title: Voluntary Medical Male Circumcision for HIV Prevention in Malawi: Modeling the Impact and Cost of Focusing the Program by Client Age and Geography.
abstract: BACKGROUND
  In 2007, the World Health Organization (WHO) recommended scaling up voluntary medical male circumcision (VMMC) in priority countries with high HIV prevalence and low male circumcision (MC) prevalence. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), an estimated 5.8 million males had undergone VMMC by the end of 2013. Implementation experience has raised questions about the need to refocus VMMC programs on specific subpopulations for the greatest epidemiological impact and programmatic effectiveness. As Malawi prepared its national operational plan for VMMC, it sought to examine the impacts of focusing on specific subpopulations by age and region.
  
  
  METHODS
  We used the Decision Makers' Program Planning Toolkit, Version 2.0, to study the impact of scaling up VMMC to different target populations of Malawi. National MC prevalence by age group from the 2010 Demographic and Health Survey was scaled according to the MC prevalence for each district and then halved, to adjust for over-reporting of circumcision. In-country stakeholders advised a VMMC unit cost of $100, based on implementation experience. We derived a cost of $451 per patient-year for antiretroviral therapy from costs collected as part of a strategic planning exercise previously conducted in- country by UNAIDS.
  
  
  RESULTS
  Over a fifteen-year period, circumcising males ages 10-29 would avert 75% of HIV infections, and circumcising males ages 10-34 would avert 88% of infections, compared to the current strategy of circumcising males ages 15-49. The Ministry of Health's South West and South East health zones had the lowest cost per HIV infection averted. Moreover, VMMC met WHO's definition of cost-effectiveness (that is, the cost per disability-adjusted life-year [DALY] saved was less than three times the per capita gross domestic product) in all health zones except Central East. Comparing urban versus rural areas in the country, we found that circumcising men in urban areas would be both cost-effective and cost-saving, with a VMMC cost per DALY saved of $120 USD and with 15 years of VMMC implementation resulting in lifetime HIV treatment costs savings of $331 million USD.
  
  
  CONCLUSIONS
  Based on the age analyses and programmatic experience, Malawi's VMMC operational plan focuses on males ages 10-34 in all districts in the South East and South West zones, as well as Lilongwe (an urban district in the Central zone). This plan covers 14 of the 28 districts in the country.
authors.affiliation: Health Policy Project, Avenir Health, Washington, DC, United States of America.
authors.forename: Katharine
authors.initials: K
authors.lastname: Kripke
authors.affiliation: Ministry of Health, Lilongwe, Malawi.
authors.forename: Frank
authors.initials: F
authors.lastname: Chimbwandira
authors.affiliation: United States Agency for International Development (USAID), Lilongwe, Malawi.
authors.forename: Zebedee
authors.initials: Z
authors.lastname: Mwandi
authors.affiliation: United States Department of Defense, Lilongwe, Malawi.
authors.forename: Faustin
authors.initials: F
authors.lastname: Matchere
authors.affiliation: Health Policy Project, Futures Group, Washington, DC, United States of America.
authors.forename: Melissa
authors.initials: M
authors.lastname: Schnure
authors.affiliation: USAID, Washington, DC, United States of America.
authors.forename: Jason
authors.initials: J
authors.lastname: Reed
authors.affiliation: USAID, Washington, DC, United States of America.
authors.forename: Delivette
authors.initials: D
authors.lastname: Castor
authors.affiliation: Bill & Melinda Gates Foundation, Seattle, Washington, United States of America.|University of Washington, Seattle, Washington, United States of America.
authors.forename: Sema
authors.initials: S
authors.lastname: Sgaier
authors.affiliation: USAID, Washington, DC, United States of America.
authors.forename: Emmanuel
authors.identifier: http://orcid.org/0000-0001-5370-4827
authors.initials: E
authors.lastname: Njeuhmeli
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002648:Child; D002944:Circumcision, Male / Q000191:economics* / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000453:epidemiology / Q000517:prevention & control*; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D015233:Models, Statistical; D009313:National Health Programs / Q000191:economics*; D015995:Prevalence; D035141:Voluntary Programs / Q000191:economics*; D055815:Young Adult