Preventing HIV in injection drug users: exploring the tradeoffs between interventions

Injection drug users (IDUs) transmit the human immunodeficiency virus (HIV) via both needle sharing and sex. Available interventions for this population have varying costs and effectiveness and focus on different risk behaviors. In this analysis, we look at two interventions. One is inexpensive, broad-based and provides modest risk reductions (street outreach (SO)); the other is narrowly focused, expensive and relatively effective (methadone maintenance). This analysis explores the effects of population risk behavior, intervention effectiveness, intervention costs, and decision constraints when allocating funds between these two interventions to maximize effectiveness. We develop a model of the spread of HIV, dividing IDUs into susceptibles (uninfected) and infectives, and separately portraying sex and injection risk. We simulate the epidemic in New York City for time periods from the mid-1980s to the early 1990s, and incorporate the behavioral effects of two interventions performed singly or in combination to find the allocation that maximizes the number of infections averted in the IDUs and their noninjecting sex partners, assuming interventions have increasing marginal costs. We find that the optimal allocation nearly always involves spending the maximum allowable amount on SO. This result is largely insensitive to variations in risk parameters, intervention efficacy, or cost. The model's structure, however, makes clear that many factors contribute to this insensitivity, namely the scope of the interventions, the dual drug/sex nature of HIV risk in the population, the asymmetry of sexual risk for men and women, and the potential benefits to nonIDUs.