Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis

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Abstract

Objective

From 2011 to 2013, the Global Fund (GF) supported needle and syringe programmes in Mexico to prevent transmission of HIV among people who inject drugs. It remains unclear how GF withdrawal affected the costs, quality and coverage of needle and syringe programme provision.

Design

Costing study and longitudinal cohort study.

Setting

Tijuana, Mexico.

Participants

Personnel from a local needle and syringe programme (n=6) and people who inject drugs (n=734) participating in a longitudinal study.

Primary outcome measures

Provision of needle and syringe programme services and cost (per contact and per syringe distributed, in 2017 $USD) during GF support (2012) and after withdrawal (2015/16). An additional outcome included needle and syringe programme utilisation from a concurrent cohort of people who inject drugs during and after GF withdrawal.

Results

During the GF period, the needle and syringe programme distributed 55 920 syringes to 932 contacts (60 syringes/contact) across 14 geographical locations. After GF withdrew, the needle and syringe programme distributed 10 700 syringes to 2140 contacts (five syringes/contact) across three geographical locations. During the GF period, the cost per harm reduction contact was approximately 10-fold higher compared with after GF ($44.72 vs $3.81); however, the cost per syringe distributed was nearly equal ($0.75 vs $0.76) due to differences in syringes per contact and reductions in ancillary kit components. The mean log odds of accessing a needle and syringe programme in the post-GF period was significantly lower than during the GF period (p=0.02).

Conclusions

Withdrawal of GF support for needle and syringe programme provision in Mexico was associated with a substantial drop in provision of sterile syringes, geographical coverage and recent clean syringe utilisation among people who inject drugs. Better planning is required to ensure harm reduction programme sustainability is at scale after donor withdrawal.

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Most cited references 15

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Effectiveness of needle-exchange programmes for prevention of HIV infection.

Susan Hurley, Damien Jolley, John Kaldor (1997)

Needle-exchange programmes (NEPs) are potentially a key strategy for containing the spread of HIV infection among injecting drug users, but their implementation has been limited by uncertainty about their effectiveness. We used an ecological study design to compare changes over time in HIV seroprevalence in injecting drug users worldwide, for cities with and without NEPs. Published reports of HIV seroprevalence in injecting drug users were identified, and unpublished information on HIV seroprevalence for injecting drug users entering drug treatment in the USA between 1988 and 1993 was obtained from the Centers for Disease Control and Prevention. Details of the implementation of NEPs were obtained from published reports and experts. For each of the 81 cities with HIV seroprevalence data from more than 1 year and NEP implementation details, the rate of change of seroprevalence was estimated by regression analysis. The average difference in this rate for cities with and without NEPs was calculated. On average, seroprevalence increased by 5.9% per year in the 52 cities without NEPs, and decreased by 5.8% per year in the 29 cities with NEPs. The average annual change in seroprevalence was 11% lower in cities with NEPs (95% CI -17.6 to -3.9, p = 0.004). A plausible explanation for this difference is that NEPs led to a reduction in HIV incidence among injecting drug users. Despite the possibility of confounding, our results, together with the clear theoretical mechanisms by which NEPs could reduce HIV incidence, strongly support the view that NEPs are effective.

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The cost-effectiveness of harm reduction.

David Wilson, Braedon Donald, Andrew J. Shattock … (2015)

HIV prevalence worldwide among people who inject drugs (PWID) is around 19%. Harm reduction for PWID includes needle-syringe programs (NSPs) and opioid substitution therapy (OST) but often coupled with antiretroviral therapy (ART) for people living with HIV. Numerous studies have examined the effectiveness of each harm reduction strategy. This commentary discusses the evidence of effectiveness of the packages of harm reduction services and their cost-effectiveness with respect to HIV-related outcomes as well as estimate resources required to meet global and regional coverage targets. NSPs have been shown to be safe and very effective in reducing HIV transmission in diverse settings; there are many historical and very recent examples in diverse settings where the absence of, or reduction in, NSPs have resulted in exploding HIV epidemics compared to controlled epidemics with NSP implementation. NSPs are relatively inexpensive to implement and highly cost-effective according to commonly used willingness-to-pay thresholds. There is strong evidence that substitution therapy is effective, reducing the risk of HIV acquisition by 54% on average among PWID. OST is relatively expensive to implement when only HIV outcomes are considered; other societal benefits substantially improve the cost-effectiveness ratios to be highly favourable. Many studies have shown that ART is cost-effective for keeping people alive but there is only weak supportive, but growing evidence, of the additional effectiveness and cost-effectiveness of ART as prevention among PWID. Packages of combined harm reduction approaches are highly likely to be more effective and cost-effective than partial approaches. The coverage of harm reduction programs remains extremely low across the world. The total annual costs of scaling up each of the harm reduction strategies from current coverage levels, by region, to meet WHO guideline coverage targets are high with ART greatest, followed by OST and then NSPs. But scale-up of all three approaches is essential. These interventions can be cost-effective by most thresholds in the short-term and cost-saving in the long-term.

