VMMC LANDSCAPE IN EASTERN AND SOUTHERN AFRICA: PAST, …regist2.virology-education.com/2016/10INTEREST/45_Mwandi.pdf · 2016-05-26 · 6 MODELING FOR DECISION MAKING •In 2011, the

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VMMC LANDSCAPE IN EASTERN AND SOUTHERN

AFRICA: PAST, PRESENT, FUTURE

PRESENTED BY ZEBEDEE MWANDI, USAID

MAY 2016

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INTEREST WORKSHOP 2016

• Where did we come from?

– Evidence to action

• What progress have we made?

– Progress toward targets and

impact

– Challenges along the way

– Lessons learned

• Where are we going?

PRESENTATION

OVERVIEW

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WHERE DID WE COME

FROM?

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SCIENTIFIC EVIDENCE

• Biological plausibility: Inner surface of the foreskin highly vulnerable to HIV infection [1]

• Over 50 ecological and observational studies: lack of male circumcision associated with higher HIV in men [2]

• Three RCTs in Kenya, Uganda, South Africa: 60% protection [3,4,5]

• Longer-term (4–5 years) follow-up of the Kenya and Uganda RCT participants: protective effect sustained/increased [6]

• Community-level impact evaluation in South Africa (Orange Farm) demonstrated 76% incidence reduction [7]

MAY 2016 INTEREST WORKSHOP 2016

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UNAIDS-WHO RECOMMENDATIONS 2007FOR MALE CIRCUMCISION PRIORITY COUNTRIES


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MODELING FOR DECISION MAKING

• In 2011, the DMPPT was used to model the impact and cost of VMMC

scale-up in 14 high-priority countries in Eastern and Southern Africa with

high HIV incidence and low male circumcision (MC) coverage

• The model estimated that 20.3 million circumcisions would be required

to increase circumcision prevalence from 2011 baseline levels to 80% by

the end of 2015 in men ages 15–49 years

• The model predicted that if 80% male circumcision prevalence was then

maintained through 2025 (requiring an additional 8.4 million circumcisions

over 10 years), a total of 3.36 million HIV infections would be

averted over the period 2011–2025


UNAIDS-WHO JOINT STRATEGIC ACTION

FRAMEWORK FOR ACCELERATION OF THE

VMMC SCALE-UP 2012–2016

Neither the elegance of the science nor the strength of the effect predict

the ease of implementation

1. PEPFAR-UNAIDS Publications in PLoS Medicine: Signpost the way forward to

accelerate the scaling up of VMMC service delivery safely and efficiently to reap

individual- and population-level benefits

2. PEPFAR-WHO-UNAIDS-BMGF-World Bank collaboration to launch the WHO-

UNAIDS Joint Strategic Action Framework for Acceleration of the Scale-Up of

VMMC

3. Purpose of the Framework is to guide key stakeholders to collaborate and

cooperate towards common goals: country ownership, expanded coverage, and

contribute to getting to '0' infections

www.ploscollections.org/VMMC2011

MAY 2016 7INTEREST WORKSHOP 2016

WHAT PROGRESS HAVE

WE MADE?


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INCREASE IN NUMBERS OF VMMCs

• The total number of VMMCs performed annually in the 14 priority

countries:

– 2008: 21,000 (programs in only 5 countries)

– 2012: 1.71 million (programs started in all countries)

– 2013: 2.66 million

– 2014: 3.24 million

– Cumulative total of 9.1 million by end 2014

• The greatest cumulative numbers of VMMCs were performed in Uganda

(2.15 million), South Africa (1.86 million), and Tanzania (1.23 million)

• Greatest increase in the number of VMMCs performed occurred in 2013


December 2015, Harare

ANNOUNCEMENT AT ICASA:

10 MILLION MALES CIRCUMCISED

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WIDE VARIATION IN PROGRESS AT COUNTRY LEVEL


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Country10–14 15–19 20–24 25–29 30–34 35–49 10–34 15–49 15-29

Base 2015 Base 2015 Base 2015 Base 2015 Base 2015 Base 2015 Base 2015 Base 2015 Base 2015

