Project aims
Population model methods
Economic analysis methods
Summary of investment
Effectiveness of NSPs
Economic analysis of NSPs during 2000-2009
Results about future NSPs
Conclusions
Key tables

Project aims

This project aimed to:
  1. Estimate the population benefits of needle and syringe programs (NSPs) on HIV and hepatitis C virus (HCV) related outcomes among injecting drug users (IDUs) in Australia and in each State and Territory over the period from 2000 to 2009.

  2. Explore changes in the provision of NSPs, populations at risk, and sharing behaviour on these outcomes

  3. Calculate the net present value and future values and cost-effectiveness of NSPs in terms of HIV and HCV infections averted from a health sector (government as third party payer) perspective.]

Population model methods

A mathematical epidemic model was developed to simulate HIV and HCV transmission among IDUs in Australia. The model was informed by detailed biological data, Australian IDUs behavioural data (e.g., the annual NSP survey/finger prick survey), and the number of injecting equipment units distributed by NSPs each year. The model described IDUs in the community and not those in prisons. The extensive available data enabled the model to describe well the complex injecting behaviour and mixing patterns of Australian IDUs and viral transmissions within this population. The model was used to determine the population-level effectiveness of NSPs in preventing transmissions of HIV and HCV through the distribution of sterile injecting equipment. It accurately reflected the current HIV and HCV epidemiology in Australia. Separate analyses were carried out for IDUs in Australia and by each Australian state and territory as well as Australian Aboriginal and Torres Strait Islander people who inject drugs.
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The decade from 2000-2009 was investigated to estimate the number of HIV and HCV infections with and without NSPs in the past, thus determining the effectiveness of NSPs. The model was then used to forecast epidemic trajectories over the next 70 years (2010-2079) under assumptions that funding and services of NSPs or behaviour of IDUs remain unchanged or according to changes in conditions. This time horizon was chosen in order to consider whole of lifetime impacts. Shorter timeframes are also analysed. These results became inputs into an economic analysis.

Economic analysis methods

An economic analysis used the epidemic model results and detailed data on costs. Costs associated with NSPs were provided by State and Territory health departments. Healthcare costs for HIV and HCV were estimated from activity-based analysis and national databases. All costs are presented in 2008 Australian dollars. The outcome of interest from the economic analysis was:
  • Disability-Adjusted-Life-Years (DALYs).
A range of time horizons were chosen for the analyses:
  • 2000-2009
  • 2010-2019
  • 2010-2029
  • Life-time of current IDU cohort.
Discounting was applied at 3% and 5% where appropriate (discounting assesses the value of money at different time periods).1

Summary of investment

  • The number of needles and syringes distributed in Australia increased during the past decade (from ~27 million to ~31 million).

  • Expenditure on NSPs increased by 36% (adjusted for inflation) over this time period, mostly associated with personnel and not principally for equipment (Table a); a significant portion of the increased investment has been the Illicit Diversion Supporting Measures for NSPs to increase referrals to drug treatment and other services.

  • Over the last decade there has been:
    • Increases in funding for primary sites.
    • Increases in the number of secondary sites.
    • Increases (by 15%) in the numbers of units of equipment provided.
    • Stable spending on sterile injection equipment.
    • At the time of writing there were 85 primary sites, 737 secondary sites, 20 enhanced secondary sites, and 118 vending machines.

Effectiveness of NSPs

It was estimated that over the last decade (2000-2009) NSPs have directly averted:
  • 32,050 new HIV infections;
  • 96,667 new HCV infections.
Table b summarises the epidemiological benefits of NSPs over the last decade. When secondary transmissions (sexual or mother-to-child transmission from infected IDUs) are considered, the epidemiological benefits are even greater. The cumulative benefits of NSPs are further pronounced if long-term projections are considered, as the preventative effects of NSPs flow through to influence the incidence of long-term clinical complications.Top of page

Economic analysis of NSPs during 2000-2009

During 2000-2009, gross funding for NSP services was $243m. This investment yielded:
  • Healthcare costs saved of $1.28 billion ($1.12bn-$1.45bn, IQR).
  • Approximately 140,000 DALYs gained.
  • Net financial cost-saving of $1.03 billion ($876m-$1.98bn, IQR).
The net present value of NSPs (in 2000) is $896m (disc 3%)(Table c) and $817m (disc 5%).

