Ireland United Kingdom Neth. Belarus Russia Germany Poland Bel. K a z a k h s t a n Lux. Czech Rep. Ukraine Slovakia Moldova Switz. Liech. Austria Hungary Slovenia Romania France Croatia Bosnia & Herz. Uzbekistan San Marino Serbia Andorra Mont. Georgia Corsica Kosovo Bulgaria Turkmenistan Portugal Italy Mac. Armenia Azores Spain Albania Azerbaijan Sardinia Balearic Greece Islands Turkey Sicily I r a n Madeira Malta Cyprus Syria Islands Crete Ireland Tunisia Lebanon Morocco United Kingdom Iraq Belarus Russia Israel Neth. Germany Poland Bel. Canary Islands Jordan K a z a k h s t a n Kuwait Lux. Czech Rep. Ukraine A l g e r i a Slovakia Moldova Switz. Liech. Austria Bahrain Western Sahara Hungary (Occupied by Morocco) L i b y a E g y p t Slovenia Romania France Croatia Qatar Bosnia & Herz. U. A. E. Uzbekistan San Marino Serbia Andorra Mont. Georgia Corsica Kosovo Bulgaria Turkmenistan Portugal Italy Mac. Armenia Azores Spain Albania Azerbaijan Mauritania Saudi Arabia Sardinia M a l i Balearic www.ploscollections.org/vmmc2011Greece Oman Islands Turkey Sicily I r a n Senegal Madeira Malta Cyprus Syria VoluntaryIslands Medical Male Circumcision forYe HIV m e n Prevention:Crete The Cost, Gambia Morocco Tunisia Lebanon Burkina Faso Impact, and Challenges of Accelerated Scale-Up in Southern and Iraq Israel Guinea-Bissau Canary Islands Jordan Benin Eastern Africa Kuwait Guinea Sierra Ghana Togo A l g e r i a Leone Cote d'Ivoire A UNAIDSWestern Sahara and PEPFAR Collection Bahrain (Occupied by Morocco) L i b y a E g y p t Qatar Liberia U. A. E. Equatorial Guinea Male CircumcisionMauritania Saudi Arabia Sao Tome & Principe M a l i Uganda Prevalence Oman N i g e r Rwanda 0%–9.9% C h a d Senegal Eritrea Ye m e n Gambia 10%–19.9% Burkina Faso Tanzania Dijbouti Guinea-Bissau 20%–29.9% Benin Guinea 30%–87%Sierra Ghana Togo Leone Cote d'Ivoire Liberia Malawi Zambia Equatorial Guinea Sao Tome &Mozambique Principe HIV Prevalence Uganda Zimbabwe Namibia 3%–9.9% Reunion Rwanda Botswana 10%–14.9% 15%–19.9% Tanzania Swaziland 20%–26% Lesotho South Africa Malawi Zambia Mozambique Zimbabwe Namibia Reunion Botswana Swaziland Lesotho South Africa Produced with support from the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR). The PLoS Medicine editors have sole editorial responsibility for the content of this collection. The views expressed in this collection are those of the authors and do not necessarily reflect the official policy or position of the U.S. Government and UNAIDS. Image credit: PEPFAR Male Circumcision Technical Working Group Voluntary Medical Male Circumcision for HIV Prevention The Cost, Impact, and Challenges of Accelerated Scale-Up in Southern and Eastern Africa November 2011 The views expressed in this publication do not necessarily reflect the views the U.S. Government. Table of Contents Introduction to the UNAIDS and PEPFAR Collection……………………………………..…….… 1 Prepared Talking Points on the Collection..……………..…….….….….….….….….….….….….… 3 Voluntary Medical Male Circumcision: An Introduction to the Cost, Impact, and Challenges of Accelerated Scaling Up……………………………………………………………… 9 Catherine Hankins, Steven Forsythe, and Emmanuel Njeuhmeli Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa…………………………… 15 Emmanuel Njeuhmeli, Steven Forsythe, Jason Reed, Marjorie Opuni, Lori Bollinger, Nathan Heard, Delivette Castor, John Stover, Timothy Farley, Veena Menon, and Catherine Hankins Voluntary Medical Male Circumcision: A Framework Analysis of Policy and Program Implementation in Eastern and Southern Africa…………………………………………. 31 Kim E. Dickson, Nhan T. Tran, Julia L. Samuelson, Emmanuel Njeuhmeli, Peter Cherutich, Bruce Dick, Tim Farley, Caroline Ryan, and Catherine A. Hankins Voluntary Medical Male Circumcision: A Cross-Sectional Study Comparing Circumcision Self-Report and Physical Examination Findings in Lesotho…………………………… 45 Anne Goldzier Thomas, Bonnie Robin Tran, Marcus Cranston, Malerato Cecilia Brown, Rajiv Kumar, and Matsotetsi Tlelai Voluntary Medical Male Circumcision: Logistics, Commodities, and Waste Management Requirements for Scale-Up of Services………………………………………………. 51 Dianna Edgil, Petra Stankard, Steven Forsythe, Dino Rech, Kristin Chrouser, Tigistu Adamu, Sameer Sakallah, Anne Goldzier Thomas, Jennifer Albertini, David Stanton, Kim Eva Dickson, and Emmanuel Njeuhmeli Voluntary Medical Male Circumcision: A Qualitative Study Exploring the Challenges of Costing Demand Creation in Eastern and Southern Africa…………………………………………. 