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Young AM, Havens JR, Cooper HLF, Fallin-Bennett A, Fanucchi L, Freeman PR, Knudsen H, Livingston MD, McCollister KE, Stone J, Vickerman P, Freeman E, Jahangir T, Larimore E, White CR, Cheatom C, Community Staff K, Design Team K. Kentucky Outreach Service Kiosk (KyOSK) Study protocol: a community-level, controlled quasi-experimental, type 1 hybrid effectiveness study to assess implementation, effectiveness and cost-effectiveness of a community-tailored harm reduction kiosk on HIV, HCV and overdose risk in rural Appalachia. BMJ Open 2024; 14:e083983. [PMID: 38431295 PMCID: PMC10910671 DOI: 10.1136/bmjopen-2024-083983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/13/2024] [Indexed: 03/05/2024] Open
Abstract
INTRODUCTION Many rural communities bear a disproportionate share of drug-related harms. Innovative harm reduction service models, such as vending machines or kiosks, can expand access to services that reduce drug-related harms. However, few kiosks operate in the USA, and their implementation, impact and cost-effectiveness have not been adequately evaluated in rural settings. This paper describes the Kentucky Outreach Service Kiosk (KyOSK) Study protocol to test the effectiveness, implementation outcomes and cost-effectiveness of a community-tailored, harm reduction kiosk in reducing HIV, hepatitis C and overdose risk in rural Appalachia. METHODS AND ANALYSIS KyOSK is a community-level, controlled quasi-experimental, non-randomised trial. KyOSK involves two cohorts of people who use drugs, one in an intervention county (n=425) and one in a control county (n=325). People who are 18 years or older, are community-dwelling residents in the target counties and have used drugs to get high in the past 6 months are eligible. The trial compares the effectiveness of a fixed-site, staffed syringe service programme (standard of care) with the standard of care supplemented with a kiosk. The kiosk will contain various harm reduction supplies accessible to participants upon valid code entry, allowing dispensing data to be linked to participant survey data. The kiosk will include a call-back feature that allows participants to select needed services and receive linkage-to-care services from a peer recovery coach. The cohorts complete follow-up surveys every 6 months for 36 months (three preceding kiosk implementation and four post-implementation). The study will test the effectiveness of the kiosk on reducing risk behaviours associated with overdose, HIV and hepatitis C, as well as implementation outcomes and cost-effectiveness. ETHICS AND DISSEMINATION The University of Kentucky Institutional Review Board approved the protocol. Results will be disseminated in academic conferences and peer-reviewed journals, online and print media, and community meetings. TRIAL REGISTRATION NUMBER NCT05657106.
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Affiliation(s)
- April M Young
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Jennifer R Havens
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah L F Cooper
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | | | - Laura Fanucchi
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Patricia R Freeman
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, Kentucky, USA
| | - Hannah Knudsen
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Melvin D Livingston
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kathryn E McCollister
- Division of Health Services Research and Policy, University of Miami, Coral Gables, Florida, USA
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Edward Freeman
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | - Tasfia Jahangir
- Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Elizabeth Larimore
- Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky, USA
| | - Carol R White
- Department of Epidemiology and Environmental Health, University of Kentucky, Lexington, Kentucky, USA
| | | | - KyOSK Community Staff
- College of Medicine, University of Kentucky, Lexington, Kentucky, USA
- College of Public Health, University of Kentucky, Lexington, Kentucky, USA
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2
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Killion JA, Magana C, Cepeda JA, Vo A, Hernandez M, Cyr CL, Heskett KM, Wilson DP, Graff Zivin J, Zúñiga ML, Pines HA, Garfein RS, Vickerman P, Terris-Prestholt F, Wynn A, Martin NK. Unit costs of needle and syringe program provision: a global systematic review and cost extrapolation. AIDS 2023; 37:2389-2397. [PMID: 37773035 PMCID: PMC10653296 DOI: 10.1097/qad.0000000000003718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Needle and syringe programs (NSPs) are effective at preventing HIV and hepatitis C virus (HCV) among people who inject drugs (PWID), yet global coverage is low, partly because governments lack data on the cost and cost-effectiveness of NSP in their countries to plan and fund their responses. We conducted a global systematic review of unit costs of NSP provision to inform estimation of cost drivers and extrapolated costs to other countries. METHODS We conducted a systematic review to extract data on the cost per syringe distributed and its cost drivers. We estimated the impact of country-level and program-level variables on the cost per syringe distributed using linear mixed-effects models. These models were used to predict unit costs of NSP provision, with the best performing model used to extrapolate the cost per syringe distributed for 137 countries. The total cost for a comprehensive NSP (200 syringes per PWID/year) was also estimated for 68 countries with PWID population size estimates. RESULTS We identified 55 estimates of the unit cost per syringe distributed from 14 countries. Unit costs were extrapolated for 137 countries, ranging from $0.08 to $20.77 (2020 USD) per syringe distributed. The total estimated spend for a high-coverage, comprehensive NSP across 68 countries with PWID size estimates is $5 035 902 000 for 10 887 500 PWID, 2.1-times higher than current spend. CONCLUSION Our review identified cost estimates from high-income, upper-middle-income, and lower-middle-income countries. Regression models may be useful for estimating NSP costs in countries without data to inform HIV/HCV prevention programming and policy.
