title: Evaluating the cost of adult voluntary medical male circumcision in a mixed (surgical and PrePex) site compared to a hypothetical PrePex-only site in South Africa.
abstract: BACKGROUND
  Several circumcision devices have been evaluated for a safe and simplified male circumcision among adults. The PrePex device was prequalified for voluntary male medical circumcision (VMMC) in May 2013 by the World Health Organization and is expected to simplify the procedure safely while reducing cost. South Africa is scaling up VMMC.
  
  
  OBJECTIVE
  To evaluate the overall unit cost of VMMC at a mixed site vs. a hypothetical PrePex-only site in South Africa.
  
  
  METHODS
  We evaluated the overall unit cost of VMMC at a mixed site where PrePex VMMC procedure was added to routine forceps-guided scalpel-based VMMC in Soweto, South Africa. We abstracted costs and then modeled these costs for a hypothetical PrePex-only site, at which 9,600 PrePex circumcisions per year could be done. We examined cost drivers and modeled costs, varying the price of the PrePex device. The healthcare system perspective was used.
  
  
  RESULTS
  In both sites, the main contributors of cost were personnel and consumables. If 10% of all VMMC were by PrePex at the mixed site, the overall costs of the surgical method and PrePex were similar - US$59.62 and $59.53, respectively. At the hypothetical PrePex-only site, the unit cost was US$51.10 with PrePex circumcisions having markedly lower personnel and biohazardous waste management costs. In sensitivity analysis with the cost of PrePex kit reduced to US$10 and $2, the cost of VMMC was further reduced.
  
  
  CONCLUSIONS
  Adding PrePex to an existing site did not necessarily reduce the overall costs of VMMC. However, starting a new PrePex-only site is feasible and may significantly reduce the overall cost by lowering both personnel and capital costs, thus being cost-effective in the long term. Achieving a lower cost for PrePex will be an important contributor to the scale-up of VMMC.
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Hae-Young
authors.initials: HY
authors.lastname: Kim
authors.affiliation: Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Limakatso
authors.initials: L
authors.lastname: Lebina
authors.affiliation: Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Minja
authors.initials: M
authors.lastname: Milovanovic
authors.affiliation: Population Services International, Johannesburg, South Africa.
authors.forename: Noah
authors.initials: N
authors.lastname: Taruberekera
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Dowdy
authors.affiliation: Perinatal HIV Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.|Center for Tuberculosis Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA; martinson@phru.co.za.
authors.forename: Neil A
authors.initials: NA
authors.lastname: Martinson
mesh_terms: D000328:Adult; D002944:Circumcision, Male / Q000191:economics* / Q000295:instrumentation / Q000379:methods; D003362:Cost-Benefit Analysis; D004180:Direct Service Costs; D015658:HIV Infections / Q000517:prevention & control; D006801:Humans; D008297:Male; D013019:South Africa; D013525:Surgical Instruments / Q000191:economics*
keywords: HIV prevention; PrePex; South Africa; cost analysis; male circumcision