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Cost and cost-effectiveness of voluntary medical male circumcision in street-connected youth: findings from an education-based pilot intervention in Eldoret, Kenya
© The Author(s) 2018
- Received: 2 May 2018
- Accepted: 8 November 2018
- Published: 29 November 2018
Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention. VMMC policies have achieved initial targets in adult men yet continue to fall short in reaching younger men and adolescents.
We present the cost and scale-up implications of an education-based, VMMC intervention for adolescent street-connected males, for whom the street has become their home and/or source of livelihood. The intervention was piloted as part of the Engaging Street Youth in HIV Interventions Project in Eldoret, Kenya.
We used a micro-costing approach to estimate the average cost of a VMMC intervention in 116 street-connected youth. Average cost was estimated per individual and per cohort by dividing total cost per intervention by number of clients accessing the intervention over a 30-day period. Total average costs included direct and support procedure costs, educational costs, and direct research costs. Cost-effectiveness was measured in cost per DALYs averted over a 5 and 10-year period.
The total cost of the intervention was $12,526 over the 30-day period, with an average cost per individual of $108. The direct VMMC procedure cost was approximately $9 per individual. Personnel costs contributed the greatest percentage to the total intervention cost (38.2%), with mentors and social workers representing the highest wage earners. Retreat-related and education costs contributed 51% and 13% respectively to the total average cost, with surgical equipment costs contributing less than 1%. At a cost of $108 per individual, the intervention averted 60166 DALYs in 5 years resulting in a cost per DALY averted of $267.
The VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to reach SCY. Further scale-up may be warranted to effectively apply this intervention in comparable populations.
New HIV infections in Kenya have decreased by more than 19% in adults since 2013 but the number of new infections in young people ages 15–24 has increased by 17% with more than 35,000 annual new infections and 160,000 adolescents currently living with HIV [1–3]. Nearly 29% of all new infections occur among adolescents and AIDS continues to be the leading cause of death among young people in the country [1, 4].
Among young adults in Kenya, certain subpopulations are at an increased risk for HIV infection. Research suggests a ‘hidden hot spot’ of HIV exists among the country’s estimated 300,000 street-connected youth (SCY), defined as any girl or boy for whom the street has become her or his habitual abode and/or sources of livelihood, and who is inadequately protected, supervised or directed by responsible adults . Street-connected youth frequently engage in transactional sex and multiple concurrent partnerships, with rape being an endemic part of street life for girls [6–8]. Alcohol and drug use, low condom use and prior STI infections are largely characteristic of SCY in Kenya and are associated with increased risk for HIV . While these findings are consistent with studies of SCY in other low- and middle-income countries [10–17], research on reaching SCY with effective HIV interventions remains limited, especially in sub-Saharan Africa.
Voluntary medical male circumcision (VMMC) is a critical component of HIV prevention and is widely understood to be cost-effective if provided to males between 15 and 49 years [18–22]. Latest model estimates in several African countries indicate that circumcising youth and adolescents can have a greater cost-savings per HIV infection compared to circumcising adult males alone [23–26]. The strategies Kenya has used to achieve the national target of circumcising 80% of the country’s adult males  have routinely overlooked SCY who do not access health services through traditional channels [27, 28]. Programs which employ innovative and locally-tailored approaches to youth and hard-to-reach populations have shown higher circumcision rates, more efficient resource utilization and increased cost-savings [29–32].
This paper presents the costs and scale-up implications of an education-based VMMC intervention in adolescent street-connected males in Eldoret, Kenya. This intervention is part of a larger study to engage street youth in the HIV prevention-care continuum [33, 34].
Eldoret is the administrative capital of Uasin Gishu (UG) County with a population of nearly 300,000. Eldoret is home to the Moi Teaching and Referral Hospital (MTRH) and the Academic Model Providing Access to Healthcare (AMPATH) program, a large HIV care and treatment program [35, 36]. In 2010, 51.3% of UG County lived below the national poverty line and approximately 52% of the population were age 20 years or younger .
