Thinking Ahead: Voluntary Medical Male Circumcision Roll-Out With Non Surgical Devices:
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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

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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


Voluntary medical male circumcision
Voluntary Medical Male Circumcision… With Non Surgical Devices:

  • 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


Dmppt estimate of number of adult 15 49 y ears vmmc needed per countries to reach 80 coverage
DMPPT Estimate of Number of Adult With Non Surgical Devices: 15–49 Years VMMC Needed per Countries to Reach 80% Coverage


Strategy for achieving pace and scale
Strategy for Achieving Pace and Scale With Non Surgical Devices:

  • 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


Costing study research q uestions
Costing Study Research With Non Surgical Devices: 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


Cost categories
Cost Categories With Non Surgical Devices:

  • Staff

  • Training

  • Consumables

  • Device

  • Durable equipment

  • Supply chain management

  • Waste management


Caveats
Caveats With Non Surgical Devices:

  • 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


Site comparison and cost d rivers
Site Comparison and Cost With Non Surgical Devices: Drivers


Mixed site device based circumcisions
Mixed site: % device-based circumcisions With Non Surgical Devices:


Site capacity sensitivity analysis
Site capacity sensitivity analysis With Non Surgical Devices:


Conclusions
Conclusions With Non Surgical Devices:

  • 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



Acknowledgements
Acknowledgements With Non Surgical Devices:

  • 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


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