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Using Top‐down and Bottom‐up Costing Approaches in LMICs: The Case for Using Both to Assess the Incremental Costs of New Technologies at Scale

Lucy Cunnama, Edina Sinanovic, Lebogang Ramma … (2016)

Abstract Purpose Estimating the incremental costs of scaling‐up novel technologies in low‐income and middle‐income countries is a methodologically challenging and substantial empirical undertaking, in the absence of routine cost data collection. We demonstrate a best practice pragmatic approach to estimate the incremental costs of new technologies in low‐income and middle‐income countries, using the example of costing the scale‐up of Xpert Mycobacterium tuberculosis (MTB)/resistance to riframpicin (RIF) in South Africa. Materials and methods We estimate costs, by applying two distinct approaches of bottom‐up and top‐down costing, together with an assessment of processes and capacity. Results The unit costs measured using the different methods of bottom‐up and top‐down costing, respectively, are $US16.9 and $US33.5 for Xpert MTB/RIF, and $US6.3 and $US8.5 for microscopy. The incremental cost of Xpert MTB/RIF is estimated to be between $US14.7 and $US17.7. While the average cost of Xpert MTB/RIF was higher than previous studies using standard methods, the incremental cost of Xpert MTB/RIF was found to be lower. Conclusion Costs estimates are highly dependent on the method used, so an approach, which clearly identifies resource‐use data collected from a bottom‐up or top‐down perspective, together with capacity measurement, is recommended as a pragmatic approach to capture true incremental cost where routine cost data are scarce.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2019

Publication date (Electronic): 29 January 2019

Volume: 9

Issue: 1

Electronic Location Identifier: e026298

Affiliations

[1 ] departmentDivision of Infectious Diseases and Global Public Health , University of California San Diego , La Jolla, California, USA

[2 ] departmentInstitute for Health Policy Studies, School of Medicine , University of California , San Francisco, California, USA

[3 ] Centro de Servicios (SER) , Tijuana, Mexico

[4 ] departmentDepartment of Social and Human Development , State Government of Oaxaca , Oaxaca, Mexico

[5 ] Prevencasa AC , Tijuana, Mexico

[6 ] departmentPopulation Studies , El Colegio de la Frontera Norte , Tijuana, Mexico

[7 ] National Center for the Prevention and Control of HIV and AIDS , Mexico City, Mexico

[8 ] departmentSchool of Social and Community Medicine , University of Bristol , Bristol, UK

Author notes

[Correspondence to ] Dr Javier A Cepeda; jacepeda@ 123456ucsd.edu

Article

Publisher ID: bmjopen-2018-026298

DOI: 10.1136/bmjopen-2018-026298

PMC ID: 6352756

PubMed ID: 30700490

SO-VID: 9d0c4fba-c838-4197-b065-11254d4adcf8

License:

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

History

Date received : 01 September 2018

Date revision received : 13 December 2018

Date accepted : 21 December 2018

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ScienceOpen disciplines: Medicine

Keywords: health economics,epidemiology

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ScienceOpen disciplines: Medicine

Keywords: health economics, epidemiology

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Evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in Tijuana, Mexico: a costing analysis

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Abstract

Objective

Design

Setting

Participants

Primary outcome measures

Results

Conclusions

Related collections

Pan African Medical Journal

Most cited references 15

Effectiveness of needle-exchange programmes for prevention of HIV infection.

The cost-effectiveness of harm reduction.

Using Top‐down and Bottom‐up Costing Approaches in LMICs: The Case for Using Both to Assess the Incremental Costs of New Technologies at Scale

Author and article information

Journal

Affiliations

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Article

History

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Custom metadata

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Similar content 74

Cited by 5

Most referenced authors 287