Hepatitis C disease transmission and treatment uptake: impact on the cost-effectiveness of new direct-acting antiviral therapies

Factors associated with perceived ease of access to syringes in Appalachian North Carolina

PURPOSE

To examine associations between perceived ease of syringe access, syringe sources, injection behaviors, and law enforcement (LE) interactions among people who inject drugs (PWID) in rural Appalachian North Carolina (NC).

METHODS

Using respondent-driven sampling, a diverse sample of 309 self-reported PWID were recruited from rural Appalachian NC. Data were collected via audio computer-assisted self-interview technology from February 2019 through March 2020. Respondents reported demographics, sources of syringes, LE interactions, and injection behaviors. Univariate, bivariate, and linear regression analyses were performed.

FINDINGS

Respondents most often obtained syringes from pharmacies and syringe service programs (SSPs). Twenty-one percent disagreed that it was easy to obtain sterile syringes, with 28% reporting low or no access to an SSP. PWID who reported longer physical distances to an SSP had greater difficulty accessing syringes (P<.001). PWID who reported greater ease of access to syringes reported engaging in receptive syringe sharing less often (P<.01). PWID who were stopped and searched by LE more often reported injecting drugs somebody else prepared with nonsterile supplies more often (P<.01). Participants shared used injection supplies more than twice as often than they shared used syringes.

CONCLUSIONS

These results underscore the importance of SSPs to mitigate the spread of human immunodeficiency virus and viral hepatitis in rural areas. Supporting mobile SSP services in rural areas could increase access to sterile syringes and injection supplies. SSPs should educate PWID about the importance of not sharing injection supplies. Pharmacies could increase syringe access in areas where SSPs do not operate.

Cost Effectiveness of Screening for Hepatitis C Virus in Iraq in the Era of Simplified Testing and Treatment

BACKGROUND AND OBJECTIVE

Recent advances in hepatitis C virus (HCV) diagnostic testing methods allow for a one-stop simplified 'test and cure' approach. The cost effectiveness of incorporating this simplified approach into HCV screening in Iraq remains uncertain. This study aimed to compare the cost effectiveness of different HCV testing and diagnostic approaches, and screening strategies in Iraq from a health service perspective.

METHODS

A cost-effectiveness analysis was undertaken using a hybrid model comprising a screening decision tree linked to a lifetime Markov model to estimate outcomes in HCV-infected people. Cost and utility estimates were sourced from the published literature and expert guidance provided by clinicians and policy makers in Iraq. Cost estimates were reported in 2019 USD or 2019 Iraqi Dinar and both costs and benefits were discounted at 3.5% annually.

RESULTS

Strategies using a simplified approach were found to be cost saving in addition to improving patient outcomes when compared with a standard testing and diagnostic approach. When considering risk-based screening, a simplified approach was associated with a total cost saving of Iraqi Dinar 4375 billion (USD 3.7 billion) and per patient life-year and quality-adjusted life-year gains of 0.30 and 0.55, compared with a standard approach. Benefits and cost savings were driven by a 32.2% and 23.6% reduction in the incidence of cirrhosis and hepatocellular carcinoma, respectively. Estimated benefits and cost savings increased under total population screening. All screening and testing and diagnostic approaches were cost effective compared with a no screening scenario.

CONCLUSIONS

Improvements in the detection of HCV combined with a simplified one-stop testing and diagnostic approach represents an opportunity to reduce the burden of HCV in Iraq and may play a significant role in meeting World Health Organisation HCV elimination targets.

Systematic Review of Health State Utility Values Used in European Pharmacoeconomic Evaluations for Chronic Hepatitis C: Impact on Cost-Effectiveness Results

BACKGROUND

Health state utility values (HSUVs) identified from utility elicitation studies are widely used in pharmacoeconomic evaluations for chronic hepatitis C (CHC) and are particularly instrumental in health technology assessment (HTA) evaluations such as those from the National Institute for Health and Care Excellence (NICE).

