Background: HIV prevalence is higher for men aged 20-34 years than for younger males (aged 15-19 years) in Tanzania. Voluntary medical male circumcision (VMMC) is a proven HIV prevention intervention, but uptake in Tanzania is highest among younger males. A cluster randomised controlled trial was conducted to assess the effectiveness of a locally-adapted demand creation intervention in increasing uptake of VMMC among men aged 20-34 years in Tabora and Njombe regions of Tanzania. The intervention evaluated included: demand-creation messages; use of peer promoters; separate waiting areas for older clients; and information sessions for female partners. This study presents the total, incremental and unit costs of this VMMC intervention.
Methods: Cost data were collected from a provider''s perspective on surgical, demand-creation and supervisory activities in all clusters across both trial arms. Costs per circumcision were calculated taking into account staff, supplies, start-up and capital costs. Univariate sensitivity analyses were conducted to understand drivers of unit costs.
Results: The total mean costs per cluster were higher in the intervention arms ($48,820 and $46,222, in Tabora and Njombe, respectively) than the control arms ($36,088 and $37,344). Cluster-level client load varied widely across clusters and was higher in the intervention arms (480 to 1187 in Tabora, and 218 to 500 in Njombe) than in the control arms (272 to 951, and 102 to 268, respectively). Demand increased more than proportionately, resulting in lower unit costs: the costs per male circumcised in the intervention arms were $62 ($42-$99) in Tabora and $139 ($93-$195) in Njombe, while in the control arms they were $72 ($39-$123) and $202 ($132-$313), respectively. The sensitivity analysis showed that client volume was a greater determinant of unit costs than input prices or other variables.
Conclusions: The higher unit cost of VMMC in Njombe compared to Tabora may be due to greater VMMC saturation: the number of clients in Tabora was 2.5 times higher than in Njombe. Despite added costs of delivering the intervention, mean unit costs per circumcision were lower. Developing a tailored demand creation package for older VMMC clients is likely an effective approach to increase uptake and ultimately reduce unit costs.

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