evaluating the impact of global fund withdrawal on needle and syringe provision, cost and use among people who inject drugs in tijuana, mexico: a costing analysis

Target 2011 to 2013, Global Fund (GF)
Support needle and syringe programmes in Mexico to prevent HIV transmission among people who inject drugs.
How GF withdrawal affects the cost, quality and coverage provided by the needle and syringe scheme is not clear.
Design cost studies and longitudinal cohort studies.
Located in Tijuana, Mexico.
Personnel participating in the local needle and syringe program (n=6)
And people who inject drugs (n=734)
Participate in a longitudinal study.
The provision of needle and syringe program services and costs (
Each contact and USD per syringe allocated in 2017)
During GF support (2012)
After exiting (2015/16).
Another result included the use of needles and syringe schemes for the population who injected the drug at the same time during and after GF withdrawal.
As a result, during GF, the needle and syringe scheme distributed 55 u2009 932 syringes to 920 contacts (
60 syringes/contacts)
It is distributed in 14 geographical locations.
After GF withdrew, the needle and syringe program distributed 10 2140 700 syringes to 700 contacts (
5 syringes/contacts)
Across three geographical locations.
During GF, the cost of each reduction in damage contact is about 10-
Higher than after GF ($44. 72 vs $3. 81);
However, the cost of each syringe allocated is almost equal ($0. 75 vs $0. 76)
Due to the difference in the syringe per contact and the reduction of the auxiliary kit assembly.
Average logarithmic probability of accessing the needle and syringe program after the event
The GF period is significantly lower than the GF period (p=0. 02).
Conclusion The withdrawal of GF support for needle and syringe programmes in Mexico is related to the provision of sterile syringes, geographic coverage, and a significant decrease in the use of clean syringes by people who have recently injected drugs.
Better planning is needed to ensure that the sustainability of harm reduction programmes after the withdrawal of donors reaches scale.
Target 2011 global fund by 2013GF)
Support needle and syringe programmes in Mexico to prevent HIV transmission among people who inject drugs.
How GF withdrawal affects the cost, quality and coverage provided by the needle and syringe scheme is not clear.
Design cost studies and longitudinal cohort studies.
Located in Tijuana, Mexico.
Personnel participating in the local needle and syringe program (n=6)
And people who inject drugs (n=734)
Participate in a longitudinal study.
The provision of needle and syringe program services and costs (
Each contact and USD per syringe allocated in 2017)
During GF support (2012)
After exiting (2015/16).
Another result included the use of needles and syringe schemes for the population who injected the drug at the same time during and after GF withdrawal.
As a result, during GF, the needle and syringe scheme distributed 55 u2009 932 syringes to 920 contacts (
60 syringes/contacts)
It is distributed in 14 geographical locations.
After GF withdrew, the needle and syringe program distributed 10 2140 700 syringes to 700 contacts (
5 syringes/contacts)
Across three geographical locations.
During GF, the cost of each reduction in damage contact is about 10-
Higher than after GF ($44. 72 vs $3. 81);
However, the cost of each syringe allocated is almost equal ($0. 75 vs $0. 76)
Due to the difference in the syringe per contact and the reduction of the auxiliary kit assembly.
Average logarithmic probability of accessing the needle and syringe program after the event
The GF period is significantly lower than the GF period (p=0. 02).
Conclusion The withdrawal of GF support for needle and syringe programmes in Mexico is related to the provision of sterile syringes, geographic coverage, and a significant decrease in the use of clean syringes by people who have recently injected drugs.
Better planning is needed to ensure that the sustainability of harm reduction programmes after the withdrawal of donors reaches scale.
Effectiveness of the needle and syringe scheme (NSP)
Reduce the spread of HIV and hepatitis C virus (HCV)
Among the people who inject drugs (PWID)
There are already good records.
Findings from meta-
Analysis Report, NSPs and 58% from high-quality research (95% CI 0. 22 to 0. 81)
Reduce the spread of HIV.
1 Similarly, recent Cochrane systematic reviews and meta-
The analysis found that NSPs were associated with a 21% reduction in HCV transmission (RR=0. 79, 95%u2009CI 0. 39 to 1. 61)
, Although in Europe to see a stronger effect (RR=0. 24, 95%u2009CI 0. 09 to 0. 62).
