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H. Naning 1 , C. Kerr 2 , A. Kamarulzaman 1 , M. Dahlui 3 , CW Ng 3 , D. Wilson 2

Cost-effectiveness and return on investment of harm reduction programmes for people who inject drugs in Malaysia. H. Naning 1 , C. Kerr 2 , A. Kamarulzaman 1 , M. Dahlui 3 , CW Ng 3 , D. Wilson 2

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H. Naning 1 , C. Kerr 2 , A. Kamarulzaman 1 , M. Dahlui 3 , CW Ng 3 , D. Wilson 2

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  1. Cost-effectiveness and return on investment of harm reduction programmes for people who inject drugs in Malaysia H. Naning1, C. Kerr2, A. Kamarulzaman1, M. Dahlui3, CW Ng3, D. Wilson2 1Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 2Kirby Institute, University of New South Wales, Sydney, Australia 3Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

  2. HIV Epidemic in Malaysia • HIV epidemic in Malaysia mainly concentrated in four key affected populations • People who inject drugs (PWID) remain the largest group of people living with HIV in Malaysia (68 per cent of cumulative HIV cases) Source: Ministry of Health, 2012

  3. Background • Harm reduction as an evidence-based approach to HIV prevention, treatment and care for injecting drug users(WHO, UNODC, UNAIDS) • Malaysia adopted harm reduction strategy comprising Methadone Maintenance Therapy (MMT) and Needle-Syringe Exchange Programme (NSEP) • Implemented in stages from 2006 • Expansion underway, but coverage remains limited • Services delivered by governmental and non-governmental agencies (NGOs) • Funded predominantly by the government, supplemented by Global Fund and International HIV/AIDS Alliance • Concerns raised that public funding may not be sustainable in the long run • Thus, evidence on the impact and cost effectiveness of harm reduction programmes is needed

  4. Harm Reduction Coverage MMT Coverage • Service delivered by MOH, Prison, National Anti-Drug Agency (NADA), NGOs, private practitioners • Expanded from 17 facilities in 2006 to 292 facilities in 2011 • By 2011, 20,955PWIDs had registered to receive free MMT services from public sites and 23,473 registered with private practitioners NSEP Coverage • MOH and NGOs as main provider • Expanded from 45 centres and outreach points in 2006 to 297 centres and outreach points in 2011 • By 2011, 34,244PWIDs had registered to receive NSEP services

  5. Aims & Methods • Study aims to examine • effectiveness of harm reduction programmes in averting HIV infections • cost-effectiveness of programmes • direct HIV health care cost savings • return of investments on direct HIV health care costs • A dynamic compartmental mathematical model (PrevTool) developed by Kirby Institute, University of New South Wales • model simulates the number of people in the population who become infected with HIV over time and the extent of disease progression in terms of CD4 count • Model required extensive input of • Epidemiological data • Clinical data • Health care cost data Primary data: Hospital admission expenditure Secondary data: Literature review, hand-searches, data request

  6. Direct HIV Health Care Costs • Antiretroviral (ARV) for PLHIV with CD4 count < 350 cell/mm3 • Outpatient • Estimate costs by unit cost for services • Frequency of visit, monitoring by CD4 count • Inpatient • Cost exercise conducted in main hospital for HIV management in Malaysia • Covers inpatient services for HIV positive PWIDs for HIV related conditions

  7. RESULT

  8. Impact of NSEP on HIV Risk Behaviour

  9. Impact of MMT on Number of Active PWIDs

  10. HIV Incidence 3,100 HIV infections averted

  11. Direct HIV Health Care Cost Savings Direct HIV health care cost savings based on infections averted. Estimates are medians with 95% confidence intervals provided in parentheses USD 1 ≈ RM3.1

  12. Cost effectiveness • ICER (Incremental cost effectiveness ratio) - cost per QALY (quality-adjusted life years) gained • Cost effectiveness threshold – maximum value that society is willing to pay or can afford for a unit of health gain (based on GDP per capita) Estimates are medians with 95% confidence intervals provided in parentheses Malaysia GDP per capita in 2011 ≈ USD 9,650 ≈ RM29,915 CE threshold : <GDP per capita (highly cost effective); 1-3 x GDP per capita (cost effective); > 3 x GDP per capita (not cost effective). (WHO Commission on Macroeconomics and Health, 2001)

  13. Return On Investment Return measured only in direct HIV health care costs saved (not overall return on investment) Estimates are medians with 95% confidence intervals provided in parentheses

  14. Return on Investment • Cost savings from direct HIV health care costs relatively small in comparison to investment • Public health system main provider of care for PLHIV in Malaysia • Use of auxiliary health care staff to provide care, generic pharmaceuticals all contribute to a relatively efficient system • ROI only examined impact from health perspective, other associated social benefits such as reduction in illicit of drug use, reduction in criminal activities, employment, society integration were not considered

  15. Conclusion • Harm reduction programmes in Malaysia • averted HIV infections among people who inject drugs • highly cost effective • produced saving in direct HIV health care costs • Strong evidence that MMT and NSEP programmes are an effective and cost-effective strategy for averting HIV infections in Malaysia

  16. Acknowledgement National Anti-Drug Agency Dr SangeethKaur University of New South Wales Richard Gray Lei Zhang Josephine Reyes Centre of Excellence for Research in AIDS Theresa Anthony Christine Standley Howie Lim Jeannia Fu Alexander Bazazi Ministry of Health Dr Chong CheeKheong Dr Sha’ariNgadiman Dr FazidahYusman SgBuloh Hospital Datuk Dr Christopher Lee Dr Suresh Kumar Dr Benedict Lim Ritta David MasitahMohdSalleh The study was funded by • World Bank

  17. Appendix

  18. Programme Cost Source: Ministry of Health, 2012

  19. Parameters *Adapted based on available study and consultation with HIV clinician

  20. Parameters

  21. Direct Health Care Costs USD 1 ≈ RM3.1

  22. Cost Effectiveness • QALY (quality adjusted life years) • Incorporate both the prolongation of life and the quality of life by avoiding HIV Estimates are medians with 95% confidence intervals provided in parentheses

  23. MMT Coverage (2006-2011) By 2011, 20,955 IDUs had registered to receive free MMT services from public sites and 23,473 registered with private practitioner

  24. NSEP Coverage (Dec 2010) 1 4 2 2 20 1 7 10 2 4 8 *Over 200 of outreach points 1 9 By 2011, 34,244 IDUs had registered to receive NSEP services from 221 NGO’s outreach points and 76 MOH clinic 1 4 3 1

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