Background: In 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS (UNAIDS) identified 14 priority countries across eastern and southern Africa for scaling up voluntary medical male circumcision (VMMC) services. Several years into this scale-up effort, we reflect on progress made thus far.
Methods: Using the Decision-Makers'' Program Planning Tool (DMPPT) 2.1, we assessed the age-specific impact, cost-effectiveness, and coverage attributable to circumcisions performed through end 2014. The analysis also compared impact of actual progress to that of achieving 80% coverage among men ages 15-49 in 12 VMMC priority countries and Nyanza Province, Kenya. The models were populated with age-disaggregated VMMC service statistics, and with population, mortality, and HIV incidence and prevalence projections exported from country-specific Spectrum/Goals files, assuming achievement in each country of the new 90-90-90 treatment targets.
Results: Over 9 million VMMCs had been conducted through 2014: 43% of the estimated 20.9 million VMMCs required to reach 80% coverage by end 2015. Assuming each country reaches the 90-90-90 HIV treatment targets, the modelling analysis projected that VMMCs conducted through 2014 will avert a total of 240,000 infections by 2025, compared to 1.1 million if each country had reached 80% coverage by 2015. The median estimated cost per HIV infection averted was $4,400. Nyanza province in Kenya, the 11 priority regions in Tanzania, and Uganda have reached or are approaching MC coverage targets among males ages 15-24, while coverage in other age groups is lower. Across all countries modelled, over 50% of the projected HIV infections averted were attributable to circumcising the 10- to 19-year-olds.
Conclusions: The priority countries have made considerable progress in VMMC scale-up, and VMMC remains a cost-effective strategy for epidemic impact, even assuming near-universal HIV diagnosis, treatment coverage, and viral suppression. Examining circumcision coverage by 5-year age groups will provide countries with better insights into the progress of their VMMC programs and help them to make more informed decisions about next steps.