Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor, USAID Washington

1. Thinking Ahead: Voluntary Medical Male Circumcision Roll-Out With Non Surgical Devices: costing, global access, logistic, and training considerations Emmanuel Njeuhmeli, MD, MPH, MBA Senior Biomedical Prevention Advisor, USAID Washington Co-Chair PEPFAR Male Circumcision Technical Working group

2. 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

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

4. 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

5. 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

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

7. 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

8. Site Comparison and Cost Drivers

9. Mixed site: % device-based circumcisions

10. Site capacity sensitivity analysis

11. 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

12. High Volume, High Quality Service Delivery

13. 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. MufutaTshimanga, University of Zimbabwe • Dr. TonderaiMangwiro, University of Zimbabwe • Dr. Owen Mugurungi, Zimbabwe MOHCW • Sinokuthemba Xaba, Zimbabwe MOHCW • PessanaiChikobo, ZICHIRE