Background: Voluntary medical male circumcision (VMMC) is an effective HIV prevention strategy for males. Since 2007, the President´s Emergency Plan for AIDS Relief has supported VMMC programs in 14 priority countries in Africa. Today several of these countries are transitioning to program sustainability and maintaining high levels of male circumcision in the population. Alternative strategies being considered: circumcising adolescents over the long term, integrating early infant male circumcision (EIMC) into existing programs, or some combination of the two.
Methods: The paper uses the Decision Makers Program Planning Tool (DMPPT) 2.0 model to assess the cost and impact of VMMC sustainability strategies in multiple countries, particularly in Zimbabwe. The model was populated with national estimates of population, mortality, and HIV prevalence and incidence using the Spectrum/Goals model and the Zimbabwe Demographic and Health Survey 2010-2011. Various scenarios were analyzed to 2051. Additional sensitivity analyses examined the effects of different timing of introducing and scaling up EIMC, and of different discount and baseline MC prevalence rates.
Results: Adopting a strategy to introduce EIMC immediately, or in a phased approach increases the total number of circumcisions needing to be performed, but will not substantially decrease HIV incidence. It may, however, result in cost savings, depending on the ratio of cost of EIMC vs. cost of adolescent VMMC. This timing of the introduction of EIMC, and the duration of scale-up, whether over five or ten years, had only a marginal impact on the number of infections averted, the cumulative cost of the program, and on the number of VMMCs required to avert a single HIV infection.
Conclusions: Introducing EIMC into existing VMMC programs provides little or no additional reduction in HIV incidence, and is being considered as part of sustainability plans because of implementation and safety considerations. Because the relative cost of EIMC compared to adolescent VMMC is still unknown, the overall cost effectiveness of introducing EIMC will depend on findings from future costing studies. But if the cost is 50% or less than the cost of adolescent VMMC, then the introduction of EIMC for sustainability of the VMMC program will be cost saving for most countries.

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