OBJECTIVE

The aim of this study was to identify HSUVs used in cost-utility analyses (CUAs) for CHC in Europe and to evaluate the impact of HSUV selection on cost-effectiveness results in terms of the incremental cost per quality-adjusted life-year (QALY) gained (ICER).

METHODS

A systematic search of pharmacoeconomic evaluations for CHC was updated in the MEDLINE and EMBASE databases for the periods 2012-2017 and 2017-2020. Data on health states, HSUVs, and utility elicitation studies were extracted. The difference in HSUVs of the same health state in different CUAs, and the difference between HSUVs of one health state and of the interlink health state in the same CUAs, were calculated. A quality assessment was performed to evaluate the selection of HSUVs in CUAs. Sets of HSUVs identified were used in a reconstructed CUA model to assess the impact on the ICER.

RESULTS

Twenty-six CUAs conducted in European countries and referring to 17 utility elicitation studies were included. The difference in HSUVs of the same health state in different CUAs ranged from 0.021 (liver transplant) to 0.468 (decompensated cirrhosis). The difference between HSUVs of one health state and of the interlink health state of the next disease severity level was calculated between the health states of F0-F1/mild and F2-F3/moderate (n = 11, 0.040-0.110), F2-F3/moderate and F4/compensated cirrhosis (n = 18, 0.027-0.130), compensated cirrhosis and decompensated cirrhosis (n = 22, 0.020-0.100), decompensated cirrhosis and hepatocellular carcinoma (n = 24, 0.000-0.200), hepatocellular carcinoma and liver transplant in the first year (n = 17, - 0.329 to 0.170) and liver transplant in the first and subsequent years (n = 17, - 0.340 to 0.000). The utility elicitation study selected by most CUAs (n = 11) was recommended as the source of HSUVs, at least for the CUAs conducted in the UK, based on the results of quality assessment. Seven sets of HSUVs were generated to fit the reconstructed model and changed the results of the incremental analysis from being cost effective to not being cost effective (ICER ranging from £2460 to £24,954 per QALY gained), and to being dominated in the UK setting.

CONCLUSIONS

The CUAs for CHC were found to apply to various HSUVs from different utility elicitation studies in the same health state. This variability in HSUVs has the potential to significantly affect ICER and ICER-based reimbursement decisions. A rigorous selection of HSUVs in CUAs to inform healthcare resource allocation is suggested for future studies of CUAs and for guideline development.

Cost-effectiveness of second-generation direct-acting antiviral agents in chronic HCV infection: a systematic literature review

BACKGROUND

Our objectives were to review the economic modelling methods and cost-effectiveness of second-generation direct-acting antiviral agents for the treatment of chronic HCV infection.

METHODS

A systematic literature search was performed in February 2017 using Scopus and OVID to review relevant publications between 2011 to present. Two independent reviewers screened potential papers.

RESULTS

The database search resulted in a total of 1,536 articles; after deduplication, title/abstract and full text screening, 67 studies were included for qualitative analysis. The vast majority of studies were conducted in high-income countries (n=59) and used Markov-based modelling techniques (n=60). Most of the analyses utilized long-term time horizons; 58 studies calculated lifetime costs and outcomes. The examined treatments were heterogenic among the studies; seven analyses did not directly evaluate treatments (just with screening or genotype testing). The examined treatments (n=60) were either dominant (23%), or cost-effective at base case (57%) or in given subgroups (18%). Only one (2%) study reported that the assessed treatment was not cost-effective with the given setting and price.

CONCLUSIONS

Despite their high initial therapeutic costs, second-generation direct-acting antiviral agents were found to be cost-effective to treat chronic HCV infection. Studies were predominantly conducted in higher income countries, although we have limited information on cost-effectiveness in low- and middle-income countries, where assessment of cost-effectiveness is even more essential due to more limited health-care resources and potentially higher public health burden due to unsafe medical interventions.