Sampling and recruitment
Male SCY aged 12–24 who had lived on the street for more than 3 months and spent more than 75% of their days and nights on the street or with other SCY in a shared shelter were approached. SCY who were spending both days and nights on the streets and had limited-to-no guardian contact or who had a caregiver to whom they returned at night were also eligible. Those who had not yet been circumcised were invited to participate in the program. Youth were recruited through a snowball-sampling approach by community leaders and peer navigators who conducted outreach and sensitization activities. Eligible SCY were invited to attend a series of local community assemblies (‘mabaraza’) [38, 39] where the intervention was explained to them in a central location before registering at the start of each intervention cycle. Additional details about the eligible population and recruitment strategy is described elsewhere .
The VMMC intervention was piloted in three separate cohort groups over a total of 30 days. Each cohort group participated in the intervention over a 10-day period and received the same program components. Forty SCY consented to participate in groups 1 and 2 and 36 SCY consented to participate in group 3. A target of 40 SCY per group was set based on the number of circumcisions that could reasonably be carried out in a 1-day period. Group 1 was conducted in December 2016 and Groups 2 and 3 were conducted in May 2017. The intervention took place on the grounds of a community organization and rehabilitation center for street-connected boys located on the outskirts of Eldoret.
On day 1, SCY consented or assented to the intervention. Social workers conducted baseline quantitative surveys and a clinical officer (CO) and nurse screened participants to ensure suitability for circumcision. Provider-Initiated Testing and Counselling (PITC) staff tested SCY for HIV. On day 2, the CO and nurses conducted the circumcision surgery in accordance with Kenya’s National Voluntary Medical Male Circumcision Strategy . From days 3–5, the SCY recovered from the procedure under the supervision of a nurse and nurse assistant. From days 6–9 trained mentors facilitated educational modules which focused on life skills, sexual health, and HIV prevention. The modules were taught after circumcision because, following local cultural beliefs, males are thought to enter manhood after being circumcised and it was the hope that SCY would be increasingly open to the subjects that were taught during this time. Teaching the modules after the procedure further allowed wounds to heal under medical supervision and in a sanitary setting. At the end of the modules, SCY completed the end-of-intervention quantitative survey and program evaluation. A graduation ceremony was held on day 10 and included community leaders, the County Children’s Officer, and other support staff and relatives. SCY received a t-shirt and a monogrammed bracelet as an award for completing the program. If a participant indicated wanting to leave the streets, a social worker met with him to begin the process of returning the youth to his family home or Charitable Children’s Institution (CCI) [33, 34].
Costing perspective and procedures
We used a micro-costing approach, from the perspective of the program implementer, to document and account for resources used to implement the VMMC program. Costs were recorded in real time on an ongoing-basis over the course of the intervention. Costs were recorded in Kenyan Shillings (KES) and later converted to United States Dollars (USD) using the average exchange rate during the 30-day intervention period . All costs are presented in USD ($).
All costing information was based on program implementation records; no human subjects’ data were used in this analysis. Costs above the service-delivery level, such as program management, supply chain and staff training costs were excluded from this analysis. These higher-level costs were largely fixed costs for the overall VMMC program, so they are less relevant for a pilot study and micro-costing approach. Experience from other programs suggested that supply chain costs alone could add significantly to total program costs [41, 42].