It was estimated that:
  • For every one dollar invested in NSPs, more than four dollars were returned (additional to the investment) in healthcare cost-savings in the short-term (ten years) if only direct costs are included; greater returns are expected over longer time horizons.

  • NSPs were found to be cost-saving over 2000-2009 in seven of eight jurisdictions and cost-effective in the other jurisdiction. Over the longer term, NSPs are highly cost saving in all jurisdictions.

  • The majority of the cost savings were found to be associated with HCV-related outcomes. However, when only HIV-related outcomes were considered in the analysis, it cost $4,500 per DALY gained associated with HIV infection.

  • If patient/client costs and productivity gains and losses are included in the analysis, then the net present value of NSPs is $5.85bn; that is, for every one dollar invested in NSPs (2000-2009), $27 is returned in cost savings. This return increases considerably over a longer time horizon.

  • NSPs are very cost-effective compared to other common public health interventions, such as vaccinations (median cost per QALY of $58,000), allied health, lifestyle, and in-patient interventions (median cost of $9,000 per DALY gained), and interventions addressing diabetes and impaired glucose tolerance or alcohol and drug dependence (median cost of $3,700 per DALY gained).2

Results about future NSPs

If NSPs were to decrease in size or number, then relatively large increases in both HIV and HCV could be expected with associated losses of health and life and reduced returns on investment (Table d). Significant public health benefits can be attained with further expansion of sterile injecting equipment distribution.

Investment in NSPs was cost-saving for current NSP funding when analysed for all time periods. Cost savings were:
  • $782m (2010-2019)
  • $3.23bn (2010-2029)
  • $17.75bn (2010-2059)
  • $28.71bn (2010-2079).
The net present value of current NSP investment at 2010 (discounted 3%):
  • $641m (2010-2019)
  • $2.27bn (2010-2029)
  • $8.41bn (2010-2079).
Increased funding and provision of NSPs would be associated with greater cost-savings. The maximum return would be achieved at 125% to 200% of current levels (Table e); this is when the total net savings (NPV) is maximal. Expansion of NSPs in all jurisdictions would be cost-saving. There is potential for expansion, considering that only approximately 50% of all injections are currently with a sterile syringe.Top of page

Conclusions

Investment in NSPs (2000-2009) has resulted in:
  • An estimated 32,050 HIV infections and 96,667 HCV infections averted;
  • Substantial healthcare cost savings to government related to HCV and HIV;
  • Substantial gains in Disability Adjusted Life years.
For every dollar currently spent on the activities of NSP, more than four dollars will be returned (in addition to the investment; i.e., five times the investment) and approximately 0.2 days of disability-adjusted life gained. Over a longer time horizon there is even greater return.

Results from model-based projections into the future (2010 onwards) suggest that:
  • Maintenance of current levels of NSP funding will continue to provide
    • substantial and increasing healthcare cost savings;
    • gains in life years.

  • Increases in the funding and provision of NSPs will:
    • avert additional HCV and HIV infections;
    • lead to further and increased cost-savings of funding up to 150-200% of current level if met with demand;
    • reduce marginal return on investment as funding increased.
    • the maximum return would be achieved at 150% to 200% of current levels.
It is important to note that this report is based on the effectiveness of NSPs in averting HIV and HCV infections among IDUs only and not on the many other benefits of NSPs, such as avoided mental health episodes and injecting related injury, psychosocial benefits, other support, referral, education and prevention etc. Costs of NSPs in this analysis included some other services (but not primary healthcare or drug and alcohol programs or the human resource cost of providing sterile injecting equipment) and thus results are conservative estimates of the true return on investment.

