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:
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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
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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 = $10 (Clinical Innovations)
Comparative trial costing results
Cost Category - direct
Consumable supplies
Non-consumable supplies
Device cost
Personnel costs
Training costs
Environmental costs
Subtotal
Cost Category - indirect
Capital equipment costs
Support personnel costs
Subtotal
TOTAL UNIT COST OF EIMC
All costs in 2013 US$
AccuCirc
Cost($)/ EIMC
Mogen Clamp
Cost($)/EIMC
$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
$0.04
$5.50
$5.54
$51.62
$0.06
$5.50
$5.56
$58.13
Cost Comparison of Comparative Trial and Field study**
Cost Category - direct
Consumable supplies
Non-consumable
Device cost
Personnel costs
Training costs
Environmental costs
Subtotal
Cost Category - indirect
Capital equipment costs
Support personnel costs
Subtotal
TOTAL UNIT COST OF EIMC
All costs in 2013 US$
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
Procedure
capacity
Salaries
duration
utilization
$39.65
$36.74
$39.45
Percent
change
30%
AccuCirc
Price
$41.24
20%
$40.24
$39.18
$37.16
$39.05
10%
$39.24
$38.71
$37.65
$38.65
Base case
$38.25
$38.25
$38.25
$38.25
-10%
$37.24
$37.78
$38.96
$37.84
-20%
$36.24
$37.31
$39.86
$37.44
Field study cost results cont’d
 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
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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
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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