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Editorial
. 2019 Nov 4;5(4):179-190.
doi: 10.1016/S2055-6640(20)30031-5.

Targeted HCV core antigen monitoring among HIV-positive men who have sex with men is cost-saving

Stephanie Popping  1 , Brooke Nichols  1   2 , Bart Rijnders  3 , Jeroen van Kampen  1 , Annelies Verbon  3 , Charles Boucher  1 , David van de Vijver  1
Affiliations
Editorial

Targeted HCV core antigen monitoring among HIV-positive men who have sex with men is cost-saving

Stephanie Popping et al. J Virus Erad. .

Abstract

Introduction: The World Health Organization declared the goal of hepatitis C virus (HCV) elimination by 2030. Micro-elimination, which is the reduction of incidence to zero in targeted populations, is less complex and costly and may be the first step to prove whether elimination is feasible. A suitable target group are HIV-positive men who have sex with men (MSM) because of their high-risk behaviour and high incidence rates. Moreover, HCV monitoring is integrated in HIV care. The current HCV monitoring approach is suboptimal and complex and may miss new HCV infections. Alternative monitoring strategies, based on alanine aminotransferase, HCV-PCR and HCV-core antigen (HCV-cAg), combined with immediate direct-acting antiviral (DAA) treatment, may be more effective in reducing new HCV infections.

Methods: A deterministic mathematical transmission model was constructed representing the Dutch HCV epidemic among HIV-positive MSM to compare different HCV monitoring strategies from 2018 onwards. We evaluated the epidemiological impact of alternative and intensified monitoring in MSM with HCV. In addition, the cost-effectiveness was calculated over a lifetime horizon.

Results: Current HCV monitoring and treatment is projected to result in an incidence of 1.1/1000 person-years, 0.24% prevalence, at a cost of €61.8 million (interquartile range 52.2-73.9). Compared with current monitoring, intensified monitoring will result in a maximum 27% reduction of incidence and 33% in prevalence at an increased cost. Conversely, compared with current monitoring, targeted HCV-cAg monitoring will result in a comparable incidence (1.1/1000 person-years) and prevalence (0.23%) but will be €1 million cheaper with increased quality-adjusted life year.

Conclusion: Targeted monitoring reduces the HCV epidemic in a cost-saving manner; however, micro-elimination may not be obtained by 2030, highlighting the need for harm-reduction programmes.

Keywords: HIV; cost-effectiveness; diagnostics; elimination; hepatitis C; men who have sex with men.

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Figures

Figure 1.
Figure 1.
Simplified schematic representation of alternative monitoring strategies in the hepatitis C transmission model. This model is based on our previously published model . The stage of fibrosis is represented by METAVIR stages F0, F1, F2, F3 and F4. In our model, 15%–20% of the patients can spontaneously clear their infection. The current monitoring strategy is indicated in the first column (left) and based on the European AIDS Clinical Society guidelines where all patients are monitored with biannual ALT tests and annual HCV-antibody tests. In the next column, monitoring is either increased (time interval of 3-monthly or monthly) or ALT monitoring is replaced with a more sensitive test such as the HCV-PCR or HCV-cAg in all HIV-positive MSM [36–39]. In the third column the alternative monitoring strategies are targeted to the high-risk group (previously HCV-infected HIV-positive MSM), while all other HIV-positive MSM follow the monitoring approach based on ALT testing (current monitoring approach). All HCV-infected individuals follow the natural course of HCV when they are not treated with direct-acting antivirals. DAA: direct-acting antivirals; HCC: hepatocellular carcinoma; HCV: hepatitis C virus; MSM: men who have sex with men; SVR: sustained virological response. ¶ Intensified monitoring from 6-monthly time intervals to 3-monthly and monthly monitoring. ¥ More sensitive monitoring using an HCV-PCR test or an HCV-core antigen test with higher probability of diagnosing HCV [36–39]
Figure 2.
Figure 2.
One-way sensitivity analysis of the incremental cost-effectiveness ratio (ICERs) (€/QALY). We compared the current situation with monitoring the high-risk group with an HCV-cAg test at 6-monthly time intervals and varied different key parameters. The bars show the range in ICER if these key variables are varied. All ICERs are stated in euros. DAA: direct-acting antivirals; EACS: European AIDS Clinical Society; HCV-cAg: HCV-core antigen; ICER: incremental cost-effectiveness ratio; MSM men who have sex with men; QALY: quality-adjusted life year
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References

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Supplementary references

    1. Popping S, Hullegie SJ, Boerekamps A et al. . Early treatment of acute hepatitis C infection is cost-effective in HIV-infected men-who-have-sex-with-men. PLoS ONE 2019; 14( 1): e0210179. - PMC - PubMed
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