1. AIDS 2012— Turning the Tide Together 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 % 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

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 Effective Communicati on 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

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

14. 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.