Abstract
Background
HIV incidence is increasing in eastern Europe and central Asia, primarily driven by injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy are suboptimal, with many people who inject drugs (PWID) being incarcerated. We aimed to assess whether use of monies saved as a result of decriminalisation of drug use or possession to scale up ART and opioid agonist therapy could control HIV transmission among PWID in eastern Europe and central Asia.
Methods
A dynamic HIV transmission model among PWID incorporating incarceration, ART, and opioid agonist therapy was calibrated to Belarus, Kazakhstan, Kyrgyzstan, and St Petersburg (Russia). Country-specific costs for opioid agonist therapy, ART, and incarceration were collated or estimated. Compared with baseline, the model prospectively projected the life-years gained, incremental costs (2018 euros), and infections prevented over 2020–40 for three scenarios. The decriminalisation scenario removed incarceration resulting from drug use or possession for personal use, reducing incarceration among PWID by 24·8% in Belarus, Kazakhstan, and Kyrgyzstan and 46·4% in St Petersburg; the public health approach scenario used savings from decriminalisation to scale up ART and opioid agonist therapy; and the full scale-up scenario included the decriminalisation scenario plus investment of additional resources to scale up ART to the UNAIDS 90-90-90 target of 81% coverage and opioid agonist therapy to the WHO target of 40% coverage. The incremental cost-effectiveness ratios per life-year gained for each scenario were calculated and compared with country-specific gross domestic product per-capita willingness-to-pay thresholds. Costs and life-years gained were discounted 3% annually.
Findings
Current levels of incarceration, opioid agonist therapy, and ART were estimated to cost from €198 million (95% credibility interval 173–224) in Kyrgyzstan to €4129 million (3897–4358) in Kazakhstan over 2020–40; 74·8–95·8% of these total costs were incarceration costs. Decriminalisation resulted in cost savings (€38–773 million due to reduced prison costs; 16·9–26·1% reduction in overall costs) but modest life-years gained (745–1694). The public health approach was cost saving, allowing each setting to reach 81% ART coverage and 29·7–41·8% coverage of opioid agonist therapy, resulting in 17 768–148 464 life-years gained and 58·9–83·7% of infections prevented. Results were similar for the full scale-up scenario.
Interpretation
Cost savings from decriminalisation of drug use could greatly reduce HIV transmission through increased coverage of opioid agonist therapy and ART among PWID in eastern Europe and central Asia.
Funding
Alliance for Public Health, US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse, and Economist Intelligence Unit.
HIV incidence is increasing in eastern Europe and central Asia, primarily driven by injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy are suboptimal, with many people who inject drugs (PWID) being incarcerated. We aimed to assess whether use of monies saved as a result of decriminalisation of drug use or possession to scale up ART and opioid agonist therapy could control HIV transmission among PWID in eastern Europe and central Asia.
Methods
A dynamic HIV transmission model among PWID incorporating incarceration, ART, and opioid agonist therapy was calibrated to Belarus, Kazakhstan, Kyrgyzstan, and St Petersburg (Russia). Country-specific costs for opioid agonist therapy, ART, and incarceration were collated or estimated. Compared with baseline, the model prospectively projected the life-years gained, incremental costs (2018 euros), and infections prevented over 2020–40 for three scenarios. The decriminalisation scenario removed incarceration resulting from drug use or possession for personal use, reducing incarceration among PWID by 24·8% in Belarus, Kazakhstan, and Kyrgyzstan and 46·4% in St Petersburg; the public health approach scenario used savings from decriminalisation to scale up ART and opioid agonist therapy; and the full scale-up scenario included the decriminalisation scenario plus investment of additional resources to scale up ART to the UNAIDS 90-90-90 target of 81% coverage and opioid agonist therapy to the WHO target of 40% coverage. The incremental cost-effectiveness ratios per life-year gained for each scenario were calculated and compared with country-specific gross domestic product per-capita willingness-to-pay thresholds. Costs and life-years gained were discounted 3% annually.
