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Abstract Objective: To determine whether providing a needle exchange program to prevent HIV transmission among injection drug users would cost less than the health care consequences of not having such a program. Design: Incidence outcome model to estimate the number of cases of HIV infection that this program would prevent over 5 years, assuming that the HIV incidence rate would be 2% with the program and 4% without it, and that an estimated 275 injection drug users would use the service over this time. Setting: Hamilton, Ont. Outcome measures: Estimated number of cases of HIV infection expected to be prevented with and without the program over 5 years; estimated lifetime health care costs of treating an AIDS patient. The indirect costs of AIDS to society (e.g., lost productivity and informal caregiving) were not included. Projected costs were adjusted (discounted) to reflect their present value. In a sensitivity analysis, 3 parameters were varied: the estimate of the HIV transmission rate if no needle exchange program were provided, the number of injection drug users participating in the program, and the discount rate. Results: With very conservative estimates, it was predicted that the Hamilton needle exchange program will prevent 24 cases of HIV infection over 5 years, thereby providing cost savings of $1.3 million after the program costs are taken into account. This translates into a ratio of cost savings to costs of 4:1. The sensitivity analysis confirmed that these findings are robust. Conclusion: Needle exchange programs are an efficient use of financial resources. AIDS is a global epidemic. In Canada, there have been 14 677 cases and 10 735 deaths as of March 1997, of which 624 cases have been attributed to injection drug use.(f.1) It has been estimated that cases of HIV/AIDS are underreported by one-third to one-half, and therefore these figures are likely an underrepresentation.(f.2) AIDS can be acquired from injection drug use through the sharing of infected needles.(f.3,4) The impact of this risk behaviour extends beyond those participating in it: in the US, studies indicate that at least 40% of drug users have been in intimate relationships with nonusers(f.5) and that, as of 1995, 80% of HIV-positive heterosexual men and women who never used injection drugs had become infected through sexual contact with someone...