Transcript Slide 1

The Economics and Financing
of Harm Reduction
David Wilson and Nicole Fraser, Global HIV/AIDS Program, World Bank
David Wilson, University of New South Wales, Australia
Tuesday 10 June 2013
IHRA 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 Injecting Drug Use
Mathers et al, Lancet (2008)
Prevalence of HIV among PWID
Mathers et al, Lancet (2008)
HIV prevalence among PWID in
Eastern and Central Asia
80%
72%
60%
42%
37.20%
40%
20%
0%
17%
15% 15.60%
13% 13.40%
0% 0.40% 0.60% 1.40% 1.50% 1.60%
2.14%
5.00%
8% 8.15% 9.20%
Source: Bradley Mathers, Lancet 2008
HIV infections in PWID as share of infections
in Eastern Europe and Central Asia
80%
77%
70%
66%
67%
69%
62%
60%
54%
49%
50%
40%
33%
30%
57%
36%
36%
38%
28%
20%
10%
0%
Source: Own calculation based on data from EuroHIV (2007)
HIV prevalence among sex workers in
Central Asia
Surging HIV epidemic among PWID in
Greece
HIV, HCV and TB
• PWID have higher HCV and TB rates
• 10 million PWID may have HCV - surpassing
HIV infection
• HIV+ PWID 2 to 6-fold higher risk of TB
infection
• TB risk 23-fold higher in prisons
Global State of Harm Reduction, 2012
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
What we know about NSP
No. of
injecting
episodes
Injecting risk
behavior
Sexual
risk
HIV
Cost-effective
incidence
Yes
Needles and
Syringes
Programs
No effect
Tilson H. et al.
Institute of
Medicine 2007
Palmateer N.
et al. Addiction
2010
Palmateer
N. et al.
Addiction
2010
Tilson H. et al.
Institute of
Medicine 2007
Jones L. et al.
2010
Yes
Safe injection
No effect
centers
Kerr T. et
al.2007
Hedrich D. et
al. 2010
Andersen MA et
al. 2010
Bayoumi AM,
Zarig GS 2008
Source: L. Degenhardt Lancet July 2010
What we know about NSP
HIV prevalence in 99 cities worldwide (MacDonald
et al, 2003)
19% per year in cities with NSP
8% in cities without NSP
International evidence shows NSP effective (Wodak,
2008)
What we know about OST (versus
compulsory detention)
No. of
injecting
episodes
Injecting risk Sexual HIV
Cost effective
behavior
risk
incidence
Yes
OST
Tilson H. et al.
(2007)
Growing L. et al.
(2008)
Faggiano F. et al.
(2009)
Mattick RP et al.
(2009)
Tilson H. et al.
2007
Growing L. et
al. (2008)
No effect
Tilson H. et
al. (2007)
Sullivan LE.
Et al. (2005)
Tilson H. et al.
(2007)
No
Detention
WHO 2010
Pearshouse R. et
al. 2010
Open Society
Institute (2010)
WHO 2010
Pearshouse R.
et al. (2010)
OSI(2010)
Constella (2008)
Source: L. Degenhardt Lancet July 2010
What we know about OST (versus
compulsory detention)
Compulsory detention common especially
in Asia and Eastern Europe
Detention costly
Minimum cost $1,000 annually in Asia –
mainly security
Average OST cost $585 annually
Two evaluations in progress in Malaysia
and Vietnam
Effectiveness of community OST versus
compulsory detention
 Preliminary data from Malaysia
95% relapse after compulsory detention
7% relapse in community OST
What we know about OST

All RCTs of OST positive (Mattick et al, 2003)

Large observational studies show OST decreases heroin use and
criminal activity (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 and
NSP reduced HIV incidence by 66%

Recent meta-analysis (Mcarthur BMJ2012) shows OST reduces HIV
incidence by 50%
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 included
 NSP costs vary by region and delivery system (pharmacies,
specialist programme sites, vending machines, vehicles or
outreach)
USD
NSP unit cost estimates, regional averages
180
160
140
120
100
80
60
40
20
0
2
158
70
62
62
21
South, East & Latin America Middle East &
SE Asia
& Caribbean
North Africa
1
15
W Europe, N
America &
Aus
E Europe &
Central Asia
Sub-Saharan
Africa
UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies
identified in the 6 regions
What are the cost ranges?
