WASUA came into existence over a decade ago and the first thing we did was establish a fixed site needle and syringe exchange staffed by peers (people with their own personal experience of illicit drug use).

There is a very important and practical reason why services like WASUA depend on peers and that is because people who inject drugs (PWID) are regarded as a "hard to reach" group. There are a variety of reasons why this is the case - chief amongst them being the illegality of injecting drugs and the severe penalties that can apply to those who engage in this behaviour. Providing a service run by peers enables our clients to speak freely about their circumstances - in doing so providing us with the opportunity to give them the information, support and advice that they need to reduce some of the harms associated with their illicit drug use.Needle and syringe exchanges are the frontline in the battle against the transmission of blood borne viruses like Hepatitis C and HIV (the virus that causes AIDS).

Some people find it difficult to accept that needle and syringe programs exist and are supported by funding from governments - both State and Federal. Given that, for the most part, injecting drugs is illegal some people content that services such as ours "encourage" drug use. However there is a wealth of evidence that shows needle and syringe exchange programs don't encourage people to inject drugs. Indeed for many injecting drug users organisations like WASUA provide them with a critical point of contact with health services, advice about treatment and information on how to lower the inherit risks associated with injecting illicit substances.

As we live in a country with a public health, the cost of an individual's health problems are borne by the community as a whole. The cost of caring for a single individual with HIV for example can be in excess of $1,000,000 over their lifetime. Thus preventing just one case of HIV can save our health system an enormous amount of money. Luckily for our health system Australia responded quickly to the potential threat of high rates of HIV amongst our injecting drug user population by establishing needle and syringe exchange programs. As a result of this and other measures the rate of HIV amongst injecting drug users in Australia is one of the lowest in the world. Needle and syringe programs ensure that this continues to be the case.

The savings to the public health system were examined in the following report (pdf):

Return on Investment in Needle and Syringe Programs in Australia

Some of the reports findings are detailed below.

ESTIMATES OF INJECTING DRUG USERS LIVING WITH HIV/AIDS

- WITH NSP INTRODUCTION

The number of injecting drug users living with HIV/AIDS is estimated to have peaked in the early 1990s at approximately 470 cases, with a peak in people living with AIDS of less than 100 in the late 1990s. The cumulative number of deaths from HIV/AIDS by 2010 is projected to be approximately 350.

- WITHOUT NSP INTRODUCTION

The number of injecting drug users living with HIV/AIDS is estimated to peak in 2000 at approximately 26,000, with a peak in people living with AIDS of almost 3,000 in 2010. The estimated cumulative number of deaths from HIV/AIDS by 2010 is projected to be approximately 5,000.

- PREVENTED THROUGH NSP INTRODUCTION

By the year 2000, approximately 25,000 HIV infections are estimated to have been prevented among injecting drug users since the introduction of NSPs in 1988, and by 2010 approximately 4,500 deaths are projected to have been prevented.

ESTIMATES OF INJECTING DRUG USERS WITH HCV AND HCV-RELATED DEATHS

- WITH NSP INTRODUCTION

In 2000, the number of injecting drug users living with HCV was estimated to be approximately 200,000 (approximately 150,000 with chronic HCV infection). By 2010 an estimated 11,800 injecting drug users are projected to be living with cirrhosis, and estimated cumulative HCV-related deaths are projected to be 1,800.

- WITHOUT NSP INTRODUCTION

In 2000, the number of injecting drug users living with HCV is estimated to be approximately 220,000 (approximately 165,000 with chronic HCV infection). By 2010 an estimated 12,500 injecting drug users are projected to be living with cirrhosis, and estimated cumulative HCV-related deaths are projected to be 1,900.

- PREVENTED THROUGH NSP INTRODUCTION

By the year 2000, approximately 21,000 HCV infections are estimated to have been prevented among injecting drug users since the introduction of NSPs in 1988, (of which approximately 16,000 would have developed chronic HCV); while by 2010 approximately 650 fewer injecting drug users are projected to be living with cirrhosis and 90 HCV-related deaths would have been prevented.

FINANCIAL EFFECTS OF NSPS

EXPENDITURE ON NSPS

Between 1991 and 2000, an estimated $141 million ($150 million in 2000 prices) was expended on NSPs across Australia, comprised of $122 million (87%) by government, and $19 million (13%) in consumer expenditure. Return on Investment in Needle & Syringe Programs - Report 3 These data cover expenditure on NSPs operating within the programs managed by State and Territory health authorities. It excludes costs associated with the many retail pharmacies that also sell needles and syringes on a commercial basis, for which reliable data is not available on the number of needles sold or the level of expenditure by consumers.

TREATMENT COSTS AVOIDED

Estimates of the lifetime costs of treatment for HIV and HCV cases avoided are based on past and current treatment regimes by disease stage and applied over the projected lifetime of cases. Standardised costs have been used for each component of health care using year 2000 prices.

- Human Immunodeficiency Virus (HIV)

For HIV, annual treatment costs are estimated to rise progressively to the year 2008 as patients progress to later stages of the disease, at which time they peak at approximately $269 million. Thereafter, annual costs decline, brought about mainly by the declining number of patients in the second and third stages of HIV. Total HIV treatment costs avoided over the lifetime of cases are estimated at $7,025 million (undiscounted). These represent the savings that accrue from a combination of the following:

• Approximately 25,000 cases of HIV avoided,
• who live for an average of about 24 years after infection,
• and who incur average treatment costs of nearly $14,000 each year of their life after diagnosis.

- Hepatitis C Virus (HCV)

For HCV, annual treatment costs rise progressively to the year 2040, at which time they peak at approximately $18.8 million and decline thereafter. The major factor influencing this cost profile is the number of patients who progress to liver failure who, while relatively small in number, have extremely high costs of treatment. Total HCV treatment costs avoided over the lifetime of cases are estimated at $783 million (undiscounted).

Overall, total treatment costs avoided over the life of the cases of HIV and HCV avoided by NSPs are approximately $7,808 million (before discounting). The costs of HIV treatment avoided are approximately ten times those for HCV, which reflects a combination of the number of cases avoided in the first instance (25,000 for HIV compared to 21,000 for HCV), a higher diagnosis rate for HIV than HCV, and higher average annual treatment costs for HIV than for HCV.

CONCLUSION

The study into the effect of NSPs on HIV and HCV, and the consequent return on investment from these programs has reinforced the original findings by Hurley, Jolley and Kaldor. The results demonstrate that NSPs are effective in reducing the incidence of both diseases and that they represent an effective financial investment by government.

From a financial perspective, we have considered only the direct costs of treatment saved by the avoidance of HIV and HCV. Such an approach is inherently conservative, and it is likely that there are further financial benefits derived from the investment in NSPs not included in our findings. As such, the savings we have demonstrated, if anything, understate the total financial benefits to government and members of the community.

When considering the effect of NSPs on the lives of those immediately affected by their operation, namely injecting drug users, the study again demonstrates that NSPs have a positive impact. This has been measured in terms of avoidance of deaths, gains in the duration of life and improvements in the quality of life of injecting drug users. Such benefits are additional to the financial benefits demonstrated.

The study has considered the investment in NSPs during the 1990s, at which time we have assumed that the investment ceased. The consideration of effect has been limited to the future benefits accruing from the cases of HIV and HCV avoided during the investment period. The results demonstrate that, across all measures of effect used in the study, NSPs have yielded a significant public health benefit, and that continued investment is warranted from both a financial and human perspective.

This article is subject to change.