Study identifies cost-effective ways to combat HIV risk among intravenous drug users

May 24, 2017

With the abuse of opioids on the rise in the United States, Stanford University researchers are concerned that increased HIV transmission from shared needles won't be far behind.

"There's an opioid epidemic in our country, and there's a real public health crisis associated with injecting," said Cora Bernard, a graduate student in management science and engineering. "We think it's important to understand what investments give highest value because HIV prevention programs, and especially programs that reduce the prevalence of injection drug use, can have outsized, positive impact on individuals, families and public safety."

Bernard is the lead author of a study on prevention programs that could head off a resurgence of HIV and perhaps decrease the effects of the opioid crisis. The study will be published online May 24 in PLOS Medicine. The senior author is Margaret Brandeau, PhD, professor of management science and engineering.

In July 2016, Bernard and her co-authors published a different study examining pre-exposure prophylaxis, or PrEP, a pill that reduces a person's risk of infection when they come into contact with the HIV virus. The researchers found that PrEP was effective, but expensive.

The new study examines alternatives that also reduce the risk of HIV infection but are more cost-effective. They created a model to determine how many quality-adjusted life years -- a metric that incorporates both life expectancy and quality of life -- a person could gain from four HIV prevention methods, and what those years would cost.

"The dynamics of HIV prevention and treatment are complex," Brandeau said. "Our model allows us to evaluate the costs and effects of the interventions, singly and in combination, to determine what programs would be effective and cost-effective in preventing the spread of HIV among persons who inject drugs."

Prevention models studied

Of the prevention programs simulated in the model, the authors found that opioid agonist therapy, or OAT, was the most cost-effective. OAT replaces drugs like heroin with a prescription that provides similar effects under safer conditions. Methadone and buprenorphine maintenance therapies are the most common.

Needle-syringe exchange programs, in which people swap their dirty needles for clean ones, were the next most cost-effective option. This was followed by test-and-treat programs, which identify people with a high risk of contracting HIV, test them for the virus and treat them before the disease has much chance to spread -- both within their own bodies and to others who are exposed.

The study estimated that PrEP can also successfully reduce HIV, but not in a cost-effective way. The authors write that the other three techniques could all cost less than $50,000 for each quality-adjusted life year gained by individuals. PrEP would likely cost more than $600,000 per quality-adjusted life year.

The prevention programs were most effective when used in combination. The authors project that combining OAT and needle-syringe exchanges could avert up to 40,000 HIV infections over 20 years among people who inject drugs, not to mention preventing downstream sexual transmission of HIV to others in the population.

According to Bernard, one of the benefits of OAT in particular is that in addition to reducing the risk of HIV, it can also help people stop injecting drugs. The authors project that expanding OAT access could decrease the size of the injection population by up to 23 percent over 20 years for low-coverage expansions and up to 37 percent over 20 years for more extensive program expansions.

OAT found to be 'highest-value investment'

"We started out thinking about this as an HIV problem, but we realized that the majority of health benefit actually comes from reducing injection drug use and improving quality of life for drug users," said Bernard. "This is why we found OAT to be the highest-value investment."

Bernard and her co-authors believe that employing techniques like OAT could help reduce the effects of the opioid crisis.

"Our study aims to help policymakers and clinicians understand how a variety of interventions can help improve health outcomes and prevent HIV," said study co-author Douglas Owens, MD, professor of medicine and internist at the Veterans Affairs Palo Alto Health Care System. "We hope our analyses help show how to use limited resources efficiently to prevent the devastating consequences of substance use."
The study's other co-author was Jeremy Goldhaber-Fiebert, PhD, associate professor of medicine.

The work was supported by the National Institute on Drug Abuse and the Department of Veterans Affairs.

This work was also supported by the departments of Management Science and Engineering and of Medicine and by Stanford Health Policy.

The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit The medical school is part of Stanford Medicine, which includes Stanford Health Care and Stanford Children's Health. For information about all three, please visit

Print media contact: Nicole Feldman (650) 725-3389 (
Broadcast media contact: Margarita Gallardo at (650) 723-7897 (

Stanford University Medical Center

Related HIV Articles from Brightsurf:

BEAT-HIV Delaney collaboratory issues recommendations measuring persistent HIV reservoirs
Spearheaded by Wistar scientists, top worldwide HIV researchers from the BEAT-HIV Martin Delaney Collaboratory to Cure HIV-1 Infection by Combination Immunotherapy (BEAT-HIV Collaboratory) compiled the first comprehensive set of recommendations on how to best measure the size of persistent HIV reservoirs during cure-directed clinical studies.

The Lancet HIV: Study suggests a second patient has been cured of HIV
A study of the second HIV patient to undergo successful stem cell transplantation from donors with a HIV-resistant gene, finds that there was no active viral infection in the patient's blood 30 months after they stopped anti-retroviral therapy, according to a case report published in The Lancet HIV journal and presented at CROI (Conference on Retroviruses and Opportunistic Infections).

Children with HIV score below HIV-negative peers in cognitive, motor function tests
Children who acquired HIV in utero or during birth or breastfeeding did not perform as well as their peers who do not have HIV on tests measuring cognitive ability, motor function and attention, according to a report published online today in Clinical Infectious Diseases.

Efforts to end the HIV epidemic must not ignore people already living with HIV
Efforts to prevent new HIV transmissions in the US must be accompanied by addressing HIV-associated comorbidities to improve the health of people already living with HIV, NIH experts assert in the third of a series of JAMA commentaries.

The Lancet HIV: Severe anti-LGBT legislations associated with lower testing and awareness of HIV in African countries
This first systematic review to investigate HIV testing, treatment and viral suppression in men who have sex with men in Africa finds that among the most recent studies (conducted after 2011) only half of men have been tested for HIV in the past 12 months.

The Lancet HIV: Tenfold increase in number of adolescents on HIV treatment in South Africa since 2010, but many still untreated
A new study of more than 700,000 one to 19-year olds being treated for HIV infection suggests a ten-fold increase in the number of adolescents aged 15 to 19 receiving HIV treatment in South Africa, according to results published in The Lancet HIV journal.

Starting HIV treatment in ERs may be key to ending HIV spread worldwide
In a follow-up study conducted in South Africa, Johns Hopkins Medicine researchers say they have evidence that hospital emergency departments (EDs) worldwide may be key strategic settings for curbing the spread of HIV infections in hard-to-reach populations if the EDs jump-start treatment and case management as well as diagnosis of the disease.

NIH HIV experts prioritize research to achieve sustained ART-free HIV remission
Achieving sustained remission of HIV without life-long antiretroviral therapy (ART) is a top HIV research priority, according to a new commentary in JAMA by experts at the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

The Lancet HIV: PrEP implementation is associated with a rapid decline in new HIV infections
Study from Australia is the first to evaluate a population-level roll-out of pre-exposure prophylaxis (PrEP) in men who have sex with men.

Researchers date 'hibernating' HIV strains, advancing BC's leadership in HIV cure research
Researchers have developed a novel way for dating 'hibernating' HIV strains, in an advancement for HIV cure research.

Read More: HIV News and HIV Current Events is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to