Cost-Effectiveness of Drop-in-Centres to Prevent HIV Among Injecting Drug Users, IDUs, in Karachi, Pakistan

Background: The HIV epidemic in Pakistan is at present concentrated among high-risk groups including IDUs. Pakistan has approx. 75 000 IDUs - 12 300 are living in Karachi. The HIV prevalence rate among the IDUs in Karachi is 26%. During 2005 and 2006 Pakistan Society, an NGO working for vulnerable populations in Pakistan, established three Drop-In-Centres, DICs, in Karachi including outreach services using motorbikes. At present 850 IDUs visit at a daily basis for clean needles, counselling and care services including detoxification (10%). Objectives: 1) To discuss the methodologies used to determine the cost-effectiveness of IDU interventions in Pakistan when up-scaling to 60% coverage as recommended by UNAIDS, 2) to examine how these interventions fair comparative to the findings from a literature review, and finally 3) to suggest policy options to improve efficiency of providing HIV preventive services that will keep the HIV epidemic from spreading into the general population. Methodology: The cost information was collected in May - June 2006. The costs included are financial and economic costs from the perspective of the provider. The Rapid Costing Approach, RCA, was used to generate total costs as well as the unit costs over five years under different up-scaling assumptions. The behaviour change for the IDU population in Karachi is derived from surveys undertaken in 2005/2006 and imputed into a dynamic mathematical model (IDU 2.4) with data from the IDU population in Karachi. The costs of the IDU interventions in Karachi is being compared with the findings from a literature survey on costing and cost-effectiveness studies in Asia and Eastern Europe, which is also characterized by HIV epidemics driven by IDUs and sex workers. Results: The results show unit costs of IDU interventions in the range of USD 74-105 per IDU/year ranging from 100% utilisation of capacity to 70%. The cost-effectiveness ratio is estimated at USD 78-242 per HIV over five years - the range covering different coverage of intervention (7-60%) and 3% or 6% discount rate, respectively. A comparison with results from Bangladesh (3 year time horizon) shows that the IDU interventions provide a relatively better cost-effectiveness ratio at USD 64-200 per HIV averted comparative to Karachi IDU interventions at USD 117-260. Both IDU approaches are very cost-effective by any measure at USD 2-25 per DALY gained. Discussions: The discussion includes how sensitive the results are to changes of key variables and what it will take to ensure such favourable cost-effectiveness ratio; the validity and reliability of the mathematical model; and finally what messages the result bring to the table of decision makers.