Research
Open Access

Cost–benefit analysis of Canada’s Prison Needle Exchange Program for the prevention of hepatitis C and injection-related infections

Farah Houdroge, Nadine Kronfli, Mark Stoové and Nick Scott
CMAJ December 16, 2024 196 (43) E1401-E1412; DOI: https://doi.org/10.1503/cmaj.240648

Abstract

Background: Needle exchange programs are effective public health interventions that reduce blood-borne infections, including hepatitis C, and injection-related infections. We sought to assess the return on investment of existing Prison Needle Exchange Programs (PNEPs) in Canadian federal prisons and their expansion to all 43 institutions.

Methods: We developed a stochastic compartmental model that estimated hepatitis C and injection-related infections under different PNEP scenarios in Canadian federal prisons. Scenarios projected for 2018–2030 were no PNEP, status quo (actual PNEP implementation 2018–2022, with coverage maintained to 2030), and PNEP scale-up (coverage among people who inject drugs in prison increasing over 2025–2030 to reach 50% by 2030). We calculated the benefit–cost ratio as benefits from health care savings, divided by PNEP costs.

Results: By 2019, PNEPs were implemented in 9 of 43 federal prisons, with uptake reaching 10% of people who injected drugs in prison in 2022. Compared with no PNEP, this was estimated to cost Can$0.45 (uncertainty interval [UI] $0.32 to $0.98) million and avert 37 (UI 25 to 52) hepatitis C and 8 (UI −1 to 16) injection-related infections over 2018–2030, with a benefit–cost ratio of 1.9 (UI 0.56–3.0). Compared with the status quo, the PNEP scale-up scenario cost an additional $2.7 (UI $1.8 to $7.0) million and prevented 224 (UI 218 to 231) hepatitis C and 77 (UI 74 to 80) injection-related infections, with a benefit–cost ratio of 2.0 (UI 0.57 to 3.3).

Interpretation: Every dollar invested in the current PNEP or its expansion is estimated to save $2 in hepatitis C and injection-related infection treatment costs. This return on investment strongly supports ongoing maintenance and scale-up of the PNEP in Canada from an economic perspective.

See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.241661

The World Health Organization’s Global Health Sector Strategies for 2022–2030 includes 2030 hepatitis C elimination _targets of reducing new infections to fewer than 2 per 100 people who inject drugs per year, and distributing 300 needles and syringes per person who injects drugs per year.1 These _targets are specific to community settings, but to achieve elimination, a combination of high-coverage hepatitis C treatment and harm reduction services in prisons is essential,2–6 given high rates of incarceration of people who inject drugs,2,7 high prevalence of hepatitis C,8 and continued injecting drug use9 and associated injecting-risk behaviours in prison.10

Needle exchange programs are evidence-based strategies that prevent transmission of blood-borne viruses, reduce injection-related infections, improve access to medical care, and facilitate entry into substance dependence programs for people who inject drugs.11–13 Endorsed by international agencies like the World Health Organization and the United Nations,13 Prison Needle Exchange Programs (PNEPs) are recognized as 1 of the 25 essential elements of effectively preventing transmission of blood-borne viruses in prisons.14 Yet, as of 2023, only 9 countries provided a PNEP in at least 1 of their prisons,15 Canada being 1 of them. People held in federal and provincial or territorial prisons in Canada are differentiated by sentence duration, with federal prisons housing people sentenced for 2 or more years.16–20 In 2018, Correctional Service Canada launched its PNEP.21 However, coverage has been limited by suboptimal implementation.22 In 2024, the Government of Canada unveiled its 2024–2030 Sexually Transmitted and Blood-Borne Infection Action Plan, emphasizing support for harm reduction programs, including the expansion of the PNEP.23

While PNEP has not yet achieved its full potential, there remains a gap in our understanding of the health care benefits and potential cost-savings associated with the federal PNEP in Canada. Previous mathematical models have estimated the effectiveness and cost-effectiveness of community needle exchange programs in Canada,24–26 but the cost–benefit of the PNEP has never been assessed. We aimed to assess the return on investment of the existing PNEP in Canada, and of its potential expansion to all federal prisons for the period 2018–2030.

