CostEffectiveness of Needle Exchange Program among IDUs in

Cost-Effectiveness of Needle Exchange Program among IDUs in Uzbekistan Azizbek A. Boltaev IREX Contemporary Issues Program Fellow Dynamic Communications: Strategies & Tools Workshop Hotel Washington DC, December 16 -19, 2003

Research Methodology Online search in electronic data bases (MEDLINE, EBSCO, and LEXIS-NEXIS) for articles containing combination of words “Cost+Effectiveness+Needle+Exchange+HIV”; Review of reports of 7 Syringe Exchange Projects in Uzbekistan; Onsite interviews of coordinators of 2 public funded SEP in Boston, MA and Cambridge, MA; Mathematic modeling of the HIV epidemic in Uzbekistan to estimate the impact of SEPs on infections averted and disability-adjusted life years (DALY) gained based on program and survey data;

Sharing syringe or bowl/cooker

Sharing drug mixture

Budgets of Both NEPs • Office based $3, 670 • Outreach based $14, 160 Number of Clients in both NEPs 110 64

Cost per Infection Averted $9, 537 $1, 288

Projected Impact of Needle Exchange Program

Conclusions Syringe Exchange Program Among IDUs Is Effective Intervention For HIV Prevention Data from Uzbekistan show that SEPs can be operated very costeffectively (e. g. $1288 per infection averted among SEP clients for a SEP that includes outreach) from an “institutional” perspective. SEP with outreach components should be an integral part of all SEP programs. Several factors critically influence accessibility and effectiveness of SEP; these are political will, financial support, misunderstanding of the goals of SEP, collaboration of SEP with other health care and social service providers, education and skills of SEP providers No cost-effectiveness studies of other preventive or curative interventions have been identified in Uzbekistan

Conclusions contin. No cost-effectiveness studies of other preventive or curative interventions have been identified in Uzbekistan Although data for policy making are limited, this study suggests that an appropriate combination of local data and information from the international literature can be utilized in Uzbekistan with adjustment for epidemiological, economic and cultural differences between and within countries.

Recommendations At a minimum, syringe exchange programs in Uzbekistan should be continued. Syringe exchange programs should be conceptualized as an integral part of public health efforts to stem HIV infection among drug users and should be part of a comprehensive approach to drug use. The Uzbek AIDS Center should provide outreach services for syringe exchange to expand the number of its SEP participants. Additional cost-effective approaches to ease access to sterile injecting equipment, such as secondary exchange, free or low-cost syringes, and access through 24 hour drug stores should be added to SEPs.

Recommendations International donors, such as the US Government, which have bans on the use their funds for syringe exchange services should reconsider their policy regarding SEP considering the strong scientific evidence of SEP effectiveness and its absence of side effects, such as promoting the use of illegal drugs The Country Coordinating Mechanism, which will coordinate Uzbekistan’s $25 million grant from Global Fund, should use costeffectiveness analysis as a powerful tool to strengthen Uzbekistan’s policies in preventing and treating HIV and TB.

Risk formula for HIV infections averted* r = 1 -(p(1 -se(1 -uk))e +(1 -p))m r = cumulative annual probability of infection j = group of IDUs p = 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 injection e = efficiency of transmission of HIV by infected needle, per injection u = probability that bleach is used, at each injection* k = efficiency of bleach in eliminating HIV virus from a needle and syringe m = number of partners per year i = number of injections per year c = 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 *, Joanna E. Siegel, 1990. Modeling the effectiveness of bleach distribution programs for preventing AIDS among intravenous drug users. Sc. D dissertation, HSPH.

Uzbekistan: The Facts Location: Central Asia, North of Afghanistan Area: 447, 400 sq. km, slightly larger than California Capital: Tashkent Natural Recourses: Natural Gas, Petroleum, Gold, Coal, Uranium, Silver, Copper, Molybdenum Geography - note: One of the two only doubly landlocked countries in the world GDP: purchasing power parity total: $65 billion per capita: $2, 500 Population: 25, 981, 647 Median age: Total: 21. 8 yrs male: 21. 2 yrs female: 22. 5 yrs Birth rate: 26. 09 births/1, 000 pop Death rate: 7. 97 deaths/1, 000 pop Sex ratio: 0. 98 male/female Infant mortality rate: 71. 51/1000 Fertility rate: 3 children born/ wmn Life expectancy at birth: 64 years Ethnic groups: Uzbek 80%, Russian 5. 5%, Tajik 5%, Kazakh 3%, Karakalpak 2. 5%, Tatar 1. 5%, other 2. 5%

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