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

David Wilson and Nicole Fraser, Global HIV/AIDS Program, World Bank David Wilson, University of New South Wales, Australia Monday 1 July, 2013 IAS 2013. Economic and policy dimensions of HIV in Eastern Europe and Central Asia. Overview. Why worry? What works and what does it cost?

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

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  1. David Wilson and Nicole Fraser, Global HIV/AIDS Program, World Bank David Wilson, University of New South Wales, Australia Monday 1 July, 2013 IAS 2013 Economic and policy dimensions of HIV in Eastern Europe and Central Asia

  2. 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?

  3. Why worry?

  4. Prevalence of PWID and HIV in PWID % PWID % HIV among PWID Mathers et al, Lancet (2008)

  5. HIV prevalence and share of overall infections among PWID in Eastern and Central Asia HIV prevalence in PWID Share of overall HIV infections in PWID Source: Bradley Mathers, Lancet 2008

  6. HIV prevalence among sex workers in Central Asia

  7. Surging HIV epidemic among PWID in Greece

  8. What harm reduction interventions work and what do they cost? • Three proven priority interventions • NSP • OST • ART • WHO, UNODC and UNAIDS - three priority interventions plus HCT, condoms, IEC, STI, HCV and TB prevention/treatment

  9. What we know about NSP Source: L. Degenhardt Lancet July 2010

  10. What we know about NSP • HIV prevalence in 99 cities (MacDonald et al, 2003) 19% per year in cities with NSP 8% in cities without NSP

  11. What we know about OST (versus compulsory detention) Source: L. Degenhardt Lancet July 2010

  12. What we know about OST (versus compulsory detention) • Compulsory detention common in Asia and Eastern Europe • Detention costly • Minimum cost $1,000 annually in Asia – mainly security • Average OST cost $585 annually • Two evaluations underway in Malaysia and Vietnam

  13. What we know about OST • 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%

  14. Whatwe know about ART in PWID

  15. 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

  16. What are the cost ranges?NSP 2 • NSP costs $23–71 /yr 1, but higher if all costs included • NSP costs vary by region and delivery system (pharmacies, specialist programme sites, vending machines, vehicles or outreach) 1 UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions

  17. What are the cost ranges?OST 2 • OST cost : Methadone 80 mg: $363 - 1,057 / yr; Buprenorphine, low dose: $1,236 – 3,167 /yr1 • Few OST cost studies but far higher than NSP 1 UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions

  18. What are the cost ranges?ART 2 • ART cost: UNAIDS global estimate $1761 • Authors estimate PWID costs $1,000-2,000 per HIV+ PWID 1 UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions

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

  20. 86 countries and territories implement NSPs • High coverage limited to Western Europe and Australia NSP coverage The Global State of Harm Reduction, 2012

  21. NSP available as per policy(Black: community and prison, red: community only) Global State of Harm Reduction, 2012

  22. 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 Gaps in NSP coverage (1) Global State of Harm Reduction, 2012; (2) based on Mathers et al., 2010

  23. Over 14 million PWID (90%) may not access NSP Source: Authors’ literature and estimations, based on Mathers et al., 2010

  24. 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 coverage Global State of Harm Reduction, 2012

  25. OST available as per policy(Black: community and prison, red: community only) Global State of Harm Reduction, 2012

  26. 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 Gaps in OST coverage Global State of Harm Reduction, 2012

  27. Almost 15 million PWID (92%) may not use OST Source: Authors’ literature and estimates, using Mathers et al., 2010

  28. ART coverage in HIV+ PWID • Uptake highest in Western Europe (89%) and Australasia (50%) • Elsewhere ART coverage < 5% • Largest gaps in Eastern Europe & Central Asia (1 million) Source: Authors literature review and estimates, using Mathers et al. 2010

  29. About 2.5 million HIV+ PWID (85%) may not access ART Source: Authors’ literature and estimates, using Mathers et al. 2010

  30. Estimated $160 million in LMIC in 2007(3 cents per PWID per day): 90% from international donors • Global Fund largest HR funder (estimated $430 million 2002-2009) >50% to Eastern Europe and Central Asia How much is spent on harm reduction? Sources: Stimson et al 2010 (three cents report), UNAIDS 2009; UNAIDS Progress report 2012; Global State of Harm Reduction, 2012; Bridge et al 2012

  31. 17% Thailand 15% Viet Nam 14% China Global Fund PWID investments by region (US$) 30% Ukraine 10% Russ Fed 8% Kazakhstan Sources: Bridge 2012, summarised in Global State of Harm Reduction, 2012

  32. Very preliminary resource estimates • Mid and high target scenarios costed How much is needed to scale up priority harm reduction interventions?

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

  34. Summary: Estimated annual cost of scale-up of NSP, OST and ART for PWIDs 1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW

  35. Annual scale-up costs by region and intervention • Costs dominated by Eastern Europe and Central Asia 1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW

  36. CE1: ROI2: CE1: ROI2: CE1: ROI2: CE1: $402-$34,278(9) $1.1-$5.5(3) $97-$564(3) $1.4(1) $1,456-$2,952(1) $71-$2,800(7) $1.2-$8.0(4) Cost-effectiveness and relative return on investment ranges by region() number of studies in literature Western Europe, North America & Australasia Eastern Europe & Central Asia The Middle East & North Africa South, East & South East Asia Latin America & The Caribbean Sub-Saharan Africa 1: Cost per HIV infection averted 2: Total future return per $1 invested (3% discount rate)

  37. Harm reduction cost-effectiveness • Harm reduction cost-effective in all regions, with costs per HIV infection averted from $100 -$1,000 • Harm reduction returns positive, with total future returns per $from $1.1 – $8.0 (3% discount rate) Also • Unit costs fall as interventions scaled-up • Combined, integrated interventions reduce overheads • Intervention synergies increase effectiveness

  38. Australia’s example: Economic benefits of a supportive legal and policy environment • Australia invested A$243 million in NSP • Prevented estimated 32,050 HIV infectionsand 96,667 HCV cases • A$1.28 billionsaved in direct healthcare costs • Including patient/client costs and productivity gains and losses, net present value of NSPs is $5.85 billion ROI - A$27 per A$1 invested Source: Return on Investment 2, Department of Health and Ageing, Australian Government

  39. CONCLUSION • Inaction costly • NOT the equivalent of nothing happening • Hard to reverse epidemic once established • Whereas harm reduction is • Effective - in terms of HIV cases averted • Cost-effective - in terms of healthy years gained and costs • Social benefits exceed treatment costs • And benefits the whole population • Substance abuse treatment can benefit more non-drug users than drug users • Global best buy

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