Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia

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1 Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia BACKGROUND While post-soviet Georgia has experienced favorable economic, political, and social change in the last two decades, there has been a dramatic increase in illicit drug use. As of 21, there are estimated to be 4, people who inject drugs (PWID) in Georgia (Sirbiladze, 21), with opioids including heroin, non-medical use of prescription buprenorphine, and home-made stimulants the most commonly injected group of drugs in the country (Javakhishvili et al., 211; Otiashvili et al., 8; Kirtadze et al., 21). Injecting drug use is the main route of HIV transmission in Georgia, with an HIV prevalence among PWID of around 1.1 percent. The country has approximately 4, people living with HIV, and the number of new HIV cases is estimated to be growing at around 1 15 percent each year (HIV/AIDS and Clinical Immunology Research Center of Georgia, 212). Methadone and buprenorphine are listed as effective treatments for opioid dependence by the World Health Organization. Numerous studies have shown that by reducing dependence on illicit drugs, medication-assisted treatment (MAT) decreases injecting drug use and thereby reduces HIV risk (Bruce, 7; Larney, 21; Corsi, 9). Additionally, methadone substitution treatment enhances the effects of HIV treatment programs that provide antiretrovirals for people who inject drugs and helps prevent additional infections among PWID, with benefits accruing to non-pwid (Alistar et al., 211). October 212 There are currently 16 MAT sites in Georgia, including five sites supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) and 11 by the Ministry of Labor, Health, and Social Affairs (MOLHSA). Although these sites provide MAT to an average of 1, patients each month, overall MAT coverage in the country remains low. A recent study from the USAID Health Policy Initiative Costing Task Order examines the characteristics of MAT programs in Georgia and estimates the current costs of providing MAT to people who inject drugs to prevent HIV infections in Georgia at both GFATM and MOLHSA service sites. This brief presents some of the key findings generated from this study. The full report is available at DISTRIBUTION OF HIV-POSITIVE PATIENTS The analysis showed that HIV-positive patients are disproportionately enrolled in GFATM MAT programs. In 21, 12.2 percent of GFATM patients were HIV positive, compared with 1.5 percent of MOLHSA patients (see Figure 1). This may be in part due to the fact that GFATM-operated sites provide services free of charge, while only the costs of pharmaceutical methadone are covered at MOLHSA facilities, leaving patients to cover the remaining treatment costs of approximately $9 per month. This may be a potential draw for HIVpositive patients who already bear a significant cost burden for treatment. 1

2 Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia Figure 1. Distribution of HIV-positive patients in MAT facilities 8 6 MAT DOSAGE ACROSS SITES According to guidelines outlined by the World Health Organization, patients should receive an optimal methadone dose of between 6 to 12 milligrams per day. Compared with patients on dosages that are lower than 6 milligrams per day, patients receiving higher methadone dosages are shown to stay in treatment longer, use fewer injection drugs, and have lower incidence of HIV infection (CDC, 2). The study found great variation in methadone medication doses between facilities. With the exception of two facilities (see Figure 2), more than 6 percent of patients receive less than the minimum optimal dose of 6 milligrams per day, which likely affects treatment outcomes and indicators at MAT facilities in Georgia. Figure 2. Methadone doses in GFATM and MOLHSA MAT sites 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % % 87.8% GFATM 21 HIV Positive % 98.5% MOLHSA 21 HIV Negative UNIT COST ANALYSIS The study estimated the costs of MAT provision per patient per month at both MOLHSA and GFATM facilities in 21. The cost calculations both include direct and indirect costs of MAT programs. Direct costs include personnel, drugs and supplies, equipment, monitoring, and consumables; while indirect costs include utility, land, and building costs. As seen in Table 1, the total unit cost for MOLHSA facilities was 236 GEL ($137), while the unit cost in GFATM facilities was slightly less at 229 GEL ($133). Unit cost calculations for the MOLHSA sites include patient contributions that amount to 15 GEL ($9) per month for each patient. Table 1. Unit cost per patient month 21 (GEL) MOLHSA GFATM Direct costs Indirect costs TOTAL 236 GEL 229 GEL Personnel salaries, drugs and medical supplies, and utilities account for a major portion of costs associated with running MAT programs in Georgia (see Figure 3). Although the most significant budget item in both programs is the cost of personnel, the number of providers at each site is currently centrally mandated by the Georgian government. As a result, sites that do not have enough patients must continue to support expensive personnel even when the is low. Similarly, heavy volume sites are unable to plan for additional personnel. Greater autonomy for individual MAT sites would allow for determination of personnel needs based on differences in patient characteristics, geographic area, and population size. In particular, greater flexibility would enable individual sites to adjust the number of personnel to match treated. Below 6 mg (sub-optimal) Above 6 mg (optimal) 2

