Cost-EffectivenessofSustainingSupportforVMMCProgramsBackgroundWhenVMMCprogramsstartedin2008severalstudiesestimatedthattheywouldbehighlycost-effectiveandevencost-saving.Uthmanetal.EconomicEvaluationsofAdultMaleCircumcisionforPreventioninHeterosexualAcquisitionofHIVinMeninSub-SaharanAfrica:ASystematicReviewPLoSOneMarch10,2010./10.1371/journal.pone.0009628RecentmodelinganalysishasshownthatVMMCcontinuestobecost-effectiveinmostsettingsintheshort-termBansu-Matharuetal.Cost-effectivenessofvoluntarymedicalmalecircumcisionforHIVpreventionacrossSub-SaharanAfrica:resultsfromfiveindependentmodelsLancetGlobalHealth2023;11:e244-55However,theHIVepidemicismuchdifferenttodaythanin20082Incidenceismuchlowertodaycomparedto2010,withanaveragedeclineof67%from2010-20233Source:UNAIDSaidsinfoonlineManycountriesareclosetoglobaltreatmenttargets

Onaverage,80%ofPLHIVarevirallysuppressed4Source:UNAIDSaidsinfoonlineMaleCircumcisionCoverage5KenyaEthiopiaTanzaniaLesothoMozambiqueSouthAfricaBotswanaUgandaRwandaZimbabweZambiaEswatiniMalawiNamibiaWillVMMCprogramsbecost-effectiveinthefuture?Forhowlong?Thecost-effectivenessofVMMCdependsonincidence.ThatdetermineshowmanyboysandmenneedtobecircumcisedtoavertoneHIVinfection.Ifincidencecontinuestodecline,atsomepointVMMCwillnolongerbecost-effective.Highlevelsoftreatmentcoverageandviralsuppression,ifsustained,mayleadtocontinuedincidencedecline.Isitstillcost-effectivetoscaleupVMMCtoreachglobaltargets?Ifso,howlongshouldVMMCprogramsbesustained?6ScalingUpVMMCtomeetGlobalTargetsby2030iscost-effectiveinmostsettings7Discounted(at3%)netcostperinfectionavertedfrom2022-2090ofscalingupmalecircumcisioncoveragefrom2021levelsto90%ofallmen15-49by2030comparedtonofurtherVMMCprogram.Allotherinterventionsareheldconstant.NetcostsincludethecostoftheVMMCprogramminusanysavingsintreatmentcosts.ProjectionsbasedontheGoalsASMmodel.ShouldVMMCsupportcontinueafter2030?SustainabilityanalysisassumptionsAfter2030supportfortheVMMCprogramcontinuesfor0,5,10,15,20or25yearsCircumcisionratesfor15-year-oldsreturnto2008levelsoncetheVMMCprogramstopsCoverageforallotherinterventionsisconstantat2021levelsDiscountingat3%peryearEvaluationperiod:2022–20908Incrementalcostperinfectionavertedincreaseswithlongerdurationofsupportduetodecliningincidence9Incrementalcostperinfectionavertedbydurationofsupportaftertargetcoverageisreachedin2030.Costsandinfectionsarecumulativefrom2022-2090discountedat3%peryear.CostsincludeVMMCandART.Incidenceamong15–49-year-oldadultsprojectedbytheGoalsASMmodelundertheassumptionofconstantcoverageofallinterventions.AsincidencedropsduetohighviralsuppressionthePLHIVpopulationagesandaverage(age-weighted)riskdrops.InmanysettingsVMMCcostsarelikelytoexceedcost-effectivenessthresholdsatsomepointinthenext25years10DALYthresholdsarebasedonhealthspending2000-2016perDALYgainedasestimatedbyDaroudietal.(CostEffResourAlloc(2021)19:7)basedonGBDestimatesofDALYSandhealthexpenditures.TheyareonlyusedtoillustratetheconceptthatVMMCprogramswillneedtocompetewithotherhealthprioritiesasHIVincidencedeclinesinthefuture.Incidencevariessignificantlyacrosstheregion.Areasofhighincidencestillremain.11UNAIDS2022estimatesfromNaomiModelFor29%ofpopulation,incidence<0.05%,for25%itis0.05%-0.10%,for23%itis0.10%-0.35%,for23%itis>0.35%ScalingupVMMCtoachievetargetswouldbecost-savingorcost-effectiveinmostprovincesinZimbabwe12SummaryTheHIVepidemicisverydifferenttodayfrom2008whenVMMCprogramswerejustgettingstarted.IncidenceislowerandARTcoverageishigher.VMMCprogramsremaincost-effectiveinmostsettingsandwillremaincost-effectiveforthenext10years.Thereareimportantdifferencesacrosscountriesandsub-nationalregions.Cost-effectivenesswilldecline