Infections averted by a comprehensive HIV prevention intervention and its cost-effectiveness: a prospective cohort study of persons who inject drugs in Delhi, India

ABSTRACT

This paper presents the cost-effectiveness of a WHO-recommended harm-reduction programme implemented among a cohort of persons who inject drugs in Delhi, India. We estimate the number of infections averted using Bernoulli process model and calculate cost-effectiveness ratio as the total programme cost per infection averted. The intervention averted 996 HIV infections over 36 months, with a cost-effectiveness ratio of INR 24,763 (US$ 476) per infection averted per year. The first phase, when HIV testing and counselling were initiated, was more cost-effective than the second phase when full intervention package, including needle-syringe exchange, condom distribution, harm-reduction education, etc., was implemented.

KEYWORDS:

• Cost-effectiveness
• persons who inject drugs
• HIV
• harm reduction
• India

Acknowledgments

We would like to thank Dr Raman Gangakhedkar, National AIDS Research Institute, Dr Neeraj Dhingra, Deputy Director General, NACO, and Mr J K Misra, Joint Director Targeted Interventions and Delhi State AIDS Control Society for their support to the project. We would like to thank Sahara’s team of dedicated staff without whom this project would be impossible to implement. All laboratory testing was undertaken by Super Religare Laboratories, Gurgaon, India. Also, our thanks to the study participants for their willingness to share this information with us.

And finally, our sincere thanks to the anonymous reviewer of our manuscript whose feedback has significantly improved the quality of the article.

Disclosure statement

The authors report there are no competing interests to declare.

Supplementary data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/19439342.2023.2166565

Data availability statement

The data that support the findings of this study have been submitted to PATH by Population Council and can be made available from the authors upon reasonable request and with permission of PATH.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

Support for this project was provided by Arise–Enhancing HIV Prevention Programs for At-Risk Populations, through financial support provided by the Canadian Government through Department of Foreign Affairs, Trade and Development (previously Canadian International Development Agency), and via financial and technical support provided by PATH. Financial support to conduct Hepatitis C testing was provided by MSD (A subsidiary of Merck & Co. Inc., USA), though findings are not being used for the current study. Grant was received by Dr A. Sarna; Grant number: CID.1450-02135-SUB. The funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; and in the decision to submit the article for publication

Notes on contributors

Lopamudra Ray Saraswati

Lopamudra Ray Saraswati is a Public Health Researcher with RTI International, India. A Statistician and Demographer by training, she has been working for a decade and half in the development sectors using mixed methods research, formative and exploratory studies, operations research, and advance monitoring and evaluation techniques. In her research she has focused on health systems strengthening, substance use and abuse, HIV/AIDS, gender issues, and migrants’ health and wellbeing. She has published in several peer-reviewed journals and contributed to book chapters. A native of India, she also has experience working with international colleagues from Bangladesh, Germany, Kenya, Nepal, and the United States. Prior to joining RTI, Lopamudra worked with International Institute for Population Sciences, Invest India Market Research, Jawaharlal Nehru University, and Population Council. She holds her M.Phil. degree in Population Studies with a specialisation on Biostatistics

Aparajita Dasgupta

Aparajita Dasgupta is an Assistant Professor of Economics at Ashoka University. An applied microeconomist by training, she holds a Ph.D. in Economics from the University of California, Riverside. Her research interests are in the areas of Development Economics, Health Economics, Labour and Public Policy. Her research contributes to the growing literature on the dynamics of human capital formation with an interest to understand the causal linkages between early childhood environment and later life outcomes (health, fertility, cognition, schooling, labour market outcomes and inter-generation mobility). Further, she is keen to understand how households decide to invest at each stages of life and how do these decisions vary by socio-political and gender norms in society. Her research primarily uses large micro-level data, often longitudinal, from developing country settings. She has also been interested to look at measurement issues involved in using self-reported data and the use of innovative survey tools in addressing those issues.

Indrani Gupta

Indrani Gupta is Professor and Head, Health Policy Research Unit (HPRU) at the Institute of Economic Growth, Delhi. HPRU – set up by her in 1998 – is the first of its kind in India. It remains among the few places in the country that conducts policy-oriented research on the health sector using tools of economic analysis. Professor Gupta’s work experience includes teaching and positions at academic institutes, the World Bank, and the Government of India. Her areas of interest cover a wide range of topics in the area of health economics and policy, including demand for health and health care, health insurance and financing, poverty and health, costing and cost-effectiveness, economics of diseases, and international agreements. She has a Ph.D. in Economics from the University of Maryland, College Park, USA and a Masters in Economics from the University of Delhi.

Julie Pulerwitz

Julie Pulerwitz is the director of the Population Council’s HIV and AIDS programme, where she provides leadership for a portfolio of research that generates evidence to inform HIV programmes and policies around the world. An accomplished socio-behavioural scientist, Pulerwitz has over 20 years of experience in implementation science and impact evaluations, with particular expertise in gender and male engagement, sexual and gender-based violence (SGBV), stigma, and social and behaviour change. She has worked in over 20 countries across Africa, Asia, and Latin America, in addition to the U.S., and she has published more than 50 papers in the peer-reviewed literature. She is co-chair of both the socio-behavioural and structural working group of the HIV Prevention Trials Network (HPTN) and USAID’s Male Engagement Task Force. She was also awarded the Best International HIV/AIDS Abstract from the American Public Health Association. Her work has been profiled in The Lancet, NPR, Apple’s ‘Today’ portal, and The New York Times. She received her masters and doctoral degrees from the Harvard T.H. Chan School of Public Health and her undergraduate degree from the University of Pennsylvania.

Avina Sarna

Avina Sarna is a Senior Associate with the Population Council’s HIV and AIDS programme. A physician by training, she has extensive experience bridging clinical medicine with high-impact public health interventions. Sarna joined the Council in 2001 to lead the Access to HIV Treatment global operations research agenda under the Council’s Horizons programme, which documented barriers to antiretroviral treatment services, assessed community-based prevention approaches for people living with HIV, and identified integration points between reproductive health and HIV services. She has also led research on HIV prevention and treatment among injecting drug users and microbicide adherence among female sex workers. Prior to her work with the Council, Sarna practiced as a physician in India, Poland, Switzerland, the United States, and Bhutan. She has also conducted research on nutrition in Iran, and on high-dose folic acid therapy for hemodialysis patients in the United States. Sarna coordinated an FDA-sponsored clinical trial at the Division of Nephrology at Georgetown University Medical Center, Washington, DC; and has consulted with the World Health Organization and UNICEF in Iran and Switzerland. She holds MBBS, MD, MPH, and PhD degrees and has been published extensively on HIV and AIDS.