oa The Impact Of Scaling Up Voluntary Medical Male Circumcision As An Hiv Intervention In South Sudan

Background: Voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition in men. Though VMMC programs are being scaled up across sub-Saharan Africa (SSA), no VMMC program has been initiated in the world's youngest nation, South Sudan. The possibly growing HIV epidemic in this nation, currently at a prevalence of 3%, and the stark geographic variability in prevalence, suggests an opportunity for controlling HIV transmission using VMMC with sub-population prioritization. Our aim was to explore, using mathematical modeling, the impact of VMMC programming in South Sudan. Method: We used the Age Structured Model (ASM), recently developed in partnership with the Bill and Melinda Gates Foundation, to assess VMMC impact. The model has been applied in several SSA countries. The ASM stratifies the population into compartments according to sex, circumcision status, age group, risk group, HIV status and stage of infection. Results: To achieve 80% VMMC coverage by 2020 among the 15-49 years old males, 2.17 million VMMCs are needed at a total cost of $187 million USD. An additional 1.52 million VMMCs would be needed by 2030 to maintain this coverage at an additional cost of $115 million. By 2030, 123,057 HIV infections would be averted (29.7% of new infections). The number of VMMCs needed to avert one infection (effectiveness) is 30, while the cost per infection averted is $2,608. Through sub-population prioritization by age, VMMC effectiveness ranges between 28 (25-29 and/or 30-34 years age groups), and 91 (10-14 years age group). The cost per infection averted is $2,453 and $2,548 for the age groups of 25-29 and 30-34, respectively, while it is $6,837 for the 10-14. The effectiveness of geographical prioritization varies across states. The lowest number of VMMCs needed to avert one infection is 19 in the state of West Equatoria, while the highest number is 120 in the states of Warrap or Northern Bahr Ghazal. Prioritization by risk group is very effective with only one VMMC needed per infection averted by targeting the highest risk group, while 180 would be needed by targeting the lowest risk group. Conclusion: Though at higher cost per infection averted compared to other SSA countries, our findings demonstrate that a VMMC program in South Sudan can be effective and cost-saving. The effectiveness of VMMC scale-up can be optimized by sub-population prioritization of 25-34 years old males, states with the highest HIV prevalence, and high-risk populations. A VMMC program in South Sudan should be considered, and donor support should be secured to initiate and sustain its establishment.