Sofosbuvir-based treatment regimens for chronic, genotype 1 hepatitis C virus infection in U.S. incarcerated populations: a cost-effectiveness analysis

Hepatitis C virus micro-elimination in people who inject drugs: Challenges and chance in Taiwan and worldwide

With the introduction of direct-acting antivirals, elimination of hepatitis C virus (HCV) infection is becoming possible. People who inject drugs (PWID) represent a population with a high risk for HCV infection, which has been reported as high as 90% in Taiwanese PWID. To reach the goal of HCV elimination, PWID is a key population deserving special attention. Barriers in HCV care cascade still exist in PWID, and interventions to promote access to HCV diagnosis, link-to-care, treatment, and prevention for PWID are warranted. Although HCV micro-elimination can be achieved in some prisons and opioid substitution therapy (OST) centers by a multidisciplinary team and integrated care in Taiwan, there are still several unmet needs for HCV elimination in PWID. Continuous efforts, such as the participation of OST specialists and the continuum of care for HCV among PWID, are needed to achieve HCV elimination in Taiwan. In addition, the combination of harm reduction services, treatment as prevention and regular posttreatment HCV surveillance is critical to substantially reduce HCV transmission and prevalence in PWID.

HCV Microelimination for High-risk Special Populations

The World Health Organization has set tremendous goals to eliminate viral hepatitis by 2030. However, most countries are currently off the track for achieving these goals. Microelimination is a more effective and practical approach that breaks down national elimination targets into goals for smaller and more manageable key populations. These key populations share the characteristics of being highly prevalent for and vulnerable to hepatitis C virus (HCV) infection. Microelimination allows for identifying HCV-infected people and linking them to care more cost-effectively and efficiently. In this review, we discuss the current obstacles to and progress in HCV microelimination in special populations, including uremic patients undergoing hemodialysis, people who inject drugs, incarcerated people, people living in hyperendemic areas, men who have sex with men with or without human immunodeficiency virus (HIV) infection, transgender and gender-diverse populations, and sex workers. Scaling up testing and treatment uptake to achieve HCV microelimination may facilitate global HCV elimination by 2030.

Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection

The Infectious Diseases Society of America and the American Association for the Study of Liver Diseases have collaboratively developed evidence-based guidance regarding the diagnosis, management, and treatment of hepatitis C virus (HCV) infection since 2013. A panel of clinicians and investigators with extensive infectious diseases or hepatology expertise specific to HCV infection periodically review evidence from the field and update existing recommendations or introduce new recommendations as evidence warrants. This update focuses on changes to the guidance since the previous 2020 published update, including ongoing emphasis on recommended universal screening; management recommendations for incomplete treatment adherence; expanded eligibility for simplified chronic HCV infection treatment in adults with minimal monitoring; updated treatment and retreatment recommendations for children as young as 3 years old; management and treatment recommendations in the transplantation setting; and screening, treatment, and management recommendations for unique and key populations.

Economic Impact of Universal Hepatitis C Virus Testing for Middle-Aged Adults Who Inject Drugs

INTRODUCTION

The objective of this study was to estimate the economic impact of providing universal hepatitis C virus testing in commercially insured middle-aged persons who inject drugs in the U.S.

METHODS

This study developed a dynamic 10-year economic model to project the clinical and economic outcomes associated with hepatitis C virus testing among middle-aged adult persons who inject drugs, from a payer's perspective. Costs related to hepatitis C virus testing, direct-acting antiviral, and liver-related outcomes between the (1) current hepatitis C virus testing rate (i.e., 8%) and (2) universal hepatitis C virus testing rate (i.e., 100%) were compared. Among patients testing positive, 21% of those without cirrhosis and 48% of those with cirrhosis were assumed to initiate direct-acting antivirals. Sensitivity analyses were performed to identify variables (e.g., direct-acting antiviral drug costs, hepatitis C virus testing costs, direct-acting antiviral treatment rate) influencing this study's conclusion.

RESULTS

The model predicts that during the 10-year period, universal hepatitis C virus testing will cost an additional $242 per person who injects drugs to the payers' healthcare budgets compared with the current scenario. Sensitivity analyses showed values ranging from $1,656 additional costs to $1,085 cost savings across all varied parameters and scenarios. A total of 80% of the current direct-acting antiviral costs indicated that cost savings will be $383 per person who injects drugs.

CONCLUSIONS

Universal hepatitis C virus testing among persons who inject drugs would not achieve cost savings within 10 years, with the cost of direct-acting antivirals contributing the most to the spending. To promote universal hepatitis C virus testing among persons who inject drugs, decreasing direct-acting antiviral costs and sustainable funding streams for hepatitis C virus testing should be considered.

Cost-effectiveness of mass screening for Hepatitis C virus among all inmates in an Irish prison

BACKGROUND

In Irish prisons, there is a high proportion of people who inject drugs (PWID; 26%) and a high prevalence of HCV (16%), making prison a high priority setting for HCV testing and treatment. We evaluate the cost-effectiveness of a mass HCV screening intervention in Mountjoy Prison, Dublin, compared to the standard-of-care of intermittent screening on committal.

METHODS

Primary cost data was collected from the intervention using an overall provider perspective. Standard-of-care (SOC) costs were estimated through interview. All costs were inflated to 2020 Euros. An HCV transmission and disease progression model among incarcerated and community PWID and ex-injectors was calibrated to the Dublin HCV epidemic, allowing inclusion of population-level health benefits. The model used intervention data, suggesting 419 individuals were screened, 50 HCV infections diagnosed and 32 individuals initiated treatment, to project the resulting costs and health benefits (quality adjusted life years or QALYs) over 50 years with 5% discounting. The incremental cost effectiveness ratio (ICER), cost per QALY gained, was estimated for the screening intervention compared to the standard-of-care. Probabilistic sensitivity analyses (PSA) determined the probability that the intervention was cost-effective compared to a willingness-to-pay threshold of €30,000/QALY as used in Ireland. The ICER for 1- or 3-yearly mass screening in all Dublin prisons was also calculated.

RESULTS

The total direct costs of the intervention (not including treatment drug costs) was €82,392, with most costs being due to staff (43%) and overhead or management costs (38%). Despite having little epidemiological impact due to the small numbers treated, over 50 years the incremental cost of the intervention was €36,592 and 3.8 QALYs were gained, giving a mean ICER of €9,552/QALY. The majority (84%) of PSA runs were below the willingness-to-pay threshold. Yearly mass screening had an ICER of €2,729/QALY compared to SOC and gave a higher net monetary benefit (€7,393,382) than screening every 3 years (€6,252,816).

CONCLUSION

Prison mass screening could be a cost-effective initiative for increasing testing and treatment of HCV in Ireland.

Cost-effectiveness of new antiviral treatments for non-genotype 1 hepatitis C virus infection in China: a societal perspective

Objective

This study aimed to estimate the cost-effectiveness of direct-acting antivirals (DAAs) among patients with non-genotype 1 for the eradication of hepatitis C virus (HCV) infection in China.

Methods

A decision-analytic Markov model was developed to estimate the lifetime costs, quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) for DAAs and pegylated interferon plus ribavirin (PEG-RBV) from a societal perspective. The model inputs were derived from the literature, a patient survey, HCV expert opinions and a specialised drug price database available in China. Sensitivity analysis was conducted to evaluate the model robustness and calculate reasonable prices of DAAs.

