1. EVALUATING THE COST-EFFECTIVENESS OF NEEDLE AND SYRINGE EXCHANGE PROGRAMS (NSEPs),TAJIKISTAN REGIONAL STUDY COST-EFFECTIVENESS EVALUATION OF NSEPs IN EASTERN EUROPE AND CENTRAL ASIATechnical assistance:UNIVERSITY OF NEW SOUTH WALES (AUSTRALIA) JOINT UNITED NATIONS PROGRAMME ON HIV/AIDS (UNAIDS)UNDP HIV/AIDS, TUBERCULOSIS AND MALARIA CONTROL IN TAJIKISTAN Team of experts in Tajikistan (Republican AIDS Centre, UNAIDS and UNDP) with the technicalassistance of David P. Wilson (University of NewSouth Wales, Australia), Carlos Avila(UNAIDSGeneva), and Anna Yakusik (Health Finance Consultant, Belarus

2. Executive Summary 4,004 new HIV infections and 6,124 new HCVinfections were averted due to NSEPs in Tajikistan More than 505 DALYs related to HIV wereaverted, and more than 2,860 DALYs related to HCVwere averted Impact is still higher on reducing the HCVprevalence in 2020 as the prevalence of HCV ishigher than that of HIV Should the country get half of the currentresources for needle exchange over the next tentears, the results would be 3912 new HIVinfections and 5533 new HCV infections (hencethe need for funding!) By adding just 25% to the current resources, the 3. EVALUATING THE COST-EFFECTIVENESS OFNSEPs: STUDY OBJECTIVES, DESIGN ANDMETHODOLOGYBACKGROUND OF THE STUDYThe primary aim of NSEPs is to prevent the shared use of injecting equipment inorder to reduce the risk of acquiring blood-borne infections among IDUsInjecting drug use along with growth of commercial sex industry and increasingmigration of the population remains the main driving force of the HIV epidemicin Tajikistan. Since HIV prevalence for a number of years has been higher than 5%among MARPs, particularly IDUs, Tajikistan is in the concentrated epidemic stageHIV/AIDS effectiveness evaluation and cost-effectiveness studies have becomeimportant analytical tools to understand what HIV investments havebought, whether the interventions averted new infections and AIDS deaths, and atwhat cost. They can support decision-making and prioritization of interventionstrategies and target groups within the HIV/AIDS response with its overall goals ofminimizing the burden of disease and maximizing health outcomes 4. BACKGROUND OF THE STUDY The primary aim of NSEPs is to prevent the shared use ofinjecting equipment in order to reduce the risk of acquiringblood-borne infections among IDUs IDUs along with growth of commercial sex industry andincreasing migration of the population remains the main drivingforce of the HIV epidemic in Tajikistan. Since HIV prevalence for anumber of years has been higher than 5% amongMARPs, particularly IDUs, Tajikistan is in the concentratedepidemic stage HIV/AIDS effectiveness evaluation and cost-effectiveness studieshave become important analytical tools to understand what HIVinvestments have bought, whether the interventions averted newinfections and AIDS deaths, and at what cost. They can supportdecision-making and prioritization of intervention strategies andtarget groups within the HIV/AIDS response with its overall goalsof minimizing the burden of disease and maximizing healthoutcomes 5. STUDY OBJECTIVES Estimate the population benefits that NSEPsin Tajikistan have likely had in preventing HIVand HCV infections and related healthoutcomes among IDUs Explore the cost-effectiveness of NSEPs inTajikistan from health sector perspectiveTherefore, It is important to assess the impact of NSEPs and estimate the cost-effectiveness of current programs as well as the cost- effectiveness of increasing and decreasing the allocation of resources to NSEPs and the programs that they deliver 6. STUDY DESIGN AND METHODOLOGY Cost-effectiveness evaluation of NSEPs in Tajikistan was carried out using a standardized model and software package, first developed for evaluation of NSEPs in Australia and adapted for general application to any setting in a joint collaboration between UNAIDS and the University of New South Wales (Sydney, Australia) The mathematical transmission model was informed by all available epidemiological, biological, behavioral and clinical data as relevant for the population of IDUs in Tajikistan, as well as trends in the number of syringes distributed through NSEPs The relationship between NSEPs and risk behavior specific to Tajikistan was used to define appropriate