David Wilson and Nicole Fraser, Global HIV/AIDS Program, World Bank
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David Wilson and Nicole Fraser, Global HIV/AIDS Program, World Bank David Wilson, University of New South Wales, Australia Tuesday 10 June 2013 IHRA 2013. The Economics and Financing of Harm Reduction. Overview. Why worry? What works and what does it cost? What’s the coverage?

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The economics and financing of harm reduction

David Wilson and Nicole Fraser, Global HIV/AIDS Program, World Bank

David Wilson, University of New South Wales, Australia

Tuesday 10 June 2013

IHRA 2013

The Economics and Financing of Harm Reduction


Overview

Overview

  • Why worry?

  • What works and what does it cost?

  • What’s the coverage?

  • How much is spent on harm reduction?

  • How much is needed to scale-up harm reduction?

  • What’s the cost-effectiveness/return on investment?


Why worry

Why worry?


The economics and financing of harm reduction

Prevalence of Injecting Drug Use

Mathers et al, Lancet (2008)


The economics and financing of harm reduction

Prevalence of HIV among PWID

Mathers et al, Lancet (2008)


The economics and financing of harm reduction

HIV prevalence among PWID in Eastern and Central Asia

Source: Bradley Mathers, Lancet 2008


Hiv infections in pwid as share of infections in eastern europe and central asia

HIV infections in PWID as share of infections in Eastern Europe and Central Asia

Source: Own calculation based on data from EuroHIV (2007)


The economics and financing of harm reduction

HIV prevalence among sex workers in Central Asia


The economics and financing of harm reduction

Surging HIV epidemic among PWID in Greece


Hiv hcv and tb

HIV, HCV and TB

  • PWID have higher HCV and TB rates

  • 10 million PWID may have HCV - surpassing HIV infection

  • HIV+ PWID 2 to 6-fold higher risk of TB infection

  • TB risk 23-fold higher in prisons

Global State of Harm Reduction, 2012


What harm reduction interventions work and what do they cost

What harm reduction interventions work and what do they cost?

  • Three proven priority interventions

    • NSP

    • OST

    • ART

    • WHO, UNODC and UNAIDS - three priority interventions plus HCT, condoms, IEC, STI, HCV and TB prevention/treatment


The economics and financing of harm reduction

What we know about NSP

Source: L. Degenhardt Lancet July 2010


The economics and financing of harm reduction

What we know about NSP

  • HIV prevalence in 99 cities worldwide (MacDonald et al, 2003)

    19% per year in cities with NSP

    8% in cities without NSP

  • International evidence shows NSP effective (Wodak, 2008)


The economics and financing of harm reduction

What we know about OST (versus compulsory detention)

Source: L. Degenhardt Lancet July 2010


The economics and financing of harm reduction

What we know about OST (versus compulsory detention)

  • Compulsory detention common especially in Asia and Eastern Europe

  • Detention costly

    • Minimum cost $1,000 annually in Asia – mainly security

    • Average OST cost $585 annually

  • Two evaluations in progress in Malaysia and Vietnam


Effectiveness of community ost versus compulsory detention

Effectiveness of community OST versus compulsory detention

  • Preliminary data from Malaysia

    • 95% relapse after compulsory detention

    • 7% relapse in community OST


The economics and financing of harm reduction

What we know about OST

  • All RCTs of OST positive (Mattick et al, 2003)

  • Large observational studies show OST decreases heroin use and criminal activity (Mattcick, 1998)

  • OST reduces injecting and increases safe injections (Cochrane Syst. Review; Gowing, 2008; Mattick, 2009)

  • Amsterdam cohort study (Van den Berg, 2007) showed OST and NSP reduced HIV incidence by 66%

  • Recent meta-analysis (Mcarthur BMJ2012) shows OST reduces HIV incidence by 50%


The economics and financing of harm reduction

Whatwe know about ART in PWID


What we know about combined nsp ost art

What we know about combined NSP+OST+ART

Modelling evidence: NSP+OST+ART combination: 5-year impact on HIV incidence 

Source: Degenhardt et al, 2010


What are the cost ranges nsp

What are the cost ranges?NSP

2

  • NSP costs $23–71 /yr 1, but higher if all costs included

  • NSP costs vary by region and delivery system (pharmacies, specialist programme sites, vending machines, vehicles or outreach)

1 UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions


What are the cost ranges ost

What are the cost ranges?OST

2

  • OST cost : Methadone 80 mg: $363 - 1,057 / yr; Buprenorphine, low dose: $1,236 – 3,167 /yr1

  • Few OST cost studies but consistently far higher than NSP

1 UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions


What are the cost ranges art

What are the cost ranges?ART

2

  • ART cost: UNAIDS estimate $1761

  • Estimated costs by authors $1,000-2,000 per HIV+ PWID

1 UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions


The economics and financing of harm reduction

What is the current coverage

of NSP, OST and ART in PWID?


