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

Nalinee Sangrujee and Albena GodloveConstella Futures, Gayle Martin, World Bank

International AIDS Economics Network22 February 2008

Outline

• Background• Estimating resource needs• Resource allocation• Implementation challenges

– Supply side– Demand side

• Monitoring and evaluation• Areas for further economics research

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)

Male circumcision intervention could have two benefits:

DIRECT - accrues to men that receive circumcisionINDIRECT – accrues to everyone in the population (to different degrees)

HIV infections averted over the first 20 years of the intervention

0

20

40

60

80

Circumcised men Women Uncircumcised men

Infe

ctio

ns

avert

ed (

%)

Direct effect (+ 2nd-hand indirect effect)

1st-hand indirect effect

2nd-hand indirect effect

5-times less 5-times less

Indirect effects

Source: Jennifer Smith, Tim Hallett, Simon Gregson, Ben Lopman, Kamal Desai, Marie-Claude Boily, Geoff GarnettDepartment of Infectious Disease Epidemiology Imperial College London

Estimating Resource Needs

Cost Analysis

Resource Needs

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

Comprehensive MC services

Excluded: training costs, policy formulation, community consultation etc.

Breakdown of Comprehensive MC Services

$0.00

$10.00

$20.00

$30.00

$40.00

$50.00

$60.00

Lesotho Swaziland Zambia

Communications

Testing

Counseling

Surgical procedure

$56$51

$47

Breakdown of Comprehensive MC Services

$0.00

$10.00

$20.00

$30.00

$40.00

$50.00

$60.00

Lesotho Swaziland Zambia

Communications

Testing

Counseling

Surgical procedure

$56$51

$47

Variation in Direct Costs

Direct Costs

$0

$10

$20

$30

$40

$50

$60

1 2 3 4 5 6 7 8 9 10 11

Facilities

Variation in Indirect Costs

Indirect Costs

$0

$5

$10

$15

$20

$25

$30

1 2 3 4 5 6 7 8 9 10 11

Facilities

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

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

Lesotho Swaziland Zambia Mozambique

Program coverage target 52.5% 57% 58%

# MC per month 2,289 964 13,948 10,000

Average annual cost of MC$1.3

million $0.5

million $6.5

Million$5.4 Million

Cumulative cost of MC (2008-2020)

$17.2 M $6.6 M $84.9 M $26 M

Number of physicians needed 6.1 FTE120 surgeons (50% effort), 500 doctors

in country

Number of other key personnel needed

4.5 FTE surgical nurses

240 medical assts (50%)

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: 1. Historical growth in coverage of VCT and PMTCT applied to prevention and care

& treatment 2. Universal access by 2015 3. 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

Key Methodological Assumptions for Cost Analysis

• 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

Resource Allocation

Global perspective

National perspective

MALE CIRCUMCISION AND POPULATION BASED HIV PREVALENCE IN AFRICA

0 10 20 30

Botswana

Zambia

Kenya

Cameroon

Ghana

Burkina Faso

Guinea

Sierra Leone

Senegal

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

High (>80%) male circumcision

Low (<20%) male circumcision

What is the impact of the pace of scale-up of circumcision?

Swaziland

Linear scale-up Slower scale-up Faster scale-up

2008-2020 % difference with linear scale-up

Avg annual # MCs

11,297 -1.2% +1.3%

Avg annual # IAs

2,809 -14.5% +13.7%

Cost per IA* $292 +12.1% -8.2%

*Real discount rate = 3%

Due to the first, second and third hand indirect effects associated with MC (Hallet et al. 2007)

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

Financing

Country PreventionFunding

Addt’l Funding June 07

MC FundingFrom

Addt’l Funding

HIV Prevalence²

On-going MC

Service

delivery

MCSvce

Planned

Situat’lAssess-ments

For MC

Provision

CORE Countries

Botswana 15,739 5,500 N/A 24.10%    

Kenya 72,449 60,000 5,000 6.10%

Training Facility    

Mozambique 38,282 15,500 N/A 16.10%    

Namibia 19,332 8,130 N/A 19.60%    

Rwanda 17,776 10,600 N/A 3.10%    

South Africa 54,480 35,050 1,000 18.80%    

Uganda 43,560 23,926 1,200 6.70%    

Zambia 45,147 25,249 3,000 15.60%

Training Facility    

Other Countries

Lesotho N/A N/A N/A 23.20%    

Malawi N/A N/A N/A 14.10%    

Swaziland N/A N/A N/A 33.40%    

Total Lesotho, Malawi and Swaziland 1,000        

Total PEPFAR FY07 Funding for MC Activities 16,000 * Prepared by A. Godlove, Constella Futures

Implementation Challenges

Supply side

Demand side

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?

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.

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

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)

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

Thank You!