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Affiliation(s)
- Jordan A Killion
- University of California San Diego, La Jolla
- San Diego State University, San Diego, California
| | | | | | - Anh Vo
- Johns Hopkins University, Baltimore, Maryland, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Natasha K Martin
- University of California San Diego, La Jolla
- University of Bristol, Bristol, UK
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3
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Bollinger LA, Bellows N, Linder R. Examining the characteristics of social and behavior change communication intervention costs in low- and middle-income countries: A hedonic method approach. PLoS One 2023; 18:e0287236. [PMID: 37319243 PMCID: PMC10270606 DOI: 10.1371/journal.pone.0287236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/01/2023] [Indexed: 06/17/2023] Open
Abstract
Understanding the costs of health interventions is critical for generating budgets, planning and managing programs, and conducting economic evaluations to use when allocating scarce resources. Here, we utilize techniques from the hedonic pricing literature to estimate the characteristics of the costs of social and behavior change communication (SBCC) interventions, which aim to improve health-seeking behaviors and important intermediate determinants to behavior change. SBCC encompasses a wide range of interventions including mass media (e.g., radio, television), mid media (e.g., community announcements, live dramas), digital media (e.g., short message service/phone reminders, social media), interpersonal communication (e.g., individual or group counseling), and provider-based SBCC interventions focused on improving provider attitudes and provider-client communication. While studies have reported on the costs of specific SBCC interventions in low- and middle-income countries, little has been done to examine SBCC costs across multiple studies and interventions. We use compiled data across multiple SBCC intervention types, health areas, and low- and middle-income countries to explore the characteristics of the costs of SBCC interventions. Despite the wide variation seen in the unit cost data, we can explain between 63 and 97 percent of total variance and identify a statistically significant set of characteristics (e.g., health area) for media and interpersonal communication interventions. Intervention intensity is an important determinant for both media and interpersonal communication, with costs increasing as intervention intensity increases; other important characteristics for media interventions include intervention subtype, target population group, and country income as measured by per capita Gross National Income. Important characteristics for interpersonal communication interventions include health area, intervention subtype, target population group and geographic scope.
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Affiliation(s)
| | - Nicole Bellows
- Avenir Health, Glastonbury, Connecticut, United States of America
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Lim AG, Trickey A, Thompson LH, Emmanuel F, Reza TE, Reynolds R, Cholette F, Melesse DY, Archibald C, Sandstrom P, Blanchard JF, Vickerman P. Elucidating Drivers for Variations in the Explosive Human Immunodeficiency Virus Epidemic Among People Who Inject Drugs in Pakistan. Open Forum Infect Dis 2021; 8:ofab457. [PMID: 34584901 PMCID: PMC8465332 DOI: 10.1093/ofid/ofab457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Pakistan's explosive human immunodeficiency virus (HIV) epidemic among people who inject drugs (PWID) varies widely across cities. We evaluated possible drivers for these variations. METHODS Multivariable regression analyses were undertaken using data from 5 national surveys among PWID (n = 18 467; 2005-2017) to determine risk factors associated with variations in city-level HIV prevalence. A dynamic HIV model was used to estimate the population-attributable fraction (PAF; proportion of HIV infections prevented over 10 years when that risk factor is removed) of these risk factors to HIV transmission and impact on HIV incidence of reducing their prevalence. RESULTS Regression analyses suggested that city-level HIV prevalence is strongly associated with the prevalence of using professional injectors at last injection, heroin use in last month, and injecting ≥4 times per day. Through calibrating a model to these associations, we estimate that the 10-year PAFs of using professional injectors, heroin use, and frequent injecting are 45.3% (95% uncertainty interval [UI], 4.3%-79.7%), 45.9% (95% UI, 8.1%-78.4%), and 22.2% (95% UI, 2.0%-58.4%), respectively. Reducing to lowest city-level prevalences of using professional injectors (2.8%; median 89.9% reduction), heroin use (0.9%; median 91.2% reduction), and frequent injecting (0.1%; median 91.8% reduction) in 2020 reduces overall HIV incidence by 52.7% (95% UI, 6.1%-82.0%), 53.0% (95% UI, 11.3%-80.2%), and 28.1% (95% UI, 2.7%-66.6%), respectively, over 10 years. CONCLUSIONS Interventions should focus on these risk factors to control Pakistan's explosive HIV epidemic among PWID, including a concomitant expansion of high-coverage needle/syringe provision, opioid substitution therapy, and antiretroviral therapy.
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Affiliation(s)
- Aaron G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Adam Trickey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Laura H Thompson
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Faran Emmanuel
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
- Canada-Pakistan HIV/AIDS Surveillance Project, Islamabad, Pakistan
| | - Tahira E Reza
- Canada-Pakistan HIV/AIDS Surveillance Project, Islamabad, Pakistan
| | - Rosy Reynolds
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - François Cholette
- National HIV and Retrovirology Laboratories, JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, Canada
- Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, Canada
| | | | - Chris Archibald
- Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada
| | - Paul Sandstrom
- National HIV and Retrovirology Laboratories, JC Wilt Infectious Diseases Research Centre, Public Health Agency of Canada, Winnipeg, Canada
| | - James F Blanchard
- Centre for Global Public Health, University of Manitoba, Winnipeg, Canada
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Ranta J. Reducing harms through interactions: Workers orienting to unpredictable frames in a low-threshold project for people injecting drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 82:102828. [PMID: 32599555 DOI: 10.1016/j.drugpo.2020.102828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 05/27/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND People using injection drugs and living in complex, vulnerable and stigmatised life situations can face many kinds of barriers when accessing social and healthcare services. Thus, they are often encountered in easily reachable low-threshold services aimed at harm reduction. However, little is known about how clients' multiple drug-related needs are actually encountered in the everyday practices of harm reduction work. METHODS This ethnomethodologically oriented interaction analysis examines harm reduction work in a Finnish low-threshold project, the aim of which is to support clients broadly in their drug-related life situations. The data consist of 12 audio-recorded client-worker meetings observed in 2017 by utilising mobile ethnography. In this context, workers are expected to react to clients' needs in situ; they must take different kinds of orientations within the interactional frames that the clients have set for the meetings. This study asks: 1) In what kinds of frames are client-worker conversations conducted in the project? 2) How do the workers orient to these frames? RESULTS The results point out that participants orient to various frames - practical, therapeutic, educational and casual - during the meetings. The workers respect the frames set by the clients and maintain them by taking variable interactional orientations. By doing so, they are able to respond to the clients' individual and acute needs, and they conduct a client-centred harm reduction approach through interactions. CONCLUSIONS The study highlights that when workers utilise situationally reactive interactional approaches, they conduct client-centred harm reduction work through interactions. When people using injection drugs are given much interactional freedom, they can be powerful actors in institutional contexts. Thus, harm reduction is not merely about reducing the concrete risks of drug use; it is also about social interactions that show respect for the interests of the people visiting the service.