Calculations provided in supplemental content
Basic information for VMMC intervention
Parameters used in the VMMC intervention
14–24 years; “street-connected”a
Total SCY recruited
Total VMMCs completed
Personnel salaries (daily rate)b
CO, nurse and social worker
PITC counsellor, nurse, nurse assistant, mentors, helpers, cooks
Direct procedure costs per individual (% total cost)
Procedure support costs per individual (% total cost)
Education cost per individual (% total cost)
Direct research cost per individual (% total cost)
KES/$ [Dec 1, 2016–May 31, 2017]
Base value [range]
Parameters used to calculate cost per DALY averted
Male circumcision prevalence in Kenya, age 10–19 (%)
1, 44, 46
VMMC direct procedure cost, $ per circumcision
Pilot data; 44, 27, 49
Annual discount rate (%)
HIV incidence—Nyanza County, 2015 (%)
HIV prevalence in males 15–24 years (%)
Adolescent male population in Kenya, 2020 estimatesc
10–14 years (thousands)
10–19 years (thousands)
10–29 years (thousands)
DALYs/HIV infection averted
Cost of the intervention was itemized by direct procedure costs, procedure support costs, costs of the education component, and research-related costs. Personnel costs included costs to hire the 24 staff recruited to oversee and implement the intervention. AMPATH staff members were paid a daily volunteer rate according to their existing pay grade and volunteer staff were paid based on responsibilities and the local pay scale.
Materials for meals and firewood for cooking were bought locally and in bulk to keep costs to a minimum. All supplies, consumable and reusable, were obtained through the AMPATH procurement department and purchased from the supplier with the lowest quote.
To be able to better inform potential scale-up, we estimated the cost per DALY averted for the VMMC intervention using sensitivity analyses. Price estimates, coverage, and years to scale-up were varied and parameters are reported in Table 1.
Table 1 describes the program implementation parameters and the parameters used to estimate the cost per DALY averted. One hundred and sixteen SCY completed the 10-day program. While it was the goal to recruit only HIV-negative SCY, one participant tested positive for HIV at screening but was allowed to remain in the study to benefit from the education modules and to prevent experiencing stigma amongst his peers. No additional recruitment costs were incurred outside of the personnel costs included in the supplementary materials.
Direct costs of the VMMC surgical procedure
The total direct cost of the VMMC surgical procedure was $994 for the 116 SCY, $8.57 per individual. The average cost of medical supplies was $648 and contributed the greatest proportion to the direct procedure costs (65.2%). Total personnel costs were $291, contributing 29.2% to the direct procedure cost. One clinical officer, two nurses and two nursing assistants were involved in the clinical procedure. Clinical staff were paid a daily salary of $9.69 and worked six of the 30 intervention days. Equipment costs amounted to 5.6% ($56) of the direct procedure costs.
Procedure support costs
Procedure support costs contributed more than 75% ($83.53) to the total intervention cost per individual. Support costs included the cost of supplies to prevent infection after the procedure (e.g. underwear, petroleum jelly, shorts), site rental costs, and costs of non-clinical personnel which accounted for 33% of all procedure support costs. The cost of food for the 10-day intervention period was $18.65 per individual, one-fifth of all support costs.
Costs of HIV education component
Education-related costs included personnel costs for mentors to lead modules on life skills, sexual health, and HIV prevention ($10 per individual), costs of education-related materials, and graduation costs of less than $3 per individual. Education costs contributed 13% to the total intervention cost.
Research-related costs were negligible ($1.80 per individual) and included personnel costs and printing costs for consent/assent forms.
Total intervention costs
The total cost of the intervention for 116 SCY over the 30-day period was $12,526, $108 per individual. Personnel costs totaled $4789 for the 30-day period and contributed the largest proportion to the cost of the intervention (38.2%). Non-clinical personnel were the highest wage earners. The cost to employ four education mentors was $1163 and accounted for 9.28% of the total costs. Cooks, general helpers and security guards received the second highest earnings, $827 each for the 30-day period.
After personnel costs, the greatest expenses related to the retreat components. Personal effects totaled $3415 and food amounted to $2163, contributing 27.3% and 17.3% respectively to the total cost. The cost to purchase shorts for the SCY amounted to 11.6% of the total intervention cost, more than the cost of surgical equipment and medical supplies combined.