yet conservative counterfactual scenarios, that is, the assumed conditions that would likely have been had NSEPs not been in place for the period of 2005-2010 The software was also used to estimate the expected epidemiological and economic benefits associated with increases or decreases in NSEPs in Tajikistan over the next 10 years (2011-2020) 7. EVALUATING THE COST-EFFECTIVENESS OFNSEPs: INPUT DATATajikistan 8. General epidemiological trends related to injecting drug use inTajikistan 9. Population size of IDUs and average number of years ofinjecting for a typical drug user in Tajikistan 10. Risk injecting behavior of IDUs in Tajikistan 11. NSEPs interventions for IDUs in Tajikistan (2005-2010) 12. Sources of funding of NSEPs interventions for IDUs inTajikistan (2005-2010) In 2005-2010, gross funding of NSEPs interventions in Tajikistan was US $ 2.9 million (in 2010 US dollars) In 2005-2010, the sources of funding of NSEPs in Tajikistan were the following:1. UNDP Project "HIV/AIDS, TB and Malaria Control in Tajikistan" funded by the GFATM (about 79% of total spending on NSEPs interventions)2. Central Asian Regional HIV/AIDS Programme (CARHAP)3. Central Asia AIDS Control Project (CAAP)4. Open Society Institute - Assistance Foundation, Tajikistan (data available for 2009 and 2010) 13. Investments in NSEPs in Tajikistan (2005-2010)Total funding of NSEPs interventions in NSEPs interventions cost distributionTajikistan (US $) by line item (%)TOTAL (US $), unadjusted to CPITOTAL (US $), adjusted to CPI$1,000,000.00 100% $900,000.0090% $800,000.0080% $700,000.0070%Recurring maintenanceand service costs $600,000.0060% Ongoing personnel costsOne-off infrastructure $500,000.0050% investmentCost of needle-syringedisposal $400,000.0040%Cost of needle-syringedistribution $300,000.0030% $200,000.0020% $100,000.0010% $0.00 0% 2005 20062007 2008 2009 2010 2005 2006 20072008 2009 2010Year 14. EVALUATION OF THE PAST IMPACT OF NSEPs INTAJIKISTAN (2005-2010)Tajikistan 15. HIV notifications and expected cases among IDUs and model-basedestimations with and without NSEPs (2005-2010), TajikistanGreen curve represents the level suggested by the model as prevalence without NSEPs 16. HCV notifications and expected cases among IDUs and model-basedestimations with and without NSEPs (2005-2010), TajikistanGreen curve represents the level suggested by the model as prevalence without NSEPs 17. Indicators for economic evaluation of NSEPs in Tajikistan(2005-2010) Efficiency of NSEPs in Tajikistan was estimated based on the following indicators and in relation to HIV and HCV:1. Number of new cases of disease in a population in a given time averted (HIV averted cases & HCV averted cases)2. Health outcomes (DALYs) averted3. Cumulative costs per DALY averted4. Health care costs saved 18. Evaluating the past impact of NSEPs on IDUs in Tajikistan(2005-2010)For the period of 2005-2010 study presents: Gross funding on NSEPs interventions in Tajikistan: US $ 2.9 million Averted infections: 4,004 HIV infections and 6,124 HCV infections averted DALYs averted: 505 DALYs related to HIV and 2,860 DALYs related to HCV averted.Thus, NSEPs interventions appeared to be cost-effective Cumulative costs per DALY averted: US $ 7,109 per DALY averted related to HIV & aboutUS $ 1,313 per DALY averted related to HCV Health care costs saved due to HIV averted cases: US $ 0.11 million saved for the periodof 2005-2010 Health care costs saved due to HCV averted cases: US $ 8.87 million saved for theperiod of 2010. Savings of heath care costs due to HCV aversions for the period of 2005-2009 were not included into the study results as HCV treatment of patients with chronichepatitis C (particularly treatment with pegylated interferons) is being provided onlysince 2010 (15% of patients in need with HIV-HCV coinfection) Net financial costs: US $ -6.08 million. Thus, NSEPs interventions appeared to be cost-saving. US $ 6.08 million saved due to economy on health care costs Return on investment (ROI): on one US dollar spent on NSEPs interventions the gainwas of about US $ 3 saved on HIV&HCV health care costs 19. EVALUATING CHANGES TO NSEPs IN THEFUTURE OVER THE NEXT TEN YEARS(2011-2020)Tajikistan 20. Projected impact on HIV and HCV cases among IDUs inTajikistan associated with changes in NSEPs over the next tenyears