Results

For patients infected with HCV genotype 2, the pan-genotypic regimen sofosbuvir/velpatasvir (SOF/VEL) was the most cost-effective strategy compared with PEG-RBV, with an ICER of US$5653/QALY. For genotype 3, the combination of sofosbuvir plus daclatasvir (SOF-DCV) was the most cost-effective approach, with an ICER of US$3314/QALY. All DAA regimens for genotype 6 were cost-saving, and sofosbuvir plus ribavirin (SOF-RBV) was the optimal regimen. One-way sensitivity analysis demonstrated that the ICERs were most sensitive to the utility values, discount rate and drug costs. Probabilistic sensitivity analysis indicated that using a threshold equal to one time the gross domestic product (GDP) per capita in China (US$9769/QALY, 2018), the probability of SOF/VEL, SOF-DCV and SOF-RBV being cost-effective was 58%, 83% and 71% for genotype 2, 3 and 6, respectively. Threshold analysis showed that the price of DAAs should be reduced by some degree to achieve better affordability.

Conclusions

DAAs were cost-effective compared with traditional treatments. A reasonable reduction in the price of DAAs will increase drug affordability and is of great significance as a global strategy to eradicate viral hepatitis.

New hepatitis C virus infection, re-infection and associated risk behaviour in male Irish prisoners: a cohort study, 2019

BACKGROUND

Prisoners are recognised as a high-risk population and prisons as high-risk locations for the transmission of hepatitis c virus (HCV) infection. Injecting drug use (IDU) is the main driver of HCV infection in prisoners and harm reduction services are often suboptimal in prison settings. HCV prevalence and incident data in prisoners is incomplete which impacts the public health opportunity that incarceration provides in identifying, treating and preventing HCV infection. The aim of this study is to identify new HCV infection and associated risk factors in an Irish male prison.

METHODS

We conducted a follow up (18-month) cohort study on prisoners who had previously tested negative, self-cleared or had been successfully treated for HCV infection. We conducted the study in a male medium security prison located in Dublin Ireland (Mountjoy Prison) using HCV serology, a review of medical records and a researcher-administered questionnaire.

RESULTS

99 prisoners with a mean age of 33.2 yrs. participated in the study and 82(82.8%) completed a research-administered questionnaire. Over half (51%) had a history of drug use from a young age (14.8 yrs.), 49.9% a history of heroin use and 39% a history of IDU. The prevalence of HIV and hepatitis B virus core antibody was 3% and HCV antibody was 22.2%. No new HCV infections were identified in those who had never been infected (n = 77), had self-cleared (n = 9) or achieved sustained virological response (n = 12). Small numbers of prisoners continued to engage in risk-behaviour including, IDU both in the prison (n = 2) and the community (n = 3), sharing syringes (n = 1) and drug taking paraphernalia (n = 6) and receiving non-sterile tattoos (n = 3).

CONCLUSION

Despite the high numbers of Irish prisoners with a history of IDU and HCV infection, new HCV infection is low or non-existent in this population. Small numbers of prisoners continue to engage in risk behaviour and larger studies are required to further understand HCV transmission in this cohort in an Irish and international context.

Hepatitis C treatment strategies in prisons: A cost-effectiveness analysis

In Australian prisons approximately 20% of inmates are chronically infected with hepatitis C virus (HCV), providing an important population for targeted treatment and prevention. A dynamic mathematical model of HCV transmission was used to assess the impact of increasing direct-acting antiviral (DAA) treatment uptake on HCV incidence and prevalence in the prisons in New South Wales, Australia, and to assess the cost-effectiveness of alternate treatment strategies. We developed four separate models reflecting different average prison lengths of stay (LOS) of 2, 6, 24, and 36 months. Each model considered four DAA treatment coverage scenarios of 10% (status-quo), 25%, 50%, and 90% over 2016–2045. For each model and scenario, we estimated the lifetime burden of disease, costs and changes in quality-adjusted life years (QALYs) in prison and in the community during 2016–2075. Costs and QALYs were discounted 3.5% annually and adjusted to 2015 Australian dollars. Compared to treating 10% of infected prisoners, increasing DAA coverage to 25%, 50%, and 90% reduced HCV incidence in prisons by 9–33% (2-months LOS), 26–65% (6-months LOS), 37–70% (24-months LOS), and 35–65% (36-months LOS). DAA treatment was highly cost-effective among all LOS models at conservative willingness-to-pay thresholds. DAA therapy became increasingly cost-effective with increasing coverage. Compared to 10% treatment coverage, the incremental cost per QALY ranged from $497-$569 (2-months LOS), -$280–$323 (6-months LOS), -$432–$426 (24-months LOS), and -$245–$477 (36-months LOS). Treating more than 25% of HCV-infected prisoners with DAA therapy is highly cost-effective. This study shows that treating HCV-infected prisoners is highly cost-effective and should be a government priority for the global HCV elimination effort.

Cost-effectiveness and Budgetary Impact of Hepatitis C Virus Testing, Treatment, and Linkage to Care in US Prisons

BACKGROUND

Hepatitis C virus (HCV) testing and treatment uptake in prisons remains low. We aimed to estimate clinical outcomes, cost-effectiveness (CE), and budgetary impact (BI) of HCV testing and treatment in United States (US) prisons or linkage to care at release.

METHODS

We used individual-based simulation modeling with healthcare and Department of Corrections (DOC) perspectives for CE and BI analyses, respectively. We simulated a US prison cohort at entry using published data and Washington State DOC individual-level data. We considered permutations of testing (risk factor based, routine at entry or at release, no testing), treatment (if liver fibrosis stage ≥F3, for all HCV infected or no treatment), and linkage to care (at release or no linkage). Outcomes included quality-adjusted life-years (QALY); cases identified, treated, and cured; cirrhosis cases avoided; incremental cost-effectiveness ratios; DOC costs (2016 US dollars); and BI (healthcare cost/prison entrant) to generalize to other states.

RESULTS

Compared to "no testing, no treatment, and no linkage to care," the "test all, treat all, and linkage to care at release" model increased the lifetime sustained virologic response by 23%, reduced cirrhosis cases by 54% at a DOC annual additional cost of $1440 per prison entrant, and would be cost-effective. At current drug prices, targeted testing and liver fibrosis-based treatment provided worse outcomes at higher cost or worse outcomes at higher cost per QALY gained. In sensitivity analysis, fibrosis-based treatment restrictions were cost-effective at previous higher drug costs.

CONCLUSIONS

Although costly, widespread testing and treatment in prisons is considered to be of good value at current drug prices.

Pilot study using the ECHO model to enhance linkage to care for patients with hepatitis C in the custodial setting

Prisoners in most countries have a higher prevalence of HCV than the general population, but their access to treatment is very limited. Our aim was to evaluate a pilot programme using the ECHO model to enhance linkage to care in patients with HCV in 3 Argentinean prisons between October 2018 and January 2020. All inmates were invited to participate, and data were collected through a personal interview. We then estimated HCV prevalence with dried blood spot and performed a logistic regression analysis to identify risk behaviours associated with HCV infection. Finally, HCV management was assessed and monitored through ECHO. Overall, 1141 inmates agreed to participate, representing 39.7% of the total prison population. Anti-HCV prevalence was estimated at 1.58% (CI 0.93; 2.48), being significantly higher in women 2.98% (CI 1.4;5.6) than in men 1.07% (CI 0.5; 2.0); P = .03. Patients with anti-HCV were significantly older than those who tested negative, 42.3 years (CI 37.6;47.1) vs 30.1 years (CI 30.6;31.2), P < .001, respectively. Multiple logistic regression analysis, identified age OR 1.07 (CI 1.03;1.12, P = .001), history of sexually transmitted disease OR 3.08 (CI 0.97;9.82, P = .057) and intravenous drug use OR 12.6 (CI 3.31;48.53, P < .001) as risk factors associated with anti-HCV. Treatment was initiated in all the patients with specialist physician support utilizing ECHO model. In conclusion, our pilot study reported a low prevalence of anti-HCV in the studied population. Incarceration provides an ideal opportunity for testing and treating HCV. ECHO model arises as a useful tool to support assessment and treatment for inmates with chronic HCV.