The cost to conduct 4 days of education modules per intervention group was driven largely by the cost to employ mentors with minimal costs for materials. Research and evaluation costs contributed less than 1.0% to the total program cost.
The direct clinical cost to circumcise high-risk, street connected youth in this program was less than $10 per procedure. This is considerably less than previous estimates for similar VMMC procedures that target high-risk or hard-to-reach populations: $47 per procedure in South Africa , $53 in Swaziland , and $34–$61 in rural communities in Uganda . We attribute this difference in cost primarily to task-shifting clinical responsibilities to lower-paid staff instead of physicians and to the use of reusable surgical instruments. Based on evidence that task-shifting VMMC procedures reduces costs and maintains comparable levels of quality , four healthcare professionals (1 clinical officer and 3 nurses) carried out the procedures such that 2 circumcisions were conducted at the same time which enabled up to 40 circumcisions per day, double the average number of procedures Kenya’s district hospitals can support in a given day . Sterilizing and reusing the instruments between patients limited the costs of new surgical materials and reduced set up time between patients. Additionally, because the circumcisions were carried out during the day in a tent, there were no electricity costs attributed to the procedure.
The major cost drivers of this intervention were related to the retreat structure (to improve outreach and to prevent infection after the procedure) and the education component. The cost to provide three meals a day over the 30-day period was approximately 18% of the total cost, which was significantly more than the cost of surgical equipment and medical supplies. Employing mentors to facilitate the education modules was 10% of the individual intervention cost.
Estimates from the sensitivity analyses indicate that the VMMC intervention is highly cost-effective when administered to street-connected youth, even at a cost of $108 per individual, and these estimates are in line with previous findings from the literature [20, 23, 32]. While differentiated approaches have shown encouraging results for developing VMMC programs that target adolescents [29–31], they often incur greater costs to reach this age group and are limited to the local context . Findings from this pilot intervention are consistent with studies modelling age-specific VMMC programs in Sub-Saharan Africa [23–25] and may support, from a cost-effectiveness perspective, spending more on the differentiated approaches needed to reach these populations.
In terms of strengths, this article contributes a specific example of applying a micro-costing approach to account for the resources used to implement a VMMC intervention for street-connected youth. Since each intervention group remained within the community center for the full 10-day duration, we could more precisely attribute costs to each component of the intervention, in comparison to itemizing costs at a routine clinic where resources are shared across services. The high retention rate allowed cost comparisons between groups and not only at the individual level. Estimates of the cost per DALYs averted indicate that the intervention is highly cost-effective for reaching this high-risk population which may warrant more formal modelling analyses to understand how costs of the intervention will vary in other settings. The main weakness of this study is that we could only observe costs at a single time point due to the cross-sectional nature of the data, and did not attempt to measure causal relationships between the cost of the intervention and HIV outcomes in SCY. Additionally, the costs estimated in this study pertain to a program implemented in the context of a research study. Thus, costs may vary when considering the supply-side costs that would be involved in introducing the intervention in different setting.
Including outreach and HIV-education activities to engage street connected youth in a VMMC intervention was highly cost-effective in Kenya, despite the additional costs incurred to target this population. Further scale-up may be warranted to effectively apply this intervention in other comparable populations.
OG conceptualized the research, analyzed the data and provided overall guidance on methodology development and implementation throughout the course of the study. PS collected the cost data during the study intervention period and drafted the methodology and results sections of this article. MWB wrote, edited, and finalized the manuscript and led the submission process for this article. PB and DA lead the parent study design and oversee overall study implementation. All authors read and approved the final manuscript.
We are grateful to the Canadian Institutes of Health Research for their support and funding of this research. We acknowledge the contribution of all AMPATH staff and volunteers for their hard work in this study.
The authors declare that they have no competing interests.
Availability of data and materials
All data generated or analyzed during this study are included in this published article and its additional file.