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Affiliation(s)
- Johanna Ranta
- Faculty of Social Sciences, Tampere University, SOC, 33014 Tampere, Finland.
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Gourab G, Khan MNM, Hasan AMR, Sarwar G, Irfan SD, Reza MM, Saha TK, Rahman L, Rana AKMM, Khan SI. The willingness to receive sexually transmitted infection services from public healthcare facilities among key populations at risk for human immunodeficiency virus infection in Bangladesh: A qualitative study. PLoS One 2019; 14:e0221637. [PMID: 31483809 PMCID: PMC6726367 DOI: 10.1371/journal.pone.0221637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Accepted: 08/12/2019] [Indexed: 11/19/2022] Open
Abstract
Background In Bangladesh, community-based and peer-led prevention interventions for human immunodeficiency virus infection are provided to key populations (KPs) by drop-in centers (DICs), which are primarily supported by external donors. This intervention approach was adopted because public healthcare facilities were reportedly insensitive to the needs and culture of KPs, particularly with regard to the provision of sexually transmitted infection (STI) services. Nonetheless, in the absence of external funding, STI services need to be integrated into public healthcare systems. Methods A qualitative study was conducted in 2017 to understand the willingness of KPs to uptake the STI services of public healthcare facilities. Data were collected based on 34 in-depth interviews, 11 focus group discussions, and 9 key informant interviews. The social-ecological theoretical framework was used to analyze the data thematically and contextually. Results Most participants were either resistant or reluctant to uptake STI services from public healthcare facilities because of their previous firsthand experiences (e.g., disrespectful and judgmental attitudes and behaviors), perceived discrimination, anticipatory fear, and a lack of privacy. Very few participants who had visited these facilities to receive STI services were motivated to revisit them. Nevertheless, they emphasized their comfort in DICs over public healthcare facilities. Thus, it appears that KPs can be situated along a care-seeking continuum (i.e., resistance to complete willingness). Unless policymakers understand the context and reasons that underlie their movement along this continuum, it would be difficult to encourage KPs to access STI services from public healthcare facilities. Conclusion KPs’ willingness to uptake the STI services of public healthcare facilities depends not only on individual and community experiences but also on the nexus between socio-structural factors and health inequalities. Community mobilization and training about the needs and culture of KPs for healthcare professionals are essential. Therefore, addressal of a wide range of structural factors is required to motivate KPs into seeking STI services from public healthcare facilities.
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Affiliation(s)
- Gorkey Gourab
- Programme for HIV and AIDS, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
- * E-mail:
| | | | - A. M. Rumayan Hasan
- Universal Health Coverage, Health System and Population Studies Division, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Golam Sarwar
- Programme for HIV and AIDS, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Samira Dishti Irfan
- Programme for HIV and AIDS, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Md. Masud Reza
- Programme for HIV and AIDS, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | | | - Lima Rahman
- HIV/AIDS Program, Health, Nutrition and HIV/AIDS Sector, Save the Children, Dhaka, Bangladesh
| | - A. K. M. Masud Rana
- Programme for HIV and AIDS, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Sharful Islam Khan
- Programme for HIV and AIDS, International Centre for Diarrhoeal Diseases Research, Dhaka, Bangladesh
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Sweeney S, Ward Z, Platt L, Guinness L, Hickman M, Hope V, Maher L, Iversen J, Hutchinson SJ, Smith J, Ayres R, Hainey I, Vickerman P. Evaluating the cost-effectiveness of existing needle and syringe programmes in preventing hepatitis C transmission in people who inject drugs. Addiction 2019; 114:560-570. [PMID: 30674091 DOI: 10.1111/add.14519] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 07/06/2018] [Accepted: 11/26/2018] [Indexed: 12/12/2022]
Abstract
AIM To evaluate the cost-effectiveness of needle and syringe programmes (NSPs) compared with no NSPs on hepatitis C virus (HCV) transmission in the United Kingdom. DESIGN Cost-effectiveness analysis from a National Health Service (NHS)/health-provider perspective, utilizing a dynamic transmission model of HCV infection and disease progression, calibrated using city-specific surveillance and survey data, and primary data collection on NSP costs. The effectiveness of NSPs preventing HCV acquisition was based on empirical evidence. SETTING AND PARTICIPANTS UK settings with different chronic HCV prevalence among people who inject drugs (PWID): Dundee (26%), Walsall (18%) and Bristol (45%) INTERVENTIONS: Current NSP provision is compared with a counterfactual scenario where NSPs are removed for 10 years and then returned to existing levels with effects collected for 40 years. MEASUREMENTS HCV infections and cost per quality-adjusted life year (QALY) gained through NSPs over 50 years. FINDINGS Compared with a willingness-to-pay threshold of £20 000 per QALY gained, NSPs were highly cost-effective over a time-horizon of 50 years and decreased the number of HCV incident infections. The mean incremental cost-effectiveness ratio was cost-saving in Dundee and Bristol, and £596 per QALY gained in Walsall, with 78, 46 and 40% of simulations being cost-saving in each city, respectively, with differences driven by coverage of NSP and HCV prevalence (lowest in Walsall). More than 90% of simulations were cost-effective at the willingness-to-pay threshold. Results were robust to sensitivity analyses, including varying the time-horizon, HCV treatment cost and numbers of HCV treatments per year. CONCLUSIONS Needle and syringe programmes are a highly effective low-cost intervention to reduce hepatitis C virus transmission, and in some settings they are cost-saving. Needle and syringe programmes are likely to remain cost-effective irrespective of changes in hepatitis C virus treatment cost and scale-up.