Methods

Design

We conducted a cost–benefit analysis comparing the cost of the intervention (PNEP) to the benefits from hepatitis C and injection-related infection treatment costs avoided. Rather than conducting a cost–utility analysis, we followed the Reference Case outlined in the Guidelines for the Economic Evaluation of Health Technologies: Canada,27 which allows for flexibility to undertake nonreference case analyses when justified. Cost–benefit analysis offers a clearer way to communicate the magnitude of costs saved by the PNEP intervention, particularly given ongoing debates regarding the health utility derived from curing mild hepatitis C,28 and uncertain health utilities associated with injection-related infections among people who inject drugs.

Perspective

We estimated costs and benefits from a publicly funded health care payer perspective.

_target population and intervention

The intervention is the Correctional Service Canada PNEP, with a _target population of people in Canadian federal prisons who inject drugs while incarcerated. The PNEP was launched in 2018 in 2 federal prisons. By 2019, 9 prisons had operational PNEPs.22 By mid-June 2022, an estimated 10% of people who inject drugs in prison in these 9 prisons were using the PNEP.

The PNEP is administered by prison health care workers. All new prison entrants undergo an intake assessment with a registered nurse, during which the PNEP is offered as a harm reduction measure. Those interested submit an application at any point during their sentence and complete a threat risk assessment, where risks and benefits of participation are weighed, and the warden makes a decision on PNEP access after input from the security intelligence officer and assistant warden of operations. Once approved, participants sign a contract and receive their first kit (1 syringe and needle, a mixing cup, cotton filters, vitamin C, and sterile water). Kits are exchanged at Health Services on a 1-to-1 basis. A comprehensive description of Canada’s current PNEP is provided in Figure 1 and in Appendix 1, Section A, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.240648/tab-related-content.

Figure 1:
Figure 1:

Schematic of the Prison Needle Exchange Program (PNEP) enrolment and participation process in Canadian federal prisons. A detailed description of the service delivery model can be found in Appendix 1, Section A, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.240648/tab-related-content.

Overview of mathematical model

We developed a stochastic compartmental model to capture dynamic hepatitis C transmission and injection-related infections across the entire incarcerated population in Canadian federal prisons. The model classifies people in prison according to injecting drug use status while in prison (yes or no) and chronic hepatitis C status (susceptible or infected). People can enter or exit the model through incarceration or release, and can become chronically infected with hepatitis C, receive hepatitis C treatment, or develop an injection-related infection (Figure 2). We chose the stochastic implementation to manage the influence of random processes on small compartment sizes, with integer numbers of people transitioning between compartments at each time step drawn from binomial probability distributions. We calibrated the model to demographic and epidemiologic data; Appendix 1, Section B contains a detailed description of the model, model parameters, calibration details, and convergence checks.

Figure 2:
Figure 2:

Schematic representation of the compartmental model for a Prison Needle Exchange Program (PNEP). The yearly number of people sentenced to full-time custody in Canadian federal prisons determines the number of prison entrants into the model, and individuals are instantly classified according to their injecting drug use behaviour in prison (injecting v. noninjecting) and hepatitis C RNA status (positive v. negative and susceptible) (blue arrows). Transitions are described as probabilities of becoming infected with hepatitis C (black downward arrow), receiving treatment for hepatitis C (black upward arrows), or experiencing an injection-related infection (black curved arrows). People exit the model according to a calibrated average sentence length (dashed arrows). The PNEP intervention acts by reducing the probabilities of experiencing an injection-related infection or acquiring hepatitis C among people who inject drugs in prison (red arrows). A detailed description of the model can be found in Appendix 1, Section B, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.240648/tab-related-content.

Intervention effects

In the model, the PNEP is assumed to reduce hepatitis C transmission and hospital admissions owing to injection-related infections, with impact increasing with higher PNEP coverage. Participants in PNEP were assumed not to share their needle or syringe for the periods when they accessed the program (and hence their risk of acquiring hepatitis C was 0), whereas their risk of hospital admission owing to an injection-related infection is reduced but not eliminated.29 We explore the impact of alternate assumptions in Appendix 1, Section C.

