Cost-effectiveness and budget impact analysis of facility-based screening and treatment of hepatitis C in Punjab state of India

Assessing the potential cost-effectiveness of centralised versus point-of-care testing for hepatitis C virus in Pakistan: a model-based comparison

OBJECTIVES

Pakistan has a hepatitis C virus (HCV) infection prevalence of 6%-9% and aims to achieve World Health Organisation (WHO) targets for elimination of HCV by the year 2030. We aim to evaluate the potential cost-effectiveness of a reference laboratory-based (centralised laboratory testing; CEN) confirmatory testing approach versus a molecular near-patient point-of-care (POC) confirmatory approach to screen the general population for HCV in Pakistan.

STUDY DESIGN

We used a decision tree-analytic model from a governmental (formal healthcare sector) perspective.

STUDY SETTING

Individuals were assumed to be initially screened with an anti-HCV test at home, followed by POC nucleic acid test (NAT) at nearby district hospitals or followed by NAT at centralised laboratories.

PARTICIPANTS

We included the general testing population for chronic HCV in Pakistan.

INTERVENTION

Screening with an anti-HCV antibody test (Anti-HCV) followed by either POC NAT (Anti-HCV-POC), or reference laboratory NAT (Anti-HCV-CEN), was compared, using data from published literature and the Pakistan Ministry of Health.

MEASURES

Outcome measures included: number of HCV infections identified per year, percentage of individuals correctly classified, total costs, average costs per individual tested, and cost-effectiveness (assessed as cost per additional HCV infection identified). Sensitivity analysis was also performed.

RESULTS

At a national level (25 million annual screening tests), the Anti-HCV-CEN strategy would identify 142 406 more HCV infections in 1 year and increase correct classification of individuals by 0.57% compared with the Anti-HCV-POC strategy. The total annual cost of HCV testing was reduced using the Anti-HCV-CEN strategy by US$7.68 million (US$0.31/person). Thus, incrementally, the Anti-HCV-CEN strategy costs less and identifies more HCV infections than Anti-HCV-POC. The incremental difference in HCV infections identified was most sensitive to the probability of loss to follow-up (for POC confirmatory NAT).

CONCLUSIONS

Anti-HCV-CEN would provide the best value for money when scaling up HCV testing in Pakistan.

Health-related quality of life by household income in Chile: a concentration index decomposition analysis

BACKGROUND

Health inequities have a profound impact on all dimensions of people's lives, with invariably worse results among the most disadvantaged, transforming them into a more fragile and vulnerable population. These unfair inequalities also affect dimensions focused on subjectivity, such as health-related quality of life (HRQoL), which has been positioned, in recent decades, as an important outcome in health decision-making. The main objective of this study is to estimate socioeconomic inequality in HRQoL of Chilean by household income.  METHODS: Secondary analysis of the National Health Survey (ENS 2016-2017, Chile). This survey includes a nationally representative, stratified, and multistage household sample of people aged 15 and above. Socioeconomic inequality in HRQoL (EQ5D) is estimated by the concentration index (CI) ranked by household income. Decomposition analysis is conducted to examine potential explanatory sociodemographic factors.  RESULTS: The CI for household income inequality in HRQoL was -0.063. The lower the household income, the worse the HRQoL reported by in Chile. The decomposition analysis revealed that socioeconomic position contributes 75,7% to inequality in the quality of life, followed by educational level (21.8%), female gender (17.3%), and type of Health Insurance (15%), age (-19.7%) and residence (-10.8%). Less than 1% corresponds to the unexplained residual component.

CONCLUSIONS

Our findings suggest the existence of a disproportionate concentration of worse HRQoL in the most disadvantaged socioeconomic groups in Chile. This inequality is largely, yet not completely, associated with household income. Other significant factors associated with this inequality are education, gender, and healthcare insurance. These results suggest the need of strengthening efforts to reducing socioeconomic gaps in health outcomes in Chile, as a means to achieve social justice and equity in health and healthcare.

Outcomes of Real-World Integrated HCV Microelimination for People Who Inject Drugs: An expansion of the Punjab Model

BACKGROUND

The prevalence of chronic hepatitis C (CHC) in People Who Inject Drugs (PWID) is 8-10% as compared to 3·6% in the general population in Punjab, India. We assessed the real-world efficacy and safety of free-of-charge generic direct-acting antivirals (DAAs), sofosbuvir with an NS5A inhibitor (ledipasvir, daclatasvir or velpatasvir)±ribavirin in the microelimination of CHC in PWID in a public health setting.

METHODS

An integrated care team at 25 sites provided algorithm based DAAs treatment to PWID supervised by telemedicine clinics between 18^th June 2016 and 31^st July 2019. The primary endpoint was sustained virological response at 12 weeks (SVR-12); the secondary endpoints were treatment completion, adherence, safety, and adverse events. ClinicalTrials.gov number: NCT01110447.

FINDINGS

We enrolled 3477 PWID (87·2% men; mean age 33·6±12·5 years; 83·8% rural; 6·8% compensated cirrhosis). While 2280 (65·5%) patients completed treatment, 1978 patients completed 12 weeks of follow up for SVR-12. SVR-12 was achieved in 91·1% of patients per protocol, 49.5% as per intention to treat (ITT) and 90·1% in a modified ITT analysis. Of 546 (15·7%) patients with treatment interruptions, 99 (19·7%) could be traced to test for SVR-12 with a cure rate of 77·8%. There were no major adverse events or consequent treatment discontinuation.

INTERPRETATION

Integrated care of PWID with CHC with DAAs is safe and effective. Measures for reducing treatment interruptions will further improve outcomes.

FUNDING

The Government of the state of Punjab, India under the Mukh Mantri Punjab Hepatitis C Relief Fund (MMPHCRF) project, funds the project.

Rapid Diagnostics for Hepatitis B and C Viruses in Low- and Middle-Income Countries

The global health challenge posed by hepatitis B virus (HBV) and hepatitis C virus (HCV) persists, especially in low-and-middle-income countries (LMICs), where underdiagnosis of these viral infections remains a barrier to the elimination target of 2030. HBV and HCV infections are responsible for most liver-related mortality worldwide. Infected individuals are often unaware of their condition and as a result, continue to transmit these viruses. Although conventional diagnostic tests exist, in LMIC they are largely inaccessible due to high costs or a lack of trained personnel, resulting in poor linkage to care and increased infections. Timely and accurate diagnosis is needed to achieve elimination of hepatitis B and C by the year 2030 as set out by the World Health Organization Global Health Sector Strategy. In this review rapid diagnostic tests allowing for quick and cost-effective screening and diagnosis of HBV and HCV, are discussed, as are their features, including suitability, reliability, and applicability in LMIC, particularly those within Africa.