Detection, stratification and treatment of hepatitis C-positive prisoners in the United Kingdom prison estate: Development of a pathway of care to facilitate the elimination of hepatitis C in a London prison

The United Kingdom is committed to eliminating hepatitis C virus (HCV) infection by 2025. The prison estate provides an opportunity to identify and treat HCV-positive individuals in a high-prevalence environment. We designed and implemented a pathway of care within a London prison to diagnose, stratify and link HCV-positive prisoners into care. This study was a two-phase case study of a HCV care pathway. New arrivals to the prison were offered blood-borne virus screening with dried blood spot testing at their secondary health check. Those with active infection completed disease stratification tests and were reviewed at a weekly hospital-based multidisciplinary team meeting to determine management. In Phase-2, the pathway was redesigned to improve testing and the referral of HCV-positive prisoners into treatment. Over the 30-month evaluation period, 12,946 people were received in the prison. During Phase-1, 19.6% of new arrivals completed blood-borne virus testing, with 7.3% identified as HCV-positive. Just 8.3% of HCV-positive individuals were treated or referred for treatment in Phase-1. During Phase-2, 30% of new receptions completed BBV testing and 3.9% were identified as HCV-positive. Linkage into care was improved, with 38.9% treated or referred during the second phase. Poor access to testing and referral to treatment limit the effectiveness of care provision for prisoners with HCV. Elimination of HCV in prisons requires local service configuration to ensure high uptake of testing, with all HCV-positive cases then offered treatment during custody or referral on to treatment after release.

Cost-effectiveness analysis of chronic hepatitis C treatment in the prison population in Spain

Objectives

To evaluate the cost-effectiveness of direct-acting antiviral (DAAs) treatment versus non-treatment in prisoners awaiting treatment for chronic hepatitis C (CHC) and to analyse the clinical and economic impact of the treatment on liver complications and mortality.

Material and method

A lifetime Markov model was developed to simulate treatment and disease progression from an estimated cohort of 4,408 CHC prisoners treated with DAAs over 2 years (50% of patient each year) versus no treatment. In the treated cohort, a sustained viral response of 95% was associated. Patient characteristics, transition probabilities, utilities and costs (pharmacological and healthcare states) were obtained from published literature. The model estimated healthcare costs and benefits, incremental cost-utility ratio (ICUR) based on total costs and the quality-adjusted life year (QALY) and avoided clinical events. A National Healthcare System perspective was adopted with a 3% annual discount rate for both costs and health outcomes. Sensitivity analyses were performed to assess uncertainty.

Results

In the DDA treated cohort, the model estimated a decrease of 92% of decompensated cirrhosis and 83% of hepatocellular carcinoma, 88% liver-related mortality cases were reduced, 132 liver transplants were avoided. The treatment achieved an additional 5.0/QALYs (21.2 vs. 16.2) with an incremental cost of €3,473 (€24,088 vs. €20,615) per patient with an ICUR of €690 per QALY gained.

Discussion

Considering the willingness-to-pay threshold used in Spain (€22,000-30,000/QALY), DAAs treatment for prisoners with CHC is a highly cost-effective strategy, reduces infection transmission, increases survival and reduces complications due to liver disease, as well as the cost associated with its management.

Changes in Cost-Effectiveness for Chronic Hepatitis C Virus Pharmacotherapy: The Case for Continuous Cost-Effectiveness Analyses

BACKGROUND

Cost-effectiveness evaluations for hepatitis C virus (HCV) treatments have been published frequently, but new products with significant cost and effectiveness differences make these analyses obsolete. How valuable are economic models for a fixed time period in a dynamic market?

OBJECTIVE

To estimate the cost-effectiveness of the best available HCV treatment at different points in time, using the same comparator to demonstrate how rapid innovation in a disease area influences economic outcomes.

METHODS

A Markov model was used to calculate the cost-effectiveness of treatment in 2010, 2012, 2014, 2016, and 2018 compared with a standard comparator (no treatment) from the payer perspective. Expected drug costs and treatment effectiveness estimates for sustained virologic response (SVR) were calculated using recommended regimens for each of the 6 HCV genotypes at each time point and distribution of genotypes in the United States. Patients entered the model with different stages of fibrosis. Utility estimates for each health state were used to calculate quality-adjusted life-years (QALYs) earned at each cycle. Incremental cost-effectiveness ratios were reported for each year to compare the "treatment versus no treatment" decision at that time.

RESULTS

No HCV treatment resulted in a gain of 11.54 QALYs over a 20-year time horizon at a cost of $42,938. Costs for treated groups were $69,075, $123,267, $125,431, $86,782, and $56,470 for the 2010, 2012, 2014, 2016, and 2018 scenarios, respectively. QALYs gained for treated groups were 12.90, 12.97, 13.34, 13.39, and 13.46 for the 2010, 2012, 2014, 2016, and 2018 scenarios, respectively. The incremental cost-effectiveness ratios in each year compared with no treatment were $19,218 per QALY, $56,104 per QALY, $45,829 per QALY, $23,699 per QALY, and $7,048 per QALY.

CONCLUSIONS

Treatment effectiveness for HCV has increased steadily, while treatment costs increased substantially from 2010-2014 before decreasing to its lowest point in 2018. Thus, the dynamic nature of innovation creates the need for iterative cost-effectiveness analyses.

DISCLOSURES

No outside funding supported this study. Mattingly reports unrelated consulting from the National Health Council, Bristol Myers Squibb, G&W Laboratories, Allergy and Asthma Foundation of American, and the Massachusetts Health Policy Commission. Love reports an unrelated research grant from the American Cancer Society.

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.

Value in Hepatitis C Virus Treatment: A Patient-Centered Cost-Effectiveness Analysis

BACKGROUND

Innovations in hepatitis C virus (HCV) therapy included in traditional comparative evaluations focus on sustained virologic response (SVR) without addressing challenges patients report beyond virologic cure. This study aims to evaluate the cost-effectiveness of HCV drug therapy with a patient-centered approach.

METHODS

An individual-based Markov model was constructed using guidance from a stakeholder advisory board (SAB), a patient Delphi panel, and published literature to evaluate direct-acting antivirals (DAAs) compared to no treatment. The United States (US) health sector and societal perspectives were considered for 10- and 20-year time horizons. Inputs for treatment costs and effectiveness reflect a generic regimen. Indirect costs used for the societal model included estimates from self-reported productivity in a matched-control sample. Beyond the traditional quality-adjusted life-year (QALY) health outcome, this study included two novel measures developed from the Delphi panel and SAB: infected life-years and workdays missed. All costs were measured in 2018 US dollars.

RESULTS

Health sector costs and QALYs were higher in the treatment group in both 10- and 20-year models. Total infected life-years and workdays missed were reduced in the treatment group for both models. When costs of absenteeism, presenteeism, and patient/caregiver time were included, the DAA intervention was cost-saving at both 10 and 20 years. Health sector results were sensitive to drug costs and utility estimates for post-SVR health states. Societal results were sensitive to presenteeism estimates and drug costs.

CONCLUSION

Treatment was cost-effective from a health sector perspective and cost-saving when including non-health costs such as patient/caregiver time and productivity.

