Cost-Effectiveness of Needle and Syringe Exchange for the Prevention of HIV in New York City

Shared needle and syringe use among injection drug users continues to be a major mode of transmission of HIV. Needle and syringe exchange (NSE) may be a viable strategy to reduce the transmission of the virus; yet the difficulty in measuring the actual efficacy of NSE has limited attempts to evaluate the cost-effectiveness of the intervention. Using data specific to the Lower East Side Harm Reduction Center in New York City, we assessed the cost-effectiveness of NSE over a range of conservative estimates of efficacy, obtained from both longitudinal and small-area studies. A decision-analysis model was created to compare the outcomes and costs associated with NSE. Model inputs included the cost of living with HIV and the seroprevalence of HIV among injection drug users in New York City. This analysis was conducted from both the government and societal perspectives. Tested over a range of conservative parameter estimates, NSE appears to save money and lives. The NSE program we evaluated cost $502 per client and produced a gain of 0.01 quality adjusted life years per client. It also reduced HIV treatment costs by$325,000 per case of HIV averted, and averted 4–7 HIV infections per 1000 clients, producing a net cost savings

Strategies used for the COVID-OUT decentralized trial of outpatient treatment of SARS-CoV-2

The COVID-19 pandemic accelerated the development of decentralized clinical trials (DCT). DCT’s are an important and pragmatic method for assessing health outcomes yet comprise only a minority of clinical trials, and few published methodologies exist. In this report, we detail the operational components of COVID-OUT, a decentralized, multicenter, quadruple-blinded, randomized trial that rapidly delivered study drugs nation-wide. The trial examined three medications (metformin, ivermectin, and fluvoxamine) as outpatient treatment of SARS-CoV-2 for their effectiveness in preventing severe or long COVID-19. Decentralized strategies included HIPAA-compliant electronic screening and consenting, prepacking investigational product to accelerate delivery after randomization, and remotely confirming participant-reported outcomes. Of the 1417 individuals with the intention-to-treat sample, the remote nature of the study caused an additional 94 participants to not take any doses of study drug. Therefore, 1323 participants were in the modified intention-to-treat sample, which was the a priori primary study sample. Only 1.4% of participants were lost to follow-up. Decentralized strategies facilitated the successful completion of the COVID-OUT trial without any in-person contact by expediting intervention delivery, expanding trial access geographically, limiting contagion exposure, and making it easy for participants to complete follow-up visits. Remotely completed consent and follow-up facilitated enrollment