1. Cost-effectiveness of combined sexual and injection risk reduction interventions among Female Sex Workers who inject drugs in two very distinct Mexican-US border cities José L. Burgos, MD, MPH, AAHIVS Assistant Professor Division of Global Public Health School of Medicine University of California San Diego NIMH grant # K01 MH095680 NIDA grant # R01 DA023877 NIDA grant # R01 DA023877-S1 NIMH grant #R01 MH065849 Funding:

2. Coauthors/Co-Investigators Jose Luis Burgos, UC San Diego, USA Thomas L. Patterson, UC San Diego, USA Joshua S. Graff-Zivin, UC San Diego, USA James G. Kahn, UC San Francisco, USA Gudelia Rangel, COLEF, Mx. Victoria D. Ojeda, UC San Diego, USA M. Remedios Lozada, ISESALUD, Mx. Hugo Staines, UACJ, Mx. Steffanie A. Strathdee, UC San Diego, USA Clinical trial registration number: NCT00840658

3. About Mujer Mas Segura A brief combined theory-based intervention to simultaneously reduce sexual and injection risks among IDU-FSWs ages 18+ IDU-FSWs from Tijuana and Cd. Juarez were randomized to simultaneously examine two interventions –Interactive Vs. Lecture formats Measures: questionnaires; biological samples to detect four STIs including HIV

4. http://gph.ucsd.edu/research/contaminacion.shtml

5. Intervention effects on HIV/STI incidence after 12 months: Interactive Injection Risk Intervention (Adj RR; 95% CI*) NoYes Interactive Sex Risk intervention No Group A (control) Reference Group B Yes Group CGroup D *Adjusted for # of unprotected sex acts with non-regular clients, and arrests prior to enrolment 0.38 (0.16, 0.89) 0.37 (0.16, 0.89) 1.15 (0.58, 2.28) 2x2 Factorial Design to Simultaneously Evaluate Injection and Sexual Risk Reduction Intervention TijuanaCd. Juarez 0.44 (0.19, 0.99) 1.12 (0.56, 2.25) 1.15 (0.58, 2.28) Strathdee, et al. 2012

6. Impact of Injection Risk Interventions on Injection Risk Index: Tijuana and Cd. Juarez Strathdee, et al. 2012

7. Goal of the CE analysis To assess the cost-effectiveness of a behavioral intervention combining two interventions to increase safer sex and safer injection practices among FSW-IDUs in Ciudad Juarez and Tijuana, Mexico. To inform evidenced based Sex work-harm reduction policies in the Mexico-U.S. border region in respect to access to sterile syringes and condoms among FSW-IDUs.

8. Cost Effectiveness Model Discrete transitional state mathematical model Costs and outcomes for one-year and remainder of life of FSW-IDUs comparing a lecture format to each individual interactive components and the combined MMS intervention. Societal perspective Multivariate sensitivity analysis Cost and outcomes discounted at an annual rate of 3% Currency adjusted to 2012 U.S. Dollars

9. Model Inputs a Annual costs; b Secretaría del Trabajo y Previsión Social ; c Comisión Nacional de Salarios Mínimos; d Instituto de Servicios de Salud Pública; e Mujer Mas Segura Project; f Secretaría de Economía

10. a Per 100 person years b Quality adjusted life years

11. Cost-Effectiveness on Averted STI Strategy Cost per averted episode of sexually transmitted infection TijuanaCd. Juarez Control sex groups (Lecture format) -- Intervention sex groups (Interactive format) $42 $41

12. Reported Episodes of Receptive Syringe Sharing During the Previous Month Tijuana Ciudad Juarez

13. Cost-Effectiveness on Safer Injection Practices Strategy Cost per averted episode of receptive syringe sharing TijuanaCd. Juarez Control injection groups (Lecture format) -- Intervention Injection groups (Interactive format) -- $5.00

14. Base case results for a cohort of 1,000 FSW-IDUs over a life-time Strategy Cost-Effectiveness a TijuanaCd. Juarez Didactic control -- Interactive Safe Sex/ Lecture format Safe Injection $5,921 $4,710 Interactive Safe Injection/ Lecture format Safe Sex Dominated Combined interactive Safe Sex/Interactive Safe Injection $94,166,643 $7,162.74 a Cost per QALY gained

16. Interactive format safe sex intervention/ Lecture forma safe injection intervention Interactive safer sex/ Lecture safer injection Tijuana– Multivariate Cost-Effectiveness Analysis

17. For ciudad Juarez – Multivariate analysis Interactive safer sex/ Lecture safer injection Cd. Juarez– Multivariate Cost-Effectiveness Analysis

18. Conclusions In the absence of expanded NEP the combined Mujer Mas Segura intervention is likely to be cost-effective Improved access to sterile injection equipment at the community level shows a larger impact in reducing unsafe injection practices among FSW-IDU, with no significant added benefit from the interactive safer-injection component of the Mujer Mas Segura Intervention.

19. Acknowledgements Our participants and the sex worker communities in Tijuana and Cd. Juarez NIH Grants: R01 DA023877 DA023877-S1 K01 MH095680 Staff from the Preven Casa, A. C., UCSD San Diego County Public Health Laboratory

20. References Patterson TL, Mausbach B, Lozada R, Staines-Orozco H, Semple SJ, Fraga-Vallejo M, Orozovich P, Abramovitz DA, de la Torre A, Amaro H, Martinez G, Magis- Rodriguez C, Strathdee SA. Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. Am J Public Health. 2008;98(11):2051-2057. Burgos JL, Gaebler JA, Strathdee SA, Lozada R, Staines H, Patterson TL: Cost- effectiveness of an intervention to reduce HIV/STI incidence and promote condom use among female sex workers in the Mexico-US border region. PLOS One 2010, 5(6):e11413. Strathdee SA, Magis-Rodriguez C: Mexico's evolving HIV epidemic. JAMA 2008, 300(5):571-573. Bell DC, Trevino RA: Modeling HIV risk. J Acquir Immune Defic Syndr 1999, 22(3):280-287. Sonnenberg FA, Beck JR: MARKOV-MODELS IN MEDICAL DECISION-MAKING - A PRACTICAL GUIDE. Medical Decision Making 1993, 13(4):322-338.

21. Extra Slides

22. Prop. OR for reported easy access to sterile syringes