Harm reduction data challenges

Harm reduction data challenges

  • Limited population size estimates

  • Inconsistent service quality data

  • Surveys miss hidden populations

  • ATS increasingly used and injected but missed in surveys

  • Significant but undocumented scale-down of services

Sources: UNGASS country progress reports 2012; Mathers et al., 2010; Global State of Harm Reduction, 2012


Nsp coverage

  • 86 countries and territories implement NSPs

  • 3 new NSPs since 2010 – South Africa, Tanzania, Laos-PDR

  • High coverage limited to Western Europe, Australia and Bangladesh (>200 NS/PWID/year)

NSP coverage

The Global State of Harm Reduction, 2012


Nsp available as per policy black community and prison red community only

NSP available as per policy(Black: community and prison, red: community only)

Global State of Harm Reduction, 2012


Gaps in nsp coverage

  • NSP coverage < 20% in all regions - globally, <2 clean needles distributed /PWID /month

  • Since 2010, NSP provision scaled back in several countries in Asia (Pakistan, Nepal and Cambodia) and Eurasia (Belarus, Hungary, Kazakhstan, Lithuania and Russia)

  • 72 countries with PWID without NSPs

Gaps in NSP coverage

(1) Global State of Harm Reduction, 2012; (2) based on Mathers et al., 2010


Over 14 million pwid 90 may not access nsp

Over 14 million PWID (90%) may not access NSP

Source: Authors’ literature and estimations, based on Mathers et al., 2010


Ost coverage

  • OST in 77 countries worldwide

  • 7 new countries since 2010 (Cambodia, Bangladesh, Tajikistan, Kenya, Tanzania, Macau, Kosovo)

  • Primarily methadone and buprenorphine but also other formulations - slow-release morphine, codeine, heroin-assisted treatment

OST coverage

Global State of Harm Reduction, 2012


Ost available as per policy black community and prison red community only

OST available as per policy(Black: community and prison, red: community only)

Global State of Harm Reduction, 2012


Gaps in ost coverage

  • 6–12% of PWID access OST

  • Coverage limited in much of CIS and Asia

  • OST unavailable in 81 countries with PWID

  • ATS use increasing – and limited ATS harm response

Gaps in OST coverage

Global State of Harm Reduction, 2012


Almost 15 million pwid 92 may not use ost

Almost 15 million PWID (92%) may not use OST

Source: Authors’ literature and estimates, using Mathers et al., 2010


Art coverage in hiv pwid

ART coverage in HIV+ PWID

  • Large regional discrepancies

  • Uptake highest in Western Europe (89%) and Australasia (50%)

  • Elsewhere ART coverage < 5%

  • Largest gaps in Eastern Europe & Central Asia (1 million) and South, East & South-East Asia (700,000)

Source: Authors literature review and estimates, using Mathers et al. 2010


About 2 5 million hiv pwid 85 may not access art

About 2.5 million HIV+ PWID (85%) may not access ART

Source: Authors’ literature and estimates, using Mathers et al. 2010


What is the global coverage of harm reduction services

What is the global coverage of harm reduction services?

Few PWID access all three priority interventions

Female PWID far lower access than males

Source: Authors’ literature review and estimates, using Mathers et al. 2010


How much is spent on harm reduction

  • Estimated $160 million in LMIC in 2007(3 cents per PWID per day): 90% from international donors

  • Global Fund largest HR funder (estimated $430 million 2002-2009) >50% to Eastern Europe and Central Asia

How much is spent on harm reduction?

Sources: Stimson et al 2010 (three cents report), UNAIDS 2009; UNAIDS Progress report 2012; Global State of Harm Reduction, 2012; Bridge et al 2012


Global fund pwid investments by region us

17% Thailand

15% Viet Nam

14% China

Global Fund PWID investments by region (US$)

30% Ukraine

10% Russ Fed

8% Kazakhstan

Sources: Bridge 2012, summarised in Global State of Harm Reduction, 2012


How much is needed to scale up priority harm reduction interventions

  • Very preliminary resource estimates based on regional estimates of current NSP /OST /ART coverage, population sizes and unit costs

  • Mid and high target scenarios costed

How much is needed to scale up priority harm reduction interventions?


The economics and financing of harm reduction

How much needed to scale up priority harm reduction interventions – preliminary estimates


Summary estimated annual cost of scale up of nsp ost and art for pwids

Summary: Estimated annual cost of scale-up of NSP, OST and ART for PWIDs

1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW


Annual scale up costs by region and intervention

Annual scale-up costs by region and intervention

  • Costs dominated by Eastern Europe and Central Asia

1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW


The economics and financing of harm reduction

CE1:

ROI2:

CE1:

ROI2:

CE1:

ROI2:

CE1:

$402-$34,278(9)

$1.1-$5.5(3)

$97-$564(3)

$1.4(1)

$1,456-$2,952(1)

$71-$2,800(7)

$1.2-$8.0(4)

Cost-effectiveness and relative return on investment ranges by region() number of studies in literature

Western Europe, North America & Australasia

Eastern Europe & Central Asia

The Middle East & North Africa

South, East & South East Asia

Latin America & The Caribbean

Sub-Saharan Africa

1: Cost per HIV infection averted 2: Total future return per $1 invested (3% discount rate)


Harm reduction cost effectiveness

Harm reduction cost-effectiveness

  • Harm reduction cost-effective in all regions, with costs per HIV infection averted from $100 -$1,000

  • Harm reduction returns positive, with total future returns per $from $1.1 – $8.0 (3% discount rate)

    Also

  • Unit costs fall as interventions scaled-up

  • Combined, integrated interventions reduce overheads

  • Intervention synergies increase effectiveness


Australia s example economic benefits of a supportive legal and policy environment

Australia’s example: Economic benefits of a supportive legal and policy environment

  • Australia invested A$243 million in NSP

  • Prevented estimated 32,050 HIV infectionsand 96,667 HCV cases

  • A$1.28 billionsaved in direct healthcare costs

  • Including patient/client costs and productivity gains and losses, net present value of NSPs is $5.85 billion

ROI - A$27 per A$1 invested

Source: Return on Investment 2, Department of Health and Ageing, Australian Government


Conclusion

CONCLUSION

  • Inaction costly

    • NOT the equivalent of nothing happening

    • Hard to reverse epidemic once established

  • Whereas harm reduction is

    • Effective - in terms of HIV cases averted

    • Cost-effective - in terms of healthy years gained and costs

    • Social benefits exceed treatment costs

  • And benefits the whole population

    • Substance abuse treatment can benefit more non-drug users than drug users

  • Global best buy


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