Economic and policy dimensions of HIV in Eastern Europe and Central Asia

David Wilson and Nicole Fraser, Global HIV/AIDS Program, World BankDavid Wilson, University of New South Wales, Australia

Monday 1 July, 2013IAS 2013

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?

Prevalence of PWID and HIV in PWID

Mathers et al, Lancet (2008)

% PWID

% HIV among PWID

Slova

kiaCr

oatia

Belar

usLit

huan

iaKy

rgys

tan

Kaza

khsta

nArm

enia

Uzbek

istan

Russi

aEs

tonia

0%

20%

40%

60%

80%

HIV prevalence and share of overall infections among PWID in Eastern and

Central Asia

Source: Bradley Mathers, Lancet 2008

HIV prevalence in PWID

0%

10%

20%

30%

40%

50%

60%

70%

80%

Share of overall HIV infections in PWID

HIV prevalence among sex workers in Central Asia

Surging HIV epidemic among PWID in Greece

What harm reduction interventions work and what do they cost?

Three proven priority interventionsNSPOSTARTWHO, UNODC and UNAIDS - three priority

interventions plus HCT, condoms, IEC, STI, HCV and TB prevention/treatment

Source: L. Degenhardt Lancet July 2010

What we know about NSP

No. of injecting episodes

Injecting risk behavior

Sexual risk

HIV incidence

Cost-effective

Needles and Syringes Programs

No effect

Tilson H. et al. Institute of Medicine 2007Palmateer N. et al. Addiction 2010

Palmateer N. et al. Addiction 2010

Yes

Tilson H. et al. Institute of Medicine 2007Jones L. et al. 2010

Safe injection centers No effect

Kerr T. et al.2007Hedrich D. et al. 2010

Yes

Andersen MA et al. 2010Bayoumi AM, Zarig GS 2008

HIV prevalence in 99 cities (MacDonald et al, 2003)19% per year in cities with NSP8% in cities without NSP

What we know about NSP

No. of injecting episodes

Injecting risk behavior

Sexual risk

HIV incidence

Cost effective

OSTTilson H. et al. (2007)Growing L. et al. (2008)Faggiano F. et al. (2009)Mattick RP et al. (2009)

Tilson H. et al. 2007Growing L. et al. (2008) No effect

Tilson H. et al. (2007)Sullivan LE. Et al. (2005)

Yes

Tilson H. et al. (2007)

DetentionWHO 2010Pearshouse R. et al. 2010Open Society Institute (2010)

WHO 2010Pearshouse R. et al. (2010)OSI(2010)

No

Constella (2008)

Source: L. Degenhardt Lancet July 2010

What we know about OST (versus compulsory detention)

Compulsory detention common in Asia and Eastern Europe

Detention costlyMinimum cost $1,000 annually in Asia –

mainly securityAverage OST cost $585 annually

Two evaluations underway in Malaysia and Vietnam

What we know about OST (versus compulsory detention)

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

Large observational studies show OST decreases heroin use and criminality (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+NSP reduced HIV incidence by 66%

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

What we know about OST

What we know about ART in PWID

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

NSP costs $23–71 /yr 1, but higher if all costs includedNSP costs vary by region and delivery system (pharmacies,

specialist programme sites, vending machines, vehicles or outreach)

NSP unit cost estimates, regional averages

70

21

62

158

62

15

020406080

100120140160180

South, East &SE Asia

Latin America& Caribbean

Middle East &North Africa

W Europe, NAmerica &

Aus

E Europe &Central Asia

Sub-SaharanAfrica

US

D

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

2

What are the cost ranges?OST

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

Few OST cost studies but far higher than NSPOST unit cost estimates, regional averages

565

975 1,008

2,238

1,008 972

0

500

1,000

1,500

2,000

2,500

South, East &SE Asia

Latin America& Caribbean

Middle East &North Africa

W Europe, NAmerica &

Aus

E Europe &Central Asia

Sub-SaharanAfrica

US

D

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

2

What are the cost ranges?ART

ART cost: UNAIDS global estimate $1761

Authors estimate PWID costs $1,000-2,000 per HIV+ PWID

885

1,3051,127

1,600

1,3051,189

0200400600800

1,0001,2001,4001,6001,800

South, East &SE Asia

Latin America& Caribbean

Middle East &North Africa

W Europe, NAmerica & Aus

E Europe &Central Asia

Sub-SaharanAfrica

US

D

ART unit cost estimates, regional averages

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

2

What is the current coverage of NSP, OST and ART in PWID?