Findings
Current levels of incarceration, opioid agonist therapy, and ART were estimated to cost from €198 million (95% credibility interval 173–224) in Kyrgyzstan to €4129 million (3897–4358) in Kazakhstan over 2020–40; 74·8–95·8% of these total costs were incarceration costs. Decriminalisation resulted in cost savings (€38–773 million due to reduced prison costs; 16·9–26·1% reduction in overall costs) but modest life-years gained (745–1694). The public health approach was cost saving, allowing each setting to reach 81% ART coverage and 29·7–41·8% coverage of opioid agonist therapy, resulting in 17 768–148 464 life-years gained and 58·9–83·7% of infections prevented. Results were similar for the full scale-up scenario.
Interpretation
Cost savings from decriminalisation of drug use could greatly reduce HIV transmission through increased coverage of opioid agonist therapy and ART among PWID in eastern Europe and central Asia.
Funding
Alliance for Public Health, US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse, and Economist Intelligence Unit.
| Original language | English |
|---|---|
| Pages (from-to) | e42-e53 |
| Number of pages | 12 |
| Journal | Lancet HIV |
| Volume | 9 |
| Issue number | 1 |
| Early online date | 9 Dec 2021 |
| DOIs | |
| Publication status | Published - Jan 2022 |
Bibliographical note
Funding Information:The study was commissioned by the Economist Intelligence Unit and sponsored by the Alliance for Public Health (funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria), which is a leading non-governmental organisation aiming to make an impact on the epidemics of HIV/AIDS and other serious infectious diseases in the eastern Europe and central Asia region and globally. The study was also partially funded by the US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse (NIDA; grant number R01 AI147490 to PV and ZW). JS, ZW, and PV acknowledge support from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol (Bristol, UK). PV also acknowledges support from the NIHR-funded EPIToPe project and the NIHR HTA project (NIHR128513). PV and JS acknowledge support from NIDA (grant numbers R01 DA037773, R21 DA046809, and R01 DA047952,). JS, TL, FLA, and PV acknowledge support from NIDA (R01 DA033679). FLA is supported on research related to this grant from the NIDA (K24 DA017072, R01 DA025943, R01 DA029910, R01 DA030768, R01 DA030762, R21 DA041953, and R21 DA047902). JC acknowledges support from NIDA (grant number K01DA043421). This work was carried out using the computational facilities of the Advanced Computing Research Centre at the University of Bristol.
Funding Information:
The study was commissioned by the Economist Intelligence Unit and sponsored by the Alliance for Public Health (funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria), which is a leading non-governmental organisation aiming to make an impact on the epidemics of HIV/AIDS and other serious infectious diseases in the eastern Europe and central Asia region and globally. The study was also partially funded by the US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse (NIDA; grant number R01 AI147490 to PV and ZW). JS, ZW, and PV acknowledge support from the NIHR Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol (Bristol, UK). PV also acknowledges support from the NIHR-funded EPIToPe project and the NIHR HTA project (NIHR128513). PV and JS acknowledge support from NIDA (grant numbers R01 DA037773, R21 DA046809, and R01 DA047952,). JS, TL, FLA, and PV acknowledge support from NIDA (R01 DA033679). FLA is supported on research related to this grant from the NIDA (K24 DA017072, R01 DA025943, R01 DA029910, R01 DA030768, R01 DA030762, R21 DA041953, and R21 DA047902). JC acknowledges support from NIDA (grant number K01DA043421). This work was carried out using the computational facilities of the Advanced Computing Research Centre at the University of Bristol.
Publisher Copyright:
© 2022 Elsevier Ltd
Keywords
- HIV
- people who inject drugs
- Opioid substitution therapy
- criminalisation
- incarceration
- anti-retroviral therapy
- EasternEurope and Central Asia
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This is the accepted author manuscript (AAM). The final published version (version of record) is available online via Elsevier at 10.1016/S2352-3018(21)00274-5. Please refer to any applicable terms of use of the publisher.
- Supplementary Information PDF
This is the accepted author manuscript (AAM). The final published version (version of record) is available online via Elsevier at 10.1016/S2352-3018(21)00274-5. Please refer to any applicable terms of use of the publisher.
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