Monday, February 15, 2016

Is Increased HCV Case-Finding Combined with Current or 8-12 Week DAA Therapy Cost-Effective in UK Prisons? A Prevention Benefit Analysis

Prisoners have a high prevalence of Hepatitis C virus (HCV), but case-finding may not have been cost-effective because treatment often exceeded average prison stay combined with a lack of continuity-of-care. We assess the cost-effectiveness of increased HCV case-finding and treatment in UK prisons using short-course therapies.

A dynamic HCV transmission model assesses the cost-effectiveness of doubling HCV case-finding (achieved through introducing opt-out HCV testing in UK pilot prisons) and increasing treatment in UK prisons, compared to status-quo voluntary risk-based testing (6% prison entrants/year), using currently recommended therapies(8-24 weeks) or IFN-free DAAs(8-12 weeks, 95% SVR, £3300/wk). Costs(GBP£) and health utilities(quality-adjusted life-years,QALYs) were used to calculate mean incremental cost-effectiveness ratios(ICERs). We assume 56% referral and 2.5%/25% of referred people who inject drugs(PWID)/exPWID treated within 2 months of diagnosis in prison. PWID and ex/nonPWID are in prison an average 4/8 months, respectively.

Doubling prison testing rates with existing treatments produces a mean ICER of £19,850/QALY gained compared to current testing/treatment, and is 45% likely to be cost-effective under a £20,000 willingness-to-pay(WTP) threshold. Switching to 8-12 week IFN-free DAAs in prisons could increase cost-effectiveness(ICER £15,090/QALY gained). Excluding prevention benefit decreases cost-effectiveness. If >10% referred PWID are treated in prison (2.5% base-case), either treatment could be highly cost-effective(ICER<£13,000). HCV case-finding and IFN-free DAAs could be highly cost-effective if DAA cost is 10% lower or 8 weeks duration. Conclusions Increased HCV testing in UK prisons (such as through opt-out testing) is borderline cost-effective compared to status-quo voluntary risk-based testing under a £20,000 WTP with current treatments, but likely to be cost-effective if short-course IFN-free DAAs are used, and could be highly cost-effective if PWID treatment rates were increased.

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  • 1Division of Global Public Health, University of California San Diego, USA.
  • 2School of Social and Community Medicine, University of Bristol, UK.
  • 3Leeds Community Healthcare NHS Trust, UK.
  • 4London School of Hygiene and Tropical Medicine, UK.
  • 5University of Nottingham, UK.
  • 6County Durham and Darlington NHS Trust, UK.
  • 7Glasgow Caledonian University, UK.
  • 8Public Health England, UK. 
  •  2016 Feb 10. doi: 10.1002/hep.28497.

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