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

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: c k,j = direct cost per person served at provider, j and kind of cost k k = staff, drugs, supplies etc. c l,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

Impact Model – Age and Sex BirthsS male I male AIDS Death q 0 force of infection S male S female S female I male force of infection 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.

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

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