1. H. Naning1, C. Kerr2, A. Kamarulzaman1, M. Dahlui3, CW Ng3, D. Wilson2
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

2. HIV Epidemic in Malaysia
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)
By 2011, 94,841 HIV cases of which 17,686 progressed to AIDS with 14,986 AIDS related deaths in Malaysia
Source: Ministry of Health, 2012

3. 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

4. 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
Coverage 20% NSEP, 12% MMT. Approx RM14mil (56% of total prevention) spent on harm reductions in 2011

5. 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
Epi, beh & demo - Secondary data: Peer-reviewed literature database, Grey literatures, Hand searches, Data request
Health care cost - Primary data: Sg Buloh Hospital admission expenditure (Costing Exercise). Secondary data: MOH NSEP / MMT expenditure data & MOH Act of Fees
Primary data: Hospital admission expenditure
Secondary data: Literature review, hand-searches, data request

6. 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

7. RESULT

8. Impact of NSEP on HIV Risk Behaviour

9. Impact of MMT on Number of Active PWIDs

10. HIV Incidence
3,100 HIV infections averted

11. Direct HIV Health Care Cost Savings
Direct HIV health care cost savings based on infections averted.
Harm Reduction Programme
Total direct health care cost-saving (mil. RM)
Combined MMT and NSEP
2.48
(1.97 – 3.01)
38.09
(29.20 – 48.75)
NSEP alone
2.36
(1.88 – 2.87)
35.27
(27.12 – 45.28)
MMT alone
0.17
( )
5.77
(4.17 – 748)
Estimates are medians with 95% confidence intervals provided in parentheses
USD 1 ≈ RM3.1

12. Cost effectiveness
ICER (Incremental cost effectiveness ratio) - cost per QALY (quality-adjusted 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
Incremental cost effectiveness ratio (RM/QALY gained)
Combined MMT and NSEP
18,535
(15,674 – 22,439)
2,358
(1,840 – 3,164)
NSEP alone
6,852
(5,704 – 8,331)
627
(423 – 917)
MMT alone
171,398
(147,083 – 208,099)
11,661
(9,661 – 15,404)
Threshold values for cost-effectiveness ratio = GDP per capita (WHO). GDP is a reflection of ‘fair share’ of each citizen of the nations wealth
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); > 3 x GDP per capita (not cost effective). (WHO Commission on Macroeconomics and Health, 2001)

13. Return On Investment
Return measured only in direct HIV health care costs saved (not overall return on investment)
Harm Reduction Programme
Return on investment
Combined MMT and NSEP
0.03
(0.02 – 0.03)
0.13
(0.10 – 0.17)
NSEP alone
0.07
(0.06 – 0.09)
0.37
(0.28 – 0.47)
MMT alone
0.00
(0.00 – 0.00)
(0.02 – 0.04)
Estimates are medians with 95% confidence intervals provided in parentheses

14. 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

15. 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 cost-effective strategy for averting HIV infections in Malaysia

16. 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

17. Appendix

18. Programme Cost
Source: Ministry of Health, 2012

19. 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

20. Parameters 1. HIV testing Cost per HIV positive IDUs tested
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

21. Direct Health Care Costs
Category of CD4 counts
Annual per capita cost (RM)
Inpatient Care
Outpatient Care
Total (RM)
USD
CD4<350 cells/mm3
15,683
1,461
17,144
5,530
CD4≥350 cells/mm3 NA
974
314
ARV drugs
First line
Stavudine (d4T), Lamivudine (3TC), Nevirapine (NVP)
Combivir (AZT/3TC), Efavirenz (EFV)
Combivir (AZT/3TC), Nevirapine (NVP)
2,684
865
Second-line
Combivir (AZT/3TC) and Kaletra
13,643
4,400
USD 1 ≈ RM3.1

22. Cost Effectiveness QALY (quality adjusted life years)
Incorporate both the prolongation of life and the quality of life by avoiding HIV
Harm Reduction Programme
Number of QALYs gained
Combined MMT and NSEP
4,830
(4,002 – 5,669)
104,116
(80,806 – 124,605)
NSEP alone
4,599
(3,807 – 5,400)
96,451
(74,929 – 115,572)
MMT alone
338
(279 – 394)
15,602
(11,920 – 18,493)
QALY – measure of value of health outcomes from the IDUs perspective due to the programme
Meta analysis utility by Tengs et al Method of assessment = Time trade off (2), standard gambling, rating scale, quality of well being scale and judgement (1) = somewhat significant. Stage of disease & respondent type = predictive of utility. Year not predictive of utility.
AIDS ( ), symp ( ), symp ( ). Limitation small data set, there may be other variable not considered.
TTO:  Remaining in a state of ill health for a period of time or being restored to perfect health but having a shorter life expectancy
SG: Remaining in a state of ill health for a period of time or choosing a medical intervention which has a chance of either restoring them to perfect health, or killing them
Rating scale: indicate the strength of their preference for a health state on a straight line calibrated between ’0’ (death) and ‘1’ (full health). The distance above and below the selected value represents the strength of preference relative to full health and death
QWBS: Somewhat SF-36. Mobility, physical & social activity.
Judgement:
Estimates are medians with 95% confidence intervals provided in parentheses

23. MMT Coverage ( )
MOH clinic expanded from 2 in 2006 to 168 in NADA & prison started in Others – mosque, to check status if still continue in
By 2011, 20,955 IDUs had registered to receive free MMT services from public sites and 23,473 registered with private practitioner

24. NSEP Coverage (Dec 2010)
Agency
No of NSEP sites
NGOs-based (Centre)
17*
MOH (Health Clinic) 73
Total 90
1 4 2
2 20
1 7 10 2
4 8
*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