2 despite the protection benefits of these services, the coverage of critical injury reduction services like NSPs remains unsatisfactory, especially in low/medium
Income country (LMIC)
Where are most of the burden of HIV and HCV disease.
4 Program assessments such as cost analysis are important for budgeting and can help decision makers provide evidence --
Decisions based on scarce resources.
While as resources in these countries are more limited, LMIC will benefit the most from the cost analysis of harm reduction services, economic assessments of harm reduction services are rarely published in these environments.
Studies conducted in Eastern Europe, 5 6 Bengali and China8 suggest that harm reduction services may be effective relative to costs, especially in the context of the newly born HIV epidemic in PWID.
In Latin America, there was no economic evaluation of the national strategic plan.
Despite being one of the world\'s busiest land crossings, numerous socio-economic and health differences separate Tijuana, Mexico, from San Diego, California.
Tijuana has a famous red color.
It mainly attracts drug and sex tourists from the United States, which leads to the local HIV epidemic.
It is also one of the highest concentrations of PWID in Mexico, where 4%-10% of people are infected with hiv and more than 90% are positive for HCV antibodies.
11 NSPs operating in Tijuana for more than 15 years;
Prevention of communication, however, remains a challenge.
Proportion of access to harm reduction services (
60% of PWID that contacted NSP services at least monthly in the past year.
13 from 2011 2013 Global Fund (GF)
Support the NSP provisions of Mexico.
However, due to the rising gross domestic product (gdp) in Mexico, GF suddenly withdrew its support by December 2013.
It is unclear how this withdrawal affects the delivery and economy of Mexico\'s national strategic plan.
Our analysis has two goals:1)
In 2012, NSP operations and costs for the two periods were compared (
When NSPs get funds from GF)and in 2015 (
GF stops funding projects in Mexico); and (2)
To investigate the effect of GF withdrawal on pwid nsp access to the tiwarner longitudinal queue study.
The results of this analysis may provide information on harm reduction planning and donor support planning in other settings across the region, especially those who may transition from donors --State funding-
Damage reduction clause.
Methods collect data on reduced supply and cost from an NSP website in Tijuana, Mexico.
Data collection took place between March 2016 and February 2017.
We studied NSP supply and cost data for two periods: during GF support (2012)
After GF withdrew its support (2015/2016).
To estimate the availability and cost of an efficient NSP with resource enhancements, we report the results of the maximum number of months supported by GF (May 2012).
To estimate the current supply and cost of the NSP, we report the average monthly results for 2015/2016, in addition to the supply situation for the highest number of months in 2015/2016 (July 2015)
Direct comparison with May 2012.
NSP features NSP is located in Zona Centro (near the ‘Red-
Light area, hot spots for illegal drug use and commercial activities).
The allocation of the number of syringes per contact depends on the available funds;
However, they are available to users for free.
The NSP operates for 11 months per year, offering sterile syringes, providing rapid HIV testing/consultation, and referring to hepatitis B and C testing/consultation.
During the on-site visit, we reviewed the geographic scope of needle and syringe activity, the contents of the sterile syringe kit, and the daily log of working hours.
We obtained an estimate from the activity log provided by senior staff about the number of contacts distributed per month and the number of syringes.
Calculate the cost strategy from an economic point of view, monetize all input resources including employees and supplies (
Buy or donate)
Building space and other items.
We used a ingredient. based top-
14 micro-cost calculation methods for measuring overall inputs at the programme level (
That is, we have not observed individual customers or services)
Separate and combined to generate sum per
Customer Unit cost
We divide the total monthly cost by the monthly interest output :(1)
Reduce the number of damage contacts and (2)
Number of sterile syringe kits distributed.
The study evaluated the current implementation cost, but did not consider the start-up-
Cost increase since NSP is operated by non-operator
For many years, with the support of the federal agency for HIV/AIDS prevention in Mexico, government organizations (
National Center for Prevention and Control and National Center for Prevention and Control (CENSIDA)).
We classify costs as recurring costs (
For example, personnel and non-personnel)and capital.
The personnel salary is obtained from the expenditure record for the number of hours and percentages used to operate the NSP (
Including administration)
It was obtained from interviews with senior staff.
During the GF investment, each of the distributed harm reduction kits was paid to the outreach staff.