Botswana 4% 63% 6% 40% 10% 25% 13% 21% 16% 21% 15% 21% 10% 35% 11% 31% 10% 29%

Kenya

[Nyanza only]37% 64% 47% 96% 44% 90% 47% 73% 47% 61% 48% 59% 44% 78% 45% 75% 46% 88%

Lesotho 1% 23% 13% 34% 31% 43% 31% 40% 30% 39% 30% 40% 19% 36% 26% 39% 25% 34%

Malawi 7% 11% 11% 16% 11% 15% 9% 13% 11% 13% 11% 13% 10% 14% 11% 14% 11% 11%

Mozambique 33% 45% 36% 48% 44% 52% 53% 57% 52% 59% 55% 62% 42% 51% 47% 56% 43% 52%

Namibia 13% 14% 17% 18% 22% 25% 21% 26% 21% 25% 24% 32% 18% 21% 21% 27% 19% 23%

Rwanda 3% 11% 10% 39% 16% 45% 17% 30% 18% 25% 12% 23% 12% 29% 14% 32% 14% 38%

South Africa 22% 46% 26% 43% 42% 53% 44% 51% 52% 57% 54% 61% 36% 50% 45% 55% 37% 49%

Swaziland 4% 26% 4% 23% 7% 25% 8% 24% 10% 23% 15% 26% 6% 24% 8% 25% 6% 24%

Tanzania

[11 priority

regions]

20% 55% 40% 75% 49% 70% 41% 60% 46% 55% 43% 54% 37% 63% 44% 63% 43% 69%

Uganda 23% 40% 27% 63% 31% 63% 30% 42% 27% 37% 25% 35% 27% 50% 27% 49% 29% 46%

Zambia 8% 27% 10% 36% 13% 36% 12% 29% 14% 25% 14% 22% 11% 31% 13% 29% 12% 34%

Zimbabwe 4% 21% 5% 22% 8% 16% 11% 14% 11% 14% 11% 14% 7% 18% 9% 16% 8% 18%

MC PREVALENCE BEFORE START OF VMMC PROGRAM

(“BASE”) AND MODELED ESTIMATES OF COVERAGE BY THE

START OF 2015

Source: Base from DHS and AIS surveys; coverage from DMPPT 2.1 modeling, Project SOARMAY 2016 INTEREST WORKSHOP 2016

• The goals set out in the Joint Strategic Action Framework are

highly ambitious (20 million men over 5-year period)

• The decision to circumcise involves deep-seated values and beliefs

which vary with cultural identify

• Human resource constraints hinder service capacity

• More difficult to attract males 19+

• Timely matching of supply to demand

• Seasonal preferences for VMMC in some countries

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CHALLENGES ALONG THE WAY


• Focus on programmatic efficiencies

• Systematically define site capacity and identify underutilization to

ensure resources aren’t wasted

• Prioritize sub-populations (by age, geography) to maximize impact

• Partner with private providers to open a significant and not well used

number of new VMMC sites and attract older clients

• Proper forecasting and supply planning and pooled procurement will

drive commodity prices lower and reduce lead times

• Ongoing support for novel techniques that may alleviate supply and

demand side constraints, e.g., devices, HIV self-testing, support for task

shifting & task sharing, novel demand creation approaches

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MEETING THE CHALLENGES OF SCALE-UP:

LESSONS LEARNED


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• Implementation of Continuous Quality Improvement (CQI) within VMMC services in over 200 sites in 4 countries reveal improvements in:

– Client safety

– Infection prevention and control

– Strengthened country leadership

– Reduction in client morbidity

• Addressing openly and up front the barriers to uptake, such as fear of pain and concerns about the healing period can help move men from hesitancy to action

LESSONS LEARNED,

CONTINUED

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WHERE ARE WE GOING?


