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Investigating Voluntary Medical Male Circumcision Program Efficiency Gains through Subpopulation Prioritization: Insights from Application to Zambia.

Awad SF, Sgaier SK, Tambatamba BC, Mohamoud YA, Lau FK, Reed JB, Njeuhmeli E, Abu-Raddad LJ - PLoS ONE (2015)

Bottom Line: Through geographic prioritization, effectiveness ranged from 9-12.Prioritizing Lusaka achieved the highest effectiveness.Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.

View Article: PubMed Central - PubMed

Affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.

ABSTRACT

Background: Countries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia.

Methods and findings: A population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs (age-structured mathematical (ASM) model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15-49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20-24 age-group) to 36 (45-49 age-group); cost-effectiveness ranged from $888 (20-24 age-group) to $3,300 (45-49 age-group). Circumcising 10-14, 15-19, or 20-24 year old achieved the largest incidence rate reduction; prioritizing 15-24, 15-29, or 15-34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9-12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs.

Conclusion: Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.

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Related in: MedlinePlus

Program efficiency and policy domains of age-group prioritization in the voluntary medical male circumcision (VMMC) program.A) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted (magnitude of impact) for each age-group targeted intervention. The blue line describes the expansion of the program with minimal diminishing of returns and the red line describes the expansion of the program with considerable diminishing of returns. B) Frontier-policy plot classifying the different policy domains based on the theme of maximizing program efficiency (maximizing gain while minimizing cost). Circle size represents the magnitude of the impact. C) Frontier-policy plot delineating the different policy domains based on the theme of maximizing the total impact of the VMMC program. Circle size here represents the total number of VMMCs needed relative to the baseline VMMC intervention scenario. In both B and C, the orange circles represent the age brackets that fall within the optimal policy domain and the blue circle represents the baseline VMMC intervention scenario.
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pone.0145729.g004: Program efficiency and policy domains of age-group prioritization in the voluntary medical male circumcision (VMMC) program.A) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted (magnitude of impact) for each age-group targeted intervention. The blue line describes the expansion of the program with minimal diminishing of returns and the red line describes the expansion of the program with considerable diminishing of returns. B) Frontier-policy plot classifying the different policy domains based on the theme of maximizing program efficiency (maximizing gain while minimizing cost). Circle size represents the magnitude of the impact. C) Frontier-policy plot delineating the different policy domains based on the theme of maximizing the total impact of the VMMC program. Circle size here represents the total number of VMMCs needed relative to the baseline VMMC intervention scenario. In both B and C, the orange circles represent the age brackets that fall within the optimal policy domain and the blue circle represents the baseline VMMC intervention scenario.

Mentions: The VMMC program efficiency of age-group prioritization is illustrated in Fig 4. The expansion path in Fig 4A represents the incremental change in total cost of the VMMC program relative to the incremental change in total number of HIV infections averted for each age-group targeted intervention. It starts with targeting the age group that has the highest effectiveness, which is the 20–24 year old (Fig 3A). The program then expanded by adding the other age groups based on a hierarchy of decreasing effectiveness. Though the number of infections averted increased with each age-group expansion, the total cost also increased and at a higher rate. This was especially true as the expansion reached the population older than 35 years of age, or younger than 15 years of age. Here, the diminishing returns of the expansion became evident, highlighting the decline in program efficiency. Fig 4B provides an alternative view of program efficiency through the Gain/Pain index. This measure was >1 only when male populations 15–19, 20–24, 15–24, 15–29, and 15–34 years of age were targeted, affirming the result that this age range brackets the populations with the highest program efficiency. This measure was <1 when targeting male populations 10–14, 25–29, 30–34, 35–39, 40–44, 45–49, 10–24, 10–29, 10–34, and 10–49 years of age.


Investigating Voluntary Medical Male Circumcision Program Efficiency Gains through Subpopulation Prioritization: Insights from Application to Zambia.

