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, Malaysia2Kirby Institute, University of New South Wales, Sydney, Australia3Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

1

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)

2

Source: Ministry of Health, 2012

Female Sex worker

Transgender Men who have sex with men

PWID

4.25.7

12.6

18.9

HIV Prevalence (Selected States), 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 needed3

Harm Reduction CoverageMMT 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

4

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

5

Primary data: Hospital admission expenditureSecondary 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 conditions6

RESULT

7

Impact of NSEP on HIV Risk Behaviour

8

Impact of MMT on Number of Active PWIDs

9

HIV Incidence

10

3,100 HIV infections averted

Direct HIV Health Care Cost Savings

11

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)

Direct HIV health care cost savings based on infections averted.

USD 1 ≈ RM3.1

Estimates are medians with 95% confidence intervals provided in parentheses

Cost effectiveness

12

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)

Estimates are medians with 95% confidence intervals provided in parentheses

• 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)

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)

Malaysia GDP per capita in 2011 ≈ USD 9,650 ≈ RM29,915

Return On Investment

13

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)

0.03 (0.02 – 0.04)

Return measured only in direct HIV health care costs saved (not overall return on investment)

Estimates are medians with 95% confidence intervals provided in parentheses

Return on Investment

14

• 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

15

• 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

16

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

17

Programme Cost

18

2006 2007 2008 2009 2010 20110

2

4

6

8

10

12

14

16

18

4.3

5.96.3

9.7

7.3

9.8

1.32.2

4.6

5.66.2 6.1

MMT NSEPTotal (unadjusted) Total (CPI adjusted to 2011 RM)

Pro

gra

mm

e C

ost

(m

il.

RM

)

Source: Ministry of Health, 2012

Parameters

*Adapted based on available study and consultation with HIV clinician

Data Parameters required

Demographic IDUs population size

EpidemiologyHIV prevalence of IDUs

Treatment

Testing rate per year*Treatment rate per year*Number of HIV diagnosedNumber of patients on ART*

Behavioural

Percentage of shared injectionsAverage number of injections per yearPercentage of reused syringes that are cleanedPercentage of IDUs on Methadone

19

Parameters

20

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 Average cost per HIV positive IDU per year

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 974 974 314

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

21

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

22

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)

Estimates are medians with 95% confidence intervals provided in parentheses

MMT Coverage (2006-2011)

23

By 2011, 20,955 IDUs had registered to receive free MMT services from public sites and 23,473 registered with private practitioner

2006 2007 2008 2009 2010 20110

20

40

60

80

100

120

140

160

180

MOH Clinic MOH Hospital GP NADA Prison Others

No

of M

MT

site

s

NSEP Coverage (Dec 2010)

24

10

2

1 9

1 4

3 1

4 8

1 7

2 2021 4

Agency No of NSEP sites

NGOs-based (Centre)

17*

MOH (Health Clinic)

73

Total 90

By 2011, 34,244 IDUs had registered to receive NSEP services from 221 NGO’s outreach points and 76 MOH clinic

*Over 200 of outreach points