• By the end of 2016, PEPFAR will provide 11 million voluntary medical

male circumcisions for HIV prevention, cumulatively

• By the end of 2017, PEPFAR will provide 13 million voluntary medical

male circumcisions for HIV prevention, cumulatively

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PEPFAR HIV PREVENTION TARGETS ANNOUNCED

AT UN GENERAL ASSEMBLY, SEPT. 2015


• Countries should prioritize age group 15-29 years old (10-29 for

Tanzania and 15-34 for South Africa)

• The focus should be to saturate and reach 80% among this age

group in a short period of time

• Once a district or province has reached 60% among the 15-29 year

age group, the prioritization of 10-14 year olds can progressively

increase

• VMMC services should not be denied to any medically eligible men

MAY 2016 INTEREST WORKSHOP 2016 18

PEPFAR TECHNICAL CONSIDERATIONS

• In some countries, progress has been uneven: certain age groups and districts are

reaching saturation before others. Based on the initial targets, these regions will

need to start planning for sustainability sooner than originally thought.

• Tanzania is an example of this: Iringa and Njombe regions are close to saturation

among males 15–24. Now planning for sustainability.

MAY 2016 INTEREST WORKSHOP 2016 19

PLANNING FOR SUSTAINABILITY

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WHAT DOES VMMC SUSTAINABILITY ENTAIL?

• Sustainability of a VMMC program = When local stakeholders maintain high

circumcision prevalence after the initial scale-up is reached.

• Generally occurs by incorporating into routine newborn and adolescent

service delivery systems:

– Early infant male circumcision (EIMC)

– Early adolescent voluntary medical male circumcision (EAVMMC)

– Or both


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EARLY INFANT MALE CIRCUMCISION (EIMC)

Advantages of EIMC:

No sutures (less bleeding)

Reduced costs

Quicker healing

Lower complication rates

Done long before becoming

sexually active

Tanzania, Kenya, Lesotho,

Botswana, Swaziland, Zimbabwe

have introduced EIMC

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WHAT ABOUT DEVICES?

Advantages of devices:

Don’t require highly skilled provider

Procedure time is less

Clients can resume normal routine sooner

Don’t require injection of anesthesia

or sutures

Questions that remain:

Are they stimulating incremental demand?

Can costs be brought down?

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LESSONS LEARNED FROM TRANSITIONS IN

OTHER HEALTH PROGRAMS

• Early planning is critical to successful transitions

• Technical and managerial support is often needed to build domestic

capacity and ensure the institutionalization of support mechanisms

• A systematic, phased approach to transition planning allows for course

corrections and helps ensure that critical elements are considered

• Post-transitional support is important to ensure quality as well as to

assess transition effectiveness

• Sustaining the status quo is not a requisite; transition could also involve

moving to more efficient and effective service delivery modalities and

better targeting

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REFERENCES

1. Hussain LA, Lehner T. Comparative investigation of Langerhans cells and potential receptors for HIV in oral, genitourinary and rectal epithelia. Immunology. 1995;85:475–484.

2. Halperin DT, Bailey RC. Male circumcision and HIV infection: 10 years and counting. Lancet.1999;354:1813–1815.

3. Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet. 2007 Feb 24;369(9562):643-56.

4. Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369:657-666.

5. 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 Nov;2(11):e298. Erratum in: PLoS Med. 2006 May;3(5):e298.

6. Mehta, S. D., Moses, S., Agot, K., Odoyo-June, E., Li, H., Maclean, I., Hedeker, D. and Bailey, R. C. The long term efficacy of medical male circumcision against HIV acquisition. AIDS. 2013. doi: 10.1097/01.aids.0000432444.30308.2d

7. Auvert B, Taljaard D, Rech D, Lissouba P, Singh B, Bouscaillou J, Peytavin G, Mahiane SG, Sitta R, Puren A, Lewis D. Association of the ANRS-12126 Male Circumcision Project with HIV Levels among Men in a South African Township: Evaluation of Effectiveness using Cross-sectional Surveys. PLoS Med. 2013;10(9):e1001509. doi: 10.1371/journal.pmed.1001509.

MAY 2016

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Documents

VMMC LANDSCAPE IN EASTERN AND SOUTHERN AFRICA: PAST, …regist2.virology-education.com/2016/10INTEREST/45_Mwandi.pdf · 2016-05-26 · 6 MODELING FOR DECISION MAKING •In 2011, the