Economic Evaluation of Hepatitis C Treatment Extension to Acute Infection and Early-Stage Fibrosis Among Patients Who Inject Drugs in Developing Countries: A Case of China

We aimed to assess the cost-effectiveness of (1) treating acute hepatitis C virus (HCV) vs. deferring treatment until the chronic phase and (2) treating all chronic patients vs. only those with advanced fibrosis; among Chinese genotype 1b treatment-naïve patients who injected drugs (PWID), using a combination Daclatasvir (DCV) plus Asunaprevir (ASV) regimen and a Peg-interferon (PegIFN)-based regimen, respectively. A decision-analytical model including the risk of HCV reinfection simulated lifetime costs and quality-adjusted life-years (QALYs) of three treatment timings, under the DCV+ASV and PegIFN regimen, respectively: Treating acute infection (“Treat at acute”), treating chronic patients of all fibrosis stages (“Treat at F0 (no fibrosis)”), treating only advanced-stage fibrosis patients (“Treat at F3 (numerous septa without cirrhosis)”). Incremental cost-effectiveness ratios (ICERs) were used to compare scenarios. “Treat at acute” compared with “Treat at F0” was cost-saving (cost: DCV+ASV regimen—US$14,486.975 vs. US$16,224.250; PegIFN-based regimen—US$19,734.794 vs. US$22,101.584) and more effective (QALY: DCV+ASV regimen—14.573 vs. 14.566; PegIFN-based regimen—14.148 vs. 14.116). Compared with “Treat at F3”; “Treat at F0” exhibited an ICER of US$3780.20/QALY and US$15,145.98/QALY under the DCV+ASV regimen and PegIFN-based regimen; respectively. Treatment of acute HCV infection was highly cost-effective and cost-saving compared with deferring treatment to the chronic stage; for both DCV+ASV and PegIFN-based regimens. Early treatment for chronic patients with DCV+ASV regimen was highly cost-effective.

Mathematical modeling of hepatitis c virus (HCV) prevention among people who inject drugs: A review of the literature and insights for elimination strategies

In 2016, the World Health Organization issued global elimination targets for hepatitis C virus (HCV), including an 80% reduction in HCV incidence by 2030. The vast majority of new HCV infections occur among people who inject drugs (PWID), and as such elimination strategies require particular focus on this population. As governments urgently require guidance on how to achieve elimination among PWID, mathematical modeling can provide critical information on the level and targeting of intervention are required. In this paper we review the epidemic modeling literature on HCV transmission and prevention among PWID, highlight main differences in mathematical formulation, and discuss key insights provided by these models in terms of achieving WHO elimination targets among PWID. Overall, the vast majority of modeling studies utilized a deterministic compartmental susceptible-infected-susceptible structure, with select studies utilizing individual-based network transmission models. In general, these studies found that harm reduction alone is unlikely to achieve elimination targets among PWID. However, modeling indicates elimination is achievable in a wide variety of epidemic settings with harm reduction scale-up combined with modest levels of HCV treatment for PWID. Unfortunately, current levels of testing and treatment are generally insufficient to achieve elimination in most settings, and require further scale-up. Additionally, network-based treatment strategies as well as prison-based treatment and harm reduction provision could provide important additional population benefits. Overall, epidemic modeling has and continues to play a critical role in informing HCV elimination strategies worldwide.

We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade

Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.

Hepatitis C virus cure with direct acting antivirals: Clinical, economic, societal and patient value for China

About 10 million people in China are infected with hepatitis C virus (HCV), with the seroprevalence of anti-HCV in the general population estimated at 0.6%. Delaying effective treatment of chronic hepatitis C (CHC) is associated with liver disease progression, cirrhosis, hepatocellular carcinoma, and liver-related mortality. The extrahepatic manifestations of CHC further add to the disease burden of patients. Managing CHC-related advanced liver diseases and systemic manifestations are costly for both the healthcare system and society. Loss of work productivity due to reduced well-being and quality of life in CHC patients further compounds the economic burden of the disease. Traditionally, pegylated-interferon plus ribavirin (PR) was the standard of care. However, a substantial number of patients are ineligible for PR treatment, and only 40%-75% achieved sustained virologic response. Furthermore, PR is associated with impairment of patient-reported outcomes (PROs), high rates of adverse events, and poor adherence. With the advent of direct acting antivirals (DAAs), the treatment of CHC patients has been revolutionized. DAAs have broader eligible patient populations, higher efficacy, better PRO profiles, fewer adverse events, and better adherence rates, thereby making it possible to cure a large proportion of all CHC patients. This article aims to provide a comprehensive evaluation on the value of effective, curative hepatitis C treatment from the clinical, economic, societal, and patient experience perspectives, with a focus on recent data from China, supplemented with other Asian and international experiences where China data are not available.

