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

Overview

Journal PLoS One

Specialties General Medicine
Science

Date 2015 Dec 31

PMID 26716442

Citations 35

Authors

Susanne F Awad

Sema K Sgaier

Bushimbwa C Tambatamba

Yousra A Mohamoud

Fiona K Lau

Jason B Reed

Emmanuel Njeuhmeli

Laith J Abu-Raddad

Affiliations

Soon will be listed here.

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.

Citing Articles

Impact of a potential Chlamydia vaccine in the USA: mathematical modelling analyses.

Makhoul M, Ayoub H, Awad S, Chemaitelly H, Abu-Raddad L BMJ Public Health. 2025; 2(1):e000345.

PMID: 40018092 PMC: 11812766. DOI: 10.1136/bmjph-2023-000345.

Health technology assessment to support health benefits package design: a systematic review of economic evaluation evidence in Zambia.

Simangolwa W, Govender K, Mbonigaba J BMC Health Serv Res. 2024; 24(1):1426.

PMID: 39558344 PMC: 11572362. DOI: 10.1186/s12913-024-11914-z.

Evidence Gaps in Economic Evaluations of HIV Interventions Targeting Young People: A Systematic Review.

Zimmerman A, Fawole A, Shahid M, Dow D, Ogbuoji O J Adolesc Health. 2024; 75(5):709-724.

PMID: 39140926 PMC: 11490367. DOI: 10.1016/j.jadohealth.2024.06.013.

Understanding dynamics and overlapping epidemiologies of HIV, HSV-2, chlamydia, gonorrhea, and syphilis in sexual networks of men who have sex with men.

Omori R, Chemaitelly H, Abu-Raddad L Front Public Health. 2024; 12:1335693.

PMID: 38628844 PMC: 11018893. DOI: 10.3389/fpubh.2024.1335693.

Infectious Disease Modelling of HIV Prevention Interventions: A Systematic Review and Narrative Synthesis of Compartmental Models.

Giddings R, Indravudh P, Medley G, Bozzani F, Gafos M, Malhotra S Pharmacoeconomics. 2023; 41(6):693-707.

PMID: 36988896 PMC: 10163138. DOI: 10.1007/s40273-023-01260-z.

References

Liljeros F, Edling C, Amaral L, Stanley H, Aberg Y . The web of human sexual contacts. Nature. 2001; 411(6840):907-8. DOI: 10.1038/35082140. View

Gregson S, Nyamukapa C, Garnett G, Mason P, Zhuwau T, Carael M . Sexual mixing patterns and sex-differentials in teenage exposure to HIV infection in rural Zimbabwe. Lancet. 2002; 359(9321):1896-903. DOI: 10.1016/S0140-6736(02)08780-9. View

Barrat A, Barthelemy M, Pastor-Satorras R, Vespignani A . The architecture of complex weighted networks. Proc Natl Acad Sci U S A. 2004; 101(11):3747-52. PMC: 374315. DOI: 10.1073/pnas.0400087101. View

Handcock M, Jones J . Likelihood-based inference for stochastic models of sexual network formation. Theor Popul Biol. 2004; 65(4):413-22. DOI: 10.1016/j.tpb.2003.09.006. View

Cleland J, Boerma J, Carael M, Weir S . Monitoring sexual behaviour in general populations: a synthesis of lessons of the past decade. Sex Transm Infect. 2004; 80 Suppl 2:ii1-7. PMC: 1765850. DOI: 10.1136/sti.2004.013151. View

Auvert B, Taljaard D, Lagarde E, Sobngwi-Tambekou J, Sitta R, Puren A . Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med. 2005; 2(11):e298. PMC: 1262556. DOI: 10.1371/journal.pmed.0020298. View

Hogan D, Baltussen R, Hayashi C, Lauer J, Salomon J . Cost effectiveness analysis of strategies to combat HIV/AIDS in developing countries. BMJ. 2005; 331(7530):1431-7. PMC: 1315644. DOI: 10.1136/bmj.38643.368692.68. View

Williams B, Lloyd-Smith J, Gouws E, Hankins C, Getz W, Hargrove J . The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med. 2006; 3(7):e262. PMC: 1489185. DOI: 10.1371/journal.pmed.0030262. View

Abu-Raddad L, Patnaik P, Kublin J . Dual infection with HIV and malaria fuels the spread of both diseases in sub-Saharan Africa. Science. 2006; 314(5805):1603-6. DOI: 10.1126/science.1132338. View

10.

Bailey R, Moses S, Parker C, Agot K, Maclean I, Krieger J . Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007; 369(9562):643-56. DOI: 10.1016/S0140-6736(07)60312-2. View

11.

H Gray R, Kigozi G, Serwadda D, Makumbi F, Watya S, Nalugoda F . Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet. 2007; 369(9562):657-66. DOI: 10.1016/S0140-6736(07)60313-4. View

12.

Nagelkerke N, Moses S, de Vlas S, Bailey R . Modelling the public health impact of male circumcision for HIV prevention in high prevalence areas in Africa. BMC Infect Dis. 2007; 7:16. PMC: 1832203. DOI: 10.1186/1471-2334-7-16. View

13.

H Gray R, Li X, Kigozi G, Serwadda D, Nalugoda F, Watya S . The impact of male circumcision on HIV incidence and cost per infection prevented: a stochastic simulation model from Rakai, Uganda. AIDS. 2007; 21(7):845-50. DOI: 10.1097/QAD.0b013e3280187544. View

14.

Bansal S, Grenfell B, Meyers L . When individual behaviour matters: homogeneous and network models in epidemiology. J R Soc Interface. 2007; 4(16):879-91. PMC: 2394553. DOI: 10.1098/rsif.2007.1100. View

15.

Hamilton D, Handcock M, Morris M . Degree distributions in sexual networks: a framework for evaluating evidence. Sex Transm Dis. 2008; 35(1):30-40. PMC: 4370286. DOI: 10.1097/olq.0b013e3181453a84. View

16.

Hallett T, Singh K, Smith J, White R, Abu-Raddad L, Garnett G . Understanding the impact of male circumcision interventions on the spread of HIV in southern Africa. PLoS One. 2008; 3(5):e2212. PMC: 2387228. DOI: 10.1371/journal.pone.0002212. View

17.

Abu-Raddad L, Longini Jr I . No HIV stage is dominant in driving the HIV epidemic in sub-Saharan Africa. AIDS. 2008; 22(9):1055-61. DOI: 10.1097/QAD.0b013e3282f8af84. View

18.

White R, Glynn J, Orroth K, Freeman E, Bakker R, Weiss H . Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when?. AIDS. 2008; 22(14):1841-50. DOI: 10.1097/QAD.0b013e32830e0137. View

19.

J Wawer M, Makumbi F, Kigozi G, Serwadda D, Watya S, Nalugoda F . Circumcision in HIV-infected men and its effect on HIV transmission to female partners in Rakai, Uganda: a randomised controlled trial. Lancet. 2009; 374(9685):229-37. PMC: 2905212. DOI: 10.1016/S0140-6736(09)60998-3. View

20.

Weiss H, Hankins C, Dickson K . Male circumcision and risk of HIV infection in women: a systematic review and meta-analysis. Lancet Infect Dis. 2009; 9(11):669-77. DOI: 10.1016/S1473-3099(09)70235-X. View