Voluntary Medical Male Circumcision: Logistics, Commodities, and Waste Management Requirements for Scale-Up of Services

Dianna Edgil and colleagues evaluate the supply chain and waste management costs needed to deliver mobile medical male circumcision services to 152,000 men in Swaziland, finding that per-procedure costs almost double when these factors are taken into account. Background: The global HIV prevention community is implementing voluntary medical male circumcision (VMMC) programs across eastern and southern Africa, with a goal of reaching 80% coverage in adult males by 2015. Successful implementation will depend on the accessibility of commodities essential for VMMC programming and the appropriate allocation of resources to support the VMMC supply chain. For this, the United States President’s Emergency Plan for AIDS Relief, in collaboration with the World Health Organization and the Joint United Nations Programme on HIV/AIDS, has developed a standard list of commodities for VMMC programs. Methods and Findings: This list of commodities was used to inform program planning for a 1-y program to circumcise 152,000 adult men in Swaziland. During this process, additional key commodities were identified, expanding the standard list to include commodities for waste management, HIV counseling and testing, and the treatment of sexually transmitted infections. Conclusions: Experience with the VMMC program in Swaziland indicates that supply chain and waste management add approximately US$60 per circumcision, nearly doubling the total per procedure cost estimated previously; these additional costs are used to inform the estimate of per procedure costs modeled by Njeuhmeli et al. in “Voluntary Medical Male Circumcision: Modeling the Impact and Cost of Expanding Male Circumcision for HIV Prevention in Eastern and Southern Africa.” Program planners and policy makers should consider the significant contribution of supply chain and waste management to VMMC program costs as they determine future resource needs for VMMC programs. : Please see later in the article for the Editors' Summary Background: About 33 million people (including 22.5 million in sub-Saharan Africa) are currently infected with HIV, the virus that causes AIDS. Although antiretroviral drugs keep HIV in check, there is no cure for HIV/AIDS. Consequently, prevention of HIV transmission is extremely important. Because HIV is usually spread through unprotected sex with an infected partner, individuals can reduce their risk of becoming infected with HIV by abstaining from sex, by having only one or a few partners, and by always using male or female condoms. In addition, trials in sub-Saharan Africa have shown that male circumcision—the removal of the foreskin, the loose fold of skin that covers the head of the penis—reduces the risk of HIV infection in men by 60%. In 2007, the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) recommended that voluntary medical male circumcision (VMMC) should be part of HIV prevention programs in regions with a generalized HIV epidemic and a low level of male circumcision. Together with the United States President’s Emergency Plan for AIDS Relief (PEPFAR), WHO, and UNAIDS also prioritized 14 countries in eastern and southern Africa for VMMC program scale-up. Mathematical models suggest that, if 80% VMMC coverage is reached by 2015 (which will entail performing 20.33 million circumcisions between 2011 and 2015) and sustained thereafter, VMMC programs in these priority countries will avert more than 4 million HIV infections among adults between 2009 and 2025. Why Was This Study Done?: Successful VMMC scale-up will depend on the commodities that are essential for VMMC services being accessible and on the appropriate allocation of resources to support VMMC programs (which, in addition to circumcision, include HIV testing and counseling, sexually transmitted infection screening and treatment, condom provision and promotion, and counseling on risk reduction and safer sex). To help program planners and policy makers, costing studies have been undertaken in several African countries. These studies considered the costs of a standard list of commodities prepared by PEPFAR, WHO, and UNAIDS and estimated that, on average, one male circumcision costs about US$53. However, these studies did not include the costs of the supply chain, waste management, HIV counseling and testing, treatment of sexually transmitted infections, or the temporary infrastructure needed to deliver mobile VMMC services. Here, the researchers estimate these hitherto ignored costs for the Accelerated Saturation Initiative (ASI; Soka Uncobe [Circumcise and Conquer] in SiSwati), a one-year program to circumcise 152,000 men in Swaziland. What Did the Researchers Do and Find?: The researchers used current market prices of goods and services to calculate the fixed and variable costs of various aspects of the VMMC commodity supply chain such as procurement, international freight, in-country distribution to service delivery sites, and warehousing, and of various aspects of waste management, such as the transportation of waste to incinerators and the maintenance of incinerators. They also estimated the staffing costs of supply chain and waste management services. From these component costs, the researchers estimate that, overall, the costs of supply chain and waste management, including procurement of commodities and associated labor, add US$58.92 if 152,000 men are circumcised and US$73.57 if 75,000 men are circumcised to the previously estimated cost of performing one adult male circumcision through the Swaziland ASI VMMC program. What Do These Findings Mean?: This study suggests that, for the Swaziland ASI VMMC program, procurement, supply chain, and waste management costs nearly double the previously estimated cost per VMMC procedure. That is, the supply chain and waste management costs for this program are nearly as high as the costs of the equipment and staff needed to do the circumcisions. Because these costs were not taken into account during the planning stages of Swaziland’s ASI VMMC program, the initial needs assessment for this program underestimated the actual costs by about US$8 million. Although the magnitude of this underestimate cannot be generalized to other settings, this analysis emphasizes the importance of considering the contribution of supply chain and waste management to costs when determining the future resource needs of VMMC programs. Moreover, it provides a framework to help program planners and policy makers estimate the costs involved in the scale-up of VMMC programs in other priority countries. Additional Information: Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001128.