Should we treat acute hepatitis C? A decision and cost-effectiveness analysis

Abstract

It is not standard practice to treat patients with acute hepatitis C virus (HCV) infection. However, as the incidence of HCV in the United States continues to rise, it may be time to re-evaluate acute HCV management in the era of direct-acting antiviral (DAA) agents. In this study, a microsimulation model was developed to analyze the trade-offs between initiating HCV therapy in the acute versus chronic phase of infection. By simulating the lifetime clinical course of patients with acute HCV infection, we were able to project long-term outcomes such as quality-adjusted life years (QALYs) and costs. We found that treating acute HCV versus deferring treatment until the chronic phase increased QALYs by 0.02 and increased costs by $483 in patients not at risk of transmitting HCV. The resulting incremental cost-effectiveness ratio was $19,991 per QALY, demonstrating that treatment of acute HCV was cost-effective using a willingness-to-pay threshold of $100,000 per QALY. In patients at risk of transmitting HCV, treating acute HCV became cost-saving, increasing QALYs by 0.03 and decreasing costs by $3,655.

Conclusion: Immediate treatment of acute HCV with DAAs can improve clinical outcomes and be highly cost-effective or cost-saving compared with deferring treatment until the chronic phase of infection. If future studies continue to demonstrate effective HCV cure with shorter 6-week treatment duration, then it may be time to revisit current HCV guidelines to incorporate recommendations that account for the clinical and economic benefits of treating acute HCV in the era of DAAs. (Hepatology 2018;67:837-846).

Figure 1. State-transition diagram for a microsimulation model evaluating acute versus chronic HCV treatment

At any given time a patient occupies one of the health states represented by rectangles/circles/ovals. Arrows between states represent possible transitions based on probabilities. As time progresses, patients can transition to other states and acquire costs and health-utilities associated with that state. The model stops when all patients transition to a death state. A patient can transition to a death state from any of the above states as the result of background mortality (these transitions are not shown in the figure for clarity). Abbreviations: HCV, hepatitis C virus; DAA, direct-acting antiviral; SVR, sustained virologic response; F0–F4, METAVIR fibrosis score; DC, decompensated cirrhosis; HCC, hepatocellular carcinoma; LRD, liver related death; LT, liver transplant.

Figure 2. Tornado diagrams for one-way sensitivity analyses of the incremental cost-effectiveness ratio (ICER)

(A) Analysis for patients who are not at risk of transmitting HCV. (B) Analysis for patients who are at risk of transmitting HCV. Abbreviations: p, probability; q, quality of life utility; ICER, incremental cost-effectiveness ratio; QALY, quality adjusted life years; HCV, hepatitis C virus; DAA, direct-acting antiviral; SVR, sustained virologic response; F0–F4, METAVIR fibrosis score.

Figure 3. Two-way sensitivity analysis of the probability of spontaneous clearance and sustained virologic response (SVR) rates in acute HCV treatment

Displayed on the graphs are the regions in which varying combinations of these two parameters lead to cost-effective or cost-saving results. (A) Analysis for patients who are not at risk of transmitting HCV. (B) Analysis for patients who are at risk of transmitting HCV. Abbreviations: ICER, incremental cost-effectiveness ratio; QALY, quality adjusted life years; HCV, hepatitis C virus; SVR, sustained virologic response.