h. naning 1 , c. kerr 2 , a. kamarulzaman 1 , m. dahlui 3 , cw ng 3 , d. wilson 2
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Cost-effectiveness and return on investment of harm reduction programmes for people who inject drugs in Malaysia. H. Naning 1 , C. Kerr 2 , A. Kamarulzaman 1 , M. Dahlui 3 , CW Ng 3 , D. Wilson 2 - PowerPoint PPT PresentationTRANSCRIPT
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)
2Source: 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 - 2023Combined 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 HealthDr Chong Chee Kheong Dr Sha’ari NgadimanDr Fazidah Yusman
Sg Buloh HospitalDatuk Dr Christopher LeeDr Suresh KumarDr Benedict LimRitta DavidMasitah Mohd Salleh
The study was funded by• World Bank
National Anti-Drug AgencyDr Sangeeth Kaur
University of New South WalesRichard GrayLei ZhangJosephine Reyes
Centre of Excellence for Research in AIDSTheresa AnthonyChristine StandleyHowie LimJeannia FuAlexander Bazazi
Appendix
17
Programme Cost
18
2006 2007 2008 2009 2010 201102468
1012141618
4.3
5.9 6.3
9.7
7.3
9.8
1.32.2
4.65.6
6.2 6.1
MMT NSEPTotal (unadjusted) Total (CPI adjusted to 2011 RM)
Pro
gram
me
Cos
t (m
il. R
M)
Source: Ministry of Health, 2012
Parameters
*Adapted based on available study and consultation with HIV clinician
Data Parameters required
Demographic IDUs population size
Epidemiology HIV 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 CostsCategory 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