We excluded the impact of the PNEP on HIV transmission given the low HIV prevalence among incarcerated people in Canadian federal prisons (< 1% in 2020) and because the majority of people living with HIV are on treatment and virally suppressed before incarceration.22 We also excluded needlestick injuries as there was no evidence showing that these injuries have increased in prisons where PNEP was implemented.21,30

Demographic and epidemiologic parameters

We sourced prison population data from Statistics Canada,31,32 and derived chronic hepatitis C prevalence among prison entrants with a history of injecting drug use — assumed to be the same as community prevalence among people who inject drugs — from Canadian modelling studies and surveys.33,34 We projected that future hepatitis C prevalence in the community would remain stable, as it is not clear whether the declining trend will continue, but this assumption is tested in sensitivity analyses. For the prison environment, we estimated data on chronic hepatitis C prevalence, hepatitis C incidence, and hepatitis C treatment numbers from Correctional Service Canada data.22,35–37 We took data on injecting drug use continuation after incarceration or initiation during imprisonment, as well as the incidence of hospital admissions owing to injection-related infections among those who engage in injecting drug use, from recent cohort studies on drug use patterns in Australian prisons, as no such data exist for Canada.10,38–40 Demographic, epidemiologic, and behavioural data and sources used in the model are detailed in Table 1, with additional information in Appendix 1, Section B.

View this table:
Table 1:

Population and epidemiologic data for the Prison Needle Exchange Program model in Canada

Scenarios and comparators

We projected the following scenarios over 2018–2030 to estimate new hepatitis C infections and injection-related infections:

  1. Counterfactual: Without the PNEP

  2. Status quo: Current estimated PNEP coverage in 9 prisons initiated in 2018/19, with a linear increase in participation from 0% in 2018 to 10% in 2022 and future coverage remaining constant at 10% from 2022 to 2030

  3. Scale-up: PNEP expanded to the remaining 34 federal prisons between 2025 and 2027, with coverage among people who inject drugs in prison increasing linearly from 10% in 2025 to 50% by 2030. We conducted analyses comparing the status quo to the counterfactual, and the scale-up to the status quo.

Costs

We calculated economic costs of the PNEP using an ingredients-based approach, including start-up costs per prison, enrolment cost per participant, costs per kit exchanged, and annual operational costs.

Because the Canadian PNEP is integrated within the existing health care services infrastructure, this analysis considered only costs additional to existing practice. Start-up costs included a 1-time 1-hour PNEP education session for all nurses and correctional officers. We factored in a 15.5% staff turnover rate, based on the 2023 Canadian Turnover Survey,41 to accommodate annual training needs of new personnel. One-off costs per participant New prison entrant included staff time for the enrolment process, the application process, and other administrative tasks. Costs per unit dispensed included staff time to order, assemble, and exchange the kit; the contents of the kit; and sharps containers. Annual operational costs included shipping costs of PNEP supplies and twice-daily security checks by correctional officers. We identified operational tasks primarily from publicly available information or expert opinion. Inputs of the costing analysis are provided in Table 2 and Table 3, with their uncertainties and sources.

View this table:
Table 2:

Cost components for Canada’s Prison Needle Exchange Program

View this table:
Table 3:

Health care costs associated with managing hepatitis C infections and injection-related infections*

Benefits

We calculated benefits as costs saved from averting hepatitis C and injection-related infections. We assigned a diagnosis and treatment cost to hepatitis C infections. We took hepatitis C diagnosis costs from the schedule of benefits for laboratory services in 2023 and from recent studies estimating the cost-effectiveness of hepatitis C testing in Canada,54,56,57 and obtained hepatitis C treatment costs from the Ontario Drug Benefit Formulary and the Régie de l’assurance maladie du Québec.58,59 We assumed that treatment costs in prison were one-third of those in the community, owing to the purchasing power of Correctional Service Canada. We did not include hepatitis C–related complications (e.g., cirrhosis, hepatocellular carcinoma) in this analysis, meaning benefits are likely to be underestimated. The cost of managing an injection-related infection in a tertiary care hospital was based on a study that identified a median hospital stay cost of $12 351 related to infectious complications of injecting drug use in Regina, Saskatchewan, in 2018 (equivalent to about $14 545 in 2023).55

Currency and discounting

We used the Statistics Canada Consumer Price Index for health care60 to inflate prices to 2023 Canadian dollars and discounted future costs at 1.5% per annum.27

Time horizon

We included the costs for those initiating or using the PNEP in the 2018–2030 (inclusive) intervention period. We included benefits from injection-related infections averted if they occurred during the 2018–2030 intervention window, and included benefits of hepatitis C diagnosis and treatment averted if the hepatitis C infection was prevented in the 2018–2030 intervention window.

