Cost-benefit Analysis of Canada's Prison Needle Exchange Program for the Prevention of Hepatitis C and Injection-related Infections

Overview

Journal CMAJ

Date 2024 Dec 16

PMID 39681365

Authors

Farah Houdroge

Nadine Kronfli

Mark Stoove

Nick Scott

Affiliations

Soon will be listed here.

Abstract

Background: Needle exchange programs are effective public health interventions that reduce blood-borne infections, including hepatitis C, and injection-related infections. We sought to assess the return on investment of existing Prison Needle Exchange Programs (PNEPs) in Canadian federal prisons and their expansion to all 43 institutions.

Methods: We developed a stochastic compartmental model that estimated hepatitis C and injection-related infections under different PNEP scenarios in Canadian federal prisons. Scenarios projected for 2018-2030 were no PNEP, status quo (actual PNEP implementation 2018-2022, with coverage maintained to 2030), and PNEP scale-up (coverage among people who inject drugs in prison increasing over 2025-2030 to reach 50% by 2030). We calculated the benefit-cost ratio as benefits from health care savings, divided by PNEP costs.

Results: By 2019, PNEPs were implemented in 9 of 43 federal prisons, with uptake reaching 10% of people who injected drugs in prison in 2022. Compared with no PNEP, this was estimated to cost Can$0.45 (uncertainty interval [UI] $0.32 to $0.98) million and avert 37 (UI 25 to 52) hepatitis C and 8 (UI -1 to 16) injection-related infections over 2018-2030, with a benefit-cost ratio of 1.9 (UI 0.56-3.0). Compared with the status quo, the PNEP scale-up scenario cost an additional $2.7 (UI $1.8 to $7.0) million and prevented 224 (UI 218 to 231) hepatitis C and 77 (UI 74 to 80) injection-related infections, with a benefit-cost ratio of 2.0 (UI 0.57 to 3.3).

Interpretation: Every dollar invested in the current PNEP or its expansion is estimated to save $2 in hepatitis C and injection-related infection treatment costs. This return on investment strongly supports ongoing maintenance and scale-up of the PNEP in Canada from an economic perspective.

Citing Articles

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References

Merone L, Ashton S, Harris A, Edwards W, Preston-Thomas A, Gair R . A complex increase in hepatitis C virus in a correctional facility: bumps in the road. Aust N Z J Public Health. 2022; 46(3):377-381. DOI: 10.1111/1753-6405.13238. View

Brothers T, Lewer D, Jones N, Colledge-Frisby S, Bonn M, Wheeler A . Effect of incarceration and opioid agonist treatment transitions on risk of hospitalisation with injection drug use-associated bacterial infections: A self-controlled case series in New South Wales, Australia. Int J Drug Policy. 2023; 122:104218. DOI: 10.1016/j.drugpo.2023.104218. View

Duchesne L, Dussault C, Godin A, Maheu-Giroux M, Kronfli N . Implementing opt-out hepatitis C virus (HCV) screening in Canadian provincial prisons: A model-based cost-effectiveness analysis. Int J Drug Policy. 2021; 96:103345. DOI: 10.1016/j.drugpo.2021.103345. View

Cheng Q, Cunningham E, Shih S, Amin J, Bruneau J, Artenie A . Patient-Reported Outcomes During and After Hepatitis C Virus Direct-Acting Antiviral Treatment Among People Who Inject Drugs. Value Health. 2023; 26(6):883-892. DOI: 10.1016/j.jval.2022.12.016. View

Kronfli N, Buxton J, Jennings L, Kouyoumdjian F, Wong A . Hepatitis C virus (HCV) care in Canadian correctional facilities: Where are we and where do we need to be?. Can Liver J. 2022; 2(4):171-183. PMC: 9202815. DOI: 10.3138/canlivj.2019-0007. View

Moazen B, Moghaddam S, Silbernagl M, Lotfizadeh M, Bosworth R, Alammehrjerdi Z . Prevalence of Drug Injection, Sexual Activity, Tattooing, and Piercing Among Prison Inmates. Epidemiol Rev. 2018; 40(1):58-69. DOI: 10.1093/epirev/mxy002. View