in Belarus The mathematical model was also used to project the expected number of HIV and HCV cases in the future according to scenarios whereby current syringe distribution levels are maintained or if there are increases or decreases in the provision of syringes through NSEPs Different coverage rates were simulated across IDUs up to year 2020 : if NSEPs cease to distribute injecting equipment (2011-2020); if NSEPs decrease overall distribution of injecting equipment by 50% (2011-2020); if NSEPs decrease overall distribution of injecting equipment by 25% (2011-2020); with current conditions of syringe distribution and coverage maintained (2011- 2020); if NSEPs increase overall distribution of injecting equipment by 25% (2011-2020); if NSEPs increase overall distribution of injecting equipment by 50% (2011-2020); if NSEPs increase overall distribution of injecting equipment by 100% (2011-2020); if NSEPs increase overall distribution of injecting equipment by 200% (2011-2020). 21. Projections of HIV and HCV prevalence, incidence and deathsamong IDUs in Tajikistan due to decreases in NSEPsdistribution of injecting equipment (2011-2020) 22. Projected impact associated with changes in NSEPs over the next 10 years (2011-2020), Tajikistan NSEPs investmentInvestments in Change in DALYsChange in infectionsIncremental ICER (ChangeNSEPs *, US $related to HIVHIVHCV costs (changein costs / millionand HCVin NSEPsChange in investmentsDALYs) relative to the baseline), US $million50% of current levels4.65 (m $)+4,659+3,912+5,533-4.65 -99875% of current levels6.98 (m $)+1,505+1,158+1,778 -2.32 -1,541Maintain current 9.30 (m $)levels**125% of current levels11.62 (m $) -568-410-665 +2.32+4,084150% of current levels13.95 (m $) -765-548-894 +4.65+6,078200% of current levels18.60 (m $) -853-609-997 +9.30+10,903300% of current levels29.90 (m $) -864-617 -1,009+20.60 +23,843* Assuming costs scale linearly with current implementation costs** Current level of NSEPs is the level of costs of 2010 with the same level of needle and syringe distribution (US $ 0.93 million peryear) 23. Reproducing of the past impact of NSEPs on IDUs in Tajikistan(2005-2010) Based on the population transmission model, it was estimated that if NSEPs were not in place, the incidence of HIV and HCV would have increased substantially, hence a large epidemic of HIV and HCV among IDUs could have been expected: 4,004 HIV infections and 6,124 HCV infections averted The modeling also suggests that NSEPs in Tajikistan have significantly reduced the potentially higher prevalence of HIV and HCV NSEPs interventions appeared to be cost-effective: 505 DALYs related to HIV and 2,860 DALYs related to HCV averted with key partners (national and international) willingness to pay US $ 7,109 per DALY averted related to HIV & US $ 1,313 per DALY averted related to HCV NSEPs interventions appeared to be cost-saving: US $ 6.08 million saved due to economy on health care costs which would occur if NSEPs have not been in place in the period of 2005-2010 Return on investment (ROI): on one US dollar spent on NSEPs interventions the gain was of about US $ 3 saved on HIV&HCV health care costs 24. Reproducing of the projected impact of NSEPs on IDUs inTajikistan over the next 10 years (2011-2020) Projected impact associated with changes in NSEPs over the next 10 years (2011-2020) in Tajikistan show that relatively small shortfalls in funding increase the riskof injecting equipment shared use due to the lack of convenient access to sterileneedle and syringes, therefore increases the risk of acquiring blood-borneinfections among IDUs and increases the pace of the HIV and HCV epidemic in thecountry It appears to be cost-effective to maintain and increase the level of NSEPsinvestments and needle and syringe distribution among IDUs in Tajikistan up to150% of the current level: 125% of current level of investments and needle and syringe distribution: oneadditional DALY gained will require additional investment of US $ 4,084; 150% of current level of investments and needle and syringe distribution: oneadditional DALY gained will require additional investment of US $ 6,078. Consistent allocations of resources on NSEPs influences on substantial reductionof the pace of the HIV and HCV epidemic in Tajikistan 25. Thank you for your attention