title: Comparative Cost of Early Infant Male Circumcision by Nurse-Midwives and Doctors in Zimbabwe.
abstract: The 14 countries that are scaling up voluntary male medical circumcision (VMMC) for HIV prevention are also considering early infant male circumcision (EIMC) to ensure longer-term reductions in HIV incidence. The cost of implementing EIMC is an important factor in scale-up decisions. We conducted a comparative cost analysis of EIMC performed by nurse-midwives and doctors using the AccuCirc device in Zimbabwe.
  
  
  
  Between August 2013 and July 2014, nurse-midwives performed EIMC on 500 male infants using AccuCirc in a field trial. We analyzed the overall unit cost and identified key cost drivers of EIMC performed by nurse-midwives and compared these with costing data previously collected during a randomized noninferiority comparison trial of 2 devices (AccuCirc and the Mogen clamp) in which doctors performed EIMC. We assessed direct costs (consumable and nonconsumable supplies, device, personnel, associated staff training, and waste management costs) and indirect costs (capital and support personnel costs). We performed one-way sensitivity analyses to assess cost changes when we varied key component costs.
  
  
  
  The unit costs of EIMC performed by nurse-midwives and doctors in vertical programs were US$38.87 and US$49.77, respectively. Key cost drivers of EIMC were consumable supplies, personnel costs, and the device price. In this cost analysis, major cost drivers that explained the differences between EIMC performed by nurse-midwives and doctors were personnel and training costs, both of which were lower for nurse-midwives.
  
  
  
  EIMC unit costs were lower when performed by nurse-midwives compared with doctors. To minimize costs, countries planning to scale up EIMC should consider using nurse-midwives, who are in greater supply than doctors and are the main providers at the primary health care level, where most infants are born.
authors.affiliation: Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe.
authors.forename: Collin
authors.initials: C
authors.lastname: Mangenah
authors.affiliation: Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe University College London, London, United Kingdom.
authors.forename: Webster
authors.initials: W
authors.lastname: Mavhu
authors.affiliation: Population Services International, Harare, Zimbabwe.
authors.forename: Karin
authors.initials: K
authors.lastname: Hatzold
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Andrea K
authors.initials: AK
authors.lastname: Biddle
authors.affiliation: Ministry of Health and Child Care, Harare, Zimbabwe.
authors.forename: Getrude
authors.initials: G
authors.lastname: Ncube
authors.affiliation: Ministry of Health and Child Care, Harare, Zimbabwe.
authors.forename: Owen
authors.initials: O
authors.lastname: Mugurungi
authors.affiliation: University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors.forename: Ismail
authors.initials: I
authors.lastname: Ticklay
authors.affiliation: Centre for Sexual Health and HIV/AIDS Research (CeSHHAR), Harare, Zimbabwe University College London, London, United Kingdom.
authors.forename: Frances M
authors.initials: FM
authors.lastname: Cowan
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Harsha
authors.initials: H
authors.lastname: Thirumurthy
mesh_terms: D002944:Circumcision, Male / Q000191:economics* / Q000379:methods*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009721:Nurse Midwives / Q000191:economics*; D010820:Physicians / Q000191:economics*; D015030:Zimbabwe