Estimating the costs of early infant male circumcision

Estimating the costs of early infant male circumcision in Zimbabwe: results from a comparative trial of AccuCirc and Mogen Clamp KARIN HATZOLD , MD, MPH Population Services International Collin Mangenah, CeSSHAR Zimbabwe Harsha Thirumurthy, UNC 8th International AIDS Economics Network Pre-Conference Meeting July 19, 2014 Melbourne, Australia Study Background EIMC is cheaper, quicker, simpler & has complete healing in less than 7 days with low rate of AEs Zimbabwe plans to offer EIMC for HIV prevention alongside adult and adolescent VMMC Currently EIMC devices prequalified by WHO New device - AccuCirc pre-packaged, disposable, potentially usable by midwives AccuCirc previously evaluated in

Botswana, (single-arm study with 151 male infants) Prequalification studies in Zimbabwe Comparative trial Field trial AccuCirc vs Mogen Clamp AccuCirc only Nurse mid-wife delivered n=500 No randomisation Doctor delivered n = 150 Ratio=2:1 Primary outcomes Relative safety Relative acceptability Relative cost Primary outcomes Safety Acceptability Cost

Costing research questions What is the unit cost of EIMC in Zimbabwe? AccuCirc Mogen Clamp What are the key cost drivers for EIMC in Zimbabwe? Role of various components: Device and Commodities price Personnel salaries Facility capacity utilization Nurse mid-wives procedure time EIMC comparative trial: safety and acceptability results 150 eligible male infants enrolled 100 Accucirc, 50 Mogen clamp 2 moderate (and quickly resolved) adverse events in the AccuCirc arm (95% CI 0.0040.077) and 0 in the Mogen clamp arm (95% CI 0.0-0.089) Nearly all parents (99.5%)

reported great satisfaction with the outcome All parents, regardless of arm said they would recommend EIMC to other parents, and would circumcise their next newborn son EIMC Costing Methods Unit costs Direct (personnel, drugs, supplies, training & environmental costs ) + indirect (capital & overheads) Time and motion to calculate labor costs Stopwatch & video camera captured time spent on each task One way sensitivity analysis Device price, Salaries, Site Capacity Utilization, Procedure time Analysis excludes Costs to clients (transport, caregiver costs) Demand creation costs Key assumptions Personnel 100% dedicated to EIMC Personnel Salaries based on PSI/Z & CeSHHAR scales Costs collected under pilot field study environment

Use of MoHCC perspective excludes costs to clients, care giving costs Analysis based on 3024 annual procedures based on site capacity (12 procedures/day x 252 working days) Doctors trained by international consultants; nurses / midwives trained by local master trainers AccuCirc device price = $10 (Clinical Innovations) Comparative trial costing results AccuCirc Cost($)/ EIMC Mogen Clamp Cost($)/EIMC Consumable supplies Non-consumable supplies Device cost Personnel costs Training costs Environmental costs Subtotal Cost Category - indirect

$15.01 $0.27 $10.00 $17.13 $1.88 $1.80 $46.09 $32.05 $0.10 $0.21 $17.13 $1.88 $1.20 $52.57 Capital equipment costs Support personnel costs Subtotal TOTAL UNIT COST OF EIMC $0.04 $5.50 $5.54 $51.62 $0.06

$5.50 $5.56 $58.13 Cost Category - direct All costs in 2013 US$ Cost Comparison of Comparative Trial and Field study** Cost Category - direct Consumable supplies Non-consumable Device cost Personnel costs Training costs Environmental costs Subtotal Cost Category - indirect Capital equipment costs Support personnel costs Subtotal TOTAL UNIT COST OF EIMC All costs in 2013 US$ Doctor Cost($)/ EIMC

Nurse / mid-wife Cost($)/EIMC $15.01 $0.27 $10.00 $17.13 $1.88 $1.80 $46.09 $15.01 $0.27 $10.00 $4.68 $0.95 $1.80 $32.71 $0.04 $5.50 $5.54 $51.62 $0.04 $5.50 $5.54

$38.25 ** Based on 400 EIMCs delivered by nurse/midwife One way sensitivity analysis Site Personnel capacity Procedure Salaries utilization duration $39.65 $36.74 $39.45 Percent change 30% AccuCirc Price $41.24 20% $40.24 $39.18 $37.16

$39.05 10% Base case $39.24 $38.25 $38.71 $38.25 $37.65 $38.25 $38.65 $38.25 -10% $37.24 $37.78 $38.96 $37.84

-20% $36.24 $37.31 $39.86 $37.44 Field study cost results contd Total cost of EIMC procedure $38.25 by midwives vs $51.62 by doctors Would improvements by nurse mid-wives in time taken to perform a procedure impact the cost? Improvement in time taken by nurse midwives on EIMC procedure leads to further reductions in the cost of an EIMC but by a small amount. Conclusions EIMC using AccuCirc is cheaper compared to Mogen Clamp ($51.62 vs $58.13) Nurse-delivered EIMC is considerably cheaper than by doctors ($38.25 vs $51.62) Key cost drivers are device price, personnel costs, & site

capacity utilization Sensitivity analysis confirms device price, personnel costs & site capacity utilization as key cost drivers Improvements in time taken to perform EIMC does not lead to substantial cost reductions ($38.25 vs $ 37.44) Recommendations Device price is a large portion of AccuCirc costs; Need to negotiate price reduction Site capacity utilization is an important cost driver; Ensuring demand for EIMC is therefore critical Cost substantially reduced if EIMC is performed by nurse mid-wives instead of doctors (this is also likely to make procedure more widely available) Acknowledgements Centre for Sexual Health & HIV/AIDS Research (CeSHHAR) Zimbabwe, Harare, Zimbabwe Centre for Sexual Health & HIV Research, University College London, London, UK Ministry of Health and Child Care, Harare,

Zimbabwe Population Services International Zimbabwe, Harare, Zimbabwe University of Zimbabwe, Harare, Zimbabwe London School of Hygiene & Tropical Medicine, London, UK UNC Gillings School of Global Public Health, NC, USA Bill & Melinda Gates Foundation, USA City Health Department, Harare, Zimbabwe EIMC Study team Gerald Gwinji, MoH Zimbabwe Getrude Ncube, MoH Zimbabwe Owen Mugurungi, MoH Zimbabwe Cynthia Chasokela, MoH Zimbabwe Margaret Nyandoro , MoH Zimbabwe Nontando Mothobi, MoH Zimbabwe Ismail Ticklay, University of Zimbabwe Karin Hatzold, Population Services International

Christopher Samkange, University of Zimbabwe Collin Mangenah, CeSSHAR; Frances Cowan, CeSHHAR; University College London Judith Sherman, UNICEF Zimbabwe Webster Mavhu, CeSHHAR; University College London Helen Weiss, London School of Hygiene & Tropical Medicine Harsha Thirumurthy, University of North Carolina at Chapel Hill Andrea Biddle, University of North Carolina at Chapel Hill

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