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Voluntary Medical Male Circumcision

Voluntary medical male circumcision (VMMC), the complete surgical removal of the foreskin from the penis, is a crucial biomedical component of HIV combination prevention. Clinical trials in Kenya, Uganda, and South Africa demonstrated that VMMC can reduce the risk of female-to-male sexual transmission of HIV by up to 60%. , , Increasing access to VMMC services is a priority in 14 countries in east and southern Africa. These countries, identified by the World Health Organization, UNAIDS, and PEPFAR, have high HIV incidence rates and a low prevalence of male circumcision. PSI and its partners are working to create informed demand for VMMC and to increase access to safe male circumcision services.

VMMC is accompanied by a minimum package of services. This package includes HIV testing and counseling, syndromic management of sexually transmitted infections, risk reduction and safer sex counseling, provision of male and female condoms, and linkages to onward services, particularly HIV care and treatment for clients testing HIV positive. The VMMC model only takes risk reduction from circumcision into account.

Unit of interventionPer circumcision

Target populationHIV-negative men (15-49 yrs.)*

PSI implements a range of HIV prevention initiatives as part of its combination prevention approach. These include the marketing and provision of male and female condoms, HIV testing and counseling, voluntary medical male circumcision, and linkages to care, among others. For more information about these initiatives, visit our website at:
http://www.psi.org/program/voluntary-medical-male-circumcision/

*NOTE: The target population for this intervention is HIV-negative men. However, HIV positive men and men with an unknown HIV status may be circumcised per national and international guidelines.

Model Overview

PSI’s male circumcision model estimates the number of new HIV infections averted, the number of deaths averted), and the number of DALYs averted per circumcision.

The model is designed with two core components. The first is a baseline scenario in which the PSI male circumcision program is NOT present. The Spectrum Suite software is used to create the second scenario, in which country profiles are built in Goals and projected in the AIDS Impact Model (AIM). In this intervention scenario, the PSI male circumcision program is projected to be scaled up to for 100%. By comparing the intervention scenario with the baseline scenario, we are able to isolate the impact of the intervention and estimate the number of HIV infections averted and HIV-related DALYs averted as a result of the male circumcision intervention.

Estimating the baseline scenario

The baseline scenario estimates the potential disease burden from new HIV infections in a given year. This is modeled by estimating an individual’s risk of HIV infection from sexual contact with discordant partners (i.e. the risk of an HIV-negative individual being infected from sexual contact with an HIV-positive individual).

Estimating the intervention scenario

The intervention scenario estimates the reduction in risk of being infected with HIV that occurs as a result of implementation of the male circumcision program. It uses the same parameters as the baseline scenario to estimate an individual’s risk of HIV infection from sexual contact, except in this scenario a circumcised individual’s risk of being infected is reduced. By comparing the intervention scenario with the baseline scenario, we are able to estimate the number of new HIV infections that would be averted by a male circumcision intervention in a specific country. This also provides the correlated estimate of the number of HIV-related deaths averted per circumcision.

The benefit of a circumcision procedure in terms of new infections averted is calculated by summing the protective benefit over a 20-year lifespan. However, because circumcision conveys only partial protection, the model takes into account that a circumcised male can contract HIV through sexual transmission during the 20-year modeled effective lifespan. Incorporating this dynamic aspect into the model requires an estimation of the likelihood a circumcised male will contract HIV each year over the 20-year modeled period.

Output

Estimating DALYs averted

The estimated number of new infections averted per circumcision is translated into an equivalent figure measured in DALYs averted per circumcision. This is done by estimating the number of years of healthy life that are lost per HIV and other sexually transmitted infection and applying disability weights from the 2010 Global Burden of Disease study.

Model Outputs (impact metrics)

Estimates of DALYs averted, deaths averted, CYPs provided, and unintended pregnancies averted represent the projected health impact of the intervention. It is projected because it has not been directly measured.

Examples based on provision of circumcision to HIV-negative males in Myanmar in 2016 Statement of modeled results, examples:

In 2016, an estimated 13 infections and 541 DALYs would be averted if 10,000 male circumcisions were performed in Myanmar.