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Research findings April, 2015

Research findings April, 2015

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Research findings April, 2015

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  1. Economic evaluation comparing center-based compulsory rehabilitation (CCT) and community-based methadone treatment (MMT) in Hai Phong City, Vietnam Research findings April, 2015 Contributors: Thu T.H. Vuong1, Nhu Nguyen2, Giang Le3, Alison Ritter1, Marian Shanahan1, Robert Ali4, Khue Pham5, Thu A. Vuong2, Thuy Dinh3 1 UNSW Australia; 2 FHI360 Vietnam; 3 Hanoi Medical University; 4 Adelaide University; 5 Hai Phong Medical University

  2. Presentation outline • Research background • Research questions • Research partnerships • Research design • Research findings: • Part 1: Comparison of sample characteristics • Part 2: Cost analysis • Part 3: Comparison of effectiveness • Part 4: Cost-effectiveness analysis • Implications and discussions

  3. Background (1): Two primary drug treatment modalities in Vietnam OUT OF: 185,000 dependent drug users In community-based methadone maintenance treatment (MMT) (started in 2008) In the community: either no treatment or back from CCT In center-based compulsory rehabilitation (CCT) (started in 1993) (50% voluntary track and 50% compulsory track) Sources: MoPS, MOLISA, MOH and NCADP (2015)

  4. Background (2): Evidence of effectiveness • To date, no research on effectiveness of CCT modality has been done in Southeast Asia, including Vietnam, even though this is the dominant drug treatment modality in the region • Many international studies have been conducted to evaluate the effectiveness and cost-effectiveness of MMT compared to other treatment modalities (Mattick et al., 2009, Cochrane review). Results show positive outcomes on: • reduction of heroin use • reduction of HIV risk behaviors related to drug use • reduction of criminal behaviors • improved employment • In Vietnam, the 2008 MMT cohort study found positive effects for MMT among Vietnamese heroin users

  5. Background(3): The need for a cost-effectiveness research • Vietnam became a middle-income country in 2010 (Palmieri, 2010): • From 2014, funding from international donors has been declining • There is a need for the Government of Vietnam to be proactive in the reallocation of resources for HIV services in general and drug dependence treatment services in particular • Research evidence from cost-effectiveness research comparing the 2 drug treatment modalities in Vietnam (CCT and MMT) is critical as a resource of scientific evidence to assist Vietnamese Government leaders in evidence-based drug policy decision making

  6. Leadership of Hai Phong city Government • 18 Oct 2011: FHI360 sought approval for research • 7 Feb 2012: Official approval from Hai Phong city People’s Committee • 14 Feb 2012: 1st meeting with Hai Phong city Gov. agencies to discuss research protocol • Mar-Jun 2012: Full research protocol reviewed and endorsed by all Gov agencies • Apr 2012: new leadership of DOLISA Hai Phong • 6 Jun 2012: 2ndmeeting with Hai Phong city Gov. agencies to seek approval from new leadership • 17 Jun 2013: Re-newed approval from new leaders of Hai Phong city Gov. agencies • 15 July 2013: Research activities commenced Photo: first meeting on 14 Feb 2012

  7. Research partnerships • HP People’s Committee • HP Dept. of Labour, Invalids and Social Affairs (DOLISA) • HP Dept. of Health • Political back-up by MOLISA Government buy-in and ownership Research independence Funding • Atlantic Philanthropies, through FHI360 Vietnam • Endeavour PhD scholarship • NDARC PhD scholarship • DPMP/NDARC/UNSW Australia • FHI360 in Vietnam • Hanoi Medical University • Hai Phong Medical University

  8. The two research questions (1) In Hai Phong city, Vietnam: • What is the effectiveness of CCT rehabilitation compared to MMT treatment in improving health and social outcomes for heroin dependent users? Health and social outcomes include: • Heroin use • Use of all illicit drugs (including synthetic drugs) • Number of days using drugs • Drug-use related illegal behaviors • Drug-use related HIV risk behaviors • Overdose incidents • Monthly expenditure on drugs

  9. The two research questions (2) • Is CCT more cost-effective compared to MMT for the following measures? • Heroin use • Use of all illicit drugs (including synthetic drugs) • Number of days using drugs (for all illicit drugs) • Drug-use related illegal behaviours • Drug use related HIV risk behavior • Overdose incidents • Monthly expenditure on drugs

  10. Research design (3-year time horizon)

  11. Research findings

  12. Part 1: Baseline characteristics • Compare the characteristics of the two groups • Identify differences for handing in the data analysis to ensure unbiased results in comparison of effectiveness

  13. Part 1-1: Socio-economic characteristics • Interpretations: • The level of education for both groups was not statistically different; • CCT group was younger, more likely to be single, employed and had higher legal monthly income;

  14. Part 1-2: Drug use behaviors • Interpretations: • Both groups started to use drug at similar age (early 20’s); • The proportion of people who used HEROIN daily was not statistically different; • CCT group had a higher proportion starting with heroin but their daily use frequency was lower AND they had been using drugs for less years

