Estimating the cost efficiency of the PrePex circumcision device in Zambia

AIDS 2014, Melbourne, Australia

July 25th, 2014

Authors: L. Vandament, B. Tambatamba, A. Kaonga, P. Clark, A. Samona, F. Mpasela, N. Chintu

GOVERNMENT OF THE REPUBLIC OF ZAMBIA

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Devices present a potential solution to the human resource constraints faced by countries scaling up male circumcision

Beginning in 2007, fourteen African countries set ambitious short-term targets to reach universal coverage of MC among the existing population of sexually active men.

However, increasing access to a surgical procedure in resource limited countries facing human resource shortages has proven to be a challenge.

Despite significant donor support, and the proliferation of service delivery models for resource limited setting, as of December 2012 priority countries had achieved only 15.2%1 of their 2015 targets.

MC devices, such as PrePex, may allow for increased provider productivity and task shifting, lessening HR constraints.

1. WHO, Progress in scaling up VMMC for HIV prevention in East and Southern Africa, 2013.

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A comparative cost analysis for surgical vs. PrePex circumcision was conducted in Zambia to inform potential introduction

PrePex is non-surgical, reducing procedure times and potentially reducing HR costs per MC by increasing output.

The device is currently approved for adults 18+ (~60% of demand in Zambia) and studies suggest that an additional 7.4%3 of adults are ineligible for anatomical reasons.

At the time of the study, the device cost was $20.2. WHO, Guideline on the use of Devices for Adult Male Circumcision for HIV Prevention, October 2013

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Data on staffing, commodity consumption and output was analyzed to calculate unit cost during the study period

Comparison: Standalone PrePex service delivery compared to standalone surgical circumcision services (dorsal slit method)

Data collected:– Volume of commodities (procurement and consumption data)– Number of health care workers providing services– Number of staff conducting demand creation activities– Number of daily MCs performed

Study sites: 2 urban Society for Family Health sites in Lusaka

Timeframe: Oct 7 - Dec 31, 2013

Analysis: Estimated unit cost of service delivery by method

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Unit cost comparison of PrePex and surgical circumcision

Surgical Prepex$0

$20$40$60$80

$100$120$140

$68 $78

$3$5$10

$27

CommoditiesTrainingHuman Resources

$81.66

Total MCs 910 430Study days 73 73

Sites 2 2

MCs/site/day 6.25 2.95

$109.96

Average unit cost of MC by method

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Human resource cost per MC by method

Surgical Prepex$0

$20

$40

$60

$80

$100

Health PromoterCounselorHygiene AssistantSessional ProviderProvider

$68.17$78.04

• In Zambia, both the provider and the assistant for all circumcisions must be trained providers, leading to a relatively high unit cost for provider time.

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Distribution of MC method by age group

% of MCs 0% 10% 17% 18% 23% 32% 1%PrePex uptake 0% 0% 0% 22% 43% 53% 0%

<1 year 1-9 Years

10-14 Years

15-19 Years

20-24 Years

25-49 Years

50+ Years

0

100

200

300

400

500Surgical

Prepex

Nu

mb

er

of

MC

s

PrePex is currently pre-qualified for 18+

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Projected PrePex unit cost for varying levels of adult uptake

35%45%

55%65%

75%85%

95%$0

$20$40$60$80

$100$120$140$160$180

Estimated Prepex unit cost ($20 device)Estimated Prepex unit cost ($12 device)Surgical unit cost parityObserved Prepex unit cost during study

PrePex uptake (%)

Uni

t cos

t of P

rePe

x ($

) Cost parity would have been achieved at 81% uptake during the study for a $20 device

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Expected impact of PrePex introduction on the cost of scale up

A projection of the annual cost of scale-up in Zambia for 2 scenarios

Increased commodity costs for PrePex circumcisions offset human resource cost savings, leading to very similar scale up costs under both scenarios

Year 1 Year 2 Year 3 Year 4 Year 5 $- $5

$10 $15 $20 $25 $30 $35 $40 $45

PrePex introduced

Year 1 Year 2 Year 3 Year 4 Year 5 $- $5

$10 $15 $20 $25 $30 $35 $40 $45

Surgical only

US

D,

mil

lio

ns

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Further research is required to identify models which would allow PrePex to generate costs savings in Zambia

In our initial study, cost parity for current levels of demand was only achievable above 80% uptake for adults 18+.

In our revised analysis looking at the cost of “mixed” service delivery, even high levels of PrePex uptake failed to yield material cost savings.

Alternate scenarios using a reduced PrePex price of $12 or where the age of eligibility was reduced to 13 years did not change results substantially.

Further studies which evaluate the economics of PrePex only sites, as well as demand creation models targeted to PrePex are needed.

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Acknowledgements

GOVERNMENT OF THE REPUBLIC OF ZAMBIA

• The MC unit at the Ministry of Community Development, Mother & Child Health

• The data collection team from CHAI Zambia - Felton Mpasela & Trevor Mwamba

• The Society for Family Health staff at YWCA and Chachacha health centres

• The study staff from ZPCTII (FHI360)

• The Bill & Melinda Gates Foundation

• AIDS 2014!