Abstract
BackgroundWhile there is a general acceptance among public health officials and policy-makers that syringe services programs can be effective in reducing HIV transmission among persons who inject drugs, local syringe services programs are often asked to provide economic justifications for their activities. A cost-effectiveness study, estimating the cost of preventing one HIV infection, would be the preferred methods for addressing this economic question, but few local syringe services programs have the needed data, staff and epidemiologic modeling resources needed for a cost–effectiveness study. We present a method for estimating a threshold value for the number of HIV infections prevented above which the program will be cost-saving to society. An intervention is considered “cost-saving” when it leads to a desirable health outcome a lower cost than the alternative.MethodsThe research literature on the effectiveness of syringe services programs in controlling HIV transmission among persons who inject drugs and guidelines for syringe services program that are “functioning very well” were used to estimate the cost-saving threshold at which a syringe services program becomes cost-saving through preventing HIV infections versus lifetime treatment of HIV. Three steps are involved: (1) determining if HIV transmission in the local persons who inject drugs (PWID) population is being controlled, (2) determining if the local syringe services program is functioning very well, and then (3) dividing the annual budget of the syringe services program by the lifetime cost of treating a single HIV infection.ResultsA syringe services program in an area with controlled HIV transmission (with HIV incidence of 1/100 person-years or less), functioning very well (with high syringe coverage, linkages to other services, and monitoring the local drug use situation), and an annual budget of $500,000 would need to prevent only 3 new HIV infections per year to be cost-saving.ConclusionsGiven the high costs of treating HIV infections, syringe services programs that are operating according to very good practices (“functioning very well”) and in communities in which HIV transmission is being controlled among persons who inject drugs, will almost certainly be cost-saving to society.
Highlights
That syringe services programs (SSP) reduce HIV transmission among persons who inject drugs (PWID) is a conclusion supported by the overwhelming weight of the scientific evidence [1]
Developing a model of how the activities of a local SSP— educating PWID about HIV transmission, distributing sterile syringes and condoms, testing for HIV and referring HIV seropositive persons to antiretroviral therapy (ART), and persons with substance use disorders to substance use treatment—avert a specific number of HIV infections requires a large amount of data
The number of PWID living with HIV is approximately 500 and has been growing slightly, as there are relatively few deaths among PWID infected with HIV. (This measure can be estimated by subtracting known deaths among PWID infected with HIV from the total of PWID diagnosed with HIV over time.)
Summary
Developing a rationale that a local SSP is extremely likely to be cost‐saving Here, we present a straightforward method of determining whether a local program is highly likely to be “costsaving,” that is whether the costs of the local program save money for society compared to the cost of treating people with HIV. If there is a reasonable amount of HIV testing in the community, newly diagnosed cases of HIV among persons with injecting drug use as the transmission risk can be used to assess whether HIV incidence and prevalence are likely to be stable or decreasing versus increasing These data are available for most localities in the USA, where an SSP works collaboratively with state and local health departments [7]. Demonstrating that a local SSP is “functioning very well” does not guarantee that the program is either effective at preventing community transmission of HIV or is cost-saving for society. As noted in the discussion of cost-effectiveness studies above, estimating the numbers of new HIV infections in the absence of an effective SSP requires extensive data and modeling of the likely HIV transmission dynamics in the local PWID population. The number of PWID living with HIV (a proxy measure of HIV prevalence) is approximately 500 and has been growing slightly, as there are relatively few deaths among PWID infected with HIV. (This measure can be estimated by subtracting known deaths among PWID infected with HIV from the total of PWID diagnosed with HIV over time.)
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