Cost and Cost-Effectiveness of a Demand Creation Intervention to Increase Uptake of Voluntary Medical Male Circumcision in Tanzania: Spending More to Spend Less

Abstract

Background: Although voluntary medical male circumcision (VMMC) reduces the risk of HIV acquisition, demand for services is lower among men in most at-risk age groups (ages 20-34 years). A randomized controlled trial was conducted to assess the effectiveness of locally-tailored demand creation activities (including mass media, community mobilization, and targeted service delivery) in increasing uptake of campaign-delivered VMMC among men aged 20-34 years. We conducted an economic evaluation to understand the intervention's cost and cost-effectiveness.

Setting: Tanzania (Njombe and Tabora regions).

Methods: Cost data were collected on surgery, demand creation activities, and monitoring and supervision related to VMMC implementation across clusters in both trial arms, as well as start-up activities for the intervention arms. The Decision Makers' Program Planning Tool was used to estimate the number of HIV infections averted and related cost savings, given the total VMMCs per cluster. Disability-adjusted life years were calculated and used to estimate incremental cost-effectiveness ratios.

Results: Client load was higher in the intervention arms than in the control arms: 4394 vs. 2901 in Tabora and 1797 vs. 1025 in Njombe, respectively. Despite additional costs of tailored demand creation, demand increased more than proportionally: mean costs per VMMC in the intervention arms were $62 in Tabora and $130 in Njombe, and in the control arms $70 and $191, respectively. More infections were averted in the intervention arm than in the control arm in Tabora (123 vs. 67, respectively) and in Njombe (164 vs. 102, respectively). The intervention dominated the control because it was both less costly and more effective. Cost savings were observed in both regions stemming from the antiretroviral treatment costs averted as a result of the VMMCs performed.

Conclusions: Spending more to address local preferences as a way to increase uptake of VMMC can be cost-saving.

FIGURE 1.

Plot graph of average cost per VMMC per cluster. The graph shows the average cost per VMMC per cluster (unit cost) plotted against the number of VMMCs per cluster. The data suggest that unit costs decrease as the number of VMMCs per cluster increases.

FIGURE 2.

Incremental cost-effectiveness plane. The 2 squares denote the ICERs for both study regions. Their position in the South-East quadrant suggests that the intervention dominates the control because it is both less costly and more effective.

FIGURE 3.

Tornado diagrams of the percentage changes in the base–case ICER (including averted costs of ART) from a deterministic 1-way analysis of key input variables per region. (1) Light blue bars show the direction and magnitude of change of the ICER when the input is at its minimum value. Conversely, dark blue bars show the direction and magnitude of change of the ICER when the input is at its maximum value. (2) Base case assumptions of parameters: ART costs: $515; ART coverage: 70%; time horizon for infections averted: 15 years; disability weights: HIV symptomatic pre-AIDS 0.274 (0.184–0.377), HIV/AIDS receiving ART 0.078 (0.052–0.111); AIDS: not receiving ART 0.582 (0.406–0.743); per diems demand creation: peer promoter $21 USD, auxiliary peer promoter $11 USD; surgical supplies costs (consumables): Tabora $24,431 (control) and $35,164 (intervention), Njombe $8070 (control) and $14,207 (intervention); clinical staff wages: $7938 USD; TSH to US dollar exchange rate: 2130 TSH:$1 USD; working days per year: 191. (3) The dotted line indicates the point at which the ICER goes from being cost-saving (left) to not cost-saving (right).