Evaluating the cost effectiveness of Needle and Syringe exchange programs (NSEPs), Tajikistan

EVALUATING THE COST-EFFECTIVENESS OF NEEDLE AND SYRINGE EXCHANGE PROGRAMS (NSEPs), TAJIKISTAN REGIONAL STUDY ‘COST-EFFECTIVENESS EVALUATION OF NSEPs IN EASTERN EUROPE AND CENTRAL ASIA’ Technical assistance: UNIVERSITY OF NEW SOUTH WALES (AUSTRALIA) JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS (UNAIDS) UNDP ‘HIV/AIDS, TUBERCULOSIS AND MALARIA CONTROL IN TAJIKISTAN’ Team of experts in Tajikistan (Republican AIDS Centre, UNAIDS and UNDP) with the technical assistance of David P. Wilson (University of New South Wales, Australia), Carlos Avila(UNAIDS Geneva), and Anna Yakusik (Health Finance Consultant, Belarus

Executive Summary 4,004 new HIV infections and 6,124 new HCV infections were averted due to NSEPs in Tajikistan More than 505 DALYs related to HIV were averted, and more than 2,860 DALYs related to HCV were averted Impact is still higher on reducing the HCV prevalence in 2020 as the prevalence of HCV is higher than that of HIV Should the country get half of the current resources for needle exchange over the next ten tears, the results would be 3’912 new HIV infections and 5’533 new HCV infections (hence the need for funding!) By adding just 25% to the current resources, the

EVALUATING THE COST-EFFECTIVENESS OF NSEPs: STUDY OBJECTIVES, DESIGN AND METHODOLOGYBACKGROUND OF THE STUDYThe primary aim of NSEPs is to prevent the shared use of injecting equipment inorder to reduce the risk of acquiring blood-borne infections among IDUsInjecting drug use along with growth of commercial sex industry and increasingmigration of the population remains the main driving force of the HIV epidemicin Tajikistan. Since HIV prevalence for a number of years has been higher than 5%among MARPs, particularly IDUs, Tajikistan is in the concentrated epidemic stageHIV/AIDS effectiveness evaluation and cost-effectiveness studies have becomeimportant analytical tools to understand what HIV investments havebought, whether the interventions averted new infections and AIDS deaths, and atwhat cost. They can support decision-making and prioritization of interventionstrategies and target groups within the HIV/AIDS response with its overall goals ofminimizing the burden of disease and maximizing health outcomes

BACKGROUND OF THE STUDY The primary aim of NSEPs is to prevent the shared use of injecting equipment in order to reduce the risk of acquiring blood-borne infections among IDUs IDUs along with growth of commercial sex industry and increasing migration of the population remains the main driving force of the HIV epidemic in Tajikistan. Since HIV prevalence for a number of years has been higher than 5% among MARPs, particularly IDUs, Tajikistan is in the concentrated epidemic stage HIV/AIDS effectiveness evaluation and cost-effectiveness studies have become important analytical tools to understand what HIV investments have bought, whether the interventions averted new infections and AIDS deaths, and at what cost. They can support decision-making and prioritization of intervention strategies and target groups within the HIV/AIDS response with its overall goals of minimizing the burden of disease and maximizing health outcomes

STUDY OBJECTIVES Estimate the population benefits that NSEPs in Tajikistan have likely had in preventing HIV and HCV infections and related health outcomes among IDUs Explore the cost-effectiveness of NSEPs in Tajikistan from health sector perspectiveTherefore, It is important to assess the impact of NSEPs and estimate the cost-effectiveness of current programs as well as the cost- effectiveness of increasing and decreasing the allocation of resources to NSEPs and the programs that they deliver

STUDY DESIGN AND METHODOLOGY Cost-effectiveness evaluation of NSEPs in Tajikistan was carried out using a standardized model and software package, first developed for evaluation of NSEPs in Australia and adapted for general application to any setting in a joint collaboration between UNAIDS and the University of New South Wales (Sydney, Australia) The mathematical transmission model was informed by all available epidemiological, biological, behavioral and clinical data as relevant for the population of IDUs in Tajikistan, as well as trends in the number of syringes distributed through NSEPs The relationship between NSEPs and risk behavior specific to Tajikistan was used to define appropriate yet conservative counterfactual scenarios, that is, the assumed conditions that would likely have been had NSEPs not been in place for the period of 2005-2010 The software was also used to estimate the expected epidemiological and economic benefits associated with increases or decreases in NSEPs in Tajikistan over the next 10 years (2011-2020)

