{"version":"sf-sfaf-naloxone-cea-v1","reviewedAt":"2026-09-07","organization":"San Francisco AIDS Foundation","program":"Additional targeted overdose-prevention outreach and naloxone distribution","confidence":"very-low","modelType":"judgmental-local-output-transfer","amountSemantics":"modeled marginal donor expenditure, not a verified funding offer","denominator":"10 incremental quality-adjusted life years","reported":{"year":2025,"reversals":2852,"doses":41399,"trainings":10041},"plannedCostAnchor":{"year":2024,"annualBudgetUsd":250000,"annualTargetDoses":26016,"semantics":"proposed ongoing bundled budget and target outputs; not executed accounts or marginal rates"},"scenarios":[{"name":"Optimistic positive","costPerDose":10,"marginalYieldRetention":0.75,"additionalSurvivalPerReversal":0.05,"utility":0.8,"annualHazard":0.055,"horizonYears":20,"discountRate":0.03},{"name":"Central analyst estimate","costPerDose":20,"marginalYieldRetention":0.5,"additionalSurvivalPerReversal":0.02,"utility":0.7,"annualHazard":0.08,"horizonYears":15,"discountRate":0.03},{"name":"Pessimistic positive","costPerDose":40,"marginalYieldRetention":0.25,"additionalSurvivalPerReversal":0.005,"utility":0.6,"annualHazard":0.15,"horizonYears":10,"discountRate":0.03}],"judgments":[{"key":"costPerDose","label":"Donor cost per additional dose","basis":"$20 is approximately twice the $9.61 planned bundle/target-dose benchmark, rounded, allowing extra outreach effort and delivery shortfalls. This transfers across years and program scopes; it is not an SFAF quote."},{"key":"marginalYieldRetention","label":"Share of reported yield retained at the margin","basis":"50% is an aggregate judgment for harder-to-reach expansion, displacement, reporting/denominator mismatch and repeated recipients. These components are not separately measured; a person-linked model is needed to resolve repeat-rescue double counting."},{"key":"additionalSurvivalPerReversal","label":"Additional acute survival per retained reversal","basis":"2% credits one additional acute survivor per 50 retained reports. Most reported reversals are assumed not to be additional lives saved because spontaneous survival and alternative rescue are possible. Historical untreated-overdose model inputs provide plausibility, not a current local counterfactual."},{"key":"utility","label":"Health utility during survival","basis":"0.70 is an explicit downward transfer from a 2024 patient-data estimate of 0.799 for HIV-negative daily heroin injection, allowing comorbidity and current-population differences. It is not a judgment about a person's moral worth."},{"key":"annualHazard","label":"Annual all-cause mortality hazard","basis":"0.08 is informed by a US overdose-survivor cohort's 778.3 deaths per 10,000 person-years. Keeping this rate constant is an approximation, not an observed 15-year SF trajectory."},{"key":"horizonYears","label":"Credited survival horizon","basis":"15 years truncates benefits because current recipient ages and long-term outcomes are unknown. This is a judgment, not a life-expectancy estimate."},{"key":"discountRate","label":"Annual QALY discount","basis":"3% is an explicit model convention; applied as an effective annual discount rate."}],"formula":"10 * costPerDose / ((reportedReversals / distributedDoses) * marginalYieldRetention * additionalSurvivalPerReversal * qalysPerDeathPrevented)","survivalFormula":"utility * (1 - exp(-(annualHazard + log(1 + discountRate)) * horizonYears)) / (annualHazard + log(1 + discountRate))","nullBoundary":"If donations replace existing provision or no otherwise-fatal events are reached, additional QALYs are zero and there is no finite price. The positive scenarios are not confidence intervals and do not exclude null benefit.","fundingRoom":{"verifiedUsd":null,"status":"unverified","nextEvidence":"A current additional outreach plan, executed program costs, unmet coverage and recipient-linked rescue records; no contact with the organization has been made."