Measurement of outcomes and uncertainty

We calculated point estimates and 95% uncertainty intervals (UIs) for cumulative hepatitis C and injection-related infections for each scenario as the median and 2.5–97.5 percentiles from 500 stochastic model runs. We estimated the numbers of infections averted between the status quo compared with the counterfactual, and the scale-up compared with the status quo, by applying a bootstrap algorithm with 1000 repetitions, using resampling with replacement, to the differences obtained from pairwise-subtracted outcomes of each simulation run.

We calculated total costs and benefits by applying point estimate costs to each simulation’s results, with benefit–cost ratios calculated as total benefits divided by total costs. We generated UIs for costs, benefits, and benefit–cost ratios using bootstrapping.

Sensitivity analyses

We explored a range of plausible parameter values to examine their effect on the benefit–cost ratios, including halving or doubling various implementation parameters, using lower and upper bound epidemiologic and costing parameters, and varying assumptions about PNEP effectiveness. We performed recalibration where required.

Ethics approval

This study used only publicly available, de-identified data and did not involve human participants, animal subjects, or personal data requiring ethics approval.

Results

Figure 3 and Table 4 show the projected outcomes in the modelled scenarios.

Figure 3:
Figure 3:

Scenario outcomes. (A, B): Status quo (blue) and counterfactual (orange). (C, D): Status quo (blue) and scale-up (red). The lines are annual medians from 500 sampled model trajectories, and the shaded areas represent the range of values from the runs. (A) and (C): Incidence of injection-related infections per 100 people who inject drugs in prison per year. (B) and (D): Hepatitis C incidence per 100 people who inject drugs in prison per year.

View this table:
Table 4:

Summary of key scenario outcomes 2018–2030*

Status quo versus counterfactual

From 2018 to 2030, the counterfactual scenario resulted in 1552 (UI 996 to 2177) new hepatitis C infections and 930 (UI 543 to 1390) injection-related infections. We estimated that the status quo PNEP scenario averted 37 (UI 25 to 52) hepatitis C infections and 8 (UI −1 to 16) injection-related infections, compared with the counterfactual scenario.

We estimated that the status quo PNEP scenario cost $0.45 (UI $0.32 to $0.98) million and saved $0.85 (UI $0.32 to $1.40) million in costs for hepatitis C treatment and injection-related infection care, with a benefit–cost ratio of 1.9 (UI 0.6 to 3.0). Start-up costs and annual operational expenses accounted for 31% and 26% of the total cost, respectively; costs related to kit distribution accounted for 39% of total costs; and 88% of savings were attributed to averted costs for hepatitis C treatment (Figure 4).

Figure 4:
Figure 4:

Incremental costs and associated health care savings (2023 Canadian dollars): status quo versus counterfactual and Prison Needle Exchange Program scale-up versus status quo, 2018–2030. The left-hand bar shows the cost breakdown, including one-off, per unit, annual start-up and operational costs. The right-hand bar shows the health care savings associated with reduced hepatitis C transmission and incidence of injection-related infection. Note that the scale-up scenario and status quo are the same up to the year 2024, so the graph represents differences across the years 2025–2030. Thin vertical bars represent 95% uncertainty intervals for total costs and benefits.

Scale-up versus status quo

From 2018 to 2030, the scale-up scenario resulted in 1286 (UI 787 to 1838) new hepatitis C infections and 844 (UI 471 to 1281) injection-related infections. We estimated that the scale-up scenario averted 224 (UI 218 to 231) hepatitis C infections and 77 (UI 74 to 80) injection-related infections compared with the status quo, and reduced hepatitis C incidence from 3.0 (UI 1.7 to 4.6) to 2.1 (UI 1.1 to 3.4) per 100 people who inject drugs in prison per year.

We estimated that the PNEP scale-up scenario cost $2.7 (UI $1.8 to $7.0) million more than the status quo and offset $5.4 (UI $2.1 to $8.7) million in associated health care costs, with a benefit–cost ratio of 2.0 (UI 0.6 to 3.3). Of the total cost, PNEP kit distribution activities accounted for 52% and annual operational expenses for 29%, whereas 81% of the benefits stemmed from averted hepatitis C treatment costs (Figure 4).

