Cost-Effectiveness of Needle Exchange Program among IDUs in Uzbekistan Azizbek A. Boltaev IREX Contemporary Issues Program Fellow Dynamic Communications:

Cost-Effectiveness Cost-Effectiveness of Needle Exchange Program of Needle Exchange Program

among IDUs in Uzbekistanamong IDUs in Uzbekistan

Azizbek A. BoltaevAzizbek A. BoltaevIREX Contemporary Issues Program FellowIREX Contemporary Issues Program Fellow

Dynamic Communications: Strategies & Tools WorkshopDynamic Communications: Strategies & Tools WorkshopHotel WashingtonHotel Washington

Washington DC, December 16-19, 2003Washington DC, December 16-19, 2003

Research MethodologyResearch Methodology

Online search in electronic data bases (MEDLINE, EBSCO, Online search in electronic data bases (MEDLINE, EBSCO, and LEXIS-NEXIS) for articles containing combination of and LEXIS-NEXIS) for articles containing combination of words “Cost+Effectiveness+Needle+Exchange+HIV”;words “Cost+Effectiveness+Needle+Exchange+HIV”;

Review of reports of 7 Syringe Exchange Projects in Review of reports of 7 Syringe Exchange Projects in Uzbekistan;Uzbekistan;

Onsite interviews of coordinators of 2 public funded SEP in Onsite interviews of coordinators of 2 public funded SEP in Boston, MA and Cambridge, MA;Boston, MA and Cambridge, MA;

Mathematic modeling of the HIV epidemic in Uzbekistan to Mathematic modeling of the HIV epidemic in Uzbekistan to estimate the impact of SEPs on infections averted and estimate the impact of SEPs on infections averted and disability-adjusted life years (DALY) gained based on program disability-adjusted life years (DALY) gained based on program and survey data;and survey data;

Sharing syringe or bowl/cookerSharing syringe or bowl/cooker

With how many others did you share a syringe or bowl?

37%

28%

24%

7%

4%

36%

28%

25%

7%

4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0 1 2 3 4+

Number of other users

% o

f re

sp

on

de

nts

SyringeBowl

Mean = 1.16Mean = 1.18

Sharing drug mixtureSharing drug mixture

Do you share your drug mixture with others?

26%

36%

38%

0%

5%

10%

15%

20%

25%

30%

35%

40%

No Sometimes Yes

% o

f re

spo

nd

ents

Number of Clients in both NEPsNumber of Clients in both NEPs

Budgets of Both NEPsBudgets of Both NEPs

AIDS Center's SEP

BRAYM's NEP

$$14,16014,160

$$3,6703,670

Office based (AIDS Center's) SEP

Outreach based BRAYM's NEP

1101106464

• Office basedOffice based

• Outreach basedOutreach based

Cost per Infection AvertedCost per Infection Averted

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

$10,000

Office based (AIDS Center's) SEP Outreach based (BRAYM's) NEP

Series 1

$9,537$9,537

$1,288$1,288

12,400

17,971

25,000

32,997

40,973

47,803

52,818

56,03557,902 58,918

12,400

17,971

40,973 41,937 42,874 43,782 44,660 45,507

32,997

25,000

0

10,000

20,000

30,000

40,000

50,000

60,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

YearNo programProgram begins 2004

Projected Impact of Needle Exchange Program

ConclusionsConclusionsSyringe Exchange Program Among IDUs Is Effective Intervention Syringe Exchange Program Among IDUs Is Effective Intervention For HIV PreventionFor HIV PreventionData from Uzbekistan show that SEPs can be operated very cost-Data from Uzbekistan show that SEPs can be operated very cost-effectively (e.g. $1288 per infection averted among SEP clients for a effectively (e.g. $1288 per infection averted among SEP clients for a SEP that includes outreach) from an “institutional” perspective.SEP that includes outreach) from an “institutional” perspective.

SEP with outreach components should be an integral part of all SEP SEP with outreach components should be an integral part of all SEP programs. programs.

Several factors critically influence accessibility and effectiveness of Several factors critically influence accessibility and effectiveness of SEP; these are political will, financial support, misunderstanding of SEP; these are political will, financial support, misunderstanding of the goals of SEP, collaboration of SEP with other health care and the goals of SEP, collaboration of SEP with other health care and social service providers, education and skills of SEP providerssocial service providers, education and skills of SEP providers

No cost-effectiveness studies of other preventive or curative No cost-effectiveness studies of other preventive or curative interventions have been identified in Uzbekistaninterventions have been identified in Uzbekistan

Conclusions contin.Conclusions contin.No cost-effectiveness studies of other preventive or curative No cost-effectiveness studies of other preventive or curative interventions have been identified in Uzbekistaninterventions have been identified in Uzbekistan

Although data for policy making are limited, this study suggests that Although data for policy making are limited, this study suggests that an appropriate combination of local data and information from the an appropriate combination of local data and information from the international literature can be utilized in Uzbekistan with adjustment international literature can be utilized in Uzbekistan with adjustment for epidemiological, economic and cultural differences between and for epidemiological, economic and cultural differences between and within countries.within countries.

