Costs and impact on HIV transmission of moving from a criminalization to a public health approach to injecting drug use in Eastern Europe and Central Asia: a modeling analysis


The incidence of HIV is increasing in Eastern Europe and Central Asia, mainly due to injecting drug use. Coverage of antiretroviral therapy (ART) and opioid agonist therapy is suboptimal, with many people who inject drugs (PWID) being incarcerated. Our objective was to assess whether using the money saved through decriminalization of drug use or possession to scale up ART and opioid agonist treatment could control HIV transmission among PWIDs in Europe. eastern and central Asia.


A dynamic model of HIV transmission among PWIDs incorporating incarceration, ART and opioid agonist therapy has been calibrated for Belarus, Kazakhstan, Kyrgyzstan and St. Petersburg (Russia). Country specific costs for opioid agonist therapy, ART and incarceration have been aggregated or estimated. Compared to the baseline, the model prospectively projected life years gained, additional costs (euros 2018) and infections avoided over 2020-40 for three scenarios. The decriminalization scenario eliminated incarceration resulting from the personal use or possession of drugs, reducing incarceration among PWIDs by 24.8% in Belarus, Kazakhstan and Kyrgyzstan and by 46.4% % in St. Petersburg; the public health approach scenario used savings from decriminalization to expand ART and opioid agonist therapy; and the full scale-up scenario included the decriminalization scenario plus the investment of additional resources to scale up ART to the UNAIDS 90-90-90 target of 81% coverage and treatment by opioid agonists up to WHO target of 40% coverage. The incremental cost-effectiveness ratios per year of life gained for each scenario were calculated and compared to country-specific gross domestic product per capita willingness-to-pay thresholds. Costs and life years gained have been discounted by 3% per year.


Current levels of incarceration, opioid agonist treatment and ART have been estimated at a cost of 198 million euros (95% credibility range 173-224) in Kyrgyzstan at 4,129 million euros (3897-4358 ) in Kazakhstan on 2020-40; 74.8 to 95.8% of these total costs were incarceration costs. Decriminalization resulted in cost savings (38 to 773 million euros due to reduced prison costs; 16.9 to 26.1% reduction in overall costs) but modest years of life were gained (745 -1694). The public health approach was cost-saving, allowing each setting to achieve 81% ART coverage and 29.7-41.8% opioid agonist treatment coverage, which saved from 17,768 to 148,464 years of life and from 58.9 to 83 · 7% of infections prevented. The results were similar for the full scale scenario.


Cost savings from decriminalizing drug use could significantly reduce HIV transmission through increased coverage of opioid agonist therapy and ART among PWIDs in Eastern Europe and Central Asia.


Alliance for Public Health, US National Institute of Allergy and Infectious Diseases and National Institute for Drug Abuse, and Economist Intelligence Unit.

About Bradley J. Bridges

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