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Affiliation(s)
- Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Zoe Ward
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Lorna Guinness
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Vivian Hope
- Public Health Institute, Liverpool John Moores University, Liverpool, UK
| | - Lisa Maher
- Kirby Institute for Infection and Immunity, UNSW, Sydney, Australia
| | - Jenny Iversen
- Kirby Institute for Infection and Immunity, UNSW, Sydney, Australia
| | | | - Josie Smith
- Public Health Wales, Cardiff, Wales, UK, CF10 4BZ
| | | | | | - Peter Vickerman
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
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Cepeda JA, Burgos JL, Kahn JG, Padilla R, Meza Martinez PE, Segovia LA, Gaines T, Abramovitz D, Rangel G, Magis-Rodriguez C, Vickerman P, Strathdee SA, Martin NK. Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis. BMJ Open 2019; 9:e026298. [PMID: 30700490 PMCID: PMC6352756 DOI: 10.1136/bmjopen-2018-026298] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 12/13/2018] [Accepted: 12/21/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision. DESIGN Costing study and longitudinal cohort study. SETTING Tijuana, Mexico. PARTICIPANTS Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study. PRIMARY OUTCOME MEASURES Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal. RESULTS During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02). CONCLUSIONS Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.
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Affiliation(s)
- Javier A Cepeda
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Jose Luis Burgos
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - James G Kahn
- Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, California, USA
| | | | | | | | - Tommi Gaines
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Daniela Abramovitz
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Gudelia Rangel
- Population Studies, El Colegio de la Frontera Norte, Tijuana, Mexico
| | | | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Steffanie A Strathdee
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, California, USA
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Platt L, Sweeney S, Ward Z, Guinness L, Hickman M, Hope V, Hutchinson S, Maher L, Iversen J, Craine N, Taylor A, Munro A, Parry J, Smith J, Vickerman P. Assessing the impact and cost-effectiveness of needle and syringe provision and opioid substitution therapy on hepatitis C transmission among people who inject drugs in the UK: an analysis of pooled data sets and economic modelling. PUBLIC HEALTH RESEARCH 2017. [DOI: 10.3310/phr05050] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background
There is limited evidence of the impact of needle and syringe programmes (NSPs) and opioid substitution therapy (OST) on hepatitis C virus (HCV) incidence among people who inject drugs (PWID), nor have there been any economic evaluations.
Objective(s)
To measure (1) the impact of NSP and OST, (2) changes in the extent of provision of both interventions, and (3) costs and cost-effectiveness of NSPs on HCV infection transmission.
Design
We conducted (1) a systematic review; (2) an analysis of existing data sets, including collating costs of NSPs; and (3) a dynamic deterministic model to estimate the impact of differing OST/NSP intervention coverage levels for reducing HCV infection prevalence, incidence and disease burden, and incremental cost-effectiveness ratios to measure the cost-effectiveness of current NSP provision versus no provision.
Setting
Cost-effectiveness analysis and impact modelling in three UK sites. The pooled analysis drew on data from the UK and Australia. The review was international.
Participants
PWID.
Interventions
NSP coverage (proportion of injections covered by clean needles) and OST.
Outcome
New cases of HCV infection.
Results
The review suggested that OST reduced the risk of HCV infection acquisition by 50% [rate ratio (RR) 0.50, 95% confidence interval (CI) 0.40 to 0.63]. Weaker evidence was found in areas of high (≥ 100%) NSP coverage (RR 0.77, 95% CI 0.38 to 1.54) internationally. There was moderate evidence for combined high coverage of NSPs and OST (RR 0.29, 95% CI 0.13 to 0.65). The pooled analysis showed that combined high coverage of NSPs and OST reduced the risk of HCV infection acquisition by 29–71% compared with those on minimal harm reduction (no OST, ≤ 100% NSP coverage). NSPs are likely to be cost-effective and are cost-saving in some settings. The impact modelling suggest that removing OST (current coverage 81%) and NSPs (coverage 54%) in one site would increase HCV infection incidence by 329% [95% credible interval (CrI) 110% to 953%] in 2031 and at least double (132% increase; 95% CrI 51% to 306%) the number of new infections over 15 years. Increasing NSP coverage to 80% has the largest impact in the site with the lowest current NSP coverage (35%), resulting in a 27% (95% CrI 7% to 43%) decrease in new infections and 41% (95% CrI 11% to 72%) decrease in incidence by 2031 compared with 2016. Addressing homelessness and reducing the harm associated with the injection of crack cocaine could avert approximately 60% of HCV infections over the next 15 years.