OST
 OST cost : Methadone 80 mg: $363 - 1,057 / yr; Buprenorphine,
1
low dose: $1,236 – 3,167 /yr
 Few OST cost studies but consistently far higher than NSP
OST unit cost estimates, regional averages
2
2,238
2,500
USD
2,000
1,500
1,000
975
1,008
1,008
972
E Europe &
Central Asia
Sub-Saharan
Africa
565
500
0
South, East & Latin America Middle East & W Europe, N
SE Asia
& Caribbean
North Africa
America &
Aus
1
UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies
identified in the 6 regions
What are the cost ranges?
ART
1
ART cost: UNAIDS estimate $176
Estimated costs by authors $1,000-2,000 per HIV+
PWID
USD
ART unit cost estimates, regional averages 2
1,800
1,600
1,400
1,200
1,000
800
600
400
200
0
1,600
1,305
1,305
1,127
1,189
885
South, East & Latin America Middle East &
SE Asia
& Caribbean
North Africa
1
W Europe, N
America &
Aus
E Europe &
Central Asia
Sub-Saharan
Africa
UNAIDS 2007 resource estimations; Schwartlaender et al 2011. 2 UNSW estimates, based on 10 studies
identified in the 6 regions
What is the current coverage
of NSP, OST and ART in PWID?
Harm reduction data challenges
Limited population size estimates
Inconsistent service quality data
Surveys miss hidden populations
ATS increasingly used and injected but missed
in surveys
Significant but undocumented scale-down of
services
Sources: UNGASS country progress reports 2012; Mathers et al., 2010; Global State of Harm Reduction, 2012
NSP coverage
86 countries and territories implement NSPs
3 new NSPs since 2010 – South Africa,
Tanzania, Laos-PDR
High coverage limited to Western Europe,
Australia and Bangladesh (>200 NS/PWID/year)
The Global State of Harm Reduction, 2012
NSP available as per policy
(Black: community and prison, red: community only)
Global State of Harm Reduction, 2012
Gaps in NSP coverage
NSP coverage < 20% in all regions - globally, <2
clean needles distributed /PWID /month
Since 2010, NSP provision scaled back in several
countries in Asia (Pakistan, Nepal and Cambodia)
and Eurasia (Belarus, Hungary, Kazakhstan,
Lithuania and Russia)
72 countries with PWID without NSPs
(1) Global State of Harm Reduction, 2012; (2) based on Mathers et al., 2010
Over 14 million PWID (90%) may not
access NSP
Estimated NSP coverage of PWID in regions
Number of PWID, Millions
5
4
3
4.005
2.911
2
3.287
2.160
1
0.119
1.777
S, E & SE
Asia
LA &
Caribbean
PWID accessing NSP
M-East & N- W-Europe, N- E-Europe &
Africa
America &
C-Asia
Australasia
SSA
NSP coverage gap (PWID in millions)
Source: Authors’ literature and estimations, based on Mathers et al., 2010
OST coverage
OST in 77 countries worldwide
7 new countries since 2010 (Cambodia,
Bangladesh, Tajikistan, Kenya, Tanzania, Macau,
Kosovo)
Primarily methadone and buprenorphine but
also other formulations - slow-release
morphine, codeine, heroin-assisted treatment
Global State of Harm Reduction, 2012
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 CIS and Asia
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
Estimated OST coverage of PWID in regions
Number of PWID, Millions
5
4
3
4.260
2.531
2
3.689
2.202
1
0.120
1.777
S, E & SE
Asia
LA &
Caribbean
PWID accessing OST
M-East & N- W-Europe, N- E-Europe &
Africa
America &
C-Asia
Australasia
SSA
OST coverage gap (PWID in millions)
Source: Authors’ literature and estimates, using Mathers et al., 2010
ART coverage in HIV+ PWID
Large regional discrepancies
Uptake highest in Western Europe (89%) and
Australasia (50%)
Elsewhere ART coverage < 5%
Largest gaps in Eastern Europe & Central Asia
(1 million) and South, East & South-East Asia
(700,000)
Source: Authors literature review and estimates, using Mathers et al. 2010
About 2.5 million HIV+ PWID (85%)
may not access ART
Number of PWID
Estimated ART coverage in HIV+ PWID in regions
1,000,000
900,000
800,000
700,000
600,000
500,000
400,000
300,000
200,000
100,000
-
958,666
79,188
708,856
598,455
3,500
S, E & SE
Asia
LA &
Caribbean
HIV+ PWID accessing ART
M-East & N- W-Europe, N- E-Europe &
Africa
America &
C-Asia
Australasia
219,895
SSA
ART coverage gap (HIV+ PWID)
Source: Authors’ literature and estimates, using Mathers et al. 2010
What is the global coverage of harm
reduction services?
