H. Naning1, C. Kerr2, A. Kamarulzaman1, M. Dahlui3, CW Ng3, D. Wilson2 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

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) By 2011, 94,841 HIV cases of which 17,686 progressed to AIDS with 14,986 AIDS related deaths in Malaysia Source: Ministry of Health, 2012

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

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, 20,955 PWIDs 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, 34,244 PWIDs had registered to receive NSEP services Coverage 20% NSEP, 12% MMT. Approx RM14mil (56% of total prevention) spent on harm reductions in 2011

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 Epi, beh & demo - Secondary data: Peer-reviewed literature database, Grey literatures, Hand searches, Data request Health care cost - Primary data: Sg Buloh Hospital admission expenditure (Costing Exercise). Secondary data: MOH NSEP / MMT expenditure data & MOH Act of Fees Primary data: Hospital admission expenditure Secondary data: Literature review, hand-searches, data request

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

RESULT

Impact of NSEP on HIV Risk Behaviour

Impact of MMT on Number of Active PWIDs

HIV Incidence 3,100 HIV infections averted

Direct HIV Health Care Cost Savings Direct HIV health care cost savings based on infections averted. Harm Reduction Programme Total direct health care cost-saving (mil. RM) 2006 - 2013 2006 - 2023 Combined MMT and NSEP 2.48 (1.97 – 3.01) 38.09 (29.20 – 48.75) NSEP alone 2.36 (1.88 – 2.87) 35.27 (27.12 – 45.28) MMT alone 0.17 (0.14 -0.21) 5.77 (4.17 – 748) Estimates are medians with 95% confidence intervals provided in parentheses USD 1 ≈ RM3.1

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) Harm Reduction Programme Incremental cost effectiveness ratio (RM/QALY gained) 2006 - 2013 2006 - 2023 Combined MMT and NSEP 18,535 (15,674 – 22,439) 2,358 (1,840 – 3,164) NSEP alone 6,852 (5,704 – 8,331) 627 (423 – 917) MMT alone 171,398 (147,083 – 208,099) 11,661 (9,661 – 15,404) Threshold values for cost-effectiveness ratio = GDP per capita (WHO). GDP is a reflection of ‘fair share’ of each citizen of the nations wealth 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)

Return On Investment Return measured only in direct HIV health care costs saved (not overall return on investment) Harm Reduction Programme Return on investment 2006 - 2013 2006 - 2023 Combined MMT and NSEP 0.03 (0.02 – 0.03) 0.13 (0.10 – 0.17) NSEP alone 0.07 (0.06 – 0.09) 0.37 (0.28 – 0.47) MMT alone 0.00 (0.00 – 0.00) (0.02 – 0.04) Estimates are medians with 95% confidence intervals provided in parentheses

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

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

Acknowledgement Ministry of Health Dr Chong Chee Kheong Dr Sha’ari Ngadiman Dr Fazidah Yusman Sg Buloh Hospital Datuk Dr Christopher Lee Dr Suresh Kumar Dr Benedict Lim Ritta David Masitah Mohd Salleh The study was funded by World Bank National Anti-Drug Agency Dr Sangeeth Kaur 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

Appendix

Programme Cost Source: Ministry of Health, 2012

Parameters Data Parameters required Demographic IDUs population size Epidemiology HIV prevalence of IDUs Treatment Testing rate per year* Treatment rate per year* Number of HIV diagnosed Number of patients on ART* Behavioural Percentage of shared injections Average number of injections per year Percentage of reused syringes that are cleaned Percentage of IDUs on Methadone *Adapted based on available study and consultation with HIV clinician

Parameters 1. HIV testing Cost per HIV positive IDUs tested Data Description 1. HIV testing Cost per HIV positive IDUs tested 2. ARV cost Average cost per HIV positive IDU had CD4 >350 and CD4 ≤350 3. Outpatient cost Average cost per HIV positive IDU per year 4. Inpatient cost

Direct Health Care Costs Category of CD4 counts Annual per capita cost (RM) Inpatient Care Outpatient Care Total (RM) USD CD4<350 cells/mm3 15,683 1,461 17,144 5,530 CD4≥350 cells/mm3 NA 974 314 ARV drugs First line Stavudine (d4T), Lamivudine (3TC), Nevirapine (NVP) Combivir (AZT/3TC), Efavirenz (EFV) Combivir (AZT/3TC), Nevirapine (NVP) 2,684 865 Second-line Combivir (AZT/3TC) and Kaletra 13,643 4,400 USD 1 ≈ RM3.1

Cost Effectiveness QALY (quality adjusted life years) Incorporate both the prolongation of life and the quality of life by avoiding HIV Harm Reduction Programme Number of QALYs gained 2006 - 2013 2006 - 2023 Combined MMT and NSEP 4,830 (4,002 – 5,669) 104,116 (80,806 – 124,605) NSEP alone 4,599 (3,807 – 5,400) 96,451 (74,929 – 115,572) MMT alone 338 (279 – 394) 15,602 (11,920 – 18,493) QALY – measure of value of health outcomes from the IDUs perspective due to the programme Meta analysis utility by Tengs et al 2002. Method of assessment = Time trade off (2), standard gambling, rating scale, quality of well being scale and judgement (1) = somewhat significant. Stage of disease & respondent type = predictive of utility. Year not predictive of utility. AIDS (0.2-0.79), symp (0.48-0.82), symp (0.69-0.88). Limitation small data set, there may be other variable not considered. TTO:  Remaining in a state of ill health for a period of time or being restored to perfect health but having a shorter life expectancy SG: Remaining in a state of ill health for a period of time or choosing a medical intervention which has a chance of either restoring them to perfect health, or killing them Rating scale: indicate the strength of their preference for a health state on a straight line calibrated between ’0’ (death) and ‘1’ (full health). The distance above and below the selected value represents the strength of preference relative to full health and death QWBS: Somewhat SF-36. Mobility, physical & social activity. Judgement: Estimates are medians with 95% confidence intervals provided in parentheses

MMT Coverage (2006-2011) MOH clinic expanded from 2 in 2006 to 168 in 2011. NADA & prison started in 2008. Others – mosque, to check status if still continue in 2012-13. By 2011, 20,955 IDUs had registered to receive free MMT services from public sites and 23,473 registered with private practitioner

NSEP Coverage (Dec 2010) Agency No of NSEP sites NGOs-based (Centre) 17* MOH (Health Clinic) 73 Total 90 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