Volunteer costs are calculated based on interviews with senior staff reporting the number of NSP
If the volunteers are hired, they will receive the relevant working hours and wages. Recurrent non-
Personnel costs include supplies (
Including syringes and auxiliary damage reduction items)
Maintenance of buildings, utilities and other services (
Accounting, maintenance, cleaning, security, etc).
Unit price for input from financial records, detailed notes/receipts and sales catalogues.
Capital costs include building space and equipment.
The senior staff provided the overall monthly rent and estimated the proportion of building space attributable solely to the provision of NSP services, which we visually confirmed during our field visit.
We multiply the rent by the proportion dedicated to NSP services to get the operating cost of providing only NSP.
All recurring expenses related to operating vehicles (
Fuel, insurance, etc)
Obtained from the expenditure record.
Equipment and vehicle charges are amortized over the estimated life of the item and then converted into monthly charges.
During the GF period, fuel costs for May 2012 were estimated using daily transport logs used to calculate mileage.
We use it to convert the estimate of the fuel economy times the fuel price of the vehicle to an estimated consumption (1L=US$0. 78).
We got the activity log in May 2012.
Since the services provided during GF are different, we are interested in choosing this month because it reflects the longest period of time (ie, ‘ideal’)
According to the interviews with the researchers, we compared the service level provided by GF investment (post-GF).
These personnel expenses were inflated by the National Bureau of Statistics\'s consumer price index to the Mexican peso in 2017, and then converted into US dollars using the exchange rate in January 2017 (20.
Mexican peso = $1).
During GF, in addition to the cost data, we also obtained the data after GF withdrew from 205to2016 (
Cost calculation period of 5-4 months).
Using the midpoint of each cost year, the cost expands to the Mexican peso of 2017 and then converts to US dollars.
Living in the PWID of TijuanaSince 2011, members of our research department tracked a set of PWIDs (n=734)
Stayed in Tijuana (
Project \"el Cuete iv \")
To assess trends and patterns in risk behaviour, HIV incidence and reduction in the use of injury services.
The study procedure has been described elsewhere and all participants agree to the study procedure.
To assess the effect of GF withdrawal on the supply of clean syringes in PWID, we analyzed the data collected from March 2012 to June 2016 (
Roughly consistent with the end of the cost calculation period)
Determine the proportion of El Cuete participants who received clean syringes from NSP in the last 6 months.
We applied the method of interrupt time series analysis and performed segmented regression 16 to estimate significant time changes in NSP utilization during GF and after GF exit.
We first fitted a logistic regression model with fixed and random effects and
Order a self-regression related structure to generate an average forecast probability for each quarter of the calendar year.
We then fit the average prediction probability into a segmented linear regression model that controls the self-regression error to estimate the coefficients of the NSP accessed by different GF cycles.
More details are provided in the online supplement.
We presented the study to community stakeholders and received their approval.
Researchers who have used drugs and reflect the community have reviewed and pre-tested the survey.
NSP features NSP is located in Zona Centro (near the ‘Red-
Light area, hot spots for illegal drug use and commercial activities).
The allocation of the number of syringes per contact depends on the available funds;
However, they are available to users for free.
The NSP operates for 11 months per year, offering sterile syringes, providing rapid HIV testing/consultation, and referring to hepatitis B and C testing/consultation.
During the on-site visit, we reviewed the geographic scope of needle and syringe activity, the contents of the sterile syringe kit, and the daily log of working hours.
We obtained an estimate from the activity log provided by senior staff about the number of contacts distributed per month and the number of syringes.
Calculate the cost strategy from an economic point of view, monetize all input resources including employees and supplies (
Buy or donate)
Building space and other items.
We used a ingredient. based top-
14 micro-cost calculation methods for measuring overall inputs at the programme level (
That is, we have not observed individual customers or services)
Separate and combined to generate sum per
Customer Unit cost
We divide the total monthly cost by the monthly interest output :(1)
Reduce the number of damage contacts and (2)
Number of sterile syringe kits distributed.
The study evaluated the current implementation cost, but did not consider the start-up-
Cost increase since NSP is operated by non-operator
For many years, with the support of the federal agency for HIV/AIDS prevention in Mexico, government organizations (
National Center for Prevention and Control and National Center for Prevention and Control (CENSIDA)).
We classify costs as recurring costs (
For example, personnel and non-personnel)and capital.
The personnel salary is obtained from the expenditure record for the number of hours and percentages used to operate the NSP (
Including administration)
It was obtained from interviews with senior staff.