Limitations
Findings are limited by the misclassification of NSP coverage and the simplified intervention definition that fails to capture the integrated services that address other social and health needs as part of this.
Conclusions
There is moderate evidence of the effectiveness of OST and NSPs, especially in combination, on HCV infection acquisition risk. Policies to ensure that NSPs can be accessed alongside OST are needed. NSPs are cost-saving in some sites and cost-effective in others. NSPs and OST are likely to prevent considerable rates of HCV infection in the UK. Increasing NSP coverage will have most impact in settings with low coverage. Scaling up other interventions such as HCV infection treatment are needed to decrease epidemics to low levels in higher prevalence settings.
Future work
To understand the mechanisms through which NSPs and OST achieve their effect and the optimum contexts to support implementation.
Funding
The National Institute for Health Research Public Health Research programme.
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Affiliation(s)
- Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Zoe Ward
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Lorna Guinness
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew Hickman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Vivian Hope
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Sharon Hutchinson
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Lisa Maher
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Jenny Iversen
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Noel Craine
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Avril Taylor
- School of Media Society and Culture, University of the West of Scotland, Paisley, UK
| | - Alison Munro
- School of Social Science, University of the West of Scotland, Paisley, UK
| | - John Parry
- Centre for Infectious Disease Surveillance and Control, Public Health England, London, UK
| | - Josie Smith
- Health Protection Division, Public Health Wales, Cardiff, UK
| | - Peter Vickerman
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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10
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Sebastian MP, Dasgupta A, Saraswati LR, Singh A, Sharma V, Madan I, Tun W, Pulerwitz J, Thior I, Sarna A. Service utilization and cost of implementing a comprehensive HIV prevention and care program among people who inject drugs in Delhi, India. Harm Reduct J 2017; 14:38. [PMID: 28615077 PMCID: PMC5471911 DOI: 10.1186/s12954-017-0165-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 06/05/2017] [Indexed: 12/02/2022] Open
Abstract
Background WHO, UNODC, and UNAIDS recommend a comprehensive package for prevention, treatment, and care of HIV among people who inject drugs (PWID). We describe the uptake of services and the cost of implementing a comprehensive package for HIV prevention, treatment, and care services in Delhi, India. Methods A cohort of 3774 PWID were enrolled for a prospective HIV incidence study and provided the comprehensive package: HIV and hepatitis testing and counseling, hepatitis B (HB) vaccination, syndromic management of sexually transmitted infections, clean needles-syringes, condoms, abscess care, and education. Supplementary services comprising tea and snacks, bathing facilities, and medical consultations were also provided. PWID were referred to government services for antiretroviral therapy (ART), TB care, opioid substitution therapy, and drug dependence treatment/rehabilitation. Results The project spent USD 1,067,629.88 over 36 months of project implementation: 1.7% on capital costs, 3.9% on participant recruitment, 26.7% for project management, 49.9% on provision of services, and 17.8% on supplementary services. Provision of HIV prevention and care services cost the project USD 140.41/PWID/year. 95.3% PWID were tested for HIV. Of the HIV-positive clients, only 17.8% registered for ART services after repeated follow-up. Reasons for not seeking ART services included not feeling sick, need for multiple visits to the clinic, and long waiting times. 61.8% of the PWID underwent HB testing. Of the 2106 PWID eligible for HB vaccination, 81% initiated the vaccination schedule, but only 29% completed all three doses, despite intensive follow-up by outreach workers. PWID took an average of 8 clean needles-syringes/PWID/year over the project duration, with a mid-project high of 16 needles-syringes/PWID/year. PWID continued to also procure needles from other sources, such as chemists. One hundred five PWID were referred to OST services and 267 for rehabilitation services. Conclusions A comprehensive HIV prevention, treatment, and care package is challenging to implement. Extensive efforts are needed to ensure the uptake of and retention in services for PWID; peer educators and outreach workers are required on a continuous basis. Services need to be tailored to client needs, considering clinic timing and distance from hotspots. Programs may consider provision of ART services at selected drop-in centers to increase uptake.
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Affiliation(s)
| | | | | | | | | | - Ira Madan
- Sahara Center for Residential Care and Rehabilitation, New Delhi, India
| | | | | | | | - Avina Sarna
- Population Council, India Habitat Center, New Delhi, 110003, India.
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11
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Pham QD, Wilson DP, Kerr CC, Shattock AJ, Do HM, Duong AT, Nguyen LT, Zhang L. Estimating the Cost-Effectiveness of HIV Prevention Programmes in Vietnam, 2006-2010: A Modelling Study. PLoS One 2015. [PMID: 26196290 PMCID: PMC4510535 DOI: 10.1371/journal.pone.0133171] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Introduction Vietnam has been largely reliant on international support in its HIV response. Over 2006-2010, a total of US$480 million was invested in its HIV programmes, more than 70% of which came from international sources. This study investigates the potential epidemiological impacts of these programmes and their cost-effectiveness. Methods We conducted a data synthesis of HIV programming, spending, epidemiological, and clinical outcomes. Counterfactual scenarios were defined based on assumed programme coverage and behaviours had the programmes not been implemented. An epidemiological model, calibrated to reflect the actual epidemiological trends, was used to estimate plausible ranges of programme impacts. The model was then used to estimate the costs per averted infection, death, and disability adjusted life-year (DALY). Results Based on observed prevalence reductions amongst most population groups, and plausible counterfactuals, modelling suggested that antiretroviral therapy (ART) and prevention programmes over 2006-2010 have averted an estimated 50,600 [95% uncertainty bound: 36,300–68,900] new infections and 42,600 [36,100–54,100] deaths, resulting in 401,600 [312,200–496,300] fewer DALYs across all population groups. HIV programmes in Vietnam have cost an estimated US$1,972 [1,447–2,747], US$2,344 [1,843–2,765], and US$248 [201–319] for each averted infection, death, and DALY, respectively. Conclusions Our evaluation suggests that HIV programmes in Vietnam have most likely had benefits that are cost-effective. ART and direct HIV prevention were the most cost-effective interventions in reducing HIV disease burden.
