Background: Voluntary medical male circumcision of males 10 years and older is a key component of PEPFAR-supported HIV prevention in 14 southern and eastern African countries. Since 2015, PEPFAR''s priority client age band for circumcision has been 15-29 years, for immediate HIV prevention. However, demand is intrinsically higher in 10-14-year-olds although services packages are the same, and the focus on older males has raised concern that unit expenditures (UEs), expenditures per circumcision, may increase. Routinely-collected 2015 PEPFAR program data allows exploration of whether this association currently exists.
Methods: Implementing partner-level fiscal year 2015 circumcision UE and client age distribution data (age bands 10-14, 15-19, 20-24, and 25-29 years) were used. Partner-level descriptive analysis was performed, followed by univariable and multivariable linear regression of log-transformed UEs on percent of total clientele represented by each age band, adjusting for country due to intercountry variations in operating costs.
Results: Thirty-nine implementing partners (counted once for each country of operation) in 12 countries had data. The median unit expenditure was $93.7, with range $40.4-727.1. The median percent of clients aged 10-14 was 39.1 (range 0.0-72.2); the median percent aged 15-29 was 48.7 (range 11.6-88.2). In univariable analysis, each 1% increase in percent of clients aged 10-14 was associated with a 1% decrease in UE; a 1% increase in percent aged 15-29 had almost no association (anti-log slope = 1.003). After adjustment for country, the association with age 10-14 did not change, but each 1% increase in clients 15-29 years was associated with a 2% UE increase. By 5-year age bands, a negative association with UE was seen for 10-14 and 15-19 years, and a positive association with 20-24 and 25-29 years.
Conclusions: In this cross-sectional analysis, programs with more 10-19-year olds had slightly lower UEs than those with more 20-29-year-olds, and programs with more clients in the combined priority age band of 15-29-year-olds had slightly higher expenditures. If these associations persist over time with successful targeting of this age range, modest UE increases could be seen. However, programs often achieve decreasing UEs over time due to increased productivity, so this association may be mitigated.

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