EVALUATING THE COST-EFFECTIVENESS OFNSEPs: INPUT DATATajikistan

General epidemiological trends related to injecting drug use inTajikistan

Population size of IDUs and average number of years ofinjecting for a typical drug user in Tajikistan

Risk injecting behavior of IDUs in Tajikistan

NSEPs interventions for IDUs in Tajikistan (2005-2010)

Sources of funding of NSEPs interventions for IDUs inTajikistan (2005-2010) In 2005-2010, gross funding of NSEPs interventions in Tajikistan was US $ 2.9 million (in 2010 US dollars) In 2005-2010, the sources of funding of NSEPs in Tajikistan were the following:1. UNDP Project "HIV/AIDS, TB and Malaria Control in Tajikistan" funded by the GFATM (about 79% of total spending on NSEPs interventions)2. Central Asian Regional HIV/AIDS Programme (CARHAP)3. Central Asia AIDS Control Project (CAAP)4. Open Society Institute - Assistance Foundation, Tajikistan (data available for 2009 and 2010)

Investments in NSEPs in Tajikistan (2005-2010)Total funding of NSEPs interventions in NSEPs interventions cost distributionTajikistan (US $) by line item (%) TOTAL (US $), unadjusted to CPI TOTAL (US $), adjusted to CPI$1,000,000.00 100% $900,000.00 90% $800,000.00 80% $700,000.00 70% Recurring maintenance and service costs $600,000.00 60% Ongoing personnel costs One-off infrastructure $500,000.00 50% investment Cost of needle-syringe disposal $400,000.00 40% Cost of needle-syringe distribution $300,000.00 30% $200,000.00 20% $100,000.00 10% $0.00 0% 2005 2006 2007 2008 2009 2010 2005 2006 2007 2008 2009 2010 Year

EVALUATION OF THE PAST IMPACT OF NSEPs INTAJIKISTAN (2005-2010)Tajikistan

HIV notifications and expected cases among IDUs and model-basedestimations with and without NSEPs (2005-2010), TajikistanGreen curve represents the level suggested by the model as prevalence without NSEPs

HCV notifications and expected cases among IDUs and model-basedestimations with and without NSEPs (2005-2010), TajikistanGreen curve represents the level suggested by the model as prevalence without NSEPs

Indicators for economic evaluation of NSEPs in Tajikistan(2005-2010) Efficiency of NSEPs in Tajikistan was estimated based on the following indicators and in relation to HIV and HCV:1. Number of new cases of disease in a population in a given time averted (HIV averted cases & HCV averted cases)2. Health outcomes (DALYs) averted3. Cumulative costs per DALY averted4. Health care costs saved

Evaluating the past impact of NSEPs on IDUs in Tajikistan(2005-2010) For the period of 2005-2010 study presents: Gross funding on NSEPs interventions in Tajikistan: US $ 2.9 million Averted infections: 4,004 HIV infections and 6,124 HCV infections averted DALYs averted: 505 DALYs related to HIV and 2,860 DALYs related to HCV averted. Thus, NSEPs interventions appeared to be cost-effective Cumulative costs per DALY averted: US $ 7,109 per DALY averted related to HIV & about US $ 1,313 per DALY averted related to HCV Health care costs saved due to HIV averted cases: US $ 0.11 million saved for the period of 2005-2010 Health care costs saved due to HCV averted cases: US $ 8.87 million saved for the period of 2010. Savings of heath care costs due to HCV aversions for the period of 2005- 2009 were not included into the study results as HCV treatment of patients with chronic hepatitis C (particularly treatment with pegylated interferons) is being provided only since 2010 (15% of patients in need with HIV-HCV coinfection) Net financial costs: US $ -6.08 million. Thus, NSEPs interventions appeared to be cost- saving. US $ 6.08 million saved due to economy on health care costs Return on investment (ROI): on one US dollar spent on NSEPs interventions the gain was of about US $ 3 saved on HIV&HCV health care costs

