International Journal of Drug Policy - 2015

Volume 26 Supp 1 Feb 2015

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International Journal of Drug Policy 26 (2015) S5–S11 Contents lists available at ScienceDirect International Journal of Drug Policy j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / d r u g p o Commentary The cost-effectiveness of harm reduction David P. Wilson a,∗ , Braedon Donald a , Andrew J. Shattock a , David Wilson b , Nicole Fraser-Hurt b a The Kirby Institute, UNSW Australia, Australia b Global HIV/AIDS Program, World Bank, United States a r t i c l e i n f o Article history: Received 10 September 2014 Received in revised form 11 November 2014 Accepted 11 November 2014 Keywords: Cost-effectiveness HIV Harm reduction People who inject drugs a b s t r a c t 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 effec- tiveness 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 out- comes 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 reduc- tion 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 tar- gets 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. © 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license ( Introduction HIV prevalence worldwide among people who inject drugs (PWID) is around 19% (World Health Organization, 2013) and almost one-third of HIV incident cases outside sub-Saharan Africa are related to injecting drug use (Open Society Institute, 2004). Injecting drug use is estimated to be responsible for around 10% of all HIV infections worldwide (UNAIDS, 2012). The spread of HIV among PWID has particularly driven epidemics throughout regions of Eastern Europe, and Central and Southeast Asia (Bridge, Lazarus, ∗ Corresponding author at: The Kirby Institute, University of New South Wales, Level 6, Wallace Wurth Building, Kensington, Sydney NSW 2052, Australia. Tel.: +61 2 9385 0959. E-mail address: (D.P. Wilson). & Atun, 2010; El-Bassel et al., 2014; Wu, Shi, & Detels, 2013). Indeed, in Eastern Europe and Central Asia the majority of HIV infections have been attributed to injecting drug use and this is the region of the world currently with the largest increase in HIV epidemics (UNAIDS, 2012). Some countries in the Middle East and North Africa region have also been experiencing rapidly emerging HIV epidemics among PWID (Mumtaz et al., 2014). Many countries in Asia and Eastern Europe have responded to injecting drug use through law enforcement measures and com- pulsory detention (Wu, 2013). There is no evidence to suggest that compulsory detention of people who use drugs is effective in reduc- ing drug dependency or rehabilitative, as most detained people return to drug dependency after release (Hall et al., 2012; WHO, 2009a). An alternate approach is harm reduction, which refers to methods of reducing health risks when eliminating them may not be possible. Harm reduction can also reduce social and economic 0955-3959/© 2015 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (

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