Sensitivity analyses

The benefit–cost ratio was greater than 1 for all scenarios tested except for a few “worst-case” scenarios in which the PNEP was no longer cost-saving, including when initial hepatitis C incidence or prevalence estimates were half of what the data suggested, the cost of hepatitis C treatment was reduced by about 66%, the declining trend in hepatitis C prevalence in the community continued, hepatitis C treatment uptake was doubled, the proportion of people in prison with a history of injecting drug use was halved, or if the program covered only low-risk injecting events (Appendix 1, Section D). The benefit–cost ratio of the scale-up scenario was most sensitive to the baseline hepatitis C incidence among people who inject drugs in prison (Figure 5). Other parameters — such as the average sentence length, proportion of people in prison with a history of injecting drug use, and kit costs and exchange frequency — also significantly influenced the benefit–cost ratio.

Figure 5:
Figure 5:

Tornado chart illustrating the parameters that were most influential on the benefit–cost ratio. The point estimate refers to the benefit–cost ratio of the scale-up scenario compared with the status quo. The blue and red bars indicate the lower and upper bounds of the parameters, respectively. The $21 163 baseline hepatitis C treatment cost is the weighted average of the $20 000 cost in prison and $60 000 in community (Table 3), as some prison-acquired infections are treated after release (Appendix 1, Section B, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.240648/tab-related-content). Additional sensitivity analyses are provided in Appendix 1, Section D. Note: IDU = injecting drug use.

Interpretation

We estimated that every dollar spent on the current implementation or further scale-up of the PNEP across all federal prisons could save $2 in reduced costs for infection treatment. Sensitivity analyses suggested that greater economic benefits could be achieved in settings with high hepatitis C incidence, longer sentence lengths, or higher incarceration rates of people with a history of injecting drug use. This return on investment strongly supports ongoing maintenance and scale-up of the PNEP in Canada, from an economic perspective.

We estimated that expanding PNEP coverage to reach 50% of people who inject drugs in prison in all federal prisons from 2025 to 2030 would prevent an additional 15% of new hepatitis C and 8% of injection-related infections compared with the status quo. Although more than 80% of the projected benefits were attributed to averted hepatitis C infections, severe complications from injection-related infections still contribute a considerable burden to the health care system. Therefore, whereas PNEP advocacy has traditionally focused on its effectiveness in preventing transmission of blood-borne viruses, its role in reducing the incidence of injection-related infection remains important.

The estimated impact of PNEPs was in addition to the impact of community and prison hepatitis C treatment scale-up in Canada. The model calibration shows a significant reduction in hepatitis C prevalence in prison from about 15% in 2015 to about 5% in 2018, owing to the introduction of direct-acting antiviral drugs. However, as has been observed globally, high reinfection rates occurring in jurisdictions with no PNEPs and limited access to other prevention measures in carceral settings undermine the benefits accrued from community and prison treatment of hepatitis C.61–63 Modelling studies have consistently shown that combining hepatitis C treatment with prevention measures such as needle exchange programs is essential for reducing hepatitis C prevalence and incidence among people who inject drugs in the community64 and in prison.3 Preventive measures therefore remain an essential component for hepatitis C elimination and should be prominent constituents of national and global hepatitis C elimination strategies.

The implementation of PNEPs in Canadian federal prisons, while integrated into the existing health care infrastructure, involves a more administratively burdensome process than some European and Central Asian models. In fact, the Canadian approach is unique, with advocacy efforts under way to simplify the application process and improve confidentiality and privacy concerns of participants.65,66 Globally, PNEP delivery varies, with models involving peer workers, nongovernmental organizations, and dispensing machines that often have a lower administrative burden and could offer lessons on more efficient implementation. Given that 49% of costs in the scale-up model were allocated to kit distribution, differences in cost and effectiveness across current and alternate PNEP models should be explored in Canada, and more broadly elsewhere, to inform and optimize PNEP implementation. It is also unclear what demand generation, destigmatization, policy, or privacy-related changes would be required to increase PNEP coverage in practice; however, these results suggest that up to $2.7 million could be spent across 2025–2030 on these activities to scale PNEP coverage up to 50%, and the PNEP would remain cost-saving.

Limitations

Our study has several limitations. First, we applied consistent model parameters and intervention implementation across all prisons irrespective of location or security level, which may not represent real-world variations. We also conducted this analysis using data from federal prisons, where people serve longer sentences than in provincial prisons; however, sensitivity analyses determined that the benefit–cost ratio remained higher than 1 even when average sentence length was halved.