An estimated 10%
access NSP
An estimated 8%
access OST
Few PWID
access all
three priority
interventions
About 14% of HIV+
PWID
access ART
Female PWID
far lower
access than
males
Source: Authors’ literature review and estimates, using Mathers et al. 2010
How much is spent on harm reduction?
Estimated $160 million in LMIC in 2007 (3
cents per PWID per day): 90% from
international donors
Global Fund largest HR funder (estimated
$430 million 2002-2009) > 50% to Eastern
Europe and Central Asia
Sources: Stimson et al 2010 (three cents report), UNAIDS 2009; UNAIDS Progress report 2012; Global
State of Harm Reduction, 2012; Bridge et al 2012
Global Fund PWID investments by region (US$)
Asia
17% Thailand
15% Viet Nam
14% China
30% Ukraine
10% Russ Fed
8% Kazakhstan
Latin America
Middle East & North
Africa
166,700,000
Sub-Saharan Africa
366,100,000
10,200,000
Western Europe
24,000,000
7,800,000
900,000
Eastern Europe & Central
Asia
Sources: Bridge 2012, summarised in Global State of Harm Reduction, 2012
How much is needed to scale up priority
harm reduction interventions?
 Very preliminary resource estimates based on
regional estimates of current NSP /OST /ART coverage,
population sizes and unit costs
 Mid and high target scenarios costed
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
How much needed to scale up priority harm
reduction interventions – preliminary estimates
ECA
SSE
LAC
MNA
SSA
WEST
11.7%
19.1M
11.45M
11.5%
26.84M
153.60M
2%
2%
17%
8.33M
26.84M
1.35M
4.35M
<1%
5.3M
15.98M
<1%
715M
1.47B
5.9%
360M
872M
<1%
427.63M
857.41M
1%
<1%
27.8%
23.17M 344.01M
---47.57M 689.75M 954.74M
1.1%
1.16B
3.59B
3.6%
856M
2.88B
1%
<1%
<1%
690.29M 34.09M 518.09M
2.13B
102.28M 1.58B
NSP
Coverage
20%
80%
OST
Coverage
20%
40%
ART
Coverage
25%
75%
16.63M
238.30M
78.5%
-------
Summary: Estimated annual cost of scaleup of NSP, OST and ART for PWIDs
Mid target
20% NSP coverage
20% OST coverage
25% ART coverage
High target
60% NSP coverage
40% OST coverage
75% 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
2,65B
7,62B
Total per year
1: Mathers et al, Lancet (2010) 2: Scale-up calculations by UNSW
Annual scale-up costs by region and
intervention
SSA
16%
E-Europe &
C-Asia
38%
S, E & SE
Asia
20%
LA &
Caribbean
24%
W-Europe,
N-America &
Australasia
1%
Costs
dominated by
Eastern
Europe and
Central Asia
M-East & NAfrica
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: $402-$34,278 (9)
ROI2: $1.1-$5.5 (3)
Eastern Europe & Central Asia
CE1: $97-$564 (3)
ROI2: $1.4 (1)
The Middle East
& North Africa
CE1: $1,456-$2,952 (1)
Latin America &
The Caribbean
South, East & South East Asia
CE1: $71-$2,800 (7)
ROI2: $1.2-$8.0 (4)
Sub-Saharan Africa
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-up
Combined, integrated interventions reduce overheads
Intervention synergies increase effectiveness
Australia’s example: Economic benefits of
a supportive legal and policy environment
Australia invested A$243 million in NSP
Prevented estimated 32,050 HIV infections and
96,667 HCV cases
 A$1.28 billion saved 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
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
And benefits the whole population
Substance abuse treatment can benefit
more non-
costs
Social benefits exceed treatment costs
drug users than drug users
Global
best buy