Improved Health Outcomes from Hepatitis C Treatment Scale-Up in Spain's Prisons: A Cost-Effectiveness Study

Hepatitis C virus (HCV) is 15 times more prevalent among persons in Spain's prisons than in the community. Recently, Spain initiated a pilot program, JAILFREE-C, to treat HCV in prisons using direct-acting antivirals (DAAs). Our aim was to identify a cost-effective strategy to scale-up HCV treatment in all prisons. Using a validated agent-based model, we simulated the HCV landscape in Spain's prisons considering disease transmission, screening, treatment, and prison-community dynamics. Costs and disease outcomes under status quo were compared with strategies to scale-up treatment in prisons considering prioritization (HCV fibrosis stage vs. HCV prevalence of prisons), treatment capacity (2,000/year vs. unlimited) and treatment initiation based on sentence lengths (>6 months vs. any). Scaling-up treatment by treating all incarcerated persons irrespective of their sentence length provided maximum health benefits-preventing 10,200 new cases of HCV, and 8,300 HCV-related deaths between 2019-2050; 90% deaths prevented would have occurred in the community. Compared with status quo, this strategy increased quality-adjusted life year (QALYs) by 69,700 and costs by €670 million, yielding an incremental cost-effectiveness ratio of €9,600/QALY. Scaling-up HCV treatment with DAAs for the entire Spanish prison population, irrespective of sentence length, is cost-effective and would reduce HCV burden.

Management of Hepatitis C in Delaware Prisons: : Approaching Microenvironmental Eradication

The management of chronic hepatitis C virus (HCV) infection has been transformed due to the arrival of HCV-specific Direct-Acting Antivirals (DAAs), which are safer, more effective, and better tolerated than the interferon-based therapies that preceded them. Compared with community healthcare systems, many prison healthcare systems have been slower to adopt the routine use of HCV DAAs despite the fact that HCV infection disproportionately affects individuals in correctional institutions. In 2015, the Delaware Department of Correction (DDOC) launched a treatment program that prioritized treatment for patients who were at greatest risk of disease complications. To date, 327/345 (95%) of eligible current HCV patients have initiated DAA therapy. A total of 196/199 (98.4%) patients who have initiated treatment and who have post-treatment data available have achieved sustained virologic response, defined as undetectable HCV viral load 12 weeks after treatment. Applying a concept of microenvironmental eradication, it can reasonably be concluded that that DDOC is approaching this benchmark with regard to chronic HCV infection and will soon enter a “maintenance phase,” during which it will be feasible to treat new cases of HCV in real time. Correctional systems with significant numbers of untreated hepatitis C patients may want to consider implementing HCV treatment programs that focus on cost-effectiveness and prioritize treatment for patients who are at greatest risk of disease complications.

Family Practitioner-Directed Hepatitis C Therapy With Direct-Acting Antivirals Achieves High-Sustained Virologic Response in Prison Population

The burden of hepatitis C virus (HCV) infection is disproportionately high in U.S. federal and state prisons. This offers a unique opportunity for targeted HCV screening and treatment. New, highly effective, oral direct-acting antiviral (DAA) agents have the potential to eliminate many of the hurdles previously imposed by older interferon-based therapies. However, a relative deficit of providers motivated or empowered to treat HCV, along with a lack of treatment data on use of DAAs in prisons, greatly restricts the ability to treat the prison population. Here, we present a retrospective chart review of HCV treatment with DAAs by a family practitioner in a California state prison. Our data demonstrate that focused treatment by a primary care practitioner can achieve high HCV cure rates even in historically difficult to treat populations. Treatment of prison populations per local and national guidelines by family practitioners should be pursued to facilitate the eradication of hepatitis C in the United States.

Was It Worth Introducing Health Economic Evaluation of Innovative Drugs in the French Regulatory Setting? The Case of New Hepatitis C Drugs

OBJECTIVE

This paper constitutes the first attempt to draw lessons from the recent uptake of health economic evaluation of innovative drugs in the French regulatory framework.

STUDY DESIGN

Taking the example of new direct-acting antivirals against hepatitis C virus, the paper asks whether and how the cost-effectiveness (CE) opinions issued by the French National Health Authority improve the information available to support the pricing decisions.

METHODS

The analysis compares the assessment of these drugs based on three different sources: CE opinions, clinical opinions, and the published cost-utility analyses (CUA) available in the literature and identified through a systematic review.

RESULTS

The results show that CE opinions bring to the fore three issues prone to impact the incremental cost utility ratio and those were not available to the decision maker through clinical opinions or published CUA: the stage of treatment initiation, the modeling of the disease progression, and the uncertainty around the efficacy rates.

CONCLUSIONS

France has introduced the criterion of the cost per QALY gained in the pricing and regulation of innovative pharmaceuticals since 2013. Our analysis shows that the use of CUA does enhance the information available to the decision makers on the value of the treatments.

A systematic review on models of care effectiveness and barriers to Hepatitis C treatment in prison settings in the EU/EEA

Hepatitis C prevalence in prison populations is much higher than in the community. Effective hepatitis C treatment within this population does not only have a direct individual health benefit, but may lead to substantial community dividend. We reviewed available evidence on hepatitis C treatment in prison settings, with a focus on the European Union/European Economic Area. A systematic review of the literature (PubMed, EMBASE, Cochrane library) was performed and complemented with searches for conference abstracts and grey literature. Thirty-four publications were included reporting on the effectiveness, acceptability and economic aspects of hepatitis C virus treatment models of care to achieve treatment completion and sustained viral response in prison settings. Available evidence shows that hepatitis C treatment in prison settings is feasible and the introduction of direct-acting antivirals will most likely result in increased treatment completion and better clinical outcomes for the prison population, given the caveats of affordability and the need for increased funding for prison health, with the resulting benefits accruing mostly in the community.

Microenvironment Eradication of Hepatitis C: A Novel Treatment Paradigm

OBJECTIVES

Prisons are major reservoirs of hepatitis C virus (HCV) in which a therapeutic approach has been particularly difficult so far. Our aim was to create a permanent program of HCV elimination in a prison based on a "test and treat" strategy.

METHODS

This open-label clinical trial was conducted in the Spanish prison "El Dueso" between May 2016 and July 2017. Viremic patients were treated with a ledipasvir-sofosbuvir regimen (8-12 weeks) according to the 2015 Spanish Guidelines. A teleconsultation program was established to follow-up patients from the hospital. Non-responders were submitted for a phylogenetic analysis and offered retreatment. An evaluation of new cases of HCV infection was performed every 6 months and upon release in all inmates.

RESULTS

847 (99.5%) inmates accepted to participate. HCV antibodies were present in 110 (13.0%) and 86 (10.2%) had detectable viremia. Most of them were genotype 1 or 3 (82.6%) and had <F2 fibrosis (52.2%). Treatment was started in the 69 inmates whose stay in prison was longer than 30 days. Sustained virological response was achieved in 64 out of 66 patients (96.9%), three of whom were successfully rescued with a salvage regimen after treatment failure. Two patients were lost to follow-up and three are currently on treatment without viremia. As a result, by July 2017 none of the 409 imprisoned was viremic, and neither reinfections nor de novo infections were detected.

CONCLUSIONS

A sustained "test-and-treat" strategy against HCV in prisons is feasible and beneficial. Spreading this strategy should entail a public health impact.

