The cost-effectiveness of Canada's only supervised injection facility has not been rigorously evaluated. We estimated the impact of the facility on survival, rates of HIV and hepatitis C virus infection, referral to methadone maintenance treatment and associated costs.
We simulated the population of Vancouver, British Columbia, including injection drug users and persons infected with HIV and hepatitis C virus. The model used a time horizon of 10 years and the perspective of the health care system. We compared the situation of the supervised injection facility with one that had no facility but that had other interventions, such as needle-exchange programs. The effects considered were decreased needle sharing, increased use of safe injection practices and increased referral to methadone maintenance treatment. Outcomes included life-years gained, costs, and incremental cost-effectiveness ratios discounted at 5% per year.
Focusing on the base assumption of decreased needle sharing as the only effect of the supervised injection facility, we found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When we also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when we considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175. Results were sensitive to assumptions related to injection frequency, the risk of HIV transmission through needle sharing, the frequency of safe injection practices among users of the facility, the costs of HIV-related care and of operating the facility, and the proportion of users who inject in the facility.
Vancouver's supervised injection site is associated with improved health and cost savings, even with conservative estimates of efficacy.
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To assess the effectiveness and cost-effectiveness of treating HIV-infected injection drug users (IDUs) and non-IDUs in Russia with highly active antiretroviral therapy HAART.
A dynamic HIV epidemic model was developed for a population of IDUs and non-IDUs. The location for the study was St. Petersburg, Russia. The adult population aged 15 to 49 years was subdivided on the basis of injection drug use and HIV status. HIV treatment targeted to IDUs and non-IDUs, and untargeted treatment interventions were considered. Health care costs and quality-adjusted life years (QALYs) experienced in the population were measured, and HIV prevalence, HIV infections averted, and incremental cost-effectiveness ratios of different HAART strategies were calculated.
With no incremental HAART programs, HIV prevalence reached 64% among IDUs and 1.7% among non-IDUs after 20 years. If treatment were targeted to IDUs, over 40 000 infections would be prevented (75% among non-IDUs), adding 650 000 QALYs at a cost of USD 1501 per QALY gained. If treatment were targeted to non-IDUs, fewer than 10 000 infections would be prevented, adding 400 000 QALYs at a cost of USD 2572 per QALY gained. Untargeted strategies prevented the most infections, adding 950 000 QALYs at a cost of USD 1827 per QALY gained. Our results were sensitive to HIV transmission parameters.
Expanded use of antiretroviral therapy in St. Petersburg, Russia would generate enormous population-wide health benefits and be economically efficient. Exclusively treating non-IDUs provided the least health benefit, and was the least economically efficient. Our findings highlight the urgency of initiating HAART for both IDUs and non-IDUs in Russia.