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Background: In 2010, South Africa embarked on scaling-up its voluntary medical male circumcision (VMMC) program based on compelling evidence that circumcision reduces men''s risk of acquiring HIV infection through heterosexual intercourse. While VMMC is offered free-of-charge, there is concern that clients seeking VMMC services might be incurring some indirect out-of-pocket expenditures such as transportation cost or foregone income. Since these costs might pose challenges to increasing uptake of VMMC services within the target population, this study assessed costs from a client perspective in order to inform policies aimed at demand creation.
Methods: Cost and demographic data were systematically collected through 190 interviews conducted in 2015 with VMMC clients or their caregivers (in the case of minor clients) at 25 Government and PEPFAR-supported VMMC facilities in 8 of the 9 provinces in South Africa. All information on costs was gathered through in-person interviews. Average costs in U.S. dollars were calculated using a bottom-up approach.
Results: The main VMMC clients'' out-of-pocket expenditure reported was transportation cost, with an average of US$ 9.20 (R 100), ranging from US$ 7.75 (R84) in Northern Cape to approximately US$ 14 (R152) in Mpumalanga. Lost days of work were reported by only 8 clients (4%). Other sources of indirect expenditures included costs of childcare or expenditures on miscellaneous items such as food or medicine, reported respectively by 1 and 20 clients.
While the average age of VMMC clients is 22 years, about 42% are < 18 years with the largest proportion of minor clients between 10-15 years of age (29%). Nearly 92% of VMMC clients are < 35 years.
Conclusions: The largest VMMC client out-of-pocket expenditure is transportation costs although there is considerable variation in costs between provinces. In 2011, poor and non-poor households in South Africa were able to spend respectively US$ 0.7 (R7) and US$ 5.8 (R63) daily on transportation.
Consequently, spending R100 on transport to access VMMC services could represent a significant burden to the expansion of VMMC demand creation. Child care expenses and lost income were not significant items identified by respondents, which was not surprising given the relatively young age of the VMMC clients.

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