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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. As the VMMC technical lead, Dr. Njeuhmeli provided 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?). To answer these and other questions, Dr. Njeuhmeli and his team developed a model called the Decision Maker’s Program Planning Tool (DMPPT).
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.

How did the DMPPT 1.0 influence the initial scale-up of VMMC in priority countries? 

The modeling team did a desk review of the impacts and cost savings from scaling up VMMC in 14 countries. (By conducting a desk review, they used previously published data rather than collecting new data, to inform parameters used in the modeling). The advocacy objective was to support scale-up of VMMC in the 14 priority countries. Many stakeholders at the global level, and a few at the country level, informed the modeling exercise regarding questions of interest, data and assumptions. The desk review provided estimates of: 1) potential costs and cost savings; 2) the number of HIV infections that could be averted (prevented) by VMMC; 3) the percentage of HIV infections that could be averted by VMMC versus other interventions. Mainly as a result of those data, the advocacy objective was achieved. That is, countries and donors fully supported VMMC, WHO/UNAIDS launched a Joint Action Framework for scale-up of VMMC (2011) and commitments led to specific planning for rollout of VMMC.

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.

Key findings/messages that came out of the modeling, and how they supported commitments to scale up VMMC included:

  • Cost of the program, based on estimates of numbers of men that needed VMMC in each country enabled countries and donors to know specifically what commitments were needed
  • Cost savings from ART costs not needed as a result of HIV infections averted and enabled funders to see there would be a clear return on investment from VMMC
  • Number of HIV infections that would be averted as a result of VMMC scale-up made the importance of VMMC very clear to all stakeholders
  • Relative importance of VMMC compared with other HIV prevention interventions showed epidemic control would not be possible without scale-up of VMMC

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.

The DMPPT 2.0 was developed in 2013 to help VMMC program planners focus their VMMC programs primarily on the age groups and subnational regions where they would have the most impact and greatest cost-effectiveness. Because the modeling exercises were done in collaboration with country stakeholders, countries were empowered to make their own decisions about how the results would inform their implementation plans.