Consent for publication
Ethics approval and consent to participate
Ethical approval was obtained from the MTRH Institutional Research and Ethics Committee and the University of Toronto HIV/AIDS Research Ethics Board. The protocol was approved by the University of Toronto’s Institutional Review Board and adhered to for the study duration.
Participants age 18 years and over provided written consent to participate in the intervention. Individuals age 17 years and under provided written consent in the presence of an adult–child advocate, with the Uasin Gishu County District Children’s Officer acting as de facto guardian. Participants were explained the nature of their participation in a research study, the study procedures, and their right to withdraw from the study at any time. Participants were assured verbally and in writing via the consent form their privacy and confidentiality would be maintained throughout the study.
This research was funded by the Canadian Institutes of Health Research through a Component I HIV Implementation Science Grant (#145367).
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- MOH Na. Kenya AIDS response progress report 2016. Nairobi: National AIDS Control Council (NACC); Ministry of Health; 2016.Google Scholar
- NASCOP&NACC. Kenya HIV estimates 2015. Nairobi: National AIDS Control Council (NACC); National AIDS and STI Control Programme (NASCOP); 2015.Google Scholar
- UNAIDS. Kenya country factsheet 2016. Geneva: UNAIDS; 2016.Google Scholar
- NACC. Kenya’s fast-track plan to end HIV and AIDS among adolescents and young people. Nairobi: National AIDS Control Council; 2015.Google Scholar
- Inter-NGO programme on street children and street youth, sub-regional seminar for the Mediterranean, Marseilles. 1983 Oct 24th–27th; 1983.Google Scholar
- Embleton L, Wachira J, Kamanda A, et al. “Once you join the streets you will have to do it”: sexual practices of street children and youth in Uasin Gishu County, Kenya. Reprod Health. 2015;12:106.View ArticleGoogle Scholar
- Winston SE, Chirchir AK, Muthoni LN, et al. Prevalence of sexually transmitted infections including HIV in street-connected adolescents in western Kenya. Sex Transm Infect. 2015;91(5):353–9.View ArticleGoogle Scholar
- Wachira J, Kamanda A, Embleton L, et al. Initiation to street life: a qualitative examination of the physical, social, and psychological practices in becoming an accepted member of the street youth community in Western Kenya. BMC Public Health. 2015;15:569.View ArticleGoogle Scholar
- Stroeken K, Remes P, De Koker P, Michielsen K, Van Vossole A, Temmerman M. HIV among out-of-school youth in Eastern and Southern Africa: a review. AIDS Care. 2012;24(2):186–94.View ArticleGoogle Scholar
- Taffa N, Bjune G, Sundby J, Gaustad P, Alestrom A. Prevalence of gonococcal and chlamydial infections and sexual risk behavior among youth in Addis Ababa, Ethiopia. Sex Transm Dis. 2002;29(12):828–33.View ArticleGoogle Scholar
- Kayembe PK, Mapatano MA, Fatuma AB, et al. Knowledge of HIV, sexual behavior and correlates of risky sex among street children in Kinshasa, Democratic Republic of Congo. East Afr J Public Health. 2008;5(3):186–92.PubMedGoogle Scholar
- Olley BO. Social and health behaviors in youth of the streets of Ibadan, Nigeria. Child Abuse Negl. 2006;30(3):271–82.View ArticleGoogle Scholar
- Mudingayi A, Lutala P, Mupenda B. HIV knowledge and sexual risk behavior among street adolescents in rehabilitation centres in Kinshasa; DRC: gender differences. Pan Afr Med J. 2011;10:23.View ArticleGoogle Scholar
