Financial Implications of Male Circumcision Scale-Up for the Prevention of HIV and Other Sexually Transmitted Infections in a Sub-Saharan African Community – Supplemental Material

Financial Implications of Male Circumcision Scale-Up for the Prevention of HIV and Other Sexually Transmitted Infections in a Sub-Saharan African Community – Supplemental Material Seema

Financial Implications of Male Circumcision Scale-Up for the Prevention of HIV and Other Sexually Transmitted Infections in a Sub-Saharan African Community – Supplemental Material

Seema Kacker BS1, Kevin D Frick PhD2, Thomas C Quinn MD3,4, Ronald H Gray PhD5, and Aaron A R Tobian MD PhD1

1 Department of Pathology, School of Medicine, Johns Hopkins University, Baltimore, MD

2 Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD

3 Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD

4 Division of Intramural Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD

5 Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD

Methods (supplemental):

Generating a Dynamic Population:

Assuming the size of each annual birth cohort remained constant at “BirthCohortSize,” the portion of individuals in each of the two subpopulations (InitialPopulation or BirthCohort) would be calculated as follows:

where “CurrentPopulationSize” and “BirthCohortSize” were defined by published demographic data, and “TotalYears” was the number of years over which outcomes were evaluated

MC Scale-up Plans:

MC scale-up plans (Strategies 2-5) incorporated a component targeting initially uncircumcised males of the initial population (catch-up MC program), and a second component targeting males of the annual birth cohorts Across all scale-up strategies, the catch-up MC program ultimately resulted in an 80% coverage rate among males 15-49 Only males between the ages 15-49 were circumcised through this catch-up program However, under Strategies 2 and 4, 10 years of scale-up were needed to achieve this level of coverage, while under Strategies 3 and 5, this level of coverage was achieved after only 5 years

Within the initial population, a portion of males were already circumcised at the start of the simulation We assumed that at the start of the simulation, 23.6% of men aged 15-49 were circumcised (baseline rate) Because certain subpopulations in Rakai often conduct MCs among infants, we assumed that 13.6% of individuals aged 0-14 were circumcised

Each year, a portion of uncircumcised individuals aged 15-49 received a “catch-up” MC, such that at the end of the catch-up period (after 5 years under Strategies 3 and 5 and after 10 years under Strategies 2 and 4), a total of 80% of males 15-49 were circumcised While the bulk of individuals eligible to obtain a “catch-up MC” could become circumcised throughout the period of scale-up, some men were initially (at the start of the simulation) below the age of 15, but became eligible during the course of the simulation In addition, some men were only eligible for “catch-up MC” during the first few years of the scale-up, since they exceeded the 49 year old maximum age during the simulation

Thus, under Strategies 3 and 5, “catch-up MC” parameters were defined for men initially aged 11-49, and under Strategies 2 and 4, “catch-up MC” parameters were defined for men initially aged

5-49 Only males between the ages 15-49 were circumcised through this catch-up program The portion

of males becoming circumcised through the catch-up program was specified for specific age groups, as shown below in Supplemental Tables 1 and 2

Under Strategies 3 and 5, individuals initially aged 15-45 would increasingly become circumcised over the period of scale-up: at the start of year 1, 23.6% of men are circumcised, but by the end of year

1, 40% of men aged 15-45 are circumcised, by the end of year 2, 50% are circumcised, by the end of year

3, etc By the end of year 5, 80% of men initially aged 15-45 are circumcised (Supplemental Table 1) Under these two strategies, men initially aged 11 would begin year 1 with an MC rate of 13.6% This rate would persist (no “catch-up MCs”) until year 4 (at which point these individuals reached age 15), and then the rate would keep pace with the 15-45 year old group Men initially aged 46 would undergo

“catch-up MCs” at the same rate as the 15-45 year old group until reaching the age of 50 (year 5) Men initially 47-49 would undergo a similar process, undergoing catch-up MCs at the same rate of the 15-45 year old group until exceeding the appropriate age range for MC

Supplemental Table 1: MC Rates Among Initial Population (Catch-up MCs Under Strategies 3 and 5)

Initial

Age

Initial MC Rate:

Start of Year 1

(%)

MC Rate:

End of Year

1 (%)

MC Rate:

End of Year

2 (%)

MC Rate:

End of Year

3 (%)

MC Rate:

End of Year

4 (%)

MC Rate: End of Year

5 (%)

A similar process was defined for Strategies 2 and 4 (Supplemental Table 2) Males initially aged 15-40 increasingly received catch-up

MCs so that at the start of year 1, the MC rate was at 23.6%, but by the end of year 10, the MC rate reached 80% Individuals who were initially aged 6-14 were only included in the MC catch-up program once they reached age 15 Individuals initially aged 41-49 were included only while they were aged 49 or below

Supplemental Table 2: MC Rates Among Initial Population (Catch-up MCs Under Strategies 2 and 4)

Initial

Age

MC Rate:

Start of

Year 1 (%)

MC Rate:

End of Year 1 (%)

MC Rate:

End of Year 2 (%)

MC Rate:

End of Year 3 (%)

MC Rate:

End of Year 4 (%)

MC Rate:

End of Year 5 (%)

MC Rate:

End of Year 6 (%)

MC Rate:

End of Year 7 (%)

MC Rate:

End of Year 8 (%)

MC Rate:

End of Year 9 (%)

MC Rate: End of Year

10 (%)

Infection Rates Specific to MC Protection Status:

Because published incidence and prevalence reflect an average population, including some individuals already experiencing MC protective benefits, incidence and prevalence rates specific to MC-protection status were derived:

, where

and

“pMC” was the prior MC rate, “(Rate|MC)” indicated incidence(or prevalence) among those with MC protection and “MC_Effect” was defined as the incidence rate ratio(IRR) of MC for the infection For BV and trichomoniasis, however, the MC_Effect parameter was defined by a prevalence risk ratio (PRR) because an IRR was unavailable from trial data.s29

Age-Specific Input Parameters (Details from Table 2): HIV Incidence (Among Men):

HIV Prevalence (Among Men):

Penile Cancer Incidence (Among Men):

Age Annual Incidence

69 0.000278

Cervical Cancer Incidence (Among Women):

Age-Specific Mortality Rates (Among Men):

11 0.00255

61 0.04313

Age-Specific Mortality Rates (Among Women):

5 0.00222

Supplemental Table 3 Change in Infection Prevalence Associated with MC Scale-Up Strategies (Base-Case Analysis)

MC Scale-up Strategies Adolescent/Adult Only (15-49) Include Infants (0-1,15-49)

5 years

Male MC-Related Infections

Female MC-Related Infections

25 years

Male MC-Related Infections

Female MC-Related Infections

Cervical Cancer - HR-HPV: Cases (%) -215 (-11.51) -239 (-12.95) -220 (-11.79) -246 (-13.39)

Supplemental Table 4: Distribution of MC-Reduced Infection Costs Attributable to each MC-Related Infection - Base-Case Analysis

Male MC-Reduced Infections Female MC-Reduced Infections

5 years

Portion of Total Infection Costs (%)

Portion of Total Infection Cost Change (%)a

2: Gradual (Adolescent/Adult Only) 45.89 -1.38 20.76 65.28 1.29 10.08 16.10 7.25 34.72

25 years

Portion of Total Infection Costs (%)

Portion of Total Infection Cost Change (%)a

aTotal Infection Cost Change calculated in comparison to the Baseline strategy

bHR-HPV among males included only cases resulting in penile cancer

cHR-HPV among females included only cases resulting in cervical cancer

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