Comparison of VMMC client age groups to their representation in the general male population that is uncircumcised.

<p>Comparison of VMMC client age groups to their representation in the general male population that is uncircumcised.</p

Cumulative number and percentage of HIV infections averted between 2011 and 2025 by scaling up adult VMMC to reach 80% coverage in five years.

<p>This figure illustrates the significant impact that achieving 80% VMMC coverage of 15- to 49-year-old men would have on the epidemics in 13 countries in eastern and southern Africa. South Africa can avert the largest number of HIV infections (over 1 million between 2011 and 2025); Zimbabwe can avert the highest percentage of new HIV infections (almost 42%). More than 20% of new HIV infections would be averted between 2011 and 2025 in nine countries: Botswana, Lesotho, Malawi, Namibia, Rwanda, Swaziland, Uganda, Zambia, and Zimbabwe. Nyanza refers to Nyanza Province in Kenya: the data presented are only for Nyanza Province in Kenya, as this is the only province in Kenya with prevalence of male circumcision lower than 80% and is the province with the highest HIV prevalence compared to the national average.</p

Priority country-specific age groups by indicator of interest.

<p>Priority country-specific age groups by indicator of interest.</p

Achievement towards target of 80% coverage.

<p>This figure illustrates that most countries have had only limited success in bridging the gap between historical male circumcision levels and the 80% target. The one exception is Kenya, which has achieved more than 66% of its objective, primarily in Nyanza Province.</p

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<p>Totals reflect progress through 2012. Percentage figures represent the achieved proportion of the target of 80% coverage among males ages 15–49, but totals include circumcisions done for all age groups, regardless of the age-range target. Data obtained from WHO 2012 VMMC report <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001641#pmed.1001641-WHOAFRO1" target="_blank">[38]</a>.</p

Timeline and key milestones of the voluntary medical male circumcision program in 14 priority countries.

<p>6 million circumcisions listed in 2013 is an estimate by PEPFAR and the Bill & Melinda Gates Foundation. RCTs, randomized controlled trials; TWG, technical working group; TAG, technical advisory group; MOVE, Models for Optimizing the Volume and Efficiency of MC services.</p

Scale-up of voluntary medical male circumcision program and coverage in 14 priority countries, aggregate, 2008–2013.

<p>Number of circumcisions completed each year in millions. Source of 2008–2012 data is the WHO 2012 VMMC report <a href="http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001641#pmed.1001641-WHOAFRO1" target="_blank">[38]</a>. 2013 numbers have been estimated using data from PEPFAR and the Bill & Melinda Gates Foundation. *CAGR, compound annual growth rate, calculated based on the average proportional growth each year. CAGR (t₀,t_n)  =  (V(t_n)/V(t₀))^{1/(tn − to)} −1, where V(t₀) is the start value and V(t_n) is the finish value and t_n − t₀ is the number of years.</p

Annual cost ($US) with 90-90-90 and 90-90-75 ART scenarios, with and without scaling up VMMC.

<p>Cost shown is the annual combined cost of providing VMMC and ART.</p

Impact and Cost of Scaling Up Voluntary Medical Male Circumcision for HIV Prevention in the Context of the New 90-90-90 HIV Treatment Targets

<div><p>Background</p><p>The report of the Joint United Nations Programme on HIV/AIDS (UNAIDS) for World AIDS Day 2014 highlighted a Fast-Track Strategy that sets ambitious treatment and prevention targets to reduce global HIV incidence to manageable levels by 2020 and end the AIDS epidemic by 2030. The 90-90-90 treatment targets for 2020 call for 90% of people living with HIV to know their HIV status, 90% of people who know their status to receive treatment, and 90% of people on HIV treatment to be virally suppressed. This paper examines how scale-up of voluntary medical male circumcision (VMMC) services in four priority countries in sub-Saharan Africa could contribute to ending the AIDS epidemic by 2030 in the context of concerted efforts to close the treatment gap, and what the impact of VMMC scale-up would be if the 90-90-90 treatment targets were not completely met.</p><p>Methods</p><p>Using the Goals module of the Spectrum suite of models, this analysis modified ART (antiretroviral treatment) scale-up coverage from base scenarios to reflect the 90-90-90 treatment targets in four countries (Lesotho, Malawi, South Africa, and Uganda). In addition, a second scenario was created to reflect viral suppression levels of 75% instead of 90%, and a third scenario was created in which the 90-90-90 treatment targets are reached in women, with men reaching more moderate coverage levels. Regarding male circumcision (MC) coverage, the analysis examined both a scenario in which VMMCs were assumed to stop after 2015, and one in which MC coverage was scaled up to 90% by 2020 and maintained at 90% thereafter.</p><p>Results</p><p>Across all four countries, scaling up VMMC is projected to provide further HIV incidence reductions in addition to those achieved by reaching the 90-90-90 treatment targets. If viral suppression levels only reach 75%, scaling up VMMC leads to HIV incidence reduction to nearly the same levels as those achieved with 90-90-90 without VMMC scale-up. If only women reach the 90-90-90 targets, scaling up VMMC brings HIV incidence down to near the levels projected with 90-90-90 without VMMC scale-up. Regarding cost, scaling up VMMC increases the annual costs during the scale-up phase, but leads to lower annual costs after the MC coverage target is achieved.</p><p>Conclusions</p><p>The scenarios modeled in this paper show that the highly durable and effective male circumcision intervention increases epidemic impact levels over those of treatment-only strategies, including the case if universal levels of viral suppression in men and women are not achieved by 2020. In the context of 90-90-90, prioritizing continued successful scale-up of VMMC increases the possibility that future generations will be free not only of AIDS but also of HIV.</p></div

Predicted average and marginal cost of VMMC programs.

<p>Red square: Average cost. Blue diamond: Marginal cost.</p