- Swart-Kruger J, Richter LM. AIDS-related knowledge, attitudes and behaviour among South African street youth: reflections on power, sexuality and the autonomous self. Soc Sci Med. 1997;45(6):957–66.View ArticleGoogle Scholar
- Embleton L, Ayuku D, Atwoli L, Vreeman R, Braitstein P. Knowledge, attitudes, and substance use practices among street children in Western Kenya. Subst Use Misuse. 2012;47(11):1234–47.View ArticleGoogle Scholar
- Nada KH, Suliman el DA. Violence, abuse, alcohol and drug use, and sexual behaviors in street children of Greater Cairo and Alexandria, Egypt. AIDS. 2010;24(Suppl 2):S39–44.View ArticleGoogle Scholar
- Lockhart C. Kunyenga, “real sex,” and survival: assessing the risk of HIV infection among urban street boys in Tanzania. Med Anthropol Q. 2002;16(3):294–311.View ArticleGoogle Scholar
- WHO. Voluntary medical male circumcision for HIV prevention. Geneva: World Health Organization; 2012.Google Scholar
- Hankins C, Forsythe S, Njeuhmeli E. Voluntary medical male circumcision: an introduction to the cost, impact, and challenges of accelerated scaling up. PLoS Med. 2011;8(11):e1001127.View ArticleGoogle Scholar
- Kahn JG, Marseille E, Auvert B. Cost-effectiveness of male circumcision for HIV prevention in a South African setting. PLoS Med. 2006;3(12):e517.View ArticleGoogle Scholar
- White RG, Glynn JR, Orroth KK, et al. Male circumcision for HIV prevention in sub-Saharan Africa: who, what and when? AIDS. 2008;22(14):1841–50.View ArticleGoogle Scholar
- Galarraga O, Wamai RG, Sosa-Rubi SG, et al. HIV prevention costs and their predictors: evidence from the ORPHEA Project in Kenya. Health Policy Plan. 2017;32(10):1407–16.View ArticleGoogle Scholar
- Kripke K, Chen PA, Vazzano A, et al. Cost and impact of voluntary medical male circumcision in south africa: focusing the program on specific age groups and provinces. PLoS ONE. 2016;11(7):e0157071.View ArticleGoogle Scholar
- Kripke K, Chimbwandira F, Mwandi Z, et al. Voluntary medical male circumcision for HIV prevention in malawi: modeling the impact and cost of focusing the program by client age and geography. PLoS ONE. 2016;11(7):e0156521.View ArticleGoogle Scholar
- Kripke K, Perales N, Lija J, et al. The economic and epidemiological impact of focusing voluntary medical male circumcision for HIV prevention on specific age groups and regions in Tanzania. PLoS ONE. 2016;11(7):e0153363.View ArticleGoogle Scholar
- Njeuhmeli E, Forsythe S, Reed J, et al. Voluntary medical male circumcision: modeling the impact and cost of expanding male circumcision for HIV prevention in eastern and southern Africa. PLoS Med. 2011;8(11):e1001132.View ArticleGoogle Scholar
- Government of Kenya MoHN. National voluntary medical male circumcision strategy, 2014/15–2018/19. Nairobi: Kenya MOH and NASCOP; 2014.Google Scholar
- Mwandi Z, Murphy A, Reed J, et al. Voluntary medical male circumcision: translating research into the rapid expansion of services in Kenya, 2008–2011. PLoS Med. 2011;8(11):e1001130.View ArticleGoogle Scholar
- George G, Strauss M, Asfaw E. The cost of demand creation activities and voluntary medical male circumcision targeting school-going adolescents in KwaZulu-Natal, South Africa. PLoS ONE. 2017;12(6):e0179854.View ArticleGoogle Scholar
- Miiro G, DeCelles J, Rutakumwa R, et al. Soccer-based promotion of voluntary medical male circumcision: a mixed-methods feasibility study with secondary students in Uganda. PLoS ONE. 2017;12(10):e0185929.View ArticleGoogle Scholar
- Kaufman ZA, DeCelles J, Bhauti K, et al. A sport-based intervention to increase uptake of voluntary medical male circumcision among adolescent male students: results from the MCUTS 2 cluster-randomized trial in Bulawayo, Zimbabwe. J Acquir Immune Defic Syndr. 2016;72(Suppl 4):S292–8.PubMedGoogle Scholar
