Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa.
Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa.
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DOI：
10.1371/journal.pmed.1001132
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发表时间：
2011-11
期刊：
影响因子：
15.8
通讯作者：
Hankins C
中科院分区：
文献类型：
--
作者：
Njeuhmeli E;Forsythe S;Reed J;Opuni M;Bollinger L;Heard N;Castor D;Stover J;Farley T;Menon V;Hankins C
Emmanuel Njeuhmeli 及其同事估计了东部和南部非洲 13 个优先国家扩大成人医学男性包皮环切术的影响和成本，发现达到 80% 的覆盖率并维持到 2025 年将避免 336 万新的艾滋病毒感染。有强有力的证据表明，自愿医疗男性包皮环切术 (VMMC) 可降低男性艾滋病毒感染率。为了告知东部和南部非洲 13 个优先国家的 VMMC 政策和目标，我们使用更新的特定国家数据估算了扩大成人 VMMC 的影响和成本。我们使用决策者计划规划工具 (DMPPT) 来模拟在博茨瓦纳、莱索托、马拉维、莫桑比克、纳米比亚、卢旺达、南非、斯威士兰、坦桑尼亚、乌干达、赞比亚、津巴布韦和肯尼亚尼安萨省扩大成人 VMMC 的影响和成本。我们使用每个国家最近的家庭调查的流行病学和人口统计数据。根据与世界卫生组织优化数量和效率模型考虑相一致的 VMMC 服务成本评估，每执行一次 VMMC 的 VMMC 成本从 65.85 美元到 95.15 美元不等。 DMPPT 模型的结果表明，要在 2015 年扩大成人 VMMC 的覆盖率，以在 13 个国家达到 80% 的覆盖率，需要在 2011 年至 2015 年期间实施 2,034 万例包皮环切术，并在 2016 年至 2025 年期间再进行 842 万例包皮环切术（以维持 80% 的覆盖率）。这样的扩大规模将导致到 2025 年避免 336 万例新的艾滋病毒感染。此外，虽然模型显示这种扩大规模在 2011 年至 2025 年间总共将花费 20 亿美元，但它将带来净节省（由于避免了治疗和护理费用）达 165.1 亿美元。这项研究表明，鉴于VMMC对该地区艾滋病毒流行和净储蓄可能产生的影响，有必要在东部和南部非洲迅速扩大VMMC。在东部和南部非洲扩大安全VMMC将导致这些国家的艾滋病毒感染人数大幅减少，并通过避免艾滋病毒护理成本来降低卫生系统成本。 请参阅本文后面的编辑摘要。 每年，大约有 250 万人（主要是撒哈拉以南非洲地区）感染艾滋病毒（HIV），这种病毒会导致艾滋病。艾滋病毒/艾滋病无法治愈。因此，预防艾滋病毒传播非常重要。由于最常见的艾滋病毒传播途径是通过与受感染伴侣进行无保护的性行为，因此个人可以通过禁欲、仅拥有一个或几个性伴侣以及使用男用或女用安全套来降低感染艾滋病毒的风险。还有强有力的证据表明，自愿医疗男性包皮环切术 (VMMC)——去除包皮（覆盖阴茎头的松弛皮肤皱襞）——可以将男性中异性恋感染艾滋病毒的几率减少约 60%。 2007年，世界卫生组织（WHO）和联合国艾滋病毒/艾滋病联合规划署（UNAIDS）建议，在艾滋病毒普遍流行和男性包皮环切率较低的环境中，应向男性提供VMMC，作为降低艾滋病毒风险综合计划的一部分。他们还优先考虑东部和南部非洲的 13 个国家来扩大 VMMC 计划。扩大 VMMC 对避免艾滋病毒感染和艾滋病死亡（流行病学影响）的影响预计会很大，而且干预措施还应减少与感染者的治疗、护理和支持相关的成本。然而，VMMC 的扩大需要大量资金和各国付出大量努力来培训人员、装备设施和提供必要的商品，其中许多国家的卫生系统薄弱且资源有限。为了支持 VMMC 扩大规模的规划，美国国际开发署卫生政策倡议与联合国艾滋病规划署合作开发了决策者计划规划工具 (DMPPT)，这是一种数学模型，允许分析师和决策者估计替代 VMMC 扩大规模计划的流行病学影响和成本。在这项研究中，研究人员使用 DMPPT 来估计在东部和南部非洲 13 个优先国家扩大成人 VMMC 的影响和成本。研究人员根据津巴布韦进行的成本评估得出了每个优先国家的 VMMC 单位成本，津巴布韦是首批使用世卫组织“数量和效率优化模型”(MOVE) 指南扩大 VMMC 服务的国家之一。他们将这些费用以及每个国家收集的最新流行病学数据（包括 HIV 感染率和 VMMC 在预防 HIV 传播方面的有效性）和人口数据（包括成年人口规模和扩大前的男性包皮环切流行率）输入 DMPPT，以及有关 HIV 治疗终生费用的信息。 DMPPT 模型的运行结果表明，要在 2015 年扩大成人 VMMC 的覆盖率，以在 13 个重点国家达到 80% 的覆盖率，需要在 2011 年至 2015 年期间完成 2033 万例包皮环切术。为了维持这一覆盖率，在 2016 年至 2025 年期间还需要完成 842 万例包皮环切术。这样的扩大规模将通过以下方式避免 336 万例新的艾滋病毒感染： 2025 年，2011 年至 2025 年间将花费 20 亿美元。然而，这将带来 165.1 亿美元的净节省（由于避免了治疗和护理费用）。这些发现表明，鉴于 VMMC 可能对该地区的艾滋病毒流行产生影响并由此节省成本，因此有必要在东部和南部非洲迅速扩大 VMMC。然而，这些发现的准确性取决于 DMPPT 中内置的假设以及输入的数据。例如，包皮环切术后可能会出现危险的行为变化。也就是说，接受过包皮环切的男性的危险性行为可能会增加。然而，研究人员表明，除卢旺达外，包皮环切术后风险行为的改变不太可能完全逆转 VMMC 的益处。这些建模结果还假设寻求 VMMC 服务的男性是一般男性群体的典型，但如果他们实际上感染 HIV 的风险异常低，那么这里报告的 VMMC 的好处可能会被高估。最后，这些研究结果假设 VMMC 覆盖率为 80%。尽管肯尼亚的结果表明这一目标是可以实现的，但这可能是乐观的。因此，各国及其国际合作伙伴如果要充分利用此处预测的 VMMC 扩大规模效益，就必须为 VMMC 扩大规模分配足够的资源，以实现高覆盖率。请通过本摘要的在线版本访问这些网站：http://dx.doi.org/10.1371/journal.pmed.1001132。这项研究是 http://www.ploscollections.org/VMMC2011 上 PLoS 文章集的一部分，并在 Hankins 等人的 PLoS 医学评论文章中进行了进一步讨论。 (http://dx.doi.org/10.1371/journal.pmed.1001127) 世卫组织、联合国艾滋病规划署和总统防治艾滋病紧急救援计划提供有关艾滋病毒/艾滋病各个方面的信息；已提供 2011 年世卫组织/联合国艾滋病规划署关于在 13 个优先国家扩大 VMMC 的进度报告 NAM/aidsmap 提供了有关艾滋病毒/艾滋病的基本信息、有关艾滋病毒护理和治疗的最新研究结果摘要以及有关男性包皮环切术以预防艾滋病毒传播的信息 可从国际艾滋病慈善机构 Avert 获取有关艾滋病毒/艾滋病许多方面的信息，包括有关艾滋病毒预防各方面的信息以及非洲艾滋病毒/艾滋病的信息（英文和西班牙文） 男性信息交换所包皮环切术是由 WHO、UNAIDS 和其他国际机构提供的资源，为 VMMC 政策制定和计划实施提供信息和工具，包括有关 DMPPT 和 MOVE 指南的信息 有关艾滋病毒/艾滋病感染者的个人故事可通过 Avert、NAM/aidsmap 以及慈善网站 Healthtalkonline 获取