3 Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia Figure 3. Key drivers of unit costs for MAT Sites 21 GFATM Drugs and medical supplies 21% Stationary office supply 1% Regional monitoring.41% MOLHSA Rental cost 5% Utility without rent/ stationary 13% Bank/car insurance fees.44% Nonmedical equipment 5% Salaries of clinical and support staff 55% month had a significantly lower unit cost of 122 GEL ($71) per month. Table 2. Unit costs for MAT sites serving the smallest and largest volume of patients GFATM Shida Kartli Narcological Center: least GFATM Batumi Narcological Center: largest MOLHSA Division 3: least MOLHSA Division 6: largest Average patients per month Unit cost patient/ month Stationary office supply % Regional monitoring trips % Drugs and medical supplies 28% Rental cost 5% Utility without rent/stationary 14% Salaries of clinical and support staff 51% Bank/car insurance fees % Nonmedical equipment 2% The study shows that the unit cost of treating one patient gradually declines as the treated at the facility increases. Table 2 shows a comparison between the largest and smallest sites in each type of facility. The cost per patient per month for the smallest GFATM site, which treated an average of 45 patients per month in 21, was 291 GEL ($169), while the cost per patient per month for the largest site, which treated an average of 117 per month in 21, was 161 GEL ($93). Similarly, the cost per patient for the smallest MOLHSA site, which treated an average of only 18 patients per month, was 72 GEL ($47) per patient, while the largest MOLHSA site, with an average of 142 patients per ASSESSING POTENTIAL FOR FUTURE EXPANSION OF SERVICES Based on interviews with key informants, this study estimates the total patient capacity at the 11 MOLHSA sites and five GFATM sites in Georgia at 1,382 and 5, respectively, for a country-wide total capacity of 1,882. The total in 21 in all MAT programs country-wide (at all sites) was approximately 1,538 (898 patients at MOHLSA sites and 436 patients at GFATM sites) less than the maximum capacity. However, while the 11 MOLHSA facilities are operating with an average well below their capacity, four out of five of the GFATM sites are currently at or near capacity. At the one remaining GFATM facility that has availability, there has historically been low demand for the program and the recruiting of patients has been difficult due to the facility s location. As such, without creating new facilities, filling the vacancies at MOLHSA facilities will be crucial to expanding MAT services to a greater number of PWID. To assess the potential effects of expanding services at MOLHSA facilities two scenarios that would allow for an increase in MAT coverage were modeled. The first scenario (scenario A) models an increase in the 3

4 (GEL) Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia coverage of PWID by 15 percent until maximum available capacity in MAT facilities is reached. The second scenario (scenario B) models a graduated expansion in MAT coverage over five years (5, 7, 9, 11, and 13 percent increases). In both scenarios, the costs of medical supplies, drugs, distribution, vaccinations, and drug screening were increased proportionally to match the percent patient increase, while the other direct costs of salaries, monitoring, and office supplies and indirect costs (which include rent, utilities, and non-medical equipment) are assumed to remain constant in the short term. Scenario A: Increasing coverage by 15 percent in successive years Given the available capacity, MOLHSA facilities can increase patient enrollment by 15 percent until 213, after which additional sites would be needed to accommodate more patients. As seen in Figure 4, unit costs decline with increases in patient enrollment. Figure 4. Scenario A: Unit costs for MOLHSA facilities (GEL) Scenario B: Graduated expansion of MOLHSA facilities Under Scenario B, a graduated expansion in the coverage of PWID by 5 percent, 7 percent, 9 percent, 11 percent, and 13 percent at existing MOLHSA MAT facilities in successive years would result in a decrease in the monthly unit cost of around 2 5 percent in subsequent years from 236 GEL ($137) to 179 GEL ($14) (see Figure 5). Assuming a capacity of 1,379 patients at MOLHSA sites, this scenario would not require an additional MAT clinic until 216 and would allow the opportunity to increase coverage of PWID in the preceding years. Figure 5. Scenario B: Unit costs for MOLHSA facilities (GEL) ,9 1,1 1,221 1, extrapolated 1, , , Under Scenario A, a 15 percent increase in coverage over successive years would result in a drop of about 9 percent in unit costs each year at MOLHSA facilities from 236 GEL ($137) in 21 to 177 GEL ($13) in 213. One caveat to note is that unit costs decline as long as patients can be accommodated in existing sites. The addition of new sites would increase costs incurred (especially start-up costs) although, it would also result in exponentially greater coverage CONCLUSIONS extrapolated 15 1 The cost to treat one patient for one month was similar at MOLHSA and GFATM sites, with a unit cost of 236 GEL and 229 GEL, respectively. The analysis also shows economies of scale as the number of MAT patients treated at a facility increases, the unit cost decreases. Although the cost of personnel salaries was the major cost driver for both service providers, individual sites must adhere to centrally mandated staffing patterns regardless of patient characteristics, geographic area, or population size. Reconsidering these staffing requirements would allow for individual sites to have greater flexibility to adjust the number of personnel to match the treated and potentially bring 5 4

