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. 2019 Dec;114(12):2267-2278.
doi: 10.1111/add.14731. Epub 2019 Aug 2.

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs

Carolina Barbosa  1 , Hannah Fraser  2 , Thomas J Hoerger  1 , Alyssa Leib  3 , Jennifer R Havens  4 , April Young  4 , Alex Kral  1 , Kimberly Page  5 , Jennifer Evans  6 , Jon Zibbell  1 , Susan Hariri  7 , Claudia Vellozzi  8 , Lina Nerlander  7 , John W Ward  7 , Peter Vickerman  2
Affiliations

Cost-effectiveness of scaling-up HCV prevention and treatment in the United States for people who inject drugs

Carolina Barbosa et al. Addiction. 2019 Dec.

Abstract

Aims: To examine the cost-effectiveness of hepatitis C virus (HCV) treatment of people who inject drugs (PWID), combined with medication-assisted treatment (MAT) and syringe-service programs (SSP), to tackle the increasing HCV epidemic in the United States.

Design: HCV transmission and disease progression models with cost-effectiveness analysis using a health-care perspective.

Setting: Rural Perry County, KY (PC) and urban San Francisco, CA (SF), USA. Compared with PC, SF has a greater proportion of PWID with access to MAT or SSP. HCV treatment of PWID is negligible in both settings.

Participants: PWID data were collected between 1998 and 2015 from Social Networks Among Appalachian People, U Find Out, Urban Health Study and National HIV Behavioral Surveillance System studies.

Interventions and comparator: Three intervention scenarios modeled: baseline-existing SSP and MAT coverage with HCV screening and treatment with direct-acting antiviral for ex-injectors only as per standard of care; intervention 1-scale-up of SSP and MAT without changes to treatment; and intervention 2-scale-up as intervention 1 combined with HCV screening and treatment for current PWID.

Measurements: Incremental cost-effectiveness ratios (ICERs) and uncertainty using cost-effectiveness acceptability curves. Benefits were measured in quality-adjusted life-years (QALYs).

Findings: For both settings, intervention 2 is preferred to intervention 1 and the appropriate comparator for intervention 2 is the baseline scenario. Relative to baseline, for PC intervention 2 averts 1852 more HCV infections, increases QALYS by 3095, costs $21.6 million more and has an ICER of $6975/QALY. For SF, intervention 2 averts 36 473 more HCV infections, increases QALYs by 7893, costs $872 million more and has an ICER of $11 044/QALY. The cost-effectiveness of intervention 2 was robust to several sensitivity analysis.

Conclusions: Hepatitis C screening and treatment for people who inject drugs, combined with medication-assisted treatment and syringe-service programs, is a cost-effective strategy for reducing hepatitis C burden in the United States.

Keywords: Cost-effectiveness analysis; direct-acting antiviral HCV treatment; hepatitis C; medication-assisted treatment; opioid modeling; people who inject drugs; syringe-service programs.

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Figures

Figure 1.
Figure 1.. Base-case results for Kentucky (a) and San Francisco (b) in the form of cost-effectiveness acceptability curves (CEACs).
The CEACs show the probability that one strategy is preferred to the other, for different maximum willingness-to-pay (WTP) for an additional quality-adjusted life-year (QALY). As decision makers are willing to pay more for an additional QALY, the more-costly and effective strategy is preferred. Baseline: current levels of syringe-service program (SSP) and medication-assisted treatment (MAT) with limited, usual hepatitis C virus (HCV) care including HCV screening and treatment with direct-acting antiviral agents (DAAs) for ex-injectors. Intervention 1: Scale-up of SSP and MAT to 50% coverage with the same level of screening and HCV treatment for ex-injectors as in the baseline intervention. Intervention 2: Scale-up of SSP and MAT to 50% coverage, plus annually screening of 90% of current injectors for HCV, followed by HCV treatment with DAAs for 90% of persons found to be chronically infected.
Figure 1.
Figure 1.. Base-case results for Kentucky (a) and San Francisco (b) in the form of cost-effectiveness acceptability curves (CEACs).
The CEACs show the probability that one strategy is preferred to the other, for different maximum willingness-to-pay (WTP) for an additional quality-adjusted life-year (QALY). As decision makers are willing to pay more for an additional QALY, the more-costly and effective strategy is preferred. Baseline: current levels of syringe-service program (SSP) and medication-assisted treatment (MAT) with limited, usual hepatitis C virus (HCV) care including HCV screening and treatment with direct-acting antiviral agents (DAAs) for ex-injectors. Intervention 1: Scale-up of SSP and MAT to 50% coverage with the same level of screening and HCV treatment for ex-injectors as in the baseline intervention. Intervention 2: Scale-up of SSP and MAT to 50% coverage, plus annually screening of 90% of current injectors for HCV, followed by HCV treatment with DAAs for 90% of persons found to be chronically infected.
Figure 2.
Figure 2.. Tornado diagram of univariate sensitivity analyses for Kentucky (a) and San Francisco (b).
Shows the change in ICERs (horizontal axis; $/quality-adjusted life-year [QALY]) compared to the base-case ICER ($6,975 per QALY for Kentucky and $11,044 per QALY for San Francisco) when different model assumptions are changed (see vertical axis). These analyses consider Intervention 2 where scale-up of MAT and SSP with hepatitis C virus screening and treatment is compared with the baseline scenario. For example, for both settings, Intervention 2 becomes more cost-effective (lower ICER) when reducing the cost of DAAs and less cost-effective (higher ICER) when decreasing the time horizon of the analysis. DAA = direct-acting antiviral agent; SSP = syringe-service program; PWID= people who inject drugs; SVR= sustained viral response; MAT= medication-assisted treatment
Figure 2.
Figure 2.. Tornado diagram of univariate sensitivity analyses for Kentucky (a) and San Francisco (b).
Shows the change in ICERs (horizontal axis; $/quality-adjusted life-year [QALY]) compared to the base-case ICER ($6,975 per QALY for Kentucky and $11,044 per QALY for San Francisco) when different model assumptions are changed (see vertical axis). These analyses consider Intervention 2 where scale-up of MAT and SSP with hepatitis C virus screening and treatment is compared with the baseline scenario. For example, for both settings, Intervention 2 becomes more cost-effective (lower ICER) when reducing the cost of DAAs and less cost-effective (higher ICER) when decreasing the time horizon of the analysis. DAA = direct-acting antiviral agent; SSP = syringe-service program; PWID= people who inject drugs; SVR= sustained viral response; MAT= medication-assisted treatment
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References

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