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

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 Injecting Drug Use Mathers et al, Lancet (2008)

5. Prevalence of HIV among PWID Mathers et al, Lancet (2008)

6. HIV prevalence among PWID in Eastern and Central Asia Source: Bradley Mathers, Lancet 2008

7. HIV infections in PWID as share of infections in Eastern Europe and Central Asia Source: Own calculation based on data from EuroHIV (2007)

8. HIV prevalence among sex workers in Central Asia

9. Surging HIV epidemic among PWID in Greece

10. 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

11. 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

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

13.  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 NSP

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

15.  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 What we know about OST (versus compulsory detention)

16. Effectiveness of community OST versus compulsory detention  Preliminary data from Malaysia  95% relapse after compulsory detention  7% relapse in community OST

17.  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 OST

18. What we know about ART in PWID

19. 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

20. 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 2011. 2 UNSW estimates, based on 10 studies identified in the 6 regions 2

21. What are the cost ranges? OST  OST cost : Methadone 80 mg: $363 - 1,057 / yr; Buprenorphine, low dose: $1,236 – 3,167 /yr 1  Few OST cost studies but consistently 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 2

22. What are the cost ranges? ART  ART cost: UNAIDS estimate $176 1  Estimated costs by authors $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 2

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

24. Harm reduction data challenges Sources: UNGASS country progress reports 2012; Mathers et al., 2010; Global State of Harm Reduction, 2012  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

25. NSP coverage The Global State of Harm Reduction, 2012  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)

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

27. 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 in Asia (Pakistan, Nepal and Cambodia) and Eurasia (Belarus, Hungary, Kazakhstan, Lithuania and Russia)  72 countries with PWID without NSPs

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

29. OST coverage Global State of Harm Reduction, 2012  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

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

31. 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

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

33. ART coverage in HIV+ PWID Source: Authors literature review and estimates, using Mathers et al. 2010  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)

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

35. What is the global coverage of harm reduction services? Source: Authors’ literature review and estimates, using Mathers et al. 2010 Few PWID access all three priority interventions Female PWID far lower access than males An estimated 10% access NSP About 14% of HIV+ PWID access ART An estimated 8% access OST

36. 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 2002-2009) > 50% to Eastern Europe and Central Asia

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

38. 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 level1022814 Scenarios: Mid target201002025 High target602004075  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

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

40. 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

41. 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

42. 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)

43. 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

44.  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

45.  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