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Topic 2: VMMC Modeling Case Study

The following case study describes how modeling influenced the scale-up of voluntary medical male circumcision (VMMC) for HIV prevention. You’ll hear from Dr. Emmanuel Njeuhmeli, the Senior Biomedical Prevention Advisor at the Office of HIV/AIDS at USAID for nine years, during which he and his team developed a model—DMPPT—to answer questions around VMMC. Dr. Njeuhmeli was the VMMC technical lead, providing support to PEPFAR programs in Eastern and Southern Africa for the introduction and acceleration of the scale-up of the VMMC program.

VMMC Modeling Case Study
In 2007, the World Health Organization (WHO) and UNAIDS issued recommendations for countries in Eastern and Southern Africa to introduce VMMC as part of the HIV prevention portfolio. The recommendations were informed by clinical trials that showed male circumcision was protective against HIV. However, countries were slow to scale up VMMC because of questions the studies didn’t answer (i.e., how much will it cost to introduce VMMC? What is the extra benefit of adding VMMC to existing efforts? How many men need to be circumcised?). Other studies likely couldn’t answer these questions either.
Click here to read the published article on the DMPPT model.

Click the play button to listen to the first interview with Dr. Njeuhmeli on the role of modeling in the scale-up of VMMC for HIV prevention.

Modeler: Dr. Emmanuel Njeuhmeli and his team created a model called the Decision Makers’ Program Planning Tool, or DMPPT. This tool can be used to answer questions about the impact of voluntary medical male circumcision on HIV incidence, and on the cost of expanding male circumcision for HIV prevention in Southern and Eastern Africa.


Modeler: Dr. Njeuhmeli, could you please explain how the DMPPT 1.0 influenced the initial scale-up of VMMC in priority countries?

Click the play button to listen to the second interview with Dr. Njeuhmeli on the role of modeling in the scale-up of VMMC for HIV prevention.

Modeler: Thanks, Dr. Njeuhmeli. It’s clear that the findings of the DMPPT provided data that were needed to advance the scale-up of VMMC. Could you say more about the key messages that came out of the modeling and how they supported these efforts?

One of the messages was the cost. We were able to estimate the volume of men that needed to be circumcised per country and in each country, per provinces or regions, and we were able to estimate how much that is going to cost. So that was then easy for donors and countries to understand what would be the level of resources that we are talking about and make commitment. We were also able to provide a clear message about the cost savings, which was estimated as savings of those who will have become HIV positive if they were not circumcised, the savings made by them not being on ARV. So that cost saving was estimated and the difference between the cost and the cost saving was extremely convincing for decision makers to say “here, this is a very good investment. We definitely need to invest that dollar because we see the return of investment that is very clear”. We were also able to estimate the number of infections averted, and that was a very powerful message. I remember that at that time it was estimated in some countries that we needed just to circumcise four men in order to avert one single HIV infection. When you bring down a message to a level that is so clear, everyone understands it. Whether they are scientific or not, the decision becomes very clear. And everyone was then on the same page about the importance of VMMC with the potential of averting new HIV infection in the future. We were also able to estimate how important VMMC is. vis-a-vis other prevention interventions. I remember that in Zimbabwe, for example, data was showing that it was impossible for the country to actually have to let people talk about the epidemic control, to actually have something close to epidemic control, without scaling up VMMC. So when the data and everyone agreed on a message like that, it’s very clear what the decision makers need to do—everyone understands that if we have 10 million dollars currently on HIV prevention, and if there’s one intervention that is actually critical for us to achieve our goal and objective in the next 15, 20 years, and that intervention is not being considered, you definitely need to re-prioritize. So then at that point, the de-prioritization discussion became something that was not dramatic at all. Resources were mobilized really overnight, because everyone was very happy of making those necessary decisions at all levels to mobilize resources to support VMMC as an intervention. So those are just some of the key messages that came from that modeling exercise and that was used at that time by stakeholders to make decisions.

As VMMC scale-up moved forward, the recommendation was for countries to provide services to men aged 15-49 years. However, data soon showed that the majority of those seeking VMMC services were boys aged 10-14 years. This knowledge produced new questions, like, “should VMMC policy state a minimum age? Why were 10–14-year-old boys accessing services? How might VMMC contribute to a reduction in HIV infections in the next 2-3 years if younger boys were getting circumcised but were not sexually active?”.

To answer these questions and others around the impact and cost-effectiveness of VMMC by age groups and sub-national geography, a new model—the DMPPT 2.0—was developed in 2013.

Click the play button to listen to Dr. Njeuhmeli discuss the role of the DMPPT 2.0.

Modeler: Dr. Njeuhmeli, how did the DMPPT 2.0 influence strategic planning and implementation decisions at the country-level?