AIDS 2014, Melbourne, Australia July 25th, 2014 Estimating the cost efficiency of the PrePex circumcision device in Zambia AIDS 2014, Melbourne, Australia July 25th, 2014 Authors: L. Vandament, B. Tambatamba, A. Kaonga, P. Clark, A. Samona, F. Mpasela, N. Chintu GOVERNMENT OF THE REPUBLIC OF ZAMBIA

Devices present a potential solution to the human resource constraints faced by countries scaling up male circumcision Beginning in 2007, fourteen African countries set ambitious short-term targets to reach universal coverage of MC among the existing population of sexually active men. However, increasing access to a surgical procedure in resource limited countries facing human resource shortages has proven to be a challenge. Despite significant donor support, and the proliferation of service delivery models for resource limited setting, as of December 2012 priority countries had achieved only 15.2%1 of their 2015 targets. MC devices, such as PrePex, may allow for increased provider productivity and task shifting, lessening HR constraints. 1. WHO, Progress in scaling up VMMC for HIV prevention in East and Southern Africa, 2013.

At the time of the study, the device cost was $20. A comparative cost analysis for surgical vs. PrePex circumcision was conducted in Zambia to inform potential introduction PrePex is non-surgical, reducing procedure times and potentially reducing HR costs per MC by increasing output. The device is currently approved for adults 18+ (~60% of demand in Zambia) and studies suggest that an additional 7.4%3 of adults are ineligible for anatomical reasons. At the time of the study, the device cost was $20. The purpose of this analysis was to assess how Zambia’s service delivery models, staffing patterns and demand will impact PrePex cost efficiency. As Zambia has task-shifted surgical circumcision to nurses and uses low cost reusable surgical tools, it will be challenging to achieve cost efficiencies through PrePex. 2. WHO, Guideline on the use of Devices for Adult Male Circumcision for HIV Prevention, October 2013

Volume of commodities (procurement and consumption data) Data on staffing, commodity consumption and output was analyzed to calculate unit cost during the study period Comparison: Standalone PrePex service delivery compared to standalone surgical circumcision services (dorsal slit method) Data collected: Volume of commodities (procurement and consumption data) Number of health care workers providing services Number of staff conducting demand creation activities Number of daily MCs performed Study sites: 2 urban Society for Family Health sites in Lusaka Timeframe: Oct 7 - Dec 31, 2013 Analysis: Estimated unit cost of service delivery by method

Unit cost comparison of PrePex and surgical circumcision Average unit cost of MC by method $109.96 $81.66 PrePex is more costly, though both methods suffered from very high human resource costs per MC due to low daily output PrePex unit cost was greater than surgical ($110 vs. $82). This was true for both human resources ($78 vs. $68) and commodities ($27 vs. $10). Higher staff costs were driven by low average daily demand at study sites (9.2 clients per day) and compounded by low PrePex uptake (52%) among eligible adults. Total MCs 910 430 Study days 73 Sites 2 MCs/site/day 6.25 2.95

Human resource cost per MC by method $78.04 $68.17 Minimum staffing levels required for PrePex in combination with low demand, resulted in high cost of human resources per MC In Zambia, both the provider and the assistant for all circumcisions must be trained providers. If this requirement were removed for PrePex, it could lead to reduced human resource costs for standalone PrePex services. It is not clear, however, that there would be an impact in the context of a mixed site as a 2-provider team would still be required for surgical. High counseling costs for PrePex related to extra requirements for study counseling as well the low demand leading to idle time of counselors assigned to PrePex. In Zambia, both the provider and the assistant for all circumcisions must be trained providers, leading to a relatively high unit cost for provider time.

Distribution of MC method by age group PrePex is currently pre-qualified for 18+ Uptake was relatively high among eligible age groups (especially given study participation time requirements), however, these older age groups only make up ~60% of current demand in Zambia. Moreover, results suggest that significantly higher uptake among eligible age groups would be required to reach cost parity with surgical services. % of MCs 0% 10% 17% 18% 23% 32% 1% PrePex uptake 22% 43% 53%

Projected PrePex unit cost for varying levels of adult uptake Cost parity would have been achieved at 81% uptake during the study for a $20 device It is possible that in a non-study setting, or in response to PrePex specific demand creation, higher levels of uptake could be achieved, making PrePex more cost efficient. In order to assess whether this may have led to a cost advantage, a projection of PrePex unit cost was developed which demonstrated that cost parity would have been achieved at 81% uptake among adults during the study, this would be reduced to 71% if PrePex devices prices were reduced to $12. This analysis was done by re-calculating the average unit cost which would have been achieved IF more eligible men had opted for PrePex, holding PrePex study staffing levels constant, but increasing staff utilization. One of the limitations of this analysis is that staff and resources for the PrePex study were separate from routine surgical staff and supplies. As such, while the sites were providing 2 circumcision methods in parallel, the sites were not operating as a true “mixed model” site where staff and resources could be flexibly allocated across methods in response to changes in relative demand. There is a need for more operational research which compares the average unit cost of a surgical site to a mixed model site which provides both methods with shared resources.

Expected impact of PrePex introduction on the cost of scale up A projection of the annual cost of scale-up in Zambia for 2 scenarios USD, millions In an attempt to overcome the limitations of our initial analysis, we incorporated data from on average daily demand across the country for the three main service delivery models used by SFH Futhermore we assumed that prepex would be introduced into all sites using a mixed model where staff are trained in both methods Based on these assumptions we found that the expected impact on cost of PrePex introduction is minimal We assumed that Prepex uptake would go from 10% in year 1 to 70% in year 3, but as you can see, costs are comparable in all years, suggesting that under a variety of scenarios any savings on human resource costs for prepex circumcisions are offset by higher commodity costs Increased commodity costs for PrePex circumcisions offset human resource cost savings, leading to very similar scale up costs under both scenarios

Further research is required to identify models which would allow PrePex to generate costs savings in Zambia In our initial study, cost parity for current levels of demand was only achievable above 80% uptake for adults 18+. In our revised analysis looking at the cost of “mixed” service delivery, even high levels of PrePex uptake failed to yield material cost savings. Alternate scenarios using a reduced PrePex price of $12 or where the age of eligibility was reduced to 13 years did not change results substantially. Further studies which evaluate the economics of PrePex only sites, as well as demand creation models targeted to PrePex are needed. Prepex eligibility may be extended to the 13-18 years olds, however, studies have shown that 50% of those 13-18 are not eligible because of size or anatomy

GOVERNMENT OF THE REPUBLIC OF ZAMBIA Acknowledgements GOVERNMENT OF THE REPUBLIC OF ZAMBIA The MC unit at the Ministry of Community Development, Mother & Child Health The data collection team from CHAI Zambia - Felton Mpasela & Trevor Mwamba The Society for Family Health staff at YWCA and Chachacha health centres The study staff from ZPCTII (FHI360) The Bill & Melinda Gates Foundation AIDS 2014!