Key tables

Table a: Investments made by financial year in 2008 Australian dollars (unadjusted financial expenditures and adjusted for consumer price index) ($'000)

Note that NSP support includes human resource costs, rent and overheads; support for secondary sites consists of human resource costs.
2000/12001/22002/32003/42004/52005/62006/72007/8
Consumables - sterile injecting equipment
5,658
5,140
5,633
6,677
6,928
6,571
7,404
6,857
Consumables - disposal equipment
911
884
952
941
1,184
1,122
1,274
1,474
Consumables - safe sex packs
15
52
70
69
246
245
289
293
Consumables sub-total
6,583
6,076
6,655
7,686
8,358
7,938
8,968
8,624
NSP support - primary NSP operations
8,851
10,510
10,417
11,261
12,505
12,274
14,450
15,929
NSP support - support for secondary NSPs
380
653
745
788
951
1,264
963
1,222
NSP support - transport
89
82
92
105
117
184
198
192
NSP support - vending machines
10
0
0
0
0
19
246
441
NSP support sub-total
9,331
11,245
11,254
12,154
13,573
13,742
15,856
17,783
Total (unadjusted for CPI)
15,914
17,321
17,909
19,841
21,931
21,680
24,824
26,407
Total (adjusted for CPI)
20,119
21,236
21,312
23,064
24,850
23,897
26,500
27,380
Total client costs
7,608
7,296
6,548
6,769
6,825
6,230
6,176
6,160
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Table b: Estimated HIV- and HCV-related outcomes, with and without NSPs (medians)

Table b is separated into 2 smaller tables in this HTML version. It is presented as one table in the PDF version.

HIV related outcomes

Outcome (2000-2009)With NSPsWithout NSPsCases averted
Prevalence of HIV among IDUs (2009)
0.1%
14.0%
Cumulative incidence of HIV infections
305
32,355
32,050
Cumulative incidence of HIV-related deaths
383
2,574
2,191

HCV related outcomes

Outcome (2000-2009)With NSPsWithout NSPsCases averted
Prevalence of HCV among IDUs (2009)
65.1%
87.1%
Cumulative incidence of HCV infections
103,124
199,791
96,667
Number of cirrhosis cases (2009)
4,337
5,030
693
Cumulative incidence of HCC
1,854
1,862
8
Cumulative incidence of liver failure
2,704
2,720
16
Cumulative incidence of liver transplants
4,277
4,278
1
Cumulative number of live-related deaths
4,084
4,088
4

Table c: Net cost of program and gains in DALYs (undiscounted) as well as net present value (discounted (3%) and undiscounted) from the perspective of year 2000

2000200120022003200420052006200720082009SUM
Costs saved $m
(IQR)
66
(57-75)
192
(171-212)
137
(119-157)
98
(84-107)
96
(86-105)
106
(94-116)
119
(107-135)
134
119-154)
153
(134-177)
176
(148-206)
DALY gain
(median)
4,087
10,825
12,863
12,799
13,089
13,705
15,148
16,922
19,301
22,386
NPV current program
$m (IQR) (undisc.)
46
(37-55)
171
(149-191)
116
(98-136)
75
(61-84)
71
(61-80)
82
(70-93)
93
(80-108)
107
(92-127)
126
(107-150)
145
(118-174)
1.03bn
(873m-1.98bn)
NPV current program
$m (IQR) (3% disc.)
46
(37-55)
166
(145-185)
109
(92-128)
69
(56-77)
63
(54-79)
70
(60-80)
78
(67-90)
87
(74-103)
99
(84-118)
110
(90-132)
896m
(758m-1.04bn)

Table d: Loss of life and reduced return associated with decreased funding period 2010- 2019 (all discounted at 3%)

NSP fundingReduction in NSP spendingLoss in DALY vs. currentReduced return
50% of current levels
$112m
36,370
$197m
75% of current levels
$56m
16,473
$98m
90% of current levels
$22m
7,607
$36m
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Table e: Gain in DALYs and net present value with level of funding in NSPs after ten years (2010-2019) compared to no program

Level of funding for NSPsNSP investmentGain in DALYNet saving (NPV)Return on investment
100% of current levels
$225m
97,229
$631m
current investment + 380%
110% of current levels
$248m
98,562
$633m
current investment + 360%
125% of current levels
$282m
104,005
$647m
current investment + 330%
150% of current levels
$338m
111,254
$656m
current investment + 290%
175% of current levels
$395m
116,874
$650m
current investment + 270%
200% of current levels
$451m
121,303
$635m
current investment + 240%
300% of current levels
$676m
132,595
$514m
current investment + 180%