NSP coverage

The Global State of Harm Reduction, 2012

86 countries and territories implement NSPs

High coverage limited to Western Europe and Australia

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

Global State of Harm Reduction, 2012

Gaps in NSP coverage

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

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

Since 2010, NSP provision scaled back in several countries (Belarus, Hungary, Kazakhstan, Lithuania and Russia)

72 countries with PWID without NSPs

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

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

Estimated NSP coverage of PWID in regions

4.005

2.160

2.911 3.287

1.7770.119

-

1

2

3

4

5

S, E & SEAsia

LA &Caribbean

M-East & N-Africa

W-Europe, N-America &Australasia

E-Europe &C-Asia

SSA

Mill

ion

sN

um

ber

of

PW

ID,

PWID accessing NSP NSP coverage gap (PWID in millions)

OST coverage

Global State of Harm Reduction, 2012

OST in 77 countries worldwide

7 new countries since 2010, including Tajikistan

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

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 FSU

OST unavailable in 81 countries with PWID

ATS use increasing – and limited ATS harm response

Global State of Harm Reduction, 2012

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

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

Estimated OST coverage of PWID in regions

4.260

2.202

2.5313.689

1.7770.120

-

1

2

3

4

5

S, E & SEAsia

LA &Caribbean

M-East & N-Africa

W-Europe, N-America &Australasia

E-Europe &C-Asia

SSA

Mill

ion

sN

um

ber

of

PW

ID,

PWID accessing OST OST coverage gap (PWID in millions)

ART coverage in HIV+ PWID

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

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

Elsewhere ART coverage < 5%

Largest gaps in Eastern Europe & Central Asia (1 million)

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

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

Estimated ART coverage in HIV+ PWID in regions

708,856598,455

79,188958,666

219,8953,500

-100,000200,000300,000400,000500,000

600,000700,000800,000900,000

1,000,000

S, E & SEAsia

LA &Caribbean

M-East & N-Africa

W-Europe, N-America &Australasia

E-Europe &C-Asia

SSA

Nu

mb

er o

f P

WID

HIV+ PWID accessing ART ART coverage gap (HIV+ PWID)

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

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

Global Fund PWID investments by region (US$)

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

166,700,000

10,200,000

24,000,000 7,800,000

900,000

366,100,000

Asia

Latin America

Middle East & North Africa

Sub-Saharan Africa

Western Europe

Eastern Europe & Central Asia

30% Ukraine 10% Russ Fed 8% Kazakhstan

17% Thailand 15% Viet Nam 14% China

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

NSP coverage

(%)

Needles / PWID /year

OST uptake

(%)

ART uptake of HIV+ PWID

(%)

Current estimated level 10 22 8 14

Scenarios: Mid target 20 100 20 25 High target 60 200 40 75

Very preliminary resource estimates

Mid and high target scenarios costed

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

ECA SSE LAC MNA SSA WESTNSP

Coverage 11.7% 11.5% 2% 2% <1% 17%

20% 19.1M 26.84M 8.33M 1.35M 5.3M 16.63M80% 11.45M 153.60M 26.84M 4.35M 15.98M 238.30MOST

Coverage <1% 5.9% <1% 1% <1% 27.8%20% 715M 360M 427.63M 23.17M 344.01M ----40% 1.47B 872M 857.41M 47.57M 689.75M 954.74MART

Coverage 1.1% 3.6% 1% <1% <1% 78.5%25% 1.16B 856M 690.29M 34.09M 518.09M ----75% 3.59B 2.88B 2.13B 102.28M 1.58B ----

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

Mid target20% NSP coverage20% OST coverage25% ART coverage

High target60% NSP coverage40% OST coverage75% ART coverage

South, East & South East Asia 527M 1,49B

Latin America & Caribbean 625M 1,47B

Middle East & North Africa 26M 55M

W- Europe, N- America & Australasia 17M 1,19B

Eastern Europe & Central Asia 1.04B 2,51B

Sub-Saharan Africa 414M 901M

Total per year 2,65B 7,62B

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

Annual scale-up costs by region and intervention

Costs dominated by Eastern Europe and Central Asia

E-Europe & C-Asia 38%

SSA16%

S, E & SE Asia20%

LA & Caribbean

24%

W-Europe, N-America & Australasia

1%

M-East & N-Africa

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

Cost-effectiveness and relative return on investment ranges by region

() number of studies in literature

Western Europe, North America & Australasia

CE1:ROI2:

$402-$34,278 (9)$1.1-$5.5 (3)

Sub-Saharan Africa

Eastern Europe & Central Asia

The Middle East & North Africa South, East & South East Asia

Latin America & The Caribbean

CE1:ROI2:

$97-$564 (3)$1.4 (1)

CE1: $1,456-$2,952 (1) CE1:ROI2:

$71-$2,800 (7)$1.2-$8.0 (4)

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

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-upCombined, integrated interventions reduce overheadsIntervention synergies increase effectiveness

Australia invested A$243 million in NSPPrevented estimated 32,050 HIV infections and

96,667 HCV cases A$1.28 billion saved in direct healthcare costsIncluding patient/client costs and productivity gains

and losses, net present value of NSPs is $5.85 billion

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

ROI - A$27 per A$1 invested

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

environment

Inaction costlyNOT the equivalent of nothing happeningHard to reverse epidemic once established

Whereas harm reduction is Effective - in terms of HIV cases avertedCost-effective - in terms of healthy years gained and

costsSocial benefits exceed treatment costs

And benefits the whole populationSubstance abuse treatment can benefit more non-

drug users than drug users

Global best buy

CONCLUSION