Hepatitis C transmission in young people who inject drugs: Insights using a dynamic model informed by state public health surveillance

Increasing injection of heroin and prescription opioids have led to increases in the incidence of hepatitis C virus (HCV) infections in US young adults since the early 2000s. How best to interrupt transmission and decrease HCV prevalence in young people who inject drugs (PWID) is uncertain. We developed an age-stratified ordinary differential equation HCV transmission model of PWID aged 15-64, which we fit to Michigan HCV surveillance data among young PWID aged 15-29. We used Latin hypercube sampling to fit to data under 10,000 plausible model parameterizations. We used the best-fitting 10% of simulations to predict the potential impact of primary (reducing injection initiation), secondary (increasing cessation, reducing injection partners, or reducing injection drug use relapse), and tertiary (HCV treatment) interventions (over the period 2017-2030) on acute and chronic HCV cases by the year 2030. Treating 3 per 100 current and former PWID per year could reduce chronic HCV by 27.3% (range: 18.7-30.3%) and acute HCV by 23.6% (range: 6.7-29.5%) by 2030 among PWID aged 15-29 if 90% are cured (i.e. achieved sustained virologic response [SVR] to treatment). Reducing the number of syringe sharing partners per year by 10% was predicted to reduce chronic HCV by 15.7% (range: 9.4-23.8%) and acute cases by 21.4% (range: 14.2-32.3%) among PWID aged 15-29 by 2030. In simulations of combinations of interventions, reducing injection initiation, syringe sharing, and relapse rates each by 10% while increasing cessation rates by 10% predicted a 27.7% (range: 18.0-39.7%) reduction in chronic HCV and a 38.4% (range: 28.3-53.3%) reduction in acute HCV. Our results highlight the need for HCV treatment among both current and former PWID and the scale up of both primary and secondary interventions to concurrently reduce HCV prevalence and incidence in Michigan.

Effect of Interferon-Free Regimens on Disparities in Hepatitis C Treatment of US Veterans

OBJECTIVES

To determine whether implementation of interferon-free treatment for hepatitis C virus (HCV) reached groups less likely to benefit from earlier therapies, including patients with genotype 1 virus or contraindications to interferon treatment, and groups that faced treatment disparities: African Americans, patients with HIV co-infection, and those with drug use disorder.

METHODS

Electronic medical records of the US Veterans Health Administration (VHA) were used to characterize patients with chronic HCV infection and the treatments they received. Initiation of treatment in 206,544 patients with chronic HCV characterized by viral genotype, demographic characteristics, and comorbid medical and mental illness was studied using a competing events Cox regression over 6 years.

RESULTS

With the advent of interferon-free regimens, the proportion treated increased from 2.4% in 2010 to 18.1% in 2015, an absolute increase of 15.7%. Patients with genotype 1 virus, poor response to previous treatment, and liver disease had the greatest increase. Large absolute increases in the proportion treated were observed in patients with HIV co-infection (18.6%), alcohol use disorder (11.9%), and drug use disorder (12.6%) and in African American (13.7%) and Hispanic (13.5%) patients, groups that were less likely to receive interferon-containing treatment. The VHA spent $962 million on interferon-free treatments in 2015, 1.5% of its operating budget.

CONCLUSIONS

The proportion of patients with HCV treated in VHA increased sevenfold. The VHA was successful in implementing interferon treatment in previously undertreated populations, and this may become the community standard of care.