RecommendationsRecommendations At a minimum, syringe exchange programs in Uzbekistan should be At a minimum, syringe exchange programs in Uzbekistan should be continued.continued.

Syringe exchange programs should be conceptualized as an Syringe exchange programs should be conceptualized as an integral part of public health efforts to stem HIV infection among integral part of public health efforts to stem HIV infection among drug users and should be part of a comprehensive approach to drug drug users and should be part of a comprehensive approach to drug use.use.

The Uzbek AIDS Center should provide outreach services for The Uzbek AIDS Center should provide outreach services for syringe exchange to expand the number of its SEP participants.syringe exchange to expand the number of its SEP participants.

Additional cost-effective approaches to ease access to sterile Additional cost-effective approaches to ease access to sterile injecting equipment, such as secondary exchange, free or low-cost injecting equipment, such as secondary exchange, free or low-cost syringes, and access through 24 hour drug stores should be added syringes, and access through 24 hour drug stores should be added to SEPs.to SEPs.

RecommendationsRecommendations

International donors, such as the US Government, which have bans International donors, such as the US Government, which have bans on the use their funds for syringe exchange services should on the use their funds for syringe exchange services should reconsider their policy regarding SEP considering the strong reconsider their policy regarding SEP considering the strong scientific evidence of SEP effectiveness and its absence of side scientific evidence of SEP effectiveness and its absence of side effects, such as promoting the use of illegal drugseffects, such as promoting the use of illegal drugs

The Country Coordinating Mechanism, which will coordinate The Country Coordinating Mechanism, which will coordinate Uzbekistan’s $25 million grant from Global Fund, should use cost-Uzbekistan’s $25 million grant from Global Fund, should use cost-effectiveness analysis as a powerful tool to strengthen Uzbekistan’s effectiveness analysis as a powerful tool to strengthen Uzbekistan’s policies in preventing and treating HIV and TB.policies in preventing and treating HIV and TB.

Risk formula for HIV infections Risk formula for HIV infections averted*averted*

*, Joanna E. Siegel, 1990. Modeling the effectiveness of bleach distribution programs for preventing AIDS among intravenous drug users. ScD dissertation, HSPH.

r = 1-(p(1-se(1-uk))e +(1-p))m r = cumulative annual probability of infectionj = group of IDUsp = probability of selecting an infected injection partner (a function of prevalence)*s = probability that needle is shared; i.e., probability that someone used the needle immediately prior to this injectione = efficiency of transmission of HIV by infected needle, per injectionu = probability that bleach is used, at each injection*k = efficiency of bleach in eliminating HIV virus from a needle and syringem = number of partners per yeari = number of injections per yearc = average contacts per partner, defined as number of injections (i), divided by number of partners (m)*These parameters are group-specific in some model versions

Uzbekistan: The FactsUzbekistan: The FactsLocation:Location: Central Asia, Central Asia,

North of AfghanistanNorth of AfghanistanArea:Area: 447,400 sq.km, 447,400 sq.km, slightly larger than Californiaslightly larger than CaliforniaCapital:Capital: Tashkent TashkentNatural Recourses:Natural Recourses: Natural Natural Gas, Petroleum, Gold, Coal, Gas, Petroleum, Gold, Coal, Uranium, Silver, Copper, Uranium, Silver, Copper, MolybdenumMolybdenumGeography - note:Geography - note: One of the One of the two only doubly landlocked two only doubly landlocked countries in the worldcountries in the worldGDP:GDP: purchasing power parity purchasing power parity

total:total: $65 billion $65 billionper capita:per capita: $2,500 $2,500

Population:Population: 25,981,647 25,981,647Median age:Median age: Total: 21.8 yrs Total: 21.8 yrs

male: 21.2 yrsmale: 21.2 yrsfemale: 22.5 yrs female: 22.5 yrs

Birth rate:Birth rate: 26.09 births/1,000 pop 26.09 births/1,000 popDeath rate:Death rate: 7.97 deaths/1,000 pop 7.97 deaths/1,000 popSex ratio:Sex ratio: 0.98 male/female 0.98 male/femaleInfant mortality rate:Infant mortality rate: 71.51/1000 71.51/1000Fertility rate:Fertility rate: 3 children born/ wmn 3 children born/ wmnLife expectancy at birth:Life expectancy at birth: 64 years 64 yearsEthnic groups:Ethnic groups: Uzbek 80%, Russian Uzbek 80%, Russian 5.5%, Tajik 5%, Kazakh 3%, Karakalpak 5.5%, Tajik 5%, Kazakh 3%, Karakalpak 2.5%, Tatar 1.5%, other 2.5%2.5%, Tatar 1.5%, other 2.5%

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