Evaluating the impact and cost-effectiveness of existing HIV prevention interventions among people who inject drugs in Ukraine

BACKGROUND: In Ukraine, people who inject drugs (PWID) have high prevalences of HIV and hepatitis C virus (HCV). Non-governmental organizations (NGOs) provide PWID with needles and syringes, condoms, HIV and HCV testing, and linkage to opioid agonist therapy (OAT) and HIV anti-retroviral therapy (ART). We estimated the impact and cost-effectiveness of NGO activities for PWID in Ukraine.
METHODS: We developed a dynamic HIV and HCV transmission model among PWID which was parameterised and calibrated to detailed data from multiple rounds of national PWID surveys. Based on these surveys, the model incorporated effects of NGOs (coverage 33% in community) on reducing injecting risk, and increasing condom use and recruitment onto OAT and ART. We estimated the historic (1997-2020) and ongoing impact (2020-2040) of NGOs in terms of proportion of HIV or HCV infections averted. We also estimated the potential impact of scaling-up NGOs to 60% coverage with and without a concurrent scale-up in OAT from 5% to 20% and ART from 64% to 81%. We estimated the incremental cost-effectiveness ratio (ICER) of NGOs by comparing incremental costs and DALYs averted over 2020-2045 between the status quo scenario and a counterfactual scenario in which NGO activities are stopped over 2020-2025.
RESULTS: The model projects that NGOs averted 10.7% (95% credibility interval: 8.7-12.9) and 6.7% (5.4-8.0) of HIV and HCV infections over 1997-2020, respectively, and will avert 15.8% (13.0-18.8) and 8.4% (7.1-9.8) of infections over 2020-2040. Without NGOs, HIV and HCV incidence would have been 31.3% (25.3-38.3) and 17.8% (15.1-20.8) higher in 2020 and would be 28.0% (21.7-34.8) and 17.7% (15.0-20.5) higher in 2040. Only scaling-up NGOs could reduce HIV and HCV incidence by 29.9% (23.4-35.8) and 23.1% (19.6-26.2) by 2040, respectively, or 52.8% (44.5-64.6) and 30.6% (27.2-33.1) with concurrent scale-up of OAT and ART. The mean ICER was estimated to be US$ 1,606/DALY averted.
CONCLUSIONS: NGOs have had important impacts on HIV and HCV transmission among PWID and are cost-effective compared with a willingness-to-pay threshold of Ukraine's GDP ($3,096). It is important that these activities continue and preferably scale-up in the face of upcoming changes to the HIV funding landscape.