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, Malaysia
2Kirby Institute, University of New South Wales, Sydney, Australia
3Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur,
Malaysia
1
HIV Epidemic in Malaysia
HIV Prevalence (Selected
States), 2012
18.9
12.6
5.7
4.2
Female Sex
worker
Transgender
Men who have
sex with men
PWID
• 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)
Source: Ministry of Health, 2012
2
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 needed
3
Harm Reduction Coverage
MMT 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
Primary data: Hospital admission
expenditure
Secondary data: Literature review, handsearches, data request
5
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 conditions
6
RESULT
7
Impact of NSEP on HIV Risk Behaviour
8
Impact of MMT on Number of
Active PWIDs
9
HIV Incidence
3,100 HIV
infections
averted
10
Direct HIV Health Care Cost Savings
Direct HIV health care cost savings based on infections
averted.
Harm Reduction
Programme
Combined MMT
and NSEP
NSEP alone
MMT alone
Total direct health care cost-saving (mil. RM)
2006 - 2013
2006 - 2023
2.48
38.09
(1.97 – 3.01)
(29.20 – 48.75)
2.36
35.27
(1.88 – 2.87)
(27.12 – 45.28)
0.17
5.77
(0.14 -0.21)
(4.17 – 748)
Estimates are medians with 95% confidence intervals provided in parentheses
USD 1 ≈ RM3.1
11
Cost effectiveness
•
•
ICER (Incremental cost effectiveness ratio) - cost per QALY (qualityadjusted 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)
Harm Reduction
Programme
Combined MMT and
NSEP
NSEP alone
MMT alone
Incremental cost effectiveness ratio
(RM/QALY gained)
2006 - 2013
2006 - 2023
18,535
2,358
(15,674 – 22,439)
(1,840 – 3,164)
6,852
627
(5,704 – 8,331)
(423 – 917)
171,398
11,661
(147,083 – 208,099)
(9,661 – 15,404)
Estimates are medians with 95% confidence intervals provided in parentheses
Malaysia GDP per capita in 2011 ≈ USD 9,650 ≈ RM29,915
CE threshold : <GDP per capita (highly cost effective); 1-3 x GDP per capita (cost effective);
12
> 3 x GDP per capita (not cost effective). (WHO Commission on Macroeconomics and Health, 2001)
Return On Investment
Return measured only in direct HIV health care costs
saved (not overall return on investment)
Harm Reduction
Programme
Combined MMT
and NSEP
NSEP alone
MMT alone
Return on investment
2006 - 2013
2006 - 2023
0.03
0.13
(0.02 – 0.03)
(0.10 – 0.17)
0.07
0.37
(0.06 – 0.09)
(0.28 – 0.47)
0.00
0.03
(0.00 – 0.00)
(0.02 – 0.04)
Estimates are medians with 95% confidence intervals provided in parentheses
13
Return on Investment
•
•
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
14
Conclusion
• 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 costeffective strategy for averting HIV
infections in Malaysia
15
Acknowledgement
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
16
Appendix
17
Programme Cost (mil. RM)
Programme Cost
18
16
14
12
10
8
6
4
2
0
9.8
9.7
7.3
6.3
5.9
5.6
6.2
6.1
4.6
4.3
2.2
1.3
2006
2007
MMT
Total (unadjusted)
2008
2009
2010
2011
NSEP
Total (CPI adjusted to 2011 RM)
Source: Ministry of Health, 2012
18
Parameters
Data
Parameters required
Demographic
IDUs population size
Epidemiology
HIV prevalence of IDUs
Treatment
Testing rate per year*
Treatment rate per year*
Number of HIV diagnosed
Number of patients on ART*
Behavioural
Percentage of shared injections
Average number of injections per year
Percentage of reused syringes that are cleaned
Percentage of IDUs on Methadone
*Adapted based on available study and consultation with HIV
clinician
19
Parameters
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
20
Direct Health Care Costs
Annual per capita cost (RM)
Category of
CD4 counts
CD4<350
cells/mm3
CD4≥350
cells/mm3
ARV drugs
Inpatient
Care
Outpatient
Care
Total (RM)
USD
15,683
1,461
17,144
5,530
NA
974
974
314
2,684
865
13,643
4,400
First line
• Stavudine (d4T),
Lamivudine (3TC),
Nevirapine (NVP)
• Combivir (AZT/3TC),
Efavirenz (EFV)
• Combivir (AZT/3TC),
Nevirapine (NVP)
Second-line
Combivir (AZT/3TC) and
Kaletra
USD 1 ≈ RM3.1
21
Cost Effectiveness
• QALY (quality adjusted life years)
• Incorporate both the prolongation of life and
the quality of life by avoiding HIV
Harm Reduction
Programme
Combined MMT
and NSEP
NSEP alone
MMT alone
Number of QALYs gained
2006 - 2013
2006 - 2023
4,830
104,116
(4,002 – 5,669)
(80,806 – 124,605)
4,599
96,451
(3,807 – 5,400)
(74,929 – 115,572)
338
15,602
(279 – 394)
(11,920 – 18,493)
Estimates are medians with 95% confidence intervals provided in parentheses
22
MMT Coverage (2006-2011)
No of MMT sites
180
160
MOH Clinic
140
MOH Hospital
120
GP
100
NADA
Prison
80
Others
60
40
20
0
2006
2007
2008
2009
2010
2011
By 2011, 20,955 IDUs had registered to receive free MMT services
from public sites and 23,473 registered with private practitioner
23
NSEP Coverage (Dec 2010)
Agency
1 4
2
2 20
1 7
10
2
4 8
No of
NSEP
sites
NGOs-based
(Centre)
17*
MOH (Health
Clinic)
73
Total
90
*Over 200 of outreach points
1 9
By 2011, 34,244 IDUs
had registered to receive
NSEP services from 221
NGO’s outreach points
and 76 MOH clinic
1 4
3 1
24