During the GF investment, each of the distributed harm reduction kits was paid to the outreach staff.
Volunteer costs are calculated based on interviews with senior staff reporting the number of NSP
If the volunteers are hired, they will receive the relevant working hours and wages. Recurrent non-
Personnel costs include supplies (
Including syringes and auxiliary damage reduction items)
Maintenance of buildings, utilities and other services (
Accounting, maintenance, cleaning, security, etc).
Unit price for input from financial records, detailed notes/receipts and sales catalogues.
Capital costs include building space and equipment.
The senior staff provided the overall monthly rent and estimated the proportion of building space attributable solely to the provision of NSP services, which we visually confirmed during our field visit.
We multiply the rent by the proportion dedicated to NSP services to get the operating cost of providing only NSP.
All recurring expenses related to operating vehicles (
Fuel, insurance, etc)
Obtained from the expenditure record.
Equipment and vehicle charges are amortized over the estimated life of the item and then converted into monthly charges.
During the GF period, fuel costs for May 2012 were estimated using daily transport logs used to calculate mileage.
We use it to convert the estimate of the fuel economy times the fuel price of the vehicle to an estimated consumption (1L=US$0. 78).
We got the activity log in May 2012.
Since the services provided during GF are different, we are interested in choosing this month because it reflects the longest period of time (ie, ‘ideal’)
According to the interviews with the researchers, we compared the service level provided by GF investment (post-GF).
These personnel expenses were inflated by the National Bureau of Statistics\'s consumer price index to the Mexican peso in 2017, and then converted into US dollars using the exchange rate in January 2017 (20.
Mexican peso = $1).
During GF, in addition to the cost data, we also obtained the data after GF withdrew from 205to2016 (
Cost calculation period of 5-4 months).
Using the midpoint of each cost year, the cost expands to the Mexican peso of 2017 and then converts to US dollars.
Living in the PWID of TijuanaSince 2011, members of our research department tracked a set of PWIDs (n=734)
Stayed in Tijuana (
Project \"el Cuete iv \")
To assess trends and patterns in risk behaviour, HIV incidence and reduction in the use of injury services.
The study procedure has been described elsewhere and all participants agree to the study procedure.
To assess the effect of GF withdrawal on the supply of clean syringes in PWID, we analyzed the data collected from March 2012 to June 2016 (
Roughly consistent with the end of the cost calculation period)
Determine the proportion of El Cuete participants who received clean syringes from NSP in the last 6 months.
We applied the method of interrupt time series analysis and performed segmented regression 16 to estimate significant time changes in NSP utilization during GF and after GF exit.
We first fitted a logistic regression model with fixed and random effects and
Order a self-regression related structure to generate an average forecast probability for each quarter of the calendar year.
We then fit the average prediction probability into a segmented linear regression model that controls the self-regression error to estimate the coefficients of the NSP accessed by different GF cycles.
More details are provided in the online supplement.
We presented the study to community stakeholders and received their approval.
Researchers who have used drugs and reflect the community have reviewed and pre-tested the survey.
Provide and use the ResultsNSP during GF (2012)
In 2012, the NSP provided six days of damage reduction services per week and outreach services covering the vast geographic area of Tijuana (figure 1A).
The contents of the damage reduction kit include: 60 syringes (
All low dead spaces)
240 alcohol swabs, 20 Condoms, 60 3 ml vials of sterile water, 200 cotton swabs, 1 aluminum plate, 60 lubricating oil pipes, and 1 bottle of bleach (figure 2).
In May 2012, the NSP reported 932 contact to reduce damage, resulting in the distribution of 55 u2009 920 syringes (table 1).
The personnel employed during this period include: coordinator, accountant, consultant and nurse.
Eight health education/outreach staff conducted needle and syringe examinations at different locations and 115 HIV tests.
Based on the monthly activity log, we estimate that we travel 234 km/h per month for outreach purposes.
View this table: view the provision of NSP services during GF (May 2012)
Maximum volume (July 2015)
Monthly average (2015/2016)
Download the geographic coverage of figure 1 needle and syringe project promotion website in the new tabDownload powerpoint (A)
During the Global Fund (GF)
May 2012 and (B)
GF after 2015/2016 exit
Geographic information system (GIS)
Publicly obtained data from the Santiago government association on major roads and boroughs of Tijuana (SANDAG)
31 and Tijuana Institute of Urban Planning.
