20th International AIDS Conference - Melbourne, Australia


THPE345 - Poster Exhibition

Age, regional, and urban/rural considerations in refocusing the voluntary medical male circumcision for HIV prevention program in Malawi

K. Kripke1, Z. Mwandi2, E. Njeuhmeli3, J.B. Reed4, S.K. Sgaier5,6, J. Stover7, A. Nkhata8

1Health Policy Project, Futures Institute, Center for Economics and Costing, Glastonbury, United States, 2US Agency for International Development, Lilongwe, Malawi, 3US Agency for International Development, Washington, United States, 4Office of the US Global AIDS Coordinator, Washington, United States, 5Bill and Melinda Gates Foundation, Integrated Delivery, Global Development Program, Seattle, United States, 6University of Washington, Department of Global Health, Seattle, United States, 7Health Policy Project, Futures Institute, Center for Modeling, Planning and Policy Analysis, Glastonbury, United States, 8Malawi Ministry of Health, Lilongwe, Malawi

Background: In 2007, WHO recommended that voluntary medical male circumcision (VMMC) be scaled up in priority countries with high HIV prevalence and low male circumcision (MC) prevalence. UNAIDS estimated that 3.2 million males had undergone VMMC by the end of 2012. Implementation experience has raised questions about the need to refocus VMMC programs on specific subpopulations for the greatest epidemiological impact and programmatic effectiveness. As Malawi prepared its National Operational Plan for VMMC, it sought to examine impacts of targeting subpopulations by age and subnational region.
Methods: The USAID- and PEPFAR-funded Health Policy Project applied the new DMPPT 2.0 model to study the impact of scaling up VMMC to different target populations disaggregated by age group and geographical subregions of Malawi. National MC prevalence by age group from the 2010 DHS was scaled according to the MC prevalence for each district and then divided by 2 to adjust for over-reporting of circumcision. The VMMC unit cost of $100 was advised by in-country stakeholders based on implementation experience. The ART cost of $451 per patient-year was derived from cost analyses conducted as part of the UNAIDS Investment Case exercise.
Results: Targeting the 10-29 and 10-34 age groups would avert 75% and 87% of infections, respectively, compared to the current strategy targeting ages 15-49. Scaling up VMMC to 80% among the 10-34 year age group would be cost-saving compared with treatment costs averted in South Western and South Eastern Zones, and highly cost-effective according to WHO criteria. In the Northern and Central Western Zones, the program would be cost-effective but not cost-saving. When comparing urban versus rural areas in the country, targeting urban areas would be both highly cost-effective and cost-saving.
Conclusions: Based on the age-targeting analyses and programmatic experience, Malawi may decide to focus its next VMMC Operational Plan on ages 10-34. The program will continue focusing on urban centers such as Lilongwe and Blantyre, and likely focus future scale-up primarily in priority districts in the Southern Health Zones. Strategic focus of the VMMC program is particularly important because of competing needs for the understaffed health workforce in Malawi.

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