AIDS 2012—Turning the Tide

Together

Thinking Ahead: Voluntary Medical Male Circumcision Roll-Out With Non Surgical

Devices: costing, global access, logistic, and

training considerationsEmmanuel Njeuhmeli, MD, MPH, MBASenior Biomedical Prevention Advisor, USAID WashingtonCo-Chair PEPFAR Male Circumcision Technical Working group

Voluntary Medical Male Circumcision…

• Effective, safe, feasible and affordable HIV prevention intervention for countries with high HIV prevalence, low MC prevalence

• Will generate substantial cost savings in the next 5 years if roll-out reaches maximum coverage possible– “every dollars spend on AIDS is an

investment, not an expenditure” Michel Sidibe, Executive Director UNAIDS

DMPPT Estimate of Number of Adult 15–49 Years VMMC Needed per Countries to Reach 80% Coverage

.000500000.000

1000000.0001500000.0002000000.0002500000.0003000000.0003500000.0004000000.0004500000.0005000000.000

345244.000

40000.000

377788.000376795.000

2101566.000

1059104.000

330218.000

1746052.000

4333134.000

183450.000

1373271.000

4245184.000

1949292.000

1912595.000

Strategy for Achieving Pace and Scale

• Political will and country ownership • Strong leadership and coordination from MOH • Effective communication strategy with strong community level

buy-in • Enough financial resources for service delivery including some

level of dedication of staff time, facilities space and commodities – Donor commitment

• Excellent technical support from partners to allow a good match of demand and supply for efficient use of limited resources available to reach maximum number of men

• Flexibility to adopt innovations as they become available --- non surgical devices

Costing Study Research Questions

• Unit costs of – surgery-only (forceps-guided, reusable kits)– mixed (forceps-guided surgery and PrePex)

• Cost drivers• Cost impact

– % site capacity used– ratio of surgery vs. device-based circumcisions at

mixed site– range of device prices

• Next step: additional scenario w/ Shang Ring

Cost Categories• Staff• Training• Consumables• Device• Durable equipment• Supply chain management• Waste management

Caveats• Not possible to obtain actual costs for device under scale-up situation;

costs were obtained from pilot field study• If data were available the modeling exercise would not be needed

Assumptions; • Indirect costs not included for all scenarios • Many costs will be higher if circumcisions are conducted in dedicated

facilities rather than integrated into public facilities• Analysis did not look at effects of task shifting for the surgery• Analysis did not look at greater number of circumcisions/day with device• Acceptability of device unknown• Costs of demand creation unknown and may contribute significantly to

costs

Site Comparison and Cost Drivers

Mixed site: % device-based circumcisions

% Device-Based Circumcision

Unit Cost

0% $42.65

5% $43.45

10% $44.25

20% $45.86

30% $47.46

40% $49.06

50% $50.67

60% $52.27

70% $53.87

80% $55.48

90% $57.08

95% $57.88

Site capacity sensitivity analysis

Conclusions• There is not significant cost differences per

procedure for surgery only programs as compared to programs that used both surgery and Prepex device

• The most important driver of costs is demand, as underutilization of sites leads to significant unit costs

• Other cost drivers are supply chain management, commodities including device costs and staffing

• Acceptability of devices as estimated by % of procedures performed using devices was not a significant driver of cost

High Volume, High Quality Service Delivery

Effective Communication focused on Demand Creation

Efficient Supply Chain System and Pooled Procurement to Decrease Commodities Costs

Dedicated Human Resources (task shifting, task sharing)

Dedicated Space

Efficient VMMC

Program

Acknowledgements• Co-investigators of the Modeling

– Dr Katharine Kripke, HPI/Futures Institute– Dr Emmanuel Njeuhmeli, USAID– Dr. Dianna Edgil, USAID– Dr. Steven Forsythe, HPI/Futures Institute– Dr Delivette Castor, USAID – Juan Jaramillo, SCMS

• Dr Jason Reed, OGAC• Dr Anne Thomas, DoD• Dr Renee Ridzon, Consultant BMGF• Tim Farley, Sigma 3 Services• Dr Dino Rech, CHAPS• Robert Bailey, University of Illinois • Walter Obiero, NRHS Kenya • Dr. Karin Hatzold, PSI• PSI, Jhpiego, FHI, SCMS, CHAPS• PrepPex study team Zimbabwe:

– Prof. Mufuta Tshimanga, University of Zimbabwe– Dr. Tonderai Mangwiro, University of Zimbabwe– Dr. Owen Mugurungi, Zimbabwe MOHCW– Sinokuthemba Xaba, Zimbabwe MOHCW– Pessanai Chikobo, ZICHIRE

AIDS 2012—Turning the Tide

Together

Thank you!This research has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under the terms of

the Health Policy Initiative, Costing Task Order.

The USAID | Health Policy Initiative, Costing Task Order (TO6), is funded by the U.S. Agency for International Development under Contract No. GPO-I-00-05-00040-00,

beginning July 1, 2010. The Costing Task Order is implemented by Futures Group, in collaboration with the Futures Institute and the Centre for Development and Population

Activities (CEDPA).

The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of USAID or PEPFAR.