Correction: The Cost of Voluntary Medical Male Circumcision in South Africa.

[This corrects the article DOI: 10.1371/journal.pone.0160207.].

Correction: Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa.

[This corrects the article DOI: 10.1371/journal.pone.0164147.].

Correction: Cost and Impact of Voluntary Medical Male Circumcision in South Africa: Focusing the Program on Specific Age Groups and Provinces.

[This corrects the article DOI: 10.1371/journal.pone.0157071.].

The Cost of Voluntary Medical Male Circumcision in South Africa.

Given compelling evidence associating voluntary medical male circumcision (VMMC) with men's reduced HIV acquisition through heterosexual intercourse, South Africa in 2010 began scaling up VMMC. To project the resources needed to complete 4.3 million circumcisions between 2010 and 2016, we (1) estimated the unit cost to provide VMMC; (2) assessed cost drivers and cost variances across eight provinces and VMMC service delivery modes; and (3) evaluated the costs associated with mobilize and motivate men and boys to access VMMC services. Cost data were systematically collected and analyzed using a provider's perspective from 33 Government and PEPFAR-supported (U.S. President's Emergency Plan for AIDS Relief) urban, rural, and peri-urban VMMC facilities. The cost per circumcision performed in 2014 was US$132 (R1,431): higher in public hospitals (US$158 [R1,710]) than in health centers and clinics (US$121 [R1,309]). There was no substantial difference between the cost at fixed circumcision sites and fixed sites that also offer outreach services. Direct labor costs could be reduced by 17% with task shifting from doctors to professional nurses; this could have saved as much as $15 million (R163.20 million) in 2015, when the goal was 1.6 million circumcisions. About $14.2 million (R154 million) was spent on medical male circumcision demand creation in South Africa in 2014-primarily on personnel, including community mobilizers (36%), and on small and mass media promotions (35%). Calculating the unit cost of VMMC demand creation was daunting, because data on the denominator (number of people reached with demand creation messages or number of people seeking VMMC as a result of demand creation) were not available. Because there are no "dose-response" data on demand creation ($X in demand creation will result in an additional Z% increase in VMMC clients), research is needed to determine the appropriate amount and allocation of demand creation resources.

Estimating Client Out-of-Pocket Costs for Accessing Voluntary Medical Male Circumcision in South Africa.

In 2010, South Africa launched a countrywide effort to scale up its voluntary medical male circumcision (VMMC) program on the basis of compelling evidence that circumcision reduces men's risk of acquiring HIV through heterosexual intercourse. Even though VMMC is free there, clients can incur indirect out-of-pocket costs (for example transportation cost or foregone income). Because these costs can be barriers to increasing the uptake of VMMC services, we assessed them from a client perspective, to inform VMMC demand creation policies. Costs (calculated using a bottom-up approach) and demographic data were systematically collected through 190 interviews conducted in 2015 with VMMC clients or (for minors) their caregivers at 25 VMMC facilities supported by the government and the President's Emergency Plan for AIDS Relief in eight of South Africa's nine provinces. The average age of VMMC clients was 22 years and nearly 92% were under 35 years of age. The largest reported out-of-pocket expenditure was transportation, at an average of US$9.20 (R 100). Only eight clients (4%) reported lost days of work. Indirect expenditures were childcare costs (one client) and miscellaneous items such as food or medicine (20 clients). Given competing household expense priorities, spending US$9.20 (R100) per person on transportation to access VMMC services could be a significant burden on clients and households, and a barrier to South Africa's efforts to create demand for VMMC. Thus, we recommend a more focused analysis of clients' transportation costs to access VMMC services.

Cost and Impact of Voluntary Medical Male Circumcision in South Africa: Focusing the Program on Specific Age Groups and Provinces.

BACKGROUND: In 2012, South Africa set a goal of circumcising 4.3 million men ages 15-49 by 2016. By the end of March 2014, 1.9 million men had received voluntary medical male circumcision (VMMC). In an effort to accelerate progress, South Africa undertook a modeling exercise to determine whether circumcising specific client age groups or geographic locations would be particularly impactful or cost-effective. Results will inform South Africa's efforts to develop a national strategy and operational plan for VMMC. METHODS AND FINDINGS: The study team populated the Decision Makers' Program Planning Tool, Version 2.0 (DMPPT 2.0) with HIV incidence projections from the Spectrum/AIDS Impact Module (AIM), as well as national and provincial population and HIV prevalence estimates. We derived baseline circumcision rates from the 2012 South African National HIV Prevalence, Incidence and Behaviour Survey. The model showed that circumcising men ages 20-34 offers the most immediate impact on HIV incidence and requires the fewest circumcisions per HIV infection averted. The greatest impact over a 15-year period is achieved by circumcising men ages 15-24. When the model assumes a unit cost increase with client age, men ages 15-29 emerge as the most cost-effective group. When we assume a constant cost for all ages, the most cost-effective age range is 15-34 years. Geographically, the program is cost saving in all provinces; differences in the VMMC program's cost-effectiveness across provinces were obscured by uncertainty in HIV incidence projections. CONCLUSION: The VMMC program's impact and cost-effectiveness vary by age-targeting strategy. A strategy focusing on men ages 15-34 will maximize program benefits. However, because clients older than 25 access VMMC services at low rates, South Africa could consider promoting demand among men ages 25-34, without denying services to those in other age groups. Uncertainty in the provincial estimates makes them insufficient to support geographic targeting.