- Torres-Rueda S, Wambura M, Weiss HA, et al. Cost and cost-effectiveness of a demand creation intervention to increase uptake of voluntary medical male circumcision in Tanzania: spending more to spend less. J Acquir Immune Defic Syndr. 2018. https://doi.org/10.1097/QAI.0000000000001682.View ArticlePubMedPubMed CentralGoogle Scholar
- Kibel M, Shah P, Ayuku D, et al. Acceptability of a pilot intervention of voluntary medical male circumcision and HIV education for street-connected youth in Western Kenya. J Adolesc Health. 2018. https://doi.org/10.1016/j.jadohealth.2018.07.027.View ArticlePubMedGoogle Scholar
- Shah P et al. Acceptability and uptake of voluntary medical male circumcision and educational modules as part of a coming-of-age retreat—an HIV prevention intervention for adolescent street youth in Western Kenya. In: The international association for adolescent health 11th world congress for adolescent health 2017 New Delhi, India.Google Scholar
- Einterz RM, Kimaiyo S, Mengech HN, et al. Responding to the HIV pandemic: the power of an academic medical partnership. Acad Med. 2007;82(8):812–8.View ArticleGoogle Scholar
- Wools-Kaloustian K, Kimaiyo S, Musick B, et al. The impact of the President’s emergency plan for AIDS relief on expansion of HIV care services for adult patients in western Kenya. AIDS. 2009;23(2):195–201.View ArticleGoogle Scholar
- Kod P. Kenya opent data project. Nairobi: Government of Kenya; 2011.Google Scholar
- Kamanda A, Embleton L, Ayuku D, et al. Harnessing the power of the grassroots to conduct public health research in sub-Saharan Africa: a case study from western Kenya in the adaptation of community-based participatory research (CBPR) approaches. BMC Public Health. 2013;13:91.View ArticleGoogle Scholar
- Naanyu V, Sidle JE, Frankel RM, Ayuku D, Nyandiko WM, Inui TS. Rooting inquiry in tradition: the health baraza as a tool for social research in Kenya. Qual Health Res. 2011;21(1):14–26.View ArticleGoogle Scholar
- Kenya CBo. Foreign Exchange Rates; 2017. https://www.centralbank.go.ke/rates/forex-exchange-rates/.
- Edgil D, Stankard P, Forsythe S, et al. Voluntary medical male circumcision: logistics, commodities, and waste management requirements for scale-up of services. PLoS Med. 2011;8(11):e1001128.View ArticleGoogle Scholar
- Njeuhmeli E, Kripke K, Hatzold K, et al. Cost analysis of integrating the PrePex medical device into a voluntary medical male circumcision program in Zimbabwe. PLoS ONE. 2014;9(5):e82533.View ArticleGoogle Scholar
- WHO. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: World Health Organization; 2003.Google Scholar
- Larson B, Tindikahwa A, Mwidu G, Kibuuka H, Magala F. How much does it cost to improve access to voluntary medical male circumcision among high-risk, low-income communities in Uganda? PLoS ONE. 2015;10(3):e0119484.View ArticleGoogle Scholar
- Ngcobo S, Wolvaardt JE, Bac M, Webb E. The quality of voluntary medical male circumcision done by mid-level workers in Tshwane District, South Africa: a retrospective analysis. PLoS ONE. 2018;13(1):e0190795.View ArticleGoogle Scholar
- Project GHD. Voluntary medical male circumcision in Nyanza Province, Kenya. Boston: Harvard Medical School; 2012.Google Scholar
- Sgaier SK, Eletskaya M, Engl E, et al. A case study for a psychographic-behavioral segmentation approach for targeted demand generation in voluntary medical male circumcision. Elife. 2017;6:e25923.View ArticleGoogle Scholar