Kendall C, Boucher L, Mark A, Martin A, Marshall Z, Boyd R . A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada. Harm Reduct J. 2017; 14(1):16. PMC: 5427560. DOI: 10.1186/s12954-017-0143-4. View

Cunningham E, Hajarizadeh B, Amin J, Bretana N, Dore G, Degenhardt L . Longitudinal injecting risk behaviours among people with a history of injecting drug use in an Australian prison setting: The HITS-p study. Int J Drug Policy. 2018; 54:18-25. DOI: 10.1016/j.drugpo.2017.12.013. View

Bartlett S, Buxton J, Palayew A, Picchio C, Janjua N, Kronfli N . Hepatitis C Virus Prevalence, Screening, and Treatment Among People Who Are Incarcerated in Canada: Leaving No One Behind in the Direct-Acting Antiviral Era. Clin Liver Dis (Hoboken). 2021; 17(2):75-80. PMC: 7916434. DOI: 10.1002/cld.1023. View

10.

Koo V, Tian F, Wong W . Cost-effectiveness analysis of hepatitis C virus (HCV) point-of-care assay for HCV screening. Liver Int. 2021; 42(4):787-795. DOI: 10.1111/liv.15123. View

11.

Degenhardt L, Peacock A, Colledge S, Leung J, Grebely J, Vickerman P . Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health. 2017; 5(12):e1192-e1207. PMC: 5683738. DOI: 10.1016/S2214-109X(17)30375-3. View

12.

Fernandes R, Cary M, Duarte G, Jesus G, Alarcao J, Torre C . Effectiveness of needle and syringe Programmes in people who inject drugs - An overview of systematic reviews. BMC Public Health. 2017; 17(1):309. PMC: 5387338. DOI: 10.1186/s12889-017-4210-2. View

13.

Kronfli N, Dussault C, Bartlett S, Fuchs D, Kaita K, Harland K . Disparities in hepatitis C care across Canadian provincial prisons: Implications for hepatitis C micro-elimination. Can Liver J. 2022; 4(3):292-310. PMC: 9202774. DOI: 10.3138/canlivj-2020-0035. View

14.

Carson J, Dore G, Lloyd A, Grebely J, Byrne M, Cunningham E . Hepatitis C Virus Reinfection Following Direct-Acting Antiviral Treatment in the Prison Setting: The SToP-C Study. Clin Infect Dis. 2022; 75(10):1809-1819. DOI: 10.1093/cid/ciac246. View

15.

Martin N, Hickman M, Hutchinson S, Goldberg D, Vickerman P . Combination interventions to prevent HCV transmission among people who inject drugs: modeling the impact of antiviral treatment, needle and syringe programs, and opiate substitution therapy. Clin Infect Dis. 2013; 57 Suppl 2:S39-45. PMC: 3722076. DOI: 10.1093/cid/cit296. View

16.

Marco A, Guerrero R, Vergara M, Gallego C, Sole C, Planella R . Reinfection in a large cohort of prison inmates with sustained virological response after treatment of chronic hepatitis C in Catalonia (Spain), 2002-2016. Int J Drug Policy. 2019; 72:189-194. DOI: 10.1016/j.drugpo.2019.05.014. View

17.

Busschots D, Kremer C, Bielen R, Koc O, Heyens L, Nevens F . Hepatitis C prevalence in incarcerated settings between 2013-2021: a systematic review and meta-analysis. BMC Public Health. 2022; 22(1):2159. PMC: 9685883. DOI: 10.1186/s12889-022-14623-6. View

18.

Dunleavy K, Munro A, Roy K, Hutchinson S, Palmateer N, Knox T . Association between harm reduction intervention uptake and skin and soft tissue infections among people who inject drugs. Drug Alcohol Depend. 2017; 174:91-97. DOI: 10.1016/j.drugalcdep.2017.01.020. View

19.

Kronfli N, Cox J . Care for people with hepatitis C in provincial and territorial prisons. CMAJ. 2018; 190(4):E93-E94. PMC: 5790556. DOI: 10.1503/cmaj.171142. View

20.

Pinkerton S . Is Vancouver Canada's supervised injection facility cost-saving?. Addiction. 2010; 105(8):1429-36. DOI: 10.1111/j.1360-0443.2010.02977.x. View