Switching from a criminalisation to a public health approach to injecting drug use in Eastern Europe and Central Asia: a modelling analysis of the costs and impact on HIV transmission
HIV incidence is increasing in Eastern Europe and Central Asia (EECA), primarily driven by injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy (OAT) are sub-optimal, with people who inject drugs (PWID) experiencing considerable incarceration. We evaluated whether using saved monies from decriminalising drug use and/or possession to scale-up ART and OAT could control HIV among PWID in EECA.
A dynamic HIV transmission model among PWID incorporating incarceration, ART and OAT was calibrated to Belarus, Kazakhstan, Kyrgyzstan and St. Petersburg (Russia). Country-specific costs for OAT, ART and incarceration were collated/estimated. Compared to baseline, the model prospectively projected the life years gained (LYG), incremental costs (2018 Euros) and infections prevented over 2020-2040 for three scenarios: (1) Decriminalisation: Remove incarceration due to drug use and drug possession for personal use, reducing incarceration among PWID by 25-46%; (2) Public Health Approach: Use savings from decriminalisation to scale-up ART and OAT; and (3) Full Scale-up: scenario 2 plus invest additional resources to scale-up ART to 81% coverage and OAT to 40% coverage. The incremental cost-effectiveness ratio (ICER) per LYG for each scenario were calculated and compared to country-specific 1xGDP per-capita willingness-to-pay thresholds. Costs and LYG were discounted 3% annually.
Current levels of incarceration, OAT and ART are estimated to cost €197-4,129 million over 2020-2040 across settings; 74.8-95.8% due to incarceration costs. Decriminalisation results in cost-savings (€38-773 million) but modest LYG (745-1,694). The Public Health Approach was cost-saving, allowing each country to reach 81% ART coverage and 29.7-41.8% OAT coverage, resulting in 17,768-148,464 LYG and 58.9-83.7% of infections prevented. Results were similar for the Full Scale-up scenario. Cost-savings from decriminalising drug use could dramatically reduce HIV transmission through increased OAT and ART coverage among PWID in EECA.