5 Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia down the cost of programs that are currently overstaffed. This brief also highlights several key issues and challenges that affect MAT programs in Georgia. For example, as program coverage is expanded, it will also be important to look at the effectiveness of MAT dosages. At present, more than 6 percent of patients received less than the optimal dose of methadone at the majority of the facilities sampled, which will likely have a negative impact on treatment outcomes and indicators. Finally, Georgia should work to ensure that all MAT facilities are affordable and accessible to people who inject drugs, particularly those that are HIV positive. The results generated from this study can help guide and inform planners and policymakers to make more informed decisions regarding the allocation of services and the scale-up of MAT in Georgia, as well as pave the way for future assessments of the costeffectiveness of MAT interventions in terms of number of HIV infections averted and cost savings from averted treatment. REFERENCES Alistar, S.S., D.K. Owens, and M.L. Brandeau Effectiveness and Cost Effectiveness of Expanding Harm Reduction and Antiretroviral Therapy in a Mixed HIV Epidemic: A Modeling Analysis for Ukraine. PLoS Medicine 8(3): e1423. Bruce, R.D. 7. HIV treatment access and scaleup for delivery of opiate substitution therapy with buprenorphine for IDUs in Ukraine programme description and policy implications. International Journal of Drug Policy 18(4): 326. Corsi, K.F. 9. The effect of methadone maintenance on positive outcomes for opiate injection drug users. Journal of Substance Abuse and Treatment 37(2): 12. HIV/AIDS and Clinical Immunology Research Center of Georgia HIV/AIDS epidemiology in Georgia. Retreived June 12, 212 from Javakhishvili, D.J, L. Strurua, D. Otiashvili, I. Kirtadze, and T. Zabransky Drug Situation in Georgia. Adiktologie 11(1): Kirtadze, I., et al. 21. Exploring the Phenomena of Homemade Stimulant Injection in Tbilisi, Georgia. Paper presented at 21 NIDA International Forum, Scottsdale, Arizona. Larney, S. 21. Does opioid substitution treatment in prisons reduce injecting-related HIV risk behaviours? A systematic review. Addiction 15(2): Otiashvili, D., P. Sarosi, and G. Somogyi. 8. Drug Control in Georgia: Drug Testing and the Reduction of Drug Use? Oxford, United Kingdom. Beckley Foundation, Drug Policy Program. Sirbiladze, T. 21. Estimating the Prevalence of Injecting Drug Use in Georgia: Consensus Report. Tblisi, Georgia: Bemoni Public Union. U.S. Centers for Disease Control and Prevention (CDC). 2. Methadone Maintenance Treatment. Washington, D.C. Retrieved October 21 from Suggested citation: Kirtadze, Irma, Veena Menon, Kip Beardsley, Steven Forsythe, and Ramona Godbole Assessing the Costs of Medication-Assisted Treatment for HIV Prevention in Georgia. Washington, DC: Futures Group, USAID Health Policy Initiative Costing Task Order. The USAID Health Policy Initiative Costing Task Order is funded by the U.S. Agency for International Development under Contract No. GPO-I , beginning July 1, 21. The Costing Task Order is implemented by Futures Group, in collaboration with the Futures Institute and the Centre for Development and Population Activities (CEDPA). 5

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