Comparison of effectiveness and discontinuation of interferon-free therapy for hepatitis C in prison inmates and noninmates

Chronic hepatitis C treatment with direct acting antiviral (DAA) therapy during incarceration is an attractive option, due to its short duration and to the possibility of directly observed treatment or supervision. The aim of this study is to compare the effectiveness and rates of discontinuation of DAA treatment in prisoners and nonprisoners. We studied all patients treated in the 10 prisons of Catalonia and at 3 public hospitals in the Barcelona area between 1 January 2015 and 30 April 2016. We analysed sustained viral response (SVR) and rates of discontinuation through intention-to-treat and modified-intention-to-treat analyses, the latter excluding discontinuations due to release from prison. One hundred and eighty-eight inmates and 862 noninmates were included. Prisoners were significantly younger than nonprisoners, with higher proportions of men, drug users, HIV infection, genotypes 1a and 3 and more treatment with psychiatric drugs. Overall, 98.4% of patients completed treatment. The discontinuation rate was low, but higher in inmates (3.7% vs 1.2% noninmates; P = .003) and in community patients >65 years old (2.8% vs 1.2% in under 65 seconds; P = .008). Among the inmates, 7 (42.8%) discontinuations were due to release. SVR was 93.1% in inmates vs 96.5% in noninmates (P = .08) by intention-to-treat and 95.1% vs 96.5% (P = .37) by modified intention-to-treat. Virologic failure rates were similar (3.8% vs 3% in noninmates; P = .60). SVR, virologic failure and discontinuation rates were similar in inmates and noninmates. Currently, prisons are considered a priority for the implementation of DAA. Improved coordination between penitentiary and community health systems would help to ensure therapeutic continuity in released prisoners.

A Multi-Fidelity Rollout Algorithm for Dynamic Resource Allocation in Population Disease Management

Dynamic resource allocation for prevention, screening, and treatment interventions in population disease management has received much attention in recent years due to excessive healthcare costs. In this paper, our goal is to design a model and an efficient algorithm to optimize sequential intervention policies under resource constraints to improve population health outcomes. We consider a discrete-time finite-horizon budget allocation problem with disease progression within a closed birth-cohort population. To address the computational challenges associated with large-state and multiple-period dynamic decision-making problems, we propose a low-fidelity approximation that preserves the population dynamics under a stationary policy. To improve the healthcare interventions in terms of population health outcomes, we then embed the low-fidelity approximation into a high-fidelity optimization model to efficiently identify a good non-stationary sequential intervention policy. Our approach is illustrated by a numerical example of screening and treatment policy implementation for chronic hepatitis C virus (HCV) infection over a budget planning period. We numerically compare our Multi-Fidelity Rollout Algorithm (MF-RA) to a grid search approach and demonstrate the similarity of sequential policy trends and closeness of overall health outcomes measured by quality-adjusted life-years (QALYs) and the total number of individuals that undergo screening and treatment for different annual budgets and birth-cohorts. We also show how our approach scales well to problems with high dimensionality due to many decision periods by studying time to elimination of HCV.

Cost-effectiveness of diagnostic and therapeutic interventions for chronic hepatitis C: a systematic review of model-based analyses

BACKGROUND

Decisions about which subgroup of chronic hepatitis C (CHC) patients should be treated with direct acting anti-viral agents (DAAs) have economic importance due to high drug prices. Treat-all DAA strategies for CHC have gained acceptance despite high drug acquisition costs. However, there are also costs associated with the surveillance of CHC to determine a subgroup of patients with significant impairment. The aim of this systematic review was to describe the modelling methods used and summarise results in cost-effectiveness analyses (CEAs) of both CHC treatment with DAAs and surveillance of liver disease.

METHODS

Electronic databases including Embase and Medline were searched from inception to May 2015. Eligible studies included models predicting costs and/or outcomes for interventions, surveillance, or management of people with CHC. Narrative and quantitative synthesis were conducted. Quality appraisal was conducted using validated checklists. The review was conducted following principles published by NHS Centre for Research and Dissemination.

RESULTS

Forty-one CEAs met the eligibility criteria for the review; 37 evaluated an intervention and four evaluated surveillance strategies for targeting DAA treatment to those likely to gain most benefit. Included studies were of variable quality mostly due to reporting omissions. Of the 37 CEAs, eight models that enabled comparative analysis were fully appraised and synthesized. These models provided non-unique cost-effectiveness estimates in a specific DAA comparison in a specific population defined in terms of genotype, prior treatment status, and presence or absence of cirrhosis. Marked heterogeneity in cost-effectiveness estimates was observed despite this stratification. Approximately half of the estimates suggested that DAAs were cost-effective considering a threshold of US$30,000 and 73% with threshold of US$50,000. Two models evaluating surveillance strategies suggested that treating all CHC patients regardless of the staging of liver disease could be cost-effective.

CONCLUSIONS

CEAs of CHC treatments need to better account for variability in their estimates. This analysis suggested that there are still circumstances where DAAs are not cost-effective. Surveillance in place of a treat-all strategy may still need to be considered as an option for deploying DAAs, particularly where acquisition cost is at the limit of affordability for a given health system.

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.

HIV and hepatitis C virus infections in Quebec's provincial detention centres: comparing prevalence and related risky behaviours between 2003 and 2014-2015

OBJECTIVES

To compare the prevalence of HIV, hepatitis C virus (HCV) infections, and related risky behaviours among inmates in Quebec's provincial prisons between 2003 and 2014-2015.

METHODS

Cross-sectional data were anonymously collected from May 2014 to March 2015 for men (n = 1315) and women (n = 250) and combined with data collected in 2003 to evaluate trends in the last decade. Participants completed a questionnaire and provided saliva samples. The data from the 2003 and 2014-2015 surveys were merged for statistical analysis.

RESULTS

HIV prevalence was stable between 2003 and 2014-2015 for men (2.4% vs. 1.8%, p = 0.4), whereas it decreased for women (8.8% vs. 0.8%, p < 0.001). HCV prevalence decreased between 2003 and 2014-2015 for both men (16.6% vs. 11.9%, p < 0.001) and women (29.2% vs. 19.2%, p = 0.02). HIV and HCV prevalence were higher among people who inject drugs (PWID), for both sexes and both studies. PWID-specific prevalence did not change between 2003 and 2014-2015, except for a decrease in HIV prevalence in PWID women. However, the proportion of prisoners reporting a history of injection drug use outside prison was lower in 2014-2015 than in 2003 for men (19.8% vs. 27.7%, p < 0.0001) and women (28.6% vs. 42.6%, p = 0.002).

CONCLUSION

The lower proportion of PWID inmates in 2014-2015 compared to 2003 explained in large part the decrease in HIV and HCV prevalence. Despite the decrease in prevalence, HIV and HCV infections among incarcerated individuals still represent a major public health problem due to the sizable increase of individuals in Quebec's correctional system over the same period.

Hospital admissions for HIV-infected prisoners in Italy

Purpose The purpose of this paper is to give a description of the clinical conditions and patient demographics of inpatient admissions of human immunodeficiency virus (HIV)-infected inmates in three hospital wards that provide hospital care for inmates in Italy. Design/methodology/approach This is a retrospective review of hospital medical admissions of patients living with HIV from January 1 to December 31, 2014, in three Italian referral centers for hospitalization of inmates. Findings A total of 85 admissions for 85 different HIV-infected inmates occurred in 2014 in the three centers participating to the study. Most patients (54.1 percent) were co-infected with hepatitis C. Discharge diagnosis largely varied ranging from common HIV-related co-morbidities to completely independent diagnosis. The most commonly observed discharge diagnoses were chronic hepatitis C, liver cirrhosis, opiate dependence and thrombocytopenia. Originality/value Discharge diagnosis between HIV-infected inmates and HIV-infected patients in freedom are strikingly and significantly different. A large number of hospitalized HIV-infected inmates were affected by chronic viral hepatitis and liver cirrhosis; this is probably a direct consequence of the high prevalence of HCV and/or HBV co-infections in the inmate population in Italy. In addition, a significantly lower proportion of cancer diagnosis was observed among inmates; this is possibly justified by the fact that in our Italian settings when HIV infection is at advanced stages or if cancer treatment is started those affected are released from prison and can continue their diagnostic and treatment follow-up in freedom.

