Background: South Africa has a low prevalence of male circumcision. On the basis of compelling and overwhelming evidence that voluntary medical male circumcision (VMMC) reduces men''s risk of becoming HIV infected through heterosexual intercourse, South Africa in 2010 embarked on scaling up its VMMC program. To project the resources needed for continued scale-up of VMMC services and ensure program sustainability, it is crucial to (1) estimate the unit cost to provide VMMC, (2) assess cost drivers and cost variances across the provinces and different VMMC service delivery modes, and (3) evaluate the costs associated with mobilizing and motivating men and boys to access VMMC services.
Methods: Cost data were systematically collected and analyzed from 33 government and PEPFAR-supported (U.S. President´s Emergency Plan for AIDS Relief) urban, rural, and peri-urban VMMC facilities from eight of South Africa''s nine provinces. Unit costs were calculated from a bottom-up approach. All costs are reported in U.S. dollars.
Results: The cost per circumcision performed in South Africa in 2014 was $132, with the largest cost drivers being direct labor (43%), consumables (24%) and quality assurance/quality improvement (13%). The unit cost was higher when performed in public hospitals ($158), compared to health centers and clinics ($121). Direct labor costs could be reduced by 17% if South Africa were to encourage task shifting from doctors to professional nurses, which could have resulted in saving as much as $15 million in 2015, during which the country had set a target of performing 1.6 million circumcisions. About $14.2 million was spent on VMMC demand creation in 2014. Most of these costs were attributable to personnel, including community mobilizers (36%) and small and mass media (35%).
Conclusions: The VMMC unit cost ($132) in 2014 was generally consistent with other studies that analyzed VMMC unit costs in South Africa. VMMC demand creation requires further investigation to assess if the level of spending and the allocation of spending are appropriate for South Africa''s VMMC program. The results of this study are expected to inform strategic planning for continued scale-up of VMMC and to identify the resources required to sustain the VMMC intervention.

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