61 Jane T. Bertrand, Emmanuel Njeuhmeli, Steven Forsythe, Sarah K. Mattison, Hally Mahler, and Catherine A. Hankins Voluntary Medical Male Circumcision: Strategies for Meeting the Human Resource Needs of Scale-Up in Southern and Eastern Africa………………………………………………… 69 Kelly Curran, Emmanuel Njeuhmeli, Andrew Mirelman, Kim Dickson, Tigistu Adamu, Peter Cherutich, Hally Mahler, Bennett Fimbo, Thembisile Khumalo Mavuso, Jennifer Albertini, Laura Fitzgerald, Naomi Bock, Jason Reed, Delivette Castor, and David Stanton Voluntary Medical Male Circumcision: Translating Research into the Rapid Expansion of Services in Kenya, 2008–2011…………………………………………………………………… 77 Zebedee Mwandi, Anne Murphy, Jason Reed, Kipruto Chesang, Emmanuel Njeuhmeli, Kawango Agot, Emma Llewellyn, Charles Kirui, Kennedy Serrem, Isaac Abuya, Mores Loolpapit, Regina Mbayaki, Ndungu Kiriro, Peter Cherutich, Nicholas Muraguri, John Motoku, Jack Kioko, Nancy Knight, and Naomi Bock Voluntary Medical Male Circumcision: Matching Demand and Supply with Quality and Efficiency in a High-Volume Campaign in Iringa Region, Tanzania…………………… 83 Hally R. Mahler, Baldwin Kileo, Kelly Curran, Marya Plotkin,Tigistu Adamu, Augustino Hellar, Sifuni Koshuma, Simeon Nyabenda, Michael Machaku, Mainza Lukobo- Durrell, Delivette Castor, Emmanuel Njeuhmeli, and Bennett Fimbo i Introduction to the UNAIDS and PEPFAR Collection This collection of nine new articles—published in PLoS Medicine and PLoS ONE, in conjunction with the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United States President’s Emergency Plan for AIDS Relief (PEPFAR)—highlights how scaling up voluntary medical male circumcision (VMMC) for HIV prevention in eastern and southern Africa can help prevent HIV not only at the individual level, but also at the community and population levels. Scaling up can also lead to substantial cost savings for countries due to averted treatment and care costs. The first article by Catherine Hankins of UNAIDS, Steven Forsythe of The Futures Institute, and Emmanuel Njeuhmeli of PEPFAR/USAID, offers an introduction to the cost, impact, and challenges of accelerated scaling up and lays out the rationale for the series. This article, as well those that follow, signposts the way forward to accelerate the scaling up of VMMC service delivery safely and efficiently to reap individual-and population-level benefits. The remaining eight papers also focus on the various factors that go into effective program expansion of VMMC, including data for decision making, policy and programmatic frameworks, logistics, demand creation, human resources, and translating research into services. The cost savings are clear: an initial investment of US$1.5 billion between 2011 and 2015 to achieve 80% coverage of VMMC services in 14 priority countries in southern and eastern Africa and thereafter US$0.5 billion between 2016 to 2025 to maintain that coverage of 80% would result in net savings of US$16.5 billion between 2011 and 2025. However, as the articles in the collection show, strong political leadership, country ownership, and stakeholder engagement, along with effective demand creation, community mobilisation, and human resource deployment are essential to effectively expanding and maintaining VMMC programs. The views expressed in this collection are those of the authors and do not necessarily reflect the official policy or position of the U.S. Government and UNAIDS. These articles were produced with support from UNAIDS and PEPFAR. The PLoS Medicine editors have sole editorial responsibility for the content of this collection. The series was published on November 29, 2011 in PLoS Medicine and PLoS ONE. All articles can be found online via the Public Library of Science at: http://www.ploscollections.org/VMMC2011. 1 2 Prepared Talking Points on the Collection Voluntary Medical Male Circumcision: estimated the impact and cost of scaling up An Introduction to the Cost, Impact, and adult VMMC using updated, country-specific data. Challenges of Accelerated Scaling Up • Given its demonstrated acceptability, low cost, • The Male Circumcision: Decision Makers’ and potential impact when provided by well- Program Planning Tool (DMPPT) was used by trained, well-equipped providers in hygienic the authors to model the impact and cost of settings, voluntary medical male circumcision scaling up adult VMMC in Botswana, Lesotho, (VMMC) should be scaled up rapidly in high Malawi, Mozambique, Namibia, Rwanda, South HIV prevalence settings to reap both individual- Africa, Swaziland, Tanzania, Uganda, Zambia, and population-level HIV prevention benefits. Zimbabwe, and Nyanza province in Kenya. Epidemiologic and demographic data from • The opportunity costs of not taking action recent household surveys for each country was now are too high to ignore. VMMC scale up is used. cost saving and creates fiscal space in the future that otherwise would