title: Modeling Impact and Cost-Effectiveness of Increased Efforts to Attract Voluntary Medical Male Circumcision Clients Ages 20-29 in Zimbabwe.
abstract: BACKGROUND
  Zimbabwe aims to increase circumcision coverage to 80% among 13- to 29-year-olds. However, implementation data suggest that high coverage among men ages 20 and older may not be achievable without efforts specifically targeted to these men, incurring additional costs per circumcision. Scale-up scenarios were created based on trends in implementation data in Zimbabwe, and the cost-effectiveness of increasing efforts to recruit clients ages 20-29 was examined.
  
  
  METHODS
  Zimbabwe voluntary medical male circumcision (VMMC) program data were used to project trends in male circumcision coverage by age into the future. The projection informed a base scenario in which, by 2018, the country achieves 80% circumcision coverage among males ages 10-19 and lower levels of coverage among men above age 20. The Zimbabwe DMPPT 2.0 model was used to project costs and impacts, assuming a US$109 VMMC unit cost in the base scenario and a 3% discount rate. Two other scenarios assumed that the program could increase coverage among clients ages 20-29 with a corresponding increase in unit cost for these age groups.
  
  
  RESULTS
  When circumcision coverage among men ages 20-29 is increased compared with a base scenario reflecting current implementation trends, fewer VMMCs are required to avert one infection. If more than 50% additional effort (reflected as multiplying the unit cost by >1.5) is required to double the increase in coverage among this age group compared with the base scenario, the cost per HIV infection averted is higher than in the base scenario.
  
  
  CONCLUSIONS
  Although increased investment in recruiting VMMC clients ages 20-29 may lead to greater overall impact if recruitment efforts are successful, it may also lead to lower cost-effectiveness, depending on the cost of increasing recruitment. Programs should measure the relationship between increased effort and increased ability to attract this age group.
authors: Health Policy Project, Avenir Health, Washington, District of Columbia, United States of America.
authors: Katharine
authors: K
authors: Kripke
authors: Population Services International, Harare, Zimbabwe.
authors: Karin
authors: K
authors: Hatzold
authors: Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe.
authors: Owen
authors: O
authors: Mugurungi
authors: Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe.
authors: Gertrude
authors: G
authors: Ncube
authors: Zimbabwe Ministry of Health and Child Care, Harare, Zimbabwe.
authors: Sinokuthemba
authors: S
authors: Xaba
authors: Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors: Elizabeth
authors: E
authors: Gold
authors: The United States Agency for International Development (USAID), Washington, District of Columbia, United States of America.
authors: Kim Seifert
authors: KS
authors: Ahanda
authors: USAID, Harare, Zimbabwe.
authors: Natalie
authors: N
authors: Kruse-Levy
authors: The United States Agency for International Development (USAID), Washington, District of Columbia, United States of America.
authors: Emmanuel
authors: http://orcid.org/0000-0001-5370-4827
authors: E
authors: Njeuhmeli
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002944:Circumcision, Male / Q000191:economics*; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009313:National Health Programs / Q000191:economics; D035141:Voluntary Programs / Q000191:economics*; D055815:Young Adult; D015030:Zimbabwe / Q000453:epidemiology