The HIV epidemic in Russia grew catastrophically in the last decade, primarily because of injection drug use. Approximately 1 million people in Russia are now estimated to have HIV infection. Currently, few people are treated with highly active antiretroviral therapy (HAART), and virtually no injection drug users (IDUs) are offered HAART. Our study evaluated the cost-effectiveness of providing HAART to HIV-infected IDUs and non-IDUs in Russia.

We developed a dynamic compartmental epidemic model that subdivides the population based on injecting behavior, HIV and treatment status, and stage of the HIV infection. We evaluated the cost-effectiveness of HAART for IDUs in a population demographically similar to St. Petersburg, Russia. We considered a population of 2.5 million individuals aged 15 to 49 in which 4% of the population is an IDU, and HIV prevalence among IDUs and non-IDUs is 40% and 0.7%, respectively. We estimated the annual cost of HAART to be $1,700; we added $500 to account for ancillary services that would be required to successfully administer therapy for IDUs. We measured all health care costs and quality-adjusted life years (QALYs) experienced in the population over a 20-year time horizon, discounted at 3% annually.

The most effective and expensive strategy is to provide HAART to all people with HIV; this strategy prevented 206,000 HIV infections, and added 74 million QALYs at a cost of $1,100 per QALY gained, relative to current practice. For selective strategies, providing HAART only to IDUs prevented 71,100 more infections than treating non-IDUs and strictly dominated providing HAART to non-IDUs exclusively. Treating IDUs exclusively cost $900 per QALY gained relative to current practice. A more realistic strategy of providing HAART equally to 50% of each group cost $10,200 per QALY gained relative to selectively treating all IDUs, but only $1,300 per QALY gained relative to current practice.

Because of their disproportionate contribution to HIV transmission, provision of HAART to IDUs provides greater total benefit at less total cost than does exclusive treatment of HIV-infected non-IDUs in Russia. Treatment of both groups relative to current practice is very cost-effective by World Health Organization guidelines. Our findings highlight the urgency of initiating treatment for both IDUs and non-IDUs in Russia.