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Affiliation(s)
- Quang Duy Pham
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- Department for Disease Control and Prevention, Pasteur Institute, Ho Chi Minh City, Vietnam
| | - David P. Wilson
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Cliff C. Kerr
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew J. Shattock
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Hoa Mai Do
- Department of Health System, Hanoi School of Public Health, Hanoi, Vietnam
| | - Anh Thuy Duong
- Department of Planning and Finance, Vietnam Administration of HIV/AIDS Control, Hanoi, Vietnam
| | | | - Lei Zhang
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- School of Public Health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, Victoria, Australia
- * E-mail:
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12
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Wilson DP, Donald B, Shattock AJ, Wilson D, Fraser-Hurt N. The cost-effectiveness of harm reduction. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2014; 26 Suppl 1:S5-11. [PMID: 25727260 DOI: 10.1016/j.drugpo.2014.11.007] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/11/2014] [Accepted: 11/11/2014] [Indexed: 10/24/2022]
Abstract
HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.
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Affiliation(s)
| | | | | | - David Wilson
- Global HIV/AIDS Program, World Bank, United States
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Kim SW, Pulkki-Brannstrom AM, Skordis-Worrall J. Comparing the cost effectiveness of harm reduction strategies: a case study of the Ukraine. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2014; 12:25. [PMID: 25873788 PMCID: PMC4396789 DOI: 10.1186/1478-7547-12-25] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 11/17/2014] [Indexed: 11/25/2022] Open
Abstract
Background Harm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study. Methods A Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars. Results The Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55]. The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies. Conclusions Despite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.
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Affiliation(s)
- Sung Wook Kim
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK
| | - Anni-Maria Pulkki-Brannstrom
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK ; Epidemiology and Global Health Department, Umeå University, Umea, Sweden
| | - Jolene Skordis-Worrall
- UCL Institute for Global Health, 30 Guilford Street, London, WC1N 1EH UK ; London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT UK
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Siapka M, Remme M, Obure CD, Maier CB, Dehne KL, Vassall A. Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries. Bull World Health Organ 2014; 92:499-511AD. [PMID: 25110375 DOI: 10.2471/blt.13.127639] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 12/26/2013] [Accepted: 12/31/2013] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.
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Affiliation(s)
- Mariana Siapka
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Michelle Remme
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Carol Dayo Obure
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Claudia B Maier
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Karl L Dehne
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Anna Vassall
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
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Spending of HIV resources in Asia and Eastern Europe: systematic review reveals the need to shift funding allocations towards priority populations. J Int AIDS Soc 2014; 17:18822. [PMID: 24572053 PMCID: PMC3936108 DOI: 10.7448/ias.17.1.18822] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 01/17/2014] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION It is increasingly important to prioritize the most cost-effective HIV interventions. We sought to summarize the evidence on which types of interventions provide the best value for money in regions with concentrated HIV epidemics. METHODS We conducted a systematic review of peer-reviewed and grey literature reporting measurements of cost-effectiveness or cost-benefit for HIV/AIDS interventions in Asia and Eastern Europe. We also collated HIV/AIDS spending assessment data from case-study countries in the region. RESULTS We identified 91 studies for inclusion, 47 of which were from peer-reviewed journals. Generally, in concentrated settings, prevention of mother-to-child transmission programmes and prevention programmes targeting people who inject drugs and sex workers had lower incremental cost-effectiveness ratios than programmes aimed at the general population. The few studies evaluating programmes targeting men who have sex with men indicate moderate cost-effectiveness. Collation of prevention programme spending data from 12 countries in the region (none of which had generalized epidemics) indicated that resources for the general population/non-targeted was greater than 30% for eight countries and greater than 50% for five countries. CONCLUSIONS There is a misalignment between national spending on HIV/AIDS responses and the most affected populations across the region. In concentrated epidemics, scarce funding should be directed more towards most-at-risk populations. Reaching consensus on general principles of cost-effectiveness of programmes by epidemic settings is difficult due to inconsistent evaluation approaches. Adopting a standard costing, impact evaluation, benefits calculation, analysis and reporting framework would enable cross comparisons and improve HIV resource prioritization and allocation.
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Teerawattananon Y, McQueston K, Glassman A, Yothasamut J, Myint CY. Health technology assessments as a mechanism for increased value for money: recommendations to the Global Fund. Global Health 2013; 9:35. [PMID: 23965222 PMCID: PMC3848836 DOI: 10.1186/1744-8603-9-35] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 08/02/2013] [Indexed: 11/10/2022] Open
Abstract
The Global Fund is experiencing increased pressure to optimize results and improve its impact per dollar spent. It is also in transition from a provider of emergency funding, to a long-term, sustainable financing mechanism. This paper assesses the efficacy of current Global Fund investment and examines how health technology assessments (HTAs) can be used to provide guidance on the relative priority of health interventions currently subsidized by the Global Fund. In addition, this paper identifies areas where the application of HTAs can exert the greatest impact and proposes ways in which this tool could be incorporated, as a routine component, into application, decision, implementation, and monitoring and evaluation processes. Finally, it addresses the challenges facing the Global Fund in realizing the full potential of HTAs.