EVALUATING CHANGES TO NSEPs IN THEFUTURE OVER THE NEXT TEN YEARS(2011-2020)Tajikistan

Projected impact on HIV and HCV cases among IDUs inTajikistan associated with changes in NSEPs over the next tenyears in Belarus The mathematical model was also used to project the expected number of HIV and HCV cases in the future according to scenarios whereby current syringe distribution levels are maintained or if there are increases or decreases in the provision of syringes through NSEPs Different coverage rates were simulated across IDUs up to year 2020 : if NSEPs cease to distribute injecting equipment (2011-2020); if NSEPs decrease overall distribution of injecting equipment by 50% (2011-2020); if NSEPs decrease overall distribution of injecting equipment by 25% (2011-2020); with current conditions of syringe distribution and coverage maintained (2011- 2020); if NSEPs increase overall distribution of injecting equipment by 25% (2011-2020); if NSEPs increase overall distribution of injecting equipment by 50% (2011-2020); if NSEPs increase overall distribution of injecting equipment by 100% (2011-2020); if NSEPs increase overall distribution of injecting equipment by 200% (2011-2020).

Projections of HIV and HCV prevalence, incidence and deathsamong IDUs in Tajikistan due to decreases in NSEPsdistribution of injecting equipment (2011-2020)

Projected impact associated with changes in NSEPs over the next 10 years (2011-2020), Tajikistan NSEPs investment Investments in Change in DALYs Change in infections Incremental ICER (Change NSEPs *, US $ related to HIV HIV HCV costs (change in costs / million and HCV in NSEPs Change in investments DALYs) relative to the baseline), US $ million50% of current levels 4.65 (m $) +4,659 +3,912 +5,533 -4.65 -99875% of current levels 6.98 (m $) +1,505 +1,158 +1,778 -2.32 -1,541Maintain current 9.30 (m $)levels**125% of current levels 11.62 (m $) -568 -410 -665 +2.32 +4,084150% of current levels 13.95 (m $) -765 -548 -894 +4.65 +6,078200% of current levels 18.60 (m $) -853 -609 -997 +9.30 +10,903300% of current levels 29.90 (m $) -864 -617 -1,009 +20.60 +23,843* Assuming costs scale linearly with current implementation costs** Current level of NSEPs is the level of costs of 2010 with the same level of needle and syringe distribution (US $ 0.93 million peryear)

Reproducing of the past impact of NSEPs on IDUs in Tajikistan(2005-2010) Based on the population transmission model, it was estimated that if NSEPs were not in place, the incidence of HIV and HCV would have increased substantially, hence a large epidemic of HIV and HCV among IDUs could have been expected: 4,004 HIV infections and 6,124 HCV infections averted The modeling also suggests that NSEPs in Tajikistan have significantly reduced the potentially higher prevalence of HIV and HCV NSEPs interventions appeared to be cost-effective: 505 DALYs related to HIV and 2,860 DALYs related to HCV averted with key partners (national and international) willingness to pay US $ 7,109 per DALY averted related to HIV & US $ 1,313 per DALY averted related to HCV NSEPs interventions appeared to be cost-saving: US $ 6.08 million saved due to economy on health care costs which would occur if NSEPs have not been in place in the period of 2005-2010 Return on investment (ROI): on one US dollar spent on NSEPs interventions the gain was of about US $ 3 saved on HIV&HCV health care costs

Reproducing of the projected impact of NSEPs on IDUs inTajikistan over the next 10 years (2011-2020) Projected impact associated with changes in NSEPs over the next 10 years (2011- 2020) in Tajikistan show that relatively small shortfalls in funding increase the risk of injecting equipment shared use due to the lack of convenient access to sterile needle and syringes, therefore increases the risk of acquiring blood-borne infections among IDUs and increases the pace of the HIV and HCV epidemic in the country It appears to be cost-effective to maintain and increase the level of NSEPs investments and needle and syringe distribution among IDUs in Tajikistan up to 150% of the current level:• 125% of current level of investments and needle and syringe distribution: one additional DALY gained will require additional investment of US $ 4,084;• 150% of current level of investments and needle and syringe distribution: one additional DALY gained will require additional investment of US $ 6,078. Consistent allocations of resources on NSEPs influences on substantial reduction of the pace of the HIV and HCV epidemic in Tajikistan

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Evaluating the cost effectiveness of Needle and Syringe exchange programs (NSEPs), Tajikistan

by UNDP in Europe and CIS on Jul 05, 2012

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Evaluating the cost effectiveness of Needle and Syringe exchange programs (NSEPs), Tajikistan Presentation Transcript