Prioritization of HCV treatment in the direct-acting antiviral era: An economic evaluation

Abstract

Background & aims: We determined the optimal HCV treatment prioritization strategy for interferon-free (IFN-free) HCV direct-acting antivirals (DAAs) by disease stage and risk status incorporating treatment of people who inject drugs (PWID).

Methods: A dynamic HCV transmission and progression model compared the cost-effectiveness of treating patients early vs. delaying until cirrhosis for patients with mild or moderate fibrosis, where PWID chronic HCV prevalence was 20, 40 or 60%. Treatment duration was 12weeks at £3300/wk, to achieve a 95% sustained viral response and was varied by genotype/stage in alternative scenarios. We estimated long-term health costs (in £UK=€1.3=$1.5) and outcomes as quality adjusted life-years (QALYs) gained using a £20,000 willingness to pay per QALY threshold. We ranked strategies with net monetary benefit (NMB); negative NMB implies delay treatment.

Results: The most cost-effective group to treat were PWID with moderate fibrosis (mean NMB per early treatment £60,640/£23,968 at 20/40% chronic prevalence, respectively), followed by PWID with mild fibrosis (NMB £59,258 and £19,421, respectively) then ex-PWID/non-PWID with moderate fibrosis (NMB £9,404). Treatment of ex-PWID/non-PWID with mild fibrosis could be delayed (NMB -£3,650). In populations with 60% chronic HCV among PWID it was only cost-effective to prioritize DAAs to ex-PWID/non-PWID with moderate fibrosis. For every one PWID in the 20% chronic HCV setting, 2 new HCV infections were averted. One extra HCV-related death was averted per 13 people with moderate disease treated. Rankings were unchanged with reduced drug costs or varied sustained virological response/duration by genotype/fibrosis stage.

Conclusions: Treating PWID with moderate or mild HCV with IFN-free DAAs is cost-effective compared to delay until cirrhosis, except when chronic HCV prevalence and reinfection risk is very high.

Keywords: Hepatitis C; People who inject drugs; Prevention; Treatment.

Graphical abstract

Fig. 1

Results on the incremental cost-effectiveness plane showing the efficient frontiers for 20% (solid line), 40% (dashed grey line), and 60% (dashed black line) chronic prevalence scenarios for the ‘Future IFN-free DAA’ treatment scenario. Results shown for treatment of PWID populations (squares) and ex-non-injectors (diamonds) with moderate disease (grey squares) and mild disease (white squares) compared to delayed treatment at the compensated cirrhosis stage. Treatment scenarios which do not fall on the frontier are dominated (more expensive with fewer benefits). Costs/QALYs are incremental to treatment of all those with compensated cirrhosis and best supportive care for all others.