 10 34-year-olds Scale up to 80% coverage among 10 34-year-olds + 80%EIMC Scale up to 80% coverage among 10 34-year-olds + 40%EIMC
EIMC Unit Cost! There is no good understanding of the unit cost of EIMC! No robust data in literature mainly desk analyses rather than primary costing studies! Only when the program is implemented will we gain understanding! Drivers of adult/adolescent VMMC are well understood! Key drivers: human resources (HR), commodities, supply chain management! HR costs and commodities costs are anticipated to be substantially less for EIMC! Adult program is often a vertical program while EIMC will be an integrated program! Unit cost of EIMC may be 50% that of adult/adolescent VMMC! Conducted sensitivity analysis setting EIMC cost at 25%, 50%, 80%, 100% of adult/adolescent VMMC, with 50% as baseline
Adding EIMC in South Africa Increases Impact by 3%, Decreases Cost by 9% (2013 2050) EIMC cost 50% of adult VMMC unit cost South Africa 10 34 10 34+ EIMC *not discounted; **both HIV infections averted and costs discounted % difference Infections averted* 1.8 million 1.8 million 3% # MCs 15 million 20 million 29% Total cost* $1.9 billion $1.7 billion -9% % Infections averted* 44% 45% VMMC per infection averted* 9 11 Cost per infection averted** $2,034 $1,959-4%! 2013 2050! Scale up to 80% 2013 2018; maintain at 80% through 2050! Fixed-cost VMMC by age! No replacement of baseline MCs! Discount rate 3%
Comparison Across Countries % change when adding EIMC to a VMMC strategy targeted to clients age 10 34 EIMC cost 50% of adult VMMC unit cost % change when adding EIMC Infections averted* Malawi South Africa Swaziland Tanzania Uganda 1% 3% 3% 4% 2% # MCs 45% 29% 24% 58% 46% Total cost* -6% -9% -12% 4% -5% Cost per infection averted** 0% -4% -5% 7% 1%! 2013 2050! Scale up to 80% 2013 2018; maintain at 80% through 2050! Fixed-cost VMMC by age! Discount rate 3% *not discounted; **both HIV infections averted and costs discounted
Adding EIMC in South Africa Increases Impact by 3%, Increases Cost by 29% (2013 2050) EIMC cost 100% of adult VMMC unit cost South Africa 10-34 10-34+ EIMC *not discounted; **both HIV infections averted and costs discounted % difference Infections averted* 1.8 million 1.8 million 3% # MCs 15 million 20 million 29% Total cost* $1.9 billion $2.6 billion 29% % Infections averted* 44% 45% VMMC per infection averted* 9 11 Cost per infection averted** $2,034 $2,689 28%! 2013 2050! Scale up to 80% 2013 2018; maintain at 80% through 2050! Fixed-cost VMMC by age! No replacement of baseline MCs! Discount rate 3%
Adding EIMC in South Africa Increases Impact by 3%, Increases Cost by 15% (2013 2050) EIMC cost 80% of adult VMMC unit cost South Africa 10-34 10-34+ EIMC % difference Infections averted* 1.8 million 1.8 million 3% # MCs 15 million 20 million 29% Total cost* $1.9 billion $2.2 billion 15% % Infections averted* 44% 45% VMMC per infection averted* 9 11 Cost per infection averted** $2,034 $2,397 16%! 2013 2050! Scale up to 80% 2013 2018; maintain at 80% through 2050! Fixed-cost VMMC by age! No replacement of baseline MCs! Discount rate 3% *not discounted; **both HIV infections averted and costs discounted
Adding EIMC in South Africa Increases Impact by 3%, Decreases Cost by 36% (2013 2050) EIMC cost 25% of adult VMMC unit cost South Africa 10-34 10-34+ EIMC % difference Infections averted* 1.8 million 1.8 million 3% # MCs 15 million 20 million 29% Total cost* $1.9 billion $1.3 billion -36% % Infections averted* 44% 45% VMMC per infection averted* 9 11 Cost per infection averted** $2,034 $1,595-24%! 2013 2050! Scale up to 80% 2013 2018; maintain at 80% through 2050! Fixed-cost VMMC by age! No replacement of baseline MCs! Discount rate 3% *not discounted; **both HIV infections averted and costs discounted
At what cost does the costeffectiveness of EIMC equal that of adolescent VMMC?
Lifetime Cost-effectiveness of Neonatal vs. Adolescent MC! Scenario: An infant and a 15-year-old are circumcised at the same time; impact calculated over the lifetime of each! Cost-effectiveness is a function of! Mortality! Discount rate (infections averted are discounted)! Baseline MC prevalence among adolescents
Cost Ratio at which Lifetime Cost-effectiveness is Equal for EIMC and Adolescent VMMC Country Unit cost of EIMC as a percentage of adolescent VMMC unit cost Baseline MC among 15 19-y.o. Discount rate 0% 3% 5% 7% 10% Malawi 11% 82% 53% 39% 30% 20% South Africa 31% 65% 42% 31% 23% 15% Swaziland 4% 86% 55% 41% 31% 21% Tanzania 40% 53% 34% 26% 19% 13% Uganda 22% 69% 44% 33% 25% 16%
Broader Context! Cost-effectiveness is only one consideration for countries in determining whether/when to introduce EIMC! Some other considerations! Individual health Other benefits of EIMC Rate of adverse events! Public health! Program implementation considerations Sustainability of program Required human resources Integration into existing health system! Cultural considerations, acceptability! Human rights
Conclusions (1)! If South Africa had 80% MC prevalence from the beginning of the epidemic, 1 million fewer people would be living with HIV, and the adult HIV prevalence would be around 2%.! Introduction of EIMC will determine the age of the client necessary for sustaining the program in the long term.! Without EIMC, the sustainability phase will focus on 10 14-year-olds! With EIMC, the sustainability phase will focus on neonates! It is more likely to have a mixed sustainability phase with adolescents and neonates
Conclusions (2)! Adding EIMC slightly increases the impact of MC, but depending on the demography of the country, it substantially increases the number of circumcisions that need to be performed. However, in most cases it decreases the total cost of the program if the cost of EIMC is 50% that of adult/adolescent VMMC.! Cost and cost-effectiveness of introducing EIMC depend on:! The relative cost of EIMC vs. adult/adolescent VMMC! Baseline MC prevalence in the country! The discount rate used
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