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Affiliation(s)
- Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP), Department of Health, Ministry of Public Health, 6th floor, 6th Building, Tiwanon Rd,, Nonthaburi 11000, Thailand.
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Lalmuanpuii M, Biangtung L, Mishra RK, Reeve MJ, Tzudier S, Singh AL, Sinate R, Sgaier SK. Scale-up of a comprehensive harm reduction programme for people injecting opioids: lessons from north-eastern India. Bull World Health Organ 2013; 91:306-12. [PMID: 23599555 DOI: 10.2471/blt.12.108274] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 12/20/2012] [Accepted: 12/26/2012] [Indexed: 11/27/2022] Open
Abstract
PROBLEM Harm reduction packages for people who inject illicit drugs, including those infected with human immunodeficiency virus (HIV), are cost-effective but have not been scaled up globally. In the north-eastern Indian states of Manipur and Nagaland, the epidemic of HIV infection is driven by the injection of illicit drugs, especially opioids. These states needed to scale up harm reduction programmes but faced difficulty doing so. APPROACH In 2004, the Bill & Melinda Gates Foundation funded Project ORCHID to scale up a harm reduction programme in Manipur and Nagaland. LOCAL SETTING In 2003, an estimated 10 000 and 16 000 people were injecting drugs in Manipur and Nagaland, respectively. The prevalence of HIV infection among people injecting drugs was 24.5% in Manipur and 8.4% in Nagaland. RELEVANT CHANGES By 2012, the harm reduction programme had been scaled up to an average of 9011 monthly contacts outside clinics (80% of target); an average of 1709 monthly clinic visits (15% of target, well above the 5% monthly goal) and an average monthly distribution of needles and syringes of 16 each per programme participant. Opioid agonist maintenance treatment coverage was 13.7% and retention 6 months after enrolment was 63%. Antiretroviral treatment coverage for HIV-positive participants was 81%. LESSONS LEARNT A harm reduction model consisting of community-owned, locally relevant innovations and business approaches can result in good harm reduction programme scale-up and influence harm reduction policy. Project ORCHID has influenced national harm reduction policy in India and contributed to the development of harm reduction guidelines.
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Vickerman P, Martin N, Turner K, Hickman M. Can needle and syringe programmes and opiate substitution therapy achieve substantial reductions in hepatitis C virus prevalence? Model projections for different epidemic settings. Addiction 2012; 107:1984-95. [PMID: 22564041 DOI: 10.1111/j.1360-0443.2012.03932.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 02/27/2012] [Accepted: 05/02/2012] [Indexed: 01/03/2023]
Abstract
AIMS To investigate the impact of scaling-up opiate substitution therapy (OST) and high coverage needle and syringe programmes (100%NSP-obtaining more sterile syringes than you inject) on HCV prevalence among injecting drug users (IDUs). DESIGN Hepatitis C virus HCV transmission modelling using U.K. estimates for effect of OST and 100%NSP on individual risk of HCV infection. SETTING Range of chronic HCV prevalent (20/40/60%) settings with no OST/100%NSP, and U.K. setting with 50% coverage of both OST and 100%NSP. PARTICIPANTS Injecting drug users. MEASUREMENTS Decrease in HCV prevalence after 5-20 years due to scale-up of OST and 100%NSP to 20/40/60% coverage in no OST/100%NSP settings, or from 50% to 60/70/80% coverage in the U.K. setting. FINDINGS For 40% chronic HCV prevalence, scaling-up OST and 100%NSP from 0% to 20% coverage reduces HCV prevalence by 13% after 10 years. This increases to a 24/33% relative reduction at 40/60% coverage. Marginally less impact occurs in higher prevalence settings over 10 years, but this becomes more pronounced over time. In the United Kingdom, without current coverage levels of OST and 100%NSP the chronic HCV prevalence could be 65% instead of 40%. However, increasing OST and 100%NSP coverage further is unlikely to reduce chronic prevalence to less than 30% over 10 years unless coverage becomes ≥80%. CONCLUSIONS Scaling-up opiate substitution therapy and high coverage needle and syringe programmes can reduce hepatitis C prevalence among injecting drug users, but reductions can be modest and require long-term sustained intervention coverage. In high coverage settings, other interventions are needed to further decrease hepatitis C prevalence. In low coverage settings, sustained scale-up of both interventions is needed.
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Wammes JJG, Siregar AY, Hidayat T, Raya RP, van Crevel R, van der Ven AJ, Baltussen R. Cost-effectiveness of methadone maintenance therapy as HIV prevention in an Indonesian high-prevalence setting: a mathematical modeling study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2012; 23:358-64. [PMID: 22884538 DOI: 10.1016/j.drugpo.2012.06.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 06/14/2012] [Accepted: 06/22/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Indonesia faces an HIV epidemic that is in rapid transition. Injecting drug users (IDUs) are among the most heavily affected risk populations, with estimated prevalence of HIV reaching 50% or more in most parts of the country. Although Indonesia started opening methadone clinics in 2003, coverage remains low. METHODS We used the Asian Epidemic Model and Resource Needs Model to evaluate the long-term population-level preventive impact of expanding Methadone Maintenance Therapy (MMT) in West Java (43 million people). We compared intervention costs and the number of incident HIV cases in the intervention scenario with current practice to establish the cost per infection averted by expanding MMT. An extensive sensitivity analysis was performed on costs and epidemiological input, as well as on the cost-effectiveness calculation itself. RESULTS Our analysis shows that expanding MMT from 5% coverage now to 40% coverage in 2019 would avert approximately 2400 HIV infections, at a cost of approximately US$7000 per HIV infection averted. Sensitivity analyses demonstrate that the use of alternative assumptions does not change the study conclusions. CONCLUSION Our analyses suggest that expanding MMT is cost-effective, and support government policies to make MMT widely available as an integrated component of HIV/AIDS control in West Java.