Strategies for the elimination of hepatitis C virus infection as a public health threat in the United States

Purpose of Review

Direct-acting antiviral regimens for chronic hepatitis C virus (HCV) became available in 2014, and these highly curative therapies have the potential to reduce HCV-associated morbidity and mortality, decrease transmission, and eliminate HCV infection as a public health problem. This review summarizes the recommendations by the National Academies of Sciences, Engineering, and Medicine for a US strategy for HCV elimination.

Recent Findings

To achieve proposed targets of reducing HCV incidence by 90% and decreasing HCV-related mortality by 60% by 2030, there is a critical need to improve HCV diagnosis and linkage to care; reduce HCV-related disease by antiviral treatment scale-up; reduce HCV incidence; and strengthen HCV surveillance to determine achievement of HCV elimination targets over time.

Summary

While HCV elimination is feasible, success of this national effort will require ongoing collaboration and critical resource investment by key stakeholders, including medical and public health communities, legislators, community organizers, and patient advocates.

Blood-borne viral co-infections among human immunodeficiency virus-infected inmates

Purpose - The purpose of this paper is to evaluate the prevalence of HBV and/or HCV co-infection among HIV-infected inmates entering the correctional facility. Design/methodology/approach - Prospective collection of data of HIV-infected inmates entered the institution over a ten-year period. Findings - During study period 365 consecutive different inmates were evaluated. HCV co-infection was observed in more than 80 per cent of the tested HIV-infected inmates, past HBV infection in 71.6 per cent and active HBV co-infection was detected in 7.1 per cent; triple coinfection (HIV, HCV and HBs-Ag positivity) was present in 6 per cent of the total. Originality/value - This study confirms high prevalence of co-infections among HIV-infected inmates. Testing for HBV and HCV in all HIV-infected inmates at entry in any correctional system is recommended to identify those in need of specific care and/or preventing interventions.

Structural Sensitivity in HIV Modeling: A Case Study of Vaccination

Structural assumptions in infectious disease models, such as the choice of network or compartmental model type or the inclusion of different types of heterogeneity across individuals, might affect model predictions as much as or more than the choice of input parameters. We explore the potential implications of structural assumptions on HIV model predictions and policy conclusions. We illustrate the value of inference robustness assessment through a case study of the effects of a hypothetical HIV vaccine in multiple population subgroups over eight related transmission models, which we sequentially modify to vary over two dimensions: parameter complexity (e.g., the inclusion of age and HCV comorbidity) and contact/simulation complexity (e.g., aggregated compartmental vs. individual/disaggregated compartmental vs. network models). We find that estimates of HIV incidence reductions from network models and individual compartmental models vary, but those differences are overwhelmed by the differences in HIV incidence between such models and the aggregated compartmental models (which aggregate groups of individuals into compartments). Complexities such as age structure appear to buffer the effects of aggregation and increase the threshold of net vaccine effectiveness at which aggregated models begin to overestimate reductions. The differences introduced by parameter complexity in estimated incidence reduction also translate into substantial differences in cost-effectiveness estimates. Parameter complexity does not appear to play a consistent role in differentiating the projections of network models.

The continuum of hepatitis C care for criminal justice involved adults in the DAA era: a retrospective cohort study demonstrating limited treatment uptake and inconsistent linkage to community-based care

BACKGROUND

Incarcerated populations are disproportionately burdened by hepatitis C virus (HCV) infection. The introduction of highly-effective, direct-acting antiviral (DAA) treatment has potential to substantially reduce the burden of liver disease in this population, but accurate information about access to and utilization of this treatment is currently limited. The goals of this study were to characterize receipt of HCV care and treatment services for a cohort of HCV-infected adults identified in a state prison system, and to describe the complex health needs of this population.

METHODS

To estimate the proportion of patients who were treated for HCV while incarcerated, and the proportion linked to HCV care after release from prison, we used a deterministic matching algorithm to link administrative prison data, health care records, and a state public health surveillance database, which captures all positive HCV-related diagnostic test results through automatic laboratory reporting. Individuals not evaluated or treated for HCV while in prison were considered likely to have been linked to care in the community if the HCV surveillance system contained a record of a quantitative HCV RNA or genotype test within 6 months of their release date. Demographic and comorbidity data were manually extracted from the electronic health records for all patients referred for consideration of HCV treatment.

RESULTS

Between 2011 and 2015, 3126 individuals were known to be living with chronic HCV infection while incarcerated in the state prison system. Of these, 570 (18%) individuals were evaluated for HCV treatment while incarcerated and 328 (10%) initiated treatment with DAAs. Of the 2556 individuals not evaluated for treatment, 1605 (63%) were released from prison during the 5 year study period. Of these, 138 (9%) individuals engaged in HCV care in the community within 6 months. Data describing medical and psychiatric co-morbidities were available for the prison-based treatment cohort, which showed a high prevalence of major depression (39%), anxiety disorder (24%), alcohol misuse (52%), cocaine use (52%) and prior injection drug use (62%).

CONCLUSION

Despite HCV treatment advances, linkage to care and treatment rates for criminal-justice involved adults remains low, particularly for those who must seek care in the community after release from prison. Treating criminal-justice involved individuals for HCV during incarceration provides an opportunity to improve linkage to care and treatment rates among this vulnerable population.

When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs

Potential cost-effective barriers in cost-effectiveness studies mean that budgetary impact analyses should also be included in post-2015 Sustainable Development Goal projects says Joshua Salomon and colleagues.

Systematic review: cost-effectiveness of direct-acting antivirals for treatment of hepatitis C genotypes 2-6

BACKGROUND

The availability of direct-acting antivirals (DAAs) has dramatically changed the landscape of hepatitis C virus (HCV) therapy; however, the cost and budget requirements for DAA treatment have been widely debated.

AIMS

To systematically review published studies evaluating the cost-effectiveness of DAAs for HCV genotype 2-6 infections, and synthesise and re-evaluate results with updated drug prices.

METHODS

We conducted a systematic search of various electronic databases, including Medline, EMBASE, Cochrane library and EconLit for cost-effectiveness studies published from 2011 to 2016. Studies evaluating DAAs for genotypes 2-6 were included. Reported costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) were abstracted. We re-estimated ICERs by varying the price of DAAs from $20 000 to $100 000, and estimated the threshold price at which DAA regimens would be deemed cost-effective (ICER≤$100 000/QALY).

RESULTS

A total of 92 ICERs for 7 different DAA regimens from 10 published articles were included. Among the abstracted 92 ICERs, 20 were for genotype 2, 40 for genotype 3, 30 for genotype 4, 2 for genotype 5 and none for genotype 6; therefore, only genotypes 2-5 were analysed. At the discounted price of $40 000, 87.0% analyses found DAA regiments to be cost-effective, and 7.6% found to be cost-saving. The median threshold price below which DAAs would be deemed cost-effective was between $144 400 and $225 000, and cost-saving between $17 300 and $25 400.

CONCLUSIONS

HCV treatment with DAAs is highly cost-effective in patients with HCV genotypes 2-5 at a $100 000/QALY threshold. Timely HCV treatment would be an optimal strategy from both a public health and economic perspective.

Economic Burden of Hepatitis C Infection

The economic burden of chronic hepatitis C might exceed $10 billion annually in the United States alone. This disease has a worldwide prevalence of up to 3%, making the global burden of the disease comparably tremendous. The cost of the disease includes direct medical expenses for its hepatic and extrahepatic manifestations, and also indirect costs incurred from impaired quality of life and the loss of work productivity. Recent emergence of treatment options that are not only highly effective and safe but also costly has emphasized the need to study the disease from the economic point of view.