Awad SF, Sgaier SK, Tambatamba BC, Mohamoud YA, Lau FK, Reed JB, Njeuhmeli E, Abu-Raddad LJ - PLoS ONE (2015)

Program efficiency and policy domains of age-group prioritization in the voluntary medical male circumcision (VMMC) program.A) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted (magnitude of impact) for each age-group targeted intervention. The blue line describes the expansion of the program with minimal diminishing of returns and the red line describes the expansion of the program with considerable diminishing of returns. B) Frontier-policy plot classifying the different policy domains based on the theme of maximizing program efficiency (maximizing gain while minimizing cost). Circle size represents the magnitude of the impact. C) Frontier-policy plot delineating the different policy domains based on the theme of maximizing the total impact of the VMMC program. Circle size here represents the total number of VMMCs needed relative to the baseline VMMC intervention scenario. In both B and C, the orange circles represent the age brackets that fall within the optimal policy domain and the blue circle represents the baseline VMMC intervention scenario.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4696770&req=5

pone.0145729.g004: Program efficiency and policy domains of age-group prioritization in the voluntary medical male circumcision (VMMC) program.A) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted (magnitude of impact) for each age-group targeted intervention. The blue line describes the expansion of the program with minimal diminishing of returns and the red line describes the expansion of the program with considerable diminishing of returns. B) Frontier-policy plot classifying the different policy domains based on the theme of maximizing program efficiency (maximizing gain while minimizing cost). Circle size represents the magnitude of the impact. C) Frontier-policy plot delineating the different policy domains based on the theme of maximizing the total impact of the VMMC program. Circle size here represents the total number of VMMCs needed relative to the baseline VMMC intervention scenario. In both B and C, the orange circles represent the age brackets that fall within the optimal policy domain and the blue circle represents the baseline VMMC intervention scenario.
Mentions: The VMMC program efficiency of age-group prioritization is illustrated in Fig 4. The expansion path in Fig 4A represents the incremental change in total cost of the VMMC program relative to the incremental change in total number of HIV infections averted for each age-group targeted intervention. It starts with targeting the age group that has the highest effectiveness, which is the 20–24 year old (Fig 3A). The program then expanded by adding the other age groups based on a hierarchy of decreasing effectiveness. Though the number of infections averted increased with each age-group expansion, the total cost also increased and at a higher rate. This was especially true as the expansion reached the population older than 35 years of age, or younger than 15 years of age. Here, the diminishing returns of the expansion became evident, highlighting the decline in program efficiency. Fig 4B provides an alternative view of program efficiency through the Gain/Pain index. This measure was >1 only when male populations 15–19, 20–24, 15–24, 15–29, and 15–34 years of age were targeted, affirming the result that this age range brackets the populations with the highest program efficiency. This measure was <1 when targeting male populations 10–14, 25–29, 30–34, 35–39, 40–44, 45–49, 10–24, 10–29, 10–34, and 10–49 years of age.

Bottom Line: Through geographic prioritization, effectiveness ranged from 9-12.Prioritizing Lusaka achieved the highest effectiveness.Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.

View Article: PubMed Central - PubMed

Affiliation: Infectious Disease Epidemiology Group, Weill Cornell Medical College in Qatar, Cornell University, Qatar Foundation, Education City, Doha, Qatar.

ABSTRACT

Background: Countries in sub-Saharan Africa are scaling-up voluntary male medical circumcision (VMMC) as an HIV intervention. Emerging challenges in these programs call for increased focus on program efficiency (optimizing program impact while minimizing cost). A novel analytic approach was developed to determine how subpopulation prioritization can increase program efficiency using an illustrative application for Zambia.

Methods and findings: A population-level mathematical model was constructed describing the heterosexual HIV epidemic and impact of VMMC programs (age-structured mathematical (ASM) model). The model stratified the population according to sex, circumcision status, age group, sexual-risk behavior, HIV status, and stage of infection. A three-level conceptual framework was also developed to determine maximum epidemic impact and program efficiency through subpopulation prioritization, based on age, geography, and risk profile. In the baseline scenario, achieving 80% VMMC coverage by 2017 among males 15-49 year old, 12 VMMCs were needed per HIV infection averted (effectiveness). The cost per infection averted (cost-effectiveness) was USD $1,089 and 306,000 infections were averted. Through age-group prioritization, effectiveness ranged from 11 (20-24 age-group) to 36 (45-49 age-group); cost-effectiveness ranged from $888 (20-24 age-group) to $3,300 (45-49 age-group). Circumcising 10-14, 15-19, or 20-24 year old achieved the largest incidence rate reduction; prioritizing 15-24, 15-29, or 15-34 year old achieved the greatest program efficiency. Through geographic prioritization, effectiveness ranged from 9-12. Prioritizing Lusaka achieved the highest effectiveness. Through risk-group prioritization, prioritizing the highest risk group achieved the highest effectiveness, with only one VMMC needed per infection averted; the lowest risk group required 80 times more VMMCs.

Conclusion: Epidemic impact and efficiency of VMMC programs can be improved by prioritizing young males (sexually active or just before sexual debut), geographic areas with higher HIV prevalence than the national, and high sexual-risk groups.

Show MeSH
Related in: MedlinePlus