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José L. Burgos, MD, MPH, AAHIVS Assistant Professor

Cost-effectiveness of combined sexual and injection risk reduction interventions among Female Sex Workers who inject drugs in two very distinct Mexican-US border cities. José L. Burgos, MD, MPH, AAHIVS Assistant Professor Division of Global Public Health School of Medicine

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José L. Burgos, MD, MPH, AAHIVS Assistant Professor

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  1. Cost-effectiveness of combined sexual and injection risk reduction interventions among Female Sex Workers who inject drugs in two very distinct Mexican-US border cities José L. Burgos, MD, MPH, AAHIVS Assistant Professor Division of Global Public Health School of Medicine University of California San Diego NIMH grant # K01 MH095680 NIDA grant # R01 DA023877 NIDA grant # R01 DA023877-S1 NIMH grant #R01 MH065849 Funding:

  2. Coauthors/Co-Investigators • Jose Luis Burgos, UC San Diego, USA • Thomas L. Patterson, UC San Diego, USA • Joshua S. Graff-Zivin, UC San Diego, USA • James G. Kahn, UC San Francisco, USA • Gudelia Rangel, COLEF, Mx. • Victoria D. Ojeda, UC San Diego, USA • M. Remedios Lozada, ISESALUD, Mx. • Hugo Staines, UACJ, Mx. • Steffanie A. Strathdee, UC San Diego, USA Clinical trial registration number: NCT00840658

  3. About Mujer Mas Segura • A brief combined theory-based intervention to simultaneously reduce sexual and injection risks among IDU-FSWs ages 18+ • IDU-FSWs from Tijuana and Cd. Juarez were randomized to simultaneously examine two interventions • Interactive Vs. Lecture formats • Measures: questionnaires; biological samples to detect four STIs including HIV

  4. http://gph.ucsd.edu/research/contaminacion.shtml

  5. Intervention effects on HIV/STI incidence after 12 months: • 2x2 Factorial Design to Simultaneously Evaluate Injection and Sexual Risk Reduction Intervention • Cd. Juarez • Tijuana • 1.15 • (0.58, 2.28) • 1.15 • (0.58, 2.28) • 0.38 • (0.16, 0.89) • 0.44 • (0.19, 0.99) • 1.12 • (0.56, 2.25) • 0.37 • (0.16, 0.89) *Adjusted for # of unprotected sex acts with non-regular clients , and arrests prior to enrolment Strathdee, et al. 2012

  6. Impact of Injection Risk Interventions on Injection Risk Index: Tijuana and Cd. Juarez Strathdee, et al. 2012

  7. Goal of the CE analysis To assess the cost-effectiveness of a behavioral intervention combining two interventions to increase safer sex and safer injection practices among FSW-IDUs in Ciudad Juarez and Tijuana, Mexico. To inform evidenced based Sex work-harm reduction policies in the Mexico-U.S. border region in respect to access to sterile syringes and condoms among FSW-IDUs.

  8. Cost Effectiveness Model • Discrete transitional state mathematical model • Costs and outcomes for one-year and remainder of life of FSW-IDUs comparing a lecture format to each individual interactive components and the combined MMS intervention. • Societal perspective • Multivariate sensitivity analysis • Cost and outcomes discounted at an annual rate of 3% • Currency adjusted to 2012 U.S. Dollars

  9. Model Inputs aAnnual costs; bSecretaría del Trabajo y Previsión Social ; cComisión Nacional de Salarios Mínimos; dInstituto de Servicios de Salud Pública; eMujer Mas Segura Project; fSecretaría de Economía

  10. aPer 100 person years • bQuality adjusted life years

  11. Cost-Effectiveness on Averted STI

  12. Reported Episodes of Receptive Syringe Sharing During the Previous Month Tijuana Ciudad Juarez

  13. Cost-Effectiveness on Safer Injection Practices

  14. Base case results for a cohort of 1,000 FSW-IDUsover a life-time aCost per QALY gained

  15. Tijuana– Multivariate Cost-Effectiveness Analysis Interactive safer sex/ Lecture safer injection Interactive format safe sex intervention/ Lecture forma safe injection intervention

  16. Cd. Juarez– Multivariate Cost-Effectiveness Analysis For ciudad Juarez – Multivariate analysis Interactive safer sex/ Lecture safer injection

  17. Conclusions • In the absence of expanded NEP the combined Mujer Mas Segura intervention is likely to be cost-effective • Improved access to sterile injection equipment at the community level shows a larger impact in reducing unsafe injection practices among FSW-IDU, with no significant added benefit from the interactive safer-injection component of the Mujer Mas Segura Intervention.

  18. Acknowledgements • Our participants and the sex worker communities in Tijuana and Cd. Juarez • NIH Grants: R01 DA023877 DA023877-S1 K01 MH095680 • Staff from the Preven Casa, A. C., UCSD • San Diego County Public Health Laboratory

  19. References • Patterson TL, Mausbach B, Lozada R, Staines-Orozco H, Semple SJ, Fraga-Vallejo M, Orozovich P, Abramovitz DA, de la Torre A, Amaro H, Martinez G, Magis-Rodriguez C, Strathdee SA. Efficacy of a brief behavioral intervention to promote condom use among female sex workers in Tijuana and Ciudad Juarez, Mexico. Am J Public Health. 2008;98(11):2051-2057. • Burgos JL, Gaebler JA, Strathdee SA, Lozada R, Staines H, Patterson TL: Cost-effectiveness of an intervention to reduce HIV/STI incidence and promote condom use among female sex workers in the Mexico-US border region. PLOS One 2010, 5(6):e11413. • Strathdee SA, Magis-Rodriguez C: Mexico's evolving HIV epidemic. JAMA 2008, 300(5):571-573. • Bell DC, Trevino RA: Modeling HIV risk. J Acquir Immune DeficSyndr1999, 22(3):280-287. • Sonnenberg FA, Beck JR: MARKOV-MODELS IN MEDICAL DECISION-MAKING - A PRACTICAL GUIDE. Medical Decision Making 1993, 13(4):322-338.

  20. Extra Slides

  21. Prop. OR for reported easy access to sterile syringes

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