Cost-effectiveness of a police education program on HIV and overdose among people who inject drugs in Tijuana, Mexico

Date

2024

Authors

Cepeda, Javier A.
Beletsky, Leo
Abramovitz, Daniela
Saldana, Carlos Rivera
Kahn, James G.
Bañuelos, Arnulfo
Rangel, Gudelia
Arredondo, Jaime
Vickerman, Peter
Bórquez, Annick

Journal Title

Journal ISSN

Volume Title

Publisher

The Lancet Regional Health - Americas

Abstract

Background: Incarceration is associated with drug-related harms among people who inject drugs (PWID). We trained >1800 police officers in Tijuana, Mexico on occupational safety and HIV/HCV, harm reduction, and decriminalization reforms (Proyecto Escudo). We evaluated its effect on incarceration, population impact and cost-effectiveness on HIV and fatal overdose among PWID. Methods: We assessed self-reported recent incarceration in a longitudinal cohort of PWID before and after Escudo. Segmented regression was used to compare linear trends in log risk of incarceration among PWID pre-Escudo (2012-2015) and post-Escudo (2016-2018). We estimated population impact using a dynamic model of HIV transmission and fatal overdose among PWID, with incarceration associated with syringe sharing and fatal overdose. The model was calibrated to HIV and incarceration patterns in Tijuana. We compared a scenario with Escudo (observed incarceration declines for 2 years post-Escudo among PWID from the segmented regression) compared to a counterfactual of no Escudo (continuation of stable pre-Escudo trends), assessing cost-effectiveness from a societal perspective. Using a 2-year intervention effect and 50-year time horizon, we determined the incremental cost-effectiveness ratio (ICER, in 2022 USD per disability-adjusted life years [DALYs] averted). Findings: Compared to stable incarceration pre-Escudo, for every three-month interval in the post-Escudo period, recent incarceration among PWID declined by 21% (adjusted relative risk = 0.79, 95% CI: 0.68-0.91). Based on these declines, we estimated 1.7% [95% interval: 0.7%-3.5%] of new HIV cases and 12.2% [4.5%-26.6%] of fatal overdoses among PWID were averted in the 2 years post-Escudo, compared to a counterfactual without Escudo. Escudo was cost-effective (ICER USD 3746/DALY averted compared to a willingness-to-pay threshold of $4842-$13,557). Interpretation: Escudo is a cost-effective structural intervention that aligned policing practices and human-rights-based public health practices, which could serve as a model for other settings where policing constitutes structural HIV and overdose risk among PWID.

Description

Keywords

structural intervention, law enforcement, HIV, overdose, modelling, cost-effectiveness

Citation

Cepeda, J. A., Beletsky, L., Abramovitz, D., Saldana, C. R., Kahn, J. G., Bañuelos, A., ... Martin, N. K. (2024). Cost-effectiveness of a police education program on HIV and overdose among people who inject drugs in Tijuana, Mexico. The Lancet Regional Health - Americas, 30, 100679. https://doi.org/10.1016/j.lana.2024.100679