The Cost and Impact of Scaling-up Medical Male Circumcision in Uganda: An Empirical Analysis

1. The Cost and Impact of Scaling-up Medical Male Circumcision in Uganda: An Empirical Analysis Nazarius Mbona Tumwesigye, Fred Wabwire-Mangen, Danstan Bagenda, Freddie Ssengooba, Alex Opio, Christine Nalwadda, John Stover, Lori Bollinger International AIDS Conference Vienna July 2010

2. Background • Uganda is developing policy guidelines and a strategy regarding medical male circumcision (MMC) • Stakeholder consultations • Assessment of health system capacity for MMC • Eeveloping a communications plan • The Decision-Makers’ Programme Planning Tool (DMPPT) for male circumcision was applied to support this process • Funding from USAID│Health Policy Initiative and UNAIDS

3. Methodology

4. Key considerations in design • Collaborative process with Uganda Ministry of Health Steering Committee on medical male circumcision • Site selection • Adapting the questionnaire • Vetting preliminary results • Defining cost and impact scenarios • Study is from the perspective of the health facility • Commodity data collected on how circumcision currently implemented for adult and newborn (where available) MC • Impact analysis performed in collaboration with a validation workshop

5. Key considerations in design #2 • Several provider types considered and levels of health facilities • Public and NGO/FBO • District hospital, referral hospital and clinic • Task-shifting: Medical officer vs. surgeon • Time allocation determined by experts • Some default values used (e.g., IEC campaign) • Ingredients approach to costing • Allows for flexibility in use of the cost analysis • Enables specific aspects of intervention to be added or subtracted to inform planning

6. Cost Estimation • Direct and indirect costs per person circumcised at each provider (j) type: where: ck,j = direct cost per person served at provider, j and kind of cost k k = staff, drugs, supplies etc. cl,j= indirect cost per person served at provider, j and kind of indirect cost l l = facility equipment, facility utilities, facility supervision etc. S=share of total health facility operation that MC services account for

7. Cost Estimation • Direct and indirect costs of MC with complications were also estimated • Unit cost is weighted by the cost of MC complications and the probability of each complication occurring

8. Cost Data Collection • Site selection process: • 27 sites • Geography • Expected number of MMC clients • Rural and urban facilities • Provider type • Hospitals (referral and district), clinics

9. Impact Model – Age and Sex force of infection 1-15q0 AIDS Death Births S male 15-24 I male 15-24 force of infection S male 25-49 I male 15-24 force of infection S female 15-24 I male 15-24 force of infection S female 25-49 I male 15-24 Force of infection by age and sex is a function of initial force of infection, average risk, proportion of contacts with 15-24/9 and 25/30-49 of opposite sex, male circumcision status and HIV prevalence in opposite sex.

10. Fitting the Model

11. Results: Cost Analysis

12. Comparison of Unit Costs for Uganda and Southern Africa by Component (US$)

13. Key points • The unit cost for MMC is US$21.48 when a surgeon performs the circumcision, US$18.86 when a medical officer performs the circumcision • Consumables account for approximately 45% of the unit cost, while personnel costs account for approximately 28% • Shifting the surgical task from surgeon to medical officer results in a reduction of 12% • Lower costs for both consumables and labor in Uganda result in relatively lower unit cost relative to southern Africa

14. Results: Impact Analysis

15. New adult HIV infections: scale up to 80% coverage of adults and newborns by 2025 (Impact data taken from the Impact part of the larger study) *Real discount rate = 3%

16. Incidence of HIV infection with and without MMC intervention by different coverage scenarios (Impact data taken from the Impact part of the larger study) *Real discount rate = 3%

17. Impact of MMC on HIV prevalence with different population target groups (Impact data taken from the Impact part of the larger study) *Real discount rate = 3%

18. Cumulative number of circumcisions per year with a target of 80% by 2025 compared to no intervention (Impact data taken from the Impact part of the larger study) *Real discount rate = 3%

19. Cost of MMC for a scale-up program compared with no intervention (US$) (Impact data taken from the Impact part of the larger study) *Real discount rate = 3%

20. How cost-effective is MC relative to other prevention interventions? • Cost per HIV infection averted: • Scaling-up to 80% by 2015: $368 • Scaling-up to 80% by 2020: $479 • Scaling-up to 80% by 2025: $672 • Cost per HIV infection averted for selected HIV interventions (from cost-effectiveness literature): • condom distribution: $10–$2,188 • VCT: $393–$482 • PMTCT: $20–$2,198 • STI treatment: $271–$514 • school-based education: $7,288–$13,326

21. Conclusion • Cost • Unit cost for MMC is US$21.48 when a surgeon performs the circumcision, US$18.86 when a medical officer performs the circumcision • Impact • MMC has the potential to avert 30,000 HIV infections in 2025 • HIV incidence could drop by as much as 0.3 percentage points • Scaling up MMC to reach 80% of adults and newborns by 2025 would increase costs rapidly peaking at US$50 million and then leveling off at US$10 million by 2021 • The cost per HIV infection averted could be as low as US$368

22. The Cost and Impact of Scaling-up Medical Male Circumcision in Uganda: An Empirical Analysis Nazarius Mbona Tumwesigye, Fred Wabwire-Mangen, Danstan Bagenda, Freddie Ssengooba, Alex Opio, Christine Nalwadda, John Stover, Lori Bollinger International AIDS Conference Vienna July 2010