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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

Projected outcomes of geographic and risk-group prioritization.A) Number of voluntary medical male circumcisions (VMMCs) needed to avert one HIV infection (effectiveness) by 2025 through geographic prioritization. B) 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 geographic targeted intervention. C) Number of VMMCs needed to avert one HIV infection by 2025 through risk-group prioritization. D) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted for each risk-group targeted intervention. In both B and D, 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.
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pone.0145729.g005: Projected outcomes of geographic and risk-group prioritization.A) Number of voluntary medical male circumcisions (VMMCs) needed to avert one HIV infection (effectiveness) by 2025 through geographic prioritization. B) 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 geographic targeted intervention. C) Number of VMMCs needed to avert one HIV infection by 2025 through risk-group prioritization. D) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted for each risk-group targeted intervention. In both B and D, 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.

Mentions: In the intermediate term, the effectiveness of geographic prioritization ranged from 9 to12 VMMCs per HIV infection averted (Fig 5A). The highest effectiveness was achieved by targeting Lusaka; the province with the highest HIV prevalence in Zambia. The expansion path curve showed the incremental change in total cost of VMMC program relative to the incremental change in total number of HIV infections averted for each geographic area targeted (Fig 5B). The curve was largely linear, with the addition of provinces in a hierarchy of lower HIV prevalence up to provinces whose HIV prevalence was similar to that of Zambia as a whole. Inclusion of provinces with lower HIV prevalence than the national (Eastern, North-Western, and Northern) was reflected as nonlinear growth in total program cost versus total impact, indicating diminishing returns. S4 Table summarizes the quantitative results and implications of the different targeting schemes that served as input to generate the program efficiency assessment for the geographic prioritization.


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)

Projected outcomes of geographic and risk-group prioritization.A) Number of voluntary medical male circumcisions (VMMCs) needed to avert one HIV infection (effectiveness) by 2025 through geographic prioritization. B) 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 geographic targeted intervention. C) Number of VMMCs needed to avert one HIV infection by 2025 through risk-group prioritization. D) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted for each risk-group targeted intervention. In both B and D, 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.
© Copyright Policy
Related In: Results  -  Collection

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

pone.0145729.g005: Projected outcomes of geographic and risk-group prioritization.A) Number of voluntary medical male circumcisions (VMMCs) needed to avert one HIV infection (effectiveness) by 2025 through geographic prioritization. B) 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 geographic targeted intervention. C) Number of VMMCs needed to avert one HIV infection by 2025 through risk-group prioritization. D) Expansion path curve showing the incremental increase in total cost of the VMMC program relative to total number of HIV infections averted for each risk-group targeted intervention. In both B and D, 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.
Mentions: In the intermediate term, the effectiveness of geographic prioritization ranged from 9 to12 VMMCs per HIV infection averted (Fig 5A). The highest effectiveness was achieved by targeting Lusaka; the province with the highest HIV prevalence in Zambia. The expansion path curve showed the incremental change in total cost of VMMC program relative to the incremental change in total number of HIV infections averted for each geographic area targeted (Fig 5B). The curve was largely linear, with the addition of provinces in a hierarchy of lower HIV prevalence up to provinces whose HIV prevalence was similar to that of Zambia as a whole. Inclusion of provinces with lower HIV prevalence than the national (Eastern, North-Western, and Northern) was reflected as nonlinear growth in total program cost versus total impact, indicating diminishing returns. S4 Table summarizes the quantitative results and implications of the different targeting schemes that served as input to generate the program efficiency assessment for the geographic prioritization.

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