  15. Part 1-3: Drug use behaviors (cont’d) • Interpretations: • From commencement of drug use until treatment entry, CCT group spent less money on drugs, which is consistent with using less frequently; • A smaller proportion of CCT group ever injected heroin; • However, CCT group were more likely to be poly drug users, with 28.3% also using methamphetamine. Among those who were poly users, CCT groups used more drug classes;

  16. Part 1-4: Treatment history • Interpretations: • CCT participants were less likely to have sought treatment. For those who did, the median number of treatment episodes was fewer; • CCT participants were less likely to have previously been in CCT center and less likely to have undergone home-based detoxification;

  17. Part 1-5: Legal consequences and overdose • Interpretations: • The proportions who had ever : 1) committed illegal behaviors; 2) been to prison; or 3) overdosed were the same for both groups • The proportion of people who had deceiving behaviors to their families was higher in CCT group • These results suggest that both groups experienced “similar levels of legal harms” caused by their illicit drug use • Illegal behaviors: • Using force to get money from others • Fraud • Theft • Robbery • Drug dealing • Assault, physical flight to get money for drugs

  18. Summary of findings of Part 1 • The two participant groups were different on some baseline characteristics: • Demographic characteristics • Socio-economic characteristics • Drug-using behaviors • Drug treatment history • However, the levels of differences were small and can be handled in the data analysis to ensure unbiased results

  19. Part 2: Cost analysis • Identify the cost to the Government and the total cost for one participant for each treatment modality

  20. Sources of cost data Programcost (a.k.a. cost to the Government): • Primary cost data on CCT modality collected from 3 CCT centers • Primary cost data on MMT program for 2013 from the Hai Phong Department of Health • Secondary cost data on MMT program for 2009 from the 2009 MMT costing study funded by USAID, conducted by the Health Policy Project Cost to the participants: • Primary cost data collected at baseline interview for both groups of participants

  21. Part 2-1: Cost to the Government Comment: In 2014, the total budget allocated to the 3 CCT centers by Hai Phong City Gov. were 72.47 bil VND (Decision #2804/QĐ-UBND), doubled the amount the CCT center managers reporting in the research questionnaires. However, the cost analysis of this research used cost data reported by the CCT center managers

  22. Part 2-2: Gov cost per trainee/patient/year Comment: The cost per 1 CCT trainee a year paid by the Gov was much bigger than the cost per 1 MMT patient a year. The per patient cost was similar across all MMT clinic whereas the per trainee cost varied significantly across CCT centers

  23. Part 2-2: Cost structure of CCT Comment: The cost structure varies significantly across three CCT centers. The largest proportion of the annual budget were: 1) personnel cost: 2) food for trainees; and 3) depreciated values of facilities.

  24. Part 2-3: Cost structure of MMT Comment: The cost structure of MMT for 2013 shows that the most significant budget items were personnel costs and methadone costs. The cost structure was similar across 3 MMT clinics.

  25. Part 2-4: Cost to the participants (in 2013 VND after adjusted for inflation using CPI) Comment: after adjusted for inflation using CPI, the cost incurred to a CCT participant for one year of treatment was nearly 8 times higher than that of a MMT participant, primarily due to the high cost of loss of productivity as a consequence of 2-year placement in the CCT centers.

  26. Part 2-5: Total cost valued in 2013 VND (after adjusted for inflation using CPI) *Note: For CCT, the three-year time horizon comprises of two years of costs only (as in the 3rd year the participants were back to the community and no more costs were incurred). Comment: Over three years, the total cost for one CCT participant was 123.04 mil VND, which was 3 times higher than the total cost for one MMT participant of 40.05 mil VND

  27. Findings of Part 2 The cost analysis suggests: • Over one year: • It costs the Gov. 19.67 mil VND to provide treatment for one CCT participant, which is 2.5 times higher thanthe cost for one MMT participant of 7.88 mil VND • It costs one CCT participant 41.85 mil VND, 8 times higher than the cost for one MMT participant (5.47 mil VND) • Over three years: • It costs the Gov. 39.34 mil VND to provide treatment for one CCT participant, which is 1.67 times higher than the cost for one MMT participant of 23.65 mil VND

  28. Part 3: Research findings on effectiveness • Compares treatment effectiveness by means of 7 outcome measures across 5 time points (three-year time horizon)

  29. Part 3: Analysis method Mixed effects regression modelling was used for the analysis of effectiveness data of this research: • It is one of the most advanced methods for analysis of longitudinal data • It has capability to take into account the baseline differences between groups

  30. Part 3: Key outcome measures • The 7 outcome measures: • Heroin use • Use of all drugs (including synthetic drugs) • Number of days using drugs • Drug-use related illegal behaviors • Overdose incident • Drug-use related HIV risk behaviors • Monthly expenditure on drugs

  31. Part 3-1: heroin use - urinanalysis Descriptive data: Mixed effects results:Over 5 time-points, the % of people who had a positive urine sample was reduced for both groups. However, CCT participants were nearly 3 times more likely to have a positive opioid urine sample compared to MMT participants

  32. Part 3-2: Use of all drugs Descriptive data: Mixed effects results:Over 5 time-points, the % of people who used any illicit drug was reduced for both groups. However, CCT participants were 3.3 times more likely to report any drug use compared to MMT participants