Hepatitis C Treatment Regimens Are Cost-Effective: But Compared With What?

BACKGROUND

Numerous economic models have been published evaluating treatment of chronic hepatitis C virus (HCV) infection, but none provide a comprehensive comparison among new antiviral agents.

OBJECTIVE

Evaluate the cost-effectiveness of all recommended therapies for treatment of genotypes 1 and 4 chronic HCV.

METHODS

Using data from clinical trials, observational analyses, and drug pricing databases, Markov decision models were developed for HCV genotypes 1 and 4 to compare all recommended drugs from the perspective of the third-party payer over a 5-, 10-, and 50-year time horizon. A probabilistic sensitivity analysis (PSA) was conducted by assigning distributions for clinical cure, age entering the model, costs for each health state, and quality-adjusted life years (QALYs) for each health state in a Monte Carlo simulation of 10 000 repetitions of the model.

RESULTS

In the lifetime model for genotype 1, effects ranged from 18.08 to 18.40 QALYs and total costs ranged from $88 107 to $184 636. The lifetime model of genotype 4 treatments had a range of effects from 18.23 to 18.43 QALYs and total costs ranging from $87 063 to $127 637. Grazoprevir/elbasvir was the optimal strategy followed by velpatasvir/sofosbuvir as the second-best strategy in most simulations for both genotypes 1 and 4, with drug costs and efficacy of grazoprevir/elbasvir as the primary model drivers.

CONCLUSIONS

Grazoprevir/elbasvir was cost-effective compared with all strategies for genotypes 1 and 4. Effects for all strategies were similar with cost of drug in the initial year driving the results.

Feasibility of Treating Hepatitis C in a Transient Jail Population

Jails represent a critical component of the public health response to HCV elimination. We report on outcomes of 104 patients receiving HCV treatment from January 1, 2014 to June 30, 2016 in a large urban jail setting. Our data demonstrate that treatment in jails is feasible, but many barriers remain.

Epidemiology of Infectious Disease-Related Death After Release from Prison, Washington State, United States, and Queensland, Australia: A Cohort Study

OBJECTIVES

People in prison may be at high risk for infectious diseases and have an elevated risk of death immediately after release compared with later; their risk of death is elevated for at least a decade after release. We compared rates, characteristics, and prison-related risk factors for infectious disease-related mortality among people released from prisons in Queensland, Australia, and Washington State, United States, regions with analogous available data.

METHODS

We analyzed data from retrospective cohort studies of people released from prison in Queensland (1997-2007, n=37,180) and Washington State (1999-2009, n=76,208) and linked identifiers from each cohort to its respective national death index. We estimated infectious disease-related mortality rates (deaths per person-years in community) and examined associations using Cox proportional hazard models.

RESULTS

The most frequent infectious disease-related underlying cause of death after release from prison was pneumonia (43%, 23/54 deaths) in the Australian cohort and viral hepatitis (40%, 69/171 deaths) in the U.S. cohort. The infectious disease-related mortality rate was significantly higher in the U.S. cohort than in the Australian cohort (51.2 vs. 26.5 deaths per 100,000 person-years; incidence rate ratio = 1.93, 95% confidence interval 1.42, 2.62). In both cohorts, increasing age was strongly associated with mortality from infectious diseases.

CONCLUSION

Differences in the epidemiology of infectious disease-related mortality among people released from prison may reflect differences in patterns of community health service delivery in each region. These findings highlight the importance of preventing and treating hepatitis C and other infectious diseases during the transition from prison to the community.

Performance of Risk-Based and Birth-Cohort Strategies for Identifying Hepatitis C Virus Infection Among People Entering Prison, Wisconsin, 2014

OBJECTIVES

The prevalence of hepatitis C virus (HCV) infection among young adults is rising in Wisconsin. We examined the prevalence of HCV infection among male and female inmates entering two Wisconsin prisons and evaluated existing and alternate risk-based strategies for identifying HCV infection at intake.

METHODS

We added HCV testing to the intake procedures for all 1,239 adults prison entrants at the Wisconsin Department of Corrections (WDOC) from November 3, 2014, to January 31, 2015. We identified risk factors associated with HCV infection during the routine intake examination and calculated the sensitivity and specificity of risk-based testing strategies for identifying HCV infection.

RESULTS

The prevalence of HCV antibody among prison entrants was 12.5% (95% confidence interval [CI] 10.7, 14.4) overall and was almost two times higher at the women's facility (21.3%, 95% CI 15.4, 27.2) than at the men's facility (11.0%, 95% CI 0.0, 12.9) (p<0.001). The sensitivity and specificity of the WDOC risk-based criteria were 88% (95% CI 83, 93) and 80% (95% CI 78, 83), respectively. Adding a new criterion, the 1945-1965 birth cohort, to the risk-based criteria improved the sensitivity to 92% (95% CI 88, 96) and lowered the specificity to 71% (95% CI 68, 74). Compared with entrants without these risk factors, HCV antibody prevalence was significantly higher among prison entrants who had the following risk factors: injection drug use (prevalence ratio [PR] = 9.9, 95% CI 7.4, 13.2), liver disease (PR=9.7, 95% CI 7.8, 12.0), and elevated levels of alanine transaminase (PR=3.6, 95% CI 2.7, 4.9).

CONCLUSION

The WDOC risk criteria for HCV testing identified 88% of HCV infections among prison entrants. Including the 1945-1965 birth cohort as a criterion along with the other WDOC risk criteria increased the sensitivity of targeted testing to 92%. These findings may be informative to jurisdictions where universal HCV testing is not feasible because of resource limitations.

Direct-Acting Antiviral Agents for Patients With Hepatitis C Virus Genotype 1 Infection Are Cost-Saving

BACKGROUND & AIMS

Direct-acting antivirals (DAAs) are effective in treatment of hepatitis C virus (HCV) genotype 1 infection, but their cost and value have been debated. We performed a systematic review of published cost-effectiveness analyses of DAAs, synthesized their results with updated drug prices, and calculated the maximum price at which DAA therapy for HCV genotype 1 infection is cost-effective (increased quality-adjusted life-years [QALYs] and increased cost that the society is willing to pay) and cost-saving (increased QALYs and decreased costs).

METHODS

We conducted a systematic review of the PubMed, Medline, EMBASE, Cochrane library, EconLit, Database of Abstracts of Reviews of Effects, National Health Service Economic Evaluation Database, Health Technology Assessment, and Tufts University databases for cost-effectiveness analyses published from 2011 through 2015. Our analysis included cost effectiveness of DAAs versus previous standard-of-care regimens (peginterferon and ribavirin, boceprevir and telaprevir), or no treatment, performed for patients with HCV genotype 1 infection. We excluded studies that were not written in English or those that did not report QALYs. Reported incremental cost-effectiveness ratios (ICERs) and treatment costs for each comparison were extracted; the threshold price was estimated for each analysis in which regimens were found to be cost-effective (ICER ≤$100,000/QALY) or cost-saving (ICER <$0), those that decreased costs and increased QALYs.

RESULTS

We identified 24 cost-effectiveness studies that reported 170 ICERs for combinations of 11 drugs, from 11 countries. Of those, 81 ICERs were determined for first-generation DAAs (boceprevir and telaprevir) and 89 ICERs were determined for second-generation DAAs (drugs approved after the first-generation DAAs) as a primary intervention. The median threshold prices at which first-generation and second-generation DAAs became cost-effective were estimated as $120,100 (interquartile range, $90,700-$176,800) and $227,200 (interquartile range, $142,800-$355,800), respectively. At the discounted price of $60,000, a total of 71% of the analyses found second-generation DAAs to be cost-saving and 22% to be cost-effective.

