Economics of Scaling up New HIV Prevention Interventions: Male Circumcision Example

1. Economics of Scaling up New HIV Prevention Interventions: Male Circumcision Example Nalinee Sangrujee and Albena Godlove Constella Futures, Gayle Martin, World Bank International AIDS Economics Network 22 February 2008

2. Outline • Background • Estimating resource needs • Resource allocation • Implementation challenges • Supply side • Demand side • Monitoring and evaluation • Areas for further economics research

3. Epidemiology behind the intervention • Weiss et al. (2000): Meta-analysis • 48% (95% CI: 32%-60%) • Auvert et al. (2005): Randomized clinical trial • 60% (95% CI: 32%–76%) • Siegfried et al. (2006): Cochrane Review/Meta-analysis • “We found insufficient evidence to support an interventional effect of male circumcision on HIV acquisition in heterosexual men.” • Pointed to protective effect among high risk males • Pointed to limitations of observational studies and the need for RCT evidence • NIH funded trials (2006): Randomized clinical trials • 51% (Uganda) • 60% (Kenya)

4. Male circumcision intervention could have two benefits: • DIRECT - accrues to men that receive circumcision • INDIRECT – accrues to everyone in the population (to different degrees) • HIV infections averted over the first 20 years of the intervention Direct effect (+ 2nd-hand indirect effect) Indirect effects 1st-hand indirect effect 2nd-hand indirect effect 5-times less 5-times less Source: Jennifer Smith, Tim Hallett, Simon Gregson, Ben Lopman, Kamal Desai, Marie-Claude Boily, Geoff Garnett Department of Infectious Disease Epidemiology Imperial College London

5. Estimating Resource Needs Cost Analysis Resource Needs

6. Cost of Male Circumcision and Implications for Cost-Effectiveness of Circumcision as an HIV Intervention* • 3 countries: Lesotho, Swaziland, Zambia • Cost data collected on how circumcision currently implemented • Adult circumcision • Public provider perspective • Considered also services not currently part of circumcision (counseling with or without testing, training, communications) • * In alphabetical order: Lori Bollinger, Steven Forsythe, Bafana Khumalo, Gayle Martin; Rejoice Nkambule, Tanvi Pandit-Rajani, Dean Peacock, Tshehlo Relebohile, John Stover conducted in 2007

7. Comprehensive MC services Excluded: training costs, policy formulation, community consultation etc.

8. Variation in Direct Costs

9. Variation in Indirect Costs

10. How do the costs compare to existing cost estimates? • Other cost studies: • Orange Farm (South Africa) $55 • Rakai (Uganda) $69 • Kisumu (Kenya) $25 • Mankayane (Swaziland) $82 • Mozambique (Fieno) $45 • Problems: • These costs are not directly comparable because it is unclear what is included in the studies

11. Resource estimates for scaling upHealth service implications (2008-2020)

12. Resource needs estimates: current approach for male circumcisionCatherine Hankins, Chief Scientific Adviser to UNAIDS and Associate Director,Department of Evidence, Monitoring and Policy • Only for sub-Saharan African countries • Overall target is 80% of 15-24 year old males circumcised • Three scenarios being considered: • Historical growth in coverage of VCT and PMTCT applied to prevention and care & treatment • Universal access by 2015 • Universal access to prevention by 2010 and to care and treatment by 2015. • Target for each country: reduce the gap between current male circumcision prevalence and the 80% target by half by 2015 (scenario 2) or by half by 2010 (scenario 3) • With these assumptions, resources needed for male circumcision: • $60-160 million in 2010 (implying about 950,000 - 2.5 million circumcisions in the year 2010) • $50-60 million in 2015

13. Differences defining the “MC service package” Establishment of targets Age groups By HIV status Number of trained providers needed to reach targets Estimation of complication rates and their cost in a non clinical setting Non-service delivery costs: Provider training, policy formulation, operationalization and enforcement; quality control; advocacy, community outreach Key Methodological Assumptions for Cost Analysis

14. Resource Allocation Global perspective National perspective

15. MALE CIRCUMCISION AND POPULATION BASED HIV PREVALENCE IN AFRICA High (>80%) male circumcision Low (<20%) male circumcision Sources:Helen Jackson, UNFPA CST, Harare presentation to ESA Regional Consultation Safe Male Circumcision & HIV Prevention Harare, 7-9 May 2007 Data source: ORC/MACRO, 2005, USAID, 2002

16. What is the impact of the pace of scale-up of circumcision?Swaziland Due to the first, second and third hand indirect effects associated with MC (Hallet et al. 2007) *Real discount rate = 3%

17. How cost-effective is MC relative to other prevention interventions? • Cost per infection averted: • Lesotho: $292 • Swaziland: $180 • Zambia: $315 • 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 Alban, Kahn et al, 2006

18. Financing

19. * Prepared by A. Godlove, Constella Futures

20. Implementation Challenges Supply side Demand side

21. Supply side: • Who will carry out safe MC? • Traditional practitioners of ritual circumcision • Private sector • HR shortages in Government facilities already significantly affects service delivery before MC demands came into effect. • How does this procedure become part of the overall package of HIV Interventions • MC is an elective surgery • Circumcision Sundays • Coordinated with other health services • What screening procedures are needed if only circumcise HIV+ men • What Quality Assurance measures • Rapid scale up without proper training could increase complication rates • What services need to be scaled up to address complications?

22. Demand side • Biggest barriers to MC are cost, and concerns about safety (risk of infection or mutilation), and pain • What are the out-of-pocket costs to the individual? Subsidies? • What additional barriers (cultural, economic) to demand and access? • Shifting demand from ritual circumcision.

23. Monitoring and Evaluation • Financial • Funding flows • Provider payments • Programmatic • Exposure to other programs • Number of HIV+ and non HIV+ men circumcised • Behavioral • Risk compensation • Attribution of program effect • Epidemiological • new infections • STIs • complication rates

24. Conclusion • Cost analysis suggests that: • Level in the health service where MC is provided matters • Pace of scaling up matters • Cost effectiveness analysis suggests: • MC can be a cost effective intervention • Benefits accrue over time • Scaling up MC is not without challenges … • Carefully crafted communication messages needed • Indirect costs should not be underestimated • Health service, financial and human resource implications are significant but not insurmountable • Innovative ways have to be found to involve all providers (including the private sector and NGOs)

25. Areas for further research • Neonatal MC (more complicated and the trainings costs higher) • Age differential in risk of infection and circumcision (young men compared to older men given their wealth and sexual behavior) • Rate of complications outside of a trial setting • Estimating additional benefits and costs (complications) • Examining other implementation strategies • combined with other (male) RH services, PMTCT, safe delivery • Analysis of synergies with other HIV prevention interventions • Is there a impact on gender imbalance? Effect of male circumcision on women’s services and deliveryTask shifting – this further complicates the problem. • Legal obstacles: the context in which non physicians (nurses) cannot conduct procedures • Protective effect for other groups: women, MSM, uncircumcised men

26. Thank You!