32 download in the new tabDownload powerpoint figure 2 damage reduction kit components for each sterile syringe distributed during the Global Fund (GF)
Duration after GF exits.
Note: As more syringes are distributed per item, some items are only partially described (
For example, three syringes were distributed per condom during GF).
Cost Provided by NSP during GFperiod (2012)
The total monthly cost of the NSP allocation in May 2012 was $681 (table 2).
The cost of each damage reduction contact is $44.
72, while the cost per syringe allocated is $0. 75. Nearly two-thirds (62%)
In the total cost of each month, the accessory suite component (
As shown in figure 2; $26,262)
The contribution of the syringe is 27% ($11,395)
10% of them are regular personnel,
Cost of personnel and funds.
Does not include the syringe Allocation Cost of the auxiliary kit assembly (
Personnel other syringes only have regular capital syringes)
The GF period is $0.
Allocate 28 per syringe.
View this table: View the inline View pop-up table 2 capacity, Best (May 2012)
Average monthly cost of NSPs operating in Tijuana, Mexico (
$ US all fees for 2017)
Provision and Use of NSPGF(2015/2016)
During and after GF\'s withdrawal of support in 2015/2016, there is a significant difference in the business and provision of harm reduction services (
Figure 1B and Table 1).
As shown in Figure 1B, after GF exits, the geographic coverage for providing damage reduction services has narrowed dramatically, mainly confined to the north of Noona.
The number of outreach personnel decreased from 8 in 2012 to 4 in 2015/2016.
Also, after
GF, significantly reduced damage kit content compared to GF period (
Tables 1 and 2).
In 2015, the damage reduction kit content includes five syringes (three low-
Dead Space and two high
Dead space compared to 60 low spaces
Dead Space syringe on 2012)
3 bottles of sterile water, 5 alcohol swabs and 3 condoms.
Also, after
GF, service provision is reduced by 1 day to 5 days per week.
Despite reduced geographic coverage and reduced opening hours, the number of kits distributed monthly in 2015 was higher than in 2012.
NSP reports an average of 2140 people/2016 per month in 2015 (
3170 contacts in the month of the highest volume in 2015/2016)
By contrast, 932 per cent were in May 2012.
However, due to a significant reduction in the number of syringes per kit, at 2015/2016-
An average of 2015/2016 700 syringes were allocated per month for 700 years.
In the maximum volume month of 2015/2016, 15 syringes 920 syringes were distributed compared to 55 syringes 850 in May 2012.
Cost after NSP offerGF(2015/2016)
Compared to the average monthly cost for the 2012/2016 period, the total monthly cost for the 2015 NSP was more than five times higher (
$681 to $8131)
, Mainly due to the higher cost of reducing the damage kit during GF ($44. 72 vs $3.
80 each kit).
By contrast, the total monthly cost of the month of the maximum reserveGF is $193 for 10 pax
Only the cost of syringe allocation (
Auxiliary kit components are not included)
Doubled from $0.
28/syringe allocated to $0 in 2012.
The syringes distributed in 2015, 53/2016, were mainly due to the decrease in the number of syringes distributed, resulting in a higher cost of personnel per syringe (figure 3).
However, after including the auxiliary kit assembly, the cost of each syringe allocated in 2015/2016 has not changed ($0. 76)
Compared to May 2012 ($0. 75)
Because the expenditure on auxiliary suite components is reduced.
Similarly, the cost change per syringe is small ($0. 64)
Distribution compared to the maximum volume month in 2015/2016.
Damage reduction kit (
Accessory parts of syringe)
Accounted for 90% of the cost of each syringe allocated during GF, while these items accounted for only 51% in 2015/2016 (figure 3).
Download the cost breakdown of each syringe distributed on the figureOpen figure 3 needle and syringe project website in the new tabDownload powerpoint (
Auxiliary damage reduction parts in the bracket). Global fund GF.
Based on the data from PWID in the El Cuete IV study, we calculated that at 17 3-
The monthly cycle, as shown in the online supplementary figure s1.
Overall, there was a significant increase in the likelihood of accessing NSP during GF, which peaked in September 2013 (
51%, 95% ci 42% to 59%).
During GF, the average log probability of accessing NSP increased by 0 times. 17 (pvalue