CONCLUSIONS

In a systematic review, we found treatment of HCV genotype 1 infection with second-generation DAAs to be cost-effective when they cost less than and $227,200; these drugs produced cost savings at current discounts.

Optimizing patient treatment decisions in an era of rapid technological advances: the case of hepatitis C treatment

How long should a patient with a treatable chronic disease wait for more effective treatments before accepting the best available treatment? We develop a framework to guide optimal treatment decisions for a deteriorating chronic disease when treatment technologies are improving over time. We formulate an optimal stopping problem using a discrete-time, finite-horizon Markov decision process. The goal is to maximize a patient's quality-adjusted life expectancy. We derive structural properties of the model and analytically solve a three-period treatment decision problem. We illustrate the model with the example of treatment for chronic hepatitis C virus (HCV). Chronic HCV affects 3-4 million Americans and has been historically difficult to treat, but increasingly effective treatments have been commercialized in the past few years. We show that the optimal treatment decision is more likely to be to accept currently available treatment-despite expectations for future treatment improvement-for patients who have high-risk history, who are older, or who have more comorbidities. Insights from this study can guide HCV treatment decisions for individual patients. More broadly, our model can guide treatment decisions for curable chronic diseases by finding the optimal treatment policy for individual patients in a heterogeneous population.

Optimizing Implementation of Hepatitis C Birth-Cohort Screening and Treatment Strategies: Model-Based Projections

Background: Chronic hepatitis C (HCV) is a significant public health problem affecting more than three million Americans. The US health care systems are ramping up costly HCV screening and treatment efforts with limited budget. We determine the optimal implementation of HCV birth-cohort screening and treatment strategies under budget constraints and health care payer's perspective. Methods: Markov model and scenario-based simulation optimization. The target population is birth cohort born between 1945 and 1975. The interventions are allocating annual budget to screen a proportion of the target population and treat a proportion of the identified chronic HCV-positive patients over 10 years. Outcomes measure is to maximize lifetime discounted quality-adjusted life-years. Results: Allocate a percentage of the annual budget to screening, then treat patients with the remaining budget and prioritize the sickest patients. When the budget is $1 billion/year, the best strategy is to allocate the entire budget to treatment. When the budget is $5 billion/year, it is optimal to allocate 60% of the budget to screening in the first 2 years and 0% thereafter for age cohort 40 to 49; and allocate 20% of the budget to screening starting in year 3 for age cohorts 50 to 59 and 60 to 69. Health benefits are sensitive to budget in the first 2 years. Results are not sensitive to distribution of fibrosis stages by awareness of HCV. Conclusion: When budget is limited, all efforts should be focused on early treatment. With higher budget, better population health outcomes are achieved by reserving some budget for HCV screening while implementing a priority-based treatment strategy. This work has broad applicability to diverse health care systems and helps determine how much effort should be devoted to screening versus treatment under resource limitations.

Hepatitis C in Australian prisons: a national needs assessment

PURPOSE

Hepatitis C (HCV) infections are prevalent in custodial settings worldwide, yet provision of antiviral therapies is uncommon. Approximately 30,000 prisoners are held in Australian prisons at any one time, with more than 30 per cent testing positive for HCV antibodies. Prisoners have been identified in the National Hepatitis C Strategy as a priority population for assessment and treatment. The purpose of this paper is to examine the rates of HCV testing and treatment, as well as barriers and opportunities for development of infrastructure for enhanced services.

DESIGN/METHODOLOGY/APPROACH

Interviews were conducted with 55 stakeholders from the correctional sector in each state and territory in Australia in two stages: service directors to gather quantitative data regarding rates of testing and treatment; and other stakeholders for qualitative information regarding barriers and opportunities.

FINDINGS

Of more than 50,000 individuals put in in custody in Australian prisons in 2013, approximately 8,000 individuals were HCV antibody positive, yet only 313 prisoners received antiviral treatment. The barriers identified to assessment and treatment at the prisoner-level included: fear of side effects and the stigma of being identified to custodial authorities as HCV infected and a likely injecting drug user. Prisoners who came forward may be considered unsuitable for treatment because of prevalent mental health problems and ongoing injecting drug use. Provision of specialist hepatitis nurses and consultants were the most frequently recommended approaches to how prison hepatitis services could be improved.

ORIGINALITY/VALUE

Many personal and systems-level barriers relevant to the delivery of HCV treatment services in the custodial setting were identified. Ready access to skilled nursing and medical staff as well as direct acting antiviral therapies will allow the prison-sector to make a major contribution to control of the growing burden of HCV disease.

Biomedical innovation in the era of health care spending constraints

Insurers, hospitals, physicians, and consumers are increasingly weighing price against performance in their decisions to purchase and use new drugs, devices, and other medical technologies. This approach will tend to affect biomedical innovation adversely by reducing the revenues available for research and development. However, a more constrained funding environment may also have positive impacts. The passing era of largely cost-unconscious demand fostered the development of incremental innovations priced at premium levels. The new constrained-funding era will require medical technology firms to design their products with the features most valued by payers and patients, price them at levels justified by clinical performance, and manage distribution through organizations rather than to individual physicians. The emerging era has the potential to increase the social value of innovation by focusing industry on design, pricing, and distribution principles that are more closely aligned with the preferences-and pocketbooks-of its customers.

Value of Treating All Stages of Chronic Hepatitis C: A Comprehensive Review of Clinical and Economic Evidence

INTRODUCTION

The goal of chronic hepatitis C (CHC) treatment is to achieve a sustained virologic response (SVR). The new generation of direct-acting antivirals (DAAs) offers 90-100% SVR rates. However, access to these treatments is generally limited to patients with advanced liver disease. The aim of this review is to provide an overview of the clinical and economic benefits of achieving SVR and to better understand the full value of CHC treatment in all stages of liver disease.

METHODS

A comprehensive literature review was performed using the PubMed, Embase, and Cochrane library databases to identify articles examining the clinical, economic, and quality of life benefits associated with SVR. Articles were limited to those published in English language from January 2006 through January 2016. Inclusion criteria were (1) patients with CHC, (2) retrospective and prospective studies, (3) reporting of mortality, liver morbidity, extrahepatic manifestations (EHMs), and economic outcomes and, (4) availability of an abstract or full-text publication.

RESULTS

Overall this review identified 354 studies involving more than 500,000 CHC patients worldwide. Evidence from 38 studies (n = 73,861) shows a significant mortality benefit of achieving SVR in patients with all stages of fibrosis. Long-term studies with follow-up of 5-12 years suggest that, particularly among non-cirrhotic patients, there is a significant decrease in mortality in SVR versus non-SVR groups. Ninety-nine studies conducted in 235,891 CHC patients in all stages of fibrosis show that SVR reduces liver-related mortality, incidence of hepatocellular carcinoma (HCC), and decompensation. A total of 233 studies show that chronic HCV infection is associated with several serious EHMs, some of which can have high mortality. Evidence from four modeling studies shows that delaying treatment to CHC patient populations could significantly increase mortality, morbidity, and medical costs.

CONCLUSIONS

There is a robust body of evidence demonstrating diverse sources of value from achieving SVR in all stages of liver disease. While access to treatment is generally limited to late-stage patients, less restrictive treatment strategies that target HCV eradication have the potential to abate the burdens of mortality, liver morbidity and extrahepatic manifestations, and the associated healthcare costs.