LAUSR

BACKGROUND AND AIMS Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally-recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment. DESIGN 10-year horizon (2016-2025) modelling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand. SETTING Three Ukrainian cities: Kyiv, Mykolaiv and Lviv. PARTICIPANTS Simulated population of people at risk of and with OUD. MEASUREMENTS Incremental cost per quality-adjusted life year gained in the simulated population. FINDINGS An estimated 12.2-fold, 2.4-fold, and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv, and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per capita GDP per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e., the proportion of persons with OUD receiving OAT) over a 10-year modeling horizon would be 20%, 11%, and 17% in Kyiv, Mykolaiv, and Lviv, respectively, owing to limited demand. CONCLUSIONS It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally-recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.