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The cost-effectiveness of consistent and early intervention of harm reduction for injecting drug users in Bangladesh


Lorna Guinness, Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail:


Aims  To assess the cost-effectiveness of the CARE-SHAKTI harm reduction intervention for injecting drug users (IDUs) over a 3-year period, the impact on the cost-effectiveness of stopping after 3 years and how the cost-effectiveness might vary with baseline human immunodeficiency virus (HIV) prevalence.

Design  Economic cost data were collected from the study site and combined with impact estimates derived from a dynamic mathematical model.

Setting  Dhaka, Bangladesh, where the HIV prevalence has remained low despite high-risk sexual and injecting behaviours, and growing HIV epidemics in neighbouring countries.

Findings  The cost per HIV infection prevented over the first 3 years was US$110.4 (33.1–182.3). The incremental cost-effectiveness of continuing the intervention for a further year, relative to stopping at the end of year 3, is US$97 if behaviour returns to pre-intervention patterns. When baseline IDU HIV prevalence is increased to 40%, the number of HIV infections averted is halved for the 3-year period and the cost per HIV infection prevented doubles to US$228.

Conclusions  The analysis confirms that harm reduction activities are cost-effective. Early intervention is more cost-effective than delaying activities, although this should not preclude later intervention. Starting harm reduction activities when IDU HIV prevalence reaches as high as 40% is still cost-effective. Continuing harm reduction activities once a project has matured is vital to sustaining its impact and cost-effectiveness.