Emmanuel Njeuhmeli and colleagues estimate the impact and cost of scaling up adult medical male circumcision in 13 priority countries in eastern and southern Africa, finding that reaching 80% coverage and maintaining it until 2025 would avert 3.36 million new HIV infections. There is strong evidence showing that voluntary medical male circumcision (VMMC) reduces HIV incidence in men. To inform the VMMC policies and goals of 13 priority countries in eastern and southern Africa, we estimate the impact and cost of scaling up adult VMMC using updated, country-specific data. We use the Decision Makers' Program Planning Tool (DMPPT) to model the impact and cost of scaling up adult VMMC in Botswana, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, Zimbabwe, and Nyanza Province in Kenya. We use epidemiologic and demographic data from recent household surveys for each country. The cost of VMMC ranges from US$65.85 to US$95.15 per VMMC performed, based on a cost assessment of VMMC services aligned with the World Health Organization's considerations of models for optimizing volume and efficiencies. Results from the DMPPT models suggest that scaling up adult VMMC to reach 80% coverage in the 13 countries by 2015 would entail performing 20.34 million circumcisions between 2011 and 2015 and an additional 8.42 million between 2016 and 2025 (to maintain the 80% coverage). Such a scale-up would result in averting 3.36 million new HIV infections through 2025. In addition, while the model shows that this scale-up would cost a total of US$2 billion between 2011 and 2025, it would result in net savings (due to averted treatment and care costs) amounting to US$16.51 billion. This study suggests that rapid scale-up of VMMC in eastern and southern Africa is warranted based on the likely impact on the region's HIV epidemics and net savings. Scaling up of safe VMMC in eastern and southern Africa will lead to a substantial reduction in HIV infections in the countries and lower health system costs through averted HIV care costs. Please see later in the article for the Editors' Summary. Every year, about 2.5 million people (mainly in sub-Saharan Africa) become infected with HIV, the virus that causes AIDS. There is no cure for HIV/AIDS. Consequently, prevention of HIV transmission is very important. Because the most common HIV transmission route is through unprotected sex with an infected partner, individuals can reduce their risk of HIV infection by abstaining from sex, by having only one or a few partners, and by using male or female condoms. There is also strong evidence that voluntary medical male circumcision (VMMC)—the removal of the foreskin, the loose fold of skin that covers the head of the penis—reduces the heterosexual acquisition of HIV in men by about 60%. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that VMMC should be offered to men as part of comprehensive HIV risk reduction programs in settings with generalized HIV epidemics and low levels of male circumcision. They also prioritized 13 countries in eastern and southern Africa for VMMC program scale-up. The impact of VMMC scale-up in terms of HIV infections and AIDS deaths averted (epidemiologic impact) is expected to be large, and the intervention should also reduce the costs associated with the treatment, care, and support of infected individuals. However, VMMC scale-up will require substantial funding and considerable effort by countries—many of which have weak health systems and limited resources—to train personnel, equip facilities, and provide the necessary commodities. To support planning for VMMC scale-up, the United States Agency for International Development Health Policy Initiative has collaborated with UNAIDS to develop the Decision Makers' Program Planning Tool (DMPPT), a mathematical model that allows analysts and decision makers to estimate the epidemiologic impact and cost of alternative VMMC scale-up programs. In this study, the researchers use DMPPT to estimate the impact and cost of scaling up adult VMMC in the 13 priority countries in eastern and