},"excluded":["Nonfatal brain injury prevention","Benefits to families","Treatment-navigation health gains","Healthcare costs after rescue and future healthcare spending","Drug procurement supplied by existing public programs"],"sources":[{"publisher":"SF Health Commission","title":"Proposed SFAF agreement 1000037481 and subcontractors","url":"https://media.api.sf.gov/documents/SFAF_-_1000037481_-_HC_Memo_May_2026.cleaned.pdf","published":"2026-05-04","retrieved":"2026-09-07","sourceType":"Newer broad proposed public bundle includes naloxone and HYA/GLIDE/HRTC; no dose target or verified supersession crosswalk to historical cost anchor"},{"publisher":"SF Department of Public Health","title":"Naloxone guideline","url":"https://media.api.sf.gov/documents/Naloxone_Guideline.pdf","published":"2025-03-06","retrieved":"2026-09-07","sourceType":"Public supply pathways; continued expansion supply is not guaranteed"},{"publisher":"San Francisco AIDS Foundation","title":"Overdose prevention and response; 2025 service reporting","url":"https://www.sfaf.org/health-services/overdose-prevention-response/","published":"Undated page; 2025 reporting","retrieved":"2026-09-07","sourceType":"Organization-reported outputs and service identity"},{"publisher":"SF Health Commission","title":"Proposed SFAF agreement 1000032060","url":"https://www.sf.gov/sites/default/files/2024-05/HC%20Memo%20Memo%20-%20%20SFAF%2032060%20Final.pdf","published":"2024-06-04","retrieved":"2026-09-07","sourceType":"Proposed public budget and output targets; dates inconsistent within document"},{"publisher":"Olfson et al., JAMA Psychiatry","title":"Causes of Death After Nonfatal Opioid Overdose","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC6143082/","published":"2018","retrieved":"2026-09-07","sourceType":"Observational US cohort; transferred survival anchor"},{"publisher":"Weiner et al., Annals of Emergency Medicine","title":"One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose","url":"https://pubmed.ncbi.nlm.nih.gov/31229387/","published":"2020","retrieved":"2026-09-07","sourceType":"Observational Massachusetts cohort; survival triangulation"},{"publisher":"Patton et al., Quality of Life Research","title":"Analyzing quality of life among people with opioid use disorder from the NIDA Data Share initiative","url":"https://link.springer.com/article/10.1007/s11136-024-03729-6","published":"2024-08-08","retrieved":"2026-09-07","sourceType":"Patient-data utility mapping across six trials"},{"publisher":"Coffin and Sullivan, Annals of Internal Medicine","title":"Cost-effectiveness of distributing naloxone to heroin users","url":"https://www.prescribetoprevent.org/wp-content/uploads/Coffin_Cost-effectiveness-article.pdf","published":"2013","retrieved":"2026-09-07","sourceType":"Historical model; 2017 correction primary text remains unverified; not using kits/death output"},{"publisher":"Chhatwal et al., Lancet Regional Health Americas","title":"Cost-effectiveness of community-based interventions: HEALing Communities simulation","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC13146536/","published":"2026-04-30","retrieved":"2026-09-07","sourceType":"External microsimulation; existing provision limits modeled expansion"}],"evaluatedScenarios":[{"name":"Optimistic positive","costPerDose":10,"marginalYieldRetention":0.75,"additionalSurvivalPerReversal":0.05,"utility":0.8,"annualHazard":0.055,"horizonYears":20,"discountRate":0.03,"qalysPerDeathPrevented":7.717208191824503,"reportedYield":0.06889055291190609,"incrementalDeathsPreventedPerDose":0.0025833957341964784,"incrementalQalysPerDose":0.01993660272266554,"costPerQaly":501.5899719279249,"costPerTenQalys":5015.899719279249,"additionalDoses":10000,"additionalDeathsPrevented":25.833957341964783,"additionalQalys":199.3660272266554,"finitePrice":true},{"name":"Central analyst estimate","costPerDose":20,"marginalYieldRetention":0.5,"additionalSurvivalPerReversal":0.02,"utility":0.7,"annualHazard":0.08,"horizonYears":15,"discountRate":0.03,"qalysPerDeathPrevented":5.154058058915759,"reportedYield":0.06889055291190609,"incrementalDeathsPreventedPerDose":0.0006889055291190609,"incrementalQalysPerDose":0.0035506590941877213,"costPerQaly":5632.757037345307,"costPerTenQalys":56327.57037345307,"additionalDoses":5000,"additionalDeathsPrevented":3.4445276455953047,"additionalQalys":17.753295470938607,"finitePrice":true},{"name":"Pessimistic positive","costPerDose":40,"marginalYieldRetention":0.25,"additionalSurvivalPerReversal":0.005,"utility":0.6,"annualHazard":0.15,"horizonYears":10,"discountRate":0.03,"qalysPerDeathPrevented":2.7867312385446508,"reportedYield":0.06889055291190609,"incrementalDeathsPreventedPerDose":0.00008611319113988262,"incrementalQalysPerDose":0.00023997431980027733,"costPerQaly":166684.50204709684,"costPerTenQalys":1666845.0204709684,"additionalDoses":2500,"additionalDeathsPrevented":0.21528297784970654,"additionalQalys":0.5999357995006933,"finitePrice":true}]}