Daclatasvir combined with asunaprevir is a cost-effective and cost-saving treatment for hepatitis C infection in China

Aim: To evaluate the cost-effectiveness of the novel all-oral direct-acting antiviral regimen daclatasvir + asunaprevir (DUAL), versus interferon-based regimens for the treatment of chronic hepatitis C virus genotype 1b infection. Methods: Inputs for a lifetime Markov model were sourced from clinical trials and published literature. Outputs include disease management costs, life expectancy, quality-adjusted life-years and cost-effectiveness. Sensitivity analyses assessed the drivers of cost-effectiveness and sustained virologic response thresholds at which DUAL is cost-saving. Results: DUAL was associated with discounted incremental quality-adjusted life-years of 1.29-3.85 and incremental life-years of 0.85-2.59 per patient, with discounted lifetime cost savings of USD$1415-8525. Associated sustained virologic response rates could fall to 45.1-84.8%, while remaining dominant. Conclusion: Treatment with DUAL provides significant clinical benefit, while accruing lower lifetime costs.

Population Health and Cost-Effectiveness Implications of a "Treat All" Recommendation for HCV: A Review of the Model-Based Evidence

The World Health Organization HCV Guideline Development Group is considering a "treat all" recommendation for persons infected with hepatitis C virus (HCV). We reviewed the model-based evidence of cost-effectiveness and population health impacts comparing expanded treatment policies to more limited treatment access policies, focusing primarily on evaluations of all-oral directly acting antivirals published after 2012. Searching PubMed, we identified 2,917 unique titles. Sequentially reviewing titles and abstracts identified 226 potentially relevant articles for full-text review. Sixty-nine articles met all inclusion criteria-42 cost-effectiveness analyses and 30 models of population-health impacts, with 3 articles presenting both types of analysis. Cost-effectiveness studies for many countries concluded that expanding treatment to people with mild liver fibrosis, who inject drugs (PWID), or who are incarcerated is generally cost-effective compared to more restrictive treatment access policies at country-specific prices. For certain patient subpopulations in some countries-for example, elderly individuals without fibrosis-treatment is only cost-effective at lower prices. A frequent limitation is the omission of benefits and consequences of HCV transmission (i.e., treatment as prevention; risks of reinfection), which may underestimate or overestimate the cost-effectiveness of a "treat all" policy. Epidemiologic modeling studies project that through a combination of prevention, aggressive screening and diagnosis, and prompt treatment for all fibrosis stages, it may be possible to virtually eliminate HCV in many countries. Studies show that if resources are not available to diagnose and treat all HCV-infected individuals, treatment prioritization may be needed, with alternative prioritization strategies resulting in tradeoffs between reducing mortality or reducing incidence. Notably, because most new HCV infections are among PWID in many settings, HCV elimination requires unrestricted treatment access combined with injection transmission disruption strategies. The model-based evidence suggests that a properly constructed strategy that substantially expands HCV treatment could achieve cost-effective improvements in population health in many countries.

Effectiveness of interferon-free therapy for the treatment of HCV-patients with compensated cirrhosis treated through the Irish early access program

BACKGROUND

We investigated the real-world effectiveness of interferon-free regimens for the treatment of patients with compensated cirrhosis infected with hepatitis C virus (HCV).

METHOD

Using the Irish national HCV treatment registry, the effectiveness and safety of interferon-free regimens for HCV-infected patients treated between April 2015 and August 2016, was determined.

RESULTS

A SVR12 was achieved in 86% of subjects treated with sofosbuvir/ledipasvir ± ribavirin (SOF/LDV±RBV), 93% treated with paritaprevir, ombitasvir and ritonavir combined with dasabuvir ± ribavirin (3D±RBV) and 89% treated with sofosbuvir/daclatasvir ± ribavirin (SOF/DCV±RBV). The discontinuation rate was 5% and the on-treatment mortality rate was 1%.

CONCLUSION

The availability of interferon-free regimens represents a significant breakthrough for the treatment of HCV infection. Treatments options, with high SVR12 rates, are now available for patients with compensated cirrhosis who were unsuitable for treatment with interferon-based regimens. Data obtained from studies conducted in real world practice provide robust information fundamental for input into future economic evaluations for agents used for the treatment of HCV infection.