southern Africa. The researchers derived VMMC unit costs for each priority country based on a cost assessment undertaken in Zimbabwe, one of the first countries to scale up VMMC services using WHO's “Models for Optimizing Volume and Efficiencies” (MOVE) guidelines. They fed these costs and recent epidemiologic data (including HIV infection rates and the effectiveness of VMMC in preventing HIV transmission) and demographic data (including the adult population size and pre-scale-up male circumcision prevalence) collected in each country into the DMPPT, together with information on the lifetime costs of HIV treatment. Results from running the DMPPT model suggest that scaling up adult VMMC to reach 80% coverage in the 13 priority countries by 2015 would require 20.33 million circumcisions to be completed between 2011 and 2015. To maintain this coverage, a further 8.42 million circumcisions would be required between 2016 and 2025. Such a scale-up would avert 3.36 million new HIV infections through 2025 and would cost US$2,000,000,000 between 2011 and 2025. However, it would result in net savings (because of averted treatment and care costs) of US$16,510,000,000. These findings suggest that rapid VMMC scale-up in eastern and southern Africa is warranted, given its likely impact on the region's HIV epidemics and the resultant cost savings. However, the accuracy of these findings depends on the assumptions built into the DMPPT and on the data fed into it. For example, there could be risk behavior changes after circumcision. That is, risky sexual behaviors may increase in men who have been circumcised. However, the researchers show that, except in Rwanda, post-circumcision risk behavior change is unlikely to completely reverse the benefits of VMMC. These modeling results also assume that men seeking out VMMC services are typical of the general male population, but if they are actually at unusually low risk of HIV infection, then the benefits of VMMC reported here are likely to be overestimated. Finally, these findings assume 80% VMMC coverage. This may be optimistic, although results from Kenya indicate that this target is achievable. Thus, countries and their international partners must allocate sufficient resources to VMMC scale-up to achieve high coverage rates if they are to take full advantage of the benefits predicted here for VMMC scale-up. Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001132. This study is part of a PLoS Collection of articles on http://www.ploscollections.org/VMMC2011 and is further discussed in a PLoS Medicine Review Article by Hankins et al. (http://dx.doi.org/10.1371/journal.pmed.1001127) Information is available from WHO, UNAIDS, and PEPFAR on all aspects of HIV/AIDS; the 2011WHO/UNAIDS progress report on VMMC scale-up in the 13 priority countries is available NAM/aidsmap provides basic information about HIV/AIDS, summaries of recent research findings on HIV care and treatment, and information on male circumcision for the prevention of HIV transmission Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including information on all aspects of HIV prevention, and on HIV/AIDS in Africa (in English and Spanish) The Clearinghouse on Male Circumcision, a resource provided by WHO, UNAIDS, and other international bodies, provides information and tools for VMMC policy development and program implementation, including information on the DMPPT and the MOVE guidance Personal stories about living with HIV/AIDS are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
影响因子：
6.4
作者：
Auvert, Bertran;Sobngwi-Tambekou, Joelle;Taljaard, Dirk
通讯作者：
Taljaard, Dirk
影响因子：
15.8
作者：
Auvert B;Taljaard D;Lagarde E;Sobngwi-Tambekou J;Sitta R;Puren A
通讯作者：
Puren A