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

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

HIV prevalence and share of overall infections among PWID in Eastern and Central Asia Source: Bradley Mathers, Lancet 2008 HIV prevalence in PWID 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 interventions  NSP  OST  ART  WHO, 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

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

Source: L. Degenhardt Lancet July 2010 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 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 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 UNSW estimates, based on 10 studies identified in the 6 regions 2

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

What are the cost ranges? ART  ART cost: UNAIDS global estimate $176 1  Authors estimate PWID costs $1,000-2,000 per HIV+ PWID 1 UNAIDS 2007 resource estimations; Schwartlaender et al 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

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

ART coverage in HIV+ PWID Source: Authors literature review and estimates, using Mathers et al  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

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 ) > 50% to Eastern Europe and Central Asia

Global Fund PWID investments by region (US$) Sources: Bridge 2012, summarised in Global State of Harm Reduction, % 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 Scenarios: Mid target High target  Very preliminary resource estimates  Mid and high target scenarios costed

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

Summary: Estimated annual cost of scale- up 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 Asia527M1,49B Latin America & Caribbean625M1,47B Middle East & North Africa26M55M W- Europe, N- America & Australasia17M1,19B Eastern Europe & Central Asia1.04B2,51B Sub-Saharan Africa414M901M Total per year2,65B7,62B 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 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 CE 1 : ROI 2 : $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 CE 1 : ROI 2 : $97-$564 (3) $1.4 (1) CE 1 :$1,456-$2,952 (1) CE 1 : ROI 2 : $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-up  Combined, integrated interventions reduce overheads  Intervention synergies increase effectiveness

 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 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 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 CONCLUSION