Second, the incidence of hospital admissions owing to injection-related infections in prisons and information on drug use initiation or continuation during imprisonment relied on data from Australian cohort studies, as Canadian data were not available.

Third, limited data existed on the cost of treating injection-related infections, and therefore we derived our estimate from a single study in Saskatchewan, which may not be generalizable across Canada.

Fourth, our assumption that PNEPs eliminate the risk of acquiring hepatitis C may not fully capture the complexities of needle-sharing behaviours in prisons.

Fifth, as we used a compartmental model, individuals and adherence are not explicitly captured; rather, the model records only the number of people accessing the service at any point in time.

Sixth, by focusing solely on people within prisons, model outcomes do not fully reflect broader population dynamics of hepatitis C transmission, including among people transitioning between community and carceral settings, the effect of reincarceration on hepatitis C transmission, and onward transmissions averted.

Seventh, we may have underestimated the full benefits associated with PNEPs by capturing only hepatitis C and injection-related infections (i.e., excluding potential reductions in transmission of other blood-borne viruses, such as HIV and hepatitis B virus, or overdose events), and also because we considered only specific cost benefits for hepatitis C related to diagnosis and direct-acting antiviral treatment avoided. Given the scale-up of hepatitis C treatment in the community in Canada since 2016, it is unclear whether people who leave prison having acquired hepatitis C would remain untreated for the time it takes to develop severe disease outcomes, and by excluding the costs of long-term morbidity associated with untreated hepatitis C infections, we produce conservative estimates for the PNEP. The analysis also does not include mortality, but given that mortality rates in federal prison are low relative to the population size and time horizon being modelled,67 and that mortality would apply equally to all scenarios, this is unlikely to affect our estimates of the benefit–cost ratio.

Eighth, the cost–benefit analysis study design is a non–Reference Case analysis within the Guidelines for the Economic Evaluation of Health Technologies: Canada,27 compared with the cost–utility Reference Case. We selected the cost–benefit study design as a simpler way to communicate the magnitude of the costs saved by the PNEP intervention.

Ninth, we derived the uncertainty bounds from probabilistic or stochastic effects over multiple simulations using point estimate parameters, resulting in wide confidence intervals owing to the small numbers of infections in some simulations. We also conducted univariate sensitivity analyses on all model parameters to understand how they influence results, but combined uncertainty from all parameters may mean that confidence intervals are underestimated.

Conclusion

Every dollar invested in the current PNEP or its expansion is estimated to save $2 in costs for treating hepatitis C and injection-related infections. This study adds to the growing body of evidence supporting PNEPs as effective harm reduction strategies that are also cost saving. Given that they show both health and economic benefits, PNEPs should be a priority not just in Canada, but globally.

Acknowledgement

The authors thank all people who informally contributed their knowledge of Canada’s Prison Needle Exchange Program.

Footnotes

  • ↵* These authors contributed equally to this article.

  • Competing interests: Nadine Kronfli reports receiving research funding from the Canadian Institutes of Health and HIV/AIDS Research Initiative (grant numbers 190374 and 185725); Dr. Kronfli is also supported by a career award from the Fonds de Recherche Québec — Santé (FRQ-S; Junior 2). Mark Stoové reports receiving a Viiv Healthcare Medical Education Grant. No other competing interests were declared.

  • This article has been peer reviewed.

  • Contributors: All of the authors contributed to the conception and design of the work, and the acquisition, analysis, and interpretation of data. Farah Houdroge drafted the manuscript. All of the authors revised it critically for important intellectual content, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work.

  • Funding: The present manuscript was supported by the National Health and Medical Research Council of Australia (grant number GNT2009408, untied research funding paid to Burnet Institute, with Nick Scott as grant holder). Funders had no role in study design or the decision to publish.

  • Data sharing: All data used in this study are publicly available from the sources listed in the manuscript (Tables 1, 2, and 3).

  • Accepted November 15, 2024.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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Vol. 196, Issue 43
16 Dec 2024

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Cost–benefit analysis of Canada’s Prison Needle Exchange Program for the prevention of hepatitis C and injection-related infections
Farah Houdroge, Nadine Kronfli, Mark Stoové, Nick Scott
CMAJ Dec 2024, 196 (43) E1401-E1412; DOI: 10.1503/cmaj.240648
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