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Affiliation(s)
- Joost J G Wammes
- Radboud University Nijmegen Medical Centre, Department of Primary and Community Care, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
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Qian HZ, Vermund SH. Are Low- and Middle-Income Countries Repeating Mistakes Made by High-Income Countries in the Control of HIV for Men who have Sex with Men? ACTA ACUST UNITED AC 2012; Suppl 4:e001. [PMID: 24455449 PMCID: PMC3893757 DOI: 10.4172/2155-6113.s4-e001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Han-Zhu Qian
- Vanderbilt Institute for Global Health, USA ; Departments of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Sten H Vermund
- Vanderbilt Institute for Global Health, USA ; Departments of Medicine, Vanderbilt University, Nashville, Tennessee, USA ; Departments of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
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Characteristics of HIV epidemics driven by men who have sex with men and people who inject drugs. Curr Opin HIV AIDS 2011; 6:94-101. [PMID: 21505382 DOI: 10.1097/coh.0b013e328343ad93] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To highlight the latest developments in mathematical transmission modelling of HIV epidemics among men who have sex with men (MSM) and people who inject drugs (PWID). RECENT FINDINGS Mathematical approaches have been applied to a wide range of topics in recent HIV research. Epidemiological models have evaluated past and forecasted future trends in prevalence and incidence, evaluated innovative behaviour modification strategies and public health programmes aimed at minimizing risk, and explored the potential impact of various biomedical interventions. MSM have developed new risk reduction strategies which models have deemed to be effective at a population level only in certain settings, such as when there are high rates of HIV testing. Modelling has also indicated that persistent circulation of drug-resistant HIV strains is likely to become an inevitable public health issue in the near future in resource-rich settings among MSM. Models have also recently been used to demonstrate that needle and syringe programmes for harm reduction among PWID are effective and cost-effective. SUMMARY Mathematical modelling is particularly amenable to single population groups of concentrated HIV epidemics, such as among MSM and PWID. Models have been utilized to evaluate innovative areas in clinical, biomedical and public health research that cannot be conducted in other population groups. Future directions are likely to include evaluation of specific public health programmes and providing understanding of the importance of specific treatment regimens and incidence and interaction of comorbid conditions associated with HIV.
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Affiliation(s)
- Chris Beyrer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21202, USA.
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Beyrer C, Malinowska-Sempruch K, Kamarulzaman A, Kazatchkine M, Sidibe M, Strathdee SA. Time to act: a call for comprehensive responses to HIV in people who use drugs. Lancet 2010; 376:551-63. [PMID: 20650515 PMCID: PMC3682471 DOI: 10.1016/s0140-6736(10)60928-2] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The published work on HIV in people who use drugs shows that the global burden of HIV infection in this group can be reduced. Concerted action by governments, multilateral organisations, health systems, and individuals could lead to enormous benefits for families, communities, and societies. We review the evidence and identify synergies between biomedical science, public health, and human rights. Cost-effective interventions, including needle and syringe exchange programmes, opioid substitution therapy, and expanded access to HIV treatment and care, are supported on public health and human rights grounds; however, only around 10% of people who use drugs worldwide are being reached, and far too many are imprisoned for minor offences or detained without trial. To change this situation will take commitment, advocacy, and political courage to advance the action agenda. Failure to do so will exacerbate the spread of HIV infection, undermine treatment programmes, and continue to expand prison populations with patients in need of care.
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Affiliation(s)
- Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Abstract
We reviewed evidence from more than 900 studies and reports on the link between human rights abuses experienced by people who use drugs and vulnerability to HIV infection and access to services. Published work documents widespread abuses of human rights, which increase vulnerability to HIV infection and negatively affect delivery of HIV programmes. These abuses include denial of harm-reduction services, discriminatory access to antiretroviral therapy, abusive law enforcement practices, and coercion in the guise of treatment for drug dependence. Protection of the human rights of people who use drugs therefore is important not only because their rights must be respected, protected, and fulfilled, but also because it is an essential precondition to improving the health of people who use drugs. Rights-based responses to HIV and drug use have had good outcomes where they have been implemented, and they should be replicated in other countries.
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Affiliation(s)
- Ralf Jürgens
- HIV/AIDS, Health, Policy and Human Rights, Quebec, Canada.
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Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M. Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet 2010; 376:285-301. [PMID: 20650522 DOI: 10.1016/s0140-6736(10)60742-8] [Citation(s) in RCA: 330] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
HIV can spread rapidly between people who inject drugs (through injections and sexual transmission), and potentially the virus can pass to the wider community (by sexual transmission). Here, we summarise evidence on the effectiveness of individual-level approaches to prevention of HIV infection; review global and regional coverage of opioid substitution treatment, needle and syringe programmes, and antiretroviral treatment; model the effect of increased coverage and a combination of these three approaches on HIV transmission and prevalence in injecting drug users; and discuss evidence for structural-level interventions. Each intervention alone will achieve modest reductions in HIV transmission, and prevention of HIV transmission necessitates high-coverage and combined approaches. Social and structural changes are potentially beneficial components in a combined-intervention strategy, especially when scale-up is difficult or reductions in HIV transmission and injection risk are difficult to achieve. Although further evidence is needed on how to optimise combinations of interventions in different settings and epidemics, we know enough now about which actions are effective: the challenge is to deliver these well and to scale.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia.
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