  33. Part 3-3: Number of days using drugs (during the last 30 days) Descriptive data: Mixed effects results:Over 5 time-points, the mean number of days using drugs (during the last 30 days) decreased significantly for both groups. However, on average one CCT participant used 9 MORE DAYS compared to one MMT participant This means over 3 years, one CCT participant used 324 MORE DAYS compared to one MMT participant

  34. Part 3-4: Drug-use related illegal behaviors Descriptive data: Mixed effects results:Over 5 time-points, the % of participants who engaged in drug-use related illegal behaviors reduced for both groups. However, CCT participants were 5.6 times more likely to engage in an illegal behavior compared to MMT participants

  35. Part 3-5: Non-fatal overdose Descriptive data: Mixed effects results:Over 5 time-points, the % of people reported having an overdose incident was reduced for both groups. The probability of having an overdose incident for MMT group and CCT group reduced by 24% and 30% respectively.

  36. Part 3-6: Drug-use related HIV risk behaviors Descriptive data: Mixed effects results:Over 5 time-points, the % of participants who reported drug-use related HIV risk behaviors was reduced for both groups. However, CCT participants were nearly 7 times more likely to report HIV risk behaviors compared to MMT participants

  37. Part 3-7: Monthly expenditure on drugs Descriptive data: Mixed effects results:Over 5 time-points, the average monthly expenditure on drugs decreased for both groups. MMT group spent 4.4 mil VND less and CCT group spent 3.6 mil VND less.

  38. Summary of findings of Part 3 Based 3-year data on 208 CCT participants and 384 MMT participants, the findings of the effectiveness analysis show that MMT is more effective in nearly all measures compared to CCT: • 3 times reduction in heroin use • 3.3 times reduction in use of all drugs • Using drugs 324 FEWER days • 5.6 times reduction in illegal behaviors • 7 times reduction in HIV risk behaviors

  39. Part 4: Cost effectiveness analysis • Identify which treatment modality is more cost-effective

  40. ICER for one drug-free day • Interpretations: • By investing in MMT, over 3 years, not only could the Gov save 15.69 mil VND for treatment for one dependent heroin user, but each dependent heroin user also use drugs 324 FEWER DAYS • Even though a proportion of MMT patients do not remain abstinent on heroin use, the significant reduction in the number of days using drugs can contribute to reduction in illegal behaviors, reduction in HIV risk behaviors & other negative consequences to the families & society

  41. Overall summary of research findings • MMT is less costly: Over 3 years, it costs the Gov. 39.34 mil VND to provide treatment for 1 CCT participant, 1.67 times higher than the cost for 1 MMT participant (23.65 mil VND) • By investing in MMT, over 3 years, not only could the Gov save 15.69 mil VND for treatment for one dependent heroin user, but each dependent heroin user could also gain: • 3 times reduction in heroin use • 3.3 times reduction in use of all drugs • Using drugs 324 FEWER days • 5.6 times reduction in illegal behaviors • 7 times reduction in HIV risk behaviors

  42. Implications (1) For Hai Phong City: • If CCT is provided for all 8,000 heroin dependent users in HP City, the cost to the Gov will be 315 billion VND (15 million US$) over 3 years (the cost for year 3 = zero) • If free MMT is provided for all 8,000 heroin dependent users in HP, the cost to the Gov will be 189 billion VND (9 million US$) over 3 years  The Gov can save 126 billion VND (6 million US$) • If co-pay MMT is provided for all 8,000 heroin dependent users in HP (patients pay 10,000 VND/day), the Gov can save 213 billion VND (10 million US$) over 3 years

  43. Implications (2) For Vietnam: • If CCT is provided for all 185,000 heroin dependent users, the cost to the Gov will be 7,278 billion VND (348 million US$) over 3 years (the cost for year 3 = zero) • If free MMT is provided for all 185,000 heroin dependent users, the cost to the Gov will be 4,373 billion VND (209 million US$) over 3 years  The Gov can save 2,900 billion VND (139 million US$) • If co-pay MMTis provided for all 185,000 heroin dependent users (patients pay 10,000 VND/day), the Gov can save 4,930 billion VND (236 million US$) over 3 years

  44. Recommendations • This cost-effectiveness evaluation research finds conclusive evidence that MMT treatment is more cost-effective for a range of measures compared to CCT modality for heroin dependent users in Hai Phong City • Based on this evidence, it is highly recommended that decision makers in Hai Phong city and in Vietnam consider this evidence and give higher priority in resource allocation for MMT treatment and scale down CCT modality • With this level of savings, the Gov could have sufficient budget for investment into the HIV program, including methadone program and will not need to be dependent on external funding

  45. Acknowledgement • The Advisory Board to the Chairman of the NCADP • Representatives of international organizations (UNAIDS, UNODC, USAID, and WHO) • Leaders of Hai Phong city Government agencies: the People’s Committee, DOLISA, Dept. of Health, Dept. of Police, directors of 3 CCT centers and managers of 3 MMT clinics

  46. Questions and discussions