Kripke Katharine, Chen Ping-An, Vazzano Andrea, Thambinayagam Ananthy, Pillay Yogan, Loykissoonlal Dayanund, Bonnecwe Collen, Barron Peter, Kiwango Eva, Castor Delivette, Njeuhmeli Emmanuel
Health Policy Project, Avenir Health, Washington, District of Columbia, United States of America.
Health Policy Project, Futures Group, Washington, District of Columbia, United States of America.
PLoS One. 2016 Jul 13;11(7):e0157071. doi: 10.1371/journal.pone.0157071. eCollection 2016.
In 2012, South Africa set a goal of circumcising 4.3 million men ages 15-49 by 2016. By the end of March 2014, 1.9 million men had received voluntary medical male circumcision (VMMC). In an effort to accelerate progress, South Africa undertook a modeling exercise to determine whether circumcising specific client age groups or geographic locations would be particularly impactful or cost-effective. Results will inform South Africa's efforts to develop a national strategy and operational plan for VMMC.
The study team populated the Decision Makers' Program Planning Tool, Version 2.0 (DMPPT 2.0) with HIV incidence projections from the Spectrum/AIDS Impact Module (AIM), as well as national and provincial population and HIV prevalence estimates. We derived baseline circumcision rates from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. The model showed that circumcising men ages 20-34 offers the most immediate impact on HIV incidence and requires the fewest circumcisions per HIV infection averted. The greatest impact over a 15-year period is achieved by circumcising men ages 15-24. When the model assumes a unit cost increase with client age, men ages 15-29 emerge as the most cost-effective group. When we assume a constant cost for all ages, the most cost-effective age range is 15-34 years. Geographically, the program is cost saving in all provinces; differences in the VMMC program's cost-effectiveness across provinces were obscured by uncertainty in HIV incidence projections.
The VMMC program's impact and cost-effectiveness vary by age-targeting strategy. A strategy focusing on men ages 15-34 will maximize program benefits. However, because clients older than 25 access VMMC services at low rates, South Africa could consider promoting demand among men ages 25-34, without denying services to those in other age groups. Uncertainty in the provincial estimates makes them insufficient to support geographic targeting.
2012年，南非设定了到2016年为430万15至49岁男性实施包皮环切术的目标。截至2014年3月底，已有190万男性接受了自愿男性医学包皮环切术（VMMC）。为加快进展，南非开展了一项建模工作，以确定对特定客户年龄组或地理位置进行包皮环切术是否会特别有效或具有成本效益。研究结果将为南非制定VMMC国家战略和行动计划提供参考。
研究团队将来自Spectrum/艾滋病影响模块（AIM）的艾滋病毒发病率预测以及国家和省级人口及艾滋病毒流行率估计值输入决策者项目规划工具2.0版（DMPPT 2.0）。我们从2012年南非全国艾滋病毒流行率、发病率和行为调查中得出基线包皮环切率。该模型显示，为20至34岁男性实施包皮环切术对艾滋病毒发病率的即时影响最大，且每避免一例艾滋病毒感染所需的包皮环切术数量最少。在15年期间，为15至24岁男性实施包皮环切术产生的影响最大。当模型假设单位成本随客户年龄增加时，15至29岁男性成为最具成本效益的群体。当我们假设所有年龄的成本恒定不变时，最具成本效益的年龄范围是15至34岁。在地理方面，该项目在所有省份都具有成本节约效益；艾滋病毒发病率预测的不确定性掩盖了各省VMMC项目成本效益的差异。
VMMC项目的影响和成本效益因年龄靶向策略而异。以15至34岁男性为重点的策略将使项目效益最大化。然而，由于25岁以上的客户使用VMMC服务的比例较低，南非可以考虑提高25至34岁男性的需求，同时不拒绝为其他年龄组的人提供服务。省级估计值的不确定性使其不足以支持地理靶向。
